Every finding on record at Ryze on the Avenue

Based on observation, interview, and record review the facility failed to ensure call lights were answered in a timely manner. This failure affected 1 (R4) of 3 residents reviewed for quality of care. Findings include:On 8/14/2026 at 12:38 PM, surveyor observed R4's call light on in the hallway as she approached R2 for an interview. On 8/14/2026 at 12:51 PM, surveyor observed R4's call light remained blinking and the call light in the hallway by the nursing station blinking. R4's electronic health record documents a diagnosis of but not limited to cerebral infarction, epilepsy-unspecified, chronic obstructive pulmonary disease, other pulmonary embolism, other muscle spasm, acute embolism and thrombosis, and type 2 diabetes mellitus; Minimum Data Set, dated [DATE] section C documents a BIMS (Brief Interview Mental Status) Score of 15 which indicates R4's cognition is intact; care plan showed R4 has a focus for impaired functional mobility related to weakness/discomfort when moving/spasm of affected area/poor motivation/ and inactivity resulting from primary history of cerebral vascular accident with left hemiparesis.On 8/14/2026 at 1:18 PM, R4 stated he (R4) pulled his call light about an hour ago because he felt nauseated; no one answered has answered my call light; and he (R4) thought all of the staff went on break at the same time. On 8/14/2026 at 1:24 PM, surveyor observed V6 (Certified Nursing Assistant/CNA) bring R4 his tray and did not ask if he pulled his call light. The call light remained blinking. On 8/14/2026 at 1:28 PM, V5 (CNA) stated staff should answer the call light if it is on to find out what the residents needs are; the purpose of answering the call light is to make sure the resident don't try to take care of their own needs which can cause the resident to fall that results in an injury.On 8/14/2026 at 1:37 PM, V6(CNA) stated she (V6) answers call lights promptly; purpose of call lights are to make sure a resident is not having a problem, emergency, or need water; and call lights not answered promptly a resident could end up falling on the floor or an accident can happen.On 8/14/2026 at 1:40 PM, V6 (CNA) stated she (V6) did not notice R4's call light on when she entered his room to pass his meal tray. On 8/14/2026 at 1:43 PM, V6 answered R4's call light. The surveyor remained in view of the call light from 12:38PM until 1:43PM.On 8/14/2026 at 1:43 PM, V7 (Licensed Practical Nurse) stated the call light system rings at the nursing station and the light above the nursing station blinks to alert the staff a call light is ringing; the call light should be answered as soon as it is rings; purpose of answering a call light promptly is to address the residents needs because it could be an emergency; and delays in answering the call light can cause harm to a resident; during meal times three CNAs are assigned to pass trays and 2 CNAs should be caring for the residents on the floor.On 8/15/2026 at 12:10 PM, V2 (Director of Nursing) stated V2 would like for a residents call light to be answered as promptly as possible in about 2 minutes; call lights should be answered promptly because a resident can be in distress or just may need some water but anyone should answer the call light; if the person answering the call light can't help the resident, that staff member should go and get the appropriate staff member to handle the resident's needs. Facility's policy titled Call Light Response dated 1/2023 revised on 5/27/2026 documents, in part, to provide the staff with guidance on responding to residents' requests and needs.Facility's policy titled Resident's Rights for People in Long-Term Care Facilities with a revision dated of 11/18 documents, in part, your facility must provide equal access to quality of care regardless of diagnosis, condition, or payment source and must provide services to keep your physical and mental health, at their highest practical levels. CNA Job Description undated documents, in part 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.

Based on interview and record review, the facility failed to protect residents' rights to be from physical abuse from another resident. This failure affects two (R4, R5) residents out of five residents reviewed for abuse in a total sample of 14. As a result of this failure, R5 hit R4 in the head on 02/27/2026 resulting in R4 sustaining a laceration to his head and being sent to the hospital. As a result of this failure, R4 hit R5 in the face on 02/27/2026 resulting in R5 sustaining a closed nasal bone fracture and being sent to the hospital.Findings include: Facility reported incident/FRI dated 02/27/2026, documents that the facility reported an altercation between R4 and R5. The FRI documents that R4 was noted with a laceration to his head. R4 stated that he had his remote control in his hand and threw it towards R5. R5 returned to the facility from the hospital, and review of hospital documentation indicated that a CT (computed tomography) scan identified a closed nasal bone fracture. On 06/12/2026 at 3:16 PM, R5 was lying on his bed, alert, responsive, and in no apparent distress. R5 stated (R5) went into someone's washroom, and he (R4) told me I couldn't use it. I asked him why not. R5 stated that they kept talking, and he (R4) hit me first with the television remote. I got mad and I (R5) hit him with my fist. I (R5) hit him on the head. Then somebody came and asked what we were doing. I (R5) went to my room. R5 stated that he went to use R4's bathroom because someone was using R5's bathroom. R5 stated I had to go bad, and it was next door's bathroom. R5 denied that he had a broken nose prior to the altercation. R5 stated that they told him at the hospital that he had a broken nose. R5 stated that R4 kept hitting R5 more than once with an item. R5 stated that it hurt R5's head when R4 hit R5.On 6/12/2026 at 6:17 PM, V1 (Administrator) stated I've been at the facility since September 2025. I am the abuse coordinator. R5 stated he had to use the restroom and that he went to the room of R4 because R5 was trying to get to the bathroom in a hurry. R4 was telling R5 not to use their restroom in their room. R4 and R5 got into a disagreement. V20 (Certified Nursing Assistant/CNA) heard R4 and R5 going back and forth. V20 entered the room to separate R4 and R5. V20 got the nurse to come to the room. R5 grabbed a water pitcher from R4's table and was trying to swing. R4 was trying to block the swing. V19 (Licensed Practical Nurse/LPN) noted that R4 was bleeding from the left side of his head. The NP (Nurse Practitioner) ordered for R4 to go out 911. R5 was sent out for psych evaluation. The hospital did not report the fracture to the facility. We found out from the paperwork. There were no witnesses in the room. Residents have the right to be free from abuse.On 6/15/2026 at 10:29 AM, V19 (LPN) stated she was the nurse for both R4 and R5 when the incident happened. V19 stated she was at the nursing station. The CNA, V19 does not remember which CNA, yelled out for the nurse. V19 went to R4's room. V19 saw R4 in the wheelchair and R5 was standing. The CNA was between R4 and R5. The CNA did not know what happened between R4 and R5. I asked R5 to leave the room. I asked R4 what happened. R4 said R5 was trying to use R4's washroom and R4 said no. R4 was bleeding but I could not tell from where because of R4's hair. The blood was on the left side of R4's forehead. The blood was not dry; it was new blood. I got a verbal order from the NP (Nurse Practitioner) to send R4 out 911. I assessed R5. R5 was upset. R5 had a small amount of blood in his nose but it was not actively leaking. The blood was new because it was not there prior when I saw R5. I could not get R5 to stay in his room, separated from other residents, which is protocol. I got orders to send R5 out for a psychiatric evaluation. On 06/15/2026 at 8:33 AM and at 11:48 AM, attempted to outreach V20 (Certified Nursing Assistant), the CNA who heard the altercation between R4 and R5, with no answer. Left a voicemail message. On 06/15/2026 at 3:15 PM, V36 (R4's and R5's Nurse Practitioner) asked if they could return the call. No call returned prior to the survey exit. R5's face sheet documents that R5's diagnoses include but not limited to: cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebrovascular disease affecting unspecified side. R5's MDS/Minimum Data Set, dated [DATE], documents that R5 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R5 has intact cognition function (with no or very little impairment). R5's progress notes dated 2/27/2026, by V19 (Licensed Practical Nurse) documents R5 was noted to have blood in the left nostril. R5 was sent to the hospital for psych eval. Hospital records dated 2/27/2026, documents R5 sustained nasal bone fracture. Abuse care plan reads R5 was involved in a resident-to-resident altercation. R4's face sheet documents R4's diagnoses includes but not limited to: discitis, unspecified, thoracic region, chronic obstructive pulmonary disease, type 2 diabetes mellitus, psychoactive substance abuse. R4's MDS/Minimum Data Set, dated [DATE], documents that R4 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R4 has intact cognition function (with no or very little impairment). R4's progress notes dated 2/27/2026, by V19 (LPN) documents R4 had active bleeding on the left side of the head following altercation with another resident. R4 was sent to the hospital via 911. R4's abuse risk care plan documents that resident (R4) is a victim of resident-to-resident altercation dated 2/27/2026. Hospital record documents that R4 was evaluated for an injury of the head. Facility document dated 10-2022 documents in part, abuse policy and prevention program. 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. 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 provide one to one (1:1) feeding assistance for one resident (R1) in the sample of 3 residents reviewed for feeding assistance.Findings include:R1's admission record documents, in part, diagnoses of dysphagia, spondylosis with myelopathy cervical region, type 2 diabetes mellitus, overactive bladder, hypertension, hypotension, anemia, neurogenic bladder, generalized anxiety disorder, bradycardia, retention of urine, localized edema, muscle spasm, and fusion of spine, cervical region.R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact. R1's Functional Abilities for eating (The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) is coded as Dependent--Helper does all of the effort. Resident does none of the effort to complete the activity.Facility list of 1:1 feed residents (undated) includes R1.On 1/26/2026 at 12:03 PM, R1 observed lying in bed with bilateral hand splints in place. R1 stated that R1 received full care from the staff. R1 stated that R1's arms move just a little, but R1 cannot use them to eat or drink by R1's self. R1 stated that on 1/24/2026, R1 received activities of daily living (ADL) bathing and incontinence care from V5 (Certified Nursing Assistant/CNA) around 11:00 AM. R1 stated that R1 then fell asleep and woke up at 2:00 PM. R1 stated that R1 did not see a lunch tray in the room, and R1 was feeling hungry. R1 stated that no staff member offered R1 a lunch meal on 1/24/2026, and staff did feed R1 the lunch meal on 1/24/2026. R1 stated that no staff asked R1 if R1 wanted to eat or not or woke R1 up to feed R1. R1 stated, At least let me (R1) see what is being served. I have the right to see the food if I want it or if I don't want it.On 1/26/2026 at 2:34 PM, V5 (CNA) stated that V5 was R1's primary CNA on the day shift on R1's floor on 1/24/2026. V5 confirmed that V5 provided ADL care for R1 around 11:00 AM that day because R1 stated that V19 (R1's Family Member 1) may visit in the afternoon. V5 stated, I (V5) did not bring (R2) a tray on Saturday (1/24/2026). I don't know who did. V5 stated that the meal trays are prepared by dietary in the dining room, and the trays are placed on the cart where then CNAs deliver the trays in the carts down to the residents rooms. V5 stated that there is no specific CNA assignment for passing the trays on the cart to the residents who are eating in their rooms, including R1. V5 stated that which CNA is available will deliver the trays on the cart to residents in their rooms. V5 stated that on 1/24/2026, V5 checked on R1 in afternoon on 1/24/2026, and R1 was sleeping with V5 not seeing a lunch tray in R1's room. V5 stated, No, I did not feed her lunch. (R1) is a feeder so whoever is assigned to do the feeding is responsible for feeding (R1). This surveyor viewed the Daily Assignment Sheet for day shift, 1/24/2026, and V5 said that R1 was assigned to V8 as a 1:1 feeder resident under special assignments.On 1/26/2026 at 3:00 PM, V20 (R1's Family Member 2) stated that R1 called V20 around 3 PM on 1/24/26 and told V20 that R1 was hungry and was asking V20 to bring R1 some food. V20 stated that R1 informed V20 that R1 wasn't given food for lunch; and that no one woke R1 up to offer lunch or to feed R1 lunch. On 1/26/2026 at 3:10 PM, R4 stated that R4 did visit R1 on 1/24/2026 around 2-3:00 PM. R4 stated that R4 helped R1 call V20 because the staff did not give R1 a lunch tray.Facility Daily Assignment Sheet, dated 1/24/2026 for the day shift (7:00 am to 3:00 pm) for R1's floor, documents, in part, 2 nurses working (V25 Registered Nurse/RN and V26 RN) and 7 CNAs (V5, V8, V14, V15, V21, V24, and V29). V5 is assigned as R1's primary CNA, and V8 is assigned under special assignment as R1's 1:1 feed.On 1/27/2026 at 11:31 AM, V8 (CNA) stated that V8 worked on the day shift on R1's floor on 1/24/2026. V8 stated that V8 normally has the same set of residents assigned to V8, which normally includes R1, but the resident assignments depend on how many CNAs are staffed and working. V8 stated that on 1/24/2026 day shift, the floor had more CNAs working (7), so V8 was not assigned to R1 as the primary CNA. V8 stated that R1 is alert and oriented and will tell staff what she wants. V8 stated that V8 performs all care for R1, and that R1's arms and hands are contracted. V8 stated that when it's mealtime and if R1 is asleep (which can be common), V8 will rub R1's shoulder and wake R1 up then offer R1 the meal tray. V8 stated that sometimes R1 will only want some of the food, which R1 will feed to R1. V8 stated that even when R1's family brings in outside food for R1, V8 will present the tray to R1 and show it to R1. V8 stated that on 1/24/2026, V8 did not see R1. When asked if V8 provide lunch to R1 on 1/24/26, V8 stated, No, I (V8) did not feed (R1). This surveyor showed V8 the Daily Assignment Sheet (day shift 1/24/2026) with R1 assigned to V8 as special assignment for 1:1 feeding. V8 stated, That was a mistake. V8 stated that on 1/24/2026 at the beginning of the day shift, V8 told V21 (CNA) who the CNA was who made the schedule that morning to not put R1 on V8's assigned schedule as a 1:1 feeder resident when R1 wasn't assigned to V9. V8 stated that V8 told V21, You (V21) have to tell that CNA (V5 who is assigned to R1) that (V5) has to feed (R1).On 1/27/2026 at 2:05 PM, V15 (CNA) stated that V15 worked the day shift on R1's floor on 1/24/2026, and R1 is a 1:1 feed resident. V15 stated that residents who are 1:1 feeds that eat in their rooms, the tray is prepared in the dining room, then placed on a cart, and delivered to the room, usually by the CNA who will be feeding the resident. V15 stated that for the breakfast meal on 1/24/2026, V15 could see R1's tray on cart and knew that R1 needed to be fed one to one. V15 stated that V15 told V8 who was assigned as R1's primary CNA that V15 was finished performing V15's assigned 1:1 feed resident and is available to feed R1. V15 stated that V15 brought R1's breakfast tray in the room on 1/24/2026 and performed R1's 1:1 feed. V15 stated that V15 did not feed R1 the lunch tray or bring in lunch tray to R1 on 1/24/2026.On 1/27/2026 at 2:36 PM, V14 (CNA) stated that V14 worked the day shift on R1's floor on 1/24/2026, and R1 is a 1:1 feed resident. V14 stated that V14 has never performed a 1:1 feed for R1. V14 stated that V14 did not bring R1 the lunch tray nor feed R1 lunch on 1/24/2026.On 1/28/2026 at 11:09 AM, V21 (CNA) stated that V21 worked the day shift on R1's floor on 1/24/2026, and R1 is a 1:1 feed resident. V21 stated that on 1/24/2026 at the beginning of the day shift, V21 was asked by the nurse to make the CNA assignments when all staff were huddled at the nurse's station. V21 stated that V21 divides up the CNAs based on the number of CNAs working, and all 7 CNAs (V21 confirmed by viewing all 7 CNAs on the Daily Assignment Sheet) were informed of their resident assignments and 1:1 feeds. V21 stated that the special assignments on the Daily Nursing Assignment are the 1:1 feeds, and the 1:1 feed residents are divided up as evenly as possible with the CNAs working to distribute the workload during mealtimes. V21 stated that V8 was assigned on 1/24/2026 day shift to 1:1 feed for R1 and was responsible for feeding R1. V21 stated that V8 did not talk to V21 about changing the 1:1 feeding assignment. V21 stated that V21 did not bring R1 the lunch meal tray or feed R1 the lunch meal on 1/24/2026.On 1/28/2026 at 11:41 AM, V22 (Restorative Nursing Aide/RNA) stated that V22 worked on 1/24/2026 and was assigned to 2 floors in the facility, one of which was R1's floor. V22 stated that RNAs help the CNAs with 1:1 feedings if needed. V22 stated that V22 was not present on R1's floor during the lunch meal service on 1/24/2026. V22 stated that V22 did not bring R1 a lunch tray or perform 1:1 feed for R1's lunch on 1/24/2026. On 1/28/2026 at 1:51 PM, V24 (CNA) stated that V24 worked the day shift on R1's floor on 1/24/2026, and R1 is a 1:1 feed resident. V24 stated that V24 has never performed a 1:1 feed for R1. V24 stated that V24 did not bring R1 the lunch tray nor feed R1 lunch on 1/24/2026.On 1/28/2026 at 2:09 PM, V25 (RN) stated that V25 worked the day shift on R1's floor on 1/24/2026, and R1 is a 1:1 feed resident. V25 stated that V25 administered medications and fluids to R1 because R1 cannot eat or drink by R1's self. V25 stated that the assigned CNA to R1 is to feed R1 1:1 for meals and it's indicated as a special assignment on the Daily Assignment Sheet. V25 stated that V25 never has performed 1:1 feeding for R1. When asked about R1 being brought a lunch tray on 1/24/2026, V25 stated that V25 assisted with making the lunch trays, and V25 wasn't aware that R1 didn't get a lunch tray on 1/24/2026. V25 stated that V25 did not feed R1 on 1/24/2026. On 1/28/2026 at 2:25 PM, V9 (RNA) confirmed that V9 was not working in the facility on 1/24/2026, and V22 is V9's replacement when V9 is not working.On 1/28/2026 at 2:44 PM, V2 (Director of Nursing/DON) stated that R1 needs to be fed R1's meals by staff and cannot feed R1's self. V2 stated that if R1 is sleeping when the meal tray is brought into R1's room, V2 expects the staff to awaken R1 so R1 can tell the staff if R1 wants to eat now or wait to eat. V2 stated that CNAs, RNAs, and nurses can feed R1. V2 stated that the staff are to chart in the eating task with what assistance was provided during eating and expects that R1 is fed one to one. V2 stated that V2 was not working in the facility on 1/24/2026.On 1/28/2026 at 2:49 PM, V26 (RN) stated that V26 worked on 1/26/2026 for the day shift and was not assigned to R1. V26 stated that V26 had a CNA (V21) make the CNA assignments at the beginning of the 1/24/2026 at the nurse's station, and V26 reviews the assignment so V26 knows which of V26's assigned 1:1 feed residents are assigned to which CNA. V26 stated that V26 does help with 1:1 feeding of resident on V26's assignment. V26 stated that R1 is a 1:1 feed, that V26 has never performed a 1:1 feeding for R1 (not on 1/24/2026), and V26 has not brought a meal tray into R1's room.On 1/29/2026 at 2:03 PM, V29 (CNA) stated that V29 worked the day shift on R1's floor on 1/24/2026, and R1 is a 1:1 feed resident. V29 stated that V29 did not feed R1 the lunch tray or bring in lunch tray to R1 on 1/24/2026.R1's Care Plan, dated 1/29/2024, documents, in part, a focus of R1 has potential for nutritional problem related to medical diagnoses with intervention listed as to provide and serve diet as ordered.R1's Care Plan, dated 11/4/2024, documents, in part, a focus of R1 requires assist with daily care needs related to paraplegia with intervention of assist resident with ADLs.R1's ADL Task charting for Eating: Self Performance, V5 (CNA) documents, in part, on 1/24/2026 at 2:18 PM, that supervision-oversight, encouragement or cueing was performed with no check mark for resident refused.R1's ADL Task charting for Eating: Support Provided, V5 (CNA) documents, in part, on 1/24/2026 at 2:18 PM, that setup help only was provided with no check mark for one person physical assist or for resident refused.R1's Lunch Meat Ticket, dated 1/24/2026, shows that R1's diet order is low concentrated sweets, no added salt diet with thin liquids, and the 1/24/2026 lunch meal was baked turkey with gravy, half baked potato with sour cream and margarine, winter blend vegetables, [NAME] fruit crumble and diet beverage.Facility policy titled Feeding Assistance dated May 2025 documents, in part, General: To attempt to provide adequate nutrition to a resident who was unable to feed themselves by hand feeding the resident. Responsible Party: RN, LPN, Speech Therapy, Certified Nursing Assistants. Guideline: 1. Residents who are unable to feed themselves are encouraged, instructed, assisted and or fed by a qualified staff member . 3. Position resident in proper body alignment for eating. 4. Qualified staff members must be sitting not standing while feeding . 8. Feed resident slowly, one bite at a time, allowing them to thoroughly chew and swallow first bite before second is given . 10. Alternate foods, allowing resident to decide if there is something they do not want. 11. If resident is not eating, offer alternatives to the meal . 17. Notify charge nurse and healthcare provider if resident is refusing meals, substitutes and/or fluids.Facility policy titled Tray Pass Policy dated May 2025 documents, in part, Policy: It is the policy of this facility to serve meals that meet the nutritional needs of the residents. Policy Explanation and Compliance Guidelines: Diets should be served in accordance with the physician's order.Job description titled Registered Nurse (undated) documents, in part, Basic Function: Under the direction of the physician, (RN) is responsible for total nursing care to all residents on the 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: 1. Participate in the development and implementation of an individualized patient care plan for the resident with allied health team members. 2. Implement total nursing care through assessment, planning and evaluation . 4. Assist in maintaining a physical, social and psychological environment, which is conducive to the overall welfare of the resident . 7. Assign nursing care duties to team members and ensure such duties are completed in an appropriate manner . 10. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in the facility's policies and procedures . 12. Adhere to all facility and department safety policies and procedures.Facility job description titled Certified Nurses Aide (undated) documents, in part, 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: . 20. Prepare resident for meals, assist serving food trays or feed as necessary and record/or report residents intake or acceptance of food . 25. Follow established safety precautions in performance of all duties . 29. Review care plans daily to ensure provision of appropriate care . 31. Treat all residents, families and visitors with kindness, dignity and respect. 32. Perform all assigned tasks in accordance with policy and procedure and instruction of your supervisor. 33. Create and maintain an atmosphere of warmth, personal interest, and positive regard as well as a calm environment throughout the unit and shift. 34. Adhere to all facility and department policies and procedures.

Based on observation, interview and record review, the facility failed to provide a home-like environment for five (R1, R4, R6, R7) of eight residents residing in the facility reviewed for physical environment. Findings include:R1 is a [AGE] year-old male, admitted to the facility 11/29/2024 with diagnoses not limited to Type 2 Diabetes Mellitus Without Complications, Essential (Primary) Hypertension, Cerebral Infarction, Unspecified, Major Depressive Disorder, Single Episode, Unspecified, Alcohol Abuse, Uncomplicated, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Other Speech and Language Deficits Following Cerebral Infarction, Restlessness and Agitation, Hyperlipidemia, Unspecified, Personal History of Traumatic Brain Injury, Unspecified Mood [Affective] Disorder. R1's BIMS Summary Score dated 12/19/2025 shows 15, indicating cognitively intact. R4 is a [AGE] year-old male, admitted to the facility 7/09/2024 with diagnoses not limited to a Essential (Primary) Hypertension, Acute Diastolic (Congestive) Heart Failure, Syncope and Collapse, Alcohol Abuse, Uncomplicated, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Anemia, Unspecified, Other Seizures, Weakness, Low Back Pain, Unspecified, Unspecified Fall, Subsequent Encounter, Ataxia, Unspecified, Alcoholic Polyneuropathy. R4's BIMS Summary Score dated 11/06/2025 shows 15, indicating cognitively intact. R6 is a [AGE] year-old male, admitted to the facility 8/12/2025 with diagnoses not limited to 57 Opioid Dependence, Uncomplicated, Ataxia Following Other Cerebrovascular Disease, Unspecified Hydronephrosis, Hematuria, Unspecified, Hyperlipidemia, Unspecified, Iron Deficiency Anemia, Unspecified, Antiphospholipid Syndrome, Unspecified Severe Protein-Calorie Malnutrition, Acute Kidney Failure, Unspecified, Other Nonspecific Abnormal Finding Of Lung Field, Vitamin D Deficiency, Unspecified, Other Obstructive and Reflux Uropathy, Cerebral Infarction, Unspecified, Hypomagnesemia, Other Disorders of Phosphorus Metabolism, Essential (Primary) Hypertension, Insomnia, Unspecified. R6's BIMS Summary Score dated 11/06/2025 shows 15, indicating cognitively intact. R7 is a -year-old male, admitted to the facility 10/4/2025 with diagnoses not limited to Hallucinations, Unspecified, Abnormal Weight Loss, Chronic Obstructive Pulmonary Disease With (Acute) Lower Respiratory Infection, Unspecified Psychosis Not Due to A Substance Or Known Physiological Condition, Type 2 Diabetes Mellitus Without Complications, Bipolar Disorder, Unspecified, Essential (Primary) Hypertension, Schizophrenia, Unspecified, Pain In Unspecified Joint, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Acute Cough. R7's BIMS Summary Score dated 12/09/2025 shows 15, indicating cognitively intact. On 1/9/2026 at 11:41am tour of facility Surveyor observed privacy curtains for R1 and R4, with large stains and dried debris. R1 and R4 stated, the curtains need to be changed, and they do not like how the curtains look. R1 stated, the curtains have been like this. Observed stained ceiling tile with exposed pipes and light fixture in bathroom with missing cover. R1 stated, that has been like that, I do not know why. On 1/9/2026 at 11:59am observed R4 ambulated independently, dressed, groomed, wearing shoes and able to make needs known. R4 stated, these curtains have been dirty, and they have all those stains, and no one has changed them. Look, the light over my bed and in the bathroom are missing covers, they have been like that. On 1/9/2026 at 1:00pm V6 (Certified Nursing Assistant/CNA) stated housekeeping makes sure curtains are clean and the room is clean. On 1/9/2026 at 1:03pm V7 (Housekeeper) stated, rooms are cleaned every day. Maintenance or floor techs change curtains in the room, but I'm not sure how often. I am not sure if I should tell somebody or not that the curtains need to be changed. V7 stated, R1, R4 and R9 curtains need to be changed, there is a lot of stuff and stains on them. On 1/9/2026 at 1:19pm V9 (Assistant Director of Nursing/ADON) and Surveyor entered R1's room. V9 stated, all the curtains are dirty. Housekeeping is supposed to make sure curtains are clean. Housekeepers are in and out of room every day. Dirty curtains should get changed every day and anyone can alert housekeeping. R4's light and bathroom light should have a cover. On 1/9/2026 at 1:24pm V10 (Maintenance Director) stated, rooms are checked every day by the housekeeper and CNA. If they see something that does not work, or curtains are dirty they are to put it in the system, and it alerts maintenance. On 1/9/2026 at 1:35pm V11 (Floor Technician) and V3 (Assistant Administrator) entered R1and R4's room with surveyor. V3 stated, curtains should not be stained. We change curtains as needed. Rooms also get a deep cleaning every month and curtains are changed then too. We will get covers for lights. Housekeeping should notify director if curtains need to be changed. Tour of R6 and R7's room. Ceiling tiles with dried debris and privacy curtains hanging off hooks. R7 stated, they have been like that and stains on ceiling have been there. V3 stated, the privacy curtains should be completely on the hooks and there should not be stains on the ceiling tiles or debris. This will be corrected. On 1/9/2026 at 3:34pm V1 (Administrator) stated Maintenance Director should oversee any room repairs or equipment repairs. Maintenance is responsible for ceiling tiles being in place and clean. Privacy curtains being clean, in good repair and hanging correctly was the housekeeping director but the housekeeping director's last day was Friday, so assistant administrator is currently responsible. We have morning meetings, and I attend most of the time. We talk about call lights not working and light covers needing to be replaced and curtains needing to be replaced. Curtains should be checked weekly or if housekeeping sees they need repair should be taken down. Deep cleans (items removed from room, dusted, walls cleaned, windows cleaned mattress inspected and cleaned and floors cleaned with top scrubber) are done monthly in all rooms. Resident Rights dated 11/18 documents in part: Your facility must be safe, clean, comfortable and homelike. Your rights to dignity and respect You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Facility Policy Preventive Maintenance Policy rev. 5/2025 documents in part: GENERAL: To provide the staff with guidance on preventive maintenance within the facility.Proof of inspections will be recorded in the electronic system or on paper tracker provided.RESPONSIBLE PARTY: Maintenance Department POLICY: Preventive Maintenance Plan INSPECTIONS: 7. Monthly surveillance of all resident rooms for any repairs needed and proper operation of all equipment. If a resident has personal equipment, it should be maintained according to manufacturer's guidelines. Maintenance Director Job Description documents in part: SUMMARY: The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. ESSENTIAL DUTIES AND RESPONSIBILITIES: Assume the administrative authority, responsibility, and accountability of directing the Maintenance Department. Assist in establishing a preventive maintenance program. Repair facility /resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Also ensure that services provided by outside vendors are properly completed/supervised in accordance with contracts/work orders. Keep abreast of economic conditions/situations and recommend to the Administrator adjustments in maintenance services that assure the continued ability to provide a clean, safe and comfortable environment. Ensure that supplies, equipment, etc., are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator. Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. QUALIFICATIONS: Must maintain the care and use of supplies, equipment, etc., and maintain the appearance of maintenance areas; must perform regular inspections of resident rooms/units for order, safety, and proper performance of equipment.

Based on observation, interview and record review, the facility failed to ensure three (R1, R2, R5) of eight residents' accommodation of needs were provided for with working call lights. Findings include: 1.) R5 is a [AGE] year-old female, admitted to the facility 12/29/2025 with diagnoses not limited to Displaced Bicondylar Fracture Of Right Tibia, Cognitive Communication Deficit, Lack Of Coordination, Abnormal Posture, Asthma, Chronic Obstructive Pulmonary Disease, Moderate Protein-Calorie Malnutrition, Obesity, Anxiety Disorder, Opioid Dependence, Pressure-Induced Deep Tissue Damage Of Right Heel, Fracture Of Right Lower Leg, Fracture Of Left Lower Leg, Constipation, Tobacco Use, Insomnia, Hirsutism, Depression. R5's BIMS Summary Score dated 1/05/2026 shows 15, indicating cognitively intact. R5's room census documents she was admitted to the current room on 12/29/25. R5's care plan documents in part:R5 is at risk for falls r/t (related to) Functional Deficits, date Initiated: 12/29/2025. Intervention: Promote placement of call light within reach and assess resident's ability to use, date Initiated: 12/29/2025. ADL (activities of daily living): R5requires assist with daily care needs r/t Cognitive and functional limitation, date Initiated: 12/29/2025. Intervention: Call light within reach, date Initiated: 12/29/2025. R5 is incontinent with bowel and bladder, date Initiated: 12/29/2025. Intervention: Place call light within easy reach, date Initiated: 12/29/2025. On 1/9/2026 at 1:59pm observation by surveyor observed R5 lying in bed alert, oriented and groom wearing a gown. R5's legs were wrapped with gauze to help prevent heel breakdown. R5 stated, her call light has not worked since she was admitted (12/29/2025) to current room, and she is unable to get out of bed or do anything without the assistance of staff. R5 stated, she is totally dependent on staff for help and when R2 (roommate) is in the room she will help me, but if R2 is not in the room, I just have to wait. There are times when she is not here and panic kicks in, I become scared that I will need help, and no one will come and when someone finally comes it will be too late. I am bedridden and cannot put weight on my legs. I am getting physical therapy, and I think it is helping. Right now, I need help to go to the bathroom. R5's pressed call light and call light did not light up at panel, did not light up outside of room nor was there any audible sound. R2 and R5 were both in room and R5 stated, if I need something, I have to ask R2 to get a nurse. R2 stated, if R5 needs anything, I will either press my call light for her or walk down to the nurses' station to let them know R5 needs help. R2 and R5's bathroom call light was without a call panel or pull switch. On 1/9/2026 at 2:05pm V2 (Director of Nursing/DON) was present and stated, I see the panel is not lit, there is no outside light that comes on when R5 presses call light. R5 is dependent on staff and has to use call light. Staff are supposed to round every 2 hours between the nurses and CNAs. If her call light was not working, she should have gotten a bell. I see it with my own eyes (referring to R5' call light not working). Clinical staff do not check call light. The call light should be working. We have bells that we give the resident in cases like this. On 1/9/2026 at 2:11pm R5 stated, she needs to be changed and mine (referring to the call light) is not working. V2 and V9 (Assistant Director of Nursing) were in room and R5 was given call light to use from empty bed next to R5. R5 told V2 and V9 that her call light has not worked for over 2 weeks, since she was put in current room. On 1/9/2026 at 2:13pm as V2 was walking out of room, V2 stated, we saw it (referring to call light). On 1/9/2026 at 2:14pm V12 (Certified Nursing Assistant/CNA), came into R5's room and stated, we round every 2 hours and every hour. I did not know call light was not working. Residents are told to use call light if they have pain, need water, want to get out of bed, if they need help with anything the resident should use the call light. R5 cannot get up on her own, she is dependent on us, and we use a slider board to get her up. On 1/9/2026 at 2:33pm V10 (Maintenance Director) stated, R5's call light is not working, and this call light (R5's) has been a constant issue. I believe in the morning the CNAs check rooms and should be checking to see if call light is working. If the call light is not working, put in (work order). For some call lights, I am waiting for new materials to fix call lights. I will let management know what we have and what we are waiting for. In morning meetings management knew the call light was not working. All directors attend and all lead management and nurses. Seems to be a communication thing with everybody else. They have known the call light has not been working and someone should have given R5 some type of communication device. Surveyor requested call light monthly log. 2.) R2 is a [AGE] year-old female, readmitted to the facility 4/18/2025 with diagnoses not limited to Hereditary And Idiopathic Neuropathy, Protein-Calorie Malnutrition, Hypokalemia, Localized Swelling, Mass And Lump, Lower Limb, Bilateral , Peripheral Vascular Disease, Bipolar Disorder, Major Depressive Disorder, Leiomyoma Of Uterus, Acute Pancreatitis, Iron Deficiency Anemia, Post-Traumatic Stress Disorder, Panic Disorder [Episodic Paroxysmal Anxiety], Anxiety Disorder. R2's BIMS Summary Score dated 10/17/2025 shows 15, indicating cognitively intact. On 1/9/2026 at 1:44pm R2 and R4 sitting in resident activity room. R2 dressed, groomed, alert and oriented and ambulating with walker. R2 stated, she feels the rules change. R2 stated, staff do not answer call lights and the call light in her room does not work, specifically R5's call light. R2 stated, she has to push her call light or go and get help when R5 needs help. R2 showed surveyor R2 and R5's bathroom which does not have a working call light. R2 pressed her call light, and it worked, but when she asked R5 to press her call light, it did not work. R2's care plan documents in part:Focus ADL: R2 requires assist with daily care needs r/t Cognitive deficit Date Initiated: 10/14/2025.Goal: R2 will maintain current daily care abilities with assistance from the staff without showing a decline throughout next review. Date Initiated: 10/14/2025. Intervention: Call light within reach Date Initiated: 04/26/2025. On 1/10/2026 at 10:13am R2 stated, bathroom still does not have a call light. If I needed help in the bathroom, I would not have a call light to pull. 3.) R1 is a [AGE] year-old male, admitted to the facility 11/29/2024 with diagnoses not limited to Type 2 Diabetes Mellitus Without Complications, Essential (Primary) Hypertension, Cerebral Infarction, Unspecified, Major Depressive Disorder, Single Episode, Unspecified, Alcohol Abuse, Uncomplicated, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Other Speech and Language Deficits Following Cerebral Infarction, Restlessness and Agitation, Hyperlipidemia, Unspecified, Personal History of Traumatic Brain Injury, Unspecified Mood [Affective] Disorder. R1's BIMS Summary Score dated 12/19/2025 shows 15, indicating cognitively intact. R1's care plan documents in part:Focus: R1 is incontinent of bowel and bladder. Date Initiated: 09/22/2025.Goal: Will maintain dignity by being kept clean, dry and odor free through stay in the facility. Date Initiated: 09/22/2025.Intervention: Place call light within easy reach. Date Initiated: 06/05/2025. Focus: FALL: R1 is at high risk for falls r/t Functional deficit, Cognitive deficit Date Initiated: 09/22/2025.Goal: Will remain free of falls causing hospitalizations r/t injury thru next review. Date Initiated: 09/22/2025.Intervention: Educate resident on the importance of complying with safety measures. Using call light for assistance with ADL care. Document residents understanding of education and instances of non-compliance Date Initiated: 07/05/2025. On 1/9/2026 at 11:41am R1 sitting in dining room dressed, groomed and wearing shoes and glasses. R1 alert and oriented and able to make needs known and answer questions. R1 stated he is okay and V14 (Social Services Manager/DUET) is great and helps him sign up for SSI. R1 stated his TV is working. He is eating and gets double portions. He is gaining weight. He has gotten therapy and gets restorative care. He exercises and goes to activities. R1stated, there are lots of activities at the facility, the ice machine works and nurses are taking care of him and making sure he takes his medicine. R1 stated, when I push the call light it does not come one. If I need something, my roommate R4 will get someone for me. My laundry is done, and I put my name and room number, so they know it is mine. My social worker is trying to help me find an apartment. R1 is observed able to ambulate with and without walker, tends to drag right leg. TV and TV remote working. Room without clutter. Surveyor asked R1 to push call light. Call light did not lite at wall panel and did not come on nor did light come on above room and no audible sound. R1 pushed call button again with same results. R1 stated, see call light does not work. At 12:25pm R1's call light was not answered. V4 (Licensed Practical Nurse) entered R1's room to give medication and did not acknowledge R1's call light due to call light not working. On 1/9/2026 at 12:45m V4 (LPN) stated R1 gets upset when he does not get his way. Aides are supposed to make round every 2 hours to make sure residents are okay and they do not need anything. Call lights are used by the residents to get staff's attention so they can get assistance. If call lights do not work, they may not be able to get help. The call light is supposed to sound at the nurses' desk to alert staff that residents need help. The nurses and the CNAs are supposed to make sure the call light is working and if not working we are supposed to put in a work ticket and the call light is fixed stat. V4 pushed R1's call light and light did not work. V4 took call light out of outlet and put it back in a few times and then call light started to work. V4 stated, I am not sure why it did not come on, maybe it got snagged on something. CNAs are supposed to make sure call light is working and within reach of the resident. On 1/9/2026 at 1:19pm V9 (Assistant Director of Nursing) stated, call lights are checked every day to see if working. Anyone can check them. We make frequent rounds and make sure staff check residents. Residents have call lights so they can get help. Someone is always doing rounds. On 1/9/2026 at 1:24pm V10 stated, rooms are checked every day by the housekeeper and CNA. If they see something that does not work, they are to put it in the system, and it alerts maintenance. V10 stated, every bed should have a functioning call light. Call lights are checked every month. There were issues with call lights prior to me. I am responsible now. V10 stated, call light for R1 was not reported that it was not working. On 1/10/2026 V2 stated, if equipment is broken resident will tell staff and staff will put in (work order). We have a reporting app to communicate broken equipment. We all should make sure call lights are working. Residents should tell us, but they may not know the call light is not working. Maintenance will do rounds as well. Call lights are being fixed as we speak. Maintenance will fix themselves or call a vendor is unable to fix. Facility Policy Preventive Maintenance Policy rev. 5/2025 documents in part: GENERAL: To provide the staff with guidance on preventive maintenance within the facility.Proof of inspections will be recorded in the electronic system or on paper tracker provided.RESPONSIBLE PARTY: Maintenance Department POLICY: Preventive Maintenance Plan INSPECTIONS: 7. Monthly surveillance of all resident rooms for any repairs needed and proper operation of all equipment. If a resident has personal equipment, it should be maintained according to manufacturer's guidelines. Facility Policy Call Light Response rev. 5/1/2025 documents in part: General: To provide the staff with guidance on responding to residents' requests and needs. Responsible Party: IDTProtocol: 5. Report all defective call lights to the nurse supervisor or maintenance director promptly.6. Answer the patient or resident's call as soon as possible. Maintenance Director Job Description documents in part: SUMMARY: The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. ESSENTIAL DUTIES AND RESPONSIBILITIES: Assume the administrative authority, responsibility, and accountability of directing the Maintenance Department. Assist in establishing a preventive maintenance program. Repair facility /resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Also ensure that services provided by outside vendors are properly completed/supervised in accordance with contracts/work orders. Keep abreast of economic conditions/situations and recommend to the Administrator adjustments in maintenance services that assure the continued ability to provide a clean, safe and comfortable environment. Ensure that supplies, equipment, etc., are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator. Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. QUALIFICATIONS: Must maintain the care and use of supplies, equipment, etc., and maintain the appearance of maintenance areas; must perform regular inspections of resident rooms/units for order, safety, and proper performance of equipment.

Based on observations and interviews, the facility failed to ensure that missing ceiling tiles were replaced in a hallway and residents' room. This failure has affected R3, R21, R22 and has the potential to affect 36 residents that reside in the first floor.Findings include:R3's diagnosis includes but not limited to: Unspecified dementia, cognitive communication deficit, major depressive disorder and essential hypertension.R21's diagnosis includes but not limited to: Unspecified dementia, adult failure to thrive, Lack of coordination, seizures and chronic viral hepatitis C.R22's diagnosis includes but not limited to: Dementia, Major depressive disorder, unspecified psychosis, essential hypertension, restless and agitation.On 9/23/25 at 11:08 am, V31 (R3's daughter) stated the following, His (R3's) room has missing ceiling tiles and it leaks.On 9/23/25 on 12:35 pm, Surveyor toured R3's room and noticed missing ceiling tile near R3's bed with debris on R3's floor, window seal and heater. At that time, V12 (Floor Technician) stated the following, This is part of the ceiling that's falling. They (administration) have been replacing ceiling tiles. There was a leakage here (R3's room) that has been repaired.On 9/24/25 at 10:15 am, Surveyor toured the facility with V20 (Maintenance Director) and noted the first-floor South hallway with missing ceiling tiles. At that time, Surveyor and V20 went to R3's room to assess the missing tiles near R3's bed.On 9/24/25 at 10:20 am, V20 stated the following, this is an old building, and we have had pipe issues. We have cast iron pipes with cracks in them so there has been leaks. The ac (air conditioning) unit above R3's room was leaking and came down through R3's ceiling. We have been working on the leakage since July. It has been one room after another. The leakage got under control around the 1st or 2nd week in September. It was a big job. We are replacing the ceiling tiles but need to ensure that the leakage has stopped first.On 9/29/25 at 11:50 am, V2 (Director of Nursing) stated the following, The missing ceiling tiles could make the residents feel unsafe and uncomfortable. Our maintenance department is working on replacing all tiles now.Facility Census dated 9/23/25 documents R3, R21 and R22 as roommates. Facility policy titled Safe and Homelike Environment documents, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment; Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on interview and record review the facility failed to assure that one resident (R7) with intact skin, received the necessary treatment and services to prevent the development pressure wounds. This failure resulted in R7's development and worsening of one pressure ulcer, requiring hospitalization for wound infection and surgical intervention of wound. The facility failed to ensure one resident's (R77) low air loss mattress was set at the correct settings. These failures affected two residents (R7 and R77) in a total sample size of 66. Findings include: 1.) On 08/24/2025 at 11:48am, R77 was lying on a low air loss mattress; setting was at 280lbs. This observation was pointed out to V12 (Registered Nurse/RN). V12 stated low air loss mattress should be set based on the resident's weight to promote healing. If the setting is higher than the resident’s weight, the surface will be hard, and it will impair with the healing process of the wound. On 08/26/2025 at 10:58am, V31 (Wound Care Nurse/Licensed Practical Nurse) stated the setting of the low air loss mattress should be based on the resident’s weight. If the weight falls between a range. Then the setting should be on the lower side of the range. The purpose of the low air loss mattress is for prevention and treatment of wounds. When the setting is above the weight of the resident, low air loss mattress creates a hard surface. A hard surface defeats the purpose of the low air loss mattress. R77’s (Active Order as of: 08/25/2025) Order Summary Report documented, in part “Diagnoses: (include but not limited to) quadriplegia, pressure ulcer of sacral region, pressure ulcer of left and right ankle, and pressure ulcer of other site. Order Summary: Skin. Pressure redistribution mattress. Order Date: 02/25/2025.” R77’s (printed: 08/24/2025) Weight and Vital summary documented, in part “08/05/2025: 116lbs.” R77’s (06/03/2025) Minimum Data Set documented, in part “Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06.” Indicating R77’s mental status as severely impaired. “Section M. Skin Conditions. M0150. Risk of Pressure Ulcers/Injuries: 1 – yes. M1200. Skin and Ulcer /Injury Treatments: B. Pressure reducing device for bed.” R77’s (05/06/2025) care plan documented, in part “risk for alteration in skin integrity. Interventions: Pressure redistribution mattress (LAL - Low air loss mattress). The Operation Manual documented, in part “The (Brand name) pump and overlay system is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive ulcer management program. Pressure-adjust Knob. Determine the patient’s weight and set the control know to that weight setting on the control unit. Operating Instruction. Step 6. Determine the patient’s weight and set the control knob to that weight setting on the control unit. 2.) R7’s medical diagnoses include but are not limited to type 2 diabetes mellitus, diastolic congestive heart failure, essential hypertension, benign neoplasm of right breast, acute kidney failure. R7’s Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 13, indicating R7’s cognition is intact. R7’s MDS dated [DATE] section M’s Determination of Pressure Ulcer/Injury Risk documents in part, “A. Resident has a pressure ulcer/injury, a scare over bony prominence, or a non-removable dressing/device…No….Is this resident at risk of developing pressure ulcers/injuries? .Yes” R7’s care plan with initiation date of 08/13/24 and revision date of 04/25/25 documents in part, “R7 has potential/ at risk for alteration in skin integrity due to risk factors associated with fragile skin, friction, immobility, decreased sensory awareness, presence of cardiac pacemaker, a PMHx (past medical history) that includes breast CA (cancer), hemiplegia, hemiparesis….Decrease/minimize risk for skin breakdown…skin checks by CNA (Certified Nursing Assistant) and floor nurse on bath/shower days paying particular attention to bony prominences, if impairment is present, follow appropriate skin impairment protocols…pressure redistribution mattress…remind/assist resident to reposition frequently.” On 08/24/25 at 12:01pm R7 stated that she did not have any wounds when she first arrived at the facility. R7 stated that she developed the wound on her sacrum area at the facility. R7 stated that the facility’s staff does not clean and reposition her as needed. On 08/25/25 at 12:15pm V31 (Wound Care Nurse/Licensed Practical Nurse) stated that R7 did not have a wound when R7 arrived at the facility. V31 stated that R7’s wound to R7’s sacral region was facility acquired on 05/29/25. R7’s progress note dated 05/29/25 documents in part, “R7 is chairfast, incontinent of B&B (bowel and bladder), and totally dependent for ADL’s (Activities of Daily Living). Staff alerted the wound care team about a skin alteration on the patient’s right buttock, assessment performed, patient noted with MASD (moisture associated skin dermatitis)…Wound care will continue to monitor and treat the wound.” Review of R7’s records show no documentation or indication that R7’s new wound to sacral area was unavoidable. R7’s wound assessment dated [DATE] documents in part, “Wound #1 Sacral is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 05/29/2025 and has received a status of Not Healed. Initial wound encounter measurements are 6.8cm length x 6.8cm (centimeter) width x 0.1 cm depth, with an area of 46.24 sq (square) cm and a volume of 4.624 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted…76-100% adherent, yellow slough.” On 08/26/25 at 2:55pm V2 (Director of Nursing/DON) stated that she assessed R7 the day R7 was sent to the hospital. V2 stated that R7 appeared lethargic and kept moaning “it hurt, it hurt”. V2 stated that she instructed the nurse to call the doctor for orders to send R7 out to the hospital. R7’s progress note dated 06/07/25 documents in part, “NP (nurse practitioner) making rounds with writer, observed resident lethargic with altered mental status, unstable vital signs…received order to send resident out 911.” R7’s hospital discharge records dated 06/16/25 documents in part, “patient was admitted for workup of AMS (altered mental status) and hypotension…Infectious workup remarkable for Bacteroides fragilis. CT (Computed Tomography) pelvis showing sacral decubitus ulcer with osseous destruction of the lower sacrum/coccyx suggestive of osteomyelitis. ID (Infectious Disease) consulted, recommended IV (Intravenous) CTX (Ceftriaxone) and Flagyl with plan to transition to Augmentin at discharge…Plastics was consulted due to concern for sacral wound being source of infection….Attempted minor debridement x2 but patient couldn’t tolerate due to pain.” R7’s progress note dated 06/17/25 documents in part, “R7 is chairfast, incontinent of bowel and bladder and requires extensive assistance transferring and completing ADL’s…wound to sacrum noted as unstageable with palpable bone.” R7’s wound assessment dated [DATE] documents in part, “clinical stage: unstageable…Measurements: size (cm) centimeters: 9.00x10.00x1.10 (L x W x D) Length times width times depth.” On 08/26/25 at 11:01am V31 (Wound Care Nurse/Licensed Practical Nurse) stated that she assessed R7’s wound upon readmission from the hospital. V31 stated that R7’s sacral wound had bone exposed. V31 stated that R7 was in a lot of pain with wound care dressing changes. V31 stated that R7 has always been compliant and has never refused care. R7’s MDS dated [DATE] section M’s Determination of Pressure Ulcer/Injury Risk documents in part, “A. Resident has a pressure ulcer/injury, a scare over bony prominence, or a non-removable dressing/device…Yes…F1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar…1.” Facility’s policy titled “Skin Care Prevention” dated 01/2025 documents in part, “General: All residents will receive appropriate care to decrease the risk of skin breakdown. Responsible Party: All Nursing Staff. Guideline: 1. The nursing department will review all new admissions/readmissions to put a plan in place for prevention based on the resident’s activity level, comorbidities, mental status, risk assessment and other pertinent information. 2. Dependent residents will be assessed during care for any changes in skin condition including redness and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. 3. All residents will be evaluated for changes in their skin condition… 5. All residents unable to reposition themselves will be repositioned as needed, based on a person-centered approach (minimum of every 2 hours).” Facility’s policy titled “Residents’ Rights” dated 11/2018 documents in part, “As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws…Your rights to dignity and respect…Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source…Your rights to safety…Your facility must provide services to keep your physical and mental health, at their highest practical levels.” Facility’s undated job description titled “Wound Care Nurse” documents in part, “Basic Function: The primary purpose of Wound Care Nurse is to provide for the day-to-day care needs of the residents in a Skilled Nursing Facility Environment…Essential Duties:…2. Must be able to identify changes in the resident condition and evaluate the resident care needs…17.Recognize significant changes in the condition of residents and take necessary action.”

Based on observation, interview, and record review, the facility failed to ensure staff monitor a resident's blood glucose per physician's order and failed to ensure staff document the result of the blood glucose accordingly. These failures affected 1 (R67) resident reviewed for professional standard of care in the total sample of 66 residents.Findings include:On 08/25/2025 at 8:57am, V22 (Licensed Practice Nurse) opened R67's electronic health record, the 7:30am glucose check was red and read as blood glucose before meals and before bedtime. V22 stated the facility serves breakfast on the first floor between 8:00am to 8:30am. On 08/25/2025 at 8:59am, V30 (Certified Nursing Assistant) was assisting R67 with feeding. R67's food tray was almost empty except for the cookie. V30 stated she (R67) still wants her cookie. On 08/25/2025 at 9:00am, V22 took R67's blood sugar; the glucometer announced the result as 309. On 08/25/2025 at 9:01am, V22 stated he was supposed to take her blood sugar before breakfast. Review of R67's (08/2025) MAR (Medication Administration Record documented, in part Blood glucose via Accuchecks before meal and at HS (hour of sleep) for diabetes. 08/25, 730(7:30am), 144. 1100 (11:00am), 131. Signed by V22 (Licensed Practice Nurse).On 08/26/2025 at 9:54am with V2 (Director of Nursing), V30 stated that she was present when V22 took her (R67)'s blood sugar on 08/25/2025 at around 9am and the result was at 300 or something.On 08/26/2025 at 11:41am, V2 (Director of Nursing) stated the expectation is to get the blood sugar before breakfast. At this time, this surveyor presented V2 the 1st floor mealtimes. V2 stated staff is expected to get the blood sugar between 7:00am and 7:15am to prevent from getting a false reading. I also expected the nurse (V22) to document the accurate result, if it is 200 then document 200. Documenting the correct result will determine the resident's endocrine system is working or an adjustment to her diabetes medications need to be done. On 08/27/2025 at 10:04am, V50 (Nurse Practitioner) stated blood glucose monitoring is usually ordered to make sure the resident's diabetes is well controlled. The staff are expected to document the correct result so when the physician reviews the results, the physician will be able to determine whether the medication is working appropriately or needs to be adjusted. The expectation is to follow the physician's order to get the blood sugar; it is usually before meals and before bedtime.R67's (Active Order as of: 08/25/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertension, chronic pain, and Type 2 Diabetes Mellitus. Order Summary: Blood Glucose via Accuchecks before meals and at bedtime for Diabetes. Order date: 07/30/2025.R67's (08/2025) MAR (Medication Administration Record documented, in part Blood glucose via Accuchecks before meal and at HS (hour of sleep) for diabetes. 08/25, 730(7:30am), 144. 1100 (11:00am), 131. Signed by V22 (Licensed Practice Nurse). The (undated) Mealtimes 1st Floor Dining Area documented in part Breakfast: 7:15am.The (01/01/2025) Blood Glucose Monitoring documented, in part Policy: It is the policy of this facility to perform blood glucose monitoring to a diabetic residents as per physician's order. Policy Explanation and Compliance Guidelines: 1. The facility will perform blood glucose monitoring per physician's orders. Procedure: 21. Document the procedure.

Based on observation, interview, and record review, the facility failed to ensure that medications are securely stored for one of one resident (R4) reviewed for medication storage in the sample of 20.Findings include:R4's face sheet documents resident is [AGE] year-old admitted to the facility on [DATE] with diagnoses including but to limited to: Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Pancreatitis, Chronic Kidney Disease, Essential Hypertension, and Atherosclerotic Heart Disease.R4's MDS (Minimum Data Set of 7/16/2025) documents a BIMS (Brief Interview for Mental Status) of 14 denoting R4 is cognitively intact.On 8/7/25 at 12:15 PM, R4 was observed ambulating with rollator down the hallway. R4 was holding souffle cup with seven tablets/capsules noted (one large white oval pill, three brown/clear capsules, one round white tablet, one oval light-yellow pill noted, one orange oval). R4 said, the nurse gave me these medications over an hour ago. Surveyor asked what they were. Surveyor wanted the names of the pills. R4 couldn't tell me. R4 left the pills with the surveyor, then left. 8/7/25 at 12:30 PM, V2 (Director of Nursing) said, staff should not leave medications at the bedside. Staff should explain what the medications are for and what the names of the medications are.8/8/25 at 11:27 AM, V3 (Registered Nurse) said, I prepared R4's medications and brought them to him. He asked what they were for. I had an emergency (a resident fell), and I ran out of R4's room to tend to the other resident. It slipped my mind that I needed to go back to R4. I never should leave medications at the bedside. I have to see the resident take the medication. Another resident could come along and take R4's medication.Medication Administration policy (Reviewed 1.2024) documents in part, 21. Remain with the resident to ensure that the resident swallows the medication.

Based on observation, interview, and record review, the facility failed to ensure call lights are answered in a timely manner for one resident (R4) in the sample of 8 residents reviewed for call lights. Findings include: R4's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, speech and language deficits following cerebral infarction, major depressive disorder. Minimum Data Set Section (MDS) section C (dated Jun 24, 2025) documents that R4 has an Interview for Mental Status (BIMS) score of 15, indicating that R4's cognition is intact.Minimum Data Set Section (MDS) section GG (dated Jun 24, 2025) documents that R4 utilizes a walker and requires supervision with toileting. Care plan (dated 12/10/2024) documents that R4 has a diagnosis of/history of cerebral vascular accident with right side residual effects. On 07/29/2025 at 11:02AM, surveyor was conducting an interview with R4. R4 verbalized that he needs staff assistance and R4 ignited the call light system at 11:05AM. Surveyor remained in the room the entire time R4 waited for staff to answer the call light. At 11:11AM, surveyor observed a staff member dressed in a purple scrub uniform (identified as a certified nursing assistant) walking past R4's room and not answering R4's call light. At 11:16AM, surveyor observed R4's call light being answered by V3 (Assistant Director of Nursing). V3 assisted R4 with his needs. R4 waited for a total of 11 minutes for his call light to be answered. On 07/29/2025 at 11:30am, R7 (R4's roommate) stated, R4 had a stroke, and he walks with a walker. R4 needs staff assistance when he goes to the restroom because he cannot put his pants on by himself. At times, R4 will put on the call light and staff will take hours to answer the call light. This happens a lot. I try to help R4 as much as I can. The nurses and certified nursing assistants bring their personal problems to work and talk about this personal issues instead of helping the residents. On 07/29/2025 at 2:57PM, V2 (Director of Nursing) stated, The expectation for call lights is that the staff will answer the call lights within a timely manner. Sometimes staff are not able to answer the resident call lights in a timely manner because there is a code, which is understandable. I think 3 to 5 minutes is an acceptable time for a resident to wait on staff to answer a call light. I answer call lights right away and acknowledge the resident's needs immediately. I never leave a resident waiting to have their call lights answered for 11 minutes because I answer the call lights right away. It is never acceptable for any staff to walk past a resident's call light and not answer it. It is never okay to walk past a call light and not answer it. I will do an in-service with the nurses and the certified nursing assistants about making sure that resident call lights are answered promptly. On 08/01/2025 at 12:20PM, V1 (Administrator) stated, An acceptable amount of time for a resident to wait to get their call light answered is between 5 to 10 minutes, depending on the situation. The certified nursing assistants are wearing purple uniforms. It is not the facility's policy for a certified nursing assistant or any staff member to walk past a resident's call light and not answer it and see what the resident needs. Call Light Response Policy (dated 01/10/2024) documents in part: To provide the staff with guidance on responding to residents' requests and needs. Answer the patient or resident's call as soon as possible.

Based on interviews and record review, the facility failed to ensure that three residents (R2, R4 and R6) were free from physical abuse. This failure resulted in R2, R4 and R6 being attacked by their roommates. R4 stated she does not feel safe. R6 stated R6 was upset and felt helpless. Findings include: 1.) R4 is [AGE] year-old with diagnosis including but not limited to: paraplegia, major depressive disorder, polyneuropathy, cerebral infarction and obesity. R4 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. R5 is [AGE] year-old with diagnosis including but not limited to, other specified disorders of bone, hypokalemia, multiple myeloma and type 2 diabetes mellitus. On 6/16/2025 at 1:36 PM, R4 stated R5 came at me with scissors while I was in bed. I pulled the call light for help, and R5 snatched the call light from me and begin to hit me with it. V9 (Restorative Aide) came in and took the scissors from her. R5 then pulled out a bigger pair of scissors once V9 left the room. I (R4) called for help again and the scissors were taken from her. She was moved to a different room, but I do not feel safe here. On 6/16/2025 at 1:44 PM, V9 (Restorative Aide) stated that she went into R5's room after she (R5) called for help and at that time, R4 had a pair of scissors in which she threw on the bed. V9 also said that she took R5's scissors to prevent R5 from stabbing R4 with the scissors, but found out later that the nurse had recovered a second pair of scissors. On 6/16/2025 at 1:53 PM, R5 stated that she did not want to talk about the incident that occurred between her and R4. On 6/17/2025 at 3:30 PM, V2 (Director of Nursing/DON) stated that she was made aware that R5 had allegedly attacked R4 with a call light and that two pair of scissors were taken from R5. R4's Care plan documents the following, R4 has a diagnosis of paraplegia; R4 is at risk for abuse and neglect related to paraplegia. Facility State Report of Abuse Allegation dated 6/4/2024 documents, alleged victims: R4; alleged perpetrators: R5, a resident-to-resident altercation occurred. Event Investigation Questionnaire dated 6/4/2025 documents the following statement given by V9 (Restorative Aide), Bed one (R4) flagged me down as I was going pass. Bed two (R5) had bed one's call light in hand and I (V9) saw a pair of scissors on her (R5) bed. I took the scissors and told the nurse that there was a disagreement going on with two residents (R4 and R5). 2.) R1 is [AGE] year-old with diagnosis including but not limited to: mood disorder, alcohol abuse, mixed anxiety disorder, restlessness and agitation. R1 is no longer a resident of the facility. R2 is [AGE] year-old with diagnosis including but not limited to: Alzheimer's disease, dementia, adult failure to thrive and generalized stomach pain. On 6/16/2025 at 2:04 PM, V10 (Licensed Practical Nurse/LPN) stated that she was the nurse that intervened when R3 reported the physical altercation between R1 and R2. At that time, V10 stated that she was unaware of how the altercation started, but that R1 and R2 were wrestling on a bed when she (V10) entered the bedroom. On 6/16/2025, R3 (R1 and R2's roommate) stated that R1 and R2 were fighting in the room and that she didn't know why. On 6/16/2025, R2 was not able to recall the details of her (R2) and R1's fight. R2's Care plan documents, potential for abuse and or neglect. Facility Reported Incident dated 4/22/2025 documents, time of incident: 10:30 AM; alleged victims: R1 and R2. The roommate (R3) alleged that a resident (R1) may have hit another resident (R2). The residents (R1 and R2) were separated, and the doctor and family notified. A body check was completed with noted redness. A police report filed. R2 and R1's Police report dated 4/22/2025 documents, simple battery. 3.) R6 is [AGE] year-old with diagnosis including but not limited to: legal blindness, pain in unspecified lower leg, dizziness, heart failure and chronic obstructive pulmonary disease. R6 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. R7 is [AGE] year-old with diagnosis including but not limited to: major depressive disorder, chronic pain, essential hypertension and insomnia. R7 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. On 6/17/2025 at 10:55 AM, R6 stated the following, R7 attacked me. He (R7) approached me and kicked me on the right leg. I (R6) was upset and felt helpless because I'm blind and couldn't defend myself at the time. I notified staff and staff removed R7 from the room. On 6/17/2025 at 11:15 AM, R7 stated that he kicked R6 because he (R7) was having a bad day. On 6/18/2024 at 11:46 AM, V24 (Nurse Practitioner) Stated, Resident to resident abuse of any kind is not acceptable because the patient can be harmed physically and emotionally. We have to protect each resident that comes into the facility from abuse. On 6/18/2025 at 1:45 PM, V2 (DON) stated that Resident to Resident abuse was not acceptable in the facility. Facility reported incident titled State Report of Abuse Allegation dated 6/5/2025 at 4:30pm, documents in part, Alleged Victim is R6, and Alleged Perpetrator is R7, Resident to Resident altercation. Residents were immediately separated. Facility document titled Event Investigation Questionnaire, dated 6/5/2025 at 4:20 pm documents, R6 activated his call light and informed V23 (LPN) that R7 kicked him (R6). R7 was propelling to the elevator. R7 stated that he did kick R6 because he (R7) was being stupid. R6's progress notes dated 6/5/2025 at 4:30 pm, documents, R6 informed writer that R6 and R7 had a disagreement and R6 alleged that R7 kicked R6's right leg. R6's care plan printed 6/17/2025, documents, R6's Active Range of Motion (AROM) Focus: R6 has impaired functional mobility due to weakness/poor motivation/Cognitive. R6's care plan printed 6/17/2025, documents, R6's Abuse Focus: Risk for abuse and neglect related to Legal Blindness. Facility's Abuse Policy and Prevention Program documents, this facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on interview and record review the facility failed to assure that a resident (R1) with pressure ulcers received the necessary treatment and services to promote wound healing. This failure caused one resident's (R1) wound to decline leading to wound infection and hospitalization . Findings include: R1's medical diagnoses include but are not limited to displaced fracture of lesser trochanter of right femur, muscle weakness, cognitive communication deficit, type 2 diabetes mellitus, pressure ulcer of unspecified heel unspecified stage, pressure ulcer of sacral region stage 3, acute diastolic heart failure. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 9, which indicates R1's cognition is moderately impaired. R1 admission progress note dated 02/06/25 at 9:32pm documents in part, has wound on the coccyx, right and left lateral heel. R1's care plan dated 02/06/25 documents in part, R1 was admitted with skin alterations and is at risk for further breakdown related to fragile skin, friction, decreased sensory awareness, impaired mobility and a past medical history that includes hypertension .infection will not develop at the wound site. Review of R1's records show no wound assessment or wound care orders until 02/14/25. R1's progress note dated 02/14/25 documents in part, Writer alerted that patient has alterations to skin, assessment performed, patient noted with open areas to his sacrum, right heel and a DTI (Deep Tissue Injury) on his left heel. MD (Medical Doctor) notified, verbal treatment orders received, carried out, and tolerated well by patient. R1's wound culture with collection date of 02/19/25 documents in part, culture wound - sacrum .gram stain: few gram-negative bacilli .few gram-positive cocci .rare white blood cells .rare epithelial cells .mixed gram-negative bacilli also present .methicillin resistant staphylococcus aureus few. R1's physician order dated 02/19/25 documents in part, Bactrim DS oral tablet 800-160 mg (milligrams) .give 1 tablet by mouth every 12 hours for wound infection for 5 days until finished. R1's wound physician assessment dated [DATE] documents in part, wound size 9 by 9 by 0.5 cm (centimeters) .periwound radius odor .exudate moderate purulent .thick adherent devitalized necrotic tissue 80% .wound progress exacerbated due to infection. R1's progress note dated 02/23/25 at 12:10pm documents in part, Noted to have altered mental status, lethargy, O2 (oxygen) saturation low 83% room air with nrb (non-rebreather) mask 15lnc (liter per nasal canula) stared O2 saturation 95%, BP (blood pressure) low with shortness of breath, diaphoretic. No fever at this time. V12 (Medical Doctor) called with order for hospital transfer stat. 911 paramedic called. R1's progress note dated 02/23/25 at 4:20pm documents in part, admitted at hospital with diagnosis of sepsis. R1's hospital records dated 02/23/25 documents in part, acute metabolic encephalopathy likely due to sepsis from sacral wound infection .sepsis due to sacral ulcer .consult wound and surgery. On 05/05/25 at 2:24pm V18 (Wound Care Nurse/Licensed Practical Nurse) stated that the facility did not have a wound care nurse for approximately one week. V18 stated that R1 was not assessed by wound care until 02/14/25. V18 stated that R1 did not have wound care orders until 02/14/25. V18 stated that if wounds are not treated then they could decline and become infected. On 05/06/25 at 12:19pm V12 (Medical Doctor/MD) stated that R1's wounds had previously been stable. V12 stated that it is possible that if the facility did not take care of R1's wounds, that could be part of R1's decline in condition. On 05/06/25 at 1:06pm V15 (Wound Care MD) stated that a resident should have wound care orders continued from the discharging hospital until she assesses them. V15 stated that if wounds are not treated then the wounds can deteriorate. On 05/06/25 at 2:34pm V2 (Director of Nursing) stated that if a resident doesn't have wound orders, then the nurse should get wound orders from the doctor. V2 stated that she was unaware that R1 did not have wound orders from 02/06/25 until 02/14/25. V2 stated that R1 not having wound orders is not acceptable practice and he should have orders, so the wound doesn't get worse. Facility's policy titled Skin Management: Monitoring of Wounds and Documentation dated 01/2023 documents in part, 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. Facility's policy titled Residents' Rights dated 11/2018 documents in part, Your rights to safety .Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Based on observation, interview, and record review the facility failed to accurately assess or evaluate a resident that are high risk for falls, failed to provide plan of care for falls. The facility failed to ensure fall preventive measures or interventions were implemented. The facility also failed to monitor and supervise a resident to prevent falls for 1 (R1) out of 3 residents reviewed for fall prevention program. These failures resulted in R1 falling twice. R1's first fall resulted in R1 being admitted to the hospital with an epidural brain bleed. R1's second fall resulted in R1 sustaining a laceration to the back of his head. Finding includes: R1 is [AGE] years old, readmitted in the facility on 01/07/2025 with repeated falls and traumatic subdural hemorrhage and coagulation defect. Clinical notes of R1 dated 02/03/2025 by V11 (Registered Nurse/RN) documents that R1 was seen on laying on the floor. R1 stated that he hit the back of his head. R1 was transferred to the hospital with admitting diagnosis of epidural brain bleed per V24 (Licensed Practical Nurse/LPN). On 03/18/2025 R1 fell again sustaining a laceration at the back of his head. R1 was transferred to the hospital, currently not in the facility. On 04/16/2025 at 12:09 PM V11 (RN) stated that she worked from 07:00 AM to 03:00 PM the day R1 fell on [DATE]. V11 stated that it was a CNA (Certified Nursing Assistant) that informed her that R1 was on the floor. V11 said, It was an unwitnessed fall. V11 said that R1 does not ambulate, non-compliant to instruction. R1 wants to try to do things that he cannot do. He needs assistance when getting up and needs 1-to-2-person assistance. V11 stated that it was around breakfast time when R1 fell . V11 stated breakfast starts at 07:30 AM and during that time, R1 ate breakfast in bed. V11 stated that she did not see anyone feed R1. V11 was asked if it would be safer for R1 to be transferred to the wheelchair and monitor by staff instead of leaving R1 in his room alone. V11 stated I am not sure if it will prevent R1 from falling. V11 stated that R1 was not transferred to his wheelchair because he is not on the get up list. V11 stated it would be hard for CNAs who are busy feeding another resident to come wash up R1 and place R1 in a wheelchair. On 04/16/2025 at 1:52 PM, V2 (Director of Nursing/DON) stated R1 kept saying he can walk, and he tries to maintain his independence. R1 was not on the get up list and was not scheduled to get up. Reviewed R1's care plan with V2. R1's fall care plan does not have any fall prevention interventions prior to the fall and was created on 02/03/2025. R1's fall care plan interventions are as follows: Encourage R1 to ask for assistance before transferring created on 2/11/2025, floor mat in place created date 03/18/2025, R1 will receive education related to potential fall risk and preventative measures created 02/10/2025. Per statement by nursing staff, R1 is non-compliant with instruction. R1 insist he can walk does not follow redirection. V2 was asked, how can these interventions help prevent R1 from falling? V2 stated the problem was that he got up without assistance. V2 was asked about the investigation she conducted. V2 was asked if the nursing staff, both nurses, and certified nursing assistants' whereabouts were accounted for. V2 replied, In doing our investigation we don't asked nursing staff where they are at the time of the fall or during the fall. V22 (CNA) that was assigned to R1 does not have written statement as part of investigation. V2 was informed that R1 fell again inside his room on 03/18/2025 sustaining laceration on the back of his head with bleeding. V2 replied, I have to look at the records. V2 stated that other interventions can prevent fall of R1, like putting signage or placing R1 in the get up list. On 04/22/2025 at 11:38 AM V7 (LPN) verified that she was the nurse on the day R1 fell on [DATE]. V7 stated that R1 was trying to get in his wheelchair when he fell . V7 stated that none of the staff was in the room. None of the staff witnessed the fall of R1. R1 had bleeding on the middle area of his head. V7 stated it happened around 08:00 PM as it was noted in her notes. R1's assessment for admitted d 01/07/2025 and re-admitted d 02/17/2025 documents that R1 is at high risk for fall with score of 16 on 01/07/2025. R1's score increased to 20 on 02/17/2025. Per assessment instructions, any score above 10 considered as high risk for falls. Although both assessments have scores higher than 10, staff who assessed put the score of 8 on both assessments indicating that R1 is not high fall risk. There was no baseline care plan intervention provided on both assessments. On 04/22/2025 at 10:18 AM, reviewed R1 fall assessments, evaluations and fall care plans with V25 (Restorative Nurse/LPN) and V26 (Restorative Nurse/LPN). V25 stated that the number or score is wrong on R1's fall assessment included during admission evaluation dated 01/07/2025 (prior to fall) and 02/17/2025 (after to fall). V25 stated that the score eight (8) represent the number of items being answered, not the score based on fall assessment. Per fall assessment ten (10) and above means high risk of fall. R1's score should be sixteen (16) for the assessment dated [DATE] which is a high risk of fall. R1's score for the fall assessment dated [DATE] should have been scored 20 which is high risk for fall. V25 was made aware that there was no baseline plan of care intervention for all fall assessments of R1. Upon reviewing the care plan, V25 stated that R1 does not have any fall care plan prior to fall. V25 said, Nothing on 01/07/2025 care plan for fall. V25 and V26 made aware on their policy fall assessment/evaluation and fall care plan review should be done during admission and quarterly to prevent resident from falling. R1 does not have fall interventions upon admitted d 01/07/2025 although he came in the facility with history of falls. On 04/23/2025 at 09:44 AM, V2 (Director of Nursing) was made aware of concerns related to R1 fall assessments/evaluations and lack of care plan interventions prior to falls. V2 stated that it will help prevent fall for R1 if there were interventions placed prior to the falls. V2 said, I cannot say that all falls can be prevented. But interventions prior to fall may help prevent falls. Fall Prevention and Management policy dated 02/2025 reads: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. 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. All fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. A fall risk evaluation is completed by the Nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall. Care plan to be updated with new intervention based on root cause analysis after each fall occurrence.

Based on interviews and review of records that facility failed to ensure personal belongings of 1 (R3) out of 3 residents were properly inventoried in accordance with facility's policy. These failures affected 1 resident (R3) resulting in not being able to unable to account personal belonging. Finding includes: R3 is [AGE] years old, initially admitted in the facility on 12/17/2024. R3 medical diagnosis includes amyloidosis, insomnia, anxiety disorder. R3 BIMS (Brief Interview of Mental Status) score dated 03/31/2025 scored at 15 means cognition is intact. On 04/15/2025 at 11:06 AM, R3 stated that his personal belongings that includes pair of headphones, mini wrench with screwdriver, State ID, orange extension cord with USB, titanium phone charging cord. R3 stated that he gave the list to V3 (Social Worker). On 04/16/2025 at 11:14 AM, V3 confirmed that R3 told her about his missing personal belongings. V3 stated that a concern form was done on R3's behalf. V3 stated that R3 should have brought to the receptionist all his belongings upon first arrival in the facility. Because R3 did not bring his belongings to receptionist his personal belongings were not inventoried. V3 stated that R3's belongings list form was not done. V3 was asked if it is the resident's responsibility or facility staff to ensure belongings were accounted to avoid prospective confusion? V3 stated, Here at this facility, we tell them, or the nurse explained to them. V3 was asked if she or any facility staff explained to R3 proper procedure. V3 stated No, I did not ask any of the staff if they did belongings list. We searched for it. All of us helped R3 to find it. We did not find it. On 04/17/2025 at 10:08 AM, V1 (Administrator) was made aware about personal belongings concern of R3. V1 stated that per proper procedure is to fill up belongings list form. And it should be done by staff to account resident's personal belongings. And to avoid future problem when resident will allege that they have certain personal belongings that no one can confirm. Personal Effects policy dated 01/2025, reads: The purpose of inventory is to limit the risk of loss of residents' personal effects and to protect the facility from liability for loss personal effects. The inventory shall be completed upon admission and signed by the resident or resident's responsible party. The inventory shall be updated when items are brought to the facility for the resident or when things are removed from the facility by the resident or resident's responsible party.

Based on interview and record review, the facility failed to prevent and protect two residents (R1, R5) from resident-to-resident abuse out of four residents reviewed for physical assault in a total sample of 14 residents. This failure resulted in R5 falling in the facility and sustaining a pneumothorax and several fractured ribs. Findings include: 1.) On 03/18/2025, at 3:22 PM, R5 states herself and her former roommate (identified as R12) were arguing because R12 never cleaned and never showered. R5 states she was encouraging R12 to clean up and take a shower. R5 states R12 then told her to shut the f**k up. R5 states she then told R12, I'm not a kid, don't tell me to shut up. R5 states R12 then took a gray colored water pitcher with water inside and threw the water on R5. R5 states she tried to cover herself by placing her hands up over her face. R5 states in the process, she slipped on the water that R12 threw at her. R5 states she hit her chest when she fell . R5 states the facility called the ambulance and she was taken to the hospital and had broken ribs. R5 states she was moved to another room when she returned from the hospital. R5 states herself and her new roommate get along well without any problems. R5 states she sees R12 in the facility and has not had any other problems with R12 since then. On 03/18/2025, at 3:30 PM, R12 states R5 was upset with her and wanted to argue. R12 states R5 had an attitude with her and wanted to fight. R12 states she threw water on R5 to calm her down. R12 states R5 slipped and fell over by the window and was taken out of the facility by the ambulance. R12 states herself and R5 are no longer roommates and when R5 returned from the hospital, R5 was moved to another room. R12 states she sees R5 in the facility but no longer speaks to R5. On 03/19/2025, at 1:39 PM, V8 (Licensed Practical Nurse/ LPN), states a CNA (Certified Nursing Assistant) came to notify her that R5 was moaning in pain and her left side was hurting. V8 states when she arrived to R5s' room, R5 informed her that she slipped, fell , and hit her side on the railing of her bed. V8 states R5 informed her that R5 fell on the previous shift. V8 states she asked R5 why R5 did not report it on the previous shift and R5 told V8 that R5 was not in pain then. V8 states she assessed R5 and R5s' side was red in color. V8 states she called the doctor and the Director of Nursing/DON (identified as V2) to notify them, but they did not pick up the phone. V8 states she then informed the supervisor on duty and the supervisor advised V8 to send R5 out to the hospital. V8 states she called the ambulance and sent R5 to the emergency room to be evaluated. V8 states she later was informed by V2 that V2 was made aware that R5 had a squabble with her former roommate (identified as R12). V8 states she was never informed by R5 that R5 was involved in an altercation with R12. V8 states she also informed V2 that V8 was not made aware of any altercations between R5 and R12. On 03/19/2025, at 3:18 PM, V2 (Director of Nursing/DON) states she was made aware by V8 (LPN) that R5 had a fall and was complaining of pain. V2 states R5 was then sent to the hospital to be evaluated. V2 states she was made aware via R5's hospital records that R5 reported that she slipped on water and fell in the facility. V2 states R5 did not originally report this to the facility. V2 states she then initiated an investigation for R5's fall. V2 states through her investigation, she was made aware that R5 and R12 had a disagreement about R5 making noise while R12 was trying to sleep. V2 states with further investigation, she was made aware that R12 alleged that R5 touched R12's shoulder. V2 states she informed V1 (Administrator) and V1 was responsible for following up with this allegation. V2 states she handles fall reportables (facility required documentation/report notifying the state surveying agency of an incident involving a resident) and V1 handles abuse reportables. V2 states she reported R5's fall to the state agency within the required time frame. On 03/21//2025, at 9:12 AM, V1 (Administrator) states she is the abuse coordinator, and she was made aware by V2 (DON) of the altercation between R5 and R12. V1 states she spoke with R12 and R12 informed her that R5 hit R12 because R5 was making noise and R12 asked R5 to stop. V1 states R12 told V1 that R12 may have thrown some water near R5 and then sat back down on R12's bed and R12 left it alone. V1 states she conducted an investigation and was made aware that R5 possibly slipped on some water. V1 states she spoke with R5 and R5 informed V1 that R12 threw water on R5. V1 states she was made aware that R5 may have fallen later after the altercation between R5 and R12. V1 states R5 did not use the verbiage that R5 fell on the water that R12 threw at R5. V1 states she reported this incident to the state agency within the required time frame. R5's Face sheet documents that R5 has diagnoses not limited to: Multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing, traumatic hemopneumothorax, subsequent encounter, unspecified fall, sequela, and vitamin D deficiency. R5's MDS/Minimum Data Set, dated dated dated [DATE], documents that R5 has a BIMS/Brief Interview for Mental Status of 9/15, indicating that R5 is moderately cognitively impaired. R5 requires substantial/maximum assistance with ADL/Activities of Daily Living care. R5 is incontinent of bladder and bowel. R5 ambulates via walker. R5's care plan dated 03/10/2025. documents R5 has 4th/6th rib Fracture r/t Fall. R5 had a traumatic hemopneumothorax. R5s' care plan dated 03/11/2025 documents Encourage resident to report all spills to staff immediately. R5s' care plan also documents that R5 is at high risk for falls. R5's hospital records dated 03/07/2025, documents that R5 has diagnoses of small left pneumothorax, acute, displaced fracture of the left fourth and sixth through ninth ribs. R5 was admitted to the hospital on 03/02/2025, due to bleeding and chest injury. R12's Face sheet documents that R12 has diagnoses not limited to: unspecified dementia, cerebral infarction, type 2 diabetes mellitus, essential hypertension, and chronic viral hepatitis C. R12's MDS/Minimum Data Set, dated dated dated [DATE], R12 has a BIMS/Brief Interview for Mental Status of 13/15, indicating that R12 is cognitively intact. R12 requires supervision assistance with ADL/Activities of Daily Living care. R12 is incontinent of bladder and bowel and ambulates via walking. R12's behavior assessment dated [DATE] documents that R12 was physically aggressive towards her roommate (identified as R5). Nursing progress note dated 03/02/2025, written by V8 (LPN) at 5:13 AM, documents R5 explains to writer that she had a fall on the previous shift and is screaming in severe pain in her left side ribs. R5 says that it hurts when she tries to move. Supervisor was notified and suggested to send R5 out to hospital for further evaluation. Nursing progress note dated 03/02/2025, at 6:15 PM documents R5 admitted to hospital with admitting diagnosis trauma, multiple rib fractures. Record review documents that R5 resided in the same as R12 on 03/02/2025. Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2028 documents in part, You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. 45001 2.) According to R1's face sheet and MDS 2/28/25 provided by facility, R1 has diagnoses that include but not limited to Alzheimer's disease, anxiety disorder. R1 has a BIMS (Brief Interview for Mental Status) score of 6 indicating severe cognitive impairment and required services of and resided on a specialized dementia/Alzheimer unit. According to R1's care plan provided by facility, R1 is care planned for wandering behavior: R1 demonstrates behavior that may be interpreted as wandering, pacing, or roaming related to the diagnosis of Alzheimer's disease. Symptoms are manifested by pacing, roaming, or wandering in and out of peer's rooms. R1 is care planned for abuse/neglect: R1's comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase his/her susceptibility to abuse/neglect. R1 is care planned for Alzheimer: R1 has diagnosis of Alzheimer's and may display moods/behaviors related to diagnosis such as agitation/aggression. According to R2's face sheet and MDS 1/3/2025, provided by facility, R2 has diagnoses that include but not limited to schizophrenia, restlessness and agitation, type 2 diabetes mellitus. R2 has a BIMS (Brief Interview for Mental Status) score of 13 indicating intact cognition. According to R2 care plan provided by facility, R2 is care planned for behavior: R2 has a history of verbal and physical aggression and threatening staff and peers. The resident has a diagnosis of schizophrenia. On 3/18/25 at 2:50 PM, V25 (Certified Nursing Assistant/CNA) stated V25 heard a scream from R1. I went to see what was going on. This happened in R2's room. When I went into the room there was a CNA (V26) in the room who was trying to get R1 and R2 apart. R2 was in a wheelchair. R1 was standing. R2 had the wheelchair armrest in hand and was hitting R1 in the head with it. R1 wanders in different resident rooms and is known to lay down in their beds. On 3/18/25 at 3:00 PM, V26 (CNA) stated V26 was walking past R2's room and heard R1 saying Stop. I went into the room and saw R2 hitting R1 with an object. R2 did make contact with R1. I immediately called for the nurse. I stood in between them. R2 was in a wheelchair. R1 was standing in R2's room. R1 is a wanderer. I believe R1 went out to the hospital. R2 went out to the hospital and has not been back to the facility. R1 gets confused, tired and wants to sit down. It is typical for R1 to wander into other residents' rooms. R2 is mean and grumpy. R2 has outburst cursing at staff. R1 has dementia. On 3/18/25 at 3:13 PM, V4 (Licensed Practical Nurse/LPN) stated R1 went into R2's room. R1 wanders. R1 started yelling. The CNA called out for help. Me and another nurse went into the room and separated R1 and R2. R2 can be irate. R2 is combative, was always yelling, mean and mad. It was a challenge to give R2 care. R2 mostly yelled and cursed at staff. R2 had the cushion from the wheelchair armrest in hand. I sent R1 and R2 to the hospital. R2 was sent for a psychiatric evaluation. R1 went to the hospital because R1 had redness/abrasion on the forehead and a scratch. I notified the physician, family, and the Director of Nursing. The administrator is the abuse coordinator. I have had abuse in-services within the last month. If I witness abuse I would intervene, separate the residents, and notify the administrator. On 3/21/25 at 12:30 PM, V12 (LPN) stated I was called to the situation. I helped separate the two (R1 and R2). I was at the other end of the unit/floor. I heard the commotion, the CNA yelled for me and said R1 is in the room having an incident with R2. I went to the room. R1 was already out of the room and R2 was wheeling himself to the door to come out of the room saying, R1 was in my room. I stepped in between and closed the door so R2 could not come out. I did not see anything in R2's hands. I monitored R2 until R2 was petitioned out to the hospital. R1 roams a lot, and I have not observed any aggressive behaviors. R2 has random outbursts if someone comes in R2's space/personal space. R2 has said Get away from me. R2 is mostly into himself. On 3/21/25 at 2:40 PM, V1 (Administrator) stated I am the abuse coordinator. I was the Administrator/abuse coordinator at the time of the incident with R1 and R2, on 1/23/25. The last abuse in-service was in 2/25/2025. Some types or abuse are physical, neglect, mental, involuntary seclusion, exploitation, financial. My expectation is for abuse to be reported to me immediately. Residents should be separated immediately. The incident with R1 and R2 was reported to me and my assistant administrator at that time. It was alleged that R2 was agitated and allegedly hit R1. The nurse, V4 (Licensed Practical Nurse), told me that when she went into the room R2 was swinging at R1. V4 said R2 had the cushion from the arm rest in hand. V4 said they immediately separated them and both residents were assessed. There were no injuries observed. Abuse was not substantiated due to the evidence. R1 and R2 were both sent to the hospital for evaluation. R1 came back from the hospital. R2 has not been back since the incident and is not returning. R2 stated R2 does not want to come back to the facility. R2 nursing progress note, 1/23/2025, 11:35 AM, reads in part: resident made physical contact with another resident. Resident stated, Resident entered my room and would not get out. Separated resident from other resident and monitored resident behavior. Resident sent to hospital for psych evaluation and treatment. MD (medical doctor) and family notified of incident and transfer. State Report of Abuse Allegation, 1/23/25, reads in part: R1, R2 and staff were interviewed related to the resident-to-resident altercation that occurred. Upon investigation, it was determined that R2 allegedly hit R1 in the forehead although the incident was unwitnessed. Residents were immediately separated to prevent further conflicts and ensure the safety of all residents. R2 was educated on the appropriate procedures for reporting concerns, emphasizing the importance of notifying staff rather than taking matters into their own hands. Both residents were sent out to the hospital for further evaluation. R2 has not returned to the facility at this time. A police report was filed. Alleged victim (R1) orientation is not alert with a diagnosis of Alzheimer's disease. Alleged perpetrator (R2) orientation is alert with a diagnosis of schizophrenia. Facility Abuse Policy and Prevention Program, 10/20/22, reads in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation or property, deprivation of goods and services by staff or mistreatment. 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 observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for residents in the dining room. The facility also failed to monitor and track residents who are on fall precautions. This failure affects one of three residents (R4) reviewed for falls. The facility also failed to monitor one resident (R1) with a known history of wandering in the facility. These failures have the potential to affect 73 residents residing on the second floor in the facility. Findings include: 1.) On 3/18/25 and 3/21/25 observed R1 walking in the hallways. According to R1's face sheet and MDS 2/28/25, provide by facility, R1 has diagnoses that include but not limited to Alzheimer's disease, anxiety disorder. R1 has a BIMS (Brief Interview for Mental Status) score of 6 indicating severe cognitive impairment and required services of and resided on a specialized dementia/Alzheimer unit. According to R1's care plan provided by the facility, R1 is care planned for wandering behavior: R1 demonstrates behavior that may be interpreted as wandering, pacing, or roaming related to the diagnosis of Alzheimer's disease. Symptoms are manifested by pacing, roaming, or wandering in and out of peer's rooms. R1 is care planned for abuse/neglect: R1's comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase his/her susceptibility to abuse/neglect. R1 is care planned for Alzheimer: R1 has diagnosis of Alzheimer's and may display moods/behaviors related to diagnosis such as agitation/aggression. On 3/18/25 at 2:50 PM, V25 (Certified Nursing Assistant/CNA) stated V25 heard a scream from R1. I went to see what was going on. This happened in R2's room. When I went into the room there was a CNA (V26) in the room who was trying to get R1 and R2 apart. R2 was in a wheelchair. R1 was standing. R2 had the wheelchair armrest in hand and was hitting R1 in the head with it. R1 wanders in different resident rooms and is known to lay down in their beds. We have to redirect R1 back into the dayroom. On 3/18/25 at 3:00 PM, V26 (CNA) stated V26 was walking past R2's room and heard R1 saying Stop. I went into the room and saw R2 hitting R1 with an object. R2 did make contact with R1. I immediately called for the nurse. I stood in between them. R2 was in a wheelchair. R1 was standing in R2's room. R1 is a wanderer. I believe R1 went out to the hospital. R2 went out to the hospital and has not been back to the facility. R1 gets confused, tired and wants to sit down. Everybody has the right to wander around. R1 wanders the whole floor. No staff walk with R1. It is typical for R1 to wander into other residents' rooms. R2 is mean and grumpy. R2 has outburst cursing at staff. R1 has dementia. We redirect R1 to the dayroom for monitoring. We (CNAs) take turns in the dayroom. On 3/18/25 at 3:13 PM, V4 (Licensed Practical Nurse/LPN) stated R1 went into R2's room. R1 wanders. On 3/21/25 at 10:50 AM, V27 (Activity Aide) stated R1 is very sweet. R1 has dementia. R1 walks a lot. R1 goes into other resident rooms. R1 will go into their rooms and talk to them and come out. R1 does not need staff to accompany R1. On 3/21/25 at 11:00 AM, V18 (LPN) stated R1 has dementia, is confused, and talks to herself. R1 is a wanderer and goes into other residents' rooms. R1 does not need staff with R1. Staff need to be aware of where R1 is. R1 can be redirected. Some residents have called to the nursing station saying there is a lady in here (their room). The resident will tell R1 that R1 can't be in there and R1 will walk back out. On 3/21/25 at 11:42 AM, V4 (LPN) stated R1 does not wear an electronic monitor. R1 walks around but does not attempt to leave. The electronic monitor is for residents that try to elope. On 3/21/25 at 12:30 PM, V12 (Licensed Practical Nurse) stated R1 roams a lot, is sweet, and I have not observed any aggressive behaviors. 2.) On 03/18/2025 at 3:05 PM, R5 and multiple other residents sitting in wheelchairs and with walkers observed sitting in the dining room on the second floor of the facility without any staff member inside monitoring the residents in the dining room. On 03/18/2025, at 3:07 PM, surveyor makes V6 (Registered Nurse/RN) aware that residents are inside of the dining room without any staff members monitoring them. V6 states there is supposed to be someone inside of the dining room monitoring the residents at all times. V6 states she is the off-going nurse and there is a change of shift happening. V6 states she is unsure of who is responsible for monitoring the dining room because the CNA assignments have not been made yet by the on-coming nurse. On 03/18/2025, at 3:08 PM, V7 (CNA) was observed walking inside of the second-floor dining room to monitor residents. V7 states she is not aware of who is supposed to be monitoring the residents because the schedule has not been made yet. V7 states she was informed by V6 to monitor the second-floor dining room until a schedule is made. V7 states if residents are not properly monitored, then they can potentially fall and injure themselves, or get into an altercation with one another. On 3/21/25 at 11:43 AM, V17 (Fall Coordinator) states V17 states the CNA staff are responsible for taking turns and monitoring the dining rooms in the facility. V17 states staff monitoring is required in the dining room while residents are present because this can help to prevent falls in the facility. V17 states there should be a staff member monitoring the dining room at all times. V17 states if staff monitoring is not provided to residents, then residents could potentially fall, experience resident on resident abuse, choke, or experience wandering in the facility. 3.) Nursing progress note dated 03/03/2025, at 8:48 AM, documents R4 noted on the floor inside of her room lying on her left side. The resident stated she hit her head and hip and just wants to go home to be with her kids. Vitals stable. ROM (Range of Motion) was assessed. Head to toe and pain assessment completed. Family member, NP/nurse practitioner notified. NP ordered to send R4 to the emergency room for brain scan and x-ray of the hip. Transportation services contacted. Son made aware R4 is going to hospital. On 03/21/2025, at 11:43 AM, V17 (Fall Coordinator) states R4 fell on ce in the facility on 03/03/2025, and she was aware by checking risk management in the electronic health records system. V17 states she does not keep a list of residents who are on fall precautions in the facility. V17 states she does not keep a fall risk precaution/intervention binder or list at the nurses' station for staff reference and knowledge. V17 states residents have a blue dot on their doors, and this represents that the resident is on fall precaution interventions. V17 states staff are made aware of residents who requires fall precautions by observing the blue dot on the residents' door. V17 states she is responsible for updating the residents' care plan whenever a resident falls. V17 states fall precaution interventions should be changed to include a new intervention each time a resident experience a fall in the facility. V17 states after R4 fell in the facility, R4s' care plan should have been updated to reflect that R4 had an actual fall while in the facility. Surveyor deploys R4s' electronic fall care plan interventions on a computer with V17 present. V17 observes interventions are dated 03/18/2025 and signed by V17. Surveyor inquires to V17 why interventions are dated after resident was already discharged from the facility. Surveyor also makes V17 aware that the care plan was signed by herself on 03/18/2025, the same date surveyor began investigations of R4s' fall. V17 states she is not sure why it is dated for 03/18/2025 and signed by herself because she does not remember signing R4s' care plan on 03/18/2025. R4s' fall care plan to reflect V17s' revisions dated 03/18/2025, was requested from V17 on 03/21/2025, at approximately 12:00 PM. This care plan for R4 was not provided to surveyor during this survey. Record review of R4s' care plan does not document that R4 is care planned for having an actual fall on 03/03/2025. Surveyor requested the facility's supervision/monitoring policy and accidents/hazards policy from V2 (Director of Nursing) on 03/18/2025 and 03/19/2025. Facility's supervision/monitoring policy and accidents/hazards policy was not provided to surveyor during this survey. Facility census dated 03/18/2025 documents that a total of 73 residents reside on the second floor of the facility. Facility policy dated 03/17/2025 titled, Baseline Care Plan documents in part, 6. Because the baseline care plan documents the interim approaches for meeting the residents' immediate needs, it should also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs .

Based on interviews and records review, the facility failed to notify a representative for one (R7) of three residents reviewed of change in condition in a total sample of 14 residents. Findings include: R7 is a [AGE] year-old individual admitted to the facility on [DATE]. R7's current face sheet documents R7's medical conditions to include but not limited to: benign neoplasm of right breast, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, other specified abnormal uterine and vaginal bleeding, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R7's MDS (Minimum Data Set) section C (Cognitive Patterns) dated 1/27/2025, documents R7's Brief Interview for Mental Status (BIMS) as 14/15 indicating R7 has intact cognition abilities. Section GG - Functional Abilities documents R7' abilities as: Eating/ Oral Hygiene-Supervision or touching assistance, Toileting Hygiene-Substantial/maximal assistance, Shower/bathe self-Substantial/maximal assistance, Upper body dressing-Substantial/maximal assistance, Lower body dressing-Substantial/maximal assistance, putting on/taking off footwear-Substantial/maximal assistance, Personal Hygiene-Substantial/maximal assistance, and R7 uses a motorized scooter. On 03/19/2025 at 2:25 PM, R7 was observed lying in bed awake and stated not too long ago she was bleeding out of her vagina. She saw it when she was assisted to the bathroom. R7 stated she has gone through menopause and was worried when two days after she started bleeding, she was sent to the hospital. R7 stated her daughter was notified the day R7 went to the hospital but she does not know if she was notified when R7 started bleeding. R7's progress notes dated 2/16/2025, 6:11 AM, by V8 (Licensed Practical Nurse/LPN) documents Certified Nursing Assistant/CNA (no name provided) brought to V8's attention that resident (R7) is bleeding vaginally and passing big clots. Writer (V8) went to assess R7 and saw clots. V8 will notify MD (Medical Doctor), DON (Director of Nursing), Family, and next shift nurse. Review of R7's progress notes document R7 was sent to the hospital on 02/18/2024. R7's family member contact was attempted on 2/18/2025 and the family was not reached. R7's progress notes do not document R7's family was attempted to be reached on 2/16/2025 and 2/17/2025. On 03/21/2025, at 10:52 AM, V18 (LPN) stated if a resident has a change in condition, the nurse notifies the doctor, DON, and resident's family member(s) the same day and charts it in the progress notes who was notified. V18 stated the nursing progress notes should read notified and not will notify because will notify is in the future and is not carried out yet. On 03/21/2025, at 12:15 PM, V12 (LPN) stated if a resident has a change in condition, the nurse notifies the doctor, the Director of Nursing, and the family. Then the nurse documents in the progress notes. V12 stated when a nurse documents in the progress notes will notify doctor, Director of Nursing, and family member, it means that the nurse has the intentions of contacting the doctor, DON and family member but has not done it yet. V12 stated once the nurse notifies the doctor, DON and family member, progress notes should read they were notified even if they were not reached. On 03/21/2025, at 2:50 PM, V2 (DON) stated V8's (LPN) documentation on R7's progress notes dated 2/16/2025, 6:11 AM, stating V8 will notify MD (Medical Doctor), DON (Director of Nursing) , family, and the next shift nurse are charted in the future and do not document that R7's family was notified of R7's change in condition on the day R7 had a change in condition. V2 stated if it's not documented correctly, it's not done. Facility policy titled Change in Resident Condition dated 1/10/2024, documents: -It is the policy of the facility except in a medical emergency, to alert the resident, residents' physician, and resident party of a change in condition.

Based on observation, interview and record review, the facility failed to ensure the resident's call light device was functioning properly for resident use. This failure affected one resident (R10) out of three residents reviewed for call lights. Findings include: On 2/11/25 at 11:54 AM, R10 was observed wheeling himself out of his room, noted with bilateral braces to lower legs; lower legs on wheelchair leg rests. R10 alert and responsive, agreed to speak to surveyor. R10 states that he is heading to therapy. R10 states that he is doing better since he began doing therapy. R10 states that when he first came in, he could hardly do anything. This surveyor questioned R10 if his call light is functioning. R10 reports that his call light has not worked and states they told him to use his roommate's call light. R10 states that his call light has never worked. R10 states that maintenance came up twice. One maintenance staff came one time and never came back. R10 states another maintenance worker came another time. He looked at it, walked out and never came back. R10 reports that his roommate's call light does work, and he uses his next-door roommate's call light. On 02/11/25, at 12:44 PM, R10 pressed his call light. No light turned on at R10's call light source and no call light turned on in front of R10's room. R10 states that when he first got to the facility, his call light not working affected him a lot. R10 states in the beginning I couldn't walk and couldn't go to the bathroom by myself. They would come and put a belt on me and walk me there. When I needed to use the bathroom, I would wait until someone would do their rounds and then they still needed to go get help. Sometimes it felt like forever. I'd have to try to reach my roommate's call light and use his. At times, R10's roommate has been upset about R10 using his call light. On 2/11/25, 1:06 PM, V8 (Certified Nursing Assistant) pressed R10's call light button and states I don't think it's working; the call light panel would have light up green. V8 continues to state. On the outside of R10's room, this would light up to white, as V8 pointed to the outdoor of R10's room's call light. When V8 walked to the nurse's station, where the call light notification is located, V8 states it shows no calls. V8 picked up the phone to attempt to call R10's call light that is in R10's room. V8 states I would say it works for us calling him, but it doesn't work for him calling us. V8 states that it is important for a resident's call light to work so they can call staff and let them know if they need anything. On 2/11/25, at 4:49 PM, V2 (Director of Nursing) R10 states that maintenance did not come for his call light. His call light is not working. R10 states that maintenance brought a table for one of his roommates. R10 states that the CNA (Certified Nursing Assistant) brought the bell in. V2 states that R10's call light should be functioning, and he should have his own and not have to use his roommate's call light. R10's Face sheet documents that R10 is a [AGE] year-old female admitted to the facility on [DATE], who has diagnoses not limited to: aftercare following joint replacement surgery, muscle weakness (generalized), infection and inflammatory reaction due to unspecified internal joint prosthesis, subsequent encounter, venous insufficiency (chronic) (peripheral). R10's Minimum Data Set (MDS), dated [DATE], documents R10 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R10 is cognitively intact. R10's care plan date initiated 1/14/2025, revised 1/21/2025, documents in part R10 is at high risk for falls r/t (related to) aftercare following joint replacement surgery. R10 will remain free of falls causing hospitalization r/t injury through next review. Interventions documents in part staff to assist as needed. Promote placement of call light within reach and assess resident's ability to use. Facility document dated 1/10/2024 titled call light response documents in part to provide the staff with guidance on responding to residents' requests and needs. Report all defective call lights to the nurse supervisor or maintenance director promptly.

Based on observation, interview, and record review the facility failed to follow generally accepted stand of professional practice when administering IV (Intravenous) fluids rate as ordered by physician for 5 of 5 residents (R8, R9, R10, R11, and R12) reviewed in the sample for IV therapy. This failure affected R8, R9, R10, R11, and R12 who were receiving IV fluid were observed not infusing at the right drip rate per minute to infuse 1000ml/hour as ordered. This has potential to affect all 73 residents listed as getting IV therapy. Findings include: On 1/22/25 at 10:40am, R8 noted in the room with an IV 1000ML bag infusing rapidly with flow meter left at open rate. No label to show the start time and no stop time. Highest calibration noted on the flow meter was 250ml/hour which will equal to 4 hours of infusion. V3 (Registered Nurse/RN) in charge of R8 stated that I (V3) don't do anything with the IV, there is an outside company that takes care of that. R8 stated that I (R8) would like to go in the bathroom, and I (R8) don't know what to do now should I carry it to the bathroom (referring to the IV pole) asking the surveyor. At 10:45am, when this observation was shown to V2 (Director of Nurse/DON) and V29 (Nurse Consultant). V2 and V29 both stated that the drip rate is too fast. V2 and V29 were unable to determine the drip rate. V29 stated that the IV infusion therapy nurse should be called to explain self. On 1/22/25 at 11:10am, V4 (RN from IV therapy infusing company) when this was shown, stated there was no way to infuse it at 1000ml/hr. as it was ordered because the (flow meter) calibration is at highest 250ml/hr. and using that it will take four hours to get the fluid into the resident, so I just leave it open. When asked whether this was communicated to the physician who ordered the medication. V4 stated that all I (V4) must do is to just speed the remaining solution up and at times it goes over one hour. V4 stated for R8 IV was started at 10:25am. When asked why the bag was not labeled. V4 could not present any documentation of vitals before and after infusion and did not answer the question. V4 stated that the flow meter in use has a 15 drops/ml. V4 stated that the fluid includes nutritional supplement and vitamins. The surveyor then asks V4 with 15 drops/ml delivery the 1000ml will not be infused in one hour. V4 stated all I (V4) must do is to just speed the remaining solution up and at times it goes over one hour. On 1/22/25 at 11:20am V29 (Nurse consultant) stated any IV infusion should be given per physician order. On 1/22/25 at 11:23am V2 (DON) stated that if a flowmeter or IV pump is not used to infuse the IV fluid, V4 should have counted drip per minute to follow the physician of 1000ml/hr. V2 stated that is not professionally accepted in nursing for safety reasons for resident not to have fluid overload. When asked what can happen to a resident if fluid is infused rapidly. V2 stated in resident with CHF (Congestive Heart Failure), with resident on dialysis or in respiratory distress this can be a serious problem. V2 stated the facility nurses on the floor does not monitor the infusion the consulted RN is performing the infusion are supposed to monitor the flow rate, use the right equipment (referring to flow meter device) and the residents. On 1/22/25 at 11:30am, on the 4th floor R9 and R10 was noted with IV infusion and same flow meter left on open calibration. V5 (Licensed Practical Nurse/LPN) stated I (V5) was wandering why the fluid was running that fast, but we (facility Nurses) have been told not to worry about the IV because the consulting IV people will be in charge (oversee) of the IV. But I (V5) can tell this is too fast. R5 stated there is no labeling of time it started or will end. On 1/22/25 at 11:44am, R11 noted in bed with IV infusion infusing at an open rate on the flow meter. V6 (RN) stated this is like just infusing without any rate. V6 stated I did not know when it was started it is not written on the IV bag but if I am the nurse giving it (administering the fluid) as a nurse I (V6) will label the infusing bag with time and rate it should be going to the resident (infusing). V6 stated that we (referring to facility licensed Nurses) don't do anything with the IV supplement infusing there is a company nurses that monitor that, but the IV therapy nurse is not on the floor right now. On 1/22/25 at 11:49am, R12 noted in the dining room with peers in activity waiting for lunch, IV infusing noted. V7 (RN from IV therapy infusing company) walked out of the elevator and was asked about the infusion rate setting and labeling of the IV bag with time started and ending time. V7 stated the flow meter has a calibration of 60 drops per hour so we just set it at open rate and the remainder we just speed it up to infuse if there is any fluid left. V7 presented unused IV administration set that showed 15 drops/ml (milliliter) not 60 drops/ml. V7 stated with this there is usually some small amount left in the bag and then when I (V7) return to the (resident) that I (V7) am taking care of I will just speed it up. V7 then walked to the dining area where R12 was sitting with peers present and disconnect the IV from R12 with some of the fluid left in the bag. On 1/22/25 at 1:28pm, V12 (Regional Operations Manager of the IV therapy company) stated that the 1000ml bag should be infusing at 15 drops/ml. When asked at what drops should that be calculated. V12 stated that the (flowmeter) on the IV administration set is 15 drops/ml but I am not a nurse if the 250ml/hour on the set is used the IV will have to infused for 4 hours and the order was 1000ml/1 hour. V12 stated there is no pumping machine device to be used by the infusion nurses so they must have 250ml in the fluid chamber that is how it is counted. The surveyor asked V12 to clarify 250ml in the infusion IV set. V12 stated that is how it is counted. Maybe I (V12) will have to get our nurse consultant for you (referring to the surveyor) on the phone. In the telephone conversation V13 (VP Clinical Operations RN) stated that with the (flowmeter) used the highest rate is 250ml/hr. V13 stated in part that with this calibration it will take 1000ml to infuse for 4 hrs. V13 stated the that the 1000ml/hr. should be infusing at 250 drops/minute. Review of R8, R9, R10, R11 and R12 medical record Physician Order sheet showed that the IV bag 1000ml should infuse at 1000ml/1hr(hour). This order was not followed. Review of R8, R9, R10, R11 and R12 medical record progress notes showed documentation that the IV therapy were administered completely within the 1 hour as ordered. The facility presented Educational In-Service titled Calculating Drip Rates for Infusion dated 1/28/25 with objective indicating that by the end of the in-service session the nurses will be able to confidently calculate drip rates for IV infusion using step by step approach, ensuring the correct flow rate is maintained for optimal patient care. Formula listed to calculate drip rate showed that with 1000ml/hour bag the drop rate should be 250gtt/min (Drops/Minute) this formula was not followed. Under educational review it showed documentation that accurately calculating drip rate is essential in providing safe and effective IV infusions. The facility policy on Medication Administration documented that all medications are to be administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Listed guideline includes but not limited to if the physician order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation) and a note should reflect the situation in the resident's medical record.

Based on observation, interview, and record review the facility failed to ensure that the medication cart was locked when not in visual proximity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all the 73- residents residing on the 4th floor. Findings include: On 01/27/25 at 1:30pm, on the 4th floor medication cart was noted in the hallway unlocked and not in visual view of the nurse. R14 was observed standing by the cart while V14 (Licensed Practical Nurse/LPN) was in a patient room. The surveyor asked R14 where the nurse is, R14 stated V14 went into that room and was waiting here for V14 to come out. On 1/27/25 at 1:33pm, when this observation was shown to V14 and was asked about the facility policy on medication/medication cart storage, V14 stated I should have locked the cart when I went into the patient's room for safety. On 1/27/25 at 2:18pm, when the surveyor made V16 (Assistant Director of Nurses/ADON) aware of the observation and was asked about the facility policy on medication cart storage and the expectation of the nurses when medication cart is not in view of the nurse and not locked. V16 stated that if they (referring to the nurses) must walk away or have their back turned (Referring to away from the cart). They must lock the medication cart. Medications and biologicals are stored safety, 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. Responsible party listed is Nursing. Listed procedure includes but not limited to medication carts and medication supplies are locked or attended by person with authorized access. The facility policy on Medication Administration documented under guidelines that never leave the medication cart open and unattended.

Based on interview and record review, the facility failed to provide appropriate assistance during ADL (activities of daily living) care and follow ADL care plan intervention for use of side rails. The facility also failed to complete fall risk evaluation/assessment in a timely manner. These failures affected 1 (R1) out of 3 residents reviewed for accidents and adequate supervision. R1 had a fall incident on 12/15/24 and sustained a left hip fracture while receiving care. The findings include: R1's admission record showed initial admitted on 6/18/19 with diagnoses not limited to Interstitial pulmonary disease, Rheumatoid arthritis, Unspecified dementia, Other pulmonary embolism, Chronic obstructive pulmonary disease, Schizophrenia, Acute on chronic right heart failure, Gastro-esophageal reflux disease, Depression, Atherosclerotic heart disease of native coronary artery, History of falling, Myocardial infarction, Hyperlipidemia. MDS (Minimum Data Set) dated 10/21/2024 showed R1's cognition was intact. R1 needed substantial/maximal assistance with toileting and personal hygiene, upper and lower body dressing; Partial/moderate assistance with roll left and right on the bed. MDS showed R1 was frequently incontinent of bladder and always incontinent of bowel. MDS coding showed in part: Partial/Moderate Assistance = Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Substantial/Maximal Assistance = Helper lifts or holds trunk or limbs and provides more than half the effort. R1's POS (Physician Order Sheet) showed in part: May have side rails up when in bed to aide in bed mobility. Order date on 2/7/23 and end date on 12/16/24. Care plan revision date on 7/31/21 documented in part: R1 has an ADL self-care performance deficit r/t (related to) stroke. Bed mobility: R1 requires extensive assistance. Side rails up as per doctor's order for safety during care provision, to assist with bed mobility. R1's latest side rail review assessment effective date 7/27/24 documented in part: Side rails are being used: 1/2 side rail. The resident will utilize side rails that are not considered a restraint and will be utilized to enable the resident to attain and maintain his / her practicable level. R1's Fall Risk Evaluation dated 7/26/24 documented in part: Score = 11 (High fall risk). No fall risk evaluation in October found in R1's record. R1's RCA (Root Cause Analysis) read in part: Resident had a fall due to not able to self-stabilize in bed during bed mobility with x 1 assist. Witness statement dated 12/15/24 by V12 (Certified Nursing Assistant/CNA) written in part: V12 went to R1's room to change incontinence pad and do patient care, in the process R1 fell . Nursing progress notes dated 12/15/2024 by V16 (Registered Nurse/RN) documented in part: Approximately at 11:50 the CNA informed V16, R1 had fallen from bed. R1 was observed lying on her left side, next to the left side of her bed. R1 was assessed and reported pain in the left hip. PRN (as needed) Pain medication was administered, and the resident was assisted back to bed in accordance with facility Protocol. A STAT (immediately) X-Ray of the left hip and pelvis was ordered by the MD (medical doctor). X-RAY completed and Resulted in Left Femur intertrochanter fracture. R1's left thigh has increased swelling. MD ordered to send R1 to the hospital for further evaluation. Nursing progress notes dated 12/16/2024 documented in part: R1 admitted with dx (diagnosis) of broken hip. Nursing progress notes dated 12/20/2024 showed in part: R1 readmitted to the facility from the hospital. R1' hospital records - Trauma History and Physical notes dated 12/15/24 showed in part: Left intertrochanteric femur fracture. Admit for ortho for operative fixation. On 12/22/24 at 11:02AM surveyor observed R1 lying on bed, on lowest position, floor mats on both sides, with bed bolster, call light within reach, appears comfortable and well groomed. R1 is alert and verbally responsive. R1 stated to surveyor I don't want to talk to you, go away. On 12/22/24 at 11:10AM surveyor attempted to interview R1 with V8 (Staffing coordinator/CNA) and V9 (CNA) and R1 agreed. R1 able to recall some information regarding the fall incident on 12/15/24, she said she was pushed/slipped from the bed. R1 said she was trying to say a prayer and wanted to be changed. R1 further stated she held onto me and get someone to help her move and slipped from the bed. She said it was a terrible experience. R1 unable to recall staff name. On 12/22/24 at 11:55am V13 (Restorative Director) stated V13 has been working in the facility since April 2024. V13 said on 12/15/24, V12 (CNA) was rendering care (bed mobility/repositioning/cleaning/changing) to R1 and fell from bed. V13 stated in-service was given to V12 regarding bed mobility. V13 said, R1 required partial to substantial assistance x 1 person assist with ADL care. She said R1 was transferred to the hospital due to fall. V13 stated RCA (Root Cause Analysis) was completed, R1 had a fall due to not able to self-stabilize in bed during bed mobility with x 1 assist. Stated R1 is a fall risk. V13 said fall risk assessment is completed upon admission, quarterly and every after fall. V13 stated R1 had fall risk assessment in July and December after the fall incident on 12/15/24 but nothing found for October. V13 stated the purpose of the fall risk assessment/evaluation is to help put all appropriate fall interventions and it will identify if resident is at risk or high risk for fall. V13 said care plan interventions should be followed by staff. On 12/22/24 at 12:54 PM V14 (Licensed Practical Nurse/LPN) stated has been working in the facility for [AGE] years and transitioned to restorative nurse about 4 months ago. She said on 12/15/24, R1 had a fall incident while V12 (CNA) was rendering care (bed mobility) to R1. V14 said prior to fall: R1 requires 1 -2 assist with ADL care. V14 stated fall incident on 12/15/24 could have been prevented if V12 asked for help or assistance. V14 stated V12 was provided in-servicing regarding bed mobility. V14 stated R1 does not use siderails. She said R1 needed partial assistance with rolling from left to right on bed and substantial assistance with toileting or personal hygiene with 1 person assist. V14 said staff should be holding/supporting the resident while providing care. She said R1 was transferred to the hospital because of the fall incident. On 12/22/24 at 1:27 PM V12 (CNA) stated, V12 has been working in the facility for about 3 months. She said had worked with R1 and on 12/15/24 while providing care by herself, R1's front side was cleaned and was turned in bed on her back. V12 stated, she got a barrier cream in the drawer and R1 slid on the other side of the bed away from her. She said, R1's bed does not have a side rail and R1 can move in bed. V12 stated she told R1, don't move, I guess she moved and slid from the bed. Stated if there was a side rails this fall could be prevented, R1 could have grabbed on the side rail to help / assist with bed mobility. V12 stated she removed her hands or was not holding R1 while reaching out for the moisture barrier cream at bedside drawer. On 12/22/24 at 2:02 PM V16 (RN) stated V16 has been working in the facility since October 2024 and regularly assigned on the 4th floor. Stated on 12/15/24, V12 (CNA) informed her that R1 fell from bed, went to R1's room immediately and saw R1 on the floor lying on her left side with c/o (complaint of) left hip pain. V16 stated, V16 did not see side rails on R1's bed. She said STAT (immediately) x-ray of left hip was completed with result of left femur fracture and R1 was transferred to the hospital. On 12/22/24 at 2:22 PM V2 (Director of Nursing) stated, she was informed by V16 (RN) that R1 fell from bed. She said there was an order for x -ray due to R1's c/o left hip pain; stat x-ray was done in the facility. Result came back that resident has left hip fracture and patient was transferred to the hospital. V2 said, a Fall risk evaluation is done upon admission, quarterly and every after fall to minimize resident risk of falling and identify the risks for fall. If fall risk assessment/evaluation was not completed timely, would not know the risk because resident was not assessed or evaluated. V2 said, the care plan is developed so staff would know what care the resident needs and care plan interventions should be followed, should be appropriate and updated to reflect the status of the resident. V2 said, side rails can be used to aid in bed mobility if resident is able to use it. V2 stated, side rail assessment should be done prior to use to make sure it is not a restraint. V2 said, R1 needed assistance with bed mobility, incontinence care, toileting/personal hygiene, not sure to what extent. Stated if resident required partial/substantial assistance, staff is expected to provide appropriate assistance for resident's safety. On 12/23/24 at 9:39 AM V15 (R1's Nurse Practitioner) stated has been working with R1 and she needed assistance with ADL care. V15 said, in much better situation, R1 should have 2 staff assistance for safety. V15 said, siderails could be used if resident is able to help with bed mobility, something to grab on so that fall could be prevented. If R1 had a fracture, then it was the result from the fall incident that happened. Facility's bed rails/side rails policy dated 5/2024 documented in part: Bed rails may be used to assist with mobility to ensure that resident maintains the optimal amount of independence. These will be used only after an assessment has been completed. Facility's fall prevention and management policy dated 1/2024 documented in part: While preventing all fall 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. A fall risk evaluation will be completed on admission, readmission, and quarterly significant change and after each fall.

Based on observation, interview, and record review the facility failed to provide an environment free from accident hazards for 3 (R3, R6, R7) out of 3 residents reviewed for accident hazards. This failure resulted in R3 getting a laceration that required 14 sutures to R3's left hand. Findings include: R3 is an [AGE] year-old male, admitted to the facility 12/12/2023 with diagnosis not limited to Acute Diastolic (Congestive) Heart Failure, Type 2 Diabetes Mellitus With Diabetic Chronic Kidney Disease, Venous Insufficiency (Chronic) (Peripheral), Bilateral Primary Osteoarthritis Of Knee, Unspecified Fall, Intervertebral Disc Degeneration Lumbar Region, Adult Failure to Thrive, Unspecified Protein-Calorie Malnutrition, Chronic Kidney Disease, Lack Of Coordination, Cognitive Communication Deficit, Weakness R3's MDS (Minimum Data Set) dated 12/22/23 documents 1.) BIMS (Brief Interview of Mental Status) score of 15/15 indicating intact cognition, 2.) R3 uses wheelchair as mobility device, 3.) R3 is dependent on staff for chair/bed transfers. R3's completed facility reported incident (FRI) for the event on 01/14/24 8:30 PM documents wherein R3 took a staff members unattended personal item and when the staff reached toward R3 to retrieve the item R3 retracked R3's hand and scraped R3's left hand across the exposed metal part of R3's wheelchair resulting in a laceration. R3 was sent to the local hospital. R3 returned to facility on 01/15/24 with 14 sutures on left hand. On 01/31/24 at 9:24 AM, V21 (Certified Nursing Assistant/CNA) stated V21 was assigned to R3 on 01/14/24 during the 3-11 shift and noticed that part of the foam was missing from R3's arm cushion after R3 left for the hospital. V21 stated V21 did not notice the missing foam before this event. On 01/31/24 at 11:57 AM, V2 (Assistant Administrator) stated V2 spoke over the phone with V17 (Agency Nurse) working 3-11 shift on 01/14/24 to determine how R3 cut R3's hand. V2 stated V17 told V2 that there was foam missing from R3's left arm cushion wheelchair and V17 could see exposed metal in that area so that is likely how R3 got cut. V2 asked V17 to take a picture of R3's wheelchair which V17 did using a cell phone and sent it to V2. V2 showed surveyor the photo of R3's wheelchair arm cushion time stamped on 01/14/24 at 8:07 PM. Surveyor could see that there was no foam covering the front portion of R3's left arm cushion, leaving a sharp edge exposed and what appears to be a thin rounded piece of metal. V2 stated R3's wheelchair was thrown out due to the exposed metal. V2 stated V2 asked V20 (Restorative Aide) to do a sweep of all the wheelchairs being used in the facility to make sure they were functional and did not have any exposed metal which could potentially cause an accident to the resident(s). V2 stated it is the Maintenance Department's responsibility to monitor equipment. V2 stated wheelchairs are pieces of equipment. Multiple attempts were made to contact V17 to conduct a phone interview on 01/31/24 and 02/01/24 however calls were never returned. On 01/31/24 at 10:32 AM, V20 (Restorative Certified Nursing Assistant) stated R3 is on restorative program for active range of motion but R2 often refuses but it is still offered. V20 stated V20 did not notice R3's wheelchair was broken during the times V20 went in to R3's room to offer R3's restorative services. V20 stated no one prior to 1/14/24 notified V20 that there was anything wrong with R3's wheelchair. V20 stated V20 saw R3's wheelchair in the front office following the incident. V20 stated V20 could see metal exposed on the end of the arm rest because it was not covered in foam. V20 stated the arm rest should have been fully covered all the way with foam so that there would not be any exposed metal. V20 stated if V20 had seen that exposed metal on R3's wheelchair V20 would have removed the wheelchair from the floor immediately and alerted maintenance or housekeeping that the wheelchair needed to be thrown out. V20 stated V20 would have removed the wheelchair because it could cause harm to the resident. On 01/31/24 at 10:50 AM, V20 stated that on 01/15/24 or 01/16/24 V20 was asked to do a facility wide audit of all wheelchairs to make sure they were functional and did not have any issues such as dysfunctional brakes, broken arm rests, missing arm cushions or any exposed metal. V20 stated the purpose of doing this audit was to monitor all wheelchairs for safety. V20 stated V20's audit did not find any other wheelchairs with exposed metal but did find some with missing arm cushions and one wheelchair that did not lock which is a safety concern because residents can fall while trying to get in/out of the chair if their wheelchair is not able to be in a locked position. Surveyor showed V20 the floor list of the wheelchair audit and V20 confirmed this was the completed audit which was submitted to V2. On 01/31/24 at 10:57 AM, V20 went with surveyor to the floor and using the completed wheelchair audit surveyor selected a few of the resident's names that were identified as having issues with their wheelchair. On 01/31/24 at 11:01 AM, observed R6 sitting in wheelchair in the unit dining room. The left brake was engaged but the right brake was not activated. R6 stated the lock on her wheelchair does not work and that she's already told staff that it needs to get fixed, but nobody had fixed it yet. V20 tried to engage the right brake but could not get it to hold. V20 stated the brake did not work and needs to be replaced because it is a safety concern. On 01/31/24 at 11:09 AM, observed R7 sitting in wheelchair in the unit dining room. The right arm cushion was missing, and a metal bolt was observed to be protruding upward from the first nail opening. V20 observed the metal bolt and stated that is a potential safety risk because R7's skin can get snagged on it. On 01/31/24 at 12:42 PM, V22 (Regional Director of Maintenance) stated the Maintenance Department does monthly checks on resident wheelchairs to make sure they are working the way they are supposed to and to see if there were anything that would cause skin damage such as a broken piece of the equipment. V22 stated if Maintenance staff sees anything wrong or if there is safety concern with a wheelchair then that wheelchair would be taken off the floor right away until they were able to replace a broken/missing part or fix the problem. V22 stated arm cushions and arm rests can be replaced rather than having to replace the entire wheelchair assuming those replacement items are in stock. V22 stated if there is a problem with a resident's wheelchair in between the monthly monitoring they rely on the restorative staff to let them know so the issue can be addressed. V22 stated since V22 has been working at the facility for the past two weeks and no one has told V22 about any broken wheelchair or any wheelchairs that need to be replaced. On 01/31/24 at 12:50 PM, V23 (Maintenance Assistant) stated when V23 is notified by the staff that there is a broken or missing part to a wheelchair V23 sees if V23 can fix the problem. V23 stated V23 has extra brakes V23 can use to replace on wheelchairs missing brakes or if the brakes are broken. At 12:51 PM, in the Maintenance Office/Storage Room observed V23 walk over to a cardboard box and pull out four wheelchair brakes to show the surveyor. Observed V23 walk over to a different cardboard box and pull out a new arm cushion wrapped in plastic. V23 stated here are the arm cushions, they come in two different sizes, large and small depending on the size of the wheelchair. V23 stated I also have extra arm rests which have arm cushion already attached which I can also replace as needed. V23 stated no one has asked me in the past two to three weeks to fix any residents brake on their wheelchair or replace any arm cushions or arm rests or given me a list of wheelchairs that need to be fixed. On 02/01/24 at 2:05 PM, V3 (Director of Nursing) someone should have noticed that R3's wheelchair was defective. V3 stated if you see something like that do something and naturally if a staff saw something like that someone should have seen it and acted on it. V3 stated damaged wheelchairs need to be removed right away so no one gets hurt. V3 stated we want to make sure we notice it and take care of it to prevent injuries with staff and residents. V3 stated, if this problem had been identified earlier then R3's accident potentially may have been prevented. R6 is a [AGE] year-old male, admitted to the facility 09/07/21 with diagnosis not limited to Unspecified Severe Protein-Calorie Malnutrition, Venous Insufficiency (Chronic) (Peripheral), Bipolar Disorder, Hereditary and Idiopathic Neuropathy, Idiopathic Hypotension, Adult Failure to Thrive, Type 2 Diabetes Mellitus with Other Circulatory Complications, Other Chronic Pancreatitis, Unspecified Psychosis Not Due to A Substance Or Known Physiological Condition, Nicotine Dependence. R6's MDS (Minimum Data Set) dated 11/03/23 documents 1.) BIMS (Brief Interview of Mental Status) score of 14/15 indicating intact cognition, 2.) R6 uses wheelchair as mobility device, 3.) R6 requires partial/moderate assistance for chair/bed transfers. R6's Fall Risk Screen dated 05/04/23 documents in part, R6 is at moderate risk based on score of 13.0. R6's transfer and ambulation care plan dated 08/04/23 documents in part to lock wheelchair brakes. R7 is a [AGE] year-old male, admitted to the facility 06/14/17 with diagnosis not limited to Alzheimer's Disease, Polyosteoarthritis, Joint Disorder, Fracture of Shaft Of Left Humerus, Lack Of Coordination, Difficulty In Walking, Unspecified Symptoms And Signs Involving The Nervous System. R7's MDS (Minimum Data Set) dated 12/15/23 documents 1.) BIMS (Brief Interview of Mental Status) score of 00/15 indicating severe cognitive impairment, 2.) R7 uses wheelchair as mobility device, 3.) R7 requires substantial/maximal assistance for chair/bed transfers. Facility provided policy titled, Resident Rights - Accommodation of Needs and Preferences and Homelike Environment Policy dated 1/2024 documents in part, the facility will provide a safe environment. Facility provided document titled, Preventative Maintenance Plan dated 1/2024 documents in part, all resident rooms should be inspected for proper operation of all equipment. Facility provided Facility Assessment Tool dated 11/2023 documents in part maintenance team audits physical equipment and performs maintenance when necessary. Wheelchairs are listed as examples of physical equipment.

Based on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention for one (R1) of three residents reviewed for falls. This failure resulted in R1 sustaining a fall resulting in a head injury and R1 requiring stitches to the left eyebrow. Findings include: On 10/14/2023 at 9:30 am, R1 was observed lying in bed awake. R1 said he fell a while ago and hurt his left eyebrow and was taken to the hospital and he received 4 stitches. R1 said he fell trying to reach for his TV remote which was on his bedside table and the bedside table was placed far away from him, and he could not reach it. R1 said he had pressed his call light, but it was not working. R1 pointed to his left eyebrow and said that is where he had four stitches and said now there is a scar. R1's bed was observed to be on high position. R1 said he does not know where his bed remote is. On 10/14/2023 at 9:35 am, surveyor and V3 (Licensed Practical Nurse/LPN) went to R1's room. Asked V3 about the position of R1's bed. V3 said R1's bed was in high position and said R1 could have manipulated the bed. R1 said he does not know where his bed remote is, and he has not touched it this morning. V3 looked for R1's bed remote and it was observed to be at the head of the bed under R1's pillow. V3 said the CNAs (Certified Nursing Assistants) could have left the bed in high position when they took care of R1 this morning. V3 said R1's bed should be on low position to prevent falls. On 10/14/2023 at 1:02 pm, V15 (LPN) said when R1 fell , he told her he was trying to get his TV remote control which was on his over bed table, but the over bed table was away from him, and he had to get up to get it, and that is then said he fell . V15 said R1's over bed table should be near him. V15 said she does not know who moved R1's over bed table away from R1, and further said that the CNA could have moved it when assisting R1 with ADL care. V15 said R1 was on the floor in his room when he fell and he had a visible injury on the left upper eye, a little cut area with blood coming out. V15 said R1 was sent to the hospital and when he returned, he has stitches on his left eyebrow. V15 said residents should be safe at the facility and fall precautions should be observed by staff to prevent resident injury. On 10/14/2023 at 1:49 pm, V17 (Director of Nursing) said when she interviewed staff, R1 was in bed listening to music on his phone and staff was alerted that when R1 went to reach for his TV remote which was on his over bed table, R1 had fallen out the bed. V1 said R1 was able to ambulate at the time of his fall. V17 said R1 sustained a cut on his left eyebrow, and he received three sutures at the hospital. V1 said R1 hospitalized from 8/25/2023 to the 8/27/2023. V17 said R1's bed should be in low position to prevent injuries if R1 was to fall out of his bed. V17 said if R1's bed is in high position and R1 fell , there is a higher risk of serious injuries. R1's nursing progress notes dated 8/25/2023 document R1 had a fall and had an injury on top of his left eye and was sent to the hospital. R1's nursing progress notes dated 8/25/2023 document sutures to R1's left eyebrow intact. R1's hospital records dated 8/26/2025 document R1 had a head injury/concussion and suture were applied to his head. Policy titled Fall prevention management dated 1/23 documents: -This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. 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.

Based on interview and record review, the facility failed to ensure that a resident remains free from neglect for one of three residents (R6) reviewed for neglect. V8 (Former Certified Nursing Assistant) failed to utilize two staff members during a mechanical lift transfer R6. This failure resulted in R6 falling from the mechanical lift and sustaining a right intertrochanteric (right hip fracture) and a right fibular fracture. Findings include: Facility's incident report of 5/17/2023 documents in part: It was reported on 5/9/2023 that resident sustained a fall. Upon inquiry, staff stated that during transport, (R6) shifted her weight causing the mechanical lift to tilt to the side and a fall was sustained. On 5/10/2023, x-ray results revealed right intertrochanteric and right fibular fracture(s). On 6/28/2023 at 10:10 AM, V11 (Human Resource Director) said she was alerted by V12 (Facility Clinical Manager) that V8 (Certified Nurse Assistant/CNA) used a mechanical lift to transfer resident (R6) improperly, and as a result resident fell from the lift. R6 was suspended immediately pending the outcome of the investigation. V8 was terminated on 5/10/2023 for neglect of a resident. V12 said that, upon hire, V8 signed off on the facility's lift policy that states two staff members are utilized for a (mechanical lift) transfer. V11 also said V8 received and signed that she received a copy of the Employee Handbook that describes abuse and neglect. Statement written by V11 (Human Resource Director) on 5/10/2023 states in part, on 5/9/2023 (V8 CNA) while working the 3p-11p shift attempted to transfer a resident (R6) with a (mechanical lift) alone and dropped the resident causing serious injury. Per the union handbook page 39-7Physical or verbal abuse, neglect, or attempting to injure residents, or other person, including any other staff member, supervisor, or manager. The above incident is defined as neglect. (Facility) has decided to terminate employment (of V8) effective 5/10/2023. Facility's Event Investigation Questionnaire dated 5/29/2023 completed by V8 (Former CNA) documents: 10:15 PM I took (R6) in the room to bed. I hooked up the (mechanical lift) with all four hooks and as I move the (mechanical lift) to lower from chair (R6) slip(ped) out the side of (mechanical lift) and I try to catch her. She still fell . V8 was not available for interview. On 9/28/2021 V8 signed that she received the facility's Safe Patient Lifting Policy. On 9/28/2021 V8 signed the facility's Employee Receipt and Acknowledgement of Employee Handbook. Facility's Abuse Prevention Program-Policy (November 22, 2017) states in part: Neglect is a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. (201 ILCS 45/1-117). Neglect is also the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Union Handbook (undated) Page 39, number 7 documents: Physical or verbal abuse, neglect, or attempting to injure residents, or other person, including any other staff member, supervisor or manager.

Based on interview and record review, the facility failed to utilize two staff members during a mechanical lift transfer for one of five residents (R6) reviewed for falls. The failure resulted in R6 falling from the mechanical lift and sustaining a right intertrochanteric (right hip fracture) and a right fibular fracture. Findings include: R6's medical record (Face Sheet) documents R6 is a [AGE] year-old initially admitted to the facility on [DATE] with diagnoses including but not limited to: Repeated Falls, Essential Hypertension, Anemia, and Protein-Calorie Malnutrition. MDS (Minimum Data Set) dated 5/8/2023 documents R6 is severely cognitively impaired; is totally dependent upon staff with a two or more physical assist for bed mobility, transfers, and toileting, and is incontinent of bladder and bowel. Facility's incident report of 5/17/2023 documents in part: It was reported on 5/9/2023 that resident sustained a fall. (R6) was observed on the floor in a right side-lying position. Upon inquiry, staff stated that during transport, (R6) shifted her weight causing the mechanical lift to tilt to the side and a fall was sustained. Noted with c/o (complaining of pain) to right lower extremity. On 5/10/2023, x-ray results revealed right intertrochanteric and right fibular fracture(s). Resident is at high risk for falls with a score of 18. (R6) is non-ambulatory, incontinent of bowel/bladder and requires extensive assistance to complete ADL (Activities of Daily Living) care and transfers. Facility's Event Investigation Questionnaire dated 5/29/2023 completed by V8 (Former Certified Nursing Assistant/CNA) documents: 10:15 PM I took (R6) in the room to bed. I hooked up the (mechanical lift) with all four hooks and as I move the (mechanical lift) to lower from chair (R6) slip(ped) out the side of (mechanical lift) and I try to catch her. She still fell . V8 was not available for interview. On 06/27/2023 at 4:15 PM via telephone, V9 (Licensed Practical Nurse) said, what I know is that a CNA (V8) came and got me. V8 told me there was a fall. I went into the room, she (R6) was on the floor. She (V8) just told me she (R6) fell during a (mechanical lift) transfer. R6 is a mechanical lift transfer, she was a (mechanical lift) transfer at the time of the fall. I did an assessment, then after I assessed her, I got her off the floor and called her physician. V9 also said two staff members are required to perform a (mechanical lift) transfer. On 6/28/2023 at 10:10 AM, V11 (Human Resource Director) said she was alerted by V12 (Facility Clinical Manager) that V8 (CNA) used a mechanical lift to transfer resident (R6) improperly and as a result resident fell from the lift. On 6/28/2023 at 11:20 AM V14 (CNA) said two to three staff should be present when transferring a resident using the (mechanical lift) for safety reasons. Staff could get hurt or the resident could get hurt. On 6/28/2023 at 11:52 AM, V20 (CNA) said two staff are required when using a mechanical lift to transfer residents, for support. You can't use the controls and try to support the resident at the same time. The resident could fall. Facility's policy Safe Patient Lifting Policy (undated) states in part: T=Total Lift Transfer with two or more caregivers (Total Assist)

Based on interview and record review, the facility failed to ensure that two residents (R2 and R3) were free from resident-to-resident physical abuse. This failure affected R2 who sustained a nasal fracture. Findings include: R2's Admission Record documents, in part, that R2's diagnoses include but are not limited to: Dependence on renal dialysis, hyperkalemia, essential (primary) hypertension, hypothyroidism unspecified, unspecified psychosis not due to a substance or known physiological condition, type 2 diabetes mellitus without complications, personal history of COVID-19, unspecified abnormalities of gait and mobility, unspecified symptoms and signs involving the nervous system, nicotine dependence unspecified uncomplicated, patient's noncompliance with renal dialysis, bipolar disorder unspecified Cognitive communication deficit, pneumonia due to other specified infectious organisms, anemia unspecified, end stage renal disease, and chest pain unspecified. R3's Admission Record documents, in part, that R3's diagnoses include but are not limited to: Constipation unspecified, esophagitis unspecified without bleeding, other specified disease of esophagus, unspecified viral hepatitis C without obstruction on gangrene, iron deficiency anemia secondary to blood loss (chronic), schizophrenia unspecified, barrettes esophagus without dysplasia, long term (current) use of anticoagulants, major depressive disorder recurrent unspecified, personal history of COVID19, essential (primary) hypertension, hyperlipidemia unspecified opioid use unspecified uncomplicated, other age related incipient cataract unspecified eye, anemia unspecified, presbyopia, presence of other heart-valve replacement, and inflammatory polyps of colon without complication. R2's Brief Interview for Mental Status (BIMS) dated 01/10/23 shows 15 cognitively intact. R3's BIMS dated 01/17/23 shows 11 some cognitive impairments. On 03/27/23 at 10:00 am, V3 (Licensed Practical Nurse/LPN, Nurse Manager), provided the surveyor with the initial and final incident reports that were sent to the state agency for the alleged incident that occurred on 02/26/2023 between R2 and R3. The final report faxed to the state agency on March 3, 2023, documents, in part, R3 and R2 were involved in a physical altercation. R2 noted with blood-tinged drainage from R2's nose and R3 sent to local hospital for psychiatric evaluation. R2 had a CT (Computed Tomography) scan of the head, diagnosed with a nasal fracture and prescribed Tylenol Extra Strength 500 milligrams (mg) oral tablet 2 tablets for 7 days as needed for pain. On 03/27/23 at 10:41 am, R3 was observed in R3's room sitting in a chair awake, alert and oriented. R3 denied any knowledge of being in an altercation with R2 on 02/26/23. R3 stated, R3 and R2 were never roommates and R3 denied ever choking R2's neck or punching R2 in the nose causing injury. On 03/27/23 at 10:47 am, R2 stated, about a month ago R2 and R3 were roommates for about six months when R3 physically attacked R2. R2 stated after breakfast, R2 was sitting in a chair next to R2's bed in R2 and R3's room. R2 stated, R3 walked to the doorway and then walked over to R2 punching R2 in R2's nose with R3's fist and then choking R2's neck with both of R3's hands. R2 stated, R2 fell from R2's chair to the floor and R2's nose began to bleed. R2 stated, while R2's nose was bleeding, R2 got off the floor and walked to R2's bathroom. R2 stated while R2 was in R2's bathroom V10 (Registered Nurse/RN) came into R2's bathroom to ask R2 what occurred. R2 stated, V10 then called the police and R2 completed a police report against R3. R2 stated, after R2 completed the police report R2 was sent to the local hospital and had an x-ray of R2's nose performed and was sent back to the nursing home. R2 said upon R2's return to the facility R3's room was changed and R2 has not seen R3 since the altercation. On 03/27/23 at 12:54 pm, V10 (RN) stated, V10 was the nurse on 02/26/23 when the altercation between R2 and R3 occurred. V10 stated, 15 minutes after checking on R2 and R3's room, V10 was down the hallway near another resident's room when R2 came to V10 in the hallway with R2's nose bleeding and stated R3 choked R2 and punched R2 in the nose twice while R2 was alone sitting in a chair in R2's room. V10 stated, R2 stated R2 did not know why R3 choked and punched R2. V10 stated, V10 rendered care to R2's bleeding nose to stop the bleeding. V10 stated, V10 observed R3 in the day room while V10 was providing care to R2. V10 stated after V10 stopped R2's nose from bleeding V10 called V1 (Administrator) right away and informed V1 of R2 and R3's altercation. V10 stated, after calling V1, V10 called R2's and R3's physicians, families, and the police. V10 stated, when V10 spoke with R3, R3 stated that R3 was tired of R2 laughing at R3 about R3's missing money. V10 stated, both residents remained separated and placed on one-to-one monitoring by Certified Nursing Assistants (CNAs). V10 stated, R2 was sent to the local hospital for a CT (Computed Tomography) scan of R2's nose and head and, R3 was sent to the local hospital for a psychiatric evaluation. V10 stated, R2 and R3 both return to the facility from the local hospitals within a few hours and upon R3's return to the facility R3's room was changed to another floor. V10 stated, R2's hospital report stated, R2 sustained a nasal fracture and that R2's neurology status was monitored for changes and change of mental status. V10 stated, R3's hospital report stated R3 was cleared by psychiatry and could return to the facility. On 03/28/23 at 1:17 pm, V1 (Administrator) stated, V1 is the facility's abuse coordinator. V1 stated, V1 recalled the incident reported where a resident was assaulted by another resident however V1 was not able to recall what resident was assaulted between R2 and R3. V1 stated, R2 and R3 was immediately separated after the altercation and sent to the local hospitals. V1 also stated, a police report was made and both residents returned to the facility residing on different floors. V1 was asked what facility measures are put into place to prevent resident-to-resident abuse. V1 stated, We try to make sure residents are compatible, cognitive intact residents are placed together, residents with like BIMS scores are place together and chose appropriate roommates. Staff should be rounding on residents as needed. On 03/28/23 at 1:32 pm, V2 (Director of Nursing/DON) stated, V2 was made aware that R3 hit R2 without reason. V2 stated, V2 was not in the facility when the incident occurred. V2 also stated, after the altercation with R2 and R3, R3 was sent out to the local hospital for a psychiatric evaluation and returned to the facility after a couple of hours. When V2 was asked if any resident was injured during the altercation between R2 and R3, V2 stated, V2 was informed that R2 had some bleeding from R2's nose. On 03/28/23 at 2:02 pm, V4 (Social Service Director) stated, V4 was not in the facility when the altercation between R2 and R3 took place on a weekend. V4 stated, V4 was made aware of R2 and R3's altercation when V4 returned to work. V4 stated, upon V4's return to the facility R3's room was changed to another floor. Facility's initial incident report to local State Agency dated 02/26/23 at 1:11 pm, documents that R3 and R2 were involved in a physical altercation. R2 noted with blood-tinged drainage from R2's nose and R3 sent to local hospital for psychiatric evaluation. Facility's final incident report to local State Agency dated 03/03/23 at 6:55 pm, documents that R2 had a CT of head and was diagnosed with a nasal fracture and prescribed Tylenol Extra Strength 500 milligrams (mg) oral tablet 2 tablets for 7 days as needed for pain. R2's hospital record dated 02/26/23 at 2:07 pm shows that R2 sustained a nasal fracture. R3's hospital record dated 02/26/23 at 2:00 pm, shows that R3 was seen at local hospital for stress management. R2's progress note dated 02/26/23 authored by V10 (RN) documents that at 9:00 am R2 reported to V10 that R3 grabbed R2's neck and punched R2 in the face. At 3:25 pm CT scan revealed R2 with a nasal fracture. R3'S progress noted dated 02/26/23 at 9:01 am, authored by V10 (RN) documents that R3 stated that R3 punched R2 in the face because R3 got tired of R2 smiling and laughing at R3. R3'S care plan dated 01/03/22 documents, in part, R3 may be susceptible to potential abuse/neglect related to (r/t) resident demonstrating difficulty with behaviors by others that can be characterized as provoking, antagonizing, disrespectful, angry, insensitive an annoying. The resident has a history and/or personality that draws him/her into unhealthy or even abusive relationships. R2's care plan dated 03/03/23 documents, in part, R2 maybe at risk for potential abuse related to (r/t) mental/emotional challenges. The facility's undated policy titled Abuse Prevention Program-Policy documents, in part, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment .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 observation, interview and record review, the facility failed to implement fall prevention interventions as care planned for one resident (R9) and failed to provide adequate supervision to one resident (R4), while using a motorized wheelchair. This failure resulted R4 sustaining an acute fracture involving the base of the proximal phalanx of R4's right great toe which required R4 to wear a post op boot. Findings include: 1. R4's face sheet documents that R4 was admitted to the facility on [DATE] with a diagnosis which includes but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Cerebral infarction unspecified, Unspecified osteoarthritis unspecified site, and unspecified symptoms and signs involving the nervous system. On 02/06/23 at 1:33 pm, Surveyor observed R4 in bed awake and alert. R4 stated that R4 was given a motorized wheelchair a few months ago from R4's insurance. R4 stated when R4 received the motorized wheelchair, V11 (Occupational Therapist/OT) was showing R4 how to use R4's motorized wheelchair in R4's therapy sessions. R4 stated that V11 left R4 sitting in R4's motorized wheelchair in R4's room to go and find help with putting R4 to bed. R4 stated that while R4 was left alone sitting in R4's motorized wheelchair, R4 tried to back R4's motorized wheelchair next to R4's bed in R4's room and R4 bumped R4's right first toe on the wall in R4's room. R4 stated that R4 did not mention the incident to the therapist when the therapist returned to R4's room. R4 stated that R4 mentioned the incident to V11 the next day when V11 came to get R4 for therapy because R4's right first toe was hurting when V11 was trying to dress R4 and place R4 in R4's wheelchair. R4 stated, I (R4) thought I (R4) knew what I (R4) was doing when I (R4) was trying to turn around in the wheelchair (referring to the motorized wheelchair), but I (R4) didn't know how to turn around in the wheelchair (referring to the motorized wheelchair) by myself (R4). On 02/07/23 at 11:05 am, V11 (Occupational Therapist/OT) was interviewed regarding R4 motorized wheelchair and V11 stated that R4 received a motorized wheelchair a few months ago. V11 explained that R4 had orders for occupational therapy to teach R4's how to operate R4's motorized wheelchair and that R4's motorized wheelchair was only to be used while R4 was being supervised in R4's therapy session. V11 explained that R4 required assistance to operate R4's motorized wheelchair safely. V11 stated that V11 would get R4 up into R4's motorized wheelchair for R4's therapy sessions to teach R4 how to use R4's motorized wheelchair safely. V11 stated that R4 was not to be in R4's motorized wheelchair unsupervised or without assistance until R4 met R4's long term and short-term goals in therapy with R4's motorized wheelchair. V11 explained that R4's goals with R4's motorized wheelchair included but were not limited to: R4 able to operate basic controls of R4's motorized wheelchair independently. R4 able to turn navigate turns, doorways independent with her motorized wheelchair. R4 able to navigate hallways independently with R4's motorized wheelchair. R4 able to park R4's motorized wheelchair in R4's room (navigating tight spaces) independently. V11 stated that on 12/23/23 after R4's therapy session, R4 asked V11 if R4 could stay in R4's motorized wheelchair a little longer. V11 stated that V11 informed R4 that R4 could stay sitting in R4's motorized wheelchair in the hallway outside of R4's room while V11 went to provide therapy services to another resident. V11 stated that V11 returned to R4 after about 30 minutes and that R4 was still sitting in R4's motorized wheelchair outside of R4's room. V11 then explained that V11 assisted R4 inside of R4's room with R4's motorized wheelchair and placed R4 back into bed. V11 stated that the next day on 12/24/23 V11 went to R4's room to get R4 up into R4's motorized wheelchair for R4's therapy session and that R4 complained of pain to R4's right first toe. V11 stated that when V11 looked at R4's toe R4's toe looked swollen and that V11 informed the nurse, and an x ray was performed on R4's right first toe. V11 stated that R4 then explained that the prior day (12/23/22) when V11 left R4 in R4's motorized wheelchair, that R4 tried to maneuver R4's motorized wheelchair without assistance in R4's room and bumped R4's toe on the wall in R4's room while R4 was trying to turn around inside of R4's room. V11 stated that R4 never informed V11 or any staff on 12/23/22 of R4's attempt to maneuver R4's motorized wheelchair without assistance because R4 was not supposed to operate R4's motorized wheelchair without the assistance of V11. When V11 was asked why V11 left R4 unsupervised with R4's motorized wheelchair, V11 stated, I (V11) was trying to trust R4 alone. R4 should have been supervised whenever R4 was operating R4's wheelchair. On 02/07/23 at 1:46 pm, V18 (R4's Physician) was interviewed regarding R4 and V18 stated that R4 is an alert and oriented resident at the facility. V18 stated that V18 recalled that R4 was being seen by therapy to operate R4's motorized wheelchair safely and properly. V18 stated that at the time of R4's incident on 12/23/22, R4 should have been supervised at all times while operating R4's motorized wheelchair until there was an order for R4 to be able to operate R4's motorized wheelchair without supervision. V18 stated, If a resident who requires supervision while operating a motorize wheelchair, operates a motorized wheelchair without supervision the resident could run into things and injury themselves, injury other people or even cause property damage. On 02/08/23 at 1:09 pm, V2 (Director of Nursing/DON) was interviewed regarding R4's motorized wheelchair and V2 stated, R4 was issued an electric wheelchair from therapy. R4 was given an okay to practice in open areas by R4's self and R4 decided that R4 wanted to practice in R4's room and R4 ran into the wall and hit R4's foot. When V2 was asked if R4 was supervised by therapy or a staff member during the time of R4's injury, V2 stated, I (V2) am not sure if therapy was supervising R4 at the time of R4's injury to R4's foot V11 (Occupational Therapist) informed nursing the next day after R4's injury. V11 stated that R4 informed V11 of R4's injury to R4's foot the day after R4's injury occurred. Once nursing was made aware of R4's injury to R4's foot, nursing informed R4's physician who order for an x ray to R4's foot. R4's foot was x rayed and R4's x ray results showed that R4 had a fracture to R4's foot. Whatever orders R4's physician gave for R4's fractured foot was carried out. I (V2) am not sure which foot R4 injured or what the exact physician orders for R4's fracture foot was. When V2 was asked what could happen to a resident who should be supervised while operating a motorized wheelchair is operating a motorized wheelchair unsupervised and V2 stated, The resident could injure themselves. A lot of possibilities of things can happen. R4's Brief Interview for Mental Status (BIMS) dated 02/03/2023 documents that R4 has a BIMS score of 13 which indicates that R4 is cognitively intact. Facility's document dated 12/25/22 and titled Patient Report documents, in part: Findings: Trauma to foot. Right Foot: 5 images . Impressions: 1. Acute fracture involving the base of the proximal phalanx of the right great toe. R4's Occupational Therapy Recertification and Updated Plan of Treatment dated 12/12/2022 through 03/09/2023 and documents, in part: STG (Short Term Goal): R4 able to operate basic controls of R4's motorized wheelchair independently . LTG (Long term Goal): R4 will be able to navigate turns doorways independently with R4's motorized wheelchair . STG: R4 will be able to navigate hallways independently with R4's motorized wheelchair . LTG: R4 will be able to park R4's motorized wheelchair in R4's room (navigating tight spaces). independently. Facility's document dated 09/27/22 and titled Motorized Wheelchair Evaluation documents, in part that R4 received a motorized wheelchair evaluation on 09/27/22. Facility's Initial Reportable to local agency dated 12/25/22 at 2:13 pm, documents, in part that on 12/23/22 R4 bumped R4's right big toe while in R4's motorized wheelchair, reviewed. Facility's Final Reportable to local agency dated 12/30/22 at 5:47 pm, documents, in part that R4 incurred injury while maneuvering R4's motorized wheelchair, reviewed. Facility's Policy dated 10/2021 and titled Safety and Supervision of Residents documents, in part: General: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wife priorities . Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents . 4. Employees shall be trained and in serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents . Resident-Oriented Approach to Safety: . 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS (Minimum Data Set) . Systems Approach to Safety: . 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 45780 2. On 2/6/23 at 11:59 AM, R9 was observed lying in bed in R9's room. No fall mats were observed on either side of R9's bed. The surveyor inquired about the most recent fall that R9 had on 12/10/22. R9 stated I slipped out the bed. On 2/6/23 at 12:10 PM, the surveyor inquired if V7 (Registered Nurse/RN) saw any floor mats on the floor or in R9's room. V7 replied, No floor mats. On 2/8/23 at 9:13AM, the surveyor observed R9 sleeping in bed with the floor mat propped up against the wall across from the bed. The rolling bedside table was noted with one end towards the bed and the other pushed away from the bed with a covered plate on it. At 9:14 AM, this observation was brought to the attention of V12 (LPN/Licensed Practical Nurse/Unit Manager). The surveyor inquired if R9 had a floor mat on the floor. V12 replied, No he (R9) doesn't. It's on the wall. They probably moved it because he (R9) has his breakfast tray. It (floor mat) should be on the side that he (R9) dominates. That's the side where his (R9) tray is. V12 called V22 (Certified Nursing Assistant/CNA) and instructed her (V22) to pick up breakfast tray and put down the floor mat. On 2/8/23 at 1:05 PM, V2 (DON) stated, My expectation is that if we have established someone as a fall risk, and if they have interventions care planned, then my expectation is that they are in place. V2 added that staff will move fall mats if the resident is eating because the bedside table will not roll over the mat, but as soon as the resident is through with eating, then I (V2) expect them to put the mat back in place. I would expect for it (fall mat) to be in place to the side that was identified. The surveyor inquired where it would be documented which side the fall mat should be placed. V2 replied, I would expect that they would say in the care plan either mat to right side or mat to left side. The surveyor inquired what is the risk to the resident if a fall mat is not in place? V2 answered, If they fall, they could potentially injure themselves. R9's Admission Record documents diagnoses including but not limited to history of falling, lack of coordination, hypotension, and acquired absence of right leg below the knee. R9's 01/20/23 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating R9's cognition is intact. R9 is listed on the facility's High Fall Risk list provided by V1 (Administrator) on 02/06/23. The facility Incidents by Date list with a date range of 11/1/22 - 2/6/23 documents that R9 had four falls on the following dates and times: 11/2/22 at 9:31 PM, 11/7/22 at 10:15 PM, 11/12/22 at 5:55 AM, and 12/10/22 at 10:31 AM. R9's 2/10/22 care plan documents, in part, Focus: (R9) has experienced an actual fall r/t (related to) impaired mobility, weakness and comorbidities. Interventions include but are not limited to Unilateral floor mat placed at bedside while in bed and removed when patient out of bed (initiated 9/30/22). The reviewed 6/21 Falls Management policy documents, in part, General: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan 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 .Fall Prevention Guidelines for all residents upon Admission/Re-admission: . 2. Residents at risk for falls will have Fall Risk identified on the interim plan of Care with interventions implemented to minimize fall risk.

Based on observation, interview and record review, the facility failed to identify and assess a new pressure injury, failed to ensure that multiple sheets are not used when using a low air loss mattress, failed to complete daily skin checks, and failed to turn and reposition every 2 hours for 1 (R1) resident out of 3 residents reviewed for pressure ulcer prevention and intervention. These failures resulted in R1 acquiring multiple facility acquired pressure injuries on the sacrum and left inner thigh and 2 new pressure injuries, one on the right upper back and one on the right lower back discovered during this survey. R1 was admitted to the facility on [DATE] and expired in the facility under hospice care on [DATE]. R1 was admitted to Hospice Care on [DATE]. Her medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:57 AM, R1 was observed lying in bed, on right side lying position with pillows in between the knees, with legs elevated using blue boots, on low bed, has special mattress, with oxygen on, non-verbal. Special mattress observed with top sheet, incontinent pad, and incontinence brief. V4 (3rd floor nurse supervisor) and V5 (Registered Nurse/RN in charge of R1) and V6 (Certified Nursing Assistant/CNA) was repositioning R1. Dressing on sacrum noted to be intact, no odor, no drainage noted. The left thigh wound is scabbed, no drainage noted. Two pressure injuries noted on back of R1, one on the right upper back and another one on the right lower back. Right upper back noted with no dressing, some serosanguineous drainage noted. On [DATE] at 11:00 AM V6 (CNA) cleaned and repositioned R1. V6 stated I reposition R1 every 2 hours. On [DATE] at 11:58 AM V2 (Nurse Practitioner) stated I know R1 had skin openings. If there was a new skin opening, I expect that I be notified, and treatment orders initiated right away. Knowing that R1 is high risk for pressure injuries, even on Hospice, it is expected that treatment orders are initiated right away. Asked if she thinks that a Deep Tissue Injury can develop overnight. V2 stated, No I don't think that Deep Tissue Injury developed overnight, it should have been picked by the facility. On [DATE] at 12:00 PM during wound care observation with V7 (Wound Care Registered Nurse), R1 is now on the left side lying position. V7 stated R1 has pressure injuries on R1's sacrum and one on the front of left thigh. R1 doesn't have anything on R1's back. R1 only has orders for R1's sacrum and the one on R1's left thigh. V7 removed old dressing to sacrum wound. No drainage noted, wound bed is pink and red, peri wound area is darker in color than R1's natural skin. V7 cleaned the wound and changed to a new dressing. Surveyor pointed out to V7 two areas on right back area. Right upper back has an open area. V7 stated that it measured 1.4 x 1.1 cm noted, wound bed is 20% pink and 80% purplish in color. Another area on right lower back was noted to be purplish in color. V7 stated it measured 1.7 x 5.2 cm and stated, I consider that a Deep Tissue Injury. This is my first time seeing R1, so I don't know if it was there yesterday already. But there are no treatment orders for those, so I assume those are new. I will call the doctor today and get orders. On [DATE] at 1:05 PM, V8 (Director of Nursing/DON) stated We do skin checks based on their Braden. If Braden is 9 and above, skin checks are done twice a week. The skin checks are documented by the nurse in the Medication Administration record. When a staff member discovers an open area or wound, they have to report it to the nurse. When on a special mattress, the resident can have a flat sheet and an incontinence pad. R1 should not have had have multiple linens on top of the special mattress. On [DATE] at 4:14 PM V6 (CNA) stated Those wounds on R1's back has been reported. I reported it to the nurse that it was red about a week ago. Yesterday it was already there, and the wound care nurse put a bandage on it. On [DATE] at 12:34 PM, V9 (Wound Care Nurse) who worked on [DATE] stated Yes, I worked on Friday, [DATE], as the Wound Care Nurse. I really don't remember R1 because I only helped out there, I am from another sister facility. I was there around after 4:00 PM. I didn't put a dressing on her back. I can't really recall where R1's wounds are because I am not familiar with the residents there because I don't work there regularly. I don't recall seeing any wound on R1's back. I don't recall rolling anybody over and seeing a wound on their back. If I saw a dressing on it, I would have checked the wound. R1's Turning and Repositioning Log for February 25, 2022, to [DATE], documents R1 is not being turned and repositioned every hour as ordered. R1's Daily Skin Check Log documents that daily skin check was not completed on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. R1's Braden assessment dated [DATE] documents a score of 11 which means that resident is high risk for developing pressure ulcers. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . POS also documents [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders for the pressure injuries on the back were found on the POS. Treatment orders for the right lower and right upper back were ordered on [DATE] after surveyor discovered the pressure injuries. Facility Wound Summary Report documents that R1 has a facility acquired Deep Tissue Pressure Injury on the Left Front Thigh that was identified on [DATE] and a facility acquired stage 3 pressure injury on the sacrum that was identified on [DATE]. There was no documentation regarding the pressure injuries on the right upper and right lower back identified by the surveyor during the survey. Progress notes document that V2 (Nurse Practitioner/NP) assessed R1 in person on [DATE]. Progress notes document that V2 (Nurse Practitioner/NP) called family of R1 to update family on R1's condition and left a message. R1 was also assessed in person by V8 (NP) on [DATE], [DATE], [DATE], [DATE]. R1 was also seen by an V9 (an Infectious Disease NP) on [DATE] to assess R1 after completing antibiotic dose. Facility presented document titled Skin Care Prevention dated ,d+[DATE] which documents in part under Guidelines: 3. All residents will be observed daily for changes in their skin condition. 4. Residents will be assessed during care for any changes in skin condition including redness or any alteration in skin integrity, and this will be reported to the nurse. Facility presented document titled Skin Management: Specialty Mattress dated ,d+[DATE] which documents in part under section Procedure: 1. As per manufacturer guideline, no more than 1 piece of linen will be placed between the mattress and the resident.

Based on observation, interview, and record review the facility failed to follow its abuse policy; failed to protect R3 from physical abuse; failed to identify and report abuse immediately. These failures affect 1 resident (R3) out of 3 residents (R1, R2 and R3) reviewed for abuse. Failures resulted in bruising of R3's left eye periorbital area requiring transfer to acute facility for CT scan. Findings include: The Facility's Abuse Prevention Program states under Objective: The objective of the Abuse Prevention Program is to comply with the seven- step approach to abuse and neglect detection and prevention. II. Identification and Internal Reporting states: The direct care staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. Internal Reporting states: Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observed, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Any employee who knows or suspects that abuse has not been reported the abuse or makes false allegations of abuse will face possible termination. Any employee who knows or suspect that abuse has occurred and makes immediate report out of a legitimate concern shall not be penalized or reprimanded for making such report. IV. Investigation states: As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation which may include the following elements: - Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the suspicion, allegation or incident; The alleged victim (if the victim is unable to be interviewed, this shall be documented); The alleged perpetrator; Any witnesses or potential witnesses to the alleged occurrence or incident; Any staff having contact with the resident during the period of the alleged incident; Roommates, other resident, family or visitors. - A review of the medical record, including care plan; - A review of all circumstances surrounding the incident; and - Physician will be notified of any incident and any medical treatment will be done as ordered. The investigation shall be conclude whether the allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation can likely be sustained. Record of the investigation shall be maintained. V. Reporting and Response states: An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed. R3 originally admitted in the facility on 7/10/20 with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief Interview of Mental Status of R3 dated 9/15/21 has a score of 2 that means R3 status during the interview was cognitively impaired. On 12/14/21 at 9:50 AM with V1 (Administrator) stated that R3 was sent to the hospital on 12/5/21 for CT scan due to left eye bruising. V1 then stated that upon investigation, V9 (Certified Nursing Assistant) admitted that she (V9) hit R3's left eye. V1 then stated that V9 did not report the incident when it happened. It was reported by a nurse that was scheduled 7:00 am to 3:00pm the following day. Per V1, V9 worked on 3pm to 11pm on 12/4/21 when the incident happened. V1 said, I agree she (V9) should have reported it. I know this is a problem, she (V9) should have reported it to me or the nursing manager. V1 then stated, upon learning about the incident V9 was suspended on 12/5/21. Later V9 was terminated after investigation, V9 was informed when she was summoned in the facility that she (V9) was terminated. On 12/14/21 at 11:10 AM R3 was seen in R3's room in a wheelchair. R3 was alert but not able to be interviewed due to R3's cognitive status. R3 has discoloration / bruising on the left eye. At the Nurse's Station, V12 (Registered Nurse) said, I worked on 12/5/21 day after the incident. And when I came on the unit reporting to work. I saw R3 sitting on the wheelchair at the Nurse's Station. Right away I noticed the left eye of R3 were swollen and bruising. I then called V1 (Administrator). V1 instructed me to call the doctor. And I (V12) was given an order to send R3 to Emergency Department of the hospital for CT scan. I do not know why the night shift nurse (V14) and all Certified Nursing Assistants working in the night shift (11pm-7am) did not catch or see the bruising of R3's left eye. On 12/14/21 at 11:20 AM V13 (Nurse Manager) stated that she worked on 12/4/21 (Saturday) until 8:00 PM. When she left the facility R3 was in the dining room. V13 then said that on 12/5/21 I (V13) received a call from V12 that R3 has a bruising on R3's left eye and it was also swollen, he (V12) also sent me (V13) a picture of R3's left eye. I then called Certified Nursing Assistants working at that time. Eventually, I spoke to V9 (Certified Nursing Assistant) who worked on 12/4/21 3:00 PM to 11:00 PM shift. V13 said, V9 told me that R3 was combative during the time that she (V9) was changing R3's clothes. And she (V9) said that she hit R3's left eye. I (V13) told her (V9) that she should have reported the incident right away. And not leave the facility without reporting it to either the nurse or nursing supervisor or the administrator. Because now it looks like she (V9) abused R3. V13 then said, V10 (Certified Nursing Assistant) was assigned to R3. Nursing staff working in the night shift should have noticed (R3) left eye bruising. It should not reach for the morning shift or for V12 to see it. R3 needs help to transfer on the wheelchair. And whoever transferred her (R3) on the wheelchair should have seen R3's left eye bruising. On 12/14/21 at 1:19 PM. V9 (Certified Nursing Assistant) said, I worked on 12/4/21, 3:00 PM to 11:00 PM shift and I was assigned to R3. It happened between the hours of 7:30 PM to 9:00 PM. R3 was wearing 2 shirts so it was hard for me to change R3's clothes. R3 was combative during that time and was holding down. I think because of my reflexes I hit R3's face. I did not report the incident, but I know I should have reported it. R3 refused R3's medication and was combative during that time. I was alone during that time and did not ask for help. I know that the right thing to do is to leave R3 alone and ask for help, but I did not do that. I started working at the facility around August this year and I was not given a training for abuse. I was trained for abuse when I got my certificate for Certified Nursing Assistant about 4 years ago. But I did not receive any abuse training from the facility. After I hit R3's left eye, I thought that it was just fine. I did not notify the nurse, it was V5 (Licensed Practical Nurse) working that day. I know that nurses are doing the assessment and I guess I should have notified her (V5). After the incident of hitting R3's left eye, I peeked into the room around 10:30 PM to 11:00 PM before I left the facility. But I did not see R3's left eye if there was bruising. So, I do not actually know if there was bruising or any injury to R3's left eye when I left the facility. On 12/14/21 at 4:17 PM. V5 (Licensed Practical Nurse) stated that she was working on 12/4/21 3PM to 11PM shift and was assigned to R3. V5 stated that V9 (Certified Nursing Assistant) put R3 to bed around 8:30 PM to 9:00 PM and that was the last time she V5 saw R3. V5 said V9 did not inform me about the incident that she (V9) hit (R3) left eye. And being R3's (V9) charge nurse, I expect V9 to report it to me. V9 should have brought R3 back at the Nurse's Station if she was having problem with R3. On 12/14/21 at 5:15 PM. V14 (Licensed Practical Nurse) stated that on 12/4/21 11:00 PM to 12/5/21 7:00 AM shift she took care of R3. And all through the shift she was not able to see the left eye bruising of R3. V14 also stated that V10 (Certified Nursing Assistant) was assigned to R3. And that the schedule provided to writer by the facility was incomplete. V14 further stated that V10 got R3 up and it was not possible to miss R3's left eye bruising. V14 said, I expect nursing assistant to update me in case that resident have incidents or unusual situations. V14 then stated that the nurse (V5) on 3:00 PM to 11:00 PM shift did not mention to her that R3 needs to be monitored. And all nursing staff that worked that shift on 12/4/21 11:00 PM to 12/5/21 7:00 AM shift was not able to report to immediate supervisor or abuse coordinator left eye bruising of R3. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/21 9:50 AM, a request was made to V1 for the nursing staff that worked on 12/4/21 when the incident happened. V1 provided an incomplete schedule. Which does not include V10. V10 (Certified Nursing Assistant) was the nursing staff assigned to R3 on 12/4/21 11PM to 12/5/21 7AM shift the shift after the incident happened. V1 then informed through email and requested for the complete nursing schedule with V10's contact information. V1 provided a non-working number of V10. And said that he (V1) will inform V10 to provide for a working number. None were provided. V1 was requested multiple times (12/14/21, 12/15/21, 12/20/21) for contact information of V10. On 12/15/21 at 10:25 AM. V1 (Administrator) stated that a complete investigation was requested. And he submitted a final incident report without details of facility staff that was interviewed. V1 stated that V13 (Nurse Manager) and V14 (Licensed Practical Nurse) were interviewed. When asked if he confirmed that V10 (Certified Nursing Assistant) was taking care of R3 on 12/4/21 11:00 PM to 12/5/21 7:00 AM. V1 said, Yes V10 was assigned to R3, V10 came in the facility today and was vague. V10 said that she saw R3's left eye bruising on Thursday 12/2/21. And when I (V1) looked at the camera R3 does not have a bruise on R3's left eye. V1 stated that it was not credible. V1 said, V10 statement was vague so I did not include it. On 12/16/21, V1 submitted handwritten document dated 12/4/21 timeline that V10 assisted R3 to Nurse's Station. V1 was then asked why V10 or any of the nursing staff (V14/LPN, V17/CNA, V18/CNA, V19/CNA and V20/RN) that worked 12/4/21 11PM to 12/5/21 7AM did not report R3's left eye bruising. V1 did not answer. A request was made to V1 to see camera footage on 12/4/21 to 12/5/21 since he was able to access prior date (12/2/21 / Thursday). V1 stated that he will check because it may be erased (V1 was not able to confirm request). V1 was then asked why any of the nursing staff both nurse and certified nursing assistants that worked 12/4/21 11PM to 12/5/21 7AM did not notice or report the bruising of R3's left eye. And R3 was on the Nurse's Station transferred by V10 to the wheelchair and R3 needs assistance during transfers. V1 did not comment. V1 was informed that according to V9 (Certified Nursing Assistant) during changing of clothes R3 was with behavior. And it was by her reflexes that she (V9) hit R3's left eye. V1 said, I did not know about that because she (V9) told me different things. But if that was the case it is an abuse. V1 was asked that since yesterday morning a request was made to him of all documentation related to R3's incident including statement of V9 and V10. And that it was not included in the submitted documents although it is pertinent to the investigation. V1 did not reply. V1 was also asked that since R3 was in hourly interval monitoring for safety as ordered and there are 5 to 6 nursing staff on the floor why was none of the nursing staff noticed or observed the bruising on R3's left eye. V1 said that they (nursing staff) must be doing other things. V1 was then asked after knowing the incident about R3 left eye bruising if he (V1) came to look at R3's left eye? V1 said, Yes, I did come and see R3's left eye, the bruise was big purple. On an email dated 12/20/21, V1 (Administrator) submitted a picture taken by V12 showing the extent of R3's left eye bruising on R3's periorbital area. 12/15/21 at 11:05 AM. V11 (Detective) that came responded and came on 12/5/21 said, The nature of her investigation is criminal. And part of her responsibility is to coordinate with the State if the facility reported the incident to the State. Because there are instances that facility do not report incidents to the State. And to notify immediate family of R3 in this case V15 (R3's Son). I (V11) spoke to V15, the facility did not inform him (V15). V15 is the Power of Attorney (POA) and he lives just walking distance from the facility. Not informing family members is a violation of the law and a case can be filed for not informing the family. R3 has a pretty bad bruise, and (R3) family does not know. I can't lie. V9 can also be arrested but I was considering that she is just [AGE] years old with no prior record. But this should be a lesson to her that she needs to notify proper authority. I will put in my report that she (V9) strike (R3) whether she (V9) intended or not and cause injury to the (R3). Progress notes of R3 have incidents of injuries reads: V16 (Registered Nurse) documented on 1/1/21 that she (V16) was informed by Certified Nursing Assistant that R3 was in bed sleeping. When R3 awoke R3 attempted to scratch Certified Nursing Assistant, R3 lost balance and fell on left elbow. On the date 1/1/21 X Ray was done on left elbow and left ribs. Left elbow has a result of distal humeral fracture. And left ribs have acute left lateral eight rib fracture. V12 (Registered Nurse) documented on 2/18/21 that R3 complaint of pain on right hand. Right hand tender to touch. X Ray on the right hand was ordered and performed. V12 (Registered Nurse) documented on 3/28/21 that R3 was noted with redness on the left elbow with small open area. X Ray on the left elbow was ordered and performed. A request through email was made to V1 (Administrator) for detailed investigation and report to State Agency related to the above noted incidents dated 1/1/21, 2/18/21 and 3/28/21. No report and details of the investigation was received. Care plan of R3 reads: R3 requires assist with ADL (Activity of Daily Living) related to co-morbidities. R3 needs extensive assist of 1 staff with dressing, toileting, personal hygiene, bathing, bed mobility, transfer, locomotion. Progress notes of R3 dated 12/5/21 by V12 (Registered Nurse) documented that due to left eye bruise and swelling R3 was sent to hospital for CT scan of the head.

Based on observation, interviews and record review the facility failed to provide clinical interventions for pain for more than 2 days and addressing fracture pain in the care plan for 1 resident (R3) of 1 resident reviewed for injury of unknown origin in a total sample of 3 residents. These failures resulted to unmanaged pain and late determination of R3's right ankle fracture that led to the transfer of R3 to the hospital and a surgery procedure was done. Findings include: R3 was admitted in the facility on 9/17/21 with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/21 at 11:09 AM surveyor observed R3 in R3's room on the bed. R3 had a brace on R3's leg right lower leg and was alert with brace on right lower leg. R3 stated, My leg hurts! (Pointing at R3's right lower foot.) Why are you here? I see you all the time snooping around! What do you want? Surveyor told V4 (Licensed Practical Nurse/LPN) R3 was not able to answer questions and asked for assistance regarding the resident but V4 said she was busy at that time. R3's progress notes dated 10/8/21 at 11:26 AM (V10 Physician Assistant- PA / Physiatrist) documented the following: R3 was complaining of pain to (R3) right ankle which noted to be swollen and bruised. R3 is unable to give any details regarding how long R3's ankle has been hurting or how it occurred. Therapy does note that R3 was unwilling to stand yesterday. Physical Examination: Ecchymosis to right ankle medially, tenderness to palpation of right ankle and pain with range of motion of right ankle. Assessment: Pain Management, right ankle pain. Plan: Tylenol as needed, Right ankle pain, pain control, X Ray to evaluate for fracture. Continue to monitor. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's right ankle X Ray result was received on 10/10/21 at 9:55 PM. The result was right ankle Distal Tibial Fracture. Per R3's progress notes dated 10/11/21 at 4:07 PM documented by V16 (LPN) it reads that R3 was admitted in the hospital with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/21 at 10:19 AM V10 (PA / Physiatrist) states I saw R3 on 10/8/21 between 9am to 2pm, and the notes I placed on 10/8/21 was my initial assessment. I noted that (R3) right ankle was swollen and with bruising that day. Yes, there was pain as I put in my notes. It was during my assessment that I observed it and no staff informed me about (R3) ankle. I discussed the problem with V14 (Clinical Nurse Practitioner) that day and ordered an X- Ray for R3's ankle. Regarding orders with residents, I always coordinate it with either the Primary Physician or the Director of Nursing. On 11/10/21 at 12:32 PM V15 (Clinical Manager) stated, When there is a change of condition of a resident, we do an assessment right away and follow the SBAR (situation, background, assessment and recommendation). Then we notified the doctor what was the change of condition. We carry out the doctor's order right away or immediately. It is also the same when the doctor is here in the facility. When an order is given, we need to carry it our immediately. I was not aware that R3 had a swollen ankle on (R3) right leg during the time V10 assessed R3. It was not right for the X-Ray to be done on 10/10/21 when it was already assessed on 10/8/21 as having swollen and bruising. I will check on this or what happened. Regarding pain, I don't know why there was not medication ordered to address pain. Yes, because R3 has a fracture pain should have been addressed. On 11/10/21 at 1:30 PM V16 (LPN) stated that R3 was assigned to her and she took care of R3 on 10/8/21, 7 AM to 3 PM shift. V16 stated that she did not know that R3 has swollen and bruising on R3's right ankle until she worked on Monday 10/11/21. V16 further stated that she was not able to assess R3 the whole day, and that R3 was unable to express self if R3 has pain. After few minutes V16 left the room, came back and said that she was mistaken. V16 said she worked on 10/8/21 and also worked double the following day, which was 10/9/21, from 7 AM to 11 PM. V16 further stated that she was not able to assess R3 right ankle, or if R3 had pain in general. On 11/10/21 at 3:10 PM V19 (Certified Nursing Assistant-CNA) stated, I worked on both days October 9 and 10 on 7 AM to 11 PM shift, and I notice that R3 has a problem on the right foot because when I did patient care R3 told me don't touch me because it hurts. I looked at R3's ankle and it was really, really, red and warm to touch. I remember (R3) barely touch R3 breakfast or lunch. I cannot remember if it was on the 9th or 10th of October, but it was really-really red, really soft and hot. I cannot remember the name of the nurse that I informed about R3 ankle. But it was super red. I remember that it was the day when an X - Ray person came in the facility and did the X-Ray. If the X-Ray was done on the 10th (October) then it must be on the 10th. I wrote it in a piece of paper about R3's ankle because I know something like this will happen. I don't know where that paper is now, but I know I wrote it. On 11/10/21 at 3:20 PM V20 (CNA) stated, Yes, I was assigned and took care to R3 on 10/8/21. R3 stayed in bed the whole day since R3 said R3 was tired. Yes, R3 needs assistance with changing R3's clothes but R3 was wearing socks, so I did not notice (R3) right ankle. I changed R3 diaper but did not see (R3's) legs the whole shift. R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Full care plan was submitted and reviewed; pain was not updated related to the fracture. On 11/10/21 at 2:45 PM V18 (MDS Coordinator) stated she should have updated the care plan to include pain related to right ankle fracture as an identified problem and to put intervention to address the problem. On 11/12/21 at 10:39 AM V21 (Primary Physician) stated that R3 was sent to the hospital and surgery was performed because of right ankle fracture. V21 said that he needs to review R3's record about why X- Ray was done after 2 days. V21 stated that V10 can place the order herself. V21 was not sure about pain management and stated that nursing staff needs to assess each resident for pain. V21 stated that any person who has fracture have some degree of pain. V21 further stated that as needed medication should have been place in case resident needs it.

Based on observation, interview, and record review, the facility failed to intervene to prevent R1, a demented resident, from falling resulting in a laceration to the back of his head that required sutures. This failure affects one of three residents reviewed for falls in a total sample of six. Findings include: R1 is a [AGE] year-old male. R1's diagnoses are but not limited to abnormalities with walking and mobility, muscle weakness, dementia with behaviors and Alzheimer's disease. R1's BIMS (Brief Interview for Mental Status), dated July 4th, notes that R1 is not cognitive. R1's BIMS also notes that he has an unsteady gait and has lower leg impairments. Fall risk screen dated 10/18/2020, the last documented assessment for falls, notes R1 as high risk for falls. The only other fall assessment in R1's medical file is after his fall. It is dated 06/26/2021. On 07/27/2021 at 12:55PM, R1 was not able to answer any questions pertaining to his fall in the facility. R1 was very confused. On 07/27/2021 at 1:15PM, R1 was ambulating throughout the facility. R1 has very unsteady balance and holds onto things as he walks. R1 is not very steady when he walks. R1's room is far away from the nurses' station. R1 walks aimlessly throughout the unit. R1 is very impulsive. Incident report dated 06/26/2021, listed as a fall with serious injury, notes R1 was noted on the floor with an open area to the back of his head. R1 could not tell staff what happened. The root cause was determined that R1 was ambulating without appropriate footwear. On 07/27/2021, at 1:11PM, V6 (Certified Nursing Assistant) stated, we get briefed about falls at the nursing station. He has fallen before. If they are a fall risk, we don't leave them in the room by them self. On 07/27/2021, at 2:24PM, V2 (Director of Nursing) stated, I was told that he was ambulating and slipped and fell backwards. He was not wearing the proper footwear. He had a laceration on the back of his head. I cannot remember if anyone told me if they intervened. On 07/29/2021, at 11:27AM, V15 (Restorative Nurse) stated, R1 ambulates short distances but his dementia makes him unsafe at times. The fall happened in his room. After the fall, the environment is assessed for safety. The resident is assessed as well to make sure they are performed like they were before. To me, he seemed to be appropriate. He was not wearing any non-slip footwear. The footwear was put in place after his fall. We encourage staff to document what they see and what they observe.

Based on interview and record review facility failed to follow their abuse policy for two residents (R1, R2) out of four residents reviewed for abuse. The failure of the facility failing to identify a pattern for R1 agitating his roommate(s) resulted in R1 agitating R2, his roommate by punching R2 in the face. This resulted in R2 punching R1 back several times in the face several and subsequently R1 sustained acute subdural hematoma and left eye enucleation from the fight. Finding Include: On 6/17/21 at 1:00 PM, R2 stated he was sitting in his bed, R1 rolled his wheelchair up to him and punched him in the nose. R2 stated he got up punched R1 a few times in the face then R1 rolled away out of the room in wheelchair into the hallway. R2 stated he and R1 had been roommates for a month before that day (12/22/21) and does not know why R1 punched him. R1's hospital records dated 12/22/20 denote R1 had an altercation with roommate resulted in bruising to face, subdural hematoma and left eye enucleation. Hospital CT scam impression denotes acute subdural hematoma. R1'S 12/22/20 7:20 AM Behavior Note Text reads: Upon during rounds client was noted in their room and resting well in his w/c. As writer was finishing my rounds. I heard yelling form room [ROOM NUMBER]. Upon entering client room. Client was noted with open to rt eyebrow and rt face swollen. Frist aid given, NP (Nurse Practitioner) and family (sister) made aware of the above information. 12/22/20 Resident was transferred to hospital for further evaluation. R1's 12/22/2020 11:30 AM Behavior Note Text reads: Writer had a shower and first-aid given before leaving unit. Client remains a/o x 3, able to make needs known. Writer asked client what happen. Per client I called him a[OBSCENITY] and rolled over and hit him and we began to fight. here for transport x 2 crew members going to ER for CT scan. During interview on 6/16/21 at 11:40 AM, V3 (Registered Nurse) stated he has been taken care of R1 and R2 for a while. V3 stated R1 has history of not being a good neighbor and doing things that make his roommates mad like shi*** on the floor. V3 stated R1 also has history of being the controller of his room and it seem like he does not like any roommates and does little things in his room when he has a roommate that can be annoying to the other person. V3 stated noticed that when R1 does not have a roommate he'll never Sh** in the floor but when he gets a roommate, he does things like that. V3 stated R2 has no history of being physically aggressive towards other resident but will not tolerate other residents being disrespectful to him and will stick up for himself. V3 stated R2 can get very upset if someone makes him upset. V3 stated was working on the floor with R1 and R2 on the day (12/22/20) of the incident. V3 stated R1 came out of his room with left eye swollen. V3 stated asked R1 what had happened. V3 stated R2 told him that their wheelchairs bumped and R2 told R1 to excuse himself and R1 told R2 he didn't have to and punched R2. V3 stated he asked R2 what happened and R2 told him that after R1 punched him he punched R1 twice in the face with his fist. V3 stated that was the first time that he knew of or heard of R2 punching/hitting another resident. V3 stated R1 has history of being the controller of his room and does not like to share rooms. V2 (Nurse Practitioner) stated an eye enucleation is a serious eye injury and subdural hematoma is a serious injury as well, which is a collection of blood between the brain and skull. V2 stated R1 had to be sent out to the hospital after an altercation with his roommate (R2) to be assessed and monitored if necessary. V2 stated the hospital did assess R1 and made a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated the other resident that hit R1 in the head caused both injuries the subdural hematoma and eye enucleation. During interview on 6/17/21 at 12:10 PM, V9 (Licensed Practical Nurse) stated she has been taking care of R1 for about five to six years. V9 stated R1 would get a roommate but after a while R1 would do little things to agitate his roommate(s). V9 stated she knew of one time when R1 got into verbal altercation with his previous roommate because he was holding the bathroom up knowing that his roommate needed to use the washroom. V9 stated the situation never escalated to physical confrontations or abuse however R1 was moved to another room if him and the roommate did not get along. Facility's abuse policy denotes residents have the right to be free from abuse, neglect, exploitation, or mistreatment. The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse. This will be accomplished by identifying occurrences and patterns or potential mistreatment.

Based on interview and record review facility failed to uphold professional standards of practice by not reconciling a resident's medications from hospital to transfer back to NH, and meds from this NH prior to transfer to hospital for one resident (R1) out of three residents reviewed for medications. This failure resulted in R1 having a Gran Mal [CONDITION(S)], and having to be taken back to the hospital. Findings Include: R1's face sheet denotes diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital transfer sheet dated 12/31/20 denote [MEDICATION(S)] 5oomg three times a day. R1's 1/11/2021 9:02 PM Nurse Practitioner Narrative/Physician Assistant Note Text reads: SUBJECTIVE: Patient seen and examined today for readmission from Hospital [CONDITION(S)]- No recent [CONDITION(S)] activity. Per Neuro while IP, [MEDICATION(S)] was stopped, but Valproate 500 mg PO TID was continued. R1's medication sheet dated from 1/11/21 thru 2/8/21 denotes R1 did not receive Valproate 500mgTID (three times a day). R1's 2/9/2021 12:40 AM Health Status/Progress Note Text reads: Upon rounds writer noted in his room slumped over in his wheelchair with noted body twitching. Resident unresponsive to all stimuli and with rapid breathing. Resident assisted to his bed per staff for assessment and having continuous Gran-mal [CONDITION(S)] activity with unresponsiveness. 911 called due to resident having continuous [CONDITION(S)] activity. Awaiting arrival. Resident remain unresponsive with rapid respirations and elevated B/P and HR. Resident transferred out to ER. R1's hospital records dated 2/9/21 denotes [AGE] year-old male with history of seizures. Presented with general tonic-clonic [CONDITION(S)]. Patient is on [MEDICATION(S)] for seizures. Medicine not on list of paperwork brought. Constitutional: no distress, regular heart rate and respiration clear upon auscultation. During interview on 6/16/21 at 11:15 AM, V2 (Nurse Practitioner) stated taking Valproate 500mg (milligrams) three times a day is medicine given to residents to prevent seizures. V2 stated the nurses were supposed to have been giving R1 Valproate 500 milligrams three times a day. V2 stated R1 did have a gran mall [CONDITION(S)] which means R1 went into convulsions that lasted longer than a minute. V2 stated when anyone has a grand mal [CONDITION(S)], they lose control of their extremities and bladder which was the case with R1. V2 stated not treating seizures can cause permanent brain damage if not treated. V2 stated R1 does not have permanent brain damage and is now on anti-seizures medications. On 6/16/21 at 2:37 PM, V7 (Nurse Practitioner) stated V7 went thru the hospital admissions paperwork on 1/11/20 and noted that R1 was to start Valproate 500mg three times a day to prevent seizures. V7 stated when she put the medications in her notes that R1 was to be started on and the facility was responsible if any questions with what is written. V7 stated she put in her note that Valproate 500mg three times day for seizures. V7 stated gran mall seizures can potentially harm the body by causing brain damage if untreated. During interview on 6/17/21 at 12:10 PM, V9 (Licensed Practical Nurse) stated she has been taking care of R1 for about five to six years. V9 stated on 2/9/21 that was the first time that she witnessed R1 having a [CONDITION(S)]. V9 stated when saw R1 having the [CONDITION(S)] he was sitting in his wheelchair, kept him in the chair from falling and yelled for someone to called 911. V9 stated they got R1 back to the bed and the [CONDITION(S)] stopped and then started back again. V9 stated if Nurse Practitioner (NP) put order in that they want the resident to take something the nurses go into the system and check for all new orders written by MD/NP. V9 stated once the order is confirmed put it on the MAR/TAR. V9 stated if NP/MD write an order in their progress note the nurse is to question or confirm if the NP/MD wanted that medicine started. Facility's medication administration policy denotes all medications are administered safely and appropriately to overcome illness, relieve, and prevent symptoms and help in diagnosis.

Based on interviews and record review, the facility failed to timely medicate and properly manage a resident's pain for one (R569) of three residents reviewed for pain in a sample of 65. This deficient practice caused R569 to suffer with increased pain over a four day time frame. Findings included: R569's admission record documents, in part, [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) for R569, dated 1/6/21, indicates a brief interview for mental status (BIMS) as 14 as cognitively intact. On 3/17/21 at 2:00 pm, R569 was interviewed and stated that her pain is not good because she has spinal stenosis. R569 stated that on 2/23/21 at 4:00 pm, she fell to the floor when trying to go to bathroom as she stood up from her bed. R569 stated that she hollered out with the room door open and that nurses responded to her. R569 stated that she didn't know the names of the nurses. R569 stated that she was in pain with her right leg hurting and that she couldn't lift her right leg. R569 stated, I was hurting so bad and that she was sent out to the hospital. On 3/16/21 at 3:00 pm, V14 (Licensed Practical Nurse, LPN) stated that on 2/23/21, he was working from 7:00 am to 7:00 pm in the facility and was reassigned to go work on the 4th floor from 3:30 pm-7:00 pm. V14 stated that he was finishing receiving report from the 4th floor off-going nurse (V13, LPN) and heard a loud noise coming from R569's room at 4:00 pm. V14 stated that he went to R569's room and saw R569 face down on the floor in front of her wheelchair in front of the bathroom door. V14 stated that R569 was alert, was complaining of right leg pain and stated that she was trying to get up and fell down. V14 stated that he performed vital signs that were stable and that he assessed R569's right leg for tenderness and sensation, saying, It was normal to me. V18 (LPN) came into R569's room and assisted him with a manual transfer of R569 from the floor to her bed. V14 stated that he didn't give R569 any pain medications at this time due to his nursing report from V13 that [MEDICATION NAME]-[MEDICATION NAME] had been given to R569 three hours ago so she wasn't due yet. V14 stated that R569 was not over-sedated or lethargic. V14 stated, (R569) will trick nurses to get more pain medications. (R569) has an addiction. V14 stated that R569 is always complaining of pain and has drug seeking behaviors. V14 stated that R569 has had neck surgery and gets whenever needed pain medications every 4 hours. R569's Medication Administration Record [REDACTED]. On 2/23/21, R569's MAR indicated [REDACTED]. On 2/23/21 at 4:00 pm, V14 documented, in part, that R569 was complaining of mild right lower leg pain which manage with pain medication. On R569's pain evaluation, dated 2/23/21 at 5:18 pm, V14 documented that R569 was having right lower leg pain, present pain level of 4 out of 10, and with alleviating factors of medication of ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 mg. On 3/16/21 at 3:00 pm, V14 (LPN) adamantly stated that he did not administer [MEDICATION NAME]-[MEDICATION NAME] to R569 on 2/23/21. V14 stated that he medicated R569 with a dose of [MEDICATION NAME] for her complaint of right leg pain on 2/23/21. V14 stated that he ended his 12 hour shift on 2/23/21 shortly after 8:00 pm. On R569's facility incident report, dated 2/23/21 at 5:18 pm, V14 documented as immediate action taken as, 500 mg [MEDICATION NAME] was given to ease the pain. Facility time record for V14 indicates that on 2/23/21, V14 worked from 6:58 am to 8:14 pm. On 3/17/21 at 12:21 pm, V18 (LPN) stated that he assisted V14 (LPN) when R569 fell on [DATE] in the facility. V18 stated that V14 was R569's primary nurse and that he did not witness R569's fall. V18 stated that when he responded, he observed R569 on the floor in her room and that R569 was saying that she was trying to go to the bathroom. V18 stated that R569 was complaining of leg pain, but could not remember which leg. V18 stated that when R569 was back in bed, she was in pain, not coherent and her eyes were rolling back. V18 stated that R569 was lethargic like and coming in and out. V18 stated that R569 is normally completely alert, so this was a mental status change. V18 stated that he then discussed this new finding with R14 and that they both tried to figure it out. V18 stated that per his nursing judgement and thinking about R569's history of overdose, he speculated that R569 may have connected with somebody to receive illicit drugs to cause her altered mental status. V18 stated that he administered [MEDICATION NAME] to R569 via her nostrils. V18 stated that after 10 seconds, R569 was alert, eyes were open and that she was still complaining of leg pain. V18 stated that he's not sure if V14 medicated R569 for the leg pain and that R569 usually gets [MEDICATION NAME]-[MEDICATION NAME] every 4 hours whenever needed for pain. R569's Medication Administration Record [REDACTED]. On 3/17/21 at 11:05 am, V21 (ADON) stated that she was briefly assessed R569 after she had fallen on 2/23/21 and that she was crying in pain, complaining of pain to her right leg and that when V21 tried to perform ROM of the right leg, R569 screamed out in pain. V21 also stated that R569 was incoherent and appeared high on something. V21 stated that she told V18 (LPN) to see if there was an order for [REDACTED]. V21 stated that she didn't know the pain medications that R569 was on at this time on 2/23/21. V21 stated that nurses are to perform pain assessments at least once a shift, at the beginning of shift and then reassess for pain one hour after any medication is administered for pain. In R569's facility document, titled Fall Event and dated 2/23/21 at 5:18 pm, V18 (LPN) documented, in part, that R569 had a deviation from usual mental status, range of motion (ROM) was painful in lower extremities and that V19 (NP) was notified at 6:48 pm on 2/23/21. On 3/17/21 at 12:21 pm, V18 stated that he documents in the electronic MAR indicated [REDACTED]. V18 stated that he took over care for R569 until he gave report to the on-coming nurse (V17, LPN) at 11:00 pm. V18 then stated that he most likely had a phone conversation with V19 (NP) on 2/23/21 and notified him of R569's fall with right leg pain. V18 stated that he then gave report to the oncoming night shift nurse (V17, LPN) on 2/23/21 at 11:00 pm. V18 stated that with a change of condition, such as altered mental status or acute pain after a fall, it would be criteria to send a resident to the hospital for further evaluation. V18 stated that did not medicate R569 for her pain on 2/23/21 and that R569 did not receive any X-rays on 2/23/21. R569's MAR, dated February 2021, documents, in part, that [MEDICATION NAME] 500 mg by mouth every 6 hours as needed for moderate pain, [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg by mouth every 4 hours for pain as needed were ordered for R569. R569's MAR indicated [REDACTED]. On 3/18/21 at 11:00 am, V19 (NP) stated that on 2/23/21, he was notified over the phone by a nurse of R569's fall incident, but he couldn't recall the nurse's name. V19 stated that he remembered being informed that R569 fell down to the floor from her wheelchair and fell face forward. V19 stated, I gave the nurse an order to send R569 out to the emergency room . V19 stated that he did not recall being informed of R569's new right leg pain after her fall incident on 2/23/21. On 3/17/21 at 7:30 am, V17 (LPN) stated that she was on 11:00 pm to 7:30 am nurse for R569 on 2/23/21. V17 stated that she received report from V18 that R569 had fallen to the floor earlier in the previous shift. V17 stated that as she is getting report from V18 at the nurse's station, she can R569 screaming in paranoia. V17 stated that R569 was screaming her name, so she went to see R569. V17 stated that R569 was in pain and asked her if (R569's) daughter was dead? V17 stated that she had never shown this behavior before. V17 stated that R569 wasn't moving and upon repositioning of R569 for comfort, she screamed, My right leg! V17 stated that R569 was clinching her teeth and screaming over and over. V17 stated that she notified V20 (Physician) about R569's mental status change, intense pain and not being able to move her right leg. V17 stated that V20 gave her a telephone order to send out R569 to the hospital for further evaluation. V17 stated that she sent R569 to the hospital on [DATE] at 2:00 am. On 3/18/21 at 4:00 pm, V20 (Physician) stated that received a call from V17 (LPN) on 2/24/21 at 12:55 am notifying her of R569's pain of 10 out of 10, not able to move her right leg, confusion and hallucinations post fall. V20 stated that she gave a telephone order to V17 to send R569 out to the hospital via 911 emergency services. On 2/25/21 at 3:12 pm, V22 (Registered Nurse, RN) documented that R569 returned to the facility from the hospital with computerized tomography (CT) scans of the head, spine and right hip that were negative for fracture. On 3/17/21 at 7:30 am, V17 stated that she was R569's primary nurse the next night on 2/25/21 after R569 had returned from the hospital. V17 stated that R569's right leg was swollen and that she was in pain and screaming. V17 stated, (F569) couldn't move her leg. (F569's) pain was over the top. (F569) was having legitimate pain. V17 stated that she did not notify a physician this night shift on 2/25/21 about R569's increased pain. On 2/26/21 at 5:17 am, V17 documented that R569 is grimacing in pain every time (F569) is moved / repositioned. (R569) needs much assisting. R569's MAR, dated February 2021, documents, in part, that [MEDICATION NAME] 500 mg by mouth every 6 hours as needed for moderate pain, [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg by mouth every 4 hours for pain as needed were ordered for R569. R569's MAR indicated [REDACTED]. On 3/17/21 at 7:30 am, V17 stated that she was R569's primary nurse on the night shift of 2/28/21. V17 stated that R569 remained in pain and was confused. V17 recalled how on the night shift before R569 fell on [DATE], she was wheeling around the floor, heating up chicken in the microwave and having normal, oriented conversation with V17. Again, V17 stated that she did not notify a physician this night shift on 2/28/21 about R569's pain, confusion and application of oxygen. On 2/28/21 at 11:40 pm, V17 documented that she received (F569) trashing about. Screaming on occasion, moaning and confused. Alert and oriented times 1-2. SaO2 (oxygen saturation) 91% on room air. (F569) placed on 2 liters per nasal cannula. R569's MAR, dated February 2021, documents, in part, that [MEDICATION NAME] 500 mg by mouth every 6 hours as needed for moderate pain, [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg by mouth every 4 hours for pain as needed were ordered for R569. R569's MAR indicated [REDACTED]. On 3/17/21 at 2:00 pm, R569 was interviewed and stated that when she returned from the hospital on [DATE], her right leg was swollen and that the pain in her right leg got worse. R569 stated, It made me feel terrible inside. I was suffering and no one was doing anything to help me. R569 stated that she did then have an X-ray performed due to her my right leg being so painful and swollen. R569 stated, I was still in terrible pain. I was acting out and crying in terrible pain. After I fell , I cried more as a grown woman than I ever did as a kid. On 3/17/21 at 11:27 am, V22 (RN) stated that on the day shift of 3/1/21, she sent R569 out to the hospital for mental status changes from an order from V19 (NP). On 3/18/21 at 11:00 am, V19 (NP) stated that he has been R569's practitioner for 5-7 years. V19 stated that R569 has pain, gets her pain medications and that she's not a difficult patient. When asked if there's any non-pharmacological interventions that facility nursing staff could have used to help with R569's pain, V19 stated, Give (R569) her pain medications on time. That's what (R569) wants. This surveyor asked V19 that when R569 returned from hospital on [DATE] and was having increased pain to her right leg, what did V19 expect was being done by the nursing staff? V19 then replied, Medicating (R569) with pain medications every 4 hours. This surveyor informed V19 that from 2/25/21 to 3/1/21, multiple nursing notes documented that R569 was screaming and thrashing in pain, with confusion and hallucinations, and V19 stated, I wasn't told about having the increased right leg pain. With R569's increased right leg pain from 2/25/21 to 3/1/21, while screaming and thrashing out in pain, with confusion and hallucinations, and not receiving her pain medications every 4 hours, this surveyor asked V19 how could this effect R569? V19 stated, Trauma to the brain. A [MEDICAL CONDITION] from pain. It would be traumatic torture (for R569). On 3/18/21 at 11:42 am, V2 (DON) stated that nurses should notify a physician or nurse practitioner of any change in condition, change of mental status, abnormal vital signs, pain not controlled or anything outside of a resident's baseline status. V2 stated that resident pain assessments are to be performed on an as needed basis, but at least every 8 hours. V2 stated that if a resident expresses pain, then nurse needs to address it, medicate the resident and the reassess for pain 30 to 45 minutes after the medication. V2 stated that if the pain is not controlled at the reassessment, the nurse should review the resident's available pain medications or perform non-pharmacological interventions. V2 stated that the nurse will notify the physician or nurse practitioner if a pain medication is not effective. R569's care plan, dated 1/16/2020, indicates a goal for R569 is to be free of any discomfort or adverse side effects from pain medication, and interventions included to administer medication as ordered and to monitor for altered mental status. R569's care plan, dated 5/1/16, indicates a focus of alteration in musculoskeletal status, and interventions included to give [MEDICATION NAME] as ordered by the physician. Monitor and document for side effects and effectiveness. Facility policy, titled Pain Management and dated 7/14, documents, in part: General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents that means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. Responsible Party: Nursing, DON. Guideline: 1. The pain management program is based on a facility wide commitment to resident comfort. Pain is defined as what ever the experiencing person says it is and exists whenever he or she says it does. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Observing for the potential for pain b. Effectively recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the resident's pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions and h. Modifying approaches as necessary . 6. Observe, verify, and confirm the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . Guidelines: 3. A licensed nurse may initiate a Pain Form under the following circumstances: a. Change in resident condition that occurs and requires pain control b. New pain is reported. 4. A licensed nurse may repeat the Pain Form under the following circumstances: a. Resident is on routine pain medication and the pain is not managed, persistent or worsening . c. A change in pain related behavior, cognition or mood occurs . 6. Licensed Nursing may notify the Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors. Facility policy, titled Medication Administration and dated 7/14, documents, in part: General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of Responsibility: RN, LPN. Guideline: . 14. Document as each medication is prepared on the MAR . 21. Document reason and response for any PRN (whenever needed) medication. Facility policy, titled Change in Resident's Condition and dated 9/16, documents, in part: General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP and resident's responsible party of a change in condition. Responsible Party: RN, LPN, Social Services. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. There is a significant change in the resident's physical, mental or emotional status . e. It is deemed necessary or appropriate in the best interest of the resident . 3. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate document.

Based on observation, interview and record review, the facility failed to ensure pain and comfort care management was carried out for one of three residents (R5) receiving end of life care in the sample reviewed for pain. This failure affected R5 who was reviewed for pain management, R5 was observed moaning and groaning in pain with clear liquid fluid streaming down R5's face. Findings include: On 3/10/21 at 10:50 am, R5 was noted in the room in bed moaning and groaning and with clear liquid fluid streaming down her face. R5 complained to the surveyor that she has being calling for help to get some water and pain medicine for hours without anyone (referring to the staff) coming to her help. The surveyor asked R5 to use the call light to call for help. R5 replied, I can't reach it (referring to call light). R5 stated she cannot turn herself, since both her legs are hurting. Surveyor asked R5 to rate pain on a scale of 1 to 10. R5 replied, 100. R5 identified V14 RN (Registered Nurse) as her nurse. R5 said the pain medication that is being given to her is not working for her. R5 said, It hurts so badly all over. R6 stated (R5) has been having pain all night and none of the staff came to help her. R6 stated R5 cannot move and they will not come and get her ordinary water. R6 stated (R5) has being trying to get some medicine for her pain and the nurse did not come to check on her (referring to R5). When this was brought to V14's (RN) attention, who was identified as R5's medication nurse, V14 immediately told the surveyor and R5 that the next dose for R5's pain medication will be at 2:00pm. When the surveyor asked V14 if any medication was ordered for breakthrough pain, V14 stated, I have to check on that, but her [MEDICATION NAME] is not due until 2:00pm. The surveyor then followed V14 to review the medication order for R5. R5's POS (Physician order [REDACTED].>R5 is under hospice care order dated 1/29/21. [MEDICATION NAME] (Concentrate) solution 20MG/ML (Pain Medication). Give 0.5ml sublingually every 6 hours for pain= (equal) 10mg (0.5ml) with start date 2/09/2021 [MEDICATION NAME] (Concentrate) solution 20MG/ML Give 0.5ml sublingually every 3 hours for pain= (equal) 10mg (.5ml). R5's EMAR (Electronic Medication Administration Record) [MEDICATION NAME] every six hours is scheduled 6:00am, 12:00pm, 6:00pm and at 12midnight. Documentation in the EMAR showed that it was last given at 5:47am and next scheduled time will be at 12:00 pm. V14 then turn to the surveyor stating, Sorry about that for saying the next dose will be at 2pm instead of 12pm. I will give her the PRN dose now. V14 said the scheduled dose and the PRN dose are the same. On 3/10/21 at 11:13am, V14 administered [MEDICATION NAME] 0.5ml medication sublingually as ordered without asking R5's level of pain. V14 documented the medication as given at 12:00pm. R5's MAR (Medical Administration Record) dated 3/1/2021 to 3/31/2021 has no documentation that R5 was getting the PRN [MEDICATION NAME] medication as ordered every 3hours. R1's Controlled Substances Proof of Use document showed that on 3/10/21 at 6am, [MEDICATION NAME] 0.5ml was administered. V14 could not present any documentation showing that R5 received any PRN pain medication on 3/10/21 after 6:00am. On 3/10/21 at 11:46am, V12 LPN (Licensed Practical Nurse) and V14 RN were unable to provide the hospice communication binder for R5's plan of care. V12 stated, She is new to the facility and does not know where the binder is kept besides being on the floor where the resident resides. It can be that they (hospice) do electronic documentation. The surveyor asked V12, about the facility's communication with hospice services for a complaint and continuity of care. V12 stated, I'm new and I'm working on straightening out all that. On 3/10/21 at 12:46pm, V12 LPN (Licensed Practical Nurse) identified herself as the unit manager on the floor. The surveyor asked V12, What is the expectation of licensed nurses in regard to pain management? V12 replied, Rate the pain on a scale of 1 to10, give the pain medication as ordered, and give the PRN pain medications if applicable for breakthrough pain. It may be as simple as repositioning the resident. R5's current plan of care for comfort documented that R5 is at risk for alteration in comfort r/t (related to) comorbidities. Interventions includes but not limited to offering PRN (as needed) and to consider both pharmacological and non-pharmacological remedies. R5's current arthritis care plan documented the goal is to maintain acceptable level of comfort. Interventions includes giving [MEDICATION NAME] as ordered by the physician. On 3/10/21 at 4:03pm, an interview was conducted with V2 DON (Director of Nurses) in the conference room concerning the expectation of licensed nurses regarding pain management. V2 stated, If a resident complained of pain, he or she should be assessed asking what the pain level is on a scale of 1 to 10, administer pain medication as ordered, reassess the resident later to see if pain medication is effective and document it in resident chart. V2 further stated, If the pain medication is not effective and the resident is still in pain check if there is a breakthrough pain medication ordered and administer as ordered. If this is not working for the resident make the physician aware just in case, he or she might want to change the pain medication dose. On 3/10/21 at 4:34pm, V17 NP (Nurse Practitioner) said she is familiar with R5. V17 explained that R5 is a hospice patient and she is being managed by hospice at this point. V17 stated in part that the pain medication is managed in a way that it will not lower (R5's) blood pressure or sedate her. Surveyor asked V17, What is the expectation of facility licensed staff concerning pain management when the pain is not control with scheduled pain medication and there is an order for [REDACTED]. V17 then stated, Did they call me? No. On 3/10/2021 as at 5:30pm the facility was unable to present hospice provider's plan of care for R5's pain management. On 3/11/21 at 10:36am, V18 (NP), stated, V17 is the (NP) for R5's primary physician and V17 sees R5 more than she does. V18 stated V17 knows R5 better than she does. V18 stated, She does not have much experience with hospice care, but pain medication should be given when the patient needs it and non-pharmacological measures are not working. V18 stated, The staff needs to let the hospice staff know or call the physician to assess the patient if the medication and PRN medication is not working. At the end of the day, the pain should be controlled. V18 said the last time she saw R5 was 2/20/21. There was no complaint about R5's pain medication made known to her. On 3/11/21 at 5:39pm, V20 (LPN) 11pm to 7pm nurse stated, The last dose of [MEDICATION NAME] on her shift was administered at 6:00am. The facility Pain Management policy presented with revision date 7/14 pointed out that in general that it is to facilitate and provide guidance on pain observations and management to facilitate resident independence, promote resident comfort and preserve resident dignity. Responsible party listed as nursing and DON (Director of Nurses). The guideline defined pain as whatever the experiencing person says it is and exists whatever he or she says it does. The facility policy on Medication Administration with revised date 7/14 pointed out in general that all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. The Appendix C and D hospice contract with the facility dated July 28, 2017 and effective as of November 16, 2016 documented in part that the facility shall communicate to the local palliative care designated personnel concerning the hospice patient including, but not limited to, any changes in condition including reactions to treatment. The hospice provider shall provide a nurse familiar with each hospice patient case that will be available 24 hour a day, 7 days a week for consultation with facility personnel concerning each hospice care plan.

Based on interview and record review, the facility failed to refill and administer medications according to physician orders [REDACTED]. This failure resulted in R4 not receiving significant medications, having elevated blood pressure and being taken to the hospital for further evaluation and treatment. Findings includes: R4's [DIAGNOSES REDACTED]. R4's progress note on 1/12/2021 at 12:59 PM by V8, LPN documents: Writer placed called to pharmacy regarding resident medication. Per pharmacy resident has outstanding bill and insurance is not covering meds. Administrator and Business Office made aware. MD made aware new order to monitor resident if resident is in any distress transfer to Mercy for follow up. Family made aware of issue with meds. Resident remains stable at this time. R4's progress note on 1/29/2021 at 09:30 AM by V14, LPN documents: Writer received resident up in wheelchair; Awake, alert and oriented x3, verbally able to make needs known; Resident denies any pain or discomfort at this time; Resident currently in dining room finishing breakfast. R4's progress note on 1/29/2021 at 10:47 AM by V14, LPN states: Resident had c/o headache at this time PRN pain medication administered; No s/sx of distress noted at this time; Will continue to monitor. R4's progress note on 1/29/2021 at 11:16 AM by Social Service states: Writer received a call from resident's sister (V22) reports that resident has abdominal pain and headache. Writer informed sister that message will be referred to Nurse for follow-up. Writer will continue to monitor as needed. R4's progress note dated 1/29/2021 at 11:30 AM by V8 Writer alerted facility SS resident family V22 (family member) called facility stated sister reported to her that she had abdominal pain and headache. Writer to 3rd floor day room resident alert and oriented x2. Resident c/o abd pain 5/10. Resident T 97.2 resident taking to room and rapid swab given with (-) result. NP in facility made aware of result. Resident has new orders carried out by assigned nurse for [MEDICATION NAME] 10 mg capsule q6 for abd discomfort and pain. Family V22 given update on POC made aware. R4's progress note on 1/29/2021 at 12:25 pm by V14, LPN (Licensed Practical Nurse) documents: Writer called to dining room at this time, Resident exhibiting [MEDICAL CONDITION] activity; Staff immediately transferred resident to bed; O2 initiated via non-rebreather mask; Resident head secured; Writer phoned 911 at this time, awaiting arrival. Review of City of Chicago Record Division record documents in part on 1/29/2021 at 12:22 vital sign Heart Rate 72, BP Systolic 180, BP Diastolic 100, 1/29/2021 at 12:32 HR 72, BP Systolic 160, Diastolic P, 1/29/2021 at 12:38 R 67, BP Systolic 150, Diastolic P. Review of emergency room medical record documents in part on 1/29/2021 at 13:41 CST arrival pt hypertensive 220 systolic, blood pressure triage /116 mmHg, latest /121 mmHg. History of Present Illness in part documented earlier today she (referring to R4) was complaining of mild headache prior to have a [MEDICAL CONDITION]. No history of [MEDICAL CONDITION]. Upon arrival to the emergency department, patient was initially hypertensive to 220 mmHg and had 1 episode of emesis. Per ED medical record R4 received 10 mg [MEDICATION NAME] with improvement of BP. R4's (1/21) Medication Administration Record documents in part: [MEDICATION NAME] tablet 5 mg daily related to sequelae of cerebral infraction: not administered (1/22/21 thru 1/27/21 - 6 doses missed). [MEDICATION NAME] Capsule 400 mg daily for [MEDICAL CONDITION]: not administered (1/22/21 thru 1/23/21 - 2 doses missed and 1/25/21 thru 1/28/21 - 4 doses missed). [MEDICATION NAME] HCL tablet 120 mg by mouth twice daily for hypertension: not administered (1/22/21 thru 1/28/21 thru 14 doses missed. R4's blood pressure not documented 1/22/21 thru 1/28/21. Review of R4's blood pressure log documents: (1/21/21) 178/92 mmHg and (1/29/21) 203/71 mmHg, no record of R4's blood pressure from 1/22/21 thru 1/28/21. Review of R4's (10/18) care plan documents resident has hypertension. Intervention: Give anti-hypertensive medications as ordered. Monitor for side effects and effectiveness, obtain blood pressure per order. Surveyor unable to obtain physician order [REDACTED]. On 2/12/21, at 9:54 AM, V7, Business Office Manager said R4 has an attorney who pays her bills. On 2/12/21, at 12:06 PM, V8 (LPN) said on 1/10/21 V9, LPN informed her R4 did not have all her medications. V8, LPN told V9, LPN to call the pharmacy and find out why medications were not there. V9, LPN informed V8, LPN that the pharmacy bill was not paid. V8, LPN told V9, LPN to get the authorization form and send it to V10, former Director of Nursing. The facility will pay for the medications if the bill is not over $500. V8 stated on 1/12/21 the pharmacy informed her that they will not send the authorization form because the bill was high, and resident was in collections. V8, LPN stated that she emailed V7,Business Office Manager and V18, former Administrator to let them know that R4 had a bill with the pharmacy, the pharmacy will not send any medications unless bill gets paid, and the bill needs to be paid immediately before the resident will run out of medications. V8, LPN stated, from that point V7, Business Office Manager took over the issue. V8, LPN stated that she told V9, LPN to call family and the doctor to let them know. V8, LPN stated she informed V17, Nurse Practitioner and V16, R4's Primary Physician. V8, LPN stated on the medication administration record any number means it was not given for a specific reason such as 9 means there is a note and a check mark mean the medication was administered. Review of V8's, LPN email on 1/12/21 at 1:59 PM to V2 DON, V18 former Administrator and V7 Business Office Manager stating, R4 has a bill with pharmacy that needs to be paid immediately. The pharmacy isn't sending any meds until Bill is paid. On 2/12/21, at 12:31 PM, V7, Business Office Manager said R4 has private insurance that her attorney pays. V7, Business Office Manager stated, R4 was responsible for medication co-payment. However, the pharmacy bills were sent to the wrong address and therefore she acquired a high balance with the pharmacy. On 2/12/21, at 12:36 PM, V8, LPN stated on 1/29/21 she heard rapid response code called. When she got to R4, the resident was having [MEDICAL CONDITION] activity. On 2/12/21, at 12:41 PM, V9, LPN stated on 1/10/21 she noticed R4's physician ordered medications were running low and the resident usually had extra medications. She called pharmacy to find out why they were not refilled. V9, LPN stated the pharmacy informed her R4's account was in collections, gave number to collections, and told her until the overdue bill was paid that the pharmacy would not send any medications. V9, LPN stated she made V8, LPN aware and V18, former Administrator. V8, LPN and V18, former Administrator told her facility will clear the matter up with the business office. V9, LPN stated on resident's medication administration record a check mean resident received the medication and any number means they did not. V9, LPN stated during the 1/10/21 phone call with the pharmacy, they gave the option for facility to pay off the past due balance and they would bill the appropriate party for the new medications. The pharmacy faxed a pay agreement and V9, LPN gave it to V10, former DON who said he would give it to the business office. On 2/12/21, at 12:52 PM, V7, Business Office Manager stated R4's balance with the pharmacy was $2,353.52 and it was paid by her attorney. On 2/12/21, at 1:06 PM, V2, Director of Nursing (DON) stated if medications are unavailable then the staff can take the medications from the stock medication cart and if that medication is not available nurses will call the doctor to get a stat medication order. V2, Director of Nursing further stated, she was not made aware R4 was not receiving her medications. V2, Director of Nursing stated, normally facility will pay for residents' medications, so they do not run out. On 2/12/21, at 1:56 PM, V2, DON stated she had no idea as to why R4's pharmacy bill was not paid by the facility. V2, DON stated the process for this kind of situation is the facility would pay for it. V2, DON stated she does not know what the communication regarding the matter was. V2, DON further said facility must have medications for residents and the facility will pay for the current medications, so the residents do not run out. V2, DON also said, the expectation of the nurse is when medications are not available to call the physician, ask for directions, and make sure to communicate the matter to the supervisor. V2, DON stated the extra medications in the facility is accessed per individual resident and does not know if staff can open it when the resident's account is in default to retrieve extra medications. On 2/12/21, at 2:14 PM, V1, Administrator stated If he was told about R4's medication situation, he would have paid the entire bill (referring to the total amount due $2353.52), this is what he would do to avoid this situation and have state agency in the facility. V1 said, he is the new facility administrator, but residents come first, and he would have paid the bill. On 2/12/21, at 2:20 PM, V8, LPN stated, on 1/12/21 R4's physician said to monitor R4 after being made aware of pharmacy billing issues and if there is any distress send the resident out for hospital evaluation. V8, LPN stated, R4's physician and V17, Nurse Practitioner on 1/12/21 were made aware about billing issues and that the medications were getting low, but she still had medications. V8, LPN said there was no order to hold R4's medications. V8, LPN also said she wrote a progress note to monitor R4 but did not enter an order in R4's chart under physician orders. When surveyor inquired why an order was not written V8, LPN stated, I am not sure, I did not write it. Normally an order is put in. On 2/12/21, at 3:15 PM, V8, LPN said the extra medications the facility has on hand is pulled under each individual resident and if a resident is in default due to a balance the computerized device will not allow the staff to take the medication. On 2/12/21, at 3:21 PM, V17, R4's Nurse Practitioner said he was familiar with R4. He was informed there was an issue with billing related to the pharmacy. V17 stated there was nothing for him to do because it was a billing issue. He was not informed of the duration R4 was not receiving her medications. V17 stated he was not made aware of the resident not receiving the medications only about the initial issue with balance the resident had with the pharmacy. There could be many complications for R4 not taking her medications from a stroke to anything, or death. R4 was taking [MEDICATION NAME] for [MEDICAL CONDITION] so, it was for pain. R4 had no history of [MEDICAL CONDITION]. The risk of R4 stopping [MEDICATION NAME], is another cerebral infraction. Medications must be taken and taken correctly. On 2/12/21, at 2:55 PM, V16, R4's Primary Physician stated he believes he was made aware by V8, LPN about issues with R4's medications and pharmacy and it was possible he could have said to monitor the resident. V16 further stated, how can a pharmacy stop sending residents medications? V16 said if R4 stopped taking her medications, it is possible for her to have complications. V16 further stated, it is unbelievable this happened and who else at the facility is this happening to. V16 also said, it is possible he instructed V8, LPN if the facility cannot get R4's medications to monitor the resident and if there is change of condition then send the resident to the hospital. On 2/12/21, at 5:12 PM, V16, R4's Primary Physician said R4 had an unfavorable outcome (referring to hypertension, [MEDICAL CONDITION], and emergency room visit) and the pharmacy did not dispense her medications. V16 said, he was made aware there were billing issues and facility was working on getting R4 her medications. V16 said, Usually there is 1or 2-day delay (referring to resolving the pharmacy being paid and the medication being dispensed) however he was not aware R4 was not getting her ordered medications every day. V16 also stated he was upset at this whole situation and asked how the pharmacy can be allowed to do this. V16 stated, When medications are withheld, the risk to a resident is the same risk as the medication is for, so if hypertensive medications are withheld then hypertension is the risk, gout medication then gout is the risk, pain medications withheld then pain and if [MEDICATION NAME] is withheld cerebral infraction is a risk, but mainly the medication is for [MEDICAL CONDITION]. On 2/15/21, at 2:01 PM, V14, LPN said she is familiar with R4 however, does not recall the specifics of the 1/29/21 occurrence. V14 stated whatever she documented in R4's chart that was what happened. V14 stated R4 was fine, stable, and later it looked like she was having a [MEDICAL CONDITION], so she was sent out for evaluation. On 2/15/21, at 2:10 PM, V13, Pharmacy said the facility was aware R4 had a balance of $2,353.52, was at risk to have her medications discontinued, and for pharmacy to refill medications, residents balance must be under $500. V13 stated R4's account balance was paid on 1/26/21. V13 further stated, On 1/14/21 pharmacy was directed by the facility to send the bill to R4's attorney because they were not going to pay it. On 2/23/21, at 9:29 AM, V13, Pharmacy said residents who have a balance with pharmacy are at risk to have their medications discontinued. V13 stated there is a specific balance but he was not sure of the actual amount. V13 stated the facility was made aware initially on 10/6/20 and the second notice to the facility was on 12/5/20. R4's account was placed on discontinued on 1/4/21 and the facility was made aware. On 2/23/21, at 9:41 AM, V20, Pharmacy stated there is a limit of $500 and over, so when a resident reaches that amount of past due, their medications are at risk of being discontinued. However, it is a 90-day process for resident's medications to be discontinued and resident has the 90 days to pay off the balance. V20 said, on 9/30/20 facility was called, and voice mail was left for V7, Business Office Manager. V20 said, R4's medication discontinuing process was started on 10/6/20. V20 also stated on 10/7/20, the pharmacy called the facility and receptionist transferred the call to V7, Business Office Manager however, her voicemail was full. The 10/7/20 phone call was followed by a fax to the facility. V20 stated on 11/6/20, a call was made again to V7, Business Office Manager without answer and a fax was sent to follow up. V20 stated the pharmacy reached out to the facility on [DATE], was unsuccessful, and they followed up with a faxed letter regarding R4's medication discontinuing status. V20 stated on 1/4/21, R4's medication refills were shut off with the pharmacy. On 2/23/21, at 10:10 AM, V20, Pharmacy stated she is unable to provide the 90-day policy and the sent faxes or any communications with the facility to the surveyor, only verbal. On 2/23/21, at 11:02 AM, V21, Pharmacy Supervisor stated the pharmacy made repeated attempts to make the facility aware R4 was at risk to have her medications discontinued. V21 said the pharmacy sent faxes which were received by the facility on 10/7/20 for the first notice of non-payment, second notice on 11/6/20, the last notice on 12/9/20, and R4's medication refill was placed on hold on 1/4/21. V21 also said, the faxes were sent along with calls to the facility. However, they were not able to get in touch with anyone. The pharmacy was transferred by the receptions or the calls were dropped. V21 also stated he is not at liberty to provide the surveyor with the faxes, the notes regarding R4, and their 90-day policy, only is able to do it verbally. On 2/24/21, at 11:21 AM, V17, Nurse Practitioner stated R4 missed blood pressure medications and [MEDICATION NAME]. They are significant medications because we do not order unnecessary medications, otherwise we would take the resident off them. V17 said, to be on blood pressure medications is to maintain and control a blood pressure. If a resident does not take their medications, then their blood pressure reading will go up. It is a significant medication because you should take the medications to maintain the blood pressure. V17 said, [MEDICATION NAME] is a lifesaving medication. V17 also said, R4 was taking [MEDICATION NAME] for neuropathic pain. Facility's (10/03) Medication Administration policy documents in part: GENERAL: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. 18. If a medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider. 20. Medications are held as specified by the Health Care Provider. Facility's Charge Nurse Drug Administration Functions documents in part: Prepare and administer medications as ordered by the physician.

Based on interview and record review, the facility failed to follow one resident's (R1) care plan by performing a two person assisted transfer from a wheelchair to the bed without the use of mechanical lift. This affects one (R1) resident of three residents reviewed for transfer. This failure resulted in R1 sustaining a left distal tibial fracture (broken leg). R1 is a [AGE] year-old resident with [DIAGNOSES REDACTED]. R1 is currently hospitalized and unavailable for interview. R1's Care Plan dated 9/22/2020 notes: R1 has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Limited Mobility. TRANSFER: Provide Mechanical Aid (Sit to Stand) for transfers with two-person assist. 7/19/19 mechanical lift with 2 staff assist. The resident has had an actual fall on 5/14/16 with no visible injuries. 8/16/16 resident self-reported that she had a fall during transfer from bed to chair, no visible injuries noted. 11/7/16 Self-reported that she had a fall during transfer from bed to chair, no visible injuries noted. 6/5/17 self-reported that she had a fall during transfer. Actual Fall 7/19/19. Interventions: 1. Mechanical lift will be used for safe transfer. Staff re-educated and disciplined for improper transfer and policy/procedure for reporting any fall/incidents. The facility's State Report of Patient Incident dated 11/28/2020 notes: R1 reported on 11/28/2020 that on 11/25/2020 around 6:30 PM after she was transferred to bed, she had pain in her left leg. Final: After interview of staff and R1 it was determined that R1 sustained her injury while being transferred from the wheelchair to the bed when her leg got entangled with the nurse during the pivot when she felt pain. The x-ray report dated 11/28/2020 taken at the facility notes: Left tibia-fibula. Findings: The tibia and fibula show acute oblique [MEDICAL CONDITION] third of the tibia. There is osteopenia. Post-operative plate and screws in the fibula. Impression: Acute oblique [MEDICAL CONDITION] third of the tibia with mild displacement. There is soft tissue swelling. Postoperative hardware in the distal fibula with anatomic alignment. Progress note written by V22 LPN on 11/28/2020 at 6:40 PM: Resident informed writer that she was having some pain in her lower left leg. Writer assessed left leg. No discoloration or deformity is noted of the leg. Writer made an attempt to move left leg, but resident is stating that it hurts when leg is being moved. Writer was not able to complete assessment on leg. Writer gave prn (as needed) Tylenol for pain. All appropriate staff was made aware. Writer called x-ray company and placed an order. Staff is waiting on the arrival of x-ray tech. Staff will continue to monitor. Progress note written by V22 LPN on 11/28/2020 at 10:45 PM: X-ray tech is in the facility to do x-ray of lower left (leg). Results are pending at this time. Staff will continue to f/u. (follow up) Progress note written by V23 LPN on 11/29/2020 at 2:15 AM: Resident lying in bed awake. At first when asked by writer, resident denied pain then stated after nurse slightly touched the left lower leg, resident then stated that she is in pain. Tylenol given and tolerated well. Progress note dated 11/29/2020 at 3:00 AM: Telehealth evaluation Date of Service: 11/29/2020 2:06 AM written by V20 MD (Medical Doctor). Patient Name: R1. Primary Chief Complaint: Radiology Review: Abnormal Results. History Present Illness : Pt (patient)with history including end stage [MEDICAL CONDITION], on [MEDICAL TREATMENT], DM2 (diabetes mellitus), [MEDICAL CONDITION] (chronic heart failure), who had c/o (complaint of ) left lower leg pain after her left leg got caught up during a transfer on Thursday. Has gotten prn (as needed) med (medication)for pain and had x-ray done which has resulted for review: left tib-fib XR: ?(question) acute oblique fx (fracture) of distal third of the tibia with mild displacement. Neurological: moving extremities equally, facial muscles symmetric, at her baseline. Diagnosis/ Assessment/Plan: needs further eval (evaluation)and splinting, will transfer to ED (emergency department) Unspecified fracture of lower end of left tibia, initial encounter for closed fracture (Primary). Orders: 1. transfer to ED (emergency department) for left tibia fracture. 2. Notify TEH (V24 Physician Coverage Service) if she returns with new orders. Disposition: Transfer to Emergency Department. Technology Used: Audio and video with patient and nurse present. Statement of Medical Necessity: Yes. Consent for telemedicine/virtual visit obtained from patient/POA: Yes. Progress note written by V23 LPN on 11/29/2020 at 3:30 AM: Ambulance service (2 attendants) here and transported resident out to Mercy ER per stretcher. The x-ray report dated 11/29/2020 for R1 from V21 local hospital notes: Minimally displaced spiral fracture involving the distal tibial metadiaphysis. R1's Restorative Mobility Nursing Screen dated 12/2/2020 notes: Mobility Devices, (for transfer) Mechanical Lift. On 2/2/2021 at 10:30 AM V1 Administrator stated he did not know anything about the incident or who was involved. I have only been the Administrator here for about 2 weeks. On 2/2/2021 at 11:30 AM via telephone, V4 R1's family member stated, My mother told me she got tangled up during a transfer to bed. She called me around 2:00 AM because she was in pain. Her leg was in pain. I spoke to the previous Director of Nursing (V19) and she told me my mother was transferred incorrectly by a nurse and a CNA. They did it themselves instead of using a mechanical lift. She said they were both fired. I don't remember the exact day, but it was Thanksgiving or the day before. On 2/4/2021 at 3:05 PM V6 Nurse Consultant and Acting Director of Nursing stated the nurse and the CNA (Certified Nursing Assistant) involved are both no longer employed here. The DON (Director of Nursing) at the time of this incident and who did the investigation is also no longer here. From the reports I have reviewed, the reports say a transfer was done for R1 without a mechanical lift. R1 was transferred by a nurse and a CNA (Certified Nurse Assistant). No incident report or charting was done on 11/25/2020 because at the time they did not know of any injury. The injury was discovered on 11/28/2020 when R1 complained of pain. R1 should not have been transferred without a mechanical lift. It could be harmful to the staff member and the resident when a lift is not used. The staff members involved in the incident are V12 LPN (Licensed Practical Nurse) and V13 CNA. The Director of Nursing at that time was V19. V12 and V13 did not return telephone messages from this writer. On 2/5/2021 2:30 PM via telephone, V6 stated V20 MD (Medical Doctor) works for a third-party health company, who covers residents between 7:00 PM and 7:00 AM. This is where the nurses call instead of the primary care physician after hours. On 2/5/2021 at 3:15 PM via telephone, V20 MD stated I was called about R1 at night, I didn't actually see her. I was given information concerning R1 by the nurse. I did review the x-ray report. The nurse told me R1 got twisted up during a transfer and she complained of pain. This type of injury could happen during a transfer, especially if there was a twisting motion. The patient is more at risk for injury if they have [MEDICAL CONDITION] or osteopenia. As far as pain, it's hard to say if R1 felt pain or how much during the time between the incident and when it was identified. If she was non weight bearing its possible, she didn't feel significant pain, and sometimes patients just don't tell you when they are in pain right away. I do remember R1 could not describe what happened.

Based on interview and record review the facility failed to ensure safe resident self-administration of medication, provide nursing education related to self adminstering medication, and monitor after [MEDICATION NAME] medication administration for a newly admitted resident on daily [MEDICATION NAME] with a history of substance abuse for 1 (R1) of 3 residents reviewed for supervision. This failure resulted in the resident falling and sustaining a laceration on the left eye leading to hospitalization . Findings include: [AGE] year-old resident admitted to facility on 7/28/20 with [DIAGNOSES REDACTED]. R1 admitted to the facility with orders for [MEDICATION NAME] HCL concentrate ([MEDICATION NAME]) orally one time per day. R1's History and Physical provided by the facility from the preadmission referral packet notes R1 had been admitted to the hospital on [DATE] for [MEDICAL CONDITION], heroine abuse on [MEDICATION NAME], and cocaine abuse with a positive screen on hospital admission. In an interview with V3, Social Services Director, on 7/31/20 at 12:50PM V3 said she met with R1 the morning of 7/29/20 before he went to his [MEDICATION NAME] clinic appointment. V3 said R1 told her about his struggle with substance abuse in the past and said the [MEDICATION NAME] had been working for him. In an interview with V4, Social Service, on 7/31/20 at 11:43AM ,V4 said she accompanied R1 to an appointment to pick up [MEDICATION NAME] from the clinic on 7/29/20 and left the facility about 1:15PM. V4 said she remained with V4 during the appointment and the clinic counselor said R1 could have 2 weeks worth of [MEDICATION NAME]. V4 said she witnessed R1 drink one dose of his [MEDICATION NAME] before they left the clinic. V4 said on return to the facility R1 had 13 bottles of [MEDICATION NAME] in his possession. V4 said she last saw the [MEDICATION NAME] after she observed R1 place the bottles in the lock box around 2:40PM. In an interview with V5, Certified Nursing Assistant (CNA), on 7/31/20 at 12:30PM, V5 said she was assigned to R1 on 7/29/20 3:00-11:00PM shift. V5 did not know anything about the lock box in the room and was not given any special instructions for providing care to R1. V5 said when she checked on R1 around 6PM he was sleepy, he was groggy. V5 said she reported to the nurse when she saw R1 on the floor around 8:30PM. V5 said R1 had blood on his face and body and she called for the nurse. V5 said the nurse came and did an assessment and wiped R1's laceration. In an interview with V6, Nurse, on 7/31/20 at 2:20PM, V6 said on 7/29/20 I knew R1 went to the [MEDICATION NAME] clinic and when he returned on my shift he went to his room. I spoke with him and introduced myself at the start of my shift. V6 said the report she received about R1 was that he had 13 bottles of [MEDICATION NAME] . Later that shift, she was notified he was on the floor. V6 said she did not see the 13 bottles of [MEDICATION NAME]. V6 said she did not know how the [MEDICATION NAME] was put in R1's lock box and was not aware that R1 had the [MEDICATION NAME] in the lock box. V6 said she saw him around 7:30PM and gave him his evening medications and she noticed he was very sleepy. V6 said when she assessed him on the floor, she saw R1 was holding a bag with his [MEDICATION NAME] bottles, in his hand. V6 said R1 told her he drank [MEDICATION NAME] before his fall. V6 said she took R1's vitals after he had fallen, but not prior to the fall. V6 said she did not know R1's baseline health status. V6 obtained a physcician order to send R1 to the hospital for further evaluation and for treatment of [REDACTED]. In an interview on 7/31/20 at 2:07PM V7, Nurse, said the nurses do medication education and discuss adverse effects of medication with the resident. V7 said the nurse documents if they did any education with the resident. V7 said the assigned nurse should monitor the resident when they take [MEDICATION NAME]. In an interview with V2, Director of Nursing, on 7/31/20 at 11:10AM V2 said when a resident returns from the [MEDICATION NAME] clinic, the resident is given a key to store his [MEDICATION NAME] in the box. R1 was given a box and a key. At 12:20PM V2 said the facility has nothing to record the count of [MEDICATION NAME] a resident receives from the clinic. At 1:40PM V2 said we can only ask the resident to show us the lock box to see the medication inside because the [MEDICATION NAME] is the responsibility of the resident. In an interview on 7/31/20 at 3:34PM V8, Physician, said it's hard to say if R1 took too much [MEDICATION NAME] and if that caused the fall. Regarding [MEDICATION NAME] clinic residents and self-administration V8 said he expects the facility to follow the policies they have. In an interview on 7/31/20 at 1:15PM V9, Clinic Counselor, said the expectation is that the facility will monitor the patient. V9 said R1 has an opioid disorder. In an interview on 8/4/20 at 10:47AM V11, Nurse stated: We don't give the residents who are treated by the clinic the [MEDICATION NAME]. They use a lock box, the resident will give their own medication. We are not to touch the [MEDICATION NAME]. We are not to touch, even if they can't open it. In an interview on 8/4/20 at 11:49AM, V2, Director of Nursing, said the nursing department has a key for each lock box that is kept by me (V2). R1's [MEDICATION NAME] is in the lock box in the administrator office now. V2 said the purpose of policies is to educate and inform staff of proper procedures to do. V2 said procedures are established to establish a baseline for residents in a facility and baselines ensure the safety of the resident. V2 said nursing will do education of self-administration of medications. V2 said V5 is not a nurse and the Self Administration tool does not state education was done on it. V2 stated As a prudent nurse I would ask the resident to show me the [MEDICATION NAME]. If assigned to a patient that returns from the clinic, I should ask about the [MEDICATION NAME] bottles, follow resident, watch the storing, check vitals, and that the resident remains stable. V2 said she would expect to be monitoring the resident for side effects during the shift and instruct the aide to help keep an eye on him. V2 said she would expect monitoring the resident's condition throughout the shift, at least every 2 hours. V2 did not comment on the policy for resident Self Administration of Medications and treatments regarding a 3-day supply of medication being dispensed initially, as stated in policy. A record entry titled Self Administration of Medication dated 7/29/20 at 2:25PM signed by V2 does not include an education section. A record entry titled Resident / Family Education dated 7/29/20 at 3:09PM is signed by V4, Social Services. No nurse signature is included on the document. A record entry titled Progress Note dated 7/29/20 at 8:15PM written by V6 reads observed on left side on the floor, resident is noted with an open area on left side of face by his eye. Vitals obtained 151/82, 71, 20, 97.1. Resident eyes round and responds slowly to light. Doctor gave order to send out for head injury and further evaluation. A record entry of R1's blood pressure summary has an entry on 7/28/20 at 5:52PM of 109/68 and a second entry on 7/29/20 at 8:15PM of 151/82. No other blood pressure were noted documented in the resident chart. A record entry titled Neuro Intensive Care Unit History and Physical dated 7/30/20 at 2:13AM reads the patient had laceration on left eye and was brought to hospital. Review on 8/4/20 of the facility policy for Self Administration of Medications and Treatments, review date 06/2015, states, in part: Self administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain independence. Resident teaching will be performed by nursing staff. Nursing will dispense medication in a similar system that the resident was utilizing at home. A 3-day supply will initially be dispensed. It will be the responsibility of the nurse to check the number of oral medications and document to determine if the proper medications and dose was taken. Nursing will review the resident's compliance of self adminstered medication at the time of each medication pass. A care plan is for resident who self administer (as written) and documentation should be present in the nursing notes of teaching related to self administration of the medications or treatments. Review on 8/4/20 of the facility policy for [MEDICATION NAME] Administration, review date January 2018, states nursing is not responsible for administration or documenting administration of medication.

Based upon observation, interview and record review, the facility failed to ensure that staff were aware of resident fall prevention interventions, failed to implement fall prevention interventions and failed to provide adequate supervision for three of three residents (R1, R2, R3) in the sample reviewed for falls. These failures resulted in the following serious injuries; R1 sustained a laceration requiring staples. R3 sustained a laceration requiring steri-strips. Findings include; The (8/13) falls policy & procedure states residents at fall risk will be identified for staff awareness. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. Recent Falls Risk Screens affirm that R1, R2, and R3 have had multiple falls at the facility from 2019 to 2020. On 3/9/20 at 2:30pm, V3 (Certified Nursing Assistant), V4 (Activities Aide) and 44 residents (including R1, R2, R3) were observed in the dining room. Surveyor inquired about R2's fall prevention interventions. V3 stated That you will have to ask the Nurse about because that I don't know. Surveyor inquired about R3's fall prevention interventions V3 responded Once again, you would have to ask the nurse about that. I usually refer to the nurse before I touch anybody. Surveyor inquired who was assigned to supervise the dining room. V3 replied I'm watching the dayroom while she's doing activities and affirmed there were only two staff present in the dayroom/dining room. At approximately 2:40pm, surveyor inquired if there was adequate staff in the dining room V4 stated Usually we have two or three aides in here. Surveyor inquired about R2's fall prevention interventions. V4 replied I don't have that. Surveyor inquired how staff identify residents at risk for falls V4 stated I usually go by their wrist. Their wristbands will tell us they are fall risk. R2 was observed not wearing a fall risk wristband at this time. R1 was observed sitting in a specialty wheelchair (adjacent the wall) in the dining room. She was not assisted to a table during ongoing puzzle activity and was not engaged with staff or peers. V4 inspected R1's wrist (as requested) for a fall risk wristband and stated She doesn't have one. Surveyor inquired about R1's fall prevention interventions V4 responded She usually has someone close by her, I don't know where she went. 1.) R1 is a [AGE] year old with [DIAGNOSES REDACTED]. R1's (1/14/20) fall risk screen determined a score of 15 (moderate risk). R1's (7/26/29) care plan states resident is at risk for fall related to impaired mobility, weakness and Alzheimer's. Interventions; frequent monitoring. a.) R1's (1/14/20) incident report states; resident observed inside room on floor. No witnesses found. b.) R1's (2/24/20) incident report states; Incident Location: Dining room. Resident was observed on the floor. Resident slid out of the chair. Injury: laceration top of scalp. R1's (2/24/20) State report of patient injury states; resident returned from hospital with 2 staples to head. (2/24/20) Witness statements include but not limited to the following; when was the last time you visually observed the resident and what were they doing at that time? Per V8 (Certified Nursing Assistant) the last time I saw the resident was in the dayroom, she was at the table with her head down. Per V9 (Licensed Practical Nurse) I seen (R1) in the dayroom at 5:50pm with her head down on the table. Per V10 (Certified Nursing Assistant) her nurse did tell me to lay her down but when I was about to it was time to pass trays for dinner. On 3/11/20 at 1:48pm, surveyor inquired about R1's (2/24/20) fall. V10 stated The incident could have been prevented, everybody on the floor had an opportunity to do something about it, but just overlooked it. She was sleeping in the chair in the dayroom with her head on the table. She was in a regular wheelchair not a (Brand Name) chair. I could have put her in a (Brand Name) chair cause she was sleeping. 2.) R3 is an [AGE] year old with [DIAGNOSES REDACTED]. R3's (1/2/20) fall risk screen determined a score of 18 (high risk). R3's (1/29/19) care plan states resident is at risk for fall related to impaired mobility, weakness, and Alzheimer's. Interventions; close monitoring for safety. On 3/9/20 at approximately 2:36pm, R3 was observed sitting idle in a wheelchair (in the dining room walkway). She was not assisted to a table during ongoing puzzle activity and was not engaged with staff or peers. R3's (2/20/20) incident report states; nurse heard a loud noise. Upon entering day room patient on floor with laceration above left eye. R3's (2/20/20) State report of patient incident states; resident returned from hospital, left forehead noted with 5 steri-strips in place. On 3/10/20 at 2:55pm, surveyor inquired about R3's (2/20/20) fall. V7 (Licensed Practical Nurse) stated The patient is always confused and is a huge fall risk. When I was done with the med (medication) pass, I heard a boom. The other nurse said she fell , head first. She was on the floor when I got there. There were two CNAs (Certified Nursing Assistants) in the dining room. The CNAs said she had been leaning forward all morning I guess trying to get out the chair. I guess she leaned too far forward that day and fell out the chair. 3.) R2's [DIAGNOSES REDACTED]. R2's (11/11/19) fall risk screen determined a score of 15 (moderate risk). a.) R2's (8/17/16) care plan states; resident experiences functional incontinence. Interventions; maintain uncluttered environment. R2's (12/13/19) incident report states; resident was observed on the floor in supine position on top of the scale. He stated I fell . No witnesses found. Predisposing factors; clutter. b.) R2's (4/1/19) care plan states; resident is at risk for fall related to impaired mobility and weakness. Interventions include; frequent monitoring. R2's (2/12/20) incident report states; resident fell in the hallway while walking to the dining room. Predisposing factors; improper footwear. On 3/9/20 at approximately 2:35pm, R2 was observed ambulating (in the dining room) with an unsteady gait. He grabbed both handles of peers' wheelchair to maintain balance, then stood there and lingered. V3 subsequently escorted R2 to a chair. He was wearing a shoe on his right foot and a sock on his left foot. At approximately 2:38pm, surveyor inquired why R2 was wearing only one shoe V4 replied I'm not sure and affirmed she would check into it. On 3/10/20 at 11:04am, surveyor inquired how staff identify residents at risk for falls if fall risk wristbands are not on. V5 (Licensed Practical Nurse-Unit Manager) responded Once you've had two falls you automatically have the bands on. Surveyor inquired why on 3/9/20, R2 was not wearing a fall risk wristband V5 replied He must have taken it off. On 3/12/20 at 10:04am, surveyor inquired about the potential harm to a patient that falls. V11 (Medical Director) stated for anybody above the age of 65 any fall puts them at great risk especially for fracture. There's a significant risk for harm for any patient falling.

Based on interview and record review the facility failed to immediately notify the physician and provide appropriate treatment to pressure sore for one (R14) of three residents reviewed for wounds. This failure resulted in a facility acquired deep tissue pressure injury to left ischium. Findings include: R14's [DIAGNOSES REDACTED]. R14's minimum (MDS) data set [DATE] under section H titled Bladder and Bowel documents that R 14 is always incontinent of bowel and urine. On 12/28/18 at 3:35 PM, V 2 (DON) said, staff are expected to call doctor and family at time of when alteration in skin is found. Wound care should evaluate site same day or following day. Any changes in skin should be reported to nurse. If nurse finds an open area on pressure area, they can apply a wet to dry dressing. It is not the facility practice to leave a wound site open to air. R14's family and doctor should have been notified on 9/29/18 of alteration in skin. Wound care should have seen R14 on 9/30/18 to evaluate site. On 12/28/18 at 2:22PM, V 50 (Primary Doctor) said that leaving a site open to air would not typically be an order to a pressure site. I do not agree with the treatment to leave site open to air (OTA) due to the risk of infection and exposure to urine and feces. On 12/28/18 at 4:06 PM, V 61 (Nurse Practitioner) said unable to recall giving an order for [REDACTED]. On 12/27/18 at 1:20 PM, V 38 (nurse) said she was informed that R14 had alteration in skin and skin assessment performed and risk watch documented. It is the protocol of facility to leave wounds open to air and wound care to assess site. Wound care is notified through risk watch to assess resident. R14's alteration in skin were open red and pink in color to right and left buttocks. On 12/28/18 at 4:24 PM, V 45 (wound care coordinator) said wound care is expected to see all new skin alterations within 24 hours. Nurse that finds initial alteration in skin should contact doctor at that time for orders. V 45 said she would not have recommended R14's alteration in skin to be left open to air. On 12/28/18 at 11:09 AM, V 20 (wound care nurse) said for changes in skin, the nurse would assess site, document a skin event, notify doctor, family and risk watch. Wound care should evaluate any new changes in skin within 24 hours. R 14's Physician order [REDACTED]. On 10/1/18 documents right ischium to clean with normal sterile saline (NSS) apply therahoney cover with dry dressing one time a day Tuesday, Thursday and Saturday and as needed; order dated 10/1/18 documents left ischium cleanse with normal sterile saline; apply venelex and foam, cover with dry dressing one time a day Tuesday, Thursday and Saturday and as needed. On 10/2/18 orders document to cleanse with normal sterile saline apply venelex and foam, cover with dry dressing one time a day Tuesday, Thursday and Saturday and as needed. R 14's treatment administration record documents treatment provided to right and left ischium on 10/2/18. No documentation noted on 10/1/18 of treatment provided to right or left ischium. R 14's care plan initiated 12/12/2017 document to report any signs of skin breakdown. R 14's progress note document with effective date of 9/30/18 at 16:20 documents as followed by V 38 (nurse); 9/29/18 3pm-11pm shift approximately 3:00pm nurse received patient in dining area awake with peers, sitting up at table. Patient complaint with medication. No noted distress, safety measures adhered to, will continue to monitor. Approximately 2100 cna made nurse aware of skin tear to right buttock; area cleaned and left open to air (OTA). Patient made clean and comfortable, safety measures adhered to will continue to monitor. 9/30/18 08:00am, upon doing rounds nurse received patient in bed asleep. No noted distress. Approximately 1000 am, cna made nurse aware of abrasion observed to patient left buttocks. Patient made clean and comfortable, safety measure adhered to, will monitor. Approximately 15:45 Nurse practitioner on call made aware; to put information in blue book. Approximately 15:50 family member made aware. Safety measures adhered to will continue to monitor. R 14's skin event dated 9/30/18 documents open areas noted to right and left buttocks. Under action taken documents area cleansed and left open to air. R 14's discharged patient summary documents R 14 had ulceration to left trochanter that was healed on 3/23/18. R 14's Braden score is 13 which means patient is a moderate risk for pressure sores. Braden score is as followed severe risk: Total score 9 high risk : Total score 10-12; moderate risk: Total score 13-14 mild risk : Total score 15-18. R 14's wound assessment details report dated 10/1/18 documents facility acquired deep tissue pressure injury to left ischium measuring 6.40x 5.30x0.10 cm(Length x Width x Depth) with scant amount of serous exudate with date identified as 10/1/18. According to the state operations manual a deep tissue injury is Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. R 14's wound assessment details report dated 10/1/18 documents facility acquired stage 3 pressure injury to right ischium measuring 7.30 x 5.60 x 0.10 cm (Length x Width x Depth) with scant amount of serous exudate and 30 percent slough non-adherent with date identified as 10/1/18. R 14's wound assessment dated [DATE] stage 3 pressure sore to right ischium measuring 10.20 x 7.00 x 0.10 cm (Length x Width x Depth) with scant amount of serous exudate and 30 percent slough non-adherent. State operations manual defines stage 3 pressure sore as a full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Facility's policy titled change in resident's condition dated 10/03 documents that nursing will notify the resident's physician or nurse practitioner when there is a significant change in the residents physical, mental or emotional status. Facility's policy titled pressure ulcer treatment guidelines dated 10/03 documents treatment for [REDACTED]. Facility's policy titled skin care prevention dated 11/03 documents that dependent residents will be assessed during care for any changes in skin condition and it will be reported to the nurse. The nurse is responsible for alerting health care provider and wound care coordinator.

Based on interview and record review, the facility failed to implement effective interventions to de-escalate a dementia care resident's aggressive behavior to prevent physical harm to the resident. This applies to one of six residents (R9) reviewed for behavior, falls and injury in the sample of 15. As a result, R9 sustained a bilateral shoulder dislocation while physically struggling with staff. Findings include: R9's medical record face sheet indicated that R9 was initially admitted to the facility on [DATE] and latest admission was dated 3/12/15 with [DIAGNOSES REDACTED]. Review of R9's progress notes documents that R9 was sent to a local hospital and was admitted with [DIAGNOSES REDACTED]. R9' s progress note dated 1/9/17 and timed 8:11am documented that R9 was very aggressive and agitated shouting and seems very confused when it was time to go to bed. On 1/11/17 at approximately 10:21am, E22 CNA (Certified Nurse Aide) stated that at 6:30am on 1/9/17 when (E22) was making the shift change rounds R9 was in bed with half curtain drawn sleeping. E22 further explained that at around 7am to 7:30am while getting R9 prepared for breakfast (E22) noted that R9's right arm looks twisted and the nurse was notified. The facility Preliminary 24 hour incident/injury investigation report dated January 9, 2017 documented at approximately 9:00am R9 was noted with lateral rotation, pain and bruising to his right arm and was transferred to a local hospital for evaluation and X-ray. On 1/11/17 at approximately 12:55pm, E15 (Dementia Unit Coordinator) stated that the staff did not handle the situation with R9 appropriately. E15 further explained that no physical hold should be used in de-escalating any behavioral situation with any resident. E15 stated that the staff should have stepped back and make sure the resident is safe. E15 stated the facility staff is not CPI (Crisis Prevention Intervention) trained. On 1/11/17 at approximately 2:43pm, E18 (nurse) stated that during the night shift between 11pm and midnight, R9 became combative and aggressive. R9 was swinging, hitting staff and said he will not like to go bed. E16 CNA (Certified Nurse Aide) was trying to get R9 to bed. E16 wrapped his hands around R9 and began to take R9 to the room, R9 began to struggle trying to get out of the physical hold. R9 then slipped through (E16's) hold and went down to R9's knees on the floor at the bed side. E18 further explained that E16 then lifted R9 up with no gait belt use and instructed that R9 to lie down, R9 then told E16 that R9 will not fight any more. When E18 was asked about R9 assessment after fall, E18 answered to be honest with you I did not know that was a fall until I was told in the morning to complete a fall assessment risk around 8:00am. E18 stated in part that when (E18) checked on R9 at 2am it was a facial check because R9 was asleep. On 1/11/17 at approximately 11:52am, Z1 NP(Nurse Practitioner) stated in looking at the class of (R9) ' s injury which is a fracture, the bruises on the right chest wall and right hip it is highly a suspicion of fall. On 1/11/17 at approximately 12:55pm, E15 (Dementia Unit Coordinator) stated that the staff did not handle the situation with R9 appropriately. E15 further explained that no physical hold should be used in de-escalating any behavioral situation the staff should have stepped back and make sure the resident is safe. On 1/12/17 E1 (Administrator) stated that the facility staff are not CPI (Crisis Prevention Intervention) trained and they did not follow the facility protocol on addressing R9's aggressive or combative behaviors. E1 further explained that a physical hold should not have been used. The facility guideline on Physical Restraints emergency dated 10/12 with revision date of 7/14 documented under guideline that although a nurse may determine the need for an emergency physical restraint, approval for use must be made by Health Care Provider Medical Director or a supervisor nurse and an order must be received within eight hours. The guideline further indicated under documentation that the date and time the physical restraint was applied and release should be documented. And the outcome of the application of emergency use of physical restraints should be documented. This guideline was not followed. The facility policy on Behavior Emergency dated 10/3 with revised date of 9/16 documented in part that, the goal of the guideline is to provide a safe, secure environment. The guideline documented that in order to foster a safe environment, a consistent staff approach to behavioral problems and emergencies are necessary. The guideline under policy indicated in part that if resident becomes violent to staff to call 911 (Emergency Help Line). The facility final investigation report dated 1/14/17 documented acknowledging that the action of the CNA (Certified Nurse Aide) contributed in R9's injury. The report further documented that the Nurse and the CNA involved did not follow the facility protocol for handling an aggressive/ combative resident on post fall evaluation.

Based on observation, interview and record review, the facility failed to have a staff member immediately report a resident's unknown unwitnessed injury to the administrator and state agency, failed to do a thorough investigation of the cause of a resident's unknown unwitnessed injury to rule out possible abuse, and failed to protect a resident from further possible abuse, after being aware of a resident's unknown unwitnessed injury according to the facility's protocol. ¿@ This applies to one of one resident (R4) in the sample, identified with an injury of unknown origin in a sample of 13 residents. ¿@ The facility's staff members (E2, E8, E9, E10 and E11) were not familiar with the facility's abuse policy for an abuse situation involving injury of unknown origin to make sure a resident was protected from possible abuse and the facility's policies for abuse and investigating a resident's unknown injury were not followed for R4's protection. This was identified as an immediate jeopardy for R4 who was discovered with multiple injuries to the facial area. ¿@ The immediate jeopardy began on 12/11/2016 when a staff member discovered R4's injury. On 12/22/2016 at 5pm, the administrator was informed about the immediate jeopardy with the director of nursing present. The immediacy was removed on 12/23/2016 when the facility began to re-in service the facility's nursing and non-nursing staff members. ¿@ Findings Include: ¿@ The facility's Abuse Prevention Program policy says the following: ¿@ Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, mistreatment or misappropriation of resident property they observe, hear about or suspect to the Administrator or Supervisor, immediately. ¿@ Injuries of Unknown Source are investigated and reported to State Agency under the procedures of an Abuse Investigation. The first step of an Abuse investigation is immediately safe guarding the resident from further abuse. ¿@ An Injury of Unknown Source is an injury not observed by a person or source that could not be explained. The facility' s policy to investigate any unexplained resident injury says the following: When any staff member notices an unexplained resident injury, it is immediately reported to the DON (director of nurses), Administrator and/or designee. The DON or designee will initiate an investigation. ¿@ R4 ' s Progress Note dated 12/11/2016 at 10:25pm written by E6 (Licensed Practical Nurse/LPN) documented: R4 was noted with some swelling to the right eye and right side of the face painful to touch. E6 received an order to monitor. The source of the injury was not identified. How the monitoring was to be conducted was not identified. E6 initiated an Incident Report # 0 calling the injury a skin issue with unknown source.¿@ ¿@ Occurrence Report # 3 dated 12/13/2016 at 7:30am initiated by E8 (Nurse) documented: R4 had a discolored bruised right eye. ¿@ 12/13/2016 at 10:45am, Z1 (Niece of R4) was interviewed in the 3rd floor day room. R4 was sitting next to Z1 playing with a doll. Z1 said she was called by facility staff Sunday 12/11/2016 at 9:15pm and was told R4's right eye was swollen. Z1 was called Monday 12/12/2016 at 9am and was told about R4's right eye being swollen but not draining. Z1 visited the facility Monday 12/12/2016 and saw R4's right black eye and noticed a bruise on the right side of R4's face and R4's right ear was discolored. Z1 notified the 3rd floor staff about the bruise on the right side of R1's face and the right discolored ear. Z1 turned R4's face to expose the bruised right side of R4's face and the right discolored ear. 12/21/2016 at 1:30pm, E9 (Certified Nursing Assistant/CNA) was interviewed by telephone. E9 works the 3-11pm shift at the facility. E9 was R4's direct care staff Saturday 12/10/2016 and Sunday 12/11/2016. E9 said she is familiar with R4. R4 has a small head and anything different would be noticed. Saturday (12/10) R4 was okay. But Sunday (12/11) R4 was sitting on her bed and told E9 she needed incontinent care. E9 came into the room to provide care when she saw the right side of R4's face was puffy around the right eye, forehead and cheek. E9 immediately called E6 and E10 (LPN) to examine R4's face. E9 said her last Abuse training was in November 2016. E9 was instructed to report to the supervising nurse on the floor anything out of the ordinary. ¿@ 12/21/2016 at 2:15pm, E11 (CNA) was interviewed by telephone. E11 works 11-7am. E11 provided R4 direct care Sunday 12/11/2016 and Monday 12/12/2016. E11 dressed R4 Monday morning. E11 said she did not see any wrong with R4 Sunday night. E11 did confirm that the 3-11pm Sunday said there was something wrong with her eye. E11 said Monday night 12/12/2016, R4's right eye was black and blue. E11 did not notice the right side of R4's face or ear. E11 said she has had 2 Abuse training in-services while employed by the facility. They were told to tell the nursing supervisor on the floor if they found anything and what abuse was. ¿@ 12/21/2016 at 11am, E8 (LPN) was interviewed. E8 works the 7-3pm shift. Tuesday 12/13/2016 was working on the 3rd floor. E8 said the 11-7am nurse told her about R4's right eye. E8 found R4 sitting in the day room, dressed. R4's right eye was swollen and discolored. R4's right temple was swollen. E8 called the Family and Physician. R4 was sent out for a CT (special x-ray) scan. E8 said she tried to ask R4 what happened. R4 started talking about something else other than her black eye. E8 told the nursing supervisors on the floor and did not alert the Administrator. E8 initiated Incident Report # 3. E8 said she did not put down that R4's right temple was swollen because she was unfamiliar with R4 and thought it might just a natural occurrence. E8 was last in-serviced on Abuse in October 2016. E8 did not know that and Injury of Unknown origin should be reported as an Abuse. ¿@ 12/21/2016 and 12/22/2016, E2 (Director of Nursing/DON) was interviewed. E2 said she was not made aware R4's injury until 12/13/2016. E2 told E1 (Administrator) and initiated an investigation. E2 said up until 12/13/2016, R4's swollen right eye was reported as an eye infection. Eye drops were ordered 12/12/2016. The swelling and bruising of the right side of the face and discoloration of the ear were not documented. E2 reported R4's right eye injury to the Illinois Department of Public Health (IDPH), 12/13/2016. ¿@ 12/21/2016 at 2:30pm, E1 (Administrator) was interviewed. E1 said she was told about R4's injury 12/13/2016. E1 instructed E2 to investigate the injury. E2 was given no other instructions from E1. E1 knew that R4's injury was identified as an Injury of Unknown origin. E1 was asked about the facility's Abuse Prevention Program. E1 knew the first step in the Prevention program is to safeguard the resident. ¿@ From 12/11/2016 to 12/13/2016 when the facility staff was asked about the injury to R4's right eye, right face and right ear, no safety measure was put in place to stop any further injury. ¿@ 12/13/2016 at 2pm, E2 (Director of Nursing/DON) said she did not find out about an injury of unknown origin concerning R4 until 12/13/2016 when she reported it to the Illinois Department of Public Health (IDPH). After the surveyor inquired about R4's injury the resident was sent out to the hospital. R4' s emergency hospital' s record provided by the facility contained a report for a CT head/brain w/o (without) contrast. The report contained for findings: Suspicious for a small right Subarachnoid hemorrhage. Although the facility removed the immediacy, the deficiency remains out of compliance at the second level of harm until all the facility's staff members are in serviced. The facility took the following steps to remove the immediate: R4 was seen/evaluated by the medical director 12/23/16 and is stable. R4's care plan was updated per Subarachnoid hemorrhage as well. Nursing staff will continue to monitor every shift until the resident condition is resolved. To complete a more concise investigation of R4's injury, the interview questionnaire for investigations was revised 12/22/16 to provide more details. Staff re-interviewed with new tool to establish any suspicion of abuse. Social worker assessed R4 on 12/23/16 for any signs of psychosocial distress. None noted. Social worker will continue to conduct daily checks on R4 to assess her well-being and document status in the resident's medical record. Social service will continue these checks for one week, then evaluate for the need of on-going visits. On 12/23/16, the social worker also updated R4's risk for abuse assessment and initiated a care plan in relation to her assessed risk. The social work team also completed a sweep to assess all residents' risk for abuse and updated the assessments and care plans for those identified at risk. On 12/22/16, Administrator initiated in-servicing on policy/procedures for injuries/bruises of unknown origin; identifying definition of such, when to report, to whom to report, etc. An employee list has been secure and the facility will ensure that all staff are in-serviced (both nursing and non-nursing) prior to returning to work by December 31, 2016. On 12/22/16, the clinical management team, lead by the Director of Nursing (DON), conducted a sweep of head to toe skin assessments on the third floor residents to identify any other occurrences as such. No other resident on the unit was identified with injuries/bruises of unknown origin. The sweep will continue throughout the remaining floors, and any occurrences as such will be resolved per policy/ procedure. Sweep to be completed by December 27, 2016. The clinical management team, lead by the DON developed a QA (qualility assurance) tool, on 12/23/16 to monitor the reporting of injuries/bruises of unknown origin. This tool will be completed/ reviewed daily for one month. Any instances identified will be reviewed for compliance with the facility policy and referred to the QA committee for any necessary follow up. The abuse coordinator developed a QA tool, on 12/23/16 for random audits of staff knowledge regarding injuries/ bruises of unknown origin, types of abuse, timeliness of reporting such, and who to report to. This tool will be completed daily with 5 random employees for one month; to ensure staff is knowledgeable of the required actions. Employees unable to properly identify the process/ policy will be re-educated immediately, and results of the tool will be referred to QA committee for any necessary follow up. The facility held an emergency QA committee meeting on 12/23/16 to review the event and removal plan.

Based on record review and interview, the facility failed to promptly notify the physician of abnormal lab results resulting in a delay in obtaining new treatment orders for one of three sampled residents (R1) reviewed for infection, in a sample of six. This failure resulted in a delay of treatment for [REDACTED]. Findings Include: R1 is a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Lab results dated 4-18-14 notes positive for [MEDICAL CONDITIONS] GDH Ag and toxin A and B. The lab report had documented: " [MEDICAL CONDITION] (result) faxed and called to E5 (Nurse) on 4-18-2014 at 1852 (6:52PM). Reported to: Skilled nursing and Living. On 4-22-14 at 1:00PM, E5 explained she was contacted about the abnormal lab results on 4-18-14 for R1 from the lab. E5 stated she told E7 (Nurse Manager) of the results but did not implement any care for R1 because she was not R1's nurse for that particular day. R1 nursing notes dated 4-18-14 at 7:34AM stated, " left message for medical doctor related to patient, 3 or more loose watery stools with foul odor. Patient also has productive sputum with yellow color. [MEDICAL CONDITION] culture in progress. Awaiting medical doctor call back, endorsed to next shift. " R1's nursing notes dated 4-19-14 at 11:02PM stated, " certified nurse's aide (CNA) reported to nurse and supervisor that resident had times 5 large watery stools tonight on [MEDICAL CONDITION] isolations. Nurse instructed to notify medical doctor and to follow up with nurse relieving him. " R1's nursing notes dated 4-20-14 at 11:14PM stated, " received results resident positive for [MEDICAL CONDITION]. Medical doctor paged; no response, will endorse to 11-7 nurse." R1's nursing notes dated 4-21-14 at 6:06AM stated, While patient was receiving care, patient was noted with redness to the scrotum, barrier cream applied until evaluations by wound care. Patient medical doctor ( Z1) called and made aware, gave order to refer to wound care. New order for [MEDICATION NAME] every 8 hours times two weeks. On 4-22-14 at 2:00PM E6 (staff nurse) stated, he tried to contact the medical attending and the nurse practitioner several times about R1 abnormal lab results. E6 stated he did not communicate with Director of Nursing, Assistance Director of Nursing nor did he call the Medical Director for direction or guidance about R1's abnormal lab results for treatment. R1's nursing notes dated 4-21-14 at 8:35PM stated , R1 was lethargic, slow to response, non-verbal, assessment was done and Z1 (R1's medical attending doctor) made aware and order to send to hospital emergency room . R1's nursing notes dated 4-21-14 at 8:47PM stated the following: called facility made nurse aware that resident was diverted to closest hospital emergency room due to [MEDICAL CONDITION]. Pulse 60, respirations 22, temperature 99.1, blood pressure (B/P) 101/68. B/P then taken again and blood pressure 72/40 (below normal). Ambulance report dated 4-21-14 at 3:40PM denotes: accident, injury or acute illness/chief complaint is decreased blood pressure and decrease level of consciousness. R1's nursing notes dated 4-21-14 at 11:04PM stated, R1 was admitted to hospital with the [DIAGNOSES REDACTED]. On 4-24-14, Z1 (R1's medical attending doctor) explained, if he was called on the day the lab results were called in, he would have given the medical treatment. The treatment probable would have prevented R1 hospitalization s and [DIAGNOSES REDACTED]. Review of the facility's policy," Change in the Residents' Condition " dated July, 2008 stated the following: 1). Should there be a change in the resident's physical, mental or emotional status the attending physician should be notified. 2). If the attending physician does not respond within 30 minutes, contact the Medical Director. 3). If the Medical Director does not call within 30 minutes, contact the Director of Nurses. On 4-22-14 at 10:00AM, E1 (Director of Nursing) explained , A change in condition must be follow up immediately and the Director of Nursing and Assistant Director of Nursing must be notified.

Based on interview and record review, the facility failed to implement interventions to prevent falls for 2 of 4 residents (R1 and R5) reviewed for fall risk in a sample of 5. This failure resulted in R1 incurring a fracture to the L4 vertebral body and R5 incurring multiple fractures to the spine requiring hospitalization and surgery. Findings include: 1. The Facility Admission Sheet, 4/9/13, documents R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Fall Risk Assessment, 2/15/13, documents R5 at risk for falls with a score of 20. The form documents, "Implement fall preclusions for a total score of 15 or greater." The facility Resident's Care Alert Card, 4/9/13, documents R5 as one person gait belt transfer and fall interventions to include a chair alarm, bed in lowest position and a dycem mat. The facility Care Plan, 2/22/13, documents R5 as having restorative services for transfers from bed to wheelchair with extensive assist from staff. There is no care plan with fall interventions prior to the fall on 6/3/13. The facility was able to provide incomplete documentation of transfer assistance provided by staff via the Point of Care History Report. This report 4/1/13 through 5/31/13, documents R5's level of assistance varied between supervision of staff to extensive assistance to transfer. The facility Restorative Nursing Observation, 5/7/13, documents R5 as extensive assistance of one person physical assist for transfers. The facility Occurrence Report, 6/3/13, completed by E13 (Nurse), documents R5 as being assisted by E12 (Nursing Assistant), to the floor as R5 was sliding from the wheelchair. The report documents R5 reported to E13 R5 was trying to go to bed and slid out of his wheelchair and fell to the floor. The immediate action taken was the application of a bed pressure alarm. The preventative measure a the time of the fall are documented as a low bed, no mats or alarm in place. On 8/8/13 at 2:55pm, E12 stated she was a regular caregiver assigned to R5. E12 stated on 6/3/13 as she was passing R5's room, R5 was in the middle of transferring himself and was in an awkward position. R5 was very tall and E12 was unable to prevent R5 from falling so E12 assisted R5 to the floor between the wheelchair and the bed. E12 stated when R5 was first admitted he would transfer himself. E12 stated, "The staff talked amongst themselves and decided he needed assistance to transfer and staff should be in the room when he transferred. We told (R5) to ask for assistance." E12 stated on dialysis days R5 was weaker than usual. E12 stated there were no alarms in place at the time of the fall and couldn't remember if there was a non-slip mat in place in the wheelchair. E12 stated she is aware of fall interventions for residents by following the facility Care Cards. On 8/8/13 at 3:10pm, E13 stated R5 reported to her that he slid from the wheelchair while transferring self. This was the first time E13 had cared for R5. E13 stated a non-slip wheelchair mat was in place. E13 stated R5 was a person assist for transfers. E13 didn't hear an alarm sounding and didn't recall R5 ever having an alarm. R5 had no complaints of discomfort, no injuries and no changes in assessment. E13 stated the facility Care Cards document fall interventions for each resident. On 8/9/13 at 9:25am, E9 (Nurse), stated she cared for R5 on 6/7/13 and was a routine nurse for R5. R5 had complained of discomfort to the tailbone and the physician was notified. E9 stated R5 was very independent and wanted to do things for himself. E9 stated R5 would sometimes transfer self and would educate him on requesting staff assistance. R5 had a non-slip wheelchair mat but not an alarm. The Resident Progress Notes, 6/6/13, documents R5 was assessed by a Physician Assistant due to complains of pain to the lumbar region. An X-ray of the lumbar spine was ordered due to a fall with lumbar pain. The Resident Progress Notes, 6/7/13, documents R5 as being sent to the hospital after Z1 reported X-ray result of a possible T11, T12 and L5 fracture. The Resident Progress Notes, 6/7/13, documents R5 as admitted to the hospital with [REDACTED]. The hospital emergency room Physician Assessment, 6/7/13, documents R5 as presenting to the emergency room with possible compression fractures at T11, T12 and L5. R5 reported falling 4 days prior while going from the wheelchair to the bed. The admitting [DIAGNOSES REDACTED]. The hospital Computed Tomography Scan of the thoracic, lumbar and cervical spine documents marked compression deformities of the C5 and C7 vertebral bodies, of indeterminate age. Probably remote compression deformities at the T9 and T10. Probable remote fractures of the left lamina of C1 and right lamina of C7. The neurosurgeon report, 6/7/13 documents marked compression deformities of the C5 and C7 vertebral bodies, of indeterminate age. Probably compression deformities at the T9 and T10. Partial fusion and compression deformities at T2 and T3, may be related to healed infection. The neurosurgeon operative note, 6/19/13 documents a posterior cervical Thoracic Laminectomy and Fusion was completed. On 8/9/13 at 10:08am, Z1 stated R5 was alert. Z1 was unable to remember the specific fracture [DIAGNOSES REDACTED]. R5 required stabilization of the spine and surgery. Z1 stated he cared for R5 at the hospital also. Z1 was unable to recall the circumstance of the fall and stated once R5 was stabilized he was discharged from the hospital to another facility. Z1 stated the fractures incurred were "Possibly as a result of the fall, but R5 had severe osteoporosis." On 8/8/13 at 3:35pm, E11 (Restorative Aide), stated R5 was a 2 person assist on dialysis days and a 1 person assist the other days. On 8/8/13 at 10:14am, E10 (Nurse), stated she had readmitted R5 to the facility on [DATE]. E10 stated R5 was at risk for falls and placed a bed alarm, chair alarm and mats as fall interventions on 4/9/13. On 8/8/13 at 3:16pm, E14 (Nurse) stated, R5 was a one person transfer and R5 had to be reminded to ask for staff assistance because R5 would transfer without assistance. E14 stated the staff are aware of each residents fall interventions by observing the facility Care Cards. On 8/8/13 at 1:54pm, E2 (Director of Nursing), stated the facility doesn't have a policy for the use of Care Cards. The purpose of the Care Cards is to give the nursing assistance information on how to take care of the residents. 2. The facility Face Sheet, 5/28/13, documents R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Fall Risk Assessment, 5/29/13, documents R1 as being at risk for falls and fall interventions placed to maintain safety. The Admission Elopement Risk Assessment, 5/29/13, documents a preventative measures of a wheelchair/bed alarm as implemented. The facility Care Plan, 5/28/13, documents R1 at risk for falling with an approach to use a personal alarm in bed and the wheelchair. The facility Occurrence Report, 6/2/13 completed by E5 (Nurse), documents R1 was found on the floor bedside at 7:30am. The fall was unwitnessed. The immediate actions taken include applying an alarm. The Falls detail report documents R1 with no alarms or mats at the time of the fall. On 8/6/13 at 3:15pm, E5 (Nurse) stated on 6/2/13 another resident (couldn't remember name) informed E5 that R1 was on the floor and needed assistance. E5 stated she went to the room and assisted R1 off of the floor and no other staff members were present. R1 reported to E5 he was trying to get into the wheelchair. E5 stated no injuries were noted and R1 denied pain. E5 reported R1 had no changes or complaints of pain the entire shift. E5 stated at the time of the fall R5's bed was in low position and no alarm was in place. E5 stated a personal alarm was added after the fall. On 8/7/13 at 3:36pm, E8 (Nurse), stated she had completed the admission fall risk assessment and initiated the initial care plan with fall interventions to include floor mats and a bed and chair alarm. E8 stated these precautions were implemented because R1 was, "antsy and wouldn't keep still. He was confused." On 8/7/13 at 4:12pm, Z1 (attending physician), stated he had not taken care of R1 prior to the admission on 5/28/13. Z1 stated the facility notified him R1 had fallen. Z1 stated R1 had not complained of any discomfort at the facility and had been sent to the hospital for altered mental status. Z1 stated, " A fracture can happen with any fall. R1 had medical conditions making him more susceptible to a fracture. I would think R1 would have complained of pain right after the fall if it caused the fracture." The Resident Progress Notes, 6/3/13 at 11:39am, documents R1 was sent to the hospital after a change in mental status. The emergency room Department Note, 6/3/13 at 12:45pm, documents a physician assessment which includes R1 being sent for evaluation of altered mental status. The back assessment documents R1 as yelling and grimacing when sitting up in bed. R1 was admitted for altered mental status. The hospital emergency room Department Note, 6/3/13 at 12:45pm, documents a physician assessment which includes R1 being sent for evaluation of altered mental status. The physician impression of R1 was documented as altered mental status secondary to a likely urinary tract infection and hypertension. The hospital Computed Tomography of the Lumbar Spine, 6/4/13, documents the testing as completed due to post trauma, evaluate for fracture. The impression documents R1 as having compression fracture of the L4 vertebral body with mild to moderate loss of vertebral height. On 8/6/13 at 2:40pm, E7 (Falls Nurse), stated the admission nurse does an initial assessment. If at risk the nurse implement appropriate interventions. Then a second fall risk assessment is done by E7 and makes any needed adjustments in interventions. If a fall occurs, a nurse follows-up with the resident every shift for 72 hours. The documentation includes an initial fall risk and pain assessment. On 8/7/13 at 10:25am, E2 (Director of Nursing), stated if a fall occurs, a fall risk assessment and pain assessment are completed. In addition, the nurse is to complete an assessment every shift for 72 hours after the fall. The facility Fall Program, undated, documents fall risk assessments are to be completed on admission, readmission, quarterly and after each fall. The care plan is to address and apply appropriate interventions. If a resident is assessed at high risk, fall interventions and a care plan is to be implemented.

Based on interview and record review, the facility failed to report allegations or suspicions of sexual abuse to supervisor or administrator immediately, failed to immediately investigate allegation of sexual abuse, and failed to protect the resident with Dementia who is unable to verbalize needs and unable to protect herself from alleged perpetrator, for 1 resident ( R3 ) out of 4 residents reviewed for abuse. This failure resulted in an Immediate Jeopardy when on 6/1/12, R3 was left unsupervised and unprotected from Z1 (family member). The facility also failed to immediately report to the physician the actual observation of kissing and fondling of R3 ' s breast and crotch area by Z1. As a result, R3 was not sent out to the hospital immediately on 6/1/12. E1 and E2 were made aware of the Immediate Jeopardy on 9/14/12 at 3:10 PM. While the Immediate Jeopardy was removed on 6/2/12, the facility remains out of compliance at severity level 2, as the facility has yet to in-service all staff including newly hires on all shifts, has yet to assess if new interventions are effective for the possible affected residents, and has yet to evaluate the new plan of care. Findings include : R3 has [DIAGNOSES REDACTED]. On 9/13/12 at 10:30 AM, R3 was observed in the recliner chair, alert but non-verbal and unable to communicate needs, and contracted on all 4 extremities. R3 ' s Incident Report dated 6/1/12 indicated that at 12:30 PM, Z1 (family member) attempted to open R3 ' s contracted hand and stretch her legs which are also contracted. R3 was also seen always patting R3 ' s arm and legs during the entire visit per this incident report written by E20 ( nurse ). On 9/12/12 at 11:40 AM, E5 ( Rehab Aide ) said that on 6/1/12 before noon time, E5 came in R3 ' s room and saw Z1 (family member) groping R3 ' s breast and patting her private area. E5 said that Z1 stopped when Z1 saw E5. E5 said that she told Z1 to excuse himself because E5 needs to take R3 ' s weight. Z1 sat at the back of the room but did not leave R3 ' s room. E5 said that she reported what she saw to E20 ( nurse ), and had E21 (Certified Nurse Aide / CNA ) and E22 ( Certified Nurse Aide / CNA ) accompany her ( E5 ) to the room. E5 said that R3 was weighed in the room, then her bed was placed in the hallways as her room is going to be deep-cleaned afterwards. E5 said that when Z1 stood up from where he was sitting in R3 ' s room, he had an erection. E5 said that afterwards, R3 was transferred from her bed to her wheelchair while in the hallway, and therapy department took her. E5 said she left around 1 PM. On 9/12/12 at 11 AM, E20 (Nurse) denied that E5 reported to her R3 ' s groping by Z1 on 6/1/12 in R3 ' s room. E20 said that on 6/1/12, no staff reported to her any allegation that involves R3 and Z1 that is sexual in nature. During above incident, R3 was left unsupervised with Z1 ( who was already seen by E5 groping her breast and private area ) when she called the nurse. Z1 was not immediately removed from direct contact with R3 to protect R3. E20 also did not remove Z1 from direct contact with R3 after E5 claimed that she reported this incident to E20. Additionally, E1 ( Administrator ) was also not notified about R3 ' s fondling at this time by E5 nor by E20. On 9/11/12 at 3:30 PM, E26 CNA/Assistant to Director of Nursing said that on 6/1/12 at around 10 - 10:30 AM, when she came out of the bathroom, she saw Z1 kissing R3 on her mouth with his tongue down her throat. E26 said that R3 was in her bed in the hallway outside R3 ' s room which is being deep-cleaned that day. E26 said that Z1 said that E26 had nothing to do with it and called E26 a [***] . E26 said she screamed for E20 ( nurse ). E20 denied E26 reporting this to her on 9/11/12. E26 added that Z1 was drunk. E26 said that they had R3 placed in the dayroom after what E26 saw, and that Z1 remained with R3 in the dayroom, despite of what E26 said she reported seeing to E20. E26 also added that although she did not see Z1 grope R3, E21 (CNA) did that afternoon. E26 continued that E4 ( CNA ) also saw Z1 ' s hand under her diaper. As E20 denied that E26 reported witnessing Z1 kiss R3 in the mouth with his tongue down her throat, there was no immediate reporting to E1 nor was Z1 immediately separated from R3 or any other residents. R3 was placed in the dayroom with Z1 where R3 was again seen being sexually assaulted by Z1. On 9/11/12 at 2:30 PM, E4 ( CNA ) said that on 6/1/12, she was in the 4th floor dayroom and R3 was in the room, covered with a blanket. Z1 was sitting next to her. E4 said that she noticed Z1 ' s hand on top of her breast area while the other hand on her crotch area. Both hands were under the blanket covering R3. E4 said that Z1 ' s hands were moving under the blanket like Z1 was touching R3' s breast and crotch under the covers. E4 said that R3 was agitated and was muttering profanities. E4 also said that Z1 was kissing her in the mouth. E4 said that when she asked Z1 if everything was okay, Z1 removed his hands and stopped what he was doing. E4 continued that later, Z1 stood up and pushed R3' s recliner chair out of the dayroom to the hallway towards her room. On 9/13/12, R3' s room [ROOM NUMBER] was noted to be away from the 4th floor day room and cannot be visually monitored as soon as R3 and Z1 were in the hallway past the 4th floor nurses station. E4 said that Z1 had an erection when he stood up. E4 was unsure where exactly Z1 took R3, but said that she assumed they were going to R3 ' s room [ROOM NUMBER], as Z1 was pushing R3 ' s recliner towards that direction. E4 said that she did not go with Z1 and R3, and remained in the 4th floor dayroom until her 30 minute dayroom watch was over in 5-10 minutes after R3 and Z1 left. Only then that E4 said she left the dayroom and reported the fondling to E23 ( Social Service Assistant ) after her schedule as dayroom monitor was over. On 9/12/12 at 1 PM, E23 denied receiving a report neither from E4 nor from any staff on 6/1/12 regarding R3 being fondled or kissed by Z1. E4 continued that that after she and a restorative aide put R3 back to bed ( which was still in the hallway ), she again witnessed Z1 fondling R3 ' s breast and crotch area under the cover while R3 ' s bed was still in the hallway. E4 said that she reported this to E25 ( nurse ) although she did not make any attempt to intervene and stop Z1 from further fondling R3. E4 said that E25 went with her towards Z1 and R3, but Z1 stopped what he was doing when he saw E4 and E25 coming. At this time, Z1 insisted that R3 ' s bed be put inside her room from the hallway. E4 said that Z1 went to E1 ( Administrator ) and E1 gave orders to put R3 ' s bed back inside her room. E4 said that they just tucked R3 ' s blanket on her side to prevent Z1 from putting his hands under the blanket to her breasts and crotch area. E4 said that 30 minutes later ( after leaving R3 with Z1 unsupervised again ) she came back and noticed that her tucked blanket had been undone. E4 said that it was around the end of her shift so she left the room and told E23 (Social Service Assistant) about it. E23 denied this as written above. E4 said that the next time she came back to work, she was told not to leave R3 alone with Z1. Additionally there was no written statement from E25 Nurse, prior to her termination why she did not report to E1, Administrator, E2 DON ( Director of Nursing ), E3 ADON ( Assist. Director of Nursing ) nor to E27 ( Social Worker ) this allegation of sexual abuse seen 2x by E4, nor did E25 intervene to protect R3 from Z1 who still allowed to stay with R3 inside her room after this report from E4. On 9/11/12 at 3:20 PM, E21 ( CNA ) said that in the afternoon of 6/1/12, she saw Z1 fondling R3 ' s left breast under R3 ' s dress. E21 said that R3 was in bed in the hallway which was across R3 ' s room. E21 said that Z1 was drunk and did not stop what he was doing even though he saw E21. E21 said that she stayed there and screamed for E20 ( nurse ). E21 said that E20 came over and E21 told her that Z1 was fondling R3 ' s breast. E21 said that Z1 denied it and started cursing E21. E21 then said she left after that because she couldn ' t believe what she saw. E20 denied this as stated above and E21 ' s written statement indicated that it was the other nurse E25 who saw Z1. This abuse observation never reached E1, E2, E3 or E24. There was no indication how the facility protected R3 from Z1 after this. On 9/12/12 at 2:30 PM, E24 ( Assist. Director of Nursing ) said that on 6/1/12 after noontime, she saw Z1 rubbing R3 ' s legs in the 4th floor dayroom. E24 said that she instructed E20 Nurse and E4 CNA to monitor R3. E24 also said that she informed E1 about this, and E1 actually came to the floor to talk to Z1. E24 said that an hour later, she came back to the floor to check on R3, and saw her still in the recliner at this time, parked in the hallway outside her room. E24 saw Z1's one hand fondling R3 ' s breast, while his other hand is fondling her vaginal area under the sheet. E24 added that Z1 did not stop what he was doing even though E24 was there with E21, E4 and E5. E24 said that she yelled for Z1 to stop what he was doing and he did, but started yelling and threatening to sue and kill E24. E24 said that R3 looked angry at this time. E24 said that she was joined by E20 and E25. E24 said that Z1 smelled of alcohol at this time. E24 said that Z1 left and did not come back after that. E24 also said she made the administrator aware of the incident she witnessed. E24 added that the staff were also instructed to do 1:1 with R3, and ensure that she should not be left alone. E24 added that the staff were told that Z1 should not have any sort of contact with R3. However unknown to E24, Z1 did not leave after he was seen fondling R3 in the hallway. As per above interview of E4, after Z1 was seen fondling R3 in the hallways in her bed, R3 ' s bed was transferred inside her room where Z1 was left unsupervised with R3 for at least 30 minutes. On 9/13/12 at 3 PM, E1 denied that any of the staff reported to him any incident of Z1 kissing R3 with tongue, or Z1 fondling of R3 ' s breast and genital areas. E1 said that on 6/1/12, the staff reported to him that Z1 was rubbing R3 ' s leg and leaning over her in the dayroom. E1 said that he came to the floor and spoke with Z1 although he did not see anything unusual. E1 said that later Z1 requested that R3 be transferred back to bed. E1 said that together with E27 ( social worker ), he observed Z1 and R3 in her room and there was nothing unusual they noted. E1 said that he sent Z1 out of the building and told him not to come back till Monday after that, because he wants to investigate what was going on, and he ( E1 ) is not there during the weekend when Z1 could come back. On 9/14/12 at 10:16 AM, Z2 (Nurse Practitioner) said that on 6/1/12, she received a report from staff that Z1 (family member) was touching R3's perineal area under the sheets. Z2 said that no staff witnessed the actual fondling of R3 and so she spoke to Z1 who according to Z2 said that he was just doing R3 ' s Range of Motion exercise and doing her perineal care. Z2 continued that she advised Z1 to let the staff do the perineal care and ROM exercises as R3 is very frail. Z2 said that Z1 smelled of alcohol but able to converse with Z1 sensibly and was not falling off the chair during that time. Z2 denied receiving a report from staff later that staff actually saw Z1 stick his tongue down R3 ' s throat or Z1 fondling R3 ' s breast or genital area. Z2 added that if she was told of the observed sexual assault on R3, she would have sent R3 to the hospital immediately for examination, call 911, separate Z1 from R3, and call the police. Z2 also said she cannot remember calling Z3 (R3's attending physician) that day as she really did not hear any report from the facility of the kissing and observed fondling of R3. Similarly on 9/14/12 at 10:48 AM, Z3 (R3's attending physician) said during phone interview that he recalled that the facility called him that R3 is being sent to the hospital for examination for sexual abuse. R3 ' s nurses notes showed this was on 6/8/12, a week after the actual kissing and fondling of R3 by Z1. Z3 added that prior to that, the facility did not call him to report that the son was observed kissing R3 and fondling her breast or vaginal area. Z3 said that if staff called him about it, he would have sent R3 to the hospital for examination immediately. R3 ' s nurses note dated 6/1/12 at 10 PM indicated that E28 ( 3-11 nurse on 6/1/12) wrote that she paged Z3 (R3's attending physican) several times during shift regarding Z1 inappropriately touching R3 but Z3 did not return call. Z4 (Medical Director) was also paged by E28 but also did not call back. On 9/13/12 at 3:30 PM, E28 verified that when she came to work on 6/1/12 on evening shift, it was reported to her to call Z3 as Z1 fondled R3. E28 said that she paged Z3 and Z3 did not call back so she paged Z4. E28 said that Z4 also did not call back and she endorsed this to the night shift. There is no indication in R3 ' s record that Z3 or Z4 was made aware of R3 ' s incident of being kissed and fondled. As there was no immediate reporting of the 6/1/12 sexual abuse observation to the supervisors E2 and E24 or E1, the facility did not conduct an immediate investigation of the allegation. The investigation started when E24 observed R3 being fondled by Z1 in the hallway on 6/1/12. On 9/13/12 at 3 PM, E1 said that staff is expected to stop Z1 if he was seen kissing R3 or fondling her breast or genital area in the dayroom. E1 continued that staff is also expected to call the supervisor or the nurse and report what the staff saw, and wait for help, then the alleged perpetrator should be separated from the resident. The resident should not be left alone and unsupervised with the alleged perpetrator per E1 after there is an allegation of sexual abuse. E1 said during this interview that there was no kissing with tongue or fondling of R3 that occurred on 6/1/12. E1 then added that if he had knowledge of kissing with tongue or fondling of breast and genital area of R3 in AM, he would have made Z1 leave the building immediately to protect the resident. E1 and E2 were notified of the Immediate Jeopardy on 9/14/12 at 3:10 PM. The facility took the following steps to correct the Immediate Jeopardy: 1) The facility reviewed all abuse investigations from 6/1/12 and noted no further sexual abuse allegation. All residents were reviewed to determine who are at risk for abuse and each were care planned. This was started on 9/14/12 and completed on 9/14/12. This was overseen by the Director of Nursing, implemented by all unit managers on each floor. 2) An in-service on abuse policy and procedure was conducted for all staff on 9/14/12 by the DON and completed on 9/18/12. Highlights of this in-service includes immediate reporting of abuse allegations, and immediate protection of residents from alleged perpetrator. A monitoring tool was made by the DON to ensure compliance for 4 weeks, and oversight is done by Administrator. After 4 weeks, the monitoring tool will be reviewed by QA committee during the monthly QA meeting to determine further need of continued monitoring. This will be overseen by the Administrator and the Medical Director. 3) Abuse in-service will be done quarterly by DON or designee. Additionally, every new hire staff will be given abuse in-service as well by DON or designee. 4)An in-service which started on 9/14/12 was also conducted by DON to all nurses to ensure that physicians will be immediately notified of all allegations of abuse. In the event the physician does not call back, the medical director will be immediately notified. This was completed on 9/18/12.

Based on interview and record review, the facility failed to follow and implement their abuse policy, by not conducting an internal investigation, no protection of the residents, and no immeidate reporting to the state agency after alleged sexual abuse occurred for 1 of 4 residents (R3), all were reviewed for abuse. This failure resulted to an Immediate Jeopardy when on 6/1/12, R3 was left unsupervised and unprotected from Z1 (family member). The facility also failed to immediately report to the physician the actual observation of kissing and fondling of R3 ' s breast and crotch area by Z1. As a result, R3 was not sent out to the hospital immediately on 6/1/12. E1 and E2 were made aware of the Immediate Jeopardy on 9/14/12 at 3:10 PM. While the Immediate Jeopardy was removed on 6/2/12, the facility remains out of compliance at severity level 2, as the facility has yet to in-service all staff including newly hires on all shifts, has yet to assess if new interventions are effective for the possible affected residents, and has yet to evaluate the new plan of care. Findings include : R3 has [DIAGNOSES REDACTED]. On 9/13/12 at 10:30 AM, R3 was observed in the recliner chair, alert but non-verbal and unable to communicate needs, and contracted on all 4 extremities. R3 ' s Incident Report dated 6/1/12 indicated that at 12:30 PM, Z1 (family member) attempted to open R3 ' s contracted hand and stretch her legs which are also contracted. R3 was also seen always patting R3 ' s arm and legs during the entire visit per this incident report written by E20 ( nurse ). On 9/12/12 at 11:40 AM, E5 ( Rehab Aide ) said that on 6/1/12 before noon time, E5 came in R3 ' s room and saw Z1 (family member) groping R3 ' s breast and patting her private area. E5 said that Z1 stopped when Z1 saw E5. E5 said that she told Z1 to excuse himself because E5 needs to take R3 ' s weight. Z1 sat at the back of the room but did not leave R3 ' s room. E5 said that she reported what she saw to E20 ( nurse ), and had E21 (Certified Nurse Aide / CNA ) and E22 ( Certified Nurse Aide / CNA ) accompany her ( E5 ) to the room. E5 said that R3 was weighed in the room, then her bed was placed in the hallways as her room is going to be deep-cleaned afterwards. E5 said that when Z1 stood up from where he was sitting in R3 ' s room, he had an erection. E5 said that afterwards, R3 was transferred from her bed to her wheelchair while in the hallway, and therapy department took her. E5 said she left around 1 PM. On 9/12/12 at 11 AM, E20 Nurse, denied that E5 reported to her R3 ' s groping by Z1 on 6/1/12 in R3 ' s room. E20 said that on 6/1/12, no staff reported to her any allegation that involves R3 and Z1 that is sexual in nature. During above incident, R3 was left unsupervised with Z1 ( who was already seen by E5 groping her breast and private area ) when she called the nurse. Z1 was not immediately removed from direct contact with R3 to protect R3. E20 also did not remove Z1 from direct contact with R3 after E5 claimed that she reported this incident to E20. Additionally, E1 ( Administrator ) was also not notified about R3 ' s fondling at this time by E5 nor by E20. On 9/11/12 at 3:30 PM, E26 CNA/Assistant to DON said that on 6/1/12 at around 10 - 10:30 AM, when she came out of the bathroom, she saw Z1 kissing R3 on her mouth with his tongue down her throat. E26 said that R3 was in her bed in the hallway outside R3 ' s room which is being deep-cleaned that day. E26 said that Z1 said that E26 had nothing to do with it and called R26 a [***] . E26 said she screamed for E20 ( nurse ). E20 denied E26 reported this to her on 9/11/12. E26 added that Z1 was drunk. E26 said that they had R3 placed in the dayroom after what E26 saw, and that Z1 remained with R3 in the dayroom, despite of what E26 said she reported seeing to E20. E26 also added that although she did not see Z1 grope R3, E21 CNA, did that afternoon. E26 continued that E4 ( CNA ) also saw Z1 ' s hand under her diaper. As E20 denied that E26 reported witnessing Z1 kiss R3 in the mouth with his tongue down her throat, there was no immediate reporting to E1 nor was Z1 immediately separated from R3 or any other residents. R3 was placed in the dayroom with Z1 where R3 was again seen being sexually assaulted by Z1. On 9/11/12 at 2:30 PM, E4 ( CNA ) said that on 6/1/12, she was in the 4th floor dayroom and R3 was in the room, covered with a blanket. Z1 was sitting next to her. E4 said that she noticed Z1 ' s hand on top of her breast area while the other hand on her crotch area. Both hands were under the blanket covering R3. E4 said that Z1 ' s hands were moving under the blanket like Z1 was touching R3' s breast and crotch under the covers. E4 said that R3 was agitated and was muttering profanities. E4 also said that Z1 was kissing her in the mouth. E4 said that when she asked Z1 if everything was okay, Z1 removed his hands and stopped what he was doing. E4 continued that later, Z1 stood up and pushed R3' s recliner chair out of the dayroom to the hallway towards her room. On 9/13/12, R3' s room [ROOM NUMBER] was noted to be away from the 4th floor day room and cannot be visually monitored as soon as R3 and Z1 is the hallway past the 4th floor nurses station. E4 said that Z1 had an erection when he stood up. E4 was unsure where exactly Z1 took R3, but said that she assumed they were going to R3 ' s room [ROOM NUMBER], as Z1 was pushing R3 ' s recliner towards that direction. E4 said that she did not go with Z1 and R3, and remained in the 4th floor dayroom until her 30 minute dayroom watch was over in 5-10 minutes after R3 and Z1 left. Only then that E4 said she left the dayroom and reported the fondling to E23 ( Social Service Assistant ) after her schedule as dayroom monitor was over. On 9/12/12 at 1 PM, E23 denied receiving a report neither from E4 nor from any staff on 6/1/12 regarding R3 being fondled or kissed by Z1. E4 continued that after she and a restorative aide put R3 back to bed ( which was still in the hallway ), she again witnessed Z1 fondling R3 ' s breast and crotch area under the cover while R3 ' s bed was still in the hallway. E4 said that she reported this to E25 ( nurse ) although she did not make any attempt to intervene and stop Z1 from further fondling R3. E4 said that E25 went with her towards Z1 and R3, but Z1 stopped what he was doing when he saw E4 and E25 coming. At this time, Z1 insisted that R3 ' s bed be put inside her room from the hallway. E4 said that Z1 went to E1 ( Administrator ) and E1 gave orders to put R3 ' s bed back inside her room. E4 said that they just tucked R3 ' s blanket on her side to prevent Z1 from putting his hands under the blanket to her breasts and crotch area. E4 said that 30 minutes later ( after leaving R3 with Z1 unsupervised again ) she came back and noticed that her tucked blanket had been undone. E4 said that it was around the end of her shift so she left the room and told E23 (CNA/Assistant to DON) about it. E23 denied this as written above. E4 said that the next time she came back to work, she was told not to leave R3 alone with Z1. Additionally there was no written statement from E25 Nurse, prior to her termination why she did not report to E1 Administrator, E2 ( Director of Nursing ), E3 ( Assist. Director of Nursing ) nor to E27 ( Social Worker ) this allegation of sexual abuse seen 2x by E4, nor did E25 intervene to protect R3 from Z1 who still allowed to stay with R3 inside her room after this report from E4. On 9/11/12 at 3:20 PM, E21 ( CNA ) said that in the afternoon of 6/1/12, she saw Z1 fondling R3 ' s left breast under R3 ' s dress. E21 said that R3 was in bed in the hallway which was across R3 ' s room. E21 said that Z1 was drunk and did not stop what he was doing even though he saw E21. E21 said that she stayed there and screamed for E20 ( nurse ). E21 said that E20 came over and E21 told her that Z1 was fondling R3 ' s breast. E21 said that Z1 denied it and started cursing E21. E21 then said she left after that because she couldn ' t believe what she saw. E20 denied this as stated above and E21 ' s written statement indicated that it was the other nurse E25 who saw Z1. This abuse observation never reached E1 Administrator, E2 DON, E3 ADON or E24 Former ADON. There was no indication how the facility protected R3 from Z1 after this. On 9/12/12 at 2:30 PM, E24 (Former Assist. Director of Nursing ) said that on 6/1/12 after noontime, she saw Z1 rubbing R3 ' s legs in the 4th floor dayroom. E24 said that she instructed E20 and E4 to monitor R3. E24 also said that she informed E1 about this, and E1 actually came to the floor to talk to Z1. E24 said that an hour later, she came back to the floor to check on R3, and saw her still in the recliner at this time, parked in the hallway outside her room. E24 saw Z1's one hand fondling R3 ' s breast, while his other hand is fondling her vaginal area under the sheet. E24 added that Z1 did not stop what he was doing even though E24 was there with E21, E4 and E5. E24 said that she yelled for Z1 to stop what he was doing and he did, but started yelling and threatening to sue and kill E24. E24 said that R3 looked angry at this time. E24 said that she was joined by E20 and E25. E24 said that Z1 smelled of alcohol at this time. E24 said that Z1 left and did not come back after that. E24 also said she made the administrator aware of the incident she witnessed. E24 added that the staff were also instructed to do 1:1 with R3, and ensure that she should not be left alone. E24 added that the staff were told that Z1 should not have any sort of contact with R3. However unknown to E24, Z1 did not leave after he was seen fondling R3 in the hallway. As per above interview of E4, after Z1 was seen fondling R3 in the hallways in her bed, R3 ' s bed was transferred inside her room where Z1 was left unsupervised with R3 for at least 30 minutes. On 9/13/12 at 3 PM, E1 denied that any of the staff reported to him any incident of Z1 kissing R3 with tongue, or Z1 fondling of R3 ' s breast and genital areas. E1 said that on 6/1/12, the staff reported to him that Z1 was rubbing R3 ' s leg and leaning over her in the dayroom. E1 said that he came to the floor and spoke with Z1 although he did not see anything unusual. E1 said that later Z1 requested that R3 be transferred back to bed. E1 said that together with E27 ( social worker ), he observed Z1 and R3 in her room and there was nothing unusual they noted. E1 said that he sent Z1 out of the building and told him not to come back till Monday after that, because he wants to investigate what was going on, and he ( E1 ) is not there during the weekend when Z1 could come back. On 9/14/12 at 10:16 AM, Z2 Nurse Practioner said that on 6/1/12, she received a report from staff that Z1 (family member) was touching R3 perineal area under the sheets. Z2 said that no staff witnessed the actual fondling of R3 and so she spoke to Z1 who according to Z2 said that he was just doing R3 ' s Range of Motion exercise and doing her perineal care. Z2 continued that she advised Z1 to let the staff do the perineal care and ROM exercises as R3 is very frail. Z2 said that Z1 smelled of alcohol but able to converse sensibly and was not falling off the chair during that time. Z2 denied receiving a report from staff later that staff actually saw Z1 stick his tongue down R3 ' s throat or Z1 fondling R3 ' s breast or genital area. Z2 added that if she was told of the observed sexual assault on R3, she would have sent R3 to the hospital immediately for examination, call 911, separate Z1 from R3, and call the police. Z2 also said she cannot remember calling Z3 (R3's attending physician) that day as she really did not hear any report from the facility of the kissing and observed fondling of R3. Similarly on 9/14/12 at 10:48 AM, Z3 (R3's attending physician) said during phone interview that he recalled that the facility called him that R3 is being sent to the hospital for examination for sexual abuse. R3 ' s nurses notes showed this was on 6/8/12, a week after the actual kissing and fondling of R3 by Z1. Z3 added that prior to that, the facility did not call him to report that the son was observed kissing R3 and fondling her breast or vaginal area. Z3 said that if staff called him about it, he would have sent R3 to the hospital for examination immediately. R3 ' s nurses note dated 6/1/12 at 10 PM indicated that E28 ( 3-11 nurse on 6/1/12) wrote that she paged Z3 (R3's attending physician) several times during shift regarding Z1 inappropriately touching R3 but Z3 did not return call. Z4 (Medical Director) was also paged by E28 but also did not call back. On 9/13/12 at 3:30 PM, E28 verified that when she came to work on 6/1/12 on evening shift, it was reported to her to call Z3 as Z1 fondled R3. E28 said that she paged Z3 and Z3 did not call back so she paged Z4. E28 said that Z4 also did not call back and she endorsed this to the night shift. There is no indication in R3 ' s record that Z3 or Z4 was made aware of R3 ' s incident of being kissed and fondled. As there was no immediate reporting of the 6/1/12 sexual abuse observation to the supervisors E2 and E24 or E1, the facility did not conduct an immediate investigation of the allegation. The investigation started when E24 observed R3 being fondled by Z1 in the hallway on 6/1/12. On 9/13/12 at 3 PM, E1 said that staff is expected to stop Z1 if he was seen kissing R3 or fondling her breast or genital area in the dayroom. E1 continued that staff is also expected to call the supervisor or the nurse and report what the staff saw, and wait for help, then the alleged perpetrator should be separated from the resident. The resident should not be left alone and unsupervised with the alleged perpetrator per E1 after there is an allegation of sexual abuse. E1 said during this interview that there was no kissing with tongue or fondling of R3 that occurred on 6/1/12. E1 then added that if he has knowledge of kissing with tongue or fondling of breast and genital area of R3 in AM, he would have made Z1 leave the building immediately to protect the resident. E1 and E2 were notified of the Immediate Jeopardy on 9/14/12 at 3:10 PM. The facility took the following steps to correct the Immediate Jeopardy: 1) The facility reviewed all abuse investigations from 6/1/12 and noted no further sexual abuse allegation. All residents were reviewed to determine who are at risk for abuse and each were care planned. This was started on 9/14/12 and completed on 9/14/12. This was overseen by the Director of Nursing, implemented by all unit managers on each floor. 2) An in-service on abuse policy and procedure was conducted for all staff on 9/14/12 by the DON and completed on 9/18/12. Highlights of this in-service includes immediate reporting of abuse allegations, and immediate protection of residents from alleged perpetrator. A monitoring tool was made by the DON to ensure compliance for 4 weeks, and oversight is done by Administrator. After 4 weeks, the monitoring tool will be reviewed by QA committee during the monthly QA meeting to determine further need of continued monitoring. This will be overseen by the Administrator and the Medical Director. 3) Abuse in-service will be done quarterly by DON or designee. Additionally, every new hire staff will be given abuse in-service as well by DON or designee. 4)An in-service which started on 9/14/12 was also conducted by DON to all nurses to ensure that physicians will be immediately notified of all allegations of abuse. In the event the physician does not call back, the medical director will be immediately notified. This was completed on 9/18/12.

Based on interview, and record review, the facility failed to ensure proper positioning during care of 1 (R4) of 3 residents reviewed for injuries/fractures. This failure led to R4 sustaining a fracture to his right arm. Findings include: R4 was admitted to the facility with the following Diagnoses: [REDACTED]. The facility ' s investigation report dated 3/15/12 documents that R4 complained of pain in his right arm while receiving ADL (activities of daily living) care. The report documents that R4 is totally dependent with bed mobility, transfers, bathing, and dressing. The report adds that R4 stated " when I was turned on my right side, I heard my arm pop. " The report goes on to read that the facility obtained an x-ray of R4 ' s arm, and it revealed a fracture. R4 ' s care plan documents that R4 is totally dependent with bed mobility and requires staff assistance. The facility ' s fall investigation summary dated 3/15/12, signed by E20 (nurse) documents that R4 informed E20 that on 3/14/12 at 6:00 a.m., when the staff turned him to his side, he heard a " crack " and when he was turned back to his original position, he heard the same sound. On 9/11/12 at 10:45am (location-resident room), R4 stated that the incident occurred on 3/14/12 at approximately 6:00 a.m. R4 added that his arm is paralyzed, but in certain locations, he has feeling. R4 stated that the CNAs (Certified Nursing Assistants) providing care were not properly positioning him. R4 added that he was trying to instruct the staff on the proper way to turn him. R4 then stated that when the staff turned him, his right arm became " stuck " and he heard a snap. R4 stated the arm snapped 2 times and he felt severe pain. R4 acknowledged that he requires staff assistance to move his extremities. On 9/11/12 at 1:20 p.m., E24 (Registered Nurse, Falls Coordinator) stated that she and E2 (Director of Nursing) investigated the incident involving R4 ' s arm. E24 stated that R4 indicated that while being turned by staff, he heard a popping noise. E24 stated that through talking with the staff, she was informed that R4 had complained of pain in the arm. E24 stated that the facility obtained an x-ray which revealed a fracture. According to E24, R4 did not have a fracture to his right arm prior to 3/14/12. On 9/11/12 at 2:45pm, E37 (C.N.A) stated that when she came to work the morning of 3/14/12, R4 complained that he had experienced arm pain during care. E37 stated that she worked with R4 on 3/13/12 and there were no complaints. E37 added that R4 had not complained of arm pain prior to 3/14/12. On 9/12/12 at 9:17am, E36 (C.N.A) stated that he, E35 and E36 (C.N.As) were providing care for R4 on 3/14/12. E36 added that R4 was " heavy. " E36 stated that upon being turned, R4 complained of shoulder pain. E36 stated he placed R4 ' s right arm on his chest prior to turning him. When asked what position R4 was turned to, E36 stated " the left " . E36 then stated " the right " . E36 stated " He ' s a big guy. He ' s the type of resident that would have you in his room all night. " E36 added that R4 has never complained of arm pain prior to this occurrence. On 9/12/12 at 9:38am, E35 stated that she was assisting with ADL care for R4 on 3/14/12. E35 stated that when the staff turned R4 onto his side, he complained of pain, so they turned him onto his back. E35 stated that R4 ' s arms were at his sides while being turned. E35 added " he has no control over that arm. " E35 stated that R4 has not complained of pain in the arm prior to that occurrence. On 9/12/12 at 12:25pm, E34 (C.N.A) stated that she was assisting with ADL care for R4 on the morning of 3/14/12. E34 stated that when the staff turned R4, he complained that his arm was hurting. E34 stated that R4 ' s arms were positioned at his sides. E34 also stated that R4 had not complained of arm pain prior 3/14/12. There were no documented nursing assessment, notification of physician/family, or interventions located in R4's medical record for 6:00am on 3/14/12. There was a nurse ' s note documented on 3/14/12 at 10:00pm (approximately 16 hours later). The nurse ' s note documents that R4 had complained of severe pain in his right arm, and the arm was swollen. The note further documents that R4 complained of arm pain with any movement and an x-ray was ordered. Subsequent nurse ' s notes documents: 12:30am on 3/15/12- x-ray was obtained. 2:30am on 3/15/12-redness to right upper arm, warm; lower arm cool to touch. 5:00am on 3/15/12- medicated with Dilaudid (Opioid analgesic) for the pain. 8:35am on 3/15/12-x-ray results received, send to hospital. The radiology report for R4 dated 3/15/12 documents: Significant findings-right humerus. Impression- fracture of the mid humeral diaphysis. The facility provided documentation on a separate nurse ' s note dated 3/16/12 (2 days post incident and after hospital transfer), which read: " addendum, 3/14/12, approx 6:50 a.m." The nurse ' s note goes on to explain that R4 had complained of arm pain during care on 3/14/12. The nurse ' s note was completed by E48 (nurse). On 9/12/12 at 12:47 p.m., E2 stated that there was no documentation by the nurse on duty (E25) on 3/14/12 at 6:00 a.m. because E25 did not document. E2 stated she disciplined E25 for not following facility policies. E2 stated that E48 documented the events on 3/16/12 (2 days later). E2 added that E25 and E48 are no longer employed at the facility. According to E2, R4 is incapable of actively moving his arms. E2 stated that R4 suffered a fracture as a result of the incident. E2 further stated that R4 did not have a fracture prior 3/14/12. E2 added that R4 has occasional pain, but the pain he endured on 3/14/12 is beyond his baseline. There was no documentation located in R4 ' s chart documenting a fracture of the right arm prior to 3/14/12. The facility ' s change in resident ' s condition policy documents: -It is the policy of the facility except in a medical emergency, to alert the resident ' s physician of a change in condition. -Nursing will notify the resident ' s physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident ' s physical, mental or emotional status

Based on record review, and interview, the facility failed to notify the physician immediately of 1 of 12 sampled residents(R1), of having hematuria following insertion of an indwelling catheter. Findings Include: Evidence indicated that on 10-6-10 at 11:00am, wound treatment intervention included the insertion of an indwelling catheter. E9(Licensed Practical Nurse/Treatment Nurse) inserted a size 14 french catheter. Nurses note indicates that "yellow urine return," and "will continue to monitor." Nursing Note dated 10-6-10 at 12:30pm indicates that " small amount of blood in tubing, will continue to monitor." Nursing note dated 10-6-10 at 3:00pm indicates that " some blood noted in drainage bag, monitor for output and color of urine." The next entry is on 10-7-10 at 8:30am indicates that " indwelling catheter discontinued due to gross hematuria." Evidence indicates that Z1 was not notified, and there was no continued monitoring of hematuria. 10-7-10 at 2:00pm, indicates that" resident has no hematuria." The next entry is on 10-8-10 at 12:00pm, indicates that " Z1 called in regards to resident Foley, new order to schedule an appointment at hospital for urology for possible supra pubic catheter insertion." The next entry in the nursing notes is 10-11-10 at 11:00am, which states " resident received in room,lethargic, and c/o pain left left lower abdomen." The nurses note further states that " resident has urine output with some blood tinged in color, resident states that he has no appetite, did not eat dinner last night or breakfast this morning." The nurses note further states that " resident request to go to the hospital." At 11:00am, Z1 was paged. R1 vital signs were assessed at 12:00pm, not immediate. Z1 returned the page at 12:15pm, and gave orders to sent resident out to the local hospital for an evaluation. At 1:00pm, R1 was transferred to the local hospital for an evaluation. Interview with E10(Licensed Practical Nurse) on 11-10-10 at 2:15pm stated that she did not put the indwelling catheter in R1 on 10-6-10. Stated that on 10-6-10 at 12:30pm, she noted small amount of blood in the tubing. Stated that she did not notify Z1. Stated that on 10-6-10 at 3:00pm, she noted blood in the drainage bag. Stated that she did not notify Z1. Stated that on 10-6-10 at 3:00pm, she endorsed the concerns to the next shift staff. Stated that on 10-7-10 at 8:30am, she removed the indwelling catheter due to " gross hematuria." Stated that on 10-8-10 at 12:00pm that Z1 was notified regarding the indwelling catheter. When asked, prior to 10-8-10, did you attempt to contact Z1 ? E10 stated "no." Interview with E11(Licensed Practical Nurse) on 11-12-10 at 10:00am stated that on 10-6-10 at 5:00pm, she observed "scant amount of blood" in the tubing of R1. She further stated that she did not call Z1, but instead, instructed the nursing staff to " push fluids," and endorse to the next shift if evidence of hematuria persist, to call Z1. E11 presented to the surveyor on 11-12-10 at 1:00pm, an addendum nurses note dated for 10-6-10 and 10-7-10. The addendum note dated 10-7-10 states that she notified Z1 at 8:00am of "150 cc of hematuria." The addendum nurses note was not part of the record of R1. The addendum nurses note was created by E11 on 11-10-10. Interview with E12(Registered Nurse), worked on 10-6-10, stated that she did not receive report from E10 regarding R1 with having hematuria. Interview with Z1(Attending Physician) on 11-10-10 at 3:00pm stated that he should have been notified immediately when R1 first presented with hematuria after the indwelling catheter insertion. Z1 further stated that R1 was admitted to the hospital with [REDACTED]. This did not occur. Review of the facility policy "Emergency Management," states that if hemorrhage occurs, "take and record vital signs," and "notify physician." these did not occur. On 11-16-10 at 1:30pm, the facility presented additional information per telephone interview. Z1, on 11-16-10 at 1:30pm, stated that the hematuria observed of R1 on 10-6-10, was not considered urgent, thus, there was no need to have been notified immediately. Z1 further stated that R1 was on anti-coagulant therapy at the time of the observed hematuria. Review of the POS [REDACTED]. One side effect of [MEDICATION NAME] is bleeding. The physician , according to facility policy, should have been notified immediately.

Based on record review, and interview, the facility failed to notify the physician immediately of 1 of 12 sampled residents(R1), of having hematuria following insertion of an indwelling catheter and failed to monitor R1 with continued symptoms associated with hematuria. These failures resulted in the development of lethargy, pain, and decreased appetite, and delayment of medical services. Findings Include: Evidence indicated that on 10-6-10 at 11:00am, wound treatment intervention included the insertion of an indwelling catheter. E9(Licensed Practical Nurse/Treatment Nurse) inserted a size 14 french catheter. Nurses note indicates that "yellow urine return," and "will continue to monitor." Nursing Note dated 10-6-10 at 12:30pm indicates that " small amount of blood in tubing, will continue to monitor." Nursing note dated 10-6-10 at 3:00pm indicates that " some blood noted in drainage bag, monitor for output and color of urine." The next entry is on 10-7-10 at 8:30am indicates that " indwelling catheter discontinued due to gross hematuria." Evidence indicates that Z1 was not notified, and there was no continued monitoring of hematuria. 10-7-10 at 2:00pm, indicates that" resident has no hematuria." The next entry is on 10-8-10 at 12:00pm, indicates that " Z1 called in regards to resident Foley, new order to schedule an appointment at hospital for urology for possible supra pubic catheter insertion." The next entry in the nursing notes is 10-11-10 at 11:00am, which states " resident received in room,lethargic, and c/o pain left left lower abdomen." The nurses note further states that " resident has urine output with some blood tinged in color, resident states that he has no appetite, did not eat dinner last night or breakfast this morning." The nurses note further states that " resident request to go to the hospital." At 11:00am, Z1 was paged. R1 vital signs were assessed at 12:00pm, not immediate. Z1 returned the page at 12:15pm, and gave orders to sent resident out to the local hospital for an evaluation. At 1:00pm, R1 was transferred to the local hospital for an evaluation. Interview with E10(Licensed Practical Nurse) on 11-10-10 at 2:15pm stated that she did not put the indwelling catheter in R1 on 10-6-10. Stated that on 10-6-10 at 12:30pm, she noted small amount of blood in the tubing. Stated that she did not notify Z1. Stated that on 10-6-10 at 3:00pm, she noted blood in the drainage bag. Stated that she did not notify Z1. Stated that on 10-6-10 at 3:00pm, she endorsed the concerns to the next shift staff. Stated that on 10-7-10 at 8:30am, she removed the indwelling catheter due to " gross hematuria." Stated that on 10-8-10 at 12:00pm that Z1 was notified regarding the indwelling catheter. When asked, prior to 10-8-10, did you attempt to contact Z1 ? E10 stated "no." Interview with E11(Licensed Practical Nurse) on 11-12-10 at 10:00am stated that on 10-6-10 at 5:00pm, she observed "scant amount of blood" in the tubing of R1. She further stated that she did not call Z1, but instead, instructed the nursing staff to " push fluids," and endorse to the next shift if evidence of hematuria persist, to call Z1. E11 presented to the surveyor on 11-12-10 at 1:00pm, an addendum nurses note dated for 10-6-10 and 10-7-10. The addendum note dated 10-7-10 states that she notified Z1 at 8:00am of "150 cc of hematuria." The addendum nurses note was not part of the record of R1. The addendum nurses note was created by E11 on 11-10-10. Interview with E12(Registered Nurse), worked on 10-6-10, stated that she did not receive report from E10 regarding R1 with having hematuria. Interview with Z1(Attending Physician) on 11-10-10 at 3:00pm stated that he should have been notified immediately when R1 first presented with hematuria after the indwelling catheter insertion. Z1 further stated that R1 was admitted to the hospital with [REDACTED]. This did not occur. Review of the facility policy "Emergency Management," states that if hemorrhage occurs, "take and record vital signs," and "notify physician." these did not occur. On 11-16-10 at 1:30pm, the facility presented additional information per telephone interview. Z1, on 11-16-10 at 1:30pm, stated that the hematuria observed of R1 on 10-6-10, was not considered urgent, thus, there was no need to have been notified immediately. Z1 further stated that R1 was on anti-coagulant therapy at the time of the observed hematuria. Review of the POS [REDACTED]. One side effect of [MEDICATION NAME] is bleeding. The physician , according to facility policy, should have been notified immediately.

Based on observations, record review and interview, the facility failed to provide effective services to address R4's emotional, mental and physical being and adjustment to his current health status and living in a nursing home This failure has resulted in R4's deterioration of his well-being as evidence of his weight declining significantly, withdrawing from others and irritability. This is for 1 of 30 sampled residents within the sample. The findings include: R4 is a [AGE] year old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].S.). R4 was in his bed for the first two and half days of the survey. The television was on but R4 was noted to drift in and out of sleep. R4 spoke very little when spoke to. When he responded to questions asked of him, the answers were appropriate. R4 did follow commands when directed. R4 has severe contractures to the left side and wears braces on hand/wrist and knee. R4's right leg was noted to be straight and not to bend when in the bed on in chair. R4 was noted to remove the braces at various times due to restlessness and R4 voicing pain/discomfort from the splints. Both side-rails were up with mats on the floor. R4 took his meals while in the bed. R4 was noted to eat 50% of his meals. R4 was removed from the bed on 9/9/10 at 12:45 p.m. via mechanical lift by E13 and E14 (both nurse aides) and taken to the dayroom for his noon meal. There was little interaction between E13 and E14 except for commands to follow during the transfers. Surveyor asked E13 and E14 about the frequency of getting out of bed and only E14 responded. She stated she does not usually work with him but stated she has seen him yell from his room asking for assistance to get out of bed. When he was in the dining room/dayroom, there was no interactions between R4 and other residents. When he was in his room, there was little interaction with others except for the nurse aide assigned to him. R4 had little expression and had a flat affect. R4 exhibited sadness and disconnect with his surroundings. On 9/7/10 between 9:50 a.m. to 12:24 p.m. during the initial tour with E5 (nurse), E5 stated that R4 is confused, he can stand, able to remove splints and knows how to lower the bilateral side rails. E5 stated R4 uses a recliner-type chair for mobility. On 9/8/10 at 11:10 a.m., E16 (Restorative aide) stated R4 is withdrawn and depressed. E16 stated R4 does complain of pain in wrist and knees. E16 stated that he has little interaction with anyone and there is only one nurse aide he has good rapport with but he has been on vacation for one month. On 9/10/10 at 9:15 a.m., E17 (Activity Aide) stated R4 has not been coming out of his room for couple of weeks. When he is out of his room, he is put in a recliner-type chair and placed in the 4th floor dayroom. E17 stated he does not participate much unless it is bingo. E17 stated he is able to hold the bingo card with the one hand and play. He enjoys card games but he needs assistance with the cards due to use of the right hand only. E17 stated she did not ask him about his interests and what activities he enjoys. E17 stated that his family use to visit but have not seen them recently. Review of the attending physician note dated 7/26/10 documents the development of contractures due to non-compliance with staff. The note documents that R4 has not been getting his physical therapy because of R4's attitude. The physician spoke with R4 and explained the need for therapy and R4 agreed to be nice to staff. There was no documentation he received any skilled therapy. The restorative documentation reflect he gets it daily 5 times a week but it was never observed performed on R4. Review of the social service notes (4/5/10 and 7/1/10) document his refusal to eat despite encouragement, he is verbally and physically abusive, at times appears sad which could be from his current health status, nursing home placement and wanting to return home. Prior to entering the facility from the hospital, R4 lived independently in the community. Review of the progress note dated 5/4/10 documents R4 not eating and having severe weight loss. R4 verbalizes he does not like the facility's food. The note documents that when his family visits, they bring food and he is better. When they don't visit, he declines physically and emotionally. R4 is 69 inches tall and was admitted with a weight of 178# and has slowly declined to 143.9# in June 2010 (6 month period). Nutritional approaches, such as, supplements and [MEDICATION NAME] were put in place to address the the weight decline. R4 weighs 150.8# as of August 2010. The 6/22/10 nutritional assessment documents the recommendation of the physician speaking with family about placement of an enteral tube feed. There is no documentation this recommendation was brought to the physician. Review of the Z2' s (house psychiatrist) notes dated 2/22/10, 3/16/10, and 4/9/10 address R4's behavior as confused, withdrawn and irritable but no major behavioral problems. The approach is to continue with the medications [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] as needed. Z2's progress note dated 5/4/10 documents R4 was readmitted to the facility from the hospital and upon return, he was no longer on [MEDICATION NAME]. Z2's progress notes dated 5/4/10, 5/28/10, 6/24/10, 7/17/10, 8/26/10 document the same behavior of confusion, withdrawn and irritable at times but no major behavioral problems. The approach is no [MEDICAL CONDITION] medications needed at this time. On 9/10/10 at 10:40 a.m., Z2 stated that he is just monitoring and observing R4 when asked what Z2 is doing for R4. Z2 was unable to say why the medication was discontinued in the hospital because he stated he was not the psychiatrist in the hospital. On 9/10/10 at 2:10 p.m., E20 (Social Service Director) stated she just completed a social service assessment. E20 stated R4's sister was visiting him in the dayroom. E20 did say he was off in the corner. E20 stated it was difficult to interview him because when she started to ask about his growing up, he became very teary-eyed and could not get the words out. E20 stated his long term memory is intact but believes him to be orient to self only. E20 stated she believes he would benefit from an anti-depressant. Review of the 9/10/10 assessment done by E20 documents his long term memory is intact but has confusion with time, situation and date. It documents that the assessment and mini depression exam were not complete due to limited attention span and refusal to answer questions by displaying verbal and physical aggression, such as, yelling at others likely due to neurological deficits.

Based on observations, record reviews and interviews the facility failed to maintain 2 of 7 residents ( R1, R8) basic Activities of daily living (toileting) abilities. As a result R1 is forced to wear a diaper and urinate and defecate in it. R7 was forced to wait several hours for assistance with toileting with a possibility of having an incident of incontinent forced upon her. This failure has the potential to effect all of the residents in the facility who need assistance with incontinence care. Findings Include: 1) Observation on 8-18-10 in her room. R1 was sitting in her wheelchair watching television. R1 told surveyor that she waits long periods of time to use the bathroom this is why she wears a diapers. R1 also told surveyor that she does not like wearing diapers. The facility makes her wear diapers but she does not want to be wet with urine or BM. R1 also told surveyor that it takes the nursing staff too long to come to assist her to the bathroom and she has just gotten use/accustom to wearing the diaper. R1 stated that she urinates in the diapers twice before she calls to nursing staff because of the long time it takes for them to get to her. Review of R1's admission records notes R1 is [AGE] year old female re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of R1's minimum data set ((MDS) dated [DATE] notes R1's cognitive ability is a level one, meaning some difficulty in new situation only. The MDS notes R1 in incontinent of bowel most of the time and frequently incontinent of her bladder. Review of the facility toileting programs dated 8-2010 notes R1 communicates her need to void and or defecate. E3 (nurse's aide) stated on 8-18-10 that R1 tell her when she must go to the bathroom, but she rarely get back to R1 in time to take her but knows R1 has a diaper on. E4 ( nurse manager) stated on 8-18-10 that R1 is on the toileting program and can communicate her needs clearly to go to the bathroom. E4 stated she does not know why R1 has on a diaper. E6 (MDS coordinator) stated on 8-18-10 that R1 uses a diaper all the times and urinates and defecates in the diaper so R1 is incontinent. This is why R1's MDS is scored in the matter of incontinent. E1 (Director of Nursing ) stated that since R1 is able to say when she has she has the need to go to the bathroom than she is not incontinent. E1 also stated that she would give an in-service to the entire nursing staff about forced incontinent which is not an acceptable practice at the facility. 2). Observations on 8-18-10 on the first floor by the elevator, R2 told E1 that 2 nights ago she had to wait a long period of time before she was taken to the bathroom. R2 stated that she told the nurse to take her to the bathroom but the nurse did not come back for several hours. E10 (nurse's aide) stated she was the nurse that care for R2 on the night in question and she does not remember R2 complaining about not going to the bathroom in a timely manner. Further observations with R2 on 8-19-10 , R2 told surveyor that she did not have an accident on herself but almost did and does not like waiting a very long time just to use the bathroom. E1 stated that an investigation will be done to determine the programs with R2 going to the bathroom in a timely manner.