Every finding on record at Sullivan Healthcare & Senior Living

Based on observation, interview and record review the facility failed to provide palatable foods for three residents (R1, R7, R8) out of three residents reviewed for Dietary Services in a sample list of nine residents. Findings include:1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's undated diet ticket documents R1 is on a regular consistency diet with thin liquids. R1 prefers two fried eggs for breakfast and is allergic to all vegetables. On 8/26/26 at 7:50 AM V12 Certified Nurse Aide (CNA) delivered R1's breakfast to R1 in his room. R1's breakfast consisted of scrambled eggs in a scoop shape, frosted flakes and drinks. On 8/26/26 at 7:53 AM V12 CNA stated R1 is supposed to get two fried eggs for breakfast every morning but rarely gets fried eggs. V12 CNA stated R1 is usually served scrambled eggs. On 8/25/26 at 11:51 AM R1 stated he is supposed to get two fried eggs for breakfast every day. R1 stated he was served fake eggs that are scrambled and 'not fit for human consumption' this morning (8/25/26). R1 stated his food is usually cold and tastes like dog s*** (expletive). 2. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as moderately cognitively impaired. On 8/26/26 at 11:45 AM R8 was exiting the dining room after eating lunch. R8's plate had 90% of R8's meal left untouched. On 8/26/26 at 3:50 PM R8 stated the food the facility serves will keep a person alive but does not taste good. R8 stated the meals are served cold and are not appetizing at all. R8 stated if you are hungry enough, it is ok but otherwise the meals are awful. 3. R7's Brief Interview for Mental Status (BIMS) dated 8/22/2026 documents R7 as cognitively intact. On 8/26/26 at 7:55 AM R7 was sitting at a dining room table eating breakfast. R7 had scrambled eggs, bacon and toast left on his plate. R7 had eaten approximately 10% of his breakfast. R7 wheeled away from his breakfast stating his meal was terrible. R7 stated R7's eggs were too hard to eat; the bacon was ice cold and greasy and the toast was rubber. On 8/26/26 at 12:30 PM V19 Dietary Manager (DM) provided a lunch test tray. The lunch meal consisted of chicken alfredo, carrots, garlic toast and dessert of grape salad. V19 obtained temperatures of the foods served which resulted in chicken alfredo temperature of 130 degrees Fahrenheit (F) and the carrots' temperature was 139 degrees F. The chicken alfredo has a scant amount of alfredo sauce and two very small pieces of processed chicken. The grape salad had a half inch piece of stem on a grape. On 8/26/26 at 12:35 PM V19 Dietary Manager (DM) stated the foods on the test tray were not hot enough to be served to residents. V19 DM stated the foods should be kept at least 135 degrees F. V19 DM stated the kitchen staff should watch out for stems on the grapes due to that could cause a problem for a resident. The facility policy titled Food and Nutrition Services revised October 2017 documents each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Based on observation, interview and record review the facility failed to provide a homelike environment for three (R1, R4, R9) out of three residents reviewed for Resident Rights in a sample list of nine residents.Findings include:1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. On 8/25/26 at 11:55 AM R1's floor was missing floor tile pieces. R1's wall surrounding the air conditioning unit showed several inches of blistering paint with a moderate amount of black dots on the paint. R1's walls showed several long scrapes of missing paint. On 8/25/26 at 11:57 AM R1 stated the facility put R1 in this room that is torn up. R1 stated the walls of his room need painted, and the mold should be removed before it makes R1 sick. R1 stated R1 is being treated like an animal thrown in the 'pig trough' of a room. 2. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as moderately cognitively impaired. On 8/28/26 at 9:10 AM R9's floor was missing several pieces of floor tile. R9's closet door was missing. On 8/28/26 at 9:11 AM R9 stated she thinks her room looks trashy due to the missing tiles and closet door. R9 stated she wants to live in a 'nice' room that is not torn up.3. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 8/26/26 at 10:35 AM R9's floor showed several missing tile pieces. R9's walls had several areas of missing/chipped paint. On 8/26/26 at 10:40 AM R9 stated she would like her room to look nice. R9 stated R9's room does not look like it is done. R9 stated R9's room looks like it is under construction due to the missing floor pieces and paint. On 8/26/26 at 10:05 AM V28 Maintenance Director stated the facility is working on replacing floor tiles and painting those areas that need touched up. V28 Maintenance Director stated the facility provides sufficient budget to buy the supplies needed but V28 Maintenance Director does not have an assistant. V28 stated V28 is also called to other buildings to complete other projects and V28 has not had the time to complete the maintenance improvements for this facility. V28 Maintenance Director stated there are many resident rooms and resident areas that need attention. The facility policy titled Resident Rights and Abuse Prevention revised December 2025 documents each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation, interview and record review the facility repeatedly failed to properly dispense medications for one (R4) out of four residents reviewed for Medication Administration in a sample list of nine residents. Findings include:R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. R4's Physician Order Sheet (POS) dated August 2026 documents a physician order starting 5/21/2026 and ending 8/26/2026 to administer Eliquis 5 milligrams (mg) twice daily. This same POS documents a physician order starting 8/26/2026 with no end date to administer Eliquis 2.5 mg twice daily. R4's Care Plan intervention dated 06/04/2025 instructs staff to administer medications with Anticoagulant affect as ordered by Physician. R4's Nurse Progress Note dated 8/26/26 at 10:52 AM documents R4 went to R4's Oncology appointment on 8/20/2026. R4 returned with no orders or paperwork. R4 stated R4 was not told anything about any medication changes. R4's Brief Interview for Mental Status (BIMS) documents R4 as cognitively intact. The facility was not aware of any medication changes until 8/26/26. R4's orders clarified with the Oncology office. R4 started (Eliquis 2.5 mg) today. R4's Medication Administration Record (MAR) dated August 2026 documents R4 has been receiving Eliquis 5.0 milligram (mg) twice daily on 8/20, 8/21, 8/22, 8/23, 8/24 and 8/25/26 totaling 12 doses. On 8/26/26 at 8:00 AM V10 Registered Nurse (RN) administered R4's scheduled morning medications. V10 RN showed R4's Electronic Medication Administration Record (EMAR) documents R4's Eliquis 5.0 milligrams to be administered twice daily. V10 RN showed R4's full pharmacy card of Eliquis 2.5 mg to be administered twice daily. R4's pharmacy card documents a delivery date of 8/20/2026. On 8/26/26 at 8:05 AM V10 Registered Nurse (RN) stated R4's EMAR and pharmacy card do not match and V10 would find out why. On 8/26/26 at 9:10 AM V4 Interim Administrator stated the facility sent papers with R4 to R4's Oncology appointment on 8/20/2026. V4 stated R4 was taken to R4's appointment via the facility van with V18 Transport/CNA accompanying R4. V4 stated R4 returned from the appointment but did not have any paperwork. V4 Interim Administrator stated since R4 is cognitively intact the facility did not reach out to V16 Oncology office to see if there were any new orders. V4 stated the facility pharmacy delivers medications every afternoon. V4 stated the nurse who checks in the medications should be checking the physician orders and the inventory sheet from the pharmacy to ensure the correct medication is being delivered. On 8/26/26 at 10:30 AM R4 stated R4 went to the Oncology appointment on 8/20/2026. R4 stated V16 Oncologist reduced one of her medications but could not remember which one. R4 stated she could not remember if any papers were given to R4 from V16 Oncologist's office. R4 stated, Ask the (facility) nurses. They should know what I am supposed to take.On 8/26/26 at 11:40 AM V17 Oncology Nurse Manager stated R4 was present at the 8/20/2026 appointment. V17 Nurse Manager stated V16 Oncologist reduced R4's Eliquis from 5.0 milligrams (mg) twice daily to 2.5 mg twice daily due to not having concerns of blood clots for an extended period of time. V17 stated all patients are sent to a separate room after their appointment to receive their After Visit Summary (AVS). V17 stated R4 would have gone to the 'holding' room on 8/20/2026. V17 stated V16 Oncologist office also faxed R4's new Eliquis order to the pharmacy on 8/20/2026. V17 stated if R4 did not return to the facility with any paperwork the facility might want to send someone with R4 to ensure no other medication errors happen again. V17 Nurse Manager stated R4 should have received Eliquis 2.5 mg twice daily starting 8/20/2026. The facility policy title Administering Medications revised April 2019 documents medications are administered in accordance with prescriber orders, including any required time frame.The facility policy titled Accepting Delivery of Medications revised November 2022 documents Any errors noted in receiving medications are brought to the attention of the pharmacist and director of nursing services.

Based on observation, interview and record review the facility repeatedly failed to provide the correct physician ordered diet for one (R1) resident out of three residents reviewed for Dietary Services in a sample list of nine residents.Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's undated diet ticket documents R1 is on a regular consistency diet with thin liquids. R1 prefers two fried eggs for breakfast and is allergic to all vegetables. R1's Physician Order Sheet (POS) dated August 2026 documents a physician ordered diet for R1's diet to be regular consistency, thin liquids and is allergic to all vegetables. R1's Electronic Medical Record (EMR) allergy list documents R1 is severely allergic to all vegetables.On 8/25/26 at 12:05 PM V12 Certified Nurse Aide (CNA) delivered R1's lunch meal to R1 in R1's room. R1's lunch meal consisted of pepper steak, rice, peas and banana split cake. R1 told V12 CNA to take the peas back because R1 can't eat vegetables. On 8/25/26 at 12:15 PM V19 Dietary Manager (DM) showed R1's meal slip documents R1 is allergic to all vegetables. On 8/26/26 at 12:05 PM V21 Certified Nurse Aide (CNA) delivered R1's lunch meal to R1 in his room. R1's lunch meal consisted of chicken alfredo, carrots, garlic toast, dessert and drinks. On 8/25/26 at 11:50 AM R1 stated he is highly allergic to all vegetables. R1 stated there are a lot of foods that R1 is not able to eat due to food preferences and/or allergies. R1 stated the facility does not follow his diet due to R1 is frequently served foods that he cannot eat or I will die. On 8/25/26 at 12:07 PM V12 CNA confirmed R1's diet slip documents R1 is allergic to all vegetables. V12 CNA stated V12 took R1's full meal to him because V12 thought R1 could decide on his own what R1 wanted to eat or not. V12 CNA stated V12 is aware that R1 is allergic to vegetables.On 8/26/26 at 12:07 PM V21 CNA stated V21 is aware that R1 is highly allergic to all vegetables. V21 CNA confirmed R1's diet slip documents that R1 is allergic to all vegetables. V21 CNA stated R1 did not say anything about the carrots so it is probably alright.On 8/25/26 at 12:16 PM V19 Dietary Manager (DM) stated residents should be served their correct diets. V19 DM stated a resident's diet includes preferences and allergies. V19 DM stated she will be educating the staff on ensuring all residents receive the correct diet. V19 DM stated R1 was served foods that R1 is allergic to. V19 DM stated residents have the right to refuse foods, but it is the responsibility of the staff to ensure the correct diet is being prepared and served. The facility policy titled Food Allergies and Intolerances revised August 2017 documents residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s).

Based on interview and record review the facility failed to ensure the dignity of one (R1) resident out of three residents reviewed for dignity in a sample list of nine residents. Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1 requires moderate assistance from staff for eating and oral hygiene and is dependent on staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers.On 8/28/26 at 9:15 AM R1 stated a Certified Nurse Aide (CNA) (V27) who worked last night (8/25-8/26) on night shift called R1 names. R1 stated V27 would not help R1 with repositioning or empty R1's colostomy bag. R1 stated R1 activated R1's call light and it took two hours before V27 CNA came to help R1. R1 stated he had to call the police to get the staff to assist him. R1 stated V26 Licensed Practical Nurse (LPN) came to R1's room after the police called the nurses station to tell the staff to do their jobs. R1 stated V27 CNA called R1 rude and selfish for asking for help. R1 stated V27 CNA then refused to assist R1 and walked out of R1's room. R1 stated, I was not abused. They (staff) just treat me like s*** (expletive). If I were abused, I would act like I used to and kill them all, but I am nicer now, so I just cuss them out.On 8/28/26 at 12:40 PM V27 Certified Nurse Aide (CNA) stated V27 knew he would be getting a call from someone about earlier this morning (8/28/26). V27 CNA stated R1 had an attitude from the moment V27 CNA walked into the room. V27 CNA stated V31 CNA both entered R1's room because R1 had the call light activated. V27 CNA stated V31 CNA didn't say anything to R1. V27 CNA stated V27 expects any resident to act with kindness. V27 CNA stated R1 asked V27 CNA for kindness and V27 responded, If you want kindness, then you have to give kindness. V27 CNA stated R1 called V27 and a****** (expletive) and V27 responded, it takes one to know one. V27 CNA stated R1 called V27 a p**** (expletive) and it struck a nerve with V27 so V27 walked out of R1's room. V27 CNA stated residents expect five star service and that is unreasonable. V27 CNA stated R1 wants things done R1's way and R1 needs to understand things will get done V27's way. On 8/28/26 at 1:00 PM V1 Administrator in Training (AIT) stated the facility is unable to contact V27 and V31 CNA's due to both CNA's work through an agency and are not responding. V1 AIT stated all residents are supposed to be treated with dignity and respect. V1 AIT stated V27 CNA will not be allowed to work at the facility due to the way V27 spoke to R1. The facility policy titled Resident Rights and Abuse Prevention revised December 2025 documents each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem.

Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by another resident for two of three residents (R2 and R8) reviewed for abuse in a sample list of nine residents.Findings include:R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. R2 requires supervision with eating and oral hygiene, moderate assistance with toileting, bathing, dressing, personal hygiene, and bed mobility, and maximum assistance with transfers due to R2 has a diagnosis of Right Below the Knee Amputation. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as moderately cognitively impaired. R8 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.On 8/28/26 at 8:35 AM R2 stated R2 and R8 were sitting outside smoking when R8 asked R2 for a cigarette. R2 stated R2 did not give R8 a cigarette so R8 yelled at R2, I am going to bust your head open with my cane. R2 stated R8 threatened to kill R2. R2 stated there were no other residents or staff present. R2 stated it makes R2 mad that R8 gets to talk to R2 like that. R2 stated R8 yells at R2 every morning and the facility is aware but does nothing about it. On 8/28/26 at 10:00 AM V25 Maintenance Director stated he walked out to the smoking area this morning right after R8 allegedly threatened R2. V25 stated R2 reported to V25 that R8 yelled at and threatened R2 and that R2 did not know what to do about it. V25 Maintenance Director stated he has not reported R2's allegation to V1 Administrator in Training (AIT) yet but plans to find V1 soon to report this to V1. On 8/28/26 at 10:35 AM V1 Administrator in Training (AIT) confirmed R8 did yell and threaten to beat R2's a** (expletive) earlier this morning (8/28) while both R2 and R8 were sharing a smoking break. V1 AIT stated R8 was placed on continuous monitoring until the investigation is completed. V1 AIT stated R8 asked R2 for a cigarette and when R2 denied R8's request, R8 raised his cane to R2 and yelled I am going to kill you. V1 AIT stated there were no other residents and/or staff around at the time this happened. V1 AIT stated R2 and R8 both gave the same verbal report of this incident to V1 AIT and the policeman who came to the facility to interview both R2 and R8. The facility policy titled Abuse Prevention revised December 2025 documents Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to harassing a resident, mocking, insulting, ridiculing, yelling or hovering over a resident, with the intent to intimidate.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 67 residents in the facility. Findings include:On 8/5/2026 at 10:30AM, V10 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V10 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager (also known as Certified Food Protection Professional) or having equivalent training. V10 denied meeting the State of Illinois standards to be a food service manager or dietary manager (required in states that have their own established standards to be a food service manager or dietary manager (483.60(a) (2)ii). V10 reported only completing a two-day course on food service sanitation (Certified Food Protection Manager) which did not include any instruction on clinical nutrition. V10 denied having any qualifications in clinical nutrition. V10 denied:-being a dietician;-being a certified dietary manager;-having an associate's or higher degree in food service management or in hospitality;-having two or more years of experience in the position of director of food and nutrition services in a nursing facility setting;-being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. On 8/5/2026 at 12:34PM, V10 (Dietary Manager) denied ever observing the facility dietician (V6) performing any work in the building since V10 began working full-time as the facility dietary service manager in May 2026. On 8/7/2026 at 9:50AM, V10 reported the food in the kitchen is available for all residents to eat.The facility Resident Matrix (8/4/2026) documents 67 residents reside in the facility.

Based on interview and record review, the facility failed to monitor vital signs and laboratory results and assess/monitor/document/report changes in condition for one of three residents (R1) reviewed for falls in the sample list of 16. This resulted in R1 being sent to the hospital 4 days after a fall, being diagnosed with a brain breed and later dying. Findings include: R1's Care Plan (undated) documents V16 as R1's legal appointed Guardian and includes interventions to advocate and discuss the best interest of R1; encourage appointed responsible party to discuss options, advanced directives and wishes with R1; and inform V16 of changes in R1's condition. R1's diagnoses include Hypertension and Atrial Fibrillation. Interventions include administering medications as ordered and monitoring for effectiveness, daily skin inspection for bruising/bleeding, increased risk of bleeding post fall, laboratory results as ordered, monitor/document/report adverse reactions of anticoagulant including sudden severe headaches, nausea/vomiting, diarrhea, lethargy, bruising, loss of appetite, sudden changes in mental status, and significant changes in vital signs. R1's April and May 2026 Medication Administration Records document R1 received Coumadin (anticoagulant) 2 milligrams (mg) by mouth daily, monitor Prothrombin Time/International Normalized Ratio (PT/INR (clotting times) monthly, and R1 received Ciprofloxacin (antibiotic) 500 mg by mouth daily 4/7/26-4/11/26. R1's Ciprofloxacin order documents a moderate drug interaction as this medication may increase the anticoagulant effects of Coumadin. There is no documentation in R1's electronic medical record (EMR) that PT/INR was obtained after 4/1/26. R1's Progress Note dated 4/16/26, recorded by V14 Nurse Practitioner, documents R1's blood pressure was elevated 145/91 millimeters of mercury (mmHg) and instructions to monitor R1's blood pressure closely and if high blood pressure persists will consider adjusting dose of Losartan. There is no documentation in R1's EMR that R1's blood pressure was routinely monitored until after R1 sustained a fall on 5/4/26. R1's Nursing Notes document R1 had diarrhea on 5/1/26 and nausea/vomiting on 5/2/26. There is no documentation R1's EMR that a provider was notified of R1's diarrhea or nausea/vomiting. R1's Nursing Note dated 5/4/2026 at 10:55 AM documents R1 sustained a fall during staff assist. R1 denied pain and R1 refused to go to the emergency room for evaluation. R1's Nursing Note dated 5/5/26 at 7:52 PM documents V15 Physician was given update report and R1's complaints of generalized not feeling well for the last week and R1 believes R1 has a Urinary Tract Infection. Orders received for urinalysis with culture and sensitivity. R1's nursing notes document R1 received Tylenol 650 mg (ordered as needed) once on 5/6/26 and once on 5/7/26 for complaints of pain/headache. R1's neurological assessment form dated 5/4/26-5/7/26 document no headache, no altered behavior, no loss of consciousness, and hand grasps equal. There is no documentation in R1's EMR of R1's bruising to right shoulder, right rib, or right side of head. There is no documentation in R1's EMR that a provider was notified of R1's complaints of headache, bruising, changes in speech or level of alertness prior to 5/9/26. R1's EMR does not document any follow up communication with V16 regarding R1's changes in condition and refusal to go to the hospital after 5/4/26. V23's (Business Office Manager (BOM)) undated Written Statement documents: On 5/6/26 R1 came to V23's office to request a cash withdrawal from R1's trust fund account. At that time R1 reported R1 had a headache and felt weak. On 5/7/26 V23 went to R1's room and R1 appeared to still have headaches. R1 had reported the same as on 5/6/26, and R1 seemed slower to answer questions. V23 reported this to an unidentified nurse. On 5/8/26 V23 went to R1's room, R1 could barely sit up and had trouble answering V23 due to R1's headaches. R1 was continuously rubbing R1's head. V23 was concerned how much R1 had declined from the day prior and V23's concerns were reported to V2 Director of Nursing (DON). R1's Nursing Note dated 5/9/2026 at 4:41 AM documents the following: Three days ago, R1 started complaining that R1 didn't feel good. At 9:00 PM last evening R1 became weaker and had difficulty holding cups and required two assist from staff for transfers. R1 was encouraged to go to the hospital but refused several times. V15 Physician was notified earlier by day shift nurse and V15 gave orders to send to emergency room if R1 agreed and/or symptoms changed. R1 complained of nausea throughout the night. R1 became weaker and R1's voice became soft and barely heard. R1's hand grasps and mobility became less and more difficult and R1 began to fall asleep during conversations. At this time R1 agreed to go to the hospital. R1's emergency room Notes dated 5/9/26 document upon arrival R1 complained of headache and R1's blood pressure was 173/114 mmHg. R1's PT/INR was 92.7/12.6, critically high. R1's Computed Tomography (CT) scan showed a large left sided intraparenchymal with mass effect and midline shift (brain bleed), and medications/treatments were given to reverse blood-thinning effects. R1 was transferred to another hospital for higher level care. R1's Intensive Care Unit History & Physical dated 5/9/26 documents R1 had bruising to right side of head and significant weakness to right arm/hand. R1's Death Certificate dated 5/9/26 documents R1's cause of death as Intraparenchymal Hemorrhage as a consequence of fall. Significant conditions contributing to death: Compression of Brain, Intracranial Bleed, Chronic Kidney Disease, and Dementia. On 6/15/26 at 2:47 PM V16 (R1's Guardian) stated: V16 did not find out about R1's condition until V16 received a call from the hospital. V16 has been R1's Guardian since 2018 due to an adult protective services case and the condition R1 was found in R1's home at that time. At that time R1 had poor cognition but that improved with proper medication/care. R1 has a history of negating R1's health and R1 never wanted to go to the hospital. R1 tried to contest the guardianship a few years ago but that did not go through, and the guardianship remained in place. All R1's medical decision making is supposed to go through V16. V16 stated the facility should have notified V16 of R1's changes in condition and refusal to be hospitalized so that V16 could have come to the facility to speak with R1 to discuss the risks and try to convince R1 to go to the hospital. On 6/15/26 at 11:53 AM V10 Licensed Practical Nurse (LPN) stated the following: R1 seemed R1's normal self the week prior to R1's fall. On 5/4/26 V7 Certified Nursing Assistant (CNA) transferred R1 from the toile to the chair, V7 reported R1 got dizzy, mis-stepped and fell. V7 and R1 denied R1 hit R1's head during the fall and R1 initially had no complaints or signs of injury/bruising. Emergency Medical Services came to the facility but R1 refused to go to the hospital. Vital signs and neurological assessments were completed. R1 complained of headache with Tylenol given as noted on the MAR. Physician and Guardian notification is documented in the nursing notes. On 6/15/26 at 2:02 PM V23 BOM stated: On 5/6/26 R1 came to get cash around 2-3:00 PM. V23 brought R1's money to R1's room on 5/7/26 around 2-3:00 PM. R1 was slow to respond and had a headache on both days. V23 reported this to V10 LPN and R1 refused to go to the hospital. The next day V23 decided to check on R1, R1 kept rubbing R1's head complaining of headache, R1 was slower to respond to questions and was unable to sit up. These things had progressively gotten worse over these three days. By the third day R1 struggled to find answers but was still alert and oriented to person, place, time and situation but R1 again refused to go to the hospital. V23 reported R1's condition to a nurse and V2 DON and R1's condition was also discussed in the management's morning meetings. On 6/15/26 at 2:50 PM V24 LPN confirmed V24 was R1's nurse on dayshift on 5/8/26. V24 stated V24 does not work that hall very often and was not as familiar with R1. V24 stated R1 was not feeling well, generalized fatigue, urine test results were pending and V24 thought a urinary tract infection (UTI) was the cause of R1's symptoms. V24 was not aware R1 had complained of headaches or was slow to respond. V24 stated V24 would have assessed R1 and reported this to V15 which would be documented in a nursing note. On 6/15/26 at 3:11 PM V20 LPN stated: Following R1's fall on 5/4/26 R1 generalized not feeling well and could not pinpoint any specifics other than being tired and sleeping more, and V20 thought this was related to a UTI. V20 had heard that R1 had complained of headache but R1 has had them before, and R1 was slow to answer questions which gradually got worse after the fall. Physician and guardian notification would be documented in the nursing notes. R1 had changes in hand grasps during R1's assessments which was difficult to assess because R1 kept falling asleep during the assessment. On 5/8/26 R1 was slumped over and unable to hold his head up. R1 had stopped eating and fluid intake had decreased. R1 had bruising to R1's right side ribs, right ear and right side of R1's head. R1's symptoms gradually got worse over the course of days. R1 refused to go to the hospital all night but finally agreed on the morning of 5/9/26. On 6/16/26 at 10:56 AM V7 CNA stated: R1 seemed perfectly fine the week prior to R1's fall. R1 was standing at the sink with R1's walker and R1 started to go down. V7 used the gait belt and tried to break R1's fall the best V7 could but R1's right side took the brunt of the fall. R1's fall was sudden as if R1 passed out and when R1 came to R1 was unaware R1 had fallen. On 6/16/26 at 11:07 AM V2 DON stated post fall monitoring should be done every shit and documented in the nursing notes. V2 stated vital signs are documented in the resident's EMR monthly unless there is an acute change and ordered more frequently. V2 confirmed nurses should document any signs or symptoms of changes in condition and neurological status and provider/guardian notification in the nursing notes. V2 stated V2 was off from work when R1 fell and did not return until 5/7/26, staff thought R1's symptoms were related to a UTI. V2 confirmed V2 was aware of R1's symptoms on 5/8/26. V2 stated V2 did not attempt to contact V16. At 11:58 AM V2 confirmed all documentation regarding provider/guardian notification and blood pressure monitoring for R1 was provided. V2 confirmed R1's blood pressure was not routinely monitored after 4/16/26 prior to R1's fall, no PT/INR results after 4/1/26, and no documented communication with a provider regarding interaction between Ciprofloxacin and Coumadin. On 6/16/26 at 12:40 PM V47 Pharmacist stated Ciprofloxacin has potential for moderate interaction with Coumadin and increases the bleeding effects, and PT/INR should be monitored closely during coadministration. On 6/15/26 at 12:17 PM V14 Nurse Practitioner stated V14 assessed R1 post fall on 5/4/26 and again on 5/7/26 when R1 complained of sleeping more and being weak. V14 stated R1 never reported a headache to V14 or V14 would have ordered a CT scan and hospital transfer. V14 stated R1 was on a low dose of Coumadin and V15 Physician ordered monthly PT/INR. V14 stated R1 was given Ciprofloxacin in April 2026, this medication can increase the bleeding effects of Coumadin, and the facility should have been monitoring R1's PT/INR at that time. V14 stated an aneurysm was the cause of R1's brain bleed and Coumadin can increase PT/INR contributing to bleeding. At 1:36 PM V14 stated the facility should have assessed R1's vision, pupil response, vital signs and hand grasps on 5/8/26 and notified V15 Physician of R1's symptoms. On 6/17/26 at 12:08 PM V14 stated V14 gives orders verbally to the nursing staff when V14 rounds at the facility. V14 stated R1's MAR should have reflected an order to check R1's blood pressure daily. V14 stated increased blood pressures could have contributed to R1's brain bleed but usually associated with systolic blood pressure of 190s, and R1 had been 140s. The facility's Change in a Resident's Condition or Status policy dated December 2025 documents the nurse will notify the resident's provider and resident's representative when there is a change in physical or cognitive status, a need to alter the resident's medical treatment significantly, and when the resident refuses treatments two or more consecutive times. The facility's Anticoagulation- Clinical Protocol dated November 2018 documents the following: Assess residents for bleeding and possible complications related to anticoagulant use. The physician should collaborate with pharmacy and nursing staff to identify potentially serious drug interactions with anticoagulants, including antibiotics. The physician should adjust the anticoagulant dose or change the medications that interact with the anticoagulant to ensure stabilized PT/INR within therapeutic range, and the physician will order PT/INR periodically to monitor the effects of anticoagulant therapy.

Based on interview and record review, the facility failed to provide quarterly trust fund statements for two of three residents (R12, R13) reviewed for resident funds in the sample of 16. Findings include: The facility's Accounting and Records of Resident Funds policy dated April 2021 documents each individual accounting records are available to the resident/representative through quarterly statements which include the beginning balance, total deposits/withdrawals, interest earned, funds available through petty cash, and the total amount of petty cash on hand. 1.) R12's Minimum Data Set (MDS) dated [DATE] documents R12 has severe cognitive impairment. R12's Resident Statement Landscape includes withdrawals and deposits for date range 5/22/26-6/1/26 and current balance as of 6/17/26. R12's Resident Trust Statement with date range 4/1/26-5/19/26 documents an accounting of withdrawals and deposits. On 6/17/26 at 11:28 AM V23 Business Office Manager stated the prior accounting system wasn't great and V23 has only been providing quarterly trust fund statements to residents. V23 knows who wants the statements or if a resident asks. V23 stated R12 opened R12's trust fund account in November 2024. R12's trust fund statements would go to V41 (R12's Family) but V23 has not provided any quarterly trust fund statements to V41. 2.) R13's MDS dated [DATE] documents R13 has moderate cognitive impairment. R13's Resident Statement Landscape includes withdrawals and deposits for date range 5/22/26-6/15/26 and current balance as of 6/17/26. R13's Resident Trust Statements dated 3/1/26-5/19/26 document an accounting of withdrawals and deposits. On 6/17/26 at 10:30 AM R13 stated has money in an account managed by the facility but R13 was unaware of any statements provided for this account. On 6/17/26 at 12:02 PM V40, R13's Family, stated V40 is only R13's healthcare power of attorney as V40 signed off for the facility to manage R13's funds and receive R13's Supplemental Security Income. V40 stated V40 does not receive statements for R13's trust fund account. On 6/17/26 at 11:28 AM V23 stated R13 opened a trust fund account in April or May 2024 and R13's quarterly trust fund statements would go to V40. V23 confirmed V23 has not provided quarterly statements for R13's trust fund account to V40.

Based on interview and record review, the facility failed to report a trust fund account met the Supplemental Security Income (SSI) limit which could affect eligibility for Medicaid or SSI for one of three residents (R15) reviewed for resident funds in the sample list of 16. Findings include: The facility's Accounting and Records of Resident Funds policy dated April 2021 documents the business office representative will notify the resident if the balance in his/her personal funds account reaches $200 less than the resident's SSI resource limit and when the amount in that account (along with the value of the resident's other non-exempt resources) reaches the SSI resource limit for one person and the resident may lose eligibility for Medicaid or SSI. On 6/17/26 at 12:30PM, R15 stated that R15 never received any letters about R15's trust account balance, or any spend down money that the facility would be taking for services. R15 stated no one has talked to R15 regarding this and stated there is no other person the facility would send notices to on R15's behalf. R15's Minimum Data Set, dated [DATE] documents R15 as cognitively intact. R15's profile documents R15 as R15's own responsible party. R15's Resident Trust Accounting Ledger dated 4/1/26-5/19/26 documents a deposit of $14,753.78 on 4/3/26, a deposit of $16,061.09 on 4/15/26 and includes a total balance of $31,878.46. R15's Resident Statement Landscape dated 6/17/26 documents a total balance of $30,753.72. The State of Illinois Department of Human Services (DHS) Notice of Decision dated 5/20/26, provided by V23 Business Office Manager, documents as of 7/1/26 R15's medical benefits will change and R15 must meet a spenddown deductible due to R15's resources being over the limit. This notice documents that R15 will not get assistance to pay the nursing facility until R15 has used R15's excess resources to pay the facility for R15's cost of care, which is identified as $8,525.0. This notice documents the right to appeal this decision, how to file an appeal and the appeal must be submitted within 60 days of the notice. On 6/17/26 at 10:26 AM V23 stated R15 recently got a large back pay from disability income and DHS sent a notice that required a spend down of $8,500 due to exceeding the SSI resource limit. At 11:28 AM V23 stated R15 will be required to pay the spend down of $8,525.00 to the facility for room/board charges. V23 stated R15 received the disability deposits approximately 60 days ago and V23 spoke with R15 regarding this spend down within the last 30 days but V23 does not have documentation of this.

Based on observation, interview, and record review, the facility failed to ensure consistent access to fluids to maintain adequate hydration for one (R9) of three residents reviewed for hydration on a sample of three.On 6/15/26 at 10:20 AM, R9 was observed sitting in a wheelchair in front of the television, calling out and asking for a drink of water. Due to R9's total visual impairment, R9 was unaware that the water cup on the over-bed table was half full. The over-bed table was pushed against the wall next to the bedside table, placing it completely out of R9's reach. Although the call light was resting in R9's lap, it was not used to summon assistance.R9's Minimum Data Set (MDS) documents the resident is cognitively intact with little to no cognitive impairment. The care plan, dated 5/19/26, identifies R9 as visually impaired and includes the following interventions: Tell the resident where you are placing their items. Be consistent. The care plan further documents that R9 has impaired functional abilities related to vision impairment, including glaucoma and blindness in the left eye.On 6/15/26 at 10:22 AM, V2, Director of Nursing (DON), was informed of R9's request and the placement of the over-bed table. V2 approached R9, verbally identified themselves, and responded to the request. The over-bed table was repositioned directly in front of R9's wheelchair, and the water cup was placed within reach. V2 verbally oriented R9 to the cup's location using the clock-face method by stating the water cup was at 12 o'clock. R9 independently grasped the cup and drank approximately 150 milliliters (mL) of water. V2 reminded R9 that the call light was in the resident's lap and encouraged its use when assistance was needed. The room was left with both the water cup and call light within reach.On 6/15/26 at 10:45 AM, V2 DON stated staff would continue to monitor R9's fluid intake, ensure hydration was accessible, and perform two-hour rounding to support hydration and overall health.On 6/16/26 at 10:00 AM, R9 stated, I can't always find my water. Staff do get it for me when I ask.On 6/16/26 at 10:10 AM, V25, Traditions Hospice Registered Nurse (RN), arrived to provide care. V25 was asked to place the over-bed table in front of R9 upon completion of care. V25 stated fresh ice water had been provided, the over-bed table had been positioned in front of R9, R9 had been informed of the location of the water cup, and both the large red assistance button and the call light in R9's lap had been identified. V25 encouraged R9 to use the call light when assistance was needed.On 6/17/26 at 1:15 PM, R9 was again observed seated in front of the television with the over-bed table pushed against the wall next to the bedside table, placing it completely out of reach. While in the room speaking with a family member using a portable phone, V2 DON repositioned the over-bed table in front of R9 and informed the resident of the location of the drinking cup.The facility's Resident Hydration and Prevention of Dehydration policy states the facility will strive to provide adequate hydration and prevent and treat dehydration. The policy further states that nurse aides will provide and encourage intake of bedside, snack, and meal fluids daily and routinely as part of resident care.R9's care plan directs staff to tell the resident where personal items are placed and to do so consistently.

Based on interview and record review, the facility failed to administer resident showers to residents dependent on staff to receive showers. This failure affects four residents (R4, R5, R6, and R9) out of six reviewed for showers on the sample list of eighteen. Findings include: 1. On 5/6/26 at 10:26 AM, in an unsolicited interview, R4 stated the facility staff are not giving showers like they are supposed to. R4 stated he got a shower the other day but it had been 2 weeks since he had one before that. R4 stated he thinks it is because the facility doesn't have enough staff, and they can't get enough staff. R4 further stated the agency staff come in, but they just sit around and won't get off their butts to do anything. R4's Medical Diagnoses List dated 5/6/26 documents R8 experiences medical conditions including Congestive Heart Failure, Diabetes Mellitus Type 2, Morbid Obesity, Chronic Atrial Fibrillation, Acquired Absence of Right (below knee) and Left (above knee) Legs, Coronary Artery Disease, Complications of Cardiac Grafts and Implants, Anxiety, Implant Cardiac Defibrillator, Bradycardia, Hypertension, and Ischemic Cardiomyopathy. R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact and dependent upon staff for showers. R4's Shower Sheets dated for April and May 2026 document R4 had a 10 day gap between 4/24/26 and 5/4/26, and a 7 day gap between 5/4/26 and 5/11/26. 2. R5's Medical Diagnoses List dated 5/8/26 documents R5 experiences medical conditions including Acute Neurologic Encephalopathy, Anxiety, Dementia, and Muscle Weakness. On 5/6/26 at 3:15 PM, R5 stated she had only received three showers the previous month. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively impaired and requires moderate staff assistance with showers. R5's Shower Sheets for April and May 2026 document R5 had an 8 day gap between 4/7/26 and 4/15/26 in receiving a shower. 3. On 5/6/26 at 11:15 AM, R6 stated the facility staff are slack on giving showers like they are supposed to. R6's Medical Diagnoses List dated 5/6/26 documents R6 experiences medical conditions including Cellulitis Left Lower Extremity, Chronic Respiratory Failure, Epilepsy, Hypertension, Anemia, Morbid Obesity, Major Recurrent Depression, Lumbago with Sciatica Right and Left Leg, Spondylosis with Lumbar Radiculopathy, Fracture Right Foot, Fibromyalgia, Polyneuropathy, Myalgia, Tachycardia, Pain Right Shoulder, Amblyopia Right Eye, and Chronic Fatigue. R6's Minimum Data Set, dated [DATE] documents R6 is cognitively intact and requires maximum assistance from staff for showers. R6's Shower Sheets dated for April and May 2026 document R6 had a 10 day gap between 4/2826 and 5/8/26 for receiving a shower. 4. On 5/6/26 at 2:35 PM, R9 stated he had gone 8 or 9 days without a shower. R9's Minimum Data Set, dated [DATE] documents R9 is cognitively intact and is dependent on staff for showers. R9's Medical Diagnoses List dated 5/6/26 includes Quadriplegia, Diabetes Type 2, Polyneuropathy, Coronary Artery Disease, Spinal Stenosis, Obesity, Polyosteoarthritis, Cervical Spondylosis with Radiculopathy, Atrial Fibrillation, Depression, and Anxiety. R9's Shower Sheets dated for April and May 2026 document R9 had a 7 day gap between 5/1/26 and 5/8/26 for receiving a shower.

Based on interview and record review the facility failed to repeatedly prevent a significant medication error for one (R2) resident out of three residents reviewed for significant medication errors in a sample list of eight residents.Findings include:R2's Electronic Medical Record (EMR) documents medical diagnoses as Paroxysmal Atrial Fibrillation, Rapid Ventricular Rate (RVR) and Hypertension. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively impaired. R2's Provider progress note dated 2/23/26 documents a physician order to administer Warfarin Sodium (anticoagulant) 4 milligrams (mg) daily starting 2/18/26 with no end date for stroke prevention.R2's Physician Order Sheet (POS) dated February 2026 documents R2's Warfarin Sodium 4 mg was discontinued on 2/21/26. R2's Medication Administration Record (MAR) dated February 2026 does not document R2's Warfarin Sodium as being administered on 2/22/26-2/28/26.R2's Physician Order Sheet (POS) dated March 2026 documents R2's Warfarin Sodium was not documented as a Physician Order from 3/1-3/2/26.R2's Medication Administration Record (MAR) dated March 2026 does not document R2's Warfarin Sodium as being administered on 3/1/26 and 3/2/26. R2's Medication Error Report dated 4/15/26 documents R2 was readmitted to the facility on [DATE] and Warfarin was not transcribed into orders. (R2) missed doses until 3/2/26. On 4/15/26 at 10:00 AM V3 Regional Clinical Nurse (RCN) stated R2 admitted to the facility with physician orders for Warfarin (anticoagulant). V3 RCN stated R2 was sent to the hospital on 2/21/26 so the order was discontinued. V3 RCN stated R2 returned to the facility on 2/22/26 with orders from the hospital to continue Warfarin Sodium 4 milligrams (mg) daily. V3 RCN stated the readmission order for R2's Warfarin Sodium did not get transcribed nor double checked by the Interdisciplinary Team (IDT) or any other nurse. V3 RCN confirmed R2 was not administered her Warfarin Sodium from 2/22/26-3/2/26. V3 RCN stated R2's International Normalized Ratio (INR) was subtherapeutic prior to the significant medication error 'so it was a big error but did not harm (R2)'. The facility policy titled Adverse Consequences and Medication Errors revised February 2023 documents a medication error is defined as the preparation or administration of drugs and/or biologicals which are not in accordance with physician orders, manufacturers specifications or accepted professional standards and principles of the profession providing services. An example of a medication error includes a drug that is ordered but not administered.

Based on observation, interview and record review the facility failed to initiate and update fall care plans, failed to implement fall interventions, failed to thoroughly investigate falls for two (R3 and R7) residents out of four residents reviewed for Accidents in a sample list of eight residents.Findings include:1.R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires supervision with transfers and toileting.R7's Care plan intervention dated 1/23/26 instructs staff to place a 'Call Don't Fall' sign in R7's room for visual reminder to allow staff to assist with Activities of Daily Living (ADL) to reduce the risk of falling. This same care plan documents an intervention dated 4/9/26 to place R7's urinal next to his chair. R7's Fall Risk Evaluation dated 2/12/26 documents R7 as a high fall risk.R7's Physician Order Sheet (POS) dated April 2026 documents a physician order for Aspirin 81 milligrams (mg) daily. R7's AIM for Wellness report dated 4/5/26 documents R7 had an unwitnessed fall on 4/5/26 after he had been in his recliner then stood up and fell backwards hitting his head. This same report documents R7 obtained a laceration to his posterior cranium due to this fall.R7's Fall Investigation dated 4/5/26 did not document when the last time staff offered toileting to R7 and what footwear R7 was wearing as he was trying to stand. R7's Hospital Record dated 4/5/26 documents R7's diagnoses as Fall, Closed head injury, Scalp Laceration. This same record documents R7 received four staples to his posterior skull due to a fall at the facility. On 4/15/26 at 11:10 AM V10 Advanced Practice Nurse (APN) removed four staples from R7's posterior scalp. Two urinals with R7's name on them were placed on a portable table out of reach of R7. R7's room did not have a 'Call Don't Fall' sign posted. R7's call light was attached to R5's (roommate) call light, out of reach of R7. On 4/15/27 at 11:30 AM R7 stated he could not reach his urinals the day he fell (4/5/26). R7 stated he had no way to call for help because he could not reach his call light. R7 attempted to stand to reach his urinal but could not unless he leaned forward approximately two feet. R7 stated, This is dangerous. I don't want to fall again.2.R3's Electronic Medical Record (EMR) documents R3 was admitted to the facility on [DATE] with medical diagnoses as Bacteremia, Metabolic Encephalopathy, Influenza, Malaise, Severe Dementia, Transient Ischemic Attack (TIA) and Cerebral Infarction. R3's Fall Risk Evaluation dated 2/25/26 documents R3 as a high fall risk.R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 requires maximum assistance with transfers.R3's Care Plan initiated 2/27/26 does not include a focus area, goal nor intervention for falls from admission on [DATE]-[DATE]. R3's Physician Order Sheet (POS) dated February 2026 documents a physician order starting 2/24/26 for Plavix 75 milligrams (mg) daily for stroke prevention.R3's AIM for Wellness report dated 2/26/26 documents R3 had an unwitnessed fall in his room after attempting to self-transfer from his wheelchair to his bed. R3 obtained a nasal fracture, and skin tears due to this fall. R3's Fall Investigation dated 2/26/26 did not document when the last time staff offered assistance to lay down to R3 and what footwear R3 was wearing as he was trying to stand. R3's Nurse Progress Note dated 2/26/26 at 2:37 PM documents R3 was self-transferring when he had a change of plane. This same note documents R3 was found on the floor and noted to have bruising on his posterior head then sent to the emergency room.On 4/14/26 at 10:45 AM V7 Licensed Practical Nurse (LPN) stated R3 was found on his floor of his room by his bed after attempting to self-transfer from his wheelchair to his bed. V7 LPN stated R3's pull alarm was sounding. V7 LPN stated she had seen R3 approximately 1:45 PM-2:00 PM sitting in the sunroom. V7 LPN stated R3 'must have' self-propelled into his room to lay himself down. V7 LPN stated R3 has Dementia and needs close supervision due to his poor cognition and lack of safety awareness. V7 LPN stated R3 had a cut to the bridge of his nose, bruising to the back of his head and a scrape on his Right Elbow. V7 LPN stated she sent R3 to the emergency room where he was diagnosed with a nasal fracture. On 4/15/26 at 11:35 AM V10 Advanced Practice Nurse (APN) stated R7 should have his urinals within reach to help prevent him from falling. V10 APN confirmed R7 could not reach his call light and there was not a precautionary sign posted in R7's room. V10 APN handed R7 his call light and R7 stated 'Oh thank you. I was looking for that'. V10 stated the facility is supposed to have a fall care plan in place for the staff to follow. V10 APN stated the staff will not know what to do for each individual resident if the care plan is not initiated/updated. V10 APN stated R3 and R7's falls may have been preventable but does not believe the facility caused the injuries. V10 APN stated the facility should train their staff on fall preventions/interventions/etc.On 4/15/26 at 2:35 PM V2 Director of Nurses (DON) stated all residents should have an at risk fall care plan in place from their admission. V2 DON stated residents who have had an actual fall should also have their fall care plan updated with an appropriate intervention for the fall the same day as the fall. V2 DON stated R3's fall could have been prevented if a fall care plan were initiated when R3 was admitted to the facility. V2 DON stated R7 should have had his urinal placed within his reach. V2 DON stated the staff were aware that R7 would use his urinal and should have known the urinal should have been in arms reach. V2 DON stated R7's fall could have been prevented. V2 DON stated the staff did not intentionally harm any resident but 'these two residents (R3, R7) injuries could have been prevented'. The facility policy titled Managing Falls and Fall Risk revised March 2018 documents staff will identify and implement relevant interventions.

Based on interview and record review the facility failed to maintain timely call lights response times. This failure affected three of four residents (R2, R3, R4) reviewed for call lights on the sample list of four.Findings Include: The facility's Call System, Residents policy dated September 2022 documents each resident is provided with a means to call staff for assistance through a communication system. Calls for assistance should be answered as soon as possible but no later than five minutes. Any urgent requests for assistance need to be addressed immediately. 1. R2's Medical Diagnoses List dated March 2026 documents R2 is diagnosed with Chronic Kidney Disease, Severe Protein Calorie Malnutrition, Adult Failure to Thrive, Rheumatoid Arthritis, Malaise, and Pressure Ulcer of the Sacral Region Stage II. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact, has impairments on both upper and lower extremities, requires maximal assistance for personal/toilet hygiene and all transfers. On 3/11/26 at 3:10 PM R2 stated she often waits over an hour for her call light to be answered. R2 stated she knows when she needs to use the bathroom but must wait on staff to transfer her to the toilet or use the bedpan. R2 stated sometimes she must wait so long that she ends up urinating in her incontinence brief. R2 stated this upsets her so much and she feels terrible. R2 stated she can't do much for herself but still knows when she needs to use the bathroom and just wishes that staff would come and take care of her needs in a timely manner. 2. R3's Medical Diagnoses list dated March 2026 documents R3 is diagnosed with Diabetes Type II, Muscle Weakness, Anxiety, and Major Depression. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact and requires supervision and touching assistance for personal/toilet hygiene and all transfers. On 3/11/26 at 3:09 PM R3 stated it often takes staff over an hour to answer her roommate's (R2's) call light. R3 stated she feels badly for R2 and knows it bothers R2 when she has an accident. 3. R4's Medical Diagnoses list dated March 2026 documents R4 is diagnosed with Chronic Obstructive Pulmonary Disease, Lymphedema, Obesity, and Peripheral Vascular Disease. R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact, uses a cane, and requires supervision and touching assistance for personal/toilet hygiene and all transfers. On 3/11/26 at 3:05 PM R4 stated it often takes staff over a half hour to answer a call light especially on night shift. On 3/11/26 at 3:47 PM both V6 and V7 Certified Nurse Assistants (CNA) stated residents often complain about long call light wait times. V6 stated the facility does not have enough CNA staff on evening and night shifts and this results in residents waiting extremely long for assistance with care. V7 confirmed V6's statements and added residents' needs aren't met timely (call lights answered) when there is not enough staff. On 3/11/26 at 3:25 PM V1 Administrator confirmed R2 does know when she needs to use the bathroom and uses her call light to alert staff she needs to go. At 3:37 PM V1 confirmed staff should be responding to call lights quickly and within a reasonable time frame. V1 confirmed not answering call lights in a timely manner can negatively affect resident care.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member. This failure affects one (R2) of three residents reviewed for abuse in the sample list of 10. Findings:A facility investigation report dated December 9, 2025, at 7:13 PM, documents an alleged incident involving R2 and V13 (Certified Nursing Assistant (CNA)). According to the investigation report, R2 reached out and grabbed V13 (CNA's) head. V13 (CNA) immediately responded grabbing R2's hand and redirecting it away from V13's (CNA) head.The facility investigation file includes a witness statement dated December 9, 2025, documenting V12 (CNA) reported that around 7:00 PM on December 9, 2025, while she and V13 (CNA) were assisting R2 into bed, R2 grabbed V13 (CNA's) head. V12 (CNA) stated V13 (CNA) responded by striking R2's hand and telling R2 not to grab her head.The investigation file contains a statement dated December 9, 2025, from the alleged perpetrator V13 (CNA), documenting V13 (CNA) asked V12 (CNA) to assist with repositioning R2 in bed and R2 grabbed V13 (CNA's) head during the process. V13 (CNA) stated she removed R2's hand from her head.R2's Minimum Data Set (MDS) dated [DATE] documents R2 has severe cognitive impairment. R2 has a diagnosis of severe dementia with anxiety with behavioral disturbances.On 1/15/26 at 10:47 AM, R2 was observed lying flat on her back in bed with upper side rails in place. R2 was unable to respond to questions related to R2's severe cognitive impairment. R2's electronic medical record (EMR) contains a health status note dated 12/9/2025 documenting that a CNA reported an alleged incident occurring in R2's room during a transfer. This note documents R2 was assessed for injuries and vital signs were obtained. On 1/15/26 at 11:12 AM, V13, (CNA), stated she is no longer employed at the facility. V13 (CNA) acknowledged that an incident involving R2 occurred but reported that she does not recall the exact details. V13 (CNA) indicated that she does not wish to speak with this writer, expressing concern that doing so might incriminate her.On January 15, 2026, at 1:07 PM, V8 (Licensed Practical Nurse (LPN)), stated on the evening of December 9, 2025, V12 (CNA) approached her regarding a situation between R2 and V13 (CNA). V8 (LPN) reported that she advised V12 (CNA) that if the situation involved an allegation of abuse, the Administrator needed to be contacted immediately. V8 (LPN) stated she also called the Administrator and was instructed to place V13 (CNA) in the conference room until V1 (Administrator) could arrive at the facility to investigate the matter.On January 20, 2026, at 3:13 PM, V1, (Administrator/Abuse Coordinator), stated she investigated the incident between R2 and V13 (CNA). V1 reported that V13 (CNA) instinctively moved R2's hand away from her long hair and confirmed that there was no injury to R2. V1 (Administrator) agreed that all residents have the right to remain free from abuse while residing in the facility and stated, Absolutely 110% residents have the right to be free from physical abuse.The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy dated September 2022 states residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy specifies it is a facility-wide commitment to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone-including facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.Additionally, the policy documents the facility will establish and maintain a culture of compassion and caring for all residents, particularly those with behavioral, cognitive, or emotional challenges. To achieve this, the facility will implement measures to address factors that may lead to abusive situations, including:Adequately prepare staff for caregiving responsibilities.Provide staff with opportunities to express challenges related to their job and work without reprimand or retaliation.Instruct staff regarding appropriate ways to address interpersonal conflicts; andHelp staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.

Based on interview and record review the facility failed to protect resident's right to be free from physical abuse by another resident for two of five residents (R2, R3) reviewed for abuse in the sample list of 17. This failure resulted in R2 obtaining lacerations to his Left Face, Left Upper Lip and Left Ear requiring treatment in the emergency room and experiencing pain and fear after R3 punched R2 in the face. Findings include:R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively intact. This same MDS documents R2 requires moderate assistance with toileting, dressing, personally hygiene and transfers. R2's Physician Order Sheet (POS) dated November documents a physician order for Xarelto 20 milligrams (mg) daily (anticoagulant). R2's Nurse Progress Note dated 9/21/25 at 9:00 AM documents R2 was involved in an altercation with R3 on 9/21/25 at 9:12 AM. R2 was using his restroom when R3 came in and started punching R2 in the face. Both residents (R2, R3) were separated and evaluated for injuries. R2 obtained lacerations to his Left Ear, Left Face and Left Upper Lip. R2 was sent to the emergency room for further evaluation. R2's Assess, Intercommunicate, Manage (AIM) for Wellness dated 9/21/25 documents R2 received Left Ear, Left Face and Left Upper Lip Lacerations during a resident to resident altercation on 9/21/25. (R3) came in and started punching me (R2) in the face. R2's Hospital Record dated 9/21/25 documents R2's chief complaint as Assault and diagnoses listed as Assault and Abrasion. R2 was sitting on his toilet at his room at the facility and R3 had a behavioral outburst. R3 came into their shared bathroom and R3 punched R2 in his Left Jaw. R2 does have a laceration to his post Auricular region. R2 was treated with antibacterial ointment and administered Tramadol for pain. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 requires maximum assistance from staff for bed mobility and transfers. R3's AIMS dated 9/21/25 documents R3 was separated (from R2) and administered as needed Haldol Intramuscularly (IM) for agitation and sent to the emergency room. On 11/24/25 at 2:05 PM R2 stated his room shares a bathroom with another resident room. R2 stated he was using the shared bathroom when R3 came charging in and hit me. R2 stated (R3) doubled up his fist and stated I am too good looking, and he needed to mess up my face because I have too many girlfriends. R2 stated he knew who R3 was prior to this incident but had never had any trouble with R3. R2 stated R3 hit him in the jaw causing R2 to be scared and shocked. R2 stated he did not know what R3 would do. R2 stated he yelled out and staff came in and dragged R3 off R2. R2 stated, Imagine you are on the toilet, and someone just comes barging in and punches you so hard you fall back. R2 stated he is very glad R3 is no longer in the facility. R2 stated he had to go the emergency room because R3 hurt him. On 11/24/25 at 9:20 AM V10 Licensed Practical Nurse (LPN) stated she and V11 LPN were in the facility medication room when she heard R3 yelling, (R2) thinks he can use my f****** (expletive) bathroom. V10 LPN stated another staff member tried to calm R3, but it didn't work. V10 LPN stated staff attempted several non-pharmacological methods such as a calm voice, no sudden movement, offering a change of atmosphere, etcetera with no positive response. V10 LPN stated R3 required an injection of Haldol to attempt to deescalate R3. V10 stated the Haldol kind of worked but (R3) was so angry even the Haldol was not enough to calm R3 down. V10 LPN stated emergency services (EMS) arrived and took both R2 and R3 to the emergency room. V10 LPN stated R3 left first because he was still yelling and cussing when EMS arrived so R3 left first so he wouldn't hurt anyone else. V10 LPN stated the staff tended to R2's lacerations. V10 LPN stated she thought that R2 would have a lot of bruising due to R3's level of anger and force when he hit R2. On 11/25/25 at 2:15 PM V1 Administrator confirmed the incident between R2 and R3 was definitely abuse. V1 Administrator stated the facility was aware this incident happened and fully expected to be cited for this resident-to-resident abuse that happened. V1 Administrator stated V1 wishes it didn't happen, but it did. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 documents residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. This same policy documents staff are to protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including other residents.

Based on observation, interview and record review the facility failed to maintain kitchen sanitation, failed to obtain temperatures of cold stored foods and foods prepared for meal service. These failures have the potential to affect all 71 residents.Findings include:The facility Daily Midnight Census dated 11/23/25 documents 71 residents reside in the facility.The facility was unable to provide any temperature logs for meal service.The facility temperature logs dated, November 2025, document temperatures obtained on 11/8 and 11/10-14/25 for the facility walk in cooler, reach in vegetable freezer, third door reach in cooler and the reach in meat freezer. There were no other temperatures documented on the logs. On 11/23/25 at 12:15 PM V9 [NAME] did not obtain temperatures of country fried steak, mashed potatoes/gravy, mixed vegetables, spaghetti or green beans prior to meal service on 11/23/25. On 11/23/25 at 12:20 PM The facility reach in cooler, reach in vegetable freezer and reach in meat freezer had an unknown pink sticky liquid spilled on the bottom shelf along with dozens of pieces of food debris. On 11/24/25 at 12:35 PM V1 Administrator obtained food temperatures on a test tray of sliced pork, mashed potatoes and gravy, green beans and cornbread. The temperature of the sliced pork was 108 degrees Fahrenheit (F), mashed potatoes with gravy was 120 degrees F and the green beans were 86 degrees F. On 11/23/25 at 12:30 PM V9 [NAME] stated the kitchen is a mess because there are not enough staff. V9 [NAME] stated the staff that work in the kitchen do their best but can't keep up. V9 [NAME] stated the temperature logs posted on the coolers and freezers are not completed as they should be. V9 [NAME] stated the hot food service temperature logs have not been completed since she started a year ago. V9 [NAME] stated she is the main cook for all three meals served five to six days per week for the past year and has never checked food temperatures for food service. On 11/24/52 at 12:45 PM V1 Administrator confirmed the test tray of foods were not warm enough to be palatable. V1 Administrator stated she has her food handler's certificate and knows what the temperatures should be and these are not up to temp.On 11/25/25 at 3:25 PM V6 Regional Certified Dietary Manager (CDM) stated the facility should be checking the temperatures of all the coolers, freezers, dishwashing cycles and food service temperatures. V6 CDM stated not checking those temperatures could cause a food borne illness.

Based on observation, interview and record review the facility failed to employ a Certified Dietary Manager (CDM). This failure has the potential to affect all 71 residents residing in the facility.Findings include:The Daily Midnight Census dated 11/23/25 documents 71 residents reside in the facility.The facility was unable to provide any documentation of employment of a CDM and/or Dietary Manager. Throughout the survey timeframe on 11/23/25-11/25/25 at various times on first and second shifts there was no CDM or Dietary Manager in the facility. On 11/23/25 at 9:00 AM, V9 [NAME] was providing verbal guidance to dietary staff. V9 [NAME] stated the facility does not have a CDM or Dietary Manager.On 11/24/25 at 12:15 PM V1 Administrator was serving resident meals from the kitchen. V1 Administrator stated she was helping due to a CDM was not onsite. On 11/25/25 at 3:25 PM V6 Regional Certified Dietary Manager (CDM) stated she splits her time in facilities with this facility and one other facility. V6 stated she had not been onsite at this facility for at least ten days. V6 stated prior to that time, she would have been onsite once a week on average. V6 stated she is not the interim Dietary Manager. V6 stated the facility has not had a Dietary Manager for six months or so.

Based on observation, interview and record review the facility failed to maintain the dignity of three (R10, R11, R12) residents by not providing Activities of Daily Living (ADL) timely out of six residents reviewed for ADL's in a sample list of 17 residents.Findings include:1.R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. This same MDS documents R10 is dependent of staff for oral hygiene, toileting, dressing, personal hygiene, transfers and requires maximum assistance from staff for bathing and bed mobility.R10's Care Plan intervention dated 1/12/23 documents staff will provide hygiene and grooming per R10's preferences. Ensure hair is in place before meals. Keep facial hair trimmed/shaved per R10's usual style. Fingernail care is on shower days and as needed. On 11/25/25 at 9:15 AM R10 was sitting in the resident lounge with another resident present. R10 had overgrown, unkempt mustache and facial hair long stubble. R10 had a piece of egg on his shirt leftover from breakfast. R10 stated he prefers to be clean shaven. R10 stated he does not get any help cleaning himself up after breakfast and can't see if he has spilled any foods. R10 stated he prefers to wear clean clothes without any food spilled on them.On 11/24/25 at 12:00 PM R10 was sitting at the lunch table in the main dining room with multiple other residents present. R10 still had the overgrown, unkempt mustache and long facial hair stubble. R10's hair was not combed as it was sticking up on the top of his head in multiple places. 2.R11's Minimum Data Set (MDS) dated [DATE] documents R11 as moderately cognitively impaired. This same MDS documents R11 as dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R11's Care Plan intervention dated 3/22/23 documents staff will provide bathing hygiene, dressing and grooming per R11's preferences. Ensure hair is in place before meals, keep facial hair trimmed/shaved per R11's usual style. Fingernail care should be on shower days and as needed. On 11/23/25 at 1:45 PM R11 was sitting in her wheelchair. R11 had a half inch of chin hair showing. R11's fingernails showed dark grime underneath the ends of her nails. On 11/24/25 at 10:00 AM R11 was sitting in her wheelchair in the hallway with other residents present. R11 still had long chin hairs showing. R11's fingernails showed dark grime underneath the ends of her nails. 3.R12's Brief Interview for Mental Status (BIMS) dated 11/13/25 documents R12 as severely cognitively impaired. R12's Minimum Data Set (MDS) dated [DATE] documents R12 as moderately cognitively impaired. This same MDS documents R12 as dependent on staff for assistance with eating, oral hygiene, bathing, dressing, toileting, personal hygiene, bed mobility and transfers.R12's Care Plan intervention dated 11/17/24 documents staff will provide oral care with morning and evening cares. Staff will provide bathing, hygiene, dressing and grooming per R12's preference. Ensure hair is in place before meals. Keep facial hair trimmed/shaved per R12's usual style. Fingernail care will be on shower days and as needed. On 11/23/25 at 11:50 AM R12 was sitting in her wheelchair in the hallway with visitors passing by. R12 had multiple chin hairs approximately an inch long and several dark mustache hairs showing. R12's fingernails showed dark grime underneath the ends of her nails. On 11/24/25 at 3:00 PM R12 was sitting in the resident lounge with other residents with the same mustache and chin hair showing. R12's fingernails showed dark grime under the same nails as previous observation.On 11/24/25 at 2:55 PM V13 Certified Nurse Aide (CNA) confirmed R11 and R12 had facial hair and grime underneath their fingernails. V13 stated residents should be shaved everyday if needed. V13 CNA stated she does not think R11 nor R12 would like to have long chin hairs. On 11/24/25 at 11:45 AM V24 Certified Nurse Aide (CNA) confirmed R10 likes to be clean shaven, in clean clothes and have his hair combed down. V24 CNA stated she was going to do that but haven't gotten around to it yet. On 11/25/25 at 11:45 AM V3 Director of Nurses (DON) stated all residents should be groomed per their preference. V3 DON stated she was aware the resident's personal hygiene was an issue with getting staff to ensure residents are clean and well groomed. V3 DON stated she has seen several female residents that need shaved, several residents that are in need of nail care and also some that need their hair brushed. V3 DON stated she is working on in servicing staff on Activities of Daily Living (ADL). The facility policy titled Dignity revised February 2021 documents each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on observation, interview and record review the facility failed to assess, monitor, and notify physician to obtain treatment orders timely and failed to implement care plan interventions for one (R2) resident's documented open buttock wounds out of three residents reviewed for incontinence care in a sample list of seven residents. This failure resulted in R2's reddened bilateral buttock areas to deteriorate to open wounds. Findings include: R2's undated Face Sheet documents medical diagnoses of Quadriplegia, Diabetes Mellitus Type II, Spinal Stenosis, Arthrodesis, Cervicalgia, Obesity, Radiculopathy Cervical Region, Sensorineural Hearing Loss, Neuropathy, Retention of Urine, Depression, Syndrome of Inappropriate secretion of Antidiuretic Hormone and Anxiety. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively impaired. This same MDS documents R2 depends on staff for all cares including toileting, bed mobility, transfers, showering and personal hygiene. R2's Care plan intervention dated 10/4/24 instructs staff to place an incontinence brief on R2 when up and to check incontinence brief every two hours and change as needed. On 1/9/25 at 11:30 AM R2 was laying on his back in his recliner chair in his room. No staff present in room. On 1/9/25 at 1:50 PM V5, V9, V10 Certified Nurse Aides (CNA) transferred R2 from his recliner chair to his bed using a total body mechanical lift and then provided incontinence care. V5 CNA cross contaminated R2's open wounds on bilateral buttocks with the soiled towel used to provide bowel incontinence care for R2 by wiping directly over R2's open wounds. R2's bilateral buttocks had nickel sized open, dark red areas with dark purple peri wounds. On 1/9/25 at 2:05 PM V5 Certified Nurse Aide (CNA) stated cross contaminating R2's wounds could cause an infection. V5 stated V5 started work at 8:00 AM, was assigned to R2 and had not been in R2's room at all on her shift. V5 CNA stated V5 thought V9 CNA had been in R2's room to offer to help him to turn/position and provide incontinence care. On 1/9/25 at 2:15 PM V9 CNA stated V9 got R2 up for the day at 7:30 AM and had not been in R2's room since V9 got R2 up. V9 CNA stated V9 was assigned to R2's hall but not directly to R2. V9 CNA stated V5 CNA was assigned to R2 and should have helped R2. On 1/9/25 at 3:10 PM V2 Director of Nurses (DON) stated sometimes R2 does refuse turning/positioning and incontinence care but R2 would not have the opportunity to refuse if the staff don't ask him. V2 DON stated the staff should be asking R2 if he would like to be turned/positioned and provided incontinence care at least every two hours. V2 DON stated R2 has an indwelling urinary catheter but should still be assisted every two hours and as needed with incontinence care. V2 DON stated R2 has had open areas on his buttocks in the past, so it is very important to keep R2 repositioned, clean and dry. V2 DON stated cross contaminating R2's wound during incontinence care could cause an infection of R2's wounds. V2 DON stated V2 is unable to find a policy for turning/positioning and cross contaminating wounds. V2 DON stated the staff are expected to turn/position incontinent residents every two hours and maintain a clean field when providing incontinence care to protect any wounds in that area. On 1/10/25 at 11:50 AM V8 Registered Nurse (RN) stated V8 visualized R2's bilateral buttocks on 12/24/24 after V15 Certified Nurse Aide (CNA) brought her the shower sheet. V8 stated V8 visualized R2's buttocks while R2 was laying on his back on a shower bed. V8 RN stated R2's bilateral buttocks had reddened areas but from what V8 could see, she did not see any open areas. V8 RN stated she should have notified V11 Physician for a treatment order, documented R2's newly acquired areas and documented a full assessment of R2's bilateral buttocks skin evaluation but did not. On 1/10/25 at 1:50 PM V7 Certified Nurse Aide (CNA) stated V7 replaced R2's mattress with a newer one due to R2 complained that R2 could feel a metal bar on his buttocks when he was in bed. V7 CNA stated R2's mattress needed replaced badly due to the middle of it being caved in. On 1/10/25 at 1:55 PM V7 CNA showed R2's previous pressure reducing mattress had a large two feet by two feet area in the middle that was extremely caved in. A side view of R2's previous mattress showed that R2's mattress was not in a straight line, but the middle section was so bowed, it showed through the opposite side of the mattress. On 1/10/25 at 3:00 PM V3 Wound LPN stated R2 has a history of having open sores on his buttocks that open and close. V3 stated R2's shower sheets dated 12/24 and 12/27 both document open sores on R2's bilateral buttocks. V3 Wound Nurse/LPN stated R2's bilateral buttock wounds were either closed reddened areas on 12/24/24 and deteriorated to being open by 12/31/24 or R2's buttock wounds were open on 12/24/24. V3 stated R2 did not get treatment orders, V11, V12 Physicians were not notified so nothing got done with R2's wounds, R2's wounds were not measured, assessed or monitored and R2's care plan was not updated with any new interventions on 12/24/24. V3 stated V11 Wound Physician rounds every Thursday but due to the holidays, V11 did not round for those two weeks. V3 stated the facility should assess, which includes measuring and describing a resident's wounds, weekly. V3 stated R2 was never put on the list for residents for V3 to review weekly. V3 Wound Nurse/LPN stated V8 Registered Nurse (RN) reported on 1/10/25 that V8 did visualize R2's buttock wounds on 12/24/24 and said they were reddened areas. V3 stated there is no documentation of this and due to the lack of monitoring, there is no way to know if R2's wounds were closed. V3 Wound Nurse/LPN stated the only information has about R2's buttock wounds is from the shower sheets which document R2's wounds as being open. V3 Wound Nurse/LPN stated V3 did review the shower sheets dated 12/24/24 and 12/27/24 but did not follow up with the nursing staff or visualize R2's bilateral buttock wounds until 12/31/24.

Based on observation, interview and record review the facility failed to provide lifesaving equipment for emergency airway management, for a resident in cardiac and respiratory arrest. This failure affected one of 18 residents (R1) reviewed for advanced directives and has the potential to affect all 72 residents residing in the facility. R1 subsequently expired. The Immediate Jeopardy began on [DATE] when R1 was found to have no pulse or respirations and Cardiopulmonary Resuscitation (CPR) was initiated. Staff could not locate a functional bag valve mask (BVM) mask to provide a full seal over R1's nose and mouth, in order to provide effective ventilation during the medical emergency. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 1:58 pm. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's Physician Order for Life Sustaining Treatment (POLST) form dated [DATE] documents R1 wished to have Cardiopulmonary Resuscitation (CPR), full treatment with the primary goal of sustaining life. R1's Diagnoses Sheet updated [DATE] documents the following: Unspecified Asthma, Uncomplicated, Hypertensive Heart Disease Without Heart Failure and Age-Related Osteoporosis with Current Pathological Fracture, Unspecified Site, Initial Encounter for Fracture ([DATE]). R1's Re-Admission Summary note dated [DATE] documents R1 returned from the hospital after right hip surgical repair. R1's Health Status Note [DATE] at 4:19 pm documents: R1 was found to have no pulse or respirations, CPR was initiated by facility staff, and 911, Emergency Medical Service (EMS) was called. R1's Death Certificate dated [DATE] document R1's cause of death included: Asthma, Dementia and Schizophrenia. The facility handwritten CPR time line notes, documents R1 was lowered to the floor (from bed) at 3:33 pm. At 3:34 pm alternating facility staff V11, Licensed Practical Nurse (LPN),V2, Director of Nursing, V18, Resident Care Coordinator preformed eight cycles of chest compressions. The same time line documents V12, Licensed Practical Nurse provided manual ventilation (with no BVM mask as documented below) for the duration of the facility staff provision of CPR. According to the same time line, EMS arrived at 3:41 pm and took over R1's CPR. EMT's (V15 and V16) and provided R1 with three cycles of CPR and completed a three lead ECG. R1's Emergency Medical Service (EMS) Report, written by V14, Lead Paramedic, dated [DATE] documents EMS was notified at 3:37 pm and arrived at the patient at 3:39 pm, and departed the facility at 3:58 pm. The report further documents: Upon Emergency Medical Technician (EMT) arrival, R1 was laying on the ground unresponsive, pulseless, and apneic (not breathing) with facility staff providing CPR (by facility timeline above, seven minute duration). The EMT's report also documents R1 was cyanotic (blueish - purple discoloration of the skin caused by low levels of oxygen in the blood). EMT's applied a cardiac monitor (ECG) electrocardiogram leads, to measure the electrical activity of R1's heart. R1's ECG reading displayed R1's heart entirely stopped beating (Asystole). V14, Lead Paramedic called the local hospital, and gave report of R1's assessment as documented. V17, Physician confirmed R1's ECG monitor reading of Asystole, indicated R1's had already deceased . V17 gave the order to cease CPR. On [DATE] at 10:37 am V14, Lead Paramedic on the scene, stated V12, Licensed Practical Nurse (LPN) was providing ventilation using a handheld manual Ambu-bag for resuscitation without a required BVM mask, which did not provide an adequate seal over R1's mouth and nose. V14 said V12, LPN was holding the oxygen tube in R1's mouth without the benefit of a BVM mask complete seal. V14 said R1's manual ventilation with an Ambu bag and no BVM mask during CPR, was inadequate for resuscitation. V14 stated a BVM mask is required for life- sustaining ventilation during CPR therefore, R1 did not have adequate life sustaining ventilation during CPR, which lead to R1's death. On [DATE] at 11:05 am V12, LPN confirmed he did not have any kind of a mask on R1 to provide R1's ventilation with the manual Ambu bag. V12, LPN said he used one hand to hold the oxygen tube in R1's mouth and tried to cover R1's nose with the same hand, while he squeezed the Ambu bag with his other hand. V12, LPN said V12, LPN was not able to find a mask on the emergency crash cart. On [DATE] at 11:18 pm V10, Physician/Medical Director (MD) confirmed he spoke to V1, Administrator on [DATE] and told V1 to continue to CPR on (R1) until the paramedics arrived and ran a strip (ECG). V10 confirmed V14, Lead Paramedic had given this surveyor accurate information regarding the necessity to use a BVM, in order to maintain a complete seal when ventilating a patient in cardiac arrest. V10 MD stated, R1's ventilation would not be adequate life-sustaining ventilation during CPR if the staff did not use a BVM with the Ambu bag during resuscitation. On [DATE] at 12:10 pm V12, LPN and this surveyor reviewed the contents of the crash cart. There was a new Ambu bag still in a plastic bag. There was one mask to attached to the Ambu-bag for resuscitation, also in the manufacturer plastic bag. V12, LPN stated, Those are brand new. There were not mask in here (emergency crash cart), I swear. I did the best I could (providing R1 ventilation during CPR, [DATE]) without the mask. On [DATE] 12:15 pm at V11, Licensed Practical Nurse (LPN) confirmed she was R1's nurse that initiated R1's CPR. V11, LPN stated V11 provided chest compression on R1 during CPR and V12, Licensed Practical Nurse provided ventilation. V11, LPN stated, I remember distinctly (V12, LPN) holding the oxygen tube in (R1's) mouth, while using his other hand to manage the Ambu bag. (V12, LPN) did not have a mask on (R1) during resuscitation and did not have his hand over (R1's) nose, at all. On [DATE] at 2:15 pm V2, Director of Nursing (DON) stated, I am the one who told (V13 LPN) to go get a new mask. The mask she gave me was broken. I was standing by to relieve (V11, LPN), who was giving chest compressions. (V12, LPN) continued to hold the oxygen in (R1's) mouth with one hand, and the Ambu bag with the other. I was not watching for (R1's) chest to rise and fall. I was more concerned with switching places with (V11, LPN) on compressions (chest). On [DATE] at 2:10 pm V13, LPN stated, I got the Ambu bag out of the storage bag. (facility started of CPR at 3:34 pm, per the facility timeline above). I was separating the Ambu bag so we could fill it up with oxygen. The mask (BVM) was in the storage bag and was broke. (V2, DON) sent me to get a new one (BVM), while (V12, LPN) started giving (R1) oxygen during CPR. When I came back down, EMT's (EMT's arrived at 3:41 pm per the facility timeline above) were here. We didn't need the mask I found. (seven minutes after CPR was started). He (R1) was already dead. The Facility Assessment last updated [DATE] documents the facility will ensure staff are educated and have competencies in the areas necessary to provide the level and type of support and care needed for their resident population. The facility Matrix documents currently 72 residents reside in the facility. The undated and untitled facility policy documents the following: Policy: The facility will strive to provide emergency care to the residents as required. Emergency care shall be provided in a calm and confident manner in an effort to preserve life, prevent worsening of the situation and promote recovery. The same policy documents: In addition to the above procedures the facility shall maintain the following controls to facilitate quality emergency care: 1. Emergency equipment shall be portable and readily available at all times. 2. An emergency cart shall he maintained containing at the minimum the following equipment: Portable oxygenation unit (including necessary oxygen tank, tubing, face mask and cannula): airway; bag-valve mask; manual ventilation device/ Ambu bag; suction machine: tubing and catheter; gloves; stethoscope; and B/P cuff. The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE] and the survey team accepted the abatement plan on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Surveyor was able to determine onsite, the facility took the following measures to remove the immediacy: 1. Provided in-service training and video for Cardio Pulmonary Resuscitation and Basic Life Support on [DATE]. V2, Director of Nursing (DON) was in-person and V27, Registered Nurse (RN), BLS Certified, [NAME] Health Care was present via tele-monitor. 2. Inspected all onsite Ambu bags on [DATE]. V1, Administrator/RN and V2, DON. 3. Facility will maintain 2 Ambu bags on the crash cart implemented [DATE]. Confirmed with V1, Administrator/RN. 4. Began a crash cart audit checklist to be completed nightly [DATE]. 5. In serviced licensed nurses on restocking crash cart after use [DATE]. 6. In serviced licensed nurses on the crash cart checklist, replacement of faulty supplies, and notification to nursing management [DATE]. V2, DON. 7. CPR certifications training for licensed nurses on [DATE]. Confirmed. 8. Began daily audits to ensure the crash cart checklist is conducted nightly [DATE]. 9. Began random audits of the crash cart inventory supplies [DATE]. 10. The Quality Assurance Quality Improvement Team meeting is scheduled for the third Wednesday in [DATE] to further address the event. V1, Administrator confirmed.

Based on observation, interview, and record review, the facility failed to provide a safe transfer, failed to implement interventions or increase supervision after a change in condition, to prevent falls, and failed to properly secure a wheelchair in the facility van impacting 3 of 4 residents (R53, R36, and R37) reviewed for accidents in the sample of 41. These failures resulted in R53 sustaining a fracture to the left humerus which required surgical repair and in R36 sustaining a right clavicle fracture. Findings include: 1. On 6/14/21 at 10:15 AM, R53 was sitting in a wheelchair in the room. R53's left arm was in a sling. R53's emergency room notes dated 6/1/21 documents R53 was in the emergency roiagnom on [DATE] due to discomfort in the upper extremity. R53 was diagnosed with a chest wall strain, R53 was brought to the emergency room due to worsening of symptoms. These notes document R53 has a communited [MEDICATION(S)] fracture through the supracondylar left humerus. R53's progress note dated 5/4/21 documented by V1 Administrator states R53 was transferred with gait belt by the nurse (V10 Licensed Practical Nurse) during a weather emergency. R53's progress note dated 5/5/21 documents R53 was found to have a bruise to the left upper extremity. On 6/16/21 at 9:55 AM, V10 Licensed Practical Nurse stated the night of the tornado (5/4/21), the tornado siren went off. I was clearing out the dining room due to a tornado warning. R53 was sitting at the back of the dining room. R53 is a two person transfer with a gait belt. I transferred R53 by myself. It was a fast transfer. I stood and pivoted R53, I am not sure if R53's arm hit anything. R53 yelled out, Oh honey. After that a bruise developed on the inside of R53's arm, breast area, and chest. Days later, R53's left side started to swell and R53's left humerus fracture was identified. On 6/17/21 at 8:24 AM, V13 Orthopedic Surgeon stated V13 operated on R53's left arm today (6/17/21). V13 stated the fracture was already healing and looked about a month old. V13 stated the bruising of R53's left arm, breast area, and chest found on 5/5/21 is consistent with that type of fracture. V13 stated at the time of R53's fracture there would have been significant bruising and since the bruising occurred after the transfer on 5/4/21 then the transfer is the cause of the fracture. 2. R36's nurse's note dated 3/16/21 at 1:00 PM, documents, (R36) very sleepy, constantly ambulating/wandering among facility. Assisted to sitting/laying multiple (times) but refuses to remain down. Gait unsteady, small shuffling gait. Affect flat, appears very drowsy. Appetite very poor. Lab results received including (u/a) results, culture not indicated. All results received sent to (physician) for review. (Telephone order) received to discontinue [MEDICATION(S)], call if not better, check vitamin B-12 level. R36's medical record nor care plan documents any new interventions or an increase in supervision to prevent R36 from falling. On 6/17/21 at 1:15 PM, V1 Administrator stated there were no additional fall interventions or documentation that supervision was increased to prevent R36 from falling when R36 was having a change in condition on 3/16/21. Nurse's note dated 3/19/21 at 4:30 PM documents, Writer was notified that (R36) was on floor by nurse's station. (R36) was walking (and) fell down. (R36) bit lower inner lip bleeding noted cold compress held on it. (vital signs within normal limits. Neurological checks started). Nurse's note dated 3/19/21 at 11:30 PM documents, (R36) complained of pain in (R36's right) shoulder/arm. Contacted MD (medical doctor) with new orders. These notes documents that R36 was sent to the hospital for an evaluation. R36's Emergency Department Encounter dated 3/20/21 documents R36 complained of shoulder pain due to a fall. R36's x-ray results documents a comminuted fracture of middle third of the right clavicle. 3. R37's Physician's Order Sheet (POS) for 6/16/21 to 7/15/21 includes the following diagnosis: High Fall Risk. R37's Care Plan dated 12/14/20 includes the following: Fall Risk factors include unsteady balance, bowel incontinence, history of fall with injury and catheter. R37's progress note dated 4/5/21 at 3:55PM documents Resident in wheelchair. Wheelchair locked in place in van with seat belt on. Driver going downhill, had to brake and resident slid forward in wheelchair. Resident caught by seat belt under chin. Driver released seat belt and resident resting on foot pedals. Emergency Medical Services called to assist with placing resident back in chair. 3 centimeter by 2 centimeter skin tear on right first toe. No other injuries noted. On 6/15/21 at 2:30PM V2, Director of Nursing (DON) stated When (R37) fell in the van we thought there must be a part missing on the restraint in the van. We checked and it was complete. V2,and V5, Certified Nurse's Aide (CNA) demonstrated the wheel chair is locked in tracts on the floor of the van. Then a seat belt which is attached to the inside of the van is threaded under both arm rests of the wheel chair across the resident's lap. The belt is then attached to the floor of the van. At that point the seat belt has to be tightened enough to restrain the resident. If this is done it would not be possible for the resident to slip. V2 stated If the restraint is on correctly it would not be possible for a person to slip down. V1 denied there is any facility policy to cover safe resident transfer per facility van.

Based on observation, interview and record review, the facility failed to investigate, to identify the root cause and implement interventions for 1 of 5 sampled residents (R7) on the sample of 15 and one supplemental resident (R16). The facility failed to provide 15 minute supervision checks and assistance with ambulation for R7, resulting in repeated falls with injury, culminating with an Acute Fractured Right Mandible for R7. The facility failed to ensure that R16 was transferred with the use of a gait belt pursuant to his plan of care and facility policy. Findings include: The Physician order [REDACTED]. The MDS(Minimum Data Set) dated 5/17/10 states R7 is cognitively impaired, is independent with transfer/ambulation and has impaired standing/sitting balance. The facility fall assessment dated [DATE] states R7 is high risk for falls. The Care Plan revised on 3/24/09 and reviewed on 3/1/10 and 5/18/10 states R7 is at risk for falls due to "unsteady gait." The Care Plan has the following interventions identified: "Keep hall free of clutter" ; "Monitor for gait changes..." ; "Ensure that pants have no pockets or that they are sewn shut, resident has a tendency to ambulate with her hand in her pocket and gets off balance." and "Ensure proper shoes with shoelaces that are short or shoes that velcro." The facility "Resident Fall Tracking" states that R7 had falls while ambulating on the following dates: 10/8/09, 10/22/09, 10/26/09, 11/16/09, 11/24/09, 1/31/10, 2/19/10 and 5/8/10. The fall tracking states the falls related to R7 losing her balance or walking too fast. The facility "Quality Care Reporting Form" dated 5/10/10 at 7:00pm states R7 had a fall, receiving a laceration above the right eye and was sent to the hospital. The "Investigation Report for Falls" dated 5/10/10 states R7 was walking at the time of the fall. There are no new interventions to prevent falls identified in the report. The letter dated 5/17/10 about R7's fall on 5/10/10 states R7 received 4 sutures to the right eyebrow and "15 minute visual checks" were initiated. The Care Plan dated as reviewed on 5/18/10 does not list visual checks as an intervention and no record of 15 minute checks are found in the record. The "Investigation Report for Falls" dated 5/17/10 states R7's "body got ahead of her". . The facility Quality Care Reporting Form dated 6/18/10 at 1:00pm states R7 had a fall while ambulating. The "Investigation Report for Falls" dated 6/18/10 states R7 was walking to the dining room, "stumbled and fell against the nurses station". The report states the fall prevention technique in use prior to the fall was "(R7) was indepen(independent) with ambulation." The new intervention identified on the report states R7 is to be "walked stand by assist." The Care Plan reviewed on 5/18/10 does not identify R7 as needing standby assist with ambulation. The facility Quality Care Reporting Form dated 6/30/10 at 6:47am states R7 had a fall receiving a "laceration under the chin." The emergency room Report dated 6/30/10 states R7 had a 3 centimeter chin laceration requiring 3 sutures. The Quality Care Report Form states staff are to check R7's pockets to ensure they are sewn shut and "Risperdal previously D/C'd(discontinued), Dr.(Doctor) aware started Risperdal again." The "Investigation Report for Falls" dated 6/30/10 states R7 was walking, going to breakfast." The "Fall Documentation Worksheet" dated 6/30/10 asks "what is being done differently to prevent a fall right now" and documents the following answer, "Nothing, she's(R7) indep. with amb(ambulation)." The report states the fall prevention technique in use prior to the fall was "She's(R7) ambulating." The section of the report asking if the fall prevention technique was in place states "She's not cognitive enough to ask 4(for) assist." There is no analysis of the fall documented. The facility Quality Care Reporting Form dated 7/10/10 at 10:10am states R7 had a fall. The "Investigation Report for Falls" dated 7/10/10 states R7 was "? walking." The "Fall Documentation Worksheet" dated 7/10/10 asks "what is being done differently to prevent a fall right now" and documents the following answer, "telling her(R7) to slow down." The report states the fall prevention technique in use prior to the fall was "She's(R7) ambulatory." The new intervention identified is "(R7) will walk too fast at times. (R7) has to be remembered to slow down." The Care Plan dated as reviewed 5/18/10 does not identify the intervention to tell R7 to slow down. The Medication Administration Record dated 4/16-5/15/10 states R7's Risperdal was discontinued on 4/27/10. There is a physician's orders [REDACTED]. E2, DON, stated on 10/15/10 at 11:00 am that R7's Risperdal was not restarted prior to 7/13/10. The facility Quality Care Reporting Form dated 7/16/10 at 11:15am states R7 fell outside the bathroom door. The "Investigation Report for Falls" dated 7/16/10 states R7 was "walking" and there was a wet floor sign and linen cart in the hall. The form documents R7 was sitting on the floor on a wet floor sign. The "Fall Documentation Worksheet" dated 7/16/10 asks "what is being done differently to prevent a fall right now" and documents the following answer, "keep the hall clear of obstacles." The facility Quality Care Reporting Form dated 7/24/10 at 5:45am states R7 fell in the lobby. The "Fall Documentation Worksheet" dated 7/24/10 asks "what is being done differently to prevent a fall right now" and "Why did the fall occur." There is nothing written in the blanks for either question. There are no new interventions identified and no analysis of the fall. The facility Quality Care Reporting Form dated 7/26/10 at 6:30am states R7 fell in the dining room. The "Fall Documentation Worksheet" dated 7/26/10 asks "what is being done differently to prevent a fall right now"and states a urine culture. The worksheet asks "Why did the fall occur" and states "uncertain." There are no new interventions identified and no analysis of the fall. Neither form documents an analysis of the fall. The physician progress notes [REDACTED]." The [DIAGNOSES REDACTED]." The physician's orders [REDACTED]. Give Ativan 2mg(milligrams) 1 time only prior to scan." The facility Quality Care Reporting Form dated 8/2/10 at 8:50am states R7 fell in the dining room. The "Fall Documentation Worksheet" dated 8/2/10 asks "what is being done differently to prevent a fall right now." There is nothing written in the blank to answer the question. The worksheet asks "Why did the fall occur" and states "She's indep(independent)." The statement dated 8/2/10 written by E10, CNA(Certified Nurse Aide), stated, "(R7) bent over to pick up bib stumbled and fell to floor...." There are no new interventions identified. The Incident Report Form dated 8/5/10 states R7 had a fall on 8/3/10 at 7:30pm. The report states R7 was on the floor beside her room door and was sent to the hospital. The hospital "Patient Visit Information" dated 8/3/10 states R7 has a [DIAGNOSES REDACTED]." The Emergency Department Transfer dated 8/3/10 states, "Nursing home reports (R7) had Ativan today before CT(computerized tomography) scan she was having due to a recent fall. (R7) fell again this evening, nursing home reports it was an unwitnessed fall....." There is no investigation or analysis of R7's fall. The facility Quality Care Reporting Form dated 8/4/10 at 7:45am states R7 fell in the dining room hall. The "Fall Documentation Worksheet" dated 8/4/10 states R7 was ambulating and "lost her balance." The worksheet states a lap cushion in the wheelchair will be implemented. E6, Corporate RN(Registered Nurse) and E2, DON(Director of Nurses's) stated on 10/13/10 at 2:00pm that "back in May (R7's) body got ahead of her." E6 stated R7's Risperdal had been discontinued and that made a difference on R7 as she "thought so fast her body couldn't keep up." E6 stated R7's Risperdal was restarted. E2 confirmed the care plan did not address doing 15 minute visual checks, ambulating with stand by assist or to tell R7 to slow down. E6 confirmed there was no analysis documented for R7's fall on 6/30/10, 7/24/10 and 8/3/10. E6 stated R7 was ambulating too fast and that's why she fell on [DATE]. E6 stated she knew they investigated R7's fall of 8/3/10 but was unable to find the investigation. 2. The October physician's orders [REDACTED]. The Fall Risk assessment dated [DATE] indicates R16 is a high risk for falls due to loss of balance when standing or walking. R16 was being ambulated from the dining room on 10/12/2010 at 12:55 PM by E2, Director of Nursing. E2 was not using a gait belt to ambulate R16. At one point during the ambulation R16 fell to his knees. It took four staff members using a gait belt to get R16 up and into a chair. The facility policy titled "Transfer Belts/Gait Belts" states "...All certified nursing assistants and licensed nursing personnel engaged in the lifting and transferring of residents will use gait belts... GAIT BELTS ARE MANDATORY..."

Based on observation, interview and record review the facility failed to make an appointment for the Wound Clinic in a timely manner and failed to use proper technique during a pressure ulcer treatment for 1 of 6 sampled residents with pressure ulcers(R5), resulting in a deterioration of R5's pressure ulcers. There was a total sample of 15 residents. Findings include: The October 2010 Physician order [REDACTED]. The Minimum (MDS) data set [DATE] and 9/21/10 state R5 requires total assist with hygiene, bed mobility, is tube fed and has 2 Stage 4 pressure ulcers. The facility skin assessment dated [DATE] states R5 is at high risk for skin breakdown. On 9/17/10 Z2, Wound Nurse, documented R5's coccyx had an open area that was "full thickness" measuring 1.0 by 0.8 cm(centimeter) by 0.2cm depth. The left hip was full thickness, measuring 1.0cm by 1.0cm by 0.2cm depth with undermining 2.0cm from 3:00 o'clock. The physician's orders [REDACTED].for wound." The Nurse's Notes dated 9/20/10 state staff will fax E5, Transportation Coordinator, in the am to make an appointment with Z1. The Nurse's Notes dated 9/21/10 state E5 was called to make a appointment for R5's "bottom." The Nurse's Notes dated 9/24/10 at 1:00pm state E5 was continuing to try to set up an appointment with the Wound Clinic, but no appointment had been made yet. There is no mention of an appointment being made or follow-up with E5 in the Nurse's Notes from 9/25-10/14/10. E8, Care Plan Coordinator, stated on 10/14/10 at 9:30am she did not see any follow-up with E5 on R5's Wound Clinic appointment. E8 then placed a call to E5 about the appointment. E9, LPN, stated on 10/14/10 at 11:55am that R5's Wound Clinic Appointment had not been made yet because of "transportation issues." E5, Transportation Coordinator, stated on 10/13/10 at 12:30pm that she made an appointment today(10/14) for R5 to see Z1, Physician, at the Wound Clinic on 10/19/10 at 9:30am. When asked why it took so long for her to make the appointment for R5, E5 stated, she was trying to figure out where Z1 would see R5, either in the office or the Wound Clinic. E5 stated the nurses told her R5 couldn't safely be transported in a wheelchair. When asked why the whole process took so long(9/20-10/14/10), E5 stated, "I really have no excuse, I should have followed through on it." The facility "Weekly Wound Tracking" contains the following information: 9/22/10-The Stage 4 coccyx area measured 4cm by 2cm with moderate drainage. There was a second area Stage 2 at the coccyx measuring 1cm by 0.2cm with 0.2cm depth. The Stage 4 left hip area measured 2.2cm by 1.2cm with depth of 0.2cm and minimal drainage. 9/29/10- The Stage 4 coccyx area measured 2.4cm by 1.5cm with 0.5cm depth with moderate drainage. The second coccyx area was healed. The Stage 4 left hip area measured 3cm by 2cm with 0.5cm depth with moderate drainage. 10/7/10-The Stage 4 coccyx area measured 1.8cm by 2.2cm with 0.2cm depth. There is no mention of a dark discoloration on the posterior rim of the coccyx open area. The Stage 4 left hip area measured 2.6cm by 1.2cm with 0.4cm depth. 10/14/10-The Stage 4 coccyx area measured 4cm by 1.8cm with a 0.2cm depth. The Stage 4 left hip measured 2.2cm by 2.8 with a 0.6cm depth. There is another open area on the left hip measuring 0.7cm by 0.3cm with a depth of 0.1cm. On 10/13/10 at 10:15am E10, CNA(Certified Nurse Aide) checked R5's coccyx and there was no dressing in place. R5 was incontinent of bowel at the time of the observation. E10 provided urinary catheter care for R5, as well as bowel incontinence care. E10 stated at the time of the observation that there was no dressing on R5's coccyx when she cleaned her at 9:30am. At 10:55am when asked if she found a dressing in R5's bed when cleaning the bowel incontinence E10 stated she had taken R5's dressing off the coccyx pressure ulcer when she cleaned him at 9:30am because it had stool on it. E10 stated she did not tell the nurse the dressing was soiled and had been removed. At 10:55am E7, LPN(Licensed Practical Nurse) cleaned R5's coccyx pressure ulcer with normal saline. R5's coccyx pressure ulcer had a dark area on the rim of the posterior end of the open area. E7 stated at the time of the observation that she had seen the area 2 weeks ago and the dark area was not present. E7 then applied Hydrogel AC and started to apply a Puricol 2 by 2 to the ulcer. The surveyor stopped E7 as she was starting to apply the Puricol, and asked if that was stool (feces) right next to the pressure ulcer. E7 stated it was stool and asked E10 to provide incontinence care to R5. At 11:10am E7 cleaned R5's coccyx pressure ulcer with normal saline. The area right next to the pressure ulcer that had been covered with stool was open. E7 confirmed at the time of the observation that the area that had stool on it, right next to the coccyx pressure sore was actually open. E7 stated the area used to be open and she measured it as a second coccyx area, but it had healed.