Every finding on record at The Haven of Bement.

Based on observation, interview, and record review the facility failed to protect the residents' right to be free from verbal and physical abuse by another resident for two of four residents (R18, R23) reviewed for abuse on the sample list of 27. This failure resulted in R23 experiencing physical pain, distress, and fear after R44 hit R23 in the stomach on three separate occasions. 1. R23's Census Detail and Medical Diagnoses List dated 3/10/26 documents R23 was admitted to the facility 11/3/25 with medical diagnoses including Cerebral Vascular Accident with Physical Symptoms, Quadriplegia, Anxiety, and Contractures. R23's Minimum Data Set Assessment (MDS) dated [DATE] documents R23 is totally dependent on staff for all daily living activity including eating, oral hygiene, dressing, grooming, personal hygiene, bathing, mobility in a specialized wheelchair, and transfers between the bed and wheelchair. This MDS documents R23 is non-verbal and communicates with yes and no responses by nodding or shaking his head. This MDS documents R23 is cognitively intact with a brief interview rating of 15 out of a possible 15. R44's Census Detail and Medical Diagnoses List dated 3/10/26 documents R44 was admitted to the facility 7/22/25 with medical diagnoses including Personality Disorder, Bipolar Disorder, Schizoaffective Disorder, Major Recurrent Depression, Anxiety, Stimulant Abuse, and Cannabis Use. R44's MDS dated [DATE] documents R44 requires only supervision to accomplish all daily living activity, is ambulatory throughout the facility, uses tobacco, and makes attempts to leave the building without notifying staff. R44's Nursing Progress Note dated 1/30/26 documents, On 1/30/26 (R44) was arrested for allegations of hitting his non-verbal roommate. The roommate indicated that (R44) had hit him in the stomach on 3 occasions due to (R44) not getting his way within the facility, (Smoking/Leaving). R23's Nursing Progress Note dated 1/26/26 documents, Was reported resident had decreased appetite yesterday, fed by staff. R23's Nursing Progress Note dated 1/28/26 documents, Resident had complained of upset stomach earlier this shift and had refused breakfast. R23's Nursing Progress Note dated 1/29/26 documents, CNA (Certified Nursing Assistant, unidentified) brought resident for this writer to talk with him and to do assessment on him. Resident was afraid to return to his room r/t (related to) his roommate. After further evaluation it was found that resident made accusation that his roommate assaulted him. Resident moved to safe place in facility. Resident was assessed from head to toe for any marks or bruises on him. There were no bruises or any markings from resident of an apparent assault. Resident was able to communicate with yes or no questions to answers by shaking his head yes or no. R23's Nursing Progress Note dated 1/30/26 documents, On 1/29/26 (R23) indicated his roommate hits him in the stomach. One hit each time with a closed fist and walks away. He doesn't say a word. This has happened three times in the last couple of weeks. (R23) indicated this seems to happen when his roommate is upset with something within the facility. (R23) and his roommate were immediately separated. (R23) was moved to the other hall of the facility, the cops (police) were called, the incident was investigated, and the roommate was removed from the facility in the custody of the (local) Police Department. R44 was not available for observations nor interview due to being a discharged resident. On 3/10/26 at 3:47 PM, R23 communicated with yes and no responses by movement of his head and eyes. R23 communicated he had experienced problems with his roommate (R44) who was punching him. R23 communicated it hurt and made him feel bad when R44 punched him. R23 communicated he was afraid of his roommate and the facility staff moved him (R23) to a different room. R23 confirmed R44 no longer resides in the facility. R23 was in bed watching a video device and besides his head movements, was only able to move his left arm approximately 4 inches. R23's Care Plan problem area dated 2/11/26 documents R23 is at risk of abuse: roommate was punching R23 in the stomach at night three times. R44's Involuntary Discharge Notice dated 1/30/26 documents R23 reported being in fear for his personal safety and exhibited signs of fear and distress observed by facility staff. On 3/12/26 at 9:40 AM, V1, Administrator, stated R44 had been arrested and charged with felony aggravated assault due to R23 being handicapped. The facility's Final Investigative Report to the State Agency (undated) documents R23 had complained of a stomachache on 1/29/26 and that was when R23 communicated that his roommate had struck him. This report documents that R44 was arrested by local law enforcement and R44 would not be returning to the facility. The (local) Police Department Incident Report dated 1/30/36 documents V21, Police Officer, responded to the facility, interviewed V1 Administrator, V22 Registered Nurse, V10 Social Services Director, all of whom had interviewed R23, and then interviewed R23, all with his body camera recording. V21 documented R23 confirmed the allegations of R44 punching him on three separate occasions and had fear of reprisal from R44 for reporting the assault if R44 stayed as a resident in the facility. V21 went on to document he had a previous experience with R44 in 2025 when R44 walked out of this same facility and threatened to be violent with staff if they tried to stop him from leaving. V21 documented he followed R44 for 10 blocks in his squad car, while in full uniform, and finally was able to take R44 into custody, with assistance of a deputy, as R44 walked down the middle of a state route. The county courtroom documentation dated 3/12/26 confirms R44 was arraigned on charge of aggravated felony assault. 2. R18's Minimum Data Set (MDS) dated [DATE] documents R18 has moderate cognitive impairment. R18's current Diagnoses List documents Major Depressive Disorder, Recurrent, In Full Remission. R15's MDS dated [DATE] documents R15 is cognitively intact. R15's Current Diagnoses List documents Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Initial Report dated 3/10/26, documents Yesterday (3/9/26), a (Private Company) staff member (V7,Psychotherapist/ Licensed Clinical Social Worker) brought to my (V1) attention that she heard (R15) call (R18) a name. The residents were moved to separate rooms at that time. (R18) expressed concerns to a surveyor regarding her former roommate, (R15). (R18) described feeling fearful of (R15), citing an incident where (R15) called her derogatory names the previous week, which (R18) was too afraid to report at the time. (R18) also noted that (R15) regularly uses offensive language and adopts a confrontational tone in her interactions with others. On 3/10/26 at 2:15 pm V10, Social Service Director (SSD) stated V7, Psychotherapist/ Licensed Clinical Social Worker (LCSW) came to V10 and reported that R15 and R18 had a verbal altercation yesterday (3/9/26). V10 stated I directed her to report to (V1, Administrator/Abuse Prevention Coordinator), and she did. On 3/10/26 at 3:20 pm V9, Certified Nursing Assistant (CNA) stated We all heard it. It was (R15) yelling at (R18) at first. (R18) was pretty upset, and (R15) was loud. (R18 and R15) then began to [NAME] back and forth. I went into their room and de-escalated things. As I said, (R18) was pretty upset initially and (R15) was still trying to [NAME] with her (R18). Once everything calmed down, I went and told the Administrator and one of the other CNAs told the nurse. This all happened about a week ago (prior to 3/09/26 witnessed verbal abuse allegation reported by V7 LCSW and V10, LCSW report). I reported it immediately after I calmed down the situation. On 03/10/2026 at 10:03 am R18 stated she had been R15's roommate and was moved to a separate room after R15 yelled, cussed, and used the f*** (expletive) word repeatedly. R18 stated she is afraid of R15 and did not want to give R15's name because she feels R15 would retaliate. R18 also stated this occurred about a week ago. R18 said She (R15) scares me. On 3/10/26 at 2:20 pm V1, Administrator/ Abuse Prevention Coordinator stated (V7, LCSW/Psychotherapist) was in the building doing rounds and reported that (R15) called (R18) a d*** a** (expletive). I thought of it as more of a grievance, though I did not write it on the grievance log. I recognize, it should have been handled as a potential abuse issue. The facility undated Abuse Prevention Policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines).

Based on interview and record review the facility failed to ensure quarterly Quality Assurance meetings were held, and failed to ensure the Director of Nursing attended the Quality Assurance meetings. This failure affects all 36-residents residing in the facility.Findings include:The Quarterly Quality Assurance (QA) Committee Signature Sheet dated 3/12/2025 fourth quarter 2024 documents a QA meeting was held on that date.The Quarterly Quality Assurance Committee Signature Sheet dated 7/17/2025 first quarter 2025, (four months and 5 days after the above meeting documented as 2024 fourth quarter) documents a QA meeting was held on that date.The Quarterly Quality Assurance Committee Signature Sheet dated 12/30/25 second quarter 2025, (five months and 13 days after the above meeting documented as 7/17/25 first quarter) documents a QA meeting was held on that date. The signature sheet does not document the Director of Nursing/Infection Preventionist attended the 12/30/25 quarterly meeting.The Quarterly Quality Assurance Committee Signature Sheet dated 01/28/26 fourth quarter 2025 documents a QA meeting was held on that date. The signature sheet does not document the Director of Nursing/Infection Preventionist attended the 01/28/25 quarterly meeting.03/12/26 at 12:20 pm V1, Administrator reviewed the quarterly signature sheets and confirmed QA quarterly meetings were not conducted in a timely manner for 2025, as required and V23, Previous Director of Nursing did not attend the 12/30/25 or 1/28/26 meetings. The facility 671 form, Long Term Care Facility application for Medicare and Medicaid dated 3/12/26 documents 36 residents reside in the facility.The facility policy GENERAL QAPI (Quality Assurance and Performance Improvement) Program dated as September 2022 documents the following: GENERAL:To ensure that all services provided by the Facility to residents meet quality standards.RESPONSIBLE PARTY:The Facility implements and maintains an ongoing, Facility-wide Quality Assurance and Performance Improvement (QAA) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems.POLICY:I. GoalsA. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety.B. To reinforce and build upon effective systems of services and positive care measures.C. To provide a structure and process to correct identified quality deficiencies.D. To establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcomes.E. To help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability; andF. To establish a system and process to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.II. AuthorityA. The Governing Body of the Facility shall be ultimately responsible for the QAPI Program.B. The Administrator is responsible for ensuring that the Facility's QAPI Program complies with local, state, and federal regulatory requirements.C. Attendees: Administrator, DON, Medical Director (or designee), Infection Preventionist, Social Service Director, Business Office Manager, Housekeeping Director, MDS ( Minimum Data Set Coordinator), Other optional attendees: Activity Director, Food Services Director, Therapy Director, Registered Dietician, Lab, Pharmacy.III. ImplementationA. The Quality Assessment & Assurance (QAA) Committee oversees implementation of the QAPI Program.i. The Quality Assessment and Assurance Chairperson, or designee, coordinates the QAA Committee activities.B. The QAA Committee will make good faith attempts to identify and correct quality deficiencies.C. The QAA committee meets at least quarterly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments.D. The QAA Committee oversees and authorizes QAPI activities, including data-collection tools, monitoring tools, and the effectiveness of QAPI activities.E. The QAA Committee approves any corrective actions, including changes in policies and/or procedures, employment practices, standards of care, etc., and shall also monitor all corrective actions for effectiveness and/or the need for alternative measures.F. Individual department managers will use quality indicators for programs and services in which they are involved, and which affect their function.G. The Facility will develop and implement a written QAPI Plan that will be reviewed and revised annually, or more frequently as needed.H. Information regarding QAPI activities is confidential and is disclosed only in accordance with applicable laws and regulations.I. Department managers submit their reports to the QAA Committee.IV. EvaluationA. The Facility will have effective lines of communication to obtain feedback from staff, residents, and families.B. The Facility evaluates the effectiveness of its QAPI Program at least annually and presents their conclusions to the Governing Body for review.V. CoordinatorA. The QAA Chairperson attends and/or reviews minutes of meetings of other committees or departments as needed.B. The QAA Chairperson helps other sub-committees, individuals, and departments develop quality indicators, monitoring tools, criteria, to assessment methodologies, and identify and evaluate concerns impacting resident care and safety.C. The QAA Chairperson acts as a liaison among committees, individuals, and departments regarding QAPI activities.VI. Focus - The following areas are monitored for quality and appropriateness of resident care and trends in performance and outcomes:A. Resident Rights B. Dental ServicesC. Admissions, Transfers, and Discharges D. Pharmacy Services, Medication ManagementE. Resident Behavior and Facility Practices F. Infection ControlG. Physical Environment H. Quality of LifeI. Administration J. Quality of Care, Nursing ServicesK. Nurse Aide Training L. Activity ServicesM. Disaster Preparedness N. SafetyO. Staff Development P. Dietary ServicesQ. Medical RecordsR. Rehabilitative Services S. Physician ServicesVII. Each department or service reviews its approaches to monitoring performance and outcomes and provides a summary of its findings to the QAA Committee no less than annually.VIII. Performance Improvement ProjectsA. As a part of the Facility's performance improvement activities, the Facility will conduct distinct performance improvement projects.B. The number and frequency of performance improvement projects (PIPs) will reflect the scope and complexity of the Facility's services and available resources, consistent with the Facility Assessment.C. Improvement projects must include projects that focus on high risk or problem-prone areas identified through data collection and analysis through the QAPI Program.One PIP must be completed at least annually.

Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use, systems to monitor antibiotic outcomes, resistance, and adverse events, and use of standardized tools and criteria to assess resident infections. This failure has the potential to affect all 36 residents in the facility.Findings include:On 3/11/2026 at 1:58AM, V2 (Regional Nurse Consultant) provided the facility antibiotic use and stewardship logs for resident infections occurring between January 2025 through March 2026. V2 reported the logs documented all of the facility antibiotic stewardship information for resident infections during the same period. On 1/8/2025 at 3:12PM, V1 (Administrator) reported the facility did not have any additional information related to their antibiotic stewardship or infection control program than the above records documented. On 3/13/2026 at 2:00pm, the above logs did not document what symptoms residents experienced signifying a potential infection, the onset of resident signs and symptoms of potential infections, the resolution of resident symptoms of infection, if any nationally recognized and standardized criteria were used to justify and guide antibiotic use, or if response to treatment was monitored to determine if the antibiotic was effective and still indicated or adjustments should be made. The logs do not document when or if an antibiotic therapy was changed when initially prescribed on an empirical basis by a medical provider or if residents experienced adverse events subsequent to antibiotic use in the facility. The facility Antibiotic Stewardship Program Guideline (4/29/2025) documents the purpose of the facility antibiotic stewardship program is to improve anti-microbial stewardship practices and to monitor outcomes and anti-microbial use. The facility Long-Term Care Facility Application for Medicare and Medicaid (3/13/2026) documents 36 residents reside in the facility.

Based on interview and record review the facility failed repeatedly to report allegations of resident-to-resident verbal abuse, to the Illinois Department of Public Health. This failure affects two of four residents (R15 and R18) reviewed for abuse on the sample list of 27.Findings include:R18's Minimum Data Set (MDS) dated [DATE] documents R18's Brief Interview of Mental Status (BIMS) score as 12 out of a possible 15, indicating moderate cognitive impairment.R15's MDS dated [DATE] documents R15's BIMS score as 15 out of a possible 15, indicating no cognitive impairment.On 03/10/2026 at 10:03 am R18 stated approximately one week ago, R15 cussed and yelled at her and she was afraid of R15. R18 then stated R18 had been R15's roommate and was moved to a separate room after R15 yelled, cussed and used the f*** (expletive) word repeatedly. R18 stated she is afraid of R15 and did not want to give R15's name because she feels R15 would retaliate. R18 said She (R15) scares me.On 3/10/26 at 10:40 am V1, Administrator/Abuse Prevention Coordinator notified by this surveyor, of the verbal abuse allegation of R18, by R15. V1 stated she was not aware of the verbal abuse allegation and will follow her abuse prevention policy and report to Illinois Department of Public Heath (IDPH) and initiate an investigation. V1 also stated R15, and resident R18 were relocated to separate rooms, partly because the previous room is being renovated and partially due to a few staff members reported the residents were not getting along. V1 stated she cannot recall who the staff were that said they were not getting along, or if not getting along had anything to do with the allegation of verbal abuse.On 3/10/26 at 2:10 pm V1, Abuse Prevention Coordinator/Administrator clarified the above interview and identified the two staff that reported the resident to resident altercation between R15 and R18 were V10, Social Service Director (SSD), and V9, Certified Nursing Assistant.On 3/10/26 at 2:15 pm V10, SSD stated that V7, Psychotherapist/ Licensed Clinical Social Worker (LCSW) came to V10, and reported that R15 and R18 had a verbal altercation yesterday (3/9/26). V10 stated I directed her (V7, LCSW) to report to (V1, Administrator/Abuse Prevention Coordinator), and she (V7, LCSW) did.On 3/10/26 at 2:20 pm V1, Administrator/ Abuse Prevention Coordinator was interviewed again regarding R15 verbal abuse of R18. V1 stated (V7, LCSW/Psychotherapist) was in the building doing rounds (3/9/26) and reported that (R15) called (R18) a d*****s (expletive). V1 stated she did not initiate an investigation, did not talk to the residents or staff, and did not report to Illinois Department of Public Health (IDPH). V1 confirmed this allegation should have been investigated and reported to determine what exactly happened. V1 stated she is sending a report to IDPH now and has started her investigation today, 3/10/26.On 3/10/26 at 3:20 pm V9, Certified Nursing Assistant (CNA) said We all heard it (V9, CNA and other unidentified Agency staff). It was (R15) yelling at (R18) at first. (R18) was pretty upset, and (R15) was loud. (R18 and R15) then began to [NAME] back and forth. I went into their room and de-escalated things. As I said, (R18) was pretty upset initially and (R15) was still trying to [NAME] with her (R18). Once everything calmed down, I went and told the Administrator and one of the other CNAs told the nurse. I can't remember who the nurse was that day. This all happened about a week ago (prior to the 3/09/26 incident reported by V7 LCSW and V10). I reported it immediately after I calmed down the situation. No one interviewed me. I reported to (V1) the administrator, that is all. The residents did not get moved to separate rooms until yesterday (3/9/26).The facility Illinois Department of Public Health (IDPH) Initial report dated 3/10/26, by V1, Administrator/Abuse Prevention Coordinator documents Yesterday (3/9/26), a (Private Company) staff member (V7, Psychotherapist/ Licensed Clinical Social Worker) brought to my attention that she (V7) heard (R15) call (R18) a name. The residents were moved to separate rooms at that time (3/9/26). (R18) expressed concerns to a surveyor regarding her former roommate, (R15). (R18) described feeling fearful of (R15), citing an incident where (R15) called her derogatory names the previous week, which (R18) was too afraid to report at the time. (R18) also noted that (R15) regularly uses offensive language and adopts a confrontational tone in her interactions with others. During my interview, (R18) confirmed her fear that (R15) might yell at her again. When asked about the source of her fear, (R18) recalled an earlier conversation in which (R15, sic), (clarified as R18) threatened to inform this writer that (R15) was smoking and allowing a boy to sleep in their room-accusations that were false. (R18) is adamant that they (this) did happen. (R15) does not have access to cigarettes and no boy has slept in her room. When interviewed (R15) stated she does not smoke and the only foul language she uses is when she is joking around with the staff. (R18) and (R15) will no longer be roommates.The facility undated Abuse Prevention Policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.This same policy includes:This will be done by: Filing accurate and timely investigative reports. DEFINITIONSThe following definitions are based on federal and state laws, regulations and interpretive guidelines. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines).EXTERNAL REPORTING1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated.

Based on interview and record review the facility failed repeatedly to investigate reported allegations of witnessed resident-to-resident verbal abuse and failed to remove the alleged perpetrator, in a timely manner. This failure affects two of four residents (R15 and R18) reviewed for abuse on the sample list of 27.Findings include:R15 and R18's Current Census records document R15 and R18 shared a bedroom from 01/01/26 until 3/09/26.R18's Minimum Data Set (MDS) dated [DATE] documents R18's Brief Interview of Mental Status (BIMS) score as 12 out of a possible 15, indicating moderate cognitive impairment.R15's MDS dated [DATE] documents R15's BIMS score as 15 out of a possible 15, indicating no cognitive impairment.On 03/10/2026 at 10:03 am R18 stated she had been R15's roommate and was moved to a separate room after R15 yelled, cussed and used the f*** (expletive) word repeatedly. R18 stated she is afraid of R15 and did not want to give R15's name because she feels R15 would retaliate. R18 said She (R15) scares me.On 3/10/26 at 10:40 am V1, Administrator/Abuse Prevention Coordinator was notified by this surveyor, of the verbal abuse allegation of R18, by R15.On 3/10/26 at 2:10 pm V1, Abuse Prevention Coordinator/Administrator confirmed the resident to resident verbal abuse allegation of R18 by R15 was reported to her previously by V10, Social Service Director (SSD) on 3/9/226 and V9, Certified Nursing Assistant.On 3/10/26 at 2:15 pm V10, SSD stated that V7, Psychotherapist/ Licensed Clinical Social Worker (LCSW) came to V10, and reported that R15 and R18 had a verbal altercation, yesterday (3/9/26). V10 stated I directed her (V7, LCSW) to report to (V1), and she (V7, LCSW) did.On 3/10/26 at 2:20 pm V1, Administrator/ Abuse Prevention Coordinator stated (V7) was in the building doing rounds and reported that (R15) called (R18) a d*** a** (expletive). I thought of it as more of a grievance, though I did not write it on the grievance log. I recognize it should have been handled as a potential abuse issue. I did not document anything in either chart. I don't see that anyone else did (document) either. V1 also stated she relocated the residents to a different room yesterday, 3/9/26 though this was reported by V9, CNA last week. V1 stated she did not initiate an investigation, did not talk to the residents or staff, and did not report to Illinois Department of Public Health (IDPH). V1 confirmed this allegation should have been investigated and reported to determine what exactly happened.On 3/10/26 at 3:20 pm V9, Certified Nursing Assistant (CNA) said she and a couple of other unidentified Agency staff all heard R15 yelling at R18 at first, and R18 was pretty upset. V9, CNA also stated she reported immediately to V1, Administrator/Abuse Prevention Coordinator last week (unidentified date), immediately after she calmed the residents down. V9 stated this all happened about a week ago (prior to 3/09/26 witnessed verbal abuse allegation reported by V7 LCSW and V10, SSD). I reported it immediately after I calmed down the situation. No one interviewed me. I reported to (V1) the administrator, that is all. The residents did not get moved to separate rooms until yesterday (3/9/26).The facility Illinois Department of Public Health (IDPH) initial report dated 3/10/26, written by V1 documents the following: Yesterday (3/9/26), a (Private Company) staff member (V7,Psychotherapist/ Licensed Clinical Social Worker) brought to my (V1) attention that she heard (R15) call (R18) a name. The residents were moved to separate rooms at that time (3/9/26). (R18) expressed concerns to a surveyor regarding her former roommate, (R15). (R18) described feeling fearful of (R15), citing an incident where (R15) called her derogatory names the previous week, which (R18) was too afraid to report at the time. (R18) also noted that (R15) regularly uses offensive language and adopts a confrontational tone in her interactions with others. During my interview, (R18) confirmed her fear that (R15) might yell at her again. When asked about the source of her fear, (R18) recalled an earlier conversation in which (R15, sic), (clarified as R18) threatened to inform this writer that (R15) was smoking and allowing a boy to sleep in their room-accusations that were false. (R18) is adamant that they (this) did happen. (R15) does not have access to cigarettes and no boy has slept in her room. When interviewed (R15) stated she does not smoke and the only foul language she uses is when she is joking around with the staff. (R18) and (R15) will no longer be roommates.The facility undated Abuse Prevention Policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. DEFINITIONSThe following definitions are based on federal and state laws, regulations and interpretive guidelines.Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines}. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CFR 483.5). Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines).The same Abuse Prevention policy documents:VI. Protection of ResidentsThe facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents.The same Abuse Prevention policy documents:VII. Internal Investigation1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected.2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.The same Abuse Prevention policy documents:4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview able. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed.

Based on interview and record review, the facility failed to provide timely assistance for incontinence cares to four residents (R11, R12, R22, R35) of four reviewed for Activities of Daily Living in the sample list of 27 residents. Findings include:R35's Medical Diagnosis sheet (3/11/2026) documents diagnoses including Multiple Sclerosis (chronic neurological disease affecting vision, mobility, and cognition), Obstructive And Reflux Uropathy (a blockage that prevents normal urine flow), Prostatic Hyperplasia With Lower Urinary Symptoms, Muscle Wasting And Atrophy, Unsteadiness on Feet, Reduced Mobility, Abnormal Gait And Mobility, and Major Depressive Disorder. R35's Resident Assessment (1/2/2026) documents R35 is cognitively intact. The same assessment documents R35 has bilateral impairment in upper and lower extremity range of motion, is completely dependent on staff assistance for toileting hygiene, and does not have behaviors, delusions, or hallucinations.R35's Care Plan (1/5/2026) documents facility staff will check R35 frequently and assist with toileting as needed. The same record documents R35 has moisture associated skin damage to R35's coccyx and may be predisposed to skin impairment related to incontinence. On 3/10/2026 at 10:38AM, R35 reported not using an incontinent brief but using a bedpan and urinal for toileting while in bed. R35 reported activating R35's call light for staff to provide a bedpan or urinal and sometimes having to wait well over 30 minutes for staff to respond to R35's call light. R35 reported sometimes having toileting accidents while waiting for staff assistance. R35 sarcastically stated having the toileting accidents makes him feel real good. On 3/11/2026 at 11:20AM, V12 (Licensed Practical Nurse) reported V12 has received complaints from R35 about evening and night staff delays in responding to R35's call light. V12 reported R35 stated staff doesn't come quick enough responding to R35's call light. V12 reported evening and night shifts in the facility do have less direct care staff to take care of residents than during the daytime. On 3/11/2026 at 1:09PM, R11, R12, and R22 all reported having toileting accidents while waiting on facility staff to respond to call lights. The facility's call light policy (2008) documents facility staff are to answer a resident's call light as soon as possible.

Based on interview and record review the facility failed repeatedly to maintain complete and accurate medical records by failing to document incidence of resident to resident altercations. This failure affected two of four residents ( R15 and R18) reviewed for abuse on the sample list of 27.Findings include:On 03/10/2026 at 10:03 am R18 stated she had been R15's roommate and was moved to a separate room after R15 yelled, cussed, and used the (f*** expletive) word, repeatedly. R18 stated she is afraid of R15 and did not want to give R15's name because she feels R15 would retaliate. R18 also stated this occurred about a week ago. R18 said She (R15) scares me.On 3/10/26 at 3:20 pm V9, Certified Nursing Assistant (CNA) stated sometime last week V9 and unidentified agency staff all heard R15 yelling at R18 and R18 was pretty upset and (R15) was loud. V9 stated R18 and R15 then began to [NAME] back and forth. V9 stated the agency staff notified the unidentified nurse and V9, CNA notified V1, Administrator/Abuse Prevention Coordinator that same day after calming residents down. There is no documentation of the allegation of verbal abuse in R15 or R18's medical records. The facility Illinois Department of Public Health (IDPH) initial report dated 3/10/26, documents reports made by V9, Certified Nursing Assistant, approximately one week ago per interview, and by V7, Psychotherapist/ Licensed Clinical Social Worker on 3/9/26. The report documents allegations of verbal abuse reported to Illinois Department of Public Health (IDPH) dated 3/10/26 and written by V1. The report documents the following: Yesterday (3/9/26), a (Private Company) staff member (V7, Psychotherapist/ Licensed Clinical Social Worker) brought to my attention that she (V7) heard (R15) call (R18) a name. The residents were moved to separate rooms at that time (3/9/26). (R18) expressed concerns to a surveyor regarding her former roommate, (R15). (R18) described feeling fearful of (R15), citing an incident where (R15) called her derogatory names the previous week, which (R18) was too afraid to report at the time. (R18) also noted that (R15) regularly uses offensive language and adopts a confrontational tone in her interactions with others. During my (V1) interview, (R18) confirmed her fear that (R15) might yell at her again. When asked about the source of her fear, (R18) recalled an earlier conversation in which (R15, sic), (clarified as R18) threatened to inform this writer that (R15) was smoking and allowing a boy to sleep in their room-accusations that were false. (R18) is adamant that they (this) did happen. (R15) does not have access to cigarettes and no boy has slept in her room. When interviewed (R15) stated she does not smoke and the only foul language she uses is when she is joking around with the staff. (R18) and (R15) will no longer be roommates.On 3/10/26 at 2:20 pm V1, stated (V7, LCSW/Psychotherapist) was in the building doing rounds and reported that (R15) called (R18) a d*** a**, (expletive). I thought of it as more of a grievance, though I did not write it on the grievance log. I recognize, it should have been handled as a potential abuse issue. I did not document anything in either chart. I don't see that anyone else did (document) either. At this time V1 reviewed R15 and R18's electronic medical record notes and confirmed V10, Social Service Director, and V7, Psychotherapist/ Licensed Clinical Social Worker nor any nurses had documented any abuse allegation or monitoring.R15's Type: Social Service Note Focus: Effective Date: 3/9/2026 at 11:54, documented by V1, Administrator/Abuse Prevention Coordinator documents this late note was created 3/12/26 at 11:56 am. This note documents Administrator and NP (unidentified Nurse Practitioner) notified resident (R15) called her (previous) roommate (R18) a name. Monitor for further behaviors. There was no documentation of alleged verbal abuse from the week before reported by V9, Certified Nurses Assistant, no documentation of the verbal abuse allegation in R15's medical record from 3/9/26 when V7, LCSW/Psychotherapist reported the allegation, and no documentation on 3/10/26 when surveyor reported the allegation of verbal abuse.R18's Type: Social Service Note Focus: Effective Date: 3/9/2026 at 11:49 am, documented by V1, Administrator/Abuse Prevention Coordinator documents this late note was created 3/12/26 at 11:53 am. This note documents Administrator and NP (unidentified Nurse Practitioner) notified that resident's roommate called her a name. Monitor for Anxiety and further behavior. There was no documentation of alleged verbal abuse from the week before reported to the Administrator by V9, Certified Nursing Assistant, no documentation of the verbal abuse allegation in R15's medical record from 3/9/26 when V7, LCSW/Psychotherapist reported the allegation, and no documentation on 3/10/26 when surveyor reported the allegation of verbal abuse.The undated Abuse Prevention Policy documents:VII. Internal InvestigationAll incidents will be documented whether abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected.The facility Charting and Documentation dated as revised August 2006 documents the following: Policy StatementAll services provided to the resident, or any changes in the resident's medical or mental condition, shall he documented in the resident's medical record.Policy Interpretation and Implementation1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records.2. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, QMA, physicians, therapists, etc.) in accordance with state law and facility policy. Certified Nursing Assistants may only make entries in the residents' medical chart as permitted by facility policy.3. All incidents, accidents, or changes in the resident's condition must be recorded.

Based on interview and record review, the facility failed to have a physician document in the medical record documenting the basis of a resident's discharge, the specific needs the resident has that cannot be met in the facility, the attempts the facility made to meet those needs, and services available at the receiving facility to meet the resident's need. This failure affects one resident (R44) out of three reviewed for discharge on the sample list of twenty-seven.Findings include:R44's comprehensive, all-inclusive, Electronic Medical Record, did not include a physician note to document basis of a resident's discharge, the specific needs the resident has that cannot be met in the facility, the attempts the facility made to meet those needs, and services available at the receiving facility to meet the resident's need.R44's Involuntary Discharge Notice dated 1/30/26 documents R44 was involuntarily discharged from the facility due to being a threat to the personal safety of another resident (R23).On 3/12/26 at 9:40 AM, V1, Administrator, with V2, Director of Nursing/ Regional Consultant present, confirmed there was not a physician note in R44's medical record concerning the basis for R44's discharge. V1 confirmed R44 had been discharged from the facility and would not be returning to the facility. V1 stated she would continue looking for a physician note. As of 3/13/26 at 11:01 AM, V1 did not provide evidence of a physician note describing the required circumstances of R44's discharge. V1 stated this was her first involuntary discharge and she was not aware of all of the requirements.

Based on interview and record review, the facility failed to include required information regarding advocacy agencies in an involuntary discharge notice. This failure affects one resident (R44) out of three reviewed for discharge on the sample list of 27.Findings include:R44's Census Detail and Medical Diagnoses List dated 3/10/26 documents R44 was admitted to the facility 7/22/25 with medical diagnoses including Personality Disorder, Bipolar Disorder, Schizoaffective Disorder, Major Recurrent Depression, Anxiety, Stimulant Abuse, and Cannabis Use.R44's Emergency Involuntary discharge date d 1/30/26 did not include the mailing and email address of the entity which would receive a request for an appeal of the discharge, nor information on how to obtain an appeal form, complete the appeal form, and submit the appeal form. This same notice did not include the name, mailing address, email address, nor phone number of the State Long Term Care Ombudsman. This notice did not include the mailing address, email address, nor phone number of an agency responsible for the protection and advocacy of individuals with mental illness. On 3/12/26 at 9:40 AM, V1, Administrator, with V2, Director of Nursing/ Regional Consultant present, confirmed the required information was not included in R44's Involuntary Discharge Notice. V1 confirmed R44 had been discharged from the facility and would not be returning to the facility. V1 stated this was her first involuntary discharge and she was not aware of all the requirements.

Based on interview and record review the facility failed to ensure a resident's bed wheels were locked for one resident (R2) out of three residents reviewed for falls in a sample of 27 residents.Findings include:The Physician Orders dated March 2026 document the following diagnoses for R2, Lumbago with Sciatica right side, Pain in the right hip, and Cellulitis of the lower right limb.The Minimum Data Set (MDS) dated [DATE] documents R2 has intact cognition, requires assistance with activities of daily living, and uses a wheelchair for mobility. The Incident Report dated 3/4/26 documents on 3/4/26 at 3:30 AM Writer (V18, LPN (Licensed Practical Nurse)) was notified by (V19, CNA (Certified Nurses Assistant)) (R2) had tried to self-transfer to go to the bathroom. (R2) was found on the floor. Full assessment was done, Vitals within normal limits, (R2) had no skid socks on. (R2) had a full mechanical lift back to bed by (V18) and (V19). The same report states under the section Notes IDT (interdisciplinary team) met to discuss. Root Cause: upon investigation, it was determined the wheels on (R2's) bed were not locked. Intervention: Staff education to ensure bed wheels are locked when resident is in bed.Attempts were made to interview V18 and V19 on 3/12/26 at 8:55 AM. On 3/12/26 at 3:30 PM V1 Administrator stated (R2) was trying to self-transfer himself to the bathroom and the wheels on his bed were not locked and the bed rolled. We don't expect the residents to be responsible for locking their bed, that responsibility belongs to staff.The facility's policy titled Fall Guidelines with revision date 8/2024 documents the following information: The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process:Identification of hazards and risksEvaluationImplementationMonitoringAnalysis

Based on observation, interview and record review the facility failed to wear Personal Protective Equipment (PPE) to provide care, for a resident on droplet precautions due to Methicillin-resistant Staphylococcus Aureus (MRSA) infection. This failure affects one of one resident (R3) reviewed for transmission-based precautions on the sample list of 27.Findings include:R3's Current Diagnoses list documents: Malignant Neoplasm of Unspecified Part Of The Right Bronchus Or Lung, Chronic Obstructive Pulmonary Disease, and Tracheostomy Status (surgically created airway access).R3's Private laboratory results dated [DATE], document the results of R3's sputum culture as, Moderate growth of a MRSA (multi-drug resistant, bacterial infection).R3's Current Physician Order Sheet documents the following: Isolation: Special Contact Droplet Precautions r/t (related/to) MRSA) in Trach every shift for Infection Control.R3's Care Plan dated 12/30/26 documents the following: Resident is on Contact/Droplet Isolation r/t MRSA in sputum. Resident will follow contact/droplet isolation guidance through resolution date. Dedicate the use of noncritical patient care equipment to a single patient to avoid sharing between residents. If use of common equipment is not unavoidable, then adequately clean and disinfect them before use for another resident. Educate resident and family on the need for isolation precautions. Educate family and staff regarding the transmission and treatment of infection. Isolation precautions: wear gowns, gloves and masks when providing care to resident. Place soiled linens and meal tray in bags marked biohazard. Place linens and meal tray in tightly closed bag. Wear gowns, gloves and mask when entering room. Wash hands with antimicrobial soap or hand sanitizer. Remove gown and gloves before leaving room. Remove mask when out of room. On 3/10/26 at 9:47am R3 had two large, red, hazard material barrels, just inside his bedroom door. One hazard container barrel was labeled laundry, and the other was labeled trash. R3 had two signs on his bedroom door that documented R3 is on infection control-droplet precautions and see a nurse before entering. A wall mounted rack in the hallway outside R3's room contained Personal Protective Equipment (PPE) of gloves, mask and gowns. R3 was lying in bed with his head elevated. R3 had a tracheostomy (trach) device present with an oxygen supply attached. On 3/10/26 at 9:50 m V4, Registered Nurse (RN) stated R3 is on infection control - droplet precautions for MRSA in his trach, and requires gown, mask, and gloves when staff are in his room. V4, RN stated she does not know if his MRSA is colonized and the facility has not had a re-culture of the tracheostomy site in a while. On 3/10/26 at 10:30 am R3 turned on his call light.On 3/10/26 at 10:37 am V6, Housekeeping Director entered R3's room to answer the call light. V6 did not wash her hands, use hand sanitizer, don gloves or don a gown. V6 entered R3's room with a surgical mask she had worn throughout the facility prior to entering R3's room. V6 removed R3's 24-ounce (approximate measure) sized thermal cup from his bedside table. V6 exited the room with R3's contaminated thermal cup and surgical mask. On 3/10/26 at 10:42 am V6, Housekeeping Director met with this surveyor just outside R3's room. V6 stated she was going to get a refill for R3's thermal cup. V6 confirmed she did not wear PPE in R3's room. V6, then stated I can't believe I did that. The signs are posted for droplet precautions (isolation precaution), and I am the Housekeeping Director. I know I am supposed to wear a gown and gloves when I am in his (R3's) room. I guess I am just nervous with state (Illinois Department of Public Health survey team) in the building.On 3/10/26 at 10:45 am V2, Infection Control Preventionist/Interim Director of Nursing confirmed the facility infection control protocol should have been followed. V2 said all staff are to wear PPE while in R3's room, because R3 is on isolation - droplet precautions due to MRSA in his Trach.The facility Isolation- Categories for Transmission-based Precautions Policy dated 01/20/24 documents the following: Policy Interpretation and Implementation:1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection.2. Signage must be placed near entry to resident room when Transmission-based Precautions are necessary to indicate type of precaution and PPE needed.3. Based on CDC definitions, three types of Transmission-Based Precautions (airborne, droplet and contact) have been established. For information regarding Enhanced Barrier Precautions, please refer to the CDC Enhanced barrier precautions guideline.docx The same policy documents: b. Resident Placement(2) Isolate the individual in a private room if it is not feasible to contain drainage, excretions, blood, or body fluids (e.g., the individual is incontinent on the floor, or wanders and touches others).(4) An individual diagnosed with respiratory multi-drug resistant organisms should not be cohorted with another individual diagnosed with respiratory multi-drug resistant organism. Exceptions may apply and would require authorizations from Physicians of all residents involved.Use personal protective equipment (PPE) appropriately, including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens.

Based on Interview and record review the facility failed to replace misappropriated goods in a reasonable time frame for one (R3) of three residents reviewed for misappropriation. R3 was upset and angered of having to replace (ear buds) with R3's own personal money and the facility not reporting this to the police as R3 wanted to press charges. This failure to report to the police and to replace the goods in a timely fashion resulted in psychosocial harm to R3.Findings Include:The Facilities Abuse Prevention Policy Dated 1/25 documents that the facility affirms the right of the resident to be free from misappropriation of property, deprivation of goods and services by staff or mistreatment. This policy also documents that the facility would keep the resident informed of the conclusions of the investigations. On 11/6/2026 at 9:30PM, R3 reported that R3's (ear buds) were missing from R3's room and the facility reported this to the state agency. On 11/14/2025 the final report was provided to the state agency which documents that on 11/6/2025 R3 went to put on R3's (ear buds) that R3 kept in a specific place when R3 realized they were not there. R3 utilized the (tracking) function on R3's cellular phone and the missing (ear buds) were pinged (located) at an address (about 30 miles away). R3 asked the Certified Nursing Assistant on shift what her address was which the Certified Nursing Assistant stated she lives with her mom who is also a Certified Nursing Assistant at the facility and confirmed the address where the missing (ear buds) were located. The Facility Incident Documents that the Certified Nursing Assistance was terminated, (Local Police Department) notified, and the facility was replacing the (ear buds) for R3. On 1/13/2026 at 12:27PM, R3 stated R3's (ear buds) were missing after R3's room was deep cleaned on 11/6/2025. The Certified Nurse Assistant was helping R3 put all R3's personal belongings on R3's bedside table. R3 stated he noticed them missing when R3 went to put the (ear buds) in around 9:00PM on 11/6/2025. R3 stated that R3 used the (racking) function on R3's cellular phone which came up to an address of a mother and daughter who were employed as Certified Nursing Assistants at the facility. R3 stated R3 reported the theft to V1 but did not speak to a police officer that night. R3 stated R3 still would like to press charges but was told by V1 Administrator that no charges are being pressed. R3 stated that V1 stated they would get R3 new (ear buds), but R3 had already bought (ear buds) out of R3's own money but stated R3 would like reimbursement for the money spent on replacing the ear buds. R3 also stated V1 came into R3's room on 1/13/2026 and told R3 that the check was mailed and R3 will be getting a refund for $249.54. R3 stated that it upsets and angers R3, as this is R3's home and that someone can just steal from R3 and other residents. R3 again stated he wants to press charges as it has been over two months since the incident.

Based on interview and record review the facility failed to accurately assess a resident for weight loss for one (R1) of three residents reviewed for nutrition. A significant weight loss was not identified, and interventions were not put in place to prevent further weight loss resulting in R1 being admitted to the hospital with a diagnosis of Hypokalemia due to malnutrition/dehydration.Findings include:The facility policy Lab, Diagnostic Test Results and Change in Resident's Condition - Clinical Protocol Dated November 2016 documents to establish guidelines for physician notifications concerning resident lab and diagnostic tests results and change(s) in resident conditions. The policy further documents 2. The person who is to communicate results to a physician will review, compile the information and be prepared to discuss the following: a. the individual's current condition and any recent changes in status, including vital signs and mental status.The facility's undated policy Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol documents 1. Monitor and document the weight and nutritional status of residents in a format which permits readily available month-to-month comparisons. 2. Assess the individual's current nutritional status and identify individuals with anorexia, recent weight loss, and significant risk for subsequently impaired nutrition. 4. The staff will notify family of significant weight gains or losses or any abrupt or persistent decline from baseline appetite or food intake.The policy further documents 1. The physician and/or designee will review possible causes of anorexia or weight loss with the nursing staff and/or dietitian before ordering interventions. a. For individuals with recent or rapid weight loss (for example, more than a pound a day), the staff and physician should consider possible fluid and electrolyte imbalance as a cause. Monitoring: I. The physician and staff will monitor the nutritional status, response to interventions, and possible complications of such interventions (for example, aspiration, diarrhea, nausea, or vomiting) of individuals with impaired nutritional status.On 01/15/26 at 11:30am, R1's care plan documented an admission date of 11/25/2025 with diagnosis of Diabetes Mellitus Due to Underlying Condition with Diabetic Neuropathy, Unspecified (E08.40), and Other Lack of Coordination (R27.8).On 01/15/26 at 11:35am, R1's medical record review documents the following weights were obtained during R1's stay at the facility: admission weight: 11/25/2025 6:17pm 175.2 pounds (lbs) Wheelchair. 11/26/2025 1:25pm 170.4 lbs Mechanical Lift (Full Body), -4.8lbs (-3%) 11/27/2025 11:20am 157.1 lbs Mechanical Lift (Full Body), -13.3lbs (-8%) 12/5/2025 11:54am 163.6 lbs Mechanical Lift (Full Body), +6.5lbs (+4%) 12/9/2025 12:41pm 164.8 lbs Mechanical Lift (Full Body), +1.2lbs (+.7%) 12/11/2025 1:48pm 164.2 lbs Wheelchair, -.6 lbs (-.5%) 12/16/2025 9:57am 161.1 Lbs -3.1lbs (-2%)Total weight loss from admission date of 11/25/2025 to date of discharge 12/16/2025 (22 Days) -14.1 lbs or -8%.On 01/20/26 at 10:37am, R1's medical record review documents during R1's stay at the facility R1 was served 61 meals. Of those 61 meals, six of them did not document a percentage of consumption. Twenty-nine of the 55 meals documented noted less than 50% of the meal consumed. Fifteen of the 55 meals documented less than 25% consumed.On 01/15/26 at 11:35am, R1's medical record review documents on 12/16/2025 a nurse practitioner called Emergency Medical Services (EMS) to take R1 to the hospital due to R1 was exhibiting signs and symptoms of a stroke.On 01/15/26 at 11:35am, R1's hospital record review documents on 12/16/2025 R1 was admitted to the local hospital with a potassium level of 2.0 (Panic level low) on a scale of 3.5-5.1 mmol/L (millimoles per liter). The hospital discharge paperwork dated 11/25/2025 documents R1 having a potassium level of 4.0 on a scale of 3.5-5.1 mmol/L.On 01/15/26 at 11:35am, R1's medical record review documents on 12/2/25 R1 had labs done while at the facility and document a potassium level of 3.5 on a scale of 3.5-5.3 mEq/L (milliequivalents per liter). Labs drawn on 12/16/25 prior to discharge from the facility document potassium 2.6 on a scale 3.5-5.3 mEq/L. Demonstrating an electrolyte imbalance/ downward trend while at the facility.On 01/15/26 at 11:35am, R1's medical record review documents on 12/11/2025 V9 License Practical Nurse (LPN), documented V23 Speech Therapist informed V9 that V23 had to assist the resident with eating lunch. V23 stated R1 seems to be declining.On 01/15/26 at 10:23am, V9 LPN stated the note in the medical record was written by V9. V9 stated V9 could not recall notifying the family or physician of a decline in health of R1. V9 stated V9 did not inform the physician or family of R1's weight loss.On 01/15/26 at 10:56am, V12 Registered Nurse/Nurse Practitioner (NP) confirmed V12 was not informed of the weight loss R1 was experiencing. V12 confirmed limited consumption of meals would lead to weight loss and electrolyte imbalance.On 01/15/26 at 12:48pm, V14 Registered Dietician (RD) confirmed V14 was not informed of the weight loss by R1. V14 stated V14 would have asked for a re-weight of R1 to confirm the weight loss and then made recommendations based on clinical evidence of the weight loss. V14 confirmed V14 did not see R1 in the nursing home and made the diet recommendation from previous speech therapy notes from R1's medical records.On 01/15/26 at 12:48pm V15, Primary Care Physician, confirmed V15 was not notified of the weight loss by R1. V15 confirmed if R1 was consuming less than 50% of meals it would lead to weight loss and electrolyte imbalance. V15 stated V15 would have ordered labs and recommendations/orders based on R1 abilities and preferences.On 01/20/26 at 10:29am V25, R1 family, confirmed V25 was not informed of R1's weight loss or lack of food consumption.On 01/21/26 at 09:18am, V23 Speech Therapist confirmed V23 noted a sharp decline in R1's abilities including talking less and not feeding herself. V23 stated on 12/11/25 V23 informed V9 that R1 was experiencing a decline in overall health and was requiring more assistance to complete tasks.On 01/21/26 at 12:48pm, V2 Director of Nursing (DON) confirmed R1 had a significant weight loss, and that family/Physician/Registered Dietician had not been notified of the weight loss. V2 confirmed R1 was sent to the local hospital on [DATE] for altered mental status, possible stoke.On 01/22/2026 at 12:24pm, V24 Hospitalist/Doctor, confirmed on 12/16/25 R1 was admitted to the hospital with the admitting diagnosis of Hypokalemia (low potassium) (electrolyte imbalance) secondary to severe malnutrition/dehydration. V24 stated R1 had to have multiple intravenous potassium injections to get the potassium back to normal range. V24 stated the lack of food and drink at the facility was the cause of the Hypokalemia.

Based on interview and record review the facility failed to have a policy to verify the identity of agency staff to ensure one (V28) of three CNA's (V18, V19) reviewed demonstrated competency in the skills and techniques necessary to care for residents. This failure resulted in a facility wide failure and effected all 39 residents in the building. Findings Include:The facility's Certified Nursing Job Description revised on 10/11/2024 documents, qualifications to perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements are to have a current certification as a Certified Nursing Assistant in accordance with the laws of the State of Illinois. On 1/9/2026 at 5:00PM, (Local County Sheriffs) were called to the facility for an altercation between two employees (V19 and V28). (Local County Sheriff's) report documented by V29 (Deputy Sheriff) states that V19 informed V29 that V28 was operating under a false name, V20, while working at the facility as a CNA. V1 then informed V29 that V28 was working for the facility under the name V20. V29 asked V1 if V28 had provided V1 with false certifications or documentation with that name. V1 explained that the contracted staffing agency profile that V28 was using was for a CNA named V20 and that was all V1 had seen. V1 then expressed concern that V28 was working as a CNA without being certified to do so. V29 then asked V28 if V28 was actually a CNA. V28 said that she is. V28 then stated that the contracted staffing agency has her certifications under the name V20. I asked V28 if the contracted staffing agency's QR code that the facility was going to scan said V20. She stated, Yeah, because she (V20) uses my account. V1 stated that V1 looked up V28's name on the registry and discovered that V28 isn't a CNA.On 1/15/2026 at 11:05AM, V1 stated there was a Certified Nurse's Assistant that was scheduled to work through their contracted staffing agency. V1 stated that V20 was scheduled to work that day. V28 arrived for the shift and provided V20's name to be able to access to the Electronic Medical Record (EMR). V1 stated V1 didn't report the incident.On 1/15/2026 at 11:24AM, received an email which documents that V28 does not have a CNA certification on the Health Care Workers Registry (HCWR) therefore V28 was not eligible to be employed as a CNA. V28 is eligible to work in a non-CNA capacity.On 1/21/2026 at 10:05AM, V20 stated that V20 didn't pick up any shifts at the facility.On 1/21/2026 at 10:35AM, V19 stated that V28 was working from 6:00AM until the incident took place around 5:00PM. Nursing Schedule dated on 1/9/2026 documents that V20 was scheduled to work 6:00am-6:00pm that day. Per the Southern Illinois Eastern University Testing Center for Certified Nursing Assistant Qualifications in the State of Illinois includes, the person is to take a registered class, with skills and competency and take a test within the State of Illinois. Facility Provided Resident Roster Documents a Census of 39 residents.

Based on Interview and Record Review the Facility failed to ensure Registry verification for one (V28) of three staff members reviewed for certification. This failure resulted with one (V28) working as a Certified Nursing Assistant while not certified. This failure affected all 39 residents residing at the facility. Findings Include: On 1/9/2026, V28 Certified Nursing Assistant (CNA) came to the facility and began working under the name of V20 CNA who was scheduled to work a shift at the facility as a Certified Nursing Assistant. After having a verbal altercation with V19 CNA, V28 confirmed that V28's identity was not V20. On 1/15/2026 at 11:05AM, V1 Administrator stated the facility uses a contracted agency to provide certified staff for employment as needed. V1 stated that V20 was scheduled to work 1/9/26. V28 came to work on 1/9/26 in the facility and provided V20's name as V28's own identity to be able to provide care and access the Electronic Medical Record. V1 stated V1 didn't report the incident to the state agency of the false identity and working of uncertified personnel providing resident care. V1 explained that the contracted staffing agency profile that V28 was using was for a CNA named V20 and that was all V1 had seen.On 1/15/2026 at 11:24AM, received an email which documents that V28 does not have a CNA certification according to the Health Care Worker Registry (HCWR) therefore V28 is not eligible to be employed as a CNA. V28 is eligible to work in a non-CNA capacity.On 1/21/2026 at 10:05AM, V20 stated that V20 didn't pick up any shifts at the facility. On 1/21/2026 at 10:35AM, V19 stated that V28 was working from 6:00AM until the incident took place around 5:00PM. V19 stated that there was an altercation of yelling and screaming from V28 in front of residents in the cafeteria and also in a resident's room. Nursing Schedule dated on 1/9/2026 documents that V20 was to work 6:00am-6:00pm that day.Facility Provided Resident Roster Documents a Census of 39.

Based on interview and record review the facility failed to notify the physician and family of the resident with a change in condition (weight loss) for two (R1, R8) of three residents reviewed for weight loss. Findings include:The facility policy Lab, Diagnostic Test Results and Change in Resident's Condition - Clinical Protocol Dated November 2016 documents to establish guidelines for physician notifications concerning resident lab and diagnostic tests results and change(s) in resident conditions. The policy further documents 2: The person who is to communicate results to a physician will review, compile the information and be prepared to discuss the following: a. the individual's current condition and any recent changes in status, including vital signs and mental status.The facility's undated Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol documents 1. Monitor and document the weight and nutritional status of residents in a format which permits readily available month-to-month comparisons. 2. Assess the individual's current nutritional status and identify individuals with anorexia, recent weight loss, and significant risk for subsequently impaired nutrition. 4. The staff will notify family of significant weight gains or losses or any abrupt or persistent decline from baseline appetite or food intake.The policy further documents 1. The physician and/or designee will review possible causes of anorexia or weight loss with the nursing staff and/or dietitian before ordering interventions. a.: For individuals with recent or rapid weight loss (for example, more than a pound a day), the staff and physician should consider possible fluid and electrolyte imbalance as a cause. Monitoring: I. The physician and staff will monitor the nutritional status, response to interventions, and possible complications of such interventions (for example, aspiration, diarrhea, nausea, or vomiting) of individuals with impaired nutritional status.On 01/15/26 at 11:30am, R1's care plan documents an admission date of 11/25/2025 with diagnosis of Diabetes Mellitus Due to Underlying Condition with Diabetic Neuropathy, Unspecified (E08.40), and Other Lack of Coordination (R27.8).On 01/15/26 at 11:35am, R1's medical record review documents the following weights were obtained during R1's stay at the facility: admission weight: 11/25/2025 6:17pm 175.2 pounds (Lbs.) Wheelchair. 11/26/2025 1:25pm 170.4 Lbs. Mechanical Lift (Full Body), -4.8lbs (-3%) 11/27/2025 11:20am 157.1 Lbs. Mechanical Lift (Full Body), -13.3lbs (-8%) 12/05/2025 11:54am 163.6 Lbs. Mechanical Lift (Full Body), +6.5lbs (+4%) 12/09/2025 12:41pm 164.8 Lbs. Mechanical Lift (Full Body), +1.2lbs (+.7%) 12/11/2025 1:48pm 164.2 Lbs. Wheelchair, -.6 lbs (-.5%) 12/16/2025 9:57am 161.1 Lbs. -3.1lbs (-2%)R1's Total weight loss from admission date of 11/25/2025 to date of discharge 12/16/2025 (22 Days) -14.1 lbs. or -8%.On 01/20/26 at 10:37am, R1's medical record review documents during R1's stay at the facility R1 was served 61 meals. Of those 61 meals, six of the meals did not include documentation of the percentage of consumption. Twenty-nine of the 55 meals documented was less than 50% consumed. Fifteen of the 55 meals documented was less than 25% consumed.On 01/15/26 at 10:23am, V9 Licensed Practical Nurse (LPN), stated the note in the medical record was written by V9. V9 stated V9 could not recall notifying the family or physician of a decline in health of R1. V9 stated V9 did not inform the physician or family of R1's weight loss.On 01/15/26 at 10:56am, V12 Registered Nurse/Nurse Practitioner (NP) confirmed V12 was not informed of the weight loss R1 was experiencing. V12 confirmed limited consumption of meals would lead to weight loss and electrolyte imbalance.On 01/15/26 at 12:48pm, V14 Registered Dietician (RD) confirmed V14 was not informed of the weight loss by R1. V14 stated V14 would have asked for a re-weight of R1 to confirm the weight loss and then made recommendations based on clinical evidence of the weight loss.On 01/15/26 at 12:48pm, V15 Primary Care Physician confirmed V15 was not notified of the weight loss by R1. V15 confirmed if R1 was consuming less than 50% of meals it would lead to weight loss and electrolyte imbalance.On 01/20/26 at 10:29am, V25 R1's family member confirmed V25 was not informed of R1's weight loss or lack of food consumption.On 01/21/26 at 12:48pm, V2 Director of Nursing (DON) confirmed R1 had a significant weight loss, and that family/Physician/Registered Dietician had not been notified of the weight loss. V2 confirmed R1 was sent to the local hospital on [DATE] for altered mental status, possible stoke.On 01/20/26 at 10:44am, R8's care plan review documents R8 was admitted to the facility on [DATE] with the following diagnosis: Mechanical Fall Acute Right Proximal Tibial and Fibular Traumatic Fracture Severe Right Lower Extremity Intractable Pain Acute Right Distal Talus Avulsion Fracture, Acute Hypotension/Acute Shock versus Anemia versus Others Acute Anemia, Suspect Secondary to Fracture and or Others, Ruled Out GI bleed No Signs of Obvious Bleeding Acute Kidney Injury on Chronic Kidney Disease, A-fib with [NAME].On 01/20/26 at 10:35am, R8's medical record review documents the following weights were obtained during R8's stay at the facility: 1/03/2026 06:46 161.1 Lbs. Mechanical Lift (Full Body)12/31/2025 09:55 156.3 Lbs. Mechanical Lift (Full Body) 12/30/2025 09:00 158.8 Lbs. Mechanical Lift (Full Body) 12/29/2025 12:42 163.9 Lbs. Mechanical Lift (Full Body) 12/28/2025 12:58 166.3 Lbs. Mechanical Lift (Full Body) 12/27/2025 11:31 166.0 Lbs. Mechanical Lift (Full Body)12/26/2025 12:17 163.7 Lbs. Mechanical Lift (Full Body) 12/25/2025 13:07 161.6 Lbs. Mechanical Lift (Full Body) 12/24/2025 13:26 168.4 Lbs. Mechanical Lift (Full Body) 12/23/2025 12:00 166.2 Lbs. Mechanical Lift (Full Body) 12/22/2025 10:44 166.7 Lbs. Mechanical Lift (Full Body)12/20/2025 11:14 172.8 Lbs. Mechanical Lift (Full Body)12/19/2025 11:28 169.4 Lbs. Mechanical Lift (Full Body)12/18/2025 13:48 178.3 Lbs. Mechanical Lift (Full Body)12/17/2025 12:06 176.2 Lbs. Mechanical Lift (Full Body) 12/16/2025 09:59 178.3 Lbs. Mechanical Lift (Full Body) 12/15/2025 13:50 178.8 Lbs. Mechanical Lift (Full Body) 12/14/2025 13:58 178.2 Lbs. Mechanical Lift (Full Body) 12/13/2025 14:20 186.8 Lbs. Mechanical Lift (Full Body) 12/12/2025 13:51 184.0 Lbs. Mechanical Lift (Full Body) 12/10/2025 14:20 184.0 Lbs. Mechanical Lift (Full Body) 12/09/2025 12:41 184.9 Lbs. Mechanical Lift (Full Body) 12/08/2025 14:46 185.5 Lbs. Mechanical Lift (Full Body)12/06/2025 14:00 198.6 Lbs. Mechanical Lift (Full Body)12/05/2025 13:58 199.8 Lbs. Mechanical Lift (Full Body) 12/04/2025 12:27 201.0 Lbs. Mechanical Lift (Full Body)12/03/2025 09:31 201.0 Lbs. Mechanical Lift (Full Body) 12/02/2025 18:22 201.8 Lbs. Mechanical Lift (Full Body) 12/01/2025 13:53 200.9 Lbs. Mechanical Lift (Full Body) 11/30/2025 16:46 198.0 Lbs. Mechanical Lift (Full Body) 11/27/2025 11:21 197.2 Lbs. Mechanical Lift (Full Body) 11/26/2025 13:25 199.3 Lbs. Mechanical Lift (Full Body)11/25/2025 11:21 192.1 Lbs. Mechanical Lift (Full Body)11/23/2025 14:36 198.0 Lbs. Mechanical Lift (Full Body) 11/22/2025 09:01 197.9 Lbs. Mechanical Lift (Full Body)R8's Total weight loss from an admission date of 11/21/2025 to date of 01/03/26 (44 Days) -36.8 lbs. or -19%.On 01/15/26 at 10:56am, V12 Registered Nurse/Nurse Practitioner (NP) confirmed V12 was not informed of the weight loss R8 was experiencing.On 1/20/26 at 10:38am, V26 R8's family member confirmed V26 was not notified of R8's weight loss. V26 stated V26 noticed R8 was losing weight but had no idea it was this drastic. V26 stated he will be talking to facility staff upon arrival this evening.On 1/20/26 at 11:11am, V27 (R8's Physician) confirmed V27 had not been notified of any weight loss by R8.On 01/21/26 at 12:48pm, V2 Director of Nursing (DON) confirmed R8 had a significant weight loss, and that family/Physician had not been notified of the weight loss.

Based on interview, and record review the facility failed to report an altercation between two (V19 and V28) employees in presence of three (R6, R9 and R10) residents and failed to report that an unqualified individual was working as a Certified Nursing Assistant. Findings include:Documents from the (Local Sherriff's Department) documents that on 01/09/2026 V29 Sheriff Deputy (SD) was operating as a uniformed patrol for the (Local Sheriff's Office). At approximately 5:00PM, V29 SD was dispatched to the facility for a threats report. Dispatch informed V29 SD that they received a call from V18 Certified Nursing Assistant (CNA) who stated that one of the CNA's V18 was working with (V28, CNA) had threatened to beat her a** (expletive) after V28's shift ends. Dispatch soon fielded a second 911 call from V28, CNA, regarding the incident. V29 SD arrived on scene and spoke with V18 CNA who stated the following, though not verbatim. V18 CNA stated that V28 CNA told V18 to meet V28 by the time clock so that V28 could beat her a** (expletive). V18 CNA said that V28 CNA saying this caused her to feel uncomfortable and unsafe. V18 stated that this started after V28 CNA approached V18 CNA near the front desk to tell V18 that one of the residents had not been taken care of since 6:00AM. V18 CNA stated that there was miscommunication which led to V28 CNA working in the south unit of the nursing home from 6:00 AM until 2:00PM. V18 said at 2:00PM V18 CNA was moved over to the east hallway where she discovered that the resident hadn't been taken care of. V18 CNA said she told V28 CNA that was V28's job since V28 was moved over there at 2:00PM until 5:00PM. V18 CNA said that V28 CNA started accusing V18 CNA of disrespecting V28 and began yelling at V18 and threatening to fight V18 after V18 got off work. V18 CNA explained that earlier in the shift, V28 CNA had gotten into a verbal altercation with a different CNA (V19). V18 CNA said that V28 CNA threatened V19 CNA after accusing V19 of not helping V28. V18 CNA said that V18 had to separate the two of them and the situation calmed down. V19 CNA said that when V19 confronted V28 for not taking care of the resident that V28 was supposed to be responsible for, V28 began yelling at V19 and accusing V19 of disrespecting V28. V19 CNA then informed me that V1 Administrator, requested that V28 CNA clock out and leave the property. V29 SD also later spoke with V1 Administrator directly on the phone and V1 stated that V1 wanted V28 CNA permanently removed for trespassing. V28 CNA then stated V28 wasn't leaving the property until V28 got paid for the work V28 did. V28 then began to make racially derogatory comments saying, I wasn't mad at first. That's that white people s*** (expletive). V28 took out V28's cell phone and began taking photographs of V19 and V19's employee badge. V28 walked by the facility's cafeteria and began insulting V19 and V18 in front of residents. V29 later called and spoke with V1 Administrator again. V1 stated that V1 looked up V28's name on the registry and discovered that V28 isn't a CNA.On 1/15/2026 at 9:35AM, V1 Administrator stated she knew about the incident, but didn't report the incident. On 1/21/2026 at 10:35AM, V19 stated that V28 was working from 6:00AM until the incident took place around 5:00PM. V1 stated that there was an altercation of yelling and screaming from V28 in front of residents in the cafeteria and also in R8's Room.On 1/21/2026 at 10:05AM, R8 stated about a week ago two Certified Nursing Assistants were yelling and having a disagreement in R8's room. R8 stated one of the Certified Nursing Assistants walked out.

Based on Interview and Record Review the facility failed to report to the police the misappropriation of ear buds in a timely manner for one (R3) of three residents on the sample list. Findings Include: On 11/6/2025 at 9:30PM, R3 reported to staff that R3's (ear buds) were missing from R3's room and the facility reported the misappropriation of goods to the state agency. On 11/14/2025 the final report from the state agency documents that on 11/6/2025 R3 went to put in R3's (ear buds) into the ear canal that R3 kept in a specific place when R3 realized the (ear buds) were not there. R3 utilized the (tracking) function on R3's cellular phone and the (ear buds) were pinged (located) at an address in (about 30 miles away). R3 asked one of the Certified Nursing Assistant on shift what her address was. The Certified Nursing Assistant stated she lives with her mom who is also a Certified Nursing Assistant at the facility and confirmed the address where the (ear buds) were located. The Facility Incident report documents that the Certified Nursing Assistant was terminated, (Local) Police notified, and the facility was replacing the (ear buds) for R3. On 1/13/2026 at 12:27PM, R3 stated R3's (ear buds) were missing after R3's room was deep cleaned on 11/6/2025 and a Certified Nurse Assistant was helping R3 put all the personal belongings onto R3's bedside table. R3 stated he noticed the missing (ear buds) when R3 went to put the (ear buds) in the ear around 9:00PM on 11/6/2025. R3 stated that R3 used (tracking) function on R3's phone which came up to an address of a mother and daughter who were employed as Certified Nursing Assistants at the facility. R3 stated R3 reported the theft to the staff but did not speak to a police officer that night, but R3 stated R3 still would like to press charges for the theft of the (ear buds) but was told by V1 Administrator that no charges are being pressed.On 1/13/2026 at 1:05PM, V1 Administrator stated V1 called the (Local) Police Department and talked to someone there on 11/6/2025 around 9:30PM but couldn't recall who V1 talked to.On 1/14/2026 at 9:37AM, V17 (Local Sheriff) stated there is no call log, dispatch or report to the facility on [DATE] or around those dates.On 1/24/2026 at 10:00AM, V1 stated V1 left a message with The (Local) Police Department that R3 wanted to press charges for theft. The Facilities Abuse Prevention Policy dated 1/25 documents that the facility affirms the right of the resident to be free from misappropriation of property, deprivation of goods and services by staff or mistreatment. This policy also documents that the facility would keep the resident informed of the conclusions of the investigations.

Based on observation, interview and record review the facility failed to maintain transport equipment in working order and failed to safely secure one resident (R1) by not applying a seatbelt properly during resident transport. R1 experienced pain and obtained two nasal fractures and six sutures after falling while being transported in the facility van. The facility failed to implement fall interventions and failed to determine root causes for four falls for one (R3) resident. These failures affected two (R1, R3) residents out of three residents reviewed for Accidents in a sample list of three residents.Findings include: 1. R1's Electronic Medical Record (EMR) documents R1's medical diagnoses as athetoid cerebral palsy, anemia, glaucoma, primary osteoarthritis, difficulty walking, acute-on-chronic heart failure, adjustment disorder with anxiety, bilateral astigmatism, bilateral myopia, bilateral presbyopia, restless-leg syndrome, and a history of myocardial infarction.R1's Minimum Data Set (MDS), dated [DATE], documents that R1 is cognitively intact. The same MDS notes that R1 is dependent on staff for transfers and transportation.R1's Care Plan intervention, dated 7/5/2024, directs staff to assist R1 in transferring to a wheelchair and to assist R1 in positioning for comfort during transfers and while up. It also instructs staff to help R1 achieve and maintain an upright posture and proper alignment, as possible, when out of bed.R1's Fall Risk Assessment, dated 6/23/25, classifies R1 as a high fall risk.R1's Physician Order Sheet (POS), dated October 2025, shows a physician's order, effective from 9/24/24 with no end date, to administer daily aspirin 81 mg (milligram).R1's Hospital Record, dated 9/22/25, indicates R1 was evaluated in the emergency room following a fall from his wheelchair while in the facility's transport van. The record reports that R1 sustained:A 4.0 cm (centimeter)x 4.0 cm forehead hematoma with mild bogginessA 1.0 cm linear partial-thickness laceration to the extraoral upper [NAME] moderate abrasion to the nasal dorsumA 0.5 cm linear full-thickness laceration to the right narisA 1.5 cm linear laceration to the upper labial mucosaIt further notes that R1 received suture repair on three lacerations under local anesthesia, and a pressure dressing was applied to the forehead hematoma.R1's CT scan of the maxillofacial region, dated 9/22/25, reveals a scalp hematoma involving the forehead and extending to the bridge of the nose and right medial canthus region, along with comminuted bilateral nasal bone fractures with slight displacement.R1's Fall Investigation, dated 9/22/25, documents that R1 had an unwitnessed fall in the facility van en route to a physician appointment. The investigation notes that R1 sustained: an abrasion to the top of the scalp; abrasion to the right elbow; an abrasion to the front of the right knee; an abrasion to the front of the left knee; facial bruising; a facial fracture; a nasal laceration; a skin tear to the back of the right hand; and a skin tear to the right forearm.R1's Nurse Progress Notes read:9/22/25, 6:31 PM: R1 left the facility at approximately 7:30 AM for a cardiology appointment and returned at 3:45 PM. The note states R1 fell during transport and was taken by ambulance to the emergency room. Upon return, R1 complained of a headache. The skin assessment found dime-size abrasions under the right knee, left knee, and right elbow; a skin tear to the right lower arm (unapproximated due to dried blood and skin); a dime-size abrasion on the top of the head; and bruising to both eyes and the nose. The note also reports six stitches on the right side/under the right side of the nose, with swelling to the right side of the face and eyes. It states: (R1's) elastic wrap is in place to forehead and, per hospital instructions, should not be removed for 24 hours due to swelling/hematoma of the forehead. Unable to assess the skin under the wrap. Swelling noted to right wrist/arm. (R1) states he was sitting up in his wheelchair in the transport van when, suddenly, he fell out, landing on his right side.9/22/25, 6:53 PM: R1 was seen in the emergency room and diagnosed with traumatic hematoma of the forehead, facial laceration, fall from wheelchair, cervical stenosis of the spinal canal, and closed nasal bone fractures.9/23/25, 11:59 AM: R1 declined a shower, stating his body was too sore from the fall on 9/22/25.R1's Provider Progress Note, dated 9/23/25 at 12:21 PM, states: (R1) is seen post fall/E.R. visit for broken nose. (R1) fell and hit his face due to van malfunction. (R1) has a mild headache and is using acetaminophen. (R1) has bruising on his face.The invoice report dated 9/26/25 for maintenance of the facility's transport van documents that the van lift inspection revealed: Missing some odds-and-ends hardware; adjusted handrail tension at stow; adjusted stow blocks; adjusted towers one and two; cleaned out floor tracks and locks on retractors.R1's final report to the State Agency, dated 9/29/25, states that R1 fell out of his wheelchair while being transported to a physician appointment on 9/22/25. The report notes that R1 was sent to the emergency room after the fall, which caused a laceration requiring six sutures to the right side of his nose and closed nasal fractures. It further documents that V3 Maintenance Director inspected the van and replaced a safety belt; an outside vendor also inspected and replaced hardware. The facility determined the fall was caused by a faulty seat belt attachment. Staff were re-educated on van mechanics and resident transportation procedures.On 10/9/25 at 1:30 PM, V1 Administrator, V2 Director of Nurses (DON), V3 Maintenance Director, V4 Transport Aide, V5 CNA (Certified Nurses Assistant), and V6 Regional Clinical Nurse reenacted the fall. V5 sat in a wheelchair in the van while V4 fastened the belts. Both rear belts were stiff and loose. V4 stated this method was unsafe. V1 confirmed the straps were too loose and could detach easily. V3 replaced a retractable anchor and remarked: Once the material has that much age on it, it tends to stiffen up. This lap belt is not safe because there is no give in it. It needs replacement.On 10/10/25 at 9:00 AM, R1 was lying in bed with dark black/gray areas under both eyes and yellow circles around the eyes.On 10/9/25 at 11:20 AM, V4 stated she assisted R1 into the van on 9/22/25, placed lap belts over his wheelchair, and attached them to floor anchors-but did not realize one anchor was loose and did not test it. Turning into the physician's parking lot, she heard a thud, looked back, and saw that R1 had been flung from the wheelchair onto the van floor. After emergency transport, V4 rechecked the van and found the back-right wheelchair anchor was unattached. Because R1's lap belt was not secured properly and the anchor was disconnected, R1 fell forward out of his wheelchair, injuring himself.On 10/10/25 at 10:10 AM, V10 PTA (Physical Therapy Aide) said R1 had declined over the past two years and restarted physical therapy on 9/12/25 after another fall. V10 said R1 has a healthy fear of falling and is very hesitant with transfers, often reaching out due to his poor vision.On 10/10/25 at 12:30 PM, R1 stated he was placed in the van for a physician appointment when the seatbelt detached from the floor anchor. He said he has been nervous about falling because he sees only cloudy figures. He said he was very scared before the 9/22/25 fall and is now terrified. He said he experienced fear and pain as a result of falling in the van. R1 said V4 buckled him in but should have verified the seatbelt's functionality prior to transport.2. R3's EMR lists medical diagnoses including cerebral infarction, vascular dementia, persistent mood disorder, reduced mobility, mild neurocognitive disorder, hearing loss, difficulty walking, muscle wasting and atrophy, gait and mobility abnormalities, muscle weakness, macular degeneration, urinary incontinence, and a cognitive-communication deficit.R3's MDS dated [DATE] documents R3 as moderately cognitively impaired, requiring maximum staff assistance for bed mobility and dependency for oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers.R3's Care Plan intervention dated 6/13/2020 mandates use of a total-body mechanical lift with two staff for all transfers. A fall intervention added 8/23/24 directs lowering R3's wheelchair seat; another intervention added 8/28/24 requires an alarm in his wheelchair. No fall intervention was added following the 9/23/25 fall.R3's Fall Risk assessment dated [DATE] classifies R3 as high fall risk.R3's Nurse Progress Notes:7/2/25 at 4:54 AM: R3 was found sitting on the floor beside his bed. He stated he had attempted a self-transfer.7/4/25: The notes lack documentation about a fall at 9:29 PM.8/8/25 at 5:18 AM: R3 was found beside his bed on the floor and said he tried to self-transfer.9/23/25: Notes omit details of a fall at 1:40 AM.R3's Fall Investigations:7/2/25: An unwitnessed fall at 4:30 AM occurred when R3 was trying to get up and was incontinent. The investigation does not include a root cause analysis.7/4/25: An unwitnessed fall at 9:29 PM found R3 lying next to his bed and incontinent. No root cause is provided.8/8/25: An unwitnessed fall at 4:15 AM left R3 on the floor beside his bed; he said he attempted to self-transfer. No root cause is documented.9/23/25: An unwitnessed fall at 1:40 AM found R3 on the floor beside his bed and incontinent. The investigation notes that R1 was unable to describe the fall. No root cause is identified.On 10/10/25 at 9:35 AM, V11 CNA transferred R3 from his bed to his wheelchair without additional staff, without a mechanical lift, and without a gait belt.At 9:40 AM, R3 was in his wheelchair in the dining room drinking hot coffee. No staff were present. His wheelchair seat was not lowered, and no personal alarms were installed.At 10:00 AM, V11 CNA admitted she transferred R3 without help, without the lift, and without a gait belt. She said she knew two staff and a mechanical lift were required but sometimes does not follow that. She said staff practices vary-sometimes using the lift, sometimes physically transferring R3.At 10:15 AM, V7, Director of Rehabilitation Services, assessed R3's wheelchair. She observed the seat was in its highest position, though it could be lowered. She said wheelchair adjustments are normally reviewed with therapy. She was unaware that R3's Care Plan includes lowering the seat.At 11:25 AM, V1 Administrator stated that R3's fall interventions did not align with his falls on 7/2/25, 7/4/25, 8/8/25, and 9/23/25, particularly because no root causes were documented. The Administrator said that when a resident falls, the interdisciplinary team (IDT) should discuss the fall, implement an appropriate intervention plan, and educate staff. She said merely documenting what happened is insufficient to identify a root cause. She commented: Just because (R3) tries to get up on his own does not tell us why he is attempting to get up. The root cause might be incontinence, hunger, pain, etcetera.She concluded that the root causes of R3's falls were never determined.The facility policy titled Falls Guideline, revised August 2024, defines a fall as any failure to maintain appropriate lying, sitting, or standing position that results in unintentional relocation to the ground or another object lower than the starting point. It mandates that all residents at fall risk be reviewed for individualized interventions. Fall management should include review of physical devices, hazard analysis, cause identification, intervention development and implementation, and ongoing evaluation. Staff must evaluate and document all falls-including when and where they occurred and observational details. Documentation should contain sufficient information to help determine the cause of the fall.

Based on interview and record review, the facility failed to provide the services of a registered nurse for eight consecutive hours seven days per week. This failure has the potential to affect all 39 residents residing in the facility. Findings include:The facility's Staffing Postings dated 9/1/25 through 9/7/25 document there was not a registered nurse working in the facility on 9/1/25 nor 9/6/25.The facility Employee Roster (undated) documents two registered nurses employed by the facility, V4 Minimum Data Set Coordinator, and V8 Registered Nurse.On 9/12/25 at 12:50 PM, V1 Administrator, confirmed on 9/6/25 there was not a registered nurse on duty in the facility. V1 further stated on 9/1/25 there was a registered nurse who worked the overnight shift from 8/31/25 and was in the facility from midnight until approximately 7:40 AM which still falls short of the requirement of having eight hours of coverage. V1 then stated the facility had not been able to provide services such as intravenous medications due to the lack of a registered nurse to administer those types of medications.The facility Resident Roster dated 9/11/25 documents 39 residents reside in the facility.

Based on interview and record review the facility failed to monitor urine characteristics, timely report changes in urine and urine culture results to the provider, and implement infection control measures to prevent catheter associated urinary tract infections (CAUTI) for one (R32) of two residents reviewed for UTIs in the sample list of 30. These failures resulted in delayed treatment of R32's CAUTI and hospitalization . Findings include: The facility's Notification for Change in Resident Condition or Status policy dated 12/7/17 documents to notify the resident's physician for sudden, change or unrelieved symptoms, when there is a need to alter treatment significantly and when there are symptoms of infection. This policy documents to record information related to the resident's change in condition in the resident's medical record. The facility's Enhanced Barrier Precautions (EBP) dated 7/13/23 documents EBP are used to reduce transmission of multidrug-resistant organisms and includes wearing a gown and gloves for high-contact care activities for residents with an indwelling medical device. On 12/11/24 at 11:10 AM R32 stated R32 admitted to the facility with a urinary catheter in May 2024, R32's urine had blood (hematuria) for a few weeks and R32 was hospitalized for urosepsis. R32 stated on 7/19/24 R32 felt the urge to urinate, urine leaked around R32's catheter, R32 had the nurse remove the catheter and R32 was able to urinate. R32 stated R32's catheter was blocked with mucus that had been present in R32's urine for a few days prior. R32 stated R32 went to the emergency roiagnom on [DATE] and was prescribed Levaquin for UTI and the urine culture results came back on 7/21/24, but R32's antibiotic was not changed until 7/24/24. R32 stated R32 started to feel worse on the evening of 7/24/24 and was admitted to the hospital for seven days for a UTI and treated with intravenous (IV) antibiotics. R32 stated staff emptied R32's catheter and was aware of the blood and mucus, but was unsure if any follow up was done. R32 stated R32 was concerned that R32's urinary changes weren't addressed timely, but R32 had never had a catheter before so R32 was not sure what the protocol was. R32 stated the facility did not implement EBP until November 2024. R32's Minimum Data Set (MDS) dated [DATE] documents R32 is cognitively intact. R32's MDS dated [DATE] documents R32 was dependent on staff assistance for toileting hygiene. R32's Care Plan initiated 5/11/24 and resolved 7/22/24 documents R32 had a urinary catheter for obstructive uropathy and includes an intervention to monitor/record/report signs/symptoms of UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns to the physician. R32's Nursing Note dated 5/11/2024 at 3:00 PM documents R32's urinary catheter was draining clear urine and R32's stool softener was held due to loose stools. There is no documentation of R32's urine characteristics and monitoring after this note until 5/24/24 at 9:49 AM when R32 had hematuria and blood clots in R32's urinary collection bag and R32 was sent to the emergency room . R32's Hospital History & Physical dated 5/24/24 documents R32 reported having cloudy/dark urine intermittently in R32's urinary catheter. R32's workup was notable for elevated white blood cell count of 14.96, and his urinalysis appeared infected. R32 was admitted for sepsis secondary to CAUTI. R32 returned to the facility with a urinary catheter and there is no documentation that R32's urine was assessed and monitored between 7/6/24 and 7/18/24. R32's Nursing Note dated 7/19/24 at 6:59 AM documents R32 complained of lower abdominal pain and R32's urinary collection bag was empty and the catheter was not draining. R32's urine contained a large amount of sediment and mucus and had a foul odor. R32 requested to remove the catheter, upon removal R32 urinated intermittently and R32 complained of burning with urination. R32 was transported to the local emergency room per R32's request. R32's emergency room Notes dated 7/19/24 documents CAUTI, culture pending, R32's catheter was discontinued and R32 discharged back to the facility with orders for Levaquin (antibiotic) 500 milligrams (mg) by mouth daily for five days. R32's July 2024 Medication Administration Record documents Levaquin was administered 7/19-7/23/24. R32's Urine Culture with result date of 7/21/24 documents the hospital sent the results to the facility via electronic facsimile on 7/21/24 at 4:44 PM, and the organism Proteus Mirabilis was resistant to Levaquin. There is no documentation in R32's medical record that this culture was reported to a practitioner prior to 7/24/24 at 10:11AM when new orders were given for Amikacin (antibiotic) 750 mg intramuscularly (IM) every 12 hours for five days. R32's Nursing Note dated 7/24/24 at 9:43 PM documents at 8:47 PM R32 was given one dose of IM antibiotics prior to being sent to the hospital for complaints of numbness in R32's arms and hands and generally not feeling well and R32 was clammy and sweating. This note documents V18, R32's Family, was present and was concerned R32 was septic from UTI due to R32's prior history of being septic from UTIs. R32's Hospital History & Physical dated 7/24/24 at 11:36 PM documents R32 reported that despite taking Levaquin R32 developed feelings of palpitation as if R32's heart was racing and associated numbness and generalized weakness which is usually consistent with an infection. R32 was admitted for complicated UTI and treated with IV antibiotics. On 12/11/24 at 12:07 PM V6 Infection Preventionist/MDS Coordinator stated for residents with urinary catheters the nurses should monitor urine characteristics for infection and notify the provider of UTI symptoms and document this in the nursing notes. V6 confirmed R32's urine culture results were received on 7/21/24 and indicated a resistance to Levaquin, and this was not reported until 7/24/24. V6 stated it was a weekend and the floor nurses should have reported the results to the provider immediately. On 12/11/24 at 12:45 PM V6 stated EBP was implemented in October 2024, confirming R32 was not on EBP when R32 had a catheter in May and July 2024. On 12/11/24 at 1:53 PM V15 Nurse Practitioner stated staff should be routinely monitoring urine color and characteristics, including discharge and sediment, and ensure the urinary catheter is clean. V15 stated if R32 had hematuria the nurses should have notified V15 and V15 would have ordered a repeat urinalysis and assessed R32. V15 confirmed R32 was hospitalized for urosepsis in May and then a UTI in July 2024. V15 stated the nurses definitely should have been assessing R32's urine routinely and documenting this. In regards to R32's 7/21/24 urine culture, V15 stated R32's culture should have been reported as soon as the report was available, and V15 would have changed the antibiotic as soon as V15 was notified. V15 confirmed the facility should have implemented EBP for R32, which is a measure to prevent infections.

Based on observation, interview, and record review, the facility failed to document wound assessments, failed to complete physician ordered wound treatments, failed to initiate a physician ordered antibiotic to treat an infected wound, failed to ensure the involvement of a wound specialist as ordered, and failed to ensure a wound bed was protected from contamination and not subjected to access by flying insects. These failures resulted in R1's wound worsening and the wound subsequently becoming infested with maggots (domestic house fly larvae). These failures were identified for one resident (R1) of three residents reviewed for wounds in a sample list of eight residents. Findings include: R1's physician's orders [REDACTED]. R1's hospice Team Care Plan dated 7/9/20 documents R1 was admitted to hospice care as of 3/5/20. R1's Care Plan includes an intervention dated 4/1/20 Apply treatment to left great toe and third toe. R1's Treatment Administration Record (TAR) for May 2020 includes an order Left great toe wound and Left third toe. Clean with soap and water prior to treatment. Apply Zeroform gauze to wound and wrap with (stretch roll gauze) one time daily This treatment has been marked through and DC (discontinued) has been hand written. There is no documentation to indicate who marked through this treatment and indicated it was discontinued or the date or reason this was documented. There are no wound assessments documented on the treatment Administration Record in May of 2020. R1's TAR for 6/2020 includes the following: 6/8/20 (R1) has necrotic areas 2 x 2 centimeters adjoining left foot next to great toe. The preprinted wound assessment on the TAR is not filled out. R1's TAR entry dated 6/17/20 states Left Bunion Area Unable to stage necrotic no drainage no odor. 4.5 X 2 centimeters Necrotic scab over wound. The 6/24/20 preprinted wound assessment on the TAR is not filled out but documents Left Bunion area Necrotic scab 6 X 2.5 centimeters. A hospice physician's orders [REDACTED]. Skin Prep BID (twice daily) to right middle toe necrotic area. Apply [MEDICATION NAME] cover with [MEDICATION NAME] at left great toe bunion area. Change every three days and PRN (as needed). This order was transcribed to the June 2020 TAR. It is initialed as completed 6/20/20. It is circled as refused 6/23/20. There is no treatment signed off as being completed on the June 2020 TAR after 6/20/20. R1's Resident Transfer form dated 7/1/20 by V15, Licensed Practical Nurse (LPN) documents R1 was transferred to the local hospital for maggots in wound on Left foot. On 9/15/20 at 5:05PM V15 stated This wound was facility acquired. The maggots were not only on top of the wound, but embedded in the wound. There was no way I could get them out. They were just too deep. I let (V6 Medical Director) know and called the family. I sent (R1) out to the emergency room . I would say we often have a fly issue in the facility. It can get pretty bad. After (R1) had the maggots they put up fly strips and it has gotten better. I don't think (R1) ever went to wound clinic or saw a wound doctor. R1's hospice Clinical Note dated 7/1/20 documents by V16, Registered Nurse (RN) documents Triage notified that facility had called. Call placed to (V15) at facility and she stated that she found at least 20 maggots on (R1's) left great toe and bunion area. (V15) removed what she could but needed help with the rest. Wound treatment had been in place but upon assessment there was no dressing on area per CNA (Certified Nurse Aide) when she noticed the maggots. My assessment: I saw at least ten full maggots and there were more embedded in the skin on the toe area. Emergency Medical Services showed up shortly after I arrived because Power of Attorney wanted (R1) to be sent out for further evaluation. (R1) did return from the hospital before the end of the night and they did no treatment per (V17) facility nurse. (V17) said there is a referral for a wound doctor to follow up. R1's discharge orders from the hospital (7/1/20) document (R1) to be followed in (local hospital) wound clinic on Wednesdays. There is no documentation this order was ever followed. emergency room practitioner also ordered [MEDICATION NAME] (antibiotic)100 milligrams two times daily for R1's foot wound infection. R1's progress note dated 7/1/20 at 9:45PM documents Unable to start antibiotic due to not in convenience box. There is no documented evidence that this antibiotic was ever administered. There is an order for [REDACTED]. Went to ER (emergency room ). (V14) wound physician will follow. There is no documentation this order was followed. On 9/14/20 at 9:00AM V2, Director of Nursing (DON) stated (V14, wound physician) hasn't come out since March 2020, verifying that R1 was never seen by V14 in the facility. On 9/15/20 at 10:03AM V6, former Medical Director stated he was aware of the maggots (in R1's wound). I ordered (V14) wound physician to see (R1). I was not notified that (V14) was not following (visit/assessment/treatment) (R1). The presence of maggots in a wound indicates poor care. Flies crawl on filth and then the wound. I know the hospital put (R1) on an antibiotic and then hospice ordered a different antibiotic for infection of the left foot wound. I would say that maggots in this wound indicates it was not covered for some time and if the wound had been clean the maggots would not have developed. The facility's policy Skin Condition Monitoring revised 1/2018 states: Documentation of a skin abnormalities must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: a. Characteristic: 1. Size 2. Shape 3. Depth 4. Odor 5. Color 6. Presence of granulation or necrotic tissue b. Treatment and response to treatment. Observe and measure pressure ulcers at regular intervals. c. Prevention techniques that are in use for the resident.

Based on record review and interview, the facility failed to safely reposition and supervise a resident (R7) with a known history of falls. These failures resulted in R7 falling two separate times, sustaining a fracture with laceration on the first incident and multiple facial fractures with the second incident. Both incidents required emergency medical treatment. R7 is one of four residents reviewed for incidents and accidents in the sample list of 23. Findings include: R7's Physician order [REDACTED]. The Minimum Data Set (MDS) for R7 dated 10/14/19 documents R7 as being severely cognitively impaired and R7's behaviors are worse. This same MDS documents R7 needing the extensive assistance of one staff member for bed mobility and R7 as not steady when moving from a seated position to standing, walking, turning around while walking and surface to surface transfers. A facility document titled Fall Risk assessment dated [DATE], 10/14/19 and 1/07/20 assess R7 as high risk for falls. 1. A facility report titled AIM (Assess, Intercommunicate, Manage) for Wellness dated 12/2/19 documents Resident found on floor - fell out of bed while CNA (V9 Certified Nursing assistant) was turning (R7) for incontinence care. Writer found (R7) with (R7's) body facing the floor, prone position. Writer seen blood coming from somewhere and it was (R7's) left 5th digit. The top of the digit was flapped over. Ambulance was called. A signed statement by V9 documents that V9 was changing R7 and rolled R7 to the right side and R7 rolled out of the bed. emergency room Notes dated 12/2/19 document the following: Fall, Contusion of multiple sites and Fingertip avulsion. An X-ray report of R7's Left Fifth Digit dated 12/2/19 and signed by V13, Radiologist documents the following: Findings: Distal tuft comminuted fracture. There may be partial amputation of the distal bone. Significant laceration and distal soft tissue amputation. Impression: Fracture and possible minimal amputation at the distal tip of the left index finger. An Addendum dated 12/2/19 and signed by V13 documents: The left fifth finger was imaged, not the second finger (index). The findings previously dictated are regarding the left fifth finger. emergency room Notes dated 12/2/19 document R7 being discharged back to the facility with 2 internal sutures, 12 external sutures to the Left fifth digit and started on an antibiotic. On 1/22/20 at 1:00 pm, V2 Director of Nursing confirmed that V9 had rolled R7 in the bed while providing incontinence care and R7 rolled off the bed, resulting in an injury and was sent to the emergency room . V2 stated there should have been better control when (R7's) leg slung over. (V9) was in-serviced on safe repositioning. 2. A facility AIM for Wellness report dated 1/11/20 documents R7 falling while trying to self ambulate from a wheelchair while in the hallway, receiving a posterior head injury of a hematoma. R7's Care Plan (current) documents interventions for the 1/11/20 fall as 15 minute checks and to place an alarm in R7's wheelchair. There was no documented evidence of 15 minute checks as proposed by the facility for R7. A facility AIM for Wellness report dated 1/13/20 documents the following: Fall with head injury, Nurses were getting report when heard sounds in dining room, went to dining room and observed resident lying supine on the floor. Wheelchair a couple feet away at table where (R7) usually sits. Observed blood from left nose, other nurse applied pressure and attended to resident while writer called 911. The report is signed by V8, Registered Nurse. emergency room Notes dated 1/13/20 document the following for R7: CT (Computed Topography) Head without contrast dated 1/13/20 at 7:38 AM and signed by V14, Radiologist. Clinical Indication: Injury/Trauma: Fall Impression: 1. Comminuted depressed/displaced fracture involving the anterior wall of the left maxilla as well as the lateral wall of the left maxilla. Fracture extends to and involves the inferior orbital wall. Much of the inferior orbital wall is displaced inferiorly within the maxillary sinus. Soft tissue about the inferior rectus muscle/enlargement of the left inferior rectus muscle likely hematoma. No entrapment. Large amount of periorbital fat extends inferiorly into the left maxillary sinus. 2. Comminuted Displaced [MEDICAL CONDITION] orbital wall. 3. Mildly Displaced nasal fractures. On 1/21/20 at 10:00 am, R7 was sitting in a wheelchair in the hallway. There was no alarm in the wheelchair at this time. R7 had a mechanical lift sling in place. R7's left side of face was purple from the forehead, extending to the left eye, nose, cheek and down the left side of R7's neck. On 1/22/20 at 1:00 pm. V2 confirmed R7 was left in the facility dining room unsupervised and was aware that R7 had a previous fall from the wheelchair while trying to self-ambulate (1/11/20 fall). V2 stated R7 should not have been left unattended in the dining room. On 1/24/20 at 12:10 pm V8 stated there was no alarm in R7's wheelchair on the morning of 1/13/20. V8 stated R7's fall happened at shift change and V8 was getting report from the 3rd shift Nurse. V8 also confirmed R7 was unsupervised in the dining room at the time of the fall. On 1/24/20 at 2:45 pm, V1 Administrator acknowledged awareness of the above falls for R7 and confirmed the falls did cause injury.

Based on interview and record review, the facility failed to provide safety for a resident (R1) during transportation via the facility van. This failure resulted in R1 falling out of the facility van in a wheelchair and sustaining two fractures (neck and finger), two facial lacerations, and a forehead hematoma. R1 is one of three residents reviewed for falls in the sample of three. Findings include: On 6/7/18, V1 Administrator, provided an incident investigation dated 4/23/18, for R1. This investigation documents R1 sustained a fall on 4/23/18 at 10:46 AM, which resulted in R1's injury of C2 (2nd cervical) neck fracture, right index finger fracture, and multiple contusions/abrasions to (R1's) face and limbs. R1's Minimum Data Set (MDS), dated [DATE], documents R1 being cognitively intact and having bilateral lower extremity impairment requiring a walker and/or wheelchair for ambulation. R1's Fall Risk assessment dated [DATE], documents R1 as being a high fall risk. R1's Trauma Surgery Discharge Summary from (acute care hospital), dated 4/25/18, documents: male (R1) admitted to the Trauma Service after an accident involving R1's wheelchair rolling off a van ramp during nursing home transport and falling off the wheelchair sustaining the following Diagnoses: [REDACTED]. This Discharge summary also documents R1 was admitted to the hospital, a C (cervical) collar was placed for R1's fracture of C2, and two lacerations on R1's left supraorbital area were repaired in the emergency room . R1's CT (Computed Tomography) of R1's facial bones dated 4/23/18, document moderate left forehead hematoma and acute fracture involving the odontoid base. R1's CT of R1's cervical spine dated 4/23/18, document acute fracture involving the base of the odontoid with 3mm (millimeters) of posterior displacement of the odontoid. R1's MRI (Magnetic Resonance Imaging) dated 4/23/18, documents acute fracture at the base of the dens, with 3mm of posterior subluxation in relationship to the body of C2. (Acute care hospital's) Minor Procedure Note regarding R1, dated 4/23/18, documents two lacerations, each 6cm (centimeters) long, were repaired with sutures. R1 received a prescription at discharge on 4/25/18 that documents Aspen Vista Cervical Collar for [DIAGNOSES REDACTED]. On 6/7/18 at 10:51 AM V2, Maintenance Director stated on 4/23/18, the person who usually drives the van was not at facility so V2 was asked to drive the van. V2 stated V2 was shown how to get residents in and out of the van with their wheelchairs but was not anything about whether or not to leave the side door opened or closed. V2 stated R1 was facing the front of the vehicle. V2 stated V2 unlocked the right side brake and then the left side brake and when V2 undid the left brake, R1 went rolling out the side doors of the van. V2 stated there were no seatbelts or locks on the wheelchair when R1 rolled out of the van. V2 stated R1 was then found on the ground face down. On 6/7/18 V1 Administrator stated V1 asked V2 to drive the van on 4/23/18 because the usual driver called off that day. V1 stated there were no set back-up drivers for the van in case the person who usually does it couldn't do it. V1 stated there was no back-up plan for a driver for the van on this day. V1 also stated V1 could not find any instructions regarding transferring residents in and out of the van and no instructions on when the side and back doors should be opened and closed. V1 stated the usual driver of the van has had training for safety and the maintenance director has not had training. On 6/12/18 at 11:41 AM V3 Medical Doctor for R1, stated the injuries R1 sustained on 4/23/18, were caused from the fall (out of the van). On 6/14/18 at 8:15 AM R1, who was discharged from the facility, stated R1's wheelchair was unlocked and R1 went out the door and fell on R1's face with the wheelchair on top of R1. R1 stated you have no idea how scary it was to be lying on the pavement face first. R1 stated the accident was very scary for me. R1 stated R1 broke R1's finger and still has to wear a neck brace. The facility's Transportation Driver Policy, undated, documents responsibilities: attends staff meetings and in-servicing. On 6/12/18 at 1:35 PM V1 Administrator, stated there is no van safety transport inservices that have been done.

Based on interview and record review facility staff failed to provide supervision to prevent one resident (R1), requiring physical assistance of staff, from rolling off the bed onto the floor. This failure resulted in R1 sustaining a fracture of the fourth cervical vertebra. R1 is one of three residents reviewed for falls in a sample of three. Finding include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R1 is severely cognitively impaired, requires total assistance with one staff for bed mobility and assistance of two staff for transfers with the aid of a mechanical lift. The Nursing Progress Review dated 9/2/15 documents R1 needs the assistance of two staff for bed mobility and transfers with the use of a mechanical lift. R1's care plan states (R1) to be free from injury related to falls and (R1) has padded full side rail to be in the up position while in bed to facilitate safe care. (R1) makes random and sudden movements that place her at increased risk for falls. R1's Fall Risk Assessments dated 7/6/15 and 4/20/15 documents R1 to be High Risk for falls. R1's Nurses Notes dated 9/13/15 at 1:15 states Writer was called to room by CNA.(Certified Nurses Assistant) (R1) noted to be lying on floor on side. CNA stated (R1) was in bed, CNA put rail down, turned to get supplies to change (R1) and when CNA turned back around (R1) had turned to her side by grabbing bed and was falling . blood noted from side of scalp Physician notified with order to send to emergency room for evaluation Ambulance arrived at 1:50 PM for transport to emergency room . The facility's report titled Incident Report Form-Illinois Department of Public Health Notification dated 9/13/15 stated (E6), CNA was providing care to resident while resident was in bed. CNA reached for supplies when resident rolled out of bed onto floor. CNA alerted (E7) LPN (Licensed Practical Nurse) who noted (R1) on left side with laceration to scalp Physician notified with order received to send to emergency room for evaluation .(R1) returned from emergency room at 5:45 PM with 3 staples to laceration on the scalp and fracture of fourth cervical vertebra R1's hospital records titled Diagnostic Imaging dated 9/13/15 at 2:19 PM documents under Impression: 1. C4 (fourth cervical) anterior vertebral body fracture with fracture extending through the adjacent anterior osteophyte . R1's Emergency Department Report dated 9/13/15 documents under Present Illness- (R1) is a [AGE] year old Female who presents to the emergency department after rolling out of bed at the Nursing Home. Discharge Impression: Laceration of scalp, Fracture of fourth cervical vertebra, Fall from bed. E6, stated on 9/18/15 at 2:16 PM I was changing (R1) and (R1) was in the bed and the bed rail was down. I realized I did not have her clean brief so I turned around to pick up the clean brief and heard (R1) starting to roll out of bed. I tried to catch her to ease the fall but was unable to. (R1) was on the edge of the bed and the bed rail was down and I did turn away .I told the nurse immediately. E1, Administrator confirmed E6 did turn away from R1 and R1 rolled out of bed and sustained a fracture and scalp laceration. The facility's undated policy titled Fall Prevention states All staff to provide for resident safety and to minimize injuries related to falls .established a visual alert system to check those at risk.

Based on observation, interview, and record review the facility failed to safely transfer one (R1) of eleven residents in the sample of eleven reviewed for transfers and falls. This failure resulted in R1 falling and sustaining a left humeral fracture and right scapular fracture. Additionally, R1 was transferred improperly, during the use of a gait belt, as R1 was held at the location of her injury. Findings include: 1.The facility Transfer Belts/Gait Belts policy dated 4/10/06 documents gait belts promote safety in transferring and ambulating residents and are used if one is indicated on the residents care plan. The gait belt is to be placed around the resident's waist and staff are to grasp the secured gait belt to provide stability and balance during the transfer. The Physician order [REDACTED]. The Care Plan dated 5/4/15 documents R1 needs to be transferred and ambulated with one staff assist, a gait belt, and a walker. The Fall Risk assessment dated [DATE] documents R1 as high risk for falls. R1 requires assist to stand, has loss of balance while standing and walking, and has right lower extremity weakness. The Minimum Data Set ((MDS) dated [DATE] documents R1 is cognitively intact and ambulates and transfers with the assistance of at least one person. The same MDS documents R1 is not steady and is only able to stabilize with staff assistance while walking and transferring. The undated Final Fall Report documents R1 fell on [DATE] when exiting the shower room. E3 Certified Nursing Assistant (CNA) was helping R1 to walk out of the shower room. E3 went to open the door and when she turned around R1 was falling backward. Following the fall, R1 complained of pain in her left arm and was sent to the emergency room for evaluation. R1 sustained a left humeral fracture and right scapular fracture due to the fall. The Fracture Clinic Consult Report dated 7/31/15 documents R1 went for a follow up appointment and it was confirmed that R1 sustained a left humeral fracture and right scapular fracture. On 8/18/15 at 11:00 AM, E3 CNA stated that on 7/24/15, she completed R1's shower and was helping her walk out of the bathroom with a gait belt and walker. E3 stated she needed to open the shower room door, so she stepped forward and let go of R1's gait belt. When E3 turned back around, R1 was falling backwards. On 8/18/15 at 3:00 PM, E2 Director of Nursing (DON) stated on 7/24/15, when exiting the shower room, E3 CNA should have kept her hand on R1's gait belt at all times. E2 stated E3 was disciplined for failure to follow proper procedure when transferring a resident with a gait belt and an in service on the gait belt policy and the proper use of gait belt use was given to all direct care staff. The Nursing Progress Review dated 7/27/15 documents R1 had a fall on 7/24/15 when exiting the shower room. The root cause is listed as loss of balance and staff error. The prevention interventions are listed as staff education and discipline. 2. On 8/19/15 at 11:05 AM, E7 CNA and E8 CNA transferred R1 from her recliner to the wheelchair. E8 placed the gait belt around R1's waist and grasped the gait belt in the front and back of R1. E7 grabbed the gait belt in the back of R1 with one hand and grasped under R1's right arm, at the location of the scapular fracture, with the other hand. Both E7 and E8 lifted R1 into a standing position and turned her towards the wheelchair. E7 let go of the gait belt and pulled the wheelchair closer, while only supporting R1 by her right arm. R1 grimaced when E7 let go of the gait belt. On 8/19/15 at 11:45 AM, E3 DON stated, during the transfer E7 CNA should have kept both hands on R1's gait belt and should not have been supporting R1 by her arm, especially since both arms had been recently fractured. E3 stated the training staff just attended a class on safe transferring and will be sharing the information with the rest of the direct care staff.

Based on record review and interview the facility failed to follow manufacturer's guidance and facility protocol for a mechanical lift transfer. The willful action of staff to transfer a resident with the assistance of one staff person instead of two resulted in neglect of R1. R1 sustained a fall from the mechanical lift which resulted in a [MEDICAL CONDITION] femur. R1 is one of 4 residents reviewed for falls in the sample of four. Findings include: The Physician order [REDACTED]. The Minimum Data Set (M.D.S.) assessment, Section G, dated 11-18-14 indicated R1 required staff assistance for all activities of daily living and required the assistance of 2 staff members for transfers. The Resident Care Plan dated 8-14-14 documents that transfers are to be accomplished with a mechanical lift with the assistance of two staff members. The Facility 'Low Lift' Policy (not dated) describes the procedure for the use of mechanical lifts. The policy states: "Training of all licensed and unlicensed nursing personnel initially, upon introduction of equipment to the home, and annually will be conducted by Nursing Administration and/or equipment vendor. All new employees shall demonstrate to licensed personnel the ability and knowledge of lift operation prior to use of any lift on a resident. Lifting of residents without the aid of lifting equipment and/or assistance will not be permitted." Nurses Notes dated 12-4-14 at 7:05 PM state: "CNA (Certified Nurse Aide) (E2) stated the (mechanical lift) sling that was under resident was not on properly, CNA was adjusting resident and sling to transfer and resident started sliding out of wheelchair. CNA safely and slowly lowered resident to floor." Physical exam revealed "range of motion within normal limits for resident, no complaints of pain, no external rotation of the lower extremities." Nurses Notes dated 12-5-14 at 8:30 AM document that R1 complained of left knee and hip pain. A portable x-ray was ordered by the attending physician (Z1) showing an acute slightly impacted [MEDICAL CONDITION] femur. R1 was transferred to a local emergency roiagnom on (12-5-14 at 1:30 PM). The x-ray report dated 12-5-14 documents the following impression: "Acute slightly impacted fracture distal medial metaphyseal area of the femur." The mechanical lift user's manual states on page 11 - ". . . highly recommends that at least two caregivers be present." Mechanical Lift educational training was conducted by Nursing Administration on 10-10-14 and 12-5-14. These trainings were mandatory (according to E1) and attended by all CNAs. Return demonstrations of the lift protocol was conducted. The Inservice Training sign-in sheet documents the attendance of E2 on 10-10-14. The document (not dated) entitled 'C.N.A. In-Service for (mechanical) Lift' describes the protocol steps discussed during inservices. The final protocol step states - "Never use a mechanical lift by yourself - always assure there is a minimum of two nursing staff during transfers with a mechanical lift". This document was written by E1 (Administrator). On 1-29-15 at 9:50 AM E1 stated: "Hoyer lifts require two assistants. The CNA (E2) did the lift alone. She (E2) is no longer employed by the Facility."

Based on interview and record review the facility failed to utilize two staff for mechanical lift transfers for one of four residents (R1) reviewed for falls on the sample of four. This resulted in R1 sustaining a fall from the lift and fracture of the distal left femur. Findings include: The Physician order [REDACTED]. The Minimum Data Set (M.D.S.) assessment, Section G, dated 11-18-14 indicated R1 required staff assistance for all activities of daily living and required the assistance of 2 staff members for transfers. The Resident Care Plan dated 8-14-14 documents that transfers are to be accomplished with a mechanical lift with the assistance of two staff members. The Facility 'Low Lift' Policy (not dated) describes the procedure for the use of mechanical lifts. The policy states: "Training of all licensed and unlicensed nursing personnel initially, upon introduction of equipment to the home, and annually will be conducted by Nursing Administration and/or equipment vendor. All new employees shall demonstrate to licensed personnel the ability and knowledge of lift operation prior to use of any lift on a resident. Lifting of residents without the aid of lifting equipment and/or assistance will not be permitted." Annually Mandated Inservices by the corporate owner group list 'Mechanical Lifts' as an 'Accident Prevention' topic. This document is dated 8-2007 with revision on 7--22-13. According to E1 on 1-29-15 at 9:50 a.m. the key topics listed are to be inserviced annually to all personnel. R1's Nurses Notes dated 12-4-14 at 7:05 PM state: "CNA (Certified Nurse Aide) (E2) stated the (mechanical lift) sling that was under resident was not on properly, CNA (E2) was adjusting resident and sling to transfer and resident started sliding out of wheelchair. CNA (E2) safely and slowly lowered resident to floor." Physical exam revealed "range of motion within normal limits for resident, no complaints of pain, no external rotation of the lower extremities." Nurses Notes dated 12-5-14 at 8:30 AM document that R1 complained of left knee and hip pain. A portable x-ray was ordered by the attending physician (Z1) showing an acute slightly impacted fracture of the distal femur. R1 was transferred to a local emergency roiagnom on [DATE] at 1:30 PM. The x-ray report dated 12-5-14 documents the following impression: "Acute slightly impacted fracture distal medial metaphyseal area of the femur." The mechanical lift user's manual states on page 11 - ". . . highly recommends that at least two caregivers be present." Mechanical Lift educational training was conducted by Nursing Administration on 10-10-14 and 12-5-14. These inservices were mandatory (according to E1) and attended by all CNAs. Return demonstrations of the lift protocol was conducted. The Inservice Training sign-in sheet documents the attendance of E2 on 10-10-14. The document (no date) entitled 'C.N.A. In-Service for (mechanical) Lift' describes the protocol steps discussed during inservices. The final protocol step states - "Never use a mechanical lift by yourself - always assure there is a minimum of two nursing staff during transfers with a mechanical lift." This document was written by E1 (Administrator). E1 (Administrator) stated on 1-29-15 at 9:50 AM "Hoyer lifts require two assistants. The CNA (E2) did the lift alone. She (E2) is no longer employed by the Facility." E3, E5, and E6 were interviewed during the observation (1-29-15 at 1:00 PM) of mechanical lift transfer. All responded that two or more staff should be present for lift transfers.

Based on observation, interview and record review the facility failed to administer pain medication patches as ordered to two of two residents reviewed for pain in the sample of seven.This failure resulted in severe pain preventing R2 and R6 from getting out of bed and participating in activities that they regularly attend. Findings include: R2 and R6 ' s October 2013 physician's orders [REDACTED]. The September 2013 Physician order [REDACTED]. According to the September 2013 Physician order [REDACTED]. According to the September 2013 Physician order [REDACTED]. The September 23 and 30, 2013 and October 7 and 14, 2013 facility Pharmacy Alert Director of Nursing Notification Fax Forms indicate that [MEDICATION NAME]es were in need of being refilled for both R2 and R6. On October 16, 2013 at 11:05am Z1 (Pharmacy Operations Manager) stated "we fax the Director of Nursing (DON) on Monday every week to inform the DON that Scheduled II medication needs a script (prescription) or when it will run out. The facility sends us the bar code when they are ready for the refill." On October 15, 2013 at 4:15pm E4 Licensed Practical Nurse (LPN) stated that she was aware that R6 had no [MEDICATION NAME]es and reported this to E4's trainer (unknown nurse). E4 had circled the dates on the MAR indicated [REDACTED]. E4 stated "I don't know why we are still out, that is why I give (R6) her Tylenol." R6's October 2013 MAR indicated as needed" 11 times since the first missed [MEDICATION NAME] October 4, 2013. On October 17, 2013 at 10:40am , E2 (Medical Director) stated "I was not aware that these residents had not received the [MEDICATION NAME]es." On October 17,2013 at 10:50am E1 (Administrator) stated " my DON takes care of this." E1 confirmed the discrepancy on R2 and R6's MAR's and Controlled Substance Use Forms stating " Yes, I can see the missed doses." On October 17,2013 at 11:45 E6 (Registered Nurse/RN -Facility Corporate Representative) confirmed the same discrepancies on R2 and R6's MAR's and Controlled Substance Use Form and stated "Yes there are missed doses. The DON should have checked these Schedule II when she received the faxes (Pharmacy Alert DON) each week." Facility employment records show the facility's DON position to be vacant October 8-15, 2013. On 10/17/2013 at 10:30am R2 was laying in bed with a cervical collar around (R2's) neck stated " I have a headache that is a definite 10 on a pain scale of 10. I have had to tell the nurses it is time for a new patch because the pain gets too great, so I know the patch is not working. I attend bingo with my daughter and now I can barely tolerate going. I also have to miss church here because my pain is too great to go. I just stay in bed alot." On 10/16/13 at 10:25 am R6 was observed leaning from (R6's) wheel chair over to (R6's) bed and stated "I am always in a lot of pain. Sometimes I have to lay down in my bed, close my eyes and pray a little." On 10/17/13 at 9:40am R6 was laying in bed and stated (R6's) pain was estimated to be 8 out of 10 (described as severe) and stated that "when I was not receiving my pain patch, I could not tolerate going to activities I really usually enjoy. I was too uncomfortable to play games or do crafts. A few times I just layed back in bed and hoped my medicine would kick in. I had no idea that I didn't receive my patch some nights, but it makes sense to me now."

Based on interview and record review staff neglected to operationalize the policy on Head Trauma for R1 who was experiencing headache and nausea following trauma to the head, resulting in a delay in medical treatment for [REDACTED]. R1 is one of three residents reviewed with falls, in the sample of three. These failures resulted in an Immediate Jeopardy situation for R1. While the immediacy was removed on 5/23/13, the facility remains out of compliance at a severity level two. The facility is still in the process of implementing new policies and monitoring the effectiveness of staff training on existing policies. Findings include: The Head Trauma Policy dated 2/2003 states it is the policy of the facility to "evaluate head injuries for a minimum period of 72 hours, to determine any negative effects, and to allow for immediate treatment to minimize permanent damage......The following procedure focuses on proper assessment of residents who have sustained a head trauma:....Assess the resident including vital signs, consciousness and neurological status....Ongoing assessment(vital signs and neuro(neurological)checks should take place as follows: a) initially and every 15 mins(minutes) for 1 hour b) every 30 mins x 1 hour c) every hour for 4 hours d) Every 4 hours for 8 hours e) Every shift for the remainder of 72 hrs.....Assessments for the first 24 hours after injury shall be recorded on the Neuro(Neurological)/Head Trauma Assessment form. Additional documentation shall be recorded in the clinical record......Signs of increased cranial pressure must be reported to the physician immediately. These signs are as follows: Nausea and Vomiting, Headache.........." The Nurse's Notes dated 5/18/13 at 3:45pm state, "(R1's) call light on...(R1) laying in bed-walker was overturned next to closet-(R1) stated he just fell -had lg(large) hematoma L(left) forehead ......Neuro's(neurological) WNL(with in normal limits)...pupils equal. (No) unusual pain just discomfort....." On 5/22/13 at 2:30pm E4, RN(Registered Nurse), stated that she notified Z2, On Call MD(Medical Doctor) and told him that R1 fell . E4 stated she did not tell Z2 that R1 was receiving [MEDICATION NAME] and Aspirin. When asked why she didn't tell Z2 about the anticoagulants R1 was receiving, E4 stated, "I kind of knew it([MEDICATION NAME]) was preventative for stroke. I thought it was more like [MEDICATION NAME], but did not thin the blood as much as [MEDICATION NAME] or [MEDICATION NAME]." The Neuro/Head Trauma assessment dated [DATE] at 3:45pm and 4:00pm documents R1 had no headache or nausea. The Neuro/Head Trauma assessment dated [DATE] at 4:15 and 4:30pm documents that R1 had "sl(slight)" headache, but no nausea. At 4:45 and 5:15pm the assessment documents that R1 had a headache and nausea. The Neuro/Head Trauma assessment dated [DATE] at 5:45pm documents that R1 had a headache, but the nausea was "better." There is no documentation in the Nurse's Notes dated 5/18/13 that Z2, On Call MD was notified of the change in R1's condition. On 5/22/13 at 2:30pm E4, RN(Registered Nurse), stated that R1 had "no headache, just general ache" when first assessed on 5/18/13 at 3:45pm. E4 stated the first time R1 mentioned a headache was on 5/18/13 at 4:15pm. E4 stated that R1 had "no nausea" when assessed on 5/18/13 at 3:45, 4:00, 4:15 and 4:30pm. E4 stated R1 complained of nausea at 4:45 and she gave him [MEDICATION NAME] for his nausea(5:10pm). E4 stated that she called Z2 when R1 fell initially and did not call him again. When asked why she didn't call Z2, MD, to report R1's headache and nausea, E4 stated, "It wasn't a bad headache, when I asked him(R1) he said he had a headache, a slight headache where he hit his head. It didn't scream out to me to call the Doctor(Z2) again." E4 stated she gave report to E2, RN, Director of Nursing(DON) the oncoming nurse at 6:00 pm. The Neuro/Head Trauma assessment dated [DATE] at 6:45, 7:45, 8:45 and 9:45pm documents that R1 had a headache and nausea. The Nurse's Notes dated 5/18/13 at 8:00pm state, "(R1) resting in bed. Ice applied to hematoma located at R(right) temple, Neuro (check) WNL V/S(vital signs) stable. (R1) alert." There is no further documentation in the Nurse's Notes until 10:30pm. The Nurse's Notes dated 5/18/13 at 10:30pm state, "(R1) c/o(complains) of pain and N/V(nausea/vomiting) noted. Neuro (check) cont(continue) to be WNL. MD(Z2) notified and sent to ER for eval(evaluation)..." On 5/22/13 at 3:00pm E2, RN, DON, stated R1 had a fall on 5/18/13 at 3:45pm and neurological assessments were started. E2 stated R1 had no increase in pain and she did not "feel (R1) was any different than before the fall", neuro's normal. E2 stated that R1 had a bruise to the right forehead above the eyebrow and ice was applied. E2 confirmed she documented that R1 had a headache and nausea at 6:45, 7:45, 8:45 and 9:45pm on the Neuro assessment dated [DATE]. E2 stated she did not call Z2, On Call MD until 10:30- or 10:45pm on 5/18/13, when R1 had a "pounding headache and vomiting." On 5/22/13 at 1:45pm Z2, On Call Physician, stated he remembered being called about R1's fall. When asked his opinion if the onset of R1's headache(4:15pm) and nausea(4:45pm) constituted a change in R1's condition, Z2 stated, "With the headache and nausea, Yes, should send (R1) to ER." The Emergency Medical Services Report dated 5/18/13 at 11:25pm states, "......found (R1) supine in bed, attended by RN(E2) vomiting into a basin.....has hematoma.......on front R side of head with bruising and some bleeding......(R1) sluggish to respond but is A&O(alert & orientated) x 4 and answering appropriately.Reports pain 'everywhere' in head, primarily site of hematoma and posterior midline (cervical) spine and occipital region. Staff reports that (R1) fell seven and a half hours ago, and did not call 911 despite head injury and (R1) being on [MEDICATION NAME] to ED(emergency department)....(R1's) responses became shorter and more delayed....." The Emergency Department Report dated 5/19/13 states that R1 was seen by Z3, Emergency Physician on "5/18/13 (at) 11:48pm." The report states, ".....(R1) presents....with head injury.......has a large hematoma to his right temple.(R1) appears confused .......says he is nauseous.....feels 'miserable'.....(R1's) mental status and obvious head injury while (on) [MEDICATION NAME] were concerning for a likelihood of [MEDICAL CONDITION]..taken to CT(Computerized Tomagraphy)....which showed a large right-sided subdural underlying his hematoma. When (R1) returned from (CT) scan we were unable to wake him......Preliminary Clinical Impression...Subdural hematoma due head trauma..Coagulopathy....." The Final Diagnostic Report dated 5/18/13 at 11:51pm of "head without contrast" states, "Large right holohemispheric acute subdural hematoma resulting in 9mm(millimeter) of leftward midline shift and moderate cerebral [MEDICAL CONDITION].Small left middle cranial fossa and tentorial subdural hematoma and moderate diffuse subarachnois hemorrhage...." On 5/22/13 at 11:50am Z3, Emergency Physician stated, when he first saw R1 he had a hematoma on his right temple from a fall. Z3 stated his "biggest concern (for R1) was the [MEDICATION NAME]." Z3 stated when a patient comes to the Emergency Department with "evidence of head trauma and is on [MEDICATION NAME], (Z3) will routinely admit to the hospital for monitoring for 24 hours." Z3 stated once R1's "headache and nausea started, even a slight headache they should have called (the Physician)." Z3 stated the headache was "significant." When asked if in his opinion neglect of R1 occurred, Z3 stated, "If (R1) has a headache, on [MEDICATION NAME] and they waited 6 hours before calling (the Physician). I feel like that's neglect." The Emergency Department Report dated 5/19/13 states that R1 was transferred from the initial Emergency Department to a Regional Trauma Center. The Regional Trauma Center Consultant History and Physical dated 5/19/13 states, "Ct of head: Large right subdural hemorrhage, seen to be increased since yesterday.......Neuro...Large SDH(Subdural Hematoma) with midline shift, traumatic....Evaluated by Neurosurgery, non operable.......Need to discuss with family...poor prognosis and massive ICB(Intracranial Bleed)...." The Regional Trauma Center Discharge Summary dated 5/20/13 states, "(R1) passed away as expected, he was pronounced at 11:55pm on 5/19." On 5/23/13 at 12:40pm an Immediate Jeopardy was identified. The Immediate Jeopardy situation began on 5/18/13 at 4:15pm when R1 who was receiving anticoagulants, developed a headache, following a fall, and staff did not recognize R1's headache and nausea as signs of increasing intracranial pressure and failed to immediately notify the Physician. E1, Administrator, was notified of the Immediate Jeopardy on 5/23/13 at 12:40pm. It was confirmed through interview and record review that the facility took the following actions to remove the immediacy: 5/23/13- All licensed nurses were inserviced on the facility policy on Head Trauma including the signs of increasing intracranial pressure, immediate notification of the Physician of changes in neurological status and documentation of neurological checks by E5, RN Consultant. 5/23/13-All licensed nurses were inserviced when notifying the Physician of a resident fall, to inform the Physician what medications the resident is receiving, including anticoagulants.

Based on interview and record review staff failed to recognize [MEDICATION NAME] as an anticoagulant agent and failed to notify the Physician that R1 who had a fall with head trauma was receiving [MEDICATION NAME]. Staff failed to recognize and immediately report R1's headache and nausea to the Physician as signs of increased intracranial pressure, delaying medical treatment for [REDACTED]. R1 is one of three residents reviewed with falls in the sample of three. These failures resulted in an Immediate Jeopardy situation for R1. While the immediacy was removed on 5/23/13, the facility remains out of compliance at a severity level two. The facility is still in the process of implementing new policies and monitoring the effectiveness of staff training. Findings include: The physician's orders [REDACTED]. The hospital Discharge Summary dated 5/11/13 states R1 has [DIAGNOSES REDACTED].The summary states, "....We stopped the aspirin and [MEDICATION NAME] because of the bleeding problem....Discharge Medications:......Continue [MEDICATION NAME] 75mg(milligrams) daily....Aspirin 81mg to be given next week onwards..." The physician's orders [REDACTED].Aspirin 81mg...take one tablet daily.." The Medication Record dated 5/11-5/31/13 document the [MEDICATION NAME] and Aspirin being given daily 5/12-5/18/13. The physician's orders [REDACTED]. The PRN Medication Record dated 5/11-5/31/13 documents the [MEDICATION NAME] being given multiple times for pain greater than 8, on a scale of 1-10, with 10 being the worst pain. The record documents that R1 does get relief of pain from the medication. The physician's orders [REDACTED]. The PRN Medication Record dated 5/11-5/31/13 does not document any [MEDICATION NAME] being given until 5/18/13 at 5:10pm. The Nurse's Notes dated 5/18/13 at 3:45pm state, "(R1's) call light on...(R1) laying in bed-walker was overturned next to closet-(R1) stated he just fell -had lg(large) hematoma L(left) forehead et(and) L wrist area.....Neuro's(neurological) WNL(with in normal limits)...pupils equal. (No) unusual pain just discomfort.....Applied ice to area..." At 4:00pm the Nurse's Notes state, "MD(Medical Doctor, Z2) notified." On 5/22/13 at 2:30pm E4, RN(Registered Nurse), stated that she notified Z2, On Call MD and told him that R1 fell . E4 stated she did not tell Z2 that R1 was receiving [MEDICATION NAME] and Aspirin. When asked why she didn't tell Z2 about the anticoagulants R1 was receiving, E4 stated, "I kind of knew it([MEDICATION NAME]) was preventative for stroke. I thought it was more like [MEDICATION NAME], but did not thin the blood as much as [MEDICATION NAME] or [MEDICATION NAME]." E4 stated that Z2 told her to "monitor" R1, but "he implied if (R1's) condition changed to send (R1) to ER(emergency room )." The instructions on the undated Neuro/Head Trauma Assessment state, "Record vital signs in appropriate box. Place an (x) in each box for each symptom found. Notify the physician if any abnormal results are found. Assess as follows: a) initially and every 15 mins(minutes) x(times) 4; b) every 30 mins x 1 hr(hour); c) every 1 hr x 4 hours; d) every 4 hours x 8 hrs; and e) every shift for remainder of 72 hrs." The Neuro/Head Trauma assessment dated [DATE] at 3:45pm and 4:00pm documents R1 had no headache or nausea. The PRN Medication Information documents on 5/18/13 at 4:00pm R1 was given [MEDICATION NAME]-[MEDICATION NAME]([MEDICATION NAME]) 5-325mg two tablets for complaint of "pain (greater than) 8", on a scale of 1-10 with 10 being the worst pain. There is nothing documented about whether the medication relieved R1's pain. The Neuro/Head Trauma assessment dated [DATE] at 4:15 and 4:30pm documents that R1 had "sl(slight)" headache, but no nausea. At 4:45 and 5:15pm the assessment documents that R1 had a headache and nausea. The PRN Medication Information documents on 5/18/13 at 5:10pm that R1 was given [MEDICATION NAME] 25mg IM for "nausea." There is no documentation in the Nurse's Notes dated 5/18/13 of R1's headache or nausea. There is no documentation in the notes that Z2, On Call MD was notified of the change in R1's condition or the need to give R1 medication for pain and nausea. The Neuro/Head Trauma assessment dated [DATE] at 5:45pm documents that R1 had a headache, but the nausea was "better." On 5/22/13 at 2:30pm E4, RN(Registered Nurse), stated that R1 had "no headache, just general ache" when first assessed on 5/18/13 at 3:45pm. E4 stated the first time R1 mentioned a headache was on 5/18/13 at 4:15pm. E4 stated that R1 had "no nausea" when assessed on 5/18/13 at 3:45, 4:00, 4:15 and 4:30pm. E4 stated R1 complained of nausea at 4:45 and she gave him [MEDICATION NAME] for his nausea(5:10pm). E4 stated that it was not unusual for R1 to have nausea, and that R1 had complained of nausea earlier in the day(5/18) and she had given him(R1) something for constipation, which took care of his nausea. E4 stated that she called Z2 when R1 fell initially and did not call him again. When asked why she didn't call Z2, MD, to report R1's headache and nausea, E4 stated, "It wasn't a bad headache, when I asked him(R1) he said he had a headache, a slight headache where he hit his head. It didn't scream out to me to call the Doctor(Z2) again." E4 stated she gave report to E2, RN, Director of Nursing(DON) the oncoming nurse at 6:00 pm. E4 stated she told E2 that R1 had a headache and nausea. The Neuro/Head Trauma assessment dated [DATE] at 6:45. 7:45, 8:45 and 9:45pm documents that R1 had a headache and nausea. The Nurse's Notes dated 5/18/13 at 8:00pm state, "(R1) resting in bed. Ice applied to hematoma located at R(right) temple, Neuro (check) WNL V/S(vital signs) stable. (R1) alert." There is no further documentation in the Nurse's Notes until 10:30pm. The Nurse's Notes dated 5/18/13 at 10:30pm state, "(R1) c/o(complains) of pain and N/V(nausea/vomiting) noted. Neuro (check) cont(continue) to be WNL. MD(Z2) notified and sent to ER for eval(evaluation)..." On 5/22/13 at 3:00pm E2, RN, DON, stated R1 had a fall on 5/18/13 at 3:45pm and neurological assessments were started. E2 stated R1 had no increase in pain and she did not "feel (R1) was any different than before the fall", neuro's normal. E2 stated that R1 had a bruise to the right forehead above the eyebrow and ice was applied. E2 confirmed she documented that R1 had a headache and nausea at 6:45, 7:45, 8:45 and 9:45pm on the Neuro assessment dated [DATE]. E2 confirmed she did not document anything in R1's record, except that he had a "headache" on the Neuro/Head Trauma Assessment Form. E2 stated, "it was a headache to the hematoma area, it was more tenderness where ice was applied, he would say to "be careful, take it easy" when putting the ice on the hematoma. E2 stated she did not call Z2, On Call MD until 10:30- or 10:45pm on 5/18/13, when R1 had a "pounding headache and vomiting." On 5/22/13 at 1:45pm Z2, On Call Physician, stated he remembered being called about R1's fall. Z2 stated "normally, especially if the head, will tell, if there is a change to send to ER." When asked his opinion if the onset of R1's headache(4:15pm) and nausea(4:45pm) constituted a change, Z2 stated, "With the headache and nausea, Yes, should send (R1) to ER." The Emergency Medical Services Report dated 5/18/13 at 11:25pm states, "......found (R1) supine in bed, attended by RN(E2) vomiting into a basin.....has hematoma.......on front R side of head with bruising and some bleeding......(R1) sluggish to respond but is A&O(alert & orientated) x 4 and answering appropriately.Reports pain 'everywhere' in head, primarily site of hematoma and posterior midline (cervical) spine and occipital region. Staff reports that (R1) fell seven and a half hours ago, and did not call 911 despite head injury and (R1) being on [MEDICATION NAME] to ED(emergency department)....(R1's) responses became shorter and more delayed....." The Emergency Department Report dated 5/19/13 states that R1 was seen by Z3, Emergency Physician on "5/18/13 (at) 11:48pm." The report states, ".....(R1) presents....with head injuy.......has a large hematoma to his right temple.(R1) appears confused and cannot answer most questioning.......says he is nauseous, has abdominal pain and feels 'miserable'.....Cannot tell me date or year. Will only follow commands after multiple prompts.......(R1's) mental status and obvious head injury while (on) [MEDICATION NAME] were concerning for a likelihood of [MEDICAL CONDITION]..taken to CT(Computerized Tomagraphy)....which showed a large right-sided subdural underlying his hematoma. When (R1) returned from (CT) scan we were unable to wake him....I spoke with (Z4, Physician) of neurosurgery.....who did not recommend Burr hole placement or Mannitol use at this time, and recommended transport....Transferred.....in critical condition....Preliminary Clinical Impression...Subdural hematoma due head trauma..Coagulopathy....." The Final Diagnostic Report dated 5/18/13 at 11:51pm of "head without contrast" states, "Large right holohemispheric acute subdural hematoma resulting in 9mm(millimeter) of leftward midline shift and moderate cerebral [MEDICAL CONDITION].Small left middle cranial fossa and tentorial subdural hematoma and moderate diffuse subarachnois hemorrhage...." On 5/22/13 at 11:50am Z3, Emergency Physician stated, his "biggest concern (for R1) was the [MEDICATION NAME]." Z3 stated in his opinion [MEDICATION NAME] is worse than [MEDICATION NAME], because there is no blood test to monitor the drug. Z3 stated there is a higher risk of bleeding with the [MEDICATION NAME] than with [MEDICATION NAME]. Z3 stated when a patient comes to the Emergency Department with "evidence of head trauma and is on [MEDICATION NAME], (Z3) will routinely admit to the hospital for monitoring for 24 hours." Z3 stated once R1's "headache and nausea started, even a slight headache they should have called (the Physician)." Z3 stated the headache was "significant." The Emergency Department Report dated 5/19/13 states R1 was transferred from the initial Emergency Department to a Regional Trauma Center. The Regional Trauman Center Consultant History and Physical dated 5/19/13 states, "Ct of head: Large right subdural hemorrhage, seen to be increased since yesterday posteriorly about parietal lobe. Appearance of left middle cranial fossa subdural hematoma. Diffuse subarachnoid blood about both hemispheres appears mildly increased. There is increasing mass effect with increased right to left midline shift. Slight further enlargement of left lateral ventricle. Mild subfalcine herniation anteriorly is present......Assessment...Neuro...Large SDH(Subdural Hematoma) with midline shift, traumatic....Evaluated by Neurosurgery, non operable.......Need to discuss with family...poor prognosis and massive ICB(Intracranial Bleed)...." The Regional Trauma Center Discharge Summary dated 5/20/13 states, "(R1) passed away as expected, he was pronounced at 11:55pm on 5/19." On 5/23/13 at 12:40pm an Immediate Jeopardy was identified. The Immediate Jeopardy situation began on 5/18/13 at 4:15pm when R1 who was receiving anticoagulants, developed a headache, following a fall, and staff did not recognize R1's headache and nausea as signs of increasing intracranial pressure and failed to immediately notify the Physician. E1, Administrator, was notified of the Immediate Jeopardy on 5/23/13 at 12:40pm. It was confirmed through interview and record review that the faciity took the following actions to remove the immediacy: 5/23/13- All licensed nurses were inserviced on the facility policy on Head Trauma including the signs of increasing intracranial pressure, notification of the Physician of changes in neurological status and documentation of neurological checks by E5, RN Consultant. 5/23/13-All licensed nurses were inserviced on the different anticoagulant medications, including [MEDICATION NAME], Aspirin, [MEDICATION NAME] and [MEDICATION NAME], and the adverse effects of such medications, especially for residents who fall and hit their heads, by E5. 5/23/13-All licensed nurses were inserviced when notifying the Physician of a resident fall, to inform the Physician what medications the resident is receiving, including anticoagulants.

These requirements were not met as evidenced by: Based on record review and interview the facility failed to complete a root cause analysis and implement appropriate interventions for two falls for R8. Failure to complete a root cause analysis for R8's first fall resulted in R8 having another fall where R8 sustained a Left Superior and Inferior Pubic Rami Fracture and Left Acetabular Fracture. R8 is one of four residents reviewed for falls in a sample of ten. Findings include: The POS (Physician order [REDACTED]. The MDS ( Minimum Data Sheet) dated 12/1/11 states R8 is severely impaired in daily decision making skills, requires extensive assist with one staff for bed mobility, transfers and toileting. The facility's report titled "Fall Risk Assessment" dated 10/6/11 and 11/19/11 states R8 is at High Risk for falls. The facility report titled "Investigation Report for Falls" dated 12/12/11 under the section titled "Where was the resident and what was the resident's position?" states "(R8) was laying on floor naked to the right side of toilet stool supine" The section titled "What fall prevention techniques were in use prior to the fall?", is blank. The same form section titled "Why did the resident fall?", is blank. The section titled "What new intervention was initiated to prevent another fall?", is blank. The facility report titled "Investigation Report for Falls" for R8 dated 12/21/11 states under the section titled "Where was the resident and what was the residents position", states "(R8) was laying on right side in room". The same form, section titled "What fall prevention techniques were in use prior to fall?", is blank. The same form under the section titled "Why did the resident fall?", is blank. The section titled "What new intervention was initiated to prevent another fall?" is also blank. R8's care plan dated 10/2/11 under the section titled "Problems/Strengths/Etiologies" states "(R8) has risk factors that require monitoring and intervention to reduce potential for self injury ..." The section titled "Approach/Intervention" does not address or revise the plan related to the two falls dated 12/12/11 and 12/21/11 with new interventions or approaches for R8. E3, RN CPC (Registered Nurse/Care Plan Coordinator) on 3/8/12 at 12:10 PM confirmed the two falls dated 12/12/11 and 12/21/11 was not addressed on the care plan and that there was no new intervention put into place for the falls. E1, Administrator on 3/8/12 at 12:55 PM stated "The Director of Nurses was gone at the time of the two falls and the root cause analysis and new interventions were not addressed for these two falls dated 12/12/11 and 12/21/11. A Radiology Report dated 12/21/11 completed following R8's fall, under section titled "Impression" states "Superior and inferior pubic rami fractures and Suspected left acetabular fracture."