Every finding on record at Tri-State Village NRSG & RHB

Based on interview and record review, the facility failed to follow their policy on loss of power during hot weather by failing to ensure that resident room temperatures were within acceptable levels during a power outage. This failure has the potential to affect 84 residents currently residing at the facility.Findings include:On 8/12/2026 at 1:44PM, V2 (Director of Nursing /DON) said that the facility lost power around 10:30AM on 8/11/2026, they ran their tornado protocol per policy, the emergency generator kicked in after the power went out. All residents on oxygen and those that use air mattress were plugged in the emergency outlets connected to the emergency generator, a temperature log was created, and ice water was passed out to the residents.On 8/12/2026 at 1:53PM, V1 (Administrator) said that they were in the middle of a tornado drill when the power went out, the generator kicked in, the staff made sure residents were okay, they initiated a temperatures log, gave out snacks and water. V1 stated that the temperature was okay and was documented in the log, The power went out around 11:30 or 10:30AM, power came back early this morning around 4:00AM, so he thinks the power was out for about 17 hours.On 8/12/2026 at 2:06PM V3 (Maintenance Director) said that the power went out around 10:00AM on 8/11/2026, they followed their severe weather drill by getting residents out of their rooms to the hallway, they used weather monitoring radio for updates. V3 stated that he only took temperatures in the morning around 6:00AM (Before the power went out) and took another one between 6:00 and 7:00PM (while the power was out). Power came back around 4:30am on 8/12/2026. V3 stated that he did not take any temperatures while the power was out between 10:30AM to 7:00PM on 8/11/2026. On 8/12/2026 at 4:02PM, V3 presented 2 documents titled air temperature (degrees Fahrenheit), with temperatures taken on 8/11/2026 at 7:00AM, 12:00PM and &7:00PM in the following locations: East wing, [NAME] wing, South wing, Front parlor, Dining room [ROOM NUMBER], Dining room [ROOM NUMBER], and therapy room. There were no temperatures documented for any resident rooms. Surveyor asked V3 where he documented resident room temperatures. He said, I did not take any temperature in any resident room, this is the area that we normally take temperatures, and this is the form we use. Review of the instruction for the temperature log states in part, document the highest temperature -humidity combined value per unit on the floor. Include day rooms, dining rooms and resident rooms. Facility was unable to provide any documentation of temperature levels in resident's rooms during the power outage and loss of air conditioning in the facility.Review of loss of air conditioning during hot weather policy with an effective date of January 2026 documented in part: Policy: To establish guidelines to maintain a safe and comfortable environment in the event of loss of air conditioning.Policy Specifications;Staff will be oriented and educated on procedures for addressing individual room air conditioners malfunctions and loss of air conditioning to the entire facility.PROCEDURE FOR LOSS OF AIR CONDITIONER TO THE FACILITY:1. Notify Administrator and Maintenance Department of the malfunction via telephone.2. The Administrator will designate the staff to contact the local electric company if appropriate and/or the heating/cooling contractor as warranted.3. Individual rooms/affected areas will have hourly temperatures taken and recorded if temperatures reach 80 degrees or above. IDPH, ISDH, Joint Commission, and Administration Code 300 Table D will be utilized when determining if residents need to be relocated.

Based on interview and record review, the facility failed to develop and implement interventions to prevent the development of pressure ulcers for one resident.This failure resulted in R45 developing facility-acquired pressure ulcer to the sacrum area and deep tissue injuries (DTI) to the right heel, that V34 (Wound Care Specialist APRN) identified as preventable wounds.This applies to 1 of 5 residents (R45) reviewed for pressure ulcers in the sample of 19. The findings include: On July 27, 2026, at 9:39 A.M., R45 was observed in bed. She stated that the mattress was too hard to sleep on and that she had developed wounds on her buttocks and left heel. R45 said she requested a softer mattress, but a staff member told her she was not a candidate for another mattress and had to meet certain criteria to qualify for an air-loss mattress.Review of R45's electronic medical record showed that she was a [AGE] year-old woman admitted to the facility on [DATE], with diagnoses that included spinal stenosis, hypothyroidism, heart failure, diabetes mellitus, and osteoarthritis.R45's significant-change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section M0150 identified R45 as at risk for pressure ulcers, while Section M1200 did not document a turning and repositioning program for skin or ulcer/injury treatment. Section GG showed that R45 was dependent or required substantial/maximal assistance with rolling, moving from sitting to lying, transferring between a chair and bed, and moving from lying to sitting at the bedside. The MDS also documented that R45 depended on staff for personal hygiene, including toileting, dressing, and bathing.R45's admission observation detail report, dated January 2, 2026, documented a Braden Scale score of 18, indicating mild risk for pressure injury. On July 29, 2026, at 9:20 A.M., V2, the Director of Nursing (DON), stated that the score had been miscalculated because R45 had a prior wound and a buttock scar at admission and should have received high risk status. Subsequent reports documented scores of 12 (high risk) on March 13 and March 19, 2026; 9.0 (very high risk) on March 30, 2026; and 12 (high risk) on July 27, 2026.R45's care plan, dated July 20, 2026, identified left-heel and sacral pressure ulcers related to bowel and bladder incontinence, immobility, spinal stenosis, and type 2 diabetes mellitus. However, it did not include an intervention for a pressure-relieving mattress.R45's Physician Order Sheet (POS), dated March 30, 2026, included an order for a pressure-reducing mattress. The July 13, 2026, POS directed staff to cleanse the left heel with normal saline, apply Betadine, cover it with an abdominal pad, and secure it with Kerlix and tape daily and as needed. It also directed staff to cleanse the sacral wound with normal saline and apply no-sting skin preparation, calcium alginate, MediHoney, and bordered foam daily and as needed.R45's wound observation history documented a sacral pressure ulcer measuring 0.2 cm x 0.2 cm x 0.0 cm on July 4, 2026, with 100% granulation tissue and edges attached to the base. On July 10, the wound was not healed, was classified as a stage 3 pressure injury with moderate exudate, and measured 1.0 cm x 1.0 cm x 0.1 cm. On July 17, it remained unhealed, had serosanguineous exudate, and measured 0.6 cm x 0.6 cm x 0.1 cm. On July 23, it was documented as a facility-acquired, unstageable sacral wound that remained unhealed and measured 0.3 cm x 0.3 cm x 0.1 cm. The wound was also classified as a stage 3 pressure injury with 10% granulation tissue.R45's wound observation history documented a facility-acquired, unstageable left-heel wound measuring 6.3 cm x 6.0 cm x 0.5 cm on July 13, 2026. On July 17, it measured 6.0 cm x 8.0 cm x 0.1 cm and was classified as full thickness with 10% granulation tissue. On July 23, the wound remained unchanged at 6.0 cm x 8.0 cm x 0.1 cm and retained the same classification.On July 28, 2026, at 11:39 A.M., V31, the Wound Care Nurse, stated that R45 had acquired pressure injuries at the facility and that they should have been prevented. V31 said R45 qualified for an air-loss mattress but did not have one, adding that although R45 did not like getting out of bed, she should have been provided with such a mattress. At 11:55 A.M., V31 measured the sacral injury at 1.0 cm x 1.5 cm x 0.0 cm and the left-heel injury at 4.5 cm x 2.5 cm x 0.0 cm.On July 29, 2026, at 8:32 A.M., V2, the Director of Nursing (DON), stated that R45 was at high risk for developing a pressure injury upon admission because she had arrived with a pressure sore that later healed and did not like getting out of bed. V2 identified the facility's preventive measures as air-loss mattresses for bedbound residents, pressure-reducing cushions for wheelchair-bound residents, and turning and repositioning. V2 stated that R45 qualified for an air-loss mattress to help prevent her current wounds. At 9:20 A.M., V2 added that R45's admission Braden Scale score of 18 (mild risk) was incorrect because of her wound history and should have reflected high risk. V2 further stated that R45 developed a stage 2 pressure injury on January 27, 2026, which should have prompted the facility to provide an air-loss mattress that could have helped prevent the current coccyx and left-heel wounds.On July 29, 2026, at 12:07 P.M., V34, the Wound Specialist/Advanced Practice Registered Nurse (APRN), stated that she had overseen wound care at the facility since March 2026 and evaluated all residents with wounds each Friday. V34 said R45 reentered wound care services on July 10, 2026, for a stage 3 sacral wound. She noted that R45 had a prior wound that healed on April 10, 2026, placing her at high risk for pressure injury. V34 stated that R45's wounds were preventable and agreed that she should have received an air-loss mattress.The facility's policy, Skin Integrity, Pressure Injury Prevention, and Wound Management Policy, reviewed in January 2026, stated that the facility would maintain each resident's skin integrity and provide timely, person-centered prevention, assessment, treatment, monitoring, and documentation for pressure injuries and other wounds. The policy's purpose was to establish a consistent process for identifying residents at risk for pressure injury and other skin breakdown.

Based upon observation, interview, and record review, the facility, failed to implement the tornado warning policy during an actual tornado warning, failed to ensure that the medication cart is locked while unattended, and medications are not accessible to unauthorized individuals, and failed to ensure that hazardous materials are not accessible to cognitively impaired residents. These failures affected 2 residents (R18, R33) exposed to hazardous chemicals and had the potential to affect all 80 residents who resided in the facility. Findings include: 1.The 7/27/26 facility roster showed 80 residents resided in the facility. On 7/27/2026 at 12:50 PM, observed staff and survey teams cellular phones alarming indicating there was a tornado warning in the facility's area. No staff responded or activated the facility's tornado (Code Gray) policy. On 7/27/2026 at 12:55 PM, the national weather service issued a tornado warning for southeastern [NAME] County until 1:45 PM. A severe thunderstorm capable of producing a tornado was located over a nearby town, moving east at 35 mph. The dangerous storm will be near the facility's town at 1:00 PM. Impact includes flying debris will be dangerous to those caught without shelter. Mobile homes will be damaged or destroyed. Damage to roofs, windows, and vehicles will occur. Tree damage is likely. Precautionary/Preparedness actions include: TAKE COVER NOW! Move to a basement or an interior room on the lowest floor of a sturdy building. Avoid windows. If you are outdoors, in a mobile home, or in a vehicle, move to the closest substantial shelter and protect yourself from flying debris. No observations of staff implementing the tornado policy. Survey team and staff personal phone alarms were alarming. No staff responded to the alarms. No residents were observed taking cover in the hallways and the tornado policy was not being activated. Observed residents in the dining room still eating, staff serving food, and all residents in the dining area near large glass windows/class doors. No window coverings were drawn on the windows. No weather radio was at the nurse's station in use. No Code Gray was announced to notify staff. Surveyor intervened and notified both V1 (Administrator) and V19 (Registered Nurse) of the tornado warning. V19 observed the dining room and confirmed all residents were still eating and were in front of large glass windows. V19 stated the residents were still eating, so where were they supposed to go? On 7/27/2026 at 1:01 PM, no residents were observed in the hallways. On 7/27/2026 at 1:04 PM, observed four residents of the facility in the hallways of the facility. No other residents were in the hallways. Residents were still eating next to the windows of the dining room. The lights were flickering on and off in the dining room from the storm. On 7/27/2026 at 1:14 PM, observed nurses' station near the dining room. A radio was at the nurse's station and was not plugged in or on to notify staff of the weather. There was no bin with emergency supplies in the nurse's station or any other vicinity. Observations confirmed with V6 (Licensed Practical Nurse). On 7/27/2026 at 1:21 PM, observed V12 (Licensed Practical Nurse) in the south hallway wheeling residents from their rooms into the hallways. Pictures were observed hanging in the hallways. On 7/27/2026 at 1:22 PM, V3 (Assistant Director of Nursing, Infection Preventionist) observed the hallway and confirmed pictures were hanging in the hallways. V3 was unsure if the tornado policy instructed staff to remove pictures in the hallways. On 7/27/2026 at 1:34 PM, observed other hallways with pictures affixed to the walls. V4 (Certified Nursing Assistant) confirmed the observation. V4 continued to pass lunch trays in resident rooms in lieu of taking cover. On 7/27/2026 at 1:41 PM, observed V35 (Certified Nursing Assistant) charting at the nurse's station. No weather radio or other emergency supplies observed at the nurse's station or in the vicinity. Observation confirmed with V35. On 7/27/2026 at 1:43 PM, V12 (Licensed Practical Nurse) observed the nurses' station and confirmed there was no radio or other emergency supplies. On 7/27/2026 at 3:43 PM, V1 (Administrator-in-Training) affirmed V1 is responsible for activating the emergency/disaster plan when a situation like a tornado warning occurred. V1 affirmed the facility should be following the disaster policy. V1 explained tornados cause high winds, rains, and lightning which can cause structural damage to the facility or flying debris to enter the facility. The roof could be torn off, loose items in the facility can fly around. V1 affirmed the priority is to get residents away from windows and into central locations (hallways). V1 explained responding to tornados warnings quickly because a tornado can develop rapidly. V1 recalled the situation and affirmed V1 did not call a code gray. V1 stated, yeah, it is my fault, I should have called a code gray, so the staff knew (about the tornado warning). V1 was unsure if there were weather radios or other supplies in the nurse's station. V23 (Regional Nurse Consultant) affirmed there should be bins in each nurse's station with emergency supplies as well as a weather radio. On 7/28/2026 at 3:26 PM, V20 (Administrator) affirmed V20 was not in the facility during the tornado warning on 7/27/2026. V20 affirmed V20 was made aware of the incident and was told parts of the tornado policy were missed, and a code gray was not called. V20 explained that any member can call a code gray, and staff should respond immediately to tornado warnings. The front desk, maintenance, all should be calling the code and helping to activate the plan. V20 described a tornado warning as an all hands-on deck approach for staff to respond and participate. V20 believed there were bins at the nurse's station for the staff but would have to check. V20 was unsure if the community tornado sirens could be heard from the facility. Facility policy titled, Tornado (Code Gray) Policy (undated) within the facility's emergency disaster plan documents the purpose is to provide guidelines for facility staff regarding the actions to be taken during a tornado. Policy specifications: 1. All facility staff have the responsibility to be alerted to environmental clues for a tornado (i.e. a dark, often [NAME] sky, high humidity, large [NAME], and a load [NAME] usually described similar to a freight train). 2. If the environmental conditions indicate a possible tornado, staff should turn on the weather radio to listen for any weather alerts. 3. Any staff member observing-or hearing a weather watch/warning'' announcement should notify their supervisor immediately. and call the Administrator. a. Tornado Watch - conditions are right for tornadoes in the area b. Tornado Warning - a tornado has been sighted or indicated by weather radar. 4. The staff member hearing the weather watch/warning'' should communicate theinformation to their supervisor. 5. A CODE GRAY will be called by the Administrator/Designee. 6. If a CODE GRAY is in effect, all available staff should take the following actions:a. Close all windows; b. Close all window coverings;c. Move all possible residents into the hallway away from the windows.d. If unable to move the resident out of the room, pull the privacy curtain closed andprovide additional blankets up to their face to protect them from flying objects.e. Remove any pictures in the hallways to prevent injuries to residents and staff.f. Offer blankets and pillows to the residents for additional protection if time allows.7. In case of a power failure, the emergency generators will provide power to various items in the facility8. Once the emergency is over and the area has been determined safe from a tornado, a CODE GRAY ALL CLEAR will be announced by Administrator/Designee . 2.On 7/29/26 at 11:48am, the (east) medication cart was unlocked and unattended in the hallway (near room [ROOM NUMBER]). On 7/29/26 at 11:49am, V18 (Licensed Practical Nurse) exited (room [ROOM NUMBER]) approached the medication cart and locked it. Surveyor inquired if the medication cart should be locked when unattended V18 responded We (staff) lock it. The security of medication cart policy (reviewed January 2026) states the nurse must secure the medication cart during the medication pass to prevent unauthorized entry. The medication cart should be parked in the doorway of the resident's room during the medication pass. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. Medication carts must be securely locked at all times when out of the nurse's view. 3.On 07/27/2026 at 10:56am with V12 (Licensed Practice Nurse) inside R18's room, there was a tub of Sani-Cloth Bleach large wipes on top of R18's nightstand. This observation was pointed out to V12. V12 stated he (R18) has sani bleach wipes on top of his night stand; the CNAs utilized wipes on the mattress and other surface, but she (V12) was not sure if it was okay to may leave the tub of bleach wipes in resident's bedside; that she would ask (V2 – Director of Nursing) about it. V12 stated he (R18) was alert and oriented to self only. R18 was not able to state the current president's name or the day of the week or the current month when asked. On 07/29/2026 at 10:14am, V2 stated bleach wipes should not be inside the resident's room specially for the cognitively impaired residents; they can put it in their mouth and wipe their skin with it and cause skin irritation. On 07/29/2026 at 1:43pm, V2 stated the two residents affected by this deficient practice were (R18) and the roommate (R33) because they can self-propel themselves when ambulating via wheelchair. R18's (07/20/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating the resident's mental status as moderately impaired. R33's (accepted date: 07/28/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating the resident's mental status as moderately impaired. The (01/2026) Poisonous and Toxic Materials documented, in part Objective: 1. Poisonous and toxic materials shall not be kept or stored in residents' rooms and shall be inaccessible to residents. Procedure: 5. Poisonous and toxic materials – including cleaning agent, disinfectants, sanitizers and similar chemicals – are not permitted in residents' rooms.

Based on observation, interview, and record review, the facility failed to ensure prepared food items were labeled with use by date, failed to accurately identify use by date of prepared food items, failed to ensure male staff wear appropriate hair restraints in an effort to prevent foodborne illnesses and failed to monitor the personal use refrigerators maintained a temperature 41F or less and were free if ice condensation in the freezer section. These failures have the potential to affect 76 residents, who receive an oral diet from the facility.Findings include: Form 671 completed by V3 (ADON, Assistant Director of Nursing) completed on July 27, 2026, showed resident census of 80. The diet list provided by the facility showed there were 4 residents who did not receive an oral diet.1.On 07/27/2026 at 9:27am, sign posted on the Kitchen door Attention: All Facility Staff. Before you enter, you must put on a hair net. Once You are inside, you must wash your hands at handwashing sink (all the time and every time). No exceptions!!!On 07/27/2026 at 9:30am inside the kitchen, V10 (Dietary Aide) was by the dish machine area wearing hair restraint. V10 had facial hair and was not wearing beard guard. V10 stated he did not have to wear a beard guard if he was in the dish machine area of the Kitchen. On 07/27/2026 at 9:34am with V9 (Dietary Aide, inside the kitchen's walk-in refrigerator observed: Egg salad with prepared date: 7/20; no use by date. [NAME] Gravy with prepared date: 7/12; no use by date.Cream of Mushroom with prepared date: 7/20; no use by date. Another tray of cream of mushroom with prepared date: 7/20/26; with use by date: 7/27/26. On 07/27/2026 at 9:53am, V8 (Cook) was wearing a hair restraint. V8 had facial hair and was wearing beard guard, not covering his mustache. V8 stated he had mustache, and it was considered a facial hair, and it should also be covered while he worked in the kitchen so no facial hair would fall on the food to prevent cross contamination.On 07/28/2026 at 12:03pm, V15 (Assistant Administrator/HR Director) stated the facial hair should be covered; mustache is considered facial hair and should be covered also; they did not want hair to get into the resident's food because it was disgusting and unsanitary and may cross contaminate the food. V15 stated before entering the kitchen area, they should put the hair restraints on. The area where the dish machine is located is part of the kitchen and staff are expected to wear hair restraints including facial hair restraint while working on the dish machine. V15 stated she had to reach out to the management about the use by date of brown gravy, boiled eggs, egg salad, and cream of mushroom.The (07/29/2026) email correspondence with V15 documented, in part Below are commonly recommended refrigerated use-by dates for a healthcare foodservice operation. Item recommended Use-By Date: Egg salad Use within 72 hours (3 days), [NAME] gravy Use within 72 hours (3 days), and Cream of mushroom soup Use within 72 hours (3 days). The (01/2026) Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices documented, in part Policy Statement. Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. 2.On 7/27/26 at 10:06am, perishable items including (6) yogurts, cream cheese, and ranch dressing were observed in R46's personal refrigerator. R46's (July 2026) resident refrigerator temperature log has a documented temperature of 38 (on July 27) however the thermometer in R46's personal refrigerator was noted to be 46F (Fahrenheit) at this time - therefore not within range. On 7/27/26 at 10:09am, surveyor inquired about R46's refrigerator temperature V6 (Licensed Practical Nurse) inspected R46's refrigerator thermometer and stated I (V6) see 50. Surveyor inquired about the required temperature range for maintaining food in the refrigerator V6 responded It's gonna be between 37 and 40 [the resident refrigerator temperature log states refrigerated foods - stored at 41* or below]. V6 subsequently inspected R46's freezer (as requested) there were 2 containers of ice cream inside with approximately 1 inch of ice encircling the bottom of the containers - which were stuck to the freezer. Surveyor inquired about concerns with ice buildup in R46's freezer V6 replied They're both frozen in here referring to the ice cream containers. V6 then closed R46's freezer/refrigerator doors and failed to discard the perishable items at this time. The resident refrigerator policy (Reviewed January 2026) states refrigerators must be inspected prior to use to ensure that they are able to maintain a temperature of 41F-degree or less. All refrigerator temperatures will be checked at least once daily and a log maintained. Staff will assist resident in inspecting and maintaining refrigerator as needed.

Based upon observation, interview, and record review, the facility failed to provide necessary assistance with ADL (Activities of Daily Living) care, including nail care, grooming and assistance with eating, for residents who required assistance, in accordance with facility policy. This failure applies to 6 of 6 residents (R2, R40, R52, R70, R73, R85) reviewed for ADL (Activities of Daily Living) care in the sample of 19. Findings include: 1.R2's diagnoses include dementia. R2's (7/23/26) BIMS (Brief Interview Mental Status) determined a score of 3 (severe impairment). R2's (7/23/26) functional assessment affirms that the resident requires supervision or touching assistance with eating. R2's (8/9/26) care plan states the resident requires assistance of staff for ADL care. On 7/27/26 at 12:40pm, R2's lunch appeared to be untouched. R2 was able to pick up the cup and drink, however use of utensils was not observed at this time. On 7/27/26 at 12:43pm, surveyor inquired if R2 requires assistance with eating V7 (Certified Nursing Assistant) stated She (R2) can feed herself. V7 failed to provide R2 feeding assistance (supervision/touching assistance – per functional assessment) or inquire why R2 wasn't eating then instructed R2 to Eat your (R2's) food and proceeded to walk away. On 7/27/26 at 12:57pm, (14 minutes later) R2's meal remained untouched. Surveyor inquired if R2 ate anything for lunch R2 stated I (R2) did but just a little, it wasn't good. The activities of daily living policy (reviewed January 2026) states based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following activities of daily living: Dining-eating, including meals and snacks. 2.The EMR (Electronic Medical Record) showed R73 was admitted to the facility on [DATE], with multiple diagnosis including osteopenia, metabolic encephalopathy, hyperglycemia, and lymphedema. R73's quarterly MDS (Minimum Data Set) dated May 5, 2026, showed R73 is cognitively intact. The MDS continued to show R73 has impairment to both sides of the upper and lower extremities. R73 requires substantial/maximal assistance from staff for oral hygiene. R73 is dependent on staff for toileting and personal hygiene. Care Plan dated June 14, 2026, showed that R73 has limited mobility to preform dressing related to decreased mobility and endurance. On July 27, 2026, at 10:12 AM, R73 was observed sitting in a wheelchair with long, jagged fingernails. 3. The EMR showed R40 was admitted to the facility on [DATE], with multiple diagnosis including malignant neoplasm of prostate, heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. R40's quarterly MDS dated [DATE], showed R40 is severely cognitively impaired. The MDS continued to show R40 requires substantial/maximal assistance from staff for oral and personal hygiene. R40 is dependent on staff for toileting hygiene. On July 27, 2026, at 10:20 AM, R40 was observed lying in bed looking unkempt with overgrown facial hair. R40 is non-verbal. 4.The EMR showed R52 was admitted to the facility on [DATE], with multiple diagnosis including cerebrovascular disease, hypertensive heart diseases, vascular dementia, hemiplegia and hemiparesis, and polyarthritis. R52's quarterly MDS dated [DATE], showed that R52 is severely cognitively impaired. The MDS continued to show R52 is dependent on staff for oral hygiene, personal hygiene, and toileting hygiene. Care plan dated June 17, 2026, showed that R52 requires staff assistance with grooming due to decreased mobility and endurance. On July 27, 2026, at 10:28 AM, R52 was observed sitting in a Broda chair in the dining room with long, jagged fingernails with a black substance underneath the nails. R52 is non-verbal. 5.The EMR showed R85 was admitted to the facility on [DATE], with multiple diagnosis including hyperlipidemia, history of other venous thrombosis and embolism, osteoarthritis, dysphagia and history of falls. R85's quarterly MDS dated [DATE], showed that R85 is moderately cognitively impaired. The MDS continued to show R85 requires substantial/maximal assistance from staff for oral hygiene. R85 is dependent on staff for toileting and personal hygiene. Care plan dated July 17, 2026, showed that R85 requires extensive assistance with dressing related to decreased mobility and endurance. On July 27, 2026, at 10:29 AM, R85 was observed sitting in a Broda chair in the dining room with long, jagged fingernails with a black substance underneath the nails. R85 is non-verbal. 6.R70 The EMR showed R70 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis following cerebral infraction affecting left dominant side, hypertensive heart disease, dysphagia, and hypotension. R70's quarterly MDS dated [DATE], showed that R70 is moderately cognitively impaired. The MDS continued to show that R70 has impairment to one side of the upper and lower extremities. R70 requires substantial/maximal assistance from staff for oral and personal hygiene. R70 is dependent on staff for toileting hygiene Care plan dated June 3, 2026, showed that R70 requires maximal assistance with ADLs (Activities of Daily Living) due to impairment of left-sided weakness. Care plan continued to show that R70 requires extensive assistance with majority of ADLs. On July 27, 2026, at 10:34 AM, R70 was observed sitting in a wheelchair in the dining room with long, jagged fingernails. On July 28, 2026, at 12:11 PM, V32 (Restorative Nurse) verbalized that CNAs are responsible for the ADL care of the residents. On July 29, 2026, at 1:56 PM, V18 (Licensed Practical Nurse) verbalized that R40, R52, R70, R73, and R85 require total or extensive assistance from staff with all ADL care. The facility's policy titled, Activities of Daily Living Policy last reviewed January 2026 states that, SUBJECT: Activities of Daily Living (ADLs)/Maintain Abilities. Procedure: . 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 3. The facility will ensure provide care and services for the following activities of daily living: a. Hygiene – bathing, dressing, grooming, and oral care. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; .

Based upon observations, interviews, and record review, the facility failed to follow policy procedures, failed to repair (R46's) drywall/baseboard, failed to repair (R7's) dresser, failed to cover (R4's) light fixture, failed to replace/repair (R21's) sink/blinds/light bulbs, failed to address/remove (R61's) soiled curtain, and failed to maintain a clean, homelike environment. This failure applies to 5 of 7 residents (R4, R7, R21, R46, R61) reviewed for environment in the sample of 19.Findings include:R4, R7, R21, R46, and R61 reside in the facility east wing.On 7/27/26 at 10:06am, R46's bedroom floor was notably sticky as surveyors walked throughout the room. On 7/27/26 at 10:10am, the facility (east wing) floors appeared heavily soiled with brown debris and were notably scuffed throughout the unit, a brown grimy buildup near the baseboards/ doorways was also noted on the floor. Surveyor inquired about appearance of the (east wing) hallway floors V6 (Licensed Practical Nurse) stated The dirty ones? These with all the scuff marks? You gotta buff them these are old. You can see it's really bad here by the doorway, the thresholds it's like old chucked up dirt, it's just really dirty they (floors) need a scrub brush. On 7/27/26 at 10:21am, some of the baseboard was off the wall (near the foot of R46's bed), and a large hole was observed in the drywall above the baseboard affixed to the wall. Surveyor inquired about concerns with R46's drywall V5 (Scheduler) stated It's a hole there, it's above the baseboard. Surveyor inquired if baseboard was covering R46's entire wall R46 responded No, not the whole wall, it's a piece falling off. On 7/27/26 at 10:27am, R7's dresser was not level, upon further inspection it was missing one of four legs. On 7/27/26 at 12:49pm, surveyor inquired how long R7's dresser has been broken R7 responded It's been like that for a while I (R7) believe.On 7/27/26 at 10:31am, R61's curtain was notably soiled with a brown substance. Surveyor inquired about the appearance of R61's curtain V4 (CNA/Certified Nursing Assistant) stated It's dirty. Surveyor inquired about the substances on R61's curtain V4 responded It could be food, BM (Bowel Movement) or feces either or. On 7/27/26 at 10:34am, food debris was observed on R21's bedroom floor. R21's blinds were also broken/bent, surveyor inquired when the blinds broke R21 responded It's always been like that. Surveyor inquired if the broken blinds were reported to staff R21 replied I (R21) complain about everything and affirmed it was reported. A pile of clothes were observed on the floor in R21's room, R21 affirmed It needs to be washed. R21's countertop edge was broken off, and the wood was exposed in front of the sink. On 7/27/26 at 10:41am, surveyor inquired about concerns with R21's countertop near the sink V5 (Scheduler) stated The little side piece is missing. Surveyor inquired about concerns with R21's blinds V5 responded It's a blind hanging by his (R21) bed, it looks bent. R21 stated They (staff) need to fix the light bulb above the sink the light bulb above the sink was dim and flickering at this time. R21 added The other light (above the bed) is not coming on and needs fixed. V5 attempted to turn R21's light on (above the bed) however the light did not turn on when the string was pulled. On 7/27/26 at 10:23am, R4's bedroom floor was notably sticky as surveyors walked throughout the room. Surveyor inquired about concerns with R4's bedroom floor V5 (Scheduler) stated I'm (V5) no housekeeper but it is sticky. Surveyor inquired about the (uncovered) opening in the wall near R4's foot of bed V5 responded It's missing a cover. Surveyor inquired if the light bulb recessed in the wall was a night light V5 replied That's what it looks like. On 7/27/26 at 10:25am, surveyor inquired about the broken blinds on the exit door(s) near rooms [ROOM NUMBERS] V5 (Scheduler) stated They are missing some pieces. Looks like somebody broke some of the pieces on it. The environmental cleaning and disinfection policy (reviewed January 2026) states the facility will maintain a clean and sanitary environment and use consistent cleaning and disinfection practices to reduce transmission of infectious organisms. Cleaning: Physical removal of visible soil and organic material using detergent or a cleaning agent and water. Routine Cleaning: Floors: Clean regularly and when soiled. The maintenance services policy (reviewed January 2026) states the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Service Functions: The following functions are performed by maintenance but are not limited to: maintain the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. Others that may become necessary or appropriate.

Based on observations, interviews, and record review, the facility failed to assess residents' hand contractures, failed to implement restorative interventions and provide services to prevent further decline in residents with hand contractures.These failures affected 6 of 6 residents (R8, R19, R25, R38, R52, and R73) reviewed for hand contractures in a total sample of 19 residents. The findings include: 1. On July 27, 2026, at 10:15 A.M., R19 was observed with a left-hand contracture and was not wearing a palm protector or splint. R19 is a [AGE] year-old male originally admitted to the facility on [DATE]. His diagnoses include, but are not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left side, diffuse traumatic subarachnoid hemorrhage without loss of consciousness, and vitamin D deficiency.R19's Brief Interview for Mental Status (BIMS), dated July 21, 2026, was 09, indicating moderate cognitive impairment. R19 stated that he needed help applying his splint and that no staff member had assisted him that day.The functional ability section of R19's Minimum Data Set (MDS), dated [DATE], documented impairment of one upper extremity, one lower extremity, and both sides. The MDS also showed that R19 depended on staff for personal and toileting hygiene.R19's care plan, initiated April 14, 2026, documented a left-hand splint/brace related to hemiplegia and the need for a restorative splint/brace program. Staff were to apply and remove the device with supervision or assistance 6-7 days per week. The plan also allowed R19 to wear a palm protector when not wearing the splint. On July 28, 2026, at 12:12 P.M., V32 (Restorative Nurse) stated that R19 should have been wearing his palm protector. V32 added that although R19 might refuse the splint, he would accept the palm protector and would need staff assistance to apply it. 2. On July 27, 2026, at 10:17 A.M., R25 was observed with a right-hand contracture and was not wearing a hand splint. R25 is a [AGE] year-old male originally admitted to the facility on [DATE]. His diagnoses include, but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, seizures, severe protein-calorie malnutrition, spastic hemiplegia affecting the right dominant side, hypertension without heart failure, and psychoactive substance abuse.R25's BIMS, dated July 15, 2026, was 03, indicating severe cognitive impairment. R25 was unable to express himself.The functional ability section of R25's MDS, dated [DATE], documented impairment of one upper and one lower extremity. The MDS also showed that R25 required substantial or maximum staff assistance with personal and toileting hygiene.R25's care plan, initiated March 11, 2026, documented a right resting hand splint and a restorative splint/brace program requiring staff supervision or assistance 6-7 days per week. Staff were to provide assistance or cues with applying and removing the splint or brace as needed. On July 28, 2026, at 12:28 P.M., V32 (Restorative Nurse) stated that R25 was followed by the restorative program for splint/brace use, bed mobility, transfers, and dressing/grooming. V32 stated that R25 should have been wearing his palm protector and that restorative staff were responsible for applying his hand splint and palm protector. 3. On July 27, 2026, at 12:01 P.M., R38 was observed with a right-hand contracture and was not wearing a palm protector or splint. R38 is a [AGE] year-old male originally admitted to the facility on [DATE]. His diagnoses include, but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and the need for assistance with personal care.R38's BIMS, dated July 15, 2026, was 03, indicating severe cognitive impairment.The functional ability section of R38's MDS, dated [DATE], showed that R38 depended on staff for personal and toileting hygiene.R38's palm-splint care plan was initiated on July 27, 2026, after the surveyor observed him without a hand splint. The plan documented the need for a right-hand palm splint related to hemiplegia/hemiparesis and directed that he wear a rolled palm towel or palm splint to reduce the risk of complications from contractures. On July 28, 2026, at 12:25 P.M., V32 (Restorative Nurse) stated that R38 was a candidate for a hand splint despite not wearing one at the time of observation. V32 further stated that she had obtained an order for his brace/hand splint. 4. On July 27, 2026, at 11:25 A.M., R52 was observed in her Broda chair with a left-hand contracture and was not wearing a palm protector or splint. R52 is a [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses include, but are not limited to, cerebrovascular disease, hospice status, hypertensive heart disease with heart failure, vascular dementia, behavioral disturbance, chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting the right dominant side, and anxiety disorder.R52's BIMS, dated June 6, 2026, was 03, indicating severe cognitive impairment.The functional ability section of R52's MDS, dated [DATE], did not identify impairment in any extremity. However, it showed that R52 depended on staff for personal and toileting hygiene.R52 had no care plan addressing a hand splint or brace. On July 28, 2026, at 12:21 P.M., V32 (Restorative Nurse) stated that she had not yet assessed R52 for a palm splint/brace and would update the care plan to include a carrot splint for R52's right hand. 5. On July 27, 2026, at 9:50 A.M., R73 was observed in her room with a left-hand contracture and was not wearing a palm protector or splint. R73 is a [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses include, but are not limited to, bone-density disorders, osteopenia at multiple sites, severe protein-calorie malnutrition, pediculosis, acute metabolic acidosis, and metabolic encephalopathy.R73's BIMS, dated May 5, 2026, was 15, indicating intact cognition. R73 stated that she had never worn a splint or brace on her left hand and would be willing to use one.The functional ability section of R73's MDS, dated [DATE], documented impairment on both sides of the upper and lower extremities. The MDS also showed that R73 depended on staff for personal and toileting hygiene.R73 had no care plan addressing her hand contracture. On July 28, 2026, at 12:22 P.M., V32 (Restorative Nurse) stated that R73 would benefit from a hand splint/brace. V32 further stated that R73 had participated in other restorative programs, including mobility, transfers, dressing, and grooming, but not a splint program. 6. On 07/27/2026 at 11:10am, observed R8 resting in bed. R8's hands appeared limp and flaccid with observable contractures to R8's right hand. R8's call light wrapped around the left handrail of the bed and hanging. R8 confirmed R8 could not reach the call light. R8 explained R8 has a history of a stroke, which causes him difficulty with using his hands and completing tasks (activities of daily living). R8 is a [AGE] year-old male resident showing his admission record having diagnosis to include but are not limited; hemiparesis following cerebral infarction and Major depressive disorder.R8's admission record documents R8 has active diagnoses including hemiplegia and hemiparesis following cerebral infarction, obesity, and major depressive disorder. On 7/29/2026 at 12:59 PM, V32 affirmed R8 has functional limited mobility in both upper extremities. R8's care plan does not identify R8 has any contractures or weakness in R8's bilateral upper extremities. On July 28, 2026, between 12:12 P.M. and 12:25 P.M., V32 (Restorative Nurse) stated that she had started the position a few weeks earlier. She confirmed that the residents identified above needed splints or palm protectors to prevent further contractures. V32 stated that nursing staff or restorative aides could apply the devices and that splints were available, although additional supplies might need to be ordered.On July 28, 2026, at 1:00 P.M., V37 (Ombudsman) stated that one issue she had observed at the facility was the lack of splints for residents with contractures.On July 29, 2026, at 1:55 P.M., V2 (Director of Nursing) stated that restorative aides were responsible for applying residents' splints and that the devices help prevent further contractures. V2 further stated that she had not been informed of any splint shortage.The facility's Splint Policy, reviewed in January 2026, stated: Purpose: A splint is a type of orthotic device that supports or corrects musculoskeletal deformities or abnormalities, treats contractures, and alleviates other joint problems.

Based upon observation, interview, and record review the facility failed to ensure that staff administered the correct medication, failed to administer medication as prescribed and failed to administer prescribed medications timely. There were 3 medication errors out of 25 opportunities resulting in a 12% medication error rate. This failure affects 6 of 7 residents (R8, R16, R48, R61, R74, R75) reviewed for medication administration in the sample of 19. The Findings include:1.On 7/28/26 at 8:42am, V18 (Licensed Practical Nurse) dispensed R61's medications (scheduled for 8am administration) in a medication cup and affirmed that he (V18) was prepared to administer them. One of the medications dispensed was incorrect, R61's physician order states Senoside-Docusate Sodium 8.6-50mg BID however GeriKot (Senna) 8.6mg was dispensed. Surveyor inquired about the Senna discrepancy V18 reviewed R61's EMAR (Electronic Medication Administration Record) and stated It says Senoside-Docusate Sodium 8.6 slash 50. V18 inspected the GeriKot 8.6mg container and stated this is 8.6 but 5 zero (50) is not there, that's medication error.On 7/28/26 at 9:25am, V19 (Registered Nurse) dispensed R48's medications (scheduled for 8am administration) in a medication cup however only 5 of 7 medications (scheduled for 8am) were in the cup. V19 stated I believe we are done and affirmed that he (V19) was prepared to administer the medications. Surveyor inquired how many medications were dispensed in the cup V19 counted the medication stated Thank you ma am then proceeded to dispense Furosemide and Metoprolol Succinate in the cup. 2.On 7/28/26 at 9:10am, several residents were highlighted red (indicating late administration) on the EMAR (Electronic Medication Administration Record). Surveyor inquired when AM medications are scheduled for administration at facility V19 (Registered Nurse) stated from 7am. Surveyor inquired about the regulatory requirement for medication administration V19 responded Should be 1 hour to the time or 1 hour after. Surveyor inquired which residents (assigned to V19) have not received medications (scheduled for 7am and/or 8am administration) today V19 affirmed that five residents (R8, R16, R48, R74, R75) had not received their medications yet. Surveyor inquired when V19 usually completes the 8am medication administration V19 replied It may be up to 10:00(am) before getting to their (residents) room before I (V19) finish it because medication, breathing treatment and everything. Surveyor inquired how many residents were assigned to V19, V19 affirmed 25. R48's medications (scheduled for 8am administration) were subsequently administered and documented at 9:47am therefore not within 1 hour - per regulatory requirement. On 7/28/26 at 9:42am, surveyor inquired what residents highlighted red on V12's (Licensed Practical Nurse) EMAR indicates V12 replied Red means that the medication is late, it's supposed to be administered at 8am its 9:42 right now. Surveyor inquired which residents (assigned to V12) have not received medications (scheduled for 8am administration) today V12 stated R84 and R66's names. Surveyor inquired about the regulatory requirement for medication administration V12 responded Medications can be passed an hour before their due or an hour after their due. R84's medications (scheduled for 8am administration) were subsequently administered and documented at 10:00am therefore not within 1 hour of scheduled time. The medication administration policy (revised 01/25) states all medications must be administered to the resident in the manner and method prescribed by the physician. Documentation on the MAR (Medication Administration Record) will be done at the time of administration of the medication. [the 5 rights are excluded].

Based upon interview and record review the facility failed to follow policy procedures, failed to obtain advance directives, failed to transcribe advance directives in physician orders, failed to ensure that advance directives on the face sheet are congruent with the POLST (Practitioner Order for Life-Sustaining Treatment) form, and/or failed to ensure that staff are aware of resident advance directives for eight of 19 residents in the sample (R4, R7, R21, R31, R45, R46, R61, R73) reviewed for advance directives.Findings include: 1) R31's ([DATE]) POLST form states attempt CPR (Cardiopulmonary Resuscitation) however R31's face sheet states Advance Directives: there are no advance directives selected for this resident. R31's physician orders (received [DATE]) exclude advance directives. On [DATE] at 3:52pm, surveyor inquired where advance directives are documented for facility residents V15 (Assistant Administrator) stated Its (referring to the POLST Form) uploaded under resident documents there's a tab called advance directives, and it also should be located in the binders on the crash carts. Surveyor inquired if advance directives are on the residents' face sheet V15 responded No, it's not in our policy. Surveyor inquired why advance directives are not on the face sheet V15 replied I would have to check on that. Surveyor inquired if the facility obtains physician orders for advance directives V15 stated That's a good question, I (V15) could find that out as well. Surveyor inquired about documentation of R31's advance directives in the medical record V16 responded He's (R31) a full code, I (V15) just pulled up the paperwork (referring to POLST Form) that was uploaded for him (R31). Surveyor inquired if R31's advance directives are documented in the medical record V15 replied Its care planned. Surveyor inquired if physician orders were obtained for R31's advance directives V15 responded I just know the care plan and resident documents uploaded through medical records. R46's ([DATE]) POLST form states NO CPR: Do Not Attempt Resuscitation however R46's face sheet states Advance Directives: there are no advance directives selected for this resident. R46's physician orders (received [DATE]) exclude advance directives. On [DATE] at 10:08am, surveyor inquired about R46's code status V18 (LPN/Licensed Practical Nurse) stated She's (R46) a full code which was incorrect. Surveyor inquired how staff are aware of the R46's code status V18 responded Her (R46) face sheet. Surveyor requested that V18 access R46's face sheet at this time however was unable to locate any advance directives. Surveyor inquired if R46's code status was on the face sheet (as stated) V18 replied No, nothing. On [DATE] at 10:33am, V18 affirmed that R46's POLST form was found in the resident documents. Surveyor inquired about R46's code status (again) V18 replied No CPR, do not attempt resuscitation. Surveyor inquired if V18 was able to locate R46's code status (Do Not Resuscitate) on the face sheet V18 stated It's not in the face sheet, it's not there. R4's ([DATE]) POLST form states attempt resuscitation/CPR however R4's face sheet states Advance Directives: there are no advance directives selected for this resident. R4's physician orders (received [DATE]) excludes advance directives. R7's ([DATE]) POLST form states attempt resuscitation/CPR however R7's face sheet states Advance Directives: there are no advance directives selected for this resident. R7's physician orders (received [DATE]) exclude advance directives. R21's ([DATE]) POLST form states attempt resuscitation/CPR however R21's face sheet states Advance Directives: there are no advance directives selected for this resident. R21's physician orders (received [DATE]) excludes advance directives. R61's ([DATE]) POLST form states attempt resuscitation/CPR however 61's face sheet states Advance Directives: there are no advance directives selected for this resident. R61's physician orders (received [DATE]) exclude advance directives. On [DATE] at 3:23pm, V15 (Assistant Administrator) affirmed that POLST forms were documented for R4, R7, R21, and R61. Surveyor inquired what R4's face sheet states under Advance Directives V15 stated There are no advance directives selected for this resident. Surveyor inquired what R7's face sheet states under Advance Directives V15 responded There are no advance directives selected for this resident. Surveyor inquired what R21's face sheet states under Advance Directives V15 replied There are no advance directives selected for this resident. Surveyor inquired what R61's face sheet states under Advance Directives V15 stated There are no advance directives selected for this resident. Surveyor inquired about physician orders for POLST directives V15 affirmed that The POLST form is a physician order however none of the POLST directives were transcribed in R4, R7, R21, R31, R46, and R61's physician orders. 2) On [DATE], at 3:06 PM, record review of physician orders and resident documents for R45 showed that there was no advanced directive or code status. R45's face sheet showed, There are no advance directives selected for this resident . On [DATE], at 4:03 PM, record review of physician orders and resident documents for R73 showed that there was no advanced directive or code status. R73's face sheet showed, There are no advanced directives selected for this resident . On [DATE], at 9:55 AM, V11 (Licensed Practical Nurse) verbalized that, The code status is in the resident documents under the advanced directives tab. V11 was unable to locate the code status or advanced directive for R45 and R73. V11 verbalized that she would have to ask medical records why it was not available in the residents' documents. V11 verbalized that the code status of residents is located in a binder on the crash cart. On [DATE], at 3:47 PM, advanced directive forms for R45 and R73 were requested. V15 verbalized that There are no advanced directive forms for (R45 and R73). The facility's policy titled, Advanced Directives (revised 1/2026) documents at the time of admission, the facility shall provide each resident written information regarding facility advanced directive policies and applicable State laws, informing them of their right to accept or refuse medical and surgical treatment, and to formulate an advanced directive, if they so choose. Copies of written advance directive documents will be filed/uploaded in the resident's clinical record. If changes or revisions are required, the care plan team will initiate the necessary process to modify the status changes in the resident's record, including contact of the resident's attending physician so that appropriate orders to reflect these status changes are secured.

Based on observation, interview, and record review, the facility failed to ensure the residents' call devices and personal belongings were within reach. This failure affected 2 (R8 and R84) residents reviewed for reasonable accommodation of needs in the total sample of 55 residents. Findings include: On 07/27/2026 at 11:07am inside R84's room, R84 requested this surveyor to help her. This surveyor requested R84 to use her call device. R84 stated the call device was on the floor and she could not reach it, that she could only walk with assistance, and she could try to pick up the call device but she was scared she would fall. R84's bedside table was also by the foot of her bed with R84 eyeglasses, mobile phone, TV remote, and ice pack. R84 stated she could not reach her mobile phone. On 07/27/2026 at 11:08am, this surveyor stepped out of R84's room and requested V14 (Office Manager/Receptionist) to assist R84. On 07/27/2026 at 11:09am inside R84's room, V14 stated her (R84)'s call device was on the floor, that there was a clip on the cord of the call device, but it was not clipped to her sheet. V14 also stated her (R84) bedside table was not within her reach; it was by the foot of the bed with her eyeglasses, TV remote, ice pack, and mobile phone. As soon as V14 placed R84's bedside table within her reach, R84 grabbed her mobile phone quickly. R84 stated the staff who came in to her room put the bedside table on the foot of her bed. On 07/27/2026 at 11:52am, V17 (Physical Therapy Assistant) stated she could not walk by herself because her balance was poor, and she was not steady; if she tried to pick up the call device on the floor, she would fall. V17 stated her mobile device, TV remote, and call device should be within her reach for safety. On 07/29/2026 at 10:09am, V2 (Director Of Nursing) stated call device should be clipped to the pillow or bedsheet within the reach of the resident so when they need help they can easily call for assistance. This is very important to prevent falls so when they ask for help, they would be helped. On 07/29/2026 at 10:12am, V2 stated personal belonging should be on the side table within reach of the resident to prevent risk of fall for safety reason and for integrity, if they are able to do things they should have ownership of that for self-determination, to have the mindset that they can still do things for themselves. During this interview, this surveyor requested personal belongings policy and procedure as it relates to placement of personal belongings. R84's (07/22/2026) Observation Details List Report documented, in part Fall Risk Observation: Activity Level. 3 confined to chair, totally unable to ambulate without assist. Risk Level: High Risk. R84's (07/22/2026) care plan documented, in part Problem: Resident has a history of falls r/t (related to) limited Mobility. Goal: Resident will remain free from Falls leading to injury. Approach: Keep call light within reach. The (01/2026) Answering the Call Light documented, in part The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 10. Call lights must be accessible to residents room their bed or other sleeping accommodation. The facility did not provide the personal belonging policy and procedure as it relates to placement. Findings include: On 07/27/2026 at 11:10am, R8 says that CNAs don't always come quickly to see him when call he pushes call light. Surveyor 50728 pushed call light at 11:15 am. [NAME] Dudley Housekeeping came in 1 minute to check on his call light. [NAME] confirmed R8's call light was not in reach. R8 prefers for call light to be in his hand. On 07/29/2026 12:14pm, V32 affirmed R8 had impairment to both upper extremities. R8 has a right-hand contracture and left-handed weakness. Observed R8 sitting in wheelchair near the bed. R8's call light was wrapped up on the left handrail of the bed. R8's call light was not within R8's reach, V32 asked R8 to back the wheelchair up so R8 could reach the call light. V32 unlocked the right wheel. R8 tried to back up but was unable to go any further. R8 stated he can't unlock the left side of the wheel lock and cannot reach the call light. V32 went around V8 and untangled the call light and gave it to him. V32 affirmed the call light has a clip and clipped the call light to R8's shirt. V32 stated the importance of having the call light within reach is to be able to call for a nurse or CNA when needed. R8's admission Record documented that R8's diagnosis includes but are not limited to hemiplegia and hemiparesis following cerebral infarction, obesity, and major depressive disorder. R8's (6/23/26) Minimum Data Set (MDS) documented, in part Section C. – Cognitive Patterns. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Cognitively intact. Additionally, R8 is dependent on staff for activities of daily living.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that 2 multidose medication vials were dated when opened, and failed to ensure that food is not stored in the medication refrigerator. This failure applies to 1 resident (R13 reviewed for medication storage and one medication refrigerator in the sample of 19. Findings include: On 7/29/26 at 11:33am, V6 (LPN/Licensed Practical Nurse) opened the (south) medication refrigerator and there were 6 containers of yogurt with medications inside. Surveyor inquired about concerns with the medication refrigerator during inspection V6 responded The yogurt but that's more for the patients. Surveyor inquired if food is allowed in the medication refrigerator V6 replied No. On 7/29/26 at 11:54am, surveyor inspected the (west) medication cart with V33 (LPN). Two (2) of R13's (120 ml/milliliter) haloperidol suspension containers were opened and undated. Each of R13's haloperidol containers contained approximately 20ml. Surveyor inquired if either of R13's (opened) haloperidol containers were dated when opened V33 inspected both containers and stated No. Surveyor inquired about staff requirements when opening multidose medications V33 responded We (staff) always put open date, then the date it expires. The storage of medications policy (reviewed January 2026) states refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and the new date of expiration.

Based upon observation, interview, and record review the facility failed to serve diet as ordered, failed to follow physician orders, and failed to ensure that dietary cards are congruent with physician orders. This failure applies to 1 resident (R31) reviewed for therapeutic diet in the sample of 19.Findings include:R31's (4/3/23) POS (Physician Order Sheets) include Diet: General, Regular double protein at all meals. R31's (6/24/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 7/27/26, the facility lunch was served late due to tornado warning. On 7/27/26 at 1:41pm, the dietary card on R31's tray stated, regular diet/double portion at all meals (R31's orders state double protein NOT portions therefore the dietary card was incorrect). Only one riblet was observed on R31's plate at this time, surveyor inquired if R31 received two (2) riblets for lunch today (double protein - as ordered) R31 stated No.The dietary orders and food & nutrition services management policy (reviewed January 2026) states food and nutrition services shall prepare and serve meals strictly adhering to current physician or delegated RDN (Registered Dietician Nutritionist) orders, maintaining accurate tray cards and distribution logs.

Based on observation, interview, and record review, the facility failed to ensure staff perform appropriate hand hygiene during dining in accordance with facility policy.This failure affected 3 (R11, R22, and R52) residents reviewed for infection control in the total sample of 19 residents. Findings include: 1.On 07/28/2026 at 12:36pm during dining observation, V11 (Nurse Supervisor/LPN) brought a chair, sat next to R11, opened R11's straw, touched R11's spoon, and assisted R11 with feeding without performing hand hygiene. 2.On 07/28 at 12:43pm, V27 (Restorative Aide) was assisting R22 with feeding. V27 picked a straw on the floor and continued feeding R22 without performing hand hygiene. 3.Then V27 pointed to V13 (Certified Nursing Assistant) a wedge cushion on the floor. V13 picked the wedge cushion and handed it to V27. V27 placed the wedge cushion on R22's side and continued feeding R22 without performing hand hygiene. V13 also continued feeding R52 without performing hand hygiene after picking the wedge cushion on the floor and after handing it to V27.On 07/28/2026 at 12:46pm, V13 stated she (V27) asked her to hand the wedge cushion on the floor, and she did not perform hand hygiene before continuing to assist (R52) with feeding. V13 stated she should have sanitized her hands after she (V13) handed the wedge cushion to (V27) and before continuing to assist (R52) with feeding to prevent germs from getting to her (R52). On 07/28/2026 at 12:48pm, V27 stated she should have washed her hands prior to continuing to assist him (R22) with feeding to stop the spread of germs. On 07/28/2026 at 12:53pm, V11 stated she performed hand hygiene prior to touching the chair and she did not see the necessity to perform another hand hygiene prior to assisting him (R11) with feeding. On 07/29/2026 at 10:26am, V3 (Assistant Director of Nursing) stated there is a hand hygiene station in the main dining room. After she (V27) picked up something on the floor and after touching the wedge cushion and repositioned him (R22), she (V27) should have immediately performed hand hygiene before resuming assisting (R22) with feeding. (V13) should have performed hand hygiene after touching the wedge cushion and before feeding (R52), and she (V11) should have performed hand hygiene after touching the chair and before assisting (R11) with feeding. The reasons for all of these is for infection control. R11's (07/03/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 07. Indicating the resident's mental status as severely impaired. Section GG. 0130. Self-Care. A. Eating: 1 - dependent. R22's Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating the resident's mental status as severely impaired. Section GG. 0130. Self-Care. A. Eating: 1 - dependent. R52's (06/16/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating the resident's mental status as severely impaired. Section GG. 0130. Self-Care. A. Eating: 1 - dependent. The (01/2026) Hand-washing/Hand hygiene documented, in part The facility will implement this policy to protect resident's rights, provide safe and person-centered care, and meet current federal and state requirements related to handwashing/hand hygiene. Purpose. Reduce transmission of infectious agents through correct and timely hand hygiene. Procedure. 2. Perform hand hygiene before touching a resident, after touching a resident, after touching the environment, before eating.

Based on observation, interview and record review, the facility failed to develop and implement a smoking policy in accordance with state laws (Smoke Free Illinois Act). This failure applies to 3 of 3 residents (R7, R16, R25) observed smoking in the sample of 19.Findings include: Facility resident smoking list (undated) documents 12 residents smoke in the facility. Smoke Free Illinois Act (410 ILCS 82/), enacted 1/1/2008 and revised 1/1/2024, documents in part, .Smoking in public places, places of employment, and governmental vehicles prohibited. No person shall smoke in a public place or in any place of employment or within 15 feet of any entrance to a public place or place of employment .On 7/28/2026 at 9:10 AM, observed a strong odor of cigarettes from the dining room. R7, R16, and R25 smoking in wheelchairs within 15 feet of the facility in the designated smoking area near the dining room. There was no signage or other indications posted that residents must smoke at least 15 feet from the facility. On 7/28/2026 at 9:12 AM, V1 (Administrator-in-Training) confirmed R7, R16, and R25 were smoking near the facility. R7, R16, and R25 were smoking in wheelchairs sitting equidistant from the facility in a line. V1 measured the distance of the residents to the facility with surveyor. V1 confirmed the residents were approximately three feet from the facility and R25 was approximately three feet from the door/entrance to the smoking area. V1 was unsure the distance residents had to be away from the facility while smoking and thought it was around five to 10 feet away. On 7/28/2026 at 9:14 AM, V21 (Activity Director) affirmed the activity department is responsible for assisting residents with smoking and monitoring residents while they are smoking. V21 looked out the window and confirmed R7, R16, and R25 were smoking too close to the facility. V21 confirmed V23 was also in the smoking area now at a bench that was a couple feet from the facility. V21 stated residents should be moved away from the facility while smoking and believed the distance away needed to be approximately ten feet. On 7/29/2026 at 11:16 AM, V1 (Administrator) affirmed residents must be at least 15 feet away from the facility when actively smoking for state laws. V1 reviewed the facility's smoking policy and affirmed the distance requirement was not in the facility smoking policy. Facility policy titled, RESIDENT SMOKING (8/2024) documents the purpose of the policy is to establish guidelines to prohibit smoking by residents and visitors in designated areas and to establish guidelines for the specific circumstances residents may smoke in designated areas. Smoking by residents and their visitors is permitted only in designated areas. The policy does not indicate the designated smoking area.

Based on interview and record review, the facility failed to conduct mandatory training on that informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program. This failure affects all 80 residents that reside in the facility. Findings include: Facility census (7/27/2026) documents 80 residents reside in the facility. On 7/27/2026 at 3:43 PM, requested documentation of the facility conducting training on the facility's QAPI program from V1 (Administrator-In-Training) and V23 (Regional Nurse Consultant). V1 stated, we will have to find it. Facility QAPI program documentation reviewed including (but not limited to data) collection, performance improvement projects, meeting minutes, and root cause analysis did not contain any documentation of staff training on the QAPI program or the goals/elements of the QAPI program. On 7/28/2026 at 12:37 PM, V5 (Scheduler/Central Supply Manager) affirmed V5 is a part of the QAPI committee. V5 could not recall when the last time V5 was trained on QAPI. On 7/29/2026 at 11:12 AM, V1 (Administrator) affirmed V1 is responsible for the QAPI programming in the facility. V1 explained the purpose of QAPI is to collect data about resident care, identify trends and put plans into place to improve the quality of care for residents and the staff. V1 affirmed the facility should be following the QAPI plan. QAPI program documentation was reviewed with V1 and V23. V1 confirmed there was no documentation of staff training on the QAPI program. V1 was unable to recall the last time facility staff were trained on the QAPI program. On 7/29/2026 at 1:15 PM, V30 (Certified Nursing Assistant) did not know what QAPI was or that the facility had a QA committee. V30 denied ever receiving training on the facility's QAPI program. On 7/29/2026 at 3:19 PM, V23 affirmed the facility did not have documentation indicating staff were trained on the QAPI program. V23 explained V23 developed tools and educational materials to train the staff on the QAPI program during after the survey began and would be conducting the training with staff. Facility QAPI plan (1/17/2023) documents the purpose of QAPI in the facility is to take a proactive approach to continually improve individualized patient care so that the facility may realize their vision to lead healthcare back to a place where people are treated like people. QAPI is an integral part of the facility and is a continuous process that aims to provide quality care for their residents. The QAPI program shall be part of the on-boarding orientation of all employees. A facility wide training shall be held as necessary for updates. A responsibility of the governing body and facility leadership is to create a culture wherein QAPI is an integral part of the day-to-day activities of the facility. The goal is to have a widespread awareness of the QAPI initiatives affecting systems of care, management, and business practices involving not only the facility staff, ut also the patients, families, vendors, physicians and the like. To achieve this, QAPI initiatives shall be communicated often and in multiple ways, such as inclusion in: 1. the on-boarding process for all new hires 2. annual performance reviews, 3. resident council meetings, 4. upon contracts with collaborating agencies/consultants 5. employee meetings. Dissemination of information/QAPI initiatives shall be done through: 1. Memorandum 2. Postings 3. Meetings: face to face, web, phone conference.

Based on interview and record review, the facility failed to 1) ensure active participation or solicit input from direct care staff in the development of the facility assessment, failed to solicit input from residents/their respective in the development of the facility assessment 2) failed to identify mandatory required training of the elements/goals of the facility's QAPI (Quality Assurance Performance Improvement) program 3) failed to consider staffing needs for each resident unit of the facility, failed to consider staffing needs for each resident shift of the facility 4) failed to identify/develop recruitment and retention program based on the facility assessment 5) identify/inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as but not limited to, the availability of direct care nurse staffing or other resources needed for resident care. 6) failed to accurately identify service capabilities by the facility regarding the capacity to accept and meet the needs of residents who are convicted of sex crimes. These failures affect all 80 residents that reside in the facility. Findings include: Facility assessment (3/26/2026) documents: 1) The persons involved in completing the assessment were V20 (Administrator), V2 (Director of Nursing), V38 (Social Services Director) and V41 (Medical Director). There is no documentation in the facility assessment that indicates any other department heads, direct care staff, governing body members, or residents/their representatives were involved or solicited for information in the development of the facility assessment. 2) The facility has a comprehensive orientation program and annual in-service calendar. Included is to be an orientation checklist, in-service calendar, and nurse & CNA competency. These documents were requested during the survey and not provided upon presentation of the facility assessment or prior to the exit of the survey. The facility assessment does not identify the requirement that facility staff must be trained/informed on the goals/elements of the QAPI program. 3) The staffing plan indicates staffing requirements are projected by resident acuity and census. The facility utilizes the staffing ratio algorithm recommended by the department of health. The facility reviews care needed by residents on each unit to determine staff assigned. There is no identification in the facility assessment to staffing needs identified by both unit and shift. 4) There is no documentation of any recruitment or retention program that is developed or maintained for direct care staff based on the facility assessment. 5) There is no documentation that identifies contingency planning for events that do not require activation of the facility's emergency plan but do have the potential to affect resident care. 6) The list of conditions and diagnoses which the facility is unable to care for and/or accept includes individuals who have a history of violence or sexual offenses. Facility QAPI plan (1/17/2023) documents the QAPI program shall be part of the on-boarding orientation of all employees. A facility wide training shall be held as necessary for updates. A responsibility of the governing body and facility leadership is to create a culture wherein QAPI is an integral part of the day-to-day activities of the facility. The goal is to have a widespread awareness of the QAPI initiatives affecting systems of care, management, and business practices involving not only the facility staff, ut also the patients, families, vendors, physicians and the like. To achieve this, QAPI initiatives shall be communicated often and in multiple ways, such as inclusion in: 1. the on-boarding process for all new hires 2. annual performance reviews, 3. resident council meetings, 4. upon contracts with collaborating agencies/consultants 5. employee meetings. Dissemination of information/QAPI initiatives shall be done through: 1. Memorandum 2. Postings 3. Meetings: face to face, web, phone conference. R76's background check (10/19/2022) documents R76 has multiple criminal convictions including home invasion/cause injury, aggravated criminal sexual assault/bodily harm, aggravated criminal sexual assault/victim >60, DUI/alcohol, and carrying/possessing a firearm in public. On 7/28/2026 at 12:37 PM, V5 (Scheduler/Central Supply Manager) affirmed V5 is responsible for scheduling the licensed nurses, certified nursing assistants and respiratory staff in the facility. V5 stated staffing is based on a budget pattern established by the administration which is based off census. The current staffing pattern is three licensed nurses every shift every day, five to six certified nursing assistants on the day/afternoon shift, and three to four certified nursing assistants on night shift. Additionally, there is a wound care nurse and respiratory nurse scheduled daily. V5 explained when someone calls off or more coverage is needed, staff are called to pick up, offered bonuses, before nurse management would pick up the shift. V5 denied knowledge of the facility assessment or a staffing plan within the facility assessment. V5 denied ever reviewing the facility assessment. V5 was unaware of any recruitment or retention program for the direct care staff based on the facility assessment. On 7/29/2026 at 11:18 AM, V20 (Administrator) affirmed V20 was responsible for completing the facility assessment. V20 explained the purpose of the facility assessment is to complete a self-assessment of the services the facility can provide to improve processes. V20 reviewed the facility assessment. V20 confirmed no information was solicited from direct care staff or residents/their representatives when V20 completed the facility assessment. V20 affirmed required QAPI training was not identified in the facility assessment. V20 reviewed the staffing plan and confirmed the staffing plan does not identify numbers of needed staff or consider staffing needs per unit and per shift. V20 affirmed uses various online programs to try to recruit staff and maintains staff by having things like bonuses or other incentives. V20 confirmed there is no mention of the recruitment or retention plan for direct care staffing in the facility assessment. V20 confirmed the facility's plan for contingency staffing efforts are not identified the facility assessment. V20 explained the facility is unable to meet the needs of violent offenders or sex offenders because the facility has an elderly population which is at an increased risk for abuse. V20 affirmed R76 is a registered sex offender and had been convicted of sexual crimes. V20 explained R76 was admitted prior to V20 assuming the role of the administrator. V20 clarified the facility could take residents that are sex offenders, but it would have to be a case-by-case basis. V20 reviewed the facility assessment, affirmed the facility assessment states the facility cannot accommodate residents that are convicted of sex crimes, and stated, yeah, I would say it (facility assessment) is incorrect. Document titled, Facility Assessment Tool documents the facility will conduct, document and annually review a facility wide assessment, which includes both their resident population and resources the facility needs to care for their residents. The purpose of the assessment is to determine what resources are necessary to care for resident competently during both day-to-day operations and emergencies. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services residents require . Guidelines for Conducting the Assessment 1. To ensure the required thoroughness, individuals involved in the facility assessment should, at a minimum, include the administrator, a representative of the governing body, the medical director, and the director of nursing. The environmental operations manager and other department heads (e.g., the dietary manager, director of rehabilitation services, or other individuals including direct care staff) should be involved as needed. Facilities are encouraged to seek input from residents, their representative(s), or families, and consider that information when formulating their assessment. The facility must review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. For example, if the facility decides to admit residents with care needs who were previously not admitted , such as residents on ventilators or dialysis, the facility assessment must be reviewed and updated to address how the facility staff, resources, physical environment, etc., meet the needs of those residents and any areas requiring attention, such as any training or supplies required to provide care. It is not the intent that the organizational assessment is updated for every new person that moves into the nursing home, but rather for significant changes such as when the facility begins admitting residents that require substantially different care. Likewise, hiring new staff or a director of nursing or even remodeling should not require an update of the facility assessment, unless these are actions that the facility assessment indicated the facility needed to do. 4. The facility assessment should serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources .The leader identifies and invites team members to be on the assessment team, including the administrator, representative of the governing body, medical director, and director of nursing, and considers other persons to be on the team. a. Consider and plan for how you will get input and participation from residents, their representatives and/or family members and CNAs (who provide most of the hands-on care) throughout the assessment process. This could include a) asking for input from both the resident council and the family council (if there is one); b) getting feedback from the local long-term care ombudsman program; and c) involving residents, their representatives, and/or family members and CNAs as part of the facility assessment team (for instance, the president of the resident council could represent residents.) b. Consider and plan for how you will engage the medical director and medical practitioners in discussing the entire approach to, and ability to care for, residents/patients .1. Review the facility assessment requirements and guidance at F838 .

Based on interview and record, the facility failed to ensure a significant change in condition was documented in the medical record for one (R2) resident. This failure affected one (R2) of four residents reviewed for change in condition. Findings include:R2's face sheet documents an admission date of 4/06/26 and diagnoses that include but are not limited to Parkinson's disease, dementia, difficulty in walking, abnormalities of gait and mobility, hypertensive disease with heart failure, atherosclerotic heart disease, chronic kidney disease stage 2, and benign prostatic hypertrophy.R2's BIMS (brief interview for mental status) score, dated 6/29/26, is 15 which indicates R2 is cognitively intact.R2 was transferred to the hospital on 6/30/26 and remains in hospital and unable to interview.R2's progress note, dated 6/30/26 at 9:41pm, per V9 (Licensed Practical Nurse/LPN), documents, in part, Writer (V9) f/u (follow-up) with the patient's (R2) health status, and was informed that the patient (R2) has been admitted for Sepsis.R2's late entry progress note, dated 7/21/26 at 11:03am (21 days after R2's change in condition), per V8 (Licensed Practical Nurse/LPN), documents, in part, Resident (R2) was observed to be confused and shaking profusely, which was beyond his (R2) baseline behavior elevated blood pressure was also noted. The NP (nurse practitioner) was notified of the resident (R2) current condition and ordered transfer to (Hospital) for further evaluation and treatment. The resident's family was notified, and Ambulance was called for transportation. Report was endorsed to the incoming nurse to follow up.On 7/20/26 at 11:33am, V2 (Director of Nursing/DON) said, He's (R2) currently hospitalized . On the afternoon of 6/30, (6/30/26) R2 was lethargic. He (R2) was up and cracking jokes earlier in the day. He's (R2) a jokester. He (R2) mentioned to the nurse (V8/Licensed Practical Nurse/LPN) that he (R2) wasn't feeling good. V8 called the nurse practitioner that gave orders for R2 to be sent to ER (emergency room) for evaluation. R2 was admitted with sepsis. V8 did not put a note about the change in condition in R2's chart. V2 did notify him (V8) and he (V8) will be putting a late entry in about R2's change in condition. It (resident's change in condition) should be documented in the medical record so we (facility) know what happened and may help with the treatment of the resident.On 7/20/26 at 2:54pm, V8 (Licensed Practical Nurse/LPN) said, Yes, he was working that day (6/30/26), and he was the nurse assigned to care for him (R2). He observed that he (R2) was shaking. V8 checked his (R2) blood pressure, and it was somewhat elevated. V8 contacted the NP (Nurse Practitioner) and was instructed that the resident (R2) be sent to the hospital. V8 then called (Ambulance Company) and notified the resident's (R2) family. While V8 was arranging the transfer, V8 had another resident who was experiencing a medical emergency that required my attention. Because of that, V8 endorsed the resident's care and pending transfer to the next nurse. This occurred sometime after 2:00 p.m. My shift was from 6:00 a.m. to 2:30 p.m. The resident was still at the facility when my shift ended. Yes, the resident had experienced a change in condition. V8 said he should have documented R2's change in his (R2) record, but he forgot because he was also caring for another resident with an emergency.Record review of facility policy titled, Change in a Resident's Condition or Status, dated January 2026, documents, in part, Our facility shall promptly notify the resident, consult with his or her Attending Physician, and notify, consistent with his or her authority, the resident representative (s) of changes in the resident's [NAME]/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: A need to transfer the resident to a hospital treatment center. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting'). b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii). 6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 7. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS [NAME] Instruction Manual.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview and record review the facility failed to assess, monitor and treat residents with multiple pressure ulcers for 2 of 3 residents (R3 and R4) This deficient practice resulted in R3 being hospitalized for necrotizing fasciitis of the wound bed. Findings include: On 3/10/2026 at 2:00pm V14(Certified Nursing Assistant-CNA) said on 10/5/2025 she entered R3 room and V10 said to clean her up she's going out to the hospital the areas on her buttocks were some what dark she did answer me correctly when I told her what I was doing she responded ok. R3 could not turn or reposition herself she was dependent on staff for all care. On 3/10/2026 at 3:00pm V8(Nurse Practitioner-NP) said that a wound can become infected with necrotizing fasciitis leading to sepsis based on three of the five criteria that the hospitals use, tachycardia, fever, increased white cells, infected wounds, disease factors, V8 said she did not observe R3 wound on 10/5/2025 she gave order to send her out because of a new wound onset. On 3/10/026 at 3:10pm V2(Director of Nursing-DON) said the floor nurses and the weekend wound care nurses do not measure resident's wounds only the wound care nurse on the week day does the measurements. On 3/12/2026 at 9:30am, V10 (Wound care Nurse) said she was the nurse for R3 on 10/5/2025, V10 said she observed a new sacral wound on R3 dark in color like a blister, and notified V8 (Nurse Practitioner -NP) of the new wound also that R3 was not responding to questions as usual. V10 said she does not do measurements on the weekend and that is why she cannot recall the size or length of R3 sacral wound, V8 gave orders to send R3 to the hospital for a wound evaluation. On 3/12/2026 at 10:30am V13(Nurse) said upon her start of shift on 10/5/2026 V10 informed me that R3 would be transferring to the local hospital for a wound evaluation, I made sure to call the family and inform V8 again, I never saw R3 wound, I do not assess any wounds I'll turn it over to the wound care nurse whom was the nurse transferring R3 to the local hospital that day. R3 could not turn and reposition herself she was dependent on staff I never entered the room the transfer was in progress at the start of my shift. R3 resident face sheet indicates that R3 has a diagnosis of hemiplegia, hemiparesis, Chronic respiratory failure, obesity, encounter for Palliative care, muscle wasting, peripheral vascular disease. A Braden score of 14 on 5/18/2024 moderate risk, on 9/9/2025 a Braden score of 16 mild risk, no Braden score on 10/5/2025, R3 was admitted on [DATE] with wounds of the left buttocks stage 2, on 2/4/2025 R3 had a skin tear to right posterior thigh, a care plan dated 8/1/2025 for skin checks per protocol report any signs of skin breakdown. On 3/10/2026 at 10:00am this writer observed R4 incontinence care, and observed two pink open areas with scant drainage to the left and right buttocks. On 3/10/2026 at 10:03am V5(Certified Nursing Assistant-CNA) said I don't know if those open areas were on his buttocks this is my first time having R4.On 3/10/2026 at 10:05am V6(Certified Nursing Assistant-CNA) said the wound care nurse should know the wounds are their R4 came from the other side with this barrier cream that V4 said to apply. On 3/10/2026 at 10:08am V8(Nurse Practitioner-NP) said the wounds are new, R4 also has excoriation to the scrotal area, which I'll order an hydrocolloid dressing three times a week and nystatin powder twice daily with barrier cream to buttocks will be ordered. On 3/10/2026 at 10:12am V4(Wound care Nurse) said that she was not informed of R4 open wound on his buttocks and applied a hydrocolloid dressing to the left and right buttocks, nystatin cream to scrotum and barrier cream to the surrounding buttocks.On 3/12/2026 at 12:30pm V4 said , she complete skin assessments twice a month on the entire building, the floor nurses do a weekly skin assessment on non-pressure ulcer residents and the residents with pressure ulcers she complete weekly assessments along with the wound care physician. I expect the wound care nurse on the weekend to assessment measure and notify the nurse practitioner of any wound just as I do on the week day and complete wound care interventions, then on Monday I will complete them. On 3/12/2026 at 11:30am V7(Certified Nursing Assistant-CNA) said she informed V4 of R4 open areas on his buttocks several times a couple of weeks ago she said to apply barrier cream. R4 resident face sheet indicates that R4 has a diagnosis of Hemiplegia, Hemiparesis, osteoporosis, lack of coordination, an weekly skin assessment dated [DATE], a initial Braden score dated 10/20/2025 of 13 indicates moderate risk and on 3/10/2026 a Braden sore of 12 high risk, on 12/10/2025 a care plan that indicates R4 was at risk for skin breakdown, , On 3/10/2026 R4 has a care plan of left buttock pressure area related to incontinent of bowel and bladder, apply dressing per medical doctor, assess the pressure ulcer for stage, size, length , width, and depth conduct systemic skin inspection weekly report any signs of any further skin breakdown. Left buttocks measuring 1.0x1.2 and Right buttocks 1.0x1.0 pink granulating tissue. Facility Policy: dated October 2025Policy: At first observation of any skin condition, the nurse is to describe and document in clinical record. The nurse is to notify the family of new skin alteration and inform physician of new alteration to obtain initial order. Wound care nurse to follow up with staging and measurements and must add to weekly wound round list for NP to follow. Wound Assessment:Identify the type of wound present such as pressure, arterial diabetic, venous and etc. Identify the stage or extent of tissue destruction involved.Pressure Ulcer and Wound Prevention /Management Program: updated 9/30/2025Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown.Responsibility: Director of Nursing, Licensed Nurses, Certified Nursing Assistants, Restorative Nursing, Care plan Coordinator, Dietician, Physician, and Medical Doctor.Policy; To ensure that residents that enter the facility do not develop pressure ulcers unless the individual's clinical condition demonstrates that the pressure ulcers were unavoidable.2. Residents will have a head to toe skin assessment upon admission, readmission, at the time of discharge and transfer and prior to return from a leave of absence by a licensed nurse.

Based on interview and record review the facility failed to ensure a resident with a history of falls was monitored during a transfer for one of three residents (R2) reviewed for falls. Findings Include:On 3/10/2026 at 1:30pm R2 said that on 3/3/2026 , his CNA sat him up on the side of the bed, went to retrieve the mechanical lift he could not hold his balance and slid to the floor. On 3/11/2026 at 12:58pm , V14(Certified Nursing Assistant-CNA) said she sat R2 on the side of the bed and went to retrieve the mechanical lift R2 yelled, she ran over to him and lowered him to the floor then went for assistance. On 3/12/2026 at 11:30am, V12(Restorative Nurse/Fall Coordinator) said R2 is a high risk for falls and should not be left alone on the side of the bed. On 3/12/2026 at 2:00pm, V2(Director of Nursing-DON) said I expect the staff to monitor any resident that is high risk for falls and never leave them alone on the side of the bed. A resident face sheet indicates R2 has a diagnosis of dementia, Parkinson's disease, edema unspecified of BLE-Bilateral lower extremities unspecified abnormalities of gait and mobility. A fall , and root cause analysis indicates R2 had a fall on 12/21/2025 rolled out of bed no injuries unwitnessed, a fall, and root cause analysis on 1/23/2026 R2 was trying to take himself to the bathroom, and a fall and root cause analysis , on 3/3/202 R2 started sliding and was lowered to the floor during a transfer. A care plan dated 2/13/2026 indicates R2 problem requires a sit to stand mechanical lift for transfers related to decreased lower extremity strength and endurance, a intervention maintain body in functional alignment during transfer, ensure safe placement of extremities during transfers Facility Policy: Falls-Clinical Protocol 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk for subsequent falling.3. A risk factor for subsequent falling include lightheadedness, or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders.

Based on observations, interviews, and record reviews, this facility failed to provide the necessary care and services to prevent a stage 3 sacral pressure ulcer from recurring, assess and document wound conditions, perform weekly wound assessments with measurements for one resident (R1) out of three residents reviewed for pressure ulcers. On 10/1/25 R1's stage 3 sacral pressure ulcer reopened; wound measured 2.9cm (centimeters) x 0.6cm x 0.1cm. On 11/14/25, R1's wound declined; wound measures 3cm x 4,3cm x 0.4cm with 50% slough and 50% granulation tissue. Findings include:On 11/17/25 at 8:45 AM, V4 (wound care nurse) stated that she believes R1's sacral pressure ulcer is facility acquired. V4 stated that the nurse is expected to chart in the resident's medical record when dressings changed. V4 stated that resident's family is updated weekly after resident is seen by wound care physician. V4 stated that the resident's family is notified if a new wound identified. V4 stated that wounds are measured weekly during wound care physician rounds. V4 stated that if resident develops a MASD (moisture associated skin damage), the nurse is expected to notify wound care team so resident can be assessed and have wound treatment orders obtained.On 11/17/25 at 11:15 AM, V2 DON (director of nursing) stated that V4 has been in the wound care nurse position for one week. V2 stated that the previous wound care nurse was not doing her job.R1's medical record notes R1 was hospitalized 9/26-9/30/25 and 10/11-10/18.On 9/30/25 at 6:30 PM, V5 LPN (licensed practical nurse) notes R1 is re-admitted after hospitalization. R1 is noted to have two old wounds (scar tissue) to the sacrum and left posterior thigh.R1's full clinical body observation, dated 9/30/25, notes R1's skin color is normal, skin temperature is warm, skin is dry, and skin turgor is normal. R1 is noted with MASD to sacrum and left posterior thigh. No pressure ulcers identified.On 10/1/25 at 12:52 PM, V6 LPN noted R1 is a readmission from hospital. Head-to-toe skin assessment completed. R1 has a 1.5cm x 0.5cm wound on her sacrum. V6 received new orders to clean with normal saline and apply calcium alginate to wound bed on sacrum and posterior thigh and cover with gauze dressing. R1's family notified of new orders.R1's wound care physician's initial note, date 10/7/25, notes R1 with stage 3 sacral pressure ulcer, measuring 2.9cm x 0.6cm x 0.12cm, 100% granulation tissue. On 10/21, the wound care physician documented R1's sacral pressure ulcer resolved.R1's wound was not monitored by wound care physician 10/22 to 11/13.R1's full clinical body observation, re-admission dated 10/18/25, notes R1's skin color is normal, skin temperature is warm, skin is dry, and skin turgor is normal. R1 is noted with a stage 3 sacral pressure ulcer. R1's POS (physician order sheet), dated 10/1/25, notes an order to cleanse sacrum with normal saline and apply calcium alginate to wound bed and cover with a dry dressing once a day; discontinued on 10/7. 10/7 notes an order to cleanse sacrum with wound cleanser and apply calcium alginate to wound bed and cover with a dry dressing once a day; discontinued on 10/11 (due to hospitalization). 10/18 notes an order to cleanse sacrum with normal saline and apply a dry dressing until wound care evaluates and treats; discontinued on 10/21. 10/26 notes an order to cleanse sacrum with normal saline and apply a foam dressing with zinc.There are no wound care treatment orders from 10/21 until 10/26.R1's TAR (treatment administration record), dated 9/30 to 11/17, was reviewed. There is no documentation R1 received wound care treatment to sacral wound on 10/3, 10/7, 10/8, 10/22, 10/23, 10/24, 10/25, 10/28, 11/4, 11/7, 11/13, or 11/15.R1's wound management documentation, dated 10/2 to 11/4, notes on 10/2 R1's sacral wound measured 2.9cm x 0.6cm x 0.1cm with100% granulation tissue; on 10/7 wound measured 2.9cm x 0.6cm x 0.1cm with100% granulation tissue; on 10/28 wound measured 3.5cm x 1cm with100% granulation tissue; and on 11/4 wound measured 3.5cm x 4cm x 0.2cm with 50% slough (yellow tissue) and 50% granulation tissue.There is no further documentation under wound management after 11/4/25.On 11/14/25, R1's sacral wound was assessed by the new wound care physician. R1's wound measures 3cm x 4,3cm x 0.4cm with 50% slough and 50% granulation tissue.

Based on interviews, observations, and records reviewed the facility failed to identify and evaluate nutrition interventions for one resident. This affected one of one resident R2 reviewed for nutrition in sample of 72. This failure resulted in R2 having a significant unplanned weight loss of 16.7% in 4 months. The findings include: R2 is alert but has diagnosis including but not limited to Dementia, Major Depressive Disorder, Schizoaffect Disorder, Restless and Agitation, and Pseudobulbar Affect. R2 is difficult to understand his words. 04/27/25 10:08 AM R2 observed eating in bed, head of bed elevated, tray table over him, food spilt along left side of chest, leaning towards left in bed. Food cover, milk carton, and food debris on the floor along left side of bed. On 04/28/25 at 12:59 PM R2 in bed, feeds self in bed. R2 said he prefers to stay in his room. On 4/30/25 at 12:17 V26, Dietary Manager, said Restorative department does weights and enters it in the resident records. V26 said I do a review of re-weights. V26 said after the re-weight we notify the Registered Dietician if then they are seen and her recommendations are given to me and then we follow them. V26 said I told them in February that weights were not done. V26 said I told restorative about it. V26 said I noticed in March. V26 said they did not tell me why the weights were missing. V26 said when she completed R2's annual assessments dated 3/18/25related to weight she used the January 2025 weight, because she did not have a current weight to use. V26 said the Policy is for at least monthly weights for all residents. V26 said R2 should have been reweighed to confirm the weight from March. V26 said I do not have reweights for R2. V26 said that is a lot of weight loss for someone. V26 said the purpose of the Nutrition at Risk Observation is to alert us of resident changes and then I am to notify the dietician. V26 said we were not sure when R2's weight loss occurred. The surveyor asked V26 what has been done for R2 to maintain his weight and V26 said I will have to look. As of 3:17PM V26 did not return or provide additional information. On 4/30/25 at 12:26PM V8, Restorative Nurse, said we do weights monthly for all residents, per the policy. V8 said we did not get a weight for R2 in February.V8 said the aid said he refused, but I did not document it, I should have. V8 said we don't have documentation that we tried again. V8 said she looked in her office and did not find anymore weights for R2. On 4/30/25 at 12:54PM V27, Registered Dietician, said the Dietary Manager generally monitors weights, I do 2 visits a month. If there is no weight on my first visit I document and ask about it. V27 said with R2, I caught that he lost 20 pounds, but we were not sure when it occurred. V27 said I asked for reweight on Monday 4/28/25. V27 said I saw him on 4/24/25, last week. V27 said R2's weight loss since January 2025 is 16.7%, this is a significant loss. V27 said I was called and notified on 4/28/25, by phone, that R2 had a weight loss. V27 said every Thursday we have a weight meeting with Dietary Manager. V27 said I was in the facility on 4/10/24 and 4/24/24 and R2 had no weight. V27 said I was told R2 was eating ok. V27 said she doesn't remember if they discussed R2. V27 said we don't have any idea what has caused the weight loss. V27 said we will weigh R2 weekly to make sure he is stable. On 4/30/25 at 2:09PM the surveyor observed as V8 and V20 Restorative Aide, obtained R2's weight utilizing the wheelchair scale. R2's weight is 168.9 pounds. R2 was calm and cooperative for this. R2's weight report documents 12/4/24 204.1 pounds; 1/6/25 202.7 pounds; 3/28/25 184.5 pounds (18.2 pound loss); and 4/28/25 168.8 pounds (another 15.7 pounds). From January to March R2 went 11 weeks without a weight obtained or documentation of him refusing weights. R2 has lost an unplanned 33.9 pounds since January 2025. Review of R2's Nutrition at Risk has weight of 203 pounds and Nutrition Assessment list weight 202.7 pounds, both assessments dated 3/18/25. R2's diet is no concentrated sweets, mechanical soft texture with thin liquids. R2's Physician Order Report includes order dated 4/28/25 for Ensure 8 ounces twice a day between meals. R2's Dietary Progress Notes 4/24/25 state he is 70 inches tall. No weight for February. Unsure when weight loss occurred. No significant changes in care noted. Further weight loss not desired at this time. Recommend reweigh. Noted no April weight complete, will discuss with nursing. Question if resident is refusing weights. Dietary Progress Notes 4/28/25 Resident was reweighed. 168.8 pounds indicating an additional 15 pound loss in 1 month. Weight loss not desired and unplanned. Will have dining readdress food preferences. Add supplement to promote weight maintenance. Weekly weights recommended to monitor closely. These are the only 2 date Dietary has a progress note for R2 since January 2025. R2's Assessment for Swallowing and Nutritional Status list weight 203 pounds and says no weight loss or gain. R2's care plan dated 3/18/25 states he at risk for malnutrition. Goal for R2 states will maintain current weight +/- 3 pounds by next review. All interventions are dated 3/18/25. Facility Nutrition Impaired/ Unplanned Weight Loss Policy dated August 2008 includes assessment and recognition, cause identification, treatment & management, and monitoring. The policy states in part monitor and document the weight and nutritional status of residents in a format which permits readily available month to month comparisons. Assess current nutritional status and identify recent weight loss and risk for impaired nutrition. Consider whether testing is indicted.

Based on interview and record review, the facility failed to provide adequate supervision to a cognitively impaired resident and provide adequate monitoring of exit doors. This failure affected one of three residents (R1) reviewed for elopement in a sample of three. This failure resulted to an Immediate Jeopardy. The Immediate Jeopardy began on 04/14/2025 at 2:30PM when R1 exited through the locked dining room door without the door alarm going off, went to the patio/courtyard, exited the patio/courtyard gate, and did not come back. V2 (Director of Nursing) and V3 (Assistant Administrator) were notified of the Immediate Jeopardy on 04/18/2025 at 2:18PM. The facility presented an acceptable removal plan, and the immediacy was removed on 04/23/2025. The surveyor conducted an onsite investigation on 04/23/2025 to confirm the removal plan was implemented. V1 (Administrator) was informed that the Immediate Jeopardy was removed on 04/23/2025. Although the immediacy was removed, the facility remains out of compliance at severity level 2 until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: R1 is a [AGE] year-old male who was initially admitted in the facility on 04/07/2025 for long-term care. R1 is diagnosed with not limited to hypertensive heart disease with heart failure, congestive heart failure, and osteoarthritis. R1's Brief Interview for Mental Status (BIMS) dated 04/08/2025 indicated R1 scored 5 which indicates severe impairment. On 04/17/2025 at 10:30AM, R1 was lying on his bed with shoes and winter coat on, and R1's head was covered with winter coat hood, conversant, and calm. On 04/18/2025 at 1:57PM during interview with V19 (R1's daughter), V19 stated that R1 was transferred in this facility due to the safety concerns raised by the assisted living facility where R1 was residing before, related to when R1 goes out of the assisted living facility on his own. V19 also stated that the assisted living facility also has concerns about R1's medication management that's why R1 was transferred to this facility. V19 stated that R1 was able to go out and come back while R1 was living in the assisted living. V19 stated that she has not received any call from the facility to ask anything about R1's history. On 04/17/2025 at 11:36AM during interview with V4 (Social Service Director), V4 stated that she kept calling R1's daughter to gather more information about R1 but was unsuccessful. On 04/17/2025 at 12:22PM during interview with V9 (Registered Nurse/RN), V9 stated that when she started her shift at around 2:00PM, she made her rounds and saw R1 sitting at the edge of his bed. V9 stated that at around 2:15PM, she saw R1 walking from his room going to the dining room. V9 stated that when she was passing medications at around 4:00PM, she did not see R1 in his room, so she went on passing medications to other residents. V9 stated that when she was done passing medications to residents in their rooms, she went to the dining room to see if R1 was there so she can give R1's medications, but R1 was not there. V9 stated that she went to other units and checked if R1 was there, but she did not find R1 on the other units. V9 stated that she activated Code Pink, and called the V2 (Director of Nursing), V16 (Assistant Director of Nursing), and V3 (Assistant Administrator). V9 stated that the V3 and V16 came in to help with the search but did not find R1. V9 stated that she cannot remember who the staff members were she asked at the time of the incident. On 04/17/2025 at 10:41AM during interview with V2 (Director of Nursing), V2 stated that she received a call from a nurse around 5PM on 04/14/2025 informing her that R1 was nowhere to be found in the building. V2 stated that she instructed her to check all rooms inside the facility, do a head count, and check the outside vicinity of the facility to make sure R1 was not in those areas. V2 stated that the nurse called a Code Pink (Elopement) so all staff will be searching the facility. V2 stated that V3 (Assistant Administrator) and V16 (Assistant Director of Nursing) were also informed, who came back to the facility to assist the staff. V2 stated that staff should be aware of the whereabouts of R1 since R1 needs supervision with ambulation. V2 stated that she was in the building at the time R1 walked out the dining room door, but she did not hear any door alarms going off. On 04/17/2025 at 11:50AM during interview with V3 (Assistant Administrator), V3 stated that she received a call from staff on 04/14/2025 at 6:41PM about R1 not being found anywhere in the facility and the vicinity. V3 stated that she lives 7 minutes away, so she came back in the building immediately to help staff search for R1. V3 stated that they searched everywhere and could not find R1. V3 stated that when she reviewed the camera, she saw that at around 2:30PM that day R1 walked to the dining room, just pushed the door, went out to the patio/courtyard, tried to open the gate but was not able to because it was locked, then went on to the left end of the patio/courtyard. V3 stated that it was the last time R1 was seen in the facility's vicinity. V3 stated that she was in the facility around the time R1 left and did not hear any door alarm going off. V3 stated that the door alarm is loud, and she could have not missed it if it went off. V3 stated that the door R1 went through was supposed to be locked and secured. V3 stated that if the door was locked and secured, the door's alarm should have gone off when R1 pushed it, but she did not hear anything at the time R1 went out of that door. V3 stated that between 1:30PM - 2:00PM is a smoking time for the residents. V3 stated that after the smoking time, the staff who supervised the smoking should make sure that all residents are inside the facility and the door is locked and secured. V3 stated that all staff should be checking the door periodically to make sure that it is locked and secured. V3 also stated that all staff should be aware of the whereabouts of their residents. V3 stated that she cannot remember if she saw any staff member present in the dining room when R1 walked through the door. On 04/18/2025 at 11:45AM during interview with V16 (Assistant Director of Nursing), V16 stated that she was working on 04/14/2025 between 7:45AM-4:20PM and denied hearing any door alarm go off and she has heard the door alarm go off before so she knows that wherever she's at, she would hear it. V16 stated that she got a call from V9 and V2 between 5:45PM-6:00PM informing her that R1 was nowhere to be found. V16 stated that she asked V9 if Code Pink was activated and if they looked inside and outside the facility, which they already did. V16 stated that she was back in the facility 15 minutes after she received the call. V16 stated that she looked around inside and outside the facility herself to make sure everything was covered already. V16 stated that V3 was in the building already, and V3 called the local police department. On 04/17/2025 at 10:30AM, R1 refused to be interviewed. At 12:53PM during interview with R1, R1 stated that he left the facility the other day and just came back yesterday to the facility. R1 stated that he went out through the front door and rode in a car with someone he didn't know. R1 stated that he was dropped off around 95th street or something like that. R1 stated that he left because he got tired of the facility. R1 was able to repeat the three words that he was told, stated it was April of 2025, unable to state the day of the week, and unable to recall the three words he was told to repeat earlier even with cue. On 04/17/2025 at 12:11PM during interview with V8 (Activity Aide), stated that she was working on 04/14/2025 between 10:00AM-5:00PM. V8 stated that she supervised the 1:30PM-2:00PM smoking time. V8 stated that R1 smoked at that time and went inside when smoking time was done. V8 stated that she was in the dining room between 2:00PM-3:00PM and did not hear any door alarm go off or see anyone go through the dining room door. V8 stated that after smoking time, all residents must go back inside the building, then Activity staff closes the door after all the residents are in. On 04/17/2025 at 12:04PM during interview with V7 (Activity Aide), V7 stated that she was working on 04/14/2025 between 8:00AM-4:00PM. V7 stated that she was not sure where she was between the hours of 2:00PM-2:45PM but she denied hearing any door alarm go off and seeing anyone go out to the patio/courtyard using the dining room door. V7 stated that during smoking times, Activity staff lets the residents out to the patio/courtyard, give them cigarettes and light it for them. V7 stated that after all the residents are done smoking or the smoking time is done, all residents are directed to go back inside the building then Activity staff closes the door. On 04/18/2025 at 9:59AM during interview with V15 (Certified Nursing Assistant/CNA), V15 stated that she was working on 04/14/2025 between 2:00PM-10:00PM on the unit where R1 is staying and has not heard any door alarm go off. V15 stated that she made her rounds during the start of her shift and attended to the immediate needs of the residents. V15 stated that at around 3:30PM, she went into the dining room because it's her turn to supervise residents in the dining room, and then Code Pink was called. V15 stated that she did not see R1 between 2:00PM until the Code Pink was called. On 04/17/2025 at 2:27PM during interview with V12 (CNA), V12 stated that she was working on 04/14/2025 between 2:00PM-10:00PM and has not heard any door alarm go off. On 04/17/2025 at 2:29PM during interview with V13 (CNA), V13 stated that she worked 04/14/2025 between 2:00PM-10:00PM and did not hear any door alarm go off. V13 stated that between 2:00PM-3:00PM, she was working in her unit which was in the South unit. On 04/18/2025 at 10:25AM, V6 (Maintenance Director) stated that activity staff are expected to make sure that the door is locked and engaged after each smoking times and ensuring that all the residents who smoked that time are inside the building. On 04/18/2025 at 11:53AM during interview with V17 (Restorative Nurse), V17 stated that R1 has a shuffling gait and needs supervision with ADLs. V17 stated that R1 needs supervision with his ADLs for safety and to ensure that he is completing the task. On 04/18/2025 at 9:37AM during interview with V14 (Nurse Practitioner), V14 stated that R1 fairly new to the facility and came from assisted living. V14 stated that R1 is alert and oriented x 2, ambulatory with limp but steady. V14 stated that she is not sure if R1 is safe to be in the community. V14 stated that she usually performs safety assessments on new residents, but she did not perform safety assessment on R1 because R1 came in from assisted living and V14 assumed that R1 is only here for short-term rehab and will be back to assisted living. On 04/18/2025 at 12:46PM during interview with V18 (Marketer), V18 stated that she reached out to Executive Director of the assisted living on 04/15/2025 and asked if R1 happened to be there. V18 stated that the Executive Director told her that R1 was there the night before and thought that R1 was just visiting. V18 stated that she told the Executive Director to call her back if R1 happens to go back at the assisted living facility. V18 stated that the Executive Director reached back to her on 04/16/2025 between 2:00PM-4:00PM to inform her that R1 went back to the assisted living, and they called the police department. V18 stated that she talked to the police department and was told that they are taking R1 to the hospital. On 04/17/2025 at 2:17PM during interview with V11 (RN), V11 stated that R1 mentioned that he wanted to leave when he first got into the facility but V11 encouraged R1 to stay for the night. V11 stated that R1 came from an assisted living facility, and he did not receive any report about R1. On 04/18/2025 at 2:05PM, V11 stated that on 04/16/2025 he received R1 back from the hospital. V11 stated that the hospital nurse endorsed to him that R1 was brought in by police department because R1 was found in an apartment building lobby wandering. V11 stated that the hospital nurse told him that R1 told the hospital staff that R1 has been on the streets for 2 days before R1 went to the apartment building where he was found because R1 was cold. On 04/22/2025 at 11:00AM during interview with V1 (Administrator), V1 stated that he watched the surveillance video four times and noted that R1 was able to open the patio gate and exited the facility through the patio gate. Review of R1's Census Records indicated R1 was admitted initially on 04/07/2025. Review of R1's Physician Order Report dated 04/07/2025 indicated R1 was admitted on [DATE] with diagnoses of not limited to hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, and unspecified osteoarthritis, and an order to may go on therapeutic pass with medications and instructions with order date of 04/07/2025. Review of R1's Brief Interview for Mental Status (BIMS) dated 04/08/2025 indicated R1 scored 5 which indicates severe impairment. Review of R1's Community Access Observation dated 04/08/2025 indicated R1's has significant memory impairment which can be a barrier to safety in the community and was not able to verbalize understanding of the curfew and sign in/out process, so it was determined that R1 may not access the community independently related to cognitive functioning. Review of R1's Initial/Baseline Care Plan dated 04/07/2025 indicated R1 needs supervision with ambulation. Review of R1's Social Services admission Note dated 04/08/2025 indicated R1 was admitted from assisted living, has BIMS score of 5 and depression score of 10. Review of progress notes from 04/07/2025-04/17/2025 indicated V4 contact to R1's daughter and left a message on 04/08/2025. No other documentation of attempt to reach out to R1's daughter was noted. Review of R1's Nurse Practitioner Progress Note dated 04/11/2024 indicated R1 provided conflicting information about R1's living situation as R1 is stating that R1 both lives with his sister, and in assisted living. It also stated that R1's cognitive assessment reveals a BIM score of 5, and R1 has depression score of 10, suggesting cognitive impairment and significant depressive symptoms. Review of R1's Cognition Loss/Dementia Care Plan created 04/08/2025 indicated problem start date of 04/08/2025, and R1 is an adult with impaired cognitive function and poor memory recall that may impact level of alertness, decision making task and responsibilities. It also indicated that according to Section C of the MDS (Minimum Data Set), R1 scored a 5 out of 15 in the BIMS assessment and R1 is severely impaired. Review of R1's Psychosocial Well-being Care Plan created 04/08/2025 indicated problem start date of 04/08/2025, and R1 requires the support, care and services of a long-term care facility and has been determined by community access assessment to be able to access the community with supervision. Review of R1's Nursing Progress Notes dated 04/14/2025 indicated V9 went to dining area during medication pass to administer R1 his medications but R1 was not there. It also indicated that V9 asked staff members that were in the dining room if they saw R1 and they said that they saw R1 walking along the patio. Review of R1's Nursing Progress Note dated 04/15/2025 indicated R1's daughter stated that R1 leaving the facility without notice is R1's behavior as R1 is used to coming and going as R1 pleased. Review of [NAME] Police Department Case Report with date and time of 04/14/2025 at 8:20PM indicated occurred incident type of Missing Person, event occurrence of 04/14/2025 at 2:30PM and R1 was reported missing. Review of [NAME] Police Department Case Supplemental Report with date and time of 04/16/2025 at 6:45PM indicated R1 was located by Chicago Police Department. Review of R1's Hospital Records indicated in nurse's progress notes dated 04/16/2025 that R1 was reported missing in [NAME], IL and was found in Chicago, IL. It also indicated that R1 arrived to the hospital at 7:07PM and was assessed for fall using [NAME] Fall Risk Assessment at 7:15PM with noted altered mental status. Review of undated, unlabeled document attached to R1's after visit summary from the hospital scanned to R1's electronic health record indicated R1 was found in the lobby of a building wandering and said he has been on the streets. Review of facility's policy entitled Elopement and Search Guideline (Code Pink) revised 09/04/2024 indicated the following: Purpose: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. Responsible Party: All staff 1. All nursing personnel are responsible for: a. Knowing the whereabouts of residents for which they are assigned. 3. Residents are not permitted to leave the building alone unless a physician order is present. Review of Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument User's Manual Section C dated October 2024 indicated the following: Health-related Quality of Life: - Most residents are able to attempt the Brief Interview for Mental Status (BIMS), a structured cognitive interview. - A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. o Without an attempted structured cognitive interview, a resident might be mislabeled based on their appearance or assumed diagnosis. - The total score: o Decreases the chance of incorrect labeling of cognitive ability and improves detection of delirium. o Provides staff with a more reliable estimate of resident function and allows staff interactions with residents that are based on more accurate impressions about resident ability. Planning for Care - Awareness of possible impairment may be important for maintaining a safe environment and providing safe discharge planning. - The BIMS is a brief screener that aids in detecting cognitive impairment. - The BIMS total score is highly correlated with Mini-Mental State Exam (MMSE; Folstein, Folstein, & [NAME], 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: o 13-15: cognitively intact o 8-12: moderately impaired o 0-7: severe impairment On 04/23/2025, the surveyor conducted an onsite review and verified that the facility implemented the following to remove the immediacy: 1. R1 exited the facility on 4-14-2025, code pink was code, physician was notified. Family was made aware. R1 returned to facility on 4-16-2025 with no injury. 2. An investigation was conducted, and it was discovered that R1 left the facility out of the patio door and then through the gate. The gate was not secure due to a malfunction in the lock mechanism. This was repaired on 4-16-25. The patio door will be locked between smoking times. 3. R1was put on 1:1 monitoring when he returned to the facility for off-shifts. R1 was reassessed, care plans updated. R1 was found to be cognitively intact with a bims of 13. We received an order from R1s physician for a wander guard, and it was placed on him. R1 was transferred to an assisted living on 4-18-25 per his request. Family notified, and agreed to the transfer. 4. Starting on 4-18-2025, All staff including staff on leave and on vacation were inserviced By DON or designee on Safety and Supervision of Cognitive Impaired Residents Policy (New Policy as of 4-18-2025) Policy outlines the supervision of cognitively impaired residents who are ambulatory and self-mobile in wheelchair. Staff will not work their shift without being in-serviced. Completion date: 4-21-2025. a. Staff completed posttest to evaluate understanding of in-service. 5. New residents who are cognitively impaired and are ambulatory or self-mobile in wheelchairs have been identified. a. These residents are listed in a binder at each nurses station. b. These residents are put on every 2-hour location monitoring. 6. Starting 4-18-2025, all staff including staff on leave and on vacation were inserviced by the DON or designee on facility's Elopement Policy. Completion date: 4-21-2025. 7. Starting on 4-18-2025, all staff including staff on leave and on vacation were inserviced by the DON or designee on ensuring all exit doors are alarmed. Completion date 4-21-2025. a. Staff will complete posttest to evaluate understanding of in-service. 8. Maintenance Director or designee will do AM checks to ensure exit doors are in good order, alarmed and functioning. The south nurse will do PM and night checks to ensure exit doors are in good order, alarmed and functioning. 9. Medical Director made aware of IJ on 4-19-2025 10. Administrator coordinator or designee will conduct QA studies: a. Starting on 4-21-25 A QA audit will be performed random twice weekly on a sample of 5 staff members to ensure staff is aware of the whereabouts of cognitive impaired residents. b. Starting on 4-18-25 A QA audit will be performed random twice weekly to ensure exit doors are alarmed. The QA will include random days and shifts twice weekly for 3 months. c. Starting on 4-19-25 A Mock Code Pink will be performed random weekly for 3 months. d. QA audit results will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. 11. An emergency QAPI was conducted on 4-21-2025

Based on interview and record review, the facility failed to develop an effective plan with interventions to prevent or reduce the risk of falling for a resident diagnosed with Dementia, wandering behaviors and identify as a high fall risk with balance problems while standing. This affected one of three residents reviewed for falls and fall prevention. This failure resulted in R2 having eight falls, seven of which were unwitnessed and one fall resulting in right periorbital soft tissue swelling and right scalp hematoma with contusion of face and scalp. Findings Include: R2 was diagnosed with Dementia, lack of coordination and need for assistance with personal care. R2's Fall risk observation dated 4/10/24 documents: disoriented times three (person, place, and time) and balance problems while standing, high risk. R2's Care Plan dated 4/12/24 documents: R2 presents with wandering behaviors. Wandering with or without a purpose. R2 was risk for falling related to Dementia, weakness, and history of falls. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 had a fall in the dining room on 4/19/24. V2 stated, she watched the facility video and saw R2 fall face forward while tying her shoestrings. On 8/11/24 at 3:20pm, V7 (nurse) stated, she was getting off duty for on 4/19/24 when she was notified of R2's swelling around eye. V7 stated, she does not recall what happened. R2 takes baby steps. R2 has a shuffled gait. Any time, R2 attempts to get up, R2 is trying to toilet self. R2 is Japanese. R2 can answer yes or no questions. R2 can ambulate by herself but it's not safe. Event report dated 4/19/24 documents: Resident (R2) noted with swelling/bruising to right brow area from unknown origin. Fall risk observation dated 4/19/24 documents: balance problems while walking. Nursing note dated 4/19/2024 documents: Observed mild swelling to resident's upper right brow with tinge redness above brow and cheek area. R2 will be admitted for observation unwitnessed fall. Hospital paperwork dated 4/19/24 documents: Syncope and Collapse. Nursing note dated 4/22/24 documents: Post fall observation for right eye orbital swellings and contusion. Nurse Practitioner note dated 4/23/2024 documents: R2 presented to emergency department due to a fall. R2 was noted with contusion of face and scalp. CT (computed tomography) of sinus facial bones showed right periorbital soft tissue swelling and right scalp hematoma. On 8/10/24 at 1:57pm, V4 (nurse supervisor) stated, R2 was seen on the floor at breakfast time in the dining room on 4/24/24. R2 was kept in the dining room for monitoring. R2 wheelchair was locked and behind R2. R2 looked like she pushed the table away from her and slid from her wheelchair. R2 has a shuffling gait and requires one-person physical assist for ambulation. R2 can ambulate by herself but is not safe. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 had an unwitnessed fall in the dining room on 4/24/24. V2 stated we determined that R2 shoes was too big. V4 witness statement dated 4/24/24 documents: observed R2 on the floor in dining room near wheelchair at breakfast time fully dressed with shoes off at the table and grip socks on. Nursing note dated 4/24/24 documents: R2 stated, she hit her head. Fall event dated 4/24/24 documents: Sent to emergency room - Intervention and immediate measures taken increased supervision and monitoring. Care plan approach dated 4/24/24 documents: R2 required shoes that fit with no laces. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 had an unwitnessed fall in the dining room on 4/28/24. R2 was used to going to the bathroom on her own. R2 will stand up and fall. V2 stated, she does not recall if R2 was wet/soiled. Intervention keep R2 in the dining room/high traffic area for monitoring. Nursing note dated 4/28/24 document: R2 had a fall in the dining room. Accident/incident IDT form dated 4/28/24 documents: R2 was last seen eating. Unwitnessed fall -offer toileting and distractions. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 had an unwitnessed fall in the dining room on 4/29/24. R2 was impulsive, R2 was able to push self-back in her wheelchair and stand up. R2 was quick. Intervention: frequent toilet. Nursing note dated 4/29/24 documents: R2 had a fall in dining room near wheelchair. R2 was not able to verbalize what happened. Fall event dated 4/29/24 documents: mental status prior to fall: confused. Writer (V2) called previous Restorative Director at another facility who stated, resident (R2) has a history of trying to escape. V2 stated R2 keeps falling because R2 wants to escape. V2 stated it took a few months for her to become familiar and stop trying to escape. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 leaned forward and repositioned self in wheelchair and slid out on 5/12/24. R2 was given a non-slip pad. Nursing note dated 5/12/24 documents: R2 had an unwitnessed fall in the dining room. Accident/Incident IDT form dated 5/13/24 documents; fell leaning forward, repositioning, slid out of wheelchair. Intervention: nonslip pad and cushion to wheelchair. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, she watched the video footage and saw R2 fall on 5/23/24 by R2 leaned back in her wheelchair. R2 fell backward. R2 was given anti-tipsters. Nursing note dated 5/23/2024 documents: R2 fell in dining room witnessed by CNA. R2 hit her head. Small lump is noted in back of head. Fall event dated 5/23/24 documents: R2 was found on the floor in dining room witnessed by cna that R2 hit her head. V5 (activity aide) witness statement dated 5/23/24 documents: R2 was seating in her wheelchair pushing back on the table when she fell backwards. Hospital paperwork dated 5/23/24 documents: Fall. Contusion to face. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 got up out of bed on 7/25/24. R2 was seen sitting on the floor mat. R2 is impulsive and will attempt to get out of bed if awoke. Fall event dated 7/25/24 document: Unwitnessed. R2 was observed on floor sitting on the mat. Intervention get up upon awaking. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 attempted to self-transfer out of bed without using the call light on 8/5/24. On 8/11/24 at 3:20pm, V7 (nurse) stated, she does not recall the incident on 8/5/24 of R2's incident. R2 takes baby steps, R2 has a shuffled gait. Any time, R2 attempts to get up, R2 is trying to toilet self. R2 is Japanese. R2 can ambulate by herself but it's not safe. Nursing note dated 8/5/24 documents: R2's roommate informed staff that R2 was on the floor in her room. R2 noted at foot of bed lying in supine position. R2 complained of right shoulder discomfort. Fall event dated 8/5/24 documents: unwitnessed fall, unsteady gait, assist when up, otherwise in wheelchair. Fall Reduction Program no documents: Intent is to assist clinical staff in determining the need of each resident through the use of standard assessment, the identification of each resident's individual risk and the implementation of appropriate interventions, supervision and or assistive device deemed appropriate.

Based on interview and record review the facility failed to provide, evaluate, and reevaluate the effectiveness of the motorized wheelchair safety/training/education to reduce the risk of injuries for one resident. This affected one of one resident (R1) reviewed for safe use of the motorized wheelchair. This failure resulted in R1 having multiple accidents attempting to maneuver the wheel motorized wheelchair. R1 sustained a fractured toe, and a laceration to the leg requiring 6 sutures. Findings include: On 6/18/24 at 11:11am R1 observed sitting in motorized wheelchair, R1 escorted to room for interview and observation assisted by V16 Licensed Practical Nurse (LPN). R1 observed alert with confusion. R1 observed to have healing scar to left lower leg. R1 was not able to recall what happened to her leg. R1 stated her toes were broken when the door hit her foot, R1 stated she was on her way out the room when the door hit her foot. R1 stated her feet were not on the footrest, (R1 demonstrated that her feet were on the floor when the door hit her foot). R1 stated she did go to the hospital. R1 wheelchair was observed to have a metal footrest. R1 was asked if the facility showed her where her feet should rest on the wheelchair when using the chair. R1 denied getting education. R1 observed with difficulty using the control arm on wheelchair, R1 not able to efficiently back up wheelchair and use control arm to turn wheelchair. V17 (certified nursing aide) assisted R1 with maneuvering wheelchair. Facility final investigation to the State Department dated 4/9/24 denotes in-part reportable event occurred 4/3/24. R1 expressed pain in the right foot while sitting in wheelchair. NP (Nurse practitioner) in-house physician notified. She states she opened a door and the door closed on her foot in her room. R1 is a [AGE] year-old resident with DX (diagnosis) of osteoarthritis, COPD (chronic obstructive pulmonary disease), osteoporosis with hx (history) of pathological fracture of vertebrae, myalgia. R1 uses a wheelchair for mobility. Per R1 interview, she states that her room door closed on her foot. Upon complaint of foot pain, R1 was assessed by nursing staff and contacted the nurse practitioner. The nurse practitioner gave orders to send R1 to the emergency room . Imaging was completed on her right foot, which showed a metatarsal fx (fracture). R1 returned from emergency room with a CAM boot and orders to see orthopedic specialist. Due to R1's DX of osteoarthritis, osteoporosis, R1 sustained metatarsal fracture. Pain assessment was done and monitored. Care plan updated. Facility final report to the State Department dated 4/25/24 denotes in-part, resident notified NOD (nurse on duty) of hitting her left leg on the bed. Observed open area on left lower leg. Resident stated she wants to go to the hospital. NP (Nurse Practitioner) and sent to ER (emergency room ) for treatment and eval. Resident returned to facility with sutures and dressing on left leg. Investigation initiated. Upon investigation it was discovered that the root cause of the accident was that R1 was not proficient in her ability to navigate her wheelchair. R1 is to be assessed by the wheelchair company and the speed on her wheelchair will be lowered. R1 was also educated on how to safely use he electric wheelchair. R1 skin integrity event dated 4/23/24 denotes in-part type of injury -laceration, left lower leg, moderate depth, open area, blood and redness at the site, activity during skin tear/ laceration occurrence- locomotion, walking/ wheel in wheelchair. Taken to emergency room for hitting leg under the bed rail using motorized wheelchair. Resident reported that she hit her leg on the bed in her room trying to backup with the electric wheelchair. Writer noted blooding running down the resident leg. Writer clean and compressed the left chin until bleeding stopped, covered with bandage, resident states that she wants to go to the hospital. Head to toe assessment completed, no c/o pain, discomfort at this time. NP and R1 daughter informed. Phone called hospital, spoke with Nurse. Ambulance states will pick up resident within 45 minutes. Resident returned to this facility from emergency roiagnom on stretcher with new orders, no related to event noted. Received sutures and 1 week appointment for wound re-check. No c/o pain or discomfort at this time. Will continue to monitor. On 6/20/24 at 11:36am V12 (Director of Nursing) said R1 received training/ education on use of motorized wheelchair. 6/20/24 V12 presents a document titled motorized wheelchair evaluation form-IL only dated 3/8/24, description motorized wheelchair training/ observation. Additional observation info, education given and understanding, acknowledged to seek assistance as needed, training by the wheelchair man, successful with nurse present, signed by V3 (Director of Rehab). There were no description of what training or education that was provided to R1. On 6/20/24 at 1:00pm V12 (Director of Nursing) presents another document titled Medical prior authorization request form and seating mobility evaluation stating, and Power mobility devices and custom manual wheelchairs physician form. V12 stated this is the education that was provided to R1 from the wheelchair company. Review of the documents presented by V12, the medical prior authorization request form and seating mobility evaluation, and power mobility devices and custom manual wheelchairs physician form there is no documentation denoting there was education provided to R1. There is no documentation denoting what education was provided to R1. 6/20/24 at 2:07pm V12 (Director of Nursing) was asked if there was any education/ training provided to R1 after R1 fractured her toes on the door. V12 was asked how did R1 fracture her toes when the foot plate is very large on the wheelchair, V12 was asked about the placement of R1's foot/ toes, if they were off the footrest when the door hit R1 foot/toes. V12 was asked was R1 educated on positioning of feet/toes when using wheelchair. V12 did not respond. V12 did not respond when asked if the facility provided R1 with any training on safe use of wheelchair after the two incidents where R1 sustained injuries. V12 was asked how's the facility reducing the risk of injuries for R1 when using the motorized wheelchair, V12 replied the wheelchair man provided R1 with education on use of wheelchair). V12 made aware that there were no documentation denoting any training provided to R1 in that packet that was presented to surveyor. On 6/21/24 at 9:49am V3 (Director of Rehab) stated the wheelchair man provided R1 with education on the use of the motorized wheelchair, V3 stated the education is in the packet that was presented to the surveyor. V3 stated the documents, in the packet that was presented to the surveyor yesterday the medical prior authorization request form and seating mobility evaluation was the education that was provided to R1 from the wheelchair company was the motorized wheelchair training. V3 stated the motorized wheelchair was new for R1. V3 stated R1 received the motorized wheelchair on 3/8/24. V3 was asked how's the facility reducing the risk of injuries for R1 when using the motorized wheelchair, V3 replied the wheelchair man provided R1 with education on use of wheelchair). V3 was asked what the wheelchair man taught R1, V3 did not respond. R1 progress note dated 4/2/24 denotes in-part received patient on AM shift in bed. CNA informed writer that resident c/o (complaints of) pain to R (right) Foot. Writer assessed R1 and discoloration was noted. Writer informed NP (Nurse practitioner). NP assessed R1 in house during rounds. Awaits new orders. R1 progress notes dated 4/3/24 denotes in-part resident returned to facility via Superior ambulance x (times) 2 attendants via stretcher, alert and responsive. No s/s of apparent pain. Resident DX (diagnosis) with Metatarsal fracture to right foot with new orders to d/c (discharge) current Norco dosage to increased Norco 10-325 mg per tablet. Follow up appt. with foot and ankle specialist within the next week or so. R1 progress notes dated 4/23/24 denotes in-part resident reported that she hit her leg on the bed in her room trying to backup with the electric wheelchair. Writer noted blood running down the resident leg. Writer clean and compressed the left chin with until bleeding stopped, covered with bandage, Resident states that she wanted to go to the hospital. Head to toe assessment completed, no c/o pain, discomfort at this time. NP (Nurse Practitioner) and (daughter) informed. Phone call to hospital, spoken to nurse. (Ambulance company name) ambulance states will pick-up resident within 45 minutes. R1 care plan dated 4.1.24 denotes in-part R1 currently has motorized related to COPD, R1 will use wheelchair throughout the facility as trained. R1 will safely maneuver throughout the facility. R1 care plan developed 26 days after receiving the motorized wheelchair. R1 emergency room records dated 4/23/24 denotes in-part patient reports to ER with c/o (complaints of) laceration of left lower leg. Chief complaint [AGE] year-old female arrives to the ED (emergency department) with EMS (emergency medical services) for left leg injury. Patient was driving motorized scooter for the first time and ran onto a wall. Patient has bruising and laceration to left lower leg. Denies hitting head/falling off, and LOC (loss of continuousness). Denies any other complaints or injuries at this time. Exam denotes in-part laceration left lower leg, 2 cm (centimeters), skin repair nylon 6 sutures. Clinical impression laceration of left leg, contusion of left leg. During this survey the facility failed to present education/ training provided to R1 related to the safe use of motorized wheelchair on or prior to 3/8/24, facility failed to present education/ training provided to R1 related to the use of motorized wheelchair after R1 hit toes on door when using wheelchair, facility failed to present education/training provided to R1 related to the use of motorized wheelchair after R1 hit leg on bed frame sustaining injury when using wheelchair. Facility failed to present any education provided to R1 related to preventing/ minimizing injures when using motorized wheelchair. Facility care plan policy with last update of 10/2022 denotes in-part an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. The facility care planning team develops and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may expect to attain. Each resident comprehensive care plan has been designed to incorporate risk factors associated with identified problems. Aide in preventing or reducing declines in the resident functional status and functional level. Care plans are revised as changes in the resident's condition dictates. R1 referred to occupational therapy on 5/2/24.

Based on interviews and records reviewed the facility failed to conduct a thorough investigation to explain the origin of bruising for one resident. This affected one of three residents (R5) reviewed for injury of unknown origin. This failure resulted in unexplained black and blue bruising to R5's face and R5 being sent to the local hospital ICU/intensive care unit for treatment. The findings include: R5's diagnosis include but are not limited to Hemiplegia and Hemiparesis following other Cerebrovascular Disease, Dementia, Palliative Care, Contusion of Scalp, Subsequent Encounter, and History of falling. On 1/31/24 at 12:02 PM V9, Certified Nursing Assistant, said when I did rounds R5 was on the floor maybe around 9:40 PM. V9 said I asked R5 what happened and she gestured, V9 demonstrated a gesture, that she rolled out of bed. V9 said R5 was on her right side, and she was close to the bed. V9 said R5 looked like she just slipped out of bed, her legs were still on the bed, and her top half was on the floor. V9 said there was no bumps, no blood, no bruising. V9 said I think V8 was the nurse and we put R5 back in the bed. V9 said R5 had nothing, as far as injury, when we picked her up off the floor. V9 said I don't know what happened to R5's face. On 1/31/24 at 2:17 PM V8, Registered Nurse (RN), said I was working 2nd shift with R5 on 10/19/23. V8 said R5 did not have a fall. V8 said later I was told the night CNA said R5 had a lot of bruises. V8 said the nurse called me and asked about what she saw. V8 said the night nurse said R5's face had been covered with her hair. V8 said I had already left the facility but when they called me, I came back. V8 said I did not see any blood when I was in the room. I saw a bruise, black and blue on one side of R5's eye. V5 said I wrote an incident report. The next day I called the CNA, V8, myself I asked her about tucking R5 into bed. V8 said V9 said R5 did not fall. V8 said I asked V9 about the bruises on R5's face and V9 said there was no bruise. V8 said V9 never said R5's top body was on the floor and her feet were in the bed. On 2/1/24 at 10:55 AM V5, Restorative Nurse, said R5 had a fall and they sent her out for discoloration on her face. V5 said the root cause of R5 fall was she had a history of trying to get out of bed by herself and ambulate. V5 said the CNA was in the room when R5 fell , and it was a witnessed fall. V5 said floor mats were not in place at the time because I didn't want R5 to trip. V5 said R5 fell because she is confused and has a history of trying to self-ambulate. V5 said R5 must have been trying to reposition herself. V5 said R5 has a history of being non-compliant. At 12:06 PM after V5 requested to review the records V5 returned and said the update to R5's care plan following the fall was to keep personal items in reach and to place her in high traffic areas. V5 said I am not sure if R5 fell on second or third shift. V5 said the Director of Nursing, will give you the investigation for R5. On 2/1/24 at 11:17AM V6, Director of Nursing (DON), said it was reported to me that they found R5 with an injury on night shift. V6 said I was told it was a fall and I gave it to the restorative nurse for investigation. At 12:07 PM V6 said V31, former Administrator, did the investigation for R5. V6 said the former administrator was the abuse investigator. V6 said I was unavailable during this investigation for R5. On 2/1/24 at 12:07 PM V13, Regional Director, said we did a reportable for R5 because she had an injury after the fall. V13 said R5 had a bruise. V13 said the nephew voiced concern and called the police so we investigated and did a reportable. R5's progress notes dated 10/19/23 at 9:48PM documents CNA said R5 was rolling out of bed, and she straightened her back out to make sure she stayed in the bed. R5's progress notes dated 10/20/23 at 12:51PM documents night staff observed the resident with bruising to the left side of her face and notified the outgoing nurse. Left forehead and left cheek have purplish discoloration. Facial skin was intact. The resident could not tell if she got out of the bed anytime this evening or used the bathroom unassisted. The roommate said she did not observe R5 get out of the bed either. Apparently, the last witness to any of R5's body misalignment was on PM/evening shift when she reported to have been straightened back up in the bed when she was rolled out of the bed. R5's progress note dated 10/20/23 at 9:27 AM documents the nurse at the hospital said waiting for the doctor to evaluate. According to progress notes R5 was readmitted to the facility on [DATE]. A safety events report dated 10/19/23 at 11:58 PM documents R5 had a fall from bed to floor during care report documents the fall was witnessed, R5 slipped from bed. Initial injuries state no injuries. Musculoskeletal section indicates normal or consistent with pre fall alignment: yes. If not normal, please fully describe facial show bruises soon developed. Observation of skin on head neck bruising left cheek and left eyebrow. At 12:51 AM night staff observed the resident with bruising to the left side of her face and notified the outgoing nurse the resident left forehead and left cheek have purplish discoloration. V8 documented this report, however V8 said R5 was never on the floor. Hospital records for R5 dated 10/20/23 identify chief complaint to be a fall. R5 noted to have a large right frontal scalp hematoma along with left orbital edema and ecchymosis. She was admitted to ICU (Intensive Care Unit) for further management. R5's progress notes dated 10/24/23 document noted with large right frontal scalp hematoma along with left orbital edema and ecchymosis. Bruises all over the face and on the chin. Progress note dated 10/25/23 at 12:04 AM states facial swelling and bruising/ecchymosis noted bilateral eyes and surrounding mouth area, left upper side of forehead with hematoma. The facility provided a facility reported incident submitted to the State Agency on 10/26/23. The incident category is documented resident neglect. The report documents that R5's family felt they had not been given the truth about what happened regarding the fall on 10/20/23 and that he had not received timely communication from the facility. The report states that an interview with V9 states she was providing care to R5 on the night of 10/20/23 the resident moved forward without self-stabilizing and rolled from the bed subsequently landing face first on the floor. The report states that V8, RN, stated R5 experienced a fall after rolling from bed which was witnessed by the CNA. V8 and V9 both interviewed by the surveyor said R5 did not fall. A signed statement from V9 provided to the surveyor on 2/1/24 documents R5 moved forward without self-stabilizing and rolled from the bed. (This is not what V9 said during the interview with the surveyor.) A signed statement from V8 provided to the surveyor on 2/1/24 documents R5 experienced a fall after rolling from bed which was witnessed per the CNA. A statement from the V32, LPN, nurse who observed the bruises on 10/20/23 could not be obtained, despite attempts on 2/7/24 9:28AM; 2/1/24 2:56PM and on 1/31/24 at 4:35PM. The facility Abuse prevention program dated 10/2022 states any allegation of abuse or any incident that results in serious bodily injury will be reported to the State Agency immediately but no more than two hours of the allegation of abuse. An injury of unknown source should be classified when both of the following conditions are met the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury. Final investigation report shall contain the following: conclusion of the investigation based on known facts.

Based on interview and record review the facility failed follow physician orders for the administration of IV/intravenous medication and obtaining lab blood draw. This failure affected two of three residents (R12, R15) reviewed for physician orders. This failure resulted in R12 not receiving the IV medication for approximately 9 days being sent to the hospital after a change in condition. R12 was diagnosed and treated at the hospital for Sepsis and UTI (urinary Tract Infection). Findings include: 1. R12's face sheet shows diagnosis of dementia. R12's hospital records dated 11/17/23 denotes in-part clinical impression sepsis, UTI, hypernatremia, encephalopathy acute, pulmonary, hypokalemia. Blood culture gram positive bacilli. [AGE] year-old female presents ER/emergency room from nursing home for altered mental status. She is tachycardic. She apparently was just diagnosed with UTI She is septic from a UTI. She was given 30 cc/kg fluid bolus. She was also given Vanco Zosyn initially, meropenem. IV potassium ordered for hypokalemia. Her lactic is 2.9. Case discussed with hospitalist who accepts admission to IMCU/intermediate care unit with no additional recommendations at this time. On 2/7/24 at 11:19am V21 (Nurse Practitioner) said she ordered IV (intravenous) antibiotics for R12's positive urine test on 11/18/23. V21 said she did not get a call from the facility stating that there was an issue with ordering the antibiotics, she did not get a call stating there was an issue with starting an IV on R12 either, V21 said she did not get a call stating there was an issue with the antibiotics that she had ordered for R12. V21 said she was under the assumption that the medication had been started. On 2/7/24 at 1:38pm V28 (medical doctor) said his expectation is that the facility implements orders as prescribed. V28 said an untreated urinary tract infection can contribute to sepsis. V28 said 9 days is a long time for no treatment. V28 said he treats a positive urine analysis on a case-by-case scenario, and when the culture comes back, he would adjust the antibiotics accordingly. On 2/6/2024 at 12:49 V24 (owner of medical assay labs), review of R12 lab report with V24 (V24 said he logged into his system to review with surveyor). V24 said R12 urine analysis was completed first and it showed positive for nitrites, V24 said the urine sample was cultured and it grew bacteria and continued to grow bacteria. V24 explained that urine culture would usually show growth in 24 hours but R12's culture continued to grow bacteria. V24 said on 11/13/23 the urine culture was final, V24 said the facility was made aware of the positive urine analysis and positive urine culture and sensitivity on 11/13/23. R12 progress notes dated 11/18/23 denotes in-part resident admitted to (hospital name) Dx (diagnosis) sepsis. R12 progress notes dated 11/17/23 at 8:05pm denotes in-part resident family requested that the resident be sent out to the hospital because she's not responding to verbal command as usual. DON (Director of Nursing) and NP (Nurse practitioner) notified. 911 is here to transport resident to local hospital. VS WNL (vital signs within normal limits). R12 progress note dated 11/17/23 denotes in part writer received resident UA (urine analysis) results, new order per V21 NP (Nurse practitioner), Imipenem IV for 5 days. (name) aware. R12 physician order sheet dated 11/3/23 denotes orders for UA with culture once, one time. 11/17/23 Imipenem-cilastatin recon solution 500 mg, intravenously, special instruction; UTI/ECOLI, every eight hours, 5:00am, 1:00pm, 9:00pm. Review of R12 medical assay laboratory (3 pages) results report dated 11/7/23 denotes in-part urinalysis color: amber, clarity: cloudy, blood: small, leukocytes; small, nitrites: positive, run by (XH) on November 7 2023 , time 4:13pm. Culture; source- urine, report status final; greater than 100,000 col/ml Escherichia coli, run by (XH) November 13, 2023, time 12:03pm, sensitivity run by ( XH) November 13, 2023 , time 12:05pm (medication that are sensitive to organism are listed). Imipenem is circled, there's a handwritten date of 11/8/23, signature of V21 with credentials, orders for potassium chloride 20MEQ x 3days is noted and orders for IV imipenem 500mg Q (every) 8 hours for 5 days is noted. Request was made to review all of R12's lab reports for November 2023. V6 (director of Nursing) presented 4 reports only. Stating that's all she has for R12. Facility policy titled change in residents' condition or status denotes in-part our facility shall promptly notify the residents, consult with his or her attending physician, and notify consistent with his authority, the resident representative of changes in the residents medical/mental condition and or status. Facility policy titled physician orders dated 4/22/2022 denotes in-part all resident medications and treatments must be ordered by a licensed physician or Nurse Practitioner. All medications administered to the resident must be ordered by the resident's attending physician or Nurse Practitioner. The nursing staff member who took the verbal, telephone, written order, or the one assigned to the resident is responsible to transcribe the order. Transcribing the order includes writing new orders on the Medication Administration Record (MAR), or Treatment Administration Record (TAR), or completing laboratory test requests, dietary notification form, or ancillary notification to inform others of the change in order as necessary. For facilities on EMR, orders must be promptly entered into computer and attached to appropriate Flowsheet(s), i.e., Medication, Treatment or Lab Flowsheet. Nursing staff will follow physician orders. In an event were a resident refuses medication or treatment, or medication is not available. Physician or Nurse Practitioner will be notified. Review of R12 progress notes presented by V6, there is no documentation denoting R12 refused the IV antibiotics imipenem 500 mg on 11/8/23, 11/9/23, 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23. On 2/7/24 at 1:59pm V29 (pharmacy representative) said the pharmacy did not delivery R12's medication to facility until 11/18/23. 40066 2. R15's diagnosis include, but are not limited to dementia, end stage renal disease, and dependence on renal dialysis. On 2/2/24 at 11:37AM V6, Director of Nursing (DON), said I don't have the labs for R15 in the facility. V6 said the labs are not in the lab portal. At 12:00PM V6 said the lab said the last result they have for R15 is on 11/7/23. V6 said R15 has orders for labs on 12/5/23. V6 said the labs should have been done on 12/6/23. V6 said the physician was called on 12/5/23 because R15 had a change in condition. V6 said the nurses should have called the lab when the labs were not drawn on 12/6/23. On 2/2/24 at 11:40AM V30, Licensed Practical Nurse, said the lab is here every day. V30 said we place the order in the computer. V30 said the lab will be here the next day unless the lab is scheduled for a particular day. On 2/7/24 at 1:45PM V26, Doctor, said when labs are ordered, I anticipate the labs will get done. Progress Note dated 12/5/23 R15 complaints about tired and pain all day long. Face swollen, notified doctor. Received order for CBC, CMP, Magnesium, Phosphorus, Lipid, TSH, B12, Folic, Vitamin D, and Urine with Culture. Physician order dated 12/5/23 states CBC, Comprehensive Metabolic Panel, Lipid Profile, Magnesium, Phosphorus, Thyroid Stimulating Hormone, Urinalysis, Vitamin B12, and Vitamin D1.

Based on observation, interview, and record review, the facility failed to honor a resident's request to obtain assistance in obtaining the legal and/or social services necessary to have his guardianship status legally re-evaluated and maintain his highest practical well-being. This failure affected one (R1) of one resident reviewed for resident rights and has resulted in R1 suffering psychosocial harm as a result of not being able to leave the facility on pass status and having his phone taken away; this was further exhibited by R1 calling the police due to feelings of imprisonment. Findings include: R1 is a [AGE] year-old male who originally admitted to the facility on [DATE] with multiple diagnoses including but not limited to the following: hemiplegia, CHF, seizures, HTN, and CAD. Minimum Data Set (MDS) assessment dated [DATE] from admission shows that R1 had a Brief Interview of Mental State (BIMS) of a 14, indicating resident was cognitively intact. Most recent MDS assessment dated [DATE], shows R1 has a BIMS of 15, and also indicating resident is cognitively intact. On 1/20/23, R1 was granted a temporary guardian, V25 (Family Member) due to R1 being in a medical induced coma and was unable to make decisions. On 5/2/23, V25 was granted permanent guardianship of resident. Progress note written by V14 (Social Service Director) states in part but not limited to the following: R1 shared their preference for community access. V14 reached out to V25 - legal resident guardian responsible for R1. V25 expressed her disagreement with the resident having community access. Progress note dated 10/20/23 states in part but not limited to the following: Police department on the unit stating that they were called by R1 with complaint that he was being held against his will. Made police officers aware that V25 is currently not giving R1 permission to leave the facility without her consent. Progress note written on 10/21/23 states in part but not limited to the following: R1 was observed trying to exit the facility to go to the grocery store. R1 informed that V25 denied resident request for community access. R1 stated Police stated he could leave and comeback. R1 said I am going to call the police again. On 12/4/23 at 12:00PM, R1 was interviewed regarding community pass and guardianship. R1 stated he is frustrated and upset because V25 is not letting him leave the building. R1 said I do not feel as if V25 is looking out for my best interest. R1 said we do not get along and did not get along prior to the guardianship. She turned off my phone and will not let me leave the building. R1 said they won't even let me go to Walmart which is in the same parking lot. R1 said I have talked to V14 (Social Service Director) in the past to let her know that I do not want V25 (Family Member) as my guardian and nothing is being done to help assist me. R1 said, I feel as if I do not need a guardian at this time, as I am not in the same state when it was originally put into place .When the guardian was assigned initially, I was in a medically induced coma and could not make decisions for myself at that time .Obviously that is not the case currently. 12/4/23 at 12:55PM, V14 was interviewed regarding community pass access for R1. V14 said when R1 was in the hospital, he was non-decisional and V25 was elected to be his guardian. Sometimes R1 and V25 are on good terms and sometimes they are not. V14 said that R1 has expressed concern to her in the past, saying that he does not want her (V25) to be his guardian anymore. I instructed him that he could contact the ombudsman and/or legal aid for assistance. This surveyor requested documentation that V14 provided R1 with contact information to both the ombudsman and legal aid. It is to be noted that V14 documented that the contact information was given to R1 on 12/4/23 at 1:15PM, after this interview was conducted; no documentation prior to this date that R1 was being provided with assistance from the facility to dispute his guardianship status. 12/4/23 at 2:45PM, R1 said, I never received any contact information from V14 for legal aid or the ombudsman. I have not heard anything from V14 after expressing my concerns. On 12/6/23 at 11:50AM, V23 (Previous Nurse Practitioner) was interviewed regarding R1. V23 said, I did not participate in collecting data for his permanent guardianship. It is to be noted that V23 was R1's nurse practitioner at the time when the permanent guardianship was put into place on 5/2/23. 12/4/23 at 2:10PM, V24 (Attorney) was interviewed regarding the process of guardianship. V24 said that at some point when the guardianship was instated, a judge had to declare the resident to be disabled. If a resident desires to terminate the guardianship, they would have to go through the process of filing a motion and potentially hiring an attorney to assist. It is to be noted that resident concern forms dated September 2023-present were reviewed. No concerns noted regarding community pass or guardianship from R1 were identified. Facility policy titled Resident's Rights with revision date of 10/2017 states in part but not limited to the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include but not limited to the resident's right to: voice grievances and have the facility respond to those grievances. Residents are entitled to exercise their rights and privileges to the fullest extent possible.

Based on interviews and record review, the facility failed to follow prevent a staff to resident incident of abuse. This affected one of three residents (R1) reviewed for abuse. This failure resulted in R1 diagnosed with dementia being involved in a verbal altercation with staff which escalated to V3 throwing a meal tray at R1. Using the reasonable person concept would cause R1 to be fearful of V3's impulsive and abusive behavior. Findings Include: Initial State Agency reportable, reads in part: with occurrence date of 9/28/23. Family member of another resident reported to the nurse that they observed an activity aide throw food at the resident. Nurse immediately provided for safety and redirected the activity aide away from residents and contacted administrator. Nursing performed head to toe assessment with no noted injury or skin alteration. R1 denied any pain or distress. Occurrence resolution: R1 denied event. During interview, V3 acknowledged that he did upend food on tray into R1's lap as a reaction. Allegation is substantiated. V3 employment terminated. Police report dated 9/28/23, reads in part: The video footage revealed V3 and R1 in what looks like a verbal altercation that turned V3 grabbing the tray of food that was on the table and throwing it at R1. V3 explained he was in a verbal altercation with R1 in which R1 grabbed a cup and threw it at V3 so in response V3 took the tray of food and pushed it toward R1. V3 advised he did not throw the food and tray directly at R1. V3 was issued a Municipal Ordinance for Battery and escorted off the facility. On 10/10/23 at 11:15AM V2 (wound Nurse) stated it was reported by another resident family member that it was observed that V3 threw a tray to R1. Stated that V3 was removed in the dining room and stayed in the reception area. Did not do any patient care and was removed in the patient area. Stated that she reported it to the administrator and the administrator came in the building. On 10/10/23 at 10:30AM, V1 (Administrator) stated that V1 received a call from the facility and the nurse reported to V1 on 9/28/23 at approximate 6:30 to 6:45 PM that a family member of another resident witnessed an employee throw food to R1. V1 called the police and was present during police interview. V1 also interviewed V3 (Activity Aide) and V3 reported to V1 that R1 threw water and as a reaction V3 upend the tray with food to R1. V3 acknowledged to V1 that V3 voluntarily upend the tray to R1 and V3 stated But R1 threw water to him. R1 has a care plan for Cognition/Memory Impairment, dated 9/29/23 reads in part: R1 is an adult with impaired cognitive function/dementia and poor memory recall may impact level of alertness, decision making tasks and responsibilities. Interventions: engage me in simple, structured activities that avoid overly demanding task. Please stop and return to me at a later time if I became agitated. Keep my routine consistent. Provide me with consistent care givers as much as possible in order to decrease my level of confusion. Abuse/neglect care plan with a start date of 9/29/23 with interventions: Takes steps to calm me and help me feel safe. Provide reassurance to me and remind me that I am in a safe and secure environment with dedicated and caring persons. Abuse Prevention Policy with revision date of 10/2022, reads in part: This facility affirms the right of our resident 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 off 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 d services by staff and mistreatment of residents. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to resident. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.

Based on interview and record review the facility failed to provide supervision and monitoring of a resident-to-resident disagreement to prevent an avoidable resident to resident physical altercation. This affected two of four residents (R1, R3) reviewed for supervision. This failure resulted in a disagreement escalating into a physical altercation and R1 being sent to the hospital and treated for 3 lacerations requiring sutures and staples. Findings include: R3 is not available for observation or interview. Facility incident report sent to department dated 7.19.23 denotes in-part, date of occurrence 7.13.23 at 4:30am, the individual allegedly involved resident and another resident. R1 and R3 name is noted. Description of occurrence at approximately 4:30am staff notified the ADON (assistant director of nursing) that R3 allegedly struck R1 stating that R1 was moving his belongings around. Staff attempted to separate R3 from R1. R3 remained aggressive police were called to assist residents were separated. R1 sustained laceration to scalp and was sent out to hospital for further evaluation. R3 was sent out to hospital for psychiatric evaluation. ADON immediately notified administrator. Occurrence resolution; prior to event R1 and R3 were rounded on per staff earlier the same morning and overnight with no apparent distress or difficulty. Neither R1 nor R3 exhibited any behaviors nor voiced any concerns with regards to the other at any time prior to event. No environmental factors noted in room. R1 received neuro checks, pain assessments and vital signs taken prior to sending to hospital. R1 returned to facility from hospital at 10:43am, accompanied by his brother, on 7.13.23 with 3 lacerations to left temple with 5 sutures and left side scalp with 3 staples and 3 sutures left front of ear. R1 denies pain or discomfort at time of return. Neuro checks ongoing when R1 returned. Staples and sutures to be removed in 5-7 days. R1 will receive trauma informed care and wellness checks. R1 progress notes dated 7.13.23 at 5:33am denotes in-part resident was in an altercation with roommate. Resident was struck on top left side of head. Staff intervened and separated roommates. 911 was called resident sent out to community Medical Center for a medical evaluation. Resident emergency contact and NP notified. At 9:58am resident returned to facility accompanied by brother from hospital. Resident has 3 lacerations left temple with 5 staples and left side scalp with 3 staples. Sutures left front of ear. MD notified. On 8.31.23 at 11:33am R1 observed alert and orient to person, place, and time. R1 said R3 went berserk on him, R1 then began talking about his shaver, and that V9 would fix his shaver for him. R1 said he was not fighting with R3. R1 said R3 hit him with a chair, and that he wanted to press charges on R3. R1 denied taking R1's charger. R1 denied fighting with R3. When asked about details of the altercation, R1 began to talk about V9 fixing his shaver for him. R1 said he was frustrated and did not want to talk anymore. On 8.31.23 at 1:35pm V4 (Nurse) said she was the nurse responsible for R1 and R3 on 7.13.23 when the incident occurred. V4 said she was at the nurse station when V10 (laundry staff) informed her that she heard R1 and R3 was arguing. V4 as she was approaching the edge of the nurse station, she observed R1 come out the room and fall to the floor. R3 was observed to push a chair from the room. V4 said she did not see R3 strike R1, she did not see R3 hit R1 with a chair. V4 said R3 was yelling and R3 would not calm down at that time, R3 was aggressive. V4 said the residents were separated. V4 said when she assessed R1, R1 was noted with some bleeding to left side of his head. V4 said 911 was called immediately. R1 did not want her to assess his vitals or render first aide. V4 said the medics arrived to escort R1 to the hospital. R1 continued to say he wanted R3 arrested. V4 said she assessed R3 once R3 calmed down, R3 had no visible injuries, and R3 was saying that R1 took his charger, and that R1 was bothering him all that day. V4 said R1 is usually all over the room, and R3 stays on his side of the room too himself. V4 said when R3 would open the room door, R1 would close it. V4 said R3 was always calm, polite, did not bother anyone, she was surprised to see R3 aggressive. On 9.1.23 at 10:48am V1 (CNA- Certified Nursing Aide) said she is the assigned aide for R1's unit (9.1.23), V1 said she was not aware of R1 taking R3's charger, but she has heard of R1 taking another residents charger. V1 said R1 is territorial of his room, liking things the way he likes them. On 9.1.23 at 10:51am V7 (Nurse) said R1 would tell R3 to turn his television off, sometimes at 8:00pm. V7 said R1 likes to control the room, V7 said she heard R4 telling another resident that R1 likes to control the room. V7 said she did not report this to anyone. On 9.1.23 at 11:37am V9 (Maintenance staff) said he has fixed R1's electric shaver in the past, V9 said a piece has broken off and it is unrepairable now. V9 said R1's shaver has been unrepairable before the altercation with R1 and R3. V9 said a facility staff purchased R1 a new shaver about 4 weeks ago (after the altercation). V9 said R1 would come to him for varies things. V9 said R1 has come to him to address the issue when R3 changed his (R3) television with his (R3) remote, R1 channel changes as well. V9 said R1 was upset by this. V9 said the issue was resolved. V9 said R1 mentioned to him that R3 has his television on at night and he does not like the television on at night, he can't sleep with the noise of the television. V9 said R1 also mentioned that he likes to close the room door at night and R3 likes the door open at night. V9 said R3 thinks the room is too dark at night that's why R3 would open the room door. V9 said he thinks R1 is used to having the room to his self. V9 said R1 informed him that R3 allowed him to use his shaver, when R1's shaver was broken. V9 said he doesn't know if it's okay for residents to share shavers. V9 said he did not report the resident-to-resident concerns to anyone. On 9.1.23 at 11:59am V8 (social worker) said she was not aware of R1 or R3 having any conflicts/concerns/disagreements amongst each other. V8 said she should be made aware when resident to resident or roommates have disagreements. V8 said she would intervene and maybe help find common ground for the two residents. V8 said she was not at the facility when the incident with R1 and R3 occurred, V8 said she talked to R1 later that morning, V8 said R1 told her that he and R3 got into a fight. V8 said R1 was making swing motions with his arms. V8 said R1 said that R3 thought R1 had his charger, that's how the argument started. V8 said she reported this to the administrator during the morning meeting. On 9.1.23 at 2:50pm V6 (ADON- assistant director of nursing) said she needs further clarification of what a problematic behavior is that denotes in the facility policy titled behavior assessment and monitoring. V6 said she will follow up with surveyor. V6 said conflicts are disagreements. V6 said it can be a resident-to-resident conflict or resident to family conflict. V6 said if there's a conflict/disagreement the residents should be separated and assessed. V6 said if there's a conflict she would need to identify if there's a personality issue if the residents are compatible roommates or if the residents are not getting along. V6 said a conflict should be addressed by assessing the situation to come to an agreement to satisfy both parties, get the resident responsible party involved. V6 said the social worker would get involved if there's behavior issues. V6 said the administrator and the Director of nursing should be made aware for further directives. V6 said the goal would be to prevent a resident-to-resident conflict from escalating into a further resident to resident conflict. V6 said that's all she can say regarding that. V6 said the facility policy needs more clarification of a problematic behavior. On 9.5.23 at 9:58am V5 (Administrator) said during her investigation her staff did not mention that R1 and R3 were having any conflicts or disagreements. V5 said she has started an in-service to her staff to identify and report resident to resident conflicts/ disagreement and reporting information during an investigation. V5 said staff should be able to identify behaviors that are considered a disagreement/conflict, behaviors that can escalate and behaviors that can increase a resident's risk for abuse. V5 said she spoke to R3's state guardian and she said she has never had any issues with R3 and that she was surprised to hear that R3 was in a physical altercation with R1. R1's hospital records dated 7.13.23 denotes in part R1 is a [AGE] year-old male HX (history of) alcohol abuse, dysphagia, anxiety anemia who presents to the emergency room complaining of head injury. EMS, patient was involved in an altercation at his nursing home with his roommate. His roommate hit him in the head with a chair. Patient says he did not pass out. He has wounds on his face. He takes aspirin. No vomiting or seizure activity. Unsure of last tetanus. Diagnosis denotes head injury, facial laceration, and scalp laceration. Physical exam denotes in-part head- laceration present. Location number one is 3cm (centimeters) v shaped laceration- oozing small amount blood, repaired with 3 staples. Location two is 0.5 cm laceration- oozing blood, repaired with 4 sutures. Location three is 3 cm laceration, no active bleeding repaired with 3 sutures. Surrounding superficial abrasion. The facial diagram depicts laceration number 1 is to the left side head, laceration number 2 is near the left ear, and laceration 3 is to the left side front head. R1's care plan with problem start date 8.16.2018 denotes R1 has history of being verbally aggressive related to being involved in a verbal altercation with his roommate and due to arguing with staff member and making gestures as if he was going to hit a staff member. R1's care plan with problem start date 8.13.23 denotes although R1 demonstrates some challenging behavioral symptoms such as verbal altercation with roommates, he is generally redirectable and does not appear to experience any unusual factors towards abuse or mistreatment. Goal is R1 will remain free from altercations while residing in the facility through next review. Educate resident on asking for assistance when he has a disagreement with a peer instead of attempting to handle situations independently. R3's face sheet shows R3 is a [AGE] year-old male, MDS dated 6.5.23 denotes BIMS score 8 (cognitive impairment). Progress notes dated 7.13.23 denotes in-part resident was in an altercation with roommate. Resident struck roommate, staff intervene, and roommates was separated. 911 was called resident was transferred in hospital for psych evaluation. Facility policy titled Behavior assessment and monitoring with revised date of 11/2017 denotes in part problematic behavior will be identified and manage appropriately. Residents will have minimal complications associated with the management of problematic behavior. The staff will document (either progress notes, behavior assessment forms, or other comparable approaches) information about specific problem behaviors. Facility policy titled Room Change guidelines with revised date 11/28/2017 denotes in-part the facility will review and assess the potential need for a room change or a room-to-room transfer including, but limited to the following: necessary to promote the resident's well-being, and roommate incompatibility. The facility will provide the resident with orientation to new room location, the characteristics of the location in the facility, and introduce the staff that routinely works in that location. The facility will make every effort to minimize unnecessary and avoidable anxiety or depression for the resident.

Based on observation, interview, and record review, the facility failed to effectively assess, treat, and manage pain for a resident at risk for pain due to multiple medical diagnoses and factors; and failed to follow their pain management policy for one (R1) of three residents reviewed for pain management. R1 was frustrated and experiencing psycho-social distress related to not receiving pain medication in a timely manner. Findings include: On 07/10/2023 at 12:47 PM, observed R1 lying in bed who said he had just finished eating lunch. R1 reported medication issues at times on the evening shift. R1 said he knows the oxycodone (narcotic pain medication) is not scheduled and is prescribed as needed. R1 then said he should get it when needed or wanted. R1 added that his last dose was this morning around 8:00 or 9:00 AM. R1 reports having some pain at this time and that staff have never offered non-medicated pain relief measures and wants to take the oxycodone every 12 hours. Observed R1 to be visibly distraught and emotional. On 07/11/2023 at 1:28 PM, observed R1 lying in bed who said his current pain level was 9/10 and doesn't recall the last time that he received pain medication. R1 added that the nurse said he will get a pain pill at 1:00 PM to get him back on schedule. R1 then said it is unbearable and frustrating to not have his pain under control. Again, observed R1 to be visibly distraught and emotional. At 1:37 PM, V4 LPN (Licensed Practical Nurse) said R1 just received a pain pill and the last time he received one was at 1:00 AM. R1's face sheet indicates resident admitted to the facility on [DATE], went on hospital leave on 06/20/2023 then readmitted to the facility on [DATE]. Face sheet also indicates resident has a past medical history not limited to complex regional pain syndrome, Type 2 diabetes mellitus with hyperglycemia and diabetic neuropathy, other gram-negative sepsis, pain in left toe(s), unspecified open wound of left great toe with damage to nail, cellulitis of left toe, hypertensive heart disease with heart failure, peripheral vascular disease, acquired absence of other right toe(s), and difficulty in walking. R1's care plan last reviewed 07/05/2023 reads in part, resident is at risk for generalized pain in which he is receiving an opioid pain medication with problem start date of 06/05/2023. Approach showed to administer pain medications as per physicians' orders, evaluate effectiveness of pain management interventions, and use non-medicated pain relief measures. Reviewed R1's current physician orders that showed the following pain medication orders for: acetaminophen 325 milligrams (mg) take 2 tablets by mouth every 6 hours as needed for pain, apply one lidocaine adhesive medicated 4% patch to affected areas once daily, oxycodone-acetaminophen 10-325 mg one tablet by mouth every 12 hours at 10AM and 10PM for optimum performance at therapy and bedtime rest with start date of 06/18/2023; diclofenac sodium 1% topical gel apply 4 grams topically to lower back at bedtime. Reviewed R1's readmission pain observation assessment with completion date of 07/07/2023 at 12:20 AM and noted assessment to be blank and not completed. Reviewed R1's medication administration record for June 2023 that showed R1's daily pain assessments were inadequately documented throughout the month for 1 of 3 shifts; his lidocaine medicated patch administrations were circled on the 17th, 18th, and 20th (no documentation that R1 refused meds or it was withheld); acetaminophen and oxycodone were minimally documented as being administered throughout entire month; diclofenac sodium 1% topical gel administration was circled on the 8th; acetaminophen 500 milligrams (mg) 2 tablets by mouth every 8 hours as needed for breakthrough pain showed no documented administrations (unsure of start and/or stop date, not included in active physician's orders). No documentation provided indicating R1 refused any medication administrations for month of June 2023. Reviewed R1's PRN Medications Notes showed resident received oxycodone-acetaminophen 10-325 mg one tablet on 6/18/2023 for pain rated at 7/10 and 6/20/2023 for pain rated at 8/10. Reviewed R1's medication administration record for July 2023 that showed R1's lidocaine medicated patch administrations were circled on the 7th, 10th, and 11th; acetaminophen and oxycodone were minimally documented as being administered throughout entire month. Reviewed R1's-controlled drug administration record that indicates R1 is to receive oxycodone-acetaminophen 10-325 mg one tablet as needed every 12 hours. The record shows R1 received one dose on unknown date at 6:00 PM, received one dose on 06/10/2023 at 10:00 AM then did not receive the medication again until 06/14/2023. The record also shows that R1 received 3 doses on 06/17/2023 and only one dose on July 5th and July 10th. On 07/11/2023, V1 (Administrator) provided June 2023 medication administration records for R1 that showed administration times for oxycodone-acetaminophen 10-325 mg scheduled for 5:00 AM and 5:00 PM from 06/16/2023 through 06/17/2023: at 10:00 AM and 10:00 PM from 06/18/2023 to current. On 07/12/2023 at 2:32 PM, V2 (Assistant Director of Nursing/ADON) said her expectations regarding medication administration are for nursing to follow physician orders, properly assess residents and to administer medications or treatments as ordered. When asked why it is important to administer pain medications as ordered by a physician, V2 (ADON) said because the physician prescribes what's best for the resident and implements orders that are needed for the resident. V2 added that pain medications should be administered as ordered to keep residents' pain free and to allow resident's the ability to function throughout the day. V2 then said nurses primarily document care provided within a resident's administration record by documenting with their initials and should document any missed administrations in the resident's medical record and/or progress note. V2 added that if an administration box is left blank or is circled, that could mean it was not administered, the resident was not available or the resident refused and should be documented in the resident's record/progress note. On 07/12/2023, V1 (Administrator) provided completed medication administration in-service record dated 07/11/2023 that reads is part, nurses are to administer medications according to policy IIA2. Reviewed IIA2 Medication Administration policy with effective date of 10/25/2014 that reads in part: Medications are administered in accordance with written orders of the prescriber, administered without unnecessary interruptions, and a schedule of routine dose administration times is established by the facility and utilized on the administration records. Reviewed pain policy last revised August 2008 that reads in part: to identify individuals who have pain or at risk for pain; assessments should occur upon admission to facility, at each quarterly review, with any significant change and when pain is suspected; identify the nature and severity of pain with use of a standardized pain assessment appropriate to resident's cognition level; evaluate how pain is affecting mood, activities of daily living, sleep and selected quality of life measures; with the input from resident, establish goals of pain treatment; physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain; if there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for as needed use, increasing the standard dose of the existing analgesic, or switching to another analgesic.

Based on interviews and record reviews, the facility failed to follow its policy related to documentation, monitoring and physician notification related to bowel movement for one (R26) of three residents reviewed for quality of care. This deficiency resulted in R26 complaining of constipation for several days before being sent to the emergency room for further evaluation and subsequently found to have fecal impaction in the rectum. Findings include: R26 is a [AGE] year-old, female, admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, morbid obesity due to excess calories and other sequelae of cerebral infarction. On 01/17/23 at 12:30PM, R26 was asked about her recent hospitalization . R26 stated, It was five or six days that I did not move my bowels. I told staff that I cannot move my bowels and I was having abdominal pain. They are giving me Miralax (Polyethylene Glycol, laxative) every day, but it did not help me move my bowels. With Miralax, I move my bowels every day. I drink water pretty good, but I was constipated. The MAR (Medication Administration Record) from November 2022 to current showed that Miralax, 17 grams, oral once a day, was administered to R26 daily, as ordered. According to progress notes dated 12/28/22, R26 was seen by V17 (Nurse Practitioner) due to constipation and ordered to continue taking the prescribed Polyethylene Glycol once a day. Progress notes dated 01/02/23 documented that she (R26) complained of feeling constipated and with too much stool inside her intestines. KUB (Kidney, Ureter and Bladder) X-ray was ordered. KUB X-ray dated 01/02/23 recorded: Impression: Generalized ileus versus bowel obstruction. On 01/04/23, she (R26) was sent to the emergency room for further evaluation for bowel obstruction. Hospital records dated 01/05/23, After Visit summary documented: Reason for visit: rectal pain; constipation Diagnoses: constipation, unspecified constipation type; fecal impaction in rectum. On 01/18/23 09:50AM, V11 (Certified Nurse Assistant, CNA) was asked regarding bowel movement (BM) monitoring of residents. V11 verbalized, I do monitor for BM every two hours. I tell the nurse about BM to document the observation. V8 (Registered Nurse) was also asked regarding R26 and BM monitoring. V8 replied, CNAs are responsible for monitoring the BM of resident. If a resident does not have a BM for three days, we have to let the physician know. If there is an order for a PRN (as needed) medication, we give the medication. But we still have to notify physician or NP for any additional orders. She (R26) has issues with constipation due to her underlying condition. Looking at her BM logs, I don't see any logs on 01/03/23; 12/25/22 and 12/29/22. R26's bowel movement logs recorded the following: November 2022: No BM on 11/09; 11/10; 11/11; 11/14, 11/15, 11/16; 11/20, 11/21, 11/22, 11/23; no record on 11/29. December 2022: No BM on 12/02; no records on 12/03 and 12/04; no BM on 12/10/22, 12/11/22, no record on 12/12/22; no BM on 12/16/22; no record on 12/17/22; no BM on 12/18, 12/20; on 12/21 at 9:28 AM, a small BM of 5 ml (milliliters) was documented; no BM on 12/22; no record on 12/25 and 12/29. January 2023: No BM on 01/01; on 01/02 at 11:19 AM, a medium sized BM of 10 ml was documented; no record on 01/03/23. Further review of R26's progress notes from November 2022 to current showed no documentation notifying physician or NP regarding not moving bowels for three days or more but on 12/28/22 that she (R26) started complaining of constipation. On 01/18/23 at 1:53PM, V17 (Nurse Practitioner) was interviewed regarding R26. V17 stated, I was first made aware that she had issues with constipation last 12/28/22, I saw her and ordered to continue Miralax. On 01/02/23, she still complained of constipation, KUB was ordered. It showed possible bowel obstruction. She was sent out, readmitted back with diagnosis of fecal impaction. She had fecal impaction due to mobility deficit, diet and hydration. In order to prevent fecal impaction on R26, staff has to do turning and repositioning, hydration, and monitor bowel movement on a daily basis. If there is no BM for three days, I should be notified. She has history of CVA (stroke) which leads her to develop decreased mobility and affects bowel function. On R26, the fecal impaction is avoidable, staff has to monitor her BM daily and when needed and document findings and notify physician and NP if there is no BM for three days. Because constipation can lead to fecal impaction. Fecal impaction could lead to bowel obstruction, leading to complete blockage of stool and perforation of intestines. 01/19/23 at 10:59 AM, V2 (Director of Nursing) was also interviewed regarding bowel movement monitoring. V2 verbalized, I expect my staff to monitor BM every shift. CNAs are responsible for monitoring the BM. If it is something abnormal, they should notify the nurses. But if none, they document it in the point of care charting. If a resident does not have BM for three days, they have to notify physician or nurse practitioner. Facility's policy titled; Bowel Program dated 05/17 stated in part but not limited to the following: Objective: To maintain proper bowel health for each resident. Procedure: 1. Residents will be monitored daily to determine if they have had a bowel movement. 2. If resident has had a bowel movement it will be documented in the resident's permanent record. 3. After three consecutive days of resident not having a bowel movement the physician is to be notified and orders for treatment shall be obtained and administered. 8. This program may be used in conjunction with routine laxative and stool softener medications as order by the physician.

Based on observation, interview and record review the facility failed to follow the prevention of pressure wounds policy and complete daily skin checks for 3 of 3 residents (R1, R7, R9) reviewed for pressure ulcer prevention. This failure resulted in R7 having an unidentified new wound requiring wound debridement revealing a stage 4 pressure ulcer, and R1 having 3 unidentified wounds, requiring debridement revealing a stage 3 pressure ulcer. Findings include: 1. R7s face sheet shows R7 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7s Braden scale with score dated 5/13/2022 shows score of 12, high risk. R7s plan of care dated 5/12/22 with last review dated of 7/14/22 shows R7 has alteration in skin integrity as evidenced by pressure ulcers R/T (related to) decreased mobility, decreased cognition, choosing choices that are inconsistent with plan of care, malnutrition. Wound healing may be hindered by refusal of care, Peripheral Vascular disease, [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] Disease, Diabetes, incontinence of bowel and bladder, Chronic combined systolic (congestive) and diastolic (congestive) heart failure, Morbid (severe) obesity. Positioning devices, low air loss mattress, and offload boots are in place to assist in healing. R7 has also been provided with a U-shape pillow to assist with comfort. Ulcer will show improvement (e.g., decrease in size, increase in granulation tissue, or decrease in necrotic tissue) by next review date unless co-morbidities/resident choices cause an unavoidable decline. Braden scale per protocol to assess risk factors. Review clinical condition to determine further risk factors for breakdown. Complete skin check and observe for complications such as pain, odor, changes in exudate characteristics, increase in necrotic tissue, infection, [CONDITION(S)], [CONDITION(S)]. Notify physician immediately if observed. Dietary Consultation as needed to evaluate nutritional needs. Educate resident regarding risk factors and compliance with care plan interventions. Encourage/assist with turning/repositioning every 2 hours and PRN (as needed). Keep clean and dry as possible. Minimize skin exposure to moisture. Provide/Assist with continence care as needed. Keep linens dry and wrinkle free to prevent further pressure forces. Maintain head of bed at/or below 30 degrees or at lowest degree of elevation consistent with the resident's medical condition to prevent sliding and shear-related injury that may prohibit wound healing and/or cause further wound development. Measure and document wound characteristics observations weekly. Minimize pain by assessing and administering pain medication as ordered by physician. If pain medication is ineffective, notify physician for possible changes to pain regimen. Obtain labs as ordered and report results to physician. Provide diet, nutritional supplements, vitamins, and minerals as ordered to aid wound healing. Reduce friction and/or shearing to prevent wound from declining and further wound development (e.g., utilize lift/turning sheets, trapeze bar, mechanical devices, lubricants, positioning devices. May use transparent film or [MEDICATION(S)] to bony prominence to reduce mechanical injury from friction). Treatment (application of ointment/medication and/or dressings) to site per physician order. Use positioning devices (such as a pillow or foam wedge, off-loading boots, bath blanket, etc.) to avoid further pressure on the affected area and to prevent further ulcer development to other bony prominences. Utilize incontinence briefs to prevent trapping moisture against the skin. Utilize incontinent skin barriers such as creams, ointment, pastes, and film-forming skin protectants as needed to protect and prevent further skin breakdown. Utilize pressure redistribution surfaces on bed and when up in chair to redistribute pressure of affected area and prevent further pressure ulcers. Observe for proper function/use of support surfaces as well as effectiveness. Wound physician consult per physician order. On 9/28/22 at 3:59pm V22 (Nurse) stated he was working with R7 on 6/15/22 on the evening shift when he was summons to R7s room to assist with care, and he noticed R7s toes were blue, V22 stated that's when he took R7s heel protector boot off and observed R7 with purplish blue discoloration to the right heel, right lateral foot and right inner foot. V22 stated he did not see anything on R7's left foot when he looked at R7s left foot. V22 stated he worked with R7 on 6/14/22 from 2pm until 7am (2 shifts) and he did not conduct a skin check on R7. V22 stated he was not aware that R7 needed daily skin checks due to being a high risk for skin break down. V22 stated he was aware that R7 was at risk for skin breakdown. V22 stated he does skin checks on R7 when the aides give R7 showers, but he has never checked R7 feet. V22 stated R7 returned from the hospital with the heel boots on, V22 stated he has never removed R7s heel boots when working with R7 to check her feet. V22 stated he reported R7s new skin issue immediately to the nurse practitioner and V13 (wound treatment nurse). V22 reviewed R7s TAR (Treatment Administration Record) for the daily skin checks, V22 stated that is not his initials for 6/14/22 and 6/15/22 when he worked with R7. V22 stated he did not see any new skin issue to R7s left foot on 6/15/22, however when R7 was seen by the wound physician on 6/15/22 the wound physician observed new skin issue to R7s left foot that required wound [MEDICATION(S)] due to necrotic tissue. Review of R7 TAR (Treatment Administration Record) dated June 2022 shows daily skin checks. There are initials in the boxes dated 6/11/22, 6/12/22, 6/13/22, 6/14/22 and 6/15/22. On 9/28/22 at 12:04pm V23 (Nurse) stated she worked with R7 on 6/11/22 and she stated she signed the TAR, and she did not see any skin issues when she checked R7s skin on 6/11/22. V23 stated she did not work one of her scheduled days because it was her husband's birthday. V23 stated she did not work on 6/13/22 and she did not sign R7s TAR on 6/13/22, V23 stated she does not work on Mondays. Review of V23s timecard, it is documented that V23 worked on 6/11/22 and 6/12/22. V23 initials are not noted on R7s TAR for completing a daily skin check on R7 on 6/11/22 or 6/12/22. Facility schedule and timecard shows V23 was assigned to work the morning on 6/11/22 and not the evening when R7s daily skin check is ordered. On 9/28/22 at 10:50pm V18 (ADON-Assistance Director Nursing) review of R7s TAR with V18, V18 stated she did not know who that nurse is that signed out the TAR for R7s daily skin checks on 6/11/22, 6/12/22, 6/13/22, 6/14/22 and 6/15/22. At 12:50pm V18 presented signatures key and the signatures/ initials noted on R7s TAR are not identified on the facility nurse signature key. On 9/28/22 at 1:00pm V5 (Administrator) was made aware that there are unidentified initials on R7 TAR and V18 does not know who the nurses are. Review of facility nurse signature log, surveyor was not able to identify who the initials belonged to, there were no nurse's name that matched up with the initials identified on R7s TAR for the dates for 6/11/22, 6/12/22, 6/14/ 22, 6/15/22. During this survey the facility did not identify who the nurses were that initialed R7s TAR for the daily skin checks on 6/11/22, 6/12/22, 6/13/22, 6/14/22, and 6/15/22. On 9/28/22 at 1:15pm V19( nurse) was identified as a nurse with the last name initials of W, V19 stated he did not sign R7s TAR on 6/14/22 and 6/15/22, V19 stated he did not check R7s skin on 6/14/22, and 6/15/22. Upon exiting this survey, the facility failed to identify who the nurse was that signed their initials for providing R7s daily skin checks on 6/11/22, 6/12/22, 6/13/22, 6/14/22, 6/15/22. On 9/28/22 at 4:01pm V13( wound treatment nurse) stated R7 is at risk for skin breakdown and should have daily skin checks for wound prevention this is to identify any skin issue. V13 stated V22 should have completed the daily skin check for R7 on 6/14/22. V13 stated she does not know who initialed that there was a completed skin check for R7 on 6/11/22, 6/12/22, 6/13/22, 6/14/22 and 6/15/22. V13 stated she did not complete the skin checks for R7 on 6/12/22, 6/13/22, 6/14/22 or 6/15/22. V13 stated she did rounds with the wound doctor on 6/15/22 when the wound doctor saw R7 for the new skin issue. V13 stated the nurses are responsible to do the daily skin checks for R7. V13 stated when conducting a daily skin check the nurse should remove anything and or clothing that would prevent them from observing the skin, the nurse should be looking for any changes in the skin. R7s skin integrity condition dated 6/15/22 with completion date of 6/23/22 shows right lateral ankle date of onset 6/15/22, acquired condition, pressure, stage 4, 5.6x 3.3x und cm, no tunneling, yellow and black in color, wound bed-slough and necrotic 70%, 30% slough, moderate drainage, serous in color, no odor, wound edges attached, surrounding tissue intact, no pain, continue current care plan, signed by V13 (wound nurse). R7s skin integrity condition dated 6/15/22 with completion date of 6/23/22 shows right lateral foot date of onset 6/15/22, acquired condition, DTI (deep tissue injury), 6.9x 4.5x und cm, no tunneling, black in color, no exudate, no odor, wound edges attached, surrounding tissue intact, no pain, no referrals necessary, continue current care plan, signed by V13 (wound nurse). R7s skin integrity condition dated 6/15/22 with completion date of 6/23/22 shows right lateral heel date of onset 6/15/22, acquired condition, pressure, stage 4, 2.0 x 2.0 x und cm, no tunneling, yellow and black in color, wound bed-slough and necrotic 50%, 50% slough, moderate drainage, serous in color, no odor, wound edges attached, surrounding tissue intact, no pain, continue current care plan, no referrals needed, signed by V13 (wound nurse). R7s skin integrity condition dated 6/15/22 with completion date of 6/23/22 shows left posterior heel, date of onset 6/15/22, acquired condition, pressure, stage 4, 3.0x2.0xx und cm, no tunneling, color of wound bed - yellow and red , wound bed- granulation and slough, 80% granulation, 20% slough, moderate drainage, serous in color, no odor, wound edges attached, surrounding tissue intact, no pain, continue current care plan, no referrals needed, signed by V13 (wound nurse). R7s wound evaluation and management summary dated 6/15/22 with signature time stamp of 12:25p.m completed by V20 (wound physician) shows in part, this patient has multiple wounds, past medical history-cerebral vascular disease, diabetes mellitus, and obesity. Focused wound site4- stage 4 pressure wound of right, lateral ankle full thickness, etiology -pressure, stage -4, duration- greater than 1 days, objective healing, wound size 5.6x3.3x not measurable cm, surface area-18.48cm (squared) , exudate- moderate serous, thick adherent devitalized necrotic tissue- 70%, slough 30%. Surgical excisional debridement procedure- indication for procedure, remove necrotic tissue and establish the margins of viable tissue, the wound was cleaned with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique 15 blade was used to surgically excise 18.48 cm (squared) devitalized tissue and necrotic muscle and surrounding fascial fibers along with slough and biofilm were removed at a depth of 1.3cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented. Focused wound site 6- stage 4 pressure wound of right, lateral ankle full thickness, etiology -pressure, stage -4, duration- greater than 1 days, objective healing, wound size 2.0x2.0 x not measurable cm, surface area-4.00cm (squared) , exudate- moderate serous, thick adherent devitalized necrotic tissue- 50%, slough 50%. Surgical excisional debridement procedure- indication for procedure, remove necrotic tissue and establish the margins of viable tissue, the wound was cleaned with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique 15 blade was used to surgically excise 4.00 cm (squared) devitalized tissue and necrotic muscle and surrounding fascial fibers along with slough and biofilm were removed at a depth of 0.3cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented. Focused wound site 7- stage 3 pressure wound of left, posterior heel full thickness, etiology -pressure, stage -3, duration- greater than 1 days, objective healing, wound size 3.0x2.0 x not measurable cm, surface area-6.00cm (squared) , exudate- none, slough 20%, granulation tissue 80%. Surgical excisional debridement procedure- indication for procedure, remove necrotic tissue and establish the margins of viable tissue, the wound was cleaned with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique 15 blade was used to surgically excise 1.20 cm (squared) devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented. Focused wound site5- pressure wound of left, lateral foot full thickness, etiology -pressure, stage -unstageable DTI with intact skin, duration- greater than 1 days, objective healing, wound size 6.9x4.5 x not measurable cm, surface area-31.05cm (squared), exudate- none, recommendations off load wound, reposition per facility protocol, sponge boot. On 9/28/22 at 2:15pm V20 (wound physician) stated she saw R7 on 6/15/22, R7 had multiple wounds, R7s wound was observed with necrotic tissue, and it is her job to remove as much dead tissue as possible during each visit. V20 stated she debrided the wound due to dead tissue and a stage 4 pressure ulcer was revealed, V20 stated surveyor would have to speak to the facility regarding their practice for daily skin checks. V20 stated she cannot speak to what contributed to the development of R7 wounds. V20 stated she does expect the facility to carry out orders and treatment when they are given. V20 stated a pressure ulcer can develop within hours. V20 stated R7 had diabetes and history of stroke, V20 would not give comments on prevention of pressure ulcers or what could have contributed to R7 skin break down and a stage 4 being revealed. V20 stated the wound evaluation shows 1 day duration because that was the first time, she saw that wound. 2. On 9/22/22 at 2:57pm with assistance from V22 (Nurse) R9 was observed to have a wound treatment dressing on his right ischium, dated 9/20/22, this was observed by V22 (Nurse) also. Review of R9s TAR, it is documented that R9 received wound treatment on 9/19/22 and 9/21/22. Review of R9s TAR with V13 on 9/30/22 at 10:27a.m, V13 (wound treatment Nurse) stated she changed R9s wound treatment on 9/21/22 and dated it for 9/21/22. V14 was made aware that surveyor observed R9s treatment dressing with V22 and it was dated for 9/20/22 and not 9/21/22. V13 stated treatment orders should be completed as ordered by the physician and should be documented when the treatment is completed, V13 stated the treatment dressing should be dated for the date they the treatment was completed. R9s POS shows orders for cleanse right ischium with normal saline or wound cleanser. Pat peri area wound dry. Apply alginate calcium and cover with dry dressing, once a day and PRN( as needed) of soiled or dislodged. Review of R9s TAR for daily skin assessment, there are no initials noted for carrying out the order from 9/27/22 to 9/29/22. Facility policy titled prevention of pressure wounds dated January 2017 shows in-part, the purpose of this procedures is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident care plan to assess for any special needs of the residents. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family an addressed. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Facility intervention/ prevention measures- skin inspection and care dated 02/2013 shows in part, documentation of daily head to toe skin assessment by licensed nurse in the resident chart or on a facility approved form- high risk Braden 10-12 and severe risk Braden score 9 or less. Facility policy titled care plans dated 4/2015 shows in part an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident medical, nursing, mental and psychosocial needs is developed for each resident. Each resident comprehensive care plan has been designed to incorporated identified problems areas, incorporate risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes, aide in preventing or reducing declines in the resident functional status and or functional levels. Care plans are revised as changes in the resident condition dictates. 3. R1 is a [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/2 at 12:47PM V9, Certified Nursing Assistant, stated while she was providing care to R1 he was complaining of pain on his buttock and when she turned him over, he had an open wound. V9 stated R1's buttock wound was open. V9 stated she reported to V19, Licensed Practical Nurse, and V13, Wound Nurse. V9 stated R1's buttock dressing was not being changed on 9/2 and 9/5/22. On 9/22/22 at 2:25PM V13 stated R1 developed a facility acquired pressure ulcer on the right ischium and sacrum. V13 stated R1 had a left ischial wound that was hospital acquired. V13 stated R1 was receiving a wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor asked why the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V13 stated I don't have an excuse for that. On 9/27/22 at 10:36AM V13 stated skin assessments for residents are done on shower days and daily for the first month following admission. V13 stated after the first month, then skin checks are done weekly. V13 stated if a resident refuses showers, the nurse should still do a skin check. V13 stated if there is a skin impairment the nurse should document it. V13 stated if a resident has an open area, then they should be on daily skin assessments. V13 stated the nurses are responsible for daily skin checks. V13 stated the purpose of doing skin checks daily on residents with skin impairments is because they may be prone to skin changes. On 9/28/22 at 9:47AM V19, LPN, stated he was not aware of R1 having a buttock wound until 9/11 when he sent R1 to the hospital. On 9/28/22 at 10:52AM V13 stated Prostat and Sugar Free (SF) Prostat are used to promote wound healing. V13 stated if a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V13 stated the nurses would administer Prostat. V13 reviewed R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V13 stated we cannot substantiate Prostat was given to R1. V13 reviewed R1's care plan with the surveyor. V13 stated she updates the care plan to include wounds. V13 stated she did not update R1's care plan for sacral and ischial wounds. V13 stated she was the first nurse to assess R1's sacral wound. V13 stated she does not have other documentation to support that R1's skin was being checked daily. On 9/28/22 at 1:22PM V4, Director of Nursing, stated I expect the nurses to follow physician orders. V4 stated the purpose of signing the medication and treatment administration records is to show the care was rendered. On 9/28/22 at 2:57PM V20, Wound Doctor, stated Prostat is a protein supplement used for wound healing. V20 stated necrosis is the death of tissue. On 9/30/22 at 12:20PM V13, Wound Nurse, stated R1 is incontinent of urine. V13 stated V13 completes the Braden Assessments. V13 stated in regard to the Assessments always is not the same as rarely V13 stated this was an error on my end for R1's 7/21/22 Braden Assessment. V13 stated the assessment score will change based on the response and this change would increase R1's risk for skin breakdown. On 9/6/22 V20 documented R1's sacral wound measures 9.4 x 5.9 cm and the depth is not measurable. 50% is necrotic tissue, 10% slough; and 40% granulation tissue. R1's treatment is to apply Santyl once daily and alginate calcium dressing and cover with gauze island once daily. R1's Left ischium stage 3 measures 2.5 x 1.8 x 0.1cm with 100% granulation tissue. R1's right Ischium stage 3 measures 1.3 x 1.8 x 0.2 cm with 100% granulation. Both left and right ischium treatment are to apply alginate calcium with silver and cover with gauze island dressing daily. R1's physician note from the same date notes surgical excisional debridement procedure was performed. 33.28 cm2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues along with slough and biofilm were removed. R1's Bath and Skin Report Sheet on 9/5/22 has feet/heel areas circled on CNA section. No wound documentation in the nurse section, except for date and signature. On 9/8/22 the nurse section has the date and nurse signature. Skin condition is not documented by the nurse. On 9/8/22 the CNA section has a circle around the buttocks. R1's MDS section H dated 7/21/22 notes he is always incontinent of bowel and bladder. R1's Braden Scale assessment dated [DATE] notes section 1 R1 is rarely moist. Pressure Ulcer care plan for R1 does not include his sacral or ischial wounds. Interventions include complete skin check and observe for complications. No interventions have been added to the care plan since 3/23/22. Treatment Flowsheets dated 8/1/22 - 8/31/22 notes skin assessment daily, but no daily signatures. Treatment Flowsheets dated 9/1/22 -9/30/22 do not have daily skin assessment. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Flowsheet does not list Prostat. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . End dated 1/30/22. The facility policy for Prevention of Pressure Wounds policy effective date January 2017 states, in part: 9.Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. 10. Immediately report any signs of a developing pressure injury. 1.Dietician will assess nutrition and hydration and make recommendation based on the individual resident's assessment. 3. Monitor laboratory values. 6. Administer vitamins, minerals and protein supplements in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interviews, observations, and records reviewed the facility failed to ensure a resident's (R2) arms were placed properly before lifting her from a chair using a mechanical lift, this failure resulted in R2 suffering a fracture to her right 4th and 5th fingers. The facility also failed to follow the fall preventions and reevaluate fall preventions for a cognitively impaired resident with high risk for falls (R6), R6 suffered 2 falls from bed after climbing over the boaster cushions, R6 sustained a bump to the forehead and small cut to the nose. This failure affects 2 of 3 residents reviewed for accidents/ incidents/ falls. Findings Include: R6 face sheet shows diagnoses of Generalized Arthritis, Dementia without behavior disturbance, Urinary Tract Infection, [CONDITION(S)], Hypertensive [CONDITION(S)] with Heart failure. On 9/29/22 at 5:15pm V26 (R6 family) stated the facility does not have fall interventions in place for R6, there's no floor mats in place and the bed boasters are ripped. V26 stated R6 has sun downing behaviors and the facility should monitor her more frequently. R6s MDS dated [DATE] section C shows BIMS score of 3 (cognitive impairments). R6s fall occurrence dated 9/3/22 shows writer heard a fall sound from the nursing station, on arrival to the resident's room, writer found resident on the floor laying on her left side, upon assessing the resident writer noted a bump on the resident's forehead and a small cut on the resident's nose. writer immediately applied ice pack to the forehead to stop the swelling and applied pressure on the nose. Writer assessed LOC (level of consciousness) and resident was conscious and able to engage eye contact with the writer. Writer immediately called for help. R6s fall occurrence dated 8/6/22 shows in-part CNA on duty stated she was moving around in the bed, and I entered the room, she was trying to get out of bed, so I assisted her to the floor mat and called the nurse. On 9/23/22 at 1:00pm V14 (MDS coordinator) stated she conducts the facility fall investigations, and she conducted R6s fall investigation for 9/3/22, V14 stated the root cause analysis was that R6 sustained a fall due to altered mental status related to a Urinary Infection. V14 stated R6 had a fall on 8/6/22 due to trying to get out of bed due to altered mental status related to a Urinary Infection. V14 stated she implemented the bed boasters in December 2021 so that R6 could identify the bed boundaries and not get out of bed or go further than the bed boasters. V14 said R6 has cognitive deficits, but she thinks R6 understand not to go beyond the boundaries of the boasters. R6 BIMs score reviewed with V14; R6 BIMs score dated 6/22/22 shows a score of 3 (cognitive impairments). V14 stated she did not reevaluate the use of the boasters, she did not reevaluate R6 cognition of understanding of the bed boasters and her boundaries when the boasters are in place. V14 stated she feels like the bed boasters are effective although R6 was not able to identify the bed boundaries when the boasters are in place and continued to climb out the bed over the bed boasters and around the boasters. V14 stated the fall from the bed is higher when the boasters are in place. On 9/30/22 at 4:50pm V14 stated she has been talking with the IDT team about R6, since the surveyor was inquiring about R6 (during this complaint investigation), V14 was asked what the plan was prior to the surveyor inquiring about R6, V14 continued to say V14 has been communicating with the IDT team recently about R6 falls. On 9/23/22 at 3:20pm R6 was observed lying in bed, V32 (CNA-Certified Nursing Assistant) assisted with observation of bed position/height, R6s bed was not observed in the lowest position. V32 had to lower R6s bed to the lowest position. Review of R6s care plan for falls with problem start date of 9/7/2017 and long-term goal date of 9/23/22 shows R6 is at high risk for fall related injury- R/T (related/to) dementia with poor judgement and decreased safety awareness, decreased transfers and mobility, weakness, and impaired balance, and new environment. R6 will remain free from severe fall related injury through next review, antibiotic for [CONDITION(S)] (urinary tract infection), ER transfer, antibiotic for [CONDITION(S)], ua/cs ( urine analysis, culture sensitivity), provide repositioning device and staff to ensure that they are in place while in bed to help the resident define the bed boundaries, staff to ensure that R6 is in the center of the bed and position properly while in the bed to aide in fall prevention, dycem to wheelchair, two staff assist for transfer, encourage, and assist with maintaining a safe environment, frequent safety checks, cues, and reminders, keep bed in lowest position when care is not being provided, keep call light in reach and answer promptly, keep frequently used items in reach. R6s progress notes dated 9/3/22 at 10:56pm shows writer heard a fall sound from the nurse station, on arrival to the resident room, writer found resident on the floor laying on her left side, upon assessing the resident writer noted a bump on the resident forehead and a small cut on the resident nose. Writer immediately applied ice pack to the forehead to stop the swelling and apply pressure on the nose. Writer assessed LOC and resident was conscious and able to engage in eye contact with the writer. Writer immediately called for help and informed the NP of the resident situation and was instructed to send the resident to the hospital. Writer called 911 and then call the family member to be aware of the resident condition and the hospital she is being transferred to for evaluation. Resident left in stable condition. Facility policy Titled Care plans, dated 4/2015, shows in part an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident medical, nursing, mental and psychological need is developed for each resident. Facility policy Titled Managing Falls and Fall Risk dated 8/2008 shows in-part based on previous evaluations and current data, the staff will identify interventions related to the resident specifics risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff, with input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If systemic evaluation of a resident fall risk identifies several possible interventions the staff may choose to prioritize interventions (to try one or a few at a time, rather than many at once). If falling reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The staff will monitor and document each resident response to interventions intended to reduce falling or the risk of falling. If the resident continues to fall, staff will re-evaluate the situation an whether it is appropriate to continue or change current interventions. As needed the attending physician will help the staff reconsider possible causes that may not previously have been identified. Review of R6s care plan there are no documented re-evaluation of R6 current fall interventions/preventions, Review of R6s progress notes dated 8/3/22 to 9/15/22 there are no documented re-evaluations of R6s current fall interventions/preventions. R2 is an [AGE] year-old with diagnoses including but not limited to [CONDITION(S)] and [CONDITION(S)] following Cerebral Vascular Disease affecting Right Dominant side, Dementia without Behavioral Disturbances, Essential Hypertension, Convulsions, [CONDITION(S)], and Contracture of Muscle. R2's cognitive assessment dated [DATE] notes R2 is severely impaired. On 9/22/22 at 9:59AM V4, Director of Nursing, stated regarding R2's injury, V7, Certified Nursing Assistant (CNA) was preparing to give R2 a shower. V4 stated she was the assigned nurse on 9/15/22 for R2. V4 stated based on her investigation R2's hand was in the space below the arm rest and the along the seat in her reclining chair. V4 stated R2's hands should have been inside the sling during the transfer. V4 stated the night shift reported bruising on R2's hand on 9/16/22. On 9/22/22 at 10:25AM the surveyor observed R2 sitting in a reclining chair without side panels under the armrest and seat. A cushioned device was present under the armrest. R2 alert but responses are nonsensical. On 9/22/22 at 11:35AM V7, CNA, stated on 9/15/22 she went to give R2 a shower. V7 stated R2 was sitting in the reclining chair with a transfer sling under her. V7 stated using the mechanical lift she raised R2 into the air to move R2 into the shower bed. V7 stated during the transfer she noticed R2's right arm was hanging out of the sling. V7 stated R2's right arm was kind of dangling outside of the sling and wedged under the arm rest. V7 stated she stopped and placed R2's arm back inside the transfer sling. V7 stated the next day R2's right hand was bruised. On 9/22/22 at 11:52AM V8, CNA, stated she was asked to assist V7 on 9/15/22 in transferring R2 with the mechanical lift. V8 stated R2 was being transferred from her reclining chair into the shower chair with the mechanical lift. V8 stated she was maneuvering the controls on the machine. V8 stated during the transfer she saw R2's hand was not in the sling. V8 stated R2 requires cues to keep her hands in the sling during transfers. On 9/22/22 at 2:00PM R2 observed sitting in the reclining chair with her right hand wrapped in white kerlix. On 9/23/22 at 1:28PM V4 stated we had the doctor come see R2 following her injury. V4 provided the surveyor with R2's progress notes on 9/23, including the doctors note from 9/20/22. On 9/28/22 at 1:22PM the surveyor asked V4 if her investigation shows R2's injury occurred during the mechanical lift transfer, why did the doctor document the injury is likely form cleaning R2's hand. V4 stated I don't know why he wrote that. On 9/29/22 at 10:45AM V24, Doctor, stated the only way that R2's fracture happened is to have opened the hand. V24 stated R2's bones are very fragile and when staff try to open the hand to clean it, this could have caused the fractures. V24 stated I have a history with R2, I have seen her before, her right hand was contracted. V24 stated R2's injury is known as boxer fingers, as if someone hit her hand against something. V24 stated this injury is deep in R2's hand, her 4th and 5th phalanges are fractured. V24 stated in the X-ray you can see the base has ripped. V24 stated with a deep injury the bruising develops in hours or later on. V24 stated R2's injury did not likely occur during the mechanical lift transfer. Skin Integrity event dated 9/16/22 1:55AM for R2 notes right hand with purplish bruising and swelling. Bruising of unknown origin. R2's Physician Order Report notes start date 9/16/22 Radiology Right hands/fingers. R2's Progress Notes dated 9/18/22 9:00AM states X-Ray order relayed to Nurse Practitioner gave order for R2 to be sent out to hospital for further evaluation related to results. Physician note dated 9/20/22 notes R2's right hand is contracted with frozen joints of the fingers. She has tenderness over the fourth and fifth proximal phalanges noted by grimacing of her face. Fracture like this with her significant [CONDITION(S)], I would think it is from trial of cleaning her hand. I doubt any injury would do this fracture more than they try to open the hand. R2's initial report to IDPH dated 9/18/22 notes R2 noted with purple bluish discoloration to the right hand, x-ray ordered and resulted with acute fracture of two fingers. R2's Functional status notes on 7/1/22 R2 requires total assistance from 2 persons for transfers. R2's ADL Skills Analysis Assessment completed on 7/4/22 notes R2 requires a mechanical lift for transfers. R2's X-ray dated 9/16/22 Impression states There are fractures of the proximal phalanges of the 4th and 5th digits of the right hand. The facility final investigation report for R2 notes on 9/16/22 R2 was noted with bruising and swelling to the right hand. The investigation notes staff reported seeing R2's hand resting under the arm rest of the chair in between the seat and the armrest. The investigation notes the probable cause of the right fourth and fifth finger is due to R2's hand caught in between the arm rest of the chair. The facility policy revised August 2008 for Lifting Machine notes prior to transfer h. Instruct the resident to fold both arms across his or her chest, if possible.

Based on interview and record review, the facility failed to provide adequate monitoring and assistance for a resident during mealtime to prevent any choking incidents. This applies to 1 of 3 residents reviewed for monitoring during meals in a total sample of 3. This failure resulted in R1 having a choking episode that caused a [CONDITION(S)]. R1 expired because of the [CONDITION(S)]. This was identified as an immediate jeopardy situation that began on [DATE] and was removed on [DATE]. V1 (Administrator) was informed of the immediate jeopardy on [DATE] at 11:00AM. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan. Findings Include: 1. R1 is a [AGE] year-old with the following diagnoses: Dementia with behavioral disturbance and type 2 Diabetes. R1 was admitted to the facility on [DATE]. R1's Physician Order Sheet (POS) dated ,d+[DATE] documents R1 receives a regular general diet with thin liquids. R1's Minimum Data Set (MDS) Section C dated [DATE] documents an interview for mental status is unable to be completed because R1 is rarely/never understood. Cognitive skills for daily decision making are documented as severely impaired - never/rarely made decisions. The MDS section G dated [DATE] documents R1 needs extensive assist with one person when eating. R1's Care Plan dated [DATE] documents R1 is limited in ability to feed self independently and requires a restorative feeding program. An intervention documented is to provide R1 with supervision to limited (hand R1 items), assist with each meal through next review. There is no documentation in the Care Plan of R1 having a behavior of overstuffing mouth when eating or R1 having an oral fixation. The OT (Occupational Therapy) Evaluation and Plan of Treatment dated [DATE] documents R1 is a total assist with feeding. R1 is alert to name only and follows one step commands with max cues/assist. The Restorative Nursing Program documentation dated [DATE] documents R1 is in the restorative program for eating and swallowing. R1 has decreased self-performance with eating and is easily distracted and needs reminders to eat. R1 will need staff to hand her finger foods that she can feed herself and assist with the rest of the meal. R1 continues to need cueing with staff assistance. 2. The Nursing note dated [DATE] documents R1 has been taken to the hospital for full [CONDITION(S)]. Around 5:44PM the nurse was called to R1's room when R1 was unable to spit out food in her mouth and would not swallow either. Mouth swipes were unsuccessful as well as the [MEDICATION(S)] maneuver. 911 was called and CPR was started when breathing stopped. R1 will be admitted to the hospital for [CONDITION(S)] once a bed becomes available. The Hospital Records dated [DATE] documents R1 presented to the emergency room in full [CONDITION(S)] emergency medical services reported prior to their arrival R1 was eating dinner at the facility when R1 became unresponsive and was choking. R1 had a large amount of food in mouth and obstructing airway. R1 was intubated and able to be resuscitated. Suspect reason for arrest was due to choking episode. An Electrocardiogram (EKG) was taken and did not appear to be a STEMI (ST Elevation [CONDITION(S)]). A CT (Computed Tomography) of the head showed Cerebral [CONDITION(S)] (swelling of the brain) and R1 was admitted to the neuro intensive care unit. R1's family was notified about the poor prognosis given the Cerebral [CONDITION(S)] and Hypoxic Brain Injury. R1's diagnoses are [CONDITION(S)] and choking. The Death Certificate dated [DATE] documents the cause of death for R1 as follows: [CONDITION(S)] Brain Injury secondary to [CONDITION(S)], Cerebral [CONDITION(S)] due to [CONDITION(S)] Brain Injury, and Cerebral Herniation (swelling of the brain). A Nursing note dated [DATE] documents the facility was notified by R1's family that R1 expired at the hospital on [DATE]. The ADL (Activities of daily living) Skills Analysis dated [DATE] documents R1 is an extensive assist when eating. While R1 performs part of the activity, help was provided greater than three times or full staff performance occurred during part but not all of the time. A one-person physical assist as needed with eating and no oral problems or nutritional problems are documented. The Interdisciplinary Resident Screen dated [DATE] documents R1 was discharged from services on [DATE] and since that time has not shown a functional decline. R1 continues to need assistance with feeding and is dependent on all other tasks. There are no comments or checked boxes by the nutrition/swallowing screen. 3. The following are interviews conducted regarding R1's incident on [DATE]: On [DATE] at 2:12PM, V3 CAN (Certified Nursing Assistant) stated, She was eating in bed that day I gave R1 the tray and I handed her a piece of bread or a piece of burger. I can't remember what it was then I left to feed another person. There was another aide that was coming in behind me to feed R1 but V6 (CNA/Activity Aide) was finishing something up. R1 was left alone less than five minutes. I was passing the trays and R1 was the first down the hall, so I went in and set R1 up. I knew V6 was coming into feed R1 and was coming down the hall. No, I didn't tell V6 I gave R1 the food. A couple minutes later I just started hearing screaming for the nurse, so I came out to see what was going on and people were going into R1's room and we saw R1 was choking and called 911. We started CPR (Cardiopulmonary resuscitation) when R1 stopped responding and having a pulse. R1's mouth was packed with food. We were trying to tell R1 to spit it out or open R1's mouth so we could get it out but R1 wasn't doing that. I know we're not supposed to leave them alone, but I saw the other CNA coming and thought she was going to R1's room. On [DATE] at 2:40PM, V4 (Nurse) stated, The CNA (V6) called me into the room to tell me R1 was having a hard time waking up to eat and said something was wrong. I tried to shake R1 to get her to pay attention to me and I was telling R1 to open her mouth so I could see inside but R1 was not listening. I realized there was food in R1's mouth and that R1 was choking. The CNA didn't tell me she put any food in her mouth. We got the crash cart and tried to get the [MEDICATION(S)] (suction catheter) in R1's mouth to clear it out. R1 was not opening her mouth so we couldn't get the [MEDICATION(S)] in there too good. We called 911 and we started CPR. I know R1 tries to suck in the food to, R1 needs to cues to chew more and not put so much in R1's mouth at once. She cannot follow directions. On [DATE] at 12:32PM, V6 (CNA/Activity Aide) stated, I was feeding R1 in her room but R1 wasn't opening her mouth. I gave R1 one bite of food and R1 just wasn't looking right. R1 stopped eating and was making weird facial expressions and her eyes got big. I fed R1 the bite of the sandwich. I called for the nurse and V4 was close to R1's room so V4 came in and started looking at R1. I left the room after that because V4 said R1 was choking, and more people started coming in. I didn't check R1's mouth before R1 started eating. I don't remember if R1 had any food in her hand when I came in. The other CNA (V3) had the tray set up when I got in there. I was finishing up with something and on [MEDICATION(S)] to R1's room to help feed her. V3 was already out of the room when I got there. On [DATE] at 2:02PM, V6 stated, During orientation, we feed the residents in the dining room with another CNA watching over us. They would just tell us stuff like don't stuff their mouth with food, give them [NAME] bits, tell them to chew more or swallow if they weren't doing that, check their mouth for food before giving another bite, and things like that. I didn't check R1's mouth because I didn't think R1 had anything to eat yet. I don't really remember if anything was in R1's hand or if anything was missing from R1's tray. On [DATE] at 11:57AM, V2 (Director of Nursing) stated, I interviewed both of the girls (V5 and V6) and they never brought to my attention that R1 was left alone. They know better than that and they should never be left alone. I know V3 set the tray down and went to feed someone else and V6 kind of came in right behind V3. That is when R1 started choking. I wasn't told that V3 gave R1 a piece of food before V3 left. 4. The following interviews were conducted to determine R1's needs for nursing assistance at mealtime and inappropriate eating behavior. On [DATE] at 12:12PM, V5 (Therapy Director) stated, R1 has a behavior of overstuffing her mouth and cheeks with food. R1 can self-feed like finger food. R1 also would put her fingers in her mouth or clothing. R1 really likes oral stimulation. It was R1's way of self-regulating. R1 just liked to put things in her mouth. We didn't want R1 putting things in her mouth like that because you can get uncoordinated and choke when the mouth is packed that full. The only behavior R1 had was the oral fixation and overstuffing her mouth. On [DATE] at 1:27PM, V7 (MDS Coordinator/Restorative Nurse) stated, R1 needed to be fed by staff because she would stuff too much in R1's mouth. R1 really liked putting stuff in her mouth. R1 would chew on pretty much anything around her R1 could get ahold of. It was an oral fixation R1 had. R1's cognition was not good. R1 could follow any directions. R1 was in the restorative eating program to try to get her to do more on her own but we always did most of the work. R1 needed a lot of verbal and physical cues to get through a meal. No, I wouldn't leave R1 alone with any food even for a sort time because of the behavior of her over stuffing. If R1 could get it to her mouth it was going in. On [DATE] at 3:12PM, V8 (Primary Physician) stated, I expect those feeding R1 to sit there and make sure R1 is swallowing, not having any difficulties eating, is comfortable, and is eating the food. I want them to be performing their job 100% of the time. I don't remember being told about R1's behavior of overstuffing her mouth. A staff member can leave the room if the food in the mouth of the resident is swallowed and they do not have access to the food when no one is there. The policy titled, Assistance with Meals, dated ,d+[DATE] documents Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents Requiring Full Assistance: 1. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity . Based on the staff interviews conducted this policy was not followed. The surveyor confirmed via observation, record review and interview facility did the following to remove the immediacy: Failure to follow the Assistance with Meals policy and procedures: On Friday [DATE]th, education was provided by the DON to all Full Time, Part Time and Casual/PRN Nursing staff (Nurses and CNA's) on all shifts regarding ensuring that all residents requiring assistance feeding themselves are fed according to their plan of care and the facilities revised Assistance with Meals policy. Facility staff education was completed on [DATE]th, 2022. All Nursing staff members have been educated and none were on vacation or a leave of absence. All new Nursing and CNA staff will be educated regarding the revised Assistance with Meals policy, to ensure that identified residents are fed and monitored according to the facility policy and their individualized plan of care during their new hire orientation period. Monitoring would consist of ensuring that resident is not eating without supervision, not putting too much food in their mouth, swallowing in between bites, not pocketing food, only eating food items and providing bite size food pieces that the resident can swallow. A QA audit will be completed on five random residents on a weekly basis by the Director of Nursing to ensure the residents do not develop behaviors of overstuffing their mouth and/or chewing/eating items that were not food. A QA audit will be completed weekly by the Director of Nursing and the Restorative Nurse on five random residents that require assistance with meals to ensure that the CNAs are providing appropriate supervision and direction to residents and assisting the residents with their meal as per the facility's revised Assistance with Meals policy. Failure to take develop a plan of care with interventions: On Friday [DATE]th, 2022 the Speech Language Pathologist, Food Service Manager, Director of Nursing, and Social Services Director reviewed all current residents in the facility to identify any residents with behaviors of overstuffing their mouth and/or chewing or eating non-food items. After a complete review of all residents there were no other residents that have been identified with the behavior of overstuffing their mouth and/or chewing or eating non-food items. Speech Language Pathologist, Food Service Manager, Director of Nursing, and Social Services Director have been re-educated regarding ensuring that any resident that has a behavior of overstuffing their mouths and/or chewing/eating non-food items must have an active plan of care in place with interventions. A QA will be completed on five random residents on a weekly basis by the Social Services Director to ensure that if a residents develops behaviors of overstuffing their mouth and/or chewing/eating non-food items - that those behaviors are noted and that there is a proper plan of care and interventions are in place. An Emergency Quality Assurance Performance Improvement meeting was held on Friday [DATE]th, 2022 with all members of the Inter-Disciplinary Team as well as the Medical Director. All facets of the Facilities response to the incident were reviewed and approved by the Medical Director. Facility QAPI Committee will continue to meet on a monthly basis and will include review of incident for a minimum of three (3) months and on an as needed basis, thereafter, determined by the QAPI Committee.

Based on interview and record review, the facility failed to notify the physician of a resident's mental change of condition and failed to have effective interventions in place to monitor a resident with a history of suicidal ideation for 1 of 3 residents (R1) reviewed accidents and incidents in a total sample 10. This failure resulted in R1 being found deceased , with a cord around the neck, and hanging from a doorstop. This was identified as an immediate jeopardy situation that began on [DATE] and was removed on [DATE]. V1 (Administrator) was informed of the immediate jeopardy on [DATE] at 12:30pm. While the immediacy was removed on [DATE], the facility remained out of compliance at a Security Level 2. The facility is performing ongoing monitoring and in-servicing to ensure ongoing compliance. Findings include: The Face Sheet documents that R1 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] and [CONDITION(S)]. The Nurse's Notes from April through September of 2021 documents that R1 has a history of suicidal ideation requiring multiple hospitalization s. R1's Suicidal Risk Observation dated [DATE] documents that R1 is at moderate risk for committing suicide and the care plan documents that staff will notify the Physician of any increased suicidal ideation. The Incident Report documents that on [DATE] at 2:30pm, R1 had suicidal ideation and delusions of being filmed for a reality TV show. Staff suggested to R1 to purchase a signal [NAME] so the resident will be assured of not being filmed. R1 was on hourly monitoring. At 2:00am, R1 was observed in bed. At 3:00am R1 was not in bed and found hanging from the bathroom door with a cord around the neck. R1 had no vitals, CPR performed, 911 called and medical examiner removed the resident's body from the facility. On [DATE] at 2:05pm V2 (Director of Nursing) stated When residents have suicidal ideation, we typically send them to the hospital for 1:1 care. R1' suicidal ideations started in August and we would send the resident out. The last few times the hospital sent the resident back. R1 stated that this behavior was for attention. On [DATE], I was told by staff that R1 was having suicidal ideation and I started the paperwork to send the resident out. When it was time to send the resident out, R1 denied suicidal ideations and said, I'm ok. R1 was on hourly monitoring and the resident was fine on second shift. On 3rd shift, R1 was seen lying in bed at 2:00am. At 3:00am R1 was not in bed and was found hanging from the bathroom door. I did not call the Physician and the Nurse caring for the resident did not call the Physician either. On [DATE] at 2:35pm V3 (Receptionist) stated on that on [DATE], R1 came around my desk area and I heard the resident say, I'm ready to do it, I'm going to kill myself. I reported it to social services right away. On [DATE] at 2:40pm, V4 (Social Services) stated R1 made multiple threats to self-harm. Most of the time, R1 was sent out involuntarily and was sent back to the facility. On [DATE] around 2:00pm, staff told me that R1 was having suicidal ideations. R1 admitted to suicidal ideation, but denied having a plan. I told V2 and the paperwork was started for involuntary petition to have the resident sent out. I left at 3:00pm, under the impression that R1 would be sent out to the hospital. I found out later that R1 was not sent out. Our usual protocol is to send residents with suicidal ideation out to the hospital. I did not call the Physician. I went right to V2. On [DATE] at 9:30am V5 (Nurse) stated I work second shift. I assessed the resident after hearing that R1 wanted to self-harm. I asked R1 about suicidal ideation and the resident denied it. R1 was on hourly monitoring. R1 has a history of suicidal ideation and was sent out on my shift once. I did not notify the Physician. On [DATE] at 9:35am V6 (Certified Nurse Assistant) stated I came in on the night shift. I did my walk through and started making rounds. R1 was sitting on the edge of the bed and was ok. I did rounds at 2:00am and R1 was in bed. At 3:00am, R1 was not in bed and was found hanging, with a cord around the neck. R1 was on hourly monitoring and I would look down the hall to make sure the resident was ok. On [DATE] at 9:40am V7 (Nurse) stated I got report that R1 was on frequent monitoring for suicidal ideation and elopement. I did my rounds at 10:30pm and R1 appeared to be on a cell phone. I did vitals around 11:30pm. There were no behaviors or nothing going on. At 12:30am I did rounds again. R1 was sitting on the bed, staring into space. R1 didn't really say or do anything. I kept on with my rounds. At 1:30am and 2:00am, R1 was observed lying in bed. At 3:00am, V6 said that R1 was not in bed. I went in the room and the resident was hanging from the bathroom door on a door stopper. R1 had a cord wrapped around the neck, twice, that was tied very tight. I called for help. I called 911. The resident was cut down and we started CPR until Police arrived. Residents with suicidal ideations are usually sent out with a Physician order. I have no idea why R1 wasn't sent out on the previous shift. My instructions were to check on the resident hourly. On [DATE] at 2:45pm V1 (Administrator) stated I spoke to the resident, asking what was going on. R1 admitted to not really wanting to self-harm and said the threat to commit suicide was made so that the resident could go to the hospital. R1 felt that a reality TV show was being filmed at the facility and thought that we had bugged the resident's room. I explained that there was no reality TV show and I offered to buy the resident a signal descrambler, a device that messes with the internet signal in the resident's room. R1 was happy with this solution because the resident did not want to participate in the reality TV show since R1 was not getting paid. On [DATE] at 10:35am V8 (Psychiatric Nurse Practitioner) stated I started seeing R1 about 2 years ago and the resident was severely depressed. We found the right medications and R1 was pretty stable but would still have suicidal ideation from time to time. R1 would be triggered after talking to family. R1 was being seen monthly and getting weekly therapy sessions. R1 was on hourly monitoring and whenever the resident would have suicidal ideation, staff would send the resident out right away. If R1 was having suicidal ideation, I would expect that staff would contact the Provider and remain with the resident until R1 could be sent out. I was not contacted about suicidal ideation on [DATE]. On [DATE] at 3:15pm V9 (Physician) stated R1 would sometimes make threats and want to go to the hospital. R1 would be sent out to the hospital and sent back to the facility. I was not notified of suicidal ideation on [DATE]. Residents with suicidal ideation should be assessed for a plan and intent, every single time, and hospitalized with any uneasiness. The hospital is where the resident can be monitored more closely. In my history, anytime a resident has suicidal ideation, they are checked on frequently to make sure that there's no intent. Social Services, Psychiatrists, and Psychologists are all trained in assessing for intent and plan. Nurses should be trained to take it seriously. Even if it happens 1000 times, you must take it seriously every single time. Suicidal ideation can't be ignored. The Facility's Policy on Suicide Threats documents that resident threats of suicide must be reported immediately, and the resident's attending Physician should be notified. Staff will examine the resident and report findings to the attending Physician to seek further medical instruction. Residents maybe temporarily secluded in a safe environment and/or placed on observation by staff when there is a potential for danger. The care plan should be assessed to determine interventions to prevent the recurrence of such threats. The surveyor confirmed via observation, record review and interview facility did the following to remove the immediacy: Failure to Notify Physician: - All Nursing staff members have been educated and none were on vacation or a leave of absence. - By adding - Standards 1.e.promptly informing, among others, the residents Physician of an incident involving a resident with suicidal or homicidal ideations. - Nursing Staff education was completed on [DATE]. All Nursing staff members have been educated and none were on vacation or a leave of absence. Failure to take threats seriously and failure to have an effective monitoring system in place: - The Suicide Risk Observations include a verbal interview with the resident identifying his/her history of suicide attempts, any history of self-injurious behavior and any suicidal ideations/plans. Observation includes a rating system of High Risk, Moderate Risk, Low Risk and No History. - The Facilities Electronic Medical Record program is called MatrixCare. There are no Assessments in the MatrixCare program. Within the system of MatrixCare, the term Observation is intended to be synonymous with an assessment. - Those residents will also have follow-up visits, on at least a monthly basis, with the Psychiatric Nurse Practitioner for follow-up sessions which include conversations with the residents assessing them for having suicidal thoughts or ideations, having a plan and/or intent with which to implement those thoughts, being a danger to themselves or others and assessing whether they are mentally/emotionally stable or if they need a higher level of care or need an adjustment of their treatment plan and/or medications. A resident who indicated that they had a suicidal ideation or attempt within the past 12 (twelve) months would be monitored on a daily basis; a resident who indicated that they had a suicidal ideation or attempt within the past 36 (thirty-six) months would be monitored on a weekly basis; while residents who indicate that they had a suicidal ideation or attempt past 36 (thirty six) months would be monitored on a monthly basis. - Monitoring would consist of interviewing the resident and asking how they are feeling and if they are having thoughts or desires to hurt or harm themselves. - After the updated Suicide Risk Observations were completed for all residents, one resident was appropriate for daily monitoring; one resident was appropriate for weekly monitoring; and three residents were appropriate for monthly monitoring. Results of the Suicide Risk Observations were also reviewed and discussed with the Psychiatric Nurse Practioner. who approved of the monitoring plan and frequency. - Room checks continue daily performed by the Inter-Disciplinary Team. Contraband items include, but are not limited to scissors, sharp objects, can openers, lighters, extension cords etc. - When a resident exhibits any suicidal ideations, they will be placed on a 1:1 supervision until Physician is made aware of behavior. After physician is notified of the behavior Facility Nursing Staff will follow and implement the Physician's recommendations. - Suicide Risk Observations and any necessary follow up (follow up with Psychiatrist or Psychiatrist N.P.), will be completed upon initial admission for new residents, upon re-admission, on a quarterly basis as well as on an as needed basis. - Psycho-Therapy sessions are being held on a weekly basis to address resident's psychological needs. Psychiatric evaluations and follow-ups are being held monthly or more frequently based on the resident's needs. - All residents scoring low, moderate, or high on their Suicide Risk Observation will additionally be reviewed monthly at the Facility's QAPI Meeting. - An Emergency Quality Assurance Performance Improvement meeting was held on [DATE] with all members of the Inter-Disciplinary Team as well as the Medical Director. During the meeting the Psychiatrist and Psychiatrist's F.N.P. were also called. All facets of the Facilities response to the incident were reviewed and approved by the both the Medical Director as well as the Psychiatrist. Facility QAPI Committee will continue to meet on a monthly basis and will include review of incident for a minimum of three (3) months and on an as needed basis, thereafter, determined by the QAPI Committee.

Based upon observation, interview, and record review, the facility failed to provide adequate supervision in the dining room, failed to ensure that staff are aware of fall prevention interventions, and failed to implement fall prevention interventions for two of three residents (R1, R2) in the sample. These failures resulted in R1's fall with injuries including hematoma and laceration requiring adhesive repair. Findings include; 1.) R1's [DIAGNOSES REDACTED]. R1's (3/5/19) care plan includes risk for falls, preventive interventions include, but not limited to; assist resident to stay in common areas during waking hours. R1's progress notes include; (2/3/20) 9:50am, upon entering resident's room observed resident lying face down on floor at the foot of her bed. Upon assessment writer observed blood coming from (R1's) forehead. R1's (2/3/20) head CT (Computed Tomography) includes small right frontal scalp hematoma. R1's (2/3/20) history & physical states patient was found to have a laceration on the front of her head which was repaired. Repair method: tissue adhesive. On 2/24/20 at 11:15am, V4 (Certified Nursing Assistant) affirmed she was aware that R1 recently fell in her room. Surveyor inquired about R1's fall prevention interventions. V4 responded As I know of, she doesn't have any. No side rails and no floor mats cause she can move. Surveyor inquired again about R1's fall prevention interventions. V5 (Certified Nursing Assistant Supervisor) inspected R1's care card and affirmed she requires staff assistance with ADL (Activities of Daily Living) care, however, fall prevention interventions (chair/bed alarm, floor mats, bed bolsters) were not inclusive and/or verbally stated. On 2/26/20 at 1:57pm, surveyor inquired about the potential harm to a dependent resident found lying face down on the floor. V19 (Medical Director) stated, A small abrasion to a bone fracture anything can happen. 2.) R2's [DIAGNOSES REDACTED]. The (9/1/19-2/24/20) fall log affirms R2 fell on the following dates: 9/7/19, [DATE] and 2/15/20. R2's (9/7/19) charge nurse fall investigation states resident was In dining room unattended. R2's (1/31/16) care plan includes potential for falls, preventive interventions include but not limited to; keep frequently used items in reach and for staff to answer light promptly. On 2/24/20 at 10:45am, R2 was in the dining room with 34 additional residents. V6 (Activities) was the only staff providing supervision. On 2/24/20 at 10:47am, V5 (Certified Nursing Assistant) placed R2 in the middle of her room (via wheelchair) and then left the room. R2's call light was observed on top of her bed not within reach. At approximately 10:56am, V2 (Director of Nursing) entered R2's room. Surveyor inquired about the location of R2's call light. V2 stated, It still was on the bed. The call light is not in reach. On 2/24/20 at 12:48pm, V7 (Family) voiced concerns regarding lack of staff in the dining room and resident falls. V7 stated she's witnessed a resident on the floor and staff were unaware. On 2/25/20 at 11:29am, R2 was in the dining room with 36 additional residents. V6 was again the only staff providing supervision. V6 stated, I'm pretty much here by myself. Surveyor inquired if all residents currently in the dining room could be seen while standing in one location. V6 responded No. Surveyor inquired if any residents have fallen while supervising the dining room. V6 replied, Not recently but it has happened. The fall prevention program (revised 08/08) states it is the policy to have a fall prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Based on interviews and record review, the facility failed to supervise R1 during personal care to prevent a fall, and failed to follow the MDS (Minimum Data Set) assessment utilizing a (2) person assist while providing care at the bedside. This failure resulted in R1 being left alone in bed during care and falling to the floor, sustaining an injury to the head. R1 was transferred to the local hospital and diagnosed with [REDACTED]. Findings Include: R1 is [AGE] years old, admitted to the facility on [DATE]. BIMS (Brief Mental Status) was 7/15. R1 is not able to make needs known and is totally dependent, requiring a 2+ person assist from staff for all ADLs (Activities of Daily Living). Diagnosis: [REDACTED]. Hospital Record: (MONTH) 27, 2019 at 3:39 pm - Seen in Emergency Department Chief Complaint - FALL, Your Diagnosis - Head Injury, A Fall requiring 6 sutures Facility Incident Report: Initial and Final report faxed to Illinois Department of Public Health (IDPH). Initial Incident Report: 09/27/19 at 1:35 pm, R1 noted on floor with open area to left side of forehead. Pain assessed, PRN pain medication given. R1 was sent to the emergency room (ER) for further evaluation. Final Incident Report: 10/04/19 at 7:22 pm, Interviews were conducted per investigation, E1 is identified as V6 (Certified Nursing Assistant - CNA) for this investigation was questioned about the fall. V6 stated that while care was being rendered to R1, V6 walked away to the sink, at that time R1 was in the center of the bed with the bed in lowest position. V6 stated while V6 was at the sink for a short period of time, R1 rolled out the bed. E2 identified as V8 (Nurse) for this investigation: When I was called to R1's room, R1 was noted on the floor and I began to assess R1. (R1) was sent to the hospital and returned with (6) stitches to the forehead, orders in place and being carried out. Review of Annual MDS dated - (MONTH) 7, 2019, Section G (Functional Status) scored R1 as followed: Self Performance Code (4) =Total Dependence, full staff performance every time during entire 7 day period. Code (3) = Extensive Assistance, resident involved in activity, staff provide weight-bearing support ADL Support Provided, R1 scored a 3 = Two + person physical assist. Bed Mobility = 3/3, Transfer = 3/3, Dressing = 3/3, Toilet Use = 3/3, Personal Hygiene = 3/2, Bathing= 4/3 Review of Quarterly MDS dated [DATE] = Bed Mobility = 3/3, Transfer = 3/3, Dressing = 4/3, Toilet Use = 3/3, Personal Hygiene = 4/2, Bathing= 4/3. Review of Care Plan revised on 07/09/19 and 10/08/19 - R1 is at risk for falls, R1 has a transfer/mobility impairment related [MEDICAL CONDITIONS]. Muscle weakness and impaired balance. Transfer - Mechanical Lift, dependent on two person staff assist. R1 is dependent on staff for Most ADL care. Review of Personal Care Chart for Resident (R1) - Transfers = Dependent x 2 Staff, Dressing, Toileting, Bed Mobility, Grooming and Bathing are all marked as Total Assist x 2 staff. During a face to face interview with V6 (CNA) on 10/22/19 at 2:15 pm, Surveyor asked V6 what happened on 7/9/19 that caused R1 to fall out of bed, sustaining an injury to the head. V6 said, Myself and another CNA (V7) helped me transfer my resident R1 to bed. V7 left the room to take care of V7's own residents. I was giving R1 care, I went over to the sink and before I could turn around good, R1 had fallen to the floor. I was at the sink trying to clean R1 up. I called for the nurse to come, V8 (nurse) came into the room to assess R1. Surveyor asked V6 if she was the only one in the room at the time V6 fell out of the bed onto the floor. V6 stated, Yes I was the only one when it happened. Two phone attempts were made to speak with V7 (CNA) on 10/22/19 at 2:20 pm and 2:50 pm; surveyor left voice mail messages; V7 did not return surveyor's call. During a phone interview with V8 (nurse) on 10/23/19 at 2:20 pm, V8 was asked if V8 was in the room when R1 fell out of bed onto the floor. V8 stated I was called to R1's room, when I arrived R1 was on the floor. V6 was in the room when I arrived, she said she was providing care, she walked over to the sink and R1 fell out of bed. I assessed R1 who was laying on the floor on the left side bleeding from the head. I cleaned and applied steri strips and went to call the doctor. R1 went to the hospital and received 6 sutures to the head. Review of Progress Note: dated 9/27/19 - Resident rolled out of bed looking for staff member whom had stepped to the sink to moisten towel for patient care, resulting in a laceration to the left side of forehead, with moderate bleeding, pressure applied, steri strips. Paramedics called for transfer to the local emergency room for evaluation, family notified. Physician Interview: Two telephone attempts were made to contact V4 (Physician), messages were left with no return call back. Facility's Policy: Falls Clinical Protocol was reviewed, # 5. Staff will document risk factors for falling and document when and where it happened, any observations of the event. On 10/29/19 at 11:00 am, during a face to face interview with V1 (Administrator), surveyor asked V1 for a policy and procedure related to fall prevention, not a post fall policy. V1 stated the policy given was the only fall policy they had.

Based on observation, interview, and record review the facility failed to perform a safe mechanical lift transfer according to the manufacture's instruction, ensuring arms were inside the lift sling, for 1 of 3 residents (R1) reviewed for reportable injuries in the sample of 3. As a result R1's left forearm became wedged underneath the wheelchair armrest while being raised by the lift, caused a jagged laceration measuring 5 centimeters (cm) long and 1.5 cm deep, and required transfer to the hospital for 7 stitches. Findings include: On 6/2/15 at 2:25pm, E4(Nurse) changed the dressing to R1's left forearm. R1 has a 5 cm jagged laceration with 7 stitches to the top of the left forearm approximately 3 cm above the wrist area. On 6/2/15 at 3:05pm, E10(Nurse Aide) and E11(Nurse Aide) transferred R1 from the wheelchair to the bed using a mechanical lift. E11 instructed R1 to cross arms across her chest. R1 followed E11's directions without hesitation or reminders to keep them there. Face sheet documents R1 was admitted to the facility on [DATE] and readmitted on [DATE]. Initial Incident Report 5/28/15 2:22pm, documents R1 was noted with a skin tear to the left arm and an investigation is in progress. This initial report was faxed to the Illinois Department of Public Health on 5/28/15 at 2:09pm. Skin Integrity Event 5/18/15 documents R1 sustained a deep laceration to the left wrist measuring 3 x 0.5 cm, steri-strips were applied for a moderate amount of bleeding, the wound edges are irregular, R1 complains of moderate pain, and the physician was notified immediately for the large or deep skin tear/laceration with jagged edges needing sutures. Pain Observation 5/28/15 documents R1 complains of pain to a laceration on the left wrist. Hospital Transfer Form 5/28/15 documents R1 was transferred to the hospital after sustaining a laceration on the left arm above the wrist from hitting arm on metal wheelchair during transfer from wheelchair to bed. Hospital emergency room records 5/28/15 document R1 sustained a laceration to the left forearm while being transferred from a wheelchair to the bed, cutting the forearm on metal on the wheelchair. Physical Examination picture documents a 1.5 cm laceration through skin and subcutaneous fat, muscle visible, fascia intact, wound margins serrated in many spots, laceration length 5 cm. Hospital Discharge Instructions 5/28/15 document 7 sutures to be removed in 10-14 days. Final Incident Investigation 5/29/15 and faxed at 6:49pm, documents R1 sustained a laceration to the left forearm, physician and family were notified, first aid was given, and R1 was sent to the hospital. Staff interviews revealed R1 was being transferred from the wheelchair to the bed with a mechanical lift, as R1 was being transferred with the mechanical lift and being raised, R1 grabbed the arm of the wheelchair and sustained a laceration to the left arm. R1's room and resident care equipment was assessed for hazard none observed. Employee In-service 5/29/15 documents E3(Nurse Aide) reviewed proper mechanical lift process and need for safe practices, return demonstration during the day while providing patient care. The investigation contains the initial and final report as described above, an unsigned statement on 5/28/15 from E4(Nurse) that E3 stated the laceration occurred when E3 transferred R1 from the wheelchair to the bed, and the care plan and E3 in service as described above. On 6/2/15 at 11:35am, E3 stated on 5/28/15, R1's was being transferred from the wheelchair to the bed with E9(Nurse Aide) using a mechanical lift. R1's arm got stuck between the metal partition and underneath the armrest and R1 said Don't break my arm and Ouch! E3 stated the transfer continued and once R1 was in bed, E3 noticed something oozing onto R1's left shirt sleeve. E3 applied pressure and instructed E9 to inform E4. On 6/2/15 at 11:55am, E2(Director of Nursing) stated that while R1 was being transferred from the wheelchair to the bed using a mechanical lift, R1 reached out for the wheelchair and sustained a cut to the left forearm. The wheelchair was inspected and nothing sharp was found that could have cut R1's arm, and do not know how it happened. E3 was inserviced that residents' arms need to be inside the sling during mechanical lift transfers. On 6/2/15 at 2:45pm, E5(Restorative Nurse) stated E2 asked her to check R1's wheelchair for sharp edges that could have caused the laceration. E5 stated nothing sharp was found on R1's wheelchair that could have caused the laceration. On 6/2/15 at 2:50pm, Z1(Physician) stated the facility notified him that R1 sustained a laceration to the left forearm during a transfer from the wheelchair back to bed. R1 has fragile skin and it would not take a lot of force to break the skin when it comes in contact with metal. Z1 stated R1's laceration was jagged and not a smooth cut, caused from the force of pressure of something hard against the skin. The incident could have been avoided by using additional help to keep R1's arms inside the sling, stopping the transfer, or check on R1's position in the lift. On 6/4/15 at 9:20am by phone, E3 stated when R1 stated to not break her arm, E3 stopped the transfer, placed R1's left arm back inside the mechanical lift sling, and started to raise R1 again using the mechanical lift. When asked why E3 was stating something different today from 6/2/15, E3 stated I had to think twice about what happened. E3 stated he spoke with E1(Administrator), E2, and Z2(Consultant) on 6/3/15 and E1 and Z2 wanted to make sure what happened really happened on 5/28/15. E3 stated R1 had a habit of reaching for things and it is E3's responsibility to make sure a resident's arms and legs are inside the mechanical lift sling during transfers. E3 stated E2 re-educated him on 5/29/15 on the proper and safe use of a mechanical lift, including keeping all body parts inside the cling during the transfer process. On 6/4/15 at 10:30am, E9 stated she did not see what happened when R1 yelled about her arm during the mechanical lift transfer. E9 stated the role of the second nurse aide during a mechanical lift transfer is to guide the sling carrying the resident, make sure the equipment is working and the patient is safe. One aide pushes the lift while the other guides the sling with the resident in it. On 6/4/15 at 11:50am, E3 returned to the facility to demonstrate how R1's arm was positioned in relation to the wheelchair at the time of the injury on 5/28/15. E3 placed the left inside forearm with the left thumb facing upwards flush to the outside of the wheelchair at the level of the space between the upright metal partition and the underneath part of the armrest. E3 stated as the mechanical lift raised R1, R1's left forearm got wedged or stuck underneath the metal part of the armrest, applying pressure to R1's forearm. Manufacture documents for using a portable mechanical lift - To put the resident back to bed, you should instruct the resident to fold both arms over his or her chest.

Based on observation, interview and record review, the facility failed to provide 2 person assist while rendering care for 1 of 5 residents (R9) reviewed for bed mobility and falls in the sample of 16 residents. The facility alos failed to develop and implement fall risk intervientions for 1 of 5 residents (R15) reviewed for falls in a sample of 16. This failure resulted in R9's falling out of bed during care resulting in hospitalization for hip fracture and hip surgery. Findings include: On 7/15/14 at 10am, R9 was observed in bed. On 7/16/14 at 10am, two staff members repositioned and turned R9. R9 was not able to turn herself. On 7/16/14 at 10am, R9 stated that she cannot remember what happened on 5/22/14 when she fell out of bed. R9's MDS (Minimum Data Sheet) dated 5/11/14 reads active [DIAGNOSES REDACTED]. On 7/15/14 at 2:50pm, E21 (CNA) stated that she witnessed R9 fall off the side of her bed onto the floor on 5/22/14. E21 stated that on 5/22/14, she knocked on R9's door. E21 asked E28 (CNA) if she needed any help with R9. E28 said no and stated she was almost finished with R9's care. E21 stated that R9 was undressed in bed and turned on her side facing the door. E21 stated that she went into R9's room and started washing her hands to assist E28. E21 stated that E28 went to the window side of R9's bed to continue cleaning and changing the pad underneath R9. When E21 turned around after washing her hands, she witnessed R9 falling off the side of her bed and onto the floor. R9's clinical notes dated 5/22/14 at 3:44pm read staff called to R9's room by attending CNA. R9 was observed on the floor. R9's clinical notes dated 5/22/14 at 4:06pm read R9 now stating that her bilateral knees hurt. R9's clinical notes dated 5/22/14 at 5:59pm read R9 complained of increased pain. On 5/22/14 at 6:18pm, x-rays of bilateral knees were ordered. On 5/22/14 at 11:23pm, x-rays were completed. On 5/23/14 at 9:45am, R9 was sent to the hospital. X-ray results revealed an impacted slightly oblique fracture of the distal shaft of the right femur with no significant displacement. R9 had hip surgery and returned to the facility on [DATE]. R9's MDS (Minimum Data Sheet) dated 5/11/14 reads Section G. Functional Status - Bed mobility - self performance extensive assist (3) and two person physical assist (3). The coding on the MDS for ADL (Activity of Daily Living) support provided is the following: 0 means no set up or physical help from staff, 1 means setup only, 2 means one person physical assist and 3 means two person physical assist. The facility failed to have 2 persons physically assist with R9's bed mobility on 5/22/14 when R9 fell off the side of her bed onto the floor. R9's care plan dated 4/14/2014 reads Injury/Potential for fall related injury related to: [DIAGNOSES REDACTED]. The goal is R9 will not sustain any severe fall related injury through the next review period. The approaches dated 4/14/2014 read assist with positioning in bed and chair for comfort and safety, frequent safety checks, cues and reminders and maintain a safe environment. The facility failed to meet the goal of R9 not sustaining any severe fall related injury. The facility failed to assist R9 safely with positioning on 5/22/14 when R9 fell off the side of her bed onto the floor. Facility's Investigation Report dated 2/8/14 shows R15 sustained a fall while performing a pivot transfer with the assist of a certified nurses aid (CNA). During the transfer from bed to wheelchair, R15 fell backwards onto the floor, sustaining a laceration to the back of her head and was sent out to the emergency room for treatment. R15's Minimum Data Set Section G0110, Activities of Daily Living, dated 11/18/13 shows R15 requires extensive (2 persons) assistance with transfers and requires 1 person assist with locomotion via wheelchair. Facility's Safe Lifting and Movement of Residents policy dated August, 2008 states"Mechanical lifting devices shall be used for any resident needing a two person assist." Care Plan dated 3/8/12 states R15 is at risk for falls with identified risk factors of history of falls, left arm contracture, history of polio[DIAGNOSES REDACTED], mental retardation and seizures. Care Plan dated 10/31/13 states R15's transfer status was changed from 'pivot' to 'stand lift.' Most recent fall risk assessment dated [DATE] shows R15 is at high risk for falls. On 7/17/14 at approximately 10:40am, R15 was in the dining/activity room sitting in a special wheelchair. The room was dimly lit as residents were engaged in watching movies. R15's wheelchair was observed to be unlocked and the chair was rolling freely back and forth. There was no tab alarm on R15's chair. There were several staff members present in the room during this observation. E19 (Nurse) was closest to R15, looked at R15 and stated she was not sure whether R15 requires use of chair alarm. E19 left the room to review R15's clinical record and later stated that R15 does not require use of chair alarm. R15's unlocked wheelchair was not addressed by staff. E2 (Director of Nursing - DON) stated on 7/17/14 at approximately 10:50am that the facility does not have a protocol for fall prevention intervention because interventions are individualized based on residents' needs. E2 confirmed that use of chair alarm for R15 is not part of her (R15) fall prevention interventions. E20 (Restorative Nurse) stated on 7/17/14 at approximately 11:20am that fall prevention interventions are developed by an interdisciplinary team based on residents' individual assessment. E20 went on to say that R15 is able to lock and unlock her own wheelchair and able to locomote independently on the unit. According to E20, R15 may have difficulty locking the left wheel of her chair due to left arm/hand contracture and requires supervision to ensure chair is properly locked.

Based on observation, interview and record review the facility failed to perform skin assessments and provide skin care in a timely manner for 1 of 3 residents (R4) reviewed for pressure sores in the sample of 14. This failure resulted in a worsening sacral pressure sore and the development of a new area of skin breakdown. Findings include: Admission record documents R4 was admitted on [DATE]. Skin Observation 12/4/12 documents R4 has a sacral pressure sore measuring 0.5x0.5x0.2 centimeters (cm). On 12/5/12 from 10:40am-2pm, in 10-15 minute intervals, R4 was in the dining room sitting in a reclining chair with a lift sling underneath her. R4 was not turned, repositioned, checked for incontinence, or changed during this time frame. At 2pm, R4 was brought back to the room and transferred into bed with the lift. E6 and E7 (Nurse Aides) removed R4's incontinent brief and it was saturated with urine and full of a large loose stool. The dressings to the sacrum and left buttocks were visibly soiled with both moist and dried stool and were falling off R4's skin. There was moist and dried stool to the areas of skin breakdown. E4 (Nurse Aide) stated R4 was last changed at 10am. On 12/5/12 E3 (Treatment Nurse) measured the sacral pressure sore as 3x1.4x0.1cm, an increase in size from 0.5x0.5x0.2 cm on 12/4/12 , a wound to the left upper posterior thigh discovered on 11/27/12 does not have any previous measurements, measured 2x1x0.1cm, and a new area of skin breakdown to the left buttock measures 2x1.5x0.2 cm. Admission Braden scale 10/24/12 scores R4 as mild risk for skin breakdown. The next Braden scale is completed on 12/5/12 now scores R4 as high risk for skin break down. 10/20/12 MDS section G functional status rates R4 as needing extensive assistance with personal hygiene and section H bladder and bowel rates R4 as always incontinent of bowel and bladder. The current care plan does not address incontinence. The wound care plan documents "keep the area clean and dry" but does not document turning and repositioning, pressure relief, or other interventions for the care and treatment of [REDACTED]." On 12/5/12 at 3:30pm, E2(Director of Nursing) stated the staff should be rounding and checking residents for incontinence and toileting every 2 hours. If residents are wet, change them. If there is already a wound, check the resident more frequently than every 2 hours. On 12/6/12 at 12:15pm, E3 (Treatment Nurse) stated Braden Assessments are done on admission and then weekly for 4 weeks, or if there is new breakdown or a worsening wound. E3 did not know why there are no weekly Braden Assessments between admit on 10/24/12 and 12/5/12, or why there is no Braden assessment on 11/27/12 with the discovery of a wound to R4's left upper posterior thigh. E3 stated there are no initial measurements for the wound on R4's left upper posterior thigh, "I didn't measure it, I don't know if it is getting worse." On 12/8/12 at 12:30pm, by phone interview, Z1(Physician) stated that not turning and repositioning R4, not keeping the skin clean and dry, and R4 sitting in urine and stool has contributed to the worsening sacral pressure sore and the new area of breakdown on the left buttock. Z1 stated R4's sacral wound was healing. "They should have been watching (R4) closer, more than every 2 hours. If they were doing all the protocols as they should, the stability of the skin would be OK. If the wounds get worse or there is new breakdown, they did not follow the protocols and that cause the skin to get worse." Policy Pressure Ulcer and Wound Prevention Management Program documents 7.c) care plan interventions ae individualized to the residents condition/situation to prevent the development of an ulcer, or if present, for the care and treatment of [REDACTED]. Policy Prevention of Pressure Ulcers documents general preventive measures for a person in a chair is to change position at least every hour. Risk factors include moisture and the resident should be placed on a minimum of an every 2 hour check and change program, chairfast residents that are unable to change own position should have their position changed at least every hour, residents incontinent of bowel and bladder should be check for incontinence at least every 2 hours and clean skin when soiled, and use the Braden Risk Assessment Form and Intervention Preventive Measures (Appendix A) to asses skin and pressure ulcer risk. Policy Support Surface Guidelines documents to reposition residents who are in a chair at least every hour and for residents who depend on staff for repositioning, change position at least every 2 hours. Policy Intervention Prevention Measures (Appendix A) documents interventions for residents at high risk for pressure ulcers are toilet/inspect resident at least every 2 hours, residents with an ulcer should not sit up in the chair for more than 1 hour and not more than 2 hours if no ulcer present.