Every finding on record at Wentworth Rehab & HCC

Based on observation, interview and record review, the facility failed to prevent, identify, report and treat a new pressure ulcer wound for one resident (R1) who assessed at risk for developing pressure ulcers in the sample of 3 residents reviewed for pressure ulcer prevention. Findings include:On 12/5/2025 at 10:14 AM, R1 observed in bed with a gown, covered with a blanket. R1 stated that R1 prefers to stay in bed and does not like to be up in R1's wheelchair. R1 stated that R1 does have a bed sore on (R1's) butt, and R1 needs help to from staff to change R1's incontinence brief and turn in bed. R1 agreed to this surveyor's request for a skin check. On 12/5/2025 at 10:34 AM, V5 (Certified Nursing Assistant, CNA) is in R1's room and confirmed that V5 is the CNA for R1. V5 pulls back the blanket and unfastens R1's incontinence brief. V5 crosses R1's legs and log rolls R1 to the left side as R1's reaching over with upper body to hold onto the bed siderail. V5 pulled back the incontinence brief from R1's buttocks showing white barrier cream on R1's sacrum and perineum. This surveyor observed an open skin area on the sacrum, approximately 2 by 2 inches, with epidermis (top skin layer) opened with the red wound base visibly noted. V5 stated that there is no dressing on it, and V5, as the CNA, just puts the white barrier cream over R1's open sacral wound after V5 cleans R1. On 12/5/2025 at 10:43 AM, this surveyor stepped out of R1's room into the hallway, and V8 (Licensed Practical Nurse, LPN) was present. When asked if R1 has an identified wound or is being seen by the wound care team, R1 stated no. On 12/5/2025 at 10:45 AM, V3 (Assistant Director of Nursing, ADON) is observed on R1's floor. When asked if R1 has a pressure ulcer wound or is being seen by the wound care team, V3 stated that V3 doesn't believe that R1 has a wound and will check V3's laptop to confirm. This surveyor and V3 go to nurses' station where V3 looks in the electronic health record (EHR) for R1, and V3 states that R1 has no skin openings and is receiving barrier cream for prevention of wounds.R1's admission Record documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, heart failure, history of falling, sciatica, fibromyalgia, hypertension, hypercholesterolemia, sleep apnea, visual disturbance, weakness, conversion disorder with seizures or convulsions, pain, and long-term use of aspirin.R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 12 which indicates that R1 has moderate cognitive impairment. R1's Behavior is assessed with no rejection of care or other behaviors. R1's Functional Abilities for bed mobility (rolling left and right) is assessed substantial/maximal assistance where the staff perform more than half of the effort in rolling R1 from side to side in bed. R1's Skin Conditions are assessed with R1 at risk for developing pressure ulcers/injuries, and R1 has zero (0) unhealed pressure ulcers/injuries, venous and arterial ulcers or other ulcers, wounds or skin problems. On 12/5/2025 at 2:34 PM, V5 (CNA) stated that V5 works different floors in the facility but, when V5 works on R1's floor, R1 is V5's regularly assigned resident. V5 stated that R1 is alert, oriented and does not have bouts of confusion. V5 stated that R1 is a one person assist for bed mobility and a two-person, mechanical transfer lift out of bed. V5 stated that V5 assesses R1's skin whenever V5 is performing incontinence care or bathing of R1. V5 stated that if V5 sees a new skin opening on a resident, V5 must report it right away to the nurse. This surveyor asked V5 that with the observation of this surveyor and V5 viewing R1's sacral pressure ulcer wound with barrier cream on it (on 12/5/2025 at 10:34 AM), was this the first time that V5 had seen R1's sacral wound, and V5 stated no. V5 stated that V5 saw R1's open sacral wound yesterday (12/4/2025) with the white barrier cream on it and reported it to the nurse. V5 stated that V5 forgot the name of the nurse, but R1's sacral skin was open and there was white cream over it on 12/4/2025. V5 reiterated again that V5 could not recall who the nurse was that V5 reported R1's sacral wound to on 12/4/2025. This surveyor informed V5 that surveyor will identify the nurse working with R1 on 12/4/2025 and speak with the nurse about V5 reporting R1's sacral pressure ulcer wound. V5 then stated that V5 did not report it to the nurse and V5 doesn't want to be lying. V5 stated that when V5 saw R1's sacral open wound on 12/4/2025 with barrier cream on it, V5 stated, I (V5) assumed that someone had reported it to the nurse, and V5 did not report R1's sacral skin opening. On 12/5/2025 at 2:27 PM, V8 (LPN) stated that V8 works different floors in the facility but, when V8 works on R1's floor, R1 is V5's regularly assigned resident. V8 stated that skin assessments are done weekly by the nurse, and they are done daily by the CNA during incontinence care and bathing care. V8 stated that if a CNA finds anything abnormal with the resident's skin, the CNA must report it right away to the nurse. V8 stated it could be a red spot on the skin, skin turgor being poor or any opening in the skin. V8 stated that the importance of the direct care staff (CNAs) reporting it to the nurse is so the nurse can follow up immediately before it gets worse. V8 stated that the nurse will contact the wound care team and the doctor so they will start treatment as ordered. V8 stated that the staff does not want the skin opening to advance any further if untreated. V8 stated that general precautions to prevent pressure ulcer wounds from forming are to turning and offloading so pressure is relieved on the body from being in one position for too long. When asked prior to today, 12/5/2025, had it been reported to V8 that R1 had a sacral pressure ulcer, V8 stated yes but that V8 can't remember the date or exactly what was said. V8 stated that if there is a new skin change, like an open pressure ulcer wound, reported to V8, V8 would document it in the resident's HER. This surveyor informed V8 that upon review of R1's progress notes and skin assessments prior to 12/5/2025, there is no documentation that R1 had a new skin opening. V8 then stated that V8 is really not sure yes or no if it was reported to V8 about R1's sacral pressure ulcer and that V8 just can't remember.On 12/5/2025 at 11:55 AM, V14 (LPN, Wound Care Nurse) stated that V14 was made aware today, 12/5/2025, of R1's open area to the sacrum and went and assessed R1. V14 stated that the sacral wound measured 4.8 centimeters (cm) in length, 3.8 cm in width, and 0.1 cm in depth with slight serosanguineous drainage, and is a stage 2 pressure ulcer. V14 stated that V14 notified R1's doctor who ordered for a cleansing with normal saline and a foam dressing with a daily and whenever needed change. V14 stated that the dry foam dressing will allow for urine or stool not to contaminate the wound.On 12/5/2025 at 3:18 PM, V15 (Wound Care Coordinator) stated that for when a new skin alteration is noted on a resident, the floor nurse is notified, and the floor nurse will then notify V15. V15 stated that V15 (or other wound care nurse, V14) will do a head to toe skin check. V15 stated that skin alterations can be breaks in the skin, rashes, or anything that looks abnormal or the resident did not have previously. V15 stated that the nurse will call the doctor to see what treatment needs to be in place. V15 stated that it's important to start this process immediately so there is not worsening skin problem want to skin intact not get any worse. V15 stated that CNAs are constantly looking at skin and must notify the floor nurse if there are changes in a resident's skin. V15 stated that R1's sacral pressure wound was not reported to V15 prior to 12/5/2025.On 12/5/2025 at 3:27 PM, V3 (Assistant Director of Nursing, ADON) stated that V2 (Director of Nursing) is currently on vacation and that V3 is responsible for the nursing department and staff. V3 stated that the importance of a CNA directly informing the floor nurse when a new skin opening is noted on a resident, like R1's sacral wound, is that it's extremely important because (skin) breakdown happens so fast. It's effective communication V3 stated that when a new skin opening is reported to the floor nurse, the floor nurse will notify the wound care coordinator (V15) who will perform a full head to toe assessment. V3 stated that the nurse will notify the doctor of the findings and receive treatment orders to be rendered. V3 stated that every day, CNAs are looking at residents' skin during activities of daily living care and bathing care and are a crucial component to identifying changes in a resident's skin condition. V3 stated that a foam dressing treatment order for a sacral pressure ulcer can protect the wound as it heals and help with pain as well. V3 stated that urine and feces can irritate or burn an open sacral pressure ulcer wound and also prevents sheering of the sacral skin. R1's WASA (Wound Area Severity Assessment) Form, effective 12/5/2025 at 11:36 am (after this surveyor's observation on 12/5/2025 of R1's sacral pressure ulcer), V14 (LPN, Wound Care Nurse) documents, in part, that R1 has a wound to the sacrum assessed as a pressure ulcer, stage 2 with size of 4.8 cm in length, 3.8 cm in width, and 0.1 cm in depth. R1's Shower/Bath Reports from November and December 2025 were reviewed with CNA documentation to the task question of during bath/shower, is there any new skin issues, and No New Skin Abnormality is documented on 12/4/2025, 11/30/2025, and 11/27/2025.R1's Progress Notes, from 8/22/2025 at 5:52 PM to 12/5/2025 at 11:15 AM, indicate no documentation of R1's sacral pressure ulcer (new skin opening). R1's Treatment Administration Record for December 2025 documents, in part, only one wound care treatment, dated 12/5/2025, for cleansing with normal saline and then apply a foam dressing adhesive 4 x 4 (4 inches by 4 inches) pad to sacral topically every day shift and whenever needed for wound care. R1's Braden Scale, dated 11/22/2025, documents, in part, that R1 is scored as 14 which indicates that R1 is at moderate risk of skin breakdown.R1's Care Plan, initiated 8/22/2025, documents, in part, a focus of R1 has potential for alteration in skin integrity with care. R1's Care Plan, initiated 8/23/2025, documents, in part, a focus of R1 requiring bowel and bladder support due to R1's bladder and bowel incontinence, decreased mobility, and CVA (cerebral vascular accident) with an intervention to: Check skin daily with cares. Report abnormalities or changes to the nurse.R1's Care Plan, initiated 8/23/2025, documents, in part, a focus of R1 has an ADL functional performance deficit where R1 is unable to turn and reposition self in bed without physical assistance from staff with interventions of assist R1 with check skin for changes during bathing and to assist R1 with ADL tasks as needed.R1's Turning and Repositioning Program Quarterly Review, dated 11/25/2025, V13 (Restorative Nurse, LPN) documents, in part, that there has been no change in R1's condition since last review and that turning and repositioning interventions have been effective at helping to manage or maintain R1's skin status. Facility policy titled Prevention and Treatment of Pressure Injury and Other Skin Alterations dated 3/2/2021 documents, in part, Policy: 1. Identify residents at risk for developing pressure injuries. 2. Identify the presence of pressure injuries and/or other skin alterations. 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Procedure: 1. Identify residents at risk for Developing pressure Injuries utilizing the Braden Scale . 3. Pressure injuries, Venous, Arterial, Diabetic ulcers and DTPI (Deep Tissue Pressure Injury) will be assessed weekly and as needed by facility staff or consulting clinician, by utilizing a WASA or other consulting clinicians' evaluation . 6. Complete a Comprehensive Pressure Injury Evaluation for identified pressure injuries . 8. At least daily, staff should remain alert for potential changes in the skin condition during resident care.

Based on interviews and record review, the facility failed to have a policy in place to assess one cognitively impaired resident's (R14) ability to consent to sex; failed to create a plan of care after becoming aware of R14's sexual activity; and failed to properly document visitation restrictions for a visitor suspected of financially abusing R14. This failure has the potential to affect 191 residents that reside at the facility. Findings include:R14 is [AGE] year old with diagnosis including but not limited to: Alzheimer's disease, moderate dementia, essential hypertension, type 2 diabetes mellitus without complications and benign prostatic hyperplasia with lower urinary tract symptoms. R14's BIMS (Brief Interview for Mental Status) dated 9/26/25 resulted in a score of 6, which indicates severe cognitive impairment. R14's BIMS (Brief Interview for Mental Status) dated 10/3/25 resulted in a score of 7, which indicates severe cognitive impairment. On 11/19/25 at 11:14 am, V1 (Administrator) stated the following, V18 (Memory Care Director) informed me that a CNA (Certified Nurse Assistant) had reported to her (V18), that R14 was observed in his room with his visitor (V20) without clothes and engaging in sexual intercourse sometime last month. V20 (R14's friend) is R14's longtime friend and has visited him in the past. However, we have banned V20 from visiting R14 at this time per R14's family request. V23 (R14's family) did not want V20 visiting R14 because she felt that there was some financial abuse going on.On 11/19/25 at 1:50 pm, V18 (Memory Care Director) stated the following, After the alleged sexual act, I assessed to see if (R14) was in distress. I also asked R14 about what happened and he (R14) stated that it was consensual sex. I (V18) did not complete any cognitive assessments or updates to care plan after the sexual incident. I am responsible for updating resident's care plans regarding cognition and sex. The facility doesn't have a Sexual Activity Assessment. I don't know who deemed R14 able to consent to sex. It was just based on a conversation that V1 and I (V18) had. I did report the incident to the administrator on 11/1/25 and V20 was banned from 11/1/25 through 11/19/25, until his (R14) checks started coming to the facility. The block was for safety reasons, for possible financial abuse. I (V18) didn't document that V20 was banned, I just added him to the list at the front desk. I didn't document the sexual incident that occurred on 11/1/25, but I had planned to document and forgot.On 11/19/25 at 12:45 pm, V2 (DON/ Director of Nursing) stated the following, Usually social services handle any resident that is banned from the building, and they post the list at the front desk. It could be documented underneath 'special instructions' in the resident's (R14) chart so that the nurses are aware that the person has a visitor restriction.On 11/20/2025 at 10:15 am, V25 (Security staff) stated the following, We have a list of people that are restricted from visiting. We don't ask everyone that visits residents for identification. When someone visits a resident on the restriction list, I ask for an ID (Identification Card) only if I am not familiar with that person. On 11/20/25 at 3:30 pm, V2 (DON) stated the following, V20 was restricted from visiting in the past but I don't know exactly when. His privileges were restricted a couple of times and reinstated after V18 spoke with R14's family (V23).On 11/24/25 at 12:15 pm, V28 (PMHNP/ Psychiatric Mental Health Nurse Practitioner) stated the following, In order to definitively measure a person's decision-making capabilities, a neuro-psych evaluation may be done. Anyone with Dementia has cognitive impairment that varies depending on the stage of dementia. At a stage 5 dementia, a person may not know where they are and are not in reality. It is obvious that they cannot consent to medical procedures, psychotropic medication, or make financial decisions on their own regarding paying bills. They would need a more in-depth assessment on their decision- making abilities.On 11/24/25 at 2:50 pm, V2 (DON/ Director of Nursing) stated the following, R14 has not had any neuro psychiatric evaluations as far as I know while he was here. We don't have an assessment to measure a resident's capability to consent to sex. Yes, a patient's care plan should be updated after observed having sexual intercourse in his room with a male visitor.On 11/24/25 at 2:25 pm, V1 (Administrator) stated the following, We do not have Sexual Assessment forms that I know of. I would expect for the sexual act between R14 and V20 to be documented. If someone is restricted from the facility. It is expected that staff document the ban in the resident's chart and at the front desk and nurse's stations.R14's Care Plan dated 10/03/25 documents, R14 is at risk for abuse related to cognitive impairment and diagnosis of dementia; R14 has an ADL (Activity of Daily Living) Functional deficit related to dementia, impaired cognition, incomplete performances and periods of confusion. R14's Memory Care Initial assessment dated [DATE] documents the following; R14 is only oriented to person (knows self); R14 is not oriented to place, time or situation (does not know where he is, does not know why he is here, and does not know the current day/ month); R14 has short-term and long-term memory problems.R14's Care Plan and Memory Care Assessments were last updated on 10/03/2025.The Initial Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.R14's Physician Order Sheet, Care Plan, Face sheet, and Medical Record exclude any orders regarding V20's visitation restrictions.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the facility will report reasonable suspicion of a crime; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences.Facility Abuse policy excludes verbiage related to assessing the sexual activity or capacity for sexual consent in residents with cognitive impairment. Facility Visitation policy documents, the facility permits visitation at all times and will not restrict visitation without a reasonable clinical necessity or safety restriction.Facility Visitation policy excludes any protocol or required documentation regarding visitors' restrictions and abuse.

Based on interviews and record review, the facility failed to report allegations of sexual and financial abuse involving one resident R14. This failure has the potential to affect 191 residents that reside at the facility.Based on interviews and record review, the facility failed to report allegations of sexual and financial abuse involving one resident R14. This failure has the potential to affect 191 residents that reside at the facility.Findings include:R14 is [AGE] year old with diagnosis including but not limited to: Alzheimer's disease, moderate dementia, essential hypertension, type 2 diabetes mellitus without complications and benign prostatic hyperplasia with lower urinary tract symptoms. R14's BIMS (Brief Interview for Mental Status) dated 10/3/25 resulted in a score of 7, which indicates severe cognitive impairment. On 11/19/25 at 11:14 am, V1 (Administrator) stated the following, V18 (Memory Care Director) informed me that a CNA (Certified Nurse Assistant) had reported to her (V18), that R14 was observed in his room with his visitor (V20) without clothes and engaging in sexual intercourse sometime last month. We did our investigation by asking R14 if he consented to the sexual act and he said yes. Just because he (R14) has dementia doesn't mean that he lost his desire to have sex. However, we have banned V20 from visiting R14 at this time per R14's family request. V23 (R14's family) did not want V20 visiting R14 because she felt that there was some financial abuse going on. On 11/19/25 at 1:50 pm, V18 (Memory Care Director) stated the following, After the alleged sexual act, I assessed to see if (R14) was in distress. I also asked R14 about what happened and he (R14) stated that it was consensual sex. I notified V1 via telephone about the sexual incident, also that R14's family (V23) was concerned about possible financial abuse. R14's family had made me aware on 11/1/25, that she was concerned with V20 possibly taking advantage of R14 and receiving money from him. V20 was restricted from visiting R14. The block was for safety reasons, for possible financial abuse. I (V18) didn't document that V20 was banned, I just added him to the list at the front desk. I didn't document the sexual incident that occurred on 11/1/25, but I had planned to document and forgot.On 11/24/25 at 2:25 pm, V1 (Administrator) stated the following, I did not report the incident between R14 and his friend (V20) because he (R14) stated that the sex was consensual. I didn't report the suspected financial abuse because V20's visiting privileges were banned.R14's Care Plan dated 10/03/25 documents, R14 is at risk for abuse related to cognitive impairment and diagnosis of dementia; R14 has an ADL (Activity of Daily Living) Functional deficit related to dementia, impaired cognition, incomplete performances and periods of confusion. The Initial Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.Facility Census dated 11/17/25 documents 191 residents.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the facility will report reasonable suspicion of a crime; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; filing accurate and timely investigative reports.

Based on interviews and record review, the facility failed to conduct investigations for allegations of financial and sexual abuse for one resident R14 in a sample of five reviewed for abuse. This failure has the potential to affect 191 residents that reside at the facility.Findings include:R14 is [AGE] year-old with diagnosis including but not limited to: Alzheimer's disease, moderate dementia, essential hypertension, type 2 diabetes mellitus without complications and benign prostatic hyperplasia with lower urinary tract symptoms. R14's BIMS (Brief Interview for Mental Status) dated 9/26/25 resulted in a score of 6, which indicates severe cognitive impairment. R14's BIMS (Brief Interview for Mental Status) dated 10/3/25 resulted in a score of 7, which indicates severe cognitive impairment. On 11/19/25 at 11:14 am, V1 (Administrator) stated the following, V18 (Memory Care Director) informed me that a CNA (Certified Nurse Assistant) had reported to her (V18), that R14 was observed in his room with his visitor (V20) without clothes and engaging in sexual intercourse sometime last month. We did our investigation by asking R14 if he consented to the sexual act and he said yes. Just because he (R14) has dementia doesn't mean that he lost his desire to have sex. However, we have banned V20 from visiting R14 at this time per R14's family's request. V23 (R14's family) did not want V20 visiting R14 because she felt that there was some financial abuse going on. On 11/19/25 at 1:50 pm, V18 (Memory Care Director) stated the following, After the alleged sexual act, I assessed to see if (R14) was in distress. I also asked R14 about what happened and he (R14) stated that it was consensual sex. I notified V1 via telephone about the sexual incident, also that R14's family (V23) was concerned about possible financial abuse. R14's family had made me aware on 11/1/25, that she was concerned with V20 possibly taking advantage of R14 and receiving money from him. V20 was restricted from visiting R14. The block was for safety reasons, for possible financial abuse. I (V18) didn't document that V20 was banned, I just added him to the list at the front desk. I didn't document the sexual incident that occurred on 11/1/25, but I had planned to document and forgot.On 11/24/25 at 2:25 pm, V1 (Administrator) stated the following, Investigations should be documented via progress note or incident report in order to keep a written documentation of keeping track of what transpired. I would expect for the sexual act between R14 and V20 to be documented.R14's Care Plan dated 10/03/25 documents, R14 is at risk for abuse related to cognitive impairment and diagnosis of dementia; R14 has an ADL (Activity of Daily Living) Functional deficit related to dementia, impaired cognition, incomplete performances and periods of confusion. R14's Medical Record excludes any investigation or documentation regarding the sexual incident on 11/1/25.The Initial Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.Facility Census dated 11/17/25 documents 191 residents.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or administrator; upon learning of the report, the administrator or designee shall initiate and incident investigation.

Based on interviews and record review, the facility failed to prevent one resident (R14) with cognitive impairment from being sexually abused by a visitor suspected of possibly financially abusing R14. This failure has affected one of five residents reviewed for abuse.Findings include:R14 is [AGE] year-old with diagnosis including but not limited to: Alzheimer's disease, moderate dementia, essential hypertension, type 2 diabetes mellitus without complications and benign prostatic hyperplasia with lower urinary tract symptoms.R14's BIMS (Brief Interview for Mental Status) dated 9/26/25 resulted in a score of 6, which indicates severe cognitive impairment.R14's BIMS (Brief Interview for Mental Status) dated 10/3/25 resulted in a score of 7, which indicates severe cognitive impairment.On 11/19/25 at 10:30 am, V18 (Memory Care Director) stated the following, I don't know anything about any sexual incident with R14. R14 has not stated anything about sexual abuse. No staff member has mentioned anything regarding R14. If I was notified of any possible sexual abuse, I would let the Administrator know immediately. R14's friend (V20) was blocked from the facility last month. R14's family member (V23) felt like V20 was financially abusing him (R14), so we (Administration) placed a temporary ban on V20's visiting privileges until R14's checks are turned over to the facility.On 11/19/25 at 11:14 am, V1 (Administrator) stated the following, V18 (Memory Care Director) informed me that a CNA (Certified Nurse Assistant) had reported to her (V18), that R14 was observed in his room with his visitor (V20) without clothes and engaging in sexual intercourse sometime last month. We did our investigation by asking R14 if he consented to the sexual act and he said yes. Just because he (R14) has dementia doesn't mean that he lost his desire to have sex. Yes, a person could be in a marriage and still be sexually manipulated or assaulted, but this was not the case for R14. V20 (R14's friend) is R14's longtime friend and has visited him in the past. However, we have banned V20 from visiting R14 at this time per R14's family request. V23 (R14's family) did not want V20 visiting R14 because she felt that there was some financial abuse going on.On 11/19/25 at 11:46 am, R14 was observed in the dining room sitting with a peer.At that time, R14 mentioned that he was waiting on a phone call and asked surveyor if he (R14) would be able to answer the call from a television remote in his hand.Surveyor and R14 left the dining room to resume the conversation.On 11/19/25 at 11:55 am, R14 stated the following, My name is (stated name), today's date is June something, I don't know where I am. I think I'm in a senior apartment building. I don't know how I got here or why. I just know I told my sister that I wanted my own apartment, so she helped me get it. No, I'm not in a nursing home. I don't even have a nurse here. This is my apartment. No one here has asked me about my relationship with V20 or if we've had sex. He is my friend, about fifteen years younger than me and yes we have had a sexual relationship in the past. I don't recall having sex with him (V20) in this place though.On 11/19/25 at 1:50 pm, V18 stated the following, Last month, V19 (CNA/ Certified Nurse Assistant) did report that he (V19) observed R14 engaging in sexual intercourse in his room with another male (V20). I did not mention the sexual incident with R14 and V20 to you (Surveyor) because I did not correlate that with sexual abuse. After the alleged sexual act, I assessed to see if (R14) was in distress. I also asked R14 about what happened and he (R14) stated that it was consensual sex. I (V18) did not complete any cognitive assessments or updates to care plan after the sexual incident. I am responsible for updating resident's care plans regarding cognition and sex. I don't know who deemed R14 able to consent to sex. It was just based on a conversation that V1 and I (V18) had. I did report the incident it to the administrator on 11/1/25 and V20 was barred from 11/1/25 through 11/19/25, until his (R14) checks started coming to the facility. The block was for safety reasons, for possible financial abuse. I didn't document that he was barred, I just added him to the list at the front desk.On 11/20/25 at 3:00 pm, V19 (CNA/ Certified Nurse Assistant) stated the following, I was making my rounds when I entered R14's room. R14 was undressed from the bottom down. R14's visitor (V20) was also undressed from the bottom down. They were both actively having sexual intercourse. I told them to stop and asked V20 to leave because I knew that previously, I was told by the Memory Care Director (V18) that R14 couldn't have visitors. Since I was not sure what was going on, I just asked him (V20) to leave. It was confusion about rather or not V20 was banned because he would be banned one minute and then the next minute he would be able to visit again. In the past, before the visitation restrictions, V20 would visit often but would never visit in the dining room. He (V20) would always visit R14 in R14's room and the door would be closed when V20 visited. I've seen him on the unit a few times in the past and I never thought anything of it because it was his friend. This particular day I knocked on the door and entered. After seeing them in the sexual act, I asked them to stop and I notified his nurse. By R14 having dementia and sometimes being confused, I feel like he might not have been in his right mind at the time and I just figured safety first.On 11/20/25 at 3:55 pm, V18 (Memory Care Director) stated the following, I notified V1 via telephone that R14's family (V23) was concerned about possible financial abuse, and I told him about the sexual incident that occurred on 11/1/25. R14's sister had made me aware on 11/1/25, that she was concerned with V20 possibly taking advantage of R14 and receiving money from him. If a person is suspected of possibly abusing a resident in any way, we would generally monitor a visitor in the dining room, or a staff member would be nearby. Yes, there was a possibility of financial abuse because the facility was not getting R14's check at the time, but we don't believe that R14 was sexually abused by R20. Any resident can be at risk for sexual abuse.On 11/20/25 at 3:30 pm, V2 (DON/ Director of Nursing) stated the following, V20 was restricted from visiting in the past but I don't know exactly when. His privileges were restricted a couple of times and reinstated after V18 spoke with the family (V23). On 11/24/25 at 10:30 am, V18 stated the following, We plan to get a state guardian appointed for R14 to oversee his care in the event he (R14) cannot make his own decisions. His sister is his point of contact but she is not his POA (Power of Attorney). I reached out to the Nurse Practitioner (V28) to complete a ccp211 form (Physician Statement for State Guardianship).At that time, V18 (Memory Care Director) stated that a State Guardian is usually appointed just to have a point of contact for a resident and not necessarily that the resident is non- decisional. V23 (R14's family) is the point of contact for R14.On 11/24/25 at 12:15 pm, V28 (PMHNP/ Psychiatric Mental Health Nurse Practitioner) stated the following, V18 (Memory Care Director) did inquire about completing a CCP211 form (Physician's statement) in order to apply for a State Guardian for R14, but I would recommend having a neuro-psych evaluation first. In order to definitively measure a person's decision-making capabilities, a neuro-psych evaluation may be done. A State Guardian would be appointed to a person that is incapable of making decisions on their own. Anyone with Dementia has cognitive impairment that varies depending on the stage of dementia. When a person's dementia is progressing, there may be behavioral issues such as psychotic symptoms and delusions because some parts of the brain is damaged. At a stage 5 dementia, a person may not know where they are and are not in reality. It is obvious that they cannot consent to medical procedures, psychotropic medication, or make financial decisions on their own regarding paying bills. They would need a more in depth assessment on their decision- making abilities.On 11/24/25 at 2:25 pm, V1 (Administrator) stated the following, We do not have Sexual Assessment forms that I know of.On 11/24/25 at 2:50 pm, V2 (DON/ Director of Nursing) stated the following, R14 has not had any neuro psychiatric evaluations as far as I know while he was here. We don't have an assessment to measure a resident's capability to consent to sex. Yes, a patient's care plan should be updated after observed having sexual intercourse in his room with a male visitor.Facility Staff schedule dated 11/01/25 documents, V19 CNA (Certified Nurse Assistant) working the 3pm- 11pm shift on the third floor. The Initial Investigation report was faxed to IDPH on 11/19/25 at 2:24 pm and documents an allegation of sexual abuse involving R14 and V20.The Initial Investigation report was faxed to IDPH on 11/20/25 at 5:49 pm and documents an allegation of financial abuse involving R14 and V20.R14's Memory Care Initial assessment dated [DATE] documents the following; R14 is only oriented to person (knows self); R14 is not oriented to place, time or situation (does not know where he is, does not know why he is here, and does not know the current day/ month); R14 has short-term and long-term memory problems; R14's FAST (Functional Assessment Staging Tool for Dementia) scale is Stage five of Seven. R14's Care Plan dated 10/03/25 documents, R14 is at risk for abuse related to cognitive impairment and diagnosis of dementia; R14 has an ADL (Activity of Daily Living) Functional deficit related to dementia, impaired cognition, incomplete performances and periods of confusion.Facility Abuse policy documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; the facility will report reasonable suspicion of a crime; the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This is done by immediately protecting residents involved in identifying reports possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; filing accurate and timely investigative reports.

Based on interview and record review the facility failed to inform residents of their monthly personal funds amount and failed to distribute residents personal fund monies monthly. This failure affected three of three residents (R8, R9, R10) reviewed for personal funds. The findings include:On 9/22/2025 at 2:03 pm, R8 stated she (R8) is not aware why she was not receiving her monthly sixty dollars from the trust fund. R8 stated V8 her nephew is the power of attorney over her healthcare, and she did not authorize V8 to have power of attorney over her finances. R8 stated the facility never notified her (R8) that the facility was giving V8 her monthly trust fund money. R8's Minimum Data Set Section C dated 9/2/2025 documents, in part, a BIMS (Brief Interview Mental Status) Score of 8 which is indicative of a moderately impaired cognition. R8's Social Security statement dated 3/2024 documents; in part, [NAME] is R8's representative payee. R8's money order receipts dated 9/3/2025 documents a payment of one hundred five dollars and sixty-four cents to [NAME] from R8 the remitter.R8's money order receipts dated 8/3/2025 documents a payment of one hundred five dollars and sixty-four cents to [NAME] from R8.R8's bank statement dated 7/24/2025 to 8/20/2025 documents, in part, a withdrawal of eighty-eighty dollars and eighty-four cents from [NAME] Financial Group Life Insurance Company. R8's bank statement documents a deposit of one hundred sixty-five dollars and sixty-four cents from a pension company on 7/30/2025.On 9/23/2025 at 11:36 am, V8 (R8 Family Member/FM) stated he (R8FM) has had power of attorney for property since December 1, 2010. V8 stated R8 receives a Social Security Check, and the facility is the representative payee. V8 stated R8 also receives a small pension check in the amount of one hundred and sixty-five dollars and sixty-four cents. V8 stated he (V8) takes sixty dollars from pension funds to pay R8's life insurance policy in the amount of eighty-eight dollars and provides the remaining one hundred five dollars and sixty-four cents to the facility in a money order. V8 stated he (V8) pays the remaining twenty-eight dollars needed to pay R8's insurance premium. V8 states his (V8's) aunt will not remember the power attorney information because she has dementia. V8 stated he V8 buys R8's clothes, snacks, personal grooming supplies, and restaurant food upon her (R8's) request. V8 stated he will bring the Financials.On 9/24/2025 at 1:38 pm, V1 (Administrator) stated V11 (Business Office Manager) meets with the residents monthly and have the resident sign for their funds. V1 stated residents who receive Social Security Benefits are deposited in a trust fund account and each resident will receive thirty dollars or sixty dollars monthly. V1 stated he (V1) was made aware this week that V8 (R8's Family Member) was receiving R8's pension fund, deducting sixty dollars from the pension fund for R8's insurance policy, and providing the balance of the pension fund to the facility. V1 stated typically every resident should receive a check monthly check from Social Security and another check for thirty or sixty dollars is allocated to the residents monthly. V1 stated a resident has the right to know about their personal funds account and he is not sure why R8 does not receive personal funds monthly. On 9/24/2025 at 2:01 pm, V21 (Director of Financial Services) stated she actually receives R8's Social Security Check of [NAME] receives one thousand two hundred and forty-seven dollars. V21 stated the facility is the representative payee and was aware V8 (R8's Family Member) was withholding the 60 dollars from R8's pension check and providing the balance of the pension check to the facility in the form of a money order. V21 stated Social Security hired a third-party company to complete their audits on Social Security Checks. V21 stated the third-party company informed her (V21) that Social Security's guidelines require Representative Payee's to handle all beneficiary funds and family members, or power of attorneys are not acceptable to manage a person's monthly benefits. V21 stated she has recognized the previous method of handling R8's funds are incorrect and moving forward will follow the guidelines outlined in the Social Security's Guide for Representative Payees to handle R8's beneficiary funds. V21 stated V8 and R8 has been notified of this decision. On 9/22/2025 at 2:15 pm, R9 stated she (R9) has not received her trust fund money this month and is not aware how much she receives. On 9/22/2025 at 2:23 pm, R10 stated he (R10) has not received any trust fund money, and he would appreciate it if he did. R10 stated he does not have a power of attorney, and his daughter was his power of attorney, but he is married now. Power of Attorney documents to the facility today. On 9/25/2025 at 11:23 am, V11 stated R10 signs for his daughter to receive his personal funds of sixty dollars monthly. V11 stated R9 does not receive personal funds because her family is her representative payee. V11 stated R9 is aware that her family is her representative payee.R9 Minimum Data Set Section C dated 8/22/2025 documents, in part, a BIMS (Brief Interview Mental Status) Score of 6 which is indicative of a severely impaired cognition.R10 Minimum Data Set Section C dated 9/2/2025 documents, in part, a BIMS (Brief Interview Mental Status) Score of 6 which is indicative of a moderately impaired cognition.R10's Trust Fund Withdrawals Affidavit dated 8/26/2025 documents a withdrawal of two hundred dollars by V22 (R10's Family Member) and a Trust Fund Signature Form dated 9/11/2025 in the amount of sixty dollars. Facility's Policy titled Resident Funds dated 1/09 documents, in part The primary purpose of the resident fund policies is to establish uniform guidelines in the protection of personal funds managed by our facility of behalf of its residents.

Based on interviews and record reviews the facility failed to follow their elopement policy to report an elopement that resulted in R1 eloping from the local emergency and not being located by the facility until a day later to Illinois Department of Public Health, for one [R1] of three residents reviewed for elopement in a total sample of three residents. Findings include:R1's clinical record indicates in part: R1 was admitted on [DATE], with the following medical diagnoses but not limited to non-Hodgkin lymphoma, schizoaffective disorder, syncope and collapse, tremors, convulsions, major depression, essential hypertension, and anxiety disorder. R1's minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively intact, alert, and oriented x3.Facility's appointment book:R1 was scheduled for follow up appointment at a cancer clinic withV5 [Restorative Certified Nurse Aide/Escort]. The appointment time was 9:30 AM.R1's Emergency Department Notes, documented in part:R1 was signed in to the emergency room on 6/27/25, at 12:00 PM.At 12:10 PM, R1 had EKG (electrocardiogram) completed.V14 [Hospital Emergency Department Triage Register Nurse] at 12:20 PM, 12:33 PM, and 12:53 PM called R1's name with no answer. R1's EKG results were unchanged, and no acute distress noted. R1 was not seen by a physician in the emergency department.R1's Progress Notes Documented in Part: 6/26/2025, at 12:14 PM, Nurses Note V8 [Licensed Practical Nurse]Note Text: the resident [R1] is out at an appointment for an infusion. The resident [R1] was sent to the ER [emergency department] due to C/O [complaints of] chest pains. 6/27/2025, 10:13 AM, Interdisciplinary Team Note [Administrator V1] Note Text: Writer received call from hospital police [V7 Hospital Campus Security]. V7 provided report #25-00954. V7 called to ensure that this facility had been properly notified that the while receiving care from hospital emergency department the resident[R1] had left the hospital and that the hospital police were making efforts to locate the resident [R1]. V7 inquired if the resident [R1] may have returned to facility and requested any phone numbers, addresses, and contact persons that the facility had on file. Writer provided V7 with all requested information and any background information that the facility had on the resident [R1]. V7 made writer aware that the hospital police would provide any updates. Writer made V7 aware that the facility would do the same. V7 provided writer with phone for any updates. Interviews:On 6/27/25, at 12:07 PM, V8 stated, I was not made aware by hospital staff that R1 was admitted to the hospital. I received a phone call on 6/26/25 around 10:00 AM, from the cancer clinic. The clinic reported R1 was complaining of chest pain and was being send over to the emergency department for an evaluation. I documented the phone encounter at 12:14 PM, because I was busy. I received a second phone call from someone at emergency department, I don't know who I spoke to, but it was a male. This occurred at approximately 2:00 PM. This person reported to me that R1 was missing from the emergency department. The person from the emergency department also stated R1 arrived at the emergency department with an escort but could locate R1 nor the escort. I immediately transferred the phone call to V4 [Assistant Director of Nursing]. When I got off the phone, I did not do anything. I did not call R1's emergency contact [V11], I did not call R1's physician. V4 told me she was going to notify V1 [Administrator]. I received a third phone call from the hospital security campus police around 3:00 PM. The police reported that R1 was missing from the hospital campus and was seen leaving on camera. He notified R1's family member [V11] and made a police report.I received a fourth phone call around 4:00 PM or 5:00 PM. I am not sure of the time, but it was during my evening medication pass. The call was from R1's family member [V11]. V11 reported to me she received a phone call from the hospital and told her that R1 was missing. I told V11, I was sorry to hear that. I did not notify R1's family member [V11] that R1 was missing from the emergency department. I was first made aware of R1 missing around 2:00 PM. I was busy passing out medications. I thought the male I spoke to told me he already had notified V11 and the police. I documented in R1's progress notes today as a late entry for 6/26/2025 12:14 PM, that I received a phone call from the police stating that R1 was seen leaving the hospital on camera. I documented my note wrong. I received a phone call from the hospital security campus police, not the city police department. I also documented I spoke with R1's family member [V11] and made her aware that R1 was missing. I documented that because the hospital security campus police told me they notified V11. I should have documented more clearly. I do not know if the report was made within the hospital or if the report was made with city police department. I documented the note for 12:15 PM, but I am not sure what time I received the phone call.On 6/27/25, at 9:50 AM, V12 [Director of Emergency Department] stated, R1 was seen at the hospital's cancer clinic. R1 was brought over to the emergency department with the nursing home facility escort and transport due to R1 complaining of chest pains during her cancer center appointment. R1 was signed in to the emergency room on 6/27/25, at 12:00 PM with her escort. At 12:10 PM, R1 had an EKG completed. V14 [Hospital Emergency Department Triage Register Nurse] at 12:20 PM, 12:33 PM, and 12:53 PM called R1's name with no answer. R1's EKG results were unchanged, and no acute distress was noted. R1 was not seen by a physician in the emergency department. Nothing in R1's EKG or labs results would have granted R1 to be admitted to the hospital. R1 would have been returned to the nursing facility. The hospital security searched the hospital campus area. R1 nor her nursing facility escort was located. At 2:30 PM, I phoned the nursing facility and spoke to V8 [Licensed Practical Nurse] and verified R1 was in fact a resident with the nursing facility. V8 said R1 was a resident there. V8 told me the escort V5[Restorative Aide/Certified Nurse Assistant Escort] was back at the facility. V8 then transferred me to the Assistant Director of Nursing [V4]. I told V8 and V4. R1 reported to the emergency department intake desk at 12:00 PM, completed an EKG, and was called by triage nurse three times with no answer. V4 and V8 both confirmed V5 left an elopement risk resident and returned back to the facility. Before any person is admitted to the hospital, they are assessed by a physician that makes the decision if a person is going to be admitted . R1 was never admitted to the hospital. Once the resident is admitted to the hospital, the hospital staff is responsible for the resident. R1's escort was to remain with R1 knowing she was an elopement risk that the cancer center nursing staff told V5, not to leave R1. I phoned R1's family member listed and city police department [#2-00954- Officer V15/City Police Officer]. On 6/27/25, at 11:00 AM, V5 [Restorative Aide/Certified Nurse Assistant/Escort] stated, I been a certified nurse assistant for ten years. I have been escorting residents to their medical appointments for nine months. I was asked to go with R1 to her medical appointment at the cancer center. R1 is alert and oriented, but R1 has some psych issues. R1 is ambulatory and uses a walker. R1 and I arrived at the cancer center at 9:22 AM. We walked in and I signed R1 in for her appointment. We waited an hour and half, and then R1 was called back around 10:30 AM to see V17 [ Advanced Practice Registered Nurse/Nurse Practitioner]. I went back into the room with R1. R1 told V17 that she was having chest pain and dizziness. They took R1's vital signs a few times. V17 said I am sending you to the emergency room to be admitted to the hospital. During R1's assessment, I asked V17 if it was alright for me to step out of the room, to blow my nose. V17 stated no, I need to stay with R1 at all times because she is an elopement risk. So, I stated never mind and blew my nose in the room. V17 gave R1 a wheelchair to sit in and told R1 and I to have a seat in the waiting area lobby for the hospital escort. About twenty minutes later a female transport person arrived and pushed R1 in her wheelchair to the emergency department and went with R1. We made it to the emergency department around 12:00 PM. We went to the intake desk and signed R1 into the emergency department. The transport staff lady then walked away. The intake lady walked around the desk and removed the cancer center wrist band and placed the emergency department wrist band. I do not know the name of the intake lady nor her job title. The intake lady might have been like a receptionist. I don't think she was a nurse or physician. I told the intake lady that R1 was a high elopement risk and was there anything else for me to do. The intake lady said no. I asked if I could leave and the intake lady said yes. The intake lady started pushing R1 to the back then I left the emergency department and called V6 for a transportation ride. I walked back over to the cancer center. I returned back to the nursing facility at 12:52 PM. The intake lady did not tell me R1 was admitted to the hospital. I did not receive any paperwork from the emergency department that indicated R1 was admitted to the hospital. V6 [ Unit Manager/Certified Nurse Assistant] and V8 [Licensed Practical Nurse] were made aware R1 was in the emergency room. I did not tell V6 or V8 that R1 was an elopement risk, I forgot to tell them.On 6/28/25, at 9:15 AM, V1 [Administrator] stated, R1 was located yesterday [6/27/25] evening by staff.On 7/1/25, at 12:19 PM, V10 [Restorative Nurse] stated, On 6/27/25 around 6:45 PM, I saw R1 coming out of a corner store and brought R1 back to the facility. I immediately phoned V1 [Administrator] and told him R1 was back in the facility. I took R1 vital signs, and they within normal limits. I completed a body assessment and phoned R1's primary physician with no answer. R1's nurse was told to follow up with R1's physician and family.On 6/28/25, at 9:30 AM, R1 stated, I had an appointment on Thursday [6/26/25], when I started having chest pain. The nurse practitioner sent me and V5 to the emergency room so I could get checked out. V5 asked some lady if she could leave, and the lady said yes. I went to the back for an EKG. When I returned to the waiting area, V5 was gone. I went to the bathroom when I heard someone call my name, but I was on the toilet. When I came out the bathroom, I asked a lady the desk who called my name. The lady said, they will call you again. Then I wanted some fresh air and walked outside. When I was outside a nice lady gave me ten dollars. I went back in the hospital and sat in the lobby, not the emergency department, because I could not find the emergency department. No one came for me to see the doctor. I never saw a doctor. I slept there in a chair all night long, and my chest stopped hurting. The next day [6/27/25] around 12:00 PM, I left the hospital and caught the bus heading south to my favorite store. I went into the store and bought some lunch meat, bread, and cheese. When I was coming out of the store, I saw V10 [Restorative Licensed Practical Nurse] when she called my name. V10 brought me back to the nursing facility.On 7/2/25, at 1:00 PM, V1 [Administrator] stated, on 6/26/25 I received a phone call from V4 [Assistant Director of Nursing] reported she received a phone call from the hospital that during R1's appointment she complained of chest pain and was sent to the emergency room to be admitted accompanied with her escort [V5]. I spoke with V5, and she reported R1 was checked in to the emergency department and hospital staff was taking R1 to the back. V5 received permission to leave. There was a custody of change from the facility's escort to the hospital staff. R1 eloped from the emergency department under the hospital staff supervision, not under the facility's supervision. V5 reported she told the hospital staff that R1 was an elopement risk and asked was there anything else to do, the emergency room staff said no and gave V5 permission to leave. Once I learned R1 was missing, V2 [Assistant Administrator] and I went out driving around the hospital looking for R1. V8 received a phone call from the hospital police reported R1 was on camera boarding a bus heading north bound. I called off the search, because I knew at that point R1 was not in the hospital local area. On 6/27/25 around 7:00 PM, V18 observed R1 coming out of a corner store, and R1 came back to nursing facility. V5 R1 told me in summary that she was taken to the emergency room with V5. Prior to going to the back, the intake lady told V5 she could leave. R1 said she went outside for fresh air, and someone gave her ten dollars. R1 said she went back in the hospital, but no one called her name, and she slept there all night. The day R1 said she left the hospital lobby the next day [6/27/25] and got on the bus heading south bound to her favorite store to buy some lunch meat because R1 said she was hungry. R1 said coming out the store, facility staff recognized her and gave her a ride back to the nursing facility. R1's census report is not correct, due to poor communication. R1's census report indicated R1 was not discharge from the nursing facility until 7/1/25 and re-admitted back on 7/2/25. I was made aware that R1 was missing on 6/26/25 around 2:00 PM, and R1 was located on 6/27/25 around 6:30 PM. R1 was missing for 28 hours. [R1's clinical record indicate R1 was a resident with the facility on the day R1 was reported missing, R1 was not discharged .]Policy Documented in part: Elopement and Management of Missing Resident dated 3/28/23.It is the policy of this facility to report and investigate all reports of missing resident and to minimize risk of elopement. Suspected Missing Resident:If unable to locate the resident, call 911 to report resident missing. Notify resident's legal representative/responsible party of the occurrence and determine if friends or family know where the resident may attempt to go.Notify attending physician or Nurse practitioner.Complete Incident reportIf the resident has not been located for 24 hours contact morgue and notify the Illinois Department of Public Health with a summary of the incident report after the dependent resident is missing for 24 Escort for Appointment: dated 2/25.The facility will provide staff escorts to resident appointment as needed. Facility escorts attend the appointment with the resident, then return to the facility with the resident and any pertinent documentation from the appointment. If a resident is transferred to the hospital and or emergency room during an appointment, the escort should return to the facility once the resident has been taken by emergency transport or has been received by the hospital and or emergency room.These guidelines are not meant to be exclusive or exhaustive. Guidelines are meant to leave room for the exercise of professional judgement based on individual circumstances.

Based on interviews and record reviews the facility failed to provide adequate supervision for 1 [R1] of three residents who is an elopement risk. This failure resulted in R1 eloping from the emergency department and not being located by facility staff until 06/27/2025. Findings Include,R1's clinical record indicates in part: R1 was admitted on [DATE], with the following medical diagnoses but not limited to non-Hodgkin lymphoma, schizoaffective disorder, syncope and collapse, tremors, convulsions, major depression, essential hypertension, and anxiety disorder. R1's minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively intact, alert, and oriented x/times3.Facility's appointment book:R1 was scheduled for follow up appointment at a cancer clinic with V5 [Restorative Certified Nurse Aide/Escort]. The appointment time was 9:30 AM.R1's Emergency Department Notes, documented in part:R1 was signed in to the emergency room on 6/27/25, at 12:00 PM. At 12:10 PM, R1 had an EKG (electrocardiogram) completed. V14 [Hospital Emergency Department Triage Register Nurse] at 12:20 PM, 12:33 PM, and 12:53 PM called R1's name with no answer. R1's EKG results were unchanged, and no acute distress was noted. R1 was not seen by a physician in the emergency department.R1's Progress Notes Documented in Part:On 6/26/2025, at 12:14 PM, Nurses Note V8 [Licensed Practical Nurse]Note Text: The resident [R1] is out at an appointment for an infusion. The resident [R1] was sent to the ER [emergency department] due to C/O [complaints of] chest pains. Nurses Note V8 [Licensed Practical Nurse] Effective Date: On 6/26/2025, at 14:15:00 [2:15 PM]Created Date: On 6/27/2025, 09:29:31 [9:29 AM]On 6/26/2025, at 2:15 PM, [Documented on 6/27/25 at 9:29 AM]Note Text: Writer received a phone from the police stating that the R1 was seen leaving the hospital on camera. The writer spoke with the resident's mother who is aware of resident leaving the hospital. A police report was made. The physician was made aware as well. [Progress note entered late}. On 6/27/25, at 12:07 PM, V8 said she received phone call from the hospital security not the city police department. A report was made with the hospital security, not with the city police department. On 6/27/2025, at 9:44 AM, Nurses Note V9 {Licensed Practical Nurse] Note Text: Writer received call from ER director [V12-Director Emergency Department] inquiring if resident [R1] returned to the facility. V12 was made aware that resident [R1] has not returned. V12 also asked if resident's mother was made aware and if she heard from the resident. Writer made V12 aware that facility did speak with resident's family member [V11] and she was aware. On 6/27/2025, at 10:13 AM, Interdisciplinary Team Note [Administrator V1] Note Text: Writer received a call from the hospital police [V7 Hospital Campus Security]. V7 provided report #25-00954. V7 called to ensure that this facility had been properly notified that while receiving care from hospital emergency department the resident [R1] had left the hospital, and the hospital police were making efforts to locate the resident [R1]. V7 inquired if the resident [R1] may have returned to facility and requested any phone numbers, addresses, and contact persons that the facility had on file. Writer provided V7 with all requested information and any background information the facility had on the resident [R1]. V7 made the writer aware that the hospital police would provide any updates. Writer made V7 aware that the facility would do the same. V7 provided the writer with a phone for any updates. On 6/27/2025, at 7:29 PM, Nurses Note Restorative [V10- Licensed Practical Nurse] Note Text: While out searching the community for the resident [R1], R1 was observed standing in front of the store at the bus stop. Staff prompted resident [R1] to come back to the facility. R1 was cooperative and agreed to allow staff transport her back to the facility. Administration was made aware.Interviews:On 6/27/25, at 9:40 AM, V8 [Licensed Practical Nurse] stated, I was R1's nurse yesterday [6/26/25]. I worked from 7:00 AM to 7:00 PM. R1 is not here in the facility. R1 had an appointment yesterday [6/26/25] at 9:30 AM. R1 left the facility at 8:30 AM. Approximately a couple hours later, the doctor's office called and said R1 was being sent to the emergency department, due to R1 complaining of chest pain. R1 was admitted to the hospital.On 6/27/25, at 12:05 PM, surveyor asked V8, why didn't she report R1 was admitted to the hospital to the surveyor. During record review of V8's progress note dated 6/26/25, but entered on 6/27/25, at 9:29 AM, surveyor was indicated that V8 documented R1 was missing from the emergency department.On 6/27/25, at 12:07 PM, V8 stated, I was confused, I am sorry. I was not made aware by hospital staff that R1 was admitted to the hospital. I received a phone call on 6/26/25 around 10:00 AM, from the cancer clinic. The clinic reported R1 was complaining of chest pain and was being sent over to the emergency department for an evaluation. I documented the phone encounter late at 12:14 PM, because I was busy. I received a second phone call from someone at emergency department, I don't know who I spoke to, but it was a male, at approximately 2:00 PM. This male reported to me that R1 was missing from the emergency department. The person from the emergency department also said R1 arrived at the emergency department with an escort but could not locate R1 nor the escort. I immediately transferred the phone call to V4 [Assistant Director of Nursing]. When I got off the phone, I did not do anything. I did not call R1's emergency contact [V11]. I did not call R1's physician. V4 told me she was going to notify V1 [Administrator]. I received a third phone call from the hospital security campus police around 3:00 PM. The campus police reported that R1 was missing from the hospital campus and was seen leaving on camera. He notified R1's family member [V11] and made a police report. I received a fourth phone call around 4:00 PM or 5:00 PM. I am not sure of the time, but it was during my evening medication pass, from R1's family member [V11]. V11 reported to me she received a phone call from the hospital. The hospital told her R1 was missing. I told V11, I was sorry to hear that. I did not notify R1's family member [V11] that R1 was missing from the emergency department. I was first made aware of R1 missing around 2:00 PM. I was busy passing out medications. I thought the male I spoke to told me he already had notified V11 and the police. I documented in R1's progress notes today as a late entry for 6/26/2025, at 12:14 PM, that I received a phone call from the police stating that R1 was seen leaving the hospital on camera. I documented my note wrong. I received a phone call from the hospital security campus police, not the city police department. I also documented I spoke with R1's family member [V11] and made her aware that R1 was missing. I documented that because the hospital security campus police told me they notified V11. I should have documented more clearly. I do not know if the report was made within the hospital or if the report was made with the city police department. I documented the note at 12:15 PM, but I am not sure what time I received the phone call.On 6/27/25, at 9:50 AM, V12 [Director of Emergency Department] stated, R1 was seen at the hospital's cancer clinic. R1 was brought over to the emergency department with the nursing home facility escort and transported due to R1 complaining of chest pains during her cancer center appointment. R1 was signed in to the emergency room on 6/27/25, at 12:00 PM, with her escort. At 12:10 PM, R1 had an EKG completed. V14 [Hospital Emergency Department Triage Register Nurse] at 12:20 PM, 12:33 PM, and 12:53 PM, called R1's name with no answer. R1's EKG results were unchanged, and no acute distress was noted. R1 was not seen by a physician in the emergency department. Nothing in R1's EKG or labs results would have granted R1 to be admitted to the hospital. R1 would have returned to the nursing facility. The hospital security searched the hospital campus area. R1 nor her nursing facility escort was located. At 2:30 PM, I phoned the nursing facility and spoke to V8 [Licensed Practical Nurse]. V8 verified R1 was in fact a resident with the nursing facility. V8 stated R1 was a resident there. V8 told me the escort V5 [Restorative Aide/Certified Nurse Assistant Escort] was back at the facility. V8 then transferred me to the Assistant Director of Nursing [V4]. I told V8 and V4, R1 reported to the emergency department intake desk at 12:00 PM, completed an EKG, and was called by the triage nurse three times with no answer. V4 and V8 both confirmed V5 left an elopement risk resident and returned back to the facility. Before any person is admitted to the hospital, they are assessed by a physician that makes the decision if a person is going to be admitted . R1 was never admitted to the hospital. Once the resident is admitted to the hospital, the hospital staff is responsible for the resident. R1's escort was to remain with R1 knowing she was an elopement risk. The cancer center nursing staff told V5, not to leave R1. I phoned R1's family member listed and the city police department [#2-00954- Officer V15/City Police Officer]. On 6/27/25, at 10:09 AM, V13 [Director of Cancer Center] stated, R1 was seen on 6/27/25, at 9:30 AM, for a follow up appointment. During the appointment R1 complained of chest pains and dizziness. R1 vital signs indicated R1's heart rate was elevated, and blood pressure was low. V17 [Advanced Practice Registered Nurse/Nurse Practitioner] assessed R1 and told R1 and V5, R1 needs to be evaluated in the emergency department. During the assessment in a private room, V5 asked V17 if she could go outside. V17 told V5 no, because R1 is an elopement risk and has to stay with R1 at all times. We got R1 a wheelchair waited for internal transport to arrive. Transport arrived and pushed R1 in the wheelchair along with V5. They walked over to the emergency department. At 2:16 PM, the emergency department notified V16 [Cancer Center Registered Nurse] that R1 was not seen by a physician. She was called three times, and the resident was not present. The emergency department was made aware that R1 was a high-risk elopement resident.On 6/27/25, at 10:22 AM, V16 [Cancer Center Registered Nurse/Nurse Navigator] stated, I received a phone call from the emergency department. The emergency department stated R1 was called by the triage nurse three times. R1 nor V5 was present. I confirmed with V17 that R1 was a flight risk and V5 was told to stay with R1 at all times. I called R1's nursing facility spoke with V8. V4 verified R1's name and date of birth . V8 and V4 both confirmed V5 left R1 at the emergency department and V5 returned back to the nursing facility after V5 was told R1 was an elopement risk. V8 and V4 were both made aware that V5 left R1 in the emergency department and R1 was missing. V4 said she will tell her administrator immediately. I called R1's family member [V11] and made her aware that R1's escort left R1 in the emergency department and returned back to the nursing facility. R1 was missing. On 6/24/25, I called the nurse and confirmed R1 will be accompanied with an escort due to R1 being a flight risk. R1 has made attempts in the past to leave the cancer center and staff located R1 trying to leave the clinic. R1 has a known history of elopement. V5 was completely aware R1 was an elopement risk and she [V5] should not have left R1 alone. R1 was not seen by a physician, nor was R1 ever admitted to the hospital. On 7/2/25, at 12:30 PM, V6 [Unit Manager- Certified Nurse Assistant] stated, R1 was admitted with a follow up appointment at the cancer center on 6/26/25, at 9:30 AM. R1 and V5 left the facility with an 8:30 AM pick up. All escorts go out with the resident, they are to stay with the resident. If anything, abnormal occurs the staff will call me. I did not know R1 was an elopement risk. According to my cell phone text messages on 6/26/25. At 11:26 AM, V5 [Restorative Certified Nurse Assistant/Escort] texted me [They are about to admit her, they are waiting for transport to get them [V5 and R1]. I responded: [okay let me know when you are ready]. At 12:15 PM, V5 texted [ I am ready for pickup.] I responded [Okay].At 12:38 PM, I [V6] texted V5: [Did they tell you why they are keeping R1]V5 texted [R1 told the cancer center that she had a heart attack two days ago, and she [R1] passed out that morning. The cancer center is worried about R1's heart rate is high, and blood pressures is low]. I responded [Oh wow, Okay]. Then I immediately reported this information to R1's nurse.On 6/27/25, at 11:00 AM, V5 [Restorative Aide/Certified Nurse Assistant/Escort] stated, I been a certified nurse assistant for ten years. I have been escorting residents to their medical appointments for nine months. I was asked to go with R1 to her medical appointment at the cancer center. R1 is alert and oriented, but R1 has some psych issues. R1 is ambulatory and uses a walker. R1 and I arrived at the cancer center at 9:22 AM. We walked in and I signed R1 in for her appointment. We waited an hour and half, and then was called back around 10:30 AM to see V17 [ Advanced Practice Registered Nurse/Nurse Practitioner]. I went back into the room with R1. R1 told V17 that she was having chest pain and dizziness. They took R1's vital signs a few times. V17 said I am sending you to the emergency room to be admitted to the hospital. During R1's assessment, I asked V17 if it was alright for me to step out of the room to blow my nose. V17 said no, I needed to stay with R1 at all times because she is an elopement risk. So, I said never mind and blew my nose in the room. V17 gave R1 a wheelchair to sit in and told R1 and I to have a seat in the waiting area lobby for the hospital escort. About twenty minutes later a female transport person arrived and pushed R1 in her wheelchair to the emergency department and I went with R1. We made it to the emergency department around 12:00 PM. We went to the intake desk and signed R1 into the emergency department. The transport staff lady then walked away. The intake lady walked around the desk and removed the cancer center wrist band and placed on the emergency department wrist band. I do not know the name of the intake lady nor her job title. The intake lady might have been a receptionist, I don't think she was a nurse or physician. I told the intake lady that R1 was a high elopement risk and asked if there anything else for me to do. The intake lady said no. I asked if I could leave, and the intake lady said yes. The intake lady started pushing R1 to the back then I left the emergency department and called V6 for a transportation ride. I walked back over to the cancer center. I returned back to the nursing facility at 12:52 PM. The intake lady did not tell me R1 was admitted to the hospital. I did not receive any paperwork from the emergency department that indicated R1 was admitted to the hospital. V6 [ Unit Manager/Certified Nurse Assistant] and V8 [Licensed Practical Nurse] was made aware R1 was in the emergency room. I did not tell V6 or V8 that R1 was an elopement risk, I forgot to tell them. On 6/28/25, at 9:15 AM, V1 [Administrator] stated, R1 was located yesterday [6/27/25] evening by staff.On 7/1/25, at 12:19 PM, V10 [Restorative Nurse] stated, On 6/27/25 around 6:45 PM, I saw R1 coming out of a corner store and brought R1 back to the facility. I immediately phoned V1 [Administrator] and told him R1 was back in the facility. I took R1 vital signs, and they were within normal limits. I completed body assessment and phoned R1's primary physician with no answer. R1's nurse was told to follow up with R1's physician and family.On 6/28/25, at 9:30 AM, R1 stated, I had an appointment on Thursday [6/26/25], when I started having chest pain. The nurse practitioner sent me and V5 to the emergency room so I could get checked out. V5 asked some lady if she could leave, and the lady said yes. I went to the back for an EKG. When I returned to the waiting area, V5 was gone. I went to the bathroom when I heard someone call my name, but I was on the toilet. When I came out the bathroom, I asked a lady the desk who called my name. The lady said, they will call you again. Then I wanted some fresh air and walked outside. When I was outside a nice lady gave me ten dollars. I went back in the hospital and sat in the lobby, not the emergency department, because I could not find the emergency department. No one came for me to see the doctor. I never saw a doctor. I slept there in a chair all night long, and my chest stopped hurting. The next day [6/27/25] around 12:00 PM, I left the hospital and caught the bus heading south to my favorite store. I went into the store and bought some lunch meat, bread, and cheese. When I was coming out of the store, I saw V10 [Restorative Licensed Practical Nurse] when she called my name. V10 brought me back to the nursing facility.On 6/28/25, at 11:30 AM, V4 [Assistant Director of Nursing] stated, I received a phone call from V16, and she told R1 was seen at the cancer clinic for a follow visit. During the visit R1 complained of chest pain, syncope, dizziness and lightheadedness. V17 [Advanced Practice Registered Nurse/Nurse Practitioner] assessed R1 and noted R1 with an elevated heart rate. R1 was sent to the emergency department with V5 her escort. V17 told V5 to stay with R1 because she was an elopement risk. R1 was called by the emergency triage nurse three times. R1 nor her escort were present, and R1 was missing. I told V16 that V5 made it back to the facility around 1:00 PM. I reported the incident to the administrator [V1] and V3 [Director of Nursing]. I was not made aware prior to R1's appointment that R1 was an elopement risk. R1 is new to the facility, she was admitted on [DATE]. R1's elopement risk assessment completed on admission; she was not an elopement risk. I did not have a conversation with V5. The administrator took over the situation.On 7/1/25, V18 [Restorative Aide/Certified Nurse Assistant] stated, I been an escort for thirteen years. The escort protocol is to stay with the resident the whole time. If a resident is being admitted , staff stay until they are fully admitted . Meaning, until the resident is in their assigned room. If I had to leave the resident due to timing or end of my shift, I would call the director of nursing so she would send another escort to take my place.On 7/2/25, at 2:45 PM, V11 [R1's Family Member] stated, The hospital notified me on 6/26/25, that my family member was missing from the emergency department. I did not know R1 was at the emergency department, nevertheless missing. The nursing facility did not notify me of anything. The facility knew R1 was an elopement risk because I told them. R1 lived in the locked unit because they knew her history. After I knew R1 was missing, I waited a couple of hours to see if the facility was going to notify me, but they did not. I called the facility and spoke to V8, she acted as if she did not know R1 was missing. I was so upset. I was happy to learn R1 was located the next evening and was not hurt or harmed. A few months ago, R1 was attacked and raped on the city train. R1 is not to be left alone in the community. The facility knows her history and recent trauma. On 7/2/25, at 1:30 PM, V3 [Director of Nursing] stated, The escorts are supposed to stay with the resident while out at an appointment. Once the hospital emergency department staff took R1 to the back, there was an exchange in custody and the nursing facility staff could leave. V5 asked if she could leave and was told she could. V5 notified nursing staff here that R1 was going to be admitted and was taken to the back with hospital staff. V5 called for a pickup ride. V5 reported back to nursing facility. R1 was discharged from the nursing facility on 6/26/25 at 6:43 PM. The facility was made aware R1 was missing around 2:00 PM. R1 was located on 6/27/25 and brought back to nursing facility. Once a resident is discharged from the facility, upon return the resident is re-admitted . R1's clinical record does not indicate any re-admission assessments nor documentation. The nursing staff was not aware that R1 was an elopement risk.On 7/2/25, at 1:00 PM, V1 [Administrator] stated, on 6/26/25, I received a phone call from V4 [Assistant Director of Nursing] reported she received a phone call from the hospital that during R1's appointment she complained of chest pain and sent to the emergency room to be admitted accompanied with her escort [V5]. I spoke with V5, and she reported R1 was checked in to the emergency department and hospital staff was taking R1 to the back. V5 received permission to leave. There was a custody of change from the facility's escort to the hospital staff. R1 eloped from the emergency department under the hospital staff supervision, not under the facility's supervision. V5 reported she told the hospital staff that R1 was an elopement risk and asked was there anything else to do. The emergency room staff said no and gave V5 permission to leave. Once I learned R1 was missing, V2 [Assistant Administrator] and I went out driving around the hospital looking for R1. V8 received a phone call from the hospital police reported R1 was on camera boarding a bus heading north bound. I called off the search, because I knew at that point R1 was not in the hospital local area. On 6/27/25 around 7:00 PM, V18 observed R1 coming out of a corner store, and R1 came back to nursing facility. V5 R1 told me in summary that she was taken to the emergency room with V5. Prior to going to the back, the intake lady told V5 she could leave. R1 said she went outside for fresh air, and someone gave her ten dollars. R1 said she went back in the hospital, but no one called her name, and she slept there all night. The day R1 said she left the hospital lobby the next day [6/27/25] and got on the bus heading south bound to her favorite store to but some lunch meat because R1 said she was hungry. R1 said coming out the store, facility staff recognized her and gave her a ride back to the nursing facility. R1's census report is not correct, due to poor communication. R1's census report indicated R1 was not discharged from the nursing facility until 7/1/25 and re-admitted back on 7/2/25. I was made aware that R1 was missing on 6/26/25 around 2:00 PM. R1 was located on 6/27/25 around 6:30 PM. R1 was missing for 28 hours. [R1's clinical record indicate R1 was a resident with the facility on the day R1 was reported missing, R1 was not discharged .]Policy Documented in part: Escort for Appointment: dated 2/25.The facility will provide staff escorts to resident appointment as needed. Facility escorts attend the appointment with the resident, then return to the facility with the resident and any pertinent documentation from the appointment. If a resident is transferred to the hospital and or emergency room during an appointment, the escort should return to the facility once the resident has been taken by emergency transport or has been received by the hospital and or emergency room.These guidelines are not meant to be exclusive or exhaustive. Guidelines are meant to leave room for the exercise of professional judgement based on individual circumstances. Elopement and Management of Missing Resident dated 3/28/23.It is the policy of this facility to report and investigate all reports of missing resident and to minimize risk of elopement. Suspected Missing Resident:If unable to locate the resident, call 911 to report resident missing. Notify resident's legal representative/responsible party of the occurrence and determine if friends or family know where the resident may attempt to go.Notify attending physician or Nurse practitioner.Complete Incident reportIf the resident has not been located for 24 hours contact morgue and notify the Illinois Department of Public Health with a summary of the incident report after the dependent resident is missing for 24 hours.

Based on observations, interviews and records review, the facility failed to follow their policy on weights and pressure ulcer measurements for one (R1) resident of three reviewed. Findings include: R1's Electronic Medical records and current face sheet document R1 was admitted to the facility on [DATE], with medical diagnoses that include but not limited to peripheral vascular disease, unspecified, pressure ulcer of sacral region, stage 4, unspecified severe protein-calorie malnutrition, pneumonia, unspecified organism, pleural effusion, not elsewhere classified, other psychoactive substance abuse with intoxication, unspecified. R1's MDS (Minimum Data Set) section C -Cognitive functions dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1's cognition is intact, and MDS section GG-Functional abilities documents R1 requires Substantial/maximal assistance/dependent on staff for activities of daily living (ADL) care. On 04/19/2025, at 12:34 PM, V4 (Wound Nurse-LPN) stated R1 admitted to the facility on [DATE]. V4 stated when she first accesses a new wound, she measures it and documents it in the resident's electronic record to have a record of reference for monitoring wound improvement with treatment. V4 stated without the initial wound measurements, the doctor will not have a point of reference to determine if the wound is getting better or worse. V4 stated she took R1's wound measurements on 03/15/2025, but did not document them. V4 stated if it's not documented, it's not done. On 04/19/2025, at 1:45 PM, V5 (Wound Nurse Practitioner) via phone stated R1 came to the facility with the sacrum wounds on admission and the wound nurse should have taken the initial wound measurements. V5 stated R1 was admitted on [DATE]. V5 saw R1 on 3/20/2025. That is when he took R1's wound measurements. V5 stated before he assessed R1's wounds on 3/20/2025, there were no baseline measurements on file since admission to the facility for V5 to compare with. V5 stated when a resident is admitted to the facility, and the wound nurse practitioner or doctor will not see the resident the same day or the following day, the wound nurse should measure the wounds and document the measurements. This gives a baseline for the wounds and allows the wound care team to know if the wounds are improving, getting worse, or if the treatment is working. V5 stated a small change can determine cause of wound treatment. On 04/19/2025, at 2:06 PM, V6 (Dietitian) via phone stated R1 was weighed when he came to the facility on [DATE]. The next weigh in was on 4/3/2025. V6 stated the facility missed a few weigh-ins for R1. V6 stated per facility policy, all newly admitted residents are weighed once week to closely monitor nutritional status to make sure they are meeting their daily nutritional needs. On 04/19/2025, at 4:28 PM, V7 (Assistant Director of Nursing) stated R1 came to the facility on [DATE]. The first weight was taken on 3/17/2025. V7 stated R1 should have had his weight taken on day of admission on 3/14/2025, on 3/21/2025, on 3/28/2025 and then on 4/4/2025. V7 stated R1 has two weights on file: 3/17/2025 and 4/3/2025. V7 stated it is important to weigh residents upon admission to obtain a baseline which allows facility to determine if the resident is gaining or losing weight. V7 stated it's a problem when a resident is not weighed weekly for four weeks. It would not give a clear picture of the residents' health because weight is part of the vitals family and would indicate if the resident is gaining or losing weight. V7 stated weekly weights allows the facility to put interventions in place quickly to improve resident health, either by increasing calories with the recommendations of the dietitian or doing a calorie count for the resident to lose weight. R1's Physician Order Sheet (POS) dated 3/20/2025, documents: Check weekly weight for four weeks, everyday shift, every Thursday for four weeks. Policy titled WEIGHTS, DATED 03/02/21, documents: -A baseline weight will be established upon admission. The resident will be weighed weekly for four weeks after admission and monthly thereafter. -Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain. Policy titled Prevention and treatment of pressure Injury and other skin alterations, dated 03/02/21 document's: -Evaluate residents for actual pressure injuries or other skin alterations on admission or readmission by utilizing the initial nursing assessment.

Based on interview and record review, the facility failed to ensure one (R2) of three residents reviewed for quality of care received appropriate care and management for the diagnosis of diabetes, by failing to monitor R2's blood sugar levels upon admission and failing to provide continuity of care through medication administration in a total sample of six residents. Findings include: According to R2 face sheet, R2 admitted is 2/11/2025. R2 has diagnoses that include but are not limited to type 2 diabetes mellitus; acute and chronic respiratory failure with hypoxia and hypercapnia; chronic obstructive pulmonary disease; heart failure; chronic kidney disease, stage 4. R2 care plan reads in part: Resident has the potential for hypo/hyperglycemic reactions secondary to diagnosis of diabetes mellitus, initiated 2/12/2025. 4/3/25, at 1:32 PM, V6 (Licensed Practical Nurse) stated for blood sugar checks, we go by the MAR (medication administration record), what the doctors order. They are usually taken before meals. We do have some residents that get checks four times daily because they get Lantus insulin (A slow acting insulin that is usually given on the night/evening shift). If a resident is on an insulin they should be getting blood sugar checks. You have to monitor the blood glucose level. You have to know what the blood sugar level is in order to give the insulin. Diabetics that are on oral medications do get blood sugar checks but maybe not as often as if they were on insulin. Its according to what the doctor orders. Blood sugar monitoring is dependent on what the doctor orders. 4/3/25, at 2:49 PM, V8 (Licensed Practical Nurse) stated blood sugar checks are done per the physician order. All diabetic residents should be getting blood sugar checks. You have to know where their sugar level is before giving insulin. If the sugar is low, interventions need to be implemented and notify the physician. If blood sugar level is too high the physician needs to be notified. For a diabetic resident you check the blood sugar before giving insulin. You need to check if the resident is on oral medications as well. You need to know the parameters. When the resident is admitted , if the resident is a diabetic, and if there is an order for insulin, the physician should be contacted immediately upon admission for blood sugar check and insulin administration. It is not proper for a diabetic resident not to have blood sugar checks, or not be given medications for a week after admission. If not checking the blood sugar level and still administering insulin their sugar can drop, and the resident could end up in a diabetic coma. You need to know if the blood sugar level is too high because you need to notify the physician if it is. 4/3/25, at 4:18 PM, V4 (Assistant Director of Nursing) stated the expectation is to follow doctors' orders for blood sugar checks. All the diabetics get blood sugar checks, at different frequencies. If the resident is receiving insulin, they should be getting blood sugar checks to monitor for levels too low or too high. If the blood sugar level is too low the resident could become dizzy and pass out. It is a dangerous thing. If the level is too high could go into diabetic ketoacidosis. We follow the orders from the hospital. We reconcile with the doctor. The nurse would know to add the blood sugar check order inside the order for the short acting insulin. For the long-acting insulin, the nurse goes by the hospital record for the blood sugar check. R2 is on Lantus and Trulicity. Since she is diabetic and on insulin the blood sugar check would be a standing order, in the morning and at bedtime. I would discuss blood sugar check frequency with the doctor. 4/3/25, at 5:23 PM, V3 (Director of Nursing) stated for newly admitted diabetics and all residents, we should be following doctors' orders for blood glucose monitoring and medication administration. R2 should have been receiving blood glucose monitoring from admission through 2/18/25, because R2 is a diabetic and receiving insulin. R2 should have been receiving blood glucose monitoring to monitor blood sugar levels. We monitor levels to know how to administer insulin. If insulin is administered incorrectly there could potentially be an adverse effect/reaction. R2 was discharged from the hospital on insulin. There should be blood sugar monitoring for long acting and short acting insulins and oral medications. R2 should have been receiving whatever medications were ordered. Insulin was ordered, it did not come from pharmacy. It was discontinued and a different insulin was ordered and started on 2/15/25. The blood sugar monitoring was not documented from 2/12/25 to 2/18/25. R2 hospital discharge medication list indicates R2 was discharged taking: empagliflozin 10 MG in the morning; Semglee insulin glargine 15 units daily; Trulicity 0.75 MG/0.5ML weekly. R2 Census List indicates R2 has been active status in the facility since 2/11/2025 6:35 PM. R2 Weights and Vitals Summary indicates one blood sugar reading on 2/11/2025, with result of 360. No other blood sugar readings noted until 2/18/2025 with result of 214. According to R2 physician order summary, orders for diabetes mellitus include: -Blood Glucose monitoring: call physician for results less than 50 or greater than 400, start date 2/18/2025, no end date. -Semglee Insulin Glargine, 15 unit subcutaneous in the morning, start date 2/12/2025, end date 3/12/2025. -Lantus Insulin Glargine, 15 unit subcutaneous at bedtime, start date 2/15/2025, end date 3/12/2025. -Empagliflozin tablet 10 MG in the morning, start date 2/12/2025, no end date. -Trulicity 0.75 MG/0.5 ML subcutaneous every Monday, start date 2/17/2025, no end date. R2 medication admission record, 2/1/25-2/28/25, indicates blood glucose monitoring started 2/18/25 with result of 214. R2 medication admission record, 2/1/25-2/28/25, indicates R2 was administered diabetes medication, Empagliflozin, 2/14 through 2/17. Blood glucose monitoring was not started until 2/18/25. R2 medication admission record, 2/1/25-2/28/25, indicates R2 was administered diabetes medication, Lantus Insulin Glargine, 2/15 through 2/17. Blood glucose monitoring was not started until 2/18/25. R2 medication admission record, 2/1/25-2/28/25, indicates R2 was administered diabetes medication, Trulicity, 2/17. Blood glucose monitoring was not started until 2/18/25. R2 medication admission record, 2/1/25-2/28/25, indicates R2 had an order for diabetes medication, Semglee Insulin Glargine, that was not administered. Progress note 2/15/2025 indicates, awaiting supply from pharmacy. Mayo Clinic at https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/blood-sugar/art-20046628#:~:text=If%20you%20take%20insulin%20to,way%20you%20eat%20or%20exercise.; documents in part: Blood sugar testing is an important part of diabetes care. If you have diabetes, testing your blood sugar levels can be a key part of staying healthy. Blood sugar testing helps many people with diabetes manage the condition and prevent health problems. If you take insulin to manage type 2 diabetes, your healthcare professional might recommend a CGM (continuous glucose monitors). Or you may need blood sugar testing several times a day. The exact number of times depends on the type and amount of insulin you use. Often, testing is advised before meals and at bedtime if you take more than one shot of insulin a day. You may need to test only before breakfast and sometimes before dinner or at bedtime if you use an intermediate- or a long-acting insulin. Facility policy Assure Platinum Blood Glucose Monitoring, 8/2024, documents in part: Document test results in medical record.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that fall risk assessments are accurate, failed to develop and/or implement preventive interventions, and failed to provide supervision to two of three residents (R2, R5) reviewed for falls. These failures resulted in the following: R5 sustained (12/31/24) fall resulting in intracranial hemorrhage and traumatic head injury requiring 4 staples. R1 sustained (1/10/25) fall resulting in left eyebrow laceration requiring 6 sutures. Findings include: R5 was admitted (11/25/24) with diagnoses which include Alzheimer's disease, glaucoma, (1/8/25) traumatic subarachnoid hemorrhage and fall, subsequent encounter. The fall incident log affirms R5 fell on [DATE], 2/3/25, 2/17/25, and 2/23/25. R5's (2/23/25) post fall risk assessment determined a score of 8 (indicating at risk) however R5 fell 3 times in February [therefore is high risk]. R5's (1/17/25) BIMS determined a score of 5 (severe impairment) with inattention behavior continuously present. R5's (1/17/25) functional assessment affirms resident requires partial/moderate assistance with sit to stand and chair/bed to chair transfer, walking was not attempted due to medical condition or safety concerns. R5's (11/26/24) care plan includes risk for falls related to poor balance, cognitive deficits, poor safety awareness and wandering behaviors. Interventions: (12/8/24) Resident will be within arm length of staff monitoring dining/day room. R5's (12/31/24) incident report states injury of unknown cause: resident noted with blood at the back of her head at about 6:30am at the nursing station. Upon assessment, writer observed a cut. Resident unable to give an account of incident. Resident sent to the hospital for further evaluation. The resident wanders with an unstable gait and is non-redirectable. R5's progress notes state (12/31/24) Writer contacted hospital to follow-up on resident. Resident being admitted with a diagnosis of intracranial hemorrhage. (1/6/25) Received resident back from the hospital. Four staples at the back of her head. R5's (12/31/24) final report states the facility has determined that the resident endured a fall due to unsteady gait while pulling the windows open. On 2/25/25 at 11:13am, surveyor inquired about R5's location V12 (Licensed Practical Nurse) stated She (R5) had a fall, she's in the hospital. She was sent there Sunday (2/23/25). On 3/3/25 at 12:13pm, surveyor inquired about R5's cognitive status V3 (ADON/Assistant Director of Nursing) responded I would say that she alert and oriented x/times 2. She's oriented to her name and location of her room. Surveyor inquired about R5's (12/31/24) injury of unknown origin V3 replied It happened at 6:30 in the morning, she (R5) came from her room and walked to the Nurse's station. That's when the Nurse observed that she (R5) had a cut on the back of her head [therefore the incident was not witnessed]. She (R5) was unable to give an account of what happened. Surveyor inquired if R5's fall care plan was reviewed and/or revised on or about 12/31/24 to prevent additional falls V3 reviewed R5's electronic medical records and stated No, I don't see it updated for that one. I don't see a intervention for that to reflect December 31st. No, I don't see nothing for an intervention for her falls care plan. On 3/5/25 at 12:37pm, surveyor inquired about potential harm to a resident that sustains an unwitnessed fall V19 (Medical Director) stated Anybody with an unwitnessed fall with a head injury they can have a bleed. Surveyor inquired what type of injury requires staple repair? V19 responded Superficial cuts which are deep enough they will need staples or sutures. Surveyor inquired what the facility should implement post falls V19 replied If the resident falls, then the facility has fall protocols which they can implement. On 2/14/25, the State Agency received allegations that R2 is supposed to have frequent/constant monitoring by staff however fell 3 times in the last 10 months. On 1/10/25, R2 fell and sustained a head wound. The fall incident log affirms R2 fell on [DATE], 5/15/24, and 1/10/25. R2's diagnoses include dementia, hemiplegia/hemiparesis affecting right dominant side, and history of falling. R2's (11/9/21) admission fall risk assessment determined a score of 8 (at risk). R2's (2/10/25) BIMS (Brief Interview Mental Status) affirms short term memory problem and cognitive skills for daily decision making is severely impaired. R2's (2/10/25) functional assessment affirms resident is dependent on staff for sit to stand, and chair/bed to chair transfer, walking was not attempted due to medical condition or safety concern. R2's (1/10/25) incident report states resident in room sitting in her wheelchair. Upon rounds Nurse observed resident in lying position on the floor. Resident has laceration above left eyebrow. Resident non-verbal unable to give description. Predisposing situation factors: ambulating without assist. R2's (1/14/25) progress note states resident has 6 sutures on the left eyebrow. R2's (4/30/24) care plan includes risk for falls due to hypotension, cognitive deficits related to developmental disability, poor balance, poor safety awareness, unsteady gait, impulsivity, and inability to follow instructions. Interventions: placement of call light within reach. Rounding at a minimum of every 2 hours. On 2/25/25 at 12:08pm, R2 was observed lying in bed and the call light was noted to be on the floor (out of reach). R2's left foot was on the floor and the right foot was near edge of the bed. R2 was alone in the room. On 2/25/25 at 12:10pm, surveyor inquired about R2's fall prevention interventions V13 (Licensed Practical Nurse) stated She has floor mats, her call light, and has her bed in lowest position. V13 subsequently entered R2's room (as requested). Surveyor inquired about the location of R2's call light V13 responded On the floor now. Surveyor inquired if R2 can walk V13 replied No, she's a 2 person assist. She will try to get out the bed on her own that's why we have to keep putting her in the bed then placed R2's left leg on the bed. Surveyor inquired if R2 can communicate V13 stated She's non-verbal. On 3/3/25 at 11:35am, surveyor inquired about R2's (1/10/25) fall V3 (ADON) stated She (R2) was in her room, the nurse made rounds and observed her (R2) on the floor with a laceration to her head. It was a unwitnessed fall. Surveyor inquired about concerns with R2's (1/14/25) post fall risk assessment V3 responded #2 predisposing condition, is supposed to be hypotension, it wasn't marked. That would have gave 2 points if it was marked. The next thing is the mentation, they (staff) put confused but in my opinion, I would have put impaired memory overall it would have been a higher score if they picked impaired memory. The assessment wasn't correct actually it would have been higher. The medication, I'm not sure about that. Surveyor inquired about R2's fall risk score which indicates at risk (instead of high risk) V3 replied It do say 5 which means at risk, but I can say overall it's not correct. Surveyor inquired about R2's fall prevention interventions (post 1/10/25 fall) to prevent additional falls V3 stated She's being supervised like her room is close to the Nurses station. She actually do get out of bed and has a mind of a 2-year-old, so we (staff) try to do what we can to protect her. The (08/2020) management of falls policy states the facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Complete a fall risk assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, incontinence, medications, assistance required with ADLS, gait/ transfer/ balance issues, behaviors, and/or cognitive status. Review and modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.

Based upon interview and record review the facility failed to follow policy procedures and failed to develop a comprehensive care plan for one of three residents (R4) reviewed for abuse. Findings include: On 2/20/25, the State Agency received allegations that V7 (Certified Nursing Assistant) has been having an intimate relationship with R4 for the past two months, and this is abuse. R4 was admitted to the facility on [DATE]. R4's comprehensive care plan (received 2/26/25) excludes risk for abuse. On 2/26/25 at 11:32am, surveyor inquired when comprehensive care plans are developed V3 (ADON/Assistant Director of Nursing) stated The initial is on new admission. [R4 was admitted roughly 5.5 months ago]. On 3/3/25 at 12:27pm, surveyor inquired if R4 has an abuse care plan V3 reviewed R4's electronic medical records and responded I (V3) just see that he's (R4) an identified offender. I don't really see a care plan that he's at risk for abuse. Surveyor inquired if abuse should be included in resident care plans due to potential risk for abuse perpetrated by staff, residents and/or visitors V3 replied I'm not really sure. The (11/2017) comprehensive care plan policy states the interdisciplinary team will develop and implement a person-centered comprehensive plan of care. The comprehensive, person-centered plan of care is developed within 7 days of the completion of the required comprehensive MDS (Minimum Data Set). Care plans are comprised of focus statements, goals, and interventions. The comprehensive person-centered care plan will: describe the services that are to be provided to attain or maintain the highest practical physical, mental, and psychosocial well-being. Identify the professional services that are responsible for interventions.

Based upon record review and interview the facility failed to follow policy procedures and failed to review/revise comprehensive care plans for two of four residents (R1, R5) reviewed for falls and pass privileges. Findings include: On [DATE], the State Agency received allegations concerning resident medical records not being updated to reflect current condition. On [DATE] at 11:32am, surveyor inquired when care plans are required to be reviewed and/or revised V3 (ADON/Assistant Director of Nursing) stated It's every 3 months and if it's a change or something new comes up. R1's care plans include the following: ([DATE]) Risk for falls, Goal Target Date: [DATE] [expired 2.5 months ago]. ([DATE]) Resident has been evaluated to be placed on a level one of the behavioral health pass program, Goal Target Date: [DATE] [expired 2.5 months ago]. On [DATE] at 12:01pm, surveyor inquired about concerns with R1's ([DATE]) fall care plan V3 (ADON) reviewed R1's electronic medical records and stated, I actually don't see anything wrong with this care plan. Surveyor inquired about R1's fall goal target date V3 responded It say [DATE], is the goal target date; today is [DATE]. Surveyor inquired when R1's fall care plan was supposed to be reviewed and/or revised V3 replied It's done every 3 months so that review should have been done [DATE] to [DATE]. Surveyor inquired when R1's behavioral health pass program care plan was last reviewed and/or revised V3 replied The target date say [DATE], it should be reviewed [DATE] to [DATE] and affirmed it was not. R5's ([DATE]) incident report states resident noted with blood at the back of her head, upon assessment, writer observed a cut. Resident unable to give an account of incident. R5's ([DATE]) final report states the facility has determined that the resident endured a fall due to unsteady gait while pulling the windows open. R5's ([DATE]) care plan includes risk for falls however preventive interventions and/or revisions on or about [DATE] are excluded. On [DATE] at 12:13pm, surveyor inquired if R5's fall care plan was reviewed and/or revised on or about [DATE] V3 reviewed R5's electronic medical records and stated No, I don't see it updated for that one. I don't see an intervention for that to reflect [DATE]st. The (,d+[DATE]) comprehensive care plan policy states the interdisciplinary team will develop and implement a person-centered comprehensive plan of care. Assessment of the resident is ongoing and care plans are revised based on the resident condition, preferences, treatments, and goals change. The (,d+[DATE]) management of falls policy states the facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the residents plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Review and modify the residents plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.

Based on record review and interview the facility failed to follow their abuse policy for one resident (R1), out of three residents reviewed abuse. This failure resulted in R1 falling to the floor during a behavior episode when a staff member who was not appropriately trained on Crisis Prevention Interventions (CPI) attempted to assist with the behavior. Finding Include: R1's care plan reads: R1 has difficulties managing her anger/frustration as evidenced by verbal and physical aggression. During periods of increased agitation, move resident to a quiet location, and intervene as appropriate. 10/26/2024 08:40 R1 Behavior Note Text reads: Writer witness resident grab food rack from staff and shove and throw (it) down, at her, and other residents in facility. Writer responded asking resident to calm down, attempting to redirect. Resident then refused and said, you can't touch me, and you will be next if you don't shut up talking to me. Resident then walked east and around towards room shouting, stop talking to me. 10/26/2024 14:14 R1 Nurses Note Text reads: resident was exhibiting aggressive behavior toward staff. DR (doctor). was called and over order to petition resident out to hospital. On 1/30/25 at 5:00 PM V4 (Certified Nurse Aide) stated she has worked at the facility for seven years. V4 stated she has worked around V1 (housekeeper) for seven years. V4 stated V1 was a nice hard-working guy from what she had seen of him. V4 stated she has never seen V1 abuse anyone or curse at the residents. V3 stated she was in the dining room passing breakfast trays when R1 came in cursing and talking to herself. V4 stated she gave R1 her tray when R1 suddenly jumped up and threw her plate of food on the floor. V3 stated then R1 snatched the cord out the socket of the television. V4 stated she called the social worker (V5) who came and talked to R1 to try to get R1 to calm down. V4 stated V1 then walked into the dining room to clean the floor so no one would slip and fall. V4 stated she was on the other side of the dining room and did not hear his conversation with R1. V3 stated V1 cleaned up the floor and then he left the dining room. V4 stated V5 escorted R1 out of the dining room. V4 stated she helped another resident leave the dining then saw R1 go down the hall to her room when she suddenly grabbed a broom and swung it at V5. V4 stated during the incident she broke V5 glasses. V4 stated during the commotion did not see what happened but that suddenly R1 and V1 were on the floor. On 1/30/25 at 5:20pm V5 (Social Worker) stated he was called to the dining because R1 was being irate and throwing food on the floor. V5 stated when he walked into the dining room, he saw R1 knocking things off the table. V5 stated he attempted to redirect and deescalate the situation. V5 stated someone had already called V1 in to clean the food off the floor. V5 stated as R1 was leaving the dining room she knocked over the food tray cart and then they called the code for security. V5 stated R1 went on the other side hallway like she was going towards her room when she picked up the broom stick and was swinging it like a baseball bat. V5 stated while talking to R1 she did hit him, and his glasses broke. V5 stated she continued swinging and she lost her balance while V1 was trying to grab it (the broom) from her and R1 slid onto her buttocks. V5 stated while R1 was sitting on the floor they eventually got the broom stick from her. V5 stated the paramedics and police arrived at the facility and R1 was taken out of the facility in handcuffs. V5 stated R1 has a history of aggression towards staff and was a considerably large woman for her size and could be intimidating to some. On 1/30/25 at 5:50pm V3 (Assistant Administrator) stated received a phone call about an incident between staff (V1) and a resident. V3 stated was told by staff that R1 was in the dining room acting out and that she threw breakfast on the floor. V3 stated told by staff they tried to deescalate the situation to get R1 to calm down. V3 stated was told staff called for housekeeper (V1) to the dining room to clean the food off the floor. V3 stated the staff told her that V1 did not curse or hit R1 while he was cleaning the floor then left the dining room. V3 stated the social worker (V5) noticed that R1 was still agitated and directed R1 to go to her room to calm down. V3 stated was told when R1 left the dining room shortly thereafter. V3 stated he was told by staff that on her way to her room R1 grabbed a broom off V1's housekeeping cart. V3 stated interviewed V1, and he told her he thought R1 was going to hit them, so he grabbed the broom and they tripped and slid onto the floor. V3 stated staff placed R1 on 1:1 supervision until the paramedics and police arrived to take R1 to the hospital. V3 stated after they were told what had transpired V1 was sent home. V3 stated V1 was suspended while an investigation could be done. V3 stated he was never trained on how to confront an aggressive resident and it was not his place or part of his duties to try to subdue R1. V3 stated even though resident sustained no injuries he (V1) was terminated because he had no training on CPI (Crisis Prevention Intervention) and because he touched her and should have not. V2 (Human Resource Manager) she on 1/30/25 at 6:15 PM stated came to work the following Monday 10/28/24. V1 stated told that an incident occurred Saturday (10/26/24) morning after breakfast between R1 and V1. V2 stated that R1 was irate and took a broom or mop off the housekeeper cart. V2 stated was informed that V1 approached R1 and while trying to get the broom from R1 they slid onto the floor. V1 stated told by staff that they called one of the supervisors and V1 directed to leave the facility until he talks with administration. V1 stated while V1 was suspended facility did an investigation and administration concluded even though R1 had no injuries, because V1 physically touched R1 and was not supposed to, he was to be terminated. R1's incident report dated 11/1/24 reads the housekeeper states that he responded physically to R1. Housekeeper stated out of concern for resident and staff safety R1 was subdued. Facility conclude that the housekeeper acted out of his scope of duty by assisting to subdue R1. Corrective measures were taken with housekeeper. V1 disciplinary memorandum dated 11/5/24 denotes Employee to be discharged for getting into a physical altercation with resident on 10/26/24. Facility's abuse policy reads the facility is committed to protecting our residents from abuse by anyone including but limited to facility staff. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion.

Based on observation, interview, and record review, the facility failed to a.) implement/revise the care plan interventions addressing the resident's required nutritional support for one (R4) resident b.) the facility's intermittent failure to provide required assistance/monitoring with eating resulted in poor intake for one (R4) resident out of three residents reviewed, in a total sample of three residents. This failure resulted in R4's significant, not severe, unplanned weight loss. Findings include: R4's current face sheet documents R4 is a [AGE] year-old individual admitted to the facility on [DATE] with diagnoses not limited to: chronic obstructive pulmonary disease, unspecified, unspecified dementia, muscle weakness (generalized), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, repeated falls, other seizures. On 11/06/2024. 12:17 PM, R4 sitting on a mobile reclining geriatric chair with a bedside table in front of him, food tray in front of R4, R4 grabbed food with hands and fed self. On 11/06/2024, 12:20 PM, Staff preparing meal trays, cook serving the meal plates, CNAs (certified nursing assistants) heading to pass out trays in rooms. On 11/06/2024, 12:20PM, R4's pillow slid towards upper back, and no longer supporting R4's back of head. R4 not eating, R4 appears laying back, chin tilted towards ceiling, mouth chewing movements. No staff helped R4. On 11/06/2024, 12:23 PM, R4 using his fork attempting to grab some food in a bowl and fed self. R4's chin slightly facing towards the ceiling, R4's head slightly tilted towards the ceiling while R4 is chewing the food. No staff helped R4. On 11/06/2024, 12:24 PM, R4 having difficulty reaching a bowl with a fork. R4 able to grab a piece of food with the fork and ate some food while food particles fell on R4's clothing. R4 grabbed a big piece of the quesadilla with fork but the quesadilla fell off, and R4 proceeded to grab the whole piece of the quesadilla with his left hand. No staff helped R4. On 11/06/2024, 12:26 PM, R4 struggling to drink with straw, appears forcing his neck up. Appears in an uncomfortable sitting position, chin facing up. No staff helped R4. On 11/06/2024, 12:32 PM, R4 sitting on a Geri-chair, R4's face slightly facing the ceiling as R4 is seen biting his sandwich. No staff helped R4. On 11/06/2024, 12:35 PM, R4 using right hand, using fork to grab food from small bowl. Requesting juice, while food is in his mouth. R4 saying out loud that he wants some cake. Observed grabbing food with his left hand but then R4 observed placing the piece of food down on the plate. No staff helped R4. On 11/06/2024, 12:50 PM, R4's ate half a sandwich, half of the quesadilla. On 11/07/2024, 12:39 PM, R4 lying in bed, right hand limited range of motion. No meal tray yet passed out to R4. V14 states I'm going to assist him. On 11/06/2024, 2:59 PM, via telephone V13 (Clinical Nutrition Manager) stated that she tries to come to the facility every week and the last time that she was in the building was last Wednesday. Surveyor questioned V13 who is involved in evaluating and addressing any underlying causes of nutritional risks or impairment. V13 stated that the dietary manager is part of the team, and V13 stated I am the one that pulls the weight changes and address weight changes. When I come in, V2 (Director of Nursing) and V14 (Assistant Director of Nursing), let me know the people that they want me to see. V13 stated that R4 weighed 138lbs (pounds) on August 7th, 2024, and then at the end of August 30th, 2024, R4 weighed 123lbs. V13 stated it was a significant weight loss, he wasn't in the hospital. That is a lot of weight to lose in a month. V13 was questioned on how often is the resident's food/supplement intake, weight, eating ability monitored? Where is it documented? V13 stated that R4's weight is monitored monthly unless there is a change to weekly, which could happen, V13 states eating is in the tasks, and med pass is in the MAR (medication administration record). V13 stated that it is important to monitor in the dining room, and if staff notice that he is not eating his meal or having difficulty than it would be the day that R4 needs help. V13 stated that R4 needs set up assist and encouragement. V13 stated as she is reviewing R4's record, task under eating, some days it looks like he needs assistance or total assistance. V13 stated that if a resident is a feeder, then it would be documented as dependent. 11/08/2024, 1:09 PM, via telephone V27 (Nurse Practitioner) stated he (R4) needs to eat more, and the goal is for weight increase. V27 stated that part of it is for staff giving V27 the weights for R4. V27 stated food intake is one part of the equation of weight loss, it's not always an indicator. V27 stated that nursing is responsible to make sure they are eating well and tell why they are not eating well. V27 reported he (R4) needs 1:1 eating, but if he does not want to be fed, they need to supervise him. V27 stated positioning matters, you cannot lie flat and eat comfortable. V27 stated that he has taken care of R4 for several years and R4 has had a significant weight loss. V27 stated it's a collection of effort, and multidisciplinary approach, meals are very important. V27 stated that the nurse and CNA are supposed to monitor. 11/07/24, 10:54 AM, via telephone V23 (Certified Nursing Assistant) stated that R4 eats and is an assistive feeder as well. V23 stated he (R4) has a hard time keeping the food on the spoon. Since I work nights, I don't know currently. V23 stated that R4 can feed himself, V23 stated although his food will fall because his hand will be unsteady. R4's nutrition note dated 10/26/2024, 5:27 PM, documents in part, current diet general/mech soft diet with thin liquids, supplements noted. Wt. (weight) -119.0# sig wt (weight) loss -14.1% -19.6 x2mo (months), -13.5% -18.6 x4mo. Diet does support 100% resident est (estimate) needs. Total assist, PO (by mouth) intake 51-100%. Will rec (recommend) appetite stimulant. R4's Nutrition Quarterly/Reassessment assessment dated [DATE] documents in part comments: Total assist. R4's Minimum Data Set (MDS), section GG dated 9/03/2024, documents in part that R4 requires supervision or touching assistance for eating. R4's weight log documents the following: June 2024 is 138.2 lbs (pounds), July shows no weight documented, August 2024 is 138.6 lbs, September 2024 is 123.4 lbs, and October 2024 is 119.0 lbs. R4's 30-day look back for CNA documentation for task: Amount Eaten shows no documentation for the following dates: 10/13/2024, 10/17/2024, 10/18/2024, 10/20/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, 11/02/2024, 11/03/2024. Several other dates noted with discrepancies (missing documentation for different meals, only one meal documented for the date). No lunch meal amount eaten documented in R3's medical record for 11/06/2024. R4's 30-day look back for CNA documentation for Eating: the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident shows no documentation for the following dates: 10/13/2024, 10/17/2024, 10/18/2024, 10/20/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, 11/02/2024, 11/03/2024. Several other dates noted with discrepancies (missing documentation for different meals, only one meal documented for some dates). R4's current care plan documents in part, R4 requires nutritional support. R4 will maintain current nutritional status with current nutritional interventions. Will maintain weight. Interventions/Tasks meal monitoring and recording as indicated. Set up resident's tray and provide assist or cueing for meals as needed. R4's care plan does not document that he has been assessed for the use of finger foods to make eating easier. The facility's Policy, titled Comprehensive Care Plans dated 11/2017, documents in part, The comprehensive person-centered care plan will: Describe the services that are to be provided to attain or maintain the highest practical physical, mental and psychosocial well-being.

Based on observation, interview, and record review the facility failed to provide special eating equipment and appropriate assistance for one (R3) resident out of three residents reviewed, in a total sample of three residents. This failure has the potential to affect the resident's ability to maintain or improve their ability to eat or drink independently. Findings include: R3's current face sheet documents R3 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia in other diseases classified elsewhere, muscle weakness (generalized). On 11/06/2024, 12:16 PM, R3 in dining room using her left-hand appears having difficulty grabbing food off the plate with a spoon. Observed dropping food off the spoon as she lifted to feed herself slowly. On 11/06/2024, 12:20 PM, R3 sitting in dining room not eating. Staff preparing meal trays, cook serving the meal plates, CNAs (certified nursing assistants) heading to pass out trays in rooms. On 11/06/2024, 12:21 PM, R3 in dining room attempting to reach her food with utensil, but unsuccessful, opened mouth, grabbed the whole piece of quesadilla with her left hand. R3 bit a piece of the quesadilla off and placed the rest on the plate. On 11/06/2024, 12:28 PM, R3 in dining room using her left hand to grab food. Did not observe staff clean residents' hands/apply hand sanitizer. On 11/06/2024, 12:30 PM, R3 sitting in dining room eating slowly, no staff sitting next to her. On 11/6/24, 12:32 PM, R3sitting in dining room not eating, sitting in front of her meal tray. On 11/06/24, 12:38 PM, R3 grabbing/touching her food with her left hand to feed herself, right hand/arm bent against her chest. R3 eating slowly. 11/06/2024, 12:43 PM, R3 sitting in dining room grabbing food with her left hand and placed it back on the plate. On 11/06/2024, 12:50 PM, R3's sitting in dining tray ticket for 11/6/2024, documents in part Adap. (adaptive) Equip (Equipment): Plate Guard. No plate guard noted. 11/07/2024, 12:45 PM, R3 lying in bed, head of the bed elevated, observed V21 (Licensed Practical Nurse) feeding R3. R3's tray ticket for 11/7/2024, documents in part Adap. (adaptive) Equip (Equipment): Plate Guard. No plate guard noted. V21 states I just came in, she (R3) was feeding herself. She was using the spoon to pick up the meat, I gave her the fork to use. 11/7/24, 12:53 PM, V25 (Dietary Supervisor) stated the nurses fill out the dietary slips and V25 just prints them out. V25 stated I add to the slips if there are double portion orders and likes and dislikes. Surveyor requested to see a plate guard. V25 stated plate guards are on order; I don't think they have been ordered yet. Let me go find out. V25 provided surveyor with documents that the plate guard orders were placed on 11/7/24. R3's Nutrition Quarterly/Reassessment assessment dated [DATE] documents in part Diet: Adaptive Equipment: Plate Guard. R3's Minimum Data Set (MDS), section GG dated 9/11/2024, documents in part R3 requires supervision or touching assistance for eating. R3's 30-day look back for CNA documentation for task: Plate Guard: promotes independence while minimizing messy spills at mealtime documents that on several days documents yes including for 11/06/2024, no refusals documented. R3's care plan does not document that she has been assessed for the use of finger foods to make eating easier. The facility's Policy, titled Restorative Nursing Program dated 3/10/2022, documents in part, it is the policy of this facility that a resident is given the appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the resident's ability to adapt and adjust to living as independently and safely as possible.

Based on interview and record review, the facility failed to maintain medical records for one resident (R1) in accordance with its policy and accepted professional standards of practices that are complete and accurately documented. This failure affects one of three residents reviewed for records, in a total sample of three residents. Findings include: During record review of R1s' electronic health record on 11/06/2024, at approximately 1:30 PM, R1s' most recent community survival assessment dated [DATE], documents that R1 is not capable of unsupervised outside pass privileges at this time. R1s' community survival skills assessment dated [DATE] and signed by V29 (Behavioral Health Counselor/BHC), documents that R1 is not sufficiently oriented and coherent affording her the potential for independent pass privileges. R1s' assessment also documents that R1 is not capable of unsupervised outside pass privileges. Surveyor requests a copy of R1s' most recent community survival assessment from V7 (Director of Behavioral Health) on 11/06/2024, at approximately 2:45 PM. On 11/06/2024, at 3:22PM, V2 (Director of Nursing/DON) states the facility staff assesses the residents quarterly to update their needs to go out on community pass. On 11/06/2024, at approximately 4:15 PM, V7 brings surveyor a community survival skills assessment dated [DATE]. Surveyor makes V7 aware that the assessment was not documented in R1s' electronic health record prior to surveyor's request. V7 states the assessment was completed on 08/08/2024 but was not signed until today 11/06/2024. On 11/06/2024, at 5:22 PM, V1 (Administrator) provided surveyor with a community survival skills assessment with information handwritten in ink dated 07/11/2023. Surveyor observes that this handwritten assessment dated [DATE], provided by V1 does not match the information from the electronic assessment dated [DATE] inside of R1s' electronic health record. On 11/07/2024, at 2:30 PM, surveyor inquires to V1 about the handwritten assessment. V1 states V7 provided the assessment to V1 to give to surveyor. Surveyor makes V1 aware that the handwritten assessment dated [DATE], provided by V7, does not match the information from the assessment dated [DATE], inside of R1s' electronic health record. On 11/07/2024 at 3:02 PM, V7 (Director of Behavioral Health) stated the reason for the handwritten assessment is because she realized that R1s' electronic community survival skills assessment was completed inaccurately. V7 stated upon her noticing it, she gave V29 (BHC/Behavioral Health Counselor) another assessment form and informed V29 to complete a new form, which is why the form is now handwritten. V7 stated the electronic assessment that is dated 07/11/2023, in R1s' electronic health record documents that R1 cannot have unsupervised pass privileges which conflicts with R1s' physician orders. V7 stated R1s' physician orders document that R1 can have unrestricted independent passes. V7 stated the community survival skills assessment are completed annually or upon any significant change. V7 stated R1s' community survival skills assessment dated [DATE], would also be considered past due since it is dated 08/08/2024 and more than one year after 07/11/2023. R1s' care plan documents in part, R1 has independent pass privileges, R1 understands that she is pass level 2, 1 hour and reports that she will comply with the pass policy of the facility. R1 community survival skills will be assessed quarterly and annually. Facility policy dated 10/2023, titled [NAME] Behavioral Health Program Assessment/Reassessment and Care Planning Requirements documents in part, Policy- [NAME] staff will complete a thorough assessment on all residents for the purpose of proper care planning and treatment. 4. a. Comprehensive Assessment (Initial, annual or significant change): - Community Survival Skills Assessment.

Based on observation, interview, and record review, the facility failed to provide the fall prevention interventions as stated in the care plans for residents with Dementia who are also at risk for falls. This failure has the potential to affect 4 residents, R8, R9, R10, and R11, reviewed for proper footwear as a fall prevention intervention. Findings include: On 10/9/24 between 10:45am and 10:55am during observation on the fourth floor, the following were observed: R11 was observed walking in the hallway and by the nursing station with red socks that are smooth on the bottom; V5(Memory Care Director) stated She's supposed to wear non-skid socks. R10 was observed in the day room in the wheelchair with black socks that are smooth on the bottom. R9 was observed in the day room with grey socks that are smooth on the bottom. R8 was observed in the day room sitting with other residents at the table with socks that are smooth on the bottom. The surveyor inquired about R8, R9, and R10, from V14 (CNA/Certified Nurse Assistant) in the dayroom/dining room. V14 stated We will change the socks for all of them. On 10/9/24 at 11:15am, V13 (Restorative Nurse) stated All residents at risk for falls need to wear gripper socks; they can wear nonskid shoes, but they cannot wear regular socks because regular socks are slippery, and they are falls hazard. R8's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R8 is at risk for falls. R8's Care plan dated 8/20/21 states that R8 is at risk for falls related to poor safety awareness. Intervention states to provide proper well-maintained footwear. R8's Basic Interview for Mental Status (BIMS) Score is 0 out of 15(Severe Cognitive Impairment). R9's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R9 is at risk for falls. R9's Care plan dated 10/12/2017 states that R9 is at risk for falls related to poor safety awareness and impaired Cognition. Intervention states provide proper well-maintained footwear. R9's BIMS Score is 9 out of 15(Mild Cognitive Impairment). R10's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R10 is at risk for falls. R10's Care plan dated 2/11/2018 states that R10 is at risk for falls related to unsteady gait, use of assistive devices, osteoporosis, use of psychotropic medication. My friends Intervention states provide proper fitting nonskid footwear. R10's BIMS Score is 7 out of 15(Moderate Cognitive Impairment). R11's records reviewed are as follows: Fall Risk assessment dated [DATE] states that R11 is at risk for falls. R11's Care plan dated 10/12/2017 states in part that R11 is at risk for falls related to impaired cognition, incontinence of bladder and bowel, cardiovascular disease with hypertensive medications, prediabetes, and depression. Intervention states to provide proper fitting nonskid footwear. R11's BIMS Score of 0 out of 15(Severe Cognitive Impairment). Facility's Fall Management Program dated 08/2020 states in part: While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies, and facilitate a safe environment. #5 states: Use standard fall safety precautions for all residents.

Based on observation, interview, and record review, the facility failed to ensure that the large community shower room on the fourth floor East-Wing is maintained in a sanitary manner free of drain/sewer back-up. This failure has the potential to affect all 37 residents on the fourth floor East-Wing. Findings include: On 10/7/24 at 10am after the entrance conference, V1(Administrator) presented the census that shows as follows: Fourth Floor Unit A - 19 residents; Fourth Floor Unit B - 18 residents; total of 37 residents on the East wing of the fourth floor. On 10/7/24 at 10:40 am, with V10 (Assistant Director of Nursing), observed the East-Wing Community shower room with a wet towel covering the black liquid oozing out of the drain. Surveyor inquired from V10 if it was okay to have the drain like that; V7 stated They used the towel to cover it because they could not use it. I will notify maintenance. The Maintenance logbook did not document anything about the clogged shower room floor drain. On 10/9/24 at 11:22am, V12 (Maintenance Director) stated Somebody told me about it yesterday. I moved the towel away and used a wire to clean out the debris out of the drain. At this time, V12 presented the Maintenance logbook that shows that the drain issue was logged in after the surveyor prompted staff. The facility's job description titled Building Manager states in part: Work involves the coordination of safety and maintenance needs to ensure a comfortable and safe environment. The facility's policy titled Facility Maintenance Request states in part: Staff will put all non-emergency requests for maintenance services in writing on the maintenance and housekeeping log. #4 states: Building manager will check binder and update form periodically during the workday.

Based on observations, interviews, and record reviews the facility failed to provide effective pest control for seven [R1, R2, R6, R7, R8, R9, R10] residents in the sample of 10. These failures have the potential to affect all 51 residents residing on the third floor. Findings include, On 8/20/24 at 10:20 AM R2 stated, I came to this facility because at my old facility, the staff was abusing me there too, and they stole my money. When I came here on 7/1/24, I moved into my room there was bugs crawling over me, the bed and privacy curtain. I told the nurse about it the next morning. I was in the day room, and someone came to me and said, 'you have to move to another room it has to be fumigated for bugs.' I was so embarrassed with my peers staring at me like I was nasty. I did not bring any bugs with me; the bugs were already here. On 8/20/24 at 10:48 AM, R6 stated, I been here since 2021. I know R2. I eat all my meals and participate in activities in the day room, but I keep getting bed bugs in my room. This is my second room change due to bed bugs. They have us take a shower, put on clean clothes, we have to leave everything in the room until the room was treated. They only treat one room at a time, that's why we had bed bugs since January. The exterminators were just here last Friday. On 8/20/24 at 11:15 AM, R7 stated, I just moved out of my room, because there were bed bugs crawling all over me. The exterminators were here last week. On 8/20/24 at 12:55 PM, R8 stated, I had bed bugs in my room crawling in my bed, and on the privacy curtain. I was moved into this room, hopefully they don't come here. This is my second time moving due to bed bugs. I'm not sure why they won't go away, they are gross. On 8/21/24 at 8:33 AM, R9 stated, I moved to this room because I had bugs in my room and in my bed. I like the new room. On 8/21/24 at 2:33 PM, R10 stated, I moved a couple of times due to bed bugs. The exterminator comes out, but it is not helping. Some other residents on the floor told me they have bed bugs as well. On 8/21/24 at 11:16 AM, V8 [Licensed Practical Nurse] stated, I been working here for a year. I am the primary nurse on the third floor. I have been R2's nurse since her admission. Several residents had room changes due to bed bugs on this floor. There has been a bed bug problem here off and on since I been working here. Residents complain about the bed bugs crawling on them while in bed and on the privacy curtains. I have seen several bed bugs in some of the resident rooms. On 8/21/24 at 12:22 PM, V1 [Administrator] stated, I started working here in January 2024, and notice there was a bed bug problem in February. The bed bug protocol is to have the resident shower and wash their hair, leave all personal items and clothing in the room, move all the residents out of the room. I call the extermination company out to assess the area. Once they tell me if they need to treat a room then I call corporate to get approval for the treatment. Corporate tells the extermination company what services they will pay for. I have no control how many rooms the extermination company treats, corporate manages and approve the treatments. When the extermination company comes out, they usually only treat the rooms where there was a sighting. The resident room changes were not entered in their medical chart. I do not know why the room changes was not documented. The resident room changes should have been documented in each resident clinical record. Pest Control Invoice was reviewed from February 9, 2024, thru August 16, 2024, the following rooms was noted with bed bug activity and only those rooms were heat treated. 2/9/24 R9's 2/14/24 R7, and R8 [Roommates] 2/14/24 R9's room 5/28/24 R9's room 7/16/24 R10's room 7/16/24 R2's room 7/25/24 R10' new room, and the room next door had sighting and treated. 8/13/24 R6's room 8/13/25 R7, and R8's room [Roommates] 8/16/24 there were two [2] more room on separate wings of the hallway treated. Policy documents in part: Bed Bug Protocol dated 1/23 Whenever there is a sighting of bug suspected of being a bed bug, the extermination company for a professional determination of the pest. If the pest control contractor determines there is a need for bed bug extermination the facility will call the purchasing director to arrange for a heat treatment for bed bugs, it may be a few days before service. The contractor will come and completed an inspection of the suspect rooms and other locations such as surrounding rooms, rooms where effected residents may have visited or spent time. 39779 On 08/20/24 at 12:28 PM R1 stated I saw what I thought to be a bed bug on the curtain maybe at the end of June. I knocked a bug off my bed onto the floor last week. On 08/21/24 at 11:45 AM V5 (Admissions Director) stated I have heard the residents talking about bed bugs and complain of having to move out of their rooms. The bed bugs are up here, and they had 2 rooms closed off on the third floor, 324 and 325. They have a service that come in and did a heat treatment one room at a time. I know they have bed bugs around. On 08/21/24 at 12:33 PM V8 (Licensed Practical Nurse) stated Some of the rooms have bed bugs and I saw them blocked off. The exterminators did heat treatments. The bed bugs have travelled because they have been in a few rooms. They treat the rooms that they saw the bugs in. Just particularly the rooms that the bed bugs are seen in. On 08/21/24 at approximately 12:45 PM Surveyor made V1 (Administrator) aware of 4 red elevated areas to the surveyor lower extremities after interviewing R1 and R3 on 08/20/24 in the residents' rooms. On 08/21/24 at 01:14 PM V1 (Administrator) stated I have housekeeping doing a sweep of those 2 rooms.

Based on observations, interviews, and records review, the facility failed to ensure a safe environment that is free from accidents and hazards for one (R85) of 5 residents reviewed in a sample of 35. This failure resulted in R85 falling and sustaining a fracture of the 2nd left finger. Findings include: R85's current face sheet documents R85 is a [AGE] year-old individual with medical conditions that include but not limited to: End stage renal disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, displaced fracture of shaft of second metacarpal bone, left hand, subsequent encounter for fracture with routine healing, history of falling, type 2 diabetes mellitus without complications. R85's MDS (Minimum Data Set) dated [DATE], documents R85 has a BIMS score of 15/15, indicating R85 has intact cognation, MDS section GG -Functional Abilities and Goals documents R5 needs supervision or touching assistance and partial to moderate assistance with Activities of Daily Living (ADL) care. On 5/28/2024 at 11:35am, R85 was observed in her room sitting at the edge of the bed and was only wearing incontinence underwear with no other clothes on. R85 stated she come this morning from the hospital after falling last night, and she was very hungry and was trying to get out of bed to get her clothes from her dresser and she was having difficulties getting out of bed into her wheelchair. R85 stated staff have not been to her room since assisting her to bed after she come from the hospital this morning, and she was trying to get out of bed, get dressed and go out ask for food because no one had given her food and she was feeling very hungry. R85 stated she did not know where her call light was. R85 fumbled with her hands around her bed looking for the call light but she did not find it. R85's side table was observed pushed on the side of her bed away and out of reach of R85. On 5/28/2024 at 11:40am, Surveyor and V4 (Certified Nursing Assistant-CNA) went to R85's room and found R85 sitting on her wheelchair next to her bed near her dresser and stated she was trying to get her clothes so that she can dress up. V4 told R85 that she is not supposed to get out of bed without calling staff for assistance because R85 fell last night. R85 stated she does not know where her call light is, and no staff has checked on her since she came back from the hospital to the facility this morning. R85 stated she was very hungry, and no one offered her food when she got here this morning. V4 stated she assisted the paramedics to put R85 on the bed when she was brought back to the facility at between 9:00am to 9:30am. V4 stated she checked R85 and R85 was not wet, but she did not ask R85 if she was hungry, and she had not checked on R85 since she assisted the paramedics to put R85 in bed. V4 also stated she does not know how R85's call light was placed on R85's bedside table, which was placed far from R85. R85's bed was observed to on normal position. V4 stated R85 is a fall risk and she fell last night and was sent to the hospital. V4 stated R85's bed cannot be lowered but can be adjusted and raised on the head and feet of the bed but cannot be lowered. V4 stated since R85 was a fall risk, her bed should be able to be adjusted to low position to prevent falls. V4 demonstrated how R85's bed can only be adjusted on front (by the head) and lower part (feet) by raising/lowering the head of the bed and the foot of the bed. On 05/30/2024 at 10:15am V23(Assistant Director of Nursing-ADON) stated R85 had multiple falls in the last one year and was sent to the hospital several times related to falls for further evaluations. 5/27/2024 injuries abrasions to left knee. V23 stated R85 is at risk according to her fall risk assessment. V23 stated anytime a resident falls, a fall risk assessment, pain assessment, and post fall occurrence is completed and these assessments help develop interventions in the care plan. R23 stated some intervention for R85 include fall mats, call light within reach, bed in lowest position. V23 stated when R85 come back from the hospital on the 5/28/2024, her call light should have been placed within reach so R85 can call for help/assistance, and safety. V23 stated the floor mats are important prevent R85 from getting injured because the last fall of 5/27/24, R85 rolled out of bed. On 05/30/2024 at 11:20am, V23 said she does not know where V6 (Maintenance Director) is as she has a tape measure, and she can measure the height of R85's bed. V23 and surveyor went to R85's room to measure the height of the bed which used to be R85's bed and now R85's roommate's bed. V23 measured the bed, and it was 25 inches in height. V23 stated this type of bed cannot be adjusted (lowered or raised) for height, and nursing staff should have called the maintenance department to bring an adjustable bed for R85 because R85 has had several falls. On 5/28/2024 at 11:38am, V5(Licensed Practical Nurse-LPN) stated she checked on R85 after R85 was brought back to the facility by paramedics at about 9:30am, and she has not checked on R85 again because she was busy passing morning medications. V5 stated she should have made sure R85's bed was in low position, and her call light was near her because R85 fall last night and was taken to the hospital related to the fall. V5 further stated she should have asked R85 if R85 wanted something to eat because R85 got back to the facility as breakfast time was ending. V5 stated the kitchen always has snacks and could have prepared something for R85 to eat as she waited for lunch. On 5/28/2024 at 12:05pm, V2(Director of Nursing) stated all staff are supposed to check resident equipment to make sure it is the right equipment for the resident, and it is in good working condition and should notify the maintenance department of any equipment needs. On 5/28/2024 approximately 30 minutes after observed and brought attention to staff R85's bed height, the bed was exchanged/swapped with R85's roommate's bed which could be lowered and/or raised up. On 5/28/2024 at 12:30pm, V6 (Maintenance Director) and surveyor observed model of R85's bed before her bed was changed and V6 stated that model of bed's height cannot be adjusted, and the only adjustments that can be done is to raise or lower the head or foot of the bed. V6 further stated that model of the bed does not come with the half rails that assist residents from coming in and out of bed by offering something to hold on to as they exit on get into bed. V6 stated he thought the height of the bed is the standard height, but stated he did not have a tape measure to measure the height of the bed. On 05/28/2024 at 12:45pm, V7 (Assistant Administrator) stated she is the one who changed/swapped R85's bed after surveyor observation, and V7 swapped the bed with the roommate's bed because R85 is a fall risk and requires a bed that can be lowered to prevent falls. R85's previous bed's height was up to surveyor's mid-thigh. V7 stated R85 should have been on a low bed to prevent falls. On 5/30/2024 at 2:49pm, V29(Nurse Practitioner) R85 should have had floor mats, call light within reach and bed in low position to prevent falls with injuries because R85 is at risk for fractures due to weak bones related to her medical comorbidities. Facility policy titled Management of Falls, dated 08/2020 documents: -The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the president's plan of care in order to minimize the risks for fall incidences and/or injuries to the resident. R85's medical records dated 5/27/2024 document: Visit Information-Fall, Finger fracture, left, Discharge Instructions for Finger Fracture. A finger fracture is a crack or break in any of the bones in a finger. Your finger may need to be kept still for about 3 weeks. It may take a few more weeks before it feels or works like it did before. Radiographs of the left hand (3 views). May 28, 2024, 0012 hours. Clinical history: FALL. Findings: fracture in the shaft of the distal phalanx of the 2nd digit. R85's care plan dated 5/11/2022 documents: Keep frequently used items within reach in room. Promote call light within reach. 5/28/2024-floor mats while in bed.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement appropriate fall prevention interventions, and/or failed to provide supervision for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in R1 sustaining a fall that resulted in laceration and sutures to R1's left eyebrow. Findings include: On 5/21/24 at 1:32pm, surveyor inquired about resident fall prevention interventions (post fall). V10 (Restorative Nurse) stated We want to put in an intervention based off of what we observed to prevent this from happening again or prevent injury. The intervention is in the care plan, we update the care plan. Surveyor inquired how staff are made aware of resident fall prevention interventions. V10 responded We have report papers, the Nurse gives the CNA (Certified Nursing Assistant) the papers and it says who we (facility) have that falls and what we (staff) do. R1's diagnoses include dementia, hemiplegia/hemiparesis (affecting right side) and history of falling. R1's (11/9/21) admission fall risk assessment determined a score of 8 (at risk). R1's (4/11/24) functional assessment affirms resident is dependent on staff for chair/bed to chair transfer. The facility fall log affirms R1 fell on [DATE] and 5/15/24. R1's (4/5/24) care plan states resident is at risk for falls due to cognitive deficits related to developmental disability, poor balance, poor safety awareness, unsteady gait, impulsivity, and inability to follow instructions. Interventions: (4/12/24) Send resident to hospital for further evaluation and treatment status/post fall. (5/16/24) Bed in lowest position and floor mats down. R1's (5/15/24) progress notes state staff observed resident attempting to stand up from wheelchair, staff immediately went to assist. Before staff could reach resident, resident fell . Skin tear noted above left eyebrow. Resident taken to (Hospital) for further evaluation. R1's (5/15/24) initial incident description states resident returned to facility (from emergency room ) with 4 sutures to the left eyebrow. On 5/21/24 at 1:43pm, surveyor inquired about R1's (4/12/24) fall V10 stated While she (R1) was in the room and provided ADL (Activities of Daily Living) care, she had a fall. She was injured, she hit her head. Surveyor inquired if R1's care plan interventions were revised on or about (4/12/24) V10 responded Yes and affirmed that Send resident to hospital for further evaluation and treatment status/post fall was documented. Surveyor inquired if sending R1 to the hospital would prevent additional falls V10 replied No. Surveyor inquired about R1's (5/15/24) fall V10 stated That one happened in the dining room; it was witnessed. She did cut her left eyebrow when she fell , and she did get 4 stitches. Surveyor inquired if R1's care plan was revised post (5/15/24) fall V10 affirmed that low bed and floor mats were added. R1's (4/11/24) BIMS (Brief Interview Mental Status) states resident is rarely/never understood. Cognitive skills for daily decision making are severely impaired. On 5/21/24 at 12:49pm, V7 (Licensed Practical Nurse) affirmed that she's assigned to R1. Surveyor inquired about R1's cognitive and functional status V7 stated She (R1) is bed bound, she's not oriented and she's non-verbal. Surveyor inquired about R1's fall prevention interventions V7 responded Bed in lowest position, frequent monitoring and that's all I can remember [floor mats were excluded]. On 5/21/24 at 12:51pm, sutures were observed on R1's left eyebrow. R1 was lying in bed (low position) however only one (1) floor mat was adjacent to the bed (neither side of R1's bed was against the wall). R1 was noted to be flailing her arms and legs and aimlessly moving about the bed. Surveyor inquired if R1 was trying to get out of bed however R1 did not respond. On 5/21/24 at 12:54pm, V8 (CNA) affirmed that she's assigned to R1. Surveyor inquired how R1 sustained the left eyebrow injury V8 stated I believe she had a fall. Surveyor inquired about R1's fall prevention interventions V8 responded We normally have pads on the floor and make sure her bed is low at all times. Surveyor inquired why only 1 floor mat was adjacent to R1's bed V8 replied I think that they (staff) came in here earlier to mop the floor and I think they were letting it dry. V8 subsequently removed a floor mat (from behind the dresser) and placed it next to R1's bed. On 5/23/24 at 1:20pm, surveyor inquired about fall prevention. V11 (Medical Director) stated We (facility) have to have general precautions for those (residents) that fall. If somebody falls, we (facility) will put fall precautions in place, so they (residents) don't fall again. Surveyor inquired about potential harm to a resident that falls V11 responded They can have fracture, they can have abrasion if the head is hit on the ground, or they can have a subdural hematoma. Surveyor inquired if implementing one (1) floor mat is appropriate if neither side of the bed is against the wall V11 replied If the space by the bed is not near the wall you need a mat on that side. If both sides have a space, then both sides need a mat. R3's diagnoses include vascular dementia, weakness, unsteadiness on feet and fracture of sacrum/coccyx (on admission). R3's (4/15/24) admission fall risk assessment determined a score of 4 (at risk). R3's (4/23/24) BIMS determined a score of 11 (moderate impairment). R3's (4/23/24) functional assessment affirms substantial/maximal assistance is required for chair/bed to chair transfer. The facility fall log affirms R3 fell on [DATE] and 5/10/24. R3's (5/9/24) incident report states resident was observed attempting to get out of bed and slid onto her buttocks at the side of the bed. Resident verbalized that she was going home. R3's (5/10/24) incident report states resident observed sitting on the floor outside her room. No witnesses found. R3's (4/15/24) care plan states resident is at risk for falls. Interventions: (5/9/24) Keep bed in lowest position. Floor mat (door side) while in bed. On 5/21/24 at 1:08pm, R3 was lying in bed (low position) however only one (1) floor mat was present (neither side of R3's bed was against the wall). Surveyor inquired if R3 recently fell R3 stated I fell 5 times right in here in this place. Surveyor inquired if R3 was able to walk R3 responded I can't walk, when I get up, I need someone holding me. Surveyor inquired about R3's fall prevention interventions V9 (Physical Therapy) stated Usually we lower the bed, call light close to the patient, and make sure the bed is locked [floor mat was excluded]. Surveyor inquired if there were two (2) floor mats adjacent to R3's bed V9 responded No. On 5/21/24 at 2:24pm, surveyor inquired about R3's (5/9/24) fall. V10 stated she (R3) was observed attempting to get out of bed when making rounds, when they (staff) went to go get her, she slid down on her bottom. Surveyor inquired about R3's fall prevention interventions, V10 responded For 5/9, I did put one floor mat for her (R3) near the door side because she's always favoring the door side. Surveyor inquired if implementing only one (1) floor mat was appropriate knowing that neither side of R3's bed was against the wall (therefore R3 could fall from either side). V10 replied I was just thinking like when she'll try to get up its always because of the door, she wants to come to the door, and she doesn't have in her head (due to impaired cognition/dementia) to use the call light. R2's diagnoses include bilateral open angle glaucoma, vascular dementia, impulse disorders, muscle weakness and abnormalities of gait/mobility. R2's (10/23/21) admission fall risk assessment determined a score of 5 (at risk). R2's (3/25/24) BIMS affirms disorganized thinking is present, fluctuates. R2's (3/25/24) functional assessment affirms resident requires substantial/maximal assistance with toileting and chair/bed to chair transfer. The facility fall log affirms R2 fell on [DATE]. R2's (5/19/24) incident report states upon making rounds resident observed laying on the floor by his bed. No witnesses found. Resident stated, I was getting out bed. R2's (10/23/21) care plan states resident is at risk for falls related to muscle weakness, poor balance, poor safety awareness and visual impairment. Interventions: (5/19/24) Floor mats while in bed. On 5/21/24 at 2:20pm, surveyor inquired about R2's (5/19/24) fall. V10 stated The Nurse was making rounds and he (R2) was observed next to his bed affirming the fall was unwitnessed. Surveyor inquired about R2's cognitive status V10 responded He has dementia and he's not cognitive enough to say what happened. Surveyor inquired if interventions were added to R4's care plan post (5/19/24) fall V10 replied I did put floor mats in for him. [R2's balance, cognition, vision is impaired, and the fall was unwitnessed however supervision is excluded]. On 5/21/24 at 12:35pm, V4 (Registered Nurse) affirmed that she's assigned to R2. Surveyor inquired about R2's cognitive and functional status V4 stated He (R2) transfers with assistance. He's vision impaired and up in a wheelchair. Surveyor inquired about R2's fall prevention interventions V4 responded Bed in lowest position. He's vision impaired so he wouldn't be able to use the call light [floor mats and/or supervision were excluded]. Surveyor inquired how staff are made aware of resident fall prevention interventions V4 replied Fall preventions are in the communication book. Surveyor requested the resident fall prevention interventions V4 searched the communication book (binder) 3 times and stated I don't know if I'm overlooking it, I'm still looking then searched the communication book (again) to no avail. V4 affirmed Sometimes things get misplaced, it should have been here. The (08/2020) management of falls policy states the facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: Develop a plan of care to include goals and interventions which address resident's risk factors. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.

Based on interviews and records review the facility failed to ensure two (R5, R10) of three residents were free from abuse. This failure resulted in R5 being hit on the face and R10 being bitten on the arm by R6. Findings include: R6 is a [AGE] year-old resident. R6's diagnoses include but are not limited to schizoaffective disorder, bipolar type, bipolar disorder, moderate intellectual disabilities, generalized anxiety disorder, schizophrenia, altered mental status. According to R6's care plan, R6 has impaired cognitive functioning related to R6's diagnoses of schizophrenia, unspecified and altered mental status, unspecified and moderate intellectual disabilities. R6 has difficulties managing anger/frustration related to diagnoses of schizophrenia and bipolar disorder. R6 has physically aggressive behavioral symptoms. R6 was physically aggressive towards peer. R6 Quarterly Behavioral Health Assessment, 2/2/2024, documents in part: Resident has a history of aggression or violence; resident remains aggressive due to mental status; mood is anxious, labile, angry, depressed; behavioral concerns include physical aggression, disruptive behavior, delusions, hallucinations. R5 is a [AGE] year-old resident. R5's diagnoses include but are not limited to schizoaffective disorder, bipolar type, hypertensive heart disease, paranoid personality disorder, osteoarthritis, blindness left eye category 3. R5 Resident Safety/Abuse Screening Assessment, 4/10/2023, documents in part: R5 has diagnoses of schizoaffective disorder, bipolar type and paranoid personality which makes R5 at risk for abuse. According to R5's care plan, R5 is at risk for abuse related to diagnosis of severe mental illness of schizoaffective disorder, loud, disruptive outbursts, and vision impairment in left eye. R10 is a [AGE] year-old resident. R10's diagnoses include but are not limited to schizophrenia, type 2 diabetes mellitus, psychosis not due to a substance or known physiological condition. According to R10's care plan, R10 has history of verbal and physical aggression toward staff and peers. R10 was bitten by a peer. Risk for abuse related to diagnosis of severe mental illness schizophrenia. On 3/20/24 at 10:25 AM, V21 (Certified Nursing Assistant) stated I was at the desk with V10. R6 came to get R6's medicine. R6 was saying R6 was tired. I was charting. R6 walked off and seconds later I heard a slap sound and then R5 yell out. R6 said R5 tried to trip R6. R5 was in the wheelchair sleep in the hallway. We separated R5 and R6. I took R6 to the social service office. R5's behavior includes shouting-out. R5's shouting is not directed at anyone. R6 behaviors include getting agitated and needing redirection. On 3/20/24 at 12:31 PM, V10 (Registered Nurse) stated I was the nurse for both R5 and R6 that morning, 1/28/24. I was giving medication. I gave R6 medications. R5 was sitting in the hallway in the wheelchair close to the nursing station. R6 got a cup of water from me, drank it, and walked away. As R6 walked pass R5, R6 just slapped R5 with open hand on the left of R5's face. R5 screamed out and said, Why did you hit me. V21 and I separated them. V21 walked R6 away. I assessed R5 and R6. No injuries on either. I notified the NP's (Nurse Practitioners), administrator, DON (Director of Nursing), supervisor, social service and both families. I sent R6 out to the hospital. R5 was not sent out because there were no injuries. The NP ordered to monitor and assess R5 for pain. R6 told me I don't know why I hit R5. It was not fair to R5 to be hit. No one wants to get hit. Residents are not supposed to hit each other, its violence. On 3/20/24 at 1:21 PM, R10 was observed in the dining room. R10 said R6 hit R10 in the face and bit R10 on the arm (R10 pulled up shirt leave on left arm to show bite mark). Observed healed circular red mark on R10 left arm. R10 said there was a little blood when R10 was bit. R10 said R10 was hurt and angry because R6 wanted to hurt R10. R10 said R10 did not know why R6 attacked R10. R10 remembers trying to get away from R6. R10 said it was a bad experience and R10 does not want to remember it. On 3/20/2024 at 3:30 PM, V1 (Administrator) stated I am the abuse coordinator. If staff witness abuse, they are to immediately separate the residents and notify me immediately. The nurse would assess the residents involved in the incident. Call doctor, family, follow physician orders. For resident-to-resident abuse I would conduct an investigation. Report to the State Agency within two-hour time frame. The incident with R5 and R6 is considered resident to resident abuse. V10 reported to me. I spoke to both V10 and V21. They were at the nursing station. R5 was sitting in the hallway asleep. R6 walked up to get medications and water. When R6 walked to the room R6 hit R5. V10 and V21 separated R5 and R6. V10 did assessments. R6 was sent out to the hospital. R5 was not sent out. R5 did not have an injury. I interviewed R5 on the following day. R5 said R5 was hit and R5's face did not hurt. I started working here 1/15/24. The incident with R6 and R10 happened before I was Administrator and before I was working here. The incident between R10 and R6 was abuse. On 3/21/24 at 1:20 PM, V24 (Psychiatrist) stated the facility has notified V24 many times for R6's behaviors. R6 has been struggling with behaviors. Behaviors are a part of R6's illness and we were trying to treat those. R6's behaviors included, long standing behaviors, verbal and physical aggression from schizophrenia, bipolar, moderate intellectual disability. R6 has a long psychiatric history, with multiple hospitalization s. R6's challenges are chronic in nature, nothing new. We first saw R6 in 12/2023. R6 admitted to auditory hallucinations, required PRN (as needed) medications, noted to be paranoid. Residents should not be biting each other. It's not a good experience to be bitten. I don't know what could have been done to prevent that. We recommended sending R6 to the hospital. R6 has episodic and sporadic behaviors, behaviors are random. I was notified about the incident on 1/28. R6 Post Occurrence Documentation, 1/28/2024 13:55, reads in part: Description of occurrence: R6 come to the nursing station and ask for cold water. Writer gave R6 the water and R6 drinks it. While walking away the resident turn and slap another resident (R5) who is sitting quietly and falling asleep in wheelchair. R6 slap the other resident on left side face. Administrator, Assistant Administrator, Clinical Director, DON (Director of Nursing), and Clinical manager made aware. NP (Nurse Practitioner) made aware and order to send the resident to hospital. POA (power of attorney) for R6 made aware of the incident and the transfer out to hospital. R6 Behavior/Interventions note, 1/1/2024 07:58, reads in part: Describe Behavior: The resident (R6) got into a verbal and physical altercation with another resident (R10) and bit the resident on the left arm. Staff have had previous conversations with the resident (R6) about outbursts towards other residents. The resident (R6) continues to exbibit uncontrollable behaviors even when being redirected. The resident (R6) continues to have difficulties evaluating consequences of own actions. Facility Reported Incidents, date of occurrence 1/28/2024, documents in part: Resident R6 approached resident R5 in the unit hall and struck R5 on the side of face. The psychiatrist for R6 contacted with orders to send R6 to hospital for inpatient psychiatric evaluation. R5 assessed and noted with redness to side of face. Facility Final Report, 1/29/2024, concludes: Resident R6 was interviewed regarding the incident. R6 stated that R6 was hearing voices and doesn't know why R6 struck R5. Resident R5 was interviewed and stated that R5 was sleeping and felt that R5 was struck on the side of face. Staff were interviewed and according to the staff present, R6 received a cup of water from nurse and upon walking back to unit dayroom, R6 struck R5 on side of face. Facility Incident Log - Reg 8, incident date 1/1/24, documents in part: Resident R6 approached resident R10 in the dining room and began arguing over a purse. R6 then bit R10 on left forearm. R10's arm was assessed and cleansed. Psychiatrist for R6 was contacted with orders to send R6 to hospital for inpatient psychiatric evaluation. Facility policy Abuse Policy, 9/20, documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other resident, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on interviews and records review the facility failed to supervise and monitor one (R3) of three residents reviewed for falls. This failure resulted in R3 falling and sustaining a right hip fracture. Findings include: R3 is an [AGE] year-old resident with diagnoses included but are not limited to intracapsular fracture of right femur, alzheimer's disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, dementia, chronic kidney disease, stage 4, history of falling, and heart failure. R3's minimum data set/MDS dated [DATE], indicates a Brief Interview for Mental Status score of 3 which indicates severe cognitive impairment. R3 has impairment both sides of lower extremities. R3 uses a wheelchair for mobility. R3 requires substantial/maximal assistance with toileting hygiene, upper body dressing, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, walk 10 feet once standing. R3 is dependent with shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer. According to R3's care plan, R3 is at risk for falls related to weakness, poor balance and has an intracapsular fracture of right femur related to history of falls. R3's Fall Risk Assessments dated 3/3/24 and 3/13/24, have scores of eight, indicating at risk for falls, implement general safety interventions. On 3/19/24 at 12:05 PM, V10 (Registered Nurse) stated R3 is a high fall risk. V10 stated we keep high fall risk residents in the day room. V10 stated we always have someone monitoring. V10 stated we do rounds when they are in bed. We keep the bed in the lowest position. V10 stated we assist residents to the toilet. V10 stated we round every hour. V10 stated I noticed R3 in pain. I V10 checked R3's labs and noticed the x-ray fracture. I V10 called the NP (Nurse Practitioner) who ordered to send R3 out to the hospital. On 3/19/24 at 12:20 PM, V11 (Registered Nurse) stated R3 is a high fall risk. R3 is a two person assist. R3 uses a wheelchair. On 3/20/24 at 8:52 AM, V19 (Licensed Practical Nurse) stated R3's fall occurred approximately 12 AM. I was R3's nurse that night. R3 was confused, trying to get out of bed. R3 was in bed at approximately 9 PM and R3 was trying to get up. R3 tried to get up multiple times and staff tried to redirect R3. I asked if R3 was in pain and where was R3 trying to go. R3 stated R3 was trying to go home. V19 stated we got R3 up to the chair approximately 10 PM in the dining room. There were approximately three or four residents in the dining room at that time. V19 stated I was in the dining, R3 stood up, tried to move, and tripped over the wheelchair. R3 fell on R3's buttock in a sitting position. I assessed R3 for pain. R3 said R3 was okay. I still gave R3 something for pain. R3 said R3 was trying to go home. We got R3 up to the chair. I took R3 to the nursing station with me and called R3's wife and NP (Nurse Practitioner). R3 was still trying to get up. R3 talked to R3's wife. R3 told R3's wife that R3's hip was hurting. I checked R3's range of motion again. R3 flinched with the right leg. The NP ordered an x-ray. R3 still kept trying to get up. At approximately 2 AM we took R3 to the room and to bed. The CNA (Certified Nursing Assistant) sat with R3. R3 can move/walk but R3's gait is very unsteady. R3 has floor mats. On 3/20/24 at 9:09 AM, V20 (Certified Nursing Assistant) stated V20 was doing rounds when V19 told me R3 fell . I assisted V19 with putting R3 back in the chair. V19 assessed R3. R3 said R3 was not in pain. V20 stated we put R3 back in bed. R3 kept trying to get up. V20 stated I did a 1:1 with R3 for the rest of the shift until someone relieved me. On 3/21/24 at 11:45 AM, V23 (Restorative Nurse) stated I do the MDS functional abilities and goals for R3. R3 required more help when R3 was first admitted . R3 was extensive to total assist when first admitted , except R3 was able to feed self. When first admitted , R3 used a manual wheelchair, was non-ambulatory. When first admitted R3 was incontinent of bowel and bladder. When first admitted , R3 was able to stand and pivot with one person staff assist with gait belt. We had to propel R3's wheelchair because R3 did not know how. R3 went through physical therapy. For on the unit mobility, R3 started improving with mobility, wheelchair mobility/propelling, standing, taking a few steps, transfers from chair to toilet and back. R3 is still incontinent. R3 currently requires one person assist with gait belt. After R3's fracture, I assessed and did a Geri chair for comfort measures. There is possibility to go back to the manual wheelchair. R3 has been picked back up for physical therapy. On 3/21/24 at 12:45 PM, V2 (Director of Nursing) stated to keep residents from falling, we assess and put interventions in place and try to monitor them. V2 stated we follow the four 'P's, observe for pain, positioning, personal items, and personal needs. V2 stated to monitor, we put the resident in common areas for supervision. V2 stated we anticipate if they are in pain, reaching for items, do they need repositioning and personal needs. According to my investigation V19 stated R3 was trying to get up from the bed and stand. V19 took R3 from the bed, put R3 in the wheelchair and took R3 to the common area to monitor R3. V19 stated that R3 stood up quickly. V19 witnessed the fall but could not catch R3 in time. V19 said even after that, R3 was still trying to get up and that is when V19 had V20 monitor R3. The fall was 3/3/24, the x-ray was ordered on 3/4, the x-ray was done on 3/4, the results from the x-ray came 3/5. R3 was sent out to the hospital 3/5. There was no delay in sending R3 to the hospital. Upon learning of an injury, the fracture, R3 was immediately sent out to the hospital. R3 Fall Progress Note, 3/3/2024 23:44, reads in part: The resident aaox1 (alert and oriented times one), confused and forgetful. R3 was in bed, continues to get up out of bed and walking to the hall stating that R3 does not know where R3 is going. The resident gait is unsteady. R3 has BLE (bilateral lower extremity) swelling/edema, and feet as well. The resident BLE are to be elevated, the foot of bed is elevated, but the resident continues to get out of the bed. The resident was sitting up in w/c (wheelchair) and got up and lost balance and fell down on buttocks. The resident did not hit head. The writer done a complete body check, no injury noted, but the resident c/o (complaint of) right hip pain after being lifted to feet and put back in w/c by the writer and staff. The resident verbalized was trying to go home. V/S (vital signs) B/P (blood pressure) 138/84, P (pulse) 72, R (respirations) 18, T (temperature) 97.6, 98% RA (room air). R3 Radiology Results Report, examination, and report date 3/4/2024, indicates right hip: possible impacted subcapital fracture; right femur: possible impacted subcapital fracture of the right femoral neck. R3 hospital record, 3/13/24, documents in part: clinical impression is closed fracture of head of right femur. Facility Reported Incident, date of occurrence 3/3/24, documents in part: R3 had a change in plane resulting in a fall. x-ray results show possible subcapital fracture of the right femoral neck. Nurse Practitioner gave order to send resident to hospital for further evaluation. Facility policy Fall Management Program, 8/2020, documents in part: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial wellbeing.

Based on interviews and record review, the facility failed to ensure 1 (R6) a totally dependent resident was free from Injuries of Unknown Origin in a sample of 11 residents. This failure resulted in R6 sustaining left upper extremity bruising, swelling and a fracture of the Left 2nd Metacarpal. Findings Include: R6 has diagnosis not limited to Dysphagia Following Cerebral Infarction, Encephalopathy, Gastrostomy, Type 2 Diabetes Mellitus, Atrial Fibrillation, Benign Prostatic Hyperplasia, Anemia, Hyperlipidemia, Essential (Primary) Hypertension, Cerebral Infarction, Vitamin D Deficiency, Morbid (Severe) Obesity Due To Excess Calories, Muscle Weakness (Generalized), Dementia, Unspecified Severity, With Other Behavioral Disturbance, Peripheral Vascular Disease, Obstructive Sleep Apnea, Herpes Viral Infection of Other Male Genital Organs, Acute Kidney Failure, Displaced Fracture of Shaft of Second Metacarpal Bone, Left Hand, Initial Encounter For Closed Fracture. R6 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 04 indicating severe cognitive impairment. R6's MDS (minimum data set) Section G Functional Status: document in part: A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture: Extensive Assistance. Two + persons' physical assist. B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Total Dependence, Two + persons' physical assist. A. Upper extremity (shoulder, elbow, wrist, hand) 1. Impairment on one side. B. Lower extremity (hip, knee, ankle, foot) 1. Impairment on one side. Section GG A. Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. Dependent. E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). Dependent. R6's Care Plan document in part: R6 has alteration in musculoskeletal status r/t (related to) fracture of the Left 2nd Metacarpal Fracture Date Initiated: 08/25/23. R6 has an ADL (Activities of Daily Living) Self Care Performance Deficit Weakness/deconditioning. Intervention: Check skin for changes during bathing. Date Initiated: 02/16/22. R6 is at risk for falls Muscle Weakness, Unsteady gait. R6 requires the use of a mechanical lift for transfers. R6 requires tube feeding and stoma site care. R6 is at risk for abuse related to: R6 has a diagnosis of dementia, there is total dependence on staff/others for care. R6 requires a soft cast to left hand. Date Initiated: 08/24/23. R6 has Dementia and is noted with cognitive impairment. R6 has the potential for alteration in function, decrease in sensation and or circulation of extremity secondary to fracture with soft cast in place. Date Initiated: 08/25/23. R6 requires assistance from staff for bed mobility; R6 unable to turn and reposition self in bed without physical assistance from staff r/t (related to) Limitations in Range of motion weakness/deconditioning. R6's Progress note dated 08/21/23 14:28 document in part: Nurses Note Text: Resident noted with redness and swelling to left upper extremity. R6's Progress note dated 08/22/23 11:56 document in part: Nurses Note Text: New order given to writer to send resident to Hospital for further evaluation related to Left hand X-ray. R6's Progress note dated 08/22/23 14:19 document in part: Nurse Practitioner Note Text: Patient seen and examined today for acute visit. Patient noted with pain, swelling, and bruising to LUE (Left Upper Extremity) with bruising/swelling to left shoulder, left inner elbow. Patient also with swelling and pain to left hand. XR (X-ray) revealed 2nd distal metacarpal transverse fracture. Total assist with ADLs (activities of daily living). EXTREMITIES: red/purple ecchymosis and swelling noted to anterior aspect of left shoulder, pain with ROM (Range of Motion) , small healing skin tear noted to central area of ecchymosis, baseball sized area of red/purple ecchymosis noted superior and laterally to antecubital fossa, additional area of red/purple ecchymosis noted to lateral aspect of antecubital fossa, limited ROM due to pain and guarding; patient resistant to extension of elbow; left dorsal hand edematous, point tenderness to palpation of 2nd metacarpal, pain with ROM to left wrist. ASSESSMENT/PLAN # (number) Left Upper Extremity Pain # Left Shoulder Pain # Left 2nd Metacarpal Fracture - No reported fall or injury - Patient with pain, swelling, and ecchymosis to LUE noted by staff on 8/21. Left Forearm XR (X-ray): Examination reveals mild soft tissue swelling with no evidence of recent fracture or dislocation. There is a slight transverse fracture of the distal shaft of the second metacarpal with no significant displacement. Transfer to ED (Emergency Department) for further evaluation. Progress note dated 08/23/23 02:08 document in part: Nurses Note Text: Resident return from Hospital with a soft cast to the left hand. Resident noted with pain, swelling, and bruising to left upper extremity with bruising/swelling to left shoulder, left inner elbow. Resident also with swelling and pain to left hand. Hospital Records dated 08/22/23 document in part: Left hand/finger, injury. Splint (Post mold applied to left hand). Patient with ecchymosis and tenderness to the left shoulder or left elbow and left mid hand, bruising appears to be more than a day old. after finding that left mid hand does have a fracture, CT head and C (Cervical)-spine added as clear injury occurred that was not reported, and patient is a poor historian. Primary Diagnosis: Second Left Metacarpal Fracture. Secondary Diagnosis: Unwitnessed fall. Primary Impression: Fracture of Second metacarpal bone of left hand. Secondary Impression: Fall. Patient Notes: Patient came in with H/O (History of) swollen hand. Restorative Nursing assessment dated [DATE] document in part: 3. Bed Mobility: Total Dependence. 4. Transfer: Total Dependence. F. Locomotion on unit: Self performance: Total Dependence. H. Locomotion off unit: Self performance: Total Dependence. 7. Dressing/Grooming: Total Dependence. 8. Eating: Total Dependence. Initial Reportable dated 08/22/23 document in part: On 08/21/23 resident noted with redness and swelling on left hand. On 08/22/23 X-ray revealed fracture of 2nd metacarpal. R6 sent to hospital for further evaluation. Final Report dated 08/28/23 document in part: R6 is extensive assist with ADLs (Activities of Daily Living), functional transfers, and functional mobility. Staff with no reported falls or any occurrences with the resident in the facility. Resident with diagnosis of oblique mildly displaced fracture of the distal third of the second metacarpal bone. Resident readmitted with soft cast to left hand. The resident was unable to recall any accidents or incidents. On 09/19/23 at 08:31 AM V8 (R6 Family Member) stated R6 finger was broken and bruised up. I don't know how the injury happened. R6 said that he was beaten. I saw R6 hand on 08/20/23, and they did an X-ray of R6 hand. On 08/21/23 the nurse called me and told me that they took R6 to the emergency room . On 09/19/23 at 12:52 V8 (R6 Family Member) stated No one knows what happen to R6 during the four days that I did not come. R6 cannot move about by himself. I came in on Monday 08/21/23 and that is when I saw the bruising and swelling to R6 entire left arm. Nothing was broken but R6 index finger. R6 was observed sitting in the dining room in a reclining wheelchair with an ace wrap to the left hand. On 09/19/23 at 01:14 PM V8 (R6 Family Member) asked R6 what happen to your hand and R6 responded a nurse kept beating my hand. V8 asked R6 the nurse's name and R6 did not respond. On 09/19/23 at 01:16 PM V12 (Licensed Practical Nurse) stated when I came back to work after being off a couple of days, I was told R6 had a fracture to the left hand. R6 had an X-ray, the results were relayed to the Nurse Practitioner on 08/22/23, and I was told to send R6 to the hospital for evaluation. I observed R6 left hand was kind of swollen. I had gotten the results that it was fractured. When you touch R6's left hand R6 would make say ouch. R6 was not able to tell you what happened, R6 is confused but alert to name. On 09/19/23 at 01:37 PM V13 (Certified Nurse Assistant) stated R6 is a two person assist and a little confused. I looked at R6's arm to see what they were talking about. R6 was feeling pain if you tried to lift the left arm up. Near the left shoulder area, I saw a dark red area larger than a quarter. I worked with R6 on 08/17/23 and did not see anything. On 09/19/23 at 01:46 PM V7 (Certified Nurse Assistant) stated I did not work with R6 a few days before the injury, but I am the one that reported the injury. I was assigned to R6 on 08/21/23 and reported the bruising to V23 (Registered Nurse). I was about to start patient care, was wiping R6 face and attempted to take off R6 gown. I observed bruises on the outer area of R6 left arm and left shoulder. I reported the skin abnormality. R6 is transferred with the mechanical lift. On 09/19/23 at 02:02 PM V6 (Certified Nurse Assistant) stated when I take care of R6 I wash him up, dress and transferred with a mechanical lift. I was assigned to R6 on 08/18/23 day shift. I did not see any bruises or swelling. On 09/20/21 at 12:20 PM V21 (Restorative Nurse) stated I never saw any bruising on R6 body, and I am not aware of any falls. I was told that R6 had a fracture, and R6 had the splint to his left hand like a half cast mold with an ace wrap holding it in place. The mold is to stabilize R6 hand. 09/21/23 at 11:12 AM V21 (Restorative Nurse) stated R6 is a restorative patient. R6 can grasp the side rails but cannot turn himself. On 09/20/23 at 12:49 V41 (Certified Nurse Assistant) stated on 08/20/23 I gave R6 patient care and bed bath and R6 remained in bed. There was no bruising or swelling. On 09/20/23 at 12:56 V23 (Registered Nurse) stated the certified nurse assistant came to me. R6 left arm and hand was red and swollen. I assessed it then notified the Nurse Practitioner who gave new orders, and I followed up on them. There was an X-ray of the left shoulder, hand, arm and a doppler. I did not see any swelling to R6 left arm prior to this. I worked 08/17/23 and 08/18/23 and did not come back until 08/21/23. R6 is able to turn with assistance, transfers with a mechanical lift and gets a g (gastric)-tube feeding. On 09/20/23 at 01:46 PM V30 (Registered Nurse) stated when I worked with R6 on 08/19/23 and 08/20/23 R6 had no bruising and swelling. R6 has a gastric tube feeding and I had to lift up R6 gown. There was no swelling or abnormalities to the skin. R6 really can't move. On 09/20/23 at 01:35 V19 (Certified Nurse Assistant) stated on 08/19/23 I did not see any bruising or swelling to R6 left arm. On 09/20/23 at 03:24 PM per telephone interview V32 (Registered Nurse) stated On 08/17/23 I did not see R6 with any redness or swelling. I only saw the redness and swelling to R6 left hand and arm on 08/21/23 when I came back to the floor. It was redness and swelling to the left upper shoulder and swelling to the left hand. On 09/20/23 at 03:54 PM per telephone interview V33 (Registered Nurse) stated the care that I provide for R6 is medications and the feeding tube. I work the night shift and days shift as well. I did not notice any swelling or redness to R6 arm. R6 has not had any recent falls and there were no reported skin issues. I was still there on 08/21/23 when they saw R6 left arm/hand redness and swelling. It was a couple hours into the day shift when I saw it. The redness was under the sleeve of R6 gown and R6 was in bed when I got there. On 09/20/23 at 04:13 PM Per telephone interview V34 (Certified Nurse Assistant) stated I only had R6 one day on the weekend on the 3-11 shift. The care that I provided because R6 was in bed we just changing R6 once. R6 had no bruising to body or arm, and I did not look for that. We are looking more of what is going on in the bottom. I noticed the redness and swelling when I put R6 to bed on 08/21/23. I took the mechanical lift and when I looked at R6 left arm, I saw the color and I did not like this. They said they were going to do and x-ray. A few hours later they came and did the X-ray. I came the next day, and I went to R6 room looking for him. I asked the nurse where R6 was, and I found out that he went to the hospital. I only saw the left arm bruising and swelling when I was putting R6 to bed. On 09/20/23 at 04:33 PM Per telephone interview V48 (Certified Nurse Assistant) stated R6 is on a gastric tube and the main care provided if R6 is in the day room, I get help to put R6 in bed and clean R6 up. R6 is transferred using the mechanical lift. On 08/20/23 R6 did not fall and there was no redness or swelling. I noticed the redness and swelling when R6 returned from the hospital. I saw the swelling to the left ankle and the left shoulder had some redness. On 09/21/23 at 08:51 AM V2 (Assistant Administrator) stated V8 (R6 Family Member) called me that day when she noticed discoloration on R6 left hand. I made the nurse aware, and the nurse followed protocol calling the doctor. The doctor placed orders. On 09/21/23 at 09:02 AM V1 (Administrator) stated The nurse called the Nurse Practitioner and R6 was sent to hospital. There has a fracture to the left finger. On 09/21/23 at 09:20 AM V36 (Certified Nurse Assistant) stated I was there Monday 08/21/23 or Tuesday 08/22/23. I went to get R6 up and when I went to pull up the pulled gown, I saw the bruising. Prior to that R6 had no bruises. On 09/21/23 at 09:30 AM V18 (Nurse Practitioner) stated on 08/21/23 there was noted redness and swelling to R6 left upper extremity. I saw R6 the next day. The X-ray of the left hand showed a transverse fracture of second metacarpal bone of left hand. It could be from turning or trauma, but I can't say if R6 was hitting his hand on the side rail. On 09/21/23 at 10:01 AM V12 (Licensed Practical Nurse) stated R6 bed has always had the bilateral upper side rails. R6 can turn and hold the side rail with assistance. R6 right side is the stronger side. On 09/21/23 at 12:22 PM V21 (Restorative Nurse) stated each resident is scheduled for a bath/shower twice a week. V21 reviewed the bathing sheet with the surveyor and stated the number 4 stands for total assist with bathing. The number 3 stands for 2 people assistance because R6 is a mechanical lift for transfers. If there are any skin issues reported to nurse n/a means R6 did not have any skin issues for 08/16/23. On 08/19/23 the number 4 stands for total assist with bathing. The number 3 stands for 2 people because R6 is a mechanical lift for transfers. The number 2 is for follow up questions and stands for no new skin abnormalities. Policy: Titled Incident/Accident Reports dated 09/20 document in part: Policy: The Incident/Accident report is completed or all unexplained bruises or abrasions, all accidents or incident where there is injury or the potential to result in injury. Procedure: an accident refers to any unexpected or unintentional incident, which may result in injury or illness to a resident. 4. all situations requiring they emergency services of a hospital. 8. any condition resulting from an accident requiring first aid, physician visit, or transfer to another healthcare facility. Note: physical harm would include a broken bone, or blood flow not stopped by a band aid or hospital or emergency room treatment that involves more than diagnostic evaluation. 15. facility must ensure that the resident environment remains as free of accident hazard as is possible; and each resident receives adequate supervision and assistance devices to prevent accident. Titled Abuse Policy dated 09/20 document in part: Policy: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its resident and 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 mistreatment, neglect, or abuse of our residents. 3. establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. This facility is committed to protecting our residents from abuse by anyone. Prevention: The facility desires to prevent abuse, neglect, and theft by establishing a resident sensitive and resident secure environment.

Based on interviews and record reviews, the facility failed to follow their policies and procedures to (a) evaluate and monitor a high-risk resident's (R5) nutritional status, (b) obtain weights monitoring, and (c) implement nutritional interventions, monitor the effectiveness of interventions and revising them as necessary. These failures resulted in a severe weight loss [more than 9% over 2 months] for 1 (R5) of 5 residents reviewed for nutrition. Findings Include: R5's clinical records show an admitted [DATE] with listed diagnoses not limited to abnormal weight loss, personal history of Malignant Neoplasm of Prostate, Hyperlipidemia, Essential Hypertension, Pulmonary Embolism, And Functional Dyspepsia. R5 was discharged to the hospital on 7/12/23 for complaint of rectal pain. R5's electronic medical records (EMR) show no weights were obtained from R5's admitted [DATE] until R5's discharge from the facility on 7/12/23. The only weight documented on R5's weight record was 182.6 lbs dated 7/15/23. On 9/20/23 at 2:33 PM, V21 (Restorative Nurse) stated that V21 entered the wrong date and the weight recorded on 7/15/23 was taken the week before July 10th. R5's hospital records prior to R5's admission to the facility printed on 5/20/23 shows R5 weighed 213.3 lbs on 5/12/23. R5's Admission Minimum Data Set (MDS) dated [DATE] shows R5 weighed 201 pounds (lbs). R5's Discharge MDS dated [DATE] shows R5 weighed 182 lbs. The facility's 2023 Documentation Survey Report v2 for R5's amount eaten shows R5 ate 50% or less on multiple occasions from 5/21/23 to 7/12/32 with some days of refusals. R5's care plan initiated on 5/26/23 shows R5 requires nutritional support with one intervention that reads, Nutritional assessment initially and quarterly. Obtain food preferences and update at least annually. R5's EMR (electronic medical record) do not show any dietary notes or nutritional assessments were completed from 5/20/23 to 7/12/23. R5's progress notes from 5/20/23 to 7/12/23 show no documentation R5's weight loss and poor appetite were communicated to V22 (R5's Physician) and V18 (Nurse Practitioner). R5's progress notes dated 5/22/23 at 5:18 PM written by V18 (R5's Nurse Practitioner) reads in part, Patient seen and examined today. [R5] expresses [R5] is not satisfied with the food [R5] has been receiving in the facility. [R5's] diet preferences have been reported to dietary services. R5's physician order sheet (POS) shows a diet order of General diet Regular texture, Thin Liquids consistency ordered on 5/20/23. R5's POS does not show any other nutritional interventions ordered for R5. On 9/19/23 at 11:30 AM, V12 (Licensed Practical Nurse) stated that R5 was having diarrhea at least twice during V12's shift but does not remember when it started. V12 stated that R5 had very poor appetite ever since R5 came to the facility. V12 stated that V43 (R5's Wife) would come and bring R5 something to eat. V12 stated that R5 only ate breakfast and every other day V43 would bring food for R5. V12 stated that R5 was a picky eater. V12 stated that R5 would only eat less than 50% or nothing at all. V12 stated that R5 would try to eat and if R5 did not like the meals, staff would offer substitutions, but R5 did not eat the substitutions either. V12 stated that V12 thought V27 (Registered Dietitian) was aware because V27 is in the facility twice a week. V12 stated that nurses did not monitor R5's weights because it was the restorative department's responsibility to obtain all residents' weights. On 9/19/23 at 1:25 PM V20 (Restorative Aide) stated that residents' weights are taken within 24 hours upon admission and re-admission, weekly weights on Thursdays, and monthly weights are taken the last 5 days of the month. V20 stated, We record the weights on the weight sheet that's given to us by the Restorative Nurse [V21] then we give it back to [V21]. On 9/19/23 at 1:35 PM, V21 (Restorative Nurse) stated that the restorative aides get the weights. V21 stated, When the resident gets admitted we try to get the weight within 24 hours. We try to ask the admitting nurse to get the admission weight, but restorative follows up the next day. Upon admission weight is taken within 24 hours, then weekly for 4 weeks, and then monthly. We enter the weights in the resident's electronic record. V21 stated that restorative notifies the nurse if there are some weight changes, and the Dietitian (V27) also monitors the weights in the residents' electronic medical records (EMR). V21 stated, They have access to the EMR. [V27] comes in once a week. Surveyor reviewed R5's weight records in R5's EMR with V21, and V21 confirmed R5's admission weight and weekly weights were not obtained. On 9/20/23 at 11:13 AM, a phone interview conducted with V27 (Registered Dietitian). V27 stated that V27 started working in the facility on May 15, 2023, and comes in to see the residents twice a week. V27 stated that it is important to monitor the resident's weights to see if there have been any critical changes like decrease in intake, any wounds, any fluid shift, and if there is anything new going on or critical going on in general. V27 stated that the resident's nutritional status needs need to be assessed to see the resident's eating patterns, if they need additional help, and their dietary preferences. V27 stated that some of the potential things that could happen if a resident's nutritional status is not monitored are weight loss, wound development, altered labs, and general health decline. V27 stated that a resident with diagnosis of cancer is at high nutritional risk and interventions to meet the resident's nutritional needs should be implemented. V27 stated that a resident with poor intake and having diarrhea could put a resident for higher risk for malnutrition because of their gastrointestinal tract being compromised. V27 stated that if a resident is eating 50% or less that could potentially put the resident for dehydration, weight loss, and possible altered nutritional intake and absorption. V27 stated that generally, if a resident is eating 50% or less, V27 would put interventions in place such as liquid supplements. V27 stated that a decrease in intake of 50% or less, decrease in weight of 5% in the last 30 days or even 3% within the last 7 days are some of the criteria to determine malnutrition with the resident. V27 stated that the nurses and the nursing managers should communicate to V27 who are the residents losing weight and who are at high nutritional risks. However, V27 stated that V27 has not gotten a lot of communication from the nurses in the facility. V27 stated that V27 has not heard of R5 until 9/19/23 when V2 (Director of Nursing) mentioned to V27 that R5's nutritional assessment did not get completed. V27 stated, Unfortunately I didn't get to assess [R5]. The staff did not communicate to me about [R5]. V27 stated that R5 was never assessed by a dietitian from admission until R5's discharge from the facility. On 9/21/23 at 9:50 AM, a phone interview conducted with V18 (Nurse Practitioner). V18 stated, I can't remember off the top of my head if they notify me about (R5's) poor appetite and weight loss. Usually, I would document it and put in some kind of intervention like a three-day calorie count, and a dietary evaluation. V18 stated that if a resident has poor appetite and the weights were not taken and their nutritional needs were not assessed, the resident could potentially lose weight and get weak. V18 stated, What we would do if someone is not eating as long as they are eating above 25% we would order the oral supplements and dietary monitoring, protein supplement, and honoring food preference. If they are eating less than the 25% over the three-day calorie count, I would send the resident to the hospital for evaluation. V18 stated that it's important to monitor the resident's weight. V18 stated, If we see a decline, then interventions need to be put in place what I mentioned earlier, and we would get the dietitian involve. The facility's policy titled; WEIGHTS dated 9/2020 reads in part: POLICY: Residents will be weighed to establish weights and identify trends of weight loss or weight gain. PROCEDURE: 1. A baseline weight will be established upon admission. The resident will be weighed weekly for 4 weeks after admission and monthly thereafter. 3.Report to nursing supervisor, physician/NP, dietary supervisor, RD consultant and family/responsible party of any weight loss or gain greater than 5% within one (1) month, 7.5% within three (3) months or 10% within six (6) months. 4.Notification to the attending physician/NP and family/responsible party in regard to the above will be documented in the medical record. The facility's policy titled; NUTRITION assessment dated ,d+[DATE] reads in part: POLICY A nutrition assessment will be completed for each resident admitted into the building. PURPOSE To reduce the risk of malnutrition. PROCEDURE 1. A trained and designated representative from the FNS Department will review each resident to determine if at low or high nutritional risk. This representative is responsible for assessing the low risk residents and providing a referral list to the LDN of high nutritional risk residents. 2. The LDN is responsible for developing a nutrition assessment for each high risk resident admitted to the facility. 3. The in-depth nutritional assessment must be developed within fourteen (14) days of the resident's admission and include at least the resident's a. Anthropometrics b. Diagnosis, condition, or disease affecting nutrition c. Abnormal laboratory values d. Clinical observation of the resident e. Nutrition intake and any significant change in overall intake and cause f. Eating habits g. Dietary restrictions h. Psychological, social or functional limitations affecting nutrition i. Use of medication with potential for drug/nutrient interactions that may affect appetite j. Diet; if therapeutic diet, indicate if this is warranted and identify the need for these restrictions

Based on observation, interview, and record review the facility failed to identify, assess, and monitor changes in skin integrity and failed to implement pressure ulcer interventions to treat and prevent the development of pressure ulcers for one resident (R2). These failures resulted in R2 experiencing previous pressure ulcers re-opening on R2's left and right buttocks and R2 developing facility acquired pressure ulcers on R2's left thigh. These failures have the potential to affect 56 residents at risk for pressure ulcer. Findings include: R2's medical record face sheet listed date of admission as 07/20/2022 with diagnosis that includes but not limited to: Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Right Non-dominant side, Cellulitis Unspecified, Lymphedema not elsewhere classified, Unspecified Asthma uncomplicated, Essential hypertension, Type 2 Diabetes Mellitus without complications, Major Depressive Disorder, Recurrent unspecified, Morbid (Severe) Obesity due to excess calories, Suicidal Ideations, Cerebral Infarction unspecified. R2's MDS (Minimum Data Set) dated 4/20/23 scored R2's BIMS (Brief Interview for Mental Status) as 05 showing R2 is cognitively impaired. Section G of the MDS for ADL's (Activity of Daily Living) assistance coded R2 for transfer 4/3 showing R2 is totally dependent on staff, for performance with two persons + physical assist. Coded 3/3 for personal hygiene showing R2 needs extensive assistance and two persons + physical assist. On 05/17/2023 at 11:55am, R2 observed lying in bed wearing a hospital gown. V11 CNA (Certified Nursing Assistant) was in R2's room assisting R2's roommate. V11 stated, I'm about to change R2 now just give me a minute. On 5/17/2023 at 12:03pm observed V11 assisting R2 with incontinent care. Observed R2's right leg with open wound. V11 stated, R2 has an open sore on that leg and so I (V11) applied Zinc cream on it to help it heal. V11 stated, There are three open wounds on the bottom (referring to R2's buttocks). I (V11) can show it to you because I'm about to clean her (R2). Observed a total of three open wound sites (two open wounds on the left buttocks and one open wound on the right buttocks) without any dressing. V11 stated, The wounds have been on R2's buttocks because when I changed R2 earlier at the beginning of the shift the wounds were there. On 5/17/2023 at 12:08pm, V8 RN (Registered Nurse) came and assessed R2's wounds. V8 stated, The open wounds could be considered pressure ulcers because the buttocks are being seated on. V8 was asked if there was an order for treatment of the wounds. V8 stated, I will have to check on the record (referring to R2's Record) for the orders. V8 further stated in part, that normally the treatment is done by the wound treatment nurse. On 5/17/2023 at 12:10pm, V8 checked the treatment orders in the electronic medical record. V8 stated, There is an order for zinc oxide ointment 20% apply bilaterally PRN (as needed) which the CNAs can apply to R2's buttocks after incontinence care. V8 stated, But there is no order for the open areas. V8 stated, With open wound like this, the CNA should let the nurse know (referring to V9 LPN, assigned to team 2). On 5/17/2023 at 12:13pm, V8 stated, Body checks are done on a weekly basis and any changes in skin the nurse should be told. V8 stated, I (V8) was not aware of the wound (Referring to R2's wound) until you (referring to the surveyor) showed it to me (V8). On 5/17/2023 at 12:15pm V9 LPN (Licensed Practical Nurse) assigned to R2 stated, I don't know R2 has any wound/pressure ulcer because the treatment nurses deal with that. On 5/17/2023 at 12:17pm V3 ADON (Assistant Director of Nurse's) stated, the wound care nurses are not in the facility currently. On 5/17/2023 at 12:32pm, V3 (ADON) returned to the 2nd floor and stated, I am not trained on how to measure the wounds. V3 was unable to measure the wound or assess R2's wound site. V3 stated, in part there is no wound care nurse in the facility at this time, but a call has been placed to V19 (Wound Care Director) to call back the facility. On 5/17/2023 at 12:38pm. V3 (ADON) observed reviewing R2's EMR (Electronic Medical Record) then V3 stated, There are no wound notes entered for R2's wounds. V3 stated, The policy is to measure and size the wound, call the doctor right away at least within 24 hours or the doctor/NP (Nurse Practitioner) on call for notification and orders. V3 stated, The expectation is for the CNA to report to the nurse assigned to the resident any skin impairment immediately and to document. On 05/23/2023 at 11:55am, V19 (wound coordinator) stated, I (V19) am familiar with R2. V19 stated, R2 had a re-opened wound on 05/16/23. V19 stated, in part She called the physician on 05/17/23 to get an order for treatment and then R2 can have a treatment on the wound. V19 stated,V31 (CNA/Wound Care Technician) informed her (V19) of R2's pressure ulcer on 05/16/23 during the night shift. V19 stated, R2's re-open wound was not measured because it was a re-opened pressure ulcer to the right buttocks. V19 stated, I (V19) did not receive any order for treatment until 05/17/23 when I started charting. On 5/23/23 at 12:00pm V19 stated, It re-opened on 05/16/23 on night shift and a call was placed to V27 NP (Nurse Practitioner). V19 was unable to present any documentation that R2's pressure ulcer was staged or measured and what treatment was put in place pending the physician or nurse practitioner orders. V19 stated, in part R2's care plan was just revised for the goals because there is no need to revise the interventions because the previous intervention fits R2 situation. V19 further stated, I (V19) did not know I (V19) must go one by one to revise the intervention or add new ones. On 05/23/23 at 4:38pm, observed V20 measure R2's wounds with the following measurements: left buttocks 3.5cm X 3.0cm X 0.2cm, right buttocks 2.5cm x 3.0 x 0.2cm and left upper area of buttocks 1cm X 1cm. V20 stated, The left upper area of the buttocks looks like dermatitis to me (V20). On 05/25/23 at 12:20pm, V20 was asked why documentation was not in the EMR when V20 did wound measurements on 05/23/2023. V20 stated, I (V20) did not document that measurement because the real measurement is done on Thursdays. I (V20) only measured it for you (referring to surveyor) as a courtesy because V27 will do the measurements. On 06/06/23 at 3:39pm, V20 stated, I think I did fax the order to them (Outside agency company). V20 (Wound Care Nurse) presented a request form made to outside agency for low air loss mattress but was unable to present any email or faxed documentation to verify request was completed or air loss mattress was delivered to facility. On 06/06/23, at 3:15pm, V20 stated, in part During the visit of 06/01/23 R2 developed more pressure sites on the left post thigh and the left thigh that requires the use of low air mattress, and it was ordered. On 6/6/2023 at 3:25pm, interview with V2 DON (Director of Nurses) regarding R2's order for use of low air loss mattress. V2 stated if the NP (referring to V27) stated it was ordered the resident (R2) should have it by now. V2 stated, the wound care nurse (V20) should be able to let the surveyor know what is going on with the mattress because she (V2) is not aware about whether R2 has the mattress in place currently. On 06/06/2023 at 3:30pm, s V20 if R2 is currently on a low air loss mattress. V20 stated, R2 has the mattress already. On 06/06/2023 at 3:33pm, V20 observed R2 was laying on a regular mattress. V20 stated, I (V20) thought R2 has it (referring to low air loss mattress) already because (R2) has an order for it. On 06/06/2023 at 3:39pm, V20 stated, The LALM bed is for pressure relieving purpose to aide healing and prevention of new pressure sore. V20 stated, R2 can benefit from the use of the mattress. V20 stated, in part The LALM was ordered 06/01/2023 and it should have been delivered and R2 should have been on it because R2 is developing more pressure sites. On 06/08/23 at 12:26pm, V27 stated, in part R2's wound is more of pressure and moisture issues like incontinence. The LALM is ordered because it can aid in healing of the pressure sore. It can evaporate some of the moisture, with the use of the zinc it can heal the open areas. R2 can benefit from the use of the mattress (Referring to LALM). After assessing the resident skin and a wound is discovered, the primary physician can be notified for initial treatment order till I (V27) come to see the resident which is every Thursday of the week. If the initial order is not appropriate enough when I (V27) come, see the resident I will change it. My order is also like a recommendation that the primary physician has the right to override. Besides that, the order must be followed. On 06/08/23 at 1:57pm, V31 stated, she is familiar with R2 and that R2 has had the pressure ulcers for a couple of weeks now. V31 stated, When I (V31) discovered the wounds, I informed V19 about it. V31 stated, in part Whenever abrasions, redness, or any skin impairment is noted on any resident she normally flags it so the nurse can follow up on it, so when she was giving R2 a bed bath she noted the pressure ulcers. V31 stated in part that she was sure it was documented and reported to V19. R2's wound care note dated 05/18/23 showed V27's (Wound Care Nurse Practitioner) documentation describing R2's wound as pressure ulcer to right buttocks stage 2 with measurement in cm (centimeter) L x W x D (Length, Width and Depth) 2.5 x 2.5 x 0.1, exudate type and amount as serous and light. Treatment initiated 05/18/23 daily and PRN Normal saline, with zinc oxide and foam dressing. Left buttocks also described as pressure ulcer stage 2 with measurement in cm (centimeter) L x W x D (Length, Width and Depth) 3.5 x 4 x 0.1, exudate type and amount as serous and light. Treatment initiated 05/18/23 daily and PRN Normal saline, with zinc oxide. Left side torso described as blister with measurement in cm (centimeter) L x W x D (Length, Width and Depth) 1.3 x 2.5 x 0.2, exudate type and amount as serous and light. Treatment initiated 05/18/23 daily and PRN Normal saline, with foam. V27's documentation dated 06/01/23 showed R2 has Left thigh stage 2 with measurement in cm (centimeter) L x W x D (Length, Width and Depth) 5 x 3 x 0.1, exudate type and amount as serosanguineous and light. Treatment initiated 05/18/23 daily and PRN Normal saline, zinc oxide with foam dressing. Left post thigh stage 2 with measurement in cm (centimeter) L x W x D (Length, Width and Depth) 1 x 5.5 x 0.1, exudate type and amount as serosanguineous and light. Treatment initiated 05/18/23 daily and PRN Normal saline, zinc oxide with foam dressing. Perineum area noted with diaper dermatitis with order to continue with normal saline and zinc oxide products, continue to off load and with peri-care as needed. Recommendation of low air mattress. During review of record, there was no documented revision of R2's wound skin plan of care since 7/20/2022. Review of R2's electronic documentation for the month of May 2023 showed that on the 16th of May 2023 there was no new skin abnormality. V3 who was present at the time showed no documentation that there was alteration in skin integrity documented. V31 then stated that it was my error because the pressure ulcer was there (referring to R2 buttocks). V3 then stated that when a skin impairment is noted by the CNAs it should be reported to the nurse in charge at the time and documented. V3 stated we (Facility) will have to correct this because the staff are just documenting without understanding of what was been documented. Further review of the document showed an entry that showed that R2 has skin impairment on 05/13/23 that was not reported to the nurse. V3 acknowledged that in nursing if it is not documented it is not done. R2's medical record progress note dated 05/17/2023 at 15:04 (3:04pm) documented by V19, a re-open pressure ulcer to right buttocks. Facility presented policy titled Prevention and Treatment of Pressure Injury and Other Skin Alterations documented to 1. identify resident at risk for developing pressure injuries.2. Identify the presence of pressure injuries and/or other skin alterations. 3. Implement preventive measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. 5. Develop a care plan for either actual or potential alteration in skin integrity and change needed. 10. Revise care plan approaches as needed based on resident's response and outcomes. Facility Job Description titled Wound Care Coordinator dated 11/2021 under job summary documented in part the responsibility that includes but not limited to delivering direct and indirect nursing care to patients with soft tissues injuries and other wound types and to supervise the day-to-day nursing activities performed by the nurses in relation to wound care, treatments, prevention, and assessments supervise. Essential functions listed includes but not limited to ensuring that all nursing procedures and protocols are followed in accordance with established policies. Directly supervise the nurses, CAN's (Certified Nurse's Aides) and other members of the IDT (Interdisciplinary Team) that wound care treatments and protocols are followed accordingly. Responsible/oversees for assessing and documenting wound status and skin care. Administer or assist with wound treatments as ordered by the physician. Review wound assessments for completeness and accuracy. Educate facility staff on pressure ulcer prevention. Arrange for therapeutic services needed for wound care as ordered by physician. Consult with other nurses, management, and other related health professionals to assist in assessing, planning and delivery and evaluating patient care. Ensuring that the wound assessment reflects that care plan is being followed. Making rounds to assure that nursing personnel are performing required duties related to wound care program and to ensure that wound care protocols and procedures are being followed. Facility Job Description for Director of Nurse's (DON) presented and dated 1/2015 documented in part that the DON is responsible to plan, organize, develop, direct and delegate (as appropriate) the overall operation of the Nursing department in accordance with current federal, state, and local standards, guidelines and regulations, and facility policies. The objective is to ensure the highest degree of quality care is always maintained. Listed essential functions includes but not limited to assuring all nursing procedures and protocols are followed in accordance with established policies. Directly supervise and instruct the ladies and gentlemen of the (Facility) on number of topics to promote job knowledge. Identify problems, develop, and implement solutions with the assistance of the administration. Monitor medication passes and treatments schedules to ensure medications are being administered as ordered and treatments are provided as scheduled. Facility Job Description for Assistant Director of Nurse's (ADON) presented and dated 1/2015 documented in part that the DON is responsible to plan, organize, develop, direct and delegate (as appropriate) the overall operation of the Nursing department in accordance with current federal, state, and local standards, guidelines and regulations, and facility policies. The objective is to ensure the highest degree of quality care is always maintained. Listed essential functions includes but not limited to assuring all nursing procedures and protocols are followed in accordance with established policies. Directly supervise and instruct the ladies and gentlemen of the (Facility) on number of topics to promote job knowledge. Identify problems, develop, and implement solutions with the assistance of the administration. Monitor medication passes and treatments schedules to ensure medications are being administered as ordered and treatments are provided as scheduled.

Based on interview and record review, facility failed to affirm the right of the resident to be free from physical abuse. This deficient practice affected 1 (R2) of 5 residents reviewed for abuse. This failure resulted in R2, a resident with dementia who resides on a secured dementia unit to be slapped on the cheek by a certified nursing assistant. Findings Include: Facility Initial Incident Report (dated 04/03/2023) states: It was reported to the administrator on 04/03/2023, that R2 had a physical altercation with a certified nursing assistant. Nurse immediately intervened and separated R2 and the certified nursing assistant. Certified nursing assistant was immediately suspended, pending investigation. Family and physician notified. Investigation initiated. Final report to follow. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Alzheimer's disease, unspecified encephalopathy, unspecified, type 2 diabetes mellitus with other specified complication, peripheral vascular disease, unspecified, generalized anxiety disorder, ischemic cardiomyopathy, delirium due to known physiological condition, cognitive communication deficit, hyperlipidemia, unspecified, dementia in other diseases classified elsewhere. Care plan (dated 03/09/2023) documents that R2 has a diagnosis of dementia. Care plan (dated 03/15/2023) documents that R2s at risk for abuse related to: Has a dx of dementia. On 04/08/2023 at 8:30am, surveyor observed R2 sitting in the dining room on the 4th floor secured dementia unit. When asked by surveyor if resident remembers being slapped by a staff member, resident replies, No. Surveyor asked if R2 felt comfortable and safe in R2's environment, R2 replied, Yes. R2 stated something else in additional, however, surveyor was not able to comprehend R2's speech, due to R2's diagnosis of Alzheimer's/Dementia. On 04/08/2023 at 8:41am, V5 (licensed practical nurse) stated, R2 never reported that R2 was handled in a rough manner and R2 never reported that R2 was slapped by a staff member. R2 is confused and does not have the cognitive capacity to remember. R2 has dementia and is cognitively impaired and unable to verbalize needs and not able to report such an occurrence. On 04/08/2023 at 1:20pm V1(administrator) stated, On 04/03/2023, V12 (licensed practical nurse) reported to me that V13 (certified nursing assistant) slapped R2 on the face. V12 had V13 leave the room right away. We sent V13 home and we started the abuse investigation. According to V11(certified nursing assistant), R2 had a fall prior to this incident and R2 was being combative. V11 told me that V11 called another CNA, V13, into the room for assistant because R2 was on the floor. V11 stated that as V11 and V13 were assisting the resident, the resident was waiving and raising R2's arms in a combative way and attempted to hit V13, and V13 was trying to block R2 from hitting V13 and somehow during the process of V13 attempting to block R2's hands, V13's hands touched R2's face. V11 stated that V13 was not trying to hit the resident but was only trying to protect herself from R2's hands. I was told by V11 that V13's hands made contact on R2's cheek. I have not completed the full investigation yet and have not submitted my final report, but V11 did say that V13's hand made contact with the resident's face. I am the abuse prevention coordinator. The abuse prevention training is on the annual training calendar. All the staff that work in the facility receive the abuse prevention training. Residents have the right to be free from abuse and live in a home like environment. On 04/08/2023 at 7:45pm, V12 (Licensed practical nurse) stated, On 04/03/2023, between 5:30am and 5:45am, I was working on the 4th floor passing mediation, and I noticed V11 (certified nursing assistant) coming out of R2's room and walking toward V13 (certified nursing assistant) and both V11 and V13 walked back into R2's room. I decided to follow them, and I stood into R2's doorway. I saw R2 on the floor and V11 and V13 placed R2 back in bed. While R2 was in bed, I saw R2 raise his arm up and all of a sudden, I saw V13 slapped R2 on the left side of the cheek. V13 slapped R2 like it was nothing. V13 did not hesitate and just slapped R2, almost like she has done it before, and I say this because of how comfortable V13 felt slapping the resident. I intervened and told V11 and V13 to leave R2 alone because he is agitated. When V13 came out of R2's room, I asked her why she slapped the resident and V13 said that she did not. I said to V13, You just slapped the s*** out of R2 like it was nothing, and V13 denied it. I informed the supervisor on duty, and I sent V13 home. I could not believe how V13 just slapped the resident without hesitation and how comfortable V13 felt doing so. I felt so bad for the resident, and I reported this incident immediately. On 04/09/2023 at 8:07pm, V13 (certified nursing assistant) stated, On 04/03/2023, V11 (certified nursing assistant) asked for assistance because R2 well and he was being combative. I know R2, and I took care of R2 many times and he is combative. R2 has hit me several times before, so I knew he was being combative. I went to R2's room along with V11, and R2 was laying on the floor. As I was assisting V11 with placing R2 back to bed, R2 hit me in my stomach. R2 was placed in bed, and he was being combative. I did slap R2. I never hit R2. V11 was present in R2's room with me the entire time and at some point V11 turned her face to grab a diaper. The nurse was standing there and told us to leave the resident alone. As I left R2's room, V12 (licensed practical nurse) said to me, Why did you just slap the resident. I told V12 that I did not hit R2, but the nurse kept saying to me that I did slap R2 and that I was going to lose my license. I denied slapping R2. V12 sent me home and I was suspended. I did not abuse any resident. I am currently suspended until they investigate the incident. On 04/09/2023 at 9:54, V11 (certified nursing assistant) stated, R2 is resistant to care often and becomes combative. On 04/03/2023. R2 was on the floor, and I asked V13 (CNA) to assist me with placing R2 back to bed because R2 has hit me before. V13 and I went to the R2's room and V13 popped his cheek. V13 said to R2, let go and slapped R2's cheeks, I guess V13 was trying to play around with the resident to get him up. I did witness V13 slap the resident's cheeks and I don't think that she was intentionally trying to harm him or abuse him. That's how V13 plays with the residents. I have been her do this several times to other residents and other nurses seen her do this too. This was not the first time that V13 has popped a resident's cheek. V13 did not slap R2 hard. R2 was already on the bed when V13 slapped his cheeks, and we were trying to clean the resident and get him dressed. After V13 slapped the resident's cheeks, the R2 pushed V13 away, and did not want V13 to touch him. Some days the resident will allow us to provide care and other days he is resistant and hits the staff. The nurse was in the room when it happened and saw this. When V13 slapped the resident's cheek she said to the resident It's time to get up now, trying to be playful and V13 was not trying to be harm R2. When V13 popped R2's cheek, it probably did hurt R2. I'm sure it hurt the resident. I would not want anybody to slap me like that. I would not want anybody to touch me like that. I was shocked that V13 did that. The nurse was in there and saw this, and I did not want to say anything since the nurse saw this, so I waited for the nurse to intervene. The nurse said to leave the resident along. V13 should not have done that. V13 definitely should not have done that at all, and I was shocked. I did receive training in the facility on abuse prevention. Resident Rights Policy (undated) states: Resident have the right to be free from physical, sexual, mental, verbal and financial abuse. Interdisciplinary Team Note (dated 04/03/2023) documents, Writer spoke with resident's daughter, to inform her of altercation with staff member. Writer also informed of facility response to altercation and investigation. Daughter voiced appreciation for the update and had no questions at this time.

Based on observation, interview and record review the facility failed to use safe technique to reposition one (R1) of 3 residents reviewed for falls in the selected sample. This failure affected R1 who was hospitalized with a head injury. Findings include: R1 was an [AGE] year old admitted to facility on [DATE] with [DIAGNOSES REDACTED]. R1's mental status was severely impaired as noted in the Brief Interview for Mental Status score of 00 out of 15 dated [DATE]. Section G of the Minimum Data Set (MDS) for R1 noted she was a two-person transfer with mechanical lift. R1 was also dependent on staff for all Activities of Daily Living Skills (ADLS). R1 was a fall risk and fell at facility on [DATE]. Fall care plan noted interventions for falls. Incident report for R1 dated [DATE] noted V4 (Certified Nursing Assistant/CNA) observed the fall as she (V4) tried to reposition R1 in reclined chair. R1 fell and she was observed to be bleeding from the back of her head. R1 was sent to community hospital and expired. The Death Certificate for R1 noted the cause of her death was Closed Head injury due to Post Fall. Hospital record for R1 dated [DATE] documented, Subdural Hematoma with left posterior scalp laceration with active bleeding. Dried blood in bilateral nares. On [DATE] at 11:00AM, V2 (Director of Nursing/DON) said R1 sustained head injury when V4 tried to reposition R1 in reclined chair. V2 said they completed an investigation into the incident and V4 was still on suspension for the incident. On [DATE] at 12:30PM, V4 (via telephone) said she tried to reposition R1 in reclined chair while she stood at the back of the chair. According to V4 the fall happened very quickly. V4 said the back of the chair was not reclined and she locked the back of the chair in the upright position. On [DATE] at 2:00PM, V5 (Physical Therapy Director) said she could not picture R1 falling backwards if V4 stood at the back of the chair. On [DATE] at 10:40AM, V8 (Certified Nursing Assistant/CNA), V3 (CNA) and V10 (Restorative Nurse) demonstrated the repositioning of R5 in reclined chair and with a mechanical lift sling on the chair. According to staff present, R1 had a similar reclined chair as R5. It was difficult to complete the task standing at the back of the chair with the back of the chair in the upward position. All staff present said the back of the chair should have been reclined and locked if the staff wanted to stand at the back. On [DATE] at 11:34AM, V9 (Nurse Practitioner/NP) said R1's fall could have been avoidable if only the staff had used two persons to reposition R1 in the chair. V9 said R1 was a two-person assist for transfers, however, since the resident had limited use of the right arm, the staff should have used two persons for safe repositioning. Facility did not present a policy on repositioning of residents in reclined chair.

Based on observation interview and record review, the facility failed to provide a safe wheelchair transport to prevent a resident from falling for one of nine residents (R9) reviewed for falls in a sample of 30. As a result R9 sustained two left leg fractures (tibia and fibula). The findings include: On 10/17/17 at 10:15 AM observed R9 in activity/dining room sitting on her wheelchair with left leg cast resting on foot rest. Record review on facility provided face sheet indicates that R9 is an [AGE] year old female with [DIAGNOSES REDACTED]. Record review on fall risk assessment dated on 6/29/17 and 9/26/17 indicate that R9 was high risk for fall with fall risk assessment score of 21. On 10/18/17 11:00 AM, E2 (Director of Nursing) stated, Resident with fall risk score of 12 or greater is high risk for fall. Record review on facility's fall log indicates that R9 had a fall on 6/24/17 with swelling to her left forehead and discoloration. R9 was send to local hospital for further evaluation. Record review on fall log indicates R9 had fall again on 8/27/17 at 6:30 AM and 7:30 PM. Record review on post occurrence documentation indicates that R9 rolled over and slid out of bed at 6:30 AM. On 10/18/17 at 11 AM E2 (Director of Nursing) stated, On 8/27/17 E8 (Certified Nursing Assistant - CNA) was the nursing assistant who propelled R9's wheel chair when fall occurred in the evening at 7:30 PM. When E8 was propelling R9 to her room, R9 leaned forward and fell . R9 was send to local hospital for further evaluation. On 10/19/17 at 12:40 PM E3 (Human Resource Manager) stated, E8 was counseled on 8/30/17 in regards to pushing R9's wheelchair and resident fall. E8 was discharged due to no call no show. Record review on post occurrence report dated 8/27/17 indicates a raised area noted with R9's left forehead and complaints of pain with left lower leg. R9 was send to local hospital for further evaluation. Record review on diagnostic imaging report from hospital indicates that R9 had an oblique non-displaced fracture of the distal third of the fibula and a comminuted non-displaced fracture of the distal of the tibia. On 10/19/17 at 3:00PM E1 (Administrator) and E2 stated, Not all the residents need leg rest. On the day of injury, there was no leg rest because she didn't need at that time. R9 put her foot down and leaned forward and fell out of chair. Record review on MDS dated on 6/30/17 and 9/28/17 indicates that R9 needed extensive assistance with transfer and ambulation. On 10/20/17 at 2 PM Z9 (Ortho Physician) stated, R9 had CVA with left side weakness. I might have questioned the fracture if the daughter told you so. Looking at the X-rays, it looks suspicious. The fracture was too angular. It looks like she may have caught her foot, twist it and then fell . If this was a child it would be known as a spiral fracture.

Based on observation, interview and record review the facility failed to follow facility policy pertaining to rescue and removal of a resident from harm during a fire, staff immediate announcement and response to a fire alarm to prevent resident's injury and immediate assessment of a resident's injury due to fire and smoke inhalation. This applies to one resident (R1) out of 7 reviewed for fire safety and has the potential affect all 49 residents residing on the facility's first floor according to the facility's resident roster on [DATE]. This was identified as an immediate jeopardy situation. E1 (administrator) was informed of the immediate jeopardy on [DATE]. The immediate jeopardy began on [DATE] and was removed on [DATE]. Findings Include: The facility's initial incident/accident/allegation notification dated [DATE] and filed [DATE] indicates that R1 was observed in the hall with some smoke noted in his room. The facility's report dated [DATE] indicates that R1 was taken to a local hospital and subsequently expired. R1's death certificate dated [DATE] indicates that R1's cause of death was thermal injury and careless use of smoking materials while on home oxygen therapy. R1 was admitted to the facility on [DATE]. R1's smoking agreement dated [DATE] indicates that R1 was not a smoker at the time of admission. R1's social services care plan conference dated [DATE] indicates that during previous placement R1 had behaviors of smoking with oxygen. On [DATE] at 12:12 pm E6 (nurse aide) stated that on [DATE] in the 9:00am hour she was standing at the hall kiosk charting and saw R1 sitting between the beds. E6 stated that the fire alarm sounded and R1 wheeled himself into the hallway in his motorized wheelchair. E6 stated that R1 had his oxygen via nasal cannula in his nares and was receiving oxygen. E6 stated that R1 did not say anything but was observed having a difficult time breathing. E6 stated that when she approached R1 she noticed that the end of R1's mattress was on fire. E6 stated that the fire on R1's mattress was small like a fire on a stove. E6 stated that R1's oxygen concentrator near the head of the bed was also burned from fire. E6 stated that she proceeded to move R1 further down the hall and grabbed the fire extinguisher to put the fire out. E6 stated that once the fire was out she put the extinguisher down and proceeded to continue down the hall with R1 (wheelchair bound). E6 stated that she noticed that the fire re-ignited and stopped to extinguish the flames. E6 stated that once the fire was out she proceeded down the hall again with R1, but she noticed the fire had re-ignited again and stopped to re-extinguish the fire, finally putting it out permanently. E6 stated that she did not yell code red or fire because she did not want to cause everyone to panic. E6 stated that E9 Social Services took over pushing R1 to the nursing station to E11 Licensed Practical Nurse (LPN). E6 stated that she received staff assistance from E10 (CNA) after coming through the fire doors and staff noticed the smoke coming from west corridor. E6 stated that she did not close the door to R1's room during the fire. E6 stated that she believes that she closed all room doors after extinguishing the fire and getting R1 to the nursing station. On [DATE] at 9:21am the surveyor with Z4 (Arson Unit Detective) facility videotape footage was reviewed with a date of [DATE] starting at 9:50 am. The videotape shows the fire doors to the southwest corridor closing at 9:52 am. The videotape shows E11 Licensed Practical Nurse (LPN) sitting at the nurse's station when the fire doors closed. At 9:53 am E11 was observed to take a sip of her drink, stand, walk over to the medication carts and place the medication carts behind the nursing station. E11 was then observed sitting back down at the nurse's station to continue her drink. E11 was not observed leaving the nursing station to assist during the fire alarm. At 9:54 am E6 CNA and E9 are observed bringing R1 through the double doors. R1 was observed to be slumped over the right side of the wheelchair, with no movement observed from R1. E11 LPN walked over to R1 and took a quick glance at R1 and walked away to stand behind the nursing station. At 9:55 am E11 walked back over to R1 and placed the nasal cannula on R1. The nasal cannula was observed to be already connected to the oxygen tank on R1's wheelchair. E11 was not observed taking vital signs or performing an assessment on R1 between 9:54am (R1's arrival at the nurse's station) and 9:57 am (R1 was moved out of camera range). Facility staff was observed evacuating residents to the dining room from the 1st floor west hall between 9:54 am and 9:59 am. The videotape from another view near R1's room shows R1wheeled himself out of the room in the motorized wheelchair with oxygen tubing attached to the oxygen tank trailing behind the wheelchair on the floor. R1 was observed sitting in an upright position in the wheelchair. E6 CNA was observed running towards R1 and then running back to get the fire extinguisher. R1 was observed sitting in the hall next to the south side of the wall (while E6 was observed running in and out of camera range with the fire extinguisher) gasping for air as the corridor filled with smoke. Z4 stated that R1 had burn marks on his face that were consistent with the oxygen tubing going around his ear. Z4 stated that there was a lighter and two cigarette butts found. Z4 stated that two oxygen tubings were observed, one in R1's room on the dresser and one coming from the oxygen tank on the wheelchair. Z4 stated that both oxygen tubings were burned. Z4 stated that R1's oxygen machine near the head of the bed was burned, as well as a section on the side of the mattress near the bottom. On [DATE] at 1:29 pm E3 Director of Nursing (DON) stated that if a resident has a change in condition they should be assessed and vital signs taken as soon as the change in condition is noted. On [DATE] at 4:00pm with E15 (Regional Administrator) videotape footage was reviewed on [DATE] during the fire. E11 LPN was not observed providing immediate emergency care to R1 after being brought to the nursing station by E6 CNA and E9 Social Services. E11 was observed applying an oxygen mask to R1 at 9:59 am, although E6 CNA reported that R1 was having a hard time breathing when she brought him to the nurse's station. Videotape footage indicates that R1 was brought to the nurse's station at 9:54 am. On [DATE] at 9:19 am Z6 Fire Marshal stated that the fire involving R1 was caused by the ignition of oxygen tank due to smoking while wearing oxygen. Z6 stated that the facility staff nurses informed him that R1 was a smoker. On [DATE] at 2:01 pm E10 CNA stated that on [DATE] during the fire she (E10) noticed smoke coming from the hall when E6 CNA came through the fire doors with R1 and E9 (social Services). E10 stated that after noticing the smoke she (E10) went down the hall where the smoke was to assist E6 in making sure all residents were safe. On [DATE] at 2:30 pm E11 LPN stated that she received R1 in the wheelchair after E9 Social Services pushed R1 to the nursing station. E11 stated that R1's respirations were deep and shallow, so she placed oxygen on R1. E11 stated that the paramedics arrived immediately and took over care for R1. R1's social services note dated [DATE] at 11:46 am indicates: social services assisted escorting R1 to the nursing station and noticed that R1's hair, right ear and face were singed; the police were in the facility and requested that an ambulance be dispatched; while waiting on the ambulance the fire department and nursing were performing Cardiopulmonary resuscitation; the emergency medical technicians (EMT) escorted R1 into the ambulance; EMT returned into the facility and reported that R1 expired in the ambulance. E19's (Security Officer) investigation report (undated) indicates that when the alarm went off E19 quickly went to the panel to see the location and paged code red 3 times (code red first floor west 3 times). E19's statement indicates that he was looking at the cameras to see where everyone was and saw staff moving residents from their rooms on all floors. E19's statement indicates that R1 was the only resident that was down his hall because E6 and E10 (CNA's) had moved residents from their room to the day room. E19's statement indicates that E11 (LPN) was working on R1. 1. The facility fire drill report dated [DATE] for actual fire indicates that the fire department received that signal at 9:00 am. On [DATE] at 12:00pm E13 Maintenance Director stated that he does not know the exact time that the alarm signal was received at the fire department. E13 stated that the alarm sounded in the 9:00 am hour. The city fire department incident report dated [DATE] indicates that the paramedics were dispatched at 9:57 am and arrived at the facility at 10:04 am. The city fire department report indicates: upon arrival R1 was found in the lobby; R1 was possibly smoking in his room with oxygen on and bed caught fire; R1 [MEDICAL CONDITION] hair. The city fire department report also indicates that R1 was unresponsive, with no respirations and no carotid pulse. The report indicates that R1 was pronounced dead on arrival at 10:30 am in the field. On [DATE] at 12:15 pm, the question was asked, What do you do if an actual fire is observed? E11 LPN replied call a code red, run to get the extinguisher, check rooms to make sure residents are safe. E11 stated that when a fire alarm sounds the staff get the fire extinguisher and walk around their assigned station to make sure residents are safe. On [DATE] at 12:20 pm, when asked what you do if an actual fire is observed, E14 CNA replied rescue the residents, inform the nurse, evacuate, get the fire extinguisher, and close the room doors. When asked if there is an actual fire what do you do for the other residents who in their rooms down the same hall as the fire, E14 replied close their room doors. On [DATE] at 12:25 pm, when asked what do you do if an actual fire is observed, E15 CNA replied pull alarm, alert staff, and check residents for safety. When asked what do you do for the residents that are in the hall where the fire is located, E15 replied that staff would close the room doors of residents in room to keep them safe. On [DATE] at 12:30 pm, when asked what do you do if an actual fire is observed, E10 CNA replied that you should try to extinguish the fire and rescue the resident. On [DATE] at 12:37 pm, when asked what staff should do if there is a fire, E13 Maintenance Director replied that staff should clear halls, close doors and listen for further instructions. E13 stated that residents who are in their rooms in the hall where the fire is located should be moved to a safe area behind the fire doors. E13 stated that the staff can try to extinguish the fire if they feel comfortable. The facility's course completion history for workplace emergencies and natural disasters: an overview does not include documentation to support that E6 completed the course in 2016. On [DATE] at 2:10 pm E2 Assistant Administrator stated that E6 has been employed at the facility for 2 years and 4 months. The facility's fire drill report dated [DATE] indicates that E6 participated in a false alarm drill. The facility's staff response to fire policy revised ,[DATE] indicates that the employee who first discovers the fire/smoke will perform task in this order: Rescue the individual(s) in immediate danger; shout code red to alert staff; activate the nearest alarm pull station; contain the fire by closing the door to the room; extinguish the fire with a fire extinguisher if the fire is small - no larger than a trash can. The policy indicates that staff will: Evacuate the immediate area, continuing to evacuate all occupants out of the smoke compartment to a safe area beyond the smoke compartment doors and behind a second set of doors if possible; keep the fire contained by closing the door, assist in moving residents to a safe area. The facility took the following steps to remove the immediacy. However, the deficiency still remains at the second level of harm until the completion of the facility's staff in-services. 1. On [DATE] the Code Red, responding to Fire Alarms, RACE process, Fire Drill and Urgency were identified as areas of failure. This included the importance of timely removal of residents from unsafe areas. Policies for these areas were reviewed. Revisions were made to the Changes in Condition policy to accentuate immediacy of response to changes in resident conditions, urgency of assessing (physical assessment of the body, vital signs, psychosocial changes and resident care needs), and providing medical interventions. The Maintenance Director, Assistant Administrator, Administrator, Director of Housekeeping and DON re-educated staff on these policies. This included the specific staff that worked on the unit on the day of the occurrence, as well as other staff in the building. Completed [DATE] and on-going until all staff members not on duty are educated. 2. On [DATE] - [DATE] the individual staff not responding to the fire alarm on the unit were addressed (provided with re-education) related to their responsiveness or lack of responsiveness. The nurse has been on administrative leave/suspension due to lack of responsiveness and lack of assessment of the resident [DATE] The two CNAs working the unit on the day of the occurrence were re-educated on RACE (including removing residents immediately from unsafe situations), immediately going to the location of the fire, and timely response to emergency [DATE] The Social Services Director was counseled and re-educated on urgency of responding to code red (RACE) and has been on administrative leave/suspension due to the lack of responsiveness [DATE]. Other staff have been re-educated (by the Administrator, DON, Assistant Administrator, Director of Housekeeping and facility consultant) on Code Red, responding to Fire Alarms, RACE process, Fire Drill and Urgency. Completion [DATE] and on going until staff not on duty have been re-educated. 3. Beginning [DATE] the Administrator, Assistant Administrator, DON, Housekeeping Director, and facility consultant initiated re-education (testing) on fire safety. On [DATE] it was revised specifically as RACE pre- and post test. All staff shall be administered this test by the above department heads. A QA tool was developed and implemented by the Administrator to monitor the results of the tests to ensure successful completion of the test including newly hired staff. On a monthly basis staff will be re-educated. Completed [DATE]. All new hires shall be educated on their first day of hire. 4. On [DATE] a review of the policies on response to medical emergencies, staff response to emergencies and assessing residents post incident/accident was completed by the ADON and facility consultant. There were no revisions made to these policies. The identified failure was lack of response and assessment in a medical emergency by the nurse and staff not following the RACE process. Staff was re-educated on RACE, communicating urgent situations immediately to the nurse. The nurses were additionally educated on the importance of immediacy of response to assessing residents post incident and accident for immediate medical needs. The responsibility of the nurse to respond immediately to situations including burns, codes, changes in mental status, falls with injury etc. The assessment including vital signs, head to toe body assessment. All urgent circumstances requiring immediate responsiveness. Completed [DATE] and on-going until all staff members not on duty have been educated. On [DATE] staff not directly involved in the occurrence were re-educated on responding to medical emergencies, emergency preparedness, assessing residents post incident and accident and RACE process, Code Red, responding to Fire Alarms, RACE process, Fire Drill and Urgency. Completed [DATE] and on-going until all staff members not on duty have completed the re-education. The nurse that was directly involved has been placed on administrative leave/suspension. Her skill set and training includes: Curriculum from LPN School (Dawson Tech) 2004. Licensed through IDPR after successful completion of NCLEX exam and Annual Electronic courses (abuse prevention, accident prevention, behavioral health, code reviews, fire safety, stress management, managing challenging behaviors, HIPAA, QA, Lifting, Back Injury, Alzheimer's, helping families, cultural diversity, hazard communication, hand hygiene, OSHA, lock out/tag out, influenza prevention, long term care, resident rights, [MEDICAL CONDITION] medications, understanding the meaning behind behaviors and actions).

Based on interview and record review the facility failed to put in place interventions to prevent a resident from smoking while on oxygen, failed to reassess a resident who was initially identified as a non-smoker once cigarette smoking was reported, failed to develop a behavioral (smoking) care plan for one resident (R1) out of seven reviewed for smoking and fire safety. R1 ignited the bed while wearing oxygen which lead to R1's death. This was identified as an immediate jeopardy situation. E1 (administrator) was informed of the immediate jeopardy on [DATE]. The immediate jeopardy began on [DATE] and was removed on [DATE]. Findings Include: R1's face sheet indicates that he was admitted to the facility on [DATE]. R1's smoking agreement dated [DATE] indicates that R1 was not a smoker at the time of admission. The facility's initial incident/accident/allegation notification dated [DATE] and filed [DATE] indicates that R1 was observed in the hall with some smoke noted in his room. The facility's report dated [DATE] indicates that R1 was taken to a local hospital and subsequently expired. The report also indicates that the police detective and investigator gave a report that the fire was accidental with an unknown origin. The city fire department incident record dated [DATE] under findings indicates that R1 was unresponsive with no spontaneous respirations, no carotid pulse and dead on arrival to the hospital. The fire department report also indicates that R1 was possibly smoking in his room with oxygen on and the bed caught fire. R1 suffered burns to his hair. R1's death certificate dated [DATE] indicates that R1's cause of death was thermal injury and careless use of smoking materials while on home oxygen therapy. On [DATE] at 2:00 pm E1 (Administrator) stated that following the fire, two cigarette butts were observed on the floor in R1's room and a lighter was observed outside of R1's room. On [DATE] at 2:10 pm E5 Registered Nurse (RN) stated that the first time that she encountered R1 trying to smoke is when she documented the behavior note on [DATE]. E5 stated that she was informed by staff CNA's that R1 was trying to smoke in the dining room and she confiscated R1's lighter and a small cigarette butt. E5 stated that she threw the lighter and the cigarette butt in the trash can but told R1 that she would put it away for him. E5 stated that R1 was wearing oxygen during the time the lighter and cigarette butt was confiscated. E5 stated that she never observed R1 smoking and assumed he was not a smoker. E5's investigation statement (undated) indicates that E7 and E8 Certified Nursing Assistants (CNA) came to E5 and told E5 that R1 was trying to light up a cigarette in the dining room. (E5) went to the dining room and R1 had a cigarette and lighter; (E5) asked R1 for it and R1 gave it to E5 and security was informed. On [DATE] at 2:22pm E7 CNA stated that she did not inform anyone that R1 was trying to smoke in the dining room. E7 stated that she had not seen R1 with any smoking materials. E7 stated that she reported to a staff nurse that R1 had a knife in his possession. E8 was not available for interview. On [DATE] at 12:12 pm E6 CNA stated that she was standing at the hall kiosk charting and saw R1 sitting between the beds. E6 stated that the fire alarm sounded and R1 came out of his room. E6 stated that when she approached R1 she noticed that his bed was on fire and proceeded to move R1 further down the hall and grabbed the fire extinguisher to put the fire out. E6 stated that once the fire was out she put the extinguisher down and proceeded to continue down the hall with R1 (wheelchair bound). E6 stated that she noticed that the fire re-ignited and stopped to extinguish the flames. E6 stated that once the fire was out she proceeded down the hall again with R1, but she noticed the fire had re-ignited again and stopped to re-extinguish the fire, finally putting it out permanently. E6 stated that she did not yell code red or fire because she did not want to cause everyone to panic. E6 stated that E9 Social Services took over pushing R1 to the nursing station to E11 Licensed Practical Nurse (LPN). On [DATE] at 2:30 pm E11 LPN stated that she received R1 in the wheelchair after E9 Social Services pushed R1 to the nursing station. E11 stated that R1's respirations were deep and shallow, so she placed an oxygen mask on R1. E11 stated that the paramedics arrived immediately and took over care for R1. On [DATE] at 12:52pm E12 Housekeeping stated that on [DATE] he was in R1's room cleaning when he heard R1 ask another resident for a cigarette. E12 stated that the other resident told R1 that he did not have any cigarettes and proceeded down the hall. E12 stated that R1 then left the room and returned minutes later. E12 stated that he did not notice anything out of the ordinary with R1 when he returned to the room. E12 stated that he left R1's room and went in the dining area and heard the fire alarm sounds approximately 15 minutes later. On [DATE] at 11:15 R6 stated that R1 was frequently seen on the smoking patio with his oxygen on smoking a cigarette. R6 stated that on [DATE] she observed R1 on the smoking patio with his oxygen on and yelled at him to go back into the facility before he blows everyone up. R6 stated that on [DATE] or [DATE] R1 was observed smoking in the dining room while wearing oxygen. R6 stated that she informed E12 Assistant Director of Nursing (ADON) of R1's smoking while wearing oxygen. E12 ADON was not available for interview. R6 stated that she also informed R1's family that R1 had been smoking with oxygen in place. On [DATE] at 3:34 pm Z2 (R1's Family) stated that her family was informed by another resident that R1 had been smoking with oxygen in place. Z2 stated that R1's family approached a male nurse to inquire about how R1 got the cigarettes and the lighter to smoke. Z2 stated that they were told that the matter was under investigation. Z2 could not recall who the male nurse was that stated that matter was under investigation. The facility could not provide documentation to indicate an investigation was conducted related to R1 smoking with oxygen in place. R1's social services care plan conference dated [DATE] indicates that during previous placement R1 had behaviors of smoking with oxygen. On [DATE] at 2:57 pm E9 (Social Service Director) stated that during the care plan meetings any concerns mentioned are documented. E9 stated that R1's behavior of smoking while wearing oxygen was not a behavior that was observed while at the facility, therefore the smoking behavior was not care planned. On [DATE] at 9:12 am E1 Administrator stated that R1 was not care planned for unsafe smoking with oxygen because it was a behavior at a past facility. R1's behavior note dated [DATE] indicates, Please monitor R1, he has tried on numerous occasions to smoke in the day room, he tries to go into other residents rooms. R1's care plan does not include smoking with oxygen as a behavior, although R1 was observed with smoking materials while wearing oxygen. The facility's smoking assessment and safety protocol (formally smoking at risk program) revised ,[DATE] indicates the following: oxygen is prohibited in smoking areas for the safety of all parties; it is against facility policy to give away, sell share, trade smoking materials or light another resident's cigarette; smokers will be evaluated by designated inter-disciplinary team member at admission (within 24 hours), quarterly and annually, as well as if unsafe smoking behaviors occur, to determine ability to comply with safety rules and their ability to carry smoking materials. The facility smoking assessment and safety protocol under consequences of smoking non-compliance indicates: residents will be re-assessed, instructed, educated and counseled about their inappropriate behavior; safe appropriate behavior will be stressed; documentation will be entered in the record accordingly; the smoking assessment will be re-completed and care plan updated to reflect new goals/approaches. The facility took the following steps to remove the immediacy. However, the deficiency still remains at the second level of harm until the completion of the facility's staff in-services. 1. On [DATE] the Assistant Administrator and VP conducted a review of the following policies: Incidents and Accidents, Smoking, Room safety rounds, Oxygen storage and use, and Fire Drills. After the review was conducted, the identified area of failure was the supervision of smoking products. The facility Quality Assurance Team (including the Medical Director, Administrator, Assistant Administrator, Clinical Director, Social Services Directors, DON, ADON and facility consultant) revised the smoking policy to include the structured smoking times and restricted access to smoking materials. Completed: [DATE] The education and re-education with staff (on the revised smoking policy and other listed policies) was initiated on [DATE] by the Clinical Director and Assistant Administrator. Subsequent education and re-education (on the above policies) was initiated by the Assistant Administrator, Clinical Director, Restorative Nurses and facility consultant. Completed: [DATE] and on-going until staff members not on duty are re-educated. On [DATE] The Administrator initiated a smoking safety QA tool which is completed on a daily basis and shall be reviewed daily for 30 days, then reviewed 3 x/week for 30 days, then weekly for 30 days and monthly. 2. On [DATE] the Assistant Administrator and Administrator immediately implemented a scheduled structured smoking program. Resident smoking materials were secured and designated supervised smoking times were identified for smoking. This policy was revised to ensure all resident smokers would have supervision during smoking. On [DATE] the Assistant Administrator, Clinical Director, Restorative Nurses and Activity Director educated staff on the revised smoking policy, and re-educated staff on the above listed policies. Completed: [DATE] On [DATE], [DATE] and [DATE] Special Resident Council Meetings were held by the Activity Director, who educated the residents on the revised smoking policy and the seriousness of safety, informed of the smoking times and the risks associated unsafe smoking. Completed [DATE] On [DATE] the Administrator further revised the smoking policy to restrict all smoking materials from all residents. The residents that were affected by the revisions (those assessed as safe smokers) were all notified (by Social Services) by [DATE]. These residents were educated on the ability to continue to have access to their smoking materials when they leave the facility and the requirement that they relinquish the smoking materials upon return to the facility. The patio was secured (alarmed) to prevent unsupervised smoking. Completed [DATE] On [DATE] visitor/family education was initiated (by Security and Receptionists) on the smoking policy and the need for the facility to secure smoking materials. The Administrator subsequently posted written notification of the smoking restrictions in the facility lobby, and the revised smoking policy was mailed to resident legal representatives and responsible parties. Completion by [DATE]. Upon admission, the Admission Director shall provide this notification to the resident's legal representatives and responsible parties. The Nurse shall provide this notification to the residents upon admission. A QA Tool was developed by the Administrator and implemented to monitor the compliance. 3. On [DATE] the Social Services Director in conjunction with the psychiatrist conducted a review of all residents to identify any unsafe and serious at risk behaviors, assessment and development of interventions for such behaviors. Completed on [DATE] The psychologist re-educated staff on accuracy of assessment, re-assessment, documentation and care planning at risk behaviors by the psychologist. Completed [DATE]. A QA tool was developed and implemented by the Social Services Director to monitor compliance. Subsequently based on QA tool monitoring, additional reviews and revisions were developed and implemented. Completion [DATE]. The Administrator shall ensure the completion and review of the QA tool on a daily basis for 30 days, then reviewed 3 x/week for 30 days, then weekly for 30 days then monthly. 4. On [DATE] the facility communication processes (associated with unsafe behaviors) was identified as an area of failure. Policies associated with communication processes were reviewed including: Daily Shift Stand Up Meeting (daily meeting on each unit to review residents), EHR communication alerts, and staff direct messaging, Point of Care (electronic documentation) alerts/tasks, Care Plan reviews, Resident and Family Concerns and 24 Hour communication. Based on the results of the review, revisions were made to the Daily Shift Stand Up Meetings policy to require all staff (including non-nursing) attendance and participation in this meeting. Staff is required to give and receive report on any resident unsafe behaviors or changes in behavior. The DON, ADON, PM Supervisor and Assistant Administrator are responsible for ensuring that this meeting occurs each shift. A QA tool has been implemented and shall be reviewed by the Administrator daily for 30 days then, 3 times a week for 30 days then weekly for 30 days then monthly. Completed: [DATE] Staff directly involved with this failure were provided with individual education. The housekeeper was re-educated on communicating unsafe behaviors; The ADON has been on administrative leave/suspension due to lack of communication of unsafe behavior; The Psychiatric Rehabilitation Services Director was re-educated on care conference documentation; The Nurse was placed on administrative leave/suspension due to the lack of communication of unsafe behavior; and The Social Services Director has been on administrative leave/suspension due to lack of communication of unsafe behavior, lack of reassessment and care planning of unsafe behaviors.

Based on observation, interview and record review the facility failed to provide immediate emergency care for a resident with a change of condition, failed to develop a care plan for unsafe smoking for a resident, failed to report a resident's elevated blood glucose level and resident's refusal of scheduled insulin to the physician and failed to implement care plan interventions for a resident with diabetes. This refers to 2 of 18 residents (R1, R11) reviewed for nursing home services in a sample of 18. This failure resulted in delayed assessment and care of R1 following a facility fire which led to R1's death. Findings Include: 1. R1's face sheet indicates that he was admitted to the facility on [DATE]. R1's face sheet [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] indicates that R1 had a Brief Interview for Mental Status score of 15, indicating no cognitive deficit. R1's smoking agreement dated [DATE] indicates that R1 was not a smoker at the time of admission. The facility's initial incident/accident/allegation notification dated [DATE] and filed [DATE] indicates that R1 was observed in the hall with some smoke noted in his room. The facility's report dated [DATE] indicates that R1 was taken to a local hospital and subsequently expired. The report also indicates that the police detective and investigator gave a report that the fire was accidental with an unknown origin. R1's death certificate dated [DATE] indicates that R1's cause of death was thermal injury and careless use of smoking materials while on home oxygen therapy. On [DATE] at 12:12 pm E6 (nurse aide) stated that on [DATE] in the 9:00am hour she was standing at the hall kiosk charting and saw R1 sitting between the beds. E6 stated that the fire alarm sounded and R1 wheeled himself into the hallway in his motorized wheelchair. E6 stated that R1 had his oxygen via nasal cannula in his nares and was receiving oxygen. E6 stated that R1 did not say anything but was observed having a difficult time breathing. E6 stated that when she approached R1 she noticed that the end of R1's mattress was on fire. E6 stated that the fire on R1's mattress was small like a fire on a stove. E6 stated that R1's oxygen concentrator near the head of the bed was also burned from fire. E6 stated that she proceeded to move R1 further down the hall and grabbed the fire extinguisher to put the fire out. E6 stated that once the fire was out she put the extinguisher down and proceeded to continue down the hall with R1 (wheelchair bound). E6 stated that she noticed that the fire re-ignited and stopped to extinguish the flames. E6 stated that once the fire was out she proceeded down the hall again with R1 but she noticed the fire had re-ignited again and stopped to re-extinguish the fire, finally putting it out permanently. E6 stated that she did not yell code red or fire because she did not want to cause everyone to panic. E6 stated that E9, Social Services took over pushing R1 to the nursing station to E11 Licensed Practical Nurse (LPN). E6 stated that she received staff assistance from E10 (CNA) after coming through the fire doors and staff noticed the smoke coming from west corridor. E6 stated that she did not close the door to R1's room during the fire. E6 stated that she believes that she closed all room doors after extinguishing the fire and getting R1 to the nursing station. On [DATE] at 9:21am the surveyor with Z4 (Arson Unit Detective) facility videotape footage was reviewed with a date of [DATE] starting at 9:50 am. The videotape shows the fire doors to the southwest corridor closing at 9:52 am. The videotape shows E11 Licensed Practical Nurse (LPN) sitting at the nurse's station when the fire doors closed. At 9:53 am E11 was observed to take a sip of her drink, stand, walk over to the medication carts and place the medication carts behind the nursing station. E11 was then observed sitting back down at the nurse's station to continue her drink. E11 was not observed leaving the nursing station to assist during the fire alarm. At 9:54 am E6 CNA and E9 are observed bringing R1 through the double doors. R1 was observed to be slumped over the right side of the wheelchair, with no movement observed. E11 LPN walked over to R1 and took a quick glance at R1 and walked away to stand behind the nursing station. At 9:55 am E11 walked back over to R1 and placed the nasal cannula on R1. The nasal cannula was observed to be already connected to the oxygen tank on R1's wheelchair. E11 was not observed taking vital signs or performing an assessment on R1 between 9:54am (R1's arrival at the nurse's station) and 9:57 am (R1 was moved out of camera range). Facility staff was observed evacuating residents to the dining room from the 1st floor west hall between 9:54 am and 9:59 am. The videotape from another view near R1's room shows R1 wheeled himself out of the room in the motorized wheelchair with oxygen tubing attached to the oxygen tank trailing behind the wheelchair on the floor. R1 was observed sitting in an upright position in the wheelchair. E6 CNA was observed running towards R1 and then running back to get the fire extinguisher. R1 was observed sitting in the hall next to the south side of the wall (while E6 was observed running in and out of camera range with the fire extinguisher) gasping for air as the corridor filled with smoke. Z4 stated that R1 had burn marks on his face that were consistent with the oxygen tubing going around his ear. Z4 stated that there was a lighter and two cigarette butts found. Z4 stated that two oxygen tubings were observed, one in R1's room on the dresser and one coming from the oxygen tank on the wheelchair. Z4 stated that both oxygen tubings were burned. Z4 stated that R1's oxygen machine near the head of the bed was burned as well as a section on the side of the mattress, near the bottom. On [DATE] at 1:29 pm E3 Director of Nursing (DON) stated that if a resident has a change in condition they should be assessed and vital signs taken as soon as the change in condition is noted. On [DATE] at 4:00pm with E15 (Regional Administrator) videotape footage was reviewed on [DATE] during the fire. E11 LPN was not observed providing immediate emergency care to R1 after being brought to the nursing station by E6 CNA and E9 Social Services. E11 was observed applying an oxygen mask to R1 at 9:59 am, although E6 CNA reported that R1 was having a hard time breathing when she brought him to the nurse's station. Videotape footage indicates that R1 was brought to the nurse's station at 9:54 am. On [DATE] at 9:19 am Z6 Fire Marshal stated that the fire involving R1 was caused by the ignition of oxygen tank due to smoking while wearing oxygen. Z6 stated that the facility staff nurses informed him that R1 was a smoker. On [DATE] at 2:01 pm E10 CNA stated that on [DATE] during the fire she (E10) noticed smoke coming from the hall when E6 CNA came through the fire doors with R1 and E9 (social Services). E10 stated that after noticing the smoke she (E10) went down the hall where the smoke was to assist E6 in making sure all residents were safe. On [DATE] at 2:30 pm E11 LPN stated that she received R1 in the wheelchair after E9 Social Services pushed R1 to the nursing station. E11 stated that R1's respirations were deep and shallow, so she placed oxygen on R1. E11 stated that the paramedics arrived immediately and took over care for R1. R1's social services note dated [DATE] at 11:46 am indicates: social services assisted escorting R1 to the nursing station and noticed that R1's hair, right ear and face were singed; the police were in the facility and requested that an ambulance be dispatched; while waiting on the ambulance the fire department and nursing were performing Cardiopulmonary resuscitation; the emergency medical technicians (EMT) escorted R1 into the ambulance; EMT returned into the facility and reported that R1 expired in the ambulance. On [DATE] at 4:00pm with E15 (Regional Administrator) videotape footage was reviewed on [DATE] during the fire. E11 (Nurse-LPN) was not observed providing immediate emergency care to R1 after being brought to the nursing station by E6 CNA and E9 Social Services. E11 was observed applying an oxygen mask to R1 at 9:59 am, although E6 CNA reported that R1 was having a hard time breathing when she brought him to the nurse's station. Videotape footage indicates that R1 was brought to the nurse's station at 9:54 am. R1 was observed receiving CPR from the paramedics with the assistance on E6 (CNA). E11 (LPN) was not observed providing CPR to R1. R1's records do not include documentation of a complete assessment, with vitals upon R1's change of condition. R1's nurse's note dated [DATE] at 9:45 am indicates: R1 was non-verbal, breathing was deep and labored, oxygen via non re-breather mask was immediately placed on R1; paramedic was assessing R1, pulse was not palpable and vitals were not attainable; resident immediately placed on flat surface by paramedic and nursing staff; respiratory rescue bag and cardiopulmonary resuscitation was initiated; fire department intubated R1 and took R1 from the facility. The facility's job description for Staff Nurse (Registered Nurse/Licensed Practical Nurse) dated ,[DATE] under essential functions indicates that staff nurses should administer professional services such as: .care of the dead/dying, etc. as required; take and record temperature, pulse, respirations, blood pressure, accuchecks, etc. as necessary. The facility could not provide evidence that these functions were performed related to R1's fire related incident. The city fire department incident record dated [DATE] under findings indicates that the fire department paramedics were dispatched at 9:57 am, and arrived at R1 at 10:05 am. The city fire department incident report indicates that R1 was unresponsive with no spontaneous respirations, no carotid pulse and dead on arrival to the hospital. The fire department report also indicates that R1 was possibly smoking in his room with oxygen on and the bed caught fire. R1 [MEDICAL CONDITION] his hair. R1's emergency room records dated [DATE] under initial comments indicates the following: R1 was brought in by the fire department for pronouncement; evidently R1 was found dead in his nursing home bed; prior to dying, he had reportedly been smoking in the bed and accidentally lit his bed on fire. R1's emergency room records indicate that R1 was dead on arrival from the facility. On [DATE] at 2:57 pm E9, Social Service Director stated that R1's unsafe smoking behaviors were discussed in a care plan meeting as a behavior from past facilities. E9 stated that she was not made aware of any unsafe smoking behaviors exhibited by R1 while in the facility. On [DATE] at 9:12 am E1 (Administrator) stated that R1 was not care planned for unsafe smoking with oxygen because it was a behavior at a past facility. R1's behavior note dated [DATE] indicates, Please monitor R1, he has tried on numerous occasions to smoke in the day room, he tries to go into other residents rooms. R1's behavioral note does not include what interventions were put in place to address R1's unsafe smoking behaviors and what actions were taken to ensure that R1 did not have additional smoking materials in his possession. The facility could not provide documented evidence that R1's unsafe behaviors were communicated to other staff. On [DATE] at 11:15 R6 stated that R1 was frequently seen on the smoking patio with his oxygen on smoking a cigarette. R6 stated that on [DATE] she observed R1 on the smoking patio with his oxygen on and yelled at him to go back into the facility before he blows everyone up. R6 stated that on [DATE] or [DATE] R1 was observed smoking in the dining room while wearing oxygen. R6 stated that she informed E12 Assistant Director of Nursing (ADON) of R1's smoking while wearing oxygen. E12 ADON was not available for interview during this investigation. R6 stated that she also informed R1's family that R1 had been smoking with oxygen in place. On [DATE] at 3:34 pm Z2 (R1's Family) stated that her family was informed by another resident (name unknown) that R1 had been smoking with oxygen in place. Z2 stated that R1's family approached a male nurse to inquire about how R1 got the cigarettes and the lighter to smoke. Z2 stated that they were told that the matter was under investigation. Z2 could not recall who the male nurse was that stated that matter was under investigation. The facility could not provide documentation to indicate an investigation was conducted related to R1 smoking with oxygen in place. On [DATE] at 11:20 am Z5 (Veteran's Administration Social Worker) stated that R1 was on her caseload. Z5 stated that she met with the E9 (social services) and E13 (Assistant Director of Nursing) along with other members of the interdisciplinary team on [DATE] to discuss R1's behaviors. Z5 stated that R1's behavior of smoking with oxygen was discussed as a behavior from previous nursing facilities but was not discussed as a current issue for R1. Z5 stated that she was informed that R1 was not a smoker. Z5 stated that it was documented that R1 tried to harm himself with a knife and was sent out for evaluation and sent back to the facility after 24 hours observation. Z5 stated that the facility did not provide appropriate monitoring when R1 was readmitted following the attempt to harm himself. R1's care plan does not include smoking with oxygen as a behavior, although R1 was observed with smoking materials while wearing oxygen. The facility's job description for Staff Nurse (Registered Nurse/Licensed Practical Nurse) dated ,[DATE] under essential functions indicates that the staff nurse should assist in developing a written plan of care for each customer that identifies the problem/needs of the customer; report all concerns, complaints made by the customer or their family to the Administrator; fill out complete accident/incident reports. The facility could not provide evidence that these functions were performed related to R1's unsafe smoking practices. 2. R11's face sheet [DIAGNOSES REDACTED]. R11's Physician order [REDACTED]. R11's potential for hypo/hyperglycemic reaction care plan dated [DATE] with a goal target date of [DATE] interventions include report results that are outside of ordered parameters to Physician. R11's refusal to take medication care plan dated [DATE] with a goal target date of [DATE] interventions include review with R11 the consequences of treatment non-compliance. R11's weights and vital signs summary indicates that on [DATE] at 8:48 am R11 had blood glucose results of 428mg/dl. R11's [DATE] MAR indicated [REDACTED]. R11's nurses note do not include documentation for Physician notification for elevated blood glucose levels or what care plan interventions were in place related to the blood glucose result greater than 400mg/dl. Z3, Nurse Practitioner stated that the expectation of the staff is to follow the Physician orders [REDACTED]. R11's hospital records indicate that on [DATE] at 4:30 am R11's blood glucose level measured greater than 500mg/dl, normal reference range 76 - 120mg/dl. R11's hospital records indicate that R11 was admitted with diabetic ketoacidosis and acute kidney injury related to dehydration. The facility's change of condition American Medical Directors Association (AMDA) guidelines for reporting (2011) indicates that blood glucose levels greater than 300 mg/dl or less than 70 mg/dl (diabetic) should be reported immediately.

Based on interview and record review, the facility failed to examine the condition of the sling straps for a mechanical lift prior to transferring a resident, according to the facility policy. This applies to one of four residents (R1) review for fall in sample of 4. As a result, during transfer by a mechanical lift, R1 fell while the sling was disconnected from the mechanical lift. R1 was treated and hospital for a closed head injury. Findings include: Facility Initial Incident/Accident/Allegation Notification indicates R1 having a fall to the floor while being transferred by staff on 8/29/16 at 8:30am. On 9/7/16 at 2:20pm E6 (Certified Nursing Assistant/CNA) stated, E11 (CNA) and I were transferring R1 to the dialysis chair from the high back chair with the sling and the mechanical lift. The night shift had put R1 into the chair and the sling was already in place under R1. We (E6, E11) connected the straps from the sling to the lift and when the sling was being lifted the scrap cut off and R1 fell to the floor. The maintenance guy checks the machine, but I don't know who supposed to check the straps to the sling. At 2:13pm on 9/7/16 E4 (ADON) Assistant Director of Nursing stated, The malfunction was the sling to the Mechanical Lift. The strap to the sling (used for transfer with the lift) was broken. I didn't see the fall but it was brought to my attention that the strap had broken. During an interview with E3 DON (Director of Nursing) on 9/7/16 at 3:30pm E3 states the following: Laundry is responsible for the maintenance of the mechanical lift sling. The CNA's, Restorative, are also responsible for the slings, and maintenance is responsible for the Mechanical Lift. Maintenance make sure that the lift is plugged and functioning, laundry wash and inspects the sling before sending it back to the floor. Laundry has an inspection sheet, and the policy is something with inspection. No sheets were presented for review during this survey, per multiple requests. On 9/12/16 at 9:44am E11 stated, I recall the incident was on a weekday. I saw E6 pushing R1 to dialysis and I offered to help. I brought the mechanical lift to the dialysis room. We (E6, E11) connected the straps from R1's lift sling to the mechanical Lift. As we pressed the button for the machine to lift R1 up, E6 had the machine (Mechanical lift) guiding it toward the dialysis chair when one strap broke. Then R1 slide out of the sling onto the floor. It happened so quick, he (R1) fell to his side. Facility Initial Incident/Accident/Allegation Notification dated 8/30/2016 related to incident occurrence date of 8/29/16 at 8:30am indicate that R1's Physician observed R1 having a large hematoma to the scalp during rounds at the hospital. Hospital's Admission record dated 8/29/16 at 9:52am is that R1 has a Primary [DIAGNOSES REDACTED]. On 9/12/16 at 2:30pm during phone interview Z1 (Physician) stated regarding R1's [DIAGNOSES REDACTED]. The facility's Total Mechanical Lift policy dated 05/16 documents: Check the sling for rips, tears or abnormal wear prior to use, if noted, take out of circulation immediately, and notify DON or designee.

Based on interview and record review, the facility failed to follow care plan intervention for mechanical lift transfer for one resident (R2) out of 3 residents reviewed for mechanical lift transfers. This failure resulted in R2's hospitalization on [DATE] for an acute oblique displaced fracture of the distal tibia and the posterior and superior aspect of the calcareous following transfer from bed to chair on 5/24/16 without use of mechanical lift. Findings include: R2 was admitted to the facility on [DATE]. R2's face sheet lists the following Diagnoses: [REDACTED]. On 6/22/16 at 9:10am, R2 was observed in a specialty chair with her lower leg wrapped in a splint and ace wrap. R2 was not able to verbalize what happened to her leg. R2's clinical records dated 5/24/16 at 7:30am read Weeping laceration & swelling to left lower leg, pain when moved. R2's clinical notes read that an x-ray was ordered on [DATE] and the results noted that R2 had an acute oblique displaced fracture to the distal tibia and the posterior and superior aspect of the calcaneus. R2 was sent to the hospital on [DATE] after x-ray report from facility revealed left tibia fracture. On 6/22/16 at 10am, E2 (Director of Nursing) stated that she conducted an investigation regarding the cause of R2's tibia fracture. E2 stated that her investigation showed that E5 (Certified Nursing Assistant) did not use the mechanical lift when transferring R2 from bed to chair on 5/24/16. E2 stated that R2 was noted to be in pain and had a weeping laceration with swelling to her left lower leg on 5/24/16 at 7:30am. E2 stated that she terminated E5 following her investigation. E2 stated that the staff were aware that R2 required a mechanical lift for transfers. E2 stated that R2 was sent to the hospital. The facility's final report sent to IDPH on 5/27/16 read Following all interviews with nurses and CNA staff, it was determined that the injury occurred during transfer. R2's care plan dated 8/21/15 reads R2 requires the use of a mechanical lift for transfers. Use total body (mechanical lift) when transferring R2.