Every finding on record at Wheaton Village NRSG & RHB CTR

Based on the interview and record review, the facility failed to report an allegation of abuse immediately to the Administrator or Administrator's designee according to the facility's policy and procedure. This applies to 1 of 3 residents (R4) reviewed for abuse in the sample of 3.The findings include:R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE], with multiple diagnoses including vascular dementia, unspecified severity, with mood disturbance, anxiety disorder, unspecified, unspecified psychosis not due to a substance or known physiological condition, and schizophrenia, unspecified. R4 was transferred to the hospital on August 8, 2026. R4's MDS (Minimum Data Set) dated May 29, 2026, showed R4 had cognitive impairment.R4's care plan initiated on August 8, 2026, showed, R4 exhibits altered thought processes characterized by paranoid and delusional beliefs, including accusatory statements toward staff, perceived harassment or mistreatment, agitation, and difficulty accepting reassurance or alternative explanations. These symptoms may interfere with R4's ability to accurately interpret her environment and interactions with others. The care plan showed, R4 had a history of making allegations that staff are physically and/or verbally abusive toward her. R4 has diagnoses of vascular dementia, anxiety disorder, and schizophrenia, which may affect her perception, interpretation, and recall of interactions. R4 verbalizes that she does not believe she needs nursing home placement and does not want to reside in the facility. Feelings of frustration, loss of independence, anxiety, perceived lack of control, and resistance to placement may contribute to behavioral escalation and allegations regarding staff interactions. All allegations of abuse will be taken seriously and addressed according to facility policy and applicable reporting requirements, regardless of R4's diagnoses or history of similar allegations. Multiple interventions were documented, and no concerns were noted.On August 26, 2026, at 1:04 PM, V4 (Wound Care Nurse) said she had been the wound care nurse at the facility since September 2025. V4 said she provided wound care to R4 in the past to her posterior left forearm due to an infection for a few weeks while at the facility. V4 said R4 was in her room on August 6, 2026 (two days before her transfer to the hospital). V4 said she was in R4's room preparing to provide wound care treatment to R4's roommate when R4 said to V4, You molested me back then, you used your hand and go around my hip and go up to my vagina. V4 said she told the resident that that did not happen. V4 said she did not report it to V1 (Administrator) because R4 was confused and she thought she was delusional. V4 said she had never touched R4 inappropriately and had never sexually abused R4 or any other resident at the facility.On August 26, 2026, at 2:18 PM, V1 said V4 did not report R4's allegation to her. V1 said the facility's policy requires staff to report any allegations of abuse to her immediately, and V4 should have notified her immediately to ensure R4's safety and begin an investigation.The facility's undated policy titled Abuse Prevention Policy showed, Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of residents property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator immediately or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.

Based on interviews and record review, the facility failed to provide adequate supervision during meals for a resident identified as being at high risk for choking. This failure resulted in a choking episode that required emergency intervention, hospitalization, and placement of a tracheostomy tube to establish and maintain the resident's airway. This applies to 1 of 1 resident (R6) reviewed for a choking incident.The Findings Include:Review of the Electronic Medical Record (EMR) showed that R6, a [AGE] year-old resident, was admitted to the facility on [DATE]. Diagnoses included drug-induced dyskinesia, schizophrenia, bipolar disorder, anxiety disorder, depression, hypertensive heart disease, type 2 diabetes mellitus, asthma, atherosclerotic heart disease, repeated falls, and right below-knee amputation.Review of the Physician Order Sheet (POS) for May 2026 showed R6 was prescribed a regular diet with regular consistency and was designated as a full code.Review of the Minimum Data Set (MDS) dated [DATE], showed that R6 was alert and oriented but had cognitive and behavioral impairments, including inattention, distractibility, difficulty maintaining focus, difficulty following conversations, and an altered level of consciousness characterized by continuous vigilance. The MDS further assessed R6 as requiring moderate assistance with eating, indicating staff provided more than half of the effort needed to complete the task.Review of the Speech-Language Pathology (SLP) Assessment and Treatment Report dated August 23-25, 2025, showed R6 received skilled speech therapy services for dysphagia. Documentation showed treatment included oral assessment, safe swallowing strategies, and cueing. The report noted R6 had upper extremity tremors that made self-feeding difficult. The SLP documented R6 demonstrated reduced bolus formation and control, suspected reduced base-of-tongue retraction, and would repeatedly hawk up and re-swallow food during meals. The report specifically stated R6 was at risk for choking with all consistencies. The SLP Discharge Assessment and Summary identified a medical alert requiring supervision with all meals due to risk for choking with all consistencies. Further documentation reviews showed nursing staff were educated to provide supervision during oral intake and cue R6 to slow the rate of eating and reduce bite size.Review of R6's current care plan, initiated February 19, 2025, identified limitations related to eating and drinking independently. The care plan specified R6 required cues, supervision, and staff assistance during all meals. The care plan further noted R6 was noncompliant, tended to rush while eating, and placed excessive amounts of food in his mouth despite reminders to slow down and chew thoroughly before swallowing. Interventions included following SLP recommendations, providing instruction on proper chewing and swallowing techniques, and implementing swallowing strategies.Review of the facility incident report dated May 14, 2026, at 8:05 a.m., showed R6 experienced a choking episode during breakfast in the main dining room. Staff performed the Heimlich maneuver, called 911, and initiated cardiopulmonary resuscitation (CPR). R6 was transported to a local hospital. Documentation showed R6 was found to be in asystole and subsequently required placement of a tracheostomy tube to establish and maintain an airway.During an interview on June 7, 2026, at 1:36 p.m., V12, (Certified Nursing Assistant (CNA/Restorative Aide), stated she delivered R6's breakfast tray, consisting of toast and scrambled eggs, and placed it in front of him. V12 stated after placing the tray, she turned away to distribute additional meal trays to other residents. V12 stated she did not stay and supervise R6 during the meal. V12 stated while several feet away, she saw R6 through her peripheral vision raising his right arm, signaling he was choking. V12 stated she immediately responded and called V14, another CNA who was serving coffee in the dining room. V12 stated she and V14 moved R6 away from the table to an open area, where V14 initiated the Heimlich maneuver. V12 stated R6 quickly turned blue in color and visible food was present in his mouth.During an interview on June 7, 2026, at 2:12 p.m., V14 stated she performed three abdominal thrusts on R6 after observing him choking on May 14, 2026, at approximately 8:05 a.m. V14 stated R6 immediately became cyanotic, 911 was called, and additional staff responded to the Code Blue.During an interview on June 7, 2026, at 2:30 p.m., V7, (Licensed Practical Nurse/LPN), stated R6 choked during breakfast on May 14, 2026. V7 reported responding after the Code Blue announcement and observed R6 had turned blue. V7 stated she initiated CPR while awaiting the arrival of emergency medical services.During an interview on June 7, 2026, at 1:52 p.m., V17, (Restorative Nurse and care plan staff member), stated R6 was with tremors on upper extremities, and this made it difficult feeding himself, with poor safety awareness, and limited ability to comprehend safety risks. V17 stated R6 should have received visual supervision and assistance during meals because he was at high risk for choking. V17 stated R6 frequently pocketed food, ate rapidly, and accumulated food in his mouth without ensuring previous bites had been swallowed. According to V17, continuous visual supervision was necessary to ensure R6's safety during meals.During an interview on June 8, 2026, at 11:30 a.m., V23, (R6's attending physician), stated R6 experienced a choking incident during breakfast on May 14, 2026.Review of the paramedic report dated May 14, 2026, showed facility staff were performing CPR when emergency medical personnel arrived. The report documented R6 was found in asystole. Paramedics assumed care and transported R6 to a local hospital.Review of hospital records dated May 14, 2026, showed R6 was admitted due to a choking incident. Diagnoses included acute hypoxemic respiratory failure and failed extubation on May 19, 2026. Documentation showed R6's family had elected to proceed with tracheostomy placement and gastrostomy tube feeding. Hospital records further showed R6 was critically ill, at risk for sudden deterioration, and required ongoing critical care management, monitoring, and complex medical treatment.

Based on interview and record review, the facility failed to ensure staff promptly reported an allegation of neglect to the facility's abuse coordinator/administrator for investigation. This applies to 1 of 9 residents (R8) reviewed for neglect. The findings include:A review of the Electronic Medical Record (EMR) showed that R8 is a [AGE] year-old male resident who was admitted to the facility from another facility on December 17, 2025. Diagnoses include bipolar disorder with psychotic features, chronic obstructive pulmonary disease, morbid obesity, Type 2 diabetes mellitus, Stage IV chronic kidney disease, anxiety disorder, chronic pain syndrome, difficulty walking, left leg pain, left hand fracture, lack of coordination, fracture of the shaft of the right tibia, and a history of open reduction internal fixation.Review of the Minimum Data Set (MDS) showed that R8 was cognitively intact and required partial to substantial assistance with Activities of Daily Living (ADLs).Review of the care plan dated March 5, 2026, showed that R8 exhibited behavioral distress related to ineffective coping mechanisms, poor communication skills, inability to appropriately express himself, chronic mental illness, and feelings of powerlessness and loss of control. The care plan documented verbally aggressive behaviors, use of profanity, demeaning statements, verbal threats, yelling, racial, ethnic, religious, and gender-based slurs, conflict with staff and residents, poor frustration tolerance, ineffective coping skills, repeated criticism of staff, unprovoked expressions of anger, and derogatory language.On June 6, 2026, at approximately 4:37 p.m., V24 (Social Worker) stated that R8 informed her of concerns regarding the care he received on May 21, 2026, prior to his transfer to the hospital. According to V24, R8 stated that although he was able to get out of bed independently, he required assistance with cleansing his buttocks and perineal area, which was not provided before his transfer to the hospital. R8 reported he was experiencing pain in his buttocks and did not receive pain medication. Additionally, R8 stated he and his wife felt threatened after reporting concerns and that he feared retaliation if he returned to the facility. V24 stated she contacted the facility and informed staff of R8's allegations regarding the care not provided and his fear of retaliation. V24 further stated she notified V10 (Nurse) and V18 (Facility Social Worker) of R8's allegations on May 21, 2026.On June 8, 2026, at approximately 10:00 a.m., V1 (Administrator) stated neither V10 nor V18 had informed her of R8's allegations. V1 stated she would initiate an abuse investigation upon learning of the allegations to determine whether neglect had occurred.On June 9, 2026, at approximately 10:30 a.m., V18 stated she did not report R8's allegations to V1 after being informed of the concerns by V24.On June 6, 2026, at approximately 11:00 a.m., R8 was observed lying in bed covered only by a top sheet. Redness and irritation were noted in the axillary areas, abdominal folds, and groin regions. A bed sheet was wrapped around his perineal area, and his buttocks were exposed. R8 stated that he was unable to reposition himself because of pain in his buttocks. R8 reported he had received pain medication at 8:00 a.m. and would not be eligible for another dose until noon. The bed linens contained bloody drainage and brown staining with a urine-like offensive odor. R8 stated, I guess I am okay now. I do not feel threatened or scared. R8 further stated he was not provided assistance with perineal care before he was transferred to the hospital on May 21, 2026.Review of the facility's Abuse Prevention and Reporting Policy showed that all allegations of abuse, neglect, misappropriation of resident property, exploitation, or injuries of unknown source must be immediately reported to the Administrator or designated abuse coordinator to ensure prompt investigation and implementation of protective measures.

Based on observation, interview, and record review, the facility failed to adequately assess pain management effectiveness and failed to notify the physician for additional interventions when pain relief measures were ineffective. This applies to 1 of 3 residents (R8) reviewed for pain management.The findings include:A review of the Electronic Medical Record (EMR) showed R8 is a [AGE] year-old male resident who was admitted to the facility from another facility on December 17, 2025. Diagnoses include bipolar disorder with psychotic features, chronic obstructive pulmonary disease, morbid obesity, Type 2 diabetes mellitus, Stage IV chronic kidney disease, anxiety disorder, chronic pain syndrome, difficulty walking, left leg pain, left hand fracture, lack of coordination, fracture of the shaft of the right tibia, and a history of open reduction internal fixation.Review of the Minimum Data Set (MDS) showed R8 was cognitively intact and required partial to substantial assistance with Activities of Daily Living (ADLs).Review of the care plan dated March 5, 2026, showed R8 exhibited behavioral distress related to ineffective coping mechanisms, poor communication skills, inability to appropriately express himself, chronic mental illness, and feelings of powerlessness and loss of control. The care plan documented verbal aggression, profanity, demeaning statements, verbal threats, yelling, racial, ethnic, religious, and gender-based slurs, conflict with staff and residents, poor frustration tolerance, ineffective coping skills, repeated criticism of staff, unprovoked anger toward staff, and derogatory language.On June 6, 2026, at approximately 11:00 a.m., R8 was observed lying in bed covered only by a top sheet. Redness and irritation were noted in the axillary areas, abdominal folds, and groin regions. A bed sheet was wrapped around his perineal area, and his buttocks were exposed. R8 stated he was unable to reposition himself because of pain in his buttocks. He reported he had received pain medication at 8:00 a.m. and would not be eligible for another dose until noon. The bed linens contained bloody drainage and brown staining with an offensive odor.On June 7, 2026, at approximately 10:40 a.m., R8 was observed lying in bed and reported ongoing pain in his buttocks. During the observation, R8 independently turned onto his right side. Observation showed severe excoriation to both buttocks with multiple open areas ranging in size from approximately a nickel to a quarter in diameter. The sacral fold was reddened, excoriated, and contained open areas.R8 stated, I am having a lot of pain from my buttocks, and I need a pain pill. I do not even have a dressing there to provide cushioning to my wound. No dressing was present over the wound bed. V20 (Nurse) stated, It is not your time for your pain medication yet. I will give your Norco in 30 minutes.At approximately 12:40 p.m., R8 was reassessed and continued to complain of sacral pain. R8 stated the pain medication provided did not relieve his pain.Review of the Medication Administration Record (MAR) dated June 7, 2026, showed Hydrocodone/Acetaminophen was administered to R8; however, there was no documented post-medication pain assessment to evaluate the effectiveness of the medication or determine whether pain relief was achieved.Review of the Physician Order Sheet (POS) for June 2026 showed the following physician order:- May 15, 2026: Hydrocodone/Acetaminophen 10 mg/325 mg, one tablet every six hours as needed for chronic pain syndrome.Further review revealed no documented reassessment of R8's pain after medication administration and no evidence the physician was notified when R8 reported the medication was ineffective. Additionally, there were no physician orders for alternative or breakthrough pain management interventions despite R8's continued complaints of uncontrolled pain.Review of the facility's Pain Management Policy dated August 2008 showed staff were required to identify, assess, evaluate, and monitor pain, assess the effectiveness of pain interventions, and notify the physician when additional pain management measures were needed.

Based on observation, interview, and record review, the facility failed to ensure physician-ordered treatment for skin alterations was implemented to promote healing. This applies to 1 of 3 residents (R8) reviewed for skin alterations.The findings include:A review of the Electronic Medical Record (EMR) showed R8 is a [AGE] year-old male resident who was admitted to the facility from another facility on December 17, 2025. Diagnoses include bipolar disorder with psychotic features, chronic obstructive pulmonary disease, morbid obesity, Type 2 diabetes mellitus, Stage IV chronic kidney disease, anxiety disorder, chronic pain syndrome, difficulty walking, left leg pain, left hand fracture, lack of coordination, fracture of the shaft of the right tibia, and a history of open reduction internal fixation.Review of the Minimum Data Set (MDS) showed R8 was cognitively intact and required partial to substantial assistance with Activities of Daily Living (ADLs).Review of the care plan dated March 5, 2026, showed R8 exhibited behavioral distress related to ineffective coping mechanisms, poor communication skills, inability to appropriately express himself, chronic mental illness, and feelings of powerlessness and loss of control. The care plan documented verbal aggression, profanity, demeaning statements, verbal threats, yelling, racial, ethnic, religious, and gender-based slurs, conflict with staff and residents, poor frustration tolerance, ineffective coping skills, repeated criticism of staff, unprovoked anger toward staff, and derogatory language.On June 6, 2026, at approximately 11:00 a.m., R8 was observed lying in bed covered only by a top sheet. Redness and irritation were noted in the axillary areas, abdominal folds, and groin regions. A bed sheet was wrapped around his perineal area, and his buttocks were exposed. R8 stated he was unable to reposition himself because of pain in his buttocks. He reported he had received pain medication at 8:00 a.m. and would not be eligible for another dose until noon. The bed linens contained bloody drainage and brown staining with an offensive odor. Observation revealed no dressing covering the excoriated and open wound areas on R8's sacral region and buttocks.On June 7, 2026, at approximately 10:40 a.m., R8 was again observed lying in bed. R8 stated he had not been cleaned since the previous evening. V19 (CNA), who was present at the bedside, stated she would provide perineal care. R8 stated he was able to use the bathroom independently but required assistance cleansing his buttocks and sacral area because he was unable to reach those areas.R8 independently turned onto his right side for assessment. Observation revealed severe excoriation to both buttocks with multiple open areas ranging in size from approximately a nickel to a quarter in diameter. The sacral fold was reddened, excoriated, and contained open areas. R8 stated, I am having a lot of pain from my buttocks, and I need a pain pill. I do not even have a dressing there to provide cushioning to my wound. No dressing was present to protect the wound bed. V20 (Nurse) stated, It is not your time for your pain medication yet. I will give your Norco in 30 minutes. V20 confirmed no dressing was in place over the sacral wound area.At approximately 12:40 p.m. on June 7, 2026, R8 was reassessed. No dressing remained in place over the sacral wound area.Review of the Treatment Administration Record (TAR) dated June 7, 2026, showed no documentation the ordered wound treatment had been provided to R8.Review of the Physician Order Sheet (POS) for June 2026 showed the following physician order: May 15, 2026: Cleanse bilateral buttock wounds with normal saline and apply hydrocolloid dressing every Monday, Wednesday, Friday, and as needed.Review of the facility's wound care policy showed wound dressings were to be applied in accordance with physician orders and established wound care protocols to promote healing and prevent complications.

Based on interviews and record review the facility failed to address complaints and grievances from residents or significant others concerning issues with resident laundry and call light response. This failure applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for grievances. Findings include:1) On March 02, 2026 at 10:40 AM, V20 (Caregiver) said she sees R3 regularly per family's request. V20 said it can take staff 15-20 minutes to respond to the call light. V20 said sometimes R3 goes to the bathroom on her own because if she presses the call light it may take 15-20 minutes before staff responds and by that time R3 will have an accident. R3 agreed with V20's report regarding call light response time.On March 02, 2026 at 12:20 PM, R1 said he uses his call light or cell phone to request staff assistance. R1 said he wears pullups because of bed sores and staff takes an hour to respond to his call light when pressed, and there is often no response. On March 04, 2026 at 1:31 PM, V2 (Director of Nursing) said there has been some reports regarding call light response, she probably receives concerns regarding call light response approximately once per week, and there have been some complaints received from the Ombudsman regarding call lights. V2 said call light concerns should be documented on grievance forms and followed up on and agreed that if this process does not take place that potential call light response issues may not be identified. V2 could not provide evidence of how or if these reported concerns were followed up on. Grievances from December 2025 - March 2026 provided by the facility 03/03/2026 and 03/05/2026 did not include reports, findings, or resolutions of poor call light response times. 2) On March 02, 2026 at 10:40 AM, V20 (Resident Representative) said R2's family does her laundry because of items going missing, and during the winter months even some comforters went missing. R2 agreed clothing items sometimes go missing. A large pile of clothes was sitting on a bedside table next to R2's bed. R2's clothes were not labeled. V8 (Certified Nursing Assistant) said a family member was washing all R2's clothes but no longer is. The family delivered the clothes but had not labeled them and will not be doing R2's laundry anymore. V8 was not exactly sure when the clothes were brought in for R2, but it had been recently. There was no other inventory lists found in R2's medical records other than during the time of her admission on [DATE] and the facility did not provide any other inventory lists for R2 as requested on 03/04/2026. On March 02, 2026 at 10:40 AM, V20 (Caregiver) said she sees R3 regularly per families' request. V20 said other resident's clothes are returned to R3's room from laundry and she has reported this to V21 (Business Office manager/Admissions), every week something of R3's is missing, and this is a common issue. Approximately 6 months after R3 was admitted the facility attempted to inventory her belongings but no more after that. R3 confirmed V20's report regarding having missing items from laundry. On March 02, 2026 at 12:20 PM, R1 said his clothes went missing and he saw other residents wearing his shirts. The facility did not inventory his belongings on admission, and he is missing about five pairs of shoes. R1's medical records did not include, and the facility did not provide as requested 03/04/2026 any documentation of R1's personal items being inventoried or R1 declining to have his personal items inventoried. On March 03, 2026 at 9:47 AM V8 (Certified Nursing Assistant) said there had been some issues in the past month with items missing from laundry due to laundry staff turnover. On March 03, 2026 at 10:02 AM, R4 said there had been some issues with clothes being returned from the laundry and he has reported this to nurses. On March 03, 2026 at 12:00 PM, V11 (Certified Nursing Assistant) said she has received complaints from residents regarding laundry. Residents have reported they didn't receive their clothes. V11 said the former permanent laundry aide no longer worked at the facility and the new laundry staff aren't familiar with the resident's clothes. V11 said resident's clothes are labeled. December 2025 resident council meeting reports include concerns regarding clothes not being returned to the right person due to laundry staff not reading labels. January and February 2026 resident council meeting reports include concerns regarding clothes from laundry not going to the correct rooms, and missing clothes from laundry. Grievance form dated 02/21/2026 includes concerns reported from the Ombudsman regarding a resident's missing items. On March 04, 2026 at 1:31 PM, V2 (Director of Nursing) said the facility has an inventory form and the aides document all the resident's belongings on admission, and once completed the form is uploaded to the chart. V3 (Assistant Director of Nursing) said if a resident refuses to have their items inventoried it's documented. V3 said families are educated to label resident's belongings, and if no family or representative is available the facility labels resident's items, V2 said at one point the laundry unit was short staffed and there were issues with residents getting their clothing back from laundry. V2 and V3 said this issue had been going on for a couple of months and lasted up to approximately two weeks ago. The facility's Resident Rights Policy received 03/04/2026 states:Residents have The right to a safe environment. The facility must take reasonable care to protect personal property from loss. Based on interviews and record reviews the facility failed to ensure prompt efforts were made to resolve potential grievances residents may have by not documenting or following up on reported concerns regarding call light response times. The facility failed to address The facility's Grievance Policy received 03/04/2026 states:The purpose of the policy is To provide a process to assist residents, their representatives such as, other resident advocates in filing grievances or complaints when such requests are made. Grievances and/or complaints may be submitted orally or inwriting. Upon receipt of a written grievance and/or complaint, the designated individual will investigate the allegations and submit a written report of such findings to the administrator within 5 working days of receiving the grievance and/or complaint.

Based on observation, interview, and record review the facility failed to ensure significant medications were administered to residents as indicated by physician orders. This applies to 2 of 5 residents (R3, R4) who were reviewed for medication administration in a sample of 7.Findings Include:On 01/21/2026 at 11:40 AM, this writer asked V4 (Licensed Practical Nurse-Agency) if she could observe medication administration for residents with scheduled medications at 12:00 PM -1:00 PM. V4 said she already finished her afternoon medications, and the review of manual medication administration showed medications were signed off. At 2:00 PM, V2 (Assistant Director of Nursing) said she asked V4 why the residents had finished their afternoon medication so early, and V4 told her she started medication by 10:45 AM. At 3:00 PM, V1(Administrator) said upon review of the video footage, there was no indication of V4 administering medications to R1-R4 between 10:45 AM and 11:40 AM. 1.On 01/21/2025, at approximately 1:50 PM, R4 said she did not receive her Gabapentin for the afternoon. A review of R4's EMR showed R4 has diagnoses of diabetic polyneuropathy, osteoarthritis, and hemiplegia. R4's MDS dated [DATE] showed R4's cognition was intact, and the physician's order dated 11/25/2025 showed R4 to receive Gabapentin 800 milligrams at 08:00 AM, 01:00 PM, and 05:00 PM.2. On 01/21/2025, at approximately 12:30 PM, R3's EMR showed R3 has diagnoses of chronic obstructive pulmonary disease and acute and chronic respiratory failure. R3's MDS dated [DATE] showed R3's cognition was intact, and the physician's order dated 01/31/2025 showed R3 to receive Combivent Respimat 20-100 microgram one puff every 6 hours at 05:00 AM, 11:00 AM, 05:00 PM, and 11:00 PM.On 01/22/2026 at 2:34PM, a review of video footage dated 01/21/2026 from 10:45 AM with V1 (Administrator) and V9 (Director of Nursing) showed V3 (Agency Licensed Practical Nurse) was by the nursing station at 10:15 AM. At 10:41 AM V3 came to the medication cart and opened the medication administration record and came back to the nursing station. At 10:57 AM, V3 went to the bathroom, then to the medication room at 11:04, and returned from the medication room at 11:08 AM. V3 went to the medication room at 11:14 AM and at the medication cart at 11:35 AM. At 11:40 AM, this writer went to V3 for the observation and interview. The video footage did not show V3 having the medication cart by the residents' room, preparing medication, and going to their rooms.On 01/21/2026at 12:00 PM, 2:00 PM, and 2:00 PM, and on 01/22/2025 approximately at 2:35 PM, V5 (Licensed Practical Nurse), V2 (Assistant Director of Nursing), and V9 (Director of Nursing) respectively said nurses should administer medications as ordered by the physician.The facility's medical administration policy, with no date, stated that drugs will be administered in accordance with orders of licensed medical practitioners in this State, and that the Medication cart shall be moved to the areas closest to the resident before preparing and administering medications.

Based on observation, interview, and record review, the facility failed to properly label/date/store/discard items, ensure the dishwasher was functioning, dispose of garbage, and maintain proper levels of chlorine in the dishwasher and quaternary in sanitizer buckets. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 110 residents. On [DATE] at 11:16 AM, V4 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On [DATE] starting at 9:59 AM, the facility kitchen was toured in the presence of V4 (Dietary Manager) and the following was observed: Kitchen low temperature dishwasher: 1. On [DATE] at 10:35 AM, V4 tested the chlorine level of the low temperature dishwasher with strip that showed low reading between ,d+[DATE]ppm (parts per million). During this time, V5 (Dietary Aide/Dish washer) was using the dishwasher to wash dishes. V4 did not tell V5 to stop washing dishes. At 10:44 AM, V5 (Dietary Aide) pointed out to V4 (Dietary Manager) the red tube coming from the dishwasher labeled detergent was broken/split/completely detached from the dishwasher. At 10:47 AM, V5 (Dietary Aide) said he noticed the red tubing to the dishwasher was broken earlier in the day. At [DATE] at 11:07 AM, V5 was observed still using the dishwasher to clean dishes in the kitchen. At 11:10 AM, while surveyor and V4 (Dietary Manager) were leaving the kitchen together, V5 was still using the dishwasher to clean dishes. At this time, surveyor asked V4 (Dietary Manager) if V5 (Dietary Aide) should still be using the dishwasher to clean dishes with the detergent line not functioning and the chlorine level measuring low. V4 said, No. V4 instructed V5 to use the 3 compartment sink to wash the dishes. 2. On [DATE] at 10:48 AM, V4 tested with strip the quaternary level of V6's (Cook) sanitizer bucket in the kitchen and received a low reading between ,d+[DATE]ppm. V6 said she had been using the sanitizer bucket to clean in the kitchen. 3. On [DATE] at 10:28 AM, the thermometer on the outside of the milk cooler showed a reading of 49 degrees Fahrenheit (F). There was a numerous amount of 4 ounce cartons of milk inside the cooler and no thermometer inside the cooler. V4 (Dietary Manager) then removed a 4 ounce 2% milk and tested the temperature with digital thermometer. First 2% milk tested showed a reading of 45 degrees F. A second 2% milk was tested with digital thermometer and showed reading of 43.8 degrees F. V4 said, It is warm in the kitchen, this building is pretty old, it gets to be hot. 4. ,d+[DATE] pound cartons of thawed frozen egg product not dated. 5. 11 tomatoes that appear to be rotten/soft with black spots on them. 6. First in, first out method not used to store 2% 5 pound cottage cheese containers. 5 containers with a December expiration date were placed in front of 2 containers with November expiration date. 7. ,d+[DATE] ounce bags of raisins expired, with best by date of [DATE], bags were noted to be dusty with a white powder on them. 8. A box of 10- 16 ounce bags of sweetened coconut with sell by date of [DATE] and delivery date on box of [DATE]. Bags are sticky and dusty. V4 said these bags need to be discarded and cannot be served to the residents. 9. On [DATE] at 10:40 AM 2 large garbage cans were seen uncovered near the dishwasher with visible food debris in cans, appeared to be scrambled eggs. Again, on [DATE] upon return to the kitchen at 11:28 AM, 2 large garbage cans were seen uncovered in dishwasher room with food debris inside the cans and on the outer rim of the garbage bag. 10. On [DATE] at 11:12 AM, clean plates were stacked in preparation for lunch service and set up on a tray right next to/pushed up against the handwashing sink within splash distance. 11. On [DATE] at 11:13 AM small black flies were seen flying in hallway immediately outside the kitchen. On [DATE] at 11:02 AM, V4 (Dietary Manager) said all food items in the kitchen are supposed to be labeled and dated to know when they were received, opened, and when the items should be used and/or discarded by. V4 said labeling and dating is important for food safety to prevent food borne illness of the residents. V4 said expired food items should be disposed of by their expiration date to make sure the items are not served to the residents with the potential to cause food borne illness. V4 said food items are supposed to be stored using the first in- first out method to make sure residents are not served expired foods, they are receiving fresh items, and the facility is not wasting food. V4 said the refrigerators/coolers should be holding cold foods at or below 40 degrees F. V4 said hold cold food items stored above 40 degrees can spoil and cause food borne illness of the residents. V4 said V5 (Dietary Aide) should not have been using the dishwasher on [DATE] once it was discovered that the detergent tubing was not connected, and the chlorine strips were not showing safe levels. V4 said the dishwasher did not have detergent so the dishwasher was not properly washing the dishes or sanitizing the dishes with the chlorine. V4 said the garbage cans should be covered with lids to prevent flies and food debris from coming out of the garbage cans. V4 said the chlorine strip reading should show 100ppm and the quaternary strips should show 200ppm. The facility provided undated policy titled, Labeling and Dating Foods states, Policy: Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste . The facility's policy titled, Labeling and Dating Foods last revised 2017 states, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded .Procedure: Refrigerated Food: .Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date . The facility provided undated policy titled, Dishwashing Procedure states, Policy: To prevent food borne illness, all dish wares will be cleaned in the dish machine. Policy Specifications: .2. Check chemicals to determine adequate supply. If not, replace .Test strips are available through the food service supervisor. Before dishes are washed, the sanitation temperature or level of chemical sanitizer in the dish machine should be tested with the correct test strip .For chemical sanitizing machines: .The test strip should turn the appropriate color to indicate 50ppm for chlorine. If the test strip does not turn the appropriate color, the above procedure should be repeated. If the test strip does not turn the appropriate color on the second attempt, the dish machine should be evaluated for proper functioning before the dishes are washed . The facility provided undated policy titled, Sanitizing Solution states, Policy: TO prevent food borne illness through cross contamination, sanitizing solution will be made and strategically located throughout the kitchen. Policy specifications: 4. Wiping cloths should be stored in a sanitizing bucket with the following concentrations: Chlorine- ,d+[DATE]ppm, . Quaternary- ,d+[DATE]ppm. The facility provided undated policy titled, First In- First Out states, Policy: .Stock not used by the expiration date will be discarded. Policy Specifications: 1. New supplies are placed on the shelf behind the supplies on hand. Products with the earliest expiration date are stored in the front of products with later dates so that the older food is used first. 2. Cans or boxes will be labeled with the delivery date before being placed on shelves. The facility provided undated policy titled, Storage Temperatures states, Policies: Temperatures of food storage areas are monitored, and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies . Refrigerated Storage: 41 degrees F or below .Each mechanically refrigerated unit storing potentially hazardous food shall be provided with a numerically scaled indicating thermometer . The facility provided undated policy titled, Garbage Disposal states, Policy: Dispose of garbage and refuse properly. Purpose: To prevent odors, minimize breeding places for insects and rodents, and keep service areas clean. Procedure: .3. Use garbage cans that are leak proof, non-absorbent and have tight fitting lids .

Based on observation, interview and record review, the facility failed to provide access to resident call system to obtain needed assistance. This applies to 5 of 5 (R2, R9, R35, R37, R67) residents reviewed for call lights in the sample of 23. Findings include: 1. On 10/30/24 at 10:25 AM, R2 was sitting on his wheelchair resting. Observed R2's call light was on the floor next to the dresser entangled among his guitars. R2 stated he cannot reach the call light. On 10/30/24 at 10:30 AM, V14 (CNA-Certified Nursing Assistant) made the bed for R2 and did not ensure the call light was within R2's reach. R2's Minimum Data Set (MDS) dated [DATE] showed he is cognitively intact and needs extensive assist for ADLs (activities of daily living). 2. R9 was observed on 10/29/24 at 11:00 AM. R9 had no call light. R9 confirmed she did not have a call light. On 10/30/24 at 9:11 AM, R9 had no call light. V14 (CNA) verified R9 did not have a call light. On 10/31/24 at 12:20 PM, V12 (RN-Registered Nurse) also verified R9 did not have a call light. R9's Minimum Data Set (MDS) dated [DATE] showed she is cognitively intact and needs extensive assist for ADLs. Progress Notes dated 10/23/2024 at 3:08 PM showed R9 can communicate her needs to staff and is able to use call lights for staff assistance. Progress Notes dated 07/23/2024 at 11:24 AM showed, R9 can communicate her needs to staff and is able to use call light for staff assistance. 3. On 10/29/24 at 12:35 PM, R35 was sitting on his bed and verbally calling out for help five times. R35 was noted not to have a call light. On 10/30/24 at 9:10 AM, R35 was sitting in a chair next to his bed. R35 did not have a call light. On 10/31/24 at 12:11 PM, V12 (RN) stated, R35 can use a call light if he had one. R35's MDS dated [DATE] showed he had moderate cognitive impairment and needs extensive assist for ADLs. Progress Notes dated 10/23/2024 at 3:08 PM showed R9 can communicate her needs to staff and is able to use call lights for staff assistance. 4. On 10/29/24 at 12:30 PM, R37 had no call light. R37 stated he did not know where his call light was. On 10/30/24 at 9:00 AM, R37 had no call light. R37 stated, he doesn't know how he would call for assistance. On 10/31/24 at 12:09 PM, V13 (RN) verified, R37's call light was behind the dresser, and he is able to use call light appropriately. R37's MDS dated [DATE] showed he had no cognitive impairment and needs extensive assist for ADLs. 5. On 10/29/24 at 11:31 AM, R67 was lying in her bed. R67's call light was lying under the bed. R67 stated she did not know where her call light was. On 10/30/24 at 9:40 AM, observed R67's call light was lying under her bed. On 10/31/24 at 12:19 PM, V12 (RN) verified R67's call light was lying under her bed. R67's MDS dated [DATE] showed she had no cognitive impairment and needs moderate assist for ADLs. Progress Notes dated 08/09/2024 at 04:28 PM showed R67 can communicate her needs to staff and is able to use call lights for staff assistance. On 10/31/24 at 01:15 PM, V2 (DON-Director of Nursing) stated everyone should have a call light to ensure they have access to help. Policy on 'Answering the Call Light' revised on August 2008 showed, ' Call lights must be accessible to residents from their bed, bathroom, shower or other position accommodations.

46380 46409 Based on observation, interview, and record review, the facility failed to properly store medications for residents who were not assessed or had orders to self-medicate or store medications at the bedside. This applies to 5 of 5 residents (R65, R94, R98, R14, R44) reviewed for medication storage in a sample of 23. The findings include: 1. On October 30, 2024 at 9:43 AM, R65's dresser had a medication cup with her name written on it and a pale, orange pill inside the cup. The pill had the letters TEVA- 5728, which was Famotidine 20 mg (Milligrams). R65 was not in the room, but her roommate was. R65's face sheet showed she was admitted to the facility with diagnoses including rheumatoid arthritis, paranoid schizophrenia, arthritis, anxiety disorder, borderline personality disorder, and heart disease. R65's POS (Physician Order Sheet) showed an order for Famotidine 20 mg once a day at 6 AM. R65's POS did not show an order to keep medications at bedside. R65's MDS (Minimum Data Set) dated January 11, 2024 showed R65 was cognitively intact. The facility was unable to provide an assessment form to show R65 was evaluated to self-administer medications or to store medications at bedside. 2. On October 29, 2024 at 11:33 AM, during initial tour, R94's bedside table had three bottles of Flonase 50 mcg (Micrograms). On October 30, 2024 at 9:41 AM, R94 still had three bottles of Flonase on her bedside table. R94 said she had been taking the Flonase every morning by administering one spray in each nostril. R94's face sheet showed she was admitted to the facility with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, tremor, borderline personality disorder, carpal tunnel syndrome in bilateral upper limbs, chronic pain syndrome, chronic rhinitis, and abnormalities of gait and mobility. R94's MDS dated [DATE] showed R94 was cognitively intact. The facility was unable to provide an assessment form to show R65 was evaluated to self-administer medications or to store medications at bedside. R94's POS shows an order for Flonase Allergy Relief 50 mcg/actuation; 1 spray in each nostril once a day 8 AM, which started on April 5, 2024 and was discontinued on October 30, 2024 (during the survey). The POS showed a new order, which was started October 30, 2024 for Flonase Allergy Relief 50 mcg/actuation; May keep at bedside and self-administer. R94's care plan dated October 31, 2024 showed [R94] can self-administer medication: Flonase. Resident wants to self-administer medication. R94's care plan dated July 15, 2024 showed Upon admission, hospital record indicates that family believes [R94] would intentionally and unintentionally take the wrong medications. [R94] does not recall such events. On October 31, 2024 at 10:59 AM, V13 (RN/Registered Nurse) said she worked on October 30, 2024 starting from 6:30 AM. V13 said the night shift pulled the 6 AM medications, and the nurse who worked on October 30, 2024 until 6 AM was an agency nurse. V13 said she had not seen the pill on the side dresser, as R65 had come to the medication cart for her morning medications and was not sure if R65 took her medication or not. V13 said she went to R65's room around lunchtime, and the medication was not there. V13 said R65 was not allowed to have medications at the bedside. V13 said when the nurses were doing medication administration, they had to make sure the resident takes all the medication and to assess if they swallowed the medication or not. At 11:28 AM, V13 said R94 was allowed to keep her Flonase at bedside as of October 30, 2024 (during the survey). V13 said the medications should be locked as there was a potential for another resident walking in and grabbing the medications. On October 31, 2024 at 11:08 AM, V12 (RN) said none of the residents should have medications left at the bedside. V12 said the nurses should watch the resident take and swallow the medications, as some of the residents were known to pocket the medications. V12 said the medications should be kept locked in the medication cart. V12 said the residents were allowed to administer their medications themselves but had to be supervised by the nurse. On October 31, 2024 at 11:10 AM, V9 (RN) said some of the residents were allowed to self-administer medications, but an observation with an assessment needed to be completed first. V9 said the doctor needed to put an order in. V9 said both these steps needed to be done prior to the resident being allowed to self-administer or store the medications at bedside. V9 said the nurses never keep the pills at the bedside when they passed medications. V9 said the staff should make sure the residents swallow the pill as there are residents who pocket their pills. V9 said they do tongue checks if the resident was known to pocket their pills. On October 31, 2024 at 12:29 PM, V2 (DON/Director of Nursing) said if a resident expressed that they wanted to keep their medications at bedside, they needed a doctor's order and an assessment to evaluate if the resident was cognitively able to keep medications at bedside. V2 said the assessment form would evaluate whether they were able to self-administer, as well as store medications. V2 said if the resident was allowed to store their medications at bedside, it should ideally be locked up or inside a drawer. V2 said if it was left out, another unattended resident could come and take the medications. V2 said if a resident was allowed to keep medications at bedside, they also would not need to have multiple containers/bottles of the same medication. V2 said it was his expectation the nurses made sure the resident took their medications by asking them and staying to watch the resident take the medication. V2 said if the nurse left the medication unattended, another resident could see a pill and take it. 3. On 10/29/24 at 12:35 PM, R98 was noted with Breztri 160mcg (micrograms)/9mcg/4.8mcg inhaler on his bedside table. R98 said he takes two puffs every morning and if he is having a bad day he will use the inhaler again at night. R98's MDS (Minimum Data Set) dated 9/19/24 shows his cognition is intact. R98's POS (Physician Order Set) shows an order dated 2/23/24 Breztri Aerosphere aerosol inhaler 160-9-4.8 mcg/actuation 2 puffs twice a day at 8AM and 4PM. R98's POS does not show a physician order that he can self-administer medications or store medications at his bedside. R98's Care Plan dated 1/4/24 shows he has potential for impaired gas exchange secondary to diagnosis of COPD (Chronic Obstructive Pulmonary Disease) and interventions include provide inhalation meds and/or inhalation treatment as ordered. R98's Care Plan does not say he self-administer medications or store medications at his bedside. 4. On 10/29/24 at 12:28 PM, a tube of prescription ketoconazole cream was seen on the bedside table of R14. On 10/31/24 at 11:14 AM, the tube of ketoconazole cream was again seen on the bedside table of R14. R14 was not in her room, and at 11:17 AM, R14 was found sleeping with her head down on the table in the dining room of the basement. Staff woke up R14, but surveyor was unable to interview R14 about the ketoconazole cream before she fell right back to sleep. R14's POS shows an order dated 8/14/24 ketoconazole cream 2% thin layer topical to lips as needed for flare. R14's POS does not show a physician order that she can self-administer medications or store medications at her bedside. R14's Care Plan does not say she can self-administer medications or store medications at her bedside. On 10/31/24 at 11:19 AM, V8 (LPN/Licensed Practical Nurse) said none of the residents can keep their medications at their bedside, and the nurses have to give all residents their medications. V8 said the ketoconazole cream should not be kept at the bedside of R14. V8 said the ketoconazole cream should be given to R14 in a small cup when she requests it, and she should be observed when she puts it on her lips. V8 said all medications should be kept in the nurse's locked medication cart for resident safety because they have a lot of wandering residents and residents with dementia that it is unsafe to keep medications out in the open. V8 said R98 can administer his inhalers himself in the presence of the nurse. V8 said R98's inhalers need to be kept locked in the nurse's medication cart and not at his bedside, for the safety of all residents. On 10/31/24 at 2:17 PM, V2 (DON) said both R98 and R14 are not able to have medications stored at their bedside. 5. On 10/29/24 at 10:554 AM, 10/30/24 at 9:30 AM and 10/31/24 at 9:20 AM, there was Nystatin Powder on R44's nightstand. The Nystatin Powder was labeled and showed to apply to abdominal folds once a day on Monday, Wednesday, and Fridays. The Nystatin Powder did not have a cap on and was uncovered. R44 said she applies the powder on her abdominal fold whenever she feels itchy. R44 said she uses the powder multiple times in a day. An unlabeled eye drop named Polyethylene Glycol 400%; Tetrahydrozoline Hydrochloride 0.05 % lubricant was observed on her bed side table. R44 said she administers the eye drop herself twice a day. She said facility provides the eye drops. On 10/31/24 at 9:20 AM, V9 (RN) said R44 does not have an order for medications to stay at her bedside or to self-administer medication. V9 said it is important to make sure that medication is properly stored because it can pose as danger to the resident and/or her roommate. She said powder might spill on the floor and resident might slip and fall. The powder was also uncovered, she said it is an infection control issue. On 10/31/24 at 1:00 PM, V2 (DON-Director of Nursing) said if medication is left at the bedside and not stored properly, there will be a safety concern especially if resident is not able to manage medication appropriately. R44 was admitted to the facility on [DATE]. R44's face Sheet documents diagnoses of schizoaffective disorder, hypertensive heart disease, Type II Diabetes Mellitus, morbid obesity, and hyperlipidemia. MDS (Minimum Data Sheet) dated 9/13/24 documents she requires partial/moderate assist with personal hygiene and shower/bathe self. Review of R44's POS (Physician Order Sheet) showed there was no order for R44 to have medication by the bedside and to self-administer medication. During survey, on 10/31/2024 at 9:57 AM, facility obtained order for eye drop to stay at the bedside and may self-administer with supervision. Facility's Policy on Self-Administration of Medications dated 10/25/2014 stated the following: Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the Interdisciplinary team of the resident's cognitive (including orientation to time), physical and visual ability to carry out this responsibility during the care planning process.C.5) The resident is asked to complete a bedside record indicating the administration of the medication (if bedside storage is to be used). E. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. F. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into rooms of, or room with, residents who self-administer. Conditions outlined in ID3: BEDSIDE MEDICATION STORAGE are met for bedside storage to occur. Facility's Policy on Bedside Medication Storage dated 10/25/2014 stated the following: .Policy: Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team.Procedures: A. A written order for the bedside storage of medication is present in the resident's medical record. B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medications.C.1) The manner of storage prevents access by other residents.

46380 Based on interview and record review, the facility failed to provide bed hold policy in writing to resident/resident's representative upon their transfer to the hospital. This applies to 2 of 2 (R51, R73) residents reviewed for discharge in a sample of 23. The findings include: 1. R73's Face Sheet documents R73 was admitted to facility on 9/16/2024. Diagnoses includes spinal stenosis, Alzheimer's Disease, Type II Diabetes Mellitus, chronic kidney disease, atrial fibrillation, and benign prostatic hyperplasia. R73's Progress Notes dated 10/27/2024 at 3:08 PM documented R73 was observed to be very weak, not responding to verbal stimuli and had a sudden change of mental status. Progress Notes dated 10/27/2024 at 3:29 PM documented R73 was sent to a local hospital in an ambulance. Progress Notes written on 10/27/2024 at 9:48 PM documented R73 was admitted for diagnoses of dehydration and urinary tract infection. On 10/31/2024 at 1:00 PM, V2 (DON-Director of Nursing) said the facility forgot to give R73's representative the bed hold notice upon his discharge to the hospital. V2 said he is aware bed hold notice should be given to residents/resident representatives when they are transferred to the hospital. No documentation of bed hold notice being given to R73 or his representative prior to his transfer to hospital on 10/27/2024 was found in his medical records. Facility's Bed Hold and Readmission Policy dated November 2016 stated the following: .Standards: 1. Residents or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. The facility provides written notification at the time of transfer as included in the designated state form. The notice to the resident or their representative will specify the facility's policy, the duration of the state hold policy and the reserve bed payment policy. 2. The clinical records of R51 showed diagnoses included end-stage renal failure dependent on dialysis, chronic anemia, moderate protein-calorie malnutrition, cirrhosis of the liver, and hypertensive cardiac diseases. The current Minimum Data Set, dated dated dated [DATE] indicated R51 is cognitively intact. On 10/30/2024at 1:30 PM, R51 said she went to the hospital multiple times and didn't recall receiving a notice upon discharge to the hospital. The progress report review for R51 showed R1 had multiple hospitalization s related to chronic anemia and received blood transfusions, the most recent ones being on 10/02/2024 and 10/23/2024. The clinical records lacked the documentation of providing R51 and the Ombudsman with written notice to be aware of a facility's bed-hold and reserve bed payment policy to R51 before and Ombudsman upon transfer to a hospital. On 10/31/2024 at 11:30 AM, V1(Administrator) and V2 (Director of Nursing) said the facility does not practice providing a copy of the notice in writing to residents, family, and the Ombudsman. The policy titled bed hold and readmission policy, dated 11/2026 in parts standards #1, states the facility provides written notification to the resident or their representative at the time of the transfer.

Based on interview and record review, the facility failed to notify the resident/resident's representative of the reason for the discharge in writing. The facility also failed to send a copy of the notice to the Ombudsman. This applies to 2 of 2 (R51, R73) residents reviewed for discharge in a sample of 23. The findings include: 1. R73's Face Sheet documents R73 was admitted to facility on 9/16/2024. Diagnoses includes spinal stenosis, Alzheimer's Disease, Type II Diabetes Mellitus, chronic kidney disease, atrial fibrillation, and benign prostatic hyperplasia. R73's Progress Notes dated 10/27/2024 at 3:08 PM documented R73 was observed to be very weak, not responding to verbal stimuli and had a sudden change of mental status. Progress Notes dated 10/27/2024 at 3:29 PM documented R73 was sent to a local hospital in an ambulance. Progress Notes written on 10/27/2024 at 9:48 PM documented R73 was admitted for diagnoses of dehydration and urinary tract infection. On 10/30/2024 at 11:40 AM, V1 (Administrator) said facility does not notify the resident and resident's representative in writing of the reason for the transfer/discharge to the hospital. V1 said they also do not send a copy of the notice to the ombudsman. No notification of discharge with reason for discharge was found in R73's medical records. Facility was not able to show proof the Ombudsman was notified of R73's discharge during the duration of the survey. The facility does not have a policy addressing written discharge notification for resident/resident representative and informing ombudsman of the discharge. 2. The Electronic Medical Records (EMR) records of R51 showed diagnoses included end-stage renal failure dependent on dialysis, chronic anemia, moderate protein-calorie malnutrition, cirrhosis of the liver, and hypertensive cardiac diseases. The current Minimum Data Set, dated dated dated [DATE] indicated R51 is cognitively intact. On 10/30/2024at 1:30 PM, R51 said she went to the hospital multiple times and doesn't recall receiving a notice during transfer to the hospital. The progress report review for R51 showed R1 had multiple hospitalization s related to chronic anemia and received blood transfusions, the most recent ones being on 10/02/2024 and 10/23/2024. The clinical records did not provide a copy of the notice in writing to R51 and the Ombudsman. On 10/31/2024 at 11:30 AM, V1(Administrator) and V2 (Director of Nursing) said the facility does not practice providing a copy of the notice in writing to residents, family, and the Ombudsman. The facility policy titled Discharge Summary and Plan with no date did not address notice before discharge to resident, representative and informing the Ombudsman after discharge to the hospital. 46380

Based on Observation, Interview and Record Review the facility failed to ensure resident received respiratory care and services in accordance with professional standards of practice for 3 of 3 residents (R2, R33 and R95) reviewed for respiratory therapy in the sample of 23. Findings include: 1. On 10/29/24 at 11:59 AM, R2 was sitting on his wheelchair next to his bed. Using Oxygen at 4 lpm (Liters per minute) via nasal cannula. On 10/30/24 at 9:47 AM, R2's nasal cannula was noted on the floor near the bathroom and R2 was not in the room. The floor in R2's room was dirty, dusty and was noted with used tissue paper and food debris lying around. On 10/30/24 at 10:25 AM, observed R2 wheeled himself into the room on his wheelchair, pick up the nasal cannula from the floor and apply it into his nostrils. On 10/31/24 at 12:17 PM, V12 (RN) stated, R2 has an order for oxygen at 2 lpm as needed, but he is using it all the time. V12 (RN) stated, he witnessed multiple times that R2 leaves the nasal cannula on the bed when not in use. V12 (RN) stated, he should have educated R2 that the canula must be bagged when not in use. The cannula should not be re-used once it has fallen on the floor as the floor is not clean and will cause infection. V12 (RN) stated, when not in use, nasal cannula must be placed in a plastic bag. R2's face-sheet showed R2 was admitted on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease and Schizoaffective Disorder. R2's Physicians orders for October 2024 showed, 'May administer 2-5 liters oxygen via nasal cannula as needed to titrate SPO2 >90%. R2's Care Plan dated 10/16/24 addressed his need for oxygen. 2. On 10/29/24 at 11:45 AM, R33 had a CPAP (Continuous Positive Airway Pressure) machine on her bedside table and the oxygen tubing was located on the floor under her bed. R33 stated, she uses the machine every night and demonstrated how. The floor in R33's room was dirty, dusty and had old food debris. R33's face-sheet showed R33 was admitted on [DATE] with diagnoses to include Dementia, Obstructive Sleep Apnea and Diabetes Mellitus. R33's Physicians orders for October 2024 included using CPAP at bedtime and remove in the morning. Care Plan dated 8/29/24 addressed R33's Sleep Apnea and use of CPAP machine. 3. On 10/29/24 at12:12 PM R95 stated, she uses CPAP at night. R95 pulled out her CPAP machine from the dresser drawer from among her clothing with the mask not bagged. On 10/31/24 at 12:35 PM, V12 (RN) verified that R95's CPAP machine, tubing and mask were located in R95's dresser along with her clothing. The mask was noted to be unbagged. V12 (RN) stated it was not right to leave the CPAP mask unbagged among her clothes in the dresser as it will catch dust and fiber particles. R95's Face-sheet showed R95 was admitted on [DATE] with diagnoses to include Asthma, Heart Failure, Depression and Obstructive Sleep Apnea. R95's Physicians orders for October 2024 included using CPAP at bedtime and remove in the morning, as needed. Care Plan dated 10/08/24 addressed R33's Sleep Apnea and use of CPAP machine. On 10/31/24 at 01:06 PM V2 (DON-Director of Nursing) stated, ideally nasal cannula should be bagged in a plastic bag when not in use. If the RN sees the canula on the floor, she should replace it. If the CNA (Certified Nursing Assistant) sees it on the floor, she should notify the nurse about it. Cannulas, masks & tubing for respiratory treatments should be bagged when not in use to prevent contamination and potential infection. Policy on Oxygen Administration revised March 2004 did not include it's 'infection control' aspect.

Based on observation, interview, and record review, the facility failed to provide nail care for residents dependent on staff. This applies to 2 of 2 residents (R71, R107) reviewed for ADL (Activities of Daily Living) care in a sample of 23. The findings include: 1. On October 29, 2024 at 10:35 AM, R71 had nails on his hands that were about a quarter of an inch long and jagged. R71 said he had been asking the staff to cut his nails for months and they had not done it, saying they would get back to him, but never did. R71 said he had arthritis, and it was hard to cut them and was the reason he asked for help from the staff. On October 31, 2024 at 10:46 AM, R71 said he had never had his nails cut since being admitted to the facility. R71 said he would see other residents have their nails cut and would ask why it was not done for him. R71 said it was not easy for him to cut his nails and he needed help. R71's face sheet showed he was admitted to the facility with diagnoses including chronic pain, rheumatoid arthritis, chronic gout, and primary osteoarthritis. R71's MDS (Minimum Data Set) dated October 11, 2024 showed R71 was cognitively intact needed substantial assistance for personal hygiene. R71's care plan dated March 8, 2024 showed R71 is limited in ability to groom self [related to] decreased mobility and endurance and requires a restorative grooming program. 2. On October 29, 2024 at 10:28 AM, R107 had fingernails on both hands which were one inch long. R107 said she had arthritis in both her hands. On October 31, 2024 at 10:55 AM, R107's fingernails were still one inch long. R107 said she did not like the length of her nails and preferred them shorter. R107 said she needed help to cut her nails since she had arthritis and was unable to do it herself. R107 said she could not remember the last time the staff had cut her nails. R107's face sheet showed she was admitted to the facility with diagnoses including schizoaffective disorder, depression, unilateral primary osteoarthritis, and anxiety disorder. R107's MDS dated [DATE] showed R107 was cognitively intact and needed substantial assistance from staff for personal hygiene. On October 31, 2024 at 12:47 PM, V11 (CNA/Certified Nurse Assistant) said she was the CNA for R71 and R107 and had never done nail care for either resident. V11 said the residents' nails should be short to prevent them from being dirty and reduced the risk of infection. On October 31, 2024 at 12:52 PM, V10 (CNA) said R71 and R107 both needed help with personal hygiene and were unable to cut their own nails. V10 said the CNAs are the ones who cut the residents' nails on shower days. V10 said the staff should cut their nails if they see the nails are long or if the resident asked. V10 said if a resident refused to have their nails cut, the CNA should notify the nurse so they can document accordingly. On October 31, 2024 at 12:57 PM, V12 (RN/Registered Nurse) said the CNAs usually cut the residents' nails and if they are unable to, would let the nurses know. V12 said the nails should be cut short as it could grow fungus, have infections, or collect dirt. On October 31, 2024 at 1:33 PM, V2 (DON/Director of Nursing) said the CNAs were responsible for cutting the residents' nails. V2 said nail care was done as needed, typically on shower or spa days. V2 said nails should be cut short to prevent scratching, inadvertently hurting themselves, and could also accumulate dirt under them. The facility's Nail Care Guideline policy dated February 2023 showed nail care includes routine cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The facility's undated Activities of Daily Living policy showed A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interviews, and record review, the facility failed to provide at least 80 square feet for residents for 12 of 48 resident rooms. This applies to rooms A18, A19, A22, A24, A26, A28, A30, A31, A33, A34, B7 and B8. The findings include: Historical room documentation determined rooms A22, A24, A26, A28, A30, A31, A33, and A34 are set up to provide occupancy for three resident beds each and are undersized, providing 74 square feet. Rooms A18, A19, B7, and B8 are set to provide four residents each have 78 square feet per resident respectively. The facility provided residents with a daily roster dated 10/29/2024, showing undersized rooms occupy 35 of 110 residents. On 10/31/2024 at 11:00 AM, V1(Administrator) said that since its inception, the facility has had the same structure and room sizes, and the facility receives the deficiency during the annual survey every year.

Based on observations and interviews, the facility failed to have the floor of the resident rooms at the garden or above the ground level. This applies to 36 of the 36 (R1, R4, R6, R7, R11, R14, R15, R16, R18, R26, R29, R31, R34, R36, R39, R42, R43, R45, R46, R47, R52, R53, R66, R67, R68, R76, R87, R91, R98, R99, R101, R102, R103, R104, R108) residents reviewed for physical environment. The findings include: Residents rooms B1, B2, B3, B4, B5, B6, B7, B8, B9, B10, B11, B12, B13, and B14 are below the below the garden or ground level. On 10/31/2024 AT 11:00 AM, V1 (Administrator) said since its inception, the facility has had the same structure, and every year, the facility receives the deficiency during the annual survey.

Based on interview and record review the facility failed to provide resident trust fund cash to residents within three business days. This applies to 2 of 3 residents (R6 and R7) reviewed for trust funds in a sample of 8. The findings include: 1. On 7/1/24 at 12:40 PM, R6 stated she waited weeks for her requested trust fund cash. R6 stated the facility told her they were waiting for the check to post. R6 stated the delays in receiving requested trust fund cash was ongoing for a few months and R6 was still waiting for her requested money. Resident (R6) Statement, dated 3/29/24 to 7/1/24, shows on 6/6/24 R6 requested $450.00 from her trust fund. Facility check documentation, dated 6/24/24, shows check number 1009 was issued to V1 (Administrator) on 6/24/24 which included R6's requested $450.00 from her trust fund. On 7/1/24 at 3:13 PM, V12 (Activity Aide / Office Assistant) stated the check for resident trust fund cash requests comes in a little late recently. On 7/1/24 at 3:42 PM, V11 (Activities Director) stated R6 requested $450.00 cash from her trust fund on 6/6/24. V11 stated the check for the cash requests arrived at the facility from corporate on 6/25/24. On 7/2/24 at 10:29 AM, V13 (Business Office Manager) stated the check for the trust fund requests on 6/6/24 was cut on 6/24/24 because that was when resident signatures were provided to corporate for the cash withdrawal requests. V13 stated the requests for trust fund cash were transmitted on 6/6/24 but they were transmitted without resident signatures verifying the cash requests. On 7/1/24 at 12:47 PM, V1 (Administrator) stated she received the check for the trust fund withdrawal requests which was stored in the facility safe and needed to be cashed to disburse the money to the residents. 2. On 7/3/24 at 1:30 PM, R7 stated he had waited a long time for his trust fund cash withdrawals. R7 stated, The checks aren't coming! I'm not getting my money! R7 stated he waited a month for his cash withdrawal when the facility changed banks months ago and the process had not improved. R7 stated he was still experiencing a delay in receiving his cash withdrawals from the facility. Facility Resident Admission Packet, revised 12/2023, shows, Your Rights and Protections as a Nursing Home Resident - . Manage your money: You have the right to manage your own money or to choose someone to trust to do this for you . The nursing home must allow you access to your bank accounts, cash and other financial records Resident Personal Trust Funds Policy & Procedures, dated 4/15/24, shows, 7. Residents may make deposits or receive funds at the Business Office Monday through Friday during regular business hours or at specific times posted at the facility. A. Withdrawals less than $60.00 will be made immediately. B. For cash on hand and resident safety reasons withdrawals over $60.00 will required 24 hour notice by the resident and the resident may receive a check from the personal funds account. The policy fails to show trust fund withdrawals $100.00 or greater will be honored within three banking days.

Based on interview and record review, the facility failed to report an allegation of abuse per facility policy. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 8. The findings include: On 6/27/24 at 12:48 PM, V14 (CNA - Certified Nursing Assistant) stated on 5/23/24 she reported to V1 that V7 (CNA) told V14 that V7 stated V7 hit R1 in the face, R1 fell back, and R1 hit the bed. V14 stated she also attempted to report the allegation to IDPH (Illinois Department of Public Health) and called a telephone number on a poster at the entrance of the facility to report the allegation, but later believed it was only a corporate telephone number and not IDPH. On 6/27/24 at 10:00 AM, V1 (Administrator) stated R1 recently experienced a facial injury. V1 stated the incident was investigated and the facial injury was determined to be caused by R1 becoming combative during care and hitting his face on the wall. V1 stated she was not aware of any allegations of abuse toward R1. On 7/3/24 at 9:30 AM V2 (Director of Nursing) stated the facility investigated R1's injury at the time of the injury and determined with confidence that the injury was caused when R1 became combative during care provided by V7 (Certified Nursing Assistant) and hit his face against the wall. V2 stated V8 (Nurse), as well as other witnesses, were close by during the incident and assisted V7 with R1 at the time of the incident. V2 stated after the investigation, V14 (CNA) alleged that V7 told V14 that V7 hit R1 in the face. V2 stated the incident had already been investigated and felt the cause of the injury was confidently determined to be caused by combativeness during care. V2 stated he did not investigate/report the new allegation of abuse to IDPH (Illinois Department of Public Health) or the police. Review of facility abuse investigations, dated 4/1/24 to 7/1/24, show no abuse investigations regarding V14's allegation that R1 was hit by V7. Abuse Prevention Policy, dated 2/2027, shows Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence Reports will be documented, and a record kept of the documentation Any allegation of abuse . will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse The facility shall also contact local law enforcement authorities . in the following situations: .Physician abuse involving physical injury inflicted on a resident by a staff member or visitor Within five days after the report of the occurrence, a complete written report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegations, will be sent to the Department of Public Health

Based on interview and record review the facility failed to keep residents free of abuse from other residents. This applies to 3 of 3 residents (R2, R3, R12) reviewed for abuse in the sample of 12. The findings include: 1. The Facility Incident Report Form dated 11/11/23 states, (R3) reported (R2) was yelling at her and did not let her go to the bathroom, and that she (R2) wasn't supposed to be in the room. (R2) reported (R3) seemed confused and was going into closet which she seemed to think was the bathroom. When she (R2) told her (R3) to get out of there (R3) rolled over to her bed and grabbed her (R2) then (R2) pulled (R3's) hair to try to get her off her. (R2) had bruising around her shoulder and beneath her neck, reported stiffness in neck the next day that resolved. X-ray indicated no significant injury. R2's Progress Notes dated 11/11/23 states, Reported by resident (R2) that approximately 1 AM, roommate (R3) was opening closet door. Resident told roommate that it's all her clothes (and) not hers. She (R3) got upset and came closer to resident (R2) and started putting her hands on her (R2's) throat. Resident (R2) yelled at roommate (R3) to stop but roommate continues. She (R2) grabbed her (R3) hair but wasn't able to stop roommate (R3), so she (R2) pushed the wheelchair and she (R3) rolled back. Then she started yelling, 2 CNAs came and separated roommate. Staff moved roommate (R3) to another room. Upon body assessment, resident (R2) noted with scattered bruise on her neck purplish red in color. Resident (R2) stated that her neck is stiff and hurts upon movement. R3's Progress Notes dated 11/11/23 stated, Reported by peer that allegedly resident (R3) placed her hands into her (R2) neck approximately around 1:00 AM. Upon interview resident (R3) stated that she just wanted to go to the bathroom and peer (R2) pulled her hair. Resident (R3) states that she does not know why peer (R2) pulled her hair. She (R3) was moved to a different room. Assessment done noted with no redness or swelling noted on resident's head. Denies any pain. Resident (R3) has a diagnosis of Dementia. On 2/20/24 at 10:00 AM R3 was seated in her wheelchair in her room. R3 had her eyes closed and was having a full conversation with herself. Surveyor got R3's attention by touching gently her on the arm. R3 stopped talking and smiled at surveyor. R3 offered no complaints and said everything at the facility was wonderful. R2 was unavailable for interview during this survey. On 2/20/24 at 11:30 AM V2 (Director of Nursing) stated, (R2) was in a situation. Her roommate (R3) and her got into an argument. The roommate (R3) was in her closet and (R2) told her to stop so the roommate (R3) grabbed her (R2) by the chest and was yelling at her. The staff came in and separated them. She (R2) had some bruising around her neck. R2's Physician's Order Sheet dated 1/20/24-2/20/24 shows R2 has diagnoses including Vascular Dementia, Cognitive Communication Deficit, Alcoholic Cirrhosis of the liver with ascites, and Stage 5 chronic kidney disease. R2's Care plan dated 12/28/23 states, (R2) may be at risk for abuse due to serious mental illness, confusion and verbally threatening behavior. R2's X-ray of neck, soft tissue dated 11/11/23 states, Limited study secondary to technique and positioning. Nonspecific radiopaque densities are present overlying the neck soft tissue. Limited study, repeat imaging is recommended. This report was sent to R2's physician and handwritten on the page it states, Repeat. On 2/20/24 at 1:42 PM V2 (Director of Nursing) stated, Unfortunately, they did not repeat the follow-up x-ray so I do not have another one. R3's Physician's Order Sheet dated 1/20/24-2/20/24 shows that R3 has diagnoses including Dementia, Anxiety Disorder and Schizoaffective disorder. R3's Care plan dated 1/8/24 states, (R3) may be at risk for abuse due to residing in a mental health facility with others who exhibit behaviors. R3's care plan states, (R3) displays physical behavioral symptoms directed toward staff when providing care. These behaviors include attempting to hit and kick the staff. (R3) does have grandiose behavior and often will refuse care and can be argumentative. (R3) hitting the staff is new behavior that is now being presented when in her manic state. Update: on 11/11/23 (R3) was physically aggressive towards peer/roommate. 2. The Facility Incident Report Form dated 2/7/24 states, (R3) and (R12) were in an altercation in their room. (R3) reported (R12) had come into her room with a switchblade so she (R3) grabbed her (R12). (Neither (R3) nor (R12) had any weapons). (R3) assessed with a scratch on her left arm. (R12) assessed without injury. Both residents placed on monitoring. R3's Progress Notes dated 2/6/24 state, Resident (R3) noted to be physically aggressive towards peer, peer also became physically aggressive to resident. Staff separated both residents, body assessment done to resident and noted to have a skin tear to left upper extremity and abrasion to right upper extremity, treatment done. Asked resident what happened, She (R12) came in my room and pulled out a switchblade. Peer does not have a switchblade . R12's Progress Notes dated 2/6/24 state, Resident (R12) was alleged to have had a physical altercation with peer/roommate. Resident was noted in her room in her bed when peer/roommate went into the room and grabbed this resident on the arm. Resident stated she was defending herself and struck peer. Resident and peer were immediately separated and assessed; this resident had no injury. On 2/20/24 at 1:50 PM V2 (Director of Nursing) stated, According to (R3), (R12) did not belong there. Although they were roommates. (R3) said (R12) drew a switchblade on her but there were no weapons found on either of them. (R12) said (R3) grabbed her and she tried to get away and they ended up falling in the hallway. (R12) is ambulatory and pretty with it but very Schizophrenic. As far as what happened in the room- I only have their (R3 and R12) descriptions of what happened. (R3) ended up with a skin tear on her arm and (R12) had no injuries. On 2/20/24 at 2:05 PM V11- LPN- PM Supervisor stated, I was called to the nurse's station because (R12) and (R3) were being aggressive with each other. The staff had separated them, (R3) was by the nurse's station and (R12) was in her room. (R12) said (R3) grabbed her and she tried to defend herself. (R3) had a skin tear on her right upper forearm and (R12) didn't have any injuries. (R3) kept saying that (R12) had a switchblade but there were no weapons found. This had not happened before with those two. We moved (R3) to another room. Both residents are confused and have a mental illness. R12's Physician's Order Sheet dated 1/20/24- 2/20/24 shows that R12 has diagnoses including Paranoid Schizophrenia, Borderline Personality Disorder, Anxiety Disorder and Cognitive Communication Disorder. R12's Care plan dated 2/6/24 states, (R12) displays behavioral symptoms directed toward others as evidenced by on 2/6/2024 (R12) was alleged to have been in a physical altercation with her roommate/peer. (R12) was grabbed by peer and was defending myself. (R12) has no history of physical aggression or behavior in the facility. This was an isolated incident. The facility Abuse Prevention Policy dated 2/2020 states, This facility affirms the right of our resident to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.

Based on interview and record review, the facility failed to notify either the resident or their representative of a significant change in condition and room changes. This applies to 2 of 4 residents (R1, R8) reviewed for notifications when changes occur in the sample of 4. The findings include: 1). The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], and discharged from the facility on [DATE], at the local hospital, where R1 expired. R1 had multiple diagnoses including bipolar disorder, chronic obstructive pulmonary disease, asthma, heart failure, type 2 diabetes, spondylolisthesis lumbosacral region and morbid obesity. R1's MDS (Minimum Data Set) dated [DATE], showed R1 to be cognitively intact, and required extensive assistance with ADLs (Activities of Daily Living) including bed mobility, transfer, dressing, toileting, personal hygiene and required total assistance with bathing and limited assistance with mobility while using a wheelchair. On [DATE]. 2023, at 1:03 PM, V7 (RN-Registered Nurse) stated she was R1's nurse on [DATE] at 3:00 AM when R1 was found unresponsive, CPR (Cardiopulmonary Resuscitation) had been initiated and R1 was transferred to the local hospital. V7 stated she did not contact V9 (R1's mother/POA/ Power of Attorney) to notify her of R1's transfer to the hospital. V7 also stated she was R1's nurse on [DATE], at 1:20 AM, when R1 had a fall that required transfer to the local hospital for a CT (computer tomography) scan of his head. V7 stated she could not recall if she contacted V9 regarding the fall incident and transfer to the hospital. R1's progress notes, written by V7, of [DATE], regarding the fall incident and transfer and the progress note of [DATE], describing R1's change in condition and transfer to the hospital did not include notification to V9. On [DATE], at 3:00 PM, V2 (DON) stated R1 had a room change on [DATE], due to his roommate's request due to odors caused by R1. There is no documentation to include R1's agreement to the move, or notification to either R1 or V9 (R1's representative) regarding the room change. V2 also stated R1 and R8 had exchanged rooms to accommodate room change requests. On [DATE], at 2:00 PM, V9 stated she was not informed by the facility of R1's transfer to the hospital or his change in condition. V9 further stated during the summer she was not informed of her son's fall or transfer to the hospital. V9 stated her last conversation with R1 was on [DATE], when R1 complained to her that his room had been changed, R1 did not understand why his room was changed and he did not like the roommates in his new room. 2). R8's MDS (Minimum Data Set) dated [DATE], showed R8 was cognitively intact and required extensive assistance with ADLs including bed mobility, transfer, toileting, dressing and personal hygiene, and mobility while using wheelchair, and limited assistance with eating. The EMR showed R8 was admitted to the facility on [DATE], and had multiple diagnoses including Chronic obstructive pulmonary disease, dementia, type 2 diabetes, schizophrenia, and chronic kidney disease. R8's progress notes showed R8 developed a cough, and an X-ray of his chest was ordered and completed on [DATE]. The next progress note was written on [DATE], by R8's physician. R8's admission record has an emergency contact person listed. There is no documentation that either R8 or the emergency contact was informed of either his illness or the room change that the census report showed occurred on [DATE]. On [DATE], at 2:15 PM, V2 (DON) stated there should be documentation when a resident agrees to a room change or when resident representatives are notified of condition changes or transfer to the hospital. The facility's policy Notification of Change in Condition Policy dated [DATE], showed under Standards: A licensed nurse shall promptly inform the resident, consults with the resident's physician and if known, notify the resident's legal representative or an interested family member of - a. An accident involving the resident in which there is a potential or an actual injury b. a significant change in the resident's physical, .deterioration .in either life threatening conditions or clinical complications c. a need to alter treatment and d. a decision to transfer or discharge the resident facility.

Based on observation, interview and record review, the facility failed to comprehensively assess/evaluate and inform the physician of the residents complaint of pain to help manage existing pain and/or prevent pain. This applies to 2 of 6 residents (R38 and R105) reviewed for pain management in the sample of 29. This failure resulted in R38 verbalizing complaint of worsening pain for two consecutive days (10/30/23 and 10/31/23). R38's frequent pain level of eight, documented in the resident's October 2023 medication flowsheet pain scale. The findings include: 1. R38 had multiple diagnoses including COPD, dementia without behavioral disturbance, type 2 diabetes mellitus with diabetic cataract and generalized osteoarthritis, based on the face sheet. R38's significant change in status MDS (minimum data set) dated 9/27/2023 showed the resident was moderately impaired with cognition and required extensive to total assistance from the staff with most of his ADLs (activities of daily living). On 10/30/23 at 10:58 AM, R38 was sitting in his reclined wheelchair inside his room. R38 was alert and verbally responsive. R38 complained of pain all over his body. V4 (Registered Nurse) was present and asked R38 to express his pain level scoring between zero to ten (0-10), ten being the worst possible pain. R38 responded his pain level was ten. V4 stated R38 received his ordered Tramadol medication at around 9:30 AM for chronic pain. On 10/31/23 at 10:51 AM, R38 was sitting in his reclined wheelchair, inside his room. R38 was alert and verbally responsive. R38 complained of pain all over his body and when V4 asked R38 for his pain level, the R38 responded 10/10 (10 being the worst). V4 stated R38 received his ordered Tramadol medication at around 8:00 AM for chronic pain. V4 offered R38 his ordered topical analgesic heat rub to be applied, R38 agreed and stated to apply the said topical analgesic on his body specifically on his back. R38's active Physician order report showed an order dated 6/14/23 for, Tramadol 50 mg, 1 tablet for pain, neck and back pain, twice a day (8:00 AM, 4:00 PM). Further review of R38's order report showed an order dated 11/2/22 for, Bengay ultra strength cream 4-30-10%, small amount topical, apply to neck and knees, may apply patch, every shift (Shift 1, Shift 2, Shift 3). R38's October 2023 medication flowsheet showed the R38's Tramadol 50 mg was administered on 10/30/23 and 10/31/23 at 8:00 AM. The same October 2023 medication flowsheet showed the resident's Bengay ultra strength cream was applied on 10/30/23 and 10/31/23 on all the three shifts. There was no documentation with regards to the effectiveness of the Tramadol medications and the topical analgesic cream. Further review of R38's October 2023 medication flowsheet showed the resident's pain scale was being assessed every shift (shift 1, shift 2 and shift 3). The pain scale assessment showed evidence R38's pain scale was scored eight, 19 times during shift 1 (6:30 AM-2:30 PM), on 10/2, 10/3, 10/6, 10/7, 10/8, 10/9, 10/11, 10/12, 10/13, 10/14, 10/16, 10/17, 10/20, 10/21, 10/22, 10/23, 10/26, 10/27 and 10/28/23. The same pain scale assessment showed evidence R38's pain scale was scored eight, 19 times during the shift 2 (2:30 PM-10:30 PM), on 10/2, 10/3, 10/6, 10/7, 10/8, 10/9, 10/10, 10/12, 10/13, 10/14, 10/16, 10/17, 10/20, 10/21, 10/22, 10/23, 10/26, 10/27 and 10/28/23. Further review of R38's pain scale for 10/30/23 during shift 1 and shift 2 showed the pain score of eight (on both times). On 10/31/23 during shift 1, R38's pain score was nine and during shift 2, R38's pain score was eight. R38's active Physician order report from 10/1/23 through 11/1/23 showed no other breakthrough pain medication was ordered. R38's medication flowsheet showed no documentation what pharmacological intervention was provided to the resident on 10/30/23 and 10/31/23, after the resident complained to V4 of all over body pain with pain level of 10 (10 being the worst). Review of R38's progress notes for the entire month of October 2023 showed no documentation the physician was notified of R38's frequent pain scale of eight as documented in the resident's October 2023 medication flowsheet. The same progress notes showed no documentation and evidence the physician was notified of R38's all over body pain, which according to the resident's pain scale was ten on 10/30/23 and 10/31/23. R38's most recent pain observation for cognitive aware evaluation dated 9/27/23 showed a pain scale of 3 described as aching pain comes and goes. It was documented R38 had a scheduled Tramadol 50 mg, 1 tablet twice a day for neck pain and back pain. The same evaluation showed the Tramadol was always effective, the pain was less than daily (highest level of pain in the last 7 days), and the pain was mild (highest level of pain in the last 7 days). The was no other comprehensive pain assessment/evaluation for R38 in the month of October 2023 to evaluate the resident's pain score of eight to further determine the location, duration, quantity, quality and the effectiveness of the Tramadol medication, and the need to inform the physician for other pain management options. R38's active care plan initiated on 9/30/23 showed the resident had complained of back pain, left hip pain and knee related to severe DJD (degenerative joint disease), history of fracture (thoracic spine) T-12, spinal stenosis, and knee replacement. The same care plan showed multiple approaches including, Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Monitor and record any complaint of pain, its location, duration, quantity, quality, alleviating factors, aggravating factors. On 11/1/23 at 12:05 PM, V2 (Director of Nursing) stated if R38 had multiple documented pain scale level between eight and nine for the month of October 2023, a comprehensive pain assessment/evaluation should be performed to assess the pain and the effectiveness of the pain medication being administered. V2 stated the nurses should call the physician and inform of R38's high pain scale rating (documented between eight and nine) to obtain any other appropriate pain medication for the resident to attempt to control his pain. R38's progress notes dated 11/1/23 (1:06 PM) created by V2 showed, Discussed residents Pain with him. Asked him he could determine the difference between pain of 1 and a pain of score of 10. He reported I don't know what that means. I asked him how long he has been in pain that is unbearable. He said every day since he was [AGE] years old to now. He is 63 (R38 is 81). Always been in pain and won't go away till he dies and goes to Heaven. He indicated nothing relieves the pain. It is always 10 or like 10. When asked whether medicine was effective, he said Bengay and medication help him feel better. But he always had a 10. Introduced him to face scale for pain as it may be more effective tool for monitoring effectiveness of interventions. Informed MD (Medical Doctor) of recent breakthrough pain. Added Norco 5/325 for breakthrough pain for one week. R38's prescription order dated 11/1/23 (created at 1:28 PM) showed an order for hydrocodone-acetaminophen 5-325 mg, 1 tablet every 6 hours as needed for breakthrough pain, until 11/8/23. On 11/1/23 at 1:46 PM, V16 (Physician) stated he had been R38's physician for the past [AGE] years. V16 stated R38 had diagnoses of dementia with behavior. V16 stated it is the protocol for the facility to call and inform the physician of a resident's complaint of pain, especially if it was documented/scored at eight or nine to determine appropriate action, such as prescription of pain medication or breakthrough pain medication to address and/or relieve the resident's of pain. V16 stated he only received a call from the facility that day about R38's pain and he ordered Norco 5-325 mg, 1 tablet every 6 hours as needed for pain. 48308 2. R105's face sheet showed R105 with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non dominant side, vascular dementia with other behavioral disturbance, chronic respiratory failure unspecified, gastric ulcer, hypertensive heart disease, general anxiety disorder and polyneuropathy. R105's MDS dated [DATE], showed R105 is cognitively intact and requires extensive assistance from staff for bed mobility, toileting, dressing, bathing and transfer activities of daily living. On 10/31/23 at 10:54 AM the resident was observed lying in bed with the bed covers over her head. V17 (CNA) stated R105 did not want to get out of bed and was not feeling good. R105 was having too much pain and she had reported this to the nurse. On 10/31/23 at 2:10 PM, R105 was still in bed. V17 stated R105 was not feeling well and remained in bed all day. On October 31, 2023, at 6:38 PM, R105 was transferred to the local hospital emergency room for complaint of left hip pain. According to R105's hospital visit documentation dated 10/31/23 at 6:44 PM, R105 arrived in the emergency room crying related to complaint of pain and was administered opioid medication with subsequent pain relief. On 11/1/23 at 09:30 AM, R105 was observed lying across the bed, with her glasses on her face sleeping. On 11/1/2023 at 1:03 PM, R105 stated her pain occurs on the left side of her body and described the pain as a stabbing nerve pain that occurs daily. R105's MAR (Medication Administration Record) for September 2023 showed R105's pain scores for the day shift as follows: A pain score of 6/10 on 9/1, 9/3, and 9/11/23. A pain score of 9/10 on 9/2, 9/5 and 9/22/23. A pain score of 7/10 on 9/7, 9/10, and 9/20/23. A pain score of 8/10 was recorded for all the remaining days of the month. R105's Lidocaine 4% analgesic patch ordered to be administered daily at 6:00 AM, is not documented as administered on 9/1, 9/4, 9/6, 9/7, 9/8, 9/10, 9/29 and 9/30. The September MAR also shows documentation of the Lidocaine 4% patch not available on 9/2, 9/5, 9/9, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, and 9/17/23. The documentation showed R105's pain score remained above 6/10 every day and the Lidocaine 4% topical analgesic was not administered as ordered 18 of 30 days for the month of September 2023. R105's MAR for October 2023 showed R105's pain scores documented for the dayshift as follows: A pain score of 7/10 on 10/17, 10/18, 10/19, 10/20, 10/21, 10/23,10/24,10/25, 10/26 and 10/28. A pain score of 8/10 on 10/4, 10/5, 10/6, 10/7, 10/10, 10/12, 10/22, 10/27, 10/30 and 10/31. The Lidocaine 4% topical analgesic patch, ordered to be administered daily was documented as not administered 19 days. On 11/01/23 at 12:35 PM, V2 (DON) stated R105 has pain related to her previous stoke and that it is neuropathic pain. V2 stated R105 seeks pain relief from opioid medications. R105 is prescribed opioid medication scheduled three times a day and as needed up to four times per day. R105's pain assessment dated [DATE] does not accurately reflect the resident's daily day shift pain score as being greater than 6. The assessment question, Is the resident expressing pain? is answered no. V2 stated on 11/10/23 at 12:35 PM the question on the assessment was answered incorrectly. R105's progress note dated 9/21/23 at 4:30 PM showed V16 (Physician) referred R105 for consultation with pain management physician. There was no documentation regarding the results of the pain management consultation in the progress notes reviewed from 9/22/23 through 10/31/23. Those progress notes do not include documentation of non-pharmacological interventions attempted to relieve pain. There was also no documentation regarding informing the Physician of unrelieved pain in those progress notes. The progress note of 10/20/23 at 5:00 PM states R105 was examined by V16 with no mention if review of pain management was assessed and no new orders given. The facility's Pain Management policy dated July 2019, showed the purpose of the pain management program is To establish a program with a multi-level approach to pain management to assist the facility in delivering safe, individualized pain care. The facility's policy further showed the purpose of this policy is to accomplish the goals through an effective pain management program. The definition of the policy showed The facility will utilize a consistent pain assessment. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify any changes in the pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes and changes in behavior and mood will be used to determine the presence of pain. The policy showed components of the Pain Management Program includes .Accurate and complete documentation of pain assessment and monitoring .Informed resident participation in care decisions including managing pain .medication for the control or relief of anxiety. Also included in the facility's policy are standards, 1. Pain assessment protocol may be initiated under any of the following situations: .Resident received routine pain medication and/or pain is not controlled .A significant increase in the need for use of PRN use of pain medication .A change in pain identification related to behavior, cognition, or mood and 6. A provision of pain treatment that includes pharmacological and non-pharmacological interventions will be included in the care plan and 12. The resident's physician will be notified of the resident's complaint of pain which are not relieved by comfort measures including pain medications.

Based on observation, interview, and record review, the facility failed to keep residents safe from a potential fire, explosion, and/or from inhaling carbon monoxide when the facility used an outdoor gas grill inside the facility for cooking. This failure resulted in an Immediate Jeopardy (IJ) and has the potential to affect all 113 residents living at the facility. The IJ began on August 27, 2017 at 2:00 PM when an outdoor gas grill which was connected to the propane tank was brought into the facility's kitchen. The facility's Administrator was notified of the IJ on August 29, 2017 at 1:07 PM. Although the immediacy was removed on August 28, 2017 at 11:50 AM when the gas grill was removed from the facility's kitchen, the facility remains out of compliance at Severity Level II due to the need to evaluate the implementation of the new policies and procedures and Quality Assurance monitoring tools. The findings include: The CMS form 672 titled Resident Census and Condition of Residents dated August 28, 2017, shows the facility resident census as 115. On August 29, 2017 at 11:22 AM, E1 (Administrator) stated there were only 113 residents in the facility on August 27 and 28, 2017 and two residents were out on bed hold. On August 28, 2017 at 9:50 AM during the tour of the kitchen with E3 (Food Service Manager), an outdoor, gas grill sat in front of an oven in the kitchen. The grill was not directly placed under the ventilation hood. The grill was turned on and flames were emitting from the burners below the grill grates. Two large pots of food (one pot of stew and the other corn) were placed side by side on the grill grates and were being heated by the flames. A gas propane tank was located on the bottom shelf of the grill and connected to the grill. E3 stated they brought the grill in to heat food and provide a hot meal for the residents due to the gas temporarily being shut off. E3 stated they placed the grill closest to the hood for ventilation. On August 28, 2017 at 11:50 AM, E1 (Administrator) stated the facility was using the grill to try to provide a hot meal for the residents because they had a cold meal yesterday due to a gas interruption. E1 stated the staff placed the grill closest to the hood for ventilation. On August 28, 2017 at 3:10 PM, E3 stated facility workers deactivated the hood on August 27, 2017, but the hood was reactivated and available for use the morning of August 28, 2017. E3 stated that he brought the grill into the kitchen on August 27, 2017 at approximately 2:00 PM. E3 stated the kitchen staff did not utilize the grill on August 27, 2017 and served only cold foods for meals. E3 stated they stored the grill and propane gas tank in the kitchen on August 27, 2017 and overnight through August 28, 2017. E3 stated he turned on the grill between 9:30 AM and 10:00 AM on August 28, 2017 to begin to heat food for lunch. On August 28, 2017 at 12:37 PM, Z1 (Propane Manufacturer Customer Representative) stated the propane tank should not be used in any indoor setting. Z1 stated, You are not supposed to have those tanks indoors at all. If there is a leak in the tank, the gas could cause a fire. Z1 stated storing the propane tank indoors could lead to a fire or potentially an explosion hazard especially if there is a spark. On August 28, 2017 at 12:55 PM, Z2 (Propane Manufacturer District Manager) stated the propane tank should never be stored or used inside of a building. Z2 stated if a rapid temperature or pressure change occurs, the pressure increases inside the tank, the relief valve would open, and allow flammable gas to be released. Z2 stated release of propane vapor could build up and any spark, such as a light switch being turned on, could cause the gas to explode. Z2 stated the Liquefied Petroleum Gas Code Pamphlet 58, written by the National Fire Protection Association, provides the usage guidelines for any propane tanks. On August 28, 2017 at 1:22 PM, Z3 (Gas Grill Manufacturer Customer Service Representative) stated, based on the grill model number retrieved off the bottom of the grill, the corresponding grill owner manual was [PHONE NUMBER]. Z4 (Gas Grill Manufacturer Customer Service Representative) stated page three of the grill user manual documents the grill is approved for outdoor uses only. Z4 stated even with industrial ventilation, the grill is not an indoor appliance and is only approved for outdoor use. Z4 stated indoor use of the grill results in the risk of fire and carbon monoxide gas accumulation. Z4 stated there is no ventilation system designed to accommodate this grill approved for outdoor use only. Z4 also stated the grill is only approved for private residential, and not industrial, use. The Propane tank consumer warning label, undated, shows, For outdoor use only. Do not use or store cylinder in a building, garage, or enclosed area, except as authorized by NFPA (National Fire Protection Association) 58. The label shows, Danger - Extremely flammable gas. Contains gas under pressure; may explode if heated. NFPA 58, dated 2017, shows, LP (Liquid Propane) - Gas containers shall be located outside of buildings unless they are specifically allowed to be located inside of buildings. The outdoor gas grills manufacturer instructions, Model [PHONE NUMBER], shows, If the information is not followed exactly, a fire resulting in death or serious injury could occur Never use your gas grill in a garage, porch, shed, breezeway, or any other enclosed area. Your gas grill is to be used outdoors only. Through observation, interview, and record review the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: 1. On August 28, 2017, at 11:50 AM, E1 stated he would remove the grill from the facility immediately. At 11:56 AM, the grill was no longer in the kitchen and was relocated outside the facility. 2. On August 29, 2017, the kitchen staff was in-serviced regarding gas outage and not cooking on alternative sources including propane based sources including grills. Kitchen staff was not allowed to work until they received this in-service. 3. Revised the policy of Disruption of Gas, Electric and Water, dated April 27, 2016, to add instructions to not utilize alternative sources of cooking and heating food including Propane based sources/grills. 4. On August 29, 2017, the Dietitian educated the staff on the use of the Emergency Menu Guide (No power, No gas, Water Back-up) when necessary. The emergency menu was posted in the kitchen on the refrigerator. 5. On August 29, 2017, an Emergency QA/CQI meeting was held to discuss the incident. 6. On August 29, 2017, E1 stated in case of any gas outage that effects cooking, he or his designee will ensure the Dietary Department will follow the Disruption of Gas, Electric and Water policy. E1 also stated that he or his designee will go down to the kitchen to monitor meal preparation twice per meal to ensure the policy of Disruption of Gas, Electric and Water is followed.

Based on observation, interview and record review the facility failed to: -Transfer a resident (R7) in the manner to avoid potential accident hazard. -Provide supervision to prevent resident to resident verbal and physical altercations. This is for three of 22 residents (R7, R17 and R22) in the sample and 12 residents (R24, R33, R37, R49, R59, R60, R74, R84, R91, R98, R104, and R110) from the supplemental sample. Findings include: 1. On 10/25/11 at 11:30 am E9, E10 and E11 Certified Nurse Aides (CNAs) transferred R7 with a total mechanical lift from her bed to motorized chair. R7 has morbid obesity, and totally dependent on staff for her activities of daily living. During the transfer the staff placed R7's motorized chair in the hall way; E10 and E11 had R7 in the sling; E9 operated the lift. After R7 in her sling reached the chair, she was too high in the air and did not land on the chair even after E9 lowered her in the lift to the maximum. At this point E9 lifted the mechanical lift to tilt R7 on to the motorized chair. In the process of E9 lifting the mechanical lift, there is great risk R7 could have been dropped to floor. On 10/25/11 at 11:45 am E9 stated he has been always transferring R7 from bed to wheel chair with a total mechanical lift and each time he had tilt the lift in order for him to place R7 in her chair. The mechanical lift operational manual recommended to use their brand weight appropriate size sling. The Restorative Nurse on 10/27/11 at 2:40 pm stated one size sling fits all. R7's plan of care for falls and transfers did not determine the size of sling appropriate for R7. On 10/26/11 at 4:00 pm the survey team discussed the concern with the facility administration staff. 2. On 1/16/11 R22 11:30 am was watching Television (TV), another male resident came and changed TV channel. R22 got up set and hit the male resident on his back with his fist. It was note in the Occurrence Resolution to seek staff for assistance immediately. It was unclear how an impulsive behavior resident will seek staff assistance. The investigation do not indicate where the staff was during the occurrence. 3. On 2/3/11 at 1:45 pm R49 was under the influence of her delusions thinking she was the elevator operator. When R49 and R110 was in the elevator R110 pushed the button to the floor where he was going, R49 scratched R110 to prevent R110 to operate the elevator. The event investigation did not specify if R49's delusions were acute or chronic. The facility sent R49 for acute psychiatric hospitalization . When R49 returned to the facility no plan of care developed to deal with R49's delusions. 4. On 2/27/11 at 11:30 am R33 kicked R37's chair and said mean words. R37 got upset and threatened R33. 5. On 3/9/11 at 9:15 am R104 pushed R17 because R17 yelled at R104 for leaving bath room messy. R17 on 10/26/11 stated it happens all the time, staff do not care when reported such incidents. 6. On 3/20/11 at 5:30 pm R110 got upset during meals because of R98's talking continuously during dinner, got up and left to his room; and later R110 met R98 in hall way and kicked R98 in legs. The event report investigation did not include as to where the staff was or how such occurrences will be prevented. 7. On 6/29/11 at 2:20 pm R74 pushed R59 when R59 approached R74 to help with the vending machine. The facility sent R74 to hospital for evaluation. When R74 readmitted to the facility no change in the interventions noted to prevent further occurrences. 8. On 8/1/11 at 6:27 pm R91 hit R60 on back of her neck. Upon questioning R91 stated she thought R60 was talking about her even though R60 was sitting quietly in her wheel chair and not talking at all. The facility sent R91 for psychiatric hospitalization on 8/1/11, upon R91's returning to the facility no revised interventions were developed to avoid further occurrences. 9. On 10/19/11 12:15 pm R24 hit R84 with a milk carton when R84 stated he was going to marry her. The investigation reported had no information to indicate where the staff was. There were three other incidents of resident to resident altercations on 5/27/11, 7/4/11 and 7/27/11 involving the residents who are not at the facility.