Every finding on record at Winning Wheels

Based on observation, interview, and record review the facility failed to ensure hot liquids were safely served and failed to ensure a process was in place for hot liquids for 1 of 3 residents (R5) reviewed for safety in the sample of 8. This failure resulted in R5 spilling his coffee on his lap and sustaining two partial thickness burns to his left inner knee causing R5 pain.The findings include:R5's face sheet showed his most recent readmission to the facility on 1/11/25 with diagnoses to include acute and chronic respiratory failure with hypoxia, atherosclerotic heart disease, chronic cough, dysphagia, epilepsy, hemiplegia and hemiparesis, and mononeuropathy of left lower limb. R5's facility assessment dated [DATE] showed he has no cognitive impairment and requires substantial to maximum assist for most cares.R5's 2/3/26 Nurse's Note entered at 9:22 AM showed, Resident spilled hot coffee at 7:45 AM on left knee during breakfast. Area cleaned, TAO (triple antibiotic ointment) applied and covered with dressing. Red area with no open areas at this time measures 5 inches by 3 inches to inside of left knee. Resident complained of level 5 pain to area, prn (as needed) Tylenol given.R5's 2/3/26 Skin Check showed, . New Skin Issue. Location: Front left knee. Issue Type: Burn. Wound acquired in-house. Length (cm) 12.5; Width (cm): 7.5.On 2/5/26 at 12:50 PM, R5 showed this surveyor his coffee cup. It was a short metal, insulated coffee cup with a plastic lid that had a small hole to drink out of. R5 said, I had my coffee cup, and the lid has a little hole to drink out of. I was trying to turn the cup in my hand to get the drink hole where I could drink from it, and I fumbled the cup. It fell on my lap and the coffee poured out of the little hole onto my leg. It hurts, Yeah, it hurts.On 2/5/26 at 12:55 PM, V25 (Nurse) was changing the dressing to R5's knee. R5's knee had a triangular shaped area to the inner aspect of the left knee that extended down to the area just above the crease of the posterior left knee. There was an oval shaped area above the triangular shaped area on the inner left knee. Both areas appeared as open areas where fluid filled blisters had burst. V25 said the treatment had just been changed due to the blisters opening up.R5's 2/3/26 Social Service Note entered at 3:39 PM showed, SW (Social Worker) met with [R5] on this date. [R5] spilled his hot coffee this morning resulting in a burn on his left leg. [R5] stated that he would start drinking iced coffee instead.R5's Care Plan showed, Diet downgraded to pureed and NTL (nectar thick liquid). [R5] also had moderate spillage of food and fluids at times will fall asleep during meals or engage in conversations with peers during meals requiring max verbal cues to complete task of eating meals. [R5] will take off the lids on cups causing liquid to spill out of cups onto self and floor. (added 2/3/26) Add ice to hot beverages; (added 2/4/26) cups with lids and handles due to spillage of liquids as resident allows. (added 7/22/22) Ensure resident has a clothing protector on for all meals due to spillage as resident allows - resident likes to utilize towels at times.R5's Care Plan initiated 1/1/2019 showed, the resident has hemiplegia/hemiparesis related to stroke.R5's Care Plan initiated 4/29/24 showed, the resident has an alteration in chronic left rotator cuff tear with hemiplegia and masses on the shoulder and scapula. limiting strength and mobility to left side.R5's Care Plan initiated 4/17/2020 and revised 2/5/26 showed, Risk for Impaired Skin Integrity due to CVA (Cerebral Vascular Accident), hemiparesis, impaired mobility, improper repositioning technique by resident in wheelchair, poor safety awareness with left side of body due to left side neglect from stroke. [R5] at times will try to remove his coffee lid himself despite requiring assistance due to hemiplegia.R5's Care Plan initiated 2/3/26 showed, Wound Management, Skin impairment to left front and inner knee due to trying to remove his own coffee lid. Provide wound care per treatment order. [Wound Care Company] to assess wound. Waterproof clothing protector added to improve safety.R5's Care Plan initiated 10/30/23 showed, The resident has a swallowing problem related to loss of food/liquids from mouth while eating.R5's February 2026 eTAR (electronic Treatment Administration Record) showed a new treatment started 2/3/26 to, Cleanse area to left front and inner knee with wound cleanser, pat dry, apply TAO (triple antibiotic ointment) and dry dressing to area.R5's Skin assessment dated [DATE] showed, . Skin Issue: Burn; Location: Front left knee; Length (cm): 12.5; Width (cm): 7.5.On 2/5/26 10:49 A, V2 (Dietary Aide) said, We don't do temperature checks on the coffee.On 2/5/26 at 11:33 AM, V26 CNA (Certified Nursing Assistant) said the coffee comes down on the top of the cart, with a lid on the cup. I've never been asked to check temperatures of coffee before serving it.On 2/5/26 at 3:11 PM, V3 RN (Registered Nurse) said, [R5] spilled his coffee yesterday. He is going to have iced coffee now instead of hot coffee. It was 7:45 AM when he was eating breakfast in the common area. I am the one who first assessed. He doesn't use his left arm. I would say he has about 75% dexterity in his right arm. The initial treatment got changed due to fluid filled blisters forming.On 2/5/26 at 1:15 PM, V23 (Restorative) said a lot of the residents have their own mugs. V23 said the facility is going to ensure all the cups have lids as the residents will allow. V23 said R5 can't turn the lid himself because he only has use of his right arm due to his stroke. V23 said R5 might have put the cup between his knees to try and hold the cup while he was attempting to turn the lid and the coffee spilled that way.On 2/5/26 at 11:26 AM, V7 (Dietary Manager) was in the kitchen pouring coffee into R5's insulated coffee cup. V7 used a digital thermometer to check the temperature of the coffee. The temperature was 164 degrees. V7 then added water to the cup and rechecked the temperature and the temperature came down to 147 degrees. V7 put the lid on the cup and put the cup on top of the meal cart to go down to R5's unit. At 11:37 AM, V7 was sitting on the unit with a thermometer, waiting for R5's coffee to be given to him. V7 said, Typically we would pour the coffee, put it on the cart, and they would serve it. We wouldn't 'temp' the coffee all the time. If we did temp it, we would document the temperature, but I don't know where that documentation would be. The reason we don't want to serve it too hot is because of burn risks. A lot of residents here have neurological impairments that make it so they might not be able to hold their cups. I don't do any assessments for residents to handle hot liquids. I would say we do 'random temperature checks' on the coffee. Maybe we have done 2 in the past 30 days, but I can't tell you where it would be documented at. The facility's policy and procedure titled Hot Liquid Safety showed, Policy: Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. Definitions: Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns. Scalding is a burn caused by spills, immersion, splashes, or contact with hot water, food and hot beverages, or steam. Policy Explanation and Compliance Guidelines: 1. Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure. Refer to the table attached to this policy for an illustration of the time required for a burn to occur at various temperatures. 2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. 3. Residents with difficulties will receive appropriate supervision and use of assistive devices in order to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care. 6. General safety precautions when serving hot liquids include, but are not limited to: . d. Regulate temperature of hot liquids to which residents have direct access.

Based on observation, interview, and record review the facility failed to implement it's pest control policy. This failure has the protentional to affect all residents residing in the facility. The findings include:The facility census provided on 2/4/26 but dated 2/1/26 showed 74 residents reside in the facility. On 2/5/26 at 11:55 AM, R4 stated there were mouse dropping in her dresser in October of 2025. R4 then presented a photograph on her laptop. The photograph showed her dresser with small mouse droppings and what appeared to be crystalized urine. R4 said, It was disgusting and a real disease problem. Mice carry diseases. On 2/4/26 at 11:40 AM, R8 said, I've never had any issues with seeing mice but there have been mouse droppings on my bed. The last time I saw mouse droppings was last week. On 2/4/26 at 1:35 PM, V10 Environmental Services Director stated the facility employs a third-party pest elimination contractor. V10 stated the contractor generates a report stating trouble areas with the building; areas where bugs and rodents can enter the facility. V10 was shown the 1/13/26 pest elimination contractor report which showed areas of entry and repair recommendations. V10 stated, I have not seen this. If I don't know about these gaps and holes, I can't do anything about it. He is the expert and he is identifying entry points into the building. V10 stated he does not round with the pest control expert. V10 stated the report goes to administration then they notify him if there are areas to be repaired. V10 stated, They (administration) don't forward it to me unless there are any issues that need to be resolved. They have not sent anything to me recently. We have not had any problems in a long time. I haven't seen one (pest control report) since September. On 2/4/26 at 2:15 PM, V11 Senior Pest Elimination Specialist (contracted pest elimination specialist) stated mice can enter the building through a hole the size of dime. V11 stated the facility pays him to make recommendations to prevent pest and rodent intrusions. V11 stated he makes recommendations to minimize rodent intrusions and then provides those recommendations to administration. V11 said, I expect they (administration) are getting it (his recommendations) to maintenance. On 2/5/26 at 10:05 AM, V1 Administrator stated it was her understanding V24 Safety Supervisor was notifying V10 of the pest recommendations. V1 stated V10 would be the person to make any repair recommendations from the pest contractor. V1 stated the purpose of paying for the contractor and repairing the recommendations is to minimize rodent and pest infestations. The 1/13/26 pest elimination report showed the B wing exit door had a greater than 0.25-inch gap and the door sweep needed to be replaced. This issue was also present on the 12/9/25 report, 11/11/25 report, and 10/14/25 report. On 2/5/26 at 12:00 PM, the B hall exit door showed a 1 inch wide by 0.5-inch-tall gap (larger than a dime) open to the outside. This opening was at ground level and at the point where the two exit doors joined. The facilities Pest Control Program policy showed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated.

Based on observation, interview and record review the facility failed to check placement of a narcotic pain patch as ordered for 1 of 3 residents (R1) reviewed for patch placement and administration.The findings include:R1s admission record shows he was admitted on [DATE] with multiple diagnoses including other chronic pain and unspecified pain. The January Medication Administration Record (MAR) shows a 11/10/24 order for Fentanyl patch 25 mcg (micrograms)/hour every 72 hours. Apply 1 patch trans dermally (to the skin) every 72 hours for pain. Rotate site and remove per schedule. The MAR also shows an order for Fentanyl Patch placement check every shift. The checks were scheduled for day and night shift. The MAR shows the checks were completed on 1/21/26 for both shifts. On 1/27/26, R1 was observed to have a Fentanyl patch located on his left chest. The patch was dated and initialed by the nurse. The facility incident report of 1/21/26 documents V2 Director of Nursing was notified by nurses during the night shift placement check of R1s Fentanyl patch, the patch was missing.On 1/27/26 at 10:22 AM, V4 Licensed Practical Nurse (LPN) said Fentanyl patches are checked for placement every shift. We go with the outgoing nurse to look at the patch, this way you can check and find it is missing a lot sooner. The patches should have the date and person's initials of who placed it. We document on the MAR it is in place.On 1/27/26 at 10:30 AM, V5 Registered Nurse (RN) said narcotic patches are checked every shift and it is documented on the MAR. The nurse on duty checks the patch, we do not go with the previous (outgoing) nurse.On 1/27/26 at 11:42 AM, V8 LPN said patches should be checked every shift, the previous shift nurse should walk with and verify the patch is in place. V8 said she usually always lays eyes on the patches but the morning of 1/21/26, she was on her way down to see R1s patch and was distracted by other residents and events going on in the hallway. She did not actually see the patch that morning, but documented the patch was in place. V8 said at the end of her shift on 1/21/26, she was checking placement with V7 LPN, and the patch was missing. V8 said she should have checked No on the MAR for patch placement because she did not see it.On 1/27/26 at 11:16 AM, V2 said each Fentanyl patch has an order for both shifts to check placement. Both ongoing and outgoing nurses are to check the placement together. She said V8 should have checked the placement of the patch on 1/21/26, but when asked about it, she did not recall performing the patch placement check.The facility's undated policy for narcotic pain patches documents: It is the policy of this facility to maintain records of all narcotic patches at the time of receiving in the facility until destruction. Policy Explanation and Compliance Guidelines: 8. Verification of the patch site and date will be completed every shift and documented in the medication administration record.

Based on interview and record review, the facility failed to protect 6 residents (R1,R2,R3,R4,R5,R6) from misappropriation of medications. This applies to 6 of 6 residents reviewed for misappropriation in the sample of 14. The findings include:The facility's investigation dated 10/8/25 showed, Between 9/29-9/30 from 11:55PM until about 4:00AM, (V5) is seen in the medication room sleeping. Around 4:00AM, (V5) is seen on (unit) with her medication cart. She can be seen in the medication drawer dispensing medications from the cards into her bare hands and then putting them into a cup. During this time, (V5) is not seen at any point looking at the EMAR (Electronic Medication Administration Record) .At approximately 5:07AM after pulling medications she is seen putting something in her mouth. Approximately 5:14AM she is seen going through the narcotic box and pulling medications from the cards into her bare hands. It then appears that she puts something in her left front pocket of her hoodie that she is wearing. At 6:00AM, she is seen going through the narcotic box and (Narcotic Reconciliation System) and checking out medications she has removed.R1's September 2025 physician's orders showed R1 receives Oxycodone 5mg two times a day at 12:00PM and 8:00PM and Pregabalin 50mg three times a day at 5:00AM,12:00PM, and 8:00PM. The facility's narcotic reconciliation record dated 10/2/25 showed on 9/30/25 V5 (Licensed Practical Nurse) removed 1 additional dose of R1's oxycodone 5mg and 1 additional dose of R1's Pregabalin and did not document administration of either medication to R1. R2's September 2025 physician's orders showed R2 receives Oxycodone 5mg every 6 hours as needed.The facility's narcotic reconciliation record dated 10/2/25 showed on 9/30/25 V5 removed 1 additional dose of R2's oxycodone 5mg and did not administer this medication to R2.R3's September 2025 physician's orders showed R3 receives lorazepam 0.5ml (1mg) by mouth every 2 hours as needed and morphine 0.5ml (10mg) by mouth every 2 hours as needed.The facility's narcotic reconciliation record dated 10/2/25 showed on 9/30/25 V5 removed 1 dose of R3's lorazepam 0.5ml and morphine 0.5ml and did not document administration of either medication to R3.R4's September 2025 physician's orders showed R4 receives diazepam 5mg two times a day at 5:00AM and 4:00PM and Norco 5/325mg at 5:00AM, 12:00PM, and 8:00PM.The facility's narcotic reconciliation record dated 10/2/25 showed on 9/30/25 V5 removed one additional dose of R4's diazepam 5mg and one additional dose of R4's Norco 5/325mg and did not document administration of either medication to R4.R5's September 2025 physician's orders showed R5 receives Norco 5/325mg every 6 hours as needed.The facility's narcotic reconciliation record dated 10/2/25 showed on 9/30/25 V5 removed two doses of R5's Norco 5/325 and did not document administration of either dose to R5.R6's September 2025 physician's orders showed R6 receives Pregabalin 15ml (300mg) two times a day at 5:00AM and 4:00PM.The facility's narcotic reconciliation record dated 10/2/25 showed on 9/30/25 V5 removed two doses of R6's Pregabalin 20mg/ml solution and did not document administration of either dose to R6.Surveyor corroborated the above investigation through observation of the facility's video camera footage of the facility provided by V1 (Administrator) on 12/20/25.On 12/20/25 at 1:01PM, V4 (Licensed Practical Nurse) stated, I supposed the only way to prove that we gave a medication is to sign it out in (Narcotic Reconciliation System) and document it in the resident's MAR. If both of those things aren't done, then you cannot assume a medication was given. Furthermore, it is possible to just sign a medication out of (Narcotic Reconciliation System) and never give it to the resident. You would catch that on their MAR and it would alert us that they missed a dose. On 12/20/25 at 2:10PM, V6 (Registered Nurse) stated, I followed (V5) after her shift on 9/30 and didn't see anything unusual. I also didn't work with her overnight though and I guess that was a different story. All of the counts were accurate, so I didn't investigate anything further because we don't look at when medications were pulled, just the count to ensure it matches. (R1) complained of pain and he didn't remember getting his pain medicine from (V5) but it was signed off on the MAR (medication administration record) so all I could offer him was Tylenol & Ibuprofen which he accepted. I did report to the DON (Director of Nursing) immediately that he said he did not get his morning medicine and that's when they started looking at the (Narcotic Reconciliation System) records and noticed discrepancies.On 12/20/25 at 2:50PM, V1 stated, It was so obvious that (V5) was diverting medications. She had to have ingested some of them on her shift with the number of times she was falling asleep, dropping items, and spilling things. She looked at the camera almost every time she took a medication from a medication card and whenever she put something in her mouth. We have cameras showing her from every angle taking those medications. At one point she was also vaping while she was down the resident hallways. I reported it to (local police department) and they initiated an investigation. They are opening a larger investigation into (V5) as this isn't the first facility she has done this to in our area. I feel bad because we are supposed to be protecting our residents from this type of thing. She flat out stole from them right on camera.On 12/21/25 at 8:35AM, V2 (Director of Nursing) stated, I was the ADON (Assistant Director of Nursing) during this investigation. The previous DON got alerted from (Narcotic Reconciliation System) of discrepancies and we started looking into it and noticed (V5) was checking out 2 pills at a time for residents at the end of her shift on 9/30/25. The night nurse, V3 (Licensed Practical Nurse) also said something didn't seem right with (V5) and she had been falling asleep all night and not caring for her residents. We did some more digging and made (V1) aware and we watched the cameras to see what (V5) did all night. It was pretty evident right away that she was diverting narcotics. She was falling asleep multiple times throughout her shift and putting things in her mouth and popping pills out of the medication cards and not administering them. We didn't have anything in place before to stop the nurse's from checking out multiple doses in the (Narcotic Reconciliation System) but now we have a lock in the system so they can't document removing more than the ordered dose for each resident.During the course of this investigation, 3 attempts were made to contact V5 without success.The facility's policy titled, Abuse Program: Investigation/Reporting/Response dated 3/17 showed, 8. MISAPPROPRIATION OF RESIDENT PROPERTY means the deliberate misplacement, exploitations, orwrongful, temporary or permanent use of a resident's belongings or money without the resident's consent .The facility's policy titled, Controlled Substance Administration & Accountability dated 2025 showed, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .G. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record

Based on interview and record review, failed to report alleged violations of misappropriation for 6 residents (R1, R2, R3, R4, R5, R6) to IDPH (Illinois Department of Public Health) within 24 hours, failed to implement policies and procedures for reporting the possible crime to law enforcement. These failures apply to 6 of 6 residents reviewed for misappropriation in the sample of 14. The findings include:The facility's investigation dated 10/8/25 showed, Between 9/29 to 9/30 from 11:55PM until about 4:00AM, (V5-Licensed Practical Nurse-LPN) is seen in the medication room sleeping. Around 4:00AM, (V5) is seen on (unit) with her medication cart. She can be seen in the medication drawer dispensing medications from the cards into her bare hands and then putting them into a cup. During this time, (V5) is not seen at any point looking at the EMAR (Electronic Medication Administration Record) .At approximately 5:07AM after pulling medications she is seen putting something in her mouth. Approximately 5:14AM she is seen going through the narcotic box and pulling medications from the cards into her bare hands. It then appears that she puts something in her left front pocket of her hoodie that she is wearing. At 6:00AM, she is seen going through the narcotic box and (Narcotic Reconciliation System) and checking out medications she has removed.On 12/20/25 at 12:36PM, V3 (LPN) stated, (V5) had some concerning behaviors when I worked with her on 9/29/25. She's not a very good nurse in my opinion. She appeared to pass medications during med pass time but then would go right to the medication room and was sleeping very sound. She did not wake up to any stimulation. I know they found some medication discrepancies after she left, but I didn't know that or observe that during the shift. I reported my concerns about (V5) to the previous DON (Director of Nursing) around 5am or so on 9/30 as soon as she came to the facility. I was concerned that (V5) was sleeping so sound but I couldn't prove that she was under the influence of anything so I'm not sure what else I could have done differently. If I would have known what I know now about her I would have walked her out of the facility myself and called the DON right away.On 12/21/25 at 8:35AM, V2 (Director of Nursing) stated, V3 made the previous DON aware of her concerns with (V5) when she got to facility that morning (9/30). I would expect the nurses to notify me immediately of any concerns with any staff, not just agency staff. If we would have received a call from (V3) we would have had (V5) leave the facility immediately and another nurse would have worked the rest of the shift. We could have possibly prevented some of this diversion of medications had we been notified of (V5's) behavior sooner.On 12/21/25 at 9:39AM, V1 (Administrator) stated, We didn't really realize the medications had been taken right away. On 9/30, (V6-Registered Nurse) reported to the DON that (R1) was saying he didn't get his medications that morning. That's when we first started looking into the medications. Misappropriation is part of abuse so that needs to be reported within 2 hours I believe. Misappropriation was reported to IDPH on 10/8/25 and to local police on 10/8/25. (9 days after investigation was initiated by the facility). The reason we didn't report anything right away is because we were still looking into everything so initially there wasn't anything missing but once we noticed that there were medications that had been taken, we reported it. The staff usually report unusual behavior to us, but I believe (V3) did not report to us right away because she was busy with her own stuff. I can only assume that she was just busy and focusing on her own residents. At the time (V5) was falling asleep, she was in the medication room, so she wasn't taking care of residents when (V3) started noticing everything. (V3) did go check on the residents to make sure they were ok so at least they ended up getting the cares they needed. We did not get a copy of the police report because it is an open investigation, so the report is not ready yet and we have all the evidence at this time to prove that (V5) stole the medications and we substantiated misappropriation. The facility's policy titled, Abuse Program: Investigation/Reporting/Response dated 3/17 showed, Employees are required to immediately notify the Administrator and the Director of Nursesand staff that is on duty of any complaints of, observation of, or suspicion of resident abuse,mistreatment or neglect .Continue the facility investigation as needed, to be concluded within 48-72 hours, if possible.

Based on interview and record review, the facility failed to ensure medications were administered per physician's orders for 4 of 6 residents (R4, R5, R6, R14) reviewed for pharmacy services in the sample of 14. The findings include:The facility's incident report dated 10/8/25 showed, On 9/30/25 at 7AM, V1 (Administrator) received a phone call from Director of Nursing, stating that it was reported to her that the agency night nurse (V5-Licensed Practical Nurse) had slept most of the night. Concerns were brought up that (V5) did not complete her wound treatments, failed to sign out medications in EMAR (Electronic Medication Administration Record) .2 residents were identified to have not received their scheduled medications .R4's September 2025 MAR (Medication Administration Record) showed R4 receives Amantadine 100mg, fluoxetine 10mg, lactulose 15ml, omeprazole 20mg, baclofen 10mg, buspirone 5mg, diazepam 5mg, levetiracetam 1000mg, Norco 5/325mg at 5:00AM. No documentation was present showing R4 received his 5:00AM medications from V5 on 9/30/25.R5's September 2025 MAR showed R5 receives fluticasone 50mcg spray, omeprazole 40mg, aspirin 81mg, finasteride 5mg, furosemide 40mg, lidocaine 4% patch, trelegy inhalation 100-62.5-25mcg/act, venlafaxine 225mg, doxycycline 100mg, Eliquis 5mg, metformin 1000mg, metoprolol 12.5mg, oxybutynin 5mg, gabapentin 900mg, and baclofen 20mg at 5:00AM. No documentation was present showing R5 received his 5:00AM medications from V5 on 9/30/25.R6's September 2025 MAR showed R6 receives Escitalopram 25mg, scopolamine 1.5mg patch, tizanidine 4mg, Colace 100mg, famotidine suspension 20mg, levetiracetam 2500mg, Lyrica 300mg, and trihexyphenidyl 2mg at 5:00AM. No documentation was present showing R6 received her 5:00AM medications from V5 on 9/30/25.R14's September 2025 MAR showed R14 receives aspirin 81mg, Colace 100mg, amantadine 100mg, propranolol 20mg, and baclofen 15mg at 4:00AM. No documentation was present showing R14 received her 4:00AM medications from V5 on 9/30/25.On 12/21/25 at 12:27PM, V2 (Director of Nursing) stated, If there is nothing documented in the residents MAR we would have to go through the medication cards to see if they were popped or not and that was not done. It would have shown it was missed or given because our medication cards are dated. We would have been able to see if they were given or not and depending on time if they could receive it or not. I can't recall what was given and what wasn't but that's the process we would take. The residents that are not able minded we just monitored for pain after this incident. The charting system switches when the shift switches over so the next round of meds would have displayed on the screen so it may not have triggered for the next nurse to see that medications weren't given. Surveyor was unable to view the medication cards from September 2025 for R4, R5, R6, R14.The facility's policy titled, Medication Administration dated 2/25 showed, The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident .15. After the resident has taken the medication, immediately sign out on MAR. Never delay this action.

Based on observation, interview and record review the facility failed to ensure a meal was served in a sanitary manner and failed to ensure the temperature of resident refrigerators were monitored. This has the potential to affect all 77 residents residing in the facility. The findings include: 1. On 7/21/25 at 11:30 AM, V15 (Cook) was plating the noon meal from the steam table. V15 had gloves on and was putting the fish sticks and cornbread onto the plates using her hands. At 11:45 AM, V15 coughed onto her right wrist area. At 11:49 AM, V15 sneezed into her left elbow area. At 11:51 AM, V15 wiped her nose with her left wrist area. V15 continued to serve the food with her hands and did not remove her gloves and perform hand hygiene. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that staff should always be using utensils to serve food to the residents. V4 said that if the staff coughs or sneezes while plating food, they should leave the line and wash their hands and put a new pair of gloves on. The facility's Handwashing Guidelines for Dietary Employees shows, Dietary employees shall keep their hands and exposed portions of their arms clean .Dietary employees shall clean their hands and exposed portions of their arm immediately before engaging in food preparation including working with exposed food .and also in the following situations: After coughing, sneezing, or blowing your nose . 2. R30’s Facility assessment dated [DATE] showed R30 is a fifty-one-year-old cognitively intact female resident admitted to the facility on [DATE]. On 7/21/25 at 10:15 AM R30’s room refrigerator had no thermometer in it. The refrigerator had 2 yogurt containers, lunchmeat, and sliced cheese. R30 stated she did not remember the last time any of the staff had checked the refrigerator. R30 stated there has not been a thermometer in it in a long time. 3. R2’s Facility assessment dated [DATE] showed R2 is a forty-eight-year-old cognitively intact female resident admitted to the facility on [DATE]. On 7/21/25 at 1:25 PM, R2’s refrigerator had no thermometer in it. The freezer/fridge had an open ice cream container, an opened heart (Valentine’s Day) candy box, yogurt, guacamole, and assorted small candies. R2 stated they did not know if/when anybody has checked the fridge. R2 stated when she gets food leftovers they put it in the refrigerator. On 7/23/25 at 10:20 AM, V10 Safety Director stated they do room checks, but do not have documentation for the resident room refrigerators. They should all have a thermometer in them to make sure they are working. The facility’s undated Resident Food Storage and Handling Policy showed the facility ensure proper handling, serving a storage of any food items brought into the facility.

Based on observation, interview and record review the facility failed to ensure residents on a pureed diet were served a meal in a form that meet their needs for 4 of 4 residents (R4, R16, R38 and R42) reviewed for pureed diets in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit and an alternative of pureed breaded fish and pureed potatoes. On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 pureed breaded fish sticks and added warm milk. V15 then placed the pureed fish into a container. When scooped into the container, the fish appeared very thick. V15 then pureed barbecue pork and added warm milk. V15 then placed the barbecue into a container. When scooped into the container, the barbecue appeared thick. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed meal. On 7/21/25 at 12:15 PM, the pureed fish and barbecue was tasted. The fish and barbecue were thick, dry and not a smooth consistency. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that pureed foods should be pureed to a smooth, pudding like consistency. The facility's Puree Food Preparation Policy shows, Puree foods should be prepared in such a manner to prevent lumps and chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes.

Based on observation, interview and record review the facility failed to follow the pureed diet menu for 4 of 4 residents (R4, R16, R38 and R42) reviewed for menus in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit.The Recipe for Pureed Barbecue Pork on Cornbread shows ingredients of: BBQ Pork on cornbread with creamed corn and milk.On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 placed 10 scoops of barbecue pork into the blender bowl and processed it. V15 added warm milk and processed again. V15 then place the pureed barbecue into a container and placed it onto the steam table. V15 did not add cornbread to the barbecue. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed barbecue without a cornbread serving. V15 then ran out of pureed barbecue and prepared additional barbecue by adding corn bread into the barbecue. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that the menu and recipe should be followed by the staff when making pureed food. V4 said that the pureed barbecue should have had corn bread added to it during the puree process. The facility's Puree Food Preparation Policy shows, Puree Food Preparation Guidelines for serving per individual recipes.

Based on observation, interview and record review the facility failed to ensure a multidose insulin pen was discarded 28 days after being opened for 1 of 18 residents (R3) reviewed for medication storage in the sample of 18. The findings include:On 7/21/25 at 10:13 AM, R3's Lispro Insulin Pen was in the medication cart. The pen was labeled with an open dated of 6/15/25 and there was no discard date documented. 07/21/2025 10:13 AM, V7 (Licensed Practical Nurse) said that all insulin pens should be marked with the open date when it is opened and a discard date should be documented for 28 days after the date that it was opened. R3's July Medication Administration Record shows that she received Lispro Insulin Pen five times between 7/13/25 and 7/21/25. The facility's Insulin Pen Policy shows, Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date Insulin pens should be disposed according to manufacturer's recommendations. The Lispro Manufacturer Guidelines show, Throw away the Insulin Lispro Pen you are using after 28 days, even if it still has insulin left in it.

Based on observation, interview, and record review the facility failed to ensure residents rooms were free from pests which applies to 2 of 18 residents (R46, R54) reviewed for pest control is a sample of 18.The findings include:The facility's resident roster dated 7/16/25 showed R46 and R54 are roommates on the B-wing of the facility.R46's Facesheet printed on 7/22/25 showed R46 is a [AGE] year-old male with diagnoses which include tracheostomy, traumatic brain injury, and hemiplegia of the left side.On 7/21/25 at 10:30 AM, R46 was lying in bed with no shirt on. R46 had 4-6 flies flying around bed area and landing and walking on R46. R46 was having difficulty waving the flies off himself. R46 nodded when asked if the flies were bothering him. No pest reduction methods were in the room at this time. There were more than a dozen flies in R49's room at this time.R54's Facesheet printed on 7/22/25 showed R54 is a [AGE] year-old male with diagnoses which include intracranial injury with loss of consciousness, quadriplegia, and dysphagia.On 7/21/25 at 2:10 PM, R54 was in his room resting in reclined wheelchair. R54 had several flies landing on his face and crawling across his nose and cheek. R54 would flex his arm, but due to quadriplegia was unable to scare flies away.On 7/22/25 at 10:30 AM, V16 pest control specialist (3rd party) stated they do have treatments for flies, but they cannot utilize them in resident rooms. The main treatment is a chemical spray in open areas. The resident rooms are maintained by the facility. If we are told a certain room or hallway has pests (flies) we can go and give recommendations to reduce the issue. V16 stated they have not had anyone direct them to any specific resident rooms for pest (flies) control concerns.On 7/23/25 at 10:20 AM, V10 Safety Director stated if any of the staff notice a bug issue (ants, flies, etc.) they need to let me know so we can try to reduce the issue and let the pest control group about the problem when they come in. V10 stated he was not notified about R46 and R54's fly problem. There should not be flies crawling on residents. The facility's Pest Control Policy dated 2025 showed the facility is to maintain an effective pest control program that contains common household pests including bed bugs, ice, roaches, ants, mosquitos, flies, mice, and rats.

Based on observation, interview, and record review, the facility failed to date and time liquid nutrition when it was initiated for 1 of 4 residents (R34) reviewed for tube feeding in the sample of 18.The findings include:R34's Order Summary dated July 22, 2025 shows R34 was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, dysphagia, pain, contractures, aphasia, and epilepsy. A liquid nutrition order was entered on November 22, 2024 for Isosource 1.5 two times per day.On July 21, 2025 at 9:39 AM, there was a bag of liquid nutrition hanging next to R34's bed. There was no resident's name on the bag nor date nor time. There was liquid nutrition noted in the tubing and the bag of nutrition was half empty. At 1:05 PM, this same unlabeled bag was still hanging next to R34's bed.On July 23, 2025 at 9:27 AM, V2 Director of Nursing said the liquid nutrition should be labeled with the date and time it was hung, the type of liquid nutrition, and the resident's name.The facility's Tube Feeding Policy and Procedure effective November 2012 shows, To provide a means of safely introducing a complete nutritional feeding to the resident, using a formula that is premixed and premeasured in a specifically designed container with a bacterial filter to protect the formula from being exposed to harmful airborne contaminates. Procedure using clean technique, write the date, and initials on the label provided on the tubing of the pump set and enter the residents name, room number, date, start time, rate and initials on the identification information label on the bottle of tube feeding.

Based on interview and record review, the facility failed to administer a medication as ordered by the physician for one of 18 residents (R3) reviewed for pharmacy services in the sample of 18. The findings include:R3's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including myocardial infarction, congestive heart failure, generalized anxiety disorder, major depressive disorder, pain, major depressive disorder, post-traumatic stress disorder, alcohol use, and other bipolar disorder.On July 22, 2025 at 10:39 AM, R3 said it takes the facility a long time to start new medication orders. R3 said the psych doctor ordered an increase in her trazodone but she did not get the medication when it was ordered. I take it to help me sleep.R3's note from the psychiatry nurse practitioner dated July 10, 2025 shows, Plan Med changes: Patient's diagnosis of major depressive disorder is worsening and unstable at this visit. Increase trazodone to 100mg by mouth at bedtime.R3's Order Summary Report shows an order for trazodone 100mg (milligrams) one tablet by mouth at bedtime for mood related to major depressive disorder was entered July 11, 2025 to start on July 11, 2025.R3's Medication Administration Record (MAR) dated July 1, 2025-July 31, 2025, shows she received trazodone 75 mg from July 1, 2025-July 10, 2025 as ordered. The new order for the increase in trazodone to 100mg at bedtime was to start July 11, 2025. R3's MAR shows that R3 did not receive trazodone 100mg until July 13, 2025. R3's Psychotropic Informed Consent form for the increase in trazodone was signed by R3 on July 13, 2025.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said she did not know why R3 had not received her increase dose of trazodone.The facility's Medication and Treatment Orders policy revised July 2016 shows, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.

Based on observation, interview, and record review, the facility failed to ensure a dressing was in place for a resident with a stage 4 pressure injury for one of one resident (R71) reviewed for pressure injuries in the sample of 18.The findings include:R71's Order Summary Report dated July 22, 2025 shows he was admitted to the facility on [DATE] with diagnoses including spina bifida, urinary tract infections, wheelchair dependence, pressure injury of left buttock stage four, and malnutrition. Orders for calcium alginate apply to left buttock topically every day shift started July 14, 2025.On July 21, 2025 at 10:18 AM, V8 Certified Nursing Assistant placed R71 into the shower chair and placed him in the shower so he could shower himself. At 10:49 AM, V8 placed R71 back into bed and dried off R71's body and got him dressed. There was a dressing that came off of R71's left buttock. The wound to R71's left buttock had some depth to it and was a little bigger than a quarter size in diameter. V8 put a shirt onto R71 and said she was waiting for the wound doctor to come to replace the dressing. R71 was positioned in bed onto his back with no dressing on his buttocks. At 2:26 PM, V8 said the wound care doctor is in the building but is on a different hallway and has not been to R71's room yet. At 2:35 PM, R71 said no staff have replaced the dressing on his left buttock. R71 said he is still in bed because they are waiting for the wound doctor to replace the dressing. R71 said he prefers to be in his wheelchair and not in the bed.R71's Treatment Administration Record dated July 1, 2025-July 31, 2025 shows R71's dressing to his left buttock was not documented as done on July 18, 2025 and July 21, 2025.R71's Wound Evaluation Management Summary dated July 21, 2025 at 3:35 PM shows that R71 has a stage four pressure injury to his left buttock that measured 4.2 X 3.5 X 3.5 cm. Dressing treatment plan was alginate calcium apply once daily and as needed; if saturated, soiled, or dislodged. Secondary dressing was gauze island with border apply once daily and as needed if saturate, soiled, or dislodged.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said dressings should be replaced to pressure injuries if they come off.The facility's Prevention of Pressure Injuries policy dated April 2020 shows, Review the resident's care plan and identify the risk factors as weel as the interventions designed to reduce or eliminate those considered modifiable. Use facility-approved protective dressings for at risk individuals.

Based on observation, interview, and record review the facility failed to provide dental services for a resident which applies to 1 of 1 resident (R49) reviewed for dental services in a sample of 18.The findings include:R49's Facility assessment dated [DATE] showed R49 is a thirty-nine-year-old male resident with moderate cognitive impairment. R49 was admitted to the facility on [DATE] with diagnoses which include hemiplegia/hemiparesis and intercranial injury.On 07/21/2025 at 2:00 PM, R49 was sitting in their wheelchair watching television. R49 had several broken teeth on their upper jaw, and dark colored tooth fragments/tooth roots along their lower jaw.R49's electronic medical record showed the last dental consent and appointment notes were dated 10/20/2020.On 7/23/25 at 1:50 PM, V11 Social Services stated we set up in house or out of house services for dental work. R49 does get seen out of the facility for dental services. V11 stated R49 does have broken teeth and gum issues. V11 stated they were not aware R49 has not seen a dentist since 2020.The facility's Dental Policy dated 2025 showed the facility is to assist residents with obtaining routine (covered by the State plan) and emergency dental care.On 7/23/25 at 2:00 PM, V1 Administrator stated they had no other documentation of R49 receiving dental care since 10/20/2020.

Based on observation, interview, and record review, the facility failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for one of 18 residents (R34) reviewed for infection control in the sample of 18.The findings include:R34's Order Summary Report dated July 22, 2025 shows she was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, insomnia, dysphagia, atopic dermatitis, and neuromuscular dysfunction of the bladder.R34's Care Plan initiated on April 20, 2020 shows R34 has bowel and bladder incontinence. R34's Care Plan initiated on April 15, 2025 shows R34 is on enhanced barrier precautions and ensure proper hand washing is completed as resident allows.On July 21, 2025 at 9:39 AM, V5 and V6 Certified Nursing Assistants (CNAs) provided incontinence care to R34. V6 CNA removed R34's incontinence brief. There was a large amount of urine in R34's incontinence brief. V6 then touched the mechanical lift sling to place underneath R34, touched the mechanical lift sling controls to elevate R34 and place her into the shower chair. V6 then showered R34. V6 did not change her gloves while doing the above.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said gloves should be changed prior to touching any clean items when doing incontinence care.The facility's Handwashing/Hand Hygiene policy revised October 2023 shows, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated after contact with blood, body fluids, or contaminated surfaces and before moving from work on a soiled body site to a clean body site.

Based on interview and record review the facility failed to ensure psychotropic medications were prescribed for a defined duration for 1 of 5 residents (R12) reviewed for unnecessary medications in the sample of 18.The findings include:R12's Order Summary Report dated 7/23/25 shows R12 has an order for a psychotropic medication (Diazepam) to be administered as needed. The start date for the order was 3/10/25. There is no end date. On 7/23/25 at 10:10 AM, V9, MDS Coordinator, said psychotropic medications ordered as needed can only be prescribed for a duration of 14 days, then a new order must be obtained. The facility's Psychotropic Medication Use Policy (undated) shows psychotropic medications are subject to prescribing, monitoring and review requirements; psychotropic medication management includes duration.

Based on interview and record review the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 screen after a resident that was diagnosed with schizoaffective disorder diagnoses which applies to 1 of 18 residents (R7) reviewed for PASARR assessments in a sample of 18.The findings include:R7's Facesheet printed on 7/23/25 showed R7 is a sixty-year-old male originally admitted to the facility on [DATE].R7's Physician Summary notes dated 3/31/2020 showed R7's schizoaffective disorder diagnosis onset is dated 4/17/2019.R7's electronic record showed no PASARR level 2 was completed after R7 received the new diagnosis of schizoaffective disorder.The facility's PASARR Policy dated 2024 showed a resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related conditions will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review.On 7/23/25 at 2:00 pm, V1 Administrator stated a resident with a new mental disorder diagnoses needs a level 2 PASARR assessment.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner for 1 of 18 residents (R73) in the sample of 18 reviewed for safety.The findings include:On 7/21/25 at 11:03 AM, R73 was sitting in a recliner in the TV room. V12, Certified Nursing Assistant (CNA), was pulling R73's left arm to get him out of the recliner. R73's left arm was pulled to the point where his left elbow was above the level of his head. On 7/23/25 at 9:30 AM, V2, Director of Nursing (DON), said a gait belt should be used to help pull a resident out of their chair. A resident's arm should not be pulled because it could cause an injury. R73's admission Record dated 7/23/25 shows he was admitted to the facility on [DATE]. R73's diagnoses include, but are not limited to, traumatic brain injury, quadriplegia, and repeated falls. R73's current care plan provided by the facility shows R73 has limited mobility, decreased strength, history of falls, and decreased sitting and standing balance and requires assistance with ambulation and transfers. The facility's Safe Resident Handling/Transfers Policy (undated) shows all residents require safe handling when transferred to prevent or minimize the risk for injury.

Based on observation, interview and record review the facility failed to ensure safety measures were implemented for three residents (R1, R2, R3) who fell during cares and/or transfers of three residents reviewed for falls. This failure resulted in R1 sustaining a fractured left humerus. The findings include: Facillity Policy/Safety and Supervision, last revision date 02/2025, documents: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Bed/Chair Safety; Safe Lifting and Movement of Residents. Facility Policy/Managing Falls and Fall Risk dated 2001 documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Fall Risk Factors Environmental factors that contribute to the risk of falls include: Wet floors Obstacles in footpath Footwear that is unsafe or absent. Resident Factors that may contribute to the risk of falls include: Lower extremity weakness Poor grip strength Medication side effects Functional impairments Medical factors that contribute to the risk of falls include: Neurological disorders and Balance and gait disorders. Facility Policy/Safe Lifting and Movement (undated) documents: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Facility Policy/Bath, Tub/Shower dated 2001 documents: Place a non-skid bath mat on the floor where the resident will step in/out of the tub or shower. Assist the resident out of the tub or shower. Hold firmly to the resident. Move slowly. 1. Current Physician Order Summary Report indicates R1 has diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side, History of Falls, Generalized Muscle Weakness, Heart Disease, COPD (Chronic Obstructive Pulmonary Disease), and Fatigue. Final Fall Investigation Report: dated 5/18/2025 indicates: On 5/17/2025 R1 was being assisted off of the toilet by V4, CNA (Certified Nurse Assistant) and R1 lost balance while stand-pivoting from toilet to wheelchair. Report indicates V4 was able to help minimize R1's fall and R1's left arm landed on the foot pedal of his wheelchair with left arm behind his back. After falling, R1 complained of left shoulder pain. R1 was sent to ED (Emergency Department) for evaluation and treatment. R1 returned to the facility at 4:30am on 5/18/2025 with diagnosis of left proximal end humerus fracture. Order for shoulder immobilizer and prescription for Norco (opioid) for pain. On 5/27/25 at 10:50 AM R1 was in his room, wearing an oxygen cannula sitting in a wheelchair with one left footrest attached to the wheelchair. At that time, R1 stated he was being transferred off the toilet and was holding onto the grab bar nearest the toilet during the transfer (on 5/17/25). R1 stated he was wearing shoes (pointing to the shoes he was wearing). R1 stated the CNA did not use a gait belt, But they do now. R1 was wearing an immobilizer on his left arm and stated he was still having pain and receiving pain medication. On 5/27/25 at 1:52 PM V4, CNA, stated she was assisting R1 off of the toilet (on 5/17/25). V4 stated R1 stood up, holding onto the grab bar with his right hand. V4 stated as R1 was attempting to step/slide/turn around to sit in the wheelchair, R1 lost his balance, fell to the side with his left (flaccid) arm behind his back and fell on to the left footrest of his wheelchair. V4 stated R1's pants were almost up and so she had nothing to grab onto to try to prevent R1 from falling. V4 stated sometimes they will assist/guide R1 during a transfer by grabbing onto the waistband of R1's pants. V4 stated she did not use a gait belt during the transfer with R1 because she was never trained to use one with him, but they now are using a gait belt for all transfers with R1. On 5/27/25 at 10:50 AM V3, Restorative Nurse, stated the CNAs were not required to use a gait belt with R1, however she was aware they were sometimes holding onto R1's pants during transfers. V3 stated that due to R1's medical diagnoses some days he is stronger than other days. V3 stated a gait belt is now required during all transfers. 2. Current Physician Order Summary Report indicates R2 has diagnoses that include Muscular Dystrophy, Lack of Coordination, Dependence on Wheelchair. Progress Note dated 4/21/25 at 10:03 PM indicates V8, CNA, was pushing R2 in a shower chair out of the shower when R2 slid out of the shower chair onto the floor. Note indicates V8 stated, (I) thought (I) put the seatbelt on but don't think it clicked. Note indicates R2 did not receive any injuries from the fall. Fall Details Note dated 4/21/25 at 10:43 PM indicates R2's fall was witnessed, occurred in the bathroom and the reason for the fall was (R2) did not have seatbelt secure and (R2) slid out of the chair. Current Care Plan indicates R2 is high risk for falls related to deconditioning, gait/balance problems, lack of awareness of safety needs. Care Plan indicates R2 has poor trunk control with poor sitting balance. On 5/27/25 at 11:10 AM V3, Restorative Nurse, stated after R2 fell from the shower chair, maintenance checked all shower chairs and safety belts on the chairs and all were working and locking properly. At that time, V3 demonstrated the lock mechanism on the shower chair R2 slid out from (on 4/21/25). The lock portion of the shower chair safety belt produces a loud clicking sound when lock is fully engaged. The lock could not be pulled apart or loosened when locked properly. 3. Current Physician Order Summary Report indicates R3 has diagnoses that include Diffuse Traumatic Brain Injury Attention Deficit Hyperactivity Disorder, Abnormalities of Gait and Mobility, Unspecified Dementia with Behavioral Disturbance, Cervical Spinal Stenosis. Post Fall Evaluation Note dated 3/21/25 at 1:18 PM indicates R3 fell on [DATE] at 11:45 AM. Note indicates R3 was in the shower area and staff were attempting to pull up R3's pants when R3 lost balance and fell . Note indicates reason for fall was unsteady gait and loss of balance. Note indicates R3 sustained a mid-back superficial abrasion. Current Care Plan indicates R3 had a change of plane with minor injury after falling onto his buttocks in the shower area due to floor being wet. On 5/27/25 at 2:00 PM V9, CNA, stated she was the CNA assisting R3 in the shower on 3/21/25. V9 stated R3 was done with his shower and stood up as she was trying to dry his bottom when R3 slipped and fell down. V9 stated there was no anti-skid mat or strips on the shower floor at that time. V9 stated sometimes she put a towel down for a resident to stand on but she did not put one down before R3 stood up. On 5/27/25 at 1:05 PM V3, Restorative Nurse, stated the floor in the shower was wet when R3 fell . V3 stated R3 was not wearing socks or shoes when he fell .

Based on interview and record review the facility failed to supervise a resident with exit-seeking behaviors to prevent her from eloping from the building unsupervised. This failure resulted in R1 eloping from the facility and being able to reach a heavily traveled highway. This applies to one of three residents (R1) reviewed for the safety in the sample of 8. The Immediate Jeopardy began on 4/24/24 when R1 was able to elope from the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/30/24 at 12:50 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 5/1/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility face sheet for R1 shows diagnoses to include hypoxic ischemic encephalopathy (type of brain damage caused by a lack of oxygen to the brain), major depression disorder with psychotic features, anxiety, dementia and cardiomyopathy. The brief interview for mental status (BIMS) dated 2/19/24 shows R1 be cognitively intact. R1's facility assessment shows her to be able to walk independently. The elopement risk assessment dated [DATE] shows R1 to be at high risk for elopement. The facility incident report dated 4/24/24 shows R1 was seen by maintenance staff in the back parking lot, wandering. R1 became physically aggressive with the staff by picking up a block of wood and threatening to hit staff. R1 had cut off her code alert bracelet from her ankle. On 4/26/24 at 8:20 AM, V1 Administrator said R1 left the building on 4/24/24 out the front door, she had cut off her wander guard alert bracelet. R1 was seen on video going over the fence and walking away. On 4/26/24 at 10:00 AM, V3 Certified Nursing Assistant (CNA) said she was outside at the back of the building around 12:30 PM - 1:00 PM on her break, when she saw R1 walking alone in the back parking lot. V3 said she called to the staff inside the building with her cell phone, alerting them that R1 was outside alone. V3 attempted to redirect R1 from leaving the property but R1 would not listen to her. On 4/26/24 at 11:10 AM, V4 Maintenance said he was outside having his break and saw R1 walking alone outside. V4 said he approached R1, trying to get her to stop walking. V4 said R1 was in the back parking lot. On 4/26/24 at 11:43 AM, V2 Director of Nursing said by the time she got to the back parking lot, there were several staff trying to redirect R1. V2 said she was told R1 had picked up a stick from the ground and attempted to hit the staff. V2 said she phoned 911 for help with the situation. V2 said R1 had removed her code alert bracelet and she was not sure how this happened. On 4/26/24 at 10:45 AM, V5 Occupational Therapy Assistant said she was at the entrance to the facility when she heard R1 was outside. V5 said she ran to the back of the building and saw R1 with two CNA's trying to redirect R1 back into the building. V5 said R1 was walking to the road and picked up a piece of wood she found and attempted to hit the staff. R1 was yelling and swearing at the staff. V5 said a car drove by on the road and V5 flagged them down asking them to stop and put on their flashers to alert other people passing by to slow down. When R1 saw the flashers, she turned and walked away from the road back towards the facility. On 4/26/24 at 10:30 AM, V1 said the video of R1 going over the fence showed she had fallen on the other side. The video showed R1 used the building to help lift herself over the fence. V1 said it was about two minutes between the time stamp on the video and when the first CNA called the building to alert us R1 was outside alone. V1 said when she got outside, R1 was walking up the hill towards the road, yelling at the staff. R1 picked up a stick off the ground and attempted to hit the staff. V1 said a car drove by and put on their flashers and this made R1 turn around from the road and go back to the parking lot. V1 said 911 was called and arrived to help with the situation. V1 said R1 cut off her wander guard somehow. On 4/30/24 at 9:10 AM, V7 RN said she was working with R1 on the day she eloped out the front door on 4/24/24. That morning R1 met her at the back door, R1 was knocking on the kitchen door. R1 was hallucinating and saying she needed to leave to get to the hospital because her kids were sick. V7 said R1 has been hallucinating for a while now. R1thinks her family has been killed or are sick and she needs to help them. V7 said she walked with R1 back to her room, and R1 was sitting on the bed talking to the smoke detector she thought were talking to her. R1 said in a whisper, I gotta run out the door, and then put her shoes on. V7 said she told R1 she was fine and she needed to rest. V7 said R1 laid down on the bed and went to sleep. V7 said R1 has not been sleeping other than a few hours at a time for the last 4-5 days prior to being sent out. A facility alerts listing report dated 4/21/24 shows R1 was trying to climb the fence surrounding the facility. (Three days prior to when R1 eloped at the same fence) On 4/30/24 at 9:38 AM, V1 said on 4/21/24, R1 did make it to the fence and was shaking the fence. She was hallucinating and thought she had to get to the hospital to see her kids. On 4/30/24 at 10:20 AM, V8 CNA said she was in another resident's room on 4/21/24 when she saw R1 outside the facility at the front gate. R1 had one leg up on the fence. V8 said she ran outside right away and it was then that she saw the restorative Aide was with R1 trying to talk her down and to come back in the building. On 4/30/24 at 10:30 AM, V9 Restorative CNA said she saw R1 walk out the front doors on 4/21/24. The alarm sounded that someone with a wander guard had gone outside the doors. R1 walked down to the fence and had both feet on the bottom rung of the fence. V9 said she was able to redirect R1 from the fence and bring her back inside. On 5/2/24 at 2:10 PM, V23 Physician Assistant said, When R1 is hallucinating and having exit seeking behaviors she would expect to staff to have very close observation on the resident to keep her safe from harming herself or eloping. Nursing progress notes dated 4/11/24 to 4/24/24 shows: On 4/11/24 at 5:36 AM, R1 saying her mother and son are dead and her daughter is dying, and she needs to get out of the facility. R1 walked to the front doors. On 4/17/24 at 8:20 AM, R1 saying her mother was dead and she had to get out of the building. She walked to the front lobby and sat down. R1 was saying her mother was dead, she had been raped here, her son had been raped, didn't understand why she could not leave the building. On 4/17/24 2:34 PM was eating lunch in her room and the intercom told her she was getting out of here soon. Hearing voices and wants to leave. On 4/20/24 8:15 PM upset and wandering in the halls saying she needed to get out of here, wants to leave. On 4/21/24 at 2:30 PM R1 trying to climb the fence/gate, trying to open locks. Said her children were dead and today is the funeral. On 4/22/24 5:48 AM, attempted to open the dining room doors saying she had to get out of here. The kitchen staff reported that she attempted to go out the doors again. 4/23/24at 3:24 PM staff unable to redirect as she was saying she needed to get out of the building. On 4/23/24 11:51 PM, yelling and walking fast, saying she needed to get out of here. Walked to the lobby, threw a wet floor sign, punching the glass, picked up a lamp and slammed onto the table. Police were notified. On 4/24/24 6:05 AM, R1 met nurse at the back door asking staff to open the kitchen door her children were dead, and she needs to get to the hospital. On 4/24/24 9:33 AM, R1 went to the dining room as the intercom told her it was time for breakfast, kitchen staff sent her back to her room and given a snack. Sitting on bed, looking at the smoke detector and overheard whispering she had to run out the back door. R1 then put on her shoes and asked the nurse to leave her alone in her room and to turn off the lights. On 4/24/24 at 12:50PM, R1 found by staff in the back parking lot. R1 became physically aggressive with the staff, attempting to hit staff with a piece of wood. Resident said she was leaving. 911 was called. R1's care plan dated 4/15/2020 shows the resident is at risk for elopement risk/wanderer due to tendency to wander into other resident rooms and take items as her own. She has poor cognition and unaware of situations at hand and is risk for elopement due to cognitive deficits. Resident exhibits exit seeking behaviors, thinking she has somewhere to go or that someone is coming to get her. R1's care plan dated 3/25/24 shows R1 is/has potential to be verbally aggressive with yelling out and cursing due to auditory hallucinations . The facility policy with a revision date of 3/17 for safety and supervision shows 7. resident supervision is a core component of the systems approach to safety. 8. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the enviroment or if there is a change in the residents condition. The Immediate Jeopardy that began on 4/24/24 was removed and the deficient practice corrected on 5/1/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance. Immediate action to ensure residents' elopement interventions are effective and appropriate to prevent elopement incidents: 1. Social Services will review all care plans of residents at high risk for elopement by 5/7/24. 2. IDT will ensure elopement interventions are implemented following findings of high-risk residents and report to MDS Coordinator starting 4/30/2024. MDS Coordinator will complete audits weekly starting 4/30/2024 x 2 weeks then monthly x 2 months then quarterly x one year (concluding November 2025). Audits will be reported to QAPI monthly starting 5/1/2024 and then quarterly until 11/25/2025. 3. Any residents that are actively exit seeking, will be placed on line of sight supervision while in courtyard, Code alert checks will be increased to q 4 hours and Code alert will be double banded starting 5/1/2024. 4. BeSpoke Hotline will be utilized with new onset of hallucinations. 5. Medical Director will be contacted for support and/or any orders to assist in new onset of hallucinations. 6. Upon R1 return she will be placed on line of sight supervision while in courtyard, Code alert check q 4 hours, and Code alert bracelet will be double banded. Procedures to identify residents at risk for elopement: 7. Upon admission, admitting nurse will complete Elopement Risk Assessments. Social Services or designee will now complete monthly reassessments for high risk residents starting 5/1/2024 and continue Elopement Risk Assessments on all other residents quarterly. Procedures to increase visual monitoring of courtyard: 8. Maintenance staff to place cameras in front courtyard by 5/1/2024 . A monitor will be placed in the front office to have visuals of courtyard by 5/3/2024. 9. Maintenance will immediately complete daily checks x 2 weeks starting 5/1/2024 then weekly starting 5/16/2024 on all door alarms/maglocks, and Code Alert wandering systems. 10. Front outside door to courtyard will be locked at night by nursing staff or designee and unlocked in the morning by maintenance staff or designee starting 4/30/2024. Procedures in place to prevent elopement for residents with prior elopements: 11. Administrator will audit Social Services immediate care plan review to ensure that Elopement Reassessments are complete on high risk elopement residents by 5/7/2024. 12. Administrator will audit Social Service or designee monthly Elopement Risk Assessments on high risk residents once a month x 6 months starting 5/2024 and ending 10/2024 and results will be reported to QAPI x6 months ending 10/2024. 13. When resident is determined to be at high risk for elopement and has attempted a prior elopement at this facility, resident will be placed on line of sight supervision while in courtyard by nursing administration and/or Administrator. 14. Safety Coordinator or designee will place a Code Alert bracelet on residents that are not high risk with exit seeking behaviors followed by 15 minute checks for a minimum of 72 hours until IDT evaluates. 15. Following an elopement, all exit door codes will be changed by Safety Director or designee. 16. All new hires complete Elopement Training upon hire by Safety Director and all current staff currently complete Elopement Training annually via Company) Training. However due to incident, all staff will now be required to complete immediate and quarterly training on Preventing and Responding to Elopement x one year via (Company) Training. Immediate training will be completed by 5/7/24. 17. Safety Coordinator or designee will make all staff aware of high-risk residents for elopement on PCC communications on 5/1/2024. Safety Coordinator or designee will now place a note at time clock for staff notifying them of any changes to Residents at High Risk for Elopement and to check PCC communications. 18. IT will do weekly maintenance on cameras to ensure they are working properly starting 5/1/2024.

Based on interview and record review, the facility failed to administer a resident's pain medication as ordered, failed to manage a resident's pain at a comfortable level, and failed to obtain emergency doses of a resident's pain medication when it was unavailable. These failures resulted in R12's Norco supply becoming depleted, R12 missing 16 doses of a prescribed narcotic pain medication, and R12 experiencing increased pain levels. The findings include: R12's electronic face sheet printed on 11/2/23 showed R12 has diagnoses including but not limited to intracranial injury with loss of consciousness, hemiplegia, encephalopathy, epilepsy, contractures, and behavioral syndromes. R12's facility assessment dated [DATE] showed R12 has severe cognitive impairment and experiences pain almost constantly. R12's care plan dated 7/8/20 showed, The resident is on pain medication therapy due to lower back pain. Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. R12's most recent pain assessment dated [DATE] showed R12 experiences pain on a daily basis and has limited day-to-day activities because of pain. R12's physician's orders dated 4/15/20 showed R12 receives hydrocodone-acetaminophen 7.5-325mg three times a day for pain. R12's Medication Administration Records for September 2023-October 2023 showed R12's Hydrocodone-Acetaminophen 7.5-325mg was unavailable for 2 doses on 9/29/23, unavailable for 3 doses 9/30/23 and 10/1/23, unavailable for 2 doses on 10/2/23, unavailable for 3 doses from 10/28/23-10/30/23. (R12 missed a total of 16 doses over a 2 month period and was given Ibuprofen 600mg as a substitute pain medication). R12's pain assessments for September 2023-October 2023 showed R12 experienced non-verbal indicators of pain levels ranging from 2-10 during the days his pain medication was unavailable. R12's nursing progress notes dated 9/29/23 showed, Hydrocodone 7.5/325mg not available, nurse practitioner notified, stock coming with delivery tonight. (R12's Hydrocodone was not delivered to the facility until 10/2/23). The facility's emergency narcotic box list from the facility pharmacy showed, Hydrocodone-Acetaminophen 7.5/325mg .Quantity: 12. R12's nursing progress notes from September 2023-October 2023 showed no evidence that R12's Hydrocodone-Acetaminophen 7.5/325mg was removed from the facility's emergency narcotic supply. On 11/2/23 at 12:24 PM, V3 (Director of Nursing) stated, If a resident runs out of a medication, the nurse should immediately notify the physician and then call the pharmacy to reorder the medication for a STAT delivery. There is no reason why any resident should run out of their medications as it is the nurse's responsibility to reorder in the appropriate timeframe to get the medication delivered before any doses are missed. (R12) has chronic pain in his back and hip and should be kept on his scheduled pain medication so that he has the best quality of life and can keep doing the daily activities he enjoys without being in pain. As soon as the nurse realized that (R12) was out of his medication she should have notified the pharmacy, physician, myself or (V4-Assistant Director of Nursing) and then followed our process for removing his pain medication out of the emergency narcotic box. The reason we have the emergency box is for new orders but also if a resident happens to run out of their pain medications. We would have had plenty of supply for the nurse's to administer doses of Norco to (R12) so that he didn't miss any doses. This was poor judgement on their part just to let him go without it. On 11/2/23 at 1:17 PM, V11 (Pharmacist) stated, If a medication is needed out of the emergency box, the nurse has to call the pharmacy, then we verify there is an order for the medication then give them the code and send them a new sealed kit. There would be a proof of use slip that the nurse needs to fill out and that has to accompany the box so we can keep that for our records. We have not received any used kits or proof of use slips for (R12). Obviously if a pain medication is not given to a resident they are going to experience increased pain. I would not consider Ibuprofen an acceptable substitute for Norco. If the facility has a resident that is receiving Norco and they run out they can use their emergency supply. The facility's policy titled, Medication Administration dated 1/2020 showed, 21. The medication being unavailable is not a valid reason for not giving the medication, and should never be documented as the reason. a. if the medications is not in the emergency supplies, it must be called in to the pharmacy so it can be administered as soon as possible. b. The physician must be notified if the pharmacy cannot bring the dose by an acceptable time. The facility's policy titled, Management of Pain dated 10/2008 showed, Our mission is to facilitate resident independence, promote resident comfort, and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our resident the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement .For the purposes of this policy, pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in R2 feeling unsafe and in fear of R3. The findings include: R2's face sheet printed on 8/1/23 showed he was admitted to the facility on [DATE] with diagnosis including but not limited to injury at the C4 level of cervical spinal cord and paraplegia. The facility assessment dated [DATE] showed no cognitive impairment. The same assessment showed R2 needs extensive staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. On 8/1/23 at 9:15 AM, R2 was lying in bed with a lap top device and cellular phone on the table over him. R2 was fully alert and oriented. R2 said there are a lot of wandering residents, but one that is especially bad (R3). He is in the room right next door to me and comes in here yelling and cussing. He has brain issues and once I even saw him eating his own feces. That is how bad he is. He hits other residents and even the staff. I saw him grab a nurse's necklace and yank it so hard she was bruised. I hear him yelling F#*k you all the time. He yells to be put to bed, then 2 minutes later, is screaming and crawling around on the floor. The aides have to watch him continually or he wanders into my room. I can push my call light with my head, but it takes them time to get here, especially later in the day. I am so afraid of him. Just last night after about 3 AM, I heard something in my room. I could see him crawling on the floor near my bathroom door. He was growling and coming towards my bed. I immediately called my mom on my cell phone (using voice activation). I was terrified! I can't use my arms or legs well. If he grabbed me, there is nothing I can do to protect myself. I keep praying this man stays away from me. He comes in here 3-4 times weekly. I am completely afraid for my safety and the safety of others. I understand this guy has brain problems, but I shouldn't have to live like this. On 8/1/23 at 9:41 AM, R3 (does reside in room next door to R2) was lying in bed on a low mattress and fall mats were on the floor. R3 did not respond to his name or react to this surveyor's presence. At 9:45 AM, R3 was heard moaning loudly and observed crawling on the floor of his room and about to exit into the hallway. V4 and V5 (Certified Nurse Aides) entered the room and assisted R3 into a wheelchair. V4 said he gets out of bed and crawls on the floor a lot. He can walk alone too, although he is not supposed to. At 9:55 AM, V6 (R3's case worker) said R3 has cognitive loss and lots of behaviors. He has a history of acting out aggressively at times and will hit others. Right now, I am unaware of any changes in the behaviors. On 8/1/23 at 10:00 AM, this surveyor entered R3's room and attempted to hold a brief conversation. R3 mumbled in reply and then suddenly began yelling and screaming. R3 yelled F*#k you b*&th* repeatedly. This surveyor exited the room while R3 easily wheeled himself out of the room and down the hall, while continuing to scream profanities. R3 did not stop until a staff member approached and took him back into his room. On 8/1/23 at 11:20 AM, V10 (R2's family member) stated R2 called her this morning around 3:30 AM. V10 said he was absolutely terrified. R2 was whispering into the phone saying a man was crawling on the floor in his room. He was whispering because he was afraid to arouse the man and cause him to be attacked. V10 said she could see fear and terror (via face time) on R2's face. He said the man was coming right toward his bed. V10 said she heard a staff member taking the man out of the room. V10 said R2 explained it was the man that lives next door (R3). V10 said R2 has told her he has seen R3 being physical to other residents and staff members. V10 said R3 repeatedly wanders into other rooms. V10 said he wandered into the room the last time she was visiting. V10 said, How is it safe for an aggressive resident to wander into rooms in the middle of the night?! V10 stated, (R2) was afraid last night when he called me. R3's face sheet printed on 8/1/23 showed diagnoses including but not limited to concussion with loss of consciousness, postencephalitic Parkinsonism, traumatic brain injury, dementia with agitation, bipolar disorder, insomnia, restlessness and agitation. R3's facility assessment dated [DATE] showed R3 was unable to complete the cognitive assessment. The same assessment showed R3 has physical behaviors toward others, verbal behaviors toward others, and other behavior symptoms directed toward self. The assessment showed R3's symptoms put others at significant risk for physical injury and significantly intrude on the privacy of others. The last three months of facility incident reports were reviewed and showed a resident-to-resident incident on 6/8/23. R3 was arguing with another resident and propelled toward him. R3 struck the resident in the left shoulder. An incident report dated 7/5/23 showed R3 propelled by another resident and kicked her in the left shin. (Both reports showed no resident injury and that the Illinois Department of Public Health was notified.) On 8/1/23 at 11:37 AM, V7 (Social Service) stated R3 is physically and verbally aggressive to staff and other residents. He growls, yells out, and swears. He is being treated by the psychiatric staff and I think there have been changes to his medications. We try to do a lot of one-on-one activities with him and would do counseling too but he can't comprehend that. On 8/1/23 at 11:55 AM, V9 (Registered Nurse) said R3 is aggressive at times. We all have to pitch in to keep an eye on him. He has had a lot of medication changes in the past. He gets clonazepam (anti-anxiety) twice a day. It is typically effective unless he was up a lot the night before. He does get up a lot during the night. He is hit or miss on how he will act each day. One minute he is fine, and the next minute he is acting out. On 8/1/23 at 12:05 PM, V8 (Licensed Practical Nurse) stated R3 does have lots of behaviors and gets agitated easily. He does see psychiatric services and they are here on a weekly basis. I know there have been lots of medication changes in the last three months or so. We give him snacks and do one on one supervision until he is calmed down. He does crawl on the floor and wander into other resident rooms. We redirect him and it varies on how well that works. On 8/1/23 at 12:15 PM, V4 and V5 (Certified Nurse Aides) said R3 gets overstimulated easily and that causes him to escalate quickly. He yells and swears. He does get out of bed by himself and crawls around on the floor. He is able to self-propel his wheelchair around. He goes in and out of other resident rooms. We try to keep a banner across other resident doors, so he doesn't go in there. (R2's door banner was wrapped up and tucked under the wall handrail during the entire survey.) We redirect him with TV, movies, or discuss something to get him off focus. It is generally effective. If he still won't calm down, we tell the nurse. On 8/1/23 at 1:24 PM, R2 was interviewed again and stated every once in a while they put the banner over my doorway, but it depends on who is working. (R3) is terrifying. He scares the crap out of me when he gets close to me. I hardly leave my room because I know when I come back he will be in here. I try to redirect him the best I can. I call my mom on face time when he is agitated because I don't know if staff will get to me in time. I am only [AGE] years old and I hate admitting that I am scared. On 8/1/23 at 12:52 PM, V2 (Director of Nurses) stated R3 is seen by psychiatric services every two weeks. There have been several medication adjustments and some his mother would not allow. We have been trying to get R3 into a facility near Chicago, but they do not have the space yet. On 8/1/23 at 1:20 PM, V1 (Administrator/Abuse Coordinator) stated he would consider hitting or kicking others as abuse. V1 said he would agree with abuse as defined in the facility's policy. V1 said R3 does have a history of hitting or kicking others and does wander in and out of R2's room. V1 said he believed R2 and R3's were friends and did not realize it was an issue until now. V1 stated there is a video camera in the hall right outside R2 and R3's room. He would review it and get back to the surveyor. At 2:00 PM, V1 said the camera did show R3 crawling on the hallway floor around 3 or 4 AM but he could not see exactly if R3 entered R2's room. V1 said staff are afraid of R3 too and that is why we have been trying different avenues for him. The facility Abuse Program policy last revision dated 3/17 states: PURPOSE: To ensure on-going safety of resident. DEFINITIONS: 10. RESIDENT TO RESIDENT ABUSE is the willful inflection or injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident towards another.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in R2 feeling unsafe and in fear of R3. The findings include: R2's face sheet printed on 8/1/23 showed he was admitted to the facility on [DATE] with diagnosis including but not limited to injury at the C4 level of cervical spinal cord and paraplegia. The facility assessment dated [DATE] showed no cognitive impairment. The same assessment showed R2 needs extensive staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. On 8/1/23 at 9:15 AM, R2 was lying in bed with a lap top device and cellular phone on the table over him. R2 was fully alert and oriented. R2 said there are a lot of wandering residents, but one that is especially bad (R3). He is in the room right next door to me and comes in here yelling and cussing. He has brain issues and once I even saw him eating his own feces. That is how bad he is. He hits other residents and even the staff. I saw him grab a nurse's necklace and [NAME] it so hard she was bruised. I hear him yelling F#*k you all the time. He yells to be put to bed, then 2 minutes later, is screaming and crawling around on the floor. The aides have to watch him continually or he wanders into my room. I can push my call light with my head, but it takes them time to get here, especially later in the day. I am so afraid of him. Just last night after about 3 AM, I heard something in my room. I could see him crawling on the floor near my bathroom door. He was growling and coming towards my bed. I immediately called my mom on my cell phone (using voice activation). I was terrified! I can't use my arms or legs well. If he grabbed me, there is nothing I can do to protect myself. I keep praying this man stays away from me. He comes in here 3-4 times weekly. I am completely afraid for my safety and the safety of others. I understand this guy has brain problems, but I shouldn't have to live like this. On 8/1/23 at 9:41 AM, R3 (does reside in room next door to R2) was lying in bed on a low mattress and fall mats were on the floor. R3 did not respond to his name or react to this surveyor's presence. At 9:45 AM, R3 was heard moaning loudly and observed crawling on the floor of his room and about to exit into the hallway. V4 and V5 (Certified Nurse Aides) entered the room and assisted R3 into a wheelchair. V4 said he gets out of bed and crawls on the floor a lot. He can walk alone too, although he is not supposed to. At 9:55 AM, V6 (R3's case worker) said R3 has cognitive loss and lots of behaviors. He has a history of acting out aggressively at times and will hit others. Right now, I am unaware of any changes in the behaviors. On 8/1/23 at 10:00 AM, this surveyor entered R3's room and attempted to hold a brief conversation. R3 mumbled in reply and then suddenly began yelling and screaming. R3 yelled F*#k you b*&th* repeatedly. This surveyor exited the room while R3 easily wheeled himself out of the room and down the hall, while continuing to scream profanities. R3 did not stop until a staff member approached and took him back into his room. On 8/1/23 at 11:20 AM, V10 (R2's family member) stated R2 called her this morning around 3:30 AM. V10 said he was absolutely terrified. R2 was whispering into the phone saying a man was crawling on the floor in his room. He was whispering because he was afraid to arouse the man and cause him to be attacked. V10 said she could see fear and terror (via face time) on R2's face. He said the man was coming right toward his bed. V10 said she heard a staff member taking the man out of the room. V10 said R2 explained it was the man that lives next door (R3). V10 said R2 has told her he has seen R3 being physical to other residents and staff members. V10 said R3 repeatedly wanders into other rooms. V10 said he wandered into the room the last time she was visiting. V10 said, How is it safe for an aggressive resident to wander into rooms in the middle of the night?! V10 stated, (R2) was afraid last night when he called me. R3's face sheet printed on 8/1/23 showed diagnoses including but not limited to concussion with loss of consciousness, postencephalitic Parkinsonism, traumatic brain injury, dementia with agitation, bipolar disorder, insomnia, restlessness and agitation. R3's facility assessment dated [DATE] showed R3 was unable to complete the cognitive assessment. The same assessment showed R3 has physical behaviors toward others, verbal behaviors toward others, and other behavior symptoms directed toward self. The assessment showed R3's symptoms put others at significant risk for physical injury and significantly intrude on the privacy of others. The last three months of facility incident reports were reviewed and showed a resident-to-resident incident on 6/8/23. R3 was arguing with another resident and propelled toward him. R3 struck the resident in the left shoulder. An incident report dated 7/5/23 showed R3 propelled by another resident and kicked her in the left shin. (Both reports showed no resident injury and that the Illinois Department of Public Health was notified.) On 8/1/23 at 11:37 AM, V7 (Social Service) stated R3 is physically and verbally aggressive to staff and other residents. He growls, yells out, and swears. He is being treated by the psychiatric staff and I think there have been changes to his medications. We try to do a lot of one-on-one activities with him and would do counseling too but he can't comprehend that. On 8/1/23 at 11:55 AM, V9 (Registered Nurse) said R3 is aggressive at times. We all have to pitch in to keep an eye on him. He has had a lot of medication changes in the past. He gets clonazepam (anti-anxiety) twice a day. It is typically effective unless he was up a lot the night before. He does get up a lot during the night. He is hit or miss on how he will act each day. One minute he is fine, and the next minute he is acting out. On 8/1/23 at 12:05 PM, V8 (Licensed Practical Nurse) stated R3 does have lots of behaviors and gets agitated easily. He does see psychiatric services and they are here on a weekly basis. I know there have been lots of medication changes in the last three months or so. We give him snacks and do one on one supervision until he is calmed down. He does crawl on the floor and wander into other resident rooms. We redirect him and it varies on how well that works. On 8/1/23 at 12:15 PM, V4 and V5 (Certified Nurse Aides) said R3 gets overstimulated easily and that causes him to escalate quickly. He yells and swears. He does get out of bed by himself and crawls around on the floor. He is able to self-propel his wheelchair around. He goes in and out of other resident rooms. We try to keep a banner across other resident doors, so he doesn't go in there. (R2's door banner was wrapped up and tucked under the wall handrail during the entire survey.) We redirect him with TV, movies, or discuss something to get him off focus. It is generally effective. If he still won't calm down, we tell the nurse. On 8/1/23 at 1:24 PM, R2 was interviewed again and stated every once in a while they put the banner over my doorway, but it depends on who is working. (R3) is terrifying. He scares the crap out of me when he gets close to me. I hardly leave my room because I know when I come back he will be in here. I try to redirect him the best I can. I call my mom on face time when he is agitated because I don't know if staff will get to me in time. I am only [AGE] years old and I hate admitting that I am scared. On 8/1/23 at 12:52 PM, V2 (Director of Nurses) stated R3 is seen by psychiatric services every two weeks. There have been several medication adjustments and some his mother would not allow. We have been trying to get R3 into a facility near Chicago, but they do not have the space yet. On 8/1/23 at 1:20 PM, V1 (Administrator/Abuse Coordinator) stated he would consider hitting or kicking others as abuse. V1 said he would agree with abuse as defined in the facility's policy. V1 said R3 does have a history of hitting or kicking others and does wander in and out of R2's room. V1 said he believed R2 and R3's were friends and did not realize it was an issue until now. V1 stated there is a video camera in the hall right outside R2 and R3's room. He would review it and get back to the surveyor. At 2:00 PM, V1 said the camera did show R3 crawling on the hallway floor around 3 or 4 AM but he could not see exactly if R3 entered R2's room. V1 said staff are afraid of R3 too and that is why we have been trying different avenues for him. The facility Abuse Program policy last revision dated 3/17 states: PURPOSE: To ensure on-going safety of resident. DEFINITIONS: 10. RESIDENT TO RESIDENT ABUSE is the willful inflection or injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident towards another.

Based on interview and record review, the facility failed to recognize and treat a resident with an infected Stage 4 pressure injury for 1 of 3 residents (R1) in the sample of 7. This failure resulted in R1 being hospitalized for a systemic infection due to an infected Stage 4 pressure injury requiring surgical debridement. The findings include: R1's face sheet showed a [AGE] year-old female with diagnosis of nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis affecting left non-dominant side, Type 2 diabetes, anxiety disorder, epilepsy, dysphagia, left shoulder contracture, major depressive disorder, and hypertension. On 5/23/23 at 9:14 AM, V4 wound nurse, said R1's wound declined from 5/12-5/15/23. On 5/15/23 there was thick green purulent drainage, the surrounding tissue had changed. There was no indication of an infection. Signs of infection would include a fever, increased pain, increased sleepiness. If a wound is infected, it won't heal. It could progress to sepsis and death. V4 said R1 didn't have any recent wound infections. At 9:50 AM, V11 Licensed Practical Nurse (LPN) said on 5/17/23, V12 Certified Nursing Assistant (CNA) reported to her and V15 night nurse that R1 was not acting right. V11 said she V15 and V12 went to R1's room and found her up in her chair lethargic, didn't know who I was, and was unable to speak. V11 said she and V15 did a full body assessment and R1 was transferred into the bed without incident. R1 was cold and V11 could not obtain a blood pressure or oxygen saturation. V11 said she had to use a stethoscope over her chest to obtain a pulse. V11 said R1 was clammy, pale and was having 15-30 seconds of apnea. 911 was called and R1 was sent to the hospital. At 9:58 AM, V12 said she is a restorative aid and on 5/17/23 was going to bring R1 to the restorative dining room for breakfast when she found her slumped over to her right side while in the chair in her room. V12 said R1 was out of it, having periods of apnea, and not recognize staff so she reported this to V11. At 11:42 AM, V1 Administrator said R1 did not see the facility's wound care provider in April 2023 due to her payor source. On 5/24/23 at 1:24 PM, V9 (Surgeon) said on 5/19/23 she assessed R1 in the hospital. R1 had a Stage 4 pressure ulcer to the right trochanter which measured about 4 centimeters (cm) X 4 cm. V9 said the wound had purulent drainage, was foul smelling, necrotic, and the subcutaneous tissue and muscle were involved. It was infected. It was pouring out pus. The foul odor and drainage were indicative of an infection. The worst tunnel was 2 cm to the bone. Not seeing a wound care provider for 2 months could absolutely cause a decline in the wound and infection. V9 said she sees patients with wounds every 1-2 weeks. It's unacceptable that R1 was not sent to a wound clinic if the provider could no longer see her at the facility. V9 said she took R1 to surgery on 5/19/23 to clean the wound out. On 5/25/23 at 8:59 AM, V4 wound nurse said R1 did not see the facility wound care provider after the 3/7/23 appointment until 5/9/23. R1's 5/23/23 and 5/24/23 hospital infectious disease notes showed R1 had sepsis due to her (infected) decubitus ulcer. This note showed an infected decubitus ulcer in the right buttock. R1's 3/7/23 wound provider note showed a Stage 3 right buttock pressure wound measured 2 cm X 2 cm X 0.6 cm. There was light serous exudate, 75% thick adherent devitalized necrotic tissue and no change in wound progress. A follow up evaluation by the wound care specialist in 8-14 days with further intervention as indicated was recommended. There were no further wound provider notes from the 3/7/23 visit until 5/9/23. R1's 5/9/23 wound provider note showed the Stage 3 right buttock pressure wound measured 1.5 cm X 2.8 cm X 0.5 cm. There was moderate serous drainage, 80% thick adherent devitalized necrotic tissue and the wound had deteriorated. R1's 5/16/23 wound provider note showed a now Stage 4 right buttock pressure wound measured 1.5 cm X 2.6 cm X 1 cm. There was an odor and undermining at 7 o'clock. There was heavy serous exudate, 100% thick adherent devitalized necrotic tissue and the wound had again deteriorated. R1's 5/15/23 note authored by the facility nurse practitioner showed R1 continues to complain of pain in her buttocks due to wound. R1's 5/17/23 note, authored by V11 LPN, showed R1 was unresponsive, unable to obtain a blood pressure, pulse was erratic, and could not obtain an oxygen saturation. This note showed R1 was transported to a local hospital at 6:55 AM. R1's 5/19/23 hospital consultation note authored by V9 (Surgeon) showed she was consulted to determine if the pressure ulcer required debridement. This note showed a 4 cm X 4 cm wound over the right trochanter that was foul smelling and purulent. This note showed necrotic tissue was present and there was concern the wound was the source of her infection as other sources (knee and urine) had been ruled out. R1's 5/19/23 operative report showed a large amount necrotic subcutaneous and muscle in the wound. There was a tunnel at the 12 o'clock position that went to the bone. A bone biopsy was obtained. The post debridement measurements were 2 cm width X 3 cm height X 1 cm depth. There was a tunnel at 12 o'clock, a 1 cm tunnel at 3 o'clock, and a 1 cm tunnel at 6 o'clock. R1's 4/13/23 assessment showed R1 was cognitively intact. R1's 4/14/23 facility assessment showed total dependence on two plus persons physical assistance to transfer, extensive assistance of two plus persons physical assistance for bed mobility, dressing, and toilet use, extensive assistance of one plus person physical assistance for personal hygiene and bathing, and limited assistance of one-person physical assistance for eating. R1's pressure care plan had not been updated since 3/21/23. The facility's 6/2014 Pressure Ulcer Prevention Program showed the facility will promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible). The Wound Care Coordinator confers with the facility wound consultation firm, when appropriate, and implement recommendations. The MDS (Minimum Data Set) Coordinator updates the resident care plan whenever a change occurs in the status of the wound or when the treatment plan is altered.

Based on interview and record review, the facility failed to supervise a resident with difficulty swallowing at mealtime and failed to ensure a cognitively impaired resident with knee pain and a history of self-transfers was supervised to prevent self-transfer for 2 of 3 residents (R1, R2) reviewed for safety and supervision in the sample of 7. This failure resulted in R1 choking and requiring resuscitation and R2 falling (right leg was fractured) and hitting his head. The findings include: 1. R1's face sheet showed a [AGE] year-old female with diagnosis of dysphagia, nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis affecting left non-dominant side, Type 2 diabetes, anxiety disorder, epilepsy, left shoulder contracture, major depressive disorder, and hypertension. On [DATE] at 8:48 AM, V27 Restorative Aide said at lunch on [DATE] she was the only staff person assisting residents in the restorative dining area. Usually there are two staff, but she could do it by herself. There were ,d+[DATE] residents present. V27 said there were two tables in the restorative dining area. She was seated at a table with four residents who required feeding. R1 was seated at the other table with her back towards V27. R7 was also at R1's table with his spouse (V21) and another resident. V27 said she was alerted by V21, R7's spouse, that R1 couldn't breathe and was choking. V27 said R1 had not been eating well, needed to be supervised, and needed assistance to eat. V27 said she's not sure what R1 choked on. At 10:32 AM, V21, R7's spouse said they're short staffed sometimes and on [DATE], there was only one staff person in the restorative dining area during lunch. The girl that was helping was at the other table. R1, me and R7 were at the other table. I'm here almost every day for lunch. R1's back was toward the girl (staff) and R1 was facing me and R7. R1 has trouble eating. V21 said she looked at R1 and she (R1) couldn't talk. Her face was white, lips were blue, eyes were open wide, startled and she mouthed to me that she couldn't breathe. I yelled at the girl in the dining area, V27, that R1 couldn't breathe. R1's [DATE] nurses note showed R1 was found choking in the restorative dining area. There was no evidence of air exchange. R1's lips and mucous membranes were cyanotic. The Heimlich maneuver was done three times without success. R1 became pulseless and not breathing. Cardiopulmonary resuscitation (CPR) was started. R1 became conscious. R1was sent to the emergency room for further assessment due to choking with loss of consciousness, respirations and pulse. R1's [DATE] facility assessment showed (R1) required supervision and one-person physical assistance for eating. R1's [DATE] care plan intervention showed to monitor for signs and symptoms of choking and to serve meals in the restorative dining room for supervision and assistance. R1's [DATE] speech therapy note showed patient required supervision at mealtime prior to onset of therapy, staff will be trained on safe swallowing strategies to provide prompts to patient during mealtimes and consistent cueing was required for mastication and oral clearance. This note showed patient had a recent choking incident that required the abdominal thrust and CPR, as patient coded. 2. R2's face sheet showed a [AGE] year-old male with diagnosis of diffuse traumatic brain injury, monoplegia affecting the left upper non-dominant side, epilepsy, schizoaffective disorder, anxiety disorder, and major depressive disorder. On [DATE] at 2:55 PM, V30 R2's orthopedic physician assistant-certified said he was viewing the x-ray and there was no bone cancer, so the fracture was not pathological. V30 said the bone spur was on the opposite side of the knee as the fracture and had nothing to do with the injury. The bony abnormality had nothing to do with the fracture. It was an otherwise normal x-ray. The fracture was from a fall. He must have fallen at the nursing home. On [DATE] at 8:16 AM, V25 R2's mother said R2 has no history of issues with his right leg. V25 said R2 called her and complained of right knee pain on [DATE]. V25 said she called the facility to tell them about it and they were aware. R2's [DATE] fall risk assessment showed ,d+[DATE] falls in the past 3 months, R2 was chairbound, required use of assistive devices for gait/balance, had intermittent confusion and was at risk for falls. R2's [DATE] at 10:10 AM provider note showed R2 complained of right knee pain, unknown injury and acetaminophen was not effective. An x-ray was ordered. R2's [DATE] therapy note showed R2 had acute right knee pain and refused to ambulate in the restorative gym. R2's [DATE] at 10:32 AM order showed to do a right knee x-ray due to pain. R2's [DATE] right knee x-ray report showed the results were reported at 10:13 AM and there was a depressed fracture of the medial margin of the tibial plateau presumably acute. R2's [DATE] 9:25 PM fall incident showed blood on the floor and a large hematoma to the left temple and resident was sent to the hospital. This report showed R2 was confused, had a gait imbalance and impaired memory, there was poor lighting and the incident occurred during a (self) transfer. (Fall occurred less than 12 hours after receiving x-ray report showing a fracture) R2's 4//,d+[DATE] progress note authored by V30 orthopedic physician assistant showed R2 complained of right knee pain on [DATE] and fell [DATE]. This note showed a fracture to the medial aspect of the right tibial plateau and a large osteophyte (bone spur) to the lateral distal femur. R2's [DATE] incident note showed the knee injury (fracture) occurred prior to the fall (on the evening of [DATE]). R2's current care plan showed R2 had a history of falls. R2 fell on [DATE] with minor injury; on [DATE] R2 fell with a minor injury after a self transfer. R2 had a fall after a self transfer on [DATE] with injury. R2's care plan also showed short term memory deficits and is unable to recall any education given. R2's care plans do not show interventions to prevent self-transfers. R2's [DATE] at 8:40 AM nurse note showed R2 was found on the floor in his room after a self-transfer. The facility's Fall Prevention Program policy with a revision date of ,d+[DATE] showed, the facility will identify residents at risk for falls, develop care plans for residents at risk for falls, develop and implement interventions to prevent falls and investigate to determine root causes of falls and implement interventions to prevent reoccurence of falls.

Based on observation, interview, and record review the facility failed to ensure interventions were in place for a resident at risk for pressure ulcers, failed to identify pressure ulcers prior to becoming advanced stages, and failed to complete weekly assessments of pressure ulcers for 4 of 7 residents (R30, R19, R26, and R80) reviewed for pressure ulcers in the sample of 18. These failures resulted in R30 developing two pressure ulcers identified at a stage 2 and an unstageable, R19 developing a pressure ulcer identified at unstageable, and R26 developing 2 pressure ulcers identified at Stage 3 and unstageable. The findings include: 1. R30's face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's facility assessment dated [DATE] showed he has moderate cognitive impairment and requires extensive physical assistance of 2 staff for bed mobility, dressing, and toilet use and is completely dependent for transfers. R30's assessment for predicting pressure ulcer risk dated 9/22/22 showed R30 to be at high risk. R30's 10/25/22 entered at 12:09 PM, Skin/Wound Note entered by V4 Wound Care Nurse showed, New area to left knee at bend observed. Measures 1.0 cm x 1.0 cm granulating tissue. Edges attached. Cleansed and dry dressing applied. Appears catheter tubing to have been caught in bend of leg. Pressure area to lateral aspect of right foot 5th digit measures 0.5 cm x 1.0 cm x 0.0 cm. Hard/firmly attached. Denies pain. Resident educated on not wearing shoes at this time. Air mattress in place . On 10/26/22 the area to the 5th digit of the right foot was observed with a scab over the injury making the area unstageable. R30's care plan initiated on 9/3/22 showed, [R30] is at risk for impaired skin integrity and pressure ulcer injuries due to Spinal Cord Injury, Wounds, history of not following wound interventions, history of failed wound flaps, and history of wound infections. Resident has limited mobility, decreased strength, and incontinence of bowel . Interventions: . Air mattress on bed for pressure relief. Ensure proper functioning for air mattress daily . R30's care plan initiated on 10/25/22 showed, Documented Pressure Ulcer. New area to left knee at bend observed. Measures 1.0 cm x 1.0 cm x 0.0 cm granulating tissue. Edges attached. Cleansed and dry dressing applied. Appears catheter tubing to have been caught in bend of leg . Interventions: . Notice to staff to ensure catheter tubing is in correct position . R30's care plan initiated 10/25/22 showed, Documented Pressure Ulcer. Pressure area to lateral aspect of right foot 5th digit measures 0.5 cm 1.0 cm x 0.0 cm. Hard/firmly attached. Denies pain. Resident educated on not wearing shoes at this time. Resident has had an increase in swelling to bilateral lower extremities . Interventions: . Educated resident on the importance of not wearing shoes until wound has healed . R30's care plan initiated 10/19/22 showed, Documented Pressure Ulcer DTPI (Deep Tissue Pressure Injury) to right heel measures 1.0 cm x 1.5 cm. admitted with this from the hospital . R30's Skin Only Evaluation dated 10/25/22 showed, .Skin Issue: Pressure Ulcer/Injury. Skin Issue Location: knee bend, Pressure Ulcer/Injury Stage 2 . New area to left knee at bend observed. Measures 1.0 cm x 1.0 cm x 0.0 cm granulating tissue Appears catheter tubing to have been caught in bend of leg. Pressure area to lateral aspect of right foot 5th digit . Resident educated on not wearing shoes at this time. Air mattress in place . R30's complete care plan was reviewed and showed no updates regarding R30 not being able to wear shoes. On 10/25/22 at 1:30 PM, R30 was in his room sitting in his motorized wheelchair. R30 was wearing white tennis shoes. On 10/26/22 at 9:39 AM, V4 LPN-WCN (Licensed Practical Nurse-Wound Care Nurse) and V13 CNA (Certified Nursing Assistant) were providing wound care for R30. R30's air mattress control box was on the footboard of his bed. The air mattress power button was in the off position. V4 was providing wound care to R30's right foot, 5th toe. V4 said she found this pressure area yesterday. V4 said R30 should have cushioned heel boots on when in his chair, V4 then said R30 should have heel boots on at all times. The surveyor asked V4 if the mattress on R30's bed is an air mattress. V4 responded, It is a pressure reduction mattress, it does basically the same but the air doesn't go thru the coils like a low air loss mattress does. On 10/26/22 at 1:51 PM, R30 was observed in his motorized wheelchair in the main hallway. R30 was wearing his tennis shoes. On 10/27/22 at 11:15 AM, V13 CNA said, We rotate [R30] on his sides when in bed and in his chair he has the option to adjust the chair to prevent pressure. It's ok for him to wear shoes. I haven't been told he can't. He doesn't have an air mattress. On 10/27/22 11:10 AM, R30 was laying in his bed. The air mattress control box on the footboard of his bed was in the off position. R30 said he doesn't think he has an air mattress on his bed. R30 then said, I don't have a bed that the air goes in and out of if that is what you mean. I can wear shoes. No one has ever told me that I shouldn't wear shoes. They never said anything like that to me. If they told me I had sores on my feet, I would be ok with not wearing shoes while they heal. On 10/27/22 at 12:53 PM, V4 WCN said, R30 has the air mattress for pressure prevention. It is a pressure relieving mattress, but not the coil one. The pressure ulcer to his 5th digit of his right foot I just found the other day. It was quite possibly caused by his shoes that he has still been wearing. He isn't supposed to be wearing shoes since he came back from the hospital. I put the shoes on hold and he is supposed to be boots only. The CNAs know he isn't supposed to wear shoes. I found the one behind his knee on Monday the same time as I found the one on his 5th digit. The cause of the knee one was easy to figure out, when I found it, his catheter tubing was ran behind his knee and was still there. I educated the CNAs on them watching the placement of his catheter tubing. 2. R19's face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's facility assessment dated [DATE] showed he is cognitively intact and requires the extensive physical assistance of 2 staff for bed mobility, dressing, and toilet use. R19's care plan initiated on 8/29/22 showed, Documented Pressure Ulcer, Deep Tissue Pressure Injury, Unstageable, 5.1 cm x 3.8 cm soft, dark purple area inside of a 8.0 cm x 9.1 cm lightly discolored area to his left heel. R19's 8/30/22 Skin/Wound Note showed, Resident seen by wound nurse for pressure area to left heel . On 10/27/22 at 1:02 PM, V4 LPN/WCN said, [R19] gets a pressure injury on his heel whenever he wears his shoes, so then we put his shoes on hold. They heal pretty quickly, always start as a blister. For prevention he wears heel boots in bed at all times and he has frequent skin checks. I think his skin checks are weekly. I frequently go in and check him in between skin checks too. The CNAS look over the skin and are supposed to notify the nurses on a shower sheet for any changes to the skin. The nurses have their scheduled skin checks too. So I would expect a wound to be identified at a stage 1. It should be noticed and reported the minute they find it red. 3. R26's face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's facility assessment dated [DATE] showed he has no cognitive impairment and requires extensive assistance of 2 staff members for all cares. R26's care plan initiated on 4/20/20 showed, Risk for Impaired Skin Integrity and a high risk for pressure ulcers per assessment. Resident requires total assist for transfers, TBI ([CONDITION(S)]) [CONDITION(S)] . Residents BLE (Bilateral Lower Extremities) fluctuate with [CONDITION(S)] at times causing skin issues . R26's care plan initiated on 9/9/22 showed, Documented Pressure Ulcer-Stage 2 dark fluid filled blister to plantar aspect of left foot. Measures 2.0 cm x 2.5 cm, light drainage from lateral blister due to foot hitting the end of the headboard . Notify staff to ensure resident is up all the way in bed and reduce sliding in bed with knees and feet elevated . R26's care plan initiated on 9/29/22 showed, Documented Pressure Ulcer 2.3 cm x 3.0 cm, Stage 3 pressure area to left malleolus. Granulating tissue with moderate sanguineous drainage. Edges firmly attached. Resident unable to feel area . CNAs educated on positioning of leg . R26's 9/9/22 Skin/Wound Note showed, Resident reports dark fluid filled blister to plantar aspect of left foot. Measures 2.0 cm x 2.5 cm, light drainage from lateral blister. Resident often slides to foot of bed pressing feet against the footboard. Is unable to feel pressure. Blister cleansed and skin prep applied R26's 9/9/22 Skin Only Evaluation showed R26 to have a new stage 2 pressure injury to plantar area of his left foot. R26's Wound Physician note dated 9/13/22 showed, Unstageable DTI (Deep Tissue Injury) of the left, plantar, lateral foot . R26's 9/29/22 Skin/Wound Note showed, New Pressure Ulcer: During rounds observed resident to have 2.3 cm x 3.0 cm, Stage 3 pressure area to left malleolus. Granulating tissue with moderate sanguineous drainage. Edges firmly attached. Resident unable to feel to area . LLE (Left Lower Extremity) floated on pillow to prevent pressure. CNAs educated on positioning of leg . On 10/27/22 at 12:44 PM, V4 LPN/WCN said, [R26] has pressure to his left malleolus and left plantar foot. He is so long that his mattress slides to the end of the bed so his foot ended up against the footboard. We have ordered a wedge that will go between the mattress and the footboard to prevent the mattress from sliding down. He is extremely tall, I think he is over 6 feet and he is in our longest bed. V4 said she is the one that finds most of the new skin issues because she finds them when she is doing treatments. V4 said both the left malleolus and left plantar foot were identified by her while she was doing R36's other treatments because she has a habit of doing skin checks while she does treatments. V4 said the nurses on the floor do skin checks as well. V4 said prevention measure for R26 are wearing heel protectors and staff checking to make sure he is pulled up in bed frequently. V4 said the bed adjusts at the knees and feet which help to prevent sliding. V4 said R26 actually prefers to have his feet up. The facility's policy titled Pressure Ulcer Prevention Program with revision date of 6/2014 showed, It is the policy of this facility that upon admission, a licensed nurse assesses each resident for pressure area potential . The facility will ensure that a resident that enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. The facility will promote the prevention of pressure ulcer development; The facility will promote the healing of pressure ulcers that are present . The facility will prevent the development of additional pressure ulcers . The facility's policy titled Skin and Wound Care Program with revision date of 12/2015 showed, Wound Management: An Interdisciplinary Approach/Wound Care Team . Due to the complexity of managing a resident with wounds, a coordinated approach to resident care is essential for promoting maximum resident outcomes. Each team member assesses the resident's needs and communicates this information so that treatment planning is interdisciplinary and holistic in nature. The interdisciplinary approach will increase staff awareness of the problem, heighten identification of ulcers at earlier stages, reduce the incidence of pressure ulcers in the health care setting and provide enhanced control measures by management . 4. On 9/25/22, R80 was found to have a stage 1 pressure injury to her left outer heel measuring 1.7 cm by 1.9 cm. On 9/26/22, V4 noted a blister to the left heel fluid filled with a slow leak of serous drainage. The 10/3/22 assessment shows the wound to measure 2.0 cm x 2.3 cm with necrotic tissue. No further assessments were completed for the wound until 10/26/22. On 10/26/22, R80 was observed to have an open dime sized reddened wound on her left heel. R80 denied any pain and does not know exactly how she acquired the pressure injury, but believes it to be from her shoes. On 10/26/22 at 8:10 AM, the wound had no drainage and was left open to air. V4 stated all wounds are measured and assessed weekly and documented in the progress notes. On 10/27/22 at 8:17 AM, V4 stated she missed 2 weeks of measurements and assessments when she was out with Covid. She said the nurses should have been treating and ideally measuring and documenting. On 10/27/22 at 12:08 PM, V2 DON (Director of Nursing) said (V4) is the wound nurse and performs the assessments and measurements. When she was not here, the floor nurses should have been doing the assessments and measurements. The facility's 12/2015 skin and wound care program documents Wound care coordinator: responsibilities 2. Documentation of the stage wound occurs weekly. 5. Completes the weekly pressure sore documentation using the weekly assessment forms provided by the facility.

Based on interview and record review the facility failed to safely transport a wheelchair bound resident for 1 of 3 residents (R1) reviewed for accidents in the sample of 8. This failure resulted in R1 suffering an upper arm fracture that required surgical repair. Findings include: The facility report dated 3/25/2022, documents R1 requires staff assistance to propel her power wheelchair and as she was being propelled in the facility, R1's swung out her arm and struck the wall. An x-ray at the facility showed a fractured arm. The facility face sheets documents R1 has diagnosis to include [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and kyphosis. The facility assessment dated [DATE], documents R1 to be oriented and has modified independence in daily decision making. The same assessment documents R1 to be totally dependent on 1 staff for locomotion on and off the unit. R1's care plan for functional performance dated 5/27/2021 documents one staff to drive the wheelchair. The care plan for falls dated 5/26/2021 documents to ensure wheelchair is off to decrease risk of hitting joy stick with resident spasms. On 4/5/2022 at 9:45 AM, R1 said the activity lady was not watching where she was going as she assisted her to the activity. R1 said her arm was broken, and she needed surgery to repair the injury. On 4/5/2022 at 10:00 AM, V3 Activity Aide said she was assisting R1 to the activity in the dining room. V3 said she had never helped R1 before because V3 is new to the facility. V3 said as she was controlling the electric wheelchair, she came upon a wet floor sign in the entry of the dining room and had to move over closer to the wall. V3 said at the same time R1 swung out her arm and it hit the wall as she continued to advance her forward. V3 said she had never been trained on how to use R1's wheelchair and that it is different from any kind of wheel chair she (V3) had seen before. On 4/5/2022 at 9:40 AM, V4 Certified Nursing Assistant (CNA) said R1 flails her arms around so when she is being transported in the wheelchair and you come to a door way or have to get close to the wall, the staff should put there body between the wall and R1. On 4/5/2022 at 9:45 AM, V5 CNA said R1's arm will swing out while being transported (in her electric wheel chair) and the staff must protect her arms from hitting the wall or getting caught in the doorways. On 4/5/2022 at 10:21 AM, V6 Licensed Practical Nurse (LPN) said R1 has very brittle bones and caution is needed with her transfers and transports out of her room. R1 needs to be reminded to keep her arms in, the wheel chair should be driven slowly and make wider turns that a normal wheel chair. On 4/5/2022 at 2:35 PM, V2 Assistant Director of Nursing (ADON) said V3 was not familiar with R1's wheelchair and it can be switched to manual mode and can be pushed. V2 said he would expect the staff to protect R1's arms while transporting her by either using the manual mode or putting themselves between R1 and the wall. V2 said staff should be trained with anything they are not familiar with. V2 said he was not aware if V3 had been properly trained since the incident has happened. R1's nursing progress note dated 3/25/2022, documents R1 was being transported by the activity staff when her right arm swung out and got stuck to the wall while her chair continued forward. That same day a nursing note showed an x-ray was completed and R1 had an unofficial humerous (upper arm) break. R1 was transferred to the local hospital. The hospital discharge record dated 3/30/2022, documents a right humeral fracture with surgical repair. The record also shows R1 was experiencing pain and required pain medication. The facility policy on safety and supervision with a revision date of 3/17 shows implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff, c. providing training, as necessary, and d. ensuring that interventions are implemented.

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident exhibiting exit seeking behaviors was supervised to prevent elopement. The facility also failed to ensure interventions were effective to prevent an elopement for one of three residents (R1) reviewed for elopement in the sample of 3. The Immediate Jeopardy began on 10/12/21 when R1 left the facility grounds undetected. The Immediate Jeopardy was identified on 10/14/21. V1 Administrator was notified of the Immediate Jeopardy on 10/19/21 at 8:44 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/20/21, but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the immediacy removal plan. The findings include: R1's 10/14/21 face sheet showed a [AGE] year-old male admitted to the facility on [DATE]. R1's diagnosis included Metabolic [CONDITION(S)], Alcoholic [CONDITION(S)] of the Liver, Protein Calorie Malnutrition, and Altered Mental Status. On 10/14/21 at 3:36 PM, R1 was seated alone on a bench outside the facility's main entrance. The bench less than 10 feet from a gate that exits into an open parking lot and adjacent road. R1 had an elopement alert bracelet around his left ankle. The elopement alert detectors were located inside the facility main entrance. The gate utilizes a key code to unlock the gate to exit the facility grounds. R1 was asked how he was able to exit the facility on 10/12/21. R1 said It's pretty easy to crack the code to that. I've done it lots of times. I'm not stupid. I hope I don't get anyone in trouble. R1 then stood up, walked over to the gate and after pulling it twice, the gate opened up. R1 did not use the keypad to enter a code and was able to open the gate by pulling on it. R1 was without elopement prevention measures on 10/14/21 when he opened the exit gate (the only barrier between himself and leaving the facility grounds). No facility staff responded to the front gate area after R1 opened the gate. This surveyor asked R1 to walk back into the facility with her. Once inside, V9 Business Office Manager was standing near the entrance and said she observed R1 open the gate and that she told V4 Social Worker about it. V4 was also standing near the front office/entrance area. No administrative staff responded to the area. The facility is located in a rural farming community. The area R1 was found on 10/12/21 involved R1 walking over a creek and along a two-lane road with ditches, wooded areas and corn fields along the roadway. On 10/14/21 at 11:30 AM, V1 Administrator said there haven't been any recent elopements that were reportable. V1 said R1 got out the front gate and was brought back (on 10/12/21). At 2:09 PM, V1 said he's still investigating how R1 got off grounds and he planned to put it into QAPI (Quality Assurance Performance Improvement) and try to figure it out. V1 said on 10/12/21, V5 Certified Nursing Assistant (CNA) called V6 Registered Nurse on the phone to notify her that she saw a person resembling R1walking along the road outside the facility. R1 was located by staff members less than a mile from the facility. R1 used to live out there. R1 was about three miles from his home. V1 said R1 was allowed to be out front. He'd (R1) sit and watch. R1 was not at risk for elopement. V1 said the facility video showed R1 going out the front door at 3:30 PM on 10/12/21 and where R1 was found was about three miles from his home (previous residence). At 2:15 PM, V2 Director of Nursing said interventions are put in place if a resident is at risk for elopement. The IDT (Interdisciplinary team) determines on a case-by-case basis if interventions are needed. V2 said R1 was not exit seeking at that time and did not need to be supervised. R1 now had an elopement alert bracelet on. At 2:20 PM V3 Admission Coordinator said R1 would always talk about going to his farm. He still thinks he has cows and needs to do something with the animals. V2 and V3 said R1's 10/1/21 elopement assessment showed he was at risk for elopement, the IDT determined that no interventions were needed. At 1:55 PM, V4 Social Worker said R1 would occasionally ask about going home. Elopement alert detectors were located at the front and rear entrances of the facility. V4 said R1 was gone from the facility about 30 minutes from the time I was aware he was gone and the time he returned. R1 talked about leaving and how to be discharged . V4 said she isn't 100% sure how he got out. I'm guessing he was at least a mile away from the facility when he was found in the direction of his old house and farm. At 2:34 PM, V5 CNA said she left the facility around 3:30 PM on 10/12/21. I saw someone walking on the side of the road and I thought it was R1. I called the facility at 3:42 PM and spoke to V6 RN. I told her to check and make sure R1 was in the building because it looked like him (walking down the road). R1 was not authorized to be off grounds by himself. V5 CNA stated it probably isn't safe for him (R1) to be out walking along the road by himself. At 2:48 PM, V6 RN said V5 CNA called her on the facility phone and asked if R1 was supposed to be out walking along the road. I started looking for him in the facility and asked the aides to help. V1 was out of town at a meeting and V2 was not in her office. I checked all the courtyards. I hopped in my car and started driving around looking for him. R1 was always talking about having to go check the cows and the fields. R1 always said he wanted to go home and needed to go home. I returned to the facility after searching the area for him. The police were notified. V1 arrived where they found him and was able to get him (R1) into his pickup truck. At 3:04 PM, V7 Social Worker said V8 CNA found R1 (on 10/12/21) about a half a mile away walking on [NAME] Road trying to get home. R1 did not stop. He kept walking. At 3:11 PM, V8 said she was dropping her daughter off at the facility on 10/12/21 before 4:00 PM. I heard they were looking for R1. R1 told me last week where he used to live. I realized he may head toward his old home. I got about a mile down the road (toward his old house) and found him walking along the road. He seemed upset and he wouldn't stop walking. I could tell he was annoyed with me interrupting his purpose but he was polite. V1 arrived and was able to get R1 into his truck. On 10/15/21 at 9:10 AM, V9 Business Office Manager said R1 left the facility grounds on 10/12/21. V9 said she was monitoring R1 from leaving the facility grounds. V9 said she was seated inside the facility and R1 was alone outside the facility near the exit gate. V9 said the alarm bracelet R1 wore would not prevent elopement as he was in front of the building and past the detector. V9 said there were no interventions in place the afternoon of 10/14/21 to prevent R1 from leaving the facility grounds. V9 said her watching R1 would not prevent R1 from leaving the grounds again. At 9:13 AM, V2 said there was nothing in place to prevent R1 from leaving the facility grounds yesterday (10/14/21). The facility's elopement assessment determines if a resident is at risk or not at risk for elopement. The software does not determine a level of risk i.e., low or high as the facility policy indicates. (The facility Policy and the facility elopement risk assessments are incongruent). At 12:20 PM, V10 Safety Director said the front gate mag lock is not consistently locking. V10 said he became aware of the problem on 10/14/21 when R1 opened the front gate. Normally, the keypad unlocks the gate from the inside and an automatic eye opens the gate from the outside. We haven't been using the gate. We've had the control shut off to keep people from using the front entrance. Even with the control shut off the mag lock should engage and keep the gate secured. The mag lock is powered at all times. V10 said he doesn't believe there is a policy for maintenance and safety checks on the gate. V10 is not aware of any manufacturer's recommended maintenance schedule or safety check requirements on the gate. At 12:37 PM, V11 Maintenance said the gate is [AGE] years old and has lots of wear and tear the past two months. We resurfaced the back parking lot, so everyone was in and out the front gate. V11 said he is responsible for checking the gate weekly. He did it last week and does not keep a log. V11 said he does not know the manufacturer's required maintenance and safety check schedule for the gate. At 1:09 PM, V4 Social Worker said they don't do a life skills assessment for the residents. R1 will ask the same questions every day. R1 doesn't understand why he is here, why his brother has guardianship and why he doesn't live on the farm anymore. He asks me these questions almost every day. R1's orientation fluctuates. He remembers a lot of his past but confuses other things. R1 believes he still operates a dairy farm. R1's cognition and memory are impaired. He confuses a nurse as being his former wife and said I look like a relative. R1 is not safe to be off facility grounds unsupervised. At 2:40 PM, V12 Nurse Practitioner said R1 has a history of Dementia and is unsafe to be off facility grounds unsupervised. R1 is only oriented to person and believes he is at his farm. He is able to walk independently but due to his cognition he wouldn't be safe. A directional map showed the distance from the facility to where R1 used to live was five miles. The facility map indicates V9 was seated inside the facility while R1 was alone outside the facility and approximately 84 feet away when R1 opened the exit gate (on 10/14/21). R1's 10/1/21 facility assessment showed R1 had moderate Cognitive Impairment. R1's 4/26/21 Elopement Evaluation showed R1 was at risk for elopement. The evaluation showed a history of elopement or an attempted elopement while at home, wandering behavior, recent admission to the facility and not accepting the situation. R1's 5/5/21 Elopement Evaluation showed R1 was at risk for elopement. The evaluation showed wandering behavior and the wandering was goal directed (i.e., specific destination in mind, going home etc.). R1's 10/1/21 Elopement Evaluation showed R1 was at risk for elopement. This evaluation showed the resident had verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. This evaluation showed to monitor the resident's location frequently. R1's Elopement Care Plan initiated 7/8/21 and revised 8/18/21 showed R1 is an elopement risk related to his cognition and not understanding reason for placement. R1 talks about wanting to leave. R1 enjoys sitting outside and walking laps on the front patio. R1's elopement intervention showed R1 is to be supervised when outside. R1's Elopement Care Plan had not been updated since his 10/12/21 elopement incident. R1's Fatigue Care Plan initiated 7/14/21 showed resident is wandering throughout the day and not sleeping well at night due to confusion and wanting to find his cattle. Due to constant movement, resident can become very fatigued with ambulating and requires use of a wheelchair. This care plan showed to provide supervised assistance for ambulation. R1's Fatigue Care Plan had not been updated since his 10/12/21 elopement incident. R1's Cognition Care Plan revised 5/18/21, showed R1 has impaired cognitive function related to [CONDITION(S)] and history of [CONDITION(S)]. R1 is not oriented to time or place and believes he is still working on his farm. R1's Fall Care Plan revised 4/27/21 showed the resident had a fall, had poor safety awareness and an unsteady gait. R1's High Risk for Falls Care Plan revised on 4/27/21 showed R1 is a high risk for falls due to confusion, deconditioning, and gait/balance problems. R1 is unaware of safety needs and is unable to recall any education given about safety needs. R1's 10/12/21 Social Service Progress Note showed at 2:30 PM (an hour before elopement), R1 questioned how he can discharge as he thinks he is physically fine. R1 was focused on his brother having guardianship and was getting upset. R1 verbalized he didn't understand and didn't want his brother as guardian and then continued to walk toward his room. R1's 10/12/21 incident authored by V6 showed at 3:50 PM, she was notified by phone by off duty staff that R1 was seen walking down the road. Multiple employees went in search of the resident in vehicles. Resident was located and brought back to the facility. R1's 10/13/21 at 1:14 PM Nurse's Note showed resident continues to exit seek non-stop, also verbalizing the desire to leave the facility. R1's 10/13/21 at 1:32 AM Nurse's Note showed resident appeared extremely agitated prior to bedtime and said, I am getting out of here! R1's 10/14/21 at 10:32 AM Nurse's Note showed resident continues to exit seek non-stop, also verbalizing the desire to leave the facility. The Administrator, Director of Nursing and Assistant Director of Nursing were made aware. R1 was unable to be redirected. R1's safety skills/life skills assessment was requested, and none was received. The manufacturer's recommendations for maintenance and safety checks for the front gate was requested and none was received. R1's 7/2/21 Elopement Evaluation showed R1 was at risk. R1's 7/4/21 12:56 Nurse's Note showed resident had increased anxiety and exit seeking behavior. Resident continues to go out every exit door available that opens. R1's 7/9/21 1650 Nurse's Note showed exit seeking behavior this shift. R1's 7/13/21 3:04 AM Nurse's Note showed resident informed nurse he had to go feed his cows. Resident continued to be upset. R1's 7/15/21 13:01 nurse's note showed resident had increased anxiety and was exit seeking. R1's 7/21/21 18:33 Nurse's Note showed R1 had chronic wandering, was agitated, confused and had short term memory loss. This note showed disorientation was considered to be baseline for this resident. The facility's 3/17 Elopement Policy showed it is the policy to assess each resident for the potential to wander and/or elope. The facility will provide preventative interventions as necessary for the safety of the resident identified. A resident who is identified as being at High Risk for wandering and/or elopement will have attached to their wheelchair, walker/assistive devices, or wear a Code Alert transmitter and/or other appropriate intervention as assessed by the Inter Disciplinary Team (IDT). If a high Risk resident attempts elopement their individual care plan will be reviewed to determine if current interventions are adequate to ensure their safety. Appropriate interventions will be implemented by the IDT and will be at the discretion of the Administrator or his/her designee and determined on a case-by-case basis. If a resident is observed attempting to leave the premises the IDT team will update the president's plan of care to include elopement precautions. The facility's 3/17 Safety and Supervision Policy showed the interdisciplinary team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include ensuring that interventions are implemented. Monitoring the effectiveness of interventions shall include ensuring that interventions are implemented correctly and consistently and evaluating the effectiveness of interventions. Resident supervision is a core component of the systems approach to safety. The Immediate Jeopardy that began on 10/12/21 was removed on 10/20/21 when the facility took the following actions to remove the immediacy: Social Services will complete new Elopement Risk Assessments on all residents by 10/26/21. Social Services will review all care plans of residents at high risk for elopement by 10/26/21. IDT will ensure elopement interventions are implemented following findings of new high-risk residents and reported to the MDS Coordinator. MDS Coordinator will complete audits weekly X2 weeks then monthly X2 months then quarterly X 1 year. Audits will be reported to QAPI. Upon admission, admitting nurse will complete Elopement Risk Assessments and in addition Social Services will now complete monthly reassessments for high risk (residents). Outside gate was fixed by Certasite on 10/15/21. Maintenance will immediately complete daily checks X2 weeks then weekly on all door alarms/maglocks, and Code Alert wandering systems. Administrator will audit Social Services immediate care plan review and that new Elopement Reassessments are complete on high-risk elopement residents. Administrator will audit Social Service monthly Elopement Risk Assessments on high-risk residents once a month X6 months and results will be reported to QAPI. New Elopement Risk Assessment will be integrated into PCC to match current policy by 10/22/21. All nursing and Social Service staff will be trained on new Elopement Risk Assessment by 10/22/21. When a resident is determined to be at high risk for elopement and has attempted a prior elopement at this facility, resident will be placed on direct 1:1 supervision while in front courtyard. A code alert will be placed on residents with exit seeking behaviors followed by 15-minute checks for a minimum of 72 hours until IDT evaluates. Following an elopement, all exit door codes will be changed. All new hires complete Elopement Training upon hire and all current staff complete Elopement Training annually. However, due to incident, all staff will now be required to complete immediate and quarterly training on Preventing and Responding to Elopement X one year. Immediate training will be completed by 10/26/21. All staff will be made aware of high-risk residents for elopement on PCC communications. A note will now be made at time clock for staff notifying them of changes to Residents at High Risk for Elopement and to check PCC communications.

Based on interview and record review, the facility failed to allow a resident with impaired mobility to retain his motorized wheelchair for one of three residents (R1) reviewed for resident rights in the sample of 9. This failure contributed to R1 experiencing an increase in depression and anxiety symptoms and two wounds. The findings include: R1's 8/6/21 face sheet showed a [AGE] year-old male admitted to the facility on [DATE]. Admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 7/5/21 Facility Assessment showed he is cognitively intact and has range of motion impairment of the upper and lower extremity on one side. On 8/6/21 at 8:47 AM, R1 said V2 Director of Nursing (DON) and the safety person (who's on vacation) told me I had to lose weight to get my (motorized) chair back. They said the weight limit was 350 pounds and I believed them until I looked it up and it said it holds 450 pounds. They kept the chair away from me for over a year. They knew it (manual wheelchair) was causing a sore to the back of my right leg. They actually removed the chair from my room and put it in the garage. It was a pretty big blow to my depression. They took away a lot of my freedom to move about more easily and without pain. My left side is paralyzed, and I have arthritis in my right knee, elbow and shoulder and carpal tunnel in both wrists. It definitely aggravated the pain (not having motorized chair). The pain would interfere with my therapy. I couldn't do certain parts due to the pain. I spoke to V1 Administrator and the prior Administrator and asked for the power chair manual and never got it. Social Services was aware of it. I was always bugging them about it. At 11:13 AM, V3 Certified Nursing Assistant (CNA) said R1 hasn't had his motorized power chair for at least six months. V4 CNA said R1 got his power chair back on 8/3/21. At 12:05 PM, V1 Administrator said the maximum weight capacity for R1's motorized chair is 400 pounds due to the adjustable seat on it. I'm not sure how we came up with 350 pounds. We gave him his chair back on 8/3/21 because he stayed under 350 pounds for two weeks in a row. V1 was unable to determine when R1's power chair was taken from him. At 12:13 PM, R1 said his social worker and V2 told him there was a 350-pound weight restriction on his chair. They said I was over that limit and had to get out of the chair. I wasn't given a choice. It's my personal chair. I got tired of being jerked around. This was not a mutually agreed upon weight loss plan. I've been wheelchair dependent for [AGE] years and unable to walk. I had a brain aneurysm and a stroke. At 12:50 PM, V5 Dietary Manager said the Minimum Data Set (MDS) coordinator said R1's chair weight limit was 350 pounds. R1 wanted to stay in his electric chair. At 1:03 PM, V2 DON said she was under the impression that R1's chair limit was 350 pounds. R1's chair absolutely should not have been taken away if he wasn't over the weight capacity. R1's main mode of mobility is the wheelchair. At 1:19 PM, V6 psychiatric Nurse Practitioner said R1 has baseline depression, situational stressors like losing the use of his electric wheelchair exacerbate his depression and anxiety symptoms. At 2:20 PM, V8 Grievance Officer said R1 had to be under 350 pounds for two consecutive weeks in order to use his motorized chair. V7 Director of Social Services said R1 came to her to get his power chair back sometime after 7/26/21. I reminded him he needed to be under 350 pounds for two weeks first. At 3:00 PM, V9 wheelchair supply company representative said (on speaker phone to V1 with this surveyor present) R1 has had the same motorized wheelchair since 2017. The manufacturer's manual for R1's power chair showed a maximum weight capacity of 400 pounds with the adjustable seat height installed. The Dietary Manager provided a document with R1's weights. R1's weight was 353 on 2/4/21, 356 on 4/6/21, and 349 on 8/3/21 (consistently under the recommended weight of 400 pounds). R1's revised 5/9/2019 contract showed R1 was made aware by the Safety Director and Social Worker that his electric wheelchair had a maximum weight limit of 350 pounds (lbs.). R1 was made aware and understood he is to maintain a weight of 340 lbs. or less for both his safety in the chair and the condition of the chair itself in the case there is a weight fluctuation at any time. R1 was made aware and understood by both the Safety Director and Social Worker that should R1's weight exceed 340 lbs.; he would be transferred into his manual wheelchair until his weight is at 340 lbs. or less. R1's care plan created 9/30/20 showed R1 utilizes an electric wheelchair that has a weight capacity of 350 pounds. If resident is at 350 pounds or over, resident will have to utilize a bariatric manual wheelchair. This care plan showed the resident was educated on the weight limit of the electric wheelchair and resident had to remain underweight (350 pounds) for two weeks in order to receive the electric wheelchair. Educate resident on importance of reducing snacks and sugars. R1's undated functional performance care plan showed if R1 is over 350 pounds he will be in a manual wheelchair. R1's undated acute pain/chronic pain care plan showed a history of [CONDITION(S)], chronic headaches, [MEDICATION(S)] vertebrae fracture, depression and a ruptured right side brain aneurysm. R1's undated wound management care plan showed a wound to the right buttock measuring 2.0 centimeters (cm) X 3.0 cm due to rubbing on the manual wheelchair. R1's second wound management care plan showed a wound to the right ischial measuring 3.0 cm X 4.0 cm due to resident being in the manual wheelchair and rubbing the back of his leg. R1's August 2021 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 1/22/21 Social Service Note showed the social worker informed R1 that he would need to lose 2.6 pounds in order to remain in his power chair. It was explained if he did not lose this weight, he would be given his manual wheelchair again. R1's 4/27/21 Social Service Note showed R1 needed to maintain a healthy weight to remain in it (his power chair). The dietary manager provided a list of R1's weights. R1 was 353 pounds on 2/4/21, 356 pounds on 4/6/21, and 349 pounds on 8/3 (consistently under the manufacturer recommendation of 400 pounds). R1 was 349 pounds on 6/22/21, and 347 pounds on 6/29/21. The facility still did not allow him to have his wheelchair despite meeting the facility requirement to be under 350 pounds. R1's 1/26/21 Plan of Care note showed R1 is over 350 pounds which is the maximum capacity for his electric wheelchair. Resident was notified of having to switch to his manual wheelchair. R1's 3/4/21 psychiatric assessment note showed R1 feeling down and rated depression a 4-6 (on a 0-10 scale) related to having a different wheelchair. R1's 4/12/21 note showed feeling down because he is still in a self-propelled wheelchair. R1 rated his depression a 7 (on a scale of 0-10) worse than usual. R1 reported difficulty pushing his current chair around due to arthritis in his right arm (left side [CONDITION(S)]). R1 reported he would feel better if he could get back into his old wheelchair (motorized). R1's 6/21/21 note showed anxiety had been worse lately and reported the average daily rating a 6 (on 0-10 scale). R1 reported that anxiety is his biggest concern at that time. R1 said he is anxious to get back into his motorized wheelchair so he can get out of the facility on his own. This note showed R1's anxiety medication was increased from twice daily to three times daily. R1's 7/15/21 Advanced Practice Nurse note showed R1 used a wheelchair and self-propels (not motorized). This note showed an increase in R1's depression symptoms. The facility provided resident rights booklet showed as an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United States. You may keep and use your own property. You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Based on observation, interview, and record review, the facility failed to safely secure a resident during a transport in a facility vehicle for one of eight residents (R1) reviewed for safety in the sample of 8. This failure resulted in R1 suffering bilateral leg fractures. The findings include: R1's face sheet (printed 6/30/21) showed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis listed included [CONDITION(S)], [CONDITION(S)], liver disease and pressure ulcers. R1's 4/30/21 facility assessment showed he is cognitively intact and has a traumatic spinal cord dysfunction. On 6/30/21 at 9:50 AM, R1 was supine in bed. He was alert and oriented to person, place and time. R1 had bilateral hinged braces to both legs extending from the thigh to lower legs. There was residual bruising to both anterior lower legs. R1 had a suprapubic catheter and [CONDITION(S)] present. R1's wheelchair was near the bed. The footrest was one flat piece of metal with a tread on top to support both feet when up. There was a lap seat belt attached to the chair. R1 became visibly upset (tears in eyes) when talking about the incident on 6/18/21. On 6/30/21 at 8:10 AM, V3 Activity Aid (drove van during 6/18/21 incident) said I think I didn't check how tight his (R1's) seat belt was. I stopped more abruptly than I usually do at a stop sign. I think the momentum from that caused him (R1) to fall. His (R1's) hands were on the floor (of the van). R1 said part of him was in contact with the floor. His hips and butt stayed in the chair, but he came forward. I heard his CD bag fall out of the chair and he cried out as well and told me to stop. I grabbed him under his arms to get him back to a seated position. He was bent pretty far forward so his fingers could touch the ground. He couldn't straighten himself up. I put an extra shoulder strap on him. The brakes are really touchy. When I got back to the facility, I told my supervisor (via text message) that I pressed the brakes too suddenly and R1 had fallen. At 8:42 AM, V6 Orthopedic Provider said R1's lower leg fractures would not have occurred without an impact injury (not caused by osteopenia). At 8:39 AM, V4 RN said V3 told her R1 fell forward due to a loose seatbelt. When V4 talked to R1. R1 said his whole wheelchair fell forward and almost hit the other resident in the van. At 9:50 AM, R1 said on 6/18/21 he was in the facility van for an outing and on the way back the driver hit the brakes too hard. R1 said his wheelchair seat belt was loose and had about 5-6 inches of slack between his torso and the belt. R1 said he cannot secure or adjust his seat belt due to his decreased hand dexterity. I ended up on all fours. I put my hands down in front of me, so I didn't hit my face on the floor. My catheter got disconnected due to the momentum and urine was leaking on me and the van floor. I am paralyzed from the chest down. I don't feel pain like normal people. Sometimes my body has other symptoms to show distress. I made them send me to the hospital because I knew something was wrong with me. At 10:50 AM, R8 was interviewed with the assistance of V7 CNA Coordinator due to R8's communication deficits. V7 confirmed all question responses prior to documentation. V7 confirms R8 is a reliable historian. R8 said he was in the facility van with R1 on 6/18/21 on the outing. R8 said he was not injured. R8 said R1 was behind him in the van. R8 said R1 fell forward out of the chair during an abrupt stop. R8 said R1's chair didn't fall over but R1 fell out of the chair. R1 was on the floor (of the vehicle) on his hands and knees. At 10:57 AM, V8 LPN said she got report that he (R1) went over in his wheelchair while in the van and there were no injuries. At 12:19 PM, V11 Director of Therapy said if R1's center of gravity is beyond his base of support he has limited control (of upper body). R1 has limited core control. I can't see how he could end up with his hands on the floor. I don't believe he could normally reach his feet. A chest belt would be beneficial for a resident with poor trunk control. R1's 6/22/21 progress note from a wound clinic visit showed the resident presented for ongoing wound care, however, the resident stated he fell a few days ago during an outing. He states he fell forward and landed on his shins. He notes that he has observed bruising in the area, but as he is insensate, he does not appreciate any pain. He is also bedridden secondary to a cervical spine injury. New acute findings of the lower extremities, there is diffuse ecchymosis with minor blistering involving the anterior aspects of both proximal tibial areas. This is a [AGE] year-old male who has fallen recently and now has concerning bruising involving the anterior aspects of both distal lower extremities. We obtained bilateral x-rays of the lower extremities and confirmed bilateral acute fractures. R1's 6/22/21 right tibia-fibula radiology report showed acute proximal right tibial fracture with slight impaction and incomplete fracture of the proximal right fibula. R1's 6/22/21 left tibia-fibula radiology report showed a comminuted fracture of the tibial plateau with interarticular extension. Significant displacement at the fracture site. The facility's incident investigation report showed staff retraining in relation to incident of resident tipping forward in van causing potential injury. The van driver (V3) said he had to make an abrupt stop and assist R1 to an upright position. V3 said R1's seat belt was a little loose. R1's interview showed the brakes were touchy The seatbelt was loose and V3 stopped abruptly and I fell forward and my hands were on the floor of the van to prevent me from falling on my face. I think I was on all fours. The facility's 5/22/2018 Transportation Guidelines and Training Manual showed all employees who utilize the vans must follow designated speed limits and safety precautions along with cell phone policies and state laws. Chest straps are provided for residents who have trouble with balance and should be used at the driver's discretion. Stopping: The ability to stop your vehicle safely should be considered when deciding your speed. While braking, push the brake steadily-do not pump. As you get closer to the stop sign, let up on the brake slightly-this will give you a slow, steady stop without a jerking motion. If there is an accident with an injury and you are not at the facility, the first thing to do is dial 911.

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided by not assessing a resident after an incident while in a facility vehicle and failed to assess a resident after a return from a hospital stay. The facility failed to investigate an incident which occurred in a facility vehicle until five days later for one of eight residents (R1) reviewed for quality of care in the sample of 8. These failures resulted in R1 remaining untreated in the facility for five hours after suffering bilateral lower leg fractures. The findings include: R1's face sheet (printed 6/30/21) showed a [AGE] year-old male admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 4/30/21 facility assessment showed he is cognitively intact and has a traumatic spinal cord dysfunction. On 6/30/21 at 9:50 AM, R1 was supine in bed. He was alert and oriented to person, place, and time. R1 had bilateral hinged braces to both legs extending from the thigh to his lower legs. There was residual bruising to both anterior lower legs. R1 had a suprapubic catheter and [CONDITION(S)] present. R1's wheelchair was near the bed. R1 became visibly upset (tears in eyes) when talking about the incident on 6/18/21. On 6/30/21 at 8:10 AM, V3 Activity Aid (driver of van for 6/18/21 incident) said he was driving the facility van on 6/18/21 with R1 as a passenger. V3 said I came to a stop sign and stopped more abruptly than I usually would. I guess the momentum from that caused him (R1) to fall. R1's hands were on the floor and his hips and butt stayed in the chair, but he came forward. R1's catheter bag came detached during the incident and he asked me to help him reconnect it which I did. When I got back to the facility, I told my supervisor (via text message) that I pressed the brakes too suddenly and R1 had fallen. R1 told his nurse. I believe the nurse was V4 Registered Nurse (RN). V3 said I was asked (on 6/22/21) to write a report of the incident and bring it in when I returned to work on June 23, 2021. At 8:39 AM, V4 RN said V3 told her R1 fell forward due to a loose seatbelt. When V4 talked to R1. R1 said his whole wheelchair fell forward and almost hit the other resident in the van. R1 was wet with urine so I asked the staff to put R1 in bed. R1's catheter came apart during the fall in the van, so he was wet. Usually after an incident or hospital stay, I would do a complete head to toe assessment. I didn't examine R1 because it was shift change and he was still in his chair. The nurses work 12-hour shifts-6-6. I told the oncoming nurse, V8 Licensed Practical Nurse (LPN), he needed a head to toe assessment. At 9:50 AM, R1 said on 6/18/21 he was in the facility van for an outing and on the way back the driver hit the brakes too hard. R1 said his wheelchair seat belt was loose and had about 5-6 inches of slack between his torso and the belt. R1 said he cannot secure or adjust his seat belt due to his decreased hand dexterity. I ended up on all fours. I put my hands down in front of me, so I didn't hit my face on the floor. My catheter got disconnected due to the quick momentum and urine was leaking on me and the van floor. I am paralyzed from the chest down. R1 said nobody at the facility looked at him for injuries after he returned from the outing. I started having bad chills later that night. I usually have a UTI (urinary tract infection) because of my catheter. I believe my symptoms were automatic dysreflexia due to the pain in my legs. I don't feel pain like normal people. Sometimes my body has other symptoms to show distress. I made them send me to the hospital because I knew something was wrong with me. At 10:57 AM, V8 LPN said she didn't do a head to toe assessment on R1 6/18/21. I wasn't the nurse that was there when he came back. I got report that he (R1) went over in his wheelchair while in the van and there were no injuries. The nurse who accepts the resident back should do a head to toe assessment. V4 didn't tell me I had to do the assessment. I never did a head toe assessment for injuries. At 12:19 PM, V11 Director of Therapy said if R1's center of gravity is beyond his base of support he has limited control (of upper body). R1 has limited core control. I can't see how he could end up with his hands on the floor. I don't believe he could normally reach his feet. A chest belt would be beneficial for a resident with poor trunk control. At 3:29 PM, V12 wound nurse said I found (R1's) bruises on 6/22/21. I notified the Director of Nursing and had her look at the wounds. There were bruises and blisters that were not there the last time I saw him. Staff nurses are to do a head to toe assessment when a resident return from a hospitalization and after an incident. At 3:50 PM, V2 Director of Nursing said a nursing assessment should be done as soon as possible when a resident returns from a hospitalization and after a resident incident. This includes a head to toe assessment. This should be documented in the progress notes. It's important to assess the resident after a hospitalization to identify skin issues that were not there when they left the facility. After an incident, it's important to see if there were any injuries from the incident. No new skin issues is not an adequate assessment. An assessment should include vital signs. R1's progress note (authored by V4) dated 6/18/21 at 5:43 PM showed he returned to the facility from an outing. It was reported to the nurse that R1 fell forward due to a loose wheelchair seat belt. R1 told the nurse his whole chair came forward and R1 had to brace himself to keep his face from hitting the floor. R1's progress note (authored by V8) dated 6/18/21 at 22:48 showed R1 was very persistent on going to the hospital and was transported there at 10:41 PM. R1's 6/22/21 progress note showed R1 returned to the facility from the hospital stay on 6/21/21 at 5:15 PM. R1's progress note dated 6/21/21 at 11:15 PM showed no new skin issues observed (after return from hospital stay). Photographs taken 6/19/21 at the local hospital showed diffuse swelling and bruising to both of R1's lower extremities. R1's medical record showed the first skin assessment with findings dated 6/22/21 at 10:30 AM. This note authored by V12 showed bruises blisters and scabbed areas to both lower legs. R1's 6/22/21 progress note from a wound clinic visit showed the resident presented for ongoing wound care, however, the resident stated he fell a few days ago during an outing. He states he fell forward and landed on his shins. He notes that he has observed bruising in the area, but as he is insensate, he does not appreciate any pain. He is also bedridden secondary to a cervical spine injury. New acute findings of the lower extremities, there is diffuse ecchymosis with minor blistering involving the anterior aspects of both proximal tibia areas. This is a [AGE] year-old male who has fallen recently and now has concerning bruising involving the anterior aspects of both distal lower extremities. We obtained bilateral x-rays of the lower extremities and confirmed bilateral acute fractures. R1's 6/22/21 right tibia-fibula radiology report showed acute proximal right tibial fracture with slight impaction and incomplete fracture of the proximal right fibula. R1's 6/22/21 left tibia-fibula radiology report showed a comminuted fracture of the tibial plateau with interarticular extension. Significant displacement at the fracture site. The facility's investigation of the 6/18/21 incident does not show any interviews prior to 6/23/21 (5 days after the incident). The initial note in the investigation is only a summary of nursing progress notes. R1's progress notes do not show any documentation of a head to toe nursing assessment done after return to the facility on [DATE] or 6/21/21. This documentation was requested on 6/30/21 and none was received. The facility's 3/17 Return from Hospital Transfer Policy showed patient will be assessed by nurse upon return for vital signs, skin condition, weight, etc. Patient's condition will be documented on at least once a shift for 72 hours. The facility's 3/17 Accident/Sentinel Event Investigation Policy showed the initial investigation will be done by the supervisor, Administrator and/or Assistant Administrator immediately after the victim has been properly cared for, and there is no more threat of injury. An accident is a series of events that takes place and causes the undesirable loss. To maintain a quality safety environment, accidents and close calls will be investigated.

Based on interview and record review the facility failed to ensure a resident was free from sexual abuse by V4. These failures resulted in R1 being sexually abused. This applies to one of three residents (R1) reviewed for abuse in the sample of three. The Immediate Jeopardy began on 12/18/20 when the facility received notification that V4 (CNA-Certified Nurse Aide) was having a sexual relationship with a resident. The Immediate Jeopardy was identified on 1/5/21. V1 (Administrator) was notified of the Immediate Jeopardy on 1/7/21 at 10:10 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 1/7/21, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and education on abuse. The findings include: R1's face sheet shows [DIAGNOSES REDACTED]. R1's facility assessment dated [DATE] shows moderate cognitive impairment and with no hallucinations, no delusions, and no disorganized thinking. The facility assessment shows R1 requires extensive staff assistance with bed mobility, dressing, eating, and personal hygiene. The assessment shows R1 requires total staff assistance with transfers, dressing, toilet use, and bathing. On 1/5/21 at 1:15 PM, R1 was seated in a high back wheelchair. R1 was alert, talkative, and coherent. R1 stated he started dating one of the aides (V4) about one month ago. R1 said she would bring in food and energy drinks to him on the nights she was working. R1 said they spent a lot of time together on the night shift talking and kissing. R1 stated V4 tried to put her mouth onto his penis one time. R1 said V4 would let him lick her breasts with his tongue. R1 said it happened a few times and always on the night shift. R1 said he did not tell anyone about the relationship in the beginning but other people were noticing she was hanging out in his room a lot during her night shift. R1 said he did eventually tell another CNA about the sexual encounters with V4. R1 said he told V3 (male CNA) that V4 had allowed him to put his mouth on V4's breasts. R1 said he also eventually told V1 (Administrator) and V2 (Assistant Administrator) about the sexual encounters. R1 said he did deny it the first time V1 asked about the situation. R1 said he decided to admit the two of them were in a sexual relationship because (V1) is a nice guy and I decided to tell the truth. R1 also stated he has been texting V4 for the past month, via his voice recognition program on his personal cell phone. R1 said V4 also has been responding and communicating back with him through his cell phone. On 1/6/21 at 9:00 AM, V3 (male CNA) stated he was working on 12/18/20 and in R1's room around 2:15 PM changing the bed linens. V3 said R1 asked him if he had heard any rumors about himself and V4. V3 said R1 stated, You know the rumors are true, right? (V4) let me suck on her (breasts). You heard me. She let me suck on them. But that's just between me and you, ok? V3 said he asked R1 for clarification and again R1 repeated the same thing. V3 said he has cared for R1 many times and they have a good connection. V3 said he had no doubt R1 was being truthful. V3 said R1 is very alert, oriented, and completely knows what is happening around him. V3 said he left the room and immediately reported the information to V1. On 1/5/21 at 10:15 AM, V1 (Administrator) stated he was notified on 12/18/20 by V3 that R1 had said he was in a relationship with V4. V1 said he immediately interviewed R1. R1 confirmed he was in a relationship with V4 and that they were in love. R1 said V4 pleases him with her hand while putting a condom-type catheter on him. R1 said V4 lets him put his mouth on her breasts. R1 said he also has been having repeated text conversations with V4 when she is off work, via his cell phone. V1 said they asked R1 for permission to view the text history on his cell phone and there were hundreds of text messages back and forth between R1 and V4. V1 said the messages discussed their love between the two of them and food V4 was bringing into the facility for R1. V1 said a full investigation into the allegation was done and V4 was terminated on 12/22/20 after violating facility policy. On 1/5/21 at 10:45 AM, V2 (Assistant Administrator) stated she interviewed R1 on 12/18/20 after V3 reported the sexual incidents. V2 said R1 did initially deny any intimate involvement with V4, but after repeated questioning, he did admit to a sexual relationship. V2 said R1 stated he and V4 had been texting back and forth when she was not working. R1 said V4 would bring food and drinks into him on the nights she was working. R1 said V4 wanted to bring him to Kentucky and she was in love with him. R1 said V4 would give him oral sex and let him put his mouth on her breasts. V2 said she reviewed the text messages with V1. V2 said there was nothing sexual on the text messages but the communication between the two was definitely inappropriate. V2 said R1 has a spinal cord injury but is alert and oriented. V2 said R1 is able to send out text messages and make calls on his cell phone through a voice command system on his personal phone. On 1/5/21 at 1:45 PM, V4 (CNA) stated she was terminated from the facility on 12/22/20. V4 said it had something to do with an allegation of sexual harassment by (R1). V4 said she did care for R1 a lot and requested to work on his hallway. V4 said she routinely worked the night shift and cared for R1 every time she worked. V4 said she began dating R1 the day after she was fired from the facility. V4 said the administrator asked her about personal texts between herself and while being a care giver for R1. V4 said she believes someone hacked into her phone and sent weird sexual texts to R1. V4 said she did talk with R1 over the phone but it was only in regards to vocational rehabilitation questions he had. V4 denied any sexual relationship between herself and R1 but also stated R1 was 100% alert and oriented when I was caring for him. V4 denied bringing any food or drink into the facility for R1. V4 denied any romantic interest in R1. (Text messages show exact opposite.) R1 and V4's text messaging start dated 11/19/20 and end dated 12/17/20 were reviewed by the surveyor and showed repeated statements by V4 including: I love you . I can't wait for you to see me . Sounds kinky . I miss you babe . Go to sleep, before you know it I'll be there to take care of you . I have 3 NOS (energy drinks) for you . I've got the (candy) for you . I'm home and missing you already . I am wearing nothing by the way . Are you getting excited or what . Will you still love me after 3 days of me being gone? On my way to KY .Call me if you want . I don't want to just be friends . I hope no one can see these texts . Laying in bed thinking of you . Love you (R1's name) . Are you IN LOVE with me yet? . The facility's Abuse Program policy revision dated 4/2018 states under PURPOSE section: To ensure on-going safety of resident. The policy defines sexual abuse as: includes but not limited to sexual harassment, sexual coercion, or sexual assault. The facility's Staff Socialization with Residents policy revision dated 3/2017 states under the procedure section: 1. Socializing while off -duty with residents or their family/guardian while the resident it actively participating in the facility's programs is prohibited. This socialization crosses the professional boundaries between caregiver and resident. Socialization would include .g. Contact with resident .by telephone, texting, meetings, in writing or through the internet. The Immediate Jeopardy that began on December 18, 2020 was removed on January 7, 2021, when the facility took the following actions to remove the immediacy: Immediacy removal plan: The staff member involved in the incident was terminated on 12/22/2020 and has not been allowed in the building since. Winning Wheels will immediately ensure all residents are protected from any type of abuse which will include, but not limited to, staff education on recognizing and preventing abuse from happeneing and education on appropriate staff and resident interaction/socialization. This education began immediately on 12/21/20, will continue during new hire orientation, and will be provided to all staff quarterly for one year. Winning Wheels is committed to reviewing every resident to ensure no additional abuse has occured. Social services has initiated reviewing and educating every resident on signs of abuse and socialization policies on 01/07/21. The education for both staff and residents will be completed by 01/12/21. [MEDICATION NAME] Licensed Adminstrator will perform weekly audits on 3 interviewable residents x8 weeks to ensure that said residents 'feel safe' snd that no additional abuse has occured. Resident audits will be reported to QAPI each month.

Based on interview and record review, the facility failed to prevent a resident from abusing other facility residents. This failure resulted in R1 attempting to harm himself. This applies to 1 of 7 residents (R1) reviewed for abuse in the sample of 7. The findings include: R2's social service intake note shows R2 suffered a [MEDICAL CONDITION] on (MONTH) 3, (YEAR) due to an assault. R2 was admitted to the facility on (MONTH) 11, (YEAR). R2's baseline Care Plan shows R2 can independently get around the facility in the wheelchair and has sexually inappropriate behaviors. R2's social service progress note dated (MONTH) 12, (YEAR) shows identified behaviors of verbal, physical, and sexually inappropriate nature. R2's baseline care plan shows redirection, 1:1 with social services, music, electronics, call family, coloring, and socialize with others as interventions for behaviors. R2's nursing notes dated (MONTH) 11, (YEAR), show R2 spit into another resident's face and then threw what looked to be a piece of his wheelchair at the other resident. A state agency report dated (MONTH) 7, (YEAR), submitted by the facility shows R2 was in his wheelchair and went behind R6 and pushed his lower leg with his foot. The nursing progress note from this incident shows staff asked R2 to stop and R2 laughed and started doing it again. R2's (MONTH) 20, (YEAR) nursing note shows R2 kicked another resident (R6) from behind causing his knees to buckle and him falling. Both residents were separated and R2 grabbed the wrist of R6. This note shows R2's physical behaviors are willful and purposeful. When separating R2 from other residents, R2 smiles and attempts to return right back to inappropriate behaviors. R2's nursing note dated (MONTH) 21, (YEAR) shows R2 touched R7's (female resident) breast. R2 was told to stop which he did not. R2's nursing note dated (MONTH) 24, (YEAR), shows R2 would get really close to female residents with a smile on his face, scaring female residents. R2 then rolled his wheelchair into the hallway blocking other residents from going through. When nurse asked R2 to move, R2 punched nurse in the breast hard and said F**k You. R2's notes dated (MONTH) 28, (YEAR) shows he grabbed R7's wrist and when the nurse requested he let go R2 refused. An investigation summary dated (MONTH) 28, (YEAR) shows R2 touched R3's (female resident) breast. R2's (MONTH) 6, 2019 nursing note shows R2 hit another (unknown) resident in the breast. Later the same day, R2 punched R6 in the forearm. R2's (MONTH) 2, 2019 nursing note shows R2 punched R3 in the arm. R2's (MONTH) 4, 2019 nursing notes show at 9:00 AM, R2 grabbed R4's wrist and twisted the skin leaving a mark. At 11:00, R2's nursing note shows he grabbed a female resident's (R4) breast. At 11:05 AM, R2 grabbed a male resident's (R1) genitals, squeezed and twisted them. The facility's Resident Abuse and Neglect Policy dated (MONTH) (YEAR) shows it strictly prohibits the abuse and mistreatment of [REDACTED]. This policy defines abuse as willful infliction of injury, intimidation with resulting physical harm, pain or mental anguish. Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. Physical abuse is defined as hitting, slapping, pinching and kicking. On (MONTH) 21, 2019 at 11:25 AM, V1 Certified Nursing Assistant (CNA) said she knows R2 did grab R1's genitals based on his reaction. It absolutely occurred. R1 told me R2 grabbed a hold of his privates and wouldn't let go. R1's eyes were fully open and he was uneasy. At 11:50 AM, R6 said R2 punched me a couple times. He hit me in the nuts. I saw him punch R3 in the arm. At 12:50 PM, V2 LPN (Licensed Practical Nurse) said R2 would intentionally antagonize R3 because he knew it bothered her. R2 punched me a few times. R4 told me she was afraid of R2. R2 grabbed R4's breast. At 1:30 PM, V3 Nurse Practitioner said R2 grabbed R1's penis area and touched R4's breast. After R2 grabbed R1's genitals, R1 was irate, upset and crying. He was loud and flailing his arms around. I'm sure he felt violated and confused, almost didn't know how to react. All of this was definitely out of R1's character. At 1:57 PM, V4 (R1's father) said when R2 grabbed R1's genitals R1 told me he tried choking himself with intent of killing himself after this incident. R1's current [MEDICAL CONDITION] is a result from a suicide attempt by hanging in (YEAR). R1 couldn't cope with what happened. He can't protect himself, he can't call out. I took R1 home on (MONTH) 4, 2019 and brought him back to the facility on (MONTH) 11th. I picked him up again on (MONTH) 20th, it was traumatic to him. He's still not the same. I'm not sure if he will be able to stay at the facility. At 2:00 PM, V5 LPN said R2 would propel himself in the wheelchair using one arm and his feet. R2 grabbed my wrist and twisted it trying to hurt me. At 2:15 PM, R5 said R2 is dangerous and goes after people all the time. At 3:00 PM, V6 CNA Coordinator said she witnessed R2 antagonize his peers verbally and R2 was very difficult to redirect. On (MONTH) 26, 2019 at 10:20 AM, V7 Director of Nursing said abuse is the willful infliction of pain on another person. Grabbing a breast or groin should be considered possible abuse and kicking should be looked at as possible assault.

Based on interview and record review, the facility failed to supervise a resident with aggressive and sexually inappropriate behaviors and failed to provide a safe environment. This failure resulted in 3 of 7 residents (R3, R4, R6) being fearful and afraid. The findings include: R2's social service intake note shows R2 suffered a [MEDICAL CONDITION] on (MONTH) 3, (YEAR) due to an assault. R2 was admitted to the facility on (MONTH) 11, (YEAR). R2's baseline Care Plan shows R2 can independently get around the facility in the wheelchair and has sexually inappropriate behaviors. On (MONTH) 21, 2019, at 9:05 AM, R4 said R2 grabbed R3's boob, would pull out his man part in the hallway and show it to female staff and residents. R2 made me nervous when he grabbed me because I can't move to go anywhere. I was stuck and he wouldn't let go of my arm. Residents were nervous to go down the hallways when he was here. I did not like the way the facility handled the situation. At 10:00 AM, R3 said R2 punched me in the boob and started laughing. R2 punched me in my left arm. I was scared to leave my room. R2 made the residents fearful. I didn't want R2 to know where my room was. The Administrator always stuck up for him (R2). R2 was always going off by himself. There was rarely any staff with him. At 11:25 AM, V1 Certified Nursing Assistant (CNA) said R2 would grab others' hands and not let go, kick other residents until they fell , push their wheelchairs backwards. I could see R2 made the other residents uncomfortable. I had to move him and his wheelchair out of the hallway because the residents would not go by him. At 11:50 AM, R6 said R2 kicked the back of my leg and I fell to the ground. R2 made living here uneasy. People tried to stay away from him. I had to hide in my room to stay away and put a door stop on my door. R2 hit me in the nuts and with a fist a couple of times. R2 made my life hell. At 12:50 PM, V2 Licensed Practical Nurse (LPN) said R2 would intentionally antagonize R3 because he knew it bothered her. R2 has punched me a few times.R4 told me she was afraid of R2. R2 grabbed R4's arm and twisted it and then grabbed her breast. R2 grabbed R1's genitals. R2 would masturbate in front of the CNAs. There wasn't enough staff to do 1:1 supervision of R2. R2 has had these same behaviors since he got here. The residents wanted to know why he was still here and not gone. At 1:30 PM, V3 Nurse Practitioner said R2 had aggressive behaviors, invaded others personal space and was sexually inappropriate toward staff. V3 said she had not seen any 1:1 supervision of R2 until (MONTH) 4, 2019. At 2:15 PM, R5 said R2 is dangerous. He goes after people to attack them all the time. He makes residents scared. There's no telling what he'll do. He could pretty much do what he wanted without repercussion. It didn't seem like they attempted to deal with R2 and his behaviors. At 3:00 PM, V6 CNA said some of the CNA staff were fearful of R2 because he was sexually inappropriate and there was not usually 1:1 supervision of R2. R2's nursing notes dated (MONTH) 11, (YEAR), show R2 spit into another resident's face and then threw what looked to be a piece of his wheelchair at the other resident. A state agency report dated (MONTH) 7, (YEAR), submitted by the facility shows R2 was in his wheelchair and went behind R6 and pushed his lower leg with his foot. The nursing progress note from this incident shows staff asked R2 to stop and R2 laughed and started doing it again. R2's (MONTH) 20, (YEAR) nursing note shows R2 kicked another resident (R6) from behind causing his knees to buckle and him falling. Both residents were separated and R2 grabbed the wrist of R6. This same note shows R2's physical behaviors are willful and purposeful. When separating R2 from other residents, R2 smiles and attempts to return right back to inappropriate behaviors. R2's nursing note dated (MONTH) 21, (YEAR) shows R2 touched R7's (female resident) breast. R2 was told to stop which he did not. R2's nursing note dated (MONTH) 24, (YEAR), shows R2 would get really close to female residents with a smile on his face, scaring female residents. R2 then rolled his wheelchair into the hallway blocking other residents from going through. When nurse asked R2 to move, R2 punched nurse in the breast hard and said F**k You. R2's notes dated (MONTH) 28, (YEAR) shows he grabbed R7's wrist and when the nurse requested he let go R2 refused. An investigation summary dated (MONTH) 28, (YEAR) shows R2 touched R3's (female resident) breast. R2's (MONTH) 6, 2019 nursing note shows R2 hit another (unknown) resident in the breast. Later the same day, R2 punched R6 in the forearm. R2's (MONTH) 2, 2019 nursing note shows R2 punched R3 in the arm. R2's (MONTH) 4, 2019 nursing notes show at 9:00 AM, R2 grabbed R4's wrist and twisted the skin leaving a mark. At 11:00, R2's nursing note shows he grabbed a female resident's (R4) breast. At 11:05 AM, R2 grabbed a male resident's (R1) genitals, squeezed and twisted them. R2's care plan for sexually inappropriate behavior dated (MONTH) 19, (YEAR) shows to redirect and provide 1:1 with social services for interventions. After a (MONTH) 21, (YEAR) incident (care plan shows (MONTH) 20) when R2 grabbed R7's (female resident) breast, a (MONTH) 28, (YEAR) incident when R2 touched R3's (female resident) breast, and a (MONTH) 6, 2019 incident when R2 hit another resident's breast there were no new interventions implemented. R2's care plan for aggressive behaviors dated (MONTH) 19, (YEAR) shows to redirect, divert attention and notify social services for 1:1 as needed. A care plan intervention dated (MONTH) 29, (YEAR) shows to provide 1:1 close and constant supervision to monitor whereabouts and proximity to those easily upset by behaviors. After aggressive behavior incidents on (MONTH) 7, 11, and 20, (YEAR), (MONTH) 28, (YEAR), (MONTH) 6, 2019, and (MONTH) 2, 2019 there were no new interventions implemented. The facility's Behavior Management and Cognition Policy dated (MONTH) (YEAR) shows when a person served displays cognitive needs and/or exhibits dangerous or maladaptive behavior, it is the responsibility of staff to take steps to protect the client, the staff and the environment.

Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner. This failure contributed to R1's left leg being twisted and R1 sustaining a spiral fracture of the tibia and fibia bones of the left leg. This applies to 1 of 5 residents (R1) reviewed for safety and supervision with transfers. The findings include: R1's Minimum Data Set, dated dated dated [DATE] showed R1 has a BIMS (Basic Interview for Mental Status) score of 11 and requires extensive assistance of 2 people for transfers. R1's Care Plan revised July 6, 2017 showed R1 has [DIAGNOSES REDACTED]. R1's Emergency Department Documentation dated July 25, 2017 at 10:00 AM showed that R1 presented to the hospital with the report of a left ankle injury after the patient's leg got twisted when he was being moved last night. Chief Complaint: patient was being transferred last night at the facility by 1 aide, deformity to left ankle. R1's Emergency Department X-ray report dated July 25, 2017 at 10:08 AM showed, Spiral fractures of the distal diaphyses of the tibia and fibia on the left. Transverse fracture through the base of the first metatarsal. On July 31, 2017 at 8:30 AM, R1 was seated in an electric wheelchair with a blue plaster cast noted to his left lower leg. R1 stated that on July 24, 2017, during the evening shift, a new girl got me up using a sit-to-stand lift. I don't remember her name. I told her to go get help because they are supposed to use 2 staff to help move me, not 1. The girl told me she had been trained and knew what she was doing. She got me up in the lift and my left knee and left leg hurt right away. It was positioned wrong, my leg was turned wrong. I told her my leg hurt and then she went to go get help. On August 1, 2017 at 8:20 AM, E3 Certified Nursing Assistant (CNA) stated that she provided cares for R1 during the evening shift on July 24, 2017. E3 CNA stated, E7 CNA and I got R1 up to the toilet and to bed that night but E7 CNA kept walking in and out of R1's room. When we initially stood R1 up in the sit-to-stand lift, R1 complained of left knee and left ankle pain so I repositioned his left leg and then got R1 on the toilet. R1 usually complains of pain so I didn't think much of it. When we got R1 off of the toilet and into bed, he kept complaining of left knee and left ankle pain so I let the nurse know. E3 CNA stated that R1 remained attached to the sit-to-stand lift while on the toilet. E3 CNA stated she was making R1's bed and E7 CNA had stepped out of R1's room while R1 was being toileted. When E3 CNA was asked how R1 should be transferred, E3 replied, I believe R1 is a sit-to-stand lift with 2 person assistance. On July 31, 2017, E4 CNA, E6 CNA, E7 CNA and E8 Registered Nurse (RN) each denied helping with or transferring R1 during the evening shift on July 24, 2017. On July 31, 2017 at 2:00 PM, E2 Director of Nursing (DON) stated, I was called to R1's room by the nurse around 8:30 AM on July 25, 2017. R1 was lying in bed with his legs directly out in front of him. His left foot was rotated outwards at a 90 degree angle at the ankle. His left ankle was swollen. E2 stated that R1 was immediately sent to the hospital. E2 DON also stated that R1 is to be transferred by a mechanical lift with 2 persons assisting. On July 31, 2017 at 9:00 AM, Z3 (Nurse Practitioner) stated, R1 can't stand at all. He needs a mechanical lift with 2 person assistance for all transfers. On July 31, 2017 at 10:15 AM, E1 Administrator stated, E3 CNA told me she transferred R1 with a sit-to-stand lift that evening (July 24, 2017) while E7 CNA was in R1's room. R1 was supposed to be transferred with a mechanical lift. On August 1, 2017 at 8:45 AM, Z2 (R1's Orthopedic Physician) stated that R1's left tibia/fibia fracture sustained on July 24, 2017 was an acute spiral fracture. This fracture can be caused by hitting the leg on an object but is typically caused by the twisting of the leg while standing, possibly during a fall. The facility's Transfer Policy/Use of Mechanical Lifts revised September 2010 showed, The final decision on the method of transfer and amount of assist ultimately rests with the treatment team, and will be reflected on each individual care plan .

Based on observation, interview and record review the facility failed to keep a resident free from physical abuse on November 3, 2016. This failure resulted in E4 hitting R1 in the face with a closed fist three times which resulted in physical injuries to the right side of the face and a change in R1's behavior as manifested by anxiety and paranoid behaviors, and documentation of symptoms of post-traumatic stress disorder. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings include: The May 25, 2016 physician history and physical for R1 documents he was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The October 31, 2016 quarterly MDS (Minimum Data Set) documents R1 to have a BIMS (Brief Interview for Mental Status) of 15, cognitively intact. The MDS section G documents R1 is totally dependent on staff with a mechanical lift for all transfers to and from his wheelchair. The MDS documents R1 has verbal behavioral symptoms towards staff and other residents and refuses personal care assistance from the staff. The October 31, 2016 [MEDICAL CONDITION] medication assessment shows R1 has behaviors which alter his ability to function including: resist care, verbally abusive, physically abusive, yelling out, anxious complaints, and combative behavior. On November 15, 2016 at 12:15 PM, R1 stated on the night of November 3, 2016, E6 and E4 CNA ' s (Certified Nursing Assistants) pushed him into his room for his shower. R1 said E6 was in the room and turned the shower on and E4 attacked him. R1 said E4 was standing over him and hit him in the face. R1 said he had not provoked her or had any issues with E4, and this assault came out of nowhere. On November 15, 2016 at 9:30 AM, E6 said he took R1 to his room to be showered and needed to use the mechanical lift to transfer R1 into the shower chair. E6 said E4 was in the room to assist with the transfer. E6 said as he was attempting to raise R1 with the lift, and R1 swung his arm at E4. E6 did not see if R1 had hit E4 or if he had missed her. E6 said E4 then hit R1 on the right side of his face with a closed fist 3 times. E6 said after E4 hit R1 she removed her gloves and left the room. E6 said R1 appeared to be confused and scared. E6 said he stayed with R1 until the nurse arrived to assess him. E6 said R1 has swung him at before but has never hit him. E6 said R1 has been different since he was hit by E4, and R1 is calmer now, and does not have the physical behavior as he did before. On November 15, 2016 at 9:00 AM, E7 (CNA), said she entered R1's room just in time to see R1 swing his arm at E4 and then E4 hit R1 in the face with a closed fist 3 times. E7 said after E4 hit R1 she removed her gloves and left the room. E7 said R1 was in his chair crying and looked dumbfounded about what had just happened. E7 said E4 had worked with R1 prior to this incident. E7 said if R1 is having behaviors the staff is to give him time to think about what he needs to do and then re-approach him. E7 said if R1 does not like the aide, and then ask someone else to help. E7 said after E4 hit R1 he had a black eye and his face was swollen for days. E7 said since this incident R1 is a lot more cooperative, and a little edgy around staff. On November 15, 2016 at 9:35 AM, E9 LPN (Licensed Practical Nurse) said she was on duty the night R1 was hit by E4. E9 said she was in the medication room when E7 reported to her E4 had just hit R1 in the face. E9 said E4 was standing behind E7 crying trying to say R1 had hit her. E9 said she kept E4 in the medication room while she assessed R1 for injuries. E9 said R1 appeared very upset and was telling her that no one had ever hit him before. E9 said R1's face had already started to appear swollen and a dark area on his skin was starting to appear around his eye and cheek area, and was complaining of neck pain. E9 said R1 has asthma and was having shortness of breath and documented his oxygen saturation level at 82%, so she applied oxygen. E9 said after her assessment of R1, she called the administrator and the local police. E9 said the police arrived and took statements from all of the staff involved and suggested R1 be sent to the hospital for examination by a physician. E9 said she notified the nurse practitioner and R1 was sent to the local emergency room . E9 said when R1 returned to the facility his right eye was swollen shut and his cheek bone was bruised and the right side of his face appeared to be swollen as well. On November 4, 2016 at 3:00 AM, E9 documents R1 returned from the emergency room and the CT scan was negative and no pain medications were given. On November 15, 2016 at 9:00 AM, E5 (CNA), said R1 had hit her in the mouth once while she was attempting to provide care. E5 said she made sure he was safe with another staff member and left the room. E5 said she left because that is what the staff is trained to do when dealing with R1 ' s behaviors. On November 15, 2016, E11 (CNA), said R1 is combative when trying to provide care. E11 said R1 will kick and swing his right arm trying to hit staff. E11 said she has had no problems when caring for R1 and if any aide has difficulty with him, the aide can trade places with someone who works better with R1. R1's care plan for May 27, 2016 document a problem with physical aggression toward staff and others. This includes yelling, swearing, calling names. R1 has a history of refusing cares, hitting and pushing staff away during cares. The interventions for this behavior are to allow R1 time and opportunity to express self and verbalize frustrations. Allow him time to calm down, re-approach at a later time. Call for assistance as needed. Do not argue or force R1 into something he does not want to do. R1's care plan for being at risk for abuse and neglect shows he has episodes of refusing cares, which leads to hitting, kicking, scratching and pushing staff. At times resident behavior/actions can cause peers to become upset. The November 4-13, 2016 daily nurses notes document R1 had swelling to his right eye, and bruising of his eye and cheek bone area. On November 10, 2016 the nurse documents the bruising had extended down to the jawline. On November 13, 2016, the nurse documents bruising to the right eye and right side of his face, and bruising is visible below his neck and appears dark purple. On November 15, 2016 at 12:20 PM, 12 days after the incident, R1 was observed to have a purple area above his right eye. Bruising was noted in an approximate one inch wide line from his right ear, under his chin, to the bottom of his left ear. On November 15, 2016 at 10:50 AM, E8 (social services), said he was aware of R1 ' s behaviors and had encouraged him to speak with a psychiatrist and deal with what issues he may have. E8 said R1 has had an increase in his behavior as his stay continues. E8 said R1 has always refused to talk with anyone about his problems, but since the incident he had agreed to speak with the facility psychiatrist. On November 15, 2016 at 11:00 AM, E5 said since the incident R1 has changed his behaviors and he is not as physically aggressive and swinging at staff like he was before. E5 said she thinks R1 is afraid of being hit again. On November 15, 2016 at 12:15 PM, R1 stated he feels like he is always looking over his shoulder now when he is out of his room. The November 4, 2016 social service progress notes document R1 had continued to refuse psychological services. On November 8, 2016, E8 approached R1 again with the suggestion of psychological services and R1 accepted, and agreed to see the psychologist. On November 8, 2016, R1 was seen by Z1 (Psychologist) and Z1 documented R1 asks himself why it happened to him, explaining that he is a nice guy and gets along with people. Z1 documents that R1 showed signs of post- traumatic stress disorder ([MEDICAL CONDITION]), due to R1 frequently thinking about the incident and having dreams about it. Z1 documented a [DIAGNOSES REDACTED]. Z1 documents R1 will be followed for supportive psychotherapy. The undated facility policy for resident abuse and neglect shows that the organization strictly prohibits the abuse, neglect, mistreatment, involuntary seclusion of residents. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. Procedures: 3. Prevention: Staff are trained to be proactive, and interventions are taught to promote intervention before situations get out of control. Staff receives ongoing training through the MANDT program (positive behavior support), behavior modification training and individual resident behavior management programs.

Based on Observation, Interview and Record Review the facility failed to monitor residents assessed by the facility at high risk for pressure ulcers and identify pressure ulcers for these residents prior to becoming a stage II or higher. The facility failed to ensure pressure ulcer preventative measures are provided and evaluated for effectiveness for residents at risk for pressure. These failures contributed to R1 developing a pressure ulcer to his left outer ankle that was not identified until it was a stage III on 3/24/14. R2's pressure ulcer to his left achilles was not identified until it was a stage III on 2/2/14. R2's pressure ulcer to his left hip was not identified until it was a stage III on 2/26/14. R3's pressure ulcer to his right great toe was not identified until 5/1/14 when is was purple and a stage that was unable to be determined. This applies to 3 of 3 (R1, R2 & R3) reviewed for pressure ulcers in the sample of 3. The findings include: 1. The Weekly Pressure Ulcer Surveillance Report dated 10/31/13 for R1 showed he had a Stage III pressure ulcer to the left outer ankle that was present on admission to the facility on [DATE]. The Weekly Pressure Ulcer Surveillance Report dated 1/30/14 for R1 showed the pressure ulcer to his left outer ankle was healed. The Weekly Pressure Ulcer Surveillance Report dated 3/27/14 for R1 showed, "Onset date - 3/24/14; Place acquired - House (in house at the facility); Site acquired - Left outer ankle; Stage III; Size - 1.5cm x 0.9cm x 0.2cm; Appearance - 100% granulation tissue; re-occurring area re-opened." On 5/13/14 at 11:06am, E3 (Registered Nurse/Wound Care Nurse) stated, "R1 came in to the facility on [DATE] with a pressure ulcer to his ankle and one on his bottom. The pressure ulcer on R1's bottom has healed. The pressure ulcer to R1's ankle healed and re-opened. R1's left outer ankle pressure ulcer was a stage III when it was first identified again. I don't have any input on the care plan. The care plans are done by the Minimum Data Set (MDS)/Care Plan Coordinator." On 5/13/14 at 2:10pm, R1 stated, "The pressure ulcer to my left ankle is because of how my leg lays to the outside." Pt stated he did not have any offloading device in place to his left foot until the the left outer ankle re-opened at the facility. The High Risk Pressure Ulcer Care plan for R1, that was initiated on 10/25/13 and revised on 4/22/14, showed, "1/30/14 - discontinue treatment to left outer ankle. Apply skin prep and a dry dressing to the left outer ankle daily for one week." There was not any additional information or treatment orders documented on R1's care plan for his left outer ankle that re-opened on 3/24/14. The facility's Pressure Ulcer Prevention Program policy (no date) showed, "Wound Care Coordinator: Role and Responsibilities: Updates the resident care plan whenever change occurs in the status of the wound or when treatment is altered." The Weekly Pressure Ulcer Surveillance Report dated 11/14/13 for R1 showed a new pressure ulcer identified on 11/11/13 to R1's posterior left great toe that was "black" and measured 0.4 x 0.5cm. The black area on R1's left great toe had a stage listed as "unable to be determined." The Weekly Pressure Ulcer Surveillance Report dated 12/5/13 showed on 11/29/13 R1 acquired 2 new pressure ulcers that were first identified at a stage II to the right upper buttock. The Weekly Pressure Ulcer Surveillance Report dated 12/12/13 for R1 showed he had a new pressure ulcer to his right hip that was first identified on 12/7/13 at a stage II. The facility's Skin Care Protocol (8/2012) showed, "Certified nursing assistants are to notify the nurse of any changes of the skin while performing daily cares; The Wound Care Coordinator will stage pressure ulcers according to current staging guidelines." The Weekly Pressure Ulcer Surveillance Report dated 5/6/14 for R1 showed he has a stage II pressure ulcer to his left buttock that was acquired at the facility on 11/29/13. On 5/13/14 at 10:00am, R1's wheelchair had a pressure relief cushion in the chair that did not fit the width of the chair. The cushion was worn, flat and was 1.5 inches in depth. The manufacturer's dimensions for R1's pressure relief cushion showed the depth of the cushion should be 3 inches. On 5/13/14 at 11:06am, E3 stated, "R1's skin checks are done weekly. I don't check the pressure relief cushions for the wheelchairs. I don't know who checks them." On 5/13/14 at 2:10pm, R1 stated, "The cushion in my wheelchair is flat when my weight is on it. They come in and help me. They don't always reposition or turn me every 2 hours. Sometimes they get busy so I try to do it." The facility's Preventive Skin Care policy (no date) showed, "Resident's identified as being high risk for potential breakdowns shall be turned and repositioned every two hours or per plan of care; Pressure reduction cushions may be used in wheelchairs, if appropriate." The Pressure Ulcer Scale for R1 dated 1/22/14 showed a score of 9; a score of 10 or less equals high risk. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/13 and 4/24/14 for R1 showed a score of 15 for the Brief Interview for Mental Status (BIMS); no cognitive impairment. R1's Physician order [REDACTED]. 2. The Weekly Pressure Ulcer Surveillance Report dated 2/26/14 for R2 showed he had a pressure ulcer to his left achilles on 2/2/14 and was a stage III when it was first identified; R2 had a pressure ulcer to his left hip that was identified on 2/26/14 and was a stage III when it was first noticed. R2's Nurses Notes dated 2/26/14 showed, "CNA reported to this nurse an open area on R2's left hip. The area is a stage III. This is a re-occurring area that had last healed on 1/28/14." On 5/13/14 at 11:30am, E3 (Registered Nurse/Wound Care Nurse) stated, "R2's achilles was rubbing on the back of his shoe and it caused a pressure ulcer. The Certified Nursing Assistants (CNA) are to notify the nurse if they see anything on the residents skin." E3 stated the pressure ulcer to R2's left achilles was not identified until it was a stage III. On 5/13/14 at 10:10am, R2 was observed sitting in a wheelchair in his room. R2 had his left foot in a offloading boot that was resting on his foot pedal. R2 had a sock on his right foot. R2's right foot rested on the floor. R2 was able to cover his [MEDICAL CONDITION] and state his name. R2 said he did not know if he had a sore on his left lower leg. R2 stated the CNA's do not turn him when he is in bed. The Care Plan dated 1/28/14 for R2 showed, "R2 is at risk for skin breakdown due to left [MEDICAL CONDITION] and decreased independence. R2 wears braces to bilateral knees and a splint to his left hand which increases the risk of breakdown; 2/6/14 - Discontinue liquid protein; 2/26/14 - Cleanse left hip with normal saline, apply treatment and dry dressing daily and as needed; Monitor skin during cares and report changes to the nurse; Skin checks by nurse, document and report changes to provider." The POS dated 5/1/14 for R2 showed [DIAGNOSES REDACTED]. 3. The Nurses Notes dated 5/1/14 for R3 showed, "Purplish area noted on the tip of right great toe. R3's feet stick out farther than the foot cradle and sheets lay on top of his toes. Per R3's guardian, fold sheets off R3's toes to prevent sheets/blankets from laying on his toes." The Weekly Pressure Ulcer Surveillance Report dated 5/1/14 for R1 showed he has a facility acquired pressure ulcer to his right great toe; "Unable to Determine" for the stage; measures 1.2 by 1.0cm; dark purple in appearance. On 5/13/14 at 10:21am, R3 was observed sitting in a wheelchair, wearing tennis shoes. On 5/13/14 at 12:00pm, a copy of R3's care plan was requested and never received while at the facility on 5/13/14. The POS dated 5/1/14 for R3 showed [DIAGNOSES REDACTED].

Based on Observation, Interview and Record Review the facility failed to identify a pressure ulcer on R7's right foot prior to it becoming a Stage III and failed to identify pressure ulcers for R1 and R2 before becoming stage II. The facility failed to provide pressure relief to the area after the pressure ulcer was identified. The facility failed to determine causative factors for R7, R1, R2 and R19's pressure ulcers and failed to provide preventative measures to prevent skin breakdown. These failures resulted in R7 developing a stage III pressure ulcer to his right foot. This applies to 4 of 8 residents (R7, R1, R19, R2) reviewed for pressure ulcers in a sample of 13. The findings include: 1. The physician's orders [REDACTED]. R7's Norton Plus Pressure Ulcer Scale dated 8/1/12 shows that R7 scored a 10. (10 or less= High Risk) Nurse's Notes dated 7/26/12 states, "New treatment order: cleanse arch of right foot. Apply Therahoney Gel and cover with protective dressing." R7's Skin Issue Details Report dated 7/26/12 shows that the pressure ulcer on R7's right foot measured 3.5 x 4 x 0 cm. It is described as 50% beefy red, 50 % slough, edges macerated, small amount of serosanguinous (drainage), Stage III. No information is given regarding the causative factors of the pressure ulcer. On 8/7/12 at 9:00 AM, E3 (Treatment RN) stated, "The foot wound developed here. " On 8/7/12 at 1:45 PM, E3 was observed as she changed the dressing on R7's right foot. On the inner aspect of R7's right foot there was a quarter sized pressure area. The area was covered with a stringy white/yellow tissue (slough). No drainage was observed. On 8/7/12 at 1:55 PM, E3 was asked how R7 got the wound on his right foot. E3 stated, "If I had to guess, if I had to be psychic, I would say it is from the way the shoe sits on the foot rest. The CNA found the wound and told me. We got the boot last week and it has helped because before that he was still wearing his shoe. It could be because he is so flat footed and there is an arch in the shoe." R7's Care plan dated 8/1/12 does not list any approaches to remove or reduce pressure from R7's right foot to prevent the pressure ulcer from getting worse or to prevent additional pressure ulcers from developing. The facility ' s Pressure Ulcer Prevention Program showed, " The facility will promote the prevention of pressure ulcer development.; Skin Care Protocol: Nurse aides and certified nurse aides are to notify the nurse of any changes of the skin while performing daily cares. The nurse will start a newly acquired skin care sheet. The sheet is turned in to the DON (Director of Nursing) for assessment and staging of the area. The DON or her designated appointee according to current staging guidelines will stage pressure ulcers. Weekly documentation to include ulcer location, stage, size, exudates amount, pain, wound bed characteristics and description of ulcer margins, surrounding skin, and odor noted.; Use proper positioning, turning, and transferring techniques to minimize skin injury due to friction and shear forces. " 2. The Physician order [REDACTED]. The Minimum Data Set of 6/19/19 shows R1 is at risk for developing pressure ulcers. On 8/7/12 at 2:30 PM, E3 (Treatment Nurse) was observed changing a wound dressing on R1's left hand over the first knuckle. E3 stated the pressure wound was caused by pressure from R1 pressing his hand against his bare skin on his abdomen. Both of R1's hands and arms were stiff and in severely contracted positions. E3 stated the CNA staff are to report any changes in a resident's skin and she will follow up with assessing the area. The wound documentation for R1's left finger wound shows the ulcer was first identified on 8/1/12 and measured 1.0 cm x 0.5 cm, Stage II. The wound documentation on 8/2/12 measures the wound at 1.0 cm x 0.8 cm with slough over the wound bed. On 8/7/12 at 2:40 PM, R1's left hand was observed lying on the plastic arm rest of the high back reclining wheelchair. R1's right arm and hand were very stiff and E3 was unable to open R1's hand. R1's fingers were contracted inward toward the palm of his hand. R1's left hand was lifted off the arm rest and on the top of the 2nd, 3rd and 4th fingers deep indentations were noted in the skin. Deep red circular areas were noted around the indentations. On the lateral wrist area, an indentation was also noted with a dark red circular area. The indentations and deep red circular areas on the right fingers and wrists had not resolved when re-examined 5 minutes later. E3 stated she was not aware of these areas, and stated a support surface under the hand would be definitely be helpful to alleviate the pressure. E3 stated thoroughly washing the inside of R1's right hand would help resolve the odor from the hand. The Physician order [REDACTED]. Passive Range of Motion to all extremities are to be done twice a day. R1's care plan does not identify the risk factors for pressure to his hands and does not list preventative measures to prevent pressure to his hands and fingers. On 8/6/12 at 2:50 PM, E11 (CNA) was asked for the whereabouts of R1's right hand splint. E11 stated she was not aware of any hand splints for R1. The undated facility Pressure Ulcer Prevention Program states daily skin inspection of residents by CNA during cares, and to notify the nurse of any findings. 3. On 8/7/12 at 3:15 PM, R19 was observed sitting in a wheelchair with his left leg positioned on the leg and foot rest attached to the chair. R19 was unable to independently move his left arm or left leg. The left hand was lying on a padded arm cushion; a hand splint was not in place. R19's foot was strapped to the foot rest with a velcro strap. R19's knee and upper leg were pressed firmly into the upper part of the leg rest where it attaches to the chair. A sharp metal edge was noted between the leg rest and R19's skin. R19 stated, "I think there is a pad that should be there to prevent that from digging into the skin on my leg. I have very poor feeling in my leg and can't tell if the pad is in place. E7 (Restorative Nurse) was asked to check R19's leg placement. E7 lifted R19's leg and deep red skin indentations were noted on his knee and upper calf area. The Care Plan dated 5/9/12 states R19 is at risk for skin breakdown due to Left [MEDICAL CONDITION] and Obesity. R19 is dependent of staff for transfers and requires extensive assist for bed mobility. The care plan shows on 6/13/12 a left resting hand splint to be used for R19. The care plan does not list interventions to alleviate pressure caused from the leg rest of the wheelchair. 4. On 8/7/12 at 9:25am R2 was observed sitting up in his wheelchair wearing tennis shoes with his feet on his foot rests. On 8/7/12 at 9:38am R2 was observed laying in bed with his heels touching the bed surface. R2 ' s Nurse ' s Notes showed, " 1/2/12 - R2 has a blister on his right heel. New treatment to cleanse and apply skin prep and daily as needed until healed.; 5/25/12 - New order to apply skin prep to the blisters to right inner heel and arch of foot until healed.; 8/1/12 - New order: Apply skin prep to right great toe daily until healed. " The Monthly Note for R2 dated 6/12/12 showed, " R2 has a potential for alteration in skin integrity related to decreased mobility. R2 has a history of skin alterations. R2 also has a blister to right inner heel and arch of right heel that we are putting skin prep on after cleansing. " On 8/8/12 at 10:15am E3 (Treatment Nurse/Registered Nurse) stated, " R2 had a blister on the right great toe. Skin prep was applied to the blister to toughen it and prevent it from popping. I don ' t remember if I filled out any skin sheet assessments. I am not sure what stage pressure ulcer a blister is. I would have to go to E2 (Director of Nursing - DON) about that. I don ' t know what caused the blister to R2 ' s toe. " R2 ' s Care Plan dated 6/21/12 showed, " Document on all skin alterations, measurements, appearance and progress or lack of progress weekly. " R2 ' s Care Plan dated 6/21/12 showed no interventions for the prevention of pressure ulcers to R2 ' s feet. The facility ' s Pressure Ulcer Prevention Program showed, " Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. " The Physician order [REDACTED].