**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to position residents properly to prevent injury for 1 of 3 residents (R1) reviewed for accidents in a sample of 11. This injury resulted in R1 sustaining a closed displaced fracture of right femoral neck. This past non-compliance occurred between 01/19/25 and 01/23/25. Findings include: R1's face sheet documents an admission date of 06/06/24 with diagnoses including: fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, Alzheimer's disease, osteoarthritis, iron deficiency, shortness of breath, nutritional deficiency, anxiety disorder, insomnia, muscle weakness, rheumatoid arthritis, pain, unsteadiness on feet, age related osteoporosis without current pathological fracture, mid cognitive impairment of uncertain or unknown etiology, vitamin D deficiency, displaced intertrochanteric fracture of left femur, presence of right artificial hip joint, nausea with vomiting, major depressive disorder. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 02, indicating R1 has severe cognitive impairment. R1 is documented as being dependent for being able to wheel 50 feet with two turns in a manual wheelchair and dependent for being able to wheel 150 feet in a manual wheelchair. R1's care plan documents a problem of pain with a start date of 07/30/24 with an approach of: handle gently and try to eliminate any environmental stimuli with a start date of 07/30/24. R1's care plan documents a problem category of: ADLs (Activities of Daily Living) functional status/rehabilitation potential with a problem start date of 06/06/24 with an approach listed as: overall I (R1) require extensive assistance with oral care, extensive with bathing, extensive with grooming, limited with eating, extensive with dressing, extensive with mobility with a start date of 06/11/24 and an approach listed as: safety: I (R1) will need to be monitored to prevent falling in my new environment. I will need assistance with bed/chair mobility, assistance with transfers, assistance with locomotion to prevent falling or injury with a start date of 06/11/24. R1's Serious Injury Incident Report to the Illinois Department of Public Health (IDPH) dated 01/27/25 and is documented as a final report. This report documents an incident date of 1/20/25 and documents under the section titled, detailed incident summary that facility ordered an x-ray on 01-20-25 due to resident grimacing in pain and having issues standing and rolling in bed. X-ray showed an acute subcapital right femoral neck fracture. DON (Director of Nursing) notified, family POA (Power of Attorney) of x-ray results and they wanted her sent to the hospital. Resident (R1) has an extensive history of Alzheimer's disease, osteoarthritis, nutritional deficiency, muscle weakness, rheumatoid arthritis, age related osteoporosis, mild cognitive impairment, vitamin D deficiency, past MVA (motor vehicle accident) where her right side was crushed and had screws in femoral plate. Resident was sent to the hospital and admitted . Resident's last fall was 01/07/25 with no complaints or pain noted. Following facility investigation while facility attempted to weigh resident her position in the wheelchair resulting in residents leg making contact with the bar on the scale resulting in impact to the right leg/foot area. Upon immediate assessment of resident she denied any pain or discomfort, following assessment noted grimacing from resident resulting in facility initiated x-ray. Due to resident's age, medical history, ortho notes of previous ORIF (Open Reduction Internal Fixation) of hip along with the accident all being contributing factors resulting in fracture. Facility has began reeducation and training on nurse on body alignment and positioning and have scheduled additional training. Facility will continue to monitor for any additional changes and needs and address any concerns. The facility investigation documents were requested from the facility and provided for review. These documents included Incident Investigation Reports documenting interviews with V5 (Licensed Practical Nurse/LPN) and V6 (Certified Nursing Assistant/CNA) and document the following: V5's statement dated 01/21/25 documents on Sunday 01/20/25 (per calendar Sunday's date was 1/19/25) I got reweight [sic] on the scale when pushing her on the scale she had her legs crossed and right foot hit the bar. Resident (R1) said 'ouch' wheelchair backed up and repositioned. Upon assessment ankle and foot evaluated and no abnormalities noted. V6's statement dated 01/21/25 documents over the weekend I noticed the resident (R1) was a lot weaker than normal. She was a 2 assist (hard). Resident had complained of hip on Sunday for sure and foot when you put on her shoe (right foot but kept left foot straight). I had layed [sic] resident down Sunday evening, but had to get her back up to get weighed. The nurse V5 (LPN) helped me get her back in bed and I had mentioned it to her again of her hip pain and she noticed that her right leg went inward. R1's Progress Notes document the following: 01/19/25 at 4:59 PM (recorded as late entry on 01/25/2025 at 4:59 PM) This LPN (V5) needed to reweight [sic] res (resident) (R1) as a result from a previous weight not being consistent with baseline. Staff was assisting res into bed as nurse came in and explained the need to reweight [sic]. Staff and nurse assisted res back into wheelchair and this nurse pushed res to weight scale. Once weight scale was turned on res was gently pushed up the incline when nurse heard res say ouch nurse observed res right foot resting against the bar on weight scale. This nurse observed res right foot resting against the bar on weight scale. This nurse immediately retracted the WC (wheelchair) from weight scale. Skin was observed to be free of marks or abnormalities. No outward rotation or shortening noted to right lower extremity. No pain noted as evidence by no facial grimace or verbal complaints of pain upon assessment once res in bed. 01/20/2025 at 6:32 AM documents (x-ray company) called and confirmed the order and will send to tech at this time. 01/20/2025 at 3:14 PM documents received notification via (x-ray company) that results show right hip is displaced. POA notified and stated would like resident sent to ER (Emergency Room) for evaluation. (V11-family) also stated that she understood that resident is a 'stinker' at times and tries to transfer self and does not communicate needs at times. Doctor notified and stated resident's osteoporosis and advanced age plays a factor in risk for fracture. PRN (as needed) Tylenol order increased, and preparations started to send resident to ER. 01/20/2025 at 3:16 PM documents (R1) is displaying sign of pain such as grimacing and withdraw. This LPN adm (administered) tyn (Tylenol) and ineffective. NP (Nurse Practitioner) made aware and tramadol recommended for pain, tramadol administered. 01/20/2025 at 3:41 PM documents (R1) left facility via EMS (Emergency Medical Services) 01/21/2025 at 7:36 AM documents (R1) admitted to hospital on [DATE]. 01/25/2025 at 2:16 PM documents in part (R1) arrived to facility via transportation from hospital. Report was being called in while resident was arriving. Report states that (R1) was admitted on the 20th for right hip fx (fracture) .Script for Norco was sent in packet. Also states that can re-start tramadol. New order for ASA (aspirin) 325mg (milligrams) BID (twice a day) x 14 days. Trouble taking fish oil and was not able to take and states that they have been crushing meds in ice cream and no issues noted since crushing. States that resident will need a f/u (follow up) appointment with (name of physician) in 10-14 days post-surgery and surgery. R1's X-Ray report with a date of service of 1/20/25 documents an 'Impression of Acute subcapital right femoral neck fracture. R1's local hospital History and Physical dated 1/20/25 document a Chief Complaint of hip pain. R1's Discharge Summary from the local hospital dated 1/25/25 documents a Principle Problem of Closed displaced fracture of right femoral neck. On 02/21/25 at 10:16 AM, V5 (Licensed Practical Nurse) stated, R1 was weighed earlier in the morning on 1/19/25 and her weight was off so she was supposed to get a re-weight for R1. They had already put R1 to bed so they had to get her back up. R1 was in her wheelchair and had her legs crossed. When she pushed her up on the wheelchair platform her right leg/foot hit the vertical bar of the scale on R1's left side. R1 said ouch and she backed up and repositioned the wheelchair on the scale. R1 did not have foot pedals on her wheelchair. V5 stated she weighed R1 around 5:30 PM. V5 said she assessed R1 when they put her to bed and did not notice anything and then she left at 6:00 PM. V5 stated, R1 is a small lady, she did not propel herself in her wheelchair and she did not move around a lot or flail around. V5 stated R1 is confused, R1 will babble and her sentences usually do not make sense. On 02/20/25 at 1:36 PM, V7 (Certified Nurse Aide) stated, she worked at 6:00 AM on the Monday morning of 01/20/25. V7 stated R1 is not cognitive all the time but when she was transferring R1 she was saying ouch but she couldn't figure out where the pain was coming from. Then she saw R1's hip and it did not look right so she told the nurse and the nurse came down to evaluate R1. V7 stated she did not get R1 out of bed, the previous shift gets her up due to she gets up around 4:00 AM and moves to the recliner before breakfast, she was getting R1 ready for breakfast. On 02/20/25 at 1:50 PM, V4 (Licensed Practical Nurse/LPN) stated, V12 (CNA) came in at 10:00 PM on 1/19/25 and R1 was sleeping, they noticed on 1/20/25 at 4:00 AM when R1 gets up that she was uncomfortable and she starting assessing R1 then. On 02/20/25 at 8:52 PM, V6 (CNA) stated she assisted R1 the weekend of 01/19/25. On 01/18/25 R1 seemed weak so another girl helped her transfer her. On 01/19/25, V6 noticed R1 had not been reweighed yet and reweighed her. Over the weekend R1 seemed like she was in pain but not excruciating pain. V6 said that she did not notice her foot on 01/18/25 or 01/19/25 until the evening of 01/19 when her foot seemed like it was turned inward. V6 said she told V5 about it. On 02/20/25 at 12:05 PM, V8 (Therapy Director) stated she heard about the incident with R1 and her leg hitting the scale but she was not present. The injury R1 has can occur due to a fall, any impact with limb, depending on the person. R1 has declined after surgery, mainly due to her cognition level. R1 was evaluated for therapy but was declined due to cognition limitations. On 02/21/25 at 5:35 PM, V1 (Administrator) stated the injury with R1 they felt was a positioning concern therefore all the staff has been in-serviced on correct positioning and transferring after the injury with R1 occurred. The facility policy dated 09/08/23 titled, Safe Patient Handling Program documents: purpose: to identify, assess and develop strategies to control the risk of injury to resident, nurses and other health care workers associated with lifting, transferring, repositioning, or movement of a resident. This program applies to all staff-assisted resident lifts, transfers and ambulation performed by employees under normal conditions, during the performance of non-routine tasks and in the event of emergencies. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 01/23/25. In attendance - V1, V4 (LPN), V13 (Director of Nursing/facility nurse practitioner), V15 (Registered Nurse), V16 (Medical Records), and V17 (Director of Maintenance). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V1, V4, V13 (Director of Nursing/facility nurse practitioner) and V14 (Regional Clinical Director) provided in-service to nursing staff regarding weight management policy and body alignments in chair and positioning. Completed on 1/23/25. 4. Plan to monitor performance to ensure solutions are sustained: V13/designee will audit transfer and repositioning 3 a week for 2 weeks, 2 times a week for 2 weeks and weekly for 1 month identifying transfer and repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and, record review the facility failed to treat residents with dignity by answering call lights in a timely manner for two residents of nine residents (R1,R6) reviewed for resident rights in the sample of nine. This failure resulted in R1 and R6 experiencing feelings of embarrassment and humiliation. Findings include: 1. R1's Face Sheet documented an admission Date of 12/3/24 and listed diagnoses including Displaced Comminuted Fracture of Shaft of Left Femur, Fibromyalgia, Polyneuropathy, Depression, and Anxiety Disorder. R1's Brief Interview for Mental Status Score (BIMS) dated 12/8/24 documented a score of 14, indicating R1 has minimal deficits in cognition. R1's Nursing Progress Note dated 12/3/24 documented, admitted a [AGE] year-old Caucasian female via ambulance from (local hospital). Brought into facility via stretcher and transferred to chair per 2 EMT's (Emergency Medical Technicians) with TTWB (Toe Touch Weight Bearing) status to LLE (Lower Left Extremity) (due to fractured left femur). This note further stated, Resident. States she has chronic pain due to Fibromyalgia and rates it normally at a chronic 4 (on a 0-10 scale). On 12/18/24 at 1:40pm, R1 was alert and oriented to person, place, and time. R1 stated she had fallen while living in the community and fractured her femur and needed nursing facility care for rehabilitation. R1 stated she was admitted to the facility on [DATE]. R1 stated call lights routinely take over an hour to be answered. R1 stated she had experienced difficulty with loose stools and had been incontinent in bed while waiting long periods on her call light. R1 stated, That was very hard on my dignity. R1 stated when she had complained to one of the Certified Nursing Assistants (CNA) (identity unknown) about waiting so long, the CNA told her to, Just go ahead and go in the bed and we will clean you up later. On 12/19/24 at 10:50am, R1 was alert and oriented to person, place, and time. R1 stated, You can't imagine how embarrassing it is to turn on your call light and wait for over an hour and then lose control of your bowels because nobody came to check on you. Then you have to have somebody clean you up. It's pretty humiliating. 2. R6's Face Sheet documented an admission Date of 12/10/24 and documented Diagnoses including Fracture of Left Femur, Malignant Neoplasm of Colon and Low Back Pain. R6's BIMS dated 12/17/24 documented a score of 15, indicating R6 has no deficits in cognition. R6's Nursing Progress Note dated 12/10/24 documented, Resident arrived to facility at approx 1:45pm via facility transport van. Left hip surgery on 12/5/24, left hip dressing has moderate serosanguinous drainage with purple bruising to left hip. Maximum 2 assist pivot transfer with front wheeled walker from wheelchair to bedside commode. On 12/17/24 at 12:25pm, R6 was alert and oriented to person, place, and time. R6 stated call lights generally take about 45 minutes at minimum. R6 stated she fell at home and broke her left leg and is dependent on staff for transfers, and she cannot ambulate at this time. R6 stated she has been having loose stools since admission and has had several accidents while waiting for her call light to be answered. R6 stated she wears incontinence briefs but prefers to defecate on the commode rather than the incontinence brief. R6 stated when she has accidents, staff have to clean her up and it is very embarrassing. R6 stated, I've pretty much thrown my dignity out the door since I've been here. V11, R6's family member, who was also in the room with R6 stated he has been present during several of these instances and he corroborated her account. 3. On 12/17/24 at 9:35am, V10, Ombudsman, stated complaints about long call light wait times comes up at almost every monthly resident council meeting. Resident Council Meeting Minutes documented the following: 9/26/24: Call lights not being answered in a timely manner still an issue. Leaving residents on the toilet too long. Not having beds made and leaving beds dirty. 10/24/24: Still not having call lights answered in a timely manner. On 12/19/24 at 8:45am, V2, Director of Nurses, when asked what her expectation is as to how long residents should have to wait on call lights. V2 stated the State Agency does not specify in any regulations as to how long it should take for call lights to be answered, but ideally, they should be answered as soon as possible. V2 stated she did not feel the problem was that call lights are not answered timely, but that resident's perception is that it takes longer than it actually does. V2 further stated a former CNA staff member contractually employed via a staffing agency had a lot of complaints from residents about her being slow to answer call lights, and since she left their employment in October 2024, the problem seems to have resolved. V2 stated it is not acceptable for staff to tell residents to be purposely incontinent in bed if it takes too long to answer call lights. The facility's, Answering the Call Light Policy, dated July 2014 stated, The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 8. Answer the resident's call light as soon as possible. The facility's, Resident Rights, policy dated August 31st, 2023, stated, The resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility, including: A facility must treat each resident with respect and dignity and care for the resident manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents individuality. The facility must protect and promote the rights of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to formulate a Care Plan to address a resident's pain and to provide as needed pain medication in a timely fashion for one resident of nine residents (R1) reviewed for quality of care in the sample of nine. This failure resulted in R1 experiencing unresolved excruciating pain from a femur fracture, with accompanying feelings of fear and anxiety. Findings include: R1's Face Sheet documented an admission Date of 12/3/24 and listed diagnoses including Displaced Comminuted Fracture of Shaft of Left Femur, Fibromyalgia, Polyneuropathy, Depression, and Anxiety Disorder. R1's Care Plan dated 12/9/24 did not document any problem areas nor interventions addressing pain. R1's 12/8/24 Brief Interview for Mental Status Score documented a score of 14, indicating R1 has minimal deficits in cognition. R1's December Physicians Order Sheet documented orders for hydrocodone-acetaminophen 5-325 milligrams take one tablet every 4 hours as needed for pain, not to exceed 3 grams of acetaminophen every 24 hours, and methocarbamol 500 milligrams take one tablet every 4 hours as needed for muscle cramps/spasms. R1's December Medication Administration Record documented that R1 received the hydrocodone-acetaminophen and the methocarbamol on 12/13/24 at 4:39pm and not again until 12/14/24 at 7:34am, with V8, Registered Nurse (RN) administering the 12/14/24 dose. The same MAR documented R1's pain on 12/14/24 at the beginning of the day shift (6am) as zero on a scale of zero to ten. On 12/18/24 at 1:40pm, R1 was alert and oriented to person, place, and time. R1 stated she had fallen while living in the community and fractured her femur, needed nursing facility care for rehabilitation, and therefore was admitted to the facility on [DATE]. R1 stated she has experienced a significant amount of pain from the fracture, as well as anxiety. R1 stated when she asked for her as needed pain medication and muscle relaxer, it rarely came within 20 minutes, and it generally took at least an hour. R1 stated this made her pain more difficult to control. R1 stated on Saturday 12/14/24 at 3am, she was experiencing excruciating pain from the fracture and turned on her call light and told, One of the CNAs (Certified Nursing Assistants), she needed the pain medication and muscle relaxer. R1 stated after several minutes, nobody came back, so she turned her call light on several more times throughout the early morning hours, and CNA staff told her the nurse was busy on another hall, the nurse had a delivery of medications she needed to put away, and that she was busy with another resident. R1 stated she did not receive the medications until about 7:30am that morning, when V8 came in to give her morning medications. R1 stated she told V8 how upset she was about waiting all that time and being in pain, and V8 stated the night nurse (V9, Registered Nurse) was new and she was overwhelmed. R1 stated when she finally received the medications, She was in terrible pain and it took the medications a lot longer to be effective, and they didn't control the pain as well, and she was extremely upset. When R1 was told by the Surveyor that the beginning of shift documentation rated her pain at zero, R1 stated, It wasn't a zero, it was a ten. R1 stated, She called her husband and said, I want to go home, I'm not safe here, I'm scared, they aren't giving me my pain pills after I ask for them and they aren't answering my call light. R1 stated her husband came and got her and she left without signing any discharge paperwork. R1 stated since she left AMA (Against Medical Advice) and did not consult with staff, she did not have any discharge medications. R1 stated her pain got much worse as the day wore on, and she ended up going to the emergency room that evening. R1 stated she is still in the hospital and is being treated for Pneumonia. R1's Nursing Progress Note dated 12/3/24 documented the following: admitted a [AGE] year-old Caucasian female via ambulance from (local hospital). Brought into facility via stretcher and transferred to chair per 2 EMT's (Emergency Medical Technicians) with TTWB (Toe Touch Weight Bearing) status to LLE (Lower Left Extremity) (due to fractured left femur). This note further stated, Resident states she has chronic pain due to fibromyalgia and rates it normally at a chronic 4 (on a 0-10 scale). R1's Nursing Progress Note, authored by V8, dated 12/14/24 at 10:15am documented the following: This morning this nurse went to residents' room to give her morning meds, she asked for pain pill along with her meds. Resident took meds without any further complaints. Shortly after the stepson came in facility and said resident called him and wanted to go home. This nurse went to resident room to speak with resident. Resident stated I was supposed to go home soon anyways, I think I am good to go home now. I will feel better being at home with my husband and my family can care for me there. Spoke with resident and stepson about the need to stay further for therapy and to be monitored. Stepson stated he felt she should stay a few more days anyways because her husband would not be able to fully care for her. Resident stated, I do not care I am leaving this place this morning either way. Spoke with resident and stepson about being toe touch weight bearing, the risk, and dangers of leaving against medical advice, she stated she understood all of that and was still adamant of leaving and going home. The stepson said the husband was on his way, I told him I would be back in to speak with him further when he arrived. Shortly after the PTA (Physical Therapy Assistant) came to inform nurse that husband just came in, grabbed residents' things, and took her out via wheelchair and they was gone without signing the paperwork. (V1) Administrator, (V2) DON (Director of Nurses), MD (Medical Doctor) and (V3) ADON (Assistant Director of Nurses) all notified. On 12/18/24 at 11:30am, V8 stated when she came in to work at 6am on 12/14/24, nothing was said in report from the night shift about R1 being in pain or upset. V8 stated she went into R1's room about 8am to give R1 her morning medications. V8 stated R1 asked if her pain medication and muscle relaxer were being given and V8 stated no, do you need them, and R1 stated yes. V8 stated she did not recall what R1's pain level was at that time. V8 stated R1 said she had asked for them on night shift but did not receive them. V8 stated later during the morning, an extended family member of R1 came in and said R1 had called, was upset about not receiving her pain medications timely, and wanted to go home. V8 stated she went and talked to R1 and told her she was not ready for discharge and strongly discouraged her leaving. V8 stated R1 said her husband was coming to get her and she was leaving. V8 stated she told R1 she would need to sign some documents before she left, and R1 said OK. V8 stated when she re-entered the room shortly thereafter, R1 and her belongings were gone. On 12/18/24 at 2:30pm, V9, stated she worked 6pm to 6am on 12/13/24-12/14/24. V9 stated it was the first night she worked alone at the facility after having, Trained on a couple of night shifts. V9 stated she found herself, Working by herself with 2 CNAs and 40 something residents. V9 stated it was, A horrible night. V9 stated she had a newly admitted resident with a blood sugar of over 600 who had no medications or insulin, and had another resident sustain a fall. V9 stated she could not remember anything about R1 and did not recall R1 having asked for pain medication, but as chaotic as it was, it's possible she did. V9 stated after that night, she texted V2, Director of Nurses, to let her know she would not be returning, as she did not feel she could provide safe resident care under those circumstances. V9 stated the Surveyor calling her was the first she had heard anything about R1 not receiving pain medication that night. On 12/19/24 at 8:45am, V2 stated the role of the 6pm-6am nurse is to pass medications, supervise CNA staff, assist CNA staff as needed, and assess residents as needed. V2 stated she has heard no complaints from residents or families about not receiving as needed pain medications in a timely fashion. When asked about what happened with R1 as outlined above, V2 stated she had heard on 12/14/24 from staff that R1 left AMA because R1 was upset that she didn't get her pain medication timely. V2 stated she did not investigate R1's complaint, but V3, Assistant Director of Nurses, did. On 12/19/24 at 9:20am, V3 stated, She did not really do an investigation into (R1's) not getting pain medication because nobody would admit to her having asked for it. V3 stated she did ask V9 about it, and V9 stated, She had a really rough night, and she didn't remember (R1) asking for pain medication. The facility's Pain Prevention and Treatment Policy dated October 2017 documented, Policy: To assess for, reduce, the incidence of, and the severity of pain to help residents attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. The facility will develop and implement a plan, using pharmacological and non-pharmacological interventions to manage pain and/or try to prevent the pain consistent with residents goals.