**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure adequate supervision and proper use of assistive devices for one wheelchair dependent resident (R1) of three residents reviewed, resulting in an injury requiring urgent transport to the hospital for an acute comminuted femur fracture.This past non-compliance occurred from 07/29/2025 to 08/05/2025.Findings include: R1 is a [AGE] year-old resident of the facility with a Brief Interview for Mental Status (BIMS) score of 12, and with pertinent medical diagnosis including but not limited to Displaced Comminuted Fracture of Shaft of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Age-Related Osteoporosis; Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease; End Stage Renal Disease; and Dependence on Renal Dialysis. On 08/11/2025 at 1:04 PM, upon request, R1 agreed to speak with this Surveyor in her room. R1's room was dark; the television was on, so R1 turned it off; a wheelchair was located on the right side of R1's bed; one attachable wheelchair footrest was noted on the seat of the wheelchair; and the room appeared clutter-free. R1 said that most of the time, the pain level from her right leg, post-surgery, was a ten out of ten, but, on occasion, it went down to five. R1 said she didn't remember the date, but about two weeks ago, at about 1:00 or 2:00 PM, V4 (CNA) wheeled her outside of her room, while on her wheelchair, in order to take her to get her hair done at the facility's hair salon. R1 said that as V4 was pushing her in the hallway, her right foot rolled under her wheelchair, she hollered, then V4 ran back to her room to get a footrest, fastened it to the wheelchair, and placed her right foot on it. R1 said her knee was hurting so bad. R1 said V4 then wheeled her to her hair appointment; and when she was done, she was wheeled back to her room. On 08/12/2025 at 11:50 AM, R1 reiterated to this Surveyor that on 07/29/2025, V4 was wheeling her on her wheelchair towards the hair salon, and that she had no footrests on either side of the wheelchair at the time she was being pushed down the hallway. R1 said that after her right foot rolled under her wheelchair, V4 went inside her room, got a footrest for her, fastened it to her wheelchair, placed her right foot on it, and wheeled her to her hair appointment. On 08/11/2025 at 11:17 AM, V12 (Family Member) told this Surveyor that about two weeks ago, on a Tuesday, at about 5:50 PM, R1 called her from the long-term care facility, and said V4 rolled her right leg under her wheelchair while she was taking her to the beauty shop, and her wheelchair did not have a leg brace to support her leg. V12 said that R1 told her that, after V4 realized R1's right leg had been rolled under the wheelchair, she put a leg brace on the wheelchair and put R1's right foot on it. V12 said that the hospital doctor told her R1's right leg had been fractured in two places. On 08/14/2025 at 9:29 AM, V4 told this Surveyor that on 07/29/2025, R1's right foot came off her wheelchair's leg rest while she was wheeling her about halfway down the hallway to the hair salon for an appointment. V4 said she did not know how it happened, only that it (R1's right foot) slipped off. V4 said she never looked at R1's feet or legs while she was pushing her wheelchair from behind. V4 said that when she went to the front of the wheelchair after R1 hollered, ow, my leg, R1's leg was under the wheelchair, but she did not know how far it had gone under. In a progress note from 07/29/2025 at 6:28 PM, V13 (RN) stated in part that R1 verbalized pain on her right knee and said that it was during transfer when she went down to the salon this morning. In a progress note from 07/30/2025 at 9:00 AM, V14 (APN) stated in part that R1 presented with very bad knee pain and ten out of ten severity for one to two days. In a progress note from 08/01/2025 at 11:34 AM, V15 (NP) stated in part that R1 complained of pain to her right leg, which was not improving with medication, and the pain had been there since her foot dragged under the wheelchair while she was going for an appointment. On 08/12/2025 at 12:32 PM, V6 (APN, Orthopedic Surgery) told one of the Surveyors that she remembered R1 and her injury while at the hospital; and she believed it would have been unlikely that R1's right foot would have gotten caught underneath the wheelchair if the footrests and her feet were put on properly (if they were put on at all). On 08/12/2025 at 12:40 PM, V5 (Restorative Nurse) told this Surveyor that she assessed residents to determine if they were able to move on wheelchairs unassisted, and in R1's case, she was unable to wheel herself, independently, and needed substantial dependent assistance with locomotion. V5 said she had approved two footrests for R1's wheelchair and had instructed nurses and CNA's to ensure they were attached to R1's wheelchair whenever she was going to any destination. V5 said R1 had minimal strength in her legs, her core strength was weak, she was unable to hold her legs up for a long period of time, and believed that it would always be a safe measure to put both footrests on her wheelchair for long distances, like going to the hair salon. V5 said that due to R1's poor functional abilities in her lower extremities, if she was not positioned well while the CNA was transporting her, there could be a problem; so, the staff should make sure that there was proper resident positioning prior to pushing R1. V5 reiterated that, due to R1's weak lower extremities, it was most important that her feet and body be positioned properly. R1's MDS, section GG, dated 07/18/2025, stated in part that R1 was wheelchair dependent, and, thus, unable to wheel herself fifty feet unassisted. On 08/12/2025 at 2:38 PM, V1 (Administrator) told this Surveyor that the administration did not have a facility policy that addressed the proper supervision and use of wheelchairs on 07/29/2025, when R1's right leg injury happened. V1 said they looked for one but could not find it. V1 also said that no video footage of R1's wheelchair incident on 07/29/2025 existed because it had been erased after seven days, and no one reviewed the footage while it was available because there was a lot of footage to go over in order to locate it. R1's x-ray report, dated 08/01/2025, stated in part that R1 suffered an acute comminuted distal femur fracture and an 11mm lateral displacement with distal fragments. A hospital progress note dated 08/06/2025 at 2:25 PM from V6 stated in part that R1 presented to the hospital with a closed right distal supracondylar femur fracture after getting right leg caught under wheelchair while someone was pushing her.R1's hospital summary report dated 08/06/2025 described R1's operative procedure as closed reduction and intramedullar nailing right distal femur on 8/5.The facility provided documentation to the Survey team on 08/12/2025 that outlined steps the facility began taking on 08/02/2025 to address the acceptable supervision for and proper use of assistive devices, such as a wheelchair, after R1's incident.Prior to the survey date of 08/11/2025 the facility had taken the following actions to correct the noncompliance:conducted an in-service training on the following topics:Proper Placement of Feet on FootrestsEmphasis on correct use of footrestsImportance of proper foot positioning during wheelchair useFall Prevention StrategiesIndividualized interventions and supervision tailored to resident needsReinforcement of fall prevention protocolsSafe Handling and Use of WheelchairsCompetencies and training completed for all nursing staffFocused on proper wheelchair use and resident safety during transfers and transportOn-going monitoring by facility administration

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's safety while providing incontinence care. This failure affects one of three residents (R2) reviewed for falls in a total sample of six residents. This failure resulted in R2 sustaining left leg fracture to the tibia and right leg fracture to the femur, requiring hospitalization. The past non-compliance occurred from 05/5/2025 to 05/13/2025. Findings include: R2 is a [AGE] year-old female. R2's diagnoses are but not limited to end stage renal disease, chronic pulmonary edema, chronic respiratory failure, dependence on renal dialysis, major depressive disorder, stroke, heart failure, adult failure to thrive, traumatic subdural hemorrhage, and dependence on supplemental oxygen. R2's BIMS (Brief Interview for Mental Status) dated 5/01/2025, notes R2 is alert. R2's MDS (Minimal Data Set) Section GG dated 4/03/2025, notes R2 is dependent with toileting. R2 requires substantial to maximal assistant to roll left and right in the bed. R2's care plan notes R2 is at risk for falls. Interventions include observe and report unsafe conditions and situations. Staff is to ensure proper positioning. Lying to sitting on the side of bed is dependent. Progress note dated 5/5/2025, notes R2 had a witnessed fall on 05/05/2025, at 5:00 PM. The aide informed the nurse that the resident slid down from her bed during a brief change. R2 landed on the floor on her knees. R2 was assessed for pain, injury, wound, and possible fracture -- none noted. R2 had bilateral leg pain. R2 said she fell as she rolled over during a briefs change. Progress note dated 05/07/2025, notes R2 was admitted to the local hospital for left fibula fracture. On 5/17/2025, at 11:54 AM, R6 stated, R2 was in the mechanical lift. The side rail had to be up for her to roll out of bed because she cannot move. The aide that handled her is rough. It was one aide. I was told it was supposed to be two aides. She did not go get any help right away when R2 fell. That aide was standing there in a state of shock. R2 kept saying she was on her knees. R2 landed on her knees. The aide left the resident by herself to go get help instead of calling for help. It was a man aide that came and picked R2 up and put R2 in the bed. R2 was crying out telling the aide please be patient with me. They did not take x-rays until the next day. They did not send R2 out right away either. This place needs to be shut down. R2 laid in bed with those fractures all night. R2 was begging for help. I never heard the aide say anything to the resident. I was told by a person who works here that R2 is in the hospital with broken bones. That aide is too rough, and I told the nurse about it. I want to remain confidential. I feel sad I could not help her that night. On 5/17/2025, at 3:10 PM, V2 (MDS Nurse) stated, R2 is dependent for transfers. This means the staff needs to assist her totally or they might use a mechanical lift. On 5/17/2025, at 4:02 PM, V5 (Fall Coordinator) stated, R2 is more dependent with transfers. She is not able to ambulate. She is a mechanical lift for transfers. I reviewed this incident. From my understanding, it happened during toileting hygiene when the aide was trying to clean her. R2 fell out of the bed; she rolled out of bed. With transfers, R2 requires two people. With mobility, R2 requires maximum assistance with one aide. She can slightly roll over while the aide is changing her. I spoke with the nurse not the aide. The nurse stated she was informed that during toileting hygiene, R2 rolled out of bed and landed on her knees. The root cause of R2's fall was weakness, limited mobility related to functional ability deficits, and degeneration of the joints. R2 stated she rolled out of the bed and could not catch herself. The resident did not say anything else to me. On 5/18/2025, at 9:30 AM, V6 (Assistant Director of Nursing) stated, the nurse told me that she was notified by the aide that during ADL (Activities of Daily Living) care, R2 rolled towards the aide. The aide was not transferring R2 but was just doing regular ADL care. R2 was not able to keep her balance. She rolled and landed on her knees. X-rays were done and she was sent to the hospital. At the hospital, she had fractures to both legs. On 5/18/2025, at 10:00 AM, V8 (Certified Nursing Assistant) stated, R2 is a two person assist with the mechanical lift, or if she needs to be pulled up in bed. When staff is changing her in bed, staff is supposed to put up the bed rail and clean her. R2 can assist you with rolling and holding onto the bar while cleaning her. If staff forget to put the railing up while cleaning her, she is going to fall. The rail must be up because she has poor truck control. I do not see R2 letting staff clean her up without the rail being up or a second assistant being there in front of her. She will say, I'm scared or ask you to go to get some assistance? R2 is very verbal. She will tell staff what she needs, what to do or need to do. I heard about the incident, but I was not there. The aide that was helping told me that she was cleaning R2. When the aide turned R2 over to clean her, R2's head was hanging off the bed. The aide told R2 I got you. R2 said something about her legs. The aide stated she lowered R2 gently to the floor. It took four people to get R2 off the floor. The aide should have the rail up or had a second assistant. Some people just do not listen. If she did not know she could have asked another aide or looked in the POC. There is a care plan book to look in for information as well. On 5/18/2025, at 10:11 AM, V9 (Certified Nursing Assistant) stated, R2 has good bed mobility. She can grab the rail, and she can hold on. She is pretty good about that. She must have the railing to hold on to prevent her from failing. She will tell you make sure the rail is down. Her legs are not good. If there is no railing her legs may slide out. The railing must be up to prevent her from failing out of bed. I do not know what the situation was with that aide. I have worked with that aide, and she was new. I remember talking about the mechanical lift and having two people. If the railing was not up, she should have made sure both were up. Having the railings up is for safety. I was one of the people that helped to get R2 off the floor. On 5/18/2025, at 11:10 AM, V12 (Certified Nursing Assistant) stated, yes, I remember what happened that day. Me and the nurse just got R2 from dialysis and put her to bed. The nurse stepped out and I begin to change R2 on her left side towards the door. I rolled her and her feet began to slide off the bed. As her feet where sliding, I began to push her back into the bed. She kept saying my legs are sore. I stated I needed to go get help because she was sliding out of the bed. She was holding the pole. I yelled for assistance. I had to put her down because she was sliding out of the bed, and she would not allow me to push her out of the bed. I was pushing her legs. The bed was on the floor. She did not fall. It took four of us to put her back in the bed. She did not fall, but I had to lower her down to her knees. She is not good at moving, staff must do all the work. I have only been in the facility for three weeks. Both bed railings were not up. Only the one railing towards us was up. I was never told information if she was a two person or one person. It looks like she required two people assistance. On 5/18/2025, at 11:50 AM, V13 (Registered Nurse) stated, I was the nurse that was on duty. After R2 came from dialysis, we transferred her to the bed with the mechanical lift. We positioned her for comfort. I went to pass medication. The aide called me and told me R2 had a fall. I checked her vitals, and they were normal. R2 had chronic knee pain. She stated the pain was the same. I notified the nurse practitioner (NP). The NP asked me to order bilateral hip and knee x-rays. I ordered them. I informed the relative. I notified the DON. The resident stated when the aide was changing her, she rolled over out of the bed when she turned on her side. The aides must put the railing up for her to hold on. When she turns, she can hold on to turn her upper body. The railing helps with safety and mobility. On 5/18/2025, at 1:06 PM, V23 (Director of Nursing) stated, I was informed about R2's fall. I do not recall when I was informed, but I was informed. She had slipped from the bed during ADL care. The aide assisted her to the floor. The aide stated she was performing peri-care and she felt the resident coming close to her. She tried to reposition the resident, and it was not happening. She assisted the resident to the floor. The resident is alert. I did not get a chance to interview her before she went to the hospital. The IDT (Interdisplinary) team reviews all the falls, the fall risk assessments, description of the falls, factors, root causes analysis and IDT interventions. I expect staff for dependent residents to look at bed mobility, transfers, and ADL care. If they do not know what type of assistance a resident requires, I expect them to ask other nurses or aides. On 5/19/2025, at 10:26 AM, V25 (Nurse Practitioner) stated, I am aware of the patient. They did inform me about the assisted fall. I had treated her for medical problems. Yes, it is possible for the resident to fall out of bed and sustain fractures. Being an elderly frail resident she is an increased risk for fractures. Facility policy titled Fall Prevention Program, dated 11/21/2017, notes to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. Direct care staff will be oriented and trained in the Fall Prevention Program. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. Prior to the survey date of 05/19/2025, facility had taken the following action to correct the noncompliance: 1. R1 new fall assessment completed with new interventions and are plan updated. 2. Nursing staff in-serviced on fall policy and interventions from 05/06/2025 to 5/09/2025. Nurses and aides in-serviced on high-risk residents, frequent monitoring and supervision. 3. Aides and nurses in-serviced on proper bed mobility and positioning. 4. Facility wide assessment has been done to identify all residents that are at risk for fall new interventions put in place. The binder was updated, and care plans were updated. Audits will be conducted daily to ensure fall risks are completed and interventions are in place. After any fall occurs for six months and discussed in daily meetings. 5. Nurses in-serviced on completing new fall risk assessments after fall interventions are updated and care plan is updated. The director of nursing and the nurse consultant will audit each new fall with record review and observation to ensure compliance weekly for six months.

Deficiency Text Not Available

Based on observations, interviews, and record reviews, the facility failed to follow its physician - family notification - change in condition policy and notify the attending physician/nurse practitioner of a resident having severe hypoglycemia and obtain emergent treatment orders. This failure affected one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. On 2/21/25, R1 was nonresponsive and with a blood sugar level of 29; no treatment initiated prior to EMS (emergency medical services) 911 arrived and transported R1 to the hospital emergently. Findings include: On 3/2/25 at 7:49 PM, V7 LPN (licensed practical nurse) stated that V7 does recall R1. V7 stated that V7 was about to leave facility at end of shift on 2/21/25 when the CNA (certified nurse aide) told her that R1 did not look right. V7 went to R1's room and checked R1's blood sugar and it was low. V7 stated that R1 was non-responsive. V7 stated that V7 was alone on nursing unit as the rest of the evening shift staff left. V7 stated that another nurse came to assist her, but does not recall the nurse's name. V7 stated that V7 last saw R1 during evening medication pass. V7 stated that R1 did not have any oral diabetic medications and R1 was not receiving insulin. When questioned if V7 administered any medication to R1 to treat low blood sugar, V7 did not respond. On 3/3/25 at 11:34 AM, V8 ADON (assistant director of nursing) stated that staff are expected to try nursing interventions, call NP (nurse practitioner) on call and follow the orders given. V8 stated that if the resident is alert, give hard candy or a packet of sugar. V8 stated that if the resident is not alert, there is glucose in the crash cart and emergency kit. V8 stated that there is a crash cart and emergency kit located at the nurses' station on each nursing unit. V8 stated that V12 (nursing supervisor) works 10:00 PM until 6:00 AM and should have been called to assist V7 with R1. On 3/3/25 at 11:40 AM, this surveyor and V8 ADON checked emergency box located in medication room on R1's nursing unit. The kit contained two doses of baqsimi (nasal glucagon) nasal spray for treatment of severe hypoglycemia. V8 stated that when a medication is used from emergency kit, the nurse documents on the sign out sheet, so medication can be replaced. V8 stated that on 2/21/25 baqsimi medication was not removed from the emergency kit. On 3/3/25 at 11:50 AM, V8 ADON stated that V8 reviewed R1's progress notes. V8 stated that V7 documented R1's blood sugar was 29, notified V10 NP, and sent R1 out via EMS (emergency medical services) 911. V8 stated that staff are expected to know what is in the emergency kit. V8 stated that after reviewing the policy, V7 LPN did not give R1 anything to treat hypoglycemia. On 3/3/25 at 12:20 PM, V12 (nursing supervisor) stated that V12 worked on 2/21/25. V12 stated that V12 did not receive any calls for a resident with low blood sugar. V12 stated that V12 heard about this event a few days later when staff were talking about it. V12 stated that if V12 had been made aware V12 would have instructed V7 to administer baqsimi nasal spray from the emergency kit and would have gone to R1's bedside to assist. On 3/3/25 at 12:46 PM, V10 NP (nurse practitioner) stated that V10 was not notified by nursing that R1's blood sugar was 29 and R1 was nonresponsive. V10 stated that if a resident has a blood sugar of 29 and is nonresponsive, V10 would expect the nurse to administer medication to treat hypoglycemia while waiting for EMS 911. On 3/3/25 at 1:05 PM, V14 (EMS paramedic) stated that when V14 arrived at R1's bedside V14 and crew were informed that the night shift nurse was making rounds and found R1 nonresponsive. V14 stated that the crew was informed that the evening shift nurse had already left facility. V14 stated that the crew quickly got R1 in to the ambulance to start treatment while in route to the hospital. V14 stated that the crew was informed that no treatment was initiated by the nurse prior to their arrival. V14 stated that the crew checked R1's continuous blood glucose system receiver. V14 stated that R1's blood sugar bottomed out at 7:30 PM and remained that way until their arrival at 11:34 PM. R1's EMS (emergency medical services) run sheet, dated 2/21/2025, notes EMS crew was dispatched to the facility at 11:27 PM for a resident with a diabetic problem. The crew arrived at R1's bedside at 11:34 PM. Upon arrival R1 was in the room with a CNA, unresponsive, diaphoretic, with a GCS (glascow coma score) of 3. The CNA advised the crew that R1 had low blood sugar. V7 LPN just checked it, but I don't know what it is. R1's continuous blood glucose system receiver just says 'LOW'. The crew looked at R1's continuous blood glucose system receiver and the trends it showed was: blood glucose at a normal level around 3:00 PM with it dropping to LOW around 3:30 PM and continuously being at LOW until the crew's arrival at 11:34 PM. R1 was loaded on to the stretcher and brought down to the ambulance. R1's vital signs were taken, and all were within normal limits with the exception of her blood glucose level which was at 31. Two intravenous catheter insertion attempts were made, one in each forearm but were unsuccessful. IO (intraosseous) equipment was set up, the hospital was called to clear the IO insertion. An IO was established in R1's left tibia. R1 was administered dextrose 10% at a keep open rate. R1's oxygen saturation level was starting to decrease in route. A nasal cannula was placed on R1 and oxygen was delivered at 4 liters. The facility's physician orders-entering and processing policy, revised 1/31/2028, notes if the medication is needed immediately, it will be removed from the emergency drug kit. All appropriate paperwork will be filled out when a drug is removed from the emergency drug kit. The facility's physician - family notification - change in condition policy, revised 11/13/2018, notes the facility will consult with the resident's physician or NP when there is a significant change in the resident's physical, mental, and psychosocial status (deterioration in health, life threatening condition). The facility's hypoglycemia guidelines, undated, notes contact physician if blood sugar is below 60. Take vital signs. Repeat finger stick in 15 minutes after intervention. If unable to swallow notify the physician and prepare glucagon from the emergency drug kit for administration as ordered. Document findings, interventions, and physician contact in resident's clinical record.

Based on interviews and record reviews, the facility to provide quality care and services in accordance with professional standards of practice for blood sugar monitoring, insulin administration, recognizing the signs and symptoms of hypoglycemia, and implementing interventions to treat hypoglycemia for one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. This failure resulted in R1 receiving intermediate-acting insulin on 2/21/25 at 11:31 AM and 12:19 PM leading to severe hypoglycemia with a blood sugar level of 29. Findings include: On 3/2/25 at 7:49 PM, V7 LPN (licensed practical nurse) stated that V7 does recall R1. V7 stated that V7 was about to leave facility at end of shift on 2/21/25 when the CNA (certified nurse aide) told her that R1 did not look right. V7 went to R1's room and checked R1's blood sugar and it was low. V7 stated that R1 was non-responsive. V7 stated that V7 was alone on nursing unit as the rest of the evening shift staff left. V7 stated that another nurse came to assist her, but does not recall the nurse's name. V7 stated that V7 last saw R1 during evening medication pass. V7 stated that R1 did not have any oral diabetic medications and R1 was not receiving insulin. When questioned if V7 administered any medication to R1 to treat low blood sugar, V7 did not respond. V13 CNA (agency certified nurse aide) worked 3:00 PM - 11:00 PM shift on 2/21/25. V13 was unavailable for interview during this survey. On 3/3/25 at 5:00 PM, V10 NP (nurse practitioner) stated that R1 had an order for insulin 70/30 subcutaneous daily. V10 was not made aware that R1's insulin was changed to three times a day. V10 stated that V10 would not have changed R1's insulin to be given three times daily. V10 stated that insulin should not be administered intramuscularly. V10 stated that insulin should be administered within 30 minutes of when blood sugar is checked. V10 stated that insulin 70/30 is an intermediate-acting insulin and should not be given two doses close together. On 3/3/25 at 1:05 PM, V14 (EMS paramedic) stated that when V14 arrived at R1's bedside V14 and crew were informed that the night shift nurse was making rounds and found R1 nonresponsive. V14 stated that the crew was informed that the evening shift nurse had already left facility. V14 stated that the crew quickly got R1 in to the ambulance to start treatment while in route to the hospital. V14 stated that the crew was informed that no treatment was initiated by the nurse prior to their arrival. V14 stated that the crew checked R1's continuous blood glucose system receiver. V14 stated that R1's blood sugar bottomed out at 7:30 PM and remained that way until their arrival at 11:34 PM. On 3/4/25 at 9:13 AM, V8 ADON (assistant director of nursing) stated that the nurse is expected to review discharge paperwork sent with new admission from the hospital. V8 stated that if there is a question regarding any physician order, the nurse is expected to clarify the order prior to implementing it. When questioned why insulin administration was changed from subcutaneous to intramuscular, V8 stated that V8 will have to look into this. When questioned reason insulin 70/30 was changed from daily to three times a day, V8 stated that she will have to look into this as well. V8 stated that the nurse is expected to know when insulin peaks and duration of its action. R1's POS (physician order sheet), dated 2/18/25, notes an order for novolin 70/30 insulin, administer 20 units subcutaneously once a day. On 2/19/25 at 00:50 AM, the insulin order was changed to 20 units intramuscularly three times a day. V15 LPN (licensed practical nurse) created the order changing R1's insulin from subcutaneous to intramuscular and from daily to three times daily. V15 was unavailable for interview during this survey. R1's MAR (medication administration record), dated February 2025, notes six nurses administered insulin 70/30 intramuscularly. R1 received a total of 9 doses intramuscularly. It also notes on 2/21/25 the 9:00 AM scheduled dose of novolin 70/30 insulin was administered at 11:31 AM by V11 LPN (licensed practical nurse) and the 12:00 PM scheduled dose was administered at 12:19 PM by V11. R1's EMS (emergency medical services) run sheet, dated 2/21/2025, notes EMS crew was dispatched to the facility at 11:27 PM for a resident with a diabetic problem. The crew arrived at R1's bedside at 11:34 PM. Upon arrival R1 was in the room with a CNA, unresponsive, diaphoretic, with a GCS (glascow coma score) of 3. The CNA advised the crew that R1 had low blood sugar. V7 LPN just checked it, but I don't know what it is. R1's continuous blood glucose system receiver just says 'LOW'. The crew looked at R1's continuous blood glucose system receiver and the trends it showed was: blood glucose at a normal level around 3:00 PM with it dropping to LOW around 3:30 PM and continuously being at LOW until the crew's arrival at 11:34 PM. R1 was loaded on to the stretcher and brought down to the ambulance. R1's vital signs were taken, and all were within normal limits with the exception of her blood glucose level which was at 31. Two intravenous catheter insertion attempts were made, one in each forearm but were unsuccessful. IO (intraosseous) equipment was set up, the hospital was called to clear the IO insertion. An IO was established in R1's left tibia. R1 was administered dextrose 10% at a keep open rate. R1's oxygen saturation level was starting to decrease in route. A nasal cannula was placed on R1 and oxygen was delivered at 4 liters. R1's hospital record, dated 2/22/25, was unavailable for review during this survey. The facility's hypoglycemia guidelines, undated, notes contact physician if blood sugar is below 60. Take vital signs. Repeat finger stick in 15 minutes after intervention. If unable to swallow notify the physician and prepare glucagon from the emergency drug kit for administration as ordered. Document findings, interventions, and physician contact in resident's clinical record. Per the National Library of Medicine, insulin is absorbed faster after intramuscular injection compared to subcutaneous injection. Intramuscular injections should be avoided as they increase the risk of hypoglycemia. Per the FDA (Food and Drug Administration), novolin insulin 70/30 is an intermediate-acting insulin. The effects of Novolin 70/30 start working 30 minutes after injection. The greatest blood sugar lowering effect is between 2 and 12 hours after the injection. This blood sugar lowering may last up to 24 hours. Symptoms of hypoglycemia may include, but not limited to: sweating, confusion, shakiness. Severe hypoglycemia can cause unconsciousness, seizures, and death. The Centers for Medicare & Medicaid Services requires nurses to verify specific information prior to the administration of medication to avoid errors, referred to as verifying the rights of medication administration. These rights of medication administration are the vital last safety check by nurses to prevent errors in the chain of medication administration that includes the prescribing provider, the pharmacist, the nurse, and the patient. The nurse ensures the route of administration is appropriate for the specific medication and also for the patient. Some medications can only be given safely via one route. Nurses must administer medications via the route indicated in the order. If a nurse discovers an error in the order or believes the route is unsafe for a particular patient, the route must be clarified with the prescribing provider before administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents from resident to resident physical abuse. This failure affects four of four residents (R1, R2, R3 R4) reviewed for abuse. This failure resulted in R1 getting feces thrown in R1's eye and on R1's body. This physical abuse caused R1 to feel upset, disgusted, abused, and scared R4 would throw more and R4 would try to attack R1. Findings include: 1.) R1 is an [AGE] year-old resident admitted to facility on 2/17/2024 with medical diagnoses including but not limited to: major depressive disorder, moderate protein-calorie malnutrition, adult failure to thrive and age-related osteoporosis. R1 has a Brief Interview for Mental Status (BIMS) score of 9/15 dated 10/30/2024 which suggests moderate cognitive impairment. Minimum data set (MDS) section GG dated 10/30/2024, R1 requires substantial/maximal assistance for shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. R1 is dependent on staff for toileting hygiene. R1 needs partial/moderate assistance for oral hygiene. R1 needs supervision or touching assistance for eating. R1 reported an allegation of abuse on 11/19/2024 that had allegedly happened on 11/17/2024 to the State Survey Agency. On 11/25/2024, at 09:33 AM, R1 stated, regarding another resident throwing feces/urine at me this happened in R1's old room. R4 was my old roommate. They moved me after that. R4 uses a colostomy bag. Feces got in my eye. The facility did not send me to the doctor. My linens were all a mess, and I was hollering, and the nurse came to my room. The nurse V5 LPN (Licensed Practical Nurse) helped clean me up. The social worker came in and asked me what happened I am not sure if the other resident (R4) is still here. I did have eye drops put in my eyes after that which helped. I do not have any other problems other than my complaint. On 11/25/2024, at 12:31 PM, R1 stated it made me feel awful and scared when R4 threw feces on me. We shared food and stuff before this. I feel safe to stay here now. I don't believe they will allow anyone to come in here and abuse me again. On 11/26/2024, at 11:05 AM, R1 stated I felt just terrible and awful when R4 threw feces at me. It felt disgusting to have feces all over me. It got in my eye and all over my body. I was scared that R4 might throw more or reach over and try to attack me. I called my son right after the nurse (V5) cleaned me up to tell him because I was so upset. My son got upset too. It felt like something was under my eyelid. That was an uneasy feeling. On 11/25/2024, at 12:23 PM, surveyor asked R4 if she got in an altercation with R1 last week. R4 stated, I am a nice person I did not try to throw anything on R1 I have nervous hands. I am a nice person. R1 don't like me. I'm going to stay in this room. I like it here. I am a nice person; I didn't try to do that. R1's Progress note dated 11/17/2024 documents: Late Entry: Narrative: V5 informed by certified nursing assistant that resident roommate bodily fluids made contact with her. V5 immediately intervened, R1 sitting on the own separate bed, close curtains to make sure remain separation. Full head to toe body assessment made and no injuries noted. ADL care performed on R1. V5 remain with resident until certified nursing assistant came and took resident to shower room. R4 progress note dated 11/18/2024 documents in part: Note Text: Resident's behavior/mood noted at times. Resident's behavior noted as was physically aggressive. Other resident specific behaviors not noted above: Bodily fluids making contact to roommate (R1) Reportable initial transmission dated 11/25/2024 for this incident that occurred on 11/17/2024 reviewed. On 11/27/2024, at 12:43 PM, V30 (CNA) stated, regarding the incident that involved R1 and R4 about a week ago, I went down the hall and when I got to that room R4 was upset about not eating her lunch as it ended up on the floor. Both R1 and R4 were arguing back and forth on how the lunch got on the floor. I went to get her a sandwich, cookies and potato chips. She was thankful for that and R1 and R4 were calm. I went to check on R1 and R4 about an hour later. R4 asked if I could help her empty her colostomy bag. R4 said, I can do it, but her hand was shaking really bad. I put two towels under her breast like R4 asked and R4 pushed the bowel movement out of her colostomy bag into the gradual container. I cleaned the gradual. R4 asked me for the gradual container back so she could empty colostomy later. Both residents were calm when I left the room. Later, I was passing down the hall with my dirty linen cart and R1 and R4's room light was on. R1 stated, R4 got bowel movement on me. I had already done rounds on that room. I went in the room to see what R1 needed and seen bowel movement on R1's arm. R4's gradual container to empty R4's colostomy was laying on R1's arm. R1 was starting to make a phone call. R1 was upset and I went and told the nurse. On 11/25/2024, at 1:34 PM V6 (Social Worker) stated, I was notified of the incident with R4 throwing feces at R1 on Monday when I returned. That incident happened on a Sunday from my understanding. I asked how the situation escalated. R1 and R4 had already been separated in different rooms. I interviewed each resident to see what went on. R4 did not have much to say except being upset that she could not discharge home. R4's mom can no longer care for her. R4 stated she had been under some stress over this and kind of reacted. R1 explained R4 was having an episode and R1 was asking if R4 was ok. R4 started calling R1 names and everything escalated from there. R1 said she got feces in her eye and mouth and R1 was screaming. The nurse (V5) and certified nursing assistant got her into the shower chair and went to clean her up and separated R1 and R4 immediately. I have been doing well being checks on R1 and R4 since that incident. On 11/25/2024, at 09:56 AM, V5 Licensed Practical Nurse (LPN) stated I am aware of an incident of R4 throwing feces at R1. It happened last week Sunday (11/17/2024). R4 is still here and on this floor. When I came in that morning, I was informed by certified nursing assistant that R4 threw feces on R1. That happened before I got here. I went straight to that room. Both R1 and R4 were in their bed. I cleaned R1 up and stayed with her until certified nursing assistant came and got her up to go to shower. R1 had already notified her son. I did notify V3 (Director of Nursing). R1 said some feces splashed in her eye so I rinsed them out. V31 (Nurse Practitioner) came later in the week to see her. No new orders. R4 is now in a room by herself. That was the only time R4 ever did something like that. On 11/26/24, at 11:27 AM, V3 Director of Nursing (DON) stated, regarding the situation with R1 and R4, I do recall this was on a Sunday (11/17/2024). The nurse sent me a message that R1 had feces on her. I asked what happened and R1 stated it came from R4 direction. The nurse would get assistance to clean her up. I asked how both residents were. Nurse stated, they were both ok. I told her to ask R4 if she knew how the feces got on R1. R4 initially said, I don't know. I did delegate to nurse to notify family and physicians. I don't recall hearing about R4's family. I do know the nurse got ahold of R1's son. I was made aware there were no injuries. When they cleaned up R1 the staff removed her from the room while we investigated what had happened. I was not made aware that R1 stated she got feces in her eye. I was made aware she had feces in her hair and on left shoulder. Monday morning comes and it is thoroughly investigated, and administration got involved. Monday it was found out that R4 threw feces at R1. R4 did tell a staff member on Monday that her cousins made her do it. R4's cousins were not in the facility at this time. This would be considered abuse. V1 (Administrator) is the abuse coordinator. I did report this to V1 on Sunday (11/17/2024). I do not know when this was reported to the state survey agency. My expectation of staff regarding any type of abuse is to notify V1 the administrator immediately. On 11/25/24, at 2:16 PM, V2 (Assistant Administrator) stated, regarding R1 and R4 incident where R4 threw feces at R1, R4 was sent out by involuntary petition to a local hospital. The hospital held her for a period of time. This incident was not reported to the state because we did not have all the details until Monday morning when we investigated. The incident happened on a Sunday (11/17/2024). This incident as of 11/25/2024 still has not been reported to the state survey agency. On 11/25/2024, at 11:47 AM, V1 (Administrator) stated, we investigated the incident with R4 throwing feces at R1. We did a full investigation. I will bring the whole binder on it. We did not report it right away as we were not aware of the feces hit the resident. This should be reported. We were made aware last Monday (11/18/24) that feces did hit the resident We did put in an action plan and a removal plan in place and did education for full house. We did abuse/neglect screenings on everyone. The resident (R4) that threw feces is still in the facility. R4 had never done anything like this. R4 has an unrealistic view of discharge and was going through some things. We put R4 in a private room. I do not think R1 went out to hospital. I know she was assessed. This should have been reported to the state survey agency once we found out feces hit R1. The staff handled it well. R1 was cleaned up. In this situation the staff handled the situation well even though we were not 100 percent knowledgeable of extent of the incident. I will bring you the whole binder for this investigation. R1 Care plan dated 4/8/24 documents: Focus: ABUSE | NEGLECT | EXPLOITATION | TRAUMA I am an adult living with chronic health conditions, challenges, and comorbidities. Based on the comprehensive facility assessment conducted, there is benefit from placement in a skilled care setting and stability has been demonstrated throughout the admission screening process. Denies having been the perpetrator and/or recipient of mistreatment, abuse, neglect, and/or exploitation. It is determined that symptomatological factors exist that require monitoring. Goals: I will be cared for in a safe manner and verbalize to staff any incidences of abuse or neglect through review date. Interventions: Conduct appropriate screening to determine any history of maltreatment including abuse, neglect, living through trauma or surviving combat/violence. Reach and communicate to the resident that their safety, security and dignified care are the priority. o Ensure safety if feeling unsafe. [certified nursing assistant (CNA), registered nurse (RN), LPN] o Focus on PERSON-CENTERED CARE. Follow person-centered care models affording the resident as much initiative, control and self-determination as possible. Remind the individual that person-centered care or person-first care is a treatment model based upon honesty, sharing valid concerns, integrity and being forthright with care partners. o Observe resident in care situations. [LPN,RN] o Observe resident when in company of peers. [CNA] o Provide reassurance when negative feelings occur. [CNA,LPN] o Recognize that the resident is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless. Work with the resident to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making. o Report any verbalization of abuse or neglect to administrator immediately. [certified nursing assistant (CNA)] 2.) R2 is an [AGE] year-old resident admitted to facility on 08/07/2024 with medical diagnoses including but not limited to: moderate protein-calorie malnutrition, diabetes mellitus type 2, dementia severe without behavioral disturbance, and adult failure to thrive. R2 has a Brief Interview for Mental Status (BIMS) score of 6/15 dated 10/01/2024 which suggests severe cognitive impairment. According to minimum data set (MDS) section GG dated 10/01/2024, R2 requires partial/moderate assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. R2 needs supervision or touching assistance for eating and oral hygiene. R2 Care plan dated 10/3/2024 documents: Focus: ABUSE | NEGLECT | EXPLOITATION | TRAUMA I am an adult living with chronic health conditions, challenges, and comorbidities. MODERATE Based on the comprehensive facility assessment conducted, there is benefit from placement in a skilled care setting and stability has been demonstrated throughout the admission screening process. Denies having been the perpetrator and/or recipient of mistreatment, abuse, neglect, and/or exploitation. It is determined that symptomatological factors exist that require monitoring. Goals: I will be treated with respect, sensitivity, dignity, and feel safe while I live here in the facility Interventions: Conduct appropriate screening to determine any history of maltreatment including abuse, neglect, living through trauma or surviving combat/violence. Reach and communicate to the resident that their safety, security and dignified care are the priority. Focus on PERSON-CENTERED CARE. Follow person-centered care models affording the resident as much initiative, control and self-determination as possible. Remind the individual that person-centered care or person-first care is a treatment model based upon honesty, sharing valid concerns, integrity and being forthright with care partners. Recognize that the resident is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless. Work with the resident to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making [social worker (SW)] R2 Progress note dated 10/2/24 documents in part: Note Text: Resident's behavior/mood noted at This shift. Resident's behavior noted as none noted. Other resident specific behaviors not noted above: Behavior triggers: Other resident becoming physically aggressive toward them. R3 Progress note dated 10/2/2024 documents: Note Text: Resident's behavior/mood noted at This shift. Resident's behavior noted as was physically aggressive. On 11/25/2024, at 10:04 AM, R2 stated, I have not gotten in a fight with anyone. No one has hit me. I have not hit anyone. I do not know anyone by that name. I have not had any problems with anyone that I know of. If I need help, I will use call light, but I don't need help right now. I have not had any injuries. The staff comes to help me to the restroom. I like it here. I don't have any issues here. I am not neglected. I broke my glasses; I have to talk to my daughter when she comes maybe tomorrow. They come and take care of my hip. Resident sitting up in wheelchair watching television. Resident is clean and well groomed. Resident is thin. No foul odors noted. On 11/25/2024, at 10:24 AM, R3 stated, I have not gotten in a fight with anyone here. I have not hit anyone, and no one has hit me. No physical abuse or neglect has happened. Staff comes to help me when I hit the call light. I have not had any falls or hurt myself. Resident in bed resting. Resident clean and well groomed. No foul odors noted. R2/R3 Investigation 10/2/24 notes in investigation packet document: R3 - He tried to hit me, but he did not hit me. I did not hit him. I am not happy about the lights being on and the tv being too loud. R2 - He lightly slapped me on the left side/cheek of my face. I did not hit him back. Family notified. Immediately seperated. Room change R3. Statement from V7 Registered Nurse (RN) in investigation packet for incident on 10/2/2024 between R2 and R3 documents: I was informed by a V8 (CNA) that R3 and R2 was arguing about the television. R3 stated that he wants to sleep but R2 won't turn off the lights and doesn't want to lessen the volume of the television. We immediately separated the R2 and R3 and did room change. R3 stated that he slapped R2 because R2 didn't listen to R3. body assessment done, no injuries. Vital signs checked, within normal limits. Both residents didn't complain of pain. (DON), management, (NP) and family notified. Statement from V8 (CNA) in investigation packet for incident on 10/2/2024 between R3 and R2 documents: I heard R2 and R3 yelling at each other about the lights being on and the TV being too loud. R3 wanted R2 to turn his TV down and turn the lights off. I heard R2 say that if R3 hits him again he will hit him back. I separated the residents and informed the nurse who then reached out to the (DON) and administrator. On 11/26/24, at 11:27 AM, V3 Director of Nursing (DON) stated, regarding R2 and R3, I know we separated the residents due to a disagreement over TV volume. R2 and R3 were having a disagreement and R2 stated, R3 became physical with him. That is why we initiated separation. Staff did not witness the physical altercation. During investigation it was found to be that R3 slapped/hit R2 on his cheek. I was called on this incident and I notified V1 (Administrator) but my nurse (V7) also notified the abuse coordinator. R3 got sent out for a psychiatric evaluation and returned within 24 hours. I do not recall if R2 was sent out to the hospital. Normally we send the aggressor to the hospital in a situation like this and assess the other resident to see if there is a need to be sent out to hospital. R2 did not have any injuries upon assessment. Family was notified for both R2 and R3. I did not speak to families, but the nurse (V7) did as it is part of our protocol. On 11/25/24, at 2:16 PM, V2 (Assistant Administrator) stated regarding R2/R3 incident R2 stated he was hit by resident R3, and it made slight contact with his cheek. We did not send out R2 because during the investigation it seemed like the aggressor would have been R3. Our investigation results were that R2 was hit by R3. R3 denied allegations. On 11/26/24, at 09:40 AM, V1 (Administrator) stated, regarding R2 and R3 staff overheard the argument and got the nurse (V7) and separated the R2 and R3. R3 hit R2 so we sent R3 out for psychiatric evaluation. R3 came back stable. We put them in separate rooms. This was the first time R3 had hit anyone. It is hard to gauge intensity, but from what we could tell it was minor but there was contact. On 11/25/2024, at 2:23 PM, V7 RN (Registered Nurse) stated, regarding R2 and R3, I remember V8 (CNA) told me that they were arguing because R3 he wanted to sleep around that time, and he wanted to turn off the lights but R2 wanted to watch TV and leave the lights on. V8 went in because they were arguing, and she heard loud voices. As far as I remember it was just a verbal altercation. When I went in there, I immediately separated R2 and R3 to prevent further incident. I informed V3 (DON) right away and V1 (Administrator). I told them that we could change the room of the one resident. R3 was more aggressive. When I got in the room, they were both in the middle of the room. R2 was sitting in w/c watching the TV. R3 was telling R2 to lessen the volume of the TV because R3 couldn't sleep. I do not think it had progressed to anyone putting hands on the other. On 11/26/2024, at 2:11 PM V8 (CNA) stated, I do recall the incident between R2 and R3. I was next door from their room and was doing my care for the resident there. I heard R2 and R3 talking back and forth. At first, I thought it was the television. It was getting louder. Then I stopped what I was doing and went next door to See what was going on. R2 and R3 were talking at the same time. R2 and R3 were arguing about the television. R2 said, R3 hit him on his face. He told this to me. I did not tell anyone other than my nurse (V7). I talked to R3 and guided him out of the room. R2 was in his bed. I then told the V7 (nurse) when I was in the hallway talking to R3. I don't remember exactly. V7 may have been at the nurse's station because R2 and R3's room was right by the nurses station. V7 talked to R2 and R3 and we decided to change rooms. I did not hear or witness any hits or slaps or sounds like that. Our abuse coordinator is V1 the administrator. This is an allegation of abuse. Our policy states we are to report any abuse to the administrator(V1). I did not call the V1 because I had reported it to the V7 (registered nurse) so I thought V7 would do it. It didn't dawn on me to report it. I remember V7 texting V1 (administrator) at that time. The last time we had an abuse in-service was last week sometime. V2 (Assistant Administrator) is the one that did the in-service and he did go over that we are all to report to V1 (administrator). I am just used to the nurse reporting it. On 11/26/2024, at 12:16 PM, V9 (Social Worker) stated, regarding R3 and R2, I was made aware there was a situation over the TV being too loud. I was told by staff that nobody seen it, but R2 told me that R3 hit him on the cheek. I assessed both residents and followed up with both residents. I moved R3 to a room with a resident that he can better cohabitate with. I gave R2 another roommate that fits well with him. R2 had also told V8 (CNA) that he was hit by R3. Our abuse coordinator I think is V3 (DON). Typically, we go through the DON as well as V22 (Social Worker Director). I was not there when it happened. I did not report to the abuse coordinator. I usually report to my director and my director usually reports to the abuse coordinator from what I know. I know we had abuse training recently; I do not know the exact date but it was about a couple weeks ago. Abuse Prevention and Reporting - Illinois Policy dated 11/28/2016 and with last review dated of 12/17/2021 documents (in part): Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property: Resident-to-Resident Abuse (Any type): Resident -to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations. Internal Reporting Requirements and Identification of Allegations: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. External Reporting Initial Reporting of Allegations: When any allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. Five-day Final Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment by not adequately assessing, monitoring or supervising residents at risk for falls for 4 of 5 (R1, R3, R4, R5) reviewed for falls; and failed to follow their fall prevention program by not ensuring fall interventions were securely in place for a resident (R1) with a history of and risk for falls. These failures resulted in R1 falling and being hospitalized for laceration to the left ear; R3 falling and being hospitalized for laceration to the left eyebrow; R4 falling and being hospitalized for right femur fracture with surgical repair; and R5 falling and being hospitalized for left femur fracture. Findings include: (R1) 1. On 05/24/2024 at 11:40 AM, R1 said he had a fall incident a few months ago in March. R1 added that after taking his nighttime medication, he sat on the side of his bed and had went out. R1 then said he awoke approximately ten minutes later and was on the floor next to his bed and he was bleeding from his left ear. He said the nurse who came to check him out, sent him to the hospital where he received stitches to his left ear and stayed at the hospital for a few days. On 05/24/2024 at 12:00 PM, reviewed fall leaf program binder located at nursing station on the third floor. R1 was not listed on undated fall leaf program residents. R1 was listed on undated fall intervention log that indicated R1 should have non-skid strips to the floor at bedside to improve traction/prevent slipping and call for assistance. (Non-skid strips were not observed in place during interview with R1 on 05/24/2024 at 11:40 AM or during room observation at 4:01 PM.) On 05/24/2024 at 1:14 PM, V8 (Licensed Practical Nurse) said on day of R1's fall incident, R6 (R1's roommate) went to the doorway around 10:00 PM and said that R1 was on the floor. Upon entering R1's room, V8 saw R1 on the floor with blood coming from his left ear. V8 (LPN) added that R1 is on seizure precautions, is a frequent faller, and seemed confused after the fall. V8 then said that she had previously discussed R1's frequent falls with previous Director of Nursing. On 05/24/2024 at 2:17 PM, V6 (LPN/Restorative Nurse) said R1 takes seizure medications that make him sleepy, so his meds were adjusted a few months ago because R1 was sedated at times. V6 added that R1 had previous falls on 02/24/24 and 03/09/2023. At 02:26 PM, V6 reviewed fall leaf program residents then indicated that R1 was mistakenly not included but will be added due to his history of falls, medical diagnosis, seizure precautions and seizure medications. V6 then said R1 has current fall interventions in place to: call don't fall and non-skid strips to floor near bedside and non-skid footwear. R1's face sheet indicated resident recently admitted to facility on 01/09/2024 and has a past medical history not limited to: hemiplegia and hemiparalysis following cerebral infarction affecting left non-dominate side, seizures, abnormalities of gait and mobility, lack of coordination, weakness, age-related physical debility, unspecified escherichia coli, bipolar disorder, insomnia, and tremors. R1's Fall Risk assessment dated [DATE] indicated R1 is at risk for falls. R1's care plan with last completion date of 04/09/2024 reads in part: risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, possible medication side effects, seizure disorder, tremors, cerebrovascular accident with left hemiplegia (date initiated 12/30/2023). R1's hospital paperwork dated 03/02/2024 indicated resident was treated by V10 (emergency room MD) for laceration to the left earlobe status post unwitnessed fall encounter at facility. R1's facility reported final incident report dated 03/08/2024 indicated R1 had a fall incident on 03/02/2024 in his room and sustained a laceration to his left ear. R1 was emergently transferred to local hospital where he received five stitches to the open area on his left ear. Report also indicated R1 requires supervision to limited assistance with activities of daily living (ADL's), transfers and toileting. (R3) 2. On 05/24/2024 at 12:11 PM, observed V5 (Certified Nursing Assistant) pushing R3 in his wheelchair out of his room. Observed dressing to R3's left outer eye, resident alert to self. V5 said R3 had an injury to his left eye from his fall a few weeks ago. On 05/24/2024 at 2:42 PM, V6 (LPN/Restorative Nurse) said regarding R3's last fall on 05/06/2024, he was observed sitting on the toilet seat with a facial wound and was sent out to a local hospital for a laceration to his left brow. V6 added that R3 has dementia and should be closely monitored by staff. R3's FRI (facility reported incident) final report dated 05/14/2024 indicated resident was observed sitting on the toilet by staff with a bleeding open wound to his left eyebrow on 05/06/2024. R3 self-reported falling to the floor while ambulating to the bathroom, stood himself up from the floor then continued to ambulate himself to the bathroom. R3 was emergently transferred to a local hospital where he received six sutures to the laceration above his left eyebrow. R3's hospital paperwork dated 05/06/2024 indicated that R3 was treated emergently by V11 (Doctor of Osteopathic Medicine) post fall for facial lacerations and received stitches. R3's Fall Risk assessment dated [DATE] indicated R3 is at risk for falls. R3's face sheet indicated resident admitted to facility on 04/01/2024 and has a past medical history not limited to: epilepsy, dementia, generalized osteoarthritis, abnormal posture, lack of coordination, history of falling, syncope and collapse, and insomnia. R3's active physician orders showed order to clean left eyebrow with normal saline, pat dry, apply triple antibiotic ointment then cover with dry dressing daily and as needed (active date 05/09/2024); send resident to [hospital] for further evaluation related to fall and left eyebrow laceration per family request (active date of 05/06/2024). R3's care plan with last completion date of 4/17/2024 reads in part: at risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, possible medication side effects, incontinence, Seizure disorder, syncope, dementia, history of falls, spinal stenosis, osteoarthritis (date initiated 02/17/2023). (R4) 3. R4's face sheet indicated resident admitted to facility on 12/30/2021 and has a past medical history not limited to: abnormalities of gait and mobility, hemiplegia and hemiparalysis following cerebral infarction affecting right dominate side, fatigue, abnormal posture, lack of coordination, right femur fracture, history of falling, vascular dementia, seizures, insomnia, hypertension, and repeated falls. R4's facility reported final incident report dated 02/28/2024 indicated resident had a fall incident while staff was present on 02/27/2024. R4 stood to adjust himself, slipped and fell the complained of right hip pain. Report also indicated that R4 requires assistance with ADL's, transfers and toileting. Fall incident report indicated R4 was transferred into a wheelchair post fall, taken to his room and transferred back to bed. Upon further assessment of range of motion, R4 complained of right hip pain and was then sent out emergently for x-ray of right hip. R4's hospital records dated 2/28/2024 through 03/04/2024 and discharge summary signed by V12 (Medical Doctor) on 03/04/2024 both indicated resident was treated for a right femur fracture post fall in the shower at facility that required surgical repair on 02/28/2024. R4's fall risk assessment dated [DATE] indicated resident is at risk for falls. R4's care plan with last completion date of 03/14/2024 reads in part: at risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, possible medication side effects, cerebrovascular accident with right side weakness, frequent falls, seizure disorder, low back pain, incontinence, abnormal gait/mobility, lack of coordination, abnormal posture, fatigue. readmitted to the facility status post-acute hospital stay 03/04/24 (date initiated 12/31/2021, revision on 03/14/2024). On 05/26/2024 at 4:33 PM, V13 (Certified Nursing Assistant) indicated that after she showered R4, she left the resident unattended to retrieve an incontinence brief from the next shower stall when R4 had a fall incident and complained of right hip pain. V13 (CNA) then indicated that she put him in his chair and took him to the room then went to inform the nurse. (R5) 4. R5's face sheet indicated resident initially admitted to facility on 03/28/2024 with last admission date of 05/07/2024 and has a past medical history not limited to: hemiplegia and hemiparalysis following cerebral infarction affecting left non-dominate side, left femur fracture, end stage heart failure and renal disease, presence of left artificial hip joint, seizures and history of falling. R5's care plan with last completion date of 04/09/2024 reads in part: at risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, incontinence, possible medication side effects, left hemiparalysis, history of falls, seizure disorder, abnormal gait/mobility, unsteadiness, on feet, lack of coordination (date initiated 04/02/2024, revision on 04/08/2024). R5's hospital record/note dated 05/06/2024 by V19 (Internal Medicine Resident) and V20 (Medical Doctor) indicated R5 presented with left femoral fracture post fall at the facility. R5's facility reported final incident report dated 05/07/2024 indicated that resident had a fall incident while ambulating self to the bathroom on 05/02/2024 at 12:20 AM. R5 was emergently sent out to a local hospital for further evaluation and was diagnosed with a mild left femur fracture. R5's fall risk assessment dated [DATE] indicated R5 is at risk for falls and had a recent admission in March for falls. On 05/24/2024 at 11:00 AM, R5 was observed near second floor nurse's station. Resident alert to self and not interviewable at this time. Reviewed fall leaf binder located at nurse's station that indicated R5 is in the program. On 05/25/2024 at 11:30 AM, V6 (Restorative Nurse/LPN) presented nursing in-service dated 05/24-05/25 with topics of fall prevention/falling leaf program. On 05/26/2024 at 3:25 PM, V18 (Licensed Practical Nurse) said she was called to room by V15 (Certified Nursing Assistant) who said R5 was on the floor. Upon her assessment, she noted R5 laying on his side with a bed pad under his head. V18 added that R5 was favoring his left shoulder, he said it was bothering him. She and two other staff members stood resident up and put him into the bed. She completed assessment and noted no range of motion limitations to lower legs. She notified all parties including physician, x-ray was ordered, which she added x-ray of left hip due to fall a few weeks prior in which left side was x-rayed as well. V18 (LPN) added that R5 couldn't tell her how he fell, but he had a history of falls and dementia. R5 transferred into a dialysis chair shortly after incident and was given acetaminophen prior to be transported to dialysis for restlessness with dialysis. When R5 returned from dialysis, V18 (LPN) said she was no longer on duty but was told that R5 was x-rayed between noon and 1:00 PM that day and was found to have a femur fracture. On 05/26/2024 at 3:34 PM, when asked for timeline of R5's post fall evaluation and treatment, V1 (Administrator) said the following: facility called for stat x-ray at 1:17 AM on 05/02/2024, x-ray technician arrived at 11:49 AM and x-rays were completed at 1:30 PM. Resident was not complaining of pain and vitals were stable so 911 wasn't necessary and we were told ambulance would be arriving shortly. It came at 4:15 PM then left 20 minutes later. I feel that my staff addressed the fall in a timely manner. Sending resident to dialysis at the time wasn't the wrong call because the resident was not stating pain or discomfort. Staff did make two follow up calls and were told tech was in route. Resident was stable and not in pain so waiting on x-ray tech made sense. Fall Prevention Program policy last revised 11/21/2017 reads in part: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The fall prevention program includes the following components: Methods to identify risk factors, methods to identify residents at risk, care plan incorporates but not limited to the identification of all risk/issue and preventative measures. Safety interventions will be implemented for each resident identified at risk. Fall/Safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the fall prevention program. Nursing personnel will be informed of residents who are at risk for falling. The fall risk interventions will be identified on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident (R2) of 4 residents in the sample (R1, R2, R4 and R5) from physical abuse inflicted by his roommate (R3). This failure caused R2 to be struck with a metal rod multiple times to the face resulting in an emergent transfer to the hospital for treatment of his injuries. Findings include: R2 is an [AGE] year old with significant cognitive impairment and diagnoses including dementia, stage 3 chronic kidney disease and otsteoarthritis. R3 is an [AGE] year old with significant cognitive impairment and diagnoses including dementia, hemiplegia and hemiparesis, and aphasia following cerebral infarction. On 4/6/24 at approximately 4:10 AM, R2 was lying awake in bed and was suddenly physically assaulted by his roommate (R3) with a metal rod taken from the closet. R3 used this metal rod to strike R2 multiple times in the face with no apparent provocation. On 5/10/24 at 11:10 AM, V11 (CNA Certied Nurses Aide) stated, I heard screaming when I was in the hallway and went and saw (R3) standing over (R2's) bed and hitting the man. R3 was hitting R2 in the head area as he was sitting in bed. I immediately went to the guy with the pole and tried to calm him. I was successful in calming him down but when the man (R2) tried to get up, R3 said that he was going to hit him again. I called another CNA (V12) and I told her to got some towels to stop the bleeding from R2's head. We both got V10 (Agency LPN Licensed Practical Nurse) , who I think was an agency nurse who came and took over to help with R2's bleeding. I really don't know this man R3 but I know that R2 is a nice guy and that he gets up in the middle of the night and walks around and that's probably what might have got R3 going. On 5/10/24 at 12:10 PM, V1(administrator) stated, V2 (assistant administrator) did most of the investigation as I was off that week. The facility contacted me on that day 4/6/24 to let me know that (R3) had hit his roommate (R2) with a piece of metal in the face and the CNA (V11) was documenting in the hallway close to the room at the time and heard yelling and went in to the room saw R3 standing over R2 who was lying in bed at the time. Staff reported that V11 pulled R3 pulled away from (R2.) V12 CNA entered the room and grabbed a towel to apply first aide on the resident and the other CNA V11 was calming R3 down. The nurse V10 came in and assessed and provided first aide to R2; and R3 was escorted out to the room and he was allegedly calm and did not continue to be aggressive and taken to the dining room to be monitored 1:1. 911 was called and R2 was transported to the ER and R3 was sent to a psychiatric hospital. I was told in the hospital that the family of R2 did not want the resident to come back. I saw R2 in the ER on [DATE] and spoke with ER staff who said he had stitches on right eye and were admitting him for observation. R2 had facial contusions and laceration. one above right eye was stitched up across the eyebrow. As for R3, he was diagnosed with a psychotic episode in the hospital. R3 was experiencing a psychotic episode which led to the resident walking over to R2 and struck the resident multiple times across his face and head. Surveyor asked who provided this information pertaining to R3, V1 indicated that it was the psychiatric hospital staff but did not specificity as to which staff person. On 5/10/24 at 12:15 PM, V2 (assistant administrator) stated, It was reported to me by my administrator what occurred and I did the actual investigation of the incident involving (R2) and (R3). I spoke with (V11/CNA) and she notified me that she heard screaming coming from R2 and R3's room and saw (R3) with a metal object in hand and hit (R2). She mentioned she called for assistance from (V12/CNA) and arrived to help her and that R3 reportedly took the metal pole from the closet rod away from R3. They then called for the nurse V10 to provide first aide and assured everyone was separated and called an ambulance around 4:20 AM. R3 was given 1:1 in the common area in the nursing station. Both CNA's were providing 1:1 to R3 in the nursing station until the police arrived. The police and fire arrived at around 4:30 AM and then R2 was sent to hospital for treatment and we issued an involuntary notice petition for R3 and sent to the psychiatric hospital. It was not reported to me R3 was having a psychotic episode and that the resident just got physically aggressive. There were no occurrences between the two residents and it seemed that it came out of the blue and no antecedent to it all. We couldn't pinpoint any factor in my investigation. Efforts to reach V10 LPN and V12 CNA three times were left with unanswered calls. V1 (administrator) tried to facilitate the efforts and explained that both staff were currently working in alternative facilities at the time. Facility's internal investigation showed an interview with V10 (Agency LPN) which reads, At approximately 4:20 AM, writer was notified of room needing assistance. upon enteringroom patient in bed 2 (R2) was siting at bedside bleeding profusely from face. Assessed patient and applied pressure to bleeding. 911 called and vitals recorded. Nursing assistant stated the patient in bed 3(R3) hit paitent in bed 2 (R2) with metal object. Metal object was confiscated. The aggressor (R3) stated he will hit him again and needs to die. Patient removed from room, while waiting for ambulance. Facility's internal investigation showed interview with V12 (CNA) which reads, At about 4:30 AM, V11 (CNA) called for help. I quickly got up and hurried over to room and helped redirect the resident who hit the resident with the piece of metal. I called the nurse from the hall and told her to call the ambulance. I then took the metal object from the resident. Facility abuse policy and procedures titled Abuse Prevention and Reporting reads in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The policy and procedures however did not specifically address the management and/ or handling related to resident-to- resident abuse. Hospital records dated 4/26/24 reads in part, 82yo M with PMH of dementia, DM, HTN, HLD, who is admitted to trauma service after being assaulted at nursing home. Medicine consulted for co-management of chronic medical conditions. Pt unable to provide much history to me - somewhat limited by facial swelling and appears to be confused, trying to get out of restraints/bed. Spoke to son who also was unable to provide much history or medication list. PMH:Patient seen and examined with resident staff; their full history and physical is pending. Patient presented as a trauma level 2, from scene; I was present in the ED soon after patient arrival. 82 yo male, status post assault by roommate at nursing facility, struck by pole. Denies Loss of consciousness. Primary survey with airway intact, bilateral breath sounds, palpable pulses equal pupils. Secondary survey with multiple facial lacerationss and swelling. Labs and imaging reviewed. Hgb 11.5 CT head, c-spine, face pendingA/P: s/p assault, facial lacs and likely fractures- OMFS consulted - if requires admission, will admit to Trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure administration operationalizes and oversees facility's policies and procedures regarding substance abuse to ensure the safety of residents with a history of substance abuse. This failure resulted in a delayed response to the facility's substance abuse issue and resulted in 5 residents (R1, R2, R3, R9, and R12) overdosing on illegal substances and requiring Narcan administration, emergency services, and in some cases CPR. The findings include: The facility's records show the first episode of an overdose on illegal substances at the facility occurred on [DATE] and continued to occur through [DATE]. R1's [DATE] Nurses Note entered at 11:23 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs arrived and resident was taken to [acute care hospital] . R2's [DATE] Nurses Note entered at 9:16 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs arrived and resident was taken to [acute care hospital] . R3's [DATE] at 1:15 PM progress note showed, It was reported to writer that patient was found incoherent out on the patio and may have used an outside controlled substance . R3's [DATE] Acute Hospital Documents showed he arrived at the ED at approximately 5:44 PM. These same documents showed, Diagnoses: heroin abuse . R12's [DATE] acute care hospital records showed, . Brought in by [emergency medical services], was found down on the floor by NH (nursing home) staff . reports taking Heroin today. Patient presents for overdose from snorting heroin . Diagnosis and Impressions: 1. Accidental overdose of heroin . R9's [DATE] Nurses Note entered at 12:39 AM showed, Resident assisted to bed x 3 person . resident became responsive after 2 Narcan administration. Resident stated I'm okay. Urine collected, positive for opioid substance . The incidents for R1, R2, R3, R9, or R12's were not reported the local law enforcement or the State Survey Agency. A complete list of residents who experienced an overdose and required Narcan was requested repeatedly and not received throughout this survey. Social Services Assessments were reviewed and were not completed accurately regarding resident drug abuse history to compile an accurate list of residents at risk. On [DATE] at 12:03 PM, V32 CNA (Certified Nursing Assistant) said, I don't know but sometimes the hallways smell like weed . On [DATE] at 11:14 AM, V37 (Restorative Aide) said, There are drugs everywhere, a lot of residents have them. They always smell of marijuana. One day a paralyzed resident was in his bed smoking a joint. Someone had to give that to him. V37 said he saw a resident in a motorized wheelchair drop a bag of marijuana off his lap onto the floor. V37 said he just rolled his wheelchair over it to hide it and another resident picked it up and gave it back to him. V37 said there are a lot of residents that go out in front of the building to smoke and he sees cars pull up to them and get out, they will only be there a couple minutes then leave. I haven't seen a transaction but it's odd. I've reported to the administrator. The nurses have started carrying Narcan in their pocket. On [DATE] at 12:40 PM, V36 LPN (Licensed Practical Nurse) said, We did a code for [R2], got him stabilized, took vitals and probably gave him Narcan . We know to consider Narcan if the resident is unresponsive to pain. The resident's usually have friends that alert us if they have been using substances that day . specifically [R2] we monitor. Friends say he is out smoking and don't know what he was smoking . On [DATE] at 10:50 AM, V7 LPN said he was present when R12 overdosed. V7 said when R12 was not responding to a sternal rub and his pupils were dilated he knew it was time for Narcan. V7 said sometimes when residents are out smoking they have symptoms of potential overdose. V7 said room checks are initiated when they smell marijuana. On [DATE] at 12:14 PM, V41 (Medical Director) said, I was made aware of the issue of overdosing in the facility several weeks into the situation. It was actually brought to my attention by one of my Nurse Practitioners that they had used Narcan on some of our residents. I called the Administrator and he said they were working on it through education . He said they traced it back to just one resident and he was transferred out. I would think the police would have been involved too . Of course I would have expected to have been notified right away. I would have been able to help with the situation, reach out to an addict team, Notify (State Survey Agency), Treat medically whoever was in need, and ensure the regulatory stuff would have been followed through. This is a bizarre situation that looks like someone is bringing drugs in . On [DATE] at 12:44 PM, V1 (Administrator) said, At first we didn't know we had a Fentanyl problem. I thought maybe they were nervous and everyone that was 'out of it' (unresponsive) so they were just giving them Narcan too. When we looked into it and [R12] was positive for cocaine I started looking at Fentanyl. That's when I got a test kit, not a urine test kit. It was a substance test kit. I got the substances to test from a room search. If you go online, it won't let you buy the Fentanyl test kits because of weird political or probably money reasons. In Illinois you can't buy Fentanyl test kits but at 333 State St, in downtown Chicago they have a box on the 3rd floor in the Chicago Department of Public Health office where you can take as many Fentanyl test strips and Narcan as you want. They are there for the drug users who don't want to die from Fentanyl so they can test their own product. I've reached out and I'm getting 500 Fentanyl test strips that I can distribute to other facilities and family members. I said we gotta get ahead of this, so we put an action plan together for people who even smoke a little pot and become unresponsive. I know weight wise it's good to put it (Fentanyl) in heroin but why put it in marijuana. The drug dealers who are cutting the marijuana, the heroin, or the cocaine are using the same surfaces, it's a cross contamination issue. Two people told me that, one was a coordinator we were talking to about NA (Narcotics Anonymous) meetings for our facility and also Dr. Google (Internet search engine). When we were using Narcan like nobody's business, we assessed all residents for a history of substance abuse and updated a list. (List was requested repeatedly and not received until [DATE] upon exit.) One of the people were non-responsive on the patio but our staff monitor that, but that's one set of eyes. If they wheel somebody to the elevator and back that's not a problem they don't have to necessarily be out there. So we set up a camera. We did do training on nurses for drug overdose and responding and Narcan usage . We did start to do some searches of bags and personal things, nothing super harsh because we know if someone wants to sneak something in they can. We initiated random room searches. Those are documented in the resident's records. No checklist. We did a resident council meeting . I told them if they are smoking pot and they are feeling 'out of it' they should let the nurses know because it could be Fentanyl . we have a new company that will be working with our active substance users to look at other underlying mental health issues such as anxiety and depression that could be contributing to their substance use . We did also reach out to [a local company] and they are willing to come in and meet with the residents to discuss overdosing. They are a harm reduction group. They will go over the signs of OD and what they should do (at the time of this survey there was no evidence this had been completed) . [R12] is going to NA meetings because he is somebody that when he is out in the community he goes immediately to get cocaine, like a moth to a flame . Something I still don't know is where the Fentanyl was coming from. Too many different people in and out of the facility. They had to have been getting it from someone. We talked to everybody, I looked at probably 30 hours of video checking to see if staff were going in and out of rooms more frequently . Just because you have community access and are found with drugs on you it doesn't mean that you are sharing. We haven't used Narcan in months (last documented Narcan usage found in resident sample was [DATE].) That's good considering how often we were using it . I tested the drugs myself. [R3] was actually honest about it. Until we Narcan' d him, we didn't even know he had a heroin issue. He told us he was using heroin every day. Now all of a sudden he is out (unresponsive). So when we tested it and found it had Fentanyl in it, he was really upset about it. He said he would get on the bus and go back into the neighborhood or somewhere to get it but that doesn't mean he is being honest. I believe we actually looked at who had a substance abuse history between nursing consultants and our social services team. They did the assessments. (A document was provided by the Administrator with some steps taken by the facility, all undated, all marked 'completed'.) It shows 'completed' but it was varying dates. At one point we sat down and said 'We are outgunned here.' After that multiple Narcan usages. I would say the education started in September. At first we were like 'hmm [R2] just got really drunk or someone overdosed on something they were taking. Maybe it's an isolated incident.' The two residents would have been isolated verses widespread. Then in September is when we realized we had a pattern. It was shocking to me because [R2] is no newbie when it comes to using substances so how in the world are they overdosing. Especially [R3] too. We were absolutely playing defense. Narcan was being given and the resident perked up and they (the nurses) were like 'oh he is good' and let them just go back to their rooms. I flushed the drugs. I did not call the police. I did not report to (State Survey Agency). I don't know what the reasoning would be to report it. We look at harm. (This surveyor asked V1 if he considered a resident overdosing on illegal drugs, requiring CPR (cardiopulmonary resuscitation), emergency services, and in some cases a hospital stay an 'unusual event' that would require reporting and be considered harm?) I guess I'll take your input on that. We were actually expecting IDPH to come out earlier because a lot residents were freaking out I figured someone would call in. We were well expecting you guys. The reality is Fentanyl is a problem. I'm still trying to figure out how this would be reportable. This is uncharted territory and I guarantee you we did some things wrong here. There hasn't been any more Narcan use 'knock on wood' but we are putting things into place where residents are educated and are smarter now. We were going to bring drug sniffing dogs in, not the police though because the police don't want to do it. I called the Chicago police (not the local police department) to see if they take their dogs in to facilities and they said 'If a resident has a bag of heroin and he is in a wheelchair with no legs, we don't want to be on the news 'perp walking' them out of the facility. It's bad PR (Public Relations). The facility's job description titled Administrator created [DATE] showed, Summary: The Administrator directs the day to day functions of the facility in accordance with current federal and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures . Review and check competence of workforce and make necessary adjustments/corrections as required or that may become necessary . Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas .Ensure that all facility personnel, residents, and visitors follow established safety regulations to include fire protection/prevention, smoking regulations, infection control, etc. Review accident/incident reports (e.g. falls, injuries, or an unknown source, abuse, etc Monitor to determine the effectiveness of the facility's risk management program .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise and provide minimum assistance to prevent falls for 2 of 3 residents (R1 and R2) reviewed for falls in a total sample of 11. This failure resulted in R1 suffering from a right tentorial subdural hemorrhage, and R2 suffering from acute fractures of the posterolateral and lateral 5th-9th ribs, left pneumothorax and slight left lung contusion. Finding include. 1. On 5/30/23 at 2:00pm, V8 (RN) stated that she was informed by R2 at the end of her shift that he fell in the bathroom. V8 stated that R2 can walk to the bathroom with one assist. V8 stated that R2 requested to be changed and she sent V36 to go and change R2. V8 stated that she witnessed V36 go into R2's room and was informed by V36 that R2 has been changed. V8 stated that R2 needs were addressed during her shift, and he did not complain or have any concerns during her shift. On 6/1/23 at 2:00pm, V36 (CNA) stated I checked on R2 in his room during rounds and he was dry. He did not tell me he had fallen in the bathroom. V36 stated she checked the second time during rounds after 2pm and R2 had a bowel movement so she changed R2. V36 stated that, the third time she gave him water and R2 did not mention anything about a fall. V36 stated that she had witnessed R2 walk to the bathroom and walk out of the bathroom in the past; V36 stated I have seen him sitting at his bed side by himself and standing. V36 stated that she is not sure of R2's fall status. He would put his call light on for assistance. V36 stated that residents will have a fall band if at risk for falls and all fall risk residents are assisted in the wheelchair if they need to go to the bathroom. On 5/30/23 at 2:30 pm, V9 (2nd Floor Supervisor) stated that she was informed by the outgoing nurse that R2 fell on his side in his room. V9 stated that an x-ray of his ribs was done and R2 was sent to the hospital once x-ray results came back positive. V9 stated that R2 did not inform anybody he needed assistance with toileting. He can walk to the bathroom by himself. On 6/1/23 at 11:15 am, V24 PT (Physical Therapy Assistance) stated that R2 needs a minimum of one assist with bed mobility, turning side to side, sitting at the bedside. V23 (Physical Therapist) and V24 both stated that R2 did not receive a physical therapy evaluation and did not provide a reason. R24 stated that R2 was referred to OT (Occupational Therapy) on 2/27/23 but was picked up by PT on 5/23/23. He is receiving bed mobility from PT due to max assist. On 6/1/23 at 3:15pm, V2 (DON) stated that a fall assessment is done on all residents and the fall interventions are documented in the care plan. V2 stated that a leaf is placed on the resident's door to identify high risk residents. Physician order dated 2/27/23 reads; Physical Therapy (PT) Evaluation and Treatment as Indicated. Fall risk assessment dated [DATE] reads; Score:13 Category: At Risk for Falls. Facility's standing order set reads, PT eval and treat as indicated. Facility's fall incidents show; R2 fell on 4/11/23 and 5/10/23. Facility's document reads; Report to IDPH (Illinois Department of Public Health) [NAME] Office. Initial 5/10/23 and Final 5/10/23. Physician order dated 5/23/2023 reads; Therapy: PT Evaluation and Treatment 3-5 x/week x 41 days, to address ther-ex, ther-ac, neuromuscular re-education, gait training, w/c management, manual therapy. Minimum Data Set Section G. Functional Status reads; I-Toilet use: Self Performance 3 (Extensive assistance) and Support 2 (One-person physical assist). Care plan initiated 2/27/23, reads I am at risk for falls and injury related to falls. PT and OT to evaluate and treat as indicated. 2/28/23 reads; Assist with toileting upon awakening, before and after meals, during rounds, before bedtime PRN. 5/15/23 reads; PT, OT (Occupational Therapy) and RT (Raspatory Therapy) to evaluate upon return from the hospital. Radiology Results Report dated 5/10/23 reads, Impression: (1) Acute facture of posterolateral and lateral left 5-9 ribs, including comminuted segmental fracture of the 6th, 7th, and 8th ribs. (2) 30% or so left pneumothorax and slight left lung contusion. Hospital report dated 5/11/23 reads; Current admission Orders: Diagnosis; Traumatic pneumothorax, initial encounter. Facility's policy titled; Fall Prevention Program; Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk falls and implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary . Standards: . Safety interventions will be implemented for each resident identified at risk. . Residents who require staff assistance will not be left alone after being assisted to bath, shower, or toilet. 2. On 05/30/2023 at 2:30PM, R1 stated that she remembers she was being assisted by CNA to the bathroom while walking with her walker when she slipped and fell backwards. On 05/31/23 at 2:50PM, V35 (Agency Certified Nursing Assistant) said while she was assisting R1 with walking to the bathroom with her walker, R1 asked her to adjust the toilet raiser before entering the bathroom, and while she was doing that, R1 suddenly fell backwards. On 06/01/23 at 11:45AM, V24 (Physical Therapy Assistant - PTA) and V25 (Physical Therapy - PT) said that at the time of the fall, R1 needed minimal assistance with rollator, which means staff has to physically hold her while walking. V25 said that he knows R1 because he has worked with her and R1 has the tendency of falling when no one is holding her because she leans backwards, and her hips are very unstable. V24 also clarified that their software does not allow putting in minimal assist so they put partial/moderate assist which could mean minimal to moderate assist. On 06/01/2023 at 1:18PM, V39 (PTA) said that around the time of R1's fall, he was just coming back from leave. He said that during that time, R1 needed minimal help with everything like transfers, and ambulation with rollator. He also mentioned that he told R1 that he felt R1 was not ready for the rollator use yet because she becomes really tired. He described that R1 manifests shakiness when she gets tired. He also said that during the treatment, he was just grabbing the gait belt that was on her because she was becoming really shaky. He also mentioned that minimum assist means constantly touching the resident to give them the 25% of help they need. On 06/02/2023 at 10:30AM, V39 stated that R1's therapy performance fluctuates but the safest assistance she needed is minimum assist by 1 person. R1's face sheet order summary report dated 6/2/2023 indicated admission of 05/23/2023 and diagnoses including repeated falls, presence of right artificial knee joint, presence of right artificial hip joint, dependence on renal dialysis, malignant neoplasm of left kidney, except renal pelvis, malignant neoplasm of colon, hypotension, fracture of coccyx, end stage renal disease, other low back pain, unsteadiness on feet, abnormal posture, other abnormalities of gait and mobility, and other lack of coordination. R1's fall risk assessment dated [DATE] indicated at risk for falls, and gait/balance problem while standing and walking. Skilled evaluation dated 4/27/2023 indicated unsteady gait, poor balance, use of manual wheelchair, and safety concerns. Documentation survey report for April 2023 indicated walking in the room did not occur for 4/24/2023 - 4/26/2023 and 4/28/2023, and extensive assistance with one-person physical assist on 4/27/2023. PT Treatment Encounter Note dated 4/28/2023 indicated R1 was instructed with gait training using rollator with min A x 1 (minimal assist by 1 person) on level surface for x (for) 40 feet each and unsteady gait pattern. PT Discharge Summary for dates of service 3/7/2023 to 4/28/2023 indicated functional skill on ambulation as partial/moderate assistance. Care plan revised 5/24/2023 indicated R1 is at risk for falls and injury related to falls, and risk factors include lack of coordination, abnormal posture and abnormal gait/mobility. Hospital admission record dated 4/29/2023 indicated Neuro ICU H&P (Neurology Intensive Care Unit History and Physical) Note chief concern of R SDH (right subdural hemorrhage), and CT Head without IV (intravenous) contrast final result dated 4/29/2023 indicated findings of stable known right tentorial leaflet subdural hemorrhage, and impression of stable known right tentorial subdural hemorrhage. PT provided a document entitled Suggested Terminology for Objective Data that indicated the following: Minimal (Contact) Assistance - Patient requires small amount of help to accomplish activity; patient requires no more help than touching and expends 75% or more of the effort. Patient is able to assume all of his body weight, but requires guidance for initiation, balance, and/or stability during the activity. Moderate Assistance - Patient requires more help than touching; expends half (50%) or more (up to 75%) of the effort. Patient is able to assume part of his body weight in initiating and performing activity. Facility Policy: Title: Fall Prevention Program: Revisions: 11/21/2017 Purpose: To assure safety of all residents in the facility, when possible. Fall/safety interventions may include but are not limited to: Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Monitor gait, balance, and fatigue with ambulation if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage one residents with type one diabetes by failing to get a continuous blood glucose monitoring device and not following physician orders for Lantus. This affected 1 of 3 residents (R3) reviewed for diabetes. This failure resulted in R3 being hospitalized for diabetic ketoacidosis Findings include: R3 was admitted to the facility on [DATE] with a diagnosis of type I diabetes and gastroparesis. R3's physician progress note dated 2/21/23 documents: Patient states blood sugar this morning was 55. Requesting a continuous blood glucose device to avoid finger sticks. Ordered from pharmacy. Patient states asymptomatic this morning. R3 physician order sheet dated 2/21/23 documents: order for continuous blood glucose system sensor. R3's medication administration record for February 2023 under Dexcom documents: 9 which indicates other /see nursing note on 2/21/23, 2/22/23, 2/24/23 and 2/25/23. R3's progress note documents continuous glucose device placed on 3/21/23. On 4/14/23 12:55PM, R3 who was alert and oriented at time of interview said she requested for continuous blood glucose monitoring device because she had one prior to entering the facility. R3 said she was unsure that she could get the device and when she went out on pass back home she got her equipment and brought it back to the facility. R3 said she knows how to change and monitor device and that the blood glucose reading will alert to her phone if too high or low. R3 said she placed it on 3/21/23. On 4/14/23 at 3:53Pm, V18(ADON) said physician's orders are expected to be followed. V18 said facility was trying to get R3's glucose device from pharmacy but there was an issue wih the insurance. V18 presented email communication with the pharmacy dated 3/22/23. There were no other communications presented. On 4/14/23 at 3:10PM, V67(pharmacy) said pharmacy has continuous blood glucose equipment and device but as part of facility contract, the facility would have needed to call and request for item to be sent. There are certain items and medications that default to profile only and will only be sent if specifically requested. V67 said she was unable to access that far back in the system to see if there were any requests made. R3's medication administration record for February 2023 under insulin lantus : inject 34 unit subcutaneously at bedtime. On 2/20/23, 2/21/23 and 2/23/23 documents: 15. 15 indicates no insulin needed. On 2/25/23 documents 3: 3 absent from home. R3'a blood glucose on 2/20/23 at 21:35 78, 2/21/23 at 22:08 95, 2/23/23 at 21:22 95. There were no documented blood glucose readings for R3 from 2/25/23 at 11:22am was 320 until 2/26/23 at 7:42Am documents: 400. R3's progress note dated 2/25/23 at 10:45: Resident complains of emesis 6-7 times, medication given but not effective, was not able to tolerate her breakfast, latest vitals are blood pressure-115/57, pulse-119, respirations 24, temperature 98.2 Blood sugar 309 mg/dl. Referred to MD, advised to be sent to local hospital, called ambulance for transportation eta given is after 1 hour. R3's local hospital record dated 2/25/23 documents under chief complaint: nauseas and vomiting due to hyperglycemia. Last blood glucose reading documented at 19:08 at 166. There was no documentation of any insulin given during hospital stay. R3's progress note dated 2/25/23 at 23:40 documents: Resident returned to the facility from local hospital in stable condition via stretcher by two EMTs, no signs of distress observed, vitals WNL, no new order given, will continue to monitor. The next progress note was dated 2/26/23 at 23:15 which documents: Writer placed a call to hospital for a follow up and was made aware that the resident was still being evaluated, endorsed to night shift nurse to follow. On 2/27/223 at 23:01 documents: resident admitted for diabetic ketoacidosis. On 4/19/23 at 11:22AM, V18(ADON) said blood sugar should be assessed at time of readmission. On 4/21/23 at 1:41PM, V63(MD) said staff should call to verify if medication like Lantus should be held. V63 said unsure parameters for lantus and if or when it should be held, just base it on the patient at time of administration and staff should call him to make decision. On 4/21/23 at 4:54PM, V59(Nurse) said a low blood sugar would be less then 100 and we would call the doctor if we held any insulin. V59 was unable to recall R3. R3's 911 report dated 2/26/23 documents: call received at 8:29AM, at patient 8:36AM. Under narrative documents: dispatched for breathing problems. R3 was found alert and confused breathing quickly while sitting in bed. Per staff, R3 was seen yesterday for vomiting and returned last night. This morning, staff noted that R3 breathing quickly. R3 was placed on oxygen by nursing staff. Staff reported patient blood glucose reading was high. Assessment of R3 note tachypnea, warm skin and disorientation. Vital signs heart rate 140, blood pressure 108/68, pulse ox 97 %, respirations 36, and glucose was high. R3's hospital record dated 2/26/23 documents under diagnosis: Type I diabetes with ketoacidosis without coma. Upon arrival glucose above 600. R3's after visit summary from V62(MD) documents: always administer lantus to patient. Not administering basal insulin will result in diabetic ketoacidosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor and supervise the common dining area and failed to follow the Minimum data set for transfers. This affected 2 of 3 residents (R8, R10) reviewed for falls and supervsion. This failure resulted in R8 having an unwitnessed fall sustaining a laceration requiring 4 sutures. Findings include: 1. R8 - R8 was admitted to the facility on [DATE] with a diagnosis of hemiplegia affecting left side, history of falling, anxiety disorder and abnormalities of gait and mobility. R8's brief interview for mental status dated 1/17/23 documents a score of 12/15 which indicates moderately impaired. R8's Minimum Data Set, dated [DATE] under functional status documents: Transfer- how resident moves between surfaces including to or from bed, chair, wheelchair, standing position(excludes bath/toilet) documents a score of 3 under self-performance which indicates extensive assistance- resident involved in the activity, staff provide weight bearing support; under support documents a score of 3 which indicates two person assist. Under balance from surface-to-surface transfer (bed to chair or wheelchair) documents a score of 2- not steady only able to stabilize with staff assistance. R8 fall risk assessment dated [DATE] documents: at risk for falls. R8 incident report dated 1/11/23 at 19:05 documents: resident had unwitnessed fall in the dining room. Observed lying on the floor on his side, has lacerated wound and bleeding to left eyebrow. Under resident description: I was trying to get up from wheel chair but I lost my balance. R8's hospital record dated 1/11/23 documents: patient had unwitnessed fall, Patient was found in dining room on the floor by staff. Laceration noted to left eyebrow. Under procedure documents: 3.5 cm laceration to left eyebrow. Suture repair was done with derma bond and close approximation of wounds. On 4/5/23 at 4:24PM, V7(Nurse) said R8 fell on 1/11/23 and she was alerted by another resident that R8 was on the floor. V7 said she was unable to recall if there were any staff in the dining room at the time of fall but dining room is monitored by staff when residents are present. On 4/8/23 at 4:35PM, V8(CNA) said staff monitor dining room area when residents are present. Each staff is assigned every 30 minutes to monitor residents. On 4/14/23 at 3:53PM, V18(ADON) said common dining rooms are monitored by staff when residents are present. V18 said he is unable to recall if any staff were present in the dining room at the time of R8's fall. V18 said that R8 only requires one to one monitoring if presenting with exit seeking behavior. On 4/14/23 at 3:40PM, V43(CNA) said staff are monitoring the dining room when residents are present. V43 said he was not assigned to the dining room at time of R8's incident but assisted the nurse with transferring R8 back to wheelchair. R8's incident report dated 1/24/23 documents: Resident had witnessed fall in his room, the Certified nursing assistant was preparing the residents bed and instructed to stay still on his wheelchair when suddenly fell to the floor as he was trying to stand from his wheelchair, the resident struck his head in the floor. Under resident description: resident stated he did not know what happened. Under action taken: put pressure to stop bleeding on the lacerated wound. R8 final report dated 2/1/23 documents under occurrence: Resident had a witnessed fall when he suddenly stood up from his wheelchair as the CNA was preparing to transfer him from his wheelchair to his bed at bedtime. Resident stated that he did not know why he self-transferred without waiting for assistance. R8's hospital record dated 1/24/23 documents: witnessed fall from wheelchair. Patient stood up and lost balance, falling forward into floor, laceration to left eyebrow. 3 cm jagged scar above left mid and lateral eyebrow from last time. Has new depth wound 4cm medial to this with bleeding, depth to muscle. Under procedures documents: laceration repair 4 cm laceration was repaired using 4 x 4.0 nylon suture. On 4/8/23 at 4:35PM, V8(CNA) said she was assisting R8 to go to bed. R8 was in his wheelchair next to the bed when he suddenly got up and fell hitting his head in the floor, while she was fixing the bed. V8 said no one else was in the room with her at time of incident. R8's plan of care date initiated 1/12/22 documents chair to bed transfer 1 assist, may require 2 person assist. R8's care plan initiated on 5/3/22 revised 2/6/23 documents: I am wanderer related to exit seeking. Impaired safety awareness. Interventions: one to one with staff. R8 is at risk for falls and injuries related to falls. Risk factors: requires assistance with activities of daily living, possible medication side effects, incontinence, stroke, dementia, history of falls. Low back pain, lack of coordination, abnormal gait and posture initiated on 1/11/22 and revised on 2/3/23; interventions dated 1/13/22: assess for altered cognition, decline in safety awareness, assess for pain; physical therapy and occupational therapy to evaluate and treat, orient to environment, observe, report unsafe conditions, interventions dated 1/13/23 therapy to evaluate upon readmission, continue to educate resident to ask for staff assistance, monitor for syncope, assess for pain. 2. R10 - R10 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, abnormalities of gait and mobility, lack of coordination, type II diabetes, arthritis, and pain in left leg. R10 brief interview for mental status score dated 1/3/23 documents a score of 15/15 which indicates cognitively intact. R10s Minimum Data Set, dated [DATE] under functional status documents: Transfer- how resident moves between surfaces including to or from bed, chair, wheelchair, standing position(excludes bath/toilet) documents a score of 3 under self-performance which indicates extensive assistance- resident involved in the activity, staff provide weight bearing support; under support documents a score of 3 which indicates two person assist. Under balance from surface-to-surface transfer (bed to chair or wheelchair) documents a score of 2- not steady only able to stabilize without staff assistance. On 4/6/23 at 11:30AM, R10 who was alert and oriented at time of interview, said staff transferred her without hoyer lift and she fell. R10 said a female staff was going to transfer her to her wheelchair by herself. R10 said she told the staff she needs a hoyer lift but staff did not listen and said they could transfer R10 to the chair by themselves. R10 said she ended up on the floor in pain and was sent to the hospital. R10 said she did not have any serious injuries from fall. On 4/11/23 at 12:18PM, V18(ADON) said they are unable to identify the staff member that was assisting R10 during transfer at time of fall. R10's fall risk dated 1/3/20 documents at risk for falls. R10s incident report dated 2/24/23 documents: Writer was notified by staff after transferring resident to wheelchair her feet started sliding and she slid down; resident description documents: after transferring to my chair I started sliding down. Under mental status documents oriented to place, time , person and situation. R10's physical therapy Discharge summary dated [DATE] documents: Transfer dependent. Under recommendations: transferring to wheelchair using hoyer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident drank fluid to stay hydrated. This affected 1 of 3 (R4) residents reviewed for hydration. This failure resulted in R4 being hospitalized and treated for hydration with a 1500ml bolus of fluid. Findings include: R4 had the diagnosis of Dementia, hemiplegia and hemiparesis and dysphagia and a lack of coordination. Minimal data set dated [DATE] documents; R4 requires extensive assistance with one person physical assist with eating. R4's laboratory results dated [DATE] documents BUN 127 (Critical) Reference range 7-28mg/dL. On 4/19/23 at 10:43, V75 (Certified Nurse Assistant, C.N.A.) said, I did not measure the amount fluid I gave R4. I was instructed to put the amount of fluid the pitcher held. Point of care charting dated February 20/21, 2023 documents: No fluid was given for the day and evening shift. 400 ml was given on the night shift for 2/20/23 and 200ml was given on the night shift on 2/21/23. Emergency Department notes dated 2/21/22 - Chief complaint lab abnormalities. BUN high. R4 had a blood urea nitrogen (BUN) was 127. R4's mouth: mucous membranes dry. R4 endorsed not feeling well Fluids were given for dehydration. Sodium chloride 500milliters (mL) and Lactated ringers 1000 Ml *fluid bolus* was infused. Water Pass- Hydration dated 11/28/12 documents: To provide fresh drinking water to residents in a clan and sanitary manner to meet hydration needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of catheter care by not emptying the bedside urinary catheter bag for a resident, putting them at risk of urine backing up into the bladder. This failure applied to one (R23) of one resident reviewed for catheter care. Findings include: R23 is a [AGE] year old male who was admitted to the facility 9/3/21 with diagnoses that include Spinal Stenosis, Vascular Dementia, and urine retention. On 1/30/23 at 2:08PM, V25 RN (Registered Nurse) was observed in the hallway outside the room of one resident, R23, with a new urinal in hand and preparing medications. At 2:10PM V25 said, I asked the CNA to empty R23's urinary drainage bag hours ago when I saw it was pretty full. She still hasn't done it and now it is about to burst open. When going into the room with V25, Surveyor noted that the urinary bag was so full that it was tightly expanded, and urine was backed up into the tubing. R23 said, I can feel when the bag is full because it starts pulling and it is uncomfortable. I asked the CNA to empty it earlier because it hasn't been emptied since last shift- about 6AM. I put on my call light, and they came in to turn it off and told me they would be back. They came to give me lunch and removed my tray but didn't empty the bag. Surveyor observed urinary bag to have approximately 2500ml of urine. V25 RN was seen filling up the urinal fully, twice, and then a third time. V25 said, I wasn't really paying attention to the amount because I had to empty it three times, as you saw, but I think it was about 2300ml. At 2:20PM V26 CNA (Certified Nursing Assistant) was observed at the nursing station with a personal bag of food, using a personal cell phone and speaking with coworkers. V26 said I haven't changed R23's urinary bag this shift. I have been in the room several times today. The nurse asked me to empty it earlier but I got busy. I haven't washed him up or cleaned his bed today. I'm about to help with a transfer and then I leave at 3PM. Based on observation, interview, and record review, the facility failed to provide timely incontinence care for residents known to require staff assistance with toileting. This failure affected six of six residents (R11, R12, R14, R22, R24, R25) reviewed for incontinence care and resulted in three residents ( R12, R14 and R24) developing multiple urinary tract infections while in the facility. Findings include: 1. R11 is a [AGE] year old male admitted to the facility 12/27/2019 with diagnoses that include Paraplegia, Morbid obesity and Pressure Ulcer Stage III. Review of R11's medical record MDS (Minimum Data Set) dated 2/3/23 indicates that he is cognitively intact and requires extensive two person physical assistance with toileting as he is always incontinent of bowel and has an indwelling urinary catheter. On 01/30/2023 from 11:59 AM - 12:10 PM R11 stated he has to call down to the nurse's station to get staff to respond to the call light. R11 stated he begs the staff to change him. 2. R12 is a [AGE] year old female admitted to the facility 11/5/2015 with diagnoses that include Arthritis, Morbid obesity, and Urinary Tract Infections. MDS dated [DATE] indicates that R11 is cognitively intact and requires one person physical staff assistance with toileting due to urinary and bowel incontinence. On 01/30/2023 from 11:38 AM - 11:46 AM R12 stated it takes staff hours to answer her call light and there was a couple of times that she wasn't provided with incontinence care timely. R12 stated the excuse staff gives is that they are short of staff. On 01/30/2023 from 11:34 AM - 11:48 AM R12 stated she rang the call light at 8:15 AM because she had urinated and needed to be changed and urinated again at 10 AM. R12 stated at 11:15 AM she notified V6 (Patient Relations) she needed to be changed because no one had responded to her call light and her bed and adult brief were soaked with urine. R12 stated V6 then sent a CNA (Certified Nursing Assistant) to assist her and the CNA told her she wasn't assigned to her but did provide her with incontinence care. Medical Record reviewed for R12. Urinalysis collected 12/1/22, resulted with positive culture results on 12/6/22 and indicated Escherichia coli and Proteus mirabilis bacteria present. Progress notes dated 12/7/22 written by V31 Nurse Practitioner stated that R12 was diagnosed with a UTI (urinary tract infection) and placed orders for antibiotic Ciprofloxacin 250mg every 12 hours for 3 days. Medication Administration Record dated 12/7/22 indicated that R12 received antibiotic Ciprofloxacin 250mg every 12 hours for 3 days for infection. 3. R14 is a [AGE] year old woman admitted to the facility with diagnoses which included Chron's Disease, Heart failure, Polyneuropathy and Anxiety Disorder. According to MDS (Minimum Data Set Assessment) dated 1/5/23 indicates that R14 is incontinent of bowel and bladder functioning and requires extensive two person staff assistance with toileting. On 1/30/23 at 1:00PM, R14 was observed in bed, alert and oriented. R14 said, I usually have to wait a long time to be changed. I have Chron's Disease and have diarrhea frequently sometimes and since I can't get up to the toilet I go in my brief. Sometimes the staff gets mad at me because I have diarrhea but I can't help my body. I haven't been changed since this morning and need to be changed now. I keep getting Urinary Tract Infections because I'm sitting in my stool. At 1:20PM V27 CNA came into the room and removed R14's lunch tray. V27 did not provide incontinence care for R14. During observations on the unit, it was noted that R14 had not received any incontinence care between 1:00PM and 2:45PM. At 2:00PM V21 LPN Unit Manager was seen collecting R14's belongings. V21 said, R14 has a urinary tract infection that requires isolation because it is highly transmissible and may be resistant to some antibiotics. We are moving her room temporarily. She was complaining of symptoms over the weekend and the final results for the culture came back today, positive for E. Coli bacteria with ESBL (extended spectrum of beta lactamase). Urine culture collected 12/6/22 resulted on 12/9/22 and was positive for E. Coli bacteria. Physician orders dated were placed for treatment. On 12/29/22, a follow up culture was obtained via urinary catheter and was negative for bacteria. Urine culture reported 1/28/23 noted that sample was collected on 1/26/23 and was positive for Escherichia coli (E. Coli) bacteria of greater than 100,000 colonies. 4. R22 is an [AGE] year old female admitted to the facility 10/6/22 with diagnoses that included Dementia, Osteoporosis, and Major Depressive Disorder. According to MDS (Minimum Data Set Assessment) dated 12/19/22 R22 is incontinent of bowel and bladder function and requires extensive staff assistance with toileting and hygiene. On 1/30/23 at 2:33PM, R22 was observed lying in bed, on a low air loss mattress with a strong smell of urine. At 2:43PM, V27 CNA (Certified Nursing Assistant) was observed sitting at the nurse's station on the phone. Surveyor asked to check R22 for incontinence care and at 2:45PM V27 and surveyor went to R22's room. When V27 removed the top covers, R22 was observed in a heavily saturated brief. V27 was observed wiping the front genital area and buttocks and placed a new brief. Surveyor asked V27 the proper way of cleaning female genitals while providing incontinence care and V27 cleaned between the legs and labia, after prompted by surveyor. V27 finished providing care and placed a new brief without changing gloves or performing hand hygiene. Surveyor noticed large dark yellow rings on the bed pad. V27 said it could be urine but it's not wet. I haven't changed the bed pad today; it was put there by the night shift. I last checked her this morning. Care plan dated 10/7/22, revised 1/8/23 states that R22 has the potential for complications related to incontinence, with a past medical history of UTI (urinary tract infection). Interventions include that the CNA should wash, rinse and dry perineum; change clothing as needed after incontinence episodes. Assist with toileting before and after meals, upon rising in the AM and before bed at night and as needed. On 2/1/23 at 11:10AM V3 DON (Director of Nursing) said, CNA's should document that they provided incontinence care for every occurrence in the Point of Care section of the chart. Delays in receiving incontinence care may lead to poor results in customer service, skin breakdown and poor hygiene. I can tell if an incontinent resident has not been changed for an extended period of time based on a heavily soiled brief or if they told me. R14 has Chron's Disease and should be changed more frequently because she has frequent stools. I would not expect her to have to wait in a soiled brief for over an hour because a delay in changing could contribute to developing UTIs (urinary tract infection). At 12:59PM V31 NP (Nurse Practitioner) said R14 has been treated for several UTIs while in the facility. Poor incontinence care could be the cause of frequent UTIs. I ordered a urinalysis because she complained to me of painful urination. UTIs can occur with residents who are incontinent because stool has E. Coli and can get in to the urinary hole if the resident is sitting for any time. 5. R24 is a [AGE] year old woman admitted to the facility 12/30/22 with diagnoses that include, Spinal Stenosis, Morbid obesity, Abnormalities of gait and mobility and Urinary Tract Infection. MDS dated [DATE] indicates that R24 has full cognition and requires extensive one person staff assistance with toileting as she is frequently incontinent of bowel and bladder functions. R24's medical record was reviewed. On 1/30/2023, Physicians Order Sheet included an order for urinalysis with a reflex culture. The specimen was collected 1/31/23 and resulted 2/3/2023 and contained E. Coli bacteria. On 2/1/23, an order was placed for antibiotic Ciprofloxacin 250mg by mouth every 12 hours for UTI for 7 days. Care Plan for incontinence initiated 1/2/23 stated R24 had a past medical history of UTI. UTI care plan initiated 2/1/23 included interventions that state Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. 6. R25 is a [AGE] year old female admitted to the facility 1/20/23 with diagnoses that included Morbid obesity, Pressure Ulcer of left heel Stage 3, Major Depressive Disorder, Hypertension and Anxiety Disorder. According to MDS (Minimum Data Set) dated 1/25/23, R25 requires Extensive physical assistance for toileting and hygiene and is incontinent of bowel and bladder function. On 2/7/23 at 11:45AM R25 said, On Saturday 2/4/23, it was about 1:15PM when I had a bowel movement and called for help. I was waiting for about 30 minutes or so, and then I called down to the front desk using my cell phone to get some assistance. At about 2pm someone came in but brought the wrong size brief. Shift change is at 3pm. They never came back. Someone on the second shift changed me at 3:50PM. Facility Policy titled Incontinence Care revised 4/20/21 states in part; Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode. 4. Wash the labia first then groin areas; In the female, separate labia wash with strokes from top downward each side separately with a clean cloth or clean area of the cloth. Keep labia separated with one hand. 9. Change gloves and perform hand hygiene; 10. Apply clean incontinence brief or incontinence pad.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an individualized, resident-centered, plan of care and interventions to address significant weight loss for a resident with a history of weight loss and failure to thrive. This failure affected one (R13) of three residents reviewed for nutrition services and resulted in R13 having an unintended weight loss of over 40 pounds in a period of approximately two months. Findings include: R13 is a [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction, Adult Failure to Thrive and Vascular Dementia. MDS (Minimum Data Set Assessment) dated 10/26/22 indicated that R13 was cognitively intact and required one person staff supervision with eating. During her stay, R13 lost a total of 43.4 lbs from the date of admission to discharge which calculates to 26.67% percent weight loss. R12 was transferred to the hospital 12/19/22 for evaluation of failure to thrive. On 1/31/23 V51 (Family Member) said, the facility called to inform me that R13 was losing weight, and there was a point where I asked for gastric tube consult because she had one in the past that was effective. Two weeks went by, and she was still losing weight. The next thing they are telling me, is they ordered a palliative care consult that we never discussed. They finally told me they would do the consult and sent her out. On 2/1/23 at 11:10AM, V3 DON (Director of Nursing) said, I believe R13 was determined to have a diagnosis of failure to thrive due to weight loss and poor eating habits. Nursing staff should have been documenting the amount of food that was eaten with each meal. We followed dietary recommendations and reached out to the family. Unfortunately, since the recommendations were not successful, the team sought hospice or palliative care. The Nurse Practitioner would have made the decision to place a consult for hospice or palliative care. I don't recall if there was ever a GI consultation to place a gastric tube. On 2/7/23 at 11:40AM V31 Nurse Practitioner said, I was aware of R13's weight loss and was often refusing the foods and shakes (house supplements) due to psych issues. I remember talking to R13 and the family about increasing portions to double during mealtimes. R13 needed encouragement during meals, but the facility doesn't have enough staff to sit there for a 1:1 feed and watch her eat. I think I asked R13 about a gastric tube but I don't know if it is documented. I usually would document that sort of consult. Later R13's daughter asked about a g-tube consult and I placed the order. On 2/7/23 at 2:24PM V44 Physician said, I was aware of R13's significant weight loss and the interventions we placed were not effective. I tried to speak with her, and she was very depressed. Surveyor asked V44 about the rationale for increasing portions and frequency of house supplements when the medical team was aware that R13 was already not accepting prior orders and V44 said that they weren't sure. V44 was asked if a gastric tube consult would have been appropriate after it was determined that R13 lost 20.8 lbs over 28 days (from 10/22/22-11/19/22) and at what point would it have been appropriate to seek higher level of care for R13 when it was documented that the interventions in place for nutrition status were not effective? In response, V44 abruptly ended the interview without answering the last questions asked. R13's medical record was reviewed from 10/21/22 to 12/19/22. admission progress note 10/21/22 said R13's admitting diagnosis included failure to thrive. Physician Order Sheet dated 10/30/22 included order to give house supplement 3 times daily. October Documentation Survey Report indicates meal intake was not reported 7 times, and R13 ate 17 out of 24 meals reported. Physician Order Sheet dated 11/21/22 added additional nutrition supplements. In November 2022, Documentation Survey Report indicated that meal intake was not reported 26 times and R13 ate 50% or less of 46 out of 73 meals reported. December Medication administration Record indicated that R13 regularly refused all nutritional supplements including house shakes and on 12/12/22, nutritional shakes were increased in frequency from 3 times to 4 times daily. On December 2022 Documentation Survey Report indicated meal intake was not reported for 21 of 54 meals, 19 meals were refused and only 5 meals were reported to have been eaten over 50%. Weight results from admission to discharge were recorded as follows (in lbs): 10/22/2022 162.8 11/6/2022 162.5 11/17/2022 144.5 11/19/2022 142.0 11/25/2022 137.5 12/8/2022 127.0 12/19/2022 119.4 Facility Policy titled Physician-Family Notification-Change in Condition revised 11/13/18 states in part; The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment; A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on the at resident before). (D) A decision to transfer or discharge the resident from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R9 is a [AGE] year-old female who was admitted to the facility on [DATE] with past medical history including, but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia, pneumonia due to coronavirus disease, unspecified lack of coordination, dysphagia oropharyngeal phase, hematuria, anxiety disorder, aphasia, etc. 1/29/2023 1:00PM, R9 was observed in her room in bed sleeping and unable to awaken to her name. Room was noted to be cluttered, bed not on low position, no floor mats noted on both sides of the bed, resident had half bed rails on both sides of the bed. No call light was noted by resident or within reach. 1/29/2022 at 2:35PM, R9 was observed in her room, awake, but unable to answer any questions. Resident's call light was still not within reach and still tied under the mattress. Observed a high back wheelchair at the bedside, with urinary catheter, noted in a privacy bag and half side rails were noted on both sides of the bed and lowered. Facility abuse risk assessment dated [DATE] coded resident with a score of 0, indicating low risk for abuse. Facility reportable dated 12/12/2022 documented that R9 was allegedly abused by a staff member identified as V29 (C.N.A) investigation was initiated and will continue. The same reportable stated that resident was interviewed about the incident and she shook her head yes and gestured her hand to her forehead and whispered, the C.N.A, the one that changes me. The document states under actions for other residents who could be affected that staff member is suspended until investigation is completed. The investigation was signed as completed on 12/16/2022. 1/31/2023 at 1:49PM V1 (Administrator) said that the allegation between R9 and V29 (C.N.A) was unfounded, R9 had a bump on her head but the source is undetermined. V1 said he is not sure of resident's need, but she is probably dependent on staff, he is not sure if V29 has been named in another allegation, she was the assigned C.N.A for R9 on the day of the incident, she may have been called back to work before the other incident. Surveyor asked V1 if staff on suspension could be called back before the investigation is over and he said, sometimes you can call them back, it is done on a case-by-case basis. V1 said that V29 no longer work at the facility, she was terminated for breaking rule #7 of the union code. Surveyor pointed out to V1 that the rule #7 was documented as abusing a resident or another staff, so was V29 terminated based on this, he said Yes. V1 added that there is no proof that V29 abused resident, but she was terminated anyway. V1 was asked if it is the facility practice to terminate staff without proof and he said that it is determined on a case-by-case basis. 1/31/2023 at 2:54PM, V8 (Social Services) said that she is aware of the incident involving R9 and a staff, she was informed that the C.N.A supposedly hit the resident, she was shadowing her supervisor (Social Service Director) at that time and helped her with completing the incident report. V8 added that her supervisor spoke to the resident, she was not present and not sure what the resident said. 1/31/2023 at 3:07PM, V10 (Social Service Director) said that the C.N.A involved in the abuse allegation no longer works at the facility, the resident shook her head yes when she was asked about the incident, and she showed how the incident occurred by winging her hand to her head. V10 stated that herself, the nurse practitioner, and the administrator interviewed resident and she confirmed that the incident happened. V10 said that resident had a bruise to her forehead, she spoke to the daughter who was very upset, and said that she was filing a police report due to the incident. 2/2/2023 at 1:13PM, V41 (Wound Care Nurse), said that he went to do an admission assessment with R9's roommate when R9 motioned him to her bed, she was pointing to her head, she asked her if she have a headache and resident said no, he asked her if she was hit she nodded yes, V41 asked R9 by your nurse and she nodded her head no, he then asked by your C.N.A and she nodded yes. V41 said he then reported to the nurse supervisor who told him to report to the administrator (V1). 2/2/2023 at 2:45PM, V42 (Nurse Practitioner) said that she is familiar with R9, her daughter showed V42 a video of what happened that she recorded in the emergency room, the resident nodded yes when she was asked if she was hit by staff. V42 stated that she saw the resident, did not notice any physical evidence, resident is aphasic and does not have a clear speech, she can only nod yes or no. V42 said that yes when herself, the administrator and another staff went to see her, the abuse was founded, the staff no longer work at the facility because that is unacceptable. 3. R18 is a [AGE] year-old male who has resided at the facility since 9/30/2022 with medical history including, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, major depressive disorder, lack of coordination, essential primary hypertension, muscle weakness, etc. On 1/30/2023 at 12:45PM, R18 was observed in his room in his motorized wheelchair, awake, alert and oriented and stated that he is doing okay. R18 stated that he recalls having an issue with a staff member, she was angry with him because he had a bowel movement. The staff kept on pouring hot water and cold water on him and pushing him around while in his shower chair. R18 said that he reported the issue to staff and called the police, a police report was done. Facility reportable dated 12/14/2022 documented that the same staff member V29 (C.N.A) was involved in another abuse investigation with R18. R18 alleged that V29 was being rough with him while assisting him with ADL care. Police report (#) documented on the reportable. Further review of the reportable indicated that the C.N.A (V29) was interviewed on 12/14/22 during the investigation. This investigation was concluded on 12/19/2022. 4. R10 is an [AGE] year-old male with a diagnoses history of Dementia, Major Depressive Disorder, Hearing Loss, Epilepsy, History of Falling, and Spinal Stenosis who was originally admitted to the facility on [DATE]. R10's progress note dated 12/6/2022 documents: Around 9PM while V7 (Licensed Practical Nurse) was walking along the hallway, he witnessed two residents up against each other's wheelchair in their room. V7 called the floor staff to separate the two. Assessed both residents for injuries. R6 denies any pain, however when the writer assessed R10, he observed that his right foot has a minor scratch on the dorsal section. Resident was moved temporarily to another room. The family member was notified and explained the situation. R10's Physician progress note dated 12/07/2022 documents: he was seen for right foot pain; Patient was recently struck by another patient in his motorized wheelchair. Patients right foot mildly swollen but no bruising or malformation seen. Will obtain X-rays to verify no fracture or dislocation. Encouraged patient to use analgesic if he feels he needs it; assessment and plan for x-rays of right foot 3 views. R10's Current Care plan initiated 08/26/22 documents he is at risk for abuse/neglect related to Dementia, history of physical abuse with interventions initiated 08/26/22 including observe resident in care situations; Observe resident when in company of peers. R10's care plan initiated 08/17/2022 documents he has cognitive impairment and experiences disorientation to time and has problems with recall/periods of confusion, which is related to a diagnosis of dementia with interventions including: provide me with orientation/grounding information (verbal, description) information throughout the day to help me increase my comfort level and awareness of my environment. On 02/01/2023 from 9:41 AM - 09:43 AM R6 stated in December while he and R10 were both ambulating in their wheelchairs in opposite directions, R10 observed R6 reach for hismcane and stated what are you about to do with that stick? R6 stated R10 then grabbed R6's wheelchair remote control and pulled it. R6 stated he then began pushing R10 out of the room so he can get staff to come and remove R10. R6 stated V7 (Licensed Practical Nurse) had observed him and R10 during this time when their wheelchairs were in contact with each other and had another staff remove R10. R6's Physician Progress note dated 12/08/2022 documents Discussed with patient argument patient had with roommate. R6 states he just made him get away from his belongings. That the other patient kept trying to take his things. He is not normally aggressive. R6's Behavior/Mood Charting assessment dated [DATE] documents he was verbally and physically aggressive, behavior triggers include others entering their personal space (getting too close) or their room; other resident yelling, cursing or verbal aggression directed at them. Mood exhibited included repeated verbalizations, displayed anger with self/others, agitated/easily upset. Location of occurrence was resident's room. Physician and family notified. On 01/31/2023 from 09:19 AM - 09:25 AM V6 (Patient Relations) stated R10 and R6 shared a room and R10 was in bed one. V6 stated R6 was irritated with R10 constantly calling out for the nurse so R10 was moved out of the room. V6 stated R6 has been in the facility for 13 years and has been in his current room the entire time so he feels he has seniority. V6 stated R6 was moved from his room January 12 due to an altercation with another resident. On 01/31/2023 from 10:23 AM - 10:35 AM V7 (Licensed Practical Nurse) stated he found R6 and R10's wheelchair were in contact while facing each other and overheard R10 saying back off, back off. V7 stated he immediately informed V32 (Charge Nurse/Registered Nurse). V7 stated he stayed with R6 and R10 and continued to observe them then V32 came immediately to separate them. V7 stated he advised V32 to immediately remove R10 because he has some confusion and will move around and try to go in the bathroom on his own, so he was moved two doors down to another room. V7 stated R10 doesn't use the call light and will have bowel incontinence and spread feces on floor and walls. V7 stated R10 does go in other residents rooms and bathrooms. V7 stated if he was in charge of making room changes, he would not put someone who is confused or could go in other people's belongings or touching other people's items with a resident who is alert and oriented and independent. V7 stated R6 is very neat and independent. V7 stated R10 does not generally get agitated. On 01/31/2023 from 2:01 PM - 2:17 PM V1 (Administrator) stated it was documented in the medical records that there was an incident with R6 and R10 where one rolled over the other one's foot. V1 stated it was reported that V7 (Licensed Practical Nurse) passed by the room observed R6 and R10's wheelchairs together and one of the resident's foot was rolled over and that resident was sent to the hospital. V1 stated he was not given any additional details about the incident and that's all that he was told. V1 stated if more information was provided, he may possibly have looked further into it. V1 stated if something indicated that an allegation of abuse occurred then an abuse investigation would have been initiated. V1 stated indicators of abuse would include someone reporting a deliberate hit or comment. V1 stated based on the information reported by V7 to the surveyor about this incident there could possibly be a need to determine if R10's foot was ran over intentionally or unintentionally however there were no details to indicate to investigate further at the time. V1 stated once an investigation is initiated it would then be reported to the state. V1 stated if willful intent occurs care plans would be updated, room changes may occur, a resident may be sent out for evaluation, a psychosocial/emotional well-being report and an abuse assessment would be completed, and 72 charting for nursing and social services regarding the incident would be conducted. V1 stated staff need to report an allegation immediately once they feel an allegation is made. On 02/01/2023 at 09:52 AM V39 (Certified Nurse's Assistant) stated she has worked at the facility for seven months. V39 stated R10 becomes confused when leaving the dining area while looking for his room. V39 stated R10 does attempt to use the bathroom by himself and cannot use the bathroom by himself. V39 stated when R10 attempts to use the bathroom by himself he may make a mess and spread his excrements around the bathroom. V39 stated at times, typically in the morning R10 will be extra alert or excited and will attempt to go to the bathroom by himself. V39 stated if she observed R10 in this state she will take him out of his room or have him near her. On 02/01/2023 from 12:33 PM - 12:51 PM V1 (Administrator) stated if R6 pushed R10 out of the room during their incident on 12/06/2022 it was willful and if R6's foot was hurt in the process that would be willful. 5. R12 is a [AGE] year-old female with a diagnoses history of Morbid Obesity due to Excess Calories, Type 2 Diabetes Mellitus, and Recurrent Major Depressive Disorder who was originally admitted to the facility 7/8/2015. R20 is a [AGE] year-old female with a diagnoses history of Schizoaffective Disorder Depressive Type, Vascular Dementia, and Human Immune Deficiency Virus who was admitted to the facility 06/13/2022. On 01/30/2023 from 11:38 AM - 11:46 AM R12 stated in the last room she was in her roommate scratched her and the social worker was informed. R12 stated her roommate was prone to that type of behavior and she asked the facility why they didn't just place her roommate in a room by herself. R12 stated she had two scratches on her hand as a result of the incident. R12 stated her roommate was aiming to scratch her legs and when the nurse saw this she instructed her roommate to leave her alone. R12 stated her roommate called her a profane name, told her to shut up, and told her she wished she was dead. On 02/01/2023 from 10:53 AM - 10:56 AM R12 stated when she shared a room with R20, R20 was always cursing at her and calling her names. R12 stated this did upset her and hurt her feelings. R12 stated she was scared R20 might do something to her in her sleep. R12 stated she expressed these concerns to the Certified Nursing Assistant's but they would always say that R20 won't do anything to her. Abuse Investigation Report dated 01/12/2023 documents: on 01/10/2023 after a comment was made by R12 about R20 being loud, R20 began using profanity at R12 and reached for R12; V21 (Licensed Practical Nurse) was present during the incident and grabbed R20's wheelchair to pull her away from R12. V21 observed redness on R12's foot; R12 reported that when R20 was escorted into the room by V21 she made a statement about R20 being loud leading to a verbal disagreement and during this incident R20 reached over and grazed R12's foot; R17 was present during the incident reported that she heard R20 cursing and going back and forth verbally and R20 has these outburst often; Care plans were updated, and residents 72 hour checks were initiated. Statements attached to abuse investigation report dated 01/12/2023 documents: V21 (Licensed Practical Nurse) reported on 01/10/2023 R20 became upset about a statement that R12 made that Here comes R20 she's so loud, and yelled to R12 shut up (profane word)!; R12 told R20 you need to stop cursing at me.; R20 continued to curse at R12 calling her a profane word and stating to R12 you need to stop stealing my stuff you ugly (profane word).; R20 then turned around from her wheelchair and attempted to reach R12's foot and was pulled away and removed from the room; when R12 was assessed there was redness noted on her right foot but no scratch was seen. R12 reported that when R20 was in her wheelchair she turned around and attempted to grab her foot and when she pulled her foot away R20 told her to get the (profane word) out of her room; when R20 reached and scratched her foot/hand that's when the nurse pulled her away R20 never liked me. R17 Reported she heard R20 cursing and cursed R12 out real bad and told her to stay out of it before she puts me out, R20 also used profanity at R17, R20 curses at everyone. R12's Progress note dated 1/10/2023 documents: Resident was seen having a verbal disagreement with her roommate concerning the inappropriate behavior she expresses such as cursing out loud and accusing her of stealing her personal belongings. Roommate was up in her room in her wheelchair receiving her medication via feeding tube when roommate reached out to resident´s foot and scratched her. Roommate was then removed and re-educated. Resident requested a room change. Social Services made aware. Resident was transferred from to another room oriented to new room belongings in place and medication in cart. R12's Physician Progress note dated 1/11/2023 documents: Patient also upset because she had an altercation with one of her room mates. They ended up moving her to a different room and not all of her possessions are with her yet. R12's progress note dated 1/12/2023 created by V21 (Licensed Practical Nurse) documents: This writer followed up with resident regarding behavior on 1/10 no injury noted only redness on resident's foot at the time. R20's progress note dated 11/28/2022 documents: Resident attempting to get on the elevator alone, when writer tried to detain her, she hit writer & continued to swing at her. Resident calling writer out her name & using profanity, writer attempted to re-direct without success. R20's progress note dated 1/3/2023 documents: Behavior, resident screaming and shouting from the bed, using curse words at roommate, resident stated she is getting out of the (curse word) bed, staff made several attempts to redirect resident, she tried to get out of bed and rolled herself to the floor, writer and certified nursing assistant helped resident back to the bed, when staff departed the room resident rolled herself on the floor a second time, writer and certified assisted resident back to bed for a second time, writer administered psychotropic medication, resident was able to calm herself and fell asleep. R20's progress note dated 1/10/2023 documents: Behavior Note, Resident was seen having a verbal disagreement with her roommate concerning the inappropriate behavior she expresses such as cursing out loud and accusing her roommate of stealing her personal belongings. Resident was receiving her medication via feeding tube when she reached out to roommate´s foot and scratched her. Resident was removed and re-educated regarding her continuous behavior towards her peers. Resident stated, I am sorry. Social Services made aware. R20's progress note dated 1/12/2023 documents: Behavior Note Text, This writer spoke to resident regarding her behavior she did not intend to scratch her roommate. Resident is oriented times two with a Vascular dementia without behavioral disturbances staff will continue to monitor; at 2:10 PM Behavior Note Text: After this writer spoke to resident who had no intentional or act upon intended. No injury noted only redness on roommate's foot staff will continue to monitor as needed. R20's current care plan initiated 07/01/2022 documents she has a mood problem related to admission with interventions including administer medications as ordered; Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these; Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.); Educate the resident/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. R20's care plan initiated 01/12/2023 documents she has the potential to be verbally aggressive related to poor impulse control with interventions including: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document; monitor behaviors (Specify Frequency) Document observed behavior and attempted interventions. R20's medical records do not document that she had a behavior consult, was seen by the psych doctor regarding a pattern of abusive behavior, that a root cause analysis was conducted regarding her behavior, hospitalization for behavior, placed on a 1:1, or an attempt to place her in a private room. On 02/01/2023 from 10:43 AM - 10:51 AM V21 (Licensed Practical Nurse) stated on 01/10/2023 she had brought R20 back to the room she shared with R12 and was preparing to administer medication to her via a tube feeding. V21 stated R20 was impatient and was complaining that she wanted go smoke a cigarette. V21 stated she explained to R20 that she really needed to administer the medication and that as soon as she was done she could continue with her day. V21 stated during this exchange R12 made a comment such as oh boy here comes the loud one which triggered R20 to become verbally aggressive with R12. V21 stated R20 began swearing at R12 and called her profane name. V21 stated R12 responded to R20 that she didn't like being called that term. V21 stated the arguing continued while she was administering medication to R10. V21 stated when she had finished administering medication to R20 she ambulated in her wheelchair towards R12 and reached for R12's foot. V21 stated she pulled R20 back before she could attack R12 however, R20 was able to grip R12's foot briefly causing her foot to turn red. V21 stated she redirected R10 and attempted to deescalate the situation. V21 stated R12 then stated she didn't want to be in a room with R10 anymore because she is consistently cursing at her. V21 stated R20's behavior is considered verbal abuse and it was reported to V2 (Assistant Administrator) and V1 (Administrator). V21 stated R12 did not go out to the hospital and did not report any pain. On 02/01/2023 from 12:33 PM - 12:51 PM V1 (Administrator) stated he believes the incident that occurred between R12 and R20 didn't meet the qualifications for an abuse incident to that needed to be reported to the state agency such as a willful infliction of injury or verbal abuse depending upon the words used. V1 stated the social services staff would be responsible for handling behaviors or incidents between the residents and would report any allegations of abuse to the administrator. V1 stated being called a profane name, being told to shut up using profane words, or being told I wish you were dead would potentially constitute abuse and this would have been investigated if reported. V1 stated if R12 expressed to the certified nursing assistants that she was fearful that R20 may harm her they should have reported it and it may be a sign of some type of potential abuse. V1 stated that R20 scratching R12 while grabbing her was not willful. V1 stated R20 was being verbally aggressive towards her R12 during the incident. V1 If he grabs someone during a disagreement and they pull back they may be scratched in the process, but he didn't intend to scratch them. V1 stated if R6 pushed R10 out of the room that is willful and if R6's foot was hurt in the process that would be willful. 02/02/2023 2:19 PM V1 stated if a resident is exhibiting a pattern of abusive behavior the facility should investigate and find out the root cause, there may be a room change, hospitalization, separating residents, or possibly putting them on a 1:1. V2 (Assistant Administrator) stated this might also include having the psychiatric doctor come in and see the resident. V2 stated a resident may need to be placed in a private room if necessary. V40 (VP Clinical Operations) stated the resident may need to be sent out for a psych evaluation. V40 stated all residents should be assessed to identify who's at risk for being abused, and the facility should ensure dementia residents are not with aggressors. V2 stated that the facility would ensure that residents are appropriately matched with residents to ensure their safety. V40 stated he is not sure that he can say that a minor abrasion from physical contact made between two people can be considered a willful attack because the aggressor in the incident with R12 has dementia. V1 stated that none of the interventions mentioned for a resident exhibiting a pattern of abusive behavior including the investigating the root cause, room changes, hospitalization, separating residents, placing on a 1:1, having the psychiatric doctor come in and see the resident, or placing the resident in a private room was implemented for R20. V1 stated placing R5 in the room with R6 turned out not to be a good match. V40 stated there could have been a better match made in that situation. V2 stated a behavior consult would be initiated when a resident is exhibiting behaviors. The facility's Abuse Prevention and Reporting Policy reviewed 01/31/2023 states: Guidelines: The resident has the right to be free from abuse. Abuse is the willful infliction of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse and physical abuse. During orientation of new employees, the facility will cover at least the following topics: What constitutes abuse or mistreatment of resident. Staff obligations to prevent and report abuse and mistreatment. Dementia management and resident abuse prevention. On an annual basis, staff will receive a review of the above topics. As part of the resident social history evaluation and Minimum Data Set assessments, staff will identify residents with increased vulnerability for abuse and mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse or mistreatment. Staff will continue to monitor the goals and approaches on a regular basis. Employees are required to report any incident, allegation or suspicion of potential abuse or mistreatment to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. Employees, without fear of retaliation, may also indpendently report to the state survey agency any allegation of abuse or mistreatment. Reports should be documented and a record kept of the documentation. Employees of this facility who have been accused of abuse, mistreatment, will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. All incidents will be documented, whether or not abuse or mistreatment occurred, was alleged or suspected. Any incident or allegation involving abuse or mistreatment will result in an investigation. The appointed investigator will. at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The administrator or person designated to act as administrator in the administrator's absence will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The administrator or designee is also responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken. Based on observation, interviews and record reviews, the facility failed to follow their abuse policy and procedure in preventing and protecting residents from verbal and physical abuse. This failure affected seven (R5, R6, R9, R10, R12, R18, and R20) of eleven residents reviewed for abuse. This failure resulted in R5 being hit with a cane by R6 and sustaining a laceration on the left side of head and closed fracture of the distal left ulnar shaft requiring surgical repair; R9 was hit by a staff member and sustained a hematoma to the forehead and was sent to the hospital for further evaluation; R10 was struck by another resident with a motorized wheelchair and sustained a scratch and swelling to his right foot; R12 was cursed out, accused of stealing personal belongings, and was struck on the hand and foot causing an abrasion; and R18 experienced abuse by a staff member who poured hot and cold water on R18, while pushing him around while in his shower chair. Findings include: R5 is a [AGE] year old, male, admitted in the facility on 07/11/2022 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Schizoaffective Disorder, Bipolar type; Major Depressive Disorder, Recurrent, Unspecified and Anxiety Disorder, Unspecified. According to MDS (Minimum Data Set) dated 01/01/2023, R5 has BIMS (brief interview for mental status) of 13, which means little to no impairment in cognition. Incident report dated 01/12/23 documented that R6 struck R5 with his cane on his left arm and left side of his head. R5 stated his roommate hit him with his cane on his head and arm. R5 stated his roommate's (R6) table was in his way and when he moved it that R6 got up and hit him with his cane. On 01/30/2023 at 1:54 PM, R5 was in his room, lying in bed, with soft cast on left hand covered with a bandage. R5 is alert and oriented, was asked on what happened to his hand. R5 stated he does not remember what happened. R5 was also asked if he had any incident with another resident that he was hit with a cane. R5 stated that there was none. Per R5's progress notes dated 01/12/23, time stamped 8:36 PM, documented: R5 touches roommate's (R6) table ending up things on the floor. Roommate (R6) got upset and had exchange words and roommate (R6) hit him with a cane on the left side of his head and left arm. On 01/31/23 at 3:47 PM, V30 (Licensed Practical Nurse, LPN/Supervisor) was interviewed regarding R5 and incident on 01/12/23. V30 stated, A couple of weeks ago, I was called to the floor, went to their (R5 and R6) room. They were roommates. It was reported that they had a physical altercation. R5 was in the washroom washing his hands and was asked on what happened. He (R5) showed me a cut on the forehead and bruise on his left arm. He said R6 hit him with a cane. I asked why, he said that he tried to get the remote control on the table to turn down the TV. I cleaned his forehead because of the cut and asked if he has any pain. He denied any pain, dried the cut and applied antibiotic. I moved him to another room. I went to R6, asked what happened. He (R6) admitted that he hit R5 with his cane because he (R5) moved his table and everything went to the floor. Then I told him (R6) that if he had issues with another resident to call nurse or call for help. For R6, it was the first time. For R5, he always complained about his roommate's television volume. Progress notes dated 01/14/23 recorded that R5 was experiencing left lower arm pain, X-ray to left arm was taken. X-ray result dated 01/15/23 documented: X ray left radius/ulna, AP (anterior posterior) and lateral Impression: Minimally comminuted acute fracture of the distal left ulnar shaft. Progress notes dated 01/16/23 documented that R5 was sent to the hospital and was admitted with diagnosis of fracture. Hospital records dated 01/15/23 recorded: Diagnoses: Assault, Closed f[TRUNCATED]