Every finding on record at Alden Long Grove Rehab &HC CTR

Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse. This applies to 2 of 6 (R1, R2) reviewed for abuse in the sample of 6. The findings include:R1's Brief Interview for Mental Status (BIMS) dated 6/3/26 shows R1 is cognitively intact. R3's BIMS dated 7/1/26 shows R3 is cognitively intact. R4's BIMS dated 7/20/26 shows R4 is cognitively intact. R6's BIMS dated 7/23/26 shows R6 is cognitively intact. R2's BIMS dated 6/24/26 shows R2's cognition is moderately impaired. On 8/26/26 at 10:15 AM, R6 said on 8/15/26 around 6:30 PM, R6 was by the nurse's station by the front entrance with his wife when he saw R1 angrily and quickly walk through the main entrance and walk down the middle hallway, towards the smoking area where the fish tank is located. R6 asked R1 if R1 was okay and R1 responded by cursing and continued to storm down the hallway towards R2. On 8/26/26 at 9:55 AM, R4 said on 8/15/26, R4 was in R5's room with R3 after dinner. R4 said they heard a woman yelling in the hallway at someone else and left the room to see who it was. R4 exited R5's room, propelled their wheelchair to the area by the fish tank outside R5's room and was a couple feet from R2. R4 saw R1 slap R2 across the face, knocking R2's glasses off his face. R4 said R1 then started walking back down the middle hall towards the main entrance, turned back around, and again continued to yell and curse at R2. R4 said R1 and R2 are frequently seen together walking the halls of the facility holding hands and believes R1 and R2 are intimate. R4 said no staff were present when R1 slapped R2. On 8/26/26 at 11:30 AM, R2 said R1 and R2 are in an intimate relationship. R2 said he has been working on securing housing for R1, R2, and R1's children to stay at together. R2 said on 8/15/26, R1 heard rumors regarding him, and was mad at him. R2 said R1 walked up to him and slapped him across the face. R2 said he did not sustain any injuries from the slap. On 8/26/26 at 12:25 PM, V5 (Registered Nurse/RN) said V5 and V6 (Licensed Practical Nurse/LPN) heard yelling from the middle hallway's nurse's station. V5 said V6 was first to go towards the altercation and then V6 requested V5 to come. V5 said by the time V5 arrived, R1 and R2 were already separated, R1 was no longer there, and V5 called to V8 (RN) to come and assess R2 for injuries while V5 called V1 (Administrator) to inform V1 of the altercation. On 8/26/26 at 12:35 PM, V7 (RN) said she was working the north hallway and could hear screaming through the halls. V7 walked towards the screaming and saw R1 yelling at R2. V7 immediately separated R1 and R2 and brought R1 to the second floor. V7 ensured R1 and R2 remained separated. On 8/26/26 at 12:52 PM, V8 said when V8 assessed R2, R2 had no injuries or any complaints of pain, dizziness, and escorted R2 to the basement unit. V8 said the police came that night to talk with R2 regarding the incident. V8 reported the incident to the incoming shift and instructed them to round on R2 more frequently to assess. On 8/26/26 at 8:55 AM, V2 (Director of Nursing) said it was a pretty straight forward investigation. R1 and R2 were said to be in an intimate relationship, R1 slapped R2, the police were notified and nobody wanted to press charges. Facility Abuse Policy dated 03/2026 states, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion . Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on observation, interview and record review the facility failed to ensure pain management was provided to a resident related to right tibia fracture. This failure resulted in R1 experiencing severe pain without receiving ordered pain medication for approximately 24 hours. This applies to 1 of 7 residents (R1) reviewed for pain management in the sample of 7. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnosis including displaced fracture of right tibia, type 2 diabetes, hypertension, difficulty walking, and history of falls. On 4/6/26 at 10:33 AM, R1 was in her room laying in bed. R1 said she came to the facility after falling at home and fracturing her right knee. R1 said she is non-weight bearing to her right lower extremity and wears the immobilizer when she is out of bed. R1 said she was having a lot of pain to her right knee when she came to the facility and increased pain after therapy. She was getting hydrocodone (opioid) pain medication every four hours as needed for pain. R1 stated, I needed pain medication every 4 hours for pain. She would call requesting the pain medication and would have to wait up to 1.5 hours after requesting her pain medication. On two occasions nursing did not have my pain medication available. Nursing reported they were waiting on pharmacy to deliver the pain medication. I was really angry one night because I was in pain. R1 said I exploded at the CNA (Certified Nursing Assistant), because no one was helping me. R1 said she was having pain, and no one would do anything for her pain. R1 said she told two doctors and one said, He doesn't deal with that. R1 said she was so upset she asked to speak to the administrator. R1 said, The administrator came up the next day and I explained to her what was going on. They would run out of pain medication at night, it happened twice. Why were they running out of pain medication?On 4/7/26 at 10:38 AM, V6 (Registered Nurse-RN) said if a resident has narcotics ordered they need a script from the physician and then it's faxed over to pharmacy. Pharmacy delivers medications to the facility at 3:00 PM and the 2nd delivery is at midnight. She is not sure if they can pull narcotics from the emergency medication cart. V6 said R1 had hydrocodone for pain, and she followed up with pharmacy because she did not have R1's pain medication. I was not able to give the narcotic because I did not have the supply. V6 said she did not pull the medication from the emergency supply because pharmacy said it was going to be delivered. On 4/7/26 at 10:55 AM, V5 (RN) said R1 was alert and oriented, and able to express herself. Initially after her admission she would request pain medications every 4 hours. R1 would rate her pain at a 6-7 and was always putting on her call light every 4 hours requesting her pain medication. V5 said there was one time she did not have R1's pain medication to administer. R1's Medication Administration Record (M.A.R.) dated March 2026 shows orders to administer Hydrocodone 5-325 mg (milligrams) one tablet every 4 hours as needed for moderate to severe pain. R1's M.A.R. shows on 3/13/26 and 3/17/26 shows there was no pain medication administered. R1's M.A.R. shows on 3/16/26 hydrocodone was administered at 11:29 PM and the next dose was administered on 3/18/26 at 12:59 AM (approximately 24 hours later). R1's M.A.R. shows pain score 4-8 recorded with hydrocodone administered. R1's Controlled Drug Receipt Record shows 18 pills of hydrocodone were delivered to the facility on 3/12/26. On 3/13/26 the controlled record shows she was medicated for pain at 8:00 PM (This does not reflect on R1's M.A.R.) R1's physician progress note dated 3/13/26 documents (R1) complains of significant pain with any pressure or movement of her right leg. R1's progress note dated 3/17/26 documents moderate to severe right knee pain, asking for hydrocodone every 4 hours.R1's progress note dated 3/19/26 by V10 (Previous Assistant Administrator) documents R1 stated, Where the h*ll are my pain meds? Why are you people not getting them pharmacy? V9 explained to her controlled substances have to wait until the day of the last dose for the prescription to be filled. On 4/7/26 at 12:48 PM, V2 (Director of Nursing-DON) said she was not aware of any concerns regarding R1's pain medications not being available. V2 said, If the narcotic is ordered and they are waiting on pharmacy to deliver, I would expect nursing to pull the medication from the emergency supply. Pain should be treated when the resident is requesting pain medication and not delayed. She was not aware V10 spoke with R1 regarding this concern. I don't know why (V10) did not talk to me about (R1's) pain medication. There is a reason why V10 is no longer here. V2 reviewed R1's M.A.R. with this surveyor and confirmed R1 did not receive pain medication over a 24-hour period on 3/17/26. V2 said nursing should have communicated the concern to her and administered the narcotic. R1's current care plan shows to assess pain every shift and monitor the effectiveness of pain relief.The facility's Pain Management Evaluation Policy dated 4/2025 states, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Residents shall be evaluated for pain upon admission, re-admission, post fall with significant change.pain will be evaluated each shift.

Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse for R1 and failed to substantiate an allegation. This failure resulted in allowing V4 (Certified Nursing Assistant) access to all residents in the facility. This failure has the potential to affect all 93 residents residing within the facility.The Immediate Jeopardy began on 2/28/26 when R1's initial report of sexual abuse was reported to V3 (Social Services Director) and V1 (Administrator). V4 returned to the facility for his scheduled shifts on 3/2/26, 3/3/26, 3/5/26, and 3/6/26. V1 (Administrator) was notified of the Immediate Jeopardy on 3/10/26 at 10:46 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/10/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:R1's face sheet showed she was admitted to the facility 7/13/24 with diagnoses to include chronic obstructive pulmonary disease, Type 2 Diabetes, major depressive disorder, atherosclerotic heart disease, hyperlipidemia, insomnia, supraventricular dysfunction of bladder, generalized abdominal tenderness, systemic sclerosis, and overactive bladder. R1's facility assessment dated [DATE] showed she has no cognitive impairment, no behaviors, and requires physical assistance of staff assistance for most cares including dressing, personal hygiene, bed mobility, and transfers. R1 requires a wheelchair for mobility. R1's complete care plan was reviewed and showed no history of making false allegations of any kind toward staff. R1's 3/6/26 Antibiotic Therapy Note showed, . What antibiotic being used for: LRTI (Lower Respiratory Tract Infection) . Antibiotic . Doxycycline Hyclate Oral Tablet, 100 mg twice daily .R2's face sheet showed she was admitted to the facility 8/3024 with diagnoses to include cellulitis of right lower limb, non-pressure chronic ulcer of left ankle with unspecified severity, acute and chronic respiratory failure, insomnia, chronic kidney disease, and hyperlipidemia. R2's facility assessment dated [DATE] showed she has no cognitive impairments and no behaviors. R1's complete care plan was reviewed and showed no history of making false allegations of any kind toward staff. R2's record was reviewed and showed a note entered on 3/28/25 (almost one year ago) at 11:48 AM which showed, Resident told writer her room is not cleaned. Writer spoke with housekeeping director who stated it was cleaned but not by the usual housekeeper. Writer followed-up with the resident who stated, yes, it was cleaned but it's just not the same when someone else does it. Writer advised resident that staffing can/will change but her room does get cleaned. Resident verbalized understanding. Care plan reviewed and updated. On 3/7/26 at 10:30 AM, R1 said when asked if any staff members have ever behaved inappropriately or made her feel uncomfortable, I had a problem like that just last week, but I was told to be quiet about it and not talk to people about it. V3 told me not to talk about it. They said they were handling it. (This surveyor explained this is what I am here specifically investigating and that if she could describe the details of this incident, it would be helpful. R1 was very hesitant at first but then began describing the situation.) It was [V4] CNA (Certified Nursing Assistant). Nothing like this happened before. I told [V3] from Social Services when it happened. He is the social worker here. I don't think [V4] was thinking, he was saying things like 'I could be his girlfriend' and 'I know you want it'. This happened last week. The exact date would be on [R2's] phone. I think [V4] was thinking it was a joke or something, I think he thought this was a joke. He puts me to bed at night and then usually comes back about 5AM to change my (incontinence brief). This happened around 9 or 10 PM when he was putting me to bed. He hasn't been around me since then either, but my roommate got sick, so they moved me to a room upstairs and when I went up there, they said he was the one working that area and they knew he wasn't able to take care of me anymore. I said, 'oh no, he can't be around me.' They do make sure he isn't around me anymore, but he still works here. When this happened, I was already changed, and the blankets were on. He wasn't standing over me, he was in my bed lying sideways and rubbing the side of my breast. That is what bothers me so much, he was giggling and laughing and saying, 'you know you want it'. I had called [R2] when he came into my room, and she listened to whole thing. She could hear him. At 11:33 AM, R1 said, The day before this incident was the first time something was happening. I knew the night before, he was getting 'way too friendly' and I was telling [R2] about it. I told [R2] that no one is going to believe me about what is going on, So I called her when he was coming in so she could hear our interaction. I told him I'm married, and he has a girlfriend. He was on top of the comforter when he was in my bed and rubbing the side of my breast through the blanket. I told him to 'get out' and to 'leave my room.' When I reported this to [V3] I told him that I had debated about telling him what happened. He said it was a 'no no ' and they don't allow 'this kind of behavior'. He said he was reporting to [V1] (Administrator) and offered for me to talk to him later if I needed to. I reported to him exactly what I just told you.R2 was sitting in her wheelchair in room with the bedside table in front of her. R2 said, Sometime last week I listened to a conversation over the phone with [R1]. I heard the gentlemen saying sexual remarks, it was [V4]. He was saying come on honey and she kept telling him to quit and he kept coming back at her. She kept saying 'no, go away, get out of here'. He would laugh at her, and say 'come on, you know you want it'. What I heard was inappropriate. [R1] doesn't want anyone to get in trouble but something like this can't be let go. [R1] told me no one was going to believe her unless someone else hears it, so I told her to call me. He wanted to lay on the bed with her, he just kept laughing and she was repeatedly telling him no. He works 11-7 normally. No one from here has interviewed me about this or about what I heard. Even her family has kept telling her she had to tell someone about this. We don't want anyone getting fired or losing their job, but we can't have them doing things like this.On 3/7/26 at 3:32 PM, V7 (R1's Sister) said, First let me tell you, my sister is of sound mind. I know my sister well enough to know when something isn't right. I asked her what was going on. She said nothing at first but then she told me that the CNA jumped into bed with her and started to rub her breast. She said she told him to get up and get out of there, but he had already touched her breast. She told him to get out. She said another person came and said to her 'don't start anything, we will take care of it'. According to my sister, how they took care of it is they moved him to the memory floor. The social worker came in and talked to my sister and said they were going to take care of it, but they won't tell her how they are doing it. I told her she has to tell someone because he can't be on the memory floor with people who can't tell them what happened. My sister said she was embarrassed. I told her there is nothing to be embarrassed about, but you have to speak up. She told her husband as well. She was hesitant to say anything, because she is there all the time and they asked her not to talk about it. That is all I can say about it, I have been up at night trying to figure out how to get her out of there. It's like they acknowledged that it happened, and said they would take care of it, but never followed through. She has never mentioned that she has had issues with anyone, except this situation. It scared her and embarrassed her. She wanted to know where he was going to be because she is a little on the fearful side at night now about who is working the floor. This is a sexual assault of someone who was in bed and couldn't get up on their own. She can only verbalize for it to stop. In her words, she felt helpless and afraid, and why should she have to be afraid in a nursing home where we put her to get good care? The only reason she told me about it was because I noticed something was wrong. My sister is very social, very talkative, very much telling me about everything, she tells me what she is doing, what doctor came to see her, I always know what is going on with her at the facility. She was so quiet, I couldn't get her to answer me, she was saying she isn't hungry today, was very down, and said I couldn't help her. That is when she said he jumped into bed and started touching her breast and that she told him to get out. We thought she was safe. Obviously, she wasn't as safe as we thought, and that is bothersome to me. I have to worry about who is touching her and I don't want her to have to feel embarrassed.On 3/8/26 at 2:36 PM, V8 (Local Sheriff's Office Deputy) said, In summary, the resident [R1] stated that on an unknown date. a CNA [V4] who was assigned to work with her, jumped into bed with her and stated that she could be his girlfriend and touched the sides of her breasts. [R2] was interviewed as well and said she was on the phone with [R1] during the incident and the CNA fell into [R1's] bed, tried to kiss her and was heard making inappropriate remarks about wanting to have relations with her, the CNA kept pushing for it and [R1] kept saying no. [R1] said she didn't want this to happen to any other women.On 3/7/26 at 1:00 PM, V6 (R1's Husband) said, [R1] told me about it. She didn't give me details. It was about 10 days ago, she basically just told me that this CNA got in the bed with her.On 3/7/26 at 12:40 PM, V3 (Social Services Director) said, . Concerns are another big one of the things I do here. I'm kind of the go-to person for the residents. I don't want to say I'm the 'middleman', but I point the residents in the right direction, so they hear it from the 'horse's mouth' you know. [R1] reported something at the end of February. [R1] divulged to me that she had an issue with one of the CNAs at night. She started to tell me it was concerning her chest and I stopped her right there and told her I needed to talk to the Abuse Coordinator. [R1] kept talking but I didn't listen or retain anything, because I stopped at the fact that this involved her breasts, I had tunnel vision, and just kept thinking, I have to talk to [V1]. I was in the facility at that time, I called [V1]. I spoke with her right away, it was February 28th. I think it was a Saturday. [V1] said we need to get on this. I am not apprised to the procedure, I just know our Abuse Coordinator is [V1] and if the residents think there is something hinky, we go straight to the [V1]. I did follow up a couple days later, I try not to be intrusive because I know [R1], and she does come to me with certain things, and I didn't want to open up any wounds so I just asked her if she was okay and she said 'yeah for now'. I told her to reach out if she needed anything. [R1] doesn't have any behaviors. She is alert and oriented. I'm familiar with [R2]. [R2] has no behaviors and is alert and oriented. Both [R1] and [R2] are reliable historians I would say. The only time I was interviewed about this was on the phone when I called [V1]On 3/7/26 at 2:50 PM, V10 RN (Registered Nurse) said, I'm very familiar with [R1]. She is very alert, not confused. Husband comes in very frequently, they are a very pleasant family.The facility's Incident/Accident Notification showed, . Initial Sent on 2/28/26 . It was reported on 2/28/26 Administrator received a phone call from resident [R1] that Certified Nursing Assistant [V4] touched residents' breast during routine peri care and incontinence care. Certified Nursing Assistant [V4] is now pending investigation without the need to suspend due to not being on the schedule.The facility's daily schedule for February 25th through March 7th was reviewed. The allegation of sexual abuse was made Saturday, 2/28/26 and reported to IDPH at 4:47 PM. The investigation shows it was completed and not substantiated on 3/2/26 at 4:47 PM. V4's next scheduled shift started at 7:00 PM on 3/2/26.The facility's Incident/Accident Notification dated 3/2/26 showed, [R1] a [AGE] year-old female resident reported that during her ADL and Peri care this morning, CNA on duty [V4] touched her breast. CNA [V4] was notified of the pending investigation and is not scheduled until March 2, 2026, investigation has been initiated. [R1] reported to the administrator on 2/28/26 that a couple days ago CNA on duty touched her breast during routing ADL/Peri care. CNA was interviewed and denied all allegations of abuse and inappropriate touching. CNA stated, he was performing routine ADL/Peri care to [R1], he had to reposition her body because she needs assistance. CNA reiterated and denied touching [R1] inappropriately during care. CNA was immediately investigated, and not on the schedule until March 2, 2026, until after the investigation is completed. [R1] was interviewed and first stated CNA touched her breast during her brief change. [R1's] interview was inconsistent throughout. Facility completed a thorough investigation which included chart, care plan, and assessment reviews, resident(s) interview, staff interviews, and facility in-service training. [R1] has a BIMS score of 15. Chart review completed. During the interviews for residents and staff, there were no reports of any incident/accidents of care and no concerns of inappropriate behavior/touching. [R1's] roommate was interviewed with an interpreter and denied any incidents with the CNA that night. All other residents that were interviewed during this time stated they felt safe within the facility. All other residents declined any inappropriate behavior from staff. [R1] reported that she feels safe within the facility. [R1] was offered a room change which she declined. The Administrator presented [R1] with her resident rights and ombudsman packet and offered to send [R1] to the hospital for evaluation as well as assist in calling the police, both in which [R1] vehemently refused to do. [R1] stated during her interview that she wants to continue to keep this CNA as her CNA despite this allegation. The facility will review this request. Care plans were further reviewed and updated. The facility. does not currently have any findings and finds this allegation to be unsubstantiated.The facility's daily nursing and CNA schedule showed V4 CNA was working 2/26/26 (a couple of days before the 2/28/26 allegation).On 3/7/26 at 12:21 PM, V1 (Administrator) said, It was brought to my attention on Saturday back in February. I received a phone call from her, and she had told me that a couple days prior, she couldn't give me an exact date, [V4] had touched her breast, I had then started to ask her if this was during care, what was going on, where were you? She said she was on the edge of her bed, and he was in his routine to provide care. I asked her if she wanted to call the police to make a report, I asked her if she wanted to go to the hospital. She told me she didn't want him getting in trouble, she just wanted to make me aware. I offered a room change. I told her there would be an investigation initiated and to contact me if she needed anything else. I started my investigation immediately, contacted [V4] and began asking him questions like do you remember where you worked, and did anything come up that would be considered abnormal for your nightly care while you were here in the building. I told him it was a sexual abuse investigation being conducted and let him know that he was essentially being blamed for touching a resident's breast. He said he was providing care. I asked him if anything occurred specifically in the middle wing. I told him he was suspended pending investigation. It was his weekend off, so he wasn't on the schedule. He said he wouldn't touch anyone's breasts. I talked to [R1] again while I was still in the process of my investigation, I followed up with her briefly, in passing, while I was doing rounds, and just checked in to see how she was. She said she was okay and when I asked if she needed anything else she said no. V1 said V3 had called her and reported the incident and then R1 called her right after that. V1 confirmed the phone call was the only conversation she had with R1 regarding the sexual abuse allegation she made.On 3/7/26, V1 provided a copy of an undated interview which she states she conducted with R1 on 2/28/26 over the telephone. This interview showed, . What happened last night during your routine ADL care? A couple of days ago, [V4] touched my breast during my brief change. Can you explain how the CNA touched you? . While he was repositioning me into bed his hand touched my breast. Did you say anything to the CNA when this happened? I told [V4] to stop, and he told me Stop what?, and I told him to stop touching my breast and he did. where were you when this occurred and how were you laying, and where was the CNA? I was laying down straight on my back in bed, [V4] was standing over me repositioning me for my incontinence care because I struggle moving. Did you report the initial occurrence to any staff member? Yes. Do you feel safe with your current caregivers? Yes, they are all wonderful and I still want [V4] to continue my care during his shifts, I still want him. Do you want to go to the hospital? No. Do you need assistance calling the police? No, I do not want the police to get involved. On 3/7/26, V1 provided a copy of an interview with V4 dated 2/28/26 which showed, What happened during your shift last night/this morning? I think my boss was telling me that someone passed. Did anything out of the ordinary happen during your shift? No. Is there anything you need to disclose to me? I don't think so. Were you the primary caregiver for [R1]? Yes I usually have her. What type of care did you provide for [R1]? I provided incontinent care, water. Did [R1] voice anything to you regarding her care? No. Have any patients complained about the care you provide or ever asked you to stop your care? Never, I am a great CNA. Do you believe [R1] had any problems with the care that she received from you? No she did not say anything to me during her care. Did you inappropriately touch [R1] during her ADL/Peri care? No, I would never do that. Did you touch [R1's] breast during Peri Care/ADL care? No I would never.On 3/10/26 at 9:37 AM, V1 (Administrator) and V2 (Director of Nursing) were interviewed together. V1 said, We initiated a new reportable on Saturday (3/7/26), completed interviews with [R1], and was notified that she had a potential witness. We interviewed [R2], interviewed the CNA [V4], the Police were notified, and an incident report was made. The investigation through the police is still pending. V2 said, We just want to let you know, she (R1) does have a UA out and she has been on doxycycline for a urinary tract infection. She has leukocytosis. I'm not insinuating it's a fabrication; I wanted to rule out anything clinical. She had a telehealth visit yesterday with [psychiatric services], I wanted a check in from that point. She has no changes to her medication, and they will continue to follow up. I kind of don't want to get ahead but [R2] has a history of behaviors. We ran her urine too. She has maladaptive behaviors. she has something care planned about housekeeping having cleaned her room and she said it wasn't cleaned. Psychiatric is on consult for her too. [psychiatric services] did a telehealth visit with her too, and started her on hydralazine as needed for anxiety. Her urinalysis was dirty too. I am not accusing either of the women of anything, my suspicion is that it is highly suspicious that because [another facility] was in the news for abuse and these two are best friends, they talk, play poker together. Considering both of them have a care plan for behaviors, it was highly suspicious to me and me alone that all of a sudden, it was in the news, and this allegation was made when she (being R1) was comfortable with the CNA for a very long time. This is 'he said she said'. there is no death sentence for 'he said she said', I don't believe or side with anyone because I have to be neutral.The facility's policy and procedure date 3/2026 showed, Abuse Policy, Policy: The facility affirms the right of our residents to be free from abuse. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: . Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; . Immediately protecting residents involved in identifying report of possible abuse; . Implementing systems to investigate all reports and allegation of mistreatment promptly and aggressively, and making the necessary changes to prevent further occurrences. Filing accurate and timely investigative reports; . Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault.The Immediate Jeopardy that began on 2/28/26 was removed on 3/10/26 when the facility took the following actions to remove the immediacy.Allegations of non-compliance #1Sexual inappropriate behavior of staff member to residents.Corrective Action Taken:Full body check performed on resident on 3/7/2026. No indication of trauma and no findingsFull body check performed on residents in the facility that are not interviewable .Family and physician notifications (Exhibit A).Resident care plan was updated pertaining to the alleged abuse on 3/7/2026 (Exhibit B).CNA was immediately suspended, pending an investigation On 3/7/2026 the DON, Administrator, ADON, Nurse Consultant and Medical Director reviewed the facility resources for stress management and policy related to the occurrence: Abuse. No changes were made.Educated staff on how to take initial report of abuse and what should be included in the report. Educated Social Service Director how to take initial report of abuse and what should be included in the report. Educate Administrator on how to conduct a thorough investigation and how to determine if abuse occurred.Identifying other residents having the potential to be affected by the same deficient practice:Resident were assessed (by female nurse) for any markings that could be related to physical contact and residents interviewed who are able to be interviewed. Assessments started on 3/7/2026 and is ongoing. No concerns noted today (Exhibit C).On 3/7/26, interviews were conducted with residents and complete concerns (Exhibit D).Measures taken to ensure that the problem is corrected and will not recur.All staff and managers are being reeducated on facility abuse policy and abuse prevention, stress management. The reeducation was provided on 3/7/2026 and is ongoing (Exhibit E).The facility leadership team provide pop quizzes to staff about abuse which began on 3/7/2026 and is ongoing (Exhibit F).Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur.A review of compliance using Quality Assurance Audit tool for abuse started 3/7/2026 (Exhibit G). Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained for 4 months. A review of results of audit regarding abuse with the facility's interdisciplinary team started 3/7/2026 (Exhibit H). Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained for 4 months. Abuse policy and prevention will be discussed with all new hires at new hire orientation. Quality Assurance Plans to monitor facility performance:Audits on all resident's abuse assessment and abuse care plan was reviewed for accuracy. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee. All audits will be reviewed by the QA committee with evaluation of trends/patterns and corrective action implemented as indicated. Ongoing audit frequency will be based upon goal attainment to start 3/7/2026 This will be monitored by the Administrator.An emergency QA meeting was held on 3/7/2026 at time by the Administrator with the Interdisciplinary Care Team and Medical Director. Abuse allegation on 3/7/2026 was discussed along with plans of correction. Medical Director and Interdisciplinary Care Team approved the plan of correction (Exhibit I). This will be monitored by the Administrator.

Based on observation, interview, and record review the facility failed to protect a resident (R1) from sexual abuse from a staff member (V4). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in V4 climbing into bed with R1, rubbing the side of R1's breast, and making sexually inappropriate comments such as 'you could be my girlfriend', 'you know you want it', and 'come on honey'. The Immediate Jeopardy began on 2/28/26 when R1's initial report of sexual abuse was reported to V3 (Social Services Director) and V1 (Administrator) as happening a couple of days ago. V1 (Administrator) was notified of the Immediate Jeopardy on 3/10/26 at 10:46 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/10/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include:R1's face sheet showed she was admitted to the facility 7/13/24 with diagnoses to include chronic obstructive pulmonary disease, Type 2 Diabetes, major depressive disorder, atherosclerotic heart disease, hyperlipidemia, insomnia, supraventricular dysfunction of bladder, generalized abdominal tenderness, systemic sclerosis, and overactive bladder. R1's facility assessment dated [DATE] showed she has no cognitive impairment, no behaviors, and requires physical assistance of staff assistance for most cares including dressing, personal hygiene, bed mobility, and transfers. R1 requires a wheelchair for mobility.R1's care plan initiated on 11/12/25 showed, [R1] demonstrates socially inappropriate behaviors as evidenced by maladaptive behaviors such as telling one staff member one story then telling a different story to another staff member. Avoid Overstimulation; Provide comfort measures for basic needs. Support appropriate moods and behaviors.R1's care plan initiated on 3/7/26 (the day the IDPH investigation into R1's incident started) showed, [R1] is at risk for abuse related to history of socially inappropriate behavior. [R1] has been known to tell one person one story then staff another story. [R1] will remain safe, calm, and free from abuse through next review. Interventions (all dated 3/7/26): check and assure physical comfort; Consider possible antecedents: fear, fatigue, loss of control over a situation; Encourage resident to participate in activities; Investigate accusation.R1's complete care plan was reviewed and showed no history of false abuse allegations.R2's face sheet showed she was admitted to the facility 8/30/24 with diagnoses to include cellulitis of right lower limb, non-pressure chronic ulcer of left ankle with unspecified severity, acute and chronic respiratory failure, insomnia, chronic kidney disease, and hyperlipidemia. R2's facility assessment dated [DATE] showed she has no cognitive impairments and no behaviors.On 3/7/26 at 10:30 AM, R1 was sitting in her wheelchair in a common area with her husband nearby. R1 was clean, well groomed, and pleasant.On 3/7/26 at 10:30 AM, R1 said when asked if any staff members have ever behaved inappropriately or made her feel uncomfortable, she stated I had a problem like that just last week, but I was told to be quiet about it and not talk to people about it. V3 told me not to talk about it. They said they were handling it. (This surveyor explained this is what I am here specifically investigating and that if she could describe the details of this incident, it would be helpful. R1 was very hesitant at first but then began describing the situation.) It was [V4] (Certified Nursing Assistant-CNA). Nothing like this happened before. I told [V3] from Social Services when it happened. He is the social worker here. I don't think [V4] was thinking, he was saying things like 'I could be his girlfriend' and 'I know you want it'. This happened last week. The exact date would be on [R2's] phone. I think [V4] was thinking it was a joke or something, I think he thought this was a joke. He puts me to bed at night and then usually comes back about 5AM to change my (incontinent pad). This happened around 9 or 10 PM when he was putting me to bed. He hasn't been around me since then either, but my roommate got sick, so they moved me to a room upstairs and when I went up there, they said he was the one working that area and they knew he wasn't able to take care of me anymore. I said, 'oh no, he can't be around me.' They do make sure he isn't around me anymore, but he still works here. When this happened, I was already changed, and the blankets were on. He wasn't standing over me, he was in my bed lying sideways and rubbing the side of my breast. That is what bothers me so much, he was giggling and laughing and saying, 'you know you want it'. I had called [R2] when he came into my room, and she listened to whole thing. She could hear him. At 11:33 AM, R1 said, The day before this incident was the first time something was happening. I knew the night before, he was getting 'way too friendly' and I was telling [R2] about it. I told [R2] that no one is going to believe me about what is going on, So I called her when he was coming in so she could hear our interaction. I told him I'm married, and he has a girlfriend. He was on top of the comforter when he was in my bed and rubbing the side of my breast through the blanket. I told him to 'get out' and to 'leave my room.' When I reported this to [V3] I told him that I had debated about telling him what happened. He said it was a 'no no ' and they don't allow 'this kind of behavior'. He said he was reporting to [V1] (Administrator) and offered for me to talk to him later if I needed to. I reported to him exactly what I just told you.On 3/7/26 at 10:43 AM, R2 was sitting in her wheelchair in room with the bedside table in front of her. R2 was clean, well groomed, and free of odors. R2 said, Sometime last week I listened to a conversation over the phone with [R1]. I heard the gentlemen saying sexual remarks, it was [V4]. He was saying come on honey and she kept telling him to quit and he kept coming back at her. She kept saying 'no, go away, get out of here'. He would laugh at her, and say 'come on, you know you want it'. What I heard was inappropriate. [R1] doesn't want anyone to get in trouble but something like this can't be let go. [R1] told me no one was going to believe her unless someone else hears it, so I told her to call me. He has not been inappropriate with me. He wanted to lay on the bed with her, he just kept laughing and she was repeatedly telling him no. He works 11-7 normally. No one from here has interviewed me about this or about what I heard. Even her family has kept telling her she had to tell someone about this. We don't want anyone getting fired or losing their job, but we can't have them doing things like this.The facility's Incident/Accident Notification showed, . Initial Sent on 2/28/26 . It was reported on 2/28/26 Administrator received a phone call from resident [R1] that Certified Nursing Assistant [V4] touched residents' breast during routine peri care and incontinence care. Certified Nursing Assistant [V4] is now pending investigation without the need to suspend due to not being on the schedule. The facility's Incident/Accident Notification showed, Final Sent on 3/2/26. [R1] a [AGE] year-old female resident reported that during her ADL and Peri care this morning, CNA on duty [V4] touched her breast. CNA [V4] was notified of the pending investigation and is not scheduled until March 2, 2026, investigation has been initiated. [R1] reported to the administrator on 2/28/26 that a couple days ago CNA on duty touched her breast during routine ADL/Peri care. CNA was interviewed and denied all allegations of abuse and inappropriate touching. CNA stated, he was performing routine ADL/Peri care to [R1], he had to reposition her body because she needs assistance. CNA reiterated and denied touching [R1] inappropriately during care. CNA was immediately investigated, and not on the schedule until March 2, 2026, until after the investigation is completed. [R1] was interviewed and first stated CNA touched her breast during her brief change. [R1's] interview was inconsistent throughout. Facility completed a thorough investigation which included chart, care plan, and assessment reviews, resident(s) interview, staff interviews, and facility in-service training. [R1] has a BIMS score of 15. Chart review completed. During the interviews for residents and staff, there were no reports of any incident/accidents of care and no concerns of inappropriate behavior/touching. [R1's] roommate was interviewed with an interpreter and denied any incidents with the CNA that night. All other residents that were interviewed during this time stated they felt safe within the facility. All other residents declined any inappropriate behavior from staff. [R1] reported that she feels safe within the facility. [R1] was offered a room change which she declined. The Administrator presented [R1] with her resident rights and ombudsman packet and offered to send [R1] to the hospital for evaluation as well as assist in calling the police, both in which [R1] vehemently refused to do. [R1] stated during her interview that she wants to continue to keep this CNA as her CNA despite this allegation. The facility will review this request. Care plans were further reviewed and updated. The facility. does not currently have any findings and finds this allegation to be unsubstantiated.On 3/7/26 at 3:32 PM, V7 (R1's Sister) said, First let me tell you, my sister is of sound mind. She had back surgery that went wrong and that is why she is in the facility. I know my sister well enough to know when something isn't right. I asked her what was going on. She said nothing at first but then she told me that the CNA jumped into bed with her and started to rub her breast. She said she told him to get up and get out of there, but he had already touched her breast. She told him to get out. She said another person came and said to her 'don't start anything, we will take care of it'. According to my sister, how they took care of it is they moved him to the memory floor. The social worker came in and talked to my sister and said they were going to take care of it, but they won't tell her how they are doing it. I told her she has to tell someone because he can't be on the memory floor with people who can't tell them what happened. My sister said she was embarrassed. I told her there is nothing to be embarrassed about, but you have to speak up. She told her husband. She was hesitant to say anything, because she is there all the time and they asked her not to talk about it, and they just said they took care of it. She said someone made a comment to her about him having a new girlfriend, meaning my sister. That is all I can say about it, I have been up at night trying to figure out how to get her out of there. It's like they acknowledged that it happened, and said they would take care of it, but never followed through. She had never spoke about this CNA to me before. I think this totally, just surprised her, and I don't know if she even had him before. She has never mentioned that she has had issues with anyone, except this situation. It scared her and embarrassed her. She wanted to know where he was going to be because she is a little on the fearful side at night now about who is working the floor. This is a sexual assault of someone who was in bed and couldn't get up on their own. She can only verbalize for it to stop. In her words, she felt helpless and afraid, and why should she have to be afraid in a nursing home where we put her to get good care? The only reason she told me about it was because I noticed something was wrong. My sister is very social, very talkative, very much telling me about everything, she tells me what she is doing, what doctor came to see her, I always know what is going on with her at the facility. She was so quiet, I couldn't get her to answer me, she was saying she isn't hungry today, very down, said I couldn't help her. That is when she said he jumped into bed and started touching her breast and that she told him to get out. We thought she was safe. Obviously, she wasn't as safe as we thought, and that is bothersome to me. I have to worry about who is touching her and I don't want her to have to feel embarrassed.On 3/7/26 at 1:00 PM, V6 (R1's Husband) said, [R1] told me about it. She didn't give me details. It was about 10 days ago. She basically just told me that this CNA got in the bed with her.On 3/7/26 at 12:40 PM, V3 (Social Services Director) said, . Concerns are another big one of the things I do here. I'm kind of the go-to person for the residents. I don't want to say I'm the 'middleman', but I point the residents in the right direction, so they hear it from the 'horse's mouth' you know. [R1] reported something at the end of February. [R1] divulged to me that she had an issue with one of the CNAs at night. She started to tell me it was concerning her chest and I stopped her right there and told her I needed to talk to the Abuse Coordinator. [R1] kept talking but I didn't listen or retain anything, because I stopped at the fact that this involved her breasts, I had tunnel vision, and just kept thinking, I have to talk to [V1]. I was in the facility at that time, I called [V1]. I spoke with her right away, it was February 28th. I think it was a Saturday. [V1] said we need to get on this. I am not apprised to the procedure, I just know our Abuse Coordinator is [V1] and if the residents think there is something hinky, we go straight to the [V1]. I did follow up a couple days later, I try not to be intrusive because I know [R1], and she does come to me with certain things, and I didn't want to open up any wounds so I just asked her if she was okay and she said 'yeah for now'. I told her to reach out if she needed anything. [R1] doesn't have any behaviors. She is alert and oriented. I'm familiar with [R2]. [R2] has no behaviors and is alert and oriented. Both [R1] and [R2] are reliable historians I would say. The only time I was interviewed about this was on the phone when I called [V1]On 3/7/26 at 12:21 PM, V1 (Administrator) said, It was brought to my attention on Saturday back in February. I received a phone call from her, and she had told me that a couple days prior, she couldn't give me an exact date, [V4] had touched her breast, I had then started to ask her if this was during care, what was going on, where were you? She said she was on the edge of her bed, and he was in his routine to provide care. I asked her if she wanted to call the police to make a report, I asked her if she wanted to go to the hospital. She told me she didn't want him getting in trouble, she just wanted to make me aware. I offered a room change. I told her there would be an investigation initiated and to contact me if she needed anything else. I started my investigation immediately, contacted [V4] and began asking him questions like do you remember where you worked, and did anything come up that would be considered abnormal for your nightly care while you were here in the building. I told him it was a sexual abuse investigation being conducted and let him know that he was essentially being blamed for touching a resident's breast. He said he was providing care. I asked him if anything occurred specifically in the middle wing. I told him he was suspended pending investigation. It was his weekend off, so he wasn't on the schedule. He said he wouldn't touch anyone's breasts. I talked to [R1] again while I was still in the process of my investigation, I followed up with her briefly, in passing, while I was doing rounds, and just checked in to see how she was. She said she was okay and when I asked if she needed anything else she said no. V1 said V3 had called her and reported the incident and then R1 called her right after that. V1 confirmed the phone call was the only conversation V1 had with R1 regarding the allegation.On 3/7/26 at 3:07 PM, V4 (CNA) when asked if he is familiar with [R1] said he couldn't recall her, wasn't very familiar with her, and asked for her room number. Upon hearing R1's room number, V4 stated that this would be considered the 'middle assignment', and he doesn't work that assignment anymore. V4 said he was no longer being assigned the 'middle assignment' starting last week. V4 said, A week ago or so, I was told that a patient had said I touched her. I didn't. I helped her to peri care, change her stuff, and everything. I was told they were looking into it, so I was moved to the other floor. They called me Friday (2/28/26), I was off Saturday and Sunday. Now they have me on a different unit. I think [R1] is the one on the middle unit. She was the one the Administrator was asking me all the questions about. I never talked to anyone like that. Not a resident. She was a one assist with a gait belt, and incontinent. Basically, that is what I remember, she needed help with incontinence care. She is alert and oriented, but sometimes she isn't always with it sometimes she says things that is not true. I would say she is not fully there.On 3/8/26 at 2:36 PM, V8 (Local Sheriff's Office Deputy) said, In summary, the resident [R1] stated that on an unknown date. a CNA [V4] who was assigned to work with her, jumped into bed with her and stated that she could be his girlfriend and touched the sides of her breasts. [R2] was interviewed as well and said she was on the phone with [R1] during the incident and the CNA fell into [R1's] bed, tried to kiss her and was heard making inappropriate remarks about wanting to have relations with her, the CNA kept pushing for it and [R1] kept saying no. [R1] said she didn't want this to happen to any other women.On 3/7/26 at 2:50 PM, V10 (Registered Nurse-RN) said, I'm very familiar with [R1]. She is very alert, not confused. Husband comes in very frequently, they are a very pleasant family.The facility's policy and procedure date 3/2026 showed, Abuse Policy, Policy: The facility affirms the right of our residents to be free from abuse. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: . Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; . Immediately protecting residents involved in identifying report of possible abuse; . Implementing systems to investigate all reports and allegation of mistreatment promptly and aggressively, and making the necessary changes to prevent further occurrences. Filing accurate and timely investigative reports; . Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault.The Immediate Jeopardy that began on 2/28/26 was removed on 3/10/26 when the facility took the following actions to remove the immediacy. Allegations of non-compliance #1Sexual inappropriate behavior of staff member to residents.Corrective Action Taken:Full body check performed on resident on 3/7/2026. No indication of trauma and no findings.Full body check performed on residents in the facility that are not interviewable.Family and physician notifications (Exhibit A).Resident care plan was updated pertaining to the alleged abuse on 3/7/2026 (Exhibit B).CNA was immediately suspended, pending an investigation On 3/7/2026 the DON, Administrator, ADON, Nurse Consultant and Medical Director reviewed the facility resources for stress management and policy related to the occurrence: Abuse. No changes were made.Educated staff on how to take initial report of abuse and what should be included in the report. Educated Social Service Director how to take initial report of abuse and what should be included in the report. Educate Administrator on how to conduct a thorough investigation and how to determine if abuse occurred.Identifying other residents having the potential to be affected by the same deficient practice:Resident were assessed (by female nurse) for any markings that could be related to physical contact and residents interviewed who are able to be interviewed. Assessments started on 3/7/2026 and is ongoing. No concerns noted today (Exhibit C).On 3/7/26, interviews were conducted with residents and complete concerns (Exhibit D).Measures taken to ensure that the problem is corrected and will not recur.All staff and managers are being reeducated on facility abuse policy and abuse prevention, stress management. The reeducation was provided on 3/7/2026 and is ongoing (Exhibit E).The facility leadership team provide pop quizzes to staff about abuse which began on 3/7/2026 and is ongoing (Exhibit F).Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur.A review of compliance using Quality Assurance Audit tool for abuse started 3/7/2026 (Exhibit G). Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained for 4 months. A review of results of audit regarding abuse with the facility's interdisciplinary team started 3/7/2026 (Exhibit H). Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained for 4 months. Abuse policy and prevention will be discussed with all new hires at new hire orientation. Quality Assurance Plans to monitor facility performance:Audits on all resident's abuse assessment and abuse care plan was reviewed for accuracy. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee. All audits will be reviewed by the QA committee with evaluation of trends/patterns and corrective action implemented as indicated. Ongoing audit frequency will be based upon goal attainment to start 3/7/2026 This will be monitored by the Administrator.An emergency QA meeting was held on 3/7/2026 at time by the Administrator with the Interdisciplinary Care Team and Medical Director. Abuse allegation on 3/7/2026 was discussed along with plans of correction. Medical Director and Interdisciplinary Care Team approved the plan of correction (Exhibit I). This will be monitored by the Administrator.

Based on interview and record review the facility failed to ensure a fall intervention of wheelchair anti-tip bars were facing downward for 1 of 32 residents (R47) reviewed for safety in the sample of 32.The findings include:R47's Fall assessment dated [DATE] showed R47 was at risk for falls.On 01/13/2026 at 9:52 AM, R47 was sitting in her wheelchair attempting to self-propel. R47 had anti-tip bars on her wheelchair. The anti-tip bars were angled upward.On 01/13/2026 at 10:19 AM, V11 (Restorative Nurse) said anti-tip bars are a fall prevention intervention and should be pointed downward to help prevent the wheelchair from tipping backward. V11 confirmed R47's wheelchair anti-tip bars were facing upward. V11 said V12 (Maintenance Director) was responsible for installing and making sure the anti-tip bars were in the correct position. On 01/13/2026 at 12:01 PM, V12 said maintenance does not install anti-tip bars on wheelchairs and it was the responsibility of the nursing staff to ensure the bars are positioned correctly.R47's wheelchair manufacture's brochure, provided by V3 (Director of Nursing), contained a picture of R47's wheelchair. In the picture the anti-tip bars were facing downward. The description next to the wheelchair picture indicated the anti-tip bars came standard with the wheelchair. R47's Fall Care Plan with an initiated date of 1/28/19 listed under interventions was to encourage the appropriate use of the wheelchair. R47's Fall Incident report dated 10/18/25 showed R47 had fallen from her wheelchair.

Based on observation, interview and record review the facility failed to provide feeding assistance to a resident that required staff assistance to eat for 1 of 32 residents (R1) reviewed for activities of daily living in the sample of 32.The findings include:R1's hospice admission order dated 8/14/25 showed R1 was admitted to hospice due to his diagnoses of dementia and severe protein calorie malnutrition. R1's weight record showed R1 lost 23.8 pounds from 8/21/25 to 1/9/26.R1's resident assessment dated [DATE] showed R1 required partial to moderate staff assistance to eat.R1's current care plan showed R1 was severely cognitively impaired. The plan showed, Set up resident's tray and provide assist or cueing for meals as needed.On 1/12/25 from 9:15 AM-9:40 AM, a continuous observation of R1 was made by this surveyor. From 9:15 AM-9:40 AM, R1 was seated in a high back wheelchair in the dining room. R1's face was thin. R1 appeared gaunt. R1's breakfast tray was in front of him on a table. A serving of pureed eggs and a serving of a pureed brown substance was noted on R1's plate. An opened container of orange yogurt and a bowl of oatmeal, covered with a lid, were noted on R1's tray. R1 did not consume any of the eggs, brown pureed substance, oatmeal, or yogurt. R1 was awake, looking around the room. V4 Certified Nursing Assistant (CNA) fed two other residents seated at R1's table. V4 did not speak to R1. V4 did not attempt to assist R1 with eating. No other staff spoke to R1 or attempted to feed R1. At 9:40 AM, R1's breakfast tray was removed from the dining room by a staff member. R1 consumed no food from his breakfast tray.On 1/12/26 from 1:00 PM-1:15 PM, a continuous observation of R1 was made by this surveyor. During this time, R1 was seated in a high back wheelchair in the dining room. A lunch tray of pureed foods was noted in front of R1. An opened cup of chocolate ice cream was also noted on R1's tray. A spoon was placed in the ice cream, but no ice cream was consumed by R1. R1 consumed none of his pureed foods. No other staff spoke to R1 or attempted to feed R1 during this time. On 1/13/26 at 10:15 AM, V8 (R1's Hospice Nurse) stated R1 required staff assistance and encouragement to eat.On 1/13/26 at 11:20 AM, V9 Dietician stated R1 required staff assistance and encouragement to eat. The facility's Feeding A Resident policy dated 9/2020 showed, Residents who need assistance will be fed a well-balanced meal, by a nurse, CNA or an individual who has completed a state approved feeding course. Encourage the resident to eat all his or her meal. Encourage and engage in resident centered conversation.

Based on observation, interview and record review the facility failed to ensure a paraplegic resident that is unable to move her lower extremities received services to prevent a decrease in range of motion for 1 of 12 residents (R13) reviewed for range of motion in the sample of 32.The findings include:R13's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of: cord compression, polyneuropathy, edema, necrotizing vasculopathy, radiculopathy and lupus.R13's Physical Therapy Discharge Summary shows that she received physical therapy from 9/13/25 to 10/10/25. Upon discharge, she was able to perform bed mobility with supervision assist. Discharge Status and Recommendations show, To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs (Restorative Nursing Program) has been completed with the IDT (Interdisciplinary Team): bed mobility, ROM (Passive) and transfers.On 1/12/26 at 9:51 AM, R13 was lying in bed. R13 was unable to move her bilateral lower extremities. R13 said that since October, the staff have not done any exercises to her lower extremities, and she is unable to move them herself due to being paralyzed from the waist down. On 1/13/26 at 12:40 PM, V14 (Restorative Aide) said that she has worked at the facility for 17 years. V14 said that if a resident is paraplegic, they typically will do Passive Range of Motion (PROM) to their lower extremities for 15 minutes at least three times a week. V14 said that she has never done PROM to R13's lower extremities. V14 said that she is the restorative aide for R13's unit.On 1/14/26 at 12:28 PM, V17 (Restorative Licensed Practical Nurse) said that she performed R13's Restorative Assessment after she discharged from Physical Therapy. V17 said that R13 was already on a bed mobility and grooming program. V17 said that she kept her on the bed mobility and grooming program and did not add anything else. V17 said that the bed mobility program consists of the Certified Nursing Assistants (CNAs) providing cares to R13 and having her help with rolling in bed. V17 said that when she did her assessment, she was thinking that she could work on maximizing her bed mobility and then would work on PROM. V17 said that PROM is done to prevent residents from getting contractures and loosing strength in their arms or legs. V17 said that at the time of her assessment, she did not know of therapy's recommendation for PROM and based on her clinical judgement, she felt that R13 would benefit most from being in the bed mobility and grooming program and not PROM. V17 said that when she became the restorative nurse, she received training from the facility on how to do an assessment and had not had any training in the past regarding restorative assessments. On 1/14/26 at 10:45 AM, V16 (Occupational Therapist) said that R13 has been paraplegic for years and is unable to move her legs. V16 said that when she was previously in therapy, they were doing PROM to her lower extremities to maintain mobility of her joints and prevent contractures. V16 said that it would be important to continue with the PROM to prevent a decline in mobility of her joints and to prevent contractures. V16 said that when a resident discharges from therapy, a recommendation is given and it is important for the facility to follow them to prevent any declines. On 1/14/26 at 11:39 AM, V15 (Therapy Director) said that when R13 came to the facility, she was getting Physical Therapy, Occupational Therapy and Speech Therapy. V15 said that R13 has been unable to move her legs on her own for years due to being paraplegic. V15 said that when she was in therapy, they were doing PROM to her lower extremities to help with tone, increase blood flow and try and prevent contractures. V15 said that her lower body strength was 0 out of 5 upon assessment. V15 said that everyone should have some type of range of motion to prevent a decline. R13's Minimum Data Set assessment dated [DATE] shows that her cognition is intact, has limited range of motion to both lower extremities, is not receiving therapy services and has not had any days of PROM.R13's Current Care Plan does not document that she is on any type of range of motion program for her lower extremities. The facility's Restorative Nursing Program Policy shows, It is the policy of this facility that a resident is given appropriate treatment and services to enable residents to maintain or improve his or her abilities. An individualized program will be developed based on the resident's needs as appropriate.The purpose of a Restorative Nursing Program is to Prevent secondary complications.A Restorative Nursing Program will be established.when the resident is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or.in conjunction with formalized rehabilitation therapy.An initial screening by the appropriate therapy(s) will be performed if indicated.A physician's order is not required for an RNP.When in doubt, nursing should consult with physician and therapy for limitation and precautions.The restorative nurse will review the functional assessment and care plan with involved nursing staff and therapy to assure specific needs are identified, plan implemented, and resident placed in the appropriate restorative program(s).The facility's Passive or Active Range of Motion Exercises Policy shows, Passive Range of Motion is defined as a program of passive movement exercises to maintain flexibility and useful motion in the joints of the body. The caregiver moves the body par around a fixed point or joint through the resident's available ROM.Routine performance of range of motion exercises will assist to maintain or improve joint mobility to assist resident in maintaining or achieving maximum function by.Preventing or reducing contracture and deformity.For both active and passive range of motion: movement by a resident that is incidental to dressing, bathing, etc., does not count as part of a formal restorative nursing program.Range of motion should be delivered by staff who are trained in the procedures.

Based on observation, interview, and record review the facility failed to ensure a resident received their dietary supplements for 1 of 7 residents (R67) reviewed for dietary supplements in the sample of 32. The findings include:R67's Order Summary Report printed on 1/14/26 showed R67 was to receive fortified pudding with breakfast, lunch, and dinner and a (high calorie and protein supplement) cup with lunch and dinner.A facility assessment with an effective date of 10/1/25 showed R67 was mentally intact. On 01/12/2026 at 9:28 AM, R67 was in bed eating his breakfast. There was a meal ticket on his tray that indicated he was to receive fortified pudding. There was no pudding on his tray. R67 confirmed he did not receive pudding. On 01/12/2026 at 1:01 PM, R67 was in the dining room eating lunch R67 was not served a (high calorie and protein supplement) cup. R67's meal ticket, that was on the table, indicated R67 was to receive a (high calorie and protein supplement) cup.On 01/12/2026 at 1:18 PM, R67 had finished his meal and started to exit the dining room. R67 said he was not served a (high calorie and protein supplement) cup. On 01/13/2026 at 11:22 AM, V9 (Dietitian) said R67 was on several supplements including fortified pudding and (high calorie and protein supplement) cup. V9 said it was the expectation that R67 received his supplements as ordered. R67 Nutrition assessment dated [DATE] showed he was to receive fortified pudding with meals and a (high calorie and protein supplement) cup with lunch and dinner.

Based on observation, interview and record review the facility failed to ensure medication were stored in a safe manner for 1 of 32 residents (R44) reviewed for medication storage in the sample of 32.The findings include:On 1/12/2026 at 10:29 AM, R44 had nasacort nasal spray, systane eye drops and a bottle of ammonium lactate 12% lotion sitting on a shelf in her room. R44 said that she uses the cream on her legs and the eye drops two to three times a week. R44 said that she uses the nasal spray as she feels she needs it but was not sure how often. R44's Physician's Order Sheet (POS) shows an order for ammonium lactate to be applied to her bilateral legs every 12 hours as needed. No orders were found for Systane eye drops or Nasacort nasal spray. R44's POS does not show an order for self-administration of medications. A Nursing Note dated 11/14/25 shows, Writer spoke with resident and advised her she cannot buy OTC medications and/or keep them in her room and self-administer.R44's Care Plan does not document that she is able to self-administer medications safely.On 1/13/26 at 1:55 PM, V3 (Director of Nursing) said that self-administration of medications is not allowed for any resident that currently resides at the facility. V3 said that R44 should not have any medications including nasal spray, eye drops or medicated lotions in her room. The facility's Self Administration of Medications Policy shows, Residents will not be permitted to administer or retain medications in their rooms unless so ordered by the attending physician, assessed for their cognitive, physical, and visual ability to self-medicate, and approved by the care planning team.Storage of legend drugs at the bedside will meet the conditions of the above, and will additionally be specifically ordered by the prescriber of the drugs; and be limited to sublingual or inhalation forms of emergency drugs.

Based on observation, interview and record review the facility failed to provide a resident's requested food preferences for 1 of 32 residents (R1) reviewed for food preferences/choices in the sample of 32.The findings include:R1's hospice admission order dated 8/14/25 showed R1 was admitted to hospice due to his diagnoses of dementia and severe protein calorie malnutrition. R1's weight record showed R1 lost 23.8 pounds from 8/21/25 to 1/9/26.R1's current care plan showed R1 was severely cognitively impaired. The plan showed R1 requires nutritional support. No pork, no beef, no pasta. On pleasure feeding. Per family request, grilled cheese, no crust with meals. Honor food preferences. On 1/12/26 from 9:15 AM to 9:40 AM, a tray of pureed breakfast foods, including a cup of yogurt, was noted in front of R1. No fruit or banana were noted on R1's tray. R1's meal ticket on R1's tray showed Standing orders > 1 banana. Dislikes bacon, ham, pork, sausage.On 1/13/26 at 8:51 AM, R1's breakfast tray was placed in front of R1. R1's breakfast tray consisted of pureed eggs, a pureed pink substance and oatmeal. No banana or fruit was noted on R1's tray. V6 Memory Care Director began feeding R1. When V6 was asked what the pureed pink substance on R1's tray was, V6 stated, It's pureed ham. On 1/12/26 at 12:43 PM, V7 Family of R1 stated R1 had lost a lot of weight. V7 stated (R1) won't eat meat or even likes meat or most of the food they provide for him there (facility). He will eat fruit, vegetables, and grilled cheese sandwiches. He needs to get fruit or a vegetable with every meal. Other than the smoothies I bring in for him to drink, fruits and vegetables are all he will eat. On 1/13/26 at 11:20 AM, V9 Dietician stated, I do remember (R1) did not eat any meat. I do remember (V7 Family of R1) requested that (R1) get fruits, vegetables and smoothies to eat. (R1) should be getting fruits and/or vegetables with every meal.The facility's Food Preferences policy dated 11/2025 showed, Upon admission or within 24 to 72 hours the resident will be interviewed by the Food & Nutrition Services Manager or designee for food preferences and menu selection. A record will be maintained of the resident's food preferences and food allergies.

Based on observation, interview and record review the facility failed to ensure a resident on contact and droplet isolation remained in her room with her door closed. The facility failed to educate and redirect a resident to maintain contact and droplet isolation. These failures apply to 1 of 32 residents (R32) reviewed for infection control in the sample of 32.The findings include:A facility isolation list dated 1/12/26 showed by 1/7/26, two residents (R143, R183) in the facility had tested positive for COVID-19. R32's progress note dated 1/9/26 showed R32 developed a cough. R32 was placed on isolation precautions due to her cough. R32's physician order dated 1/9/26 showed, Isolation: Contact and Droplet and N-95 Precautions - Due to suspected Acute Respiratory Illness every shift for 10 days.On 1/12/26 at 9:22 AM, R32 was seated in a wheelchair, in the doorway of her room, actively coughing with no mask on. The door to her room was wide open. A N95 Plus Eye Protection and Contact Precautions sign was noted on the doorframe of R32's room with a cart containing PPE (personal protective equipment) noted in hallway by R32's door. R32 asked V5 Activity Aide to remove her breakfast tray from her room. V5 stated, Just a minute. V5 kept walking down the hall. At 9:24 AM, R32 remained at the doorway of her room. R32 slightly propelled her wheelchair out into the hallway as she continued to cough. R32 wore no mask. R32 again asked V5 to pick up her breakfast tray. V5 stated he would come back to get the tray and walked away into the dining room on the unit. At 9:26 AM, R32 remained in her wheelchair, just outside of her room in the hallway. R32 wore no mask. R32 continued to cough. R32 again asked V5 Activity Aide to pick up her breakfast tray. V5 stated, I will tell your CNA (certified nursing assistant). I am not allowed to come in your room. V5 slowly propelled herself back into her room. At no time during this observation did V5 Activity Aide or any other staff member educate or redirect R32 to remain in her room with her door shut due to her cough. On 1/13/26 at 8:37 AM, V10 Registered Nurse (RN) stated R32 is on droplet and contact isolation because R32 developed an acute cough and respiratory symptoms. V10 stated R32 should remain in her room with the door closed in an attempt to prevent the spread of R32's respiratory illness. V10 stated if R32 comes out of her room for any reason she is to wear a mask. V10 stated R32 is confused at times so if she attempts to leave her room, staff are to remind her to stay in her room due to her cough. The facility's Droplet Precautions policy August 2025 showed, Use Droplet Precautions as recommended in CDC's (Centers for Disease Control) Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings for residents known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a resident who is coughing, sneezing, or talking.The facility's N95 Plus Eye Protection and Contact Precautions isolation signage dated 1/2025 showed, Door to room must remain closed.

Based on interview and record review, the facility failed to ensure a resident (R1) received medications as ordered by a physician. This applies to 1 of 3 residents reviewed for medications in the sample of 5.The findings include:R1's electronic face sheet printed on 7/24/25 showed R1 has diagnoses including but not limited to chronic obstructive pulmonary disease, osteoarthritis, rheumatoid arthritis, ESBL, idiopathic scoliosis, and history of falls.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment.R1's physician's orders for July 2025 showed, Enoxaparin Sodium Injection Solution Prefilled Syringe 40mg (milligram)/0.4ML (milliliter). Inject 0.4ml subcutaneously one time a day for DVT (Deep Vein Thrombosis) prophylaxis.On 7/24/25 at 10:36AM, R1 stated, I have missed doses of my Lovenox (Enoxaparin Sodium) before. It was at the beginning of this month. They said it was delivered to the wrong unit but that's not excuse for me to not receive my medication.R1's medication administration record for July 2025 showed R1 did not receive her dose of Enoxaparin Sodium on 7/2, 7/3, and 7/4.R1's nursing progress notes showed, 7/2/25 Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML. Inject 0.4 ml subcutaneously one time a day for DVT Prophylaxis INJECT ENTIRE CONTENTS OF SYRINGE. Pharmacy pending delivery. 7/3/25 Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML. Inject 0.4 ml subcutaneously one time a day for DVT Prophylaxis INJECT ENTIRE CONTENTS OF SYRINGE. Drug is unavailable. 7/4/25 Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML. Inject 0.4 ml subcutaneously one time a day for DVT Prophylaxis INJECT ENTIRE CONTENTS OF SYRINGE not delivered by pharmacy yet.On 7/24/25 at 1:46PM, V8 (Registered Nurse) stated, If you order a medication at 10am it will arrive here by the same afternoon. The pharmacy usually comes twice a day. If we have a medication that hasn't been delivered, we will call the pharmacy to see what is going on. I'm not sure if Enoxaparin Sodium is a stock medication or not in our (emergency pharmacy stock machine). I don't really use it, so I don't even know where to look and see if we have it.The facility's document titled, (Facility emergency pharmacy stock machine list) showed, Enoxaparin Injection 40mg/0.4ml.2 syringes.On 7/24/25 at 2:45PM, V3 (Director of Nursing) stated, We have a (emergency pharmacy stock machine) that has Enoxaparin in it. There is a list of all the medications in that hangs on the side of the machine so all the nurse's have to do is look at the list, see we have the medication, and then pull it out for the specific resident. There is no reason why (R1) should not have received her medication because we always have 2 syringes of it in our machine. Any time a nurse uses a medication out of the machine, that report goes to the pharmacy, so they know to bring a refill out on their next delivery.The facility's policy titled, Medication Administration dated 09/2020 showed, Medications will be administered in accordance with the established policies and procedures.1. Drugs must be administered in accordance with the written orders of the attending physician.The facility's policy titled, Reordering Medications dated 03/2021 showed, Medications are reordered in advance so as not to have lapse in therapy.

Based on observation, interview and record review the facility failed to ensure insulin was administered at the ordered/scheduled time for 2 residents (R3 and R1) reviewed for medication administration in the sample of 4. The findings include: 1. On 2/10/25 at 9:50AM V3 (RN) was observed passing medications to R3. V3 stated, I'm late with his insulin. V3 then stated that breakfast is served about 8:00 AM, sometimes a little earlier and sometimes a little later. R3's February Medication Administration Record shows that R3 has an order for Insulin Aspart (Fast acting insulin for treating diabetes) 20 units twice a day before meals at 8:30 AM and 4:00 PM. The facility policy entitled Medication Administration dated 9/2020 states, Drugs must be administered in accordance with written orders of the attending physician. 2. On 2/10/25 at 1:00 PM R1 stated, About 1/2 the times I needed my insulin I would wheel myself to the nurse's station and ask for it, if I didn't then it was late. When I didn't get my insulin before my meal my blood sugars went up to 300-381. (R1 discharged from the facility on 2/8/25) R1's Medication Administration Records for January and February 2025 shows that R1 had orders for Insulin Aspart 8 units with meals scheduled at 8:00 AM, 12:00 PM and 5:00 PM. R1's Medication Administration Audit Report shows R1's insulin was administered at the following (late times): 1/18/25 at 9:07 AM, 1/20/25 at 1:14 PM, 1/21/25 at 1:06 PM, 1/25/25 at 9:43 AM and 1:13 PM, 1/26/25 at 1:17 PM, 1/27/25 at 1:35 PM and 7:43 PM, 1/28/25 at 9:49 AM, 1/29/25 at 10:06 AM, 1/30/25 at 10:11 AM, 1/31/25 at 11:50AM, 3:02 PM and 6:35 PM, 2/4/25 at 1:00PM, and 2/6/25 at 10:30 AM. On 2/10/25 at 12:45 PM V2 (Director of Nursing) stated, If insulin is supposed to be given with meals then it would probably be 8 AM, 12 PM and 5 PM.

Based on observation, interview and record review the facility failed to ensure a resident with a JP (Jackson Pratt) drain dressing was changed as ordered. This failure resulted in R22's JP drain site not being assessed for 11 days and becoming infected. The facility also failed to change non-pressure dressings as ordered and failed to ensure a resident's elastic wraps were applied to lower legs as ordered. This applies to 3 of 32 residents (R22, R37 & R113) reviewed for quality of care in the sample of 32. The findings include: 1. On December 2, 2024 at 9:20 AM, R22 was lying in bed. He had a tube with a bulb hanging from his stomach. He stated, that was his JP drain because he needed his gallbladder out. He showed this surveyor the dressing on the drain. The dressing was dated November 21, 2024 (11 days prior). He stated, no one does anything with it. They don't change the dressing or empty it. He empties it himself. On December 3, 2024 at 2:09 PM, V5 (Wound Care Nurse/WCN) was changing R22's dressing to his JP drain. The dressing was still dated November 21, 2024 (same dressing as the day before). She removed the dressing from the drain. The dressing was heavily soiled with a bloody drainage. The site around the tube had crusted dried blood on it, had an odor, was red and tender to touch. V5 (WCN) verified that R22's orders were to be changed daily and it should be done by the staff nurses. R22's progress notes dated December 3, 2024 by V5 (WCN) shows, Pt. (patient) cooperative at this time. Was able to change JP drain dressing. Sl. (slight) erythema (redness) to incisions side and few stitches, in place. No s/s (signs and symptoms) of inf. (infection) T dressing applied as ordered post ns (normal saline) cleanse. Pt. nurse at bed side, will monitor erythema. Tx. (treatment) order changed to daytime 11am per pt. request. R22's treatment administration record (TAR) for November and December 2024 shows, JP drain site- cleanse with normal saline, pat dry, cover with T-dressing and secure with tape. The order was signed out every day that the site was assessed and the dressing was changed. The same record did not show, R22 refused or the nurses did not change the dressing. On December 4, 2024 at 11:29 AM, V5 (WCN) stated, she re-assessed R22's JP drain site. The skin around his tube/drain was red and had edema (swollen). She called the doctor and got an order for bacitracin cream (antibiotic ointment) to be applied with the dressing changes. R22's progress notes dated December 4, 2024 shows, JP drain site assessed with pt. nurse. Assessed with sl. erythema and serosang. (bloody) exudate (drainage). (V11 Nurse Practitioner/NP) made aware with new orders for daily bacitracin (antibiotic ointment) and ca (calcium) alginate and cover with T dressing daily and PRN (as needed). On December 4, 2024 at 11:42 AM, V11 (NP) stated, yes, possibly the staff not changing the dressing or assessing the JP drain site for 11 days could result in needing an antibiotic ointment to the site. R22's physician orders shows, Bacitracin Ointment 500 UNIT/GM (gram) (Bacitracin (Topical), Apply to JP drain site topically one time a day for Skin Condition CLEANSE AREA W/NS (with/normal saline), PAT DRY, APPLY OINTMENT, ca (calcium) alginate and COVER W/T DRSG (dressing) and secure with tape. AND Apply to JP drain site topically as needed for skin condition CLEANSE AREA W/NS, PAT DRY, APPLY OINTMENT, ca alginate and COVER W/T DRSG and secure with tape. R22's electronic medical record did not show any non-compliance/refusals by R22 for dressing changes to the JP drain site. The facility's Jackson Pratt drain care policy dated September 2020 shows, Policy: A Jackson Pratt drain (or grenade drain) will be cared for to prevent incision complications. 45540 2. On 12/2/2024 at 12:36 PM, R37 was observed sitting up in her room in her wheelchair with a dressing wrapped around her head. R37's dressing had brownish colored drainage on the left side of her head, approximately dime sized. R37 said her dressing was last changed on Friday (11/29/2024) by the wound care nurse. R37 said her dressing doesn't always get changed on the weekends, but the wound care nurse changes it during the week. On 12/3/2024 at 1:30 PM, V6 (Registered Nurse/RN) said R37's dressing change is done daily and as needed. V6 said the nurse or wound care nurse should be doing the dressing changes. V6 said the primary nurse is responsible for the dressing changes on the weekends. V6 said the nurse should document when the dressing change is done or if the resident refuses the dressing change. R37's Treatment Administration Record (TAR) dated 11/1/2024 - 11/30/2024 shows an order for Collagen Micro Scaffold Wound Dressing 4.25 x 4.5 pad (Puracol Plus) Apply to scalp topically every day shift for skin condition related to unspecified open wound of scalp, initial encounter cleanse area w/ns, apply collagen/adaptic, 4x4 and cover with kerlix, order date 10/11/2024. R37's TAR has no documentation listed on 11/16/2024, 11/17/2024 and 11/23/2024, indicating if the dressing change was completed by the nursing staff. The facility provided Prevention and Treatment of Pressure Injury and Other Skin Alterations policy dated 3/2/2021 states, . Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. 33760 3. R113's Physician Order Sheet (POS) dated 12/24 shows R113 has diagnoses that include diabetes mellitus with diabetic neuropathy. The same document shows R113 with an order of ace wrap or tubi grip to right foot on in am off at night with an order date of 8/29/24. On 12/2/24 at 1 PM, R113 was sitting in her wheelchair in her room alert and pleasant. R113 said she has neuropathy, this hurts pointed to her legs, pulled her pants up. Both of R113's lower legs were noted to be swollen. no tubigrip or ace wrap was noted. On 12/3/24 at 12:00 PM, R113 was in her room sitting in her wheelchair. R113 showed this surveyor her lower legs again and said still no tubigrip and acewrap noted to her right lower legs. Review of R113's Treatment Sheet for November and December 2024 show R113's tubigrip was being applied. V7 (Registered Nurse/RN) said she does not know why R113's treatment sheet was being signed (with initials) as applied but obviously R113 does not have her tubigrips on. At 12:10 PM, V7 (RN) said ace wrap or tubigrip are applied normally on night shift before the resident gets up. V7 then asked R113 if she wanted her tubigrip on, R113 responded of course I need that. V7 said R113 needs her tubigrip to help decrease her leg swelling. V7 said she will apply the tubigrip now.

Based on observation, interview, and record review the facility failed to label a resident's tube feeding in accordance with professional standards of nursing. This applies to 1 of 3 (R100) residents reviewed for tube feeding in the sample of 32. The findings include: On 12/2/2024 at 11:33 AM, R100's tube feeding bag was observed hanging on the pump with a brownish colored solution in the bag, connected to the resident, with no label indicating what type of tube feeding solution was being administered to the resident at that time. On 12/2/2024 at 11:55 AM, V7 (Registered Nurse/RN) said the tube feeding bag should be labeled. V7 said R100 has an order for tube feeding for Diabetisource tube feeding supplement. On 12/4/2024 at 9:16 AM, V7 said we label the tube feeding bag because we are using the cans or canisters of tube feeding. R100's Order Summary Report as of 12/2/2024 states, Enteral Feed Order every shift for nutritional supplement Diabetisource 1.2 at 60mL/hr (milliliters/hour) total volume to infuse 900ml/day, to start at 7PM. The facility provided Enteral Nutritional Feeding policy dated 9/2020, states . label bag/container with name, date, time.

Based on observation interview and record review the facility failed to ensure a device was applied to a contracted hand for 1 of 6 residents (R24) reviewed for range of motion in the sample of 32. The findings include: R24's Physician Order Sheet (POS) show R24 has diagnoses of respiratory failure with tracheostomy. R24's facility assessment show R24 has no cognitive impairment. R24 has trach but able to verbalize her needs by mouthing off her words clearly. On 12/2/24 at 11:30 AM, R24 was sitting in her bed, R24's left hand was in a closed tight fist position. A splint was noted by her bedside still in plastic and another splint by her wheelchair. V8 (Registered Nurse) came to R24's room and tried to apply the splint. Then V8 (RN) went to check R24's medical record. V8 said R24's POS did not show any direction regarding when to wear the splint. On 12/3/24 at 10 AM, R24 said no one exercises her hand and now it was hard to open her left hand. R24's progress notes dated 11/26/24 by V10 (Physician Assistant) shows, Left hand contracture . OT to provide with L (left) resting WHO (wrist hand orthotic). On 12/3/24 at 10:30 AM, V9 (Restorative Director) said she was made aware of R24's declined range of motion to her left hand last week. V9 said she went to speak to R24 and R24 agreed to wear a splint to her left hand. V9 said R24's left hand splint should be applied daily. The order written on 12/3/24, shows, splint to left hand, apply in the morning remove in the evening, may remove during ADL and care. The facility policy entitled Restorative Nursing Program dated 3/10/22 show, It is the policy of this facility that a resident is given appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the residents ability to adapt and adjust to living as independently and quality as possible. Increased independence fosters self-esteem and promotes quality of life for residents.

Based on observation, interview and record review the facility failed to ensure an x-ray was obtained in a timely manner for a resident with an acute injury. This applies to 1 of 1 residents (R128) reviewed for radiology results in the sample of 32. The findings include: On December 2nd, 3rd & 4th, 2024, R128 was observed at various times up in her wheelchair in the dining room. She had a soft cast on her right wrist. R128's post occurrence documentation dated October 31, 2024 shows, Description of occurrence : Writer was doing evening med (medication) pass down the hallway from residents room when noted resident ambulating with unsteady gait near room doorway. Writer immediately went towards residents room but resident lost balance and fell on her right side when nurse was about 4 feet away. Head to toe assessment done, witnessed resident not hit her head, fell on her right side, ROM (range of motion) intact to baseline, LOC (level of consciousness) intact to baseline, resident c/o (complained of) pain to right wrist, no other complaint of pain or discomfort, able to move bilateral legs and bilateral arms without problem. No SOB (shortness of breath) noted, in no distress. No bumps, no scrapes nor new bruising from fall present on either scalp or skin upon assessment. Resident was assisted back into wheelchair with the use of a gait belt and 2 person assist. Local on-call doctor was contacted with orders for XR (x-ray) to right wrist 2-3 views and neuro (neurological) checks for precaution. R128's physician order dated October 31, 2024 shows, an x-ray ordered to right wrist due to a fall at 6:29 PM. R128's actual x-ray films show the x-ray of her right wrist was done on November 1, 2024 at 8:42 PM (26 hours and 13 minutes after being ordered). The facility did not get the results of the x-ray until November 2, 2024 at 11:34 AM (approximately 14 hours later). On December 3, 2024 at 1:29 PM, V2 (Director of Nursing) stated, she did not know why it took that long to get an x-ray done. X-rays are done within 24 hours if not ordered STAT (immediately). The facility's laboratory/radiology (x-ray) services policy dated September 2020 shows, Policy: Clinical laboratory and radiology services to meet the needs of our residents are provided by our facility. Procedure: 2. The following diagnostic services are available twenty-four (24) hours a day, seven (7) days a week, including holidays: .radiology .

Based on observation, interview, and record review the facility failed to ensure a resident who is dependent on staff for toileting received incontinence care. This applies to 1 of 3 residents (R1) reviewed for activities of daily living in the sample of 3. The findings include: R1's face sheet shows he is a [AGE] year-old male with diagnosis including hemiplegia affecting right dominant side, dysphagia, aphasia, muscle weakness and abnormalities of gait and mobility. On 11/22/24 at 9:30 AM, R1 was lying in his bed, his right arm was drawn into his chest. R1's speech was slow with minimal difficulty expressing his words. R1 said he had a stroke and with right sided deficits. He said he waits a long time to be changed. He said he was changed last on the previous shift. R1 pressed his call light for staff assistance. At 9:40 AM, a staff answered the call light, R1 said he needed the CNA (Certified Nursing Assistant) assistance. R1 was told they would let the CNA know. At 10:00 AM, R1 pressed the call light for the 2nd time. V6 (CNA) entered the room. R1 said he was soiled and needed to be changed. R1's incontinent brief was saturated with urine and large amounts of stool on his bottom. Dry stool was on his incontinent pad. V6 provided incontinence care and stated it's so dirty. V6 changed R1's clothing and assisted him to the edge of the bed. V6 moved R1's wheelchair next to the bed, a streak of dry brown matter was on his wheelchair cushion. V8 (R1's spouse) entered the room, she saw the soiled wheelchair cushion, removed it and said the cushion is soiled with stool. On 11/22/24 at 10:39 AM, V6 said residents should be checked and changed for incontinence care every two hours. V6 said she did not know when R1 was changed last, she had not changed him prior. On 11/22/24 at 10:41 AM, V5 (RN) said staff should remove soiled linen and clean up soiled surfaces. R1's Minimum Data Set assessment dated [DATE], shows he is cognitively intact, has limited range of motion with impairments on one side to his upper and lower extremity and dependent on staff for toileting. R1's care plan dated 8/2024 shows he is incontinent of bowel and bladder; interventions include to provide peri-care with episodes of incontinence.

Based on interview and record review the facility failed to schedule a urologist appointment after it was recommended by a Nurse Practitioner for 1 of 3 residents (R1) reviewed for professional standards in the sample of 3. The findings include: On 8/26/24 at 11:40 AM, V6 (Infectious Disease Nurse Practitioner) said she saw R1 on 7/24/24 regarding a recurring urinary tract infection (UTI). V6 said she recommended R1 to see a urologist. V6 said she let a nurse know about the recommendation and put the recommendation in the progress notes. V6 said the nurses are responsible for scheduling appointments. R1's Infectious Disease Progress Note entered on 7/24/24 by V6 showed a recommendation was made for R1 to see urology. On 8/26/24 at 11:05 AM, V1 (Administrator) said the facility started to arrange/schedule a urology appointment for R1 on 8/15/24 (22 days after V6 made the recommendation). V1 said the process of arranging the appointment was started because R1's family made the request for R1 to see urology on 8/15/24. R1's Progress Note dated 8/15/24 showed R1's family requested a urology appointment and the facility started the process for arranging the appointment. On 8/26/24 at 11:05 AM, V2 (Director of Nursing) said the facility's nurses set up appointments. V2 added when a healthcare provider makes the recommendation for a resident to see a specialist, like a urologist, they need to enter an order for the appointment. V2 said the scheduling/arranging of the appointment will start the day the order is received or the next day. V2 said without an order the nurses will not know to set up the appointment. V2 confirmed R1 did not have an order placed for an urologist appointment after V6 saw R1 on 7/24/24. On 8/26/24 at 1:30 PM, V2 said it was common practice for the providers to enter an order for residents to see specialists. The facility's Appointment policy showed physician's orders are received for appointments and resident, family members, responsible party, or physician notifies the facility of residents appointment needs.

Based on interview and record review, the facility failed to supervise one of three residents (R1) with a history of exit seeking and at risk for falling, failed to ensure a resident with a history of exit seeking room was not near an exit, and failed to ensure a door alarm sounded when an exit door was opened in the sample of three. This failure resulted in R1 falling down the stairs, experiencing a fibular fracture which contributed to R1 being hospitalized . This failure has the potential to affect all ambulatory residents in the memory care unit. The Immediate Jeopardy began on June 9, 2024 when R1 went out of an exit door and fell down the stairs and obtained a fibular fracture. V1 Administrator was notified of the Immediate Jeopardy on June 19, 2024 at 12:21 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was: Removed, and the deficient practice corrected, on June 10, 2024, prior to the start of the survey.This past compliance occurred from 6-9-24 to 6-10-24. The findings include: R1's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including heart failure, alcoholic cirrhosis of liver, unspecified dementia, morbid obesity, urinary tract infection, anxiety disorders, major depressive disorder, Alzheimer's disease, adjustment disorder with anxiety, glaucoma, and history of falling. R1's Fall Risk assessment dated [DATE] shows R1 is at risk for falls. R1's Nurses Noted dated May 25, 2024 at 10:56 AM, shows resident noted with increased confusion as evidenced by seen by staff in front of the building verbalizing desire to go to the bank. Stated 'I need to go to the bank to check my money.' Re-directed resident but hard to re-direct. Called resident daughter, daughter talked to resident and finally agreed to come inside. R1's Behavior Note dated June 5, 2024 at 1:51 PM shows R1 repeatedly stated that he wants to go home and he can take care of himself and has friends to help him. R1 was confused per baseline. Staff continue to closely monitor R1. R1's Nurses Note dated June 5, 2024 at 4:51 PM shows R1 wanted to leave the unit. R1 kept opening the alarm exit doors. R1 stated he was going to the bank because he is missing money from his checking account. Staff were unable to re-direct R1 and R1 was getting aggressive. R1's Care Plan initiated July 3, 2023 shows R1 is frequently trying to leave the unit. R1 frequently wants to go outside to smoke, is frequently resistant to return to the unit after designated smoke times are over and difficult to re-direct. R1's Care Plan intitiated June 8, 2023 shows R1 is at risk for falls: encourage appropriate use of wheel chair. Care Plan initiated January 3, 2024 shows R1 is at risk for elopement related to physical ability to leave the unit/facility. R1 will safely remain on the unit or off under supervision. Monitor behaviors. R1's Physician Progress Notes dated June 6, 2024 shows R1 became confused on May 25, 2024 and was determined to leave the facility to go to the bank. Staff had difficulty redirecting. R1 began treatment for a urinary tract infection and his mentation had not returned to his baseline and R1 remained confused. R1 was moved to the memory care unit at this time. On June 18, 2024 at 2:53 PM, R1's room was noted to be near the exit door that R1 escaped out of. The exit door was around the corner and not visible from the nurses station nor the dining room. R1's Post Occurrence Documentation done by V4 LPN (Licensed Practical Nurse) dated June 9, 2024 at 6:44 PM shows at 3:10 PM, R1 was seen in the hallway in his wheel chair. At 3:20 PM, R1 was heard screaming for help by a staff member. R1 was discovered sitting in the middle of the stairway in a sitting position. R1's wheel chair was at the bottom of the stairway. Per R1, he stated he wanted to go out and smoke. No noticeable injuries were noted. R1 complained of pain to his right ankle and left knee. R1 was left on the stairs until the ambulance arrived. R1's Nurses Notes dated June 9, 2024 at 7:58 PM, shows R1 was admitted to the local hospital with a closed fibular fracture, accidental fall, and urinary tract infection. On June 18, 2024 at 2:46 PM, V14 RN (Registered Nurse) said there was only one recent fall. V14 did not name R1 as a recent fall. At 2:53 PM, the exit door near R1's room was checked for an alarm. R1's room was directly across from the exit door that led to stairs which led to a door to the outside. V14 said the nurses check the alarms on the doors. At 2:55 PM, V14 showed this surveyor the log that includes when the nurses check the alarms on the doors. This log began on June 9, 2024. V14 said this log began after there was an incident involving R1. V14 said R1 was was found in the stairway about 3/4 of the way down the stairs and his wheel chair was at the bottom of the stairs. V14 said that R1 complained of pain to his right leg. V14 said that V4 LPN was R1's nurse that day. V14 said that R1 normally propels himself around the facility while in his wheel chair. Multiple attempts were made to contact V4 unsuccessfully. The facility's Fire Exit Door Alarms log shows it was started on June 9, 2024. The facility's Fall Report dated June 9, 2024 at 3:20 PM, done by V8 RN (Registered Nurse) shows at 3:20 PM, R1 was heard screaming for help by a staff member. R1 was discovered sitting in the middle of the stairway in a sitting position. R1's wheel chair was at the bottom of the stairway. Per the resident, he wanted to go out and smoke. R1 complained of pain to his right ankle and left knee. On June 18, 2024 at 4:47 PM, V8 RN said she was sitting at the nurses station learning the computer with V14 RN. V8 said a young man called out and waved to V8 and V14. V8 said the staff member was helping with trays in the dining room when he yelled There's someone yelling for help. V8 said she wasn't sure who the staff member was because she was not familiar with him. V8 said that V8, V14, and V4 went in the direction that the yelling was coming from. V8 said that R1 was down most of the step sitting up. V8 said R1's wheel chair was at the foot of the stairs. V8 said R1 told her he pushed his wheel chair down the stairs. V8 said no one knows how R1 got out. V8 said she did not know if the door that R1 got out of has an alarm on it. V8 said she has heard the alarms go off before and that the alarms are loud. V8 said she does not remember an alarm sounding. V8 said prior to the fall with R1, R1 would always try and leave the unit. V8 said that R1 is a very strong gentleman. V8 said that R1 would try and take advantage of anyone trying to leave through the exit doors. [R1] would try to leave. R1's Hospital Records dated June 9, 2024 shows, Right ankle fracture. Arrived to the emergency room [DATE] from [facility]. He tried to get [out] a door and was in his wheel chair and then fell down seven stairs. Patient was confused in the emergency room disoriented to date and time. He endorsed right ankle pain with no other complaints. A distal fibular fracture was identified. Patient was placed in a fracture boot to the ankle. On June 19, 2024 at 10:20 AM, V15 R1's daughter said the facility put R1 on the memory care unit because they said he would be safer there since he kept trying to leave the facility. V15 said she received a call from the facility on June 9, 2024 saying that R1 got out of the unit and fell down the stairs in his wheel chair. V15 said that R1 was currently still in the hospital and were looking for placement at a different facility. V15 said prior to R1's fall, R1 was able to transfer, but now after his fall he requires maximum assistance to transfer. On June 18, 2024 at 7:18 PM, V3 Medical Doctor said if a resident has a history of trying to leave the facility, then their room should be near the nurses station and not near an exit door. On June 18, 2024 at 4:35 PM, V6 Scheduler/CNA (Certified Nursing Assistant) said R1 likes to go back and forth in the hallways while in his wheel chair. V6 said that R1 is always setting the door alarms off. He's always trying to escape. The facility's Fall Management Policy dated August 2020 shows, The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial well being. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies and facilitate a safe environment. The facility's Wanderers (Elopement) policy dated September 2020 shows, residents identified as wanderers will have a preventative program to prevent possible injury. A determination is made for a floor and room assignment that will provide increased observation capabilities by staff. The Immediate Jeopardy that began on June 9, 2024 was removed on June 10, 2024 when the facility: -Performed a head count on all units. -All facility door alarms were checked for proper functionality. -All residents, including the resident in question, were assessed for exit seeking behaviors. -The administrator, nurse consultant and medical director reviewed the facility policies related to the occurrence: Door alarms, routine resident checks, and incident/accidents. -The director of nursing/assistant director of nursing and social service have reviewed and updated as need related to patient safety care plans. -The elopement binder was reviewed and updated on June 10, 2024. -All residents deteremined to have exit seeking behaviors have been evaluated for a possible room change to the alarmed unit of the facility. -All residents fall interventions were assessed to ensure proper interventions are in place. -All staff in serviced on the following topics: How to redirect residents that are wandering away from exits, how to promote safer outcomes for residents through supervision, answering door alarms promptly and reporting any changes in cognition or exit seeking behaviors to the nurse. -All staff and managers are being reeducated on routine resident check, incidents/accidents, wandering policy and procedure and where to locate the at risk of elopement binders. -A review of compliance using QA tool for response to door alarms completed on June 9, 2024. -An emergency QA meeting was held on June 10, 2024. The deficient practice was corrected on June 10, 2024 after the facility performed the above.

Based on observation, interview and record review the facility failed to obtain and monitor a resident's weights (R141) . The facility failed to notify the physician (V11) of R141's significant weight loss in a timely manner. The facility failed to supervise and assist a resident (R141) with significant weight loss during meals. These failures apply to 1 of 11 residents (R141) reviewed for weight loss in the sample of 30. These failures contributed to R141's significant weight loss of 13.44 % in 19 days. The findings include: R141's current care plan showed R141 was admitted to the facility on [DATE] with diagnoses of dementia and cognitive impairment. The care plan showed R141 was at risk for weight loss due to her diagnosis of dementia. The plan showed R141 had a poor appetite upon admission to the facility. R141's resident assessment dated [DATE] showed R141 needed one person to physically assist her with eating. R141's physician order dated December 1, 2022 showed, Check weight weekly .every Thursday for 4 weeks. R141's Weight Summary Report printed January 10, 2023 showed R141 weighed 114.1 pounds (lbs) on December 1, 2022 (admission to the facility), 116.1 lbs on December 15, 2022, and 100.5 lbs on January 3, 2023. The report showed R141 sustained a significant weight loss of 13.44 % (15.6 lbs) in 19 days (12/15/22-1/3/23). The report showed no documented weights for R141 during the weeks of December 8, 2022 and December 29, 2022. R141's Comprehensive Nutritional assessment dated [DATE] showed, Resident experienced a significant weight loss over 30 days . Weight loss is not desirable . On January 9, 2023 at 9:35 AM, R141 appeared frail and thin as she was lying in bed. On January 9, 2023 at 1:09 PM, V9 (Husband of R141) stated, I know she (R141) has lost some weight. The staff have to help her eat. On January 10, 2023 at 8:12 AM, V6 Certified Nursing Assistant (CNA) entered R141's room and placed a breakfast tray on R141's bedside table. R141 was lying in bed, looking at her cell phone. V6 immediately exited R141's room without repositioning R141 in bed to eat or opening up R141's food tray or drink containers. On January 10, 2023 at 8:17 AM, V6 CNA walked back into R141's room, said hello to R141, and then proceeded to start feeding R141's roommate. R141's food remained covered. R141 looked around her room as she laid in bed. V6 CNA provided no verbal encouragement, verbal cueing, or physical assistance to eat to R141. On January 10, 2023 at 8:22 AM, R141's food remained covered. No food had been consumed by R141. V6 CNA continued to feed R141's roommate. On January 10, 2023 at 8:25 AM, R141's food remained covered. R141 was awake in bed. V5 Licensed Practical Nurse (LPN) walked into R141's room to speak with V6 CNA. V5 LPN provided no verbal encouragement, verbal cueing, or physical assistance to eat to R141. On January 10, 2023 at 8:33 AM, R141 lifted the cover off her food, looked at it, and placed the cover back down. R141 opened a small container of low-fat yogurt and began feeding herself. V6 CNA remained in R141's room, feeding R141's roommate. V6 CNA provided no verbal encouragement, verbal cueing, or physical assistance to eat to R141. R141 consumed 50% of the low fat yogurt. On January 10, 2022 at 8:40 AM, V6 CNA walked into R141's room and lifted the cover off of R141's tray. One scoop of uneaten scrambled eggs and one muffin were noted on the tray. A small carton of milk remained unopened. A small container of half-eaten yogurt was noted. V6 CNA looked at R141 and stated, You don't want anything to eat? R141 stated, I don't like my breakfast. V6 CNA immediately picked up R141's tray and exited the room with the tray. On January 10, 2023 at 10:30 AM, V10 Registered Dietician stated, Newly admitted residents are to be weighed once a week for the first four weeks and then once a month. We rely on resident's food intake reports and weights to monitor residents for weight loss. The goal, of course, is to prevent weight loss before it becomes significant. If a resident experiences significant weight loss, it should be reported to the physician, dietician, and the resident's family as soon as possible. I see there are no recorded weights for (R141) on December 8th or 29th, 2022. The no weight for December 29, 2022 is really a concern because it was during that time that (R141) lost all of that weight. Her weight loss is very concerning. It looks like (R141) was at risk for weight loss upon admission because she was not eating well. It looks like she needs anywhere from supervision to the assistance of one person to eat. If she is not eating, she would need more assistance. She definitely needs encouragement and cueing when eating. On January 10, 2023 at 1:55 PM, V11 Physician stated, I was informed of (R141's) weight loss today (1/10/23) during rounds. Maybe the reason no one called to let me know about her weight loss last week was because they knew I would be rounding today? The facility's Weights policy dated September 2020 showed, Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain .1. A baseline weight will be established upon admission. The resident will be weighed weekly for 4 weeks after admission and monthly thereafter . 3. Report to nursing supervisor, physician/NP, dietary supervisor, RD (registered dietician) consultant and family/responsible party of any weight loss or gain greater that 5% within one (1) month, 7.5% within three (3) months or 10% within six (6) months .

Based on observation, interview, and record review, the facility failed to isolate unvaccinated residents that are on a 14 day quarantine and failed to follow Center for Disease Control (CDC) guidance for proper COVID-19 Personal Protective Equipment (PPE) for new admissions that are on a 14 day quarantine. These failures have the potential to affect 4 residents who are unvaccinated and have not had COVID-19. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/17/21 when isolated residents began wandering on the dementia unit. The Immediate Jeopardy was identified on 5/17/21. V1 (Administrator) was informed of the Immediate Jeopardy on 5/19/21 at 9:05 AM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 5/19/21. However, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. This applies to 4 of 4 residents (R45, R64, R282, R283) reviewed for infection control in the sample of 27. The findings include: 1. R282's Face Sheet shows that she was admitted on [DATE] and has never had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R282's electronic immunization record does not show that she has received a COVID-19 vaccination. On 5/17/21 9:38 AM, R282's room was vacant. There was a sign on the door that said R282 was on contact/droplet isolation. R282 was observed in the hallway with no mask on the face talking to R30 that was less than 6 feet away from her. 9:40AM, R282 was walking down the hallway with no mask on the face. 9:46 AM, V3 (Memory Care Director) applied a mask to R282 but did not try and re-direct her to her room. 10:07 AM, R282 was talking to R30 with no mask. R30's mask was below his nose and they were less than 6 feet apart. 11:48 AM, R282, R30, and R283 (additional isolation resident) were in the hallway talking and less than 6 feet apart. V4 (Registered Nurse) was observing the interaction but did not re-direct R282 or R283 to their rooms. 12:09 PM, R282 was talking to V4 and less than 6 feet away. V4 had a surgical mask on and no eye protection. 12:16 PM, R282 and R283 in the hallway talking less than 6 feet apart and they both did not have masks on there face. R282 gave R283 a piece of paper. R282 and R283 quit talking at 12:27 PM. Multiple staff were in the area and did not redirect them to their rooms. 12:39 PM, R282 went into the dining room and sat next to R127. R282 did not have a mask on and R127 had her mask on her forehead. R282 took the towel that R127 was using folded, and wrapped her mask around it and gave it to R127. R282 then began talking to R127 with her face less than a foot away from R127 and rubbing her back. 12:42 PM, V5 (Activity Aide) tried to put a mask on R282 but the resident refused. V5 did not re-direct her back to her room. V6, Certified Nursing Assistant (CNA) also saw the interaction but did not re-direct R282 back to her room. R45 and R64 (unvaccinated residents) were in the dining room. 12:51 PM, R282 left and went into the hallway. 1:44 PM, R30 was in R282's isolation room helping her make the bed. R282 did not have a mask on her face, and R30's mask was below the nose. 1:47 PM, R30, and R282 were in R282's room holding hand's face to face with each other. Their faces were less than one foot apart. 2. R283's Face Sheet shows that she was admitted to the facility on [DATE] and does not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R283's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/21 at 9:51 AM, there was a sign on R283's door that said contact/droplet isolation and the room was vacant. R283 was sitting in the dining room that had other residents present including R45 and R64 (unvaccinated residents). R64 was sitting unmasked at an adjacent table. R283 was sitting at the table petting a stuffed animal (white fur cat). V5 (Activity Aide) was in the dining room and had a surgical mask on her face. V5 did not try and re-direct R283 back to her room. 10:35 AM, R283 was still sitting at the table. R283 was holding the fur cat and cuddling it next to her face. R283 had her mask under her chin. 11:53 AM, V6 (CNA) walked past R283 with a surgical mask on and did not re-direct R283 back to her room. At 11:55 AM, R283 walked into the dining room and was standing by the table that R64 was sitting at and started talking to her. At 11:58 AM, R283 was wandering around the dining room with other residents present in the dining room. V8 (CNA) was doing an activity with R45 (unvaccinated resident) and R283 came up to her and started talking to her. R283 was within 6 feet of V8 and V8 only had a surgical mask on. V8 touched R283 on the shoulder and directed R283 to sit in a chair in the dining room that was within 6 feet of R78 who was not wearing a mask. At 12:03 PM, R283 was at the beverage cart that was located in the hallway touching the cups. At 12:07 PM, R283 was pacing the hallway. V9 (Admissions Director) was talking to R283 and was within 6 feet of her with a surgical mask on. V9 did not re-direct her back to her room. V9 spoke with her until 12:15 PM. 11:55 AM, the same cat was on the table within reach of R64 (unvaccinated resident). At 11:51 AM, R283 was in the hallway talking with R30 and was less than 6 feet away from him. R283's Nursing Notes dated 5/16/21 show, wanders in the unit but no attempt to open exit doors, calm and cooperative during the shift, noted at times talking to herself, wanders in the unit but easily redirected. During observations on 5/17/21 between 9:50 AM and 1:47 PM, no behaviors besides wandering were observed for R282 and R283. On 5/17/21 at 10:19 AM, V10 (Registered Nurse) said that R282 and R283 are on isolation since they are new admits from the hospital. On 5/17/21 at 1:47 PM, V11 (Business Office Manager) stated when he is doing a 1:1 with an isolation resident he just has to make sure that they do not touch anything and if they do, he has to disinfect the item. V11 said that they could be out of their rooms but they should not be in close contact with another resident. V11 also said that other residents should not be going into isolation rooms. On 5/17/21 at 2:26 PM, V2 (Infection Control Registered Nurse) said that all new admissions are put on contact/droplet isolation for 14 days. Isolation residents should stay in their room. V2 said that gloves, gown, N95 mask and a face shield is the required PPE before entering an isolation room. V2 said that any staff member that is in contact with a contact/droplet isolation resident should be wearing PPE. V2 said she tries to schedule 1:1 supervision for R282 and R283 since they wander and are on isolation. V2 said that the staff member should watch to make sure that they do not come out of their room and if they do, they should immediately re-direct them back to their room. V2 said that the on the morning of 5/17/21, R282 and R283 did not have 1:1 supervision but the CNAs should be watching them and re-directing them back to their room if they exit the room. V2 said she did tell the dementia unit staff that they should be wearing N95s but not face shields. V2 said that CNAs should also be watching other residents to prevent them from going in an isolation room. On 5/18/21 at 8:54 AM, V7 (CNA) stated if a resident is on contact/droplet isolation, they should be isolated in their room. If a staff member sees them outside of the room, they should immediately redirect them back to their room. V7 stated they do not go in the dining room, they do activities and eat in their room. V7 said R282 and R283 are easy to re-direct and she has never had any issues with re-directing them besides them coming out again. The facility provided call log to the county health department from 5/17/21 documents, Memory Care Units are a hard area when it comes to isolation because of the unique needs of memory care residents She stated, to be safer and take extra precaution practice is for all staff to wear N95s and face shields in the unit, as other staff members might be in the position to redirect residents back into their isolation room until resident is out of their 14 day quarantine. The facility provided Immunization Report printed on 5/17/21 shows that R45, R64, R282 and R283 have not received the COVID-19 vaccine. The facility provided Residents COVID Positive Log 2020-2021 reviewed on 5/18/21 shows that R45, R64, R282, R283 all have not had COVID within the past 90 days. The facility's Admission/Readmission to Long Term Care Facilities Policy updated on 4/9/21 shows, The facility will follow the guidance and recommendations from the CDC (Center for Disease Control), state and federal health departments when admitting/readmitting patients .Unvaccinated, Partially Vaccinated or Unknown Vaccination Status Recommendations: New or returning residents who are not fully vaccinated, unvaccinated, partially vaccinated or whose vaccination status is unknown will be admitted to a single room within the designated facility transition area and will quarantine with transmission-based precautions for 14 days from the date of admission. Contact/droplet precautions can be discontinued, and the resident can be moved to a regular unit after 14 days The CDC guidance titled Preparing for COVID-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions updated 11/20/2020 shows, HCP (Healthcare personnel) should wear an N95 or higher-level respiratory, eye protection, gloves, and gown when caring for new admissions and readmissions. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. The CDC guidance titled Memory Care Units updated on 5/12/21 shows, Infection Prevention and Control (IPC) Guidance for Memory Care Units .Limit the number of residents or space residents at least 6 feet apart as much as feasible when in a common area, and gently re-direct residents who are ambulatory and are in close proximity to other residents or personnel .When residents on a memory care unit are suspected or confirmed to have COVID-19 As it may be challenging to restrict residents to their rooms, implement universal use of eye protection and N95 or other respirators (or facemask's for all personnel when on the unit to address potential for encountering a wandering resident who might have COVID-19. The Immediate Jeopardy that began on 5/17/21 was removed on 5/19/21 when the facility took the following actions to remove the immediacy: 1. Facility provided all staff on memory care unit with N95 and face shield. Completed 5/19/21. 2. Facility immediately ensured all residents are isolated who are on a 14-day quarantine. Facility provided 1:1 for residents who are non-compliant with quarantine. Completed 5/19/21. 3. Facility will provide 1:1 for all unvaccinated new admissions with a history of wandering. Completed 5/19/21. 4. Administrator/DON or designee in-serviced with post-test on when residents should be isolated for COVID-19 and transferred to the COVID unit. Implemented 5/19/21, staff will be required to complete before the start of their next shift. 5. Administrator/DON or designee in-serviced with post-test on proper PPE usage (in quarantine room, signage outside of quarantine rooms) including the need to wear N95 masks and face shields for new admissions who are on 14- day quarantine. Implemented 5/19/21, staff will be required to complete before the start of their next shift. 6. Administrator/DON or designee in-serviced with post-test on the need to wear N95 masks and face shields when entering memory care unit. Implemented 5/19/21, staff will be required to complete before the start of their next shift. 7. Administrator and DON reviewed IDPH and CDC guidance Considerations for Memory Care Units in Long-term Care Facilities with local health department to ensure COVID-19 regulations are incorporated in facility's policies and implemented. Completed 5/19/21. 8. Facility policy updated to address residents on a memory care unit that are suspected or confirmed to have COVID-19. Facility implemented universal use of eye protection and N95 for all personnel when on the unit. Completed 5/19/21. 9. The facility reviewed all residents on the memory care unit for signs or symptoms of COVID-19. No residents were identified as having signs or symptoms of COVID-19. Completed 5/19/21. 10. The facility PCR tested unvaccinated residents on the memory care unit, residents who were identified as wandering had negative results. Other results still pending. Completed 5/19/21. 10. QA audits on staff PPE use for isolated unvaccinated residents that are on 14-day quarantine. These will continue daily x one week and then weekly x 2 months. Implemented 5/19/21 and ongoing. 11. QA audits completed on isolation for unvaccinated residents that are in 14-day quarantine. These will continue daily x one week and then weekly x2 months. Implemented 5/19/21 and ongoing.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse for one of five residents (R1) reviewed for abuse in the sample of 5. This failure resulted in R1 being punched multiple times in the face, falling to the floor, and being dragged by his feet. Since the incident R1 has not been able to ambulate. The findings include: On (MONTH) 16, 2019 at 9:25 AM, R1 was in the secured memory care unit in the dining room. His head was resting on the table. V6 (Certified Nursing Assistant) asked R1 to wake up, R1 lifted his head then put it back down on the table. R1's left ear was dark purple, enlarged and swollen. A dark purple bruise was under his left eye, the left side of his neck was completely covered with a dark purple bruise, and he had multiple bruises throughout his arms and hands. At 9:35 AM, V14 (CNA) wheeled R1 to his room. R1 stated, I'm not feeling good. Dried blood splatter was on his shoes. V4 attempted to transfer R1 back to bed. R1 stood up several times then sat back in his wheelchair; he was unable to stand and transfer. V14 said R1 used to walk all the time, I'm not sure what happened. On (MONTH) 16, 2019 at 2:10 PM, V10 (Housekeeping) said on (MONTH) 5, 2019 she heard a scream and went to R2's room. She found R1 on the floor with R2 grabbing his heels. She said she told R2 to stop, but he did not listen. V10 said she then went to get help. On (MONTH) 17, 2019 at 8:45 AM, V15 (Activity Aide) said on (MONTH) 5, 2019 he was in the dining room when he heard V10 call out for help. When V15 entered R2's room R1 was on the floor bleeding from his ear. R2 was trying to drag R1 out of his room by his feet. V15 said R2 was very irritated he was screaming at R1. R2 said he hit R1 because he wouldn't leave his room. V15 said R1 is confused and wanders a lot into other resident's rooms, he needs to be re-directed. On (MONTH) 16, 2019 at 12:12 PM, V8 (CNA) said on (MONTH) 5, 2019 he heard V10 calling out for help. When I got to R2's room. R1 was on the floor. R2 was standing next to R1. R2 said he was upset R1 was in his room and R2 said he hit R1. V8 said R2 usually keeps his door shut, but I'm not sure what happened. V8 said R2 likes to be by himself, he has a private room because he did not get along with other residents. V8 said R1 would walk the halls independently and wander into other residents' rooms. On (MONTH) 16, 2019 at 12:57 PM, V4 (Licensed Practical Nurse) said she was R1's nurse on (MONTH) 5, 2019. V4 said she was on break and staff alerted her there was altercation between R1 and R2. V4 said when she entered the room, R1 was on the floor, and he was bleeding from his left ear, and had multiple skin abrasions, and redness to his neck. R2 said R1 went to into his room and threw soup on R2. R2 told V4 he hit R1 several times. V4 said R1 was sent out the local hospital and returned to the facility. He sustained a hematoma to his left ear and abrasions. V4 said R2 was sent out to the local behavioral health hospital for aggression and has not returned to the facility. V4 said R2 was very territorial and has a history of verbal aggression. On (MONTH) 16, 2019 at 9:19 AM, V6 (CNA) said R1 used to walk independently daily, since the incident he has not been able to walk. The Abuse Investigation Dated (MONTH) 5, 2019 documents R1 and R2 reside on a secured dementia unit. Staff observed R1 on the floor with R2 attempting to move R1 out of his room. Staff separated the residents and placed on one to one supervision. R2 said he hit R1 for not leaving his room. R1 sustained a laceration to his lower eye and open skin tear to his left ear. R1 was sent out to the hospital for evaluation. R2 was sent out to a behavioral health hospital. The physician and families were notified. The police interviewed both residents. R2's Interview statement dated (MONTH) 5, 2019 states, He was lying in bed, watching TV and R1 came into his room. R2 said he told R1 to get out of his room twice. R2 told R1 he better gets out or he would make him get out. R2 said R1 grabbed the soup and threw it him. R2 said he punched R1 a few times, I don't know how many. Then R2 dragged R1 out and the other guy came and broke it up. The hospital records dated (MONTH) 5, 2019 shows R1 sustained a hematoma to his left ear, and skin tears to his left hand and left cheek. R1's Physician order [REDACTED]. R1's Minimum Data Set assessment dated (MONTH) 17, 2019 shows his cognition is impaired and he requires supervision when he is walking and requires assistance with his activities of daily living. R2's Physician order [REDACTED]. R2's updated care plan shows he has anxiety with observed symptoms of agitation. R2 has had episodes of verbal aggression, and on (MONTH) (YEAR) he became agitated and reported homicidal ideation toward a family member. On (MONTH) 5, 2019 he became physically aggressive toward another resident. Interventions include to monitor the effectiveness of his medication treatments, avoid over and under stimulation, and encourage an exercise routine that expends energy. The P.O.S. shows orders for [MEDICATION NAME] (mood stabilizer) 250 mg twice a day. On (MONTH) 16, 2019 at 10:11 AM, V4 (LPN) said V16 (R2's POA) reported to me a few days before the incident he was concerned about increased aggressive behaviors in R2. On September19, 2019 at 9:30 AM, V16 (R2's POA) said his dad has a history of verbal aggression. V16 said he notified V4 (LPN) a few days before the altercation he noticed a behavior change in R2. I'm noticing something different. R2 was calling multiple family members more anxious and reported this to V4. V16 said V4 told him R2's mood stabilizer medication was decreased recently. V16 said this was distressing to me, V17 (Physician Assistant) did not notify me of this change. V16 said he called V17 and expressed his concern about decreasing R2's mood stabilizer medication. V16 said V17 told him she was not going to increase R2's mood stabilizer medication back to the original dose. Then a few days later I get call from the facility that my dad got into a fist fight. Since R2 has been hospitalized they increased his mood stabilizer medication to his regular dose and he's been fine. On (MONTH) 19, 2019 at 12:25 PM, V18 (Nurse Practitioner) said On (MONTH) 3, 2019, she was covering for V17 (Physician Assistant). V18 said it was reported to her R2's mood stabilizer was addressed by V17 about a week ago and family reported increased behaviors for R2. The Psychiatric Evaluation dated (MONTH) 3, 2019 by V18 (Nurse Practitioner) documents R2's chief complaint shows V16 (R2's POA) is requesting psych services. As per staff (R2's) been lethargic so his mood stabilizer was decreased he has been calling the family more, wanting to leave anxious (R2) has been refusing lab draws his mood stabilizer could not be determined. R2 has been more alert since his mood stabilizer has been decreased. R2 was observed restless and elevated today. The same reports show he was receiving [MEDICATION NAME] (mood stabilizer) 500 mg twice a day. The Involuntary Petition dated (MONTH) 5, 2019 documents R2 hit another resident (R1) in the face. (R1) did not have any behaviors towards R2. R2 has psych [DIAGNOSES REDACTED]. R2 gets verbally aggressive towards others. On (MONTH) 16, 2019 at 12:45 PM, V5 (Memory Care Director) said R2 was sent out to an inpatient psych hospital on (MONTH) 5, 2010 for aggression. R2 remains hospitalized and has not returned to the facility since the incident (11 days). V5 said R2 has a history of verbal aggression, R2 did not do well with having a roommate. He was moved to a single room as intervention for his verbal aggression. The facility's Abuse Policy dated (MONTH) 2019 states, The facility affirms the right of our residents to be from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion

Based on observation, interview, and record review the facility failed to ensure the door alarm was activated and failed to supervise a resident who was high risk for elopement. These failures resulted in R1 exiting the facility unknown to staff at 4:30 AM (MONTH) 7, 2019. R1's whereabouts were not known for an hour and ten minutes. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on (MONTH) 7, 2019 at 4:30 AM when R1 left the facility unknown to staff and was discovered walking 2 miles from the grounds near a busy intersection, and had fallen, and hit his head. V1 (Administrator) was notified of the Immediate Jeopardy on (MONTH) 14, 2019 at 10:15 AM and the Immediate Jeopardy template was given to V1 at that time. The Immediate Jeopardy was removed on (MONTH) 14, 2019. While the immediacy was removed the facility remains out of compliance at a severity level 2 as they are in the process of educating and re-educating staff regarding elopement precautions, monitoring residents on 15 minute checks, code green, elopement policy, not allowing residents to open the door, and alarming the door after someone enters (setting the alarm after letting someone in or out of the building). This applies to 1 of 4 residents (R1) reviewed for safety/supervision in the sample of 5. The findings include: R1's (MONTH) 2019 physician's orders [REDACTED]. R1's (MONTH) 2, 2019 Minimum Data Set (MDS) shows that R1 is cognitively impaired, requires assistance with mobility and is not steady with walking. R1's MDS also shows he requires assistance with activities of daily living (ADL's). R1's active care plan dated through (MONTH) 2, 2019 shows that he is high risk for falls, has deficits with ADL's, requires staff assistance when walking, and is high risk for elopement. Interventions show 1:1 immediately upon attempt, and every 15-minute checks following. The care plan goal indicated the resident will remain safely on the unit or under supervision. R1's (MONTH) 2, 2019 Elopement Risk Assessment shows that he is high risk for elopement. R1's (MONTH) 6, 2019 Elopement Risk Assessment completed at 11:00 AM shows that R1 was discontinued from 1:1 even though he had continued verbalizations as recently as 3/4/19 about wanting to leave the facility. R1's (MONTH) 28, 2019 nursing progress notes shows that R1 became upset and began yelling and demanding to go home with his family and pushed his mother out of the way to go through the front door. R1's (MONTH) 1, 2019 nursing progress note shows at 5:00 PM R1 was still verbalizing a desire to go home and walked through the front door of the facility. R1's (MONTH) 4, 2019 nursing progress note shows at 6:02 PM R1 was still verbalizing a desire to go home and R1 stated I want to go home and get out, I goanna walk. R1's (MONTH) 6, 2019 nursing progress note shows at 11:00 AM R1's 1:1 monitoring was discontinued, and he was started on 15-minute checks. R1's (MONTH) 7, 2019 nursing progress note shows at 4:40 AM another resident from the facility (R2), informed V6, Licensed Practical Nurse (LPN) that R1 had went outside. (R1) was unable to be located and the police were notified. The same note states the police found him and brought him back to facility. At 6:15 AM R1 was sent to a local community hospital for evaluation. A local police department report shows, On (MONTH) 7, 2019 at approximately 5:10 AM {5 deputies} were dispatched to {the facility} about a missing adult male. {dispatch} advised that facility staff reported a patient, (R1) had walked away from the facility at approximately 4:30 A.M. Staff advised that (R1) has [MEDICAL CONDITION]'s disease, and a [MEDICAL CONDITION] with hallucinations. (R1) was last seen wearing a black jacket, and blue jeans. Upon arriving, I spoke to the facility administrator (V1) via telephone. (V1) said she checked the surveillance cameras remotely but didn't have footage of (R1) leaving the facility. (V1) said her staff checked the interior of the facility but were unable to locate (R1). She said (V6) was caring for (R1) before he went missing. I then spoke to (V6). He said and not verbatim that he last saw (R1) in his room at 4:00 A.M. He said at approximately 4:30 A.M. another patient told him he saw (R1) leave the facility through the main doors. (V6) said normally the main doors are alarmed but someone must have deactivated the alarm because he did not hear the alarm go off. (V6) said once they determined (R1) was missing the facility began checking the interior, and exterior of the building. He said the staff were unable to locate (R1) so they called the police. While I was speaking to (V6) another staff member said someone called and reported a male walking north on {a busy street approximately 2 miles away}. I then requested one of the Deputies check this area. A short time later {the Deputy} said he located (R1) {walking on a busy intersection}. {The Deputy} brought (R1) back to the facility. Additional narrative states. On 03-08-19 {Sgt.} was reviewing reports and read {the deputies} report titled Missing Adult. In summary, (R1) . left the facility at about 4:30 AM and was located a few miles aware on {a busy street} at about 5:40 AM {an hour and ten minutes after exiting the facility}. Due to (R1) being exposed to the cold elements, (R1) was transported to the hospital. R1's (MONTH) 7, 2019 emergency room (E.R) records from a local community hospital show R1 arrived via ambulance at 6:28 AM. R1's 6:28 AM E.R. progress note states Patient reported he escaped from the facility at {4:30 AM} and was found wandering down the streets a few miles from the {facility}. Additional notes said that R1 reported he had fallen backwards and hit his head while he was out walking on the street attempting to walk home. On (MONTH) 8, 2019 at 4:45 PM, R2 said he was sitting in the front lobby overnight playing on his new phone the night of (MONTH) 7, (YEAR) into the morning hours. R2 said that at 12:30 AM he saw V5, Certified Nursing Assistant (CNA), open the main door to let another resident (R6) into the building, and shut off the door alarm without turning it back on. R2 said that at approximately 3:30 AM he himself let the laboratory girl into the building, he did not see staff present at that time and the alarm definitely did not sound because it was not on. R2 stated I saw another resident (R1) walk out the front door at 4:30 AM the alarm was not set, or it would have gone off. R2 said at 4:40 AM when he found the nurse (V6) he notified him that R1 had left out the front door. On (MONTH) 11, 2019 at 10:15 AM, R2 said that the door alarm was usually turned on and off by a keypad on the door and that the staff frequently turn the alarm off at night. R2 said that V1 (Administrator), V2 (Director of Nursing), and V3 (Assistant Director of Nursing) have all come to talk to him about witnessing R1 leaving the facility that morning. R2 said he told them all about witnessing V5 turn the alarm off at 12:30 AM. R2 said that when the day shift came in that morning the alarm was working. R2 said that V6 turned the alarm on when the police came to show them it was working. R2's (MONTH) 16, 2019 MDS shows that R2 has no cognitive impairments. On (MONTH) 8, 2019 V1 presented investigative interviews and documented that R2 said he didn't remember if anyone turned the alarm off, and that he did not see anyone turn the alarm off. Her statement continues to show that R2 told V6 that when R1 came into the lobby at around 4:30 AM R1 walked right out the door. On (MONTH) 8, 2019 at 5:50 PM, V6 said that the last time he saw (R1) that morning was around 4:30 AM (the police report indicated he told them 4:00 AM), V6 said he was notified by R2, that R1 had left the building and he went to search. V6 said he never heard the door alarm go off that morning. V6 additionally said that R1 had recently (earlier that day) had his 1:1 monitoring stopped and was started on 15-minute checks, but the staff is not always able to do them on time because they may be in with another resident. V6 stated he {R1} should have been on a 1:1. On (MONTH) 8, 2019 at 5:24 PM, V1 (Administrator) said that V2 called me around 5:00 AM and when I got to the building the police were looking for R1. V1 said I don't know how he would walk out of the front door. The alarm was never malfunctioning, and no one reported to me that it may have been turned off. I don't know if it was an alarm malfunction we got a new one. On (MONTH) 8, 2019 at 4:32 PM, V12 (Receptionist), said that she is the person who sets the door alarm every night at 8:00 PM when she leaves the facility. V12 said she turned the alarm on at 8:00 PM on (MONTH) 6, 2019 when she left the facility. The surveyor asked V12 what the reason would be the alarm did not sound. V12 stated the only way that could happen is someone had to turn off the alarm that is the only way it makes sense. The only time the alarm is turned off is during high traffic hours, shift changes, and it probably wasn't turned back on. On (MONTH) 8, 2019 at 3:50 PM, R1 said I broke out and went out the lobby door. The door was unlocked so I just opened it and no staff were watching me and the alarm did not go off. R1 said I walked a long way and it was cold outside. R1 said I have just been so tired lately I fell backwards and hit my head while I was walking. On (MONTH) 11, 2019 at 2:00 PM R1 was observed walking in his room and his gait was slow, and debilitating. R1 said that when he went the door he was heading home to Round Lake. According to MapQuest it is 17.2 miles to Round Lake. The path that R1 walked did include heavy traffic, uneven ground surfaces with ice, and road construction. On (MONTH) 11, 2019 at 10:46 AM, V13 (Memory Care Director) said if a resident is determined to be high risk they are monitored on a 1:1 for 72 hours. R1's progress notes show on (MONTH) 4, 2019 at 6:02 PM he was still verbalizing wanting to leave the facility and go home. R1's Elopement Risk assessment completed by V13 on (MONTH) 6, 2019 at 11:00 AM shows that R1's 1:1 monitoring was discontinued, and he was started on 15-minute checks. (41 hours after verbalizing statements to leave the facility). On (MONTH) 11, 2019 at 12:40 PM, V14 (Maintenance), stated he changed out the door alarm and installed a new one on (MONTH) 7, 2019. V14 said that there was nothing wrong with the old door alarm, he tested it daily and it was working fine on (MONTH) 6, 2019 and again on (MONTH) 7, 2019 at 10:00 AM when he checked it. V14 set off a door alarm that was identical to the one that was on the main door at the time R1 left the facility, the alarm was extremely loud and could be heard throughout the unit. On (MONTH) 8, 2019, interviews were conducted between 3:45PM and 4:17 PM. V7, V8 both Registered Nurses (RN's), and V9, V10 (CNA's) said that over the past couple weeks R1 had begun showing behaviors of wanting to leave the facility and had recently had 1:1 monitoring reduced to 15-minute checks. V7, V8, V9, V10 said that R1 has unsteady gait, and staff must walk with him to the dining room at the facility. V7, V8, V9, and V10 said that R1 would not be safe walking down the street alone at in night in the cold weather. V7 additionally said that on 2 prior occasions he had to stop R1 from attempting to leave the facility. V7 said that the alarm should have sounded the morning that R1 left the facility if it was turned on. Documentations on the 15-minute checks dated (MONTH) 7, 2019 shows V6 documented that he saw R1 in his room at 4:00AM, 4:15AM, and 4:30 AM. The Police report dated (MONTH) 7, 2019 page 2 paragraph 4, documents that V6 stated he last saw R1 in his room at 4:00 AM. The same document shows that V6 reported to police he was informed at 4:30 AM by R2 that R1 had left the facility. On (MONTH) 11, 2019 at 12:05 PM, V5 (CNA) said that she saw R2 open the door and let the laboratory staff in at about 3:30 AM. V5 said the alarm did not sound. When this surveyor asked V5 why the alarm didn't sound when R2 opened the door V5 stated, Sometimes the alarm is turned off. V5 said she also did not hear the alarm go off and is not sure if it did go off when R1 went out on the morning of (MONTH) 7, 2019 because she was in room providing care near the front exit door. On (MONTH) 11, 2019 at 1:30 PM, V3 (Assistant Director of Nursing) said the exit door alarm is very loud you can hear the alarm throughout the building. V3 said if you push open the door from the inside the alarm should sound and it should sound until the staff come and shut it off. V3 said that V6 did not hear any alarm he was told by R2 that R1 had left the building. V3 said R2 told her he could not find any staff to report R1's leaving the building. When V6 came to give R2 his medications he told him. V3 said I know the alarm works I tested it 2 weeks ago because we don't want smokers to go out in the cold weather. On (MONTH) 11, 2019 at 1:04 PM, R6 said that she had been out on a pass with her boyfriend and returned (MONTH) 7, 2019 at approximately 12:30 AM and V5 had let her back into the facility and turned off the alarm. On (MONTH) 11, 2019 at 2:19 PM, V2 (Director of Nursing) said that they have no formal policy on the door alarm, we just tell everyone. It is expected to be turned on at 8:00 PM every night and turned off at 8:00 AM the next morning when the receptionist comes in. V2 said if the door alarm is turned off a staff person must be sitting right there watching the door. The Accuweather data for (MONTH) 7, 2019 shows the minimum temperature was 15 degrees Fahrenheit and the high for the day was 25 degrees Fahrenheit and sunrise was at 6:17 AM. MapQuest shows it is approximately 17.2 miles from the facility to Round Lake. Through interview and record review on (MONTH) 14, 2019 the surveyors confirmed that the facility took the following steps to remove the immediacy. 1. The facility's Elopement policy and Elopement Assessment policy were reviewed on (MONTH) 7, 2019. After the review the facility Quality Assurance (QA) team consisting of the Medical Director, Administrator, Assistant Administrator, Social Services, and Director of Nursing recommended education with facility staff, and daily door alarm checks for all exit doors. The education and re-education with staff, on elopement precautions, monitoring residents on 15-minute checks, code green, elopement policy, and alarm protocol was initiated on (MONTH) 7, 2019 and completed on (MONTH) 9, 2019. 2. Audits of all residents' elopement risk were initiated on (MONTH) 7, 2019. All residents that are at risk for elopement are on 1:1 supervision or residing in the secured dementia unit. 3. The facility's QA team conducted a review of the elopement assessment policy on (MONTH) 14, 2019 and revised the policy to include when a resident is identified at low risk, the resident will be placed on 15-minute monitoring until resident is reassessed as no risk or unless resident already resides on a secure unit. 4. New facility protocol was initiated on (MONTH) 14, 2019 that includes nursing staff are to check all door alarms and exit alarms on each shift and a staff member will be present near the front door from 8:00 PM to 8:00 AM to monitor the door. Additional staff education on the revised protocol was initiated on (MONTH) 14, 2019 and will be completed by (MONTH) 15, 2019. All staff will be in-serviced on the following topics prior to the start of their shift: elopement precautions, monitoring residents on 15-minute checks, code green, elopement policy, and alarm protocol. Any staff that is ill, or out of the facility will be in-serviced over the phone. 5. A QA tool was revised on (MONTH) 14, 2019 to include additional checks throughout the day and from 8:00 PM to 8:00 AM to ensure that the door is alarmed and that when tested the alarm is audible when it has been activated. The QA audits will be conducted by the manager on duty, Administrator, Admission Director, Memory Care Director, Activity Director, Restorative Nurse or floor nurse. The QA will be completed daily and will be reviewed daily for 60 days, then 3 times a week for 30 days, then weekly for 30 days, and then monthly. 6. On (MONTH) 14, 2019 the administrator initiated a QA tool to review 15-minute checks for residents with known risk for elopement. The residents' elopement status will be reviewed daily at the morning meeting. Residents that are assessed at a low risk will be placed on 15-minute monitoring. The QA checks will assess that the 15-minute checks are being completed on time and will be conducted at random times throughout the day. The QA tool will be completed by the manager on duty (Assistant Administrator, Admissions Director, Memory Care Director, Activity Director, and Restorative Nurse). This QA tool will be completed daily and will be reviewed daily for 60 days, then 3 times a week for 30 days and then weekly for 30 days, then monthly. 7. All staff education and in-services were initiated on (MONTH) 14, 2019 to provide education on 15-minute checks for residents at risk for elopement, not allowing residents to open the door and alarming the door after someone enters. All staff training will be completed by (MONTH) 15, 2019. Any staff that is ill, or out of the facility will be in-serviced over the phone.

Based on observation, interview and record review the facility failed to ensure a resident was free from abuse. This resulting in R1 experiencing sexual abuse and having feelings of anger, humiliation, and sadness. This applies to 2 of 3 residents ( R1, R3) reviewed for abuse: The findings include: 1. The Physician order [REDACTED]. The Minimum Data Set assessment dated [DATE] shows R1's cognition is moderately impaired, has no behaviors of hallucinations and delusions, requires extensive assist with activities of daily living and is frequently incontinent of urine and stool. The Care Plan dated through January 2018 shows R1 is at risk for abuse related to a [DIAGNOSES REDACTED]. The facility's final abuse investigation report dated January 11, 2018, involving R1 and V7 (terminated Certified Nursing Assistant) shows on January 4, 2018 R1 expressed concerns that 3-4 weeks ago V7 was joking around during genital care. The facility's investigation showed there were no reports of abuse. The identified staff member (V7) was terminated for inappropriate behavior towards a resident and the facility reported the identified staff member to the nurse aide registry. R1's statement dated January 4, 2018 states, that 3 or 4 weeks ago V7 was changing her and he was inappropriate during genital care. R1 said V7 is usually great and he's always joking around but this time it felt inappropriate. R1 stated, he (V7) was changing me and I was laying down on the bed when he pulled open my right labia and said one door open, then pulled my left labia open and said two doors open, I could just go right in. R1 denied any penetration by V7. R1 stated, V7 was joking around and she did not like it. I told him, That's not right. R1 said she did not want to get V7 in trouble because he's usually very good but this time he took it too far. R1 said V7 has not taken care of her since the incident but has brought me my tray for breakfast a few times. R1 said nothing else has happened with V7 since the incident. R1 stated V7 has been very nice. R1 denied any other incidents of inappropriate behavior with any other staff. R1 stated It was just the one time that he took the joke too far. On January 4, 2018, during the interview, V10 (R1's partner) was in the room. V10 said she has known about the incident since it happened and has been trying to get R1 to tell someone, but R1 didn't want to tell anyone so she didn't push her to tell until now. V10 said V7 has delivered trays to R1 since the incident while V10 has been in the room with R1. V10 said what R1 told me happened is definitely not ok. V10 said she could not recall a specific date when R1 told her but said about 3 to 4 weeks ago. V10's statement dated January 8, 2018 stated One more thing, a few weeks ago after R1 told me what happened with V7, V10 went looking for him (V7) when he was working. V10 said she found V7 on a different hallway and grabbed him by the front of the shirt and pulled him in close to her. I told him that if he ever did that to R1 or anyone else ever again I'd knock him out. V10 was unable to recall an exact date of this incident. V10 stated, I don't remember exactly maybe around Christmas time because I remember the decorations being up, but I don't care if I have to go to jail for defending R1. I'll do it again if I have to. I'll get anyone I need to in order to make sure R1 stays safe. V7's (terminated staff member) statement dated January 4, 2018 was asked if he has ever given care to R1. V7 stated, not in the last 2 months I don't think, I don't remember the exact last time I was her assigned CNA. V7 was asked if he ever gave care alone to R1. V7 stated, not that I can remember, I usually ask for help from V11 and V12 (Both CNA's). V7 was asked if R1 has ever complained of improper or inappropriate care from any staff. V7 stated, No, R1 never complained about anyone to me. V7 was asked to describe his work ethic. V7 stated, I like to have fun and sometimes joke around but it's always appropriate and only if the residents joke around first. I'm never abusive or inappropriate with anyone ever. V7 was asked if he has ever joked around with R1. V7 stated, No, R1 doesn't like to joke around so I don't do that with her. V11's (CNA) statement dated January 4, 2018 said the last time she helped V7 care for R1 was a long time ago more then 4 or 5 months ago. V12's (CNA) statement dated January 4, 2018 said she has not assisted V7 provide care for R1. R1 needs one person for assistance. On January 29, 2018 at 11:00 AM, V11 said she works days shift on the North Wing. V11 said she helped V7 one time with cares but could not recall the timeframe. V11 said R1 needs one person assistance for incontinence cares. On January 29, 2018 at 9:00 AM, V12 said she works days shift on the North Wing. V7 normally works second shift. V12 said she did not assist V7 provide care to R1. V7's time sheet report from December 2018 shows he worked 29 out of 31 days. The Daily Nursing Schedule assignment sheet for December 2018 shows V7 was scheduled on the North Wing 24 out of 31 days were R1 resides in room [ROOM NUMBER]. On January 17, 2018 at 9:45 AM, R1 was observed in her room with the door closed and her untouched breakfast tray on her bedside table. R1 stated, V7 was changing her incontinent brief and took her vaginal lip opened it and said here's a door and did the same thing with her other vaginal lip here's a door and I come in. R1 said she was shocked and told V7 he was a very dirty man, V7 replied back to me Maybe you're dirty too. R1 said V7 did not penetrate me. R1 said she kept this to herself for a long time then she told V10 (R1's partner) because it was bothering her. I felt bad for myself and angry. R1 said she made a statement with the police and reliving the incident as she wrote what happened to her I was crying like a baby. I think back and have feelings of anger, I feel like grabbing his neck. R1 said she did not report this right away because she did not want any problems. Everyone liked V7. V7 had never joked like that before, It made me feel uncomfortable. After I told V10, she found V7 working one day and grabbed him by the shirt and told him if he'd ever do anything like that again he'd be in big trouble. R1 said I'm sure this is not the first time V7 has done something like this. Another female resident (whom R1 could not recall) told me V7 is no good. On January 18, 2018 at 9:00 AM, V10 (R1's partner) said R1 waited about 1 week to tell me what happened with V7. R1 told me V7 came in the room to change R1's incontinent brief. R1 told V10, V7 starred at R1, pulled each of her vaginal lips to the side and said that's the door and Then I go in. R1 said she was shocked, upset and humiliated. R1 told V10 that this has never happened before. V10 said when R1 told her what happened she found V7 working on a different hall and confronted him. V10 said she grabbed V7 by his shirt collar one day when he was working and told him If I hear anything else like this again you're in trouble. V10 said she has been together with R1 for over [AGE] years and R1 is suffering mentally and physically. R1 is not trusting of others, she cries easily, and has anger regarding what happened with V7. On January 17, 2018 at 2:00 PM, V2 (Assistant Administrator) said on January 4, 2017 V10 was visiting R1 in her room. V10 said to R1 why don't you tell (V2) what's wrong. R1 replied to V10 hush don't say anything. V2 said she prompted and R1 told her V7 was providing incontinence care to R1 opened each vaginal labia and said one door open and did the same to other vaginal labia and said 2nd door open and I can go right in. V2 said V7 was interviewed about the incident. V2 said she asked V7 when was the last time he cared for R1. V7 replied about two months ago. V2 said she did not go into detail with V7 about the alleged allegations. V2 told V7 an allegation of sexual abuse was made by R1. V7 denied any sexual abuse regarding R1. V7 said he usually changes R1 with another staff member present. On January 17, 2018 at 1:45 PM, V1 (Administrator) said R1 reported to V2 an allegation of sexual abuse regarding V7 on January 4, 2017. V1 said V7 denied the alleged allegations of sexual abuse, but because of another allegation made of inappropriate employee behavior about a week earlier by R3 they terminated V7 and reported him to the CNA agency. V1 said the allegation of sexual abuse was substantiated. On January 18, 2018 at 10:45 AM, V7 (terminated CNA) said V2 said there was an investigation on me making inappropriate comment about R1's breasts. V7 denied any sexual abuse regarding R1. V7 denied the incident regarding V10 (R1's partner) grabbing him by the shirt. V7 said he was terminated because of the alleged incident because they did not want any problems. V2 said V7 had been accused of inappropriate employee behavior by R3 about a week earlier and denied those accusations. On January 18, 2018 at 1:15 PM, V2 said she never stated to V7 the allegation was regarding inappropriate comments about R1's breasts. V2 said she told V7 there was an alleged allegation regarding sexual abuse but did not go into details. On January 18, 2017 at 1:45 PM, V2 said V7 should have been terminated on December 28, 2018 after he was accused of alleged inappropriate behavior by R3. The facility's Employee Separation Notice dated January 10, 2018 shows V7 was terminated for inappropriate behavior towards a resident. The Freedom Of Information Act Request Form was requested by the facility dated January 10, 2018. FOIA # for police report #18-134. The undated Lake County Freedom Of Information Act Denial of Request letter states we are denying your request based on the following exemption obstruction of ongoing investigation. This matter is still under investigation. On January 31, 2018 at 10:00 AM V21 (Detective) said V7 has a warrant for his arrest and will be charged with two felonies. V7 will be charged with abuse of an adult in a long term care facility, and aggravated battery. 2. The Physician order [REDACTED]. The Minimum Data Set assessment dated [DATE] shows R3's cognition is intact and has no behaviors of delusions or hallucinations. The Care Plan dated through January 2018 shows R3 is at risk for abuse. On January 17, 2018 at 11:05 AM, R3 was in her motorized wheelchair in her room. R3 said she has problems with V7. R3 said V7 had slapped her on her butt and showed her his butt several times. V7 would run his hands from the top of my head down my body. R3 said it was uncomfortable and she reported this to V2 at the end of December 2018. The facility's Final abuse allegation report dated December 29, 2018 involving R3 and V7. R3 expressed concerns regarding staff (V7) acted inappropriately. Facility interviewed residents within direct vicinity with no reports of abuse. Upon further investigation and during another interview with R3 stated, V7 isn't really inappropriate he is just sometimes obnoxious. The incident report did not specify what inappropriate behavior what V7 was accused. R3's statement dated December 28, 2017 shows R3 stated, V7 is acting inappropriate towards me. R3 stated that it started in the beginning but was unable to provide specific dates of events. R3 stated that V7 wiped his hands down my body. R3 stated V7 woke her up in bed a few times he cracked me on the butt. It was really hard the other day. It hurt. R3 reported V7 pulled down his pants in her room behind the curtain and bent over and showed me his butt. R3 stated this was approximately one week ago she asked V7 not to pull down his pants and he stopped. V7's statement dated December 28, 2018, was asked when the last time he worked with R3. V7 replied I worked with her 2 days ago, but I only took her breakfast tray to the room, I don't take care of her all the time because she is primarily independent. I'm not her assigned CNA but I help them pass breakfast trays in the morning. I try to avoid her because she (R3) always following me everywhere I go. R3 tries to be funny with me. Always trying to make jokes and her behavior is appropriate. R3 was asked if he ever joked with R3. V7 replied I've never joked with her, I've always been appropriate. V7 was asked if he reported R3's behavior to anyone. V7 replied, no he did not report this. On January 17, 2018 V2 (Assistant Administrator) said on December 28, 2018 R3 reported V7 was acting inappropriately. R3 said V7 would spank her on her bottom to wake her up and expose his bare bottom to her. V2 said this was inappropriate behavior. On January 18, 2018 at 2:00 PM, V2 said during the interview V7 asked V2 what were the allegations said by R3. V7 denied smacking R3 on her bottom and denied exposing himself to her. On January 18, 2018 at 10:15 AM, V7 said at the end of December there was an alleged abuse investigation involving him and R3. V7 said he was being investigated because R3 complained he touched her feet. V7 denied any inappropriate behaviors with R3. V7 said he does not know why R1 and R3 made allegations of abuse against him. On January 17, 2017 at 1:45 PM, V1 (Administrator) said R3 has made no complaints from other staff in the past. R3 is alert and oriented. Smacking a resident on the bottom or exposing himself is inappropriate behavior. The allegation was not substantiated. V7 was counseled on inappropriate behavior. About a week later another allegation was made of sexual abuse against V7. V1 said she should have terminated V7 on December 28, 2018 after the alleged allegation made by R3. The facility's Abuse Policy dated February 2017 states, The facility affirms the right of our residents to be free from abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Willful means the individual acted deliberately .Sexual abuse is non-consensual sexual conduct of any type with a resident. This includes, but is not limited to sexual harassment, sexual coercion or sexual assault

Based on interview and record review the facility failed to follow their policy and procedure to protect a resident from abuse. This resulted in R1 experiencing sexual abuse and having feelings of anger, humiliation, and sadness. This applies to 2 of 3 residents (R1, R3) reviewed for abuse. The findings include: On January 17, 2018 at 9:45 AM, R1 was observed in her room with the door closed and her untouched breakfast tray on her bedside table. R1 stated, V7 was changing her incontinent brief and took her vaginal lip opened it and said here's a door and did the same thing with her other vaginal lip here's a door and I come in. R1 said she was shocked and told V7 he was a very dirty man, V7 replied back to me Maybe your dirty too. R1 said V7 did not penetrate me. R1 said she kept this to herself for a long time then she told V10 because it was bothering her. I felt bad for myself and angry. R1 said she made a statement with the police, and reliving the incident as she wrote what happened to her I was crying like a baby. I think back and have feelings of anger, I feel like grabbing his neck. R1 said she did not report this right away because she did not want any problems. Everyone liked V7. V7 had never joked like that before, It made me feel uncomfortable. After I told V10 she found V7 working one day and grabbed him by the shirt and said if you ever do anything like that again you will be in big trouble. R1 said I'm sure this is not the first time V7 has done something like this. Another female resident who she could not recall told me V7 is no good. On January 17, 2018 at 11:05 AM, R3 was in her motorized wheelchair in her room. R3 said she has problems with V7. R3 said V7 had slapped her on her butt and showed me his butt several times. V7 would run his hands from the top from my head down my body. R3 said it was uncomfortable and she reported this to V2 at the end of December 2018. On January 17, 2018 V1 (Administrator) said the facility should protect residents from abuse. V7 should have been terminated after the alleged allegation on December 28, 2018 made by R3. On January 31, 2018 at 10:00 AM V21 (Detective) said V7 has a warrant for his arrest and will be charged with two felonies. V7 will be charged with abuse of an adult in a long term care facility and aggravated battery. The facility's final abuse investigation report dated January 11, 2018, involving R1 and V7 (terminated Certified Nursing Assistant) shows on January 4, 2018 R1 expressed concerns that 3-4 weeks ago V7 was joking around during genital care. The facility interviewed residents within direct vinicity with no reports of abuse. R1 stated, V7 said jokes around a lot. I think V7 took the joke too far that one day. R1 also stated she did not feel this was sexual abuse since he did not seem to mean it as anything other than a joke. R1 stated she feels safe in the facility and feels she can report abuse or inappropriate behavior to staff without retaliation. Facility interviewed identified staff member who stated there were no concerns voiced to him during care and care was provided appropriately at all times. Although there were no reports of abuse through further investigation, the identified staff member was terminated for inappropriate behavior toward resident and facility reported identified staff member to nurse aide registry. The facility's Abuse Policy dated February 2017 states, The facility affirms the right of our residents to be free from abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Willful means the individual acted deliberately .Sexual abuse is non-consensual sexual conduct of any type with a resident. This includes, but is not limited to sexual harassment, sexual coercion or sexual assault

Based on observation, interview, and record review the facility failed to ensure a resident was free from sexual abuse. This failure resulted in R1 experiencing anxiety about her care and emotional distress. This applies to 1 of 35 residemts (R1) reviewed for abuse in a sample of 35. This applies to 1 of 35 residents (R1) reviewed for abuse in a sample of 35. The findings include: R1's Facesheet shows R1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. R1's Minimum Data Sheet dated June 14, 2017 shows a Basic Interview for Mental Status score of 15, Cognitively Intact. R1's Minimum Data Sheet dated June 14, 2017, shows R1 needs extensive assistance from staff for transfers, mobility, hygiene, dressing, and grooming. On June 20, 2017 at 8:30 AM, R1 was sitting up in bed. R1 had an electric wheel chair with formed padding, pressure relieving air mattress, indwelling urinary catheter, and pillows for assistance with leg positioning. R1's hands were contracted and a specialized easy touch call light was next to her. R1 stated:That night (March 8, 2016) E3, Certified Nursing Assistant (CNA) got me ready for bed. About 30 minutes later I needed to be repositioned so I used my call light. E3 came in and repositioned me to a more comfortable position. After that, we talked for a little while. The conversation started to revolve around sex. E3 closed the door to my room, and came to my bed side. It was dark in my room. He asked 'do you know what this is?' Then E3 placed my hand on his penis. I pulled my hand away. After that he put his penis back in his pants. He talked for a few more moments then left the room. R1 said she was surprised and a little shocked at what happened between her and E3. While describing the incident R1 would break eye contact, was fidgeting with her napkin on her food tray, and became teary-eyed. R1 stated she was worried if she told anyone she would not receive the same care she was receiving. On June 20, 2017 at 3:45 PM, Z2 (R1's daughter) stated: R1 had called me in the morning of March 9, 2016. When R1 called her voice sounded off while she told me what had happened. Z2 stated she asked R1 if she told anyone about what happened and R1 said no. Z2 stated R1 did not want her to tell anyone about it. Z2 stated This is not something you don't say anything about. Z2 stated after getting off the phone with R1 she immediatly contacted the facility to report the incident. On June 21, 2017 at 8:45 AM, E3 stated I put R1 to bed, and we started talking. I got close, pulled down my zipper, and took out my penis. I said look what I got, and moved her hand to my penis. R1 pulled her hand away. I asked if she knew what that was? She said, of course. I put my penis away and left. On June 19, 2017 at 4:40 PM, Z1 (Police officer) stated I interviewed E3 on June 16, 2017. E3 described the incident between R1 and himself with close details which match the details in R1's initial police report dated March 10, 2016. On June 21, 2017 at 1:35 PM, E2 ,Director of Nursing stated it is not appropriate for a staff member to make sexual advances toward a resident. On June 21, 2017 at 2:45 PM, E1, Administrator stated it is not appropriate for staff to make any sexual advances toward a resident. The Police Report dated March 10, 2016 shows E3 asked her to grab something which was near her face. R1 said it was very dark. She reached out and secured what she learned to be two of his fingers. E3 then asked her to let go and grab something else in front of her .She reached out and grabbed it, she learned it was his penis. The facility's Abuse Prevention Policy dated February 2017, shows The facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff .

Based on interview and record review the facility failed to transfer a resident according to facility's policy and failed to follow plan of care. This applies to 1 of 3 residents (R2) reviewed for accidents in the sample of 3. R2 was sent to the hospital with admitting [DIAGNOSES REDACTED]. The findings include: R2 has [DIAGNOSES REDACTED]. Nurse ' s notes dated June 8, 2015 showed that R2 is alert and oriented with confusion and needed a two person assist. Nursing post occurrence documentation dated June 16, 2015 showed E7 CNA ( Certified Nursing Assistant ) notified E6 RN ( Registered Nurse) after lunch on June 14,2015 that R2 had left upper arm lump noted, swelling with mild tender, no redness or bruise noted with touch feel like water crackles. R2 did not verbalize pain. E6 called Z1 ( Nurse Practitioner) on June 14, 2015 and ordered venous Doppler on left arm. Venous Doppler result came with normal result but R2's symptoms was getting worst when RN saw R2 on June 16, 2015. R2 had swelling on all left arm, with bruise present. R2 complained of pain with movement on left arm. R2 had good flexion and extension on elbow. R2 had limited abduction and adduction on left arm. R2 was seen by Z1 on 06/16/15 with order of STAT x-ray on left shoulder and arm. X-ray was done and result came with fracture of mid humerus. Z1 saw the result and ordered to send R2 to the hospital for further treatment. Nurses notes dated June 14, 2015 at 10:27 PM showed that R2 was alert and oriented x1 with confusion. R2 had a care taker from 8 AM to 7 PM. R2 was noted with large lump on left upper arm, lump with minimal tenderness when touch and feel like water crackles. R2 complain of mild pain with touch, no redness noted. Z1 ( nurse practitioner) was called and order Venous Doppler on left upper arm. Nurses notes dated June 16, 2015 showed R2 alert x1 with confusion. R2 received from night shift with getting worst symptoms on left upper arm. R2 has swelling and mild tenderness, large lump with no redness, no bruise on June 14, 2015. Today ( June 16, 2015 ) R2 had swelling on left arm, with bruise present on left upper arm. R2 complained of pain on left arm, left arm elevated by pillow and applied ace wrap to immobilize left arm. R2 has good flexion and extension on elbow, limited adduction and abduction. R2 took PRN pain medication Tylenol with good effect. R2 was seen by NP today in the morning and she ordered STAT x-ray on left shoulder and left arm. R2's x-ray result received with fracture of mid humerus. NP saw the result and order to send R2 to hospital for further evaluation. R2 left around 7:30 PM from unit. On July 1, 2015 at 11:10 AM, E6 stated that she went to checked R2 after CNA reported to her that she heard crackling sound on the left arm. E6 assessed R2 and noted left upper arm swelling with tenderness to touch, on the side felt like water crackles. R2 denies pain and no moaning. E6 called Z1 and notified her of R2's condition as swollen, tenderness and touch like water crackles on left upper arm. NP ordered venous Doppler. E6 said that she endorsed to 7 PM -7 AM E8 (nurse) that a CNA notified her that R2 had a crackling sound on left upper arm. E6 further stated that she told E8 that she informed Z1 and ordered venous Doppler and will be done the following day and to continue to monitor R2. E6 said that she was off Monday June 15, 2015 and came back to work on Tuesday June 16, 2015 and saw R2 in the morning with more swelling and bruises on left arm and more in the upper arm. Z1 was called and Z1 saw R2 in that morning and ordered STAT X-ray of the left upper arm and whole arm. X-ray was done in the afternoon and result was received at around 5:30 PM with left arm humeral fracture. Z1 was informed of the X-ray result and ordered to send R2 to the hospital. R2 left the facility around 7:30 PM. E6 was asked if she did pain assessment on R2 on June 14, 2015. E6 said No, but it was done on June 15, 2015. There was no documentation of R2's left arm being monitored by the nursing staff between 7PM June 14 to 7AM June 16, 2016. On July 1, 2015 at 1:30 PM, E7 stated that she worked 7 AM - 7 PM that Sunday (June 14, 2015) when Z3 (caregiver of R2) asked her to get the resident up from bed to the wheelchair. E7 stated that they lowered the bed and sat R2 up. E7 said that R2 said ouch which he normally does. E7 then checked R2 ' s clothing, body for bruises but found nothing. E7 described R2's need for transfer as 2 assist. E7 stated that Z3 was on R2's left side and she was on the right side. E7 said that they pulled his head up and supported the back to help R2 sit up. E7 stated Z3 and E7 attempted to get the wheelchair next to the bed .E7 stated R2 kept resisting, not wanting to go to the wheelchair. E7 went to R2's backside to help R2 sit back up. Once the wheelchair was near the bed, E7 stated the plan was to transfer him to the wheelchair. E7 described R2's right arm as on his side during transfer and was aware that R2 was more on total assist, able to stand but unable to pivot the hip. E7 stated that she held R2's elastic jogging pant on the back part and lifting it up. E7 stated that during transferring, she was in the front and the care giver was at the back of R2. E7 stated that she was more on the upper torso so R2 would not fall over. E7 stated that she was not using a gait belt during transfer. E7 stated that they were supposed to use gait belt to transfer R2. E7 further stated that they checked him (R2) over after putting him in wheelchair. E7 said that Z3 called her after one hour and told her that R2's left arm did not look good. E7 then called E6 (nurse) and E6 came back with her. E7 described R2's left arm as very swollen below shoulder. On July 1, 2015 at 2:15 PM Z3 ( Care giver ) stated that she's been taking care of R2 for a couple of week and when R2 was in previous facility. Z3 said that on Sunday June 14, 2015, she sat up R2 in bed for breakfast. During lunch time R2 needed to get up but R2 was dead weight. Z3 said that she called E7 CNA (Certified Nursing Assistant) for assistance in transfer. Z3 said she put R2's head of the bed up and E7 was behind helping R2 to sit up. Z3 said that she was on R2's left side; put her arm under R2's left shoulder around R2's waist. Z3 stated E7 went around to R2's right side and transferred R2 to the wheel chair. Z3 said that R2 helped very little and they (E7 and Z3) held onto the back part of R2's sweat pants and transferred him this way without a gait belt. Z3 said a half hour later she noticed a bump on R2's left upper arm. Z3 said she told E7 and E7 told the nurse. Z3 was asked if they use a gait belt when they transfer R2. Z3 said I cannot remember, I didn't have my gait belt at that time. I was just there to assist with bath and care. On June 16, 2015 Z1 documented left upper arm swelling, pain and bruises, pain with abduction of left upper arm, positive crepitus, and decreased range of motion. Z1 ordered a stat X-ray. The X-ray showed Acute overlapping comminuted fracture of mid humerus. Review of current care plan (date initiated June 9, 2015) showed that R2 requires the use of a mechanical lift for transfer related to muscle weakness and Parkinsons. This was not followed when R2 was transferred from bed to wheel chair on June 14, 2015. Facility's policy and procedure dated 05/10 on transfer technique showed - to place gait belt around resident's waist unless contraindicated. - Note: Depending upon the amount of assistance required, the nurse may either support the resident on his/her affected side of stand in front of the resident. Support may be provided by use of a waist belt. Do not support the resident under the arms as this prevents the resident from using his/her unaffected extremity. Do not allow resident to put arms around your neck. The facility does not have a policy on how care givers assist in transferring. Z3 and E7 were not using gait belt, assisting in the transfer but not following facility's resident transfer policy.

Based on observations, interviews, and record reviews the facility failed to supervise and monitor resident smoking, failed to accurately assess resident smoking risks and failed to develop a care plan with safe smoking interventions. This failure resulted in R4 sustaining facial burns from smoking unsupervised with Oxygen in use. This applies to one resident (R4) from a sample of ten reviewed for smoking (R5, R6, R7, R9, R10, R11, R12, R13 and R14) from a total sample of 15. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begun on 11-30-14 when R4 sustained facial burns from smoking. E1 (Administrator) and E3 (Director of Nursing) were notified of the Immediate Jeopardy on 12-8-14 at 2:47pm. While the Immediate Jeopardy was removed on 12-9-14 at 11:20am, the facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of corrective measures put in place, the need to complete the in-servicing plan, and to monitor and evaluate the effectiveness of the smoking program. The findings include: R4 is a [AGE] year old male resident with impaired right sided movement who is coded a 3/2 (extensive one person assistance) for dressing and transfer per the MDS (Minimum Data Set) assessment dated [DATE]. R4 is unable to move the right side of his body. R4 uses 02 (Oxygen) at 2-3 liters per portable tank. R4 is also coded as having a 7 score for his BIMS (Brief Interview for Mental Status) indicating that R4 is cognitively impaired. R4 also needs extensive assistance to move in and out of the wheel chair. The facility's incident report dated 11/30/2014 showed R4 went to one of the facility's patios and started smoking around 11:30 a.m., but did not remove the nasal cannula with oxygen as he usually does. There was a short burst of flames around his nose. R4 received burns to his face. The physician was contacted and R4 was transported to the hospital at 11:55 a.m. On 11-30-14 about 11:30am, R4 was smoking in the outdoor patio with his 02 running. According to another resident present (R6) there was a pop and a spark and R4 ' s face and beard was on fire. R6 attempted to put the fire out with his bare hands and then R6 ran to get staff inside the building. R6 then saw E7 (Nurse Aid) in the hall way and was able to bring E7 to the outdoor patio to R4. E7 then ran to get help and E5 (Registered Nurse) responded and provided basic first aid and the physician was called and R4 was sent to the local hospital emergency room . Hospital records dated 11/30/2014 showed R4 sustained burns to a 2 centimeter (cm.) area next to his right nare. The burn extended across R4's nose and to a small, 1 cm. area in diameter above the left lip. There was scorching to both nares (nostrils) with soot at bilateral nares openings. R4 was discharged back to the facility with orders to treat the burned areas with Silvadene ointment twice a day and pain medication every 4 hours as needed. A follow up appointment was also to be scheduled within 3 to 5 days at a burn clinic. E7 (Nurse Aid) stated during interview on 12-4-14 at 10:25am, that she responded to R4 from inside the building. She was on break and saw that R4 was burnt with black soot on his face. The 02 tubing was separated into two pieces. E5 (Registered Nurse) also responded and noted the burns. The physician was called and the resident was sent for treatment to the local ER. The resident has since received additional treatment at the burn center at Loyola Hospital. R6 was interviewed on 12-4-14 about R4 ' s incident. R6 said that he was with R4 and other residents smoking then R6 heard a pop like a plane. R6 said R4's face was on fire. R6 tried to smother the flame on R4's face using his hands. R6 added it was like a flash. R6 left the patio and ran for help inside the facility. "I saw E7 CNA (Certified Nursing Assistant) in the hallway." R6 was able to bring E7 to the patio to care for R4. R6 was also asked about the facility's smoking schedule. R6 said that he does not pay attention to the schedule. R6 stated the residents smoke whenever they want. R6 said he keeps his own cigarettes and the lighter in his room. On 12/04/2014 at 9:35 a.m., E5 (RN - Registered Nurse) said R4 had cigarettes in his room the day of the incident, and that perhaps they were brought to him by a family member. In a separate interview on the same day at 4:02 p.m., E5 said R4 did not come to him to request his oxygen tank be turned to off before he visited the smoking area, as he had done in the past. E5 said R4 typically asked a nurse to turn his oxygen tank to off, and then the nurse would remove his nasal cannula, drape it over the wheelchair handle, and R4 would proceed out to the smoking patio with the oxygen tank and tubing attached to his wheelchair. On 12/04/2014 at 2:50 p.m., E1 (Administrator) stated that residents who smoke can smoke whenever they want. E1 said that there were set smoking times when the atrium patio was used as the smoking area, but that was to ensure that the doors were not opened during meal times, as the atrium patio was adjacent to the dining room. Since the smoking area was moved to the patio off of the hallway where the incident occured, set smoking times and supervision stopped. E1 stated that smoking assessments are done for all residents who smoke. A review of the facility ' s smoking assessment indicates that resident physical mobility issues and other physical impairments are not included in the assessments. R4 was assessed to be a " safe " smoker on the assessment completed 7-18-14; however, R4 has severe mobility issues as well as cognitive issues. The use of Oxygen was not addressed as a risk factor. R4 ' s care plan dated 10-26-11 indicates that R4 is a " safe smoker " and is allowed his own cigarettes and no restrictions regarding smoking. The care plan did not address R4 ' s BIMS score, mobility issues, and use of Oxygen. A review of the facility ' s policy entitled, " Smoking Assessment and Safety Protocol " revised May of 2014 shows, " Oxygen use is prohibited in smoking areas for the safety of all parties. " On 12/04/2014 at 2:30 p.m., E3 (Director of Nursing) stated that when R4 wanted to go to the patio to smoke, he would obtain his cigarettes from the nurse. E3 said that R4 would remove his nasal cannula from his face and loop the tubing over the back of his wheelchair. The nurse would then turn off the oxygen tank, but would leave the tank attached to the back of R4's wheelchair while he went out to the patio to smoke. E3 stated that staff members do not monitor the smoking patio. E3 stated that R4 did have his oxygen on when he went to smoke on 11/30/2014. She said that she was unaware if there were any other times that R4 would go to the patio to smoke while his oxygen was in use and the oxygen tank was in the on position. E3 also said that she was unsure how often R4 would go out to smoke each day but thought that it might be three times a day. E3 stated that she did not witness the burn to R4's face because she was not present at the time. E3 said that based on the report from the nurse who was present, R4 had peeling skin immediately after the incident, and she would think that the burns were second degree burns. Z2 (Owner of Oxygen Supply Company) was interviewed on 12-4-14 at 3:30pm and stated that no flames or smoking should be in the same area as Oxygen, even if the tank is outdoors. R4 followed up at the burn clinic on 12/4/2014. The burn clinic progress note dated 12/4/2014 showed both nares were "raw with debris occluding the opening, partial thickness burn to nose; upper lip pink with open, crusted area." In both hospital records it is noted that R4 was smoking with 02 running. During a telephone interview on 12/4/2014 at 4:00 p.m., Z3 (Advanced Practice Nurse - burn clinic) said all of R4's facial burns were 2nd degree burns, all of the nasal mucosa hair is gone, and the "nares look pretty bad." Z3 said it was too early to say if R4 will have permanent scarring from the burns. On 12/04/14 at 9:30 a.m., R6, R9, and R10 were observed on the patio smoking. There was no staff supervision of the residents while they were smoking. At 9:45 a.m., R6 was again observed on the patio, smoking by himself. There was no staff supervising the smoking area. On 12/04/2014 at 9:15 a.m. R5 stated that he is a smoker and that he is allowed to keep his own cigarettes in his room. R5 said that prior to this week he had seen R4 out on the smoking patio with oxygen tubing on his nares. He stated that he was not on the patio at the time of the incident. R5 also said that he had not seen any staff members on the patio unless they were out there to smoke themselves. R5 is cognitively intact per his BIMS dated 9-25-14. According to the BIMS assessment dated [DATE], R7 was cognitively intact. On 12/04/2014 at 9:55 a.m. R7 stated that she is a smoker and uses the patio for smoking. R7 stated that there were never any staff members out on the patio while she was out there. R7 stated that prior to this week she has seen R4 out on the patio smoking while he had the oxygen nasal cannula in place on his face. R7 said that she was unaware if the oxygen was turned on during that time but said the tubing was definitely on his face. She stated that she would have said something if she would have known the oxygen was on. R7 denied that she was on the patio during the incident with R4. On 12/04/2014 at 11:00 a.m. R7 stated that there is no schedule for smoking that she is aware of. She said that the facility was relaxed about that and residents can go out to the patio to smoke anytime they want. On 12/04/2014 at 10:25 a.m. R8 stated that she was not a smoker but was aware that the residents that smoke will go in and out of the patio whenever they want and that staff members are not present on the patio. According to the BIMS assessment dated [DATE], R8 was cognitively intact. On 12/04/2014 a sign was posted on R4 ' s closet door indicating 5 different smoking times between the hours of 8:30 a.m. and 7:15 p.m. The various times also indicated which staff would be supervising the smoking area. This schedule was dated 10/22/2013. On 12/04/2014 at 11:18 a.m., E11 (Activity Director) said the schedule posted in R4 ' s room was an old schedule that was not in use anymore. E11 said the old schedule was used when residents smoked in the atrium patio adjacent to the dining room. E11 said the schedule was used to guarantee smoking did not interfere with meal times, as residents frequently complained about the smoke and outside air coming into the dining room during mealtimes. E11 said since the smoking area was moved to a different patio, the schedule and supervision stopped, and she believed this happened several months ago. E11 also stated she is aware that residents share cigarettes with each other. On 12/4/2014 at 11:10 a.m., E9 and E10 (Activity Assistants) said " We stopped watching the residents smoke when they moved the smoking area. Someone from administration said we don ' t have to follow the schedule anymore. " The facility submitted the following action plan to remove the immediacy and this plan was verified by observation, record review and interview December 8 and 9, 2014. 1. Complete smoking assessments were completed on all residents that smoke and care plans were updated by the NHA/designees. 12-4-14 completed 2. NHA or designee identifies all smokers in the building by interviewing residents, staff and families. 12-4-14 completed. 3. If additional residents are identified as smokers the following will be completed by the NHA and or designee: a. smoking assessment, b. smoking agreement and c. care plan implemented or revised based on risk assessment. 4. In-service for all staff regarding smoking policy, residents at risk, holding of smoking materials and prohibiting oxygen use while resident is smoking by the Assistant NHA or designees. This was implemented on 12-7 and staff will be trained until all staff in serviced. 12-7-14 and ongoing. 5. All residents that smoke will be educated on the smoking policy and sign another smoking agreement by the NHA. 6. Smoking will be monitored during designated smoking times. Completed 12-8-14 7. Educate all the staff and educate resident ' s that smoke regarding the designated smoking times by Assistant NHA or designee. Completed 12-8-14 8. All residents that have mobility limitations such as paralysis or Parkinson ' s will be provided a smoking apron and the smoking supervisor will remain in close proximity. Completed 12-8-14 9. All residents that smoke and use 02 will have 02 and 02 tanks removed during smoking. Completed 12-8-14 10. The facility smoking policy was revised to include monitoring during smoking times by the NHA, completed by 12-8-14. 11. Family and friends will be educated on the smoking policy via posting in the front of the building. Ongoing education will be provided on admission, quarterly care conferences and during visits. This will be reinforced during the care conferences. Completed 12-8-14. 12. Compliance with supervised smoking will be monitored by the NHA or designee on a daily basis for a week, if compliance is maintained monitoring/audit will continue on a weekly basis. Results will be presented to the QA committee at the next meeting. Continued monitoring or auditing will be determined by the QA committee. 12-9-14 and ongoing. 13. Smokers that are new admissions will be identified. This will be monitored by the NHA or designee on a daily basis for a week, if compliance is maintained monitoring/audits will continue on a weekly basis. Results will be presented to the QA committee at the next meeting . Continued monitoring or auditing will be determined by the QA committee. 12-9-14 and ongoing.

Based on interview and record review, the facility failed to revise a plan of care after a fall to prevent additional falls and conduct a post fall assessment to rule out a head and neck injury prior to rolling and moving a resident after a suspected head injury. This failure resulted in direct care staff moving and rolling R1 after a head injury and R1 sustaining an acute cervical fracture after a fall incident on 11-12-14. This applies to one resident out of three (R1) reviewed for falls. The findings include: The facility's incident report dated 11/12/2014 showed R1 is an [AGE] year old with multiple [DIAGNOSES REDACTED]. R1 was originally admitted to the facility on [DATE]. The facility's incident report showed R1 had three falls for period of 10 months. The incident report showed the details of the fall incidents: 1) On 9/8/2014 at 1:00 P.M., (R1) observed lying on the floor on his back. Per kitchen staff member, "(R1) was walking in the hallway close to his room and fell on the floor." R1 was sent to the hospital due to the fall. R1 sustained a subarachnoid hemorrhage precipitated by the fall incident. 2) On 9/26/2014 at 7:35 A.M.; R1 was found lying on the floor. R1 was sent to the hospital precipitated by this fall. 3) On 11/12/2014 at 10:35 A.M.; R1 was found lying on the floor in an empty resident room. R1 was found lying with his face down. R1 was found by Z1 (R1's family member), E4 (CNA-Certified Nurse Aide) and E10 (Activity Aide). R1 was sent to the emergency room via 911. The hospital CT (Computerized Tomography) of the cervical spine result dated 11/12/2014 at 11: 58 A.M. reflects the following document: " (R1) admitting Diagnoses: [REDACTED]. The findings: Bilateral C2 acute laminar fracture. There is resultant severe anterior subluxation of C2 and C3 by almost 1.5 cm. The Impression: Severe bilateral C2 fracture with anterior C2-C3 subluxation." On 11/17/2014 at 10:00 A.M., E2 (Director of Nursing) and E14 (Nurse Consultant) provided all existing which included resolved and current care plan of R1. The care plan provided was reviewed together with E2. There was no revision of care plan to prevent further fall when R1 had a fall incident on 9/26/2014. Furthermore, there were no specific revised fall interventions when R1 was readmitted back to facility on 11/7/2014. E2 stated she had made an interim care plan dated 11/7/2014. The interim care plan interventions were nonspecific and lacked analysis if the fall interventions prior to R1 being sent to hospital on [DATE] hospital were still applicable. The current care plan dated 9/14/2014 with target goal date of 01/01/2015 showed that R1 was at high risk for fall and one intervention to prevent fall was for R1 to have a sensor monitoring alarm while in bed. During the investigation, the sensor monitoring alarm was not implemented when R1 had a fall on 11/12/2014 according to interviews held with E3 (LPN), E4 (CNA), E7 (CNA), E6 (CNA) and E8 (CNA). On 11/17/2014 at 3:00 P.M., E1(Administrator) and E2(Director of Nursing ) stated that there was no specific fall care plan since R1 was only readmitted on [DATE] and the care plan was not due yet. The facility policy for "Fall Risk Assessment Policy" dated 3/2012 showed that: "...a resident who scores 12 or greater will have individualized High Risk interventions implemented" "...With fall, the care plan interventions will be reviewed for effectiveness and modified as appropriate to reduce hazards and risk to the residents." The fall assessment dated [DATE] showed R1 scored 21; on 10/1/2014, scored 22 and 11/7/2014, scored 22. These results were all indicative of high risk for falls. The fall assessment policy was not followed when R1 had a score of 22 on 11/7/2014 and the plan of care showed no specific high risk fall interventions. The policy was also not followed when R1 had a fall on 9/26/2014 and there was no revision of the care plan. On 11/7/2014 at 12:03 P.M., E4 (CNA) stated that together with E10 (CNA) and Z1 (R1's family member), on 11/12/2014 at around 10:35 A.M., R1 was found lying on the floor in patient room (former R1's room). The room was closed when R1 was found on the floor, E4 added. E4 also stated that they searched 2 other patient rooms before finally finding R1. E4 also added that R1 was lying on the floor next to bed and that there was no sensor monitoring alarm attached to the bed in room the patient was found. On 11/17/2014 at 2:10 P.M., E8 (CNA) stated that R1 did not have a sensor monitoring alarm in place when R1 was in bed in room the night before the fall incident of 11/12/2014. E8 also stated that R1 had a sensor alarm in room patient's present room, but not in room where patient was located on 11/12/14. On 11/17/2014 at 11:20 A.M., E7 (CNA) stated that R1 had no sensor monitoring alarm when in bed in the morning of the fall incident on 11/12/2014. E7 also stated that she saw R1 on 11/12/2014 around 8:20 A.M. to 8:30 A.M. E7 further stated that R1 was agitated and was in an angry tone of voice when he told E7 "Get out of here, leave me alone." E7 further stated that she left R1 alone in room (The patient's former room) and did not return to check R1. E7 also stated that she did not inform E3 (Licensed Practical Nurse- assigned to R1) regarding R1's agitation. On 11/17/2014 at 11:35 A.M., E3 stated that she saw R1 at around 8:15 A.M. to 8:30 A.M. on 11/12/2014. E3 stated that R1 refused his medications and was resistive to care. E3 further added that R1 told her to "Get out of here; I don't need it (medications)". E3 stated that R1 had no sensor monitoring alarm when found in bed in room (Not the patient's assigned room). E3 also stated that R1 had a sensor monitoring alarm in room (R1's room) and used to have 1:1 supervision before R1 was sent out to the hospital on [DATE]. As E3 further stated, R1 was sent out to a mental/behavioral hospital due to aggressive behavior and R1 was returned to the facility on [DATE]. E3 also added that she did not check R1 again until the fall incident at 10:35 A.M. E3 also added that E7 did not inform her that R1 was agitated. E3 further stated that increase and close supervision could have been provided to R1 if she would have known about R1's agitation. E3 had added that she saw R1 lying on the floor on a supine position perpendicular to bed and window. E3 assessed R1 by checking blood pressure, pulse and temperature. E3 added that R1 complained of headache but did not assess R1 for possible head injuries. E3 also stated that R1 was only noted with redness on bilateral knees and right side of the upper torso. On 11/17/2014 at 12:41 P.M., E6 (CNA) stated that when he arrived in room at around 10:35 A.M on 11/12/2014, R1 was lying on the floor perpendicular to bed and window. E6 added that R1's face was touching the floor and was blocking R1's nose and mouth and therefore R1 had difficulty in breathing. E6 further stated that he took a bed linen from the bed, crunched it up and placed it on R1's forehead so R1's nose and mouth was not touching the floor. On 11/17/2014, E5 (LPN, Restorative Nurse) stated that on 11/12/2014 at 10:35 A.M., he saw R1 on the floor in a prone position and R1's face was touching the floor. E5 also stated that R1 had a crunched out cloth material on his forehead and that R1 had difficulty breathing. Then E5 added, together with E6, R1 was rolled over to a supine position. E5 also stated that during the turn, E5 supported R1's head and neck by placing his hands behind R1's ears, back of head and neck while E6 was supporting R1's lower extremities. E6 also stated that R1 did not require oxygen administration after the change of position. E5 also added that R1 complained of pain, however, E5 did not assess for possible neck/head injury before R1 was rolled over. On 11/17/2014 at 2:20 P.M., Z2 (R1's Attending Physician) stated that R1's C2 and C3 cervical fracture could have been caused from an impact. Z2 further added that if it was a non witnessed fall, an assessment to rule out possible neck and head injury should have been done. Then Z2 added, R1 should not have been rolled over, not unless there was traction to immobilized R1's head/neck. Z2 further added that staff should have just removed the bed linen/cloth material that was obstructing R1's airway and should have just waited for the paramedics. On 11/17/2014 at 4:00 P.M., during the daily status meeting, E1 (Administrator), E2 (Director of Nursing) and E14 (Nurse Consultant) had all stated that the facility does not have a policy and procedure regarding care that would include assessment and changing a resident's position immediately after the fall incident. On 11/17/2014 at 9:30 A.M., Z1 stated that R1 was placed on hospice care after the fall incident.

Based on observation, interview and record review the facility failed to assess and to provide care to prevent the development of acquired pressure sores. This is for 3 of 5 residents ( R4, R1, R6) reviewed for pressure sores in a sample of 30. This failure resulted in R1 and R4 developing pressure sores. Findings Include: 1. Review Of R4's medical record, R4 was initially admitted to the facility in March 2011. At this time R4 was ambulatory and has no documentation of any pressure sores. Interview with E10 ( Registered Nurse ) stated R4 fractured her hip while on leave at her sons home. 911 was called at that time and R4 sent to the hospital for a hip repair. R4 was readmitted to the facility on [DATE]. R4's initial nursing assessment dated [DATE] indicates R4 has redness of a callous on her right heel at this time. There are no preventative measures taken to prevent any further break down to R4's right heel until 9/26/11. On 9/26/11 there is a physicians order for bilateral heel protectors. On 9/29/11 R4 has an un-stageable pressure sore on her right heel. Since 9/29/11 R4 has had her right heel debrided at least once in December 2011. On 12/19/11 R4's right heel was observed to have a stage 4 pressure sore. 2. R1 was readmitted to facility on 7/23/11 with [DIAGNOSES REDACTED]. At time of readmission R1's initial nursing assessment denotes R1 had no pressure ulcers at that time. R1's Braden Scale dated 8/12/11 assessed R1 as at moderate risk for pressure sores. R1 is assessed as incontinent of urine and requiring extensive assist by staff. Nurses notes dated 10/29/11 denotes R1 was found with "pressure ulcer to left heel #1 about 1.8 centimeters x 1.8 centimeters with dark brown discoloration, skin intact. #2 0.6 cm x 0.8 centimeters whitish discoloration. R1's physician was notified and order obtained R1 was assessed by wound doctor on 11/3/11. Documentation includes R1's wound to left heel measured 2 x 2, color black, eschar 100%. Dressing instructions include to clean with normal saline, apply [MEDICATION NAME] and cover with foam. E3 stated on 12/21/11 R1's did not have two wounds found on 10/29/11, that when the wound doctor measured the left heel wound it was measured as only one to the left heel. 3. Review of "Comprehensive Pressure Ulcer Assessment" dated 8/25/2011 showed R6 is a [AGE] year old with [DIAGNOSES REDACTED]. This assessment also showed that R6 has a stage 2 pressure ulcer on the right ischium. As indicated in this assessment, R6 is chair-fast and need physical assist for ADL (activities of daily living). Review of the pressure ulcer report dated 8/25/2011 showed that R6 has a stage 2 pressure ulcer on the right ischium. The pressure ulcer measured 1.5 cm in width, 0.5 cm in length and 0.1 cm in depth. There was also a minimum serosanguinous drainage of the wound. E3 (Assistant Director of Nursing) stated on 12/21/201 at 1:15 P.M. stated that R6's stage 2 pressure ulcer on the right ischium was acquired at the facility. E3 also stated that this pressure ulcer had healed on 9/8/2011 however, it had reopened on 10/13/2011. E3 further stated that "(R6's) right ischium pressure ulcer had reopened because (R6) is always sitting on her wheelchair and scoots down a lot which cause too much friction." Review of current POS (physician order [REDACTED]." Review of pressure ulcer report dated 12/12/2011 showed that R6's reopened stage 2 pressure ulcer wound measures 0.5 cm in length, 0.5 cm in width and 0.1 cm in depth . The pressure ulcer has minimal serosanguinous drainage. On 12/20/2011 at 1:40 P.M., E16 (Registered Nurse) was observed performing pressure sore treatment on R6's in R6's room. E17 (CNA-certified nurse assistant) ) was in the room for standby assist. Observation showed that there was no dressing that was in placed prior to E16 applying [MEDICATION NAME] dressing. E17 confirmed that there was no dressing on R6's pressure ulcer when E17 gave R6 shower at 7:00 A.M. on 12/20/2011. E17 also stated that she did not inform E16 that there was no dressing because E16 was not aware that R6 was supposed to have a dressing on the pressure ulcer. E16 stated that R6 was supposed to have the "[MEDICATION NAME] dressing" , however, she was not aware that the dressing was off. R6 stated on 12/20/2011 at 1:50 P.M. that her pressure ulcer hurts when she seats because the dressing was off and that the dressing serves as a pad and protection from her scooting down. R6 also stated that her [MEDICATION NAME] has not been applied for 3- 5 days. E17 stated on 12/20/2011 at around 3:30 P.M. stated that she replaced the R6's [MEDICATION NAME] on 12/19/2011. Review of TAR (Treatment administration record) showed that [MEDICATION NAME] dressing was not signed by E17 to indicate that the [MEDICATION NAME] was applied. E17 stated on 12/21/2011 at 1:15 P.M. that R6 removes the [MEDICATION NAME] herself. E17 also validated that she did not revise R6's plan of care for the pressure ulcer in order to address why R6 removes the [MEDICATION NAME].

A. Based on observation, interview and record review the facility failed to ensure that R3 was transferred safely, and failed to adequately assess and care plan for transfers. These failures resulted in (R3) sustaining a severe comminuted humeral neck fracture. This is for 1 resident (R3) out of 7 reviewed for falls in the total sample of 30. The findings include: R3 is a severely cognitively impaired resident with multiple [DIAGNOSES REDACTED]. R3 is totally dependent on staff for all transfers and requires 2+ persons physical assist according to the MDS's dated 10/31/11, 8/1/11 and 5/2/11. R3 has a right BKA and a left foot drop, and is unable to flex and extend her left foot, according to the Functional Limitation in Range of Motion (ROM) Assessment completed by E5 (Restorative Nurse) and dated 10/31/11. Additionally, R3 has limitations in both shoulders, both elbows, both wrists, both hands, both knees and in her left hip according to the 10/31/11 ROM Assessment. R3 sustained a shoulder fracture according to an x-ray report dated 12/5/11. According to the facility's investigation, E7 (CNA) transferred R3 on 12/3/11 (7-3 shift) without assistance from another staff member and without a gait belt. On 12/3/11 E7 noted that R3's shoulder/upper arm was swollen but did not tell anyone according to documentation on the Injury of Unknown Origin Staff Interviews form and Occurrence report. R3's physician was not notified about R3's swollen shoulder/upper arm until 12/4/11 at 11:55 AM according to nursing note documentation. During an interview on 12/21/11 at 3:45 PM E7 (CNA) stated that on 12/3/11 (7-3 shift) she transferred R3 from the bed to the wheelchair without assistance from another staff member and without using a gait belt. E7 stated that R3 could not bear weight at all. E7 said that she placed R3 on the side of the bed and placed the wheelchair next to the bed. E7 said that she transferred R3 by placing her arms under R3's arms and around R3's mid-back. E7 said that she then "scooped" R3 up from the bed and transferred her to the wheelchair. E7 said that she had transferred R3 this way before without any problems. There was no assessment and no care plan regarding how R3 was to be safely transferred according to review of the record. On 12/14/11 at 12:10 PM E5 (Restorative Nurse) confirmed that there was no assessment or care plan developed for R3's transfers. E5 said that prior to the fracture R3 needed a mechanical lift for transfers because she couldn't bear weight. At 12:30 PM E5 retracted her statement and said that R3 did not need a mechanical lift prior to the fracture, but needed to be transferred using a gait belt and 2 - 3 assist. On 12/14/11 at 2:35 PM E2 (Director of Nursing) also confirmed that there was no care plan that addressed how R3 was to be transferred, prior to R3's fracture. R3 was in bed on 12/14/11 at 9:20 AM. R3 had extensive bruising on her left shoulder, left upper arm and left chest/breast area, adjacent to her underarm. R3's upper arm appeared swollen and tight. R3 smiled and rattled the right bed rail with her right hand when her name was called, but was otherwise unable to communicate. R3 was in bed on 12/20/11 at 10:30 AM. R3's left foot was noted in a fixed extended position. B. Based on observation and interview the facility failed to keep 1 of 6 housekeeping closets containing hazardous chemicals locked; failed to maintain a visual view of housekeeping carts in the Dementia unit; and failed to ensure resident's televisions are securely placed on furniture. These failures affect 3 wings (Nor wing, Northwest Wing and Dementia Wing) out of 5 wings in the facility. The findings include: On 12/20/11 during the environmental tour the housekeeping closet on the Nor Wing was unlocked. E9 ( Maintenance Supervisor ) removed paper and 2 vinyl gloves that had been stuffed into the door cylinder preventing the door from locking. This closet contained 2 bottles of mopping disinfectant, 1 bottle of furniture polish and 1 bottle of of an abrasive cleanser. All of these bottles read hazardous if swallowed and a number to call in an emergency. The mopping disinfectant noted it is hazardous to skin and eyes as well and to call a physician. E8 ( Housekeeping Supervisor ) stated this door should have been locked and did not know who placed the items into the door cylinder. Interview with E1 on 12/21/11 in the facility conference room stated that residents on the Nor Wing are long term care residents. During the initial tour of the facility with E20 (admission coordinator) on 12/19/2011 from 10:00 a.m. to 10:55 a.m. the following were observed: a) television sets with sizes ranging approximately from 32 to 51 inches were placed on top of small bedside dresser in resident rooms: 172, 176, 178, 187, 191 and 192. The television sets are extending over the edge of the small dresser table which has the potential of falling or tipping over. b) a wall light fixture without a cover and an electrical wire was exposed in room 177-1. c) a lap top computer was on top of an over-the-bed table . The computer was at the edge of the table. This is a 1 leg table and the table top was slanting down towards the floor.

Based on interview and record review, the facility failed to supervise, monitor and determine the location of one (R2) of three residents assessed for high risk for elopement in the sample of five. This failure resulted in R2 eloping on 5/31/2011, after going to a doctor's appointment without an escort. R2 did not return to the facility after the appointment, but instead, walked to a grocery store, bought hard liquor and proceeded to go to a bar and consumed alcohol. R2 who has unsteady gait, had walked a mile or two, had to pass by major streets, cross multi lane traffic to reach the grocery store and bar. R2 was intoxicated and was taken to local hospital by the police. Findings include : R2 is a [AGE] year old with [DIAGNOSES REDACTED]. R2 was originally admitted to the facility on [DATE]. Review of R2's "Community Survival Skills Assessment" showed the following: -- 4/6/2011 showed that "(R2) has poor short term memory due to alcohol abuse. At this time, (R2) needs supervision for any outside passes." -- 1/7/2011 showed that "(R2) has history of substance abuse , needs to be supervised for outside passes." -- 10/8/2010, "(R2) has short term memory loss due to substance abuse. (R2) often makes poor decision and needs supervision for outside passes." -- 7/7/2010, "(R2) makes poor decisions and judgement in the community related to substance abuse. (R2) needs supervision for passes at this time." Review of R2's "Elopement Risk Assessment " dated 4/6/2011 showed that R2 was assessed as " high risk due to attempts of elopement, setting off exit doors, verbalizes intent to leave." Review of R2's "Safety Assessment " dated 4/7/2011 showed that R2 had "attempted to elope from facility , setting off exit doors. Attempted several times to elope, difficult to redirect." Review of facility's "Elopement Details Report" dated 5/18/2011 at 3:30 P.M. , showed that "(R2) broke siding of his window, to get out of his room and to escape on ground level. (R2) is unable to care for himself and is verbally aggressive and potentially violent. (R2) refuses therapeutic interventions despite several attempts. (R2) made his way out to the parking lot but was redirected back to the facility and into his room. (R2) injured his right ankle related to escaping through window. (R2) says he will continue to escape until he succeeds." Further review of this report indicated that R2 was sent to the local hospital on [DATE] and was admitted due to a fractured ankle. R2 was later readmitted back to the facility on [DATE] with an additional [DIAGNOSES REDACTED]. Review of the nurse's notes dated 5/19/2011 showed that on 5/18/2011, "(R2) jumped from his window ledge , landing on an uneven surface that had caused the injury." Review of current care plan dated 4/12/2011 showed that R2's pass privileges is at Level 1. It is also indicated that Level 1 needs supervision at all times. This care plan also showed that (R2) is unable to function independently without supervision or assistance related to alcohol induced dementia and signs and symptoms of short term memory loss. This care plan also showed that "(R2) looks persistently for a way to get out or get home, attempts to use the alarm, fire exit doors. " The interventions for this current care plan were as follows: -"check and assure physical comfort, staff will continue to monitor any cognitive changes in resident, continue with 15 minute check on resident to ensure safety, monitor behavior, determine preferred setting, offer alternative ADL(activities of daily living) that maybe engaging". Further review of care plan showed that there were no revised and specific interventions when R2 had eloped on 5/18/2011 resulting to an injury due to a fall from a window. There was no interventions to address how R2 is going to be monitored and supervised in an event R2 has outside medical appointments related to recent ankle fracture. As a result of this failure, facility had sent out R2 to a doctor's appointment (orthopedic appointment) without escort/supervision on 5/31/2011 at 9:45 A.M.. Review of facility's investigation report dated 5/31/2011 showed that R2 did not return to the facility after a doctor's appointment, but instead, walked to a grocery store, bought a liter bottle of hard liquor and 6 pack of beer. R2 proceeded to go to a bar and consumed alcohol. Further review of incident report showed that R2 was intoxicated when found inside the bar by E3 (Director of Behavioral Unit), E4 (Counselor ) and local police. R2 was taken to the nearby hospital by the police for detoxification. E3(Director of Behavioral Unit) stated on 8/30/2011 at 11:15 A.M., that R2 has unsteady gait, had walked a mile or two, had to pass by major street, cross multi lane traffic to reach the grocery store and bar when R2 decided to eloped after a doctor's appointment on 5/31/2011. E3 also stated that R2 was endangering himself if he will consume alcohol as this might cost him his(R2's) life. E3 further stated that R2 should have been provided with an escort for supervision and to prevent R2 from elopement when R2 went out for a doctor's appointment. E3 continued to state that R2 was assessed as Level 1 for pass privileges which means it is the most restrictive pass and that R2 needs supervision at all times. E3 also stated that she and E4 (Counselor Behavioral Unit) and local police found R2 drinking alcohol inside a local bar. As E3 added, R2 was intoxicated and was brought to the local hospital by the police. E3 also stated that when R2 was found, R2 had a 1/2 empty liter bottle of Vodka that was found in his grocery bag. E3 also stated that R2 had a doctor's appointment at 10:00 A.M., left the doctor's clinic after the appointment, and was found after lunch approximately around 1:00 P.M. or 2:00 P.M. This indicated that R2's location was not known for approximately 2 to 3 hours. E4 (Counselor Behavioral Unit) was interviewed together with E3. E4 had validated what E3 had stated. E1 (administrator) stated 8/30/2011 at 1:30 P.M. that R2 was sent out to a doctor's office on 5/31/2011 without an escort from the facility. E1 has no explanation why the facility allowed R2 to leave facility while he was on the most restricted pass privilege (Level 1). E1 further stated that R2 was admitted to a behavioral unit in a local hospital after the elopement incident on 5/31/2011. E1 also stated that R2 had not returned back to the facility because R2 needed a more structured environment for close monitoring. Review of facility's protocol on elopement prevention, indicates that residents identified as being "at risk" for elopement should only leave the facility when accompanied by facility staff or responsible family member.

Based on record review, interview and a review of the medical examiner coroner death certificate the facility failed to provide supervision to 1 of 4 residents (R2) with a history of falls. As a result of this failure R2 fell and expired due to a Subdural Hematoma. Review of R2's medical record R2 is newly admitted on [DATE] with [DIAGNOSES REDACTED]. R2's care plan at the facility and nurses notes indicate R2 has an unsteady gait and was informed several times on [DATE] to use the call light without success. R2's care plan indicates R2 is high risk for falls and MDS(Minimum Data Set ) that R2 requires 1 staff extensive assist with ambulation. Nurse note at 11:00 PM on [DATE] indicates R2 is alert times 3 although coherent times 2. R2's care plan and nurses notes indicate supervision is to be provided yet R2 continued to get up without supervision. Interview with E14 RN (registered nurse) on [DATE] stated R2 was confused but alert. E14 stated she did the admission part for R2 on [DATE]. Interview with E13 CNA ( certified nurse assistant ) on [DATE] stated, " He( R2) was weak. R2 was trying to do things by himself. R2 was told to call for help but R2 really didn't care. R2 was walking by himself. " Further interview with E13 stated the day he(R2) fell , He (R2) walked down the hall and asked E13 for water." E13 allowed R2 to walk unassisted back to his room while E13 obtained the water. By the time I (E13) went to the nurses station and back to his( R2's) room he (R2) had fallen. I (E13) found him(R2) on the floor in the bathroom with a bump on the side of his forehead. Interview on [DATE] with E12 (RN) (registered nurse ) stated the CNA(E13) called E12 from break saying R2 was on the floor. R2 had slipped and fell while trying to go to the bathroom. Interview on [DATE] with E11(CNA) stated R2, " He was weak, really weak. Yes he used his walker to walk." Interview on [DATE] with E10 (RN) stated she admitted R2 the day before R2 fell . R2's gait wasn't stable. Review of R2's medical record on [DATE] at 4:00 A.M. R2 was discovered on the floor in the bathroom with an abrasion on the left eyebrow and face and bleeding from the penis. R2 was sent to the hospital and admitted with a [DIAGNOSES REDACTED].