Every finding on record at Alden Terrace of Mchenry Rehab

Based on interview and record review the facility failed to ensure a resident was free of abuse. This applies to 1 of 10 residents (R1) reviewed for abuse in a sample of 10.The findings include:R1's Facility assessment dated [DATE] showed R1 is cognitively intact.On 8/4/26 at 10:00 AM, R1 requested V2 (Registered Nurse-RN) to be present during the interview. V2 was present the entire time of the interview. R1 stated R2 and herself got into an argument over the television remote in the dining room Sunday morning (8/2/26) just before breakfast. R1 stated R2 was very rude and started yelling at her over the remote. R1 said she moved closer to R2 during the argument then R2 moved his arms towards her to either push her away or hit her. R2 caught R1 on the left side of her neck. R1 pointed to a location at the base of her neck where the clavicle bone meets the neck. There was no visible redness or bruising on R1's neck. R1 stated it hurt at the time R2 struck her. R1 stated V4 (Certified Nursing Assistant-CNA) saw what happened and pulled R2 to a different table. R1 stated she was mad and upset at the time of the incident.On 8/4/26 at 10:15 AM, V2 stated she did not see the incident between R1 and R2. V2 stated R1 told her R2 hit her in the neck right after it happened. V2 stated they did not see any bruises or redness bruise on R1's neck at the time of the incident. V2 stated R1's story has not changed. V2 stated hitting and shoving are considered physical abuse.On 8/4/26 at 10:35 AM, V4 stated he was in the dining room Sunday (8/4/26) morning getting the trays ready to pass out for breakfast. R1 and R2 started arguing and raising their voices. R2 moved forward and shoved R1. R1 yelled out when R2 shoved her. V2 stated he moved R2 away from R1. V4 stated V3 (Activity Aide) left to go get V2. R1 looked mad and upset after the incident. Residents should not hit or push other residents.On 8/4/26 at 10:45 AM V5 (CNA) stated from where she was sitting, she could hear R1 and R2 arguing. V5 stated she saw R2 lunge forward at R1. V5 stated she could not see R2's hands when he moved, but R1 moved back quickly like she had been pushed. V4 was there and separated them. On 8/4/26 at 10:50 AM, R3 stated he was sitting at the same table as R1 when the argument with R2 happened (Sunday 8/2/26). R1 had come into the dining room and asked about the television remote. R2 had the remote and started arguing with R1. R1 and R2 wheeled their chairs closer to each other while they were arguing. R2 pushed R1 hard, and R1 yelled. V4 came over and moved R2 to a different table. R2 should not have shoved R1. R2 is a lot bigger than R1. R3 stated R2 is grouchy all the time and thinks he is the boss of everything.The facilities Abuse Policy dated 3/2025 showed the residents have the right to be free from all types of abuse. This policy showed abuse means any physical, mental injury, or sexual assault inflicted upon a resident other than accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on interview and record review the facility failed to report an allegation of abuse to a State Agency which applies to 1 of 10 residents (R1) reviewed for abuse in a sample of 10.The findings include:On 8/4/26 at 10:00 AM, R1 stated she got into an argument with R2 over the television remote in the dining room Sunday morning (8/2/26) just before breakfast. R1 stated R2 was very rude and started yelling at her over the remote. R1 stated R2 struck her in the neck. R1 stated she had talked with V2 (Registered Nurse-RN) after the incident. On 8/4/26 at 10:15 AM, V2 (RN) stated she did not see the incident between R1 and R2. V2 stated R1 told her R2 hit her in the neck right after it happened. V2 stated they did not see any bruises or redness on R1's neck at the time of the incident. V2 stated R1's story has not changed. V2 stated hitting and shoving are considered physical abuse. V2 stated she reported the incident to V1 (Administrator).On 8/4/26 at 10:35 AM, V4 stated he was in the dining room Sunday (8/4/26) morning getting the trays ready to pass out for breakfast. R1 and R2 started arguing and raising their voices. R2 moved forward and shoved R1. R1 yelled out when R2 shoved her.On 8/4/26 at 10:50 AM, R3 stated he was sitting at the same table as R1 when the argument with R2 happened (Sunday 8/2/26). R2 shoved R1 hard, and R1 yelled.On 8/4/26 at 11:25 AM, V6 (Housekeeping Manager) stated he was the manager on duty (MOD) on 8/2/26. V6 stated he was called to check on an incident between R1 and R2. V6 stated he talked with R1 and R2 separately with V1 (Administrator) on the phone. V6 stated the only other person he had talked to about the incident was V2. On 8/4/26 at 12:15 PM, V1 (Administrator) stated she was informed of the incident between R1 and R2, but since the incident did not seem like abuse. V1 said she did not send any notification to Illinois Department of Public Health for R1's allegation of abuse.The facility's Abuse Policy dated 3/2025 showed initial reporting of allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public health.

Based on interview and record review the facility failed to conduct a thorough abuse investigation after an allegation of abuse which applies to 1 of 10 residents (R1) reviewed for abuse in a sample of 10.The findings include:On 8/4/26 at 10:00 AM, R1 stated she got into an argument with R2 over the television remote in the dining room Sunday morning (8/2/26) just before breakfast. R1 stated R2 was very rude and started yelling at her over the remote. R1 stated R2 struck her in the neck. R1 stated she had talked with V2 (Registered Nurse-RN) after the incident.On 8/4/26 at 10:15 AM, V2 stated she did not see the incident between R1 and R2. V2 stated R1 told her R2 hit her in the neck right after it happened. V2 stated they did not see any bruises or redness on R1's neck at the time of the incident. V2 stated R1's story has not changed. V2 stated hitting and shoving are considered physical abuse. V2 stated she reported the incident to V1 (Administrator).On 8/4/26 at 10:35 AM, V4 stated he was in the dining room Sunday (8/4/26) morning getting the trays ready to pass out for breakfast. R1 and R2 started arguing and raising their voices. R2 moved forward and shoved R1. R1 yelled out when R2 shoved her. V4 stated no one had come to ask him any questions about the incident since it happened.On 8/4/26 at 10:45 AM V5 (Certified Nursing Assistant/CNA) stated from where she was sitting, she could hear R1 and R2 arguing. V5 stated she saw R2 lunge forward at R1. V5 stated she could not see R2's hands when he moved, but R1 moved back quickly like she had been pushed. V4 was there and separated them. V5 stated no one had come to interview her about the incident. V5 stated that after something like that happens someone usually comes and asks some questions or to write a statement about what we saw. On 8/4/26 at 10:50 AM, R3 stated he was sitting at the same table as R1 when the argument with R2 happened (Sunday 8/2/26). R2 shoved R1 hard, and R1 yelled. R3 stated none of the staff had come and asked him about R2 shoving R1.On 8/4/26 at 11:25 AM, V6 (Housekeeping Manager) stated he was the manager on duty (MOD) on 8/2/26. V6 stated he was called to check on an incident between R1 and R2. V6 stated he talked with R1 and R2 separately with V1 (Administrator) on the phone. V6 stated the only other person he had talked to about the incident was V2. On 8/4/26 at 12:15 PM, V1 (Administrator) stated she was informed of the incident between R1 and R2, but since the incident did not seem like abuse, V1 said she did not conduct a full abuse investigation into R1's allegation of abuse.The facility's Abuse Policy dated 3/2025 showed the administrator or designee will investigate the allegation. The finale investigation report shall include interviews of witnesses as part of the investigation.

Based on interview and record review the facility failed to protect a resident from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. The findings include:R1's Behavior Note dated 5/27/26 at 7:20 PM shows, Resident was observed by staff hitting another resident with a hair brush.R2's Post Occurrence Note dated 5/27/26 shows, Resident stated he and the other resident got into an argument and the other resident hit him on the head and shoulder with a hair brush.On 6/3/26 at 9:45 AM, R2 said that about a week ago, he was hit by another resident (R1). R2 said that he was sitting in his wheel chair by the nurses station when he saw R1 walk down the hallway and enter his room. R2 said that he immediately went down the hall to see why R1 was in his room but R1 was not in his room, he was in the room next to his looking in the drawer. R2 said that he then parked his wheelchair in the middle of the doorway and asked R1, What are you stealing now?. R2 said R1 got upset and started coming towards him and yelling at him. R2 said then staff immediately came to separate them. R2 said R1 was brought to his room and he started wheeling toward the dining room. R2 said he was very upset and wanted to see what R1 stole so he wheeled himself down to R1's doorway and said, I want to see what you stole. R2 said V3, Certified Nursing Assistant (CNA) was still near R1's door. R2 said himself and R1 started yelling at each other. R2 said then R1 came to the doorway and was shaking his fists in the air at him so he said, If you are going to hit me, then hit me. R2 said he took his glasses off and handed them to V3 because he didn't want to break them and they continued to yell at each other. R2 said then R1 went into his room where his night stand was and grabbed a brush. R2 stated to R1, Are you really going to hit me with a brush? V3 told him to leave so he did and as he turned to leave, R1 came out of the room and hit him on the back of the head with a brush and then hit him on the left shoulder area and the back. R1 said he then yelled that he was going to call 911 because he was just assaulted. On 6/3/26 at 12:41 PM, V3, Certified Nursing Assistant (CNA) said he was in a resident room when she heard two men yelling at each other. V3 said when she exited the room, R1 and R2 were yelling at each other. V3 said R1 was standing in the doorway of a room (not his room) and R2 was sitting in his wheelchair in the hall at the entrance of the room. V3 said she started pushing R2 out of the way but somehow, they got back together, and she separated them again. V3 said when R2 was rolling down the hallway in the opposite direction of R1's room, R1 came out of his room with a brush and hit R2 on the back of the head, shoulders and back and then R1 grabbed R2's wheelchair and kept hitting him. V3 said the first altercation took place at the doorway of another resident's room and then she separated them but then somehow R2 got to R1's doorway and the second altercation took place there. V3 said she is unsure how R2 got to R1's room because he was going in the opposite direction. V3 said she did hold R2's glasses but she does not recall why.On 6/3/26 at 1:29 PM, V2 (Director of Nursing) said if a resident hits another resident, it would be considered physical abuse. R1's Care Plan initiated on 1/18/26 shows, [R1] has difficulties managing his anger/frustration as evidenced by his behaviors. Noted behaviors include verbal aggression with staff and residents, noted physical aggression. Interventions include: Allow resident time to blow off steam and vent frustrations in a safe manner, assess resident for any changes in baseline mood and behavior when needed, and intervene as appropriate.The facility's Final Incident Report shows, On 05/27/26 at approx. 7:20 pm, staff observed [R1] hit [R2] with a hair brush.During the investigation, it was determined that an altercation occurred between [R1] and [R2] related to [R1] going into another resident's room and placing an item that was not his in his own pocket. [R2] asked [R1] what he stole, which led to an exchange of words, and ultimately [R1] striking [R2] with a hairbrush.The facility's Abuse Policy shows, This facility affirms the right of our residents to be free from abuse. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents.Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility.Physical Abuse includes hitting, slapping, pinching, kicking.

Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a timely manner for one of three residents (R3) reviewed for incontinence care in the sample of six.The findings include:R3's Face Sheet dated May 11, 2026, shows R3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, lymphedema, history of falling, major depressive disorder, and overactive bladder.R3's Minimum Data Set, dated [DATE], shows R3 is not cognitively intact. R3 is dependent on staff for toileting hygiene and is always incontinent of bowel and bladder. R3's Care Plan shows R3 has an activity of daily living (ADL) functional performance deficit due to Alzheimer's, asthma, obesity, and anxiety disorder. Assist with ADL tasks as needed. Peri care after incontinent episodes.On May 11, 2026, R3 was observed in the units dining room in the same wheeled recliner multiple times from 9:22 AM-1:05 PM. At 1:05 PM, R3 said she had been in the chair for a long time and the right side of her buttocks hurt. V5 and V8 Certified Nursing Assistants transferred R3 into her bed. V8 provided incontinence care to R3. R3's incontinence brief was saturated with urine. The was a urine smell. R3 had creases to her buttocks area from sitting. V8 said she got up R3 out of bed at 7:00 AM. On May 11, 2026, at 10:49 AM, V6 Registered Nurse and V5 Certified Nursing Assistant said incontinence care should be provided at least every two hours, if not more so that resident don't get pressure injuries. At 1:42 PM V2 Director of Nursing said staff should be checking residents and changing their briefs at least every two hours and as needed to prevent any skin breakdown.

Based on observation, interview, and record review the facility failed to ensure a medication cart was locked when it was left unattended. This failure applies to residents with medications in the 500 hallway medication cart. The findings include:The facility provided list of residents whose medications were stored in the 500 hall cart showed 15 residents medications were contained in the cart. On 4/15/26 8:10 AM, the 500 hallway medication cart was near two doors in the 500 hall. The lock for the cart was extended outwards indicating the cart was not locked. The drawers were opened, and medications were in the cart. There were no staff monitoring the cart. The 500 hall nurse, V6 (Registered Nurse), then exited a resident's room. The medication cart was not visible from that resident's room. V6 then locked the cart. On 4/16/26 at 10:22 AM, V2 (Director of Nursing) stated medication carts should be locked when staff leave the cart unattended. V2 stated this is to protect medications and protect residents. The facility's Medication Storage (dated 9/2020) policy does not state medication carts need to be locked.

Based on observation, interview and record review the facility failed to follow a Physician order to apply compression wraps for R94 and failed to document a change in a resident's condition when sent to the emergency room for R150. This applies to two of two residents (R94, R150) reviewed for quality of care in the sample of 49.The findings include:1. On 4/14/26 at 10:30 AM, V9, (R94's wife), was observed telling the nurse that her husband's compression hose had not been applied and the staff needed to do better. R94 was observed in bed without any compression wraps to his legs. Both of R94's lower legs were observed to be swollen. V9 said her husband's legs are to be wrapped every morning and this was not being completed for him daily as ordered. The facility face sheet for R94 shows he was admitted to the facility with diagnoses to include congestive heart failure and lymphedema. The facility assessment dated [DATE] shows R94 to have severe cognitive impairment and was dependent on staff for his care. A Physician Order dated 4/4/26 shows that ace wraps (compression wraps) are to be applied daily in the morning and removed at bedtime. On 4/16/26 at 8:41 AM, V6 RN (Registered Nurse-RN) said the night shift nurses are to apply the compression wraps at 6 AM every morning. On 4/16/26 at 9:49 AM, V2 Director of Nursing said the Physician Orders for each resident are to be followed by the nursing staff. The Treatment Record for R94 for April 2026 shows compression wraps are to be applied at 6 AM and removed at bedtime. No documentation of the wraps being applied on 4/14/26 was observed on the treatment record for R94. The care plan dated 1/16/26 for R94's edema does not show any interventions for the use of compression wraps. The facility policy dated 3/2024 for hose application shows the purpose of the hose is to provide firm support, reduce pain, apply pressure and to reduce swelling. 2. R150's admission record documents he was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's Disease, Dementia and Chronic Obstructive Pulmonary Disease COPD. R150's nursing progress notes show on 12/10/25 he had congestion. His assessment shows he was afebrile and had no pain. The notes documented he was put on an antibiotic and had an Xray. The notes for 12/11/25 and 12/12/25 show monitoring of symptoms while on the antibiotic. On 12/13/25 at 11:13 PM, the notes show he was taken to the hospital by way of ambulance. He was transported and admitted to the hospital for pneumonia. The notes do not indicate any change of condition, reason for the transfer, notifications of the physician or power of attorney. The progress notes show he did not return until 12/17/25. On 4/16/26 at 10:58 AM, V2 (Director of Nursing) said there should be a nursing note of what happened. V2 would have to check for any documentation. V2 said she would have to check the policy to know what should be included in the progress note. On 4/16/26, no further documentation was provided. On 4/16/26 at 9:48 AM, V16 (RN) said when a resident has a complaint and need to be sent out, there should be a progress note so everyone knows what change of condition occurred. The note should include the notification of physician, power of attorney and calling the hospital and giving the report. When a resident is sent out the DON and administrator are also notified, and all that information goes into the notes. The facility's 9/2020 policy for change of condition states the purpose is to ensure the resident's physician/physician on call/ Nurse Practitioner and responsible party is kept informed regarding the resident's change of condition. See change in conditions and signs and symptoms from AMDA clinical practice guidelines/interact 4.0. Report on why vital signs were taken, diagnostic procedures and symptoms.

Based on interview and record review the facility failed to provide assistance with appointments for vision care in a timely manner for 1 of 2 residents (R88) reviewed for resident rights in the sample of 49.The findings include:On 4/14/2026 at 10:37 AM, R88 was sitting in a wheelchair in his room and stated he needed an appointment for his cataract in his right eye. R88 stated he couldn't see out of it and now his left eye is almost gone. R88 stated soon he would be blind. R88 stated he has needed the appointment for his cataracts for months. R88 stated they said they were waiting for a referral. R88 stated he wanted to know what was going on.On 4/15/2026 at 2:31 PM, V18 (Social Services) stated appointments are made by the nurses and transportation is arranged by the receptionist. V18 stated R88 mentioned to her a concern about his eyes and she told the (Assistant Director of Nurses-ADON).On 4/15/2026 at 2:44 PM, V15 (ADON) stated it was brought to her attention a little over a week ago that R88 needed an appointment for his cataracts with ophthalmology. V15 stated she was in contact with the nurse practitioner (NP) about the referral and had to call the NP again because one place she had contacted for R88 stated they never received the referral. V15 stated the floor nurses are to make all the appointments, and she helps when she can. V15 stated she did not know anything about this concern for R88 before when she found out a little over a week ago. V15 stated she has called two places for R88.On 4/16/26 at 11:41 AM, V10 (R88's daughter) stated R88 has been at the facility since November 2025 and when he went to the facility, they were told he needed cataract surgery. V10 stated she asked them if that was something that the facility could help with and they said they could. V10 stated nothing was done. V10 stated she has called social services a couple of times and left messages and no one has returned her calls. V10 stated she has talked to the nurse, told her R88 has cataracts and needs surgery. R88 needs to see a specialist. V10 stated she called in January 2026 and then in February 2026 she called and asked the nurse to make a note of it in his chart because it shouldn't take this long. It took a while before R88 saw an eye doctor; in March 2026 he was seen and was told he needs a referral for cataract surgery. V10 stated she hadn't heard anything about it. V10 stated R88 can't see, and it is very frustrating; he is grumpy and upset over it.The Nurses Note dated 2/6/26 at 7:01 PM for R88 showed the resident was to be placed on optometrist list and daughter be called when optometrist is seeing resident.The Optometrist Note dated 3/5/26 for R88 showed he has glasses that he does not wear, they make no difference. He had an exam two months ago, was referred to for cataract consult but never went. No history from staff.The Face Sheet dated 4/16/26 for R88 showed diagnoses including type 2 diabetes mellitus, venous insufficiency, chronic obstructive pulmonary disease, obstructive sleep apnea, atrial fibrillation, congestive heart failure, hypertensive heart disease, muscle weakness, polyosteoarthritis, weakness, lymphedema, benign prostatic hyperplasia, and localized edema.The facility's Vision policy (9/2020) showed, Policy: Ensure that residents receive proper treatment and assistive devices to maintain vision. Procedures: 1. Assist resident in making appointment; 2. Assist resident in arranging transportation to and from the office of a practitioner specializing in the treatment of vision or hearing.The facility's Residents' Rights for People in Long-term Care Facilities policy from the Illinois Long Term Care Ombudsman Program showed, your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on observation, interview and record review the facility failed to trim the toenails of a resident. This applies to one of one resident (R33) in the sample of 49 reviewed for nail care.The findings include:The facility face sheet for R33 shows he was admitted to the facility with a diagnosis to include peripheral vascular disease and mild cognitive impairment. The facility assessment dated [DATE] shows R33 to have mild cognitive impairment and requires partial assistance with putting on footwear.On 4/14/26 at 10:15 AM, R33 said, My toenails are so long they have put holes in my slippers. R33 was wearing slippers, and a hole was observed above the great toe on both of his slippers. R33 removed his slippers, and his toes nails were observed to be long, thick and discolored. On 4/15/26 at 2:57 PM, V5 (Memory Care Director) said any staff can add a resident to the podiatry list if there is a concern about a resident's toenails.On 4/16/26 at 9:39 AM, V7 (Certified Nursing Assistant-CNA) said resident toenails are observed everyday while helping the resident get dressed. V7 said if the resident's nails are observed getting long, it should be reported to the nurse. On 4/16/26 at 12:01 PM, V17 (Podiatrist) said he sees R33 every 3-4 months to avoid complications. V17 said if R33's nails were long enough to cut through his slippers; he should have been notified of it to prevent problems.The podiatry notes for R33 show he was seen last on 11/19/25 for a nail trimming and the recommended follow-up was in 2-3 months (5 months ago).The facility policy dated 9/2020 for care of nails shows all residents will have clean, well-trimmed nails.

Based on observation, interview, and record review the facility failed to ensure a resident with a history of falls had new interventions in place for 1 of 6 residents (R1) reviewed for falls in the sample of 49. The findings include:R1's face sheet printed on 4/16/26 showed diagnoses including but not limited to chronic kidney disease, spinal stenosis, polyneuropathy, bipolar disorder, and artificial knee joint. R1's facility assessment dated [DATE] showed no cognitive impairment. The same assessment showed partial/moderate staff assistance with transfers. The assessment showed substantial/maximal assistance for dressing and toilet hygiene. R1's fall risk assessment dated [DATE] showed at risk for falls. On 4/15/26 at 11:20 AM, R1 was seated in a wheelchair alone in his room. R1 said, I have a lot of medical issues and need help from the staff. I fell a couple of times since I got here. I have no patience to wait for the aides to come help me. I would wet my pants if I waited for one of them to finally show up. I just do it by myself. I can get in and out of bed alone. I fell getting out of bed alone once too. The facility provided fall log showed R1 experienced two falls since the admission date of 1/14/26. The first fall was on 2/19/26 and the second fall was on 4/11/26 (four days ago). R1's progress note dated 4/11/26 stated: This writer visually observed resident on the floor, on upright position right next his bed and wheelchair. Stated he went to washroom and went to bedside table fixing something on the phone cord then his left knee gave up. Denies hitting his head. Stated 'I fell on my butt'. R1's progress note dated 2/19/26 stated: .CNA [Certified Nursing Assistant] was coming out of another resident room, resident call light was answered and observed sitting on the floor next to bed by CNA reported to writer, resident noted sitting upright next to bed facing tv, legs extended forward even denies hitting head no redness no swelling noted no open area. Resident stated I was trying to go to bed by myself and slid down. On 4/15/26 at 2:16 PM, V3 (Restorative Nurse) stated all residents are considered a fall risk. Fall assessments are done at admission, quarterly, annually, and after each fall. V3 said, The assessments show us their abilities and help us decide where their activities of daily living levels are at. If a resident does fall, it is a team approach to decide what interventions need to be started. New interventions are important after each fall because it helps stop more falls. If a resident is having repeat falls it is clear the current interventions are not working as well as they should. Updated interventions should be started shortly after a fall. An initial intervention is started by the nurse and then updated after the team reviews why the falls are continuing. V3 said R1 does like to do things by himself and often tries to do things alone. V3 said, He has weaknesses and is at risk for more falls. There was a new intervention started back in February to encourage him to use the call light for staff assistance. But there is not anything started after the recent fall in April. A new one should have started after that fall and I don't see anything in his care plan. (R1) wheels all over the building so more frequent checks would be helpful. He should be encouraged to go to activities and ensure items are close to reach for him. He wants to be independent. There are a lot more interventions that could be trialed on him to stop him from getting up alone. R1's care plan showed a focus area related to risk of falls due to diagnoses of chronic obstructive pulmonary disease. The most recent intervention to encourage resident to use call light for staff assistance was dated 2/20/26. The care plan had no interventions following the fall on 4/11/26 in his room. The facility's Management of Falls policy dated 8/2020 states: 9. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.

Based on observation, interview, and record review the facility failed to keep catheter tubing off the floor, the drainage bag below the level of the bladder and the drainage bag covered for 2 of 5 residents (R127 & R171) reviewed for catheters in the sample of 49.The findings include: 1. On 4/14/26 at 10:58 AM, R127 was sitting in his wheelchair in dining room at table with clothing protector on. R127's catheter tubing was on floor with cloudy yellow urine in the tubing. On 4/14/26 at 1:15 PM, R127 was sitting in his wheelchair in his room. The catheter tubing was on the floor under his chair. V12 (Certified Nursing Assistant-CNA) and V13 (CNA) had gown and gloves on and turned R127's chair around with his catheter tubing dragging under his chair. V13 took the catheter bag from the dignity bag and handed it through to V12 who put in dignity bag on lower side of bed. V12 applied the gait belt around R127 and V12 and V13 did a two person stand-pivot transfer to his bed. They turned R127 from side to side in bed to remove the gait belt. V13 removed his shoes. They turned R127 from side to side to remove his pants. V12 lifted the catheter drainage bag above the level of R127's bladder to remove the drainage bag from the resident's pant leg. V12 stated the catheter tubing should not be on the floor because there is a risk for infection. The drainage bag cannot be above the bladder because urine can flow back, be retained, and cause an infection. The Care Plan dated 2/23/26 for R127 showed he requires the use of an indwelling catheter due to diagnosis of obstructive and reflux uropathy. Position collection bag below the level of the bladder. Provide catheter care. The Minimum Data Set (MDS) dated [DATE] showed he is dependent for activities of daily living. The Face Sheet dated 4/16/26 for R127 showed diagnoses including congestive heart failure, atrial fibrillation, cerebral palsy, dysphagia, obstructive and reflux uropathy, hypertensive heart disease with heart failure, benign prostatic hyperplasia, orthostatic hypotension, retention of urine, cardiomyopathy, acute on chronic respiratory failure, anemia, ileus, gastrointestinal hemorrhage, supraventricular tachycardia, dysarthria and anarthria. The facility's Indwelling Catheter policy (9/2020) showed place drainage bag below the level of the resident's bladder to facilitate drainage and minimize stasis of urine. 2. R171's face sheet printed on 4/16/26 showed diagnoses including but not limited to chronic kidney disease, acute kidney failure, and congestive heart failure. R171's April 2026 showed an order for an indwelling urinary catheter due to status post stent removal. On 4/14/26 at 11:00 AM, R171 was lying in bed, and his catheter bag was hanging from the bed railing. The bag was visible from the doorway, and it was half full of yellow urine. A wheelchair was across the room with a blue dignity bag hanging underneath it. R171 stated he got the catheter at a recent hospital stay and wants it out as soon as possible. R171 said he does not like it hanging from him. At 11:30 AM, the urinary drainage bag was still visible from the doorway. At 12:31 PM, the bag was in the same position. On 4/16/26 at 9:44 AM, V2 (Director of Nurses) stated catheter bags should be in a dignity bag for privacy. They cover the drainage bag, so others do not see the urine bag and what is in it. It should be used anytime the bag is visible to others. V2 said staff should put the urine bag inside the dignity bag whenever care is not being done. R171's care plan showed a focus area related to the use of an indwelling catheter. Interventions included: Keep drainage bag covered to promote privacy. Date Initiated: 04/13/2026.

Based on observation, interview, and record review the facility failed to stop an infusion of tube feeding when it was leaking at the insertion site for 1 of 3 residents (R36) reviewed for tube feeding in the sample of 49.The findings include:On 4/15/2026 at 11:20 AM, R36 was sitting up in his chair with tube feeding infusing at 55 milliliters (ml) per hour. The front of his shirt was wet in the lower middle of his abdomen. R36 stated his feeding tube was no good and it was not working. R36 stated he had a new feeding tube put in yesterday. At 11:23 AM, V14 (Licensed Practical Nurse-LPN) stated she thinks there was something wrong with the tube feeding site and he needed his dressing and shirt changed. V14 then walked away stating she needed to talk to her (Director of Nursing-DON). At 11:29 AM, V14 came back onto the floor and stated the DON placed a call to the doctor and was waiting for the gastroenterologist to call back. V14 stated the tube feeding wasn't leaking from the tube but from the sight. V14 stated the tube feeding was still infusing at 50 ml per hour and he has water that also infuses at 45 ml per hour. At 11:33 AM V4 (Wound Care Nurse) was at R36's bedside and told the resident he was going to change the dressing around his feeding tube. V4 lifted R36's shirt and the dressing around the feeding tube was saturated. When the dressing was removed there was a milky white substance coming from the gastrostomy site.On 4/15/26 at 2:44 PM, V15 (Assistant Director of Nursing-ADON) stated if tube feeding is leaking the infusion should not be infusing. V15 stated they need to figure out why it is leaking; there is a risk for complications. V15 stated she would stop the infusion right away and notify the physician.The Care Plan dated 4/5/26 for R36 showed he requires nutritional support. R36 is on the following diet: NPO (Nothing by Mouth), NPO texture, NPO consistency. Check for placement and patency of feeding tube prior to administering meds, feedings and flushes. Assess and document on stoma site weekly and as needed. The Face Sheet dated 4/16/26 for R36 showed diagnoses including cerebral palsy, chronic respiratory failure, spastic hemiplegia, dysphagia, severe protein calorie malnutrition, atherosclerotic heart disease, hypertensive heart disease, anemia, cachexia, abdominal pain, vascular disorder, myocardial infarction, iron deficiency, obstructive and reflux uropathy, and disorders of bone density. The April 2026 Physician Orders for R36 showed tube feeding at 50 ml/hour to infuse 1000 ml day. Water flush to infuse through feeding pump at 45 ml/hour for a total of 900 ml/day while tube feeding is infusing. The Enteral Nutritional Feeding policy (9/2020) showed complications related to a feeding tube included leaking around the insertion site, erosion at the insertion site, stomach or intestine perforation, inflammation, ulceration, strictures, fistulas of the esophagus and trachea. The policy did not state what to do if there was a complication.

Based on observation, interview, and record review the facility failed to administer insulin in accordance with manufacturer's instructions. This applies to 1 of 1 residents (R125) reviewed for insulin administration in the sample of 49. The findings include:R125's Face Sheet showed a diagnosis of diabetes type 2. R125's April 2026 Medication Administration Record showed a current order, as of 4/15/26, for rapid-acting insulin to be given at a dosage which is dependent upon R125's blood sugar value (sliding scale insulin). This sliding scale insulin is done before each meal. On 4/15/26 at 11:55 AM, V11 (Registered Nurse-RN) began preparing R125's sliding scale insulin. V11 removed R125's prefilled multi-dose insulin pen from the medication cart. V11 wiped the tip of the pen with an alcohol wipe, threaded on a new needle, dialed the pen to two units, held the pen horizontally, and punched the dose knob (plunger) with the palm of her hand then immediately released the plunger. R125's pen did have a small bubble within the insulin which remained in the pen following the priming procedure. V11 did not remove the needle cap to verify a drop of insulin. V11 then dialed R125's 2 units of insulin to be administered and entered R125's room. V11 wiped the back of R125's right arm with alcohol, inserted the needle into R125's arm, depressed the dose knob, immediately released the knob, and then continued to hold the pen against R125's skin for seven seconds. V11 did affirm that she depressed the plunger, released the plunger, then held the needle against R125's skin. At 4/16/26 at 10:22 AM, V2 (Director of Nursing-DON), stated the facility follows manufacturers instruction regarding the proper use of insulin pens. V2 stated, in general, the nursing staff should hold the insulin pen vertically during the priming process to remove any possible bubbles within the insulin. V2 stated, if the manufacturer's instructions state the plunger must be held during the priming process, she would expect her staff to follow that procedure. V2 stated the purpose of following the priming procedure is to ensure the resident receives their full dose of insulin. V2 stated when administering insulin to a resident via an insulin pen, most manufacturers recommend holding the plunger while the needle is inserted for the prescribed amount of time. V2 stated this is to ensure the resident receives the full dose of insulin. The manufacturer's instructions for R125's rapid-acting insulin (Revised July 2023) showed that during the priming process 2 units should be selected, the insulin pen should be held vertically, the pen should be tapped gently to collect air bubbles at the top (the end of the pen opposite the plunger), the needle cap removed, then the dose knob pressed and held for a 5 second count. The instructions show if a drop of insulin is not expressed the priming process should be repeated. The instruction showed that during the insulin administration process, after the needle is inserted in the skin, Push the dose know all the way in. continue to hold the dose knob in and slowly count to 5 before removing the needle.

Based on observation, interview and record review the facility failed to ensure gloves were changed when going from a dirty to a clean area to prevent cross contamination for 2 of 6 residents (R49 & R127) reviewed for infection control in the sample of 49.The findings include:1. On 4/14/26 at 1:02 PM, V12 (Certified Nursing Assistant-CNA) and V13 (CNA) were at R49's bedside to provide incontinence care. V12 and V13 had gloves on. V12 was incontinent of urine and a small amount of bowel movement. V12 unfastened R49's incontinence brief and pulled the front down. V12 took disposable wipes and cleaned one side of his groin, discarded the wipe and did the same procedure to the other side of his groin. V12 took a wipe and cleaned under his penis and scrotum area. V12 had bowel movement under the scrotum towards his anus that she wiped off and discarded the wipe. V12 did not change her gloves. V12 tucked the mechanical lift sling under the resident and placed a clean incontinence brief under him. V12 assisted R49 resident to turn to his side and pulled the resident towards her as V13 pushed him onto his side and finished removing the sling. R49 was placed on his back, and they both fastened the brief closed. V12 tied up the trash, removed her gloves and used hand sanitizer.On 4/14/26 at 1:24 PM V12 (CNA) stated gloves are changed anytime they go from dirty to clean, after peri-care, when they come into a room, when they leave a room. done for infection control.On 4/15/26 at 2:44 PM, V15 (Assistant Director of Nursing) stated gloves are to be changed if they are soiled. V15 stated that when they go from dirty to clean, they should remove gloves, use hand sanitizer, and put on a fresh pair of gloves.The Face Sheet dated 4/16/26 for R49 showed diagnoses including hemiplegia and hemiparesis, metabolic encephalopathy, type 2 diabetes mellitus, atherosclerotic heart disease, hypertensive heart disease, hyperlipidemia, obesity, dysarthria following cerebral infarction, dysphagia, major depressive disorder, suicidal ideation, weakness, legal blindness and anxiety disorder. The Minimum Data Set (MDS) dated Care Plan dated 3/8/26 for R49 showed dependence for toileting hygiene and personal hygiene, frequently incontinent of bowel and bladder. The facility's Glove Use policy (4/2024) showed gloves will be used to prevent the spread of infection and disease to other residents, personnel, and visitors. Gloves will be used when anticipating touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and non-intact skin. The Incontinence Care Policy was not received.2. On 4/14/26 at 1:24 PM, R127 was transferred to bed by V12 (CNA) and V13 (CNA). R127 had an indwelling urinary catheter and an incontinence brief in place. R127 was incontinent of stool. V13 took a disposable wipe and cleaned one side of his groin and discarded the wipe. V13 did the same thing to the other side of his groin and there was bowel movement present. V13 took a disposable wipe and cleaned under his penis and scrotum and discarded the wipe. V13 did not change her gloves. V12 and V13 turned R127 onto his side. V13 cleaned bowel movement from his buttocks and anus and discarded the wipes. V13 rolled up the incontinence brief and discarded it. V13 grabbed the clean incontinence brief and put it under the resident. V12 and V13 placed R127 his back, pulled the clean brief through and fastened it closed. They removed their gloves. V12 stated gloves are changed anytime they go from dirty to clean, after peri-care, when they come into a room, and when they leave a room. V12 stated it is done for infection control.The Care Plan dated 2/23/26 For R127 showed R127 has an activity of daily living self-care performance deficit due to cerebral palsy, dysphagia, history of falls, acidosis, hypertension, obstructive and reflux uropathy. Assist with activities of daily living as needed. Provide needed level of assistance and support to complete activities of daily living. R127 is incontinent of bowel. The Face Sheet dated 4/16/26 for R127 showed diagnoses including congestive heart failure, atrial fibrillation., cerebral palsy, dysphagia, obstructive and reflux uropathy, hypertensive heart disease with heart failure, benign prostatic hyperplasia, orthostatic hypotension, retention of urine, cardiomyopathy, acute on chronic respiratory failure, anemia, ileus, gastrointestinal hemorrhage, supraventricular tachycardia, dysarthria and anarthria. The Minimum Data Set (MDS) dated [DATE] for R127 showed he is dependent for activities of daily living.

Based on interview and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 2 of 3 residents (R1 & R2) reviewed for dignity in the sample of 6. The findings include:On 4/4/26 at 9:31 AM, R1 stated, he was upset at V4 Certified Nursing Assistant (CNA). R1 stated that about a week ago, R1 was in the dining room and asked V4 to help a lady who is [AGE] years old who looked like she was pleading for help and can't speak English. V4 CNA refused to help him or the lady. R1 stated, he couldn't remember the resident's name but knows she lives on the 100 hall, is [AGE] years old, and speaks only Spanish. The facility's census showed a resident on the 100 hall that is [AGE] years old (R2). R1 confirmed that it was the resident, and he just needed to hear her name. He stated, V4 CNA is Spanish speaking as well and that is why he asked her to please help R2 because he couldn't understand what she was saying. V4 CNA told him 'no' and to ask the activity aide (V8) for help and left the dining room. On 4/4/26 at 11:30 AM, V8 activity aide stated, she was in the dining room the day R1 asked V4 CNA for help with R2. V8 was doing an activity with other residents. V4 CNA was bringing another resident to the dining room when R1 asked her to help R2. V4 CNA told him, she was busy and not right now. R1 told her it was very important, R2 needed help, and he didn't understand what R2 was saying. V4 CNA said no and told him to ask V8, for help. R1 said V8 stated, she couldn't help either because she does not know any Spanish and R2 is Spanish speaking only. V4 CNA left the dining room without helping R1 or R2. On 4/4/26 at 10:54 AM, V4 CNA stated, she was taking a resident into the dining room after her shower when R1 asked her if she could help R2. She told R1, she would look for R2's CNA to help her and left the dining room to find R2's CNA. V4 stated, she was suspended for about a week because of the incident. On 4/4/26 at 12:26 PM, V1 Administrator stated, R1 was upset because he asked V4 CNA for help with R2, and V4 refused to help R1 or R2. V1 did give V4 CNA disciplinary action for telling him that she was busy and couldn't help them. V1 told V4 CNA that all residents are everyone's responsibility. V1 said, She had two seconds to see what (R2) needed and she should have asked before leaving.V4 CNA's disciplinary memorandum dated 3/25/26 shows, Description of violation: #12 Discourteous behavior to any resident or visitor. Detailed information of violation/corrective action taken: On 3/25/26, it was reported that a resident requested assistance from staff and did not receive a response from you. Failing to acknowledge or respond to a resident's request for help is considered discourteous and does not meet the expectations for resident-centered care. Policy/Expectation: Staff are required to treat all residents with dignity and respect and to respond to requests for assistance in a timely manner, as outlined in facility policies regarding resident rights and customer service standards. The same memorandum shows, she was suspended for 3 days: 3/29/26, 3/30/26 & 3/31/26. R1's Minimum Data Set, dated [DATE] shows he is cognitively intact. The facility did not provide a policy for dignity. On 4/4/26 at 1:49 PM, V1 Administrator stated they did not have a policy on dignity but the residents do have the right to be treated with dignity as the disciplinary memorandum shows.

Based on interview and record review the facility failed to notify a resident's guardian of a change in resident status for 1 of 4 residents (R1) reviewed for notification in the sample of 4.The findings include:R1's Face sheet shows R1 was admitted to the facility on [DATE]. This same Face sheet shows V5 is R1's Resident Representative State Guardian. R1's Nurses Note dated [DATE] at 1:54 AM shows, Resident expired, family and Hospice nurse present at bedside. On [DATE] at 3:54 AM the Nurses Notes show Resident's body picked up by funeral home. There is no further documentation in R1's progress notes regarding R1's death or that V5 was notified. On [DATE] at 10:41 AM, V4 (Licensed Practical Nurse) said when a resident expires the nurse notifies the physician, the resident's Power of Attorney and emergency contacts, and a guardian if the resident has one. V4 said if the resident were on hospice, they would need to be called also. V4 said the nurse on duty needs to chart in the progress notes the time of death and who was notified. On [DATE] at 12:15 PM, V2 (Director of Nursing) said upon a resident's death the nurse needs to notify hospice if applicable, emergency contacts/ Power of Attorney or guardian and the physician. V2 said if hospice is present at the time of death, hospice will, in collaboration, with nursing help with notification. V2 said nursing should chart who was notified and the time of death in the progress notes. V2 said hospice does document also. On [DATE] at 12:36 PM, V6 (Director for Hospice) said there was a hospice nurse at the bedside when R1 expired, as well as family. V6 said the hospice nurse was new and did not have access to the electronic medical record and did not think to ask if there were other emergency contacts or a guardian to notify. V6 said R1's guardian was not notified of R1's death. V6 said there is no documentation in the hospice nurses charting that R1's guardian was notified. The facility's Change of Condition (Resident) Policy dated 9/2020 shows To ensure that the resident's physician/physician on call/Nurse Practitioner and responsible party is kept informed regarding the resident's change in condition. Place call to responsible party to notify them of the resident's change in condition.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3.The findings include:A facility abuse investigation report dated 1/18/26 showed R2 was slapped in the face by R1 after R1 and R2 had a verbal altercation. R2 sustained a minor bloody nose because of the incident. R1 and R2 were separated by staff. R1 was sent to a local hospital for an evaluation. R1 was moved to a different unit, separate from R2, upon R1's return to the facility. The report showed both R1 and R2 had a diagnosis of dementia. R1's current care plan showed R1 was mildly cognitively impaired. R1 had a history of being verbally and physically abusive towards peers and staff. A progress note dated 5/16/25 showed R1 struck another resident with a television remote. A progress note dated 11/23/25 showed R1 pushed a CNA (certified nursing assistant). R2's current care plan showed R2 was severely cognitively impaired. On 1/26/26 at 9:00 AM, R1 stated he remembered the incident on 1/18/26 involving R2. R1 was able to identify R2 by full name. R1 stated, on 1/18/26, he struck R2 in the face because R2 had stabbed his arm. R1 was unable to state what R2 stabbed him with. R1 stated he didn't remember what was said between himself and R2 on 1/18/26 but stated, She (R2) stabbed me, so I hit her back. On 1/26/26 at 9:15 AM, an attempt to interview R2 about the incident on 1/18/26 was unsuccessful due to R2's impaired cognition. R2 had no recollection of the incident. On 1/26/26 at 10:42 AM, V4 CNA stated he witnessed the incident between R1 and R2 on 1/18/26. V4 stated on 1/18/26, R2 was seated at a table by the window in the dining room of the memory care unit. V4 stated R1 walked over to look out the window and stood directly next to R2 as she was seated at the table. R2 tapped R1 on the shoulder and asked R1 to move away from her in which R2 told R1 to mind her business. V4 stated R1 and R2 began to argue. V4 stated R2 then took her hand and put her hand on R1's chest to attempt to push R1 away from her. R1 then slapped R2 in the face. V4 stated R1 and R2 were separated by staff. V4 stated R2 did not stab R1 with anything during the incident. V4 stated R2 suffered a minor nosebleed as a result of the incident.On 1/26/26 at 11:34 AM, V5 Activity Aide stated she witnessed the incident involving R1 and R2 on 1/18/26. V5 stated, on 1/18/26, she was leading an activity on the memory care unit when she heard a commotion in the back of the room. V5 stated R1 was standing next to R2 as they were arguing back and forth. V5 stated R2 tapped R1 on the shoulder. R1 and R2 continued to argue. R1 then slapped R2 in the face. V5 stated R1 and R2 were separated by staff. V5 stated, (R1) kept saying she (R2) hit me first, so I hit her back. V5 stated she never saw R2 hit or stab R1 at any time during the incident.On 1/26/26 at 12:10 PM, V1 Administrator stated she completed the abuse investigation involving R1 and R2 on 1/18/26. V1 stated she substantiated the allegation of R1 physically abusing R2. The facility's abuse policy dated July 2025 showed, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies. The policy defined physical abuse as hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for transfers in the sample of 3.The findings include:R1's facility assessment dated [DATE] show R1 has a BIMS of 15-no cognitive impairment.The same assessment show R1 has no behavior of making false statements.R1's care plan (undated) documents R1 is at risk for falls due to diagnoses of multiple sclerosis (MS) with left sided weakness.R1 requires the use of mechanical lift for transfers, with intervention of: provide 2 staff assistance for transferring. On 12/18/25 at 9AM, R1 said the agency Certified Nursing Assistant -CNA came to the room last night and said it was time for your shower. R1 said he reminded V7 (CNA) that he needed another staff to help. V7 insisted he can do it himself. V7 said when he was strapped in the mechanical lift, and V7 was placing him in the shower chair, the shower chair moved, the shower chair tipped over with R1, both ending on the floor.On 12/18/25 at 11:30 AM when this surveyor asked V5 (Registered Nurse) if there were any falls she was following up. V5 said V6 (CNA) reported to her that R1 told him, he fell last night. V5 said she spoke to R1, and asked what happened, R1 said the same thing he told the V6 CNA (and this surveyor). R1 said he was being transferred by one staff last night using the mechanical lift when he fell with the shower chair. V5 said R1 is a mechanical lift transfer needing 2 staff for transfer for safety.R1's progress notes dated 12/18/25 documents, Residents stated he was in the mechanical lift transfer being transferred to the shower chair then states the shower chair tipped over backwards and he fell backwards with it, he reports that the (mechanical lift) sling broke his fall so he didn't get hurt.On 12/18/25 at 1:31 pm V6 CNA said R1 told him this morning that the agency CNA (V7) dropped him (R1) when the CNA V7 by himself put R1 in the shower chair and R1 ended on the floor.On 12/18/25 at 2PM, V3 (Asst Administrator) said V7 was an agency CNA with a DNR (do not return) status at this time. R1 had been consistent with his statements. V3 said the investigation was ongoing with R1's fall.

Based on interview and record review the facility failed to ensure a resident's representative was notified of a resident's change in condition to 1 of 3 residents (R1) reviewed for notification in the sample of 7.The findings include: R1's electronic face sheet under contacts documents V9 (R1's daughter) was: Resident Representative, emergency contact #1, care conference person, customer care representative V9's information included V9's address and phone number. On 9/26/25 at 10:10 AM, R1 was in bed with oxygen on at 2L via nasal cannula alert and able to verbalize her needs. R1 said she wanted her daughter to be informed of whatever was going on with her. R1 said she was hoping she will be able to speak to her soon, my daughter is the love of my life. R1's physician order sheet dated 8/17/25 documents Azithromycin Tablet 250 MG, give 2 tablets by mouth one time only for pneumonia, then Give 1 tablet by mouth in the afternoon for pneumonia for 4 Days.R1's medical record as confirmed with V2 (Director of Nursing) did not show that V9 R1's daughter and representative was informed of R1 with pneumonia and R1 being treated with antibiotics due to pneumonia. V2 said R1's daughter should have been informed of R1 having pneumonia and being treated with antibiotics. V2 said R1's updated her phone number prior to R1 having pneumonia. R1's electronic EMR has V9's updated phone also confirmed with V2 (DON), V2 said Families need to be informed so they know what was going on with their loved ones. On 9/26/25 at 1:45 PM V10 (Registered Nurse) said R1's daughter (V9) was R1's representative and emergency contact. V10 (RN) said V9 was the one to be called for any change in R1's condition including new orders of meds and antibiotics and then document in the resident's medical record.The facility policy on Change of Condition (Resident) dated 9/20 show: to ensure that the resident's physician and responsible party is kept informed regarding the resident's change in condition- 5. place call to responsible party to notify them of the residents change in condition.

Based on interview and record review the facility failed to follow its policy for a resident that left the facility without supervision and staff knowledge for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 9.The findings include:Findings include:R1's Face sheet dated 8/16/25 showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to COPD (chronic obstructive pulmonary disease), moderate protein-calorie malnutrition, iron deficiency anemia, alcohol dependence, mood (affective) disorder, and hypertension.R1's Physician Order Sheet showed he was allowed to go out on a community pass alone.R1's Elopement Risk Assessment completed 7/17/25 showed he was not at risk for elopement.R1's facility assessment dated [DATE] showed he was cognitively intact and was independent with all Activities of Daily Living (ADLs).On 8/16/25 at 10:55 AM, V7 (Registered Nurse) said she was taking care of another resident when the door alarm went off. V7 said she immediately went to the door and R4 was outside smoking. V7 said R4 reported that R1 had walked out the front door and down the road. V7 said she walked down the street and could not see R1. V7 said she returned to the facility, informed staff to start looking for R1, and called V1 (Administrator). V7 said she did not call the police. V7 said R1 didn't tell anyone he was leaving, and they were all surprised. V7 said they didn't know where R1 was going.On 8/16/25 at 11:21 AM, V9 (police detective) said R1 walked out the front door of the facility on 8/13/25 at 4:45 AM. V9 said the facility reported that R1 set off the door alarm. V9 said the facility didn't notify the police R1 was missing. V9 said time is crucial with a missing person. V9 said the facility staff went to V33's house (R1's family member), in a different town, instead of calling the police. V9 said V33 was out looking for R1, happened to see the police, and filed a missing person report. V9 said a few hours had passed since R1 left the facility. V9 said R1 was located in another state, contact was made by local police, and he was deemed not a risk to himself or others. V9 said their missing persons case for R1 was closed.R1's Progress Note dated 8/13/25 showed R1 left the facility at 4:45 AM against medical advice (AMA). This note showed R1 was observed walking out the front door with his belongings in a handbag. This note showed R1 was alert, oriented, and decisional. This note showed V33 (R1's family member) was notified. This note does not show that the facility notified the police.R1's Police Report showed that V33 (R1's family member) reported him missing on 8/13/25 at 7:09 AM. This report showed the facility video footage was observed and R1 left the facility at 4:45 AM. This report showed that R1 was located in another state; was deemed of sound mind with no mental deficiencies; R1 refused to go to the hospital; and R1 was not appropriate for an involuntary hold.On 8/19/25 at 12:24 PM, V1 (Administrator) said he got a call from V7 (RN) on 8/13/25. V1 said he was told R1 left the building, and they could not find him. V1 said he went to V33's house (R1's family member) to see if R1 went there. V1 said V33 told him that R1 had run off before and she provided a few places to look. V1 said he went to a local hotel and the hospital to look for R1. V1 said he didn't call the police to report R1 missing. V1 said the police called him around 8 AM on 8/13/25 to gather information about R1. The surveyor asked V1 why he didn't follow the facility's policy for Missing Residents. V1 replied, He left AMA. The surveyor asked if the facility knew where R1 was going and he replied, No. The surveyor referenced the facility's policy and V1 said he should have called the police.The facility's Missing Resident Policy dated 9/2020 showed, It is the policy of this facility to report and investigate all reports of missing residents. Procedure: 1. All personnel are responsible for reporting a resident suspected of missing to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving.2. Should an employee discover that a resident is missing from the facility, he or she should: .f. Call 911 to report the resident missing. g. The Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident. The following steps should occur: .iv. Notify the sheriff and/or police department and file a missing person report. ix. Document appropriate notations in the medical record.

Based on interview and record review the facility failed to ensure a discrepancy with a resident's psychotropic medication was reconciled with a physician upon re-admission after a hospitalization for hypertension for 1 of 31 residents (R137) reviewed for significant medication errors in the sample of 50. This failure resulted in R137 not receiving depakote, which was previously prescribed for aggressive behaviors, to display aggressive behaviors towards another resident and subsequently be sent out to the hospital for an evaluation. The findings include: R137's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: depression, anxiety, history of traumatic brain injury and history of suicidal behavior. R137's Psychiatric Nurse Practitioner Note dated 10/9/24 shows, Nursing and staff report moods labile with sarcastic passive aggressive comments at times .He endorses a history of becoming angry and threatening people, states you don't want to piss me off; admits to recent feelings of anger with moods up and down at times .I recommend to continue his current medication regimen and start depakote 125 mg (milligrams) bid (twice a day). R137's Psychiatric Nurse Practitioner Note dated 12/11/24 shows, He feels that his moods are generally stable, but he still gets angry more frequently than he believes he should, especially regarding his roommate when they turn on the lights during the night or early morning. An increased dose of depakote to 250 mg p.o (by mouth) twice daily was discussed and patient is agreeable to this change. R137's Psychiatric Nurse Practitioner Note dated 2/19/25 shows, Mood and behaviors at baseline. Currently on depakote 250 mg twice daily, which was increased 12/11/24 due to anger management issues, and patient tolerating the dose well. Continue current psychiatric medication regimen including depakote. R137's Hospital After Visit Summary shows that he was admitted to the hospital from 3/17/25-3/19/25 for hypertension. R137's After Visit Summary does not show that R137 should stop taking depakote nor does it say to start taking depakote. R137's March Medication Administration Record (MAR) shows that he received depakote 125 mg - two tablets twice a day until 3/17/25. R137 March MAR does not document that he received depakote upon re-admission on 3/19/25 to 3/26/25. R137's Administration Note dated 3/25/25 shows, On 3/24/25 at approximately 9:30 AM [R137] stated to this writer that he was very unhappy with his roommate. During the conversation [R137] verbalized signs of aggression involving his roommate. He stated, If my roommate is still here tonight I'm going to kill him.he was sent to the hospital for a psych evaluation. On 3/26/25 at 1:25 PM, R137 said that he does not recall the hospital changing or discontinuing his depakote when he was admitted to the hospital for his high blood pressure. On 3/26/25 at 1:30 PM, V23 (Physician) said that once a resident re-admits from the hospital, the nurse from the hospital and the nurse from the facility should go over all ordered medications and compare them to their previous medications and if there is a discrepancy, they should discuss the reason for the discrepancy and if they can not figure out why a certain medication is not re-ordered, they should contact the physician or nurse practitioner to get the discrepancy clarified. V23 said, Especially if it is an important medication like this one.

Based on observation, interview, and record review the facility failed to supervise residents on the dementia unit while an exit door was alarming and unlocked. This failure resulted in R1 exiting the building, being picked up by a stranger, and driven away from the facility. This failure has the potential to affect the 17 residents who reside on the dementia unit with wandering or exit seeking behaviors. This past compliance occurred from 10/7/23 to 10/7/23. The Immediate Jeopardy began on 10/7/23 at approximately 9:15 AM when R1 exited the facility unsupervised through an alarmed, unlocked door to the dementia unit. R1 was later found by a stranger and driven 1-1 1/2 miles from the facility. When the stranger realized R1 was confused, they notified the police and R1 was returned to the facility. The Immediate Jeopardy was identified on 10/13/23. V1 Administrator was notified of the Immediate Jeopardy on 10/13/23. The findings include: The facility face sheet showed R1 to have diagnoses to include unspecified dementia with other behavioral disturbance, cerebral ischemia (impaired blood flow to the brain) and cognitive communication deficit. The initial nursing assessment dated [DATE] shows to be oriented to person only and is considered confused. The facility assessment dated [DATE] shows R1 can walk independently. The assessment showed R1 had wandering behaviors daily and required supervision for activities of daily living. A facility incident report dated 10/7/23 showed R1 was found outside the facility by a police officer and was returned to the facility. R1 was described as alert and oriented times one (Person) The facility investigation report showed the staff were redirecting another resident (R2) away from the dementia unit exit door, which was alarmed. R2 was able to push open the door, activating the alarm. The staff were busy dealing with the behaviors of R2 and feel this is when R1 was able to exit the building un-noticed through the alarming and unlocked exit door. On 10/13/23 at 9:28 AM, V12 responding police officer said the police department received a call at 9:30 AM on 10/7/23. The call was from a citizen who said they had picked up an elderly woman on a busy street near the facility to give her a ride. They quickly realized the person was very confused and called the police. V12 said R1 was picked up by the police about 1-1 1/2 miles from the facility in a cul-de-sac of a residential neighborhood. V12 said R1 told him she was going to visit her uncle V but was not even sure what town he lived in, or where she was. V12 said he assumed she was from a nursing home near-by, but she did not know where she lived. V12 said when he asked R1 if she was from this facility, she said yes. V12 then called the facility to notify them of the situation and returned R1 to the facility. On 10/12/23 at 9:05 AM, V11 R1's Power of Attorney-POA, said the family decided to place R1 in a nursing home because she had dementia and was unable to care for herself. V11 said prior to nursing home placement, R1 lived at home with her husband. V11 said R1's husband had a fall and had to go to the hospital. V11 said while R1's husband was in the hospital, R1 called the police two or three times and said she was being held prisoner and they were trying to poison her. V11 said R1 had called the police on herself, because she was the only one there at the time. V11 said R1 and her husband lived in Arizona prior to moving to this state and one day R1 had driven to the store and could not remember how to get home. V11 said he did not know if R1 was cognitively intact enough to safely cross streets on her own. V11 said his fear was that she would be so excited about getting out of the door, that she would take off running and run out into traffic. V11 said R1 had told the family before she was even placed in a nursing home, that if we ever put her into a nursing home she would run into traffic. V11 said prior to being transferred to the current facility, she was at another facility and had an elopement. V11 said the other facility had a wander guard alarm on R1 and she would try to chew it off, tear it off, anything to get it off so she could get out of the facility. V11 said the other facility told him that R1 could not stay there because it did not have a locked unit. V11 said the elopement from the other facility was in June of 2023 and R1 was only there for another week or two before she was transferred to the current facility. On 10/11/23 at 10:06 AM, V8 Certified Nursing Assistant (CNA) said she was working the day R1 got out of the building. V8 said she had left the unit to go get linens and use the bathroom. V8 said she heard the announcement of the dementia unit exit door being opened so she quick got her linens, used the bathroom, and hurried back to the unit. V8 said when she got back to the unit another CNA was trying to get R2 to settle down and quit trying to hit the staff. V8 said she continued to help R2 until she calmed down and then went to give another resident a shower. V8 said after the shower the nurse told her that R1 had gotten out of the building and was being brought back to the facility by the police. V8 said R1 is ambulatory by herself, likes to wander, and talks about leaving the unit to go home often. On 10/11/23 at 10:35 AM, V9 CNA said she saw R2 head down towards the exit door at the end of the hall, so she followed her down because she knows R2 would try to open the door. V9 said R2 was able to get the door to open before she could stop her. R2 was hitting V9, biting her, and slamming her head back into V9's body. V9 said the nurse came to help her and together they were able to get R2 away from the door and back to the activity room. V9 said she was not able to get the door to stop alarming due to R2's behavior. V9 said the nurse kept trying to get the alarm to stop but was not able to, so the nurse went and got the activity aide to shut the alarm off. On 10/11/23 at 10:50 AM, V6 Registered Nurse (RN) said she was the nurse working on the dementia unit on 10/7/23 when R1 left the building. V6 said she heard the door alarm go off and saw V9 struggling with R2 at the exit door. R2 was hitting, trying to bite V9, and was slamming her head into V9's body. V6 said she went down and helped get R2 away from the exit door and up the hall to the activity room. V6 said she could not get the alarm to stop and was worried about the safety of the staff and R2, so she left the exit door unattended. V6 said as they were bringing R2 away from the door, R1 was observed walking into her room on the same hall of the exit door that was alarming. V6 said the door was not being monitored for approximately 10-15 minutes. V6 said about 15 minutes later, the receptionist called her and told her the police had found R1 walking around outside and were bringing her back to the facility. V6 said she did not know R1 had left the unit. On 10/11/23 at 11:05 AM, V7 Activity Aide said she was doing activities with the residents when R2 was found trying to leave the unit. V7 said she tried to help the CNA's calm R2 down after she was brought to the activity room. V7 said the nurse asked her if she could go shut off the alarm on the exit door. V7 said she walked down the hall to the door. V7 said there were no staff present at the door and the door had been alarming for 20 to 30 minutes. On 10/11/23 at 11:16 AM, V4 Receptionist said she does not remember what time the call came in as she was busy at the front desk. A call came in and the caller ID said it was the City of [NAME]. When she answered, the caller did not identify themselves and just asked if the facility had a resident by the name of a resident not in the facility. V4 said she told them no and they hung up. V4 said about 15 minutes later a police officer called and asked if the facility had a resident by the name of R1. V4 told them yes and V4 said the officer then said R1 was found walking around outside and the officer would bring the resident back to the facility. On 10/11/23 at 2:03 PM, V2 Assistant Administrator said the staff are expected to stay at a door when is is alarming to assure no residents can leave the locked unit. On 10/13/23 at 10:22 AM, V1 Administrator said he expects the staff to reengage the alarm after it alarms and if not able to stop the alarm and reengage the lock, the staff are to stay with the door until it can be relocked. On 10/11/23 at 12:11 PM, V5 Maintenance Director and V1 Administrator showed the surveyor the door that R1 left from. The bar to the door had to be held down for 15 seconds and the door was able to be opened. The alarm sounded to the door. The door did not lock again until the code was entered into the keypad. V1 said once the door is alarmed, it will not engage the lock again until the code is entered. On 10/11/23 at 3:27 PM, V10 R1's Primary Care Physician said he would expect staff to monitor an exit door that is alarming, but not secured, so that other residents with wandering and exit-seeking behaviors cannot get out of the facility. V10 said that is why R1 is at this facility, because she had elopements at the previous facility. V10 said R1 had a wander guard alarm on at the previous facility, but they were so worried she was going to get out again. V10 said that is why R1 was transferred, so she would be safer on a locked unit, and not be able to get out of the facility. The admission resident safety/abuse screening assessment dated [DATE] for R1 showed R1 had a history of exit seeking and wandering. The 6/23/23 discharge papers, from the previous long term care facility R1 resided at, showed R1 needs a secure unit because she is self-ambulatory to all destinations without assistive devices. She requires 24-hour supervision. The facility Psychiatric note dated 8/11/23 shows R1 having intermittent behaviors and agitation. R1 was observed ambulating in the facility with increasing agitation and anxiety. R1 was calling staff inappropriate names and hitting the staff. R1 was looking for her husband and demanding to see him. An episodic behavior assessment dated [DATE] for R1 showed her to be wandering and attempting to try and leave the unit. The behavior assessment showed R1 was agitated because she felt she was not fed breakfast. R1 was showing threatening behaviors towards staff and attempted to leave the unit 3 times. R1's care plan dated 7/3/23 showed she had wandering behaviors such as moves with no rational purpose, seemingly oblivious to needs or safety. One of the interventions in place was to remove resident from other resident's rooms and unsafe situations. A care plan for anxiety shows her to wander up and down the halls, asking where her husband is, and asking to go home. The facility investigation into the incident on 10/7/23 showed a note from V6 RN stating she was assisting the staff with a combative resident (R2) who had opened an exit door causing the alarm to sound. V6 stated she saw R1 going into her room, as the emergency exit door was still beeping but she could not get the alarm to stop. V6 then stated she asked another employee to enter the code to shut off the alarm. After the alarm was silenced, she went back to passing her medications and was notified by the front desk that the police had found R1 outside of the building and were bringing her back. The facility provided a list of the residents that are identified as having wandering behaviors on 10/13/23. The facility policy dated 9/2020 for door alarms shows the facility will provide a safe environment for the residents and staff will be provided to assure resident and visitors safety by setting door alarms at all times and re-setting the door alarms immediately after used. The procedure includes: 1. Set door alarms, 2. Monitor alarm panel to assure set, 3. Respond immediately when alarm sounds by checking alarm panel for location of alarm and proceed to door, 4. Investigate reason for the alarm, 5. Determine if all residents are safe and accounted for, 5. Reset alarm. The facility policy for elopement and management of missing resident dated 3/28/23 shows it is the policy of this facility to report and investigate all reports of missing residents and to minimize risks of elopement. Elopement is defined as a dependent (cognitively impaired, non-decisional) resident leaving a facility without staff awareness and under circumstances that place the residents health, safety or welfare at risk. B. if able to determine the reason for the alarm sounding, reset the door alarm and no further action is needed. Prior to the survey date of 10/13/23, the facility had taken the following action to correct the noncompliance: Area of non-compliance Lack of supervision of an alarmed exit door in the memory care unit leading to a Resident wandering out. Corrective Action Taken: Resident was reassessed for elopement risk on 10/7/2023 after the elopement occurred and deemed to be at risk. Resident care plan was updated pertaining to elopement on 10/7/2023. 15-minute checks for R1 have been implemented for 72 hours after which the facility will re-evaluate. A head count of all units was completed to make sure no other Residents were affected. Everybody was accounted for. All door alarms on the memory care unit were checked for proper operation. All were in perfect working order. On 10/7/2023 the Administrator, Assistant Administrator, Nurse Consultant and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Exit Seeking, Abuse, and Incidents/Accidents. No changes were made. The DON/ADON and Social Service are responsible for the assessments and updating care plans. The Administrator/designee is responsible for monitoring and reeducation of staff to ensure safety. Identifying other residents having the potential to be affected by the same deficient practice: All residents that are identified to be at-risk for elopement during admission had a review of their care plan and updates were made where applicable, completed on 10/7/2023. The elopement binder was reviewed on 10/7/2023 and is available on all nursing stations and at the front desk. All residents determined to be at-risk for elopement and with active exit-seeing behaviors will be evaluated for a possible room change to the secured unit of the facility. These interventions started on 10/7/2023 and will continue until their next assessment. On 10/7/2023, interviews were conducted with all staff present during the incident. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur. All staff and managers are being reeducated on routine checks of Residents with exit seeking behaviors. All staff and managers are being reeducated on abuse prevention and incidents/accidents. All staff and managers are being reeducated on elopement policy and procedure and where to locate the elopement binders. The reeducation was provided on 10/7/2023 and was completed on 10/9/2023. Quizzes are being completed by the staff to test competency. All staff and managers are being reeducated regarding door alarms checks and response specifically on how to secure an alarmed door. In-service started on 10/7/2023 and was completed on 10/9/2023. All staff and managers are being educated on initiating a head count as soon as the facility receives a call of a missing person. During orientation of new hires, specific education will be provided on the items above. Elopement drills will be conducted weekly on different shifts until substantial compliance is achieved. A head count is being completed on every nurse shift change on all units. Quality Assurance Plans to monitor facility performance: A review of compliance using Quality Assurance Audit tool for elopement started on 10/7/2023. The Audits will be done weekly on different shifts until substantial compliance is achieved. The facility Quality Assurance Team/ IDT includes the Medical Director, Administrator, Assistant Administrator, Social Services, DON, ADON, Activities Director, Restorative Nurse, Resident Care Coordinators, Treatment nurse and facility consultant. The QA meeting is held quarterly and as needed. An emergency QA meeting was held on 10/7/2023 at 11:00am by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from facility on 10/7/2023 was discussed along with Abatement Plan. The Medical Director and Interdisciplinary Care Team approved this Abatement Plan. This will be monitored by the Administrator, DON, ADON, and Social Services.

Based on observation, interview and record review the facility failed to ensure a resident was repositioned in a safe manner. This failure resulted in R78 rolling out of bed during repositioning, sustaining a laceration requiring emergency medical treatment and 8 sutures to her forehead. The facility also failed to provide assistance to residents by ensuring they safely returned to the facility and failed to ensure the front door alarm was on from 8:00 PM until 7:00 AM. This applies to 7 of 25 residents (R78, R66, R114, R98, R49, R86 & R74) reviewed for safety in the sample of 25. The findings include: 1. R78's fall incident report dated June 2, 2023 shows, Incident Description: Nursing Description: Resident fell off bed. Per CNA V10 (Certified Nursing Assistant), she put her on her L (left) side to change her diaper, turned around to reach for the diaper on the table, saw the resident falling as the bed moved. Resident Description: Resident is nonverbal. Immediate Action Taken: Description: Physically assessed, noted a 4x1 cm (centimeter) laceration above R (right) eyebrow, 3x3 cm skin tear L hand and bilateral knee abrasion R78's MD (Medical Doctor) progress notes dated June 2, 2023 shows, History of Present Illness: Alz (Alzheimer's) dementia, PE (pulmonary embolism), aphasia, anemia, on Eliquis (blood thinner) had a witnessed fall. She rolled over bed as bed moved. She hit her head and had a laceration above her [NAME] {SIC (statement is correct)] (right) eye. Has HA (headache). No neck pain. She is bleeding profusely from her laceration. Physical Exam: Exam findings per nurse and video observation. Physical Exam- Notes: Gen (general) has distress due to pain. Head: laceration noted above RT (right) eye. Fresh blood noted . Orders: Transfer to ER (emergency room ) as PT (patient) will need sutures and further W/U (work up) to rule out ICH (intracerebral hemorrhage) . R78's emergency room after visit summary dated June 2, 2023 shows, Reason for Visit: Fall, Diagnoses: Head injury, fall from bed, cut on face. Instructions: Today you were evaluated for injuries to you face and head. You also had a laceration in this area that required repair. You have 8 sutures in total that will need to be removed in 5 days . R78's nurse notes/progress notes dated June 2, 2023 shows, resident returned to facility from hospital with 8 sutures to forehead . On July 11, 2023 at 9:13 PM V11 Registered Nurse (RN) stated, she wasn't in the room at the time of the fall. V10 CNA came and got her saying R78 was lying on the floor. V10 CNA told V11 RN that she was changing R78 in bed. She turned R78 on her side when she turned around to get a diaper. The bed moved a little bit and R78 fell off the bed. R78 landed face down on the floor. V10 CNA was by herself changing R78's diaper. V11 RN stated, R78 does not move on her own and the staff have to repositioned her. If you put her on her side, chance of gravity will either fall back onto the bed or forward off the bed. On July 11, 2023 at 10:05 AM, R78 was lying in bed, asleep. On July 11, 2023 at 12:03 PM, V13 CNA stated, R78 should have two people when taking care of her. She is a mechanical lift. She can not move herself. You are supposed to have everything ready before you start doing care. On July 11, 2023 at 11:53 AM, V12 Nurse Practitioner stated, if she wouldn't have fallen off the bed she would not have gotten sutures to her head. The fall caused the laceration. R78's Minimum Data Set (MDS) dated [DATE] shows, she is not cognitively intact. The same assessment shows she requires extensive assist of two persons for bed mobility and toilet use. R78's care plan date initiated December 31, 2018 shows, Focus: R78 has an ADL (activities daily living) Self Care Performance Deficit due to Dx Alzheimer's Disease, unspecified dementia without behavioral disturbance, dysphagia, oropharyngeal phase, aphasia . 2. On July 12, 2023 at 9:05 AM, R66 stated, last week (July 5, 2023) the facility would not let them smoke because it was too hot outside. We had to go off the property if we wanted to smoke. So we did. R66 and her friend R114 went out the front door to smoke off the property. They went out the front door to the sidewalk right in front of the building in the shade. When they were done smoking R66 got stuck and couldn't get back in the building. They called the facility and spoke with V17 Receptionist. V17 told them it was shift change and no one would come get them. So they called 911 instead. 911 came and helped get them back into the facility. On July 10, 2023 at 12:09 PM, R114 stated, there were three days the facility canceled smoking outside because it was too hot out. On the 3rd day, V1 Administrator told us if we wanted to smoke we had to go off the property to do it. They went out the front door down the sidewalk in front of the building to smoke. It was her (R114) and R66. When they were done smoking they called the facility and spoke with V17 Receptionist who told them the staff was busy, it was shift change and no one was coming to get them. They waited 5 minutes and called again to see if anyone was coming to get them and were told no again. They called V22 Ombudsman who told them to call 911. They called 911 and 911 helped them get back into the facility. On July 11, 2023 at 9:22 AM, V17 Receptionist stated, she works at the front desk Monday through Friday. V1 Administrator had canceled smoking due to the high temperatures outside on July 5, 2023. When R66 and R114 came to the front desk, she told them it was hot outside and they would have to sign out showing they were aware of the risk of going outside to smoke. They stated, they didn't care and went outside. V17 went to V1 Administrator and let him know they went outside smoking. R66 and R114 were visible from the receptionist desk. R66 and R114 called at 2:06 PM saying they needed help coming back into the facility. V17 called V1 Administrator and he told her, it was not our responsibility because they signed the binder. She told R66 and R114 it was shift change they might be busy. R66 called again and asked if someone was coming to get her and she told her she would try to get someone to come get her. R66 said if no one came she would call 911. She did end up calling the ambulance. They told me not to find anyone because they signed the binder. The fire fighters came and wheeled them to the entrance of the facility. On July 10, 2023 at 3:10 PM, V22 Ombudsman stated, R66 and R114 called him saying they were outside the front of the building smoking and R66 got stuck and no one would come help them get back into the facility. He told them to call 911 because it was hot outside. They (the facility) furthered what was already unsafe. It was a power play. On July 12, 2023 at 10:40 AM, V30 Local Police Dispatch stated, they received a call on July 5, 2023 for a lift assist from a caller (R66) stating she needed help getting back to her room. They sent the fire department to assist. R66's progress notes dated July 5, 2023 shows, This writer (V1 Administrator) and the activities director had a conversation with R66 in regards of canceling the supervised smoking program due to the inclement weather. We advised R66 for safety to not go outside to smoke today. R66 refused to acknowledge the risk and stated that she will go on the street to smoke. Again this writer and the activities director urged her to reconsider her decisions since R66 can not safely propel her wheelchair to get back to the facility from the sidewalk . R66's progress notes do not show, she called 911 and they brought her back to the facility from the sidewalk. R66's MDS dated [DATE] shows, she is cognitively intact. R114's progress notes dated July 5, 2023 shows, This writer (V1 Administrator) and the activities director had a conversation with R114 in regards to the facility canceling the supervised smoking program due to the inclement weather. We advised R114 for her safety to not go outside to smoke today. R114 refused to acknowledge the risk and stated that she will go on the street to smoke. Again this writer and the activities director urged her to reconsider since she can not safely propel her wheelchair to get back to the facility from the sidewalk . R114's MDS dated [DATE] shows, she is cognitively intact. 35174 3. On 7/10/23 at 5:00 AM, the facility's front entrance door alarm did not sound upon entering the facility. There were no staff present at the front desk or in the front hallway of the facility at that time. On the backside of the door there is a sign posted which stated an alarm is set on the door after 8 PM. The facility's Elopement Risk List of Residents printed on 7/10/23 showed R49, R74, R86, and R98 are 4 residents living on the first floor of the facility not residing within the memory care unit. R49, R74, R86, an R98's careplans showed all 4 residents have focuses for elopement with goals of remaining on their units or under supervision. On 7/10/23 at 11:00 AM, V17 Receptionist stated the evening receptionist gets the alarm key and should set the alarm before leaving the facility around 8:00 PM. The key is kept at the nurses station on the 400 wing. On 7/10/23 at 11:30 AM, V28 Director of Life Safety stated the front door alarm needs to be activated at night to ensure the safety of the residents to let staff know if a resident had attempted to leave through that door. On 7/11/23 at 10:55 AM, V1 Administrator showed the process to activate the alarm with the key. When the door was opened a loud alarm went off. V1 stated the alarm should be activated after 8:00 PM when the front desk staff leave, and the key returned to the 400 hall nurse. V1 stated the front door alarm is the only one needing to be set with a key after hours.

Based on observation, interview and record review the facility failed to provide sufficient and competent staff to meet the needs of the residents. This failure resulted in R78 rolling out of bed while being repositioned by V10 Certified Nursing Assistant in Training (CNA-T), sustaining a laceration requiring emergency medical treatment and 8 sutures to her forehead. This applies to 3 of 25 residents (R78, R227 & R28) reviewed for competent staff in the sample of 25. The findings include: 1. R78's fall incident report dated June 2, 2023 shows, Incident Description: Nursing Description: Resident fell off bed. Per CNA V10 (Certified Nursing Assistant), she put her on her L (left) side to change her diaper, turn around to reach for the diaper on the table, saw the resident falling as the bed move. Resident Description: Resident is nonverbal. Immediate Action Taken: Description: Physically assessed, noted a 4x1 cm (centimeter) laceration above R (right) eyebrow, 3x3 cm skin tear L hand and bilateral knee abrasion R78's nurse notes/progress notes dated June 2, 2023 shows, resident returned to facility from hospital with 8 sutures to forehead . V10 CNA-T's (Certified Nursing Assistant in Training) date of hire is March 10, 2023. She was hired as a Certified Nursing Assistant in Training. On July 11, 2023 at 1:47 PM, V10 CNA-T stated, she is a CNA in training and hasn't taken her exam yet. On July 11, 2023 at 11:53 AM, V12 Nurse Practitioner stated, the facility should be following their policy in regards to CNAs and RAs (resident assistants) scope of practice. V10's CNA-T basic nurse assistant training program clinical skills evaluation shows, she didn't complete her training evaluation until July 7, 2023. On July 11, 2023 at 12:42 PM, V2 Director of Nursing stated, V10 CNA-T was an RA at the time of R78's fall out of bed. She should not have been providing care by herself. The facility's job description last updated March 2023 shows, Title: Certified Nursing Assistant in Training. I. Job Summary: Assist nurse aides with designated resident care specific areas of eating, drinking and personal hygiene. Receive and carry out instructions concerning the specific feeding, hydration and/or personal hygiene care needs of the residents whom he/she will be assigned to assist. Assists with resident activities and transportation . II. Essential Functions: A. Meets the following direct care needs of the resident: (Once proper training has been received- for letter A only): a. Washing a resident's hands and face, b. Feeds residents who do not have complicated feeding problems, c. oral hygiene, d. Shaving residents with electric razor; B. Meets nutritional needs by passing trays, ice water, nourishments, uses adaptive equipment; tray monitoring, C. Applies Makeup, D. Brushing and combing of residents hair, E. Assists in the dining room with tray service and serves trays to the resident's room as requested. Reports any observed changes in resident's eating habits to the staff nurse, F. Makes unoccupied beds, changes linens, straighten rooms, closets, and drawers, G. Cleans mattresses or notifies housekeeping and reports if mattresses need replacement, H. Answers call lights and telephones as needed, I. Observes and reports change in condition or behavior, J. Reports any skin abnormalities or bruising to the staff nurse when identified, K. Meets safety needs by reporting environmental hazards, L. Makes rounds to assure residents are safe and comfortable, M. Assists in weights for wheelchair, independent residents that do not need assistance with transfers, N. Assist with needs/request of the dying resident, O. Observe infection control measures, P. Relates courteously and sensitively to residents, families, visitors, and staff, Q. Responsible for attending assigned in-service programs, R. Documents in POC (plan of care)- amount eaten/eating support, behaviors, offer and encourage fluids, personal hygiene (shaving with an electric shaver, brushing teeth an combing hair, supplements and snacks, weights as needed, S. Assist residents with packing personal possessions when they are transferred to a new room or when being discharged , T. Performs personal laundry duties for each resident which may include completing their personal clothing list, hand washing some of their articles or placing some of their items through the wash cycle when personal laundry facilities are available, U. Stocks isolation carts for each resident on isolation and empties the bins in the room when full, V. Inventories and stores the new residents' personal possessions, W. Assist in unstocking of supply deliveries and restocks floors as needed, X. Participates in In-service education programs, Y. Other duties as assigned . 35541 2. The facility's July 2023 nursing schedule showed V4 CNA-T (CNA in Training) and V5 Licensed Practical Nurse (LPN) were the only staff scheduled on the 400 Wing from 11:00 PM on 7/9/23 until 6:00 AM on 7/10/23. The facility roster dated 7/10/23 showed a resident census of 28 residents on the 400 Wing. V4's Job Description form dated 6/9/23, showed V4 accepted a job as a CNA-T, at the facility, on that date. On 7/11/23, V4's employee file was reviewed and showed no active CNA license. On 7/10/23 at 5:24 AM, V4 CNA-T and V5 LPN were the only staff observed on the 400 Wing. When V4 CNA-T was asked about 400 Wing staffing, V4 stated, I am headed in to check to see if (R227) needs to be changed. We didn't have a CNA assigned to this wing last night. I am not a CNA yet; I don't have a CNA license. I am basically a resident assistant right now. I am starting CNA school in a couple of weeks. V4 entered R227's room by herself. On 7/10/23 at 5:46 AM, V4 CNA-T exited R227's room, carrying a bag of soiled linen. V4 stated, I just changed (R227's) brief. He had a bowel movement. I take residents to the bathroom and change them if they are wet. I have worked here about a month. I've never had a CNA assigned to work with me at night. I pretty much provide cares to the residents by myself. V4 CNA-T stated she provided incontinence care to R227 by herself. On 7/10/23 at 12:30 PM, V2 Director of Nursing (DON) stated, (V4 CNA-T) was hired as a CNA in-training. She has not started CNA class yet. She is not to provide any hands-on care at this time. She is not to provide incontinence care to residents. She is not to transfer or toilet residents. I didn't know she was the only aide scheduled on the 400 Wing on the night shift. She should have called a CNA, from another floor, to come provide those cares. R227's resident assessment dated [DATE] showed R227 required the extensive assistance of one staff for toileting/incontinence care and was always incontinent of stool. 3. A facility list printed 7/11/23 showed V7 was employed by the facility as a CNA-T (CNA in Training). On 7/11/23, V7 CNA-T's employee file was reviewed and showed no active CNA license. The employee file showed V7 was currently enrolled in a CNA class but showed no documentation that V7 had passed the clinical portion of her CNA training. On 7/10/23 at 6:15 AM, V7 CNA-T stated, I am CNA in-training. I am in CNA school currently. On 7/10/2023 at 6:33 AM, V7 Certified Nursing Assistant in Training (CNA-T) entered R28's room, by herself, to provide cares. V7 repositioned R28 and provided incontinence care to her as she was incontinent of urine. V7 wiped R28's perineal area and removed R28's soiled incontinence brief. Without changing her soiled gloves, V7 placed a clean incontinence brief on R28 and dressed R28 in clean pants. No other staff were noted in the room while V7 provided cares to R28. R28's resident assessment dated [DATE] showed R28 was severely cognitively intact. The assessment showed R28 required the assistance of two staff for repositioning and toileting/incontinence care. On 7/11/23 at 11:12 AM, V2 DON stated, Human Resources does the hiring of the CNAs in-training (CNA-T). Human Resources makes sure the employee is enrolled in the CNA course that is offered at the nearby community college. Staff that are CNAs in-training are not to provide any hands-on care to residents until they have finished and passed their clinical portion of their CNA training. Until a CNA in-training has successfully completed their CNA clinicals, they are considered resident assistants so they can only assist with eating, take a resident to activities, and documenting on transmission-based precautions. A CNA in-training cannot provide incontinence care and/or transfer residents. Once a CNA in-training has successfully completes their CNA clinicals but has yet to pass the CNA licensing test, that CNA in-training can provide hands-on care to residents, but it must be supervised by a nurse or a CNA. When V2 DON was asked why there was only a CNA-T, not a CNA, assigned to the 400 Wing, on the night of 7/9/23, V2 DON stated, That shouldn't be happening. During COVID, we didn't have enough staff, so we used resident assistants and CNAs in-training to help. Per corporate, our staffing was recently cut because we stopped using agency staff. Going forward, we need to make sure fully certified staff are scheduled to make sure they can provide the residents with the cares they need. The facility's Certified Nursing Assistant in Training Job Description dated March 2023, showed, Assist nurse aides with designated resident care specific areas of eating, drinking and personal hygiene. Receive and carry out instructions concerning specific feeding, hydration and/or personal hygiene care needs of the residents whom he/she will be assigned to assist. Assists with resident activities and transportation . The facility's Resident Attendant Job Description, dated 12/2021, showed the only resident cares a resident attendant can provide include washing a resident's face, brushing a resident's hair, oral hygiene, shaving a resident with an electric razor, applying makeup to a resident, passing meal trays, and feeding residents who do not have complicated feeding problems.

Based on interview, and record review, the facility failed to ensure a safe transport of a resident via wheel chair by not ensuring foot rest were in place for three of three residents (R1, R3, R4) reviewed for safety in the sample of four. This failure resulted in R1 sustaining a fall with injuries including a nasal fracture which required five sutures. R1 was transferred to the local emergency room (ER). The findings include: 1. R1's Order Summary Report shows R1 was admitted to the facility on [DATE] with diagnoses including: [CONDITION(S)] and collapse, [CONDITION(S)], long term use of aspirin, chronic pain, and dementia. R1's MDS (Minimum Data Set) dated 10/1/21, shows R1 is not cognitively intact. R1 requires extensive two person assist with transferring and requires extensive one person assistance with locomotion. R1 has a limited range of motion on both of her lower extremities. R1 is dependent on staff to put on and taking off her footwear. R1 requires substantial/maximal assistance with the manual wheel chair. R1's Fall Risk assessment dated [DATE] shows R1 is at risk for falls. R1's Care Plan initiated 8/30/19 shows, R1 is at risk for falls due to poor safety awareness and cognitive deficit due to diagnosis of dementia, use of high risk medications, incontinence. R1 is noted to be unsafe with wheelchair cushion including with dycem applied due to leaning forward in wheel chair. R1 lacks trunk control. Bilateral leg rests applied for transporting resident (added to care plan 10/14/21). R1's Nurses Notes dated 6/29/21, shows R1 requires extensive staff assist with completion of ADLs (Activities of Daily Living). R1 utilizes a wheelchair propelled by staff for locomotion. R1's Post Occurrence Documentation note dated 10/13/21, shows, RA (Resident Aide) informed nurse of R1's fall. Resident observed sitting on her bottom in front of her wheelchair with her feet crossed in her room. Resident alert, observed with top of nose bleeding. Skin tear 1.5 cm (centimeters) X 0.4 cm on nose. Staff member verbalized resident was being pushed in wheelchair and R1 leaned forward and fell to the floor hitting her nose on the floor. Order received to send resident to the ER for evaluation and treat. R1's Nurses note dated 10/13/21 shows, R1 returned from local hospital and placed in her bed. Five sutures noted to bridge of nose with slight redness surrounding. Tylenol given for pain. Resident sitting upright in bed awaiting dinner. Discharge papers received and orders entered. CT (cat scan) shows fracture to tip of the bridge of her nose. On 10/25/21 at 11:14 AM, V2 DON (Director of Nursing) said foot rests on wheel chairs for resident's that do not self propel are a fall prevention, and intervention for wheel chair safety. V2 said, V3 Resident Aide (RA) was transporting R1 via the wheel chair to take R1 to the dining room for lunch. V2 said, R1 has history of leaning forward while in her wheel chair. V2 said, while V3 was pushing R1 in her wheel chair, R1 leaned forward and fell . R1 was sent out to the hospital for evaluation and a fracture was found in R1's nose. V2 said, when R1 fell , she landed on her face. V2 said, after R1's fall, staff was educated to hold R1 upright via her shoulder and to make sure R1 has foot rests on with every transport. V2 said, R1 did not have foot rests on her wheel chair prior to this fall and they are a new fall prevention intervention. V2 said, during R1's fall investigation, the facility implemented that residents that cannot self propel in the wheel chair to have foot rests on. the wheelchair. V2 said, foot rests on wheel chairs are a part of safety. V2 said, the facility did a house wide audit to see if residents that needed foot rests had foot rests available. On 10/25/21 at 11:47 AM, V3 Resident Aide with V1 Administrator as a translator said, she was taking R1 into the dining room for lunch when R1 leaned forward and fell out of the wheel chair. V3 said, when R1 fell , R1 hit her face on the floor. V3 said, R1 did not have foot rests on her wheel chair. V3 said, R1 was bleeding from her nose. V3 said, she has received education from the facility to make sure every resident has leg rests on the wheel chair and resident is positioned well in the wheel chair. On 10/25/21 at 2:24 PM, V6 CNA said, R1 is a total care resident. V6 said, R1 is not able to use her feet while she is in her wheel chair and R1 is not able to follow directions. 2. On 10/25/2021 at 9:55 AM, V7 Activity Aide was pushing R3 in her wheel chair throughout the facility. R3's legs were hanging down. On 10/25/21 at 2:15 PM, V5 CNA said, R3 should have foot rests on her wheel chair. V5 said, R3 is not able to use her feet while she is in the wheel chair. V5 said, foot rests are used for wheel chair safety and fall prevention interventions. On 10/25/21 at 1:21 PM, V2 said, R3 had foot rests on her wheel chair when she was first admitted to the facility. V2 said, R3 went to the hospital and when R3 came back to the facility, her wheel chair was changed. V2 said, R3 should have foot rests on her wheel chair when she is being pushed for a long time. On 10/25/21 at 12:00 PM, R3 said, she does not have foot rests for her wheel chair, but she would like to have foot rests for her wheel chair. R3's Care Plan initiated 9/18/21 shows, R3 is at risk for falls due to diagnoses [CONDITION(S)], diabetes mellitus, chronic kidney disease, spinal stenosis, dysphagia, history of falling, and lack of coordination. Encourage appropriate use of wheel chair. R3's Fall Risk assessment dated [DATE], shows R3 is at risk for falls. R3's MDS dated [DATE] shows, R3 is cognitively intact. R3 requires total assistance with two people for transferring and requires total assistance of one person with locomotion on the unit. R3 has an impairment in functional range of motion to both of her lower extremities. 3. On 10/25/21 at 9:46 AM, V7 was pushing R4 down the hall towards R4's room. R4 did not have foot rests on her wheel chair. R4 was holding her legs up slightly above the ground while V7 was pushing her wheel chair. R4's Fall Risk assessment dated [DATE], shows that R4 is at risk for falls. R4's Care Plan initiated 5/12/19 shows, Staff to ensure that resident's leg is placed properly in the leg rest. Care Plan initiated 12/31/18, R4 is at risk for falls related to ADL deficit, cognitive deficit related to Alzheimer's disease. R4's MDS dated [DATE], shows R4 is not cognitively intact. R4 requires total assistance from two staff members with transferring and requires total assistance with one person for locomotion on the unit. On 10/25/21 at 12:05 PM, V4 CNA said, fall prevention interventions include locking the wheel chair, making sure the resident is sitting straight and using foot rests in the wheel chair. On 10/25/21 at 1:21 PM, V2 DON said, R4 should have foot rests on her wheel chair while transporting. The facility's Fall Management Program policy dated 8/2020 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 resident at risk for falls, plan for preventative strategies and facilitate a safe environment.

Based on observation, interview, and record review, the facility failed to notify the physician, wound care nurse, and director of nursing, upon identification of a new skin concern with redness. The facility also failed to obtain treatment orders, and failed to document a wound assessment for a resident at high risk for developing pressure injuries. These failures led to R37's reddened sacral area becoming an unstageable pressure injury for 1 of 5 residents (R37) reviewed for pressure injuries in the sample of 26. The findings include: R37's admission record shows she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R37's Braden Scale (risk for pressure injury development) dated 7/16/2020 shows she has a high risk for developing a pressure injury. On 09/28/20 at 10:19 AM V12 Hospice CNA (Certified Nursing Assistant) was performing incontinence care for R37. R37 had a foam dressing to her sacral area that measured approximately eight inches wide by four inches long. There was a small amount of brownish drainage in the middle of the dressing that was visible through the dressing. V12 said that R37 has a new pressure ulcer. The foam dressing was not intact at the bottom towards R37's rectum. Upon review of R37's electronic orders, there were no wound orders noted for R37's sacral area. On 9/29/2020 at 10:39 AM, V13 RN (Registered Nurse)/Wound Care Nurse and V14 ADON (Assistant Director of Nursing)/previous wound care nurse came in to resident's room to change a dressing to R37's right heel. V13 or V14 did not turn or change R37's sacral wound dressing. On 9/29/20 at 11:07 AM, V15 CNA and V6 CNA went into R37's room to perform incontinence care. V15 and V6 turned R37 onto her side and the same foam dressing was noted to R37 sacral area. Brownish drainage was noted from the outside covering the entire foam dressing. This drainage amount increased from 9/28/2020. The bottom of the dressing was still not intact and completely opened towards R37's rectum. On 9/29/20 at 2:00 PM, V16 LPN (Licensed Practical Nurse) said R37 has a dry dressing order for her right great toe, a dressing on her right heel blister, and no other dressings that she know of. V16 said the wound care nurse rounds weekly with the wound doctor on Wednesdays. V16 said the floor nurses do the dressing changes on the other days. V16 said she was not aware of a dressing on R37's sacral area, but V15 reported it to her today (9/29/2020) prior to V13 and V14 entering R37's room to change her heel dressing (at 10:39 AM). V16 said she has not changed the dressing to R37's sacral area. V16 said she didn't see any notes in R37's electronic medical record regarding this sacral dressing. V16 said that if a cna notices something on the residents skin, then the cna reports it to the nurse and the nurse goes in to assess the wound. Residents' skin is assessed on shower days or with increased pain. V16 stated that R37 receives a shower on Tuesday, Friday, and Sunday evenings. On 9/29/20 at 2:17 PM V17 Nurse consultant and V14 ADON (Assistant Director of Nursing)/previous wound care nurse went into R37's room. This surveyor entered R37's room and asked if they were aware of a dressing to R37's sacral area. V14 said he was not aware of a sacral dressing on R37. V16 entered R37's room to assist with positioning. V14 removed the dressing on R37's sacral area. The dressing was saturated with dark drainage. The wound was irregularly shaped with the top layer of skin absent and the wound bed was dark in color. V14 cleaned the wound with saline and stated the wound was an unstageable pressure injury. V14 measured the wound and said it measured 3.3 cm (centimeters) x 5.5 cm with no depth. V14 said he did not know who put the dressing on R37's sacral area. V16 said the nurse will report if there was a new dressing placed on a resident during shift to shift report. At 2:34 PM V14 said when staff sees a new skin alteration they are to let him know, let V2 DON (director of nursing) know, and let wound care nurse know. The nurse that finds the skin alteration will enter a skin note into the electronic medical record and report it to nurse practitioner or the doctor and start treatment right away. The wound care nurse will follow up on the wound and a referral to the wound doctor will be sent if necessary. R37's shower documentation in the electronic medical record shows R37 received a shower on 9/28, 9/24, 9/20, 9/17 with no new skin abnormalities marked. On 9/27 Not Applicable was marked for skin abnormality. On 9/30/20 at 9:29 AM V17 said they interviewed all staff in regards to R37 sacral wound. During the facility's investigation, it was found that V20 RN (Registered nurse) placed the dressing on R37's sacral area on Sunday, 9/27/2020 (two days prior). V15 CNA reported redness to V20 and V20 placed a foam dressing on R37. V20 stated R37 had redness on her sacral area but there were no open areas. V17 said V20 did not document the wound anywhere, did not call the doctor, and did not call R37's family. During this same interview, V2 DON said V20 should have put in wound orders, notified the doctor, and it should be passed onto next shift nurse. The same dressing has been on R37's sacral area from Sunday-Tuesday. On 9/30/2020 at 10:47 AM, V14 ADON/previous wound care nurse said the purpose of dressings on pressure injuries are for protection. The dressings should be changed in order to keep the wound dry because it is a good medium for bacterial growth, help prevent infection, and protect the wound. V18's Wound Care Doctor note dated 9/30/2020 shows R37 has an unspecified stage pressure injury to her sacral area and it measures 3.5 cm X 8 cm with no depth. R37's Medication Admission Record shows her skin was checked on 9/27/2020 and 9/28/2020. V20's counseling and disciplinary action form dated 9/29/2020 shows, On Sunday 9/27/2020, I was made aware of the fact that (R37) had some skin changes on her buttocks. I went to look at her and the sacrum was only slightly reddened in two small spots. This was new. R37's Care Plan initiated on 11/10/2018 shows, (R37) has an actual altered skin integrity related to history or pressure injury to the sacrum .inspect skin daily with care. The facility's Prevention and treatment of [REDACTED]. Complete a comprehensive pressure injury evaluation for identified pressure injuries. At least daily, staff should remain alert for potential changes in the skin condition during resident care. The facility's Change of Condition policy dated 6/19 shows,The attending physician or physician on call/nurse practitioner and responsible party will be notified with changes in a resident's condition. The facility's Weekly Assessment of Skin Alteration Form policy dated 4/2020 shows, The weekly Assessment of Skin Alteration (WASA) Form should be used for the following wound types: pressure. Based on the findings of the completed WASA form determined appropriate interventions/changes and implement as needed, notify as appropriate, interdisciplinary team member, doctor/nurse practitioner, the resident and/or family members.

Based on interview and record review the facility failed to allow a resident to remain in the facility. The facility also failed to have care and services arranged for the welfare of the resident prior to discharge. This applies to 1 of 5 residents (R1) reviewed for discharge in the sample of 35. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 8/23/2018 when R1 was discharged from the facility to a community center that does not provide housing. On 10/11/2018 at 2:15 PM V1 (Administrator) was informed of the Immediate Jeopardy. The Immediacy was removed on 10/15/18. While the immediacy was removed the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures. The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18, V1 (Administrator) stated, On 8/21/18 (R1) fell and started bleeding but he refused to go to the hospital. The doctor told us to monitor him. We suspected him of being intoxicated. We don't know if he had any alcohol (no evidence found) not sure if someone brought some in to him or if he went out and got some. Staff never actually saw him drinking. We tried to get him to sign a behavioral contract and he refused to sign it. He said just let me go. He said he wanted to leave so we set up a taxi to the Firehouse Shelter. R1's Incident Report dated 8/21/18 states, Around 2:00AM (R1) was asking for a Band-Aid for his chin, prompted what happened , he said he fell in the toilet and claimed hitting his chin on the sink. About 3cm shallow cut observed in his right chin and also a bruise to his right shoulder. Minimal bleeding was noted. Resident is on [MEDICATION NAME] (anticoagulant) 15mg. Prompted to call (V13- R1's physician) and ordered to send the resident to ER for eval and treatment . Resident refused to come with (Ambulance) personnel and even refused to sign the refusal form . Resident recalled that he fell because he felt light headed and hit his chin on the sink. The Notes at the end of this same document written by V19 (Restorative Nurse) dated 8/24/18 ( The day after R1 was discharged from the facility) state, Resident was asking nurse for a band aid and stated that he fell while washing himself up he felt dizzy and slipped hitting his chin on the sink. Nurse called MD and tried to send resident to the ER, resident refused. Resident smelled like alcohol and staff suspected he was intoxicated which contributed to his fall. Resident put on 15 min check. On 10/10/18 at 1:00PM V31 (RN) stated, (R1) came out and asked me for a Band-Aid. He said he fell and bumped his chin. He said he tried to stop the bleeding; there was a streak of blood in his sink. I assessed his chin and gave him a Band-Aid. He kept saying it was no big deal. I did not notice (R1) to be drinking. If I thought he was drinking, I would have put it in my notes. He did not smell like alcohol. I am not aware of (R1) ever drinking or being drunk while in the facility. On 10/10/18 at 2:00PM, V19 stated, I got the information (Resident smelled like alcohol and staff suspected he was intoxicated which contributed to his fall) from what V31 wrote or else what he told me. I'm not sure where else I would have gotten it. V19 stated she knew of R1 drinking through hearsay but stated that she had never actually seen him drinking. V19 also stated she was not aware of R1 having any behaviors and stated that R1 was very quiet and interacted very little with the staff or other residents. R1's EMR shows a Resident Behavior and Conduct Contract dated 6/18/18 signed by resident. This form states: Behavior to improve: Going out on pass and buying alcohol- drinking alcohol at the facility. There are no progress notes in R1's EMR showing that this behavior occurred before or after this contract was signed. R1's Care Plan dated 7/31/18 states, Resident demonstrates socially inappropriate behaviors as evidenced by being sexually inappropriate with staff. R1's Care Plan dated 7/10/18 states, (R1) has a history of substance abuse. His drug of choice is alcohol. His last instance was (MONTH) (YEAR). R1's Behavior assessment dated [DATE] states, Resident became inappropriate with staff member, he grabbed the staff member by the hips while the staff member was bending down. Resident was suspected of drinking. R1's Minimum Data Set of 8/17/18 shows that R1 had some verbal behaviors (1-3 days of assessment period). This same assessment shows that these behaviors had no impact on resident or others. On 10/10/18 at 1:20PM V3 (Social Service) stated, V1 came to me and told me that R1 had had these behaviors so I did the behavior assessment. Then that prompted the initiation of the care plan. R1's Progress Notes dated from 6/27/17- 8/23/18 do not document any behaviors of R1 drinking alcohol in the facility, being drunk in the facility or displaying socially inappropriate behaviors with staff. On 10/10/18 at 2:50PM V32 (Care Plan Coordinator/ RN) stated, I'm sorry but we were unable to find any documentation in the progress notes that (R1) was drinking in the facility. The only thing we have is the risk management assessment (incident report) but that was written after he was discharged and the behavior contract showing his behavior dated 6/8/18. R1's Progress Notes written by the Nurse Practitioner dated 11/27/17 states, He reports that he has been in detox a few times. His last drink was early August. He reports he has been sleeping well with adequate (oral) intake. Staff deny aggressive behaviors, no s/s of anxiety. R1's Progress Notes written by a Nurse Practitioner dated 4/23/18 states, Care discussed with nursing staff. Nursing staff denies any concerns or changes. R1's Progress Notes written by the Nurse Practitioner dated 5/30/18 states, He reports that he has been in detox a few times. His last drink was early August. He reports he has been sleeping well with adequate (oral) intake. Staff deny aggressive behaviors, no s/s of anxiety . Staff and social work notes reviewed. R1's physician's orders [REDACTED]. R1's Progress Notes written by V3(Social Worker) dated 8/23/18 state, When attempting to do discharge paperwork with resident he became non-complaint and non-responsive to this writer. He did not want to tell writer who his PCP is and did not want to be involved in making discharge plans. R1's Nurse's Noted dated 8/23/18 state, Resident discharged to Firehouse Center in Woodstock. Resident verbalized understanding of discharge medications. Left via taxi at 1200 noon, gave all meds except [MEDICATION NAME] {[MEDICATION NAME]} which he says he doesn't need. On 8/28/18 at 11:00AM V3 (Social Service) stated, I was not too involved. The discharge came from {V1- Administrator}. I tried to do discharge paperwork with (R1) but he was not very cooperative with making discharge plans. He went to the Old Firehouse, it is a homeless shelter. People live there and they offer free services. I called and left a voicemail for them. Never spoke to anyone but I have sent people there before. They have transitional programs and are staffed from 8:00AM-3:00PM but they are open 24 hours a day. They help people find housing. On 8/28/18 at 1:40PM V11 (R1's daughter) stated, My dad called me the day before and told me that he was being discharged for walking in the halls, smoking and drinking. When I went to talk to them the next day they said I was only the emergency contact. I told them that they called me two days before when he fell but I guess him leaving the facility is not an emergency. They said they tried to get him to sign a behavior contract and he refused. He does not recall being given a choice. He should have been given 30 days. He won't get his social security check until (MONTH) so that 30 days would have been nice and at least allowed us some time to make arrangements for him. I don't think he wanted to leave knowing that he had no place to go. He thought the Firehouse was a place he could stay. I paid my brother to drive him to Rockford because someone told him if he goes to the hospital there another facility would take him. He is at {local} Motel tonight. I had his car towed so that gave him $100. He has enough money to stay one more night. He can't stay with me, we have tried that before and it didn't work. He will be homeless as he was before. He was just lucky enough to stay at {facility} for the past year. A written statement by V1 dated 8/24/18 (typed and presented to surveyor on 8/29/18 and not part of R1's EMR) states, Daughter came to facility asking what happened to her father and why he had been discharged from the facility. I explained that resident had a fall and staff reported that he had been drinking. I let her know that we were not trying to kick (R1) out of the facility but we were trying to work with him and have him sign a behavior contract. I explained that on the behavior contract it addressed his drinking, smoking, sexual inappropriateness with staff and going into resident's room without knocking but that (R1) had refused to sign the behavior contract. (R1) was the one that stated to just get me out of here; I explained that he was alert and oriented and that he was his own decision maker. On 8/28/18 at 2:00PM, V9 (Registered Nurse) stated, (R1) went to the Woodstock Firehouse Center- Homeless Shelter. They (V1 and V2) tried to make a contract with him and he refused to sign it so they discharged him. He said, I just want to go. I wasn't there for the conversation. I did touch base with him and sent him with his medication {Current med list shows resident receiving the following medications: [REDACTED]}. He needs a PT/INR (blood test) who was going to meet up with him to do that? I write the order but social service sets it up. He has respiratory issues and can run into trouble easily. I don't think he could live at home with his daughter. Several residents go to the gas station to get alcohol. On one incident they said he was drunk. I didn't think he was drunk . He left in a Uber or something, or taxi, (V1) set up his ride . On 8/28/18 at 12:00PM V4 (Old Firehouse employee) stated, We are not a homeless shelter. Our day service is open 9:00AM- 3:00PM Monday through Friday. There is nowhere to sleep here. (R1) yes, I know him. He came here and claimed he was told by {facility} that there were places to sleep here. He came in asking where the beds are at. He was told this was a shelter. I told him no. I reached out to another facility in the area. (R1) spoke to someone there. This person said that (R1) was not a good fit for their facility but said he could go to {another facility in a city 30 miles from here} if he went to the hospital in {that city}. He went all the way to {city} and that fell apart, {facility} would not accept him because of what {current facility} said about him. He was here {Firehouse} yesterday. He has no phone. I don't know where he went after he left here. I tried my best to get him somewhere to go. He was scared. He said that {facility} never worked on getting him housing or anything. Never got him on any listings for housing. On 8/29/18 at 12:35PM, V6 (Ombudsman) stated, I was completely unaware of this. Even if he wanted to leave the facility he has to leave to a place that provides his level of care. If they are paying for an Uber and determining the destination, the destination better be a place that the resident can live and have some type of existence. A resident can leave on their own accord but the facility has to have determined that the destination is appropriate for them. On 8/30/18 at 12:15PM V13 (Physician) stated, (R1) was there long term. He has bad [MEDICAL CONDITIONS] and he is pretty weak and having some difficulty with ambulation. V13 was asked if he was aware that R1 had been discharged from the facility. V13 stated, I was told he no longer needed skilled care and he was getting along well. All of his needs were pretty much custodial. V13 was asked if he thought it was safe for R1 to be discharged from the facility with no place to live. V13 stated, I empathize for that but I don't really know what the requirements of the facility are in terms of that. I told them as long as he has his regular medications; he is chronically ill, and if he is only using the facility as a means of housing then it was okay for him to be discharged . V13 was asked why Home Health Services were ordered if R1 only required custodial care. V13 stated, We pretty much use home health as a transition to minimize the risk of re-hospitalization . Almost all residents that are discharged from long term care are referred to home health. V13 was asked if he was aware of R1 having any behaviors while in the facility and if any type of rehab services had been offered to R1. V13 stated, Yes I had heard that he was intoxicated and the RNs were quite upset about that. There were no other behaviors that I am aware of. I think the nurses had talked to him about rehab but the first step would be for him to acknowledge that he had a problem and he was not at that point. The facility policy entitled Discharge or Transfer, Involuntary dated 11/2017 states, The facility must provide sufficient preparation and orientation to the residents to ensure safe and orderly discharge. This must be documented in the resident's record. This same policy states, The facility shall assist the resident in arranging alternative living arrangements. All assistance will be documented in the resident's record. Through interview and record review on (MONTH) 15, (YEAR) the surveyors confirmed that facility took the following steps to remove the immediacy: 1. With regards to all discharges, a review by the Social Service and Memory Care Directors will be conducted to assess the resident's current care needs and their ability to obtain services out in the community (e.g. shelter, home health services, medication). Completion Date: 10/15/18 of all in house residents and on-going. 2. Residents that request to discharge to a specific location- the social service and memory care directors with ensure that discharge is to an appropriate setting; this may be accomplished by contacting the site provided by resident, online search consulting with other social service agencies if appropriate, and/ or providing quality measures if to another long-term care placement so resident/representative can make an informed choice. Completion date: 10/15/18 of all in-house residents and on-going. 3. The Social Service and Memory Care Directors shall assess residents that are potential for discharge, and/or scheduled and planned for discharge in the next 30 days, to ensure proper discharge planning, included but not limited to the appropriateness of placement, services needed in the home environment, such as durable medical equipment, home health or hospice services, medications, follow-up appointments with medical professionals, including any other service needs that resident would require. Completions date: 10/15/18 of all in-house residents and on-going. 4. Upon a resident's request to discharge against medical advice (AMA), they will be assessed for their decisional capacity and their ability to understand. This information will be gathered by a discussion with the resident, contact the attending physician and review of medical records. The attending physician and responsible party, if applicable, will be contacted to ensure a safe discharge. Social services, or designee, will meet with the resident to provide education on risks of discharging AMA vs. proper discharge planning or potential benefits of remaining in facility, with documentation included in the resident record. Completion Date: 10/11/18; result: No residents expressed the desire to discharge AMA: Ongoing action to be taken. 5. Facility Administration reviewed the Discharge Planning and Exit Seeking/Elopements vs. Unplanned Discharge Policies. Completion Date: 10/12/18 6. The Social Service and Memory Care Directors reassessed all residents in house using Discharge Memo Tool. All discharge care plans reviewed and updated. Completion Date: 10/15/18 7. Corporate Operations Director of Clinical Programs re-educated all IDT including but not limited to: Administrator, Social Services, DON, ADON, Activity Director and Memory Care Director. The DON re-educated the nursing staff regarding discharge planning. Educational sessions also included signs that a resident is a potential for leaving the facility AMA. Also the facility reviewed the Discharge Planning and Exit Seeking/Elopement vs. Unplanned Discharge Policies with IDT and nurses. Completion Date: 10/15/18 8. QA/QI Tools were developed and implemented to ensure proper discharge planning. Completion Date: 10/12/18. To be completed on-going by Social Service and Memory Care Directors using the following increments: First 30 days, starting 10/12/18, completed for every planned discharge and AMAs. Next 30 days, completed for up to a total of 10 planned discharges and AMAs. Final 30 days, totaling 90 days, up to a total of 5 planned discharges and AMAs.

Based on interview and record review the facility failed to provide medically related social services by not ensuring social services participated in identifying, planning and providing for individual discharge needs of the residents. This failure resulted in R1 being discharged from the facility on 8/23/2018 to a community center that does not provide housing and R3 signing himself out against medical advice(AMA) from the facility on 7/27/2018 with no housing address to discharge to. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 7/27/2018 when R3 signed himself out AMA. On 10/11/2018 at 2:15PM V1 (Administrator) was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 10/15/18. While the immediacy was removed the facility remains out of compliance at at level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures This applies to 2 of 5 residents (R1, R3) reviewed for medically related social services in a sample of 35. The findings include: 1. R1's EMR(Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Incident Report dated 8/21/18 states, Around 2:00AM {R1} was asking fro a Band-Aid for his chin, prompted what happened , he said he fell in the toilet and claimed hitting his chin on the sink. About 3cm shallow cut observed in his right chin and also a bruise to his right shoulder. Minimal bleeding was noted. Resident is on [MEDICATION NAME]{anticoagulant} 15mg. Prompted to call {V13- R1's physician} and ordered to send the resident to ER for eval and treatment . Resident refused to come with {Ambulance} personnel and even refused to sign the refusal form . Resident recalled that he fell because he felt light headed and hit his chin on the sink. The Notes at the end of this same document dated 8/24/18 (Day after R1 was discharged from the facility) state, Resident was asking nurse for a band aid and stated that he fell while washing himself up he felt dizzy and slipped hitting his chin on the sink. Nurse called MD and tried to send resident to the ER, resident refused. Resident smelled like alcohol and staff suspected he was intoxicated which contributed to his fall. Resident put on 15 min check. R1's physician's orders [REDACTED]. R1's Nurse's Noted dated 8/23/18 state, Resident discharged to Firehouse Center in Woodstock. Resident verbalized understanding of discharge medications. Left via taxi at 1200 noon, gave all meds except [MEDICATION NAME]{[MEDICATION NAME]} which he says he doesn't need. On 8/28/18, V1 (Administrator) stated, On 8/21/18 {R1} fell and started bleeding but he refused to go to the hospital. The doctor told us to monitor him. We suspected him of being intoxicated. We don't know if he had any alcohol {no evidence found)}not sure if someone brought some in to him or if he went out and got some. Staff never actually saw him drinking. We tried to get him to sign a behavioral contract and he refused to sign it. He said just let me go. He said he wanted to leave so we set up a taxi to the Firehouse Shelter. V1 was asked how home health would be able to contact R1. V1 stated, The home health is our sister company so we sent an email referral to them. They would see him at the Firehouse. On 8/28/18 at 11:00AM V3(Social Worker) stated, He went to the Old Firehouse, it is a homeless shelter. People live there and they offer free services. I called and left a voicemail for them. Never spoke to anyone but I have sent people there before. I was not too involved. The discharge came from {V1- Administrator}. I tried to do discharge paperwork with {R1} but he was not very cooperative with making discharge plans. On 10/10/18 at 1:50PM V3 stated, I try to do the bulk of the discharge planning for most residents. I set up the services. For (R1) I was not really involved. Him and I did not have a good rapport. He never wanted anything to do with me. I think it was because whenever he was caught drinking, I was the one that had to talk to him. I only did that a couple of times. V1 was working with him more and she would come and check my work. I didn't have have much to do with R3. In terms of his discharge, V1 did that. V3 continued, V1, V12 (Memory Care Unit Director) and a Social worker from another facility were doing social services while I was new. They should have been documenting in the the medical record when ever they were involved with the residents. On 10/11/18 at 11:00AM, V1 stated, R1 was alert and oriented and he was the one who didn't want to participate in the discharge planning. He said said fine, get me out of here. V3 would go and talk to him and he would say, do whatever. My definition of a safe discharge- making sure what they have when they go home. If they don't have a home then we would look for some place for them to go or talk to the family or look for another appropriate setting. R1 going back to live in his care would not be appropriate, I'm not sure how R1 was supposed to get his PT/INR done. I'm not sure if I ever had any contact with the Firehouse Shelter. R1's Progress Notes throughout his stay at the facility do not document any social service involvement with R1. On 8/28/18 at 2:00PM, V9(Registered Nurse) stated, {R1} went to the Woodstock Firehouse Center- Homeless Shelter. They (V1- Administrator and V2 Director of Nursing) tried to make a contract with him and he refused to sign it so they discharged him. He said, I just want to go. I wasn't there for that conversation. I write the order but social service sets it up. He left in a Uber or something, or taxi, {V1} set up his ride . On 8/28/18 at 12:00PM V4 (Old Firehouse employee) stated, We are not a homeless shelter. Our day service is open 9:00AM- 3:00PM Monday through Friday. There is no where to sleep here. {R1} yes, I know him. He came here and claimed he was told by {facility} that there were places to sleep here. He came in asking where the beds are at. He was told this was a shelter. I told him no. I reached out to another facility in the area. {R1} spoke to someone there. This person said that {R1} was not a good fit for their facility but said he could go to {another facility in a city 30 miles from here} if he went to the hospital in {that city}. He went all the way to {city} and that fell apart, {facility} would not accept him because of what {current facility} said. about him. He was here {Firehouse} yesterday. He has no phone. I don't know where he went after he left here. I tried my best to get him somewhere to go. He was scared. He said that {facility} never worked on getting him housing or anything. Never got him on any listings for housing. On 8/29/18 at 12:35PM, V6(Ombudsman) stated, A resident can leave on their own accord but the facility has to have determined that the destination is appropriate for them. On 8/30/18 at 12:15PM V13(Physician) stated, {R1} was there long term. He has bad [MEDICAL CONDITION] and he is pretty weak and having some difficulty with ambulation. V13 was asked if he was aware that R1 had been discharged from the facility. V13 stated, I was told he no longer needed skilled care and he was getting along well. All of his needs were pretty much custodial. V13 was asked if he was aware of R1 having any behaviors while in the facility and if any type of rehab services had been offered to R1. V13 stated, Yes I had heard that he was intoxicated and the RNs were quite upset about that. There were no other behaviors that I am aware of. I think the nurses had talked to him about rehab but the first step would be for him to acknowledge that he had a problem and he was not at that point. The facility policy entitled Discharge or Transfer, Involuntary dated 11/2017 states, The facility must provide sufficient preparation and orientation to the residents to ensure safe and orderly discharge. This must be documented in the resident's record. This same policy states, The facility shall assist the resident in arranging alternative living arrangements. All assistance will be documented in the resident's record. The facility Social Service Director job description dated 1/2015 states, Initiate, facilitate and/or participate in the written discharge plan which states the resident's specific need to be in the facility or if the resident is expected to be able to function in a more independent setting. The discharge plan should include consultation with other disciplines, the family and of course the resident. 2. The electronic medical record for R3 lists his [DIAGNOSES REDACTED]. The minimum data set for R3 dated (MONTH) 2, (YEAR) shows, he has severe cognitive impairment. The facility's care conference review form for R3 dated (MONTH) 26, (YEAR) shows, R3 was present and his friend, was phone conferenced in. Therapy will be ending Friday, due to insurance. Explained to R3 that we need to do a couple more things before figuring out the next step after therapy. Plans are to do a neuro/psych eval to determine if R3 has decisional capabilities. Once that eval is done then we can make further plans. The progress notes by nurse practitioner for R3 dated (MONTH) 23, (YEAR) show, [AGE] year old male seen on 500 unit, lying in bed. He was alert, in NAD (No apparent distress), with calm demeanor. With interview, he repeatedly asked I don't know what is going on. He has significant impairment with short- term memory loss. Resident had moderate flight of ideas with loose associations. His orientation was to self only, with difficulty answer some questions. He stated he was in a hospital in local city, uncertain of year, POTUS (President of the United States) was Obama. He stated several times he wants to go home, reporting he feels depressed . The last progress noted for R3 dated (MONTH) 27, (YEAR) shows, Resident alert, oriented x3 and wanted to sign AMA (against medical advice), resident signed AMA papers and pick up by his friend. (Friend not listed in electronic medical record under contacts). The facility's against medical advise form: release from responsibility for discharge for R3 dated (MONTH) 27, (YEAR) shows, R3 signed the form. On (MONTH) 29, (YEAR) at 11:33 AM, V1 Administrator stated, R3 was here for about a month or so. He was the one who wanted to leave the facility. A couple of times he was trying to walk out and the receptionist tried to stop him. He was very persistent on leaving the facility. We were working on getting a neuropysch (consult) on him. He wasn't necessarily able to verbally communicate his needs. He was a gentlemen who was homeless. He ended up going to a local city. His friend picked him up that day. We had a conversation with him and tried to educate him on the importance of trying to stay here. The doctor stated, if he was alert and oriented then he is his own decision maker. He did have some confusion. On (MONTH) 10, (YEAR) at 1:02 PM, V30 R3's Medical Doctor stated, at times R3 was lucid and at times he was confused. Psych was following him and give us advice on if he was able to live in the community or not. The psychological evaluation for R3 dated (MONTH) 22 & 24, (YEAR) shows, Test results indicate R3 presents with symptoms indicating moderate-sever cognitive deficits . After careful consideration of the results of this assessment, a [DIAGNOSES REDACTED]. For R3, this is characterized by the development of multiple cognitive deficits manifested by memory impairment and moderate-severe disturbance in cognitive functioning. As is often consistent with many individuals with dementia, it appears R3 may not have a realistic understanding of his deficits and may underestimate his needs when outside of a nursing home setting. R3 also has a history of [MEDICAL CONDITION], alcohol dependence, recurrent [MEDICAL CONDITION] and a history of [MEDICAL CONDITION] that may further hinder his abilities to truly understand his cognitive impairments. Through interview and record review on (MONTH) 15, (YEAR) the surveyors confirmed that facility took the following steps to remove the immediacy: 1. With regards to all discharges, a review by the Social Service and Memory Care Directors will be conducted to assess the resident's current care needs and their ability to obtain services out in the community (e.g. shelter, home health services, medication). Completion Date: 10/15/18 of all in house residents and on-going. 2. Residents that request to discharge to a specific location- the social service and memory care directors with ensure that discharge is to an appropriate setting; this may be accomplished by contacting the site provided by resident, on;line search consulting with other social service agencies if appropriate, and/ or providing quality measures if to another long-term care placement so resident/representative can make an informed choice. Completion date: 10/15/18 of all in-house residents and on-going. 3. The Social Service and Memory Care Directors shall assess residents that are potential for discharge, and/or scheduled and planned for discharge in the next 30 days, to ensure proper discharge planning, included but not limited to the appropriateness of placement, services needed in the home environment, such as durable medical equipment, home health or hospice services, medications, follow-up appointments with medical professionals, including any other service needs that resident would require. Completions date:10/15/18 of all in-house residents and on-going. 4. Upon a resident's request to discharge against medical advice (AMA), they will be assessed for their decisional capacity and their ability to understand. This information will be gathered by a discussion with the resident, contact the attending physician and review of medical records. The attending physician and responsible party, if applicable, will be contacted to ensure a safe discharge. Social services, or designee, will meet with the resident to provide education on risks of discharging AMA vs. proper discharge planning or potential benefits of remaining in facility, with documentation included in the resident record. Completion Date:10/11/18; result: No residents expressed the desire to discharge AMA: Ongoing action to be taken. 5. Facility Administration reviewed the Discharge Planning and Exit Seeking/Elopements vs. Unplanned Discharge Policies. Completion Date:10/12/18 6. The Social Service and Memory Care Directors reassessed all residents in house using Discharge Memo Tool. All discharge care plans reviewed and updated. Completion Date: 10/15/18 7. Corporate Operations Director of Clinical Programs re-educated all IDT including but not limited to:Administrator, Social Services, DON, ADON, Activity Director and Memory Care Director. The DON re-educated the nursing staff regarding discharge planning. Educational sessions also included signs that a resident is a potential for leaving the facility AMA. Also the facility reviewed the Discharge Planning and Exit Seeking/Elopement vs. Unplanned Discharge Policies with IDT and nurses. Completion Date: 10/15/18 8. QA/QI Tools were developed and implemented to ensure proper discharge planning. Completion Date: 10/12/18. To be completed on-going by Social Service and Memory Care Directors using the following increments: First 30 days, starting 10/12/18, completed for every planned discharge and AMAs. Next 30 days, completed for up to a total of 10 planned discharges and AMAs. Final 30 days, totaling 90 days, up to a total of 5 planned discharges and AMAs.

Based on observation, interview, and record review, the facility failed to supervise a resident with known history of aggressive behavior towards others. This resulted in R1 assaulting R2. R2 sustained a fracture on her right 5th finger and a laceration on her left eyebrow that required sutures. This applies to 2 of 3 residents (R1, R2) reviewed for safety and supervision in the sample of 5. The findings include: R1's Physician order [REDACTED]. R1's Minimum Data Set assessment dated (MONTH) 13, (YEAR) shows R1's cognition is severely impaired. The same MDS shows R1's behavioral symptoms towards others (hitting, kicking, grabbing, and abusing others) is exhibited every 1-3 days. The facility's final incident report dated (MONTH) 28, (YEAR) showed that on (MONTH) 22, (YEAR), R1 grabbed R2 by the hair and R2 landed on the floor. R2 sustained a laceration to R2's left eyebrow and 4th and 5th digit fracture to R2's right hand. R2 was sent to the hospital and received sutures on the laceration of R2's left eyebrow. R2 was also sent to an Orthopedic clinic and confirmed R2 has a fracture on the 5th finger of R2's right hand. R1's progress notes dated (MONTH) 28, (YEAR) shows R1 was readmitted to the facility on (MONTH) 28, (YEAR) after being readmitted to a behavioral hospital unit due to the incident mentioned above. On (MONTH) 30, (YEAR) at 9:00 AM, R1 was pacing from the dining room to the hallway aimlessly. R1 would sit in the family room then move to the dining room back and forth. At 10: 30 AM during group activity R1 sat down for a short time then went to sit in the family room then returned to the activity. On (MONTH) 30, (YEAR) at 8:55 AM, V5 (Dementia Unit Manager) said that on (MONTH) 22, (YEAR), V5 was informed of R1 being combative. V5 said R1 pulled R2 down to the floor. R2 injured R2's right 5th finger and lacerated R2's left eyebrow. V5 said R1 had exhibited aggressive behavior on the evening shift in the past. R1 needs to be monitored closely. V5 said when R1 started to get aggressive, staff should have stayed with R1, providing 1:1 monitoring. V5 said that could have prevented R1 from hurting R2. On (MONTH) 30, (YEAR) at 9:00 AM, V4- Certified Nursing Assistant (CNA) said that on (MONTH) 22, (YEAR), R1 was very agitated. V4 said R1 was pacing back and forth and was attempting to exit the back door. At dinner time around 6-6:30 PM, R1 kept on going to the medication cart, got the ice water pitcher then slammed it down. Water spilled over the floor. R1 took the bottle of supplement and poured to the floor. V4 said R1 took V4's hand and bent it back. V4 said V4 tried to pacify R1 but R1 proceeded to attempt to get out from the back door. Then R1 came back and sat on the couch in the family room. V4 said V4 then went to the dining room and left R1, by R1's self in the family room. V4 also said V4 had to toilet another resident. V4 said then V4 heard screaming. V4 went back to the family room and saw R2, already on the floor bleeding. V4 said R1 has a history of aggressive behaviors. R1 had thrown a chair at a staff last month. R1 had hit staff and attempted to open exit doors. V4 said staff have difficulty redirecting R1 when R1 becomes agitated. V4 said on (MONTH) 22 (YEAR) when the incident happened, there was no one watching R1 at all times. Staff were busy feeding and helping other residents with toileting and laying down residents to bed. On (MONTH) 30, (YEAR) at 10:11 AM, V6 CNA said that on (MONTH) 22, (YEAR), R1 was very angry and agitated at the start of the evening shift-3:00 PM. At around dinner time, (6:00 PM) R1 continued to be agitated, R1 was grabbing things on top of the med cart. No one was with R1 when the CNAs were with other residents. V6 said V6 was in another resident's room putting the resident to bed when V6 heard screams coming from the family room. V6 said V6 looked and R2 was on the floor. On (MONTH) 30, (YEAR) at 12:54 PM, V3 (Registered Nurse) said V3 was the nurse on (MONTH) 22, (YEAR). V3 said R1 was very anxious and aggressive. R1 was attempting to open V3's med cart. R1 was pacing back and forth to the medication cart. R1 took the water pitcher and the pill crusher from the med cart. V3 said V3 tried to redirect R1. V3 said V3 tried to give R1, R1's medication but R1 refused. R1 then went to the family room and sat on the sofa. V3 said V3 was inside the dining room passing medication and occasionally would look out to the family room as V3 was passing V3's meds. When V3 went back to the family room, V3 saw R1 pull R2's hair and R2 landed on the floor. R2 was bleeding. V3 said R2 was sent to the hospital. V3 said a staff should have stayed with R1 when R1 was in the family room. That would have prevented R1 from harming R2. R1's progress notes dated (MONTH) 3, (YEAR) at 3:56 PM, (MONTH) 1, (YEAR) at 3:26 PM and (MONTH) 30, (YEAR) at 5:20 PM, (all evening shift) shows R1 had physical aggressiveness towards others. R1's careplan dated (MONTH) 16, (YEAR), show When R1 become physically aggressive, 1.remove R1 of area of trigger. 2. Inform resident of his body language and physical aggressive towards others. 3. Ask resident to assist staff with project to redirect from behavior. R1's careplan had no revisions following the occurrences listed above. The facility policy on Behavioral Emergencies dated (MONTH) (YEAR) shows, each resident will be provided with a safe place of residence. The facility did not provide policies for Dementia Care and Behaviors at the time of this investigation.

Based on observation, interviews and record review facility failed to provide adequate and necessary supervision to two cognitively impaired residents (R3), with wandering behaviors and (R24), with swallowing difficulties on aspiration precautions. This applies to one of five sampled residents (R3) reviewed for falls in a sample of 23 and one supplemental sample resident (R24), reviewed with swallowing problems. These failures resulted in R3 having a fall incident with a fracture injury and R24 having a choking incident occur. The Findings include: R3 is one of nine independently ambulatory residents on the 300 unit (Dementia Unit). R3 ' s medical records include : [DIAGNOSES REDACTED]. 4/07/14 Minimum Data Set Assessment (MDS) and/ or current care plan, document presence of severe cognitive impairment, unable to make needs known, highly impaired vision and requires one person assistance with transfer and ambulation activity. R3's care plan also includes daily wandering behavior and history of pacing until the point of exhaustion. R3's May 2014 behavior tracking record documents daily wandering behavior. On 5/23/14 at 10:00AM, E10 (Acting Administrator - Vice President of Operations), said R3 is one of nine cognitively impaired, independent wanderers on the 300 (Behavior), unit. 4/05/14 fall assessment scored R3 as a high risk for falls and stating R3 is confused, independent mobility with steady gait and with history of falls in past 1-6 months. R3's care plan includes intervention to monitor and redirect R3 as needed while wandering. R3's 5/04/14 Occurrence report includes at 11:30PM, R3 was witnessed tripping over a metal door stopper and fell to the floor. R3 complained of left shoulder and elbow pain. On 5/05/14 an X-ray done and revealed an impacted neck and head fracture of left humerus with some degree of subluxation of the Glenohumeral joint. Root Cause: magnetic door stopper on ground. Interventions put in place as a result of this fall: placed a chair over the magnetic door stopper to deter patient from walking by it and staff will re-direct patient when seen walking by potential obstacles. Will continue to monitor for safety and update care plan as needed. 5/20/14 during initial tour, R3 was observed in a wheelchair in the 300 wing dining room with her left arm in an over the shoulder sling. 5/22/14 at 3:30PM, a 4 inch by 4 inch metal box that was approximately 4 inches high directly on the floor and more than a foot away from the wall in the hallway. There was a dining room chair placed over the magnetic box during this observation. On 5/22/14 at 12:43PM, while sitting at the nursing station, R24 over heard coughing, gagging and attempting to call out " Help Me. " Upon entering R24 ' s room, R24 observed in bed, alone in her room with oxygen in place at 2 litters per nasal cannula and with lunch meal tray on bedside table in front of her. R24 observed short of breath, coughing and asking for help. R24's lunch tray contained thickened liquids. At 12:43PM no staff observed in or around the 300 Unit nursing station and no staff present within audible range to hear R24's cry for help. E9 (nurse), was immediately summoned to R24's room. E9, E11 (Alzheimer Unit coordinator) and E6 (clinical supervisor / restorative nurse), came immediately into R24's room and stayed with the resident until she felt better. After this coughing episode, R24 refused to eat or drink anything else. E6 removed R24's lunch tray out of her room, turned off the room lights and left a full glass of thickened liquids on bedside table, within R24's reach. On 5/22/14 at 1:00PM, E9 said R24 has swallowing problems, is currently receiving antibiotics for an upper respiratory infection and always uses oxygen therapy. E9 also stated this resident usually eats all meals in the dining room but she became tired so decided to eat lunch in her room. R24's medical record includes: 5/22/14 10:29AM, Speech therapy evaluation. This evaluation documents presence of oropharyngeal phase dysphagia. R24 takes un-safe intake amounts with decreased self correction, decreased safety awareness and poor self-monitoring skills. Recommendations include " Close supervision, facilitate safety and efficiency. The patient is recommended to use the following strategies and / or maneuvers during oral intake: no straws, specified swallowing precautions and to remain in upright posture for at least 30 minutes after meals. R24's May 2014 physician order [REDACTED]. R24 is on a mechanically altered diet with nectar thicken liquids. R24's current care plan includes: Swallowing / Chewing problem. Observe resident for difficulty swallowing, signs of choking and/ or aspiration. Provide assistance for meals as needed. On 5/23/14, R24's nursing progress notes were reviewed. R24's 5/22 and 5/23/14 nursing progress notes failed to include the 5/22/14 12:43PM choking and coughing episode or physician notification.

Based on record review, interview and observation the facility failed to protect 2 dementia residents (R2 and R3) from inappropriate sexual contact. R1 abused R2 sexually on 10/21/10 in an enclosed, unoccupied room on the Alzheimer's Unit. R1 abused R3 sexually on 8/16/10, also on the Alzheimer's Unit. This resulted in an immediate jeopardy identified on 12/1/10 and called on 12/1/10 at 11:20am to E2 the Director of Nursing. The immediate jeopardy started on 10/21/10 at 4pm and was removed on 10/25/10 when facility presented a plan to educate and protect their residents from further possible abuse that could result from poor staff response. Findings Include: R1 was observed with his head between the legs of R2 on 10/21/10 by E5 (nurse's aide) in an enclosed, unoccupied room on the Alzheimer's unit per review of facility investigation dated 10/27/10. Review of medical records shows both residents are demented and unable to give consent as they have been given legal guardians. R2 wears a diaper, is non verbal and per chart review is severely cognitively impaired. Medical record does not reflect that this resident seeks out male companionship or has ever engaged in any sexual acting out while on the unit. R2 was noted to be tearful and crying at the time of the 10/21/10 event by E5 (cna) in her written statement. Surveyor observation of R2 on 11/12/10 found R2 unable to communicate or express her needs. R2 would not have been capable of consent nor able to remove her diaper independently. R2 was not sent out to hospital for any physical evaluation per phone interview with E1 (acting administrator) on 12/1/10. R1 remained in the facility for 2 days following this incident on 10/21/10. In the meantime, facility implemented every 15 minute checks for the two days. A similar situation was documented in R1's nurse's notes dated 8/16/10 in which the "cna (nurse's aide) reported to this NOD (nurse on duty) that during rt. (routine) rounds, found resident (R1) performing oral sex to female resident". This female resident was R3 per E2 statement on 11/12/10. R3 is also unable to give consent and has a legal guardian. Because facility failed to follow their abuse policy and do an abuse investigation, Surveyor is unable to document and substantiate what measures facility took after the abuse of R3. E2 (director of nursing) confirmed on 12/1/10 that there was no investigation nor had IDPH been notified of this inappropriate sexual contact that occurred between R1 and R3 on 8/16/10. E2 confirmed that R3 was not sent out for evaluation following the 8/16/10 incident nor had R2, following that incident of 10/21/10. The facility took the following steps to remove the immediate jeopardy which resulted in a level two deficiency as the facility needs to implement their abuse policy consistently and to take appropriate action whenever abuse is suspected. Surveyors will revisit facility and review next episode of alleged abuse and facility actions taken to assure the investigation is complete and timely. 1. R1 was discharged to hospital on [DATE] and did not return to facility. 2. An investigation of the 10/21/10 incident between R1 and R2 was initiated on 1022/10 and completed on 10/27/10. 3. All staff were inserviced on 10/25/10 and on an ongoing basis, regarding what to do when sexually inappropriate or abusive behavior is witnessed, suspected or reported and on the facility abuse policy and procedures, particularly related to prevention, identification, protection, investigation and reporting of sexual abuse. 4. All resident behaviors were reviewed for displays of sexually inappropriate behavior or risk for abusing other residents. 5. As of 11/1/10, the facility has a new administrator who will oversee the implementation of this removal plan.

Based on record review and staff interview, facility failed to operationalize policy and procedures to protect residents from abuse. The facility failed to assure that staff are trained in recognizing and acting on suspected abuse in a manner that reflects knowledge of the policy and procedures implemented by the nursing home to protect residents from possible abuse. This failure resulted in staff leaving two demented residents on the designated Alzheimer's unit in compromised sexual activity (R1 and R2) without immediate intervention and physical assessment which resulted in an immediate jeopardy. The facility also failed to investigate and report a similar incident between R1 and R3 which occurred on 8/16/10. The immediate jeopardy started on 10/21/10 at 4pm. The immediate jeopardy was identified on 12/1/10 at 11:20am. E2 Director of Nursing was notified. The immediate jeopardy was removed on 10/25/10 when facility presented a plan to educate, protect and intervene in situations in which abuse is occurring and keep their residents safe from further possible abuse that could result from poor staff response. This includes investigating all potential abuse situations and staff taking immediate action to protect residents from abuse. Findings Include: Per facility final investigation dated 10/27/10, R1 was observed on 10/21/10 by E5 (nurse's aide) to be "giving oral sex " to R2. R1 was sitting between R2's legs with her diaper and pants off and legs spread apart. R1 had his pants "part way down with his face down in between her legs" . The investigation states E5 discovered R1 and R2 in an unoccupied room with the door closed on the Alzheimer unit on 10/21/10 at 4:00pm. E5 did not attempt to separate either resident at the time and went to the nurse (E6) to inform her of her observations. E6 "was in the middle of giving a medication to another resident" and directed E5 to go inform the unit director, E3. Both E5 and E3 failed to follow the abuse policy policy and procedure when they did not immediately intervene with R1 and R2. E3 went to the room to intervene and saw R2 without his pants on . E3 asked R1 what he was doing and immediately separated the residents. E3 stated to surveyor on 11/12/10 that he immediately contacted the former administrator and asked her if R1 should be discharged to the hospital and she told E3 "no". R1 was not sent out until 2 days later when a bed became available in the psychiatric unit. Facility provided documentation indicating R1 was placed on 15 minute checks until discharge on [DATE]. A similar situation was documented in R1's nurse's notes dated 8/16/10 in which the "cna (nurse's aide) reported to this NOD (nurse on duty) that during rt. (routine) rounds, found resident (R1) performing oral sex to female resident". This female resident was R3 per E2 statement on 11/12/10. R3 is also unable to give consent and has a legal guardian. Because facility failed to follow their abuse policy and do an abuse investigation, Surveyor is unable to document and substantiate what measures facility took after the abuse of R3. E2 (director of nursing) confirmed on 12/1/10 that there was no investigation nor had IDPH been notified of this inappropriate sexual contact that occurred between R1 and R3 on 8/16/10. E2 confirmed that R3 was not sent out for evaluation following the 8/16/10 incident nor had R2, following that incident of 10/21/10. Facility abuse policy instructs staff to implement systems to investigate all reports and allegations of mistreatment promptly and aggressively and make the necessary changes to prevent future occurrences and to file timely and investigative reports. The facility failed to follow their abuse policy and procedure in these areas. E3 (Alzheimer director) stated on 11/12/10 that when R1 came back on 9/8/10, E3 could barely keep (R1) awake for his meals. E3 confirmed no new interventions or revisions were put in place to assure R1 did not sexually abuse others upon his readmission (9/8/10) because R1 was really out of it for the first few weeks. But then R1 started with his old sexual behaviors. E3 confirmed that no monitoring interventions were put in place for behavior monitoring even then except for keeping R1 busy with his own self directed activities. Following the 8/16/10 incident, R1 was sent out that day for psych care from 8/16/10 to 9/8/10 and readmitted on [DATE]. R1 apparently showed no further sexual acting out until around 10/4/10 when physician ordered depo [MEDICATION NAME] for 4 weeks which was changed 4 days later to [MEDICATION NAME] on 10/8/10. There is no indication in the nursing notes why on those dates the facility obtained this order for libido. E2 (director of nursing) stated on 11/12/10 that she was not sure why the order had been obtained. The facility took the following steps to remove the immediate jeopardy which resulted in a level two deficiency in order to evaluate the effectiveness of inservices and training of staff and evaluate their response to potential abuse allegation. 1. R1 was discharged to hospital on [DATE] and did not return to facility. 2. An investigation of the 10/21/10 incident between R1 and R2 was initiated on 10/22/10 and completed on 10/27/10. 3. All staff were inserviced on 10/25/10 and on an ongoing basis, regarding what to do when sexually inappropriate or abusive behavior is witnessed, suspected or reported and on the facility abuse policy and procedures, particularly related to prevention, identification, protection, investigation and reporting of sexual abuse. 4. All resident behaviors were reviewed for displays of sexually inappropriate behavior or risk for abusing other residents. 5. As of 11/1/10, the facility has a new administrator who will oversee the implementation of this removal plan.

Based on record review, interview and observation the facility failed to supervise one alzheimer resident (R1) who engaged in a second incident of inappropriate sexual contact on the Dementia unit. This failure to supervise R1 who has a history and documented evidence of inappropriate sexual acting out and sexual preoccupation resulted in incidents of inappropriate oral sex for two 2 dementia residents (R2 and R3) who are unable to give consent for such a sex act. The immediate jeopardy started on 10/21/10 at 4pm. The immediate jeopardy was identified on 12/1/10 at 11:20am. E2 Director of Nursing was notified. The immediate jeopardy was removed on 10/25/10 when facility presented a plan to review all residents behaviors for sexually inappropriate behaviors or those residents at risk for abusing other residents, intervene in situations in which abuse is occurring and keep their residents safe from further possible abuse that could result from poor staff response. This includes investigating all potential abuse situations and staff taking immediate action to protect residents from abuse. Findings include: Review of a facility investigative report dated 10/27/10 states that on 10/21/10 E5 (nurse's aide) opened an unoccupied resident's room on the dementia unit and observed R1 performing oral sex with R2. R2 was observed to be crying according to E5's statement. R2's most recent Minimum Data Set ((MDS) dated [DATE] shows that R2's cognition is severely impaired, is rarely/never understood or understands and has highly impaired vision. Care plan dated 8/20/10 in the area of communication states that R2 has [DIAGNOSES REDACTED]. Another care plan (same date) states that R2 wanders in and out of other peers room and typically leaves any activity she is escorted to. The abuse care plan goal (same date) 8/20/10 states that R2 will remain safe, calm and free from abuse by 11/20/10. This goal was not achieved as R2 was sexually abused by R1 on 10/21/10. R1's care plan dated 9/13/10 states that R1 is sexually preoccupied and makes sexual comments and gestures. Review of nurse's notes in R1's medical record document that on 8/16/10, R1 was observed to be performing oral sex with R3, a dementia resident residing on the Alzheimer's unit. This incident of 8/16/10 was not included in R1's plan of care nor were any specific, individualized intervention strategies to prevent or monitor for reoccurrence. R1 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. R1's behavior began to deteriorate over the next few weeks as evidenced by statements made by E2, E3 and E4 on 11/12/10: E2 (director of nursing) said that when R1 came back from the hospital (9/8/10) after the prior sexual encounter with R3 (8/16/10), R1 was "really out of it but then he started with his old behaviors and that's when the doctors put him on hormone injections." E3 (Alzheimer director) stated that when R1 came back on 9/8/10, E3 could barely keep (R1) awake for his meals. E3 confirmed no new interventions or revisions were not put in place to assure R1 did not sexually abuse others upon his readmission (9/8/10) because R1 was really out of it for the first few week. E3 stated that no new interventions were put in place once R1 started with his old sexual behaviors. E3 said that he tried to keep R1 busy with his own self directed activities. E4, (nurse's aide) stated that R1 was really out of it and stayed in his room a lot when he first came back from the hospital (9/8/10) after the incident with R3 (8/16/10). E4 stated that R1 eventually got back to his old self however and began making sexual comments and motions to the female residents again. Review of physician order [REDACTED]. There is no indication in the nursing notes why on those dates the facility obtained this medication order for libido. There is no documentation that any monitoring or interventions were put in place or of the effectiveness of this medication in the 2 weeks leading up to the sexual abuse incident of R1 to R2 on 10/21/10. The facility took the following steps to remove the immediate jeopardy which resulted in a level two deficiency which would allow for time to evaluate every resident for potential abuse. 1. R1 was discharged to hospital on [DATE] and did not return to facility. 2. An investigation of the 10/21/10 incident between R1 and R2 was initiated on 1022/10 and completed on 10/27/10. 3. All staff were inserviced on 10/25/10 and on an ongoing basis, regarding what to do when sexually inappropriate or abusive behavior is witnessed, suspected or reported and on the facility abuse policy and procedures, particularly related to prevention, identification, protection, investigation and reporting of sexual abuse. 4. All resident behaviors were reviewed for displays of sexually inappropriate behavior or risk for abusing other residents. 5. As of 11/1/10, the facility has a new administrator who will oversee the implementation of this removal plan.