Every finding on record at Allure of Galesburg

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects one (R2) of three residents reviewed abuse in a sample of 10. This failure resulted in R2 sustaining a facial injury and loss of two teeth requiring evaluation in the emergency department.Findings include:The facility's Abuse, Neglect, Exploitation policy revised 2/25 documents that it is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in harm, pain, or mental anguish. R1's current care plan documents a history of behaviors related to schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder, and Post Traumatic Stress Disorder (PTSD), including verbal aggression/agitation/agitation and physical aggression toward peers. The facility's Serious Injury Report dated 8/2/26 documents an alleged altercation between R1 and R2. The report documents that staff immediately separated the residents and assessed both residents for injuries. R2 was noted to have blood from the mouth and two missing teeth. R1 had no injuries noted at that time. Local police were notified, and both residents were sent to the emergency department for evaluation. The facility investigation, including review of video footage and interviews, determined that R1 and R2 were involved in an altercation in the hallway in front of their room. Staff immediately responded and separated the residents. R2 was noted to have a swollen lower lip with blood present. While the nurse was assessing R2, R2 removed two lower teeth from his mouth. R1 did not appear to have injuries. Police responded to the facility. No arrests were made. R1's Nurse Progress Note dated 8/2/26 documents that while the nurse was completing medication pass. the nurse observed R1 punch R2 in the face. The nurse yelled for the resident to stop, staff responded and separated the residents, and 911 was called. R2 was sent to the emergency department for evaluation. On 8/18/26 at 11:00 AM, R1 was interviewed regarding the 8/2/26 altercation. R1 stated that he recalled the physical altercation with R2, his former roommate. R1 stated that he and R2 had a disagreement the night before regarding a guitar. R1 stated that after he moved the guitar to his side of the room, R2 approached him and wanted to fight. R1 stated that he told R2 they should go into the hallway because there was a camera. R1 stated that in the hallway, R2 blocked the doorway, put R1 against the wall, and would not allow R1 back into the room. R1 stated that R2 then lunged at him and that R1 punched R2 in the face. R1 stated that staff separated them after he punched R2. On 8/18/26 at 1:15 PM, V2, Director of Nursing, stated that R1 and R2 were involved in a physical altercation in the facility hallway on 8/2/26 and that staff separated the residents after R1 punched R2 in the face. V2 confirmed that R2 was no longer residing at the facility and was discharged against medical advice (AMA) on 8/11/26.

Based on record review and interview, the facility to ensure resident property [medication] is not misappropriated, by facility staff, for 2 residents (R1, R2) of three residents, in a total sample of three, reviewed for misappropriation of property. Findings include:Facility Policy, entitled Abuse, Neglect, and Exploitation, document: Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.1. R1's Electronic Medical Record/EMR, document R1's diagnosis to include: Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Major Depressive Disorder, Diabetes Mellitus Type II, Hypertension, Bipolar Disorder, Hypothyroidism, Muscle Wasting and Atrophy, Cystitis, Cognitive Communication Deficit, Cellulitis of Left Toe, Hallucinations, Hyperlipidemia, Dysphasia, Morbid Obesity, Generalized Anxiety Disorder, and Lymphedema.R1's Medication Administration Record/MAR, for July 2026, documents R1 receives: Novolin R (Regular) Injection Solution 100 UNIT/ML (Insulin Regular (Human)) Inject 12 unit subcutaneously three times a day. R1 received her Insulin as ordered.The facility's Final Report [to the State Agency] document on 7/12/26, V5/Licensed Practical Nurse-LPN reported that V3/LPN took and used insulin belonging to R1. Investigation revealed by video and statements that V3 did take insulin-R from the medication cart labeled to R1 and injected it into herself. V3 admitted to taking and using the insulin.V3's, facility transcribed text messages, document, in-part, The first incident was exactly how I said it I just used a needle! The second time my blood sugar was elevated to 580 and I had some at my house but I didn't feel like I could drive over there because I was feeling so out of it and like I was gonna pass out, so l asked [V5] if she had some reg[ular] insulin on her cart and she did, so I drew up 30 units to take, it was either that or call 911, I wasn't thinking straight, I didn't look at it like abuse and I wanted to continue the rest of the shift so I could do my job! I'm very very sorry!On 7/31/26, V1/Administrator confirmed, through the facility investigation, based on interviews and the facility surveillance cameras, that V3 did use R1's insulin and was subsequently terminated and reported to the [State] Department of Professional Regulation.2. R2's Electronic Medical Record/EMR, document R2's diagnosis to include: Polyosteoarthritis, Visual Hallucinations, Major Depressive Disorder, Diabetes Mellitus Type II, Hemiplegia affecting Left Non-dominant Side, Congestive Heart Failure, Hypertension, Alzheimer's Disease, Cerebral Infarction, Generalized Anxiety Disorder, Muscle Wasting and Atrophy, Cognitive Communication Deficit, Repeated Falls, Chronic Obstructive Pulmonary Disease, Anemia, Dysphasia, History of Falling, and Major Depressive Disorder.R2's Medication Administration Record/MAR, for July 2026, documents R2's multiple Dilaudid prescription administration details including: Dilaudid (narcotic pain reliever) Oral Tablet 2 MG [milligram] (Hydromorphone HCl) Give 0.5 mg [milligrams] by mouth every 6 hours as needed for pain give 1/2 tablet.The facility's Final Report [to the State Agency], document on 7/12/26, Investigation: Reported that [V4/Licensed Practical Nure-LPN] inappropriately wasted Dilaudid. [V4] states that she dropped the medications in the cart and I was only initially able to find the Ativan. I took the Ativan to V6/LPN] to witness the medication being wasted. I gave her the wrong sheet (Dilaudid) to sign by mistake. I later had [V7/RN] help me look in the cart and we found it. [V7] witnessed me destroying the medication, but we forgot to sign the sheet. [V6/LPN] states that [V4] did come to her to destroy an Ativan and the wrong sheet was signed for witnessing the wasted medication. She did not see a Dilaudid be wasted. [V7] states that she has no memory of finding or wasting medication with [V4]. The controlled count sheets show a wasted dose on both the Ativan and Dilaudid sheets. Dilaudid is the only wasted medication with a witness signature (which is the incorrect witnessed medication). Video footage does not show [V4] and [V7] looking for or wasting any medications. Video footage does show her looking in the med cart with [V8/Certified Nursing Assistant]. [V8] states that she did help her look but was not in the cart (video footage supports this) and that a small white pill was found. [V4] has not returned calls or messages for follow-up interviews. Video footage and investigation from that day shows that two Dilaudid are unaccounted for.On 7/31/26, V1 and V2/Director of Nursing confirmed, through the facility investigation, based on interviews and review of the facility surveillance cameras, that two hydromorphone tablets, belonging to R2, were unaccounted for by V4, and subsequently V4 was terminated and reported to the [State] Department of Professional Regulation.

Based on interview, observation, and record review, the facility failed to provide adequate supervision and reassess elopement risk status to prevent a resident with known cognitive impairment, and with a known attempt of exiting the building unauthorized, from eloping from the facility for one of three residents (R1) reviewed for elopement in the sample of three. Specifically, the facility failed to adequately supervise (R1) with a known diagnoses of Bipolar and with cognitive impairment, who was documented at risk for elopement and a history of unauthorized exit attempts. The facility also failed to respond to and investigate sounding door alarms at secured facility exits and conduct a missing resident sweep/headcount when exit alarms were triggered. These systemic failures resulted in (R1) eloping from the facility undetected through an alarmed exit door, (R1) then crossed a busy roadway after exiting the building unauthorized and remained unsupervised during a weather-related heat advisory (ambient outdoor temperature of 86-degrees F (Fahrenheit) with a 95-degree F heat index). (R1) remained unsupervised in these extreme weather conditions for approximately 21 minutes, traveling approximately 0.6 miles to a previous residence (group home). The facility failed to identify the elopement, remaining completely unaware of (R1's) absence until notified by staff at (R1's) former residence. Serious adverse outcomes likely to occur include the risk to (R1's) health and safety, medical complications, or being struck by a motor vehicle.The Immediate Jeopardy began on 7/1/26, with R1 eloping from the facility. V1/Administrator, V16/Regional Nurse Consultant, and V17/Vice President of Operations were notified of the Immediate Jeopardy on 7/20/26 at 11:03 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, as of 7/5/26, prior to the start of the survey on 7/17/26, and was therefore Past Noncompliance. This past non-compliance occurred from 7/1/26 - 7/5/26.Findings include:The Facility's Elopements and Wandering Residents Policy, dated 7/1/26, documents Policy: This ensures that the residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal direct. (Example: the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (example: order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with doors locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. the interdisciplinary team will evaluate the unique factors contributing to risk in order to develop person-center care plan. D. Adequate supervision will be provided to help prevent accidents or elopements.The facility's Door Alarm Policy, undated, Documents Purpose: To ensure a prompt and consistent response to all door alarms in order to protect residents from unauthorized exit, prevent elopement, and maintain a safe environment. Policy: Every door alarm shall be treated as a potential resident elopement until proven otherwise. Staff are expected to respond immediately. Procedure: 1. Immediate Response- Staff members will immediately respond to the alarm, do not assume another employee is responding, proceed directly to the alarming exit. 2. Assess the Door: Determine- Is the door open or closed, is anyone exiting, is there a resident at the door, if not, staff will walk the perimeter of the facility to ensure a resident has not left visual range of the door, if staff does not visualize a resident, they will return to the facility and initiate a head count with use of the resident roster. Staff to make room assignments and visualize each resident by face and check them off the roster as they go. If a resident is identified as missing, the need to initiate the elopement policy, and make appropriate notification. Is it a visitor, employee, vendor, or resident causing the alarm.The facility's Accidents and Supervision Policy, dated 7/1/26, documents Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.The facility's Resident Alarms Policy, dated 10/2025, documents Policy: It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practical level of physical, mental, and psychosocial well-being. Definition: An alarm is any physical or electronic device that monitors residents' movement and alerts the staff, by either audible or inaudible means, when movement is detected. Policy Explanation and Compliance Guidelines: 1. The use of alarms does not eliminate the need for adequate supervision of the residents. Types of alarms include e. Wander/elopement alarms- include devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. This includes devices that are attached to the resident's assistive device or other belongings. 6. Monitoring and modification: a. Supervision shall be provided to the residents in accordance with resident's plan of care. b. When alarms are utilized, additional monitoring shall be provided, including but not limited to 1. Verifying alarms are used in accordance with the resident's care plan.R1's Face Sheet documents R1 is a [AGE] year-old male who admitted to the facility on [DATE] and has the following, but not limited to, diagnoses: Bipolar Disorder, Epilepsy, Cerebral Infarction, and Chronic Viral Hepatitis C.R1's PASRR (Pre-admission Screening and Resident Review) Level 1 Form, dated 5/29/26, documents R1 has Major Depression, Psychotic/Delusional Disorder, Bipolar Disorder, Anxiety Disorder, Stimulant Dependence in early remission (Severe), Major Neurocognitive Disorder due to Vascular Disease, Cerebrovascular Accident, Seizure Disorder, Hypertension, smokes 10 cigarettes daily per medical records, history of drinking alcohol using tobacco, methamphetamine, and cocaine, history of being hospitalized multiple times for treatment of R1 's mental health systems, at risks for falls and needs help to regain strength. This same PASRR documents Crisis intervention or services plan: A safety and crisis plan will help you and your nursing facility staff to outline a plan with steps for managing a mental health crisis, including identifying triggers, developing coping strategies, and establishing a support network. The purpose is to provide immediate, short-term help to you if you experience a crisis, aiming to reduce potential long-term harm. The focus is to ensure safety, de-escalating the situation, and connecting individuals with resources and ongoing supportR1's MDS (Minimum Data Set) Assessment, dated 6/10/26, documents R1 is severely cognitively impaired and ambulates with supervision or touching assistance.R1's Elopement Evaluation, dated 6/1/26, documents R1 is not at risk for elopement.R1's Progress Note, dated 6/2/26 and signed by V9/Psychiatric Rehabilitation Services Coordinator, documents, (R1) became upset because (R1) cannot smoke in (R1's) room. (R1) attempted to Elope. (V1/Administrator) walked out of the building alongside (R1) and convinced him to return. (V9) left a voice message for the (V8/R1's Guardian) to call (V9) back regarding (R1's) desire to leave and (R1's) behavior.R1's Care Plan, documents Date 6/2/26: Tobacco Use Status: (R1) is a smoker. (R1) knows he has access to materials during designated smoking breaks and therapeutic leave and (R1) knows how to ask for assistance. Intervention: 6/2/26- First Offence on 6/2/26.- (R1) attempted to smoke in (R1's) room and when re-educated on the facility policy regarding smoking (R1) exited the facility. (R1) was re-educated and (R1's) smoking privileges were held for 24 hours. This same care plan does not include additional interventions to ensure (R1's) behavioral non-compliance is managed through clinical interventions-such as physician-ordered nicotine replacement therapies-rather than punitive restrictions that increase elopement risks.R1's Progress Notes dated 7/1/26 from 4:42 AM through 9:25 AM documents following reports of smoke smell in R1's room and V15/RN (Registered Nurse) smelling cigarette smoke in R1's room, V12/Social Service and V15/Activity Director conducted a room search and confiscated a hidden lighter, marking this R1's second violation of the facility's tobacco policy. Consequently, the IDT (Interdisciplinary Team) reviewed the infraction and suspended smoking privileges for two weeks. This restriction was formally explained to R1 by V12 with V5/CNA (Certified Nursing Assistant) present as a witness.R1's Progress Note, dated 7/1/26 at 10:12 AM and signed by V12/Social Service, documents (V12) called (V8/R1's Legal Guardian) and explained (R1's) smoking policy infraction. (V12) explained that (R1) has lost smoking privileges for two weeks due to being second offense. (V8) explained that (R1) may increase behaviors due to his history of smoking. (V12) explained smoking policy to (V8). (V8) expressed she may look into other placements for (R1).R1's Care Plan, documents Date 7/1/26- Tobacco Use Status: (R1) is a smoker. (R1) knows he has access to materials during designated smoking breaks and therapeutic leave and (R1) knows how to ask for assistance. Second Offense: 7/1/26- (R1) was found smoking in his room and putting cigarettes out on the wall and flushing the butts. (R1) had two lighters in his possession that were confiscated. (R1) was re-educated on the smoking policy and informed that (R1's) smoking privileges were being held for two weeks. This same Plan of Care documents Date 6/5/26: Elopement Risk: (R1) is at risk for elopement related to Serious Mental Illness diagnoses as well as impulsive behaviors. (R1) attempted to leave the facility on (R1's) first day to go have a cigarette. A wander guard was placed on my left wrist, and I have been added to the elopement risk book found at the nurses station. Date: 6/5/26- (R1) has a behavior problem related to Bipolar Disorder. (R1) can become verbally agitated and has the potential of elopement. Date 6/23/26- (R1) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue, stroke, slow cognition, arthritis, and cervical disc degeneration. Date-6/23/26- (R1) is at risk for falls related to poor communication/comprehension, psychoactive drug use, epilepsy, and residual cardiovascular accident effects. These care plans do not include additional interventions to ensure R1's behavioral non-compliance is managed through clinical interventions-such as physician-ordered nicotine replacement therapies-rather than punitive restrictions that increase elopement risks or to prevent an elopement.R1's Progress Note, dated 7/1/26 at 11:52 AM and signed by V7/Social Service, documents (V7) received a call from (a local group home) at 11:52 AM, stating that (R1) showed up at his previous group home, two blocks from the facility.R1's Progress Note, dated 7/1/26 at 12:00 PM and signed by V7/Social Service, documents (V7) contacted (V8/R1's Legal Guardian) to inform (V8) of (R1's) elopement to (R1's) old group home. R1's State of Illinois Department of Public Health Report, dated 7/7/26, documents Report Type: Final. Incident Date: 7/1/26. Time of Incident: 11:29 AM. Resident involved: (R1): Ambulatory. Informed Decisions: No. Detailed Incident Summary: (R1) with (Bipolar Disorder and Cerebral Infarction) exited the building unaccompanied. (R1) was safely brought back inside the facility and assessed for injuries. No injuries noted. This same Report documents, (R1) was frustrated by the smoking rules in the facility and exited through the front door. Staff were alerted to (R1) being out of the facility. Staff retrieved (R1) and returned him to the facility.R1's Incident Investigation Report, dated 7/7/26 and signed by V1/Administrator, documents on 7/1/26 at 11:29 AM R1 exited the building, at 11:30 AM the facility's alarm was reset staff did not respond to alarm appropriately, at 11:50 AM, the facility received a call that R1 was at his previous place of residence, at 12:11 PM R1 returned to the facility with facility staff. This same Incident Investigation Report, documents (R1) removed his wander guard and placed it under his pillow. (R1) then went to the dining room and waited for staff to be engaged with other residents and ran out the front door. Door alarm sounded. Staff did not immediately respond to alarm. Once alarm was deactivated, staff failed to search area or call for a head count. (R1) went to a previous place of residence approximately 2 1/2 blocks from the facility. We (the facility) were notified that (R1) was at the house area by the house staff. The facility staff immediately went to the house area and brought (R1) back to the facility.V4/CNAs Corrective Action Form, dated 7/7/26, documents Date of Incident: 7/1/26. Description of Incident: Negligence or any careless action which endangers the health, life or safety of another person. Per corporate you are being terminated from our employment.V5/CNAs Corrective Action Form, dated 7/7/26, documents Date of Incident: 7/1/26. Description of Incident: Negligence or any careless action which endangers the health, life or safety of another person. Per corporate you are being terminated from our employment.R1's Medical Records did not include evidence of staff checking R1's wander guard function or placement from 6/5/26 through 7/1/26.Map [NAME] documents an approximately 20-minute walk from the facility to the local group home (where R1 was located).The Weather Underground Report, dated 7/1/26, documents on 7/1/26 at 11:35 AM the outside temperature was 86 degrees F with 67 percent humidity, which translates to 95 degrees F heat index.On 7/18/26 at 12:05 PM this surveyor drove from the facility's parking lot to the local group home where R1 was located. During the drive it was observed R1 would have crossed five main roads along with one main highway (that has multiple businesses and traffic). Per odometer reading it was 0.6 miles from the facility to the local group home.On 7/17/25 at 12:35 PM V7/Social Service stated, upon receiving a call from the local group home on 7/1/26 stating that R1 had arrived there, V7 immediately notified V1/Administrator. V9/Psychiatric Rehabilitation Service Coordinator and V14/Activity Director then went to retrieve R1 and return R1 to the facility. Because R1 was assigned a wander guard, they were initially unsure how R1 managed to exit undetected, until R1 returned and showed them that R1 had taken it off and hidden it under R1's pillow. R1 was not identified as an elopement risk during R1's initial admission. However, the following day, R1 became highly upset when staff caught R1 smoking in his room and staff informed R1 that his smoking privileges were suspended for 24 hours, prompting R1 to attempt to exit the building while staff followed. R1 has very low cognition, making communication difficult. V7 acknowledges that an elopement evaluation should have been completed following the 6/2/26 incident, but verified none was done. V7 reported while the facility did place a wander guard on R1 after that initial exit attempt, the facility staff did not implement any specific interventions to address R1's agitation regarding smoking restrictions and then on 7/1/26, R1 became upset again when staff caught him smoking in his room once more, resulting in R1's smoking privileges being revoked for two weeks for breaking his smoking contract. V7 stated she was unaware of any clinical interventions put into place to manage the behavioral non-compliance that originally triggered R1's exit-seeking behavior.On 7/17/26 at 12:44 PM, V4/CNA stated, On 7/1/26 sometime around 10:30 AM I heard the alarm going off at the front door. I looked out the door and saw a female getting into a car. I knew another resident was getting ready to leave, so I turned the alarm off at that time. I didn't see anybody else out there, so I didn't think that I needed to go out. Around thirty minutes after that I found out (R1) had exited the building unattended and ended up at his prior group home. I do recall now if we don't see anybody then we do a headcount, or if we can't find somebody that we do a headcount. I guess I didn't realize that we do that every single time the alarm goes off. They (the facility) terminated me and told me the reason was I endangered a resident by not following facility protocol when (R1) got out the door.On 7/18/26 at 1:05 PM V3/Assistant Director of Nursing, stated, We (the facility) do not have documentation that (R1's) wander guard was functioning properly or being checked for placement until 7/1/26 after (R1) left the facility unattended. V3 stated there should have been an order on 6/2/26 (when R1's wander guard was placed) to check R1's wander guard for functionality each night and check for placement each shift. Facility staff should have been alerted to be on the lookout for increased anxiety, agitation, and eloping when R1's smoking privileges got taken away. R1 had a cognitive impairment related to his stroke and had poor decision making, and impulsive behaviors making it unsafe for R1 to be unattended outside of the facility.On 7/20/26 at 8:19 AM V8/R1's Legal Guardian stated when R1 was being admitted to the local nursing home, V8 let the nursing home know how important smoking was to R1. When R1 broke the smoking rule right away and R1's privileges were taken away for 24 hours, R1 was exit seeking then. The second time staff called me to let me know (R1) had broken the smoking rules and smoking would be taken away for two weeks, I expressed concern that (R1) was not going to be able to cope with that, asked if there were any other alternatives to try with (R1), and let them know (R1) would have increased behaviors. The facility said there was nothing else they could do and that they have a very strict smoking policy. (R1) does have impulsive behaviors, and the facility was aware of that. I am not sure how (R1) even found his prior residence because he is not from the area, and he has poor cognition and is not safe to wander around by himself due to his impulsive behavior and previously had a stroke.On 7/20/26 at 9:05 AM V12/Social Services stated the same day prior to R1 eloping from the facility unattended, R1 had broken the smoking rules. IDT (interdisciplinary team) determined since this was R1's second offense, R1's smoking privileges would be taken away. I let (R1) know that and (R1) seemed like he understood. V12 stated she notified V8/R1's Legal Guardian of R1 breaking the smoking rules a second time and that R1's smoking privileges were being taken away for two weeks. V8 voiced concern regarding R1's smoking privileges being taken away for that long since R1 was used to smoking whenever he wanted and for how long he wanted prior to admitting R1 to the facility. V8 did express concerns that R1's behaviors would probably get worse if he was not allowed to smoke for that long. V8 denied being aware of additional follow up or interventions being put into place (like heightened monitoring) after R1's smoking privileges were taken away a second time to help R1 cope with the situation and after R1 exhibited exit seeking behaviors the first time R1's smoking privileges were taken away.On 7/18/26 at 11:54 AM, V1/Administrator stated, On 7/1/26 the local group home called to report that (R1) was at their facility, which was the first we knew (R1) was out of the building. I reviewed the video surveillance, and it showed that at 11:29 AM, (R1) came up B hallway, went through the activity area, and waited around for staff to go down different hallways while (V5/CNA) was standing at the nurses' station with her hands on her hips and (V4/CNA) was by the indoor smoking area. From the video footage you could see (R1) wait for staff to not pay attention, lay a piece of paper on the table, then ran out the door, and bolted, which caused the front door alarm to sound. You could see (R1) did not have his wander guard on at that time. (V5) stood by the nurses' station with her hands on her hips for around a good minute, and as others headed toward the dining room, (V4) literally peeked through the glass on the main door, entered the code to turn off the alarm, and walked away. You could see by the video surveillance that all (V4) did was quickly glance out the door window for a brief second and then reset the alarm. Although (V4) claimed she looked out and saw a resident she thought was going home leave in a car, the video surveillance showed no cars or families in view, and that specific resident she thought she saw was seated at a table in the dining room. (V4) never even opened the door to check outside. When (R1) arrived back to the facility, (R1) told us that he took off his wander guard and placed it under his pillow that morning. I am not sure how (R1) got his wander guard off, because the band was not cut or ripped or anything. (R1) was wearing blue jeans, a t-shirt, shoes, and a hat when he left the building. V1 verified that there is no documentation indicating when R1 was last seen wearing his wander guard. Additionally, V1 was unaware of the last time anyone observed R1 with the device in place. V1 acknowledged that all staff members must respond to a door alarm, following the facility's protocol prior to silencing it. V1 acknowledged R1's initial elopement attempt occurred after he was caught smoking in his room and his smoking privileges were taken away for a day and because R1 was caught smoking in his room a second time, resulting in the revocation of his smoking privileges. Staff should have implemented specific interventions to help him cope with this restriction and prevent further elopement attempts.Prior to 7/17/26, survey, the facility took the following actions to correct the deficient practice:Per skin assessment, progress notes, and interviews R1 returned to the facility on 7/1/26 and assessed for injuries, with no injuries identified.Per Care Plan and Physician Orders, R1's wander guard was changed from R1's wrist to R1's left ankle on 7/1/26.All residents who identified at risk for elopement were reviewed by V2/Director of Nursing and V3/Assistant Director of Nursing and completed 7/2/26.Facility Wide elopement assessments were completed by staff with a completion date of 7/2/26.Care Plans for residents at risk for elopement were reviewed and updated as needed by V18/MDS Coordinator and completed 7/2/26. Facility elopement book updated on 7/1/26 by V2/Director of Nursing.V1/Administrator and V3/Assistant Director of Nursing In-serviced all staff regarding door alarms response times and expectations, elopement and wandering policy, wander guard policy, accidents and supervision policy, wander guard book (location and how to use), behavioral interventions and redirection, and wander guard placement and functionality checks as ordered starting on 7/1/26 and ending on 7/5/26.Quality Assurance Study, Quality Assurance Performance Improvement, and Root Cause Analysis completed on 7/1/26.An audit tool to review compliance was developed to ensure elopement book is up to date, elopement risk assessments and care plans are up to date, wander guard is functioning as it should and documented, and wander guard in place and documented. An audit tool to review compliance was also developed to monitor if any resident attempted to elope and if staff were able to redirect resident, if an alarm alerted staff and if staff responded appropriately. The audits will be done weekly for six weeks then monthly for three months.Elopement drills have been completed on 7/1/26 and then weekly and will continue for six weeks then monthly for three months by V1/Administrator.

Based on Interview and Record Review, the facility failed to implement its abuse policy when an allegation of staff-to-resident sexual abuse was received for one of four residents (R2) reviewed for abuse in the sample of four. Findings Include:The facility's Abuse, Neglect, and Exploitation policy dated 1/30/2026 documents, Policy explanation and compliance guidelines, 1. The facility will develop and implement a written procedure that: c. includes training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written. Prevention of abuse, neglect, bribery and exploitation, the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, bribery, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, bribery, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that staff have assigned have knowledge of the individual residents care needs and behavioral symptoms.On 6/18/2026 at 12:30 PM, I attempted to contact R2 and left a message. R2 is no longer a resident at the facility.On 6/18/26 at 12:55 PM, V8 (Certified Nursing Assistant, CNA) confirmed she has heard rumors about V3 (CNA) having a sexual/personal relationship with a resident who used to live in the facility (R2). V8 stated, I don't know if anyone has mentioned the rumors to (V1). I first heard about this in a group conversation with other CNAs (V5 and V6) a few months ago. It was said that (V3) previously had a relationship with (R2) while he was in the facility and after discharge.V1 (Administrator) confirmed he was the abuse coordinator and stated he was not aware of the allegation of R2 and V3 (Certified Nurse Assistant) having a relationship while R2 was a resident or after he was discharged . V1 stated he was not the Administrator at the time R2 was a resident and had no knowledge of this allegation. V1 stated he became aware of the allegation today (6/18/2026) after staff started talking about it, no one had come to me to tell me about the allegation until today.

Based on interview and record review, the facility failed to provide significant medications for High Blood Pressure, Depression, Anxiety, High Cholesterol, and Bipolar Schizoaffective Disorder for one (R3) of three residents reviewed for medications in a sample of seven. These failures resulted in R3 having an increase in blood pressure of 198/101 where he was dizzy and had headaches, and an increase in his anxiety which resulted in R3 getting an increase in his dosage of Hydroxyzine from twice a day to three times a day for his anxiety.Findings include:Facility Therapeutic Leave policy, copyright 2025, documents The facility will coordinate with the resident and/or representative the length of time the resident will be gone to ensure the adequate amounts and appropriate medications is ready for administration while on the leave.R3's electronic health record documents the following medical diagnoses: Schizoaffective disorder Bipolar type; suicidal ideations; major Depressive disorder, recurrent; essential (Primary) Hypertension (high blood pressure); mixed Hyperlipidemia (elevated cholesterol); restlessness and agitation; and anxiety disorder.R3's medical record documents R3's current medication orders for April 2026 documents R3 takes the following: Amlodipine 5mg/Benazepril 10mg given once a day at 7am related to Essential (Primary) Hypertension (high blood pressure) hold for b/p less than 100, with an order date of 1/10/26 and to give at 7AM; Cariprazine HCl Oral Capsule 3 MG Give 1 capsule by mouth one time a day related to Schizoaffective Disorder, Bipolar with an order date of 1/22/26 and to give at 7am; Fenofibrate Oral Tablet 160 MG give 1 tablet by mouth one time a day related to mixed Hyperlipidemia (high cholesterol) with an order date of 1/12/2026 and to give at 7am ; Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG give 1 tablet by mouth one time a day related to major depressive disorder, recurrent with an order date of 2/13/2026 and to give at 7am; Hydroxyzine HCl Oral Tablet 50 MG give 1 tablet by mouth two times a day related to anxiety disorder with an order date of 3/30/26 and to give at 7AM which was discontinued on 4/7/26; and was increased to Hydroxyzine HCl Oral Tablet 50 MG give 1 tablet by mouth three times a day related to anxiety disorder with an order date of 4/7/26 and to give at 7am, 12pm, and 5pm.R3's electronic and paper medical record has no documentation R3 was sent with all his medications for his therapeutic leave.R3's electronic medical record documents on 4/7/26 documents R3 asked his nurse to have his Hydroxyzine (anxiety medication) 50mg/milligrams increased from BID/twice a day to TID/three times a day. This record documents R3 got the extra dose on 4/7/26 at 12pm for anxiety.R3's medical record documents R3's blood pressure/b/p on the day he left (4/3/26) at 8:36AM his b/p was 126/84. Upon R3's return to the nursing home on 4/6/26, his b/p on 4/6/26 at 8:33 AM was 198/101.R3's medical record census sheet documents R3 was on therapeutic leave from 4/3/26 (Friday) until 4/6/26 (Monday) when his census was marked active (meaning back in the building from leave).R3's Medical Record nurses note, dated 4/4/26 at 5:30am by V8 LPN documents Resident. called and stated he did not get his morning meds this am and they were not packed for the home visit for the rest of the week. Nurse told him he could come back and I could check them for him and that I was sorry that happened. Resident stated he will try to stay the home visit but if he has problems he will go to the ER. Nurse stated ok and notified the Administrator of this.R3's Medication Regimen Review Nursing Staff Recommendation, dated 4/14/26, documents the following: Residents medications were reviewed per regional nurse request after resident missed morning medications on [NAME] visit. It appears resident left on 4/3 and returned on 4/6/26. Of note, B/P (blood pressure) was elevated on return from home visit. Resident also voiced increased depression and anxiety upon return from visit. Amlodipine 5mg/Benazepril 10mg given once a day at 7am related to Essential (Primary) Hypertension (high blood pressure) hold for b/p less than 100. Residents b/p was elevated upon return from home visit which could have been secondary to missing this medication. The antihypertensive effect of Amlodipine is at least 24 hours. The half life of Benazapril is lower at 10 to 11 hours and therefore could lead to an increase in b/p if missed for two days. Cariprazine HCl Oral Capsule 3 MG Give 1 capsule by mouth one time a day related to Schizoaffective Disorder, Bipolar half life is two to four days.Fenofibrate Oral Tablet 160 MG give 1 tablet by mouth one time a day related to mixed Hyperlipidemia (high cholesterol) half life is 20 hours. Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG give 1 tablet by mouth one time a day related to major depressive disorder it is not recommended to abruptly discontinue Buproprion/Wellbutrin therapy, and the half life is also approximately 21 hours after chronic dosing. Hydroxyzine HCl Oral Tablet 50 MG give 1 tablet by mouth three times a day related to anxiety disorder. Increased on 4/7/26; residents orders was for 50mg twice daily when gone for home visit. Hydroxyzine has a half life of approximately 20 hours in adults. It is possible to experience rebound anxiety if abruptly stopping.R3's current care plan has no documentation that R3 has a history of false allegations or not being truthful.R3's MDS/Minimum Data Set, dated [DATE], documents R3 is cognitively intact.On 4/13/2026 at 11:42 AM, R3 was in his room, dressed, shoes on, and sitting on the edge of his bed. R3 stated on the morning of 4/4/26 he called the facility to let them know he did not receive any morning medications for the weekend. At that time, R3 provided white envelop medication packets dated 4/3/26, 4/5/26, and 4/6/26 which indicated his name and to Take at 5pm signed byV10 LPN.On 4/15/26 at 2:25PM, R3 was dressed, alert and oriented in his room, and stated he left on 4/3/26 about 5pm and was given his medications for 4/3/26 nighttime in a white medication packet envelop to take home. He stated his medications were already packed for the day before his brother came to get him because he told the nurse early he was leaving so the medications would be ready to be given to him when he left. R3 stated he was given his medication packets right before he left (4/3/26) and R3 stated he never paid attention to what the medication packets were the nurse gave him (he just put them in his pocket after he saw the one marked 4/3/26 at 5pm, and multiple other medication packets) because he has never had a problem before with not getting all his medications. R3 stated he got his night medication for 4/3, 4/4, and 4/5/26. R3 stated his b/p was The highest it had ever been after the weekend because I did not get my b/p medications for three days. R3 stated he came back on 4/6/26 about 8am and the nurse checked his b/p and it was high. R3 also stated he was more anxious, dizzy, and had headaches after the weekend from not getting his medications for the morning for three days on Sat, Sun, and Mon. After the nurse noticed my b/p was high I got medications for 4/6/26 in the morning.On 4/15/26 at 11:15AM, V8 Licensed Practical Nurse/LPN stated (R3) called me when he was out on leave, he stated he did not get his morning medications for while he was on leave, I told him he could come back in and we could see what medications he was missing, he stated he did not have a ride back to the nursing home because he was (out of town 45 minutes away), he told me he would go to the ER/emergency room if he had any problems, and I notified (V1 Administrator). We usually chart in the medical record when they go out on home visits and if medications were sent, we use a lot of agency nurses here, and when (R3) came back he said he was anxious so I got an order to increase his Hydroxyzine 50mg from twice a day to three times a day. (R3) has been getting the Hydroxyzine three times a day since the home visit. (R3) has never called or stated before he has not gotten his medications when on a home visit except for this time, he is alert and oriented and able to speak for himself. I do not know who packed his medications or sent them with him, but we pack them for each day for morning, noon, evening or night and indicate that with their name and the dates on the packets. He goes home frequently on home pass and has never complained of not getting his medications before. Sometimes residents refuse medications, and each nurse distributes the medications their own way (when asked if the medication cards indicate whether the medications were punched out on the day they were to be given).On 4/15/26 at 1:01PM, V9 RN/Registered Nurse Nurse Consultant stated nursing home staff said (R3) has never complained of not getting his medications on home pass before; and R3's blood pressure was elevated when he came back and they rechecked it and it went down after medication. I know he missed his B/P medications; his chart does not have a note in the record that he was sent with his medications and there usually is; his brother brought him home that weekend; his MAR/Medication Administration Record does not have where he was sent home with his medications; I am not sure why the medications missing were only for day shift (acknowledged it was a PM shift agency nurse that packed the medications); and stated she verified with R3 that he had all his PM shift medications and he left on the PM shift of 4/3/26. None of the medications missing were narcotics, they were for his B/P, cholesterol, and mental health. He does have a history of depression and anxiety and gets frequent medication changes either to increase or decrease. The medications are delivered in cards for the month, and some places push them out of the card on the numbered day of the month they are to be given but that was not done here because we have agency and they just dispense the medication from any day on the card.

Based on interview, and record review, the facility failed to prevent physical abuse from happening for four (R1, R2, R4, and R5) of four residents reviewed for abuse in a sample of seven. The abuse altercation on 3/1/26 between R1 and R2 resulted in R1 going to the hospital to be evaluated for injuries. The abuse altercation between R1 and R5 resulted in R5 going to the hospital to be evaluated due to neck pain after being hit in the back of his head.Findings include:Facility Resident Rights Policy, copyright 2026, documents The resident has the right to a dignified existence inside and outside the facility.Facility Abuse, Neglect, and Exploitation, copyright 2024, documents It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury resulting in physical harm, pain, or mental anguish which can include resident to resident altercations. The facility will develop and implement written policies and procedures that prohibit and prevent abuse. The facility will implement policies and procedures to prevent and prohibit all types of abuse. Possible indicators of abuse include physical abuse of a resident observed.On 4/14/26 at 10:00AM, V1 Administrator provided facility reported abuse allegations to the state dated 3/1/26, 3/22/26, and 3/27/26. At that time V1 verified R1, R2, R4, and R5 were involved in resident-to-resident physical alterations; and were reported to the state.1.R1 and R2's incident reported to the state by V1 Administrator, dated 3/1/26 at 1:40PM, documents R1 and R2 are alert, oriented, and able to make informed decisions. (R1 and R2) were involved in a verbal altercation that turned physical. (R1) stated (R2) took a cane that he had and poked him with it. (R1) stated his side hurt as a result. (R2) stated there was a verbal altercation that was taking place, but the reason he poked (R1) with the cane was due to (R1) having struck him on his side. (R2) stated he did not poke (R1) hard, I just wanted him to get away from me after he hit me. Police department was notified and officer responded to the call. (R1) was sent to local hospital for evaluation and treatment per resident request. (R1) returned to the facility with no injuries and no new orders. (R1) decided to press charges and both residents have a notice to appear in court.R1's nurses note, dated 3/1/2026 at 8:58am by V5 RN/Registered Nurse, documents Resident had an argument with his roommate (R2) which led to him reporting that his roommate hit him across his chest with a cane. Res is now headed to Emergency Department to be evaluated.On 4/14/26 at 3:00PM, R2 was alert and oriented walking around independently and stated on 3/1/26 he was roommates with R1. On that date, R1 said R2 hit him with a cane but R2 denies hitting R1 with a cane. R2 stated the cops were called, had to go to court, and both were to pay a $100 fine. R2's MDS/Minimum Data Set, dated [DATE], documents R2 is cognitively intact.On 4/14/26 at 1:35PM, R1 Resident was in a manual wheelchair, alert and oriented, and stated on 3/1/26 he was asleep in his room and his roommate at that time (R2) hit him with a cane across his chest. R1 stated it woke him up and he screamed and yelled for help. I went to the ER/emergency room later that night to be evaluated. R1 stated the cops were called, they had to go to court and were ordered to pay $100 fine.2. R1 and R5's incident reported to the state by V1 Administrator, dated 3/22/26, documents R1 and R5 are alert, oriented, and able to make informed decisions. (R1 and R5) were involved in an alleged resident to resident altercation. (R1 and R5) were engaged in an altercation in the dining room during meal time. (R1 and R5) were in an argument over snack food that (R1) alleged (R5) took. (R1) continued to get more upset at (R5's) dismissal of him, causing (R1) to throw a cup of liquid at (R5).R1's nurses note, dated 3/22/2026 at 1:29PM by V7 RN, documents Resident eating lunch at table, got up and started moving chairs then poured cup of coffee on another residents (R5) back for 'stealing'. Incident appeared to be unprovoked.On 4/14/26 at 1:35PM, R1 Resident was in a manual wheelchair, alert and oriented, and stated on 3/22/26 he was in the dining room with his cookies and R5 wanted his cookies. R1 and R5 made an agreement to trade cookies for a Mountain Dew. R1 gave R5 the cookies, R5 started stuffing the cookies in his mouth and then told R1 he did not have any Mountain Dew or the $1.75 for the vending machine. R1 stated he asked R5 for a Mountain Dew or money multiple times and then told R5 that he was a liar and stealer. R5 laughed at R1 and R1 stated I snapped. When someone steals from you, you punch them in the head. I punched (R5) in the head with a coffee cup.On 4/14/26 at 1:15PM, R5 was alert and oriented, ambulatory, and stated on 3/22/26 he was hit in the back of his head with a tray by R1 over cookies and a Mountain Dew when they were in the lunchroom. I went to the ER after that because I had my neck fused four years ago from a fall and I wanted to make sure the fusion was not messed up. It did hurt at the time.3. R2 and R4's incident reported to the state by V1 Administrator, dated 3/27/26 at 9:55PM, documents R2 and R4 are alert, oriented, and able to make informed decisions. (R2 and R4) alleged resident-to-resident altercation occurred. Police department was notified and officer responded. Neither resident wanted to press charges.R2's nurses note, dated 3/27/2026 at 11:08PM by V6 RN, documents: Resident stated that other resident (R4) hit him and wanted to press charges on him. Police called and upon speaking to both the residents they agreed not to press charges.On 4/14/26 at 3:00PM, R2 was alert and oriented, walking around independently, and stated on 3/27/26 R4 started the argument and hit him, the cops were called, and charges were not pressed.3/27/26 R4 started the argument and hit him, the cops were called, and charges were not pressed.On 4/14/26 at 2:13PM, R4 was alert and oriented, walking independently and stated the incident on 3/27/26 R2 started an argument and hit him. We were roommates, I was sleeping, and he hit me in the legs to wake me up so I hit him in the stomach. The cops were called but no charges were pressed.

Based on observation, interview, and record review, the facility failed to store medications in their original packaging and failed to destroy medications according to their policy for one (R1) of three residents reviewed for medications in a sample of seven.Findings include:Facility Medication Storage Policy, copyright 2026, documents It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Unused medications: The consultant pharmacist routinely inspects for medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our policy.R3's current care plan has no documentation that R3 has a history of false allegations or not being truthful.R3's MDS/Minimum Data Set, dated [DATE], documents R3 is cognitively intact.R3's electronic health record documents the following medical diagnoses: Schizoaffective disorder Bipolar type; suicidal ideations; major Depressive disorder, recurrent; essential (Primary) Hypertension (high blood pressure); mixed Hyperlipidemia (elevated cholesterol); restlessness and agitation; and anxiety disorder. This record also has multiple prescription medications ordered for each diagnosis.On 4/15/26 at 2:25PM, R3 was dressed, alert and oriented in his room, and stated I have brought back medications before when I forgot to take them when out on leave.On 4/15/26 at 11:15AM, V8 Licensed Practical Nurse/LPN stated) (R1) has brought back medication to the nursing home he has not taken when out on leave before.On 4/15/26 at 1:01PM, V9 RN/Registered Nurse Consultant stated Nursing home staff said (R3) has brought back medications from home pass before, still had the returned medications in the cart in envelopes, and the facility had not destroyed them (the medications observed were in white paper medication envelopes with R3's name on them, were not dated or signed by the nurse, but indicated the times they were to be taken.) At that same time, V9 verified the medications in the white paper envelopes were in the nurse's medication cart and she was unsure what pills were in the envelopes. V9 stated she was not sure what day these were from, what medications they were, and why they were still in the medication cart from when R3 brought them back from a previous home visit/therapeutic pass. V9 was not sure why the medications were not destroyed because they should have been.

Based on interview, and record review, the facility failed to have accurate medical records regarding a therapeutic leave, medications, and a physical altercation for two (R1 and R2) of seven residents reviewed for accurate medical records in a sample of seven.Findings include:Facility Maintenance of Electronic Clinical Records Policy, copyright 2025, documents A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident.1.R3's current care plan has no documentation that R3 has a history of false allegations or not being truthful.R3's MDS/Minimum Data Set, dated [DATE], documents R3 is cognitively intact.R3's electronic medical record notes have no documentation when R3 left or returned from therapeutic leave. A resident sign in/out sheet for the facility documents R3 left the faciity on 4/3/26 at 5:00PM with his brother but has no sign in date or time.R3's Medication Administration Record/MAR for April 6, 2026, documents for the 7am medication pass R3 was out on therapeutic leave, and did not get his medications that morning.On 4/15/26 at 2:25PM, R3 was dressed, alert and oriented in his room, and stated he left on 4/3/26 about 5pm, and returned on 4/6/26 about 8am. At that same time, R3 stated he got his morning medications on 4/6/26 because After the nurse noticed my b/p (blood pressure) was high I got medications for 4/6/26 in the morning.On 4/15/26 at 11:15AM, V8 Licensed Practical Nurse/LPN verified a resident's electronic medical record should document when the resident leaves, returns, who they left with, and whether the resident was sent with their medications for the durations of their days on leave.On 4/15/26 at 1:01PM, V9 RN/Registered Nurse/Nurse Consultant verified R3's medical record was not accurate/complete for when R3 left and returned to the facility, and the MAR was also not accurate for medications given.2. R2's electronic medical record has no documentation of his 3/1/26 physical altercation with R1.R1 and R2's incident reported to the state by V1 Administrator, dated 3/1/26 at 1:40PM, documents R1 and R2 are alert, oriented, and able to make informed decisions. (R1 and R2) were involved in a verbal altercation that turned physical.On 3/14/26 at 3:00PM, R2 was alert and oriented walking around independently and stated on 3/1/26 he was roommates with R1. On that date, R1 said R2 hit him with a cane but R2 denies hitting R1 with a cane. R2 stated the cops were called, had to go to court, and both were to pay a $100 fine. R2's MDS/Minimum Data Set, dated [DATE], documents R2 is cognitively intact.

Based on observation, interview and record review the facility failed to ensure emergency medical equipment was present, functional, routinely checked and available for use during a medical emergency, for one of three residents (RI), reviewed for emergency response. The facility also failed to ensure nursing staff were trained and competent in the contents and operation of emergency equipment. These failures resulted in staff being unable to provide timely life- saving interventions to R1, who suffered an unplanned medical emergency and died. The deficient practice placed all facility residents at risk for delayed or ineffective emergency response.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R1 experienced a medical emergency and facility staff failed to ensure emergency equipment was available, functioning, routinely checked and staff were competent in its use during a resident emergency.V1 (Administrator), V19 (Corporate Regional Director of Operations) and V20 (Corporate Regional Nursing Officer) were notified of the Immediate Jeopardy on [DATE] at 12:56 P.M. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.The (undated) facility policy, Emergency Crash Cart directs staff that the purpose of the policy is to ensure that all supplies critical to basic life support are readily available on the emergency cart. Compliance Guidelines document that the facility will store the emergency cart in a location that is readily accessible; That the equipment/supplies are used only when emergency care is provided; Equipment/supplies are noted and replaced promptly; The emergency crash cart is checked every 24 hours and after every use; Clinical staff are educated on the location and use of the emergency cart and Nursing staff should be familiar with the contents located on and within the cart.The facility form, (monthly) Emergency Crash Cart Checklist, provided by V2/Director of Nurses on [DATE], includes a daily checklist and designated place for staff to initial the presence of the following equipment, Respiratory Equipment: Non-breather Masks, Nasal Cannulas, Ambu Bag, Oral Airways; Suction Equipment: Normal Saline, Yankauer, Suction Kit, Suction Container, Portable Machine; Personal Protective Equipment: Gloves and Additional Supplies: Emergency Cart Checklist, Flash Light, Alcohol Wipes, Lubricating Jelly, Back Board, Blood Pressure Cuff and Stethoscope. R1's facility Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Frontotemporal Neurocognitive Disorder, Malignant Neoplasm of the Right Breast, Dysphagia and Diabetes Mellitus.R1's Nursing Progress Notes, dated [DATE] and signed by V3/Registered Nurse document, (R1) observed to have had a small emesis so nurse helped (R1) to get cleaned up and cleared mouth and neck from emesis. (R1) was then sat up and verbalized feeling okay. Upon arrival back into the room (R1) was observed to have had another emesis so I asked (staff) assigned to her cares, to help her get cleaned up. When the CNA (Certified Nursing Assistant) finished cleaning (R1) up (bowel movement and emesis) she stated to the nurse she thought (R1) sounded kind of gurggly. She also stated (R1) verbalized feeling okay and she had a brief conversation with (R1). I then went to the main core (nurse's station) to ask a second nurse (V4/Licensed Practical Nurse) to come listen to (R1)'s lung sounds with me, to make sure I was correctly identifying (R1)'s lung sounds. When (V4) got to (R1)'s room, (R1) was having another emesis and slightly pale in color. I immediately called 911. (R1) had a pulse was not unresponsive. When (R1) became unresponsive and (R1)'s pulse was no longer felt, CPR (Cardiopulmonary Resuscitation) was initiated. EMT (Emergency Medical Technician) services arrived and they took over CPR. (R1) was pronounced deceased at 8:13 P.M. V4/Licensed Practical Nurse's written statement, provided on [DATE] and dated 12//16/25 at 9:56 P.M., documents, (V3/Registered Nurse/RN) came up to the front nurse's station and asked me if I could listen to (R1's) lung sounds. I said sure. Upon (me and V3/RN) arriving to (R1's) room, (R1) was pale in color and vomit was coming out of her mouth and nose. I went to (R1's) side and began cleaning up the vomit. I yelled for someone to assist me since (V3/RN) went to the desk to dial 911. While I was cleaning (R1) up, (R1) was moving her head back and forth. Once I cleaned up all the vomit, I asked (R1) if she was okay. (R1) said yes. I went to the front nurse's station to have more CNAs (Certified Nursing Assistants) help and to grab (V3/Registered Nurse) for assistance. I went back into the room and (R1) had a faint pulse. We were asking (V3/RN) to find the crash cart for suction. The crash cart only had trach (tracheal) suctioning, not proper yank (yankauer) with tubing. (R1) looked at me and I checked her pulse. I did not feel one. I told (V13/Certified Nursing Assistant/CNA) to lower the head of the bed so I could begin compressions. I checked her pulse before beginning compressions, and she had one. (R1) began to vomit again, so we raised the head of the bed, and we began to clean her up. I did another pulse check, and the police arrived. (R1) had no pulse. (V3/RN) came in and stated that (R1) was a full code, so I began compressions. Fire (Department) took over with CPR (Cardiopulmonary Resuscitation and moved (R1) to the floor, since she needed to be on a hard surface. They hooked up the AED (Automatic External Defibrillator) pads and continued CPR. They could not shock as (R1) had a pulse and was asystole. Fire (department) intubated and bagged (R1). V3/Registered Nurse/RN's written statement dated [DATE] documents, Around 7 (PM), I went into (R1's) room to give her her medication. I noticed (R1) had spit up some saliva, so I got a wet towel and cleaned up her face and neck area. I asked (R1) was she ok and put the head of her bed up. (R1) said she was ok and thanked me. I proceeded to give (R1) her medication and (R1) swallowed it with ease. (Meds/medications crushed in pudding) per usual. With (R1) still setting up, I proceeded to go get her roommates medications ready. I had a few distractions while getting back to my cart, so I ended up taking (R1's) roommates medications within 5 to 10 minutes later. When I walked into (R1's) room to give her roommate medication, (R1) was gagging and throwing up. (R1) did not throw up very much, it was mostly just saliva and gagging. When (R1) stopped and was able to talk to me. I went out of the room and got (V11/Certified Nursing Assistant/CNA) to help clean (R1's) chin, as it was covered with saliva. When (V11/CNA) went into the room with (R1) she was still talking and thanking us for cleaning her up. I then went to the front of the building to get another nurse who I know has lots of experience with lung sounds. When me and (V4/Licensed Practical Nurse) got back to (R1's) room, (R1) was pale and now vomiting out of her mouth and nose. I immediately went to call 911. (V4/LPN) stayed in the room with (R1) while another nurse came down the hall with the crash cart. When I was finished calling 911, I went back into (R1's) room and she was still gagging and vomiting. The other two nurses were trying to find a suction machine within the crash cart and there was not one. Police arrived and within seconds, (R1) went limp and CPR was started by (V4/LPN). Paramedics took over when they arrived and the medics stated that (R1) was in asystole and her pulse kept going in and out. They moved (R1) to the floor and continued efforts of saving her with the lucas ([NAME] University Cardiopulmonary Assist System). At 8:13 P.M. they called (R1's) time of death.R1's (City) Hospital Ambulance Service Report, dated [DATE] documents that a call was received on [DATE] at 7:40 P.M. from the facility, requesting services, due to a resident with cardiac arrest. P1 (Paramedic 1) was dispatched for a patient unresponsive with no pulse, responded immediately. Upon arrival to scene found (City) Fire Department attending to the patient. Prior to P1 arrival, (City) Fire Department (performed) Treatment: (suctioning) Vomit; Amount: 700 (ML) (milliliters). It was reported by staff that they were doing CPR on the patient for about 10 minutes prior to fire (department) getting there. Patient was found by staff with emesis on her face, lips cyanotic and it was unknown by staff how long she had been down, staff reported patient was checked on about 10 minutes before CPR was first initiated. Patient was switched to cardiac monitor and defib (defibrillator) pads at this time with patient being in asystole. CPR and ventilations with suctioning were continued. IO (Intraosseous) and IV (Intra Venous) were established at this time with first epi (epinephrine) given and fluid bolus started at 1955 (7:55 P.M.). CPR and ventilations were continued with additional epi given at 2002 (8:02 P.M.) and 2008 (8:08 P.M.) due to patient being in asystole after pulse checks. Patient was suctioned and igel was switched to tracheal intubation due to excessive amounts of vomit coming up with compressions to protect airway. CPR and ventilations were administered for 25 minutes before calling med control (medical control). Per med control, resuscitation efforts could be discontinued at 2013.R1's (City) Fire Department report, dated [DATE] at 7:42 P.M. documents, Dispatched for a subject experiencing emesis and lips turning blue; immediately followed bythat the PT (patient) was not breathing and no pulse found. Initial PT (patient) contact with two staff members who were performing CPR. Verified no pulse and no respirations and took over one round of compressions. (Emergency Medical Technicians) arrived on scene with the rest and we assisted lowing the PT onto the floor. PT was continuing to vomit and a CNA (Certified Nursing Assistant) was attempting to clean the PT's face while we continue to perform CPR. Staff on scene stated that the PT was last seen conscious approximately 5 minutes ago. Continued compressions while (EMT) prepared BVM (Bag Valve Mask) with O2 (Oxygen). Prepared AED (Automatic External Defibrillator) pads for placement, and performed a jaw thrust to the PT and began to administer AR (artificial respirations) via BVM. Then placed a size 4 supraglottic airway and secured it with the retaining strap; Continued AR via bag valve to the airway. AED cycled three rounds and advised no shock all three times; no carotid pulse was found during each cycle assessment. GHAS (City Hospital Ambulance Service) arrived on scene and PT care and information was transferred to them. Performed suction to clear the PT's airway due to continuous emesis. (City Fire Department) assisted (City Hospital Ambulance Service with preparation of Advanced Life Support intervention as directed by Paramedics. We assisted with placement of the LUCAS device (artificial compression system) to the PT and Continued AR. Multiple more rounds of CPR were performed and ALS (advanced life support) were given until Paramedics were given direction by Medical Control to cease further life saving measures. Equipment was secured and scene was cleaned and prepared for Coroner. R1's Certificate of Death, dated [DATE] documents R1's Immediate Cause of Death as Aspiration Pneumonia (within hours), Chronic Obstructive Pulmonary Disease and Dementia.On [DATE] at 2:30 P.M., a red emergency cart was located at the (facility) Back Nurse's Station. V5/Registered Nurse (RN) was present and stated third shift was responsible for checking the emergency cart daily. V5/RN was unable to locate the emergency cart check sheet for [DATE], or any other month. V5 stated she was not sure where it was. With V5/RN present, the contents of the cart were reviewed. No manual resuscitator (Ambu bag), oral airways, Normal Saline, yankauer suction catheter, suction kits, flashlight, alcohol wipes, lubricating jelly, blood pressure cuff or stethoscope were present on the cart. A suction machine and a blue-topped canister were present in a grey zippered bag, on top of the cart, a tracheal suction tubing in a package, was also in the grey bag. When an attempt was made to connect the tubing to one of three stems on top of the blue cannister, suction was unable to be achieved. A green oxygen tank was present, on the side of the cart. The required backboard was unable to be located on the cart, or in the emergency cart. V5/RN verified the missing equipment and stated the suction machine would be useless as it was, in an emergency. V5/RN states she can't recall ever receiving training on the contents of the facility emergency crash cart, or the use of the contents.On [DATE] at 2:36 P.M., a red emergency cart was located at the (facility) Front Nurse's Station. V6/Licensed Practical Nurse (LPN) and V7/Registered Nurse (RN) were present. The emergency cart was a white tubular cart on wheels, with red mesh drapes. Upon observation of the top of the cart and removal of a covering over the suction machine, large amounts of dust particles were present. No emergency cart sign off sheet was present. Both nurses stated they thought third shift checked the cart, but they weren't sure. The contents of cart were reviewed with V6/LPN and V7/RN present. No manual resuscitator (Ambu bag), oral airways, Normal Saline, yankauer suction catheter, suction kits, flashlight, alcohol wipes, lubricating jelly, blood pressure cuff or stethoscope were present on the cart. A suction machine and blue-topped canister were present, however, the suction machine was inoperable, as there was no tubing to connect the cannister to the suction machine or the suction machine to a suction catheter. A green oxygen tank was hanging from the side of the cart. V6/LPN and V7/RN verified the missing equipment and stated the machine would be useless as it is, in an emergency. V6/LPN and V7/RN both stated they can't recall every receiving training on the contents of the facility emergency crash cart, or the use of the contents.On [DATE] at 3:04 P.M., the facility front and back emergency carts were observed with V2/Director of Nurses (DON). At that time V2/DON verified the inoperable suctioning machine on both carts, the missing emergency equipment and the missing Emergency Cart Checklist. V2/DON stated the carts were nasty and needed cleaned. On [DATE] at 12:58 P.M., the facility's Front Nurse's Station emergency cart had a nonfunctioning suction machine, on top. No other suction machine or equipment to suction a resident, in a medical emergency, was available. No emergency cart checklist was present to verify the required contents of the cart, or the functioning of the equipment was present on either the North or South emergency cart.On [DATE] at 4:10 P.M., the facility's Front Nurse's Station emergency cart had a nonfunctioning suction machine, on top. No other suction machine or equipment to suction a resident, in a medical emergency, was available. No emergency cart checklist was present to verify the required contents of the cart, or the functioning of the equipment was present on either the North or South emergency cart.On [DATE] at 1:35 P.M., V3/Registered Nurse (RN) stated she was the nurse that was present on the evening of [DATE] when R1 died. States R1 had been eating supper in the facility MDR (Main Dining Room) and appeared fine. States she thinks it was after supper and the CNA (Certified Nursing Assistant/CNA) (unable to recall which one) came to her and said that R1 was vomiting. States she went to R1's room, assisted CNA in cleaning up emesis, R1 stated she was fine, and V3/RN left the room. The CNA came back to V3 and said R1 then sounded gurggly. V3 states she asked V4/Licensed Practical Nurse to grab the crash cart and come to R1's room with her, to assist her. V3/RN states when she got to R1's room the second time, R1 had another emesis, was very pale, was gurgling, but had a pulse. V3/RN states she called 911, after she attempted to suction R1. States there was an empty cannister on top of the crash cart at the Back Nurse's Station, but the cannister was not connected and was inoperable. V3/RN stated she was unable to suction R1at that time, R1 became nonresponsive, without a pulse and CPR (Cardiopulmonary Resuscitation) was initiated. Once the emergency crew arrived, they took over CPR and pronounced R1 deceased . R1 Stated she can't recall ever receiving training on the contents of the facility emergency crash cart, or the use of the contents.On [DATE] at 2:53 P.M., V2/Director of Nurses (DON) stated she was responsible for checking the emergency carts after each use and periodically. V2 stated she doesn't complete a checklist after she checks the carts. Unable to state when she last checked either cart. Unable to provide documentation of emergency crash cart checklists for the past year, or facility staff training on the emergency cart location, contents of the cart or function of the contents. At that time, V2/DON stated she didn't have an investigation into R1's unplanned death. On [DATE] at 3:23 P.M., V4/Licensed Practical Nurse (LPN) stated she was working the night that R1 had multiple emesis, became unresponsive and died. Stated V3/Registered Nurse yelled for her, and she ran to R1's room. Upon arrival, she yelled at staff to get the crash cart (emergency cart) so R1 could be suctioned. Stated R1 was never suctioned due to the suction machine being inoperable. States she started CPR (Cardiopulmonary Resuscitation) on R1 when she became nonresponsive, a policeman arrived on the scene, followed by the fire department and then the EMT's (Emergency Medical Technicians). EMT's took over the scene and she left the room. Stated R1 was pronounced deceased on the scene and never left the building. Stated she can't recall ever receiving training on the contents of the facility emergency crash cart, or the use of the contents.On [DATE] at 3:30 P.M., V2/DON (Director of Nurses) provided a copy of the facility Emergency Crash Cart Checklist form. Stated the facility emergency carts are supposed to be checked daily to ensure all listed items are present and functioning for use in an emergency. At this time, V2/DON stated she had not implemented the daily Emergency Crash Cart Checklist form, despite R1 experiencing multiple episodes of emesis on [DATE] and facility staff being unable to emergently suction R1 due to an inoperable suction machine on the back nurse's station emergency cart.On [DATE] at 3:30 P.M., V1/Administrator stated he did not do an investigation into R1's unplanned death and did not report R1's unplanned death to the state agency.On [DATE] at 9:40 A.M., V8/Licensed Practical Nurse stated she can't recall ever receiving training on the contents of the facility emergency crash cart, or the use of the contents. On [DATE] at 9:47 A.M., V10/Licensed Practical Nurse stated she can't recall ever receiving training on the contents of the facility emergency crash cart, or the use of the contents.On [DATE] at 9:53 A.M., V9/Licensed Practical Nurse stated she can't recall ever receiving training on the contents of the facility emergency crash cart, or the use of the contents.On [DATE] at 11:07 A.M., V11/Certified Nursing Assistant stated she was the person who assisted R1 on [DATE] when she had multiple emesis. States she alerted V3/Registered Nurse after assisting R1, as R1 began gurgling. Stated V3/RN responded to R1's room and she went to assist another resident and didn't see R1 again that shift. Stated she gave a written statement of the events to V2/Director of Nurses. Stated other staff working that night also gave statements due to the non-working suction machine and the concern for R1.On [DATE] at 11:44 A.M., V14/Medical Doctor (MD) stated that R1's cause of death was aspiration pneumonia, that occurred within hours of her death. V14/MD also stated that had R1 been immediately suctioned, by facility staff, when she began vomiting repeatedly, her death could have possibly been avoided.The facility Midnight Census Report, dated [DATE] and provided and confirmed by V1/Administrator documents 84 residents currently reside in the facility.An Abatement Plan was received on [DATE] at 4:23 P.M., from the facility Administrator. After review, the Abatement Plan was accepted on [DATE] at 4:48 P.M.On [DATE] the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy:Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]).CPR was initiated immediately when R1 became unresponsive and continued until EMS (Emergency Medical Services) arrived.The ADON (Acting Director of Nursing) completed a full crash cart audit of both carts and ensured all required components were on the cart and functional on [DATE].Nurses have been educated to verify Crash Cart checklist items are present and equipment is fully functional on 3rd shift.DON (Director of Nurses) to verify weekly that the crash cart checks are being done, and any used or nonfunctional items are to be replaced immediately.Nursing staff have been trained on the contents and how to operate emergency equipment found on the crash cart on [DATE].Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE])The ADON completed a full crash cart audit of both carts in house, and verified all required equipment was on the cart and functional on [DATE]. Any missing, expired or broken items were replaced with fully functioning items.All Oxygen equipment, suction and Ambu bags were checked and verified as being operational.Administrator conducted a facility wide audit of all emergency locations to verify appropriate quantities of emergency equipment.Administrator, Regional Nurse Consultant and ADON provided nursing staff in-service on location of emergency equipment, Emergency response procedures, Basic Life Support and CPR expectations, Crash cart contents, crash cart locations, and operation of oxygen, suction, ambu bag, and other emergency equipment on [DATE]. This training required return demonstration from staff to ensure adequate knowledge. Any staff who do not complete the mandatory training will complete in person training with return demonstration prior to the start of their next shift.Nurses and CNA CPR certification were verified by RDO (Regional Director of Operations). Any clinical staff in need of CPR will obtain within the next 60 days. The facility will ensure a minimum of two CPR certified staff in the building at all times, at least one staff member will be on duty who has been properly trained in medical emergencies as required.Crash Cart check lists will be reviewed and documented on third shift every day.DON or designee will audit the crash cart weekly for verification that the daily checks are being done and all equipment is present and is fully functional.Emergency QAPI was held on [DATE] with the Medical Director.Medical Emergency Response was reviewed and revised to indicate who shall inspect the emergency equipment, the frequency of inspection, identify frequency and type of training related to emergency situations, and required documentation.A root cause analysis was completed.All residents in facility are at potential risk to immediate access to emergency equipment throughout the facility.A QA audit will be done weekly for 6 weeks, and then monthly for 3 months to ensure thatWere all crash cart checks completed daily?If something was missing, broken or expired, was it replaced immediately?Did DON or designee do their weekly crash cart checks?Was all clinical staff trained annually or upon hire on Emergency Response Procedures, BLS and CPR expectations, Crash Cart contents, Operation of Oxygen, Suction, Ambu bag, and other emergency equipment (with return demonstration)?Abatement completion date: [DATE]

Based on interview and record review, the facility failed to ensure a resident unplanned death was investigated and reported to the state agency, within the required time frame. This failure has the potential to affect all 84 residents currently residing in the facility.R1's electronic medical record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Frontotemporal Neurocognitive Disorder, Major Depressive Disorder, Dysphasia, Chronic Obstructive Pulmonary Disease, Anxiety Disorder and Diabetes Mellitus. R1's Advance Directives form, dated [DATE] documents that R1 was a Full Code.R1's Nursing Progress Notes, dated [DATE] and signed by V3/Registered Nurse documents, (R1) observed to have had a small emesis so nurse helped (R1) to get cleaned up and cleared mouth and neck from emesis. (R1) was then sat up and verbalized feeling okay. Upon arrival back into the room (R1) was observed to have had another emesis so I asked the CNA (Certified Nursing Assistant) assigned to her cares to help her get cleaned up. When the CNA finished cleaning (R1) up (bowel movement and emesis) she stated to the nurse she thought (R1) sounded kind of gurggly. She also stated (R1) verbalized feeling okay and she had a brief conversation with (R1). I then went to the main core (nurse's station) to ask a second nurse (V4/Licensed Practical Nurse) to come listen to (R1)'s lung sounds with me to make sure I was correctly identifying (R1)'s lung sounds. When (V4) got to (R1)'s room, (R1) was having another emesis and slightly pale in color. I immediately called 911. (R1) had a pulse was not unresponsive. When (R1) became unresponsive and (R1)'s pulse was no longer felt, CPR (Cardiopulmonary Resuscitation) was initiated. EMT (Emergency Medical Technician) services arrived and they took over CPR. (R1) was pronounced deceased at 8:13 P.M.R1's Certificate of Death, dated [DATE] documents R1's Immediate Cause of Death as Aspiration Pneumonia (within hours), Chronic Obstructive Pulmonary Disease and Dementia.On [DATE] at 1:35 P.M., V3/Registered Nurse (RN) stated she was the nurse that was present on the evening of [DATE] when R1 died. States R1 had been eating supper in the facility MDR (Main Dining Room) and appeared fine. States she thinks it was after supper and the CNA (Certified Nursing Assistant/CNA) (unable to recall which one) came to her and said that R1 was vomiting. States she went to R1's room, assisted CNA in cleaning up emesis, R1 stated she was fine, and V3/RN left the room. The CNA came back to V3 and said R1 then sounded gurggly. V3 states she asked V4/Licensed Practical Nurse to grab the crash cart and come to R1's room with her, to assist her. V3/RN states when she got to R1's room the second time, R1 had another emesis, was very pale, was gurgling, but had a pulse. V3/RN states she called 911, after she attempted to suction R1. States there was an empty cannister on top of the crash cart at the Back Nurse's Station, but the cannister was not connected and was inoperable. V3/RN stated she was unable to suction R1at that time, R1 became nonresponsive, without a pulse and CPR (Cardiopulmonary Resuscitation) was initiated. Once the emergency crew arrived, they took over CPR and pronounced R1 deceased . R1 Stated she can't recall ever receiving training on the contents of the facility emergency crash cart, or the use of the contents.On [DATE] at 2:53 P.M. V2/Director of Nurses stated she didn't have an investigation into R1's unplanned death. V2/DON also confirmed that the state agency had not been informed of R1's death.On [DATE] at 3:30 P.M., V1/Administrator stated he did not do an investigation into R1's unplanned death and did not report R1's unplanned death to the state agency.The facility Midnight Census Report, dated [DATE] and provided and confirmed by V1/Administrator documents 84 residents currently reside in the facility.

Based on record review and interview the facility failed to protect a resident from staff-to-resident sexual abuse, failed to assess a resident's ability to consent to sexual activity, and failed to protect residents from staff-to-resident verbal abuse for three of seven residents (R2, R3, and R6) reviewed for abuse in the sample of seven. These failures resulted in V7 (Prior Dietary Aide) engaging in behavior indicating an attempt to initiate a personal or romantic relationship with R3 in June 2025, V7 continuing to have sexually inappropriate conversations and video nudity by electronic communication with R3, and V7 sexually assaulting R3 on at least three occasions while R3 was attending church services. These failures also resulted in V7 verbally abusing R6 on multiple occasions once R6 witnessed R3 and V7 engaging in inappropriate conversations and video nudity by electronic communications.These failures resulted in an Immediate Jeopardy:While the immediacy was removed on 1/31/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Abuse, Neglect, and Exploitation dated 2/3/25 documents, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse included but is not limited to, sexual harassment, sexual coercion, or sexual assault. Verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. Allegations of staff to resident sexual abuse-Nursing home staff are entrusted with the responsibility to protect and are for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff members role as a caregiver and will be considered an abuse of power. Also, for some health care professionals to have a relationship with a resident. Any sexual relationship between a staff member and a resident with or without diminished capacity may constitute sexual abuse in the absence of a sexual relationship that existed prior to the resident admitted to the facility, such as a spouse or partner, and must be thoroughly investigated to prevent abuse and implement policies and procedures to prevent and prohibit all types of abuse, neglect, bribery, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, bribery, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. The facility's current Agreement with the Employees International Union Healthcare Illinois/Indiana documents, These work and safety rules and regulation shall be applicable to each facility and its employees in the bargaining unit. It is essential to the successful operation of the facility's business and the welfare of its patients and employees that fairly established standards of discipline, health, safety, attendance, workmanship, and honesty be maintained. Employees shall have an opportunity to sign formal warning, acknowledging that such warning has been given and to comment on such warning. Maintaining or attempting to maintain a relationship (whether or not consensual) with a resident that is sexual or romantic in nature unless the resident is the employee's spouse. First offense-Discharge. The Illinois Guardianship and Advocacy Commission Guardianship Fact Sheet (undated) documents, Guardianship Facts: Guardianship is needed when a person is unable to make and communicate responsible decisions regarding his personal care or finances due to a mental, physical, or developmental disability. The extent to which a guardian is allowed to make decisions for a ward is determined by the court based on a thorough clinical evaluation and report. Two basic types of guardianship are person guardianship and estate guardianship. A guardian of the person is appointed by the court when a disabled individual cannot make or communicate responsible decisions regarding his personal care. This guardian will make decisions about medical treatment, residential placement, social services, and other needs. The court appoints a guardian of the estate when a disabled person is unable to make or communicate responsible decisions regarding the management of his estate or finances. The guardian will, subject to court supervision, make decisions about the ward's funds and the safeguarding of the ward's income or other assets. The Illinois Probate Act gives the court the flexibility to tailor guardianship to meet the needs and capabilities of disabled persons. Depending on the decision-making capacity of the disabled person, the court can appoint a limited guardian who is granted the power to make only those decisions about personal care and/or personal finances that the court specifies. The court can also appoint a plenary guardian who generally has the power to make all decisions about personal care and/or finances for the disabled person. R3's Legal Guardianship dated 2/27/15 and signed by V12 (Judge) documents, Because of (R3's) physical and mental conditions, (R3) is not able to manage her person or property and is therefore a disabled person. Because of (R3's) disability (R3) lacks sufficient capacity to make and communicate responsible decisions concerning the care of her person and because of (R3's) disability, (R3) lacks capacity to manage her estate; and for these reasons it is necessary to appoint a guardian of the person and estate of (R3). A limited guardianship will not provide sufficient protection for (R3). (V3/R3's Plenary Guardian) is qualified to act as a guardian. In order to protect the best interests of (R3), a guardian of (R3's) person and estate should be appointed. (V3) is capable of making residential decisions for (R3). Now, therefore, it is hereby ordered and adjudged: A. That (R3) is a disabled person in need of the appointment of a plenary guardian of her person and or estate. R3's Face Sheet Form documents R3 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Borderline Personality Disorder, Attention-Deficit Hyperactivity Disorder, Major Depressive Disorder, Anxiety Disorder, Suicidal Ideations, and Major Depressive Disorder with Severe Psychotic Symptoms. This same Form documents V3 is R3's Legal Guardian. R3's Emergency Department Provider Notes dated 7/8/25 document R3 was sent to the emergency room for suicidal ideations and had been feeling suicidal for the past couple days and having thoughts of cutting her wrist in order to attempt suicide. This report documents R3 reports that she was living (at the facility) and was physically assaulted by two other resident yesterday and has not been able to sleep since then. This same report documents R3 was transferred to an inpatient psychiatric treatment for the treatment of suicidal ideations. R3's Sign In/Sign Out Report Sheets dated 11/1/25 through 12/31/25 document R3 attended outside church services or the library on 11/9/25, 11/14/25, 11/16/25, and 11/23/25. These sheets do not include the staff/family/friend that R3 attended the library with on 11/14/25 or the church on 11/23/25. R3's Progress Notes dated 11/10/25 at 6:27 PM document, Staff talked to (R3) about roommate (R6) complaint of getting completely naked in the room with door and curtain open talking or videoing on social media. Staff reminded (R3) to close curtains and doors and be respectful of roommate's concerns. R3's Behavior Note dated 11/20/25 at 8:30 AM and signed by V6 (Psychosocial Rehabilitation Coordinator) documents, Another resident (R6) approached (V6) to report that (R3) was engaging in sexual conversation. When (R6) asked (V3 and R7) to refrain from doing this while (R6) was in the room, the male (V7) on the call began cursing at (R6) and calling (R6) names. (R6) stated that incidents like this occur often, and it is making (R6) feel uncomfortable. R3's IDT (Interdisciplinary Team) Note dated 11/21/25 documents, IDT reviewed (R3's) behavior involving smart phones, social media contact, and video calling and potential risk to (R3) and peers. (R3) continues to require assistance to think through logically regarding safety and well-being and refrain from impulsive decisions/actions per behavior documentation. (R3) did not successfully follow (R3's) suggested social media guidelines during walking pass trial. In order to help (R3) better manage impulsivity and better gauge whether (R3's) putting herself at risk of exploitation or abuse or how her choices impact peer residents' safety and well-being, IDT recommended a behavior management program where all phone use occurs with supervision/in supervises area upon request and when not in use as outlines, smartphones are secured at the nurses' station. These safety interventions are not included in R3's current care plan. R3's Progress Note dated 11/25/25 at 5:53 PM and signed by V5 (SSD/Social Service Director) documents V3 (R3's Plenary Guardian) gave authorization for R3 to receive phone calls, receive visits at the facility, or leave for therapeutic outings or scheduled community activities with only V3 (R3's Plenary Guardian, V21-V24 (R3's Family Members) or facility staff. These safety interventions were not included in R3's current care plan. R3's Final Abuse Investigation dated 12/3/25 and signed by V1 (Administrator) documents on 11/23/25 R3 had multiple instances of non-consensual sexual contact with a male (V7/Prior Dietary Manager) in the parking lot of a church on Sundays during church services. This same report documents, (R3) stated that (R3) had at least three encounters with (V7) and that none were consensual. (R3) states that the first time it happened, (R3) was in (V7's) vehicle in the church parking lot, and (V7) forced himself on (R3). The second time that it occurred, (V7) told (R3) to get in (V7's) vehicle because (V7) had food for (R3). (R3) stated she ate the food and then started to feel woozy and then blacked out. (R3) states she awoke by herself in the vehicle and proceeded to go to church services. The third time that it happened (V7) lured (R3) into (V7's) vehicle because (R3) offered her snacks and once again, (R3) became woozy and blacked out and woke up alone and went to services after.Undated text message screenshots stored on R3's personal cellular phone and provided to this surveyor by V3 (R3's Plenary Guardian) on 1/31/26 documents ongoing personal, romantic, and sexually explicit communication between R3 and V7 (former Dietary Aide). The messages documented expressions of emotional attachment, intimate relationship discussions, and sexual content between V7 and R3. Text messages sent from V7 to R3 included statements such as, I miss you so much already, with R3 responding, I miss you more. Additional messages reflected plans to meet in the community, including R3 stating, Just come inside [NAME], I don't want to go back outside, it's cold and I'm starting to get a cough, and V7 responding, The car is warm (though), it's up to you. Further review of the text messages revealed discussions of a committed romantic relationship and future plans together. V7 texted R3, I really wanted to start a family with you and have a real life together.more than anything, and later stated, I do love you and miss you.you're my life, but I want more. Additional messages between R3 and V7 contained sexually explicit content. V7 texted R3, Making love to you means the world to me and I love you, and I want a real relationship with you. R3 sent a message to V7 stating, I love you more than I have ever loved anyone, and R3 stated she wanted V7 to c*m inside her and not pull out.R3's Individual Psychotherapy Follow-Up Evaluation Note dated 12/19/25 and signed by V8 (Clinical Therapist) documents R3 reported continued contact from R3's ex-partner (V7) and V7 gave R3 a note asking R3 to contact V7 however R3 stated she is setting boundaries and telling V7 to leave R3 alone. R3's Individual Psychotherapy Notes dated 1/9/26 and signed by V8 (Clinical Therapist) document, (R3) reported ongoing stress related to (R3's) ex-partner who continues attempting to contact (R3) directly and through others. (R3) expressed being done with the situation and wanting to leave town to feel safer. (R3) noted an increase in night tremors and shares significant fear that (V7) may approach (R3) when (R3) is not with staff or family, stating (R3) worries that something bad will happen. (R3) described how this fear has begun to affect her faith, though she continues coping by reading her Bible and listening to sermons. V7's Employee File documents V7 was hired at the facility on 9/26/23. V7's Employee File indicates V7 received Abuse Prevention training on 3/2/25. The Facility's In-Service Training Logs document V7 received training on 2/1/25 on what constitutes abuse, sexual abuse, sexual contact, sexual images, and staff requesting images from the residents, personal boundaries with the residents, and what constitutes all forms of abuse and bribery. The Facility's In-Service Training Logs document V7 received training regarding the facility's Abuse policy on 4/15/25 and 5/20/25. V7's Employee Termination Form dated 6/27/25 and signed by V1 (Administrator), V10 (Prior Dietary Manager), and V11 (Human Resource Manager) documents, (V7's) last day worked 6/27/25. Type of termination: Resignation. Reason for termination: Due to (V7's) growing feelings for a resident (R3). (V7) resigned effectively immediately. Eligible for rehire: No. R3's Police Report #25-049356 dated 11/26/25 at 1:17 PM and signed by V27 (Local Police Officer) documents, On 11/26/25 I (V27) was dispatched to (the facility) in regard to a sexual assault report. Upon arrival I met with (R3) and (V1/Administrator) who had reported the incident. (V1) advised that on 11/23/25, (R3) and (V3/R3's Guardian) had an argument regarding (R3) meeting former facility employee (V7) at (local church) on Sundays and having sex in (V7's) car in the parking lot during Sunday school before church. It should be noted that (V7) chose to resign from (the facility) due to a romantic interest in (R3), in which (V7) was told (V7) could not work at (the facility) due to a romantic interest in a resident (R3). (V3) also took (R3's) electronic devices after the argument and discovered inappropriate messages between (R3) and (V7). Today, (V1) advised that (R3) told one of her caregivers that (V7) forced (R3) to have sex without (R3's) consent, therefore (V7) was alerted and contacted the police. (R3) stated that she does love (V7) but was not ready to have sex with (V7). (R3) advised there has been three occasions where (V7) lured (R3) to (V7's) vehicle in the parking lot of the church and forced (R3) to have sex with (V7) which has occurred each Sunday, since the first week of November. I asked (R3) to walk me through each occurrence, beginning with the first time it happened. First Occurrence: (R3) stated that the first time this occurred, (R3) went to church on the shuttle that transports (facility) residents to church. Shortly after (R3) arrived at church (R3) received a message from (V7) to come outside to talk. (R3) believed (V7) just wanted to talk and then (V7) asked (R3) to get into his vehicle, which (R3) described as a black SUV (Sport Utility Vehicle). (R3) stated she was hesitant to get in the vehicle, but (V7) kept persisting and it was cold outside, so (R3) got inside the vehicle in the front passenger seat. After (R3) sat down, (R3) stated that (V7) said he wanted to show her how a real man makes loves to somebody, and locked the doors, opened his driver door, and walked around to the back of the car where he opened the trunk. (R3) stated (V7) climbed into the back seat from the trunk. (R3) did not know why he did it this way. (R3) then stated that (V7) pulled her into the back seat and (R3) told (V7) to leave her alone. (R3) advised that (V7) said, It'll be fun and proceeded to remove (R3's) pants and underwear and began to have sex with (R3) without a condom or any protection. After (V7) had sex with (R3), (R3) stated she kicked (V7) to get (V7) off, and to get out of the vehicle, and then ran into the church. At this time, (R3) was advised church was ending, and (R3) departed on a shuttle back to (the facility). Second Occurrence: The second time this occurred, (R3) advised she arrived at church and (V7) told her he had breakfast and coffee in the car. (R3) came out and sat in the car when (V7) told her because (R3) was scared. This time (R3) sat in the back seat because (R3) did not want to sit right next to him. (R3) said (V7) did have breakfast and (R3) began to eat, and (V7) left for five to ten minutes. When (V7) came back (R3) was feeling very tired and disorientated and (R3) said You're ready. (R3) advised she kept telling (V7) no but does not remember what happened after that. (R3) advised that when (R3) started becoming aware again, (R3's) pants and underwear were off and (V7) was not there. (R3) stated she remembered feeling pain in (R3's) groin area after this occurred but did not seek help. Third Occurrence: On the third occurrence, (R3) advised (V7) told (R3) he had snacks in the car. When (R3) came outside with (R3), (R3) stated that (V7) was sitting in the backset and told (R3) he wanted to apologize, and he asked (R3) to get in the car so he could apologize. (R3) stated that she refused, and then (V7) grabbed her waist and said, You're mine and pulled (R3) into the car. (R3) told (V7) she had a headache and said (V7) offered a square shaped red pill that (R3) said was ibuprofen and forced it down (R3's) throat. After that, (R3) said (V7) told her if she ever tells anyone (V7) will stop at nothing to finish her off, and if (R3) screams (V7) would knock her ass out and do (R3) right there. (R3) stated she felt like she blacked (out) shortly after and believed it was from the pill (V7) gave her. (R3) stated that this time, she woke up, she was completely naked and believed (R3) felt semen inside of her, and once again, (V7) was no longer there. (R3) stated that again, (R3) went back inside the building and came back to (the facility) on the shuttle. Follow-up with (V1/Administrator): Following my interview with (R3), (R3) returned to her room. I met with (V1), who advised that (R3) has diagnoses Borderline Personality Disorder, Anxiety Disorder, and Impaired Social Interaction. (V1) advised that there were notes in her file stating that (R3) has a history of lying to and manipulating staff, especially when attempting to leave the building, and using (R3's) phone to manipulate men online and engage in inappropriate communication. (V3/R3's Plenary Guardian) found out (R3) was meeting (V7) at church this past Sunday, which led to an argument with (R3) in which officers had to response. (V3) had gone through (R3's) phone and had found out earlier today that (R3) had been having sex with (V7). After talking with (V1), I departed the facility. On December 17, 2025, I (V27) was able to make contact with (V7) on the phone. I asked (V7) if he was familiar with (R3) and had him describe his relationship with (R3). (V7) advised that he was very close with (R3), and (V7) did resign from (the facility) in the past in order to maintain a relationship with (R3). (V7) did confirm that (V7) and (R3) were conversating over the phone and going to the same church, approximately one month ago and they would talk to each other while in church. (V7) stated that there were times that (V7) and (R3) went to his car and kissed, but they never engaged in any other sexual acts or intercourse. (V3) also called to follow up on 12/17/25. (V3) advised (V3) still has (R3's) phone, and that (V7) is still texting (R3). (V3) provided (V27) with more screenshots of more messages from (V7) and (R3). In these messages (V7) references our Sundays and at one point stated, If you (R3) are able to leave and also not talk to me and move on after making love, then you (R3) do not love me (V7). I (V27) will continue investigating this and due to conflicting statements. I will follow up with (R3) again, as well as (V7). On January 3, 2026, I (V27) met with (V7) at the public safety building and (V7) voluntarily gave a statement regarding (V7's) relationship with (R3), and their interactions. The following is a summary of my recollection of (V7's) statements. (V7's) full statement has been captured on body camera, and video recorded in the interview room. (V27) began a recording in the interview room and escorted (V7) to the room. I advised (V7) he was not under arrest but still read (V7) his [NAME] Warning from a pre-printed card. (V7) advised that he would speak with me and answer questions. (V7) advised that he did, in fact, resign from (the facility) because (V7) and (R3) had feelings for each other, and (V7) was told he could not remain employed (at the facility) if (V7) was going to have a personal relationship with (R3). (V7) stated that (R3) and (V7) were going to (local church) together for a couple months, and that (R3) enjoyed going to church with (V7), and they would often sit together. (V7) stated that they (R3 and V7) spoke with a pastor, together at one point for guidance in their relationship. (V7) did advise that sometimes he would step out to his car for a cigarette, and (R3) would follow (V7). According to (V7), (R3) came out to his care with him three or four times. (V7) stated that he occasionally brought some pop to drink in his car. (V7) advised that (V7) and (R3) would occasionally hug and kiss in the car, and there was one occasion in the car, at the church parking lot, in which their (R3 and V7's) physical contact escalated to protected sex. (V7) advised the sex was consensual and that (R3) stated to (V7) that (R3) did not withdraw from, or request (V7) to stop during sex at any time. (V7) said that (V7) and (R3) probably did occasionally talk about sex both over phone communication and in person, but they only had sex one time. Due to (V3's) mentioning a letter that was sent after (V3) confiscated (R3's) electronics, I asked (V7) if he ever sent a letter to (R3). (V7) stated he did give a letter to a mutual acquaintance to give to (R3). I asked (V7) if there was any particular reason (V7) could think of that would cause (R3) to feel uncomfortable with (V7), or their relationship all of a sudden, or if (R3) had not been mad at (V7) or uncomfortable with (V7) or told (V7) anything to indicate (R3) was upset, or uncomfortable with (V7). (V7) advised that after (V7) found out (R3) no longer had her phone or computer, (R3) attempted to contact (V7) multiple times from other phones such as her roommate's phone or landline phone at (the facility). Copies of questions (V27) asked (V7) during the interview and (V7's) personal notes he brought with have been added to the case file, and digital copies have been added to case pictures under this report number. Due to (R3's) statements in the original incident report of not consenting and being forced to have sex, and conflicting statements from (V7), I am requesting that this report be send to the State's Attorney's Office for a probable cause review for (V7) to be charged with Criminal Sexual Assault.R3's current Plan of Care as of 1/30/26 documents, Focus date initiated 3/6/25: Impaired Social Interaction-(R3) is frequently speaking with, texting, or calling objects of opposite sex. (R3) is easily emotionally involved and makes poor decisions related to opposite sex related to diagnoses of Borderline Personality Disorder, Anxiety, MDD (Major Depressive Disorder), and ADHD (Attention-Deficit Hyperactivity Disorder). Goal: (R3) will embrace positive thinking statement and will participate in social situations. Focus date initiated 7/8/25: (R3) has a behavior problem related to Borderline Personality Disorder, ADHD, MDD, Anxiety Disorder, and history of SI (Suicidal Ideation). (R3) will manipulate situations/peers/staff to be able to leave the building and go where (R3) is potentially not safe and lie about where (R3) is going against guardian's wishes and also use manipulation to be sent to the hospital at will. (R3) takes other belongings thinking that it is comical, uses cell phone to attempt to manipulate men online to come pick her up from facility (unsafe decision making) as (R3) does not know these men. (R3) makes false accusations against staff and peers. (R3) Makes false allegation against other residents stating they have come into her room and hit her, and investigations show untruth. This same care plan does not include any updated interventions since the last update on 6/27/25 to address and protect R3 from sexually inappropriate conversations and video nudity by electronic communication with V7 or any other male and does not address or protect R3 from being sexually assaulted by V7 or any other male. This care plan also does not include R3's cognitive ability to consent to sexual activity. R3's Electronic Health Record dated 2/25/25 (admission) through 1/29/26 does not include an evaluation to determine R3's ability to consent to sexual activity. The facility's Root Cause Analysis Worksheet (undated) documents, (R3) was engaged in a relationship with (V7) in the community. (R3) would attend church services with groups from the facility on Sundays, with no staff supervision. (R3 and V7) would meet at a church and attend services together. (R3) was noted to leave church services and go to the parking lot with (V7). It was reported (R3 and V7) were having sexual relations in the parking lot of the church. (V3/R3's Plenary Guardian) was made aware of the sexual relationship between (R3 and V7) and (V3) stopped (R3) from attending church services. (R3) then alleged that the sexual relationship was non-consensual. The facility's QAPI (Quality Assurance and Performance Improvement)/QAA (Quality Assurance Assessment) Meeting Agenda dated 11/26/25 documents the facility immediately implemented protection measures and increased supervision of R3. R3's current Care Plan does not include these increased supervision and protection measures as documents in the QAPI agenda.On 1/28/26 at 10:30 AM V3 (R3's Plenary Guardian) stated, I am (R3's) legal guardian. At seven years old I adopted (R3). About the age of three to four years old (R3) wasn't reaching goal marks. (R3's) doctor told me I need to file for guardianship to keep (R3) safe from others, so I did. On 6/26/25, (V1/Administrator) called me and told me that (R3's) roommate (R6) had reported to (V1) that (R3) was in a relationship with (V7/Dietary Aide). (V1) told me they (the facility) were going to do an investigation, and I gave permission to look through (R3's) electronics. (V1) reported to me that (R3 and V7) were not having a sexual relationship but (V7) was sending (R3) messages saying, I love you. I am going to get you out of this place. You are the best thing that has happened to me. (V1) also said (R3 and V7) were video chatting at night. I had a CNA (Certified Nursing Assistant) tell me that she had gone into check on (R3) and saw (R3) was on a video call with (V7). I cannot remember that CNAs name. I was very upset over this whole thing of an employee trying to have a sexual relationship with (R3). I asked (V1) for (V7's) discharge records and I was told (V7) left on his own, so the facility did not have to do the paperwork or report this to IDPH (Illinois Department of Public Health). I told them IDPH needs to know that one of their employees (V7) is trying to have a sexual relationship and boyfriend-girlfriend relationship with my daughter (R3) and this is exploitation of my daughter. I am a nurse and know a staff member should never try to have a relationship with a resident. I told the facility to take (R3's) electronics and that (R3) was not to have any further contact with (V7). After that (R3) was calling me and screaming at me that I am the worst mom ever. (R3) wanted to have a relationship with (V7) and started threatening suicide and was sent to a psychiatric unit for treatment. When (R3) returned to the facility, (R3) was put on lockdown and was not to leave the facility without supervision. I allowed (R3) to go to church back in November 2025. (R3) was able to leave to go to church with the facility dropping (R3) off and the church would bring (R3) back to the facility, and I told the facility to ensure (R3) was supervised at church. (R3) has a history of lying and being manipulative and a nurse (unknown name) told me that she thought (R3) was meeting up with (V7) while at church. I decided to drive three hours down and went to that church and sat in the back row. (R3) was not at church when I was there, even though I was told by the facility (R3) was going to church. About an hour into church, (R3) came into church from a side door. After church was over, I waited for (R3) to notice me. I walked up behind (R3) and tapped (R3) on the shoulder. I took (R3) back to the facility myself. I went outside and was looking for her and one of the residents in the facility van said to me, Just so you know (R3) has not been going to Sunday school for weeks. (R3) was angry at me for questioning her. The van driver (V13) told me he knew for weeks that (R3) had been sneaking around with (V7) at church. (R3) admitted to me that (R3) and (V7) were having intercourse while (V7) was working at the facility and (R3) had even met (V7's) daughter. The facility did not keep (R3) safe, and the facility said they would keep (R3) safe. (R3) is not allowed to leave now. (R3) cannot consent to sex. I told the police officer (V27) that (R3) cannot consent, and I am her legal guardian and did not consent to (R3) having a relationship with (V7). After (R3 and V7) were caught together at church, (V27) and (V1) were made fully aware that (V7) was the male meeting up with my daughter at church. I am legal guardian, and the police and facility should have done a rape kit on Sunday (11/23/25). There was also no STD (Sexually Transmitted Disease) testing done. I have since read all the text messaging done between (R3 and V7) and I turned all those text messages over to (V27). (V7) knows (R3) is disabled and takes advantage of (R3). (V7) needs to leave my daughter alone! The messages between (R3 and V7) started before June 2025. (V7) would send messages to (R3) saying, I[TRUNCATED]

Based on record review and interview the facility failed to report allegations of staff-to-resident sexual abuse and exploitation, allegations of resident-to-resident physical abuse, and allegations of staff-to-resident verbal abuse immediately to the State Agency, Local Police, and Administrator once the facility was made aware for two of seven residents (R3 and R6) reviewed for abuse in the sample of seven. These failures resulted in V7 (Prior Dietary Aide) continuing to have non-consensual sex with R3, V7 continuing to sexually exploit R3 by electronic communications, and V7 verbally abusing R6 on multiple occasions once R6 witnessed R3 and V7 engaging in inappropriate conversations and video nudity by electronic communications.These failures resulted in an Immediate Jeopardy:While the immediacy was removed on 1/31/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Abuse, Neglect, and Exploitation dated 2/3/25 documents, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of property. Investigation of Alleged Abuse, Neglect and Exploitation. Reporting/Response. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes: a. immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Any sexual relationship between a staff member and a resident with or without diminished capacity may constitute sexual abuse in the absence of a sexual relationship that existed prior to the resident admitted to the facility, such as a spouse or partner, and must be thoroughly investigated to prevent abuse and implement policies and procedures to prevent and prohibit all types of abuse, neglect, bribery, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. B. Identifying, correcting, and intervening in situations residents and, neglect, exploitation, bribery, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.1.R3's Legal Guardianship dated 2/27/15 and signed by V12 (Judge) documents, Because of (R3's) physical and mental conditions, (R3) is not able to manage her person or property and is therefore a disabled person. Because of (R3's) disability (R3) lacks sufficient capacity to make and communicate responsible decisions concerning the care of her person and because of (R3's) disability, (R3) lacks capacity to manage her estate; and for these reasons it is necessary to appoint a guardian of the person and estate of (R3). A limited guardianship will not provide sufficient protection for (R3). (V3/R3's Plenary Guardian) is qualified to act as a guardian. In order to protect the best interests of (R3), a guardian of (R3's) person and estate should be appointed. (V3) is capable of making residential decisions for (R3). Now, therefore, it is hereby ordered and adjudged: A. That (R3) is a disabled person in need of the appointment of a plenary guardian of her person and or estate. V7's Employee Termination Form dated 6/27/25 and signed by V1 (Administrator), V10 (Prior Dietary Manager), and V11 (Human Resource Manager) documents, (V7's) last day worked 6/27/25. Type of termination: Resignation. Reason for termination: Due to (V7's) growing feelings for a resident (R3). (V7) resigned effectively immediately. Eligible for rehire: No. R3's Electronic Health Record dated 2/25/25 (admission) through 1/29/26 does not include an evaluation to determine R3's ability to consent to sexual activity. R3's Progress Notes dated 11/10/25 at 6:27 PM document, Staff talked to (R3) about roommate (R6) complaint of (R3) getting completely naked in the room with door and curtain open talking or videoing on social media (with another male). Staff reminded (R3) to close curtains and doors and be respectful of roommate's concerns. R3's Behavior Note dated 11/20/25 at 8:30 AM and signed by V6 (Psychosocial Rehabilitation Coordinator) documents, Another resident (R6) approached (V6) to report that (R3) was engaging in sexual conversation. When (R6) asked (R3 and R7) to refrain from doing this while (R6) was in the room, the male (V7) on the call began cursing at (R6) and calling (R6) names. (R6) stated that incidents like this occur often, and it is making (R6) feel uncomfortable. R3 and R6's Medical Records and the facility's Abuse Investigations do not include evidence of R3 and R6's allegations of R3 being sexually exploited by video on social media or R6 witnessing this sexual exploitation on 11/10/25 or 11/20/25 being reported to the State Agency or Local Police.R3's Police Report #25-049356 dated 11/26/25 at 1:17 PM and signed by V27 (Local Police Officer) documents R3 was sexually assaulted by V7 (Prior Dietary Aide) on three separate occasions while R3 was attending church services. This same Police Report documents V27 requested this Police Report be sent to the State's Attorney's Office for a probable cause review for (V7) to be charged with Criminal Sexual Assault.R3's Final Abuse Investigation dated 12/3/25 and signed by V1 (Administrator) documents, On 11/23/25 R3 had multiple instances of non-consensual sexual contact with a male (V7/Prior Dietary Manager) in the parking lot of a church on Sundays during church services. This same report documents, (R3) stated that (R3) had at least three encounters with (V7) and that none were consensual. (R3) states that the first time it happened, (R3) was in (V7's) vehicle in the church parking lot, and (V7) forced himself on (R3). The second time that it occurred, (V7) told (R3) to get in (V7's) vehicle because (V7) had food for (R3). (R3) stated she ate the food and then started to feel woozy and then blacked out. (R3) states she awoke by herself in the vehicle and proceeded to go to church services. The third time that it happened (V7) lured (R3) into (V7's) vehicle because (R3) offered her snacks and once again, (R3) became woozy and blacked out and woke up alone and went to services after. R3's Sign In/Sign Out Report Sheets dated 11/1/25 through 12/31/25 document R3 attended outside church services or the library on 11/9/25, 11/14/25, 11/16/25, and 11/23/25. These sheets do not include the staff/family/friend that R3 attended the library with on 11/14/25 or the church on 11/23/25. R3's Individual Psychotherapy Notes dated 1/9/26 and signed by V8 (Clinical Therapist) document, (R3) reported ongoing stress related to (V7) who continues attempting to contact (R3) directly and through others. (R3) expressed being done with the situation and wanting to leave town to feel safer. (R3) noted an increase in night tremors and shares significant fear that (V7) may approach (R3) when (R3) is not with staff or family, stating (R3) worries that something bad will happen. (R3) described how this fear has begun to affect her faith, though she continues coping by reading her Bible and listening to sermons.On 1/28/26 at 10:30 AM V3 (R3's Plenary Guardian) stated, I am (R3's) legal guardian. At seven years old I adopted (R3). About the age of three to four years old (R3) wasn't reaching goal marks. (R3's) doctor told me I need to file for guardianship to keep (R3) safe from others, so I did. On 6/26/25, (V1/Administrator) called me and told me that (R3's) roommate (R6) had reported to (V1) that (R3) was in a relationship with (V7/Dietary Aide). (V1) told me they (the facility) were going to do an investigation, and I gave permission to look through (R3's) electronics. (V1) reported to me that (R3 and V7) were not having a sexual relationship but (V7) was sending (R3) messages saying, I love you. I am going to get you out of this place. You are the best thing that has happened to me. (V1) also said (R3 and V7) were video chatting at night. I had a CNA (Certified Nursing Assistant) tell me that she had gone into check on (R3) and saw (R3) was on a video call with (V7). I cannot remember that CNAs name. I was very upset over this whole thing of an employee trying to have a sexual relationship with (R3). I asked (V1) for (V7's) discharge records and I was told (V7) left on his own, so the facility did not have to do the paperwork or report this to IDPH (Illinois Department of Public Health). I told (V1) IDPH (Illinois Department of Public Health) needs to know that one of the employees at the facility, (V7), is trying to have a sexual relationship and boyfriend-girlfriend relationship with my daughter (R3) and this is exploitation of my daughter. I am a nurse and know a staff member should never try to have a relationship with a resident. When (R3) returned to the facility, (R3) was put on lockdown and was not to leave the facility without supervision. I allowed (R3) to go to church back in November 2025. (R3) was able to leave to go to church with the facility dropping (R3) off and the church would bring (R3) back to the facility, and I told the facility to ensure (R3) was supervised at church. (R3) has a history of lying and being manipulative and a nurse (unknown name) told me that she thought (R3) was meeting up with (V7) while at church. I decided to drive three hours down and went to that church and sat in the back row. (R3) was not at church when I was there, even though I was told by the facility (R3) was going to church. About an hour into church, (R3) came into church from a side door. After church was over, I waited for (R3) to notice me. I walked up behind (R3) and tapped (R3) on the shoulder. I took (R3) back to the facility myself. I went outside and was looking for her and one of the residents in the facility van said to me, Just so you know (R3) has not been going to Sunday school for weeks. (R3) was angry at me for questioning her. The van driver (V13) told me he knew for weeks that (R3) had been sneaking around with (V7) at church. (R3) admitted to me that (R3) and (V7) were having intercourse while (V7) was working at the facility and (R3) had even met (V7's) daughter. The facility did not keep (R3) safe, and the facility said they would keep (R3) safe. (R3) is not allowed to leave now. (R3) cannot consent to sex. I told the police officer (V27) that (R3) cannot consent, and I am her legal guardian and did not consent to (R3) having a relationship with (V7). (V7) knows (R3) is disabled and takes advantage of (R3). (V7) continued to text me and say he cares about (R3), and they love each other. I do not want (V7) to have any further contact with (R3).On 1/28/26 at 12:51 PM V6 (Psychosocial Rehabilitation Coordinator) stated, (R3) came into my office and said she was upset because they (R3 and V7) were in love and were texting back and forth and video chatting while (V7) worked here. (R3) let me read text messages and (V7) texting (R3) saying he missed and loved (R3) and knows (R3) is with other people and how (R3) could do that too (V7). I reported this to (V1) immediately and (V7) was given the option to resign or be terminated. On 11/20/25 (R6) reported to me that she saw (V7), who (R6) described as the little guy that used to work here, on a phone video with (R3) and (R3 and V7) were being provocative, having sexually inappropriate conversations, and having sexual acts. (R6) said she told (R3 and V7) to Knock that off. (R6) said (V7) began cursing at (R6) and told (R6) to Shut the f**k up and (R3) continued to yell at (R6). (R6) was frustrated. I reported (R6's) report to (V1) and we discussed it in an IDT (Inter-Disciplinary) meeting and then (R3) was supposed to stop using electronics.On 1/28/26 at 1:15 PM R3 stated, I want to leave and get closer to my family. I got involved with a staff member, (V7), while he worked here. I started to play songs that I had written and (V7) would come out and say he was into music. Around March of last year (V7) sent me a message request on Facebook and I said back to (V7), How did you find me? (V7) said we (R3 and V7) share mutual friends on Facebook. After that we started text messaging back and forth while (V7) was at work. Eventually (V7) started asking me for phone sex and naked pictures and I was not okay with that. (V7) was living with the mother of his child during this time. (V7) told me that (V1/Administrator) gave (V7) the option to leave and not have legal repercussions or (V7) could stay employed and get both of us in trouble. (V7) started to say I was f**cked up in the head and (V7) did not want me. Our relationship grew and when I started to go to church, (V7) would meet up with me at church. (V7) lured me into his car by saying he wanted to talk to me privately. That should have been my first red flag. I went to (V7's) car and (V7) raped me and it was not consensual. (V7) raped me on three different Sundays. I asked (V7) to stop. (V7) wanted me to tell everyone it was consensual. (V7) told me he wanted our conversations to make it sound consensual. I talked to (V7) once since church by phone here at the facility and told (V7) to leave me the h**l alone. (V7) said he was not going to leave me alone and that he loved me. I told (V7) I am leaving this town because of (V7). (V3) is my guardian, and I am not sure if (V3) decides if I can have sex or not. I told the police and (V1) that (V7) raped me. The police said they were investigating. I am okay with the police seeing my phone messages and I am okay with you (this surveyor) seeing those messages. I feel like I could scream and do not feel comfortable here and I am having night terrors about what happened to me from (V7). I just want to leave this town. (V7) is not allowed on the property, and I am not allowed to leave because I do not want to put myself in an unsafe spot and see (V7). I told (V1) that (V7) raped me, and it was (V7).On 1/29/26 at 10:30 AM V11 (Human Resources Director) stated, On 6/27/25 me and (V1) met with (V7) after (V1) read text messages between (R3 and V7). (V7) was inappropriately texting (R3's) cellphone as in boyfriend/girlfriend type texting and telling (R3) he wanted to have a relationship with (R3).On 1/30/26 at 1:00 PM (V29/LPN/Licensed Practical Nurse) stated, (V3)(R3's Plenary Guardian) came to the facility on [DATE] and was livid after (V3) caught (R3 and V7) having sex in the parking lot of the facility. I reported this to (V1) on 11/23/25.On 1/29/26 at 12:40 PM V1 (Administrator) stated, (V10/Prior Dietary Manager) came to me around 6/26/25 and said he was told a dietary staff member (V7) was texting with (R3). (V7) told (V10) he was not texting with anyone. (R3) gave me her phone. I found out (V7) was texting (R3) and trying to have a relationship with (R3). It did not look like anything sexually inappropriate at that time. I said to (V7), I thought you weren't texting (R3). I told (V7) he could not be an employee and have a relationship with (R3). (V7) decided to resign because he wanted to have a relationship with (R3) and was having feelings for (R3). I called (V3) and told (V3) that (V7) decided to resign. Later, I was told by (V3) that (V7 and R3) were having sex in the parking lot. At this time V1 verified he did not notify the State Agency or the local police when V1 became aware that V7 was trying to initiate a personal relationship with a resident (R3). The police and state agency were not notified about (R3) and (V7) having sexual relations while at church until 11/26/25 (three days after (V3) reported this to (V29/LPN).On 1/29/26 at 1:05 PM V17 (CNA) stated, There were several evenings that (V7) and (R3) were videochatting sexually back and forth in November. I would report this to the nurses anytime I witness them. I do not recall the nurses I was reporting this to as a lot of them were agency nurses and I do not know their names. I know it was inappropriate and should not have been happening. We (facility) staff were never told whether or not (R3) could consent to sexual relationships. Still today I am not sure if (R3) can consent to sexual relationships or not and have not been told that we need to supervise (R3).On 1/29/26 at 1:30 PM V10 (Prior Dietary Manager) stated, While I was the dietary manager at the facility I started noticing (V7) was not doing his job and spending a lot of time around (R3) in the day room and out on the patio. I asked (V7) about it and told (V7) it is not appropriate to have a relationship with a resident. Later, sometime in June (2025), (V7) came to me and said he was starting to have feelings for (R3). I immediately reported this to (V1). (V1) then asked (R3) if he could see her cellphone messages between (R3 and V7) and found out (R3) had more than one cellphone (V1) read the messages that were being sent back between (R3 and V7) while (V7) was an employee and (V7's) messages to (R3) were that (R3) was the love of his (V7's) life and (V7) wanted to get (R3) pregnant. (V7) was trying to have an intimate relationship with (R3). The next day after (V1) read the inappropriate text messages between (R3 and V7), (V7) was asked to resign.On 2/1/26 at 9:15 AM V1 (Administrator) stated no one had reported R6's report of R3 being naked and videochatting with a male on 11/10/25, therefore V1 has not reported this to the State Agency or the Local Police.2.R3's Emergency Department Notes dated 7/8/25 document, (R3) reports that she has been feeling suicidal for the past couple days. (R3) reports having thoughts of cutting her wrists in order to attempt suicide. (R3) reports that she was physically assaulted by two other (unknown) residents yesterday and has not been able to sleep since then. (R3) denies any injuries or complaints from that assault.R3's Medical Record and the facility's Abuse Investigations do not include evidence of R3's allegation on 7/8/25 being reported to the State Agency or Local Police.On 2/1/26 at 9:15 AM V1 (Administrator) verified he found out about R3's allegation regarding being physically assaulted by roommates, after receiving R3's hospital records on 1/30/26. V1 stated he has yet to notify the local police or State Agency regarding R3's allegation.3. R6's Face Sheet documents R6 is a [AGE] year-old that was admitted to the facility on [DATE]. R6's MDS (Minimum Data Set) assessment dated [DATE] documents R6 is cognitively intact and has no behaviors. R3's Behavior Note dated 11/20/25 at 8:30 AM and signed by V6 (Psychosocial Rehabilitation Coordinator) documents, Another resident (R6) approached (V6) to report that (R3) was engaging in sexual conversation. When (R6) asked them to refrain from doing this while (R6) was in the room, the male (V7) on the call began cursing at (R6) and calling (R6) names. (R6) stated that incidents like this occur often, and it is making (R6) feel uncomfortable. R6's Progress Notes do not include any documentation regarding R6's alleged altercation with V7 on 11/20/25. On 1/28/26 at 12:05 PM R6 stated, I watched (R3) and (V7) having sex on her phone several times (unknown dates) and whenever I would try to make (R3 and R7) stop (V7) would yell at me and tell me to mind my own business and call me a b***h. I asked (R3 and V7) to stop. I didn't want to see or hear that. The last time I asked (R3) and (V7) to stop having phone sex, (V7) yelled at me, You b***h! You are going to get you're a** kicked. I told (V5/SSD/Social Service Director) that (V7) threatened me and has threatened me several times. I definitely felt abused and worried that (V7) would do something to me.On 1/28/26 at 12:51 PM V6 (Psychosocial Rehabilitation Coordinator) stated, On 11/20/25 (R6) reported to me that she saw (V7), who (R6) described as the little guy that used to work here, on a phone video with (R3) and (R3 and V7) were being provocative, having sexual inappropriate conversations, and having sexual acts. (R6) said she told (R3 and V7) to Knock that off. (R6) said (V7) began cursing at (R6) and told (R6) to Shut the f**k up and (R3) continued to yell at (R6). (R6) was frustrated. I reported this immediately to V1.On 1/29/26 at 12:40 PM V1 verified he has not notified the local police or the State Agency regarding R6's allegations made on 11/20/25 regarding V7.The Immediate Jeopardy started June 26 2025 when V1 became aware that (V7/Prior Dietary Aide) started engaging in behavior indicating an attempt to initiate a personal or romantic relationship with R3, while V7 was employed at the facility, and did not report this to the police or state agency, which resulted in V7 continuing to have sexually inappropriate conversations and video nudity by electronic communication with R3 that was not reported to the police or state agency, and V7 sexually assaulting R3 on at least three occasions while R3 was attending church services.On 1/30/26 at 11:25 AM V1 (Administrator), V25 (Corporate Nurse Consultant), and V26 (Regional Nurse Consultant) were notified of the Immediate Jeopardy.On 2/3/26 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.V7 resigned from the facility on 6/27/25. 2. V1 initiated an abuse investigation into R3's abuse allegation dated 7/8/25 to IDPH on 1/31/26 and a final report will follow. 3.V1 initiated an abuse investigation into R3's abuse allegation dated 11/10/25 to IDPH on 1/31/26 and a final report will follow. 4. V1 initiated an abuse investigation into R3 and R6's abuse allegations dated 11/20/25 to IDPH on 1/30/25 and a final report to follow. 5. On 11/26/25, V1 initiated an abuse investigation, notified IDPH, and notified the local police regarding R3's abuse allegation that occurred on 11/23/25. 6. On 1/29/26 and 1/31/26 V5 (Social Service Director) completed assessments on R3's capacity to consent to sexual relations with the involvement of V3 (R3's Plenary Guardian), V35 (R3's Physician), and V36 (R3's Psychiatrist). The facility is still evaluating R3's capacity to consent to sexual relations and have implemented precautions to keep R3 safe. The facility also developed a plan to ensure R3 has staff supervision while using the facility phones to ensure safe communication with others. On 11/26/25 V3 (R3's Plenary Guardian) removed R3's phone from R3 and V3 restricted R3's church visits. R3's Care Plan was updated with interventions to increase R3's safety on 1/31/26. 7. On 1/30/26 V26 (Regional Nurse Consultant) reviewed all residents to ensure no residents suffered from past abuse. 8. On 1/30/26, the Quality Assessment and Assurance Committee met for an emergency QAPI (Quality Assurance and Performance Improvement) meeting and developed and implemented plans to ensure no further abuse occurred within the facility and all policies and procedures were followed correctly. 9. On 1/30/26 the facility's abuse policies were reviewed by the QA (Quality Assurance) committee prior to educating staff. 10. On 1/30/26 the facility's staff intimate relationships policy was reviewed by the QA committee. 11. On 11/19/25, 11/26/25, 1/13/26, and again on 1/30/26 V1, V2 (Director of Nursing/DON), and V38 (MDS Coordinator) educated all staff on abuse prevention and abuse reporting and all abuse related policies and procedures. 12. On 1/31/26 V25 (Regional Director of Operations) educated V1 on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of Abuse/Neglect/Exploitation Policy to IDPH. 13. On 1/30/26 V1, V2, and V38 educated all staff on maintaining professional boundaries with residents and staff are not to have any inappropriate relationship with residents. 14. On 1/28/26 through 1/31/26 R3 and R6's care plans have been updated with safety interventions to protect them from abuse. Completion Date: 1/31/26.

Based on record review and interview the facility failed to protect residents from staff-to-resident sexual abuse and verbal abuse, failed to develop and implement interventions to increase safety and adequately supervise the residents, failed to immediately initiate and investigation of allegations of staff to resident sexual and verbal abuse, and failed to submit a final investigation report of allegations of staff-to-resident sexual and verbal abuse to the State Agency within five working days for two of seven residents (R3 and R6) reviewed for abuse in the sample of seven. These failures resulted in V7 (Prior Dietary Aide) having continual access to R3 after V7 was engaging in behavior indicating an attempt to initiate a personal or romantic relationship with R3 in June 2025 and V7 continuing to sexually exploit R3 and have non-consensual sexual relations with R3. These failures also resulted in V7 verbally abusing R6 on multiple occasions once R6 witnessed R3 and V7 engaging in inappropriate conversations and video nudity by electronic communications.These failures resulted in an Immediate Jeopardy:While the immediacy was removed on 1/31/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Abuse, Neglect, and Exploitation dated 2/3/25 documents, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of property. Prevention of Abuse, neglect, bribery, and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, bribery, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to sexual contact will be made and where this documentation will be recorded; and the residents' right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, bribery, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms; D. the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the residents right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. V. Investigation of Alleged Abuse, Neglect and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, bribery, or exploitation occur. Written policies for investigations include: 1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation;3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged preparator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, bribery, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; increased supervision of the alleged victim and residents; room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of incident or abuse. Reporting/Response: The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies.1.R3's Legal Guardianship dated 2/27/15 and signed by V12 (Judge) documents, Because of (R3's) physical and mental conditions, (R3) is not able to manage her person or property and is therefore a disabled person. Because of (R3's) disability (R3) lacks sufficient capacity to make and communicate responsible decisions concerning the care of her person and because of (R3's) disability, (R3) lacks capacity to manage her estate; and for these reasons it is necessary to appoint a guardian of the person and estate of (R3). A limited guardianship will not provide sufficient protection for (R3). (V3/R3's Plenary Guardian) is qualified to act as a guardian. In order to protect the best interests of (R3), a guardian of (R3's) person and estate should be appointed. (V3) is capable of making residential decisions for (R3). Now, therefore, it is hereby ordered and adjudged: A. That (R3) is a disabled person in need of the appointment of a plenary guardian of her person and or estate. V7's Employee Termination Form dated 6/27/25 and signed by V1 (Administrator), V10 (Prior Dietary Manager), and V11 (Human Resource Manager) documents, (V7's) last day worked 6/27/25. Type of termination: Resignation. Reason for termination: Due to (V7's) growing feelings for a resident (R3). (V7) resigned effectively immediately. Eligible for rehire: No. R3's Electronic Health Record dated 2/25/25 (admission) through 1/29/26 does not include an evaluation to determine R3's ability to consent to sexual activity. R3's Progress Notes dated 11/10/25 at 6:27 PM document, Staff talked to (R3) about roommate (R6) complaint of (R3) getting completely naked in the room with door and curtain open talking or videoing on social media (with another male). Staff reminded (R3) to close curtains and doors and be respectful of roommate's concerns. R3's Behavior Note dated 11/20/25 at 8:30 AM and signed by V6 (Psychosocial Rehabilitation Coordinator) documents, Another resident (R6) approached (V6) to report that (R3) was engaging in sexual conversation. When (R6) asked (R3 and R7) to refrain from doing this while (R6) was in the room, the male (V7) on the call began cursing at (R6) and calling (R6) names. (R6) stated that incidents like this occur often, and it is making (R6) feel uncomfortable. R3 and R6's Medical Records and the facility's Abuse Investigations do not include evidence of a final abuse report being submitted to the state agency regarding R3 and R6's allegations of R3 being sexually exploited by video on social media or R6 witnessing this sexual exploitation on 11/10/25 or 11/20/25 being investigated, a final abuse report being submitted to the state agency, or any safety interventions being developed or implemented to protect R3 and R6 from further sexual exploitation by video.R3's Police Report #25-049356 dated 11/26/25 at 1:17 PM and signed by V27 (Local Police Officer) documents R3 was sexually assaulted by V7 (Prior Dietary Aide) on three separate occasions while R3 was attending church services. This same Police Report documents V27 requested this Police Report be sent to the State's Attorney's Office for a probable cause review for (V7) to be charged with Criminal Sexual Assault.R3's Final Abuse Investigation dated 12/3/25 and signed by V1 (Administrator) documents, On 11/23/25 R3 had multiple instances of non-consensual sexual contact with a male (V7/Prior Dietary Manager) in the parking lot of a church on Sundays during church services. This same report documents, (R3) stated that (R3) had at least three encounters with (V7) and that none were consensual. (R3) states that the first time it happened, (R3) was in (V7's) vehicle in the church parking lot, and (V7) forced himself on (R3). The second time that it occurred, (V7) told (R3) to get in (V7's) vehicle because (V7) had food for (R3). (R3) stated she ate the food and then started to feel woozy and then blacked out. (R3) states she awoke by herself in the vehicle and proceeded to go to church services. The third time that it happened (V7) lured (R3) into (V7's) vehicle because (R3) offered her snacks and once again, (R3) became woozy and blacked out and woke up alone and went to services after. R3's Sign In/Sign Out Report Sheets dated 11/1/25 through 12/31/25 document R3 attended outside church services or the library on 11/9/25, 11/14/25, 11/16/25, and 11/23/25. These sheets do not include the staff/family/friend that R3 attended the library with on 11/14/25 or the church on 11/23/25. R3's Individual Psychotherapy Notes dated 1/9/26 and signed by V8 (Clinical Therapist) document, (R3) reported ongoing stress related to (V7) who continues attempting to contact (R3) directly and through others. (R3) expressed being done with the situation and wanting to leave town to feel safer. (R3) noted an increase in night tremors and shares significant fear that (V7) may approach (R3) when (R3) is not with staff or family, stating (R3) worries that something bad will happen. (R3) described how this fear has begun to affect her faith, though she continues coping by reading her Bible and listening to sermons.On 1/28/26 at 10:30 AM V3 (R3's Plenary Guardian) stated, I am (R3's) legal guardian. At seven years old I adopted (R3). About the age of three to four years old (R3) wasn't reaching goal marks. (R3's) doctor told me I need to file for guardianship to keep (R3) safe from others, so I did. On 6/26/25, (V1/Administrator) called me and told me that (R3's) roommate (R6) had reported to (V1) that (R3) was in a relationship with (V7/Dietary Aide). (V1) told me they (the facility) were going to do an investigation, and I gave permission to look through (R3's) electronics. (V1) reported to me that (R3 and V7) were not having a sexual relationship but (V7) was sending (R3) messages saying, I love you. I am going to get you out of this place. You are the best thing that has happened to me. (V1) also said (R3 and V7) were video chatting at night. I had a CNA (Certified Nursing Assistant) tell me that she had gone into check on (R3) and saw (R3) was on a video call with (V7). I cannot remember that CNAs name. I was very upset over this whole thing of an employee trying to have a sexual relationship with (R3). I asked (V1) for (V7's) discharge records and I was told (V7) left on his own, so the facility did not have to do the paperwork or report this to IDPH (Illinois Department of Public Health). I told (V1) IDPH needs to know that one of the employees at the facility, (V7), is trying to have a sexual relationship and boyfriend-girlfriend relationship with my daughter (R3) and this is exploitation of my daughter. I am a nurse and know a staff member should never try to have a relationship with a resident. When (R3) returned to the facility, (R3) was put on lockdown and was not to leave the facility without supervision. I allowed (R3) to go to church back in November 2025. (R3) was able to leave to go to church with the facility dropping (R3) off and the church would bring (R3) back to the facility, and I told the facility to ensure (R3) was supervised at church. (R3) has a history of lying and being manipulative and a nurse (unknown name) told me that she thought (R3) was meeting up with (V7) while at church. I decided to drive three hours down and went to that church and sat in the back row. (R3) was not at church when I was there, even though I was told by the facility (R3) was going to church. About an hour into church, (R3) came into church from a side door. After church was over, I waited for (R3) to notice me. I walked up behind (R3) and tapped (R3) on the shoulder. I took (R3) back to the facility myself. I went outside and was looking for her and one of the residents in the facility van said to me, Just so you know (R3) has not been going to Sunday school for weeks. (R3) was angry at me for questioning her. The van driver (V13) told me he knew for weeks that (R3) had been sneaking around with (V7) at church. (R3) admitted to me that (R3) and (V7) were having intercourse while (V7) was working at the facility and (R3) had even met (V7's) daughter. The facility did not keep (R3) safe, and the facility said they would keep (R3) safe. (R3) is not allowed to leave now. (R3) cannot consent to sex. I told the police officer (V27) that (R3) cannot consent, and I am her legal guardian and did not consent to (R3) having a relationship with (V7). (V7) knows (R3) is disabled and takes advantage of (R3). (V7) continued to text me and say he cares about (R3), and they love each other. I do not want (V7) to have any further contact with (R3).On 1/28/26 at 12:51 PM V6 (Psychosocial Rehabilitation Coordinator) stated, (R3) came into my office and said she was upset because they (R3 and V7) were in love and were texting back and forth and video chatting while (V7) worked here. (R3) let me read text messages and (V7) texting (R3) saying he missed and loved (R3) and knows (R3) is with other people and how (R3) could do that too (V7). I reported this to (V1) immediately and (V7) was given the option to resign or be terminated. On 11/20/25 (R6) reported to me that she saw (V7), who (R6) described as the little guy that used to work here, on a phone video with (R3) and (R3 and V7) were being provocative, having sexually inappropriate conversations, and having sexual acts. (R6) said she told (R3 and V7) to Knock that off. (R6) said (V7) began cursing at (R6) and told (R6) to Shut the f**k up and (R3) continued to yell at (R6). (R6) was frustrated. I reported (R6's) report to (V1) and we discussed it in an IDT (Inter-Disciplinary) meeting and then (R3) was supposed to stop using electronics. I do not see that any interventions have been added to (R3) or (R6's) care plans to protect them from further sexual exploitation or verbal abuse.On 1/28/26 at 1:15 PM R3 stated, I want to leave and get closer to my family. I got involved with a staff member, (V7), while he worked here. I started to play songs that I had written and (V7) would come out and say he was into music. Around March of last year (V7) sent me a message request on Facebook and I said back to (V7), How did you find me? (V7) said we (R3 and V7) share mutual friends on Facebook. After that we started text messaging back and forth while (V7) was at work. Eventually (V7) started asking me for phone sex and naked pictures and I was not okay with that. (V7) was living with the mother of his child during this time. (V7) told me that (V1/Administrator) gave (V7) the option to leave and not have legal repercussions or (V7) could stay employed and get both of us in trouble. (V7) started to say I was f**cked up in the head and (V7) did not want me. Our relationship grew and when I started to go to church, (V7) would meet up with me at church. (V7) lured me into his car by saying he wanted to talk to me privately. That should have been my first red flag. I went to (V7's) car and (V7) raped me and it was not consensual. (V7) raped me on three different Sundays. I asked (V7) to stop. (V7) wanted me to tell everyone it was consensual. (V7) told me he wanted our conversations to make it sound consensual. I talked to (V7) once since church by phone here at the facility and told (V7) to leave me the h**l alone. (V7) said he was not going to leave me alone and that he loved me. I told (V7) I am leaving this town because of (V7). (V3) is my guardian, and I am not sure if (V3) decides if I can have sex or not. I told the police and (V1) that (V7) raped me. The police said they were investigating. I am okay with the police seeing my phone messages and I am okay with you (this surveyor) seeing those messages. I feel like I could scream and do not feel comfortable here and I am having night terrors about what happened to me from (V7). I just want to leave this town. (V7) is not allowed on the property, and I am not allowed to leave because I do not want to put myself in an unsafe spot and see (V7). I told (V1) that (V7) raped me, and it was (V7).On 1/29/26 at 10:30 AM V11 (Human Resources Director) stated, On 6/27/25 me and (V1) met with (V7) after (V1) read text messages between (R3 and V7). (V7) was inappropriately texting (R3's) cellphone as in boyfriend/girlfriend type texting and telling (R3) he wanted to have a relationship with (R3).On 1/30/26 at 1:00 PM (V29/LPN/Licensed Practical Nurse) stated, (V3) came to the facility on [DATE] and was livid after (V3) caught (R3 and V7) having sex in the parking lot of the facility. I reported this to (V1) on 11/23/25. I am not aware of any interventions to increase supervision or safety of (R3) to keep (R3) free from further sexual abuse. I am not even sure if (R3) can consent to sex.On 1/29/26 at 12:40 PM V1 (Administrator) stated, (V10/Prior Dietary Manager) came to me around 6/26/25 and said he was told a dietary staff member (V7) was texting with (R3). (V7) told (V10) he was not texting with anyone. (R3) gave me her phone. I found out (V7) was texting (R3) and trying to have a relationship with (R3). It did not look like anything sexually inappropriate at that time. I said to (V7), I thought you weren't texting (R3). I told (V7) he could not be an employee and have a relationship with (R3). (V7) decided to resign because he wanted to have a relationship with (R3) and was having feelings for (R3). I called (V3) and told (V3) that (V7) decided to resign. Later, I was told by (V3) that (V7 and R3) were having sex in the parking lot. V1 verified R3 and R6's care plans have not been updated with interventions to keep R3 and R6 safe from V7 and R3's medical record does not include an evaluation to determine if R3 has the ability to consent to sex.On 1/29/26 at 1:05 PM V17 (CNA/Certified Nursing Assistant) stated, There were several evenings that (V7) and (R3) were videochatting sexually back and forth in November. I would report this to the nurses anytime I witness them. I do not recall the nurses I was reporting this to as a lot of them were agency nurses and I do not know their names. I know it was inappropriate and should not have been happening. We (facility) staff were never told whether or not (R3) could consent to sexual relationships. Still today I am not sure if (R3) can consent to sexual relationships or not and have not been told that we need to supervise (R3).On 1/29/26 at 1:30 PM V10 (Prior Dietary Manager) stated, While I was the dietary manager at the facility I started noticing (V7) was not doing his job and spending a lot of time around (R3) in the day room and out on the patio. I asked (V7) about it and told (V7) it is not appropriate to have a relationship with a resident. Later, sometime in June (2025), (V7) came to me and said he was starting to have feelings for (R3). I immediately reported this to (V1). (V1) then asked (R3) if he could see her cellphone messages between (R3 and V7) and found out (R3) had more than one cellphone (V1) read the messages that were being sent back between (R3 and V7) while (V7) was an employee and (V7's) messages to (R3) were that (R3) was the love of his (V7's) life and (V7) wanted to get (R3) pregnant. (V7) was trying to have an intimate relationship with (R3). The next day after (V1) read the inappropriate text messages between (R3 and V7), (V7) was asked to resign.On 1/31/26 at 9:00 AM V29 (LPN/Licensed Practical Nurse) stated, I have been told (R3 and V7) were caught having a sexual relationship together which is a big no. A staff member should never have relationships with a resident. I have never been told that (R3) needs supervised with her electronics or using the phone. I also have not been told whether (R3) can consent or have sexual relations with other residents or not.2.R3's Emergency Department Notes dated 7/8/25 document, (R3) reports that she has been feeling suicidal for the past couple days. (R3) reports having thoughts of cutting her wrists in order to attempt suicide. (R3) reports that she was physically assaulted by two other (unknown) residents yesterday and has not been able to sleep since then. (R3) denies any injuries or complaints from that assault.R3's Medical Record and the facility's Abuse Investigations do not include evidence of R3's allegation on 7/8/25 being investigated or a final report being sent to the State Agency.On 2/1/26 at 9:15 AM V1 (Administrator) verified he found out about R3's allegation regarding being physically assaulted by roommates, after receiving R3's hospital records on 1/30/26. V1 stated he has not started an investigation into this allegation at this time.3. R6's Face Sheet documents R6 is a [AGE] year-old that was admitted to the facility on [DATE]. R6's MDS (Minimum Data Set) assessment dated [DATE] documents R6 is cognitively intact and has no behaviors. R3's Behavior Note dated 11/20/25 at 8:30 AM and signed by V6 (Psychosocial Rehabilitation Coordinator) documents, Another resident (R6) approached (V6) to report that (R3) was engaging in sexual conversation. When (R6) asked them to refrain from doing this while (R6) was in the room, the male (V7) on the call began cursing at (R6) and calling (R6) names. (R6) stated that incidents like this occur often, and it is making (R6) feel uncomfortable. R6's Progress Notes do not include any documentation regarding R6's alleged altercation with V7 on 11/20/25. On 1/28/26 at 12:05 PM R6 stated, I watched (R3) and (V7) having sex on her phone several times (unknown dates) and whenever I would try to make (R3 and R7) stop (V7) would yell at me and tell me to mind my own business and call me a b***h. I asked (R3 and V7) to stop. I didn't want to see or hear that. The last time I asked (R3) and (V7) to stop having phone sex, (V7) yelled at me, You b***h! You are going to get you're a** kicked. I told (V5/SSD/Social Service Director) that (V7) threatened me and has threatened me several times. I definitely felt abused and worried that (V7) would do something to me.On 1/28/26 at 12:51 PM V6 (Psychosocial Rehabilitation Coordinator) stated, On 11/20/25 (R6) reported to me that she saw (V7), who (R6) described as the little guy that used to work here, on a phone video with (R3) and (R3 and V7) were being provocative, having sexual inappropriate conversations, and having sexual acts. (R6) said she told (R3 and V7) to Knock that off. (R6) said (V7) began cursing at (R6) and told (R6) to Shut the f**k up and (R3) continued to yell at (R6). (R6) was frustrated. I reported this immediately to V1. I do not think (R6's) care plan has been updated to keep (R6) safe from (V7's) threats.On 1/29/26 at 12:40 PM V1 verified he has not investigated or submitted a final report to the State Agency regarding R6's allegations made on 11/20/25 regarding V7 and is not aware of R6's care plan being updated with interventions to keep R6 safe from V7.The Immediate Jeopardy started June 26 2025 when V1 became aware that (V7/Prior Dietary Aide) started engaging in behavior indicating an attempt to initiate a personal or romantic relationship with R3, while V7 was employed at the facility, and did not submit a final report to the state agency regarding V7's attempt to initiate a personal relationship with R3 or develop and implement interventions to keep R3 safe from V7 which resulted in V7 continuing to have sexually inappropriate conversations and video nudity by electronic communication with R3, and V7 sexually assaulting R3 on at least three occasions while R3 was attending church services. On 1/30/26 at 11:25 AM V1 (Administrator), V25 (Corporate Nurse Consultant), and V26 (Regional Nurse Consultant) were notified of the Immediate Jeopardy.On 2/3/26 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.V7 resigned from the facility on 6/27/25. 2. V1 initiated an abuse investigation into R3's abuse allegation dated 7/8/25 to IDPH on 1/31/26 and a final report will follow. 3.V1 initiated an abuse investigation into R3's abuse allegation dated 11/10/25 to IDPH on 1/31/26 and a final report will follow. 4. V1 initiated an abuse investigation into R3 and R6's abuse allegations dated 11/20/25 to IDPH on 1/30/25 and a final report to follow. 5. On 1/29/26 and 1/31/26 V5 (Social Service Director) completed assessments on R3's capacity to consent to sexual relations with the involvement of V3 (R3's Plenary Guardian), V35 (R3's Physician), and V36 (R3's Psychiatrist). The facility is still evaluating R3's capacity to consent to sexual relations and have implemented precautions to keep R3 safe. The facility also developed a plan to ensure R3 has staff supervision while using the facility phones to ensure safe communication with others. On 11/26/25 V3 (R3's Plenary Guardian) removed R3's phone from R3 and V3 restricted R3's church visits. R3's Care Plan was updated with interventions to increase R3's safety on 1/31/26. 7. On 1/30/26, the Quality Assessment and Assurance Committee met for an emergency QAPI (Quality Assurance and Performance Improvement) meeting and developed and implemented plans to ensure no further abuse occurred within the facility and all policies and procedures were followed correctly. 8. On 1/30/26 the facility's abuse policies were reviewed by the QA (Quality Assurance) committee prior to educating staff. 9. On 1/30/26 the facility's staff intimate relationships policy was reviewed by the QA committee. 10. On 11/19/25, 11/26/25, 1/13/26, and again on 1/30/26 V1, V2 (Director of Nursing/DON), and V38 (MDS Coordinator) educated all staff on abuse prevention and abuse reporting and all abuse related policies and procedures. 11. On 1/31/26 V25 (Regional Director of Operations) educated V1 on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of Abuse/Neglect/Exploitation Policy to IDPH. 12. On 1/30/26 V1, V2, and V38 educated all staff on maintaining professional boundaries with residents and staff are not to have any inappropriate relationship with residents. 13. On 1/28/26 through 1/31/26 R3 and R6's care plans have been updated with safety interventions to protect them from abuse. Completion Date: 1/31/26.

Based on record review and interview the facility failed to prevent misappropriation of a resident's controlled-substance medication for one of three residents (R8) reviewed for misappropriation of medications in the sample of seven. Findings include:The facility's Abuse, Neglect, and Exploitation Policy dated 2/3/25 documents, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent us of a resident's belongings or money without the resident's consent. R8's Face Sheet documents R8 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Major Depressive Disorder, Suicidal Ideations, Anxiety Disorder, Alcohol Abuse with Intoxication, Insomnia, and Muscle Spasms of the Back. R8's MDS (Minimum Data Set) assessment dated [DATE] documents R8 is cognitively intact. R8's Order Summary Report printed on 1/28/26 documents, Order Date 3/13/25: Norco (Hydrocodone-Acetaminophen) 10/325 mg (milligrams) one tablet by mouth every eight hours as needed for pain. The Pharmacy's Proof of Delivery and Packing Slip dated 12/6/25 documents 30 tablets of (R8's) Hydrocodone-APAP 10/325 mg were delivered to the facility on [DATE]. R8's Final Report dated 12/17/25 and signed by V1 (Administrator) documents, Incident Date: 12/9/25, (V2/Director of Nursing) noted (R8's) medication card missing. Pharmacy records show that the medication was sent on 12/6/25. The nurse (V28/Agency RN/Registered Nurse) receiving the medication states that she signed the medication in and appropriately stored the medication. This is backed by video evidence. Medication was reordered on 12/9/25 at 12:00 PM (and) was denied due to just being filled. Investigation initiated to verify delivery from pharmacy. Investigation includes video footage, interviews, and medication records. The investigation has narrowed down to an agency nurse (V19/Agency RN). This nurse (V19) has been DNR (Do No Return) from the facility as a precaution. (Local) police department has been given all requested information. V28's (Agency RN) statement dated 12/9/25 and signed by V33 (ADON/Assistant Director of Nursing) documents V28 received a delivery from pharmacy on 12/6/25 at 4:00 AM which include 30 tablets of R8's Norco (10/325 mg). This same statement documents V28 placed the 30 tablets of R8's Norco 10/325 mg in the medication cart. On 1/28/26 at 10:00 AM V2 (Director of Nursing) stated, On 12/8/25 when I came into work (V34/LPN/Licensed Practical Nurse) told me she tried to re-order (R8's) Norco from pharmacy and the pharmacy told (V34) the Norco could not be refilled because the Norco had been refilled and sent to the facility on [DATE]. I watched video footage and saw that (V28/Agency RN) received (R8's) Norco 30 tablets from pharmacy on 12/6/25 and put (R8's) Norco in the medication cart. By the time I found out (R8's) Norco was missing, two days had passed by. I did an audit of the controlled substance inventory sheets and noticed numerous nurses were not counting the controlled substances and cards at the beginning and end of their shifts like they were supposed to. I watched video surveillance and could not see if a nurse had stolen (R8's) Norco. In the video surveillance there are times the medication cart cannot be visualized. After I did an investigation, I determined that the only nurse that could have taken (R8's) Norco was (V19/Agency Nurse) because all the other nurses have worked here and we have never had missing narcotics. (V19) was the only new nurse that had worked. On 2/2/26 at 11:34 AM V28 stated, On a Friday (12/6/25) I received (R8's) Norco 10/325 mg 30 tablets from pharmacy. I put (R8's) Norco in the medication cart. I signed the pharmacy delivery sheets to confirm I received (R8's) Norco 30 tablets and when I left the facility in the morning around 6:00 AM (12/6/25) I counted all the controlled medications cards and pills and there were no discrepancies. That is the last time I worked.

Based on record review and interview the facility failed to properly store and account for a resident's controlled-substance medication for one of three residents (R8) reviewed for medication storage in the sample of seven.Findings include:The facility's Controlled Substance Administration and Accountability Policy dated 2025 documents, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substance. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel. Areas without automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use. Controlled substances are delivered to and signed for by a licensed nurse. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. The facility's Controlled Substance Inventory Count Sheets dated 12/6/25 through 12/9/25 document, Nurse coming on to shift must verify all controlled substance with nurse coming off shift or anytime the medication cart keys are exchanged. Nurse must count total number of cards/containers and total number of count sheet, both for individual residents and applicable contingency supplies with controlled drugs. Nurse must verify actual drug counts against each individual resident count sheet. Any discrepancies must be reported immediately to (V2/Director of Nursing/DON) or nursing supervisor. These same Inventory Count Sheets document two nurses did not count or verify the number of controlled substances/controlled substance cards within the medication cart for six oncoming/offboarding shifts between 12/6/25 and 12/9/25. The Pharmacy's Proof of Delivery and Packing Slip dated 12/6/25 documents 30 tablets of (R8's) Hydrocodone-APAP 10/325 mg were delivered to the facility on [DATE]. R8's Final Report dated 1217/25 and signed by V1 (Administrator) documents, Incident Date: 12/9/25. (V2/Director of Nursing) noted (R8's) medication card missing. Pharmacy records show that the medication was sent on 12/6/25.On 1/28/26 at 10:00 AM V2 (Director of Nursing) stated, On 12/8/25 when I came into work (V34/LPN/Licensed Practical Nurse) told me she tried to re-order (R8's) Norco from pharmacy and the pharmacy told (V34) the Norco could not be refilled because the Norco had been refilled and sent to the facility on [DATE]. I watched video footage and saw that (V28/Agency RN/Registered Nurse) received (R8's) Norco 30 tablets from pharmacy on 12/6/25 and put (R8's) Norco in the medication cart. By the time I found out (R8's) Norco was missing, two days had passed by. I did an audit of the controlled substance inventory sheets and noticed numerous nurses were not counting the controlled substances and cards at the beginning and end of their shifts like they were supposed to.

Based on record review and interview the facility failed to properly prepare and administer medications to prevent a significant medication error for one resident (R4) of three residents (R3, R4, and R5), reviewed for medication administration errors in a total sample of 21. These failures resulted in R4 receiving the wrong medication and being hospitalized for lethargy, heart rate in 40s, difficult to arouse, and subsequently being intubated.These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 9/10/25, the facility remains out of compliance at severity level 2 while the facility continues to educate the nursing staff on proper medication preparation and administration and conduct audits to ensure continued compliance.FINDINGS INCLUDE:The Facility's Medication Administration Policy, not dated, documents: 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug; c. Right dosage; d. Right route; e. Right time; f. Right documentation; 11. Review MAR to identify medication to be administered; 12. Compare medication source (bubble pack, vial, etc.) with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time; 14. Remove medication from source, taking care not to touch medication with bare hand; 17. Administer medication as ordered in accordance with manufacturer specifications; and 23. Correct any discrepancies and report to nurse manager.The Facility's Medication Error policy, not dated, documents: 3. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. The nurse assesses and examines the resident's condition and notifies the physician or care practitioner as soon as possible; b. Monitor and document the resident's condition, including response to medical treatment nursing interventions; c. Document actions taken in the medical record; d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor completes the incident or occurrence report.The facility's Medication Error Report Form, dated 8/15/25, document: Resident Name [R4]; Date/Time Error Occurred: 8/15/25 at 4:24 a.m.; Date/Time Error Discovered: 8/15/25 at 7:15 a.m.; Discovered by [V4/Licensed Practical Nurse-LPN]; Medication(s) involved: Vit[[NAME]] C 500 mg, ASA [aspirin] 81 mg, Claritin 10 mg, clonazepam 1 mg, Plavix 75 mg, fluoxetine 60 mg, Ibuprofen 600 mg, Lyrica 300 mg, MVI [multivitamin], Methocarbamol 750 mg, Seroquel 100 mg, and vitamin D3 5000 IU; Description of Error: Nurse gave another residents medications to wrong resident; and What symptoms, if any did the resident experience: lethargy, decreased BP [Blood Pressure].R4's Electronic Medical Record/EMR document R4's diagnosis to include: Hemiplegia, Poisoning by Unspecified Drugs Accidental, Bradycardia, Parkinson's Disease, Muscle Wasting, Acute Pain due to Trauma, Major Depressive Disorder, Crohn's Disease, and Acute Hepatitis C.R4's August 2025 Medication Administration Record/MAR document, on the 15th, V3/Licensed Practical Nurse-LPN, [after administering R5's medication to R4], administered R4's Carbidopa/Levodopa 25/100 two tablets, and Diazepam 5 mg. The MAR also document V4 gave R4 his 7:00 a.m. medications-Lexapro 10 mg, Celebrex 200 mg, Protonix 40 mg, Keppra 1500 mg, Metoprolol 50 mg, Morphine Sulfate Extended Release 15 mg, Carbidopa/Levodopa 25/100 2 tabs, Entacapone 200 mg, and Lacosamide 100 mg. R4's EMR progress notes document: 8/15/25, at 7:15 AM, this nurse [V4] was notified by resident [R5] that he saw the third shift B/E Hall nurse [V3] give his 5 AM medications to this resident. Resident stated he felt unwell this a.m. Resident laying bed and vitals checked, and resident noted to be hard to arouse and lethargic. [V8/medical doctor], 911, Local hospital], and brother notified.On 9/9/25, at 1:25 p.m., V2/Director of Nursing confirmed: On 8/15/25, V3 (3rd Shift Nurse) pre-popped [pre-prepared] and stacked residents' medications. R4 was subsequently administered R5's medications-Ascorbic Acid 500 milligram/mg, Aspirin 81 mg, Claritin 10 mg, Clopidogrel 75 mg, Fluoxetine 60 mg, Multivitamin, Seroquel 100 mg, Vitamin D3 125 ug (micrograms), Lyrica 300 mg, Klonopin 1 mg, ibuprofen 600 mg, Robaxin 750 mg; After realizing the error, V3 then administered R4's correct medication which included-diazepam 5 mg, carbidopa/levodopa 25/100 2 tabs; V3 did not report the error; V4/Licensed Practical Nurse/LPN 1st shift nurse administered R4's 7:00 a.m. medications-Lexapro 10 mg Celebrex 200 mg Protonix 40 mg, Keppra 1500 mg, Metoprolol 50 mg, Morphine Sulfate Extended Release 15 mg, Carbidopa/Levodopa 25/100 2 tabs, Entacapone 200 mg, and Lacosamide 100 mg; R5 then told V4 that V3 had given his medications to R4; and R4 was sent to the emergency room where R4 was admitted .R4's hospital documentation: 8/15/25 Emergency Room-Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: CNS [Central Nervous System] failure or compromise, metabolic crisis and respiratory failure; Hospital admission History & Physical-Admitting diagnosis: Medication overdose; and Discharge Summary, dated 8/18/25, document: [R4] was admitted after unintentional medication overdose given at facility. Patient noted to be lethargic, upon arrival is also bradycardic into 40s. Patient given Narcan x3 in ED and was protecting his airway and brought to ICU [Intensive Care Unit]. ICU attending when rounding on the patient noted that he had gone apneic and was difficult to arouse and patient was then intubated. He was extubated the following day and did well. He was started on a diet and his home medications and was at his baseline mental status.On 9/10/25, at 4:00 a.m., the State Agency entered the facility and found V5/Registered Nurse and V6/LPN had pre-prepared and stacked medicine cups on and in their medicine carts. Among the medicines, pre-popped, five resident med cups contained controlled medicines which were signed out on the narcotic log. V5 and V6 confirmed they should not have pre-prepared/stacked medicine cups.On 9/10/25, at 4:15 a.m., R4 stated, The facility tries to make me feel better by telling me that the nurse is no longer working, but it doesn't make me feel better. If [R5] didn't tell them [facility staff] I got the wrong medicine, I would be dead.On 9/10/25, at 1:55 p.m., V8/Regional Nurse confirmed the medication error should have been immediately reported and all medications held pending the medical doctor's approval.On 9/10/25, at 3:25 p.m., R5 confirmed he saw the nurse give his medicine, with pudding, to R4. He did not know that those were R5's meds at the time. Then the nurse, realizing her mistake, took the empty med cup which had R5's name written on it and said to R5, I suppose this is you? When R5 said, yes, she popped his meds out again and gave them to him. R5 went to the dayshift nurse [V4] and asked her if his meds were double punched, and when she said, yes, he told V4 that his meds had been given to R4.The Immediate Jeopardy began on 8/15/25, at 4:24 a.m., when V3 administered the wrong pre-prepared medications to R4. V1/Administrator was notified of the Immediate Jeopardy on 9/10/25, at 3:09 p.m.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R4's medical record confirms R4 was sent immediately to the emergency room, on 8/15/25, for treatment of lethargy and low blood pressure and remained in the hospital until 8/18/25.2. On 8/18/25, V3's employment, with the facility, was terminated and the incident reported to the State Nursing Board.3. On 9/10/25, An emergency Quality Assurance Performance Improvement (QAPI) meeting was held to review and interpret all audit findings, reviewed all procedures, review investigation, review root cause analysis, review all facts surrounding the incident. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. All applicable facility policies and procedures for medication administration were reviewed/revised by the QAPI team.4. On 9/10/25, V11/Assistant Director of Nursing re-educated licensed nurses on facility policies regarding Medication Administration as well as medication errors and medication administration reconciliation guidelines. All nurses were educated prior to working their next shift including agency nurses. Sign-in sheets were utilized.5. On 9/10/25, an audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V11 and continued.6. V8 verified the facility's contracted pharmacy service performed a med cart audit and medication administration audit on 9/10/25.7. The DON or designee will audit med carts on all shifts to ensure medications are being prepped and administered accordingly weekly for 4 weeks then bi-weekly for 2 months. The audits will continue until compliance can be maintained for 3 consecutive months.8. The DON or designee will educate all new hire licensed nurses on medication administration and reconciliation guidelines. 9. On 9/11/25, Education on Medication Administration and Medication Error sign in sheets and course material reviewed with no concerns.10. On 9/11/25, V12/LPN, V13/LPN, and V14/LPN, confirmed they had received education on proper medication preparation and administration procedures on 9/10/25.11. On 9/11/25, Medication Cart Audit was completed by [and observed by the State Agency] V12, V13, and V14's med carts. No concerns.Completion date 9/10/2025

Based on observation, interview, and record review, the facility failed to ensure nurses do not pre-prepare and stack clear medication cups (with meds) in/on medicine carts for 16 residents (R5-R21) of 16 residents reviewed for medications not being pre-prepared, in a total sample of 21. FINDINGS INCLUDE:Facility Policy, entitled Medication Storage, copyright 2025, document: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls; b. Only authorized personnel will have access to the keys to locked compartments; and c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.On 9/10/25, at 4:00 a.m., the State Agency entered the facility and observed V5/Registered Nurse and V6/LPN had pre-prepared and stacked medicine cups, with resident medication, on and in their medicine carts. Among the medicines, pre-prepared, five resident med cups (R8, R12, R13, R14, R15), along with non-controlled medication, contained controlled medicines which were signed out on the Controlled Drug Received/Record/Disposition Form.On 9/10/25, at 4:00 a.m., V5/Registered Nurse confirmed V5 should not have pre-prepared and stacked the clear med cups, containing residents' morning medication, on top of the medicine cart for R6, R7, and R8-R14. Additionally, V5 stated, I am forced to do that here because the type of residents who get mad when they are not ready and it takes time to pop them out one at a time.On 9/10/25, at 4:05 a.m., V6 confirmed V6 should not have pre-prepared and stacked the clear med cups, containing residents' morning medication for R15-R21, in the top drawer of the medicine cart.The individual medicine carts, Controlled Drug Received/Record/Disposition Form document the following controlled medicine was signed out, as morning medication, by V5 and V6: R8-Clonazepam 0.5 mg, R12-Ativan 0.5 mg, R13 Tylenol with Codeine 300/30 mg, R14-Ativan 1 mg, and R15-Ativan 1 mg.On 9/10/25, V1/Administrator confirmed V5 and V6 should not have pre-prepared resident medication, and they won't be back.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 91 residents in the facility. Findings include: The facility's Food Safety Requirements policy dated 2025 documents the following: Practices to maintain safe refrigerated food storage include: iv. Labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) discarded; d and v. Keeping foods covered or in tight containers. On 6/29/25 at 7:35am 11 individual servings of mixed fruit and two individual cups of applesauce were uncovered and undated on a shelf in one of the refrigeration units at the front of the kitchen. In the back refrigerated unit six cooked chicken breast servings were undated and wrapped in foil with open areas exposing the chicken breasts. On 6/29/25 at 8:10am V16 Dietary Manager verified refrigerated foods should not be stored undated or uncovered. On 6/29/25 the facility's Matrix documents 91 residents are currently residing in the facility.

Based on interview and record review, the facility failed to notify the state mental health authority to reevaluate residents when the Preadmission Screening and Resident Review (PASRR) approval had ended for six of 26 residents (R26, R41, R79, R81, R87, R498) reviewed for PASRR compliance in a sample of 42 residents. Findings include: The Resident Assessment-Coordination with PASARR Program policy, not dated, documents all applicants to this facility will be screened for serious mental disorders (MD) or intellectual disabilities (ID) and related conditions in accordance with the State's Medicaid rules for screening. A PASRR Level II is a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual and recommends any specialized services and/or rehabilitative services the individual needs. The PASRR Outcome Explanation Notice of Short-Term Nursing Facility Approval documents short term nursing facility services are approved for the length of time listed on the Notice of PASRR Level II Outcome that came with this letter. The Effective date on the Notice of PASRR Level II Outcome is the first approved day for you to enter a nursing facility. 1. R26's Notice of PASRR Level II Outcome dated 5/8/24 documents the short-term approval ended on 8/4/24. R26's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended. 2. R41's Notice of PASRR Level II Outcome dated 2/20/25 documents the short-term approval ended on 5/21/25. R41's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended. 3. R79's Notice of PASRR Level II Outcome dated 10/4/24 documents the short-term approval ended on 1/2/25. R79's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended. 4. R81's Notice of PASRR Level II Outcome dated 11/21/24 documents the short-term approval ended on 1/20/25. R81's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended. 5. R87's Notice of PASRR Level II Outcome dated 1/21/25 documents the short-term approval ended on 5/21/25. R87's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended. 6. R498's Notice of PASRR Level II Outcome dated 4/20/24 documents the short-term approval ended on 10/17/24. R498's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended. On 6/30/25 at 10:54 AM, V5 (Social Services Director) stated R26, R41, R79, R81, R87 and R498 were not reevaluated by the state mental health and should have been revaluated when the short-term approval had ended.

B. Findings include: Facility Fall Prevention Program, dated 2024, documents: each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls; the nurse will indicate on the Resident's fall risk and initiate interventions on the Resident's base line care plan, accordance with the Resident's level of risk; each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care; and interventions will be monitored for effectiveness and the plan of care revised as needed. 1. R24's Fall Report (#410), dated 12/22/24, document a fall in R24's bathroom hitting head on tub. The Report or R24's Care Plan does not document fall interventions. R24's Fall Report (#411), dated 12/26/24, documents a fall in R24's bathroom (communal bathroom). R24 was ambulating without assistance and got up from the toilet, went to sit in wheelchair, feet slipped on wet floor and sat himself down. The intervention was to place non-skid strips in front of toilets in communal bathroom. R24's Fall Report (#412), dated 12/30/24, documents R24 slipped out of bed, mattress to bed noted to be displaced, bed in lowest position. The Report documents an intervention of non-adhesive pad to the bed frame. R24's Fall Report (#493), dated 6/13/25, documents R24 attempted to transfer self to bed and slipped out of the chair. The Report documents that non-skid strips to left side of the bed/opposite side of bed from the bathroom. 2. R25's Fall Report (#427), dated 3/2/25, documents R25 was found sitting on the floor in front of recliner and the intervention was for non-skid strips in front of recliner. 3. R72's Fall Report (#428), dated 2/14/25, documents R72 had fallen out of bed and needed assistance and the intervention was a perimeter/scooped edge mattress. On 7/1/25 at 11:45 am, V2 (Director of Nursing/DON) did a tour of R24's R25's and R72's rooms and communal bathroom, and verified that no fall interventions were in place. R24's non-skid strips in bathroom, non-skid strips by bed and non-adhesive to R24's bed frame were not in place. R25's non-skid strips in front of the recliner were not in place. R72's perimeter/scooped edge mattress were not in place. V2 stated, I just came here not long ago to work and I do not know why none of these interventions are in place. I have not had a chance to review all of the falls here yet, that is on my list of things to do so these things do not happen. Facility failures resulted in two deficinct practices. A. Based on interview and record review the facility failed to accurately assess one resident (R87) for smoking safety and the facility failed to follow facility smoking policy for one resident (R87) of two residents reviewed for smoking in a total sample of 42. B. Based on observation, record review and interview the Facility failed to implement documented fall interventions for three of four Residents (R24, R25 and R72) reviewed for Falls in a sample of 99. A. Findings include: R87's Resident Smoking Contract/Agreement dated 1/22/25 documents: You must first be evaluated for smoking safety skills before you obtain your smoking privileges. Marijuana/cannabis/gummies/THC/edibles are not allowed in (the facility) building. There is absolutely no use of vapes or any kind of tobacco product inside (the facility) or in any (facility) vehicle. All smoking materials must remain locked in a secure designated location when not in use. R87's medical record documents R87 was admitted [DATE] with diagnosis to include, but not limited to: Schizoaffective Disorder, Bipolar Disorder, Depression, and Suicidal Ideations. R87's progress notes dated 02/14/2025 at 9:37 PM documents: This nurse was doing med pass and smelled marijuana in the hall, checked rooms, the smell was the strongest in this resident's room. The resident admitted that he had a marijuana vape and turned (it) over to the nurse and was very sorry for what he did. R87's progress notes dated 02/15/2025 at 2:52 am documents: Checking on resident, had another vape in his hand while sleeping, this nurse woke resident up with aide in room and asked for the vape that was in his hand, handed it over to the nurse and went back to sleep. R87's progress notes dated 02/27/2025 at 1:50 PM documents: Resident was informed it is against facility policy for him to have a lighter in his room. He explained he wanted to hold on to it due to sentimental value. He was informed his lighter would be labeled with his name and put in the social services file cabinet. R87's progress notes dated 03/12/2025 at 11:17 PM documents that Nicotine vape juice, a lighter, (and) (marijuana) edibles found in resident's room (and) placed in (medication) room. Administrator notified. R87's progress notes dated 03/28/2025 at 2:54 am documents: CNA (Certified Nurse's Aide) was doing 15 (minute) checks, and resident had obtained a vape, which was in his bed. CNA came and got the nurse; Nurse woke resident up and requested that he hand it to her. Resident handed this nurse the vape with no altercation. Resident then went back to sleep. R87's Smoking and Safety assessment dated [DATE] documents: follows facility's policy on smoking times and location. On 7/1/25 at 12:30 PM V14 (Chief Nursing Officer) stated that Smoking and Safety Assessments should be done on admission and quarterly. V14 confirmed that R87's Smoking and Safety assessment dated [DATE] was not marked correctly because R87 had multiple documented incidents of noncompliance with smoking policy. On 7/1/25 at 12:35pm V5 (Social Service Director) confirmed R87's noncompliance with the facility's Smoking Policy. V5 confirmed there was not any documentation to confirm that facility followed Resident Smoking Policy to ensure R87's safety.

Based on record review and interview the facility failed to prevent staff to resident sexual abuse and mental abuse for one of three residents (R1) reviewed for abuse in the sample of four. These findings resulted in R1 being subjected to bribery with alcohol and drugs and sexual abuse by V3 (CNA/Certified Nursing Assistant) on more than 100 occasions, R1 suffering fear and depression, and R1 requiring prophylaxis for prevention of STDs (Sexually Transmitted Diseases). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 6-1-24 when V3 started bribing R1 with alcohol and drugs and started sexual abusing R1 within the facility. V1 (Administrator), V15 (Regional Director of Operations), V17 (Corporate Nurse) were notified of the Immediate Jeopardy on 2-3-25 at 11:00 AM. While the immediacy was removed on 2-3-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse, Neglect, and Exploitation dated 2024 documents, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility's Agreement with the Employees International Union Healthcare Illinois/Indiana dated 5-1-22 through 5-30-25 documents, These work and safety rules and regulation shall be applicable to each facility and its employee in the bargaining unit. It is essential to the successful operation of the facility's business and the welfare of its patients and employees that fairly established standards of discipline, health, safety, attendance, workmanship, and honesty be maintained. Employees shall have an opportunity to sign formal warning, acknowledging that such warning has been given and to comment on such warning. Maintaining or attempting to maintain a relationship (whether or not consensual) with a resident that is sexual or romantic in nature unless the resident is the employee's spouse. First offense-Discharge. R1's Pre-Admission Hospital History and Physical dated 5-1-24 documents, Chief Complaint: Suicidal Ideation. (R1) is a [AGE] year-old with past reported psychiatric history of Bipolar I Disorder with Psychotic Features, stimulant use disorder (methamphetamine), and alcohol use disorder admitted voluntarily for suicidal ideation in the context of methamphetamine use. (R1) has been non-adherent with medication and utilizing methamphetamine which is likely a significant exacerbating factor. The patient warrants inpatient level of care for safety and stabilization. R1's Admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Bipolar Disorder Severe with Psychotic Features, Suicidal Ideation's, Major Depressive Disorder, Persistent Mood Affective Disorder, Hallucinations, and Psychotic Disorder not due to a substance or know Psychotic Condition. R1's current Physician's Orders document, 24-hour nursing care. Mirtazapine 30 mg (milligrams) one daily at bedtime for the Major Depressive Disorder. Hydroxyzine HCL (Hydrochloride) 50 mg twice daily for Anxiety. Alprazolam one mg three times daily for Anxiety. Aripiprazole 15 mg one time daily for Bipolar with Severe Psychotic Features. R1's Brief Interview for Mental Status dated 1-8-25 documents R1 is cognitively intact. The facility's Serious Injury Incident and Communicable Disease Report dated 1-29-25 documents (R1) reported that (V3/CNA) has been having inappropriate sexual encounters with (R1). (V3) previously resigned from her position. Last day to work was 1-7-25. (Local) police department notified. (Primary Care Physician) notified. Investigation initiated. Final to follow. R1's Hospital Emergency Department Notes dated 1-29-25 and signed by V16 (Hospital Physician) document, Primary diagnosis: Sexual assault of adult. (R1) reports he is here for a rape kit. (R1) reports for something that happened three weeks ago. (R1) reports he has showered and changed his clothing. (R1) reports police have been notified and wanted him to have a rape kit. (R1) reports he just showed them the video. (R1) is from a nursing facility and reports the person was a worker but no longer is employed at the facility. RN (Registered Nurse) spoke with the charge nurse at (the hospital). Due to (R1) reporting this happened three weeks ago, (R1) wouldn't be in the time frame for a rape kit. Medical Decision Making: I (V16) have evaluated (R1) and performed medical screening exam. Evidence was not collected. I have discussed all information regarding the risk of contracting sexually transmitted infections as well as the possibility of pregnancy, as applicable, Prophylaxis for gonorrhea, chlamydia, and trichomonas was given. (R1) declined baseline HIV (Human Immunodeficiency Virus) test, (R1) declined other STD testing as noted in orders. Counseling: You (R1) are a survivor of sexual assault. You may have trouble sleeping. You may have anxiety, irritability, depression, and other symptoms. This is normal. They are reactions to trauma. You can get help. Rape crisis centers have free counseling services. R1's Police Report Incident Number 25-003634 dated 1-29-25 at 3:44 PM and signed by V5 (Local Police Officer) documents, On January 29, 2025, at 3:44 PM I (V5) was dispatched to (the facility) in reference to a Criminal Sexual Assault. During the investigation, the victim (R1), also admitted to sending video of the sexual encounters to other people who work at (the facility). (R1) and (V3), an ex-employee, have been having sexual intercourse for the past six months and just recently stopped having sexual encounters after (V3) quit on January 7, 2025. (R1) would also state they (R1 and V3) have had sex approximately 50 times or more. (R1) stated he felt threatened by (V3) and that (V3) has said on several occasions that (V3) could get (R1) kicked out of (the facility) if (R1) did not do what (V3) wanted him to do. (R1) stated (V3) would come into his bedroom, while he was sleeping, and started giving him blow***s. (R1) would wake up and push (V3) away and she would continue to give (R1) a blow**b. (R1) advised that (V3) would also help him with his showers due to him not being able to reach his right side with how badly his left arm is injured. (V3) would help him in the shower and while helping him in the shower (V3) would get naked and bend over so (V3 and R1) could have sex. (R1) stated (V3) would take him to her friend's residence who lived close to the nursing home when (R1) was able to leave on his own time. (R1) and (V3) would go to her friend's residence and have sex, along with (R1) recording some of these sexual encounters happening. (R1) stated the last time (R1) had a blow**b or sex with (V3) was before (V3) quit on January 7, 2025. When (R1) was asked about the recordings he stated he advised (V3) about the recordings and (V3) was okay with him recording the two of them. (R1) showed (V5) one of the videos of (V3) giving (R1) a blow**b in (R1's) room inside (the facility). (R1) stated (V3) would send pictures and videos back and forth of the two masturbating on several occasions. (R1) advised he would like to go to the hospital and have a sex assault kit done.(V1/Administrator) and (V15/Regional Director of Operations) stated they would arrange transportation for (R1) to get to the hospital. (R1) advised he was supposed to leave and spend time with (V3) on January 27th, 2025, but (V3) had canceled plans. (R1) advised he was upset with (V3) due to her not being able to spend time with him. (R1) advised he was feeling down and upset on January 28, 2025. While feeling like this (R1) finally told an employee about the sexual encounters between him and (V3). (R1) stated he recorded the two (R1 and V3) having sexual encounters several times with (V3's) permission. (V3) sent the videos via (social media). Once (R1) sent the video to one employee, other employees started to ask (R1) for the video to be sent via (social media). (R1) stated he sent the videos to several employees including (V11/CNA), (V12/CNA), (V13/LPN/Licensed Practical Nurse), and (V14/LPN). R1's updated Care Plan dated 6-4-24 to current documents, Focus: I am at risk for abuse/neglect/exploitation related to my SMI (Serious Mental Illness) diagnoses of Bipolar Disorder with Psychotic Features, Major Depressive Disorder, and Anxiety. Goal: I will verbalize to staff any instanced of abuse/neglect/exploitation through the next review period. Interventions/Task Provide care in a manner consistent with training and (facility) policies and procedures as appropriate to responsibilities and job tasks. Provide re-assurance if negative feelings occur. Provide regular opportunity for me to communicate my choices, preferences, needs/wants, related to my care and opportunity for me to express my concerns about care. Report any verbalization of abuse/neglect/exploitation to administrator immediately. Focus: Due to personal report of trauma history, I benefit from trauma informed care. I shared that my three-month-old daughter accidentally suffocated after my ex-wife put her in bed with her after coming home from work near Christmas of 2016. Goal: I will share my trauma related history and the challenges it presents to the degree I am comfortable in order to begin the healing and recovery process through the next review. Interventions/Tasks: Encourage me to participate in group/individual psychotherapy/counseling. Monitor of signs/symptoms of PTSD (Post Traumatic Stress Disorder), document, and notify my IDT (Inter-Disciplinary Team) including therapist as applicable, psychiatrist, and Primary Care Provider. Respect my choices/wishes. Offer care and assistance in a way that promotes re-assurance, comfort, choice, dignity, and safety. On 1-31-25 at 1:30 PM R1 stated, Around six months ago (June 2024) V3 (CNA) would bring me in alcohol, gummies, and vapes (electronic cigarettes) in to trade for sex. We would have sex in my room with other residents in the room. (R2) caught us several times. We have had sex almost every time (V3) has worked, over 100 times. I would have to have sex when she wanted to, or she would cut me off from vapes or anything else I wanted. It was a threat over my head. I have not had sex with any other residents here. A couple times I woke up to her giving me h**d. I told her to knock it off and she continued to give me h**d. She would say she is union, and they can't fire her, and the facility would never believe anything she said. I recorded with my phone when she would give me oral sex. I felt like she was the one in power. She initiated the sex the first time and the last time. She would bribe me with home visits and would sign me out. She would meet me at the corner of the building so staff would not see us. I went to her house twice and had sex and sex at a hotel once. We would have normal sex and oral sex. She even told me she was pregnant with my child and had a miscarriage. That caused me severe depression as I have had a child of mine die in the past. I have not spoken to her in the last three days. I have blocked her on all accounts. I lived at an apartment prior to here. The police officer said it was the best thing to do was to go to the hospital for a rape kit. The hospital said it had been over three weeks so there was really no reason to do a rape kit since I have showered, and all the evidence would be gone. She would bring me in alcohol and vapes as a bribe for sex. Once in a while she would bring me in THC (Tetrahydro-Cannabinol) gummies. I am not aware of her having sexual relations with any other residents. I showed some staff the videos because the staff asked me to send them to them. I sent videos to staff on Monday. On 1-31-25 at 12:55 PM V1 (Administrator) stated, On Wednesday (R1) reported to me that he felt coerced and raped by (V3). When (R1) reported it on Monday to me, (R1) did not report feeling coerced or raped by (V3). As soon as (R1) reported sex with (V3) as not being consensual, I notified the police and the physician. (R1) was interviewed by the police for three and a half hours. We (the facility) sent (R1) to the hospital to have a rape kit done. A rape kit could not be done since it had been over three weeks since (R1 and V3) had sex. Staff having sex with residents is against company policy and against the employees' union agreement. (V3) had not worked here since January 3, 2025, as (V3) quit after I had suspended her after having reports that (V3) was bringing in CBD (Cannabidiol) gummies to the residents. On 1-31-25 at 2:10 PM R2 (R1's roommate) stated, I would hear or see (V3) and (R1) having sex almost every time (V3) worked. I would tell (V3) that it was going to catch up with her and (V3) was going to get fired. I would see (V3) bring in alcohol, vape pens, and weed to (R1). A couple times I heard (R1) say he did not want to have sex and (V3) told (R1) if he didn't want to have sex anymore she was not going to bring him in any more alcohol or vapes. It really bothered me that (R1 and V3) would have sex in my room. On 1-31-25 at 2:20 PM V6 (LPN) stated, On Saturday night (R1) showed me a video of (V3) performing oral sex on (R1). I was not sure if it was consensual. It is not ethical and against company policy for a staff member to have sex with a resident. (R1) said (V3) had been having sex with him for months. On 1-31-25 at 2:30 PM V7 (R1's Primary Physician) stated, (R1) should not be subjected to sex from a staff member. That is unethical and abuse. Staff should not be bringing in drugs or alcohol to the residents. On 1-31-25 at 4:40 PM V12 (CNA) stated, Either last Saturday or Sunday (R1) told me (V3) was having sex with (R1) while (V3) was working within the facility. (R1) sent a video on Monday to my (social media) and I saw (V3's) face plain as day, in (R1's) bed, performing oral sex on (R1). That is not okay. On 1-31-25 at 5:10 PM V14 (CNA) stated, (R1) told me Sunday night that (V3) was having sex with (R1) in his room with (R1's) roommates in the room. (R1) said for the past six months (V3) would bring him alcohol and THC edibles and have sex with (R1) while (V3) was supposed to be working. (R1) said (V3) had told him she (V3) was pregnant with his child and then told (R1) she had a miscarriage. That was terrible as (R1) has lost a child in the past and was very upset. It is not appropriate for staff to be bringing in drugs and alcohol to the residents or have sex with the residents. (R1) sent me a video on my (social media) and the video was (V3's) face and (V3) was giving (R1) a blow**b while in (R1's) bed. There was also a picture of (V3) in the facility's shower room. (V3) had her shirt raised, exposing her breasts to (R1). (V3) was manipulating (R1). On 2-1-25 at 12:00 PM V13 (LPN) stated, (R1) showed me a video on Monday night of (V3) performing oral sex on (R1). It was disgusting. I could see (R1's) face in the video and could tell by the surrounding they (R1 and V3) were in (R1's) bed. (R1) said (V3) would bring (R1) in alcohol and drugs for sex. (R1) said (V3) would have sex with him almost every night she worked. (R1) seemed upset while telling me about it. That is so inappropriate. Staff should never have sex with residents. On 2-1-25 at 1:00 PM V11 (CNA) stated, (R1) sent me a video on (social media) of (V3) giving (R1) a blow**b. I could tell it was (V3) on the video. Staff should not have sex with residents. On 2-4-25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The Administrator (V1) or designee immediately ensured the safety and well-being of the (R1). V3 was no longer employed with the facility as of 1-7-25. 2. On 1-29-25 V1 initiated and abuse investigation into R1's abuse allegation. 3. On Upon notification of the allegation on 1-29-25, police were notified and R1 was sent to the emergency room for evaluation and examination. 4. As of 02-03-25 V1 or designee educated all staff on what constitutes all forms of abuse and bribery. 5. As of 02-03-25 V4 (Social Service Director) completed an Abuse/Neglect/Trauma screening on all residents and any resident who triggered at risk for abuse neglect, or trauma was educated on what to report and who to report to. 6. On 02-02-25 the quality assessment and assurance committee developed and implemented plans to ensure further abuse and bribery of the residents does not continue within the facility. 7. On 02-03-25 the abuse policies were reviewed and revised by the quality assurance committee prior to educating staff. 8. On 02-03-25 a root cause analysis was completed for the alleged sexual relationship that occurred between R1 and V3. 9. V1 received education on 2-1-25 from V15 (Regional Director of Operations reporting abuse timely and thoroughly investigating all abuse allegations. 10. All newly hired staff and agency staff will be educated by V1 (Administrator), V20 (Director of Nursing), or designee prior to the start of their shift on abuse prevention and reporting as well as what constitutes bribery, prohibiting staff from providing contraband to residents, and maintaining professional boundaries with residents, staff not having a physical relationship with residents, and for staff to not request or view photos or videos of residents. Completion date: 2-3-25

Based on observation, interview and record review the facility failed to place the COVID-19 positive residents and the exposed roommates on transmission based precautions, failed to ensure staff wore required PPE (Personal Protective Equipment) with direct care during a COVID-19 outbreak, failed to place COVID positive residents in a dedicated COVID unit with dedicated staff, failed to ensure required infection control signage was on COVID positive resident doors, failed to keep the door closed for a resident with COVID-19, including a resident receiving aerosolized oxygen via [CONDITION(S)] mask on droplet isolation precautions, failed to ensure the chemical dishwasher was functioning according to manufacturer's recommendations, and failed to utilize disposal tableware for residents on transmission based precautions. These failures resulted in the facility having a widespread COVID 19 infection outbreak with 79 residents becoming infected with COVID 19 and two residents of those 79 residents, being hospitalized for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures have the potential to affect all 92 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1-25-22, the facility remains out of compliance at Severity level II as the facility continues to implement a COVID-19 dedicated area with dedicated staff, ensure the dishwasher has the required amount of Chlorine and/or use paper products for COVID-19 positive residents, continues to implement their revised COVID-19 Testing policy, and continues to implement their Quality Improvement auditing tool regarding compliance with COVID-19 appropriate use of PPE, correct isolation signage. Findings include: The Facility's Infection Control Policy and Procedure for COVID-19 Facility Response Strategy revised 1/21/2022 documented the following: Universal PPE (Personal Protective Equipment) If a resident is suspected or confirmed to have COVID-19, or is an unvaccinated resident identified to be close contact, HCP (Health Care Personnel) must wear and N95 respirator, eye protection, gown, and gloves. When community transmission levels are substantial or high (HCP) must wear a well-fitted mask and eye protection. This same policy documents the following under the section titled, Management of Residents with Confirmed COVID-19; Resident placement-single room, door closed (if safe to do so), designate a separate area or unit as a COVID-19 unit, isolate using transmission-based precautions, monitor the resident every four hours, dedicate HCP to the COVID-19 unit if possible (including environmental services or housekeeping staff), staff wear full PPE (N95 respirator, gown, gloves, eye protection); communal dining-not allowed in communal areas. Dining should occur in resident room. Group activities-resident should not participate in group activities until recovered. On 1/23/22 at 7:45 a.m. upon entrance to the facility a warning sign was posted on the door that the facility had COVID-19 positive cases in the facility. On 1/23/22 at 8:05 a.m. a tour of the facility was conducted and there was no dedicated COVID-19 unit set up in the facility. On 1/23/22 at 8:30 a.m. V1 (Administrator) provided a facility room roster highlighting seven residents (R9, R19, R59, R65, R76, R80, R81) that are positive for COVID-19 at this time. V1 stated the facility does not have a COVID-19 unit. V1 stated the seven positive residents reside on three different halls throughout the facility. On 1/23/22 and 1/24/22, during the noon meal hall tray pass, the residents on transmission-based precautions were served their meal on regular tableware and not disposable tableware. On 1/23/2022-1/25/2022 from 8:30 am-3:00 pm residents were observed in group activities, communal dining and/or socializing without social distancing and some residents without wearing masks. On 1/23/22 at 9:00 a.m., R9 and R80's room door had a droplet isolation warning sign posted, oxygen in use sign on the door, and the door was wide open. On 1/23/22 at 9:02 a.m., R9 stood up and walked towards the door within approximately three feet of the door to the hallway and entered the bathroom independently. On 1/23/22 at 9:05 a.m., R80 had a [CONDITION(S)] with a blue corrugated tube running to a machine on the over bed table. R80 coughed numerous times during this observation. R80's current computerized Physician Orders, documents to administer Oxygen 6 liters per minute with 35% aerosol per [CONDITION(S)] mask. On 1/23/22 at 7:45 A.M., V6/Licensed Practical Nurse (LPN) was sitting at the facility's main Nurse's Station, located adjacent to the Main Dining room. Seven residents were present, at tables, in the Dining Room. V6/LPN wore only a surgical mask. V6/LPN did not have an N-95 mask or a face shield on. When asked, V6/LPN stated, We currently have COVID positive residents in our building. On 1/23/2022 at 8:15 A.M., V7/Activity Assistant (AA) was passing breakfast trays on the facility E-Hall wing. V7/AA wore an N-95 mask. V7/AA did not have a face shield on. V7/AA entered R59 and R76's room without performing hand hygiene prior to entering the room or prior to exiting the room. On 1/23/22 at 10:00 am., R19 was in his room with his roommate (R65). R19 stated, (R65) had infection (COVID-19) a while back and (I) was asked to move out of the room and (I) told staff (I) did not want to move so they left me in here. (I) now have the infection. R19's door was open with no isolation sign on the door with staff and residents having to pass by the open room to enter B hall and to enter C hall. R19's room is located at the entrance of B hall and has to be passed to enter C hall. On 1/24/22 at 9;30 am., R19's room door was wide open with R19 sitting in his wheelchair next to the doorway without a mask. R19 can propel himself. At this time residents from B and C hall, and staff were walking by R19's room heading towards and or out of the dining room. On 1/24/22 at 9:43am., V4 (CNA/Certified Nursing Assistant) was in the dining room talking to R73. V4 was not wearing any face shield/goggles at this time. At 9:47am., V4 was still talking to R73 without her face shield or goggles. At this same time R53 was sitting at a table next to R73 with his mask under his nose. On 1/24/22 at 9:50am., V5/CNA was walking down one of the halls from the breakroom. V5 did not have a face shield, or any goggles on at this time. V5 stated, (I) have my goggles up front, but the building is clear of COVID at this minute anyway and (I) have been vaccinated. On 1/25/22 at 9:00 am., V15/Activity Director was standing at the nurse's desk in the dining room with several staff and residents with no goggles on. V15 stated, (I) should have had my goggles on. On 1/24/2022 at 12:40 pm V34, CNA (Certified Nursing Assistant) was in the dining room standing at the serving window with her eye goggles situated on the top of her head. V34, then proceeded to walk from the dining room down C Hall with her eye goggles still on the top of her head. On 1/23/22 at 8:15 a.m., V3, Licensed Practical Nurse stated he was in charge of part of B Hall and all of C Hall. V3 stated that the only resident that was still on COVID-19 isolation was R81. On 1/23/22 at 9:00 a.m., V3, Licensed Practical Nurse stated, I was wrong about the residents that I have on isolation. V3 stated in addition to the one I already told you (R81), R9 and R80 share a room and are still in isolation for COVID-19 diagnoses. On 1/24/22 at 9:43am., V4 stated she just returned from break and her goggles were on C-hall (where she is scheduled to work) and she will put them on when she gets back to that hall. V4 verified she has to walk through B-hall to enter C-hall past R19's room. (COVID Positive Resident). On 1/24/2022 at 10:25 am V1, Administrator and V2, ICP (Infection Control Preventionist) were interviewed. V2 stated the first staff to test positive was V13, Dietary Aide who is responsible for preparing desserts and drinks to be served to the residents. V2 stated V13 was PCR (Polymerase Chain Reaction Test) tested on [DATE] and the results came back positive from the lab on 12/16/2022. On our regular testing date 12/21/2022 V12, CNA (Certified Nursing Assistant) was PCR tested for COVID. On 12/23/2022 V12's PCR COVID test results came back positive. On 12/28/2021 V2, ICP stated she rapid COVID tested all the residents on C hall due to V12 being assigned to C Hall. V2 stated she was unsure if V12, CNA went anywhere else in the building during her shift. V2, ICP stated on 12/28/2021 R83 and R90 were PCR (Polymerase Chain Reaction) COVID tested . V2 stated R83's COVID test came back positive on 1/1/2022 and R90's COVID test came back positive on 1/2/2022. V2 stated the facility had a designated COVID hall in the beginning but then once The COVID started spreading through the facility they just kept residents in the rooms they were in. V2 stated if a resident had a roommate, they completed a rapid COVID test on them but if they were negative, they still left the roommates together because, what is the point of moving them, they have already been exposed. V2 stated she was advised not to stop communal dining and activities per CDC (Center for disease control) guidelines. V2 stated R5, R7, R12, R22, R23, R36, R50-R52, R55, R56, R61, R77 and R346 have not had positive COVID test results. V2 stated the other 79 residents residing in the facility had already contracted COVID-19. V2, ICP stated the facility did not assign dedicated staff to COVID 19 positive residents. V2 stated there are not any residents who are bedfast and that the majority of the residents in the facility are ambulatory. V2, stated staff are to wear eye protection and N95 masks if there is any COVID-19 in the facility. V2 stated when caring for COVID-19 residents' staff should wear N95, eye protection, and a gown. On 1/25/2022 at 2:20 pm V33, LHD (local health department) stated the following: There have been a lot of discrepancies with the facility's COVID-19 reporting and timing of communication. The only information I have received is from V1, (Administrator) was regarding accepting new admissions while the facility was in a COVID-19 outbreak. V33 stated V2, ICP (Infection control Preventionist) has never contacted V33 regarding COVID-19 outbreak or guidance. R86's Admission History and Physical Report from the local hospital, dated 1/1/22, documents, (R86) is a [AGE] year-old male with a history of being a nursing home resident secondary to Mental Illness, Type 2 Diabetes, [CONDITION(S)], Chronic Obstructive Pulmonary Disease, and Hypertension who was sent to the emergency room apparently for concern of altered mental status, was found to be septic with a heart rate above 100 and a temperature of 102.8 as well as being COVID positive. Assessment and Plan, Principal Problem: COVID-19. [CONDITION(S)] secondary to COVID-19 with dehydration and lactic acidosis-Intravenous therapy hydration. R43's Critical Care New Consultation Note from the local hospital, dated 1/7/22, documents, (R43) is a [AGE] year-old male initially admitted for respiratory arrest secondary to COVID-19 and bacterial pneumonia. Plan: Repeat ABG/Arterial Blood Gas in one hour, [MEDICATION(S)] and [MEDICATION(S)] for sedation, [MEDICATION(S)], Follow-up sputum culture, titrate oxygen to Sp02 (Oxygen saturation) to 88-92%, Trend troponin, Limited Echocardiogram, [MEDICATION(S)] 6 mg (milligram) QID (four times daily), Repeat chest X-ray tomorrow. On 1/23/2022 at 11:30 A.M., V20/Dietary Services Manager stated, We don't use disposable serving ware. It's not in our budget. The Manufacturer's Recommended booklet, provided by V1/Administrator documents, Machine Operational Requirements as manufactured by dish machines: Required 50 PPM (parts per million) chlorine. On 1/23/2022 at 11:50 A.M., V8/Cook and V11/Dietary Aide were preparing to serve the facility Noon meal. V8/Cook placed the meal on a plastic plate, covered the food with a reusable, plastic dome and placed the plate on an open serving cart. At that time, both staff members stated they do not serve meals on disposable serve wear as instructed by the dietary manager. V8/Cook further stated that the facility did not have disposable serve wear available for use. On 1/24/2022 at 8:36 A.M., V9/Dietary Aide was placing soiled breakfast dishes in dishwashing trays and sending them through the facility chemical dishwashing machine. Multiple attempts to check the required parts per million of chemical sanitizer resulted in the chlorine test strip remaining white (no chemical sanitizer being detected.) The unsanitized dishes were then placed on a metal, rolling cart and taken into the facility kitchen. At that time, V3/Dietary Services Manager stated, We have been having problems with that machine. An Immediate Jeopardy was identified on 1-25-22 at 3:16 PM. The Immediate Jeopardy began on 1-23-22 when staff were unable to identify which residents were COVID-19 positive, COVID-19 positive residents were located on multiple halls, incorrect isolation signage was on residents doors, no signage on some doors, a dedicated COVID-19 area was not established, staff were not utilizing required PPE, and ensure chemical dishwasher was functioning. On 1-25-22 at 3:16 PM V1 (Administrator) and V29 (Director of Operations) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A COVID-19 dedicated unit with dedicated staff was established with appropriate isolation signs and equipment. Disposable utensils were put in place for COVID-19 residents. The dish machine was tested to ensure correct chemical PPM of chlorine. 2. The QAPI (Quality Assurance and Performance Improvement) committee reviewed and revised the COVID-19 policy, infection control and PPE. 3. V35 (Registered Nurse/Chief Nursing Officer) completed in-service training on 1-25-22 with all staff including the Administrator, Director of Nursing, and Infection Preventionist regarding infection control processes, PPE donning and doffing, hand washing, COVID-19 precautions and COVID-19 signs and equipment. 4. The facility created a Quality Improvement auditing tool regarding compliance with COVID-19 isolation requirements, staff knowledge of COVID-19 positive residents, proper signage and equipment in isolation rooms, staff utilizing appropriate PPE and hand hygiene per facility policy. This plan will be implemented at lease three times a week for a period of three months by the Director of Nursing, Assistant Director of Nursing or designee. Completion Date 1-25-22.

Based on record review and interview the facility failed to follow up on staff and resident COVID-19 (Coronavirus Disease 2019) laboratory (lab) reports within 48 hours once an outbreak of COVID-19 was identified and failed to initiate alternative testing procedures when experiencing a delay in obtaining lab reports to prevent further [CONDITION(S)] transmission of COVID-19. These failures resulted in COVID-19 positive staff working directly with the residents and residents with COVID-19 not being isolated promptly, causing an outbreak of COVID-19 within the facility. These failures have the potential to affect all 92 residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1-26-22, the facility remains out of compliance at Severity level II as the facility continues to POC (rapid point of care) COVID-19 test all residents and staff who have not had COVID in the last 90 days every three to seven days until there are no new cases for 14 days, continues to implement their revised COVID-19 Testing policy, and continues to implement their Quality Improvement auditing tool regarding compliance with COVID-19 testing every week for three months. Findings include: The Centers for Medicare and Medicaid Services Interim Final Rule, CMS-3401-IFC, Reference QSO (Quality Safety and Oversight)-20-38-NH (Nursing Home) Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirement Memorandum dated 9-10-21 documents, This rule establishes LTC Facility Testing Requirements for staff and residents and provides guidance for facilities to meet the new requirements. To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS (Health and Human Services) Secretary. Facilities can meet the testing requirements through the use of rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory. POC testing is diagnostic testing that is performed at or near the site of resident care. Facilities without the ability to conduct COVID-19 POC testing should have arrangement with a laboratory to conduct tests with rapid reporting of results (example within 48 hours) should be selected to rapidly inform infection prevention initiatives and limit transmission. If the 48-hour turn-around time cannot be met due to community testing supply shortages, limited access or inability of laboratories to process tests within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments. The Facility's Infection Control Policy and Procedure for COVID-19 Facility Response Strategy dated 1-21-22 and the facility's Laboratory Services Agreement with [MEDICATION(S)] Labs (Laboratories) dated 8-24-20 does not include any documentation or policies to address facility COVID-19 testing requirements to ensure quick reporting of results (within 48 hours), and/or measures to implement if COVID-19 test results are not back within 48 hours. V8 (Cook), V16 (Activity Aide), V17 (CNA/Certified Nursing Assistant) [CONDITION(S)] (Severe Acute Respiratory Syndrome) COVID rt-PCR (reverse transcription-Polymerase Chain Reaction) Detection laboratories (labs) and the facility's COVID-19 Staff Log of COVID-19 positive staff document V8, V16, and V17's labs were collected on 12-31-21. V8, V16, and V17's same labs document V8, V16, and V17's positive COVID results were reported to the facility on [DATE] (seven days after collection). V4(CNA), V23 (LPN/Licensed Practical Nurse), V22 (LPN), and V25's (Cook) [CONDITION(S)] COVID rt-PCR Detection lab and the facility's COVID-19 Staff Log of COVID positive staff document V4, V23, V22 and V25's labs were collected on 1-5-22. V4, V23, V22 and V25's same labs document V4, V23, V22, and V25's positive COVID results were reported to the facility on [DATE] (six days after collection). V28's (Physical Therapy Assistant) [CONDITION(S)] COVID rt-PCR Detection lab and the facility's COVID-19 Staff Log of COVID positive staff document V28's labs were collected on 1-7-22. V28's same labs document V28's positive COVID results were reported to the facility on [DATE] (five days after collection). V20 (Dietary Manager), V21 (RN/Registered Nurse), and V24's (Resident Care Coordinator) [CONDITION(S)] COVID rt-PCR Detection lab and the facility's COVID-19 Staff Log of COVID positive staff document V20, V21, and V24's labs were collected on 1-5-22. V20, V21, and V24's same labs document V20, V21, and V24's positive COVID results were reported to the facility on [DATE] (five days after collection). R83 and R90's [CONDITION(S)] COVID rt-PCR Detection labs and facility's resident line listing of COVID positive residents document R83 and R90's labs were collected on 12-28-21. R83's same lab documents R83's positive COVID result was reported to the facility on [DATE] (four days after collection), and R90's same lab documents R90's positive COVID result was reported to the facility on [DATE] (five days after collection). This same resident line listing documents R83 was isolated for COVID on 1-1-22 and R90 was isolated for COVID on 1-2-22. R83's MDS (Minimum Data Set) dated 1-7-22 documents R83 ambulates independently. R90's MDS dated [DATE] documents R90 ambulates independently. On 1-26-22 at 1:00 PM V6 (LPN) stated, (R83) and (R90) ambulate independently. (R83) comes out of his room to smoke several times daily. (R90) conducts her own church service with the residents in the main dining room. R26, R28, R64, and R67's [CONDITION(S)] COVID rt-PCR Detection labs document R26, R28, R64, and R67's labs were collected on 12-31-21, received by the laboratory (lab) on 1-6-22 (six days after collection), and reported to the facility on [DATE] (seven days after collection) that R26, R28, R64, and R67 were positive for COVID. This same resident line listing documents R26, R28, R64, and R67 were not isolated for COVID until 1-7-22. R1, R2, R3, R4, R11, R13, R14, R16, R20, R24, R29, R30, R34, R38, R40, R41, R44, R46, R48, R49, R54, R65, R68, R70, R71, R74, R75, R78, and R95's [CONDITION(S)] COVID rt-PCR Detection labs and the facility's resident line listing of COVID positive residents document R1, R2, R3, R4, R11, R13, R14, R16, R20, R24, R29, R30, R34, R38, R40, R41, R44, R46, R48, R49, R54, R65, R68, R70, R71, R74, R75, R78, and R95's labs were collected on 1-5-22, and reported to the facility on [DATE] (six days after collection) that R1, R2, R3, R4 R11, R13, R14, R16, R20, R24, R29, R30, R34, R38, R40, R41, R44, R46, R48, R49, R54, R65, R68, R70, R71, R74, R75, R78, and R95 were positive for COVID. This same line listing documents R1, R2, R3, R4 R11, R13, R14, R16, R20, R24, R29, R30, R34, R38, R40, R41, R44, R46, R48, R49, R54, R65, R68, R70, R71, R74, R75, R78, and R95 were not isolated for COVID precautions until 1-11-22. R6, R8, R9, R33, R35, R42, R57, R58, R69, R76, and R397 [CONDITION(S)] COVID rt-PCR Detection labs document R6, R8, R9, R33, R35, R42, R57, R58, R69, R76, and R397's labs were collected on 1-7-22 and reported to the facility on [DATE] (five days after collection) that R6, R8, R9, R33, R35, R42, R57, R58, R69, R76, and R397 were positive for COVID. This same line listing documents R6, R8, R9, R33, R35, R42, R57, R58, R69, R76, and R397 were not isolated for COVID precautions until 1-12-22. R60's [CONDITION(S)] COVID rt-PCR Detection lab and the facility's resident line listing documents R60's lab was collected on 1-5-22 and reported to the facility on [DATE] (eight days after collection) that R60 was positive for COVID. This same line listing documents R60 was not isolated for COVID until 1-13-22. The Local Health Department's Call Report/Notes dated 1-5-22 document the health department requested a comprehensive line listing of all facility associated cases since the outbreak testing response began from V1 (Administrator). The Local Health Departments Call Report/Notes dated 1-10-22 document the health department requested a line listing again from V1. The Local Health Departments Call Report/Notes dated 1-13-22 document the health department still had not received a line listing from V1, and a request was emailed to V1 to provide the health department with a line listing by Friday 1-14-22. The facility's CMS Resident Census and Conditions of Resident Form 672 dated 1-23-22 and signed by V2 (Infection Preventionist) documents 64 residents ambulate independently. The facility's Daily Census Log dated 1-23-22 documents 92 residents currently reside within the facility. On 1-23-22 at 10:25 AM V2 (Infection Control Preventionist) stated, The lab has not been getting us our COVID lab results for at least three to seven days after we obtain the test. I did not know the lab was having problems getting the labs processed until 1-7-22. The lab told me that one of their machines was broke down. At that point I only rapid tested residents and staff who had symptoms of COVID. I did not rapid test any other staff or residents and I did not try to get another lab to process COVID labs. I have never spoke to the health department to get guidance on what to do if we are not receiving our COVID-19 lab results within 48 hours. I had enough rapid tests (POC) to test everyone. I am only one person and did not have the time. I did not think about isolating the residents that the positive staff and positive residents would have had direct contact with. I did not isolate these residents until I received a positive COVID test result. On 1-24-21 at 11:00 AM V32 (Facility's Lab Account Representative) stated, The facility knew January second that one of the lab's machines broke down and the facility's COVID-19 results over the next several weeks would be delayed. On 1-25-22 at 10:00 AM V2 stated, I do not believe our facility policies or our lab contract includes policies on what to do if a COVID-19 lab report does not return within 48 hours. I did not know CMS S&C letters even existed regarding testing procedures. On 1-25-22 at 1:40 PM V2 stated V4, V8, V16, V17, V20, V21, V22, V23, V24, V25, and V28 were never quarantined or removed from work for COVID-19 positive results because their positive lab results were not received by the facility until five to six days later after taking their test and these same staff members could have worked all hallways with all resident's while being positive with COVID-19. On 1-25-22 at 10:10 AM V1 (Administrator) verified that the facility's infection control policies do not include policies on what to do if a COVID-19 lab report does not return within 48 hours and the facility does not have a contract with the laboratory including an arrangement to obtain rapid COVID-19 lab results. I did not know anything about the CMS S&C letter regarding testing procedures. On 1/24/2022 at 10:25 am V2 stated when COVID-19 first started a long time ago it took forever to get results. The facility normally gets test results in 3-7 days and that 7 days is too long and not acceptable to wait for COVID-19 test results. V2 stated the lab was having difficulties and she was unaware of the difficulties until 1/7/2022. On 1/25/2021 at 9:20 am V29 (Vice President of Operations) stated the labs for COVID-19 testing have always been seven days behind and are like that in all of his buildings. On 1-25-22 at 2:20 PM V33 (Local Health Department Representative) stated, The facility never did inform the health department that they were not receiving COVID-19 test results timely or ask for guidance on what to do since they were not receiving their test results timely. I did not receive a line listing from the facility that residents or staff were even positive for COVID-19 until 1-14-22 at 3:27 PM, which was way after the outbreak. If I would have known I would have told the facility to use a private lab or do rapid testing (POC) on everyone while waiting on the results. I have provided the facility with links and contacts to local labs and have sent all the guidance and S&C letters from CMS to the facility, so the facility should have been aware that lab results should be back within 48 hours. We (the health department) were trying to figure out why there was such a huge outbreak of COVID-19 within the facility, and now I know that it was because there was no follow-up with positive COVID-19 labs getting back timely and staff and residents were allowed to have contact with other residents and staff while being positive for COVID-19. I have never once heard from V2 regarding anything to do with the delay in lab results, or regarding anything with the facility's COVID-19 outbreak. An Immediate Jeopardy was identified on 1-25-22 at 5:02 PM. The Immediate Jeopardy began on 1-1-22 when the first resident (R90's) PCR COVID-19 test results came back to the facility four days later (1-1-22) positive after being at the lab since 12-28-21. Once the facility was aware of R90's delayed lab results the facility failed follow up, on multiple future testing dates, staff and resident PCR COVID-19 lab test results within 48 hours, resulting in staff and residents who were COVID-19 positive having direct contact with the rest of the staff and residents within the building for five to eight days after their PCR COVID-19 test collection dates. During the period of waiting for the lab results, the facility failed to initiate alternative testing procedures (POC COVID-19 testing) or obtain alternate lab vendors to process PCR COVID-19 tests when experiencing the delay in obtaining lab reports to prevent the further [CONDITION(S)] transmission of COVID-19 to the rest of the residents and staff. On 1-26-22 at 9:40 AM V1 (Administrator) and V29 (Director of Operations) was notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V2 continued to conduct POC (rapid point of care) COVID-19 testing of all residents and staff who have not had COVID in the last 90 days every three to seven days until there are no new cases for 14 days. 2. The QAPI (Quality Assurance and Performance Improvement) committee reviewed and revised the COVID-19 testing policy. 3. V35 (Registered Nurse/Chief Nursing Officer) completed in-service training on 1-26-22 with the Administrator, Director of Nursing, and Infection Preventionist regarding measures to initiate when COVID-19 Rt-PCR test results are not back to the facility within 48 hours and current CMS COVID-19 Long Term Care testing requirements. 4. The facility created a Quality Improvement auditing tool regarding compliance with COVID-19 testing that will be implemented every week for three months by the Director of Nursing. Completion Date 1-26-22.

Based on observation, interview, and record review the facility failed to administer pain medication to one resident (R80)and failed to provide pain management, and notify the physician of reports of pain for one resident (R3) of 32 residents reviewed for pain in the sample of 48 residents. This failure resulted in R80 experiencing pain with grimacing, and stiffening of body during wound treatment when not treated for [REDACTED]. Findings include: Facility Pain Management program dated/revised 7/6/18 indicates: The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes and changes in behavior/mood will be used to determine the presence of pain. Pain management program includes: - Documentation of pain assessment and monitoring. - Medications for the control or relief of anxiety related to pain. Pain assessment protocol will be initiated under any of the following situations: - Resident has a [DIAGNOSES REDACTED]. All caregivers are instructed to report the resident or family's report of pain. The resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medications. 1) Physician order [REDACTED]. MDS/BIMS dated 2/15/19 indicates R80 has memory, is cognitively impaired and not able to consistently understand or be understood. On 2/20/19 at 2:30pm R80 was receiving wound care for a stage two sacral ulcer. R80 grimaced, groaned and stiffened during treatment. At that time, V12, Wound/LPN stated that she would see if R80 had anything for pain. On 2/21/19 at 1:31pm V12 stated that she reported off to evening nurse yesterday about R80's pain with positioning during wound care and the nurse told her R80 didn't have anything ordered and R80's wife didn't want him to have anything that would make him sleepy. V12 stated that she would notify the physician right away. V12 stated that she hadn't noticed that R80 had Tylenol as needed for pain already ordered. At 2:00pm V12 stated that she spoke with the physician and he ordered scheduled Tylenol([MEDICATION NAME])today to be given three times per day and R3's wife consented. On 2/21/19 at 1:00pm V21, PT (Physical Therapist) stated that he is concerned R80 is having back pain due to [DIAGNOSES REDACTED]. V21 stated that he agrees it might be helpful to get something for pain, in case R80 is not able to verbalize his pain. Care Plan revised 1/22/19 indicates R80 has chronic pain related to history of lumbar fracture and that pain medication is to be given 1/2 hour before care or treatments; anticipate the residents need for pain relief and respond immediately. Physician order [REDACTED]. MAR (Medication Administration Record)dated 2/2019 indicates R80 did not receive any medication for pain in that month. 2) On 2/19/19 at 10:00am R3 complained of left foot pain stating My left foot is sore. I would love to have something for pain. I've been asking since morning. R3 stated that his pain was a 10 /10. R3's left foot was noted to be positioned on top of the mattress. At that time V18, CNA (Certified Nurse Assistant) came into R3's room and was told by R3 that he had pain in his foot. V18 stated that she would tell the nurse. On 2/19/19 at 1:05pm V12, Wound/LPN (Licensed Practical Nurse) assisted R3 to reposition, R3 again complained of foot pain, specifically a discolored area of his heel. R3 also grimaced and stated Ow when his left leg was moved. On 2/19/19 at 1:13pm V3,LPN stated he was told by staff in the morning that R3 complained of pain. V3 stated that he did not give any pain medication to R3 because R3 has no pain medications ordered. V3 stated that R3 is in end stage [MEDICAL CONDITION] and everything has been discontinued because it accumulates in his body and makes him so lethargic he won't eat and ends up being sent to the hospital. V3 stated the physicians don't want R3 to have anything for pain and that he reminded R3 of the reason for no pain medication when he went to see R3 about the pain in his foot. On 2/21/19 at 9:45am R3 was seen sitting in a recliner chair in the dining room and reported that his left foot still hurt. R3 also stated that he was told by the nurse (V3) that he can't have anything for pain. MDS/BIMS (Minimum Data Set/Brief Interview for Mental Status) dated 2/11/19 indicates R3 scored 11/15 and is able to make needs known; to understand and be understood. No notes or assessment of R3's reported pain were found or presented. Physician order [REDACTED]. On 2/21/19 at 10:45am V19, Physician stated it is not true that R3 cannot have any pain medication due to his kidney function. V19 stated that if R3 is having pain it should be assessed and he should be notified. V19 stated that he should have been notified on the day R3's pain was discussed.

Based on record review, and interview, the facility failed to follow hospital readmission order for one of five residents (R1) reviewed for behavioral management in the sample of eight. This failure resulted in R1 having a relapse of symptoms, and threatening harm to others as well as self harm threats requiring re-hospitalization . Findings include: The facility's Behavior Management Program dated 10-30-17 documents, To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to maintain the highest practicable mental and psychosocial well-being. Services include: Medications prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness. The facility's Admission of Resident policy dated 12-11-18 documents, To facilitate a smooth transition into a health care environment. To gather comprehensive information as a basis for planning individualized therapeutic care. Using information obtained, contact the attending physician, ensuring that admission ordereds cover all aspects of the required care and treatment. R1's Face Sheet documents R1 is a [AGE] year old that was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 10/31/2018 at 10:03 AM, R1's Nurse's Note documents, (R1) was talking to himself stating he wants to kill others. This nurse notified (V4/R1's Primary Care Physician). (V4) stated to send (R1) in for a psychiatric evaluation. On 10/31/2018 at 10:33 PM, R1's Nurse's Note documents R1 was transferred to a (behavioral health hospital). Facility's Census Report documents R1 remained at the behavioral health hospital from 10-31-18 to 11-16-18. R1's Behavioral Healthcare System discharge instructions dated 11-16-18 document the following orders: [MEDICATION NAME] 0.1 mg (milligrams) daily at 8:00 PM for the [DIAGNOSES REDACTED]. [MEDICATION NAME] 10 mg two tablets daily at 8:00 PM for the [DIAGNOSES REDACTED]. R1's Medication Administration Records and Progress Notes dated 11-16-18 to 11-29-18 do not include any documentation of R1 receiving the behavioral health systems orders to administer [MEDICATION NAME] 2 mg daily, [MEDICATION NAME] 10 mg two tablets daily, or [MEDICATION NAME] 0.1 mg daily. R1's Behavioral Note dated 11/29/2018 at 11:30 AM documents, (R1) is pacing back and forth from his room to the dining room stating he is going to kill himself, and kill other people. (R1) is not easily directed. When trying to speak to (R1), (R1) turns the other way and walks away. Resident refused medication at this time. R1's Nurse's Note dated 11/29/2018 at 11:56 AM documents, (R1) continues to pace, curse, and state he is going to kill himself, and others. (V2/Director of Nursing) stated to send (R1) for a psychiatric evaluation at this time. R1's Communication Progress Note dated 11/30/2018 at 12:31 PM, documents, Advised (R1's Power of Attorney/V10) that an emergency involuntary transfer discharge is being issued for (R1) due to the fact that (R1's) needs cannot be met in this facility. (R1) refuses to take his medications, and (R1's) physician states that (R1) needs a more secure environment. On 12-11-18 at 11:20 AM, V13 (Pharmacy Accountant) stated, The facility has never ordered [MEDICATION NAME] 0.1 mg, [MEDICATION NAME] 2 mg, or [MEDICATION NAME] 10 mg for (R1) from this pharmacy. On 12-11-18 at 12:00 PM, V2 (Director of Nursing) stated, The admitting nurse (V15/Registered Nurse) did not get orders from the behavioral healthcare when (R1) was readmitted to the facility (11-16-18). (V15) assumed the medication orders in the computer, prior to (R1) being sent to the psychiatric unit, were the medications ordered for (R1) upon (R1's) return. It was miscommunication on our part. We (the facility) should have made sure we had the orders from the behavioral healthcare and ensured (R1) received the medications ordered by the behavioral healthcare facility. (R1) was sent to the behavioral health system to stabilize (R1), and we should have made sure we followed their orders when (R1) was readmitted . I know someone in this building received the behavioral health orders from (V4/R1's Primary Care Physician) on 11-21-18, but (R1's) medications were still not started. On 12-11-18 at 12:30 PM, V1 (Administrator) stated, When (R1) was re-admitted to the facility on [DATE] the nurse (V15/Registered Nurse) should have ensured (R1's) medication orders, and treatment orders were obtained from the behavioral healthcare system that discharged (R1), or from (R1's) physician. On 12-11-18 at 10:55 AM, V4 (R1's Primary Physician) stated, When (R1) was sent for a psychiatric evaluation on 10-31-18 and re-admitted to the facility on [DATE], the facility should have made sure (R1) received the medications ordered from the psychiatric hospital. (R1) was sent to the psychiatric hospital to manage his behaviors and stabilize him. I was not notified that (R1) had never received the medications ordered from the psychiatric hospital. I saw (R1) several days after he was re-admitted to the facility on [DATE] due to (R1) having behaviors, but was never told that his medication ordered by the behavioral hospital were not being given. I am not a psychiatric doctor and tried my best to stabilize (R1). The facility should have ensured they followed the psychiatric hospital's discharge instructions to keep (R1) stabilized, which could have prevented (R1) from having the same behaviors that lead up to the involuntary discharge. On 12-11-18 at 1:30 PM, V17 (Assistant Hospital Administrator) stated, (R1's) Hospital progress notes document we (the hospital) were in constant contact with (V2/Director of Nursing). When we sent (R1) back to the facility, R1's behaviors were stable. (R1's) orders were sent to the transferring facility and faxed to (V4/R1's Primary Physician). The facility should have followed (R1's) orders and treatment plan. If for some reason the facility did not get (R1's) orders, then the facility should have called us to ensure continuity of care for (R1). Our facility is open 24 hours a day/seven days a week. (R1) would have needed the ordered medications to remain stable.

Based on record review and interviews the facility failed to reposition and provide the proper preventable treatment to prevent one new pressure sore on R1's left ischium and prevent the reoccurrence of pressure sores to both heels for one of three residents reviewed for pressure sores in a sample of three. Findings include: R1 was readmitted to the facility on [DATE] from the hospital with only one pressure sore on his coccyx. R1's current face sheet and care plan dated 4/12/18 notes his [DIAGNOSES REDACTED]. On 6/14/18 at 3:52 P.M. V6 (Wound Physician) stated that she had been seeing R1 at the facility since 4/19/18. V6 stated that on 4/19/18 R1 had the area on the coccyx which was considered two areas (Left and right buttocks) and both heels had scabs on them. V6 stated that on 5/17/18, R1 had developed a new stage two pressure sore on R1's left ischium that measured 0.5 x 0.5 x 0.1 cm. V6 stated that by the last time V6 had seen R1 in the facility on 5/24/18, R1's heels had both healed up. Hospital records on 6/2/18 note that R1 has new pressure sores on both heels that have developed in the facility between 5/24/18 and 6/2/18 when R1 was admitted to the hospital. R1's hospital records note that R1 was hospitalized initially on 4/12/18 and then again on 6/2/18 for issues unrelated to the pressure sores. R1's hospital records on 4/12/18 noted R1 to only have the pressure sores on R1's coccyx that were unstageable. R1's hospital records on 6/2/18 noted that R1 had three new pressure areas at that time. The first was the left ischium which has gotten worse since 5/17/18 and measures 5 x 4 x 0.4 cm and is a stage three. Then the right heel 2.5 x 1.5 x 0.1 cm is unstageable and left heel 5 x 4 x 0.3 cm is a stage three. V6 stated that R1's pressure sores are preventable and that with more frequent repositioning R1's pressure sores could be prevented. On 6/8/18 at 11:10 A.M. V5 (hospital wound physician) stated that lack of appropriate repositioning and treatment by the facility is the reason for R1's development of the new pressure sores. V5 stated that R1 should be repositioned at least every hour to help with healing. R1's care plan dated 4/12/18 noted that facility staff was instructed to turn and reposition R1 every two hours prior to 6/2/18. On 6/14/18 at 4:02 P.M. V2 (Director of Nursing) verified that R1 had only been repositioned every two hours until 06/2/18.

Based on interview and record review the facility failed to report an allegation of abuse to the Administrator, failed to remove the alleged perpetrator from direct contact with residents, and failed to report an allegation of abuse to the state agency. R1 was subjected to threatening verbal abuse by E42 C.N.A. (Certified Nurse Aide) which was not reported to the Administrator immediately. E42 was allowed to continue to work and not removed from resident care. This failure has the potential to affect all 102 residents in the facility and resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 03/06/14 at 6:10PM, the facility remains out of compliance at a severity level two as the facility continues to educate management and staff on the abuse reporting policies and procedures and continues to monitor residents for any complaints or signs of abuse. Findings include: On 03/06/14 at 1:50 PM R1 stated that about a month ago E42 (CNA) went down to R1 ' s room, pointed at R1 ' s face and stated, " I have been stabbed and punched before, and you don ' t scare me. Don ' t ever call me ' daddy ' again. R1 reported this to E17 C.N.A. (Certified Nurse Aide) later that evening. R1 then stated E17 reported this to E1 (Administrator) and E3 (Care Plan Coordinator) several days later. On 03/04/14 at 2:25PM, E17/C.N.A. stated that on either 01/23/14 or 01/24/14 E17 observed E42 being verbally threatening to R1. E17 also started that later on in the evening E42 C.N.A. (Certified Nurse Aide) returned to R1 ' s room and again threatened R1 by saying " If anyone tries to get in my way I will mess them up or kill them. " E17 then verified that this was not reported to E2(Director of Nursing) and E3 (Care Plan Coordinator) until the next day and that E42 continued to work the evening of the abuse and the following day. E17 also stated that E1/Administrator and E3 spoke with R1 about the allegation the following day. On 03/04/14 at 1:45PM E5 C.N.A. (Certified Nurse Aide) stated she knew something about E42 being " mean " to R1 but could not remember the " specifics. " E5 stated (E5 ) reported the allegation to E2 (Former Director of Nursing/DON) around a month ago. On 03/04/14 E2 (DON) stated that approximately one to two months ago that she was notified that R1 was " afraid " of E42. E2 stated that R1 felt threatened because E42 stated to R1 " if it gets back to me that you (R1) reported me, I will know who did it. " E2 then stated she reported the allegation to E1 and E3 immediately. E2 then verified that E42 continued to work in direct resident care following the allegation for approximately two days before E42 resigned. On 03/04/14 at 3:05PM E1 stated that E1 had not received any allegations of abuse involving E42 or R1. E1 stated that she felt the situation between R1 and E42 was not an abuse but instead R1 putting self in the middle of a conversation between E42 and E17 with R1 " just being nosey. " E1 then stated she was unable to find an abuse investigation or evidence that this was reported to the state agency. On 03/10/14 E42 C.N.A. stated, " I was never suspended. I quit because I did not get third shift (hours). " Facility time card for E42 documents that E42 worked on 01/24/14 from 1:59PM to 6:01AM and on 01/28/14 from 2:00PM to 10:00PM. The facility's Abuse Policy dated 1-1-2012 documents, "It is the responsibility of all employees to report any incident of suspected or witnessed abuse immediately to the Administrator. It is the responsibility of the Administrator to immediately initiate an investigation of the allegations, and report any finding to the Illinois Department of Public Health." According to the CMS 672 Census and Condition Report dated 3-3-14 and signed by E3 (Care Plan Coordinator), 102 residents currently reside in the facility. On 3-6-14 at 1:05 p.m., an Immediate Jeopardy was identified to have begun on 1-24-14 when R42 allegedly verbally abused R1 (CNA) and was allowed to continue to have direct contact with residents, following the allegation. E1 (Administrator) was notified of the Immediate Jeopardy on 3-6-14 at 1:05 p.m. The surveyor confirmed through interview and record review that the facility took the follwing actions to remove the Immediate Jeopardy. 1. On 3-6-14 at 6:10 p.m., all abuse policies and procedures had been reviewed by the facility corporate nurse (E46). 2. On 3-6-14 at 6:10 p.m., all staff in-servicing was started and will continue until all staff have been in-serviced on the following areas by E46 (Corporate Nurse): The types of abuse, Immediate reporting, Who to report to, and the investigation process. 3. On 3-6-14 at 6:10 p.m., E46 (Corporate Nurse) will conduct the abuse investigation regarding R1's allegations. 4. On 3-6-14 at 6:10 p.m., all residents of the facility will be monitored for any complaints or signs/symptoms of abuse.

Based on interview and record review the facility failed to remove alleged perpetrators of verbal abuse ,E1 (Administrator) and E42 (Certified Nursing Assistant/CNA), from contact with residents during the abuse investigation, failed to report to the Administrator immediately R1's allegation of verbal abuse against E42, failed to investigate immediately R1's allegation of verbal abuse against E42, and failed to report immediately to the State Agency R1's allegation of verbal abuse against E42. E1 was allowed to conduct the investigation which alleged E1 as the perpetrator. E42 was not removed from direct care after an allegation of threatening verbal abuse was made and was allowed to return to the R1's room to further threaten R1. All the actions the facility failed to do were required by the facility's Abuse Policy. This has the potential to affect all 102 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 03/06/14 at 6:10PM, the facility remains out of compliance at a severity level two as the facility continues to educate management and staff on the abuse reporting policies and procedures and continues to monitor residents for any complaints or signs of abuse. Findings include: A facility Abuse Policy dated 1-1-2012 documents, "Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within hearing distance. Examples of verbal abuse include threats of harm or saying things to harm a resident. When a report is made of suspected abuse of a resident indicating an involvement of an employee, the employee should be suspended pending an investigation. It is the responsibility of all employees to report any incident of suspected or witnessed abuse immediately to the Administrator. It is the responsibility of the Administrator to immediately initiate an investigation of the allegations, and report any finding to the Illinois Department of Public Health." On 3-4-14 at 1:45 p.m., E5 (CNA) stated E5 knew something about E1, E3, and E42 being mean to R1, but could not remember specifics. E5 stated E5 reported the allegation to E2 (Director of Nursing/DON) around a month ago. On 3-4-14 at 1:50 p.m., R1 stated about a month and a half ago, E17 (CNA) notified E1 (Administrator) and E3 (Care Plan Coordinator) about verbal abuse that occurred from E42 towards R1. On 3-4-14 at 2:40 p.m., E17 (CNA) stated on either 1-23-14 or 1-24-14, E42 was verbally threatening to R1. E17 did not report the occurance to E2 (DON) and E3 (Care Plan Coordinator) until the next day. E17 stated E42 worked the rest of that night and another night, and then resigned. E17 stated E1 (Administrator) and E3 talked to R1 following the allegation against E42. On 3-4-14 at 2:25 p.m., E2 (DON) stated approximately one to two months ago, E2 was notified by E17 that R1 was afraid of E42. E2 stated R1 felt threatened by E42. E2 stated E2 reported the allegation to E1 and E3 (Care Plan Coordinator) immediately. E2 stated E42 remained working,in direct resident care, in the facility, following the allegation, for approximately two days, before E42 finally resigned. On 3-4-14 at 3:05 p.m., E1 stated E1 has never received any allegations of abuse involving E42 or R1. E1 stated E1 could not find any documentation regarding E17 and E42. E1 (Administrator) went through her desk drawer and filing cabinet and could not find or provide an abuse investigation or evidence of the state agency being notified of R1's alleged verbal abuse against E42. On 3-5-14 at 11:50 a.m., E5 (CNA) stated R1 reported to E5 that E1 (Administrator) and E3 (Care Plan Coordinator) went into R1's room last night (3-4-14) and were very rude. E5 stated R1 felt like E1 and E3 were nazis. E5 stated R1 states, "You would not believe how (E1 and E3) talked to me. E5 stated E5 does not know who to report this allegation to since E1 is who R1 made the allegation against, and E1 is the Abuse Coordinator. On 3-5-14 at 2:00 p.m., E5 stated R1 reported to E5 that E43 (Social Service Director) and E1 interviewed R1 regarding the verbal abuse allegations from E1 and E3. E5 states, "Isn't that confrontational that the accused abuser confronted the resident that accused them?" On 3-5-14 at 12:20 p.m., E1 (Administator) verified E1 and E3 talked to R1 last night about the allegations made against E42 yesterday. E1 was then informed of allegations made by R1 of verbal abuse by E1 and E3. On 3-5-14 at 12:22 p.m., E1 immediately notified E47 (Facility Manager) via telephone of R1's alleged verbal abuse from E1 and E3. E1 stated E47 instructed E1 to do the investigation, as always, regarding R1's allegations of verbal abuse by E1 and E3. On 3-6-14 at 9:20 a.m., E43 (Social Service Director) stated E43 and E1 interviewed R1 last night. According to the CMS 672 Census and Condition Report dated 3-3-14 and signed by E3 (Care Plan Coordinator), 102 residents currently reside in the facility. On 3-6-14 at 1:05 p.m., an Immediate Jeopardy was identified to have begun on 1-24-14 when R42 allegedly verbally abused R1 (CNA) and was not removed from direct contact with other residents, the Administrator was not notified immediately, an abuse investigation was not initiated immediately, and the state agency was not notified immediately. E1 (Administrator) was notified of the Immediate Jeopardy on 3-6-14 at 1:05 p.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. On 3-6-14 at 6:10 p.m., all abuse policies and procedures had been reviewed by the facility corporate nurse (E46). 2. On 3-6-14 at 6:10 p.m., all staff in-servicing was started and will continue until all staff have been in-serviced on the following areas by E46 (Corporate Nurse): The types of abuse, Immediate reporting, Who to report to, and the investigation process. 3. On 3-6-14 at 6:10 p.m., E46 (Corporate Nurse) will conduct the abuse investigation regarding R1's allegations. 4. On 3-6-14 at 6:10 p.m., all residents of the facility will be monitored for any complaints or signs/symptoms of abuse.

Based on observation, interview, and record review, the facility failed to have in place and functioning a collaborative infection control program between nursing, housekeeping, and laundry services to prevent the spread of communicable infections to residents who are immuno-compromised and at risk for infection. Those failures include: failure to demonstrate knowledge of and implementation of isolation precautions to prevent cross contamination of communicable infections; failure to educate staff and visitors on current standards of infection control practices during and following the provision of care; failure to have infection control policies and procedures accessible to staff; failure to adequately monitor infections; and failure to effectively clean and disinfect environmental surfaces, laundry, and resident equipment. These failures resulted in an Immediate Jeopardy. These failures have the potential to affect all 102 residents residing in the facility. While the Immediate Jeopardy was removed on 3/5/14, the facility remains out of compliance at severity level two. Additional time is needed for the facility to complete staff infection control policies and procedures, monitor the effectiveness of the implementation of protocols, and for oversight visits. Findings include: 1. R1's wound culture dated 10-30-13, documents R1 has the following organisms in the coccyx wound: Acinetobacter baumannii, Escherichia coli, and Staphyloccus aureus. On 2-24-14 at 11:00 a.m., R1's room door had a sign documenting "see nurse before entering." R1's urinary catheter bag and tubing were lying on the floor. On 2-24-14 at 11:05 a.m., E5 (Certified Nursing Aide/CNA) stated R1 is to have "universal precautions" used when caring for R5. E5 stated only gloves are to be worn when caring for R5, because gown and masks are only used with residents that are in droplet isolation. E5 states, "I do not know what infections, or where, (R1's) infections are. I have worked medical records for six months and have not been working on the floor with the residents." On 2-24-14 at 11:15 a.m., E7 (Licensed Practical Nurse/LPN/R1's first shift nurse) states, "I am not sure what type of isolation (R1) is in or what type of organism (R1) has. I have not been working this hallway since recently." On 2-24-14 at 1:15 p.m., E5 applied gloves, washed wound drainage off of R1's bilateral buttock and back ( from R1's uncovered wound), removed R1's bed sheet and bedpad (soaked in wound drainage) from R1's bed, held the linens, soiled in drainage, against E5's clothing (without a gown on), and disposed of the drainage soaked linens in a red bag. E5 stated E5 did not need to wear an isolation gown because R1 was only in contact isolation. R1 then asked E5 to use the bedpan, so E5 applied a new pair of gloves and placed R1 on the bedpan. On 2-24-14 at 1:25 p.m., E5 removed R1 from the bedpan, washed feces from R1's buttock with washcloths, then, using the same soiled gloves, touched R1's catheter bag, right siderail, over the bed table, and R1's gown, before removing the soiled gloves. E5 then, using the same soiled gloves, took the bedpan ( filled with feces), emptied the feces into R1's toilet, washed the feces soiled bedpan in R1's sink, wiped the bedpan out with a paper towel, and placed the bedpan in a trash bag on the floor. E5 states, " I am taking care of all residents on this hallway today." E5 then returned to R1 and continued to provide care. On 2-25-14 at 9:30 a.m., E25 (CNA) and E11 (CNA) entered R1's room, applied gloves, and removed R1 from the bedpan. E11 wiped feces from R1's buttock and took R1's bedpan (containing R1's feces), places it in a trash bag, and took the bedpan to the soiled utility room. On 2-25-14 at 9:50 a.m., E25 (CNA) states, "We are never told why the residents are in isolation. I did not use a gown when caring for (R1) earlier because there were no gowns in (R1's) room to use. I emptied (R1's) bedpan in the hopper, then sprayed the bedpan and hopper down with a disinfectant spray. I did not use bleach." On 2-24-14 at 2:20 p.m., E18 (Registered Nurse/R1's 2nd shift nurse ) states, "I cannot tell you what type of isolation (R1) is in. I would have to ask the infectionist." On 2-25-14 at 10:05 a.m., E14 (LPN) states, "We do not have policy and procedure manuals to use. All policies are kept in the Administrator's office." On 2/25/14 at 9:40 a.m., E1 (Administrator) stated the facility does not have a policy on how to set up the different types of isolation rooms. E1 stated "you have to remember we are a new company and don't have all of our policies and procedures yet. E1 verified there were no policy and procedure manuals accessible to staff. On 2-25-14 at 11:50 a.m., E2 (Director of Nursing/DON) states, "Anytime the staff come into contact with drainage, they should wear a gown." On 2-25-14 at 2:30 p.m., E4 (LPN/Infectionist) states, "(R1) is in contact isolation for high resistive organisms in the wound and catheter. Staff are to wear gloves only with contact isolation. The staff do not have to wear gowns if drainage is present. Staff should always change gloves between clean and dirty procedures. Staff should absolutely not touch catheter bags or tubing, siderails, or anything else with soiled gloves. Urinary catheter bags and tubing should not touch the floor. An undated contact precautions policy documents the following: Gloves are to be changed after having contact with infective material (fecal matter and wound drainage); A non-sterile gown is to be worn to protect skin and prevent soiling of clothing during procedures that are likely to cause soiling of clothing; Remove gloves and wash hands before leaving the resident's room; Gown are to be worn if wound drainage is not contained by a dressing; Equipment is to be adequately cleansed before being used between residents. An undated hand washing policy documents the following: All staff will wash hands with an antimicrobial agent or water-less antiseptic agent immediately after glove removal, between tasks and procedures on the same residents to prevent cross contamination of different body sites, after handling soiled linens, and after handling bedpans, soiled urinals, or handling urinary drainage bags. An undated infection control policy documents the following: An infection control manual of written policies and procedures will be developed and implemented; All facility personnel shall adhere to the Infection Control Program in the performance of daily assignments;The facility shall assure the necessary training, equipment and supplies are maintained to carry out the infection control program. An undated urinary catheter care policy documents the following: Handwashing shall be performed before and after touching any part of the urinary catheter drainage system; Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor; 2. On 3-1-14 at 5:20 a.m., E26 (Registered Nurse/RN) used a blood glucose monitor to check R4's blood glucose level. E26 immediately left R4's room and went to R1's room. E26 then took R1's blood glucose level with the same blood glucose monitor. E26 did not cleanse the blood glucose monitor between use for R4 and R1. On 3-1-14 at 5:30 a.m., E26 stated E26 checked R1, R4, R49, R51, R56, R58, R59, R106 's blood glucose this morning and used the same glucose monitor. E26 states, "I did not cleanse the blood glucose monitor with bleach or the cleanser we are suppose to use, because I cannot breathe those chemicals. I just clean the machine with an alcohol swab." On 3/10/14 at 11:00 a.m., E4 (Licensed Practical Nurse), states the following residents are in isolation. R49 is in contact isolation, R4 is in droplet precautions, R61 is in droplet precautions, R1 is in contact precautions, and R106 is in contact isolation. R4's Final Antimicrobial Susceptibility and Organism Identification Report, dated 9/22/13, documents Serratia marcascens and Morganella morganii ssp morganii positive in R4's sputum culture. R61's Final Antimicrobial Susceptibility and Organism Identification Report, dated 1/21/13, documents Pseudomonas aeruginosa, Providencia stuartii, and Acinetobacter baumannii positive in R61's sputum culture. R49's Final Antimicrobial Susceptibility and Organism Identification Report, dated 1/6/14, documents Morganella morganii ssp and staphylococcus aureus positive in R49's urine. R106's Final Antimicrobial Susceptibility and Organism Identification Report, dated 6/18/13, documents Proteus mirabilis positive in R106's urine. R1's Final Antimicrobial Susceptibility and Organism Identification Report, dated 11/2/13, documents Staphylococcus aureus positive in R1's coccyx wound. R58's Physician order [REDACTED]. On 3/10/14 at 9:40 a.m., E3 (MDS/Care Plan Coordinator), stated "as long as the glucometer is sanitized with bleach wipes, it is ok to use with a hepatitis resident. I can't answer if it is ok to use alcohol pads or not I'm not sure. I would not use an alcohol pad between glucometer uses on different residents. Our policy calls for (bleach disinfectant) wipes to be used with each resident between glucometer checks." An undated maintaining the blood glucose meters policy documents the following: A blood glucose monitor should be cleaned and disinfected between each resident test with a pre-moistened wipe/towel of 1 ml (milliliter) or 5-6% bleach and 9 ml of water to achieve a 1:10 dilution; A glucose monitor should be allowed to air dry for a minimum of one minute at room temperature following cleaning of the monitor. 3. On 2/24/14 at 1:15 p.m., R3's door had an isolation sign posted. R3's Physician order [REDACTED]. R3's Physician order [REDACTED]. On 2/24/14 at 2:00 p.m., E4 (Licensed Practical Nurse), stated "(R3) is on droplet precautions at this time. (R3) was on droplet isolation at admission because the hospital discharging (R3) had communicated that (R3) was on isolation but there were no reports of what (R3) was on isolation for and no cultures present. No cultures were done because (R3) was not symptomatic. We normally do not reculture residents unless they are symptomatic with the amount of highly resistant bugs around here. (R3) has had highly resistant wound cultures but droplet covers all of those In December of 2013 (R3) had positive cultures and they were treated but not recultured. I am unsure of what (R3) is currently on antibiotics for I was not aware of any current infections. (R3) may have been started on [MEDICATION NAME] for [MEDICATION NAME] then ordered a urinalysis, this is normal for Dr. Hill." On 2/25/14 at 9:20, E12 (housekeeping/laundry), stated "when a resident is on droplet precautions we use gown, mask, and gloves. E12 is unaware of why (R3) is on isolation. We use Don-O-Mite CF foaming disinfectant deodorizing cleaner in all rooms to clean surfaces and DON Miro Spray heavy duty glass cleaner to clean glass and mirrors. There are not different cleaners for different organisms. Mop water and mop head are changed every two rooms but if in isolation I change mop water and mop head with each one. I work all the halls as a housekeeper and laundry." On 2/25/14 at 9:40 a.m. E1 (Administrator), stated "we do not have a written policy for specific organisms for isolation. We just know what isolation they need. we have them set up prior to admit. We inservice staff on types of isolation." On 2/25/14 at 9:45 a.m., observed cleaning supplies that housekeeping utilizes are as follows: DON Miro Spray Heavy Duty Glass Cleaner has no disinfecting contents. DON Don-O-Mite CF Foaming disinfectant deodorizing cleaner kills Aspergillus niger, [MEDICAL CONDITION][MEDICATION NAME], E-coli, [DIAGNOSES REDACTED] pneumiae, H1N1, Penicillium pinophilum, Penicillium variable, pseudomonas, aeruginosa, Salmonella, Staphylococcus aureus, Streptococcus pyogenes, [MEDICATION NAME] mentagrophytes, Vanco resistant [MEDICATION NAME] faecalis, adenovirus Type 2, Herpes simplex virus 1 and 2, Influenza A2/Japan virus, Vaccinia (Pox virus) On 2/25/14 at 9:50 a.m., E13 (Housekeeping/Laundry Supervisor), stated "if a resident has[DIAGNOSES REDACTED] the cleaner Virasept is what we use to clean. Notes are left for staff if a resident has[DIAGNOSES REDACTED] to use different cleaner. The facility inservices staff to make sure they know the types of cleaners to use. (E12) normally works laundry but (E12) should know that we don't only use one disinfectant for all rooms." On 2/25/14 at 9:45 a.m., E13 provided bottle of Virasept. On Virasept bottle states it kills[DIAGNOSES REDACTED], Pseudomonas aeruginosa, Staph aureus (MRSA), Serratia marcescens, E-coli, Shigella flexneri, [MEDICATION NAME] aerogenes, [DIAGNOSES REDACTED] pneumoniae, VRE, Salmonella, Proteus vulgaris, [DIAGNOSES REDACTED], Morovirus, Hepatitis B, HIV 1, RSV, Human Coronavirus, Rhinovirus type 37, Rotavirus, Influenza A, Avian Influenza A, Adenovirus type 4. The label states the wet time is ten minutes for[DIAGNOSES REDACTED]. On 2/25/14 at 9:45 a.m., E13 stated when using Virasept the surface wet time is approximately five minutes. On 2/25/14 at 10:00 a.m., E11 (Certified Nursing Assistant) and E17 (Certified Nursing Assistant) were providing cares to R3. E11 and E17 removed R3's soiled bed sheets, then removed E11 and E17's gloves. E11 and E17 applied new gloves without cleansing hands and proceeded to apply clean sheets to R3's bed. On 2/25/14 at 10:30 a.m., E16 (housekeeper), stated "we use Don-o-mite disinfectant and Miro Spray in all rooms unless they have a different type of bug then we use the Virasept or Bleach. We use the Virasept for MRSA or[DIAGNOSES REDACTED]. We spray the Virasept then leave it wet for 15 minutes. We are told why the residents are on isolation by our supervisor." On 2/25/14 at 11:20 a.m., E9 (housekeeping), stated "Don-o-mite disinfectant and Miro spray are used in all rooms. We use the Virasept in the mop water for all the rooms. I change mop water and mop head every three or four rooms if not in isolation. If a patient is in isolation I change my mop head with each room and I change my mop water every third room. When I mop with the virasept I leave the floor wet for eight minutes. I clean the sinks, toilets, surfaces in room, and on top of the lights with the Don-o-mite disinfectant in all the rooms including isolation rooms. I don't know why they are on isolation I just assume they have something." The Isolation Room Cleaning Policy, dated 2/14/12, documents to clean and disinfect room. Use a germicidal solution to clean and disinfect furniture, door handles, light fixtures, hand rails, television, mirrors, bathroom fixtures and handles, and any other items in rooms. Note: Germicidal solution containing 1 ml or 5-6% of sodium hypochlorite solution (household bleach) and 9 ml water to achieve a 1:10 dilution final concentration of 0.5-0.6% sodium hypochlorite. Note: allow surface to air dry for ten minutes. On 2/25/14 at 11:30 a.m., E12 (housekeeping/laundry) was cleaning room number C7, a room with droplet precautions. E12 removed the mop head in the room and placed it in a clear bag and brought it along with broom, mop handle, and dust pan and brought the out of the room. E12 did not disinfect any of these surfaces listed on the Isolation Cleaning Policy. The mop head in clear bag was brought into housekeeping closet and placed in white trash bag, lying on the floor, with many other mop heads in clear bags. A new mop head was applied and mop water was changed out. E12 stated, "we put all mop heads in clear bags then they all go into the big white trash bag in housekeeping closet and they are brought down to the laundry room. We wash the mop heads by themselves on isolation and then on personal setting." On 2/25/14 at 12:00 p.m., E10 (housekeeping/laundry), stated "mop heads come into laundry on 2nd shift to wash so I don't usually wash them but I did when I worked on 3rd shift. The mop heads are brought back to laundry in barrels. I put the setting on washing machine to towels because it provides bleach and soap. All mop heads regardless if they were in isolation come back in the the same bag and barrel you can't tell the difference. The mop heads go thru one washing cycle. All isolation red bag linens go thru two washing cycles on the isolation settings. If we wash items more than once we will put on our laundry load log the number of times washed. This log tells what we wash with each load." On 2/25/14 at 12:10 p.m., E13 (housekeeping/laundry supervisor), stated "the policy is to wash mop heads on isolation setting but the towels setting is ok because it has bleach in it. No matter what setting we put washing machine on everything is disinfected. All mop heads come back to laundry together and unable to tell the difference if they were in isolation or not. The mop heads are bagged in rooms then placed in barrel in housekeeping closet then barrel is taken to laundry. Virasept is not to be put in mop water it's used to clean the rooms." On 2/25/14 at 1:45 p.m. E3 (Care Plan Coordinator), stated "we do not have a mop head cleaning policy. We wash our mop heads just like we do all of our isolation stuff. We put it on isolation setting and wash it two times." Record review of Laundry daily load count, dated 2/24/14, documents that load number one on washer number 2 of third shift mops and rags were washed together on one cycle. On 2/27/14 at 2:10 p.m., E12 (housekeeping/laundry), stated "the mop heads and rags are not washed together. We normally wash mop heads on isolation but the settings do not matter because everything is sanitized on all settings. We always mark on laundry load log if we wash more than one cycle if no number on the log it was washed once." The Linen and Laundry Handling for Laundry Dept (date unknown), documents mop heads and cleaning cloths will be cleaned and dried separately. On 3/3/14 at 12:00 p.m., Z5 (R3 family member), stated "We aren't sure why the gowns and masks are worn. We don't wear them it's not like (R3) is contagious. Sometimes staff wears the stuff and sometimes they don't." On 3/6/14 at 2:00 p.m., R12's wound care was performed by E4 (Licensed Practical Nurse) with the assistance of E29 (Respiratory Therapist) and E5 (Certified Nursing Assistant). E5 removed gloves following ostomy cares and applied new gloves without cleansing hands. E5 removed soiled linens and removed gloves and applied new gloves without cleansing hands. E4 performed dressing changes on multiple wounds. With each wound a new pair of gloves were applied without cleansing hands, also no cleansing of hands after removing gloves used to remove old dressing before applying clean gloves to apply clean dressing. 4. Facility's Droplet Precautions policy (undated), documents "In addition to Standard Precautions, Droplet Precautions are required for residents known or suspected to be infected with microorganism transmitted droplets that can generate by the resident during coughing, sneezing, talking, or the performance of procedures. Wear a mask when working within 3 feet of the resident in addition to other Standard Precautions. Gowns must be worn when performing or assisting with any procedure such as suctioning when there is a possibility that respiratory secretions may contaminate or soil the healthcare workers' clothing." R12's current care plan dated 01/05/14 documents R12 is in droplet isolation precautions for [MEDICATION NAME]-Resistant [MEDICATION NAME] and Acinetobactor. This care plan does not document the source of where these organisms are present. On 03/03/14 at 11:40 a.m., E9 (Housekeeper) was cleaning R12's room. E9's housekeeping cart was parked inside R12's room. E9 verified E9's housekeeping cart was parked inside a droplet isolation precautions room. E9 was not wearing a mask and stated, "I should be wearing one." E9 then exited R12's room wearing gloves and pushed the housekeeping cart and parked it near the facility's C hall Nurse's Station. Three black garbage bags were sitting on the floor in the facility's C hall near room C1. E9 drug these bags across the floor and placed them on the floor near the housekeeping cart. E9 verified that three garbage bags were sitting on the floor in the facility's C Hall, and stated that E9 did not wash E9's hands before exiting R12's room. On 03/05/14 at 2:50 p.m., E48, Respiratory Therapist, was providing Tracheostomy care to R12, who is in droplet isolation precautions. During care, R12 requested ice water. E48 was wearing gloves, a gown, and a mask. E48 carried R12's drinking cup and stood in a square area inside R12's doorway outlined in red tape on the floor. E20, Certified Nurse's Aide, was standing in the hallway outside of R12's room with an ice cooler on a wheeled cart, removed an ice scoop from the cooler and began filling R12's drinking cup with ice, and placed the ice scoop back into the cooler full of ice after filling R12's drinking cup. E20 stated, "If they (residents) are in isolation, I push the ice cart to the room and fill it in the doorway." E48 walked to R12's bedside, assisted R12 to drink ice water, and then continued R12's tracheostomy care. When R12's tracheostomy care was complete, R48 removed R48's gloves, washed R48's hands, walked and stood in the square area outlined in red tape on the floor inside the doorway of R12's room wearing a mask and gown, reached out of R12's room to grab a pulse oximeter off of a cart parked in the hallway and returned to R12's bedside to obtain a pulse oximetry reading. On 03/05/14 at 3:05 p.m., E48, Respiratory Therapist, verified standing in the red square area outlined in red tape on the floor in R12's room wearing gloves, a gown, and a mask. E48 then verified reaching out of R12's doorway while wearing a gown and mask to grab a pulse oximeter in the hallway outside of R12's room. On 03/05/14 at 5:18 p.m., E1, Administrator, stated staff should not fill a resident in droplet isolation precautions drinking cup in the doorway of the room. E1 stated, "They (facility staff) know better. They are supposed to take in disposable cups of ice." On 03/05/14 at 11:40 a.m., E1, Administrator, stated the square area outlined in red tape on the floor of R12's room is the, "clean" area where facility staff is supposed to apply gloves, a gown, and a mask prior to providing care to R12. E1 then stated that staff should not be standing in the square area on the floor outlined in red tape in R12's room wearing gloves, a gown, or a mask after providing care to R12. 5. Facility's Isolation List dated 03/03/14 documents R3 is in droplet isolation precautions and R106 is in contact isolation precautions. On 03/06/14 at 1:05 p.m., Z6, Oxygen tank supplier and filler, entered R11's room, applied a gown, gloves, and a mask and exchanged R106's oxygen tank with a full one. Z6 then removed the gown, gloves, and mask and exited R106's room pushing the empty oxygen tank into the facility's C Hall. Z6 did not wash Z6's hands before exiting R106's room. The empty oxygen tank from R106's room remained parked in the facility's C Hall while Z6 entered R3's room, applied gloves, a gown, and a mask, and exchanged R3's oxygen tank with a full one. Z6 then removed the gloves, gown, and mask and exited R3's room pushing the empty tank into the facility's C Hall. Z6 did not wash Z6's hands before exiting R3's room. Z6 then pushed the empty oxygen tanks from R3 and R106's rooms through the facility's C Hall and pushed the tanks outside through the facility's B Hall exit door. Z6 did not apply gloves before handling the empty tanks. Z6 verified not washing Z6's hands after exiting R3 and R106's rooms and stated Z6 does not disinfect the empty tanks until after they are refilled outside the facility. Facility's undated Droplet Precautions policy does not address the handling of equipment used in droplet isolation precautions rooms. Facility's undated Contact Precautions policy documents, "Remove gloves and wash hands before leaving the resident's room. After glove removal and hand washing do not touch potentially contaminated environmental surfaces or items in the resident's room to avoid transfer of microorganisms to other residents, staff or environments." Facility's Isolation List dated 03/03/14 documents R4 is in droplet isolation precautions. On 03/10/14 at 2:00 p.m., R4 was sitting in a wheelchair in the facility's C Hall television lounge. R4 was wearing a gown and a mask over R4's tracheostomy site. R4 did not have a mask over R4's nose and mouth and was not wearing gloves. E29, Respiratory Therapist verified R4 was not wearing all protective equipment required for droplet isolation precautions. Facility's undated Droplet Precautions policy documents, "When transport or movement (of a resident) is necessary, minimize resident dispersal of droplets by having the resident wear a mask." R17's Care Plan dated 02/09/14 documents, "The resident is in droplet isolation precautions due to Acinetobactor in sputum." On 03/04/14 at 10:10 a.m., E29, Respiratory Therapist, performed tracheostomy care on R17. E29 stated E29 was, "unsure," of which organism is requiring R17 to be in droplet isolation precautions. 6. On 2/24/14 from 11:18 a.m. and 12:00 p.m., E4 (Licensed Practical Nurse) administered medications to R5, R7, R8, R9, and R10 without washing E4's hands in between residents. On 2/24/14 at 11:55 a.m., E4 (Licensed Practical Nurse) administered insulin subcutaneous to R5 and re-capped the needle prior to disposing in the sharps container. On 2/25/14 at 10:48 a.m., E2 (Director of Nursing) stated nurses should wash hands in between each resident on medication pass. E2 stated nurses should never re-cap a needle prior to disposal. An Hand Washing Policy (date unknown), documents hand washing will be done before dispensing medications. An Infection Control Policy (date unknown), documents needles shall not be recapped, broken, or bent prior to disposal. 7. On 3-1-14 at 6:00 a.m., two linens carts were left uncovered with washcloths falling out on to the floor and linens stocked on top of the linen carts. On 3-1-14 at 6:02 a.m., E27 (CNA) stated the uncovered linen carts are used for two hallways. A room roster list dated 3-1-14 documents the following residents reside on the two hallways ( R1- R5, R8, R11-R12, R16-R17, R32-R33, R35-R61, R106). On 3-1-14 at 5:30 a.m., E24 (CNA) states, "This is my first night working here. I do not have a clue why the residents are in isolation. I just try to wear gloves in the rooms." 8. A facility Infection Control log was last updated on 2/19/14. On 3/10/14 at 10:20 a.m., E4 (Wound Nurse) stated the Infection Control Log should be updated daily. E4 verified the Infection Control Log was last updated on 2/19/14. E4 stated E4 has not had time to update the log with new infections or discontinue any infections that may have resolved. E4 stated there are residents with infections that are not on the Infection Control Log. On 3-3-14 at 1:10 p.m., E4 (LPN/Infectionist) states, "I use to make rounds every morning to ensure infection control procedures are being followed, but I have not been able to for quite a while. No staff are monitoring/ensuring that infection control procedures are being followed." 9. On 3/10/14 at 9:00 a.m., E1 (Administrator) stated E1 was only able to provide documentation of two inservices for the year 2013. E1 verified no inservice documentation was provided for infection control training. A Resident Census and Conditions of Residents report dated 3/3/14 and completed by E3 (Care Plan Coordinator) documents there are currently 102 residents residing in the facility. On 3-5-14 at 11:05 a.m., an Immediate Jeopardy was identified to have begun on 2/25/14. E1 (Administrator) was notified of the Immediate Jeopardy on 3-5-14 at 11:05 a.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3-6-14 at 4:40 p.m., all infection control policies and procedures had been reviewed and a binder with all infection control policies and procedures were made available to all staff by the Administrator (E1). 2. On 3-5-14 at 4:40 p.m., all staff in-servicing was started and will continue until all staff have been in-serviced on the following areas by E1: the types of isolation; what personal protective equipment to use for which isolation; policy and procedure for glucose meter disinfecting; policy and procedure for handwashing; policy and procedure to cleaning an isolation room to include changing of mop water; and policy and procedure for handling lines. 3. On 3-5-14 at 4:40 p.m., E1 (Administrator) monitor all residents of the facility for any signs and symptoms of infection. 4. On 3-5-14 at 4:40 p.m., E1 (Administrator) initiated daily rounds and weekly chart audits to monitor the effectiveness of the infection control policies and procedures.

Based on interview and record review, the facility failed to train staff in the use of emergency manual resuscitator bags to ventilate four of four residents (R3, R12, R16 and R17) in the sample of 21 and three residents (R49, R56 and R106) on the supplemental sample, all of whom are ventilator dependent. The facility also failed to train all staff in emergency preparedness evacuation for all residents. This failure had the potential to affect all 102 residents living at the facility and resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 3/7/13, the facility remains out of compliance at Severity Level Two. Additional time is needed for the facility to monitor the effectiveness of the inservices and implementation of the newly revised policies and procedures for emergency evacuation. Findings include: E29 (Respiratory Therapist) stated on 3/5/14 at 12:15 PM that E29 has worked at the facility for 12 to [AGE] years and, "There has never been a drill done for evacuating this Unit (C Hall Ventilator Unit.) I think we would use our generator policy for evacuation." E5 (Certified Nurse Aide (CNA)) stated on 3/5/14 at 12:05 PM, "It would take all of our staff to just get the C Hall residents out for evacuation. We have never had an inservice or drill on evacuation since I have worked here." The Nurse Aide Roster dated 3/4/14, which the facility completed for the survey, indicated that E5 was hired in May 2009. E11 (CNA) stated on 3/6/14 at 11:30 AM that E11 has worked at the facility since October 2013, normally working on the C Hall. E11 said that since E11 was hired, E11 has not received any training on using the manual resuscitator bag. E11 said that in order to work on C Hall, "it is a must to know how to use it." E11 said that E11 knows how to use the bag because E11 also worked at the facility about two years ago, and E11 received training on how to use it then. E11 stated, "Quite a few CNA's that work down on C Hall do not know how to use them." E11 also stated that, "Adequate training is not done for the whole building." E30 (CNA) stated on 3/6/14 at 10:05 AM, "I have not been trained to use a (manual resuscitator bag) on a ventilator patient. I have been here about one month and one week. I do not even know what that is." The Nurse Aide Roster dated 3/4/14, which the facility completed for the survey, indicated that E30 was hired on 2/11/14. E4 (Licensed Practical Nurse) stated on 3/6/14 at 10:15 AM, "We have seven ventilator dependent residents on C Hall. I have worked here eight years , and we have never done a drill to evacuate the building. I have not seen a plan of the procedure to evacuate the residents. I think there would be an issue in having enough people to get out (evacuate) C Hall residents. We would have to call 911 because the ventilators would only have a 30 minute backup, then they (ventilator dependent residents) would need to be bagged. [MEDICAL CONDITION](resident with a [MEDICAL CONDITION]) has an emergency kit with a bag at the bedside." E29 (Respiratory Therapist) stated on 3/6/14 that the last staff inservice involving the use of manual resuscitator bags was on 11/1/13. E29 said that administrative staff have not been regularly notifying E29 when newly hired CNA's are to start working on C Hall. E29 stated that E29 thought that information on the use of the bags should be included in the staff "hire packet." E29 said, "I feel all CNA's and nurses in the building should be inserviced on using the (manual resuscitator bag.) E22 (Maintenance Supervisor) stated on 3/6/14 at 9:20 AM, " We have not had an evacuation drill in the facility in the last three years since I have been here. We have policies and procedures in place of how to get them (the residents) out and where to take them (the residents.) Ventilator patients would be bagged and taken out to the parking lot, then the hospital would provide ambulances for transportation." E1 (Administrator) stated on 3/6/14 at 1 PM that the facility has an evacuation policy/procedure, but that the policy does not delineate how often the procedure is to be practiced. E1 stated, "I would want to do it (evacuation drill) annually. I do not know when this was last done here (at the facility.) I came last May." E1 also stated that there was no specific evacuation policy/procedure for evacuation of ventilator patients. E1 said that Nurses and CNA's would be responsible for manually ventilating the ventilator dependent residents in an emergency if the back-up batteries in the mechanical ventilators failed. E1 said that CNA's are to receive manual resuscitator bag training annually and "as soon as possible for new hires." The facility's undated Emergency Disaster Manual addressed the issue of an emergency building evacuation on the third page of the document. The manual gave general instructions for evacuation, but provided no procedural instructions to staff for evacuation of the C hall ventilator unit nor any information as to how often building evacuation drills are to be done. A facility resident room roster dated 3/3/14 and provided by the facility indicated that the facility currently had seven ventilator dependent residents on C Hall (R3, R12, R16, R17, R49, R56 and R106) The Centers for Medicare and Medicaid Services (CMS) form # 672 completed by the facility indicated that the resident census was currently 102. The Immediate Jeopardy was identified on 3/6/14 at 5:15 PM, when E1 and E46 (Corporate Nurse) were notified. The Immediate Jeopardy began on 2/11/14 when E30 (CNA) was hired, and the facility failed to train E30 on the emergency use of a manual resuscitator bag. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Inservicing done by Respiratory Therapists on the use of a manual resuscitator bag on a ventilator resident began immediately on 3/6/14 and continued until all Nurses and CNA's coming to work on shifts at the facility were trained by 3/7/14. 2. On 3/7/14, the evacuation policy and procedure was reviewed and revised to include the emergency use of a manual resuscitator bag on a ventilator resident. 3. The facility will perform a simulated full evacuation of residents by 4/30/14.

Based on interview and record review the facility failed to remove E42 (CNA/Certified Nursing Aide) and E1 (Administrator) from having direct contact with residents after each was alleged to have abused R1. E42 returned to R1's room and made further threats and E1 was allowed to conduct the investigation of the allegation of abuse by E1. This had the potential to affect all 102 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 3-6-14 at 6:10 p.m., the facility remains out of compliance at a severity level two as the facility is still educating management and staff on the Abuse Prohibition Policy. Findings include: A facility Abuse Policy dated 1-1-2012 documents, "Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within hearing distance. Examples of verbal abuse include threats of harm or saying things to harm a resident. When a report is made of suspected abuse of a resident indicating an involvement of an employee, the employee should be suspended pending an investigation." 1. R1's Minimum Data Set ((MDS) dated [DATE], documents R1 is cognitively intact, with a Brief Interview for Mental Status Score (BIMS) of 15 . On 3-5-14 at 11:50 a.m., E5 (CNA)stated R1 reported to E5 that E1 (Administrator) and E3 (Care Plan Coordinator) went into R1's room last night (3-4-14) and were very rude. E5 stated R1 felt like E1 and E3 were nazis. E5 stated R1 states, "You would not believe how (E1) and (E3/Care Plan Coordinator) talked to me." E5 stated E5 does not know who to report this allegation to since E1 is who R1 made the allegation against, and E1 is the Abuse Coordinator. On 3-5-14 at 12:10 p.m., R1 stated E1 and E3 came into R1's room last night around 8-8:15 p.m., and started questioning R1 about E42 alleged abuse. R1 stated E1 and E3 were very intimidating, rude, and verbally abusive. R1 stated E1 informed R1 that R1 would be discharged home within two weeks. R1 states, "I cannot even defend myself. I am stuck in this bed." On 3-5-14 at 2:00 p.m., E5 stated R1 reported to E5 that E43 (Social Service Director) and E1 interviewed R1 regarding the verbal abuse allegations from E1 and E3. E5 states, "Isn't that confrontational that the accused abuser confronted the resident that accused them?" On 3-5-14 at 12:20 p.m., E1 (Administator) verified E1 and E3 talked to R1 last night about the allegations made against E42 yesterday. E1 stated E1 and E3 also talked to R1 about going home. E1 stated E1 never talks to R1 alone. E1 was then informed of allegations made by R1 of verbal abuse by E1 and E3. On 3-5-14 at 12:22 p.m., E1 immediately notified E47 (Facility Manager) via telephone of R1's alleged verbal abuse from E1 and E3. E1 stated E47 instructed E1 to do the investigation, as always, regarding R1's allegations of verbal abuse by E1 and E3. On 3-6-14 at 9:20 a.m., E43 (Social Service Director) stated E43 and E1 interviewed R1 last night. E43 stated R1 reported to E43 and E1 that E1 and E3 were playing "bad cops." E43 stated R1 felt like E1 and E3 were "nazis." E43 stated R1 does not make up things and does not have behaviors. E43 stated it would be considered abuse if CNA's or other staff would curse in front of a resident. 2. On 3-4-14 at 1:50 p.m., R1 reported about a month and a half ago that, E42 went down to R1's room, pointed in R1's face and said,'I have been stabbed and punched before, and you don't scare me. Don't ever call me daddy again." R1 states R1 then replied to E42, "I cannot even get out of this bed. What do think you are going to do to me." R1 stated R1 reported the incident to E17 (CNA) that same night and E17 (CNA) notified E1 (Administrator) and E3 (Care Plan Coordinator) several days later about the occurrence between R1 and E42. R1 stated after E1 and E3 were notified, E1 and E3 went down to R1's room and told R1, "Who do you think you are the Queen of Galesburg Terrace? You cannot do a thing about it. Keep your nose out of the C.N.A.'s business. You are stuck here." On 3-4-14 at 1:45 p.m., E5 (CNA) stated E5 reported that E1, E3, and E42 were verbally abusive to R1, to E2 (Director of Nursing/DON) around a month ago. E5 stated E1 and E3 always go into resident rooms together to "Cover for each other." On 3-4-14 at 2:25 p.m., E2 (DON) stated approximately one to two months ago, E2 was notified that R1 was afraid of E42. E2 stated R1 felt threatened because E42 stated to R1, "If it gets back to me that you (R1) reported me, I will know who did it." E2 stated E2 reported the allegation to E1 and E3 immediately. E2 stated E42 remained working,in direct resident care, in the facility, following the allegation, for approximately two days, before E42 finally resigned. E2 stated no abuse investigation was started at that time. On 3-4-14 at 2:40 p.m., E17 (CNA) stated the following: On either 1-23-14 or 1-24-14, R1 said to E42, "Who are you, (E17's) daddy." E42 then replied to R1, " If anyone tried to hurt (E17) I would kill them. Do not ever call me daddy in front of (E17) again." Later on that night, R1 reported to E17 that E42 returned to R1's room, and stated to R1, "If anyone tries to get in my way I will mess them up or kill them." E17 did not report the occurance to E2 (DON) and E3 (Care Plan Coordinator) until the next day. After E17 reported the occurrence, E2 and E3 counseled E17 and E42 about talking about personal business and stalking each other at work. E42 worked the rest of that night and another night, and then resigned. E1 (Administrator) and E3 talked to R1 following the allegation against E42. R1 reported to E3, " I felt scared and threatened by (E42) when (E42) yelled at me." On 3-4-14 at 3:05 p.m., E1 stated E1 has never received any allegations of abuse involving E42 or R1. E1 stated the situation between E17 and E42 was not resident abuse. E1 stated, "(R1) put (R1's) self right in the middle of E17 and E42, because the CNA's have talked to (R1) at separate times about personal business." E1 stated, "(R1) was just being nosey." E1 stated E2 had pulled the two CNA's (E17 and E42) in E2's office to discuss the disagreement between E17 and E42. E1 stated E42 was a no call no show the next day. E1 stated E1 could not find any documentation regarding E17 and E42. E1 stated, "(E2) must have it." On 3-4-14 at 3:05 p.m., E3 (Care Plan Coordinator) stated no allegations were ever made about E42 being threatening or rude to R1. E3 stated E17 and E42 were counseled about talking about their personal lives in resident rooms. E3 stated the only thing E1 and E3 have talked to R1 about, is R1's placement. On 3-10-14 at 11:50 a.m., E42 stated E42 and E17 were pulled in E2's office. E42 stated E17 reported E42 was sexually harassing E17. E42 stated E17 and E42 do talk in R1's room, at times, about personal issues. E42 stated R1 did say "you are old enough to be (E17's) daddy." E42 stated E3 told E42 that R1 reported E42 said something about being arrested in R1's room. E42 stated E42 knows E3 ran a criminal background check after R1 made allegations against E42. E42 also verified E2 (DON) and E3 (Care Plan Coordinator) counseled E17 and E42 about talking about personal issues in resident rooms. E42 states, "I was never suspended. I quit because I did not get 3rd shift hours." According to the CMS 672 Census and Condition Report dated 3-3-14 and signed by E3 (Care Plan Coordinator), 102 residents currently reside in the facility. On 3-6-14 at 1:05 p.m., an Immediate Jeopardy was identified to have begun on 1-24-14 when R42 allegedly verbally abused R1 (CNA) and was allowed to continue to have direct contact with residents, following the allegation. E1 (Administrator) was notified of the Immediate Jeopardy on 3-6-14 at 1:05 p.m. The surveyor confirmed through interview and record review that the facility took the follwing actions to remove the Immediate Jeopardy. 1. On 3-6-14 at 6:10 p.m., all abuse policies and procedures had been reviewed by the facility corporate nurse (E46). 2. On 3-6-14 at 6:10 p.m., all staff in-servicing was started and will continue until all staff have been in-serviced on the following areas by E46 (Corporate Nurse): The types of abuse, Immediate reporting, Who to report to, and the investigation process. 3. On 3-6-14 at 6:10 p.m., E46 (Corporate Nurse) will conduct the abuse investigation regarding R1's allegations. 4. On 3-6-14 at 6:10 p.m., all residents of the facility will be monitored for any complaints or signs/symptoms of abuse.

Based on observation, interview, and record review the facility failed to provide necessary equipment and assistance with activities of daily living for four of twenty one residents (R1, R3, R11, R15) reviewed for accommodation of needs in the sample of twenty one. These failure resulted in R1 feeling "incarcerated" (in solitary confinement) in the facility. Findings include: 1. R1's February 2014 Physician order [REDACTED]. R1's current Minimum Data Sheet dated 12-1-13, documents R1 is cognitively intact. On 2-24-14 at 11:05 a.m., R1's hair was matted, oily, and up in a pony tail. R1 had a strong body odor. On 2-24-14 at 11:05 a.m., R1 states, "I would love to have a shower and my hair washed, but the staff never have time. I would like to get up every day into my chair, but the facility does not have a (mechanical) lift sling to get me up. I never get out of this bed. I am incarcerated here." On 3-10-14 at 10:15 a.m., E5 (Certified Nursing Assistant/CNA) stated R1 is suppose to be transferred to the wheelchair twice a day using a mechanical lift with a sling. E5 stated the facility has not had a sling, to use, to transfer R1 to the wheelchair, so R1 has had to stay in bed. E5 stated the facility has not had enough mechanical lift slings for at least one year. E5 stated R1 does not receive showers on day shift. On 2-25-14 at 2:10 p.m., E20 (CNA) stated the staff only have one mechanical lift sling to transfer residents to their wheelchairs, with the mechanical lift. E20 stated E20 can not transfer R1 to the wheelchair because the facility does not have a mechanical lift sling to fit R1. On 2-25-14 at 2:10 p.m., E20 attempted to transfer R1 up to the wheelchair three times with a split leg sling, but R1 yelled out in pain with every attempt. E20 states, "this is not the right sling to use, but we do not have a full body sling that we normally use to get (R1) up to the chair." E20 was unable to transfer R1 to the wheelchair from the bed. E20 states, "(R1) never gets a shower because the staff cannot transfer (R1) to a wheelchair, due to not have a mechanical lift sling to fit (R1)." On 2-25-14 at 10:30 a.m., E11 (CNA) stated R1 only gets bed baths. Ell states, "I am not sure why we don't give (R1) showers." On 2-25-14 at 12:00 p.m., R1 states, "I have only received two showers since I have been here (May 2013). I would love to have my hair washed. It would feel so good." R1's CNA weekly shower body checklist dated 1-1-14 through 2-21-14, did not include a shower ever being given to R1. 2. R11's March 2014 physician order [REDACTED]. On 03/04/14 R11 was unable to respond correctly or appropriately to questions posed. The 03/02/14 fall documentation for R11 , provided by E3,the Minimum Data Set (MDS)/Care Plan Coordinator on 03/06/14, indicates that R11 was assessed after a fall to not be able to physically use R11's call light. On 03/06/14 at 10 A.M. R11's current call light was of the push button on a cord type of device. E14, Licensed Practical Nurse (LPN), verbally confirmed on 03/06/14 at 10:05 A.M.that R11 could not physically use the call light system currently available for R11's use in R11's room. E14 stated no awareness of R11's need for a different type of call light being addressed at this time. 3. On 2/26/14 at 1:30 p.m., E11 (Certified Nursing Assistant), states R3 gets up every other day because we don't have enough wheelchairs and she shares a wheelchair with another resident. On 3/3/14 at 12:00 p.m., Z5, (R3's family member), states we don't think they ever get R3 up in her w/c. On 3/4/14 at 9:15 a.m., E5 (Certified Nursing Assistant), states R3 shares a geri chair with R56. Today is not R3's day to get up. On 3/4/14 at 11:00 a.m., E5(Certified Nursing Assistant), states we have at least ten resident that use mechanical lift slings. We maybe have six slings back here, we never have enough slings to use. On 3/4/14 at 11:10 a.m., E11 (Certified Nursing Assistant), states we have at least eight mechanical lift residents. It depends on the day for the number of slings we have. We run out of them all the time and then residents aren't able to get up. If a sling gets wet or soiled we don't have extras to use in place of them. A lot of our slings are torn so we don't use them due. We let administration know multiple times that slings are torn and they haven't been replaced. 4. On 03/03/14 at 9:35 a.m., 11:20 a.m, and 1:15 p.m., R15 was resting in bed. The call light for R15's room had one string which was hanging down between R15's bed and R91's (roommate) bed and not within reach for either R15 or R91. On 03/04/14/at 9:50 a.m., E22 (Maintenance Supervisor) confirmed the call light was not adequate and stated that he (E22) would fix it.

Based on interview, observation and record review, the facility failed to provide nail care for one of two residents (R16) reviewed for non-pressure related wounds in the sample of 21. This failure resulted in R16 developing a painful right great toe wound due to nail overgrowth. Based on interview and record review, the facility failed to develop a pain management plan for three of 11 residents (R1, R14, and R15) reviewed for pain in the sample of 21. Based on interview and record review, the facility failed to implement interventions for a resident receiving [MEDICAL TREATMENT] for one resident (R58) reviewed for [MEDICAL TREATMENT] in the sample of 21. Findings include: A. R16's Face Sheet documents R16 was admitted to the facility on [DATE]. R16's Minimum (MDS) data set [DATE] documents R16 requires total dependence with one person physical assist to perform personal hygiene cares. On 03/03/14 at 3:07 p.m., R16 was laying in bed. R16's right foot was propped on a pillow, and R16's right great toe was red and shiny. A small open area draining red fluid was present on the tip of R16's right great toe. R16, who is nonverbal, stated per written note that Z2, facility's previous Podiatrist, left some time ago, and it took a long time to fill the position. R16 then stated that R16's toenails had never been cut by facility staff, causing R16's toenail to grow into the tip of R16's right great toe, resulting in Z3, facility's current Podiatrist, addressing and treating R16's right great toe. On 03/04/14 at 11:10 a.m., R16 was laying in bed with R16's right foot propped on a pillow. R16's right great toe was red and shiny. A small open area was present on the tip of R16's right great toe. R16 stated, "It (R16's right great toe) hurts like Hell." On 03/06/14 at 2:00 p.m., E5, Certified Nurse's Aide, stated, "(R16) has bad toes. I don't cut them and never have." Fax cover sheet dated 03/05/14 from Z2, facility's previous Podiatrist, documents Z2 never treated R16. This same form also documents Z2 no longer treated residents at the facility after 10/22/13. On 03/11/14 at 2:18 p.m., Z3, facility's current Podiatrist, stated Z3 began seeing residents at the facility in late December 2013. R16's Podiatry Notes document R16 was seen by Z3, facility's current Podiatrist, on 01/29/14 and 03/05/14. Z3's Podiatry Note for R16 dated 01/29/14 documents R16's toenails are long, thick, and painful on both feet. R16's Physician order [REDACTED]." R16's Physician order [REDACTED]. For every change, clean right big toe with sterile saline, dry with guaze and apply [MEDICATION NAME] daily." On 03/10/14 at 9:33 a.m., Z3, facility's current Podiatrist, stated R16 had a blood collection under R16's right great toenail. Z3 then stated that this could have resulted from the overgrowth of R16's toenail. Z3 verified R16 currently has a wound on R16's right great toe, and has daily wound care and dressing orders in place. On 03/06/14 at 11:20 a.m., E4, Licensed Practical Nurse, provided wound care to R16's right great toe. R16 began grimacing as soon as E4 began cleaning R16's right great toe and continued grimacing until E4 completed the treatment. R16's right great toe was red and shiny, and began draining red drainage after E4 cleaned R16's right great toe. R16 then stated per written note that R16's right great toe is extremely painful when touched. On 03/10/14 at 8:45 a.m., E3, Care Plan Coordinator, could not confirm or provide any documentation verifying R16's toenails had been cut by facility staff from R16's date of admission to the facility until R16 was seen by Z3, Facility's current Podiatrist on 01/29/14. B. The facility's undated Pain Management Policy states that the Pain Assessment protocol will be initiated under the following situations: Any indication of pain based on the Pain Assessment performed for each resident at admission, quarterly and with any condition change associated with the potential for pain, When MDS (Minimum Data Set) triggers an indication of pain, Resident receives routine pain medication and /or pain is not controlled. This policy instructs staff to use a pain rating scale and that pain will be assessed during routine medication passes. 1. The initial Minimum (MDS) data set [DATE] and the quarterly reassessment dated [DATE] indicate that R14 has frequent pain,rated at 6 on a 1 - 10 scale. R14's clinical record includes no comprehensive pain assessment. On 03/04/14 at 8:20 a.m., E3 (Care plan Coordinator) stated that a Pain Assessment should have been completed on R14, and it should be in R14's chart. On 03/04/14 at 12:00 p.m., E1 (Administrator) reviewed R14's clinical record and verified that no Pain Assessment was present. A Physical Therapy assessment dated [DATE] states that R14 was referred to Physical Therapy after sustaining a fall and complaining of shoulder pain. A physician order [REDACTED]. The care plan dated 01/28/14 states that R14 has back and foot pain, but does not address R14's shoulder pain or headaches. The February and March 2014 Medication Administration Records document that nurses administer [MEDICATION NAME] 325 milligrams one or two tablets twice daily, but nurses did not document the number of tablets administered. The February Medication Administration Record [REDACTED]. The nurses did not rate R14's pain prior to administration of [MEDICATION NAME] or [MEDICATION NAME] and did not evaluate effectiveness of the [MEDICATION NAME] medication. 2. The February 2014 physician's orders [REDACTED]. R15's clinical record included no Pain Assessment. On 03/04/14 at 12:00 p.m., E1 (Administrator) stated that R15's Pain Assessment should have been in her clinical record. The care plan dated 01/26/14 stated that R15 has osteoarthritic pain and instructs nurses to use the pain scale to assess pain. The Medication Administration Record [REDACTED]. 3. On 2-24-14 at 11:05 a.m., R1 stated R1's right hand and right thumb hurts terrible. R1 states, "around a month ago, a CNA (Certified Nurse's Aide) caught my right thumb between the bed rail and over the bed table, and it feels like my thumb has been broke ever since. I have asked for an X-Ray numerous times, but the staff just ignore me." On 2-26-14 at 11:00 a.m., E11 (CNA) stated R1 has complained of pain to the right hand "for at least a month." E11 stated R1 told E11 that a CNA (E19) caught R1's hand between a bed rail and a side table. On 2-26-14 at 11:45 a.m., E19 (CNA) stated R1 complains of pain daily to the right hand. On 2-26-14 at 1:20 p.m., E7,LPN (Licensed Practical Nurse) states, "The CNA's have never reported to me that (R1's) hand was hurting, so I have not contacted (R1's) Physician or done a pain assessment." On 2-26-14 at 2:00 p.m., E4 (LPN) stated R1 has complained of pain to the right thumb for at least two weeks. E4 stated R1 reported to E4 that a CNA had caught R1's right thumb in a bed sheet or bed rail. E4 states, "I don't think the Physician had been notified of (R1's) hand hurting." On 2-26-14 at 2:45 p.m., E2 (Director of Nursing) stated the staff should have notified the Physician and reported R1's pain to the right hand/thumb. R1's nurses' notes from 11-1-13 to 2-24-14 do not contain any documentation of R1's incident involving R1's right hand, R1's complaints of right hand/thumb pain, or the Physician and E2 (DON) being notified of R1's complaints of pain. 4. On 2-24-14 at 11:05 A.M., R1's right and left great toe nails had crusty red drainage and were reddened at the edges of the nails. On 2-24-14 at 11:05 a.m., R1 stated, "I need to go to the Doctor's office to get my nails removed, but the facility cannot provide me transportation." R1 also states, "my toenails have hurt me for several months, and nobody treats them." On 2-24-14 at 1:15 p.m., E7 (LPN/Licensed Practical Nurse) states, "(R1) does not have anything to treat the great toes. I am not sure that the Doctor is even aware." R1's Nurses Notes dated 1/1/14 through 2/23/14 do not document the condition of R1's toes. On 2-25-14 at 10:30 a.m., E11 (CNA/Certified Nursing Assistant) states, "(R1's) toe nails have had bloody drainage for at least one month. (R1) does not like (R1's) toes touched because it causes too much pain." On 2-25-14 at 11:10 a.m., Z2 (R1's previous Podiatrist) stated R1 is Diabetic and has a terrible time with ingrown toe nails that become infected and painful. Z2 stated Z2 only treated R1 once every two months. Z2 stated the facility should have "at least" called Z2, another Podiatrist within the area of the facility, or R1's Physician, if R1 continues to have pain, drainage, or redness to the great toes, between Z2's visits to the facility. Z2 stated the facility has never notified Z2 between the scheduled every two month visits, about R1's pain, redness, or drainage to the great toenails. Z2 states, "I just don't feel like the facility is "In tune" to their residents there." On 2-25-14 at 11:30 a.m., Z3 (R1's current Podiatrist) stated the facility should call either another Podiatrist within the area of the facility to look at R1's toes, or at least notify R1's Physician if R1 continues to complain of pain or has bloody drainage to the great toes. Z3 stated Z3 only visits the facility once a month. C. R58's Physician order [REDACTED]. On 3/5/14 at 11:25 a.m., E4 (Licensed Practical Nurse), stated, "If a patient is on fluid restrictions they would be on Intake/Output tracking. (R58) should be on Intake/Output unless we ran out of the tracking sheet and they didn't replace it." On 3/5/14 at 12:05, E5 (Certified Nursing Assistant), stated, "We do not keep Intake/Output on (R58). I didn't know (R58) had a fluid restriction. We don't keep track because (R58) does everything for (R58). I didn't know (R58) was suppose to be on Intake/Output. I fill out the Intake/Output sheets for who it says on the forms." On 3/5/14 at 1:40 p.m., E4 (Licensed Practical Nurse), stated, "We don't have anything on our Medication Administration Record [REDACTED] maintenance and cares on (R58's) fistula. I am unsure of where the fistula is located. I don't do anything with the site. I don't check for bruits or thrills. We have no formal communication between [MEDICAL TREATMENT] and our facility." On 3/6/14 at 9:15 a.m., R58 stated, "I have been on [MEDICAL TREATMENT] for about a year. I have a fistula in my left arm. They do not check my fistula for bruit or thrills. They don't do nothing with it. I'm suppose to be on a fluid restriction for [MEDICAL TREATMENT] but they don't follow it." On 3/6/14 at 9:25 a.m., E15 (Dietary Supervisor), stated, "Dietary cards are printed with each meal. Our cards state how much fluid (R58) gets with each meal but does not include nursing amounts." Facility's undated [MEDICAL TREATMENT] Hemo: AV Fistula or Graft Care Policy documents procedure upon returning from [MEDICAL TREATMENT] treatment: ascultate fistula/graft for swishing bruit indicating active circulation to area, palpate fistula/graft for buzzing/pulse sensation thrill indicating patency to area. R58's March and February 2014 Medication Administration Records, Treatment Administration Records and Physician order [REDACTED]. regarding R58's left upper arm [MEDICAL TREATMENT] fistula. R58's admission orders [REDACTED] document R58 attends [MEDICAL TREATMENT] three days per week, a daily fluid restriction and a [MEDICAL TREATMENT] dietary supplement with each meal. Facility's undated Fluid Restriction Policy documents "Procedure: in general the nursing staff will use a designated amount of fluid for medication pass and dietary staff will use the remaining cc (cubic centimeters) intake for meal service and bedtime snack. Inform all appropriate facility staff. Dietary documentation must reflect the number of cc intake ordered from the physician and the amount of cc intake the resident is receiving from the dietary department and the nursing department." On 3/6/14 at 9:15 a.m., E41 (dietary), stated, "Dietary does not give ([MEDICAL TREATMENT] dietary supplement) to (R58)." On 3/10/14 at 2:00 p.m., E4 (Licensed Practical Nurse), stated, "Yes we provide ([MEDICAL TREATMENT] dietary supplement) for (R58). Nursing gives ([MEDICAL TREATMENT] dietary supplement) to (R58). I am not sure without looking of when (R58) gets ([MEDICAL TREATMENT] supplement). I have not given (R58) any today. No fluids are given from nursing to (R58). I Need to ask CNAs if water is kept in (R58's) room. On 3/10/14 at 2:15 p.m., E1 (Administrator), stated, "I would have to check policy, but most places is once a day to check fistulas. Nursing would administer ordered ([MEDICAL TREATMENT] dietary supplement) and it should be on the Medication Administration Record. A [MEDICAL TREATMENT] resident should be on Intake/Output and weight frequency would be up to the physician.(R58's) fluid restriction is on the Physician order [REDACTED]. being broke down and in what places, I would have to ask the dietary supervisor. Facility's undated Intake and Output Recording (Fluid Balance Monitoring) policy, documents, "Intake and output should be initiated as follows: I.V., fluids, enteral feedings, foley catheter, [MEDICAL TREATMENT] residents, whenever ordered by a physician. Record all liquid intake. [MEDICAL TREATMENT] residents will have Intake/Output done only if on fluid restriction." R58's [MEDICAL CONDITION]-[MEDICAL TREATMENT] Comprehensive Care Plan dated 3/4/14 documents the following interventions: "Maintain the resident's graft, fistula and/or catheter per protocol, dietary to provide 1440 milliliters daily and nursing provides 560 milliliters daily, post [MEDICAL TREATMENT] monitoring: follow physician orders [REDACTED]."

Based on observation, interview, and record review, the facility failed to identify skin breakdown for one of seven residents (R7) reviewed for pressure ulcers in the sample of 21. R7 complained of moderate to severe pain in the left buttock area and had a large open pressure ulcer, unknown by the facility, on the buttocks. The facility failed to have an ongoing program to monitor and assess skin breakdown for three of seven residents,(R7, R1 and R3,) reviewed for pressure ulcers in the sample of 21. Findings include: 1. A Physician order [REDACTED]. On 3/3/14 at 1:30 p.m., E4 (Licensed Practical Nurse/Wound Nurse) provided a treatment to a wound on R7's right heel. E4 stated "there's no treatment to R7's buttocks that I am aware of." On 3/4/14 at 9:40 a.m., E35 (Certified Nurse Aide) and E37 (Certified Nurse Aide) provided incontinence care for R7. R7's buttocks did not have any treatment in place. R7 had an approximate two centimeter open area at the bottom of R7's left buttock. R37 stated "we put a barrier cream on (R7's buttocks) several times a day." R37 stated R7 has experienced ongoing skin problems on her buttocks. On 3/4/14 at 9:50 a.m, R7 stated "it's (buttocks) very sore. I've had diarrhea and sittting in that wheelchair doesn't help." On 3/4/14 at 10:10 a.m., E4 (Licensed Practical Nurse/Wound Nurse) stated "I am not aware of any open area on (R7's buttocks)." On 3/4/14 at 11:55 a.m., E3 (Care Plan Coordinator) stated "I have no idea about (R7) having an open area. If (E4) doesn't know about it, I sure don't." On 3/5/14 at 9:00 a.m., R7's Treatment Administration Record did not document any assessment of R7's open area on the left buttock. On 3/5/14 at 9:03 a.m., E44 (Licensed Practical Nurse) stated "I have not seen (R7's wound). I did hear about (R7's wound) in report and faxed (R7's) doctor to get a treatment order. (R7's) wound hasn't been assessed according to her chart." On 3/5/14 at 9:50 a.m., E4 (Licensed Practical Nurse/Wound Nurse) stated "I haven't had a chance to assess (R7's) wound. I can't tell you what type of a wound (R7) has. I've been working the floor and haven't had time to do any wound assessments. The Pressuer Ulcer Log hasn't been updated in a couple weeks. I should be updating the log weekly." A weekly pressure ulcer log dated 2/21/14, does not document R7's right heel wound or the open area on R7's buttocks. 2.R1's pressure ulcer log dated 2-21-14, documents R1 was admitted on [DATE] with a stage four coccyx wound with drainage, measuring approximately 5.7 cm (centimeter) length by 2.5cm width by 1.2 cm depth. R1's coccyx wound culture dated 10-30-13, documents R1's coccyx wound is infected with Acinetobacter Baumannii, Escherichia coli, and Staphylococcus aureus. R1's Physician order [REDACTED]. On 2-24-14 at 1:15 p.m., R1's stage four coccyx wound was uncovered with large amounts of yellow drainage soaking the bed sheets and bed pad. On 2-24-14 at 1:15 p.m., E5 (Certified Nursing Aide/CNA stated R1's dressing to the coccyx wound fell off around 11:00 a.m. and E5 forgot to tell R1's nurse until 1:15 p.m. E5 stated R1's bed was soaked with wound drainage because the wound did not have a dressing. On 3-1-14 at 5:30 a.m., R1's coccyx wound was uncovered with large amounts of yellow drainage saturating the bed pad. R1 stated, "I cannot remember the last time the nurse applied a dressing to my wound. I think it was two days ago." On 3-1-14 at 5:30 a.m., E24 (Certified Nursing Aide/CNA) stated the last time E24 changed R1 was at approximately 4:30 a.m., and R1 did not have a dressing on the coccyx wound then. E24 states, "This is my first night working here, and I did not know (R1) was suppose to have a dressing on the wound. I did not tell the nurse." On 3-1-14 at 5:50 a.m., E23 states, "(R1) has not had a dressing on (R1's) wound all night since at least 10:00 p.m. I have not told my nurse that the wound doesn't have a dressing." On 3-1-14 from 5:30 a.m.- 7:00 a.m., R1's coccyx wound remained uncovered with large amount of drainage soaking R1's bedpads and sheets. On 3-1-14 at 8:30 a.m., E7 (LPN/R1's 1st shift nurse) stated E7 was notified of R1's wound being uncovered around 7:30 a.m., so E7 treated and covered the wound at that time. On 3-4-14 at 10:55 a.m., E4 (LPN/wound nurse) stated the Certified Nursing Aides should notify the nurse immediately when R1's dressing falls off of R1's coccyx wound, so the nurse can apply a new treatment. On 3-4-14 at 11:00 a.m., E7(LPN) stated the Certified Nursing Aides should notify the nurse "as soon as possible" when a dressing falls off of R1's coccyx wound, so the nurse can re-apply a new treatment. A facility pressure ulcer log was last updated on 2/21/14. On 3/10/14 at 10:20 a.m., E4 (Wound Nurse) stated the Pressure Ulcer Log is to updated on a weekly basis. On 3/10/13, E4 (Wound Nurse) verified the pressure ulcer log was last updated on 2/21/14 due to E4 working the floor and not having the time to get wound assessments completed. The General Wound and Skin Care Guidelines Policy (date unknown), documents to "document wound assessment, treatment performed and response to treatment on the appropriate documentation form. A Minimum Data Set assessment dated [DATE], documents R7 scored fourteen out of fifteen (cognitively intact) on the Brief Interview for Mental Status, is incontinent of bowel and bladder, and requires assistance with toileting needs. 3. Record review of Physician order [REDACTED]. Record review of weekly pressure log dated 2/21/14, documents that R3 has a Stage three pressure ulcer to right buttock with eschar/necrotic present. Pressure ulcer to right buttock was facility acquired on 1/22/14. Pressure ulcer to right buttock measures 3 cm(Length) x 5 cm(width) x 0.3cm(depth). Weekly pressure log dated 2/13/14, documents pressure ulcer to right buttock is a stage two with no eschar/nectrotic present and measures 3.2cm(length) x 2.5cm(width) and no depth. On 2/24/14 at 1:30 p.m., observed R3 lying on her back. Reviewed 15 minute visual check log dated 2/24/14, documents at this time R3 was on her left side from 12:00 p.m to 1:30 p.m. On 2/24/14 at 2:30 p.m., observed R3 lying on her back. Reviewed 15 minute visual check log dated 2/24/14, documents at this time R3 was on her back from 1:45 p.m. to 3:45 p.m. On 2/25/14 at 9:15 a.m., observed R3 lying in bed on her back. Reviewed 15 minute visual check log dated 2/25/14, documents at this time R3 was on her left side from 8:00 a.m to 9:45 a.m. Record review of !5 minute visual checks dated 2/18/14 thru 2/25/14, on 2/18/14 R3 was in floating position from 6:00 a.m. to 9:00 am and on her left side from 9:15 a.m. to 12:00 p.m. On 2/19/14, R3 was in floating position from 6:00 a.m. to 10:00 a.m., on her left side from 10:15 a.m. to 1:00 p.m., and on her back from 1:15 p.m. to 3:45 p.m. On 2/20/14, R3 was her left side from 8:00 a.m. to 10:45 a.m. On 2/21/14, R3 was on her left side from 8:00 a.m. to 10:45 a.m. On 2/23/14, R3 was on her left side from 1:45 p.m. to 4:00 p.m. On 2/25/14, R3 was on her right side from 10:00 a.m. to 12:45 p.m. On 2/25/14 at 9:35 a.m., E7 (Licensed Practical Nurse), states I have completed all of R3's treatments this morning. To prove we have done the treatments we sign off the Treatment Administration record. I am unsure of why the Treatment Administration record has not been signed at all from 2/14/14, start of treatment, to present for treatment to right buttock. On 2/25/14 at 1:50 p.m., E11 (Certified Nursing Assistant), states yes the 15 minute visual check list states that R3 was on her right side starting at 10:00 a.m. today. Two hours later we turned her at 1:00 p.m. to float her on her back. On 2/25/14 at 2:45 p.m., E2 (Director of Nursing), states no weekly pressure ulcer logs are available for 11/19/18, 11/26/13, 12/19/13, 1/2/14, 1/16/14, and 1/30/14. If they're not there they weren't done. On 2/26/14 at 2:35 p.m., E2 (Director of Nursing), states patients on turning and repositioning program should be turned and repositioned every two hours there is no reason why a patient should go three hours without being repositioned. On 2/27/14 at 9:30 a.m., R3 lying on her left side. Record review of !5 minute visual checks dated 2/27/14 at 9:30 a.m., document no positioning or visual checks from 6:00 a.m. to 9:30 a.m. Record review of Repositioning and Turning policy (date unknown), documents Policy: It is the policy of the Nursing Department that residents, unable to reposition themselves, will be turned and positioned every one or two hours, in accordance with their needs, using a written care plan as determined by licensed staff. Record review of Treatment Admistration record dated 2/2014, documents patient has a treatment to her right buttock that was ordered on [DATE]. No documentation is present that this treatment has been completed since it was ordered with no nurse initials. On 2/27/14 at 9:45 a.m., Z4 (Registered Dietician), states I am aware that R3 is not getting the full 1440 milliliters/24 hour period I have discussed with the facility shutting R3's feeding off for two hours during the date and increasing the rate but staff was concerned of her tolerance. The decrease in calories from not getting the total 1440 milliliters may contribute to weight loss and worsened pressure ulcer but is not definite. She should receive 1728 calories/day from her current feeding and 180 calories from prostat. Her daily requirements are 1700-1995 calories/day. On 2/27/14 at 1:50 p.m., E5 (Certified Nursing Assistant), states R3 is up in wheelchair. We got R3 up at 10:45 a.m.and should lay back down around 2:30 p.m. R3 has two pillows on each side of R3 floating. R3 will be up almost four hours. We changed pillows at 10:00 a.m. and 12:00 p.m. to reposition R3 but we don't document it we just do it. On 2/27/14 at 3:00 p.m., Z1 (Physician), states I was not aware that R3 was not receiving the total amount of feeding in the day like R3 was prescribed. That is not desirable. I certainly expect the staff to be turning and positioning R3 every two hours with her inability to reposition herself and with her pressure ulcers. It is not desirable for R3 to not be turned and positioned every two hours the more times she is not positioned the worse the pressure ulcers could get. Yes these factors could contribute to her worsening pressure ulcer .