Every finding on record at Arcadia Care Havana

Based on observation, interview and record review the Facility failed to discontinue enteral feeding tube orders after an enteral gastrostomy feeding tube was removed and failed to assess, document and treat drainage and redness around a gastrostomy site for one of two Residents (R1) reviewed for gastrostomy care in a sample of three.Findings include:The Facility Gastrostomy Tube-Feeding and Care Policy, dated 8/2020, documents: to provide nutrients, fluids and medications per physician orders to residents requiring feeding through an artificial opening in the stomach; licensed nurse will review physician orders for type of formula, concentration, rate of flow and method of administration; inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent drainage or gastric leakage, immediately report skin irritation or infection and provide treatment; and document tube feeding site for signs/symptoms of infection and abnormal findings will be reported to the physician.The Registered Nurse Job Description (7/2023) and Licensed Practical Nurse Job Description (7/2023) document: responsible for providing direct nursing care to the residents; and supervise in accordance with federal, state and local standards, guidelines and regulations that govern our Facility to ensure that the highest degree of quality care is maintained; chart nurses notes in informative and descriptive manner that reflects the care provided and perform routine charting duties as required; and administer professional services such as tube feedings as required.R1's Physician Order Sheet, dated 7/21/26, documents diagnoses including: Moderate Protein Calorie Malnutrition, Hypertension, Traumatic Hemorrhage of Left Cerebrum with loss of consciousness, Altered Mental Status, Nervous System surgery, Dysphagia Oropharyngeal, Gastrostomy, Hyperosmolality and Hypernatremia, Hypotension, Restlessness and Agitation, Muscle Wasting and Atrophy, Cognitive Communication Deficit, Traumatic Subdural Hemorrhage with loss of consciousness and Mood Disorder. R1's Physician Order Sheet, dated 7/21/26, documents physician orders: Enhanced Barrier Precautions related to indwelling medical device (gastrostomy/g-tube); staff to don/doff gown and gloves for direct care; check g-tube site every shift for sign and symptoms of pain and/or tenderness to that area (6/4/26); Regular diet, pureed texture, honey consistency (3/17/26); enteral feed in the morning 30 milliliters/ml of water before and after administering medications through g-tube and at night; feeding (Jevity 1.5) 356 ml syringe bolus cleanse g-tube site with soap, warm water, pat dry, and monitor for any signs and symptoms of infection/skin changes around insertion site (3/12/26); and head of the bed elevated related to tube feedings (1/26/26). R1's Physician Order Sheet does not document a stop date/discontinue order for R1's gastrostomy feeding tube bolus feedings or treatment orders for R1's red/draining gastrostomy stoma site.R1's Nursing Progress Note, dated 7/19/26 at 5:47 am, documents R1's g-tube as gone and I went to (R1's) room and observed stoma site without (R1's) g-tube present, which I located on the floor of (R1's) room. Placed in isolation bag and area cleansed and noted dark pink skin irritation surrounding stoma site, as well as yellow/brown tinged drainage and a foul odor. (R1) yelled out when cleansing the area. The Nursing Progress Notes does not document a Physician treatment order for the stoma site.R1's Nursing Progress Note, dated 7/19/26 at 6:32 am, documents g-tube placed back in with difficulty, balloon keeps deflating. The Nursing Note does not document that R1's Physician was notified.R1's Nursing Progress Note, dated 7/20/26 at 11:29 pm, documents g-tube pulled out by (R1) multiple times and (R1's) spouse does not want it back in. R1's Nursing Progress Note, dated 7/21/26 at 12:28 pm, documents paperwork faxed to (V5/R1's Physician) and waiting for a response.R1's Nursing Progress Note, dated 7/21/26 at 12:51 pm, documents R1's refusal of g-tube feedings, removal of g-tube should be considered if (R1) continues to decline use.On 7/21/26 at 11:00 am, V4 (Licensed Practical Nurse) entered R1's room to observe R1's g-tube site and R1 did not have a g-tube present. V4 stated, (R1) pulled the g-tube out again a couple of days ago and it has not been replaced since. (R1's) stoma site is red and does have drainage, I think (V3/V5's Nurse Practitioner) is going to look at (R1) today.On 7/21/26 at 11:02 am, V3 (Nurse Practitioner) stated, They just asked me to look at (R1) and are supposed to be faxing over paperwork because we do not have (R1) as a patient right now in our system. They did tell me that (R1) refuses g-tube feedings and even pulled (R1's) g-tube out the other day and that is his right to do so if he does not want it. So, I am going to look at (R1) today. It may be that he needs palliative care or hospice care because he is refusing feedings and lots of cares.On 7/21/26 at 12:40 pm, V2 (Director of Nursing) observed R1's g-tube site and verified that R1's stoma site was red and had drainage. On 7/21/26 at 12:45 pm, V2 (Director of Nursing) stated, (R1) pulled out the g-tube a couple of nights ago, and we have not had one put back in yet. V2 stated, We probably should have looked at the Physician Order Sheet, we did not discontinue g-tube feedings. We were working on changing (R1's) doctor to our Medical Director (V5) and we were not able to do that until today, so the orders remained in place. I do not see treatment orders for (R1's) red and draining g-tube stoma site.On 7/21/26 at 2:05 pm, V1 (Administrator in Training) stated, From what I understand, (R1) pulled out (R1's) feeding tube a couple of nights ago, and I do not think that it has been put back in. We have a Care Plan meeting tomorrow (7/22/26) and we will be discussing the feeding tube.

Based on interview and record review, the facility failed to prevent abuse for one (R3) of three residents reviewed for abuse, in a total sample of three. This failure resulted in R3 being verbally abused. This past noncompliance, which involved R3, occurred from 4/25/2026 to 6/03/2026.The facility Abuse Policy document: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents; Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents.The facility's Final Abuse Allegation Investigation, reported to the State Agency, dated 4/28/26, document: On 4/25/2026 at approximately 06:30PM, the facility abuse coordinator was notified of an alleged staff to resident altercation involving [V6/Laundry Aide] and [R3]. Upon interview, resident [R3] stated that staff member [V6] raised his voice, cursed, and called him names regarding clothing that he was wanting returned to him from the laundry; Facility obtained staff interviews-[V15/Certified Nursing Assistant-CNA] interviewed and stated that she heard [V6] call [R3] names and swear at him. [V14/CNA-former employee] interviewed and stated that she heard [V6] call [R3] names Fucking cry baby and swear at him. [V10/Licensed Practical Nurse] interviewed and stated that she heard [V6] call [R3] names and swear at him; Facility obtained interview of R3 documents [R3] said [V6] called him a grown ass man got a problem with me for no reason; and subsequent to the facility investigation, V6's employment was terminated for verbal abuse of R3.R3's EMR document R3's diagnosis to include: Psychoactive Substance Dependence with Psychoactive Substance Induced Psychotic Disorder with Hallucinations, Generalized Anxiety Disorder, Depression, other Seasonal Allergic Rhinitis, Opioid Dependence, Social Phobia, Attention-Deficit Hyperactivity Disorder, Altered Mental Status, Abnormal Results of Liver Function Studies, Major Depressive Disorder, Chronic Viral Hepatitis C.R3's Minimum Data Set/MDS document R3's Brief Interview for Mental Status/BIMS as 15/15, which indicates R3 is cognitively intact.On 6/16/26, at 1:45 p.m., R3 stated, I do not remember exactly what happened. All I remember is that [V6] called me a grown ass man, crying.Prior to the survey date of 6/24/2026, the facility had taken the following actions to correct the non-compliance:1. Immediate actions taken: immediate suspension and subsequent employment termination of V6, notification to law enforcement, ombudsman, and medical doctor, nursing evaluation, and review and update of care plans.2. All staff Inservice on facility abuse was completed 4-26-2026.3. All facility staff were re-in serviced on the facility abuse policy by V1 (Administrator in Training) and V16 (Regional Director of Operations) 6-3-2026. 4. IDT including Administrator educated on facility Abuse Policy by V16 (Regional Director of Operations/RDO) on 6-3-26. 5. Abuse/neglect added to facility morning meeting tracking log on 6-3-26 by V16 (RDO) 6. V10 (Vice President of Clinical Services) reviewed facility Abuse policy and updates completed on 6-3-26. 7. Audit findings, identified concerns, corrective actions, and compliance trends will be reviewed weekly through the facility QA process to ensure continued compliance and determine the need for ongoing monitoring by IDT. 8. Any identified concerns during the audit process will result in immediate re-education and corrective action by V1 (Administrator in Training).

Based on observation, interview and record review the facility failed to prevent physical abuse for five residents in the Alzheimer's Unit (R2,R3,R4,R8 and R16). The facility also failed to put any interventions to prevent further abuse of residents by R1 in place to protect all 16 other residents in the Alzheimer's Unit (R2-R17). This failure leaves the potential for abuse for all 16 residents who reside in the Alzheimer's Unit.The Immediate Jeopardy began on 3/4/2026 at 7:30 PM when R1 first abused another resident and had no intervention in place to stop further abuse. While the Immediacy was removed on 6/3/2026 the facility remains out of compliance at a Level 2 while the the facility assesses the effectiveness of their plan of removal and Quality Assurance program. The facility's Abuse Prevention and Reporting policy dated 3/2026 documents Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The facility's Abuse Prevention and Reporting policy dated 3/2026 documents a resident-to-resident altercation should be reviewed as a potential situation of abuse. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents. R1's Medical Record documents that he was admitted on [DATE] with diagnosis to include but not limited to Alzheimer's, Type II Diabetes Mellitus and Depression. R1's Medical Record documents that he is severely cognitively impaired and does not always answer questions appropriately. R1's Medical Record does not contain any interventions put in place to prevent him from continuing to abuse residents in the Alzheimer's Unit.On 6/2/2026 and 6/3/2026 in the mornings R1 was pleasant and able to answer questions about his family to include names, relationships, where he was and time of day. On 6/2/2026 and 6/3/2026 in early afternoons/directly after lunch R1 refused to speak to surveyor, became agitated when spoken to and stated Shut up b*tch. The facility's Final Abuse Investigation dated 3/10/26 documents that on 3/4/2026 R1 purposefully ran into R16's legs with his walker. R1's Psychiatry Note dated 3/13/26 documents R1 was being seen for episodic agitation and staff reported intense behaviors such as pulling out his catheter, pushing his walker into another resident and knocking another resident down. The facility's Final Abuse Investigation dated 4/20/26 for incident on 4/15/2026 includes a written and signed statement by V11 (Certified Nurse Aide) documenting that she saw R1 strike R4. R1's Psychiatry Note dated 4/17/2026 documents (R1) recently hit his roommate in the head unprompted, threw and broke his TV and gets 'very physically aggressive.' The facility's Final Abuse Investigation dated 4/19/2026 documents that on 4/19/2026 R1 swung at R3 and did not make contact, then R3 swung and connected with R1's face. R1's Psychiatry Note dated 5/11/2026 documents R1's clinical course is marked by significant physical and verbal aggression, including instances of hitting his roommate, punching a nurse in the jaw, and throwing his television across the room. These high risk behaviors necessitated 1:1 supervision. The prioritized treatment plan focuses on stabilizing his aggressive behaviors through medication titration. R1's Psychiatry notes dated 5/22/26 document due to ongoing impulsive behaviors and need for increased supervision, the resident was recently moved closer to the dayroom. The facility could not produce any documentation of increased supervision of R1 at any time.The facility's Final Abuse Investigation dated 4/26/2026 documents that on 4/21/2026 R1 purposefully ran his walker into R2's walker pushing her walker into her stomach and causing her to slam into a wall. The facility's Preliminary 24-hour Abuse Investigation Report dated 5/28/2026 includes a written and signed statement by V12 (Certified Nurse Aide) that documents V12 (CNA) heard yelling and went into R1's room to find R1 moving his walker up and down as if he might have bumped (R8) with it. On 6/2/26 V5 (Certified Nurse Aide) stated that R1 is very aggressive and random. You never know what will set him off. On 6/2/26 V6 (Certified Nurse Aide) stated she had witnessed a couple of the abuse incidents between R1 and other residents. He(R1) just gets so mad. He gets mad at us too, he has punched a nurse in the jaw, kicked a CNA in the stomach and he ripped his TV off the mounting in his room. It doesn't matter if it is a resident or a staff member, if he is mad and you are close he will get you. R1's current care plan dated 3/20/2026 does not include any documentation of R1 hitting or being mean to any other residents. R1's current care plan does not include any interventions after any of R1's incidents on 3/4/26,4/15/26,4/19/26,4/21/2026 and 5/28/2026. On 6/3/2026 at 9:00 AM V1 (Administrator in Training) confirmed that R1 had multiple instances of founded abuse towards other residents with no new interventions put in place to prevent further abuse of other residents.On 06/03/2026 at 11:39 AM the facility presented an abatement plan On 06/03/2026 at 12:28 PM the facility presented an amended abatement plan On 06/03/2026 at 2:04 PM Regional Office requested more information from the facility On 06/03/2026 at 3:22 PM the facility presented an amended abatement plan On 06/03/2026 at 4:16 PM Regional Office requested more information from the facility On 06/03/2026 at 4:41 PM the facility requested more information from the facility On 06/03/2026 at 4:48 PM the facility's abatement plan was accepted by Regional Office. On 06/05/2026 the surveyor confirmed through observation, interview and record review the facility took the following steps to stop the Immediate Jeopardy: All 16 residents on the dementia unit's care plan were reviewed and interventions were implemented as needed on 6/3/26 by V13 (Social Services Director) and V14 (Regional Social Services). All 16 residents on the dementia unit were assessed for abuse/neglect by V13 (Social Services Director) and V14 (Regional Social Services.) R1 was placed on 1:1 immediately on 6/3/2026 in utmost abundance of caution for 48 hours. Skin assessment done by V15 (Corporate Infection Preventionist), aggressive behavior screening done by V14 (Regional Social Services) V3 (Regional Nurse Consultant),V1 (Administrator in Training), V13 (Social Services Director), V14 (Corporate Social Services),V15 (Corporate Infection Preventionist) V16 (Regional Director of Operations) and V17 (Psychiatrist) comprehensive care plan and behavior review to determine further care needs on 6/3/26 R1 was moved closer to the nurse's desk on 5/17/2026 Slide lock added on R1's adjoining bathroom to prevent R8 from entering R1's room; completed by V18 (Maintenance Director). On 6/3/26 V14 (Regional Social Services) reviewed R1's care plan and additional interventions were added to prevent physical aggression towards others including Attempt to mitigate triggering events: neighbor entering room uninvited, others rummaging in room, place stop sign on inside of resident's bathroom door to deter neighbor from entering room through adjoining restroom, Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes, Monitor for signs of impending aggression (ex - balling fists, raising voice, abrupt actions). When noted, provide redirection/assist to alternative location with lower stimulation, Provide a program of activities that is of interest and accommodates residents status. V3 (Regional Nurse Consultant) V16 (Regional Director of Operations) V1 (Administrator in training) and V13 (Director of Social Service and Activities) held a conference call with V17 (Psychiatrist) related to R1's history of abuse allegations on 6/3/26. Additional interventions were discussed and added to R1's care plan to include 1:1 activity programing and social service director to increase pop-in visits. Also discussed appropriate specialized alternate placement if interventions continue to be unsuccessful. All facility staff were re-in serviced on the facility abuse policy by V1 (Administrator in Training) and V16 (Regional Director of Operations) 6-3-2026. Skin checks were completed on all residents residing in the facility on 6-3-26 by V15 (Corporate Infection Preventionist). IDT including Administrator educated on facility Abuse Policy by V16 (Regional Director of Operations) on 6-3-26. IDT (Intra disciplinary Team) educated on facility comprehensive care plan policy on 6-3-26 by V3 (Regional Nurse Consultant). IDT educated on facility Behavioral Health Services Program policy on 6-3-26 by V13 (Director of Social Service) and V14 (Regional Social Services)Abuse/neglect added to facility morning meeting tracking log on 6-3-26 by V16 (RDO) Behavior added to facility morning meeting tracking log on 6-3-26 by V16 (RDO)V10 (Vice President of Clinical Services) reviewed facility Abuse policy and updates completed on 6-3-26. Ad Hoc QA completed on 6-3-26 with the IDT regarding alleged non-compliance. Audit findings, identified concerns, corrective actions, and compliance trends will be reviewed weekly through the facility QA process to ensure continued compliance and determine the need for ongoing monitoring by IDT. Any identified concerns during the audit process will result in immediate re-education and corrective action by V1 (Administrator in Training).

Based on observation, interview, and record review, the facility failed to identify, assess, and treat pressure ulcers/wounds, failed to prevent pressure ulcers/wounds from worsening, failed to develop and implement pressure relieving interventions and a pressure ulcer care plan, failed to ensure pressure ulcer care and treatment was provided in accordance with professional standards of practice, failed to implement and maintain infection control practices during wound care, failed to maintain clean wound care supplies and treatment surfaces, and failed to ensure ordered dressing changes were completed as prescribed for three (R1, R11, and R12) of four residents reviewed for pressure ulcers in the sample of 41. These failures resulted in worsening, infected pressure ulcers requiring debridement, multiple hospitalizations, increased pain requiring opioid medication, treatment with intravenous (IV) and oral antibiotics, and hospice admission related to pain management and wound infection for R1. Findings include: The facility policy titled, Pressure Ulcer Prevention, dated 12/2025, documented the purpose of the policy was to prevent and treat pressure sores/pressure injuries. The policy further documented staff were to maintain clean and dry skin during hygiene measures; inspect skin several times daily during bathing, hygiene, and repositioning; keep linens dry and wrinkle free; reposition dependent residents approximately every two hours or as needed; utilize pillows, pads, and positioning devices to protect bony prominences and reduce friction and shearing; utilize pressure reducing mattresses for residents at risk; utilize specialty mattresses for residents with multiple stage two wounds or one or more stage three or stage four wounds; utilize pressure reducing chair pads for residents identified as moderate/high/severe risk; encourage residents to reposition regularly; and provide nutritional and hydration support to promote skin integrity and wound healing. The facility policy titled, Dressing Change – (Clean/Non-Sterile), dated 12/2025, documented staff were to prepare a clean, dry work area prior to beginning wound care; disinfect bedside surfaces or place a protective barrier prior to placing wound care supplies on surfaces; perform hand hygiene prior to wound care; remove soiled gloves and perform hand hygiene after removal of old dressings; apply clean gloves prior to cleansing wounds; observe wounds for signs and symptoms of infection; apply prescribed dressings per physician order; utilize separate gloves and perform hand hygiene between each wound site because each wound was considered a separate treatment; prevent contamination of clean dressing supplies; initial and date dressings; and sanitize bandage scissors after use. The Glove Use- Nursing policy dated 1/26, documents non-sterile gloves shall be worn for procedures that require contact with blood or body fluids such as removing soiled dressings and non-sterile dressing changes. Gloves used for contact shall be removed and discarded after contact with each person, fluid item or surfaces. Hand hygiene will be performed after removing gloves. The Negative Pressure Wound Therapy (NPWT) Device Instructions for Use documents to ensure all components of the NPWT Wound Dressing Kit are installed correctly and that the port pad assembly tubing is not kinked to avoid leakage and blockage during NPWT therapy. Position the NPWT System and drainage tubing appropriately to avoid the risk of causing a trip hazard. When possible, position the pump device and drainage tubing at or below the level of the wound. The Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress operator's [NAME] documents to press the Static/Alternating button to operate the air mattress in Static mode or Alternating Pressure mode. The Power Failure indicator, System Failure indicator and Low-Pressure indicator light (red) will [NAME] when there is no power input to the control unit, the system fails to alternate or the pressure is below the pre-defined level. Hang the control unit over the frame or at the foot of the bed and secure. It is recommended to always keep control unit in the Alternating Pressure mode when the patient is in position for more efficient pressure ulcer prevention and treatment. The Static mode provides an even support surface that will make the patient transfer or reposition easier. The facility's document, Medacure User Manual for Oasis Alternating Pressure Mattress, dated 2019, includes, Product Functions: 1) Pressure Adjust Valve: Adjust the valve to increase or decrease the pressure for a softer or firmer setting between 1-8 range or by patient's weight as noted on the panel. 2) Alternating/Static Mode Switch: Press this switch to adjust the mode from Alternating to Static. 1.R1's admission Record, reviewed on 5/5/26, documented diagnoses including paraplegia, obesity, diabetes, stage four pressure ulcers of the sacral region and right hip, osteomyelitis, and sepsis. R1's Braden Skin Risk Assessment, dated 1/27/25, documented R1 was at risk for pressure ulcer development; however, no preventative interventions were listed. R1's Quarterly MDS (Minimum Data Set) assessment, dated 4/7/26, documented R1 was dependent on staff for bed mobility, toileting, and personal hygiene, was at risk for developing pressure ulcers, and had two stage four pressure ulcers. R1's current Care Plan, reviewed on 5/6/26, documented R1 had a focus, initiated on 2/13/25, indicating R1 was at risk for skin impairment related to friction/shearing, paraplegia, morbid obesity, and diabetes with a goal to maintain or develop clean and intact skin by the review date. Interventions included: assess and record changes in skin status; monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs or symptoms of infection, maceration, etc. to physician; provide/monitor effectiveness of pressure relieving or reducing devices; report pertinent skin status changes to the provider; and treatment as ordered. This same care plan documented R1 had a focus, initiated on 5/5/25, stating R1 had an actual skin impairment related to friction/shearing, paraplegia, and diabetes with a goal for R1's wound to show signs of improvement through the review date. Interventions for this focus included: monitor site for signs or symptoms of infection, treatment as ordered, refer to infectious disease doctor for non-healing wounds, and wound doctor to evaluate and treat as ordered. On 5/4/26 at 9:33 AM, R1 was observed lying on his back with the head of the bed elevated approximately 45 degrees while his alternating pressure mattress remained in static mode. R1 stated he stayed in the same position most of the time and staff only sometimes offered repositioning. R1 stated he believed the mattress relieved pressure automatically. R1 further stated he had painful wounds, was recently hospitalized due to wound infection, and was currently receiving hospice services related to his wounds and pain. Point of Care (POC) documentation for the past 30 days and progress notes dating back to January 2026 were reviewed and failed to demonstrate staff consistently repositioned R1 every two hours or implemented alternative interventions when repositioning was refused. POC documentation reflected bed mobility and rolling left and right only one to three times daily with no consistent documentation of repositioning offers or refusals in either the POC documentation or progress notes. On 5/4/26 at 2:15 PM, V13/Licensed Practical Nurse (LPN) provided wound care to multiple pressure ulcer sites for R1. R1's cloth pad and bed linens were soiled with a brown liquid and ring present. R1 has a suprapubic catheter and lower left quadrant colostomy. R1 had multiple wounds on each side of his buttocks and thighs. V13 started performing wound care by removing multiple old dressings to R1's left buttock and thighs with the same gloves on. The dressings were heavily saturated and soiled when R1 rolled on his right side and two of the dressings on R1's right buttocks and thigh were dated 5/2/26. V13 confirmed at this time that wound care and dressing changes were ordered daily to the wounds and the dressing should have been changed on 5/3/26, but it was not. Heavy blood drainage was present and draining down R1's leg and V13's gloves were visibly soiled with the bloody drainage. The left buttock wound was observed with black tissue at the wound base, and a foul odor was present. V13 measured R1's left buttock with a cotton tip applicator and stated it was 2.5 cm (centimeters) deep with tunneling present at 10 o'clock that measured 4.0 cm. V13 stated R1's left buttock wound bed extended to the bone and was black in color with necrosis and slough at the wound base. Using the same soiled gloves, she used to remove the old, soiled dressing, V13 picked up clean gauze moistened with cleaning solution from a soiled counter containing debris and proceeded to cleanse R1's left buttock and left thigh wounds with these gloves on, moving from the left buttock wound to the left thigh wound with the same gauze. V13 then with the same soiled gloves to pack R1's left buttock wound bed with a new clean, primary dressing and touched the inside of the secondary dressing with the soiled gloves before she applied the same dressing to both the left buttock and left thigh wounds. R1's left buttock wound was not completely covered after V13 finished the dressing change. During the wound care observation, R1's air mattress was in 'Static' mode. V13 stated R1's air mattress is always on this setting, and she does not mess with the settings. On 5/4/26 at 2:46 PM, V13/LPN confirmed she failed to perform hand hygiene and glove changes between contaminated and clean tasks, contaminated clean supplies, performed wound care to multiple wounds simultaneously, and used one dressing for two separate wounds. V13 acknowledged each wound required separate dressings and glove changes to prevent cross-contamination and further confirmed R1's left buttock wound was infected and required antibiotics. V13 stated, (R1's) air mattress is always on the 'Static' setting and I don't touch it. R1's Order Summary Report, dated 5/6/26, documented R1 had physician orders to receive daily wound care to multiple buttock and thigh wounds. R1's Treatment Administration Record for May 2026 failed to document wound care completion on 5/3/26 for R1's buttock and thigh wounds as ordered. Wound assessments completed by V19/Wound Care Nurse Practitioner between February 2026 and April 2026 repeatedly documented R1's left buttock stage four pressure ulcer was deteriorating noting in her weekly wound assessment: increasing measurements, heavy drainage, a strong odor, necrotic tissue, exposed bone and muscle, tunneling, and suspected osteomyelitis. V19's documentation further reflected ongoing infection concerns, recommendations for MRI evaluation, Infectious Disease consultation, systemic antibiotics, and wound deterioration despite treatment interventions being updated and ordered. R1's Multi Wounds Chart Details Report, dated 2/4/26, completed and signed by V19/Wound Care Nurse Practitioner, documented a wound assessment of R1's left buttock stage four pressure ulcer that measured 5.5 cm (centimeters) (length) by 5.0 cm (width) by 6.0 cm (depth) with tunneling at 10 o'clock measuring 6 cm. V19 documented R1's pressure ulcer to his left buttock was deteriorating and had heavy serosanguineous drainage (thin, watery drainage with a red or pink tint) with a strong odor. The wound had 71-80% slough and 11-20% grey tissue with muscle and bone exposure, muscle necrosis, suspected osteomyelitis, and V19 documented she was awaiting results. This same assessment documented there were signs and symptoms of infection, systemic antibiotics were prescribed, and an x-ray was advised. R1's Multi Wounds Chart Details Report, dated 2/11/26, completed and signed by V19/Wound Care Nurse Practitioner, documented a wound assessment of R1's left buttock stage four pressure ulcer that measured 4.8 cm (centimeters) (length) by 6.0 cm (width) by 5.0 cm (depth) with tunneling at 10 o'clock measuring 6 cm. V19 documented R1's pressure ulcer to his left buttock was deteriorating and had heavy serosanguineous drainage (thin, watery drainage with a red or pink tint) with a strong odor. The wound had 71-80% slough and 11-20% grey tissue with muscle and bone exposure, muscle necrosis, suspected osteomyelitis, and V19 documented she was awaiting results. This same assessment documented there were signs and symptoms of infection, systemic antibiotics were prescribed, and an x-ray was advised on 2/4/26. R1's Multi Wounds Chart Details Report, dated 2/25/26, completed and signed by V19/Wound Care Nurse Practitioner, documented a wound assessment of R1's left buttock stage four pressure ulcer that measured 3.5 cm (centimeters) (length) by 4.5 cm (width) by 2.0 cm (depth) with tunneling at 10 o'clock measuring 5.4 cm. V19 documented R1's pressure ulcer to his left buttock was deteriorating and had heavy serosanguineous drainage with a strong odor. The wound had 91-100% grey tissue with muscle and bone exposure, muscle necrosis, and V19 wrote she suspected osteomyelitis and was awaiting results. This same assessment documented there were signs and symptoms of infection, systemic antibiotics were prescribed, and an MRI (Magnetic Resonance Imaging) of the left hip and sacrum/coccyx was needed to rule out osteomyelitis. R1's Multi Wounds Chart Details Report, dated 3/4/26, completed and signed by V19/Wound Care Nurse Practitioner, documented a wound assessment of R1's left buttock stage four pressure ulcer that measured 4.2 cm (centimeters) (length) by 4.5 cm (width) by 1.7 cm (depth) with tunneling at 10 o'clock measuring 5.4 cm. V19 documented R1's left buttock pressure ulcer was deteriorating, had 91-100% grey tissue, exposed muscle and bone, and she suspected osteomyelitis and was awaiting results. V19 also documented the pressure ulcer had a strong odor with heavy serosanguineous drainage. R1's Multi Wounds Chart Details Report, dated 3/18/26, completed and signed by V19/Wound Care Nurse Practitioner, documented a wound assessment of R1's left buttock stage four pressure ulcer that measured 4.2 cm (centimeters) (length) by 4.5 cm (width) by 5.0 cm (depth) with tunneling at 10 o'clock measuring 5.0 cm. V19 documented heavy serosanguineous drainage with a strong odor, 1-10% eschar (hardened, dead tissue), 81-90% grey tissue, and exposure of muscle and bone with suspected osteomyelitis, awaiting results. V19 mechanically debrided tissue to R1's left buttock pressure ulcer on this same date and documented under assessment notes she ordered an MRI of the left hip and sacrum/coccyx, continue wound V.A.C. (Vacuum-Assisted Closure), labs to rule out infection, and referral to Infectious Disease for poor wound healing. R1's Multi Wounds Chart Details Report, dated 3/25/26, completed and signed by V19/Wound Care Nurse Practitioner, documented a wound assessment of R1's left buttock stage four pressure ulcer that measured 3.0 centimeters (cm) (length) by 4.0 cm (width) by 1.7 cm (depth) with tunneling at 10 o'clock measuring 5.0 cm. V19 documented heavy serosanguineous drainage with a strong odor, 1-10% eschar, 81-90% grey tissue, and exposure of muscle and bone with suspected osteomyelitis, awaiting results. V19 mechanically debrided tissue to R1's left buttock pressure ulcer on this same date and documented under assessment notes, Unable to determine. Inconclusive d/t (due to) testing and specialty consultation delays. A progress note, dated 3/25/26, documented R1 was transferred by ambulance to (local hospital emergency department) requested by V19/Wound Care Nurse Practitioner for evaluation of wounds. R1's Hospital History and Physical, dated 3/25/26, documented R1 was admitted inpatient to (local hospital) due to worsening sacral pressure ulcer from 3/25/26 to 4/10/26. This report documents R1 was found to have worsening bilateral sacral pressure ulcers extending to the bone. Sharp debridement was performed on 3/27/26 to remove non-viable tissue. An MRI (Magnetic Resonance Imaging) of the pelvis was done and confirmed osteomyelitis of left buttock wound. R1 was referred to Infectious Disease specialists and received intravenous (IV) antibiotics, fluids, and opioid pain medications while hospitalized . He was discharged back to the facility on 4/10/26 with orders for two oral antibiotics for six weeks due to osteomyelitis of left buttock pressure ulcer and continued wound care to pressure ulcers. A Progress Note, dated 4/15/26 at 10:17 AM, documented, (R1) continues to be disoriented, increased confusion, scrambling of words. Per wound doctor, new order received to send to (local hospital emergency department) for eval (evaluation) and treatment, per ambulance. R1's Hospital History and Physical, dated 4/15/26, documented R1 was admitted inpatient to (local hospital) from 4/15/26 to 4/21/26 for altered mental status and sepsis workup due to infected sacral pressure ulcer. R1 received intravenous (IV) antibiotics, fluids, and opioid pain medications while hospitalized . R1 was discharged back to the facility with orders to continue two oral antibiotics for osteomyelitis of left buttock pressure ulcer and continued wound care for pressure ulcers. A Progress Note, dated 4/22/26 at 2:56 PM, stated, This writer (V12/Social Services Director) met with resident to talk about resident's current wants. Resident wants to be comfortable without pain but states that he is in pain with his wounds. A Progress Note, dated 4/27/26 at 4:22 PM, documented, Hospice admitted resident with primary diagnosis of osteomyelitis. Received new orders focused on comfort care and pain management. R1's Order Summary Report, dated 5/5/26, documented R1 had an order for hospice to evaluate and treat on 4/24/26. This same document includes an order for Fentanyl (opioid pain medication) transdermal patch 25 MCG/HR (micrograms per hour) – apply 1 patch transdermally every 72 hours for pain with a start date of 4/27/26. On 5/5/26 at 11:55 AM, V2/DON stated staff were expected to perform hand hygiene before and after wound care, change gloves between contaminated and clean tasks and between wound sites, and avoid contamination of clean supplies. V2 confirmed failure to follow infection control practices during wound care could contribute to wound contamination and worsening infection. On 5/5/26 at 12:23 PM, V19/Wound Care Nurse Practitioner stated an alternating pressure mattress left in static mode would not provide alternating pressure relief and would contribute to increased pressure to wounds and pressure points. V19 further confirmed failure to perform hand hygiene, failure to change gloves, missed dressing changes, and cross-contamination during wound care could contribute to worsening wounds and infection. On 5/6/26 at 10:15 AM, V17/Wound Care Regional Director of Operations stated V19/Wound Care Nurse Practitioner had previously voiced concerns regarding staff not completing dressing changes as ordered, failure to follow wound care recommendations, and staff competency concerns related to wound care practices. 2.On 5/4/26 at 8:30 AM, Resident R11 stated his bottom was very sore and felt like he may have a wound on his coccyx. R11's electronic medical record did not contain documentation related to redness, excoriation, skin impairment, or pressure ulcers to R11's coccyx area. On 5/4/26 at 12:54 PM, V4 (Certified Nursing Assistant/CNA) was observed providing peri-care to R11. R11 had an Enhanced Barrier Precaution (EBP) sign posted on the door; however, V4 was observed performing care without wearing a gown. During care, V4 turned R11 onto his side and R11's coccyx area was observed to be red and excoriated. R11 stated his bottom felt raw. V2 (Director of Nursing) entered the room during the observation and stated the area looked moisture associated. V2 confirmed Resident R11 required treatment to the coccyx area. V2 instructed V4 to remove the barrier cream from the coccyx area. V4 rubbed the cream off using a rag located in R11's room. R11 winced in pain and yelled ow. R11's top layer of skin was macerated, V2 stated R11's coccyx area appeared consistent with a Stage II pressure ulcer. R11's Braden assessment dated [DATE] documents R11 was assessed as high risk for skin breakdown. R11's electronic clinical record did not contain documentation of wound measurements, wound assessment, or treatment documentation for the coccyx ulcer identified on 5/4/26. On 5/6/26 at 10:13 AM, V17, Regional Director of Wound Care Operations, stated V19 Wound Nurse Practitioner had not been notified of R11's coccyx ulcer and indicated R11 would have been added to the wound list to be seen that day if notification had occurred. On 5/6/26 at 2:00 PM, V19 stated that R11's coccyx wound was a deep tissue injury and would likely worsen before it gets better. V19 stated the use of barrier cream by the facility for this wound only made it worse and V19 should have been notified soon to initiate an appropriate treatment. V19 stated the coccyx wound measures 15 centimeters by 15 centimeters, and she would be ordering Medi Honey (a medical grade honey product used for wound healing) and an adhesive foam bandage to be changed daily. V19 stated she will follow R11's wound care. 3. R12 was admitted on [DATE] with diagnoses of Pressure Ulcers, Osteomyelitis of Vertebra, Long Term use of Antibiotics, Arthritis due to Bacteria, Infectious Disease, Nightmare Disorder, Spinal Cord Injury, Sepsis and Type 2 Diabetes Mellitus. R12 was hospitalized on [DATE] with a diagnosis of Sepsis from left hip wound and surgical debridement of pressure wound was conducted, then returned to the facility on 4/27/26. R12 is cognitively intact. R12's Physician Orders dated 4/28/26 includes instruction for wound vac (Negative Pressure Wound Therapy/NPWT) to left hip at 125 mm/Hg (millimeters of Mercury) continuous/intermittent therapy, as well as dressing change orders. R12's current care plan documents R12 has a Pressure Ulcer to left hip, has a low loss air mattress and minimize pressure over boney prominences. The care plan had not been updated to include the use of or interventions for the Negative Pressure Wound Therapy (NPWT/wound vac). Upon entering R12's room on 5/5/26 at 11:00 AM, the NPWT/wound vac machine with drainage collection cannister was hanging from a pole, approximately 12 inches above R12's head, the machine was beeping an alarm sound and leak was displayed on the screen The Alternating Pressure Mattress control unit was lying under the bed, facedown and was alarming. R12 stated the machines were alarming since staff removed his breakfast tray although was unable to give a specific time. Staff Nurse was notified at 11:10 AM of the alarms. On 5/5/26 at 11:56 AM, V2 (Director of Nursing/Infection Preventionist) and V36 (Certified Nurse Aide, Scheduler/Medical Records Manager) entered R12's room. V2 stated I don't know why this (wound vac) is beeping. R12 was rolled to his side, and the wound vac dressing was not intact. V36 picked up the air mattress control unit off the floor, and the power failure light was flickering red. After turning the machine on and off and checking the cords, V36 identified the machine was not plugged in. During the wound vac dressing change, V2 was observed to remove the outside dressing with gloved hands, then reach to the bedside table and picked up a 250 ml (milliliter) bottle of saline, used the saline to moisten the dressing packed inside the wound, removed the soiled dressing and discarded it, went to the dresser across the room, picked up 2 packages of sterile gauze and scissors and placed on the bedside table, used a spray cleanser on the wound and wiped with non-sterile gauze and found more foam (type of material used to pack a wound) inside the wound, put spray bottle back on bedside table beside the 2 packages of sterile gauze and removed the foam dressing with the same pair of gloves donned throughout. After conducting hand hygiene and donning new non-sterile gloves, V2 picked up the spray cleaner again and cleansed the wound, opened the dressing change supplies and cut foam and outer covering of the dressing with scissors, coughed into the right arm of her gown (personal protective equipment used during wound care), completed the dressing change, pick up the two packages of sterile gauze and scissors from the bedside table and placed them back into the basin on the dresser with other clean supplies and did not cleanse the scissors or change gloves after wound care was conducted. On 5/5/26 at 1:30 PM, V1 (Administrator) stated V2 (Director of Nursing) is also the Infection Preventionist and Should set the standard for all staff. It sounds like (V2) contaminated the entire room. V1 agreed the wound vac and the air mattress should have been functioning and turned on. On 5/5/26 at 11:15 AM, V14 (Registered Nurse) stated a wound vac should be placed below the resident's wound and stated the machine may not be able to drain the contents of the tubing into the cannister adequately and backflow into the wound, especially if the machine has a leak error because suction is lost. V14 stated the only time an air mattress should be on static mode is during repositioning or if the resident requests it when sitting up to eat but should not be used for long periods of time.

Based on interview and record review, the facility failed to ensure allegations of abuse and injury of unknown origin were reported and thoroughly investigated timely for one (R11) of three residents reviewed for abuse in a sample list of 41. Findings include:The facility's Abuse Prevention and Reporting policy revised 3/2026 documented nursing staff are responsible for reporting suspicious bruises, lacerations, or abnormalities as they occur. The policy further documented incidents involving allegations or suspicions of abuse or mistreatment were to be documented and reported to the administrator or designee for investigation.R11's Skin assessment dated [DATE] documented purple discoloration measuring four centimeters by four centimeters to R11's left ankle.On 5/4/26 at 9:20 AM, R11 stated V6 (Certified Nursing Assistant/CNA) injured R11's left foot during a transfer on 4/17/26. R11 stated he immediately reported the incident to V5 (Registered Nurse/RN) because his foot hurt. R11 stated V1 (Administrator) and V2 (Director of Nursing) did not speak with him regarding the incident until 4/20/26.On 5/4/26 at 11:27 AM, V5 (RN) stated V6 informed V5 of the incident on the night it occurred. V5 acknowledged she did not document the incident, complete an assessment, or report the allegation for investigation because she didn't think R11 was that hurt.R11's electronic medical record did not contain documentation of an incident report, assessment, abuse investigation, physician notification, family notification, or report to the administrator regarding the alleged injury occurring on 4/17/26.On 5/4/26 at 1:42 PM, V12 (Social Services Director) stated R11 informed V12 on 4/20/26 that V6 injured his foot during a transfer on 4/17/26. V12 stated she observed a dark bruise to R11's left ankle and reported the allegation to nursing staff and V1.On 5/5/26 at 10:59 AM, V1 (Administrator) stated the incident should have been reported and documented on 4/17/26 and V1 was not made aware of the allegation until 4/20/26 after V12 notified V1.

Based on interview, and record review the facility failed to ensure allegations of abuse and injury of unknown origin were thoroughly investigated, documented, and reported timely for one (R11) of three residents reviewed for abuse in the sample list of 41. Findings include:The facility's Abuse Prevention and Reporting policy revised 3/2026 documented the facility affirms residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment. The policy documented nursing staff are responsible for reporting suspicious bruises, lacerations, or abnormalities as they occur. Upon reporting such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation, and reporting to the administrator or designee. The policy further documented that employees accused of abuse, neglect, exploitation, or mistreatment shall be removed from resident contact immediately pending investigation results. All incidents were to be documented whether abuse, neglect, exploitation, mistreatment, or misappropriation occurred, was alleged, or suspected.The facility's Transfer-Manual Gait Belt and Mechanical Lifts policy revised 8/2023 documented mechanical lifting devices shall be used for residents requiring a two-person assist or who cannot be transferred safely by normal transfer techniques. The policy further documented mechanical lifts requires two caregivers for transfers.R11's Minimum Data Set (MDS) dated [DATE] documents R11 is cognitively intact and dependent on staff for all activities of daily living.R11's Skin assessment dated [DATE] documents purple discoloration measuring four centimeters(cm) by four centimeters to the left ankle.On 5/4/26 at 9:20 AM, R11 stated V6 (Certified Nursing Assistant/CNA) transferred R11 with a mechanical lift alone at approximately 8:30 PM on a Friday night (4/17/26). R11 stated while suspended in the lift, V6 attempted to open the legs of the mechanical lift and smashed R11's left foot between the wall and the door. R11 stated he told V6 his foot was smashed, but V6 continued the transfer and told R11 he was fine. R11 stated he notified V5 (Registered Nurse) immediately after the incident because R11's foot hurt. R11 stated V1 (Administrator) and V2 (Director of Nursing) later spoke with him on Monday (4/20/26) and photographed the bruise on R11's left ankle. R11 additionally stated V6 previously made inappropriate comments to R11 regarding pierced nipples and not wearing a bra. R11 stated he reported these comments previously to V2 Director of Nursing, but staff laughed it off.On 5/4/26 at 11:27 AM, V5 (Registered Nurse/RN) stated V6 came out of R11's room yelling, I'm not arguing with you. V5 stated she did not witness V6 transferring R11 or observe R11's foot being injured because V5 was not in the room. V5 stated she informed V1 of the incident but was not asked to complete a witness statement or have staff complete a witness statement. V5 stated the witness statement completed later by V1 did not accurately reflect what V5 reported to V1 because V5 informed V1 she had not witnessed the event. V5 stated she believed V6 was alone with R11 during the transfer because another unknown CNA had left the room. V5 acknowledged she did not report the incident to outside agencies, did not document the event, and did not complete an assessment because she didn't think R11 was that hurt. V5 stated R11 was alert and oriented.On 5/4/26 at 1:12 PM, V6 (CNA) stated she transferred R11 with the mechanical lift while V5 was passing medications in the hallway. V6 confirmed R11 yelled, My foot got stuck. V6 stated she completed the transfer, placed R11 in bed, and then obtained V5 (RN) because V6 wasn't going to tolerate R11's lies. V6 stated she told R11 to stop lying. V6 stated R11 made her uncomfortable and described him as a weirdo. V6 stated she never reported concerns regarding resident comments or behaviors. V6 further stated I'm (V6) glad I don't work at that place and have to see R11 anymore.The facility staffing schedule documents V6 (CNA) and V5(RN) worked second shift on 4/17/26. The schedule documented V6 continued to work on 4/18/26 and 4/19/26 and was removed from the schedule on 4/20/26 pending investigation.R11's electronic medical record did not contain documentation of an assessment, progress note, physician notification, family notification, incident report, or investigation regarding the reported injury sustained during the transfer on 4/17/26.On 5/4/26 at 1:42 PM, V12 (Social Services Director) stated on 4/20/26 R11 informed V12 that V6 transferred him alone with a mechanical lift and injured his foot by smashing it between the wall and the door. V12 stated she observed a dark, baseball-sized bruise on R11's left ankle and reported the allegation to nursing staff and V1. V12 further stated R11 previously reported inappropriate comments made by V6 and V12 reported those concerns to V2; however, she doubted the allegations were investigated.On 5/4/26 at 1:53 PM, V2 (Director of Nursing) stated she had previously received abuse allegations from R11 regarding V6 but was unable to locate grievances or documentation related to those prior allegations.On 5/5/26 at 10:59 AM, V1 (Administrator) stated the incident should have been reported and documented on 4/17/26 by V5 (RN). V1 stated she was not made aware of the allegation until 4/20/26 after V12 spoke with R11.

Based on record review and interview the facility failed to obtain a physician ordered MRI (Magnetic Resonance Imaging) for one of seven residents (R1) reviewed for pain in the sample of seven.Findings include:The facility's Physician Notification of Laboratory/Radiology/Diagnostic Results dated 12/2025 documents, Purpose: To ensure physician ordered diagnostic tests are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. A licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing and for monitoring receipt of test results.R1's Pain Clinic Progress Notes dated 3/19/26 and signed by V10 (Pain Specialist) document, (R1) is an [AGE] year-old presenting with pain that is predominately left cervical and right knee. Stenosis was noted in the cervical region. (R1) pain she graded 10/10 (severe pain) with a range of 4-10 with tenderness, exhausting, penetrating, miserable, and tiring pain which interferes with general activity, mood, walk, sleep, enjoyment of life and relations with people. It's aggravated with sitting as well as lying down and physical activity. Treatment: Imaging: MRI C-Spine (Cervical Spine) Neck without contract.R1's Pain Clinic Progress Notes dated 4/16/26 and signed by V10 (Pain Specialist) documents R1 did not get the MRI as ordered on 3/19/26.On 4/24/26 at 1:35 PM V12 (V10's Medical Assistant) stated, (R1) came to our pain clinic on 4/16/26 for a follow-up. The facility did not do (R1's) MRI as ordered on 3/19/26.On 4/24/26 at 1:55 PM V14 (Hospital X-Ray Technician) stated, Just a few minutes ago, (V5/Social Service Director) called here to ask for (R1's) MRI results. I informed (V5) that (R1) was supposed to get her MRI yesterday and on 4/9/26, but (R1) did not show up. (R1) had not had an MRI yet. V5 had to re-schedule (R1's) MRI for 4/20/26.On 4/24/26 at 2:02 PM V5 (Social Service Director) stated, I was not made aware that (R1) did not get her MRI on 4/9/26 as scheduled. There is no documentation why (R1) did not get the MRI on 4/9/26. I am the scheduler and was not made aware that (R1's) MRI was re-scheduled for 4/23/26, therefore (R1) has not received the MRI yet.

Based on record review and interview the Facility failed to maintain safe/functioning locks on a bed and maintain a clear pathway to prevent two separate falls for one of seven Residents (R4) reviewed for Falls in a sample of seven.Findings include:The Facility Fall Prevention Program Policy, dated 1/2026, documents: to assure safety of all residents in the Facility when possible; the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary; methods to identify risk factors; use and implementation of professional standards of practice; adherence to manufacturer's recommendation in use of medical devices and special care equipment; identification of all risk/issues; preventative measures; the environment will be kept clear of clutter which would affect ambulation and remove hazards; and the bed locks will be checked to assure they are in the locked position at all times.The Facility Incidents by Incident Type Report, dated 4/25/26, documents R4's witnessed fall incident (3/30/26 and 4/8/26) and un-witnessed fall incident (4/23/26).R4's current Care Plan documents diagnoses including History of Transient Ischemic Attack/TIA; Cerebral Infarction; Age-Related Osteoporosis without pathological fracture; Alzheimer Disease; Muscle Wasting and Atrophy; Protein Calorie Malnutrition, Generalized Anxiety Disorder; Unspecified Dementia with Psychotic Disturbance and Depressive Disorder. R4's current Care Plan documents: has impaired visual function related to poor eyesight; receiving anti-psychotic medications; is at risk for falls related to dementia; requires supervision to partial/moderate assist for activities of daily living/ADL; alter/remove any potential causes if possible; anticipate and meet the resident's needs; be sure the call light is within reach and encourage the resident to use it for assistance as needed; bolsters/scoop mattress to bed to help define edges; and ensure that the resident is wearing appropriate footwear.R4's Minimum Data Set/MDS, dated [DATE], documents severe cognitive loss on a Brief Interview for Mental Status/BIMS (score 4/15) and requires partial/moderate staff assistance with ADL's (bed mobility and transfers).R4's Progress Notes, dated 3/30/26, documents R4 was sitting on floor at bedside next to bed and that R4 had been ambulating in the hall prior to the fall. R4 stated at the time that R4 was going to lay down in bed the bed moved and R4 rolled out of bed onto the floor. R4's Progress Notes, dated 3/31/26, documents after the Interdisciplinary Team review, the root cause was determined to be that R4's bed brakes were not locked, and the intervention was for V15 (Maintenance Director) to repair the bed locks.R4's Progress Notes, dated 4/9/26, documents after the Interdisciplinary Team review, the root cause was determined to be that R4 was ambulating and tripped on a (mechanical lift) and the intervention was to store the mechanical lift in the clean utility room when not in use.R4's Witnessed Fall Report, dated 3/30/26, documents: observed sitting up on floor beside bed; no debris on floor; had been up ambulating in hall prior; sat on bed and was getting ready to lay down when the bed moved away; bed was not in locked position; stated was going to lay down and fell off of the bed. The Fall Report intervention documents V15 (Maintenance Director) was notified to repair the bed lock. No injuries were noted.R4's Witnessed Fall Report, dated 4/8/26, documents: R4 was attempting to exit a nearby door and tripped over a mechanical lift that was in the D Hall walkway when R4 was ambulating the halls. R4 was found on the D Hall floor with R4's legs between the mechanical lift legs. The Fall Report documents R4 is confused and has impaired memory, uses antipsychotic medication, is an active exit seeker/ wanders, is restless and has behavior symptoms. No injuries were noted.On 4/25/26 at 11:50 am, V2 (Director of Nursing) stated, (R4's) brake was broke on R4's bed when (R4) fell out of bed on the 3/30/26 fall so we had to have (V15/Maintenance Director) fix it because it would not lock. On the 4/8/26 fall, (R4) is known to walk around the Facility and (R4) tripped over a (mechanical lift) that was in the hallway. The staff should know that they need to keep the hallways clear of equipment so that does not happen.

Based on observation, interview and record review, the facility failed to ensure infection control monitoring/surveillance and isolation precautions for Sarcoptes scabiei (scabies) were implemented for nine of 15 Residents (R4, R8, R9, R10, R11, R12, R13, R14 and R10) reviewed for Scabies in a sample of 16. This failure has the potential to affect all 59 Residents residing in the Facility.Findings include: The Facility Resident Census Roster, dated 3/23/26, documents 59 Residents residing in the Facility. The Facility Infection Prevention and Control Program Policy, dated 12/2025, documents: preventing, identifying, reporting, investigating and controlling infection and communicable diseases for all Residents and Staff; infection control program meets the guidelines of the United States Department of Health and Human Services' Centers for Disease Control and Prevention, Local, State and Federal rules; designated Infection Control employee and Quality Assurance Committee is responsible for effectiveness of the program and improving outcomes; provides recording of each suspected infection and surveillance activities as they relate to individual Resident infections and a log is maintained of suspected and actual infections on a day-to-day basis; McGreer's Criteria is used to determine if criteria for an infection is met; employees will receive orientation to infection control policies and procedures; all facility personnel are required to routinely wash hands and use appropriate barrier precaution to prevent transmission of infections; contact precautions in addition to standard precautions will be initiated as specified in the specific isolation policy (refer to Centers for Disease Control Precaution Guidelines by Organism); and communicable disease outbreaks and infections that meet criteria for reporting will be reported to the Local and State Health Department; and the investigation and/or outbreak line listing report will be completed as recommended. The Facility Infection Precautions Guidelines Policy, dated 1/2026, documents contact precautions should be implemented for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact. The policy also documents scabies and rash of unknown origin as examples of transmissible infections requiring contact precautions. R4's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream (Permethrin) order dated 3/11/26, for Sarcoptes Scabiei (Scabies). R8's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 2/12/26, for Sarcoptes Scabiei (Scabies). R9's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 3/23/26, for Sarcoptes Scabiei (Scabies). R10's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 2/10/26, for Sarcoptes Scabiei (Scabies). R11's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 2/12/26, for Sarcoptes Scabiei (Scabies). R12's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 2/11/26, for Sarcoptes Scabiei (Scabies). R13's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 2/12/26, for Sarcoptes Scabiei (Scabies). R14's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 2/11/26 and 2/12/26, for Sarcoptes Scabiei (Scabies). R15's Physician Order Sheet, dated 3/25/26, documents an external topical medicated cream order dated 2/11/26, for Sarcoptes Scabiei (Scabies). The facility Infection Surveillance Report dated January 1, 2026, through March 24, 2026, documents no parasitic infections or skin infections. This report documents three residents (R11, R13, R14,) were treated with antiparasitic medication, however the parasite option on the form to check for each resident was not marked. (R4, R8, R9, R10, R12, R13, R14, and R15) were also treated for parasitic infection from February 2026 to March 2026, however the facility Infection Surveillance Report does not include their names or their treatment for Sarcoptes Scabiei (Scabies) skin infestation. On 3/24/2026 at 9:30 AM, R4's entrance door did not have a Contact Precautions sign and did not have Personal Protective Equipment (PPE) available outside of R4's room. R4 was sitting up in R4's bed without a shirt on, covered in multiple (over hundred) red sores on the chest, back and arms, which R4 described as itchy. R4 was itching R4's back while speaking. R4 stated, staff do not use gowns or gloves when in my room but do use gloves only when touching my skin. R4's Nursing Note, dated 3/5/2026 at 3:12 PM, documents R4 has an itchy rash over most of R4's body and is requesting a referral to a dermatologist. R4's Weekly Skin Observation, dated 3/5/2026 at 3:14 PM, documents R4 had a new skin concern, rash over body and the medical doctor was notified. R4's Physician Medication Order, dated 3/12/2026, documents an anti-parasitic topically applied medication, used to treat Sarcoptes scabiei (scabies). Physician Orders for Contact Precautions were not noted in R4's electronic health record on March 24, 2026. On 3/24/2026 and 3/25/2026, R4's room did not have contact precautions signage on R4's entrance door or personal protective equipment available. R4's Treatment Administration Record, dated March 2026, documents an anti-parasitic topically applied medication was administered on 3/19/2026. On 3/24/26 at 10:25 am, V9 (Certified Nursing Assistant) stated, I put the scabies cream on (R4) last week and only wore gloves. I usually never wear PPE (Personal Protective Equipment) when I go into (R4's) room, or any other room that has been treated for scabies. I am not really sure who has it or who has not. On 3/24/26 at 11:01 am, V8 (Licensed Practical Nurse) stated, No one told us that (R4) actually had scabies, I just figured because we were treating (R4) with the scabies medication. I have not been wearing PPE (Personal Protective Equipment) when I go into (R4's) room. (R4) also has a roommate (R5) and they have not moved (R5). There have been many people treated for scabies here in the last few months. V8 confirmed that no Contact Isolation sign was on the entry door to R4's and R5's room and that no PPE was being used. On 3/24/2026 at 1:35 PM, V11 (V3's/Medical Director's Registered Nurse) stated, (V3/Medical Director) saw (R4) on 3/11/2026, diagnosed (R4) with scabies and ordered an antiparasitic cream to be applied topically. On 3/25/26 at 9:31 am, V2 (Director of Nursing) stated, No skin scrapings have been completed on any of our people with scabies and we have not been keeping surveillance records even though they are getting treated as scabies. V2 confirmed that no isolation precautions were implemented on Resident's doors for scabies precautions. On 3/26/26 at 1:30 pm, V1 (Administrator) stated, We just put contact isolation signs on the doors. I was not even aware that we had any Residents that were being treated for scabies until you guys came in. No one ever told me they were being treated.

Based on observation, interview, and record review, the facility failed to provide showers/bathing as scheduled for four (R1, R2, R3, and R16) of eight residents reviewed for showers/bathing in a sample of 16.Findings include: The facility's, Bathing - Shower and Tub Bath Policy, dated January 2026, documents: purpose to ensure resident's cleanliness to maintain proper hygiene and dignity; a shower, tub bath or bed/sponge bath will be offered according to resident's preference, two times per week or according to the resident's preferred frequency and as needed or requested.The facility's document titled, Shower Schedule, updated 3/4/2026, documents residents are scheduled to receive two showers each week and lists residents' room numbers under specific days of the week (R1 scheduled on Mondays/Thursdays, R2 is scheduled on Tuesdays/Fridays, R3 scheduled on Wednesday/Saturday and R16 scheduled on Wednesdays/Saturdays).1.R1's current Care Plan documents: diagnoses including Hemiplegia, Chronic Pain and Impaired Cognitive Function/Dementia; and is dependent on staff with bathing/grooming.R1's Section GG Activities of Daily Living Report, dated 1/29/26 through 3/24/26, does not document a shower on 2/2/26 (Monday), 2/6/26 (Thursday), 2/13/26 (Thursday), 2/16/26 (Monday), 3/9/26 (Monday), 3/12/26 (Thursday), 3/16/26 (Monday) and 3/19/26 (Thursday).R1's Shower Sheets, dated 2/1/26 through 3/24/26, document a shower on 2/9/26 (incomplete with no Nurse/Director of Nursing signature documented), 2/10/26 (incomplete with no Nurse/Director of Nursing signature documented), 2/12/26 (incomplete with no Nurse/Director of Nursing signature) and 2/23/26 (incomplete with no Nurse/Director of Nursing signature). The 2/23/26 Shower Sheet documents refused three times and in too much pain.2. R2's admission Record, dated 3/25/26, documents R2 has medical diagnoses including but not limited to: Type II Diabetes Mellitus, Chronic Kidney Disease, Stage 4 (Severe), Asthma, Sarcoidosis, Unsteadiness on Feet, Other Abnormalities of Gait and Mobility, Weakness, Other Lack of Coordination, Other Symptoms and Signs Involving the Musculoskeletal System, Abnormal Posture, and Excoriation (Skin-Picking) Disorder.R2's Care Plan, dated 1/14/2026, documents R2 has an ADL self-care performance deficit and requires supervision/cueing/touching assistance with bathing and showering related to weakness, Type II Diabetes, and Chronic Kidney Disease.R2's electronic health record report titled, GG ADL Lookback, does not document R2 received a shower on the following dates: 2/3/26, 2/20/26, 2/24/26, 2/26/26, or 3/13/26.R2's shower sheets were reviewed for the time period between February and March with one shower sheet given for 2/20/26 that is incomplete with no Certified Nursing Assistant's signature or Nurse Manager's signature.On 3/24/26 at 9:30 AM, R2 was observed in R2's room lying in bed awake and alert. R2's shirt and protective sleeves were observed with multiple stains. R2 stated, The stains on my shirt are from my scabs bleeding on my arms. R2 stated R2 received a shower over a week ago and no other showers were given since then. I need help taking a shower and I don't always get one when on the days I am supposed to. I don't like feeling dirty when I don't get a shower like I should.3.R3's current Care Plan documents: diagnoses including Hemiplegia, Chronic Back Pain, Limitation of Activities due to Disability and Muscle Disorder; and requires one/two staff assistance with bathing/grooming.R3's Section GG Activities of Daily Living Report, dated 1/29/26 through 3/24/26, does not document a shower on 2/21/26 (Saturday) or 2/25/26 (Wednesday).On 3/25/26, V2 (Director of Nursing) stated, I do not have (R3's) Shower Sheets for 2/21/26 or 2/25/26.4. R16's admission Record, dated 3/25/26, documents R16 has medical diagnoses including but not limited to: Anemia, Schizoaffective Disorder, Bipolar Type, Disorder of Lung, Morbid (Severe) Obesity, Chronic Pulmonary Embolism, Osteoarthritis of Knee, Unspecified, Overactive Bladder, Bipolar Disorder, Major Depressive Disorder, Other Ill-Defined Heart Disease, Cervical Spondylosis, and Personal History of Urinary Tract Infections.R16's Care Plan, dated 1/13/26, documents R16 has an ADL self-care performance deficit related to diagnosis of dementia, morbid obesity, and requiring assistance for bathing and hygiene related to large skin folds. This same Care Plan documents R16 is dependent on one staff member for bathing and showering.R16's electronic health record report titled, GG ADL Lookback and Shower Sheets were reviewed. There is no documentation of bathing or showers between 2/5/26 and 2/14/26 for R16.On 3/24/26 at 9:55 AM, R16 was observed lying in bed in R16's room awake and alert. A strong, foul smelling urine odor was present in the hallway on B Wing and in R16's room at this same date and time. There was a constant malodorous urine smell present in R16's room and in the hallway on B Wing (where R16 resides) on 3/24/26 between the hours of 8:30 AM and 12:00 PM, on 3/25/26 between the hours of 8:45 AM and 11:30 AM, and 3/26/26 between the hours of 8:45 AM and 12:30 PM.R16 stated R16 is incontinent of urine and needs help getting changed and getting cleaned up after an incontinent episode. R16 stated, I don't always get two showers every week. The staff here are busy, and they don't always have time to give me a shower. R16 stated R16 does not get washed in bed when R16's showers are not given on scheduled shower days.On 3/26/26 at 12:25 PM, V2/Director of Nursing, stated, All residents in the facility are scheduled for showers two times a week per the facility's Shower Schedule. V2 confirmed there was no documentation for showers for R1, R2, R3, and R16 for the dates stated above. V2 stated showers should be documented in the electronic health record or on a shower sheet when completed.

Based on interview and record review the facility failed to reasonably accommodate a resident's request to electronically monitor her own room for one resident (R1) and the facility failed to allow one resident (R3) to electronically monitor his own room of two residents reviewed who had requested electronically monitor their rooms. The State of Illinois Ombudsman Program Booklet documents You have a right to purchase and use an electronic monitoring device after providing notice to the facility using the Electronic Monitoring Notification Consent Form.1.R1's Medical Record documents that she was admitted on [DATE] with diagnosis to include but not limited to hemiplegia and hemiparesis following a cerebral infarction, anxiety and restless leg syndrome. R1's Medical Record documents that she is cognitively intact and makes all of her own decisions. Throughout the survey R1 was alert, oriented and answered all questions appropriately. On 3/12/25 at 9:00 AM R1 stated that she had asked V16 (Social Services Director) about electronically monitoring her own room. I've signed a consent; they keep telling me they are waiting to hear back from corporate. They gave me a long list of things I had to do to be able to put a video camera in my room. I feel like they are intentionally making it hard for me to do because they don't want to be recorded and that is not fair. On 3/12/26 at 9:30 AM V16 (Social Services Director) confirmed that R1 had asked about electronic monitoring. I was told by corporate that if residents want to electronically monitor their rooms they have to sign a consent, which (R1) did willingly, and the resident has to pay a professional to install the camera, the resident cannot use facility wi-fi, they must set up their own internet service and that the residents have to have a security company that will monitor the feed for the resident.An email from V17 (Compliance Officer) to V16 (Social Services Director) documents What internet provider is the resident going to use? (a) Use of a Wi-fi: For security purposes, use of Facility's existing private or existing guest Wi-Fi network for purposes of transmitting data to or from an Electronic Monitoring Device is prohibited. If an Electronic Monitoring Device is found to be connected to a Facility's private or guest Wi-Fi, the Electronic Monitoring Device will be turned off and the Resident or Resident's Representative will be advised that the resident is responsible for providing and contracting with an internet service provider if they elect to have electronic monitoring device that uses internet technology.On 3/12/26 at 10:00 AM V16 (Social Services Director) confirmed that the Maintenance Director is usually the person responsible for hanging resident's wall decorations and/or pictures. V16 (Social Services Director) confirmed that all residents currently have access to the Facility's Wi-Fi for their phones or laptops at no charge. V16 (SSD) confirmed that no resident has ever requested to know what the security on the internet provider was. V1 stated that R1 uses her phone independently all the time and is able to navigate connecting it to and from wi-fi. V16 (SSD) stated that she thought R1 would be able to navigate a user friendly electronic monitoring device. 2. R3's Medical Record documents that he was admitted to the facility on [DATE] with diagnosis to include but not limited to Multiple Sclerosis, Chronic Pain and Post Traumatic Stress Disorder. R3's Medical Record documents that he is cognitively intact and makes all of his own decisions. On 3/12/26 at 9:30 AM R3 stated that he was using Bluetooth on his phone to connect to his TV so he could play his games better. R3 stated that he mentioned to one of the CNAs that if he wanted to, he would be able to look inside of his own room through his TV on his phone. R3 stated I used to work for Google, so I am pretty computer and internet savvy. R3 stated I get out of bed very rarely, I am always in my room, so I was really just pointing it out, but then (V16/Social Services Director) came in and told me I am not allowed to monitor my room without a consent so I said ok, I will sign that, then she said I had to be on my own internet provider even though my system wasn't even using the internet. Now it's just a matter of what is right to do. I don't think they should be able to make me incur costs to monitor my own room. On 3/12/26 at 10:00 AM V16 (Social Services Director) confirmed she told R3 that he could not monitor his room via Bluetooth on his phone. V16 (SSD) stated can't monitor his room with Bluetooth. It must be on his own internet provider with a security company monitoring it for him.

Based on interview and record review the facility failed to ensure seven residents (R1 through R7) were free from abuse of seven residents reviewed for abuse.This failure caused the residents to initially feel fear for their safety and has caused ongoing stress and anxiety.Findings include:The Facility's Abuse Prevention and Reporting policy dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services by staff or mistreatment. The Facility's Abuse Prevention and Reporting policy documents Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental mean. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The Facility's Abuse Prevention and Reporting policy documents Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. The Facility's Abuse Prevention and Reporting policy documents Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion.1.The Facility's Final Abuse Investigation Report dated 1/23/26 documents that on 1/18/26 V5 (Certified Nurse Aide) pushed facility staff member with residents present. On 3/11/26 at 11:30 AM V7 (Certified Nurse Aide) said that on 1/18/26 she overheard yelling and cursing so she walked up the hallway to see V8 (Registered Nurse) walking behind V5 (Certified Nurse Aide) who was yelling and cursing. V7 said there were residents out in the hallway and even those in their rooms could hear her. V7 (CNA) stated I said something to the effect of you are scaring the residents and I heard her say I will kick your a*s too, you stupid mother*ucker. V7 (CNA) said V5 (CNA) grabbed her by her throat and lifted her in the air I literally could not feel ground beneath my feet and slammed her into a door then threw her to the floor. V7 (CNA) stated It was the most violent and scariest thing I have ever been through. V7 said I was just worried about the residents because of the way she was acting. On 3/11/26 at 1:00 PM V8 (Registered Nurse) said that on 1/18/26 V5 (CNA) was the CNA responsible for staying in the main dining room during meals. V8 (RN) saw V5 (CNA) at the nurse's desk so she said, You need to be in the dining room and V5 stated I ain't doing sh*t, I'm fixing to leave. V8 (RN) stated I told her if she wasn't going to report to the dining room immediately, she should go ahead and leave early and she exploded. V8 (RN) stated that V5 (CNA) stated she wasn't leaving until I get my f*cking money b*tch. Get me my money you stupid mother*ucker. V8 (RN) stated she called the on-call person who pushed through V5 (CNA)'s payment for time worked and told V5 (CNA) that she could leave since she had been paid. V8 (RN) said that V5(CNA) began walking towards the door and yelled about what a sh*thole the facility was and that the facility f*cking needed her, you stupid b*tch. V8 (RN) said she was in my face at a couple points, and she was just being as vile as she possibly could. V8 (RN) said that V7 (CNA) came around the corner and said, please quit yelling you are scaring the residents. V8 (RN) said that V4(CNA) grabbed V7 (CNA) by the throat and slammed her into a doorway and then flung V7 (CNA) to the ground. When someone yelled call 911 V7 (CNA) ran out while spitting on (staff).The Facility's Final Abuse Investigation dated 1/23/26 documents It was witnessed that (V4/CNA) raised her voice, used profanity, and pushed (V7/CNA) with residents present during the exchange. No residents were involved in the altercation.On 3/10/26 at 1:30 PM V1 (Administrator) stated that the abuse allegation for the 1/18/26 incident would be considered not substantiated because no residents were involved in the altercation. On 3/12/26 at 10:00 AM R1 recalled V4 (CNA) beating up V7 (CNA). R1 stated that V5 (CNA) was yelling and cursing, it was very scary.On 3/11/26 at 12:00 PM R2 recalled the incident on 1/18/26. R2 stated I didn't see how it all got started, when I got out there (V7/CNA) was on the ground holding her neck and crying and there were people everywhere. I am a big man with a rough past, I don't worry for myself, I am still able to take of myself, I worry about the people who can't take care of themselves if this is the kind of staff they (facility) are hiring.On 3/11/26 at 9:30 AM R3 recalled the incident on 1/18/26. R3 stated I wasn't out there for any of it, but the whole building was tense for the rest of the night. R4's nurse's note dated 1/20/26 at 10:46 AM as 72 hour Follow Up documents resident is alert and oriented. Has sad and worried look on his face.R5's nurse's note dated 1/18/26 at 6:46 PM documents resident alert and oriented. resident had episodes of crying. Resident verbalized being fearful related to being a witness to altercation between 2 CNAs. On 3/11/26 at 12:15 R6 recalled the incident on 1/18/26. (V7/CNA) was on the floor crying. Boy, I did not like that. R7's nurse's notes 1/19/26 at 2:53 PM document that R7 stated he was struggling with having been a witness to an altercation between two CNAs. 'I'm so mad about it.' Resident was in a safe space and that behavior like that was not tolerated and would not happen again. R7 had discharged home sometime after the incident and did not answer any phone calls made to the listed home phone during the survey.On 3/12/26 at 10:00 AM V1 (Administrator) stated the whole building was in an uproar over this incident. 2. The Facility's Final Abuse Investigation dated 3/6/26 documents that R2 told V1 (Administrator) that he had loaned V3 (Certified Nurse Aide) $50 and that she wasn't paying it back.On 3/10/26 at 9:45 AM R2 stated that V3 (CNA) had been complaining about her money situation so R2 offered her a loan. R2 stated at the time he only had a $50 bill on him so that is what he gave V3. R2 said he's unsure of exact day but it was about 2 weeks ago. The Facility's undated interviews with residents document that when asked, R3 stated that V3 (CNA) had asked him for money but he said no.On 3/10/26 at 10:00 AM R3 stated that a couple of weeks ago V3 (CNA) asked him for money but he said no. On 3/10/26 at 1:30 PM V1 (Administrator) stated that abuse allegation related to R2's concern about his money was considered unsubstantiated because R2 could not prove that he actually gave the staff member money. V1 (Administrator) stated that R2 handled his own finances therefore V1 (Administrator) could not prove that R2 even had $50 to loan in the first place.

Based on interview and record review the facility failed to ensure all Certified Nurse Aides had 12 hours of required In-Service Training. This failure has the potential to affect all 56 residents who currently reside in the facility. The Facility's (Temporary Agency) Client Service Agreement dated 6/30/2023 documents (Facility) acknowledges that Professional Providers are independent contractors operating as self-employed individuals who use (Temporary Agency) to offer and provide healthcare services to (Facility). (Facility) acknowledges and agrees that (Temporary Agency) has no responsibility for, control over, or involvement in the scope, nature, quality, character, timing or location of any work or services performed by Professional Providers between (Facility) and Professional Providers. (Facility further represents, acknowledges, and warrants that throughout the term it shall at all times treat Professional Providers as independent contractors and (Facility) will take no action that is inconsistent with such classification. The Facility's (Temporary Agency) Client Service Agreement also documents (Facility) hereby acknowledges and agrees that (Temporary Agency) is not the employer of, or joint employer or integrated or single enterprise with any Professional Provider. (Facility) understands and agrees that through the term (Temporary Agency) is not responsible for the performance or non-performance of any Professional Provider. On 3/12/26 at 9:00 AM V1 (Administrator) stated she did not have any documentation of any trainings done by (Temporary Agency) staff. I know that (Temporary Agency) keeps that on file. On 3/12/26 at 10:00 AM V1 (Administrator) stated that she would not be able to provide any documentation of any trainings done by (Temporary Agency) staff. V1 confirmed that about 50 % of the Certified Nurse Aide staff was from (Temporary Agency) On 3/12/26 at 10:00 AM R1 stated (Agency) staff are horrible, they don't seem to know what is going on.On 3/11/26 at 12:00 PM R2 stated (Agency) staff don't care and have no idea what they are doing. On 3/12/26at 9:30 AM R3 stated (Agency) staff don't know anything about (the residents) and they always do the bare minimum.

Based on interview and record review the facility failed to recognize allegations of abuse as substantiated instances of abuse. This failure has the potential to affect all 56 residents who currently reside in the facility. The Facility's Abuse Prevention and Reporting policy dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services by staff or mistreatment. The Facility's Abuse Prevention and Reporting policy documents Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental mean. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The Facility's Abuse Prevention and Reporting policy documents Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. The Facility's Abuse Prevention and Reporting policy documents Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion.The Facility's Final Abuse Investigation dated 1/23/26 documents It was witnessed that (V5/CNA) raised her voice, used profanity, and pushed (V7/CNA) with residents present during the exchange. No residents were involved in the altercation.On 3/12/26 at 10:00 AM R1 recalled V5 (CNA) beating up V7 (CNA). R1 stated that V5 (CNA) was yelling and cursing, it was very scary.On 3/11/26 at 12:00 PM R2 recalled the incident on 1/18/26. R2 stated I didn't see how it all got started, when I got out there (V7/CNA) was on the ground holding her neck and crying and there were people everywhere. I am a big man with a rough past, I don't worry for myself, I am still able to take of myself, I worry about the people who can't take care of themselves if this is the kind of staff they (facility) are hiring.On 3/11/26 at 9:30 AM R3 recalled the incident on 1/18/26. R3 stated I wasn't out there for any of it, but the whole building was tense for the rest of the night. R4's nurse's note dated 1/20/26 at 10:46 AM as 72 hour Follow Up documents resident is alert and oriented. Has sad and worried look on his face.R5's nurse's note dated 1/18/26 at 6:46 PM documents resident alert and oriented. resident had episodes of crying. Resident verbalized being fearful related to being a witness to altercation between 2 CNAs. On 3/11/26 at 12:15 R6 recalled the incident on 1/18/26. (V7/CNA) was on the floor crying. Boy, I did not like that. R7's nurse's notes 1/19/26 at 2:53 PM document that R7 stated he was struggling with having been a witness to an altercation between two CNAs. 'I'm so mad about it.' Resident was in a safe space and that behavior like that was not tolerated and would not happen again. R7 had discharged home some time after the incident and did not answer any phone calls made to the listed home phone during the survey.On 3/10/26 at 1:30 PM V1 (Administrator) stated that the abuse allegation for the 1/18/26 incident would be considered not substantiated because no residents were involved in the altercation. V1 confirmed that there were 5 residents (R2 through R7) were in the hallway and witnessed V5 (CNA) attack V7 (CNA). V1 also confirmed that it was reported to her that V5 (CNA) was screaming, cursing and threatening anyone who tried to calm her down. V1 stated None of the residents were within arm's reach of (V5/CNA) and (V4/CNA) didn't specifically state she was going to hurt a resident. (V5/CNA) was mad at the nurse. 2. The Facility's Final Abuse Investigation dated 3/6/26 documents that R2 told V1 (Administrator) that he had loaned V3 (Certified Nurse Aide) $50 and that she wasn't paying it back.On 3/10/26 at 9:45 AM R2 stated that V3 (CNA) had been complaining about her money situation so R2 offered her a loan. R2 stated at the time he only had a $50 bill on him so that is what he gave V3. R2 said he unsure of exact day but it was about 2 weeks ago. The Facility's interview form with abuse questions dated 3/6/26 had a handwritten note at the bottom from V15 (Regional Director of Operations) documenting (V3/CNA) refused to show for interviews and made herself unavailable. Throughout the survey messages were left at multiple phone numbers for V3(CNA) with no return phone call. The Facility's undated interviews with residents document that when asked, R3 stated that V3 (CNA) had asked him for money but he said no.On 3/10/26 at 10:00 AM R3 stated that a couple of weeks ago V3 (CNA) asked him for money but he said no. On 3/10/26 at 1:30 PM V1 (Administrator) stated that abuse allegation related to R2's concern about his money was considered unsubstantiated because R2 could not prove that he actually gave the staff member money. V1 (Administrator) stated that R2 handled his own finances therefore V1 (Administrator) could not prove that R2 even had $50 to loan in the first place. V1 (Administrator) confirmed that R2 is alert and oriented and does not have a history of fabricating stories for any reason and is usually pretty laid back, get along with everyone kind of guy. V1 (Administrator) confirmed that she was made aware that during the investigation into V3 taking money from R3 had also reported that V3 (CNA) had asked him for money also. No one can prove that, that is just hearsay. V1 (Administrator) confirmed that R3 is alert and oriented and does not have a history of fabricating stories for any reason. It still shouldn't be considered abuse because it is not misappropriation of funds, (R2) offered the money on his own accord. On 3/10/26 at 9:00 AM V1 (Administrator) confirmed she was the Abuse Coordinator for the facility. The facility's Resident Census and Condition list dated 3/10/26 documents 56 residents currently reside in the facility.

Based on observation, interview and record review the Facility failed to maintain a heating system, comfortable temperature ranges in the Facility's Dining Room and perform temperature checks/documentation following a faulty heating system. This failure has the potential to affect all 57 Residents that consume meals in the Dining Room.Findings include:The Facility Resident Daily Census Report, dated 1/24/26, documents 57 Residents residing in the Facility.The Facility's Code White-Extreme Weather Policy, dated 1/2026, documents the following measures are to be taken during cold weather months: encourage to wear suitable clothing in the facility (sweaters, long sleeves shirts, long pants and socks); the Facility Maintenance Director and Administrator are to be notified of heating system failures and/or significant concerns regarding temperatures; and if a heating unit fails in an area of the Facility and/or the temperature becomes uncomfortable, upon direction of the administrative personnel, Residents affected may be moved to another area in the Facility where temperature is adequate; winter storm safety precautions include notifying the Administrator and management team, make sure all emergency equipment and supplies are on hand, make sure heating system is operable, have extra blankets and keep Residents as warm as possible.The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: the Facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; must provide services to keep your physical and mental health at their highest practical levels; and must be safe, comfortable and homelike.A computer online internet web search for weather in Havana, Illinois, dated 1/24/26, documents: very cold winter weather with sub-zero wind chills; a high temperature of ten degrees Fahrenheit/F and a low temperature of five degrees Fahrenheit; snow accumulation of one to three inches; and 20-degree Fahrenheit below zero wind chill advisory until noon.The Facility Grievance Tracking Logs, dated 12/2025 and 1/2026, document issues with heat on 12/8/25, 12/10/25 and 1/8/26. The Tracking Log does not document a date of resolution follow up notification.On 1/24/26 at 8:34 am, V4 (Registered Nurse/RN) was passing medication in the Facility Dining Room and stated, It is freezing in here and we have a lot of medically compromised Residents in here. Go over by the door next to the serving window, the door does not close all the way and there is a draft coming in. My poor Residents' teeth are chattering. They have to wear gloves, coats, stocking hats and extra blankets and those are not even helping. Management is aware this has been going on for weeks and they finally put this little wall mount heater in a day or so ago and it is not doing the job, it is way too small for this room. The heater is set at 95 degrees, and no one can even feel any heat. I have so many Residents complain to me about the cold temperature in here (Dining Room). I have had family members complain also and they have even had to bring extra warm clothes within the last week or so.On 1/24/26 at 8:57 am, V5 (Certified Nursing Assistant/CNA) stated, It has been so cold in the Dining Room, and we still have to serve all their meals served in there anyway. The Residents have extra blankets and jackets on, but they still all complain every day, how cold it is in there (Dining Room). Management makes us take them down to the Dining Room or we get into trouble, and they get mad at us, if we do not make the Residents go down there (Dining Room). Management is aware that it has been cold in the Dining Room for a couple of weeks and they finally a day or so ago, put a space heater on the wall, but it does not even do anything.On 1/24/26 at 9:59 am, V6 (CNA) stated, It is so cold in the Dining Room. We have to bundle them up and put extra blankets on our Residents, but it does not even help them. They are elderly and they like everything to be warmer than usual. I think we just got a new space heater in there (Dining Room), but honestly, it does absolutely nothing. It is way too small for that big room.On 1/24/26 at 9:09 am, V7 (CNA) stated, It has been cold in that Dining Room all winter. (V9/Maintenance Director) just put a new heater in and it does not feel any warmer. Residents are still asking for extra blankets. They are still making us take them to the Dining Room anyway. The door on the left side of the serving window does not feel like it is shut, and it has been that way for years. There is a huge draft that comes in from that.On 1/24/26 at 10:01 am, R5 stated, It is cold as h*** in that dining room. It was really, really cold as of yesterday. I have to wear a coat and blanket, it is terrible.On 1/24/26 at 10:04 am, R6 stated, I did not go to the Dining Room this morning because it is freezing. It used to be warm in there and I did not even need a jacket then. Now I have to wear a coat and gloves because it is cold as h***. It is ridiculous how cold it is in there. What's worse is, we usually get down to the Dining Room and have to sit and wait a while to get our food, and I sit there freezing while I am waiting.On 1/24/26 at 10:26 am, R3 stated, My room is warm, but that Dining Room is freezing. I have to always take a blanket with me. I do not like it that cold. Now I have a sore throat too.On 1/24/26 at 10:21 am, R7 stated, Oh it is freezing in the Dining Room. I have to wear a coat and cover with blankets because they do not turn the heat on. It is very uncomfortable to eat when you are cold.On 1/24/26 at 8:30 am, the Facility was serving the breakfast meal in the Facility Dining Room. On 1/24/26 at 9:58 am, from the nurse's station hallway into the Facility Dining Room doorway entry, the lower air temperature change was immediate. There was a cold draft from the door positioned to the left of serving window.On 1/24/26 at 9:55 am, R9 was sitting in the Dining Room and stated, It is colder than heck in here. I always have to wear a shawl, and I even have two blankets on right now. They put a new heater in, but it has not gotten any better. It makes it hard to eat when you are cold.On 1/24/26 at 10:14 am, V10 (Dietary [NAME]) stated, They just installed that wall heating unit, and it does not help at all. We are keeping the door to the kitchen open to help try and heat the dining room. We put blankets in the window seals to help with the drafts. So many of the Residents complain that they are cold. It really is cold in here for them.On 1/24/26 at 10:16 am, V11 (Dietary Cook) stated, All of the Residents complain about how cold it is in this dining room.On 1/24/26 at 10:18 am, V12 (Dietary Aide) stated, Everyone complains about it being freezing in this dining room. We have the doors open to the kitchen trying to help heat it (Dining Room), but it really does not help. They need to fix the original heater that broke in here because that little wall unit is not even helping at all.On 1/26/26 at 10:17 am, R8 stated, I am getting sick and tired of having to eat in the cold. I did not even finish my breakfast this morning because I had to get back to my room because it was so cold in the dining room. They got some new heater in there, but it does not even work. They have the old unit covered up over there; I just do not understand why they do not just fix that one. They have had it covered with a blanket for a couple weeks now. I can feel that draft coming in from that door while I am eating. I have to come down to eat now with two sweatshirts and a jacket on. If I end up getting sick over this, I am going to be mad. There are so many people in here that are complaining about the cold.On1/24/26 at 10:27 am, V9 (Maintenance Director) stated, I am the Maintenance Director. I also am the Housekeeping and Laundry Manager. The big heating unit in the Dining Room stopped working correctly. I have heard complaints that the Dining Room is colder than normal. I put in a work order, and my boss approved the wall mount heating unit. I just installed it, and I have the temperature control monitoring connected through an application on my phone. I do not have any maintenance records for the heating unit. If something were to go wrong with it, then I would get approval to call a local heating distributor. I only tempted the Dining Room on random normal temperature checks, I have not specifically been doing temperature checks in there (Dining Room) since the heating unit went out, so I do not have any documentation of the temperature checks. The door to the left of the serving window never gets used. It looks like it is not sealed correctly. V9 verified that rust and a draft was coming in through the door. V9 opened up the application on V9's phone, and the lowest temperature registered 57 degrees Fahrenheit on 1/23/26 through 1/24/26. We have not been using any other forms of heat sources until I just installed that wall unit.On 1/24/26 at 10:30 am, V9 performed temperature checks in four different areas of the Facility's Dining Room. The temperatures registered at 66.9 degrees Fahrenheit/F, 67.1 F, 67.3 F and 68.4 F. On 1/24/26 at 11:42 am, approximately 25 Residents were seated in the Facility Dining room with blankets and coats on prior to the lunch service meal.On 1/24/26 at 9:40 am, V1 (Administrator) stated, I was not aware of it being cold in the Dining Room, but we did just install a new heater in there.On 1/24/26 at 12:43 pm, V1 (Administrator) stated, I was not sure what was going on with the heating, and I was not really involved in it because (V9/Maintenance Director) was dealing with it with our corporate.

Based on interview and record review, the Facility failed to provide a properly maintained transportation van causing safety risks for one of three Residents (R3) during transportation with weather risks (rain) and after sundown.Findings include:The Facility Transportation Driver Job Description, dated 7/2023, documents: is responsible for safety of Residents at all times; monitors Resident safety on the bus; responsible for general upkeep including conducting preventative maintenance, delivering vehicle to authorized service facility, maintains vehicle according to the requirement of the Facility, including completing all required paperwork; follow all safety procedures and protocol as dictated by local policy, federal and state regulations and standard practice; reports all hazardous conditions, defective equipment and incidents to the supervisor immediately; and maintains accurate activity and vehicle report logs.The Facility Grievance Tracking Logs, dated 12/2025 and 1/2026, document issues with headlights on 1/8/26. The Tracking Log does not document a date of resolution follow-up notification.On 1/24/26 at 9:09 am, V7 (Certified Nursing Assistant/CNA) stated, I was here when (R3) and (V15/R3's Daughter) got back from the van ride. (R3) and (V15) were so upset. (V15) was crying about it.On 1/25/26, at 8:45 am, V3 (Transportation Driver) stated, I started with the company on 11/3/25 and I knew the headlights were not working at that time. I had a late appointment back in November, when I had to drive in the dark and I was told to just keep the bright lights on because the headlights were very dim. Somewhere around Christmas time, I got a phone call around 7:00/7:30 pm, that (V9/Maintenance Director) and I had to transport a Resident to a hospital over an hour away. It was dark out and we had to drive without the headlights working properly. I almost hit three deer. (V9) was with me and knew that the headlights did not work correctly. Then on 1/25/26, I had to transport a Resident (R3) to an appointment that was again over an hour away and we had to drive back in the rain, and it was dark. (V15/R3's daughter) was with us in the van. The windshield wipers were broken and we had no headlights, so I had to go about 40 miles an hour on the interstate. It was so scarry. (V15) was scared too, it was awful. They got new headlights a day or so after (V15) complained, but the headlights still are not fixed. I have been driving around with the new headlight box sitting in my van. (V9) attempted to change the headlights but apparently a panel needs removed in order to fix them, so they have to take them into a professional for service. (V9) has so much to do and is over so many departments, (V9) has not had a chance to get them fixed. I drive the transportation van, and it has almost 300,000 miles and there are lights on the dashboard that stay lit. I am still driving the van, but I do not want to drive after dark with it. On 1/24/26 at 1:29 pm, V9 (Maintenance Director) verified that the Facility transport van headlights were burnt out. V9 could not provide maintenance records for the transportation van. On 1/24/26 at 10:42 am, V9 (Maintenance Director) stated, I was notified after (V15) complained about the headlights not working during a van ride to (R3's) appointment. I tried to change the headlights, but it is too complicated because dashboard panels and other things need removed, and a professional needed to replace them.On 1/24/26 at 12:43 pm, V1 (Administrator) provided a receipt, dated 1/24/26, for the headlight replacement.

Based on interview and record review the Facility failed to protect one of three Residents (R1) reviewed for Verbal Abuse from a Facility staff perpetrator. Findings include:The Facility Abuse Prevention and Reporting Policy, dated 12/2025, documents: the Facility affirms the right of our Residents to be free from abuse; Facility prohibits abuse; establishes a resident sensitive and resident secure environment; and orienting and training employees on how to deal with stress.The Facility's Final Abuse Investigation Report, dated 12/22/25, documents, on 12/16/25 at approximately 6:00 pm, a verbal abuse altercation between R1 and V8 (Agency Certified Nursing Assistant/CNA). The Abuse Investigation Report also documents: R1 is a [AGE] year-old, has altered cognitive deficits (Brief Interview for Mental Status/BIMS-score 12/15) and admitted to the Facility with diagnoses including Right Femur Fracture and Chronic Obstructive Pulmonary Disease. V8 (Agency CNA) swore at R1 and disregarded R1's hip pain when transferring. The Investigation Report documents that V8 had a poor attitude while V8 was working in the building and V14 (R1's Spouse) witnessed the interaction and stated that V8 was very rude and impatient with R1. V8 was escorted out of the building and placed on Do Not Return status.V8's (Agency CNA) Employee File, documents V8 was terminated (Do Not Return) on 12/16/25 due to witnessed verbally abusing a Resident. V8's Employee File does not document Abuse Training.The Facility Certified Nursing Assistant Job Description, dated 7/2023, documents: to provide Residents to safeguard the health, safety and welfare in accordance with the Facility's established policies and procedures and applicable laws and regulations; assure that the highest degree of quality care is maintained at all times; be sensitive to Residents' families and respond in an appropriate professional way; carry out assignments for Resident care; follow established safety precautions when performing tasks; must demonstrate ability to deal tactfully with staff, residents and family members; and knowledge of Public Health Department regulations.On 1/24/26 at 8:34 am, V4 (Registered Nurse) stated, (R1) was here short term for rehabilitation. (V8/CNA) was cussing at (R1) with (V14/R's Spouse) in the room. (V14) pulled (R1) out of the Facility before the end of (R1's) rehabilitation over that incident with (V8).On 1/24/26 at 12:43 pm, V1 (Administrator) stated, I received a phone call that (V8/CNA) was berating and swearing at (R1) in front of (V14/R1's spouse). We walked (V8) out of the building and because (V8) was an Agency CNA, we placed (V8) on the Do Not Return list. I had reports that (V8) was being rude and using profanity. We do not allow that behavior.

Based on observation, interview, and record review the facility failed to ensure the facility assessment included the amount of direct care staff required daily to meet the needs of the residents, ensure there were an adequate amount of direct care staff to perform daily ADLs (Activities of Daily Living) to the residents, ensure residents received fresh ice water every shift, and ensure call lights were answered timely. These failures have the potential to affect all 58 residents residing within the facility.Findings include:The Facility's Daily Census Log dated 1/15/26 documents there are 58 residents currently residing within the facility.The Facility's Assessment Tool dated 11/25 through 11/26 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies Staff Type-support staff including plant operations, custodians, housekeeping, and maintenance staff. Staffing Plan- Enter number of staff needed or average or range. Direct Care Staff: Refer to facility assessment addendum. This same Facility Assessment does not include an addendum to provide the facility with the staffing plan and number of direct staff needed daily to meet the needs of the residents.The Residents' Rights Illinois-Long Term Care Ombudsman Program dated 11/2018 documents, Your facility must provide services to keep our physical and mental health at their highest practical levels. You should receive the services and/or times included in the plan of care.The Bathing-Shower and Tub Bath Policy dated 8/26 documents, Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed/sponge bath will be offered according to resident's preferences, no less than once per week or according to the resident's preferred frequency and as needed or requested.The facility's Water Pass-Hydration Policy dated 7/26 documents, Purpose: To provide fresh drinking water to residents in a clean and sanitary manner to meet hydration needs. Fresh cold ice water will be provided to each resident a minimum of three times each day, unless contraindicated.R2's current Care Plan documents R2 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.The facility's Shower Schedule documents R2 is to receive showers every Tuesday and Friday during day shift.R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is dependent on staff for personal hygiene and showers.A Concern Form dated 1/12/26 documents, Person Relating concerns: (R2). Nature of Concern: Not getting showers. It's been another whole week without a shower.R2's Shower Reports and Shower Tasks dated 1/1/26 through 1/17/26 do not include evidence of R2 receiving his scheduled shower on 1/9/26 (Tuesday).R7's current Care Plan documents R7 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed. This same Care Plan documents R7 has a decreased oral fluid intake related to cognitive impairments and is at risk for dehydration and staff should offer fluids in an easy-to-handle container and offer small sips throughout the day reminding R7 to drink as cognitive impairment may cause R7 to forget.R7's MDS dated [DATE] documents R7 is dependent on staff for showers, personal hygiene, and toileting.R8's current Care Plan documents R8 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.R9's current Care Plan documents R9 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.R9's MDS assessment dated [DATE] documents R9 is dependent on staff for personal hygiene and showers.The facility's Shower Schedule documents R9 is to receive showers every Tuesday and Friday during day shift.R9 Shower Report dated 1/13/26 and signed by V7 (CNA/Certified Nursing Assistant) and V9 (LPN/Licensed Practical Nurse) documents R9's scheduled shower was not given on 1/13/26 due to the facility not having enough staff.R17's MDS assessment dated [DATE] documents R17 is cognitively intact and is dependent on staff for personal hygiene and showers.R17's Current Care Plan documents R17 prefers to shower on Tuesdays has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.R17's Shower Report dated 1/13/26 and signed by V7 (CNA) and V9 (LPN) documents R17's scheduled shower was not given on 1/13/26 due to the facility not having enough staff.R19's MDS assessment dated [DATE] documents R19 is cognitively intact.On 1/15/26 from 8:55 AM through 10:00 AM and 1/16/25 from 2:00 AM through 3:00 AM tours were conducted throughout the facility. During these tours there were four hallways (A, B, C, and D) with residents residing. During this tour, no residents had fresh ice water at the bedside.On 1/15/26 at 8:55 AM R7 was sitting in a wheelchair in his room. R7 had no fresh water at the bedside. R7 stated, It takes hours to get anything around here. There are days my call light is on for over one hour. The staff that are here are good, there is just not enough of them. I would like to get showers more frequently.On 1/15/26 at 9:10 AM R19 was sitting in her room. R19 had no water at the bedside. R19 stated she does not get fresh ice water every shift and it takes a very long time to get her call light answered whenever she needs anything.On 1/15/26 at 9:45 AM R8 stated, There is never enough staff to answer my call light in time to get me off the bed pan. The staff never get me fresh ice water. I went three weeks in November, and I did not get the last two showers on my shower days because there was not enough staff to do them.On 1/16/26 at 6:20 AM R9 was lying in bed. R9 did not have any water at the bedside. R9 stated the staff do not give her showers every Tuesday and if she wants water, she has to bring the water she gets during her meals to her room.On 1/17/26 at 12:15 PM R2 was lying in bed. All R2's fingernails were long, jagged, and had brown debris underneath. R2's water jug was sitting on his over the bed table. R2's water jug was empty. R2 stated, I do not get my showers, or my nails clipped when I am supposed to. I never get fresh ice water. There are not enough staff here to do everything. You never know how long it is going to take to get your call light answered. It takes hours at times.On 1/17/26 at 12:30 PM R17 was sitting in the dining room. R17's fingernails were long and jagged. R17 stated she does not always get her showers and does not get fresh water every shift.On 1/15/26 at 8:40 AM V4 (CNA) stated, There are not enough CNAs to get the scheduled showers done every day and we hardly ever get to pass fresh ice water to the residents. There is never enough help to get everything done for the residents.On 1/15/26 at 8:50 AM V5 (CNA) stated, We are short-staffed almost daily and cannot possibly get everything done for the residents. Ice water does not get passed every day and showers do not get done as scheduled. We hardly ever have six CNAs on day shift and that is what it takes to get everything that needs to be done. We (facility staff) are stressed out almost daily. I have filed numerous complaints with the bosses.On 1/15/26 at 10:20 AM V7 (CNA) stated, We never have enough staff on first shift to get everything done. Resident showers do not get done and ice water does not get passed. I have started documenting on the resident shower sheets whenever their showers cannot get done due to low staffing. We have a lot of residents who require mechanical lifts and two staff for showers and transfers. Those cannot possibly get done when there is only one staff member on the hallway.On 1/15/26 at 11:40 AM V11 (RN/Registered Nurse) stated, We do not have enough staff to take care of the residents. The residents do not get their showers or cleaned up because of it.On 1/15/26 at 12:50 PM V16 (CNA) stated, There are times there are only four CNAs working second shift and it is impossible to get everything done. I haven't been able to pass fresh ice water to the residents in weeks. Resident showers do not get done and residents are on their call lights for a long time before we can get them answered. I get very stressed out.On 1/15/26 at 12:55 PM V17 (CNA) stated the CNAs do not have time to pass ice water every shift, get showers done, or answer call lights quickly when there are not at least five CNAs working second shift. V17 stated it has been weeks since she was able to pass fresh ice water to the residents.On 1/16/26 at 2:50 AM V21 (CNA) stated, I work third shift. There was one night (unknown date) that I was the only CNA in the entire building. Call lights were going off and there was no way to get them all answered. We do not get time to pass ice water.On 1/16/26 at 3:00 AM V22 (LPN) stated, The facility needs to improve the staffing. I know showers get left undone, call lights are on for way to long, and ice water does not get passed.On 1/16/26 at 3:15 AM V23 (CNA) stated that there are some nights there is not enough time to pass ice water to all the residents.On 1/16/26 at 3:30 AM V24 (LPN) stated the facility has not had clean linens or second shift laundry staff for the past two weeks. V24 stated the linens they do have are stained.On 1/17/26 at 7:10 AM V14 (RN) stated, There was one night that (V21) was the only CNA in the building. There were a lot of nights there were only two CNAs working within the entire building for four hallways of residents. Ice water does not get passed and call lights take a long time to get answered.On 1/17/26 at 11:30 AM V2 (Director of Nursing) stated that from 11/1/25 through 12/10/25 the facility should have staffed five CNAs on day shift, four CNAs on second shift, and three CNAs on third shift to meet the needs of the residents. V2 stated that starting on 12/10/25 the facility should have staffed six CNAs on day shift, five CNAs on second shift, and four CNAs on third shift to meet the needs of the residents. V2 confirmed that the facility was unable to staff the required number of CNAs to meet the needs on the residents during multiple days during these timeframes.This surveyor chose a random number of days to review the direct care staffing within the facility which included 12/14/25, 12/31/25, 1/7/26, and 1/14/26. The facility's CNA Schedules and Staff Time Sheets dated 12/14/25 documents there were only three CNAs that worked on day shift. The facility's CNA Schedules and Staff Time Sheets dated 12/31/25 documents there were only five CNAs that worked on day shift and only three CNAs that worked on third shift. The facility's CNA Schedules and Staff Time Sheets dated 1/7/26 documents there were only four CNAs that worked on day shift and only three CNAs that worked on third shift. The facility's CNA Schedules and Staff Time Sheets dated 1/14/26 documents there were only four and a half CNAs that worked on day shift. On 1/17/26 at 11:30 AM V2 confirmed on 12/14/25, 12/31/25, 1/7/26, and 1/14/26 the facility did not staff the minimum number of CNAs needed.

Based on observation, interview, and record review the facility failed to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to ensure the facility was kept clean and free of odors, to ensure the facility had a sufficient amount of clean linens, mechanical lifts, mechanical lift slings, to ensure the facility's clean utility rooms and all resident rooms were cleaned at least daily, and to ensure the facility's walls, floors, mechanical lifts, lights, window coverings, and toilets were kept maintained and in good repair. These failures have the potential to affect all 58 residents residing within the facility.Findings include:The Facility's Daily Census Log dated 1/15/26 documents there are 58 residents currently residing within the facility.The Facility's Assessment Tool dated 11/25 through 11/26 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies Staff Type-support staff including plant operations, custodians, housekeeping, and maintenance staff. Staffing Plan- Enter number of staff needed or average or range: Staff other (department heads, nurse educator, quality assurance, ancillary staff, housekeeping, dietary, laundry): Refer to facility assessment addendum. This same Facility Assessment does not include an addendum to provide the facility with the staffing plan and number of staff needed to perform maintenance services, housekeeping services, and laundry services.The Maintenance Director Job Description dated 03/2025 documents, The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the maintenance department in accordance with current, federal, state, and local standards, guidelines, and regulations governing our facility. Essential duties and responsibilities: Repair facility/resident property as necessary. Inspect storage rooms, workrooms, utility/janitorial closets, etc. (etcetera), for upkeep and supply control. Ensure that supplies, equipment, etc. are maintained to provide safe and comfortable environment. Ensure that maintenance policies and procedures identify appropriate safety precautions and equipment to use when performing tasks that could result in bodily injury. Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. Place orders for equipment and supplies as necessary or as may be required.The Housekeeper Job Description dated 7/24 documents, The primary purpose of the housekeeper is to perform the day-to-day activities of the housekeeping department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility. Essential Duties and Responsibilities: Ensure that work/cleaning schedules are followed as closely as practical. Clean, wash, sanitized, and/or polish fixtures, ledges, room heating/cooling units, bathrooms fixtures, etc. Clean floors including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting, etc. Discard waste/trash into proper containers and reline trash receptacle with plastic liner.The Laundry Aide Job Description dated 07/2024 documents, The primary purpose of the Laundry Aide position is to perform the day-to-day laundry department functions, to assure that quality services are provided on a daily basis, to safeguard the health, safety and welfare of all residents of the facility, and to assure the facility laundry is maintained in a clean, safe, and sanitary manner.The Residents' Rights Illinois-Long Term Care Ombudsman Program dated 11/2018 documents, Your facility must be safe, clean, comfortable, and homelike.The Mechanical Lift's Manufacturer's Manual dated 2015 documents, When battery power goes below 50% (percent), the controller has an audible beep warning. When the low battery warning is heard, charge the battery immediately. Please note that a lifted patient cannot be lowered down when battery is out of power. Push the emergency red button if the control unit system is not functioning properly. In the event of a power failure, a person can be lowered by pulling up on the red quick release lever.On 1/15/26 at 1:45 PM V2 (Director of Nursing) provided a list of residents who use a mechanical lift and sling for transfers. This list included R2, R6, R8, R9, R11, R12, R13, R14, R15, and R17.The facility's Housekeeping/Laundry Schedule dated 1/1/26 through 1/15/26 was reviewed and documents there was only one laundry aide working eight hours total on 12 days out of the 15 days.The facility's Housekeeping/Laundry Schedule dated 1/1/26 through 1/15/26 was reviewed and documents there was only one housekeeper working eight hours total on seven days out of the 15 days.A Concern Form dated 1/7/26 documents, Staff member making report: (V5/CNA/Certified Nursing Assistant). Nature of concern: 1/3/26 there were no slings (mechanical lift) during the AM (morning shift) and nine showers to give. 1/5/26 AM shift no slings. Staff had to dig through dirty laundry to find the least dirty one (sling). 1/7/26 AM shift no clean slings at all for showers again. Nine showers to give and six of them are (mechanical lift) showers. This same concern form has no follow-up of pertinent findings or corrective actions taken to address this concern.A Concern Form dated 1/12/26 documents, Person Relating concerns: (R2). Nature of Concern: 95 percent of laundry comes to (R2) stinking, dirty, or badly stained.A Concern Form dated 1/12/26 documents, Person Relating concerns: (V20/R1's Friend). Nature of Concern: Sheets hanging on dining room windows. Very tacky. No pictures on walls. Very plain.R9 and R17's Shower Reports dated 1/13/26 and signed by V7 (CNA) and V9 (LPN) documents R9 and R17's scheduled showers were not given on 1/13/26 due to the facility not having mechanical lift slings or linens (washcloths and towels).On 1/15/26 from 8:55 AM through 10:00 AM and 1/16/25 from 2:00 AM through 3:00 AM tours were conducted throughout the facility. During these tours there were four hallways (A, B, C, and D) with residents residing. One hallway consisted of a special memory care unit that had closed alarmed doors. On the special memory care unit, the dining room had two windows that did not have blinds or curtains and there were two see-through bed sheets tacked up unevenly covering a quarter of the windows. The A, B, and C Hallways clean linen storage room contained a three-tier cart with an ice water cooler on the top tier. The second and third tiers of this three-tier cart were covered in chunky brown debris and brown stains. The sink in this clean linen storage room was covered in a rusty substance, all the walls in this room had holes and exposed, unpainted drywall patches, and the floor had brown staining on all floor tiles and trash and debris throughout. There were no clean bed pads or washcloths in this linen storage room. All other linens, including towels and sheets, within this storage room were stained a light brown color and smelled of feces. R3 and R4's bathroom wall had missing chunks of drywall and numerous areas of exposed, unpainted drywall and the bathroom floor had scattered debris. R3's cubicle curtain had multiple brown stains and the wall behind R3's bed headboard has missing chunks of drywall. R8's floor had scattered debris and R8's trashcan was overflowing onto the floor. R2 and R7's floors had scattered debris. R13 and R19's wall above the heating/cooling unit had cracking and bulging drywall.On 1/15/26 at 12:00 PM V8 (Maintenance Supervisor) demonstrated using the mechanical lift machine. The mechanical lift emergency button was missing from the machine and the machine's legs were completely covered in debris and brown stains. V8 stated, I did not realize the emergency button was missing. V8 confirmed the emergency button is the only means to lower a resident whenever the mechanical lift battery runs dead. V8 also stated he was unaware of who is responsible for cleaning the mechanical lift and stated, The (mechanical lift) is extremely dirty.On 1/15/26 at 12:55 PM The C and D Hallways clean linen storage room had four missing floor tiles, a trashcan that was full and overflowing onto the floor, scattered debris on the floor, and a white buildup of debris in the sink and around the sink handles. There were no clean wash clothes within this clean linen storage room.On 1/15/26 at 2:20 PM R16's window had a bedspread draped over the curtain rod. R16 stated at this time, I have never had curtains, so I hung my bedspread up over the window to block the sun from beating through the window.On 1/16/26 at 2:55 AM R15 was lying in bed sleeping. R15's above the bed light was flicking on and off continuously.On 1/17/26 at 12:15 PM R2 was lying in bed. R2's top sheet was stained and smelled of feces. R2 stated, My sheets always stink like feces. I bought myself my own washcloths because I refuse to let the staff use the facility's dirty washcloths on me. I have not had a housekeeper clean my room since January third. A few weeks ago, my toilet was overflowing every day, and I would have water and turds overflowing into my room. How would you like to have turds all over your floor? This place is gross.On 1/15/26 at 8:40 AM V4 (CNA/Certified Nursing Assistant) stated, There are not enough housekeepers to clean the entire facility daily.On 1/15/26 at 8:50 AM V5 (CNA) stated, I have never seen the (A, B, C) hallway linen closet cleaned by housekeepers. We (facility staff) never have enough wash clothes or bed pads. This morning, I had to use towels to wash the residents up. We also do not have enough clean (mechanical lift) slings to get all the residents up. I have had to go to laundry on multiple occasions and pull out a dirty sling to use to get the residents up. There is one first shift staff doing laundry every day. There is no staff doing laundry on second or third shifts, therefore there is no clean linens or (mechanical lift) slings to use in the mornings when we are getting the residents up. I filled out a grievance, and nothing has been done that I am aware of. (R2 and R7's) toilet overflows constantly into R2 and R7's rooms and had been overflowing for over two weeks before somebody finally fixed it. Usually there is only one housekeeper, and all the resident rooms do not get cleaned daily.On 1/15/26 at 9:05 AM R19 stated, My wall has always been cracked around the heater and the housekeepers are not able to clean my room every day. My trash is always full.On 1/15/26 at 9:50 AM R3 stated, My walls and floors are always dirty. I would like my room to be cleaned daily. My toilet overflowed into my room for two weeks (around a month ago) before somebody fixed it. I had turds on my floor.On 1/15/26 at 10:10 AM V6 (Housekeeper) stated, There are a lot of days when we only have one housekeeper working for the entire day. There is no way to get all the housekeeping done with one person. All the residents' rooms do not get cleaned daily and I do not have time to wash all the surfaces when there is only one housekeeper. I have to work quickly and just get the basics done like taking out the trash and sweeping/mopping some of the rooms. It is very stressful. We also do not have any floor staff or janitors.On 1/15/26 at 10:20 AM V7 (CNA) stated, We never have enough clean linens or (mechanical lift) slings. Resident showers do not get done when we don't have slings or clean linens. The linens we do have are dingy and stink. When we don't have washcloths, we have to use towels to wash the residents. The C-Hallway is the hallway I work on, and I have not seen it get cleaned one day this week. The clean linen rooms are always dirty and do not get touched by housekeeping. The mechanical lift does not have an emergency release button and there are not enough batteries to keep the mechanical lift going. Residents get stuck up in the air because the batteries die and there is no emergency release. I have told (V2/Director of Nursing) about the emergency release being broken several times and maintenance is aware that the mechanical lift batteries are junk and do not keep the lift charged. (R2, R3, R4, and R7's) were overflowing for weeks before maintenance ever fixed them. We have also been told we cannot use the hopper to clean dirty washcloths and linens, so now we are sending linens covered in feces to laundry. It is just disgusting.On 1/15/26 at 11:30 AM V10 (Laundry Aide) stated, We have been down a second shift laundry aide for over two weeks. When I come in in the mornings all the laundry barrels are overflowing with dirty laundry and the staff do not have clean slings, washcloths, or bed pads. It usually takes me until around 10:00 AM daily to get one load of clean slings, washcloths, and bed pads out to the clean storage rooms and that is still not enough to take care of all the residents. I have spoken with (V8/Maintenance Supervisor) numerous times about not being able to keep up with the laundry.On 1/15/26 at 11:40 AM V11 (RN/Registered Nurse) stated, We do not have clean washcloths, towels, slings, or bed pads daily. The residents do not get their showers or cleaned up because of it. There is usually only one housekeeper working a day. One housekeeper cannot clean this entire facility. The facility is always dirty.On 1/15/26 at 12:50 PM V16 (CNA) stated, We run out of linens daily. We usually do not have washcloths or bed pads. We also do not have enough (mechanical lift) slings. The trash in all the rooms is usually overflowing and there are usually no housekeepers working on second shift.On 1/15/26 at 2:20 PM V8 (Maintenance Supervisor) stated, We (the facility) did have two full mechanical lifts, but one of the lifts broke about a month ago. We have only had one lift that has been working for the last month. I am the laundry/maintenance supervisor. I am told I can have three and a half full-time staff daily to do laundry and housekeeping. I am aware that I have not had enough staff working in housekeeping and laundry for the last two weeks and have been told there are not enough clean linens.On 1/16/26 at 2:50 AM V21 (CNA) stated, I work third shift. We never have clean washcloths or bed pads. There is no laundry staff here on second or third shift and the CNAs do not have time to do laundry. (R15's) above the bed light has flickered like a strobe light for weeks and I know (R15's) family has told maintenance. It still has not been fixed and I am always worried it will cause (R15) to have seizures.On 1/16/26 at 3:00 AM V22 (LPN) stated the facility never has clean linens.On 1/16/26 at 3:15 AM V23 (CNA) stated, We never have clean linens and there are no laundry staff working on second or third shift.On 1/16/26 at 3:30 AM V24 (LPN) stated the facility has not had clean linens or second shift laundry staff for the past two weeks. V24 stated the linens they do have are stained.On 1/17/26 at 7:10 AM V14 (RN) stated, The linens smell like feces and are all stained. There are no clean slings, washcloths, or bed pads every morning. A few days ago, I went to use a clean washcloth, and it smelled of feces so bad. I took it into (V1's/Administrator's) office and the department heads were having a meeting. I asked all of them if they would like to use this washcloth on their faces. The linens here are so disgusting and there are not enough housekeepers or laundry staff to keep up.On 1/17/26 at 11:00 AM V25 (CNA) stated, We are always out of slings and washcloths in the morning and cannot get the residents up because of it. For some reason we were told we can no longer use the hopper to clean out the linens, so now we take poopy linens down to the laundry room. It is gross. A couple days ago, I went to wash up a resident with a clean washcloth and when I opened the washcloth up to use it, it had feces stuck to it. The linens are stained and smell of poop.

Based on observation, interview, and record review the facility failed to ensure residents' toilets were clean and operable for four of ten residents (R4, R7, R8, R9) reviewed for safe, clean, comfortable, and homelike environment in the sample of 10.Findings include:The facility's Maintenance Director Job Description dated 3/2024 documents The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator to assure that our facility is maintained in a safe and comfortable manner. Essential Duties and Responsibilities: Repair facility/resident property as necessary.The Illinois Long-Term Care Ombudsman Program Residents' Rights Booklet, dated 11/2018, documents Your rights to safety: Your facility must be safe, clean, comfortable, and homelike.R4's Census List dated 9/26/25 through 11/24/25 documents R4 previously resided in room [ROOM NUMBER]-A from 9/26/25 through 11/3/25 before R4 was moved to a different room on 11/3/25.R7's Census List dated 12/6/24 through 11/24/25 documents R7 resided in room [ROOM NUMBER]-A from 12/6/24 through 10/7/25 before R7 was moved to a different room on 10/7/25.R8's Census List dated 12/4/24 through 11/24/25 documents R8 resided in room [ROOM NUMBER]-B from 12/4/24 through 10/7/25 before R8 was moved to a different room on 10/7/25.On 11/24/25 at 9:05 AM a toilet located in a bathroom between room [ROOM NUMBER]-A and 79-A was full to the bottom of the lid with standing water that contained feces. There were no residents residing in these rooms at this time.On 11/24/25 at 10:33 AM V1 (Administrator) verified R7 and R8's toilet was not fixed until 10/27/25.On 11/24/25 at 9:10 AM V4 (CNA/Certified Nursing Assistant) stated, The toilet in room [ROOM NUMBER]-A has been full of feces since sometime in September (2025). That toilet will not flush. The entire time (R4) lived in that room the toilet did not work and would overflow nasty water with feces onto (R4's) floor. (R4) lived in that room for around two months. (V5/Maintenance Director) is aware and had never fixed the toilet. The same goes for room [ROOM NUMBER]. (R7) and (R8) lived in room [ROOM NUMBER] for over a month with a toilet that wouldn't flush and was full of feces before (R7) and (R8) were moved to another room. (R9's) toilet backs up and overflows onto the floor quite often.On 11/25/25 at 9:40 AM V5 (Maintenance Director) stated, I was not aware of the toilet in room [ROOM NUMBER]-A not working or the toilet in R9's room not working. room [ROOM NUMBER]'s toilet took a while to fix because the wrong toilet was ordered. V5 verified R7 and R8 were not moved out of room [ROOM NUMBER] while the toilet was inoperable. At this time V5 went down to room [ROOM NUMBER]-A and confirmed the toilet did not flush and was full of dirty water and feces.On 11/24/25 at 9:45 AM R4 stated, When I lived in room [ROOM NUMBER]-A my bathroom toilet would not flush and was full of stool every day. The toilet would back up into my room and overflow the dirty water all over my floor. My toilet would overflow at least two or three times a week the entire time I lived in that room (77-A). It was disgusting.On 11/24/25 at 9:50 AM R8 stated, My toilet would not flush in my old room and would overflow onto the floor. It seemed like my toilet would not work for a long time.On 11/24/25 at 11:10 AM V14 (Anonymous Participant) stated, Last week (R9's) bathroom had water all over the floor and (R9) was a fall risk. I know the sewer system here does not work that well.

Based on record review and interview the facility failed to report allegations of exploitation of funds from residents' guardians immediately to the state agencies, local police, and Administrator, once the facility was made aware, for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in R2 and R3's guardians exploiting their monetary funds, even after the facility was made aware, and the Administrator, local police, State agency, Office of Inspector General, and Social Security Office not being made aware. As a result, R2 and R3's money situation worsened, resulting in R2 expressing feelings of anger and fear of displacement without an alternate plan, R2 being unable to purchase personal care items, and R3 being provided with a past due bill indicating R3 may be subjected to a notice of involuntary discharge without an alternate plan.These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 8/8/25, 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 Abuse Prevention and Reporting policy dated 9/2024 documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Exploitation means taking advantage of a resident for a personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a residence belongings or money without the residents sent. Misappropriation of a residence property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residence belongings or money without the resident's consent. Reporting Requirements and Identification of Allegations: employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Reports should be documented, and record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator and the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect exploitation mistreatment or misappropriation of resident property. Any allegation of abuse or incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. The resident's physician and representative, if necessary, shall be notified of any incident or allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. External Reporting Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities (i.e. (example) telephoning 911 when available) in the following situations: When there is a reasonable suspicion that a crime has been committed in the facility by a person other than a resident. If there is a reasonable suspicion that a crime has been committed that results in serious bodily harm, a report shall be made to local law enforcement immediately and Department of Public Health notified within 2 (two) hours. If there is a reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then a report to local law enforcement and Department of Public Health as soon as possible but within 24 hours of when the suspicion was formed. The resident or residence representative will also be informed of the report of an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property and that an investigation is being conducted.The Business Office Manager policy dated 7/2023 documents, Essential Duties and Responsibilities: Monitor and collect accounts receivable. Report delinquent accounts to the Accountant/Director of Finance/Administrator.R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Obsessive Compulsive Disorder and Generalized Anxiety Disorder.R2's current Care Plan documents R2 and R2's responsible party are in favor of long-term placement and have expressed a desire to remain at (the facility) for permanent placement, No discharge/transfer potential at this time. This same Care Plan documents R2 displays signs and symptoms of depression and anxiety.R2's Past Due [NAME] Dated 1-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R2) that you have an outstanding balance at (the facility) in the amount of 3,755.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R2's Past Due Statement Dated 8/1/25 and sent to R2 and V11 (R2's Guardian) documents, Amount Due: 15,297.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R2's Banking Statement dated 1/1/25 through 1/31/25 documents R2's primary checking account has V11 listed as Guardian of the account. This statements document 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,800.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2. The first date noted that a transfer was made to the account not associated with R2 (ending in 2428) was on 1/6/25 in the amount of 155.00 dollars.R2's Bank Statement dated 2/1/25 through 2/28/25 documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 460.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 3/1/25 through 3/31/25 documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,500.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 4/1/25 through 4/30/25 documents 2,253.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,175.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 5/1/25 through 5/31/25 documents 2,322.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,145.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 6/1/25 through 6/30/25 documents 2,329.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,348.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Final Abuse Investigation Report dated 8/1/25 documents, Original Allegation: Exploitation of funds. On 7/30/25 V1 (Administrator) was notified by the Business Office Manager (V3) and Regional Financial Coordinator (V5) were gathering financial information for (R2's) Medicaid application. During review of financial documents, concerns were noticed that (R2's) social security income was being deposited into (R2's) personal bank account, but then immediately transferred to a different/unknown bank account that (R2) claims to have no access to. Conclusion and Action Taken: Based on the results of the investigation the facility found the following: a. (V3/Business Office Manager) and (V5/Regional Financial Coordinator) noted discrepancies on (R2's) banking documents. B. Facility abuse coordinator contacted local authorities with concerns related to potential financial exploitation. 3. Facility is working with legal and State Office of Guardianship to address change of guardian due to concerns of not being able to contact them and concerns about monetary misappropriation.R2's Local Police Department Report dated 7/30/25 and signed by V16 (Local Police Officer) documents, I (V16) received a call from (V1/Administrator). (V1) advises some of her employees notice that (R2's) bank accounts appear to have fraudulent activity. (V1) advised (R2's) Medicaid checks are coming in, but it appears the money is then moved to another account.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility I suspected (R2's Guardian/V11) was stealing (R2's) money because (V11) wasn't paying (R2's) bill starting sometime around January 2025. Sometime in March 2025 I (R2) reported to me that she felt like (V11) was stealing (R2's) money and using the money. I did not report this to (V4/Prior Administrator) or V1 (Administrator). I was so busy with everything I did not get time to report.On 8/6/25 at 1:55 PM R2 was sitting in the dining room. R2 stated, I told (V6/Prior Business Office Manager) around March (2025) that I needed a new pair of shoes and asked my sister (V11) to get me some shoes and (V11/R2's Guardian) told me I didn't have any money to get shoes. I told (V6) that I thought (V11) might be stealing my money since (V11) is on my bank accounts and I couldn't even get a pair of shoes. (V6) told me she thought (V11) might be stealing my money too because my stay at the nursing home was not being paid for by (V11). No one has gotten back to me until about two weeks ago when (V3/Business Office Manager) asked me if it was okay for the facility to get a copy of my bank statements and said they suspect (V11) might be taking my funds. I gave them the okay to get my bank statements because I am scared I will not get to live here, and this is the only place I have ever lived. I do not want to leave here due to (V11) not paying my bills.On 8/7/25 at 10:10 AM V12 (CNA/Certified Nursing Assistant) stated, (R2) has reported to me clear back since 2022 that her sister (V11) takes her social security check and is stealing (R2's) money. (R2) has been very upset and tells me she is mad and feels like (V11) does not care about her. (R2) told me around four or five months ago that (V6) knows, and she thinks (V6) is finally going to do something about it. I know (V4/Prior Administrator) was aware.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I know we (the facility) thought (V11) was spending (R2's) social security and the facility was not getting paid. When I was at the facility the financials were a hot mess. (R2) would say that (V11) was not turning over (R2's) money. V4 verified she never reported the suspicion of V11 exploiting R2's social security money to any state agencies or the local police.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) should have reported the suspicion that V11 was exploiting R2's social security money when V6 first became aware in January 2025. V1 confirmed she was not made aware, and the state agencies and local police were not made aware until V3 (Current Business Office Manager) reported the allegation to V1 on 7/30/25. On 8/9/25 at 9:10 AM V1 (Administrator) verified the first electronic transfer out of R2's checking account made to another account ending in 2428, that was not associated with R2, was on 1/6/25 in the amount 155.00 dollars.2. R3's admission Record documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Bipolar Disorder, Vascular Dementia, Aphasia, Schizoaffective Disorder, and Depression. This same admission Record documents V8 is R3's Guardian and Responsible Party.R3's MDS assessment dated [DATE] documents R3 is cognitively impaired.R3's current Care Plan documents R3 has an appointed Legal Representative/Guardian as evidenced by a court order and R3's Guardian (V8) will advocate and discuss best interest of R3 when in question of decision maker. This same Care Plan documents R3 has expressed a desire to remain at (the facility) for permanent placement and R3 has episodes of depression as evidenced by mood triggers.R3's Statement dated 1-1-25 documents, Amount Due: 4,238.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R3's Past Due [NAME] Dated 4-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 1,993.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Past Due [NAME] Dated 7-29-25 and signed by V5 (Regional Financial Coordinator) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 14,277.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Banking Statements dated 12/5/24 through 6/3/25 document R3 as the primary bank account holder of the account number ending in 7125, and V8 was listed on the account as R3's Guardian. These same Bank Account Statements document 1,354.00 dollars were being deposited monthly into R3's account number ending in 7125 from R3's long-term disability, and 2,191.00 dollars were being deposited monthly into R3's account number ending in 7125 from the Social Security Administration. These Banking Statements document none of R3's 1,354.00 dollars deposited by R3's long term disability have been surrendered to (the facility) and also document multiple charges have been taken out of R3's account for purchases to grocery stores, gas stations, department stores, fast food restaurants, cannabis dispensary's, car dealerships, online retailers, and car dealerships, and multiple payments to credit card accounts were made during this time.R3's Final Abuse Investigation dated 7/7/25 documents, Original Allegation: Exploitation of funds. On 7/2/25 (V1/Administrator) was notified by (V3/Business Office Manager) and (V5/Regional Financial Coordinator). (V3) and (V5) were gathering financial information for (R3's) Medicaid application. During review of (R3's) financial documents, concerns were noticed that (V8/R3's Guardian) was spending (R3's) private income on personal use items and this was brought to the attention of the facility's Abuse Coordinator (V1). Based on the facts of the investigation the facility has found the following: (V3) and (V5) noted discrepancies on (R3's) banking documents. (V1) contacted local authorities with concern related to potential financial exploitation.R3's Local Police Department Report dated 7/2/25 and signed by V16 (Local Police Officer) documents, On 7/2/25, (V16) was on duty for the (local) police department. I was contacted by (V1/Administrator). (V1) advises that they have a resident (R3) that they believe has fraudulent activity to their bank account. (V1) advised that the resident is (R3). (V1) advises (R3's) brother (V8) is (R3's) stated approved Guardian. (V1) stated that she observed transactions from (R3's) account for oil changes, groceries, and the cannabis dispensary that were made by (V8). (V1) advised (R3's) income comes from SSI (Supplemental Security Income) and Disability and believed the case with be Social Security/Medicaid Fraud.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility, (V8/R3's Guardian) stopped paying the entire amount for (R3's) bill to the facility. (V8) was the representative payee for (R3's) social security check. I was supposed to do (R3's) Medicaid recertification sometime around March 2025 and noticed (R3) was also getting a disability check from prior employment. (V8) had never been turning the disability check money over. I recall (R3's) disability check being over 1,000.00 dollars per month. I stuck the information in (R3's) file and never got time to deal with (V8) not paying the facility. I figured (V8) was spending (R3's) money. I never reported this to the administrator. On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, (R3) has been getting a check from long-term disability for years. The facility has always been aware. In fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (R3) and take (R3) out to dinner. V8 also confirmed he has been using R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, (V6/Prior Business Office Manager) never reported anything to me while I worked at the facility about (V8) taking (R3's) funds and not paying (R3's) bill.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) never made V1 aware of V6's suspicion that V8 was exploiting R3's funds. V1 verified V6 should have reported the suspicion that V8 was exploiting R3's funds when V6 first became aware in March 2025. V1 confirmed she was not made aware, and the state agencies and local police were not made aware until V3 (Current Business Office Manager) reported the allegation to V1 on 7/2/25. The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (R2's guardian) was exploiting R2's funds and failed to report this to the Administrator, therefore the local police and state agencies were not notified immediately upon suspicion. V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM. On 8/9/25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1 on the facility's abuse policy regarding immediately reporting abuse.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding the facility's abuse policy and procedures.4. On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with reporting Abuse and Misappropriation of resident funds.5.On 7/31/25 V1 notified the Social Security Administration and R2's social security funds were suspended.6.On 8/8/25 V1 notified the Social Security Administration and R3's social security funds were suspended.7. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for R3's long term disability check to be sent directly to R3 in care of (the facility) due to exploitation of finances by (V8/R3's Guardian).8. On 8/8/25 V3 (Business Office Manager) reported all discrepancies of residents' payments not being made to V1, and V1 reported all discrepancies of resident payments not being made to the local police and state agency.Completion Date: 8/8/25.

Based on record review and interview the facility failed to protect residents from exploitation of funds from their guardians, once the facility suspected misappropriation of funds, and failed to immediately initiate an investigation of an allegation of misappropriation of funds for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in funds from R2's social security funds being transferred out of R2's checking account monthly into another account not associated with R2, even after the facility was made aware and no interviews, no bank record reviews, and no referrals sent to the state agencies. As a result, R2's money situation worsened, resulting in R2 expressing feelings of anger and fear of displacement to another facility, R2 being unable to purchase personal care items, and resulted in R3's monthly pension funds and social security funds being exploited by R3's guardian (V8) after the facility was made aware, and no bank record reviews, no interviews, and no referrals send to the state agencies, As a result, R3's money situation worsening, and R3 being provided with a past due bill indicating R3 may be subjected to a notice of involuntary discharge. These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 8/8/25, 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 Abuse Prevention and Reporting policy dated 9/2024 documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Exploitation means taking advantage of a resident for a personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a residence belongings or money without the residents sent. Misappropriation of a residence property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residence belongings or money without the resident's consent. Protection of Residents The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his for her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents. Accused individuals not employed by the facility will be denied unsupervised access to their residence during the course of the investigation. Internal Investigation: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. Investigation Procedure: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview table. Any written statements that have been submitted will be reviewed, along with any medical records or other documents. The administrator or person designated to act as administrator in the administrator's absence will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident.R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Obsessive Compulsive Disorder and Generalized Anxiety Disorder.R2's current Care Plan documents R2 and R2's responsible party are in favor of long-term placement and have expressed a desire to remain at (the facility) for permanent placement, No discharge/transfer potential at this time. This same Care Plan documents R2 displays signs and symptoms of depression and anxiety.R2's Past Due [NAME] Dated 1-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R2) that you have an outstanding balance at (the facility) in the amount of 3,755.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R2's Past Due Statement Dated 8/1/25 and sent to R2 and V11 (R2's Guardian) documents, Amount Due: 15,297.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R2's Banking Statement dated 1/1/25 through 1/31/25 documents R2's primary checking account has V11 listed as Guardian of the account. This statements document 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,800.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2. The first date noted that a transfer was made to the account not associated with R2 (ending in 2428) was on 1/6/25 in the amount of 155.00 dollars.R2's Bank Statements dated 2/1/25 through 6/30/25 document R2's social security deposits into R2's personal checking account ending in 5990 continued to be electronically transferred into another bank account ending in 2428, that was not associated with R2.R2's Facility Financial Statement dated 2/1/25 through 8/1/25 document V11 has not made a payment to the facility for R2's room and board during this timeframe. R2's Final Abuse Investigation Report dated 8/1/25 documents, Original Allegation: Exploitation of funds. On 7/30/25 V1 (Administrator) was notified by the Business Office Manager (V3) and Regional Financial Coordinator (V5) were gathering financial information for (R2's) Medicaid application. During review of financial documents, concerns were noticed that (R2's) social security income was being deposited into (R2's) personal bank account, but then immediately transferred to a different/unknown bank account that (R2) claims to have no access to. Conclusion and Action Taken: Based on the results of the investigation the facility found the following: a. (V3/Business Office Manager) and (V5/Regional Financial Coordinator) noted discrepancies on (R2's) banking documents. B. Facility abuse coordinator contacted local authorities with concerns related to potential financial exploitation. 3. Facility is working with legal and State Office of Guardianship to address change of guardian due to concerns of not being able to contact them and concerns about monetary misappropriation.R2's Local Police Department Report dated 7/30/25 and signed by V16 (Local Police Officer) documents, I (V16) received a call from (V1/Administrator). (V1) advises some of her employees notice that (R2's) bank accounts appear to have fraudulent activity. (V1) advised (R2's) Medicaid checks are coming in, but it appears the money is then moved to another account.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility I suspected (R2's Guardian/V11) was stealing (R2's) money because (V11) wasn't paying (R2's) bill starting sometime around January 2025. Sometime in March 2025 I (R2) reported to me that she felt like (V11) was stealing (R2's) money and using the money. I did not report this to (V4/Prior Administrator) or V1 (Administrator). I was so busy with everything I did not get time to report.On 8/6/25 at 1:55 PM R2 was sitting in the dining room. R2 stated, I told (V6/Prior Business Office Manager) around March (2025) that I needed a new pair of shoes and asked my sister (V11) to get me some shoes and (V11/R2's Guardian) told me I didn't have any money to get shoes. I told (V6) that I thought (V11) might be stealing my money since (V11) is on my bank accounts and I couldn't even get a pair of shoes. (V6) told me she thought (V11) might be stealing my money too because my stay at the nursing home was not being paid for by (V11). No one has gotten back to me until about two weeks ago when (V3/Business Office Manager) asked me if it was okay for the facility to get a copy of my bank statements and said they suspect (V11) might be taking my funds. I gave them the okay to get my bank statements because I am scared I will not get to live here, and this is the only place I have ever lived. I do not want to leave here due to (V11) not paying my bills.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I know we (the facility) thought (V11) was spending (R2's) social security and the facility was not getting paid. When I was at the facility the financials were a hot mess. (R2) would say that (V11) was not turning over (R2's) money. V4 verified she never investigated the allegation of V11 exploiting R2's funds and never protected R2 from further exploitation.On 8/7/25 at 11:30 AM V1 (Administrator) verified an investigation had not been done and no one protected R2 from further exploitation of funds until 7/30/25 (six months after V5/Prior Business Office Manager) was made aware. 2. R3's admission Record documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Bipolar Disorder, Vascular Dementia, Aphasia, Schizoaffective Disorder, and Depression. This same admission Record documents V8 is R3's Guardian and Responsible Party.R3's MDS assessment dated [DATE] documents R3 is cognitively impaired.R3's current Care Plan documents R3 has an appointed Legal Representative/Guardian as evidenced by a court order and R3's Guardian (V8) will advocate and discuss best interest of R3 when in question of decision maker. This same Care Plan documents R3 has expressed a desire to remain at (the facility) for permanent placement and R3 has episodes of depression as evidenced by mood triggers.R3's Statement dated 1-1-25 documents, Amount Due: 4,238.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R3's Past Due [NAME] Dated 4-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 1,993.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Past Due [NAME] Dated 7-29-25 and signed by V5 (Regional Financial Coordinator) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 14,277.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Banking Statements dated 12/5/24 through 6/3/25 document R3 as the primary bank account holder of the account number ending in 7125, and V8 was listed on the account as R3's Guardian. These same Bank Account Statements document 1,354.00 dollars were being deposited monthly into R3's account number ending in 7125 from R3's long-term disability, and 2,191.00 dollars were being deposited monthly into R3's account number ending in 7125 from the Social Security Administration. These Banking Statements document none of R3's 1,354.00 dollars deposited by R3's long term disability have been surrendered to (the facility) and also document multiple charges have been taken out of R3's account for purchases to grocery stores, gas stations, department stores, fast food restaurants, cannabis dispensary's, car dealerships, online retailers, and car dealerships, and multiple payments to credit card accounts were made during this time.R3's Final Abuse Investigation dated 7/7/25 documents, Original Allegation: Exploitation of funds. On 7/2/25 (V1/Administrator) was notified by (V3/Business Office Manager) and (V5/Regional Financial Coordinator). (V3) and (V5) were gathering financial information for (R3's) Medicaid application. During review of (R3's) financial documents, concerns were noticed that (V8/R3's Guardian) was spending (R3's) private income on personal use items and this was brought to the attention of the facility's Abuse Coordinator (V1). Based on the facts of the investigation the facility has found the following: (V3) and (V5) noted discrepancies on (R3's) banking documents. (V1) contacted local authorities with concern related to potential financial exploitation.R3's Local Police Department Report dated 7/2/25 and signed by V16 (Local Police Officer) documents, On 7/2/25, (V16) was on duty for the (local) police department. I was contacted by (V1/Administrator). (V1) advises that they have a resident (R3) that they believe has fraudulent activity to their bank account. (V1) advised that the resident is (R3). (V1) advises (R3's) brother (V8) is (R3's) stated approved Guardian. (V1) stated that she observed transactions from (R3's) account for oil changes, groceries, and the cannabis dispensary that were made by (V8). (V1) advised (R3's) income comes from SSI (Supplemental Security Income) and Disability and believed the case with be Social Security/Medicaid Fraud.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility, (V8/R3's Guardian) stopped paying the entire amount for (R3's) bill to the facility. (V8) was the representative payee for (R3's) social security check. I was supposed to do (R3's) Medicaid recertification sometime around March 2025 and noticed (R3) was also getting a disability check from prior employment. (V8) had never been turning the disability check money over. I recall (R3's) disability check being over 1,000.00 dollars per month. I stuck the information in (R3's) file and never got time to deal with (V8) not paying the facility. I figured (V8) was spending (R3's) money. I do not think an investigation was ever done about this.On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, (R3) has been getting a check from long-term disability for years. The facility has always been aware. In fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (R3) and take (R3) out to dinner. V8 also confirmed he has been using R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I am not aware of an investigation ever being done regarding (V8) exploiting (R3's) funds.On 8/7/25 at 11:30 AM V1 (Administrator) verified an investigation was not done and R3's funds were not protected from V8 until 7/2/25 (approximately four months after V5 was made aware).The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (R2's guardian) was exploiting R2's funds and failed to report this to the Administrator, therefore R2 was never protected from further exploitation of funds and in investigation was not done immediately.V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM. On 8/9/25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1 on the facility's abuse policy regarding protection of the residents from abuse and initiating an investigation immediately.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding the facility's abuse policy and procedures.4. On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with reporting Abuse and Misappropriation of resident funds.5.On 7/31/25 V1 notified the Social Security Administration and R2's social security funds were suspended.6.On 8/8/25 V1 notified the Social Security Administration and R3's social security funds were suspended.7. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for R3's long term disability check to be sent directly to R3 in care of (the facility) due to exploitation of finances by (V8/R3's Guardian).8. On 8/8/25 V3 (Business Office Manager) sent all residents and residents' representative current financial statements by certified mail.9. On 8/8/25 V1 provided all families with a copy of the facility's Abuse Policy by certified mail.Completion Date: 8/8/25.

Based on record review and interview the facility failed to protect R2 and R3 from financial exploitation from their guardians, after the facility was made aware, for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in V11 (R2's Guardian) continuing to have access to R2's accounts after the facility was made aware on 1/29/25 of potential exploitation of R2's funds of 3,755.00, subjecting R2 to 11,542.00 more dollars of representative social security monetary fraud/exploitation after 1/29/25, R2 expressing feelings of anger and fear of displacement to another facility with no alternate plan, and R2 being provided with a past due bill indicating R2 may be subjected to a notice of involuntary discharge, and V8 (R3's Guardian) continuing to access R3's accounts after the facility was made aware on 4/29/25 of potential exploitation of R3's funds of 1,993.00, subjecting R3 to 12,284.00 more dollars of representative monetary fraud/exploitation after 4/29/25.These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 8/8/25, 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 Abuse Prevention and Reporting policy dated 9/2024 documents Guidelines: The facility affirms the right of our residents to be free from abuse, neglect, exploitation misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Identifying occurrences and patterns of potential mistreatment; Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; Filing accurate and timely investigative reports. Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, the goods of services that are necessary to attain and or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Exploitation means taking advantage of a resident for a personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a residence belongings or money without the residents sent. Misappropriation of a residence property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residence belongings or money without the resident's consent.The facility's admission Contract Between Resident and Facility documents A. Definitions 3. Reasonable Party is an individual who has control and/or access to Resident's funds and or assets. The Responsible Party who executes this Agreement agrees to act on Resident's behalf and agrees to cause payment of fees and charges incurred by or on Resident's behalf from Resident's funds, assets or estate. The Responsible Party agrees to provide an accounting of Resident's funds, assets and estate upon request including providing documentation to verify accounts. Failure to cause payment or fees and charges incurred by or on Resident's behalf from Resident's funds, assets or estate shall constitute a failure to exercise due care and will subject the Responsible Party to personal liability for the charges incurred by Resident. The Responsible Party may act in more than one capacity and agree to other applicable terms and conditions of this Agreement. The Responsible Party, if any, must also agree to and comply with Attachment B: Income and Personal Resource Statement. 4. Resident Representative is the individual who has the legal authority to make decisions on the Resident's behalf regarding healthcare. By signing this Contract as the Residents Representative, the individual represents that he/she has the legal authority to make health care decisions on behalf of the Resident. The Resident Representative agrees to provide the Facility a copy of all documentation relating to his/her status as the legal decision maker (e.g., (example) healthcare power of attorney, letters, or guardianship) 5. Representative Payee A person(s) who execute this Contract as the Representatives Payee will receive social security benefit for and on behalf of the Resident, which benefits are assets of the Resident. The Representative Payee is hereby authorized and requested by the Resident, immediately upon receipt to pay all such amounts due the Facility. The Representative Payee further agrees to notify the Facility upon registration, removal, or appointment of a new Representative Payee. d. Transfer of Assets. The Resident shall not transfer or dispose any beneficial interest in his assets while a resident at the Facility that would in any way affect Residents ability to pay for services at the Facility. Failure of the Resident's Representative and/or Responsible Party to properly allocate the Resident's funds and assets for the payment of the Resident's care may constitute abuse and/or financial exploitation.1. R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Obsessive Compulsive Disorder and Generalized Anxiety Disorder.R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is cognitively intact.R2's admission Contract between R2 and the facility was signed on 2/3/25.R2's current Care Plan documents R2 and R2's responsible party are in favor of long-term placement and have expressed a desire to remain at (the facility) for permanent placement, No discharge/transfer potential at this time. This same Care Plan documents R2 displays signs and symptoms of depression and anxiety.R2's Past Due [NAME] Dated 1-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R2) that you have an outstanding balance at (the facility) in the amount of 3,755.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R2's Past Due Statement Dated 8/1/25 and sent to R2 and V11 (R2's Guardian) documents, Amount Due: 15,297.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R2's Bank Statement dated 1/1/25 through 1/31/25 document V11 as Guardian of this account. This same Bank Statement documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,800.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2. The first date noted that a transfer was made to the account not associated with R2 (ending in 2428) was on 1/6/25 in the amount of 155.00 dollars.R2's Bank Statement dated 2/1/25 through 2/28/25 documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 460.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 3/1/25 through 3/31/25 documents 2,167.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 1,500.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 4/1/25 through 4/30/25 documents 2,253.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,175.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 5/1/25 through 5/31/25 documents 2,322.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,145.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Bank Statement dated 6/1/25 through 6/30/25 documents 2,329.00 dollars were deposited during this timeframe into R2's account ending in (5990) and 2,348.00 dollars were debited during this timeframe and transferred to another bank account, (ending in 2428) that is not associated with R2.R2's Final Abuse Investigation Report dated 8/1/25 documents, Original Allegation: Exploitation of funds. On 7/30/25 V1 (Administrator) was notified by the Business Office Manager (V3) and Regional Financial Coordinator (V5) were gathering financial information for (R2's) Medicaid application. During review of financial documents, concerns were noticed that (R2's) social security income was being deposited into (R2's) personal bank account, but then immediately transferred to a different/unknown bank account that (R2) claims to have no access to. Conclusion and Action Taken: Based on the results of the investigation the facility found the following: a. (V3/Business Office Manager) and (V5/Regional Financial Coordinator) noted discrepancies on (R2's) banking documents. B. Facility abuse coordinator contacted local authorities with concerns related to potential financial exploitation. 3. Facility is working with legal and State Office of Guardianship to address change of guardian due to concerns of not being able to contact them and concerns about monetary misappropriation.R2's Local Police Department Report dated 7/30/25 and signed by V16 (Local Police Officer) documents, I (V16) received a call from (V1/Administrator). (V1) advises some of her employees noticed that (R2's) bank accounts appear to have fraudulent activity. (V1) advised (R2's) Medicaid checks are coming in, but it appears the money is then moved to another account.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility I was doing human resources, admission contracts, and business office manager. I started on 12/1/24 and was terminated on 6/12/25. I had three jobs and could not keep up. (V11/R2's Guardian) was (R2's) rep (representative) payee and received (R2's) social security checks. (V11) was responsible for paying (R2's) bill at the facility. I suspected sometime around January 2025 that (R2's Guardian/V11) was stealing (R2's) money because (V11) wasn't paying (R2's) bill. Sometime in March 2025 (R2) reported to me that she felt like (V11) was stealing (R2's) money and using the money. (R2) was really upset because she could not even buy herself a new pair of shoes. (R2) told me she was wanting new shoes and (V11) couldn't get (R2) new shoes because (R2) did not have any money. I did not have time to do anything about (V11) not paying (R2's) bills.On 8/6/25 at 11:30 AM V3 (Business Office Manager) stated, (R2's) Medicaid recertification was due months ago and the facility asked for an extension. When I had to get (R2's) Medicaid Recertification documents submitted I had to ask for (R2's) bank statements. When I requested (R2's) bank statements I noticed (R2's) social security income was being transferred to another account that did not belong to (R2). I suspected (V11) was stealing (R2's) social security funds as (V11) was (R2's) only person that had access to (R2's) funds and was the payee for (R2's) social security. Also, (V11) had not been paying (R2's) bill since January 2025.On 8/6/25 at 11:43 AM V14 (Local Bank Bookkeeper) stated, The only person that has access to (R2's) online electronic banking number ending in 5990 that I am aware of is (V11). All the funds taken out of (R2's) account have been transferred electronically, using online banking, to an account ending in 2428. Legally I cannot tell you who's account ends in 2428, but what I can tell you is (V11) is the only one that has access to (R2's) account that would be able to make those transfers.On 8/6/25 at 1:55 PM R2 was sitting in the dining room. R2 stated, I told (V6/Prior Business Office Manager) around March (2025) that I needed a new pair of shoes and asked my sister (V11) to get me some shoes and (V11/R2's Guardian) told me I didn't have any money to get shoes. I told (V6) that I thought (V11) might be stealing my money since (V11) is on my bank accounts and I couldn't even get a pair of shoes. (V6) told me she thought (V11) might be stealing my money too because my stay at the nursing home was not being paid for by (V11). No one has gotten back to me until about two weeks ago when (V3/Business Office Manager) asked me if it was okay for the facility to get a copy of my bank statements and said they suspect (V11) might be taking my funds. I gave them the okay to get my bank statements because I am scared I will not get to live here, and this is the only place I have ever lived. I do not want to leave here due to (V11) not paying my bills.On 8/7/25 at 10:10 AM V12 (CNA/Certified Nursing Assistant) stated, I have worked here three years. (R2) never has money to buy clothes, snacks, or shoes. We (facility staff) try to buy (R2) things she needs. (R2) has reported to me clear back since 2022 that her sister (V11) takes her social security check and is stealing (R2's) money. (R2) has been very upset and tells me she is mad and feels like (V11) does not care about her. (R2) told me around four or five months ago that (V6) knows, and she thinks (V6) is finally going to do something about it.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, I know we (the facility) thought (V11) was spending (R2's) social security and the facility was not getting paid. When I was at the facility the financials were a hot mess. (R2) would say that (V11) was not turning over (R2's) money.On 8/7/25 at 10:45 AM V13 (CNA) stated, I know (R2) gets upset and tells me (V11) keeps her money and won't let (R2) buy anything. (R2) does not get the clothes or shoes she needs.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) should have tried to protect R2's funds from being exploited by V11 when V6 first became aware (January 2025).On 8/9/25 at 9:10 AM V1 (Administrator) verified the first electronic transfer out of R2's checking account made to another account ending in 2428, that was not associated with R2, was on 1/6/25 in the amount 155.00 dollars.2. R3's admission Record documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Bipolar Disorder, Vascular Dementia, Aphasia, Schizoaffective Disorder, and Depression. This same admission Record documents V8 is R3's Guardian and Responsible Party.R3's MDS assessment dated [DATE] documents R3 is cognitively impaired.R3's admission Contract between R3 and the facility was signed on 2/19/25.R3's current Care Plan documents R3 has an appointed Legal Representative/Guardian as evidenced by a court order and R3's Guardian (V8) will advocate and discuss best interest of R3 when in question of decision maker. This same Care Plan documents R3 has expressed a desire to remain at (the facility) for permanent placement and R3 has episodes of depression as evidenced by mood triggers.R3's Statement dated 1-1-25 documents, Amount Due: 4,238.00 dollars. The balance is due upon receipt. If the balance is not paid in 30 days, an Involuntary Transfer and Discharge Notice may be issued.R3's Past Due [NAME] Dated 4-29-25 and signed by V6 (Prior Business Office Manager) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 1,993.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Past Due [NAME] Dated 7-29-25 and signed by V5 (Regional Financial Coordinator) documents, This letter is to inform you (R3) that you have an outstanding balance at (the facility) in the amount of 14,277.00 dollars. Statement is enclosed. All payments are due by the fifth of the month. If you should have questions, please feel free to call me at [PHONE NUMBER]. Note: Please note if payment is not received in full within 30 days (the facility) may take further action, including but not limited to issuing a Notice of Involuntary Transfer or Discharge.R3's Banking Statements dated 12/5/24 through 6/3/25 document R3 as the primary bank account holder of the account number ending in 7125, and V8 was listed on the account as R3's Guardian. These same Bank Account Statements document 1,354.00 dollars were being deposited monthly into R3's account number ending in 7125 from R3's long-term disability, and 2,191.00 dollars were being deposited monthly into R3's account number ending in 7125 from the Social Security Administration. These Banking Statements document none of R3's 1,354.00 dollars deposited by R3's long term disability have been surrendered to (the facility) and also document multiple charges have been taken out of R3's account for purchases to grocery stores, gas stations, department stores, fast food restaurants, cannabis dispensary's, car dealerships, online retailers, and car dealerships, and multiple payments to credit card accounts were made during this time.R3's Final Abuse Investigation dated 7/7/25 documents, Original Allegation: Exploitation of funds. On 7/2/25 (V1/Administrator) was notified by (V3/Business Office Manager) and (V5/Regional Financial Coordinator). (V3) and (V5) were gathering financial information for (R3's) Medicaid application. During review of (R3's) financial documents, concerns were noticed that (V8/R3's Guardian) was spending (R3's) private income on personal use items and this was brought to the attention of the facility's Abuse Coordinator (V1). Based on the facts of the investigation the facility has found the following: (V3) and (V5) noted discrepancies on (R3's) banking documents. (V1) contacted local authorities with concern related to potential financial exploitation.R3's Local Police Department Report dated 7/2/25 and signed by V16 (Local Police Officer) documents, On 7/2/25, (V16) was on duty for the (local) police department. I was contacted by (V1/Administrator). (V1) advises that they have a resident (R3) that they believe has fraudulent activity to their bank account. (V1) advised that the resident is (R3). (V1) advises (R3's) brother (V8) is (R3's) stated approved Guardian. (V1) stated that she observed transactions from (R3's) account for oil changes, groceries, and the cannabis dispensary that were made by (V8). (V1) advised (R3's) income comes from SSI (Supplemental Security Income) and Disability and believed the case with be Social Security/Medicaid Fraud.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility, (V8/R3's Guardian) stopped paying the entire amount for (R3's) bill to the facility. (V8) was the representative payee for (R3's) social security check. I sent several of (R3's) overdue bills to (R3) and (V8) from January 2025 to June 2025. I was supposed to do (R3's) Medicaid recertification sometime around March 2025 and noticed (R3) was also getting a disability check from prior employment. (V8) had never been turning the disability check money over. I recall (R3's) disability check being over 1,000.00 dollars per month. I stuck the information in (R3's) file and never got time to deal with (V8) not paying the facility. I figured (V8) was spending (R3's) money. I never reported this to the administrator. On 8/6/25 at 11:30 AM V3 (Business Office Manager) stated, (R3's) Medicaid recertification was due months ago and the facility asked for an extension. When I had to get (R3's) Medicaid Recertification documents submitted I had to ask for (R3's) bank statements and noticed (R3's) private income was being used by (V8/R3's Guardian) on personal use items and not for (R3). I also noticed (R3) was getting a long-term disability check that was not being turned over to the facility and the facility was not getting the entire payment for (R3's) stay.On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, (R3) has been getting a check from long-term disability for years. The facility has always been aware. In fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (R3) and take (R3) out to dinner. V8 also confirmed he has been using R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) should have tried to protect R3's funds from being exploited by V8 when V6 first became aware (March 2025).The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (R2's guardian) was exploiting R2's funds and failed to protect R2 from further exploitation. V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM.On 8/9/25 and 8/11/25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1 on the facility's abuse policy regarding immediately reporting and investigating abuse.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding the facility's abuse policy and procedures.4.On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with Abuse and Misappropriation of resident funds.5.On 8/8/25 V1 provided all families with a copy of the facility's Abuse Policy by certified mail.6.On 8/8/25 V18 (Activity Director) in-serviced all residents regarding the facility's abuse policy and procedures.7.On 7/31/25 V1 notified the Social Security Administration and R2's social security funds were suspended.8.On 8/8/25 V1 notified the Social Security Administration and R3's social security funds were suspended.9. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for R3's long term disability check to be sent directly to R3 in care of (the facility) due to exploitation of finances by (V8/R3's Guardian).10. R2 no longer requires a Guardian, and the facility is currently working with R2 to appoint R2 a power of attorney in the event R2 is no longer able to make her own healthcare decisions. 11.On 8/8/25 V1 contacted the facility's legal department and Office of State Guardianship to file a petition to change R3's Guardian. 12. On 8/8/25 V3 (Business Office Manager) sent all residents and residents' representative current financial statements by certified mail.13. On 8/8/25 V3 (Business Office Manager) reported all discrepancies of residents' payments not being made to V1, and V1 reported all discrepancies of resident payments not being made to the local police and state agency.Completion Date: 8/8/25.

Based on observation, interview and record review the Facility failed to initiate resident specific fall interventions for one of four Residents (R1) reviewed for falls in a sample of four. This failure resulted in R1 requiring laceration treatment and radiography testing, on two separate occasions, at the local hospital Emergency Department. Findings including: Facility Fall Prevention Program Policy, revised 5/2022, documents: to assure the safety of all Residents in the Facility when possible; the program will include measures which determine the individual needs of each Resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary; methods to identity risk factors and identify Resident's at Risk; use and implementation of professional standards of practice; addresses each fall; interventions are changed with each fall, as appropriate; preventative measures; and Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. R1's Incident Report Form to the local State Agency, dated 9/23/24, documents R1 was found on the floor after a self-transfer, with a cut on the skull/bleeding and R1 was sent to the local hospital for treatment of the skull laceration (three staples to head). The Report Form documents a fall intervention of staff in-service and R1 was educated on fall prevention and assessed for a new wheelchair. R1's Physician Order Sheet, dated 12/10/24, documents R1's diagnoses including Pneumonia, Dysphagia, Traumatic Brain Injury, Seizures, Bipolar Disorder, Muscle Wasting and Atrophy, Lack of Coordination, Abnormal Gait and Mobility. R1's diet order of Regular texture thin consistency and pleasure feedings was discontinued on 12/3/24 and a new order, on 12/10/24, for Regular, pureed texture and nectar liquids. R1's Minimum Data Set/MDS, dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of moderate/severe cognitive impairment (0/15). The MDS Functional Abilities documents upper and lower limited range of motion and requires substantial/maximal assistance with activities of daily living. R1's current Care Plan documents: that R1 is at risk for decreased mobility, impaired mobility related to a history of weakness; has a history of falls; impaired cognitive function related to Traumatic Brain Injury/TBI and unable to answer BIMS questionnaire; communication problem; mood fluctuations related to TBI and Bipolar diagnosis; and has risk factors that require monitoring and intervention to reduce potential for self-injury related to TBI, unsteady gait and fall history. The Care Plan does not document specific Resident fall interventions for the individual falls for R1. R1's AIM for Wellness Event Record, dated 9/16/24, documents R1's 9/16/24 at 8:15 pm, fall out of the wheelchair onto the floor, while trying to open bathroom door to empty urinal. R1 sustained a hematoma and abrasion to the Right Forehead (2.5 centimeter/cm in length and superficial depth). No intervention is documented. R1's AIM for Wellness Event Record, dated 9/23/24, documents R1's 9/23/24 at 1:00 pm, unwitnessed fall with head injury and (R1) states (R1) was putting (R1) to bed and fell , hitting (R1's) head on (R1's) end side table. R1 was transferred to the local Hospital Emergency Department for treatment of a scalp laceration (7.0 by 0.1 centimeter/cm) and the fall intervention was to not applicable (NA) to be determined (TBD). R1's AIM for Wellness Event Record, dated 10/5/24, documents R1's 10/5/24 at 3:00 am, fall in room from bed and the intervention was to re-educate (R1) on importance of using call light when assistance is needed. R1's AIM for Wellness Event Record, dated 10/10/24 at 3:15 pm, documents R1's 10/10/24 at 3:15 pm, fall when transferring from the wheelchair to the bed and R1 sustained a laceration to the forehead. R1 was transferred to the local Hospital Emergency Department for treatment of the forehead laceration (2.0 cm by 1.0 cm) and the intervention was to remind (R1) to ask for assistance with transfers. R1's local Hospital Discharge Disposition, dated 9/23/24, documents R1 sustained a minor closed head injury and superficial laceration, requiring staples to the scalp after a fall/tripping. The Disposition documents staple removal in ten days. R1's local Hospital Discharge Disposition, dated 10/10/24, documents R1 was treated for a superficial laceration to the Forehead after a fall from a chair on the same level by slipping. On 12/10/24 at 9:55 am, attempts to interview R1 were unsuccessful. R1 was unable to communicate. R1 was sitting in the middle of R1's room, in a wheelchair, leaning to the right side and drool/saliva on mouth. R1 did not have a call light within reach. On 12/11/24 at 10:44 am, R1 was in R1's room and R1 did not have a call light within reach. On 12/10/24 at 10::00 am, R5 (Resident Council President/R1's Roommate) stated, He (R1) has fallen many times and a lot lately. I am not sure what exactly they are doing to help him, because look at him, he definitely needs their help with everything. He just keeps getting up on his own. On 12/11/24 at 9:50 am, V3 (Assistant Director of Nursing/ADON) stated, (R1) is pretty much nonverbal and has had falls with injury that required (R1) to go to the hospital. I know that (R1) had some lacerations from the falls and also had to have a Comminuted Tomography (CT scan), but that was negative. I do not think that all the fall interventions have been appropriate for (R1). I completely understand that the interventions we have been using are not working. On 12/11/24 at 9:50 am, V2 (Director of Nursing/DON) stated, (R1) does have a brain injury and is impulsive. (R1's) communication is also impaired. On 9/16/24 the intervention for (R1) was to encourage (R1) to use the call light. On the 9/23/24 fall, the intervention was to stay in common area and remind (R1) to use the call light. On the 10/10/24 fall, the intervention was to remind (R1) to ask for assistance to transfer and for (R1) to stay in sight. I can see that these interventions are not appropriate for (R1). (R1) does continue to be impulsive and continues to fall and injury himself. We will start looking at the interventions for our falls a little more now and make them more appropriate.

Based on interview and record review, the facility failed to protect R1 through R74's right to be free from misappropriation of property from V4, Business Office Manager, for 74 of 75 residents (R1-R74) reviewed for misappropriation of funds in the sample of 75. These failures resulted in the facility failing to monitor the residents' pooled trust account monthly resulting in V4 stealing, over a period of eight months, $11,815.00/dollars of funds out of the residents' pooled facility trust fund account without residents' knowledge and resulted in V4 keeping R46's pre-paid social security card and making fraudulent charges, without R46's permission, on multiple occasions from April 2024 to September 2024 These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/10/24 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 Prevention Program dated 11/28/16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individual. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belonging or money without the resident's consent. The facility's Resident Funds Policy and Procedure (undated) documents, Upon written authorization of a competent resident the facility will hold, safeguard, manage, and account for personal monies deposited with the facility. If the resident has been determined to be incompetent, the written authorization may be signed by the resident's fiduciary guardian, legal representative, or immediately family. All funds shall be held in an interest bearing, pooled monies account. The facility will institute security measures to ensure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight of the facility Administrator, and signed quarterly statements. Further, the facility will require dual signatures on all banking transactions requiring signatures as well as require receipts for all purchases made from residents' personal monies that shall include date of purchase amount of purchase, and detail of all items or services purchases. V4's (Business Office Manager/Social Service Director) Employee Data Sheet, undated, documents V4 was hired on 10/16/2023 as Business Office Manager/Social Service Director (BOM/SSD). V4 (Business Office Manager's/BOM) Individual Employee Timecard dated, 7/16/24 to 7/31/24, documents V4's last day worked was 7/29/24. The facility's Long Term Care Facility-Serious Injury Incident and Communicable Disease Report, dated 7/30/24, documents Final: Theft of residents and this facility's health care fund. Staff involved: (V4/BOM) Terminated. Detailed Incident of Summary: Investigation still ongoing. Employee (V4) who was the Business Office Manager for (the facility) wrote checks to cash by forging authorized signer's signatures and then deposited those funds into her own bank account. While interviewing the residents we found out that (V4) employee was taking money from the residents to purchase things. They (the residents) were not getting the receipts from the items purchased. A couple of residents said they never received the items or their money back. All items in the business office were loaded up and taken to the corporate office and turned over to V13 (Corporate Attorney) along with V7 (Corporate Trust Manager) and V8 (Corporate Trust Manager). It has been determined that there is over 11,000 dollars missing from the account which was for room and board and resident's monies. The Local Police Departments Report, dated 7/30/24, and signed by V17 (Local Police Sergeant), documents On 7/30/24, I (V17/Police Sergeant) was on duty for the (local Police Department). At approximately 2:24 PM I arrived at (the facility) regarding a theft of a large sum of money. I made contact with (V6/Regional Director of Clinical Operations/Prior Administrator) and (V19/Senior [NAME] President of Operations) regarding a theft of a large sum of money. (V6/Prior Administrator) advised that the employee in question was (V4/BOM). (V6) advised that the resident trusts fund is one bank account that holds the money for all the residents. (V6) advised that there is then a ledger (kept by the facility) showing how much money each resident has in the account. (V6) advised money can only be withdrawn from the account by writing a check to cash and have both her (V6) and (V3/Prior Administrator in Training/AIT) signatures on the check. (V6) advised the check would then be sent to (local bank) with (V4), and (V4) would cash the check. (V6) advised that (V4) would then, a short time after removing the cash, return to the (local bank) and deposit the cash into (V4's) personal bank account. (V6) advised that the (local bank) staff observed (V4) do this numerous times and used marked bills to make sure (V4) was depositing the same cash into her account. (V6) advised she believes the amount could be between 20,000 and 50,000 dollars. (V6) showed me (V17) the check book receipts. (V6) advised there were checks in the books that had (V3's) name forged by (V4), and several checks that were missing and blank. I believe the checks in question were numbered 4002 through 4049. The blank checks in the receipt book were check numbers 4023, 4037, 4040, 4045, 4048, and 4049. (V19) advised the majority of this money was Medicaid money and, in the past, they have used (State Police) Medicaid fraud division in handling incidents. (V19) advised he had to notify Law Enforcement within 24 hours and requested I completed a report, but he had to take all their records to their home office in (another city) today. I asked (V19) if he would like (local police department) to handle the incident or (State Police) Medicaid Fraud. (V19) advised he would have (State Police) handle the incident. I advised (V19) that I would complete an initial report in the event they needed and provide (V19) with the case number. I cleared (the facility). I made contact with (V9/Local Branch Manager). (V9) advised they have witnessed (V4) on several occasions cash a check from the resident fund and deposit that money into her account. (V9) advised they had used marked bills to confirm (V4) had done this. (V9) advised she has since, notified (the facility) and closed the accounts. I asked (V9) if she could forward copies of the checks and statements to me. (V9) advised she would, and I provided my department emailed address. R5's Trust Fund Withdrawal Logs dated January through April 2024 document 229.00 dollars of cash withdrawals that do not contain a resident signature or a reason for the withdrawals. R14's Trust Fund Withdrawal Logs dated January through April 2024 document 124.00 dollars of cash withdrawals that do not contain a resident signature or a reason for the withdrawals. R16's Trust Fund Withdrawal Logs dated January through April 2024 document 1685.00 dollars of cash withdrawals that do not contain a resident signature or a reason for the withdrawals. R24's Trust Fund Withdrawal Logs dated January through April 2024 document 70.00 dollars of cash withdrawals that do not contain a resident signature or a reason for the withdrawals. R26's Trust Fund Withdrawal Logs dated January through April 2024 document 15.00 dollars of cash withdrawals that do not contain a resident signature or a reason for the withdrawals. R51's Trust Fund Withdrawal Logs dated January through April 2024 document 481.00 dollars of cash withdrawals that do not contain a resident signature or a reason for the withdrawals. The facility's Audit dated January through July 2024 and signed by V7 (Corporate Trust Manager) documents there was an 11,815.00-dollar deficit of residents' trust funds that V4 (BOM) had misappropriated without the consent of the residents. The facility's trust fund withdrawal logs were missing from the facility for the months of May, June, and July 2024. The facility Resident Fund spreadsheet dated 12/30/23 to 7/31/24, document that the following residents have a facility trust fund that was managed by V4 (BOM): R1-R74. On 8/30/24 at 10:46AM, V3 (Prior AIT) stated she was not monitoring the monthly trust fund account or ensuring quarterly statements were given to the residents. V3 stated, I would offer to do the resident shopping for (V4/Business Office Manager) for the residents and tell (V4) I can get the stuff since she was busy. (V4) would say 'No, I got it.' I did not go over the monthly trust fund account or receipts and sign off on them or ensure residents were getting their quarterly statements. On 8/30/24 at 11:55 AM, R46 stated in March 2024 V4 (BOM) started handling his bills at the facility and took his (pre-paid card). R46 stated, I told (V4) I wanted receipts for all my bills when my pre-paid social security card was used. I never received any receipts. I called social security around three months ago and they told me that there were purchases on my card for girls' clothes and girls' shoes. I was so upset and angry. I reported to staff at the facility at that time, that I believed (V4) was stealing money from my account and fraudulent charges. V3 (Prior AIT) was aware of it too. I thought I could trust (V4), and now I am so angry. I don't have any money and it makes me very upset. (V4) never returned my pre-paid social security card to me. On 8/30/24 at 12:06 PM, V9 (Local Bank Manager) stated she noticed for the last few months that (the facility) was cashing a lot more checks than normal (like two to three times per week) instead of once or twice a month. V9 stated, I noticed a few times that (V4/BOM) would come to the local bank, cash a check from the residents' trust fund account, drive around the block, then come back in and deposit cash into (V4's) own personal bank account. I started watching (V4) closer and when she came in to cash a check this last time, I marked bills before giving the bills to her. Fifteen minutes later, (V4) drove around the block and deposited the marked money into (V4's) personal checking account. On 8/30/24 at 10:34 AM, V1 (Regional Director) stated, The (local bank) reported the alleged allegation to (V6/Prior Administrator). (V6) then contacted our Corporate Office. To my knowledge (V4/BOM) was falsifying (V3/Prior Administrator in Training) and (V6's) signatures to cash the checks and was stealing the residents' money for herself. (V4) should have kept a record of when a resident asked for money and had the resident sign by their name of how much they took each time a withdrawal was made. We (the facility) do not have trust fund withdrawal logs for the months of May, June, July 2024. No one was watching over the trust funds at this time. After doing an audit it was determined that $11,815.00 (dollars) was missing from the residents' trust fund account. I am not sure which residents' money was taken from that account because (the facility's) Corporate Office has everything. The (local bank) reported the alleged allegation to (V6/Prior Administrator). (V6) then contacted our Corporate Office. Our Corporate Office showed up on a Tuesday (7/30/24) and immediately suspended (V4/BOM) and took everything out of (V4's) office. (V7/Corporate Trust Manager) is the one who has all the information now. We (the facility) are still trying to find out what residents gave (V4) money and never received their items they were wanting or their money back. We (the facility) have not identified those residents yet. In order for (V4/BOM) to replenish the trust fund account the BOM would fill out a check and either (V3/Prior AIT) or (V6) would have to sign off on it. If someone went shopping for residents, that person should have had a copy of the receipt, put the residents name at the top of the receipt with the date and time, and give a copy to the resident, then write it down in the trust fund under the resident's accounts. (V4) should have been sending monthly trust fund reports to the Corporate Office with withdrawal logs and the receipts showing what residents purchased. To my knowledge no one was overseeing (V4) in the building with the trust fund or reviewing the logs. I believe (V8/Corporate Trust Manager) was having trouble getting information for those trust fund reports from (V4) as well. The (local bank) stated (V4) would cash the residents trust fund check, drive around the block, then go back in the bank and deposit money into her own account. (V3) was the Administrator in Training at the time of those occurrences. On 8/30/24 at 1:10 PM, R51 reviewed his withdrawal logs for January 2024 to April 2024 for his trust fund account. R51 stated, I did not withdrawal 481.00 dollars from my account. What would I spend that much money on? Someone is stealing my money. On 8/31/24 at 11:40 AM, V18 (R16's Responsible Party) stated the only thing she approved to be purchased out of R16's trust fund account was a new wheelchair. Other than that, she would have not approved any purchases. V18 stated R16 would have not asked for more than a few dollars a month at most. V18 stated, (R16) has nowhere to spend his money. (R16) would be very angry and upset if someone was spending or stealing his money. On 9/1/24 at 6:15 AM, R16 reviewed the withdrawal logs from R16's trust fund accounts for the months of January, February, March, and April 2024 and was visibly upset. R16 stated he did not sign anything and that he never took out any money from his trust fund account. R16 stated, I earned that money over the years. I will beat up whoever it is that took it. That's b******t. I want a block put on my account now. On 9/1/24 at 6:30 AM, R33 reviewed the withdrawal logs from R33's trust fund accounts for the months of January, February, March, and April 2024. R33 stated, My signature is forged on 1/24/24 for the withdrawal amount of 35.00 dollars and on 1/31/24 for the amount of 30.00 dollars. R33 also reviewed a withdrawal of 105.00 dollars on 1/19/24. R33 stated, I would never request to take out 105.00 dollars here. What would I spend that on? I always request 5.00 dollars or 10.00 dollars to be taken out at a time. Look, you can see where I signed to take out 5.00 dollars, someone added a little one and zero in front of the five to make it look like I took out 105 dollars. R33 stated that the 2/19/24 cash withdrawal was not correct either and she did not take out 24.00 dollars and 50 cents. No signatures from R33 were present next to the withdrawal on the February 2024 withdrawal trust fund log. R33 was visibly upset and angry. On 9/1/24 at 1:10 PM, R26 reviewed the withdrawal logs from R26's trust fund accounts for the months of January, February, March, and April 2024. R26 stated, I did not request 15.00 dollars to be taken out of my account in April 2024. I always made sure to sign when I wanted money out of my account. On 9/3/24 at 9:55 AM, R14 reviewed the withdrawal logs from R14's trust fund accounts for the months of January, February, March, and April 2024. R14 stated he did not withdraw 124.00 dollars between January 2024 to April 2024, nor did he give anyone permission to withdraw money from his account. R14 stated, I didn't even know I had that much money in my account. I am very upset to know someone took my money. On 9/3/24 at 9:39 AM, V6 (Prior Administrator) stated around 7/22/24 V9 (Local Bank Manager) pulled V6 aside at the (local bank) and told V6 to take (the facility's) check book away from V4 (BOM). V6 stated, (V9) told me there was suspicious activity going on with the resident's trust fund account from (V4). (V4) had the checkbook to use to make withdrawals from the residents' pooled trust fund account (R1-R74's account). On 9/4/24 at 8:38 AM, V7 (Corporate Trust Manager) stated the first check she is aware of that was misappropriated by V4 (BOM) out of the residents' pooled trust fund account was January 11th, 2024, for 450.00 dollars. V7 stated, We (Corporate) went through all the resident's withdrawal logs from January 2024 to current and confirmed that there was a deficit of 11,815.00 dollars that V4 had stolen without the consent of the residents. V7 verified at this time that the monthly trust fund withdrawal logs for the months of May, June, and July 2024 are missing. On 9/4/24 at 11:45 AM, V2 (AIT) stated (V2) and (R46) spoke with the Social Security's office on 9/3/24. During the phone call V2 stated it was determined that R46 does have a pre-paid social security card and that there have been fraudulent charges being made. V2 stated, The social security's office stated they could only see August and September's 2024 charges. On 8/5/24 a fraudulent charge was made in the amount of 75.00 dollars and on 9/1/24 two fraudulent charges were made, one for 77.95 dollars and the other amount for 0.75 cents. The social security's' office stated (R46's) account statements from 2023 to present would be sent to (the facility) within five to ten business days. The Immediate Jeopardy started on 1/11/24 when V4 (BOM) started misappropriating funds out of the residents' pooled trust fund account. V1 (Regional Director) and V2 (AIT) were notified of the Immediate Jeopardy on 9/4/24 at 3:56 PM. This surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility staff have interviewed all cognitive residents to identify those residents who allowed the facility to manager their monies and who had given V4/Business Office Manager monies for items and never got items, receipts, or monies back from 8/10/24 to current. 2. On 9/3/24 V1 (Regional Director) notified all resident's/responsible parties of discharged residents of misappropriation of funds. 3. On 8/8/24 V2 (Administrator in Training/AIT) was in serviced by V1/Regional director on the facility's Abuse Policy and Procedures. 4. On 9/3/24 V2 (AIT) was educated by V1 (Regional Director) on how the resident trust fund is supposed to work and procedures on handling the resident's cash. 5. On 9/6/24 V20 (Business Office Manager) was thoroughly trained by V1 (Regional Director) on the resident trust. 6. On 9/6/24 a deposit was made in the amount of 11,815.00 to the resident's new trust fund account. This amount was the amount audited and determined by V7 (Corporate Trust Manager) to be missing from the resident's pooled trust fund account. 7. The facility's Audit dated January through July 2024 and signed by V7 (Corporate Trust Manager) documents there was an 11,815.00-dollar deficit of residents' trust funds that V4 (BOM) had misappropriated without the consent of the residents. On 9/9/24 at 9:20 AM V21 (Housekeeper) was in the facility's break room and stated, I do not recall being in serviced on Abuse or the steps to take if I did not feel the abuse coordinator handled an abuse allegation appropriately. On 9/9/24 at 9:55 AM V23 (Certified Nursing Assistant) stated over the phone, I have not been in-serviced on any of the abuse policy and procedures in a very long time. I just worked last night 9/8/24. On 9/9/24 at 10:20 AM V26 (Agency Registered Nurse/RN) was at the nurse's desk and stated, I have not been in-serviced on the abuse policy and procedures since I have worked here. This surveyor reviewed the in-service sheet from 8/10/24 and 9/6/24 on the abuse policy and procedures and the staffing schedules. It was determined that V22 (Dietary), V24 (Certified Nursing Assistant), and V25 (Certified Nursing Assistants) signatures were not on the Abuse in-service sheets. This surveyor reviewed all residents that resided in the facility and that was affected by the misappropriation of the residents pooled trust fund account. Only two resident's (R16 and R33's) representatives had been notified. On 9/9/24 at 11:00 AM V20 (Social Service Director) verified the only two resident's she documented on for notifying the resident's representatives was R16 and R33 on 9/3/24. On 9/9/24 at 1:30 PM V1 (Regional Director) stated, I spoke with V27 (Resident Care Coordinator) when I was writing the removal plans and V27 confirmed that all employees were in-serviced on abuse policy and procedures on 8/10/24. On 9/6/24 I realized that not all employees were in-serviced so I in-serviced more employees on 9/6/24. I specifically told V2 (AIT) that no one could work until they had been in-serviced on abuse policy and procedures. I did not realize all employees have not been in-serviced yet. V1 also stated, I spoke with V2 (AIT) and, V2 had told me that all the resident representatives had been notified of the misappropriation of resident funds and that a progress note had been entered by V20 (Social Service Director) in the resident's medical record. I once again was not aware this wasn't done. On 9/9/24 at 2:00 PM V2 (AIT) verified that V21 (Housekeeper), V22 (Dietary), V23 (Certified Nursing Assistant), V24 (Certified Nursing Assistant), V25 (Certified Nursing Assistant), and V26 (Agency RN) had not been in-serviced on the Abuse Policy and Procedures on 8/10/24 or after. V2 (AIT) stated, I did not realize how the process worked, so not everyone got in-serviced on abuse policy and procedures. V2 also stated, V20 (Social Service Director) had texted me and stated she had put in a progress note of notifying all the resident representatives of the misappropriation of resident property/funds. I did not double check this. V2 verified all resident representatives had not been notified and the only two notified was V18 (R16's Power of Attorney) and V28 (R33's Son). Due to all staff not being in-serviced on the abuse policy and procedures on 8/10/24 or prior to their shift and the responsible parties of the residents in the facility not being notified of the misappropriation of property/funds the facility's abatement plan was not completely executed on 9/6/24 as documented by the facility. Therefore, the immediacy could not be removed on 9/6/24. On 9/10/24 the facility completed all measures on the abatement plan, including providing in-servicing to all the staff on abuse policy and procedures and notifying all responsible parties of the residents in the facility of the misappropriation of funds, therefore the abatement plan could be approved on 9/10/24. Completion Date: 9/10/24.

Based on interview and record review, the facility failed to follow their Abuse Policy to immediately report allegations of misappropriation of residents' funds to the local police department, the state agency, and the residents/residents' representatives for 75 (R1-R75) of 75 residents reviewed for reporting of allegations of abuse in the sample of 75. These failures resulted in R75 reporting to V3 (Prior Administrator-In-Training/AIT) on 6/20/24 that she suspected V4 (Business Office Manager/BOM) was making fraudulent charges from her debit card. This allegation was not reported to the state agency. On 7/22/24 V6 (Prior Administrator) was notified by V9 (Bank Manager) that she suspected V4 was making fraudulent withdrawals out of the resident's trust fund for personal use. V6 did not contact the police or notify the state agency until 7/30/24 (8 days later), leaving R1-R74's trust fund accounts vulnerable to further theft. After an audit, a deficit of $11,815.00/dollars was discovered missing from the residents' pooled trust fund account. On 8/30/24 V1 (Regional Director) was made aware of R46 reporting that V4 never returned R46's pre-paid social security card and there were fraudulent charges being made on his card. The state agency was not notified of this allegation until 9/3/24 and as of 9/4/24 the police have still not been notified. R46's pre-paid social security card continued to be subjected to fraudulent charges on 9/1/24 after this surveyor reported the allegation to V1 on 8/30/24. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/10/24 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 Prevention Program policy dated 11/28/16 documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents they observe, hear about, or suspect to a supervisor and the administrator. The administrator or designee is also responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and (State Agency) immediately after forming the suspicion (but not later than two hours after forming the suspicion), otherwise, the report must be made not later than 24 hours after forming the suspicion of a crime. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential abuse of resident and that an investigation is being conducted. The administrator, or designee will inform the resident or resident's representative of the conclusions of the investigation. If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately notify local law enforcement as soon as possible but no later than 24 hours in accordance with 300.695 (b) in the following situations: d) When a crime has been committed in a facility by a person other that a resident. The Local Police Departments Report, dated 6/20/24, and signed by V17 (Local Police Sergeant), documents V17 returned a call to R75 and R75 advised that her bank account had been fraudulently hit and R75 was missing 2000.00 dollars to 3000.00 dollars. R75 advised V17 that V4 (BOM) was the one who had her debit card. The facility's Long Term Care Facility-Serious Injury Incident and Communicable Disease Report, dated 7/30/24, documents Final: Theft of residents and this facility's health care fund. Staff involved: (V4/BOM) Terminated. Detailed Incident of Summary: Investigation still ongoing. Employee (V4) who was the Business Office Manager for (the facility) wrote checks to cash by forging authorized signer's signatures and then deposited those funds into her own bank account. While interviewing the residents we found out that (V4) employee was taking money from the residents to purchase things. They (the residents) were not getting the receipts from the items purchased. A couple of residents said they never received the items or their money back. All items in the business office were loaded up and taken to the corporate office and turned over to V13 (Corporate Attorney) along with V7 (Corporate Trust Manager) and V8 (Corporate Trust Manager). It has been determined that there is over 11,000 dollars missing from the account which was for room and board and resident's monies. The Local Police Departments Report dated 7/30/24, and signed by V17 (Local Police Sergeant), documents On 7/30/24, I (V17/Police Sergeant) was on duty for the (local Police Department). At approximately 2:24 PM I arrived at (the facility) regarding a theft of a large sum of money. I made contact with (V6/Regional Director of Clinical Operations/Prior Administrator) and (V19/Senior [NAME] President of Operations) regarding a theft of a large sum of money. (V6/Prior Administrator) advised that the employee in question was (V4/BOM). (V6) advised that the resident trusts fund is one bank account that holds the money for all the residents. (V6) advised that there is then a ledger (kept by the facility) showing how much money each resident has in the account. (V6) advised money can only be withdrawn from the account by writing a check to cash and have both her (V6) and (V3/Prior Administrator in Training/AIT) signatures on the check. (V6) advised the check would then be sent to (local bank) with (V4), and (V4) would cash the check. (V6) advised that (V4) would then, a short time after removing the cash, return to the (local bank) and deposit the cash into (V4's) personal bank account. (V6) advised that the (local bank) staff observed (V4) do this numerous times and used marked bills to make sure (V4) was depositing the same cash into her account. (V6) advised she believes the amount could be between 20,000 and 50,000 dollars. (V6) showed me (V17) the check book receipts. (V6) advised there were checks in the books that had (V3's) name forged by (V4), and several checks that were missing and blank. I believe the checks in question were numbered 4002 through 4049. The facility's Audit dated January through July 2024 and signed by V7 (Corporate Trust Manager) documents there was an 11,815.00-dollar deficit of residents' pooled trust funds that V4 (BOM) had withdrawn without the consent of the residents. The facility Resident Fund spreadsheet dated 12/30/23 to 7/31/24, document that the following residents have a facility trust fund that was managed by V4 (BOM): R1-R74. On 8/30/24 at 11:55 AM, R46 stated in March 2024 V4 (BOM) started handling his bills at the facility and took his (pre-paid card). R46 stated, I told (V4) I wanted receipts for all my bills when my pre-paid social security card was used. I never received any receipts. I called social security around three months ago and they told me that there were purchases on my card for girls' clothes and girls' shoes. I was so upset and angry. I reported to staff at the facility at that time, that I believed (V4) was stealing money from my account and fraudulent charges. V3 (Prior AIT) was aware of it too. I thought I could trust (V4), and now I am so angry. I don't have any money and it makes me very upset. (V4) never returned my pre-paid social security card to me. R46 denied being notified by the facility regarding the alleged allegation of misappropriation of funds from R46's trust fund account. On 8/30/24 at 12:00 PM, V1 (Regional Director) was notified by this surveyor of R46's allegation of V4 (BOM) making fraudulent purchases from R46's pre-paid social security card and R46 stating V4 still had his pre-paid social security card in her possession. On 8/30/24 at 12:06 PM, V9 (Local Bank Manager) stated she noticed for the last few months that (the facility) was cashing a lot more checks than normal (like two to three times per week) instead of once or twice a month. V9 stated, I noticed a few times that (V4/BOM) would come to the local bank, cash a check from the residents' trust fund account, drive around the block, then come back in and deposit cash into (V4's) own personal bank account. I started watching (V4) closer and when she came in to cash a check this last time, I marked bills before giving the bills to her. Fifteen minutes later, (V4) drove around the block and deposited the marked money into (V4's) personal checking account. I notified (V6/Prior Administrator) of my suspicion of (V4) taking resident funds for her own use on 7/22/24 in person. On 8/30/24 at 1:10 PM, R51 reviewed his withdrawal logs for January 2024 to April 2024 for his trust fund account. R51 stated, I did not withdrawal 481.00 dollars from my account. What would I spend that much money on? Someone is stealing my money. No one has reported to me that anyone has stolen money out of my account. On 8/31/24 at 11:40 AM V18 (R16's Responsible Party) stated, (R16) has nowhere to spend his money. (R16) would be very angry and upset if someone was spending or stealing his money. No one from the facility has notified me that (R16) has money missing out of his account. On 9/1/24 at 6:15 AM R16 stated he did not sign anything and that he never took out any money from his trust fund account. R16 stated no-one from the facility has notified him that money was missing out of his account. On 9/1/24 at 6:30 AM R33 reviewed the withdrawal logs from R33's trust fund accounts for the months of January, February, March, and April 2024. R33 stated, My signature is forged on 1/24/24 for the withdrawal amount of 35.00 dollars and on 1/31/24 for the amount of 30.00 dollars. R33 also reviewed a withdrawal of 105.00 dollars on 1/19/24. R33 stated, I would never request to take out 105.00 dollars here. What would I spend that on? I always request 5.00 dollars or 10.00 dollars to be taken out at a time. Look, you can see where I signed to take out 5.00 dollars, someone added a little one and zero in front of the five to make it look like I took out 105.00 dollars. R33 stated that the 2/19/24 cash withdrawal was not correct either and she did not take out 24.00 dollars and 50 cents. No signatures from R33 were present next to the withdrawal on the February 2024 withdrawal trust fund log. R33 was visibly upset and angry. R33 stated, No one has even told me about this until you (this surveyor) showed me. On 9/1/24 at 1:10 PM R26 stated, I did not request 15.00 dollars to be taken out of my account in April 2024. I was not told from anyone at the facility that my money was stolen. On 9/3/24 at 9:39 AM V6 (Prior Administrator) stated around 7/22/24 V9 (Local Bank Manager) pulled V6 aside at the (local bank) and told her to take (the facility's) check book away from V4 (BOM). V6 stated, (V9) told me there was suspicious activity going on with the resident's pooled trust fund account from (V4). (V9) advised they have witnessed (V4) on several occasions cash a check from the resident fund and deposit that money into her account. (V9) advised they had used marked bills to confirm (V4) had done this. (V9) advised she has since, notified (the facility) and closed the accounts. I did not notify the police or state agency of the allegation until 7/30/24 (eight days after the allegation was made). (V4) had the checkbook to use to make withdrawals from the residents' pooled trust fund account (R1-R74's account). (V4)'s job was to manage the resident's trust fund account. On 9/3/24 at 9:55 AM, R14 stated he did not withdraw 124.00 dollars between January 2024 to April 2024, nor did he give anyone permission to withdrawal money from his account. R14 stated, I didn't even know someone was stealing my money. On 9/4/24 at 11:45 AM V2 (AIT) stated (V2) and (R46) spoke with the Social Security's office on 9/3/24. During the phone call V2 stated it was determined that R46 does have a pre-paid social security card and that there have been fraudulent charges being made. V2 stated, The social security's office stated they could only see August and September's 2024 charges. On 8/5/24 a fraudulent charge was made in the amount of 75.00 dollars and on 9/1/24 two fraudulent charges were made, one in the amount of 77.95 dollars and one in the amount of 0.75 cents. The social security's' office stated (R46's) account statements from 2023 to present would be sent to (the facility) within five to ten business days. The local police have not been notified by me or anyone at the facility of (R46's) fraudulent charges on his pre-paid social security card. On 9/1/24 at 10:36 AM, R75 stated that on 6-20-24 she got a notification that her bank account was overdrawn 369 dollars and prior to 6/20/24 she had given V4 (BOM) her debit card and V4 did not return the card. R75 stated she requested bank statements and there were unauthorized charges from May 15th to June 5th, 2024, for a total of 1,028.49 dollars that was not R75's charges and R75 notified V3 (AIT) that R75 suspected V4 had taken 1028.49 dollars out of R75's account without R75's permission. R75 reported she felt like (V3) did not want to hear about it, and that R75 almost had another heart attack. This allegation was not reported to the state agency. On 9/04/24 at 12:20 PM, V3 (Prior AIT) stated R75 did report to V3 that R75 had fraudulent charges between 2,000 to 3,000 dollars taken out of her account on 6-20-24. V3 stated she did not report to the state agency R75's allegation on 6-20-24 of fraudulent charges being made from R75's bank account. On 9/1/24 at 8:25 AM V1 (Regional Director) stated no resident's or residents' representatives have been notified of the investigation regarding their misappropriation of funds from their (R1-R74's) trust fund account. On 9/4/24 at 8:38 AM, V7 (Corporate Trust Manager) stated the first check she is aware of that was misappropriated by V4 (BOM) out of the residents' trust fund account was January 11th, 2024, for 450.00 dollars. We (Corporate) went through all the resident's withdrawal logs from January 2024 to current and confirmed that there was a deficit of 11,800.15 dollars that V4 had withdrawn without the consent of the residents. On 8/30/24 at 12:06 PM, V9 (Local Bank Manager) stated on 7/22/24, V9 (Local Bank Manager) was noticing (the facility) was cashing checks more frequently (like two to three times per week) instead of once or twice a month. V9 noticed suspicious activity from V4 (BOM) regarding fraudulent charges being made from the resident's trust fund account and notified V6 (Prior Administrator) on 7/22/24 in person regarding suspicious activity of V4. The Immediate Jeopardy started on 6/20/24 when V3 (Prior AIT) did not report to the state agency, after R75 reported fraudulent charges from her debit card that was in possession of V4 (BOM). V1 (Regional Director) and V2 (AIT) were notified of the Immediate Jeopardy on 9/5/24 at 1:34PM. This surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 7/30/24 V4/Business Office Manager was suspended and has not worked at (the facility) since. 2. V3 (Prior Administrator in Training/AIT) last day at the facility was 7/8/24 and V6 (Prior Administrator's) last day at the facility was 7/31/24 confirmed by V2 (AIT). 3. On 8/8/24 V2 (AIT) was educated by V1 (Regional Director) on the Abuse Policy and Procedures with an emphasis on two-hour reporting window to (State Agency), notifying the responsible party, doctor, and local police. 4. On 9/3/24 V2 (AIT) and on 9/6/24 V20 (Business Office Manager/Social Service Director) were both in-serviced by V1 (Regional Director) on how the resident trust fund is supposed to work and procedures on handling the resident's cash. On 9/9/24 at 9:20 AM V21 (Housekeeper) was in the facility's break room and stated, I do not recall being in serviced on Abuse or the steps to take if I did not feel the abuse coordinator handled an abuse allegation appropriately. On 9/9/24 at 9:55 AM V23 (Certified Nursing Assistant) stated over the phone, I have not been in-serviced on any of the abuse policy and procedures in a very long time. I just worked last night 9/8/24. On 9/9/24 at 10:20 AM V26 (Agency Registered Nurse/RN) was at the nurse's desk and stated, I have not been in-serviced on the abuse policy and procedures since I have worked here. This surveyor reviewed the in-service sheet from 8/10/24 and 9/6/24 on the abuse policy and procedures and the staffing schedules. It was determined that V22 (Dietary), V24 (Certified Nursing Assistant), and V25 (Certified Nursing Assistant) signatures were not on the Abuse in-service sheets. On 9/9/24 at 1:30 PM V1/Regional Director stated, I spoke with V27 (Resident Care Coordinator) when I was writing the removal plans and V27 confirmed that all employees were in-serviced on abuse policy and procedures on 8/10/24. On 9/6/24 I realized that not all employees were in-serviced so I in-serviced more employees on 9/6/24. I specifically told V2 (AIT) that no one could work until they had been in-serviced on abuse policy and procedures. I did not realize all employees have not been in-serviced yet. On 9/9/24 at 2:00 PM V2 (AIT) verified that V21 (Housekeeper), V22 (Dietary), V23(Certified Nursing Assistant), V24 (Certified Nursing Assistant), V25 (Certified Nursing Assistant), and V26 (Agency RN) had not been in-serviced on the Abuse Policy and Procedures on 8/10/24 or after. V2/AIT stated, I did not realize how the process worked, so not everyone got in-serviced on abuse policy and procedures. Due to all staff not being in-serviced on the abuse policy and procedures on 8/10/24 or prior to their shift, the facility's abatement plan was not completely executed on 9/6/24 as documented by the facility. Therefore, the immediacy could not be removed on 9/6/24. On 9/10/24 the facility completed all measures on the abatement plan, including providing in-servicing to all the staff on abuse policy and procedures and notifying all responsible parties of the residents in the facility of the misappropriation of funds, therefore the abatement plan could be approved on 9/10/24. Completion Date: 9/10/24.

Based on interview and record review the facility failed to follow their Abuse Policy to thoroughly investigate all allegations of misappropriation of funds and to remove the alleged perpetrator V4 (Business Office Manager/BOM) from contact with residents and residents' funds while an investigation was occurring for 75 (R1-R75) of 75 residents reviewed for protection of abuse in the sample of 75. These failures resulted in R75 reporting on 6/20/24 to V3 (Prior Administrator-In-Training/AIT) that R75 suspected V4 was making fraudulent charges from R75's debit card. This allegation was not investigated, V4 was not suspended, and the residents' funds were not protected from V4. On 7/22/24 V6 (Prior Administrator) was notified by V9 (Bank Manager) that she suspected V4 was making fraudulent withdrawals out of the resident's trust fund for personal use. V6 did not suspend V4 immediately or initiate an investigation immediately. Then on 8/30/24, R46 reported to this surveyor who then reported to V1 (Regional Director) that V4 never returned R46's pre-paid social security card and fraudulent charges were being made. V1 failed to immediately investigate the allegation and call the social security's office for R46 resulting in continued fraudulent charges on 9/1/24 (2 days) after this surveyor reported the allegation to V1 on 8/30/24. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/10/24 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 Prevention Program policy dated 11/28/16 documents, Upon learning of the report, the administrator, or designee, shall initiate an investigation. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse, or misappropriation of resident property will be immediately removed from the resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse, or misappropriation of resident property shall not complete their shift as direct care provider to residents. The administrator or designee is responsible for forwarding the final written report of the results of the investigation and corrective action to the (State Agency) within five working days of the reported incident. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including the steps the facility had taken in response to the allegation, will be sent to the (State Agency). The facility's Business Office Job Description, undated, documents Position is responsible for maintaining daily entries and current balances in the facility's ledger and resident monies accounts. Responsibilities: 1. General duties. b. Completes monthly [NAME] and statements for both private pay and public aide residents. d. Handles petty cash. g. Receives and receipts payments. h. Prepares and makes bank deposits. i. Accurately maintains resident monies account ledgers and reconciles resident monies to bank statements. 1. The Local Police Departments Report, dated 6/20/24, and signed by V17 (Local Police Sergeant), documents V17 returned a call to R75 and R75 advised that her bank account had been fraudulently hit and R75 was missing $2,000.00 dollars to $3,000.00. R75 advised V17 that V4 (BOM) was the one who had her debit card. On 9/1/24 at 10:36 AM, R75 stated that on 6-20-24 she got a notification that her bank account was overdrawn $369 and prior to 6/20/24 she had given V4 (BOM) her debit card and V4 did not return the card. R75 stated she requested bank statements and there were unauthorized charges from May 15th to June 5th, 2024, for a total of $1,028.49 dollars that was not R75's charges and R75 notified V3 (AIT) that R75 suspected V4 had taken 1028.49 dollars out of R75's account without R75's permission. R75 reported she felt like (V3) did not want to hear about it, and that R75 almost had another heart attack. This allegation was not reported to the state agency. On 9/04/24 at 12:20 PM, V3 (Prior AIT) stated R75 did report to V3 that R75 had fraudulent charges between 2,000 to 3,000 dollars taken out of her account on 6/20/24. V3 stated she did not do an investigation and did not suspend V4 at this time. 2. The facility's Long Term Care Facility-Serious Injury Incident and Communicable Disease Report, dated 7/30/24, documents Final: Theft of residents and this facility's health care fund. Staff involved: (V4/BOM) Terminated. Detailed Incident of Summary: Investigation still ongoing. Employee (V4) who was the Business Office Manager for (the facility) wrote checks to cash by forging authorized signer's signatures and then deposited those funds into her own bank account. While interviewing the residents we found out that (V4) employee was taking money from the residents to purchase things. They (the residents) were not getting the receipts from the items purchased. A couple of residents said they never received the items or their money back. All items in the business office were loaded up and taken to the corporate office and turned over to V13 (Corporate Attorney) along with V7 (Corporate Trust Manager) and V8 (Corporate Trust Manager). It has been determined that there is over 11,000 dollars missing from the account which was for room and board and resident's monies. On 8/30/24 at 12:06 PM, V9 (Local Bank Manager) stated she noticed for the last few months that (the facility) was cashing a lot more checks than normal (like two to three times per week) instead of once or twice a month. V9 stated, I noticed a few times that (V4/BOM) would come to the local bank, cash a check from the residents' trust fund account, drive around the block, then come back in and deposit cash into (V4's) own personal bank account. I started watching (V4) closer and when she came in to cash a check this last time, I marked bills before giving the bills to her. Fifteen minutes later, (V4) drove around the block and deposited the marked money into (V4's) personal checking account. I notified (V6/Prior Administrator) of my suspicion of (V4) taking resident funds for her own use on 7/22/24 in person. On 9/3/24 at 9:39 AM, V6 (Prior Administrator) stated that around 7/22/24 V9 (Local Bank Manager) pulled V6 aside at the (local bank) and told V6 to take (the facility's) check book away from V4 (BOM). V6 stated, (V9) told me there was suspicious activity going on with the resident's pooled trust fund account from (V4). I did not do an investigation or report it until 7/30/24 and did not suspend (V4) immediately. (V4) was not suspended until 7/30/24. (V4's) last day worked was 7/29/24. V6 verified that V4 was the only one with access to the check book to the resident's pooled trust fund account (R1-R74's account) and that V4's job was to manage the resident's pooled trust fund account. The facility's Audit dated January through July 2024 and signed by V7 (Corporate Trust Manager) documents there was an $11,815.00/dollar deficit of residents' pooled trust funds that V4 had withdrawn without the consent of the residents. 3. On 8/30/24 at 11:55 AM, R46 stated in March 2024 V4 (BOM) started handling his bills at the facility and took his (pre-paid card). R46 stated, I told (V4) I wanted receipts for all my bills when my pre-paid social security card was used. I never received any receipts. I called social security around three months ago and they told me that there were purchases on my card for girls' clothes and girls' shoes. I was so upset and angry. I reported to staff at the facility at that time, that I believed (V4) was stealing money from my account and fraudulent charges. V3 (Prior AIT) was aware of it too. I thought I could trust (V4), and now I am so angry. I don't have any money and it makes me very upset. (V4) never returned my pre-paid social security card to me. On 8/30/24 at 12:00 PM this surveyor reported to V1 (Regional Director) that V4 (BOM) never returned R46's pre-paid social security card and there are fraudulent charges being made on R46's card. This allegation was not immediately investigated, and the state agency was not notified of this allegation until 9/3/24 R46's pre-paid social security card continued to be subjected to fraudulent charges on 9/1/24 (2 days) after this surveyor reported the allegation to V1 on 8/30/24. On 9/3/24 at 1:35 PM V1 (Regional Director) stated she just notified the state agency today that R46 had reported V4/BOM had R46's prepaid social security card and fraudulent charges were being made. V1 stated, I did not immediately investigate R46 reporting this allegation on 8/30/24. I should have immediately investigated it to prevent further fraudulent charges being made. On 9/4/24 at 11:45 AM, V2 (AIT) stated (V2) and (R46) spoke with the Social Security's office on 9/3/24. During the phone call V2 stated it was determined that R46 does have a pre-paid social security card and that there have been fraudulent charges being made. V2 stated, The social security's office stated they could only see August and September's 2024 charges. On 8/5/24 a fraudulent charge was made in the amount of 75.00 dollars and on 9/1/24 two fraudulent charges were made, one in the amount of 77.95 dollars and one in the amount of 0.75 cents. The local police have not been notified by me or anyone at the facility of (R46's) fraudulent charges on his pre-paid social security card. V2 verified she did not immediately investigate the alleged allegation on 8/30/24 of V4/BOM having R46's pre-paid social security card with fraudulent charges being made and should have. The Immediate Jeopardy started on 6/20/24 when V3 (Prior AIT) did not do an investigation or suspend V4, after R75 reported fraudulent charges from her debit card that was in possession of V4 (BOM). V1 (Regional Director) and V2 (AIT) were notified of the Immediate Jeopardy on 9/5/24 at 1:34PM. This surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 7/30/24 V4 (Business Office Manager) was suspended and has not worked at (the facility) since. 2. V3 (Prior Administrator in Training/(AIT) last day at the facility was 7/8/24 and V6 (Prior Administrator's) last day at the facility was 7/31/24 confirmed by V2 (AIT). 3.On 8/8/24 V2 (AIT) was educated by V1 (Regional Director) on the Abuse Policy and Procedures with an emphasis on two-hour reporting window to (State Agency), notifying the responsible party, doctor, and local police. 4.On 9/3/24 V2 (AIT) and on 9/6/24 V20 (Business Office Manager/Social Service Director) were both in-serviced by V1 (Regional Director) on how the resident trust fund is supposed to work and procedures on handling the resident's cash. On 9/9/24 at 9:20 AM V21 (Housekeeper) was in the facility's break room and stated, I do not recall being in serviced on Abuse or the steps to take if I did not feel the abuse coordinator handled an abuse allegation appropriately. On 9/9/24 at 9:55 AM V23 (Certified Nursing Assistant) stated over the phone, I have not been in-serviced on any of the abuse policy and procedures in a very long time. I just worked last night 9/8/24. On 9/9/24 at 10:20 AM V26 (Agency Registered Nurse/RN) was at the nurse's desk and stated, I have not been in-serviced on the abuse policy and procedures since I have worked here. This surveyor reviewed the in-service sheet from 8/10/24 and 9/6/24 on the abuse policy and procedures and the staffing schedules. It was determined that V22 (Dietary), V24 (Certified Nursing Assistant), and V25 (Certified Nursing Assistant) signatures were not on the Abuse in-service sheets. On 9/9/24 at 1:30 PM V1/Regional Director stated, I spoke with V27 (Resident Care Coordinator) when I was writing the removal plans and V27 confirmed that all employees were in-serviced on abuse policy and procedures on 8/10/24. On 9/6/24 I realized that not all employees were in-serviced so I in-serviced more employees on 9/6/24. I specifically told V2 (AIT) that no one could work until they had been in-serviced on abuse policy and procedures. I did not realize all employees have not been in-serviced yet. On 9/9/24 at 2:00 PM V2 (AIT) verified that V21 (Housekeeper), V22 (Dietary), V23(Certified Nursing Assistant), V24 (Certified Nursing Assistant), V25 (Certified Nursing Assistant), and V26 (Agency RN) had not been in-serviced on the Abuse Policy and Procedures on 8/10/24 or after. V2/AIT stated, I did not realize how the process worked, so not everyone got in-serviced on abuse policy and procedures. Due to all staff not being in-serviced on the abuse policy and procedures on 8/10/24 or prior to their shift the facility's abatement plan was not completely executed on 9/6/24 as documented by the facility. Therefore, the immediacy could not be removed on 9/6/24. On 9/10/24 the facility completed all measures on the abatement plan, including providing in-servicing to all the staff on abuse policy and procedures and notifying all responsible parties of the residents in the facility of the misappropriation of funds, therefore the abatement plan could be approved on 9/10/24. Completion Date: 9/10/24.

Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions, develop a pressure ulcer care plan, and failed to perform daily skin checks for one of two residents (R36) reviewed for pressure ulcers in the sample of 29. These failures resulted in R35 developing a facility acquired unstageable pressure ulcer to the right heel that required surgical debridement and R35 developing a stage three pressure ulcer to the right buttock. Findings include: The Pressure Sore Prevention Guidelines policy dated 3/16/23, documents Policy: It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. Responsibility: all nursing staff and the dietary manager. Interventions/Comments for High-Risk residents. Special Mattress/Specify type of mattress on the Care Plan. Daily Skin Checks/follow protocol for coding skin conditions. Interventions/Comments for High or Moderate Risk residents: Turn and reposition every two hours. Turning and positioning may be more often than every two hours for high risk, if indicated. Care Plan Entry/Skin risk and appropriate interventions are to be placed on the Care Plan. If despite interventions a pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of Pressure Ulcers. Interventions/Comments as needed for High or Moderate Risk residents. Positioning Devices/Devices while in chair or in bed as needed to maintain turning. Specify on Care Plan. Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse. R36's Admission Nursing Evaluation dated 1-5-24 documents R36 was admitted to the facility with a femur fracture and was admitted with no pressure ulcers or wounds. R36's Braden Scale (assessment used to determine pressure ulcer risk) dated 1-16-24 documents R36 was at risk for developing pressure ulcers, was chair fast, was slightly limited on the ability to change, and control body position and had a potential problem with friction and shearing. This same assessment documents R36 had no pressure ulcers at that time. R36's Braden Scale dated 4-19-24 documents R36 was at high risk for developing pressure ulcers, was slightly limited on the ability to change and control body position, had a potential problem with friction and shearing, and had a pressure ulcer present with the seven days prior to the Braden Scale assessment dated of 4-19-24. R36's MDS (Minimum Data Set) Assessment Section C Cognitive Patterns dated 3-26-24 documents R36 is cognitively intact. R36's Wound Assessment Progress Note dated 3-6-24 and signed by V15 (Wound Nurse Practitioner) documents, Right heel pressure ulcer. Etiology: Pressure. Stage: Unstageable. Wound Size: 3.0 cm (centimeters) by 3.5 cm by 0.1 cm. 100 percent eschar (dead tissue). Exudate Type Amount and Type: Scant Sanguineous (blood tinged drainage). Pressure ulcer right buttock. Etiology: Pressure. Stage three. Wound Size: 1.5 cm by 2.0 cm by 0.1 cm. Exudate Amount and Type: Scant Sanguineous. 60 percent granulation (new tissue) and 40 percent slough (dead tissue cells). Notes: Float heels during the day with off-loading bootie, continue routine turning protocol, utilize wheelchair cushion, and perform swift incontinence management. R36's Weekly Wound Tracking dated 5-1-24 documents R36 has a stage three facility acquired stage III pressure ulcer to the right heel that developed on 3-1-24 and on 5-29-24 measured 0.5 cm by 0.5 cm by 0.3 cm depth with 80 percent granulation tissue and 20 percent slough. R36's Wound Assessment Progress Note dated 5-29-24 and signed by V15 documents, Right heel pressure ulcer. Etiology: Pressure. Wound Size: 0.5 cm by 0.5 cm by 0.3 cm. 80 percent granulation and 20 percent slough. Exudate Type Amount and Type: Moderate Sanguineous. 100 percent surgical debridement performed. R36's Physician's Order Sheets dated 6-2-24 documents R36 has the following treatment order: Order date 5-29-24 cleanse right heel with wound cleanser and apply medi-honey and calcium alginate every day and cover with island border gauze dressing every days shift every two days. R36's 5-14-24 Care Plan does not include an individualized care plan to address R36's pressure ulcer development to the right heel and right buttock with goals or interventions to treat and prevent worsening R36's pressure ulcer to the right heel and prevent further pressure ulcer development. R36's Treatment Administration Record dated 3-1-24 (date of development of pressure ulcer to right heel) through 6-5-24 were reviewed and do not include documentation of the staff performing daily skin checks. On 6-2-24 at 7:44 AM R36 was sitting in her chair with her legs elevated. R36 had a pressure relieving boot to the right foot. R36 stated, I got a wound to my right heel and butt and didn't know it. I did not have boots before, and the staff were not elevating my heel off of the bed. I got a sore on my butt too from lying in bed too long. There was not enough staff to turn me when I got here. When I was admitted a had a broken femur to my right leg and had a leg brace on that went down to my ankle. The brace did not cover my heel. I could not turn myself or raise my leg up without help. On 6-4-24 at 10:45 AM V20 (Agency RN/Registered Nurse) provided pressure ulcer treatments to R36's right heel. V20 removed the dressing to R36's right heel and cleansed the heel with normal saline. The dressing had a moderate amount of sanguineous drainage on it. R36's right outer heel had a pressure ulcer approximately 0.5 cm by 0.5 cm by 0.3 cm. with new white tissue cover almost 90 percent of the wound and 10 percent of mushy yellow slough covering the rest of the wound. V20 applied medi-honey and calcium alginate to the wound and covered the wound with a four-by-four bordered gauze. On 6-3-24 at 1:00 PM V17 (CNA/Certified Nursing Assistant) stated, When (R36) was first admitted she had a brace to her right leg. (R36's) right heel was exposed. (R36) did not have heel protectors on before she developed the wound to her right heel. On 6-3-24 at 1:33 PM V4 (Resident Care Coordinator) stated, (R36) does not have a plan of care to address (R36's) pressure ulcers. I am not responsible for (R36's) care plan development. When (R36) was admitted to the facility she had a brace to her right leg and the right heel was exposed. (R36) did not have a cast when admitted . (R36) should have had heel protectors on while in bed when she was admitted . (R36's) pressure ulcers were caused from pressure and developed in-house. (R36's) butt ulcer did end up healing. The staff did not do daily skin checks once (R36) developed a pressure ulcer and should have.

Based on interview and record review the facility failed to follow a physician order and schedule a sonogram for 1 resident (R1) of 3 residents reviewed for diagnostic services. This failure resulted in the resident's treatment being delayed, causing him prolonged pain and a subsequent return visit to the emergency room for further treatment. Findings include: The Resident Rights Booklet/Policy dated 11/18, documents You have a right to dignity and respect. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your rights to safety. Your facility must provide services to keep your physical and mental health, at their highest levels. On 10/19/23 at 4:17 PM, V8 (emergency room Doctor) stated that R1 has been to the hospital several times and she was familiar with R1. On 10/12/23, R1 was crying in pain and was not his usual self. R1 was to have an ultrasound on 9/13/23 and it was not done. The facility was called, and an unknown nurse said that the order was missed. R1 has been suffering because he got an infection. R1 had pain due to getting an infection in both testicles and the gland above the testicles. Typically, only one side is affected but since R1 was not treated both sides were affected. R1 was treated in the emergency room /ER and returned to the facility the same day. On 10/20/23 at 2:33 PM, V10 (V9's Office Nurse) stated that V9 (R1's Primary Care Physician) ordered R1 to have an ultrasound done on 9/13/23 for scrotum pain. The ultrasound was not done until 10/12/23 at the hospital. On 10/20/23 at 3:08 PM, V9 (R1's Primary Care Physician) stated that he had ordered the sonogram of R1's testicles 9/13/23 due to R1 complaining of pain in his scrotum. R1 probably had an infection that could have been detected with the sonogram. It would have been beneficial to know so an antibiotic could have been started sooner. It may have prevented R1 from having to go to the hospital. On 10/20/23 at 3:13 PM, V3 (Interim Director of Nursing/Regional Quality Control) stated that if the sonogram had been done as ordered it could have prevented R1 from having pain and needing to go to the emergency room . Since there was an order, the sonogram should have been done right away. On 10/20/23 at 3:43 PM, V7 (Assistant Director of Nursing) stated that V9 (R1's Primary Care Physician) did put the order in on 9/13/23 for R1 to have a sonogram for scrotal pain. The sonogram was not scheduled but it should have been. On 10/20/23 at 4:25 PM, V12 (Previous Director of Nursing) stated that she had given her notice in August to leave the facility at the end of September 2023. There were a lot of things that happened at the facility after she gave her notice that she was not aware of. V12 was aware that R1 was complaining about his penis and scrotal pain. V12 did not know that V9 (R1's Primary Care Physician) had examined R1 and that V9 had ordered a sonogram of R1's testicles. V12 also stated The sonogram should have been arranged immediately when (V9) ordered it. On 10/20/23 at 5:30 PM, V21 (Certified Nursing Assistant) stated that she was working on the day R1 went to the hospital (10/12/23). R1 was in the bathroom and put his call light on for help. R1 was complaining of a lot of pain in his private area. V21 helped R1 to bed and got V23 (Agency Licensed Practical Nurse). V23 assessed R1 and immediately called the ambulance to take R1 to the hospital. On 10/21/23 at 12:32 PM, V23 (Agency Licensed Practical Nurse) stated that on 10/12/23 R1 was crying and in pain. It was odd behavior for R1. V23 sent R1 to the ER and shortly after he got there an emergency room Nurse called to ask about a test that R1 was supposed to have had and wanted to know the results. V23 found where the doctor had ordered the sonogram on 9/13/23 but did not see that it was done. V23 took the order to V2 (Administrator in Training) to see if it had been scheduled and V2 did not know. On 10/21/23 at 1:00 PM, V4 (Transportation/Previous Business Office Manager) stated that at the beginning of this week she was assigned to do the transportation. The previous transportation person went back to working the night shift as a Certified Nursing Assistant about a month ago and there was not a specific person assigned to do the job. There was no scheduler, and the nurses have no idea what they are supposed to do to schedule an appointment. V4 also stated that she did not hear that R1 was to have a sonogram done until she heard V23 (Agency Licensed Practical Nurse) talking about the hospital calling to see if it was done. On 10/21/23 at 3:20 PM, V1 (Administrator/Regional Manager) stated that after the nurse confirmed the order for the sonogram a Trip Ticket should have been left for the Director of Nursing so the appointment could be scheduled. Usually, the transport person does the scheduling and then takes the resident to the appointment. Until recently there has not been an assigned transport person. V1 also stated that there is no policy on scheduling the appointments the staff should just follow what the doctor orders. On 10/21/23 at 3:40 PM, R1 stated that he went to the hospital because he Hurt really bad. R1 motioned towards his groin stating, It was all red and gave me pains. R1's Nursing Note dated 9/13/23 at 5:41 PM, documents (V9/R1's Primary Care Physician) here on rounds, new order for a sonogram of scrotum, d/t (due to) scrotal pain. R1's Order Audit Report dated 10/20/24 at 3:38 PM, documents on 9/13/23 at 4:13 PM, there was an order put in by V9 (R1's Primary Care Physician) for a sonogram of the scrotum for scrotal pain. The order was confirmed by V7 (Assistant Director of Nursing) on 9/13/23 at 5:40 PM. The Facility Appointment Book for 2023 was reviewed from 9/13/23 to 10/12/23 and did not have R1 scheduled for an appointment to have a sonogram. R1's Nursing Note dated 10/12/23 at 2:12 PM, documents that R1 has not been feeling well over the last few days. V9 (R1's Primary Care Physician) was notified on 10/11/23 and wanted a Urinary Analysis/UA with Culture and Sensitivity. The UA came back and was normal. Today R1 is complaining of overall not feeling well, burning with urination, pain with urination, and slightly weak. R1 requested to go to the hospital. R1 is weak, pale, clammy, and in tears. Emergency Medical Services were called and R1 will be going to the hospital. R1's Nursing Note dated 10/12/23 at 4:19 PM, documents that R1 is returning to the facility from the emergency room /ER. The ER did a sonogram and R1 has epididymitis. R1 will discharge to the facility on an antibiotic. R1's Nurses Clinical Report (from the hospital) written by V11 (emergency room Nurse) dated 10/12/23 at 5:31 PM, documents that R1 arrived at the emergency room /ER on 10/12/23 at 2:22 PM. The Chief Complaint was Pain with urination. R1 reported chills and a generalized feeling of unwell. R1 also reported he had one emesis today (10/12/23). Physical Assessment- Abdominal tenderness in the suprapubic area and burning with urination that is associated with frequency. It was noted in R1's chart from the facility that R1 had a Testicular Sonogram ordered on 9/13/23. V11 called the facility to obtain the results and (unknown nurse) reported R1 does have an order for the sonogram, but it has not been completed. Hospital Nursing Notes - R1's testicles also assessed with V8 (emergency room Doctor). There were no enlargement present, mild redness noted, moderate tenderness to R1's right testicle, and mild tenderness to his left testicle. At 3:30 PM, a testicular sonogram was done at R1's bedside. At 3:47 PM, (R1) attempted to urinate and is unable to at this time. R1 was given Naproxen 500 milligrams/mg and Levaquin 500 mg in the ER. At 4:11 PM, V11 called the facility and gave report to V23 (Agency Licensed Practical Nurse) and R1 was discharged to the facility at 4:45 PM. R1's Physicians Clinical Report (from the hospital) written by V8 (emergency room Doctor) dated 10/12/23 at 8:17 PM, documents that R1 arrived at theER on [DATE] at 2:22 PM. Chief Complaint: Dysuria. R1 has had discomfort with urination and the problem is described as moderate. R1 is a well-known patient to the ER. R1 is tearful today which is not his usual self. Labs and a Testicular Sonogram were done. Impression: Hyperemia of the bilateral testicles and epididymis suggestive of bilateral epididymitis and orchitis. Course of Care: Review of (the facility) records show that (R1) had a testicular ultrasound ordered on 9/13/23 by (R1's Primary Care Physician). These results were not in our system, so we contacted (the facility). Spoke with (unidentified nurse) at (the facility) and asked if they had results of the sono (sonogram). Nurse reported that she did see the order when she looked for it after we asked about it but that it appeared that it was missed previously and never completed. R1 was given his first doses of medication in the ER. R1 was discharged back to the facility with Levaquin 500 mg and Naproxen 500 mg for pain. R1's Hospital Prescription dated 10/12/23, documents an order for Levaquin 500 milligrams/mg to be taken every 12 hours for 10 days and Naproxen 500 mg to be taken every 12 hours for 10 days as needed for pain.

Based on observation, interview, and record review, the facility failed to ensure a resident was repositioned in a safe manner, assess pain, and provide pain medication in a timely manner for one of three residents (R1) reviewed for injury in the sample of three. This failure resulted in R1 sustaining a fractured humerus, severe pain and mental anguish. Findings include: The facility's Limited Lift Resident Handling Policy and Procedures (undated) documents the following: Moving a Resident Up In Bed: 4. Use a friction reducing device or draw sheet and work in unison with co-worker to slide the resident up in bed. The facility's Pain Prevention and Treatment policy (revised 12/7/17) document the following: 2. Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response, and 3. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., arthritis, wounds, fractures, etc.). R1's medical records document the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's current care plan documents she is dependent on staff for cares, uses a bariatric bed, and Ensure lift sheet is intact and correct size for resident. R1's Report of Monthly Weight and Vitals document her June 2022 weight as 225.2 pounds. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 understands, is understood, is moderately cognitively impaired, requires extensive assistance with bed mobility and is totally dependent on staff for transfers. On 6/29/22 at 11:20am, incontinence care and repositioning were provided for R1 by V4, V14, and V15, Certified Nursing Assistants (CNA), and R1 winced and cried due to pain from movement of her right arm/shoulder. At this time, R1 stated her right arm/shoulder pain is so bad it makes her nauseated, upset, and she cries a lot, and rated her pain as a 10 out of 10 on the pain scale (a score of 10 being the worst pain). R1 stated on 6/21/22 before supper, V10 and V13, Certified Nursing Assistants (CNA), pulled her up in bed by placing their hands/arms under her armpits and pulling her up in bed. R1 stated she screamed and cried because her right arm/shoulder hurt so bad, she had excruciating pain, and she heard her shoulder pop. R1 stated her right arm doesn't go anywhere, just hangs since her stroke that affected her entire right side. R1 stated the Certified Nursing Assistants (CNA) (V10 and V13) said there was not enough sheet for them to grasp and slide her up in bed, so they reached under her armpits and pulled her up towards the head of the bed. R1 stated she heard her shoulder pop, she had excruciating pain, she cried, and screamed. R1 stated they had never moved her like that before and when they put their hands under her arms, she said That arm won't move (right arm)!, but before she could get the words out to request to not move her that way (with their hands/arms under her armpits), they did it anyway. R1 stated that they did it so fast she couldn't say No!. R1 again stated the pain in her right shoulder that night was so bad that she cried, screamed, and felt nauseous. R1 stated she told V10 and V13 she wanted to see a nurse, and V10 went out of the room and then returned saying The nurse is too busy. The abuse investigation dated 6/22/22 for R1 documents on 6/21/22 before the supper meal, approximately between 4:00pm-4:30pm, V10, Certified Nursing Assistant (CNA) and V13, CNA, pulled R1 up in bed by placing their hands and arms under R1's armpits and pulling. The report documents R1 stated she heard a pop and started to cry more. The investigation documents V1, Administrator, was notified of the allegation of abuse at approximately 11:00pm, by V8, Licensed Practical Nurse (LPN), who called V1 on the phone. The investigation also documents V1's interview with R1 about the incident on 6/22/22 in which V1 stated During the explanation, R1 had to stop and calm down from crying multiple times, and R1 requested that V13 not be allowed in her room anymore. R1's right humerus X-ray dated 6/22/22 documents Sclerotic density of humeral neck with mild irregularity of cortex compatible with acute impacted fracture or old healed fracture. Correlate clinically for point tenderness. R1's Nurse's notes document the X-ray was performed at 2:00am on 6/22/22. R1's Orthopedic Consultation on 7/1/22 with V18, Orthopedic Surgeon, documents R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/7/22 at 9:23am, V18, Orthopedic Surgeon, stated A proximal humerus fracture is a very painful injury, especially initially- it is a painful injury. On 6/29/22 at 1:34pm, V10, CNA, stated on 6/21/22 she and V13, CNA, pulled R1 up in bed by placing their hands under her arms and pulling her up. V10 stated as soon as they did this, R1 started screaming and crying more and saying, My arm is broken, something's broke! V10 stated she went right out of R1's room and told a nurse (does not remember which nurse) about the incident, and that R1 thought her shoulder was broken. V10 stated R1 was crying and screaming at them (V10, V13) throughout the procedure, and against my better judgement, I pulled her up using my hand under her right armpit. (V13) helped me. This was a busy time, and a lot of call lights were going off. V10 stated it is not her usual practice to pull a resident up in bed by placing her hands and arms under a resident's armpits. On 6/29/22 at 2:22pm, V13, CNA, stated she assisted V10 with pulling R1 up in bed by placing her arms under R1 armpits and pulling R1 up in bed. V13 stated R1 was yelling and screaming prior to pulling her up in bed, that R1 was mad about her pencils being moved, but as soon as they did pull her up in bed, she screamed even more and cried and stated her arm popped. V13 stated the lift sheet was completely underneath R1, and they couldn't get any hold on it, so they put their arms under her armpits and pulled her up. V13 stated (R1) screamed even more, crying and saying her arm or shoulder popped. When she's having these behaviors-screaming and yelling and crying, we just wanted to get her done as quickly as possible. On 6/29/22 at 1:55pm V7, Licensed Practical Nurse (LPN)/the nurse assigned to take care of R1 on second shift 6/21/22, stated I saw R1 earlier in the shift (before the incident) when I checked her pain scale, but I didn't see her after that. Later in the shift, a CNA told me R1 was having screaming and yelling behaviors and R1 didn't want anyone to come into her room. I'm not sure what or why R1 was upset that day, except about her pencils (being moved). It was not reported to me that (R1) had hurt her arm/shoulder or that it had popped. On 6/29/22 at 2:15pm, V2, Registered Nurse (RN) who worked 6/21/22 on second shift, stated I was not assigned to care for R1 on 6/21/22. I heard (R1) yelling and screaming. I did not go into her room. On 6/29/22 at 2:01pm, V8, LPN/third shift nurse, stated About 11pm (on 6/21/22) I saw (R1) in her room, she was crying very hard-when I finally got her to calm down so I could understand her, she stated two CNAs had lifted her by her arms. I called and spoke to V1, Administrator. I didn't see anything unusual (on R1's arm/shoulder), but there was a large area in her right upper and mid to lower arm that was very painful to palpation. I paged the doctor and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/29/22 at 12:00pm, V2, Director of Nursing, stated that it is not appropriate to pull a resident up in bed by putting your hands/arms under their armpits. A faxed physician communication regarding R1 dated 6/23/22 documents (R1) cont (continues) to c/o (complain of) pain to R (right) shoulder. She does not have a PRN (as needed) order for pain. V3, R1's Primary Care Physician (PCP), responded to the request on 6/23/22 with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The faxed response sheet documents the response and new order was Noted 6/24/22 by V7, Licensed Practical Nurse (LPN), and C2 (Controlled substance, Schedule Two) form faxed to PCP (V3). On 6/29/22 at 12:00pm, V2, Director of Nursing (DON), stated (V3, PCP), gave an order on 6/24/22 for [MEDICATION(S)] 5/325mg (prn) for R1's pain from her fractured shoulder. After (the surveyor) asked about (R1's) pain management, we looked and found that order and the medication is not here. On 6/28/22 V9, RN, noted that it had not yet been delivered, but did not follow up until today (6/29/22). We did not know that R1 was in so much pain until (the surveyor) told us R1 reported her pain as a ten on a scale of one to ten (ten being the worst). At this time V2 stated the [MEDICATION(S)] is available in their convenience box in the facility. On 6/29/22 at 12:00pm, R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Pain Management Flow Sheet (to be completed each shift) from 6/21/22-6/29/22 documents the following: 6/21/22 no pain on any shift; 6/22/22 second shift documents yes for pain but records no location, intensity, or intervention; 6/23/22 first and third shift no pain, second shift not completed; 6/24/22 third shift not completed, no pain on first shift and second shift documents pain in arm and shoulder, rates it as three on a scale of one to five, and interventions provided; 6/25/22 and 6/26/22 no pain; 6/27/22 no pain on first and third shift and second shift not completed; 6/28/22 third shift not completed and first and second shift no pain; and 6/29/22 third shift not completed and no pain on day shift. On 6/29/22 at 12:00pm, V2, DON stated R1's Pain Management Flow Sheets are not being filled out correctly by the nurses, and that (R1's) flow sheet has many blanks. V2 stated there is only one entry (6/24/22 on 2nd shift) after the incident (of 6/21/22) which documents R1's pain and interventions.

Based on observation, interview, and record review, the facility failed to assess pain and provide pain medication to one of three residents (R1) reviewed for pain in the sample of three. This failure resulted in R1 sustaining severe pain and mental anguish from a fractured humerus without benefit of an as needed pain medication from 6/22/22-6/28/22. Findings include: The facility's Pain Prevention and Treatment policy (revised 12/7/17) document the following: 2. Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response, and 3. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., arthritis, wounds, fractures, etc.). R1's medical records document the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's abuse investigation report dated 6/21/22 documents R1 was injured when being pulled up in bed when V10 and V13, Certified Nursing Assistants (CNA) pulled her up in bed by hooking their arms through her armpits and pulling her up. The investigation documents that R1 screamed and cried when she was pulled up in bed. R1's X-ray of her right humerus dated 6/22/22 documents Sclerotic density of humeral neck with mild irregularity of cortex compatible with acute impacted fracture or old healed fracture. Correlate clinically for point tenderness. R1's Orthopedic Consultation on 7/1/22 with V18, Orthopedic Surgeon, documents R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/7/22 at 9:23am, V18, Orthopedic Surgeon, stated A proximal humerus fracture is a very painful injury, especially initially- it is a painful injury. On 6/29/22 at 9:55am, R1 stated on 6/21/22 before supper, V10 and V13, Certified Nursing Assistants (CNA), pulled her up in bed by placing their hands/arms under her armpits and pulling her up in bed. R1 stated she screamed and cried because her right arm/shoulder hurt so bad, had excruciating pain, and she heard her shoulder pop. R1 stated the pain in her right shoulder was so bad she cried and felt nauseous. R1 stated she continues to have severe pain in her right arm and shoulder that is so bad it makes her nauseous, and she cries and screams whenever she has to move. On 6/29/22 at 2:01pm, V8, Licensed Practical Nurse (LPN)/third shift, stated when she assessed R1 on 6/21/22 at 11:00pm, R1 had a large area in her right upper and mid to lower arm that was very painful to palpation. R1's Nurse's Notes dated 6/21/22 written by V8 documents having lots of pain in right arm. On 6/29/22 at 11:20am, V4, V14, and V15, CNAs, provided incontinence care and repositioning for R1. R1 was turned side to side, and a lift sheet was used to pull R1 up in bed. R1 cried, grimaced, and moaned as she was repositioned. At this time, R1 stated the pain in her right arm and shoulder was so bad that it makes her nauseated and rated it a 10 out of 10 on a pain scale of one to ten, with ten being the worst pain. V4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A faxed physician communication dated 6/23/22 documents Res (resident) cont (continues) to c/o (complain of) pain to R (right) shoulder. She does not have a PRN (as needed) order for pain. She cont to have [MEDICATION(S)] scheduled. V3, R1's Primary Care Physician (PCP), responded to the request on 6/23/22 with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The faxed response sheet documents the response and new order was Noted 6/24/22 by V7, Licensed Practical Nurse (LPN), and C2 (Controlled substance, Schedule Two) form faxed to PCP (V3). On 7/1/22 at 2:00pm, V16, Registered Nurse (RN)/ V3 PCP Office, stated The facility faxed us a request for pain medication (for R1) on 6/23/22, and I faxed back the order on 6/23/22. The facility called us on 6/29/22 telling us the medication ([MEDICATION(S)]) had not been received. The facility sent us the C2 (Controlled substance, Schedule II) form to be completed and sent to (Pharmacy) on 6/24/22 at 9:52pm (A Friday night). We are not in the office then, and we didn't return to the office until Monday (6/27/22). We don't see faxes sent Friday evening or over the weekend until Monday- and our clinic hours are from 1:30pm to 5pm. 6/27/22 we were back in the office but did not hear anything from the facility as far as the [MEDICATION(S)] not being delivered. The facility should have called or paged (V3) over the weekend for the medication. On 6/29/22 at 12:00pm, V2, Director of Nursing (DON), stated (V3, PCP), gave an order on 6/24/22 for [MEDICATION(S)] 5/325mg (prn) for R1's pain from her fractured shoulder. After (the surveyor) asked about her pain management, we looked and found that order and the medication is not here. We contacted V3 and he said he signed the order for it and his staff faxed it to the pharmacy. Today (6/29/22) the pharmacy stated the order for the [MEDICATION(S)] was not received. Today (6/29/22) we sent another request/order for V3 to sign and fax to the Pharmacy. On 6/28/22 V9, RN, noted that it had not yet been delivered, but did not follow up until today (6/29/22). We did not know that R1 was in so much pain until (the surveyor) told us R1 reported her pain as a ten on a scale of one to ten (ten being the worst). V2 also stated [MEDICATION(S)] is available on site at the facility in the convenience box. On 6/29/22 at 12:00pm, R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Pain Management Flow Sheet (to be completed each shift) from 6/21/22-6/29/22 documents the following: 6/21/22 no pain on any shift; 6/22/22 second shift documents yes for pain but records no location, intensity, or intervention; 6/23/22 first and third shift no pain, second shift not completed; 6/24/22 third shift not completed, no pain on first shift and second shift documents pain in arm and shoulder, rates it as three on a scale of one to five, and interventions provided; 6/25/22 and 6/26/22 no pain; 6/27/22 no pain on first and third shift and second shift not completed; 6/28/22 third shift not completed and first and second shift no pain; and 6/29/22 third shift not completed and no pain on day shift. On 6/29/22 at 12:00pm, V2, DON, stated the Pain Management Flow Sheets are not being filled out correctly by the nurses, and that (R1's) flow sheet has many blanks- there is only one entry (6/24/22 on 2nd shift) after the incident (of 6/21/22) which documents pain and interventions. V2 stated she will have to retrain the nurses to use the pain management flow sheets correctly. On 7/6/22 at 12:26pm, V3, R1's Primary Care Physician, stated R1 should have received the [MEDICATION(S)] for her pain management before 6/29/22 since he ordered it on 6/23/22, and the facility should have followed up on the medication not being sent by pharmacy before 6/29/22.

Based on interview, observation and record review, the facility failed to ensure pain management was implemented for one of one resident (R157) reviewed for pain in the sample of 32. This failure resulted in R157 vocalizing and experiencing pain with facial grimicing causing difficulty with therapy and activities. Findings include: The facility's Notification for Change in Resident Condition of Status policy (dated 07/01/19) documents the following: The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: Any symptom, sign or apparent discomfort that is: Sudden in onset; A marked change (i.e. more severe) in relation to usual signs or symptoms; Unrelieved by measures already prescribed. R157's Pain Assessment (dated 05/03/19) documents the following: R157 reported almost constant pain in the past 5 days that has made it hard to sleep at night, and limited her day-to-day activities. This same assessment documents R157 rated her worst pain over the last 5 days a 10/10, with the intensity of her pain, very severe/horrible. R157's Pain Management Flowsheet (dated 05/04/19 - 05/07/19) documents the following: R157 rated her pain a 5/10 on 05/04/19; No pain assessment was conducted on 05/05/19; and no pain rating was documented when R157 reported pain on 05/07/19. On 05/07/19 at 10:30 AM, R157 was sitting in a chair in her room. R157 had a [DEVICE] sitting nearby R157's chair. R157 stated that R157 has a wound in her right groin area, and has a [DEVICE] in place to help it heal. R157 stated They inserted the [DEVICE] yesterday, and it hurt really bad. I'm in a lot of pain. R157 attempted to reposition herself in the chair several times, and was visibly uncomfortable with facial wincing and moaning noted with each attempt. R157 stated, I am in so much pain. It hurts to move. I had a few [MEDICATION NAME] tabs that came with me the day I admitted that I took for pain, and once I ran out, they haven't given me anything but a Tylenol, and that is just not helping. They are supposed to be checking on getting me some more [MEDICATION NAME], but I haven't had anything since Sunday. I'm in a lot of pain. I wish I would have had some [MEDICATION NAME] yesterday when they put that [DEVICE] in. It was awful. On 05/07/19 at 11:42 AM, V8 (Licensed Practical Nurse) stated, I haven't called the doctor yet, but (R157) needs something more for pain. She's in a lot of pain and only has a Tylenol ordered. I think they have sent out faxes to the doctor a couple of times the past couple days, but we haven't heard anything back yet. On 05/07/19 at 11:45 AM, V8 (Licensed Practical Nurse) stated, I called and left a message for the nurses at V13's (R157's physician) office since they don't get in the office today until 2:00 PM. (R157) came to the facility with a few [MEDICATION NAME] tablets when she was admitted , but ran out shortly after. She hasn't had anything more than a Tylenol since she ran out, and has been reporting pain for the past few days. She is in a lot of pain. She needs something else for pain control. On 05/07/19 at 01:17 PM, R157 was sitting in a wheelchair in her room participating in therapy with V14 (Physical Therapy). R157 stated she hasn't had any [MEDICATION NAME] since Sunday, and currently her pain level is, Pretty high. It makes therapy more difficult. V14 continued conducting R157's therapy and stated, (R157) is going to get OT (Occupational therapy) next. On 05/07/19 at 01:35 PM, V1 (Administrator) stated physician notification by nursing staff, Depends on what time of the day it is. If it's during the day, the nurses should be calling. If it is at night, there is a call system and the call system gets a hold of the physician on call. At this same time, V2 (Director of Nursing) stated, Sometimes the nurses send faxes, but should be speaking to a physician if a resident needs pain medication. V2 then verified that R157's physician should have been paged and notified in regards to R157's continued reports of pain, especially if staff has not received a response after faxes have been sent. V2 stated that R157 has gone without [MEDICATION NAME] pain medication since Sunday and stated, This is unacceptable.

Based on interview and record review, the facility failed to give the resident the opportunity to make the choice to remain in the facility, for one of five residents (R1) reviewed for Involuntary Discharge in the sample of 11. This failure resulted in R1, after residing at the facility for [AGE] years, to be transferred to another facility in Chicago away from family and against R1 ' s wishes. This transfer caused R1 emotional upset to the point where R1 refused medication and would not leave R1's room, only to be transferred yet again to another facility in Chicago. Findings include: The Facility's Involuntary Transfers and Discharge policy (date unknown), states Prior to transfer or discharge the Social Service Director shall counsel the resident and summarize the counseling session in the resident's record. R1's Physician order [REDACTED]. R1's Plan of Care last updated on 6/22/18, states (R1) is able to point and make gestures to make needs known; staff and residents understand (R1's) communication techniques. A Social Service progress note completed by V2 (Administrator in Training) dated 6/14/18, states (R1) was given notice of 30 day Involuntary Discharge due to physically assaulting another resident (on 6/13/18). (R1) said 'Bulls**t' and threw papers at me. Explained to (R1) that POA (Power of Attorney) is also aware of seeking appropriate placement and 30 day notice. (R1) became louder stating 'Bulls**t' and pushed papers out of my hands. Papers left on (R1's) bed. On 7/9/18 at 2:30 p.m., V3 (Administrator in Training) stated I didn't discuss the Involuntary Discharge Notice (ID) with (R1) anymore (after issuing the ID on 6/14/18). (R1) was able to make (R1's) needs known. I didn't specifically ask (R1) if (R1) wanted to remain in the facility. I only gave (R1) the discharge papers. R1's Medical Record dated 6/14/18 through 6/22/18 (date of discharge) does not contain documentation that R1 was counseled regarding the involuntary discharge or allowed the opportunity to express his desire to remain in the facility. On 7/9/18 at 2:10 p.m., V4 (Social Service Director) stated R1's record did not document attempts of counseling R1 regarding the Involuntary Discharge Notice or allowing (R1) the opportunity to communicate (R1's) desire to remain in the facility. On 7/10/18 at 10:31 a.m., V6 (Ombudsman) stated: I went to the facility to meet with (R1) on 6/18/18 to discuss (the Involuntary Discharge) with (R1). (R1) was very upset over the discharge and did not want to leave (R1's) home of [AGE] years. I have known (R1) for years and (R1) was definitely cognitively intact. (R1) was able to communicate with gestures and make (R1's) needs known. I have since gone to Chicago to see how (R1) was doing and (R1) was very unhappy at the new facility. (R1) cried and clearly let me know (R1) did not want to be there. I called there about a week later and the new facility told me that (R1) was not there but would not give me any details. On 7/10/18 at 11:05 a.m., V12 (Chicago Facility/Director of Nursing) stated (R1) was discharged from here on 6/29/18. (R1) was not happy here. (R1) was refusing most cares and would not take (R1's) medications. (R1) wouldn't talk to the staff. Other than being upset with the new environment (R1) had no other behaviors. Never did (R1) get physically aggressive. We were able to find (R1) another facility in Chicago. On 7/9/18 and 7/10/18, V4 (Social Service Director), V9 (Regional Ombudsman), V10 (New Facility/Social Service Director), V11 (R1 Family Member), V13, V14, V15 (Certified Nurse Aides), V16 and V17 (Licensed Practical Nurses) all stated that R1 was able to make R1's self understood with non-verbal communication and R1 was able to understand others.

Based on interview and record review, the facility failed to attempt behavioral interventions prior to issuing an Involuntary Discharge Notice and allow a resident to remain in the facility pending appeal of Involuntary Discharge Notice for one of five residents (R1) reviewed for Involuntary Discharge in the sample of 11. This failure resulted in R1, after residing at the facility for [AGE] years, to be transferred to another facility in Chicago away from family and against R1 ' s wishes. This transfer caused R1 emotional upset to the point where R1 refused medication and would not leave R1's room, only to be transferred yet again to another facility in Chicago. Findings include: R1's Physician order [REDACTED]. R1's Minimum Data Set (MDS) assessment dated [DATE], documents R1 is unable to ambulate and requires a wheelchair for locomotion. R1's Plan of Care last updated on 6/22/18, states (R1) is able to point and make gestures to make needs known; staff and residents understand (R1's) communication techniques. (R1) communicates by saying bulls**t, damn, and hand gestures. An Incident Report dated 6/13/18 at 5:45 a.m., documents R1 placed R6 in a choke hold around the neck and threw R6 to the floor from a dining room chair. R6 was not injured. The Incident Report documents a nurse immediately responded and separated the residents and R1 had 1:1 supervision until Emergency personal and Police arrived. R1 was sent to the local Emergency Department for evaluation and treatment for [REDACTED]. Local Emergency Department indicates no risk.; Discharge plan 6/13/18, POA aware of Involuntary Discharge with 30 day notice due to aggressive behavior displayed towards other resident; R1 to be 1:1 supervision until other placement located; R1 will not have a roommate until discharge; R1 had charges signed against him on 6/13/18; Facility to notify local Police Department when R1 is placed at another facility; POA is also currently seeking other placement. R1's plan of care was revised on 6/22/18 with the following: Transfer to Chicago. R1's Plan of Care does not document any further interventions were implemented regarding R1's one time physically aggressive behavior. A Notice of Involuntary Transfer and Discharge and Opportunity for Hearing dated 6/14/18, documents R1 was given a 30 day notice of Involuntary Discharge, citing the facility was seeking to discharge R1 to another facility due to the safety of individuals in this facility is endangered. The Notice of Involuntary Discharge cites R1's proposed transfer/discharge date as 7/14/18. A Social Service progress note completed by V2 (Administrator in Training) dated 6/14/18, states (R1) was given notice of 30 day Involuntary Discharge due to physically assaulting another resident (on 6/13/18). (R1) said 'Bulls**t' and threw papers at me. Explained to (R1) that POA (Power of Attorney) is also aware of seeking appropriate placement and 30 day notice. (R1) became louder stating 'Bulls**t' and pushed papers out of my hands. Papers left on (R1's) bed. R1's Medical Record and behavior monitoring sheets dated 1/1/18 through 6/22/18 (date R1 discharged ) does not document any physical behaviors towards others until 6/13/18. R1's Medical Record dated 6/14/18 through 6/22/18 (date of discharge) does not contain documentation that R1 was counseled regarding the involuntary discharge or allowed the opportunity to express his desire to remain in the facility. On 7/9/18 at 8:17 a.m., V1 stated R1 had never been physically aggressive towards another resident until 6/13/18. V1 stated R1 was placed on 1:1 supervision until (R1) was discharged to another facility on 6/22/18. V1 stated no other interventions were attempted prior to issuing R1 an Involuntary Discharge Notice. On 7/9/17 at 1:16 p.m., V5 (R1's primary physician) stated The facility staff told me (R1) had been physically aggressive prior to (R1's) altercation with another resident on 6/13/18. I asked them for the incident reports but they never did provide them to me. I have no knowledge of (R1) ever being physically aggressive and I've known (R1) for years. On 7/9/18 and 7/10/18, V4 (Social Service Director), V11 (R1 Family Member), V13, V14, V15 (Certified Nurse Aides), V16 and V17 (Licensed Practical Nurses) all stated they had no knowledge of R1 ever being physically aggressive towards others. Facility Incident Reports dated 3/7/18 (R11), 3/27/18 (R9, R10), and 5/17/18 (R8, R5), document resident to resident physical altercations. On 7/9/18 at 8:17 a.m., V1 (Administrator) stated the Involuntary Discharge was issued on 6/14/18 and the effective dated of the proposed discharge was 7/14/18. V1 verified that the discharge notice documents an appeal can be filed up to 10 days after receiving the Involuntary Discharge Notice. V1 stated R1 was discharged on [DATE]. V1 stated (V7/R1's Power of attorney) did not want to appeal the discharge. He was fine with it so we found (R1) a new facility and transferred (R1) with the approval of (V7). V1 was not aware if R1's medical record documenting any staff attempts to explain to R1 that (R1) had the right to appeal the discharge that was initiated by the facility. V1 stated the facility was not aware of V6 filing an appeal on behalf of R1 until after R1 was discharged . On 7/9/18 at 8:45 a.m., V1 (Administrator) stated there have been no Involuntary Discharges issued in the past year due to resident to resident altercations except for R1. On 7/9/18 at 11:04 a.m., V4 (Social Service Director) stated V4 had not discussed the opportunity to appeal the Involuntary Discharge with R1. V4 stated I only talked to (V7) about it. (V7) was fine with us sending (R1) to Chicago. R1's plan of care states (R1) communicates by saying bulls**t, damn, and hand gestures. (R1) is able to make gestures to make needs known; staff and residents understand (R1's) communication technique. The State Agency Notice of Prehearing Conference dated 6/20/18, documents a prehearing phone conference was scheduled for 6/27/18 at 10:00 a.m. On 7/10/18 at 10:31 a.m., V6 (Ombudsman) stated I received notification of (R1's) Involuntary Discharge via fax on 6/14/18. I went to see (R1) on 6/18/18 and talked to (R1) about the Involuntary Discharge Notice. (R1) was very upset about it and did not want to leave (R1's) home of [AGE] years. (R1) cannot cannot communicate verbally but R1 can definitely make R1's needs known through non-verbal communication. I have known (R1) for years and have no problems understanding R1). (R1) is cognizant enough to make decisions. (R1) did not want to move to another facility so I asked (R1) permission to file an appeal to the Involuntary Discharge. (R1) agreed to the appeal. I file the appeal with (the State Agency) on 6/19/18. (The State Agency) then sent all parties involved a Notice of Prehearing Conference which was scheduled for 6/27/18 at 10:00 a.m. When I arrived at the facility on 6/27/18 at approximately 9:00 a.m., I was told my staff that (R1) had been discharged on [DATE] to a facility in Chicago. The facility is not allowed to discharge a resident during the appeal process. (R1) was not given the opportunity to speak for (R1's) self and express (R1's) wishes. I have since gone to Chicago to see how (R1) was doing and (R1) was very unhappy at the new facility. (R1) cried and clearly let me know (R1) did not want to be there. I called there about a week later and the new facility told me that (R1) was not there but would not give me any details. On 7/10/18 at 11:05 a.m., V12 (Chicago Facility/Director of Nursing) stated (R1) was discharged from here on 6/29/18. (R1) was not happy here. (R1) was refusing most cares and would not take (R1's) medications. (R1) wouldn't talk to the staff. Other than being upset with the new environment (R1) had no other behaviors. Never did (R1) get physically aggressive. We were able to find (R1) another facility in Chicago. On 7/9/18 and 7/10/18, V4 (Social Service Director), V9 (Regional Ombudsman), V10 (Indian Head Park Nursing Home/Social Service Director), V11 (R1 Family Member), V13, V14, V15 (Certified Nurse Aides), V16 and V17 (Licensed Practical Nurses) all stated that R1 was able to make (R1's) self understood with non-verbal communication and R1 was able to understand others.

Based on record review and interview, the facility failed to prevent the deterioration of an existing pressure ulcer on the coccyx and failed to prevent the development of a new pressure ulcer on the heel for one of two residents (R2) reviewed for pressure ulcers, in the sample of 10 and failed to provide the physician ordered treatment to a pressure ulcer, for one of two residents (R3) reviewed for pressure ulcers, in the sample of 10. This failure resulted in R2's coccyx wound being left untreated for [REDACTED]. Findings include: Pressure Sore Prevention Guidelines dated 11/12 documents it is the goal of the facility To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. 2) The pressure ulcer will be assessed and documented on the Treatment Administration Record. i) document size, stage, site, depth drainage, color, odor, and treatment (upon obtaining from the physician). 4) Notify the physician for treatment orders. 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR. The assessment must include: i) Characteristic (i.e. size, shape depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to the treatment. Decubitus Care/Pressure Areas Policy dated 5/07 documents, To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. 2) The pressure area will be assessed and documented on the Treatment Administration Record (TAR). 4) Notify the physician for treatment orders. 1. A physician's orders [REDACTED]. The 10/02/17 physician's orders [REDACTED]. A Braden scale for predicting pressure ulcer dated 10/2/17 documents R2 is HIGH Risk for pressure ulcer, confined to bed, completely immobile (does not even make even slight changes in body or extremity position without assistance) and has very poor nutrition. Nursing admission assessment by E17 Licensed Practical Nurse (LPN) dated 10/2/17 at 3:45 p.m., under Skin Inspection, documents a Stage II wound to R2's left buttock measuring 2 cm (centimeters) x 1 cm x 0.3 cm and a Stage II wound to R2's right buttock measuring 3 cm x 1 cm x 0.5 cm. On 10/2/17 a shift report document, A/B (Hall) 24 Hour report documents O/A's (Open areas) on (R2's) coccyx, need treatment besides cream. Care Plan dated 10/2/17 documents, Offload pressure to buttock and heels; nurse to measure and monitor wound status progression and notify physician of changes and document response. The Weekly Wound tracking sheet for 10/06/17, documents R2's Coccyx wound had progressed to 11 cm x 5.4 cm, and was described as unstageable and deteriorating. On 10/06/17, 4 days after R2's admission with open buttock wounds, a telephone order was received from Z3 to begin treatment and cleanse the area with theraworx, apply hydrogel, cover with [MEDICATION NAME] island dressing, change daily and as needed. R2's October 2017 Treatment Administration Records fail to document weekly the size, stage, site, depth, drainage, color or odor, as directed per the Pressure Sore Prevention Guidelines and Decubitus Care/Pressure Areas Policy. On 10/25/17 at 3:50 p.m., E17 Licensed Practical Nurse (LPN) states (R2) had 2 small superficial wounds to the left and right buttock upon admission to the facility on [DATE]. The director of nursing is supposed to assess any wounds within 24 hours after admission and request orders or treatments from the primary physician. There were no new orders received for (R2) until after the wound became one big wound which was approximately 4 or 5 days after (R2) was admitted . On 10/26/17 at 9:50 a.m., E1 Administrator stated she assessed R2's buttock wounds within 24 hours of R2's admission, but failed to document the wound's appearance on the TAR or obtain physician's orders [REDACTED]. The Weekly Wound Monitoring report documents R2's buttock wound deteriorated as follows: On 10/10/17 - Coccyx wound 13 cm x 6 cm x 0.1 cm is unstageable and is deteriorating, on 10/17/17 - Coccyx wound 13 x 7 and is unstageable and is deteriorating, and on 10/24/17 - Coccyx wound measuring 12 cm x 8 cm and is unstageable. On 10/30/17 at 12:20 p.m., Z3 Physician stated I was notified of (R2's) wounds on 10/6/17, 4 days after (R2's) admission, at which time I ordered a treatment. I was not made aware on admission of (R2's) Stage II wounds to the buttocks. Additionally, Z3 stated, I should have been notified of (R2's) wounds upon admission in order to prescribe/suggest a treatment. I would not have expected (R2) to go 4 days with no wound treatment. On 10/30/17 at 1:15 p.m., E15 Nurse Practitioner (NP) states, I would have expected the primary physician to have been notified upon admission of (R2's) 2 Stage II wounds to (R2's) left and right buttock. I did not see (R2) until 10/10/17 and at that time the wound had progressed to one large wound measuring 13 cm x 6 cm x 0.1 cm with an area of 78 sq cm and the bed of the wound was covered 76-100% of dry black eschar. On 10/23/17 at 12:15 a.m., E4 (Certified Nursing Assistant) stated the facility has not been staffed appropriately on second shift the last few weeks. E4 stated on 10/16/17, they only had two CNAs in the facility for the first half of the shift (from 1:00 p.m. - 4:00 p.m.) and on two other dates they only had three CNA's for the entire second shift. E4 recalled 10/22/17 as one date, but could not recall the second date. E4 stated R2, who has a pressure ulcer on R2's bottom, needs to be turned and repositioned every two hours, but on nights where there were only 2-3 CNAs, R2 wasn't repositioned until the end of the shift, as it takes three staff to turn R2. On 10/24/17, during weekly wound clinic rounds, E15 NP was made aware of a new blister with clear fluid to R2's right heel. E15's progress notes dated 10/24/17 by E15 states new wound identified 3 days ago (10/21/17), is blister with clear fluid, skin is intact. Orders include: Apply skin prep daily and offload right and left heels at all times. Follow facility pressure ulcer prevention policy/protocol. On 10/25/17 at 7:30 a.m., R2 was resting in bed, right and left heels resting directly on the bed. On 10/25/17 at 9:15 a.m., E3 LPN confirmed that R2's right and left heels were not being correctly offloaded as ordered. On 10/26/17 at 8:00 a.m., E2 DON stated R2's right heel blister was acquired at the facility on 10/24/17. E2 stated the wound is a pressure ulcer and was caused by not offloading R2's heels as ordered. On 10/30/17 at 1:15 p.m., E15 NP stated I was made aware of a blister to (R2's) heel by (E3 LPN) during rounds. (E3) states the wound had been there for three days. The wound to (R2's) right heel measures approximately 3.5 cm by 3.5 cm and is an acquired pressure ulcer and a direct result of (R2's) heel resting directly on the mattress and not being offloaded as previously ordered. On 10/24/17 a Situation, Background, Appearance and Recommendation (SBAR) for R2 dated 10/24/17 states blister right heel measuring 4 cm x 4 cm, skin prep daily and offload heels at all times. Plan of Care revision Communication Form for R2 dated 10/6/17 and signed by staff states extensive assist of two, two hour repositioning and offload heels. Care Plan dated 10/2/17 states Offload pressure to buttock and heels; nurse to measure and monitor wound status progression and notify physician of changes and document response. 2. The facility policy, titled Decubitus Care/Pressure Areas (05/07), documents it is the facility's practice to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. A Profile Face Sheet documents R3 was admitted to the facility on [DATE]. A Braden Scale for Predicting Pressure Ulcer Risk, dated 7/15/17, identifies R3 as High Risk for skin breakdown. A Plan of Care (no date) documents R3 as at risk for skin breakdown per Braden Risk Assessment. Risk score high. Additional risk factors: DM (Diabetes Mellitus) Type 2, Obesity, Does not ambulate, Frequently Incontinent. A SBAR (Situation Background Appearance Recommendation) Communication Form, dated 8/18/17, documents R3 developed an open area to the coccyx, measuring 1.5 cm (centimeters) by 1.5 cm by 0.1 cm. A Nursing Note, dated 8/18/17 at 7:00 p.m., documents a treatment of [REDACTED]. On 9/12/17, Wound Progress Notes for R3 document R3's wound as a open Stage III Pressure Injury Pressure Ulcer, measuring 1.2 cm by 1.0 cm by 1.2 cm, with a new treatment order of cleaning the open area with wound cleanser and applying moisture barrier cream daily. The Treatment Administration Record documents no wound treatment for [REDACTED]. On 9/19/17, the weekly wound tracking report documents R3's Stage III coccyx wound measured 2.5 cm by 2.0 cm by 0.2 cm and as deteriorated. Wound Progress Notes on 9/19/17 documents, Wound is larger today, wound most likely aggrevated by frequent moisture. Per staff, (R3) is not very compliant with laying on her side. In the past, duoderm and boarder foams have not worked for her. She sits in bed and causes the dressing to roll up and exposes the wound. Reviewed the importance of laying on her side and how continuous pressure delays wound healing. Will change treatment to Zinc Oxide twice per day and as needed. Nursing Notes document R3 was discharged to the hospital on [DATE] and did not return to the facility. On 10/26/17 at 9:30 a.m., E2 (Director of Nursing) stated that R3's initial treatment order of a [MEDICATION NAME] dressing to the coccyx wound daily was received, but not transcribed to the Treatment Administration Record, so the first treatment to the coccyx wasn't completed until 8/24/17. E2 stated that the same error occurred with the change in treatment for [REDACTED].

Based on observation, record review and interview, the facility failed to do behavior tracking and care plan development, failed to anticipate potential behavioral changes after dosing changes in an anti-depressant and anti-psychotic and failed to educate staff on Dementia management for one of four residents (R1) reviewed with behaviors, in a sample of 15. This failure resulted in R1 being transferred to the emergency roiagnom on three different occasions when R1 exhibited behaviors towards staff, only to be sent back as stable thus causing overstimulation and excess stress on R1 and the facility attempting to Involuntarily Discharge R1. Findings include: The facility policy, titled Behavior Tracking Sheets (no date), documents Each form has the resident's name and target behaviors. Some residents have more than 2 behaviors addressed, so there may be more than one form. Some intervention are standard and resident specific interventions should be written on the form. The standardized interventions that may be appropriate for the resident should be highlighted. If you are aware of additional interventions that work, notify the Social Service/Psychosocial Director. Each shift should note the date and time of each targeted behavior. List the corresponding code/letter to the intervention you used. Code +, O, or - depending on the effectiveness of the intervention. The facility policy, titled Comprehensive Care Planning (05/01/16), documents It is the policy (of the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practicable physical, mental and psychosocial well-being. The Comprehensive Care Planning policy further documents, The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the resident. The facility policy, titled Abuse Prevention Program (11/28/16), documents employees are to receive training on Dementia management and resident abuse preventions; Including, how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff on a annual basis. A physician's orders [REDACTED]. A Pre-Screening/Screening Assessment for Harmful Behaviors form scored R1 as a Moderate Risk for harmful behaviors, secondary to a history of Talks about/threatens harm towards others and/or aggressive behaviors towards others, harboring considerable fears over separation from support system, and poor safety awareness and/or has poor judgement. A Minimum Data Set, dated dated [DATE], identifies R1 as having severe cognitive impairment. A physician's orders [REDACTED]. A Telephone Order, dated 3/20/17, documents R1 was prescribed the anti-biotic Linezolid 600 mg twice per day for five days for a Urinary Tract Infection. The 3/20/17 Telephone Order advised staff to not give R1 her scheduled [MEDICATION NAME] 25 mg until the course of Linezolid was complete, due to a potential drug interaction. The 3/17 Medication Administration Record [REDACTED]. Nursing notes document R1 developed sudden onset of aggressive behavior towards staff on 3/28/17. Nursing notes document R1 displayed further aggressive behaviors directed towards staff, residents and visitors on 3/29/17, 3/31/17, 4/01/17, and 4/02/17. Nursing Notes, dated 4/02/17, document at 12:45 p.m. R1 punched a nurse in the left side of the chest as she was passing R1 in the hallway. Later on 4/02/17, at 5:00 p.m., Nursing Notes document R1 hit a resident in the back of the head with an open hand and the physician ordered R1 to be evaluated by a Geriatric Psychiatric facility in a nearby town; however, that facility did not have a open bed for R1. Nursing Notes document at 8:00 p.m. that R1 was sent to the local hospital for evaluation and R1 was returned to the facility as R1 was determined not a danger to herself. Nursing Notes, dated 4/03/17, document R1 was sent to the local hospital again for medical clearance to be admitted to a different Geriatric Psychiatric facility that did have an open bed. Documentation indicates R1 returned to the facility that evening at 5:25 p.m., with an increase in her anti-depressant and anti-psychotic medications. A SBAR (Situation Background Assessment Recommendation) Communication form, dated 4/04/17, documents E10 (Medical Director) instructed staff to send R1 to the emergency room after R1 rammed her walker into a family member that was visiting another resident. The 4/04/17 emergency room Notes document R1 presented for evaluation of agitated dementia and after spending over three hours in the emergency room , (R1) has NOT been agitated or aggressive while here. The 4/04/17 emergency room Notes further document (R1) has chronic dementia and SHOULD remain at nursing home. (E10 - Medical Director) is aware of all, just spoke and also says (R1) belongs at nursing home and will not benefit from a 'psychiatric transfer.' (E10) even adjusted (R1's medication) yesterday (4/03/17). (E10) is upset that the nursing home is not being cooperative in this fashion and says that if (the nursing home) will not accept (R1) back, we should call the family to pick her up and find care elsewhere. On 4/17/17 at 11:56 a.m., E7 (Registered Nurse) stated she had R1 sitting behind the Nurses Station with her on the evening of 4/05/17, in attempt to supervise R1 closely during dinner. E7 stated R1 just out of the blue hit her in the jaw. E7 stated R1 struck her once and expressed no further signs of aggression towards anyone. E7 stated E1 (Administrator) has advised staff to automatically send R1 out to the emergency room with any sign of aggression, even if the resident can be redirected. Hospital emergency room Records, dated 4/05/17, document The patient presents to the emergency department with anxiety, chronic dementia with agitation. (R1) has been sent here multiple times due to the failure of nursing home staff to be able to manage and de-escalate a patient with dementia. Each admission here, the patient shows absolutely no aggression. POA (Power of Attorney) is trying to find an alternative living situation without success due to Medicaid. Nursing home has been told by Administrator to call 911 and send to ER (emergency room ) each time. She has been evaluated by multiple physicians who do not believe there will be any benefit from (psychiatric) placement, as patient cannot participate due to level of dementia and need for assistance in most, if not all (activities of daily living). (Nursing Home) refuses to deal with the situation and I believe are actually getting into this patient's face to escalate her agitation. The Hospital emergency room Record further documents R1's aggressive symptoms a non-existent while in the emergency room , and R1 discharged back to the Nursing Home in good condition. The Hospital Crisis Report on 4/05/17, completed by Social Services, documents (R1) is calm/resting. (R1) is not demonstrating any mental health symptoms that would require psychiatric hospitalization . (R1's) mood is good. Affect congurent with mood. No delusions, illusions, or hallucinations reported. (R1) is not suicidal. (R1) does not appear to be a threat to herself or others. Nursing Notes, dated 4/06/17 at 5:40 p.m., document (R1) in dining room, CNA (Certified Nursing Assistant) assisting with eating, slapped CNA (and) spit (at) her. 5:46 p.m. POA notified of incident. 5:50 p.m. 911 called for transport to ER. Nursing Notes at 6:30 p.m. document the ER physician evaluated R1 and everything (alright and R1) to be discharged back to facility with no new orders. Hospital emergency room Records, dated 4/06/17, document (R1) presents to the ER with complaints of alleged aggressive behavior at nursing home - Chronic Dementia. (R1) has Chronic Dementia and lives at (nursing home) where every so often she will allegedly hit or try to hit a staff member. She does not have ongoing aggression, and this has been chronic for a long time. She has been repeatedly sent here for this many times, (six) times in the last (five) days. She has even had an evaluation by a mental health worker yesterday, and there are no new suggestions. Nursing home insists that 'due to policy', they will continue to send her here each time she does anything similar. The Hospital emergency room Record documents R1's Psychological Exam as every other time, she is calm and not aggressive, but very demented with unintelligible speech. She carries a toy doll with her, whom she babbles to and seems very comfortable. On 4/17/17 at 2:19 p.m., E8 (Registered Nurse) stated, on 4/11/17, R1 took her walker and rammed a CNA up against the wall in the hallway. E8 stated the CNA was not injured and R1 was able to be redirected immediately after the incident. E8 stated R1 had an appointment later in the afternoon with a Psychiatrist; however, she informed E1 of the incident. E8 stated E1 (Administrator) instructed her to get a order from E10 (Medical Director) to send R1 out to the emergency room for an evaluation. E8 stated E10 refused to give an order to send R1 to the emergency room for the behavior exhibited. E8 stated E1 instructed her to call 911 and have R1 transported to the emergency room anyway, which she did. On 4/11/17 at 9:30 a.m., E1 (Administrator) stated R1 was getting ready to leave the facility via ambulance for ramming a staff member with her wheeled walker. At that point, R1 was observed ambulating independently with her wheeled walker, accompanied by E11 (Activities Director). R1 was not displaying any aggression as she would sit down for 1-2 minutes and then get up and ambulate in the halls. R1 would occasionally cry for a short moment and hug her doll. R1 was observed continuously until the paramedics arrived at 9:55 a.m. R1 displayed no behaviors/aggression with the paramedics and complied with instructions to get on the stretcher. R1's current Plan of Care (no date), documents My behavior is sporadic. I have no cognitive ability to understand or be educated. I have a (diagnosis) of Dementia, Depression, [MEDICAL CONDITION] Disorder and Pseudobulbar Affect. My behaviors include approaching peers with my walker and ambulating too close at times, bumping into them. I lack safety awareness. I will attempt to sit on my peers laps and I will hit my peers with my baby doll. I have limited verbal interactions and I cry often. The interventions identified on the Plan of Care to manage R1's behaviors are: increasing visual checks on 3/22/17, implementing activities of interest and relaxation for redirection on 3/27/17 and sending R1 to the hospital with each aggressive episode on 4/03/17. The current Plan of Care fails to identify specific interventions for staff to de-escalate/manage R1's aggressive behavior and failed to anticipate potential behavioral changes that could have been contributed to the discontinuation of R1's [MEDICATION NAME] for five days. On 4/11/17 at 12:27 p.m., E6 (Care Plan Coordinator) stated she tries to change the (resident's) care plan immediately, if a resident has a new behavior/change in behavior and then develop a intervention to correspond with the behavior. E6 stated behavior monitoring includes Behavior Tracking, which allows the facility to analyze and identify triggers/trends to a resident's behavior. E6 stated R1's Plan of Care was not updated after she developed aggressive behaviors (on 3/29/17), until 4/03/17. E6 stated E1 (Administrator) advised her on 4/03/17 to include the the intervention of sending R1 out of the facility for a psychiatric evaluation with each episode of aggression, and no specific interventions to de-escalate R1's aggression towards staff were developed. Behavior Tracking for the months of March and April 2017 document the facility was monitoring R1 for a sad expression; tearful, crying and exit seeking. There is no documented evidence R1 was being monitored for aggressive behaviors or what interventions staff implemented after episodes of aggression. On 4/11/17 at 10:41 a.m., E5 (Social Service Director) stated the facility does not currently have behavior tracking, as outlined in the Behavior Tracking Sheets policy, for R1's aggression. E5 stated if they monitor and document (R1's) aggression, it looks like they are allowing (R1) to ram people with her walker and strike out. E5 stated R1 does respond well to her baby doll and staff need to approach R1 in a calm manner. E5 stated, unless staff are with (R1) 1:1, you couldn't anticipate R1's behaviors because there is no pattern. E5 also stated that the facility doesn't send residents out to the (emergency room ) if they are aggressive with staff, typically. They try to manage those behaviors. On 4/18/17 at 10:25 a.m., Z2 (emergency room Supervisor) stated each time R1 has been transferred to the emergency room , she has never displayed signs of aggression. Z2 stated R1 might resist when assessing vital signs, but R1 is easily redirected with the correct approach. Z2 stated E10 (Medical Director) and the emergency room Physicians have all agreed that R1 would not benefit from inpatient psychiatric care, but needs behavior management and medication. On 4/17/17 at 2:19 p.m., E8 (Registered Nurse) stated staff need to visualize R1 at all times and would benefit from someone to do constant activities with her. E8 stated R1 cries frequently and likes someone to be with her all the time to comfort her. E8 stated R1 needs someone with her 1:1, but the facility doesn't have the staff to do so. On 4/13/17 at 2:10 p.m. Z3 (Psychiatrist) stated he felt R1's increased behaviors could have been triggered by a recent urinary tract infection and the need to hold R1's anti-depressant for 5 days due to a potential drug interaction. Z3 stated the facility sending R1 to the emergency room for agitation/aggression towards staff on 4/5/17, 4/6/17 and 4/11/17 was unwarranted, because the staff should be able to manage those types of behaviors in a resident with Dementia. Z3 stated, if a resident has aggression towards staff that can easily be redirected or is not ongoing, the resident would benefit from staying in their current environment rather than the excess stimulation that occurs when being transferred out of the facility. Z3 stated a facility that admits a resident with a history of known behaviors/aggression, should be able to manage that resident when aggressive with staff. Additionally, Z3 stated the increase made to the dosage of R1's anti-depressant and anti-psychotic on 4/3/17, could take two to four weeks to see a therapeutic effect and could potentially help decrease her behaviors. A Notice of Involuntary Transfer or Discharge and Opportunity for Hearing, dated 4/05/17, was mailed to Z4 (Power of Attorney for R1), citing the facility was seeking to Emergency Transfer R1 out of the facility, due to R1's welfare and needs cannot be met in this facility, as documented in your clinical record by your physician and the safety of individuals in this facility is endangered. The Notice of Involuntary Transfer cites R1's proposed transfer/discharge date as 5/05/17. On 4/11/17 at 11:17 a.m., E1 (Administrator) stated the facility did not have a written statement from E10 (Medical Director) stating why the facility is unable to meet the needs of R1, but was awaiting one. E1 stated she has tried to convince R1's family to transfer R1 to a facility that has a secured unit, but they have no interest. E1 confirmed that the facility staff had not had the Dementia Management training, as outlined in the 11/28/16 Abuse Prevention Program, and that effective 4/10/17 that training had been initiated.

Based on observation, interview, and record review the facility failed to have an effective behavior management plan in place and to monitor and offset behaviors for one of four residents (R1) reviewed for behaviors in the sample of 15. This failure resulted in R1 being inappropriately transferred to the emergency roiagnom on three different occasions when R1 exhibited behaviors towards staff, only to be sent back as stable thus causing overstimulation and excess stress on R1. Findings include: A physician's orders [REDACTED]. A Pre-Screening/Screening Assessment for Harmful Behaviors form scored R1 as a Moderate Risk for harmful behaviors, secondary to a history of Talks about/threatens harm towards others and/or aggressive behaviors towards others, harboring considerable fears over separation from support system, and poor safety awareness and/or has poor judgement. A Minimum Data Set, dated dated [DATE], identifies R1 as having severe cognitive impairment. Nursing Notes, dated 4/02/17, document at 12:45 p.m. R1 punched a nurse in the left side of the chest as she was passing R1 in the hallway. Later on 4/02/17, at 5:00 p.m., Nursing Notes document R1 hit a resident in the back of the head with an open hand and the physician ordered R1 to be evaluated by a Geriatric Psychiatric facility in a nearby town; however, that facility did not have a open bed for R1. Nursing Notes document at 8:00 p.m. that R1 was sent to the local hospital for evaluation and R1 was returned to the facility as R1 was determined not a danger to herself. Nursing Notes, dated 4/03/17, document R1 was sent to the local hospital again for medical clearance to be admitted to a different Geriatric Psychiatric facility that did have an open bed. Documentation indicates R1 returned to the facility that evening at 5:25 p.m., with an increase in her anti-depressant and anti-psychotic medications. R1's current Plan of Care (no date), documents My behavior is sporadic. I have no cognitive ability to understand or be educated. I have a (diagnosis) of Dementia, depression, [MEDICAL CONDITION] Disorder and Pseudobulbar Affect. My behaviors include approaching peers with my walker and ambulating too close at times, bumping into them. I lack safety awareness. I will attempt to sit on my peers laps and I will hit my peers with my babydoll. I have limited verbal interactions and I cry often. The Plan of Care advises staff to Send (R1) out to receive (psychological evaluation) with each episode. Nursing Notes by E7 (Registered Nurse), dated 4/05/17 at 5:45 p.m., document R1 sitting (at) desk (with) this nurse, just finished supper. Resident hit this nurse in jaw. 911 called (and R1) transferred to ER (emergency room ) per ambulance. POA (Power of Attorney) notified. A SBAR (Situation Background Assessment Recommendation) form dated 4/05/17, related to the incident, documents under Resident Evaluation that R1 had no changes in mental status or behaviors at that time. Nursing Notes, dated 4/05/17 at 9:30 p.m. (emergency room ) called. (R1) had evaluation from Mental Health Advisor (and resident) is to return to the facility. On 4/17/17 at 11:56 a.m., E7 (Registered Nurse) stated she had R1 sitting behind the Nurses Station with her on the evening of 4/05/17, in attempt to supervise R1 closely during dinner. E7 stated R1 just out of the blue hit her in the jaw. E7 stated R1 struck her once and expressed no further signs of aggression towards anyone. E7 stated E1 (Administrator) has advised staff to automatically send R1 out to the emergency room with any sign of aggression, even if the resident can be redirected. Hospital emergency room Records, dated 4/05/17, document The patient presents to the emergency department with anxiety, chronic dementia with agitation. (R1) has been sent here multiple times due to the failure of nursing home staff to be able to manage and de-escalate a patient with dementia. Each admission here, the patient shows absolutely no aggression. POA (Power of Attorney) is trying to find an alternative living situation without success due to Medicaid. Nursing home has been told by Administrator to call 911 and send to ER (emergency room ) each time. She has been evaluated by multiple physicians who do not believe there will be any benefit from (psychiatric) placement, as patient cannot participate due to level of dementia and need for assistance in most, if not all (activities of daily living). (Nursing Home) refuses to deal with the situation and I believe are actually getting into this patient's face to escalate her agitation. The Hospital emergency room Record further documents R1's aggressive symptoms as non-existent while in the emergency room , and R1 discharged back to the Nursing Home in good condition. The Hospital Crisis Report on 4/05/17, completed by Social Services, documents (R1) is calm/resting. (R1) is not demonstrating any mental health symptoms that would require psychiatric hospitalization . (R1's) mood is good. Affect congruent with mood. No delusions, illusions, or hallucinations reported. (R1) is not suicidal. (R1) does not appear to be a threat to herself or others. Nursing Notes, dated 4/06/17 at 5:40 p.m., document (R1) in dining room, CNA (Certified Nursing Assistant) assisting with eating, slapped CNA (and) spit (at) her. 5:46 p.m. POA notified of incident. 5:50 p.m. 911 called for transport to ER. Nursing Notes at 6:30 p.m. document the ER physician evaluated R1 and everything (alright and R1) to be discharged back to facility with no new orders. Hospital emergency room Records, dated 4/06/17, document (R1) presents to the ER with complaints of alleged aggressive behavior at nursing home - Chronic Dementia. (R1) has Chronic Dementia and lives at (nursing home) where every so often she will allegedly hit or try to hit a staff member. She does not have ongoing aggression, and this has been chronic for a long time. She has been repeatedly sent here for this many times, (six) times in the last (five) days. She has even had an evaluation by a mental health worker yesterday, and there are no new suggestions. Nursing home insists that 'due to policy', they will continue to send her here each time she does anything similar. The Hospital emergency room Record documents R1's Psychological Exam as every other time, she is calm and not aggressive, but very demented with unintelligible speech. She carries a toy doll with her, whom she babbles to and seems very comfortable. On 4/11/17 at 9:30 a.m., E1 (Administrator) stated R1 was getting ready to leave the facility via ambulance for ramming a staff member with her wheeled walker. At that point, R1 was observed ambulating independently with her wheeled walker, accompanied by E11 (Activities Director). R1 was not displaying any aggression as she would sit down for 1-2 minutes and then get up and ambulate in the halls. R1 would occasionally cry for a short moment and hug her doll. R1 was observed continuously until the paramedics arrived at 9:55 a.m. R1 displayed no behaviors/aggression with the paramedics and complied with instructions to get on the stretcher. On 4/17/17 at 2:19 p.m., E8 (Registered Nurse) stated, on 4/11/17, R1 took her walker and rammed a CNA up against the wall in the hallway. E8 stated the CNA was not injured and R1 was able to be redirected immediately after the incident. E8 stated R1 had an appointment later in the afternoon with a Psychiatrist; however, she informed E1 of the incident. E8 stated E1 instructed her to get a order from E10 (Medical Director) to send R1 out to the emergency room for an evaluation. E8 stated E10 refused to give an order to send R1 to the emergency room for the behavior exhibited. E8 stated E1 instructed her to call 911 and have R1 transported to the emergency room anyway, which she did. Hospital emergency room Records, dated 4/11/17, indicate R1 was sent to the emergency room for aggressive behavior. The Hospital emergency room Records document, The patient (R1) presents to the emergency department with anxiety, R1 was given [MEDICATION NAME] 1 mg (milligram) and discharged back to the facility. On 4/18/17 at 10:25 a.m., Z2 (emergency room Supervisor) stated each time R1 has been transferred to the emergency room , she has never displayed signs of aggression. Z2 stated R1 might resist when assessing vital signs, but R1 is easily redirected with the correct approach. Z2 stated E10 (Medical Director) and the emergency room Physicians have all agreed that R1 would not benefit from inpatient psychiatric care, but needs behavior management and medication. On 4/13/17 at 2:10 p.m. Z3 (Psychiatrist) stated he felt R1's increased behaviors could have been triggered by a recent urinary tract infection and the need to hold R1's anti-depressant for 5 days due to a potential drug interaction. Z3 stated the increase made to the dosage of R1's anti-depressant and anti-psychotic on 4/3/17, could take two to four weeks to see a therapeutic effect and could potentially help decrease her behaviors. Z3 stated the facility sending R1 to the emergency room for agitation/aggression towards staff on 4/5/17, 4/6/17 and 4/11/17 was unwarranted, because the staff should be able to manage those types of behaviors in a resident with Dementia. Z3 stated, if a resident has aggression towards staff that can easily be redirected or is not ongoing, the resident would benefit from staying in their current environment rather than the excess stimulation that occurs when being transferred out of the facility. Z3 stated a facility that admits a resident with a history of known behaviors/aggression, should be able to manage that resident when aggressive with staff.

Based on observations, interviews, and record review the facility failed to recognize, assess and implement interventions to prevent pressure ulcers for a resident identified to be at high risk for development of pressure ulcers for one of four residents (R2) reviewed for pressure ulcers in a sample of four. This failure resulted in R2 developing an unstageable pressure ulcer to the coccyx. Findings include: Pressure Sore Prevention Guidelines, revised 11/12, state, "Policy: To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the (skin assessment tool). Responsibility: All Nursing Staff and Dietary Manager. Procedure: The following guidelines will be implemented for any resident assessed at High or Moderate skin risk. Turn and reposition every two hours, range of motion, special mattress, positioning devices, incontinence care, daily skin checks, weekly skin checks, quarterly review by dietary manager, and care plan entry. Any resident scoring a high or moderate risk for skin breakdown will be noted on the Treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet." Policy titled "Decubitus Care/ Pressure Areas", revised 05/07, states, " Procedure: 1) Upon notification of skin breakdown, a Newly Acquired Skin Condition report will be completed and forwarded to the Director of Nurses. 5) Documentation of the pressure area must occur upon identification and at least once a week on the TAR." Save Our Skin Alert Form from local hospital, dated 09/25/14, documents, "Skin Intact, Turn every two hours, barrier cream and keep pressure off heels." Facilities Nursing Admission assessment dated [DATE] documents excoriation to coccyx. Care plan for R2 dated 09/25/14 documents, pressure ulcers present on readmission. Unstageable areas noted to coccyx, right and left heel. Interventions include nurse to measure and monitor wound status progression or deterioration every week. Notify MD and family of changes. Document physician response. Daily skin check with documentation and as needed with any new open areas. R2's (Skin Assessment Tool For Predicting Pressure Ulcers) dated 09/26/14, documents a score of 14, indicating high risk. R2's (Skin Assessment Tool For Predicting Pressure Ulcers) dated 10/02/14, documents a score of 12, indicating high risk. Nursing Progress Review for R2, dated 10/02/14, states, "Pressure ulcer unstageable to coccyx and bilateral heels." R2's Treatment Administration Record, dated 10/01/14-10/31/14, states, "10/7/14 left heel 7 x 7 cm unstageable, right heel 2 x 4 cm unstageable, and coccyx 7 x 6 cm unstageable." Patient Progress Notes from local hospital, dated 10/08/14, state, "pressure ulcer stage 2, to coccyx measuring approximately 9 x 7 cm. Areas of blackish and purplish area noted with moderate serousanguinois drainage noted. Right heel has stage 1 pressure ulcer measuring approximately 1.5 x 1 cm brownish in color. Left heel has stage 1 pressure ulcer measuring approximately 7 x 6 cm area of redness and 4 x 3.5 cm area of brownish discoloration. Scrotum noted 2 x 3 cm area with top two layers sloughed off and 3 more smaller areas noted." R2's History and Physical from local hospital, dated 10/09/14, states, "Skin: 8.6 cm x 5 cm open area decubitus, foul smelling with drainage and surrounding redness, multiple open areas to scrotum, open wound on left heel." R2's medical record did not include Weekly Wound Tracking sheets. On 10/10/14 at 11:30 AM, a large reddened opened area with small drainage and foul smell, extended across R2's right and left buttocks. There were several large yellowish scabs on scrotum. There were large reddened areas to bilateral heels with some drainage noted. On 10/10/14 at 11 AM, E2 DON (Director of Nurses) stated that the pressure ulcers on R2's heels were identified on 10-1-14 and on R2's coccyx on 10-6-14, and that R2's care plan was erroneously dated for 9-25-14. At that time, E2 confirmed that wound tracking was not done weekly per facility policy and the Treatment Administration Record documentation for daily skin assessments does not include the identification of any pressure ulcers from 10-1-14 through 10-6-14. On 10/10/14 at 2:00 PM E2/DON stated, "Residents with pressure ulcers or those at moderate or high risk for pressure ulcers, would be on a daily skin assessment. This is all I have for documentation for (R2). The certified nursing assistants are expected to report any areas of concern to the nurse and the nurse would inform the physician." The 's' charted on the Treatment Administration Record means surgical wound." On 10/10/14 at 4:00 PM, Z1(R2's Physician), stated, "I was livid when I received the phone call from the ER describing (R2's) pressure ulcers. My office received a call on 10/01/14 stating some redness to (R2's) heels, then on 10/06/14 the office received a call about reddened area on coccyx and my partner gave orders because I was out. On the morning of the 8th I returned and called to have labs drawn. I was later called with results and notified of (R2's) family concern of (R2's) condition. I gave an order for [REDACTED]. I was never notified of the sores on (R2's) scrotum. After seeing the condition (R2) was in when brought in, I would say the sores were avoidable. I could not believe it when I saw (R2).

Based on observation, interview, and record review the facility failed to investigate falls, failed to analyze root cause analysis of falls, and failed to implement new and/or resident specific interventions after falls for 5 of 7 residents (R3, R12, R15, R9, R1) reviewed for falls in the sample of fourteen. These failures resulted in R12 falling and sustaining a lumbar compression fracture and R15 falling and sustaining a hip fracture. Based on record review, observation, and interview the facility failed to ensure resident safety with the use of side rails for one of seven residents (R17) reviewed for safe side rail use, in the sample of 14. Findings include: A Fall Prevention Policy (date unknown), documents a fall investigative report will be completed after each fall; Care Plans will be updated after each fall review with the Interdisciplinary Team and the Care Plan Coordinator; all new interventions will be written on the care plan; the Director of Nursing is to observe for and react to trends in incidents On 4/21/14 at 2:00 p.m., E2 (Director of Nursing) stated "I'm not allowed to provide any fall investigations or fall logs to (the State Agency)." E2 stated, "This is a Corporate Office rule." On 4/22/14 at 10:45 a.m., E2 stated the facility could not provide the survey team with a list of falls for specified residents. E2 stated "(state surveyors) are only allowed to look at resident nurses notes and resident care plans." 1. Nurses Notes dated 3/23/14 at 6:20 a.m., document R12 was found lying on the floor mat in front of R12's bed. A State Agency Notification form dated 3/24/14, documents R12 complained of left hip pain on 3/24/14 and R12 was sent to the hospital. An x-ray report dated 3/24/14, documents R12 had a Lumbar Compression Fracture. Nurses Notes dated 6/25/13 through 4/22/14, document R12 had falls on 8/24/13, 8/25/13, 9/11/13, 10/7/13, 10/28/13, 1/22/14, 2/28/14, 3/3/14, 3/13/14, 3/23/14, and 3/24/14. R12's Plan of Care dated 8/22/13, includes no new interventions implemented after R12's falls on 8/24/13, 8/25/13, 9/11/13, and 1/22/14. R12's Plan of Care dated 2/16/14, includes no interventions implemented after R12's fall on 10/7/13, and 10/28/13. R12's Plan of Care dated 2/14/14, includes no new interventions implemented after R12's falls on 2/28/14, 3/3/14, and 3/13/14. On 4/24/14 at 9:36 a.m., E2 (Director of Nursing) verified that R12's plan of care dated 2/14/14, does not document new interventions implemented after R12's falls on 8/24/13, 8/25/13, 9/11/13, 1/22/14, 2/28/14, 3/3/14, and 3/13/14. R12's Nurses Notes 8/24/13, 1/22/14, and 3/24/14, document R12's falls involved the floor matt next to R12's bed. R12's Plan of Care dated 8/22/13 and 2/16/14, do not document the removal of R12's fall floor matt next to R12's bed. On 4/21/14, 4/22/14, and 4/23/14, R12 has a matt on the floor next to the bed. On 4/22/14 at 2:20 p.m., R12's personal alarm was sounding and R12 got out of bed, walked over the fall matt lying on the floor next to the bed and proceeded to walk across the room (approximately six feet) to the enclosed walker. R12 was assisted by staff back to bed. On 4/22/14 at 4:23 p.m., R12's personal alarm was sounding and R12 was standing next to bed on top of the fall matt on the floor. R12 again was assisted to bed by staff. On 4/24/14 at 9:36 a.m., E2 (Director of Nursing) stated E2 does not know why R12 has a matt on the floor next to the bed. E2 verified that the fall matt had contributed to R12 falling in the past, including R12's fall on 3/23/14 which resulted in a fracture. R12's Plan of Care revision dated 3/23/14, documents to encourage resident to utilize call light and ask for assistance for placement of footwear. On 4/24/14 at 9:36 a.m., E2 stated R12's Plan of Care Revision dated 3/23/14 was not an appropriate intervention for R12 due to severely impaired cognitive skills. E2 stated "actually the intervention I had in my documentation was to put (R12's) shoes in the closet at night." On 4/23/14 at 2:15 p.m., E2 (Director of Nursing) stated "The Interdisciplinary team, which consists of Administrator, Director of Nursing, Care Plan Coordinator, Social Services Director, Dietary Manager, and Therapy, are responsible for fall investigations. After the investigation is done the new interventions are immediately communicated to the staff and documented on the care plans." 2. R15's Nurses Note dated 11/11/13 at 10:15 p.m., documents R15 was in R15's room lying on back with legs straight out in front, back and head against recliner, and bedding down around R15. R15's Nurses Note, dated 3/21/14, documents that at 3:20 p.m., R15 was in R15's room sitting on his buttocks with his legs crossed next to the bed. R15's Care Plan, dated 2/1/13 and 11/14/13, document no new interventions for R15's accidents on 11/11/13 and 3/21/14. R15's Nurses notes, dated 4/22/14, documents that at 3:00 p.m. R15 was lying on R15's right side in dining room with right upper extremity bleeding. At 9:15 p.m. R15 was admitted to Mason District Hospital. On 4/23/14 at 8:45 a.m., E9 (Licensed Practical Nurse) stated, "(R15) fell yesterday and was admitted to Mason District Hospital with a hip fracture." R15's Radiology report, dated 4/23/14, documents R15 has a mildly impacted femoral neck fracture. On 4/24/14 at 9:50 a.m., E2 (Director of Nursing), confirmed that R15's care plans, dated 2/1/13 and 11/14/13, do not have new interventions for accidents on 11/11/13 and 3/21/14. 3. R3's Nurses Notes dated 6/24/13 through 4/23/14, documents R3 had falls on 6/24/13, 6/27/13, 7/17/13, 7/21/13, 8/7/13, 9/20/13, 10/29/13, 12/22/13, 2/11/14, 3/22/14, and 4/10/14. R3's Plan of Care last updated on 4/11/14, does not document new interventions or evidence of investigation for R3's falls on 7/17/13, 8/7/13, 12/22/13, or 2/11/14. On 4/26/14 at 9:36 a.m., E2 (Director of Nursing) verified R3's Plan of Care last updated on 4/11/14, fails to document R3's falls on 7/17/13, 8/7/13, 12/22/13, and 2/11/14. 4. A physician's orders [REDACTED]. A Minimum Data Set, dated dated [DATE], identifies R1 as having severe cognitive impairment. R1's current Plan of Care (no date), documents R1 as high risk for falls and having an unsteady gait. Nursing Notes dated 11/15/13, document R1 was found on the floor of the bathroom and R1 had indicated "I was trying to go to the bathroom and fell ." The 11/15/13 Nursing Note states the fall was unwitnessed and R1's "(wheelchair) alarm turned off, therefore, (not) sounding....(Certified Nursing Assistant) reprimanded (at this time due to not) following proper procedure when (R1) was up this (morning)." Nursing Notes document R1 fell on [DATE], sustaining a 7.5 cm (centimeter) by 1 cm abrasion to the leg, fell twice on 1/24/14 (11:00 a.m. and 8:10 p.m.) and fell on [DATE] while attempting to use the urinal. R1's current Plan of Care (no date) fails to reflect that these falls occurred or the development of new fall prevention interventions. On 4/24/14 at 9:40 a.m., E2 (Director of Nursing) stated that the C.N.A. (Certified Nursing Assistant) caring for R1 on 11/15/13 was reprimanded for not turning on R1's personal body alarm that morning. E2 concluded, given the fact that R1 had just experienced a hip fracture from a fall on 11/05/13, proper utilization of the personal body alarm was imperative. E2 stated that the facility did not have documented evidence to support an investigation into R1's falls on 12/18/13, 1/24/14 or 2/14/14 or that new interventions were developed to prevent future falls. 5. A physician's orders [REDACTED]. Minimum Data Sets, dated 3/09/14 and 8/30/13, identify R9 as having severe cognitive impairment with short term and long term memory loss. R9's current Plan of Care (no date), identifies R9 as high risk for falls and requiring the assist of two staff and a gait belt for all transfers. Nursing Notes, dated 9/09/13, document R9 fell while being transferred from the toilet to the wheelchair and the nurse "noted floor wet from shower given earlier." The 9/09/13 Nursing Note does not identify how many C.N.A.'s were present during the transfer or which staff witnessed the fall. R9's current Plan of Care (no date) does not reflect the fall on 9/09/13 or the development of new fall prevention interventions. Nursing Notes, dated 10/15/13, document R9 was found on the floor in the television room next to the couch. The current Plan of Care (no date) does identify that the fall occurred and instructs the staff to frequently remind R9 to ask for assistance with transfers and care needs. Nursing Notes, dated 1/10/14, document R9 was on the floor in the shower room with the shower chair tipped forward. The Nursing Note does not identify how many staff were present or who witnessed the fall. R9's current Plan of Care (no date) does not reflect the fall on 1/10/14 or the development of new fall prevention interventions. On 4/24/14 at 9:40 a.m., E2 (Director of Nursing) stated that the facility does not have any documented evidence to support an investigation into R1's falls on 9/09/13, 10/15/13 and 1/10/14. E2 stated the Care Plan intervention developed after the 10/15/13 fall was not appropriate for R9, given R9's cognitive impairment. E2 stated staff were instructed to maintain resident safety and ensure the floor was dry before transferring residents, after R9's fall on 9/09/13. E2 stated staff were instructed, after R9's 1/10/14 fall out of the shower chair, to use a larger shower chair because the shower chair staff had used was too small for R9. E2 concluded that two C.N.A.'s should have been present while showering R9 on 1/10/14. 6. R17's Physician order [REDACTED]. R17's Nurse's notes, dated 4/15/14 at 7:30 a.m., document R17 was on hands and knees next to R17's bed. On 4/17/14 at 5:10 p.m., R17 was noted to have a 6 centimeter x 5.5 centimeter purple discoloration to her left lower face. On 4/22/14 at 9:00 a.m., R17 was up in reclining wheelchair chair in dining room. There was a large dark purple bruise to left side of R17's face. The bruise extended from below the corner of left lower lip up to left ear and down R17's neck. On 4/23/14 at 10:50 a.m., R17 was lying in bed on R17's left side with bilateral half side rails up and a bolster pillow on the right side between R17 and side rail. R17's bed was against the wall on R17's left side. On 4/23/14 at 1:50 p.m., E8 (Certified Nursing Assistant) stated, "(R17) rolls around in bed that is why (R17) has side rails so (R17) doesn't roll out of bed. (R17's) family wants the bolster pillow in the bed to add extra padding since (R17) rolls around. (R17) is not able to grab the side rails and turn." E8 instructed R17 to grab the side rails and assist E8 to turn R17 in bed. R17 was unable to follow directions and participate in bed mobility. R17's Care plan, dated 11/5/13, documents the need for use of side rails as an enabler that does not limit movement/accessibility. Bilateral top half side rails are used for bed mobility, positioning, and transfers. R17's Physical Restraint Progress notes, dated 3/28/14, documents the half side rails aid against random movements that cause falls. R17 is not actively seeking getting out of bed independently. On 4/24/14 at 9:50 a.m., E2 (Director of Nursing) stated, "(R17) now has a low bed and side rails removed for a new intervention because of the safety risk for (R17), related to R17's fall on 4/15/14." On 4/24/14 at 1:50 p.m., R17 was lying in bed. R17's bed was in low position with a quarter side rail on R17's right side and a half side rail on R17's left side. R17 had a bolster pillow in place to R17's right side between the side rail and R17. On 4/24/14 at 2:00 p.m., E10 (Licensed Practical Nurse) stated, "I was the nurse that discovered R17's bruise. The bruise to the left side of face was from (R17's) fall a few days before."

Based on record review and interview, the facility failed to follow operational policies and procedures regarding Advance Directives and failed to ensure resident requested Advance Directives regarding Cardiopulmonary Resuscitation (CPR) were honored, for one of three residents (R1) reviewed for Advance Directives, in a sample of three. These failures resulted in R1 receiving CPR after cardiac activity had ceased and the prolonging of R1's death. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding staff knowledge of Advance Directives and the continued effort to update all current resident Advance Directives to a specific color and location in the resident's medical record. Findings include: An Admissions Summary (no date) documents R1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A Uniform Do-Not-Resuscitate (DNR) Advanced Directive, dated [DATE] and signed by Z1 and E3 (Medical Director), indicates in an event of "Full Cardiopulmonary Arrest (When both breathing and heartbeat stop): Do Not Attempt Cardiopulmonary Resuscitation" or in a "Pre-Arrest Emergency (When breathing is labored or stopped and heart is still beating): Do Not Attempt Cardiopulmonary Resuscitation." A physician's orders [REDACTED]. A Plan of Care, dated [DATE], documents "(R1) has chosen Advance Directives" and "(R1) has chosen DNR, do not proceed with CPR if resident is found unresponsive without pulse AND/OR respiration." A Minimum Data Set, dated dated [DATE], documents R1 as cognitively intact. A Quarterly Social Service Progress note, dated [DATE], documents R1 as having a continued "code status DNR." Nursing Notes, dated [DATE] at 11:35 a.m., document "(R1's) eyes fixed, skin pale, cold, dry. Respirations shallow with periods of apnea (temporary cessation of breathing). (R1) unresponsive to name. Unable to voice anything. (R1) wheeled to room and (lifted) onto bed. Unable to get (blood pressure) reading....(R1) continued to have periods of apnea. (Hospital) called and ambulance on its way..." A Ambulance Service Patient Care Report, dated [DATE], documents "Called by nursing home on Hospital line for (person) that was having periods of apnea and not responding. Immediately on arrival at scene we were advised that the patient was a Full Code. On entering the scene presented with [AGE] year old (person) laying in bed, agonal respirations. Patient pulseless. BMV (Bag Valve Mask) ventilations initiated. Poor chest rise secondary to patient's position on bed. Cardiac monitor applied and patient presenting with PEA (Pulseless Electrical Activity) at approximately 10 beats per minute, NO PULSE associated with beats. Ambulance crew again advised that the patient was a FULL CODE. IV (Intravenous) attempted (once) with no success. Patient moved to cot, ventilation continued with chest rise, compressions initiated.....CPR for duration of transport. No change in status on arrival...." The Ambulance Service Report documents the Ambulance Team was at the facility at 11:46 a.m. and departed the facility at 11:54 a.m. Hospital Nursing Notes, dated [DATE] at 11:55 a.m., document "Appears (R1) in [MEDICAL CONDITION]. Behavior is unresponsive....Level of consciousness is unresponsive. Cardiovascular: Rhythm is asystole. Respiratory: Respiratory effort is none." At 12:01 p.m., Hospital Nursing Notes document, "(E2 - Director of Nursing) called and speaking (with) this nurse on trauma room phone, informs this nurse that patient is a DNR. (Z5 - emergency room Physician) immediately informed and per (Z5) CPR stopped at this time." At 12:05 p.m., Hospital Nursing Notes document, "After declaring stopped resuscitation efforts, (Z5) noted spontaneous return of circulation, sinus rhythm noted on monitor, patient appears to be attempting spontaneous breaths...." Hospital Physician's Notes, dated [DATE] at 12:32 p.m., document "Patient's Daughter (POA - Power of Attorney), Sister and Brother in Law, state that (R1) would not want to be on a ventilator and ask for the ET (Endotracheal) tube to be removed per patient's wishes. I advised them of the risks with removing the tube, including loss of airway, resulting in respiratory and [MEDICAL CONDITION]. They state they are aware of the risks, but want to respect the patient's wishes. They would like to have the ET tube pulled and place the patient on comfort measures only." A Hospital History and Physical, dated [DATE] at 7:18 p.m., document R1 as experiencing "[MEDICAL CONDITION]" and as having a "history of advancing [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, who was found unresponsive in the Nursing Home. At that time, there was some confusion on (R1's) code status. The Nursing Home immediately thought (R1) was a full code. EMS (Emergency Medical Support) was called and resuscitation was started." The [DATE] History and Physical further documents, "Resuscitation and intubation was undertaken and was able to get back spontaneous respirations and spontaneous pulse, but again, the patient was a DNR and there was a mix-up through the Nursing Home. Spoke with the Nursing Home and it seems that the nurse on the Wing is a PRN (part-time) nurse and a CNA (Certified Nursing Assistant) was also there, and they thought that the patient was a full code at the time. Once the patient was taken to the Emergency Department, they did find in the chart that (R1) was a DNR and immediately called the Emergency Department to let them know.....We will order [MEDICATION NAME] 4 mg (milligrams) (every one) hour for any respiratory distress or air hunger." A Hospital Death Summary, dated [DATE] at 8:10 a.m., documents R1 expired. On [DATE] at 12:10 p.m., E8 (Certified Nursing Assistant) stated R1 was sitting near the Nurses Station after lunch on [DATE]. E8 indicated, when wiping R1's nose, R1 was unresponsive, eyes were open, pupils fixed, and breathing small short breaths. E8 stated E10 (Licensed Practical Nurse) was assigned to R1, but E10 had been out of the building on lunch for approximately 30 minutes. E8 indicated that someone summoned E4 (Licensed Practical Nurse) from the other Wing. E8 stated E4 (Licensed Practical Nurse) "looked at (R1)" and called 911. On [DATE] at 12:00 p.m., E9 (Certified Nursing Assistant) stated (on [DATE]) R1 was sitting near the Nurses Station and (E9) and E8 noticed R1's nose needed wiped. E9 stated, when E8 wiped R1's nose, R1 was unresponsive and breathing abnormal with periods of apnea. E9 called for E4, who was at the other end of the building, because R1's assigned nurse (E10) was out of the building for lunch. On [DATE] at 4:55 p.m., E4 (Licensed Practical Nurse) indicated R1 had not been assigned as (E4's) patient on [DATE], but E4 was working the facility's other wing. E4 stated, shortly after E10 had left the building for lunch, CNA's (Certified Nursing Assistant's) found R1 unresponsive while sitting in the wheelchair. E4 immediately assessed R1 and R1 was having periods of apnea, no blood pressure and a "very low pulse." E4 stated (E4) immediately phoned E2 (Director of Nursing) to see what needed to be done and was instructed to call for an ambulance. E4 indicated (E4) had R1's medical record, but "I couldn't find a DNR in the chart. I probably passed right by it." E4 stated, "EMS (Emergency Medical Services) arrived and asked if (R1) was a full code and I told them I didn't know." E4 stated several staff were in R1's room at that time and were all yelling, "(R1's) a full code." E4 stated Z2 (Paramedic) indicated R1 may have been a full code, based on knowledge of R1 from previous emergency room visits. E4 stated EMS initiated CPR on R1 and R1 was transported to the emergency room . E4 indicated, (E4) has only been employed at the facility for a few months and works every other weekend. E4 stated, "I didn't get much orientation" and could not recall receiving orientation regarding Advance Directives or how to determine a resident's code status. On [DATE] at 10:40 a.m., E11 (Certified Nursing Assistant) stated (E11) had gone up to the Nurses Station during the lunch service of [DATE] and noticed staff rushing R1 into R1's room. E11 stated that (E11) "thought (R1) was a full code" and met the EMS Team at the front door, opening it for them. E11 stated (E11) told Z2 (Paramedic) that R1 was a full code. E11 indicated that R1's code status had been discussed the day before, and it was believed, because of R1's age of 60, R1 was a full code. E11 stated that the Certified Nursing Assistants had not received training as to the importance of Advance Directives or where to locate Advance Directives in the chart, until this incident and all staff were given an inservice on [DATE]. On [DATE] at 1:02 p.m., Z2 (Paramedic) stated they were called to the facility on [DATE] for a resident who was unresponsive with periods of apnea. Z2 stated a staff person met (Z2) at the door of the Nursing Home and stated R1 was a full code and in distress. Z2 stated R1 was found in R1's room, with no pulse and agonal (gasping breathing often present during [MEDICAL CONDITION]) respirations. Z2 stated the "nurse in the room" told Z2 two more times that R1 was a full code. Z2 stated R1 was given CPR in route to the Hospital and in the emergency room , up until E2 called indicating R1 was actually a DNR. Z2 stated the facility did not provide Z2 or the other Emergency Responders with any documentation regarding R1's code status. Z2 stated the first responders "depend on the Nursing Home" to be knowledgeable of a resident's code status. On [DATE] at 1:20 p.m., Z4 (Paramedic Student) stated (Z4) accompanied the EMS Team that responded to R1's respiratory distress, on [DATE]. Z4 stated "staff" told the first responders two to three times that R1 was a full code. On [DATE] at 2:20 p.m., Z3 (Emergency Medical Technician) stated on [DATE], they arrived at the nursing home and staff met them at the door to the facility. Z3 stated one staff member indicated R1 was in "distress" and that R1 was a full code. Z3 stated that Z2 confirmed with the nurse in the resident's room what R1's code status was. Z2 was told by nursing home staff, R1 was a full code. Z3 stated CPR was initiated at that point, as R1 had no pulse and agonal breathing. On [DATE] at 9:55 a.m., E2 (Director of Nursing) stated E4 phoned on [DATE], indicating R10 had left the building for lunch and R10 had been called to the other side of the facility because R1 was unresponsive. E2 instructed E4 to call an ambulance and verify R1's code status. E2 immediately came to the facility. Upon arrival, the first responders were wheeling R1 out on a stretcher. E2 obtained R1's medical record and was the first responders had initiated CPR on R1. E2 immediately called the emergency room and instructed the nurse that R1 had a valid DNR in effect. On [DATE] at 1:08 p.m., E10 (Licensed Practical Nurse) stated R1 was assigned to (E10) as a patient on the day shift of [DATE]. E10 stated that (E10) left the building for lunch. Upon return, E10 found out R1 became unresponsive and went to the emergency room . E10 indicated, had (E10) been in the facility at the time, (E10) would have known where to locate the DNR paperwork for R1. E10 concluded, (E10) could not remember the last time inservicing on Advance Directives was provided, "if ever". On [DATE] at 12:42 p.m., E3 (Medical Director) indicated it was unknown to (E3) who exactly is responsible for letting first responders know what a resident's code status is, when responding to an emergency situation. On [DATE] at 10:04 a.m., Z1 (Power of Attorney) stated R1 has had a DNR in effect for many years and the facility was aware upon R1's admission of R1's code status. Z1 stated R1, "only wanted to die peacefully and with dignity and they took that from (R1)." Z1 stated, R1's family had to watch R1 suffer for 20 hours before R1 died (on [DATE]), because R1 was given CPR. The facility policy, titled "Advance Directive", documents "It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments, whenever possible." The "Advance Directive" policy further indicates, "This facility shall provide education to all employees regarding advance directives and the implementation of such. In-servicing of advance directive policy and procedure shall be conducted annually. New employees, within a week of start date, shall be educated by a member of the nursing staff on advance directives and his/her role in implementing the directive." An Inservice Attendance, dated [DATE] and provided by E1 (Administrator), indicates Advance Directives were discussed; however, E8, E9 and E10 are not identified as having attended the inservice. On [DATE] an Immediate Jeopardy was identified to have begun on [DATE] when facility staff failed to provide EMS with R1's DNR Advance Directive and R1 received CPR after being found in [MEDICAL CONDITION], prolonging R1's death and suffering. E1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 1:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. On [DATE], E2 and Social Services Staff immediately completed an audit of all resident's Advance Directives. 2. On [DATE], E2 initiated an investigation into the [DATE] incident involving R1. 3. On [DATE], E2 conducted an all staff inservice regarding the facility policy on Advance Directives and their location in the medical records. 4. Management Staff will continue to review the resident Advance Directive for accuracy, with all Quarterly Assessments, Annual Assessments and significant changes. 5. The Social Services Department has been directed to notify Management Staff of changes to one's Advance Directive and those changes will be Care Planned as needed. 6. E2 will educate Nursing staff once per month, for the next three months, regarding Advance Directive Policy and the location of code status in the medical record. 7. E2 and Social Services Staff will present all concerns to E1 (Administrator) during the daily and quarterly Quality Assurance Meeting. 8. For all residents who do not have a red or green DNR in their medical record, E2 has obtained a new DNR and is in the process of obtaining signatures from the necessary parties in an effort to maintain continuity.

Based on observation, interview, and record review the facility failed to: 1) Identify R21's behaviors were potentially dangerous to self and other residents, failed to follow R21's care plan by removing R21 from potentially harmful situations, failed to protect R33 from a potentially harmful situation, failed to provide adequate supervision to R21, and failed to protect other residents when R21 was displaying unusual behaviors. R21 threw a wheeled walker at R33 who was sitting in a wheelchair. R21 threw shoes towards staff, residents, and visitors, and into the laps of residents. R21 threw shoes while in the hallway and dining room which were areas accessible by all facility residents. R21 grabbed at silverware while sitting at a table in the dining room with R1, R18, and R47. R21 threw silverware across the floor while in the dining room. R21 threw a toy while in the activities office with E2 (Director of Nurses). These failures resulted in an Immediate Jeopardy and have the potential to effect all 61 residents in the facility. 2) The facility also failed to follow the plan of care for three of nine residents (R3, R16, and R20) identified as increased risk for falls in a sample of 15 and, 3) The facility also failed to keep 18 multi-dose vials of insulin in a secured, locked area that is not accessible to cognitively impaired, wandering residents. This deficient practice affected six of six residents (R1, R5, R6, R7,R16, R18) who were ambulatory or could self propel a wheelchair, and were confused in a sample of 15 and 25 residents (R2, R9, R10, R12, R13, R24, R26, R29, R34, R36, R41-R44, R46-R49, R53-R55, R60-62, R64) in the supplemental sample. While the Immediate Jeopardy was removed on 6-13-13, the facility remains out of compliance at severity Level Two. Additional time is needed for the facility to complete staff education on behavioral monitoring, monitor the effectiveness of the implementation of protocols, and for oversight visits.Findings include: 1) A physician's orders [REDACTED]. The POS documents that 6-05-13 a physician's orders [REDACTED]." A Minimum Data Set (MDS) assessment dated [DATE] documents that R21 is severely cognitively impaired, has no range of motion limitations, and has had, "physical behavioral symptoms directed toward others." one to three days per week. The MDS includes the definition of physical behavioral symptoms as, "hitting kicking, pushing, scratching, grabbing..." A care plan dated 5-02-13 documents that R21 also has a [DIAGNOSES REDACTED]." The care plan also documents that R21, "has risk factors that require monitoring to reduce potential for self injury." The care plan includes interventions for R21's behavioral symptoms which include: "Remove resident from potentially harmful situations to self or others...Calmly inform resident that behavior is hurtful...Review abnormal behaviors with IDT (Interdisciplinary Team)." On 6-12-13 at 3:30p.m. R33 was sitting in a wheelchair at the nurse's station. R21 was sitting in the C/D hallway in front of the nurse's station with a walker in front of R21's chair and with E20 (Certified Nurse Aide) and E15 (Licensed Practical Nurse) standing on either side of R21. R21 was displaying symptoms of agitation which included pushing R21's walker with enough force to cause the walker to leave the ground and hit the back of R33's wheelchair, located approximately five feet away. When R21's walker hit R33's wheelchair, R33 cried out, " Ouch!" E15 and E20 did not turn their attention to R33 to see if R33 was injured, but instead attempted to calm R21. R21 was able to push the walker across the floor a second time without making contact with R33 who remained present and within approximately five feet. At 3:35p.m. E2 (Director of Nurses) approached the A/B hallway nurse's station to assist E15 and E20 with calming R21. R21 continued to display agitated behavior, which included throwing shoes, pushing E15, E20 and E2 for a total of approximately 15 minutes before R21 was transferred to a recliner chair and taken outside to the facility patio area to calm down. On 6-13-13 at 2:00p.m. E20 (Certified Nurse Aide) stated that in the afternoon of 6-12-13 at around 3:00p.m. she had noticed that R21 was repeatedly trying to stand up out of the high backed wheelchair. E20 stated that she (E20) decided to take R21 for a walk, using R21's walker, down the D wing hallway. E20 stated that when E20 and R21 arrived near the facility beauty shop and across from the nurse's station R21 kept, "trying to sit on the floor and take R21's pants off." E20 stated that E15 (Licensed Practical Nurse) brought a chair for R21 to sit in. E20 stated, "When we tried to sit R21 down in the chair, R21 took R21's shoes and socks off, then threw the walker." E20 stated, "This week R21 was more agitated than usual...Yesterday was the first time I saw R21 try to bite self." On 6-11-13 at 10:00a.m. R21 was in E2's (Director of Nurses) office sitting in a chair while E2 and E3 (Assistant Director of Nurses) were present. R21 was agitated and anxious, fidgeting in the chair and rapidly sitting and standing. R21 took off one of R21's shoes and threw it in the direction of E3. E2 and E3 laughed after R21 threw the shoe with E3 stating, "She does that." On 6-11-13 at 10:12a.m. R21 was sitting in the activities office with E2 (Director of Nurses)and E6 (Activities Director). R21 was holding two plastic toys, one red and one blue. R21 threw the blue toy in the direction of E2, who picked up the toy and handed it back to R21. E2 did not ask R21 to refrain from throwing the toy. On 6-10-13 at 12:42p.m. R21 was sitting in a high backed, wheeled chair in the dining room during the noon meal and with an alarm attached to the chair. R21 repeatedly stood up out of the chair causing the alarm to sound. R21 also was grabbing at the silverware on the table which was intended for R21 and R1, R18, and R47 who were seated at the table with R21. R21 was also grabbing at the centerpiece on the table. On 6-13-13 at 2:50p.m. R47 stated that during meals R47 sits at the same table as R21. R47 stated, "I just stay away from her. I don't want nothing to do with her." On 6-12-13 at 12:40p.m. E21(CNA-Certified Nursing Assistant) was sitting with R21 in R21's room with the door closed. E21 stated that R21 had to, "leave the dining room," because of R21 displaying "behaviors." A behavior tracking sheet dated 6-10-13 to 6-13-13 documents that R21 had symptoms of "restlessness" on those dates. On 6-13-13 at 2:00p.m. E2 (Director of Nurses) stated that R21 had only displayed behaviors since 6-10-13. E2 failed to recognize R21's behaviors of 6-12-13 as a physical behavior and stated that R21 only had the behavior of restlessness, not physical behaviors towards others. On 6-13-13 at 9:00a.m. E2 (Director of Nurses) stated that she had not written an incident report about R21's behaviors, which including hitting R33's wheelchair with a walker, from the day before. E2 stated that she did not see R21's walker hit R33 and that because R21 was just having behaviors E2 did not think an incident report was necessary. E2 stated that E1 (Administrator) was not notified of R21's behaviors either. E2 stated that R21 had not displayed any behaviors until, "this week." E2 stated that R21 had been taking an antibiotic for a Urinary Tract Infection (UTI) and that R21's behaviors were "probably" a result of the UTI. On 6-13-13 at 2:20p.m. E15 (Licensed Practical Nurse) stated that when R21 became agitated on 6-12-13, E15 thought the incident was because R21 does not like using a walker and that E20 (CNA) was walking R21 with a walker. E15 stated that while R21 was agitated R21 "threw shoes and R21's walker. I was trying to keep it from going too far." E15 stated that R21, "wasn't angry but more like frustration. R21 started to settle down after R21 went outside." E15 stated that R21 had never displayed behavioral symptoms until that week. On 6-13-13 at 12:00p.m. E21 (Certified Nurse Aide) stated that R 21 had been taken to R21's room during the noon meal on 6-12-13 because R21 had been, "throwing shoes and silverware across the floor." E21 stated that she noticed R21 had a restlessness about her the day before. On 6-13-12 at 12:15p.m. E19 (Certified Nurse Aide) stated that R21, "Does have some behaviors." E19 stated that sometimes R21, "takes off her clothes and screams when she gets mad," and that, "I've seen a slipper go into a resident's lap before." On 6-13-13 at 12:40p.m. E24 (Certified Nurse Aide) stated, "I don't know if, with everyone here, (that) has made R21 nervous or R21 feels tension." Nurse's notes dated 4-22-13 to 6-12-13 document that R21 frequently refused medications and had once thrown a liquid medication when it was given to R21. The nurse's notes do not document any of R21's behaviors which occurred 6-10-13 to 6-12-13. On 6-10-13 at 9:40a.m.during a tour of the facility E3 (Assitant Director of Nurses) stated that R21 and R18 are roomates. A Minimum (MDS) data set [DATE] documents that R18 is Severely cognitively impaired, requires extensive assitance to ambulate. On 6-10-13 at 12:50p.m. E8 (Certified Nurses Aide) stated that R18 is mostly nonverbal. E8 stated that R18 speaks sometimes but not that often. E8 stated that R18 is unable to get out of bed without assistance. On 6-13-13 at 12:30p.m. E4 (Care Plans/Minimum Data Set Coordinator) stated that R21 was assessed as having physical behaviors directed toward others on the initial Minimum Data Set (MDS) because R21 is, "like a child, always reaching and grabbing." E4 stated that R21, "occasionally tossed R21's shoe, but never at anyone. It (assessing R21 with physical behaviors towards others) was just to make everyone aware that R21 is mentally handicapped." E4 stated that E5 (Social Services Director)completed section E of the MDS which included physical behaviors towards others. On 6-13-13 at 12:40p.m. E5 (Social Services Director) stated that E5 didn't know why E5 had documented R21 as having "physical behavioral symptoms directed towards others," such as hitting, kicking, pushing, or scratching. E5 stated that the reason E5 had documented R21 as having behavior symptoms on the MDS was, "Maybe because R21's grabby. R21 likes to grab things." A behavior tracking log dated 6-10-13 to 6-13-13 documents that R21 had "Restlessness" on those dates. The behavior tracking log does not include when R21 threw shoes while sitting in E2's office or E6's (Activity Director) office. A facility document called Managing Resident Behavior (undated) documents that the facility must document resident behaviors. The document indicates that when a resident starts to get agitated that staff should ,"isolate the situation by removing the audience..." A facility document called Golden rules for Working with All Residents (undated) indicates that the facility should,"Maintain an ongoing, regularly updated assessment. On 6-13-13 at 9:00a.m., an Immediate Jeopardy was identified to have begun on 6-12-13 at 3:30p.m.when facility staff, including E2 (Director of Nurses) failed to protect R33 who was sitting at the D wing nurse's station and vulnerable to further harm by R21 while R21 was exhibiting physically aggressive behaviors. E2 did not notify E1 (Admoinistrator) of the incident and the state agency was not notified of the incident. E1 (Administrator) and E25 (Corporate Nurse) were notified of the Immediate Jeopardy on 6-13-13 at 3:40p.m.The surveyor confirmed through inteview and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R21 was removed from the facility and sent to the emergency room for evaluation of escalating behaviors on 6-13-13 as soon as the Immediate Jeopardy investigation was initiated.2. The facility started an investigation into the incident from 6-12-13 involving R21 which caused the Immediate Jeopardy. 3. An initial Illinois Department of Public Health report was faxed to the State Agency. 4. R33, resident involved in incident with R21, was interviewed. 5. R21's physician was notified of the incident and a statement regarding R21's history of behaviors was received. 6. All facility staff present at the time of the Immediate Jeopardy 6-13-13, and all facility staff who were scheduled to work the next shift 6-13-13 following the immediate jeopardy were provided with education on behaviors/interventions/ potential behaviors. 7. In-service to E2 (Director of Nurses) and E3 (Assistant Director of Nurses) for signs of potential behaviors. 8. E5 (Social Services Director) completed assessments for Harmful Behaviors to identify others at risk for causing harm to self or others. 9. All staff will receive an in-service on behaviors, as stated in number 6, by E2 (Director of Nurses) and E3 (Assistant Director of Nurses) prior to working next scheduled shift. 2) On 6-11-13 from 8:30 a.m. to 10:00 a.m., R3 was in bed, sleeping, with a pressure pad alarm on. R3's high back wheelchair remained beside R3's bed in an unlocked position. R3's quality care reporting form dated 5-18-13 at 3:15 p.m., documents R3 ambulated out of bed, without assistance, to get into R3's unlocked (high back wheelchair) and fell . According to R3's 5-18-13 quality care report, actions taken to prevent further falls are to keep the (high back wheelchair) next to R3's bed, within R3's reach and in locked position, while R3 is in bed. On 6-11-13 at 10:00 a.m., E1 (Administrator) verified R3's high back wheelchair was in an unlocked position, while R3 was in bed, and should have been locked to prevent R3 from falling. b) R16's quality care reporting form dated 10-26-12 at 3:00 p.m., documents R16 attempted to transfer self to bed and fell , resulting in a right wrist skin tear and a left forearm abrasion. R16's pressure alarm did not sound. According to the 10-26-12 quality care report, the alarm was not turned on by facility staff, and the staff member was reprimanded for not following R16's plan of care to prevent falls. On 6-11-13 at 10:30 a.m., E1 (Administrator) verified R16 fell on [DATE] at 3:00 p.m., due to facility staff not turning on R16's pressure alarm, resulting in R16 receiving a right wrist skin tear and a left forearm abrasion. c) On 06/10/13 at 9:47 a.m., R20 was sitting in a high back wheelchair alone in (R20's) room. On 06/11/13 at 8:17 a.m., 9:35 a.m., and 12:10 p.m., R20 was sitting in a high-back wheelchair alone in (R20's) room. R20's current fall care plan dated 04/25/13 documents the intervention, "keep in supervised area when out of bed." On 06/11/13 at 12:12 p.m., E27, Licensed Practical Nurse, verified R20 was currently sitting in a high-back wheelchair unsupervised in (R20's) room. E27 stated (E27) was unsure whether or not R20 was allowed to be in (R20's) room alone and placed a telephone call to E2, Director of Nursing, to verify. E27 then verified that R20 required supervision when out of bed and confirmed R20's current care plan dated 04/25/13 documents this intervention. 3) Based on observation, record review, and interview, the facility failed to keep 18 multi-dose vials of insulin in a secured, locked area that is not accessible to cognitively impaired, wandering residents. This deficient practice affected six of six residents (R1, R5, R6, R7,R16, R18) who were ambulatory or could self propel a wheelchair and were confused in a sample of 15 and 25 residents (R2, R9, R10, R12, R13, R24, R26, R29, R34, R36, R41-R44, R46-R49, R53-R55, R60-62, R64) in the supplemental sample. On 6-10-13 at 4:10 p.m., E15 (Licensed Practical Nurse) went into R56's room to administer insulin, and left an unlocked box of multi-dose vials of insulin on top of the medication cart, out of sight of licensed staff, and in the hallway for eight minutes. On 6-10-13 at 4:20 p.m., E15 went into R19's room to administer medications, and left the same unlocked box of multi-dose vials of insulin on top of the medication cart, out of sight of licensed staff, and in the hallway for five minutes. The unlocked box contained two multi-dose vials of Lantus insulin, three multi-dose vials of Novolog 70/30 insulin, three multi-dose vials of Novolin R insulin, three multi-dose vials of Levemir insulin, three vials of Novolog flex pen, two multi-dose vials of Novolin N, and two multi-dose vials of Humulin R insulin. On 6-10-13 at 4:40 p.m., E2 (Director of Nursing) stated, "the nurses are suppose to keep the box of insulins locked up, in the bottom of the medication cart". On 6-11-13 at 9:00 a.m., E2 provided a list documenting 31 residents (R1, R2, R5, R6, R7, R9, R10, R12, R13, R16, R18, R24, R26, R29, R34, R36, R41-R44, R46-R49, R53-R55, R60-62, R64) who are cognitively impaired and can ambulate or self propel their wheelchairs independently, and E2 verified all 31 residents would have access to the unlocked vials of insulin.

Based on interview and record review, the facility failed to transfer one resident (R7) out of nine sampled residents in a safe manner causing R7 to fall sustaining a skin tear. Findings include: Facility's quality Care Reporting Form states on 7-29-13 at 9:30 a.m., R7 was "transferred per one assist with no gait belt from w/c (wheelchair) to toilet. (R7) lost balance and fell to floor - CNA (Certified Nursing Assistant) relieved of duty due to not following (Facility) policy resulting in fall with injury." This report states R7 sustained an 11.5 cm (centimeter) x 4 cm abrasion to the right lower back area. R7's fall care plan updated 7-20-13 states "Use 2 assist and gait belt for all transfers." Facility's Transfer Belt/Gait Belt policy revised 4/10/06 states "All certified nursing assistants and licensed nursing personnel engaged in the lifting and transferring of residents will use gait belts...Gait belts are mandatory..." On 8-1-13 at 3:15 pm, E2 (DON/Director of Nursing) stated the CNA should have used a gait belt to transfer R7 per facility policy.