Every finding on record at Aspyre of Bronzeville

Based on observations, interviews and record reviews, the facility failed to ensure temperatures were comfortable and offer room changes to residents whose room temperatures exceeded 81 F due to air cooling units not working. This affected five (R6, R7, R8, R9, and R10) residents of 20 reviewed for physical environment. Findings include:On 7/1/2026 starting at 10:30 AM, R6's room felt hot and uncomfortable. R6's floor air conditioning wall unit (called by the facility's maintenance director, V11, a radiator) was not working. Even though it was on, no air came from its vent. R6 walked over to the unit, opened the flap and said it was not working. R6 said R6 was hot and uncomfortable.On 7/1/2026 starting at 10:30 AM, R8's air conditioning unit was on but the air coming through it was weak. R8 looked uncomfortable (seemed to have difficulty breathing) and said he was hot. The room was very warm and stuffy. On 7/1/2026 starting at 10:30 AM, R9 and R10's rooms were dark, warm and stuffy though the windows were closed, and the curtains were pulled shut. R9's roommate was asleep lying in his bed wearing shorts. On 7/1/2026 starting at 10:30 AM, R7's room was very hot and the air from the floor air conditioning unit was blowing out weak air. R7 was lying in the room alone closest to the door and farthest away from the air conditioner. R7 said the room was hot.The surveyor returned to the above rooms at 10:42 AM with V11 (Maintenance Director). V11 stated that the air thermometer device was calibrated. The room temperatures were as follows:R6's room measured 84.5F R7's room measured 89.5FR8's room measured 85.2FR9 and R10's room measured 82.9FOn 7/1/2026 at 4:00PM, the surveyor accompanied by V11 and V1(Administrator), revisited the residents' rooms that were hot and where the residents complained of being uncomfortable. The room temperatures were as follows:R6's room measured 80.4F R7's room measured 85.6FR8's room measured 83.1FR9 and R10's room measured 80.9FR7 and R8 rooms were still hot and comfortable. And residents were still in their rooms. R6 stated that R6 was offered a room changed just a few minutes ago. R7 and R8 stated R8 they were not offered a room change during the hot room temperatures.The facility failed to follow their undated Hot Weather policy that reads they will relocate residents to the cooler part of the facility and temperature and humidity should be measured in several rooms on each floor that has been identified as the warmest area of each floor or unit.

Based on observation, review of records and interviews facility failed to provide supervision, assistance, assessments and interventions to maintain the right of every resident to be free from accidents, hazards and injuries for 1 out of 1 resident (R6) for a total sample of 29 residents. These failures affected 1 resident (R6) who sustained multiple falls resulting to right arm fracture on 05/21/2025 and right hand/finger fracture on 06/14/2025.Findings include: On 09/02/2025 at 10:56 AM, R6 seen alert but had a hard time elaborating when questions asked. R6 stated he had recent fall and went to hospital by nodding his head and short statements when asked. R6 was seen with bed about 2 feet high. R6 was not able to move both extremities well more on right side grimacing upon slight movement. R6's head was positioned opposite of the wall far from bedside table where items out of reach. Review of R6 fall clinical notes and care plan documents multiple falls: R6 had an actual fall (1/30/25) with no injuryR6 had an actual fall (1/31/25) with no injuryR6 had an actual fall (3/15/25) with no injuryR6 had an actual fall (5/21/25) with injuryR6 had an actual fall (6/02/25) with no injuryR6 had an actual fall (06/12/25) with injury R6's clinical notes related to falls are as follows:Dated 03/15/2025 by V35 (Registered Nurse) R6 fell when reaching TV remote. Clinical notes document, I was trying to reach my TV remote, and I fell. R6's fall care plan dated 03/15/2025 reads, determine and address causative factors of the fall. No intervention on the care plan was done to determine or address the cause of R6's fall. Dated 05/21/2025 by V16 (Licensed Practical Nurse), R6 fell in the bathroom. Transferred to hospital admitted with closed right humeral fracture. R6 now uses right cast/wrap mold and sling. Hospital records dated 05/27/2025 documents that R6 sustained closed right humeral fracture. Dated 06/02/2025 by V9 (Registered Nurse) documents that R6 fell in his bedroom. Per V9 notes, R6 able to ambulate with assistance. Per MDS (Minimum Data Set) assessment R6 dependent to facility staff on transfers and unable or not attempted to walk due to medical condition or safety concerns. Dated 06/12/2025 by V31 (Registered Nurse) documents that R6 fell in his bedroom in front of his wheelchair. After two days on 06/14/2025 V32 (Licensed Practical Nurse) clinical notes reads right hand with large swelling, pain 9 out of 10. V34 (Nurse Practitioner) medical notes dated 06/14/2025 documents that R6 wearing soft cast on right arm / hand with pain and swelling, X-Ray pending. The same date 06/14/2025, V33 (Licensed Practical Nurse) noted X-Ray done with result of right fracture of the fifth metacarpal. R6 was sent to hospital. R6's fall care plan does not address each fall that occurred on 05/21/2025, 06/02/2025 and 06/12/2025 when R6 sustained injuries by providing interventions. Most current care plan intervention was dated 04/21/2025. R6 was assessed as high risk of fall dated 05/27/2025 the only fall assessment done since 11/24/2020. On 09/03/2025 at 2:05 PM, V20 (Restorative Nurse / Registered Nurse) after review of R6 clinical records confirmed that R6 have multiple falls. V20 stated that all falls of R6 were not addressed in his plan of care. V20 stated that most current intervention for R6 was dated 04/21/2025 which does not address repeated falls on 05/21/2025, 06/02/2025 and 06/21/2025 which R6 sustained injuries. V20 stated that R6 sustained closed right humerus fracture due to fall on 05/21/2025 and right 5th metacarpal (finger) due to fall on 06/12/2025. V20 stated that interventions needed every time R6 fall to prevent R6 from recurrent falls. V20 stated that care plan interventions should be based on assessments that needs to be reviewed from time to time to prevent falls to reoccur. On 09/04/2025 at 09:49 AM, V2 (Director of Nursing) denies any knowledge that R6 have fractures. V2 said, I don't know if there was history of fracture. V2 stated that there needs to have fall interventions because interventions are there to prevent falls. Decline of R6's functional abilities were noted based on Minimum Data Set (MDS) assessment dated [DATE] compared to 06/04/2025). 05/16/2025 assessment documents that R6 needs partial moderate assistance on transfers and ambulation. 06/04/2025 assessment after the fall dated 05/21/2025 when R6 sustained fracture injury. R6's MDS assessment documents dependent on transfers where facility staff needs to help R6 totally and unable or not attempted to walk due to medical condition or safety concerns. Per clinical notes dated 09/02/2025 by V20, R6 was transferred to hospital due to uncontrolled pain with highest pain score of 10 out of 10 and swelling of right arm. Fall Program Policy dated 03/2021provide guidance to facility staff. Per policy all residents need evaluation for falls on admission, at least quarterly after admission, change in condition and after a fall. Upon completion of the fall evaluation, residents that are identified at risk for falls develop a care plan or update. Falls will be reviewed with the Interdisciplinary Team discussions will include any trends, education needed or recommendations. Review of interventions and care plan occurs.

Based on observation, interview and record review, the facility failed to (a) provide treatment or services, equipment or device and (b) develop comprehensive care plan to address contractures for two (R4 and R34) of two residents reviewed for limited range of motion in sample of 29. This failure resulted to left hand contracture of one (R34) resident admitted with full range of motion and / or mobility status. The findings include:R4's admission record showed admit date on 5/7/24 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysarthria following unspecified cerebrovascular disease, Personal history of traumatic brain injury, Pain in left upper arm. On 9/2/25 at 11:35AM Observed R4 sitting on the side of the bed, alert and oriented x 3, responsive, nonverbal, communicate through gestures, nodding and shaking head. Observed with left hand contractures, no device in place. R4 was shaking his head side to side indicating no or he was not wearing device or splint, and range of motion exercises were not provided for his left-hand contracture. MDS (Minimum Data Set) dated 8/12/25 showed R4's cognition was intact. He had functional limitation ROM (Range of Motion) or impairment on one side of upper and lower extremities. R4 needed supervision or touching assistance with eating, oral and personal hygiene, shower / bathe self, upper and lower body dressing, chair / bed and toilet transfer; Partial / moderate assistance with toileting hygiene. MDS showed R4 received restorative nursing program for dressing and / or grooming, Communication. OT (Occupational Therapy) evaluation note dated 5/10/24 showed R4's LUE (Left upper extremity) ROM (Range of Motion) assessment was Impaired. R4's OT Discharge summary dated [DATE] showed recommendations not limited to Restorative range of motion program.Functional abilities and goals assessment dated [DATE] showed R4 had Impairment on one side of the upper extremity ROM.Restorative observation and planning assessment dated [DATE] showed R4's LUE (Left upper extremity) ROM (Range of Motion) deficit. Restorative programs: Communication, Dressing / Grooming.R4's EHR (Electronic Health Record) did not reflect R4 was provided with restorative nursing program for ROM.Reviewed R4's care plan, did not reflect plan of care for left hand contracture.R34's admission record showed initial admit date on 3/21/24 with diagnoses not limited to Peripheral Vascular Disease, Thrombosis of atrium, Hypertensive heard disease, Acquired absence of left leg below knee, Human immunodeficiency Virus (HIV) disease, Unspecified mental disorder. On 9/2/25 at 11:42AM Observed R34 sitting up on wheelchair, alert and oriented x 3, verbally responsive, with left below knee amputation. Observed left hand contracture, not able to open middle, ring and little fingers on left hand. No device or splint on left hand. R34 said he has been residing in the facility for over a year, and he developed contracture on left hand about 6 months ago while residing in the facility. He said left hand contracture started when he had a fracture from a fall incident in the facility. MDS admission assessment dated [DATE] showed R34's cognition was severely impaired. R34 had no functional limitation in ROM or no impairment on both upper extremities. MDS dated [DATE] showed R34's cognition was moderately impaired. He had functional limitation in ROM or impairment on one side of the upper extremity. He needed supervision or touching assistance with eating, upper body dressing; Substantial / maximal assistance with oral, toileting and personal hygiene, shower / bathe self, lower body dressing, chair / bed and toilet transfers. MDS showed R34 received restorative nursing program for Active ROM and dressing and / or grooming. OT (Occupational Therapy) evaluation and plan of treatment report dated 3/22/24 showed R34's left upper extremity ROM was within functional limits or no impairment. OT evaluation and plan of treatment report dated 4/22/24 showed R34's left upper extremity (LUE) ROM was impaired, no contracture.R34's OT discharge summary report dated 7/17/24 showed recommendations not limited to restorative program for LUE PROM (Passive Range of Motion) and RUE AROM (Active Range of Motion). R34's EHR reviewed, no documentation found that PROM (Passive Range of Motion) to LUE was provided to R34.OT evaluation and plan of treatment report dated 10/16/24 showed R34's left upper extremity (LUE) ROM was impaired, left-hand contracture (middle, ring and little finger). R34's OT discharge summary report dated 11/26/24 showed recommendations not limited to: Restorative program for left hand PROM. Splint and brace program. Left hand contracture cushion to be worn daily (evening) or as tolerated. R34's EHR (electronic health record) reviewed, no documentation found that PROM and splint or brace to left hand were provided to R34.OT evaluation and plan of treatment report dated 6/16/25 showed R34's LUE ROM was impaired, left-hand contracture. R34's OT discharge summary report dated 7/11/25 showed recommendations not limited to: Restorative ROM program. PROM to left hand. R34's EHR reviewed, no documentation found that PROM to left hand was provided to R34.Care plan reviewed, no plan of care found to address or focus R34's left hand contracture. Functional abilities and goals assessment dated [DATE] showed R34's ROM had no Impairment. Functional abilities and goals assessment dated [DATE] showed R34's ROM had Impairment on one side of the upper extremity. On 9/3/25 at 2:42PM V20 (Restorative Nurse, Registered Nurse / RN) stated she started working in the facility in July 2025. She said if resident has limited ROM or contractures, should provide restorative programs such as AROM / PROM or rehab evaluation and treatment if appropriate. V20 said the goal is to maintain resident's functional mobility, prevent contractures or further contractures. She said if resident has hand contracture, palm protector / splint could be provided. V20 said care plan should be developed for limited ROM or Contracture so staff would know the plan of care or what to focus on the resident. She said the purpose of splint or brace is to prevent further contracture or possible injury. V20 said resident's care plan should be individualized to address concern / problem and would include goals, interventions / approaches. Stated does not know if R4 and R34 have limited ROM or contracture because she is new to the facility. Surveyor reviewed R4 and R34's EHR with V20. She said R4 is on restorative program for communication and dressing / grooming. She said if there is limited ROM / Contracture, PROM or AROM could be provided to resident. V20 was not able to find documentation if AROM / PROM was provided to R4's LUE impairment. Stated she could not find care plan for R4's LUE impairment or left-hand contracture. V20 said R34 has limited ROM / impairment on one side of the upper extremity. She is not sure if R34 has left hand contracture. V20 said could not find care plan for left hand contracture on R34's EHR. Stated she does not know if PROM or splint was provided to R34's left hand because she is new to the facility and she was not able to find documentation in R34's EHR.On 9/4/25 at 10:21AM Surveyor and V20 checked R4 and R34. V20 said R4 and R34 have contractures to left hand, no device / splint in place to affected area. On 9/4/25 at 10:34AM V30 (CEO of ARC Rehab, OT / Occupation Therapist) was interviewed via phone and reviewed R4 and R34's EHR. She said R4's last OT evaluation and treatment was on 5/10/24 until 6/7/24. V30 said per documentation R4's LUE ROM was impaired, with contractures. She said R4's treatment goal was splinting on LUE / left hand. V30 said R34's initial OT eval and treatment was on 3/21/24 to 4/3/24. She said R34 was evaluated by OT on 3/21/24, documentation showed both upper extremities ROM within functional limits, no impairment on right and left UE, No contracture. V30 said R34 had another OT eval and treatment on 10/2024 to 11/2024. She said R34's LUE with impairment and contracture to left hand. V30 said treatment goal included donning and doffing of splint on the left hand and wearing hand splint finger contracture and decreasing pain. She said R34 last OT eval and treatment was on 6/16/25 to 7/11/25. V30 said R34 had LUE impairment or left-hand contracture. Stated R34's treatment goal included wear palm roll or hand splint on left hand.On 9/4/25 at 11:25AM V2 (Director of Nursing / DON) stated if there are limited ROM / contractures, resident should have Restorative nursing program like ROM as appropriate. She said it should be a team effort and what is best for the resident. V2 said the goal is to maintain resident's ROM, prevent contractures or further contractures, if possible, by giving or providing resident with necessary or appropriate services or care best for the resident. On 9/4/25 at 12:08PM V27 (MD / Medical Doctor) was interviewed via phone and stated contractures could be preventable by giving resident necessary services such as hydration, nourishment, therapy, restorative nursing programs. Stated he knows R34, and he is the attending physician. V27 said R34 has multiple comorbidities, he has HIV and muscle weakness / wasting that could possibly lead to limited ROM or contractures. He said the goal is to prevent contracture or further contracture by giving appropriate services or care needed for the resident. Facility's Restorative Nursing policy dated 3/2021 showed in part: The facility shall ensure that restorative care approaches and principles aimed at improving, preventing decline or maintaining a resident's functional level and quality of life are integrated into the individualized plan of care. If therapy department determines that skilled therapy is not indicated, Restorative nursing recommendations will be forwarded to the Restorative Nurse. The Restorative Nurse will initiate individualized goals and objectives based on therapy recommendations and monitor the implementation of the plan of care. Care plan will be individualized and specific to the resident needs. Evaluation and reevaluation fo the resident's status is ongoing and at least quarterly.

Based on observation, interview and record review, the facility failed to follow their policy and procedure for preventing foodborne illnesses to ensure dairy in the main cooler was discarded by the best by date, and to ensure staff was wearing hair restraint while in the kitchen. These failures have the potential to affect all 143 residents in the facility who are receiving oral diet.Findings Include: On 9/2/25 at 9:54 AM, during the initial tour in the kitchen with V4 (Dietary Manager), surveyor found a carton of 2% milk labeled with best by date of 6/11/25. V4 stated it should have been discarded and not be stored in the main cooler.On 9/3/25 at 11:07 AM, surveyor observed V25 (Director of Rehab) entered the kitchen with no hair restraint on. V4 stated that everyone entering the kitchen should wear hair restraint to prevent hair contaminating the food.On 9/3/2025 at 12:01 PM, V4 further stated that foods or dairies stored in the main cooler should be discarded the day of the best by date because it may not be any good and should not be given to the residents. V4 stated nothing spoiled should be given to the residents because it could cause food poisoning or food borne illness.The facility's 9/2/25 residents' roster documents 144 residents in the facility with 1 resident who is NPO (Nothing By Mouth).The facility's Personal Hygiene and Attire (no date) documents in part: Incorporate appropriate personal habits and hygiene that minimize the risk of food-borne illness. Hair restraints acceptable in your operation (hair net, visor, cap or hat, other). The facility's Kitchen/Dietary Guidelines dated 4/20 documents in part: Hairnets, caps, or other approved coverings are mandatory for all staff working in food preparation, storage, or service areas.The facility's Storage, Rotation, and Disposal of Foods dated 4/20 documents in part: Food items past their expiration date, use-by date, or showing signs of spoilage (e.g., odor, discoloration, texture changed must be removed.

Based on observation, interview and record review, the facility failed to ensure the dumpsters and garbage bins were properly covered and not overflowing to prevent the harborage and feeding of pests. This deficient sanitation practice has the potential to affect all 144 residents residing in the facility. Findings Include: On 9/2/25 at approximately 10:00 AM, V4 (Dietary Manager) brought surveyor outside to inspect the facility's dumpsters. Surveyor observed two dumpsters with the lid not fully closed due to overflowing of garbage. V4 stated that all dumpsters should be fully closed to prevent rodents and other pests' infestation. V4 stated, They did not pick up the garbage this morning. V4 stated that pest will be all over the overflowing garbage and residents will be at risk to get sick. V4 stated, They called me yesterday saying garbage was overflowing. [V1 (Administrator)] called the company, and they said they will pick them up this afternoon. Surveyor also observed in the basement hallway by the kitchen one black garbage bin and two gray garbage bins with no covers filled with waste from the kitchen, and one yellow cart with no cover overflowing with black garbage bags. V4 stated they were garbage collected by housekeeping from all floors. The facility's Garbage Disposal policy dated 4/20 documents in part: To prevent odors, minimize breeding places for insects and rodents, maintain sanitary conditions, and ensure service areas remain lean and safe. Use garbage cans that are leak-proof, non-absorbent, and have tight-fitting lids. Empty garbage cans as they become full. Do not allow overflow. Keep garbage can lids closed. Keep open garbage cans away from food production areas. The facility's roster dated 9/2/25 documents 144 residents residing in the facility.

Based on observation and interviews facility failed to ensure 3rd floor corridor handrails used by residents are firmly secured. These failures have the potential to affect 63 residents' safety when using handrails for support.Findings include: On 09/02/2025 at 11:15 AM In the hallway near the nurse station, resident using a wheelchair was using handrails when locomotion. Handrails was seen moving when resident holds to move his wheelchair. Close view of handrails shows that it easily wobbles with slight pressure. Brackets are loose that may detach upon further pressure. On 09/02/2025 at 12:32 PM with V12 (Walker Maintenance Director) went to check the handrails. V12 held and moved the rail that was loose. V12 saw that there was one bracket missing and 2 brackets that has one loose screw instead of 2 screws. Handrails has a total of 4 brackets to support its structure. V12 stated, yea, this is loose. this is located at northwest area of the nurse station. V12 said that handrails are required because it gives support to those that needs to get up while using a wheelchair. Handrails needs to be maintained and checked for safety. V1 (Administrator) was made aware of concern, stated that facility does not have policy specific to handrails and only has maintenance policy. Maintenance policy dated 04/2020, maintenance service shall be provided to all areas of the building, grounds and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in safe and operable manner at all times. The Maintenance Director is responsible for developing and maintaining a schedule of preventative maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

The facility failed to ensure reusable medical equipment (blood pressure monitor) was cleaned and sanitized between residents use and failed to ensure proper PPE (Personal Protective Equipment) was worn during care of one (R1) resident on Enhanced Barrier Precautions with a Nephrostomy tube. The facility also failed to perform hand hygiene during and after performing direct care and catheter care for 1 (R41) resident on Enhanced Barrier Precautions. This failure has the potential to affect all residents residing on the second and third floors of the facility.Findings Include:Findings include: R41 is [AGE] years old with initial admission date of 07/17/2024. R41 diagnosis includes type 2 diabetes and kidney transplant. R41 has a BIMS of 15 dated 06/24/2025 that means resident cognition is intact. R41 has an order for enhanced barrier precautions due to urinary catheter and wounds. On 09/02/2025 at 10:10 AM inside R41's room, V13 (Certified Nursing Assistant) was preparing R41 for appointment. R41 said that he is going to his kidney appointment. V13 was seen changing clothes of R41, performing care of R41's urinary catheter. V13 stated that he gave R41 bed bath when asked about why moving side table was wet. V13 then transferred R41 from bed to wheelchair in a hugging position. Urinary catheter bag was seen on R41's bed. V13 then attached urinary bag to R41's right leg. During all these care, handwashing or hand hygiene was not performed. V13 uses single glove not changing and without gown. On 09/02/2025 at 10:23 AM, V14 (Registered Nurse) stated that nursing staff needs to use gown and gloves when performing patient's care. Pointing to the poster that reads: Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Staff must also wear gloves and gowns for the following high-contact resident care activities that includes dressing, bathing, transferring, providing hygiene, device care or use that includes urinary catheter. V14 stated that the purpose is to prevent the spread of infections. V13 stated that the purpose of using PPE for residents on transmission barrier precaution is prevent potential infection. V13 said, I forgot to use gown and change gloves during care. On 09/04/2025 at 09:49 AM V2 (Director of Nursing) stated that gloves and gown, catheter care needs gloves and gown. Nursing staff needs to perform handwashing before and after performing care. Enhanced Barrier Precautions dated 12/2019 policy purpose is to prevent the spread of infections in facilities. To use PPE based on anticipated exposure. Hand Hygiene Policy dated 08/01/2015: All personnel are responsible for hand hygiene. Wash hands with a non-antimicrobial soap and water or an antimicrobial soap and water when hands are visibly dirty or contaminated. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. After moving from a contaminated body site to a clean body site during patient care. R109 has diagnosis not limited to Cerebrovascular Disease, Hypertensive Heart Disease with Heart Failure and Hyperlipidemia. 0n 09/02/2025 at 09:37 AM V5 (Registered Nurse) entered R109 room and said to R109, come out and take your blood pressure. At 09:40 AM V5 placed the blood pressure cuff on R109's right arm while standing at the medication cart with a blood pressure reading of 81/54 pulse 100. V5 placed the blood pressure cuff on R109 left arm and rechecked R109's blood pressure with a reading of 104/75 pulse 101. V5 placed the blood pressure cuff on top of the medication cart without cleaning/sanitizing it. R96 has diagnosis not limited to Anemia, Malignant Neoplasm of Upper Lobe, Right Bronchus or Lung, Hypertensive Heart Disease, Facial Weakness Following Unspecified Cerebrovascular Disease, Primary Generalized (Osteo)Arthritis, Lack of Coordination, Constipation, Chronic Pain, Sleep Disorder, Neuralgia and Neuritis, Simple Chronic Bronchitis, Sciatica, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Major Depressive Disorder. On 09/02/25 at 09:51 AM V5 (Registered Nurse) picked up the blood pressure monitor from the medication cart, entered R96's room, placed the blood pressure cuff on R96's right arm, placed the blood pressure monitor on R96's bed and obtained a reading of 130/69 pulse 75. V5 exited R96's room and placed the blood pressure monitor on top of the medication cart without cleaning/sanitizing it. R92 has diagnosis not limited to Acute on Chronic Diastolic (Congestive) Heart Failure, Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure, Nonrheumatic Aortic Valve Disorder, Cardiomegaly, Peripheral Vascular Disease, Atherosclerosis of Native Arteries of Right Leg and Hypertrophic Cardiomyopathy. On 09/02/25 at 10:04 AM V5 (Registered Nurse) told R92 you are on blood pressure medications so let me take you blood pressure. V5 picked up the blood pressure monitor from the medication cart, placed blood pressure cuff on R92's left arm, placed the monitor in R92's lap and obtained a blood pressure reading of 112/48 pulse 63 then placed the blood pressure monitor on top of the medication cart without cleaning/sanitizing it. On 09/02/25 at 10:14 AM V5 (Registered Nurse) said when cleaning the blood pressure monitor, I clean it when I first start, in the middle and when I'm done. It should be cleaned between each resident with the minute wipes for infection control, to avoid passing things from one resident to the other. On 09/02/25 at 11:42 AM R1 was observed lying in bed with the urinary drainage leg bag wrapped in a brief. R1 began unwrapping the drainage bag from the brief then threw it on the floor near the garbage can and said I don't know why they wrapped it in the diaper because it is not leaking. The brief was observed to be wet with a large yellow stain. The urinary drainage bag was observed without the blue screw cap on it. R1 was observed twisting on the white extension then picked up the blue cap from the bed and tried to screw it on the extension to the urinary drainage leg bag. R1 said the leg bag is not closed, I am trying to put the blue cap on here. On 09/02/25 at 01:50 PM Enhanced Barrier Precaution signage was posted on R1's entry door. Surveyor asked V7 (Registered Nurse) to assess R1's urinary drainage leg bag. V7 said let me get some gloves and maybe I can put the blue cap back on. V7 reentered R1's room at 01:51 PM put on gloves and attempted to screw the blue cap back on the urinary drainage leg bag. V7 said I fixed it for you, and I put the cap back on it. V7 emptied the urine from the drainage bag into a urinal. V7 removed her gloves then picked up the soiled brief from the floor and placed it in the garbage can. V7 did not have the required PPE (Personal Protective Equipment). V7 said I have worked here since December. R1 gets up out of the bed and is on Enhance Barrier Precautions. I should have had on gloves, mask and a gown when doing care. I am not sure why R1 urinary drainage leg bag was wrapped in a diaper. I put the blue cap back on there, made sure it was working and not leaking. There is a potential for infection. On 09/04/25 at 09:06 AM V2 (Director of Nursing) stated my expectations of the staff when using the blood pressure monitor is to use the proper size and cleaned it between residents with the antibacterial wipes. If the blood pressure monitor is not clean/sanitizing between residents, there is a potential to transmit anything from one resident to another. My expectation for the care of a resident with a nephrostomy tube is that all care is to be given as ordered. For the resident on EBP (Enhanced Barrier Precautions I expect the precautions to be followed when providing care for the resident. Gloves and gowns should be worn. If the PPE (Personal Protective Equipment) is not worn there is a potential for cross contamination. If the urinary drainage is leaking, it should not be wrapped in a brief. The urinary drainage leg bag should be connected to R1's leg. If the urinary drainage leg bag screw cap was off it is the best interest to change the leg bag. There is a potential for contamination that can possibly lead to a urinary tract infection. Enhanced Barrier Precautions signage indicated Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident care activities: Device care or use: central line, urinary catheter, feeding tube. Policy: Titled Cleaning Titled Enhanced Barrier Precautions effective date 12/19 document in part: 1. Enhanced Barrier Precautions are a new approach for preventing the spread of infections in facilities. 3. Enhanced Barrier Precautions are focused on residents with MDRO (Multi Drug Resistant Organisms) colonized and infected residents. 4. Enhanced Barrier Precautions will be in place for residents with wounds, indwelling medical devices (catheter) regardless of MDRO status to address the issue of unknown colonization status and silent spread of MDRO's. Standard: 1. Enhanced Barrier Precautions expand the use of PPE (Personal Protective Equipment) beyond standard precautions and in situations when Contact Precautions do not apply. Procedure: Gloves and gowns should be used when providing the following High-Contact activities: g. Device care or use of a device: catheter. Titled Cleaning and Disinfection of multi-use equipment effective dated 03/21 document in part: To prevent inadvertent contamination and ensure surfaces and equipment may be cleaned per the manufacturer's recommendations. Procedure: Wipe the item thoroughly following the manufacturer's recommended contact time and cleaning instructions.

Based on observations, interviews and record review the facility failed to label/date medications when opened and remove expired medications from the medication carts and medication room during review of medication storage and labeling.Findings Include:On 09/02/25 at 12:52PM the third floor A medication cart was reviewed with V7 (Registered Nurse) R100's Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 inhalation inhale orally one time a day dispensed 08/15/25 was observed in the medication cart with no label/open date. V7 said when the inhalers are opened, they are supposed to be dated. One multi dose vial of Lantus insulin 100/units/ml was observed in the medication cart drawer open with no date with a label indicating discard after 28 days. Surveyor asked V7 what could potentially happen if the Lantus insulin was used passed the 28 days. V7 responded, it does not have the potency. R101's multi dose vial of Lispro insulin 100 units sliding scale was observed in the medication cart drawer labeled with an open date of 06/25/25, expires 07/23/25. V7 said it was supposed to be discarded on 07/23/25. When medication expires, we put it in the discard bin, and it gets sent back to pharmacy. On 09/03/25 at 10:47 AM the 2ND floor team b medication cart was reviewed with V16 (Licensed Practical Nurse). Docusate Sodium 100 MG with an expiration date of 07/25, Senna Plus 100 tablets with an expiration date of 06/25 100 and Vitamin C 500 MG with an expiration date of 08/25 were observed in the top drawer of the medication cart. V16 said I will toss those; they should have been taken out of the medication cart.On 09/03/25 at 10:57 AM the second-floor medication room was reviewed with V16 (Licensed Practical Nurse). One vial of Tuberculin Purified Protein Derivative 5 tu/0.1 ml was observed in the medication room refrigerator open/undated. R112's multidose vial of Lantus insulin and R112's multidose vial of Humulin R insulin 100 unit sliding scale was observed in the medication room refrigerator open/undated. (R112's Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units if above 401 call md, subcutaneously two times a day for was Discontinued on 07/19/25). Floor stock Vitamin C 250 MG with an expiration date of 12/24 and Vitamin D 10 MCG 400 iu with an expiration date of 05/25 was observed on a shelf in the medication room.On 09/03/25 at 11:06 AM the 1st floor medication cart was reviewed with V17 (Registered Nurse). Senna plus 100 tabs with an expiration date of 06/25 and One Daily Multi Vitamin with an expiration date of 08/25 was observed in the top drawer of the medication cart. V17 stated they should have been taken out of the medication cart.On 09/04/25 at 09:06 AM V2 (Director of Nursing) stated Expired medications should be removed from the cart and medication room then discarded. Expired medications should not be administered. If expired medications are administered, they could have an adverse reaction. If the nurse does not have a certain stock medication on the cart, they should come downs stairs and get it. Medication should not be taken from the original container and stored in a medication cup for administration, so we don't make mistakes. My expectations when a multidose insulin vial, multidose Tuberculin vial or inhaler is opened is that it need to be dated and stored in the proper place. Insulin and Tuberculin good for 28 days after opening. If the insulin or Tuberculin is given passed the expiration date, there can potentially be adverse reactions.PolicyTitled Medication Storage effective date 03/21 document in part: The facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines. PROCEDURE: 4. Medications that have a different route form oral are kept separated and when appropriate in labeled and dated bags in the cabinets. 7. Medications are routinely checked for expiration dates. 8. Discontinued medications are disposed of per facility policy.Titled Medication Administration effective date 03/24 document in part: To ensure that the administration of medications is performed in a safe manner to prevent medications errors. STANDARD: Medications are administered according to state and federal law. PROCEDURE: 1. Infection control practices. b. Medications are administered in a manner to prevent contamination. 2. General: No discontinued or unlabeled drugs remain on the medication cart. Multi-dose solutions/vials labeled with date opened. b. Verify the expiration date. 6. Medications are not prepared ahead of time.

Based on observation, interview and record review, the facility staff failed to reconcile and account for controlled medications accurately in 1 of 3 medication carts reviewed for medication labeling and storage.Findings Include:On 09/02/25 at 12:52PM the third floor A medication cart was reviewed with V7 (Registered Nurse). When checking the controlled substances with V7 said R100 has 25 Vimpat Oral Tablet 100 MG (Lacosamide) Twice a day for Seizure. The Controlled Drug Receipt/Record/Disposition Form document dated dispensed 08/30/25, Lacosamide Tab 100 MG take 1 tablet by mouth twice daily. Quantity dispensed, 30 amount left 26. R100's Lacosamide 100 MG medication punch card has a remaining count of 25 pills. V7 said I did not sign for the Lacosamide, 26 is documented on the sheet. It was given at 9am. R105 Phenobarbital 64.8 MG Twice a day for seizures should have 13 and there is 14 documented on the sheet. The Controlled Drug Receipt/Record/Disposition Form document dated dispensed 08/06/25, Phenobarbital Tab 64.8 MG Take 1 tablet by mouth twice daily. Quantity dispensed 30, amount left 14. R105's Phenobarbital 64.8 MG medication punch card has a remaining count of 13 pills. V7 said the Controlled Substances Check Form is signed at the beginning and end of each shift. Review of the Controlled Substances Check Form has no initials for the date of 09/01/25 7-3 on, 3-11 off, 11-7 on or 09/02/25 7-3 on. On 09/04/25 at 09:06 AM V2 (Director of Nursing) stated When administering medications the nurse should sign that the medication is given after it is given unless it is a narcotic, it should be signed before it is given. If the resident refuses the medication the nurse has to come back and waste any medications. The medication on the Medication Administration Record should be signed for after it is given. My expectations when administering narcotics and narcotic accountability is for the nurses to count the narcotics during shift change, sign accordingly and sign when the medication is given.Policy: Titled Medications-Controlled effective date 03/21 document in part: Controlled substances are signed out upon dispensing of the medication. A count of controlled drugs is maintained by nurses of the off-going and oncoming shifts. Any irregularities are reported to the director of nursing. 1. Storage of all controlled schedule II or higher substance drugs incudes: b. Nurse on duty are responsible for controlled drugs for their shift; and d. Verified by inventory every 8 hours, and/or each shift change. 2. Controlled medication documentation: a. A separate controlled substance administration control record is kept on all scheduled II or higher drugs. It contains the amount verifiable inventory. 3. Administration: a. Remove the medication from the locked container. b. Verify medication and dosage with medication sheet. c. Remove proper dose from container and place in medication cup. d. Sign out full name in appropriate space provide. e. Subtract amount given from total and verify amount remaining.

Based on observation, interview and record review, the facility failed to (a) follow oxygen liter flow as ordered by physician, (b) provide humidification for oxygen use, (c) properly stored oxygen tubing when not in use and (d) develop care plan for oxygen use for 1 (R33) of 2 residents reviewed for respiratory care in a sample of 29. The findings include: R33's admission record showed admit date on 2/11/25 with diagnoses not limited to Acute on chronic systolic (congestive) heart failure, Hypertensive heart disease with heart failure, Chronic kidney disease stage 3, Chronic obstructive pulmonary disease, Nicotine dependence. MDS (Minimum Data Set, dated [DATE] showed R33's cognition was intact. On 9/2/25 at 11:20 AM Observed R33 up and about, ambulatory with steady gait, alert and oriented x 3, verbally responsive. Observed oxygen tubing and nasal cannula placed on the bed and not properly stored, oxygen concentrator was on at 3L/min, no humidification bottle on the oxygen concentrator. R33 said he has been using oxygen most of the time. On 9/2/25 at 11:22 AM Surveyor requested V5 (RN / Registered Nurse) to R33's room and V5 said oxygen is on at 3L/min. She said if oxygen is not being used, oxygen tubing should be stored in a clear plastic bag. V5 said humidification bottle should be available, not sure why it was not available. On 9/4/25 at 11:25AM V2 (DON / Director of Nursing) said Oxygen should be administered as ordered by physician, following the liter flow. Stated oxygen tubing and nasal cannula should be stored properly in a bag when not in use. V2 said humidification should be available and should be changed weekly and as needed or as ordered by physician. Stated oxygen use should be care planned.R33's physician order summary report dated 9/3/25 showed active order not limited to: OXYGEN - Change tubing and humidifier weekly every night shift every Sunday for Weekly tubing change. Oxygen - PRN (as needed) via nasal cannula @ 2L/min. Reviewed R33's electronic health record, no care plan found for oxygen use. Facility's Oxygen therapy administration dated 3/2021showed in part: Verify order. When oxygen is not in use, store oxygen tubing and nasal cannula in labeled plastic bag. Facility's care plan policy dated 3/2021 showed in part: A person- centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing needs that are identified in the evaluation process, is developed and implemented for each resident.

Based on observation, interview, and record review the facility staff failed to provide care and services for a catheter bag for one resident. Observations of R1 revealed the attached urinary drainage leg bag was wrapped in a brief with the closure cap not in place for a resident at risk for urinary tract infections in a sample of 29.Findings include:R1 has diagnosis not limited to Gastro-Esophageal Reflux Disease, Gout, Osteoarthritis, Hypothyroidism, Pain in Left Upper Arm, Rheumatoid Arthritis, Chronic Viral Hepatitis, Hydronephrosis with Ureteropelvic Junction Obstruction, Chronic Kidney Disease, Calculus of Kidney, Major Depressive Disorder, Recurrent, Delusional Disorders, Hallucinations, Anxiety Disorder, Hypertensive Heart Disease with Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery, Hyperlipidemia, Artificial Openings of Urinary Tract Status, Presence of Urogenital Implants, Elevated [NAME] Blood Cell Count, Myocardial Infarction Type 2, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Systemic Lupus Erythematosus, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Pain In Thoracic Spine, Low Back Pain, Calculus of Gallbladder, Disease of Pancreas, Migraine, Schizophrenia, Iron Deficiency Anemia and Neuromuscular Dysfunction of Bladder.Care Plan document in part: Focus: R1 has a nephrostomy tube and is at risk for complications. Date Initiated: 02/05/25. Focus: R1 is on enhanced barrier precautions, which includes gowning and gloving for transferring, bathing, providing hygiene, changing linens, changing briefs or assisting with toileting, Incontinent care, and providing care for Nephrostomy tube. Date Initiated: 05/16/25. Interventions: Gown and glove for every time if/when R1 requires assist with transfers/bathing/dressing/hygiene care, changing linens, changing clothes and/or briefs, incontinent care, or any device care (Nephrostomy Tube). Date Initiated: 05/16/25.On 09/02/25 at 11:42 AM R1 was observed lying in bed with the urinary drainage leg bag wrapped in a brief. R1 began unwrapping the drainage bag from the brief then threw it on the floor near the garbage can and said I don't know why they wrapped it in the diaper because it is not leaking. The brief was observed to be wet with a large yellow stain. The urinary drainage bag was observed without the blue screw cap on it. R1 was observed twisting on the white extension on the urinary drainage leg bag then picked up the blue cap from the bed and tried to screw it on the extension of the urinary drainage leg bag. R1 said the leg bag is not closed, I am trying to put the blue cap on here.On 09/02/25 at 01:50 PM Enhanced Barrier Precaution signage was posted on R1's entry door. Surveyor asked V7 (Registered Nurse) to assess R1's urinary drainage leg bag. V7 said let me get some gloves and maybe I can put the blue cap back on. V7 reentered R1's room at 01:51 PM put on gloves and attempted to screw the blue cap back on the urinary drainage leg bag. V7 said I fixed it for you, and I put the cap back on it. V7 emptied the urine from the drainage bag into a urinal. V7 removed her gloves then picked up the soiled brief from the floor and placed it in the garbage can. V7 did not have on the required PPE (Personal Protective Equipment). V7 said I am not sure why R1 urinary drainage leg bag was wrapped in a brief. I put the blue cap back on there, made sure it was working and not leaking. There is a potential for infection. R1 has a nephrostomy, and this urinary bag was not broken. The drainage bag is connected to the tubing from her, and everything would have to be changed.On 09/04/25 at 09:06 AM V2 (Director of Nursing) stated My expectation for the care of a resident with a nephrostomy tube is that all care is to be given as ordered. For the resident on EBP (Enhanced Barrier Precautions I expect the precautions to be followed when providing care for the resident. Gloves and gowns should be worn. If the PPE (Personal Protective Equipment) is not worn there is a potential for cross contamination. If the urinary drainage is leaking, it should not be wrapped in a brief. The urinary drainage leg bag should be connected to R1's leg. If the urinary drainage leg bag screw cap was off it is the best interest to change the leg bag. There is a potential for contamination that can possibly lead to a urinary tract infection.Policy:Titled Nephrostomy Tube Management effective date 03/21 document in part: To provide a comprehensive approach to managing care of a resident with a Nephrostomy tube. Changing Drainage Bags: 1. Drainage bags should be changed at least every 7 days and dated. 2. If the drainage bag becomes dirty, foul smelling, or punctured, it is changed sooner.Titled Foley Catheter Use and Management Effective date 05/24 document in part: Indwelling urinary catheters should be used only when specific medical condition exists requiring the use of the catheter. PROCEDURE: 4. Proper management of resident with a Foley catheter include the following: b. A closed drainage system should be maintained. c. Urinary drainage bags should be kept below the bladder level to promote free flow of urine, by gravity. 5. Urinary leg bags should be evaluated for use, if used the following should be done. a. If a leg bag is determined appropriate, it should be only used when out of bed. b. A leg bag will be considered for discontinuation if a UTI (Urinary Tract Infection) pattern is identified. c. A leg bag should be positioned below the bladder. d. When connecting the catheter to the leg bag, follow these steps: iv. Uncap the top of the leg bag and wipe top with alcohol wipe. vi. Attach the leg bag to the catheter. vii. Apply leg straps -secure so that they are comfortable. ix. Check leg bag often and empty when needed. 7. Urinary catheter leg drainage bags are changed twice (2) a month. 10. Cleaning of Leg bags: a. Night shift will be responsible for cleaning the leg bags. e. Cleaning of the leg bag should be done every 24 hours.

Based on interviews and review of records the facility failed to maintain resident rights to access personal funds in timely manner for 1 out of 1 resident (R41). These failures affected 1 resident (R41) in his ability to support his wants and/or needs due to lack of financial funds.Findings include: R41 is [AGE] years old with initial admission date of 07/17/2024. R4 diagnosis includes type 2 diabetes and kidney transplant. R41 has a BIMS of 15 dated 06/24/2025 that means resident cognition is intact. On 09/02/2025 at 10:05 AM, R41 stated that he asked for his monthly allowance of 30 dollars on August 1 and 2. Facility staff told him (R41) that it was not yet available. R41 stated that he asked multiple times for his monthly allowance from activity staff but still have the same answer. R41 stated it was very hard because he does not have any money at all. R41 stated that because of his frustration he told the facility that he would report to the State. It was only then that facility gave him his monthly allowance. On 09/03/2025 at 10:28 AM, V15 (Business Manager) stated that facility give residents their personal funds or monthly allowance between day 2 to 5 of each month. V15 stated that itemization of personal funds is being done by corporate office. Every time resident received personal fund, a receipt will be made with residents' signature. Review of R41 July itemization documents that 30-dollar allowance was debited on July 18. V15 stated that it may be recorded but it is not the actual date of disbursement depending on the receipt. Review of R41's receipt for 30-dollar allowance for the month of August was dated on the 27 of August almost September. V15 stated that if it was available, it should have been given to R41. V15 was made aware that based on R41's itemization record of funds, R41 has enough balance to cover 30-dollar allowance at the start of August. V15 saw the record and did not comment. 09/03/2025 11:28 AM V18 (Activity Director) stated that when resident asked for trust fund it will be given right away. Once business office gave her (V18) the money, I gave it right away. V18 stated that what she received for resident's monthly allowance is always cash. V18 stated that for the current month (September 2025) business office will give her the money on Thursday (September 4) and will give it to the resident on Friday (September 5). V18 stated that monthly allowance of 30 or 60 dollars is the only money given to residents by the facility through Activity Department. V18 when made aware that R41 received his monthly allowance on August 27 almost September. V18 said, It's not that late. Under Resident Rights Policy dated 03/2021, residents will be assured of the following rights including rights regarding their money. And the right of every resident to manage their own money.

Based on interviews and record reviews, the facility failed to follow a physician's plan of care for a resident (R71) with history of significant weight loss for one resident out of a total sample of 29 residents.Findings include:F71's 'admission Record' documents in part a diagnosis of abnormal weight loss. This was acquired during R71's stay at the facility with an onset date of 3/07/2025.R71's 'Progress Notes' document in part a nutrition/dietary note from 6/04/2025. R71 lost 11.6% of body weight over six months (R71 weighed 191 pounds on 12/02/2024 and 168.8 pounds on 6/01/2025). Multiple progress notes by V27 (Physician) note R71's abnormal weight loss. Plan of care includes weekly weights. This was noted on multiple progress notes by V27 dating back to July (7/03/2025, 7/25/2025, 8/13/2025, and 8/29/2025). R71's 'Weight Summary' documents in part monthly weights. No weekly weights done in July or August. R71's 'Order Summary Report' documents in part diet orders, supplement drinks, and frozen nutritional treats but no orders for weekly weight monitoring.R71's 'Care Plan Report' documents in part unplanned/unexpected weight loss related to poor food intake and is at risk for complications (initiated 2/20/2025). Interventions do not include weekly weight monitoring.On 9/03/2025 at 3:04 PM, V20 (Restorative Nurse) stated the restorative department does the weights for the residents. V20 stated they were not doing weekly weights for R71 because there was no order for it. V20 stated no one communicated to [V20] that R71 needed weekly weights. When asked about V27's progress notes, V20 stated [V20] did not review V27's progress notes.On 9/04/2025 at 10:05 AM, V28 (Nurse) stated progress notes are there to communicate with the rest of the team. It helps everyone know what's going on with the resident and stay up to date with the plan of care. V28 stated nurses should be reading the progress notes including the physician notes. If the physician notates an intervention that is not in the orders, then the nurse should call the physician and confirm it. During a joint interview on 9/04/2025 at 10:15 AM, V5 (Nurse) and V14 (Nurse) stated progress notes help maintain an open communication with the rest of the interdisciplinary team. V14 stated progress notes contain any updates and suggestions to the residents' plan of care. If the physician updates the plan of care but it is not transcribed to the order, V5 and V14 stated the nurse should call the physician to verify the change and put it in the orders. V5 and V14 stated that the nurse should also document that they clarified the plan of care with the doctor.Facility's Physician Orders - Verbal and Fax policy (effective 3/2021) documents in part: The Physician or extender retains control of the resident's medical plan of care and is consulted when changes in condition occur, outpatient appointments with orders or any other situation that requires an alteration to prescribed treatments, medications, or additional tests.Facility's Care Plan Development policy (effective 3/2021) documents in part: The facility's Interdisciplinary Team, in consultation with the resident and his/her representative, develops and implements a person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process.Facility's Weight Management Protocol (effective 3/2021) documents in part that care plans should reflect current individualized interventions and risks. Nursing monitors completion of weights and for significant weight changes.

Based on observation, interview, and record review the facility staff failed to follow professional standards of practice with regards to medication administration by storing medication outside of its original packaging for administration. The facility also failed to ensure the physician was notified when blood pressure medications were not administered for 2 (R92, R109) of 3 (R96) residents during medication administration.Findings Include: On [DATE] at 09:37 AM V5 (Registered Nurse) entered R109's room and said to R109, come out and take your blood pressure. At 09:40 AM V5 placed the blood pressure cuff on R109's right arm while standing at the medication cart with a blood pressure reading of 81/54 pulse 100. V5 placed the blood pressure cuff on R109 left arm to recheck R109's blood pressure with a reading of 104/75 pulse 101. V5 said let me look to see if you have some blood pressure medications because your blood pressure is a little too low. V5 stated I am not giving Amlodipine; I am going to hold it because the blood pressure is a little low. R109 gets three blood pressure medications that I am going to hold. I will revisit R109 blood pressure after lunch to see if R109 needs them referring to (The blood pressure medications: Amlodipine Besylate 10 MG (Milligram) Daily, Hydrochlorothiazide 25 MG Daily and Losartan Potassium Tablet 50 MG Daily were held and not given). 1. Amlodipine Besylate 10 MG Daily (Not given) 2. Hydrochlorothiazide 25 MG Daily (Not given) 3. Losartan Potassium Tablet 50 MG Daily (Not given) On [DATE] at 09:51 AM V5 (Registered Nurse) took a medication cup stored in the medication cart drawer with Folic Acid written on it and stated I took a couple of folic acid 100 mcg from the other medication cart because when I checked the medication cart there was no folic acid, and I knew some of the residents get folic acid. V5 administered the medication to R96. 4. Folic Acid Tablet 1 MG Daily (Stored in a medication cup and not in the original packaging) R92 has diagnosis not limited to Acute on Chronic Diastolic (Congestive) Heart Failure, Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure, Nonrheumatic Aortic Valve Disorder, Cardiomegaly, Peripheral Vascular Disease, Atherosclerosis of Native Arteries of Right Leg and Hypertrophic Cardiomyopathy. On [DATE] at 10:04 AM V5 (Registered Nurse) stated I need to write a note why I did not give R109 his blood pressure medications. R92 was in a wheelchair in the hallway. V5 told R92 you are on blood pressure medications so let me take you blood pressure. V5 picked up the blood pressure monitor from the medication cart, placed the blood pressure cuff on R92's left arm, placed the monitor in R92's lap and obtained a blood pressure reading of 112/48 pulse 63. V5 said R92's blood pressure is a little low for my liking, I think I am going to hold your blood pressure medications. On [DATE] at 10:09 AM V5 (Registered Nurse) stated I am holding R92's blood pressure medications. I held the blood pressure medications, and I will check the blood pressure again after lunch referring to: (Lisinopril 10 MG Twice a day and Metoprolol Tartrate 25 MG Twice a day were held and not given). 5. Lisinopril 10 MG Twice a day (Not given) 6. Metoprolol Tartrate 25 MG Twice a day (Not given) On [DATE] at 10:14 AM V5 (Registered Nurse) stated when giving medications we check to make sure it is the right medication, right date, right time, right person and make sure it is not expired. We are not supposed to transfer the medication from the original packaging. I am going to toss the rest of the folic acid. On [DATE] at 09:06 AM V2 (Director of Nursing) stated The nurse should hold blood pressure or any medications if the blood pressure is outside of the parameters, using nursing judgement then consult with the doctor immediately to get directions if there are any abnormal blood pressures. My expectations when holding blood pressure medications is to consult with the doctor for further orders and instructions. V5 (Registered Nurse) said she notified the doctor but if it is not documented it did not happen. Potentially it depends on the patient, it is different risk for all diagnosis. I cannot say what would happen with that particular resident. The blood pressure could have potentially dropped lower or went higher depending on the resident condition. V2 was asked by the surveyor, if there is a missed dose or medication is held without a doctor order is that a medication error. V2 responded, it depends on what the documentation says, if documented it would be considered a late documentation, not a missed dose. If the nurse does not have a certain stock medication on the cart, they should come downs stairs and get it. Medication should not be taken from the original container and stored in a medication cup for administration, so we don't make mistakes. Policy: Titled Medication Administration effective date 03/24 document in part: To ensure that the administration of medications is performed in a safe manner to prevent medications errors. STANDARD: Medications are administered according to state and federal law. PROCEDURE: 4. Medication preparation/Administration. a. Five Rights: Right Medication, Right Dose. Right Time - Right Route, Right Resident/patient/guest identification by way of, photo, verbal Affirmation by staff or resident, or birth date.). c. Additional assessments are obtained prior to medication administration, such as pulse, blood pressure or oxygen level. 6. Medications are not prepared ahead of time. Document medication administration after delivering. 3. If the medication is not given or given late notify the provider for additional orders. Titled Medication Storage effective date 03/21 document in part: The facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines. Titled Physician Orders-Verbal and Fax effective date 03/21 document in part: The physician or extender retains control of the resident's medical plan of care and is consulted when changes in condition occur, outpatient appointments with orders or any other situation that requires an alteration to prescribed treatments, medications, or additional test.

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed within 48 hours - 72 hours of admission for 3 (R11, R103, R125) of 3 residents reviewed for baseline care plans in a sample of 29.Finding Include:R11 was admitted to the facility on [DATE] with diagnosis not limited to Hypertensive Heart Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Gastro-Esophageal Reflux Disease, Primary Open-Angle Glaucoma, Bilateral, Stage, Polyosteoarthritis, Schizophrenia, Hyperlipidemia and Major Depressive Disorder, Recurrent. R11's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R11's Care Plan Report document No Data Found.R11's Care Plan Report presented to the surveyor areas of Focus/Goals/ Interventions/Tasks document Cancelled and/or resolved. 40 of 40 pages document in part: Care Plan Closed Date: 08/24/23, Reason for Close: Discharge. There are no marked areas on R11's Initial Nursing Assessment interim care plan dated 08/23/25. R103 was admitted to the facility on [DATE] with diagnosis not limited to Major Depressive Disorder, Recurrent, Schizoaffective Disorder, Hypertensive Heart Disease with Heart Failure, Unspecified Psychosis, Dysphagia, Oral Phase, Constipation, Secondary Osteoarthritis, Hyperlipidemia and Alcohol Dependence with Alcohol-Induced Persisting Dementia. R103's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 06 indicating severe cognitive impact.R103's Care Plan Report with one Focus, Goal and Interventions/Task document in part: Focus: The resident is Moderate risk for falls r/t (related to) Date Initiated: 08/24/25. Goal: The resident will be free of falls through the review date. Date Initiated: 08/24/25. Interventions/Task: Anticipate and meet the resident's needs. Date Initiated: 08/24/25. There is one marked area on R103's Initial Nursing Assessment interim care plan dated 08/24/25 document in part: B. Fall Focus: The resident is Moderate risk for falls r/t. Goal: The resident will be free of falls through the review date. Intervention: Anticipate and meet the resident's needs. R103's Care Plan Report presented to the surveyor areas of Focus/Goals/ Interventions/Tasks document Cancelled and/or resolved. 45 of 45 pages document in part: Care Plan Closed Date: 08/29/23, Reason for Close: Discharge. R125 has diagnosis not limited to Paranoid Schizophrenia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertensive Heart Disease, Schizoaffective Disorder, Bipolar Disorder, Anemia, Gastro-Esophageal Reflux Disease and Hyperlipidemia.R125's Care Plan Report is incomplete and document in part: Focus: The resident has a behavior problem (SPECIFY) r/t (related to) Date Initiated: 08/27/25. Goal: The resident will have fewer episodes of (SPECIFY: behavior) (SPECIFY: daily/weekly) by review date. Date Initiated: 08/27/25. Interventions/Task: Anticipate and meet the resident's needs. Focus: The resident is (SPECIFY High, Moderate, Low) risk for falls r/t Date Initiated: 08/27/25. Goal: The resident will be free of falls through the review date. Date Initiated: 08/27/25. Focus: The resident has a psychosocial wellbeing problem (actual or potential) r/t Date Initiated: 08/27/25. Goal: The resident will demonstrate adjustment to nursing home placement by/through review date. Date Initiated: 08/27/25. Interventions/Task: Encourage participation from resident who depends on others to make own decisions. Date Initiated: 08/27/25.On 09/04/25 at 12:45 PM per telephone interview V29 (MDS/Care Plan Coordinator) stated initially the nurses on admission within 48 to 72 hours after admission is responsible for completing the baseline care plan. I review the baseline care plan and within 14 days I do the comprehensive care plan. Bowel and bladder, amount of assistance the resident needs, pain, skin, diet, if they have any medication, diagnosis pertinent, if any oral issues vision issues and behaviors should be included in the baseline care plan. The baseline care plan should be more specific than just one Focus, Goal and intervention. The purpose of the initial nursing assessment interim care plan is just to get an overall ideal of the resident needs and status so we can provide appropriate care. The information transfer from the nursing assessment interim care plan to the actual baseline care plan and they should have filled in more information.Policy:Titled Care Plan Development effective date 03/21 document in part: A person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process, is developed and implemented for each resident. Procedure:1. The facility's Interdisciplinary Team, in consultation with the resident and his/her representative, develops and implements a person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process. 7. The resident comprehensive care plan is developed within 72 hours of admission.Titled Care Plan Use effective date 03/21 document in part: The care plan is one of the tools used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Procedure: Complete care plans are available in the medical record and assessable by all care givers.Titled Care Planning-Interdisciplinary Team (IDT) effective date 03/21 document in part: The facility Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5%, by making 9 errors out of 30 opportunities with an error rate of 30%.Findings Include:On 09/02/2025 at 09:37 AM V5 (Registered Nurse) entered R109's room and said to R109, come out and take your blood pressure. At 09:40 AM V5 placed the blood pressure cuff on R109's right arm while standing at the medication cart with a blood pressure reading of 81/54 pulse 100. V5 placed the blood pressure cuff on R109 left arm to recheck R109's blood pressure with a reading of 104/75 pulse 101. V5 said let me look to see if you have some blood pressure medications because your blood pressure is a little too low. I am not giving Amlodipine; I am going to hold it because the blood pressure is a little low. R109 gets three blood pressure medications that I am going to hold. I will revisit R109 blood pressure after lunch to see if he needs them. (The blood pressure medications). There are 7 pills in the medication cup. (Amlodipine Besylate 10 MG Daily, Hydrochlorothiazide 25 MG Daily and Losartan Potassium Tablet 50 MG Daily) were held and not given. V5 administered:1. Aspirin Tablet Chewable 81 MG (milligram) Daily2. Metoclopramide HCl (hydrochloric acid) Tablet 10 MG Three times a day3. Sinemet Tablet 25-100 MG (Carbidopa-Levodopa) Three times a day4. Docusate Sodium Capsule 100 MG Daily5. Vitamin B-1 (Thiamine HCl) 1 tablet Daily6. Sertraline HCl Tablet 50 MG Daily7. Multivitamin Tablet 1 tablet Daily8. Polyethylene Glycol 3350 Powder 17 GM (gram)/SCOOP Daily9. Amlodipine Besylate 10 MG Daily (NOT GIVEN)10. Hydrochlorothiazide 25 MG Daily (NOT GIVEN) 11. Losartan Potassium Tablet 50 MG Daily (NOT GIVEN) On 09/02/25 at 09:51 AM V5 (Registered Nurse) said there is one more resident in R109's room. V5 took a medication cup stored in the medication cart drawer with Folic Acid written on it and said I took a couple of folic acid 100 mcg from the other medication cart because when I checked the medication cart there was no folic acid, and I knew some of the residents gets folic acid. There are 10 pills in the medication cup. V5 administered:1. Aspirin Tablet Chewable 81 MG Daily (ASPIRIN EC TABLET DELAYED RELEASE 81 MG WAS ORDERED)2. Ferrous Sulfate Tablet 325 (65 Fe) MG Daily3. Vitamin B12 Oral Tablet 1000 MCG (Microgram) Daily (EXPIRED 07/25)4. Folic Acid Tablet 1 MG Daily (STORED IN A MEDICATION CUP AND NOT IN THE ORIGINAL PACKAGING)5. Multivitamin Oral Tablet 1 tablet Daily6. Amlodipine Besylate Tablet 5 MG Daily7. Metoprolol Tartrate Tablet 25 MG Twice a day8. Gabapentin Tablet 600 MG three times a day9. Psyllium Oral Packet 1 packet Daily (NOT GIVEN)10. Sertraline HCl Tablet 100 MG Daily11. Vitamin D3 Oral Tablet 25 MCG 2 tablet Daily On 09/02/25 at 10:04 AM V5 (Registered Nurse) stated I need to write a note why I did not give R109's his blood pressure medications. Resident #92 was in a wheelchair in the hallway. V5 told R92 you are on blood pressure medications so let me take your blood pressure. V5 picked up the blood pressure monitor from the medication cart, placed the blood pressure cuff on R92's left arm, placed the monitor in R92's lap and obtained a blood pressure reading of 112/48 pulse 63. V5 said R92's blood pressure is a little low for my liking, I think I am going to hold your blood pressure medications.On 09/02/25 at 10:09 AM V5 (Registered Nurse) said I am holding R92's blood pressure medications. V5 (Registered Nurse) said there are 6 pills in the medication cup. I held the blood pressure medications, and I will check the blood pressure again after lunch. (Lisinopril 10 MG Twice a day and Metoprolol Tartrate 25 MG Twice a day were held and not given). V5 administered:1. Cholecalciferol Oral Tablet 25 MCG (1000 UT) Daily2. Ferrous Sulfate Oral Tablet 325 (65 Fe) MG Daily3. Apixaban Oral Tablet 5 MG every 12 hours4. Pentoxifylline ER 400 MG Three times a day5. Furosemide Oral Tablet 40 MG Daily6. Jardiance Oral Tablet 10 MG Daily7. Lisinopril 10 MG Twice a day (NOT GIVEN)8. Metoprolol Tartrate 25 MG Twice a day (NOT GIVEN)On 09/02/25 at 10:14 AM Surveyor asked V5 (Registered Nurse) to remove the bottle containing the Vitamin B 12 1000 MCG from the medication cart. V5 removed the bottle from the medication cart and while looking at the bottle V5 said it is not labeled, and it is expired. It should not have been given. When giving medications we check to make sure it is the right medication, right date, right time, right person and make sure it is not expired. If giving a resident expired medication, there is a potential it can cause toxicity. I will have to call the doctor. We are not supposed to transfer the medication from the original packing. I am going to toss the rest of the folic acid. acid. On 09/03/25 while conducting record review there was no documentation of V5 (Registered Nurse) notifying the physician for the medications that were held and the administration of the expired medication for R92, R96 or R109. Review of the blood pressure monitoring, there was no recheck of R96 and R109 blood pressure after the medications were held. On 09/03/25 at 11:40 AM Surveyor requested the blood pressure readings for R92 and R109. Surveyor informed V2 (Director of Nursing) that V5 (Registered Nurse) held both residents blood pressure medications but failed to notify the doctor or document the occurrence. V2 stated I talked to V5 about that this morning.On 09/04/25 at 09:06 AM V2 (Director of Nursing) stated The nurse should hold blood pressure or any medications if the blood pressure is outside of the parameters, using nursing judgement then consult with the doctor immediately to get directions if there are any abnormal blood pressures. My expectations when holding blood pressure medications is to consult with the doctor for further orders and instructions. V5 (Registered Nurse) said she notified the doctor but if it is not documented it did not happen. Potentially it depends on the patient, it is different risk for all diagnosis. I cannot say what would happen with that particular resident. The blood pressure could have potentially dropped lower or went higher depending on the resident condition. My expectations when staff are administering medications is for them to go by doctor orders, right resident, right time, right dose, right medication and check the expiration dates. Expired medications should be removed from the cart and medication room then discarded. Expired medications should not be administered. If expired medications are administered, they could have an adverse reaction. Surveyor asked V2, If the order reads enteric coated aspirin can chewable aspirin be given instead of the enteric coated. V2 responded, you should follow the doctor orders but if unavailable call the doctor to see what the doctor wants to do. The enteric coated aspirin is extended release, and the chewable aspirin acts immediately. If the chewable aspirin is given instead of the enteric coated aspirin, there is a potentially it will not last as long and there is a possibility it will not give the expected effect that the enteric coated aspirin would give. V2 was asked by the surveyor, if there is a missed dose or medication is held without a doctor order is that a medication error. V2 responded, it depends on what the documentation says, if documented it would be considered a late documentation, not a missed dose. If the nurse does not have a certain stock medication on the cart, they should come downs stairs and get it. Medication should not be taken from the original container and stored in a medication cup for administration, so we don't make mistakesTitled Physician Orders-Verbal and Fax effective date 03/21 document in part: The physician or extender retains control of the resident's medical plan of care and is consulted when changes in condition occur, outpatient appointments with orders or any other situation that requires an alteration to prescribed treatments, medications, or additional test.Titled Medication Storage effective date 03/21 document in part: 7. Medications are routinely checked for expiration dates.Titled Medication Administration effective date 03/24 document in part: To ensure that the administration of medications is performed in a safe manner to prevent medications errors. STANDARD: Medications are administered according to state and federal law. PROCEDURE: b. Medications are administered in a manner to prevent contamination. 2. General: 4. Medication preparation/Administration. a. Five Rights: Right Medication, Right Dose. Right Time - 60 minutes before or after the scheduled time unless otherwise specified, Right Route, Right Resident/patient/guest identification by way of, photo, verbal Affirmation by staff or resident, or birth date.). b. Verify the expiration date. c. Additional assessments are obtained prior to medication administration, such as pulse, blood pressure or oxygen level. 6. Medications are not prepared ahead of time. 10. Document medication administration after delivering. 1. If the medication you are to pass is not available, check the first dose machine/convenience box to see if the medication is there and administer if available. 3. If the medication is not given or given late notify the provider for additional orders. This includes any input from pharmacy on suggested alternatives if the medication cannot be supplied for any reason. 4. Alert the DON (Director of Nursing) or designee if you are not able to obtain the medication.

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered by the residents' Physicians orders resulting in significant medication errors for 2 (R92, R109) of 3 (R96) residents reviewed during medication administration.Findings Include:R109 has diagnosis not limited to Cerebrovascular Disease, Hypertensive Heart Disease with Heart Failure and Hyperlipidemia.0n [DATE] at 09:37 AM V5 (Registered Nurse) entered R109 room and said to R109, come out and take your blood pressure. At 09:40 AM V5 placed the blood pressure cuff on R109's right arm while standing at the medication cart with a blood pressure reading of 81/54 pulse 100. V5 placed the blood pressure cuff on R109 left arm and rechecked R109's blood pressure with a reading of 104/75 pulse 101. V5 said let me look to see if you have some blood pressure medications because your blood pressure is a little too low. I am not giving Amlodipine; I am going to hold it because the blood pressure is a little low. R109 gets three blood pressure medications that I am going to hold. I will revisit R109 blood pressure after lunch to see if he needs them. (The blood pressure medications). There are 7 pills in the medication cup. (Amlodipine Besylate 10 MG Daily, Hydrochlorothiazide 25 MG Daily and Losartan Potassium Tablet 50 MG Daily were held and not given). 1. Amlodipine Besylate 10 MG Daily (Not given)2. Hydrochlorothiazide 25 MG Daily (Not given)3. Losartan Potassium Tablet 50 MG Daily (Not given)R92 has diagnosis not limited to Acute on Chronic Diastolic (Congestive) Heart Failure, Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure, Nonrheumatic Aortic Valve Disorder, Cardiomegaly, Peripheral Vascular Disease, Atherosclerosis of Native Arteries of Right Leg and Hypertrophic Cardiomyopathy.On [DATE] at 10:04 AM V5 (Registered Nurse) stated I need to write a note why I did not give R109's his blood pressure medications. R92 was in a wheelchair in the hallway. V5 told R92 you are on blood pressure medications so let me take your blood pressure. V5 picked up the blood pressure monitor from the medication cart, placed the blood pressure cuff on R92's left arm, placed the monitor in R92's lap and obtained a blood pressure reading of 112/48 pulse 63. V5 said R92's blood pressure is a little low for my liking, I think I am going to hold your blood pressure medications.On [DATE] at 10:09 AM V5 (Registered Nurse) said I am holding R92's blood pressure medications. V5 (Registered Nurse) said there are 6 pills in the medication cup. I held the blood pressure medications, and I will check the blood pressure again after lunch. (Lisinopril 10 MG Twice a day and Metoprolol Tartrate 25 MG Twice a day were held and not given). 4. Lisinopril 10 MG Twice a day (Not given)5. Metoprolol Tartrate 25 MG Twice a day (Not given)On [DATE] at 10:14 AM V5 (Registered Nurse) said when giving medications we check to make sure it is the right medication, right date, right time, right person and make sure it is not expired. On [DATE] while conducting record review there was no documentation of V5 (Registered Nurse) notifying the physician for the blood pressure medications that were held for R92 or R109. Review of the blood pressure monitoring, there was no recheck of R92 and R109 blood pressure after the medications were held.On [DATE] at 11:40 AM Surveyor requested the blood pressure readings for R92 and R109. Surveyor informed V2 (Director of Nursing) that V5 (Registered Nurse) held both residents blood pressure medications but failed to notify the doctor or document the occurrence. V2 stated I talked to V5 about that this morning.On [DATE] at 09:06 AM V2 (Director of Nursing) stated The nurse should hold blood pressure or any medications if the blood pressure is outside of the parameters, using nursing judgement then consult with the doctor immediately to get directions if there are any abnormal blood pressures. My expectations when holding blood pressure medications is to consult with the doctor for further orders and instructions. V5 (Registered Nurse) said she notified the doctor but if it is not documented it did not happen. Potentially it depends on the patient, it is different risk for all diagnosis. I cannot say what would happen with that particular resident. The blood pressure could have potentially dropped lower or went higher depending on the resident condition. My expectations when staff are administering medications is for them to go by doctor orders, right resident, right time, right dose, right medication and check the expiration dates. Medication Administration Record should be signed for after it is given. Policy:Titled Medication Administration effective date 03/24 document in part: To ensure that the administration of medications is performed in a safe manner to prevent medications errors. STANDARD: Medications are administered according to state and federal law. PROCEDURE: 4. Medication preparation/Administration. a. Five Rights: Right Medication, Right Dose. Right Time - 60 minutes before or after the scheduled time unless otherwise specified, Right Route, Right Resident/patient/guest. c. Additional assessments are obtained prior to medication administration, such as pulse, blood pressure or oxygen level. 10. Document medication administration after delivering. Titled Physician Orders-Verbal and Fax effective date 03/21 document in part: The physician or extender retains control of the resident's medical plan of care and is consulted when changes in condition occur, outpatient appointments with orders or any other situation that requires an alteration to prescribed treatments, medications, or additional test.

Based on interviews and record reviews, facility failed to follow their abuse policy to protect the resident's right to be free from physical abuse for one [R1] of [R2, R3] three residents. This failure resulted in R1 sustaining a bruised right eye, facial areas, and pain. Findings include, R1's clinical record indicates the following in part: R1 is a seventy-four-year-old male with medical diagnosis of Parkinson's Disease, chronic obstructive pulmonary disease, dysphagia, seizures disorder, contracture of left knee, contracture of right knee, major depression disorder and schizophrenia. [NAME] Date Set [MDS] section [C] indicates R1 is cognitively impaired. R1's MDS section [GG] indicates he needs maximal assistance with ADL Care, and transfers. R1 is unable to ambulate. R1's Care Plan documented in part: R1 has Parkinson's Disease. R1 is unable to tolerate usual activities due to poor endurance. R1 is at risk for abuse due t diagnosis of mental illness [2/13/24]. R1 require maximum assistance with mobility [2/18/25]. R1 has a seizure disorder [2/18/25]. R1 requires assistance from staff for transfers related to Parkinson's Disease. R1's Progress notes indicated in part: 4/25/2025 6:55 am, Incident Note: R1 noted up in wheelchair, in dining area at vending machine, when physical altercation occurred with R2, and removed from area per security. R1 sustained bruising to right eye with swelling. R1's Progress notes indicated in part: 4/27/2025 8:45 am, Daily Skilled Note Note Text: R1 up in wheelchair, alert with confusion. Bluish discoloration with redness to sclera noted. R1's Progress notes indicated in part: 4/25/2025 8:07 pm Daily Skilled Note, Note Text: R1 returned from eye clinic, no new orders noted. R2's clinical record indicates the following in part: R2 is a seventy-four-year-old male with medical diagnosis include but not limited to violent behavior, psychotic disturbance, mood disturbance, schizoaffective disorder, and hypertensive heart disease. Minimum data set [MDS] section C indicates R2 is cognitively intact, able to make his needs known. R2 MDS section [GG] indicates R2 is independent with ADL care, transfers, and able to ambulate independently. R2's Progress Notes in part; 4/25/2025 07:52 am Behavior Note Note Text: Staff reported to writer that R2 exhibited physical aggression toward a co-peer. Staff responded immediately, intervening to de-escalate the situation and ensure the safety of all residents. Individual was receptive to redirection. Staff provided counseling and educated R2 on the potential consequences of such behavior. No injuries were reported at this time. MD has been notified, and a petition has been initiated for the R2 to be transferred for further evaluation. R2 remains on 1:1 until the arrival of ambulance. R2's Progress Notes in part; 4/25/2025 9:29 am, General Note Text: R2 was transferred to Hospital. Petition, face sheet and med list sent with. R2's Progress Notes in part; 4/25/2025 8:51 am: Daily Skilled Note Note Text: Follow up call placed to hospital, spoke to Nurse, resident admitted with a diagnosis of aggressive behavior. Interviews: On 5/31/25 at 12:10 PM, R1 stated, R2 hit me four times and he hurt my eye. On 5/31/25 at 11:30 AM R2 stated, R1 and I was in the day room and R1 got mad at me. R1 told me he was going to kill me, so I started hitting him. R1 then started hitting me, I threw him onto the floor and started stomping on him like this: [ Surveyor observed R2 hold up his leg bending his knee and came down with his leg hitting his foot against the floor making a loud noise several times.] Then the staff stopped me from hitting R1, but R1 shouldn't have told me he was going to kill me. On 5/31/25 at 11:45 AM, R3 stated, I have not been abused at the facility nor have I witness abuse. I feel safe residing here at the facility. On 5/31/25 at 1:30 PM, V3 [Licensed Practical Nurse] stated, I was working on 4/25/25. I was passing medications in the day room. I heard yelling and looked up and seen R2 bent over with his arms swinging fast in the air back and forth. I yelled out for help and security assisted me with separating the two residents. R2 jumped on R1 and was punching him in the facial areas. R1's right eye and over his face was bruised black and blue in color. I called the V2 [Director of Nursing] she was in the facility, and she came up to the day room. V2 called V1 [Administrator], and he was made aware of the incident, I heard him on the phone with V2. R1 was sent out to an eye specialist the same day for emergency eye appointment. On 5/31/25, at 1:50 PM, V4 [Licensed Practical Nurse] stated, I heard a commotion coming from the day room, I saw R1's eye was swollen and black in color. I phoned the hospital eye clinic and got him the same day appointment. R1 went out the eye appointment and returned with no new orders. On 5/31/25 at 2:10 PM, V5 [Certified Nurse Assistant] stated, I did not witness the incident between R1, and R2 I was not on the floor. On 5/31/25 at 2:23 PM, V6 [Certified Nurse Assistant] stated, I was in another residents' room providing ADL and when the incident occurred between R1 and R2. On 5/31/25 at 4:00 pm V7 [Social Service] stated, , R2 has a history of physical aggression. Upon R2's admission R2 appeared to be calm, but also exhibited inappropriate behaviors of physical touching, grabbing, of staff when being assisted with ADL's. I was not present during the altercation between R1 and R2, I heard R2 was hitting R1 in the face. R2 was petitioned out for psych evaluation. R2 had two other incidents of physical aggression toward other residents. R2 was sent out for another psych eval from a physical altercation with another resident and returned to the facility on 5/5/2. R2 is monitored one to one by social service staff. I am trying to find a nursing facility that can meet R2's needs. We will be monitoring R2 closely. On 5/31/25 at 3:00 PM, V2 [Director of Nursing] stated, I had just walked into the facility, and I was phoned, and I went up immediately to the day room. R1 had a discolored right eye, R2 was sitting with one-to-one staff monitoring. I immediately phoned V1 [Administrator] and made him aware of the physical altercation. R2 has a history of physical aggression and was petition out for psych evaluation. On 5/31/25 at 3:15 PM, V1 [Administrator] stated, The incident between R1 and R2 occurred on 4/25/25, not 4/24/25 that date was a typo mistake. [Surveyor asked V1; What was the conclusion of his investigation] V1 sated, I do not remember what happened or if I was told about the allegation, read the report, all the information you need is on there. The allegation of physical abuse was substantiated, R2 hit R1 in the facial area and note discoloration on R1's face. All new hires receive abuse training, and all staff receive abuse training annual and as needed. Policy document in part: Abuse dated 12/2024. -This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse neglect, misappropriation of resident property, involuntary seclusion, and exploitation. 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. Mental abuse includes but not limited to humiliation, harassment, threats of punishment. The facility should identity occurrence and patterns of potential mistreatment. Physical abuse is he infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Final Investigation Report: The investigator will report the conclusion of the investigation within five working days.

Based on interviews and record reviews, the facility [A] failed to follow their Abuse Prevention Program Policy and report an allegation of abuse within 2 hours of the incident to IDPH (Illinois Department of Public Health) and [B] failed to submit the final report to IDPH within five business days for two 2 (R1 and R2) of three [R3] residents reviewed for abuse. Findings include, R1's clinical record indicates the following in part: R1 is a seventy-four-year-old male with medical diagnosis of Parkinson's Disease, chronic obstructive pulmonary disease, dysphagia, seizures disorder, contracture of left knee, contracture of right knee, major depression disorder and schizophrenia. [NAME] Date Set [MDS] section [C] indicates R1 is cognitively impaired. R1's MDS section [GG] indicates he needs maximal assistance with ADL Care, and transfers. R1 is unable to ambulate. R2's clinical record indicates the following in part: R2 is a seventy-four-year-old male with medical diagnosis include but not limited to violent behavior, psychotic disturbance, mood disturbance, schizoaffective disorder, and hypertensive heart disease. Minimum data set [MDS] section C indicates R2 is cognitively intact, able to make his needs known. R2 MDS section [GG] indicates R2 is independent with ADL care, transfers, and able to ambulate independently. Interviews: On 5/31/25 at 12:10 PM, R1 stated, R2 hit me four times and he hurt my eye. On 5/31/25 at 11:30 AM R2 stated, R1 and I was in the day room and R1 got mad at me. R1 told me he was going to kill me, so I started hitting him. R1 then started hitting me, I threw him onto the floor and started stomping on him like this: [ Surveyor observed R2 hold up his leg bending his knee and came down with his leg hitting his foot against the floor making a loud noise several times.] Then the staff stopped me from hitting R1, but R1 shouldn't have told me he was going to kill me. On 5/31/25 at 1:30 PM, V3 [Licensed Practical Nurse] stated, I was working on 4/25/25. I was passing medications in the day room. I heard yelling and looked up and seen R2 bent over with his arms swinging fast in the air back and forth. I yelled out for help and security assisted me with separating the two residents. R2 jumped on R1 and was punching him in the facial areas. R1's right eye and over his face was bruised black and blue in color. I called the V2 [Director of Nursing] she was in the facility, and she came up to the day room. V2 called V1 [Administrator], and he was made aware of the incident, I heard him on the phone with V2. R1 was sent out to an eye specialist the same day for emergency eye appointment. On 5/31/25 at 3:00 PM, V2 [Director of Nursing] stated, I had just walked into the facility, and I was phoned, and I went up immediately to the day room. R1 had a discolored right eye, R2 was sitting with one-to-one staff monitoring. I immediately phoned V1 [Administrator] and made him aware of the physical altercation. R2 has a history of physical aggression and was petition out for psych evaluation. On 5/31/25 at 3:15 PM, V1 [Administrator] stated, The incident between R1 and R2 occurred on 4/25/25, not 4/24/25 that date was a typo mistake. [Surveyor asked V1; What was the conclusion of his investigation] V1 sated, I do not remember what happened or if I was told about the allegation, read the report, all the information you need is on there. The allegation of physical abuse was substantiated, R2 hit R1 in the facial area and note discoloration on R1's face. All new hires receive abuse training, and all staff receive abuse training annual and as needed. The incident occurred on 4/25/25 I uploaded documents and typed in the incident director on the IDPH portal on 5/6/25. I completed the IDPH follow up by typing in direct information on 5/12/25, that time I did not upload any documents or the final report. The IDPH portal did not give me any confirmation. Abuse allegation is to be reported immediately and the final report to IDPH is to be sent within five business days. Reviewed Facility's IDPH Report Incident of 4/25/25. Initial was loaded on the IDPH Portal on 5/6/25. [The physical abuse allegation was reported ten days later] The final report on the IDPH Portal was submitted on 5/31/2025 at 12:28 PM by V1. Policy document in part: Abuse dated 12/2024. -This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse neglect, misappropriation of resident property, involuntary seclusion, and exploitation. 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. Mental abuse includes but not limited to humiliation, harassment, threats of punishment. The facility should identity occurrence and patterns of potential mistreatment. Physical abuse is he infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Final Investigation Report: The investigator will report the conclusion of the investigation within five working days.

Based on interviews and records review, the facility failed to assist one resident (R1) of three reviewed in a sample of three with communication and access to services inside and outside the facility. This failure resulted in R1 not getting his social security card. Findings include: R1's current face sheet documents R1's medical conditions to include but not limited to: type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease, stage 3 unspecified, acquired absence of right/left leg below knee, unspecified combined systolic (congestive) and diastolic (congestive) heart failure. MDS (Minimum Data Set) section C -Cognitive Function dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1 has intact cognitive function. On 05/17/2025, at 10:06 AM, R1 was observed laying in bed awake. R1 was alert, oriented to person, place, time, and situation. R1 stated he applied for his Social Security (SS) card about four weeks ago, but he has not yet received it. R1 stated he wanted to go to social security administration offices and follow up on his SS card. R1 called the senior citizen bus company for transportation to take him to SS offices but the facility told him he cannot go alone and that the facility would assist him. R1 stated to date no one in the facility has assisted him in following up with his SS card. R1 stated he needs his SS card to apply for housing and financial assistance. On 05/17/2025, at 12:40 PM, V7 (Business Office Manager) stated if R1 has applied for his social security card, the facility has not received it yet. V7 stated V9 (Psychiatric Rehabilitation Services Coordinator (PRSC) come to the admissions office a few weeks ago in April (Cannot remember date) and was talking to V10 (Admissions Director). V10 mentioned that R1 wanted to go to social security office to get a social security card. V7 stated V10 told V9 that R1 did not have to go to the Social Security office to apply for his social security card because he can do it at the facility through the phone. V7 stated she did not follow up after that conversations and does not know if R1 was assisted with applying for or following up on his social security card. V7 stated a social security card is used for identification purposes for various things. If R1 was asking for assistance getting it, he should have been assisted by the facility. V7 stated when a resident comes to the facility all their identification including a social security card is uploaded in their electronic medical record. V7 stated R1 does not have a social security card uploaded in his electronic medical record and if R1 was assisted with getting his card, it could have been uploaded into his medical records. V7 state she, V9 and V10 could have assisted R1 in following up on his SS card. On 05/17/2025, V10 (Admissions Director) via V9's phone stated a few weeks ago (Cannot remember the date) she was informed by V9 (Psychiatric Rehabilitation Services Coordinator -PRSC) that R1 wanted to go to social security office to get a Social Security card. V10 stated she told V9 that R1 did not have to go to the social security office to apply for the card and he (R1) can come down to her (V10's) office. V10 can help R1 call Social Security and apply by phone. V10 stated R1 did not come down to the office and she did not follow up with R1. On 05/17/2025, at 1:38 PM, V9 (Psychiatric Rehabilitation Services Coordinator -PRSC) stated she does not remember the exact day, but it might have been between 28 and 30th of April when R1 told her he needed to apply for a social security card. V9 stated the social services department assists residents with getting documents such social security cards and Identification cards (IDs). V9 stated she does not know why R1 needed his social security card, and she did not document her conversation with R1. V9 further stated R1 has not been assisted with applying for his social security card and she was planning on taking R1 to the social security office with another resident but did not provide a date when R1's visit to social security office was scheduled. V9 she had documented on her personal notes on paper to assist R1 but not in his progress notes in in electronic health record. V9 was unable to show in her note book any note referring to her conversation with R1 and any documentation she had scheduled an appointment to take him (R1) to social security office. During the interview as surveyor was talking to V9, she (V9) was observed trying to write R1's initials in her notebook to show she had spoken to him. V9 was using a blue pen to write R1's initial in her notebook and her notes that were already written were in black ink. On 05/17/2025, at 3:05 PM, V1 (Administrator) stated he was not aware R1 needed to apply for new social security card. V1 stated if R1 had asked staff for assistance getting his social security card, staff should have assisted R1 either to apply by phone or to go to social security offices because the facility has a bus to transport residents to appointments. V1 stated V7, V9 and V10 should have assisted R1 with getting his SS card. V1 stated V9 had scheduled to take R1 to the social security office with another resident but V1 was not able to provide any documentation between R1 and V9 discussion or R1's appointment to SS office. Review of R1's progress notes do not document R1's appointment to SS office for SS card needs Facility Policy titled Resident Rights dated 3/31 documents: -The facility will meet with resident to attempt to resolve any issues in a timely matter. -The resident will be provided resources to assist them in exercising their rights.

Based on interviews and record reviews, facility failed to follow their abuse policy to protect the resident's right to be free from [A] physical abuse and mental abuse for one [R2] of [R1, R3] three residents. This failure resulted in R2 experiencing pain and feeling humiliated, crying, depressed and fearful of retaliation. Findings Include: Facility reported incident dated 3/27/25 documents in part: R1 and R2 were observed in alleged physical altercation. R1 clinical record indicates in part; R1 is a seventy-four-year-old male with medical diagnosis include but not limited to violent behavior, schizoaffective disorder, and hypertensive heart disease. Minimum data set [MDS] section C indicates R1 is cognitively intact, able to make his needs known. R1's Progress Notes documented in part: 3/28/2025 08:38 Daily Note Note Text: R1 admitted to the hospital diagnosis of aggressive behavior. 3/27/2025 11:12 Behavior Note Late Entry: Note Text: R1 is alert and oriented. R1 has history of confusion and forgetfulness. Writer met with R1 regarding alleged altercation with another resident [R2]. R1 seemed confused and unaware of his behavior at the time. MD was made aware, and R1 was petitioned out to the hospital. R1 being monitored till ambulance arrived. Will provide more update as needed. Care plan updated. 3/27/2025 07:30 Incident Note Note Text: This writer observed R1 standing over another resident [R2] who was sitting in a chair in the dining room. Suddenly R1 who was standing started aggressively hitting the resident [R2] who was sitting in the chair. This writer started yelling stop, stop! Called for security intervention, removed the lesser resident [R2] who was being hit to a safe location. When asked the aggressor [R1] what happened, he stated she [R2] got to stop cussing me. Then R1 then took a seat in the dining room and calmed down. Call was placed to R1's physician who gave an order to send the resident to emergency department with a petition. Administrator [V1] made aware, call placed to R1's family member, left voice mail message. R1's care plan documents in part: R1 exhibited physical aggression behavior towards another resident [4/5/25]. R1 exhibited physical aggression towards another co-peer [3/27/25]. R1 has a behavior problem [5/5/25]. R1 exhibits sexually inappropriate behavioral symptoms related to physical touching, grabbing, of staff when being assisted with ADL's. R2's clinical record indicates in part: R2 is a seventy-five-year-old female that needs an assistive device of a walker for mobility. R2 was admitted with the following medical diagnosis of schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, hypertensive heart disease, overactive bladder, unhappiness, and personal history of mental disorders. MDS section [C] indicates R2 is cognitively intact. R2's care plan document in part: R2 is at risk for abuse due to diagnosis of mental illness [11/21/24]. Interventions, assure R2 is in a safe and secure environment with caring professionals. Monitor R2's behavior to prevent predisposition to abuse [11/21/24]. R2 was involved in a physical altercation with another resident [R1] [ 3/27/25]. R2 uses psychotropic medication related to behavior management. R2 has diagnosis of schizoaffective disorder, bipolar and depressive types. R2 has a history of inappropriate attention seeking behavior but has demonstrated stability during the admission screening process; Intervene when any inappropriate behavior is observed. Communicate assertively that R2 must exercise control over impulses and behavior. R2 has history of poor verbal skills of expressing herself with the use profanity. Interviews: On 5/6 25 at 12:33 PM R1 stated, I been doing okay. I just came back from the hospital because I punched this [NAME] in the eye. I got into another fight with a lady here because she wouldn't not stop yelling. I went over and I started hitting her to make her shut up. I think I was hitting her in the head, face and chest, I am not sure I just kept swinging on her to make her shut her mouth. The nurse ran over and pulled me off R2. The lady kept screaming and crying. All that yelling makes me nervous and mad. I want to go back to my old facility where my brother lives. I do not like it here; the people here keep making me mad. On 5/6/25 at 1:10 PM R2 stated, I was attacked one morning while I was eating breakfast. This man out of nowhere started hitting me all in my head, face, and chest areas. I fell out of my chair on to the floor. I was yelling for help. The nurse stopped R1 from hitting me and helped me off the floor. I was in shock and scared. I did not know what was happening or why I was attacked. My head, face, and chest were hurting me, and I felt so humiliated, embarrassed, depressed, and scared that R1 might get mad at me because he was sent out to the hospital. I felt bad about myself, I did not know why me? Why was I attacked by this man in front of every one [residents] to see me get beat up for no reason. I cried for days every time I thought about what happened to me. They moved him to another floor. I feel safe here, but I will be nervous that I might see him again, I do not want to get beat up anymore. On 5/7/25 at 10:00 AM V3 [Licensed Practical Nurse] stated, On 3/27/25, I was in the dining room administering medications. I notice R1 moving fast, anxious, and pacing back and forth in the dining room. My intuition told me something was not right with R1. I should have removed R1 from the dining area or called extra staff for assistance, I was the only staff member in the dining area. I continue to administer medications; I could not focus all my attention on R1. Then I heard R2 say something, I am not sure what she said, but it was loud. When I looked up, I saw R1 with his hand raised up in the air standing over R2 as she was sitting in a chair, R1 started hitting R2. R1 was hitting her in the head, shoulder, and chest areas. I started to scream 'stop it, stop it' as I ran over to R2. R1 did stop striking R2 and I got R2 out of the chair to remove her from the area. During the time R1 was hitting R2, she was screaming to the top of her lungs and crying. R2 was just crying uncontrollably, she [R2] was mortified and devastated. All I could do was hug R2 trying to console her. R2 did not complain of any pain, she was just yelling out crying for quite some time, she really was not talking or answering my questions, she could not stop crying. I phoned R1 and R2's physicians, I received an order to petition R1 out for psych evaluation. I also notified the abuse coordination [V1] administrator of the incident. Moving forward I will act on my intuition and changes in resident behavior to remove the resident away from other residents to prevent an altercation. On 5/7/234 11:10 AM, V11 [Certified Nurse Assistant] stated, The day of the incident between R1 and R2, I was providing ADL care to another resident in their room. I heard screaming, and the nurse started calling my name. I ran into the dining room and saw R1 walking away from R2. She [R2] was yelling and crying. I stayed with R2, and the nurse called R1's physician. On 5/7/25 at 9:40 AM, V4 [Social Service Director] stated, R1 has a history of physical aggression. Upon R1's admission R1 appeared to be calm, but also exhibited inappropriate behaviors of physical touching, grabbing, of staff when being assisted with ADL's. I was not present during the altercation between R1 and R2, I heard R1 was hitting R2. R1 was petition out for psych evaluation. R1 had two other incidents of physical aggression toward other residents. R1 was sent out for another psych eval from a physical altercation with another resident and returned to the facility on [DATE]. R1 is monitored one to one by social service staff. I am trying to find a nursing facility that can meet R1's needs. We will be monitoring R1 closely. On 5/7/25 at 3:40 PM, V1 [Administrator] stated, R1 and R2 had a physical altercation, V3 told me that R1 walked over and punched R2 in the chest area, while R2 was sitting in a chair. While R2 was being punched she did no retaliate or hit R1 back she did not do anything. R1 said that R2 was cursing, and he wanted her stop. R1 was petition out for psych evaluation. R1 has a history of physical aggression with other residents in the facility. Until we find placement, R1 is on one-to-one supervision to ensure the safety of other residents. All new hire receives abuse training during orientation. All staff received abuse training annually and as needed. On 5/6/25 V10 [Registered Nurse], V7, V8, V9 and V11 [Certified Nurse Assistants] all said they received abuse training about two months ago and the abuse coordinator was the administrator. On 5/6/25, R3 stated, I have not experienced any abuse in the facility, I feel safe here. Policy documented in part: Abuse dated 12/2024. -This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse neglect, misappropriation of resident property, involuntary seclusion, and exploitation. 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. Mental abuse includes but not limited to humiliation, harassment, threats of punishment.

Based on observation, interview and record review, the facility failed to provide a safe and home like environment by not maintaining comfortable and safe temperature levels in the entire premises of the facility and the facility failed to follow their policy to take and record temperature levels every hour during an event of extremely hot weather. These failures resulted in an immediate jeopardy to the health and safety of all 132 residents residing in the facility who were subjected to hazardous temperatures above 80F (Fahrenheit) on 8/23/23 requiring evacuation and transfer of all 132 residents to different facilities. On 8/23/23, R1 sustained nausea, vomiting and weakness secondary to heat. This was identified as an Immediate Jeopardy which began on 8/23/23 at 9:35am per (8/23/23) facility temperature log which documents a temperature of 81.2F (Fahrenheit) in resident's room. On 8/30/23 at 2:22 pm, V9 (RDO/Regional Director of Operations), V17 (Corporate Administrator), V18 (Chief Financial Officer) and V19 (Attorney) were notified of the immediate jeopardy. The facility presented a final removal plan on 8/30/23 at 6:39pm which was not approved. The facility presented a revised final removal plan on 9/1/23 at 12:46pm which was not approved. The facility presented another revised final removal plan on 9/1/23 at 4:36pm which was accepted/approved on 9/6/23 at 8:45am. The surveyor conducted additional interviews and record reviews on 9/25/2023, 9/26/2023 and 9/27/2023 to verify the plan was implemented. The immediate jeopardy was removed on 10/02/2023 based on actions from the removal plan. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: On 8/23/23 at 6:15pm - Observed approximately 12 to 16 residents outside of the facility. They were sitting in wheelchairs lined up outside of the facility door. Most of the residents were sitting unshielded from the sunlight. According to Time and Date at https://www.timeanddate.com/sun/usa/chicago?month=8, in Chicago, sunrise was 6:06 am and sunset was 7:38 pm. According to the National Oceanic and Atmospheric Administration, National Weather Service at: https://www.weather.gov/lot/2023_08_2324_Heat#:~:text=Chicago%20officially%20observed%20a%20high,was%20116%C2%B0F**. Chicago officially observed a high temperature of 98 F on the 23rd at O'Hare Airport, setting a record daily high temperature for this date. The peak heat index observed at O'Hare Airport on the 23rd was 116 F**. According to Weather Underground at: https://www.wunderground.com/history/daily/us/il/chicago/KMDW/date/2023-8-23, in Chicago on 8/23/23 times and temperatures were as follows: 5:53 PM 96 F 6:53 PM 86 F 7:05 PM 92 F 7:53 PM 89 F - observed a truck located on the side of the facility building pumping air into the facility through 2 blue tubes placed in open windows. On 8/23/23 at 6:30 pm, - observed the facility to be very hot inside and uncomfortable. - observed multiple fans/cooling units operating in the hallways and dining room area on the 1st floor. On 8/23/23 at 6:46 pm, the (2nd floor) temperature was uncomfortably hot and there was a notable urine odor. V8 (Social Service Director) stated the facility air conditioner has been out since Monday 8/21/23 (2 days prior). On 8/23/23 at approximately 7:00 pm, a total of 39 residents (R4, R5, R7, R8, R11, R19, R20, R25, R29, R32, R33, R38, R42, R43, R45, R54, R56, R62, R63, R65, R66, R74, R75, R82, R84, R85, R86, R88, R92, R94, R96, R99, R106, R107, R116, R120, R121, R127, R133) were observed inside and/or outside the facility therefore not evacuated from the facility (roughly 9 hours after hazardous temperature was identified). On 8/23/23 at 7:15 pm, 1st floor staff were noted to be sweating and their clothes visibly wet. R21 is [AGE] years old with diagnoses which include but not limited to Alzheimer's disease, type II diabetes mellitus, and hypertensive heart disease. R21's (6/30/23) BIMS (Brief Interview Mental Status) determined a score of 10 (moderately impaired). R21's (6/30/23) functional assessment affirms (1 person) physical assist is required for bed mobility, transfers, locomotion, and toilet use. On 8/23/23 at approximately 7:30pm, surveyor observed R21 throwing up (3 times) in the (1st floor) dining room. R21 stated I'm not feeling well, it's too hot. I need to lie down, I feel weak and appeared exhausted (unable to sit upright in the wheelchair). V11 (Licensed Practical Nurse) took R21's blood pressure which read 100/62 however no additional vital signs were obtained at this time. [Low blood pressure, fatigue and weakness are signs/symptoms of heat exhaustion. Vomiting and sweating due to excess heat cause heat exhaustion]. On 8/23/23 at 7:00pm, V16 (Maintenance Director) affirmed the portable air chillers came today around 3:00pm - after the evacuation was initiated. On 8/23/23 at 7:00pm, R19 stated the air is not working in my room. On 8/23/23 at 7:02pm, V5 (PRSA/Psychiatric Rehabilitation Service Aide) stated cooling buses got here this morning around 10am and left at 5:30pm when we began evacuating the residents, however residents remained at the facility with hazardous temperature till after midnight (6+ hours longer). On 8/23/23 at 7:07pm, R79 stated it has been hot for about a month now, they (staff) provided fans. R79's (6/6/23) BIMS (Brief Interview Mental Status) determined a score of 12 (moderate impairment). On 8/23/23 at 7:22pm, R92 reported feeling hot. R92 affirmed she was in her room and (approximately 1 hour ago) staff brought her to the 1st floor dining room. R92's (7/25/23) BIMS determined a score of 15 (cognitively intact). On 8/23/23 at 7:27pm, R75 stated I feel terrible, I feel hot, I have not had anything to drink. Staff offered me something to drink but I refused to keep from having to use the bathroom. R75's (8/17/23) BIMS determined a score of 10 (moderate impairment). On 8/23/23 at 7:30pm, R45 stated yesterday and today it got really hot. The AC (Air Conditioner) in my room didn't work this morning, staff tried to turn it on, but it didn't work. R45's (7/21/23) BIMS determined a score of 12. On 8/23/23 at 9:38pm, V9 (Regional Director of Operations) stated we (facility) were able to maintain comfortable temperature levels in the building until this morning. The City of Chicago Building Department called around 12:30pm, the temperature levels were not comfortable, but the portable chillers were in route. We (facility) were told to evacuate the residents. At this time one resident (referring to R21) has been sent to the hospital. On 8/31/23 at 10:39am, surveyor inquired about the facility AC. V16 (Maintenance Director) stated two compressors went down (not working) a week prior to 8/23/23. We've (facility) been using 17 temporary portable air conditioning units. V16 affirmed on 8/23/23 around 7:30 am it was beginning to get hot in the facility, and around 9:30 am the temperature became uncomfortable. V16 stated, residents started to complain about the facility temperature around 10:30am. During an emergency weather plan, we (facility) make sure residents are hydrated and cool. We put them in one area that we know is cooler. V16 stated, my (V16) role in the emergency weather plan is to make sure the dining room is cool until everything is fixed. I (V16) put all the fans in the dining area. [note: documenting hourly hazardous temperature was excluded]. V16 stated, the facility had temporary fixes in place, but the main air conditioning unit would not be able to be fixed without new compressors. The city (Building Department, Fire Department, Police) was at the facility (8/23/23) because someone called 311. By the time the portable AC unit got to the facility it was too late, the evacuation had started. V16 said temperatures are not taken daily. When temperatures get above 80 degrees outside, then we (facility) start taking temperatures every two to three hours in random rooms and in all hallways. V16 stated, the air conditioning company came out to check the air conditioning unit, V16 thinks on the 17th, and found the compressors were down. We (facility) called the air conditioning company because we (facility) thought the unit was low on freon because of the way it was blowing the air out. V16 affirmed the air was not as cold as it should have been. On 8/31/23 at 11:02am, surveyor inquired if the facility AC malfunctioned prior to 8/23/23. V17 (Corporate Administrator) replied, I want to believe that they had a problem with the air conditioner prior to that day, which they had temporary measures (portable coolers on all the floors that blow cold air, fans, taking temperature of the building to ascertain if there's any need to evacuate) in place but because of the weather that day (referring to 8/23/23) it made the measure in place not working. Surveyor inquired about staff identification of hazardous temperature in the facility. V17 responded, the maintenance person takes temperature, the policy talks about certain thresholds and when they need to notify the administrator. Surveyor inquired when facility temperatures should be documented V17 responded, daily before the threshold, it should be every hour after that (beyond the threshold). On 8/31/23 at 12:11pm, surveyor inquired about the (8/23/23) facility temperature. V6 (Licensed Practical Nurse) stated it was humid and warm in the morning and got hotter as the day went on. Around 3pm, V2 (Director of Nursing) said to make sure residents are hydrated. Surveyor inquired about the (8/23/23) facility evacuation. V6 responded, around 4pm, V2 announced that there was a heat emergency, and the facility is evacuating [6 hours after hazardous temperature was documented]. V6 stated, the evacuation process was controlled chaos, there were no plans made to evacuate before we (staff) did it. The only orders beforehand where to hydrate the residents. V6 affirmed at 11:20pm, there were nine residents still in the facility. On 9/1/23 at 4:10pm, R86 stated, We (residents) are in another building because they (facility) didn't fix the air conditioner. They (facility) wouldn't get the compressors fixed on the unit. They were acting like nothing happened. I bought me a fan before it got really hot. Even with the fan I was hot. It was sweltering in the building. I was sweating, it was uncomfortable. It was 96F in my room. My AC (air conditioner) was not working in my room. The staff was drenched in sweat. It was hot two days before. On 9/5/23 at 12:34pm, surveyor inquired who reported the (8/23/23) facility safety concerns (re: hazardous temperature). V20 (Chicago Building Department Deputy Commissioner) stated it probably came in with 311 (non-emergency 911 equivalent) which would be called if there's a violation. Surveyor inquired about the (8/23/23) facility temperature. V20 responded V20 did temperatures in all common areas and patient rooms, readings were 85-91F between 12:30pm and 1:30pm. At that point, we (Fire/Building Departments) had made the decision that the building needed to be closed due to patient safety. We waited outside the building until all the residents were gone which was about 1 am (15 hours after hazardous temperature was identified). V20 stated, there was no deferred maintenance being done at this facility, it did not appear to me. Over time you're supposed to reinvest in your facility and make sure that any work that needs to be done gets taken care of. About a month before we shut down this building (facility) we (Buildings Department) received a complaint about their (facility) air conditioning not working. We (Buildings Department) sent someone out to take temperatures and they (facility) wouldn't let him in. I (V20) got a call from one of my inspectors that said the contractor did not get a call until that day (8/23/23) to repair the air conditioner. They (staff) tried to say that they had temporary cooling at the facility but basically, they just had fans not air conditioning. There was no air conditioning functioning in this building. This is the type of building that every room needs cooled because of the population. On 9/5/23 via email sent at 1:07pm, V17 (Corporate Administrator) wrote V16 (Maintenance Director) stated V16 did not take the temps during the evacuation due to the emergency. On 9/5/23 at 4:20pm, V2 (Director of Nursing) stated CHUG (Collaborative Healthcare Urgency Group) sent a CTA (Chicago Transit Authority) cooling bus and it was at the facility from approximately 11am until approximately 6pm. V16 (Maintenance Director) took temperatures in the building. The previous days before 8/23/23 it was warm but comfortable because we had the portable units. V16 stated, I was told the compressors went out on the air conditioning unit, but I don't know when. The (8/23/23) census includes 132 residents. The (8/23/23) facility Air Temperature Log affirms the temperature was 86.2F with humidity 76.1F in resident's room, 86.0F with humidity 77.2F in another resident's room and 86.1F with humidity 78.2F at the (2nd floor) Nurse's station documented 10:00am-10:20am. The last temperature documented (8/23/23) was at 10:40am - not hourly as warranted due to temperature above 80F. According to the National Oceanic and Atmospheric Administration, National Weather Service at https://www.weather.gov/wrh/climate?wfo=lot, the maximum temperature was 98F on 8/23/23 in the Chicago area. According to Weather Underground at https://www.wunderground.com/history/daily/us/il/chicago/KMDW/date/2023-8-23, in Chicago on 8/23/23 times and temperatures were as follows: 7:53 AM 80 F 8:53 AM 84 F 9:53 AM 88 F 10:53 AM 91 F 11:53 AM 94 F 12:53 PM 95 F 1:53 PM 97 F 2:53 PM 97 F 3:53 PM 97 F 4:53 PM 97 F 5:53 PM 96 F 6:53 PM 86 F 7:05 PM 92 F 7:53 PM 89 F 8:53 PM 90 F 9:53 PM 89 F 10:53 PM 89 F 11:53 PM 87 F City of Chicago, Department of Buildings, effective date 8/23/2023, documents in part: Re: Commissioner Closure Order, Community Care Center, located at 4314 S. Wabash Avenue. Emergency Closure Order. Community Care Center, located at 4314 S. Wabash Avenue, Chicago, Illinois is a public nuisance that is dangerous, hazardous and endangers the public health due to the violations as stated in the attached Property Condition Report. It has therefore been determined that the building constitutes an imminent and actual danger to the tenants and occupants, and to the public at large. I hereby order that Community Care Center, located at 4314 S. Wabash Avenue, Chicago, Illinois, be immediately closed, and remain vacant, and that entry be denied except by licensed and bonded contractors engaged to examine, repair, and otherwise correct the aforementioned conditions, or otherwise by authorized City of Chicago personnel until further order. City of Chicago, Department of Buildings, Department of Buildings Property Condition Report, Building Code Violations That Constitute an Actual and Imminent Danger, Inspection Date 8/23/2023, Commissioner Closure: Community Care Center, documents in part: Cooling system at this facility is inoperable, entire premises. Facility policy Hot Weather/Heat Emergencies Policy and Procedures, 11/1/2022, documents in part: Administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The Maintenance Director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of 71-80 degrees Fahrenheit. If temperatures increase, readings will be taken every hour. Maintenance will check all AC units to assure they are operating properly. On 9/5/23 via email sent at 12:54pm, V17 (Corporate Administrator) wrote we (facility) do not have a policy for homelike environment. The surveyor confirmed on 10/02/2023 through interview, record review, that the facility took the following actions to remove the Immediate Jeopardy: The facility implemented all measures on the removal plan. 1) The facility has taken the following action concerning the IJ component: a.) R21 was transferred to the hospital on 8/23/23. Per hospital, R21 has since been discharged on [DATE] to (alternate) facility to be closer to family. *On 9/6/2023, surveyor contacted alternate facility and affirmed R21 resides there. b.) All residents in the facility were safely relocated to other facilities in an orderly manner. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). c.) The facility reached safe and comfortable temperatures in the building on 8/23/23. *The (8/30/23) letter provided by contractor states company was engaged to supply necessary equipment to provide temporary air conditioning to the building due to broken compressor to the facility air conditioning equipment. The temporary equipment was brought in and set up by 6:00pm CST on 8/23/23. After the equipment was running for about 30-40 minutes it brought the temperature down considerably. By the time we (contractors) left the site it was already comfortable inside the building. 2) Statement regarding residents that have the potential of being affected. a.) All residents in the facility that have been identified to have potential to be affected were relocated on 8/23/23. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). 3) Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a.) The facility contracted a vendor to provide temporary cooling of the entire building. Temporary cooling was installed on 8/23/23. *The (8/23/23) service agreement affirms temporary air conditioning at the facility was provided by (2) 30-ton air conditioners. b.) The facility purchased replacement compressors to be installed in the facility. The compressors were delivered on 8/30/23. The installation is in process. *The (8/23/23) service agreement includes scope of work: non-functioning AC. Approximate start date 8/24/23. *The (8/29/23) consignee delivery receipt includes three (3) compressors sent to facility address. *On 9/25/23 at 2:25pm, V17 (Corporate Administrator) stated the AC is completely fixed. c.) The facility initiated in-servicing for all staff on the facility policy provision and maintenance of comfortable temperature in the facility. Staff in-servicing was completed on 9/1/23. *On 9/25/23 at 2:25pm V17 stated we completed the in-services by 9/1/23 except for the staff that were on vacation and affirmed the facility remains vacant. *The (Undated) facility staff roster (including phone numbers) affirms there are 150 employees. * The facility provided PowerPoints titled Maintaining Facility Temperatures which excludes a date and/or topic discussed. * On 10/3/2023, the facility provided the attachment to the staff/roster signature page including in-service date and topic of discussion. d.) All employees on vacation and any contract staff will be in-serviced before their first day of work. *In-service titled Maintaining Facility Temperatures was documented on 10/02/2023 and includes 16 staff * A list of staff no longer working at the facility and/or unable to be reached via telephone for the in-service was also provided by the facility on 10/03/2023 4) The Director of Nursing will monitor continued compliance via the following Quality Improvement Programs once re-entry to the building is permitted by the City of Chicago. a.) A QA tool will be developed to monitor ensure safe and comfortable temperatures are maintained throughout the building by auditing the temperature logs in the building. daily. The monitoring will continue for 4 weeks and twice weekly for 8 weeks. *The F584 QA tool states the maintenance director/designee will check daily temperature on all floors and audit the temperature log to determine if the temperature is at a comfortable level however actual temperature is excluded. *On 9/27/23 at 10:52am, surveyor requested F584 QA tools for the abatement plan V17 affirmed they were not implemented. *On 9/27/23 at 3:39pm, V17 provided F584 QA tool (dated 9/27/23) which excludes temperatures. The (9/27/23) F584 QA tool was subsequently updated (as requested) to include temperatures. * On 10/03/2023 at 1:38 PM, V17 provided QA Tools with daily temperature starting logs in the building affirming that facility temperatures are taken daily starting 9/27/2023 and did not go beyond 76.3 F. b.) The results of the monitoring will be submitted to the QA/QI Committee quarterly for review and follow-up.

Based on observation and interview the facility failed to maintain safe and comfortable temperatures in the facility, failed to monitor residents for heat exhaustion, failed to provide adequate hydration during hazardous temperature, and failed to assess and supervise one resident (R21) with a change in condition related to heat exhaustion. These failures affected R21 who was sent to the hospital exhibiting heat related signs and symptoms and has the potential to affect all 132 residents. This was identified as an Immediate Jeopardy which began on [DATE] at 9:35 am per ([DATE]) facility temperature log which documents a temperature of 81.2F (Fahrenheit) in resident room. On [DATE] at 2:22 pm, V9 (RDO/Regional Director of Operations), V17 (Corporate Administrator), V18 (Chief Financial Officer) and V19 (Attorney) were notified of the immediate jeopardy. The facility presented a final removal plan on [DATE] at 6:39 pm which was not approved. The facility presented a revised final removal plan on [DATE] at 12:46 pm which was not approved. The facility presented another revised final removal plan on [DATE] at 4:36 pm which was accepted/approved on [DATE] at 8:45 am. The surveyor conducted additional interviews and record reviews on [DATE] to [DATE] verify the plan was implemented. The immediate jeopardy was removed on ([DATE]) based on actions from the removal plan. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: The [DATE] census includes 132 residents. The ([DATE]) Daily Air Temperature Logs affirm temperatures were documented ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] - not Daily as directed. On [DATE], the Chicago temperature was 98F (Fahrenheit) with heat index 116F per National Weather Service. On [DATE] at 6:24 pm, observed residents sitting outside of the facility in wheelchairs on the sidewalk with staff. No observation of water being offer or given to the residents outside. R21's Admission Record documents, in part, that R21's diagnoses include Diabetes, depression, neuropathy, dementia, Alzheimer's, glaucoma, and hypertensive heart disease. R21's admitted to the facility is documented as [DATE]. R21's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicates that R21 is moderately impaired. R21's ([DATE]) functional assessment affirms (1 person) physical assist is required for bed mobility, transfers, locomotion, personal hygiene, and toilet use. On [DATE] at 7:30 pm, surveyor observed R21 sitting in a wheelchair leaning over throwing up (3 times) in the (1st floor) dining room. R21 stated I need to lay down. V11 (LPN/Licensed Practical Nurse) pushed R21 via wheelchair into V2's (Director of Nursing) office where there was a window unit air conditioner. R21 stated, I'm not feeling well, it's too hot. I need to lie down, I feel weak. V11 took R21's blood pressure which read ,d+[DATE]. V11 attempted to obtain R21's pulse oximeter reading a total of three times, however, was unsuccessful. No other vital signs were taken for R21 before leaving the building with the CFD (Chicago Fire Department). On [DATE] at 7:40 pm, R21 was transferred from the wheelchair to bed. V12 (CNA/Certified Nursing Assistant) attempted to obtain R21's pulse oximetry and was unsuccessful. On [DATE] at 7:43 pm, V11 (LPN) affirmed the physician was contacted and orders were received to send R21 to the hospital. V11 instructed V13 (CNA) to stay in the room with R21. On [DATE] at 7:50 pm, R21 stated, I felt like I was going to pass out, I've been hot all day. V10 (LPN) obtained R21's temperature which was 96.2 (axillary) at this time then left the room. V13 (CNA) also left the room leaving R21 unattended. Surveyor observed R21 from 7:50 pm to 8:31 pm (41 minutes) however, staff did not reassess and/or check on the resident. R21 was left in room unattended to. On [DATE] from 7:30 to 8:31 surveyor observed R21 not offered or given any kind of hydration from staff. On [DATE] at 8:31 pm, the Fire Department arrived to transport R21 to the hospital who was appearing weak and slow to respond to questions. The ([DATE]) facility Air Temperature Log affirms the temperature was 86.2F with humidity 76.1F in resident's room, 86.0F with humidity 77.2F in another resident's room and 86.1F with humidity 78.2F at the (2nd floor) Nurse's station documented 10:00am-10:20am. The last temperature documented ([DATE]) was at 10:40am - not hourly as warranted due to temperature above 80F. On [DATE] at 7:07 pm, R79 stated it has been hot for about a month now, they (staff) provided fans. R79's ([DATE]) BIMS determined a score of 12 (moderate impairment). On [DATE] at 7:15 pm, staff on the first floor were noted to be sweating and their clothes visibly wet. On [DATE] at 7:22 pm, R92 reported feeling hot. R92 affirmed she was in her room and (approximately 1 hour ago) staff brought her to the 1st floor dining room. R92's ([DATE]) BIMS determined a score of 15 (cognitively intact). On [DATE] at 7:27pm, R75 stated, I feel terrible, I feel hot, I have not had anything to drink. Staff offered me something to drink but I refused to keep from having to use the bathroom. R75's ([DATE]) BIMS determined a score of 10 (moderate impairment). On [DATE] at 7:30 pm, R45 stated yesterday and today it got really hot. The AC in my room didn't work this morning, staff tried to turn it on, but it didn't work. R45's ([DATE]) BIMS determined a score of 12. On [DATE] at 7:45 pm surveyor observed R12 sitting in the hallway not given any food or water. V10 (LPN) stated R12 has a g-tube and receives bolus feedings. R12's lips were dry and cracked. R12's MAR (Medication Administration Record) reviewed excluding R12's 5:00 pm feedings signed out on [DATE]. No observation of incontinence care given to R12. On [DATE] at 11:00 am V2 DON (Director of Nursing) stated that the building was warm, and I instructed my staff to keep checking on the residents and hydrating them. We (facility) did have a cooling bus for the residents till around 6:00 pm. The building inspector said the facility had to evacuate due to high temperatures in the building. The facility started to evacuate the building around 12:00 pm. V2 DON stated that a resident with change in condition should have vital signs taken every 15 to 30 minutes until they get out of the building. V2 stated a resident with a blood pressure of ,d+[DATE] should have their vital signs taken every ,d+[DATE] minutes. Surveyor inquired about the frequency of R21's vital signs and V2 stated the nurse should have taken more vital signs. V2 stated that every nurse and CNA in the building is equipped to take vital signs. V2 stated that staff should not leave a resident unattended if the resident is unstable. Surveyorasked the DON, if a resident says they're hot, feeling weak and feel like they're going to pass out are they considered unstable? V2 stated yes, they are unstable and should have staff at bedside. On [DATE] at 11:43 am V11 LPN (License Practical Nurse) stated on [DATE] V11's shift started at 7:00 am and that morning the temperature in the building was warm and became warmer throughout the day. V11 stated after lunch at approximately 11:30 am-12:00 pm, staff was told that the building was being evacuated and all residents need to be transferred to another facility. The first thing we (Staff) did was put residents on a CTA cooling bus. V11 stated, I don't know if all the residents got on the bus. I saw two cooling buses. The buses stayed from 2:00 pm-5:00 pm. Surveyor asked V11 about R21's change in condition and V11 stated one of the staff members yelled that R21 was throwing up. V11 stated, I (V11) went into the dining room where R21 was and asked the staff to get some ice to help cool R21 down because of the hot temperature in the building. V11 stated R21 said, I (R21) do not feel good and feel weak. V11 stated R21 had been sitting up for a while and it was hot in the facility. The only cool place on the 1st floor was the Director of Nursing's (DON's) office. I took R21 to the DON's office where I took his VS (Vital Sign). Surveyor asked V11 what vital signs were obtained at that time? V11 stated, I took the blood pressure, pulse oximetry, pulse, respirations, and Accucheck. I didn't document the vitals because I did not have access to a computer. I did call the doctor because the blood pressure was low. The blood pressure was 100 over something. Surveyor asked V11 what the other VS were. V11 stated I don't remember. Surveyor asked V11 if the pulse oximetry was working and V11 stated, Oh, I forgot that the pulse oximetry was not working so I did not get the pulse oximetry or a pulse. I think the respirations were 22. V11 stated, R21 said again that he (R21) did not feel well, felt weak and wanted to lie down. I asked staff to assist me to move R21 to a room where R21 could lie down. Surveyor asked V11 if another set of VS was taken and V11 stated V11 did not take another set of VS. V11 stated, with it being very hot in the facility and R21 vomiting, V11 wanted to call the Doctor. V11 stated there was a male CNA (V12) and a female CNA (V13) in the room, and I told the female CNA (V13) to watch and monitor R21 while I went to call the doctor. V11 stated the doctor said to send R21 to the nearest ER (emergency room ). V11 stated, I did not return back to R21's room until the ambulance came to pick up R21 at 8:31 pm. V11 stated a complete set of Vital Signs were not taken on R21 due to not having the assessable tools to assess the resident correctly. V11 stated that a complete set of vital signs is the temperature, blood pressure, respirations, pulse oximetry and if a diabetic we take an Accucheck as well. V11 stated if a resident has a change in condition, then VS should be taken every 30 minutes to an hour and the resident should be reassessed. Surveyor asked V11 if R21 should have had repeated VS and V11 stated, Yes, R21 should have had VS repeated. V11 stated, I'm upset because the residents had to leave their homes and the facility could have done better with the air conditioner situation. V11 stated V11 has not had any training on the heat exhaustion or the emergency evacuation plan. R21's ([DATE]) hospital records documents in part, history & physical states - presents with general malaise. The Nursing Home lost the air conditioning tonight and in the process of moving the patient to another facility, the patient vomited few episodes. Differential Diagnosis: dehydration, electrolyte imbalance, weakness, influenza, urosepsis, viral syndrome, dizziness. R21's ([DATE]) Critical care notes, documents in part, critical interventions of IV Fluids. R21's ([DATE]) progress note states nursing home patient presented to the emergency room complaining of nausea and weakness due to no air conditioning during the heat wave. Nausea and vomiting/weakness secondary to heat exhaustion. On [DATE] at 12:28 pm, V13 CNA (Certified Nursing Assistant) stated the scheduler called V13 into work. V13 stated, I (V13) got to work around 5:,d+[DATE]:00 pm on [DATE]. I was instructed to take the residents out to smoke to keep them calm. I came into the room with R21 to check on R21and to put some ice on R21's head because the facility was hot. Surveyor asked V13 if V13 was instructed to stay with R21 when V11 (LPN) left out of the room and V13 stated she do not remember V11 telling her to stay with R21. V13 stated I went back into the room with R21 to check on him. V13 stated if a resident has a change in condition, then someone is supposed to stay with them. V13 stated that a resident who has a change in condition VS should be taken every ,d+[DATE] minutes. V13 stated, I did not get any report to say what I should be doing with R21. I went into R21's room on my own because I heard R21 was throwing up. It was hot in the building. I felt like I was going to pass out because of the temperature in the building, I just kept drinking water because of the heat. V13 stated I have never had any training on emergency evacuation or training on identifying heat exhaustion. On [DATE] at 12:45 pm, V12 (CNA) stated that he (V12) works 11pm-7am. I (V12) came in early to help put residents into the van to transfer out with the evacuation and when the residents wanted to smoke, we (staff) would take them out and try to make them (residents) comfortable. V12 stated that day it was extremely hot. V12 stated he saw they needed helped getting R21 in bed, so I went into the room to help. I tried to get a pulse oximetry on R21, but it was not working. The nurse did not tell me to stay with R21. There was another (CNA)V13 in the room when I (V12) left out of the room. V12 stated vital signs should be taken every hour with a change in condition resident. V12 stated that the last resident left the building around 1:00 am on [DATE]. V12 stated V12 left the facility at 1:30 am after the last resident left. V12 stated, I have never had any training in emergency evacuation at the facility. On [DATE] at 2:00 pm V6 (LPN) stated I (V6) was working alone that day on the 1st floor. There were 33 residents on the first floor. V6 stated I work 7 am-3 pm and on [DATE] was asked to work a double. V6 stated that when I knew the facility had to evacuate the second shift had already come in, and the second shift starts at 3:00 pm. V6 stated it was warm in the building because it was warm outside. V6 stated on the second and third floor it was warmer, so the staff started bringing the residents from the second and third floor to the first floor around 4:00 pm, and that is when the evacuation began. The cooling buses came after lunch and the residents ate lunch around 11:30 am. I remember serving lunch and the buses came after that time. The surveyor inquired if V6 remembered R21. V6 stated R21 started vomiting in the dining room, R21 was leaning over, and I sat his (R21) head up then R21 started vomiting again. V11 (LPN) came to assist with R21. I went to get the blood pressure machine then R21 vomited a third time, so V11 pushed him (R21) in the DON's office where it was cool. V6 stated that she thinks R21 went to the hospital, but not sure. I do not remember V6 stated, V11 telling me to keep an eye on R21, as far as I know she was watching R21. R21 was moved from the DON's office into a room to lie down. I don't even know what room he went into. I was busy packing medications. I do not recall V11 telling me (V6) to watch R21. The Surveyor inquired about a change in condition, how often should vital sign and reassessment be done and what does a complete set of vital signs consist of? V6 stated, A change in condition the vital signs should be done every 2 hours. If a resident say that they feel weak, hot, and feel like they're going to pass out then you take vital signs every 1 hour. If a resident is going to the hospital check vital sign every 30 minutes to an hour. If a pulse oximetry device is not working, then you must find a pulse oximetry that works or put the resident on oxygen. V6 stated a complete set of vital signs consist of blood pressure, pulse, respirations, temperature, pulse ox, and Accucheck if a diabetic. V6 stated, the air conditioner in the building has been broken all year. Once it started to get warm that's when they (facility) started to get chillers to help cool the building down. The chillers came into the facility in July. V6 stated that she has not had been educated or in-serviced on extreme weather hot/cold or the emergency evacuation plan. On [DATE] at 3:30 pm V21(Primary doctor) stated he (V21) is very familiar with R21. V21 stated the nurse (V11) called and said that R21 was vomiting. V21 stated, I (V21) thought R21 could be septic because he has a wound, so I told the nurse to send R21 to the hospital. V21 stated the nurse (V11) did not tell him that the building was without AC (Air Conditioner). I was not aware of the extreme temperature in the building, that day ([DATE]) was very hot outside, so I can imagine how hot it was inside of the building where the residents were. V21 stated, If I had known the building did not have AC, I would have given an order to call 911 asap (as soon as possible) because in hazardous temperatures the residents can die. Some years ago, in Chicago there was an extreme heat advisory and there were 300 people who died in the city of Chicago because of extreme heat. I pronounced 20 of them, so I do not take lightly extreme heat situations. If I knew there was no AC, I would have told V11 to get him out of there now. Surveyor inquired if the signs and symptom R21 was exhibiting could have been due to the extreme temperature in the building. V21 stated, I could say yes, his condition was due to the extreme heat that could cause heat exhaustion. The signs that could have been related to the extreme heat is hypotension, mental status change then death. The facility cannot have an AC not working in a heat advisory situation. Residents who have comorbidities and even staff who is working there with normal conditions are at risk with extreme heat advisories. R21's condition was due to the physical environment that caused him to be like he was with the weakness and vomiting. I did not have the information about the AC. If I had that information, I would have given an order to call 911 and get him (R21) out of there (facility). This situation with R21 was preventable. I feel bad for the residents. This is the facility's responsibility to make sure the residents are taken care of 100%. The residents should have been kept safe and this was not a safe environment for the residents. On [DATE] at 12:10 pm V10 (LPN) stated that he came into work at 7:00 am on [DATE] and around 11:00 am the city came into the building because it was warm in the building. V10 stated, around 1:00 pm staff started moving mobile residents to the first floor. The non-mobile residents when down to the first floor after the mobile residents. Surveyor inquired about R21 and V10 stated the staff said R21 was sick so that's why I (V10) went into the room. I took a blood pressure and a temperature; I did not document my vital signs. I did give the vital signs to V6 (LPN). A resident with a change in condition VS should be taken every 15 minutes. I left out of the room and did not go back into the room where R21 was. A resident with a change in condition should not be left alone. 911 should have been called for R21. I've been hot since April. R21's progress notes reviewed for [DATE], excludes documentation regarding the change in condition and transfer to hospital on [DATE]. R21's vital signs reviewed for [DATE], excludes documentation for blood pressure, temperature, pulse, and pulse oximetry regarding the change in condition. R21's name was on the list of vulnerable residents in the facility. Facility document titled List of Vulnerable Residents included R3, R12, and R13 on the list. Records reviewed for R3, R12 and R13 excluded documentation for vital signs on [DATE]. Surveyor observations from 9:00 pm-10:00 pm residents in the first-floor dining room and by 1st floor nursing station. Eleven residents in the dining room and eight residents in the hallway by the nurse's station waiting to be transferred. Residents were frustrated and tired of waiting to be transferred. One resident stated, I'm sleepy and tired, I go to bed at 8:00 o'clock, why am I still waiting? No staff responded to resident. No observations of vital signs, fluids being offer to the residents or incontinent care to the residents who were still waiting to be transferred out. Facility Policy dated ,d+[DATE] and titled Change in Condition, documents, in part, Guideline: To keep the physician or extender, who is in charge of medical care, responsible party, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. Standard: A need to alter treatment. Facility Policy dated ([DATE]) titled Hot Weather/Heat Emergencies, documents, in part, the Administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. The Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The maintenance director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of ,d+[DATE] degrees F. If temperatures increase, readings will be taken every hour. Emergency Operations Plan: Remove residents from areas that are exposed to direct sunlight. Recommending residents to stay indoors during extreme heat conditions. Report any changes in the resident's condition. Be sure to have an up-to- date and accurate list of all residents who are high risk to be adversely affected by extreme temperatures. Facility job description undated and titled Registered Nurse, documents, in part, General Job Description: The primary purpose of the job is to provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. Duties and Responsibilities: Monitor the care delegated to the Certified Nursing Assistant. Document resident status, clinical care, and interactions in the medical record. Provide updates regarding resident's status to the health care providers. Facility job description undated and titled Licensed Practical Nurse, documents, in part, General Job Description: The primary purpose of the job is to provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. Duties and Responsibilities: Monitor the care delegated to the Certified Nursing Assistant. Document resident status, clinical care, and interactions in the medical record. Provide updates regarding resident's status to the health care providers. Facility job description undated and titled Certified Nursing Assistant/Guest Experience Coordinator, documents, in part, General Job Description: The purpose of the job is to provide ADL (Activity of Daily Living), Restorative and other care to residents of the facility within the scope of practice .Duties and Responsibilities: Report all changes in the resident's condition to the nurse as soon as practical. Report all accidents and incidents you observe on the shift that they occur. Perform Vital Signs, weights and other task as assigned. The surveyor confirmed on [DATE] through interview, record review, that the facility took the following actions to remove the Immediate Jeopardy: The facility implemented all measures on the removal plan. 1) The facility has taken the following action concerning the IJ component: a.) R21 was transferred to the hospital on [DATE]. Per hospital, R21 has since been discharged on [DATE] to (alternate) facility to be closer to family. *On [DATE], surveyor contacted alternate facility and affirmed R21 resides there. b.) All residents in the facility were safely relocated to other facilities in an orderly manner. *Resident evacuation from the facility was completed on [DATE] at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). c.) The facility reached safe and comfortable temperatures in the building on [DATE]. *The ([DATE]) letter provided by contractor states company was engaged to supply necessary equipment to provide temporary air conditioning to the building due to broken compressor to the facility air conditioning equipment. The temporary equipment was brought in and set up by 6:00pm CST on [DATE]. After the equipment was running for about ,d+[DATE] minutes it brought the temperature down considerably. By the time we (contractors) left the site it was already comfortable inside the building. 2) Statement regarding residents that have the potential of being affected. a.) All residents in the facility that have been identified to have potential to be affected were relocated on [DATE]. *Resident evacuation from the facility was completed on [DATE] at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). 3) Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a.) The facility contracted a vendor to provide temporary cooling of the entire building. Temporary cooling was installed on [DATE]. *The ([DATE]) service agreement affirms temporary air conditioning at the facility was provided by (2) 30-ton air conditioners. b.) The facility purchased replacement compressors to be installed in the facility. The compressors were delivered on [DATE]. The installation is in process. *The ([DATE]) service agreement includes scope of work: non-functioning AC. Approximate start date [DATE]. *The ([DATE]) consignee delivery receipt includes three (3) compressors sent to facility address. *On [DATE] at 2:25pm, V17 (Corporate Administrator) stated the AC is completely fixed. c.) The facility initiated in-servicing for all staff on the facility policy provision and maintenance of comfortable temperature in the facility. Staff in-servicing was completed on [DATE]. *On [DATE] at 2:25pm V17 stated we completed the in-services by [DATE] except for the staff that were on vacation and affirmed the facility remains vacant. *The (Undated) facility staff roster (including phone numbers) affirms there are 150 employees. * The facility provided PowerPoints titled Maintaining Facility Temperatures which excludes a date and/or topic discussed. * On [DATE], the facility provided the attachment to the staff/roster signature page including in-service date and topic of discussion. d)The facility will initiate in servicing for all staff. On the facility policy for monitoring and supervision of residents during inclement weather condition. In-services was initiated on [DATE] and completed by [DATE]. The facility nurses were in-service on identification of residents showing signs and symptoms of heat exhaustion and providing hydration during hazardous temperatures. The (undated) facility staff roster (including phone numbers) affirms there are 150 employees. The facility provided Power Points entitled Maintaining Facility Temperatures & Evacuation Plan: What is my role and staff roster (endorsed by 91 staff) which excludes a date, citation number and /or topic of discussion. On [DATE] facility provided more in-services for facility nurses. Topic: Facility Policy on Change in Condition. Nursing signatures noted on in-service sheet were 5RN (Register Nurses) and 17 LPN (License Practical Nurses). e) All employees on vacation and any contract staff will be in serviced before their first day of work. New signatures received on [DATE] after the initial signature page. f) Post education will include the facility staff will demonstrating their knowledge of the facility policy related to identifying signs and symptoms of heat exhaustion. On [DATE] Staff interviewed about the in-services received and could not recall the content of the in-services. 4)The Director of Nursing will monitor continued compliance via the following Quality Improvement Programs once re-entry to the building is permitted by the City of Chicago: a) A QA tool will be developed to ensure safe and comfortable temperatures are maintained throughout the building by auditing the temperature logs in the building daily. The monitoring will continue for 4 weeks and twice weekly for 8 weeks. On [DATE] at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing. The temperature QA tool content includes Direction: The maintenance director/designee will daily check temperature on all floors and audit the temperature log to determine if the temperature is at a comfortable level. Date, Floor, was temp log audited? If yes, is temp at comfortable level? If no, what corrective action taken? Comment. b) A QA tool will be developed and completed daily to monitor residents showing a change of condition and determine the cause. On [DATE] at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing. F684 QA tool content includes Direction: Daily, The DON/Designee will conduct rounds on the floor to monitor if there is any resident showing signs and symptoms of change in condition (heat Exhaustion) and determine root cause. Date, Floor, was all residents monitored? If yes is there any resident showing signs of change in condition? If yes, was action taken including finding root cause? c)The results of the monitoring will be submitted to the QA/QI Committee Quarterly for review and follow-up. On [DATE] at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing.

Based upon observation, interview, and record review the facility failed to administer medications as ordered and failed to ensure that three of three residents (R21, R51, R52) reviewed for medication administration remained free from significant medication errors. These failures resulted in R21 sustaining a high blood glucose level of 249 on 8/23/23. Findings include: 1) On 8/23/23, the facility was being evacuated due to hazardous temperature in the building. R21'S diagnoses include type II diabetes mellitus. R21's (1/13/23) POS (Physician Order Sheets) include Lispro (Insulin) per sliding scale if blood glucose 200 (and above) three times daily. R21's (8/23/23) MAR (Medication Administration Record) affirms (11:00am) blood glucose level was 400 therefore 8 units of Lispro (per sliding scale) was administered. R21's (4:00pm) blood glucose level and/or Lispro insulin however were not documented (as scheduled). On 8/23/23 at 8:31pm (4.5 hours after scheduled Lispro), R21 was observed leaving the facility via ambulance. R21's (8/23/23) history & physical affirms bedside glucose level was 249 at 9:15pm. On 9/18/23 at 12:16pm, surveyor inquired about potential harm if R21 did not receive (8/23/23) blood glucose check and/or Lispro insulin as ordered V21 (Medical Director) stated, it's not good, maybe because of the chaos (referring to evacuation) they (staff) didn't do their job. He (R21) can go into a DKA (Diabetic Ketoacidosis) or something like that, it's a dangerous thing. Surveyor inquired why DKA is dangerous. V21 responded, it's not life threatening but it (DKA) can kill you. It's (DKA) preventable, I think they (facility) need to reteach the Nurses. 2) R51's diagnoses include hypertensive heart disease. R51's (4/27/23) POS includes Lisinopril (Antihypertensive) 10mg (milligrams) daily. R51's (8/23/23) MAR affirms Lisinopril was not documented at 9:00am (as scheduled). R51's (8/23/23) 9:10pm progress note states resident left facility, going to receiving facility (12 hours after scheduled Lisinopril). 3) R52's diagnoses include paranoid schizophrenia, bipolar disorder, delusional disorders, and unspecified psychosis. R52's (11/26/22) POS includes Aripiprazole (Antipsychotic) 0.5mg twice daily for behavioral disorder. R52's (8/23/23) MAR affirms Aripiprazole was not documented at 5:00pm (as scheduled). R52's (8/23/23) progress notes exclude discharge information. On 9/18/23 at 11:17am, surveyor inquired about the regulatory requirement for medication administration. V2 (Director of Nursing) stated, they (staff) need to pass them (medications) as prescribed. If they (residents) took them (medications) they (staff) supposed to sign it (Medication Administration Record). They (staff) are supposed to document they (residents) did not take it (medications). Surveyor inquired what a blank entry indicates on the MAR. V2 responded it shouldn't be a blank, it should be code for if they (staff) did or didn't give it (medications). V2 stated, The blank entry according to the law says you didn't give it. The day we had to evacuate (8/23/23) they (Building Inspectors) were trying to get the residents out the building, so I can't say what happened with medication administration that day. The instructions went out the wind when you got other entities (Building Department) giving other directions. The (undated) Licensed Practical Nurse job description states provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines, and regulations. Dispense medications. Document the care and services delivered to the residents. The (4/2020) medication administration policy states medications are administered according to state and federal law. Document medication administration after delivering. At completion of med pass, review all EMAR's (Electronic Medication Administration Records) to assure all medications have been administered and documented.

Based on interviews and record review, the facility failed to monitor and supervise a resident (R2), who was placed on facility's 24-hour safety monitoring, who has a history of illegal substance abuse and suicidal ideation. This failure resulted in R2 eloping from the facility and presenting at a county hospital reporting hallucinations and suicidal ideation with a plan to jump into the lake. This was identified as an immediate jeopardy which began on 1/10/2023 when R2 eloped from the facility. V1(Administrator) was notified of the Immediate Jeopardy on 2/07/23 at 10:17am. The facility presented a removal plan on 2/07/23 at 12:45pm. On 2/07/23 at 2:08pm, regional office acknowledged receipt of removal plan and began review at 2:40pm on 2/07/23. At this time the removal plan was not accepted. On 2/08/23 the facility re-submitted removal plan on 2/08/23 at 11:16am. The second removal plan was reviewed and conditionally accepted by the state agency, on 2/08/23 at 2:22pm. On 2/09/23 at 1:42pm, the surveyor verified by observation, record view, and interview, the immediacy was removed. The deficiency remains out of compliance at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan and maintain substantial compliance with this regulation. Finding include: According to a face sheet, R2 is a [AGE] year-old resident admitted to the facility on [DATE]. According to psychiatric rehabilitative service coordinator note dated 12/09/2022, R2 has a history has a psychiatric diagnosis of suicidal ideation, depression and the history of bipolar disorder and schizophrenia. R2's Minimum Date Set assignment dated 12/20/2022 indicated R2 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates resident has intact cognitive response. R2's care plan dated 01/09/2023, indicated R2 has a history of substance abuse and self-harm or suicidal ideation. Nursing Progress Note dated 01/10/2023 authored by V16 document: Resident noted with unauthorized departure from the facility today, staff has presented statements due this action, MD, social services, DON, and administrator are aware, no guardian/family listed, resident is responsible for self. Safety Checklist (dated 01/10/2023) documents R2 as being in another resident's room at 4pm. The checklist does not list R2's whereabouts starting from 5pm as R2 eloped. On 01/31/2023 at 9:40am V1 (administrator) stated, R2 is no longer at the facility. R2 just left and later that day we found out that R2 was at the hospital. R2 did not even sign out against medical advice (AMA), R2 just left. R2 was no trouble as a resident, maybe on occasion R2 would use vulgar language. R2 came from the sister facility to be closer to the city. R2 would go outside and smoke and would return. On 01/10/2023, we were passing trays for diner, and we realized that R2 was not here at the facility. R2 left the building and never came back. We believe that R2 left when they went out to smoke and R2 never returned. The smoke break was at 2:30pm and we believe that R2 left the facility premises during the smoke break. R2 was never a resident who we were concerned about because R2 never attempted to leave or elope. On 01/11/2023, we received a call from the community behavioral hospital, informing us that R2 was there and wanted to know if he could return. The facility's admissions department contacted the hospital and informed the hospital that we would take R2 back to the facility. They never brought the resident back and the admissions director called the hospital several times to follow up if R2 was returning. R2 did not have a pass to go out into the community alone because R2 was still being evaluated. When R2 was admitted here on 12/09/2022, R2 was still in the process of being evaluated for an independent community pass. At the time R2 left, he was able to go into the community only with supervision and was in the process of being evaluated for an independent community pass but did not possess an independent community pass at the time R2 eloped from the facility. When the residents go out to smoke, they go out to the patio. The exit door to the patio is locked. The patio is monitored by 4 to 5 staff members when the residents are outside smoking. I did not conduct an investigation on how R2 eloped, we did a whole house search and since R2 is alert and oriented, we did not report it to the police. R2 had his jacket on him at the time R2 left because he was outside smoking so he must have planned to elope. Residents at times do attempt to climb the fence to elope from the smoking patio, that's why we have staff there to monitor the residents and prevent them from eloping. I really don't know if R2 escaped from the smoking patio. There were no door alarms going off, so the process of elimination indicates that R2 eloped from the smoking patio. It is possible for residents to elope from the smoking patio. If the resident is alert and oriented, we don't investigate on how they eloped. If they are alert and oriented it's their decision if they want to leave. R2 had the capacity to make his own decision and R2 had the capacity to leave the facility. R2 never expressed the desire to leave the facility. As of right now, I do not know how R2 left, this is only our suspicion that R2 eloped from the smoking patio. R2 somehow ended up in the community psych hospital and did not get his medication and was cold and hungry and probably ended up at the psychiatric hospital. There is a loophole of how R2 eloped, so there are other residents who are potentially able to elope from the facility. We are aware of the fact that there is a loophole on how R2 escaped, and we are monitoring other residents closely. I honestly don't know how R2 escaped it is only our suspicion that R2 escaped from the smoking patio. We did not put in any new interventions, since R2 eloped, we are just closely monitoring the residents and the doors are locked. R2 has a diagnosis of schizophrenia so R2 does have a history of psychiatric disorder. As of right now, the last we know R2 was at the hospital, and I believe R2 was discharged . R2 was not suicidal at the time. In R2's diagnosis R2 does have suicidal ideation but R2 wasn't suicidal at the time. I did not report this incident to the IDPH because R2 was alert and oriented and R2 wasn't a problem. On 01/31/2023 at 10:50am, V1(administrator) identified 8 residents at risk for elopement at the time of investigation. The following residents were identified as being at risk for elopement: R6, R7, R8, R9, R10, R11, R12 and R13. On 01/31/2023 at 11:32am V3 (social service director) stated, When a resident elopes and once we are made aware of the elopement, we call a code pink. Code pink means that there is a missing resident or elopement. We search for the resident that's missing in the facility and outside. If need be, we will call the Chicago Police Department. If the residents have family listed on the contact list, we will call them and make them aware. If we cannot find the resident, we will call the police and make a missing police report right away. That is protocol, that when a resident is missing and cannot be found, we have to call the police and make a missing police report. The protocol to call and make a police report when the resident is missing is for every resident, regardless of their cognitive status, a police report must be filed when a resident is missing. It does not matter how alert the missing resident is, when we cannot locate that resident when a search is unsuccessful, we are supposed to call the police immediately. On 01/31/2023 at 11:52am V4 (psychiatric rehabilitation service director) stated, R2 was living at our sister facility and was admitted to this facility on 12/09/2022. When we have a new resident admitted to this facility, we have to do a 72-hour behavior safety check list where we monitor them. After reviewing R2's admission packet from the hospital, we discovered that R2 has a past history of aggression, history of substance abuse and suicidal ideation. The social service department enrolls the resident into the substance abuse program. After reviewing R2's referral packet, R2 was placed on a facility safety monitoring rounding checklist because R2 has a history of suicidal ideation and substance abuse. R2 was residing on the 3rd floor which is a psychiatric floor. The rounding check list requires the staff to monitor R2 every hour and record R2's whereabouts on the checklist. According to the checklist filled out by V15 (psychiatric rehabilitative service aide) on 01/10/2023, R2 was last seen at 4pm, at that time R2 was in another resident's room. After 4pm, R2 was no longer seen. I received a call from V5 (PRSC) stating that they could not find R2 inside facility. Immediately after receiving that call, I notified the V1 (administrator) and explained to V1 that R2 is missing. I asked my staff to document on the computer about the elopement and we updated the care plan and the elopement form. The facility was searched prior to calling me and when they could not find the resident, they called me, and they called the administrator. The administrator did not call the police because R2 is alert and oriented. According to the administrator, if the resident is alert and oriented, we do not notify the police and we do not make a missing police report. R2 did not discharge from the facility, R2 eloped. R2 has a major depressive disorder and schizoaffective disorder bipolar type and schizophrenia and suicidal ideation and cocaine abuse usage and cannabis dependence which is why R2 was admitted to the facility in the first place. Medically, R2 is not fit to leave the facility. R2 needs help to be stabilized. R2 has a lot of mental health issues and should on be out of this facility according to his medical history. We do not know R2's mental state at the time R2 eloped. The facility's administrator would be the one who calls and makes a police report. On 01/31/2023 at 3:26pm V6 (certified nursing assistant) stated, I was the C.N.A working with R2 on 01/10/2023, when R2 eloped. The last time I saw R2 was at 1:30pm, when R2 was going down to smoke a cigarette on the smoking patio. I saw R2 leaving the 3rd floor to go to the 1:30pm smoke break. I do not recall seeing R2 return from the smoke break. R2 never mentioned that he wanted to leave the facility. I finished my shift at 3pm and when I returned to work on 01/11/2023, I was informed that R2 eloped. On 02/01/2023 at 9:56am V7 (certified nursing assistant stated, I was working on the 3rd floor on 01/10/2023. I saw R2 on 01/10/2023. The last time I can recall seeing R2 was during lunch time. I don't recall seeing R2 after lunch. The last time I saw R2 was during lunch time when I was passing trays. Typically, R2 was usually in his room. I don't recall ever seeing R2 visiting other resident room. R2 kept mostly to himself and stayed in his room. On 02/01/2023 at 12:32pm V10 (primary physician) stated, They called me from the facility and told me that R2 eloped. They told me that R2 just walked out from the facility. There was no AMA, there was no discharge for R2, he simply just left and walked out from the facility. The facility told me that R2 just left. R2 just ran away. R2 was being monitored for safety at the facility. I think that R2 could have jumped the fence, but I don't know. R2 was being monitored for safety and R2 was a psych patient. Often, the psych residents want to leave the facility and that's what R2 did, he just walked out of the facility. The nursing home was monitoring him for 24 hours a day. Based on the diagnosis that R2 has, R2 needs to be monitored and I hope that R2 does not kill himself or someone else. I thought that the facility called the police and made a police report and reported R2 missing. I thought it is protocol to call the police when a resident elopes. I thought that the facility called the police to report that he ran away. On 02/02/2023 at 10:32am V13 (Psychiatric Rehabilitative Service Coordinator) stated, I was the one that was supervising the smoking session on the day that R2 eloped. There was 4 of us supervising the smoking break. Typically, there should be an activity aide, a CNA, a PRSC and a PRSA. On 01/10/2023, there was only 4 of us supervising the smoke break. I don't remember if an activity aide was there and I don't remember if there was a CNA present. I don't remember seeing R2 on the patio during the smoke break. We monitor the residents during the smoke breaks. We have staff members on each side of the gate and a staff member in the middle to provide supervision during a smoke break. On the day that R2 eloped, I don't remember seeing a staff member on each side of the gate to supervise during the smoke break. There is usually a staff member supervising the front gate, but I don't remember seeing a staff member supervising the other end gate, the gate that is away from the front entrance. We wait until all of the residents come inside from the smoking patio. Once all the residents come in, we lock the door. On 02/02/2023 at 10:52am V14 (front door receptionist/Psychiatric Rehabilitative Service Assistant) stated, On 01/10/2023, R2 came down from the 3rd floor to the front lobby close to 2pm. R2 approached me and requested to speak to V1 (administrator). R2 remained in the front lobby, and I went to inform the administrator, that R2 was requesting to speak to V1, however, V1's door was closed. I came back out to the front lobby to let R2 know that V1 was in the meeting, and I told R2 to come back in 30 to 40 minutes. R2 said R2 would come back to speak to the administrator and got on the elevator. That same day, I saw R2 on the second floor around 3pm, visiting R5's room. That was the last time I saw R2. R2 did not escape during the 1:30pm smoke break because I saw R2 around 3pm on the second floor in R5's room. That was the last time I saw R2. I was informed around 5:30pm that R2 was missing and R5's room was the first place I went to search. I called a code Pink, which is a code called when a resident is missing. On 02/02/2023 at 11:23am, V15 (Psychiatric Rehabilitative Service Assistant) stated, On 01/10/2023, I was the one who signed the round sheet for R2 at 3pm and 4pm. The round sheet is used to monitor residents for safety. I witnessed R2 at 3 and 4 pm on the second floor, in R5's room. I did not see R2 in the facility after 4pm. On 02/02/2023 at 12:28pm V17 (maintenance director) stated, I checked all the exit doors with alarms in the entire building. All the door alarms are working properly. All the exit doors are secured and locked. After R2 eloped, I checked all the doors and alarms in the building, and everything was working properly. It is a possibility that R2 escaped through the service door in the basement, by the kitchen. We have food delivery and supply delivery, and everything is delivered through the back service door, so it is possible that R2 escaped through the service door in the basement. We had other residents attempt to elope through the basement service doors. We have cameras all over the facility. Surveyor, accompanied by V17 (maintenance director), checked all the door alarms in the facility. Surveyor observed the door alarms to be working. County Hospital Records (dated 01/11/2023) document: Voluntarily brought self in states that he has suicidal thoughts with a plan to jump off a bridge; denies HI and hallucination. Hospital Records dated 01/11/2023 document: Pt is a [AGE] year-old male who presented to behavioral hospital as a direct transfer from county hospital Emergency Department. Per hospital fax, pt presented with suicidal ideation with a plan to jump in the lake. Pt also reported visual hallucinations stating that people are following him. Pt has a history of schizophrenia and bipolar. Pt reported that he is compliant with his medications. Pt reported that he lived in a nursing home that provided him with the medication. Pt endorses cocaine. Pt was unable to contract for safety. Pt is a danger to self and is in need of inpatient psychiatric treatment for safety and stabilization of suicidal ideation and psychosis. Emergency Operations Plan: Elopement vs. Unauthorized/Unplanned Discharge Policy and Procedure (dated 11/17/2022) states: In the event of a possible elopement, the following procedures shall be utilized: a.) Proper code will be called overhead. b.) An investigation shall be coordinated by the facility administrator, director of nursing or manager/supervisor on duty. A search will be conducted to assist in locating the resident. d.) The local law enforcement will be notified. e) If the incident/falls into IDPH Reporting Guidelines, designated facility staff will report incident to IDPH within 24 hours. Progress note dated 01/10/2023 documents, The writer was notified by the facility staffs that the resident made an unauthorized departure on 01/10/2023. The writer informed the writer, the staffs carried out room search, the resident was located. Psych social will continue to monitor and document as needed. Progress note dated 01/11/2023 documents, The nurse M. called from the community behavioral hospital; stating that they have the above resident there and they will be admitting him and wanted to know if he can return. I advised the nurse to call the facility back later in the morning to speak with social services. She stated, OK! The writer also informed the nurse the resident eloped from our facility. Nurse Practitioner Progress Note dated 01/14/2023 document, Psychiatry Note Attempted to see patient for evaluation this date but was informed by RN that he was not available because he eloped a few days ago. The surveyor confirmed through observation on 02/09/2023, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility has taken the following actions concerning the IJ component a. The facility will review all residents who are at risk for an elopement and will update their care plans for resident specific interventions. Review and update by PRSD initiated on 2-7-23. b. Facility will immediately conduct a (RCA) root cause analysis, to be conducted by administrator, on how the resident was able to elope from the facility and what additional care plan measures could be put into place should the resident return. Plan started on 2-7-23 by the administrator. c. The resident that has been identified to be at risk of elopement has been placed on Q1-hour safety monitoring. Monitoring initiated on 2-7-23 d. Facility will ensure that residents who are at risk for self-harm, who leave the facility without authorization, will be reported to the Chicago Police Department by PRSD or designee. 2. Statement regarding how the facility identify other residents having potential to be affected by the same IJ component? a. All those at high risk for elopement have been identified to have potential to be affected. 3. Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a. All residents have been reassessed for elopement risk by PRSD. The facility has used the Elopement Risk Assessment to complete the reassessments. b. Care plan for residents identified as an elopement risk have been reviewed with individualized interventions for safety. Review initiated on 02/07/23. These include hourly safety checks and behavior monitoring as needed. c. The facility has initiated an educational in-service for all staff, including Social Services, Nursing, Activities, Front Office, Housekeeping and Managers, on the facility elopement policy and the code procedures in any incident of elopement. on monitoring resident's at risk for elopement, interventions for prevention of the elopement, and the system for monitoring residents at risk for elopement; as well as steps the staff should follow should an elopement occur. Any staff on vacation or leave will be in serviced before their next scheduled shift. In-service initiated on 02/07/23. 4. The Director of Nursing or designees will monitor continued compliance via the following Quality Improvement Programs: a. Daily, the PRSD or designee, will ensure that all resident that have been identified to be at risk of elopement are monitored hourly all through the shift. b. Quarterly the care plan for residents identified as an elopement risk have been reviewed with individualized interventions for safety. c. The results of the monitoring completed under this POC are submitted to the QA/QI Committee for review and follow-up. The QA/QI committee is made up of IDT members which include Nursing, Social Services, Psycho-social Rehab, Activities, Therapy, Administration, and Medical Director.

Based on interview and record review, the facility failed to ensure the safety of residents by not monitoring and preventing residents (R3, R6, R11, R12, R14) from receiving and using illegal drugs. This failure resulted in R3, R6, and R12 overdosing on illegal drugs, requiring transfer to local hospital for treatment. Findings include: 1. R12's medical record (Face Sheet, MDS-Minimum Data Set) notes in part, R12 is a cognitively intact [AGE] year-old with the following diagnoses including but not limited to: [CONDITION(S)] disorder and Nicotine Dependence. PAS/MH (Preadmission Screen/Mental Health 02/04/2022) notes in part, R12 has a history of alcohol, cocaine, heroin and marijuana use. R12's progress note (4/30/2022 at 3:00 PM) notes in part, R12 was observed in the pantry area in a sitting position very lethargic not responding when called by name. Skin warm but sweaty. Vital signs as follows: blood pressure-90/70, pulse-66, O2 saturation 77%. Rapid response called. Continued to be unarousable, 911 called. 911 started [MEDICATION(S)], IV (intravenous). Resident continued to be lethargic. O2 saturation increased to 85%. Security stated when resident stated to 911 team that resident had taken some heroin earlier in shift. R12's progress note (4/30/2022 at 7:00 PM) notes in part, R12 given [MEDICATION(S)]; will be returning to facility within three to four hours. R12's ambulance run sheet (04/30/2022 at 2:58 PM) notes in part, patient is lying in bed, unresponsive, breathing. Pupils fixed, pinpoint. After administration of [MEDICATION(S)], patient became alert and oriented x3. R12's hospital record (4/30/2022 at 5:58 PM) notes in part, R12 found minimally responsive with slowed respirations and given 2mg [MEDICATION(S)] IV, pulled out IV, woke up some. Upon arrival R12 groggy, not answering questions other than to say R12 does dope. Would not say who R12 is getting their drugs from. Progress Note 4/23/2022 at 5:06 PM notes, met with V12 to process their feelings due to behaviors on a previous day when drug perfumery (sic: paraphernalia) was found in resident's room. Progress Note 4/22/ at 12:59 PM notes, V12 returned from independent 2 hour pass and was observed with unusual behaviors. V12 toxicology screen indicated illegal substance in V12's system. V12's 2 hour pass was revoked. V12 was counseled and was placed in substance abuse school. Care plans, forms updated. Psychosocial will continue to follow. Progress Note 4/22/2022 at 12:10 PM notes, V12 was suspected to be under the influence of drugs or substances. Drug screen was completed, and the resident was positive for substance. The writer met with the resident regarding the incident and was counseled on the negative use of substances while on [CONDITION(S)] medication. Resident will be placed on close monitoring pending necessary policy review and treatment update. Progress Note 4/22/2022 at 2:35 AM notes, drug screen positive for cocaine. V6 (Physician) called, message left with result, will await call back for any new order. Drug Screen 4/21/2022 at 8:27 PM (specimen collected 4/20/2022) notes, positive for cocaine metabolites. Progress Note 4/20/2022 at 10:37 AM, notes resident out on pass. 11:36 AM Arrived back from out on pass. Progress Note 4/20/2022 at 9:18 AM notes, called V6 (Physician) for order for 6 panel toxicology, order received and carried out. 2. R6's medical record (Face Sheet, MDS) notes in part, R6 is a cognitively intact, [AGE] year-old admitted to the facility on [DATE] with the following diagnoses including but not limited to: [CONDITION(S)] Disorder, [CONDITION(S)] Type and Opioid Dependence. R6's progress note (4/30/2022 at 10:21 PM) notes in part, R6 suddenly lost consciousness. R6 was assessed, 911 called. R6's progress note (4/30/22 at 11:37 PM) notes in part, R6 regained consciousness at the hospital. R6's ambulance run sheet (4/30/2022 at 9:45 PM) notes in part, found lying supine in bed, unresponsive, shallow breathing with pinpoint pupils. R12 given 2mg [MEDICATION(S)] intranasally, became alert and admits to using heroin. R6's hospital record (4/30/22 at 10:28 PM) notes in part, R6 to ED (Emergency Department) after found unresponsive with pinpoint pupils. Responded to [MEDICATION(S)]. On 5/20/2022 at 4:51 PM, R6 said, they were sent to the hospital after they overdosed on heroin. R6 said they purchased a $10 bag (small plastic-held up thumb and pointer finger to indicate plastic bag approximately two inches by two inches) from R12. 3. R3's medical record (Face Sheet, MDS) notes in part, R3 is a cognitively independent [AGE] year-old, admitted to the facility on [DATE] with the following diagnoses including but not limited to: [CONDITION(S)] Disorder, [CONDITION(S)] Type and Opioid Abuse with Opioid-Induced Behavior. R3's care plan has a history of substance abuse/chemical dependency (initiated 11/29/2021) lists the goal of resident will refrain from using non-prescribed substances through the next review (initiated 11/29/21, updated 5/19/2021) with intervention of supervision while in the community (initiated 11/29/2021). R3's progress note (4/25/2022 at 8:54PM) notes in part, R3 has substance use history of cannabinoids: (marijuana, hashish); opioids and [MEDICATION(S)] derivatives: ([MEDICATION(S)], [MEDICATION(S)], heroin, [MEDICATION(S)]); stimulants: (cocaine, amphetamines, methamphetamines). R3's progress note (5/1/2022 at 10:52 PM) notes in part, R3 was admitted to local hospital due to opioid overdose. R3's progress note (5/5/2022 at 9:21 AM) notes in part, writer met with R3 to discuss the incessant violation of facility substance abuse policy. Writer gave R3 a copy of the facility substance abuse violation policy and facility resident incentive and contingency management program. R3 signed the substance abuse policy, verbalizes understanding. R3's ambulance run sheet (5/1/2022 at 7:39 PM) notes in part, found on floor, non-rebreather mask on, unresponsive with pinpoint pupils and agonal respirations. Oxygen saturation on room air in the 60's. Given 2mg [MEDICATION(S)] IV and began to wake up immediately. R3's hospital record (5/1/2022 at 8:09 PM) notes in part, presents to ED after being found unresponsive. Paramedics report R3 had depressed respirations and pinpoint pupils. Responded to [MEDICATION(S)] 2mg, told paramedics they found a bag of heroin. 4. R11's medical record (Progress Notes, MDS) notes in part, R11 is a cognitively intact [AGE] year-old admitted to the facility on [DATE] with the following diagnoses including but not limited to: Opioid Use and [CONDITION(S)] Disorder. R11's care plan has a history of substance abuse/chemical dependency (initiated 4/1/2022) lists the goal of resident will refrain from using non-prescribed substances through the next review (initiated 4/1/22) with intervention of supervision while in the community (initiated 4/1/2022). R11's progress note (4/1/2022 at 7:03PM) notes in part, R11 has a history of dual substance abuse. R11's progress note (5/4/2022 at 8:30 AM) notes in part, R11 noted lying in bed cyanotic and gasping for air. Code Blue initiated, oxygen applied, 911 called. R11's progress note (5/6/2022 at 4:09PM) notes in part, PRSC met with R11 to complete the substance abuse policy form. PRSC explained the purpose of this form. R11 showed understanding by completing this form. R11 was reminded about the substance abuse group with dated and time. R11's ambulance run sheet (5/4/2022 at 8:48 AM) notes in part, R11 showed signs of AMS (altered mental status) and was unresponsive for ten minutes. R11 has history of opioid abuse. R11's hospital record (5/4/2022 at 9:42 AM) notes in part, R11 states was sleeping in their room, when staff woke them up stating they were difficult to arouse. 05/19/2022 at 2:15 PM, R11 said they went to the hospital because somebody (R12) brought drugs (heroin) in, and we (R11 and R3) tried (snorted) it. 05/20/2022 at 12:19 PM, R11 said R12 obtained the heroin from a relative of R14. 5. R14's medical record (Face Sheet, MDS) notes R14 is a moderately cognitively impaired [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: [CONDITION(S)] and [CONDITION(S)] Disorder, [CONDITION(S)] Type. R14's PPAS/MH dated 02/15/2022 notes in part, R14 has a history of daily marijuana use. Behavior Note (05/06/2022 at 10:28 AM) notes in part, the writer was notified by the administrator (R14's) pass privilege has been revoked due to the resident contract violation (recreational use of drugs on recent pass. Behavior Note (05/06/2022 at 12:38 PM) notes in part, the resident's drug screen test result came out positive. On 05/20/2022 at 5:03 PM, R14 said, I tested positive for marijuana last month. I smoked marijuana when I was out on pass. I got it from my cousin. On 5/25/2022 at 9:36 AM, V1 (Administrator) said, We don't believe the residents overdosed on heroin. We suspected (R12) was bringing drugs into the facility. We were unsure that it was heroin until R12's urine (toxicology) came back positive for cocaine. We think the drug dealer told (R12) that it was heroin, but it was actually cocaine. None of the residents had urine drug tests done at the facility or the hospital. The residents told nursing home staff and ED staff that they took heroin. On 5/20/2022 at 3:36 PM V5 (PRSD-Psychiatric Rehabilitation Service Director) said, R6, R11 and R12 were using drugs. R6 had substance abuse issues, this resident continued to have use of illegal drugs. We did room sweeps on these residents; drug paraphernalia (pipes) were found in R12's room. R12 was the culprit, R12 brought drugs into the facility. R6 and R11 said R12 gave the drugs to them. Everyone knew R12 was bringing drugs into facility when returning from pass.

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received essential medications to treat their medical conditions as ordered by their physician. There was no nurse to pass medications on the third floor on one portion of a resident hallway and as a result, 13 residents (R18, R122, R58, R74, R32, R86, R5, R59, R61, R63, R106, R14, R95) did not receive their scheduled medications on 10/12/2021 on the day shift (7:00 AM - 3:00 PM). These failures have the potential to cause serious negative medical outcomes for all 13 residents Findings include: On 10/12/21 at 10:45 AM surveyor observed and interviewed residents on the third floor. R18, R122, R58, R74, R32, R86, R5, R59, R61, R63, R106, R14 and R95 stated that they had not received their morning medications. Surveyor observed V2 (Current Director of Nursing/DON) on third floor around noon time. On 10/12/21 at 11:43 AM, V2 stated that two nurses are required for the third floor but today only one nurse is available today. On 10/12/21 at 11:44AM, R50 stated that he did not receive his medications yet. R50 said, I'm in pain. It's in my legs. When asked if R50 had told the nurse, R50 said, I was on my way to ask the nurse. Surveyor was present when R50 asked one the nurse on the 3rd floor, opposite wing. On 10/12/21 at 11:46 AM, surveyor observed R50 ask V6 (LPN) his for medications. V6 responded to R50, You will get your medications when your nurse comes up. R50 limped back to his room. Reviewed the electronic medication administration records (e-MAR) for R50 and other resident's on the same wing of the third floor. Requested and received time stamped copies e-MAR records from V2 (Current DON). R18, R122, R58, R74, R32, R86, R5, R59, R61, R63, R106, R14, R95 e-MAR records were reviewed and were missing medications for the AM pass time, Tuesday 10/12/2021 (the spaces were blank). Surveyor also requested face sheet, and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/12/21 at 1:45 PM, V6 stated she (V6) is only nurse on the third and that she is only responsible for passing medications and treatments for her assigned residents. V6 stated V2, who was standing nearby, was going to find someone to pass medications for the other residents. V6 said, That was two hours ago that he (V2) was to get someone to pass medications for the other residents (R18, R122, R58, R74, R32, R86, R5, R59, R61, R63, R106, R14 and R95). Surveyor asked V6, what she would do if a resident asked for their medications. V6 said, They would have to wait and that I don't have time because of my residents. During an interview on 10/13/21 at 1:03 PM, V5 (Interim DON) stated that the expectation is for the staff to know the medication rights, also to administer medications safely. V5 said, I believe most of the nurses have had in-services on how to pass medications. The expectations are to pass meds one hour prior and then one hour after scheduled time of administration. V5 also stated every nurse is responsible for every resident on their floor regardless of their room section. V5 further stated nurses are to provide pain medications and wound assessments for any resident in need. When surveyor mentioned to V5 the response of V6 (LPN) to R50 in an earlier nurse patient interaction, V5 said, The nurse should not have responded in that manner. I will have an in-service with V6. On 10/13/21 at approximately 3:30pm, V20 (Primary Care Physician for R74) stated that [MEDICATION(S)] ([MEDICATION(S)]) medication (to prevent blood clots) and [MEDICATION(S)] ([MEDICATION(S)]) (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It is not good if a resident missed those medications because it could reduce the therapeutic level. Resident is at risk for compromised patient care if medications were missed. The following medications were missed on 10/12/21: 1. (R18) - [MEDICATION(S)] (Daily) for Hypertension. 2. (R122) - [MEDICATION(S)] for Seizures 3x/day (missed 9AM and 1:30 PM) [MEDICATION(S)] for anxiety, 2x/day (missed 9AM) 3. (R58) - [MEDICATION(S)] for [CONDITION(S)] 2x/day (Missed 9AM dose), [MEDICATION(S)] Sodium for [CONDITION(S)] 2x/day (missed 9AM). [MEDICATION(S)] 2x/day (missed 9AM) for diabetes, [MEDICATION(S)] for hypertension 2x/day (missed 9AM), [MEDICATION(S)] [MEDICATION(S)] for [CONDITION(S)] 3x/day (missed 9AM and 1:00 PM) 4. (R74) - [MEDICATION(S)] Tablet for seizures 2x/day (missed 9AM), [MEDICATION(S)] for Major Depressive disorder Daily (missed 9AM), [MEDICATION(S)] Tablet 25 MG for anticonvulsants (missed 9AM) 5. (R32) - [MEDICATION(S)] 2x/day (missed 9AM) for heart failure, [MEDICATION(S)] Tablet for [CONDITION(S)] disorder 3x/day (missed 2PM). 6. (R86) - [MEDICATION(S)] for seizures 2x/day (missed 9AM). 7. (R5) - [MEDICATION(S)] for [CONDITION(S)] 2x/day (Missed 9AM dose), [MEDICATION(S)] Sodium 2x/day (missed 9AM), [MEDICATION(S)] 2x day (missed 9AM), [MEDICATION(S)] for [CONDITION(S)] 3x/day (missed 9AM), [MEDICATION(S)] (for [CONDITION(S)]) 3x/day (missed 9AM and 1PM) 8. (R59) - [MEDICATION(S)] for blood thinner (missed 9AM), [MEDICATION(S)] for Seizures 2x/day (missed 9AM). 9. (R61) - [MEDICATION(S)] for [CONDITION(S)] daily (missed 9AM), [MEDICATION(S)] for [CONDITION(S)] 2x/day (missed 9AM), [MEDICATION(S)] for chronic pain 3x/day (missed 8AM). 10. (R63) - [MEDICATION(S)] for [CONDITION(S)] 2x/day (Missed 9AM dose), [MEDICATION(S)] Sodium for [CONDITION(S)] 2x/day (missed 9AM), [MEDICATION(S)] 2x/day (missed 9AM). 11. (R106) - [MEDICATION(S)] for Seizures daily (missed 9AM), [MEDICATION(S)] for Seizures 2x/day (missed 9AM), [MEDICATION(S)] HCl Tablet 10 MG 2x/daily (missed 9AM), [MEDICATION(S)] 2x/day (missed 9AM). 12. (R14) - [MEDICATION(S)] (lurasidone) for [CONDITION(S)] daily (missed 9AM), [MEDICATION(S)] HCl Tablet 5 MG 2x/daily (missed 9AM), [MEDICATION(S)] for diabetes 2x/day (missed 9AM), [MEDICATION(S)] Tablet for seizures 2x/day (missed 9AM). 13. (R95) - Sitagliptin daily for Diabetes (missed 9AM), [MEDICATION(S)] for [CONDITION(S)] 2x/day (Missed 9AM dose). [MEDICATION(S)] for diabetes 2x/day (missed 9AM). [MEDICATION(S)] 2x/day missed 9AM). Blood glucose was not checked at 11am, [MEDICATION(S)] for seizures 3x/day (9am and 1:00PM missed), [MEDICATION(S)] 100units/mL for diabetes (missed 11AM). Facility's Medication Administration policy (4/2020) documents in part: Medications are administered according to state and federal law. Medications are to be administered with an order. Five rights: Right time- 60 minutes before or after the scheduled time unless otherwise specified. If resident is not available, return to resident before or at the end of med pass. Document medication administration after delivering.

Based on observation, interview and record review the facility failed to provide supervision and failed to identify a hazardous item in a resident's room with self -harming behaviors for one resident (R1) out of 3 (R1, R2, R3) residents reviewed for safety and supervision. This failure resulted in R1 hanging himself. Findings include: R1 is a [AGE] years old male with [DIAGNOSES REDACTED]. On 7/13/20 at 10:41 am, V1 (Administrator) stated, V3 (Certified Nursing Assistant) was doing rounds on 7/12/20 around 5 am and noticed R1 was not in his room. V1 stated, a search was initiated of the building however V3 came back to R1's room and found the resident in the closet. R1 committed suicide by hanging using 2 plastic hangers. V1 further stated, R1 kneeled, placed his neck between the hangers and leaned forward to cut off his airflow. V1 further stated, R1 removed the closet metal rod from the bracket, placed 2 plastic hangers on the rod then attached the metal rod back to the bracket and used the plastic part of the hangers to commit suicide. Surveyor asked what type of residents reside on the 3rd floor, V1 stated, independent residents with psyche problems. On 7/13/20 at 11:00 am, R1's closet was observed with V1. R1's closet was on the right end of a three, side by side unit closet, the rod was not in place, it had been removed. The bracket on the right side was shaped like a half-moon, making the right end of the closet bracket able to be lifted up. Left side of closet bracket was secured to the wall and not able to be moved. On 7/13/20 at approximately 11:57 am, removable metal closet rods were identified with V9 (Certified Nursing Assistant) in rooms 302, 306, 307, 313 and 315. On 7/13/20 at approximately 12:16 pm, removable metal closet rods were identified with V8 (Licensed Practical Nurse) in rooms 319, 323, 324 and 328. On 7/13/20 at 11:07 am, V8 (Licensed Practical Nurse) stated, she worked with R1 on 7/10/20, the resident looked fine, he smiled however, he had behaviors in the past, would talk to self, sing out loud and displayed some aggression like yelling and would jump off the furniture. On 7/13/20 at 11:11 am, V9 (Certified Nursing Assistant) stated she was off the weekend however one time, the resident had a behavior, he got on top of the dresser, hit his head and was sent to the hospital for observation. On 7/13/20 at 12:54 pm, V12 (Maintenance Director) stated, the closet rods in the facility are mostly plastic however some were still metal. On 7/13/20 at 1:43 pm, V2 (Assistant Director of Nursing) stated resident rounds are made at the beginning of the shift and after that every hour. V2 also stated, resident rounds are documented only in the progress notes in the electronic medical chart. On 7/13/20 at 2:09 pm V10 (Psychosocial Rehabilitative Services Director) stated R1 has been in the facility since last year. In general, he was quiet, however he would often wander. R1 would try to elope the facility in the past. V10 also stated, R1 on one occasion was aggressive where he broke the television in his room. On 7/13/20 at 3:04 pm, V12 stated, the closet rods should not be removable, they need to be bolted down. On 7/14/20 at 10:00 am V4 (Licensed Practical Nurse) stated, she worked the night shift 11p-7 am on 7/11/20. She came on the unit, did rounds and observed R1 in bed around 11:15 pm. R1 was found by V3 (Certified Nursing Assistant) approximately 5:00 am. V4 said, she walked in the room because V3 alerted her and saw R1 in the closet in sitting position, 2 hangers around his neck, he was on his knees. V4 further stated, last time she saw R1 it was around the 11 pm hour. He was asleep, she called his name and he responded. V4 also stated, rounding on residents is done every 2 hours, and Certified Nursing Assistants do it also every 2 hours. V4 further stated, we do not have a rounding chart, we do not have to check off a list. On 7/14/20 at 10:18 am, V3 (Certified Nursing Assistant) stated, the last time she saw R1 alive was around 11 pm when she was doing rounds at the beginning of her shift. V3 further stated, she walked in to R1's room around 5:25 am and did not see him. V3 looked under the bed, checked the bathroom and as she was about to leave the room opened the closet. V3 stated, she screamed, she called out for the nurse. V3 said, R1 was found in the closet. He was balled up in there, 2 plastic hangers around his neck, and he was on his knees facing forward. V3 said, we make rounds every 2 hours. Rounds insist of checks on every resident to see if they need anything and if they are breathing. Surveyor asked V3 for resident rounding documentation. V3 stated, we do not have a rounding chart. On 7/14/20 at 10:50 am, V13 (Licensed Practical Nurse) stated, we make rounds every two hours and it is recorded in the communication book or in the residents' chart. On 7/14/20 at 2:03 pm V1 stated, he saw R1's body in the closet after 5 am on 7/12/20 because he was notified by the facility staff about the incident. R1 was kneeling forward and his head was in between the plastic hangers. V1 further stated, the plastic hangers were looped on the removable closet rod. On 7/14/20 at 2:22 pm, V2 stated, safety precautions that are put in place is close monitoring with all the residents. Frequent rounds, and when residents are admitted , staff check all their personal belongings for any hazardous items, and they remove it from the room. On 7/14/20 at 2:39 pm V7 (Social Services) stated, on 7/2/20 he heard loud yelling and he rushed to R1's room. V7 observed R1 hitting his head against the wall, so right away R7 intervened to stop any self-harm. R1 was yelling, The police cannot do anything to me. V7 said there was a demonstration outside with many police cars. On 7/14/20 at 4:10 pm, V14 (Physician) stated R1 was going back and forth to the hospital due to behaviors. V14 stated, I am not surprised the resident committed suicide, he was confined to his room due to Covid-19. V14 stated, the plan of care for R1 was to keep monitoring the resident and he had medications in place. On 7/20/20 at 9:15 am, V12 stated, he had no answer to why the closet rods were removable and not bolted down . For some reason they were this way on the third floor. Review of R1's progress note, V4 documents on 7/11/20 at 11:17pm , R1 was noted in bed, easily aroused. No distress and no behaviors noted at this time. Will continue to monitor. R1's (7/2/20 at 8:56pm) progress note by V7 documents, resident displayed physically aggressive and violent self-inflicting behavior as evidenced by him banging his head against the wall and being loudly verbal yelling the police can't do anything to me. Resident was redirected and provided with one on one counseling to calm him down. R1 was administered [MEDICATION NAME] 5 mg/ml medication by the nurse. R1's (7/2/20 at 11:19 pm) progress note by V14 documents a preventative visit to address medical conditions to promote on-going stability and prevent avoidable hospitalization s. Assessment - currently at baseline functional status, and medically stable despite episodic behavior issues. Plan- continue present management, maintain fall/safety precautions and encourage compliance. R1's (6/30/20 at 9:14 pm) progress note by V7 documents resident exhibited physically aggressive behavior as evidenced by him continuously banging his head on the wall by his room entrance. Resident was counseled by V7. R1's care plan (2/11/20) documents history of elopement, R1 hangs around facility exits, R1 has the physical ability to leave the building and R1 becomes easily confused. With intervention of- rounds/hourly room checks per facility protocol to monitor resident to assist in minimizing chance of unauthorized leave. R1's (6/8/20) care plan documents resident exhibited violet physical aggressive behavior. R1's (6/17/20) care plan documents exhibited aggression and violent physical behavior towards staff. R1's (6/30/20 and 7/2/20) care plan documents resident exhibited violent physical aggressive and self-inflicting behavior. R1's behavior care plan (initiated 6/8/20) documents interventions of safe and secure environment with caring professionals, encourage verbalization of issues or concerns, establish a counseling schedule with the resident, provide 1:1 counseling on boundary issues relating to conflict, report any incident of abuse to the administrator, intervene when any inappropriate behavior is observed, provide supportive intervention and refer R1 to a mental health professional. Facility unable to provide any documentation of care plans updated after changes in R1's behavior for the following dates: 6/17/20, 6/30/20 and 7/2/20. Facility's (7/11/20) Nursing Daily Staffing documents: V3 and V4 assigned to 3rd floor 11 pm-7 am shift Facility's CNA DUTIES/RESPONSIBILITIES/FUNCTION documents in part: 7. Make on-going rounds on assigned wing(s)/unit(s) no less than every two hours. Facility's LPN DUTIES/RESPONSIBILITIES/FUNCTION documents in part: 3. Closely monitor and supervise all facility residents per facility policies and as warranted by good nursing judgment. Facility policy (6/13) ROUTINE RESIDENT CHECKS documents in part: 1. To ensure the safety and wellbeing of our residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel. NOTE: SOME RESIDENTS MIGHT REQUIRE MORE FREQUENT CHECKS. Facility Assessment (5/1/19) documents in part: Provide person-centered care: Psycho/social/spiritual support: Identify hazards and risks for residents.

Based on interview and record review, the facility failed to ensure a resident exhibiting aggressive and self-inflicting behaviors was provided medical psychiatric services at the facility to promote well-being. This failure affected one resident (R1) out of 3 (R1, R2 and R3) reviewed for quality of care. This failure resulted in R1 hanging himself. Findings include: R1 is a [AGE] years old male with [DIAGNOSES REDACTED]. On 7/13/20 at 10:41 am, V1 (Administrator) stated, V3 (Certified Nursing Assistant) was doing rounds on 7/12/20 around 5 am and noticed R1 was not in his room. V1 stated the search was initiated of the building, however, V3 came back to R1's room and found the resident in the closet. R1 committed suicide by hanging using 2 plastic hangers. V1 further stated, R1 kneeled, placed his neck between the hangers and leaned forward to cut off his airflow. V1 further stated, R1 removed the closet metal rod from the bracket, placed 2 plastic hangers on the rod than attached the metal rod back to the bracket and used the plastic part of the hangers to commit suicide. On 7/13/20 at 11:07 am, V8 (Licensed Practical Nurse) stated she worked with R1 on 7/10/20, the resident looked fine, he smiled, however . he had behaviors in the past, would talk to self, sing out loud and displayed some aggression like yelling and would jump off furniture. V8 also stated, R1 was more quiet last year, however this year he was more loud and had behaviors. On 7/13/20 at 11:11 am, V9 (Certified Nursing Assistant) stated she was off the weekend. She recalled once the resident had a behavior, he got on top of the dresser, hit his head and was sent to the hospital for observation. On 7/13/20 at 2:09 pm V10 (Psychosocial Rehabilitative Services Director) stated R1 has been in the facility since last year, on one occasion R1 was aggressive where he broke the television in his room. On 7/14/20 at 10:50 am, V13 (Licensed Practical Nurse) stated, we make rounds every two hours and it is recorded in the communication book or in the residents' chart. On 7/14/20 at 2:39 pm V7 (Social Services) stated, on 7/2/20 he heard loud yelling and he rushed to R1's room. V7 observed R1 hitting his head against the wall, so right away R7 intervened to stop any self-harm. R1 was yelling, The police cannot do anything to me. V7 said at the time there was a demonstration outside with many police cars On 7/14/20 at 4:10 pm, V14 (Medical Doctor) stated R1 was going back and forth to the hospital due to behaviors. V14 said, he is not surprised the resident committed suicide, he was confined to his room due to Covid-19. V14 stated the plan of care for R1 was to keep monitoring the resident and he had medications in place. On 7/15/20 at 1:29 pm V15 (Psychiatrist) stated the last time he saw R1 was in February 2020. R1 had no symptoms of depression, no suicidal ideation. V15 also stated, R1 was transferred at some point under V16 (Psychiatrist) care however he was not sure when. On 7/16/20 at 9:52 am V16 (Psychiatrist) stated, R1 was never assigned to her in the facility. V16 stated she never saw R1 because he never came up on her list of residents to see. Even during covid-19 times, she was seeing residents via zoom video. V15 was seeing R1 from October 2019 to February 2020 per progress note documentation. R1 never came on our list of residents to see in the facility. In order for residents to change doctor, they have to sign consent for a doctor change and then the nursing home will assign the resident to the doctor. The facility called me for orders in May 2020 for the resident, she gave them orders. V16 stated she never saw him in the facility. V16 further stated If you look on the resident's face-sheet, V15 is assigned as a psychiatrist for the resident. The facility used to have a psychiatric nurse however she is no longer working there, and things are disorganized. On 7/16/20 at 10:07 am ,V1 stated, there is overlap between psychiatrists for R1. V16 was his doctor in the sister facility where the resident came from. On 7/20/20 at 12:32 pm, V1 said for a resident to change a physician, the facility will have a resident fill out a change of physician form, provide a reason and sign it. V1 was not sure if the facility has a change of physician form for R1. The facility will have to check to verify it. On 7/20/20 at 1:23 pm V1 said, V17 (Former Director of Nursing) made the psychiatrist switch from V15 to V16 however facility cannot locate the signed change of physician form but will provide a black form for reference. Review of R1's progress note dated 7/2/20 at 8:56pm by V7 documents, resident displayed physically aggressive and violent self-inflicting behavior as evidenced by him banging his head against the wall and being loudly verbal yelling the police can't do anything to me. Resident was redirected and provided with one on one counseling to calm him down. R1 was administered [MEDICATION NAME] 5 mg/ml injection by the nurse. Review of R1's progress note dated 7/2/20 at 11:19 pm by V14 documents a preventative visit to address medical conditions to promote on-going stability and prevent avoidable hospitalization s. Assessment - currently at baseline functional status, and medically stable despite episodic behavior issues. Plan- continue present management, maintain fall/safety precautions and encourage compliance. R1's (6/30/20 at 9:14 pm) progress note by V7 documents resident exhibited physically aggressive behavior as evidenced by him continuously banging his head on the wall by his room entrance. Resident was counseled by V7. R1's care plan (2/11/20) documents history of elopement, R1 hangs around facility exits, R1 has the physical ability to leave the building and R1 becomes easily confused. With intervention of- rounds/hourly room checks per facility protocol to monitor resident to assist in minimizing chance of unauthorized leave. R1's (6/8/20) care plan documents resident exhibited violet physical aggressive behavior. R1's (6/17/20) care plan documents exhibited aggression and violent physical behavior towards staff. R1's (6/30/20 and 7/2/20) care plan documents resident exhibited violent physical aggressive and self-inflicting behavior. R1's behavior care plan (initiated 6/8/20) documents interventions of safe and secure environment with caring professionals, encourage verbalization of issues or concerns, establish a counseling schedule with the resident, provide 1:1 counseling on boundary issues relating to conflict, report any incident of abuse to the administrator, intervene when any inappropriate behavior is observed, provide supportive intervention and refer R1 to a mental health professional. No updated care plan interventions for 6/17/20, 6/30/20 and 7/2/20 incidents of R1's behaviors. R1's Face-Sheet (printed 7/13/20) documents V15 as the resident's Psychiatrist. R1's psychiatric progress notes document resident was seen by V15 on 11/21/19 and 2/26/20. Facility does not have a Change of Physician policy, they follow residents' rights. Facility blank CHANGE OF MEDICAL DOCTOR/PSYCHIATRIST'S FORM documents resident and staff have to sign and date the form. Facility Assessment (5/1/19) documents in part: Provide person-centered care: Support emotional and mental well-being; support helpful coping mechanisms. Illinois Department of Aging Residents' Rights documents in part: You have the right to choose your own doctor.

Based on record and interview the facility failed to immediately assess a resident for injury after a fall which delayed in the treatment for [REDACTED]. As a result R3 was left in severe pain over a long period of time before he was sent out for evaluation at the local hospital. R3 was diagnosed with [REDACTED]. Findings include: R3 is a [AGE] year old admitted to the facility 2/25/14. R3 has a [DIAGNOSES REDACTED]. R3 is non verbal and not able to make his needs known. Facility fall investigation report dated 11/21/17 7:46 AM read: in room [ROOM NUMBER]-4. Resident was noted with rt (right) upper extremity(thigh) warm to the touch skin , swelling , shortness noted to rt lower extremity, upon assessment resident noted with facial grimacing when area touched. Facility's X Ray of right femur noted impacted intertrochanteric [MEDICAL CONDITION] right femur with some varus deformity. R3 was sent to the hospital for evaluation and treatment. R3 required surgery to treat the fracture. R3 did not return to the facility. This was considered an unwitnessed fall. The report implies R3 had crawled back into his bed after he fell . Also according to facility report the CNA who discovered the injury , was informed by another CNA that R3 was a total care and needs to be fed as well going to assist him with feeding. R3 was in his bed and when the CNA pulled the sheets back is when she discovered the injury. This report further states that when the investigation was completed it was noted that the previous 11-7AM nurse( V12) and CNA( V11) failed to do a proper appropriate head to toe assessment of the resident on that particular day of 11/21/17. They did not notice the resident was injured. Both the nurse and CNA received disciplinary actions which included 3 day suspension with write-up final warning. V2 ( Director Of Nursing) 5/17/18 10AM per phone stated V11( CNA) and V12( Nurse) were reprimanded for failing to to properly assess R3 on their shift(11PM -7AM) to detect a fracture to R3's right hip. They were given a three day suspension .V12 resigned at this time. Hospital record dated 11/21/17 states R3 was diagnosed with [REDACTED]. R3 required surgery to place right hip nail. On 5-16-18 2:30pm, V1, Administrator reported the investigation completed by the facility revealed R3 injury was due to a fall from his bed. The surveyor asked how did R3 get back to bed and V1 was unable to explain how the resident got back to bed. On 5-21-2018 at 12:38pm, V15 (attending physician) reported, the type of fracture R3 is caused by a fall 99% of the time. R3 could have fell due to a [MEDICAL CONDITION] or he forgot he couldn't walk and tried to get up. It is unlikely that the resident with a fracture could get himself back to bed. As far as pain, this fracture is very painful. It could have been nine on a scale of one to ten. V15 stated, R3 had dementia (frontal temporal lobe) and was non-verbal. R3 could not verbalize he was in pain. No one could have moved him without him having some reaction to the pain.

Based on observations, interview and record review, the facility staff failed to thoroughly investigate all falls and determine the root cause of the falls, failed to implement new fall intervention after a fall and/or failed to follow the care plan for fall interventions, failed to supervise residents identified as high risk for falls in the dining room, and failed to use gait belts when transferring residents. This applies to 3 (R1, R2, R6) out of 4 residents reviewed for falls in the sample of 7 residents and 4 residents (R11, R14, R16 and R17) in the supplemental sample. The failure resulted in R2 sustaining a subdural hematoma on the 9/7/17 fall and a laceration to the back of the head on the 9/29/17 fall and R1 sustaining a hematoma on the forehead from the 7/16/17 fall. The findings include R2 is a [AGE] year old, non-ambulatory female that was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Per the facility's incident report, there were 3 falls for R2. Falls are dated 8/13/17 at 12 PM and 6:11 PM and 8/22/17 at 8 AM. There is no investigation for these incidents. The falls dated 9/29/17, 9/7/17 and 9/2/17 are from the nurses' notes. There were no investigation into the 9/7/17 and 9/2/17 falls. The 9/29/17 fall investigation documents R2 was in the dining room when a CNA found R2 on the floor. R2 had sustained a laceration to the back of the head. The fall was unwitnessed by staff but witnessed by Z3 (another resident's family member). There was no statement obtained from Z3. R2 was sent to the hospital. There is no conclusion of what happened at the hospital. R2's care plan was not updated. Staff were interviewed and it was determined that there was no staff member monitoring the dining room. R2 was sent to the hospital for the 9/7/17 fall. On 9/26/17 at 9:52 AM, Z5 (Hospital Social Worker) stated that R2 sustained a subdural hematoma on her 9/8/17 hospital visit. R2's care plan on falls document it was initiated on 8/13/17 and the interventions were to determine and address causative factors of the fall, provide floor mats on sides of bed and continue interventions on the at-risk plan. Nurses' note 8/13/17 11:30 documents R2 landing on a mat. Although R2 has had 5 falls since 8/13/17, the care plan was not updated with new intervention until 9/29/17. The new intervention was to encourage R2 to join activities. The other falls on 9/2/17 and 9/29/17 were in the dining room where R2 should have been supervised. The facility's at-risk plan documents that at risk plans are triggered by admission, quarterly, annual or significant change assessments and the MDS CAA's (care area assessment) as evidenced by medications and physician's medical/behavioral diagnoses. On 9/26/17, 9/27/17 and 9/28/17, the 2nd floor dining room was continuously monitored by staff. On 9/27/17 at 10:30 AM, E5 and E6 (both CNAs) stated that the dining room is monitored by a CNA and each CNA will have a turn alternating every 30 minutes. On 10/4/17 at 10:20 AM, E1 stated that there is no written policy on monitoring the dining rooms. On 10/4/17 at 2:25 PM, and again on 10/11/17 at 9:15 AM, E1 (administrator) stated that the fall investigations were not done because the nurse failed to put in the correct information. E1 added that E2 (Director of Nursing) was terminated due to poor performances of her duties. R1 is a [AGE] year old, non-ambulatory female who was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. R1 requires extensive assistance from staff for all her activities of daily living (ADL) and is orient per her brief interview mental score (BIMS) of 14. R1 has had 2 documented falls while in the facility. The 5/8/17 fall was found on the facility's incident log and the 7/16/17 fall was found in the nurses' notes. The 5/18/17 at 08:55 fall investigation documents R1 found in sitting position next to the toilet. R1 stated she slipped while trying to use the toilet. There was no injury. There is no conclusion as to why R1 fell , what the facility decided to do after the fall, and where the assigned Certified Nurse aide was when the fall happened. The last update on R1's fall care plan (initiated on 5/4/15) which documents a history of falls was dated 11/5/16. No updates for 2017 in fall care plan. The 11/5/16 update is for a fall that required 2 sutures to the right frontal lobe. The update is to ensure R1 has proper footwear. The 7/16/17 fall has no investigation. The fall information was found in the nurses' notes. The nurses' note (7/16/17 12:40) documents that a CNA informed the nurse that R1 was on the floor in the prone position. R1 was turned over to the supine position. A hematoma was seen on R1's forehead. R1's knee was red in color but skin intact. R1 stated my leg hurts and touched the right leg. R1 was placed back in bed and cleaned. The next nurses' note 7/16/17 23:09 documents R1 returning back to the facility from the hospital. Unclear what was done in hospital because no documentation and the facility failed to determine how R1 fell . On 10/11/17 at 9:15 AM, E1 and E3 (Asst. Director of Nursing) presented hospital record for R1 when they were asked about R1's hospital visit for the 7/16/17 fall. At 10:12 AM, E1 stated there is no investigation for the 7/16/17 fall for R1. R6 is a [AGE] year old, non-ambulatory female who was admitted on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. R6's MDS documents R6 requires extensive to total assistance for dressing, hygiene and toileting. R6's care plan documents a history of falls and has impaired cognition. R6 had a fall on 9/24/17 per the facility's incident log. There was no investigation into the fall. The fall incident dated 9/24/17 documents R6 was in the dayroom laying on her back with her recliner-type wheelchair next to her. After this fall, R6's care plan was updated (9/25/17) with the at-risk plan which essentially is to re-assess resident. There were no new interventions put in place. The care plan documents the use of a wheelchair alarm being successful on 12/14/15. R6 was never observed to have her wheelchair alarm in place on 9/26/17, 9/27/17 and 9/28/17. The facility's policy labeled Incident/Accident Reports document An accident refers to to any unexpected or unintentional incident, which may result in injury or illness to resident. An incident/accident report is to be completed and shall include: time and date of accident, description and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered and notification of appropriate parties. All incidents/accidents reports are reviewed, signed and investigated by the administrator and director of nursing or assistant director of nursing. On 9/27/17 at 10:30 AM, E6 (CNA) removed R16 in her wheelchair from the 2nd floor dining room and took her to the handicap toilet room adjacent to the dining room. E6 failed to use a gait belt when assisting R16 out of her wheelchair and into the toilet room and vice versa. On 9/27/17 at 10:45 AM, E6 takes R17 to her room to do incontinent care. E6 failed to use a gait belt when transferring R17 to bed and back. On 9/27/17 at 10:53 AM, E6 removed R14 in her wheelchair to the handicap toilet room. E6 assisted R14 into the toilet room without use of a gait belt. On 9/27/17 at 11:13 AM, E14 (CNA) takes R11 back to her room and transfers R14 without use of a gait belt onto the bed. E14 states that she can handle R11 herself because R11 is so small. E14 puts her arms around R11's chest and pulls up on her with R11's legs dangling in air and places R11 onto the wheelchair. The facility's policy labeled Gait Belt documents to assure the safety of the residents and staff when assisting with a transfer, repositioning or ambulation a gait belt will be used with weight-bearing residents who require assistance.

Based on observation, interview and record review, the facility failed to monitor and document behaviors in the use of the [MEDICAL CONDITION] medication, failed to reduce medications upon admission and/or assess for the need for the medication, failed to provide documentation on the use of non-pharmacological interventions prior to and during the use of anti-psychotic medication, failed to obtain consent for the use of [MEDICAL CONDITION] medication and failed to follow their [MEDICAL CONDITION] Medication Policy for one (R2) of 4 residents reviewed for [MEDICAL CONDITION] medication in the sample of 7 residents. This failure resulted in R2 sustaining hematomas and bruising on the 9/2/17 fall, a subdural hematoma on the 9/7/17 fall and a laceration to the back of the head on the 9/29/17 fall due to being overmedicated. The findings include: On 9/26/17 between 11:50 AM to 2:10 PM on the 2nd floor accompanied by E4 (Psychiatric Rehabilitation Service Director), R2 was seated in her wheelchair at a table in the dining room, was very lethargic with putting her head down on table at different intervals and sleeping. R2 remained in the dining room the whole observation time. At 1:04 PM, R2 does not touch any of her food and receives no encouragement. E6 (certified nurse aide/CNA) asks R2 if she is done and removes the food tray. R2 consumed only her fluids. On 9/27/17 at 9:48 AM and at 10:15 AM, accompanied by E4, in the 2nd floor dining room R2 was seated in wheelchair staring out the window. At 10:15 AM in the 2nd floor dining room, E16 (activity aide) and E17 (restorative aide) were conducting an exercise activity but R2 did not participate but continued to stare out window. Between 10:30 AM to 11:04 AM in the 2nd floor dining room, 3 outside church women came in and gave a sermon to the residents. R2's back was toward the church women and R2 continued to look forward. At 12:55 PM in the 2nd floor dining room, R2 had not touched any of her food but drank her beverages. E6 asks R2 if she is done, R2 says done and E6 removes the tray without inquiring why R2 did not eat or offer her a substitute. R2 asks to be taken to her room but E6 does not listen to R2. At 1:11 PM, R2 asks 3 times Can I go back to my room?. R2 then asks E14 (CNA) Can I go back to my room? but E14 does not respond to R2 as she removes R19 from the dining room. R2 is then waving at E4 to get his attention but E4 does not see R2. At 1:30 PM, R2 is removed from the dining room by E6 and placed in the hallway by the nurses' station. R2 is then laid down by E6. E6 stated that R2 was very tired and did not want to be bothered for incontinence care but wanted to be laid down. R2 is a [AGE] year old, non-ambulatory female that was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. R2's cognition is severely impaired. R2 was admitted to the facility with the [MEDICAL CONDITION] medications of [MEDICATION NAME] 300 milligram (mg) at bedtime initiated on 7/28/17 and discontinued on 8/24/17 without a reduction, [MEDICATION NAME] (Dec.) intramuscularly (IM) 100 mg every 4 weeks initiated on 7/27/17 and discontinued on 9/7/17 without a reduction. [MEDICATION NAME] mg IM every 2 weeks on the 15th and the 30th of every month was initiated on 9/7/17 and the [MEDICATION NAME] 2.5 mg daily was initiated on 9/22/17 per the physician order [REDACTED]. Nurses' note 7/27/17 documents R2 being lethargic, non-verbal and multiple bruising throughout her body. Physician note (Z2) dated 7/27/17 documents lethargy and sleepiness. Since admission to the facility on [DATE], R2 has had 5 falls. Three falls resulted in R2 going to the hospital for subdural hematoma, laceration to the back of the head and hematomas and bruising per the nurses notes 9/29/17, 9/7/17 and 9/2/17. Two of these falls were in the dining room without staff supervision. On 9/26/17 at 9:52 AM, Z5 (Hospital Social Worker) stated that R2 sustained a subdural hematoma on her 9/8/17 hospital visit. On 10/13/17 at 10 AM, E3 (Asst. Director of Nursing) presented one behavior tracking/communication form and stated this is the only one they have for R2. The behavior tracking sheet dated 9/7/17 documents R2 laying on the floor and staff assisting R2 back to bed. Thirty minutes later, R2 found back on the floor and staff assist her to her wheelchair. No injuries noted. This is incorrect for no injuries because R2 was sent to the hospital and sustained a subdural hematoma on 9/7/17 fall. No other behavior tracking sheets were presented for R2 nor was any documentation presented on her targeted behaviors. E3 provided a psychiatric evaluation dated 8/16/17 which was difficult to read. E3 stated she is unable to read it also. The evaluation appears to have [MEDICATION NAME] Dec. listed as a anti-psychotic medication and the [DIAGNOSES REDACTED]. This is the only documentation from a psychiatrist provided or seen. On 10/13/17 at 10:55 AM, Z2 (R2's attending physician/Medical Director) stated when R2 came to the facility on her [MEDICAL CONDITION] medication, she was overmedicated and suffering from [MEDICAL CONDITION]. The previous facility was thinking of putting R2 on hospice due to her lethargy but Z2 decided to send R2 to this facility and work on decreasing her psychoactive medications. Z2 stated R2 has severe dementia and was on 3 anti-psychotic medications when admitted to the facility. Z2 stated he was trying to reduce the medications due to all her falls. Z2 stated that when R2 went to the hospital, the hospital physicians would tell him R2 was overmedicated. Z2 stated he is not a psychiatrist but geriatrician. Z2 stated that R2 was seen by psychiatrist in the hospital but not sure if she was being followed by a psychiatrist in the facility. Z2's progress notes dated 7/27/17 documents lethargy and sleepiness and R2 in bed. Continue with current admission orders [REDACTED]. The [MEDICATION NAME] was discontinued without reduction on 8/24/17. Z2's next progress note 9/30/17 documents R2 returned from hospital with altered mental status, staff say R2 has off and on agitation and continue with present management. All his progress notes document to maintain safety precautions. There was no documentation seen or presented on R2's agitation. On 10/13/17 at 12:24 PM, E18 ([MEDICAL CONDITION] Nurse) stated she is new to [MEDICAL CONDITION] medication and her new role which began July 2017. E18 stated she accompanies Z6 (facility's psychiatrist) on his weekly rounds. Each week he does a different floor and sees only the residents on his caseload. R2 is on his caseload. E18 stated she will introduce the resident to Z6 and he will prescribe the medications if needed and E18 will ensure the medications are carried out. When E18 was asked what were R2's behaviors that were being addressed, E18 stated she does not recall any behaviors. E18 stated that Z6 will document on the [MEDICAL CONDITION] medication summary sheets. E18 stated that the [MEDICATION NAME] and [MEDICATION NAME] were discontinued by Z2 because of the side effects of sleepiness and [MEDICATION NAME] and replaced with other anti-psychotic medications to decrease side effects. E18 stated the reason for the use of the behavior tracking sheet is to be able to communicate between disciplines (nursing and psychosocial staff) and helps in addressing the situation. No psychiatric summary progress notes were presented for R2 when E18 was informed there were none. No consent for the [MEDICATION NAME] medication provided when requested from E1. E1 presented the consents dated 7/28/17 for [MEDICATION NAME] and [MEDICATION NAME] which were obtained verbally and the consents dated 9/7/17 for [MEDICATION NAME][MEDICATION NAME] obtained verbally. Z6's (R2's responsible party/sister) gave a verbal consent for the medications. The 2 phone numbers listed for Z6 are not her numbers. The person answering the cellular number stated she has had this number for [AGE] years and knows no Z6. The home number was that of a couple and Z6's name was not one of them. Social service note 7/28/17 documents that R2 is responsible for herself but that Z6 (R2's sister) is her emergency contact person. Found another phone number in nurses' note 8/13/17 for contacting Z6 but it was a business number that is no longer in service. The consents provided were done by E19 (Licensed Practical Nurse) and she was not reliable. On 10/13/17 at 2:15 PM, E19 (Licensed Practical Nurse) stated that she called whatever number was listed in R2's clinical record. E19 stated that R2 was not her assigned resident but was assisting E18 ([MEDICAL CONDITION] nurse) in getting verbal consent. E19 stated that the call was taken on the speaker phone so that herself and E18 could both listen. Asked why there is no documentation of this, E19 stated that she did not document but maybe E18 documented it. There was no documentation provided or seen for obtaining the consents. The facility's policy labeled [MEDICAL CONDITION] Medication Use documents that a resident will not receive [MEDICAL CONDITION] medication unless behavioral programming and/or environmental change have failed to sufficiently modify a resident's target behavioral disturbances. A resident will not receive [MEDICAL CONDITION] medication unless such a medication is needed to treat a specific condition and each [MEDICAL CONDITION] medication will be given to treat clearly defined target behaviors. Consistent monitoring of all target behaviors will be done to assist in assessment of the risk and benefits of the [MEDICAL CONDITION] drug therapy. Prior to the administration of the anti-psychotic medication, an appropriate supporting [DIAGNOSES REDACTED]. Target behaviors will be identified with supporting documentation in the clinical record. Residents who display target behaviors or who take psychotherapeutic medications will have their behaviors quantitatively and objectively documented on the behavior tracking form. Under the consent section : For each [MEDICAL CONDITION] medication ordered either verbal or written consent from the resident or the resident's responsible party will be obtained prior to initiation of the medication. If consent is obtained verbally, a copy of the consent will be placed in the chart and the original will be sent to the responsible party for signature. A copy will remain in the chart until replaced by the returned original. The resident and responsible party will be notified of any changes in medication dosages and it will be documented in the clinical record. This was not followed.

Based on interview and record review, the facility failed to have a plan in place to prevent the sexual assault on 1 of 4 residents (R3) reviewed for sexual/physical abuse prevention. This failure resulted in R3 being found with R4 on top of her without clothing waist down and R3 being sent to the hospital for examination and treatment of [REDACTED]. Findings include: On 4/25/17 at 3pm, Z2 (complainant) stated that R3 arrived at the emergency room at 10:48 on 4/18/17 due to a nurse walking in R3's room and seeing another resident on top of R3. Z2 stated that both residents had their pants down. Z2 stated that R3 in nonverbal and is a stroke victim. Z2 stated that R3 was given a rape kit. Z2 stated that R4 is no longer in the facility. R3's face sheet lists include [MEDICAL CONDITION] disease as a diagnosis. On 4/26/17 at 12:10pm, E3 (Certified nursing assistant) stated I was doing rounds on 4/18/17 at approximately 9:25am. I went into R3's room and saw R4 on top of R3. R4 did not have any pants on. R3 was not covered. R3 was naked from waist down. I don't know how long he had been there. R3 in nonverbal. I screamed and called code white for help. On 4/26/17 at 12:30pm, E5 (Registered nurse) stated that she was standing by the nursing station and she heard E3 scream Oh my God. E5 stated that she went into R3's room and saw R3 exposed from the waist down. E5 stated that she saw R4 with his pants down and his private parts exposed. On 4/26/17 at 12:35pm, E4 (Licensed practical nurse) stated that on 4/18/17 around 9:30am, she heard screaming down the hall. E4 stated she went into R3's room and R4 was next to R3's bed with his pants down. R4 was admitted to the facility on [DATE]. R4's BIMS (brief interview mental status) score dated 4/7/17 reads 13 out of 15. Following the incident on 4/18/17, R4's notes read R4 removed from R3's room and security was called to escort R4 off unit. R4 leaves the facility escorted by 4 police officers. R3's emergency room [DIAGNOSES REDACTED]. R3's emergency room clinical work up notes dated 4/18/17 reads emergency room triage - Per E5 (Registered nurse), R3 found by CNA to be exposed waist down with legs open with other resident on top of her. Formal rape kit performed. Impression and plan - sexual assault of adult. R3 awake and makes eye contact. R3 moans and thrashes. Otherwise, no meaningful communication. Treated with 250 mg IM [MEDICATION NAME] and 1 gram [MEDICATION NAME].[MEDICAL CONDITION].RPR sent. Chlamydia swabs sent. The assailant is in custody and no risk to R3. R3 admitted for placement. R3 was not in the facility at the time of the investigation. Based on a reasonable person's response to this incident, R3 may have experienced psychological harm. R3's care plan dated 4/17/17 reads R3 is at risk for abuse/neglect: R3 is unable to make her needs known. R4's clinical documentation notes multiple incidents of going into female residents rooms. R4 was not in the facility at the time of the investigation. R4's clinical notes dated 4/15/17 reads R4 observed in a females room. R4 was redirected to leave the room. R4 walked out after several redirection but continued to go back in the room. R4's clinical notes dated 4/11/17 at 07:11 reads R4 being intrusive all night from room to room and floors. R4's clinical notes dated 4/10/17 at 21:58 reads R4 is noted trying to go into other patient's room, especially female room. R4's clinical notes dated 4/1/17 at 23:43 reads Requires close observation as he wanders into and out of other residents rooms. R4's clinical notes dated 3/16/17 at 23:18 reads R4 requires frequent redirection going in peers rooms, poor reception. R4's clinical notes dated 3/16/17 at 06:25 read R4 noted being physically and verbally aggressive with staff. R4's clinical notes dated 3/15/17 at 04:03 read R4 wanders unit with no destination, attempts to enter peers rooms as well as remove items from others rooms. Continuous ineffective redirection given. R4 noted talking to self in low tone when walking. R4 periodically has loud unprovoked outbursts. R4's clinical notes dated 3/14/17 at 23:38 read R4 noted being verbally aggressive towards staff. R4 also noted wandering unit going into other patients rooms removing items. R4's clinical notes dated 3/13/17 at 23:11 read Alert oriented to self, person, place. R4 observed wandering into other residents rooms and attempting to take their belongings. R4's clinical notes dated 3/10/17 at 20:46 read Summoned to R4's room by CNA who saw R4 hitting his roommate (who was laying in bed). R4 was sent to the hospital for psych eval. The facility's abuse prevention policy reads This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. Sexual abuse includes, but is not limited, sexual harassment, sexual coercion, or sexual assault.

Based on record review and interview the facility failed to ensure proper technique was utilized to prevent a fall accident for one resident (R3) of three sampled residents reviewed who require a mechanical lift for transfer to and from a recliner, chair and bed. This failure resulted in R3 sustaining a subdural hematoma. Findings include: R3 is a [AGE] year old resident with medical [DIAGNOSES REDACTED]. The progress note date 11/19/15 indicates the CNA (E10/certified nurse aide) reported to E6 (nurse) that R3 fell to the floor during a transfer from the portable recliner while using the mechanical lift. Small amount of clotted blood observed at R3's lower lip. Z1 (physician) was in the facility and gave orders to send R3 out to a nearby hospital emergency room for further medical evaluation. On 11/24/15 at 3:05pm Z2 (hospital social worker) stated, R3 was transferred to us from the first hospital. R3 was admitted with a subdural hemorrhage and she bit her tongue. R3 was in the ICU (intensive care unit) here. R3 is still in the hospital. The hospital CT (computerized tomography) exam results dated 11/19/15 indicate R3 sustained a acute left subdural hematoma and a large subgaleal hematoma overlying the posterolateral right scalp. On 11/24/15 at 3:15pm E6 (nurse) stated, the CNA (E10/certified nurse aide) told me that the resident had a fall to the floor. She said they were transferring her. She (R3) fell to the floor and the mat. I asked again how did she fall? E11 said they were transferring R3 with the mechanical lift. I asked E11 to show me. I and the other CNA (E10) went in with E11. E11 said they were transferring R3, turned to do something and the resident fell . She was in a recliner. I assume they were trying to transfer R3 from the recliner to the bed. At 3:50pm E9 (ADON/assistant director of nurses) stated, the nurse (E6) called me. She told me R3 fell from the mechanical lift. They said they were transferring her (R3) from the recliner to the bed. She (R3) bucked backwards and fell . They were more focused on the recliner instead of the mechanical lift. E10 told E11 to move the recliner. E11 took her hand off the resident. At 4:00pm, E9 participated in a demonstration with E7 (restorative aide) and E14 (CNA) of how to transfer a resident using the mechanical lift. During this demonstration E14 took her hands off of E9 to help E7 reposition the mechanical lift, E9 stated, oh, I can see what happened. When the one CNA took her hands off the resident, she (R3) fell out of the sling. On 11/25/15 at 12:39 via telephone interview E10 stated, I was asked to assist in moving R3 from the recliner to her bed. R3's CNA chose to use the mechanical lift. While the resident was in the air, E11 (CNA) said you need to move the recliner. I nudged the chair to move it over. R3 did a body jerk and them she fell to the floor and mat. The back of her head hit the mat. R3 was put back onto the lift so we could get her off the floor. R3 was lifted from the floor to the bed. E11 finished patient care and I left. When E10 was asked if she received training on how to use the mechanical lift prior to this incident, E10 stated, no, I just got inserviced on that this past Saturday (11/21/15). Review of E10's personnel file includes a CNA Orientation checklist that was not signed by E10. This checklist includes use of equipment (mechanical lifts) and reporting all accident & incidents immediately. ON 11/25/15 at 1:00pm via telephone interview E11 stated, I asked E10 to move the recliner. We had to pull it around. It was in front of the lift. E10 had to use her hands to move the recliner. I believe R3 jerked while she was in the air. R3 fell , half of her on the mat and the other half on the floor. Her head may have hit the floor. We started trying to get her up. We turned her over. Yes, she fell forward. We should have gotten the nurse. Yes, we had to place the sling back on the lift in order to get her to bed. I had to change and clean her up. I didn't notice any bruises but she was bleeding from her lip. The nurse (E6) said we should have gotten her when R3 initially fell . Review of R11's personnel file includes a CNA Orientation checklist that was not signed by E11. This checklist includes use of equipment (mechanical lifts) and reporting all accident & incidents immediately. The quarterly MDS (minimal data set) dated 11/1/15 indicates for Transfer a score of 4/3 which indicates total dependence/2+ personal assistance. In the area of Bed mobility R3 scored 3/3, which indicates extensive assistance/2+ personal assistance. On 11/25/15 during the daily status meeting meeting with E1 (administrator) and E2 (director of nurses), E2 stated, she (E10) was being inserviced on how to use the mechanical lift when the incident happened. During interview with E10 and E11, there was no mentioned of E10 being trained on how to use the mechanical lift at the time of the fall incident involving R3.

Based on interview and record review the facility failed to have a system to adequately monitor one resident (R2) out of four reviewed for self injurious behaviors. This failure resulted in R2 obtaining a razor he used to cut his left arm. Findings include: R2 is a [AGE] year old resident with several [DIAGNOSES REDACTED]. R2 has a history of suicidal ideations with a plan and drug abuse. The behavior note dated 12/12/14 indicates R2 showed his arm to E5 (social services). The forearm was noted with a long, red and swollen scratch. On 2/18/15 at 2:45pm E5 (PRSC/psychiatric rehab services coordinator) stated, "yes, I saw his arm. He scratched himself with plastic. He didn't know why he did it. I asked him how he felt, what's his plan. He didn't have a plan. He was placed on one to one monitoring. He was allowed to leave his room. Even though he didn't have a plan he was still watched." The incident report dated 2/9/15 indicates R2 came to the nurses station, left anterior forearm bleeding. Resident stated he cut himself because his medications were lowered and he was tired of being in pain. Review of the November 2014 through February physician's orders [REDACTED]. The Daily Note dated 2/9/15 1:15pm indicates R2 was observed with a bloody left anterior forearm. When asked what happened he stated that he opened a shaver and cut his arm. When asked why did he cut himself he did not respond. The social services note dated 2/9/15 by E4 (PRSD/psychiatric rehab services director) indicates he was informed by staff that R2 intentionally performed self harm by cutting himself. R2 reported that he wanted to harm himself to stop the pain. R2 stated that he did not want to live. On 2/18/15 at 2:45pm E5 stated, "the nurse called me and said he had a cut. He told me he felt like cutting himself. He wanted to go to the hospital. This time he had a plan, so I had to stay with him. He didn't tell me what he cut himself with. He mentioned plastic. Then another time he mentioned a blade, then he said I don't know. " On 2/18/15 at 3:00pm, E3 (nurse) stated, "he (R2) walked up to the desk. His arm was bleeding. He had cut himself. I asked him what he used to cut himself. He said a razor. I asked him where he got it from. He wouldn't say. I asked him where is it? He gave it to me. He had put it in his drawer. He said he picked the plastic away from the blade and then cut himself. The cuts were on the anterior surface of his arm. There were about 3-4 of them, somewhat long." Review of the incident report did not include information about the razor that was used or a description of the cuts on R2's left forearm. The investigation does not indicate how R2 obtained the razor. On 2/23/15 at 10:25am on the third floor E3 stated, "I discarded the blade in the sharps container. I remember if I mentioned the object he (R2) used to social services. No one from that department asked me anything." On 2/23/15 at 10:35am E1 (administrator/abuse coordinator) stated, "the DON (E2/director of nursing) called me. She said there was an incident on the floor. A resident had cut himself. I did the final report. Since he (R2) wasn't here to investigate, I went through his meds, behaviors, etc. I'm waiting on him to come back to the facility to ask him that (what he used to cut himself)." On 2/24/15 at 10:15am E2 (director of nursing) stated" we never saw the item he used to injure himself." Review of the incident report does not indicate whether the first nurse that discovered the injury was thoroughly interviewed or other staff on the floor. The investigation did not determine what R2 used to cut his left forearm. Care plan interventions dated 12/22/13 indicate the PRSC (psych rehab services coordinator) will make daily rounds 5 times a week to evaluate mood, address concerns, and provide supportive counseling as needed. Care plan dated 12/22/13 intervention includes room safety checks (frequency not specified). Care plan dated 12/22/13 intervention includes establishment of a written behavioral contract with R2. On 2/25/15 at 2:50pm, careplan interventions were reviewed with E1. E1 stated, I will ask the PRSD (psych rehab services director). We didn't sign a behavior contract with him (R2). The facility was unable to present documentation that the interventions mentioned in R2's care plan were implemented or followed.

Based on observation, interview and record review, the facility failed to implement, assess and revise interventions to promote the healing of pressure ulcers for one (R3) of three residents reviewed for pressure ulcer treatment in the sample 27. Resulting in R3 sore becoming a stage 3 pressure ulcer on the left heel. Findings include: R3 was observed on 10/14/12 at 10:00 a.m. sitting in a wheelchair in the shower room with left heel dressing off. R3 was observed with a large open pressure sore on the left heel covering the entire areas. It was approximately 5.0 cm by 4.5cm very red with no definite borderline. R3 is a [AGE] year old with [DIAGNOSES REDACTED]. 10/11/12 at 11:00 a.m., E8 stated "(R3) was admitted to the facility on [DATE] with no heel ulcer. On 10/21/11 (R3) was discharged to the hospital and returned on 10/25/11 with a heel ulcer." The Nursing Admission Assessment on 10/25/11 documents the presence of a left heel ulcer, no dimensions or staging is present. The Wound Care Physician Initial Note, 8/2/12, documents R3 with history of multiple pressure ulcers. Wound description and location documents a left deformed and hyperextended foot and left heel pressure ulcer with no depth, measuring 3.3 by 3 centimeters. Recommendations were to offload heels and a low air loss mattress. A physician progress notes [REDACTED]. A History and Physical, completed by a nurse practitioner, documents a left heel covered with a dressing, no assessment of the wound is documented. A Nurse Practitioner Progress Note, 6/18/12, documents a left foot wound with a dressing present, no wound assessment is documented. July, September and October 2012 there is no physician documentation of wound assessments. The facility "Quality Assurance Worksheet, Weekly Wound Measurements" document the left heel Pressure Ulcer as facility acquired with measurements and description as follows: 6/29/12- 3.5 X 1.5 centimeters, white 7/6/12- 3.0 X 1.5 centimeters, white, stable 7/13/12- 2.0 X 1.0 centimeters, white, improved 7/20/12- 2.0 X 1.0 centimeters, improved 7/27/12- 2.0 X 1.0 centimeters, improved 8/17/12- 4.5 X 5.0 centimeters, improved 8/24/12- 5.0 X 6.0 centimeters, stable 8/31/12- 5.9 X 6.0 centimeters 9/14/12- 4.0 x 5.0 centimeters, stable 9/21/12- 5.5 X 4.5 centimeters, stable 9/28/12- 5.0 X 4.5 centimeters, stable 10/5/12- 5.0 X 4.5 centimeters On 10/9/12 at 9:55 a.m. and 10/10/12 at 10 a.m., R3 sat in a reclining chair without heel protectors on and both heels resting on the extended footrest. On 10/10/12 at 1:50 p.m., R3 sat in a reclining chair with both heels resting on the elevated footrest. R3's sock partially covered the left foot with the heel area uncovered. The left heel dressing was pushed past the heel wound partially exposing the left heel wound. No heel protectors were on R3's heels. On 10/10/12 at 3:15 p.m., E13 (Nurse) stated "(R3) is suppose to have heel protectors on." On 10/10/12 at 3:10 p.m., E8 (Treatment Nurse) stated R3 is suppose to have heel protectors on while in the reclining chair. On 10/10/12 at 3 p.m., R3 layed in bed on a regular mattress. R3's bed is not equipped with a low air flow mattress. On 10/10/12 at 3:10 p.m., E8 stated "(R3) uses a regular mattress and I have heel protectors for (R3)." R3's Comprehensive Care Plan, 8/24/12, documents R3 is to utilize heel protectors as a pressure ulcer treatment. An air loss mattress is not listed as an intervention. The October 2012 Physician order [REDACTED]. On 10/10/12 at 11am, E8 stated when interventions are added or changed, an order is obtained by the physician and the care plan is updated. E8 stated interventions are checked for compliance everyday at the time wound care is completed. E8 stated the Director of Nurses completes weekly rounds with E8 to obtain measurements and evaluate the wounds. On 10/11/12 at 9:30 a.m, the facility provided a summary of treatments from 12/11 to 10/16/12. The "Skin Summary" documents a low air mattress 3/2012, 4/2012 and 8/29/12 to present; heel protectors 4/2012 and 8/29/2012-present; and two wound care visits 1/2012 (debridement) and 8/2012. E8 was requested to provide documentation on the measurements and treatments provided for R3 since acquiring the pressure ulcer 10/25/11. On 10/11/12 at 12:15 p.m., E8 stated, "I do not have any more information prior to June for pressure ulcers. The "Skin Summary" documents the information I could find. I started in June and I could not find any information, I looked. The only information I have is what I gave to you."