Every finding on record at Avenues at Quad Cities

Based on interview and record review the Facility failed to obtain Facility Initiated Discharge Physician Orders, follow current Discharge Care Plans, provide written 30 Day Notice of Discharges to resident's/resident's responsible party, document discharge planning and resident specific needs/services, and document sufficient preparation/orientation to residents to ensure safe/orderly transfers/discharges from the facility for 13 of 14 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 14. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger. Findings include: The Facility Resident Midnight Census Report, dated 4/25/25, documents 23 occupied Resident beds in the Facility. The Facility Resident Room Roster, dated 4/29/25, documents 20 Residents residing in the Facility. The Facility Resident Room Roster, dated 5/2/25, documents 17 Residents residing in the Facility. The Facility Action Summary, dated 4/25/25, documents discharges to area Skilled Nursing Facilities for R6 (3/27/25), R7 (4/18/25), R8 (4/18/25), R9 (4/15/25), R10 (4/10/25), R11 (4/10/25), R12 (4/16/25) and R13 (4/9/25). The Facility Discharge Report, dated 4/29/25, documents discharges to area Skilled Nursing Facilities for R2 (4/28/25) and R5 (4/25/25). The Report documents one discharge to a private home for R4 (4/26/25). The Facility Discharge Report, dated 5/2/25, documents discharges to area Skilled Nursing Facilities for R14 (4/28/25). 1) R1's Admission Record, dated 4/29/25, documents that R1 admitted to the facility on [DATE]. R1's diagnoses upon admission to the Facility includes Hemiplegia related to a Cerebral Infarction affecting Right Dominant Side, Peripheral Vascular Disease and Bypass Graft of Left Leg, On 4/25/25 at 10:57 am, R1 (Resident Council President) stated, They asked me to leave, and I turned them down. They are asking everyone to leave. R1's current Care Plan does not document discharge planning or Facility planning concerning R1's long term plan to remain in the Facility. R1's Medical Record does not document a discharge meeting, or a request made by R1 to transfer/discharge. 2) R2's Admission Record, dated 4/29/25, documents that R2 admitted to the facility on [DATE] and discharged on [DATE] at 4:00 pm to nursing home unknown. R2 has no Responsible party documented. R2's diagnoses upon admission to the Facility included Hemiplegia and Hemiparesis following Subarachnoid Hemorrhage affecting Left Dominant side, Dysphagia following Cerebral Infarction and Sacrum Fracture. R2's Physician Order Sheet, dated 4/23/25, documents: to discharge to (local Facility) on 4/28/25; to continue with current medication list and orders; will continue to follow current Physician at this facility. R2's Social Service Nursing Note, dated 4/24/25 at 12:38 pm, documents that R2 has a Power of Attorney for healthcare. The Nursing Note documents that R2 is planning on discharging to another facility/institution for long term placement and that discharge date is set for 4/28/25. R2's Nursing Note, dated 4/24/25 at 12:46 pm, documents, Admissions Coordinator from (Facility being transferred to) contacted Facility and stated they would provide transportation on 4/28/25 at 8:00 am for discharge to their Facility. R2's Nursing Note, dated 4/28/25 at 4:56 pm, documents, (R2) was discharged to (local Facility) and taken with their (Local Facility) transportation van. (R2) is alert and able to make her needs know(n). (R2) took (R2's) medications and (R2's) belongings. (R2's) skin is intact. Report called to (local Facility). R2's current Care Plan documents that R2's wish(es) to discharge to (local Facility), to establish a pre-discharge plan and evaluate progress and revise plan as needed and encourage R2 to discuss concerns and feelings impending discharge. On 4/25/25 at 11:15 am, R2 stated, They said they are doing some remodeling and restructuring or something, so I had to leave. I did not even know anything about it, but they told me I was going to tour some other Facility here in town, I did not have much of a choice. I figured I had better go or they would throw me out on the street, and I did not want to wait until last minute and not be able to find a place to stay. They did not really even give me a choice to stay here. R2's Medical Record does not document services available/unavailable/able to be provided to meet R2's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party or 30-day Notice of Transfer/Discharge. R2's Medical Record does not document a discharge meeting or R2's request for transfer/discharge. 3) R4's Admission Record, dated 4/29/25, documents that R4 admitted to the facility on [DATE] and discharged on [DATE] at 8:52 am, to a private home with home health services. R4's Responsible party is documented as V8 (R4's Son). R4's diagnoses upon admission to the Facility included Cirrhosis of the Liver, non-Hodgkin lymphoma, Peripheral Autonomic Neuropathy, Spinal Stenosis, Depression, Lymphedema and Delusional Disorders. R4's Social Service Note Nursing Note, dated 4/23/25 at 3:07 pm, documents that R4 is discharging to parents' home and have their own home health services, so will have the services help R4 with any services R4 needs. The Note also documents that R4 left with current orders and medication, follow-up within seven days of discharge, has appointment with primary doctor set up and that V16 (R4's Medical Doctor) is aware of discharge. On 4/25/25 at 10:50 am, V14 (R4's Sister/Responsible Party) was in R4's room packing personal belongings. R4 stated, We got a mess in here, we are packing because I am leaving tomorrow. We got asked to leave. My Sister (V14) and Brother-n-law are moving me to my parents' house. We are not real happy about this. On 4/25/25 at 10:54 am, V14 (R4's Sister) stated, We got asked to leave. We are taking my brother (R4) to my parents' house in Iowa. We are not real happy about all of this, but we had no choice. R4's Medical Record does not document services available/unavailable to be provided to meet R4's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R4's Medical Record does not document a discharge meeting or R4's request for transfer/discharge. 4) R5's Admission Record, dated 4/29/25, documents that R5 admitted to the facility on [DATE] and discharged on [DATE] at 4:00 pm to an unknown nursing home. (V15) is documented as R5's Responsible party. R5's diagnoses upon admission to the Facility included Cerebral Infarction, Vascular Dementia, Anxiety Disorder, Depression, Diabetes Mellitus and Morbid Obesity. R5's Nursing Note, dated 4/24/25 at 12:16 pm, documents that (R5) is aware and daughter (V15) is aware that (R5) is going to a (local Facility). (V15) is the Power of Attorney (POA). R5's Social Service Nursing Note, dated 4/24/25 at 4:56 pm, documents R5's discharge to a local facility/institution. On 4/25/25 at 11:20 am, R5 (dressed and waiting for transport, with boxes in room) stated, They tell me that I am going to another Facility. I would just as soon stay here, but they did not give me a choice. I was told that I have to go to their sister facility in Aledo, Illinois, that is a lot farther away, but I wanted to go the Facility that my daughter works at. This has been very poor planning. I did not even know anything about this until last night. My friend had to come in and pack me up, so I am all packed up and waiting for them to come get me. I do not know why all of the sudden they just want me to leave. I like my room, I do not have any problems here, they give me anxiety and I am sure that this is going to be the worst trip of my life. They are supposedly supposed to be here any time to get me. This is just a mess, I feel like I got no choice in the matter and was forced out of here, it makes me really sad and angry. Apparently, they are doing some remodel and restructuring or something, I do not really understand. They did not give me any paperwork about my discharge. R5's Nursing Note, dated 4/25/25 at 3:14 pm, documents (local Facility) came to pick up (R5) and (V15) is aware. Resident skin is intact and the area to (R5's) coccyx is intact and Doctor is aware. Treatment in place at this time for preventative. Report has been called to (local Facility). (R5) took medication and belongs (belongings). (R5) is alert and able to make needs known. (R5) uses the wheelchair, both wheelchairs and commode were sent with (R5). R5's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R5. R5's current Care Plan documents that R5 wishes to discharge to a local Facility. R5's Medical Record does not document services available/unavailable/able to be provided to meet R5's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party or 30-day Notice of Transfer/Discharge. R5's Medical Record does not document a discharge meeting or R5's request for transfer/discharge. 5) R6's Admission Record, dated 4/25/25, documents that R6 admitted to the facility on [DATE] and discharged on [DATE] at 11:40 am, to an unknown nursing home. V7 (R6's Sister) is documented as R6's Power of Attorney. R6's diagnoses upon admission to the Facility included Dementia, Anxiety Disorder, Obsessive Compulsive Disorder, heart Failure, Myocardial Infarction, Mixed Obsessive-Compulsive Disorder, Depression and Diabetes Mellitus. R6's Nursing Note, dated 3/26/25 at 4:10 pm, documents that (R6) to discharge to (sister Facility). (R6) is aware along with Doctor and (V7) has been updated. Will continue with current medication and diet order. Scripts have been updated and sent to Pharmacy. (R6) has no skin issues at this time. (R6) is alert and able to make his needs known. (R6) is able to ambulate without difficulties. (R6) does use (R6's) wheelchair to propel himself throughout the Facility. Medication will be sent with the (R6) and his belongings. R6's Nursing Note, dated 3/27/25 at 9:23 am, documents that (R6) was talked to this morning concerning relocating to (sister Facility). (R6) wants to go. (R6) does not want to stay here. (R6) is alert and able to make his needs know(n). (V7) did state to let (R6) go to (sister Facility) if this is what (R6) wants. Education was provided to (V7) this is his wish at this time. R6's Nursing Note, dated 3/27/25 at 10:33 am, documents that R6 left to another facility (Facility). R6's Nursing Note, dated 3/27/25 at 11:32 am, documents (R6) was picked up and is being transported to (sister Facility). (R6) is in (R6's) wheelchair. (R6's) skin is intact. R6's vital signs were stable and R6 denied pain. (R6's) belongings were sent with the Resident along with medication and narcs (narcotics). Report was called to the Facility and Family is aware. R6's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R6. R6's Medical Record does not document services available/unavailable to be provided to meet R6's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R6's Medical Record does not document a discharge meeting or R6's request for transfer/discharge. On 4/25/25 at 11:36 am, V7 (R6's Sister) stated, My brother (R6) has been at that facility for almost two years. I told them not to discharge my brother, but according to them, they said that my brother (R6) wanted to go, but I do not believe it. So, I finally, just told them to let him discharge. They literally gave me one day's notice. My brother (R6) told me it all started when they wanted to transfer (R6) to their sister facility, but that is over a half hour further away. I wanted a referral to a more local place in Rock Island, but I am not sure why that did not happen. I found all of this out after they made all of the arrangements. Also, apparently (R6's) local State Insurance had lapsed right before (R6) had to transfer, and I did not get any notice of this either, but it was me that had to get the paperwork together real quick for them. Apparently, from what I hear now, they are making it a mental health facility. The Facility did not give me a written Thirty Day Notice before they discharged my brother (R6). 6) R7's Admission Record, dated 4/25/25, documents that R7 admitted to the facility on [DATE] and discharged on [DATE] at 3:46 pm, to an unknown nursing home. R7's Responsible Party is documented as V9 (R7's Granddaughter). R7's diagnoses upon admission to the Facility included Alzheimer Dementia, Anemia, Osteoporosis, Anxiety Disorder and Scoliosis. R7's Nursing Note, dated 4/18/25 at 1:03 pm, documents that R7 will be discharging to another local Facility today and that R7 and R7's family are aware of orders received. R7's Nursing Note, dated 4/18/25 at 3:09 pm, documents that R7 was discharged to another local Facility and that R7's family is aware, belongings and medications went with. The Nursing Note documents that R7 is confused, and skin is intact. R7's current Care Plan documents that R7 expressed to remain in the Facility for permanent placement; concerns will be addressed in a timely manner; R7 and Responsible Party (V9) will be invited to bring any concerns to the Facility staff; will state comfort with current setting; and Responsible Party (V9) will be contacted with concerns. R7's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R7. R7's Medical Record does not document services available/unavailable to be provided to meet R7's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R7's Medical Record does not document a discharge meeting or R7's request for transfer/discharge. On 4/25/25 at 12:23 pm, V9 (R7's Granddaughter/Responsible Party) stated, My Grandma has Dementia and had been at that Facility for a couple years. My Grandpa (R8) also lived at the Facility with her (R7). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want (R7) to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small-town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and I did not receive any written notice of any kind. 7) R8's Admission Record, dated 4/25/25, documents that R8 admitted to the facility on [DATE] and discharged on [DATE] at 3:48 pm, to an unknown nursing home. R8's Responsible Party is identified. R8's diagnoses upon admission to the Facility included Alzheimer Dementia, Prostate Cancer, Behavioral Mood Disturbance and Anxiety Disorder. R8's Social Service Note Nursing Note, dated 4/17/25 at 1:17 pm, documents that R8 is discharging to a local Facility on 4/18/25 for long-term placement. R8's Nursing Note, dated 4/17/25 at 3:54 pm, documents that V17 (R8's Power of Attorney/Sister) was contacted regarding a referral to a local Facility for R8 requiring a higher level of care and that V17 agreed to the referral. The Nursing Note documents that R8 will discharge to the local Facility on 4/18/25. The Nursing Note did not document the higher level of care reason or diagnoses for the discharge or other facility referral options available for R8. R8's Nursing Note, dated 4/18/25 at 3:12 pm, documents was discharged to the local Facility; family is aware; medications and belongings were sent; alert with some confusion; skin intact; walks with a walker and does need assistance with activities of daily living (ADL's); and report was called to Facility. R8's current Care Plan documents: R8 desires to remain in the Facility for permanent placement; concerns will be addressed in a timely manner; R8 and Responsible Party (V9) will be invited to bring any concerns to the Facility staff; will state comfort with current setting; and Responsible Party (V17) will be contacted with concerns. R8's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R8. R8's Medical Record does not document services available/unavailable to be provided to meet R8's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R8's Medical Record does not document a discharge meeting or R8's request for transfer/discharge. On 4/25/25 at 12:23 pm, V9 (R8's Granddaughter) stated, My Grandpa has dementia and had been at that Facility for years. My Grandma (R7) also lived at the Facility with him (R8). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want my grandparents to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and we did not receive any written notice of any kind. 8) R9's Admission Record, dated 4/25/25, documents that R9 admitted to the facility on [DATE] and discharged on [DATE] at 10:43 am to an unknown nursing home. R9's Responsible party was V10 (R9's Mother). R9's diagnoses upon admission to the Facility included Chronic Obstructive Pulmonary Disease, Diabetes, Depression, Anxiety, Schizoaffective Disorder, Insomnia and Bipolar with Manic Severe with Psychotic Features. R9's Nursing Note, dated 4/14/25 at 10:25 am, documents that V10 (R9's Mother) was informed of Resident leaving for a Sister Facility and that everyone is in agreement and (R9) will no(t) be educated on the move until (R9) is ready to be moved related to negative behaviors. R9's Nursing Note, dated 4/14/25 at 3:08 pm, documents that V10 was informed of R9 leaving for a Sister Facility on 4/15/25 at 9:30 am. R9's Social Service Note Nursing Note, dated 4/15/25 at 11:34 am, documents that R9 was discharge to a Sister Facility. V10 helped pack up R9's belongings. R9's medications and orders were sent with transportation. The Nursing Note documents: is alert and able to make needs known; skin is intact; report was called to Sister Facility; belongings went with R9 and V10 took the rest of belongings. R9's current Care Plan documents a desire to remain at current Facility for permanent placement. R9's Physician Order Sheet, dated 4/29/25 does not document a discharge order for R9. R9's Medical Record does not document services available/unavailable to be provided to meet R9's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R9's Medical Record does not document a discharge meeting or R9's request for transfer/discharge. On 4/25/25 at 12:33 pm, V10 (R9's Power of Attorney/Mother) stated, My daughter (R9) has been at this facility for about [AGE] years and her discharge was not initiated by me, I was not given an option. Someone called me and asked me which date I wanted her to leave, and I told them that I did not know. They went ahead and made arrangements for my daughter (R9) to go to their Sister Facility that is over an hour drive away. It puts a lot of pressure on me to drive that far away. I am [AGE] years old, and I drive a 2008 vehicle that I do not trust on the interstate. My daughter (R9) had her own refrigerator, and I used to come to see her about every day and bring her stuff all the time, like food and personal items, and now I cannot do that at all because it is too far. It has been all messed up since they discharged her. First of all, they did not even transfer any of her medications, so we could not order any for her at the new place, and she takes a lot of medications for her mental issues. It has just been hectic ever since. 9) R10's Admission Record, dated 4/25/25, documents that R10 admitted to the facility on [DATE] and discharged on [DATE] at 3:55 pm to an unknown Nursing Home. R10's Responsible party was V11 (R10's Son). R10's diagnoses upon admission to the Facility included Encephalopathy, Chronic Kidney Disease Stage Three, Syncope and Collapse, Left Wrist Fracture, Cerebellar Ataxia, Hearing Loss and Dementia. R10's Social Service Note Nursing Note, dated 4/7/25 at 11:34 am, documents that R10 will discharge to another Facility/Institution. R10's Nursing Note, dated 4/7/25 at 12:36 pm, documents that R10 has orders to discharge to another local Nursing Home and that R10 and V11 are aware. R10's Nursing Note, dated 4/10/25 at 3:52 pm, documents: R10 transferred to a local Nursing Home; belongings were transported by V11; report was called; R10 is wheelchair bound; alert and confused (alert X/times 1); skin intact; and V11 is aware of transfer. R10's current Care Plan documents that R10 has expressed a desire to remain at Facility for permanent placement. R10's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R10. R10's Medical Record does not document services available/unavailable to be provided to meet R10's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R10's Medical Record does not document a discharge meeting or R10's request for transfer/discharge. On 4/25/25 at 12:47 pm, V11 (R10's Power of Attorney/Son) stated, About two weeks ago, I received a phone call from the Facility saying they wanted to move a bunch of people out of the Facility. They suggested I move Mom (R10) to one of their other Facility's in another town, but I told them that it was too far, so she went to another one here in town that is closer. My Mom has been in this Facility for two-and a-half years. They gave us little notice and did not really give us an option to stay, they pretty much said that they are going to make it a mental health Facility. So, we had to move her, and after we got her to the new Facility, we had a difficult time getting her medical records from the old place. My Mom is in Hospice care, and she is not doing good at all, and I honestly expect that she dies any day. 10) R11's Admission Record, dated 4/25/25, documents that R11 admitted to the facility on [DATE] and discharged on [DATE] at 3:55 pm, to an unknown Nursing Home. R11's Responsible party was V12 (R11's Daughter). R11's diagnoses upon admission to the Facility included Heart Failure, Spinal Stenosis, Cataract, Peripheral Autonomic Neuropathy, Chronic Obstructive Pulmonary Disease and Lumbar Vertebrae Fracture. R11's Social Service Note Nursing Note, dated 4/7/25 at 10:57 am, documents that R11 and V12 (R1's Daughter) is aware of R11's discharge to a local area Nursing Home and that orders for discharge were received. R11's Nursing Note, dated 4/10/25 at 3:43 pm, documents that R11 was transported to a local area Nursing Home and report was given. R11's belongings and medication were transported. R11 is alert, able to make needs known, uses a wheelchair to ambulate and skin intact. R11's current Care Plan documents that R11 has expressed a desire to remain at the Facility for permanent placement and that V11 will be contacted for any concerns. R11's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R11. R11's Medical Record does not document services available/unavailable to be provided to meet R11's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R11's Medical Record does not document a discharge meeting or R11's request for transfer/discharge. On 4/25/25 at 1:36 pm, V12 (R11's Power of Attorney/Daughter) stated, My Mom (R11) has been at that Facility since 2019. I got a call on Wednesday (4/9/25) that they were going to discharge my Mom. They suggested that my Mom (R11) could go to another one of their Facilities and I said no, they were too far away. I had to go get her on Thursday (4/10/25) and take her to the new place because they were not going to take her over there. They were very rude about everything and not very helpful. I really did not want Mom moved, but I did not think I had a choice. 11) R12's Admission Record, dated 4/25/25, documents that R12 admitted to the facility on [DATE] and discharged on [DATE] at 10:00 am, to an unknown Nursing Home. R12's Responsible party was R12. and R12's diagnoses upon admission to the Facility included Cerebral Palsy and Depression. R12's Nursing Note, dated 4/7/25, documents that R12 is aware of discharge to sister Facility. R12's Social Service Note Nursing Note, dated 4/15/25 at 11:16 am, documents that R12 is discharging to the community. R12's Nursing Note, dated 4/16/25 at 10:51 am, documents that R12 was discharged to a sister Facility (approximately 40 miles away). The Note documents that R12 is aware, used wheelchair, skin intact and medications/belongings sent. R12's current Care Plan documents that R12 has expressed a desire to remain at the Facility for permanent placement and to notify Physician of any changes. R12's Medical Record does not document services available/unavailable to be provided to meet R12's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R12's Medical Record does not document a discharge meeting or R12's request for transfer/discharge. 12) R13's Admission Record, dated 4/25/25, documents that R13 admitted to the facility on [DATE] and was discharged on [DATE] at 10:13 am to an unknown Nursing Home. R13's Responsible party was V8 (R13's Son). R13's diagnoses upon admission to the Facility included Chronic Obstructive Pulmonary Disease, Diabetes, Chronic Kidney Disease Stage Three and Depression. R13's Nursing Note, dated 4/7/25 at 12:03 pm, documents that R13 is discharging to a sister Facility, (V8/Son) is aware and new orders received. R13's Social Service Note Nursing Note, dated 4/7/25 at 3:48 pm, documents that R13 is discharging to another Facility/Institution. R13's current Care Plan documents R13/Responsible Party (V8) are in favor of long-term placement, no discharge/transfer potential at this time. R13's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R13. R13's Medical Record does not document services available/unavailable to be provided to meet R13's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R13's Medical Record does not document a discharge meeting or R13's request for transfer/discharge. On 4/29/25 at 9:06 am, V8 (R13's Power of Attorney/Son) stated, I moved my Dad (R13) there about a year ago for Physical Therapy. The old company got bought out and got new owners, then he (R13) did not get therapy anymore. About a month ago, I got a phone call from them, and they told me that they were transitioning to a different type of building, more for mental health. They told us that if we went to one their own facility's (a town over 30 miles from here) that my Dad could get physical and occupational therapy, because they did not offer therapy there anymore. They did not say anything about a date he was moving or anything. We really did not get an option to stay, I just figured at that time that it would be more beneficial if my Dad could get some therapy. Then out of the blue, I think it was a Thursday (3/27/25), my Dad calls me and tells me that they moved him to the new place. I found out that he had been at the new Facility for two days and I did not even know it. They did not take his recliner with him either, I had to go get it, so Dad sat without his recliner for days until I could get it to him. This new facility he is at is extremely further. Now it takes an hour to get to the new place and it used to only take me fifteen minutes to get to that place. The funny thing is, no one has even called me from the new facility and my Dad still has not even gotten screened for therapy, and he has been there at least three weeks. About a week later, I took Dad his recliner and some diet pop and he also told me at that time that he had not even gotten a shower yet either. I cannot get anyone to call from either place. I did not get a written notice of Dad's discharge or given any other option on where we could go. There were no advocates there to help me, I even mentioned bringing him near me, in Iowa, and no one was real receptive of that either. Also, his brothers and sisters live here in town and now that cannot go see him at the new place, because it is too far for them to drive. 13) R14's Admission Record, dated 4/25/25, documents that R14 admitted to the facility on ,d+[DATE]//24 and was discharged on [DATE] at 2:11 pm to an unknown Nursing Home. R14's Responsible party was R14's. R14's diagnoses upon admission to the Facility included Diagnosis: Chronic Obstructive Pulmonary Disease, Right Femur Surgical Amputation, Osteomyelitis, Diabetes, Hemiplegia, Peripheral Vascular Disease and Depression. R14's Social Service Note Nursing Note, dated 4/7/25 at 4:06 pm, documents that R14 is discharging to another Facility/Institution. R14's Nursing Note, dated 4/29/2025 at 11:12 am, documents that orders for discharge were received and family is aware. R14's Nursing Note, dated 4/29/25 at 2:31 pm, documents R14 was picked up by family and is being discharged to a local area Nursing Home. The Nursing Note documents that R14 is alert and is able to make needs known, skin intact, uses a wheelchair, medication/ belonging sent with R14. R14's Social Service Nursing Note, dated 4/29/2025 at 3:18 pm, documents that R14 is discharging to a local area Nursing Home on 4/30/25. R14's Parents plan on transporting and will pick. R14's current Care Plan documents an entry on 4/29/25, that R14 wishes to be discharged to home or another facility. R14's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R14. R14's Medical Record does not document services available/unavailable to be provided to meet R14's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R14's Medical Record does not document a discharge meeting or R14's request for transfer/discharge. On 5/2/25 at 9:02 am, V5 (Community Ombudsman) stated, When I was here last week, I notified my boss (V4) that the Facility is trying to discharge everyone, and they are not issuing thirty-day notices to the Residents before they discharge them. The Facility is the one initiating all of the discharges. They are talking to Residents and calling families about discharging to their own Facilities which are located in Aledo, Illinois or Kewanee, Illinois. They are not really giving them an [TRUNCATED]

Based on record review and interview the Facility failed to notify Resident/Resident's Representatives of transfers/discharges and the reasons for the move in writing at least 30 days prior to transfer discharge, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights for 12 of 14 Residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 18. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger. Findings include: The Facility Action Summary, dated 4/25/25, documents discharges to area Skilled Nursing Facilities for R6 (3/27/25), R7 (4/18/25), R8 (4/18/25), R9 (4/15/25), R10 (4/10/25), R11 (4/10/25), R12 (4/16/25) and R13 (4/9/25). The Facility Discharge Report, dated 4/29/25, documents discharges to area Skilled Nursing Facilities for R2 (4/28/25) and R5 (4/25/25). The Report documents one discharge to a private home for R4 (4/26/25). 1) R2's Admission Record, dated 4/29/25, documents that R2 admitted to the facility on [DATE] and discharged on [DATE] at 4:00 pm to nursing home unknown. R2's Physician Order Sheet, dated 4/23/25, documents: to discharge to (local Facility) on 4/28/25. On 4/25/25 at 11:15 am, R2 stated, They said they are doing some remodeling and restructuring or something, so I had to leave. I did not even know anything about it, but they told me I was going to tour some other Facility here in town, I did not have much of a choice. I figured I had better go or they would throw me out on the street, and I did not want to wait until last minute and not be able to find a place to stay. They did not really even give me a choice to stay here. I did not receive any paperwork. R2's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge, record the reason for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights. R2's Medical Record does not document a discharge meeting or R2's request for transfer/discharge. 2) R4's Admission Record, dated 4/29/25, documents that R4 admitted to the facility on [DATE] and discharged on [DATE] at 8:52 am, to a private home with home health services. On 4/25/25 at 10:50 am, R4's stated, We got a mess in here, we are packing because I am leaving tomorrow. We got asked to leave. My Sister (V14) and Brother-n-law are moving me to my parents' house. We are not real happy about this. We did not get any notice or anything in writing. On 4/25/25 at 10:54 am, V14 (R4's Sister) stated, We got asked to leave. We are taking my brother (R4) to my parents' house in Iowa. We are not real happy about all of this, but we had no choice. I did not receive a notice or any type of paperwork in writing. This all just happened in a matter of a few days. R4's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights. R4's Medical Record does not document a discharge meeting or R4's request for transfer/discharge. 3) R5's Admission Record, dated 4/29/25, documents that R5 admitted to the facility on [DATE] and discharged on [DATE] at 4:00 pm to an unknown nursing home. On 4/25/25 at 11:20 am, R5 (dressed and waiting for transport, with boxes in room) stated, They tell me that I am going to another Facility. I would just as soon stay here, but they did not give me a choice. I was told that I have to go to their sister facility in Aledo, Illinois, that is a lot further away, but I wanted to go the Facility that my daughter works at. This has been very poor planning. I did not even know anything about this until last night. My friend had to come in and pack me up, so I am all packed up and waiting for them to come get me. I do not know why all of the sudden they just want me to leave. I like my room, I do not have any problems here, they give me anxiety and I am sure that this is going to be the worst trip of my life. They are supposedly supposed to be here any time to get me. This is just a mess, I feel like I got no choice in the matter and was forced out of here, it makes me really sad and angry. Apparently, they are doing some remodel and restructuring or something, I do not really understand. They did not give me any type of paperwork about my discharge. R5's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights. R5's Medical Record does not document a discharge meeting or R5's request for transfer/discharge. 4) R6's Admission Record, dated 4/25/25, documents that R6 admitted to the facility on [DATE] and discharged on [DATE] at 11:40 am, to nursing home unknown. R6's Power of Attorney is identified as V7 (R6's Sister). On 4/25/25 at 11:36 am, V7 (R6's Sister) stated, My brother (R6) has been at that facility for almost two years. I told them not to discharge my brother, but according to them, they said that my brother (R6) wanted to go, but I do not believe it. So, I finally, just told them to let him discharge. They literally gave me one day's notice. My brother (R6) told me it all started when they wanted to transfer (R6) to their sister facility, but that is over a half hour further away. I wanted a referral to a more local place in Rock Island, but I am not sure why that did not happen. I found all of this out after they made all of the arrangements. Also, apparently (R6's) local State Insurance had lapsed right before (R6) had to transfer, and I did not get any notice of this either, but it was me that had to get the paperwork together real quick for them. Apparently, from what I hear now, they are making it a mental health facility. The Facility did not give me a written thirty-day notice or any paperwork when they discharged my brother (R6). R6's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R6's Medical Record does not document a discharge meeting or R6's request for transfer/discharge. 5) R7's Admission Record, dated 4/25/25, documents that R7 admitted to the facility on [DATE] and discharged on [DATE] at 3:46 pm, to nursing home unknown. R7's Responsible Party is identified as V9 (R7's Granddaughter). On 4/25/25 at 12:23 pm, V9 (R7's Granddaughter/Responsible Party) stated, My Grandma has dementia and had been at that Facility for a couple years. My Grandpa (R8) also lived at the Facility with her (R7). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want (R7) to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small-town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and I did not receive any written notice of any kind for anything to do with Grandma's discharge. R7's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R7's Medical Record does not document a discharge meeting or R7's request for transfer/discharge. 6) R8's Admission Record, dated 4/25/25, documents that R8 admitted to the facility on [DATE] and discharged on [DATE] at 3:48 pm, to nursing home unknown. V17 (R8's Sister/Responsible Party) is identified as R8's Responsible Party. On 4/25/25 at 12:23 pm, V9 (R8's Granddaughter) stated, My Grandpa has dementia and had been at that Facility for years. My Grandma (R7) also lived at the Facility with him (R8). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want my grandparents to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small-town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and we did not receive any written notice of any kind. R8's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R8's Medical Record does not document a discharge meeting or R8's request for transfer/discharge. 7) R9's Admission Record, dated 4/25/25, documents that R9 admitted to the facility on [DATE] and discharged on [DATE] at 10:43 am to an unknown nursing home. R9's Responsible party is V10 (R9's Mother). On 4/25/25 at 12:33 pm, V10 (R9's Power of Attorney/Mother) stated, My daughter (R9) has been at this facility for about [AGE] years and her discharge was not initiated by me, I was not given an option. Someone called me and asked me which date I wanted her to leave, and I told them that I did not know. They went ahead and made arrangements for my daughter (R9) to go to their Sister Facility that is over an hour drive away. It puts a lot of pressure on me to drive that far away. I am [AGE] years old, and I drive a 2008 vehicle that I do not trust on the interstate. My daughter (R9) had her own refrigerator, and I used to come to see her about every day and bring her stuff all the time, like food and personal items, and now I cannot do that at all because it is too far. It has been all messed up since they discharged her. First of all, they did not even transfer any of her medications, so we could not order any for her at the new place, and she takes a lot of medications for her mental issues. It has just been hectic ever since. V10 verified that no written notices or any paperwork was received from the Facility. R9's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R9's Medical Record does not document a discharge meeting or R9's request for transfer/discharge. 8) R10's Admission Record, dated 4/25/25, documents that R10 admitted to the facility on [DATE] and discharged on [DATE] at 3:55 pm to an unknown Nursing Home. R10's Responsible party is V11 (R10's Son). On 4/25/25 at 12:47 pm, V11 (R10's Power of Attorney/Son) stated, About two weeks ago, I received a phone call from the Facility saying they wanted to move a bunch of people out of the Facility. They suggested I move Mom (R10) to one of their other Facility's in another town, but I told them that it was too far, so she went to another one here in town that is closer. My Mom has been in this Facility for two-and a-half years. They gave us little notice and did not really give us an option to stay, they pretty much said that they are going to make it a mental health Facility. So, we had to move her, and after we got her to the new Facility, we had a difficult time getting her medical records from the old place. My Mom is in Hospice care, and she is not doing good at all, and I honestly expect that she dies any day. I did not receive any formal written discharge papers. R10's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/Discharge or provide a statement of the resident's appeal rights. R10's Medical Record does not document a discharge meeting or R10's request for transfer/discharge. 9) R11's Admission Record, dated 4/25/25, documents that R11 admitted to the facility on [DATE] and discharged on [DATE] at 3:55 pm, to an unknown Nursing Home. R11's Responsible party is V12 (R11's Daughter). On 4/25/25 at 1:36 pm, V12 (R11's Power of Attorney/Daughter) stated, My Mom (R11) has been at that Facility since 2019. I got a call on Wednesday (4/9/25) that they were going to discharge my Mom. They suggested that she could go to another one of their Facilities and I said no, they were too far away. I had to go get her on Thursday (4/10/25) and take her to the new place because they were not going to take her over there. They were very rude about everything and not very helpful. I really did not want Mom moved, but I did not think I had a choice, and they did not provide me with any type of written notices or paperwork. R11's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R11's Medical Record does not document a discharge meeting or R11's request for transfer/discharge. 10) R12's Admission Record, dated 4/25/25, documents that R12 admitted to the facility on [DATE] and discharged on [DATE] at 10:00 am, to an unknown Nursing Home. R12's Responsible party is R12. R12's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R12's Medical Record does not document a discharge meeting or R12's request for transfer/discharge. 11) R13's Admission Record, dated 4/25/25, documents that R13 admitted to the facility on [DATE] and was discharged on [DATE] at 10:13 am to an unknown Nursing Home. R13's Responsible party is V8 (R13's Son). On 4/29/25 at 9:06 am, V8 (R13's Power of Attorney/Son) stated, I moved my Dad (R13) there about a year ago for Physical Therapy. The old company got bought out and got new owners, then he (V13) did not get therapy anymore. About a month ago, I got a phone call from them and told me that they were transitioning to a different type of building, more for mental health. They told us that if we went to one their own facility's (a town over 30 miles from here) that my Dad could get physical and occupational therapy, because they did not offer therapy there anymore. They did not say anything about a date he was moving or anything. We really did not get an option to stay, I just figured at that time that it would be more beneficial if my Dad could get some therapy. Then out of the blue, I think it was a Thursday (3/27/25), my Dad calls me and tells me that they moved him to the new place. I found out that he had been at the new Facility for two days and I did not even know it. Now it takes an hour to get to the new place and it used to only take me fifteen minutes to get to that place. The funny thing is, no one has even called me from the new facility and my Dad still has not even gotten screened for therapy, and he has been there at least three weeks. I cannot get anyone to call from either place. I did not get a written notice of Dad's discharge or given any other option on where we could go. There were no advocates there to help me, I even mentioned bringing him near me in Iowa, and no one was real receptive of that either. Also, his brothers and sisters live here in town and now they cannot go see him at the new place, because it is too far for them to drive. We definitely did not receive any notices or paperwork of any kind before this happened. R13's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R13's Medical Record does not document a discharge meeting or R13's request for transfer/discharge. 12) R14's Admission Record, dated 4/25/25, documents that R14 admitted to the facility on [DATE] and was discharged on [DATE] at 2:11 pm to an unknown Nursing Home. R14's Responsible party is R14. R14's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R14's Medical Record does not document a discharge meeting or R14's request for transfer/discharge. On 5/2/25 at 9:02 am, V5 (Community Ombudsman) stated, When I was here last week, I notified my boss (V4) that the Facility is trying to discharge everyone, and they are not issuing thirty-day notices to the Residents before they discharge them. The Facility is the one initiating all of the discharges. They are talking to Residents and calling families about discharging to their own Facilities which are located in Aledo, Illinois or Kewanee, Illinois. They are not really giving them an option of where to go, they are also making promises, like therapy services at their sister Facilities and not doing therapy and making good on the promises. I am also aware that they are not going through the right discharge process. On 4/25/25, at 9:55 am, V4 (Ombudsman) stated, (V5/Community Ombudsman) notified me that when (V5) was in the building last week, (V5) was told by multiple Residents that the Facility was discharging everyone and moving people out. No one is getting Statement of Appeal Rights or Thirty Day notices or discharge meetings. They are not getting anything related to these discharges. They were told that they needed to move due to Facility renovations and also that it was getting turned into a mental health facility. Some of these Residents have been at that Facility for years, I am not sure why all of the sudden they need to be discharged , now they are displaced. This is causing families to have to travel further and not being able to visit as often. I have also heard that they are moving them to some of their own facilities that are further away and not giving them Facility options of where to go. This Facility should also be offering all the services that fall under their skilled nursing facility regulations and licensure, but they have not had therapy available for Residents and the staffing has really decreased. (V5) and myself are trying to track all of these discharges at the other Facilities. I have concerns about the Facility going through the right steps on these discharges and the Facility never notified us of all of these discharges either. On 4/29/25 at 9:55 am, V13 (Corporate Social Service Director) stated, This Facility does not currently have a Social Service Director, so I have been coming in and helping out. (V2/Director of Nursing) and I have been reaching out to Residents and making phone calls to family's about moving to our sister Facilities, because we are restructuring to become a mental health facility. I was not aware that we needed to issue Thirty Day Notices or Statement of Appeal Rights. On 4/25/25 at 10:13 am, V3 (Regional Director of Operations) stated, We are not trying to get skilled therapy services because we have not had any skilled therapy for the last few months. We are not doing any renovations that I know of, and I do not know of any work orders or bids for renovations either. We were directed to make phone calls to family members and talk to Residents about transferring to our sister facilities. We plan on making this a mental health and behavioral facility and planned on keeping the same licensure. We did not give thirty-day notices to any of the Residents that discharged . I cannot find documentation from the Physician regarding the Resident needs that could not be met and the reason for discharge, Statement of Appeal Rights or Thirty Day notices for any of these discharges. There are no plans for construction at this Facility. On 4/25/29 at 9:00 am, V2 (Director of Nursing/DON) stated, We are trying to get this to a mental health building. We were directed by Corporate to discharge all of our residents so we could do construction remodeling and restructuring of the Facility to a mental health facility. Corporate is making all of the Facilities that are named 'Avenues' Facility's into their mental health and behavioral facilities. We gave all of the Residents the option to go to our sister facilities, some went to our Facilities, and some wanted to go to other facilities here in town. I do not see in any documentation, and I am not aware that we held actual discharge planning meetings, other than placing a phone call asking for options of what facility they wanted discharged to. I gave you all of the documentation from the Resident's medical records that I have. I do not see that all of the Residents had Physician Discharge Orders, Thirty Day Notices or any documentation for reasons for discharge either. On 4/25/25 at 9:20 am, V1 (Administrator) stated, I was directed to initiate discharges so that we could restructure this facility into a mental and behavioral health facility. At first, we just called all of the families and gave the option to transfer to one of our sister facilities, but some have chosen to go to other facilities closer here in town. We have not been taking any admissions for a few months either. I cannot find any documentation for remodel plans, bids or work orders. I do not think that we have any Thirty Day Discharge Notices or anything other documentation to provide on any of the Residents that have been discharged . On 5/2/25 at 10:28 am, V16 (Medical Director) stated, I was not aware that the Facility is discharging all of these Residents. They have not given me any notice. I have not documented any discharge planning notes or discharge orders for any of the Residents either. No one has discussed this process of this becoming a mental health facility with me. Sometimes they send me just a piece of paper about something, but I never even received a paper about this either. The Facility Assessment Tool, dated 11/2024, documents: 63 licensed beds, currently 30 long stay Residents, very important to have family/friend involved in care discussion for all Residents; support emotional and mental health well-being and offer and assist Resident/Family to be involved in person-centered care planning and advance care planning; educate staff on Resident Rights and facility responsibility to properly care for its Residents; person centered care should include care planning, education of Resident and family representative about treatments and treatment preferences and advance care planning; Resident assessment; specialized care; and consider and plan for how to get input and participation from Residents and their representative/family members throughout the assessment process; getting feedback from the local long-term care ombudsman program and involving Residents and representatives. The Facility Notice of Transfer and Discharge Policy, revised 10/2022, documents: to notify the Resident and the Resident's Representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons for the transfer or discharge in the Resident's medical record; the transfer or discharge is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility; Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility; the safety of the individuals in the Facility is endangered due to clinical or behavioral status; health of the individuals would otherwise be endangered or the Resident has failed, after reasonable and appropriate notice, to pay for a stay at the Facility; when the Facility transfers or discharges a Resident under any of the circumstances (specified in reasons as stated above), the Facility must ensure that the transfer or discharge is documented in the Resident's medical record including reason for the transfer, specific Resident needs that cannot be met, facility attempts to meet the Resident needs and the services available at the receiving Facility to meet the needs; and documentation must be made by the Resident's Physician when the transfer or discharge is necessary; except otherwise specified, the notice of transfer or discharge will be made at least 30 days before the Resident is transferred or discharged ; discharge from the Facility will include review of all necessary items to maintain the individuals highest practicable well-being including medical equipment, medications, appointments and treatments; and in the case of a Facility closure, the Administrator must provide written notification prior to the impending closure to the State Agency, Office of State Long Term Care Ombudsman, Residents at Facility and Resident Representatives, as well as the plan for the transfer and adequate relocation of the Residents. The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: rights to make own choices, must be treated with dignity and respect and must care for in a manner that promotes quality of life; Facility must provide services to keep physical and mental health, at their highest practical levels; may participate in developing a person-centered care plan which states the services the Facility will provide and everything you are expected to do and the Facility must make reasonable arrangements to meet your needs and choices; should receive the services and/or items included in the plan of care; your discharge plan and steps to achieve the goals included in your care plan; have the right to keep living in your facility; must be given written notice if your facility wants you to move from the facility and the reasons for asking you to leave the facility; the notice must tell you why your facility wants you to move, tell you how to appeal the decision; provide a stamped and addressed envelope for you to mail your appeal; and be received 30 days prior to the day they want you to move from a Medicare or Medicaid Facility. The Facility Admission Packet, undated, documents: the Facility shall offer nursing care, activities, restorative and rehabilitative services, psychosocial care as identified in the Resident's Plan of Care to the extent required by the Facility Standards and in accordance with the policies of the Facility; and the Termination by Facility Involuntary Transfer or Discharge states the Facility may transfer or discharge a Resident for one more of the following reasons at any time by giving 30 days written notice to the Resident, Representative/Responsible Party as required by state law and regulations (medical reasons, health has improved such that no longer requires services, physical safety for Residents, late payment/non-payment, Facility ceases to operate or otherwise permitted by law).

Based on interview, observation and record review, the facility failed to provide supervision to a wandering resident with a known mental health history and previous elopement, conduct an assessment and investigation to determine risk of elopement, develop a care plan addressing elopement risk, and ensure the physician was notified of a resident elopement for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1, a resident with a known history of multiple psychiatric issues, eloping from the facility at night during freezing temperatures, without staff knowledge, and was later found wandering over a half of a mile from the facility, near a busy highway, with urine saturated pants, confusion, and agitation. These failures resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified to have started on 12/27/2024 when R1 eloped from the facility. The facility failed to identify and investigate R1's incident as an elopement and failed to implement interventions to prevent future elopements. On 2/3/2025 at 2:44 PM, V1 (Regional Director of Operations) was notified of the Immediate Jeopardy situation. While the immediacy was removed on 2/4/2025, the facility remained out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Finding Include: R1's current Care Plan, dated 1/20/25, documents R1 has diagnoses including but not limited to major depressive disorder, anxiety, schizoaffective disorder, bipolar disorder, and bipolar current episode manic severe with psychotic features. This same Care plan documents (R1) has behavior problem related to schizoaffective disorder. (R1) is known to have/has history of hallucinations and/or delusions. Verbal behaviors symptoms: Threatening, allegations of mistreatment by caregivers, cursing, hitting, scratching, pacing related to schizoaffective disorder with history of paranoid behavior. (R1) has conviction history of domestic battery related. Needs additional monitoring to ensure respect of other resident's rights. (R1) has diabetes mellitus. Avoid exposure to extreme heat or cold. (R1) is at risk for falls related to chronic obstructive pulmonary disease (COPD), diabetes mellitus type II, depression, anxiety, schizophrenia, insomnia, and medications that (R1) receives. (R1) has shortness of breath related to COPD. R1's Elopement Evaluation assessment, dated 11/15/24, documents R1 is not at risk for elopement. R1's Behavior Monitoring and Interventions reports for December 1, 2024-January 28, 2024, document R1 had behaviors of cursing, screaming and threatening others, anxious/restless and wandering on 12/12/24 at 10:39 AM. R1 had behaviors of pacing and rummaging on 12/26/24 at 9:46 AM. R1 had behaviors of pacing, refusing care, agitation, cursing, screaming and threatening others. R1's current medical record has no documentation of a new Elopement Risk Assessment being completed following R1's increase in wandering behaviors. R1's current medical record also had no documentation of the development of a comprehensive care plan to address R1's exit seeking behaviors with interventions to prevent R1 from eloping from the facility. R1's current Physician order sheet, dated January 2025, documents R1 has orders to receive the following psychotropic medications to treat R1's current psychotic diagnoses and behaviors: haloperidol decanoate (antipsychotic) intramuscular solution 100 MG/ML (milligrams/milliliter) 1 ml (milliliter) intramuscularly in the morning every 14 day(s); lorazepam (antianxiety) 2 mg (milligrams tablet by mouth every morning, afternoon, and bedtime; divalproex sodium oral capsule delayed release sprinkle 125 mg two capsules orally two times a day; haloperidol 5 mg tablet by mouth two times a day. R1's progress note, dated 12/27/2024 at 5:26 AM, documents (R1) refused all the medications. R1's progress note, dated 12/27/2024 at 9:43 PM documents Around 8:30 pm (R1) approached nurses' office with intention to use the phone. She (R1) called her mother (V3). Shortly after (R1) became agitated with the caller and threw the phone at the nurse. Shortly after (V3) called back and stated she is used to the verbal abuse, and she would be in to bring (R1) some things tomorrow. At this time (R1) was in her room. Around 9:30 PM (R1) was observed walking bumping into any and everything in her way. She appeared upset. (R1) walked out of the facility. The nurse (V17/Licensed Practical Nurse) and two CNAs (Certified Nursing Assistants/V9, V11) followed (R1) outside to await EMTs (Emergency Medical Technicians) and police. When the EMTs arrived (V17) explained (R1) was agitated and had already thrown a phone and could possibly be a danger to the other residents, (R1) was taken to the ER (emergency room ) for further evaluation. Nurse notified DON (V2, Director of Nursing) and (V3). R1's current medical record has no documentation of the facility identifying or investigating R1's incident on 12/27/24 as an attempt to elope from the facility. There was also no documentation of a new Elopement Risk Assessment being completed following R1's attempted incident of elopement. R1's current care plan, dated 1/20/25, had no documentation of the development of a comprehensive care plan being developed following R1's attempted elopement. R1's progress note, dated 1/8/2025 at 1:05 PM documents R1 refuses medication every day. R1's progress note, dated 1/12/2025 at 9:37 PM documents (R1) refused supper and medications this shift. R1's progress note, dated 1/13/2025 at 3:04 PM and completed by V2 (DON) documents (R1) was talking to (V3) and got upset and was screaming and yelling this occurrence (happened) several times today. (R1) then wanted to go out and smoke before lunch resident was told she needs to wait until smoke break at 12:45 and she continued to yell at this nurse and locked her wheelchair, stood up and (R1) tried to strike this nurse and just continued to come towards this nurse screaming and trying to hit the nurse, she did make physical contact. Staff were able to get the resident to sit back in her wheelchair and (R1) went to her room, (R1) then came back to the front entry way demanding to be taken out. (R1) was then educated she can go out for a cigarette after lunch then (R1) started yelling and demanding to be taken out. This nurse tried to educate (R1) and she went to her room at that time. R1's Behavior Monitoring and Interventions reports for December 1, 2024- January 28, 2024, document the following behavior occurrences after R1's attempt to elope on 12/27/24: 1/4/25 at 9:52 AM pacing, refusing care, agitation, cursing, screaming and threatening others; 1/7/25 at 10:01 AM pacing; 1/15/25 at 9:49 PM accusing others, cursing, screaming, threatening others, and expressing frustration/anger at others. R1's progress note, dated 1/16/25 at 6:20 PM and completed by V8 (Licensed Practical Nurse) on 1/20/25 at 7:18 AM, documents Late Entry: (R1) came to use the phone to talk to (V3). (R1) got upset about (V3) not coming to see her today. (V8) went to pass meds to another patient. (V8) came back to the nurse's station and (V14, R4's Family member) stated a patient followed her out the door. (V8) ran out the door and to the end of the street after the patient (and) did not see her. (V8) called the DON (V2) and told her (R1) got out the nursing home. I sent two CNAs (V10, V11) to walk around to go look for (R1). The CNAs did not see (R1). I called the (local) police to let them know (R1) got out. The CNAs came back with (R1). I called (V2) back to let her know we found (R1) by the baseball field with the police. R1's Police Report dated 1/16/2025, documents R1 was found in the road by a local grocery store. She was walking west bound with her jacket half hanging off and she seemed out of it. The report also documents V16 spoke with staff who stated they believe R1 snuck out of the building with a family member that came to visit. According to Google Maps, the distance from the facility to the location were R1 was found was 0.5 miles. On 1/28/25, observed at the end of the facility's driveway was a frontage road with a speed limit of 30 miles per hour. There is a metal chain link fence separating that road from a four-lane state highway with a speed limit of 45 miles per hour. The chain link fence had several breaks in the fence large enough for an adult to fit through. The location that R1 was found was near a local grocery store on a road with constant traffic with a speed limit of 30 miles per hour. The local weather historical data report from The Weather Channel, located at https://weather.com/weather and retrieved on 1/29/25, documents the weather for [NAME], Illinois on 1/16/25 was a high of 40 degrees daytime temperature and a low of 23 degrees nighttime temperature. This same report documents the time of sunset on 1/16/25 in [NAME], Illinois was 4:58 PM. On 1/28/2025, at 10:10 AM, V8 (LPN/Licensed Practical Nurse) stated, on 1/16/2025, at 4:45 P.M, V14 called the facility and said, R1 is outside the building. V8 stated she dropped the phone and ran outside the front door looking for R1. V8 stated later in the evening after calling V14 back that R1 followed V14 out the front door after V14 entered the passcode to leave. V8 stated once she realized R1 was not anywhere outside the facility within her visual range, she came back into the building and told V10 (CNA/Certified Nursing Assistant), V11, and V9 R1 was missing. V8 stated she instructed V10 and V11 to look by vehicle to search for R1 since V8 was the only nurse in the building. V8 stated she called V2 (DON/Director of Nursing) and told her R1 was missing. V2 instructed V8 to call 911. V8 stated around 5:30 P.M, V10 and V11 returned to the facility with R1, and assisted R1 back to her room. V8 stated R1 has been off her medications for a long time prior to this elopement and refuses daily to take medications and refuses cares daily. V8 stated R1 gets very easily agitated and verbally abusive with staff daily, especially when V3 (R1's Family Member) is unable to visit R1. On 1/28/2025, at 10:34 AM, V9 stated that on 1/16/2025, at 4:45 PM, he was coming down the women's hall when he heard V8 asking Where is R1? V9 stated he and V10 and V11 searched the hall and searched R1's room and could not locate R1. V9 stated at this point V10 and V11 got into V10's car and went to search for R1. V9 stated that this day was cold and cloudy and about 20-30 minutes later V10 and V11 returned with R1 in the V10's car. V9 stated R1 had pajama pants and pajama shirt on but does not recall R1 having a coat on. V9 stated R1 also wandered out another day on 12/27/2024, and he saw R1 in the parking lot upset and verbally abusing V5 (CNA). R1 was refusing to come in. On 1/28/2025, at 10:52 A.M, V10 stated, on 1/16/2025 around dinner time she was asked to look for R1. V10 stated V8 was in a panic and stated she cannot find R1. V10 stated V8 told her that V14 (R4's Family member) called stating she saw R1 walking down the street. V10 stated this day was super cold and freezing outside. V10 stated she took her car and V11 assisted her to look for R1. V10 stated she drove past a local grocery store and headed towards a local pharmacy when she saw R1. V10 stated once she drove up and got out of the car, R1 had her jacket half on with one arm in one side, and her other arm behind her back. V10 stated R1 was holding her pajama pants up with the hand behind her back because her pants were soaking wet with her urine. V10 stated R1 was very upset and being verbally abusive towards V16 (Police Officer) and did not want to return to the facility. V10 stated V16 told R1 that if she did not return to the facility, he would have to call 911 and have her transferred to the local hospital. V10 stated R1 was angry but agreed to get into V10's car and go back to the facility. V10 stated R1 got into her car and said a few profanity statements and allowed V11 to go and get a wheelchair in the facility and take her back to her room at the facility. On 1/28/2025, at 12:21 P.M, V11 stated, on 1/16/2025 at 4:45 PM, she was working on the men's side of the facility. V11 stated V8 came to her with concern in her voice stating R1 got out and was instructed to look for her. V11 stated she got into V10's car and drove across town looking for R1. V11 stated once they saw R1, R1 was in her pajama top and bottoms, R1's pajama bottoms were soaked in her own urine, had a blue coat on, and stated that it was cold outside. V11 stated R1 was combative and verbally abusive towards V16. R1's Psychiatry Note written by V15 (R1's Psychiatric Nurse Practitioner), dated 1/20/2025, documents, (R1) has a history of schizoaffective disorder, generalized anxiety disorder, and nicotine dependance. Previously received Haloperidol, Divalproex Sodium. Has refused per chart review. Visited on this day due to concerns from nursing reporting behavioral concerns directly related to wearing clothes for extended period soiled from incontinence and refusal in care possibly for days. Since not taking her antipsychotic has displayed increasingly impulsive and risky behavior. Recent behaviors include attacking another resident, becoming aggressive towards staff when attempting care, and running into traffic last month. Subsequently discharged from the ED (Emergency Department) with no new orders. Behavior has been noted to stay up many nights per chart. Unable to ascertain sleep hours. Mental status during day includes lying in bed most of the time, behaving aggressively, refusing care, or laying with eyes closed, responding verbally throughout the day. Suspected delirium due to dysregulated sleep-wake cycle, stopping antipsychotic and mood stabilization medications, and frequent dosing of Lorazepam administered per hospice. This same note documents, Observed (R1) on this visit lying awake in her bed, disheveled and disoriented. Asked if she knows where she is, why she is here, no response given, she just stares. Only will scream 'Get the F out.' Presents as medicated with limited insight, poor judgement, and limited cognition. R1's baseline ability to answer questions alert and oriented times three allows her to make decisions, but she is cognitively and legally incapable of keeping herself safe. With (R1) currently off antipsychotics with behaviors posing a physical risk to herself. R1's current care plan, dated 1/20/25, continues to have no documentation of a comprehensive care plan to address R1's behaviors that put R1 at risk for elopement, R1's elopement attempt on 12/27/24, nor R1's elopement on 1/16/25. As of 1/27/25, R1's medical record has no documentation of a revised Elopement Risk Assessment. On 1/28/2025 at 1:00 P.M, V2 (DON/Director of Nursing) stated the facility has not had any residents who have eloped. V2 confirmed there was no investigation regarding R1's elopement on 1/16/25 nor did R1 have a comprehensive care plan addressing R1's risk for elopement prior to or after R1's elopement on 1/16/25. V2 also stated she did not have an elopement risk assessment for R1 after R1's original assessment on 11/15/24. R1's progress note, dated 1/21/25 at 12:49 PM and completed by V2 documents Spoke to (V15) and she agreed with the medication changes and the decline in (R1) being ambulatory. We can discontinue the 15-minute checks. Hospice was here and agreed to this plan of care. R1's current medical record has no documentation of 15-minute wellness checks being completed at any time prior to R1's progress notes on 1/21/25. On 1/29/25 at 11:35 AM, V2 stated the facility does not have documentation to show R1 was provided 15-minute safety checks or one on one supervision upon returning to the facility on [DATE]. V2 stated We did not have to implement 15 min checks with (R1) so there's no documentation of that. On 1/29/2025, at 12:12 PM, V13 (R1's Physician) stated, on 1/16/2025 he does not recall being notified of R1's elopement. V13 stated that R1 is easily confused and depending on her state of mind that day, it is hard to say if R1 would be able to comprehend safety awareness when out in the community. V13 stated R1 would not have possibly been aware if it was too cold or if she was in any danger in the community due to her unstable mind set. V13 stated that he was aware that R1 is not taking her medications and it is hard to say how unstable R1 will get while being unmedicated. On 1/30/2025, at 9:45 AM, V15 (R1's Psychiatric Nurse Practitioner), stated R1 is confused and has an untreated diagnosis of psychosis and behavioral issues. V15 stated she became aware of R1's elopement on 1/16/2025 by the nursing staff when she came in for R1's first visit on 1/20/2025. V15 stated R1 is not able to make self-decisions and R1 is not in her right state of mind. V15 stated R1 refused to comply with her visit on 1/20/2025 and she feels that a psychiatric facility would be best, but due to R1's verbal and physical abuse towards staff and residents, it makes it very had to find a facility to accept her. The Facility's Code Pink-Missing Resident/Elopement Policy, dated/revised 04/2023, states, Policy Guidelines: The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of the admission. An Elopement Risk Assessment is completed on all residents a time of admission, quarterly and with any increase in exit seeking or wandering behaviors. A facility-approved risk evaluation tool (or scoring system) is utilized. The evaluation is based on various risk factors that may precipitate an elopement event. Any resident who exits facility unaccompanied is approached according to accepted guidelines as follows. Director of Nursing or designee to contact legal representative/responsibly party, attending physician, and inform them of the incident. If the resident is placed on increased supervision, safety checks are documented in the resident's record each shift for the duration of the increased supervision. Complete a new elopement risk assessment. When a resident is determined to be missing, if the resident has not been found after an immediate initial search, the Administrator or designee calls the local police and files a missing person's report. Administrator provides the officer with a picture and other pertinent information. The Administrator notifies the family and attending physician if the resident is not found and documents in the electronic health record. Incident Report to the state authorities as required. When a resident has been found, Director of Nursing or designee to contact legal representative/responsible party, attending physician, and inform them of the resident's status. The residents plan of care is updated, including, additional measures such as an electronic monitoring device if not in current use, 15-minute safety checks or 1:1 supervision. A Missing Resident form is completed, and all staff involved sign the form. Documentation, all elopement attempts and events are documented in the resident's record. Physician orders following notification, Incident Report, indicating when the resident returned and condition of resident, and complete a new Elopement Risk Assessment. The Facility Assessment, dated 11/2024, documents the facility has an average census of 30 residents with a maximum population of 36 residents. This same assessment documents the facility has 15 residents receiving Mental Health treatment and 15 residents with Behavioral Health needs. An Immediate Jeopardy situation was identified to have started on 12/27/2024 when R1 eloped from the facility. The facility failed to identify and investigate R1's incident as an elopement and failed to implement interventions to prevent future elopements. On 2/3/2025 at 2:44 PM, V1 (Regional Director of Operations) was notified of the Immediate Jeopardy situation. The facility submitted an abatement plan on 2/3/2025 and was advised by the regional office to make revisions before it would be accepted. The facility submitted the revised abatement plan on 2/4/2025. The final abatement plan was submitted and accepted on 2/4/2025. On 2/4/2025, the abatement plan was confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Facility ensured all residents are safe and not at risk and psychosocial needs are being met. The facility evaluated all residents' community survival assessments on 1/29/25 by V22 (Regional Social Services Director). 2. New Elopement Assessments were completed on all residents to ensure appropriate services are in place. These were completed on 1/29/25 by V23 (Regional Nurse Consultant). 3. Directives have been posted at timeclock and nurses' station with the procedure to follow when any signs of elopement occur. On 1/29/25 signs were posted at time clock and nurses' station for above by V1 (Regional Director of Operations). 4. All staff educated on elopement policy, mental disorders, change of condition reporting, door alarm policy, and community survival/pass on 1/29/25 by V23. 5. Residents that have severe MI (mental illness), history re-evaluated for appropriate interventions 1/29/25. 6. All residents assessed to ensure resident based intervention care plan services are in place. Initiated and completed on 1/29/25 related to severe MI (mental illness), and elopement by V22 (Regional Social Services Director). 7. All resident charts were audited for elopement, community survival, and community pass on 1/29/25 by the IDT (Interdisciplinary) team. 8. QAPI meeting held to ensure compliance on 1/29/2025. 9. On 1/29/25, it was initiated to review and discuss daily in morning meeting regarding residents identified by the facility as requiring services for mental illness. The facility will notify psychiatry and medical physician for guidance for 1:1, 15-minute checks or hospitalization . Notifications will be made immediately by nursing or social services. This is ongoing. 10. The facility door code was changed. All visitors and family will be assisted with exiting the facility. This was completed by maintenance on 2/4/2025. 11. Agency staff were educated on all policies via their agency portal before starting their shift. They are required to read and acknowledge. They will be in serviced again once in the building. Agency staff were educated on 1/29/2025 by V23.

Based on observation, interview, and record review, the facility failed to have sufficient staff available to provide nursing services to meet the residents' need in the facility. This has the potential to affect all 31 residents currently residing in the facility. Findings include: Facility Assessment Tool, reviewed 1/24/24, documents the following: Staffing plan- facility consults minimum staffing requirements to ensure facility meets the minimum requirements for staffing. Facility considers acuity, daily tasks, and resident needs to ensure staffing meets the needs of the residents. Nurse Aides total number needed (in a 24-hour period) eight. Staff Plan- Direct care staff ratio for days and evenings is three, and direct care staff ratio for nights is two. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Staff Daily Assignment postings, dated 8/23/24, 8/26/24, 8/31/24, 9/1/24, and 9/9/24, document for the night shift one CNA/Certified Nurse Aid and one nurse scheduled for the whole eight hours with an average census of 30 plus residents in the facility. No accommodations were made for coverage in the absence of a second CNA for night shift. On 9/17/24 at 1:19 PM, R20 stated We need two CNAs on night shift. I am a (mechanical) lift and require two people for cares. There have been times where there is only one CNA working at night and I have to wait a long time. At that time R20 was in a manual wheelchair sitting up straight in the wheelchair but appeared stiff and shoulders pulled back, had minimal movement of her arms, and a mechanical lift sling was in place under her body in the wheelchair. On 9/18/24 at 11:34 AM, V2 DON/Director of Nursing stated I take care of the staffing for the nursing home; nursing and CNA openings are posted in the nursing office for the staff to pick up the open shifts; nursing and CNA jobs are posted online (in a couple places) for hiring, we use three agencies for nurses and one agency for CNAs because corporate does not want us to use agency staff for CNAs; we are to use our own agency staffing service but there are never any staff available to work; ideally I would staff two CNAs on nights; we have residents who use (mechanical lifts) and require two people for personal cares; and I have had some days where there was only one CNA on night shift.

Based on interview and record review the facility failed to include the Infection Preventionist position or duties in the Facility Assessment. This failure has the potential to affect all 31 residents in the facility. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Facility assessment dated [DATE] indicates Services provided by the facility include Infection Prevention and Control: Identification and Containment of infections and prevention of infections. Facility Assessment does not include Infection Preventionist position or duties listed under Nursing Services or any other area of the assessment. Infection Preventionist Job Description/Job Summary dated 3/3/23 indicates: The Infection Preventionist is accountable for decreasing the incidence and transmission of infectious diseases between residents, staff, visitors, and community. Through strategic planning, leadership, and consultation, you will lead and direct a robust team in the identification and implementation of infection prevention goals and objectives throughout the facility. On 9/19/24 at 12:45pm V1, Administrator stated the Infection Preventionist is a key nursing position and should be included in the Facility Assessment.

Based on interview and record review, the facility failed to develop, implement, and maintain documentation; and demonstrate evidence of its ongoing QAPI/Quality Assurance Performance Improvement program. This has the potential to affect all 31 residents currently residing in the facility. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. QAPI Plan for (facility), updated 4/1/24, documents The purpose of our Quality Assurance and Performance Improvement Program is to achieve and sustain a culture of excellence by using a fact based, team driven and decision-making model with a proactive approach to continual improvement of the way we care for those we serve. Key monitors are measured and trended on a quarterly basis. The team and committee have the responsibility for planning, designing, implementing and coordinating consumer care and service. The facility was unable to present a QAPI plan to the State Survey Agency no later than one year old. The facility was unable to provide any current documentation and evidence of its ongoing QAPI program. On 9/18/24 at 11:58 AM, V1 Administrator verified the last QAPI program implemented was in February 2023, and (V1) was not currently working on any QAPI plan. I have been here only a week; I have a lot of work to do.

Based on interview and record review the facility failed to implement an ongoing infection prevention and control program (IPCP), failed to include an ongoing system of surveillance, and failed to implement a program to manage and minimize the risk of waterborne pathogens. This failure has the potential to affect all 31 residents. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Facility Policy/Infection Control: Surveillance and Monitoring dated 5/2007 documents: It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with work practices and care of protective clothing and equipment is maintained. No surveillance monitoring or tracking was found or presented for staff or resident illness. No antibiotic tracking, infection tracking/surveillance was found or presented for April, May, June, or July 2024. On 9/17/24 at 8:30am V1, Administrator stated We have no designated IP (Infection Preventionist) staff at the facility right now. The previous IP quit before I started. Our DON (Director of Nursing) does not have an IP certificate or training. The Regional IP nurse does not oversee this building, so we have no one at this time. The facility has not had a Certified Infection Preventionist since 9/27/23. On 9/19/24 at 10:23am V2, DON (Director of Nurses) stated she has worked at the facility for 2 years however has only been DON since August 1, 2024. V2 stated there have been no formal Infection Control In-services and no monitoring of infection control practices since they had an Infection Preventionist. V2 stated the last Infection Preventionist left in September 2023, and they never replaced her. V2 stated that during the COVID outbreak a few months ago, we had no formal in-services to review Infection Control practices or Transmission Based Precautions. V2 stated V11, (previous) Administrator took care of all the COVID monitoring But she wasn't even a nurse. V2 stated there has been no one doing monitoring of infection control processes like hand hygiene, catheter care, appropriate use of PPE (Personal Protective Equipment, etc. since the Infection Preventionist left. Facility Water Management Plan dated 11/4/19 documents: Maintenance Schedule: Daily - Ensure water cannot stagnate anywhere in the system; keep water tanks and cisterns covered, clean, and free of debris. Weekly - Random cold and hot water temps/record; flushing of non-used toilets, taps and shower heads. Quarterly - Clean and disinfect shower heads (disassemble); clean and disinfect faucet aerators. Annually - Risk assessment, cleaning water heaters and mixing valves; water system inspection, maintained and cleaned; servicing of boilers thermostatic mixing valves. Legionella Management Procedure dated 8/10/18 documents: Legionella Management Team is charged with the responsibility and duty to effectively control the risk from Legionella bacteria in its water systems. The Legionella Management Team comprises: Corporate Maintenance Director, Administrator and Maintenance Personnel. Corporate Maintenance Director and Administrator: Implementation and continuing review of this procedure. Ensure via appointed staff responsibility for the day-to-day delivery of the process and continuing audit. Maintenance Director: Carry out weekly/monthly checks as required. Update logbook with information gathered in weekly monthly checks. To attend training events as and when offered. A Legionella Risk Assessment shall be undertaken of all water storage tanks, calorifiers and associated pipework which are susceptible to colonization by Legionella. On completion of the risk assessment a monitoring regimen will be formatted and inserted in the site logbook. Sites shall have personnel who have been trained, instructed and who are competent to carry out weekly, monthly, quarterly monitoring regimes in-house. Suitable training and equipment will be provided to ensure the works are carried out correctly and safely. Training: Responsibility for Legionella training rests with the Corporate Maintenance Director and the Administrator. On 9/18/24 at 9:43am V4, Maintenance stated, I don't know anything about that book (Water Management Plan) or a water management program. I don't know what waterborne pathogens are. I've only been here since January (2024). I haven't had any training on any of that. I was told Housekeeping does the water temperatures and turns them into the Administrator.

Based on interview and record review the facility failed to develop and implement an ongoing facility-wide system to monitor the use of antibiotics and failed to include leadership support and accountability via the participation of an individual with designated responsibility for the infection control program (i.e., Infection Preventionist). These failures have the potential to affect all 31 residents in the facility. Findings include: Facility Policy/Assessment of Infections and Antimicrobial Usage dated 1/1/19 documents: Assessing antimicrobial use is essential for determining antimicrobial use trends. Antimicrobial use should be reviewed regularly to measure progress of antimicrobial stewardship activities. Additionally, the results are useful to identify gaps in communication, inconsistencies in documentation, and compliance with facility policies and evidence-based recommendations for antimicrobial prescribing. Align antimicrobial prescribing data and clinical documentation with published recommendations and facility policies. For each prescribed antimicrobial, determine whether the criteria were met as described by: Antimicrobial prescribing guidelines for long-term care residents. Infection surveillance definitions for long-term care facilities. Facility policies/protocols. Facility Policy/Antibiotic Stewardship Program dated 12/12/18 documents: Purpose: To improve the use of Antibiotics in healthcare, to protect residents and to reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements for Antibiotic Stewardship: Leadership Commitment - Demonstrates support and commitment for safe and appropriate antibiotic use. Accountability - Identify physicians, nurses and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities. Drug Expertise - Establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship. Action - Implement at least one policy or practice to improve antibiotic use. Tracking - Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use. Reporting - Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff. Education - Provide resources to clinicians, nursing staff, resident and families about antibiotic resistance and opportunities for improving antibiotics. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. On 9/17/24 at 8:30am V1, Administrator stated We have no designated IP (Infection Preventionist) staff at the facility right now. The previous IP quit before I started. Our DON (Director of Nursing) does not have an IP certificate or training. The Regional IP nurse does not oversee this building, so we have no one at this time. The facility has not had a Certified Infection Preventionist since 9/27/23. Pharmacy (Antibiotic) Therapeutic Class report dated 4/1/24 to 4/30/24 indicates R1, R3, R4, R5, R9, R13, R17 and R20 all received antibiotics in the month of April 2024. Pharmacy (Antibiotic) Therapeutic Class report dated 5/1/24 to 5/31/24 indicates R2, R5, R9, R13, R18 and R20 all received antibiotics in the month of May 2024. Pharmacy (Antibiotic) Therapeutic Class report dated 6/1/24 to 6/30/24 indicates R3, R6, R9, R20 and R27 all received antibiotics in the month of June 2024. Pharmacy (Antibiotic) Therapeutic Class report dated 7/1/24 to 7/31/24 indicates R3, R4, R6, R9, and R30 all received antibiotics in the month of July 2024. No antibiotic tracking, infection tracking/surveillance was found or presented for April, May, June, or July 2024.

Based on observation, interview, and record review, the facility failed to employ a Certified Infection Preventionist. This failure has the potential to affect all 31 residents in the facility. Findings include: Infection Preventionist Job Description dated 3/3/23 documents: Qualifications: Must have completed Specialty Training in Infection Prevention and Control through accredited continuing education such as: CDC (Centers for Disease Control) or APIC (Association for Infection Prevention and Control) Infection Preventionist. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. On 9/17/24 at 8:30am V1, Administrator stated We have no designated IP (Infection Preventionist) staff at the facility right now. The previous IP quit before I started. Our DON (Director of Nursing) does not have an IP certificate or training. The Regional IP nurse does not oversee this building, so we have no one at this time. On 9/18/24 at 3:24pm V1, Administrator stated the previous IP's last day employed at the facility was 9/27/23. V1 stated the previous DON took over IP at that time until April 2024, but was unsure if was IP Certified. The current DON hire date is 8/1/24 but is not IP Certified. On 9/19/24 at 11:30am V2, DON provided three Infection Control training modules, all dated 1/20/22 for V7, Previous facility DON. No certification of a completed IP program was found or presented for V7 who took over the IP program from 9/27/23 to 4/2024. The facility has not had a Certified Infection Preventionist since 9/27/23.

Based on observation, interview, and record review the facility failed to ensure documentation in the resident's medical record of the administration or refusal of the Influenza and/or Pneumococcal vaccinations for three residents (R17, R26, R29) of five residents reviewed for Influenza and Pneumonia vaccinations in the sample of 21. The facility also failed to provide surveillance monitoring and tracking of immunizations for residents. This failure has the potential to affect all 31 residents. Findings include: Facility Policy/Immunization of Residents dated 1/23/20 documents: Review the residents Immunization Record, Physician order Sheet and Consent Form to verify timing of previous vaccinations, allergies, and contraindications. Document immunization on the resident's Medication Administration Record (MAR) and on the resident's Immunization Record. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. R17's Influenza and Pneumonia Consent (undated) indicates R17 last received the Influenza vaccine 9/23/22. No documentation was found or presented to indicate if R17 was offered or refused the Influenza Vaccine in 2023. R26's Pneumonia and Influenza Vaccine Consents were signed on 11/20/23. Influenza Consent indicates R26 Already had this year. Consent does not indicate date received. MAR, Physician Orders, and Immunization Record do not indicate if R26 received the Pneumonia vaccine or if it was refused. R29's Immunization Record, MAR and Physician Orders does not include any vaccinations offered or administered. On 9/18/24 at 2:00pm V1, Administrator stated I took over as Administrator about one week ago. We have no Infection Preventionist, and I don't currently know who is monitoring and documenting the vaccination program. V1 also stated she has looked through multiple binders and could not find any resident or staff tracking or monitoring of vaccinations of any kind. V1 stated Someone should have been keeping a line list of resident vaccinations. On 9/19/24 at 1:45pm V2, DON (Director of Nursing) stated I've been DON since August 1st (2024). I don't know who was or is doing the vaccination program. The last Infection Preventionist was monitoring the vaccinations, but she left in September of last year (2023). No 'Line List tracking/monitoring of any immunizations was found or presented. No staff were identified as overseeing, monitoring, or tracking the vaccination program. Resident MARs did not contain vaccination information for any of the facility residents.

Based on interview and record review the facility failed to provide a surveillance system to identify possible communicable disease or infections, how and when to use Transmission Based Precautions and proper infection and prevention and control practices when performing resident care activities. This failure has the potential to affect all 31 residents. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Facility Policy/Infection Control Surveillance and Monitoring dated 5/2007 documents: Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator and DON (Director of Nursing). This includes but is not limited to: Surveillance of the facility to ensure required work practices are observed and that protective clothing and equipment are provided and properly used. Improvement in training, work practices, or protective equipment to prevent reoccurrence. Infection Preventionist Job Description dated 3/3/23 documents: Job Summary: The Infection Preventionist is accountable for decreasing the incidence and transmission of infectious diseases between residents, staff, visitors, and community. Through strategic planning, leadership, and consultation, you will lead and direct a robust team in the identification and implementation of infection prevention goals and objectives throughout the facility. The Infection Preventionist reports to the Director of Nursing, QAA (Quality Assessment and Assurance) Committee and partners with the Medical Director to develop a system of care that promotes sound and scientific infection prevention practices and principles. Attends and participates in continuing educational infection control programs. Responsibilities: Authority and responsibility for ensuring appropriate intervention and education occurs with staff, volunteers, and medical staff when healthcare infection trends, outbreaks or non-compliance to infection control are identified. Ensures that education and counseling on infection prevention is available for staff, volunteers, medical staff, and residents. Facility Policy/Antibiotic Stewardship Program dated 12/12/18 documents: Purpose: To improve the use of Antibiotics in healthcare, to protect residents and to reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements for Antibiotic Stewardship: Education - Provide resources to clinicians, nursing staff, resident and families about antibiotic resistance and opportunities for improving antibiotics. Resident Infection Control/Antibiotic Use Log indicates tracking of infections and antibiotics was documented January, February, March, August, and September 2024. No antibiotic tracking, infection tracking/surveillance was found or presented for April, May, June, or July 2024. Inservice Attendance sheets for more than 6 months reviewed and found only one formal Infection Control related in-service: Hand Hygiene on 3/25/24. On 9/19/24 at 10:23am V2, DON (Director of Nurses) stated she has worked at the facility for 2 years however has only been DON since August 1, 2024. V2 stated there have been no formal Infection Control In-services and no monitoring of infection control practices since we had an Infection Preventionist. V2 stated the last Infection Preventionist left in September 2023, and they never replaced her. V2 stated that during the COVID outbreak a few months ago, we had no formal in-services to review Infection Control practices or Transmission Based Precautions.

Based on interview and record review, the facility failed to develop and implement plans of action to make improvements to residents' quality of care and quality of life in its QAPI/Quality Assurance Performance Improvement program. This has the potential to affect all 31 residents currently residing in the facility. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. QAPI Plan for (facility), updated 4/1/24, documents The purpose of our Quality Assurance and Performance Improvement Program is to achieve and sustain a culture of excellence by using a fact based, team driven and decision-making model with a proactive approach to continual improvement of the way we care for those we serve. The QAPI Committee analyzes performance to identify and follow up on areas of opportunity. Identifies opportunities for improvement and uses criteria to prioritize opportunities. The team and committee have the responsibility for planning, designing, implementing, and coordinating consumer care and service. Facility will establish performance indicators for all designated goals. The facility was unable to provide a QAPI plan or PIP/Performance Improvement Project to the State Survey Agency conducted in the last year. On 9/18/24 at 11:58 AM, V1 Administrator verified the last QAPI/PIP program implemented was in February 2023, and (V1) was not currently working on any QAPI or PIP/Performance Improvement Projects. I have been here only a week, I haven't had time to develop a plan but know we need to work on some things, and I have a lot of work to do.

Based on record review and interview, the facility failed to obtain a new level one PASRR (Pre-Admission Screening and Resident Review) for 2 of 3 residents (R13 and R25) reviewed for pre-admission screenings in the sample of 21. Findings Include: The facility policy named, Resident Assessment- Coordination with PASRR Program, no date, documents, If a resident who stays in the facility longer than 30days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have a mental illness or intellectual disability to the appropriate state designated authority. The Social Service Director shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. 1. R25's Interagency Certification of Screening Results, dated 10/29/2020, documents the following: Date of admission to facility: 10/28/2020. Screening has indicated a nursing facility is appropriate. R25's Interagency Certification of Screening also documents that R25's screening is valid for only 90 days from the day of screening. R25's Medical Record lacks the documentation to show that a new Level I Screening was done. 2. R13's Interagency Certification of Screening Results, dated 9/14/2019, documents the following: Date of Admission to the facility: 9/9/2019. Screening has indicated supportive living services are appropriate. R13's Interagency Certification of Screening also documents that R13's screening is valid for only 90 days from the day of screening. R13's Medical Record lacks the documentation to show that a new Level 1 Screening was done. On 9/19/2024 at 9:30 AM, V10/SSD (Social Service Director) stated, I do not know who is responsible for taking care of the PASRR screening process. I am not sure what you are talking about. I will try and find out for you.

Based on record review and interview, the facility failed to provide a copy of the bed hold policy for the resident discharging to the hospital for one of one resident (R6) reviewed for bed hold in a sample of 21. Findings Include: The facility policy named, Bed Hold Guarantee Policy, dated 8/1/2017, documents the following. The resident, resident family or legal representative will be given the appropriate Notice of Bed Hold Policy at the time of discharge or therapeutic leave, if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. R6's Short Transfer Form from a local hospital, dated 9/6/2024, documents R6 was seen in the emergency room for a diagnosis of End of Life care. R6's medical record, dated 9/6/2024, lacks the documentation to support that R6 or V6/R6's representative was given a written notice of the bed hold policy prior to discharge. On 9/19/2024 at 10:00 AM, V2/DON (Director of Nurses) stated, No (R6 or V6/R6's representative) did not get a copy of the bed hold policy prior to leaving the facility.

Based on interview and record review, the facility failed to maintain and process pharmacist drug regimen review recommendations for one (R24) of 12 residents reviewed for drug regimen review in a sample of 21. Findings include: R24's Medication Regimen Review/MRR for July and September 2024 documents See report for any noted irregularities and/or recommendations. R24's medical record had no documentation, and the facility was unable to provide MRRs for July and September 2024 prior to the survey exit. On 9/19/24 at 12:48 PM, V2 DON/Director of Nursing stated I cannot find (R24's) MRR for July and September 2024. We keep them in the residents' medical record, but I don't know where (R24's) are.

Based on observation, interview, and record review, the facility failed to notify the physician and initiate treatment for a skin fold wound for one resident (R20) of one resident reviewed for skin impairments in the sample of 21. Findings include: Facility Policy/Skin Condition Monitoring dated 1/18 documents: It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurses notes and complete QA (Quality Assurance) form for Newly Acquired Skin Condition. The Nurse will then implement the following procedure: Notify the physician and obtain treatment order. The treatment order will include: Type of Treatment Location of area to be treated Frequency of how often treatment is to be performed How area is to be cleaned Stop date - if needed Any skin abnormality will have a specific treatment order until area is resolved. PRN (as needed) orders should not be obtained for a skin abnormality. Once the skin abnormality is healed, the treatment may then be changed to PRN with a physician's order. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: Characteristics: Size, Shape, Depth, Odor, Color, Presence of granulation tissue. On 9/16/24 at 1:45pm, R20 was sitting in her wheelchair in her room and was noted to have a large fat pad protruding under her chin causing a deep skin fold between her chin and neck. Extending out from the skin fold was an inflamed reddened area. R20 stated one of the CNAs (Certified Nurse Assistants) noticed the red area during lunch in the dining room. R20 stated the area feels moist but is not painful. R20 stated she was going to tell the nurse but never told her. Current Physician's Orders indicates R20 has orders (date initiated 5/6/24) for Nystatin (anti-fungal) powder to abdominal/breast folds - but not for neck area. Progress Note dated 9/16/24 at 6:20pm indicates R20 has an angry reddened area under chin/neck and under both breasts. Nystatin powder applied. On 9/17/24 at 2:35pm V3, LPN (Licensed Practical Nurse) stated she was told about R20's red neck area in morning report. V3 stated that R20 received a shower today and they cleaned R20's neck really good. V3 stated that V5, PM shift nurse (on 9/16/24) Put some cream or something on it but I didn't see it on the treatment sheet. The treatment sheet only says for abdomen and under breasts. (R20's) Physician was here today, I don't know if he wrote some orders for her neck. So far haven't seen anything for her neck. I didn't feel comfortable putting a treatment on an area that did not have orders. R20's Current Care Plan has no focus area/problem to address R20's neck, abdomen, or breast fungal skin issues.

Based on record review and interview, the facility failed to provide a resident and resident's representative with a written notice of transfer (R6) and the facility failed to notify the facility Ombudsman monthly of resident transfers to the hospital. This failure has the potential to affect all 31 residents residing in the facility. Findings include: 1. R6's Nurses Notes, dated 9/6/2024, documents the following: At 3:45 PM, R6 is violently tremoring. Hospice is requesting a hold of medications for comfort as Hospice believes R6 is over medicated. V6/R6's POA/Power of Attorney notified and requests that R6 be sent out to the emergency room to be evaluated. Request granted. R6 was sent to the emergency room to be evaluated. R6's chart lacks the documentation to show that R6 and V6/R6's POA was notified in writing of the transfer/discharge to the emergency room . On 9/19/2024 at 10:00 AM, V2/DON (Director of Nurses) stated, I cannot find anywhere that a written notice of transfer was given to (R6 or V6/R6's POA (Power of Attorney). I know that V6 requested a transfer, but I cannot be sure V6 was notified in writing that R6 was transferred. 2. On 9/19/2024 at 12:30 PM, V1/Administrator stated, The last notice given to the Ombudsman for resident transfers was in 2021. It has not been updated for a long time. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility.

Based on interview and record review, the facility failed to notify the physician of a diabetic resident receiving a nutritionally- inadequate clear liquid diet tray for most meals or not eating at all during the span of five days, while continuing to receive the ordered oral and injectable diabetic medications. This failure resulted in R1 being hospitalized for Hypoglycemia and Altered Mental status. FINDINGS INCLUDE: R1's facility Profile Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. R1's Medication Administration Sheet, dated June 2024 includes the following medications: Jardiance (Sodium- Glucose Co- Transporter 2 Inhibitor) 25 MG (Milligrams) one tablet daily at Noon; Tresiba (Long- Acting Human Insulin) 48 Units subcutaneous daily at Noon; Metformin (Antihyperglycemic) 500 MG one tablet twice daily; Novolin R Insulin 4 Units at 7:30 A.M. and 7 Units with Lunch and Dinner. This same form documents from the period of June 10 through June 15, 2024, staff continued to administer all scheduled doses of Jardiance, Tresiba, Metformin, and the Noon dose of Novolin R Insulin and the 5:00 P.M. dose of Novolin R Insulin on June 13, 14, 15, 2024 even though R1 either refused most meals or only drank liquids. R1's current Care Plan, dated 7/18/23 documents, (R1) has a long history of obesity. (R1) consumes more than 75% of meals. (R1) is able to feed himself after with tray set up by staff. (R1) is alert and able to make his needs known. Provide diet as ordered. A review of R1's medical record, including physician orders documents that R1's physician was notified on 6/12/24 of R1's sore throat and productive cough. No documentation that R1's physician was notified of R1's refusal to eat or facility staff only providing liquids, when R1 refused to get out of bed, for the five days preceding R1's hospitalization for hypoglycemia, is available. R1's Ambulance Sheet, dated 6/16/24 at 6:36 A.M. documents, Dispatched for complaints of a sick person at (facility). Upon arrival, (R1) was in bed. (R1) was very confused. Once (R1) was in the back of the ambulance, we evaluated (R1's) blood sugar. (R1) was hypoglycemic at 42 (normal range 70-100). R1's Hospital Discharge Summary, dated 6/21/24 documents, (R1) admitted to hospital from (facility) with Altered Mental Status and Hypoglycemia from 6/16/24 through 6/21/24. History of Present Illness: (R1) presents with altered mental status. (R1) is coming from (facility). (R1) is able to remember this morning, including nursing staff coming into his room but notes he was unable to understand what they were saying. (R1) has had a cold for the past 2 weeks and has been given Robitussin. (R1) states he did not eat breakfast or dinner yesterday. (R1) last had his long-acting insulin at 0800 yesterday and short acting insulin at 1700 yesterday. Differential Diagnosis: General Hypoglycemia. Rationale: Last dose of insulin yesterday evening. Last dose of oral Jardiance yesterday morning. Missed breakfast and dinner last night but still given his dm (diabetes mellitus) type 2 medications. With a half an amp (ampule) of dextrose given in the emergency room , sugars improved to 70's and confusion improved. (R1) denies any starvation or new diet but missed meals while given his medications, dangerous practice. Notes: (R1) is agreeable to admission if accepted, at least observation status to the medical service since (R1) hypoglycemic from recently not given his full meals at (facility), but still given his diabetic insulin including oral Jardiance, regular insulin and ultralong acting insulin. On 7/5/24 at 2:09 P.M., V5/Registered Nurse stated, Residents are not supposed to eat in their rooms, but (R2) is allowed to. I'm not sure why (R2) can. (R1) had been sick for about a week with a head cold. (R1) wasn't eating much. (R1) requested to eat in bed. (R1) can have a sick tray, if (R1) is in bed. A sick tray is only fluids. No, I didn't call his doctor (V11/Medical Doctor) about (R1) not eating. At that time, V5/RN verified she worked the evening (2 PM-10 PM) of June 13, 14 15 (2024). R5/RN also confirmed she administered R1's scheduled dose of Novolin R Insulin on the evening (5 PM) of 6/15/24, even though R1 did not eat breakfast or supper that day. On 7/6/24 at 6:29 P.M., (V11/R1's Medical Doctor) stated, I wasn't notified of (R1) missing meals or only receiving a liquid diet for the days preceding his hospitalization (for hypoglycemia). If I had been notified, I would have changed (R1's) plan of treatment. (R1) could have avoided a hospitalization .

Based on observation, interview and record review, the facility failed to allow a resident the right to exercise the choice to eat meals in bed, for two of three residents (R1, R2), reviewed for resident rights, in a sample of three. FINDINGS INCLUDE: R1's facility Profile Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. R1's current Minimum Data Set Assessment, dated 4/20/24 documents, Section C0500: BIMS (Brief Interview for Mental Status) as 15:15 (Cognitively Intact). This same form documents, Section GG0130: Eating-Set up or clean up assistance: Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. R1's current Care Plan, dated 7/18/23 documents, (R1) has a long history of obesity. (R1) consumes more than 75% of meals. (R1) is able to feed himself after with tray set up by staff. (R1) is alert and able to make his needs known. Provide diet as ordered. Staff to encourage (R1) to get up for all meals in dining room. If (R1) refuses to and wants to stay and eat in bed, (R1) needs 1:1 supervision until meal completion. If (R1) sits in recliner in room to eat, (R1) needs limited supervision until meal completion. On 7/5/24 at 8:11 A.M., R1 stated, I don't usually get up for breakfast, the meal isn't usually worth getting up for. I get up for lunch and I would like to get up for supper, but (V5/Registered Nurse) (RN) has a rule that if I get up for supper, I am the last one to get laid down for the night. Usually that is 9:00 PM and that is way too late. If I don't get up for supper, the only thing (V5/RN) will allow me to have is a 'sick tray'. It only comes with broth and tea. (V5/RN) won't let me have my regular meal. (V5/RN) told me that if I don't get up for supper, all I get is liquids. (V5/RN) said I am a choking hazard and won't let me eat in bed. The doctor at the hospital told me I wasn't a choking hazard. Yet, several other people are allowed to eat in bed. Just not me. R2's facility Profile Face Sheet documents that R2 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Anxiety Disorder, Gastric Esophageal Reflux Disease, Hemiplegia, Depression, Diabetes Mellitus, type 2, Muscle Weakness and Need for Assistance with Personal Care. R2's current Minimum Data Set Assessment, dated 4/16/24 documents, Section C0500: BIMS (Brief Interview for Mental Status) as 15:15 (Cognitively Intact). This same form documents, Section GG0130: Eating-Set up or clean up assistance: Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. R2's current Care Plan, dated 10/12/21 documents, (R2) has a known history of displaying inappropriate behavior. Isolating myself in my room. (R2) elects to remain in bed for all ADLS (Activities of Daily Living), including eating and toileting. (R2) also elects not to follow my recommended diet. If in room, door wide open while eating. On 7/5/24 at 10:47 A.M., R2 stated, I have been here about five years. I don't get up or go to the dining room for meals. They bring me my meals, three times a day, to my room. I eat all of my meals in bed. I get a regular diet. I don't get a sick tray when I am in bed. No one gives me any problems about getting up or getting my meals in bed. On 7/5/24 at 12:23 P.M., V8/Certified Nursing Assistant (CNA) walked a room tray to R2's room. V8/CNA placed the tray on a bedside table and R2 began eating. The tray contained a regular diet of tator tot casserole, green beans, bread and butter and cantaloupe. Also included were a glass of red liquid, a glass of water and a glass of milk. Upon exiting R2's room, V8/CNA stated, I have worked here for the past [AGE] years. (R2) has been here for 4 or 5 years. (R2) has never eaten in the Main Dining Room. (R2) always eats in his room. I'm not sure why (R1) can't have his regular tray when he is in bed. That's what I have always been told. On 7/5/24 at 3:06 P.M., V1/Administrator in Training stated, I have gone through (R1's) chart, I can't find any documentation that (R1) is a choking hazard. I don't see any documentation that (R1) has had a Speech evaluation or a Physician's evaluation to say that (R1) is a choking hazard. I don't know what the difference between choking from a liquid diet or choking from a regular (textured) diet is. I guess not allowing (R1) to eat in bed but allowing (R2) to eat in bed could be considered a violation of (R1's) rights. I never thought of it. On 7/5/24 at 3:14 P.M., V9/Certified Nursing Assistant stated, Residents are not allowed to eat in their rooms. If they choose to not come to the dining room, then all they get is a liquid diet. Except, for (R2). (R2) gets his regular diet. It's just the rule around here. The facility Resident Rights for People in Long- Term Care Facilities, provided to each facility resident upon admission, documents, You have the right to .Your facility must make reasonable arrangements to meet your needs and choices. Your facility may not threaten or punish you in any way for asserting your rights or presenting grievances. The facility policy, Room Trays, dated (10/08) directs staff, It is the policy of (the facility) that residents who chose not to or are unable to attend the dining room for meals will be served appropriate meals in his/her room. Residents are notified of when meals will be served in the dining room. Residents are encouraged to attend the dining room for meals. If a resident chooses not to go to the dining room or is unable to go to the dining room, the resident will be offered the same menu choices as the dining room.

Based on interview and record review, the facility failed to provide a resident with a nourishing, well balanced diet for one of three residents (R1), reviewed for nutrition, in a sample of three. FINDINGS INCLUDE: R1's current Physician Order Sheet, dated June 2024 documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. This same document includes the following diet order: CCD (Carbohydrate Controlled Diet), Regular. On 7/5/24 at 8:35 a.m., V1/Administrator stated, (R1) has been getting a sick tray for some time now. (R1) refuses to get up for supper. I myself have taken (R1) his sick tray, many times. On 7/5/24 at 2:09 P.M., V5/Registered Nurse stated, (R1) had been sick for about a week with a head cold. (R1) wasn't eating much. (R1) requested to eat in bed. (R1) wanted his regular tray, but (R1) can only have it, if (R1) is out of bed. (R1) can have a sick tray, if he is in bed. On 7/5/24 at 2:17 P.M., V6/Former CNA (Certified Nursing Assistant) stated, (R1) had been sick (before his hospitalization ). (R1) didn't want to get up. All (R1) could have was liquids. That went on for about a week. The facility policy, Clear Liquid Diet, dated (revised) 10/20 documents, It is the policy of (facility) that a clear liquid diet is available for residents with an acute inflammatory condition of the gastrointestinal tract, residents in acute stages of illnesses and prior to certain diagnostic tests or pre-operative procedures. The clear liquid diet is inadequate in all nutrients. A clear liquid diet may be used as a nursing measure and without a physician's order for less than 48 hours when a resident has an acute illness such as nausea, vomiting, diarrhea or flu-like symptoms. Once initiated, a clear liquid diet is not to be continued for more than 48 hours without an order form the physician. Appropriate clear liquid diet items may include Apple, cranberry or grape juice; clear broth/bouillon; gelatin; popsicles; coffee, tea or carbonated beverages.

Based on observation, interview and record review, the facility failed to assess and implement resident specific fall prevention interventions and evaluate current interventions following falls for one (R1) of three residents reviewed for falls. This failure resulted in R1 experiencing multiple falls with one fall resulting in a laceration to R1's head requiring evaluation at the local hospital for sutures. Findings include: Facility Fall Prevention Policy, revised 11/10/2018, documents: To provide safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility; All staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident; appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours; Assignment of the fall risk category will be determined by the Interdisciplinary Team at their conferences based on fall risk score, history of falls and medical condition which directly impacts equilibrium and/or ambulation. Facility Fall Analysis Log, dated 12/1/21 through 6/7/22, documents: R1's falls on 12/14/21 at 5:00 am, intervention of Hospice notified and resident education (wrapped self in oxygen tubing in room); 1/28/22 at 4:45 pm, intervention of 15 minute checks (fall in dining room); 2/8/22 at 12:00 pm, no intervention documented (sat on buttock in room and was wrapped with oxygen tubing); 3/2/22 at 8:40 pm, intervention of 15 minute checks (fall in room with skin tear); 3/25/22 at 3:30 pm, intervention of 15 minute checks (fall in front of resident bathroom); 3/25/22 at 9:00 pm, intervention of neurological and 15 minute checks (fall in bathroom with laceration requiring hospitalization ); 4/7/22 at 7:15 pm, intervention of requested a low bed from hospice (fall in resident room); 5/25/22 at 1:50 am, intervention of education on using call light and asking for assistance (fall in room); 5/25/22 at 1:30 pm, intervention of frequent verbal cues (fall in room with laceration); 5/25/22 at 7:00 pm, intervention of removal of mat on side of bed (fall in room with laceration requiring hospitalization ). Facility Final Report to the Local State Agency, undated, documents R1's fall of 5/25/22 at 7:50 pm., wherein R1 Ambulated self from bathroom to bed, turned her call light on and reported to staff that she was bleeding. The Report documents that R1 Feels she stumbled over the mat. R1 received first aid, Emergency 911 was notified and R1 was transported to the local Emergency Department for evaluation and treatment. R1 received 12 sutures on R1's left forehead and returned to the facility at 11:42 pm. R1 was educated on the Risks and benefits of pulling the call light and waiting for assistance, a fall mat was removed from R1's bedside and R1 remained on 15-minute checks. R1's Physician Order Sheet (POS), dated 6/1/22 through 6/30/22, documents that R1 was admitted to the facility on [DATE], with diagnoses including Hospice Services, [CONDITION(S)], Borderline Personality Disorder, Abnormal Gait Mobility, Artificial Right Knee, Anxiety Disorder, [CONDITION(S)] Disorder, Sedative Hypnotic, [CONDITION(S)] Disorder with Delusions and Psychotic Mood Disorder. R1's POS also documents that R1 has Physician Orders for a pain patch ([MEDICATION(S)]), antidepressant ([MEDICATION(S)] and Trazadone), antianxiety ([MEDICATION(S)]), oral pain medication ([MEDICATION(S)]) and an antipsychotic ([MEDICATION(S)]). R1's Minimum Data Set/MDS assessment, dated 4/2/22, documents that R1 has a Brief Interview for Mental Status/BIMS score of 10/15 (moderate cognitive deficit). The MDS assessment also documents that R1 requires staff assistance with Activities of Daily Living (transfer, locomotion, dressing, eating, toileting, hygiene and bathing). R1's AIM for Wellness, dated 3/2/22 at 11:00 pm, documents that R1 had an unwitnessed fall that resulted in a 0.5 centimeter/cm by 3.0 cm skin tear. The intervention related to this fall was for R1 to be placed on 15-minute checks. R1's AIM for Wellness, dated 3/25/22 at 9:00 pm, documents that R1 had a fall at 3:00 pm, and R1 was placed on 15-minute checks. The AIM for Wellness also documents another fall at 9:00 pm on 3/25/22, and R1 sustained a hematoma above the right eye. The 3:00 pm fall does not document an intervention and the 9:00 pm fall documents an intervention of staff teaching R1 to ask for help and for the call light to be placed in reach at that time. R1's AIM for Wellness, dated 4/7/22 at 7:55 pm, documents that R1 sustained a fall with no injuries. No additional fall interventions were documented. R1's AIM for Wellness, dated 5/23/22 at 1:50 am, documents that R1 sustained a fall, with no injuries, on the floor mat next to R1's bed and R1 stated that R1 slipped off of the bed. No additional fall interventions were documented. R1's AIM for Wellness, dated 5/25/22, with no documented time, documents that R1 had an unwitnessed fall and sustained a 4.0 cm posterior head/scalp laceration that was cleansed, pressure applied and left open to air. No additional fall interventions were documented. R1's AIM for Wellness, dated 5/25/22 at 8:30 pm, documents that R1 sustained an unwitnessed fall in R1's room and that R1 was non-compliant with the use of the call light. R1 sustained a left side forehead 3.5 centimeter/cm by 0.5 cm laceration to R1's left side of forehead and R1's left eye was light blue in color. No additional fall interventions were documented. R1's Emergency Department Instructions, dated 5/25/22 at 11:25 pm, documents that R1 was evaluated for an accidental fall and forehead laceration. R1 was ordered an antibiotic ([MEDICATION(S)] for ten days) and received stitches to the laceration, requiring a follow-up on 6/4/22 for removal of the stitches. R1's AIM For Wellness, dated 6/5/22 at 12:40 am, documents that R1 sustained a fall by the closet of R1's room. No additional fall interventions were documented. R1's current Care Plan documents that R1 is a risk for falls that require monitoring and intervention to reduce potential for self-injury; R1 is at risk for falls related to R1's use of antidepressants, antianxiety, antipsychotic and narcotics; Interdisciplinary Team/IDT will review the changes and needs and discuss fall related information to review and revise the Care Plan; review quarterly and as needed during daily care and services of resident's plan for safety; IDT review of Activities of Daily Living status and fall potential with changes in condition or fall status; request Medical Director review of medications and conditions during nursing home visit especially after falls; and to remind resident to call for help. R1's Care Plan documents that R1 had four sutures above right eyebrow as a result of a fall that occurred on 3/25/22 and 12 sutures from a fall on 5/25/22. The Care Plan also documents fall interventions of educating resident on use of call light, asking for assistance and fifteen-minute checks. The Care Plan documents an intervention for the fall that occurred on 5/23/22 and 5/25/22 but does not document specific interventions for the remaining falls that occurred 12/1/21 through 6/5/22. On 6/7/22 at 9:44 am, R1 could not recall any of the fall incidents and stated, I fell a long time ago I think, I do not remember. I did not ever see a sign reminding me to ask for help, I do not know what you are talking about. A typed written sign that was a reminder for R1 to ask for staff assistance and to use the call light was hanging on R1's roommate's closet door and was not visible to R1's pathway to the bathroom door or exit door from R1's room. Multiple other signs were also hanging on both resident's closets and bathroom doors, making the sign intended for R1 to ask for staff assistance and use of the call light not visible to R1. R1 had a laceration above R1's left eye. On 6/7/22 at 11:00 am, V3 (R1's Hospice Nurse Practitioner) stated, (R1) has had quite a few falls. (R1) has significant confusion and a history of mental health issues. (R1) had a fall mat by her bed, and the other side of bed is up against the wall, but we removed the fall mats after the last fall because she said she tripped over it, but (R1's) cognition is impaired, and they were not quite sure exactly if (R1) tripped over the mat or not, but we did remove it. On 6/7/22 at 9:17 am, V1 (Administrator/ADM) stated, We implemented fifteen-minute checks for (R1's) falls and education on the use of (R1's) call light. (R1) would constantly get up in (R1's) room and walk around. We were already doing fifteen-minute checks on (R1) because of all of (R1's) previous falls and we educated (R1) again on the use of the call light. On the incident of 5/25/22, after (R1) got back from the hospital, (R1) stated that (R1) tripped over the floor mat next to (R1's) bed, so we removed the fall mat. On 6/7/22 at 9:54 am, V2 (Director of Nursing/DON) stated, (R1) is alert to (R1's) name and is confused a lot. From what I understand, (R1) ambulated self to the bathroom and tripped over a fall mat next to (R1's) bed and hit (R1's) head on the bathroom door. (R1) got in bed and put the call light on for help with the bleeding. (R1) is on Hospice and a few falls back we asked Hospice to reduce (R1's) [MEDICATION(S)], and I am not sure that happened. I did not ever see a sign hanging in (R1's) room to remind (R1) to ask us for help. On 6/7/22 at 10:32 am, V2 (DON) stated, I went down and saw that reminder sign for (R1) to ask for help but it was hanging on the roommate's closet door. I moved it. V2 verified that the sign on R1's roommate's closet door was not viewable for R1 to see and that R1's fall interventions were not always updated and appropriate for R1's cognitive status. On 6/7/22 at 11:10 am, V4 (Licensed Practical Nurse/LPN) stated, I was the nurse when (R1) fell (on 5/25/22). We were already doing fifteen-minute checks on (R1) because of (R1's) other falls. When we were doing a fifteen-minute safety check, we found (R1) laying on her floor next to her bed trying to pick herself up, and she stated that she tripped over a mat next to her bed and hit her head on the door of the bathroom. (R1's) forehead was bleeding, so I called Emergency 911, and (R1) went to the emergency room and got twelve stitches and came back later that night. R1's call light was not on or sounding and (R1) had not quite made it to R1's bed. (R1) told me that (R1) was looking for (R1's) shoes. On 6/7/22 at 4:30 pm, V1 (ADM) stated, My Director of Nursing (V2) does all of the fall review and interventions. If you can find me some nurses, it would be great, since I cannot find nurses. I do not think the pay is competitive enough, so my Director of Nursing (V2) has to work the floor a lot. Usually (V2) is working the floor, and it is medication pass time during our morning meetings and IDT meetings, so (V2) is not there to help with the fall reviews and I am not a nurse so she handles all of that when she is not working the floor, and she works the floor almost every day during the week and sometimes on the weekends. V1 verified that no other fall interventions were initiated for R1's falls, dated 3/2/22 through 6/5/22.

Based on interview and record review, the facility failed to provide the required supervision and verbal cueing during mealtimes for R1, a resident with a documented history of choking while eating. This failure resulted in R1 choking while eating unattended and eventual death. These failures resulted in an Immediate Jeopardy when the facility staff did not monitor a resident (R1) with a history of choking and the resident choked and died . This was identified as past non-compliance that occurred from [DATE] to [DATE]. The Immediate Jeopardy was removed on [DATE]. FINDINGS INCLUDE: The Immediate Jeopardy was identifed on [DATE] at 2:00 P.M. The Immediate Jeopardy began on [DATE] at 6:00 P.M., when the facility failed to supervise a resident (R1) with a history of choking during meals. Aspen Rehab & Health Care was notified of the Immediate Jeopardy on [DATE] at 2:45 P.M., (V1/Administrator was notified of the Immediate Jeopardy). R1's facility Profile Face Sheet, documents that R1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R1's Nursing Admission Assessment, dated [DATE] documents, Diet/Feeding: Regular, thin liquids; cut up meat. R1's Dietary Admission Assessment, dated [DATE] documents, Swallowing problems identified: shoves food into mouth. R1's Baseline Care Plan, dated [DATE] documents, Eating: supervision/VC (verbal cues), cut meat, chewing concern, stuffs mouth. R1's Dietary Notes, dated [DATE] document, (R1) has been moved to a feeder table. R1's Nurse's Notes, dated [DATE] at 5:35 P.M. document, (R1) noted to be choking. Not able to speak, (skin) color abnormal. Not able to do [MEDICATION NAME] in upright position, lowered to the floor and [MEDICATION NAME] successful to dislodge meat. Color returns to normal. (R1) able to speak. [DATE] here at this time to assess (R1). V7/ sister acknowledges that (R1) has had that problem or is prone to choking because (R1) eats fast and shovels food into (R1's) mouth. Physician notified and new orders received for a Mechanical Soft diet. R1's Dietary Notes, dated [DATE] document, (R1) is at high risk for choking. (R1's) diet has been switched to Mechanical Soft due to (R1) shoving food into (R1's) mouth and is now eating with cues from staff. R1's Care Plan, dated [DATE] documents, Problem: I have a tendency to choke on my food due to not chewing my food. I have a [DIAGNOSES REDACTED]. Approach: Prepare food to recommended consistency of Speech Therapist and ordered by MD (Medical Doctor). Give verbal cues to stimulate chewing or swallowing. Stroke throat lightly at Adam's apple to stimulate swallow. R1's Care Plan, dated [DATE] documents, Problem: When I eat, I always eat too fast and I do not chew my food completely. I do not swallow my food prior to putting another bite in my mouth. I also take too large of bites in my mouth. I also take too large of bites for me most of the time. I do eat very fast. I am always hungry, it may have to do with my psyche medications I take for my depression and [MEDICAL CONDITIONS] disorder, depression and anxiety. I do have anxiety when I have food and especially at meal times. I have nurses or CNAs (Certified Nursing Assistants) sit with me to help me slow down and remind me to take smaller bites and chew my food and swallow before taking another bite and to drink in between bites. When I am done eating even though I didn't always comply with the staff's cueing I asked 'How did I do' I am looking for reassurance and praise. I do need assistance with my eating. I have had several choking episodes before coming to the facility. I am on an eating restorative program. Approach: Assist me with setting up my meal the way I like it. Remind me when I become anxious and want to eat fast and not chew my food completely what the outcome could be. Assist me to cut my food into smaller bites. Cue me to put my utensils down and take sips of fluids between bites. Give praise when the meal is over. Inform nurse of any difficulties during his meals. During meals, provide verbal cues to resident to slow eating, take small bites and chew prior to swallowing, encourage liquids as needed. If resident doesn't finish greater than 50 percent of meal, staff to assist resident with the rest of the meal. R1's Dietary Notes, dated [DATE] document, Dietician recommended all breads be quartered and moistened both sides with butter, gravy or jelly at every meal. R1's physician progress notes [REDACTED]. Please remind (R1) in slowing down rate/small bites, sips and alternate bites/sips with supervision with all intake. R1's Nurse's Notes, dated [DATE] at 6:00 P.M., document, (R1) had choking episode with no loss of consciousness. Able to remove soft food from (R1's) mouth. [DATE] called for back up if needed. Continues to sit at feeder table during meals for supervision and encouragement to eat slowly and to chew food well before swallowing. R1's Physician Orders, dated [DATE] document, Speech Therapy to eval (evaluate) and treat. R1's Speech Therapy Progress and Discharge Summary, dated [DATE] document,Discharge Plans and Instructions: Discharge to facility with mechanical soft diet and thin liquids via straw. Continue taking small bites/sips at a slow rate. Supervision is recommended with intake to remind (R1) in slow rate and smaller size bites. R1's Nurse's Notes, dated [DATE] at 1857 (6:57 P.M.) document, When writer entered (R1's) room to give medications to (R1), was choking on food. Writer able to get (R1) to lean forward. That helped (R1) able to cough food out on (R1's) own. R1's Nurse's Notes, dated [DATE] at 10:15 A.M. document, Noted to be choking/coughing during meal. R1's Nurse's Notes, dated [DATE] document, At approximately 6:00 P.M. writer (V6/Licensed Practical Nurse) responded immediately to (R1's) room, CNA (V3) in room and assisted writer to get (R1) to the floor. (R1) was conscious and attempting to draw in a breath. (R1's) face was grayish in color. Writer had staff call [DATE]. (R1's) mouth (was) observed and food present on (R1's) dentures. Writer removed food and dentures. Abdominal thrusts initiated. Assisted breathing with bag valve mask to maintain airway. Airflow noted with some resistance. Attempted to remove airway obstruction when (R1) inhaled deeply, again obstructing airway. Continued abdominal thrusts and noted loss of consciousness. Assessed (R1) and no pulse and no respirations noted. CPR (Cardio [MEDICAL CONDITION] Resuscitation) initiated. Officer arrived and assumed chest compressions while writer maintained airway. AED (Automated External Defibrillator) utilized by Officer and no shockable rhythm arose. CPR continued. EMS (Emergency Medical Services) arrived and assumed care of (R1). Able to remove obstruction with forceps. Resuscitation efforts continued. At 6:25 P.M., Physician, Resident's Responsible Party (V7), Administrator (V1) and DON (V2/Director of Nurses) notified of (R1's) condition. EMS contacted Medical Control and (R1) pronounced (deceased ) at 6:44 P.M. R1's Ambulance Service Report, dated [DATE] documents,Dispatched/responded to (facility) where a male who was choking and is now unresponsive with CPR in progress. Upon arrival (R1) is found unresponsive laying supine in room with CPR in progress. Staff states (R1) was eating a grilled cheese sandwich when he began to choke. (R1's) airway was opened with a MAC 4 and large amounts of food are removed from the airway with maguil forceps. R1's State Certificate of Death, dated [DATE] documents, Cause of death: Anoxia, Choking on Food Substance. On [DATE] at 2:52 P.M., V3/Certified Nursing Assistant (CNA) stated, I have been working here about a month. I guess (R1) had special instructions (for eating), but I wasn't aware of them. No one told me (R1) shoved food into his mouth. I didn't know. I delivered his tray and left the room. I finished passing the other trays. I was gone maybe five minutes. When I came back (into R1's room), I was helping his roommate, my back was turned to (R1). When I turned around, I saw (R1) inhale and then (R1) started choking, (R1) was slumped over. I tried to pull the food out of his mouth. I got a couple of pieces of sandwich out. There was a chunk at the back of (R1's) mouth, towards his throat. I yelled for the nurse and she came in and started CPR. I didn't know I wasn't supposed to leave (R1) alone when (R1) was eating. On [DATE] at 2:05 P.M., V6/Licensed Practical Nurse (LPN) stated, (The evening of [DATE]) I was sitting with another resident and I heard V3/CNA yell for help. I immediately went to (R1s) room. (R1) was sitting in a chair, slumped to the side, gasping. (R1) was gray. (R1) looked at me, but (R1) couldn't talk. I grabbed (R1's) belt and pulled (R1) to the floor. I opened (R1's) mouth and saw food. It was bread. I took (R1's) dentures out. I did a couple of abdominal thrusts (on R1). I yelled for someone to call [DATE]. A policeman was the first on the scene. He took over CPR. He left and ran back to his car and got the AED. (R1) had no shockable rhythm. The EMTs showed up and took over. They pulled a large amount of food out of (R1's) throat. They worked on (R1) for about thirty five minutes and then called the ER (emergency room ) doctor and the ER doctor said to stop resuscitation efforts at that time. On [DATE] at 8:15 A.M., V7/R1's sister stated, (R1) had a previous choking episode prior to admission (to the facility). I found (R1) unresponsive on the floor of his apartment. (R1) spent a week in ICU (Intensive Care Unit). I am a Licensed Speech Therapist. I told (the facility) of (R1's) history and stressed that (R1) was only able to eat or drink under supervision. I know of a couple of incidents while (R1) was at the facility, he choked. One of the more recent episodes, I specifically asked the nurse if a staff member was in the room with (R1) and she said no. I repeated how (R1) had to have someone with (R1) at all times while (R1) was eating or drinking. On [DATE] at 11:55 A.M., V2/Director of Nurses stated,Due to Covid-19 (R1) ate in (R1's) room. There was someone typically in (R1's) room, with (R1), during meals. Either a CNA or a Nurse, if the CNA were busy. (R1) had a long history of choking and needed to be monitored. Unfortunately, (V3/CNA) stepped out of the room (R1's) that night ([DATE]). At that same time, V2/DON verified R1's Care Plan and Speech Therapy recommendations were for a staff member to be present with R1 during all meals. On [DATE] at 12:47 P.M., V8/Speech Language Pathologist stated, I saw (R1) for speech therapy after an incident of (R1) choking during a meal. (R1) had an almost obsession with eating his meals very quickly, literally shoving food into his mouth. I worked with (R1) and taught (R1) compensatory strategies for safe swallowing. I also educated the (facility) staff that (R1) would need to be supervised for all food and fluid intake with frequent reminders to slow his rate of consumption and to take smaller bites. It would never be safe for (R1) to eat without staff supervision. On [DATE] at 2:00 P.M. an Immediate Jeopardy was identified to have begun on [DATE]. On [DATE] at 2:45 P.M.,V1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions, which were initiated on [DATE] and completed on [DATE] , to remove the Immediate Jeopardy: 1.) On [DATE] staff immediately checked to see that appropriate diet was served. 2.) On [DATE] QA (Quality Assurance) members completed a whole house audit to ensure all diet orders were correct on the Physician order [REDACTED]. 3.) On [DATE] QA members completed a whole house audit to ensure all Physician approved RD recommendations had been transcribed and followed. 4.) On [DATE] QA members completed a whole house audit to ensure any Physician approved Speech recommendations had been transcribed and were being followed. 5.) On [DATE] QA members completed a whole house audit to ensure diet cards had correct diet and interventions. 6.) On [DATE] QA members completed an audit to ensure care plans included correct diet and interventions. 7.) All residents identified at risk will have a food and swallowing precautions card on the meal tray in addition to the diet card. 8.) On [DATE] the Administrator and FSS (Food Service Supervisor) inserviced staff following individualized plan of care with emphasis on diet and interventions and implementation of food and swallowing precautions card. FSS and RD (Registered Dietician) completed competencies with food service staff regarding knowledge of mechanically altered food and beverage on [DATE]. 9.) [DATE] random sampling of employees were questioned regarding competency of food and swallowing precautions by Administrator with 100 percent understanding. For Quality Assurance Measures; * All newly hired staff will be inserviced on following individualized plan of care with emphasis on diet and interventions and food and swallowing precautions card. * The QA Team will discuss the diet status on all new admits and any change in condition during daily QA meeting. The Quality Assurance Team will review quarterly for compliance.

Based on interview and record review, the facility failed to provide the correct textured diet to R1, a resident with a documented [DIAGNOSES REDACTED]. These failures resulted in an Immediate Jeopardy when the facility staff did not provide a resident (R1) with their planned diet texture. This was identified as past non-compliance that occurred from [DATE] to [DATE]. The Immediate Jeopardy was removed on [DATE]. FINDINGS INCLUDE: The Immediate Jeopardy was identifed on [DATE] at 2:00 P.M. The Immediate Jeopardy began on [DATE] at 6:00 P.M., when the facility failed to serve R1 the correct therapeutic diet. Aspen Rehab & Health Care was notified of the Immediate Jeopardy on [DATE] at 2:45 P.M., (V1/Administrator was notified of the Immediate Jeopardy). The facility policy, Cycle Menu, dated (revised) ,[DATE] directs staff, Diets are modified according to the current edition of the (state) Simplified Diet Manual with some minor adjustments as noted within the diet descriptions below: Mechanical Soft: Designed for individuals who have difficulty chewing but are able to tolerate a wide variety of foods. This diet is designed to permit easy chewing. This diet includes foods soft in texture such as cooked fruits and vegetables, moist ground meat and soft bread and cereal products. Modifications in the diet need to be individualized according to the resident's needs. R1's [DATE] Physician order [REDACTED]. This same document includes the following physician orders: Mechanical diet, soft ground meat, bread quartered and moistened with butter, gravy or jelly. R1's Dietary Notes, dated [DATE] document, Dietician recommended all breads be quartered and moistened both sides with butter, gravy or jelly at every meal. R1's Care Plan, dated [DATE] documents, Problem: When I eat, I always eat too fast and I do not chew my food completely. Approaches: All breads are to be served moistened with gravy or jell, both sides (of bread) with butter and quartered, before serving, at all meals. Problem: Resident with difficulty chewing or swallowing (dysphagia) as evidenced by alteration in consistency of food (mechanical soft). Approaches: Prepare foods to recommended consistency of Speech Therapist and ordered by Physician. See Physician order [REDACTED]. Assess tolerance to consistency. Minimizes pocketing, choking, coughing, discomfort during swallowing. This same Care Plan includes the following update on [DATE], directing staff, Allowing family to bring in food on Fridays for resident's mental health to decrease depressive episodes. Food to be delivered to kitchen to be prepared per resident's diet. R1's Speech Therapy Progress and Discharge Summary, dated [DATE] documents, Diagnosis: [REDACTED]. R1's Ambulance Service, Patient Care Report, dated [DATE] documents, Dispatched/responded immediately to (facility) for a male who was choking and is now unresponsive with CPR (Cardio [MEDICAL CONDITION] Resuscitation) in progress. Staff states (R1) was eating a grilled cheese sandwich when he began to choke.(R1) assessed. CPR taken over form staff. (R1's) airway opened and large amounts of food are removed from the airway. CPR now continuous. Medical Control is contacted and advised to terminate resuscitative efforts. R1's Certificate of Death, dated [DATE] documents, Cause of death: Anoxia, choking on food substance. On [DATE] at 1:28 P.M., V4/Food Service Supervisor stated, (R1) was on a mechanical soft, no added salt diet. Our mechanical soft diet includes soft bread. Bread needed to be moistened and quartered. We started doing this in September or October of 2019 because (R1) ate too fast and he was a choking risk with bread. On [DATE], I had a call in (from staff) and I was filling in. The sandwich that (R1) ate that night, was a grilled tuna melt from (a local restaurant). (R1's) sister would bring one in every Friday and (R1) would eat half of it on Friday and the other half on Saturday. It was supposed to be moistened on both sides with milk or water, before it was served. I saw (V5/Evening Cook) take it out of the refrigerator and put it in the microwave to heat it up. I did not witness (V5) moisten the bread before she put it on the plate to be served. On [DATE] at 1:40 P.M., V5/Evening Cook stated, (R1) was on a mechanical soft diet. The bread had to moistened with milk. If it were a sandwich, both pieces of bread were spread with butter or mayo (mayonnaise). All sandwiches were cut into bite-sized pieces. (R1's) sister brings in a grilled tuna melt sandwich every Friday. I cut it into bite sized pieces. I put it in the microwave for one minute, to make it softer. I put about twelve pieces on the plate. I also sent mayo with the tray. I did not moisten the pieces (with milk) or add additional condiments (to the bread) before I served it. On [DATE] at 2:52 P.M. V3/Certified Nursing Assistant (CNA) stated, I didn't know (R1's) bread was supposed to be moistened. (R1) did have special instructions (for eating) but I wasn't aware of them. No one told me (R1) shoved food into (R1's) mouth. I didn't know, until afterwards when they did an investigation. I delivered (R1's) meal tray and left the room. (R1) had a grilled tuna melt, cut up. The bread wasn't wet. When I came back to the room, I was helping (R1's) roommate. I saw (R1) inhale and (R1) was choking. I tried to pull the food out of (R1's) mouth. I yelled for the nurse and she came in and started CPR. On [DATE] at 11:55 A.M., V2/Director of Nurses stated, (R1's) bread was to be chopped up and quartered, meat was ground. Bread was to be moistened with butter, jelly or gravy before it was served. (R1) had a history of [REDACTED]. On [DATE] at 9:15 A.M., V9/Company Dietician stated, Mechanical soft diets are served sandwiches with soft breads, with the addition of added sauces or condiments. It makes them easier to swallow. On [DATE] at 2:00 P.M. an Immediate Jeopardy was identified to have begun on [DATE]. On [DATE] at 2:45 P.M. ,V1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions, which were initiated on [DATE] and completed on [DATE], to remove the Immediate Jeopardy: 1.) On [DATE] staff immediately checked to see that appropriate diet was served. 2.) On [DATE] QA (Quality Assurance) members completed a whole house audit to ensure all diet orders were correct on the Physician order [REDACTED]. 3.) On [DATE] QA members completed a whole house audit to ensure all Physician approved RD recommendations had been transcribed and followed. 4.) On [DATE] QA members completed a whole house audit to ensure any Physician approved Speech recommendations had been transcribed and were being followed. 5.) On [DATE] QA members completed a whole house audit to ensure diet cards had correct diet and interventions. 6.) On [DATE] QA members completed an audit to ensure care plans included correct diet and interventions. 7.) All residents identified at risk will have a food and swallowing precautions card on the meal tray in addition to the diet card. 8.) On [DATE] the Administrator and FSS (Food Service Supervisor) inserviced staff following individualized plan of care with emphasis on diet and interventions and implementation of food and swallowing precautions card. FSS and RD (Registered Dietitian) completed competencies with food service staff regarding knowledge of mechanically altered food and beverage on [DATE]. 9.) [DATE] random sampling of employees were questioned regarding competency of food and swallowing precautions by Administrator with 100 percent understanding. For Quality Assurance Measures; * All newly hired staff will be inserviced on following individualized plan of care with emphasis on diet and interventions and food and swallowing precautions card. * The QA Team will discuss the diet status on all new admits and any change in condition during daily QA meeting. The Quality Assurance Team will review quarterly for compliance.

Based on interview, record review and observation, the facility neglected to identify, prevent, investigate, protect and report allegations of abuse involving R3 to the administrator, as required by the facility's Abuse Prevention Policy. This neglect resulted in R3 sexually abusing R5 once and R6 twice. R3 is one of six residents reviewed for abuse in the sample of six residents. This failure has the potential to affect all 40 female residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42) currently in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 02/05/15, the facility remains out of compliance at a Severity level 2 as the facility is still educating management and staff on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visit. FINDINGS INCLUDE: The facility policy titled "Abuse Prevention Program" dated (revised) 11/11/11 documents, "Employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator...Upon learning of the report, the administrator or designee shall initiate an investigation...The report shall be made to (the state agency) immediately after forming the suspicion. Otherwise, the report must be made not later than 24 hours after forming the suspicion...Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation." The following nurses notes dated 8/20/2014 at 9:30A.M. from R3's previous nursing home found in R3's current medical record states," Resident (R3) observed with his hand on inner thigh of resident #0022. Wife notified of incident and explained we would have to look for other placement." R3's "Interdisciplinary Discharge Summary" from a local nursing home indicates that R3 was admitted to the present facility on 09/02/14. The reason for discharge indicates, "Unable to meet resident's needs." The facility "Nursing Admission Assessment" dated 09/02/14 indicates R3 is "Alert, Cooperative, Identifies: Time, Place and Self." R3's Nurses Notes dated 09/02/14 at 10:00 P.M. document, "Resident up in wheel chair with 1:1 assist today. Alert and oriented X 3." On 02/04/15 at 8:55 A.M., E1 (Administrator) stated, "(R3) came from (a local nursing facility). They had given (R3) a 30 day discharge notice because of inappropriate behavior. (R3) touched a resident..." R3's Nurses Notes dated 09/04/14 at 8:20 A.M. document, "Resident in wheelchair in TV (Television) room sitting next to a female resident, (R3) resident reached over and put females hand on (R3)'s lap. Situation witnessed." 8:30 A.M., "Administrator notified." On 02/04/15 at 10:00 A.M., when E1 (Administrator) was interviewed concerning whether the facility investigated the incident, E1 stated, "No we (the facility) did not pursue it, because the Nurse felt it was not inappropriate sexual behavior. No investigation was done." On 02/04/15 at 10:45 A.M., E4 (Licensed Practical Nurse) stated, "(R3) was admitted two days prior (to 09/04/14) from another nursing home. I knew there had been another allegation of 'touching (at the other facility)', passed on in report to me. I knew there was a potential problem... I seen (R3) touching (R6) and then (R3) placed (R6)'s hand on (R3)'s lap and then I stopped (R3). (R3) is pretty cognizant and so (R3) stopped...Then (R3) took (R6)'s hand and placed them in the center of (R3)'s lap, (R3)'s private area." On 02/04/15 at 12:20 P.M., E9 (Certified Nursing Assistant) stated, "(R3)'s wheel chair was parked next to a female resident (R6). I seen (R3) grab (R6)'s hand and placed it between (R3)'s legs, (R3)'s private area. I said 'We don't do that here' and moved (R3) away from (R6)." R3's Nurses Notes dated 12/24/14 at 5:15 A.M. document, "Resident sitting in common living room next to female resident. (R3) was seen touching inner thigh of (R5). This nurse stopped (R3) and directed (R3) back to (R3)'s room. An hour later, (R3) was again in common living room seen rubbing the breast of another female resident (R6). (R3) was again stopped and redirected back to (R3)'s room. Administration notified." The facility's Investigation from the incident on 12/24/14 includes the following statement from E8 (Licensed Practical Nurse), "At 4:30 A.M., I noticed resident sitting next to (R5) in the living room. (R5) looked upset at (R3). I started walking out there and witnessed (R3) placing (R3)'s hand on (R6)'s inner thigh and rubbing it. (R6) was swatting (R3)'s hand away and saying 'stop it'. I told (R3) to leave (R6) alone and to stop it. What (R3) was doing was inappropriate. (R3) said 'okay' and I helped (R3) back to (R3)'s room. Then about 5:15 A.M., I saw (R3) sitting next to (R6) in the living room and (R3) was rubbing (R6)'s breast over (R6)'s top. I again told (R3) to stop and that (R3) was being inappropriate again. (R3) said 'sorry' and I again walked with (R3) back to (R3)'s room. I then called (E1) Administrator to report these incidents." Multiple attempts to notify E8 (Licensed Practical Nurse) to discuss this incident were unsuccessful. On 02/04/15 at 8:55 A.M., E1 (Administrator) stated, "I am not certain that I was notified on the first incident on 12/24/14, where (R3)'s hands were between (R5)'s thighs." On 02/05/15 at 9:00 A.M., R5 stated, "I remember a man putting his hand in my private area. I didn't feel comfortable and moved his hand away." On 02/04/15 at 8:30 A.M., R3 was propelling throughout the facility, independently. On 02/04/15 at 2:00 P.M., R3 was sitting at a table in the facility dining room with three female residents present, no facility staff were present. On 02/05/15 at 9:00 A.M., R3 was sitting in the common television room with other residents present. No facility staff were present. The Facility Room Roster, dated 02/03/15 includes the following 40 female residents: (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42). The Immediate Jeopardy was identified on 02/04/15 at approximately 3:10 P.M. to have begun on 09/04/14 when R3 inappropriately touched R6. E1 (Administrator) was notified of the Immediate Jeopardy on 02/04/15 at 3:20 P.M. Surveyors confirm through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: ? On 2/4/2015 the Regional Director in-serviced the Administrator regarding the Abuse and Neglect Policy and Procedure, thorough and appropriate investigations, and accurate and timely reporting. ? On 2/4/2015 the Administrator in-serviced Staff on the Abuse and Neglect Policy and Procedure including but not limited to timely reporting and types of abuse and neglect. ? An Audit was initiated on 2/4/2015 of all behavior sheets to ensure behaviors of this nature were identified and appropriately investigated and reported. ? On 2/4/2015 Resident was placed on 15 minute monitoring throughout the night. 1:1 while up in wheelchair. ? Regional Clinical Director reviewed the facility's behavior program on 2/4/2015 and identified areas for improvement. ? Regional Director in-serviced the Administrator on 2/5/2015 on the screening process for referrals to ensure the facility can appropriately meet resident needs and on the appropriate process for background checks. As part of the facility's ongoing quality improvement program, the following measures will be taken to ensure the practice does not recur: ? 2/5/15 the IDT will be in-serviced on steps of an effective behavior monitoring program by the Regional Clinical Director. o The SSD (Social Services Director), Administrator and DON (Director of Nurses) will review the resident behavior tracking sheets weekly and take any resident issues identified to the Weekly QA Behavioral Meeting to monitor for appropriateness of placement and care of the resident. o Any new resident triggers and interventions will be updated on the care plan and communicated to the staff. o The SSD will contact appropriate psychiatric resources for residents with identified issues as needed. ? The Regional Director will work directly with the Administrator on the next 5 abuse and/or neglect allegations. ? The Regional Director will review all abuse and neglect investigations for thoroughness and accurateness for the next 3 months. ? The Administrator will in service staff on the Abuse and Neglect Policy twice monthly for the next 3 months and quarterly thereafter. ? Residents will be in-serviced by Administrator or designee on the Abuse and Neglect Policy and Procedure on 2/5/2015 and quarterly thereafter. ? Administrator will contact Regional Director or Regional Clinical Director for any referrals with behaviors or special needs prior to accepting to ensure facility can appropriately meet resident needs and that interventions are implemented at the time of admission. ? Regional Director will review background checks for accuracy and timeliness Quarterly x 6 months.

Based on observation, interview and record review, the facility failed to report an incident of sexual assault timely to the facility Administrator, failed to investigate an incident of sexual assault, failed to report an incident of sexual assault to the State Agency and failed to prevent further abuse during an investigation involving R3, one of six residents reviewed for abuse in the sample of six. This failure has the potential to affect all 40 female residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42) currently in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 02/05/15, the facility remains out of compliance at a Severity level 2 as the facility is still educating management and staff on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visit. FINDINGS INCLUDE: Nurses Notes dated 8/20/2014 at 9:30A.M. from a local nursing home states," Resident (R3) observed with his hand on inner thigh of resident #0022. Wife notified of incident and explained we would have to look for other placement." R3's "Interdisciplinary Discharge Summary" from a local nursing home indicates that R3 was admitted to the present facility on 09/02/14. The reason for discharge indicates, "Unable to meet resident's needs." The facility "Nursing Admission Assessment" dated 09/02/14 indicates R3 is "Alert, Cooperative, Identifies: Time, Place and Self." R3's Nurses Notes dated 09/02/14 at 10:00 P.M. document, "Resident up in wheel chair with 1:1 assist today. Alert and oriented X 3." On 02/04/15 at 8:55 A.M., E1 (Administrator) stated, "(R3) came from (a local nursing facility). They had given (R3) a 30 day discharge notice because of inappropriate behavior. (R3) touched a resident..." R3's Nurses Notes dated 09/04/14 at 8:20 A.M. document, "Resident in wheelchair in TV (Television) room sitting next to a female resident, (R3) resident reached over and put females hand on (R3)'s lap. Situation witnessed." 8:30 A.M., "Administrator notified." On 02/04/15 at 10:00 A.M., when E1 (Administrator) was interviewed concerning whether the facility investigated or reported the incident to the State Agency, E1 stated, "No we (the facility) did not pursue it, because the Nurse felt it was not inappropriate sexual behavior. No investigation was done nor notification to the (State Agency)." On 02/04/15 at 10:45 A.M., E4 (Licensed Practical Nurse) stated, "(R3) was admitted two days prior (to 09/04/14) from another nursing home. I knew there had been another allegation of 'touching (at the other facility)', passed on in report to me. I knew there was a potential problem... I seen (R3) touching (R6) and then (R3) placed (R6)'s hand on (R3)'s lap and then I stopped (R3). (R3) is pretty cognizant and so (R3) stopped...Then (R3) took (R6)'s hand and placed it in the center of (R3)'s lap, (R3)'s private area." On 02/04/15 at 12:20 P.M., E9 (Certified Nursing Assistant) stated, "(R3)'s wheel chair was parked next to a female resident (R6). I seen (R3) grab (R6)'s hand and placed it between (R3)'s legs, (R3)'s private area. I said "We don't do that here' and moved (R3) away from (R6)." R3's Nurses Notes dated 12/24/14 at 5:15 A.M. document, "Resident sitting in common living room next to female resident. (R3) was seen touching inner thigh of (R5). This nurse stopped (R3) and directed (R3) back to (R3)'s room. An hour later, (R3) was again in common living room seen rubbing the breast of another female resident (R6). (R3) was again stopped and redirected back to (R3)'s room. Administration notified." The facility's Investigation from the incident on 12/24/14 includes the following statement from E8 (Licensed Practical Nurse), "At 4;30 A.M., I noticed resident sitting next to (R5) in the living room. (R5) looked upset at (R3). I started walking out there and witnessed (R3) placing (R3)'s hand on (R6)'s inner thigh and rubbing it. (R6) was swatting (R3)'s hand away and saying 'stop it'. I told (R3) to leave (R6) alone and to stop it. What (R3) was doing was inappropriate. (R3) said 'okay' and I helped (R3) back to (R3)'s room. Then about 5:15 A.M., I saw (R3) sitting next to (R6) in the living room and (R3) was rubbing (R6)'s breast over (R6)'s top. I again told (R3) to stop, that (R3) was being inappropriate again. (R3) said 'sorry' and I again walked with (R3) back to (R3)'s room. I then called (E1) Administrator to report these incidents." Multiple attempts to notify E8 (Licensed Practical Nurse) to discuss this incident were unsuccessful. On 02/04/15 at 8:55 A.M., E1 (Administrator) stated, "I am not certain that I was notified on the first incident on 12/24/14, where (R3)'s hands were between (R5)'s thighs." On 02/05/15 at 9:00 A.M., R5 stated, "I remember a man putting his hand in my private area. I didn't feel comfortable and moved his hand away." The Facility Room Roster, dated 02/03/15 includes the following 40 female residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42). The Immediate Jeopardy was identified on 02/04/15 at approximately 3:10 P.M. to have begun on 09/04/14 when R3 inappropriately touched R6. E1 (Administrator) was notified of the Immediate Jeopardy on 02/04/15 at 3:20 P.M. Surveyors confirm through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: ? On 2/4/2015 the Regional Director in-serviced the Administrator regarding the Abuse and Neglect Policy and Procedure, thorough and appropriate investigations, and accurate and timely reporting. ? On 2/4/2015 the Administrator in-serviced Staff on the Abuse and Neglect Policy and Procedure including but not limited to timely reporting and types of abuse and neglect. ? An Audit was initiated on 2/4/2015 of all behavior sheets to ensure behaviors of this nature were identified and appropriately investigated and reported. ? On 2/4/2015 Resident was placed on 15 minute monitoring throughout the night. 1:1 while up in wheelchair. ? Regional Clinical Director reviewed the facility's behavior program on 2/4/2015 and identified areas for improvement. ? Regional Director in-serviced the Administrator on 2/5/2015 on the screening process for referrals to ensure the facility can appropriately meet resident needs and on the appropriate process for background checks. As part of the facility's ongoing quality improvement program, the following measures will be taken to ensure the practice does not recur: ? 2/5/15 the IDT will be in-serviced on steps of an effective behavior monitoring program by the Regional Clinical Director. o The SSD (Social Services Director), Administrator and DON (Director of Nurses) will review the resident behavior tracking sheets weekly and take any resident issues identified to the Weekly QA Behavioral Meeting to monitor for appropriateness of placement and care of the resident. o Any new resident triggers and interventions will be updated on the care plan and communicated to the staff. o The SSD will contact appropriate psychiatric resources for residents with identified issues as needed. ? The Regional Director will work directly with the Administrator on the next 5 abuse and/or neglect allegations. ? The Regional Director will review all abuse and neglect investigations for thoroughness and accurateness for the next 3 months. ? The Administrator will in service staff on the Abuse and Neglect Policy twice monthly for the next 3 months and quarterly thereafter. ? Residents will be in-serviced by Administrator or designee on the Abuse and Neglect Policy and Procedure on 2/5/2015 and quarterly thereafter. ? Administrator will contact Regional Director or Regional Clinical Director for any referrals with behaviors or special needs prior to accepting to ensure facility can appropriately meet resident needs and that interventions are implemented at the time of admission. ? Regional Director will review background checks for accuracy and timeliness Quarterly x 6 months.

Based on interview and record review, the facility failed to follow its policy on reporting an incident of sexual assault timely to the facility Administrator, failed to investigate an incident of sexual abuse, failed to report an incident of sexual abuse to the State Agency and failed to prevent further abuse during an investigation involving R3, one of six residents reviewed for abuse in the sample of six. This failure had the potential to affect all 40 female residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42) in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 02/05/15, the facility remains out of compliance at a Severity level 2 as the facility is still educating management and staff on abuse reporting policies and procedures and continues to monitor residents for any complaints or signs of abuse. FINDINGS INCLUDE: The facility policy titled "Abuse Prevention Program" dated (revised) 11/11/11 documents, "Employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator...Upon learning of the report, the administrator or designee shall initiate an investigation...The report shall be made to (the state agency) immediately after forming the suspicion. Otherwise, the report must be made not later than 24 hours after forming the suspicion...Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation." Nurses Notes dated 8/20/2014 at 9:30A.M. from R3's previous nursing home found in R3's current medical record states," Resident (R3) observed with his hand on inner thigh of resident #0022.Wife notified of incident and explained we would have to look for other placement." R3's "Interdisciplinary Discharge Summary" from a local nursing home indicates that R3 was admitted to the present facility on 09/02/14. The reason for discharge indicates, "Unable to meet resident's needs." R3's Nurses Notes dated 09/04/14 at 8:20 A.M. document, "Resident in wheelchair in TV (Television) room sitting next to a female resident, (R3) resident reached over and put female's hand on (R3)'s lap. Situation witnessed." 8:30 A.M., "Administrator notified." On 02/04/15 at 10:00 A.M., when E1 (Administrator) was interviewed concerning whether the facility investigated or reported the incident to the State Agency, E1 stated, "No we (the facility) did not pursue it, because the Nurse felt it was not inappropriate sexual behavior. No investigation was done nor notification to the (State Agency)." R3's Nurses Notes dated 12/24/14 at 5:15 A.M. document, "Resident sitting in common living room next to female resident. (R3) was seen touching inner thigh of (R5). This nurse stopped (R3) and directed (R3) back to (R3)'s room. An hour later, (R3) was again in common living room seen rubbing the breast of another female resident (R6). (R3) was again stopped and redirected back to (R3)'s room. Administration notified." The facility's Investigation from the incident on 12/24/14 includes the following statement from E8 (Licensed Practical Nurse), "At 4:30 A.M., I noticed resident sitting next to (R5) in the living room. (R5) looked upset at (R3). I started walking out there and witnessed (R3) placing (R3)'s hand on (R6)'s inner thigh and rubbing it. (R6) was swatting (R3)'s hand away and saying 'stop it'. I told (R3) to leave (R6) alone and to stop it. What (R3) was doing was inappropriate. (R3) said 'okay' and I helped (R3) back to (R3)'s room. Then about 5:15 A.M., I saw (R3) sitting next to (R6) in the living room and (R3) was rubbing (R6)'s breast over (R6)'s top. I again told (R3) to stop, that (R3) was being inappropriate again. (R3) said 'sorry' and I again walked with (R3) back to (R3)'s room. I then called (E1) Administrator to report these incidents." On 02/04/15 at 8:55 A.M., E1 (Administrator) stated, " I am not certain that I was notified on the first incident on 12/24/14, where (R3)'s hands were between (R5)'s thighs." On 02/05/15 at 9:00 A.M., R5 stated, "I remember a man putting his hand in my private area. I didn't feel comfortable and moved his hand away." The Facility Room Roster, dated 02/03/15 includes the following 40 female residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42). The Immediate Jeopardy was identified on 02/04/15 at approximately 3:10 P.M. to have begun on 09/04/14 when R3 inappropriately touched R6. E1 (Administrator) was notified of the Immediate Jeopardy on 02/04/15 at 3:20 P.M. Surveyors confirm through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: ? On 2/4/2015 the Regional Director in-serviced the Administrator regarding the Abuse and Neglect Policy and Procedure, thorough and appropriate investigations, and accurate and timely reporting. ? On 2/4/2015 the Administrator in-serviced Staff on the Abuse and Neglect Policy and Procedure including but not limited to timely reporting and types of abuse and neglect. ? An Audit was initiated on 2/4/2015 of all behavior sheets to ensure behaviors of this nature were identified and appropriately investigated and reported. ? On 2/4/2015 Resident was placed on 15 minute monitoring throughout the night. 1:1 while up in wheelchair. ? Regional Clinical Director reviewed the facility's behavior program on 2/4/2015 and identified areas for improvement. ? Regional Director in-serviced the Administrator on 2/5/2015 on the screening process for referrals to ensure the facility can appropriately meet resident needs and on the appropriate process for background checks. As part of the facility's ongoing quality improvement program, the following measures will be taken to ensure the practice does not recur: ? 2/5/15 the IDT will be in-serviced on steps of an effective behavior monitoring program by the Regional Clinical Director. o The SSD (Social Services Director), Administrator and DON (Director of Nurses) will review the resident behavior tracking sheets weekly and take any resident issues identified to the Weekly QA Behavioral Meeting to monitor for appropriateness of placement and care of the resident. o Any new resident triggers and interventions will be updated on the care plan and communicated to the staff. o The SSD will contact appropriate psychiatric resources for residents with identified issues as needed. ? The Regional Director will work directly with the Administrator on the next 5 abuse and/or neglect allegations. ? The Regional Director will review all abuse and neglect investigations for thoroughness and accurateness for the next 3 months. ? The Administrator will in service staff on the Abuse and Neglect Policy twice monthly for the next 3 months and quarterly thereafter. ? Residents will be in-serviced by Administrator or designee on the Abuse and Neglect Policy and Procedure on 2/5/2015 and quarterly thereafter. ? Administrator will contact Regional Director or Regional Clinical Director for any referrals with behaviors or special needs prior to accepting to ensure facility can appropriately meet resident needs and that interventions are implemented at the time of admission. ? Regional Director will review background checks for accuracy and timeliness Quarterly x 6 months.

Based on observation, interview, and record review, facility staff failed to follow physician's orders when transferring one of three residents (R13) sampled in a sample of 3 residents who are transferred using a mechanical lift. R13 was transferred without the use of a mechanical lift as ordered and lowered to the floor. R13 received a fractured humerus. Findings include: The POS (Physicians Order Sheet) for R13 dated 06/01/11 documents the following Diagnosis: [REDACTED]. The same POS for R13 documents that R13 is to be transferred using a mechanical lift. The care plan for R13 dated 03/02/11 documents that R13 has poor sitting balance and is a (mechanical lift) for all transfers. Facility Investigation Summary for R13 dated 03/10/11 and signed by E1 (Administrator) documents that on 03/04/11 R13 returned to the facility from the hospital after receiving a blood transfusion. Visual inspection of the resident was completed and bruising was noted to the resident's chest and left shoulder and arm. This bruising had been reported on 03/02/11 during the residents shower. On 03/04/11 the visual inspection of R13 showed that there was swelling to the left shoulder. The swelling and reduced range of motion was reported to R13 ' s physician who ordered x-rays. The x-ray report was received at the facility on 03/05/11 and documented a complete fracture of the surgical neck of the left humerus with displacement of distal segment medially. During the investigation it was discovered that on 02/24/11, R13 was transferred from chair to bed by three facility C.N.A.s (Certified Nurse Aide) using a two person transfer and that during the transfer the resident was lowered to the floor. A fourth C.N.A. then assisted in lifting R13 from the floor to the bed. This incident was not reported to the nurse on duty. Upon completion of multiple staff interviews it is determined that the incident was most likely caused by the Osteo[DIAGNOSES REDACTED] and aggravated by the two person transfer completed on 02/24/11. Nurses' notes for R13 dated 03/02/11 documents the following: "Observed numerous bruises on resident during shower. Yellow bruise around left side of neck and across left breast. Right upper arm to elbow purplish colored bruise both anterior and posterior." Nurses notes for R13 prior to 03/02/11 do not document bruising. On 06/02/11 at 9:30a.m., R13 was lying in bed on right side. R13's left shoulder was exposed and had pale yellow bruising across left upper arm. R13's left arm was in a sling. Facility Patient X-Ray Report for R13 dated 03/04/11 documents the following: "There is a complete fracture of surgical neck of left humerus with displacement of distal segment medially. " On 06/10/11 at 10:25AM E31 (C.N.A./ Certified Nurse Aide/former employee) stated, " No one likes to use the (mechanical lift) on (R13). That evening I was working with (E32/C.N.A.), a new trainee and (E13/C.N.A). We decided to put (R13) to bed and not use the (mechanical lift) thinking it would be easier. (E33/C.N.A.) and I decided to use a two man lift while (E32 C.N.A.) pulled the geri-chair back. (E32/C.N.A.) pulled the chair out too soon and we lowered (R13) to the floor. (R13) didn ' t drop and we didn't hear anything pop. I went and got (E 34/C.N.A.) and he helped us get (R13) into bed. I was so frustrated with (E32/C.N.A.) because she was new and didn ' t know anything and it wasn't working out with her. I was mad at her for pulling the chair out too soon. I had so much to do that I didn ' t report it to the nurse. (R13) didn't act hurt or complain of any pain." On 06/10/11 at 10:20a.m., E34 (C.N.A./ Certified Nurse Aide) stated, " It wasn't my hall that night. E31 (C.N.A.) told me they had already told the nurse about putting (R13) on the floor so I helped lift (R13) into bed. I found out later they had not told the nurse about putting (R13) on the floor." On 06/10/11 at 9:50a.m., E35 (former DON/Director of Nursing) stated, "E1 (Administrator) and I spoke with all the staff involved. In the case of (R13) they did not report the incident. It was (E1)/Administrator that conducted the investigation." On 06/02/11 at 12:45PM E1 (Administrator) stated, "After investigating we discovered (R13's) fracture happened because of the 'osteo' and being lowered to the floor not using the (mechanical lift)."