Every finding on record at Avenues at Royal Oak

Based on interview and record review, the facility failed to protect a resident from physical abuse from another resident, for one of three residents (R2), reviewed for abuse, in a sample of three.The facility policy, Abuse Prevention and Reporting, dated (reviewed) 03/2026 directs staff that the facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. R1's facility admission record documents that R1 ([AGE] year old) was admitted to the facility on [DATE] with the following diagnoses, Psychosis, Schizophrenia, and Major Depressive Disorder. R1's Care Plan, dated 3/24/26 includes the following Focus Area: (R1) is/has potential to be physically aggressive r/t (related to)Poor impulse control. This same care plan also includes the following Interventions: When (R1) becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. R1's Nursing Progress Notes, dated (Late Entry) 8/3/2026 at 6:18 P.M. document, Reported to this nurse this patient (R1) pushed another patient (R2) which she lost her balance and fell to floor. On 08/04/2026 at 9:26 P.M., V6/Licensed Practical Nurse (LPN) stated she worked the evening of August 3,2026. States she was on the locked dementia unit, standing across the hallway from the unit MDR (Main Dining Room)/Activity Room when she heard V8/Certified Nursing Assistant (CNA) yell help, I need a nurse. V6 states when she entered the room, R2 was up against the wall, leaning and she ran over and her and V8 lowered R2 to the floor. States V8/CNA told her that R1 had pushed R2, then ran out of the room. On 08/04/2026 at 9:44 P.M., V8/Certified Nursing Assistant (CNA) stated she was working the evening of August 3, 2026 and witnessed R1 push R2 against the wall. States at that time her and the nurse (V6) had to lower R2 to the floor. States she is unsure if R2 sustained any injuries. States she was in the locked dementia unit talking with R2. States R1 was seated in a chair in the MDR/Activity Room, when another resident attempted to sit in R1's lap. States R1 became upset, jumped up and shoved R2 against the wall causing her to become off balance. States after R1 shoved R2, R1 ran out of the room.

Based on interview and record review, the facility failed to implement it's abuse policy of reporting, protecting residents and investigating timely an allegation of abuse for one of one resident (R2), reviewed for abuse, in a sample of three.The facility policy, Abuse Prevention and Reporting, dated (reviewed) 03/2026 directs staff that the purpose of (this) policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This same policy states that this will be done by orienting and training employees on how to deal with stress and difficult situations and how to recognize and report occurrences of abuse, immediately protect residents involved in identified reports of possible abuse and implement systems to promptly and aggressively investigate all reports and allegations of abuse. The facility form, Preliminary 24 Hour Abuse Investigation Report, submitted to the state agency by V1/Administrator on 8/4/26 at 3:59 PM. documents, An allegation of potential physical abuse between R1 and R2, August 4, 2026 at 9:45 A.M., (V1) Abuse Coordinator was notified of a reportable occurrence between two residents. Residents were immediately separated. Police, Physician, guardian and Ombudsman notified. Investigation initiated. The facility written statement of V6/Licensed Practical Nurse, dated 8/4/26 documents, I was told that R1 was sitting in the chair at the table (on 8/3/26 at 6:15 P.M.) and R2 came up behind her and R1 pushed her. I didn't actually see it happen. The facility written statement of V8/Certified Nursing Assistant, dated 8/4/26 documents, (On 8/3/26 at 6:15 P.M.) (R1) was sitting at the dining table and several residents were walking and standing around her. One resident tried to sit on her lap and another resident, (R2) got very close to R1 and R1 turned towards her, placed both hands on (R2)'s shoulders and pushed her slightly backwards towards the wall. (R2) was holding on to the chair to hold herself up. I assisted R2 to the floor and V6 (Nurse) and I assisted her back to her feet. On 8/5/26 at 3:28 P.M., V1/Administrator stated (V6/Licensed Practical Nurse) called her after supper on 8/3/26 and reported that R1 wasn't getting along with a couple of the residents, and that it was no big deal. States V6 did not tell her that R1 had shoved R2 into the wall. States she did not receive a call from (V8/Certified Nursing Assistant) reporting the incident. States on the morning of 8/4/26 while she was driving to a corporate meeting, she received a telephone call from (V4/Assistant Director of Nurses) who informed her of the incident, but states V4 told her then that R1 had shoved R2. States she instructed V4 to call V6 and V8 and interview them and to report back to her. States she also told V4 to move R1 from the locked dementia unit to the locked psychiatric unit. States when she returned from her meeting yesterday afternoon, around 3:00 o'clock, she notified the state agency of the incident. States she realizes the potential abuse incident was reported late and the investigation was started late. Also confirms that R1 was not removed from having access to R2 until 8/4/26. States V8 has been reeducated on her responsibility to notify V1 of any suspected abuse, at the time of the occurrence.

Based on interview and record review, the facility failed to report an allegation of an incident of potential abuse to the facility abuse coordinator timely and failed to report a physical altercation between two residents to the state agency timely for one of one resident (R1) in a sample of three residents, reviewed for abuse.The facility policy, Abuse Prevention and Reporting, dated (reviewed 03/2026) directs staff that employees are required to report any incident, allegation or suspicion of potential abuse to the administrator immediately. this same policy documents that any allegation of abuse will be reported to the (state agency) immediately, but no more than two hours after the allegation of abuse. The facility Preliminary 24-hour Abuse Investigation Report, submitted by V1/Administrator/Abuse Coordinator on 8/4/26 at 3:59 PM. documents an allegation of potential physical abuse between R1 and R2 (that occurred on 8/3/26 at 6:15 P.M.). (On) August 4, 2026, at 9:45 A.M., (V1) Abuse Coordinator was notified of a reportable occurrence between two residents. On 8/5/26 at 3:28 P.M., V1/Administrator stated she realizes the potential abuse incident was reported late and the investigation was started late. Also confirms that R1 was not removed from having access to R2 until 8/4/26. States V8 has been reeducated on her responsibility to notify V1 of any suspected abuse, at the time of the occurrence.

Based on interview and record review, the facility failed to protect a resident from further potential abuse, after a physical altercation with another resident, for one of three residents (R2), reviewed for abuse, in a sample of three.The facility form, Preliminary 24-hour Abuse Investigation Report, documents an allegation of potential physical abuse between R1 and R2 (that occurred on 8/3/26 at 6:15 P.M.). On 8/4/26 at 9:44 P.M., V8/Certified Nursing Assistant stated she was working the evening of August 3, 2026 and witnessed R1 push R2 against the wall. States at that time, she and the nurse (V6) had to lower R2 to the floor. States she was in the locked dementia unit talking with R2 and R1 was seated in a chair in the MDR/Activity Room, when another resident attempted to sit in R1's lap. States R1 became upset, jumped up and shoved R2 against the wall causing her to become off balance. States she yelled for a nurse and V6 came into the room and helped her lower R2 to the floor. States she was not instructed to increase supervision for R1 after the incident. On 8/5/26 at 3:28 P.M., V1/Administrator stated on the morning of 8/4/26 while she was driving to a corporate meeting, she received a telephone call from V4/Assistant Director Of Nurses who informed her of the incident of R1 shoving R2 against a wall, that occurred on 8/3/26 at 6:15 P.M. Confirms that R1 was not removed from having access to R2 until 8/4/26.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 4 of 7 residents (R1, R2, R3, R4) reviewed for abuse in the sample of 7. The findings include:1. On 6/12/26 at 9:40 AM, R2 was sitting at the bedside in his room. R2 said R1 was cussing at him and so he hit him in the face with his hand. R2 said he never said anything to R1 to provoke him and didn't know why R1 was saying those things to him. R2 said R6 saw the whole thing. On 6/12/26 at 9:44 AM, R1 was walking around his room arranging his personal items. R1 stated R2 hit me and knocked my glasses. R1 said he was not sure why R2 hit him, he wasn't talking to him or about him. R1 said R6 saw what happened. R1 said the nurse said his left cheek was red but he didn't have an injury. On 6/12/26 at 9:52 AM, R6 was sitting in her room at the bedside. R6 said they were in the dining room and R2 hit R1 in the face and knocked him over in the chair. R6 said R1 fell on the floor but R1 grabbed the table to stop himself from falling hard. R6 said the staff came right away and took care of R1. On 6/12/26 at 9:57 AM, V4 Licensed Practical Nurse said R1 talks out loud and R2 thought he was talking to him and was upset and hit R1 in the face. V4 said she witnessed it happen. V4 said R2 hit R1 with a fist to the left side of his face and R1 fell to the floor. V4 said she immediately separated them and assessed R1. V4 said R1 had some redness to his face but no bruising or other injury. V4 said she reported this to the administrator. R2's Statement dated 5/21/26 shows R1 called me a b****** and I hit him. I asked him, what are you hearing voices? He said none of your business. That's when I hit him. I hit him in the face ad he fell to the floor. R1's Statement dated 5/21/26 shows I was talking out loud and R2 got mad and thought I was talking to him, and he hit me right below the glasses on my jaw. He knocked me out of the chair. R6's Statement dated 5/21/26 shows R2 hit him over the face and R1 leaned over bracing the knee and the chair tipped. R1's Facesheet shows R1 has diagnoses of paranoid schizophrenia and obsessive-compulsive disorder. R2's Facesheet shows R2 had diagnoses of anxiety, paranoid schizophrenia, and pseudobulbar effect. 2. On 6/12/26 at 10:10 AM, R3 was in bed in his room. R3 said a male resident came to his door and kicked him so he hit him. On 6/12/26 at 10:15 AM, R4 was sitting in his wheelchair in the activity room with staff. R4 would not comment when asked about going to R3's room and what happened. On 6/12/26 at 11:55 AM, V7 Social Service said R4 went to R3's room and when R3 answered the door, R4 kicked him when asked to leave and then R3 slapped R4. V8's statement dated 5/23/26 shows I was sitting with a resident when I heard a slap. I ran to hallway and saw R3 standing by R4 with his hand raised. I told R3 not to hit R4 again but R4 hit him. I took R4 out of the situation and R3 went to his room. V8 was not able to be reached by phone. R3's statement dated 5/23/26 shows R3 states that R4 came knocking at his door, he asked him what he needed. R3 asked R4 to leave and R4 said he wasn't going anywhere. R3 says he turned away and R4 kicked him. R3 said he swung at R4 and R3 kicked him again, then R3 hit him. R3 said staff broke them up. V9's statement dated 5/23/26 shows V8 asked for nurse assistance stating R3 struck R4's face and its red. This nurse went to R4, and his right side of his face was very red. R4 was not crying just frowny. This nurse asked what happened and R4 would not respond. I asked if his face hurt and he did not respond. V9 was not able to be reached by phone. R3's Facesheet shows R3 has diagnoses of unspecified dementia, epilepsy, type 2 diabetes and adult failure to thrive. R4's Facesheet shows R4 has diagnoses of unspecified dementia, congestive heart failure, atrial fibrillation. On 6/12/26 at 12:19 PM, V1 Administrator said residents are to be free from physical abuse. V1 said she did the investigations for R1 and R2 and also R3 and R4. V1 said R2 thought R1 was talking about him so R2 slapped R1. V1 said R4 went to R3's room and kicked R3 when R3 told R4 to get out of the room. V1 said R3 then hit R4 in the face when R4 didn't leave. The facility's Abuse Prevention and Reporting Policy dated 9/2024 shows The facility affirms the right of or residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services y staff or mistreatment.

Based on interview and record review the facility failed to ensure residents were treated with dignity and respect by other residents. This applies to 1 of 3 residents (R4) reviewed for resident rights/dignity in the sample of 7. The findings include: On 5/29/26 at 10:30AM R4 stated, I get tired of hearing the F word from (R1) all the time. He's a jerk. I feel sorry for his roommate now. (R1) used to be across the hall from me and it was really bad. We had a lot of trouble right at the beginning. One time I told him to stop saying the F word because he was just going off and then he looked right at me and just started really going off- F this and F that. I know he has been in prison, and I think that is just how he is, but I don't want to hear it all the time. The CNAs were standing there, and I think they should have told him to stop. I didn't like the way he talked to me. He knows what he is doing and I just ignore him now. I just stay away from him. That was about 3 weeks ago. On 5/29/26 at 12:20PM V4 (Previous CNA) stated, (R1) cusses at everyone. One time he was sitting in the hall F this and F that and (R4) came by and said, (R1), Language! and then he started yelling at her. He called her a F***ing B**** and just kept yelling. I got between them and told him he couldn't do that, she is a woman, but he wouldn't stop. He is like that with the staff too. On 5/29/26 at 10:40AM R1 stated, I can't stand (R4). She is a smarta**. I just don't talk to her. R1's Physician's Order Sheet shows he is [AGE] years old male resident with diagnoses including Morbid Obesity, Antisocial Personality Disorder and Bipolar Disorder. R1's care plan dated 2/2/26 states, (R1) is easily irritated and is known to shout and curse at others when he is frustrated. He has shown lack of disregard for others' boundaries . The Illinois long Term Care Ombudsman Program Residents' Rights for People in Long term Care Facilities Pamphlet states, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation and interview the facility failed to ensure windows in resident rooms were able to be opened to allow them to get fresh air. This applies to 1 of 3 residents (R5) reviewed for clean, comfortable and homelike conditions in the sample of 7. The findings include: On 5/29/26 at 11:20AM R5 stated, Before the AC (Air conditioning) units were put in, the windows were screwed shut. They put a screw in the track so you can't slide the window open. I understand they don't want people climbing out the windows, but we should be allowed to get some fresh air. It's inhumane. On 5/29/26 at 11:25AM R5 showed Surveyor her window where the screw usually sits. (The screw had been removed to allow the window to be opened and the AC unit to be installed). On 5/29/26 at 2:46PM V3 (Maintenance) stated, On the A wing we put a self-tapping screw in the track so they can't open the windows and climb out. We have done that for 16 years- ever since I have worked here. I've always been told to screw them shut so they can't open the windows at all. Only on the A wing. The other windows in the facility all open. A Concern/Compliment Form dated 5/26/26 written by R5 states, Where are our air conditioning units on A-side? Our windows are screwed shut so we cannot open for any outside air at all. The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long- Term Care Facilities pamphlet states, Your facility must be safe, clean, comfortable and homelike.

Based on observation, interview and record review the facility failed to supervise a resident at high risk for elopement while on a 1:1 monitoring. This failure resulted in R4 leaving the facility unauthorized, and fracturing her foot while climbing/jumping over a fence. This failure applies to 1 of 3 residents reviewed for safety and supervision. The immediate Jeopardy began on 3/14/26 when V13 Certified Nursing Assistant (CNA) allowed R4 to shut her door and remain out of her line of vision while on a 1:1 monitoring status, allowing R4 to elope out of her window. V2 Administrator in Training was notified of the Immediate Jeopardy on 4/30/26 at 9:00 AM. The surveyor confirmed by observation, interview and record review that the immediate jeopardy was removed, and the deficient practice corrected on 3/16/26, prior to the start of the survey and was therefore Past Noncompliance. Based on observation, interview and record review, the facility failed to ensure a resident with a history of substance abuse was safe from an opioid medication not prescribed to him (R3), this failure resulted in R3 overdosing, and being sent to the emergency room for stabilization, and subsequently hospitalized for psychiatric treatment.The findings include:The findings include: 1. R4s admission record documents she was admitted on [DATE] with diagnoses of schizophrenia, unspecified psychosis, and major depressive disorder. The 3/5/26 elopement/unauthorized leave risk review notes R4 had a history of wandering/elopement and verbalized a strong desire to leave and had a diagnosis of severe mental illness. The elopement risk decision of the same document shows R4 to be at risk to elope and should be placed on the elopement risk protocol. A care plan for elopement is indicated. R4s care plan initiated on 3/5/26 states the resident is an elopement risk/wanderer related to schizophrenia and psychosis. The 3/15/26 resident assessment and care screening documents R4 to have severe cognitive impairment. R4s psychiatry note and initial evaluation of 3/11/26 documents her to have schizophrenia, cocaine abuse, opioid abuse, nicotine dependence, and insomnia. Staff report ongoing behavioral concerns including a history of running away and recent exit-seeking behavior, with the patient observed scanning perimeter fencing for possible ways to leave the grounds. R4s nursing progress notes of 3/9/26 documents she was trying to use the keypad to exit the building, pacing and looking at the exit door. On 3/10/26 she was pushing on exit doors and setting off alarms. She had hovered around exit doors and had kicked and pushed open the exit door and tried to climb through windows. On 3/11/26 she was hovering at the ambulance exit and pacing, looking out and touching the keypad. On 3/12/26 she exited the facility doors and was returned to the facility by social services. The facility incident report of 3/14/26 documents R4 sustained an unwitnessed fall on facility grounds during an unauthorized exit. Upon investigation, review of clinical records, assessment, hospital documentation, statements of staff on duty, and statement from R4, it was found that R4 exited the building and climbed over fence, landing on the ground. Since her return from the emergency department, she remains on a 1:1 supervision. The hospital records for R4 show on 3/14/26 she arrived at 7:05 AM and had complaints of foot pain secondary to jumping over the fence of the nursing home trying to escape. Xray's were completed and showed a displaced fracture of the metatarsal bone of the left foot. On 4/28/26 at 9:46 AM, V11, Licensed Practical Nurse LPN said she has been working on the behavioral unit for about 4 years. When she arrived on 3/14/26 the night shift aide assigned the 1:1 for R4 was giving report to the oncoming day shift aide taking over the monitoring. The day shift aide (V14) reported to her R4 was not in her room. V11 said she initiated a headcount and staff searched the facility. R4 was found out front of the building by a tree, holding herself up because she had injured her foot. R4 had climbed out her window and jumped the fence and went through the main dining room and exited out the activity door. She did not make it very far, but if she had not injured herself, she would have been gone. V11 said she was not sure how long R4 had been outside. She said R4 had been on 1:1 when the elopement occurred. When she asked V14, she was told the night shift aide reported that R4 was in the bathroom. V11 said R4 is alert and oriented but does have delusions and hallucinations and not always oriented to the time. She has been exit seeking since she arrived. On 4/28/26 at 10:00 AM, V11 walked through the path of R4's elopement with this surveyor. R4's former room was observed to have a shared bathroom, and a fence outside of the room. The fence appears to be approximately 6 feet high. On the other side of the fence is the smoking patio leading into the main dining room. Across the dining room is the activity room with an alarmed door. Just outside of the activity door is a large tree. V11 stated that was where R4 was located. On 4/28/26 at 10:30 AM, R4 was observed sitting in the doorway of her room with a staff member next to her. She was alert and appeared guarded with answering questions. She said she would like to go somewhere else. On 4/28/26 at 11:44 AM, V14 said on 3/14/26 at 6:00 AM, she was assigned the 1:1 with R4 due to her elopement risk. When she arrived to relieve V13 CNA, she asked V13 why the door was shut to R4's room. V14 said the door was all the way shut so she opened it and asked V13 where R4 was located. V13 told her she was in the bathroom. V13 said she put her stuff away for the shift and came back and opened the door and R4 was not in the room. She said the window was open and R4 was gone. V14 immediately reported R4 missing to the nurse. She said the staff started doing room checks and then one of the staff members found her outside. V14 said when a resident is on a 1:1 the door should never be shut, and the resident should not be out of sight. V14 said R4 was missing for about 15 minutes. She had been on 1:1 due to her intentions to leave the facility. On 4/29/26 at 11:45 AM, V13 said while working night shift she was assigned the 1:1 with R4. V13 said during the night of 3/13/26 into the 3/14/26 morning hours, R4 had been up visiting, eating and sleeping. V13 said at 5:45 AM, which is her last 15-minute check on her monitoring sheet, R4 was in her room on the floor. Then shortly after that, R4 said she wanted to use the bathroom. She left the bedroom door open so she could see the bathroom door, and she saw R4 enter the bathroom. V13 said when V14 arrived she tried to close the door, and told V14 she could not do that. She said report was given to R14 and then she left. V13 said when a resident is on 1:1 you have to keep an eye on them at all times. If you have to use the bathroom, someone has to sit and watch that resident for you. She was not sure why R4 was on a 1:1 but was told she was an elopement risk and had behaviors. On 4/28/26 at 11:09 AM, V2 said R4 was a high risk for elopement and had been a resident on the alarmed behavior unit since her admission. V15 Care plan coordinator said R4 had behaviors including pacing the hallway, kicking at the door and pushing on the doors and walking away really quick. She was placed on 1:1 on 3/12/26 when she exited the building. V15 said R4 took off with social services following her to bring her back. When she returned, R4 had a blank stare, and we tried to encourage her to express her thoughts and respond to us. V2 stated during 1:1 the resident should be in eye contact with the aide at all times. She said the bedroom door cannot be shut. The facility's 1/2026 policy for code pink-missing resident/elopement documents the facility strives to promote resident safety and protect the rights and dignity of the residents. Elopement is the ability of a cognately impaired resident, who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed and who may enter into harms way. The Inservice sign in sheet of 3/14/26 details a 1:1 status. When someone is placed on 1:1 and you are assigned to do said task, you are to stay with that resident at all times. You may sit in the hall if they are in their room or in the bed, but the door must be opened and resident in sight. If residents are persistent in shutting the door, you should position yourself in the doorway and explain that you have to be able to see them. Prior to the survey date of 4/30/26, the facility had taken the following action to correct the noncompliance: 1. On 3/14/26 all residents were re-evaluated for risk of elopement and community survival skills. Care plans were audited to ensure it matched the resident risk of elopement. Elopement binder was audited by social services. 2. On 3/14/26, all residents will continue to be evaluated for elopement risk at admission, readmission, quarterly, annually, significant change and incidentally if risk behaviors are identified. 3. On 3/16/26, the elopement policy was reviewed by IDT to ensure processes address enhanced supervision and person-centered interventions. QA to review policy and procedure as part of Quality Assurance Process for each quarterly meeting x4. 4. On 3/14/26 and 3/15/26 elopement drills were conducted for all shifts. Agency staff are educated on elopement policy prior to accepting agency shifts at the facility. Staff were educated on the elopement policy on 3/14/26, 3/15/26 and 3/16/26. 5. QA audits will be conducted on 1:1 monitoring 3 times a week for 4 weeks. Staff member who failed to fulfill 1:1 monitoring duties appropriately for resident was verbally suspended on 3/14/26. 6. All staff were in-serviced on door alarms on 3/14/26, 3/15/26 and 3/16/26. QA audit on alarm response will be conducted 3 times weekly for 4 weeks. 2. The facility's final incident report sent to the IDPH (Illinois Department of Public Health) showed R3 was found lying on his bed and not responding to staff on 4/4/26 at 4:30 PM. The nurse assessed R3, performed a sternal rub, and administered naloxone (medication to reverse opioid overdose). The report showed R3 was transferred to the local emergency room for further treatment. The report showed it was determined that R3 had obtained and self-administered an opioid analgesic not prescribed to him. R3 was medically cleared and subsequently hospitalized for psychiatric treatment. R3's face sheet printed on 4/24/26 showed diagnoses including but not limited to schizophrenia, chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder and major depression. R3's facility assessment dated [DATE] showed cognitively intact and no memory problems. R3's care plan showed a focus area related to behavior problems. History of going out with grandparents and having them buy vape pens and alcohol while in their care. He has come back intoxicated or under the influence of unknown substances. Interventions included power of attorney wants family not to take resident out on outings and to have supervised visits in facility in common areas (initiated 8/22/24). On 4/24/26 at 11:25 AM, R3 was self-ambulating down the hall of the locked behavior unit he resides on. R3 was alert, calm and coherent. R3 stated he went out to the hospital a couple of weeks ago because he was breathing strange. R3 said he wasn't sure what happened, he just woke up in the hospital. R3 said they sent him to a mental hospital after that. R3 said when he returned to the facility a nurse (V4) told him he tested positive for oxy (oxycodone=opioid medication used to treat pain) at the hospital. R3 said I don't know how it happened, but my roommate (R5) had medications in the room. We don't live together anymore; they changed our rooms after I got back. R3 said he found his roommate's medication in the dresser drawer but denied taking the medication. R3 would not elaborate on what form or type of medication he found in the dresser. On 4/24/26 at 11:40 AM, V3 (Licensed Practical Nurse) stated she heard in a morning report that R3 had been found unresponsive in his room. He had overdosed on something. He went out to the hospital and since his return, we are supposed to keep him away from (R5). I think the incident had something to do with (R5), but I am not sure. All I know is we are supposed to keep them apart. On 4/24/26 at 12:55 PM, V4 (Licensed Practical Nurse) said R3 has good cognition, can recall past events and has no memory problems. V4 said on the day of the incident, a CNA (certified Nurse Aide) told her R3 was acting weird so she went in the room with another nurse (V16) to check on him. R3 was lying on the bed and not responding. R3 was showing obvious signs of a drug overdose. He was breathing slowly, in a super deep sleep, and not responding to chest rubs. 911 was called immediately and they eventually took him to the emergency room. R3 was breathing when he went out. V4 said I've worked with drug type patients before and unfortunately know very well what that looks like. It was very obvious R3 had a drug overdose. On 4/29/26 at 9:20 AM, V16 (Licensed Practical Nurse) stated she responded with V4 the day of R3's incident. V16 said it was weird all round. R3 lives on a locked unit but is allowed to have unsupervised visits with his grandparents. R3's grandparents did visit that morning and they went outside together. Another resident was out there too. The grandparents are known to bring contraband into the building in the past. That afternoon I went down to R3's room and he was high and really out of it. The administrator was on the unit too talking with V4. I went back to check on R3 and he was unresponsive. I was shaking him and doing sternal rubs. He was breathing strange and V4 gave him Narcan (naloxone) twice. He did get slightly better and the EMTs came right away. They transferred him out. R3 was breathing but still out of it. I heard they found a white powdery substance in his room. I got a call from the emergency room nurse later and they updated me that he tested positive for oxycodone. On 4/29/26 at 8:50 AM, V17 (CNA) stated she saw R3 the day of the incident walking down the hallway wearing sunglasses and stumbling into his room. V17 said she alerted the nurse. V4 and V16 (nurses) went to check on him. They both went in right away and started working on him The nurses both were doing chest rubs and gave him Narcan. 911 was called and they took him out. V17 said she searched the room once the EMTs left and found a white, powdery substance in a dresser drawer. V17 found empty bags with some white powdery, substance in it. V17 said she assumed it was cocaine or something like that and that R3 had snorted it. V17 said she overheard a nurse on the phone later saying something about an oxycodone prescription since 3/27. R3's April 2026 physician order report was reviewed. There was no prescription for oxycodone. R3's urine drug screen performed at the local emergency room and dated 4/4/26 showed a positive result for oxycodone. R5's April 2026 physician order report was reviewed and showed an order start dated 3/27/26 for oxycodone 5 milligrams to be given as needed every 6 hours for pain related to fracture of right tibia. R5's face sheet showed an admission date of 3/26/26 and admitting diagnosis of right tabia leg fracture. R3 and R5's electronic census tab showed they did room together on 4/4/26 (day of incident). On 4/24/26 at 11:45 AM, V5 (Director of Nurses) stated R3 did have an overdose on oxycodone, just like he said. That was the diagnosis given at the emergency room. The day of the incident the administrator saw that he was not acting like himself. She told the nurse (V4) to keep an eye on him. Later, the CNA told the nurse he was unresponsive. His breathing was off and 911 was called. Yes, oxycodone was found in his system. I don't know 100% where he got it. He did have a grandparents visit that day but those are to be supervised. That has been care planned since August of 2024. V5 reviewed R3's electronic record and confirmed there was not an order for oxycodone. V5 reviewed R5's electronic record and confirmed there was an order for oxycodone at the time of the incident. V5 said we have concerns with both of them being together. Both have history of substance abuse. It is plausible R3 took R5's medication. I can't confirm where he got it. Maybe one of his grandparent's brought it in. Maybe R5 still had it with him upon admission. I investigated the situation and don't know where it came from. Either way something failed. There are multiple processes that could have been better. For example, better supervision in a couple of ways for one thing. R3's emergency room record dated 4/4/26 showed he was medically stabilized and evaluated by a mental health counselor, who recommended hospitalization for ongoing suicidal ideation. The record showed R3 was transferred the same day to the mental health facility. R3's progress notes showed he did not return to the facility until 4/11/26 (7 days later). R5's progress notes dated 4/4/26 (day of incident) showed R5 was found snorting something in his room. A crushed-up substance was found on the resident's dresser and a pen that had been taken apart. R5's care plan showed a newer focus area start dated 4/6/26. Behavior problem with pocketing medications and saving medications to take later. Hiding vapes and medications from home. The facility's Medication Administration Policy last review dated 1/2026 stated: Medications must be administered in accordance with a physician's order, e.g. the right resident, right medication, right dosage, right route and right time.Medication supplied to one resident may not be administered to another resident. The facility's Medication Storage policy states: Facility should store Schedule II Controlled Substances and other medications deemed by facility to be at risk for abuse or diversion in a separate compartment.2. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visors. (Oxycodone is a controlled substance.)

Based on observation, interview and record review the facility failed to ensure a resident was free from misappropriation of property for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:R1s admission record shows she was admitted on [DATE] with multiple diagnoses including bipolar disorders, borderline personality disorder and major depressive disorder.R1s resident assessment and care screening of 2/7/26 documents her to cognitively intact.R2s admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including Autistic disorder, adjustment disorder and anxiety. His 3/27/26 quarterly resident assessment and care screening documents him to be cognitively intact.The facility financial abuse final report of 4/10/26 documents R1 reported her wallet stolen, and the last place where she saw it was on her bed. She stated the only person in her room was R2.On 4/24/26 at 1:22pm- R1 stated she had cashed a check a couple days before for $900, the same day she went to Walmart with another resident. She spent $500 at Walmart and had $450 left in the wallet. Then on Friday morning she noticed her wallet was missing. She told the nurse and aides, and they all started looking for the wallet. They found it in R2s room sitting on top of the dresser. R1 said (R2) swears up and down, he did not do it, but he knew she had the money. R1 said she is now out $450. She said once they found the wallet and notified the police, R1 said she would drop the charges against R2 if she could get her money back. She said now there is a lock on her nightstand, so this never happens again.On 4/24/26 at 1:30 PM, a key entry lock was observed on the top drawer of her nightstand.On 4/28/26 at 10:23 AM, V6 social service said she remembers cashing a check for R1, in the amount of $900. The check was from the company, and she advised R1 to hide it or have the business office keep it safe. She said R1 decided to keep it on her person.On 4/24/26 at 12:25 PM, V10 Certified Nursing Aide (CNA) said R1 had reported to her that the wallet was missing and had about $500 inside. V10 said she reported it to the nurse, and with V9 CNA, they searched her room and R2s room. The wallet was found on top of R2s dresser, and the money was missing. On 4/24/26 at 1:39pm, R2 said he did not know how the wallet ended up in his room. He said before that, he had been out with R1 to Walmart, Burger King and Scooters, then returned to the facility. He did not know when the wallet appeared in his room. The police were here and charged me with theft because it was found in my room.R1 nursing progress note of 4/2/26 at 1:11 PM documents V6 cased a check for R1 and counted the money to the resident, and requested she keep the money safe and secure.R1s progress note of 4/4/26 at 10:49 AM, notes V2 Administrator in Training and V7 Assistant Administrator were called due to R1 being upset over her property being stolen. R1 stated her wallet was stolen and it was found in (R2) room. R1 reported she had money in her wallet, when it was returned to her the money was gone. Resident accepted the offer to speak to the police department.On 4/24/26 at 11:30 AM, V7 said she completed the investigation with V2. She said R1 reported to her R2 had stolen her wallet and money. R1 reported she had just been shopping and returned to the facility with $400 and the wallet was found in R2s room with the money missing. V7 said she interviewed the staff and R2 regarding the wallet and money. She said the police were notified and spoke with R2, and he denied taking the money, but R2 was issued a notice to appear in court for May 1, 2026. She said there were no other complaints, and the theft was substantiated.The facility's 9/2024 policy for abuse prevention and reporting documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and record review the facility failed to ensure residents were free from physical and verbal abuse. This applies to 3 of 3 residents (R1-R3) reviewed for abuse in the sample of 11.The findings include: 1. The Final Abuse Report dated 2/11/26 shows R1 is [AGE] year-old male with diagnoses including dementia, anxiety and chronic pain. R1 has moderate cognitive impairment. R2 is a [AGE] year-old male with diagnoses including dementia, COPD, and hypertension. R2 is cognitively intact. On 2/6/26, V13 (RN) heard shouting between residents when he entered the room (R1, R2) were on the floor side by side. (R2's) arm was loosely wrapped around (R1's) neck holding him to the ground and (R1) was attempting to get loose. On 2/27/26 at 10:18 AM, R2 was in his room lying in bed, he said there was something that happened between him and another resident (R1). R2 said he put R1 in a choke hold, it was a big mistake. R2 said R1 was at the wrong place at the wrong time and the staff took care of it. On 2/27/26 at 10:27 AM, R1 was in the activity room interacting with other residents. R1 was alert to self, and he was not able to answer questions. R1's speech was incoherent and gibberish. On 2/27/26 at 1:40 PM, V13 (RN) said on 2/6/26, he was in the nurses office and could hear shouting. He entered R2's room and saw R2 and R1 on the floor. R2 had his arm wrapped around R1's neck loosely like they were wrestling. R1 was yelling to get R2 off him. V13 said he separated the residents and assessed both residents. V13 said R2 did not sustain any injury or bruise to his neck and R1 had wandered into R2's room. On 2/27/26 at 12:38 PM, V1 (Administrator) said R1 and R2 shared a bathroom. R2 was new to the facility. During the night R1 went to the bathroom and exited the bathroom into R2's room. That startled R2, he reacted and placed hands on R1. V1 said she did substantiate the physical altercation. V23's (CNA) statement dated 2/9/26 shows he heard (R1) yelling profanity from another resident's room. He went into R2's room and found both residents on the floor. (R2) had (R1) in a choke hold and (R1) was pulling (R2's) hair, he yelled for V13. 2. The facility's Final Abuse report dated 2/11/26 shows allegation of verbal altercation between a resident and staff. (R3) is a [AGE] year old male with diagnoses including edema, type 2 diabetes, antisocial personality disorder, bipolar, and major depression. (R3) is cognitively intact. On 2/5/26, (R3) admitted he called a dietary staff member racial slurs.V12 (Dietary Staff/Former Employee) said he was verbally protecting himself against the racial slurs. Staff members interviewed said (R3) was screaming racial slurs at (V12). (V12) began shouting back at (R3) then moved toward him indicating that he would strike. Staff member stepped in between (R3) and (V12) and both were separated.Evidence noted (V12's) response to (R3) was inappropriate and was terminated. On 2/27/26 at 10:45 AM, R3 was in his room lying in bed. He said he got into it with the cook (V12). R3 said V12 came at me like he was going to hit me. R3 said V12 came out of the kitchen and asked what my problem was and told me I could not talk to him like that (calling him racial slurs). R3 said the facility got rid of V12 after the incident. On 2/2726 at 12:41 PM, V4 (ADON) said on 2/6/26, staff notified her of the incident with R3. When she entered the dining room, R3 and V12 were screaming, yelling back and forth using profanity. R3 was using racial slurs towards V12. V12 was starring R3 down saying come at me and I'll whoop you're a**, nobody talks to me like that. On 2/27/26 at 12:57 PM, V5 (Social Services) said on 2/5/26, she was walking down the hall getting ready to clock out and heard yelling. She went to the dining room. V12 called R3 a b**** and R3 called V12 the N word. V12 then was walking towards R3 as if he was going to strike him. V5 said she stepped in between them with her hands up to keep them separated and to deescalate. On 2/27/26 at 12:40 PM, V2 (Assistant Administrator) said she was walking out the building when staff reported there was one incident with R3 and V12. R3 and V12 were arguing back and forth. R3 was using racial slurs and V12 responded verbally back. She directed V12 to go into the kitchen and was suspended during the investigation. On 2/27/26 at 12:38 PM, V1 said R3 was using racial slurs. R3 called V12 the n word and cotton picker. V12 responded extremely inappropriately and responded verbally to R3. At the end of the investigation, V12 was terminated. V12's Interview statement dated 2/9/26 shows I was in the kitchen (R3) started yelling N****.I came out of the kitchen and asked, What's your problem. Then (R3) kept cursing at me. I did get upset and started cussing back at him because he has been calling us N*****. The facility's Abuse and Reporting Policy dated 12/25 states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment.physical abuse is the infliction of injury on a resident that occurs other than by accidental means.Verbal abuse includes the use of oral, written or gestured communication.

Based on interview and record review the facility failed to safely discharge a resident for1 of 3 residents (R6) reviewed for safe discharge in the sample of 11.The Findings include:R6's Face Sheet documents, R6 has diagnoses that include diabetes and bipolar disorder. R6 was discharged last 1/30/26. The same face sheet documents discharged to-Nursing Home unknown.R6's facility assessment dated [DATE] show R6 has no cognitive impairment.R6's vital summary shows R6 weighs 426 pounds (lbs.)On 2/27/26 at 10:10 AM, V5 (Social Service) said R6 was transferred to another Nursing Home that took bariatric residents (approximately 145 miles away) from this facility. As far as I know R6 was still at the facility up to this time. V5 said she had not called the facility to check on R6 since the time of transfer. V5 said she provided the receiving Nursing Home R6's information but cannot recall who she spoke to at the facility. V5 also confirmed she did not document this information in R6's medical records.On 2/27/26 at V15 (Administrator of the Nursing Home R6 was referred to) said R6 was never a resident in their facility.On 2/27/26 at 11: 36 AM, R6 said the time she was transferred to another Nursing Home, (1/30/26) the receiving Nursing Home said they were not ready for her and that they did not have the bed and wheelchair that would fit her. R6 said it was by that time very late, so she was brought to a hospital. At this time, she was in a different facility (not the facility she was supposed to transfer to).On 2/27/26 at 10:30 AM V14 (R6's family) said when R6 got to the Nursing Home where she was supposed to be transferred to, the Nursing Home did not have the bariatric bed or bariatric wheelchair for R6. R6 got so anxious and had palpitations so she was sent to the emergency room (ER). The hospital found a different Nursing Home that would take R6 and have the medical equipment she needed (not the Nursing Home she was referred to.)On 2/27/26 at 1:41 PM, V16 (License Practical Nurse) said she was the Nurse that discharged R6 on 1/30/26. V16 said she sent with R6 her discharged medications but did not provide any additional discharge papers to R6 because she was not instructed to do that. On 2/27/26 at 12:48 PM, V3 (Director of Nursing-DON) said when discharging a resident including a transfer to another Nursing Home, the discharging Nurse should have provided discharge instructions that included (but not limited to) list of meds and instructions, list of medical equipment that the resident need and a copy kept in the medical record to ensure continuity of care and resident's safety.The Facility Policy on Notice of Transfer and discharge date d 12/20/25 documents: When the facility transfers or discharges a resident, the facility must ensure that the transfer or discharge is documented in the residence medical record, appropriate information is communicated to the receiving healthcare institution. Discharge from the facility will include review of all necessary items to maintain the individual's highest practicable well-being, this includes necessary DME (durable medical equipment) and provision of medication prescriptions, appointments and treatments.

Based on interview and record review, the facility failed to implement it's policy and procedure to identify a potential sexual abuse allegation for one of four residents, reviewed for abuse, in a sample of six.The facility policy, Abuse Prevention and Reporting, dated (effective 12/2025) directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property. During orientation of new employees, the facility will cover at least the following topics: What constitutes abuse and Procedures for reporting incidents/allegations of abuse.The (facility) Resident Grievance form, dated 12/8/25 and signed by V10/Assistant Administrator documents, On December 8(2025) , (V10) was called and CNA (Certified Nursing Assistant/V4) stated, 'I was trying to get into (R1's) room and (V3/Transportation Driver) was behind the door and (R1) had her shirt up and (her) bra was showing. (V3) gave (R1) a sub sandwich over a bet on football. (V10) discussed with (V3) (the) incident. (V3) states I took (R1) a sub sandwich over a bet on football. I was in (R1's) room giving her the sandwich when the other (resident/R6) was coming, because (R6) continues to try and hug me, so I stay away from (R6). At no time was (R1) inappropriate with me. I was just being nice getting her a sandwich because she didn't like supper, and I lost the bet on (the) football game. (V3) was coached on appropriate behavior, such as no betting on games with food and no bringing food items. V3 stated he understood and was just being nice. (R1) states the same story when questioned.On 01/10/2026 at 8:10 A.M., V1/Administrator stated she is aware of a situation between (R1) and V3/Transportation Aide. States V3 is her brother and on 12/8/2025, she was called at home by V2/Director of Nurses with V4/Certified Nursing Assistant in the same office, stating she had witnessed V3/Transportation Aide in (R1's) room with the door closed and when V4 attempted to go into R1's room to see what was going on and why the door was closed, she was able to partially enter the room and saw R1 with her shirt up, covering her face, exposing her bra. Once V4 was able to enter R1's room, she found V3 behind the door, facing R1. At that time, V3 raised his arms in the air and stated repeatedly, don't say anything. Don't say anything. V1/Administrator states she conferred with V9/Corporate Staff, and it was decided that V4/CNA was making trouble, and she knew V3 was V1's brother and wanted to get V3 in trouble. V1 states she did not feel the situation was potential abuse, she did not report the situation to the state agency, and she did not notify the local law enforcement agency.

Based on interview and record review the facility failed to report a potential allegation of sexual abuse, to the state agency or the local law enforcement agency for one of four resident (R1), reviewed for abuse, in sample of six.The facility policy, Abuse Prevention and Reporting, dated (effective 12/2025) directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the state agency immediately. The facility shall also contact local law enforcement authorities in the following situations: sexual abuse of a resident by a staff member.The (facility) Resident Grievance form, dated 12/8/25 and signed by V10/Assistant Administrator documents, On December 8(2025) , (V10) was called and CNA (Certified Nursing Assistant/V4) stated, 'I was trying to get into (R1's) room and (V3/Transportation Driver) was behind the door and (R1) had her shirt up and (her) bra was showing. (V3) gave (R1) a sub sandwich over a bet on football.On 01/10/2026 at 8:10 A.M., V1/Administrator stated she is aware of a situation between (R1) and V3/Transportation Aide. States V3 is her brother and on 12/8/2025, she was called at home by V2/Director of Nurses with V4/Certified Nursing Assistant in the same office, stating she had witnessed V3/Transportation Aide in (R1's) room with the door closed and when V4 attempted to go into R1's room to see what was going on and why the door was closed, she was able to partially enter the room and saw R1 with her shirt up, covering her face, exposing her bra. Once V4 was able to enter R1's room, she found V3 behind the door, facing R1. At that time, V3 raised his arms in the air and stated repeatedly, don't say anything. Don't say anything. V1/Administrator states she conferred with V9/Corporate Staff, and it was decided that V4/CNA was making trouble, and she knew V3 was V1's brother and wanted to get V3 in trouble. V1 states she did not feel the situation was potential abuse, she did not report the situation to the state agency, and she did not notify the local law enforcement agency.

Based on interview and record review, the facility failed to provide eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 128 residents residing in the facility.Findings include:The facility's Facility Assessment Tool, dated 9/11/2025, documents the facility will provide a Registered Nurse (RN) eight and a half hours per day as needed to accommodate RN staffing hours.The facility's (state agency) Notice of Staffing Violations, received date 8/18/25, documents the facility's January 1st- March 31st, 2025, quarter for payroll-based journal was shortfall for RN coverage on 55 days.The facility's nursing staff schedule for September 2025, documents on Saturday 9/6/25 and Sunday 9/7/25 the facility did not have eight hours of an RN working in the facility.On 9/16/2025 at 1:00 PM, V2 (Director of Nursing) confirmed the facility does not have an RN on certain days for a minimum of eight hours. V2 stated On the dates that we don't have an RN on the schedule or the daily staffing sheet; it is because we don't have an RN. We have that issue and have been cited by the (state agency) for low RN coverage. I used to have agency RNs that we could utilize, and they (corporate) won't let us use agency RNs anymore. So now we have some days that are short RN coverage for the 8 hours a day.The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 9/14/25 and signed by V1 (Administrator), documents 128 residents currently reside within the facility.

Based on interview and record review, the facility failed to ensure that residents and their representatives were provided a clear, accurate, and understandable explanation of the arbitration agreement during the admission process, resulting in confusion and lack of informed consent for all residents reviewed. This failure has the potential to affect all 128 residents who reside in the facility.Findings include:The facility's undated Arbitration Agreement documents, Arbitration is an alternative means of resolving a dispute in place of court litigation. Binding Arbitration mean that both parties must comply with the arbitration decision, and that decision cannot be appeal. This agreement binds all parties, including, without limitation, any spouse, children or heirs of the resident, whose claims arise out of injuries, death because of alleged negligence, or wrongful act, but not intentional injury, and services rendered for any condition and arising out of the diagnosis, treatment, or care of the resident.The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 9/14/25 and signed by V1/Administrator documents 128 residents currently reside within the facility.R95's Contract Between Resident and (the facility) dated 8/11/25, documents that R95 signed the binding arbitration agreement.On 9/15/25 at 11:00 AM, R95 stated she does not recall anyone explaining what an arbitration agreement is, and R95 would not of signed this document if she knew.R43's Contract Between Resident and (the facility) dated 8/15/25, documents that R43 signed the binding arbitration agreement.On 9/14/25 at 11:10 AM, R43 stated that she does not remember V8 (Business Office Manager) explaining what an Arbitration Agreement was and if R43 had known she would not have signed the document.On 9/15/2025 at 10:00 AM, during resident council meeting, R1, R5, R21, R26, R43, and R115 did not recall signing the arbitration agreement or that anyone explained to them or their representative what it was, and all stated they would not have signed the arbitration agreement if they understood what it was.09/14/2025 10:45 AM, V8 (Business Office Manager) stated that V8 goes over all the information in the admission contract with residents and their families. V8 stated that arbitration agreement means if anything happens or comes up, the resident and family doesn't have to do anything, V8 takes care of it. When asked what V8 explains to residents and their families that the arbitration agreement is V8 stated, I tell them if Medicare or Medicaid doesn't pay something then we help take care of it.

Based on observation, interview, and record review the facility failed to ensure kitchen fans were kept clean and free of debris, label and date opened food items in the kitchen's refrigerator and freezer, complete and record cool down temperatures for meat that was prepared and stored in the facility's refrigerator and ensure dietary staff's facial hair was covered while in the kitchen. This failure has the potential to affect all 128 residents.Findings include:The facility's Ceiling and Fans Policy, un-dated, documents Frequency: All fans should be cleaned quarterly or more often, if needed, by maintenance. Purpose: To ensure a clean work environment. The facility's Storage Policy, undated, documents Policy: Food should be stored properly and used within the appropriate time period to ensure safe and high-quality food is served. Purpose: Food safety. Procedure: The Use-by Guidelines-Posted should be used to determine a use-b date when labeling opened or unopened food that must be used within a certain time frame. Foods with a manufacturer's use-by date should still require and opened-on date once the item is opened. Expired food items should be disposed of.The facility's Staff Hygiene/Hair Nets Policy, dated 9/2024, documents Purpose: To establish standards for employee dress, personal hygiene, and hand hygiene practices. 2. Dress code will include at least the following. Specific uniform criteria and colors will be at the discretion of the Food Service Supervisor: e. Beards are to be trimmed and covered with face mask or [NAME] (beard net).The facility's Cooling Foods-Hot Foods and Ambient Foods Policy, undated, documents Policy: Hot food items should be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours and to 41 degrees Fahrenheit or lower within an additional four hours. Ambient Food items should be cooled to 41 degrees Fahrenheit or lower within four hours. Purpose: Proper cooling of foods eliminates the most common cause of foodborne illnesses. Procedure: 10. Use a clean, sanitized, and calibrate thermometer to monitor temperatures and record on the cooling log at the appropriate intervals.On 9/14/25 at 8:27 AM a kitchen tour was conducted with V3/Dietary Manager. During breakfast preparation, two fans were noted blowing towards the breakfast steam table. The fans had an accumulation of thick, stringy dust and debris on their exteriors and blades. V3/Dietary Manager verified the presence of the debris and could not recall the last time the fans were cleaned. On 9/14/25 at 8:31 AM the walk-in refrigerator was found to contain three pans of food dated 9/12/25: two covered pans of pork loin and one of ground beef. V3/Dietary Manager verified these items were cooked two days prior for a meal on the current inspection day. In addition, an unlabeled 2-quart container of brownish/purple soft substance, identified by V3 as peanut butter and jelly mixture, was also observed. V3 stated the 2-quart container should have been properly labeled with its contents and preparation date. The facility's cool-down logs, covering the period of August 25, 2025, through September 12, 2025, do not document that cool down temperature records were completed for two large pans of pork loin and one large pan of ground beef, all dated September 12, 2025. On 9/14/25 at 8:33 AM, V3/Dietary Manager confirmed that these cool down log entries were missing and should have been recorded.On 9/14/25 at 8:35 AM, an open bag of pork patties was found in the freezer without a date or label. V3 verified the open bag of pork patties should have been properly labeled and dated when opened. On 9/14/25 at 8:36 AM V4/Cook with long facial hair was observed serving breakfast without a beard net. V3/Dietary Manager verified V4 was not wearing a beard net while serving breakfast and it is required. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 9/14/25 and signed by V1/Administrator documents 128 residents currently reside within the facility.

Based on observation, and interview, the facility failed to maintain a safe, clean, and comfortable environment for residents in A Wing, resulting in unsanitary conditions, structural disrepair, and the presence of black fuzzy discoloration on bathroom walls and standing water in multiple bathrooms for 46 of 46 residents (R1, R4, R14, R15, R16, R17, R19, R21, R22, R27, R28, R29, R31, R40, R42, R44, R45, R46, R48, R51, R52, R53, R56, R60, R62, R64, R70, R71, R73, R79, R81, R83, R84, R89, R96, R97, R103, R106, R107, R110, R113, R120, R125,R130, R131, and R132) reviewed for environment in the sample list of 74. Findings include: The facility's Cleaning-Sanitizing Bathing Equipment and Toilet Seats Policy revised 1/2018 documents housekeeping personnel are responsible for at least daily cleaning of bathing equipment, wipe down or scrub all surfaces with a soft brush, cleaning cloth or sponge and sanitizing agent to assure removal of organic matter and then completely rinse with clean water. The facility's Housekeeper Supervisor policy revised 7/2023 documents the primary purpose of the Housekeeper Supervisor is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. The Housekeeping Supervisor is responsible for ensuring work/cleaning schedules are followed, clean, wash sanitize, and polish fixtures, ledges, room heating/cooling units, bathrooms, clean floors including sweeping, mopping, stripping, waxing, buffing, and disinfecting. The facility's Maintenance Director Job Description revised 12/2022 documents to repair facility/resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Also ensure services that are provided by outside vendors are properly completed/supervised in accordance with contracts/work orders. Ensure supplies and equipment are maintained to provide a safe comfortable environment. The facility's Resident Roster dated 9/14/25, provided by V1 (Administrator) documents R1, R4, R14, R15, R16, R17, R19, R21, R22, R27, R28, R29, R31, R40, R42, R44, R45, R46, R48, R51, R52, R53, R56, R60, R62, R64, R70, R71, R73, R79, R81, R83, R84, R89, R96, R97, R103, R106, R107, R110, R113, R120, R125, R130, R131, and R132 reside in A wing. On 09/14/2025 from 8:30 AM to 3:00 PM, during random observations of A Wing: Hallway floors had visible dirt and debris. Paint was peeling and chipping on the walls in multiple resident rooms. Multiple resident bathrooms had black fuzzy discoloration along the walls behind toilets and sinks. Baseboards were peeling away from the walls and laying on the bathroom floors. The dining room floor was sticky and covered with dried liquid, food particles, and dirt. Several bathroom toilets were leaking water at the base of the toilet, with standing water present on the floors. Bath blankets were wrapped around the base of toilets that were leaking water. On 9/15/25 at 10:00 AM, R1 stated in a resident council meeting that A wing is very dirty and in disrepair, closet doors are falling off and drawers are sticking, paint is peeling, and the toilets never work. On 9/15/2025 at 1:01 PM, V6 (Maintenance Director) stated We replace screens often on the toilets, and I'm not sure why toilets leak so frequently. There are lots of plumbing issues because the plumbing is old and needs replaced. We plan to start painting rooms and bathrooms at some point. There is black mold from water damage in the bathrooms and housekeeping should be washing walls in the bathrooms. On 9/15/2025 at 1:30 PM, V7 (Housekeeping Supervisor) stated We use a hospital grade cleaning solution to spray on mold on walls. We put the solution in a spray bottle, spray it on, leave it for five–six minutes, then spray it off. The staff used to be good at using it, but they haven't been using it for a while. The facility is cutting five staff members' hours—and told staff it's due to budget cuts. I have a checklist that is supposed to be completed, but sometimes the staff turn them back in and sometimes they don't. I am aware there is black mold in many bathrooms. The floors in the A Wing dining room are terrible—they look awful. On 9/15/25 at 2:15 PM, V7 stated that she has done a walk-through of A wing and has found mold in every bathroom.

Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one of one resident (R63) reviewed for call lights in a sample of 74.Findings include: The facility's Call Light Policy, dated 10/2024, documents Purpose: To respond to residents' requests needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.R63's Care Plan dated 9/24/24, documents, (R63) is usually unable to perform ADLS (Activities of Daily Livings) without weight bearing/hands on assist of one to two care givers or dependent for cares related to history of Stroke. This same plan of care documents R63 requires staff assistance with all ADLS and extensive assistance with two staff members and mechanical lift for transfers.On 9/14/2025 at 9:21 AM R63 was sitting in a high back wheelchair in his room at the end of his bed. R63 was yelling help. R63 stated he was needing a staff member to help move him. R63's call light was lying out of reach on R63's bedside table in his room.On 9/14/25 at 9:24 AM V10/Certified Nursing Assistant verified R63's call light was not within reach and should have been since R63 is unable to self-propel his wheelchair to reach his call light.

Based on observation, interview, and record review the facility failed to allow a resident their preferred smoking method for one of three residents (R62) reviewed for smoking in a sample of 74. Findings Include:The Illinois Long Term Care Ombudsman Program Resident Rights Policy, Revised 11/18 documents, Your rights to dignity and respect, you have a right to make your own choices. R62's Smoking Safety Risk assessment dated [DATE] documents R62 smokes tobacco. This same assessment also documents R62 is not cognitively impaired, able to smoke, does not show potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking materials, has no history of hazardous behavior while smoking, follows facility smoking policy, and is on supervision during smoking times.R62's Smoking Progress Note dated 7/30/2025 and signed by V13 (Activity Director), documents (R62) does use tobacco. (R62) does not use an electronic cigarette or vaping device. (R62) is not interested in receiving information regarding smoking cessation. No problem with general awareness and orientation, including ability to understand the facility safe smoking policy. No concerns with general behaviors and interpersonal interaction. No problem noted to move around, general mobility. No concerns noted with potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking materials. No concerns with history of hazardous behavior (example: smoking in unauthorized areas or careless use of smoke materials, sustaining burns, fire starting). No concerns with begging, borrowing, trading items or panhandles for smoking materials. (R62) has a history of less than one pack per day. No concerns with potential for safely following the facility smoking policy. Recommendation - (R62) requires a smoking apron; is not able to store smoking materials.On 9/14/2025 at 9:00 AM R62 stated, I can do things by myself. I want to smoke cigarettes and this place makes me vape. I don't want to vape. R62 stated he likes to buy his own tobacco and cigarette cartridges and make his own, but the facility will not let him. R62 stated he is forced to buy vapes, they are expensive, and he does not want to use his money on vapes in order to smoke when he is fully capable to smoke cigarettes.On 9/16/2025 at 12:20 PM, V13 (Activities Director) stated R62 is not capable of rolling his own cigarettes. V13 stated R62 has attempted, and staff must help him. V13 stated R62 cannot load the empty cartridge on the machine and cannot pinch and roll the end without shaking and getting frustrated. V13 reported they have always helped R62 roll cigarettes if he needed it with no problem but then V1/Administrator instructed all activities staff to not help roll residents cigarettes because we are not getting paid to roll cigarettes, if residents cannot roll themselves, they need to buy their own cigarettes or vape.On 9/16/2025 at 12:25 PM, V14 (A Wing Activity Aide) stated I have helped (R62) several times roll his own cigarettes, and he cannot place the cigarette cartridge on the machine. I have no problem helping him but now I am not allowed to.On 9/16/2025 at 1:20 PM, R62 was in the main dining room, R62 loaded tobacco into cigarette machine, placed empty cigarette cartridge on machine, started the machine, loaded the cigarette cartridge, and pinched and twisted the end of the cigarette to seal the tobacco without difficulty. V13 (Activity Director) was also observing and verified R62 had no difficulty in rolling his own cigarettes.

Based on observation, interview, and record review the facility failed to provide privacy during gastrostomy cares/feeding for one of two residents (R27) reviewed for gastrostomy cares in a sample of 74.Findings Include:The Illinois Long Term Care Ombudsman Program Resident Rights Policy, Revised 11/18 documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. You have a right to privacy. Facility staff must respect your privacy when you are being examined or given care.R27's Physician Order sheet documents, Enteral Feeding Order, four times a day, every day.On 9/14/2025 at 12:43 PM, V11 (Registered Nurse) began gastrostomy cares to R27. R27's door was wide open, and R27's curtain was halfway closed. Various residents walked past R27's room and observed V11 performing R27's gastrostomy care.On 9/14/2025 at 1:00 PM, V11 confirmed she should have closed the curtain all the way or shut the door before beginning R27's cares.

Based on interviews and record review, the facility failed to follow their policy and procedure for pain management by not adequately assessing, documenting or treating a resident's (R3) pain while awaiting further evaluation and treatment post fall with significant injury. This failure applied to one of four residents reviewed for pain management related to falls in a sample size of 6. Findings include: R3's face sheet showed the resident admitted to facility on 03/28/2025 with a past medical history not limited to dementia, neurocognitive disorder, presence of right artificial hip joint (04/29/2025), lack of coordination, anxiety disorder, and obsessive-compulsive disorder. Brief Interview for Mental Status (BIMS) dated 04/10/2025 showed R3 has severe cognitive impairment. R3's admission care plan indicated the resident has impaired cognitive function (rev 04/29/2025); is at risk for falls related to dementia and restless behavior (rev 04/30/2025); is at risk for pain related to left (injury is to the right) femur fracture post-surgery (rev 04/30/2025) with interventions not limited to: pain is alleviated and/or relieved by pain management and repositioning, administer analgesics as per orders, evaluate the effectiveness and monitor/record/report to the nurse any signs or symptoms of non-verbal pain and residents complaint of pain. R3's incident fall assessment completed by V7 (Licensed Practical Nurse/LPN) with an effective date of 04/10/2025 at 12:23 AM, documented a fall incident on 04/09/2025 at 9:25 PM with pain level of three assessed same day at 10:38 PM under section B/assessment and showed under section C for actions/interventions, the physician was not notified until 12:00 AM on same day (should read as 04/10/2025 not 04/09). Under pain assessment, pain scale documented zero and staff assessment for pain was not conducted. V7's incident note dated 04/10/2025 at 12:23 AM documented R3 sustained a fall on 04/09/2025 at 9:25 PM and denied pain, then documented that the resident's pain in not a new onset. R3's progress note dated 04/10/2025 at 10:00 AM documented mobile x-ray was at the facility to perform an x-ray. Results dated the same day showed the resident sustained an acute minimally displaced fracture of the right femoral neck. V4's (Registered Nurse) follow-up note dated 04/10/2025 at 10:25 AM documented in R3's post fall assessment, No pain. The resident's pain in not a new onset. V4's note dated 04/10/2025 at 12:35 PM documented x-ray results were received and reported to V7 (Medical Doctor). V4's progress note dated 04/10/2025 at 3:43 PM documented an order was received from V7 to send the resident to the hospital for evaluation. Emergency transport services (911) were notified. Emergency department records for R3 dated 04/10/2025 at 4:34 PM indicated the resident presented with complaints of hip fracture. At 5:40 PM, records indicated R3 complains of pain into his right hip and under physical exam for musculoskeletal, R3's records documented, deformity and signs of injury present. Hospital imaging results for R3 showed the right hip was examined on 04/10/2025 at 5:44 PM for history of right hip pain due to a suspected fracture. Final investigation report dated 04/17/2025 indicated R3 had a witnessed fall on 04/10/2025 and sustained a superficial laceration to the right brow and pain to right hip was noted post fall. In-house mobile x-ray was obtained. R3 was transferred to emergency room for further evaluation and admitted with an acute minimally displaced fracture of right femoral neck that required surgical repair. Second hospital records dated 04/29/2025 and signed by V12 (Medical Doctor) indicated R3 was admitted to this hospital for right hip fracture and underwent a right hemiarthroplasty (partial hip surgical replacement) done on 04/11/2025. Review of R3's medication administration record for April 2025 showed two documented pain levels of 3 on 04/09/2025 and two documented pain levels of 4 on 04/10/2025. Record also showed order for acetaminophen oral tablet 325 milligrams (mg) give [two] tablets by mouth every [six] hours as needed for pain with start date of 03/28/2025 at 7:30 PM and discontinued date of 04/28/2025 at 3:14 PM. No documented administrations for acetaminophen were recorded on this administration record. R3's order summary report dated 05/16/2025 received from facility showed orders not limited to pain assessment every shift and acetaminophen 325mg, give two tablets by mouth every six hours as needed for pain both with order date of 04/29/2025. On 05/16/2025 at 1:41 PM, V6 (Licensed Practical Nurse) said on 04/09/2025 at around 9-10:00 PM, R3 was on the floor in the lounge area of B wing, laying on his right side. V6 then said that R3 yelled out in pain when you touched his legs and indicated that R3 wouldn't straighten out his legs and R3 was in a lot of pain. On 05/16/2025 at 2:13 PM, V4 (Registered Nurse) said she came into work on 04/10/2025 at 6:00 AM and was informed by V6 that R3 fell the night before (04/09/2025) and landed on his right hip. V4 then said she was told in report by V6 that R3 had no complaints of pain during the night until around 5:00 AM. V4 added that she believed V6 had administered acetaminophen to R3 around 5-5:30 AM and that V6 had contacted the physician after R3's fall and after his complaint of pain. V4 then said a resident is sent out emergently after a fall with complaints of pain and/or injury to a specific part of the body. On 05/20/2025 at 12:27 PM V7 (Medical Doctor) said he does not recall being notified of any significant injury for R3 post fall and that he ordered an x-ray be done due to R3's complaints of pain but did not recall the time he was informed of R3's pain complaint. On 05/20/2025 at 12:08 PM, V8 (Unit Attendant) said on 04/09/2025 at 10:00 PM, she was assigned on 1:1 monitoring for R3. V8 then said that R3 moaned a lot during the night and indicated that when the aides came in and changed his brief at approximately 12:00 AM, he was moaning out in pain and was grabbing at their hands, and after the second time they changed R3's brief around 1:30 AM, he really hollered out in pain and that was when the aides noticed bruising starting to his right hip area. She added that the aides went to get V6 (LPN) at this time and believed R3 had received pain medication from V6. On 05/20/2025 at 3:02 PM, V2 (Director of Nursing) said following R3's fall incident, there was no new order for pain management received. V2 then said her expectation for nursing when administering a pain medication is to complete a pain assessment, document the administration and pain scale then document a follow-up for the effectiveness of medication. On 05/20/2025 at 3:13 PM, V14 (Certified Nursing Assistant) said R3's fall incident occurred about 7:30 PM when he stood up then fell over and landed on his right side. V14 then said about 10:00 PM, R3 started to complain of hip pain during his brief change and continued to complain of pain every time he was checked on which was about every two hours. V14 added that every time R3 was checked on, the nurse (V6) was present and that R3 complained of pain every time staff touched him throughout the night and they placed an ice pack to his hip around 2:00 AM for the pain but R3 wouldn't leave it on. V14 then said that she believed V6 administered acetaminophen to R3 after the fall around 8:00 PM for complaint of head pain and around 4:00 AM and that during last check on R3 at 6:00 AM, that's when R3 was starting to bruise. V14 added that she both V4 (RN) and V6 (LPN) of the bruising to R3's right hip and that he was still complaining of pain. Review of R3's progress notes showed no documentation of resident's complaints of hip pain throughout the night, any pain assessments or monitoring for right hip pain, no administrations of pain medication, or of the bruising noted by V8 and V14 to R3's right hip. On 05/20/2025 at 3:55 PM, V2 (Director of Nursing) said that complaints of pain and the administration of pain medication would be expected post fall with a fracture. Pain management program policy last revised 04/2025 reads in part: to establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program .The pain management program includes the following components but not limited to documentation of pain assessment and monitoring.

Based on interview and record review the facility failed to provide medications as ordered for one of four residents (R232) reviewed for medication administration, in a sample of 45. FINDINGS INCLUDE: The facility's Medication Administration policy, dated 11/18/17, documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. The facility's Adverse Drug Reactions and Medication Discrepancy policy, dated 11/6/18, documents, It is the policy of the facility that adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nursing notes and documented in the Adverse Drug Reaction or Medication Discrepancy Report. These reports are to be completed in coordination with the Director of Nursing and filed with the Administrator and reviewed by the Medical Director and Consult Pharmacist. This policy also documents A medication discrepancy/error has been made when one of the following occurs: Wrong medication administered. Wrong dose administered. Medication administered by wrong route. Medication administered to wrong resident. Medication administered at wrong time. Medication not administered. A medication discrepancy report shall be completed for any of the above occurrences. R232's (hospital) After Visit Summary, dated 9/18/24 includes the following medications: Albuterol (Bronchodilator) Inhaler 90 MCG (Micrograms)/Actuation Take two puffs inhaled by mouth every six hours as needed for Shortness of Breath; Amlodipine (Calcium Channel Blocker) 5 MG (Milligrams) by mouth once daily for Hypertension; Emtricitabine/Tenofovir (Human Immunodeficiency Antiviral) 200/300 MG one tablet daily for HIV Infection; Fluticasone Propionate (Synthetic Glucocorticoid) 220 MCG/Actuation Inhaler two puffs inhaled every morning and evening for Allergies; and Folic Acid (Daily Supplementation) 1 MG one tablet daily. R232's current Medication Administration Record, dated September 18, 2024 through September 24, 2024 includes no nursing documentation that R232's prescribed Albuterol, Amlodipine, Emtricitabine/Tenofovir, Fluticasone Propionate or Folic Acid were added to R232's Medication Administration Record or administered from 9/18/24 through 9/24/24. On 9/24/24 at 2:30 P.M., V17/Licensed Practical Nurse stated, I was the nurse that admitted (R232) on 9/18/24. (R232) came with paper prescriptions and pill bottles, that's what I used to do his med (medication) (sign out) sheet. On 9/24/24 at 4:38 P.M., V4/Assistant Director of Nurses stated, Our facility process is to use the hospital transfer sheet to transcribe the (physician ordered) medications to the medication administration record. (V17/LPN) didn't follow our policy when he admitted (R232). At that time, V4/Assistant Director of Nurses confirmed that R232 did not receive the prescribed Albuterol, Amlodipine, Emtricitabine/Tenofovir, Fluticasone Propionate or Folic Acid on 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24 or 9/24/24.

Based on observation, interview and record review, the facility failed to ensure a resident was safely transferred with a full mechanical lift for one of four residents (R84) reviewed for falls in a sample of 45 residents This failure resulted in R84 being sent to the hospital, suffered a back contusion which required medication for back pain management and ongoing psychosocial fear of being transferred with a mechanical lift. Findings include: The Limited Resident Lift Program and Equipment Use Training Requirements, not dated, stated all direct care staff responsible for resident handling/mechanical lift equipment will be trained by the Director of Nursing or specified facility representative initially upon orientation for all new employees and annually thereafter. Staff must be able to demonstrate proficiency with all types of lifts in the facility. A competency checklist for each type of lift will be completed during training and placed in the employee file. The Admission Minimum Data Set (MDS) dated [DATE] documented R84's diagnoses as Bipolar Disorder, Deep Vein Thrombosis Upper Extremity, Neurogenic Bladder, Diabetes Mellitus, Anxiety Disorder, Depression and Obesity (423 pounds on 4/12/24). The MDS documented R84 is prescribed the following classes of medications: antidepressant, anticoagulant (blood thinners), psychotropic (mind-altering drugs that change brain function and can alter a person's mood, perception, consciousness, cognition, or behavior), hypnotics (promotes sleep) and anti-anxiety. The Careplan initiated on 9/22/23 stated R84 has limited mobility related to morbid obesity, is dependent upon staff to perform activities of daily living. Mostly requires mechanical lift for transfers, Assist to Transfer R84 using mechanical lift and two-three staff members. Ensure lift sheet is intact and correct size; is totally dependent on staff for toilet use; and on 4/16/24, R84 to be assessed for new mechanical lift sling due to body habitus. The Nurse's Progress Note dated 4/15/24 stated R84 appeared to have experienced an alleged (un)intentional change of plane (fall) on 4/15/24 at 1:35 PM. R84 appeared to have been hooked up to a mechanical lift to be transferred to bed by V15 (Certified Nurse Aide/CNA). Back/flank pain was rated as a five (pain scale, 0-no pain, 10-worst pain), physician was notified and orders to transfer R84 to hospital for evaluation were received. R84 refused the hospital transfer at that time. The note stated staff were re-educated on the importance of proper mechanical lift safety. The Emergency Department (ED) Physician's Note, dated 4/15/24 at 9:06 PM, stated R84 presented to the ED with a chief complaint of a Back Injury. The note documented R84 fell from a mechanical lift earlier in the day and hit her lower back on a bar, was given Tylenol (for pain) but the non-radiating back pain persisted. The note documented that the back x-rays were negative, the final clinical impression was a Contusion of back, unspecified laterally and was discharged back to the Facility with pain medication. The Incident Investigation Form dated 4/15/24 authored by V15, CNA documented R84 requested to use the restroom, was hooked up to the mechanical lift, V15 told R84 they needed to wait for assistance although R84 had to use the restroom really bad and then slipped out of mechanical lift sling. On 9/22/24 at 11:45 AM, R84 stated V15 lifted R84 with a mechanical lift and dropped R84 while transferring to the toilet due to transferring with only having one staff member. R84 stated V15 was fired but the facility later re-hired V15. R84 said she doesn't currently feel safe because the mechanical lift is old and the newer lift is broken. R84 stated the legs don't open all the way, the legs get stuck under the bed and the facility only has a few extra-large slings so, the facility does not always use the right size of sling. On 9/24/24 at 2:30 PM, V15 stated there were no problems with R84's sling. There should always be two staff members present and assisting with a mechanical lift. On 4/15/24, there were three CNAs assigned to the unit but one had to go on an appointment with a resident and couldn't find anyone else to help. R84 was persistent she had to go potty. V15 stated the facility does run out of extra-large slings sometimes. V15's Personnel File documented V15 was initially hired on 8/4/2016 as a Unit Aide. The Unit Aide Job summary was signed by V15 on 8/16/24 and the documented responsibilities were to execute procedures consistent with interdisciplinary care plan, Procedure Manuals and that are within the scope of the role of the Unit Aide. The Safe Working and Training orientation packet dated 8/4/16 lacked a supervisor's signature for proof of V15's completion of training for a mechanical lift. V15's Notice of Termination, dated 4/17/24, stated R84's fall was from V15 transferring R84 with a mechanical lift without the assist of two staff members which caused R84's fall. The file documented V15 was re-hired on 5/30/24. The Certified Nurse Aide In-Service Record documented V15 received mechanical lift training on 2/3/22 and 5/31/24. The Manufacturer's Guidelines documented the Medium, Large and Extra-Large Slings have a weight capacity of 450 pounds. Although (the lift company) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. It is important to inspect all stressed parts, such as slings, spreader bar and any pivot for slings for signs of cracking, fraying, deformation or deterioration. Replace any defective parts immediately and ensure that the lift is not used until repairs are made. The sling should be regularly washed in water, temperature not to exceed 180 F (82 C) and a biocidal (anti-biological) solution.

Based on observation, interview, and record review the administration failed to develop behavior management policies; failed to perform resident background checks within 24 hours of admission; failed to follow the facility's Identified Offender Policy and Procedure resulting in residents with a history of qualifying identified offender criminal conviction offenses being admitted to the facility for treatment for mental health services, without having an adequate amount of staff or adequate staff training on managing mental health disorders and behaviors, without care planning or acquiring specialized needs services as documented on those residents' PASRR (Pre-Admission Screening and Resident Review) Level II screenings and their pre-admission screenings; failed to ensure resident behavioral health needs were met and behavioral interventions were developed and implemented, failed to ensure the facility's discharge policy was followed, failed to ensure the facility provided adequate direct care staff and social service staff to provide behavioral health needs, failed to ensure a licensed administrator conducted thorough abuse investigations, and failed to ensure residents were protected from abuse. These failures resulted in residents having an unsafe environment, residents exhibiting increased behaviors causing multiple resident to resident abuse altercations, resident rights not being protected, staff experiencing burnout and frustration, and residents being involuntarily discharged to a homeless shelter and a long-term care facility that was unable to meet this resident's needs prior to admission. These failures have the potential to affect all 131 residents within the facility. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 12-4-23 when the facility admitted R37 who was a known high risk identified offender and did not inform staff or implement a plan of care to address R37's identified offender behavioral interventions, did not provide adequate supervision of R37 to prevent resident-to-resident altercations, and did not provide R37 a private room. V1 (Administrator-In-Training) was notified of the Immediate Jeopardy on 2-9-24 at 9:45 AM. While the immediacy was removed on 2-9-24, the facility remains out of compliance at a severity Level II as the facility continues to in-service all staff and newly hired staff on Emergency Care: Behavior Problem policies and watches facility training videos: How to Strategies for Intervening with Challenging Individuals, as well as Calming the Agitated Resident two times a month for three months, all residents' care plans are reviewed quarterly, or sooner, including behaviors and interventions focusing on residents with Level II PASRR's, by the Care Plan Coordinator (V30) and other members of IDT (Inter-Disciplinary Team), and all abuse investigations will be reviewed for thoroughness by a Licensed Nursing Home Administrator or Regional Director until the next QA (Quality Assurance) meeting. Regional Directors will monitor compliance of the above mentioned through internal QA process quarterly. The facility's Midnight Census form (dated 1-29-24) indicates that 131 residents are currently residing in the facility. On 2-2-24 at 12:00 PM V2 (Director of Nursing) provided a list that documents 32 residents (R1, R3, R4, R7, R8, R10, R12, R13, R16, R21, R25, R26, R27, R32, R35, R36, R37, R42, R56, R57, R58, R59, R61, R62, R63, R64, R67, R68, R69, R70, R73, R75) have a level two PASRR (Preadmission Screening and Resident Review) indicating R1, R3, R4, R7, R8, R10, R12, R13, R16, R21, R25, R26, R27, R32, R35, R36, R37, R42, R56, R57, R58, R59, R61, R62, R63, R64, R67, R68, R69, R70, R73, and R75 have mental illness requiring specialized mental health services. R1, R3, R4, R7, R8, R10, R12, R13, R16, R21, R25, R26, R27, R32, R35, R36, R37, R42, R56, R57, R58, R59, R61, R62, R63, R64, R67, R68, R69, R70, R73, and R75's current Care Plans do not include level two PASRR recommendations. 1. R2's Social Services Note Late Entry dated 9-5-23 at 10:08 AM and signed by V26 (Prior Social Service Director) documents, (R2) was involved in an alleged altercation with a female peer (R3) on 9-4-23. R2's Progress Notes dated 11-1-23 at 10:52 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spitting multiple times on peers today. R2's Progress Notes dated 11-12-23 at 12:35 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spit on a peer today. Re-directed and behavior not reported by peer again. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R2 was in a physical altercation with R1 on 1-25-24 and R2 was in a physical altercation with R5 on 1-6-24. R2's current Care Plan does not include interventions addressing R2 spitting on other residents, addressing R2 targeting R1, and addressing R2 kicking R1 in the face on 1-25-24. R2's Social Services Notes dated 1-30-24 at 2:24 PM and signed by V14 (Social Service Director) documents R2 will be moving to another long-term care facility. 2. R11's current Face Sheet documents R11 admitted to the facility on [DATE]. This same document lists R11 as being his own responsible party. R11's CHIRP (Criminal History Information Response Process) dated 12-22-2020 documents, Result: HIT. R11's CHIRP documents several convictions, Retail theft, possession of cannabis, criminal damage to property, coin machine theft, and theft. The following convictions are included on the identified offender list: Retail theft, Coin machine theft, and theft. Although requested, this was the only background check document the facility was able to provide that was completed on R11. R11's Care Plan dated 11-20-23 to 1-23-24 does not include a plan of care to address R11's CHIRP document indicating R11 was an identified offender. R11's Medical Record and Business Office Record does not include a request for a live scan State and Federal Bureau of Investigation (FBI) fingerprint check. R11's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing Nursing Home Residents form dated 1-23-24 documents an emergency transfer or discharge issued to R11 on 1-23-24 due to the safety of individuals in (the facility) being endangered. 3. R37's IDPH (Illinois Department of Public Health) Identified Offender Program Criminal History Analysis Security Recommendation Report dated 10-5-18 and signed by V55 (Clinical Psychologists) and V56 (Clinical Psychologists) documents, (R37) is high risk. (R37) has convictions for violate order protection, retail theft offenses three times, disorderly conduct, domestic battery/bodily harm, and possession liquor by minor. (R37) has a history of substance abuse and many physical difficulties as the result of a traumatic brain injury. (R37) is dysphagic, paraplegic, and uses a wheelchair to ambulate. Since his admission (to another facility) on August 27, 2018, he has been both verbally and physically aggressive. He has been involved in verbal altercations with other residents and threw a urinal full of urine on another resident. He had threatened to kill his roommate as he felt he was stealing from him. He has been verbally aggressive at his last placement at (another long-term care facility). His compliance with medical treatment and abstinence from alcohol/drug use should be closely monitored. I would deem (R37) a high risk due to verbal aggression, threats to kill another resident, and his throwing a urinal at another resident. R37's Face Sheet documents R37 was admitted to the facility on [DATE]. R37's Care Plan dated 12-4-23 to 2-5-24 does not include a plan of care to address R37 being a high risk identified offender with the recommendations as documented on R37's IDPH Identified Offender Program Criminal History Analysis Security Recommendation Report dated 10-5-18. R2, R4, R7, R8, R13, R17, R21, R25, R26, R32, R42, R56, R64, R66, R68, R69, R70, R71, R73, and R76's Business Office File and Medical Records do not contain evidence of the facility obtaining background checks of these residents since admission to the facility. R3, R27, R34, R36, R54, R57, R59, and R75 UCIA (Uniform Conviction Information Act) background checks document R3, R27, R34, R36, R54, R57, R59, and R75 had a documented hit that would require criminal fingerprinting to be conducted to determine of a resident is high, moderate, or low risk offender. No fingerprinting has yet to be conducted for R3, R27, R34, R36, R54, R57, R59, and R75. The facility's 2023-2024 Identified Offenders List documents R3, R18, R27, R34, R36, R37, R41, R44, R48, R49, R50, R51, R53, R54, R56, R57, R59, and R75 are identified offenders. R27, R37, R51, and R57's current care plans do not include a plan of care that addresses the identified offender risks and interventions to address those risks. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R37 was in a verbal altercation with R71 on 2-4-24, R37 was in a physical altercation with R25 on 2-4-24 and was in a physical altercation with R46 on 1-30-24. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R27 was in a verbal altercation with R25 on 2-2-24. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R57 had a verbal altercation with R66 on 2-4-24 and 1-10-24 and R57 had a physical altercation with R66 on 12-10-23. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R35 was in a verbal altercation with R42 on 2-2-24, was in a physical altercation with R73 on 12-18-23, R68 was in a verbal altercation with R72 on 12-15-23, R10 was in a physical altercation with R66 on 12-21-23, R25 was in a physical altercation with R40 on 12-19-23, and R66 was in a verbal altercation with R12 on 1-22-24. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R44 was in a verbal altercation with R7 on 12-26-23, R44 was in a physical altercation with R30 on 12-26-23. On 1-29-24 at 10:30 AM R1 was sitting in a recliner in the sitting area across from the nurse's desk. R1's left eye was surrounded with golf-ball sized purple bruising with a 3 cm (centimeter) by 1 cm hematoma beneath the left eye. R1 had a 3 cm laceration to the left eyelid that was approximated with steri-strips. R1 had a 1 cm laceration to the right side of her nose that was approximated with a steri-strip. R1 stated, I was sitting on the floor in my doorway and (R2) came up and kicked me three times in the face and then stomped on me. It hurt really bad. I grabbed (R2's) leg and yelled for help. (R2) threw water on me the day before and spits on me. I was abused. I was scared of (R2). (R2) always walked by me and would call me bad names. On 1-29-24 at 11:05 AM R3 was well-groomed and alert and orientated. R3 stated, (R2) always asks me for a phone to call her brother. I do not have a phone. If I do not give (R2) a phone she calls me a b***h. (R2) spit on me a month ago in the dayroom. (R2) called me a b***h yesterday. (R2) calls me a b***h about three to four times a week. I am tired of it. (R2) has also hit me in the cheek because I would not give her my soda. I try to stay away from her. Next time (R2) touches me I will hit her back! On 1-29-24 at 12:45 PM R5 was lying flat in his bed. R5 was groomed appropriately, and no odors were noted. V4 (AIT) was in R5's room. R5 stated, Around a month ago this black lady (R2) and I got into an argument in the hallway. (R2) called me a little b***h and calls other residents b*****s. (R2) is very mean. Right when I turned around R5 hit me in the back of my head. (R2) has anger issues and I am scared to even be around her. I sit in my room a lot to stay far away from her because you never know when she will just go off. On 1-29-24 from 1:10 PM through 1:45 PM and on 1-30-24 from 11:00 AM through 11:45 AM R2 was walking around without staff supervision throughout the hallways, dining room, and sitting area. All other residents who reside on the same unit (R3, R5, R12-R47) as R2 were in the dining room, sitting area, and hallways where R2 was wandering around unsupervised. On 2-6-24 at 9:45 AM R37 was in the room with his roommate R67. R37 was not in a private room as recommended by his IDPH Identified Offender Program. On 2-6-24 at 10:00 AM V1 (Administrator-In-Training/AIT) provided a list of current staff who have not received behavioral training for mental illness, or CPI (Crisis Prevention and Intervention) Nonviolent Crisis Training. This list documents V1 (AIT), V2 (Director of Nursing), V4 (AIT), V7 (CNA/Certified Nursing Assistant), V8 (CNA), V12 (CNA), V17 (Laundry Aide), V20 (CNA), V24 (Agency RN/Registered Nurse), V25 (Prior Administrator), V30 (Care Plan Coordinator), V37 (CNA), V38 (CNA), V39 (CNA, V40 (CNA), V41 (CNA), V42 (CNA), V43 (Unit Aide), V44 (Unit Aide), V46 (CNA), V47 (CNA), V48 (LPN/Licensed Practical Nurse), V49 (LPN), V50 (Nursing Assistant), V51 (Nursing Assistant), V52 (CNA), V53 (CNA), V54 (CNA), V55 (CNA), V57 (CNA), and V58 (CNA) have not received the CPI Nonviolent Crisis Interventions Training. The facility's Annual Mandatory Training Log dated 1-1-23 through 12-31-23 documents staff should be trained annually on behavior management. This same document indicates no staff has been trained within the last year on behavioral management. The facility's CNA staffing sheets dated 1-16-24 through 1-22-24 and signed by V4 (Administrator-In-Training/AIT) document the facility did not have the required amount of CNA staff needed according to the facility's minimum staff calculator to meet the needs of the residents. On 1-29-24 at 2:00 PM, V4 (Administrator in Training) confirmed that the daily CNA staffing sheets (dated 1-16-24 through 1-22-24) were accurate and staffing was below (the facility's) minimum requirements based off the staffing calculator utilized to determine staffing needs. V58's (CNA) Notice of Termination form dated 9-12-23 documents V58 was terminated from employment immediately due to an inappropriate interaction with a resident. V58's Employee Business File documents V58 was re-hired to the facility on [DATE]. On 1-29-24 at 9:45 AM V1 stated (the facility) had to initiate an emergency involuntary discharge to R11 because R11 was spitting on staff and entering staff areas without permission, and the facility had several staff walk out because of R11. V1 stated she did not know R11 was an identified offender and the facility emergency discharged R11 to (homeless shelter). On 1-29-24 at 10:05 AM V8 (CNA) stated, We could use some more staff here. It is hard to get everyone up and dressed and deal with residents' behaviors with the number of staff we have now. On 1-29-24 at 10:30 AM V7 (CNA) stated, We do not have enough staff here. Most resident have behaviors or mental health concerns. There is not enough staff to supervise all of the residents with behaviors. The staff here are getting burned out. On 1-29-24 at 2:00 PM V1 stated she was unaware when she re-hired V58 that V58 had been terminated from employment on 9-12-23 for an inappropriate interaction with a resident. On 1-29-24 at 2:10 PM V17 (Laundry Aide) stated, I have never been trained in de-escalating behaviors. On 1-30-24 at 11:19 AM V59 (LPN/Licensed Practical Nurse) and V60 (LPN) stated they are unaware of any policies readily available to them regarding dealing with mental illness and behaviors. On 1-31-24 at 2:05 PM R10 stated, I had a camera I wanted to use so the facility could see how staff was treating me and my roommate (R11). (V25/Prior Administrator) came into my room and took my camera without my permission. I have not seen the camera since. I bought the camera with my own money. I have my own hot spot on my phone that I can use for Wi-Fi connection. I do not need the facility's Wi-Fi. (V25) never offered to have me sign a consent form to use the camera. I would have signed the consent form so I can use my camera. The facility will try anything in their ability to allow me to not be able to use my camera. On 2-1-24 at 1:15 PM R11 stated, I lived at (the facility) for three years and have had no issues until (V25/prior Administrator) started to come into me and my roommate's room without my permission. (V25) was taking my roommates items without his permission. I confronted (V25) about it, and (V25) then put his foot in front of my wheelchair and would not let me move forward. I was tired of seeing the way administration was treating other residents, so I started advocating for the other residents and staff did not like it. Staff would laugh at me and treat me like an animal. They were treating me like a dog and making me stay in my room like I was in a prison around there (the facility). When I would say something back to the staff, I was told that staff were quitting because of me and that they would have to discharge me. I had put in an appeal and the facility did not even allow me to meet for the appeal. They decided to hurry up and do an emergency discharge right before the appeal (1-30-24) because their reasoning was staff were quitting because of me. I was forced to leave by the facility calling the police and intimidating me with the police. I had to go to the (homeless shelter). The (homeless shelter) was unable to accommodate my wheelchair to enter the building, I am sleeping on a floor which has caused me to be in excruciating pain due to my lower back. I have had major chest pains, and I am a nervous wreck. I am angry and I am scared I will not find anywhere to live or have transportation to make it to any doctor's appointments. I miss the staff at the facility that treated me good. On 2-2-24 at 10:30 AM V14 (Social Service Director) stated, I did not know PASRR level II's existed. All residents with PASRR level II recommendations have not had care plans developed with those recommendations. On 2-2-24 at 11:15 AM V33 (R2's POA/Power of Attorney) stated, The facility admitted (R2) from the same facility that they just discharged (R2) back to on Wednesday. That facility was not able to manage (R2's) behaviors either. I did not want (R2) to go back to that same facility. I did not even get a chance to decide on whether I was okay for the facility to transfer (R2) to another facility. (R2) had major behaviors when living at that facility before. The facility left messages on my phone and did not get my permission before sending (R2) to another facility. I called the facility and was told they had already transferred (R2) back to the old facility again because (R2) was having behaviors that they facility could not manage. The facility knew (R2) had behaviors when they accepted (R2) that she had major behaviors. (R2's) behaviors is the reason why the prior facility transferred her to this facility. (V14Social Service Director) told me the facility transferred (R2) to another facility so that (R2) would have a clean medical record regarding (R2's) behaviors and that would allow (R2) to get closer to me eventually. (R2) has had increased behaviors and anxiety the last two days since being sent to the other facility, and (R2) has been blowing up my phone. On 2-2-24 at 11:30 AM V14 (Social Service Director) stated, I tried to call (V33) four times on 1-30-24 about the facility transferring (R2) to another facility. (V33) did not answer. The other facility was a safer place for (R2). (V33) called me back the next day on 1-31-24 and I let him know we transferred (R2) to the other facility. (V33) did not really like that (R2) was transferred to the facility that she had was at before. V14 stated she was not aware of any documentation in R2's record of the needs the facility could not provide to R2 or the interventions attempted to meet those needs prior to transferring R2 to another facility. On 2-2-24 at 1:00 PM V54 (Business Office Manager/BOM) stated, I am responsible to ensure any resident that has a HIT with a qualifying conviction on their background check, gets set up for fingerprinting. I follow our policy and guidelines to ensure every step is being taken and things are followed appropriately. Once a HIT is identified we will put that resident in a private room until all steps have been completed per policy and we receive an email from the state police that lists security measures and recommendations for an identified offender. The report usually states if the resident is at low, moderate, or high risk with recommendations. V54 acknowledge R11 is an identified offender and confirmed that the only paperwork she could locate was R11's background check. V54 stated she was not here when R11 admitted , but she is now conducting a facility wide audit to ensure correct resident offender status. V54 also confirmed R11 had a roommate (R10) while residing at the facility. On 2-2-24 at 1:15 PM V18 (Corporate Regional Nurse) verified R11 is an identified offender. V18 stated the facility must have not set up R11 to have fingerprints done because (the facility) cannot find any documentation that R11 was ever set up for fingerprints. On 2-2-24 at 3:34 PM V37 (CNA) stated, I have worked at the facility for around six months. (R11) had very few behaviors when I first worked for him. Within the last couple months, I noticed his behaviors were increasing. I believe it was after the involuntary discharge was given to him. I never see (R11) get physical with residents. There was one time a resident was talking to herself and (R11) went up to her and started to be bossy, but that's about it. The facility did not train me or tell me behavioral interventions to deal with (R11's) behaviors besides getting the nurse. I never received any behavioral training. I was not taught any other behavior interventions to deal with (R11). On 2-6-24 at 2:00 PM V1 and V54 (BOM) both stated they were not aware that R37 was a high risk identified and needed a private room. V1 and V54 both stated R37 has had a roommate (R67) since admission on 12-4-23. On 2-7-24 at 2:00 PM V16 (CNA Supervisor) verified she tracks the employee trainings and the employees have not received behavioral management training since last year. The facility's Administrator's Job Description (undated) documents, The administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents, and equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulations. The Administrator will manage and conduct the business of the facility in a manner that protects the facility licensed and certification at all times. The major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical, mental, and social well-being. Responsibilities: 1. Operate the facility in compliance with all Federal and State rules and regulations. 2. Operate the facility in accordance with established policies and procedures. 5. Ensure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents. Resident Rights: 2. Ensure that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints are well established and maintained at all times. 5. Ensure that policies governing a timely notice for resident discharges and room, or roommate changes are strictly followed by all personnel. Administrative Functions: 2. Maintain written policies and procedures that govern the operation of the facility. 6. Ensure that all employees, residents, and visitors follow established policies and procedures. 14. Ensure that appropriate policies and procedures are followed when conducting background checks and when providing information to the Nurse Aide Registry. The facility's Identified Offender Policy and Procedure documents, Policy Statement: It is the policy of this facility to establish a resident sensitive and resident secure environment. In accordance with the provisions of the Nursing Home Care Act, this facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. It is the policy of (the facility) that no person will be admitted if they are sex offenders. Responsibility: Administrator or a person designated by the Administrator. Identifying Offenders: 3. Conduct a Criminal History Background Check: Within 24 hours of admission, request a name-based Uniform Conviction Information ACT (UCIA) criminal history background check based on name, date of birth, and other identifiers required by the Department of State Police for any resident seeking admission to the facility. 4. Check the UCIA response against the statue citation numbers from IDPH (Illinois Department of Public Health) identified offender conviction list and the IDPH sex offenses list. b. If the UCIA response contains convictions that match the identified offender or sex offender statute citation numbers, the resident is an identified offender and must be reported to Identified Offenders Program. Reporting Results If the Resident is an Identified Offender: 1. Once the facility determines the resident is an Identified Offender, the facility must request in 72 hours for the resident to undergo a live scan State and Federal Bureau of Investigation (FBI) fingerprint check within five business days. 2. Immediately complete and submit the IDPH Identified Offender Information (IOI) form attached and fax it to the IDPH Identified Offender Program (IOP) along with a copy of the UCIA response. 4. After the confirmation from the (IOP), the facility will receive a phone call from the Illinois State Police Division of Internal Investigation within three business days scheduling an on-site facility interview with the resident and the administrator. 6. The facility will receive an Identified Offender Report and Recommendations within four to six weeks. The identified Offender Report Recommendations shall detail whether and to what extent the Identified Offender's criminal history necessitates the implementation of security measure with the long-term care facility. The Identified Offender Report and Recommendations shall be incorporated into the facility's plan of care. Maintain written documentation of compliance with the above requirement. The Facility Assessment Policy (reviewed 10-23-23) documents the following: Resident admission based on common diseases, conditions, physical and cognitive disabilities, or a combination of conditions that require complex medical care and condition management. The list below describes residents' that (the facility) accommodates for and regularly manages. Category: Psychiatric/Mood disorder- Psychosis, Hallucinations (auditory), delusions, mental disorders, MR (Mental Retardation) disorders, anxiety, schizoaffective disorder, bipolar disorder, PTSD (Post Traumatic Stress Disorder), behavior requiring interventions, suicidal ideations, and hx (history) of substance abuse. Evaluation of the overall number of facility (direct care) staff members to ensure a sufficient number of qualified staff is determined based on the number of residents requiring skilled services. (The facility) acuity level to assist in identifying the intensity of care and services needed to provide and meet resident care needs: Special Treatments and Conditions- Behavioral Health Needs- 123 average number of residents. The Illinois Department of Public Health (IDPH) Identified Offenders Program Criminal History Analysis Security Recommendation Report (undated) documents, High Risk-The resident requires a single room in close proximity to the nursing station to permit ongoing visual monitoring. The level of observation should be sufficient for early detection of behavioral changes. Regular assessment is necessary to determine whether closer monitoring or more frequent individual contact is indicated. Moderate Risk-The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. Low Risk-the resident is subject to standard requirements for supervision in an open facility. Behavioral changes suggesting a need for closer observation should be noted and responded to according to standard facility procedures. On 2-14-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy: 1. On 2-7-24 V34 (Medical Director) reviewed and approved the Emergency Care: Behavior Problem policy. 2. On 2-7-24 V18 (Corporate Regional Nurse) in-serviced V1 (AIT) and V4 (AIT) on Emergency Care: Behavior Problem and on the facility assessment regarding services and cares the facility is able to provide based on residents needs/diagnoses. 3. On 2-7-24 V1 (AIT) in-serviced the IDT (Inter-Disciplinary Team) and Nursing Staff regarding the Emergency Care: Behavior Problem policy and on the facility assessment regarding services and cares the facility is able to provide based on residents needs/diagnoses. 4. All staff prior to their next scheduled shifts reviewed the facility training videos: How to Strategies for Intervening with Challenging Individuals, as well as Calming the Agitated Resident and were in-serviced on 2-7-24 by V1 (AIT) and/or IDT designee on Emergency Care: Behavior Problem revised policy. 5. On 2-7-24 V1 (AIT) and/or IDT designated staff in-serviced all staff on any newly developed resident behavior interventions and where in (Electronic Medical Record) monitored behaviors and interventions are located. 6. On 2-2-24 V18 in-serviced Social Service Staff regarding PASRR level II recommendations and implementation of recommendations. 7. On 2-9-24 V1 completed a screen of all employees, including re-hired staff for abusive backgrounds using IDPH (Illinois Department of Public Health) healthcare worker registry. 8. On 2-13-24 and 2-14-24 V61 (Trained CPI Instructor) trained staff currently not certified in CPI. 9. On 2/9/24 a staff survey was made available for staff to complete for recommendations on improved employee engagement and burnout and a PIP (Plan of Improvement) was developed to include front line staff. 10. The facility continued to follow and implement the plan to accrue more staff to meet the needs of the mental health residents and residents with behavioral needs and the IDT Team reviewed the staffing PIP on 2/9/24. 11. On 2/9/24 V62 (Director of a Behavioral Management Company), has been scheduled through 2/16/2024 to complete training in regard to staff burnout and stress and ways to deal with it focusing on how to deal with residents with mental illness. 12. On 2-9-24 the Facility QA Team initiated a Behavior Management PIP focused on Abuse including resident to resident abuse, to aide in promoting an abuse free environment. 13. On 2-2-24 V18 in-serviced V4 on the thoroughness of abuse investigations. 14. On 2-9-24 V54 (Business Office Manager) completed all current resident background checks. 15. On 2-9-24 V54 ensured all identified offenders with qualifying convictions were fingerprinted. 16. On 2-9-24 V31 (MDS Coordinator) implemented care plans of all residents who are identified offenders.

Based on observation, interview, and record review the facility failed to implement their Abuse policy by failing to protect multiple residents from verbal, physical, and mental abuse from another resident (R2), failing to provide adequate supervision of (R2) to prevent (R2) from further abusing other residents, failing to investigate and report to the state surveying agency multiple reports of resident-to-resident abuse, failed to thoroughly investigate resident-to resident abuse allegations, and failing to notify the police of resident-to-resident abuse for three of four residents (R1, R3, and R5) reviewed for abuse in the sample of 76. These failures resulted in R2 (alleged perpetrator) having continued unsupervised access to all residents residing within the alarmed unit after R2 physically assaulted R1 by spitting on R1 on multiple occasions, cursing at R1 on multiple occasions, kicking and stomping R1 in the face, striking R3 in the face, striking R5 in the back of the head, and pushing R5 backwards. These failures have the potential to affect all residents (R3, R5, R12-R47) residing within the alarmed unit that R2 resides. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 11-01-23 at 10:52 AM when R2 was spitting on peers and an abuse investigation was not done and the residents were not protected from R2, resulting in R2 continuing to spit on other residents and R2 continuing to physically abuse other residents. V1 (Administrator-In-Training) and V57 (Regional Director of Operations) were notified of the Immediate Jeopardy on 2-2-24 at 9:45 AM. While the immediacy was removed on 2-2-24, the facility remains out of compliance at a severity Level II as the facility continues to educate current and newly hired staff on the facility's Abuse Prevention Program, assess all residents for abusive type behaviors and protections from abuse, develop interventions/care plans and implement interventions to address those behaviors, review those care plans quarterly, and the QA (Quality Assurance) team monitors compliance. R2's Admission Summary dated 6-7-23 documents, This [AGE] year-old African American was admitted to (facility) from (another long-term care facility). Unaware of time, date, and facility. Ambulates on own. Diagnosis: Bipolar Disorder current episode manic without psychotic features. R2's Order Summary Report dated 1-29-24 documents R2 has the diagnoses of Bipolar Disorder, Episode Manic Without Psychotic Features, and anxiety disorder. R2's Social Services Note Late Entry dated 9-5-23 at 10:08 AM and signed by V26 (Prior Social Service Director) documents, (R2) was involved in an alleged altercation with a female peer (R3) on 9-4-23. R3's BIMS dated 11-9-23 documents R3 is cognitively intact. R2's Progress Notes dated 11-1-23 at 10:52 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spitting multiple times on peers today. R2's Progress Notes dated 11-12-23 at 12:35 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spit on a peer today. Re-directed and behavior not reported by peer again. R2's Progress Notes dated 11-30-23 through 12-2-23 documents on 11-30-23 R2 had an alleged physical altercation with a peer in the common area. R2's AIM (Acute Illness Management) for Wellness Event Record dated 1-6-24 at 5:05 PM and signed by V11 (LPN) documents, (R2) appears to have been involved in an altercation with a peer (R5). Just prior to/at time of the event (R2) appears to have been in the dining room. (R2's) papers states (R2) punched (R5) in the back of the head because he would not share his soda. R5's BIMS (Brief Illness of Mental Status) evaluation dated 11-14-23 documents resident is cognitively intact. R1 and R2's Final Report dated 1-25-24 documents on 1-25-24 R1 stated she was on the floor close to R2's room when R2 approached R1 and kicked her. This same investigation provided by V4 (Administrator-In-Training/AIT) does not include any staff statements regarding the incident. R2's current Care Plan does not include interventions addressing R2 spitting on other residents, addressing R2 targeting R1, and addressing R2 kicking R1 in the face on 1-25-24. R1's BIMS (Brief Interview of Mental Status) dated 11-10-23 documents R1 is cognitively intact. R1's Progress Notes dated 1-25-24 at 5:42 PM and signed by V11 (LPN/Licensed Practical Nurse) AIM (Acute Illness Management) for Wellness Event Record documents, (R1) appears to have sustained an injury that was unwitnessed. Event was first noted on 1-25-24 at 4:00 PM. Evaluation of the resident and event occurred on or about 1-25-24 at 4:01 PM. Just prior to/at the time of the event (R1) appears to have been sitting on floor. (R1's) account of the event is I was on the floor and (R2) kicked me in my head. (R1) was asked to point out the residents who allegedly kicked (R1) then pointed to (R2). Staff's response is noted as assessing (R1) who reportedly received a kick to their face. (R1) rates pain level as an eight. Vocal complaints of pain at the time of the event. Pain location includes head pain and headache. (R1) sent to the emergency room for evaluation. R1's Hospital Emergency Department Notes dated 1-25-24 document, (R1) was involved in altercation at the (facility) she suffered a contusion to her face. She has some bruising of the lateral aspect of her face and the bridge (of her nose). Applied some steri-strips. (R1) states she was kicked in the face. Chief Complaint: Head injury and assault victim. R1's Health Status Notes dated 1-25-24 at 9:49 PM documents, (R1) presenting with discoloration around the left periorbital area. Wound present on left side of face above left eyelid. Wound present on right side of nose. Wound dressed with steri-strips. Will continue to monitor. On 1-29-24 at 10:30 AM R1 was sitting in a recliner in the sitting area across from the nurse's desk. R1's left eye was surrounded with golf-ball sized purple bruising with a 3 cm (centimeter) by 1 cm hematoma beneath the left eye. R1 had a 3 cm laceration to the left eyelid that was approximated with steri-strips. R1 had a 1 cm laceration to the right side of her nose that was approximated with a steri-strip. R1 stated, I was sitting on the floor in my doorway and (R2) came up and kicked me three times in the face and then stomped on me. It hurt really bad. I grabbed (R2's) leg and yelled for help. (R2) threw water on me the day before and spits on me. I was abused. I was scared of (R2). (R2) always walked by me and would call me bad names. On 1-29-24 at 11:05 AM R3 was well-groomed and alert and orientated. R3 stated, (R2) always asks me for a phone to call her brother. I do not have a phone. If I do not give (R2) a phone she calls me a b***h. (R2) spit on me a month ago in the dayroom. (R2) called me a b***h yesterday. (R2) calls me a b***h about three to four times a week. I am tired of it. (R2) has also hit me in the cheek because I would not give her my soda. I try to stay away from her. Next time (R2) touches me I will hit her back! On 1-29-24 at 12:45 PM R5 was lying flat in his bed. R5 was groomed appropriately, and no odors were noted. V4 (AIT) was in R5's room. R5 stated, Around a month ago this black lady (R2) and I got into an argument in the hallway. (R2) called me a little b***h and calls other residents b*****s. (R2) is very mean. Right when I turned around R2 hit me in the back of my head. (R2) has anger issues and I am scared to even be around her. I sit in my room a lot to stay far away from her because you never know when she will just go off. On 1-29-24 from 1:10 PM through 1:45 PM and on 1-30-24 from 11:00 AM through 11:45 AM R2 was walking around without staff supervision throughout the hallways, dining room, and sitting area. All other residents who reside on the same unit (R3, R5, R12-R47) as R2 were in the dining room, sitting area, and hallways where R2 was wandering around unsupervised. On 1-29-24 at 11:20 AM V11 (LPN/Licensed Practical Nurse) stated, I was working on 1-25-24 and a CNA (Certified Nursing Assistant) reported to me that (R2) kicked (R1) in the face. (R1) was sitting on the floor in her doorway, which she prefers. (R1) was bleeding form her face. I sent (R1) to the emergency room . (R1) was sent back from the emergency room with steri-strips to her lacerations. (R1) knows what is going on and tells the truth. (R1) reported that (R2) kicked her in the face and spit on her. We put direct supervision of staff on (R2) after she kicked (R1), until the next day when (R1) returned to the facility. (R1) was moved to a different unit. I am not sure if any other behavior interventions have been implemented after (R2) kicked and spit on (R1). I am not sure of any behavior interventions to keep (R2) from spitting, (R2) has a lot of aggressive behaviors and has a history of spitting on (R1) and other residents. (R2) has also spit on me and (V21/Unit Aide). (R2) calls (R1) a b***h. (R2) has also punched (R5) in the back of the head. I have reported to (V1 AIT/Administrator-In-Training) that (R2) spits on staff and other residents. (R2) is allowed to roam and be around all of the residents on this unit (R3, R5, 12-R47). This unit is alarmed at the doors and (R2) is not allowed to leave this unit. On 1-29-24 at 1:10 PM V27 (LPN) stated, (R1) knows what is going on and did not deserve to be kicked by (R2). I know (R2) spits on other residents. (R2) gets agitated very easily. On 1-29-24 at 1:20 PM V28 (CNA) stated, (R2) spits on (R1) and has poured water over her head. (R1) does not lie. (R1) did get kicked in the face by (R2). (R2) will yell at (R1) f**k you b***h! (R2) is always cussing at the residents. We try to re-direct (R2) as much as possible. (R2) roams the hallways of this closed unit and is able to be around all of the residents on this unit. On 1-29-24 at 1:40 PM V29 (CNA) stated, I witnessed (R2) hit (R3) in the cheek a few months ago. (R2) wanted (R3's) pop. When (R3) wouldn't give (R2) her pop, (R2) hit (R3) in the cheek. (R3) had a red mark on her cheek. On 1-29-24 at 1:55 PM V31 (MDS/Minimum Data Set Coordinator) stated, I am responsible for (R2's) care plan. (R2) has not had an intervention developed to address (R2) spitting on other residents or staff. (R2) has not had any additional behavior interventions developed after kicking (R1) in the face. On 1-29-24 at 5:10 PM V13 (LPN) stated, (R1) has been scared of (R2) for quite some time now. (R2) spits on staff and other residents. (R1) is completely alert and would be able to tell the truth if she was kicked in the face by (R2). (R5) is also alert and would also know if (R2) hit him in the head. (R2) has a fight or flight attitude. On 1-30-24 at 11:15 AM V1 (Administrator-In-Training) stated, Residents spitting on other residents is abuse. I have no evidence of investigations being completed or reported to IDPH (State Agency) for the allegations of (R2) spitting on her peers. On 1-30-24 at 12:15 PM V24 (Agency RN/Registered Nurse) stated, I have not worked at the facility for about one month. Both times I charted on (R2) spitting on her peers, I had witnessed (R2) spit on (R1). I reported both occurrences to V25 (Prior Administrator) as abuse. (R2) would get angry at (R1) because they shared a bathroom and would spit on (R1) and call (R1) a b***h. (R1) would cry and yell out. (R1) was scared of (R2). I do not recall (R1) or (R2) ever being separated. (R1) and (R2) continued to share a bathroom after (R2) would call (R1) names and spit on (R1). (R2) has anger issues and if other residents would not give her their soda, (R2) would call them b*****s. (R2) would call (R1) a b***h quite a bit. (R2) is able to roam the hallways of the unit and is not separated from any of the residents. On 1-30-24 at 1:50 PM V14 (Social Service Assistant) stated, (R1) always sits on the floor in her doorway. (R1) is care planned that she prefers to sit on the floor. (R1) sat on the floor at home. (R1) reported to me that when (R1) was sitting in the doorway of her room, (R2) went up to her and kicked her in the face. (R1) knows what is going on. (R2) spits on other residents and throws water on other residents. Administration is aware of (R2's) behaviors. (R2) throws tantrums. I am not aware of any interventions implemented to address (R2) spitting in other resident's faces or throwing water on them. After (R2) kicked (R1) in the face, we put direct supervision on (R2) until the next morning when we moved (R1) off of the unit. After the next morning, (R2) was no longer directly supervised. I am not aware of any new behavior interventions to address (R2's) behaviors after (R2) kicked (R1) in the face. (R2) walks around the hallways and dining room of this unit. On 1-31-24 at 7:24 AM V25 (Prior Administrator) stated, I do not remember anyone reporting to me that (R2) was spitting on other residents. I never did an abuse investigation about (R2) spitting on other residents or contacted the police. I would consider spitting on other residents a form of abuse. On 1-31-24 at 11:05 AM V4 (Administrator in Training) stated, When I completed my investigation for the alleged allegation between R1 and R2 on (1-25-24), I did not interview any staff members beside the reporting nurse V11 (LPN) on the unit that R1 and R2 were on to see if they had witnessed the altercation. The facility's Abuse Prevention Program Policy dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents. and have therefore prohibits mistreatment, exploitation neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect, or abuse of our residents. This will be occurrences of mistreatment exploitation, neglect, or abuse of our residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property; Dementia management and resident abuse prevention. Immediately protecting residents involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively and making the necessary changes to prevent future occurrences. The facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse: Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regarding of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again. Serious Bodily Injury: an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administration. Upon learning of the report, the administrator or designee shall initiate an investigation. The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of any residents and misappropriation of resident property while the investigation is underway. Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. Following the Resident Protection Investigation Procedures. The appointed investigator will follow the Resident Protection Investigation Procedures, attached to this policy. The Procedures contain specific investigation paths depending on the nature of the allegation, procedures for investigation, interview parameters, and reporting requirements. Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. External Reporting of Potential Abuse: 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect, or abuse, including injuries from unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least on law enforcement agency of jurisdiction and IDPH (Illinois Department of Public Health) immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made no later than 24 hours forming the suspicion. A written report shall be sent to the Department of Public Health. The written report should contain the following information, if known at the time of report; Name, age, diagnosis and mental status of the resident allegedly abused or neglected; Type of abuse reported (physical, sexual, theft, neglect, exploitation, verbal or mental abuse); Date, time, location and circumstances of the alleged incident; Any obvious injuries or complaints of injury; and, Steps the facility has taken to protect the resident. Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the confusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the department of Public Health. The Public Health requirements for a final investigation report are detailed in paragraph five of the Internal Investigations section of this procedure. Investigation Procedures: Regardless of the specific nature of the allegation (physical, sexual, verbal/exploitation/mental, theft, or neglect), the investigation shall consist of: A review of the initial written reports; Completion of a written report on the status of the investigation of the occurrence; An interview with the person(s) reporting the incident; Interviews with any witnesses to the incident; An interview with the resident; Where appropriate, an interview with the resident's attending physician or psychiatrist; A review of the medical records of any resident involved in the occurrence; If the accused individual is an employee, review the personnel file to check for references, background check, and documentation of orientation and training; An interview with staff members having contact with the resident and accused individual during the period of the alleged incident; Where appropriate, interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident; Interviews with other residents to which the accused individual has regular contact; Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual; Obtain address, phone number and social security number of the accused individual; An interview with the accused individual or individuals (with a witness present); and a review of all circumstances surrounding the incident. On 2-9-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy: 1. On 2-2-24 V34 (Medical Director) reviewed and approved the facility's Abuse Prevention Program policy. 2. On 2-2-24 R1, R5, and R6 met one-on-one with the social service department to address any concerns and to provide TLC (Tender Loving Care). 3. On 2-2-24 V18 (Corporate Regional Nurse) in-serviced V1 (AIT) and V4 (AIT) on the facility's Abuse Prevention Program focusing on what constitutes abuse, protecting residents from abuse, thoroughly investigating all allegations of abuse, and reporting to the state surveying agency and the police department allegations of abuse. 4. On 2-2-24 V1 in-serviced the IDT (Interdisciplinary Team) and on Abuse Prevention Program focusing on procedures to protect all residents from abuse, implementing interventions to prevent further abuse, and providing adequate supervision to prevent abuse. 5. On 2-2-24 V1 and designated IDT members in-serviced all staff on Abuse Prevention Program focusing on procedures to protect all residents from abuse, implementing interventions to prevent further abuse, and providing adequate supervision to prevent abuse. 6. On 2-2-24 V1 started an initial report and investigation into R1 and R2's abuse allegations that had not been investigated prior. 7. On 2-2-24 all interviewable residents were interviewed by the social service department to ensure all residents are protected from abuse. 8. On 2-2-24 all residents with noted aggression towards others with behaviors were assessed and interventions developed, implemented, and care planned by updated accordingly by V31 (MDS Coordinator). 9. On 2-2-24 the Chief of Police for the local police department and V58 (Regional Marketing Director) reviewed the facility's Abuse Prevention Program policy with focus on local police department expectations. 10. R2 was discharged to another facility on 1-30-24. Completion Date: 2-2-24

Based on record review and interview the facility failed to document all measures the facility took to meet R2 and R11's behavioral and mental health needs that could not be met by the facility, failed to develop and implement behavioral interventions and care plans to meet those behaviors, failed to document the specific services the receiving facility will provide to meet R2 and R11's needs which could not be met by the facility, prior to discharging R2 to another long-term care facility, failed to notify R2's Physician of R2's discharge and R11's emergency discharge, and failed to allow R11 to remain in the facility while a discharge appeal was pending for two of three residents (R2 and R11) reviewed for discharge in the sample of 76. These failures resulted in R2 being transferred back to the same long-term care facility (name of facility) that was unable to meet R2 behavioral needs prior to admission to this facility and R2 experiencing increased anxiety and behaviors after being transferred to the accepting facility on 1-30-24. These failures also resulted in R11 being involuntarily discharged on [DATE], before R11's scheduled discharge appeal date of 1-30-24, to a homeless shelter that could not accommodate R11's wheelchair, where R11 has been sleeping on the floor causing R11 excruciating back pain, having major chest pain, having increased anxiety, having increased anger, having fearfulness of not finding adequate housing, and being unable to find transportation to doctor appointments from the homeless shelter. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 1-23-24 at 3:00 PM when the facility involuntarily discharged R11 to a homeless shelter that could not accommodate R11's wheelchair, where R11 has been sleeping on the floor causing R11 excruciating back pain, having major chest pain, having increased anxiety, having increased anger, having fearfulness of not finding adequate housing, and being unable to find transportation to doctor appointments from the homeless shelter. V1 (Administrator-In-Training) and V57 (Regional Director of Operations) were notified of the Immediate Jeopardy on 2-6-24 at 9:40 AM. While the immediacy was removed on 2-7-24, the facility remains out of compliance at a severity Level II as the facility continues to in-service all staff and newly hired staff on Admission, Discharge, Transfer, including Involuntary Discharge, and Emergency Care: Behavior Problem policies and watches facility training videos and all residents care plans are reviewed quarterly, or sooner, including behaviors and interventions by the Care Plan Coordinator and other members of IDT (Inter-Disciplinary Team). Regional Directors will monitor compliance of the above mentioned through internal QA (Quality Assurance) process quarterly. 1. R2's Pre-Admission Referral Packet including R2's Care Plan and Progress Notes dated 4-28-23 through 5-23-23 that was provided to the facility on [DATE] from (transferring Long Term Care Facility) documents R2 was exhibiting verbal and physical outbursts, was easily agitated with peers, responded at times with verbal and physical aggression, and was spitting on other people prior to admission to the facility on [DATE]. R2's Admission Summary dated 6-7-23 documents, This [AGE] year-old African American was admitted to (facility) from (transferring long-term care facility) on 6-7-23. Unaware of time, date, and facility. Ambulates on own. Diagnosis: Bipolar Disorder current episode manic without psychotic features and TBI (Traumatic Brain Injury). R2's Progress Notes dated 11-1-23 at 10:52 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spitting multiple times on peers today. R2's Progress Notes dated 11-12-23 at 12:35 PM and signed by V24 (RN) documents, (R2) reportedly spit on a peer today. Re-directed and behavior not reported by peer again. R2's Final Report dated 1-25-24 documents on 1-25-24 R1 stated she was on the floor close to R2's room when R2 approached R1 and kicked her. R2's current Care Plan does not include interventions addressing R2 spitting on other residents, addressing R2 targeting R1, and addressing R2 kicking R1 in the face on 1-25-24. R2's Behavioral Care Solutions for Adults and Seniors Physician's Notes dated 1-13-24, 11-12-23, 10-9-23, and 8-10-23 and signed by V35 (Psychiatric Medical Doctor) all documents R2 has had no prior history of aggression or violence. R2's Social Services Notes dated 1-30-24 at 2:24 PM and signed by V14 (Social Service Director) documents R2 will be moving to another long-term care facility (back to the Long-Term Care Facility that the resident transferred in from on 6/07/24). This same note does not document the reason for R2's transfer to another facility. R2's Discharge Summary dated 1-30-24 is incomplete. Section K. Brief Medical History and Section L. Current Treatments and Therapies of R2's Discharge Summary are incomplete and do not include R2's medical history, current treatment, or current therapies. R2's Care Plan dated 6-7-23 (Admission) through 1-30-24 (Discharge) does not include a comprehensive discharge plan. R2's Medical Record does not include documentation from the Physician (V34) of the specific needs the facility could not meet, the facility efforts to meet R2's needs, and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. On 1-29-24 at 1:55 PM V31 (MDS/Minimum Data Set Coordinator) stated, I am responsible for (R2's) care plan. (R2) has not had an intervention developed to address (R2) spitting on other residents or staff. (R2) has not had any additional behavior interventions developed after kicking (R1) in the face. On 2-2-24 at 8:20 AM V34 (R2's Physician) stated, I do not know a lot about (R2). I did not know the facility transferred (R2) to another facility. I was not asked to provide (R2's) needs, needs that could not be met by the facility, or the reason for (R2's) transfer. On 2-2-24 at 11:15 AM V33 (R2's POA) stated, The facility admitted (R2) from the same facility (transferring Long Term Care Facility) that they just discharged (R2) back to on Wednesday. That facility was not able to manage (R2's) behaviors either. I did not want (R2) to go back to that same facility. I did not even get a chance to decide on whether I was okay for the facility to transfer (R2) to another facility. (R2) had major behaviors when living at that facility before. The facility left messages on my phone and did not get my permission before sending (R2) to another facility. I called the facility and was told they had already transferred (R2) back to the old facility again because (R2) was having behaviors that they facility could not manage. The facility knew (R2) had behaviors when they accepted (R2) that she had major behaviors. (R2's) behaviors is the reason why the prior facility transferred her to this facility. V14 (Social Service Director) told me the facility transferred (R2) to another facility so that (R2) would have a clean medical record regarding (R2's) behaviors and that would allow (R2) to get closer to me eventually. (R2) has had increased behaviors and anxiety the last two days since being sent to the other facility, and (R2) has been blowing up my phone. On 2-2-24 at 11:30 AM V14 stated, I tried to call (V33) four times on 1-30-24 about the facility transferring (R2) to another facility. (V33) did not answer. The other facility was a safer place for (R2). (V33) called me back the next day on 1-31-24 and I let him know we transferred (R2) to the other facility. (V33) did not really like that (R2) was transferred to the facility that she had was at before. V14 stated she was not aware of any documentation in R2's record of the needs the facility could not provide to R2 or the interventions attempted to meet those needs prior to transferring R2 to another facility. On 2-2-24 at 11:35 AM V2 (Director of Nursing) stated she was not aware of any documentation in R2's record of the needs the facility could not provide to R2 or the interventions attempted to meet those needs prior to transferring R2 to another facility. On 2-2-24 at 11:45 AM V18 (Corporate Nurse) stated, We (the facility) decided to transfer (R2) to another facility because we felt like the other facility could offer (R2) better services for her behaviors. R2's medical record does not have physician documentation of the specific needs the facility could not meet, the facility efforts to meet R2's needs, and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. On 2-2-24 at 1:35 PM V32 (Regional Ombudsman) stated, The facility did not inform me that they were transferring (R2) to another facility. 49187 2. R11's Pre-screening/Screening Assessment for Harmful Behaviors dated 12-22-2020 (prior to R11's Admission) documents R11 has a history of the following: 1. General behavior appears to integrate manipulative statements including small lies and stretching the truth (embellished stories, half-truths, etcetera). 2. Appears to harbor considerable fears concerning issues such as: separation from support system, long term care placement, living in a group situation, being a recipient of care, and prehension regarding the disease or illness. 3. Attempts to make others including caregivers and/or family members feel guilty, ineffective, angry, and/or inadequate. 4. History or active use of addictive substances (example: alcohol abuse) and/or attempts to have doctor prescribe narcotics. Recognize chemical addiction as self-destructive behavior. 5. Non-compliance with medication and treatment regimen and/or makes frequent requests for order changes (examples: medications, diet). R11's current POS (Physician Order Sheet) documents R11 was admitted on [DATE] and has the following, but not limited to, diagnoses: schizoaffective disorder; Bipolar Type, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Heart Failure, Low Back Pain, Unspecified Asthma, and Chronic Obstructive Pulmonary Disease. This same form documents R11 receives Buspirone HCL (Hydrochloride) 10mg (milligram) one tablet two times a day for obsessive compulsive disorder and Clonazepam 0.5mg 1 tablet two times a day for Obsessive compulsive disorder. R11's BIMS (Brief Mental Interview Status) dated 12-19-2023 documents R11 is cognitively intact. R11's MDS (Minimum Data Set) assessment dated [DATE] documents R3 has exhibited no physical behavioral symptoms directed towards others. R11's Progress Notes dated 11-20-23 through 1-17-24 documents the following: On 11-29-23, 12-06-23, 12-07-23, 12-9-23, 12-11-23, 12-27-23, 12-28-23, 1-9-24, 1-10-24, 1-16-24, 1-18-24, 1-22-24, and 1-23-24 R11 had verbal behaviors or arguments directed towards staff. These same notes did not document any behavioral interventions that were attempted for R11's behaviors or if they were effective. R11's Behavior Monitoring and Interventions Report dated 11-6-23 documents R11 had verbal behaviors and physical behaviors. The only intervention attempted was one on one of staff and the form documents R11's behavior did not change. No other interventions were attempted by staff. R11's Behavior Monitoring and Interventions Report dated 11-20-23 documents R11 had multiple verbal and physical behaviors and no interventions were attempted by staff. R11's Behavior Monitoring and Interventions Report dated 12-6-23 documents R11 had verbal behaviors and insomnia and no interventions were attempted by staff. R11's Behavior Monitoring and Interventions Report dated 12-7-23 documents R11 had verbal behaviors that improved with one-on-one intervention. R11's Behavior Monitoring and Interventions Report dated 1-17-24 documents R11 had multiple physical and abusive verbal behaviors and no interventions were attempted by staff. R11's Behavior Monitoring and Intervention Report dated 11-1-23 through 1-17-24 documents R11 had no other behaviors within this time frame, except for the behaviors identified above. R11's Physician Notes dated November 2023, December 2023, and January 2024 and signed by V34 (R1's Primary Physician) does not document any behavioral concerns related to R11. R11's Progress Note dated 1-23-24 and signed by V18 (Corporate Regional Nurse) documents, This writer received call from facility Administrator. Reviewed concerns in regard to resident (R11). Reported peer concern during care plan meeting today that (R11) causes such an unpleasant environment with his constant badgering of staff and others that peer has not been coming to meal or activities. Reporting staff concerns related to behavior as (R11) continues to create an environment where staff do not feel safe to work. (R11) continues to call staff racial slurs and other derogatory names. It was reported (R11) also allegedly spat at staff. R11's Electronic Health Record (EHR) and Care Plan does not document any behaviors of R11 spitting on staff prior to 1-23-24 and does not include behavioral interventions to address R11 spitting on staff on 1-23-24. R11's (EHR) also does not document any interventions or new interventions to address R11 creating an unpleasant environment for staff and/or residents. R11's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form dated 11-20-23 documents an involuntary transfer or discharge issued to R11 on 11-20-23 due to the physical safety of other residents, the facility's staff, or visitors. The Department of Public Health State of Illinois form dated 11-30-23 documents, R11 versus (the facility). On Wednesday, December 6, 2023, at 9:30 AM, a pre-hearing will be held concerning the involuntary transfer or discharge of the Complainant to determine whether the involuntary transfer or discharge is authorized for the reasons specified by the Respondent in the Notice of Involuntary Transfer or Discharge. The hearing will be held via teleconference. R11's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing Nursing Home Residents form dated 1-23-24 documents an emergency transfer or discharge issued to R11 on 1-23-24 due to the safety of individuals in (the facility) being endangered. R11's Medical Record does not include documentation from the Physician (V34) of the specific needs the facility could not meet, the facility efforts to meet R11's needs, and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. R11's Plan of Care dated 11-20-23 through 1-17-24 does not include any new interventions regarding R11's increase in behaviors, including but not limited to, verbal behaviors towards staff, entering staff areas, causing an unpleasant environment for other residents, or spitting on staff prior to R11's initiated involuntary emergency discharge on 1-23-24. On 1-29-24 at 9:45 AM V1 AIT (Administrator in Training stated (the facility) had to initiate an emergency involuntary discharge to R11 because R11 was spitting on staff and entering staff areas without permission, and the facility had several staff walk out because of R11. V1 stated the facility emergency discharged R11 to the (homeless shelter). V1 also stated there was a hearing set on 1-30-24 with (the facility), the judge, and R11 regarding R11's involuntary discharge. (The facility) decided to initiate an emergency involuntary discharge to R11 (prior to the hearing date set on 1-30-24). V1 stated the facility emergently discharged R11 to the (homeless shelter). On 1-29-2024 at 10:11 AM R4 stated, I lived on the same hall as (R11) and was never bothered by him. I had never seen (R11) be mean to any other residents. On 1-29-24 at 10:15 AM V5 CNA (Certified Nursing Assistant) stated, R11 could be accusatory, but for the most part was easy to deal with. On 1-29-24 at 10:30 AM V7 CNA stated, I liked (R11). I did not have any concerns with him. I have never witnessed him do anything physical to anyone. On 1-29-24 at 2:10 PM V17 (Laundry Aide) stated, On 1-17-24 (R11) came barging through the laundry room doors wanting to warm his coffee up in the microwave. (R11) is not supposed to be in the laundry area. I kept telling (R11) to get out, get out! (R11) refused to get out so we called for staff to help remove (R11). (R11) was removed by staff. I did not call (R11) any names until I closed the laundry room door. After I closed the door, I called (R11) a dumb b*****d to my co-worker. I do not know what to do for (R11's) behaviors. I have never been trained in de-escalating behaviors or what to do when (R11) has behaviors. On 1-30-24 at 12:40PM R8 stated, I have never seen R11 be mean to any other resident. R11 did not prevent me from coming out of my room. I always come out to the front lobby to watch television. On 1-30-24 at 1:55 PM V32 (Regional Ombudsman) stated, I was aware of (R11's) involuntary discharge from the facility. I submitted an appeal because it was an illegal involuntary discharge. We were supposed to meet with the judge, the facility, and (R11) today regarding the appeal however the facility had already done an emergency involuntary discharge on (R11). I came to the facility on [DATE] when the facility was initiating an emergency involuntary discharge to (R11). (R11) was very angry and had tears and did not want to leave. The staff made (R11) leave and called the police. (R11) felt intimidated by the police so he thought it would be better just to go ahead and leave. I was told the reasoning for the emergency involuntary discharge was due to two staff members quitting because (R11) spit on them. (R11) is now living at the (homeless shelter) and is not handling it well. (R11's) anxiety has worsened and he reports being in more pain. The facility should have allowed for the appeal process to be done prior to involuntary discharging (R11). On 1-31-24 at 1:10 PM V12 CNA stated, (R11) was pretty good. He could be very rude to staff, but usually always apologized. On 1-31-23 at 2:05 PM R10 stated, I was (R11's) roommate. (R11) did not have any behaviors unless management staff taunted him. (R11) was tired of seeing how the residents were being treated at the facility and started to speak up, and the managers did not like it. I never saw (R11) abuse any residents. On 2-1-24 at 1:15 PM R11 stated, I lived at (the facility) for three years and have had no issues until (V25 prior Administrator) started to come into me and my roommate's room without my permission. (V25) was taking my roommates items without his permission. I confronted (V25) about it, and (V25) then put his foot in front of my wheelchair and would not let me move forward. I was tired of seeing the way administration was treating other residents, so I started advocating for the other residents and staff did not like it. Staff would laugh at me and treat me like an animal. They were treating me like a dog and making me stay in my room like I was in a prison around there (the facility). When I would say something back to the staff, I was told that staff were quitting because of me and that they would have to discharge me. I had put in an appeal and the facility did not even allow me to meet for the appeal. They decided to hurry up and do an emergency discharge right before the appeal (1-30-24) because their reasoning was staff were quitting because of me. I was forced to leave by the facility calling the police and intimidating me with the police. I had to go to the (homeless shelter). The (homeless shelter) was unable to accommodate my wheelchair to enter the building, I am sleeping on a floor which has caused me to be in excruciating pain due to my lower back. I have had major chest pains, and I am a nervous wreck. I am angry and I am scared I will not find anywhere to live or have transportation to make it to any doctor's appointments. I miss the staff at the facility that treated me good. On 2-2-24 at 8:20 AM V34 (R11's Primary Physician) stated, I did not know the facility involuntarily discharged (R11) to the (homeless shelter). I was not asked to provide (R11's) needs, needs that could not be met by the facility, or the reason for (R11's) transfer. I was unaware that the facility was doing an emergency involuntary discharge due to (R11's) behaviors. I am unable to recall the facility notifying me of any increase behaviors (R11) may have been experiencing or ever writing an order for (R11) to be involuntarily discharged . On 2-2-24 at 11:30 AM V14 (Social Service Director) stated, I had nothing to do with (R11's) discharge. I am not the one who dealt with the situation. I have not updated (R11's) care plan with any new interventions regarding (R11's) behaviors. On 2-2-24 at 11:35 AM V2 (Director of Nursing) stated she was not aware of any documentation in R11's record of the needs the facility could not provide to R11 or the interventions attempted to meet those needs prior to involuntarily discharging R11 to the (homeless shelter). On 2-2-24 at 3:27PM V36 CNA stated, I worked at the facility for five years on and off. The reasoning for leaving was not because of (R11). I do not know why administration is telling people that. I was not there at the time (R11) was discharged . I was there that morning and (R11) was not acting like himself. (R11) seemed off and seemed upset and angry. (R11) had never done anything to me since I have worked there. (R11) could easily be directed when he had behaviors. I do not think (R11) should have been discharged for behaviors. I think (R11) came to our facility because of his behaviors. I walked out because I was being harassed by another staff member because of another staff member and (the facility) did not do anything about it. I don't remember (R11) ever acting bad. On 2-2-24 at 3:34PM V37 CNA stated, I have worked at the facility for around six months. (R11) had very few behaviors when I first worked for him. Within the last couple months, I noticed his behaviors were increasing. I believe it was after the involuntary discharge was given to him. I never see (R11) get physical with residents. There was one time a resident was talking to herself and (R11) went up to her and started to be bossy, but that's about it. The facility did not train me or tell me behavioral interventions to deal with (R11's) behaviors besides getting the nurse. I never received any behavioral training. I did not see an individual plan of care that had interventions to help manage (R11's) behaviors. I was not taught any other behavior interventions to deal with (R11). On 2-2-24 at 11:45 AM V18 (Corporate Regional Nurse) stated R11's medical record does not have physician documentation of R11's specific needs the facility could not meet, the facility efforts to meet R11's needs, and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. On 2-4-24 at 11:30AM V1 AIT (Administrator in Training) stated she was only aware of two staff members that quit or threatened to quit because of R11. V1 stated, (V36 CNA) quit because of him and (V17 Laundry Aide) threatened to quit because of him. V1 was unaware of any other staff members quitting over R11. V1 also stated she is unaware of the resident that (V18 Corporate Regional Nurse) documented on in R11's progress note on 1-23-24 that was staying in their room and not coming out to meals because of R11. The facility's Transfer and Discharge Policy and Procedure policy (undated) documents, It is the policy of (the facility) not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility. In all cases except the last, documentation in the resident's clinical record shall be required. The residents attending physician must document in the resident's clinical record that the facility cannot provide for the resident's welfare, or that the resident no longer requires the facilities services. Documentation in the resident's clinical record by any physician that the health of other individuals would be endangered is cause for transfer or discharge. Involuntary transfers or discharges. Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Notice of involuntary transfer/discharge shall be on the forms prescribed by Illinois Department of Health. In all other instances of involuntary transfer or discharge the mandated and federal and state 30 day Notice Transfer or Discharge will be issued, and the following steps taken: 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents' representative and/or the person or agency responsible for the resident's placement, maintenance, and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing, including the names of those in attendance. The summary shall be made a part of the residents clinal record. 3. A physicians discharge order shall be obtained in the residents record prior to discharge. 4. Prior to transfer or discharge the Social Service Director shall counsel the resident and summarize the counseling session in the resident's record. The Facility Assessment Policy dated 10-23-23 documents, Resident admission based on common diseases, conditions, physical and cognitive disabilities, or a combination of conditions that require complex medical care and condition management. The list below describes residents' that (the facility) accommodates for and regularly manages. Category: Psychiatric/Mood disorder- Psychosis, Hallucinations (auditory), delusions, mental disorder, MR (Mental Retardation) disorder, depression, anxiety, schizoaffective disorder, bipolar disorder, PTSD (Post Traumatic Stress Disorder), behavior requiring interventions, suicidal ideation, hx (history) of substance abuse. Cares provided for the resident population include by are not limited to: Mental health and behavior- Identify and implement interventions to help support individuals with anxiety, cognitive impairment, depression, PTSD, and other psychiatric diagnosis. Support by group and individual therapies, and structured activities. In house psychiatric physician management. Management of medical conditions- Assessment an early identification of problems and change in condition. Management of medical and psychiatric symptoms and conditions. Special Care Needs- Hospice, end of life care, Mental Health Programming. Provide resident-centered- Supporting psychosocial needs, building relationships with residents, honoring resident preferences, discussion on individualized resident plan of care, culturally competent care provided, religious preferences acknowledged (if identified), opportunities for social events, prevention of abuse and neglect, identification of hazards and resident risks, family and representative support provided. On 2-9-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy: 1. On 2-7-24 V34 (Medical Director) reviewed the Emergency Care Behavior Problem policy. 2. On 2-7-24 V18 (Corporate Regional Nurse) in-serviced V1 (AIT) and V4 (AIT) regarding the facility's Emergency Care: Behavior Problem policy and the facility's Discharge policy including resident, resident representative, and ombudsman notification of discharge and appeal rights and thoroughly documenting needs that cannot be met. V1 and V4 were also in-serviced on facility assessment regarding services and cares the facility is able to provide based on residents needs/diagnoses, and Admission/Transfer/Discharge procedures. 3. On 2-7-24 V1 (AIT) in-serviced the IDT (Inter-Disciplinary Team) and Nursing Staff regarding the facility's Emergency Care: Behavior Problem policy and the facility's Discharge policy including resident, resident representative, and ombudsman notification of discharge and appeal rights and thoroughly documenting needs that cannot be met. The IDT and Nursing Staff were also in-serviced on facility assessment regarding services and cares the facility is able to provide based on residents needs/diagnoses, and Admission/Transfer/Discharge procedures. 4. All staff prior to their next scheduled shifts reviewed the facility training videos: How to Strategies for Intervening with Challenging Individuals, as well as Calming the Agitated Resident and were in-serviced on 2-7-24 by V1 (AIT) and/or IDT designee on Emergency Care: Behavior Problem revised policy. 5. On 2-7-24 V1 (AIT) and/or IDT designated staff in-serviced all staff on any newly developed resident behavior interventions and where in (electronic medical record) monitored behaviors and interventions are located. 6. On 2-7-24 V31 (MDS/Minimum Data Set Coordinator) assessed all residents, with noted aggressions towards others, behaviors and PASSR Level II recommendations and developed and implemented interventions that were not already in place. 7. An Immediate QA (Quality Assurance) meeting was held on 2-7-2024. This meeting was held with Facility IDT Team and Regional Team. IDT in conjunction with Regional Team reviewed R2 and R11. R2's and R11's re-admission to the facility did not occur. Many factors were considered including the safety of all other residents who reside in the facility as well as Illinois Public Health Code; section 3-402. Section 3-415, and section 3-416. R11 was deemed an immediate safety risk to others and decision stands on emergency involuntary discharge. R2 posed a safety risk to her and others and was accepted by and currently residing in a facility who is able to meet her needs.

Based on observation, record review, and interview the facility failed to protect residents (R1, R3, R5) from verbal, mental, and physical abuse from another resident (R2) for three of four residents (R1, R3, R5) reviewed for abuse in the sample of 76. This failure resulted in R2 spitting on R1 on multiple occasions, pouring water over R1's head, cursing at R1 on multiple occasions days before R2 physically assaulted R1 by kicking and stomping R1 in the face which resulted in R1 sustaining lacerations to the nose and left eyelid, head trauma, bruising around the left eye, a hematoma under the left eye, severe pain, and mental anguish that required emergency room care for treatment. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 1-25-24 at 4:00 PM when R2 physically assaulted R1 by kicking and stomping R1 in the face which resulted in R1 sustaining lacerations to the nose and left eyelid, head trauma, bruising around the left eye, a hematoma under the left eye, severe pain, and mental anguish that required emergency room care for treatment. V1 (Administrator-In-Training) and V57 (Regional Director of Operations) were notified of the Immediate Jeopardy on 2-2-24 at 9:45 AM. While the immediacy was removed on 2-2-24, the facility remains out of compliance at a severity Level II as the facility continues to educate current and newly hired staff on the facility's Abuse Prevention Program, assess all residents for abusive type behaviors, develop interventions/care plans and implement interventions to address those behaviors, review those care plans quarterly, and the QA (Quality Assurance) team monitors compliance. 1. R2's Admission Summary dated 6-7-23 documents, This [AGE] year-old African American was admitted to (facility) from (another long-term care facility). Unaware of time, date, and facility. Ambulates on own. Diagnosis: Bipolar Disorder current episode manic without psychotic features and TBI (Traumatic Brain Injury). R2's Progress Notes dated 11-1-23 at 10:52 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spitting multiple times on peers today. R2's Progress Notes dated 11-12-23 at 12:35 PM and signed by V24 (RN) documents, (R2) reportedly spit on a peer today. Re-directed and behavior not reported by peer again. R1's BIMS (Brief Interview of Mental Status) dated 11-10-23 documents R1 is cognitively intact. R1 and R2's Final Report dated 1-25-24 documents on 1-25-24 R1 stated she was on the floor close to R2's room when R2 approached R1 and kicked her. R1 and R2's Police Report dated 1-25-24 at 3:37 PM documents, Event: Battery. Complainant: V4 (AIT/Administrator-In-Training). Victim: (R1). Suspect: (R2). (R2) kicked another resident (R1) in the head. R1's Progress Notes dated 1-25-24 at 5:42 PM and signed by V11 (LPN/Licensed Practical Nurse) AIM (Acute Illness Management) for Wellness Event Record documents, (R1) appears to have sustained an injury that was unwitnessed. Event was first noted on 1-25-24 at 4:00 PM. Evaluation of the resident and event occurred on or about 1-25-24 at 4:01 PM. Just prior to/at the time of the event (R1) appears to have been sitting on floor. (R1's) account of the event is I was on the floor and (R2) kicked me in my head. (R1) was asked to point out the residents who allegedly kicked (R1) then pointed to (R2). Staff's response is noted as assessing (R1) who reportedly received a kick to their face. (R1) rates pain level as an eight. Vocal complaints of pain at the time of the event. Pain location includes head pain and headache. (R1) sent to the emergency room for evaluation. R1's Hospital Emergency Department Notes dated 1-25-24 document, (R1) was involved in altercation at the (facility) she suffered a contusion to her face. She has some bruising of the lateral aspect of her face and her bridge (of her nose) has been applied some steri-strips. (R1) states she was kicked in the face. Chief Complaint: Head injury and assault victim. R2's current Care Plan does not include interventions addressing R2 spitting on other residents, addressing R2 targeting R1, and addressing R2 kicking R1 in the face on 1-25-24. R1's current Care Plan does not include interventions to protect R1 from R2's past behaviors of spitting on R1 and cursing R1. On 1-29-24 at 10:30 AM R1 was sitting in a recliner in the sitting area across from the nurses' desk. R1's left eye was surrounded with golf-ball sized purple bruising with a 3 cm (centimeter) by 1 cm hematoma beneath the left eye. R1 had a 3 cm laceration to the left eyelid that was approximated with steri-strips. R1 had a 1 cm laceration to the right side of her nose that was approximated with a steri-strip. R1 stated, I was sitting on the floor in my doorway and (R2) came up and kicked me three times in the face and then stomped on me. It hurt really bad. I grabbed (R2's) leg and yelled for help. (R2) threw water on me the day before and spits on me. I was abused. I was scared of (R2). (R2) always walked by me and would call me bad names. On 1-29-24 at 11:20 AM V11 (LPN) stated, I was working on 1-25-24 and a CNA (Certified Nursing Assistant) reported to me that (R2) kicked (R1) in the face. (R1) was sitting on the floor in her doorway, which she prefers. (R1) was bleeding form her face. I sent (R1) to the emergency room . (R1) was sent back from the emergency room with steri-strips to her lacerations. (R1) knows what is going on and tells the truth. (R1) reported that (R2) kicked her in the face and spit on her. I am not sure if any other behavior interventions have been implemented after (R2) kicked and spit on (R1). I am not sure of any behavior interventions to keep (R2) from spitting, (R2) has a lot of aggressive behaviors and has a history of spitting on (R2) and other residents. (R2) calls (R1) a b***h. I have reported to (V1 Administrator-In-Training) that (R2) spits on staff and other residents. On 1-29-24 at 1:00 PM V26 (Unit Aide) stated, (R2) cusses at (R1) all the time and spits on (R1). (R2) also spit on me so bad I had to change my shirt. On 1-29-24 at 1:10 PM V27 (LPN) stated, (R1) knows what is going on and did not deserve to be kicked by (R2). I know (R2) spits on other residents. (R2) gets agitated very easily. On 1-29-24 at 1:20 PM V28 (CNA) stated, (R2) spits on (R1) and has poured water over her head. (R1) does not lie. (R1) knows exactly what happened. (R1) did get kicked in the face by (R2). (R2) will yell at (R1) f**k you b***h! On 1-29-24 at 1:55 PM V31 (MDS Coordinator) stated, I am responsible for (R2's) care plan. (R2) has not had an intervention developed to address (R2) spitting on other residents or staff. (R2) has not had any additional behavior interventions developed after kicking (R1) in the face. On 1-30-24 at 10:30 AM, V23 (CNA) stated, I was working on 1-25-24 when (R2) kicked (R1) in the face. I was in the bathroom and heard a kicking sound. I heard (R2) kick and (R1) yelling. I came out and (R1) was in sitting on the floor with her head down, crying, with blood dripping. (R1's) head was bloody and (R1) was in a lot of pain and was screaming Get her (R2) away from me! (R2) was standing next to (R1). (R1) was terrified and crying. (R1) was sent to the emergency room . (R1) is of sound mind and knows exactly what happened. I feel really bad for (R1). (R1) is a sweetheart. (R1) is never aggressive. (R1) would not make anything up and I could tell she had been kicked in the face by (R2). (R1) always prefers to sit on the ground in her doorway. (R2) has a history of spitting on (R1) and calling (R1) a b***h. (R2) has also thrown water on (R1). (R2) gets mad at (R1) because they share a bathroom, and their rooms are side by side. When (R1) returned from the hospital, staff had to directly supervise (R2) until (R1) was moved off of the unit on 1-26-24. Every time (R2) would walk by (R1) after (R1) was kicked, (R1) would yell, Get her (R2) away from me. (R1) continued to be terrified when she would see (R2). On 1-30-24 at 12:15 PM V24 (Agency RN) stated, Both times I charted on (R2) spitting on her peers (11-1-24 and 11-12-24), I had witnessed (R2) spit on (R1). I reported both occurrences to V25 (Prior Administrator) as abuse. (R2) would get angry at (R1) because they shared a bathroom and would spit on (R1) and call (R1) a b***h. (R1) would cry and yell out. (R1) was scared of (R2). I do not recall (R1) or (R2) ever being separated. (R1) and (R2) continued to share a bathroom after (R2) would call (R1) names and spit on (R1). (R2) has anger issues and if other residents would not give them their soda, (R2) would call them b*****s. (R2) would call (R1) a b***h quite a bit. On 1-30-24 at 1:50 PM V14 (Social Service Assistant) stated, (R1) always sits on the floor in her doorway. (R1) is care planned that she prefers to sit on the floor. (R1) sat on the floor at home. (R1) reported to me that when (R1) was sitting in the doorway of her room, (R2) went up to her and kicked her in the face. (R1) knows what is going on. (R1) and (R2) have always shared a bathroom and I think that is why (R2) targets (R1). Administration is aware of (R2's) behaviors. (R2) throws tantrums. I am not aware of any interventions implemented to address (R2) spitting in resident faces or throwing water on them. I am not aware of any new behavior interventions to address (R2's) behaviors after (R2) kicked (R1) in the face. 2. R3's BIMS dated 11-9-23 documents R3 is cognitively intact. On 1-29-24 at 11:05 AM R3 was well-groomed and alert and orientated. R3 stated, (R2) always asks me for a phone to call her brother. I do not have a phone. If I do not give (R2) a phone she calls me a b***h. (R2) spit on me a month ago in the dayroom. (R2) called me a b***h yesterday. (R2) calls me a b***h about three to four times a week. I am tired of it. (R2) has also hit me in the cheek because I would not give her my soda. I try to stay away from her. Next time (R2) touches me I will hit her back! On 1-29-24 at 1:40 PM V29 (CNA) stated, I witnessed (R2) hit (R3) in the cheek a few months ago. (R2) wanted (R3's) pop. When (R3) wouldn't give (R2) her pop, (R2) hit (R3) in the cheek. (R3) had a red mark on her cheek. 3. R5's BIMS (Brief Illness of Mental Status) evaluation dated 11-14-23 documents resident is cognitively intact. On 1-29-24 at 12:45 PM R5 was lying flat in his bed. R5 was groomed appropriately, and no odors were noted. V4 (AIT) was in R5's room. R5 stated, Around a month ago this black lady (R2) and I got into an argument in the hallway. (R2) called me a little b***h and calls other residents b*****s. (R2) is very mean. Right when I turned around R2 hit me in the back of my head. (R2) has anger issues and I am scared to even be around her. I sit in my room a lot to stay far away from her because you never know when she will just go off. The facility's Abuse Prevention Program Policy dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and have therefore prohibits mistreatment, exploitation neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect, or abuse of our residents. This will be occurrences of mistreatment exploitation, neglect, or abuse of our residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. On 2-9-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy: 1. On 2-2-24 V34 (Medical Director) reviewed and approved the facility's Abuse Prevention Program policy. 2. On 2-2-24 R1 met one-on-one with the social service department to address any concerns and to provide TLC (Tender Loving Care). 3. On 2-2-24 V18 (Corporate Regional Nurse) in-serviced V1 (AIT) and V4 (AIT) on the facility's Abuse Prevention Program focusing on what constitutes abuse, and how to prevent abuse. 4. On 2-2-24 V1 in-serviced the IDT (Interdisciplinary Team) on Abuse Prevention Program focusing on what constitutes abuse and how to prevent abuse. 5. On 2-2-24 V1 and designated IDT members in-serviced all staff on Abuse Prevention Program focusing on what constitutes abuse and how to prevent abuse. 6. On 2-2-24 V1 started an initial report and investigation into R1 and R2's abuse allegations that had not been investigated prior. 7. On 2-2-24 all residents that are able to be interviewed and staff were interviewed by members of IDT to ensure all residents are protected from abuse and feel safe in their home. 8. On 2-2-24 all residents were assessed by the social service department for risk of reprisal from others. 9. On 2-2-24 all residents with noted aggression towards others, behaviors were assessed, and interventions developed, implemented, and care planned and updated accordingly by V31 (MDS Coordinator). 10. On 2-2-24 V1 (AIT) and designated members of the IDT staff in-serviced all staff on adequate supervision of all residents to prevent abuse. 11. R2 was discharged to another facility on 1-30-24. Completion Date: 2-2-24

Based on observation, interview, and record review the facility failed to adequately supervise a resident while showering. The facility also failed to transfer a resident with assistance of two staff as directed by the plan of care to prevent a fall for one of three residents (R55) reviewed for falls in the sample of 76. These failures resulted in R55 sustaining a fall while in the shower room, resulting in R55 suffering a head injury, head swelling, left ankle swelling with bruising, neck pain, and a traumatic hematoma to the forehead which required hospital treatment. Findings include: The facility's Fall Prevention policy dated 11-10-18 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence with mobility. Responsibility: All staff. Procedure: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. 4. Assignment of the final risk category will be determined by the Interdisciplinary Team (IDT) at their conferences based on: a. Fall risk score. b. History of falls. c. Medical condition which directly impacts on equilibrium and/or ambulation. d. Discussion of individual circumstances. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. R55's Admission Record documents R55 was admitted on [DATE]. This same form documents R55 has the following, but not limited to, diagnoses: Mild Intellectual Disabilities, Chronic Obstructive Pulmonary Disease, Morbid (Severe) Obesity due to excess calories, Anxiety Disorder, Hemiplegia and Hemiparesis following Nontraumatic Subarachnoid Hemorrhage affecting left non-Dominant side, Weakness, Polyneuropathy, and Difficulty in Walking. R55's Care Plan dated 1-17-24 documents on 9-22-23 documents R55 is a high risk for falls and has right-side hemiplegia, bilateral weakness, and impaired cognition and safety awareness. This same care plan documents on 9-22-23 an intervention to assist to transfer R55 using a mechanical device and/or two staff members. R55's AIM (Acute Illness Management) for Wellness Event Record dated 11-23-23 at 7:05 AM documents V3 (CNA/Certified Nursing Assistant) was assisting R55 with transferring from the shower chair to the stand bar in the shower room. R55 became weak and lost her balance. V3 (CNA) lowered R55 to the floor. R55 then complained of pain and had bruising to the left knee. R55 was sent to the local ED (Emergency Department) for evaluation. R55's Emergency Department Notes dated 11-11-23 documents, Chief Complaint: (R55) presents with fall, head injury (left anterior), head swelling, and neck pain. This same form documents R55 suffered from a fall at nursing home and has a traumatic hematoma to the forehead. R55's CT (Computed Tomography) Head Scan dated 11-11-23 documents, Impression: Acute posttraumatic left frontal scalp hematoma. R55's Left Ankle X-Ray dated 11-11-23 documents, Soft tissue swelling. R55's Progress Notes dated 11-12-23 at 1:45 PM documents, (R55) left ankle has a purple discoloration to it, moderate swelling, and is having some discomfort to it. X-Ray results sent to advanced practice nurse and new order to ice, elevate, and PRN (As Needed) APAP (Acetaminophen). On 1-29-24 at 9:55 AM V3 (CNA) stated, On 11-11-23 I heard (R55) yelling for help so I went into the shower room. (R55) had tried to stand up by herself from the shower chair to grab bars on the wall. (R55) got weak and I had to lower her to the floor. I was the only one transferring (R55). I did not know (R55) needed two staff for transfers or could not be left unattended in the shower. On 1-29-24 V5 (CNA) and V8 (CNA) both stated that R55 should always be a two assist for transfers and sometimes they even have to use a (mechanical) lift to transfer R55. V5 and V8 verified R55 should never be transferred with just one assist and should not be left alone in the shower room. On 1-30-24 at 10:00 AM (R55) was crying with visible tears and stated, I was left alone in the shower room for a long time. I had to yell for help. There was a bunch of water on the floor. Someone came in and tried to get up me up and I slid and fell . I hit my head and knee. I hurt my back and neck. On 1-30-24 at 10:30 AM V9 (LPN/Licensed Practical Nurse) stated, (R55) can stand during transfers, but requires two assists. (R55) becomes unsteady periodically, so requires a (mechanical) lift at times. On 1-30-24 at 1:00 PM (AIT/Administrator in Training) stated that he was a therapist in the past and after reviewing R55's care plan confirmed that R55 should have been a two assist when being transferred in the shower room on 11-11-23.

Based on observation, interview, and record review, the facility failed to administer pain medication as ordered and assess pain on a daily basis for four of four residents (R88, R117, R233, R285) reviewed for pain in the sample of 23. These failures resulted in R285 having intractable pain following a fall that resulted in a fractured rib. Findings include: The facility's Pain Prevention & Treatment policy, dated 12/7/17, It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. Responsibility: All nursing personnel, physical therapists, occupational therapist, attending physician, Interdisciplinary Care Team. Pain Treatment Plan: a plan based on information gathered during a resident pain assessment that identifies the resident's needs and specifies appropriate interventions to alleviate pain to the extent feasible and medically appropriate. The Pain Management Flow Sheet will be initiated for those residents with but no limited to routine pain medication, daily pain, diagnosis that may anticipate pain (i.e., arthritis, wounds, fractures, etc.). Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan. 1. On 10/22/23 at 10:50 AM, R285 was alert and oriented sitting up in a wheelchair in the dining room. R285 had tremors to his bilateral hands. R285 stated, I fell last week getting up out of bed. I fell back onto my side rail and broke a rib on my back side. They were out of my (narcotic pain medication) for a few days. The pain was awful, and it's still not good. Right now, my pain is a sharp stabbing '7' (scale of 0-10). I can't even breath or talk without it hurting. I tried to pull myself up in bed, and the pain got so bad I'm pretty sure I passed out. My pain was a 10+. R285's Pain Evaluation, dated 10/11/23, documents that R285 has almost constant pain to his right shoulder rating it at a 9 on a scale of 0-10. R285's After Visit Summary, dated 10/14/23, documents, Reason for visit: Fall. Shoulder pain. Diagnoses: Closed fracture of one rib of right side. Mood disorder. Recurrent falls. Contusion of right shoulder. The Summary also documents that he has an order to receive (Hydrocodone/Acetaminophen) 5/325 mg (milligrams) every four hours prn (as needed), and a follow up appointment at a Pain Clinic on 10/23/23 at 8:00 a.m. R285's Pain care plan, dated 10/11/23, documents, The resident has chronic pain related to Parkinson's. The care plan has no revision to include R285's pain related to his closed fracture of a rib of the right side as a result of the 10/14/23 fall. R285's MAR (Medication Administration Record), dated 10/23, documents that R285 started (Hydrocodone-Acetaminophen) 5-325 mg one every six hours as needed for moderate and severe pain on 10/14/23. R285 received an as needed doses on 10/14/23 at 8:00 p.m. for pain at a level 8. On 10/15/23 at 3:30 a.m. for pain at a level 7, at 11:52 a.m. for pain at a level 5, and at 5:30 p.m. for pain at a level 8. On 10/16/23 at 4:01 a.m. for pain at a level 9, and at 10:57 a.m. for pain at a level 8. On 10/17/23 at 5:43 a.m. for pain at a level 4, at 5:25 p.m. for pain at a level 9, and at 11:21 p.m. for pain at a level 8. On 10/18/23 at 6:57 a.m. for pain at a level 9 and at 2:46 p.m. for pain at a level 9. On 10/19/23 at 5:41 a.m. for pain at a level 9. 10/21/23 at 10:15 p.m. for pain at a level 3. 10/22/23 at 6:35 a.m. for pain at a level 10 and at 1:17 p.m. for pain at a level 9. 10/23/23 at 4:30 a.m. for pain of a level 3. The MAR has no documentation of a daily pain assessment to assess the effectiveness of R285's pain control. R285's Controlled Substances Proof of Use, dated 10/15/23, documents that the pharmacy delivered two doses of (Hydrocodone-Acetaminophen) 5/325 mg and he received them on 10/15/23 at 11:52 a.m. and 5:30 p.m. After the 5:30 p.m. dose R285 had no doses remaining. R285's Controlled Substances Proof of Use, dated 10/16/23, documents that the pharmacy delivered seven doses of (Hydrocodone-Acetaminophen) 5/325 mg and he received them on 10/17/23 at 5:53 a.m., 12:00 p.m., and 5:25 p.m.; 10/18 12:00 a.m., 6:00 a.m., 3:00 p.m.; 10/19 at 5:30 a.m. After the 5:30 a.m. dose on 10/19, R285 had no doses remaining. R285's Controlled Substances Proof of Use, dated 10/21/23, documents that the pharmacy delivered twenty doses of (Hydrocodone-Acetaminophen) 5/325 mg on this date, and he didn't receive his first dose from this delivery until 10/21/23 at 10:15 p.m. The facility transportation calendar dated 10/23-10/25/23, has no documentation of an appointment for R285 to be transported to his pain clinic appointment. On 10/25/23 at 09:59 AM, V16 (Licensed Practical Nurse) stated, There is no formal pain assessment or pain flow sheet that we do regularly scheduled pain assessments. We do the assessments as needed when they need PRN (as needed) pain medication. (R285) receives (Hydrocodone-Acetaminophen) prn around the clock. I would hope that with him receiving it as often as often as he does, he wouldn't have a pain level as high as he does when he asks for it. Sometimes it's as high as a 9 when we administer it. I don't know how effective that is. When he went to the ER, they set up the pain clinic appointment because of his rib fracture. With the fracture and how much pain he has that he gets the (Hydrocodone-Acetaminophen) around the clock that pain clinic appointment was very important. He can't wait for three months to go to it. V16 confirmed that R285 did not have any (Hydrocodone-Acetaminophen) available after the 5:30 a.m. dose on 10/19/23 until 10/21/23's dose at 10:15 p.m. On 10/25/23 at 10: 30 a.m., V13 (Care Plan Coordinator) stated, (R285's) pain care plan wasn't revised after he fell and got the fracture. On 10/25/23 at 12:15 p.m., V1 (Administrator) confirmed that R285 did not attend his pain clinic appointment on 10/23/23 and it was rescheduled for some time in January. 30899 2.) Current Physician's Order Summary indicates R233 was admitted to the facility on [DATE] with diagnoses that include Chronic Pain Syndrome, Major Depressive Disorder and Anxiety Disorder. Admission Nursing Pain assessment dated [DATE] indicates R233 had vocal complaints of pain; chronic pain and acute pain related to right foot fracture. On 10/23/23 at 9am R233 was in bed and had both lower legs wrapped with elastic bandages. R233 stated that she had wounds on her left leg and was having pain in her left leg at that time as well as a headache. R233 stated that she must ask for Tylenol (analgesic) but thinks the doctor ordered it to be given without asking four times a day. R233 stated that sometimes she must wait for the nurses to bring the Tylenol and they do not bring it unless she asks. R233 stated the nurses only ask about her pain when she asks for Tylenol. On 10/23/23 at 9:10am V21 (Registered Nurse/RN) stated that she was R233's nurse and did not give R233 Tylenol when she gave R233 her morning medications because she did not ask for it. On 10/24/23 at 10am R233 had bilateral lower leg dressings changed. R233's left leg bandages were soaked with drainage from wounds - soaking through multiple layers of bandages and soaking through to the bed sheet. Once removed, R233's left lower leg was approximately 50% intact skin and 50% open, ulcerated tissue with several full thickness affected areas. At that time R233 stated that the pain in her leg is 10 out of 10 when the areas are touched and reported entire left leg throbbing after areas were cleansed and dressed. R233 also reported having pain in left leg when self-propelling her wheelchair with her feet. Wound Evaluation and Management Summary dated 10/12/23 indicates R233 has a venous wound of left leg/full thickness with only 60% intact skin. Wound summary objective to Manage pain and control infection. Current Physician's Order Summary Report indicates R233 has orders for Acetaminophen/Tylenol 650mg (milligrams) every four hours as needed for pain/fever, ordered on 9/14/23. September 2023 MAR (Medication Administration Record) indicates R233 received Tylenol 650 mg 11 times from 9/16/23 to 9/30/23. MAR indicates R233 rated her pain as an 8 five times and 10 once. MAR indicates R233 rated pain at time of Tylenol administrations between 4 and 10 on the scale of 1 (mildest) to 10 (most severe). October 2023 MAR indicates R233 received Tylenol 650 mg every day except on 10/1/23, 10/8/23 and 10/21/23. MAR indicates R233 reported pain at an 8 10 times and a 10 six times. Progress Notes indicate the following: 9/28/23 at 8:10pm R233 complaints of chronic bilateral lower extremity pain. 10/3/23 at 6:31pm R233 complaints of generalized discomfort, especially bilateral lower extremity. 10/7/23 at 8:14pm R233 complaints of bilateral lower extremity pain, chronic wound, arthritic knees. 10/13/23 at 7:38pm R233 complaints of chronic bilateral knee pain and left lower extremity wound pain. 10/20/23 at 10:26pm R233 reports severe generalized pain and requests medication. Reports I feel like I want to die. 10/20/23 at 10:34pm R233 observed tearful and upset upon assessment, reports severe generalized pain. Tylenol administered. R233 reports I feel like I want to die related to her pain. Pain Evaluation with Interview dated 10/13/23 at 11:28am indicates R233 denied having pain or hurting in the past five days, did not receive scheduled pain medication, did not receive prn (as needed) pain medication, and did not receive non-medication interventions for pain. On 10/25/23 at 10:25am V12 (Registered Nurse/RN) stated R233 asks for pain meds a lot and would definitely qualify for scheduled pain medication which would probably help manage R233's pain better. V12 stated any nurse could call the physician and request scheduled pain medications. R233's Current Comprehensive Care Plan did not include a focus area/problem identifying acute or chronic pain. On 10/25/23 at 10:00am V10 (Care Plan Coordinator) confirmed that she completed R233's pain assessment and is responsible for developing and revising resident care plans. V10 stated that R233 didn't say anything about pain in the care plan meeting (held on 10/3/23) or in the pain assessment interview. V10 stated that she wasn't aware of R233's admission pain assessment or the frequency of Tylenol given for pain. V10 acknowledged that she did see the progress note that documented R233 reported pain and wanting to die. V10 stated she should have reviewed all R233's medical record and developed a pain care plan. V10 stated there is a communication issue between staff/departments and not getting the total information. V10 stated I did question whether (R233) should have a scheduled pain medication regimen. V10 also stated there should be pain assessments done every shift - not just with prn's. V10 stated there used to be pain assessments included with resident MAR's, I don't know when they stopped being done. 3.) On 10/22/23 at 9:35 am, R88 was sitting at a table in the dining room with facial grimacing and furrowed brow and stated she has pain in ankles, knees, and hip that R88 rated 10 out of 10 on pain scale. R88 stated she has no cartridge in her knees, torn meniscus, can't lift her left leg, and if her legs dangle down it causes greater pain. R88 also stated her feet swell up which causes more pain. R88 stated she must request a pillow to put under her feet while in the wheelchair and will have the staff take her to the dining room up to a table so that she can lean on the table to help relieve pain. R88 stated sometimes she doesn't eat because she is in so much pain. R88 stated no one asks her about pain or she would tell them. The MAR (Medication Administration Record) for R88, dated 10/1/23 through 10/31/23, includes the following diagnoses for R88: Acute Embolism and Thrombosis of Deep Veins of upper extremity, Necrotizing Fasciitis, Rheumatoid Arthritis, Polycystic Ovarian Syndrome, Obesity, Critical Illness Myopathy, Psoriasis, Type 2 Diabetes Mellitus and Inflammation of Vagina and Vulva. The current Care Plan for R88 documents (R88) has chronic pain r/t (related to) Rheumatoid Arthritis. The Order Summary Report for R88, dated 10/25/23, documents the following physician orders and pain medications as: Tramadol 50 mg (milligram) every six hours as needed for moderate or more severe pain; Tizanidine 4 mg, one tablet two times a day for Rheumatoid Arthritis/muscle spasms. Do not give with Tramadol. Monitor bilateral feet for any discoloration or abnormalities that may present related to incident every shift for 7 days, every day and night shift for 7 days until finished; Rheumatology appointment for bilateral feet neuropathy; Collagenase Powder to right third toe topically every day shift every Tuesday, Thursday, Saturday for non-pressure wound; and Collagenase Powder to sacrum topically every day shift for infection. This same Order Summary Report does not include assessing R88's pain level. The MAR (Medication Administration Record) dated 10/1/23 through 10/31/23, EHR (Electronic Health Record) and Paper Chart for R88, do not include any documentation of routine pain assessments occurring or having been completed for R88. 4.) On 10/23/23 at 10:30 am, R117 was lying in bed with facial grimacing while stating he has been in so much pain that all he does is just lay around, and affects all of me and has continued losing weight. R117 stated his doctor started him on Lyrica, Ibuprofen and Gabapentin at night and takes Methotrexate every week. R117 stated his right hand sticks in place at times and is painful at times. The Order Summary Report for R117, dated 10/24/23, documents the following Diagnoses for R117: Ankylosing Spondylitis of multiple sites in Spine, Rheumatoid Arthritis. This same Order Summary Report documents the following Physician Orders: Gabapentin 600 mg (milligrams) at bedtime; Ibuprofen 800 mg three times daily; Lyrica 75 mg every morning and bedtime; and Methotrexate 2.5 mg, Give 5 (five) tablets one time a day every Thursday. The current Care Plan for R117 documents The resident has Rheumatoid Arthritis. The resident is on pain medication therapy. The resident has pain r/t (related to) rheumatoid arthritis and Ankylosing Spondylitis. Receives Inflectra infusions via outpatient services at local hospital. One intervention listed on R117's Care Plan is to Complete pain assessment as needed. There are no routine pain assessments being completed for R117. The MAR (Medication Administration Record) dated 10/1/23 through 10/31/23, EHR (Electronic Health Record) and Paper Chart for R117, do not include any documentation of routine pain assessments occurring or having been completed for R117. 30678

Based on observation, interview, and record review the facility failed to prevent physical abuse for one (R117) of four residents reviewed for abuse in the sample of 40. This failure resulted in R117 receiving an open laceration to his left jaw requiring three sutures. Findings include: The facility's Abuse Prevention Program, revised 11/28/2016, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The Initial Report for Physical Abuse of R117, dated 10/18/23, documents an allegation of Physical abuse occurred on 10/18/23 at 12:15 pm between R117 and R92 and the police was called. The Final Report for Physical Abuse of R117, documents It was reported to (V1 Administrator) that (R92) made physical contact with (R117). (R92) stated that he was trying to make peace with (R117) by bringing him his tray. (R92) stated that he offered (R117) the tray and (R117) pushed it back into (R92) spilling it on him. (R92) the stated that he became angry and threw the tray towards (R117). (R117) states that (R92) approached him with the tray and thought that (R92) was trying to dump the tray on him and blocked him resulting in the food going on (R92). According to (R117), (R92) then picked up the tray and threw it like a Frisbee that hit (R117) on the left side of his face. Residents were then separated. Staff interviews stated that (R92) had grabbed a tray from the serving table and approached (R117). (R117) attempted to block (R92's) approach and then (R92) made contact with the tray. (R92) was removed from the area and (R117) went to Social Services office to be assessed. (R117) stated that he wanted charges to be pressed and when police arrived, they were informed of this desire. (R92) was removed from the facility in police custody. (R117) was assessed by the nurse and was recommended to be assessed at the ER (emergency room ). (R117) initially declined, but with encouragement went for assessment. (R117) returned to facility after receiving three sutures to left jaw. (R92) did not return to facility. (R92) called facility to pick up belongings with friend off facility grounds. (R92) expressed no desire to return to facility. On 10/23/23 at 10:30 am, R117 was lying in bed with sutures visible to left jaw line. On 10/23/23 at 10:38 am, R117 stated he was in the dining room and R92 approached (R117) with R117's meal tray and was touching all R117's food and then pushed the tray toward R117. R117 stated he did not know if R92 was trying to hit him with the tray or dump the tray on him, so he put his arms up blocking the tray which spilled on R92. R117 stated R92 then flung the meal tray at him like a Frisbee and hit him in the face. R117 stated he ended up getting three stitches and pressed charges against R92 and R92 has not come back to the facility. On 10/23/23 at 12:00 pm, V1 (Administrator) confirmed an allegation of physical abuse was reported on 10/18/23 of R92 hitting R117 in the face with a meal tray. V1 stated there were witnesses in the dining area that he obtained statements from. V1 stated R117 did go to the hospital for an evaluation and received three stitches to his left jaw. V1 stated R117 wanted to press charges and the police took R92 to jail. V1 stated R92 was released from jail but did not want to return to the facility.

Based on observation, interview, and record review the facility failed to remove an alleged perpetrator V4 (Certified Nursing Assistant) from resident cares following staff (V4) to resident verbal abuse, failed to protect residents from an alleged abuser (V4), and failed to recognize verbal abuse for one of three residents (R1) reviewed for abuse in the sample of three. These failures resulted in V4 returning to work with all residents within the facility after verbally abusing R1, resulting in R1 feeling angry and experiencing fear. These failures have the potential to affect all 134 residents residing within the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9-6-23 when the facility failed to remove V4 (Certified Nurse Assistant/CNA) from the facility after verbally abusing R1 and failed to protect R1 and all other residents from V4 after V4 verbally abused R1. V1 (Administrator) and V9 (Activity Director) were notified of the Immediate Jeopardy on 9-8-23 at 2:28 PM. The immediacy was removed on 9-8-23. On 9-13-23 the surveyor confirmed through observation, interview, and record review that the facility took actions to remove the Immediate Jeopardy. While the immediacy was removed, the facility remains out of compliance at a severity Level II as the facility continues to train staff and all new staff on the abuse policy weekly for four weeks, then monthly for four months, and then quarterly, the Quality Assurance (QA) monitors the abuse training, and the QA identifies residents at risk of abuse and care plan as appropriate, including new admission residents. Findings include: The facility's Abuse Prevention Program policy dated 05/2021 documents, This facility affirms the right of our resident to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The facility is committed to protecting our residents from abuse by anyone including facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members, or legal guardians, friends, or any other individuals. Protection of Residents: The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse, or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed. The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 9-8-23 and signed by V1 (Administrator) documents 134 residents reside within the facility. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is a [AGE] year-old admitted to the facility on [DATE]. This same MDS documents R1 is cognitively intact and requires extensive assistance of staff for all ADLs (Activities of Daily Living). R1's Illinois Department of Public Health Notification Form dated 9-6-23 and signed by V1 (Administrator) documents, On this date (R1) reported that two CNAs were verbally abuse towards him. Time of Incident: 12:30 PM. The facility's Incident Investigation Forms (undated) and signed by V1 (Administrator) document R1, V3 (CNA), and V7 (CNA) reported to V1 that V4 verbally abused (sic) R1 in the dining room on 9-6-23 at 12:30 PM. On 9-8-23 at 8:30 AM V3 (CNA) stated V4 verbally abused R1 while in the dining room on 9-6-23 at 12:30 PM and V4 is still working within the facility with all the residents. On 9-8-23 at 10:10 AM R1 was sitting in a wheelchair in his room. R1 was alert and orientated to person, place, and time. R1 stated with tears in his eyes, On Wednesday (9-6-23) at lunchtime I was trying to eat Chinese food that I had for lunch. (V4) is always mean to me and never wants to help me. I asked (V4) for help eating and (V4) said to me I am not helping you. You are an a**. I called (V4) names and (V4) said to me, Stop f*****g talking to me! I have reported this to (V1 Administrator) and V8 (Social Service Assistant/SSA). Something needs to be done with (V4) or I am going to get legal advice. (V4) should not talk to me that way. I felt abused and it made me cry. I am still upset over it. (V4) is still here today. I do not want her (V4) anywhere around me. On 9-8-23 at 10:25 AM R1 was sitting in the sitting area in front of the nurse's desk. V4 was standing within one foot of R1 at this time. R1 had his head down. On 9-8-23 at 10:30 AM V4 stated, (R1) refuses cares from me and on Wednesday (9-6-23) (R1) was talking about his egg roll. I said something about the egg roll and (R1) said to me It is none of your business you f*****g b***h. I responded to (R1) and asked him to not talk to me and please leave me alone. I was allowed to return to work today and was not told that I could not take care of (R1). I am able to help take care of all of the residents within the facility whenever other CNA's need help or when I am in the dining room. On 9-8-23 at 11:00 AM V7 (CNA) stated V4 verbally abused R1 in the dining room on 9-6-23 around 12:30 PM and is working today (9-8-23) with the residents. On 9-8-23 at 11:35 AM V1 (Administrator) stated, I did not consider it willful when (V4) cussed at (R1). I did not feel like cussing at (R1) was verbal abuse. I allowed (V4) to return to work today. (V4) really should not have been able to work with (R1), but I did not make that clear to (V4). (V4) really should not have been on the hallway with (R1) today. On 9-13-23 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V15 (Regional Director of Operations) in-serviced V1 (Administrator) on the facility's Abuse Policy, types of abuse, and how to respond to resident behaviors on 9-8-23. 2. The facility Social Service department and designees interviewed all appropriate residents regarding feeling safe and comfortable in the facility on 9-8-23. 3. V1 in-serviced all staff on 9-8-23 on the facility's Abuse Policy, types of abuse, how to reduce resident behaviors, abuse prevention, and how to respond appropriately to resident behaviors. 4. V4 (Alleged Perpetrator) removed from the floor and schedule on 9-8-23. 5. Facility staff will continue to be trained by (V1) on how to reduce behaviors, abuse prevention and reporting weekly times four weeks then monthly times four and then quarterly and prn (as needed). 6. All newly hired staff will be trained by (V1) on how to respond appropriately to resident behaviors, abuse prevention and reporting. 7. The Quality Assurance (QA) team will monitor abuse in-servicing through the QA process and determine its effectiveness, and changes that may need to occur to ensure abuse training is effective to all staff. 8. The QA team will identify resident at risk of abuse of new admissions and care plan as appropriate. Completion Date: 9-8-23

Based on observation, interview, and record review the facility failed to prevent verbal abuse from staff V4 (Certified Nursing Assistant) to a resident for one of three residents (R1) reviewed for abuse in the sample of three. This failure resulted in V4 yelling at R1Stop f*****g talking to me (V4). You are an ass! resulting in R1 crying and experiencing mental anguish. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9-6-23 when the facility failed to prevent V4 from verbally abusing R1, resulting in R1 crying and experiencing mental anguish. V1 (Administrator) and V9 (Activity Director) were notified of the Immediate Jeopardy on 9-8-23 at 2:28 PM. The Immediate Jeopardy was removed on 9-8-23. On 9-13-23 the surveyor confirmed through observation, interview, and record review that the facility took actions to remove the Immediate Jeopardy. The facility remains out of compliance at a severity Level II as the facility continues to train staff and all new staff on the abuse policy and how to respond appropriately to resident behaviors. Findings include: The facility's Abuse Prevention Program policy dated 05/2021 documents, This facility affirms the right of our resident to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The facility is committed to protecting our residents from abuse by anyone including facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members, or legal guardians, friends, or any other individuals. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is a [AGE] year-old admitted to the facility on [DATE]. This same MDS documents R1 is cognitively intact and requires extensive assistance of staff for all ADLs (Activities of Daily Living). R1's Illinois Department of Public Health Notification Form dated 9-6-23 and signed by V1 (Administrator) documents, On this date (R1) reported that two CNAs (Certified Nurse Assistants) were verbally abuse (sic) towards him. Time of Incident: 12:30 PM. R1's Incident Investigation Form (undated) and signed by V1 (Administrator) documents, I (R1) was in the dining room, and I was joking around with another CNA. (V4 CNA) called me a name. (V4) called me an a**. I didn't like it. V3's (CNA) written statement (undated) documents R1 refused to allow V4 to help him and V4 stated to R1, You are acting like an a**! V7's (CNA) written statement (undated) documents, (R1) called (V4 CNA) a f*****g b***h in the dining room and (V4) said to (R1) stop f*****g talking to me. The facility's Inservice Attendance Form dated 8-25-23 and signed by V1 (Administrator) documents V4 was in-serviced regarding the facility's abuse policy on 8-25-23. On 9-8-23 at 8:30 AM V3 (CNA) stated, I was in the dining room on Wednesday (9-6-23). Around 12:30 PM (R1) asked (V4) for help with eating his Chinese. (V4) refused to help (R1). (R1) started to yell at (V4) for not helping him and (V4) yelled back at (R1) to stop f*****g talking to her and called (R1) an a**. (V4) should not be able to talk to (R1) that way. I immediately took (R1) to (V8's/Social Service Assistant) office and reported this to (V8 and V1). On 9-8-23 at 10:07 AM V8 (Social Service Assistant/SSA) stated, On Wednesday (R1) reported to me that (V4) had called him an a** and refused to help feed him. That is definitely verbal abuse. I know (V3) witnessed the abuse. (R1) was very angry and told me he was tired of it and that something better be done about (V4), or he was going to take legal action. I immediately got (V1) and had (R1) report his concerns to (V1). (R1) is newer to the facility, but I have never known (R1) to make up false allegations. On 9-8-23 at 10:10 AM R1 was sitting in a wheelchair in his room. R1 was alert and orientated to person, place, and time. R1 stated with tears in his eyes, On Wednesday (9-6-23) at lunchtime I was trying to eat Chinese food that I had for lunch. (V4) is always mean to me and never wants to help me. I asked (V4) for help eating and (V4) said to me I am not helping you. You are an a**. I called (V4) names and (V4) said to me, Stop f*****g talking to me! I have reported this to (V1 Administrator) and V8 (SSA). Something needs to be done with (V4) or I am going to get legal advice. (V4) should not talk to me that way. I felt abused and it made me cry. I am still upset over it. On 9-8-23 at 11:00 AM V7 (CNA) stated, I was in the dining room on Wednesday (9-6-23) around 12:30 PM I heard (R1) ask (V4) for help and (V4) refused to help (R1). (R1) yelled at (V4) and told (V4) she was a f*****g b***h. (V4) told (R1) to stop f*****g talking to her. (V4) was mad and not joking with (R1). (V4) was verbally abusive to (R1). On 9-13-23 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V15 (Regional Director of Operations) in-serviced V1 (Administrator) on the facility's Abuse Policy, types of abuse, and how to respond to resident behaviors on 9-8-23. 2. The facility Social Service department and designees interviewed all appropriate residents regarding feeling safe and comfortable in the facility on 9-8-23. 3. V1 in-serviced all staff on 9-8-23 on the facility's Abuse Policy, types of abuse, how to reduce resident behaviors, abuse prevention, and how to respond appropriately to resident behaviors. 4. V4 (Alleged Perpetrator) removed from the floor and schedule on 9-8-23. 5. Facility staff will continue to be trained by (V1) on how to reduce behaviors, abuse prevention and reporting weekly times four weeks then monthly times four and then quarterly and prn (as needed). 6. All newly hired staff will be trained by (V1) on how to respond appropriately to resident behaviors, abuse prevention and reporting. 7. The Quality Assurance (QA) team will monitor abuse in-servicing through the QA process and determine its effectiveness, and changes that may need to occur to ensure abuse training is effective to all staff. 8. The QA team will identify resident at risk of abuse of new admissions and care plan as appropriate. Completion Date: 9-8-23

Based on observation, interview, and record review the facility failed to protect one resident (R1) from physical assault of four residents reviewed for abuse in the sample of four. This failure resulted in R1 being hit in the face by (R2) with a known history of Explosive Mood disorder. R1 transferred to two different hospitals, suffered a fractured nose, swelling, bruising, and lacerations to left eye, forehead, left index finger, left middle finger, and left ring fingers and bruising to right buttocks. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 9/7/22, the facility remains out of compliance at a Severity Level II as the facility continues to conduct ongoing training of all staff, including the Administration, regarding the identification of abuse, revising care plans. Findings include: The Immediate Jeopardy was identified on 9/6/22 at 4:04 pm. The Immediate Jeopardy began on 8/20/22 at 5:00 pm, when the facility failed to protect R1 from being physically assaulted by R2. V1 AIT (Administrator in Training) was notified of the Immediate Jeopardy on 9/7/22 at 9:38 am. The facility's Abuse Prevention Program, revised 11/28/2016, defines: Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Serious Bodily Injury: an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. Establishing a Resident Sensitive Environment: Resident Assessment: As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. R1's Cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Telephone Order for R1, dated 8/15/22 at 1:00 pm, documents Admit to (local) Hospice. Terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Quarterly MDS (Minimum Data Set) assessment, dated 7/5/22, documents R1 with severely impaired cognition and is independent for all ADLs (activities of daily living) except requires set up and supervision for eating and bathing. R1's current Care Plan, documents R1 with impaired cognition related to Dementia with Behavioral Disturbances, [CONDITION(S)] related to right eye prosthetic, Impaired psychosocial well-being alteration in participation in interpersonal relationships and/or altered leisure planning, and known to wander. This care plan documents a new intervention was added on 8/20/22 for R1 to have private room at this time with 15-minute visual checks. There is no other documentation regarding goals or interventions listed related to the 8/20/22 incident. R2's Cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's annual MDS assessment, dated 7/6/22, documents R1 is cognitively intact, independent with all ADLs, including walking, except requires set up and supervision for eating and bathing. R2's current Care Plan, documents R2 with impaired cognition related to MR and intellect disability and chooses to be nonverbal, impaired Psychosocial well-being-alteration in participation in interpersonal relationships and/or altered leisure planning, altered mood state (anger/easily upset) potential for altered social reaction related to explosive behavior, known/has history of displaying inappropriate behavior and/or resisting care/services, and requires use of [CONDITION(S)] medication to manage mood and/or behavior issues. This same Care Plan documents R2 with behaviors exhibited - explosive moods, [CONDITION(S)], anxiety, aggression, and self-isolation. A new intervention was added on 8/20/22 that documents R2 moved to behavioral Health unit, 15-minute visual checks, one-to-one for 72 hours and SSD (Social Service Director) immediate counseling education then one time a week for 4 weeks for aggression. R2's Care Plan includes the following interventions: Introduce to peers who are compatible in temperament. Monitor compatibility of roommate relationships. Reduce excessive stimulation by maintaining a calm environment. If resident expressing anger with self or others: attempt to determine source of anger and encourage appropriate outlets for expression of same writing feeling down. Maintain a calm environment with limited clutter/distraction. On 9/3/22 at 10:30 am, R1 was sitting in a wheelchair in the common area, near the nurses' station. R1 had visible blue, purple, green and yellow discoloration to his left eye, left check, and forehead. R1's left index, left middle and left ring finger had visible yellow discoloration and left index finger with dried blood on it. R1 was not cognitively intact at the time of the interview. The facility's Final Report, dated 8/22/22, documents on 8/20/22 R1 and R2 were in an alleged physical altercation after being temporarily placed in a room together due to COVID-19. (R2) wrote that (R1) had been messing with his things and was standing over him while (R2 was) lying in bed. (R2) is nonverbal. (R2) also wrote that he had given (R1) a piece of paper that said, 'stop messing with me.' (R2) was asked why he did not come to staff and (R2) looked to the floor with no response. (R2) stated (R1) struck him in the shoulder and in the hand. (R2) stated (R1) was on him so he pushed him off and (R1) landed into the wall with his back. (R2) then got his belt and struck (R1) in the eye and on the hand with the belt. The CNA (Certified Nursing Assistant/V5) then heard yelling from down the hall and went to investigate. The CNA (V5) stated when she entered the room (R1) was against the wall and (R2) struck (R1) with the belt. When (R2) saw the CNA (V5) he immediately stopped and (R1) was taken off of the COVID unit. (R1) was assessed by the nurse (V6 RN/Registered Nurse) with lacerations noted to his left hand and left eye. (R1) was also noted to have discoloration to right buttock. Neuros (neurological checks) were initiated on (R1). [CONDITION(S)] for eye was noted to worsen. (R1) was sent to local ER (emergency room ) for evaluation and treat (treatment). (R1) was transferred to outlying hospital for ophthalmology consult. (R1) is expected to return 8/22/22. Upon return (R1) will be placed in a private room and remain on 15-minute checks. (R1's) areas of injury will be monitored per MD (Medical Doctor) orders. (R2) was moved to the behavioral health unit and placed on one-on-one attention for 72 hours after incident. (R2) was counseled by SSD (Social Service Director) on aggression and impulse control. (R2) was also educated on coming to staff for conflicts with peers. (R2) will remain on the behavioral health unit on strict 15-minute checks. (R2) will meet with SSD 1x (one time) weekly x4 (times four) weeks for psychosocial counseling. On 9/4/22 at 4:15 pm, V5 CNA stated, I witnessed (R2) flipping a leather belt at (R1's) face. V5 stated she saw (R1) standing against the wall with blood on his face and hands and saw the leather belt make contact with (R1's) face and noticed blood on (R1). (R1) had injuries to his left hand, cut on his forehead and left eye, left eye was cut and he was bleeding out of his eye. R1's left hand and forehead were also bleeding. V5 stated when she walked into the room and R2 saw her he stopped and walked over and laid on his bed and she took R1 out of the room into the common area and got V6 (RN). R2 was moved to the A wing behavioral unit and has not been back. V5 stated R1 and R2 were both on B side of the facility prior to the incident but were put into the same room on the B side COVID unit due to having COVID. V5 stated the rest of the night R1 was complaining of pain and the nurse was in and out of his room a lot. V6 RN took care of (R1's) wounds and stopped the bleeding. V5 stated R1 did not go to the hospital during her shift, that ended at 10:00 pm. On 9/5/22 at 10:27 am, V6 (RN) stated (V5) CNA saw the incident and reported it to me. V5 reported that R2 had hit R1 with his belt. V6 stated, I didn't see anything happen. I just separated the two residents. V6 stated she called V1 (Administrator) and V3 (RCC/Resident Care Coordinator) and reported what happened and was instructed to treat R1 at the facility if she could instead of sending (R1) out to the hospital and to move (R2) to the A wing behavioral unit and put him on one-on-one with a staff member. V6 stated she was able to get the bleeding stopped and noted a laceration underneath R1's left eye, that looked like a skin tear and she placed wound closure strips on it. V6 stated R1 also had some lacerations on his hands that she put adhesive bandages on and R1 was monitored. V6 stated V13 (LPN/Licensed Practical Nurse) assisted her in doing the treatments and We didn't send him in (to the hospital) right away because it didn't look that bad. V6 stated when she came back to work the next morning R1's left eye was very swollen, and he looked bad and I sent him out to the hospital. They (local hospital) did a CT (computed tomography) scan and R1 had a retrobulbar hematoma (a condition that involves blood congestion deep in the soft tissue of the posterior orbital septum) to the back of his left eye. V6 stated R1 is a very mild resident, has Alzheimer's and was on hospice services and never had any problems with him. V6 stated R2 does have a history of behaviors, but nothing like this. V6 stated R1 and R2 had both been on the B wing COVID unit but was only temporary. Usually the resident, with behaviors, start out on the behavioral unit and then transition to the B wing. V6 stated R1 got moved to C hall after he came out of isolation for COVID. On 9/4/22 at 12:26 pm, V1 (AIT/Administrator in Training) stated R2 told her that R1 had been walking around (R1's) bed and standing over R2 and was taking R2's personal belongings. V1 stated R2 does not speak but will nod head and wrote on paper. R2 had written on paper that he Had enough it, R1 pushed him first and R2 pushed (R1) back. R2 said that R1 hit the wall and R2 then hit him in the eye. V1 stated R2 wouldn't say anything about the belt other than it was his belt in the closet. V1 stated V5 (CNA) told her yelling Stop and when she opened the door R2 had a belt in his hand. On 9/6/22 at 10:32 am, V1 (AIT) stated she is the Abuse Coordinator and completed the investigation for the incident involving R1 and R2. V1 stated the incident occurred on 8/20/22 and when V6 (RN) initially looked at R1 he had small lacerations and didn't require anything but first aid. V1 stated The next morning it looked really bad so (V6 RN) sent him out, to ER (hospital emergency room .) V1 stated R1 and R2 were placed in a room together on 8/16/22 on the COVID unit because they both tested positive. V1 stated after the incident on 8/20/22 R2 was moved over to the A wing behavioral health unit and R1 stayed on the COVID unit until he was off quarantine and then we moved him to a private room on the C wing with 15-minute checks. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 (Administrator in Training) and V15 (Director of Nursing) were in-serviced on Abuse Investigation Procedures by V14 (Regional Director of Clinical Operations) on 09/07/2022. 2. Investigation of abuse completed and reported to (local state agency) by V1. Initial report on 08/20/2022 and final report on 8/22/2022, R1 and R2's physicians notified of alleged abuse on 8/20/2022 by staff nursing under the direction of (V2). 3. Both R1 and R2 were immediately assessed for any signs of injury or trauma by staff nurse under the supervision and direction of V1. R1 had injuries noted to left eye and left hand. Treatment was put into place and monitored. R1 was sent to (emergency room ) on 8/21/22 for worsening [CONDITION(S)] to left eye where R1 received treatment. R2 had no noted injuries. 4. In-servicing by V1 and V15 on Abuse Prevention Policy all staff was initiated 09/07/22 In-servicing training by V1 and V15 on Abuse Prevention Policy, with all staff. Will continue and any remaining employees will be required to be trained prior to reporting for work for their next scheduled shift. 5. R1 referred to sister facility with Dementia Care Unit with POA/Power of Attorney permission. POA to tour sister facility 9/8/22 prior to admit. 6. R2's care plan has been updated to include Private Room Accommodation, 15 minute visual checks, 1:1 time with V10 (Social Service Director) weekly for six months for psychosocial counseling. 7. The V4 (Social Service), V10, and V11 (Social Service) with assistance of IDT/Interdisciplinary Team conducted audit of all residents with Dementia related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Audit of all residents with Dementia related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . POA permitted referral to be made to sister facility with Dementia Care Unit. Admission team screened and accepted resident for admission to their unit on 9/7/2022. 9. Facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the Regional Consultants and facility QA (Quality Assurance) Committee for follow up and review. 10. In-servicing training by V1 and V15 on Abuse Prevention Policy with all staff will continue monthly for the next three months, then quarterly times three V15 or V1. 11. All new employees to be in-serviced on Abuse Prevention Policy upon hire during orientation process prior to working with residents. 12. All Social Workers in-serviced by V14 (Regional Clinical Director) that a Cognitive Assessment (BIMS/Brief Interview of Mental Status score) to be completed at least quarterly and as needed. Any significant changes to be notified to POA, PCP (Primary Care Physician), and IDT to determine if any revision to plan of care is needed, including room placement. 13. V1 will enforce the interventions of plan of removal of immediacy and assurance of continued posting and compliance until Licensed Administrator has been appointed.

Based on record review, observation,, and interview, the facility failed to identify and treat a pressure ulcer for one (R3) of four residents reviewed for skin integrity in a total sample of 4. FINDINGS INCLUDE: R3's Nursing Admission Assessment, dated 3/21/2019 documents, Excoriation bilateral inner buttocks, abd(ominal) fold and bilat(eral) posterior knees. R3's Minimum (MDS) data set [DATE] document R3's Brief Interview for Mental Status as a score of 15, indicating R3 is cognitively intact. R3's physician's orders [REDACTED]. R3's medical records documentation, entitled Nursing Home Documentation Form, from Family Practice Management, dated 5/18/19 and 6/22/19 document Right knee red flaking, and Bilateral medial knees with large open wounds, respectively. On 6/25/19 R3 was at R3's wound clinic consult. Progress Notes from V11 (Advanced Nurse Practitioner) document, There is a strong odor or evidence of infection. The ulcer wounds are very tender to the touch. Wound Assessment: Leg Right Upper Medial Moist; eschar; slough; black; yellow; subcutaneous tissue visible; warm; painful; red; 3.4 cm (centimeters) long x 5.3 cm wide x 1.4 cm deep; undermining; yellow, green, purulent, malodorous drainage; extending full thickness. Leg LEFT Upper Medial Moist; eschar; slough; black; yellow; subcutaneous tissue visible; warm; painful; red; 8.7 cm long x 6.8 cm wide x 1.8 cm deep; undermining; serosanguinous, yellow, purulent, malodorous drainage; extending full thickness. PR[NAME]EDURE - ulcers were not debrided as patient requires a surgical debridement and will be admitted to the hospital for evaluation and treatment. PLAN: Patients ulcers are extremely painful erythemic, warm and indurated extending beyond the wound borders. Discussed with patient and power of attorney need for intravenous antibiotic therapy and surgical debridement. Hospitalist was consulted and he was in agreement and patient will be admitted . On 6/26/19, at 11:15 a.m., at the hospital where R3 was direct admitted to from the wound clinic on 6/25/19, R3 was observed to have two pressure wounds on the inner side of both R3's knees. R3's left inner knee pressure wound was approximately 3 inches (diameter) with induration and slough surrounding the edges and eschar covering the center. R3's right inner knee wound was approximately 2 inches (diameter) with induration and slough surrounding the edges and eschar covering the center. On 6/26/19, at 11:15 a.m., R3 stated, Pain is a 10 and has been like that a long time. [MEDICATION NAME] does not work. They ere not doing skin checks like they should have or they wouldn't have got this bad. On 6/27/19 at 12:25 p.m.,V12 (R3's Power of Attorney) stated, I was not once contacted regarding any of (R3's) wounds until the day of the wound clinic visit for (R3). On 6/27/19 at 2:55 p.m. V11 (Advanced Practice Nurse) stated, She (R3) had those wounds at least a month or longer and should have been treated sooner.

Based on record review, observation, and interview the facility failed to safely provide a physical transfer in a manner that not cause harm to one resident (R1) of four residents reviewed for accidents/incidents in a total sample of 4. This failure resulted in R1 guarding R1's left arm from moving, crying in pain, and requiring pain control medication. FINDINGS INCLUDE: R1's Quarterly Minimum (MDS) data set [DATE] document R1's Brief Interview for Mental Status score as 15 - indicating R1 is cognitively intact. R1's physician's orders [REDACTED]. Throughout the survey, R1 was administered these medications as documented on the Medication Administration Record. On 6/25/19 at 12:55 p.m. during the interview regarding the alleged fall during transfer, R1 wrote the following: dropped, 2 aides, (V7/Certified Nursing Assistant) black, (V8/Certified Nursing Assistant) blonde, after supper, in room, dragged me. When asked if R1 landed on the floor, R1 nodded yes and touched R1's legs with R1's right hand. R1 had a left-[MEDICAL CONDITION] and a right-above the knee amputation. When asked if V7 and V8 picked R1 up by the arms, R1 nodded yes. R1 was guarding her left arm from moving. R1 confirmed pain and would make crying sounds when certified nursing assistants repositioned R1 prior to R1's interview. R1's left upper arm was observed to have a large faint yellow bruise covering the the distance from R1's antecubital space to the upper biceps muscle and 3 spots on outer aspect of R1's left upper arm. R1 was guarding her shoulder and did not want anyone to manipulate the arm. R1's local hospital Discharge Summary dated 6/22/2019 documents, Patient also wrote down that she was dropped/suffered a fall to her left-side shoulder at the NH (nursing home) and cries when having pain. Additionally, a limited single view of the left humerus shows chronic fracture deformities. No new displaced humeral fracture identified. On 6/27/19 at 1:35 p.m. V1 (Administrator) confirmed R1's left arm bruising and stated, I wonder if the bruising was from an improper transfer?

Based on observation, interview and record review, the facility failed to provide medication as ordered for the alleviation of pain for one resident (R1) of 24 in the sample. This failure resulted in pain and extreme discomfort to R1 during a wound treatment performed by nursing staff. Findings include: The facility Pain Prevention & Treatment Policy, Revised 6/25/14, documents "Pain Management - the assessment of pain and if appropriate, treatment in order to assure the needs of residents who experience problems with pain are met". The facility Procedure documents "Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, [DIAGNOSES REDACTED].e arthritis, wounds, fractures, etc.). R1's physician's orders [REDACTED]. On 08/06/14 at 9:10 A.M, R1 yelled out and resisted during turning and removal of a dressing to the buttock. E9 LPN/Licensed Practical Nurse stated "(R1) hates the treatments". R1 kicked continually, and pushed against the side rail and E13 CNA/Certified Nursing Assistant and E14 CNA. E13 and E14 spoke soothingly, and R1 quieted and quit kicking, until E9 began cleansing the open area on the buttock. E9 stated "(R1) really hates it when it gets packed" E9 began packing wound as ordered and R1 began yelling and kicking. On 08/06/14 at 2:00 P.M., E9 stated "It only hurts during the treatment, then R1 is fine. I don't usually premedicate (R1) because I don't want to overmedicate (R1)." "(R1) is fine after the treatment is done." "(R1) has a [MEDICATION NAME] on." E2 ( DON/Director of Nursing) stated on 08/06/14 at 1:50 P.M. that the expectation is if a resident is experiencing pain during any treatment that the nurse would stop the treatment and assess the need for any medications, or doing the treatment at a different time. R1's Medication Administration Record, [REDACTED]. [MEDICATION NAME] 100 mcg/hour patch was not applied until 08/06/14 "around" 8:00P.M. by E8 (LPN). E2 DON stated on 8/6/14 at 1:50 PM that E2's expectation would be that (E2) be called if a medication is not available so (E2) can initiate a purchase order for pharmacy to send the pain medication. E2 also stated this "was not done in this case."

Based on observation, interview and record review, the facility failed to prevent a significant medication error for one resident (R1) of 24 in the sample. This failure resulted in pain and extreme discomfort to R1 during a wound treatment performed by Nursing staff. Findings include: R1's Medication Administration Record [REDACTED]. On 08/07/14 at 10:00 A.M., E8 LPN/Licensed Practical Nurse stated R1's [MEDICATION NAME] was delivered from pharmacy on 08/06/14 and was applied by (E8). E8 also stated "I don't know why the back up pharmacy did not bring the patch last night." On 08/07/14 at 10:18 A.M. E2 DON/Director of Nursing stated "nurses should have called me and I could have initiated a p.o. (purchase order) for pharmacy to send it, I don't know why they didn't do that this time." On 8/6/14 at 9:10 A.M., R1 yelled out, kicked and resisted during (R1's) wound care treatment done by E9 (LPN). R1 then calmed after E9 completed the wound treatment.

Based on record review, interview, and observation, the facility failed to protect one of five residents (R1) in the sample of five from being physical assaulted by another resident (R2) who was identified as being physically aggressive. R2 lunged at R1, grabbed R1 by the hair, knocked her to the concrete pavement and hit R1's face on the concrete. This failure resulted in R1 being sent to the hospital with a laceration to her forehead, swelling and bruising of her forehead and eyes as well as pain in her shoulders, head, arms and legs. This deficient practice has the potential to effect all 56 residents (R1-R5 and R7-R57) residing on the locked behavioral unit. This deficient practice resulted in an Immediate Jeopardy . While the Immediate Jeopardy was removed on 4/19/11, the facility remains out of compliance at a severity level two as additional time is needed to monitor the implementation and effectiveness of the inservice education as well as the 1:1 supervision training provided to facility staff. Findings include: The incident report dated 4/13/11 at 11:30 am faxed to the Illinois Department of Public Health (IDPH) Regional Office documents on 4/11/11 at 4:45 pm: "R1 ... [AGE] year old female admitted to facility 3/29/11....History of restlessness, agitation with resulting disruptive behavior at previous nursing home not evident in this facility since admission..... R2...XXX[AGE] year old female admitted on [DATE]...Has history of aggression and distrust of staff with behavior of unprovoked aggression toward staff and depressive symptoms with threats of self harm since admission..... Multiple residents and one staff member in attendance at time of incident and additional staff members called to aide were interviewed....... According to witness accounts and investigation - Approximately 4:45 pm residents were in the courtyard for 'smoking pass' attended to by CNA (Certified Nursing Assistant). R1 and R2 were seated near each other and were engaged in conversation.....which escalated when R1 accused R2 (of stealing) her CD (compact disc) cord. R2 lunged toward R1 knocking her to the ground then climbed atop her pulling at her hair. (Another resident) and CNA attempted to remove R2 from R1 unsuccessfully. (Another resident) then summoned assistance from (Nurse) and (Unit Aide). (Nurse) and (Unit Aide) removed R2 from atop R1 and removed her from the scene." On 4/15/11 at 10:05 am R7 stated, "I was in on the fight.....(R2) grabbed (R1's) hair and began shaking her like a rag doll. Both fell , (R2) was on top beating and beating her. I tried to pull (R2) off (R1) a couple times. I went to the door and yelled 'staff/staff.' (E5/Certified Nursing Assistant/CNA) was sitting on the picnic table and did nothing! I couldn't believe it. Staff came and told me to go and everyone to go inside so there was no audience. (R2) has been verbally abusive and threatening to hurt me. (R2) and (R3) make me scared. They say they'll hurt us and stuff." On 4/15/11 at 9:40 am R8 stated she observed the altercation on the patio on 4/11/11 between (R1) and (R2) and stated,"(E5/Certified Nursing Assistant/CNA)........did not try to stop it." On 4/14/11 at 10:00 am R1 (victim) stated,"I am aching from being attacked in the yard. I have to keep everything locked up. I was beat up on Sunday I believe. (R2) keeps stealing my cord for my CD (compact disc) player. I live for my classical music. The second time she stole it I was out in the yard - I went out to enjoy the day. I asked (R2) to give me back my cord. (R2) said 'no.' I said give it back to me now. (R2) grabbed my hair and dragged me across the concrete - I am black and blue all over and have an awful headache. Some residents went to get staff and they came out. I went in the ambulance and don't remember much....I have a bad back but it's much worse. I still live next to (R2). They should have gotten rid of her right away. I feel very tense because she is still right there." Observation on 4/14/11 at 10:00 am verified R1 and R2 reside in connecting bedrooms by a shared bathroom. Doors are available so residents in both rooms have access to the bathroom as well as both rooms. On 4/14/11 at 2:30 pm R2 (perpetrator) stated, "(R1) instigated me outside about her radio cord. I said I didn't have it. Then we ended up getting into an altercation. (R7) was yelling and trying to get me off (R1). (E5/CNA) was out smoking. I think he yelled for other staff. I don't know I was busy....(R7) shouldn't have been trying to coddle (R1). (R1) deserved it. I had a laceration in my left eyeball and my sutures opened up. I went to the hospital. My finger is messed up worse now." On 4/11/11 at 4:45 pm nursing notes documented by (E8/Unit Manager/Licensed Practical Nurse/LPN) state "Resident (R2) out in court yard with peers and staff supervising. Res (R2) became argumentative with peer (R1). Suddenly became explosive...lunged at peer and engaged in aggressive physical behavior harming another peer.....Staff...separated both res. Staff attempted to redirect and divert res (R2). Res (R2) continued with psychotic delusional behavior swinging, hitting, swearing and threatening staff.....PRN given without results. Staff continue with 1:1 supervision and redirection as res (R2) continued to escalate." Nursing notes by (E19/Licensed Practical Nurse/LPN) on 4/11/11 at 4:45 pm for R1 state "This nurse was (summoned) to patio, upon entering the area, resident (R1) was observed laying on stomach. (R2) was sitting on top of (R1) with both (R2's) hands in (R1's) hair. This nurse and staff member immediately intervened and removed (R2) from (R1). This nurse went to assess (R1) on which laceration was noted to forehead with sanguinous drainage present.....(R1) did verbalize pain to right side of body, forehead and back. While performing tx (treatment) to (R1), (R2) was very belligerent and stating 'You f***ing b****. I hope you die (to R1).' R2 was (moved) and SSD (Social Services Director) notified." On 4/15/11 at 3:30 pm E5 (Certified Nursing Assistant/CNA) stated,"I was passing cigarettes and went off to my right side to light a cigarette. When I turned back (R2) had (R1) on the ground and pulling fistfuls of hair. I went over to attempt to release (R1's) hair from (R2's) grasp......(Before aggressive incident) (R2) was starting to get loud but at that time I still wasn't seeing a warning that (R2) would attack (R1)........I didn't think about getting extra help when (R2) was getting loud and defensive.....I was not aware of (R2) being physically aggressive with other residents prior to this time with (R1)." On 4/14/11 at 11:05 am E1(Administrator) stated,"(R2's) altercations have been with staff in the past. It's a way for her to get drugs ([MEDICATION NAME]/[MEDICATION NAME]). She has [MEDICAL CONDITION]'s....when she (R2) lays down at night she (R2) can feel the chorea (jerking type) movements. Her (R2) doctor and staff believe she acts out to get the drugs." On 4/14/11 at 11:05 am the facility accident/incident log for the past three months was requested including resident to resident altercations with investigations and recommendations as well as resident to staff altercations with investigations and recommendations. The nursing notes for R2 from admission date of [DATE] to 4/15/11 were reviewed and an additional 12 incidents of aggression to staff, self and/or other residents are documented. 1. Nursing notes for R2 on 1/1/11 at 1:00 pm state "at 12 n (noon) resident (R2) became a little agitated trying to run staff and peers over without success. Res (resident) redirected to room. PRN (as needed) Klonopin given....Res attempting to kick at staff.....attempted (to counsel resident) on her behavior and she then stopped eyes appear heavy and sleepy." 2. At 6:50 pm on 1/1/11 nursing notes for R2 state "Res (R2) in room [ROOM NUMBER]:1 in place, tried to harm self banging her head on window in her room then swinging her wrist in the air looking for something to cut them on.......wants to kill herself. Res redirected.....still very aggressive." 3. On 1/2/11 at 2:00 am nursing notes for R2 state "Res (R2) became aggressive with staff, staff attempted to redirect res with much difficulty......PRN [MEDICATION NAME]/[MEDICATION NAME] given." 4. On 1/3/11 at 3:00 pm nursing notes for R2 state "...(R2) Got up and approached staff stating that she 'wanted to kill herself.' Res continued to state that she wanted to 'jump through the glass window.' When questioned why she denied SI (suicidal ideation) earlier in shift res stated 'I just told you what you wanted to hear.'...." 5. The nursing notes for R2 show on 2/7/11 at 5:55 am "Res (resident) asked to leave room so this nurse (E21/Licensed Practical Nurse) could assess her roommate - Res started screaming and spitting that this F***ing B**** was not getting her to leave room. Resident started spitting and swinging arms - walked out in the hallway and started swinging at a staff member spitting at staff member and cursing loudly - using profane language....Calling staff f***ing b****es and spitting at staff - swinging arms appears to be trying to connect with staff member......" This behavior continued and nursing notes state "(R2) walked to hall (male resident hall) to another resident's (R3) room appearing to hide by bed - climbed in bed with the other resident trying to get ahold of resident to keep staff away- still calling us profane names and spitting - other resident (R3) telling (R2) to get out of bed - staff attempted to get (R2) out of (R3's) bed. (R2) still cursing and spitting at staff - swinging arms - kicking legs.........gave IM (Intramuscular medication). Resident spit at this nurse and called this nurse profane names......(R2) still cursing loudly and swinging arms and spitting at staff...." 6. On 2/28/11 at 12:00 am nursing notes document "Res (R2) (resident) upset and at the desk crying/yelling at staff. Unable to calm resident down. PRN (as needed) medication given." 7. On 3/10/11 at 9:30 pm nursing notes state "Resident (R2) in dining room yelling at staff....Very hard to redirect and get her to understand...directed to try and calm down was getting more and more anxious as staff was trying to intervene....was able to (calmly) take resident down to her room, laid in bed allowing staff to talk to her....was calm for just a few minutes when resident jumped OOB (out of bed) trying to attack a staff member grabbing at her clothing - staff member trying to step away from resident ...... Resident then lost balance as she was pushing staff - landing on floor on stomach causing a laceration approx (approximately) 1 cm (centimeter) on left lateral cheek bone near eye. Resident extremely combative and (aggressive) kicking, screaming at staff - refusing care, very hard to calm or redirect. PRN (as needed) [MEDICATION NAME]/[MEDICATION NAME] given.....New order received to send to ER (emergency room )." R2 returned to the facility with a finger splint to her right middle finger which is documented as being swollen and bruised. Xray report from a local hospital dated 3/10/11 documents under "IMPRESSION: Nondisplaced spiral fracture, proximal third phalanx." 8. On 3/17/11 at 7:15 pm nursing notes state "This nurse (E19/LPN) summoned to another residents room - (R2) had (another resident/R9) blocked in the corner of (R9's) room and was attempting to hit her - (R9's roommate/R8) in the room and grabbed R2 from behind and tried to push (R2) back. Staff intervened and asked (R2) to leave (R8 and R9's) room. (R2) left the area after cursing and calling R9 a fat a** skanky b****. (R9) noted to have a red mark on the side of her neck - (R9) stated (R2) had (thrown) a DVD (digital video disc) at her because she (R2) thought (R9) was trying to talk to her (R2) boyfriend....Upon questioning, she (R2) thought (R9) was trying to steal her boyfriend.....This nurse spoke with (R2) regarding the fact that she can not enter another residents room and she should not be trying to hit or throw things at people. (R2) stated she understood and would leave (R9) alone. SSD (Social Services Director), DON (Director or Nursing) and Administrator notified of the situation." On 4/15/11 at 9:40 am R9 stated (in regard to incident on 3/17/11),"We were out to get fresh air. I was on 1:1 at the time. I sat down on the couch and she accused me of flirting with (R3). She (R2) said 'Give me back my DVD's then I said ok. I told her to stand by the door (of room) and I would get them. She came at me and grabbed the CD's and threw them at me. There was a big red mark on my neck from the 2 CD's hitting me in the neck. She (R2) threw pop and got it all over me. I went to get staff - she (R2) grabbed my leg. R8 (my roommate) came and pulled (R2) off. The next few days she (R2) was spitting on me and said she would burn me with a cigarette. I was scared to go in my room." R8 was in the room at the time of interview with R9 and confirmed R9's statement. 9. At 8:15 pm on 3/17/11 nursing notes document "This nurse(E19/Licensed Practical Nurse/LPN) in (R9's) room administering meds when (R2) was noted to be standing in the doorway calling (R9) names - calling her fat a** etc. Medical records staff member asked resident to move from in front of other resident door......(R2) became agitated and started yelling - attempting to hit medical records staff....staff went to the dining room to call for help and (R2) started throwing objects at staff - hitting, kicking, biting - unable to redirect - resident (R2) given PRN (as needed) injection of [MEDICATION NAME]/[MEDICATION NAME] and held onto the floor by staff as she (R2) was being a threat to herself and other residents...911 called...." When resident returned to the facility at 10:45 pm nursing notes stated she (R2) was placed on "strict 15 minute checks." 10. On 3/24/11 at 12:30 am nursing notes state "Res (R2) had been laying in hall and would not go in room. Very difficult to redirect....told this nurse (E22/Registered Nurse/RN) she (R2) would like to take her PRN medications but when trying to give them she (R2) would not take them even after several attempts. Res laid on dining room floor and began screaming and kicking. Res (R2) began throwing things at staff. After being able to get resident to stop she then remained on the dining room floor. Staff had to escort res (R2) to room.....Res (R2) did try to attack staff but had to be restrained by staff..." 11. On 3/28/11 at 4:30 am nursing notes state "Res (R2) started throwing things out of her room...Came out of room - yelling and cursing at staff - spitting at staff - yelling loudly - cursing loudly - difficult to redirect. Res (R2) allowed to vent - still cursing loudly at staff .... staff backed away from resident allowed resident to lay on floor - resident (R2 kicking out and spitting. Resident screaming 'I want a shot.' ... Nurse explained to resident that already had PRN [MEDICATION NAME] at 2:00 am and it was every 4 hours....Resident calmed down and went back into her own room." 12. On 4/1/11 at 12:00 pm nursing notes state "(R2) started yelling loudly calling this nurse (obscene) names states 'I'm gonna stick my foot up your a**.' SSW (Social worker) redirected (resident) to her room. Tearful but appears to be calmer." On 4/15/11 at 3:30 pm E1 and E2 were informed of the 12 other documented incidents of aggressive behavior by R2 to other residents and staff. On 4/14/11 at 2:30 pm E1(Administrator) and E2 (Director of Nursing) provided one resident to resident altercation which was investigated by the facility dated 4/11/11. E2 stated this was the only resident to resident altercation she was aware of that she had investigated. E1 also provided one resident to staff altercation involving R2 which was investigated occurring on 2/7/11. On 4/15/11 at 3:30 pm E2 (Director of Nursing) stated she was unaware of the incidents or the gravity of the incidents documented. E2 confirmed she had not done investigations into any additional incidents as she had not been informed. E2 stated she was told about the incident on 3/17/11 but not that it escalated to physical aggression or that (R9) had red marks from the CD's being thrown at (R9). The face sheet for R1 (victim) shows admission date of [DATE] with [DIAGNOSES REDACTED]. On 4/14/11 at 10:00 am R1 was in her room sitting in a reclining chair leaning over due to the rounding of her upper back from kyphoscoliosis. R1 appears elderly with the medical record listing her age at 74. R1 rubbed her head in a circular motion. R1 stated she gets "severe" headaches now from (R2) yanking and pulling her hair when (R2) "beat her up." A gash (approximately 2 cm (centimeters) in length) is on R1's forehead extending down between her eyebrows towards the top of her nose. Two steri-strips were intact on this area. Her forehead was black and blue and both eyes were slightly swollen. During the interview R1 was guarding her left hand and stated she has been having pain in the left wrist making it very painful to move. The hospital emergency report dated 4/11/11 documents a 2 cm laceration to R1's forehead with a "Head CT (computerized tomography)" done at the hospital on [DATE] noting ".. soft tissue swelling is seen posteriorly on the left." The face sheet for R2 (perpetrator) lists admission date of [DATE] with [DIAGNOSES REDACTED]. The face sheet documents R2 is currently [AGE] years old. On 4/14/11 at 2:15 pm R2 was in the hall of the unit on 1:1 status (one staff member watching R2). R2 was moving about the unit freely with the 1:1 staff in place. On 4/15/11 at 2:03 pm E7 (Certified Nursing Assistant/CNA) stated,"About 2 weeks ago we had to de-escalate (R2). It was at lunch she (R2) was upset about meds. We moved (R2) so the other residents could get out. The residents were in line for smoke break. (E4/Social Services/SS) and E10 (Social Services) were with (R2). She (R2) was moving kind of wild. (R2) threw her coat.......she (R2) was getting in (R10's) face. (R2) was mad. I was taking (R11) to the bathroom. (R2) followed us and started coming in the room and threw a big rabbit at (R11's) head. I went over - I am trying to keep the door shut - (R2) was trying to get in. E4 (SS) was trying to talk to (R2). I feel the other residents are in danger. I think she (R2) knows who she can and can't do this to (be aggressive). Another time we came in one day - myself, (E15/Unit Aide) and (E16/CNA). (R2) was going nuts...(R12) was her (R2's) roommate (at the time). Something was wrong with (R12) and the nurse (E21/LPN) asked (R2) to leave.....She (R2) ran down the hall to (R3's) room and got in bed with (R3). I'm a CNA - the nurse (E21) wanted us to get her away from (R3) - she (R2) was kicking, hitting and spitting. She (R2) was pulling (R3) out of bed. (R3) was telling (R2) 'leave me alone' - meantime I heard (E15) yell 'Ow, she bit me.' (R2) grabbed (E16's) uniform and ripped it." On 4/15/11 at 2:15 pm E13 (Unit Aide) stated,"...(R2) is a little out of control.....usually starts verbal and goes to physical aggression.....She (R2) went after (E16/CNA) and grabbed her shirt and started spitting on us." At 2:15 pm on 4/14/11 a male resident (R13) walked up to (R2) while on 1:1, slapped R2 on the butt 5-6 times and stated,"(E18/Community Relations Coordinator) tells me you've been very bad." The person assigned to be watching R2 on the 1:1 (E4/Social Worker) was several steps ahead of R2, not looking at R2 and said nothing to the male resident." On 4/15/11 at 10:35 am E2 (Director of Nurses) stated the facility began in-servicing staff on the correct way to provide 1:1 supervision for R2. The inservice education was to be provided by administrative staff to all staff prior to working on the unit includes monitoring R2 on 1:1 basis. This training includes: "(R2) is to be on strict 1:1 which means staff needs to be present and watch what she (is) doing or saying to others. Staff needs to redirect resident away from peers when having behaviors. (R2) is able to socialize with others but (R2) needs to monitored for appropriateness. (R2) can socialize with peers in TV room and in Dining Room with 1:1 staff present. (R2) is able to attend activities and groups with staff. Whoever is 1:1 with (R2) is not to do (smoke pass). Other staff needs to pass out cigarettes - this is (due to) her impulsive behaviors. Some of (R2's) indicators of aggression could be resident could be delusional making comments about staff or peers that are not realistic, weepy, crying - (R2) is unpredictable and can cry one minute and become angry the next. Is manipulative will go to one staff to next to try to get what she wants. She (R2) is attention seeking - demands meds - she (R2) is embarrassed of her uncontrollable body movements and believes people stare at her and make fun of her which can also cause her to be aggressive." On 4/15/11 at 3:30 pm R5 (Certified Nursing Assistant/CNA) stated, "I was not aware of (R2) being physically aggressive with other residents prior to this time with (R1)." On 4/19/11 at 11:35 am E6 (Unit Aide) stated she does 1:1 with (R2) "pretty regular." E6 stated when she is on 1:1 she (E6) is to stay with (R2) all the time and not stray from her. E6 also stated she prefers to sit outside (R2's) room and she (E6) has not been told anything specific about where she is to sit when watching R2. E6 states the last time she was trained in 1:1 monitoring was "about one year ago" but "was trained in CPI (Crisis Prevention Intervention) recently." E6 was unable to state some of the major points discussed during the training. On 4/19/11 at 3:00 pm E2 (Director of Nurses) was informed E6 stated she had not yet been trained in the 1:1 monitoring guidelines for R2. E2 stated the training is ongoing and was to be completed today (4/19/11). The care plan for R2 intimally dated 12/30/10 lists one of R2's "problems" as "History of explosive behavior." This care plan last updated 4/11/11 shows the incident of 3/17/11 and the incident of 4/11/11. The only new intervention noted on the care plan is dated 4/11/11 when R2 was placed on 1:1 status. On 4/15/11 at 10:35 am E2 (Director of Nursing) stated,"(E5/CNA) is on suspension at this time because the facility doesn't feel he did what should have been done with the altercation." E2 stated E5 was not going to be working on the SMI (serious mentally ill) wing anymore. On 4/10/11 at 9:30 a.m., an Immediate Jeopardy was identified to have begun on 1/1/11 when the facility staff failed to inform E1 (Administrator) and/or E2 (Director of Nursing) of R2's aggressive incidents so E1 or E2 could investigate these incidents and develop care plans to prevent further incidents. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. 4/12/11 approximately 3:00 am R2 returned to the facility from the hospital and was placed on 1:1 supervision which has been maintained since returning and will continue while R2 resides in the facility. 2. On 4/11/11 (E10/Social Service) spoke with (E5/Certified Nursing Assistant), employee present at time of altercation and counseled employee. 3. On 4/12/11 packets were sent out to find alternate placement for R2 in an environment that may better fit her physical and psychological needs. 4. 4/14/11 R2 temporarily moved to private room with private bath. R2 will be permanently moved to a private room near located closest to social service office. 1:1 supervision remains at all times. 5. 4/14/11 - The facility began in-service education with facility staff who perform 1:1 supervision on responsibilities of 1:1 assignment and indicators that may lead to aggressive behavior with employee in-services education completed on 4/19/11. 6. 4/14/11 in-servicing education provided to staff regarding spotting impending anxious and aggressive behavior and seeking assistance for intervention. Completed on 4/19/11 for all staff. 7. On 4/15/11 all resident charts on "Unit" reviewed for last 3 months of documentation to identify residents who have shown verbal or physical aggression toward staff or other residents. 8. 4/15/11 - QA (Quality Assurance) committee Behavior Referral and Episodic Behavior Log has been reinstituted to facilitate communication of behaviors to the department supervisors for review and consideration for care plan review and/or further investigation. 9. 4/15/11 - 4/19/11 Admission Notice, Change in Care Needs Notice, DON/Administrator Required Notification Listing....and Behavior Referral In-serviced to employees at shift change.