Every finding on record at Avenues at Springfield

Based on interview and record review, the facility failed to immediately report an allegation of staff to resident verbal and physical abuse to the facility's Abuse Coordinator. This failure affected one of three residents (R1) reviewed for abuse in a sample list of nine.R1's Face Sheet documents an admission date of 7/19/2023 with diagnoses including Post Traumatic Stress Disorder, Unspecified Dementia with Psychotic Disturbance, Hypertension, and Recurrent Major Depressive Disorder.The Minimum Data Set (MDS) for R1 dated 6/4/2026 documented a Brief Interview for Mental Status (BIMS) score of 6/15, indicating severe cognitive impairment.A State Agency Facility Reported Incident dated 7/25/2026 indicated that on 7/25/2026 at 1:45 PM, V4 Licensed Practical Nurse (LPN) and V5 LPN notified V1 (Director of Nursing/Interim Administrator/Interim Abuse Coordinator) of an incident reported to them by a resident. The report stated that R1 and V2 (Certified Nursing Assistant) had a verbal and physical altercation on the evening of 7/24/2026. The facility's investigation later determined that R1 struck V2 and that V2 did not strike R1, as originally alleged.On 8/3/2026 at 11:53 AM, V2 stated that on 7/24/2026 at approximately 8:00 PM, R1 physically assaulted V2. V2 reported that while speaking with another resident in the dining room, R1 approached, grabbed a chair in front of V2, placed it on V2's foot, and sat down. When V2 attempted to move the chair, R1 stood up, verbally insulted V2, and struck V2 in the face. V2 stated V2 put their hands up in a defensive manner and made contact with R1 unintentionally, then immediately removed themselves from the interaction. V2 stated V2 did not report the incident to the Abuse Coordinator because V3 LPN witnessed the event and V2 assumed V3 would report it. V2 confirmed V2 was not interviewed or investigated until the day after the incident.On 8/3/2026, three attempts were made to interview V3; V3 was unavailable.On 8/3/2026 at 12:25 PM, V1 (DON/Interim Abuse Coordinator) stated V1 was not notified of the alleged abuse incident that occurred on 7/24/2026 until 7/25/2026 at 1:45 PM. V1 stated staff are expected to immediately report all allegations of abuse to the facility's Abuse Coordinator. V1 further confirmed that V1 is the interim Abuse Coordinator at this time due to the facilities administrator being on leave.The facilities Abuse policy last revised on 03/2026 documents the following Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, retaliation, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to rid the facility of roaches. This failure has the potential to affect all 60 residents currently residing in the facility.Findings include:On 7/27/2026 at 9:20 a.m., R2 stated R2 was admitted to the facility about two weeks ago and on R2's second night at the facility, R2 noticed roaches crawling onto R2 while R2 was in bed. R2 stated the facility staff were aware and placed traps in R2's room. R2 showed two different roach glue traps in the room. One roach glue trap was on the floor next to the nightstand and one roach glue trap was on the floor under the head of the bed. Both traps had several dead roaches in it.On 7/27/2026 at 9:30 a.m., there was an insect glue trap in R10's room placed on the floor under the head of the bed. There were some dead baby roaches stuck in the glue trap.On 7/27/2026 at 9:35 a.m., a live roach was crawling on the door frame of the shower room at the A - hall while during an interview with V6 Housekeeper.On 7/27/2026 at 9:50 a.m., a live roach was crawling on the wall in the hallway between the Social Services Director's Office and the entrance door to A - hall during an interview with V8 Business Office Manager/Human Resources Manager.On 7/27/2026 at 9:53 a.m., a live roach was crawling on the door frame of Social Services Director's office during an interview with V6 Maintenance Manager.On 7/27/2026 at 11:03 a.m., two insect glue traps were under the sink at the facility kitchen, the traps had some dead roaches stuck in them. Two insect glue traps were behind the stove, and they had dead roaches stuck to them. On 7/27/2026 at 9:35 a.m., V5 Certified Nurse Assistant confirmed seeing roaches at the facility including R2 and R10's room. V5 stated V5 just noticed roaches in the rooms recently.On 7/27/2026 at 9:35 a.m., V6 Housekeeper confirmed the live roach was crawling on the door frame of the shower room at A - Hall. V6 stated V6 placed the traps in R2 and R10's room and confirmed there was roach activity in R2 and R10's room.On 7/27/2026 at 9:50 a.m., V8 Business Office Manager/Human Resources Manager confirmed the live roaches were crawling on the wall in the hallway between the Social Services Director's Office and the entrance door to A - hall.On 7/27/2026 at 9:53 a.m., V6 Maintenance Manager confirmed the live roach was crawling on the door frame of Social Services Director's office. V6 stated pest control contractor company has been providing treatment for the kitchen, laundry and the breakroom twice a month. On 7/27/2026 at 11:03 a.m., V15 [NAME] confirmed there have been some roaches in the kitchen and the facility staff have been placing the glue traps.On 7/27/2026 at 11:07 a.m., V16 Dietary Consultant confirmed there have been roaches in the kitchen and pest control provider comes twice a month for treatment.On 7/27/2027 at 11:08 a.m., V17 Laundry Staff confirmed there have been roaches seen in the laundry area.On 7/27/2026 at 12:16 p.m., V18 Housekeeping Manager confirmed awareness of the roaches in R2 and R10's room. V18 stated V18 instructed housekeeping staff to place glue traps. V18 confirmed the roach activity started in the kitchen, then in the laundry area and later on at the breakroom and now in R2 and R10's rooms.On 7/27/2026 at 1:23 p.m., V6 Maintenance Manager confirmed roaches' activity started in the kitchen, then at the laundry and then later on at the breakroom, and now in resident rooms. V6 confirmed twice a month treatment is not sufficient to control the roach activity at this time.On 7/27/2026 at 2:01 p.m., V19 Regional Director of Operations confirmed awareness of spreading activity of roaches at the facility and will reach out to corporate for better treatment options.Exterminator Service report dated 5/28/2026 documents a visit note, Following up today on German roaches under the stove, ensuring management and employees are keeping areas clean under all machines and dish area. Replaced all monitors throughout today with new, noted few alive still under stove area around legs, treated with aerosol to remove live roaches and added more gel bait in areas, as well as duct crevices/wall voids.Exterminator Service report dated 06/09/2026 documents a visit note, On site follow up and treat as needed throughout kitchen and laundry/adjoining wall for German roaches. Last couple of visits was lots of roaches under steam tables/wheels as well as stove legs and damaged wall areas under dish sink areas. Dusted throughout kitchen baiting around appliances, electrical outlets/boxes, and treated with (aerosol) to knock down and remove live roaches. Exterminator Service report dated 06/23/2026 documents a visit note Followed up with POC (point of contact) on sanitation and structural concerns and German roaches inside kitchen and laundry areas. Many areas with lots of moisture and food crumbs concern. Structural concerns in walls and baseboards areas allowing roached areas to harborage.Exterminator Service report dated 07/16/2026 documents a visit note, Continue to have no rodent feeding or concerns with mice inside. Retreated kitchen, laundry room and breakroom today for German roaches. All areas have many structural concerns as well as moisture and sanitation issues.Exterminator Service Report dated 07/23/2026 documents a visit note, Pulled biweekly service ahead to retreat throughout the kitchen, laundry room, and breakroom as needed for German roaches.

Based on observation and interview, the facility failed to provide a homelike environment by failing to maintain residents' rooms free of roaches for two (R2, R10) of four residents reviewed for pest control in a total sample list of 10 residents.Findings include:1.) R2's Care Plan undated documents R2's diagnosis includes but not limited to Bipolar Disorder, Anxiety, Insomnia and Post-Traumatic Stress Disorder. This care plan further documents an admission date of 07/13/2026.R2' Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact.On 7/27/2026 at 9:20 a.m., R2 stated R2 was admitted to the facility about two weeks ago and on R2's second night at the facility, R2 noticed roaches crawling onto R2 while R2 was in bed. R2 stated the facility staff were aware and staff member placed traps in R2's room. R2 showed two different roach glue traps in the room. One roach glue trap was on the floor next to the nightstand and one roach glue trap was on the floor under the head of the bed. Both traps had several dead roaches in them.On 7/27/2026 at 9:35 a.m., V5 Certified Nurse Assistant confirmed seeing roaches at the facility including R2's room.On 7/27/2026 at 9:39 a.m., V6 Housekeeper confirmed the dead insects on the glue traps in R2's room were baby roaches. V6 confirmed there were roaches in the facility including R2's room and was instructed to place glue traps. 2.) R10's undated Care Plan documents R10's diagnosis includes but not limited to Major Depressive Disorder, Anxiety Disorder, Hemiplegia, Cerebral Infarction, and Aphasia. This Care Plan documents an admission date of 12/16/2025.R10's Care Plan dated 12/29/2025 documents R10 has impaired cognitive function that fluctuates due to R10's inability to express self.R10's Care Plan dated 12/29/2025 documents a Focus on Expressive Problems, Speech Problems, Aphasia. This Care Plan documents an Intervention of COMMUNICATION: Resident prefers to communicate by utilizing some sign language and basic hand signals.On 7/27/2026 at 9:30 a.m., there was an insect glue trap in R10's room placed on the floor under the head of the bed. The glue trap had some dead baby roaches stuck to it.On 7/27/2026 at 9:41 a.m., V6 Housekeeper confirmed the insects on the glue trap in R10's room were dead baby roaches. V6 confirmed there were roaches in the facility including R10's room and was instructed to place glue traps.On 7/27/2026 at 9:53 a.m., V9 Maintenance Director confirmed awareness of roaches in the facility and a contracted exterminator was treating them twice a month.On 7/27/2026 at 12:16 a.m., V18 Housekeeping Supervisor confirmed they were roaches in R2 and R10's room and instructed the housekeeping staff to place glue traps in the room.

Based on observation, interview and record review the facility failed to implement and maintain effective measures to prevent the growth and transmission of Legionella bacteria within the water system. This has the potential to affect all 64 residents residing at the facility. Findings include: 1. On 1/28/2026 at 12:12PM V6, maintenance interviewed regarding water management and prevention of legionella. V6 stated the facility calls a contractor for the prevention of legionella. V6 stated the contractor checks for algae. V6 stated he would have to check his book to see if there were any legionella in past year. V6 was unable to describe water flow and stated he would have to check his book for diagram of water flow. V6 stated he did not know the answer if the facility had empty resident rooms in regard to the prevention of legionella. On 1/29/2026 at 10:29AM V1, Administrator stated she would expect the facility to follow the water management program for the prevention and growth of legionella. V1, stated V6, maintenance not available as he was on suspension. V1 stated maintenance book was unavailable as it is not complete.The facility Water Management Program for Prevention of Legionella Growth dated last revised 1/2026 documents the purpose is to reduce Legionellae risk in the facility water systems to prevent cases and outbreaks of Legionnaires' Disease. The policy documents the bacterium Legionellae can cause a serious type of pneumonia called Legionella Disease in persons at risk. The policy documents those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression, Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. The policy documents factor internal to buildings that can lead to legionella growth can include water temperature fluctuations, water pressure changes, inadequate disinfectant, and water stagnation. The policy documents potential risk includes but are not limited to hot and cold-water storage tanks, water heaters, pipes, valves and fittings, water filters, showerheads and hoses, eyewash stations, ice machines. The policy documents development of a water management program to reduce the building's risk for growing and spreading legionella. The policy documents the elements of the water management program should be reviewed at least once a year. The policy documents water quality should be measured throughout the system to ensure changes that may lead to Legionella growth are not occurring; water heaters should be maintained at appropriate temperatures. The policy documents development of a water management program to reduce the buildings risk for growing and spreading legionella. The policy documents the water management program should be reviewed at least once a year.The CMS 671 dated 1/27/2026 documents a census of 64.

Based on observation, interview and record review the facility failed to provide a trained infection preventionist at the facility. This has the potential to affect all 64 residents at the facility.Findings include:On 01/28/2026 at 11:00 AM V1 administrator stated V2, Director of Nursing (DON) is infection preventionist. V1 stated V2 does not have a certificate and is working under V10, regional nurse. V1 stated V2, DON started on Monday, Jan. 19th 2026. On 1/28/2026 at 11:50AM V2, DON stated she does not have a certificate and is working under the regional nurse, V2, DON stated she signed up for the infection prevention course yesterday and will be taking the course this weekend.On 1/29/2026 at 10:29AM V1, Administrator stated she would expect a trained infection preventionist to be onsite at the facility. V1 did state the regional nurse does not work at the facility. On 1/29/2026 at 10:29AM V1, administrator stated the facility does not have a specific policy for infection preventionist but does follow state guidelines. The CMS 671 dated 1/27/2026 documents a census of 64.

Based on observation, interview, and record review, the Facility failed to provide 80 square feet of floor space per resident bed for 32 two-bed resident rooms residents. This has the potential to affect all 64 residents in the facility.Finding includes:The facility has 32 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide only 76 square feet per bed. All these rooms are certified for Medicaid. These rooms are as follows:The following residents reside in A1 through A16: R48, R23, R59, R35, R36, R19, R42, R33, R1, R50, R27, R64, R55, R34, R8, R25, R5, R63, R41, R47, R44, R18, R30, R17, R52, R39, R46, R28, R38, R57, R7, and R16.The following residents reside in B1 through B16: R4, R15, R11, R3, R61, R21, R2, R32, R20, R31, R54, R49, R26, R14, R51, R6, R43, R37, R60, R62, R13, R9, R58, R56, R22, R24, R10, R29, R40, R45, R12, and R53.On 1/29/26 at 1:01 PM, V12 ADON (assistant director of nursing) stated all rooms in the facility are being occupied.On 1/27/26 at 9:26 AM, V1 (administrator) stated all the rooms in the facility are under the required square footage. The Long-Term Application for Medicare and Medicaid dated 1/27/26, documents that the facility has 64 residents living in the facility.

Based on observation, interview and record review, the facility failed to perform hand hygiene and glove changes appropriately and failed to label, date and cover food in the kitchen refrigerator. The failure could affect all 64 residents who live in the facility.Findings include:1.On 01/27/2026 at 9:30 AM in refrigerator #1, there was a gallon of 2% milk, opened and had an expiration date of 1/25/26. In refrigerator #2 there was a 1/2 pound of butter opened, not labeled or dated. In the freezer there was a sandwich bag of green beans that was not labeled nor was it dated. There was also a bag of frozen fritters that was not labeled nor dated. V13, Dietary Manager was made aware of the items that were not labeled or dated.2. On 1/27/2026 at 10:00 am, V14, Dietary aide, did not have a hair net on while wrapping silverware. When he was asked about it, he stated that he should have a hair net on, but it fell off into the hood part of his sweatshirt. V14 then placed it back on his head without benefit of hand hygiene, he began wrapping silverware again. On 1/27/2026 at 10:05 AM, V13, Dietary Manager, stated the food in the refrigerators (coolers) should be labeled and dated and discarded when out of date. He also stated that hair nets should be always worn in the kitchen.3. On 1/28/2026 at 11:30 am in refrigerator #2 the 1/2 pound of butter was opened, not labeled or dated still from yesterday. Also, in refrigerator there were 3 trays of cookies that were not labeled or dated. On 1/28/2026 at 11:36, V19, Regional Dietary Manager, stated she was under the impression that they did not have to be covered or labeled or dated if they were being used the same day and that it was for supper tonight.4. On 1/28/2026 at11:50 am V15, Cook, without benefit of hand hygiene donned gloves, opened refrigerator #2 door and retrieved uncooked grilled cheese sandwiches that were in zip locked bags, and the 1/2 pound of unlabeled and not dated butter and then shut the refrigerator door. He then opened all the zip locked bags and took out the 9 sandwiches with the same gloved hands. V15 unwrapped the butter and rubbed it on the griddle on the stove then, with same gloved hands, placed 3 of the sandwiches on the griddle and rubbed the sandwiches on the griddle in the butter. V15, with same gloved hands, adjusted the stove knobs and then opened the oven door. He then, with his one hand and a spatula in the other hand, touched the top of the grilled cheese with the same gloved hand turned over the grilled cheese to cook the other side. 5. On 1/28/2026 at 12:20 pm V13, Dietary Manager, removed bowls of pureed pork from the microwave and placed them on the tray for the residents. He then donned a pair of gloves without benefit from hand hygiene and started serving lunch with V15, Cook.6. On 1/28/2026 at 12:22 pm, V16, Dietary Aide, donned a pair of gloves, without benefit of hand hygiene, opened the refrigerator door and retrieved a bowl of chicken noodle soup. He then opened the microwave door and placed the bowl of chicken noodle soup in it. He removed his gloves and without benefit of hand hygiene, donned another pair of gloves. V16 then removed the bowl of chicken noodle soup out of the microwave and placed it on a tray and then, with the same gloves, picked up a grilled cheese sandwich and put it on a plate and placed it on the tray and gave it to the cook. On 1/28/2026 at 12:50 pm V13, Dietary Manger, stated they should wash their hands before, and after glove changes.On 1/28/2026 at 12:51 PM, V15, Cook, stated he washes his hands before and after glove changes.On 1/28/2026 at 12:52 PM, V16, Dietary Aide, stated he does wash his hands before putting gloves on and after he takes them off.The facility's policy, Kitchen Sanitation Manual, dated 01/2026, documented, 1. The best way to prevent contamination of food or food surfaces is to frequently wash hands. 2. Hairnets or hair coverings will be worn at all times. It continues, 4. Food will not be handled with bare hands. Proper utensils will be used, or disposable gloves will be worn. It continues, It continues, 9. Unused food will be covered, timed, labeled and dated with their content It continues, Use of Disposable Gloves Policy: Plastic gloves for food service will be worn when handling food directly with hands. It continues, 2. hands will be washed before and putting on disposable gloves. Note: Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. It continues, 3. Hands should be washed each time disposable gloves are removed. The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid, dated 1/27/2026, documented that there were 64 residents living in the facility.

Based on observation, interviews and record reviews the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in ice machine and staff had warm water to wash their hands. This has the potential to affect the 61 residents living in this facility. Findings include: On 4/1/2025 at 9:32 AM, the metal thermometer was calibrated. On 4/1/2025 at 9:38 AM, the kitchen staff washing sink station water temperature was taken after running for one minute and the temperature was 69.5 Fahrenheit (F). On 04/01 /2025 at 9:42 AM, the ice machine was observed in sprinkler/employee break room. There was a hose that extended from the back through the wall to underneath leading to the outside. The hose to the ice storage bin of the ice machine was submersed into to pipe with no visible gap between the end of the hose and the drain to ensure that no sewage could back up into the ice machine. On 4/1/2025 at 9:49 AM, V1, Administrator stated, I am not sure what you are referring to regarding an air gap. Our machine has always been like that and the tubes in the ice machine were installed years ago. On 4/1/2025 at 10:03 AM, V8, Dietary Manager stated, We only have one ice machine in the building. The ice machine is in the 'Employee break room.' We use that ice for all the residents' drinks and for cooling and preparation of food. I am not sure how long the water has been cold at the hand washing station. On 4/1/2025 at 1:11 PM, V9, Sister Facility Maintenance Man stated, I would expect the kitchen hand washing sink to be warm for hand washing. Something is off and they called me here to look at it. I am looking into it now. That water should be a lot warmer, at least in the 100's degrees. The Resident Roster dated 4/1/2025 documents there are 61 residents living in the Facility.

Based on observation, interview, and record review, the facility failed to ensure the plumbing system provided comfortable hot water temperatures for resident use for 10 of 15 residents (R1, R2, R3, R8, R9, R10, R11, R12, R14 and R15) reviewed for safe in the sample of 15. Findings include: On 4/1/2025 at 9:28 AM, water temperatures were taken with a metal calibrated thermometer. On 4/1/2025 at 9:32 AM, R2 stated water is always cold, she shares a sink in bathroom and shower room. The water is cold at her sink and in the shower room. R1, R2 and R3 all share a bathroom sink. On 4/1/2025 at 9:33 AM, V1, Administrator stated she was not aware of any issues with water temperatures. On 04/01 /2025 at 9:47 AM, R8 stated, The water was cold today. The showers are cold too. I tried to wash my hair, but it was too cold today to wash my hair, I just can't do it. R8 shares a room with R9. R9 was not interviewable. On 4/1/2025 at 9:57 AM, R8 and R9's sink registered 69.5 degrees Fahrenheit (F). This sink is shared with R8, R9, R10 and R11. On 4/1/2025 at 10:04 AM, R14 stated the water was cold today in her room. R14 shares a room with R15. On 4/1/2025 at 10:05 AM, R14 and R15's sink was 69.5 degrees F. This sink is shared with R14 and R15. On 4/1/2025 at 1:14 PM, V9, Sister Facility Maintenance Man stated, I got called in today because they said State was here in the building and our water temperatures were off. I was able to find out the circulatory pump needed repaired, so we were not getting hot water everywhere. The Illinois Department on Aging Residents' Rights for People in Long-Term Care Facilities 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. Your facility must be safe, clean, comfortable, and homelike.

Based on interview and record review, the facility failed to prevent an elopement in 1 of 4 residents (R2) reviewed for elopement/supervision in the sample of 4. This failure resulted in an Immediate Jeopardy when R2 eloped from the facility on 12/30/24 and while missing, R2 sustained a fall resulting in a laceration and nasal fracture. This past non-compliance occurred on 12/30/24. Past noncompliance-no plan of correction required. The Immediate Jeopardy began on 12/30/24, when R2 eloped from the facility and sustained a fall resulting in a laceration and nasal fracture. On 1/15/25, at 9:30 AM, V1, Administrator, and V2, Director of Nurse, DON, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed, and the deficient practice was corrected on 12/30/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: On 1/14/25 at 8:50 AM, V1, Administrator, stated R2 recently eloped from the facility. V1 stated R2 went out the front door behind a staff member and the door alarm sounded. V1 stated R2 was found with police assist three blocks from the facility. On 1/14/25 at 1:20 PM, V1 stated R2 was identified as missing from the facility on 12/30/24 at 4:30 AM and she was notified that R2 was found by the police at 5:30 AM. On 1/14/25 at 8:50 AM, V2, Director of Nursing, DON, stated when R2 eloped he sustained a laceration to his forehead and a fractured nose. V2 stated R2 has Alzheimer's/Dementia and was unable to tell them how the injuries occurred but after watching the camera footage, R2 was seen falling causing the injuries. On 1/14/25 at 12:55 PM, V5, Certified Nursing Aide, CNA, stated on 12/30/24 at 3:30 AM, V6, Maintenance Director, came into the building to conduct a fire drill. V5 stated after the fire drill was over, she went into the dining room to see if any residents were in there and observed V7, CNA, guiding R2 away from the front door and take R2 back to his room. While V5 was in another resident room, she heard what sounded like another alarm, she wasn't sure what the alarm was, if it was another fire drill or something else. When V5 finished with the resident she was assisting, she went to through the lobby to the restroom and did not see any residents and the alarm was no longer sounding. Approximately 5-8 minutes later, V5 stated V7 told her R2 was missing. V5 stated they checked R2's room, bathroom, couldn't find him in the building so the elopement protocol was initiated. V5 stated V7 got into his car and drove around but did not see R2. V5 stated she checked all the exit door alarms to ensure they were functioning properly with all in working order. V5 stated the police were notified, found R2 and took him directly to the hospital. V5 stated she was not in the facility when R2 returned but prior to eloping, she observed R2 in a white shirt and gray sweatpants. V5 stated R2 is not cognitively intact and goes through spurts where he tries to elope, is unstable and can barely walk. V5 stated R2 has been on one-on-one supervision in the past for attempting to elope. V5 stated when she returned for her next shift, R2 was on one-on-one supervision. On 1/14/25 at 2:05 PM, V3, R2's Physician, stated R2 is not cognitively intact enough or safe to be out of the facility unsupervised. V3 stated he was notified of R2's elopement and R2 was found by police and sent to the hospital for further evaluation and treatment. V3 stated the facility has been educating their staff and checking their doors to ensure this doesn't happen again. R2's Face Sheet, undated, documents R2 has the following diagnoses: Major Depressive Disorder, Generalized Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Personal History of Traumatic Brain Injury, Conversion Disorder with Convulsions, Cerebral Infarction, Gastro-Esophageal Reflux Disease, Anemia, Hypertension, Hyperlipidemia, Insomnia, Vitamin D Deficiency and Protein Calorie Malnutrition. R2's Minimum Data Set, MDS, dated [DATE], documents R2 has a Brief Interview for Mental Status (BIMS) score of 11, indicating R2 has moderate cognitive impairment and wanders daily. R2's Care Plan, dated 8/2/23, documents R2 is at risk for elopement. There was no documented Elopement Risk Assessment or Community Survival Skills Assessment in R2's medical record prior to 12/30/24. R2's Elopement Risk Assessment, dated 12/30/24, documents R2 is at risk for elopement. R2's Community Survival Skills Assessment, dated 12/30/24, documents R2 is not capable of unsupervised outside pass privileges. R2's Progress Note, dated 12/30/24 at 5:38 AM, documents the following: Approximately 0400 (4:00 AM) resident was given AM po (administered by mouth) meds. Resident was placed in bed by nurse and CNA (Certified Nurse's Assistant). 0430 (4:30 AM) staff noticed resident was not in bed. Each room was search thoroughly x 2. 0455 (4:55 AM) DON notified of elopement. Writer then called police; information was given. Police reported resident was located 3 blocks from facility. Police informed writer they were taking resident to (local) hospital. DON notified that resident was located and being transported to (local) hospital. R2's Progress Note, dated 1/7/25 at 11:56 AM, Late Entry: Resident exited the facility via Main Entrance. Resident was evaluated in the ER (emergency room ). Resident returned to facility. Head to toe assessment completed. No pain noted at the time of assessment. Resident was re-assessed for risk of elopement and community survival skills. Plan of Care Update to reflect current risk for elopement and associated behavioral needs. All exit door alarms system functional. All resident windows are secured. Code Pink drill completed weekly X 4 weeks. Staff in-service on Code Pink. Elopement and Community Survival skills assessment completed on all residents. R2's Elopement Investigation documents the following: Final report, dated 1/6/25, Staff reported resident exited the property. Code pink was initiated. Resident exited the facility via the main entrance. Resident was evaluated in the ER. Resident returned to the facility with a nose fracture and cut on his face. Head to toe assessment completed upon return to the facility. No concerns with pain. Resident was reassessed for risk of elopement and community survival skills. Plan of care was updated to reflect current risk of elopement and associated behavioral needs. All exit door alarm systems are functional. All resident room windows are secured. Resident continues on one-on-one supervision. Evaluation completed with psychiatric services. R2's Hospital After Visit Summary, dated 12/30/24, documents R2 was diagnosed with a cut to his face and a nose fracture. The Code Pink - Missing Resident/Elopement Policy, dated 2/2024, documents elopement is the ability of a cognitively 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 harm's way. The Immediate Jeopardy and deficiency practice that began on 12/30/24, was corrected/removed on 12/30/24 after the facility took the following actions to correct the noncompliance prior to the start of the current survey: Prior to the survey date of 1/15/25, the facility had taken the following action to correct the noncompliance: ACTION TAKEN/COMPLETION DATE: 12/30/24. 1. Resident should be re-evaluated for supervision and interventions related to exit seeking/wandering behaviors, and update care plans accordingly. Resident sent to ER for evaluation. Diagnoses Cut on Face and Nose Fracture. Upon return to the facility, R1 was assessed per DON with no skin or pain issues noted on 12/30/2024. Reassessed for risk of elopement and community survival skills. Plan of care updated to reflect current risk of elopement and associated behavioral needs per PRSC (Psychosocial Rehabilitation Services Coordinator). 2. The facility needs to take immediate action to be aware when residents are leaving the facility undetected and with the potential of being harmed. The facility needs to prevent further elopements from occurring concurrent with functioning systems, i.e. electronic systems, door alarms, video monitoring, visual checks, supervision, etc. 12/30/2024 Maintenance Director confirmed door alarm/ system functional status and all resident room windows are secured. Code Pink drill to be completed weekly X 4 weeks. On 12/30/2024 IDT (Interdisciplinary team) team completed 100% In-service to staff related too visually checking outside of the facility to ensure no one has left the facility. If no one is in site immediately complete a head count. Resident was placed on 1:1 with staff on 12/30/2024 Resident remained on 1:1 with a weekly review by psych services and when discontinued by Psych Provider. This resident is currently admitted to local hospital. Reviewed and updated elopement binder on 12/30/2024 by PRSC. Code Pink, this is the color code for Elopement, Education provided to 100% of staff on 12/30/2024 by IDT Team. All residents have been assessed for elopement risk and community survival by PRSC. This was completed on 12/30/2024. 3. The facility needs to periodically re-evaluate all residents at risk for elopement and after newly identified exit seeking/wandering behaviors are identified, update care plans accordingly. The facility must educate staff on residents who are at risk for elopement and supervision needs of those residents. The facility needs to educate staff on identifying behavioral patterns of exit seeking and wandering, developing behavior tracking, reporting these behaviors, to the resident's family and physician, and developing/implementing person centered interventions. On 12/30/2024 all residents of the facility were reviewed by PRSC. All residents to be reevaluated for elopement risk at admission, readmission, quarterly, annually, and significant change or incidentally if risk behaviors are identified. This will be on-going. PRSC was assigned this responsibility as of 12/30/2024. Audit to be reviewed by administrator or designee for four weeks. Provide education to staff regarding wandering/exit seeking behavior, and when to provide/implement increased supervision to a resident exhibiting these behaviors. The IDT team consists of Administrator, DON, MDS, SS (social service), Housekeeping/Laundry Manager, Dietary Manager, Human Resource/Business Office Manager (BOM), Activity Director and Maintenance Director All staff were in-serviced in person or via phone call completed on 12/30/2024. The facility does not use agency staff. Elopement drill conducted on 12/30/2024 at 4:45pm by Administrator. Elopement drill conducted on 12/31/2024 5:30am by Administrator. Education including elopement policy to occur upon hire and will remain ongoing. 4. The facility needs to review their elopement policy to ensure processes address enhanced supervision and interventions. ADHOC QA (Quality Assurance) completed on with IDT regarding Elopement Policy and procedure on 12/30/2024. QA to review policy and procedure as part of Quality Assurance Process; next QA meeting scheduled for 1/23/2025. Elopement to be reviewed during each quarterly meeting x 4.

Based on interview, observation, and record review, the facility failed to provide 8 consecutive hours of Registered Nurse Coverage. This has the potential to affect all 61 residents residing in the facility. Findings include: On 7/30/2024, V2, Director of Nurses (DON), stated that the facility does have days that the facility is unable to staff 8 consecutive hours of Registered Nurse coverage. V2 stated she has been trying to hire Registered Nurses but hasn't had any applicants lately. On 7/31/24 at 8:30 AM, V2, stated the facility does not have a policy on 8 hours of consecutive Registered Nurse hours but she tries to meet the regulation. On 7/30/24, V2 was the only Registered Nurse in the building. The Nursing Unit Postings from 6/1/2024 - 7/29/2024 were reviewed. The facility failed to have 8 hours of consecutive Registered Nurses coverage on: 6/3/24, 6/8/24, 6/9/24, 6/17/24, 6/28/24, 7/2/24, 7/6/24, 7/7/24, 7/20/24, and 7/29/24. The Long-Term Care Application for Medicare and Medicaid dated 7/29/24, documents 61 residents reside in the facility.

Based on interview, observation, and record review, the facility failed to wear hair nets covering the hair, store food at a safe temperature, document food temperature after taking them, and have clean and sanitary equipment to prevent potential food contamination and food-borne illness. This failure has the potential to affect all 61 residents residing in the facility. Findings include: 1.On 7/29/24 from 12:05 PM until 12:26 PM, V9, Preparation Cook, was observed without out a hair net covering her hair. V9 is assisting V8, Cook, placing uncovered food items onto the resident's tray and then placing the tray onto the service counter for staff to deliver to the residents in the dining room. V9 has past the shoulder braided hair that is pulled into a ponytail. V9 's hair net is at the end and side of the ponytail caught in the hair but not covering any hair. 2.On 7/31/24 at 11:44 AM the kitchen was entered. The thermometer was calibrated and shown to V7, cook. The noon meal food items were corn dogs, stewed tomatoes, cold macaroni salad and peach cake. The macaroni salad was 60.2 degrees Fahrenheit (F) and on a preparation table. V7 stated she was going to put it on ice and that it just came out of the refrigerator. On 7/31/24 at 12:00 PM, the food temperature log was observed to be not filled out. V7 stated she was going to take them now. V7 stated that the macaroni salad temperature she got was 56 degrees. V7 failed to document the temperatures she had taken on the temperature log. At 12:07 PM V7 began to serve the meal. 7/29/24 at 1:45 PM, the can opener blade was covered in a thick black substance. On 7/31/2024 at 1:55 PM, V6, Dietary Manager, stated, (V7) should have chilled the macaroni salad down more or thrown it away. The safe temperature is 41 degrees for cold items. I don't think I can clean that can opener. I just need a new one. Everyone should wear a hair net covering their hair. The undated cleaning schedule failed to document the can opener. The Kitchen Sanitation policy failed to address hair net. The facility policy Monitoring Food Temperature for Meal Service dated, last revised 9/2023 documents if the serving/holding temperature of a cold food item or beverage is not at 41 degrees Fahrenheit (F) or below (for less than four hours in duration) when checked prior to meal service, the item will be chilled on ice or in the freezer until it reaches 41 degrees F (or less) before service. The Long-Term Care Application for Medicare and Medicaid, dated 7/29/24, documents there are 61 residents living in the facility.

Based on interviews and record review the facility failed to provide services to residents with gastrostomy tube to restore/maintain eating skills for one of one resident (R40) reviewed for tube feedings in the sample of 65. Findings include: R40's Face Sheet, date 8/1/2024, document diagnoses of Schizophrenia, major depressive disorder, anxiety, Chronic Obstructive Pulmonary Disorder (COPD), Parkinson, benign prostatic hyperplasia, Hypertension, hyperlipidemia, Gastroesophageal reflux disorder, insomnia, and protein calorie malnutrition. R40's clinical record does not document any dysphagia or swallow issues. R40's physician orders dated 4/2024, prior to hospitalization on [DATE] documents R40 was ordered a REGULAR diet, Mechanical Soft, Ground Meat texture, thin consistency on 4/1/2024. R40's Progress Note, dated 4/23/2024 at 7:52pm documented R40 was admitted to local hospital for COPD exacerbation and pneumonia. R40's Facility's progress notes dated 4/24/2024 at 11:32AM documented R40's plan of care. R40's progress note documented R40 is noncompliant and refusing majority of care currently, was admitted for pneumonia and on 4L (liters) of O2 (oxygen) NC (nasal cannula). The Note documented the hospital stated when R40 is more compliant they will attempt a swallow study and agree that R40 needs a dysphagic diet plan/ purred foods, thickened liquids if R40 will tolerate. R40's Progress Note, dated 4/29/2024 at 3:33 PM documents R40 returned to facility from hospital with admitting diagnosis of aspiration pneumonia. R40's physician orders dated 4/29/24 documents NPO (nothing by mouth), 1.5 Cal/Fiber. R40's Behavior progress note dated 5/14/2024 at 9:36 AM documents R40 noted to be putting cups of ice under his bed and eating/sucking on it when he wants. R40 educated on the risks of eating ice when he is NPO. Resident mad but voiced understanding. R40's Nurse Practitioner (Psychiatric Nurse Practitioner) dated 5/30/204 documents R40's mood is irritable. R40 states he is not doing good, because he went to the hospital and the new medicine they give him burns when they put it through the g-tube. R40 states he wants to go back to a regular diet. R40 appears irritable due to this, with some yelling but otherwise calmly in his seat. R40's progress note dated 6/15/2024 at 9:05pm documents, attempted to give R40 his G-tube feeding. R40 became belligerent and yelling obscenities at writer. Was unable to finish his feeding due to resident refusing to continue with feeding when writer attempted to calm him down. R40 yelled get out of here you stupid b****. He then came out of his room yelling obscenities at his roommate and while in the dining room continued to yell obscenities. R40's progress note dated 6/17/2024 at 3:14pm documents R40 is getting money from other residents to buy snacks. R40 was educated on the importance of not eating due to him having a feeding tube and being NPO and that we cannot get money from other residents. R40's Behavior progress note dated 7/24/2024 at 3:56 pm documents R40 has been hateful, yelling, cursing, at staff. Difficulty to redirect. Yelled at insurance nurse and refused to sign paperwork. Refused medications and noon feeling, cussing, and calling staff cuss names. Another resident gave resident a cup of soda. Took soda away from resident, which caused him to become angrier. Sitting at table in dining room yelling out. On 7/30/2024 at 2:00 PM R40 stated that he wanted to eat and drink he didn't like the tube. R40 stated he want to drink soda and he can't. R40 asked surveyor to do something so he can eat and drink again. R40 stated he is mad. On 7/31/2024 at 11:00 AM V4, Certified Nursing Assistant, CNA, stated that R40 has outburst of anger, that R40 still goes to dining room for meals but isn't supposed to be eating anything. V4 stated that R40 will get snacks out of the vending machine hide it in under his shirt or in his pants and take it back to his room to eat it. V4 stated R40 yells if you tell him he isn't supposed to eat. V4 stated R40 gets mad is his tube feeding is late. V4 stated that the first week after R40 came back from the hospital with his G tube R40 told V4 that he was supposed to be getting speech therapy so he could eat. V4 stated R40 is not receiving any speech therapy. On 7/30/2024 at 2:15 PM V2, Director of Nursing, stated there is no plan for R40 to eat or be evaluated for any oral intake. V2 stated she will ask medical director on 8/1/2024 if R40 can have a swallow study done. V2 stated that R40 did not have any orders for Speech Therapy. V2 stated the facility does have Speech Therapy services. V2 states R40 refuses his tube feeding at times and gets angry. On 8/1/2024 at 8:45 AM V2 stated that R40 has the tube feeding placed in 4/2024 because of aspiration pneumonia. V2 stated that R40 does not currently have aspiration pneumonia. On 8/1/2024 at 9:00 AM V2 stated that the facility does not have a policy on restoring eating skills.

Based on observation, interview, and record review, the Facility failed to provide 80 square feet of floor space per resident bed for 32 two-bed resident rooms residents. This has the potential to affect all 61 residents in the facility. Finding includes: The facility has 32 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide only 76 square feet per bed. All these rooms are certified for Medicaid. These rooms are as follows: The following residents reside in A1 through A16: R115, R 24, R5, R46, R10, R32, R44, R62, R19, R60, R12, R25, R43, R42, R51, R16, R50, R34, R31, R9, R36, R13, R23, R27, R61, R49, R29, R21, R59, R14, R5 and, R11. The following residents reside in B1 through B16: R40, R6, R38, R22, R52, R3, R30, R37, R54, R39, R47, R33, R45, R8, R17, R48, R41, R35, R57, R15, R7, R28, R1, R58, R4, R20, R26, R18, R2 and R56. On 7/31/2024 at 3:05 PM, V1, Administrator, stated, None of our rooms meet the square footage requirement. We have one private room which is unoccupied at this time. The Long-Term Application for Medicare and Medicaid dated 7/29/2024, documents that the facility has 61 residents living in the facility.

Based on interviews and record review the facility failed to always maintain a nurse on duty to meet the needs and safety of all residents. This failure has the potential to affect all 62 residents that reside in the facility. On 4/23/2024 at 12:27pm, V5, (Ambulance staff), stated that on 4/19/2024 around 8pm, V5 was returned R2 to the facility via ambulance transfer. V5 stated, there was no Nurse on duty in the building when they arrived to receive R2 back into the facility for care. V5 stated, V4, (Certified Nursing Assistant, CNA), told her that V3 had left and would be back shortly. V5, (Ambulance staff), stated 15-minutes passed with no signs or return to the facility of V3, (LPN). On 4/23/2024 at 2:30pm, V4, (CNA), stated, that on 4/19/2024 around 8pm, R2 returned from the hospital via Ambulance and V3, (LPN), was not in the facility. V4 stated, she called V3, and V3 will be back shortly. V4 stated, the Ambulance waited for a few minutes and then made a phone call, then left R2 at the facility with V4. On 4/23/2024 at 3:00pm, V3, (LPN), stated, that on 4/19/2024, she left the facility to deal with a family emergency, she was gone for about 15-min. V3 stated she was not present when the Ambulance arrived to returned R2. V3 stated she was the only Nurse on duty in the facility that shift. V3 did not call her Management to let them know she was out of the facility. V3 stated, there was no Nurse covering, while she was out of the facility. On 4/24/2024 at 8:30am, V1, (Administrator), and V2, (Director of Nursing), stated, they did not know until 4/23/2024 that V3 had left the faciity on [DATE], with no Nurse covering while she was gone out of the facility. V1 and V2 both stated, they expect the Nurse to stay in the facility when they are the only Nurse on duty. V1 and V2 both stated V3 should have called someone to cover her during her time away from the facility. V1 stated she expects there to always be always a nurse in the facility. On 4/23/2024, facility schedule for 4/19/2024 showed V3 scheduled as the only Nurse on duty on the second shift. R2's Patient Care Report dated 4/19/2024 from Ambulance transfer on 4/19/2024 at 8:00pm, documents, We were informed no RNs at the facility at this time, due to one taking care of personal problem. We informed them that we needed one for transfer of care. We waited approximately 10-minutes for one to arrive. While waiting, (V3) spoke with Medical Control, to inform them that we could not do a proper transfer of care. On 4/24/2024 at 8:30am, V1 stated the facility does not have a staffing policy, but the facility is supposed to follow the regulations for staffing.

Based on record review and interviews the facility failed to provide the services of a Registered Nurse for 8 consecutive hours on the dates of 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. This failure has the potential to affect all 62 residents that reside in the facility. On 04/23/2024 at 1:00pm, V1 (Administrator) stated there are some days that the facility does not have a Registered Nurse for 8 consecutive hours a day. V1 stated current census is 62 and noted by the Matrix obtained from V1. On 04/23/2024 at 1:30pm, Facility provided the Nursing schedules with no RN scheduled to work on the following dates 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. On 04/23/2024 at 2:30pm, V4 (Certified Nursing Assistant) stated there are some days that there is no RN working in 24-hours. On 04/24/2024 at 8:30am, V1 stated the facility does not have a staffing policy but the facility is supposed to follow the Regulations for staffing.

Based on interview and record review the facility failed to document narcotic pain medication administration for 4 of 4 (R1, R2, R3 and R4) residents reviewed for medication administration, in a sample of 4. Findings include: 1. R1's Physician Order sheets, dated 1/2024, documented, an order for Hydrocodone-Acetaminophen (APAP) Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain. R1's Narcotic count sheet, dated 1/14/2024 to 1/28/2024, documented, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain contained 25 entries. R1's Medication administration record, dated, 1/14/2024 to 1/28/2024, documented 5 entries of Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain. R1's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact. On 1/29/2024 at 1:30pm, R1 stated that she receives her pain when she needs them including on second and night shift. 2. R2's Physicians order sheet, dated January 2024, documented, an order for Hydrocodone APAP I tablet every 6 hours as needed for pain. R2's Narcotic count sheet, dated 1/1/2024 to 1/29/2024, documented, hydrocodone APAP I tablet every 6 hours as needed for pain contained 75 entries. R2's Medication administration record, dated 1/1/2024 to 1/29/2024, documented, 15 administrations of hydrocodone APAP I tablet every 6 hours as needed for pain. R2's MDS, dated [DATE], documented that his cognition was moderately impaired. On 1/29/2024 at 2:00pm, R2 stated that he told the staff that he wasn't get his pain meds and he was told by them that he has to ask for it. R2 stated that he originally was getting his pain meds three times a day but now he only gets it when he asks for it. R2 stated that the head nurse told him he had to ask for it or he won't get it. R2 stated, I am confused but if I ask for my pain medication. 3. R3's Physicians order sheet, dated January 2024, documented an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10. R3's Narcotic count sheet, dated 1/23/2024 to 1/29/2024, documented, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10 contains 17 entries. R3's Medication administration record, dated 1/23/2024 to 1/29/2024, documented, 3 administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10. R3's MDS, dated [DATE], documented that her cognition was intact. On 1/29/2024 at 1:51pm, R3 stated that she receives her pain when she needs them including on second and night shift. 4. R4's Physicians order sheet, dated January 2024, documented an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth two times a day for pain. R4's Narcotic count sheet, dated 1/15/2024 to 1/30/2024, documented 32 entries for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth two times a day for pain. R4's Medication administration record, dated 1/15/2024 to 1/30/2024, documented 30 administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10. R4's Physicians order sheet, dated January 2024, documented an order for tramadol HCl Oral Tablet 50 MG1 tablet by mouth every 12 hours as needed for pain. R4's Narcotic count sheet, dated 1/20/2024 to 1/29/2024, documented 19 entries for tramadol HCl Oral Tablet 50 MG 1 tablet by mouth every 12 hours as needed for pain. R4's Medication administration record, dated 1/20/2024 to 1/29/2024, documented 10 administrations of tramadol HCl Oral Tablet 50 MG 1 tablet by mouth every 12 hours as needed for pain. On 1/30/2024 at 10:45am, V3, Nurse Consultant, stated that she expects the nurses to document pain medication on the medication administration record. On 1/29/2024 at 1:15pm, V5, Licensed Practical Nurse, stated that when a resident asks for a pain medication, they are supposed to document it on the medication administration record in the resident's chart and on the narcotic count sheets. The facility's, Medication Administration Policy, dated 1/2015, documented, Controlled substance is to be documented on the resident's medication administration record and the controlled substance record.

Based on record review and interview the facility failed to thoroughly investigate an allegation of misappropriation of narcotic pain meds, for 1 of 3 (R2) residents, reviewed for abuse, in a sample of 4. Findings include: R2's Minimum Data Set, dated dated [DATE], documented his cognition was moderately impaired. On 1/29/2024 at 2:00 pm, R2 stated he told the staff he wasn't getting his pain meds and he was told by them he has to ask for it. R2 stated he originally was getting his pain meds three times a day but now he only gets it when he asks for it. R2 stated the head nurse told him he had to ask for it or he won't get it. R2 stated, I am confused but if I ask for my pain medication, I do get it. On 1/29/2023 at 9:45am, V1, Administrator, stated V3, Nurse Consultant, received a compliance line call from R2's ex-wife stating R2 was not receiving his narcotic pain medication and R2 believes someone is taking his medications. V1 stated this was investigated and the Director of Nurses conducted an audit of R2's narcotic sheets and the count was accurate and V3 conducted facility audit of the narcotic count and it was accurate. On 1/29/2024 at 2:02pm, V2, Director of Nursing (DON), stated she looked at the narcotic count sheet for R2 and the count was correct, so she was not concerned about anyone taking R2's pain meds. On 1/30/2024 at 11;00am, V1, Administrator, stated she did not interview any staff nurses because V2, DON, checked the narcotic count, and it was accurate for R2. V1 stated V3, Nurse Consultant, did an audit of the other residents who receive narcotics, and she had no concerns. V1 stated she does not know what V3 looked at in her audit. On 1/30/2024 at10:45am, V3, Nurse Consultant, stated for the investigation, she did an audit of the narcotic count for all residents in the facility and the count was accurate. V3 continued to state V1, Administrator, was responsible for the rest of the investigation and she (V3) was not aware if any floor nurses were interviewed. V3 stated she only looked at narcotic count sheets, they were accurate, and was all she looked at. R2's Investigation File, dated 1/25/2024, there was an Electronic Mail (email) from V3 (Nurse consultant) to V1 (Administrator) documented R2's family member indicated R2 believes someone was taking his narcotic medication but could not say who. The facility's Grievance form, dated 1/25/2024, documented a complaint about R2 not receiving his medications during bedtime. R2 stated on form They just don't give it to me. R2's Progress notes, dated 1/30/2024, documented, (R2) was involved in an allegation of theft/misappropriation. The alleged perpetrator was unknown at the time of the initial/final report. (R2) identified to family he believes his (Narcotic) medication was taken. Resident interviewed. Facility conducted a (Narcotic) Audit. R2's Physicians Orders, dated January 2024, documented an order for hydrocodone APAP I tablet every 6 hours as needed for pain. R2's Narcotic count sheet, dated 1/1/2024-1/29/2024, documented 75 entries. R2's Medication administration record, dated 1/1/2024 to 1/29/2024, documented at noon only contains 15 administrations of hydrocodone APAP I tablet every 6 hours as needed for pain. Facility provided Abuse Prevention policy, dated 10/2022, documented, The facility will promptly and aggressively investigate allegations of misappropriation of property.

Based on observations and interviews the facility failed to provide a safe environment by having toilets that were not securely bolted to the floor for 8 of 20 residents (R4, R5, R7, R8, R9, R10, R11 and R12) and failed to have toilet in hallway A shower room securely bolted to floor with the potential to affect 23 of 24 residents. Findings include: On 9/27/2023 at 1:15pm V1, (Administrator), stated she was not aware of toilets not being bolted securely to the floor. On 9/27/2023 at 1:00pm observations of R7's toilet not secured to floor. R7's toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 1:10pm observations of shower room on B hallway with toilet not secured to floor. Toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 3:00pm observations of room A8's toilet not secured to floor. A8's toilet had rusted bolts that no longer held toilet securely to floor. R8 and R9 reside in this room. On 9/27/2023 at 3:12pm observations of R5's toilet not secured to floor. R5's toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 3:30pm observations of room A16's toilet not secured to floor. A16's toilet had rusted bolts that no longer held toilet securely to floor. R4 and R10 reside in this room. On 9/27/2023 at 3:30pm observations of B8's toilet not secured to floor. B8's toilet had rusted bolts that no longer held toilet securely to floor. R11 and R12 reside in this room. On 9/27/2023 V1 stated R4, R5, R7, R8, R9, R10, R11 and R12 all had toilets that were not secured to the floor. V1 stated the toilets have now been tightened to secure them to the floor. V1 stated shower room on hallway A toilet has also been repaired.

Based on interview and record review, the facility failed to provide continuity of care and documentation of Physician's Assessments in the Electronic Medical Record, (EMR), in a timely fashion for 4 of 4 residents (R1, R4, R10 and R11) reviewed for Physician Services in the sample of 11. The findings include: On 8/8/2023 at 8:45 AM V1 Administrator, stated, (V4, Medical Director, MD) was working for (local hospital) but, now he has his own clinic. He (V4) is a little behind on Progress Notes, but he said he will be in today. On 8/8/2023 at 10:00 AM V1 stated, V4 is the current Medical Director, (MD). V1 stated, V4, MD, does his own Progress Notes after his visits. On 8/8/2023 at 10:43 AM, V1 stated, I was telling (V2, Director of Nurses, DON) I was concerned he (V4) hadn't put notes in the (EMR, electronic medical records). On 8/8/2023 at 11 AM, V2 stated, the facility does not have a policy pertaining to Physician's documentation. On 8/8/2023 at 11:57 AM, V4 stated, he used a different charting system up until May (2023) and his nursing staff would fax the Progress Notes to the facility. V4 also stated, I am a little behind, so I am just now writing the July visits. On 8/8/2023 at 2:11 PM, V1 stated, she asked V4 to reach out to (local hospital) to see if he (V4) could get the notes. On 8/9/2023 at 12:45 PM, V8, Registered Nurse, (RN), and V5, RN, stated Physician's Notes should be documented under the miscellaneous tab of the EMR and there were no Physician's Progress Notes for R1, R4, R10 and R11. On 8/9/2023 at approximately 1:15 PM, all Physician's Notes and H&P's for R1, R4, R10 and R11 were requested. 1. The Facility's Admission Report documents, R1 was admitted on [DATE]. R1's EMR Progress Notes documents, R1 had a History and Physical, (H&P), completed by V4 Effective 7/10/2023. It further documents, the entry was created on 8/8/2023. 2. The Facility's Admission Report documents, R4 was admitted on [DATE]. R4's EMR documents, R4 had her Initial H&P completed on 6/7/2023. R4's EMR does not include any documentation, of R4 being seen in July. 3. The Facility's Admission Report documents, R10 was admitted on [DATE]. R10's EMR does not include an initial H&P or any additional Physician's Progress Notes. On 8/9/2023 at 1:45 PM, V2, Director of Nursing verified there were no Physician's Notes in R10's EMR. 4. The Facility's Admission Report documents, R11 was admitted on [DATE]. R11's Physician's Notes document, R11 had a H&P completed, by V4 Effective 7/24/2023. It further documents, the entry was created on 8/8/2023. On 8/9/2023 at 1:51 PM, V2 stated, she would expect the facility nurses to know where the Physician's Progress Notes are and for them to be accessible.

Based on interview, and record review, the facility failed to assist residents with transfers out of bed for 1 of 3 residents (R8) reviewed for activities of daily living (ADLs) assistance in the sample of 13. This failure resulted in R8 being left in bed for 7 days feeling alone, fearful, anxious, and scared. Findings include: R8's Minimum Data Set, MDS, dated [DATE], documents R8 has no cognitive impairments and R8 is totally dependent on two staff person physical assistance for transfers. On 07/05/2023 at 11:05AM, R8 stated she was in bed for seven days because the sit to stand mechanical lift was not working. R8 stated, It was broke. R8 stated she remained in bed from Friday, 6/23 through Thursday 6/29/23. R8 stated she felt alone because she prefers to get up out of her bed and go to the dining room. R8 stated on Thursday, 6/29/2023, the city tornado sirens were sounding. R8 stated she could hear the tornado siren going off while lying in her bed. R8 stated she was scared, crying, fearful, and alone. R8 stated her window curtains were pulled, curtain drawn, and door shut and that made her feel scared, fearful, and alone. She stated the power went off and she felt even more afraid when the electricity went out and she was left alone in her room. R8's Care Plan, dated 2/17/2023 documents R8 has an Activities of Daily Living (ADL) Self Care Performance Deficit related to activity intolerance, disease process schizoaffective. R8's Care Plan Interventions documents R8 uses a wheelchair for transportation and requires assist of sit to stand with two staff for transfer. On 7/5/23 at 11:05 AM V2, Regional Operations, stated she requested a rental sit to stand related to the facility sit to stand not working. V2 stated when the rental arrived at the facility, it wasn't working because the rental company did not send a battery for the sit to stand. On 7/5/23 at 1:03 PM, V22, Certified Nurse Assistant (CNA), stated R8 transfers with a sit to stand lift. V22 stated the sit to stand was broken and R8 had to remain in bed for seven days. On 7/5/23 at 1:51 PM, V6, CNA stated she floats both halls and works mostly on A- Hall but does come to B-Hall to help when needed. V6 stated she knows the sit to stand was not working the day of the tornado warning because R8 was left in bed that day. On 7/6/23 at 2:43 PM, V20, CNA, stated sit to stand was broken for three or four days and R8 remained in bed. On 7/6/2023 at 3:17 PM, V21, CNA stated the sit to stand was broke for four or five days. V21 stated R8 was in bed those days. V21 stated, (R8) would have never stayed in bed if sit to stand was working. She likes to get up and go to the dining the room. On 7/7/23 at 9:55 AM, V9, CNA, stated when she worked Monday, 7/3/23, the sit to stand was not working. V9 stated R8 had to stay in bed. V9 stated R8 had to stay in bed probably three to four days. V9 stated the sit to stand was reported to V18, Maintenance Director. On 7/7/23 at 10:00 AM, V22 stated she complained to V2, [NAME] President of Regional Operations regarding the sit to stand. V22 stated V27, Regional Nurse Consultant, was here and reported to her as well. V22 stated they told management something needed to be done getting a new sit to stand. V22 stated IDPH was in the building so management got a rental sit to stand but it did not work. On 7/11/2023 at 3:30PM, V26, Senior Regional Maintenance Director, stated some facilities do monthly checks on the sit to stands but the facility elected to do weekly sit to stand checks. V26 stated he expects the maintenance director to follow the detailed inspection of Direct Supply the Equipment Lifecycle System (TELS). V26 should have followed the instructions of TELS and what's occurring with the broken issue. V26 stated if any part of that inspection that fails it should be taken out of service upon inspection and repaired to working proper condition. V26 stated he was not aware the sit to stand at the facility was having problem. Maintenance should have pulled the sit to stand until it was fixed and safe for the residents. V26 stated he looked at facility report and stated nobody is using the TELS system. V26 sent V3 DON a report from the TELS system but there was no documentation noted that Maintenance used the system or sit to stand was checked by TELS. This report is to conduct mobile lift system inspection. On 7/11/2023 at 3:42 PM, V26 provided Direct Supply TELS, resident lifts inspect mobile lifts documentation. Documentation had no check marks where sit to stand had been inspected by maintenance at the facility. The facility's Policy and Procedure for Transfers Manual Gait Belt, and Mechanical Lift dated, 2/2008, documents Mechanical lifting device shall be used for any resident needing a go person assist or cannot be transferred comfortably and/or safety by normal transfer technique. Mechanical lift shall be made readily available and accessible to staff 24 hours a day. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure that equipment remaining good working order.

Based on observation, interview, and record review the facility failed to assess, develop, and implement interventions to address the worsening symptoms of mental illness disorders for 1 of 5 residents (R29) reviewed for behavioral health services in the sample of 65. This resulted in R29 having a significant weight loss due to worsening and ongoing hallucinations telling him not to eat or drink. Findings include: R29's Face Sheet documents his diagnoses to include Schizophrenia, Major Depressive Disorder, Vitamin B Deficiency, Bipolar Disorder, Avoidant Personality Disorder, Panic Disorder and Anxiety Disorder. R29's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented and able to feed self independently with supervision and set up assist by staff. On 6/11/23 at 12:15 PM R29 was standing at the entrance to the dining room. He had not eaten any lunch or drank any of his fluids. He walked to the dining room and then turned around and went right back down to his room. He stated he was not going to eat lunch. His pants were so loose that he had to hold them up at the waist while he was walking. V7, Certified Nursing Assistant (CNA) stated, He just doesn't feel good today. V7 did not encourage R29 to go back to the dining room to eat and did not offer him any substitutes or alternatives. R29 returned to his room and laid on his bed. On 6/12/23 at 12:25 PM R29 was lying in bed while the lunch meal was going on. He stated the voices are telling him not to eat or drink anything. R29 stated, I haven't eaten or drank anything for four or five days. The voices told me if I eat or drink, they will make me take all my clothes off in public. V16, CNA was walking by in the hall and encouraged R29 to come to the dining room with her and she will help him eat and keep his clothes on. R29 was agreeable to this and went to the dining room with V16. V16 was assisting R29 to eat. R29's appearance is disheveled, frail, and extremely thin. R29's Social Service Progress Note dated 4/17/23 at 3:26 PM documents, (R29) refuses to eat and take his medication often. PRSC spoke with him about the benefit of taking his medications and the consequences of not taking his medications. (R29) stated that he did not agree, and that God told him not to take his medication and that he should not eat. PRSC stated scriptures that went against what he believes to help him understand the importance and he continues to disagree. PRSC spoke with (R29) about losing weight, becoming manic, and disorganized thinking that may come when he is not taking his meds. (R29) continues to refuse and stated, 'I will do what God tells me.' (R29) appears tired and moves slow. He will sit on patio for short periods but is usually in his room with a Christian program on, standing up close to the TV. R29's Social Service Progress Note date 4/18/23 at 8:20 AM documents, Resident experiences hallucinations. Resident experiences delusions. Behaviors, but not directed towards others, occurred daily during 7-day lookback. These behaviors put the resident at significant risk for physical illness. These behaviors interfere with the resident's care. Resident rejected care that was necessary to achieve the resident's goal for health and well-being daily during the 7-day lookback. R29's Social Service Progress Note dated 4/21/23 at 11:23 AM documents, (R29) often refuses to take his medications and eating meals; he experiences hearing voices and hallucinations. Psychosocial Rehab Services Coordinator (PRSC) educated (R29) on the importance of taking his medications, eating and getting involved in social activities and sitting outside on the patio to help take his mind off negative thoughts. There was no documentation in the progress notes that this information was shared with the nursing staff, medical doctor, or psychiatrist. R29's Progress Notes were reviewed from 1/1/23 to 6/13/23 with no documentation of V21, Psychiatrist, being notified of R29's hallucinations which resulted in R29's weight loss. R29's Electronic Medical Record (EMR) documents his weights over the last six months as: 6/9/23- 127.5 pounds (lbs.); 5/2/23- 135.5 lbs.; 4/4/28- 135 lbs.; 3/1/23- 138 lbs.; 2/1/23-143 lbs.; and 1/4/23-142 lbs. These weights document R29 has had significant weight loss in 1 month of 5%, in 3 months of 7.6%, and in 6 months of 10%. R29's Progress Note dated 6/13/23 at 8:19 AM, documented by V21, Psychiatrist, documents, Received a call from staff, made aware about patient's worsening symptoms. They communicate the failure of non-pharmacological interventions. Started Olanzapine 5 mg po (by mouth) q6hr (every 6 hours) PRN (as needed) x 14 days. Diagnosis Schizophrenia. Indication: Per staff, patient having increasing hallucinations. Voices are telling him not to eat and he has been losing weight. We will keep low threshold for hospitalization should patient become aggressive. Will evaluate patient at next visit. This was first documentation of notification of psychiatrist regarding R29's refusal to eat related to his increased hallucinations. R29's Physician's Order, dated 6/13/23, documented to start Megestrol Acetate Oral Suspension 400 milligrams (mg)/10 ml (milliliters), give 10 ml in morning for appetite stimulant and Olanzapine, 5 mg, one tablet by mouth every six hours as needed for hallucinations. On 6/14/23 at 10:00 AM V1, Administrator, stated there is no policy specifically for notifying the psychiatrist of changes in resident's behaviors. V1 stated this would be covered by the facility's policy for notification of change in condition. On 6/14/23 at 10:50 AM V21, Psychiatrist, stated he received a call from the facility on Monday, (6/12/23) and was told R29 was hallucinating and hearing voices telling R29 not to eat. V21 stated he started R29 on prn Olanzapine to help with his hallucinations. V21 stated that is the only communication V21 had received regarding R29 since the facility had notified him in April that another practitioner had ordered Haldol. R29 was allergic to Haldol, so it was discontinued. V21 stated the facility is aware they can email concerns or call the office if needing to talk to the psychiatrist or their nurse practitioners. V21 stated he prefers they call the office because the office keeps track of every call or message that comes in, so he can track who called, from where and why they called. V21 stated if the facility had informed him of R29's complaint of voices telling him not to eat, and his significant weight loss related to that, he would be able to retrieve those messages and see exactly when and what time he received the notification. V21 stated he was never contacted of any changes with R29 since the call regarding his Haldol on 4/10/23. V21 stated it is very important for any changes in the resident's condition related to their behaviors to be reported to him, the nurse practitioner, or the office so it can be addressed right away. V21 stated he will have the nurse practitioner who goes to this facility to call, and she may know more about what is going on with R29. On 6/14/23 at 11:37 AM V23, Psychiatric Nurse Practitioner, stated no staff from the facility told her anything about R29 having significant weight loss or complaining that the voices were telling him not to eat. V23 stated she usually talks to V3, Assistant Director of Nursing (ADON), when she first gets to the facility, but V3 never reported any concerns about R29's weight loss or him not eating. V23 stated the only thing that was ever reported to her about R29 was that R29 was having increased anxiety and V23 refilled his Ativan. V23 stated that information came from a floor nurse, not V3. V23 stated when she talked to R29 during his visits, R29 would report that he was hearing voices, but R29 never told V23 the voices were telling him not to eat. V23 stated it would be important for the facility to let V23 know if R29 was having any changes so V23 could assess R29 while she is there and address it before it significantly affects his health or well-being. V23 stated staff in the facility are aware they can call or email concerns to the office and the office forwards those concerns to V23 as soon as they get them. V23 stated any abnormal resident behaviors should be reported and addressed. The facility's policy, Behavioral Health Services (Previously Behavior Management Program) revised 1/2023, documents, Purpose: To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Initial measures: 10. Notify the physician of the resident's signs/symptoms and lack of response to medications and other interventions as indicated. 12. If the behavior symptoms do not subside or resolve, or if resident continues to exhibit behaviors that pose a threat to themselves or others, notify the physician for further orders or call 911 as deemed appropriate.

Based on observation, interview and record review, the facility failed to report a resident's significant weight loss to the physician and initiate appropriate interventions to maintain and/or improve nutritional status for 1 of 4 residents (R29) reviewed for weight loss in the sample of 65. The failure resulted in R29 having an insidious weight loss of 14.5 pounds (lbs.), a 10% weight loss in the last six months. Findings include: On 6/11/23 at 12:15 PM R29 was standing at the entrance to the dining room. He had not eaten any lunch or drank any of his fluids. He walked to the dining room and then turned around and went right back down to his room. He stated he was not going to eat lunch. His pants were so loose that he had to hold them up at the waist while he was walking. V7, Certified Nursing Assistant (CNA) stated, He just doesn't feel good today. V7 did not encourage R29 to go back to the dining room to eat and did not offer him any substitutes or alternatives. R29 returned to his room and laid on his bed. On 6/12/23 at 12:25 PM R29 was lying in bed while the lunch meal was going on. He stated the voices are telling him not to eat or drink anything. R29 stated, I haven't eaten or drank anything for four or five days. The voices told me if I eat or drink, they will make me take all my clothes off in public. V16, CNA was walking by in the hall and encouraged R29 to come to the dining room with her and she will help him eat and keep his clothes on. R29 was agreeable to this and went to the dining room with V16. V16 was assisting R29 to eat. R29's appearance is disheveled, frail, and extremely thin. R29's Face Sheet documents his diagnoses to include Schizophrenia, Major Depressive Disorder, Vitamin B Deficiency, Bipolar Disorder, Avoidant Personality Disorder, Panic Disorder and Anxiety Disorder. R29's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented and able to feed self independently with supervision and set up assist by staff. R29's Electronic Medical Record (EMR) documents his weights over the last six months as: 6/9/23- 127.5 pounds (lbs.); 5/2/23- 135.5 lbs.; 4/4/28- 135 lbs.; 3/1/23- 138 lbs.; 2/1/23-143 lbs.; and 1/4/23-142 lbs. These weights document R29 has had significant weight loss in 1 month of 5%, in 3 months of 7.6%, and in 6 months of 10%. R29's Care Plan dated 6/12/23 documents: The resident has unplanned/unexpected weight loss r/t (related to) variety of meal intake. This Care Plan was entered after R29's significant weight loss was brought to the facility's attention by surveyor. Interventions for this care plan include: Offer substitutes as requested or indicated. If weight decline persists, contact physician and dietician immediately. Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. R29's Physician Order dated 9/29/15 documents: Regular diet, regular texture, regular consistency, Med Pass (supplement drink) 120 milliliters (mls) three times a day, Vegetarian, and give milk with all meals. R29's Progress Notes were reviewed from 1/1/23 to 6/11/23 had no documentation of the physician being notified of R29's significant weight loss until 6/6/23 and no new interventions added until 6/13/23, when a new order was received to start Megestrol Acetate Oral Suspension 400 milligrams (mg)/10 ml; give 10 ml by mouth in the morning for appetite stimulant and Olanzapine 5 mg one tablet by mouth every six hours as needed for hallucinations. R29's Social Service Progress Note dated 4/21/23 at 11:23 AM documents, (R29) often refuses to take his medications and eating meals; he experiences hearing voices and hallucinations. PRSC (Psychosocial Rehab Coordinator) educated (R29) on the importance of taking his medications, eating and getting involved in social activities and sitting outside on the patio to help take his mind off negative thoughts. R29's Social Service Progress Note date 4/18/23 at 8:20 AM documents, Resident experiences hallucinations. Resident experiences delusions. Behaviors, but not directed towards others, occurred daily during 7-day lookback. These behaviors put the resident at significant risk for physical illness. These behaviors interfere with the resident's care. Resident rejected care that was necessary to achieve the resident's goal for health and well-being daily during the 7-day lookback. R29's Social Service Progress Note dated 4/17/23 at 3:26 PM documents, (R29) refuses to eat and take his medication often. PRSC spoke with him about the benefit of taking his medications and the consequences of not taking his medications. (R29) stated that he did not agree, and that God told him not to take his medication and that he should not eat. PRSC stated scriptures that went against what he believes to help him understand the importance and he continues to disagree. PRSC spoke with (R29) about losing weight, becoming manic, and disorganized thinking that may come when he is not taking his meds. (R29) continues to refuse and stated, 'I will do what God tells me.' (R29) appears tired and moves slow. He will sit on patio for short periods but is usually in his room with a Christian program on, standing up close to the TV. R29's Progress Note dated 6/6/23 at 11:02 AM documents, Patient has noted weight loss and he is aware. (Medical Doctor (MD) notified of weight loss. This was the first documentation of physician being notified of R29's weight loss in past 6 months. R29's Progress Note dated 6/13/23 at 8:19 AM, documented by V21, Psychiatrist, documents, Received a call from staff, made aware about patient's worsening symptoms. They communicate the failure of non-pharmacological interventions. Started Olanzapine 5 mg po (by mouth) q6hr (every 6 hours) PRN (as needed) x 14 days. Diagnosis Schizophrenia. Indication: Per staff, patient having increasing hallucinations. Voices are telling him not to eat and he has been losing weight. We will keep low threshold for hospitalization should patient become aggressive. Will evaluate patient at next visit. R29's most recent Nutritional Assessment by dietician was dated 4/19/23 and documented he had no significant weight loss at that time. This assessment was not completed and signed until 6/12/23. On 6/12/23 at 1:45 PM V1, Administrator, stated V6, Regional Dietician for the company, entered a new care plan regarding R29's weight loss today. V1 stated V15, the facility's dietician, was notified and is finishing her nutritional note for R29 she initiated but had not completed on 4/18/23. V1 stated she would expect the dietician to address the weight loss and finish the assessment as soon as she is aware of R29's weight loss. On 6/12/23 at 2:38 PM V2, Director of Nursing (DON), stated she would expect if there were a significant weight loss the dietician and MD should be notified right away. V2 stated she would expect this to be done as soon as the resident has a significant weight loss so appropriate interventions can be put into place. On 6/14/23 at 9:06 AM V22, Medical Doctor, returned call and acknowledged the facility did call him last week to notify him that R29 had a weight loss. V22 stated he would have expected the facility to notify him sooner, when R29 had a 3-5% weight loss and he would have put an intervention in place sooner, to promote R29 increased nutrition, before he got to the point, he had lost 10% of his weight. On 6/14/23 at 10:15 AM V15, Dietician stated she usually receives the facility's monthly weights by the 5th or 7th of the month. V15 stated that usually the weight summary in the EMR documents in the right column if there is a significant change in a resident's weight at 1 month, 3 months or 6 months, but for some reason, R29's did not show this. V15 stated R29 had significant weight loss at 1, 3 and 6 months, but V15 had to manually calculate it. V15 stated when the facility called her on Monday, she manually calculated R29's weights and R29 had lost 6% in one month, 7.7% in 3 months and over 10% in 6 months. V15 stated, that doesn't usually happen, with the system not flagging the significant weight losses. V15 stated as soon as they made her aware, she manually calculated everyone's in the facility weights. V15 stated the usual procedure if a resident flags a weight loss in 1, 3 or 6 months is that she is notified, and she makes a recommendation. V15 stated if the reason for the weight loss is related to the resident's mental illness, she would send the psychiatrist a recommendation, if appropriate. V15 stated she would first consult with the facility to try to find out why the weight loss occurred. V15 stated normally she would like the MDS Coordinator, or some other staff let her know if a resident has significant weight loss when she is due for a visit so she can review them and make appropriate recommendations before she does the other nutritional assessments that are due that month. V15 stated she has not had any reports from staff with monthly weight concerns. V15 stated the bottom line is that for whatever reason, (R29's) EMR did not flag his significant weight loss like it usually does, and she was not aware of his weight loss until the facility called her on Monday. V15 stated R29's weight loss is very concerning because he is under his recommended BMI (body mass index) and ideal body weight. V15 stated she recommended an appetite stimulant to his MD. V15 stated ideally, she should have been notified of his weight loss when he had a 5% weight loss, and it would have been addressed sooner. The facility's policy, Weight Assessment, and Intervention dated 2020 documents, Guideline: Weights are monitored monthly or more often as recommended by the interdisciplinary care team. The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Weight data will be used as one step in determining if changes to the nutritional plan of care are needed to prevent or slow unintentional weight loss within the limits of the resident's clinical condition. 4. Any weight change of 5% or more since the previous weight assessment shall be re-taken to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietician, Dining Services Manager, or other members of the interdisciplinary team. 5. The Registered Dietician will review the weight log each month to follow individual weight trends. Negative trends will be evaluated by the treatment team to determine whether or not significant weight change has occurred. 6. The threshold for significant unplanned and undesired weight loss shall be based on the following criteria: (percentage of body weight loss= (usual weight-actual weight) divided by (usual weight) x 100): 1 month 5% (significant loss) greater than 5% (severe weight loss) 3 months 7.5% (significant loss) greater than 7.5% (severe weight loss) 6 months 10% (significant loss) greater than 10% (severe weight loss) Analysis: 2. The physician along with the interdisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or an increased risk of weight loss. This includes but is not limited to: Cognitive or functional decline; Chewing or swallowing abnormalities, pain, Medication-related adverse consequences, Environmental factors (for example, noise distractions in dining room), Increased nutritional needs, Poor digestion or absorption, fluid and/or nutrient loss, Inadequate availability of food or fluids. Care Planning: Care planning for undesirable weight loss or impaired nutrition shall be a multidisciplinary effort and will include the physician, nursing staff, Registered Dietician, a member of for the Food and Nutrition Department, consultant pharmacist, and the resident or the resident's legal surrogate. Care plans will consider the wishes of the resident and the right to choose their own treatment plan. 2. Individualized care plans shall address the following to whatever extent possible: Identified of the problem that is causing the weight loss. Goals with measurable time frame for improvement. Interventions and approaches.

Based on interview, observation and record review, the facility failed to provide monitoring of water intake for 1 of 16 residents (R4) reviewed for quality of care in the sample of 66. This failure has resulted in R4 being hospitalized multiple times for a low sodium level related to excessive water consumption. Findings Include: R4's Admission Record, print date of 8/24/22, documents that R4 was admitted originally on 9/17/2015 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS), dated [DATE], documents that R4 is cognitively intact, has hallucinations and delusions, Verbal behavioral symptoms directed toward others and behavioral symptoms not directed towards others that occurred 1 to 3 days. This MDS also documents that R4's behaviors put R4 at significant risk for physical illness or injury, significantly interfere with R4's care and R4's ability to participate in activities or social interaction. This MDS also documents R4's behaviors place other residents at risk for physical injury, intrudes on others privacy or activity and significantly disrupts care or living environment. This MDS also documents that R4 does wander and his wandering places him in significant risk of getting to a potentially dangerous place and it impacts other residents. R4's Hospital Discharge Plan, dated 7/5/22, documents, General Diet; Fluid Restriction: 1500 ml (milliliter)/day. R4's Orders Summary Report, dated 8/25/22, fails to document fluid restrictions. R4's Health Status Note, dated 4/21/22, documents, Writer received called from MD (Medical Doctor) regarding lab results. MD stated to send resident out to due decline of sodium levels. Bed hold policy obtained but unable to sign from resident, ambulance called and in route. POA (Power of Attorney) did not answer phone after multiple attempts. Unable to leave voice message due to mailbox being full. R4's Health Status Note, dated 4/28/22, documents, Resident was discharge at (hospital) and returned to the facility today. R4's Health Status Note, dated 5/7/22, documents, Res (Resident) call ambulance. EMT (Emergency Medical Technicians) transferred res to hospital for eval (evaluation) and treatment. R4's Health Status Note, dated 5/17/22, documents, Res returned from (hospital). R4's Sodium Laboratory Result, dated 5/4/22, documents R4's Sodium Level at 121 meq (milliequivalent)/L (liter) normal range is 135 -145. R4's Hospitalist Discharge Summary, print date of 5/17/22, documents, admitted : 5/7/22. discharge date and time 5/17/22. Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . (R4) is a [AGE] year-old male who has a pertinent Past Family, Past Social, and Past Surgical history, and has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It continues, Patient was recently admitted here April 21 to April 28,22 after presenting with lightheadedness, found to have a sodium of 106. He was initially admitted to ICU (Intensive Care Unit). R4's Health Status Note, dated 6/30/22, documents, Res admitted to (hospital). R4's Patient Discharge Plan, dated 7/5/22, documents, Hospital Summary: I was in the hospital because: Abnormal labs. The medical name for this condition is [CONDITION(S)]. R4's Census Log documents that R4 was readmitted to the facility on [DATE] from the hospital and went back out to the hospital on 7/6/22. R4's Health Status Note, dated 7/6/22, documents, resident called 911 stating that he needed an ambulance and that he drank too much water resident sent out to (hospital) to be evaluated family and md notified. R4's Health Status Note, dated 7/12/22, documents, admission note: resident arrived at facility at (2:45 PM) via transport ambulation with no assistance vitals 134/72, 82, 16, 98.2, 98% pain assessment done resident denies any pain skin assessment completed skin intact and clear resident to follow up with (V20) will follow up in house. R4's Health Status Note, dated 7/19/22, documents, (V21, V20's [physician] Nurse Practitioner) called facility re (reference): res labs faxed, per (V21) - res to go to hosp (hospital) for eval/tx (evaluation / treatment) for [CONDITION(S)]. R4's Hospital History and Physical, dated 7/19/22, documents, Impression and Plan: Hypo- osmolar [CONDITION(S)] secondary to primary polydipsia. Plan Admit to ICU, give 1 Liter normal saline bolus, start 1 Liter fluid restriction, goal sodium 122 by 9:00 AM tomorrow morning. History of Present Illness: Patient has a history of primary polydipsia secondary to [CONDITION(S)] disorder and was hospitalized to the ICU 3 weeks ago for [CONDITION(S)]. R4's Health Status Note, dated 7/25/22, documents, resident returned from hospital. R4's Hospital History and Physical, dated 8/7/22, documents, Patient present to the ED (Emergency Department) on 8/7/22 after drinking too much water. Noted to have a Sodium of 103. admitted under (Hospital Intensive Care) for further treatment and evaluation. R4's Health Status Note, dated 8/10/22, documents, Admission Nurses Note: Patient arrived per (facility) transport without incident. Patient is [AGE] year-old male admitted from (hospital). On 08/22/22 at 10:10 AM, R4 stated that he hates the fluid restrictions, and the doctor doesn't know a thing. R4 stated that he is on fluid restriction because it makes his sodium go low. On 8/22/22 at 10:20 AM, V17, Licensed Practical Nurse (LPN), stated that R4 is non complaint with his fluid restrictions and that he will sneak fluids whenever he can. V17 stated that R4 has been hospitalized often due to low sodium. On 08/23/22 at 8:59 AM - 9:15 AM, R4 was walking with his cup from his room to the hallway. R4's cup was half full of ice water. R4 kept going back in and out of his room. R4 went into the bathroom with his cup. R4 went back to his room. On 8/23/22 at 9:15 AM, R4 was sitting on his bed. R4 was drinking from his cup which holds 1000 milliliters of fluid. R4's cup was 3/4's full of water. R4 drank the entire glass of water during the interview. At this time, R4 stated that he drinks the water because he is going to die anyway and that he has to drink the water, or he will die. On 8/23/22 at 9:30 AM, R4 is yelling that someone took his cup. R4 came out of his room with a cup and went down to R64 's room. R4 went into R64's bathroom and filled up his cup. R4 then went back to his room. On 8/23/22 from 8:59 AM to 9:30 AM, R4 appeared to be agitated and anxious at this time. At this time, no staff interacted with R4 to monitor his fluid intake or intervene with a distraction or a talk. On 8/23/22 at 10:20 AM, V9, Certified Nurse Aide (CNA), stated that they do the best they can to limit R4's water intake. V9 stated, He (R4) will go into other rooms and get water. He will go into the bathroom and get water. I have caught him drinking shower water before. He will hide a cup in the bathroom. He is fussing right now because someone took his cup away. On 8/24/22 at 10:20 AM, V12, CNA, stated, All the CNA's will tell him he is on fluid restrictions. He goes all day looking for ice. He will sneak in the bathroom. V12 was questioned about what she does to try and prevent R4 from drinking so much water, V12 stated that she just tells him he is on fluid restrictions. On 8/25/22 at 2:10 PM, V20, Medical Director, stated that he is very familiar with R4. V20 stated that R4 has been in the hospital multiple times and 2 of those times he has needed to be put into ICU because his sodium level was so low. R4 will just drink water in excess. V20 was questioned as to the medical consequences that could happen to a person with low sodium, V20 stated, Well it could lead to a coma, but he has done this for so long that his body has become used to having low sodium level. He will get headaches, get weak and have nausea from the low sodium level. Also, he knows when he has drank too much water and he will call 911 because he knows how he feels when he gets low. V20 stated that he has spoken to R4 multiple times about not drinking so much water but he doesn't know how much he retains because of his mental condition. V20 stated that when R4 shows signs of having a bad day and drinking excessively the staff should supervise him more to monitor water consumption and try to distract him. V20 added that distracting him maybe difficult because he gets agitated, and he is a very big guy and staff need to keep a distance from him for their own safety. V20 also stated that it is important to educate R4 on his good days because hopefully he is more receptive. On 8/30/22 at 4:30 PM, V16, Psychiatrist, stated that he does remember R4 and that he has delusions that he needs to drink water to help himself. V16 stated that once a person is having delusions, it does not matter what is said to them at that point they need one to one supervision but that is a strain on the facility. On 8/29/22 at 12:22 PM, V2, Director of Nurses, stated that R4 is on fluid restriction and that he will try and sneak water. V2 stated that R4 has been hospitalized many times for low sodium. V2 was questioned about how the staff should intervene when R4 starts water seeking, V2 stated that she would need to look at his (R4's) Care Plan to see what interventions are in place. R4's Care Plan, revision date of 4/25/22, documents, Is non complaint with 2300 cc (cubic centimeters) fluid restriction. Intervention: Monitor and document weight. Notify Dr regarding any significant weight change. Monitor Skin Report weekly. Serve diet as ordered. Access likes and dislikes. Substitute likes for dislikes. Will encourage compliance with fluid restriction. R4's Care Plan, revision date of 4/29/22, documents, (R4) have a behavior problem: making self vomit r/t (related to) [CONDITION(S)]. (R4) drinks more water than ordered and will throw it up stating. I drank too much now I'm sick. (R4) continues to overhydrate water and throw up claiming he is sick, heart racing, I feel weak. Interventions: Administer medications as ordered. Monitor / document for side effects and effectiveness. Anticipate and meet the resident's needs, remind (R4) of the purpose of the fluid restriction order. Minimize potential for the resident's disruptive behaviors not following fluid restriction by offering tasks which divert attention.

Based on observation, interview and record review the facility failed to provide behavioral health services to address alcohol and drug addiction/abuse for 3 of 3 residents (R1, R3, R10) reviewed for behavioral health services in the sample of 14. This failure resulted in R3 taking drugs, becoming unresponsive and requiring hospitalization for toxic overdose and aspiration pneumonia. In addition, R1, an alcoholic, continually leaves the facility, returns to the facility inebriated, and has verbal, physical and sexual aggression towards other residents. Findings include: 1. R3's Face Sheet documents he was initially admitted to the facility on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Hospital Discharge Plan dated [DATE] documents R3's Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Preadmission Screening (PAS)/Mental Health (MH) Level II Notice of Determination form dated [DATE] documents R3 is eligible for Nursing Facility. It further documents, under Special Services: Professional Observation (MD (Medical Doctor)/RN (Registered Nurse) for medication monitoring, adjustment and/or stabilization; Instrumental Activities of Daily Living training/ reinforcement; Mental Health Rehabilitation activities, Aggression/Anger management; Illness Self-Management; Community re-integration activities; and Substance use/abuse management. The PAS/MH Level II Notice documents, under Substance Use/Abuse assessment Patient has a lengthy history of substance abuse issues. Recognizes that he struggles to say no and stay away from substance abuse outside of a controlled setting and voices a desire to stay clean. Primary drugs of choice have been meth and heroin but admits to use of marijuana, K2, crack cocaine and alcohol on occasion as well. Under History of Anti-social/Maladaptive/Risk Behavior Assessment the PAS Notice documents: Criminal Justice System involvement, moderate, timeframe: [DATE]: recent charges for disorderly conduct; has had past charges for substance abuse. R3's Minimum Data Set, MDS. date [DATE] documents he was admitted to the facility on [DATE] from a psychiatric hospital. It further documents R3 is alert and oriented, and experiences other behavioral symptoms not directed toward others (e.g.(for example) physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds According to the MDS these behaviors put R3 at significant risk for physical illness or injury, significantly interferes with his care and significantly interferes with his participation in activities or social interactions. R3's Care Plan dated [DATE] documents the following: (R3) has a history of bringing contraband (marijuana) into the facility from the community. [DATE] (R3) shared a vape with a peer in the building. (R3) is no longer able to vape on facility grounds per administrator, guardian aware. (R3) asked another male resident to crush his [MEDICATION(S)] and snorted it, I was feeling anxious- revised [DATE]. The Interventions documents Appropriate staff to search (R3) upon entering the facility to ensure no contraband or vaping material is on his person and for the safety of himself and others. The Care Plan documents (R3) is resistive to care/non-compliant related to anxiety. (R3) was found to be pocketing his medications-[DATE]. The Care Plan intervention documented Educate resident of the possible outcome(s) of not complying with treatment or care. Praise the resident when behavior is appropriate. R3's Care Plan documents Trauma informed care (R3) has a long substance abuse Hx (history). He was admitted to the hospital for suicidal thoughts and has had several hospitalization s. (R3) stated that he was a cutter and used this as a coping skill to ease the pain. Date Initiated: [DATE]. The Care Plan interventions documented Provide (R3) with supportive care and services to promote a sense of safety and well-being. Provide emotional support. Determine resident's coping mechanisms. Ensure the safety of Resident and others. Date Initiated: [DATE]. R3's SS (Social Service) Community Survival Skills, dated [DATE] at 10:17 AM documents the answer no to the statement, The resident appears able to refrain from self-harmful and/or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding persons who constitute a bad influence and is able to practice harm reduction strategies. R3's Progress Note dated [DATE] at 9:20 AM documents, Called down to room. Resident not responding, just lying in his bed. Small brown sputum coming from mouth. Called 911. Resident was sat up and responding, still confused. Ambulance took resident to (local hospital). Called responsible party, mother and sister. No answer. Report given to (local hospital). R3's Hospital Records dated [DATE] document a communication from Emergency Medical Service (EMS) on [DATE] at 9:13 AM: Last known well is 5:30 AM. Staff found him unresponsive with vomit in his airway. Fire for him to wake up but he is still very lethargic. No complaints other than feeling tired. Sugar is 578 and he is diabetic. Think he aspirated. Lung sounds are congested with low sets (saturation). Working on getting those up. Be there in 10. R3's Progress Note dated [DATE] at 1:00PM documents, Writer called (local hospital) for update on resident. Writer was informed that resident had been intubated for proper airway. It was stated to writer that resident might have aspirated yet nothing is for sure at this time. Resident's parents are at the hospital. R3's hospital medical records include the documentation, Medical Decision/Rationale dated [DATE]: Pt (Patient) is a [AGE] year old male with a past medical history as noted above who presented to the emergency department due to concerns for altered mental status, [CONDITION(S)], [CONDITION(S)], and possible aspiration. All critical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was intermittently responsive. He was able to answer questions when prompted, however, was unresponsive at times. Given his recent potential aspiration, altered mental status, and unstable vital signs (including [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]) patient was intubated for airway protection and more controlled management of ventilation. Differential in this patient is quite broad with includes etiologies related to his diabetes and [CONDITION(S)] including DKA (Diabetic ketoacidosis) and HHS (Hyperosmolar hyperglycemic state), infectious acute hypoxic respiratory failure secondary to aspiration or infectious process, toxic overdose, [CONDITION(S)], or other critical etiology. Workup includes labs, EKG, and imaging to evaluate potential differential. Disposition- ICU (Intensive Care Unit). Hospital Records dated [DATE] include laboratory results of Drug Screen dated [DATE] at 11:37 AM which document R3 was positive for Benzodiazepine, cannabinoids, cocaine and [MEDICATION(S)] at that time. R3's Hospital Medical Records document his Discharge Diagnoses, dated [DATE], as: Acute Respiratory Failure requiring intubation, [CONDITION(S)]/[MEDICATION(S)] Pneumonia, Toxic Metabolic [CONDITION(S)] secondary to Polysubstance Abuse, Hx of [CONDITION(S)] Disorder and Polysubstance Abuse, Rhabdomyolyses, Elevated Liver Function Tests, and Type 2 Diabetes Mellitus uncontrolled with hemoglobin A1c of 9.7. On [DATE] at 10:45 AM V5, Psychosocial Rehabilitation Services Coordinator (PRSC) stated she had seen R3 the day before he went to the hospital, and he had seemed fine to her. She stated just a few days before he went to the hospital, he had been on a home visit with his mother. V5 stated when R3 goes on home visits his mother takes him to the marijuana dispensary and lets him buy whatever he wants. V5 stated she had not seen R3 do any illegal substances, but staff have reported that sometimes he looks high and that he sleeps a lot. V5 stated R3's mother came and got his belongings and verbalized that she was upset because she did not feel like staff checked on R3 enough and was upset because it was his roommate who found him unresponsive and not the staff. On [DATE] at 1:25 PM V12, Certified Nursing Assistant (CNA) stated she found R3 unresponsive in his bed the morning he was sent to the hospital. She stated she had made a quick round when she first arrived to work, which was her usual routine, and R3 was awake and talking at that time, and told her he was not coming to breakfast. V12 stated this did not surprise her because the night shift nurse had let her know that R3 and some of the other male residents had been hanging out in one of their rooms until about 4:00 AM that night. V12 stated she came back down to let R3 know his breakfast tray was up there in case he changed his mind, and that was when she found him lying on his side with brown sputum coming out of the corner of his mouth. She stated she called out his name and he did not respond, and when she touched him and he still did not respond, she yelled for V3, MDS Nurse to come help. V12 stated V3 sent her to get his nurse, stating, We have to get him out of here, V12 stated the ambulance got there right away and took R3 to the hospital. She stated he was starting to respond on his way out the door. V12 stated the next day she approached R10, one of the residents R3 hangs out with, and asked him what they had been doing the night before R3 went to the hospital. V12 stated R10 told her R3 had been using cocaine and taking pills the night before he went to the hospital. She stated R10 told her R3 calls some guy on the phone and then they bring him stuff through the window in his room. V12 stated another resident, R12, who was R3's roommate, kept saying he thought R3 had overdosed. V12 stated she reported what R10 reported to her to V3, MDS Nurse, V5, PRSC and V1, Administrator. R12 stated R1 is another resident who brings things into the facility. She stated he goes out every day and comes back drunk. She stated she has taken bottles of alcohol from him when checking him back in, and one time he grabbed her breast and made sexual comments to her when she was having to search him. On [DATE] at 10:53 AM during phone interview, R3 stated he was now residing in a facility in (Illinois city). R3 stated he got some of his drugs from another resident in the facility but did not want to say anyone's names. R3 stated he also got drugs from the crack house across the street from the facility. He stated he was smoking a cigarette out his bedroom window and that is how he met them, just through the window. R3 stated he knew it was a crack house because he saw all the traffic in and out if there. R3 then stated, I didn't get any of it from another resident. I was in a coma for 5 days and I forget things. He stated he only got drugs through his window a couple of times. He stated he did the drugs when he returned to the facility from his home visit. R3 stated no staff in the facility ever got drugs for him. He stated he doesn't remember staying up the night before with his friends, but he was in a coma for 5 days and can't remember. He stated he talks to his friends at this facility, and they told him R12, his roommate, found him not breathing, and got R10, who then got the staff. R3 stated they told him at the hospital that he overdosed and swallowed his vomit and that's what made him stay in the ICU for so long. R3 stated, I almost died . R3 stated he did not attend any groups for substance abuse at the facility, but he has had treatment before in the hospital. V5 stated she knew R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:20 PM R10 stated R3 had been getting stuff including cocaine, through his window from the guys across the street. He stated he has seen these men come to R3's window and hand him things. R10 stated the night before R3 went to the hospital they were hanging out in R10's room and R3 took some [MEDICATION(S)], [MEDICATION(S)] (R10 stated it was the liquid kind), and cocaine. R10 stated this was not the first time he had seen R3 get drugs from across the street. R10 stated he waits until about 1:00 AM when the staff are all up front in the lobby to get stuff through the window. R10 stated R3's mother gives him an allowance of $120 a week and brings him a lot of groceries which he sells to other residents. R10 stated some of the other residents sell their pills, stating R9 sometimes sells his [MEDICATION(S)], and another resident gives his [MEDICATION(S)] away because he does not like it. R10 stated R1 brings back those little bottles of alcohol and sells them to other residents. R10 stated R12 had walked into his room and saw R3 not looking right on that morning and had come and got R10, who then told V12 that there was something wrong with R3 and she got the nurse right away. R10 stated he did not talk to any other staff besides V12 about what goes on in the facility and what R3 did that night and stated nobody has asked him about it. R10 stated, I just stick to pot. I don't do any of those other drugs. Sometimes we do smoke pot in our rooms if someone is able to bring it back or get some. On [DATE] at 4:00 PM during phone interview, V19, Registered Nurse (RN) for V25, R3's Physician, stated V25 said he would like to see programs done in the facility to address resident's substance abuse problems, but he does not know if R3 would have participated in the programs because R3 did not feel he had an addiction problem. V19 stated V25 stated R3's overdose definitely could have contributed to his aspirating, which then caused his need for hospitalization . 2. R1's Face Sheet documents his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's document, SS (Social Service)-Community Survival Skills dated [DATE] documents the following assessment components and answers: The resident appears to refrain from self-harmful and/or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding persons who constitute a bad influence and is able to practice harm reduction strategies. The answer to this assessment component was filled out no. The Skills form documented The resident knows how to ask for/seek help in an emergent or problematic situation and the resident has knowledge of potentially dangerous situations, such as walking alone after dark, straying into an alley, accepting rides from strangers, carrying valuable items where they can be easily seen. The answer to this assessment component was cannot be determined. The Skills form documents The resident has the ability to adhere to pass privilege policies, e.g., getting permission to leave, signing out, respecting parameters and curfews, informing staff upon return; , and The resident is able to behave with respect while in the community and there have been no problems or concerns (reported or witnessed) with his or her conduct over the past 7 days, and The resident sufficiently follows rules addressing medication compliance, participation in his/her treatment plan, appropriate hygiene and grooming and treats others with respect. The answers to these components were cannot be determined. Under Recommendations and Outcomes, it documents, The resident does not appear to be capable of unsupervised outside pass privileges at this time. Under comments it documents, (R1) does go into the community with family sometimes. (Facility) does not provide unsupervised passes. R1's Minimum Data Set (MDS) dated [DATE] documents he entered the facility on [DATE] from another nursing home. The MDS documents he is cognitively intact. Under behaviors, the MDS documents R1 has verbal behavioral symptoms directed toward others (for example (e.g.) threatening others, screaming at others, cursing at others) and he has other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R1's MDS documents these behaviors put the resident at significant risk for physical illness or injury, and significantly interfere with R1's care, and with his participation in activities or social interaction. R1's MDS documents behaviors significantly intrude on the privacy and activity of others, and significantly disrupt care or living environment. The MDS also documents R1 rejects care. Per the MDS, R1's behaviors have gotten worse at the time of the assessment. The MDS documents R1 requires limited assist of one staff for bed mobility, transfers, and personal care, and is not steady when moving from a seated to standing position, when moving on and off the toilet, and during surface-to-surface transfers, and is only able to stabilize with staff assistance. R1's Care Plan dated [DATE] documents: Trauma informed care (history of gun shot, physically abused in the community). The interventions for this this Care Plan document Provide resident with supportive care and services to promote a sense of safety and wellbeing.; Psychiatry/Psychology services as scheduled. R1's Care Plan, initiation date of [DATE], also documents: (R1) is an elopement risk and has made statements of eloping. He refused to come back to the facility while visiting a friend in the community. He attempted to leave the building AMA (against medical advice). R1 is able to go into the facility (community?) independently but is required to sign out and sign in. R1 is encouraged to not use alcohol while out in the community and to not stand near liquor stores talking with friends. R1 entered the facility in the last evening appearing drunken. (Revised [DATE]). R1's Care Plan dated [DATE] documents, (R1) has a history of Alcohol Abuse. Interventions for this care plan include, Allow resident to voice frustration related to situation, no alcohol use, etc. If resident goes out on pass remind resident of risks of consuming alcohol while out. Observe for signs and symptoms of withdrawal from alcohol abuse (e.g., nervousness, shakiness, anxiety, irritability, rapid emotional changes, depression, difficulty with thinking clearly, bad dreams, headache, swearing, nausea, vomiting, loss of appetite, [CONDITION(S)], rapid heart rate, confusion, hallucinations, agitation, fever (if noted, document and report to MD). This care plan is not updated with R1's current daily abuse of alcohol or any interventions to address or treat his alcohol abuse. An untitled document dated [DATE] signed by V24, R1's Physician, documents, (R1) is current patient of (V24). At this time due to the patient's healthcare needs it is not safe for him to leave his community against medical advice. R1's Progress Note dated [DATE] at 5:58 PM documents, Social Service Note Note Text: PRSC (Psychosocial Rehabilitation Services Coordinator) spoke with (R1) about his behavior. (R1) goes into the community to visit family independently and stated to sometime drink alcohol during visit, who lives across the street from the facility. (R1) has also went to the store where his friends hang and drink alcohol or stand outside with them talking. PRSC explained the dangers of him using alcohol/substances while out of the building and greatly encouraged him to only visit his family across the street without drinking so that he can enter the facility sober after he visit. (R1) agreed to visit his family without drinking and to not hang with friends near stores or outside. He agree to stay sober during independent community outings. R1's Progress Note dated [DATE] at 5:00 PM documents, Nursing Note Note Text: Res returned to the facility. CNA notice a can of beer on the resident's pocket. Writer asked the res and try to search the res pocket. Res became agitated. Administrator was informed about the incident. Writer called the doctor's office to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress Note dated [DATE] 5:31 PM documents, Nursing Note Note Text: Writer received a call back from (MD). Res can have 1 can of beer for today as per doctor's order. Monitor the res behavior, and if any changes in behavior keep (MD)informed. R1's Progress Note dated at [DATE] 2:40 PM documents, Nursing Note Note Text: Res returned to the facility with a can of beer. Writer confiscated the can of beer. R1's Care Plan was not revised after R1 brought alcohol into the facility on ,d+[DATE] and [DATE]. R1' s Progress Note dated [DATE] at 11:24 AM documents, Social Service Note Note Text: (R1) attended a social service group on [DATE] 10:00 AM and spent 15 minutes in this group. (R1) attended Symptom management community re-entry skills management group. The group topic discussed included: 1:1 provided. PRSC provided active listening and positive feedback. PRSC provided (R1) a worksheet to discuss his recovery plan which include how alcohol/drugs affects his chances in life, make a list of what he want to accomplish and his plan to achieve, his support system, his hx of drinking and methods he used to quit. PRSC also discussed having a more structured daily routine. (R1) goes into the community independently and tends to return to the facility appearing and acting drunk. (R1) admits to drinking alcohol while in the community. PRSC informed (R1) that (a representative from an independent living facility) will be here to consult with him tomorrow [DATE], to discuss possible independent living plans as he requested. (R1's) participation in the group was noted as Passive Observed. (R1) responded to others in a(n) agreeable manner. (R1) Discussed topics, such as (R1) displayed a nonchalant mood, he agreed that he remembered the previous discussion about not using substances while in the community but showed no concern. (R1) accepted the worksheet and nodded yes to completing it. (R1) chooses not to communicate with PRSC, agreed to be present for his visit tomorrow with (representative). The plan for (R1) is to continue with 1:1 sessions. The interdisciplinary goal for (R1) is to understand and implement the plan of care to reduce distressing symptoms. (R1) will work on focusing on his recovery plan and not use substances to help reduce distressing symptom. R1's Progress Notes dated [DATE] at 1:02 PM documents, Nursing Note Note Text: Patient has been going on outings daily and drinking alcohol writer and administrator has educated the patient on going out and his safety while drinking also writer placed call to (V24) to make him aware of what the patient has been doing; there are no new orders, and no changes patient may continue to go out. R1's Care Plan was not revised with progressive interventions to address R1 leaving the facility daily and drinking alcohol. There is no documentation in R1's medical record that R1 is receiving any type of behavioral health services for his alcohol abuse. On [DATE] at 8:15 AM R1 was signing out for a walk as surveyors entered the facility, and then V18, Licensed Practical Nurse (LPN) entered the code and let him out the door. R1 had an unsteady gait and he held onto the door frame to walk out. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . His physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:20 AM V14, Laundry Aide, stated she sees R1 down on the corner at the liquor store every day. She stated he usually signs out after breakfast and stays out all day then comes back in the evening drunk. V14 stated R1 came back one day carrying a beer. She stated she does not feel he's safe being out on his own in this neighborhood. She stated a bad person might get ahold of him. V14 stated she has seen R1 down there panhandling at the liquor store. She stated every time he comes back, he smells like alcohol. On [DATE] at 9:40 AM V18, Licensed Practical Nurse (LPN), stated we have let the MD know about R1 going out and coming back drunk almost every day. She stated sometimes he's fine but other days is very drunk and belligerent. V18 stated R1's gait is very unstable in his ambulation, and then he gets out there drinking, in a bad neighborhood. She stated, I don't feel he is safe. He would not think about drinking water instead of alcohol on the really hot days we've had. He has brought alcohol back with him; I have pulled three of those airplane sized bottles of alcohol off of him, we think he is bringing it for some of the other residents. V18 stated R1 does not have any family in the neighborhood. V18 stated V1, Administrator, informed staff that it is any resident's right to sign out on pass whenever they want, and that when they sign out on pass, they are not the facility's responsibility. On [DATE] at 10:35 AM V12, Certified Nursing Assistant (CNA) came and told writer that someone had called another one of the CNAs and told her R1 had just been hit by a car down at the liquor store. Surveyor drove past the liquor store, at 10:50 AM, and R1 was sitting in a chair in the shade behind the liquor store with several other men and was holding a tall can of beer. He did not appear to be in any distress. Writer drove past same location on same day at 2:30 PM and R1 was still there. On [DATE] at 12:36 PM V3, Minimum Data Set (MDS) nurse stated R1 goes out on pass almost every day and when he returns, they have found beer, little bottles of liquor and marijuana on him and he gets belligerent when staff try to take it away from him. V3 stated she cannot explain R1 being able to continue to go out on pass even though he returns almost every night intoxicated. She stated, I was not a part of that decision to let him go out. That was the Administrator's and Corporate's decision. V3 stated, I don't feel like he (R1) is safe to be out of the facility on his own. His gait is very unsteady, and you add alcohol to that, and you know he's going to have falls. He really needs help because of his drinking. V3 stated no one goes out with R1 when he is out on pass to offer any supervision. She stated he does not always come back for meals, and he is losing weight since he is going out. On [DATE] at 12:59 PM V1 Administrator stated she is aware R1 goes out on pass and stated she is aware he has returned intoxicated. She stated she had stopped his going out because he was not safe, but then he attempted to elope, and since she has been letting him go out again, he hasn't tried to elope again. She stated V5 needs to update R1's elopement assessment because he is not an elopement risk. V1 stated R1 can sign out after breakfast, and he has to come back before dark. V1 stated she is going to have to have a meeting with R1 to set guidelines and tell him if he doesn't follow them, he won' t be able to go out on pass. V1 stated V5 has had several 1:1's with R1 regarding his drinking and behaviors. On [DATE] at 2:45 PM V13, CNA stated, I don't think this is the place for (R3). He goes out and drinks alcohol every day, and usually when he comes back in the evenings, he is belligerent and drunk with the staff and other residents. V13 stated, He is very verbal. I'm not touching him to search him because he has threatened to hit me and has jumped at me before. He sometimes doesn't even know where he is. We report his behaviors and that he comes back drunk every night to the administrator. It takes three if us to get the beer he brings back away from him. V13 stated she does not feel R1 should be allowed to go out on pass because he hangs out at the liquor street down the street. She stated he has returned to the facility so drunk before that he has defecated on himself. V13 stated R1 has been sexually inappropriate towards her and other staff when he is drunk. She stated they have taken contraband including bottles of liquor, beer and pills that are not his from him. On [DATE] at 3:00 PM V16, CNA, stated R1 does need physical assist with ADL's (Activities of Daily Living) including getting dressed and getting his shoes on. She stated he is very unsteady because he is missing part of one of his feet. V16 stated R1 goes out and drinks alcohol about every day and sometimes has bowel incontinence on his way back and needs help getting cleaned up. She stated R1 is not always incontinent, only when he is really drunk. She stated he can get aggressive especially if he tries to sneak alcohol back into the facility and staff stops him but stated sometimes his behaviors are ok when he returns. V16 stated she doesn't think R1 is safe to be out in the community because his gait is very unsteady, and it he falls, no one will know. R1's Progress Note dated [DATE] at 8:50 AM documents, Administrator educated and informed (R1) of the facility policy of not using drugs and alcohol while in the community and returning to the facility intoxicated. (R1) has been informed that if he returns to the facility intoxicated his privileges of independent community outings will be revoked. (R1) replied, OK in agreement to adhere to the policy. PRSC witnessed. R1's SS-Level of Functioning-Skills assessment dated [DATE] documents Recommended Interventions as individual counseling, therapy or support, emphasis: one to one sessions to discuss moods and behaviors; Group counseling, therapy or support, emphasis: substance abuse counseling. Under Community Skills,' the assessment documents Cannot Determine to the statement, the resident appears able to refrain from self-harmful and /or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding persons who constitute a bad influence and is able to practice harm reduction strategies. At the end of this assessment, under Recommendations and Outcomes it documents, The resident appears to be capable of outside pass privileges at this time. On [DATE] at 1:30 PM V5, Psychosocial Rehabilitation Services Coordinator (PRSC), stated she talked to R1 after the incident when he inappropriately touched R13, and he told V5 that he would work on having more appropriate behaviors when she worked on getting him discharged into the community. V5 stated she did not know if V1 called the police at the time of the incident or not. V5 stated she did not feel R1's behaviors had changed, and although she did an updated Skills Assessment for R1 today that documents resident appears to be capable of outside pass privileges at this time she does not feel he is safe to go out in the community on his own because he continues to come back into the facility intoxicated on most nights. V5 stated R1's intoxication on the evening he inappropriately touched R1 in a sexual manner probably did contribute to his behaviors. V5 stated R1 has had aggressive behaviors towards staff and peers when he has been intoxicated in the past. V5 stated she does not have any programs or classes to address R1's alcohol abuse or other residents' alcohol or substance abuse. She stated she thought that would be a good idea and will contact (psychiatric hospital) and get more information. On [DATE] at 3:40 PM during a phone interview, V20, Psychiatric Nurse Practitioner, stated she stated she did not think V28, Psychiatrist, would necessarily recommend Alcoholics Anonymous or Narcotics Anonymous because residents should have already been withdrawn from any substances when they are admitted to the facility. V20 stated she does feel like some type of programming to discuss addiction and education on drug and alcohol abuse would be good. V20 stated resi[TRUNCATED]

Based on observation, interview and record review, the facility failed to prevent abuse and neglect for two of 8 residents (R1, R13) reviewed for abuse/neglect in the sample of 14. This failure resulted in the facility neglecting and allowing R1, a known alcoholic, to continually leave the facility unsupervised and gain access to alcohol which resulted in R1 sexually abusing R13. This has caused R13 to become embarrassed, uncomfortable and scared/frightened of R1. Findings include: 1.The facility's policy, Abuse Prevention and Reporting-Illinois dated 12/21, documents, Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. If the stated purpose of a unit which prevents residents from free movement throughout the facility is to provide specialized care for residents who are cognitively impaired, then placement on the unit is not considered involuntary seclusion, as long as care and services are provided in accordance with each resident's individual needs and preferences rather than staff convenience, and as long as the resident, surrogate or representative (if any) participates in the placement decision, and is involved in continuing care planning to assure placement continues to meet resident needs and preferences. Per this policy, Neglect is defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy further documents, Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: unwanted intimate touching of any kind, especially of breasts or perineal area. Generally, sexual contact is nonconsensual if the resident either: appears to want the contact to occur, but lacks the cognitive ability to consent, or does not want the contact to occur. R13's Face Sheet documents her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Minimum Data Set, MDS, dated [DATE] documents R13's memory is alright, and she is moderately cognitively impaired. It documents she requires extensive assist with bed mobility, transfers, dressing, and toileting. It documents her balance is unsteady and she requires staff to assist to stabilize. It also documents she requires a wheelchair for mobility and is frequently incontinent of bowel and bladder. R13's Care Plan dated 3/25/22 documents Resident is at medium risk for abuse/neglect as noted from Abuse screening r/t (related to) mental illness. Interventions include: Evaluate resident's responses to interventions and provide safe and secure environment. R13's SS (Social Service)-Abuse/Neglect Screening dated 6/28/22 documents: Risk measure for likelihood for a history of previous/ recent mistreatment and/ or potential future problems/ symptoms related to mistreatment. The Screening documented R13 was at high risk for abuse. R13's Progress Notes, dated 6/28/2022 6:13 PM documents Resident reported an allegation of inappropriate touch. POA (Power of Attorney), Ombudsman and MD (Medical Doctor) notified. The facility's Preliminary 24-hour Abuse Investigation Report dated 6/28/22 identifies R13 as the resident who was allegedly abused and identifies the offense as physical abuse. On 6/29/22 at 12:15 PM V5, Psychosocial Rehab Service Coordinator (PSRC) stated when she was leaving the evening before, 6/28/22 at about 4:30 PM, one of the Certified Nurse's Aides (CNAs) in the dining room said, (R1) just touched R13's breast. V5 stated she asked R13 what happened and R13 stated he (R1) touched her neck first and moved his hand down to her breast. V5 stated R13 stated she was embarrassed because there were other people in the dining room. V5 stated the CNAs told her R1 was intoxicated and R13 told her R1 was drunk. V5 stated she does not understand why V1, Administrator, lets R1 go out into the community every day. V5 stated V1 said corporate says you cannot hold a resident against their will. V5 stated no staff go with him when he leaves to supervise him. V5 stated R1 is kept on the elopement risk flier just in case he doesn't come back one day. On 6/30/22 at 1:00 PM R13 stated R1 had touched her breast two evenings before, on 6/28/22, when she was in the dining room for supper. R13 stated, (R1) was drunk, he always goes out of the facility and gets drunk. I was just sitting in my chair, and he came up and put his hand on my neck and then touched me down my shoulder and my breast. R13 put her hand at the back of her neck and slid her hand down her shoulder and over her breast to demonstrate how R1 had touched her. I still don't feel good about it, and I'm pissed off. I hadn't talked to him, and it just came on all of a sudden. (V5) was there and told him to get his hands off of me. (V5) told me it's not right for him to put his hands on me. R13 stated V5 texted V1, Administrator and she came to the facility. R13 stated there is always a CNA in the dining room during meals and the two CNAs in the dining room that evening both saw what R1 did to her. R13 stated nobody offered to move him away from her in the dining room after it happened. She stated she was scared R1 might do it again. She stated she is kind of scared and a little frightened of R1, and that evening It embarrassed the hell out of me because he did it in front of everyone in the dining room. No other man in the facility has done this before. I just don't feel good since it happened, I'm more uncomfortable, not really depressed. I feel like maybe he should go to jail. Nobody asked me if I wanted the police called. I don't sit at the that table anymore with my friends because he sits there, and I would rather sit around all girls. The staff told me I was sitting at the wrong table this morning, but I felt more comfortable not sitting at my old table. On 6/30/22 at 1:30 PM V5, PRSC, stated she talked to R1 after the incident when he inappropriately touched R13, and he told V5 that he would work on having more appropriate behaviors when she worked on getting him discharged into the community. V5 stated she did not know if V1 called the police at the time of the incident or not. V5 stated she did not feel R1's behaviors had changed, and although she did an updated Skills Assessment for R1 today that documents resident appears to be capable of outside pass privileges at this time she does not feel he is safe to go out in the community on his own because he continues to come back into the facility intoxicated on most nights. V5 stated R1's intoxication on the evening he inappropriately touched R1 in a sexual manner probably did contribute to his behaviors. V5 stated R1 has had aggressive behaviors towards staff and peers when he has been intoxicated in the past. On 6/30/22 at 10:22 AM during phone interview with V13, Certified Nurse's Aide, CNA, she stated she witnessed R1 walk up to R13 and swiped his hand across R13's breast. V13 stated it looked like R1 was saying something, but CNA could not hear what was being said. V13 stated R1 tries to grab staff in a sexual manner, and they document and report to nurse. V13 stated she has not witnessed R1 touching residents in a sexual manner prior to the occurrence on 6/28/22. V13 stated she has heard R1 speaking inappropriately to other residents. On 6/30/22 at 10:35 AM during a phone interview. V25, CNA stated R1 walked up to R13 and rubbed his hand across her breast. V25 stated R1 was definitely being sexual with his actions. V25 stated she has not witnessed R1 speaking inappropriately to other residents and stated, I would not like it if (R1) had touched me in that manner. On 6/30/22 at 9:30 AM V1 stated it is the policy of the facility to only notify the police of an allegation of abuse if it is sexual in nature or if there is physical harm. She stated R13 told her she was sitting in the dining room and R1 put his hands on her shoulders and then moved it down to her breast. V1 stated R13 told her R1 had come up to talk to her and said hi because they have talked in the past. On 7/1/22 at 3:00 PM V21, Medical Assistant (MA) for V24, R1's Medical Doctor (MD) stated V24 does not have any specific recommendations for R1 and will discuss it with the nursing home. V21 stated they did not have any report of R1 being sexually inappropriate to a female resident when she reviewed R1's communication notes. 2. R1's Face Sheet documents his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Discharge Orders (Order Summary Report) dated 4/2/21, from previous facility (admitted from there) documents the order, May go out on LOA (Leave of Absence) with Responsible Party and Meds There was no order on these orders or R1' s current orders that he may go out independently into the community without supervision. R1's document, SS (Social Service)-Community Survival Skills dated 2/9/22 documents the following assessment components and answers: The resident appears to refrain from self-harmful and/or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding persons who constitute a bad influence and is able to practice harm reduction strategies. The answer to this assessment component was filled out no. The Skills form documented The resident knows how to ask for/seek help in an emergent or problematic situation and the resident has knowledge of potentially dangerous situations, such as walking alone after dark, straying into an alley, accepting rides from strangers, carrying valuable items where they can be easily seen. The answer to this assessment component was cannot be determined. The Skills form documents The resident has the ability to adhere to pass privilege policies, e.g., getting permission to leave, signing out, respecting parameters and curfews, informing staff upon return; and The resident is able to behave with respect while in the community and there have been no problems or concerns (reported or witnessed) with his or her conduct over the past 7 days, and The resident sufficiently follows rules addressing medication compliance, participation in his/her treatment plan, appropriate hygiene and grooming and treats others with respect. The answers to these components were cannot be determined. Under Recommendations and Outcomes, it documents, The resident does not appear to be capable of unsupervised outside pass privileges at this time. Under comments it documents, (R1) does go into the community with family sometimes. (Facility) does not provide unsupervised passes. R1's Minimum Data Set (MDS) dated [DATE] documents he entered the facility on 4/5/21 from another nursing home. The MDS documents he is cognitively intact. Under behaviors, the MDS documents R1 has verbal behavioral symptoms directed toward others (for example (e.g.) threatening others, screaming at others, cursing at others) and he has other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R1's MDS documents these behaviors put the resident at significant risk for physical illness or injury, and significantly interfere with R1's care, and with his participation in activities or social interaction. R1's MDS documents behaviors significantly intrude on the privacy and activity of others, and significantly disrupt care or living environment. The MDS also documents R1 rejects care. Per the MDS, R1's behaviors have gotten worse at the time of the assessment. The MDS documents R1 requires limited assist of one staff for bed mobility, transfers, and personal care, and is not steady when moving from a seated to standing position, when moving on and off the toilet, and during surface-to-surface transfers, and is only able to stabilize with staff assistance. R1's Care Plan dated 4/19/21 documents: Trauma informed care (history of gun shot, physically abused in the community). The interventions for this this Care Plan document Provide resident with supportive care and services to promote a sense of safety and wellbeing.; Psychiatry/Psychology services as scheduled. R1's Care Plan, initiation date of 4/5/21, also documents: (R1) is an elopement risk and has made statements of eloping. He refused to come back to the facility while visiting a friend in the community. He attempted to leave the building AMA (against medical advice). R1 is able to go into the facility (community?) independently but is required to sign out and sign in. R1 is encouraged to not use alcohol while out in the community and to not stand near liquor stores talking with friends. R1 entered the facility in the last evening appearing drunken. (Revised 6/1/22). R1's Care Plan, dated 5/6/22 documents, Wandering/poor safety awareness related to wandering risk assessment score of 9.0. At risk for wandering. Interventions include: Complete Wandering Risk Assessment upon annual, quarterly, and prn. Monitor quarterly and prn for least restrictive measures. R1's Care Plan dated 5/18/22 documents, (R1) has a history of Alcohol Abuse. Interventions for this care plan include, Allow resident to voice frustration related to situation, no alcohol use, etc. If resident goes out on pass remind resident of risks of consuming alcohol while out. Observe for signs and symptoms of withdrawal from alcohol abuse (e.g., nervousness, shakiness, anxiety, irritability, rapid emotional changes, depression, difficulty with thinking clearly, bad dreams, headache, swearing, nausea, vomiting, loss of appetite, [CONDITION(S)], rapid heart rate, confusion, hallucinations, agitation, fever (if noted, document and report to MD). This care plan is not updated with R1's current daily abuse of alcohol or any interventions to address or treat his alcohol abuse. R1's Care Plan documents, (R1) is at high potential future risk for abuse/neglect related to high-risk score for abuse/neglect revised on 5/27/22. Interventions for this care plan include: Encourage and educate resident to speak to staff if feeling uncomfortable with a situation and to remain calm. (R1) will receive meetings with Social Services to assist with feeling secure within his environment. Provide reassurance with negative feelings occur. 11/10/21 Encourage (R1) to discuss negative feelings. Report any verbalization of abuse or neglect to administrator immediately. R1's Fall Risk assessment dated [DATE] documents his score of 13, indicating he is at risk of falls. An untitled document dated 5/3/22 signed by V24, R1's Physician, documents, (R1) is current patient of (V24). At this time due to the patient's healthcare needs it is not safe for him to leave his community against medical advice. R1's Progress Note dated 5/11/2022 at 2:37 PM documents, Social Service Note Note Text: (Psychiatrist) is here to see (R1). (R1) appeared upset and informed (psychiatrist) that he would like a pass to the community. (Psychiatrist) states that he is not able to provide a community passes to the residents. (R1) became upset and walked out of meeting. R1's Progress Note dated 5/11/22 at 2:38 PM documents, Resident seen by (psychiatrist) at this time. Resident is verbal and answering MD coherently. MD stated it was his choice to go AMA (against medical advice) if he wants to, but overall, he does not make the full decisions. Writer asked for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No new orders. R1's Progress Note dated 5/13/22 at 5:40 PM documents, This afternoon resident was upset that he could not leave facility after a time that was arranged. At this time resident was noted to have crawled out a resident window and left. Resident was found outside walking where staff approached resident to explain that if this is what he's doing then he needs to sign AMA paperwork. Resident did sign paperwork and resident's medications were given to him. R1's Progress Note dated 5/14/22 at 12:07 AM documents, Patient returned to facility at 11:45 PM without any of his belongings or medication. He stated that he didn't mean to leave and wanted to come back. Writer spoke to administration and patient was let back in. Writer placed call to (MD) office to make him aware that patient has returned without incident but does not have any of his medications and belongings. Writer is awaiting a return call. Patient skin is intact; no bruising noted; no signs of harm or injury noted. R1's Progress Note dated 5/24/2022 at 5:58 PM documents, Social Service Note Note Text: PRSC (Psychosocial Rehabilitation Services Coordinator) spoke with (R1) about his behavior. (R1) goes into the community to visit family independently and stated to sometime drink alcohol during visit, who lives across the street from the facility. (R1) has also went to the store where his friends hang and drink alcohol or stand outside with them talking. PRSC explained the dangers of him using alcohol/substances while out of the building and greatly encouraged him to only visit his family across the street without drinking so that he can enter the facility sober after he visit. (R1) agreed to visit his family without drinking and to not hang with friends near stores or outside. He agrees to stay sober during independent community outings. R1's Progress Note dated 5/26/2022 at 5:00 PM documents, Nursing Note Note Text: Res returned to the facility. CNA notice a can of beer on the resident's pocket. Writer asked the res and try to search the res pocket. Res became agitated. Administrator was informed about the incident. Writer called the doctor's office to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress Note dated 5/26/2022 5:31 PM documents, Nursing Note Note Text: Writer received a call back from (MD). Res can have 1 can of beer for today as per doctor's order. Monitor the res behavior, and if any changes in behavior keep (MD)informed. R1's Progress Note dated at 5/30/2022 2:40 PM documents, Nursing Note Note Text: Res returned to the facility with a can of beer. Writer confiscated the can of beer. R1's Care Plan was not revised after R1 brought alcohol into the facility on ,d+[DATE] and 5/30/22. R1' s Progress Note dated 6/1/2022 at 11:24 AM documents, Social Service Note Note Text: (R1) attended a social service group on 06/01/2022 10:00 AM and spent 15 minutes in this group. (R1) attended Symptom management community re-entry skills management group. The group topic discussed included: 1:1 provided. PRSC provided active listening and positive feedback. PRSC provided (R1) a worksheet to discuss his recovery plan which include how alcohol/drugs affects his chances in life, make a list of what he want to accomplish and his plan to achieve, his support system, his hx of drinking and methods he used to quit. PRSC also discussed having a more structured daily routine. (R1) goes into the community independently and tends to return to the facility appearing and acting drunk. (R1) admits to drinking alcohol while in the community. PRSC informed (R1) that (a representative from an independent living facility) will be here to consult with him tomorrow 5/2/22, to discuss possible independent living plans as he requested.(R1's) participation in the group was noted as Passive Observed. (R1) responded to others in a(n) agreeable manner. (R1) Discussed topics, such as (R1) displayed a nonchalant mood, he agreed that he remembered the previous discussion about not using substances while in the community but showed no concern. (R1) accepted the worksheet and nodded yes to completing it. (R1) chooses not to communicate with PRSC, agreed to be present for his visit tomorrow with (representative). The plan for (R1) is to continue with 1:1 sessions. The interdisciplinary goal for (R1) is to understand and implement the plan of care to reduce distressing symptoms. (R1) will work on focusing on his recovery plan and not use substances to help reduce distressing symptom. R1's Progress Notes dated 6/6/2022 at 1:02 PM documents, Nursing Note Note Text: Patient has been going on outings daily and drinking alcohol writer and administrator has educated the patient on going out and his safety while drinking also writer placed call to (V24) to make him aware of what the patient has been doing; there are no new orders, and no changes patient may continue to go out. R1's Care Plan was not revised with progressive interventions to address R1 leaving the facility daily and drinking alcohol. On 6/28/22 at 8:15 AM R1 was signing out for a walk as surveyors entered the facility, and then V18, Licensed Practical Nurse (LPN) entered the code and let him out the door. R1 had an unsteady gait and he held onto the door frame to walk out. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . His physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/29/22 at 9:20 AM V14, Laundry Aide, stated she sees R1 down on the corner at the liquor store every day. She stated he usually signs out after breakfast and stays out all day then comes back in the evening drunk. V14 stated R1 came back one day carrying a beer. She stated she does not feel he's safe being out on his own in this neighborhood. She stated a bad person might get ahold of him. V14 stated she has seen R1 down there panhandling at the liquor store. She stated every time he comes back, he smells like alcohol. On 6/29/22 at 9:40 AM V18, Licensed Practical Nurse (LPN), stated we have let the MD know about R1 going out and coming back drunk almost every day. She stated sometimes he's fine but other days is very drunk and belligerent. V18 stated R1's gait is very unstable in his ambulation, and then he gets out there drinking, in a bad neighborhood. She stated, I don't feel he is safe. He would not think about drinking water instead of alcohol on the really hot days we've had. He has brought alcohol back with him; I have pulled three of those airplane sized bottles of alcohol off of him, we think he is bringing it for some of the other residents. V18 stated R1 does not have any family in the neighborhood. V18 stated V1, Administrator, informed staff that it is any resident's right to sign out on pass whenever they want, and that when they sign out on pass, they are not the facility's responsibility. On 6/29/22 at 10:35 AM V12, Certified Nursing Assistant (CNA) came and told writer that someone had called another one of the CNAs and told her R1 had just been hit by a car down at the liquor store. Surveyor drove past the liquor store, at 10:50 AM, and R1 was sitting in a chair in the shade behind the liquor store with several other men and was holding a tall can of beer. He did not appear to be in any distress. Writer drove past same location on same day at 2:30 PM and R1 was still there. On 6/29/22 at 12:36 PM V3, Minimum Data Set (MDS) nurse stated R1 goes out on pass almost every day and when he returns, they have found beer, little bottles of liquor and marijuana on him and he gets belligerent when staff try to take it away from him. V3 stated she cannot explain R1 being able to continue to go out on pass even though he returns almost every night intoxicated. She stated, I was not a part of that decision to let him go out. That was the Administrator's and Corporate's decision. V3 stated, I don't feel like he (R1) is safe to be out of the facility on his own. His gait is very unsteady, and you add alcohol to that, and you know he's going to have falls. He really needs help because of his drinking. V3 stated no one goes out with R1 when he is out on pass to offer any supervision. She stated he does not always come back for meals, and he is losing weight since he is going out. On 6/29/22 at 12:59 PM V1 Administrator stated she is aware R1 goes out on pass and stated she is aware he has returned intoxicated. She stated she had stopped his going out because he was not safe, but then he attempted to elope, and since she has been letting him go out again, he hasn't tried to elope again. She stated V5 needs to update R1's elopement assessment because he is not an elopement risk. V1 stated R1 can sign out after breakfast, and he has to come back before dark. V1 stated she is going to have to have a meeting with R1 to set guidelines and tell him if he doesn't follow them, he won' t be able to go out on pass. V1 stated V5 has had several 1:1's with R1 regarding his drinking and behaviors. On 6/29/22 at 2:45 PM V13, CNA stated, I don't think this is the place for (R3). He goes out and drinks alcohol every day, and usually when he comes back in the evenings, he is belligerent and drunk with the staff and other residents. V13 stated, He is very verbal. I'm not touching him to search him because he has threatened to hit me and has jumped at me before. He sometimes doesn't even know where he is. We report his behaviors and that he comes back drunk every night to the administrator. It takes three if us to get the beer he brings back away from him. V13 stated she does not feel R1 should be allowed to go out on pass because he hangs out at the liquor street down the street. She stated he has returned to the facility so drunk before that he has defecated on himself. V13 stated R1 has been sexually inappropriate towards her and other staff when he is drunk. She stated they have taken contraband including bottles of liquor, beer and pills that are not his from him. On 6/29/22 at 3:00 PM V16, CNA, stated R1 does need physical assist with ADL's (Activities of Daily Living) including getting dressed and getting his shoes on. She stated he is very unsteady because he is missing part of one of his feet. V16 stated R1 goes out and drinks alcohol about every day and sometimes has bowel incontinence on his way back and needs help getting cleaned up. She stated R1 is not always incontinent, only when he is really drunk. She stated he can get aggressive especially if he tries to sneak alcohol back into the facility and staff stops him but stated sometimes his behaviors are ok when he returns. V16 stated she doesn't think R1 is safe to be out in the community because his gait is very unsteady, and it he falls, no one will know. R1's Progress Note dated 6/30/22 at 8:50 AM documents, Administrator educated and informed (R1) of the facility policy of not using drugs and alcohol while in the community and returning to the facility intoxicated. (R1) has been informed that if he returns to the facility intoxicated his privileges of independent community outings will be revoked. (R1) replied, OK in agreement to adhere to the policy. PRSC witnessed. R1's SS-Level of Functioning-Skills assessment dated [DATE] documents Recommended Interventions as individual counseling, therapy or support, emphasis: one to one sessions to discuss moods and behaviors; Group counseling, therapy or support, emphasis: substance abuse counseling. Under Community Skills, the assessment documents Cannot Determine to the statement, the resident appears able to refrain from self-harmful and /or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding persons who constitute a bad influence and is able to practice harm reduction strategies. At the end of this assessment, under Recommendations and Outcomes it documents, The resident appears to be capable of outside pass privileges at this time. On 6/30/22 at 1:30 PM V5, Psychosocial Rehabilitation Services Coordinator (PRSC), stated she talked to R1 after the incident when he inappropriately touched R13, and he told V5 that he would work on having more appropriate behaviors when she worked on getting him discharged into the community. V5 stated she did not know if V1 called the police at the time of the incident or not. V5 stated she did not feel R1's behaviors had changed, and although she did an updated Skills Assessment for R1 today that documents resident appears to be capable of outside pass privileges at this time she does not feel he is safe to go out in the community on his own because he continues to come back into the facility intoxicated on most nights. V5 stated R1's intoxication on the evening he inappropriately touched R1 in a sexual manner probably did contribute to his behaviors. V5 stated R1 has had aggressive behaviors towards staff and peers when he has been intoxicated in the past. V5 stated she does not have any programs or classes to address R1's alcohol abuse or other residents' alcohol or substance abuse. She stated she thought that would be a good idea and will contact (psychiatric hospital) and get more information. On 6/30/22 at 3:40 PM during a phone interview, V20, Psychiatric Nurse Practitioner, stated she did not think V28, Psychiatrist, would necessarily recommend Alcoholics Anonymous or Narcotics Anonymous because residents should have already been withdrawn from any substances when they are admitted to the facility. V20 stated she does feel like some type of programming to discuss addiction and education on drug and alcohol abuse would be good. V20 stated residents with a history of alcohol and drug abuse should not have access to these things in the facility and if they are, then that's a problem. V20 stated it is very dangerous for R1 to be drinking alcohol and still receiving his medication. She stated that it is very scary that R1 has continued to receive his medications even when staff are aware he has been drinking. The staff should hold his medications if he is intoxicated. On 6/30/22 at 3:55 PM V1 stated V5 did a new skills assessment with R1 on 6/30/22 and on 6/1/22 V5 had educated him regarding his use of alcohol, and he has to follow the guidelines outlined on that assessment or his privileges for outside pass will be revoked. V1 acknowledged that R1 has continued to abuse alcohol and return to the facility drunk since V5 talked to him on 6/1/22. On 6/30/22 at 4:05 PM R1 was observed standing behind the liquor store down the street from the facility. The outside temperature was 88 degrees. R1's Progress Note dated 7/1/22 at 9:49 AM documents, (R1) came into the facility intoxicated though he has been previously informed of his privileges being revoked if this behavior continued. (R1) was informed that his community outing privileges are revoked. (R1) appeared anxious/agitated. He refused 1:1 with PRSC and chose to isolate and keep to himself. PRSC informed him that he can speak with PRSC when he is ready about his feelings and coping skills. The facility's forms, Release of Responsibility for Leave of Absence dated 5/19/22 through 7/3/22 was reviewed. This document is the form residents sign when leaving the facility. R1 signed out of the facility several times a week during May and June 2022 even though his care plan, elopement assessment, and SS-Community Survival Skills all document he is not appropriate for outside pass and is identified as an elopement risk. The facility's form, Release of Responsibility for Leave of Absence contains an entry dated 7/1/22 at 1:30 PM of R1 signing out of the facility after his pass privileges were revoked. It does not document the time he returned. R1's Progress Note dated 7/5/22 at 10:19 AM documents, This am resident drooling, sweating, unable to talk clearly, difficult for resident to be awakened by staff. Resident unable to make eye contact. VS (vital signs) 158/85, Pulse 103, Temp 97.8. (MD) and administrator notified. Writer sent resident out to (local hospital) per (ambulance) via stretche[TRUNCATED]

Based on observation, interview and record review the facility failed to implement progressive interventions to address weight loss and poor nutritional status for 1 of 1 resident (R44) reviewed for nutrition/weight loss in the total sample of 64. This failure resulted in R44 having a 10.39% weight loss in less than a month. Findings include: On 7/25/2021 at 9:40 AM R44 in low bed covered with a sheet and asleep. At 12:43 PM R44 remained in bed covered with a sheet. R44 stated, I haven't had anything to eat or drink yet. R44 appears severely underweight, R44's hip bones, rib cage and spinal column were visible and R44's cheeks are drawn in on observation. On 7/26/2021 at 11:25 AM V15 Certified Nurse's Assistant (CNA) stated, If (R44) tells me that he hasn't eaten anything, I believe him because he can talk, and he knows what's going on. V15 stated, That is why I get him out of bed to assist him with something to eat and drink. V15 stated (R44) is a good eater. On 7/26/2021 at 12:10 PM R44 was in dining room with V15 assisting with meal and R44 consumed 75-100% of the lunch meal. On 7/27/2021 at 12:20 PM V18 CNA assisting R44 with noon meal. R44's meal ticket documents that R44 is to receive 4 ounces of pudding with lunch. R44 did not receive 4 ounces of pudding on his lunch tray. R44's lunch consisted of pureed Salisbury steak, pureed carrots and pureed cake. V18 CNA stated, I don't see any pudding on his plate. R44 consumed 100% of noon meal. On 7/28/2021 at 1:40 V29 Dietary Aide stated, We fortify the pudding that R44 receives. V29 stated we add powder milk, brown sugar giving it more calories. R44's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R44's PO, dated 9/29/2020 documents R44 is to receive a nutritional supplement, 90 milliliters of 2.0 calories three times daily. The PO documents that staff should chart the amount consumed three times daily for weight loss. R44's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/27/2021 at 11:35 AM V9 Licensed Practical Nurse (LPN) stated We give (R44) his 90mls of 2.0 liquid supplement with medication pass. V9 stated, It is documented on (R44)'s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R44's Care Plan, initiation date of 5/26/16, documents Modified diet regular, puree, super cereal at breakfast, power pudding at lunch, 90ml 2.0 three times day. R44's Care Plan Interventions, with initiation dates of 5/26/16, documents Monitor weight and food/fluid intakes. Provide diet as ordered. R44's Care Plan, revised on 4/13/21, documents R44 has Activities of Daily Living self-care performance deficit related to confusion and poor motivation. R44's Care Plan Interventions, revised on 4/13,21, documents The resident requires total assist of one staff to eat. Feeds self after set up. R44's Dietary initial/quarterly/annual dated 6/23/2021 documents; regular, puree, super cereal at breakfast, 4 oz pudding at lunch, 90mls 2.2 three times day. R44's medical record documented R44's weights as follows: 7/12/21 102 pounds (lbs.); 6/4/21, 97.0 lbs.; and 5/3/21 91.6 lbs. On 7/27/2021 at 12:48PM V15 weighed R44's highboy chair which weighed 77.4 lbs. V15 then weighed R44 in the highboy chair resulting in 168.8 lbs. The highboy chair weight of 77.4lbs was deducted from the total weight of 168.8 lbs. R44 weighed 91.4lbs. This was a 10.6 lbs. weight loss in one month, resulting in over at 10% weight loss. R44's Registered Dietician (RD) note documents: RD consult hospice care, severely underweight with significant wt. (weight) gain noted this month. July wt. 102# BMI: 17 underweight per standards. 7/21/21 skin assessment reports no pressure ulcers or edema; no new labs. Diet: general, pureed supplemented with 4 oz pudding @ lunch, super cereal at breakfast, med pass 2.0 90 cc TID d/t (due to) wt. loss and hospice. Continue plan of care per hospice and facility protocol. Refer to RD prn. R44's Comprehensive metabolic panel (CMP) dated 7/8/2021 documents [MEDICATION(S)] 3.3 g/dl normal ranges 3.5-5.5 g/dl. There is no documentation in R44's medical record the facility has implemented any new interventions to address R44's weight loss and poor nutritional status since the facility implemented the nutritional supplement three times daily on 9/29/20. On 7/28/2021 at 2:10PM V30 (R44's daughter/POA) stated, I live in California, so I have not been to the facility that my father is in. V30 stated, (R44) is a very intelligent man who served in the Armed Forces, served as a Sheriff and later became a detective. V30 stated I have flown my father (R44) to California at least 4 times, my father is very talkative and when he was here, I couldn't get him to stop eating. I would catch him in the refrigerator late at night. V30 stated, (R44) is a good eater and always has been. The Facility's Policy and Procedure 'Nutritional Monitoring' undated documents Ensure staff awareness of resident diet order and food consistency requirements. Monitor each meal to assess the nutrition and hydration consumption and ability to chew and swallow. Record the food intake as follows on the Nutritional Monitoring Worksheet. Monthly weights are to be measured and recorded as per schedule. Undesired or unanticipated weight losses or weight gains of 2 1/2 % in one week, 5% in one month or 10% in 180 days shall be reported to the physician, Dietary Manager and RD. Chart pertinent evaluations, measurements and notifications in the nursing notes. The Facility's Policy and Procedure Weights, dated 1-/17/19 documents Residents identified at nutritional risk may be weighed weekly or biweekly as per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Re-weight should be taken as soon as possible after an unanticipated weight change is noted and prior to calling the physician. (Usually within 72 hours) Undesired or unanticipated weight gains/loss of 5% in 30 days, 7.5% in 3 months, or 10% in six months shall be reported to the physician, Dietician and/or Dietary Manager as appropriate. Weekly weights may be discontinued if the resident's weight has remained stable for four consecutive weeks or as determined by the Interdisciplinary Team, Dietician or the physician.

Based on interview, observation and record review, the facility failed to provide Range of Motion (ROM) to prevent the reduction of ROM and/or contractures and failed to identify/assess range of motion limitations for 3 of 4 residents (R44, R24, R2 ) reviewed for ROM exercises in a sample of 64. This failure resulted in R44 having increased contractures in his right lower extremities. Findings include: R44's Minimum Data Set (MDS) dated [DATE] documents R44 had no functional limitations in range of motion in both lower and upper extremities. The MDS documents R44 was receiving Restorative Nursing Programs of Passive Range of Motion for 5 days per week and Active Range of Motion 5 days per week. R44's MDS dated [DATE] documents R44 had impairment on only one side of his lower extremities. The MDS documented R44 was receiving 7 days per week. R44's Minimum Data Set (MDS) dated [DATE] documents R44 had Functional Limitation in Range of Motion on one side of his upper extremity and impairment on one side of his lower extremity. The MDs documented he was receiving passive range of motion 7 days per week. R44's Restorative Observation Sheet, dated 6/23/21, documented that R44 had normal mobility in his right knee and hip and had fixed/no mobility in his left hip and knee. On 7/25/2021 at 09:40 AM R44 was in low bed. R44's legs were drawn into his chest area (fetal position). On 7/26/2021 at 11:55 AM V15 Certified Nurse's Assistant (CNA) and V13 (CNA) attempted to get R44 to straighten out his lower extremities independently. R44 was unable to straighten out either leg. R44's legs were drawn up to his torso area. V15 and V13 stated R44 was able to walk a year ago and then his legs began to contract. On 07/27/21 at 12:57 PM V18 (CNA) stated she does not perform range of motion on R44. V18 stated she has not seen any other staff member perform range of motion with R44. On 7/27/2021 at 3:15 PM V26 CNA stated, We used to have a restorative aide, but no more. V26 CNA stated, No I don't conduct range of motion. On 7/27/2021 at 3:16PM V19 CNA stated, No, I don't conduct range of motion, I usually have the residents do it themselves by raising their arms. On 7/28/2021 at 08:30 AM V4, Licensed Practical Nurse (LPN)/Restorative Nurse stated, They are charting like it is getting done. V4 LPN stated, I check the charting to see if it is done. R44's Care Plan dated, with revision date of 4/13/20, documents I have a limited range of motion in LUE (left upper extremities)/LLE (left lower extremities) extremities. R44's Care Plan Goals documents I will be able to complete Passive Range Of Motion Program 10 reps to LUE/LLE (left upper extremity/left lower extremity) BID (twice a day) x 7 per week.R44's Care Plan Interventions document Demonstrate exercise and have resident return demonstration. The Care Plan did not address R44's legs being contracted to his chest and interventions to address his increased limited range of motion in both his legs. 2. R24's MDS dated [DATE], documented no impairment with cognition, alert to person, place and time, and receives Passive Range of Motion 7 days a week. R24's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . admitted ,d+[DATE]. R24's Care Plan dated 5/26/2021, documented, limited range of motion in right arm, shoulder, elbow, wrist, hand and fingers. Passive Range of Motion, (PROM) and Active Range of Motion, (AROM) to right arm and right leg/foot and Active Range of Motion to left arm and left leg/foot at 10 repetitions twice a day, 7 days per week. R24's Nursing Rehabilitation/Restorative Certified Nursing Aide, (CNA) Tracking Sheet, documented on the following dates and times, that R24 received AROMs and PROMs; on 7/21/21 at 2:03PM, 7/22/21 at 2:04PM, 7/26/21 at 2:05PM and 7/27/21 at 2:06PM. On 7/27/21 at 2:25PM, V22, CNA, stated to state surveyor when asked to see range of motion performed on R24, V22 states, No! I can't, I have a cast on my arm and on restrictions. V22 stated residents are cared for often, dressed, toileted, repositioned, as the residents can move their arms and legs during care and 15 minutes of the program is documented. On 7/27/21 at 2:30PM, V21 CNA, stated, she does not chart range of motion every day as the residents can move their legs and arms already, especially during dressing, toileting and repositioning, the 15 minutes is documented, under the Active and/or Passive Range of Motion section in the medical record. On 7/25/21 at 2:15PM, R24 states, No one does exercises on my arms or legs and would like to have it done. When asked who his caregivers were today, R24 states, (V12 and V23) and no one has come in to do exercises on me. 3. R2's MDS dated [DATE], documented no mild impairment with cognition, alert to person, place and time, makes self-understood and receives Passive Range of Motion 7 days a week. R2's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan dated 5/26/2021, documented, The resident has ADL, (activity of daily living) self-care performance deficit related to Limited Mobility. Resident primary mode of locomotion is wheelchair. Resident believes that she is unable to use her legs. Resident believes her legs are clone legs and they do not work. Resident is able to bear weight. (R2) will be non-compliant/resistive to care with: Care Interventions, there are times that (R2) will refuse to do PROM's to LLE, (left lower extremity) r/t, (related to) the fact that she does not feel that she needs them as initiated on care plan problem dated 7/24/2019. R2's, Nursing Rehabilitation/Restorative Tracking Sheet, documented on the following dates, that R2 received PROMs, twice a day, from 7/14/21 through 7/26/21 and on 7/27/21 at 9:00PM was the only documented refused. On 7/26/21 at 1:45 PM, V15, CNA stated, she does not provide PROMs, because R2 refuses. On 07/27/21 10:20 AM, V18, CNA stated, R2 refuses to have PROM's performed. On 7/27/21 at 10:30 AM, V18 states, I will not lie to you, I have charted 15-minutes of AROM/PROM being performed when it was not done. On 7/27/21 at 2:40 PM, V1 stated, she has been informed from the CNAs regarding residents restorative programs, and stated the CNAs had to be informed the procedure of performing AROM and PROMS, as the CNAs had a misunderstanding of the exercise and the documentation. V1 continued to state that all CNAs will be in-serviced for performing these restorative programs. The facility's policy and procedure, entitled, Passive Range of motion Exercise, undated, documented, If the resident is recommended for a PROM program, trained nursing staff will provide the range of motion exercises. The facility's policy and procedure, entitled, Restorative Nursing Program, dated 11/28/21, documented, To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Documentation of the interventions and resident's response will be completed with each implementation. Each resident's progress will be evaluated periodically by the licensed nurse.

Based on record review and interview, the facility failed to implement their policy "Suicide Observation and Prevention", safety measures, assess, monitor, supervise and care plan for 4 of 8 residents (R1, R2, R4, R8) reviewed for self-injurious behaviors in the sample of 8. This failure resulted in R1's repetitive self inflicted injuries of cutting her wrist during two facility based incidents. This resulted in an Immediate Jeopardy. While the immediacy was removed on 6-10-2014 at 7:35p.m., the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff, evaluate and monitor the effectiveness of the facility policies and procedures and provide inservice training on identifying residents for self injurious behavior and suicidal ideation, resident supervision, room sweeps, body searches, fifteen minute checks, 1 on 1 supervision to include consequence of failure to follow policy and procedures, updating care plans to address self injurious behaviors and suicidal ideation and behavior monitoring for self injurious behavior and suicidal ideation. Findings include: 1. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a [DIAGNOSES REDACTED]. R1's MDS documents that she has behavioral symptoms that put R1 at significant risk for injury. R1's Care Plan, dated 3/26/2014, documents she has attempted self-harmful acts in the past and has a psychosocial well-being problem related to suicidal ideations. R1's Psychiatric Evaluation, dated 3/1/2014 prior to admission to the facility, documents R1 has a history of multiple suicide attempts including attempting to hang herself, slitting her wrist and walking into traffic. Per telephone interview with Z1, R1's Physician, on 6/10/2014 at 10:00 am, he stated R1 is a "cutter" and relieves her emotional pain by causing physical pain to herself. On 6/6/2014 at 9:45 am E12, Licensed Practical Nurse (LPN) was interviewed in regards to incidents with R1. E12 stated that R1 was admitted with the behaviors of cutting her wrist and attempting to kill herself by walking into traffic. 0n 5/21/2014 Resident Out On Pass documents that R1 left the facility at 5:00pm with a friend and went to the store. R1 returned to the facility at 6:05pm. Nurse's Notes, dated 5/21/2014 , no time documented, E12, LPN documents that R1 had a razor blade on her person and it was taken away. E12, LPN documents in the Nurses Notes at 10:00pm R1 was found in her room with a self inflicted cut to left wrist approximately 11 centimeters in length. The Incident Summary Form dated 5/21/2014 at 10:00pm documents the interventions for R1 after being sent to the hospital and returning. R1 was to be placed on 15 minute checks and a sweep of R1's room revealed a box of razor blades. R1's Nurse's Notes dated 5/24/2014 at 9:30pm, documented that R 1 was found in her room with a cut to her left wrist measuring 4-41/2 inches in length running from hand toward the elbow in a straight line. R1 was sent to the hospital and returned. Incident Summary dated 5/24/2014 at 9:30pm, documents that R1 had self inflicted razor blade cut to the left wrist. It documents that R1 was placed on one to one supervision after R1 returned from the hospital, and R1 was to have a body search after any outings with family or friends. R1's Nurse's Notes, dated 5/26/2014 at 8:00 am, E2, Director of Nursing (DON) documented that R1 stated she bought the razor blades on a visit, prior to the 5/21/2014 incident. E2 documented that that she asked R1 where she got the razor blade as R1's room had been searched. R1 reported that she hid a razor blade on her body. On 6/10/2014 at 2:28 pm E12, LPN was interviewed, E12 stated she does not remember what time the razor blade was taken away from R1. E12 stated that she did a body search on R1 at that time. On 6/11/2014 at 2:13pm E13, Certified Nursing Aide, (CNA) was interviewed in regards to the incidents of 5/21 and 5/24/2014 . E13 stated that she was made aware R1 had a razor blade on her person from another resident at the facility. E13 stated that she could not recall who took the razor blade from R1. E13 stated that later in the evening R1 turned on her call light. E14, CNA answered the call light and R1 had cut her left wrist. E13, CNA stated that it was end of shift and room search was done. E13 stated there were no razor blades found at that time. E13 stated that R1 did end up giving staff a box of seven razor blades. E13 stated that was a total of nine razor blades with one blade still missing as the box contained ten blades. Nurse's Notes, dated 5/21/2014 failed to document there had been any room searches or body search on 5/21/2014. Per interview with E2, DON on 6/12/2014 at 1:27 PM, she stated that she would have done a body search on R1 on 5/21/2014 based on her history. E2, DON stated that R1 "is very with it, and better at hiding things than anybody else at the facility, because she is fat." E2 reports that R1 was placed on 1:1 from 5/24/2014-6/1/2014. E2 stated that R1 was placed on 15 minute checks after the first incident on 5/21/2014, and after the second incident was when the 1:1 was initiated. E2 stated that corporate reports when residents on 15 minutes checks and out of facility they are not liable for the resident. Documentation on the 15 Minute Check Sheet documents that R1 was on 15 minute checks 5/25/-5/29/2014. Incident Summary, dated 6/5/2014 at 7:05pm documents that R1 was found with a cord wrapped around her neck. R1 was sent to the hospital and admitted . Facility Policy Suicide Observation and Prevention documents that in the event there are behavior symptoms which indicate a suicide emergency, safety interventions will be promptly initiated., A search of residents room will be conducted, including clothing for any harmful objects and remove,. Initiate a monitoring form or document checks every 15 minutes and stay within visual close access of the resident at all times as determined by the charge nurse and medical doctor until medical psychiatric evaluation indicates it is no longer necessary. 2. Interview of E2, DON, on 6-9-2014 at 6:45p.m. E2 stated R1, R2, R4 and R8 were admitted with suicidal ideation and were on 15 minute checks. The 15 Minute Check Sheets, not dated but provided by E10, CNA, on 6-9-2014, documented R2 and R8 were not provided 15 minute checks, from 2:15p.m to 6:15p.m. on 6-9-2014. R4 did not have a 15 Minute Check Sheet. It was also noted that R1 did not have 15 Minute Check Sheets for 5-22-2014, 5-23-2014 and 6-2-2014 through 6-4-2014. The Immediate Jeopardy situation was identified to have began on 6-10-2014 when R1 was identified as having self injurious behaviors during three incidents facility based occurrences. The facility failed to provide identify R1's self injurious behaviors and failed to properly assess, monitor and supervise R1. E1 and E2 were notified of the Immediate Jeopardy on 6-10-2014 at 4:05p.m. On 6-10-2014 through interviews, observation and record review, the facility took the following actions to remove the Immediacy: 1. On 6-10-2014, by 7:15p.m., all residents were assessed for self injurious and suicidal ideation. 2. On 6-10-2014, the facility began inservicing all staff on identified and identifying residents for self injurious behaviors and suicidal ideation, updating care plans to address self injurious behaviors and suicidal ideations, perform behavior monitoring for self injurious behaviors and suicidal ideation, resident supervision, updated/revised policies and procedures on room sweeps, body searches, 15 minute checks 1 on 1 supervions and consequences on failure to follow policy and procedures.

Based on record review and interview, the facility neglected to implement their policy "Suicide Observation and Prevention", safety measures, assess, monitor, supervise and care plan for 4 of 8 residents (R1, R2, R4, R8) reviewed for self-injurious behaviors in the sample of 8. This failure resulted in R1's repetitive self inflicted injuries of cutting her wrist during two facility based incidents. This resulted in an Immediate Jeopardy. While the immediacy was removed on 6-10-2014 at 7:35p.m., the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff, evaluate and monitor the effectiveness of the facility policies and procedures and provide inservice training on identifying residents for self injurious behavior and suicidal ideation, resident supervision, room sweeps, body searches, fifteen minute checks, 1 on 1 supervision to include consequence of failure to follow policy and procedures, updating care plans to address self injurious behaviors and suicidal ideation and behavior monitoring for self injurious behavior and suicidal ideation. Findings include: 1. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a [DIAGNOSES REDACTED]. R1's MDS documents that she has behavioral symptoms that put R1 at significant risk for injury. R1's Care Plan, dated 3/26/2014, documents she has attempted self-harmful acts in the past and has a psychosocial well-being problem related to [MEDICAL CONDITION]. R1's Psychiatric Evaluation, dated 3/1/2014 prior to admission to the facility, documents R1 has a history of multiple suicide attempts including attempting to hang herself, slitting her wrist and walking into traffic. Per telephone interview with Z1, R1's Physician, on 6/10/2014 at 10:00 am, he stated R1 is a "cutter" and relieves her emotional pain by causing physical pain to herself. On 6/6/2014 at 9:45 am E12, Licensed Practical Nurse (LPN) was interviewed in regards to incidents with R1. E12 stated that R1 was admitted with the behaviors of cutting her wrist and attempting to kill herself by walking into traffic. 0n 5/21/2014 Resident Out On Pass documents that R1 left the facility at 5:00pm with a friend and went to the store. R1 returned to the facility at 6:05pm. Nurse's Notes, dated 5/21/2014 , no time documented, E12, LPN documents that R1 had a razor blade on her person and it was taken away. E12, LPN documents in the Nurses Notes at 10:00pm R1 was found in her room with a self inflicted cut to left wrist approximately 11 centimeters in length. The Incident Summary Form dated 5/21/2014 at 10:00pm documents the interventions for R1 after being sent to the hospital and returning. R1 was to be placed on 15 minute checks and a sweep of R1's room revealed a box of razor blades. R1's Nurse's Notes dated 5/24/2014 at 9:30pm, documented that R 1 was found in her room with a cut to her left wrist measuring 4-41/2 inches in length running from hand toward the elbow in a straight line. R1 was sent to the hospital and returned. Incident Summary dated 5/24/2014 at 9:30pm, documents that R1 had self inflicted razor blade cut to the left wrist. It documents that R1 was placed on one to one supervision after R1 returned from the hospital, and R1 was to have a body search after any outings with family or friends. R1's Nurse's Notes, dated 5/26/2014 at 8:00 am, E2, Director of Nursing (DON) documented that R1 stated she bought the razor blades on a visit, prior to the 5/21/2014 incident. E2 documented that that she asked R1 where she got the razor blade as R1's room had been searched. R1 reported that she hid a razor blade on her body. On 6/10/2014 at 2:28 pm E12, LPN was interviewed, E12 stated she does not remember what time the razor blade was taken away from R1. E12 stated that she did a body search on R1 at that time. On 6/11/2014 at 2:13pm E13, Certified Nursing Aide, (CNA) was interviewed in regards to the incidents of 5/21 and 5/24/2014 . E13 stated that she was made aware R1 had a razor blade on her person from another resident at the facility. E13 stated that she could not recall who took the razor blade from R1. E13 stated that later in the evening R1 turned on her call light. E14, CNA answered the call light and R1 had cut her left wrist. E13, CNA stated that it was end of shift and room search was done. E13 stated there were no razor blades found at that time. E13 stated that R1 did end up giving staff a box of seven razor blades. E13 stated that was a total of nine razor blades with one blade still missing as the box contained ten blades. Nurse's Notes, dated 5/21/2014 failed to document there had been any room searches or body search on 5/21/2014. Per interview with E2, DON on 6/12/2014 at 1:27 PM, she stated that she would have done a body search on R1 on 5/21/2014 based on her history. E2, DON stated that R1 "is very with it, and better at hiding things than anybody else at the facility, because she is fat." E2 reports that R1 was placed on 1:1 from 5/24/2014-6/1/2014. E2 stated that R1 was placed on 15 minute checks after the first incident on 5/21/2014, and after the second incident was when the 1:1 was initiated. E2 stated that corporate reports when residents on 15 minutes checks and out of facility they are not liable for the resident. Documentation on the 15 Minute Check Sheet documents that R1 was on 15 minute checks 5/25/-5/29/2014. Incident Summary, dated 6/5/2014 at 7:05pm documents that R1 was found with a cord wrapped around her neck. R1 was sent to the hospital and admitted . Facility Policy Suicide Observation and Prevention documents that in the event there are behavior symptoms which indicate a suicide emergency, safety interventions will be promptly initiated., A search of residents room will be conducted, including clothing for any harmful objects and remove,. Initiate a monitoring form or document checks every 15 minutes and stay within visual close access of the resident at all times as determined by the charge nurse and medical doctor until medical psychiatric evaluation indicates it is no longer necessary. 2. Interview of E2, DON, on 6-9-2014 at 6:45p.m. E2 stated R1, R2, R4 and R8 were admitted with suicidal ideation and were on 15 minute checks. The 15 Minute Check Sheets, not dated but provided by E10, CNA, on 6-9-2014, documented R2 and R8 were not provided 15 minute checks, from 2:15p.m to 6:15p.m. on 6-9-2014. R4 did not have a 15 Minute Check Sheet. It was also noted that R1 did not have 15 Minute Check Sheets for 5-22-2014, 5-23-2014 and 6-2-2014 through 6-4-2014. The Immediate Jeopardy situation was identified to have began on 6-10-2014 when R1 was identified as having self injurious behaviors during three incidents facility based occurrences. The facility failed to provide identify R1's self injurious behaviors and failed to properly assess, monitor and supervise R1. E1 and E2 were notified of the Immediate Jeopardy on 6-10-2014 at 4:05p.m. On 6-10-2014 through interviews, observation and record review, the facility took the following actions to remove the Immediacy: 1. On 6-10-2014, by 7:15p.m., all residents were assessed for self injurious and suicidal ideation. 2. On 6-10-2014, the facility began inservicing all staff on identified and identifying residents for self injurious behaviors and suicidal ideation, updating care plans to address self injurious behaviors and [MEDICAL CONDITION], perform behavior monitoring for self injurious behaviors and suicidal ideation, resident supervision, updated/revised policies and procedures on room sweeps, body searches, 15 minute checks 1 on 1 supervions and consequences on failure to follow policy and procedures.

Based on observation, interview and record review, the facility failed to continue to assess and monitor 1 (R1) of 1 sampled residents, who fell and had a decline in ambulation and Activities of Daily Living due to continuous pain and fractures of foot and ankle. Findings include: R1's Admission Information form shows R1 is a [AGE] year old female with a current admission to the facility on [DATE]. R1's admitting [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) of 12-27-10 shows she was independent with transfer, bed mobility, ambulation, dressing, toilet use, hygiene and bathing. R1's Physician order [REDACTED]. R1's Monthly Summary of 12-15-10 states R1 is alert, ambulatory, independent in ADL's (Activities of Daily Living), is not at fall risk, has a good appetite, has no behaviors and is in good spirit. Monthly Summary of 1-14-11 identifies R1 as being alert, ambulatory, independent in ADL's, good appetite, easily upsets and is cooperative. Summary note states Recent fall due to increase in meds. Meds reduced and no falls. Nurses Note was written on 1-7-11 showing R1 had fallen. Note at 9AM,states R1 continues to complained of pain to BLE (Bilateral Lower Extremities). New Order received for X rays. (X ray report states X rays were taken of Bilateral ankle and feet with no fracture or dislocation.) Facility 72 hour charting form (used by Nurses after a resident has a fall) shows note of 1-7-11 at 0300, "R1 reported that on her way to BR (Bathroom), R1 became dizzy and fell . ROM (range of motion) WNL (within normal limits) 0 injury. R1 also stated she hit her head. 0 head trauma. Pearl A & O (alert and oriented) x 3. Hand grasps equal. R1 assested (assisted) up and gotten back to bed. Z1 aware. R1 is own POA (Power of Attorney)." Note at 9PM shows R1 is alert and complains of legs hurting. X ray at 1600 awaiting results. Assist with ADL's (activities of daily living) at this time. Note of 2230 states R1 resting in room and complain of hip pain and took [MEDICATION NAME]. Assisted to bathroom by aides. 72 hour charting notes of 1-8-11 at 0130 state staff assist with taking R1 to the bathroom. Note at 0930 state R1 in bed and complaining of ache all over and weakness. Faxed X ray reports which were negative to Z1's office. ROM WNL. Note at 1900 states R1 is in a wheel chair and complains of unable to walk... Alert and oriented x 3. 72 hour charting notes of 1-9-11 at 0200 state R1 standing for short periods of time. Using wheel chair for mobility. ROM WNL. Note at 0900 states R1 up walking short distances. Received [MEDICATION NAME] PRN for pain to legs/feet. Uses wheel chair at times for mobility due to weakness to legs. Note at 2000 state R1 up ambulating slowly complains of pain. Stated she did not use wheel chair today. Refused [MEDICATION NAME]. ROM improving. (Yet above notes state ROM WNL.) Nurses Note of 1-11-11 states R1 complained of a little weakness to both lower legs. Note of 1-13-11 states c/o (complained of) some weakness from fall. Note of 1-14-11 at 9pm states up with steady gait. Worried she won't walk right again. Reassured resident. Note of 1-16-11 at 0700 states R1 has a temperature of 100.5 and BLE [MEDICAL CONDITION] and wheezing both lungs. Notified MD and order received to send to the hospital. Note at 2 PM states returned from ER (emergency room ) with new orders. ABT (antibiotic) for pneumonia, splints for fracture of right ankle, shoe for hairline fracture of left foot, increase [MEDICATION NAME] for [MEDICAL CONDITION]. E5, LPN (Licensed Practical Nurse) stated on 2-9-11 at 12:30PM, she sent R1 to the hospital on 1-16-11. R1 was walking stiff and limping. her feet were swollen. E5 stated she can't remember how R1 was prior to being sent to the hospital, "Can't get it straight in my mind." E4, LPN stated on 2-9-11 at 3:07PM, she worked on the 7th of January. The day R1 fell . R1 was limping. She stated her ankle hurt. They did a mobile Xray and there were no fractures. Couldn't tell that week if she was limping a lot or not. Don't remember. Just thought maybe had a sprain. On 2-1-11, R1 was observed to be propelling herself in a wheel chair and was wearing a walker boot and special shoe on her feet. On 2-1-11 at 9:12AM, R1 stated the night she fell , she had gotten up to go to the bathroom and was dizzy. She fell flat on her face twice. She stated she couldn't get up and was lifted up to bed by staff. She stated she slept most of the day and complained of her feet and legs hurting. Portable X rays were ordered and there were no findings of fractures. R1 stated she walked on her feet and was hurting for 9 days before they called Z1. Z1 was called per her request and she was sent to the ER. They found her left foot was fractured and her right ankle was fractured. R1 stated she had Pneumonia and her [MEDICAL CONDITION] levels were also found to be low. On 2-4-11, E2, Director of Nursing, stated on the day R1 was sent to the ER, 1-16-11, Z1 was called of concerns of continuing to complain of pain to her feet and ankles. E2 stated Z1 was called because R1 requested him to be called and he ordered her to be sent to the ER. On 2-4-11 at 9:20AM, Z3, Z1's Nurse, stated Z1 was informed of R1 falling on 1-7-11 and ordered a portable Xray. The results were negative. Z1 got another call on Sunday 1-16-11 stating R1 had been having problems for over the past week with walking and complaints of legs hurting. Z1 was concerned of possible embolism. He sent her to the hospital for evaluation. The ER Physician did call Z1 and discussed findings and medication changes. R1 had fractures and Pneumonia and her [MEDICAL CONDITION] medication needed to be increased. Z3 stated R1 was very reliable. She knows what's going on. R1 said she fell and couldn't move. R1's a Nurse. She knew she was over medicated. Z3 stated it was very unusual that R1 would be using a wheel chair or requiring assist for toileting. She's independent. Hospital Emergency Department Notes of 1-16-11 states, R1 states she fell 10 days ago, had negative Xrays at that time, has bruising to right leg. States that today both legs are painful and feel heavy... she says she still feels like legs are heavy, so she is unsteady with walking but no other falls. She does say that she has a lot of pain at dorsum of left foot, right ankle and right lateral/lower knee. Today she also noted diffuse aching, nonproductive cough and chills. Physical Exam: Normal ROM, bil ankles mild swelling. TTP ([MEDICAL CONDITIONS] Purpura) left foot over base of 5th metatarsal from bil ankles, but TTP mildly over bil Malleoli, both ankles. TTP right fibular head from bil hips/knees. Radiology results: infiltrate, probably represents pneumonia. Left foot healing fracture distal 5th metatarsal with some callous. Rt knee, area of osteochondritis dessicans at lat femoral condyle, no acute fracture and positive [MEDICAL CONDITION] narrowing. Rt ankle, nondisplaced fibular fracture, no callus, could be in past week. Left ankle, no fracture. Impression and Plan: Pneumonia, fever, rt ankle nondisplaced distal fibular fracture and left foot fracture, distal 5th metatarsal. On 2-4-11 at 9:20AM, Z3, Z1's Nurse, stated Z1 had not been informed R1's [MEDICATION NAME] was increased. Z3 stated he would have wanted to know due to her taking other medications. Z1 was informed of R1 falling and ordered a portable Xray. The results were negative. Z1 got another call on Sunday 1-16-11 stating R1 had been having problems for over the past week with walking and complaints of legs hurting. Z1 was concerned and he sent her to the hospital for evaluation. The ER Physician did call Z1 and discussed findings and medication changes. R1 had fractures and Pneumonia and her [MEDICAL CONDITION] medication needed to be increased. Z3 stated Z1 was concerned it took the facility so long to let him know R1 was having problems walking and having pain. Z3 stated it was very unusual that R1 would be using a wheel chair. She's independent with walking and care.

Based on record review and interview, the facility failed to notify the Physician for 1 (R1) of 3 residents reviewed for a change of condition, out of 3 sampled residents. This failure resulted in a boil on her left upper thigh increasing in size with signs of infection. R1 was admitted to the hospital with [REDACTED]. Findings include: R1's Nurses Notes of 3-15-11 at 9:15AM states a red swollen boil was noted to her left upper inner thigh. Z2, Nurse Practitioner, was notified and new order for Keflex 500 mg twice a day for 7 days was ordered, according to the Physician order [REDACTED]. Note at 1320 shows temperature was 102.1 and Z2 notified of increased temperature. Order received to give Narco 1 tab now. (POS shows an order of 3-15-11 for Narco 5/35 mg now.) Nurses Notes from 3-15-11 through 3-18-11 identify R1 as having a red raised area on left upper inner thigh, but there is no assessment as to the size of the area as to increase or decrease in size. Nurses Note show R1 complained of pain and had an elevated temperature and received pain medication and Tylenol for temperature. Nurse Note of 3-16-11 states temperature is 99.4. Area to left inner thigh with redness and warmth, drainage from boil noted. Continue antibiotic without adverse reaction noted. Tylenol for increased temperature and discomfort. Complains of pain from area. Nurses Note on 3-17-11 states R1's temperature is 98. Area draining yellow white fluid. Note at 0500 states R1 complained of diarrhea x 3. Note at 0930 states Temp 97.4. Continue antibiotic. Z2 notified of R1 complaining of loose stool last night... complained of pain to boil area, received [MEDICATION NAME] as ordered. Note at 9PM states temperature is 97.2 Area to left inner thigh remains red and warm to touch. (There is still no assessment as to the size of the boil and red area that is warm to touch.) Nurses Note on 3-18-11 at 0045 states temperature 98. Area remains red and warm to touch. No complaint of pain. Note at 1500 states R1 was sent to the hospital per Z2's orders. (POS shows Z2 was was at the facility and wrote a note to send to hospital emergency room related to abscess/[MEDICAL CONDITION].)Note at 2000 states R1 was going to be admitted to the hospital for a [DIAGNOSES REDACTED]. R1's Hospital History & Physical of 3-18-11 states R1 had a "12 x 10 cm size swelling on the medial side of the upper thigh, which is tender and indurated, not fluctuating, and has small yellow pustule noted on the top. There is marked [DIAGNOSES REDACTED] in the surrounding skin, tender to touch...Alert and oriented to time, place, and person...ASSESSMENT AND PLAN: 1. Left upper thigh swelling secondary to abscess formation. She will need I&D (Incision & Drainage). We will start her on broad-spectrum antibiotics for associated [MEDICAL CONDITION] plus abscess, [MEDICATION NAME] and [MEDICATION NAME]. We will give her Tylenol for fever and [MEDICATION NAME] for pain..." On 3-22-11 at 10AM, Z2 stated she was called by the facility and told R1 had a boil. They stated it was the size a nickle. Z2 stated she started Keflex. Z2 was called and told R1 was running a fever but the boil was better and improving. Z2 stated she wanted to wait to see if fever resolved as she did not know the cause of the fever, especially if the boil was improved. Z2 stated she had planned to be at the facility on 3-17-11 but did not make it there. She went to the facility on [DATE] and looked at R1's leg. R1 had a hard core the size of a base ball with redness the size of a football surrounding the hard core. Z2 stated it was hot and she knew R1 had [MEDICAL CONDITION] and she ordered for R1 to be taken to the hospital. Z2 stated she would have definitely seen R1 earlier if she had been informed of the condition of the boil. Z2 stated she had been told it was the size of a nickle and was not informed of the increase in size. Z2 stated they had told her the boil had improved. Z2 stated she was surprised when she saw R1's inner left thigh. Z2 stated they failed to assess the increase in size and to inform her. Z2 stated she was surprised when she saw R1 and knew immediately she needed to go to the hospital for [MEDICAL CONDITION].

Based on record review and interview, the facility failed to assess, monitor and treat appropriately, a boil with increased size, , tenderness, drainage, redness and tender to touch for 1 (R1) of 3 resident's reviewed for changes in condition, of 3 sampled residents. R1 was admitted to the hospital with [REDACTED]. The abscess required surgical incision and drainage. . Findings include: R1's Nurses Notes of 3-15-11 at 9:15AM states a red swollen boil was noted to her left upper inner thigh. Z2, Nurse Practitioner, was notified with new orders. (Physician order [REDACTED]. Note at 1200 shows temp 100.5 and Tylenol 1000mg was given as a PRN (as needed) order. Note at 1320 shows temperature was 102.1 and Z2 notified of increased temperature. Order received to give Narco 1 tab now. (POS shows an order of 3-15-11 for Narco 5/35 mg now.) Note at 9PM states temperature was 100.6. Tylenol given per increased temp., Antibiotics continues with no adverse reaction. Complained of area on left upper thigh discomfort. PRN med given along with routine [MEDICATION NAME] continue to monitor. Nurses Note of 3-16-11 at 2300 states temperature is 100.2 and Tylenol given. R1 on keflex with [DIAGNOSES REDACTED]. "Area red and raised. Painful to touch." (There is no documentation as to the size of the red and raised area.) Note of 3-16-11 at 10AM states temperature is 99.4. No drainage noted. Area red and raised. Painful to touch. Encourage warm moist compress to area. Tylenol PRN given for temperature and pain. Note at 9PM states temperature is 99.4. Area to left inner thigh with redness and warmth, drainage from boil noted. Continue antibiotic without adverse reaction noted. Tylenol for increased temperature and discomfort. Complains of pain from area. Nurses Note on 3-17-11 states R1's temperature is 98. Area draining yellow white fluid. Note at 0500 states R1 complained of diarrhea x 3. Note at 0930 states Temp 97.4. Continue antibiotic. Z2 notified of R1 complaining of loose stool last night... complained of pain to boil area, received [MEDICATION NAME] as ordered. Note at 9PM states temperature is 97.2 Area to left inner thigh remains red and warm to touch. (There is still no assessment as to the size of the boil and red area that is warm to touch.) Nurses Note on 3-18-11 at 0045 states temperature 98. Area remains red and warm to touch. No complaint of pain. Note at 1500 states R1 was sent to the hospital per Z2's orders. (POS shows Z2 was was at the facility and wrote a note to send to hospital emergency room related to abscess/[MEDICAL CONDITION].)Note at 2000 states R1 was going to be admitted to the hospital for a [DIAGNOSES REDACTED]. Nurses Notes from 3-15-11 through 3-18-11 show there is no documentation as to the size of R1's boil on her left inner thigh and surrounding red tissue. There is no documentation that R1's Physician was informed of increase in size of the boil or red surrounding tissue. R1's Hospital History & Physical of 3-18-11 states R1 had a "12 x 10 cm size swelling on the medial side of the upper thigh, which is tender and indurated, not fluctuating, and has small yellow pustule noted on the top. There is marked [DIAGNOSES REDACTED] in the surrounding skin, tender to touch...Alert and oriented to time, place, and person...ASSESSMENT AND PLAN: 1. Left upper thigh swelling secondary to abscess formation. She will need I&D (Incision & Drainage). We will start her on broad-spectrum antibiotics for associated [MEDICAL CONDITION] plus abscess, [MEDICATION NAME] and [MEDICATION NAME]. We will give her Tylenol for fever and [MEDICATION NAME] for pain..." R1's Hospital Discharge Summary states reason for admission was upper left medial thigh abscess and [MEDICAL CONDITION]. R1 had I&D of left thigh abscess on 3-19-2011 by general surgery. R1 presented with a left upper medial thigh [MEDICAL CONDITION], swelling and redness along with fever, chills. Discharge Summary also showed R1 had [MEDICAL CONDITION] Resistant Staff Aureus (MRSA) of the wound. On 3-22-11 at 10AM, Z2 stated she was call by the facility and told R1 had a boil. They stated it was the size a nickle. Z2 stated she started Keflex. Z2 was called and told R1 was running a fever but the boil was better and improving. Z2 stated she wanted to wait to see if fever resolved as she did not know the cause of the fever, especially if the boil was improved. Z2 stated she had planned to be at the facility on 3-17-11 but did not make it there. She went to the facility on [DATE] and looked at R1's leg. R1 had a hard core the size of a base ball with redness the size of a football surrounding the hard core. Z2 stated it was hot and she knew R1 had [MEDICAL CONDITION] and she ordered for R1 to be taken to the hospital. Z2 stated she would have definitely seen R1 earlier if she had been informed of the condition of the boil. Z2 stated she had been told it was the size of a nickle and was not informed of the increase in size. Z2 stated they had told her the boil had improved. Z2 stated she was surprised when she saw R1's inner left thigh. Z2 stated they failed to assess the increase in size and to inform her. Z2 stated she was surprised when she saw R1 and knew immediately she needed to go to the hospital for [MEDICAL CONDITION]. E3, Registered Nurse, stated on 3-22-11 at 2:30PM, she first saw the boil on R1's left inner thigh and it was red raised and the size of a dime with 1 inch [DIAGNOSES REDACTED] around the boil. E3 stated she called Z2 and she started Keflex. E3 stated she looked at it every day she worked. E3 stated by March 17th it looked better not as raised. Was still about the size of a dime and the [DIAGNOSES REDACTED] around the boil was less. This conflicts with facility Non-Pressure Ulcers/Wounds Report. The report shows a red area was noted on R1's left inner thigh on 3-15-2011 measuring 2.5 cm. The next documentation is on 3-17-2011 showing the area measured 8 inches by 4 inches red with a 3 inch x 3 inch center. There is no documentation of drainage or what was the color of the 3 x 3 inch center. There is no documentation that R1's Physician was notified of the increase in size. R1's TREATMENT RECORD for March 2011 show there is no documentation on the Treatment Record addressing R1's abscess and no assessment of the abscess.

Based on observation, record review and interview, the facility failed to ensure 1 (R1) resident of 3 sampled residents, who were receiving antipsychotic medications, did not receive dosage increases without documented justification and dosage increases were according to manufacturer's recommendations and increased gradually. The facility failed to monitor for signs and symptoms of adverse side effects after R1's [MEDICATION NAME] dosage was doubled from 300mg to 600 mg at night. This failure resulted in R1 falling and fracturing her right ankle with a nondisplaced distal fibular fracture and left foot fracture with a distal 5th metatarsal fracture. Findings include: R1's Admission Information form shows R1 is a [AGE] year old female with a current admission to the facility on [DATE]. R1's admitting [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) of 12-27-10 shows she was independent with transfer, bed mobility, ambulation, dressing, toilet use, hygiene and bathing. MDS identified no behaviors. R1's Care Plan of 9-26-10 states R1 has potential for falls related to use of [MEDICAL CONDITION] medications. Care Plan approaches/interventions: Administer meds as ordered. Monitor for side effects, aims test every 6 months. Report any gait changes to Physician. Ensure hallway and room is free of clutter. Educate her to notify nursing of any dizziness or unsteadiness. Care Plan states R1 has potential for adverse reactions related to use of routine [MEDICAL CONDITION] meds. Approaches include, in part, Observe for [MEDICATION NAME] effects=sedation, [MEDICAL CONDITION], dizziness and risk for falling. Assess response to meds and notify MD as needed R1's Physician order [REDACTED]. December 2010 and January 2011, POS, shows R1 received the following medications, in part: [MEDICATION NAME] 200 mg at HS (bedtime) for [MEDICAL CONDITION], [MEDICATION NAME] 2 mg QID for Anxiety, [MEDICATION NAME] 100 mcg daily for [MEDICAL CONDITION] and [MEDICATION NAME] 12.5 mg QID, PRN (as needed) for dizziness all ordered on 9-13-10; 300 mg of [MEDICATION NAME] XR at HS for [MEDICAL CONDITION] ordered on 11-9-10; 40 mg [MEDICATION NAME] BID (twice daily) ordered on 11-15-10 and [MEDICATION NAME] HCL 75 mg ordered on 12-2-10. January POS shows R1's [MEDICATION NAME] was increased from 300 mg at HS to 600mg at 6PM on 1-5-11. R1's MAR (Medication Administration Record) shows [MEDICATION NAME] was change to 600 mg at 6PM, but there was no documentation that the 600 mg of [MEDICATION NAME] was given on 1-5-11 and 1-6-11 at 6PM. R1's Behavior Management Program for December 2010 and January 2011 show R1 has a [DIAGNOSES REDACTED]. Disrupted sleep patterns may emerge. Lack of appetite or insatiable appetite. -- Anger." Medications: "Klonopin, [MEDICATION NAME]" (The POS shows R1 was not receiving any of these medications.) December 2010 Tracking Form shows 2 episodes of behaviors. One behavior shows she got upset when staff told her she could not pass trays to other residents and she started talking loudly about staff to the MD. The other incident states, "R1 love talking about things she heard & seen and i do mean everyone." January 2011 Behavior Tracking Form shows no behaviors. A note of 1-19-11 states R1 stated someone stole her money, I.D. card and her whole wallet. R1's Monthly Summary of 12-15-10 states R1 is alert, ambulatory, is not at fall risk, has a good appetite, has no behaviors and is in good spirit. Monthly Summary of 1-14-11 identifies R1 as being alert, ambulatory, independent in ADL's, good appetite, easily upsets and is cooperative. Summary note states Recent fall due to increase in meds. Meds reduced and no falls. Review of Nurses Notes show there are no Nurses Notes for R1 for December 2011. (This was confirmed by E2, Director of Nursing, on 2-9-11 who stated there was only a Monthly Summary for December.) Nurses Notes show a note written on 11-23-10 stating Z1, R1's Medical Doctor, office had called and received new order related to labs. The next Nurses Note was written on 1-5-11 at 11AM, stating Z2, Psychiatrist, had seen R1 and gave new orders, see POS. (POS shows Z2 increased R1's [MEDICATION NAME] from 300mg to 600 mg to be given at 6PM.) There are no Nurses Notes showing the facility was monitoring R1 for adverse side effects from the increase of [MEDICATION NAME] from 300 to 600mg. The next Nurses Note was written on 1-7-11 showing R1 had fallen, Note at 9AM,states R1 continues to complained of pain to BLE (Bilateral Lower Extremities). New Order received for X rays. Note at 3PM states Z2 made aware of fall . Lowered [MEDICATION NAME] XR to 300mg BID. Facility 72 hour charting form (used by Nurses after a resident has a fall) shows note of 1-7-11 at 0300, "R1 reported that on her way to BR (Bathroom), R1 became dizzy and fell . ROM (range of motion) WNL (within normal limits) 0 injury. R1 also stated she hit her head. 0 head trauma. Pearl A & O (alert and oriented) x 3. Hand grasps equal. R1 assested up and gotten back to bed. Z1 aware. R1 is own POA (Power of Attorney)." Note at 9PM shows R1 is alert and complains of legs hurting. X ray at 1600 awaiting results. Assist with ADL's (activities of daily living) at this time. Note of 2230 states R1 resting in room and complain of hip pain and took [MEDICATION NAME]. Assisted to bathroom by aides. 72 hour charting notes of 1-8-11 at 0130 state staff assist with taking R1 to the bathroom. Note at 0930 state R1 in bed and complaining of ache all over and weakness. Faxed X ray reports which were negative to Z1's office. ROM WNL. Note at 1900 states R1 is in a wheel chair and complains of unable to walk... Alert and oriented x 3. 72 hour charting notes of 1-9-11 at 0200 state R1 standing for short periods of time. Using wheel chair for mobility. ROM WNL. Note at 0900 states R1 up walking short distances. Received [MEDICATION NAME] PRN for pain to legs/feet. Uses wheel chair at times for mobility due to weakness to legs. Note at 2000 state R1 up ambulating slowly complains of pain. Stated she did not use wheel chair today. Refused [MEDICATION NAME]. ROM improving. Nurses Notes of 1-10-11 at 1130 state Z2 notified R1 request med changes due to [MEDICATION NAME] not helping and [MEDICATION NAME] making her tired. Received N.O (new order) See POS. (POS shows [MEDICATION NAME] XR was changed to give 150 mg in AM and 300 mg at HS. [MEDICATION NAME] 40 mg BID was discontinued. [MEDICATION NAME] 40 mg daily was ordered.) Nurses Note of 1-11-11 states R1 complained of a little weakness to both lower legs. Note of 1-13-11 states c/o (complained of) some weakness from fall. Note of 1-14-11 at 9pm state up with steady gait. Worried she won't walk right again. Reassured resident. Note of 1-16-11 at 0700 states R1 has a temperature of 100.5 and BLE [MEDICAL CONDITION] and wheezing both lungs. Notified MD and order received to send to the hospital. Note at 2 PM states returned from ER (emergency room ) with new orders. ABT (antibiotic) for pneumonia, splints for fracture of right ankle, shoe for hairline fracture of left foot, increase [MEDICATION NAME] for [MEDICAL CONDITION]. On 2-1-11, R1 was observed to be propelling herself in a wheel chair and was wearing a walker boot and special shoe on her feet. On 2-1-11 at 9:12AM, R1 stated she had told Z2 that she did not think [MEDICATION NAME] was working. Z2 told her he would increase her [MEDICATION NAME] a little. She stated she had seen Z2 for less than 2 minutes. R1 stated the night she fell , she had gotten up to go to the bathroom and was dizzy. She fell flat on her face twice. She stated she couldn't get up and was lifted up to bed by staff. She stated she slept most of the day and complained of her feet and legs hurting. Portable X rays were ordered and there were no findings of fractures. R1 stated she walked on her feet and was hurting for 9 days before they called Z1. Z1 was called per her request and she was sent to the ER. They found her left foot was fractured and her right ankle was fractured. R1 stated she had Pneumonia and her [MEDICAL CONDITION] levels were also found to be low. On 2-4-11 at 9:20AM, Z3, Z1's Nurse, stated Z1 had not been informed R1's [MEDICATION NAME] was increased. Z3 stated he would have wanted to know due to her taking other medications. Z1 was informed of R1 falling and ordered a portable Xray. The results were negative. Z1 got another call on Sunday 1-16-11 stating R1 had been having problems for over the past week with walking and complaints of legs hurting. Z1 was concerned. He sent her to the hospital for more Xrays. The ER Physician did call Z1 and discussed findings and medication changes. R1 had fractures and Pneumonia and her [MEDICAL CONDITION] medication needed to be increased. Z3 stated R1 was very reliable. She knows what's going on. R1 said she fell and couldn't move. She knew she was over medicated. R1's a Nurse. Z3 stated it was very unusual that R1 would be using a wheel chair. She's independent. On 2-4-11 at 9:37AM, Z2 was asked why he would increase [MEDICATION NAME] from 300 to 600mg a day and not increase gradually. Z2 stated a 300 mg a day increase would be a large increase and it has been done for some patients, but not R1. Z2 stated he increased the [MEDICATION NAME] 100mg a day. She had been receiving [MEDICATION NAME] twice a day, 200mg in the AM and 300mg at HS, which he adjusted to 600 mg in the evening. (POS and MAR (Medication Administration Record) shows R1 was not receiving 200mg of [MEDICATION NAME] in the AM.) Z2 stated R1 was anxious, Psychotic, not sleeping well. She had anxiety, agitation and unpredictable behaviors. When asked what her unpredictable behaviors were, Z2 stated he didn't know, but it should be documented in the Nurses Notes. Z2 stated that's were he gets his information on how residents are doing, from the Nurses Notes. " How else am I to know how the patient is doing." (There are no Nurses Notes from 11-23-10 to 1-5-11 when Z2 increased the [MEDICATION NAME] from 300mg to 600 mg.) Z2 was asked about the effect of [MEDICATION NAME] on [MEDICAL CONDITION] Disease and Z2 stated it was no concern, no problem. Z2 stated the [MEDICATION NAME] was not working so he change it. On 2-4-11 at 11:10, E3, PRSC (Psychiatric Rehabilitation Services Coordinator) stated he hadn't really noticed any changes in R1 for the past few months. R1 is the same as when she was at the facility during a previous admission. She get's distressed about environmental issues, such as, if residents stack soda cans differently than she want's them to for the Kountry Store. R1 is in charge of the Kountry Store. R1 had reported to E3 the past month of acute distress and crying. R1 was communicating at that time with her mother, they don't get along, and that could have been part of the problem. R1 hasn't talked to her mother in the last 4 weeks and its been better, pretty mild. E3 states he gives Z2 a verbal paraphrase of what's going on with residents for the last 90 days. Z2 does not get the behavior tracking forms/notes for residents to review. E3 stated there is not much time when Z2 comes to visit residents. Never enough time. They have 60 plus residents. E3 stated Z2 usually spends about 2 to 3 minutes with residents when he sees them. Z2 talked with R1 longer the day he increased her [MEDICATION NAME], maybe 16 to 17 minutes. It seemed longer this time. Not sure exactly how much time. E3 was asked if he talked to Z2 this morning and E3 stated yes, Z2 called the facility after he was contacted by the Surveyor. E3 was asked why Z2 called and E3 stated he wanted to make sure their notes for R1 were in order. E3 stated the previous day, Z2 came to the facility and R1 refused to see him. She wants another Psychiatrist. On 2-4-11, E2, Director of Nursing, stated Z1 had not been informed of R1's increase of [MEDICATION NAME] from 300 mg to 600mg. It is not the facility policy. Z1 was notified of R1's fall. E2 stated on the day R1 was sent to the ER, Z1 was called of concerns of continuing to complain of pain to her feet and ankles. Z1 was called at R1's request. E2 confirmed Z2 had called the facility this AM after talking to the Surveyor about R1. "Z2 wanted to know what was in her notes." Z2's Progress Note of 1-6-11 states, "R1 is still having mood lability, crying, which she is able to reconstitute fairly quickly. she is on [MEDICATION NAME] XR 300 mg in the evening: I will increase it to [MEDICATION NAME] XR 600 mg in the evening. She is on [MEDICATION NAME] 200 mg daily, [MEDICATION NAME] 80 mg daily, [MEDICATION NAME] 2 mg four times a day. Plan: There is not much room to increase the above medications. It is appropriate to increase the [MEDICATION NAME] to 600 mg daily for better mood regulation. The other medications will be continued as is. I will review her in three months." According to LEXI-COMP'S DRUG REFERENCE HANDBOOK Drug Information Handbook for Nursing of 2007, under Warning/Precaution, [MEDICATION NAME] may be sedating. [MEDICATION NAME] should be used with caution in patients with [MEDICAL CONDITION] disease. Prescriptions should be written for the smallest quantity consistent with good patient care. Dosage for adult [MEDICAL CONDITION]/[MEDICAL CONDITION]. Recommends further adjustments may be made, as needed, at intervals of at least 2 days in adjustments of 25 -50 mg twice a day. On 2-4-11 at 9:05AM, Z4 (Facility Consultant Pharmacist), stated the facility should have been monitoring for increase for falls, unusual behaviors, dizziness and confusion when R1's [MEDICATION NAME] was increased. Z4 stated 300 mg is a good increase.