Every finding on record at Benton Rehabilitation and Health Care Center

Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the Illinois Department of Public Health within the required time frame for 1 (R1) of 3 residents reviewed for reporting abuse allegations in a sample of 8.The findings include: R1's admission Record documents an admission date of 2/1/2024 and included diagnoses of emphysema, hypertension, anxiety, major depressive disorder and tobacco use among others.R1's Minimum Data Set (MDS) assessment dated [DATE] documented R1 has a Brief Interview for Mental Status (BIMS) score of 9, indicating R1 has moderate cognitive impairment. This MDS also documents R1 is independent with walking and needs staff supervision for most activities of daily living.On 6/4/2026 at 8:30am, V6 (Former Social Service Director) stated when she came to work on Monday, June 1st, R1 told her about an incident that happened over the weekend between R1 and V4 (Certified Nursing Assistant/CNA). V6 stated R1 reported to her that on Saturday (5/30/2026) at 10:00am smoke break, V4 grabbed R1's right wrist, squeezed it and forcibly removed a cigarette from R1's hand. V6 said R1 had gotten a cigarette from R3 because he was done smoking and there was more of the cigarette left to smoke. V6 said R1 told her when she got the cigarette from R3, that is when V4 grabbed R1's wrist and took the cigarette away from her. V6 said she noticed V4 was at work on Monday (6/1/26) and had not been suspended pending an investigation outcome. V6 said she spoke with V1 (Administrator) about the incident and V1 told V6 the incident was not abuse, but instead was a grievance about customer service and thus did not need to be investigated or reported as abuse. V6 brought this surveyor a written statement dated 5/30/2026 (written by V3 - Licensed Practical Nurse/LPN) and stated If I don't give this statement to you directly it will disappear. It documented the following: 5/30/26, (V4/CNA) came to the desk and said (R1) took a cigarette out of another resident's hand to smoke so (V4) told me and (V5) that she (V4) grabbed (R1) by the arm and took the cigarette from (R1). (R1) told (V4) she was rough and twisted her arm back to grab the cigarette from her hand. Signed by V3.On 6/4/2026 at 8:45am, V1 (Administrator) said she did not suspend V4 when the allegation was reported to her because she did not know at the time if abuse had happened. V1 said since R1 said she didn't feel abused, V1 intended to investigate the incident as a customer service complaint and not as an abuse investigation. V1 said she did not report the allegation to IDPH because she felt it was not an abuse allegation.On 6/4/2026 at 10:10am, V3 (Licensed Practical Nurse/LPN) said she was working the day shift on 5/30/2026 with V5 (Registered Nurse/RN). V3 said around 10:00am, V4 (CNA) took the residents who smoke outside for their scheduled smoke break. V3 said afterwards, V4 came to the nurse's station and self-reported an incident between her and R1. V3 said V4 reported grabbing R1 by the wrist and forcibly removing a cigarette from her hand. V3 said R1 was very upset and acted like V4 hurt R1's arm due to twisting it backwards when removing the cigarette from R1's hand. V3 said V5 called V1 (Administrator) and reported the incident.On 6/5/2026 at 8:15am, V5 (RN) said she worked on the day shift on Saturday 5/30/2026 and was the nurse providing care for R1. V5 said V4 (CNA) came to the desk after taking the residents out for their 10:00am scheduled smoke break and self-reported to V3 and V5 an allegation of physical abuse between herself (V4) and R1. V5 said V4 reported R1 claimed V4 mangled her wrist when she forcibly removed a cigarette from R1's right hand. V5 said she immediately reported the allegation to V1 (Administrator). V5 said V1 instructed her to interview R1 to see if R1 felt abused and when R1 denied feeling abused, V1 would speak to V4 on Monday about the situation, and nothing further was instructed by V1 at that time. V5 said she assessed R1's right wrist and saw no evidence of bruising or injury and R1 had normal range of motion to her right hand, wrist and arm. V5 said she didn't think V4 meant to hurt R1, but she should not have put her hands on R1 like that.On 6/5/2026 at 10:00am, V2 (Director of Nursing/DON) said per the facility's abuse policy, allegations of abuse are supposed to be reported to the Illinois Department of Public Health within two hours of receiving the allegation. The facility's Abuse, Prevention and Prohibition Policy (dated November 2025) under the section titled Reporting/Response documented the following in part: the facility administrator, employee, or agent who is made aware of allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. All alleged violations involving abuse.will be reported immediately to the administrator. The person made aware of the allegations of abuse/neglect or the administrator will report the allegation of abuse and neglect to the mandated state agency. The allegation will be reported no later than 2 hours, or per stat regulation, after the allegation is made.

The facility failed to timely initiate and thoroughly investigate an allegation of staff to resident abuse for 1 (R1) of 3 residents reviewed for abuse in a sample of 8. Findings included:On 6/4/2026 at 8:30am, V6 (Former Social Service Director) stated when she came to work on Monday, June 1st, R1 told her about an incident that happened over the weekend between R1 and V4 (Certified Nursing Assistant/CNA). V6 stated R1 reported to her that on Saturday (5/30/2026) at 10:00am smoke break, V4 grabbed R1's right wrist, squeezed it and forcibly removed a cigarette from R1's hand. V6 said R1 had gotten a cigarette from R3 because he was done smoking and there was more of the cigarette left to smoke. V6 said R1 told her when she got the cigarette from R3, that is when V4 grabbed R1's wrist and took the cigarette away from her. V6 said she noticed V4 was at work on Monday (6/1/26) and had not been suspended pending an investigation outcome. V6 said she spoke with V1 (Administrator) about the incident and V1 told V6 the incident was not abuse, but instead was a grievance about customer service and thus did not need to be investigated or reported as abuse. V6 brought this surveyor a written statement dated 5/30/2026 (written by V3 - Licensed Practical Nurse/LPN) and stated If I don't give this statement to you directly it will disappear. It documented the following: 5/30/26, (V4/CNA) came to the desk and said (R1) took a cigarette out of another resident's hand to smoke so (V4) told me and (V5) that she (V4) grabbed (R1) by the arm and took the cigarette from (R1). (R1) told (V4) she was rough and twisted her arm back to grab the cigarette from her hand. Signed by V3.On 6/4/2026 at 8:45am, V1 (Administrator) said on 5/30/2026, she received a phone call from V5 (Registered Nurse/RN) concerning an allegation of V4 (Certified Nursing Assistant/CNA) grabbing R1 by the right wrist and removing a cigarette from R1's hand when R1 would not give the cigarette to V4 when asked. V1 said she did not suspend V4 when the allegation was reported to her because she did not know at the time if abuse had happened. V1 said she did not come to the facility to investigate the allegation and decided to deal with V4 on Monday (6/1/26). V1 said since R1 said she didn't feel abused, V1 intended to investigate the incident as a customer service complaint and not as an abuse investigation. V1 said she did not report the allegation to IDPH (Illinois Department of Public Health) because she felt it was not an abuse allegation. V1 said she performed an informal investigation into the incident between R1 and V4 but did not document the investigation and cannot reproduce any evidence of performing the investigation except for a statement from R1 written on notebook paper. R1's statement documented the following: May 30th 2026, (R1) stated she is not afraid of CNA (Certified Nursing Assistant) (V4). (R1) also stated she does feel very safe around the CNA and knows that CNA did not mean to upset her or startle (R1). (R1) did say she had only wished the CNA had explained why she could not have the cigarette instead of grabbing it. At 9:30am, V1 said she began to investigate the abuse allegation self-reported by V4 on 5/30/2026.On 6/4/2026 at 9:30am, V1 (Administrator) said on Saturday 5/30/2026, V4 called her and self-reported an incident between her and R1. V1 said V4 reported R1 was stealing cigarettes again. V1 was asked if V4 reported grabbing R1 by the wrist and forcibly removing a cigarette from R1's hand and V1 answered V4 only reported grabbing R1 by the jacket sleeve and did not make contact with R1's skin. V1 again stated she did not suspend V4 pending an investigation outcome, but instead made the nurse keep V4 up at the nurse's station while V5 (Registered Nurse/RN) interviewed R1 about the incident. V1 said R1 told V5 that she was not afraid of V4, did not feel V4 abused her, but wished she would have asked her nicer and felt comfortable at this facility. V1 said R1's answers determined if V1 would investigate this incident as abuse and since R1 wasn't afraid of V4 and didn't feel abused, V1 did not investigate the incident as abuse. On 6/4/2026 at 10:10am, V3 (Licensed Practical Nurse/LPN) said she was working the dayshift on 5/30/2026 with V5 (RN). V3 said around 10:00am, V4 took the residents who smoked outside for their scheduled smoke break. V3 said afterwards, V4 came to the nurse's station and self-reported an incident between her and R1. V3 said V4 reported grabbing R1 by the wrist and forcibly removing a cigarette from her hand. V3 said R1 was very upset and acted like V4 hurt R1's arm due to twisting it backwards when removing the cigarette from R1's hand. V3 said V5 called V1 (Administrator) and reported the incident.On 6/5/2026 at 8:15am, V5 (RN) said she worked day shift on Saturday 5/30/2026 and was the nurse providing care for R1. V5 said V4 (CNA) came to the desk after taking the residents out for their 10:00am scheduled smoke break and self-reported to V3 (LPN) and V5 an allegation of physical abuse between herself and R1. V5 said V4 reported that R1 claimed V4 mangled her wrist when she forcibly removed a cigarette from R1's right hand. V5 said she immediately reported the allegation to V1 (Administrator).On 6/5/2026 at 10:00am, V2 (Director of Nursing/DON) said per the facility's abuse policy, allegations of abuse are supposed to be reported to the Illinois Department of Public Health within two hours of receiving the allegation. V2 said all allegations of abuse are supposed to be immediately investigated. V2 said on Monday 6/1/26, she performed her own investigation but did not document the investigation. V2 said she did type up a summarized statement. The statement documented the following: 6/1/26, On 5/29/26 [sic] it was reported by V4 that while taking the residents to their smoke break that resident (R1) had grabbed the cigarette out of the mouth of (R3) and was attempting to put in her own mouth. CNA reported that she then removed the cigarette from (R1's) hand. (R3) recently treated for respiratory illness and CNA reports she was concerned with cross contamination. Once back inside the CNA reported the incident to the nurse on duty (V5). Nurse then contacted the administrator for directions. Nurse was instructed to interview resident (R1) which she did. (R1) stated that she just wished (V4) would have asked for the cigarette instead of taking it. Nurse was asked if she felt that the situation was abuse and nurse stated that she doesn't feel like the CNA did it with any ill intention but that it could have been handled in a better way with communication. (V4) educated on effective communication and residents' rights. Understanding voiced. Signed by V2 (DON) and V4.The facility's Abuse, Prevention and Prohibition Policy dated November 2025, documented the following in part: Under the section titled Investigation, Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individuals' rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. Initiate investigation including initial reporting to all required agencies. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement.

Based on interview and record review the facility failed to ensure physician orders were obtained prior to performing pulmonary function tests (PFT) for 4 of 4 residents (R11, R13, R15, R16) reviewed for physician orders in the sample of 17. Findings Include:1.R11's admission Record with a print date of 9/29/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, heart failure, and chronic obstructive pulmonary disease. R11's MDS (Minimum Data Set) dated 8/23/25 documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R11 is cognitively intact. R11's current Care Plan documents a Focus Area of Respiratory: DX (diagnosis) COPD, Respiratory failure .Date Initiated: 09/17/2024. This Focus area includes interventions of, Bipap as ordered Date Initiated: 02/18/2025 .Meds/Labs/Treatments as Ordered/Accepted Date Initiated: 09/17/2024. Encourage/assist with Oxygen as ordered/accepted/needed. Date Initiated: 09/17/2024 .On 9/29/25, V1 (Administrator) provided this surveyor R11's Pulmonary Function Test results dated 3/20/25. R11's undated Care Profile does not document a physician order to perform PFT testing on or near 3/20/25. On 9/29/25 at 2:23 PM, R11 stated he doesn't remember if he had a pulmonary function test done.2. R13's admission Record with a print date of 9/29/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include diabetes, peripheral vascular disease, heart failure, hypertension, and anemia. R13's MDS dated [DATE] documents a BIMS score of 15, indicating R13 is cognitively intact. R13's current Care Plan does not address a Focus area related to respiratory diagnoses. On 9/29/25, V1 (Administrator) provided this surveyor R13's Pulmonary Function Test results dated 3/20/25. R13's undated Care Profile does not document a physician order to perform pulmonary function test on or near 3/20/25. On 9/29/25 at 2:27 PM, R13 stated she had PFT test done a few months ago and didn't have any concerns with it. 3. R15's admission Record with a print date of 9/29/25 documents R15 was admitted to the facility on [DATE] with diagnoses that include diabetes, dementia, hypertension, and delusional disorder. R15's MDS dated [DATE] documents a BIMS score of 09, indicating a moderate cognitive deficit. R15's current Care Plan documents a Focus area of, Respiratory: Dx-COPD Sleep apnea Date Initiated: 03/26/2025. The interventions for this Focus area include, Meds/Labs/Treatments as ordered/Accepted. Date Initiated: 03/26/2025.On 9/29/25, V1 (Administrator) provided this surveyor R15's Pulmonary Function Test results dated 3/20/25. R15's undated Care Profile does not document a physician order to perform pulmonary function tests on or around 3/20/25. On 9/29/25 at 2:34 PM, R15 denied concerns with the PFT testing that was performed. 4. R16's admission Record with a print date of 9/29/25 documents R16 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart failure, hypertension, and COPD. R16's MDS dated [DATE] documents a BIMS score of 11, indicating a moderate cognitive deficit. R16's current Care Plan documents a Focus area of, Respiratory: Dx-Respiratory failure with hypoxia COPD. Date Initiated: 02/11/2025. This Focus area includes the intervention of, Meds/Labs/Treatments as Ordered/Accepted, Date Initiated: 02/11/2025.On 9/29/25, V1 (Administrator) provided this surveyor R16's Pulmonary Function Test results dated 3/20/25. R16's undated Care Profile does not document a physician order for PFT testing to be performed on or around 3/20/25. On 9/29/25 at 2:39 PM, R16 stated she doesn't remember if she had PFT tests done. On 9/29/25 at 10:43 AM, V6 (MDS Coordinator) stated Pulmonary Function Tests (PFT's) have been done on residents without physician orders in the past. V6 stated the respiratory therapist showed up this week to do more and they didn't have the orders, so they didn't do them. On 9/29/25 at 11:26 AM, V12 (Registered Nurse) stated they have an outside company who sends a respiratory therapist to the facility to perform PFT testing on the residents. V12 stated they had done testing twice as far as she knew, and they were testing everyone in the facility. When asked why they were doing the test on all of the residents, V12 stated she didn't know. V12 stated they didn't have a physician order for them and when they came in the last time, V21 (Physician) wouldn't sign the orders to do them. On 9/29/25 at 2:50 PM, V20 (Licensed Practical Nurse) stated she didn't think V21 (Physician) felt the PFT tests were necessary and didn't want all of the residents to have them. V20 stated V1 asked the nurses to get V21 to sign the orders and he refused.On 9/29/25 at 12:29 PM, V1 (Administrator) stated the oxygen supply company sends the respiratory therapist to the facility to do the PFT's. V1 stated V21 (Respiratory Therapist) came to the facility last week and wouldn't do the tests because the physician had not given the orders. V1 stated they are doing the tests to see if residents have chronic obstructive pulmonary disease (COPD) to make sure they are treating everything they need to. V1 stated according to her regional with corporate it is the gold standard of care and anyone who doesn't have a diagnosis of COPD should be screened upon admission. On 9/29/25 at 4:04 PM, V22 (Registered Respiratory Therapist) stated she went to the facility in 3/2025 and performed PFT tests on residents. When asked if there were physician orders in place prior to performing those tests, V22 stated the facility told her there were but she didn't see the actual orders. On 9/29/25 at 4:18 PM, V5 (Director of Nurses) stated there should be physician orders in place prior to performing PFT tests on residents and she wasn't sure why there weren't orders documented in the medical records for the tests performed on 3/20/25. On 9/30/25 at 11:21 AM, V1 (Administrator) stated the facility was owned/operated by a different company in 3/2025 and there was no policy available for physician orders for that time frame.On 9/30/25 at 3:00 PM, V21 (Physician) stated he didn't remember if he gave orders for the PFT to be administered in 3/2025.

Based on interview, observation and record review the facility failed to provide the correct portion size of meat for altered textured diets for 9 (R1, R7, R12, R15, R16, R17, R25, R27, and R35) of 12 residents reviewed for altered textured diets in a sample of 32. Findings include: On 04/21/25 at 12:00 PM during lunch time V10 (Cook) served a #16 scoop (2 ounces) of pureed turkey and a #16 scoop (2 ounces) of mechanical soft turkey onto the trays for multiple residents that included R1, R7, R12, R15, R16, R17, R25, R27, and R35. The facility spreadsheet dated week 3 Monday documents the lunch meal should include: mechanical soft: 3 oz (ounces) and (ground) seasoned turkey pot roast, #8 scp (scoop) mashed potatoes, 2 oz L (liquid) gravy, 4 oz s (solid) green beans, 1 sq (square) cornbread, and 1 sq (square) frosted cake. The pureed diet documents: 1 pur (pureed) seasoned turkey pot roast, #8 scp mashed potatoes, 2 oz L gravy, #12 scp pur green beans, #16 scp pur cornbread, #12 scp pur frosted cake. The facility recipe for pureed seasoned turkey pot roast dated 2025-2025 Week 3 Monday- noon meal, documents: portion: #8 scp (3.75 ounces/1/2 cup). The untitled facility document dated 04/21/25 signed by V9 (Dietary Manager) documents: R1, R27, and R35 receive a puree texture diet and R7, R12, R15, R16, R17, and R25 receive a mechanical soft texture diet. On 04/24/25 at 10:33 AM, V9 stated on 04/21/25 the spreadsheet indicated 3 oz of turkey should have been served to the mechanical soft textured diet and the pureed diet should have received the #8 scoop which is 3.75 ounces or a half a cup. Serving 2 ounces of meat was incorrect and she does not know why she (V10) served that amount.

Based on observation, interview, and record review the facility failed to assist residents during meals to promote dignity for 2 of 12 residents (R1, R15) reviewed for dining in a sample of 32. Findings include: 1. R15's Admission Record documents an admitted [DATE]. R15's Admission Record documents diagnosis in part hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, dementia, and weakness. R15's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) was unable to be completed due to resident is rarely or never understood and has short and long-term memory problems. Section GG of that same MDS under self-care documents R15 is partial or moderate assistance with eating. R15's most recent Care Plan documents an Activities of Daily Living (ADL) deficit and intervention for eating is supervision or assist. On 4/22/2025 at 12:16 PM, V11 (Regional Consultant MDS) was feeding R15 while standing beside him as R15 was sitting at the table in the dining room. On 4/23/2025 at 3:51 PM, V11 stated she will stand or sit while feeing residents and when she assisted R15 she stood because there wasn't another chair at the table. On 4/23/2025 at 12:05 PM, V8 (Certified Nurse Aide/CNA) was feeding R15 at the same time as she was assisting another resident at the same table in the dining room. 2. R1's Admission Record documents an admitted [DATE]. R2's Admission Record documents diagnosis in part convulsions, pervasive developmental disorders, dysphagia, profound intellectual disability, and lack of coordination. R1's MDS dated [DATE] documents a BIMS of 00 indicating severe cognitive impairment. Section GG of that same MDS under self-care documents R1 is dependent with eating. R1's most recent Care Plan documents an ADL deficit and intervention for eating is total dependence. On 4/23/2025 at 12:05 PM, V8 was feeding R1 while standing beside him as R1 was sitting at the table in the dining room. V8 was also feeding R15 at the same time, at the same table in the dining room but would sit down when feeding R15. On 4/24/2025 at 10:10 AM, V8 stated she normally sits while assisting residents with meals but on 4/23/2025 she was assisting two residents at the same time, and she had to stand while feeding R1. On 4/24/2025 at 1:15 PM, V2 (Director of Nursing) stated staff should be sitting down when assisting residents with eating. The facilities undated policy titled Skills Checklist Feeding Assistance, documents residents are to be fed one at a time with staff sitting next to them at the table.

Based on interview and record review the facility failed to notify the physician and the resident's responsible party of a change of condition for 1 of 2 residents (R35) reviewed for notification of changes in the sample of 32. Findings include: R35's Admission Record documents an admitted [DATE]. R35's Admission Record documents diagnosis including in part pressure ulcer of sacral region stage 4, unspecified severe protein-calorie malnutrition, type 2 diabetes, adult failure to thrive, dementia, cognitive communication deficit, and dysphagia. R35's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 7 which indicates severely impaired cognition. R35's most recent Care Plan documents actual/at risk and/or potential for complications with nutrition and hydration. R35's Admission Record documents V18 (Family) as R35's Power of Attorney (POA)-care substitute decision maker. R35's medical record, under weights/vitals tab documents R35 weighed 191.0 pounds on 3/4/2025, weighed via wheelchair and on 4/6/2025 R35 weighed 168.8 pounds, weighed via mechanical lift. This indicates a 22.2 pound, 11.62% weight loss in one month. There was no documentation in R35 electronic medical record that R35's physician or that R35's POA had been notified of R35's alleged 22.2 pound weight loss in a month. On 4/23/2025 at 02:20 PM, V18 stated she has not been notified of R35 experiencing weight loss. On 4/24/2025 at 12:15 PM, V9 (Physician) stated he has not been notified of any weight loss on R35. V9 stated he would expect to be notified by the facility of any significant or severe weight loss of a resident. On 4/24/2025 at 1:32 PM, V12 (Nurse Practitioner) stated he doesn't remember being notified of R35 having any weight loss. V12 stated if a resident is experiencing weight loss he would expect to be notified. 04/23/25 9:50 AM, V3 (Dietary Manager) stated she goes through the monthly weights either the day they weigh the residents or the next day. V3 stated she saw the significant weight loss for R35, and she requested a reweigh two times and the staff told her the same weight both times. On 4/24/2025 at 1:15 PM, V2 (Director of Nursing) stated the physician and responsible party should be notified of significant/severe weight loss. A facility Weight Assessment and Intervention Policy dated 12/2024 documents in part 1 month- 5% weight loss is significant; greater than 5% is severe. A Facility Significant Condition and Change and Notification Policy dated 12/2024 documents in part, Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: . A significant change in the resident's physical, mental or psychosocial status . 5% weight loss or gain in 30 days .

Based on interview, observation, and record review, the facility failed to ensure that a resident's dresser was in a state of good repair for 1 of 1 resident (R31) reviewed for environment in the sample of 32 . Findings include: R31's Admission Record dated 04/24/25 documents an admitted [DATE] with diagnoses in part of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and other paralytic syndrome following other cerebrovascular disease affecting non-dominant side. R31's MDS (Minimum Data Set) dated 03/28/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 12 which indicates moderately impaired. R31's current Care Plan documents a focus area Restorative/Functional Program bed mobility, dressing and grooming. On 04/21/25 at 9:38AM, R31 was lying in his bed in his room. His room was noted to have one dresser in the room. The dresser was noted to have the bottom drawer hanging out and not on track and the middle drawer of dresser appeared to not have a front part to the drawer. At that time R31 who was alert and oriented stated that his dresser in his room has been like that for a while. R31 said that he has been missing the middle drawer for a while and the bottom drawer keeps falling out. On 04/23/25 at 10:20AM, R31's bottom drawer to his dresser was on track and back inside the dresser. The middle drawer was still missing the front part of the dresser. On 04/23/25 at 10:40AM, R31 stated that he doesn't use his dresser often. R31 said that he does keep some stuff in the top drawer of his dresser. On 04/24/25 at 11:35AM reviewed Facility Maintenance tracking log for April, March, February and January document nothing regarding R31's dresser drawers. On 04/24/25 at 11:45AM, V7 (Maintenance Director) stated that he was not aware that R31's dresser was broken and that the drawer in the middle is missing the front. V7 stated that when staff notices that something is broken in a resident room that they should put it on a Maintenance repair form. V7 stated that he did not get anything on R31's dresser being broken or in need of repair. V7 stated that he was going to go down right away and look at R31's dresser. V7 stated he does not do routine room checks to check for things that needs repaired. V7 stated he doesn't have a lot of time and depends on the floor staff to let him know what needs repaired. The facility Policy titled Facility Maintenance and Prevention Service Policy undated documents under Policy, It is the policy of the facility that maintenance follow preventative maintenance procedures for routine service and ensure proper working condition of mechanical equipment within the facility, ensure building is maintained for safety of staff and residents, routine upkeep of facility rooms, hallways and shower rooms, and ensure life safety checks are completed as required. Maintenance supervisor should complete repairs and projects in a timely manner and give routine updates on repairs ongoing in the facility to ensure status of repairs are reported and completed.

Based on record review, observation and interview, the facility failed to ensure a resident's AIMS (Abnormal Involuntary Movement Scale) Assessment was accurately completed for 1 of 1 resident (R20) reviewed for accuracy of assessments in the sample of 32. Findings include: R20's Admission Record dated 04/24/25 documents an admitted [DATE] with diagnoses of dementia mild with mood disturbance, anxiety, paranoid schizophrenia, agoraphobia with panic disorder, delusional disorder, and sleep disorder. R20's MDS (Minimum Data Set) dated 03/31/25 documents in Section C a BIMS (Brief Interview for Mental Status) score 13 which indicates that R20 is cognitively intact. Section GG documents eating as set-up and clean up assistance and personal hygiene as partial/moderate assistance. R20's current Care Plan documents a focus area of the resident (R20) uses antipsychotic medications r/t (related to) schizophrenia This focus area has a goal of the resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions include 1. Administer psychotropic medication as order by physician monitor for side effects and effectiveness. 2. Consult with Pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate at least quarterly. 3. Monitor/document/report PRN (As need) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (Extrapyramidal Syndrome) (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. R20's AIMS assessment dated [DATE] documents under instructions, either before or after completing the examination procedure, observe the resident unobtrusively at rest (e.g., in the dining room). The chair to be used in this examination should be a hard, firm one without arms. Complete the examination procedure below, before scoring the resident movement. Ask patient whether there is anything in his/her mouth (ie, gum, candy, etc) and if there is, to remove it. Examination Procedure 2. Ask resident whether he/she notices any movement in mouth, face, hands, or feet. If yes, ask to describe and to what extent they currently bother resident or interfere with his/her activities. Under Extremity Movement #5 Upper (arms, wrists, hands, fingers) include movement that are Choreic (sic) (rapid, objectively purposeless, irregular, spontaneous) or athetoid (slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements) this documents none. R20's Physicians order summary documents on 03/13/25 Risperidone 2mg (milligrams) give 2mg by mouth two times a day. On 04/24/25 at 10:15AM, R20 stated that he has had abnormal movement to his right arm for a while now. R20 said that the movement is irregular and that it bothers him a lot when he is eating. R20 said that it makes it hard for him to eat because his arm is shaking and jerking when he is trying to feed himself. R20 is unsure why his right arm is doing this. On 4/24/25 at 10:15AM observed R20 lying in bed. R20's right hand and arm shaking while he was talking. R20 was trying to stop his right hand and arm from shaking by holding it with his left arm during the conversation. On 04/24/25 at 9:35AM, V5 (Registered Nurse/RN) stated that she did do the AIMS assessment for R20 on 03/13/25. V5 stated R20 does have involuntary movement to his right arm. V5 stated she was probably in a hurry and did not check the correct box on the AIMS assessment for involuntary movement of arms and hands. V5 said that she did put none, and she should have put minimal to moderate. On 04/24/25 at 10:40AM, V2 (Director of Nursing/DON) stated that R20 does have involuntary movement to his right arm. V2 stated that R20's AIMS assessment was completed incorrectly if it is marked none. V2 stated that R20 has involuntary movement to his right arm that is moderate. V2 said that she would expect the AIMS assessments completed accurately. On 04/24/25 at 11:41AM, V1 (Administrator) stated that the facility does not have a policy on AIMS assessments.

Based on observation, interview, and record review the facility failed to provide supervision to a resident experiencing seizures and implement effective interventions to prevent falls for 1 of 1 resident (R33) reviewed for falls in the sample of 32. Findings include: R33's face sheet records an admitted [DATE]. Related diagnosis recorded in electronic medical record (EMR) include but are not limited too chronic obstructive pulmonary disorder, other seizures, migraine, unspecified, not intractable, without status migrainosus, otitis media, unspecified left ear, other amnesia, personal history of transient ischemic attack, and cerebral infarction without residual effects. R33's current Physician's Orders document R33 has an order dated 3/3/25 for Keppra 750mg (milligram) tablet - take 1 tablet twice daily; Order for lacosamide 200mg table take 1 tablet twice daily for epilepsy was ordered 12/9/24. R33's Minimum data sheets (MDS) dated [DATE] records a brief interview for mental status (BIMS) score of 15 indicating R33 is alert, oriented, and able to answer questions appropriately. Section GG of MDS - Functional Abilities - records that R33 is supervision or touching assistance for walking 10 feet, walking 50 feet with two turns, and walking 150 feet. Section I of MDS - Active diagnosis - records a diagnosis of seizure disorder or epilepsy. Section N of MDS - Medications - records resident being prescribed an anticonvulsant. Care plan dated 3/21/25 states that R33 is at risk for potential complications with falls. Interventions listed for that problem is 2/14/2025 smoking policy to be gone over and explained with resident and for her to sign the policy that's in place; 1/21/2025 medication review to be completed; 11/19/2024 resident sent to the emergency room for evaluation, labs and CT (computed tomography) were done in ER (emergency room ), med review to be completed; 12/21/2024 encourage resident to sit down in dining room chair or lay down for fifteen minutes after smoking; resident to wear non-skid shoes; encourage resident to not wear crocs; nurse practitioner med review completed; 12/8/2024 Sent to ER, safety checks upon return from emergency room for forty-eight hours after return; diagnosis of ear infection with antibiotics in place; Obtain Keppra levels as ordered. 2/26/2025 re-educated staff that resident needs to sit down in dining room and/or lay down after smoking; 4/18/2025 obtain labs to check levels due to diagnosis of seizures; bed in lowest position while in bed, call light positioned for easy access while in room, check for unmet needs, encourage/assist with non-skid shoes/socks, ensure environment is free of clutter, fall review per facility protocol, have commonly used articles within easy reach. Care plan focus for ADLs (activities of daily living) record R33 as independent with ambulation, independent with toilet use, independent with transfers. On 04/21/25 at 02:22 PM, R33 stated I fell twice on Saturday. I had two seizures. I've had seizures for about 10 yrs. The doctors don't know the cause of the seizures. R33 said that if she falls that it's usually related to a seizure. On 04/23/25 at 01:20 PM, R33 stated that her seizures began about 2014. The cause was never discovered. R33 stated she was unsure of what her current anti-seizure medications are. R33 stated she was unable to give an estimate how often she had seizures. She stated she doesn't know that she's had a seizure until someone tells her. R33 stated she remembers nothing about the event prior to or immediately after the seizure. R33 said she is unable to correlate her seizures to any activity or time. R33 stated that there is no warning of seizures. She said that the only interventions that the facility has put into place that she is aware of is to walk slow, to use the handrails, and to sit down if she feels strange in relation to falls caused by seizures. R33's EMR (electronic medical record) documents that R33 has had 7 falls while living in the facility. R33's Fall investigation dated for 2/17/25 documents that R33 had fallen on 2/14/25 due to smoking 2 cigarettes instead of her normal one cigarette. R33 walked into facility from smoking and fell to the floor. Intervention put in place was to have staff to go over the smoking policy with R33 again and have her sign it. R33's Nurse's progress note dated 2/26/25 documents that CNA (Certified Nurse Aide) observed R33 fall backwards and was unconscious. R33's Fall investigation dated 2/28/25 documents that cause of fall was determined to be falling after returning from smoking. Intervention was to re-educate staff that R33 needs to sit down or lie down immediately after returning from smoking. R33's Nurse's note dated 4/18/2025 at 5:00 PM documents, CNA witnessed resident walk out of her room stop and look up at ceiling and fall backwards. Resident didn't know what happened. No injuries noted. No bump on head. Neuro checks started. Denies pain. Assisted up without difficulty and taken back to her room. R33's Fall investigation dated for 4/22/25 documents that on 4/18/25 R33 looked up and then fell backwards. Intervention was to contact practitioner to order labs and verify anti-seizure medication levels were in therapeutic range. Nurses note dated 4/22/25 documents the following: 4/22/2025 10:12 NURSE PROGRESS NOTE Note Text: Call to (V12) regarding current falls, seizure like activity with new order: TSH (thyroid stimulating hormone, Free T4 (free thyroxine), D12 (vitamin B12 level), Keppra, Valporic, CBC (complete blood count), CMP (comprehensive metabolic panel), and folate next lab date. On 04/23/25 at 1:17 PM, R33 was noted coming into the facility from being outside smoking. There was no staff assisting her or encouraging her to sit or lie down. On 04/23/25 at 1:35 PM, V14 (Certified Nurse's Aide /CNA) stated that she is aware that R33 has seizure disorder but has never witnessed one. V14 stated the interventions she's aware of for R33 is to Make sure she's safe, check vitals, and watch where she's at. When asked if there were any interventions she was aware of to help reduce risk of injury prior to falls in general or those falls related to seizures. She said she wasn't aware of any. On 04/23/25 at 1:42 PM, V15 (CNA) stated that she is aware of R33 has a seizure diagnosis but has never witnessed one. V15 stated she didn't know anything about them. V15 stated that the only interventions she is aware of is to keep her room free of clutter and to monitor her. She said that she isn't aware of any interventions in place to prevent injury prior to falls in general or falls related to seizures. On 04/23/25 at 1:47 PM, V8 (CNA) stated that she is aware that R33 has a seizure disorder but has never witnessed one. She reports that the only interventions for falls or seizure activity for R33 is to keep her head protected, and afterwards they are supposed to check on her. V8 stated that she is not aware of any interventions in place to prevent injuries prior to falls in general or those related to seizures. On 04/23/25 at 1:51 PM, V5 (Registered Nurse/ RN) stated the only thing she knows about R33 that she has seizures, and they give her medicine for them. She reports that R33, Has them on occasion. V5 stated that it had been a long time since she witnessed a seizure. V5 said that she is not aware of any interventions in place to prevent injury prior to falls in general or falls related to seizures. On 4/24/25 at 9:09 AM, V2 (Director of Nurses) gave the following responses in relation to interventions reviewed with her after each of R33's falls. V2 stated that she thought that the fall intervention for the fall on 2/14/25 was appropriate because having R33 review the smoking policy and having her sign it would help to remind her of current policy and calm her down. V2 stated that R33 was upset at the time, and staff were concerned her agitation could cause a seizure and in turn, a fall. Related to fall interventions put in place for fall on 2/14/25, V2 said that she thought that the review of the policy and having her sign it, because of her agitation over not being able to smoke as often or as much due to extreme temperatures, would help to remind her and calm her down because staff were concerned that with increased agitation that it could cause a seizure and in turn a fall. Related to interventions put in place for fall on 2/26/25, V2 said that re-education of staff on having resident lay down or sit down was an appropriate intervention because R33 literally inhales two cigarettes as quickly as possible, and they thought that her blood pressure was bottoming out after she stood up. V2 said that having her sit down or lie down would help to bring her back to her normal baseline blood pressure and keep her from having a seizure or passing out. Related to 4/18/25's interventions put in place for fall, V2 said they thought that was an appropriate intervention because the facility wanted to draw levels to see if her therapeutic levels were too low, and if they could contact (MD) medical doctor and have Keppra increased which would decrease risk of seizure. V2 said that R33 is independent in all her activities of daily living (ADLs), so the only other intervention that she could think of would be to have R33 one on one with a staff member, and that is very difficult to have one to one staff/resident care.

Based on observation, interview, and record review the facility failed to date and secure oxygen tubing and a humidification bottle for one of one resident (R4) reviewed for oxygen in the sample of 32. Finding include R4's Admission Record documents an admitted [DATE]. R4's Admission Record documents diagnosis including in part chronic combined systolic and diastolic heart failure, chronic obstructive pulmonary disease (COPD), and panlobular emphysema. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status of 15 which indicates intact cognition. Section O of that same MDS documents R4 is on oxygen therapy. R4's most recent Care Plan documents a diagnosis of COPD with an intervention of encourage/assist R4 with oxygen as orders/accepted/needed. R4's Physician Orders for April 2025 document oxygen at 2L (liters) via NC (nasal cannula) or 5L via oxygen mask and check oxygen saturation every shift, every day and night shift. There are no physician orders as to when or how often to change oxygen tubing. On 4/21/2025 at 2:39 PM, R4 was propelling himself down the hallway in his wheelchair and his oxygen tubing was dragging on the floor behind him. On 4/22/2025 at 10:30 AM, R4 was sitting in his wheelchair in room receiving oxygen via nasal cannula and the tubing was dated 4/7/2025. The humidifier bottle on the concentrator was undated. On 4/23/2025 at 10:41 AM, R4 was laying in bed receiving oxygen via nasal cannula and the tubing was dated 4/7/2025 and the humidifier bottle on the concentrator was undated. On 4/23/2025 at 10:44 AM, V2 (Director of Nursing/DON) stated oxygen tubing is to be changed every Sunday and it is documented in the Medication Administration Record (MAR). V2 stated if it is being changed it will be in the MAR. V2 stated all oxygen tubing and the humification bottle should be dated when changed. On 04/24/25 at 1:24PM V2 (DON) stated that she would prefer that the oxygen tubing change be on the MAR to be signed off completed because she could assess it faster, but it usually always goes on the TAR (Treatment Administration Record). R4's TAR for the month of April documents oxygen at 2L via NC or 5L via oxygen mask and check oxygen saturation every shift, every day and night shift. R4's TAR does not contain any documentation as to when or how often to change oxygen tubing, nor does it document R4's oxygen tubing has been changed.

Based on observation, interview and record review, the facility failed to offer and provide dental services for one of one resident (R28) reviewed for dental services in the sample of 32. Findings include: R28's electronic medical record (EMR) shows an admitted [DATE]. In R28's EMR diagnoses includes but is not limited to dysarthria following cerebral infarction, anxiety disorder, other chronic pain, major depressive disorder, and alcohol abuse. R28 diagnoses did not contain any diagnosis related to dental/teeth issues. R28's MDS (Minimum Data Set) dated 3/19/25, section J documents no complaints of pain from R28. Section C of R28's MDS dated [DATE] indicates R28 had a (BIMS) brief interview for mental status score of 11, indicating moderate impaired cognition. R28's current care plan has no documentation of interventions for dental pain or a focus area of dental/teeth issues. R28's Physician's orders include a prescription for Oragel 20-0.26% 1 application dental every 6 hours as needed for oral pain with an original order date of 6/13/24. A review of R28's Medication Administration Records (MAR's) document that this medication was never administered since original order. On 04/21/25 at 1:43 PM, R28 who was alert to person, place and time stated that he has had a toothache for some time. R28 could not give this surveyor an approximation of how long his tooth had been aching. R28 stated that he takes Tylenol routinely for the pain. R28 stated that he has some teeth that are bad and need to be pulled. It is also noted that upon speaking with R28 that he has a communication deficit (stuttering and loss of words) that he said was caused by his history of a stroke. On 04/22/25 at 2:55 PM, R28 stated that he's had the toothache periodically for over the past year. When R28 was asked to show where his pain was R28 pointed to his right and left lower teeth and right upper teeth. R28 then stated that the pain is present on average 3 days a week. R28 said that he often asks the nursing staff for Tylenol, and they give it to him. He said that in the past the staff has told him that he couldn't see dental because his insurance didn't cover that. He could not remember who told him that regarding seeing the dentist due to his insurance. On 04/22/25 at 10:26 AM, R28's EHR (Electronic Health Record) was reviewed and under the miscellaneous tab was an (name of dental facility) note/referral dated 4/19/24 recommends evaluation and extraction for #32, #17, and #19. On 04/22/25 at 11:00 AM, R28's pain scale monitoring under vitals tab dated 12/09/24 through 4/24/25 reports that R28 has denied any pain every day except for 2/4/2025 at 20:37 (8:37pm) reports pain level of 5; and 2/8/2025 at 19:50 (7:50pm) reports pain level of 2; 2/28/2025 at 07:52 (am) pain level of 2; and 2/28/2025 at 07:53 (am) pain level of 2. R28's MAR documents R28 has a current order for acetaminophen 325mg tablets - take 2 tablets by mouth every four hours for pain. Also has current order for ibuprofen 200mg tablet - take 2 tablets by mouth every six hours for pain. R28's April 2025 MAR shows that R28 had not received nor requested any Tylenol or ibuprofen for pain. On 04/22/25 at 10:26 AM, reviewed progress notes dated 4/1/2025 - 4/22/2025 and no notes of dental pain or complaints mentioned in progress notes tab. On 04/22/25 at 10:40 AM, V4 (Certified Nurse Aide/CNA) stated R28 had not mentioned to her having a toothache. V4 stated facility has gotten a dental visit recently in last couple months, but doesn't remember who was seen. On 04/22/25 at 10:47 AM, V5 (Registered Nurse/RN) stated that R28 has mentioned a toothache and is supposed to see dentist next time they are on site. V5 stated dental services comes in house. V5 stated R28 has only mentioned dental pain once to her about one week ago. V5 stated when asked what she would do if someone complained of dental pain, V5 stated, I usually ask (V6, Social Services Director) in social services to put them on the list if they complain of dental pain. I don't remember if I called the doctor to order him something for pain or if I gave him anything for pain. On 04/22/25 at 10:52 AM, V2 (Director of Nurses/DON) stated that R28 had mentioned to her about 4-5 months ago that he had a toothache but has not heard about it since. On 04/22/25 at 10:54 AM, V6 stated (name of a dental provider) is who provides dental services. She said that they were just in at the end of the month, and they come in once every 3 months. V6 stated, I don't think they take Medicaid. I will call and ask them and get back to you. On 04/22/25 at 11:10 AM, V6 stated she had called and sent a voice mail to (name of a dental provider) dental services and asked them to return her call. On 04/22/25 at 2:05 PM, V6 stated that she had called (name of a dental provider) and they stated that they would pick up R28 up as a patient. She said that (name of a dental provider) would try and see R28 sooner than their next scheduled visit but did not give a specific date. She said that 4 months ago R28 told staff that he was experiencing tooth pain. He was then referred to (name of a dental provider) dental at that time. R28 had told (name of a dental provider) dental that he only made fifty-eight dollars a month, and they said that they couldn't take him. V6 stated that she wasn't in her current position in April 2024 when R28 had initially saw dental and been referred to oral surgery. She said she didn't know anything about resident's toothache at that time, but she agreed that the facility should have made the referral to oral surgery much sooner. On 04/22/25 at 2:17 PM, V2 stated she didn't know anything about the dental referral in April 2024. V2 stated, As far as the Oragel order for (R28) in December 2024 that's the first time I've heard of it, and I notified social services at that time. I would expect the dental referral made in April 2024 to have been made much sooner. On 04/22/25 at 2:21 PM, V1 (Administrator) stated she didn't start until August 2024. She doesn't know anything about the oral surgeon referral made in April 2024. She stated that it should have been followed up on sooner, though. The facility's dental policy dated 12/2024 states, Routine and emergency dental care is available. Should a resident need emergency dental care, the dental provider shall be notified so that arrangements for the emergency care can be made. Dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; or any problem of the oral cavity appropriately treated by a dentist that requires attention.

Based on interview and record review the facility failed to administer vaccinations resident previously had consented for, for 2 residents of 5 residents (R29 and R35) reviewed for immunizations in a sample of 32. Findings include: 1. R29's Admission record documents an admitted [DATE] with diagnoses including: protein calorie malnutrition, deaf/nonspeaking, major depressive disorder, adult failure to thrive, anxiety disorder, anorexia nervosa, and vitamin D deficiency. R29's Physician Order Sheet documents an order for: immunization: may have annual flu vaccine with consent unless contraindicated with an ordered date of 05/09/24 and end date listed as 'indefinite.' On 04/24/25 at 3:00 PM R29 who was alert and oriented to person, place and time stated, he has never signed a consent for influenza. R29 stated that he wouldn't mind getting the influenza vaccine. R29 stated he has never received the influenza vaccine since he has been at the facility. R29's Patient Consent form or Seasonal Influenza Vaccination dated 03/18/24 signed by V20 (family) documents: a check mark in front of the statement, I consent to receive the Seasonal Influenza Vaccination. On 04/22/25 at 2:32 PM V1 (Administrator) stated, she does not know how or why R29 would have a consent form that was signed prior to his admitted . R29's electronic immunization record for influenza vaccination documents: a confirmation date of 10/17/24 with immunization status of pending listed. R29's Medication Administration record dated 10/01/24 - 10/31/24 does not document any influenza vaccination administered. On 04/23/25 at 9:28 AM, V1 (Administrator) stated, R29 did not get his influenza vaccination in November 2024 when the clinic was present due to his insurance denied the vaccination. She is not for sure what the facility's policy is to do if the insurance denies, and the resident has not received the vaccination. R29 has still not received the vaccination. The facility document dated 09/22 titled, Infection Prevention and Control Manual Resident Immunizations and Vaccinations documents: policy; 1. It is the policy of this facility that all residents will be offered immunization against influenza, 7. The timing of vaccination is in the fall and winter with only 1 dose required - the end of September and throughout October are ideal. Procedure: 4. Every new admission and existing resident are screened using the criteria contained within the standing protocol and based on the ACIP (advisory committee on immunization practice) and CDC (Center for Disease Control and Prevention) recommendations for influenza, 7. If the resident or resident representative elect to receive the influenza vaccine, the obtain informed consent with the respective form, 12. If the resident chooses to be immunized, then order the influenza vaccine, 14. If resident is afebrile and has no moderate to severe acute illness, then proceed with vaccination, 15. Administer the vaccine via the specified route, IM (intramuscularly) or intranasally, per manufacturer's recommendations, respectively, 16. Document in the resident's medical record and on the immunization record: a. education was provided b. specific medication or vaccine, c. manufacturer, lot number and expiration date d. route of administration e. site of injection f. date and time the vaccine was given g. who administered the vaccine h. any adverse reactions, 17. Complete vaccination billing log 18. Observe for side effects. 20. A record of vaccination will be placed in the resident's medical record and in their vaccination record. 2. R35's Admission Record documents a admitted [DATE] with diagnoses including: osteomyelitis of vertebra, severe protein calorie malnutrition, type 2 diabetes mellitus, dementia, and adult failure to thrive. R35's Pneumonia Vaccination Consent form dated 03/06/25 contains the statements: I consent to receive the Pneumococcal vaccine (PCV15), I consent to receive the Pneumococcal vaccine (PCV20), I consent to receive the Pneumococcal vaccine (PPSV23) checked. On 04/22/25 at 2:30 PM, R35's (PPSV23) pneumococcal vaccination vial was observed in the refrigerator in the medication room dated 03/10/25. On 04/23/25 at 10:15 AM, V5 (Registered Nurse) stated the date on R35's pneumococcal vaccination is the date it was received which was 03/10/25. On 04/23/25 at 9:28 AM, V1 (Administrator) stated R35 also had complications for her pneumococcal vaccination and insurance. V1 stated R35 has a consent for the pneumococcal vaccination signed on 03/06/25 and R35's pneumococcal vaccination is in the medication room dated 03/10/25. V1 stated she does not know why R35 has not received the vaccination she should have. On 04/24/25 on 1:47 PM, V2 (Director of Nursing) stated they do not have a policy for pneumococcal vaccinations, they just follow the CDC guidelines.

Based on observation, interview and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 resident (R10, R12, R27 and R30) reviewed for room size in a sample of 32. Findings include: 1. On 4/23/25 at 11:25 AM, V7 (Maintenance) accompanied by this surveyor measured R12 and R27's room. The room measured 11 feet 9 inches by 12 feet 7 inches, total square feet = 151.13 (75.57 square feet per resident bed). The room contained 2 beds, 2 nightstands and 1 inset dresser. The measurements did not include the inset dresser area. On 4/23/25 at 11:47 AM, R27 who was alert to person, place and time stated her room size is ok and has no complaints. On 4/23/25 at 11:35 AM, R12 who was alert to person, place and time stated her room is ok and they have enough room. 2. On 4/23/25 at 11:30 AM, V7 accompanied by this surveyor measured R10 and R30's room. The room measured 12 feet 3 inches by 11 feet 9 inches, total square feet = 146.37 (73.19 square feet per resident bed). The room contained 2 beds, 2 nightstands, 1 inset dresser and 1 additional dresser. The measurement did not include the inset dresser area. On 4/23/25 at 11:32 AM, R30 who was alert to person, place and time, while in her room, stated she was ok with her room and had no complaints. On 4/23/25 at 11:32 AM, R10 who was alert to person, place and time, while in her room stated, They could use more room, but it's ok. When asked about the size of her room. On 4/23/25 at 11:56 AM, V1 (Administrator) stated rooms 1-18, 20-25, and rooms 30-33 were all waivered rooms that did not meet the 80 square feet per resident bed requirement. V1 stated these rooms were Medicaid certified. A facility Midnight Census Report provided by the facility on 4/21/23, documents that R10, R12, R27 and R30 reside in the rooms observed and measured by V7. Inquiries made regarding the size of the waivered rooms during the survey from 4/21/25 to 4/24/25, found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the waivered rooms.

Based on observation, interview and record review, the facility failed to maintain the shower room on the South Hall in a clean and sanitary condition. This has the potential to affect 23 residents residing on the South Hall. Findings include: On 12/02/24 at 10:19am, the shower room B on the South hall was observed to have an area in the corner behind the toilet where there was a significant buildup of an unknown black substance. On 12/02/24 at 10:32am, R2 who was alert to person, place, and time, stated that the shower rooms could be cleaner at times. On 12/02/24 at 10:53am, R13 who was alert to person, place, and time, stated the facility was pretty dingy before they started painting around here and the bathrooms are often dirty and damp. On 12/02/24 at 11:02am, R11 who was alert to person and place, stated the bathrooms could use a good cleaning. On 12/02/24 at 11:43am, V3 (Housekeeping) took a rag that was damp with cleaner and attempted to wipe an area of black buildup in the corner by the toilet of shower room B on the South hall, it did not wipe off after multiple swipes. It appeared that some of it was under a layer of clear sealant. On 12/04/24 at 10:00am, The buildup in the corner of shower room B was clean, there was no longer any clear sealant observed on the wall. On 12/04/24 at 12:00pm, V8 (Certified Nursing Assistant/CNA) stated everyone on this end of the South hallway uses shower room B. V8 stated it has a toilet and a shower and there is no one bed bound on the hallway, so it is possible that they all could use it at one time or another. On 12/04/24 at 12:00pm, V8 (CNA) confirmed that there were 23 residents on this end of the South hallway. On 12/04/24 at 1:40pm, V1 (Administrator) was asked about the spot in the corner of shower room B, she stated she did not know anything about it but assumed that housekeeping would have cleaned it. A review of the facility floor plan and census dated 12/03/24, documents there are 23 residents that reside in zone 3 of the south hallway where shower room B is located. A review of facility policy titled Physical Plant and Environmental Policy and Guidelines documents under the section titled Housekeeping that routine and daily cleaning and monthly schedules deep cleaning is to be performed in shower rooms.

Based on interview and record review, the facility failed to prevent the misappropriation of resident trust funds and private checking accounts from V3, former Business Office Manager for 50 of 50 residents (R1-R50) reviewed for theft in a sample of 52. This failure resulted in checks written for cash on R1 through R50's pooled resident trust account, totaling $5515.19 and checks written from R1's individual checking account totaling $10,650. These actions would cause a reasonable person to have feelings of sadness, worry, stress and anguish while residing in a home where monetary theft occurred. The Immediate Jeopardy began on 12/21/23 when V3 wrote a $250 check for cash on R1's personal checking account, with no documentation as to what happened to the money. V11, Regional Director of Clinical Operations, was notified of the Immediate Jeopardy on 8/13/24 at 3:28pm. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/10/24, prior to the start of the survey and was therefore past noncompliance. Findings include: A letter dated 6/10/24 addressed to IDPH (Illinois Department of Public Health) stated in part, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), V3. V6 voiced some vague concerns regarding V3 and the resident trust fund. (V3) was immediately suspended pending the results of the investigation. The Medical Director, Ombudsman, and local Police Department were made aware, and investigation initiated . (V6) was interviewed and revealed that (V7) Housekeeping Supervisor, had communicated this information during a conversation. (V6) voices (V7) made the comment to 'Keep an eye on your brother's (R3) money'. (V6) brother, (R3) is a resident of the facility) . (V3) was interviewed and denies using resident monies an any way other than for the residents. In subsequent interviews (V3) was asked to explain her bookkeeping process, obtaining receipts and regarding recent checks written from the resident trust account. (V3) was unable to locate some receipts and unable to answer some specific questions related to checks written from the resident accounts and the resident trust account . (R2) was interviewed and voices she would have (V3) order items from a catalog for her. (R2) voices she requested some items to be ordered and never received them. The items (R2) requested for order have since been ordered .(V4), Regional Admissions/BOM reconciled the resident trust petty cash box. Based on that reconciliation, the facility is unable to account for $2728.59. The facility has replaced this amount for the resident trust petty cash box. (V10) Transportation (Staff), was interviewed and voices since February 2024, (V3) would have her take (R1) to her (R1's) bank to cash a check written to cash for (R1's) rent. (V10) voices (V3) would write a check out at the beginning of the month and about mid-month. (V10) voices she would take (R1) to the bank, cash the check, and then purchase (R1) a carton of cigarettes. (V10) voices they would return to the facility and (R1) would give (V3) the remaining cash. (V10) voices she doesn't know what (V3) did with the cash. (R1's) account was reviewed, and it was noted R1 owes $9857.00 for Room and Board. (R1's) checking account was reviewed and reveals $10,650 in checks written to cash. (R1) was re-imbursed the amount written out of her account. (R1's) room and board invoices was paid in full . The actual resident trust bank account was reconciled with bank statements by (V4). Based on that reconciliation, the facility was unable to account for $5515.19. The facility has replaced the above amounts that were unaccounted for .(V3) has been terminated from employment effective immediately. The investigation has been turned over to the Local Police Department. The facility will fully cooperate with any requests made by the Police Department. This letter was signed by V1, Former Administrator. R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Diabetes Type 2, Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease. R1 is listed as being her own responsible party. R1's Care Plan dated 6/5/24 documented problem areas, Resident has diagnosis and takes medication for anxiety, and Impaired cognition as related to confusion at times. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating R1 has moderate impairment in cognitive functioning. R2's Face Sheet documented an admitted [DATE] and listed diagnoses including Major Depressive Disorder, Unspecified Psychosis, Chronic Kidney Disease, and Hypertension. The Face Sheet also listed V23 from OSG (The Office of State Guardian) as R2's Power of Attorney (POA). R2's Care Plan dated 7/2/24 documented a problem area, Resident displays impaired cognition. R2's 6/25/24 Minimum Data Set (MDS) documented a BIMS score of 12, indicating R2 has moderate deficits in cognitive functioning. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. On 8/2/24 at 1:10pm, R1 who was alert and oriented to person and place, but not time stated that, The lady who took care of the money took some from my account. R1 stated she was not sure how much money she got every month, and did not know how much her checking account had in it or how much it should have in it. R1 stated she had never previously had any suspicions about staff taking her money. R1 stated she would go out twice a month to buy a carton of cigarettes, and that R1 would make out a check for cash and take it to the bank, and bring all the change back to, The lady who took care of that stuff, and she was supposed to be putting it toward my bill here, but I guess she wasn't. R1 stated she is not sure how much she wrote the checks for cash out for or how much change she was bringing back. R1 stated she was not really upset by any of this as R1, Doesn't let stuff like that get to her. R1 stated she does not recall ever getting any notification from the facility that her bill was not being paid. R1 stated she keeps her checkbook in her room. On 8/7/24 at 1:45pm, R2 was alert and oriented to person and place but not time. R2 stated in the spring of this year, V3 was supposed to be taking money out of R2's trust account and loading it onto a prepaid credit card and ordering items for R2 from a catalog. R2 stated the items never came and when she asked V3 about it, she would put R2 off. R2 stated she did not know how much money was taken out of her account, how much money she has in it, or how much money she should have in it. R2 stated the facility went ahead and ordered and paid for the items, and she is satisfied with this outcome. R2 stated she got her items, and that was all she had wanted. On 8/2/24 at 11:10am, V11 (Regional Director of Clinical Operations), stated she had assisted V1 (Former Administrator), in the above referenced investigation. V11 stated when she went to pull V3's background check from her hire date of 4/22/21, there wasn't one on file. V11 stated she ran a background check on V3 on 5/31/24, and it came back with a disqualifying offense, but it did not show what the offense was. V11 stated all employee background checks were then audited with no other disqualifying offenses found. On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May, date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this happened on a Thursday, and V6 stated V3 was here the remainder of that day at least until 1:30pm when V6 gets off. V6 stated she returned to work the following Tuesday and heard V3 had been walked out and an investigation started. An undated letter provided to this surveyor by V1, that is addressed to V1 and signed by V6, stated, (V7) said (V3) is always so poor and always broke, (R3)'s money should be monitored closely. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 who said an investigation had begun. V10 stated, I don't think (R1) really understands really what happened. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated she assumed the facility had done a background check on her at that time. V3 stated years ago she had a forgery conviction for writing bad checks in her husband's name. V3 stated, I have never taken or stolen money from any resident, from their account, or cash, or their belongings, or petty cash. V3 stated on 5/24/24 she was informed by V1 that a facility employee had written a letter to V1 stating that V7 had told the employee to watch her brother R3's resident trust account carefully because V3 couldn't be trusted. V3 stated she does not know why V7 would say that. V3 said she was told to gather her belongings and was walked out. V3 stated V1 called V3 around 6/1/24 and stated they were terminating V3 due to her background check showing she was ineligible to work due to a criminal conviction. V3 denied she confessed to V1 that she had misappropriated funds. V3 stated twice a month, R1 would tell V3 to write out a check on R1's checking account, and R1 would tell V3 how much to write the check for. V3 stated R1 spent all her money but didn't have anything to show for it and V3 doesn't know what she spent it on. V3 stated V10 nor R1 ever brought V3 any cash. V3 stated the last time she was aware, R1 owed the facility around $20,000 for room and board. V3 stated she tried to talk to R1 about R1's bill, but she ignored V3. V3 stated she could not remember any specific check amounts. V3 stated R1 did not have a POA or guardian and was capable of handling her own financial affairs. V3 stated she does think she discussed R1's outstanding bill with somebody from the corporate office, but is not sure who or when. V3 stated in October of 2023, a cyberattack took out the program used for resident trust accounts, and she did not have any way to find out what resident balances were. V3 stated she would call the corporate office, but they would never get back to her. V3 stated within a few weeks after the corporation went into receivership in early February of 2024, all the trust information was forwarded to V3 but the accounts hadn't been balanced since October 2023. V3 stated she did not then balance them because she did not have time, as she was overwhelmed from all the administrative changes that were going on. V3 stated the receivership organization set up a new system for accounting, but she had not taken the training required to use it. On 8/8/24 at 9:00am, V2 (Director of Nurses) stated there have been no changes in R1's level of functioning since the misappropriation was discovered. V2 stated R1 has not had an increase in behaviors, remains confused a lot of the time, has not required any medication changes, and R1's level of cognition has remained at baseline. V2 stated the most recent training about abuse she has had was on 5/24/24. V2 stated abuse is to be reported immediately to the Administrator. V2 stated she was unaware of any problems with resident accounts until 5/24/24. On 8/8/24 at 10:15am, V4 (Corporate Business Office Manager) stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars worth of cash. V4 stated the resident trusts are comingled in one account with separate recordkeeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted form that resident's trust account amount. V4 stated V3 kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated the previous corporation who managed the facility has refused to provide any resident trust documentation to the current receivership corporation, which took over on 2/8/24. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 12/1/23 to 6/1/24, all of whom would be affected by misappropriation from the pooled account. V4 stated R1 should never have had large checks written for cash and then brought back to the facility, but instead written a check to the facility for the room and board with the remaining Medicaid $60 individual allowance put in R1's resident trust account. V4 stated her audits documented a total of $9,857 outstanding balance on R1's room and board, $10,650 of checks written out to cash from R1's account. V4 stated the pooled resident trust account, on which V3 had written checks for cash, was missing $5,515.19, although the checks V3 had written totaled less than that amount, indicating V3 may have written checks earlier than 2/1/24, although there is no documentation. V4 stated the facility has reimbursed all the missing money. V4 stated an audit of R2's trust account balance showed no suspicious activity, but since R2 reported items had been paid for by her and not received, these items were ordered for R2 and paid for by the facility. V4 further stated Business Office Managers are not to keep resident checkbooks unless the resident specifically signs a written consent, which none of the residents, including R1, have done. V4 stated R1 keeps her checkbook in her room. V4 stated during the investigation, V3 came to the facility and was asked to provide receipts for the petty cash and for the cash R1 brought in, but V3 was unable to do so. V4 stated there were no other staff members found to be involved as the checks were all written and signed by V3. V4 stated since the investigation has concluded, it is to be noted that R1 has not requested any checks to be written or to be given cash, and the only thing R1 has requested is cigarettes. On 8/8/24 at 1:45pm, V1 stated she considered V6 (Housekeeper) to be a disgruntled employee, and when V6 approached her with the letter on 5/23/24, she considered it to be about, Staff drama. V1 did state the letter said that according to V7, V6 should keep a close eye on R3's money. V1 stated she discussed the letter with V16 (Corporate Marketing Director), Who must have notified (V11- Regional Director of Clinical Operations). V1 stated she then gave the letter to V11 and the investigation was started. V1 stated as far as she knew, V3 was doing her job, and V1 did not suspect V3 of misappropriating resident funds. V1 stated at some point, not sure when, V10 approached V1 with a check written on R1's checking account, and V1 stated she did not realize V10 was reporting potential misappropriation. V1 stated she was hired in 2023 and V3 was already employed at the facility. V1 stated she was not aware the previous Administrator had not completed a background check. V1 stated in retrospect, she did recall on one occasion R1 had not felt well and had not wanted to go to the bank that day, and V3 became upset and said no, she has to go to the bank today. V1 stated she spoke with V3 privately during the investigation, and that V3 confessed to V1 that she had misappropriated the money as outlined above. V1 stated for Easter 2024, the previous corporation gave the facility $500 for a community easter egg hunt, and there was a rumor going around that V3 stole $5 bills out of three or four eggs for the kids. V1 stated at that time she asked V3 about it, which V3 denied. On 8/8/24 at 2:50pm, V17 (Police Officer/Patrolman) stated he was called by the facility on 5/24/24 sometime in the morning by V1 to report that V3 was suspected of misappropriating resident funds. V17 stated he interviewed multiple staff members. V17 stated he did not interview R1 as she was asleep. V17 stated all staff were very forthcoming during interview. V17 stated V3 had not yet been interviewed as V3 is avoiding law enforcement. V17 stated the investigation at this time is still ongoing, and as such a Police Report cannot be released. V17 stated after V3 is interviewed, the investigation will be sent to the States Attorney where charges may be filed at the States Attorney's discretion. On 8/13/24 at 8:50am, V16 (Regional Director of Marketing and Development) stated V1 showed her a letter on 5/23/24 written by V6 stating V6 was told by V7 not to trust V3 with R3's trust account. V16 stated she advised V1 to immediately notify V11 and to start an investigation. V16 stated the following day, V16 asked V11 if V1 had contacted her about the letter, which she hadn't. V16 stated she informed V11 about the contents of the letter, and V11 started an immediate investigation. V16 stated she was present during an interview with V3 during the investigation in which V3 was unable to produce receipts for the missing money as outlined above. V16 stated when the investigation was initiated, V16 retrained all facility staff about reporting abuse and misappropriation and provided staff with a copy of the current Abuse Policy. V16 stated staff are to report any knowledge or suspicion of abuse, neglect, or financial misappropriation to the Administrator immediately. On 8/14/24 at 9:10am, V6 stated if R3 was cognitively intact and found out that staff may have stolen his money, His heart would be hurt, like mine was when I found out (V3) took other resident's money. He wouldn't be mad, he would be hurt. On 8/16/24 at 9:15am, R47 was alert and oriented to person, place, and time. R47 stated he has a resident trust account. R47 stated he was not aware of anybody misappropriating his resident trust money. R47 stated if this happened he would, Be agitated, he would not have access to cigarettes and he is addicted to nicotine. A Grievance Complaint Report dated 5/31/24 documented,(R2) reported clothing and DVDs (Digital Video Disc) she ordered have not been delivered. Resident reported these items should have been delivered 5/4/24-5/7/24. Resident reported she had assistance from (V3) when ordering these items. Method of correction: Replaced all her DVD's and clothes that she had ordered and purchased items for resident. Copies of checks written to cash provided with R1's bank statements were reviewed. The checks were signed by R1 and were written on the following dates with amounts as follows: 12/21/23: $250 12/29/23: $200 1/3/24: $1,800 1/22/24: $200 2/2/24: $1,500 2/14/24: $300 3/1/24: $2,000 3/13/24: $250 4/3/24: $1,900 4/17/24: $250 5/3/24: $2,000 Copies of checks to written to cash, written on the pooled resident trust account were written on the following dates and signed by V3 with amounts as follows: 2/1/24: $500 3/14/24: $500 4/19/24: $1000 5/16/24: $1000 5/21/24: $600 The facility was unable to provide documentation as to what the cash was used for, such as receipts given to residents. R1's [NAME] Statement documented that between 2/29/24 through 6/1/24, nothing was applied to R1's room and board, and the outstanding balance as of 6/1/24 was $9,857. A Checking Account Activity Report dated 8/15/24 documented that $10,650 was deposited into R1's account on 6/6/24. A Resident Trust Checking Account Statement dated 6/27/24 documented that on 6/7/24, $5,515.19 was deposited into that account. An IDPH Healthcare Worker Registry Background Check dated 5/31/24 documented, (V3): Work Eligibility: Ineligible: Disqualifying Criminal Offenses. Date: 10/22/07. No waivers on record. The facility policy titled Abuse Prevention Program dated 11/28/16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below . This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals . Under the section titled Definitions it documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Immediate Jeopardy that began on 12/21/23 was removed prior to the survey date on 6/10/24 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review: 1. The resident trust cash box was reconciled and assured of accuracy on 5/30/24 by V4. 2. The resident trust account was balanced and the missing funds were deposited into the account on 6/5/24 by V4. 2. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 3. V3 was removed as an authorized user of the resident trust account on 5/31/24 by V4. 4. The former Administrator was inserviced on employee background checks on 5/31/24 by V11. 5. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 6. 100% of employee background checks were audited on 5/31/24 by V1. 7. V11 will review abuse reports weekly for four weeks to ensure thorough investigations are being completed. 8. V5, Current Administrator/BOM, will review all employee new hires for complete background checks as indicated. 9. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5. The Committee will make recommendations as indicated.

Based on interview and record review, the facility failed to manage, safeguard, and accurately account for residents trust funds and personal checking accounts for 50 residents (R1-R50) reviewed for resident trust fund accounts in the sample of 52. This past noncompliance occurred from 12/21/23 to 6/10/24. Findings include: A letter dated 6/10/24 addressed to IDPH (Illinois Department of Public Health) stated in part, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), V3. V6 voiced some vague concerns regarding V3 and the resident trust fund. (V3) was immediately suspended pending the results of the investigation. The Medical Director, Ombudsman, and local Police Department were made aware, and investigation initiated . (V6) was interviewed and revealed that (V7) Housekeeping Supervisor, had communicated this information during a conversation. (V6) voices (V7) made the comment to Keep an eye on your brother's (R3) money. (V6) brother, (R3) is a resident of the facility) . (V3) was interviewed and denies using resident monies in any way other than for the residents. In subsequent interviews (V3) was asked to explain her bookkeeping process, obtaining receipts and regarding recent checks written from the resident trust account. (V3) was unable to locate some receipts and unable to answer some specific questions related to checks written from the resident accounts and the resident trust account . (R2) was interviewed and voices she would have (V3) order items from a catalog for her. (R2) voices she requested some items to be ordered and never received them. The items (R2) requested for order have since been ordered .(V4), Regional Admissions/BOM reconciled the resident trust petty cash box. Based on that reconciliation, the facility is unable to account for $2728.59. The facility has replaced this amount for the resident trust petty cash box. (V10) Transportation (Staff), was interviewed and voices since February 2024, (V3) would have her take (R1) to her (R1's) bank to cash a check written to cash for (R1's) rent. (V10) voices (V3) would write a check out at the beginning of the month and about mid-month. (V10) voices she would take (R1) to the bank, cash the check, and then purchase (R1) a carton of cigarettes. (V10) voices they would return to the facility and (R1) would give (V3) the remaining cash. (V10) voices she doesn't know what (V3) did with the cash. (R1's) account was reviewed, and it was noted R1 owes $9857.00 for Room and Board. (R1's) checking account was reviewed and reveals $10,650 in checks written to cash. (R1) was re-imbursed the amount written out of her account. (R1's) room and board invoices was paid in full . The actual resident trust bank account was reconciled with bank statements by (V4). Based on that reconciliation, the facility was unable to account for $5515.19. The facility has replaced the above amounts that were unaccounted for. (R3's) resident trust account was reconciled by (V4) with no concerns noted. (V3) has been terminated from employment effective immediately. The investigation has been turned over to the Local Police Department. The facility will fully cooperate with any requests made by the Police Department. This letter was signed by V1, Former Administrator. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 (Regional Director of Clinical and Operations) who said an investigation had begun. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated, I have never taken or stolen money from any resident, from their account, or cash, or their belongings, or petty cash. V3 stated twice a month, R1 would tell V3 to write out a check on R1's checking account, and R1 would tell V3 how much to write the check for. V3 stated R1 spent all her money but didn't have anything to show for it and V3 doesn't know what she spent it on. V3 stated V10 nor R1 ever brought V3 any cash. V3 stated the last time she was aware, R1 owed the facility around $20,000 for room and board. V3 stated she tried to talk to R1 about R1's bill, but she ignored V3. V3 stated she could not remember any specific check amounts. V3 stated R1 did not have a POA (Power of Attorney) or guardian and was capable of handling her own financial affairs. V3 stated she does think she discussed R1's outstanding bill with somebody from the corporate office, but is not sure who or when. V3 stated in October of 2023, a cyberattack took out the program used for resident trust accounts, and she did not have any way to find out what resident balances were. V3 stated she would call the corporate office, but they would never get back to her. V3 stated within a few weeks after the corporation went into receivership in early February of 2024, all the trust information was forwarded to V3 but the accounts hadn't been balanced since October 2023. V3 stated she did not then balance them because she did not have time, as she was overwhelmed from all the administrative changes that were going on. V3 stated the receivership organization set up a new system for accounting, but she had not taken the training required to use it. On 8/8/24 at 10:15am, V4 (Corporate Business Office Manager) stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars worth of cash. V4 stated the resident trusts are commingled in one account with separate record keeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted form that resident's trust account amount. V4 stated V3 kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated the previous corporation who managed the facility has refused to provide any resident trust documentation to the current receivership corporation, which took over on 2/8/24. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 12/1/23 to 6/1/24, all of whom would be affected by misappropriation from the pooled account. V4 stated R1 should never have had large checks written for cash and then brought back to the facility, but instead written a check to the facility for the room and board with the remaining Medicaid $60 individual allowance put in R1's resident trust account. V4 stated her audits documented a total of $9857 outstanding balance on R1's room and board, $10650 of checks written out to cash from R1's account. V4 stated the pooled resident trust account, on which V3 had written checks for cash, was missing $5515.19, although the checks V3 had written totaled less than that amount, indicating V3 may have written checks earlier than 2/1/24, although there is no documentation. V4 stated the facility has reimbursed all the missing money. V4 stated an audit of R2's trust account balance showed no suspicious activity, but since R2 reported items had been paid for by her and not received, these items were ordered for R2 and paid for by the facility. V4 further stated Business Office Managers are not to keep resident checkbooks unless the resident specifically signs a written consent, which none of the residents including R1 have done. V4 stated R1 keeps her checkbook in her room. V4 stated during the investigation, V3 came to the facility and was asked to provide receipts for the petty cash and for the cash R1 brought in, but V3 was unable to do so. V4 stated there were no other staff members found to be involved as the checks were all written and signed by V3. V4 stated since the investigation has concluded, it is to be noted that R1 has not requested any checks to be written or to be given cash, and the only thing R1 has requested is cigarettes. Copies of checks written to cash provided with R1's bank statements were reviewed. The checks were signed by R1 and were written on the following dates with amounts as follows: 12/21/23: $250 12/29/23: $200 1/3/24: $1,800 1/22/24: $200 2/2/24: $1,500 2/14/24: $300 3/1/24: $2,000 3/13/24: $250 4/3/24: $1,900 4/17/24: $250 5/3/24: $2,000 Copies of checks to written to cash, written on the pooled resident trust account were written on the following dates and signed by V3 with amounts as follows: 2/1/24: $500 3/14/24: $500 4/19/24: $1000 5/16/24: $1000 5/21/24: $600 The facility was unable to provide documentation as to what the cash was used for, such as receipts given to residents. R1's [NAME] Statement documented that between 2/29/24 through 6/1/24, nothing was applied to R1's room and board, and the outstanding balance as of 6/1/24 was $9857. An undated Resident Funds Policy and Procedure stated, (The facility) recognizes the resident's right to manage his/her own financial affairs and does not require the resident to deposit their personal funds with facility. However, upon written authorization of a competent resident the facility will hold, safeguard, manage and account for personal monies deposited with the facility. If the resident has been determined to be incompetent, the written authorization may be signed by the resident's fiduciary guardian, legal representative, or immediate family. In all cases the authorization must be witnessed by a disinterested party in an interest bearing, pooled Resident Monies Account. All accrued interest paid to the Resident Monies Account is prorated among those residents having personal funds in the account. In this manner, the resident will have access to his/her monies within the same day. At least quarterly, the facility will provide the resident or his/her representative a written, itemized statement of all transactions to his/her account which occurred in the last quarter. A review of the resident's account status is available to the resident upon request and in a reasonable amount of time. The facility will institute security measures to insure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include; signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight by the facility Administrator, and signed quarterly statements. Further, the facility will require dual signatures on all banking transactions requiring signatures as well as require receipts for all purchases made from residents' personal monies that shall include date of purchase, amount of purchase, and detail of all items or services purchased. If a resident is incapable of handling his/her own funds and does not have a fiduciary guardian, legal representative, or an immediate family member, the facility shall notify the Office of the State Guardian. Procedure: 1. The facility shall appoint a qualified designee who will be responsible for maintaining resident funds upon written authorization. The facility Administrator will have ultimate oversight over all aspects of the handling of the resident trust and resident funds. 2. The facility has adopted the Answers on Demand computerized Resident Trust Program to assure a full, complete and separate accounting for each resident. The Resident Trust Program shall be maintained according to generally accepted accounting principles. 3. Resident funds will not be commingled with facility funds, or any other funds, except that all resident personal funds shall be maintained in a single interest bearing Resident Monies Account. 4. The Resident account maintained in the Resident Trust Program for each participating resident shall be updated in a timely manner. This personal account detail shall be available to the resident and/or his/her legal representative to review upon request within a reasonable time-frame. 5. Receipts for purchases from resident's personal monies shall be obtained for every purchase and maintained to verify: date of purchase, amount of purchase, and items purchased. The facility shall require that the Resident Trust Account be a dual signatory account requiring the signature of the Administrator or Corporate designee and the appointed qualified facility designee for all account transactions requiring a signature, where allowed by the financial institution. 6. Interest earned on the account shall be prorated to individual accounts within two working days of notification of interest earned from the financial institution. 7. The facility Administrator will complete, or require the facility designee to complete, a Resident Trust Reconciliation form on a monthly basis. The Administrator will compare and review the Resident Trust Reconciliation and Resident Trust Account banking Statement to insure the secure handling of resident funds. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. The resident trust cash box was reconciled and assured of accuracy on 5/30/24 by V4. 2. The resident trust account was balanced and the missing funds were deposited into the account on 6/5/24 by V4. 3. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 4. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current BOM). The Committee will make recommendations as indicated.

Based on interview and record review, the facility failed to maintain accurate records for residents trust funds and personal checking accounts for 50 residents (R1-R50) reviewed for resident trust fund accounts in the sample of 52. This past noncompliance occurred from 12/21/23 to 6/10/24. Findings include: A letter dated 6/10/24 addressed to IDPH (Illinois Department of Public Health) stated in part, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), V3. V6 voiced some vague concerns regarding V3 and the resident trust fund. (V3) was immediately suspended pending the results of the investigation. The Medical Director, Ombudsman, and local Police Department were made aware, and investigation initiated . (V6) was interviewed and revealed that (V7) Housekeeping Supervisor, had communicated this information during a conversation. (V6) voices (V7) made the comment to Keep an eye on your brother's (R3) money. (V6) brother, (R3) is a resident of the facility) . (V3) was interviewed and denies using resident monies an any way other than for the residents. In subsequent interviews (V3) was asked to explain her bookkeeping process, obtaining receipts and regarding recent checks written from the resident trust account. (V3) was unable to locate some receipts and unable to answer some specific questions related to checks written from the resident accounts and the resident trust account . (R2) was interviewed and voices she would have (V3) order items from a catalog for her. (R2) voices she requested some items to be ordered and never received them. The items (R2) requested for order have since been ordered .(V4), Regional Admissions/BOM reconciled the resident trust petty cash box. Based on that reconciliation, the facility is unable to account for $2728.59. The facility has replaced this amount for the resident trust petty cash box. (V10) Transportation (Staff), was interviewed and voices since February 2024, (V3) would have her take (R1) to her (R1's) bank to cash a check written to cash for (R1's) rent. (V10) voices (V3) would write a check out at the beginning of the month and about mid-month. (V10) voices she would take (R1) to the bank, cash the check, and then purchase (R1) a carton of cigarettes. (V10) voices they would return to the facility and (R1) would give (V3) the remaining cash. (V10) voices she doesn't know what (V3) did with the cash. (R1's) account was reviewed, and it was noted R1 owes $9857.00 for Room and Board. (R1's) checking account was reviewed and reveals $10,650 in checks written to cash. (R1) was re-imbursed the amount written out of her account. (R1's) room and board invoices was paid in full . The actual resident trust bank account was reconciled with bank statements by (V4). Based on that reconciliation, the facility was unable to account for $5515.19. The facility has replaced the above amounts that were unaccounted for. (R3's) resident trust account was reconciled by (V4) with no concerns noted. (V3) has been terminated from employment effective immediately. The investigation has been turned over to the Local Police Department. The facility will fully cooperate with any requests made by the Police Department. This letter was signed by V1, Former Administrator. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 (Regional Director of Clinical and Operations) who said an investigation had begun. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated twice a month, R1 would tell V3 to write out a check on R1's checking account, and R1 would tell V3 how much to write the check for. V3 stated R1 spent all her money but didn't have anything to show for it and V3 doesn't know what she spent it on. V3 stated V10 nor R1 ever brought V3 any cash. V3 stated the last time she was aware, R1 owed the facility around $20,000 for room and board. V3 stated she tried to talk to R1 about R1's bill, but she ignored V3. V3 stated she could not remember any specific check amounts. V3 stated R1 did not have a POA (Power of Attorney) or guardian and was capable of handling her own financial affairs. V3 stated she does think she discussed R1's outstanding bill with somebody from the corporate office, but is not sure who or when. V3 stated in October of 2023, a cyberattack took out the program used for resident trust accounts, and she did not have any way to find out what resident balances were. V3 stated she would call the corporate office, but they would never get back to her. V3 stated within a few weeks after the corporation went into receivership in early February of 2024, all the trust information was forwarded to V3 but the accounts hadn't been balanced since October 2023. V3 stated she did not then balance them because she did not have time, as she was overwhelmed from all the administrative changes that were going on. V3 stated the receivership organization set up a new system for accounting, but she had not taken the training required to use it. On 8/8/24 at 10:15am, V4 (Corporate Business Office Manager) stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars worth of cash. V4 stated the resident trusts are commingled in one account with separate recordkeeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted form that resident's trust account amount. V4 stated V3 kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated the previous corporation who managed the facility has refused to provide any resident trust documentation to the current receivership corporation, which took over on 2/8/24. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 12/1/23 to 6/1/24, all of whom would be affected by misappropriation from the pooled account. V4 stated R1 should never have had large checks written for cash and then brought back to the facility, but instead written a check to the facility for the room and board with the remaining Medicaid $60 individual allowance put in R1's resident trust account. V4 stated her audits documented a total of $9857 outstanding balance on R1's room and board, $10650 of checks written out to cash from R1's account. V4 stated the pooled resident trust account, on which V3 had written checks for cash, was missing $5515.19, although the checks V3 had written totaled less than that amount, indicating V3 may have written checks earlier than 2/1/24, although there is no documentation. V4 stated the facility has reimbursed all the missing money. V4 stated an audit of R2's trust account balance showed no suspicious activity, but since R2 reported items had been paid for by her and not received, these items were ordered for R2 and paid for by the facility. V4 further stated Business Office Managers are not to keep resident checkbooks unless the resident specifically signs a written consent, which none of the residents including R1 have done. V4 stated R1 keeps her checkbook in her room. V4 stated during the investigation, V3 came to the facility and was asked to provide receipts for the petty cash and for the cash R1 brought in, but V3 was unable to do so. V4 stated there were no other staff members found to be involved as the checks were all written and signed by V3. V4 stated since the investigation has concluded, it is to be noted that R1 has not requested any checks to be written or to be given cash, and the only thing R1 has requested is cigarettes. Copies of checks written to cash were signed by R1 and were written on the following dates with amounts as follows: 12/21/23: $250 12/29/23: $200 1/3/24: $1800 1/22/24: $200 2/2/24: $1500 2/14/24: $300 3/1/24: $2000 3/13/24: $250 4/3/24: $1900 4/17/24: $250 5/3/24: $2000 Copies of checks to written to cash, written on the pooled resident trust account were written on the following dates and signed by V3 with amounts as follows: 2/1/24: $500 3/14/24: $500 4/19/24: $1000 5/16/24: $1000 5/21/24: $600 The facility was unable to provide documentation as to what the cash was used for, such as receipts given to residents. R1's [NAME] Statement documented that between 2/29/24 through 6/1/24, nothing was applied to R1's room and board, and the outstanding balance as of 6/1/24 was $9857. An undated Resident Funds Policy and Procedure stated, (The facility) recognizes the resident's right to manage his/her own financial affairs and does not require the resident to deposit their personal funds with facility. However, upon written authorization of a competent resident the facility will hold, safeguard, manage and account for personal monies deposited with the facility. If the resident has been determined to be incompetent, the written authorization may be signed by the resident's fiduciary guardian, legal representative, or immediate family. In all cases the authorization must be witnessed by a disinterested party in an interest bearing, pooled Resident Monies Account. All accrued interest paid to the Resident Monies Account is prorated among those residents having personal funds in the account. In this manner, the resident will have access to his/her monies within the same day. At least quarterly, the facility will provide the resident or his/her representative a written, itemized statement of all transactions to his/her account which occurred in the last quarter. A review of the resident's account status is available to the resident upon request and in a reasonable amount of time. The facility will institute security measures to insure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include; signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight by the facility Administrator, and signed quarterly statements. Further, the facility will require dual signatures on all banking transactions requiring signatures as well as require receipts for all purchases made from residents' personal monies that shall include date of purchase, amount of purchase, and detail of all items or services purchased. If a resident is incapable of handling his/her own funds and does not have a fiduciary guardian, legal representative, or an immediate family member, the facility shall notify the Office of the State Guardian. Procedure: 1. The facility shall appoint a qualified designee who will be responsible for maintaining resident funds upon written authorization. The facility Administrator will have ultimate oversight over all aspects of the handling of the resident trust and resident funds. 2. The facility has adopted the Answers on Demand computerized Resident Trust Program to assure a full, complete and separate accounting for each resident. The Resident Trust Program shall be maintained according to generally accepted accounting principles. 3. Resident funds will not be commingled with facility funds, or any other funds, except that all resident personal funds shall be maintained in a single interest bearing Resident Monies Account. 4. The Resident account maintained in the Resident Trust Program for each participating resident shall be updated in a timely manner. This personal account detail shall be available to the resident and/or his/her legal representative to review upon request within a reasonable time-frame. 5. Receipts for purchases from resident's personal monies shall be obtained for every purchase and maintained to verify: date of purchase, amount of purchase, and items purchased. The facility shall require that the Resident Trust Account be a dual signatory account requiring the signature of the Administrator or Corporate designee and the appointed qualified facility designee for all account transactions requiring a signature, where allowed by the financial institution. 6. Interest earned on the account shall be prorated to individual accounts within two working days of notification of interest earned from the financial institution. 7. The facility Administrator will complete, or require the facility designee to complete, a Resident Trust Reconciliation form on a monthly basis. The Administrator will compare and review the Resident Trust Reconciliation and Resident Trust Account banking Statement to insure the secure handling of resident funds. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. The resident trust cash box was reconciled and assured of accuracy on 5/30/24 by V4. 2. The resident trust account was balanced and the missing funds were deposited into the account on 6/5/24 by V4. 3. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 4. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current BOM). The Committee will make recommendations as indicated.

Based on interview and record review, the facility failed to perform a pre-employment background checks on the business office manager. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 4/22/21 to 6/10/24. Findings include: An IDPH (Illinois Department of Public Health) Notification Form dated 5/24/24 at 9:40am documented, Staff reported an allegation of misappropriation of resident property. Staff member immediately suspending pending the results of investigation. POA (Power of Attorney), MD (Medical Doctor), and Police notified. Final (Report) to follow. A letter dated 6/10/24 addressed to IDPH stated, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), (V3). A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 having had resident trust accounts within that period of time. On 8/2/24 at 11:10am V11, Regional Director of Clinical Operations, stated she had assisted V1, Former Administrator, in the above referenced investigation. V11 stated when she went to pull V3's background check from her hire date of 4/22/21, there wasn't one on file. V11 stated she ran a background check on V3 on 5/31/24, and it came back with a 'disqualifying offense', but it did not show what the offense was. V11 stated all employee background checks were then audited with no other disqualifying offenses found. V11 stated V3 was suspended and walked out on 5/24/24 pending the results of the misappropriation investigation, and was subsequently terminated after it was determined she had misappropriated resident's funds. An IDPH Healthcare Worker Registry Background Check dated 5/31/24 documented, (V3): Work Eligibility: Ineligible. Disqualifying Criminal Offenses: Date: 10/22/07. No waivers on record. On 8/7/24 at 9:55am, V3 stated she was hired as Business Office Manager on 4/22/21. V3 stated she assumed the facility had done a background check on her at that time. V3 stated, Years ago, she had a forgery conviction for, writing bad checks in her husband's name. On 8/8/24 at 10:15am, V4, Corporate Business Office Manager, stated she first entered the facility on 5/31/24 to audit the accounts as part of the misappropriation investigation. V4 stated that audits of resident trust fund petty cash showed checks written and signed by V3 documented that at one point, the facility would have had about $3000 in petty cash, whereas a facility of its size should only keep a few hundred dollars' worth of cash. V4 stated the resident trusts are commingled in one account with separate record keeping for each individual resident. V4 stated when a resident takes money out of petty cash, it is to be deducted from that resident's trust account amount. V4 stated V3 kept meticulous records which when audited, balanced correctly, up until November 2023, at which point V3 stopped balancing the accounts. V4 stated a total of fifty current and former residents had resident trust accounts for the period of 11/1/23 to 6/1/24, all of whom would be affected by misappropriation from the pooled account. On 8/8/24 at 1:45pm, V1 stated she was hired in 2023 and V3 was already employed at the facility. V1 stated she was not aware the previous Administrator had not completed a background check on V3. The facility's Abuse Prevention Program Policy dated 11/28/16 stated, The facility will not knowingly employ any staff convicted of any crimes listed in the Healthcare Worker Background Check Act (unless waivered under the provision of the act), or with findings of abuse listed on the Illinois Healthcare Worker Registry. A Facility Matrix dated 8/1/24 documented a total of 46 residents living at the facility. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 2. The former Administrator was inserviced on employee background checks on 5/31/24 by V11. 3. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 4. 100% of employee background checks were audited on 5/31/24 by V1. 5. V5, Current Administrator/BOM, will review all employee new hires for complete background checks as indicated. 6. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5. The Committee will make recommendations as indicated.

Based on interview and record review, facility staff failed to immediately report to the Administrator an allegation of potential staff to resident misappropriation of funds. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 4/1/24 to 6/10/24. Findings include: On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's (Former Business Office Manager) office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 (Former Administrator) of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this happened on a Thursday, and V6 stated V3 was here the remainder of that day at least until 1:30pm when V6 gets off. V6 stated she returned to work the following Tuesday and heard V3 had been walked out and an investigation started. An undated letter to V1, signed by V6, stated, (V7) said (V3) is always so poor and always broke, (R3)'s money should be monitored closely. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 (Regional Director of Clinical Operations) who said an investigation had begun. V10 stated, I don't think (R1) really understands really what happened. On 8/8/24 at 1:45pm, V1 stated she considered V6 to be a disgruntled employee, and when V6 approached her with the letter on 5/23/24, she considered it to be about, Staff drama. V1 did state the letter said that according to V7, V6 should keep a close eye on R3's money. V1 stated she discussed the letter with V16 (Corporate Marketing Director), Who must have notified (V11). V1 stated she then gave the letter to V11 and the investigation was started. V1 stated as far as she knew, V3 was doing her job, and V1 did not suspect V3 of misappropriating resident funds. V1 stated at some point not sure when V10 approached V1 with a check written on R1's checking account, and V1 stated she did not realize V10 was reporting potential misappropriation. V1 stated for Easter 2024, the previous corporation gave the facility $500 for a community easter egg hunt, and there was a rumor going around that V3 stole $5 bills out of three or four eggs for the kids. V1 stated at that time she asked V3 about it, which V3 denied. On 8/13/24 at 8:50am, V16 stated V1 showed her a letter on 5/23/24 written by V6 stating V6 was told by V7 not to trust V3 with R3's trust account. V16 stated she advised V1 to immediately notify V11 and to start an investigation. V16 stated the following day, V16 asked V11 if V1 had contacted her about the letter, which she hadn't. V16 stated she informed V11 about the contents of the letter, and V11 started an immediate investigation. V16 stated she was present during an interview with V3 during the investigation in which V3 was unable to produce receipts for the missing money as outlined above. V16 stated when the investigation was initiated, V16 retrained all facility staff about reporting abuse and misappropriation and provided staff with a copy of the current Abuse Policy. V16 stated staff are to report any knowledge or suspicion of abuse, neglect, or financial misappropriation to the Administrator immediately. A Facility Matrix dated 8/1/24 documented a total of 46 residents living at the facility. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. An Abuse Prevention Policy dated 11/28/16 documented in part, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Upon learning of the report, the Administrator or designee shall initiate an investigation. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 2. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. 3. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 4. V11 will review abuse reports weekly for four weeks to ensure thorough investigations are being completed. 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current Business Office Manger). The Committee will make recommendations as indicated.

Based on interview and record review, the facility failed to begin an immediate investigation into an allegation of staff to resident misappropriation. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 5/23/24 to 6/10/24. Findings include: On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's (Former Business Office Manager) office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 (Former Administrator) of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this happened on a Thursday, and V6 stated V3 was here the remainder of that day at least until 1:30pm when V6 gets off. V6 stated she returned to work the following Tuesday and heard V3 had been walked out and an investigation started. On 8/7/24 at 9:05am, V10 (Transportation) stated she was hired on 2/1/24. V10 stated from the beginning of her employment, twice a month she would take R1 to R1's bank with a check written for cash, R1 would get the cash and V10 would take R1 to a liquor store to buy a carton of cigarettes. When they returned to the facility, she or R1 would give V3 the remainder of the money, which V3 had stated was being put toward R1's room and board. V10 stated V3 never gave R1 a receipt. V10 stated the checks were never written for the same amount, and the checks written on the first of the month would be written for anywhere from $2000 to $2500, with the checks written toward the middle of the month between $300 to $700. V10 stated she found this situation confusing and felt something was off about it. V10 stated she went to V1 about it on the morning of 5/23/24 and told her to look into this money thing with R1. V10 stated, I made myself clear that I thought something was not right about it. (V1) was rustling papers around on her desk and not listening to me. She said I don't deal with that, that's the business office take it up with (V3). V10 stated she then approached V16 (Corporate Regional Director of Marketing) and talked to her about it. V10 stated the next day, she was interviewed by V11 who said an investigation had begun. V10 stated, I don't think (R1) really understands really what happened. An undated letter to V1, signed by V6, stated, (V7) said (V3) is always so poor and always broke, (R3)'s money should be monitored closely. On 8/8/24 at 1:45pm, V1 stated she considered V6 to be a disgruntled employee, and when V6 approached her with the letter on 5/23/24, she considered it to be about, Staff drama. V1 did state the letter said that according to V7, V6 should keep a close eye on R3's money. V1 stated she discussed the letter with V16 (Corporate Marketing Director), Who must have notified (V11) (Regional Director of Clinical Operations). V1 stated she then gave the letter to V11 and the investigation was started. V1 stated as far as she knew, V3 was doing her job, and V1 did not suspect V3 of misappropriating resident funds. V1 stated at some point not sure when V10 approached V1 with a check written on R1's checking account, and V1 stated she did not realize V10 was reporting potential misappropriation. V1 stated for Easter 2024, the previous corporation gave the facility $500 for a community easter egg hunt, and there was a rumor going around that V3 stole $5 bills out of three or four eggs for the kids. V1 stated at that time she asked V3 about it, which V3 denied. On 8/13/24 at 8:50am, V16 stated V1 showed her a letter on 5/23/24 written by V6 stating V6 was told by V7 not to trust V3 with R3's trust account. V16 stated she advised V1 to immediately notify V11 and to start an investigation. V16 stated the following day, V16 asked V11 if V1 had contacted her about the letter, which she hadn't V16 stated she informed V11 about the contents of the letter, and V11 started an immediate investigation. V16 stated she was present during an interview with V3 during the investigation in which V3 was unable to produce receipts for the missing money as outlined above. V16 stated when the investigation was initiated, V16 retrained all facility staff about reporting abuse and misappropriation and provided staff with a copy of the current Abuse Policy. V16 stated staff are to report any knowledge or suspicion of abuse, neglect, or financial misappropriation to the Administrator immediately. An IDPH (Illinois Department of Public Health) Notification Form dated 5/24/24 at 9:40am documented, Staff reported an allegation of misappropriation of resident property. Staff member immediately suspending pending the results of investigation. POA (Power of Attorney), MD (Medical Doctor), and Police notified. Final (Report) to follow. A List of Resident Trust Accounts from 2/1/24 through 5/24/24 documented R1 through R50 as having a resident trust account during that time period. A Facility Matrix dated 8/1/24 documented a total of 46 residents living at the facility. An Abuse Prevention Policy dated 11/28/16 documented in part, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Upon learning of the report, the Administrator or designee shall initiate an investigation. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. V3 was suspended on 5/24/24 and terminated on 6/10/24 by V1. 2. V3 was removed from as an authorized user of the resident trust account on 5/31/24 by V4. 3. Facility staff were inserviced on the Abuse policy with a focus on misappropriation of resident property on 5/31/24 by V16. 4. V11 will review abuse reports weekly for four weeks to ensure thorough investigations are being completed. 5. The results of the above audits will be discussed in the Quality Assurance meeting with any discrepancies/patterns/trends discussed by V5 (Administrator/Current Business Office Manager). The Committee will make recommendations as indicated.

Based on observation, interview, and record review the facility failed to implement interventions and follow facility policies to prevent falls for three of three residents (R1, R2, and R3) reviewed for falls in the sample of 3. These failures resulted in R1 having injuries including a dislocated shoulder and an intertrochanteric fracture of the right femur. The findings Include: 1. R1's Face Sheet documents an admitted [DATE] with diagnoses including: Hemiplegia following unspecified cerebrovascular disease affecting right dominated, Essential hypertension, End stage renal disease, Type 2 diabetes with diabetic peripheral angiopathy, Unspecified sequelae of cerebral infarction, Unspecified systolic heart failure, Peripheral vascular disease, unsteadiness on feet, Cerebral infarction, reduced mobility, Muscle wasting and atrophy, Aphasia, and right peri trochanteric femur fracture with a long cephalomedullary nail (Closed 2 part intertrochanteric fracture of right femur). R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 14, indicating R1 is cognitively intact. Section G documents: self-performance for transfers as an extensive assistance (resident involved in activity, staff provide weight bearing support) and support as 3 indicating two persons physical assistance, toilet use is documented as a 3 for self-performance indicating; extensive assistance (resident involved in activity, staff provide weight bearing support) and support as a 2 (one-person physical assist). R1's nursing summary dated 08/21/23 notes, right side flaccid. R1's Nursing summary dated 11/21/23 notes, alert and oriented with forgetfulness. R1's Fall Risk assessment dated [DATE] documents a score of 18, this form documents a score of 10 or higher is a high risk. R1's Care Plan documents: Category: Falls: Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Has CVA (Cerebrovascular Accident) impacting mobility, hemodialysis three times weekly effecting endurance with a start date of 08/23/23. The Goal dated 02/21/24 documents: Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors through next 90 days. Interventions are documented as: Review quarterly and as needed during daily care and services of resident's plan for safety, giving verbal cues as needed to gain resident participation in minimizing risk factors and injury with a start date of 08/23/23. Encourage and assist placement of proper nonskid footwear with a start date of 08/23/23. Attempt to anticipate needs: toileting, hydration, hunger and provide cares before resident attempts to fulfill on own with a start date of 08/23/23. Fall risk assessment quarterly and as needed with change in condition or fall status with a start date of 08/23/23. Resident reminded to use call light when assistance needed for transfers and help with toileting. Call do not fall sign put in room with a date of 10/17/23. Non-skid strips applied to bedside for fall prevention with a date of 10/26/23. Reeducate on safety repeat demonstration on call light use with a date of 11/05/23. Grabber provided so resident can reach things while in bed with a date of 11/15/23. Resident to wear proper fitting shoes with a date of 12/13/23. Locked wheels on bed and wheelchair with a date of 12/16/23. ER regarding the fall, see order with a date of 01/03/24. R1's Nurse's Note dates 11/04/23 at 11:55 PM documents: R1 fell on floor laying on right side, R1 stated I have to take a s*** assisted up R1 and taken to the toilet. R1 had already became incontinent of bowels. ROM same denies hitting head. No apparent injury noted. Resident reminded to use call light for assistance, R1 voices understanding. R1's Nurse's Notes on 11 /06/23 at 8:30 AM document: R1 complains of shoulder pain form his fall on 11/04/23 left a message with V11's (Medical Doctor) office for x-ray waiting for call back. At 8:45 AM x-ray ordered. On 11/08/23 X-ray order shows dislocation to shoulder and sling ordered. R1's patient report form radiology dated 11/08/23 documents; reason for visit: post fall with complaints of pain to the right upper arm and shoulder with a date of service of 11/07/23. The section titled, Impressions: Inferior shoulder dislocation. There was no new fall investigation for R1 provided for review for the fall occurring on 11/4/23. (Resident reminded to use call light when assistance needed for transfers and help with toileting was implemented 10/17/23) R1's Nurse's Note on 01/03/24 at 5:45 AM documents: At approximately 3:00 AM CNA (Certified Nursing Assistant) notified V4 (Licensed Practical Nurse/LPN) of R1 on floor in the bathroom. CNA told V4 she assisted R1 onto toilet and gave R1 the call light to ring when he was done. CNA notified V4 (LPN) right after that R1 was lying on his back on the floor. R1 denied hitting his head at the time. R1 has complaints of pain to right hip. R1 was assisted back to bed. V11 (Medical Doctor) sent R1 to emergency room (ER) for evaluation for fracture. When EMS (Emergency Medical Service) arrived R1 was loaded on the stretcher, R1 told EMS he hit his eye when he fell . R1 was transported to hospital via ambulance at approximately 3:30 AM. R1's Quality Care Reporting Form documents an alleged fall on 01/03/24 at 3:00 AM, ROM (Range of Motion/Extremities ): Unable to move right hip, Pain Location: right hip, What does the resident say happened: fell getting off toilet, what fall prevention techniques were in use prior to fall: call light within reach, slipper socks on, Why did the fall occur: res non-compliant with call light use, What are you doing differently to prevent another fall right now: Encourage resident to use call light. The facility document titled, Investigation Report for falls dated 01/03/24 documents: Areas of concern identified for further analysis: with Res (Resident) non-compliant with call light use and what new intervention was implemented to prevent any further falls? with Remind/encourage res (resident) to use call light for assistance as a response. The section titled, Falls: Resident-Root Cause with R1 at 3:00 AM fracture hip, fell off toilet, educate on call light. R1's Nurse's notes on 01/10/24 at 7:30 PM document: R1 returned to facility via a stretcher with EMS from the hospital. R1's returning diagnosis was right femur fracture with IM (Intramedullary) nail repair. R1's report from (Orthopedic specialist) dated 01/31/24 documents: referral to Physical Therapy with a diagnosis of Closed 2-part intertrochanteric fracture of right femur, initial encounter. On 02/21/24 at 10:55 AM, R1 stated he had a fall in the bathroom during the night. R1 stated, he was assisted to the toilet, but he was finished, and he was trying to transfer himself back to the wheelchair as he was ready to go back to bed. R1 said, he always required assistance for a safe transfer. R1 stated, he was ready to go to bed and he thought that they didn't want to have to put him to bed. R1 stated, he doesn't recall how long he laid on the floor of the bathroom or how long he had waited on the toilet to be transferred to his wheelchair. On 02/21/24 at 1:15 PM, R1 stated he has had some falls. R1 stated he will have dreams at night that he can still walk, and he will need something or get confused and will get up. That is how he fell the last time. He cannot put any weight on his leg or knee, it just gives out. On 02/23/24 at 2:52 PM, V4 (Licensed Practical Nurse) stated, she worked the evening of 01/03/24 when R1 had the fall that fractured his femur. V13 (CNA) went down to assist R1 to the toilet. V13 stated R1 asked her to leave the bathroom while he was using the toilet. V4 stated she is unaware if V13 stayed outside the door and waited or if she left, she does not know V13 told her she gave R1 the call light before she left him. V4 stated R1 is non-compliant with using a call light and he does get confused, has impaired decision making, and has had hallucinations before at night. V4 stated, V13 was new and was not that familiar with R1. Attempts to contact V13 for an interview during the survey were unsuccessful. On 02/22/24 at 2:45 PM, V2 (Director of Nurses/DON) stated residents including R1 should not have the same intervention used more than once. V2 stated she does see where; reeducation on using his call light was used more than once as an intervention for R1's falls. V2 also stated, send to ER (emergency room ) for evaluation is not an appropriate intervention, it does not help prevent any future falls. V2 stated, she does see where R1 has had several falls. On 02/21/24 at 10:35 AM, V9 (CNA) stated there should be a list at the nurse's station that has all of the interventions listed. She stated that the nurses usually tell the CNA's the new interventions. V9 states that we don't always know what is going on. V9 stated she did not know what intervention was put into place after R1's fall. On 02/21/24 at 10:35 AM, V10 (CNA) stated, the nurses are supposed to tell us about new interventions that are put into place. V10 stated that she doesn't know anything about an intervention list. V10 (CNA) also states that she doesn't know the interventions for R1 after his fall. On 02/21/24 at 10:40 AM, V6 (LPN) stated that there is no list of fall interventions kept at the nurse's station. V6 said she is knowledgeable of interventions by looking at the care plans or from report from the nurse that she is relieving. V6 said that the nurses inform the CNA's whenever there is a new intervention put in place. On 02/21/24 at 10:00 AM, V1 (Administrator) stated they have had people with several falls, they are just not on the fall log, they have been behind with the fall log, but all the investigations should be in the fall book. V1 stated, they do not do fall investigations with interviews and that type of investigation if the fall is unobserved, because it is unobserved. On 02/21/24 at 10:00 AM the fall book was reviewed, there was one fall investigation in the book, there were no fall investigations for R1. On 02/22/24 at 10:30 AM, V2 (Director of Nursing) stated she has not been at the facility that long but there should definitely be more than four falls on the fall log for January and she does not know why there are no falls on the fall log for February. V2 also stated there should be more than one fall investigation in the fall book, she does not know why there is only one investigation in the book. On 02/21/24 at 2:40 PM, V3 (MDS/ Care Plan Coordinator) stated that a Fall Risk Assessment should be done with every fall. V3 stated that the floor nurse that is taking care of the resident at the time of fall is responsible for doing the Risk Assessment. V3 also stated that the nurse in charge of the resident at the time of fall is responsible for implementing an appropriate intervention and writing that on the care plan that is in the chart. V3 stated the falls are reviewed every morning in the Quality meetings with department heads. V3 stated they may change an intervention at that time. V3 was asked if the charts go to the meeting, so they can review the care plan to see what intervention if any was put into place by surveyor. V3 replied no but we should . V3 was asked if the Risk assessment was reviewed during the QA meeting and she said no, but it should be. V3 stated, the charge nurse also fills out the fall packet when a fall occurs. V3 was asked if the Fall Risk Assessment tool was in the fall packet so it is available for the nurse, and she said no. 2. R2's Profile Face Sheet documents an admitted [DATE]. R2's Physician Order Sheet documents diagnoses of Pneumonia, CHF (Congestive Heart Failure), Respiratory Failure with hypoxia, Increased INR (International Normalized ratio). Additional diagnoses were noted on hospital notes dated 2/16/2024 of diagnosis of Bell's palsy, COPD (Chronic Obstructive Pulmonary Disease), HTN(Hypertension), GERD (Gastroesophageal Reflux Disease), Hypothyroidism, Pneumonia, Dementia and COVID-19. R2's Fall Risk Assessments includes assessments dated 9/12/2023 and 12/12/2023 and document the following. The score on 9/12/2023 is documented as 17. The score on 12/12/2023 is documented as 18. This assessment tool reads: 10 points or more = High Risk Score. There are no other assessments noted on this document. Request of more recent Fall Risk Assessments were not received. R2's Care Plan for the section of falls contains documentation of review date of 6/11/2023. R2's Care Plan documents a Problem/ Need of resident has risk factors that require monitoring and interventions to reduce the potential for self-injury. An Approach/ Intervention dated 2/22/22 documents Review quarterly and PRN (as needed) resident's ADL (Activities of Daily Living), mobility, cognitive, behavior, and overall medical status. IDT (Interdisciplinary Team) review of changes and needs w/ (with) resident and/or responsible party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed. The following interventions are handwritten on the care plan: Reminded (R2) to use call light, continue with skilled therapy dated 2/8/22; non-skid socks and education on call light re-introduced, dated 2/8 (no year documented); reminded R2 when feeling sleepy go lay in bed, dated 7/15/22; 15 minute checks, dated 8/9/22; remind R2 to wear O2 (oxygen) as MD ordered, offer to plug in cell phone at bedtime, dated 8/13/22; send R2 to ER, remind R2 to ask for assistance when transferring, dated 10/6/22; remind staff to offer R2 assist, continue above intervention, dated 10/21/22; Show R2 where urinal is placed, remind R2 if he can't find items to ask for help, dated 10/31/22; frequent visual checks, educate R2 to sit more towards middle of bed, dated 11/29/22; ensure R2 has O2 on and is properly working, refer to skilled therapy, dated 12/19/22; ensure O2 tubing doesn't interfere with ADL's, dated 2/2/23; red tape on O2 tubing so R2 can see where tubing is placed, dated 2/9/23; non-skid strips in front of recliner on floor, dated 3/13/23; remove recliner from room, dated 5/9/23; call don't fall sign in room as a reminder, dated 8/9/23; ER after fall with right hip pain, no new orders, dated 8/9/23; orthostatic BP (blood pressure) x 3 days report if not WNL (within normal limits) to MD, dated 8/15/23; re-educate on use of call light when tried to prevent falling out of wheelchair, dated 8/28/23; PT/ ST (Physical Therapy/ Speech Therapy) orders see POS (Physician's Order Sheet), dated 9/23/23; D/C (discontinue) therapy, dated 10/16/23. There was no new intervention noted for the falls on 2/16/2024 nor 2/18/2024. R2's nurses notes for the date of 2/16/2024 at 5:20 AM reads: Heard res (R2) calling out for help found R2 laying on right side near wheelchair. R2 is able to move all ext (extremities) except limited ROM (Range of Motion) to right wrist, lg (large) hematoma to right wrist. Documentation on 2/16/2024 at 5:59 AM reads: R2 states I fell asleep in wheelchair. V8 (CNA) had made several attempts to get R2 to lay down and refused each time. Late entry 5:25 AM Phoned ambulance service. 6:00am R2 to ER for evaluation. On 2/16/2024 at 9:25 am returned from (name of local hospital) Right wrist sprain. Ace wrap applied to area. No new orders. Investigation Report for Falls for R2 completed for the fall on 2/16/2024 documents the following: the areas titled, areas of concern identified for further analysis this area is blank. Another area titled, what new interventions was implemented to prevent any further falls? was blank as well. R2's Nurses Notes by V10 (LPN) for 2/18/2024 document, CNA at NS (Nurse's Station) heard noise in (R2's Room). Found (R2) laying on floor called for the nurse, body assessment shows no apparent injury. (R2) denies pain, moves all extremities (ext.) without difficulty. Assisted up x2 and gait belt into wheelchair then into bed after couple mins. ROM (Range of Motion) WNL (Within Normal Limits) denies hitting head. Denies pain or discomfort 'not even this hurts.' (R2) holding right wrist, 'it's almost healed already.' (R2) call light was in reach prior to fall, had grippie socks on, 1:1 to place call for assist at least for a few days. (R2) voiced understanding states, 'I will, I will.' When asked what he was trying to do 'I stood up tried to get into my wheelchair but hit the edge and I just fell down.' (R2) was going to put pictures away. Investigation Report for Falls for R2 completed 2/19/2024 for the fall occurring on 2/18/24 documents the following: the areas titled, areas of concern identified for further analysis is blank. Another area titled what new interventions was implemented to prevent any further falls? was blank as well. A document titled Quality Care Reporting Form date 2/18/2024 for the fall occurring that date was reviewed. This document has information on assessments, time and date of fall, and notifications, these areas were completed, however there are areas on this form that are left blank, such as, MD notification, Investigation completed, and Date of QA review, these areas are blank. This document was signed by V1(Administrator). 3. R3's New Admission Sheet documented R3's initial admitted to facility as 1/11/2024. R3's Physician Order Sheet documents diagnoses including Gastrointestinal Bleed, Abdominal Mass, Adenocarcinoma, and Metastatic Mass. R3's Minimum Date Sheet (MDS) dated [DATE] documents R3 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R3 is cognitively intact. The same MDS in section GG documents that R3 requires ambulation with a walker and a wheelchair and self-care is noted as independent. R3's Fall Risk Assessment sheet in the medical record documented an assessment dated [DATE] and documents a score of 9. The document instruction notes that 10 points or more = High Risk Score, indicating that R3 is not considered a High Fall Risk. There were no other assessments documented on R3's Fall Risk Assessment sheet. Despite the fact that he had multiple falls documented on 1/24/24, 1/26/24, 1/27/24, and 1/31/24 the fall assessment completed on 1/11/2024, which is the only assessment completed, has under history of falls 0, which leaves the score as a 9 which is not considered a high fall risk. R3's Skilled Progress Note notes on 1/24/2024 at 10:45 AM, R3 was seen getting up from wheelchair to walk across the hall, he lost his balance and fell face hit the doorframe, he landed on right side. Has a small cut on bridge of nose, red area on left cheek. At 12:15pm during neuro (neurological) check noted more confusion and slurred speech. Resident (R3) complained of right arm shoulder pain and dizziness. Sent R3 to ER (emergency room ) for evaluation. Ambulance service called. R3 taken to the hospital at 12:45pm. New orders for Magnesium Oxide and Potassium Chloride. Right sided weakness noted, V11 (Medical doctor) faxed of R3's (con) condition and (NO's) new orders. R3's local hospital Emergency Department (ED) records dated 1/24/2024 documented R3 had a recent stroke that was approximately a week old. The hospital records from hospital were reviewed and CT (computed tomography) scan that was performed on 1/24/2024 reads as, Impression: There is no intracranial stenosis or signs of acute vascular occlusion nor intracranial aneurysm or vascular malformation. The HPI (history of present illness) reads on 1/24/2024 at 16:29 (4:30 PM) This [AGE] year-old white male presents to ED via EMS (Emergency Medical Service) with complaints of signs and symptoms of possible stroke. Patient (R3) fell out of a chair today, patient (R3) is saying that he has a weakness on the right side for about a week, also his speech is not clear. He has appointment with oncologist tomorrow regarding his adenocarcinoma of the rectum and thinks that patient (R3) will not have any therapy due to mental status of this disease, but she is not sure yet what she and her father will decide about it, waiting on oncologist opinion. R3 returned to the facility at 1900 (7:00 PM) with new orders for Magnesium and Potassium due to abnormal labs. R3 had a recent stroke that was approximately a week old. R3 returned to the facility that evening with new orders for Magnesium and Potassium due to abnormal labs. R3 had a recent stroke that was approximately a week old. There was no documentation in the hospital records of injuries sustained from the fall. On 2/22/2024 at 1012AM, the fall packet and investigation were requested from V1 and again on 2/22/2024 2:00PM from V2. There was no fall packet or investigation provided from V1 or V2 for review during the survey. R3's Skilled Progress Note on 1/26/2024 at 4:30 AM documents: Heard voice found R3 sitting on floor near doorway leaning against nightstand and trash can. R3 has small skin tear above right elbow. R3 stated that he was going outside. 1-1 right time of day dark outside. R3 voiced understanding. Denies need for care but also agrees to call for assist when wants to get up and walk and get into wheelchair. R3's Skilled Progress Note on 1/27/2024 at 4:30 PM documents: R3 was noted laying on his back on the floor in his room. R3 stated he does not know why he got up from bed. No injuries found on R3. Able to move all extremities the same as prior to fall without pain. No shortening or rotations of lower extremities. Denied hitting head. No evidence of head injury noted. Assisted with gait belt and assist x2 to wheelchair. All parties notified of incident. Vital signs 98.9-108-20-120/76. R3's Post Fall Root Cause Worksheet dated 1/27/2024 documents as a heading Bring Chart/Care plan/ 24-hour report. Under the heading of number 10 of this document, Assess fall location for potential contributing factor, circled call light off, and noncompliance with safety reminders. Number 18 on this document's states Safety Measures and Interventions: call light, floor mat, low bed, call don't fall sign. The question listed as: Were all care plan interventions carried out? Marked yes. The worksheet has a designated area for Root Cause Analysis, this area was left blank. This document also has a question that states, what interventions to prevent another fall need to be implemented today? Written answer to this question is documented Nonskid socks at all times. Next written question is Why this Intervention? Documented: To prevent feet sliding. R3's Skilled Progress Notes for 1/31/2024 document that at 10:10 AM R3 was observed on the floor next to bed. R3 states he slid off bed trying to get up, assessment done no s/s (signs/ symptoms) injury, denies hitting head, assist back to bed, nonskid strips applied to floor next to bed for fall prevention. The Quality Care Reporting Form for R3 dated 1/31/24 The documents the time of fall, assessment, notifications, and vital signs. A specific area of this document was titled Investigation Completed date was left blank. Another area was titled Date of QA Review date was also left blank. The area of this document titled Summary of event and any action taken documented Non-Skid Strips applied to bedside. This document is signed by V1. R3's Investigation Report of Falls dated 1/31/24 in the section that is titled Observations it documents was (R3) wearing adequate footwear? with a documented response of No socks on. The section Completed by and date at the bottom of the document, was missing a date. R3's Fall Risk Assessment sheet in the medical record documented an assessment dated [DATE] and documents a score of 9. The document instruction notes that 10 points or more = High Risk Score, indicating that R3 is not considered a High Fall Risk. There were no other assessments documented on R3's Fall Risk Assessment sheet after R3's documented falls on 1/24/24, 1/26/24, 1/27/24, and 1/31/24. R3's Care Plan dated 1/18/2024 documented in the Fall section interventions listed, Call Don't Fall sign in room, Nonskid socks at all times, and soft mat in floor by bed. These interventions all fell under the date of 1/18/2024. No new interventions noted past that date. On 2/21/2023 an observation of R3's room was conducted to validate all intervention indicated on the Plan of Care dated 1/18/2024, were in place. Call Don't Fall sign was on the wall beside R3's bed. Nonskid strips were beside the bed on the floor. The Plan of Care documents that R3 has a soft mat beside the bed, a soft mat was not located in the room. The facility document dated 11/10/18 titled, Fall Prevention documents: Procedure: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM (Assess, Intercommunicate, Manage) or Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. The facility document dated 07/01/12 titled, Notification for Change in Resident Condition or Status Procedure: 1. The nurse supervisor/change nurse will notify the resident's attending physician or on call physician when there has been: a. Any symptom, sign or apparent discomfort that is: 1. Sudden in onset, 2. A marked change 3. Unrelieved by measures already prescribed. B. An accident or incident involving the resident; c. A discovery of injuries of an unknown source; h. A need to transfer the resident to a hospital/treatment center.

Based on interview and record review, the facility failed to provide supervision to an intoxicated resident with a history of falls to prevent future falls, failed to investigate the source of an unwitnessed injury as a potential suicide attempt, and failed to update a resident's care plan to include new interventions for episodes of intoxication for 1 resident(R1) of 4 residents reviewed for accidents and supervision in the sample of 4. This failure resulted in R1 sustaining a fall on 12/19/22 resulting in a fractured left hip and sustaining a fall on 3/24/23 resulting in sutures and staples to the back of the head and neck. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documented the following: Diagnoses of Heart Failure, Unspecified, Essential Primary Hypertension, Chronic Obstructive Pulmonary Disease, and Unspecified Atrial Fibrillation. R1's admitted was 09/30/22. R1's Brief Interview for Mental Status Score was 14, indicating R1 is cognitively intact. R1's Mood Indicators document little interest or pleasure in doing things, and feeling down, depressed, or hopeless, for 7-11 days in the 14 days look back period. R1 requires assistance of at least one staff member for bed mobility and transfers. R1 displayed no behaviors in the 14-day lookback period. R1's Fall Risk assessment dated [DATE] documented a score of 18, indicating R1 is at high risk for falls. R1's Care Plan dated 2/1/23 listed a problem area, Falls: Resident has risk factors that require monitoring and intervention to reduce the potential for self-injury. This problem area documented the following interventions: 12/29/22: Xray left hip. Education related to drinking while outside the facility. Med (medication) times changed. 12/20/22: Sent to ER. There were no fall interventions added for R1's 2/26/23, 3/24/23, and 3/27/23 falls. There were no interventions targeting toward keeping R1 safe from falls while intoxicated. There was no problem area nor interventions on the Care Plan addressing R1's possible suicide attempt on 3/24/23. A Fax Worksheet IDPH (Illinois Department of Public Health) Notification Form dated 3/24/23 documented, Time of incident: 4:15pm. (R1) returned a visit with family with no injuries noted at the time. At approximately 4:15pm, staff entered (R1)'s room, noting lacerations to his neck .When asked what had happened, (R1) who is alert and oriented, stated he tried to kill himself. (R1) was sent to ER (emergency room ) for tx (treatment), investigation started per (facility) protocol, final follow up report to follow. A Final Report document dated 03/31/23, submitted via fax to IDPH, stated, This letter will serve as a follow up and final report to the initial report submitted on 03/24/2023 regarding an alleged suicide attempt involving (R1) On 03/24/2023, (R1) had returned from and outing with family (at) around 1:43 pm. (R1) was noted on the floor by staff. (The) Nurse assessed (R1), noting a scratch on his neck; (The) nurse cleaned (the scratch) and (R1) resumed (his) normal routine. (V8-Social Services Designee/SSD) checked in with (R1) (and) he told (V8) he had cut himself shaving, (and) reported to her he had fallen while out with his brother. (R1) was also noted to have an empty bottle of rum on his person. When asked if he had been drinking (R1) replied, 'Yes, I have.' At approximately 4:10 pm staff noted (R1) on the floor with blood on his face, neck, and shirt. (The) nurse was notified and she assessed (R1) noting, (a) laceration to (the) back of (the) head and neck. (V5 - Physician) (was) notified with (an) order given to send (R1) to (the) ER (for) eval(evaluation) and treatment. When asked what happened, (R1) stated, I slit my neck with a razor knife. (R1) received 3 staples to the back of his head and 3 sutures to his neck. On 3/27/2023 (R1) spoke to (V1 - Administrator) and apologized for telling staff he slit his neck with a razor knife and that he was just joking. Investigation revealed that (R1) admitted he did not try to commit suicide and he was just joking, however per (R1) he had consumed alcohol while on an outing with family and that he was attempting to self-transfer from his bed to his wheelchair when he lost his balance and fell . Root cause (of fall): Drinking alcohol, causing unsteady gait, and attempting self- transfer from bed to wheelchair. New Intervention (added): Educate (R1) on the effects of drinking alcohol while out with family or friends. (V8 is) to follow (R1) three times weekly regarding (the) effects of drinking. (R1) is on a waiting list for an apartment . 3/24/23 (ER) Physician Documentation noted, (R1) was trying to get into bed and fell , causing cuts to face and scalp. Bleeding a lot. Was out with brother to local tavern during a day pass today. Wounds: #1. 1cm (centimeter) laceration. to left jaw. Skin closed using simple sutures. #2. 1cm laceration .to left jaw. Skin closed using simple sutures. #3. 2cm laceration .to scalp. Skin closed with three staples using staple gun. #4. 2cm .laceration to face. Skin closed using simple sutures. R1's Care Plan with a review date of 2/1/23 documented a problem area, (R1) is noted to smell like alcohol and states 'I'm drunk' after returning from friends visit, (R1) continues to drink when out with his brother and friend. The following are the interventions for this problem area: 02/26/23: Education provided to (R1) about the facility being alcohol free after bringing alcohol into the facility again. Undated: Education was provided to (R1) related to drinking while in the facility. Undated: Education provided again to (R1) and brother related to drinking outside the facility and returning intoxicated, and the risk it has on the med(medications) (R1) is taking. Undated: (V8) to remind (R1) of policy and procedures. There was no indication in this document that R1 was screened by a mental health professional for suicidal ideation or behavior, nor for the potential need for inpatient psychiatric care. There were no interventions related to offering R1 access to a substance abuse evaluation/treatment/AA (Alcoholics Anonymous). There were no interventions outlining keeping R1 safe when he is intoxicated. There were no interventions related to restricting R1's access to alcohol which he sneaks in. There were no interventions regarding holding any of R1's medications when he is intoxicated. There were no interventions related to the safety of R1's peers when R1 is intoxicated. An SBAR (Situation, Background, Assessment, and Recommendation) Communication Form dated 12/19/22 at 1:45pm documented, (R1) fell in bedroom. (V4 - Physician) notified. See corresponding Nurses Note. (R1) Denies pain at this time. Recommendations-Monitor; change Verapamil and Plavix med(ication) times to 8:00pm with instructions to hold these med(ications) if (R1) consumes alcohol that day. A corresponding Nurses Note dated 12/19/22 at 1:30pm documented, (R1) on LOA (Leave of Absence) with friend. When he returned, this nurse was summoned to his room with a report of a fall. Upon assessment, (R1) (was) noted to smell heavily of alcohol and was sitting on the floor on his buttocks with his feet pointed to(ward) the bed. (R1) stated he was trying to get in bed and his shoe slipped. (His) shoes were still on his feet and the floor was noted to be dry. No signs or symptoms of injury. (R1) was assisted up and to bed. Reeducated on the need to abstain from drinking alcohol related to his medications and the risk of falling. Resident did not respond verbally when asking if he understood. (The incident was) reported to management. Notified (V15 -Nurse Practitioner/NP) of the fall. Cardiac med(medication) times (were changed) to 8pm with instructions that if (R1) consumes alcohol that day, then cardiac meds need to be held that evening. A Nurses Note dated 12/19/23 at 2:00pm documented, Assessed (R1) for pain, he denies pain at this time. He was sleeping. No other discomfort noted. The next Nurses Note is dated 12/19/23 at 8:30pm (Portable Xray Company) here to x-ray residents left hip. There were no Nurses Notes to indicate what happened between 2:00pm and 8:30pm. A Physicians Order dated 12/19/23 and signed by V15 stated, (Obtain) 2 view x-rays of left hip. An Xray Patient Report dated 12/19/23 at 9:21pm documented, Acute left femoral neck (hip) fracture. On this report was handwritten at the bottom, (Order received to) Send to ER for evaluation and tx. An ER Provider Note dated 12/20/23 documented,(R1) is brought to the ER. Patient fell while trying to get back in bed, patient fell on the left hip. Xray revealed a left femoral neck fracture .fell yesterday at the facility. Did not complain of pain at the time Alcohol use: Yes. Occasional binge. On 04/05/23 at 8:45am, V1 (Administrator) was asked to provide the investigation for the above referenced incident. V1 stated she had not done a written investigation because she is fairly new to the position and did not realize she should. On 04/05/23 at 9:10am, R1 was alert and oriented to time, place, and person. At this time, R1 had no sutures or staples to the head or neck. R1 stated he goes out with his brother and/or a friend usually once a week on weekends and may or may not drink alcohol during these visits, depending on his mood that day. R1 stated he does not have a problem with alcohol. R1 stated after being out of the facility with his brother on 12/19/23, when he returned, he fell during an attempted self-transfer. R1 stated initially he had no pain or other signs of injury, but as the day wore on, he began experiencing pain in his left hip, and an x-ray showed a left hip fracture. R1 denied being intoxicated at that time but did acknowledge he may have been 'buzzed.' R1 stated that on 3/24/23, he returned to the facility after being out with his brother and may have been 'buzzed' but was not intoxicated. R1 stated he did not fall or otherwise injure himself during this outing. R1 stated he does not recall if on either of these occasions staff searched his person upon returning to the facility. R1 stated early in the afternoon of 3/24/23, he fell in his room while trying to self-transfer from the wheelchair to the bed. R1 stated he sustained a small cut on his neck which staff cleaned and bandaged, but he was not otherwise injured. R1 stated later that same afternoon, he was ambulating in his room and fell against the nightstand, cutting his neck and the back of his scalp. R1 denied that he cut himself or told staff that he had cut himself and stated he would not have had anything to cut himself with. R1 denied having had a knife on his person. R1 stated he was sent to the local ER where his lacerations required sutures and staples. R1 stated he was not having issues with depression or suicidal ideation on 03/24/23 or since then. On 4/5/23 at 1:00pm, V5 (RN/Registered Nurse), stated she was working 6am to 2pm on 3/24/23. V5 stated in the early afternoon, R1 returned from a visit with his brother. V5 stated she is not sure exactly when he returned, but she checked his person and clothing for alcohol, and there was none found, nor any weapons. V5 stated she recalled that she did not smell alcohol on R1, but her sense of smell isn't very good. V5 stated at the end of her shift at around 2:00pm, R1 was found on the floor by his bed and R1 said he fell as he was trying to get himself from the wheelchair to the bed. V5 stated R1 had a small cut to his jaw area which she cleaned and bandaged. V5 stated she assessed R1 and didn't see any other injuries. V5 stated she finished her shift and was relieved by V6 (LPN/Licensed Practical Nurse). V5 stated she later heard from other staff, she is not sure whom, that at about 4:00pm on 3/24/23, R1 cut his throat trying to kill himself, and that a knife was found in his pants pocket when the pants went to the laundry. V5 stated to her knowledge, R1 had no history of suicidal ideation or behavior. V5 stated she is not aware of any new interventions being added after 3/24/23 for R1 falling and/or the reports of him cutting himself while intoxicated. V5 stated the safety plan for R1 when returning intoxicated is to Search him for alcohol when he comes back. V5 stated R1 is known to sneak alcohol into the facility and has been caught drinking in the facility. On 4/5/23 at 1:50pm, V6 (LPN) stated she worked the 2:00pm to 10:00pm shift on 03/24/23. V6 stated she was told by V5 during shift report that R1 had been out that day with his brother drinking, and upon his return, fell in his room at about 2:00pm, causing a scratch to the jaw. V6 stated that around 3pm, she was notified that R1 was in his bed bleeding from the neck. V6 stated she observed three fairly deep, profusely bleeding lacerations to the neck and chin area, as well as a laceration to the back of R1's head. V6 stated R1 told her he didn't know how it happened. V6 stated R1 smelled of alcohol and his eyes were red. V6 stated the ambulance was called and she cleaned R1 up while they were waiting. V6 stated when R1 left in the ambulance, she called the emergency room with report and spoke to V16 (RN at emergency room ). V6 stated after she got off the phone, one of the CNAs (Certified Nursing Assistant) told her that R1 reported to the CNA that he, cut his neck with a razor knife. V6 stated she again called V16 to tell him what the CNA had reported. V6 stated V16 told V6 that R1 would receive a mental health evaluation while at the hospital. When V6 was asked about a safety plan for when R1 comes back home intoxicated, V6 stated, We try to monitor him more frequently. He is usually up in his wheelchair in the dining room, or in his room sleeping it off. V6 stated R1 at times refuses to let nursing staff assess him when he returns, at times will not allow staff to search him, and sometimes the friend or family member with whom he has been out will drop him off at the front door and he will make his way back in unescorted, and half the time we don't even realize he's back in the building. V6 stated when R1 returned from the ER right before the end of her shift, We checked his vitals, did every five-minute check with him and let him sleep it off. V6 stated she assumed that R1 had the mental health evaluation while at the hospital. V6 stated when she returned to work the following day, V4 (Physician) had been in to see R1 and had discontinued the five-minute checks. V6 stated she is not aware of any new safety interventions initiated for R1 following the 3/24/23 incidents. V6 stated R1 is known to sneak alcohol into the facility and has been caught drinking in the facility. When asked if she thought R1's lacerations were self-inflicted, V6 stated in retrospect she is not sure. On 4/5/23 at 2:30pm, V7 (CNA) stated she was working the 2:00pm to 10:00pm shift on 03/24/23 and was assigned to float between the halls. V7 stated about 4:00pm, she saw staff congregated outside R1's room. V7 stated she peeked in, saw R1's bloody neck, and asked R1 what had happened. V7 stated R1 shook head and said, I slit my throat with a razor knife. V7 stated she doesn't think anybody else heard him say that. V7 stated she immediately reported this to V6 (LPN). V7 stated she has not heard R1 make any statements about suicidal ideation or attempts before or since that incident. V7 stated she is not sure if R1 got back from the hospital while she was still on duty. V7 stated when R1 goes out with his brother he frequently comes back drunk and agitated. V7 stated they have to check him to see if he has alcohol on him, but sometimes R1 refuses to let them check. V7 stated R1 is otherwise generally pleasant and cooperative, and she has not seen him become aggressive with peers, nor have peers verbalized being afraid of him. She has never witnessed him fall. On 4/6/23 at 10:15am, V8 (SSD) stated she has been in the position about four weeks. V8 stated on 3/24/23, she worked from 8:00am to 4:00pm. V8 stated about 4:00pm, she was working with another resident on R1's hall, and heard staff say R1 has blood everywhere. V8 stated she looked in the room, where R1 was in bed. V8 stated she looked R1 over and he had three gashes to his neck and a small cut to the jawline which were bleeding profusely, and R1 was holding a towel to the area. V8 stated R1 told her he cut himself shaving. V8 stated she told R1 the cuts looked too deep for a shaving accident, and R1 stated, That's how it happened. V8 stated she noticed the back of R1's head was bleeding. V8 stated V6 came in then and asked V8 what happened, and V8 showed her the cuts and V6 ran out to call an ambulance. V8 asked R1 if he had been drinking on his earlier outing and he said yes. V8 stated R1 said he fell while out and that caused his jaw wound. V8 stated the ambulance came a few minutes later. V8 stated she looked around the room and didn't see anything [NAME] or anything that R1 could have hurt himself with. V8 stated later staff found a bottle of alcohol in R1's room. V8 stated on Saturday 3/25/23, V8 worked a half day. V8 stated R1 was on every five-minute suicide precaution checks so while R1 was in the dining room, V8 watched him from V8's office. When asked what interventions V8 provided on 03/25/23, V8 stated she asked R1 if he was suicidal and R1 said no. V8 stated she did not do any formal assessment that day. V8 stated she has reached out to R1's friends and family members and told them alcohol use is dangerous for R1 because of the medications he is on and because R1 is a fall risk, but they all deny he has a problem, and R1 has told V8 that R1 is buying their alcohol on these outings. V8 stated sometimes they will drop R1 off at front door and he comes back in, and staff don't realize he is back. V8 stated she has discussed the dangers of mixing alcohol with medications many, many times with R1, and R1 always denies he has a problem. V8 stated during 3/27/23 Monday morning staff meeting, two days after R1 came back, V2 (Director of Nurses) told staff that R1 had not had a mental health evaluation while in the hospital. V8 stated she was very concerned that he needed one, as R1 has extremely poor judgement and safety awareness especially while drinking. V8 stated she brought up the possibility of R1 being seen by V11 (Advanced Practice Nurse in Psychiatry), but the consensus of staff was that V11 would not medicate R1 because of his drinking. V8 stated she did not discuss treatment for substance abuse or behavioral health with R1 until the morning of 04/06/23, which she stated was because V8 has only been in the position for four weeks and is just starting to get familiar with the residents.V8 stated she does take part in the Care Plan meetings, but V8 does not think there has been a Care Plan Meeting for R1 since she was hired. V8 stated she has not contacted any substance abuse or mental health treatment providers on R1's behalf. V8 stated she also thinks R1 might benefit from inpatient services at an out of state geriatric mental health program, but V8 has heard they have a waiting list and has not contacted them. V8 stated she does not believe staff routinely search R1's room. As far as a safety plan for R1, V8 stated staff Try to watch when (R1) comes back in and then search him if he will let them. V8 stated she did a Mood Assessment on 3/27/23 and R1's result was a 10, with a score of 10-14 indicating moderate depression. V8 stated her plan with R1 moving forward is to do one to one session with him three times per week for alcohol use education. When V8 was asked about her plan regarding R1's mental health, V8 stated she is not focusing on that because R1 does not outwardly show signs of depression. V8 stated she is not a licensed therapist or social worker. V8 stated R1 wants to move to an apartment, but this is not a feasible goal given his care needs and community history of drinking and becoming homeless. A Mood assessment dated [DATE] documented a score of 10, indicating R1 experiences moderate symptoms of depression, such as feeling down or depressed, or having little interest or pleasure in doing things, 7 to 11 days in the 14 days prior to the date of the assessment. On 4/6/23 at 10:55am, V1 (Administrator) stated that Fall Investigations are internal Quality Assurance (QA) documents and therefore cannot be shared during the survey process. On 4/6/23 at 11:00am, V9 (Corporate Quality Assurance RN) was interviewed regarding R1's falls, with V9 using the QA documents the facility would not allow this surveyor to access. The following is R1's fall history from his 9/30/22 admission to 4/6/23 according to V9's verbal account: 12/19/22 at 1:30pm: R1 was found on the floor of his room in a sitting position. R1 stated he was trying to self-transfer from the wheelchair to the bed, and R1 stated his shoes slipped and he fell . R1 was noted to be wearing appropriate footwear and the floor was dry and clutter free. The root cause of the fall was determined to be altered mental status related to alcohol use. R1 initially denied pain but at around 2:00pm, R1 started to complain of left hip pain so (V15/NP) ordered a portable x-ray, which showed an acute left femoral fracture, for which (V15) ordered R1 to be sent to the emergency room , and R1 was sent out at 8:45pm. The care plan intervention added was to, Educate (R1) about not using alcohol on outings. 2/26/23 at 3:20pm: R1 was coming back in the building from the patio during smoke break when R1 fell . R1 had no injuries and did not require hospitalization . The root cause was determined to be alcohol impairment. The intervention added to the care plan was to Ensure (R1) is safe to participate in smoking act. 3/24/23 at 1:30pm: R1 was found lying on the floor of his room, R1 stated he was trying to self-transfer from the wheelchair to the bed. R1 sustained a skin tear to left side of cheek, which was cleaned and bandaged. R1 was not sent out and no other injuries were noted. The root cause of the fall was determined to be impairment due to alcohol use. The care plan intervention added was to Educate and encourage R1 to use his call light for transfers. 3/24/23 at 4:10pm: R1 was found in bed bleeding from injuries to the neck, back of head, and jaw. R1 stated he did not know what happened. A fall was presumed but later information indicated the injuries could have been self-inflicted. The root cause was determined to be alcohol intoxication. R1 was sent to the emergency room . The new care plan intervention added was to educate R1 about alcohol use. 3/27/23 at 2:30pm: R1 was found on the floor of his room after attempting to self-transfer from wheelchair to bed. R1 stated his boots were unlaced and he tripped. The root cause was determined to be R1's boots being unlaced resulting in R1 losing balance and falling. R1 was not injured and not sent out. The new care plan intervention added was for R1 to request assistance with transfer and to wear proper footwear. On 4/6/23 at 1:10pm, V16 (emergency room RN) stated R1 was treated there on the afternoon of 3/24/23. V16 stated facility staff called with report and stated R1 sustained neck injuries due to a fall. V16 stated a few minutes later, staff called back and reported that R1 reported feeling suicidal, but nothing was said about the injuries potentially being self-inflicted. V16 stated R1 was alert and oriented, and R1 stated earlier in the day he went out and had drinks then came back and fell . V16 stated R1 adamantly denied suicidal ideation and self-injurious behavior. V16 stated R1 had superficial bleeding injuries to the neck and the back of the head. V16 stated that R38's injuries appeared consistent with a fall. V16 stated the emergency room Physician evaluated and treated R1, cleaning, suturing, and stapling the areas. V16 stated the Physician asked R1 about suicidal ideation and self-injurious behavior, which R1 denied, so R1 was therefore not referred for a Mental Health Evaluation. V16 stated he does not recall telling facility staff that R1 would get a Mental Health Evaluation before he was sent back. A Physicians Encounter Note dated 03/25/23, authored by V4 (Physician) documented, (R1) got a laceration on the left cheek that was sutured at the emergency room across the street yesterday, they (staff) thought he had a knife, and he did it himself. He does not talk about that, but it has been sutured and it looks good .He will not tell me, either he does not know, or chooses not to tell how he got that laceration .He said he did not do it, so they (staff) want to know if he needs to be on suicide watch. I think we will take him off one on one but again I am available 24/7. On 4/6/23 at 1:40pm, this surveyor contacted the office of V15 (Advanced Practice Nurse/Collaborative Associate of V4). Office staff stated V15 was not available for the next week due to attending the funeral of a family member. On 4/6/23 at 1:45pm, V4 confirmed V15 will be unavailable all week due to a death in the family. V4 stated he and V15 have been following R1 since R1's admission to the facility. V4 stated R1 has multiple chronic health issues. V4 stated facility staff have made him aware that R1 is leaving the facility to drink. V4 stated R1 drinking on his medications is dangerous, and R1 has had several falls at the facility related to drinking. V4 stated the facility contacted him about R1's incident around 4:00pm on 03/24/23 and V4 was told R1 first stated he fell , then later R1 had stated he cut his neck. V4 stated staff never reported that R1 may have had a knife or that a knife may have been found in R1's pants. V4 stated R1 should have been referred for a mental health evaluation and a substance abuse evaluation when he returned on 03/25/23. V4 stated he has left standing orders for some of R1's medications to be held on the days when he drinks, and facility staff should be notifying him or V15 every time R1 returns to the facility under the influence. V4 stated the facility should have a safety plan for how to deal with R1 coming back intoxicated. V4 stated when R1 returns after he has been drinking, R1 should have constant one on one supervision for safety. On 4/7/23 at 9:40am, V10 (CNA) stated she always works weekends. V10 stated R1's friends and family generally pick him up after lunch around 12pm to 1:00pm, but the time they bring him back varies, sometimes not until 6:00pm. V10 stated sometimes he will be dropped off at the front door and staff are not aware he is back in the building. V10 stated she was working from 6am to 6pm on 3/24/23. V10 stated R1 had gone out with family after lunch and returned that afternoon extremely intoxicated and smelling strongly of alcohol. V10 stated she checked R1 for alcohol in his clothing, but there was none, and R1 had no weapons. V10 stated when R1 is drunk he usually gets loud, sometimes he is pleasantly drunk, but he is always quicker to get frustrated, and V10 stated she has witnessed R1 lunge at staff and be verbally aggressive toward staff. V10 stated she has never seen R1 hit staff or peers or be verbally aggressive to peers. V10 stated sometimes R1 will just go to straight to his room and go to sleep until dinner. V10 stated that afternoon R1 was different, he was in his room and was quiet and withdrawn. V10 stated about 4pm, V10 was doing pre-supper rounds. V10 stated she went by R1's room, looked in and saw R1 lying in bed and there was blood all over his neck. V10 stated there was another CNA with her, she cannot recall which one, and that CNA ran to get V6 (LPN). V10 stated she asked R1 what happened, and he said he didn't know. V10 stated R1 was not very alert and was slurring his words. V10 stated R1 didn't seem to be aware he was bleeding. V10 stated she noted there was no blood anywhere in the room except on R1's neck, and there was no blood on the floor as if R1 had fallen. V10 stated V6 came to the room and was helping R1, and the ambulance came soon after. V10 stated when R1 comes back staff try to get him to let them look through his clothing, usually he will let them, and they ask him how many drinks he's had. V10 stated she has never seen any weapons or knife on R1, but he does try to sneak alcohol into the building. V10 stated R1 has never seemed to have mood issues or depression and has never said anything about suicidal ideation. V10 stated when R1 is sober, staff remind him he's not supposed to be drinking on his medications. V10 stated the safety plan for when R1comes back drunk is that staff try to monitor him and check on him more. V10 stated none of R1's peers seem afraid of him, but sometimes they complain he has the TV on too loud. V10 stated the only friend R1 has is R2, they sit at the same table for meals. V10 stated R1 gets around via wheelchair and requires assistance of one staff member and a gait belt for transfers. V10 stated R1 is mostly independent with other activities of daily living. V10 stated during morning care, staff give R1 a disposable razor for shaving and then take the razor back when he is done. V10 stated this is the procedure for all residents, so it would be highly unlikely R1 had access to a disposable razor. V10 stated R1's room is searched periodically for alcohol. On 4/7/23 at 10:15am, R2 was alert and oriented to person, place, and time. When asked if there are any peers whose behavior concerns him, R2 stated yes, and named R1. R2 stated he was previously R1's roommate and he is aware that R1 has purchased knives through an online retailer and had them shipped to the facility. R2 stated he believed one was intercepted by facility staff right after it was delivered, and it was sent back to the retailer. R2 stated he was not sure if R1 ever had knives on his person or in his room. R2 stated R1's family takes R1 out to the bar and R1 comes back drunk and R1 yells at the CNAs. R2 stated staff have to search R1 for alcohol when he comes back. R2 stated he has never witnessed R1 trying to hit staff or peers. On 04/07/23 at 11:00am, V2 (DON) stated she has been in the position about three weeks. V2 stated on Friday 3/24/23 she worked 8:00am to 4:00pm. V2 stated R1 had gone out on a visit with his family after lunch and returned intoxicated. V2 stated she was notified by staff at about 4:50pm that R1 had been sent to the emergency room after falling. V2 stated staff did not say anything at that time about R1 possibly having cut himself. V2 stated when she returned the following Monday, 3/27/23, She heard secondhand from one of the CNAs that he tried to kill himself. V2 stated she was told by staff that V4 (Physician) came in on 3/25/23 to evaluate R1 and had discontinued R1's every five-minute check. V2 stated staff discussed R1 in the Monday morning staff meeting, and the consensus of the group was that R1 had told different stories to different people, that R1 said he fell and got hurt when out with the brother, that he later said didn't know what happened, and later still told one of the CNAs apparently that he cut himself, but staff found no weapons in the room. V2 stated staff present determined that the plan going forward would be that V8 (SSD) would meet with R1 three times a week to provide alcohol education. V2 stated she reviewed the patient discharge packet R1 returned with (from the hospital) and noted that R1 had not received a mental health evaluation, but V2 did not call the hospital for details as to why or try to arrange a mental health evaluation for R1. When asked what interventions she personally had provided for R1 on 3/27/23, V2 stated she had a casual conversation with (R1), it's not like I filled out a piece of paper on him or anything. V2 stated she does not think R1 made a suicide attempt, Maybe he did, but I think he probably fell . V2 stated she has made no changes to R1's nursing plan of care since 3/24/23. V2 stated she has tried talking to R1 about the dangers of alcohol use with his medications, but R1 always denies having an alcohol problem. V2 stated she did not hear reports from any staff members that R1 might have had a knife. V2 stated staff search R1 for alcohol when he comes back from visits, and she has n [TRUNCATED]

Based on observation, interview, and record review the facility failed to identify, monitor, and treat a pressure wound for 1 (R3) of 3 residents reviewed for wounds in the sample of 3. This failure resulted in R3 developing at minimum a Stage II pressure wound to the left buttock after admission with no consistent assessments or treatments documented to determine the actual wound onset. Findings Include: R3's Profile Face Sheet documents an Original admitted to the facility on [DATE]. R3's Braden Scale for Predicting Pressure Ulcer Risk dated 12/18/22 documents a total score of 15, indicating R3 was at high risk. The same document marks N for no to the questions of: Does the resident currently have any unresolved pressure ulcers? Have there been any resolved pressure ulcers in the last 90 days? Does the resident currently have any unresolved venous or arterial ulcers? This is the only Braden score documented as being complete during R3's admission at the facility. R3's current and active Plan of Care as provided by the facility documents a Problem/Need of, at risk for Pressure Ulcer per Braden Risk Assessment. The Goal for this area is for R3 to have no new open areas caused by pressure or friction for the next 90 days. Approach/Interventions listed for this problem area include, Skin risk assessment: Braden Scale weekly x 4 weeks upon admission or readmission and then quarterly. An additional Approach/Intervention listed for this same area is, Assess skin- If open or bruised areas noted, report to MD (medical doctor) and responsible party. R3's most recent comprehensive Minimum Data Set (MDS) dated [DATE] documents in section C0500 a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Section M0150 of the same MDS documents 1 indicating yes to the question, Is this resident at risk of developing pressure ulcers/injuries? R3's Physician Orders sheets dated for 12/16/22 - 12/31/22 document a treatment of Weekly Skin Assessments with Note on Tuesdays during the 2-10 PM shift. This same document has the answer of Yes circled by the question, High Skin Risk. Review of R3's Physician Order's in their entirety, as provided by the facility for December 2022 contain no wound treatment orders. R3's Treatment Administration Record (TAR) dated/labeled for 12/16/22 - 12/31/22 document that the 12/16/22 skin assessment (at the time of R3's original admitted to the facility) was the only skin assessment completed in December 2022. An additional entry noted on this same document under the area of Treatment dated 12/22/22 documents, SSD (Silver Sulfadiazine), Collagen, Cal (Calcium) Alginate & DD (dry dressing) to right inner buttock dly (daily) until healed. No nursing initials are present on this administration record to indicate this treatment was ever completed during December 2022. R3's Physician's Orders dated for 1/1/23 - 1/31/23, under the section labeled Treatment Orders document the order of weekly skin assessment with note. Review of R3's Physician Order's in their entirety as provided by the facility for January 2023 contain no wound treatment orders. R3's Treatment Administration Record for 1/1/23 - 1/31/23 documents weekly skin assessments were complete on the following days with the corresponding notes: 1/2/23- Skin good red on coccyx no open areas. 1/9/23- Red on coccyx tx. (treatment) done. 1/16/23- No open areas tx. To coccyx cream. 1/23/23- Red area cream to coccyx area. An additional entry noted on this same document under the area of Treatment, dated 12/22/22 documents, SSD, Collagen, Calc. (Calcium) Alg. (Alginate) to right inner buttock daily UH (until healed). The treatment is documented as being completed daily on the 2-10 PM shift, even on 1/18/23 when R3's Clinical Record reflects he was out of the facility due to being admitted to the local hospital that day. On 1/24/23 at 3:03 PM, V5 (Licensed Practical Nurse, LPN) was observed providing wound care to R3's left buttock, in which a Stage 2 pressure wound was observed. R3's bilateral buttocks were observed as being red in color with no wound observed to R3's right buttock. V5 removed the old dressing in place to the left buttock, and the area was cleansed with Normal Saline. V5 prepared the new dressing by using a bordered gauze placed on a barrier on R3's bed side table, placed a piece of a sheet of collagen directly on the gauze part of the bordered dressing, placed a piece of calcium alginate dressing on top of the collagen piece, and applied SSD cream on top of the calcium alginate. V5 was observed tearing the calcium alginate with her gloved hands and the collagen sheet was observed as crumbling into several pieces when V5 placed it on the gauze pad. The layered dressing was then put in place to R3's left buttock. The collagen and calcium alginate boxes were observed as not being labeled for R3, but rather stock use. On 1/26/23 at 12:15 PM, V3 (Licensed Practical Nurse/LPN) stated she had just inspected R3's buttocks. V3 confirmed the open area to R3's bottom was to his left buttock, and not his right as indicated on the treatment administration record. V3 also confirmed with the current treatment orders wrote on the TAR, she is unsure of the directions the order is giving and cannot verify where the SSD cream was to go, if the collagen was powder or a sheet, directions for dressing the wound, etc. On 1/26/23 at 12:32 PM, V3 confirmed the area to R3's left buttock was currently a stage 2 pressure wound. On 1/26/23 at 1:09 PM, V7 (Registered Nurse) stated that she recalls performing skin assessments on R3 in January. V7 stated at no time did she visualize any open areas. V7 stated the only treatment R3 was receiving was Silvadene cream to his buttocks where he was red. V7 cannot say when the dressing treatment was initiated. V7 stated she was not aware of any orders or treatments in place for R3 which utilized collagen, calcium alginate, or any type of dressing. On 1/26/23 at 2:05 PM, V4 (Certified Nurse Assistant) stated she frequently worked with R3. V4 stated she cannot say the exact date the wound to R3's buttock formed, but stated it had been a while ago, not like this week it had started or anything. V4 stated she knows this because of seeing a dressing in place when providing R3's care. On 1/26/23 at 2:35 PM, V14 (Physician) stated that he would expect skin assessments to be completed on residents as ordered. V14 acknowledged that performing skin assessments can help timely identify, treat, and possibly prevent wound formation. On 1/26/23 at 2:47 PM, V15 (Nurse Practitioner) stated that she works with V14 and saw R3 once while he was in the facility. V15 stated that V16 (Wound Physician) provides wound care at the facility, so any wounds that form she (V15) requests to be notified, then makes the referral to V16 for services. V15 stated she has no notes made that she was ever notified of any wounds to R3. V15 stated she was unaware of any SSD, Calcium Alginate, Collagen dressing order R3 had. R3's Clinical Record contains no documentation regarding any open wounds to R3. The left buttock wound onset date, initial size, staging, physician notification, physician wound orders, and R3's response to treatment cannot be determined due to lack of documentation. On 1/26/23 at 12:17 PM, V12 (Regional Quality Assurance Nurse) acknowledged that although requested, she is unable to provide a physician's order for wound treatment, progress note or any documentation indicating the onset date, measurements, or ongoing monitoring for improvement or decline of the wound to R3's buttock. On 1/27/23 8:40 AM, V1 (Administrator) confirmed the facility is unable to provide any reproducible evidence regarding the origination, monitoring, physician notification, physician orders for wound treatment, or description of R3's wound including initial measurements/staging. V1 stated that her expectations for staff would be to complete skin assessments as ordered and provide wound care per facility policies. V1 stated that the facility is going to start training with nursing staff today regarding skin assessments and wound care. The facility policy titled, Skin Condition Monitoring with a revised date of 1/18 stated, It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities 1. Upon notification of a skin lesion, or other skin abnormality, the Nurse will assess and document the findings in the nurses notes and complete the QA (Quality Assurance) form for Newly Acquired Skin Condition. The Nurse will them implement the following procedure: a. Notify the physician and obtain treatment order. B. The treatment order will include: 1. Type of treatment. 2. Location of area to be treated. 3. Frequency of how often treatment is to be performed. 4. How area is to be cleaned. 5. Stop date, if needed. 3. Any skin abnormality will have a specific treatment order until area is resolved 4. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: a. Characteristic 1. Size, 2. Shape, 3. Depth, 4. Odor, 5. Color, 6. Presence of granulation tissue or necrotic tissue. B. Treatment and response to treatment. Observe and measure pressure ulcers at regular intervals. The facility policy titled, Pressure Sore Prevention Guidelines with a revised date of 1/18 stated, It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale .Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse.

Based on observation, interview, and record review, the facility failed to identify, assess, and treat potential symptoms of pain for 1 of 3 residents (R2) reviewed for pain management in a sample of four. This failure resulted in R2 having unidentified and untreated pain care related to his diagnosis of Metastatic Neuroendocrine Carcinoma, as evidenced by outward physical signs of facial grimacing, eyes closed while deep breathing and holding lower left side/abdomen, and unable to answer questions. Findings Include: R2's Face Sheet documents an admitted [DATE]. R2's Diagnosis sheet documents a diagnosis of: Metastatic Neuroendocrine Carcinoma. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status as 09 (moderately impaired). R2's History of Present Illness with a transcription date of 12/02/2022 and a date of visit of 11/28/2022 from the healthcare clinic document diagnosis including Metastatic Neuroendocrine Carcinoma, UTI (Urinary Tract Infection), hyponatremia, anemia, type 2 diabetes, dizziness, hypertension, and Anxiety. R2's Physician Order Sheet dated 12/01/22 to 12/31/22 documents an order for Tylenol 325mg, 2 tablets, orally, every six hours prn (as needed). On 12/27/22 at 12:35 PM, R2 made grimacing faces and held his lower left side while speaking and trying to reposition himself. R2 was observed with his face scrunched up taking deep breaths through his mouth. R2 continued to do this for over a minute, then kept his face tightened and his eyes closed. R2 would no longer answer any questions. On 12/27/22 at 2:15 PM, R2 stated it doesn't hurt as bad with his eyes still closed. When R2 was asked if the staff ask him if he would like any medication for pain, R2 shook his head No. On 12/29/22 at 12:30 PM, R2 stated his left ankle gives him problems sometimes and hurts. R2 stated he fell out of a truck years ago and fractured something in his pelvis and hurt his ankle. He has also hurt his hip, it does give him problems and hurt sometimes. Sometimes he gets pain in his stomach. He is ok right now. On 12/27/22 at 12:45 PM, V3 (Registered Nurse) stated she has never given R2 any pain medication. She believes he has an order for prn (as needed) Tylenol, but he has never asked for any. V3 stated, she has never asked him if he has needed any. When asked if scrunching one's face and breathing deeply through their mouth would be a sign of pain, V3 stated, well, maybe, but R2 is just odd. On 12/27/22 at 2:00 PM, V4 (Licensed Practical Nurse/LPN) stated, she does not know if R2 has a tumor or cancer with a tumor. V4 (LPN) stated, she has never given R2 any pain medication and she has never asked R2 if he needed any pain medication. R2's Medication Administration Record for 12/01/22-12/31/22 does not document any Tylenol had been administered to R2. On 12/29/22 at 2:27 PM, V26 (Registered Nurse at the local cancer treatment center) stated, R2 has a type of tumor that causes a Carcinoid Syndrome. The Carcinoid Syndrome is caused by the chemicals secreted by the Carcinoid tumor. R2 could definitely have abdominal pain sometimes with his diagnosis. On 12/28/22 at 8:53 AM, V11 (LPN at the local cancer treatment center) stated, R2 has Metastatic Neuroendocrine Carcinoma which is a tumor in the pancreas. R2 has a well differentiated tumor at the pancreatic tail. The tumor has been progressing. R2 had a scan done on 11/15, which showed progression with the cancer increasing. R2 could feel pain sometimes, symptoms with this diagnosis can vary and come and go. On 12/28/22 R2's Nurse's note documents: 12/28/22 at 12:05 AM Resident (R2) complains of weakness, says he can't move. Send to ER (emergency room ) for evaluation and treatment. R2's Hospital records dated 12/28/22 at 00:38 (12:38 AM) document: Diagnosis: weakness, UTI (Urinary tract infection, site not specified), and unspecified open wound on left lower leg. Exam: CT of the left lower extremity without contrast was performed. R2 has a history of Left hip pain. The CT exam was compared to left hip radiograph performed on 03/10/2022. The section titled Finding's document: Intact left hip arthroplasty hardware, no acute fracture or dislocation, degenerative changes are seen within the lower lumbar spine, and old healed mid sacral fracture with sclerosis. R2's Care plan with a start date of 12/02/22 documents: Problem/Need: Alteration in Comfort/Pain related to diagnosis of cancer that has Metastatic. The Goal documented will verbalize comfort with current pain regime times 90 days, with a goal date of 03/02/2023. The interventions document: Initiate pain flow sheet prn, complete pain assessment prn, administer pain medication as ordered, pace activities, and monitor lab work as ordered. R2's Pain Assessment Flow Sheet dated, [DATE], has the first date and time documented as 12/24/22 shifts; 6-2 with no pain noted, 2-10 with no pain noted, 10-6 nothing for pain is noted. The 2nd date listed is 12/25/22 which documents shift as 6-2 no pain, and the 2-10 and the 10-6 shifts have nothing documented in the boxes. The date 12/26/22 shift 6-2 has no documentation in the pain column and nothing documented in the 2-10 and the 10-6 timeframes. On 12/27/22 shift 6-2 box has nothing documented and the 2-10 and 10-6 shifts have nothing documented. On 12/28/22 no shift has anything documented in the pain category. The Urology Care Foundation website dated 11/2022, documents: Symptoms: when you have a UTI, the lining of the bladder and urethra become red and irritated, just like your throat does when you have a cold. The irritation can cause pain in your lower abdomen or your pelvic area and even lower back and will usually make you feel like urinating more often. WWW.urologyhealth.org The Mayo Clinic website (www.mayoclinic.org) dated January 11, 2022 documents; under the section: Neuroendocrine tumors - In general, neuroendocrine tumor signs and symptoms might include: pain from a growing tumor, a growing lump you can feel under the skin, feeling unusually tired, and losing weight without trying. Neuroendocrine tumors that produce excess hormones symptoms may include skin flushing, diarrhea, frequent urination, increased thirst, dizziness, shakiness, and a skin rash. The American Cancer Society website (www.cancer.org) dated [DATE] documents: under the section Neuroendocrine tumors. The signs and symptoms of carcinoid syndrome depend on which chemicals the carcinoid tumor secretes into your bloodstream. The most common signs and symptoms include Diarrhea - frequent, watery stools sometimes accompanied by abdominal cramps may occur These tumors often make serotonin or its precursor, 5HTP (5-Hydroxytryptophan). When these spread, they can start releasing hormones directly into the blood. This can cause the carcinoid syndrome. When pancreatic NETs (neuroendocrine tumors) spread, most often they go to the liver, this can enlarge the liver which can cause pain and loss of appetite. The facility policy dated 12/7/2017 titled, Pain Prevention & Treatment documents: Procedure: 1. Each resident will be assessed for pain using the Pain Assessment Form including an appropriate Pain Rating Scale upon admission. The MDS Coordinator will complete the Pain Assessment Form at least quarterly and with any significant change in resident condition. 2. Assessment of pain will be completed with changes in the resident's condition, self-reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. 3. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, diagnosis that may anticipate pain (i.e. arthritis, wounds, fractures, etc.). 4. Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan.

Based on interview, observation, and record review the facility failed to provide the prescribed diet, nutritional supplements and the appropriate portion size of protein documented on the approved menu for 4 of 10 residents (R10, R26, R7, & R35) reviewed for weight loss in the sample of 40. This failure further contributes to continued harm to R10, R26, R7 and R35, who have a documented history of severe weight loss. Findings Include: 1. R10's facility's document titled, Profile Face Sheet documents that R10 was admitted to the facility on [DATE]. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] & Levillocytosis. R10's Minimum Data Set/MDS dated [DATE], Brief Interview for Mental Status (BIMS) Section C documents a BIMS score of 3, severely impaired, section G, Functional Status, documents supervision with transfer to seated to standing position, walking, and physical help with part of bathing activity and limited to transfer only, supervision with one-person physical assist as needed at meals. R10's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's meal card documents nutritional juice at breakfast and lunch and nutritional ice cream at lunch and supper meal. On 6/27/2022 at 2:00 PM V6 (Dietary Assistant) stated that R10 should get nutritional juice at breakfast and lunch and nutritional ice cream at lunch and supper meal. The Facility document titled, Report of Monthly Weight and Vitals documents: [DATE], R10's weight was documented as 94 pounds. [DATE], R10's weight is documented as 85 pounds. [DATE], R10's weight is documented as 85 pounds. [DATE], R10's weight is documented as 87 pounds. May 2022, R10's weight is documented as 83 pounds. Jun 2022, R10's weight is documented as 84 pounds. R10's weight loss is 10.64% in 6 months. R10's Care plan dated 10/24/2019 documents: Category: Nutritional Status: R10 may be at risk for altered nutritional status related to moderately impaired cognition, very small frame, manages own fluids and then feeds self, has full dentures and eats all meals in the dining room. A goal target date of 07/05/2022 documents a goal of; R10 will have no unresolved alteration in nutrition x 90 days. An Approach Start Date of 10/24/2019 documents: provide diet as ordered, see physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Approach Start date of 10/23/2021 documents: house supplement 60cc three times daily. An Approach Start date of 2/22/2022, house supplement 90cc three times daily and nutritional juice twice daily. R10's Progress Notes documents on 2/22/2022, Dietary Notes: February weight 85 pounds with significant weight loss x 1 month (9.57%), x 3 months (7.61%). Basic Metabolic Index (BMI): 14.3 (underweight). Diet continues with Minced or ground meat with gravy/sauce, pureed vegetables, nutritional ice cream twice daily, whole milk and 60cc house supplement three times daily. Intake: 100% at breakfast and lunch, 50-100% at supper per February log. Medications reviewed. No new labs. No pressure injuries reported. Will recommend to increase house supplement to 90cc three times daily and add nutritional juice twice daily. Registered Dietician (RD) to follow up as needed. (signed by RD) R10's Progress Notes document on 06/23/2022, Dietary Notes: June weight 84 with a significant weight loss x 6 months (10.64%). Body Mass Index (BMI): 14 (underweight). Diet continues as per 3/24/2022 Registered Dietician's (RD) note. Intake of 100% of meals per June log. Medications reviewed. No new labs. No pressure injuries reported. Weight increased 1 pound x 1 month. Supplements in place. Continue plan and RD to follow up as needed. On 6/27/22 at 11:45 AM, R10 received her lunch tray which contained her mechanical soft meal and her beverage, no nutritional ice cream supplement or nutritional juice was given. On 6/28/22 at 11:48 AM, R10 received her lunch tray which contained her mechanical soft meal and her beverage, no nutritional ice cream supplement or nutritional juice was given. On 6/28/2022 at 1:00 PM, V6 (Dietary Assistant) stated she forgot to put R10's supplements on her tray on 6/27/2022 & 6/28/2022. On 06/29/22 at 11:37 AM, V19 (Registered Dietician) stated she would expect R10 to receive nutritional juice at breakfast/dinner and nutritional ice cream at lunch/supper as ordered. 2. R26's facility's document titled, Profile Face Sheet documents that R26 was admitted to the facility on [DATE], Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Minimum Data Set/MDS, dated [DATE], Brief Interview for Mental Status (BIMS) Section C documents a BIMS score of 3, severely impaired, under Section G, Functional Status documents total dependence with two-person physical assist with activities of daily living, total dependence with one-person physical assist with eating. R26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's meal card documents: Diet: Puree. (Brand name fortified cereal), whole milk, nutritional juice, and nutritional ice cream at breakfast, nutritional juice and nutritional ice cream at dinner, and nutritional ice cream at supper. The Facility document titled, Report of Monthly Weight and Vitals documents: [DATE], R26's weight was documented as 124 pounds. [DATE], R26's weight was documented as 116 pounds. [DATE], R26's weight was documented as 119 pounds. [DATE], R26's weight was documented as 118 pounds. May 2022, R26's weight was documented as 117 pounds. Jun 2022, R26's weight was documented as 117 pounds. R26's weight loss is 10.69% in 6 months. R26's Care plan dated 11/16/2020, documents: Category: Nutrition: R26 has potential risk for altered nutritional status and/or weight loss related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A goal target date of 8/10/2022 documents a goal of; R26 will not lose a significant amount of weight x 90 days. An Approach Start Date of 11/16/2020 documents: provide diet as ordered, see physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Progress Notes, Dietary Notes documents on 3/24/2022, that nutritional ice cream was increased to three times daily and [MEDICATION(S)] was increased to 30mg daily on 2/22/2022 with a weight increase of 3 pounds in one month (signed by RD). R26's Progress Notes document on 06/23/2022, Dietary Notes: June weight 117 with a significant weight loss x 6 months (10.69%). BMI: 17.7 (underweight). R26's diet continues with intake of 75-100% most meals with some 50% noted and 100% supplements per June log. Medications received; [MEDICATION(S)] continues. No new labs. No pressure injuries reported. Weight x Feb-Jun: 116-119-118-117-117 with supplements in place. No further recommendations. RD to follow up as needed. On 6/27/22 at 11:45 AM, R26 received her lunch tray which included a pureed meal and her beverage, no nutritional ice cream was given, and no pureed bread was given with her meal. On 6/28/22, at 11:48 AM, R26 received her lunch tray which contained a pureed meal and her beverage, no nutritional ice cream was given. No pureed bread was given with her meal. On 6/28/2022 at 1:00 PM, V6 (Dietary Assistant) stated she forgot to put R26's supplements on her tray on 6/27/2022 & 6/28/2022. 06/29/22 at 11:37 AM, V19 (Registered Dietician) stated she would expect R26 to receive nutritional juice at breakfast/dinner and nutritional ice cream with her meals as ordered. 3. R7's facility's document titled, Profile Face Sheet documents that R7 was admitted to facility on 12/21/2020, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R7's Minimum Data Set/MDS, dated [DATE], Brief Interview for Mental Status (BIMS) Section C documents a BIMS score of 7, severe impairment, Section G, Functional Status, documents extensive assistance with two-person physical assist with activities of daily living, supervision with set-up help for eating. R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's current meal card documents R7's diet as Puree. R7's meal card does not document any house supplements. The Facility document titled, Report of Monthly Weight and Vitals documents: [DATE], R7's weight was documented as 115 pounds. [DATE], R7's weight was documented as 112 pounds. March 2022, R7's weight was documented as 110 pounds. [DATE], R7's weight was documented as 109. May 2022, R7's weight was documented as 110 pounds. Jun 2022, R7's weight was documented as 109 pounds. R7's weight loss is 7.56% in 3 months. R7's Care plan dated 1/01/2021, documents: Category: Nutrition: Approach Start Date of 03/26/2022, House Supplement 60cc three times a day, an Approach Start Date of 4/29/2022, documents: Diet upgrade from pureed to minced & moist. R7's Progress Notes document on 03/24/2022, Dietary Notes: March weight 110 with significant weight loss x 3 months (7.56%). BMI: 17.7 (underweight). R7's diet continues with intake 50-100% (Breakfast/Lunch) and 50-75% (Dinner) per March log. Medications received. No new labs. No pressure injuries reported. Weight is decreased 9 pounds since December. Will recommend 60 milliliters (Nutritional Supplement drink) three times a day and RD to follow up as needed. On 6/27/2022 & 6/28/2022 observed R7 receive a pureed diet at the lunch meal. On 6/28/2022, at 12:00 PM, observed V11 (Licensed Practical Nurse) give R7 his house supplement. On 6/28/2022, at 1:30 PM, V5 (Dietary) stated that R7 received a pureed diet on 6/28/2022 because it states on his meal card that he has a pureed diet. On 7/07/2022, at 2:00 PM, V18 (Dietary Assistant), stated that he follows the meal cards and prepares the residents' meals according to the diet that is on their meal card. 4. R35's facility's document titled, Profile Face Sheet documents that R35 was admitted to the facility on [DATE], Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's Minimum Data Set/MDS dated [DATE], Brief Interview for Mental Status (BIMS) Section C documents a BIMS score of 12, under section G, Functional Status, documents that R35 is independent with no setup or physical help from staff with activities of daily living, independent with set-up help for eating. R35's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's Care plan documents: Category: Nutrition: R35 has potential risk for altered nutritional status and/or weight loss related to [CONDITION(S)], weakness, with a start date of 5/01/2019. A goal target date of 8/31/2022 documents a goal of; R35 will not lose significant amount of weight x 90 days. An approach start date of 5/01/2019 documents: provide diet as ordered, honor food preferences, replace disliked foods when possible, R35 consents to use of clothing protector at meal times, and follow recommendations of Registered Dietician/Licensed Dietician Nutritionist, (RD/LDN), notify RD/LDN of discrepancy of recommendation with R35's preferences or care goals, an Approach Date of 4/20/2022 documents: Nutritional Supplement drink 90 milliliters four times a day and Nutritional Juice drink at breakfast. R35's current meal card documents R35 diet as Regular CCD. There is no nutritional juice or supplements listed on R35's meal card. R35's Progress Notes document on 06/23/2022, Dietary Notes: June weight 135 with a significant weight loss x 3 months (8.78%) x 6 months (16.15%). BMI: 23.8 (Within normal limits). R35's diet continues with intake 0% at breakfast, 25-50% at lunch, and 50-100% at dinner per June log. Medications received. No new labs. No pressure injuries reported. Weight decreased 4.93% x 1 month with nutritional drink acceptance = 0%. Will recommend to discontinue nutritional juice drink at breakfast, discontinue Consistent Carbohydrate Diet restriction and add nutritional ice cream at supper. RD to follow up as needed. On 6/29/2022, at 9:30 AM, R35 stated she did not get her nutritional juice on 6/27/2022 & 6/28/2022. R35 stated she does not like the nutritional juice anyway. On 06/28/22 at 11:45 AM during lunch service, R35 was given an approximately 1.5 ounce chicken breast for lunch. 06/29/22 at 11:37 AM, V19 (Registered Dietician) stated she would expect R35 to have received her nutritional juice at breakfast on 6/27/2022 & 6/28/2022. V19 stated she recommended this month to discontinue nutritional juice at breakfast and her house supplement of 90cc four times a day and add nutritional ice cream at the supper meal. V19 stated she would expect all the residents ordered to have supplements would receive supplements On 06/28/22, at 1:00 PM, V18 (Dietary Assistant) stated, the nutritional supplements are listed on the meal cards and are put on the resident's trays by the kitchen staff that is serving at that time. On 06/29/22 at 3:00 PM, V1 (Administrator) stated, she is not sure what a reasonable amount of time for a supplement ordered by V19 (Registered Dietician) would be to get to V24 (Physician) and on to R35's dietary card, a week maybe. On 06/29/22 at 1:30 PM, V11 (Registered Nurse) stated, the recommendations from V19 (Registered Dietician) that were made on 06/23/22 were given to her today (06/29/22) to fax to V24 (Physician) for review. On 07/08/22 at 11:05 AM, V25 (Regional Director) stated, she is not for sure if there is a specific timeframe for a recommendation to get from V19 (Registered Dietician) to the V24 (Physician) but she thinks it should be done in a couple days, but she believes it should be implemented in a week. 5. On 06/28/22 at 11:40 AM, 2 ounces of BBQ chicken breast was provided to the residents receiving the Mechanical Soft diet and Puree Diet with a #16 scoop (2 ounces). On 06/28/22 at 12:25 PM after all of the plates had been served out, V18 (Dietary) weighed the BBQ chicken breast that was given to the regular diet residents which weighed 1.5 ounces. The Menu titled, Week 4 Tuesday documents 1 each for the Regular diet and the Mechanical Soft diet, and a #6 scoop (5.33 ounces) for the puree diet. On 06/29/22 at 11:35 AM, 2 ounces of roasted pork was provided to the residents receiving the Mechanical Soft and Puree diets with a #16 scoop (2 ounces). The amount of Roast Pork, which was loose pulled meat, for the Regular Diet was not weighed and was different portion sizes. The menu titled, Week 4 Wednesday documents 3 ounces of Roast Pork to be served to the Regular Diet and the Mechanical Soft Diet and a #8 scoop (4 ounces) for the Puree diet. On 06/29/22 at 1:35 PM, V19 (Registered Dietician) stated 4 ounces of BBQ chicken was required to be served and that is what she would expect to be served. The recipe card states, 1 each, but that is incorporated into what is needed to be ordered. Therefore, there would be a list derived that documents the appropriate size chicken breast that is to be ordered. The puree diet should have received the #6 scoop of the BBQ chicken (5.33 ounces) and the Mechanical Soft diet to receive 4 ounces of BBQ chicken. For Wednesday's diet, the puree diet should have received the #8 scoop (4 ounces) of protein, the roast pork and the Mechanical Soft diet should have received 3 ounces of protein, the roast pork. On 06/30/22 at 12:45 PM, V5 (Dietary) stated, she does not know why she used those scoops for the mechanical soft and puree diets, she must have grabbed the wrong scoops on Tuesday and Wednesday. On 06/30/22 at 2:15 PM V1 (Administrator) stated, since V9 (Dietary Manager) has been out sick for over a month she was assisting with the kitchen duties. There was only one person in the kitchen on 06/27/22 and 06/28/22 because a second dietary person had called in. When V1 was asked about only one person working in the kitchen for all tasks, V1 stated, sometimes our staff put us in precarious situations.

Based on observation, interview and record review, the facility failed to provide person-centered interdisciplinary behavioral health services to include individualized interventions to promote the highest level of physical, mental, and psychosocial well-being for one (R14) of 3 residents reviewed for behavioral health services in the sample of 40. These failures resulted in R14 receiving two injections of the anti-psychotic medication [MEDICATION(S)] and one trip to the hospital emergency room . Findings Include: A Facility Profile Face Sheet documents R14 was admitted to the facility on [DATE]. The record also documents R14 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . An undated Cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 fell and sustained a head injury, requiring a Craniotomy. The Progress Note documents R14 moved back to the mid-west and was living with his mother. R14 stopped taking a medication to prevent seizures and began using Marijuana instead. R14's mother found him unresponsive, called 911 and R14 was admitted to a hospital. R14's Nurses Note dated 12/21/2022 at 10:00 AM, documents V20 (Nurse Practitioner/NP) visited (R14) at the facility and ordered a psychiatric evaluation and an anti-anxiety medication. An undated paper from V1 (Administrator) documents R14 had appointments at a local clinic with a psychiatrist on January 21, 2022, February 22, 2022, March 22 and 25, 2022, April 11, 2022 and June 23, 2022. On 06/28/22 at 9:40 AM, V1 said the facility does not have any documentation from R14's psychiatry visits. On 6/30/22 at 11:40 AM, V15 (Transportation/Driver) said that he takes R14 to his appointments when R14 sees V22 (Psychiatrist). V15 said he waits in the waiting area while R14 talks with V22. V15 said he takes a stack of paperwork from the facility and gives the papers to the receptionist each time R14 has an appointment. V15 said the paperwork contains doctors order sheets, a list of current medications, insurance information and other pertinent information related to R14. V15 said V22's receptionist does not return the paperwork. V15 said sometimes V22 comes out and says everything is ok, no changes. V15 said he has taken R14 to see V22 at least five times, maybe more. V15 said when he takes other residents out to their appointments, the receptionist or nurse will return the doctor's orders sheet and other paperwork to him so he can give the paperwork to the (facility) nurses when they return to the facility. On 6/29/22 at 7:45 PM, V21 (Power of Attorney) said R14 has a long history of mental illness. V21 said R14 was living in deplorable conditions when she moved him to the mid-west from the southwest. V21 said R14 cannot care for himself and needs supervision. V21 said R14's mental state has gotten worse in the last couple of years. V21 said R14's mother is [AGE] years old, and she cannot care for him. V21 said R14 is very intelligent and convincing. V21 said R14 is a great conversationalist and a talented artist. V21 said R14 likes to draw and is very good at it. V21 said drawing seems to calm R14. V21 said she has tried to contact V22's office twice since January because she feels like V22 needs to know the other side of R14. V21 said R14 can flip like a switch and become condescending, angry and unreasonable. V21 stated R14 can be pleasant then get angry and yell and talk in a condescending manor to people. V21 said she has heard and seen R14 bait people, trying to get them to hit him. R14 once told a policeman to shoot him. V21 said R14 makes very poor choices at times. V21 said she thinks R14 may have had a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V21 said a few years ago R14 was a patient in a rehabilitation center. V21 said she attends Care Plan meetings and feels like the facility is trying to help, but she keeps telling facility staff that R14 needs a medication adjustment. V21 said the facility has called her twice in the past four months because they gave R14 an injection of medication to calm him down. V21 said R14 has problems with his telephone and gets angry when the phone does not work. V21 said the cell phone is expensive and sometimes needs to be charged and R14 forgets to charge it or uses the wrong charger. V21 said V4 (Registered Nurse/RN) has gone above and beyond to try and get R14 to understand what is going on with him. V21 said V4 has been very compassionate with R14. On 06/29/2022 at 5:00 PM, V20 (NP) said she has not seen any notes from a psychiatrist regarding R14. V20 said she knows a psychiatric evaluation was ordered in January. V20 said sometimes notes from the doctor's offices do not make it into the charts. V20 said the facility does not have electronic medical records. V20 said she asks for paperwork from the nurses, and she does not get what she asks for. V20 said the facility does not have a Director of Nursing right now, and things are scattered. V20 said she has seen R14 several times in the facility and said she does not know if R14 is telling the truth or if he has grandiose ideas. V20 said R14 is very intelligent and convincing. A Nurses Note Dated 03/05/2022 at 2:00 PM documents R14 had a verbal altercation with another resident. An SBAR (Situation, Background, Appearance and Resident) evaluation form dated 03/05/2022 documents R14 was yelling at a female resident about talking on a cell phone. R14 was pointing his finger in the females face telling her to hit him so he could punch her into another zip code. The SBAR documents the doctor ordered an injection of [MEDICATION(S)] and R14 received it. Another Nurses Note dated 06/18/2022 (Accurate date is 06/19/2022 - see below interview with V4/RN) documents R14 went outside after breakfast at 7:00 AM, and said he was going to walk 20 miles to his mother's house. R14 refused to come back into the facility. R14 got upset with staff and began yelling and chest bumping them. The police arrived. An ambulance was called and R14 was taken to the local hospital. A Nurses Notes documents later at 10:30 AM, the ambulance brought R14 back to the facility. V4 documented that the doctor said R14 was calm and did not need any medication. V4 documented she got an order from V20 (NP) to give [MEDICATION(S)] to R14 when he returned from the hospital. On 06/28/2022 at 4:30 PM, V4 said the incident referenced above actually happened on Sunday the 19th (6/19/22). V4 stated she must have written the wrong date. V4 said R14 was at the nurse's desk drawing that morning when she came in at 6:00 AM (on 06/19/2022). V4 said R14 is very artistic, and drawing seems to calm him. V4 stated that staff told her R14 had been up since 2:00 AM. V4 stated that R14 is a big guy, he can flip like a switch, nice one minute and threatening the next. V4 said R14 walked out of the facility around 7:00AM after breakfast (on 06/19/22). V4 said staff followed R14 outside. V4 said R14 told staff he was going to walk to his mother's house approximately twenty miles away. V4 said R14 was very agitated. V4 said she told R14 he had two choices, to either come back into the building or go the hospital. V4 said R14 said he was not going to do either one. V4 said R14 threw water on staff and broke the water pitcher he was carrying. V4 said she called the doctor. V4 said V20 (Nurse Practitioner) was on call. V4 said V20 ordered a [MEDICATION(S)] Injection for R14. V4 said one policeman and the ambulance arrived. V4 said three paramedics had to manually pick R14 up out of an outdoor chair and physically place him on a stretcher and strap him in. V4 said she was not able to administer the [MEDICATION(S)] injection to R14 before the ambulance took him to the hospital. V4 said R14 was outside, in front of the facility for about an hour and a half before the ambulance took him to the hospital. V4 said she called the hospital around 10:00 AM and a nurse told her they were sending R14 back to the facility. V4 said she asked if the doctor ordered any medication for R14, and the nurse said no that there was nothing wrong with him. V4 said as soon as the Ambulance brought R14 back from the hospital, she gave him the [MEDICATION(S)] injection. V4 said that R14 told her he had not slept in three nights, and he was anxious. V4 said she gave the injection around 10:30 AM. V4 said about an hour later she was passing noon medications and R4 was in the dining room talking to his table mates. V4 said R14 apologized to her and the other staff for his behavior that morning. V4 said the [MEDICATION(S)] did nothing for R14. On 06/29/2022 at 10:55 AM, V16 (Certified Nurse Aide/CNA) said a week ago Sunday, R14 walked out the front door with a water pitcher and soda. V16 said R14 told them he was walking to his mother's house. V16 said R14 got really mad because they told him it was too hot and too far. V16 said he threw water on her, shook his soda up and sprayed them all. V16 said R14 was chest bumping her and telling her to hit him so he could knock her into another area code. V16 said a policeman arrived and told R14 he would arrest him if he hit V16. V16 said finally the ambulance came and took him to the hospital. V16 said R14 came back from the hospital, ate lunch, took a nap and apologized for throwing water on her. V16 said R14 can make you feel really small and stupid then be as nice as can be. V16 said other staff were saying R14 had not slept in 48 hours. Physician Documentation from the local hospital Emergency Department dated 06/19/22 at 9:30 AM, documents R14 is angry because he has a broken cell phone. At worst severity of symptoms is moderate. He does not want help. Wants to go back to his room. Disposition Summary: Symptoms have improved. Problem: ongoing problem. Condition: good. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] R14's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R14 is cognitively intact. On 6/29/22 at 11:40 AM, R14 said he does not believe he has dementia. R14 said he is trying to cope with his attention deficit. R14 said he knows there is some problem with his brain. R14 said he is trying to understand and cope with it. R14 said he bought a 5G phone several years ago and he does not like it. R14 said it is too complex. R14 said V4 (RN) did give him a shot last Sunday and it made him feel much better. R14 said he thought the shot would hurt but it did not. Social Service Notes dated 06/17/2022 at 3:20 PM, document that R14 was upset his phone was not working. At 6:17 PM, R14 wrote a note to V1 (Administrator) that his phone is not working. A nurses note dated 6/29/22 at 2:30 AM documents R14 demanded that the nurse call the police and ambulance so he could get a phone. R14 said his phone has not worked in six weeks. R14's Care Plan Summary/Participations Records dated 01/03/2022 document R14 has been aggressive toward staff and other residents. R14 will see a psychiatrist on 01/21/2022. Care Plan Summary dated 04/21/2022 documents R14 has outbursts. R14's current care plan, updated 04/18/2022 does not document R14's visits to the psychiatrist, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation that the interdisciplinary team discussed recommendations from R14's psychiatric visits. R14's care plan does not document any problems, goals or interventions related to R14's cell phone. Behavior Tracking Logs from April, May and June 2022, document R14 has anxiety, voiced concerns and worries about many things. R14's issues with his cell phone are not identified as concerns in R14's current care plan or behavior tracking, therefore there are no person-centered interventions to assist R14 when he has difficulty with his cell phone. R14's current care plan also does not identify art as an approach to help R14 calm down. On 06/30/22 at 11:35 AM, V1 (Administrator) said the Quality Assurance Committee and the Medical Director have not addressed the issues related to obtaining medical records from V22 (Psychiatrist) when asked about coordination of care.

Based on record review and interview the facility failed to provide adequate assistance and supervision to prevent a fall with injury for one of three residents (R3) in a sample of 3. These failures resulted in a 5 day hospitalization , initially on the Intensive Care Unit and then on the Neurosurgical floor. R3 sustained a Traumatic brain injury - bifrontal and biparietal hemorrhagic contusions, right frontal subdural hematoma; Left parietal skull fracture and status [REDACTED]. The findings include: R3's undated, Profile Face Sheet, documented [DIAGNOSES REDACTED]. Minimum (MDS) data set [DATE] documents R3 has a score of 15 on the Brief Interview for Mental Status, meaning R3 is cognitively intact. The facility fall log lists 2 falls for R3 as follows: 1. 8-10-15 R3 attempted to get up unassisted and fell with no injury noted. 2. 9-16-15 (see below for details) R3's PT (Physical Therapy) Daily Treatment Note dated 9/16/15 (no time recorded) documented, Found patient lying on the sidewalk supine with knees bent. Called for nursing. Patient reported he was standing outside with walker and closed his eyes to stand in sun he stated he thinks he got dizzy and fell down. Nursing examined patient. Therapy and nursing transferred pt from ground to standing position and patient became very dizzy losing his balance buckling his knees. Sat patient back down for couple of minutes to regain balance. Stood patient with therapy and nursing to transfer to wheelchair. Nursing took vitals and applied ice to back of head. Patient complained of bad headache and feeling dizzy. Asked patient how he fell outside or if he hurt anything and patient now had no memory of falling outside. Reminded patient of what he told us 10 minutes earlier and patient continued to have no memory of falling or of us picking him up off the sidewalk even after telling him 4 more additional times he continued to act surprised that he was outside and no memory of being found lying on sidewalk. Transferred patient care giver assist to bed per nursing request with ice pack on back of head and feet elevated. Patient complained of another dizzy spell while lying in bed. Nursing reported to Director of Nursing and was going to inform wife of fall. Patient refused to be sent out to hospital. R3's Physician Communication and Progress Note with the date 9/16/15 documented at 9:30am therapy observed R3 laying on the sidewalk with his eyes closed. This form also documented R3 stated, I was standing here with my eyes closed in the sun and R3 did not know what happened. The form documented R3 stated, I'm dizzy and my head hurts and R3 does have raised area on back of head which is sl (slightly) red but does not look like a contusion more like he might have rubbed his head concrete sidewalk. The form also documented R3 refused to go to the hospital. On 10-8-15 at 11:00 a.m., the door that R3 had exited out of prior to falling on 9-16-15, was noted in a hall behind the nurses station and has a coded pad alarm present. The door requires a code to open it. On 10/8/15 at 12:00pm, E10 (Therapy employee) said she went into R3's room on 9/16/15 to find him and he wasn't there. E10 said she looked out the window and seen R3 laying flat on his back on the ground so she notified the nurse as she went outside where R3 was. E10 said R3 opened his eyes and said he couldn't remember why he had fallen. E10 said she was present when the nurse assessed R3 and there was no bleeding anywhere but R3 had a red bump on the head that was tender to touch and R3 complained of a headache. E10 said she had been doing therapy with R3 and he was stand by assist at this time. E10 said she is unsure how R3 would have gotten outside because the door has a code to put in. E10 said she had seen R3 outside by himself before. E10 said R3 should should have been a stand by assist. On 10/8/15 at 11:25am, E3 (Registered Nurse) said R3 has had two falls while residing in the facility. E3 said she was the nurse on duty when R3 fell outside on 9/16/15. E3 said she assessed R3 and he had not been unconscious but he did have red blotchy spots on the back of his head. E3 said R3 complained of having a headache and dizziness but declined to go to the hospital. E3 said when asked R3 could not remember why he fell . E3 said R3 would have had someone open the door for him to go outside because he couldn't do it himself. E3 stated around a week ago the DON told E3 it was okay for R3 to go outside alone. R3's Nurse's Notes dated 9/18/15 and timed 8:15pm documented, Late entry for 9/16/15. 10:15am. Neurological checks done and within normal limits. Ice applied to back of head. Resting in bed acts like normal self. Answers questions appropriately. Asked if he wanted to go to hospital he stated no, I am alright. R3's Nurse's Notes dated 9/16/15 and timed 3:15pm documented, Alert and oriented. No complaint of headache or dizziness. Neurological checks were within normal limits. R3's Nurses Note's dated 9/16/15, documented at 8pm, complaining of shortness of breath, oxygen applied and R3 refused to go to the hospital at this time. R3's Nurses Notes documented at 10:00pm, R3 complained of severe head pain related to fall, shortness of breath noted, resident agreed to go to the emergency department. On 10/9/15 at 9:15am, E5 (Licensed Practical Nurse) said she worked on night shift on 9/16/15. E5 said R3 complained of pain behind his eyes and a headache. E5 said R3 had a bump on the back of his head. E5 said R3 agreed to go to the emergency room at that time. R3's Nurse's Note dated 9-17-15 at 2:40 am states that R3 was transferred to a local hospital. R3's records dated 9-17-15 at 4:45AM from the out of state emergency department, where R3 was transferred to, documented R3's assessment as: Traumatic brain injury - bifrontal and biparietal hemorrhagic contusions, right frontal subdural hematoma, Left parietal skull fracture and status [REDACTED]. This documentation was electronically authenticated on 10/7/15. R3's Nurses Notes documented R3 returned to the facility on [DATE] and then was discharged home on[DATE]. On 10/8/15 at 2:15pm, E7 (Registered Nurse, Care Plan Coordinator) said R3 should always have stand by assist. E7 said R3's care plans were marked to have assist with transfers and ambulation. On 10/13/15 at 9:10am, E7 said she was not aware R3 was going outside alone and had not added this to any care plan. E7 said she is not sure how R3 got outside but he shouldn't have been alone. E2 (Director of Nurses) was interviewed at 10:12am on 10/9/15 and said R3 had two falls while living in the facility that she knows of. E2 said R3 used a walker and required assist to ambulate. E2 said R3 was not always compliant with this. E2 said R3 did go outside by himself on 9/16/15 and did have a fall. E2 stated R3 had been going outside for weeks alone and knew how to get out the door. E2 said R3 was alert and had rights. If he wanted to go out he could go out. E2 said the nurse on duty assessed R3 after the fall and he didn't have any injuries observed. E2 said R3 refused to go to the hospital and she didn't fight it. On 10/8/15 at 10:05am, E4 (Licensed Practical Nurse) said she wasn't here at the time R3 had a fall. E4 said she did provide care for R3 when she works and R3 had asked her if he could go outside alone. E4 said she didn't think R3 should be going outside alone but the Director of Nursing said he could. E4 said she (E4) has opened the door for him to get outside before. R3's Minimum Data Set (MDS) with the date 9/2/15, documents R3 requires limited assist of one for transfers and ambulation and R3 receives Physical Therapy and Occupational Therapy for training of transfers and ambulation. The MDS documents R3 requires a walker or wheelchair for mobility. The MDS has no behaviors, wandering or rejection of care documented. There were no recent falls documented on the MDS. The MDS documented R3 has bilateral upper extremity impairment. R3's Certified Nurse Aide (CNA) Flow Sheet with the date September 2015, documented R3 required assist of one for ambulation. R3's Fall Risk Assessment completed on 9/16/15 documented R3 had loss of balance while standing, loss of balance while walking, wide base of support, jerking while turning, use of assistive device and required assist to stand. The form also documented R3 received an antipsychotic medication and had a [DIAGNOSES REDACTED]. R3's Fall Care Plans documented: On 8/10/15, educated to use call light for assistance. WW (wheeled walker) with SBA (stand by assist). On 8/21/15 the fall care plan was marked as reviewed and it was documented, R3 requires assist of one for transfers and use of one assist and gait belt for transfers. On 8/27/15, Resident has become noncompliant with safety. Ambulates without walker at times in spite of fall risk education per staff and therapy and family. Resident will comply by requesting assist to ambulate and use wheeled walker following fall risk safety and have no falls. Remind resident to use walker, request stand by assist and use call light. On 9/16/15, patient to use main courtyard with assistance until cleared by therapy. R3's PT (Physical Therapy) Daily Treatment Note dated 9/15/15 documented, patient ambulated without assistive device for 200 feet with two stand by assist / care giver assist.

Based on record review and interview, the facility failed to implement safety measures for 1 of 5 residents (R11) reviewed for falls in the sample of 11. This failure resulted in R11 sustaining a Fractured Right Knee. The findings include: 1. R11's Fall Risk assessment dated [DATE] documents that she had decreased muscle coordination, loss of balance while standing and walking, and had a previous fracture from a fall at home before admission to the facility on [DATE]. The Minimum (MDS) data set [DATE] for R11 documents that R11 was totally dependent on 2 or more staff for transfer between surfaces including chair or wheelchair. The nurse's notes, dated 06-18-11 at 3:40 pm, state that while transferring R11 from the toilet to the wheelchair, R11 fell to the floor on her right knee. This note continues to state that R11 complained of severe pain to the right knee. R11's nurse's notes for 06-18-11 at 8 pm state that R11 was admitted to the hospital with [REDACTED]. The facility Incident Investigation Form dated 06-18-11 at 4:20 pm documents that R11 had reported that her "good leg gave out and I hit my knee on the floor" while E8, Certified Nurse Aide, was assisting her onto the toilet. E1, Administrator, verified on 03-08-11 at 2 pm that E8 was the only staff person assisting with the transfer of R11.