Every finding on record at Bria of Cahokia

Based on observation, interview, and record review, the facility failed to properly store medication and discard expired medication. This has the potential to affect all 109 residents residing in the facility.Findings include: On 5/11/2026 at 11:53 AM the facility Medication room was inspected. The medication room contained: Two 100 tablets bottle of Zinc 50 milligrams (mg) bottles. Expiration date 01/2026. One 13 ounces (oz) bottle of Psyllium Husk. Expiration date 3/2026. One 200 tablet bottle of Aspin 325mg. Expiration date unreadable. Two 4.5 fluid oz of Enema Saline Laxative. Expiration date March 2026. On 5/11/2026 at 12:06 PM V36, Licensed Practical Nurse (LPN), stated that the over-the-counter medication in the medication room are stock and are used for all residents unless it is labeled for a specific person. V36 stated that if she needs to refill her medication then the medication in the medication room is where she would get the medication. On 5/14/2026 at 8:57 AM V9, LPN, stated that when walking away from the medication cart the cart and the screen are locked. V9 stated that the residents' medications are in cards. V9 stated that when the medication is popped out a pill may fall in the cart. V9 stated that the medication is removed and wasted at that time. V9 stated that the over-the-counter medications are for every resident as long as they have an order. V9 stated that when the over-the-counter medication runs out the medication is taken from the medication room. V9 stated that if the medication is expired the medication is removed immediately and new bottle is retrieved. On 5/14/2026 at 8:59 AM V37 stated that the over-the-counter medications are for every resident if they have an order. V37 stated that when the over-the-counter medication runs out the new omedication is taken from the medication room. V37 stated that if the medication is expired the medication is removed immediately and new bottle is retrieved. V37 stated that stated that when walking away from the medication cart the cart and the screen are locked. V37 stated that the residents' medications are in cards. V37 stated that when the medication is popped out a pill may fall in the cart. V37 stated that the medication is removed and wasted at that time. On 5/14/2026 at 8:57 AM V38, LPN, stated that the residents' medications are in cards. V38 stated that when the medications are popped out pills may fall in or on the cart. V38 stated that the medications are removed and wasted at that time. V38 stated that the medication can't stay there. V38 stated that when an over-the-counter medication runs out the new medication is taken from the medication room. V38 stated that if the medication is expired the medication is removed immediately and new bottle is retrieved. V38 stated that the over-the-counter medications are for every resident if they have an order. V38 stated that when walking away from the medication cart the cart and the screen are locked. On 5/14/2026 at 12:42 PM V5, Infection Preventionist, stated that she is responsible for stocking the medication in the medication room. V5 stated that she is aware of the expired medications and destroyed them. The facility's Medication storage policy, dated 6/25/2026, documents that GENERAL: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURE: 3. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access: 14. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists. 5. On 5/13/26 at 9:30 AM, The Medication Cart by the conference room and the nurse's desk was seen unlocked with computer screen open, a nurse's cell phone, and a purse sitting on top of the cart. V29, LPN, was seen coming back to the cart and upon notifying her of the unlocked cart, V29 stated Oh Ok. 6. On 5/13/26 at 9:40 AM, That same medication cart was inspected with random medication tablets in one compartment of the top drawer. There were Loperamide 2 MG X 6 pills, Nurtec 75 MG X 1 pill, and Prednisone 5 MG X 1 pill. When questioned on these loose pills, V29 stated I'm not sure why those are in there, or whose they are. The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 5/11/26, documented that there were 109 residents living in the facility.

Based on interview, observation, and record review, the facility failed to provide reasonable accommodation of resident needs by not providing residents with their call light in reach for 4 of 23 residents (R20, R32, R41, R92) reviewed for call lights in reach in the sample of 40.The findings include:1. R32's admission Record, dated 5/11/26, documents R32 was originally admitted to the facility on [DATE] with diagnosis of seizures, personality disorder, nicotine dependence, depression, anxiety disorder, and schizophrenia. R32's Care Plan, dated 9/13/24, documents R32 is at risk for falls related to seizure disorder and use of psychotropic medication. Interventions: 5/4/26: Physical Therapy to eval and treat, 1/8/26: Resident educated on slow position changes and sitting up on the side of the bed prior to standing, 2/19/25: Staff education on ensuring salt is applied to icy areas and consider an alternative smoke break location in bad weather, 4/24/26: Patient educated on proper footwear, 4/28/26: Patient encouraged to wait on staff to pick up his hall tray, 7/25/25: Staff will monitor resident during periods of high activity and ensure environment remains clutter-free to minimize tripping hazards, 9/13/24: Assess pattern for sleeping and encourage rest per pattern/preference, document s/sx (signs/symptoms) of adverse effects of medication on resident, encourage and offer rest periods when walking long distances, encourage resident to keep room free of obstacles/ clutter, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, keep bed in lowest position, keep frequently used items within reach, monitor for any changes in condition, monitor resident for tolerance and endurance, schedule tasks accordingly, notify MD (medical doctor) and family of any new fall, promote placement of call light within reach and assess residents ability to use, restorative care as appropriate, rounding at a minimum of Q (every) 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. R32's Minimum Data Set (MDS), dated [DATE], documents R32 is cognitively intact and requires supervision/touching assistance for Activities of Daily Living (ADLs). On 5/11/26 at 9:43 AM, R32 stated he had fallen while in the facility. R32's call light was seen on the floor behind the bedside table and not in reach. On 5/13/26 at 9:45 AM, R32 lying in bed with his call light on the floor behind his side table and not in reach. R32 stated he had fallen at the facility. 2. R92's admission Record, dated 5/11/26, documents R92 was originally admitted to the facility on [DATE] with diagnosis of Cerebral infarction, hemiplegia/hemiparesis, dysphagia, generalized anxiety disorder, traumatic left above knee amputation (AKA), epilepsy, cardiomyopathy, intracranial hemorrhage, major depressive disorder, congestive heart failure (CHF), anemia, cocaine abuse, nicotine dependence, schizophrenia, and affective mood disorder. R92's Care Plan, dated 3/31/25, documents R92 is at risk for falls related to functional deficits, seizure disorder, and use of psychotropic medication 4/29/25: Fell due to poor positioning related to hemiplegia. 7/9/25: Fell out of bed due to vomiting. Interventions: 4/15/25: Assess pattern for sleeping and encourage rest per pattern/preference, document s/sx of adverse effects of medication on resident, encourage and offer rest periods when walking long distances, encourage resident to keep room free of obstacles/ clutter, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, keep bed in lowest position, keep frequently used items within reach, monitor for any changes in condition, monitor resident for tolerance and endurance. schedule tasks, accordingly, notify MD and family of any new fall, restorative care as appropriate, rounding at a minimum of Q (every) 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry, therapy to evaluate and treat as indicated, therapy evaluated and placed resident in a high back wheelchair. 4/30/25: arm trough to assist with positioning to left side. 7/9/25: Get resident out the bed for all meals. 12/1/25 Added to HS (hours sleep/nights) get up list. 5/3/26: Provided with a grabber to pick things up from the ground. R92's Care Plan, dated 3/31/25, documents R92 ADLs requires assist with daily care needs related to cerebral infarction, hemiplegia, left BKA (below knee amputation), and weakness. He requires a full body mechanical lift device for transfers. He uses a custom manual wheelchair with safety belt. He wears a helmet as tolerated. res is known to be non-compliant with transfer status. Interventions: 4/15/25: Assist resident with ADLs, Keep clean and dry after each incontinent episode. R92's MDS, dated [DATE], documents R92 has a moderate cognitive impairment and requires substantial/maximal assistance from staff for toileting, bathing, and dressing. R92 is dependent on staff for transfers. R92 is occasionally incontinent of urine and always incontinent of bowel. On 5/12/26 at 10:00 AM, R92 sitting in bed, stated he is saturated and waiting to get back to his wheelchair so he can go smoke during smoke break. V92 stated he told them about 30 minutes ago and is still waiting. R92 asked to push his call light button for him because he couldn't find it. R92's call light was seen located across the room by the other bed in the room. R92 stated they always put his call light where he cannot get to it. On 5/14/26 at 1:12 PM, V2, Director of Nursing (DON), stated I would expect the staff to keep the resident's call light in reach at all times and to answer it timely. 3.R41's Facesheet with a print date of 5/14/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, encephalopathy, chronic obstructive pulmonary disease, and weakness. R41's Care Plan dated 9/16/21 documented she was at risk for falls and on 5/1/23 an intervention to promote placement of call light within reach and assess residents ability to use was added. R41's MDS dated [DATE] documented she was cognitively intact. On 5/13/26 at 9:21 AM, R41's call light was left out of reach and lying on the bed next to hers. On 5/13/26 at 9:39 AM, R41 was finishing her breakfast and stated she needed help swinging her legs onto the bed to lay down. R41 stated she didn't know where her call light was. R41 attempted to swing her legs on to her bed, her right leg was halfway off the mattress, and she couldn't get it any further on. R41 stated all she needs is someone to cover her up with the blanket now, but she doesn't know where the call light was. R41 remained lying in bed clothed in a hospital gown with the gait belt still wrapped around her, a brief halfway off her buttocks and non-slip socks with no blanket. R41 stated she gets cold and likes to be covered. On 5/13/26 at 10:02 AM, V30 nurse practitioner (NP) stated if R41 needs assistance she can press her call light which should be in reach. V30 stated to R41 where is your call light and looked over her bed and was unable to located it. V30 stated a minute later there it is, on the other bed and handed R41 her call light. 4. R20's Face Sheet, admission date of 03/10/25, documents R20 has diagnoses of but not limited to difficulty in walking, unsteadiness on feet, and dementia. R20's Minimum Data Set (MDS), dated [DATE], documents R20 is severely cognitively impaired and requires assistance with her activities of daily living (ADLs). R20's Care Plan, admission date of 03/10/25, documents R20 is at risk for falls and interventions include but are not limited to encourage resident to keep room free of obstacles/clutter and keep frequently used items within reach. R20's Fall Risk Evaluation, dated 03/25.26, documents R20 is a high fall risk. On 05/11/26 at 9:30 AM, R20's call light was seen laying at the foot of her bed out of reach. 05/13/26 at 10:20 AM, R20 is lying in bed at this time, and her call light is across the room lying on the floor and out of reach of R20. 05/13/26 at 11:50 AM, R20 is up and sitting up on the side of her bed and her call light remains across the room on the floor and out of her reach. On 05/14/2026 at 11:05 AM, V2, Director of Nursing (DON) said she would expect the call lights to be within reach of the resident. On 05/14/2026 at 12:46 PM, As of this time the facility has failed to produce any call light policy. The facility's Call Light Response, review date 12/2025, documents General: To provide the staff with guidance on responding to resident's request and needs. It further documents 4. When the patient or resident is in bed or confined to bed or chair, provide the call light within easy reach of the patient or resident.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with a safe/clean/home like environment and has the potential to affect all residents that consume meals in the dining room. Findings Include: 1. R20's Face Sheet, admission date of 03/10/25, documents R20 has diagnoses of but not limited to difficulty in walking, unsteadiness on feet, and dementia. R20's Minimum Data Set (MDS), dated [DATE], documents R20 is severely cognitively impaired and requires assistance with her activities of daily living (ADLs). R20's Care Plan, admission date of 03/10/25, documents R20 displays difficult behaviors when dealing with peers and/or staff over perceived fault findings. R20 is known to hoard items and will often refuse to allow staff to enter her room to clean or perform care. She has been noted to refuse medication most times. The resident is known to defecate in basins and empty them into the toilet. Resident Council Meeting Minutes, dated 02/25/25, documents Housekeeping: need to clean all rooms every day. Resident Council Meeting Minutes, dated 03/27/26, documents Housekeeping: okay, not cleaning room good. Resident Council Meeting Minutes, dated 04/27/26, documents Housekeeping: do not clean east hall. On 05/11/2026 at 9:20 AM, 20 is lying quietly in her bed. R20's floor has trash and debris all over by her bed. Scraps of paper, food/crumbs, and a plastic spoon. There was no trash can to be noted in the room. R20's over the bed table had multiple used medication cups on it and many food items/crumbs all over. R20's Behavior Tracking for the past 30 days was reviewed and has no documentation she refused to let housekeep clean her room. On 05/14/2026 at 12:23 PM, V30, Housekeeping Supervisor said on a daily basis she would expect the housekeeping staff to get in there and do their jobs. To do everything on their job description. That includes sweeping, mopping, dusting, and keep it smelling good in here. The facility Healthcare Cleaning Policy, not dated, documents Policy: To clean a facility to a measure of cleanliness routinely maintained in care area of the health care setting as they are periodically monitored and audited with feedback and education. Procedure: 1. Floors and baseboards are free of stains, visible dust, spills and streaks. It further documents 10. High touch surfaces in client/patient/resident care areas are cleaned and disinfected with hospital- grade disinfectant. 2.R12's Facesheet with a print date of 5/14/26 documented he was admitted to the facility on [DATE]. 3.R27's Facesheet with a print date of 5/14/26 documented he was admitted to the facility on [DATE]. On 5/11/26 at 9:10 AM, R12 and R27's room spelled of urine. R12 had a full urinal on floor. The floor was covered with a sticky substance when walking through it. 4. On 5/11/2026 observed noon meal. Dining room appears congested and disorderly. Resident crammed into room. No walking space between tables. Residents sitting at over bed tables, against the wall, and piano awaiting meal. From 12:26 PM to 12:41 PM observed R16 and R49 sitting at piano with plates of food on piano eating meal. R49's Minimum Data Set (MDS), dated [DATE], documents that R49 is cognitively intact. On 5/11/2026 R49 stated that she would love to sit at a table but there is no room. R49 stated that she feels pushed and thrown to the side and not important. R49 stated she guess she should be happy she has a place to eat at all. R49 stated that she has not had anyone offer her another place. R49 stated that there is nowhere to sit. 5. On 5/13/2026 at 2:00 PM R10, R15, R53, R57, R60, R78, R100, and R111 attended a Resident Council meeting and stated that the dining room is chaotic. Stated that there is no assigned seating, first come first serve. R100 stated that if you don't get to the dining room early there are no seats and you have to go to your room. R100 stated that sometimes you get a tray and sometimes not. R15 stated that he is the only person that has an assigned seat in the dining room. On 5/14/2026 at 9:27 AM V2, Director of Nursing, stated that the dining room set up is congested and not homelike in setting. On 5/14/2026 at 9:52 AM V2 stated that the facility did not have a policy for dining. V2 stated that the management is aware that the dining room does not have enough tables to accommodate the residents' needs. V2 stated that management has been in contact with corporate repeatedly. V2 stated that the immediate intervention is they will start 2 dining. The Long Term Care Facility Application for Medicare and Medicaid form, dated 5/11/2026, documents total residents 109.

Based on interview, observation, and record review, the facility failed to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents for 4 of 10 (R1, R10, R32, R92) reviewed for resident safety in the sample of 40.The findings include: 1. R92's admission Record, dated 5/11/26, documents R92 was originally admitted to the facility on [DATE] with diagnosis of cerebral infarction, hemiplegia/hemiparesis, dysphagia, generalized anxiety disorder, traumatic left above knee amputation (AKA), epilepsy, cardiomyopathy, intracranial hemorrhage, major depressive disorder, congestive heart failure (CHF), anemia, cocaine abuse, nicotine dependence, schizophrenia, and affective mood disorder.R92's Care Plan, dated 3/31/25, documents R92 is at risk for falls related to Functional Deficits, Seizure disorder, and Use of Psychotropic Medication 4/29/25: fell due to poor positioning related to hemiplegia. 7/9/25: Fell out of bed due to vomiting. Interventions: 4/15/25: Assess pattern for sleeping and encourage rest per pattern/preference, Document s/sx of adverse effects of medication on resident, Encourage and offer rest periods when walking long distances, Encourage resident to keep room free of obstacles/ clutter, Evaluate multiple falls to determine commonalities or patterns, Fall risk assessment quarterly and as needed, Keep bed in lowest position, Keep frequently used items within reach, Monitor for any changes in condition, Monitor resident for tolerance and endurance. Schedule tasks, accordingly, Notify MD and family of any new fall, Restorative Care as appropriate, Rounding at a minimum of Q (every) 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry, Therapy to evaluate and treat as indicated, therapy evaluated and placed resident in a high back wheelchair. 4/30/25: arm trough to assist with positioning to left side. 7/9/25: Get resident out the bed for all meals. 12/1/25 Added to HS get up list. 5/3/26: Provided with a grabber to pick things up from the ground.R92's Care Plan, dated 3/31/25, documents R92 ADLs requires assist with daily care needs related to cerebral infarction, hemiplegia, Left BKA (below knee amputation), and weakness. He requires a full body mechanical lift device for transfers. He uses a custom manual wheelchair with safety belt. He wears a helmet as tolerated. res is known to be non-compliant with transfer status. Interventions: 4/15/25: Assist resident with ADLs, Keep clean and dry after each incontinent episode.R92's MDS, dated [DATE], documents R92 has a moderate cognitive impairment and requires substantial/maximal assistance from staff for toileting, bathing, and dressing. R92 is dependent on staff for transfers. R92 is occasionally incontinent of urine and always incontinent of bowel. R92's Fall Risk Assessment, dated 12/1/25, documents R92 is a High Fall Risk with a score of 17. Scoring a 10 or higher makes resident high risk for falls.R92's Fall Investigation, dated 12/1/25, documents in part Resident description: Stated I wanted to get out of bed and smoke. I used my call light after I fell. Notes: IDT discussed recent fall. Resident a [AGE] year-old male. History of weakness, generalized anxiety disorder, epilepsy, Tbolden25, hypertension, and BKA. Resident is compliant with medications and ADLs. Resident is a 2 assist with transfers. BIMS is 15. RCA: Stated he fell trying to get out of bed to smoke. Intervention: Added HS to get up list.R92's Nurses Note, dated 12/1/25 at 7:01 AM, documents Pt. (patient) unwitnessed fall in room at 658 (6:58 AM). Denies any pain. Vital signs taken BP 138/78 Temp.97.7F. O2 97% pulse 84. abrasion to right knee. Stated He wanted to get out of bed and smoke Head to toe assessment ROM good. CNA and nurse transferred to chair.R92's Telehealth Visit, dated 12/1/25 at 6:45 PM, documents Chief Complaints: fall pt unwitnessed fall in room. Denies any pain. vital signs taken BP 138/78 Temp.97.7F. O2 97% pulse 84. abrasion to right knee. stated He wanted to get out of bed and smoke Head to toe assessment ROM good. CNA and nurse transferred to chair. Fall precautions, Neuro checks, supportive care, monitoring vitals. Objective: Health Vitals: Height: 5.0 ft 11.0 ins Assessment: Diagnoses: Unspecified fall, initial encounter [W19.XXXA].R92's Fall Risk Assessment, dated 5/3/26, documents R92 is a Fall Risk, but not a high fall risk, with a score of 5. R92's Fall Investigation, dated 5/3/26, documents in part Resident description: Resident stated that he was trying to pick his food up that fell on the floor, but his wheelchair was not locked, and he fell out of w/c. Notes: IDT discussed fall. Resident a [AGE] year-old male. History of weakness, generalized anxiety disorder, epilepsy, Tbolden25, hypertension, and BKA. Resident is compliant with medications and ADLs. Resident is a 2 assist with transfers. BIMS is 15. RCA: Stated he fell trying to pick something up from the ground. Intervention: Patient provided with a grabber to pick things up from the ground.R92's Nurses Note, dated 5/3/26 at 2:50 AM, documents unwitnessed fall. Resident observed sitting on floor on buttocks with helmet on. resident w/c found flipped over with back wheels on bed. BP 94/67. Pulse 82. RR 17. Temp 97.2F. no c/o pain. resident stated that he was trying to pick his food up that fell on floor, but his w/c was not locked, and he fell out of w/c. This nurse contacted MD (awaiting call). Contacted ADON. Fall form, risk management completed. Neuros started.On 5/12/26 at 10:00 AM, R92 sitting in bed, stated he is saturated and waiting to get back to his wheelchair so he can go smoke during smoke break. V92 stated he told them about 30 minutes ago and is still waiting. R92 asked to push his call light button for him because he couldn't find it, located across the room by the other bed in the room. R92 stated they always put his call light where he cannot get to it. R92 stated he fell out of his wheelchair once while reaching for a piece of paper. R92's bed was left unlocked during incontinent care and the transfer from bed to his wheelchair and the bed was seen moving while both CNAs were leaning on the bed during care. R92's seat belt was not fastened in his wheelchair prior to R92 rolling out of the room.2. R10's admission Record, dated 5/11/26, documents R10 was originally admitted to the facility on [DATE] with Diagnosis of Cerebral Infarction, Dysphagia, End Stage Renal Disease, Dependence on Renal Dialysis, Morbid Obesity, Type 2 Diabetes Mellitus (DM), COPD, Anemia, Atrial Fibrillation, Paranoid Schizophrenia, Major Depressive Disorder, Anxiety Disorder, Congestive Heart Failure (CHF), Hypertension (HTN).R10's Care Plan, dated 1/19/19, documents R10 is at high risk for falls r/t poor Balance and history of falls. R10 has a h/o putting herself on the floor. She is using a rollator walker at this time for mobility with supervision with transfers. She is noted to walk around without shoes or socks at times. 4/29 - res prefers to have bariatric mattress to improve positioning while turning in bed. 9/8/22 Ambulating without walker, slipped and fell in hallway. 9/19/22 Resident found on floor. Interventions: 12/27/19: Document s/sx (signs/symptoms) of adverse effects of medication on resident, encourage appropriate use of Walker, encourage appropriate use of wheelchair, encourage resident to keep room free of obstacles/ clutter, fall risk assessment quarterly and as needed, keep bed in lowest position, keep frequently used items within reach, monitor for any changes in condition, monitor resident for tolerance and endurance, schedule tasks accordingly, notify MD (medical doctor) and family of any new fall, promote placement of call light within reach and assess residents ability to use, restorative care as appropriate, rounding at a minimum of Q (every) 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry, 2/1/21: Resident should use shower chair and walker when taking showers. 7/11/21: R10 will have someone assist her while in shower and R10 to call for help when needing something picked up of floor of shower. 7/15/21: Resident to shower with assist of one from staff. 5/6/21: re-educated on calling for assist if her roommate needs assistance and to not lean forward in her wheelchair. 6/26/22: Resident issued Rollator [NAME] per Therapy. 9/8/22: Resident re-educated on the importance of using assistive device/walker when ambulating. 9/19/22: Resident re-educated on safety precautions when walking with her walking to maintain both hands on walker to ensure proper gait management. There were no new interventions placed in the care plan after each fall. The last interventions added was in 2022 with R10 continuing to have falls.R10's MDS, dated [DATE], documents R10 is cognitively intact (BIMS 15) and requires substantial/maximal assistance for toileting, partial/moderate assistance for other ADLs. R10 is occasionally incontinent of urine and always continent of bowel.R10's admission Fall Risk Assessment, dated 11/15/18, documents R10 was a High Fall Risk.There were no Fall Risk Assessments after R10's fall on 3/17/26, 4/14/26, or the 5/4/26 falls. R10's admission Fall Risk Assessment, dated 4/29/26, documents R10 was a High Fall Risk.There were no Follow-Up Monitoring/Fall Assessments done for R10's 3/17/26, 4/20/26, or the 5/4/26 falls.R10's Fall Investigation, dated 3/9/26 at 5:00 AM, documents in part Resident description: She was taking a shower and once she finished, she got up from the shower chair and her feet slid. She sat on her butt and called for help. Notes: IDT discussed resident fall following recent fall. Resident is a [AGE] year-old female with a history of chronic respiratory failure, generalized weakness, bradycardia, and heart disease. Resident is independent with activities of daily living and utilize a rollator for transfers and ambulation. Resident remails compliant with care and medication regimen. BIMS score is 15, indicating intact cognition. RCA: Patient was attempting to get out of the shower and her foot shifted across the floor. Intervention: Non-slip mats placed in the shower room by maintenance supervisor.R10's Nurses Note, dated 3/9/26 at 5:52 AM, documents CNA reported res was on the floor in the shower. Res said she slid while trying to stand and fell to her bottom. I called ems to come help evaluate res and help get her off the floor. Res refused the hospital and wanted to go to dialysis. Her vitals were stable BP 140/67, Hr 76, BS 137, Temp 98.4. Res has had her morning meds and is stable and ready for dialysis.R10's Fall Investigation, dated 4/14/26, documents in part Resident description: I tripped on my shoe trying to get up and go get the dining room and fell onto my butt. Denied hitting head. Notes: IDT discussed resident fall following recent fall. Resident is a [AGE] year-old female with a history of chronic respiratory failure, generalized weakness, bradycardia, and heart disease. Resident is independent with activities of daily living and utilize a rollator for transfers and ambulation. Resident remails compliant with care and medication regimen. BIMS score is 15, indicating intact cognition. RCA: I tripped on my shoe trying to get up and go get the dining room and fell onto my butt. Intervention: Staff will encourage resident to change planes slowly when changing positions.R10's Nurses Note, dated 4/14/26 at 10:29 AM, documents This nurse was informed that this resident had fallen at approximately 0708 by staff. Upon entering the room, this resident was sitting on the left side of the bed with feet on floor. This resident had fallen and got up by herself per resident. This resident explained that she was trying to get up for the dining room when she tripped on a shoe alongside her bed. She admitted falling onto buttocks and denied hitting her head. Denied pain/discomfort. No injuries noted. education provided on the importance of a clutter free environment to prevent future falls. Resident agreed that she would make changes to room. vs WNL (within normal limit). ROM performed. gait steady. alert to baseline. responsible partied made aware. plan of care is ongoing.R10's Fall Investigation, dated 4/26/26, documents in part Resident description: Resident noted that she has been noticing a change in condition for what she thinks is about two weeks. Resident reported that recently her arms and legs have been having spasms at a time and on the fourth one she will fall or trip if it happens to one of her lower extremities; or shake or drop stuff if it happens in one of her upper extremities. Resident stated I will not go to the hospital I don't care what is going on I am telling you that now. Notes: IDT discussed resident fall following recent fall. Resident is a [AGE] year-old female with a history of chronic respiratory failure, generalized weakness, bradycardia, and heart disease. Resident is independent with activities of daily living and utilize a rollator for transfers and ambulation. Resident remails compliant with care and medication regimen. BIMS score is 15, indicating intact cognition. RCA: Patient lost her balance in the smoking area. Intervention: Medication reviewed by NP on site. Medication adjusted and referral made to neurology.R10's Nurses Note, dated 4/26/26 at 1:19 PM, documents Resident refused any hospital care immediately upon nursing taking vital signs. The nurse stayed with resident and assessed her before moving for pain or bruising. VS obtained. resident A&Ox4. Three out of ten pain and requests PRN for pain. Full body assessment with no deformities or acute findings observed. Resident assisted from floor to bed with assistance of staff using proper technique.R10's Fall Investigation, dated 4/29/26, documents in part Resident description: Resident stated that she was trying to turn in bed, but her foot slipped causing her to fall out of bed. Notes: IDT discussed resident fall following recent fall. Resident is a [AGE] year-old female with a history of chronic respiratory failure, generalized weakness, bradycardia, and heart disease. Resident is independent with activities of daily living and utilize a rollator for transfers and ambulation. Resident remails compliant with care and medication regimen. BIMS score is 15, indicating intact cognition. RCA: Resident stated that she was trying to turn in bed, but her foot slipped causing her to fall out of bed. Intervention: Patient received Bariatric mattress and bed to allow more sleeping space.R10's Nurses Note, dated 4/29/26 at 10:37 AM, documents This writer spoke with the residents sister/POA [NAME] in regard to residents fall out of her bed earlier this morning. Resident did refuse to go to the hospital after the fall. Staff will monitor for changes in condition. Residents sister/POA [NAME] expressed she would like for the residents seroquel to be held until she can see her neurologist. NP made aware and Seroquel placed on hold at this time. No other concerns expressed during this call.R10's Nurses Note In Draft, dated 4/29/26 at 1:36 AM, documents Resident had unwitnessed fall. resident found in room on left side. resident stated that she hit her head on the nightstand. This nurse assessed resident and stated to resident that since she is on Plavix and hit her head, she needs to be sent to hospital for evaluation. Resident refused to be sent to hospital. there was two CNAs that witnessed residences who refused hospital care. Vitals were taken. BP-100/62. pulse 70. RR 18. Tempt 97.1F. O2 94% room air. Resident A&Ox4. No c/o pain. no skin tears. Resident able to move all four limbs. Resident stood with assistance. bed lowered at all times. Slip resistance sock to be worn while in bed. ADON Contacted. After hours doc (doctor) contacted. Nuero checks started. Risk management completed.3. R32's admission Record, dated 5/11/26, documents R32 was originally admitted to the facility on [DATE] with diagnosis of seizures, personality disorder, nicotine dependence, depression, anxiety disorder, and schizophrenia.R32's Care Plan, dated 9/13/24, documents R32 is at risk for falls related to Seizure disorder and use of psychotropic medication. Interventions: 5/4/26: Physical Therapy to eval and treat, 1/8/26: Resident educated on slow position changes and sitting up on the side of the bed prior to standing, 2/19/25: Staff education on ensuring salt is applied to icy areas and consider an alternative smoke break location in bad weather, 4/24/26: Patient educated on proper footwear, 4/28/26: Patient encouraged to wait on staff to pick up his hall tray, 7/25/25: Staff will monitor resident during periods of high activity and ensure environment remains clutter-free to minimize tripping hazards, 9/13/24: Assess pattern for sleeping and encourage rest per pattern/preference, document s/sx (signs/symptoms) of adverse effects of medication on resident, encourage and offer rest periods when walking long distances, encourage resident to keep room free of obstacles/ clutter, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, keep bed in lowest position, keep frequently used items within reach, monitor for any changes in condition, monitor resident for tolerance and endurance, schedule tasks accordingly, notify MD (medical doctor) and family of any new fall, promote placement of call light within reach and assess residents ability to use, restorative care as appropriate, rounding at a minimum of Q (every) 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry.R32's MDS, dated [DATE], documents R32 is cognitively intact and requires supervision/touching assistance for ADLs. On 5/13/26 at 9:45 AM, R32 lying in bed with his call light on the floor behind his side table and not in reach. R32 stated he has fallen and bruised himself - took off his shirt to show bruising to his left chest, left shoulder, and left upper arm, stated he fell but unsure when. R32's Fall Investigation, dated 1/8/26, documents in part Resident Description: Res stated that he got dizzy when he stood up. He also said he hit his head. Notes: IDT discussed recent fall. Resident is a [AGE] year-old male with a history of personality disorder, seizures, anxiety, depression, and schizophrenia. Resident is independent with transfers and uses no mobility devices. Resident is compliant with taking meds and incompliant with bathing at times. BIMS is a 15. RCA: Resident stated he got dizzy when he stood up. Intervention: Resident educated on slow position changes and sitting up on the side of the bed prior to standing.R32's Nurses Note, dated 1/8/26 at 8:21 AM, documents This nurse witnessed res in the day area when he stood up from the chair to walk, when res fell to the floor. this nurse and another nurse went to assess res. Res stated that he got dizzy when he stood up and that caused him to fall to the floor. Res stated that he hit his head. res VS upon assessment were T-97.2 R-20 P-71 BP-97/56 O2-98% Room Air. ADON called NP [NAME] at 8:18am and made her aware, she gave orders to send res to the ER r/t res hitting his head and to get further evaluation. ADON called (local EMS) at 8:26am, this nurse called [NAME] memorial at 8:31am to give report on res, this nurse spoke with nurse (local hospital). res Guardian was notified, and he stated that Res is not listed in their system. (POA) was also contacted and she was ok with the decisions.R32's Fall Investigation, dated 4/24/26, documents in part Resident Description: Resident stated that he tripped over his shoe. Notes: IDT discussed recent fall. Resident is a [AGE] year-old male with a history of personality disorder, seizures, anxiety, depression, and schizophrenia. Resident is independent with transfers and uses no mobility devices. Resident is compliant with taking meds and incompliant with bathing at times. Res BIMS is a 15. Intervention: Patient educated on proper footwear.R32's Nurses Note, dated 4/24/26 at 9:14 AM, documents Resident experienced a fall and after he c/o vertigo. Resident denies pain at this time. No apparent injuries noted. Resident was assisted to the chair with staff assistance. Resident did not hit his head. MD notified resident remains alert and in stable condition.R32's Fall Investigation, dated 4/28/26, documents in part Resident description: I dropped my drink off my tray and slipped on it and fell. Notes: IDT discussed recent fall. Resident is a [AGE] year-old male with a history of personality disorder, seizures, anxiety, depression, and schizophrenia. Resident is independent with transfers and uses no mobility devices. Resident is compliant with taking meds and incompliant with bathing at times. Res BIMS is a 15. RCA: Patient dropped his drink off his hall tray and slipped in the liquids. Intervention: Patient encouraged to wait on staff to pick up his tray.R32's Nurses Note, dated 4/28/26 at 11:40 AM, documents Staff alerted this nurse that this resident had fallen on the floor. Slipped on juice he wasted on the Carnation hallway in front of the bedroom. Staff witnessed the fall. Staff and this resident both denied hitting his head. Upon arrival, this resident was sitting on buttocks with legs extended and both hands on knees. admitted to dropping drink and slipping on it. Admits to falling onto buttocks. Denies any pain/discomfort to that area. Skin c/d/I. No bruising, swelling or redness noted. Able to move all extremities to baseline. Transferred from floor to feet with 1 staff assist. gait steady. NP/responsible parties made aware. own responsible party. NNO (no new orders).R32's Nurses Note, dated 4/29/26 at 11:39 AM, documents During weekly skin assessment, this nurse observed a purplish bruise to anterior L scapula. grimacing noted. admits his shoulder started hurting while sleeping. May be the way I slept or the fall. PRN given per pain. PRN effective. responsible parties made aware. R32's Fall Investigation, dated 5/4/26, documents in part Resident description: I was trying to get my snack and lost my balance. Notes: IDT discussed recent fall. Resident is a [AGE] year-old male with a history of personality disorder, seizures, anxiety, depression, and schizophrenia. Resident is independent with transfers and uses no mobility devices. Resident is compliant with taking meds and incompliant with bathing at times. Res BIMS is a 15. RCA: Patient was getting a snack out of the vending machine and lost his balance. Intervention: PT to eval and treat.R32's Nurses Note, dated 5/4/26 at 12:32 PM, documents Nurse reported left scapula x-ray to NP [NAME]. No recent fracture or dislocation noted. No new orders. Patient made aware and no concerns voiced.R32's Nurses Note Draft, Resident was found sitting on floor in Main DR in front of vending machines. Resident stated he fell while trying to get his snack out of the machine. VS (vital signs) WNL (within normal limits),4. R1's admission Record, dated 3/11/26, documents R1 was admitted to the facility on [DATE] with diagnosis of Schizophrenia, Type 1 Diabetes Mellitus (DM), Hypertension (HTN), Mood (affective) disorder, Cerebral Infarction, Major depressive disorder, and Hepatitis C.R1's Care Plan, dated 5/8/26, documents R1 requires assist with daily care needs r/t (related to) poly neuropathy and cerebral infarction. He walks with supervision throughout the facility. He requires encouragement with ADLs. Interventions: Assist resident with ADLs, monitor for changes with daily care abilities and provide more or less assist if needed, Monitor skin integrity during routine care and report abnormal findings, Notify MD of any abnormal findings, Provide rest periods during ADL care if needed, Restorative program as appropriate, Skilled therapy as ordered.R1's MDS, dated [DATE], documents R1 is cognitively intact and requires supervision/touching assistance with most ADLs. There were no Smoking Risk Assessments completed for R1. R1's Care Plan does not address R1 as being a smoker/tobacco user.On 5/13/26 at 9:20 AM, Upon questioning V1, Administrator, and V2, Director of Nursing (DON), about smoking assessments, R1's smoking assessment was then entered into his medical record.R1's Safe Smoking Risk Assessment, dated 5/13/26 at 9:36 AM, documents R1 is a Safe smoking program independent smoker.On 5/11/26 at 10:10 AM, R1 had a can of [NAME] long cut chewing tobacco on his bedside table.On 5/13/26 at 9:55 AM, R1 sitting on side of his bed with a can of [NAME] long cut on his bedside table with an empty soda bottle for him to spit into.On 5/13/26 at 9:20 AM, V2, Director of Nursing (DON), stated If a resident's Smoking Assessment indicates that the resident requires supervised smoking, then that resident should not have his/hers tobacco products and should be monitored when using them.On 5/14/26 at 1:10 PM, V1, Administrator, stated I would expect the MDS Nurse to keep up with the resident's care plans and update them when needed and to follow resident fall interventions to keep them safe.The Facility's Fall Prevention and Management Policy, dated 1/2026, documents in part This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Upon admission: 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. 2. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP (individual service plan) with interventions implemented to minimize fall risk. Facility guidelines following a fall incident: 1. Evaluate the resident for any injury and notify the physician and emergency contact. 2. Complete a fall incident report in the PCC risk management portal. 3. A fall risk evaluation is completed by the Nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall. 4. Care plan to be updated with a new intervention based on root cause analysis after each all occurrence. 5. Complete the follow-up monitoring form every shift for 72 hours. 6. All incident and accident with serious physical injury will be reported to IDPH within 24 hours. A full written investigative report is required by IDPH within seven (7) days of the incident. Please refer to your state specific guidelines. The Facility's Smoking Policy, dated 7/2018, documents in part The facility is committed to maintaining a safe environment. Residents will no longer be allowed to keep any smoking materials in their possession. This includes cigarettes, cigars, pipes, tobacco (including rolling tobacco). Our activity department will now hold all smoking materials and will distribute them to the residents during the approved smoking times on our smoking patio.The Facility's Smoking Policy, dated 9/2024, documents in part The facility must ensure precautions are taken for the resident's individual safety, as well as the safety of others. 1. Residents who wish to smoke tobacco products are assessed upon admission, readmission, with significant change, quarterly, and annually utilizing the Smoking Safety Risk Assessment in PCC. 2. Resident's plan of care will be developed and implemented based on the results of the Smoking Safety Risk Assessment. 3. Smoking is confined to designated areas of the building, and at designated times. 4. Residents will be allowed to smoke unsupervised unless the Smoking Safety Assessment indicates that supervision is needed. 5. If a resident is unable to smoke unsupervised, their smoking materials are locked in an area designated by the facility. 6. If a resident, who is able to smoke unsupervised, does not follow the smoking rules, their smoking material may also be locked in an area designated by the facility. 7. If a resident fails to abide by the smoking policy, a 30-day discharge may be issued. 8. Any resident who desires smoking cessation material can request the material from social services. If necessary, a referral will also be made to the physician.

Based on interviews, observation and record review, the facility failed to complete hand hygiene and change gloves for 3 of 7 residents (R6, R92, R48); reviewed for Infection Control in a sample size of 40.Findings include:1.R48's Facesheet with a print date of 5/14/26 documented he was admitted to the facility on [DATE]. On 5/11/26 at 9:43 AM, V6 LPN administered R48's medications without completing hand hygiene. 2. On 5/14/2026 at 9:47 AM observed V28, Certified Nurse's Assistant (CNA), V39, CNA, and V40, CNA, transferred R6 into the bed Once in bed R6's incontinent brief with green line on incontinent brief was exposed. V40 reached inside R6's urine soiled depend. Using the same gloves V40 then pulled R6's cover over her, placed call light next to R6 on the bed. Using the same soiled gloves V40 touched the bed, and bedside table. On 5/14/2026 at 11:47 AM V28 returned to the room. V28 and V39 performed incontinent care. R6 was heavily soiled with urine. V39 opened R6's incontinent brief and used a wet washcloth wiped R6's groin. Using the same urine soiled gloves V39 and inner labia with the towel. Using the same urine soiled gloves placed hand in clean water and grabbed clean washed cloth. Using the same urine soiled gloves V39 grabbed R6's clean linen, applied clean incontinent brief, and adjusted R6's clothes. 3. R92's admission Record, dated 5/11/26, documents R92 was originally admitted to the facility on [DATE]. On 5/12/26 at 10:00 AM, V11, CNA, and V12, CNA, entered to do incontinence care on R92. V11 donned gloves with no hand hygiene done. V12 stated she washed her hands in the restroom across the hall, then donned gloves. R92's pants pulled down his legs, and his saturated brief was tucked between his legs, R92 rolled and saturated brief removed. V11 put half of a towel into the basin of water and wiped R92's penis. Using the same gloves, V11 put another half of a towel into the water and wiped R92's scrotum, then bilateral groins and pubic area, then dried all areas with same gloves on. R92 rolled to his left and V11 wiped his right buttock, then dried with same gloves on. R92 rolled to his back while both CNAs changed gloves and did hand hygiene. R92 then rolled to his right while V12 used half towel from basin of water and wiped R92's anal area, used same gloves and got another half of a towel from the water and wiped R92's left buttock, then dried areas with same gloves on. On 5/14/26 at 1:12 PM, V2, Director of Nursing (DON), stated I would expect all staff to do hand hygiene and glove changes when appropriate. The Facility's Hand Hygiene Policy, dated 4/2024, documents in part Proper hand hygiene is necessary for the prevention and the transmission of infectious disease. 1. Hand hygiene is done before and after resident contact, before and after any procedure, after using a Kleenex or the rest room, before eating or handling food, when hands are obviously soiled and regardless of glove use. 2. Hand hygiene is to be done before putting on gloves and after removing gloves.

Based on interview and record review the facility failed to notify the provider of an incident timely for 1 out of 2 residents (R53) reviewed for Resident Rights in a sample of 40.Findings include:1.R53's Facesheet with a print date of 5/14/26 documented he was admitted to the facility on [DATE] with diagnosis of, in part, type two diabetes mellitus, acute hepatitis C, and protein calorie malnutrition.R53's Progress Note dated 4/12/26 at 9:00 PM, documented V34 (LPN) stated, During med (medication) pass V34 administered medication to R53 and later realized the medication was given incorrectly. The resident remained stable and no immediate adverse effects were observed. V34 acknowledged this was an error and reported It the oncoming nurse. R53 was stable all night as well as in the am (morning) when giving a walk through report. R53 slept all night with no complaints.V34's statement for R53's Incident Report dated 4/12/26 documented, On the 4/12/26 I was 04/15/2026 09:22 V34 LPN assigned to care for Resident R53. During my shift, I completed my responsibilities to the best of my ability and ensured the resident received their medications. However I acknowledge that I did not complete all required documentation and procedures as thoroughly as expected, specifically regarding calling the doctor and asking for help. I educated patient on my mistake and assured him it was a sleeping med that he received. I assured him I would monitor him all night. I take full responsibility for that oversight. There was no intent to harm, and the residents remained stable. I reported it to the on coming nurse. Moving forward I understand the importance of accurate documentation and adherence to all protocols and I will ensure that all steps and completed properly and consistently.R53's Incident Report dated 4/12/26 documented the resident description as follows: Res (resident) took the pills and shortly after mentioned it being a white pill in there which he wasn't familiar with but he swallowed them anyway. Res stated he was going to bed anyway and needed a good nights rest.On 5/13/26 at 2:29 PM, V34 (LPN) stated she was doing medication pass with two residents at the same time when she administered Trazadone to R53. V34 stated she immediately told R53 she gave him the wrong medication and assessed him with vital signs and were stable. V34 stated she texted V5 infection preventionist (IP) what happened sometime mid-morning prior to the end of her shift. V34 stated her shift was from 7 PM to 7 AM. V34 stated she also reported the medication error to V13 (LPN) who was the oncoming nurse. V34 stated she did not notify a provider that night and did not hear back from V5 before she left work.On 5/14/26 at 12:43 PM, V5 stated she never was texted by V34 about her medication error with R53. On 5/13/26 at 3:17 PM, V13 (LPN) stated she was the dayshift nurse for R53 when she was told in report from V34 (LPN) that she had given R53 Trazadone in a medication error, but she did not say if she had reported it to anyone. V13 stated she assumed everyone had been notified. V13 stated V34 asked her to continue monitoring him. V13 stated she is usually a night shift worker and doesn't see R53 during the days normally, but he was out of bed and doing activities for her shift. V13 stated for a medication error, the provider and management should be notified.On 5/13/26 at 12:33 PM, V1 (administrator) stated she was the first one to notify the doctor about R53's medication error and it happened while making my rounds and R53 reported not feeling like himself on 4/14/26. V1 stated R53 told her he didn't want to get anyone in trouble, but he was given the wrong medication. V1 stated she had V30 Nurse Practitioner (NP) assess R53 and then she had him sent out on 4/14/26 for change in condition. V1 stated she started a full investigation that day with staff education. V1 stated both V13 licensed practical nurse (LPN) and V34 (LPN) did not report the medication error to anyone including a provider. V1 stated her expectation is that the provider, family and us (management) when there is a medication error or incident. V1 stated it was a delay. Both V1 and V2 director of nursing (DON) stated there was no notification to them about the error.On 5/13/26 at 2:05 PM, V30 (NP) stated V1 notified her of R53's medication error 4/14/26. V30 stated delaying notification of the medication error could have masked R53's symptoms of infection, she could have looked sooner for lethargy verses infection. V30 stated she does not believe this would have the potential to worsen R53's condition. V30 stated the provider needs to be notified of medication errors for proper assessment and monitoring to be done.The facility's Change in Resident Condition Policy dated 9/2025 documented nursing will notify the resident's physician or nurse practitioner when the resident is involved in an accident or incident. The facility's Medication Error Policy dated 8/2025 documented an Incident Report is completed for all medications errors.

Based on interview and record review, the facility failed to complete a mandatory resident assessment with the pre-admission screening and resident review (PASARR) for residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 of 8 residents (R7, R101) reviewed for completion of PASARR in the sample of 40.The findings include: 1. R7's admission Record, dated 5/11/26, documents R7 was admitted to the facility on [DATE] with current diagnosis of Schizoaffective disorder, major depressive disorder, vascular dementia, traumatic brain injury, cerebral vascular disease with hemiplegia/hemiparesis, seizures, hepatitis-C, chronic obstructive pulmonary disease (COPD), emphysema, nicotine dependence, hypertension, and peripheral vascular disease.R7's Care Plan, dated 3/20/23, documents R7's Psych Social: R7 has diagnosis of Major depressive Disorder, Schizoaffective Disorder Depressive Type, Psychotic disturbance, mood Disturbance and anxiety. R7 has a diagnosis of Dementia and/or Alzheimer's and may display moods/behaviors related to diagnosis. 1/20/11: R7's demonstratessignificant mood distress/depression related to Major Depressive Disorder.R7's Minimum Data Set (MDS), dated [DATE], documents R7 has a severe cognitive impairment and requires substantial/maximal assistance from staff for toileting, bathing, and transfers.R7's PASARR level 1 was completed on 10/28/10 during an inpatient psych facility.R7's PASARR level 2 was completed on 10/28/10 during an inpatient psych facility.R7's Medical Diagnosis list includes added diagnosis since the PASARR was completed in 2010. Schizoaffective Disorder and Major Depressive Disorder were added on 3/1/2017. with no new PASARR completed. 2. R101's admission Record, dated 5/11/26, documents R101 was originally admitted to the facility on [DATE] with current diagnosis of Dementia, psychosis, bipolar disorder, anxiety disorder, cocaine abuse, alcohol use, and nicotine dependence.R101's Care Plan, dated 2/2/26, documents R101 is diagnosed with paranoid schizophrenia and has a Level 2 PASARR and in Sub Part S Program. Interventions: Resident will receive rehabilitation services that consist of but not limited to; Pharmacotherapy including administration and monitoring of the effectiveness and side effects of medication which have been prescribed to change inappropriate behavior. Daily living skills to improve independence and self-determining included but not limited to grooming, personal hygiene, mobility, nutrition, vocational skills, health,drug therapy, mental health education, money management and maintenance of living environment. Socialization to decrease isolation. R101's MDS, dated [DATE], documents R101 has a moderate cognitive impairment and requires supervision/touching assistance from staff for ADLs. The facility provided R101's Interagency Certification of Screening Results, dated 10/28/24, documents Screening indicated nursing facility services are appropriate. This was screened by The Department of Aging/Senior Services of Central Illinois. R101's PASARR, dated 10/28/24, documents No Level II Required.R101's Diagnosis List indicates that R101 was diagnosed with Dementia on 11/19/24, Bipolar Disorder, Psychosis, and Anxiety Disorder on 3/3/26 with no new PASARR completed, On 5/12/26 at 8:45 AM, V10, Psych/Social Director, stated I get notified by the (Healthcare Electronic System) when a resident's screening (PASARR) is to be done, then I will do the Level 1 PASARR and submit it to (Outside Assessment Company) for them to come out and do a level 2. When asked how she gets triggered or alerted when a resident has a new diagnosis and/or needs a new PASARR, and/or new screening, V10 stated I don't know how I am alerted. When asked about R7 not having a PASARR screening done since 2010 and having new diagnosis of Schizoaffective disorder and Major Depressive Disorder on 3/1/17 with no screening done, V10 stated (R7) had his screening done while in the hospital prior to his arrival in 2010 and it says that nursing facility services are appropriate. I'm not sure why I was not alerted to his new diagnosis. On 5/14/26 at 1:10 PM, V1, Administrator, stated I would expect the resident's PASARR to be completed when required and to be updated with any change in resident's condition that requires it.On 5/14/26 at 1:20 PM, V2, DON, stated We do not have a policy on PASARR's.

Based on interview, observation, and record review, the facility failed to ensure each resident's care plan is reviewed and revised after each resident assessment and/or change in condition for 4 of 23 residents (R1, R10, R34, R108) reviewed for updated resident care plans in the sample of 40.The findings include: 1. R1's admission Record, dated 3/11/26, documents R1 was admitted to the facility on [DATE] with diagnosis of schizophrenia, type 1 diabetes mellitus (DM), hypertension (HTN), mood (affective) disorder, cerebral infarction, major depressive disorder, and hepatitis C. R1's Care Plan, dated 5/8/26, documents R1 requires assist with daily care needs related to poly neuropathy and cerebral infarction. He walks with supervision throughout the facility. He requires encouragement with activities of daily living (ADLs). Interventions: Assist resident with ADLs, monitor changes with daily care abilities and provide more or less assist if needed, monitor skin integrity during routine care and report abnormal findings, notify MD (medical doctor) of any abnormal findings, provide rest periods during ADL care if needed, restorative program as appropriate, skilled therapy as ordered. R1's Care Plan does not address R1 as being a smoker/tobacco user. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires supervision/touching assistance with most ADLs. On 5/13/26 at 9:20 AM, Upon questioning V1, Administrator, and V2, Director of Nursing (DON), about smoking assessments, R1's smoking assessment was then entered into his medical record. R1's Safe Smoking Risk Assessment, dated 5/13/26 at 9:36 AM, documents R1 is a Safe smoking program independent smoker. On 5/11/26 at 10:10 AM, R1 had a can of [NAME] long cut chewing tobacco on his bedside table. On 5/13/26 at 9:55 AM, R1 sitting on side of his bed with a can of [NAME] long cut on his bedside table with an empty soda bottle for him to spit into. On 5/13/26 at 9:20 AM, V2 stated If a resident's Smoking Assessment indicates that the resident requires supervised smoking, then that resident should not have his/hers tobacco products and should be monitored when using them. 2. R10's admission Record, dated 5/11/26, documents R10 was originally admitted to the facility on [DATE] with Diagnosis of cerebral infarction, dysphagia, end stage renal disease, dependence on renal dialysis, morbid obesity, type 2 diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), anemia, atrial fibrillation, paranoid schizophrenia, major depressive disorder, anxiety disorder, congestive heart failure (CHF), HTN. R10's Care Plan, dated 1/19/19, documents R10 is at high risk for falls r/t poor Balance and history of falls. R10 has a h/o putting herself on the floor. She is using a rollator walker at this time for mobility with supervision with transfers. She is noted to walk around without shoes or socks at times. 4/29 - res prefers to have bariatric mattress to improve positioning while turning in bed. 9/8/22 Ambulating without walker, slipped and fell in hallway. 9/19/22 Resident found on floor. Interventions: 12/27/19: Document s/sx (signs/symptoms) of adverse effects of medication on resident, encourage appropriate use of Walker, encourage appropriate use of wheelchair, encourage resident to keep room free of obstacles/ clutter, fall risk assessment quarterly and as needed, keep bed in lowest position, keep frequently used items within reach, monitor for any changes in condition, monitor resident for tolerance and endurance, schedule tasks accordingly, notify MD (medical doctor) and family of any new fall, promote placement of call light within reach and assess residents ability to use, restorative care as appropriate, rounding at a minimum of Q (every) 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry, 2/1/21: Resident should use shower chair and walker when taking showers. 7/11/21: R10 will have someone assist her while in shower and R10 to call for help when needing something picked up of floor of shower. 7/15/21: Resident to shower with assist of one from staff. 5/6/21: re-educated on calling for assist if her roommate needs assistance and to not lean forward in her wheelchair. 6/26/22: Resident issued Rollator [NAME] per Therapy. 9/8/22: Resident re-educated on the importance of using assistive device/walker when ambulating. 9/19/22: Resident re-educated on safety precautions when walking with her walking to maintain both hands on walker to ensure proper gait management. There were no new interventions placed in the care plan after each fall. The last interventions added was in 2022 with R10 continuing to have falls. Facility Fall Log for past 6 months, documents R10 has had falls on 3/9/26, 4/14/26, 4/26/26, and 4/29/26. R10's MDS, dated [DATE], documents R10 is cognitively intact and requires substantial/maximal assistance for toileting, partial/moderate assistance for other ADLs. R10 is occasionally incontinent of urine and always continent of bowel. On 5/14/26 at 1:10 PM, V1, Administrator, stated 5/14/26 at 1:10 PM, V1, Administrator, stated I would expect the MDS Nurse to keep up with the resident's care plans and update them when needed. 3. R34's Face Sheet, admission date of 04/11/22, documents R34 has diagnoses of but not limited to other generalized epilepsy and epileptic syndromes, into intractable with status epilepticus, paranoid schizophrenia, and hypertension. R34's Minimum Data Set (MDS), dated [DATE], documents R34 is moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 12 out of 15. R34's Care Plan, admission date of 04/11/22, documents R34 is at risk for seizure activity related to (r/t) a diagnosis (Dx) of seizure disorder and is receiving routine medication and lab monitoring. Interventions include but are not limited to follow with neurologist as needed and monitor labs. R34's Progress Notes were reviewed and documents R34 had seizures on the following days: On 01/16/26 R34 had a three-minute seizure. On 01/24/26 R34 had a seizure lasting two minutes. On 02/08/26 R34 he had a one-minute seizure. On 02/12/26 R34 had a two-minute seizure. On 02/19/26 R34 had a two-minute seizure. On 02/25/26 R34 had a seizure lasting less than a minute. On 03/09/26 R34 a seizure. On 05/11/26 R34 a five-minute seizure. R34's Care Plan has not been updated/revised with new progressive interventions regarding his above seizures. 4. R108's Face Sheet, admission date of 07/25/25, documents he has diagnoses (dx) of but not limited to cerebral infarction, Major Depressive Disorder (MDD), Type II diabetes mellitus (DM), hypertension (HTN), and unspecified convulsions added on 05/01/26. R108's MDS, dated [DATE], R108's MDS documents R108 is cognitively intact with a BIMS of 15 out of 15 and he requires supervision/touching assistance or is independent with ADLs. R108's Care Plan, admission date of 07/25/25, was reviewed and had no documentation of R108 having a new diagnosis of unspecified convulsions and no interventions were implemented. R108's Progress Note form the Nurse Practitioner (NP), dated 05/04/26, documents he was being seen for a readmit visit and he returned with a new dx of Seizures. 05/14/2026 11:22 AM, V3, Assistant Director of Nursing (ADON)/Care Plan nurse said when someone comes back from the hospital the floor nurse would be the one to initiate a new diagnosis in the baseline care plan. She said she would have been the one to update R108's care plan with the new diagnosis and she said she hasn't done it. V3 said after a resident has a seizure, she doesn't care plan it or add any new interventions to the care plan. She said she would, after someone had a fall but not a seizure. The facility's policy, review date of 03/2026, documents General: The facility must develop a comprehensive person-centered plan for each resident. Policy: 1. The comprehensive care plan must be completed within 7 days after the comprehensive MDS assessment by the interdisciplinary team. It further documents 4. The comprehensive care plan should be reviewed with the resident and/or resident representative and changes made as appropriate. 5. The comprehensive care plan is reviewed quarterly, annually, and with any significant change.

Based on observation, interview and record review the facility failed to perform complete and timely incontinent care for 2 of 2 (R6, R92) residents reviewed for toileting in a sample of 40.Findings include:1 R6's Care plan, dated 5/13/2026, documents that ADL: (R6) is noted to be alert to person with confusion at times r/t (related to) Dx (diagnosis) of Schizoaffective disease, dementia and psychosis. She requires assistance with daily care needs. She uses a (mechanical lift) for transfers. Resident has functional incontinence of bowel and bladder. It also documents Assist resident with ADLs (activity of daily living). Keep clean and dry after each incontinent episode. R6's Minimum Data Set (MDS), dated [DATE], documents that R6 is cognitively impaired, always incontinent of bowel and bladder and dependent on staff for toileting. On 5/13/2026 at 9:47 AM observed V28, Certified Nurse's Assistant (CNA), V39, CNA, and V40, CNA, transferred R6 into the bed. R6 stated that she had to pee. Once in bed R6's incontinent brief with blue line was exposed. V40 stated that R6 was not wet. R6's covers were placed over R6 and staff left room. On 5/13/2026 at 11:47 AM observed V28 in R6 rooms with cover down and undergarment exposed. V28 stated that she was checking to see if R6 was wet and R6 was wet. V28 then left R6's room. On 5/13/2026 at 11:50 AM V28 returned to the room. V28 and V39 performed incontinent care. R6 was heavily soiled with urine. V39 opened R6's incontinent brief and used a wet washcloth wiped R6's groin and inner labia with the towel. V39 and V28 rolled R6 onto her left side and using a wet washcloth wiped R6's anus. V39 and V28 rolled R6 onto her right side and V28 cleansed R6's left buttock. On 5/14/2026 at 10:33 AM V9, Licensed Practical Nurse (LPN), stated that when a resident is incontinent, she would expect the staff to clean them as soon as they can, no longer than 30 minutes. V9 stated that she expects the staff to clean all areas of incontinence including peri area, inner and outer labia, both buttocks, and inner thighs. On 5/14/2026 at 10:35 AM When asked how she knows when a resident is wet? V39 stated that the diaper has a green stripe that indicates that the resident is wet. V39 stated that when the diaper is placed on the resident the stripe is white and when the stripe changes color it indicates that the resident is wet. V39 stated that she would change the resident right then. V39 stated that she would clean all areas of incontinence when providing incontinent care. V39 stated that this includes the peri area, both buttocks, inner thighs because when a female urinates the urine travels and at times will go up the resident back and down there legs. The facility's Incontinent Care policy, dated 9/2025, documents that GENERAL: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. 5. Clean peri area with appropriate cleanser and dry. Appropriate cleanser can mean soap and water, periwash, etc. Cleansing should always be from front to back. 2. R92's admission Record, dated 5/11/26, documents R92 was originally admitted to the facility on [DATE] with diagnosis of Cerebral infarction, hemiplegia/hemiparesis, dysphagia, generalized anxiety disorder, traumatic left above knee amputation (AKA), epilepsy, cardiomyopathy, intracranial hemorrhage, major depressive disorder, congestive heart failure (CHF), anemia, cocaine abuse, nicotine dependence, schizophrenia, and affective mood disorder. R92's Care Plan, dated 3/31/25, documents R92 Activities of ADLs requires assist with daily care needs related to cerebral infarction, hemiplegia, Left BKA (below knee amputation), and weakness. He requires a full body mechanical lift device for transfers. He uses a custom manual wheelchair with safety belt. He wears a helmet as tolerated. res is known to be non-compliant with transfer status. Interventions: 4/15/25: Assist resident with ADLs, Keep clean and dry after each incontinent episode. R92's MDS, dated [DATE], documents R92 has a moderate cognitive impairment and requires substantial/maximal assistance from staff for toileting, bathing, and dressing. R92 is dependent on staff for transfers. R92 is occasionally incontinent of urine and always incontinent of bowel. On 5/12/26 at 10:00 AM, R92 sitting in bed, stated he is saturated and waiting to get back to his wheelchair so he can go smoke during smoke break. V92 stated he told them about 30 minutes ago and is still waiting. R92 asked to push his call light button for him because he couldn't find it. R92's call light was located across the room by the other bed in the room. R92 stated they always put his call light where he cannot get to it. V12, CNA, initially brought in a pack of wipes and a clean brief. Upon surveyors entrance, V12 left and obtained further supplies, then reentered with them on a bedside table. V11, CNA, unlocked the bed and moved it away from the wall, V11 donned gloves with no hand hygiene seen, V12 stated she washed her hands in the restroom across the hall, then donned gloves. R92's pants pulled down his legs, and his saturated brief was tucked between his legs, R92 rolled, and his saturated brief removed. V11 put half of a towel into the basin of water and wiped R92's penis. Then using the same soiled gloves, put another half of a towel into the water and wiped R92's scrotum, then his right groin and pubic area, then dried all areas using the same soiled gloves. R92 rolled to his left and V11 wiped R92's right buttock, then dried the area with the same gloves on. R92 rolled to his right while V12 used half towel from basin of water and wiped R92's anal area, used the same gloves and got another half of a towel from the water and wiped R92's left buttock, then dried all areas with the same soiled gloves on. A clean brief placed under and R92 rolled to his back and the brief was fastened and pants pulled up. There was no wiping of R92's left groin or his inner thighs from being incontinent. The CNA used soiled gloves while putting her hands in the clean water to get a wet cloth to continue cleaning R92. On 5/14/26 at 1:12 PM, V2, Director of Nursing (DON), stated I would expect all staff to provide timely and complete incontinent care to all residents in need. I would also expect them to do hand hygiene and glove changes when appropriate.

Based on interviews and record review the facility failed to administer the correct medication for 2 of 2 residents (R53, R21); reviewed for Pharmacy Services in a sample of 40.Findings include:1.R53's Face sheet with a print date of 5/14/26 documented he was admitted to the facility on [DATE] with diagnosis of, in part, type two diabetes mellitus, acute hepatitis C, and protein calorie malnutrition.R53's orders documented he does not take Trazadone.R53's Progress Note dated 4/12/26 at 9:00 PM, documented V34 (LPN) stated, During med (medication) pass V34 administered medication to R53 and later realized the medication was given incorrectly. The resident remained stable and no immediate adverse effects were observed. V34 acknowledged this was an error and reported It the oncoming nurse. R53 was stable all night as well as in the am (morning) when giving a walk through report. R53 slept all night with no complaints.V34's statement for R53's Incident Report dated 4/12/26 documented, On the 4/12/26 I was 04/15/2026 09:22 V34 LPN assigned to care for Resident R53. During my shift, I completed my responsibilities to the best of my ability and ensured the resident received their medications. However I acknowledge that I did not complete all required documentation and procedures as thoroughly as expected, specifically regarding calling the doctor and asking for help. I educated patient on my mistake and assured him it was a sleeping med that he received. I assured him I would monitor him all night. I take full responsibility for that oversight. There was no intent to harm, and the residents remained stable. I reported it to the on coming nurse. Moving forward I understand the importance of accurate documentation and adherence to all protocols and I will ensure that all steps and completed properly and consistently.R53's Incident Report dated 4/12/26 documented the resident description as follows: Res (resident) took the pills and shortly after mentioned it being a white pill in there which he wasn't familiar with but he swallowed them anyway. Res stated he was going to bed anyway and needed a good nights rest.On 5/13/26 at 2:29 PM, V34 (LPN) stated she was doing medication pass with two residents at the same time when she administered Trazadone to R53. V34 stated she immediately told R53 she gave him the wrong medication and assessed him with vital signs and were stable. V34 stated she texted V5 infection preventionist (IP) what happened sometime mid-morning prior to the end of her shift. V34 stated her shift was from 7 PM to 7 AM. V34 stated she also reported the medication error to V13 (LPN) who was the oncoming nurse. V34 stated she did not notify a provider that night and did not hear back from V5 before she left work.On 5/14/26 at 12:43 PM, V5 stated she never was texted by V34 about her medication error with R53. On 5/13/26 at 3:17 PM, V13 (LPN) stated she was the dayshift nurse for R53 when she was told in report from V34 (LPN) that she had given R53 Trazadone in a medication error, but she did not say if she had reported it to anyone. V13 stated she assumed everyone had been notified. V13 stated V34 asked her to continue monitoring him. V13 stated she is usually a night shift worker and doesn't see R53 during the days normally, but he was out of bed and doing activities for her shift. V13 stated for a medication error, the provider and management should be notified. On 5/13/26 at 12:33 PM, V1 (administrator) stated she was the first one to notify the doctor about R53's medication error and it happened while making my rounds and R53 reported not feeling like himself on 4/14/26. V1 stated R53 told her he didn't want to get anyone in trouble, but he was given the wrong medication. V1 stated she had V30 Nurse Practitioner (NP) assess R53 and then she had him sent out on 4/14/26 for change in condition. V1 stated she started a full investigation that day with staff education. V1 stated both V13 licensed practical nurse (LPN) and V34 (LPN) did not report the medication error to anyone including a provider. V1 stated her expectation is that the provider, family and us (management) when there is a medication error or incident. V1 stated it was a delay. Both V1 and V2 director of nursing (DON) stated there was no notification to them about the error.On 5/13/26 at 2:05 PM, V30 (NP) stated V1 notified her of R53's medication error 4/14/26. V30 stated delaying notification of the medication error could have masked R53's symptoms of infection, she could have looked sooner for lethargy verses infection. V30 stated she does not believe this would have the potential to worsen R53's condition. V30 stated the provider needs to be notified of medication errors for proper assessment and monitoring to be done.The facility's Medication Administration Policy dated 5/2025 documented an order is required for administration of all medication. The policy continued to document check the medication administration record prior to administering medication for the right medication, dose, route, patient/resident and time.R21's Care Plan, dated 6/20/2024, documents that (R21) has potential for altered cardiac function r/t (related to) heart disease. It also documents Medication as ordered.R21's POS, not dated, does not have orders for amolodipine 2.5mg, atorvastatin 10mg, divalproex 125mg, propranolol 80mg, ingrezza 40mg, lisinopril 10mg, metformin 500mg, multi vitamin, seroquel 100mg, sertraline 25mg instead of citalopram hydrobromide 20mg, clopidogrel bisulfate 75mg, finasteride 5mg, flomax 0.4mg, and olanzapine 10mg.R21's Nurses Notes, dated 4/16/2026 at 8:59 AM, documents that Note Text: during morning med pass administration this nurse discovered res received incorrect medication: amolodipine 2.5mg, atorvastatin 10mg, divalproex 125mg, propranolol 80mg, ingrezza 40mg, lisinopril 10mg, metformin 500mg, multi vitamin, seroquel 100mg, sertraline 25mg instead of citalopram hydrobromide 20mg, clopidogrel bisulfate 75mg, finasteride 5mg, flomax 0.4mg, and olanzapine 10mg res assessed immediately vs were 110/61 pulse 72 temp 98.1 resp 18 o2 98 res alert and oriented x3 no immediate adverse reaction to medication administration called placed to np (nurse practitioner) awaiting return call. R21's Medication Error report documents that R21 received medication that was not his.V5's Written Statement, dated 4/16/2026, documents that V5 pooped the pills in medication cup and V41 administered the medication to the wrong resident.V41's, Registered Nurse, Written Statement, dated 4/16/2026, documents that V41 administered the wrong medication R21. It documents that V5 popped the pills in the cup and V41 failed to identify the resident correctly and administered the medication to R21 instead of its intended person.On 5/14/2026 at 12:42 PM V5 stated that she had previously popped the medications out and the resident walked away. V5 stated that she then popped the pills out for another resident and this resident's medications were given to R21. V5 stated that she will wait until the resident returns before preparing another resident's medication.On 5/14/2026 at 1:23 PM V2 stated that the nurse that prepares the medication is the nurse that administers it.

Based on observation, interview, and record review the facility failed to maintain cleanliness and to distribute food under sanitary conditions regarding cleanliness. This failure has the potential to affect all 113 residents residing in the facility.Findings include: On 4/20/2025 at 11:44 AM observed dark black, sticky and matted substance approximately 1 quarter thick along the perimeter of the kitchen. The substances were beneath and beside the ice machine, stove, refrigerator and cooler. The hood vent over the stove had a brown substance on it. The wall behind and to the side had a brown substance.On 4/20/2026 at 10:45 AM the kitchen floor, walls and hood vent remained the same. No change.On 4/20/2026 at 12:15 PM V5, Cook, stated that the kitchen is cleaned every day. V5 stated that it is a work in progress because as the day goes on and things are moved around and spills happen, dishes are used so the kitchen can get dirty. V5 stated that they clean as they go, as they can and before leaving the shift. V5 stated the floor is mopped twice a day and as needed. V5 stated that they have not had a deep cleaning in about 6 months. V5 stated that this is where the things are pulled from the wall and cleaned behind and under. V5 stated that there is build up on the floor. V5 stated that housekeeping for a period did scrub the floors and that helped a lot. V5 stated that this has stopped. V5 stated that mopping the floor can get some things but the buildup will need to be scrubbed.On 4/20/2026 at 11:55 AM V4, Dietary Manager, stated that the staff have daily cleaning assignments. On 4/20/2026 at 12:24 PM V6, Dietary Aide, stated that they clean the kitchen daily. V6 stated that they have not deep cleaned in about 6 months.On 4/20/2026 at approximately 11:11 AM V2, Director of Nursing, provided a daily census, dated 4/19/2026, documents total residents 113.The facility's Cleaning Schedule, not dated, documents that the dietary aide is responsible for cleaning the Hoods/Filters Hood Monthly (more often as needed). Outside Vendor Every 6 months. The cleaning schedule does not address cleaning of the floor or walls.

Based on interview, observation, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This has the potential to affect all 113 residents residing in the facility.The findings include:The facility's Pest Control Service Information, dated 4/17/2026, documents Inspected room [ROOM NUMBER] (R6's, R7's, and R8's room) for bed bugs. Found live ones on curtain. They Want to schedule service for next week (not prepared) and do inspections of all rooms on that hall and treat as needed. On 4/21/2026 at approximately 11:20 AM observed 2 small, flat, reddish-brown, wingless insects approximately the size of an apple seed R8's bed. Observed 1 small, flat, reddish-brown, wingless insect on the privacy curtain. Observed 2 dead small, flat, reddish-brown, wingless insects on the floor. On 4/20/2026 at 9:08 AM V10, Maintenance Director, stated that he was notified of the bedbugs last week in room [ROOM NUMBER]. V10 stated that he notified the bug company, and they came out and inspected and will be back this week to treat. V10 stated that at this point the room has not been treated. V10 stated that the residents are allowed to leave the room, and the room is not being isolated. V10 stated that room [ROOM NUMBER] has active bedbugs in room. 1. R6's Minimum Data Set (MDS), dated [DATE], documents that R6 is cognitively intact. On 4/21/26 at 11:24 AM R6 stated that there were bed bugs in room and pointed to the privacy curtain. 2. R7's MDS, dated [DATE], documents that R7 is cognitively impaired. R7's Nurses Notes, dated 4/16/26, documents that R7 is alert and oriented x3. On 4/21/26 at 11:08 AM R7 stated that there are bed bugs on the floor. R7 stated that some are dead, and some are alive. 3. R8's MDS, dated [DATE], documents that R8 is cognitively intact. On 4/21/26 at 11:10 AM when asked if there were any bugs or insects in the room? R8 stated yes, they're all over my bed. 4. On 4/20/2026 at 3:54 PM observed a brown flat body insect with antennas crawling on the floor On 4/20/26 V27, Certified Nurse's Assistant (CNA) stated that they insect was a roach. 5. On 4/22/26 at 9:20 AM, R12 stated that she has ants all over her bed and they are biting her all night long. R12 stated she has not seen any other bed bugs or roaches in her room but has seen roaches around the dining room and kitchen area. Upon assessment of R12's bed, there were small black ants crawling around in her bed, on the windowsill, and on top of the air conditioner. R12's Minimum Data Set (MDS), dated [DATE], documents R12 is cognitively intact. 6. On 4/22/26 at 9:30 AM, R13 stated there are ants all over in her room but no bed bugs or roaches. Upon assessment, R13 did have small black ants seen on her windowsill and the air conditioner. R13's MDS, dated [DATE], documents R13 is cognitively intact. 7. On 4/22/26 at 11:10 AM, R1 stated she had seen ants all over in her room and in her restroom. R1's MDS, dated [DATE], documents R1 is cognitively intact. On 4/23/26 at 11:05 AM, V21, Licensed Practical Nurse (LPN), stated she works the night shift, and she frequently sees roaches both in the halls and in resident rooms, with some rooms worse than others. On 4/23/26 at 12:10 PM, V1, Administrator, stated some residents are considered hoarders and always have food items in their room, those resident rooms are deep cleaned, and they have a pest control company out monthly to spray, then they try to find out the cause and take care of it. As of 4/23/2026 the facility had not provided documentation of treatment for bedbugs in room [ROOM NUMBER]. The facility's Pest Control policy, dated 8/2024, documents that GENERAL: Facility shall maintain an effective pest control program. RESPONSIBLE PARTY: Maintenance, Administrator GUIDELINE: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. On 4/20/2026 at approximately 11:11 AM V2, Director of Nursing, provided a daily census, dated 4/19/2026, documents total residents 113.

Based on interview and record review the facility failed to properly assess and supervise a resident during an out of state physician's appointment for 1 of 4 residents (R2) reviewed for supervision in a sample of 16. This failure resulted in R2 who is known of returning from day passes intoxicated, not returning to the facility on [DATE] directly after the appointment with non-emergency ambulance transportation provider or staff escort and instead returning on public transportation after going sightseeing.The Immediate Jeopardy began on 08/19/25 when Due to the facility's failure to properly assess and supervise a resident (R2) during an out of state physician's appointment. This failure resulted in R2 not returning to the facility on [DATE] and instead going sightseeing on public transportation. This comes following a history of R2 not returning to the facility as planned, after being signed out with V5, R2's friend and the facility not being able to locate R2, despite contacting the friend. R2 subsequently arrived back to the facility intoxicated after being on a leave of absence (LOA) on both 06/15/25 and 08/15/25. Findings Include: V1, Administrator, V20, Regional Operations, and V22, Registered Nurse Certified (RNC) were notified of the Immediate Jeopardy on 09/04/2025 at 10:46 AM. Abatement number one and two on 09/04/25 were not accepted. Abatement number three accepted on 09/04/25 at 2:44 PM. The Immediate Jeopardy was removed on 09/05/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R2's admission Sheet, admission date of 11/20/24, documented R2 has diagnoses of but not limited to spinal stenosis, major depressive disorder, repeated falls, other psychoactive substance abuse, alcohol use, unspecified with intoxication. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and he requires supervision or touching assistance with some of his activities of daily living (ADLs). R2's Care Plan, admission date of 11/20/24, documented ABUSE: R2 is at risk for abuse and neglect related to (r/t) polyneuropathy, alcohol abuse, major depression, malnutrition, and spinal stenosis. Resident prefers to go on appointments alone (revision date 08/28/25). Goals: Staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect throughout next review. Interventions include but not limited to Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings, identify areas that put resident at risk.Review assessment information. Emphasize treatment of casual factors and/or interventions designed to moderate/reduce symptoms (make treatment of compulsive behavior, substance abuse, anger and mental health issues available to the resident, as indicated). It also documented R2 has a history of trauma related to being beat up in the community, and homeless. Some intervention includes but not limited to provide a safe and supportive environment. R2's care plan further documented R2 is at risk for injury related to impaired coordination, impaired judgment, and altered level of consciousness dur to alcohol intoxication. Goal Resident will remain safe and free from injury during and after the episode of intoxication. Intervention: Implement fall precautions (bed alarm, non-slip footwear, frequent rounding). R2's Elopement Evaluation, dated 11/20/24 at 5:03 PM, documented R2 had a score of 16 which is high risk for elopement. R2's Elopement Evaluation, dated 03/27/25 at 3:46 PM, documented R2 had a score of 2 which is no risk for elopement. The facility's Release of Responsibility for Leave of Absence dated 04/02/25, documented R2 was signed out of the facility by V5 (R2's Friend) at 2:46 PM and wasn't signed back into the facility until 04/03/25 at 10:06 PM. The facility's Release of Responsibility for Leave of Absence dated 04/15/25, documented R2 was signed out of the facility by V5 at 10:25 AM and was then signed back into the facility on [DATE] at 6:23 PM. R2's Progress Notes, effective date: 04/16/25 at 5:25 PM (created date: 04/16/25 at 10:27 PM), documented Resident called facility and stated that he will be arriving back to facility within a couple of hours. R2's Progress Notes, effective date: 04/16/25 at 6:23 PM (created date: 04/17/25 at 7:49 AM), documented Resident returned to facility via friend vehicle. Remains stable at this time. No signs of distress noted at this time. R2's Progress Notes, dated 6/15/2025 at 5:43 PM, documented Note Text: Resident returned from leave of absence (LOA), he appeared intoxicated and smelled like liquor. Resident gait is unsteady, alert with slurred speech. VS (vital signs) 97.8-82-20-92/60 sats 94% on RA (room air). Respirations even and unlabored. No s/s (signs/symptoms) of distress. Staff will monitor q (every) 15 min (minutes). Evening medications held. Resident now resting quietly in bed. NP (Nurse Practitioner) aware. Will continue to monitor. R2's Progress Notes, dated 6/15/2025 at 8:12 PM, documented Note Text: Resting in bed. Continues q 15min checks. Appetite good. Po (by mouth) fluids encouraged. Alert with decrease in slurred speech. No s/s of distress. Will continue to monitor. R2's Progress Notes, dated 6/16/2025 at 09:17 AM, documented Social Service Note: Spoke with resident in regard to accusations made by staff. Resident denied accusations stating he left the building on LOA between 9-10am and was out with his friend all day until around 5:30pm. Resident stated he did not sign back in at 2:30pm he did not get back to the facility until 5:30pm. Resident agreed to a behavior contract in regard to following the facility policies. R2's Behavior Contract, dated 06/16/25, documented R2 was placed on a behavior contract as an intervention to his treatment plan and in an attempt to maintain his safety, and well-being during his stay at the facility. He agreed to the following: Refrain from going out on LOA and returning to the facility intoxicated. R2's Elopement Evaluation, dated 06/16/25 at 10:43 AM, documented R2 had a score of 41 and is considered a high risk for elopement. The facility's Release of Responsibility for Leave of Absence dated 08/12/25, documented R2 left the facility with V5, R2's friend at 5:05 PM and the log says he was back at 12:48 AM on 08/13/25 but the Nurses notes said he didn't return until 7:53 AM. R2's Progress Notes, dated 8/12/2025 at 5:18 PM, documented Note Text: Resident going out LOA at this time without meds with plans to return in a few hours. Resident informed to notify staff upon return. R2's Progress Notes, dated 8/13/2025 at 07:53 AM, documented Nurses Notes Resident returned no sign/symptoms (s/s) of discomfort and no new skin issues. The facility's Release of Responsibility for Leave of Absence dated 08/15/25, documented R2 left the facility with V5 at 10:00 AM and returned to the facility at 5:35 PM. Nurses note said he appeared intoxicated. R2's Progress Notes, dated 8/15/2025 at 6:08 PM, documented Note Text: Resident came back LOA appeared intoxicated. spoke with Physician who said to hold narcotics and Psychotics just for tonight. Make sure blood pressure is taken before administering meds no blood thinners. Resident resting in bed call light in reach. On 8/15/2025 7:28 PM, Acute Care Note, documented Patient returned to facility from LOA with family patient mediation held due to nursing staff reporting patient observed with slurred speech and unsteady gait. patient approached by staff with reports of strong odor of alcohol on breath Patient admitted to consuming alcohol off site prior to return to facility. No chest pain or dizziness reported. No nausea or vomiting noted. History of Present Illness: This is a [AGE] year-old male admitted to the facility on [DATE] with a primary dx (diagnosis) of multiple falls, patient had multiple witnessed falls by bystanders, with at least one fall involving head trauma. In the ED (Emergency Department) patient was made code stroke status on arrival. CT (Computed Tomography scan) head negative for stroke or hemorrhage. Stroke team recommended no TNK (Tenecteplase). Patient was hypertensive to 165/104 with HR (Heart Rate) 113. R2's Electronic Medical Record (EMR) was reviewed and had no documented time of when R2 left for his appointment or documented time of when he returned to the facility from his appointment. R2's EMR had three prescriptions from the out-of-town appointment, dated 08/19/25 at 10:33 AM, and documented he was to start on Gabapentin 300 milligrams (mg) take on capsule three times a day, Camphor-menthol 0.5-0.5% lotion, apply to affected area three times daily as needed for itching, and Kenalog 0.1% cream, apply to affected areas twice daily as needed for itch. On 08/27/25 at 11:15 AM, V3, Activities Aide said the incident happened sometime last week she isn't sure of the dated. She said R3 went out to a doctor's appointment by himself and when transportation went to go and pick him up, he wasn't there. She said V1 and two other staff went to look for him and they found him down on state street and he was drunk. V3 said transportation called up to the facility and asked if R3 was back yet and they told them no. She said that's why residents aren't allowed to go by themselves on appointments now someone must go with them. On 08/28/25 at 9:15 AM, R2 said when he goes on appointments the facility will take him in the van or they will have a med car or uber take him sometimes. R2 said after his doctor's appointment on the 19th (August) he was supposed to call the driver of the car service, and the driver would come back and get him, but he didn't do that. He said he found an adventure pass for the bus, so he used it to come back to the facility. He said he wanted to just go sight-seeing, and he returned to the facility about 2:00 PM or 3:00 PM at afternoon. R2 said the time he was found on State/25th street was a different time. He said V5, (R2's friend), had signed him out and he had slipped away from V5 because V5 was being a little irresponsible. R2 said the facility had then called V5 to track him down because V5 would know where to find him. He said V5 found him on 25th street after he spent the night there. R2 said when he is out, he will have a cigarette and a beer sometimes. On 08/28/25 at 11:37 AM, V5, (R2's friend) said on one incident the facility called him and asked if he knew where R2 was at. He said I know where he hangs out, so I went and found him and took him back to the facility. V5 said he did not stay with him that night and he doesn't know where he stayed. V5 said that was the first time R2 had left him like that. V5 said R2 use to work down on 25th street so he knows a lot of people from that area. On 09/02/25 at 11:10 AM, V7, Transportation stated when someone has an appointment, he is the one who makes up all of the resident packets that is sent with them and he is also the one who calls and makes the arrangements for the resident's rides to and from the appointments. He said with R2 he called the insurance company and gave them the information regarding the appointment. The insurance company then will put it out there for someone to pick it up. V7 said he knows on the day of R2's appointment it was A- One med care that picked R2 up from the facility. He said R2 had an envelope with all of information in it and on the back of the envelope was the phone number of the facility and of the car service. V7 said R2 was to either call the car service or he could call the facility to let them know he was done with his appointment and the facility would then call the car service and let them know he was ready to be picked up. V7 said when you call to inform the car service you are ready to be picked up it can take them up to an hour to come and get you. V7 said on this day R2 didn't call the facility or the car service to let them know he was ready to be picked up. He said the car service then called the facility and asked them if they had heard from R2 because it was getting close to time for him to quit for the day and he hadn't heard from R2. The facility told him they haven't seen R2 and that he wasn't at the facility at that time. V7 said he believes Illinois Department of Public Health (IDPH) was in the facility at the time this all happened. He said some of the staff went over to the doctor's office where R2 had his appointment and were looking for him and he wasn't there. V7, he doesn't believe R2 returned with the staff when they came back either. He said this has happened on several occasions and they haven't been documenting on it. V7 said he know for a fact that on this day V8, Receptionist was on and off the phone with the car service regarding R2. On 09/02/25 at 12:48 PM, V11, (med car transport) said he was the person who took R2 to his doctor's appointment in St. Louis. He said he dropped R2 off at the appointment and just kind of waited around for R2 to get a hold of him after he was done with the appointment, but he never contacted him. He said it was getting late and close to the end of his shift for the day, so he called the facility and checked to see if R2 was there. He said he talked with V8 at the facility and she called the doctor's office and was on hold for 30 minutes and while she was on hold R2 came walking in the doors. V11 said they don't know how he made it home he just showed up. On 09/02/25 at 1:23 PM, V9, Primary Care Physician said R2's baseline is he is cognitively intact with a BIMS of 15 so he can make sound decisions. As for when he is drinking is anybody capable of making sound decisions. V9 said they should always monitor and make sure the resident is okay while they are intoxicated. He said they have policies in place for that to determine their cognition. V9 said if he would expect the facility to assess the resident at that point and time and monitor their alcohol use. It's kind of bordering on resident rights. He would also expect them to make an on-the-spot assessment to determine if they are cognitively impaired in anyway. On 09/02/25 at 1:45 PM, V8, Receptionist said she let R2 know when he was done with his appointment to contact the facility, and they would call the ride company and send them to get him. She said R2 never did contact the facility, and the car company called the facility asking if they knew where R2 was. She said the car company was closing early that day, and they still hadn't heard from R2, and he was calling to check about him. V8 said she did try and contact the doctor's office regarding R2, but she could never get through to anyone and she was on the phone waiting for over a half an hour. She said she was on hold until after 1 PM. She said that was when she informed them (facility staff) here about R2. V8 said he did come in the front door during this time, but she isn't sure how he got here to the facility. She said she was busy working the desk and didn't see how he got here. On 09/02/25 at 2:40 PM, V12, Licensed Practical Nurse (LPN) said when someone goes on an appointment, they usually send someone with that person, and she doesn't know why he (R2) didn't have someone with him. V12 said no she doesn't feel like R2 is able to make safe decisions at all. She said he wouldn't be here if he was. He's here for a reason. V12 said she has seen R2 here at the facility intoxicated. On 09/02/25 at 2:45 PM, V13, LPN said she usually isn't R2's nurse that she always works on a different hall when she works. She said she heard about R2 and what happened but that's it. She said they usually have someone with them when they go out on an appointment. She doesn't feel R2 is safe to make sound decisions at all. On 09/03/25 at 1:40 PM, V17, Certified Nursing Assistant (CNA) said 25th and State Street is a busy street, and a lot of people hang out there. She said it depends on what you get yourself into, but that street can be rough. V17 said about six to eight months ago a restaurant located on that street had an employee who was shot and fatally wounded while at work and it was shut down for about three weeks. She said there is a lot of drinking and some people there are doing drugs. She said you will see people begging for $2 or $3 to get themselves something to eat and when they get the money, they will go to the convenience store and buy alcohol. On 09/09/25 at 2:25 PM, V1, Administrator stated she doesn't know why R2 was sent on a doctor's appointment without staff. She said her and two other staff members went to the doctor's office to check and see if he (R2) was there at the office. V2 said while they were at the doctor's office R2 returned to the facility.The facility's Leave of Absence policy, review date of 09/2024, documented General: To document a resident has taken a leave of absence and verify their safe return. It further documented 3. The resident must let the nursing staff know when they are leaving and returning to the building. 4. When a resident is ready to leave, the resident or responsible party must let the nurse know where they are going and their expected return time. The resident or responsible party should call the facility if they are going to be late. It also documented 6. If the resident does not return by the anticipated time, the staff will try to contact the resident or their responsible party. 7. If the nurse cannot get a hold of the resident or responsible party, then the DON (Director of Nursing) and/or Administrator are notified and make a determination regarding alerting the police. 8. If the resident or responsible party does not return the resident to the facility as planned, the resident is considered AMA (Against Medical Advice) and the physician is notified. 9. If the resident does not return, the responsible party is notified within 24 hours. 10. The above will be documented in the progress notes. The facility's Appointments and Transportation policy, review date of 9/2024, documented Policy: When a resident has an appointment outside of the facility, the staff will make the transportation arrangements, unless the responsible party choses to make the arrangements themselves. Purpose The purpose of this policy is to provide guidance for appointments and transportation in the facility. It further documented Procedure: If the family will not be accompanying the resident, the staff nurse or designee will inform the DON (director of nursing) to determine if an escort is needed for the resident. The Immediate Jeopardy that began on 08/19/25 was removed on 09/05/25 when the facility took the following actions to remove the immediacy. 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Date: 9/4/25 R2 resides at the facility Admin/DON/Designee initiated in-servicing on elopement policy & LOA policy 9/04/25 and will be ongoing. staff to be in-serviced prior to the start of their next shift. R2 was offered substance abuse rehabilitation offsite on 9/4/25 Completed by Admin. Resident care plans have been reviewed and updated to meet residents' needs. Completed by RNC 9/4/25. RNC/VP reviewed Elopement & LOA policy 9/04/25 Residents will be supervised when going offsite to medical appointments as of 8/21/25. In Serviced all nursing staff prior to next shift 9/4/25. Completed by DON. Transportation and Medical records were in serviced by Administrator on ensuring all residents are accompanied by staff for appointments. 8/21/25 All residents were reassessed by the clinical leadership team, using the Elopement Risk Assessment Tool completed 8/31/25. Completed by Administrator/SSD. All residents identified as at risk for elopements have had their care plans reviewed by the MDS nurses for resident specific interventions. Completed 8/31/25. The elopement binder was reviewed by the SSD, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. Completed 8/31/25.2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. Initiated 9/4/25. The DON/designee will in-service staff on facility elopement policy once a month for the next 3 months. The DON/designee will audit all new admissions and readmissions daily to ensure the Elopement Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the individualized service plan. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months.Completion Date: 9/04/25

Based on observation, interview and record review the facility failed to provide supervision to prevent elopement for 1 of 5 residents (R5) reviewed for supervision to prevent accidents in a sample of 8. This failure resulted in R5 eloping through the front entrance at 2:38 AM, on 8/13/25, unsupervised and returning to the facility at 3:36 AM after staff found him approximately 1.2 miles from the facility.The Immediate Jeopardy began on 8/13/25 at 2:38 AM when R5, a confused resident, exited the facility unsupervised and was found 1.2 miles away. R5 returned back to the facility with staff at 3:36 AM. On 8/19/25 at 9:03 AM, V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/20/25. Findings include:R5's Face Sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, epilepsy, moderate protein-calorie malnutrition, cannabis abuse and schizophrenia.R5's Minimum Data Set (MDS) dated [DATE], documented R5 was severely cognitively impaired and required supervision or touching assistance with transfers. R5's MDS continued to document his ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel was not attempted due to medical condition or safety concerns. R5's Care Plan dated 7/7/25, documented he was at risk for elopement with the following interventions put in place for R5 to be 1:1 with staff date initiated: 07/02/2025; encourage R5 to keep busy with activities date initiated: 07/02/2025; give R5 an opportunity to talk about why he wants to leave, remind him that the doctor would need to approve him leaving date Initiated: 07/07/2025; praise R5 when cooperative date initiated: 07/02/2025; when R5 begins to make statements that he want to go home distract with an activity, offer him a drink, based on weather offer to accompany him to patio date initiated: 07/07/2025. R5's Elopement Risk Assessments dated 7/7/25 and 8/14/25 documented he was at high risk. R5's Progress Note dated 7/6/25 at 5:03 PM documented, Code yellow called this nurse along with other staff exited the facility to retrieve the R5. R5 noted at the end of the with staff following at a safe distance. Staff asked resident multiple times to return to the facility. R5 cont. (continued) to refuse, R5 yelled he would not return and took off walking faster. Local police arrived and was able to talk R5 into returning. R5 was transported back by cop car, and c/o (complaints of) not wanting to stay and being locked in a prison when he has to work. R5 noted to be mentally unstable and very confused. R5 agreed to wait in the dining room but states he will not stay here at the facility. N.P. (Nurse Practitioner) and Admin (administrator) and management made aware.R5's Psychotropic Provider Note dated 7/8/25 at 10:50 AM documented, 70 yo (year old) M (male) with Schizophrenia, restlessness and agitations. Update obtained from R5 and staff. R5 pleasant and cooperative with assessment. Recently admitted after being hospitalized for a witness seizure. Sitting in the common area at time of assessment. R5 is an elopement risk and is disruptive with his behaviors.R5's Progress Note dated 7/24/25 at 10:02 AM documented, R5 attempted to leave facility at 9:50 am. Staff able to redirect patient away from door. R5 placed on 15-minute face checks at this time.R5's Progress Note dated 8/1/25 at 2:45 AM documented, R5 has been awake/up most of NOC (night), wanders halls and sits in dining room. Elopement attempt x 2, this nurse able to redirect without difficulty. Frequent monitoring continues. R5's Psychotropic Provider Note dated 8/1/25 at 1:01 PM documented, 70 yo M with restlessness and agitation and unspecified sleep disorder. Update obtained from patient and staff. Patient pleasant and cooperative with assessment with confusion. Noted to be ambulating the halls at time of assessment. Speech continues to be intermittently nonsensical. Staff report that patient stays up most nights wandering the facility and attempting to elope.R5's Progress Note dated 8/13/25 at 2:45 AM documented, R5 in bed at this time. At approx. (approximately) 0300 (3:00 AM) staff hears front door alarm with no staff exiting building and no one seen outside the front doors. Staff begins room checks for resident accountability. CNA (Certified Nursing Assistant) reports that said resident is not accounted for. Administrator notified. Staff splits up and building search repeated and other staff members outside of building to search with no results. 3 different staff members leave facility in cars to search surrounding areas. Police notified by staff member/receptionist. R5 located on local street (street facility is located on) by staff member at approx. (approximately) 0325 (3:25 AM). Resident returns to facility via private vehicle. No injury noted. No distress. R5 states I just needed my ID, I'm going to local town Call placed to ambulance for transfer of resident to have eval (evaluation) done. Ambulance arrives at approx 0425 (4:25 AM) with 2 attendants and will be taken to local hospital for eval and tx (treatment).R5's Ambulance Report dated 8/13/25 at 4:30 AM, documented he was being transferred to a local hospital for a psychiatric evaluation after elopement from the facility approximately one hour prior. R5's Progress Note dated 8/13/25 at 10:16 AM documented, R5 returned from local hospital with no new orders.On 8/14/25 at 11:53 AM, V3, CNA, stated she is sitting one on one with R5 to make sure he doesn't go outside. R5 was laying with his blanket over his body and head in bed while V3 sat in a chair at the end of his bed. V3 stated she was not sure what happened, and this is the first time she's really had direct care of R5 so she's not familiar with his behaviors or past if he's ever eloped.On 8/14/25 at 11:58 AM, R5 stated he doesn't remember being outside the facility or at the hospital. R5 stated he was hungry and felt messed up after being asked if he was hurt in any way. R5 did not respond to questions at times and continued to lay in bed with his blanket over his head.On 8/14/25 at 12:35 PM, V1, Administrator, stated on the night of the 12th to the 13th (August 2025), she saw via video footage, R5 exit the building unsupervised at approximately 2:37 AM through the front door. V1 stated the receptionist working at the time was on a lunch break but somebody really needs to sit up there while she is on break, and she was educated on that after it happened. V1 stated staff called her at about 3:00 AM to let her know R5 had eloped then shortly after that they found him between 3:00 AM and 3:30 AM. V1 stated her staff did a quick head count twice after hearing the front door alarm and found that R5 was not in his room. V1 stated staff reported they had seen R5 in his room about 10 minutes prior to him leaving the facility. V1 stated she is currently investigating the incident of elopement on R5.On 8/14/25 at 1:42 PM, V5, Receptionist, stated she was working the night R5 eloped. V5 stated she was on a lunch break when R5 got out the front entrance and was told by another CNA when she was returning to the facility that a resident had gotten outside so she turned around a left to look for them. V5 stated she saw R5 close to the board of education building, but he didn't recognize her and told her he was going to the gas station. V5 stated she was nervous about trying to get R5 into her car alone, so she called the police and waited with him. V5 stated after 10-12 minutes she called the facility because the police didn't show. V5 stated R5's CNA V6 was a male and agreed to come help get him back to the facility. V5 stated R5 was not injured from what she could tell but he was out of breath when they got back. V5 stated R5's nurse, V7, gave him a soda to drink. V5 stated she had seen R5 try to exit the building multiple times but was able to redirect him. V5 stated R5 had not eloped for her before this. V5 stated the facility is keeping R5 safely supervised now with a CNA 1:1 assigned to him. V5 stated staff do hourly checks to supervise the residents, door alarms alert us and using visual site to keep residents safe from elopement. V5 stated she had concerns about R5 because he was a flight risk. V5 stated she had never been told not to leave the front reception desk empty but after it happened, she was retrained and told someone needs to be up there at all times. V5 stated she had told a CNA she was going to a local fast-food restaurant before she left. V5 stated she was not sure if the front door alarm could be heard back behind the front doors. V5 stated she was gone for about 15-20 minutes after leaving at 2:15 AM but by the time she came back, R5 was gone.On 8/14/25 at 2:17 PM, V8, Licensed Practical Nurse, LPN, stated she was working when R5 got out. V8 stated a CNA came to her and said R5 was not in his bed so she got in her car and started looking for him. V8 stated she's never been R5's nurse but she noticed the aides had been checking on him often. V8 stated his nurse said R5 was in his bed just 30 minutes prior to him leaving. V8 stated she could not hear the front door alarm going off, but she thinks one of the CNAs heard it and that's what prompted everyone to start looking for R5. V8 stated R5 was not injured. V8 stated 1:1 supervision is put in place and frequent rounding is done to prevent elopements. V8 stated the staff were doing everything they were supposed to do, and it still happened. V8 stated R5's room was not close to a nurse's station or any exits and cannot be seen from a nurse's station either. On 8/14/25 at 2:34 PM, V9, CNA, stated her and V6, CNA, had been doing rounds the night R5 eloped. V9 stated V6 noticed R5 wasn't in his bed and continued to look for him then when he wasn't found quickly, the code yellow for elopement was called. V9 stated for a code yellow everyone stops what they are doing to search for the resident. V9 stated R5 had been in his room around 2:00 AM sleeping. V9 stated they do rounds every two hours and she would take turns with other staff to walk by R5's room more frequently. V9 stated V6 was in close proximity to R5 most of the night she thought. V9 stated interventions to prevent elopement are frequent checks and psychosocial staff located on each hall. V9 stated everyone was doing what they were supposed to. V9 stated she doesn't leave her section assigned and will sit on the hall. V9 stated V6 noticed first that R5 was not in his room and then noticed the front door alarm had been going off. V9 stated she was not sure how long it took for R5 to be found and doesn't think he was injured.On 8/18/25 at 11:25 AM, V11, Registered Nurse, RN stated R5 usually stays quiet in his room, he will have cigarettes outside but then goes back to bed. V11 stated every once in a while, R5 wants to leave the building but she is able to redirect him by letting him know they can get things for him like cigarettes. V11 stated R5 is usually confused that he still needs to go get things for himself like at the gas station or the bank but is reminded we can do that for him here. V11 stated 15-minute face checks are implemented for 24 hours after attempting to leave the facility and 1:1 but not sure how long for 1:1. V11 stated it is for R5's benefit to be in a facility because he requires assistance to take care of himself safely. V11 stated it is not safe for R5 to be outside unsupervised on his own because it could have the potential for him to get into an unsafe situation such as someone else being afraid of him, he's a very tall guy. V11 stated R5's room is not close to the nurse's station but is able to alternate checking on him frequently with the CNAs. V11 stated it's random when R5 is exit seeking, not sure what prompts it and not often.On 8/18/25 at 11:34 AM, V12, CNA, stated R5 is pretty chill, he comes out to eat and then goes back to lay down, at nighttime he will ask for snacks around 12:00 and go back to his room. V12 stated R5 just stays to himself, and he's never tried to leave the building while he was working. V12 stated at nighttime, if R5 is out of his room, he will try to keep him occupied and redirect him. V12 stated he keeps a close eye on all of his residents typically doing rounds every 30 minutes to an hour. V12 stated R5 doesn't have many needs. V12 stated when assigned to R5's hall it is just his hallway, and it's split with another CNA. V12 stated when he goes on breaks, he will let someone else know. V12 stated it's not safe for R5 to be outside the building on his own; he needs the assistance and direction of staff to cue him and help with his care or it won't get done and wouldn't know how to get back.On 8/18/25 at 12:33 PM, V10, Medical Director, stated he was aware R5 eloped on 8/13/25 and expects staff does everything they can to prevent. V10 stated being in a facility is necessary for R5.On 8/18/25 at 12:35 PM, V13, Nurse Practitioner, stated she was aware R5 eloped on 8/13/25. V13 stated not only is it unsafe for R5 to be outside the facility unsupervised but it is unsafe for any resident to be unsupervised outside this facility. V13 stated 1:1 supervision and frequent rounds help prevent elopement. V13 stated she expects staff to be doing frequent rounds and for staff to be at the front reception door to know that no one has gotten out. V13 stated the area this facility is in isn't the best and not many people are walking outside to begin with. V13 stated it would be suspicious to see R5 walking alone at night outside.On 8/18/25 at 3:20 PM, in a joint interview with V1, Administrator, and V14, Corporate/Regional Nurse, V1 stated on 7/6/25 R5 left the facility but staff had eyes on him the entire time until police arrived to take him back to the facility because he didn't want to come back. V1 stated R5 was then placed on 1:1 supervision for 72 hours with no signs of elopement behaviors and put on 15-minute checks after that. V1 stated R5 was trying to leave that time because he didn't have any more cigarettes. V1 and V14 stated R5's initial admission Elopement Risk Assessment was high because they do that for new admissions to be safe being in a new environment. V1 and V14 stated after that initial assessment was done, the social worker will complete another one and update it in the records with their first visit. V1 stated the 6/23/25 assessment was high because he was new and then on 6/30/25 he was re-evaluated and deemed not at risk and that is what we were going off of prior to his elopement on 7/6/25.On 8/14/25 at 1:06 PM, the facility's video footage of R5 on 8/13/25 at 2:38 AM was reviewed and showed R5 exiting the front door of the facility unsupervised. At 2:40 AM, a person outside the front door appears but does not enter and walks away. At 2:51 AM, staff appear inside the building checking the front door.On 8/14/25 at 2:47 PM, the facility's video footage was reviewed and showed R5 returning to the facility on 8/13/25 at 3:36 AM accompanied by staff.On 8/14/25 at 1:05 PM, V1 activated the facility's front door alarm and went back to where the floor staff would be (past two double doors after walking in the front entry doorway. V1 stated she could not hear the alarm. This surveyor went past the double doors where staff would be working behind and could not hear the front door alarm. V4 (receptionist) stated the front door alarm could not be heard past the double doors.The facility's Elopement Policy last reviewed on 9/2022 documented residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. The policy further documented elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. It continued to document alert residents are not in the same category of potential danger as the resident with impair cognition trying to leave the facility. During the validation of the facility's abatement plan, on 8/20/25, some staff had not had in-services regarding the elopement policy. The facility re-inserviced all staff on 8/20/25. The facility took the following to remove the Immediacy which began on 8/13/25:Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Date: 8/20/25.1. R5 returned to the facility and has been on 1:1 supervision since returning. Facility is looking for alternate placement for R5. 8/13/25 Completed by V1, Administrator/V35 SSD (social services director) RNC (regional nurse consultant) in-serviced V2, Director of Nurses, (DON) and V1, Administrator on elopement policy 8/14/25 completed by V14, RN (registered nurse) RNC V2, DON/Designees to provide in-serving on elopement policy to all staff by 8/20/25 or prior to the start of their next shift. All residents were reassessed by the clinical leadership team, using the Elopement Risk Assessment Tool completed 8/14/25. Completed by DON/SSD All residents identified as at risk for elopements have had their care plans reviewed by the V36, MDS (minimum data set) nurses for resident specific interventions. Completed 8/14/25 The elopement binder was reviewed by the Regional Nurse Consultant, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. Completed 8/14/25. Facility has 24 Hour a day Receptionist from 8/13/25 revised by V1, Administrator/Lead Receptionist V1, Administrator/Designee In-Serviced All Receptionist on not leaving the Front Desk unattended 8/13/25. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Completion Date: 8/20/25 The DON/designee will in-service staff on facility elopement policy once a month for the next 3 months. The DON/designee will audit all new admissions and readmissions daily to ensure the Elopement Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the individualized service plan. A QAPI (Quality Assurance and Performance Improvement) PIP (performance improvement plan) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA (quality assurance and assessment) meeting. Monitoring/auditing and reporting will continue for a minimum of three months.

Based on interview and observation the facility failed to assist with financial matters for 1 out of 1 residents (R2) reviewed for social services in the sample of 8. Findings include:R2's Face Sheet documented he was admitted to the facility on [DATE] with diagnoses of, in part, metabolic encephalopathy, type two diabetes mellitus, artificial left eye, lack of coordination, dementia, and cognitive communication deficit.R2's Minimum Data Set (MDS) dated [DATE] documented he was moderately cognitively impaired and required supervision or touching assistance with transfers and ambulation. R2's Care Plan dated 6/2/25 documented he required assistance with daily care needs related to safety concerns and has impaired vision related to his left eye prosthesis.On 8/14/25 at 11:45 AM, R2 could not answer appropriately when asked if he every goes to the bank or if he wanted to close his bank account out. R2 could not recall going to the bank.On 8/19/25 at 12:15 PM, V1, Administrator, stated R2 had recently gone out to the bank and the teller called us and said she was going to call us into the state. V1 stated R2 was brought to the bank by V15, Medical Records, and V17, Transportation, to get R2's bank statements. V1 stated R2 needed to get his bank statements because of a Medicaid Spend Down issue. V1 stated it was discovered during R2's redetermination that he had too much money in his account for Medicaid to enroll him. V1 stated R2's bank account statements were needed for this process in order for R2 to be eligible for Medicaid. On 8/19/25 at 12:24 PM, V16, Regional Business of Manager, stated the State of Illinois was needing R2's bank account statements for redetermination for Medicaid but he couldn't access his accounts when he went to the bank because he had no identification. V16 stated now we are in the process of getting him proper identification to be able to get his account information. On 8/19/25 at 12:30 PM, V15, Medical Record, stated V16 needed R2 to go to the bank. V15 stated she went to R2's room and explained everything that was going on and what was needed. V15 stated V17 was the one who took R2 to the bank. V15 stated while R2 was at the bank, the bank teller called her and was concerned about what R2 needed. V15 stated she explained everything about Medicaid and redetermination to the teller over the phone, but she had seemed questionable about what was going on and because R2 didn't have identification, she wasn't able to do anything. V15 stated she's not sure how transportation handles taking residents to the bank, but she thinks if he was alert and ambulating then he went in by himself but V15 went in soon after.On 8/19/25 at 12:37 PM, V17, Transportation, stated he took R2 to the bank but wasn't sure why, only that the business office needed him to go. V17 stated he got R2 inside the bank with the teller and then waited in the van until he was flagged down by the teller because R2 couldn't communication or articulate to them what he needed done. V17 stated R2 used his walker to ambulate. V17 stated the bank called V15 for clarification but they were not able to complete anything due to R2 not having proper identification on him. On 8/20/25 at 9:50 AM, V1, Administrator, stated she would have expected R2 to be accompanied by a staff member at the bank with providing assistance and assumed that had taken place. The facility's Resident Rights Policy dated 8/1/22 documented the facility strives to consistently and fully comply with the various laws and regulations, including but not limited to the treatment, services and needs of residents to attain or maintain residents' highest practicable physical, mental and psychosocial well-being. The policy continued to document the facility shall safeguard residents' financial affairs.

Based on observation, interview and record review the facility failed to have call light within reach for 1 of 3 residents (R2) reviewed for resident rights in the sample of 6.The Findings include: On 7/21/2025 at 1:31PM R2 sitting in room in wheelchair. R2's call light string hanging down from wall behind chest on opposite side of bed from where R2 sitting in his wheelchair out of R2's reach. R2 stated he did not know where his call light was located.On 7/22/2025 at 12:40 PM R2 in his room in wheelchair, call light out of reach, remains hanging on wall behind chest on opposite side of bed from where R2 sitting in his wheelchair. R2's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 14. R2's MDS documents R2 requires substantial /maximal assistance for toileting, bathing, putting on and taking off footwear. R2's MDS documents R2 requires partial/moderate assistance for oral hygiene, lower body dressing and personal hygiene.R2's undated care plan documents R2 is at high risk for fall due to his history of frequent falls while at home, diagnosis of Dementia, seizure disorder, decreased mobility related to Cerebrovascular Accident (CVA) with right sided weakness and medication R2 is receiving. R2's care plan documents intervention dated 11/30/2023 documents encourage resident to use call light when the need to transfer arises. On 7/22/20205 at 3:12PM V1, Administrator stated she would expect call lights to be in reach of residentsThe facility policy Call Light Response dated revision 9/2024 documents to provide staff with guidance on responding to resident's request and needs. The policy documents to ensure call light is within resident's reach at all times, when the patient or resident's is in bed or confined to bed or chair, provide the call light within easy reach of the patient or resident.

Based on interview and record review, the Facility failed to prevent verbal abuse for 1 of 5 residents (R9) by (R6) for two residents (R9, R6) reviewed for abuse in the sample of 9. Findings include: R9's Face Sheet documents R9 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, need for assistance with personal care, and vascular dementia. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact and required substantial assistance with bed mobility and transfer. R9's Care Plan dated 11/14/18 documents R9 is at risk for abuse and neglect related to communication deficit, weakness to right side and requirement for assistance with care tasks. R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses including depression and paranoid schizophrenia. R6's MDS dated [DATE] documented R6 was moderately cognitively impaired and ambulated with supervision. R6's Care Plan dated 10/1/14 documents R6 has a history of peer to peer altercations and is verbally aggressive and hard to redirect at times. R6's Progress Note by V20, Registered Nurse (RN), on 3/24/25 documents R6 was getting an item off the food tray cart and another resident told him he cannot do that without staff permission. R6 made explicit comments and aggressive behaviors walking toward the other resident. V20 attempted to de-escalate and redirect R6, but R6 approached the other resident with his fist balled up to side. V20 stepped in between the resident and R6 and closed the door to provide a barrier. R6 then began speaking toward V20 in an explicit and aggressive tone. R6 was encouraged to go to his room and calm down. On 7/1/25 at 2:20 PM, V20 stated R6 was taking an item off the food cart and R9 told him he should not do that. R6 then became aggressive toward R9 and walked toward him with his hand in a fist. V20 stepped between the two residents and closed the door to R9's room. There was no physical contact, but R6 made verbally abusive comments toward R9. The Facility's Final Report dated 3/24/25 documents, Resident to resident verbal altercation. (R6) was getting his lunch tray off the cart when another resident seen him and stated you were told not to touch that. (R6) and (R9) then had a verbal altercation. Nurse was walking down the hall and shut the door of (R9) to defuse {sic} the situation. MD (Medical Doctor) and POA (Power of Attorney) notified. More to follow pending final investigation. Upon final investigation it was found that the staff told (R6) not to touch the cart full of food that they are in the process of passing it out. When the staff member walked away he tried to be sneaky and get his stuff off the cart. (R6) started a verbal altercation with the resident. Another resident stood by the nurse. The nurse redirected that resident shut (R9)'s door and descalated {sic} (R6). (R6) went back to his room and no further altercation occurred {sic}. (R6) was educated on not touching the food cart to wait for the staff to pass the trays out. (R9) was educated to not partake in negative behavior by other residents. On 7/1/25 at 4:20 PM, V1, Administrator, stated she expects the Facility to follow its abuse policy. The Facility's Abuse Prevention Program reviewed 9/2017 documents the Facility affirms the right of their residents to be from abuse, neglect, exploitation, misappropriation of property or mistreatment of residents, which includes verbal abuse.

Based on interview and record review, the Facility failed to report reasonable suspicion of a crime to law enforcement for 1 of 5 residents (R4) reviewed for abuse policy in the sample of 9. Findings include: 1-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, alcohol abuse, and poisoning by unspecified drugs. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was severely cognitively impaired and ambulated with supervision. R4's Care Plan initiated 1/20/25 documents R4 is at risk for abuse and neglect related to altered mental status and history of drug and alcohol abuse, having had overdose on Fentanyl in the past, requiring hospitalization. The care plan also documents R4 has a history of criminal behavior R4's Progress Notes for the month of February and March 2025 document R4 had routine leave of absences from Facility. On 6/27/25 at 11:20 AM, V1, Administrator, stated R4 went out a leave of absence with family and returned with a crack rock. V17, Former Director of Nursing (DON), was here at the time, and she flushed it down the toilet. On 6/27/25 at 2:15 PM, V1 stated when R4 came back to the Facility with the white substance V17 flushed, staff did not know what it was but assumed it could have been drugs. On 6/27/25 at 3:23 PM, interviewed V10, Psychosocial Aid, stated a while back R4 came from a home visit and emptied his pockets. There were two crack rocks that were round and white. V17 took the substance from V10, and V10 does not know what happened to the substance after that. On 6/27/25 at 3:30 PM, V11, Activities Aide, stated R4 came back from a home visit with a crack rock in his pocket. The Facility just brushed it under the rug, and the police were not contacted. On 7/1/25 at 10:00 AM, V1, Administrator, stated V10 was the staff who called her and told her there was a substance on R4. The police were not contacted. On 7/1/25 at 11:48 AM, V1, Administrator, stated she reported the allegation to V19, Former Regional Clinical VP Operations. She stated the only thing she could have done differently is call R4's doctor and document the incident. On 7/1/25 at 12:03 PM, V18, Current Regional Clinical VP Operations, stated if we suspected a crime we would have called law enforcement, but V17 didn't think it was a drug. On 7/1/25 at 12:30 PM, V17, Former DON, stated V11 asked her to look at what they found in R4's possession, because she thought it might be drugs. The substance was powdery, and there was no smell or shininess. V17 did not report it to V1 because that was her last day in the Facility, but she normally would have reported it. V17 did not call the police because it was not a drug. On 7/1/25 at 4:20 PM, V1 stated she expects the Facility to adhere to its abuse policy. The Facility's Abuse Prevention Program documents the Facility shall contact local law enforcement authorities within 24 hours of reasonable suspicion of a crime has been committed that does not involve bodily injury.

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 out of 4 residents, (R1, R3, R4, and R5); reviewed for resident rights in a sample of 5. Findings include: 1.R1's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, alcohol abuse, cognitive communication deficit, and cerebral aneurysm. R1's minimum data set (MDS) dated [DATE] documented R1 was moderately cognitively impaired. On 6/5/25 at 10:20 AM, R1's room had several dead cockroaches on the floor under her bed, a strong musty smell was present, dirty dishes and trash bin are covered in gnats. R1's floor had several dried-up liquid markings and missing floorboards containing dark residue. R1 stated she would like her room to be cleaned very much. 2.R2's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, Parkinson's disease, mild protein-calorie malnutrition, and type two diabetes mellitus. R2's MDS dated [DATE] documented R2 was cognitively intact. On 6/5/25 at 11:00 AM, R2's bathroom sink, and toilet had yellow-colored rings. R2 stated he doesn't understand why they can't clean his restroom up nicely. R2 stated it does not smell good at this facility ever and the paint is chipped throughout his room. R2's paint was chipped in multiple locations of his room. R2's air conditioning (A/C) unit was filled with dirt and dust as it blew air out. R2 stated the A/C unit isn't even sealed properly. 3.R4's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and anxiety disorder. R4's MDS dated [DATE] documented she was cognitively intact. On 6/5/25 at 11:30 AM, R4 stated the floors here are too filthy for even my family to visit, they refuse to come. R4's A/C unit had trash inside the blowers including a tissue, a bottle cap, and random unidentifiable objects. 4.On 6/5/25 at 12:04 PM, R5's room had missing floorboards, a strong musty smell, and paper towels in A/C unit seals with a build up of dust where the air blows out. On 6/5/25 at 10:09 AM, the south hall community bathroom/shower room had black buildup on the wall where tiles were missing, several floor tiles had cracks with dark discoloration in them. On 6/5/25 at 10:28 AM, the bath/shower room on [NAME] hall has cracked tiles with dark discoloration. On 6/5/25 at 10:57 AM, the central hall community bath/shower room had missing tiles behind the toilet, cracked missing tiles next to the shower with dark matter inside and part of the actual wall missing, a strong musty urine and stool smell is noted with humidity and damp floors. On 6/5/25 at 12:05 PM, pink and black discoloration on cracks of the bottom creases and corners seen shower on [NAME] community bath/shower room located across the hall from room [ROOM NUMBER]. On 6/5/25 at 10:15 AM, V3, housekeeping, stated the condition of the south hall bathroom has been that way since at least October of 2024, the central hall community bath/shower rooms also have these same issues included the one next door to this one. V3 stated that the missing tiles soak up all the dirt and bacteria but there is no way we can clean them up enough because they are broke. The bath/shower room next door was seen and had cracked tiles on floor and walls with the wall broken through to the wooden bases. V3 stated the wall tiles and foundation behind it are broke with discoloration seen. V3 stated it's concerning because these are high moisture areas the toilet overflows a lot due to one of the residents as well. V3 stated there is black buildup of some sort there. V3 stated R1's room has a cockroach problem also. On 6/5/25 at 10:28 AM, V3 (housekeeping) stated the missing floorboards are a concern just like the cracked tiles because they hold everything in and when liquids such as urine spill, it gets trapped it those places. V3 stated she would like to be able to clean it better, but we can't use bleach. V3 stated she doesn't know what they plan to do about it. On 6/5/25 at 11:15 AM, V4, housekeeping, stated she's noticed a lot of the dirt cracked tiles and floorboards for about 4 months now (since she started working here) and they harbor a lot of bacteria and it's worrisome. V4 stated there is a musty smell throughout the building and they need better cleaning products to be able to manage things properly. V4 stated the black/dark discolored sections in the bath/shower rooms could be mold. On 6/5/25 at 12:17 PM, V5, registered nurse (RN) stated the facility could be a bit more sanitary. On 6/5/25 at 12:17 PM, V6 certified nursing assistant (CNA) stated the cleanliness of the facility needs improvement, there are gnat build ups, but they have been getting better. On 6/5/25 at 2:50 PM, V1, Regional Administrator, stated she does not expect the facility to have a gnat buildup, cockroaches, and dirty buildups in the shower rooms, toilets, or sinks. V1 stated she expects the tiles and floorboards to be intact for sanitary and dignity reasons. V1 stated she expects all the A/C units are maintained in good working conditions without dirt, dust, or garbage within them. Resident Council Meeting Minutes dated 5/28/25 documented housekeeping needed to clean all rooms every day and maintenance not doing their job. R4 stated her floors are dirty. Resident Council Meeting Minutes dated 4/30/25 documented an issue of bad odor in the building and residents feel it never smells good. Resident Council Meeting Minutes dated 3/26/25 documented residents want 24-hour housekeeping to stop the smell. The facility's Pest Control policy dated 10/2017 documented the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The policy goes on to document that Garbage and trash are not permitted to accumulate and are removed from the facility daily; maintenance services assist, when appropriate and necessary, in providing pest control services. The facility's Resident Rights policy dated 2/2024 documented it is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Based on observations, interviews, and record reviews the facility failed to treat 3 out of 3 residents, (R2, R3, and R4) with dignity and respect; reviewed for resident rights in a sample of 5. Findings include: 1.R2's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, Parkinson's disease, mild protein-calorie malnutrition, and type two diabetes mellitus. R2's minimum data set (MDS) dated [DATE] documented R2 was cognitively intact. On 6/5/25 at 11:00 AM, R2 stated he likes to help a lady resident out at the facility by getting her soda but when he did so, staff yelled at him you can't do that, this is a women's hall, get out. R2 stated they treated him like a child being disciplined and he's a grown man. 2.R3's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, paranoid schizophrenia, mild protein-calorie malnutrition and low back pain. R3's MDS dated [DATE] documented he is cognitively intact. On 6/5/25 at 10:50 AM, R3 stated a lot of the staff talk rudely and disrespectfully to us all. R3 stated just yesterday it was the planned day to go to the store so he asked the activities staff if they could go and they responded with an angry attitude saying we can't take you, we don't have time. R3 stated he has no concerns with abuse or with staff ever being threatening. R3 stated both of the ladies that work for the psych(psychological)/social department are very disrespectful all the time. 3.R4's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and anxiety disorder. R4's MDS dated [DATE] documented she was cognitively intact. On 6/5/25 at 11:30 AM, R4 stated sometimes the staff are disrespectful and rude. R4 stated last night she told her CNA (certified nursing assistant) that she had a bowel movement so she cleaned her up but there was some still up in her front peri region, so she requested another towel to clean it up herself. R4 stated the CNA snapped at her and said I just cleaned you, you're crazy, I'm not giving you another towel. I can clean myself up, but you can't. R4 stated later that night, the CNA through two dry towels at her but didn't get soap and water to use. R4 stated she likes to make sure she is cleaned up well because she doesn't want to get any more UTIs (urinary tract infections). R4 stated she knows when she has to use the toilet or bed pan but is never offered those especially at night and wishes she was. R4 stated she thinks this place is a psych (psychological) facility and it's horrible. On 6/5/25 at 2:50 PM, V1, Regional Administrator, stated she expects all the residents to be treated with dignity and respect. Resident Council Meeting Minutes dated 3/26/25 documented concerns with CNAs (certified nursing assistants) not talking to residents right. Resident Council Meeting Minutes dated 3/26/25 documented that CNAs are telling residents what they will and won't do and when they will and won't get the up; the dietary weekend staff is very disrespectful to resident and when it's reported nothing happens. The facility's Resident Rights policy dated 2/2024 documented it is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Based on observation, interview and record review the facility failed to assess resident's skin upon admission, failed to provide ongoing assessments, failed to follow/update physician's treatment orders, failed to complete physician ordered pressure ulcer treatments and failed to put interventions in place to prevent skin breakdown for 3 of 3 residents (R1, R2 and R3) reviewed for pressure ulcers in a sample of 3. This failure resulted in R2 developing a deep tissue injury (DTI) to R2's right hip which worsened by increasing in size. evolved to an unstageable pressure ulcer and the left hip pressure ulcer a DTI evolved to a Stage 3 pressure ulcer. Findings include: 1. R2's Undated Face Sheet, documented he was initially admitted to the facility on [DATE]. No diagnosis of pressure ulcers was documented. R2's Care Plan, dated 10/28/2022 documents, Resident is at risk for skin complications r/t (related to) unspecified dementia without behavioral disturbances, altered mental status. 12/27 (year not documented) right hip treatment in progress res (resident) follow up with in house wound NP. 2/15 (year not documented) treatment in progress to hip. Goal: will maintain adequate skin integrity throughout next review. Interventions: skin assessment weekly 10/28/2022, ensure proper body alignment 12/14/2024, increase protein intake 12/14/2024, Prostate 30 milliliters (ml) BID (twice a day) 1/8/2025 and low air loss mattress 3/7/2025. R2's Minimum Data Set (MDS) dated [DATE] documents resident is rarely/never understood, at risk for pressure ulcers but does not have any unhealed pressure ulcers. Pressure reducing device for chair and bed. R2's Skin Screen dated 12/14/2024 documents right iliac crest (hip) reddened area noted. Actions taken notified treatment nurse of area and wound NP (nurse practitioner) made aware. Foam dressing reapplied. R2's Progress Note, dated 12/14/2024 at 7:06 PM documents, No open areas noted. R2's Readmission Braden Scale for Predicting Pressure Sore Risk, dated 12/14/2024 documents 11 - very high risk. R2's Progress Note, dated 12/16/2024 at 1:38 PM documents, Res (Resident) noted to have reddened area to right hip, area cleansed, and foam dressing applied, res (resident) voiced no c/o (complaint of) pain or discomfort. DON (Director of Nurses) notified, POA (Power of Attorney) notified will continue to monitor wound np (nurse practitioner) notified. There was no other description of R2's pressure ulcer documented. R2's Progress Note, dated 12/20/2024 documents, Res was seen by wound care nurse and wound NP treatment as ordered, area stable and no s/s (signs or symptoms) of infection noted, plan of care continue. There was no description of R2's pressure ulcer documented. R2's Medical Record had no documentation from the Wound NP regarding the assessment or description of R2's pressure ulcers on 12/20/2024. R2's Wound Assessment Report, dated 12/27/2024 documents right hip pressure/DTI (deep tissue injury) measured: 1.1 cm (centimeters) x 0.6 cm, wound status: reopened, acquired in house, 100% epithelial, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: none, exudate description: none, odor post cleansing: none. Treatment: weekly and PRN cleanse with wound cleanser, skin prep and hydrocolloid. The National Pressure Injury Advisory Panel (NPIAP) website defines Deep Tissue Pressure Injury as the following Intact or non-intact skin with localized area of persistent non-blanchable deep red, [NAME], purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and or/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extend of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are not visible, this indicates full thickness pressure injury (Unstageable, Stage 2 or Stage 4). R2's Medical Record didn't document a Wound Assessment Report or weekly skin assessment from 12/28/2024 through 1/16/2025. On 3/19/2025 at 11:00 AM V7, Infection Preventionist/Former Wound Nurse stated she was the facility wound nurse from October 2024 through December 2024. V7 recalled R2's right hip was red on 12/20/2024 and the nurse practitioner didn't write a treatment order or document the reddened area because R2's right hip wasn't open at that time. When she left as the wound nurse at the end of December 2024 staff were cleansing R2's right hip and applying a bordered foam dressing to protect his skin from breaking down. V7 wasn't aware there was a new wound treatment was ordered for R2's right hip on 12/27/2024 because she was promoted to a different nurse position at the facility. R2's Wound Assessment Report, dated 1/17/2025 documents right hip pressure/DTI, measured: 0.7 cm x 0.6 cm x 0.1 cm, wound status: improved with delayed wound closure, acquired in house, 100% epithelial, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: none, exudate description: none, odor post cleansing: none. Treatment: weekly and PRN cleanse with wound cleanser, skin prep and hydrocolloid. R2's Wound Assessment Report, dated 1/24/2025 documents right hip unstageable pressure ulcer, measured 3.5 cm x 3.8 cm x 0.1 cm, wound status: worsening, 40% epithelial, 10% granulation, 50% eschar, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: moderate, exudate description: serosanguineous, odor post cleansing: mild. Treatment: daily and PRN cleanse with wound cleanser, SSD, collagen hydrogel, collagen particles and bordered foam dressing. R2's Physician's Order Sheet (POS) dated 12/19/2024 through 1/30/2025 documents right hip pressure ulcer treatment cleanse with wound cleanser, apply foam border dressing everyday shift for prophylaxis. The facility failed to change the pressure ulcer treatment orders from the wound nurse practitioner on the Wound Assessment Report dated 12/27/2024 and 1/24/2025. R2's TAR (Treatment Administration Record) dated 12/19/2024 through 1/30/2025 documents right hip pressure ulcer staff documented treatment was administered per the POS. This was not the correct wound treatment per the wound nurse practitioner's wound assessment report dated 12/27/2024 through 1/24/2025. R2's Medical Record documents from 12/27/2024 through 1/30/2025 failed to change the right hip pressure ulcer treatment order from the wound nurse practitioner from 12/27/2024 through 1/30/2025. R2's Wound Assessment Report, dated 1/31/2025 documents right hip unstageable pressure ulcer, measured 3.5 cm x 3.8 cm x 0.1 cm, wound status: stable eschar, 100% eschar, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: moderate, exudate description: serosanguineous, odor post cleansing: mild. Treatment: daily and PRN cleanse with wound cleanser, medical grade honey and bordered foam dressing. R2's Medical Record documents no Wound Assessment Report or weekly skin assessment dated [DATE] through 2/13/2025. R2's POS, dated 2/4/2025 through 2/17/2025 documents a new physician's order left hip cleanse wound cleanser and apply bordered foam dressing everyday shift. There is no documentation of any pressure ulcer to R2's left hip at that time. R2's Wound Assessment Report, dated 2/14/2025 documents right hip unstageable pressure ulcer, measured 3.5 cm x 3.8 cm x 0.1 cm, wound status: stable eschar, 30% granulation, 70% eschar, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: moderate, exudate description: serosanguineous, odor post cleansing: mild. Treatment: daily and PRN cleanse with wound cleanser, Santyl and bordered foam dressing. R2's Medical Record no documentation R2's left hip skin assessment regarding the physician's order dated 2/4/2025 through 2/17/2025. R2's POS dated 2/18/2025 through 2/25/2025 documents a new physician's order cleanse right hip with wound cleanser, apply Santyl and cover with a dry dressing. This was a wound nurse practitioner treatment order from the wound assessment report dated 2/14/2025. The POS was not updated with the new wound nurse practitioner treatment order for 4 days. R2's POS, dated 2/18/2025 through 2/24/2025 documents a new physician's order to left hip: cleanse with wound cleanser and apply Santyl to wound bed and cover with bordered foam dressing as needed for left hip wound and everyday shift for left hip. R2's TAR, dated 2/18/2025 through 2/24/2025 staff documented R2's treatment to the right hip was administered per physician's orders, expect a blank box dated 2/24/2025. R2's MDS, dated [DATE] documents resident rarely/never understood, resident is at risk for developing pressure ulcers and resident has 1 unhealed unstageable pressure ulcer. Pressure reducing device for chair and bed, pressure ulcer care, application of nonsurgical dressings and applications of ointments/medications applied. R2's Wound Assessment Report, dated 2/21/2025 documents right hip unstageable pressure ulcer, measured 4.5 cm x 5.7 cm x 0.7 cm, wound status: improving with delayed wound closure, 10% granulation, 90% slough, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: moderate, exudate description: serosanguineous, odor post cleansing: mild. Treatment: daily and PRN cleanse with wound cleanser, SSD, collagen hydrogel, collagen particles, calcium alginate and a bordered foam dressing. R2's Medical Record no documentation R2's left hip skin assessment regarding the physician's order dated 2/17/2025 through 2/24/2025. R2's POS dated 2/25/2025 documents a new physician's order cleanse right hip with wound cleanser, apply SSD, collagen, hydrogel, collagen particles, calcium alginate, cover with bordered gauze everyday shift. This is from the Wound Assessment Report, dated 2/21/2025. The POS was not updated with the new wound nurse practitioner treatment order for 4 days. R2's TAR dated 2/25/2025 through 3/7/2025 staff documented right hip cleanse with wound cleanser, apply SSD, collagen, hydrogel, collagen particles, calcium alginate, cover with bordered gauze everyday shift. R2's Wound Assessment Report, dated 2/28/2025 documents right hip unstageable pressure ulcer, measured 4.8 cm x 5.4 cm x 1.1 cm, wound status: improving with delayed wound closure, 20% granulation,80% slough, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: moderate, exudate description: serosanguineous, odor post cleansing: mild. Treatment: daily and PRN cleanse with 0.125% Dakin's solution, SSD, collagen hydrogel, collagen particles, calcium alginate, silicone bordered superabsorb dressing. New left hip pressure/DTI documented date acquired in house 2/28/2025 measured 1.5 cm x 0.7 cm 100% epithelial, exposed tissue: epithelium and dermis. Wound edges: attached, periwound: fragile and scarring. No exudate, no odor post cleansing. Treatment: 3 times per week and PRN cleanse with normal saline, skin prep and bordered foam dressing. R2's POS dated 2/25/2025 through 2/28/2025 documented no physician's order to treat R2's left hip pressure ulcer. R2's TAR dated 2/25/2025 through 2/28/2025 no documentation staff administered a treatment to R2's left hip pressure ulcer. R2's POS, dated 3/1/2025 through 3/6/2025 no physician's order to treat R2's left hip pressure ulcer. R2's TAR, dated 3/1/2025 through 3/6/2025 no staff documentation R2's left hip pressure ulcer treatment was administered. R2's POS dated 3/7/2025 through 3/13/2025 documents a new physician's order left hip: cleanse with normal saline apply calcium alginate every 24 hours and one time a day every Monday, Wednesday, Friday. R2's TAR dated 3/10/2025 through 3/13/2025 staff documented left hip cleanse with normal saline and apply calcium alginate one time a day every Mon, Wed, Fri treatment was administered. R2's POS, dated 3/8/2025 documents a new physician's order right hip cleanse with Dakin's solution, moisten gauze, silicone border superabsorbent dressing every day shift. This treatment order was from the Wound Assessment Report, dated 2/28/2025. The POS was not updated with the new wound nurse practitioner treatment order for 8 days. R2's Wound Assessment Report, dated 3/7/2025 documents right hip unstageable pressure ulcer, measured 4.6 cm x 6.5 cm x 1.5 cm, wound status: worsening, undermining from 2 o'clock to 7 o'clock, 1.1 cm, 20% granulation, 80% slough, exposed tissue: epithelium, wound edges: attached, periwound: fragile erythema, scarring, exudate amount: heavy, exudate description: seropurulent, odor post cleansing: malodorous. Treatment: daily and PRN cleanse with 0.125% Dakin's solution, silicone bordered superabsorb dressing. Left hip stage 3 pressure ulcer measured 1.0 cm x .5 cm x 0.1 cm, wound status: stable, 80% granulation, 20% slough, exposed tissue: epithelium, dermis and subcutaneous, wound edges: attached, periwound: fragile and scarring, exudate amount: scant, exudate description: serosanguineous, odor post cleansing: none. Treatment order: 3 times a week and PRN cleanse with normal saline, calcium alginate and bordered gauze. R2's POS, dated 3/8/2025 documents a new physician's order for right hip treatment daily and PRN cleanse with 0.125% Dakin's solution, silicone bordered superaborb dressing. R2's TAR, dated 3/8/2025 through 3/13/2025 staff documented right hip treatment administered per physician's orders. On 3/20/2025 at 3:20 PM V17, Wound NP stated she expects staff to do a head-to-toe skin assessment as soon as possible within 72 hours of admission. As soon as staff are aware of an open area/pressure ulcer staff should notify the wound NP within 2-3 hours to get treatment order. There is a standing order for pressure ulcers which is cleanse the area with normal saline and apply a dry dressing. When she is at the facility she communicates with the wound nurse and/or charge nurse to let them know of wound treatment changes while she is at the facility, and she expected the wound treatment changes to go into effect immediately unless the primary physician doesn't agree with the wound treatment order then the facility should notify her within 24 hours so she can get a new treatment order in place. When a resident has a pressure ulcer, she expects staff to administer the current pressure ulcer treatment and for staff to follow all physician's orders. V17 stated she wasn't aware staff didn't follow wound treatment orders for R2 and that he went without wound treatment as well. V17 stated she expected a treatment to be in place at all times and if there wasn't a wound treatment ordered staff should have notified her so she could get a treatment ordered as soon as possible. Staff not changing/updating physician's wound treatment order could lead to the deterioration of the pressure ulcer(s.) V17 expected facility staff to have interventions in place to prevent pressure ulcers from getting worse and the facility should have had a specialty air loss mattress for residents with a DTI or stage 3 pressure ulcer to help in reliving pressure. On 3/20/2025 at 3:40 PM V18, Nurse Practitioner stated she's never had to approve of the wound nurse practitioner's treatment orders, the wound nurse practitioner writes orders for wounds and the facility should implement the treatment orders as soon as possible. The facility not following or changing wound treatment order could lead to the deterioration of the pressure ulcer. V18 wasn't aware the facility didn't administer the correct pressure ulcer treatment orders for R2 or that the facility failed to ensure treatment orders were ordered for pressure ulcers for R2. 2. R1's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with no diagnosis of pressure ulcer documented. R1's Braden Scale for Predicting Pressure Sore Risk, dated 3/10/2025 documents she is very high risk for pressure ulcers. R1's Progress Note, dated 3/10/2025 at 5:00 PM documents, resident arrived to facility via ambulance and has open area to coccyx. R1's Undated Care Plan, no documentation that she has a pressure ulcer on her coccyx or interventions to prevent it from getting worse. R1's Skin Screen, dated 3/11/2025 documents open area on coccyx no measurements or wound assessment documented. R1's Medical Record documents no assessment of pressure ulcer on coccyx from 3/10/2025 through 3/13/2025. R1's Wound Assessment Report, dated 3/14/2025 documents present on admission stage 4 pressure ulcer on R1's sacrum measured 5.5 cm x 10 cm x 3.5 cm with 30% granulation, 40% slough, 30% eschar exposed tissue: hypergranulation, epithelium, dermis subcutaneous and bone. Wound edges: attached, periwound: fragile, exudate amount: heavy, exudate description: purulent, odor post cleansing: malodorous. R1's Medical Record documents no physician's treatment order dated 3/10/2025 or 3/11/2025. R1's POS, dated 3/12/2025 documents a treatment order for coccyx: cleanse with Dakin's and apply Dakin's soaked gauze and cover with dry dressing. R1's TAR, dated 3/2025 staff documented treatment to coccyx pressure ulcer per physician's orders. On 3/19/2025 at 9:40 AM V5, Registered Nurse, RN entered R1's room and rolled her to her left side and showed a large intact dressing on her coccyx. V5 stated he just administered pressure ulcer treatment to (R1's) coccyx. 3. R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with no diagnosis of a pressure ulcer. R3's MDS dated [DATE] documents BIMS 11, resident at risk for developing pressure ulcers and has one unhealed pressure ulcer. Pressure reducing device for bed and pressure ulcer care. R3's Admission Braden Scale for Predicting Pressure Sore Risk, dated 3/4/2025 was 14 - moderate risk. R3's Nurse Progress Note, dated 3/4/2025 at 6:10 PM documents, resident arrived to the facility via EMS (emergency medical services) services. Resident has wound to right shin. R3's Skin Screen, dated 3/5/2025 documents right calf reddened area full thickness. No further assessment documented. R3's Medical Record dated 3/4/2025 through 3/6/2025 no documentation of wound/pressure ulcer on right calf. R3's Wound Assessment Report, dated 3/7/2025 documents right lateral calf stage 3 pressure ulcer present on admission measured 5.3 cm x 6.9 cm x 0.2 cm and wound tissue was epithelium, dermis and subcutaneous. Wound edges: attached, periwound: fragile and scarring, exudate amount: scant, exudate description: serosanguineous, no post odor cleansing. Treatment order: daily and PRN: cleanse with wound cleanser, xeroform and bordered gauze dressing. R3's POS dated 3/4/2025 through 3/8/2025 documents no treatment orders for wound/pressure ulcer on right calf. R3's POS, dated 3/9/2025 documents cleanse right calf with wound cleanser, apply xeroform and dry dressing one time a day for wound care. R3's TAR, dated 3/9/2025 through 3/19/2025 staff documented right calf pressure ulcer treatment per physician's orders. On 3/19/2025 at 10:30 AM V3, Wound Nurse/Assistant Director of Nurses (ADON) stated she started working as the facility wound nurse 2 weeks ago. When a resident is admitted to the facility, she expects staff to document if the resident has open areas/wounds in the nurse progress notes, floor nurses are not expected to document wound assessments she follows up on all admissions residents daily, she typically works Monday through Friday from 7:00 AM through 5:00 PM. She expects the admission skin assessment to be documented in the nurse progress notes within 4-6 hours of the resident being admitted to the facility. She expects the admitting floor nurse to document if there is an open area and to what it is located. Floor nurses are not expected to document an assessment including measurements or a wound bed assessment. She reviews new resident admission documentation and residents with open areas/wounds the facility has a standing order for wet to dry dressing until the wound nurse practitioner rounds and assesses the resident's wound on Fridays. V3 doesn't assess wounds or measure them at all, the wound nurse practitioner does that on Fridays this does not matter what day the resident is admitted to the facility the wounds will not be assessed until Friday. V3 stated if she is not at the facility when a resident is admitted she does a triple check through their medical record the next day is works and she checks the resident's admission nurse progress note, physician's orders for wound treatment and the resident's care plan to ensure it addresses wounds. On 3/25/2025 at 11:48 AM V2, Director of Nursing (DON), stated she started working at the facility as the DON 3 weeks ago and was the ADON for approximately 3 weeks prior to that. V2 stated skin assessment should done within 1 hour of arrival to the facility because you want to know if resident has open areas/pressure ulcers. Staff should document in nurse notes exactly what they see what they see what it is drainage, odor present, use measuring tape to measure wound and document assessment of the wound bed in the nurse's notes or the skin screen form. Staff should notify the facility nurse and/or the wound np that rounds every Friday. V2 doesn't except staff to measure the wound/pressure ulcer unless they have the proper measuring tape, and they are trained to measure the wound to ensure accuracy. Staff should obtain a treatment in place for a pressure ulcer border foam dressing. Depending on wound/pressure ulcer after wound nurse assesses resident's skin, she notifies the wound NP and gets a proper treatment in place. A treatment is expected to be ordered 24 hours of resident being admitted to the facility. Wound NP does rounds every Friday and sends report that night and facility wound nurse gets the facility wound treatment report and changes the orders the same night and the new treatment should start the next day. V2 expects staff to follow facility policies and physician's orders. Restorative and therapy are updated at the Nutrition Assessment Risk (NARs) which assess all residents including residents with pressure ulcers and they are the ones who recommend a resident receive a low air loss mattress. V1 stated she wasn't aware residents including R1 and R3 were admitted to the facility with pressure ulcers not being thoroughly documented, no pressure ulcer treatment in place and that resident's with pressure ulcers care plan not updated, physician's orders not being followed, and physician's orders not being changed/updated. She didn't know why these nurse responsibilities were not carried out. On 3/19/2025 at 11:40 AM V1, Administrator stated when a resident is admitted to the facility the wound nurse is responsible for documenting a pressure ulcer assessment including measurement and what the wound bed looks like and then the wound nurse notifies the wound nurse practitioner, and they round every Friday. A treatment order is ordered from the wound nurse practitioner initially until the pressure ulcer is assessed on Friday and then the pressure ulcer treatment maybe changed per the wound nurse practitioner's recommendations. V1 stated she wasn't aware nursing staff failed to document R1's and R3's pressure ulcers upon admission to the facility. The Facility's Admission/Re-Admission Policy revision date 1/2023, documents all new admissions within 24 hours of admission have NRSG: Admission Observation. The Facility's Physician's Orders Policy, revision date 2/2024 documents each medication order is documented in the resident's medial record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in the computer and the MAR or TAR. The following steps are initiated to complete documentation: clarify the order, enter the orders with administration schedule in the computer and transmit to pharmacy and if order is replacing a previous order d/c (discontinue) previous order in the computer. The Facility's Skin Care Prevention Policy, revision date 5/2021 documents all residents will receive appropriate care to decrease the risk of skin breakdown. The nursing department will review all new admission/re-admissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. Dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching erythema) and this will be reported to the nurse. The nurse is responsible for alerting the health care provider. All residents will be evaluated for changes in their skin condition weekly. All residents unable to reposition themselves will be repositioned as needed, based on a person-centered approach per the resident's plan of care. Educate the resident and resident representative regarding pressure ulcer prevention and treatment as appropriate. The Facility's Skin Management: Pressure Injury Treatment/General Wound Treatment Policy revision date 5/2021, documents routine and PRN treatments in the treatment administration record. Document all significant observations in the nursing progress note. Pressure injuries will be evaluated, and the following areas documented weekly (minimum every 7 days) location, stage, size, depth, presence and location (based on the clock) of undermining/tunneling/sinus tract, exudate: type, color, and approximate amount, pain: nature and frequency, wound bed: color and type of tissue/character including evidence of healing (granulation tissue) or necrosis. Description of wound edges and surrounding tissues (rolled edges, redness, maceration, etc.) The staff will notify the wound nurse upon identification of skin impairment. If the wound nurse is not available, the staff should alert the health care provider for treatment orders. When the wound care team assesses the resident, they will take a picture, measure the wound, review the orders, and update any notes and care plans as appropriate. If a wound shows no signs of healing after three weeks, a reevaluation of the treatment plan including determining whether to continue or modify the current interventions is done. If the decision is made to retain the current regimen, documentation of the rationale for continuing the current plan will occur.

Based on interview and record review the Facility failed prevent resident to resident verbal and physical abuse for 8 of 13 residents (R1, R23, R24, R28, R29, R33, R43, R44) reviewed for abuse in the sample 51. This failure resulted in R43 throwing a punch, falling from his chair, and fracturing his hip. Findings include: 1. R43's Physician Order Sheet (POS) dated January 2025 documents diagnoses of Paranoid Schizophrenia, need for assistance with personal care, weakness, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture (1/27/2025), unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance and anxiety, brief psychotic disorder. R43's Minimum Data Set, MDS, dated [DATE] documents R43 was cognitively intact for decision making of activities of daily living. R43's MDS documents R43 has no impairment on his upper and/or lower extremity and with most Activities of Daily Living (ADL's) Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R43's Care Plan: Abuse/Neglect: At risk for abuse and neglect r/t (related to) DX (diagnosis of) Paranoid Schizophrenia, Psychosis, behaviors such as delusions and hallucinations. Goal with a target date of 12/12/2024, Staff will monitor well being of others. Resident will have zero episodes of abuse and neglect throughout the next review. R43's resident to resident altercation on 1/25/2025 was not noted on the R43's current care plan. R43's Nurse's Notes dated 1/23/2025 at 5:33 PM, Res (Resident) has been admitted to (Psych Hospital) r/t (related to) r (right)/femur fx (fracture). R43's Initial Report dated 1/23/2025 at 8:00 AM, Resident to Resident altercation was reported. Resident (R44) was in the bathroom when resident (R43) barged in and was upset (R44) was taking too long. Residents made contact and resident (R44) came to report the incident to (V27) Psychosocial Director. Both residents were immediately separated and assessed. MD (Medical Doctor) and POA (Power of Attorney) notified, more to follow pending final investigation. On 2/6/2025 at 2:34 PM, V27, Psychosocial Director stated, (R44) came to me I was sitting here at my desk working on the computer and he said, '(V27), (R43) is on the bathroom floor. 'I said, 'what is he doing on the bathroom floor?' and he said, 'I was in the bathroom washing a cup and (R43) got upset because I was taking too long and called me the 'N' word and then hit me in the face, so I hit him back and he's on the bathroom floor now. I then reported it to the nurse. (R43) messes with everyone and usually everyone ignores him. I think he went too far this time and (R43) got hurt. I think he fractured his hip. On 2/13/2025 at 10:46 AM, R43 stated, I hurt my hip when I slipped and fell and broke my hip. I hit (R44) but I apologized. I was mad and hit him in the bathroom and then he hit me back and I fell . R43's Final Report dated 1/23/2025 at 8:00 AM, Resident to Resident altercation was reported. (R44) was in the bathroom when resident (R43) barged in and was upset (R44) was taking too long. Residents made contact and resident (R44) came to report the incident to (V27), Psychosocial Director. Both residents were immediately separated and assessed. MD (Medical Doctor) and POA (Power of Attorney) more to follow pending final investigation. On final investigation it was found that (R44) was getting water from the bathroom sink and (R43) barged in and demanded (R44) to get out. Resident (R43) made contact with resident (R44). Resident (R44) made contact back and exited the bathroom. (R43) was moved off the Psychosocial hall and has had no further altercations since. R43's Involuntary Discharge papers undated documents, Patient punched another resident in his arm and started using racial slurs calling the other patient a 'N' word. Patient is rambling words and hard to redirect. Patient stated if he sees the other person again, he will hit him. R43's Hospital Records dated 1/23/2025 document, [AGE] year-old male, independent ambulatory without assistive devices, residents in nursing home. He was involved in altercation today at the nursing home when he and another resident were arguing over a cup of water. He fell and landed on his hip with subsequent pain and inability to bear weight. He presented to emergency department where he was found to have intertrochanteric fracture. The patient is admitted for further observation status post orthopedic surgery. X-ray document intertrochanteric fracture of right femur (Broken Hip), intertrochanteric fracture of femur. R44's January 2025 POS documents diagnoses of disorganized schizophrenia, cognitive communication deficit, paranoid schizophrenia, major depression, type 2 diabetes mellitus with hyperglycemia, and need for assistance with personal care. R44's MDS dated [DATE] documents R44 was cognitively intact for decision making of activities of daily living. R44's Care Plan: under Abuse documents, At risk for abuse and neglect r/t (related to) his dx (diagnosis of) Schizophrenia. 5/22/2023 Resident was accused of inappropriate behavior with a peer. 9/23- inappropriate behavior towards another resident. The Care plan does not address the 1/23/2025 abuse. R44's Nurse's Notes dated 1/23/2025 at 5:14 PM, documents nurse was notified by staff that resident was in an altercation with another resident, another resident tried to force this resident out of the bathroom, this resident asked if he could wait which lead to altercation, resident stated he was asked by the resident to get out the bathroom, resident stated he told him to wait till he was done, he stated the resident started using racial slurs and calling names and then it was lead to an altercation between the two, resident also stated that resident then tried walking back to the room once altercation was over, but then lost balance and fell , np (Nurse Practitioner) and psych np was notified, called POA (Power of attorney) and left VM (voicemail), no answer at this time, no injuries noted upon skin assessment, resident remains in stable condition, remains at normal baseline with no complications. R44's Initial Report dated 1/23/2025 at 8:00 AM, Resident to Resident altercation was reported. Resident (R44) was in the bathroom when resident (R43) barged in and was upset (R44) was taking too long. Residents made contact and resident (R44) came to report the incident to (V27) Psychosocial Director. Both residents were immediately separated and assessed. MD (Medical Doctor) and POA (Power of Attorney) notified more to follow pending final investigation. R44's Final Report dated 1/23/2025 at 8:00 AM, documents Resident to Resident altercation was reported. (R44) was in the bathroom when resident (R43) barged in and was upset (R44) was taking too long. Residents made contact and resident (R44) came to report the incident to (V27), Psychosocial Director. Both residents were immediately separated and assessed. MD (Medical Doctor) and POA (Power of Attorney) more to follow pending final investigation. On final investigation it was found that (R44) was getting water from the bathroom sink and (R43) barged in and demanded (R44) to get out. Resident (R43) made contact with resident (R44). Resident (R44) made contact back and exited the bathroom. (R43) was moved off the Psychosocial hall and has had no further altercations since. On 2/6/2025 at 2:13 PM, R44 stated, I remember when I got into it with (R43). I was in the bathroom and then (R43) came in and he pushed me against the wall and hit me in the lip. (R43) was mad because I guess he thought I was taking too long. He is a bully, and he was yelling and screaming at me. He was going to hit me again, but I hit him back and then he fell on the floor. I did not think I hit him that hard and he hit me first. Then I went and told (V27, Psychosocial Director) what had happened. 2. R28's POS dated January 2025, document diagnoses of alcohol abuse, chronic obstructive pulmonary disease, difficulty in walking, muscle weakness, major depression disorder and hypertension. R28's MDS dated [DATE] documents R28 is cognitively intact for decision making of activities of daily living. R28's Care Plan date initiated of 6/2/2021 under Abuse documents, (R28) is risk for abuse and neglect r/t (related to) his history of ETOH (ethyl alcohol or ethanol abuse) and major depressive disorder. Mr. Ray is known to leave for LOA (Leave of Absence) and return to the facility under the influence of alcohol. He admits to drinking beer and liquor. He denies having a problem with alcohol and does not want to seek treatment at this time. He has been educated on the impact of his use on his medical diagnoses and need to withhold medications when he is under the influence. R28's Progress Notes dated 10/11/2024 at 11:53 AM, documents Note Text: After another resident's w/c (wheelchair) became locked with his, (R28) balled up his fist and struck said resident in the chest 2 times. R28's Initial Report documents on 10/11/2024 at 10:45 AM, It was reported that (R33) and (R28) were in the Psych/social office. (R33) was trying to back up, and his wheelchair bumped into (R28's) wheelchair, and their wheels locked together. It was reported that (R28) hit (R33) in the chest twice with a closed fist. (R33) hit (R28) back (staff reported he was slapping at him). Both residents were separated for their safety. Officer (V20), Local Police reported to the facility. Residents' physician and responsible parties notified. (R28) was sent to (Psych Hospital) for evaluation. (R33) was assessed with no apparent injuries noted. Final investigation to follow. R28's Final Report documents on 10/11/2024 at 10:45 AM, It was reported that (R33) and (R28) were in the Psych/social office. (R33) was trying to back up, and his wheelchair bumped into (R28's) wheelchair, and their wheels locked together. It was reported that (R28) hit (R33) in the chest twice with a closed fist. (R33) hit (R28) back (staff reported he was slapping at him). Both residents were separated for their safety. Officer V20, Local Police reported to the facility. Resident's physician and responsible parties notified. (R28) was sent to (Psych Hospital) for evaluation. (R33) was assessed with no apparent injuries noted. (same as initial report). The Undated Statement from, Psychosocial Director, V27, documents, On Friday, 10/11/2024 at approximately 10:45 AM, Resident (R33) was observed bumping into resident (R28's) chair. This worker then observed staff redirect (R28) to stop. This worker observed (R28) hitting (R33), the two were separated and redirected. Statement from V28, Activity Aide dated 10/11/2024, documents (R28) was in Psyche Social and the resident (R33) was trying to back his chair and he bumped his chair into and (R28) hit (R33) in his chest two times (R33) hit him back but not that hard. R33's POS for January 2025 documents diagnoses of unspecified mood (affective) disorder, need for assistance with personal care, weakness, alcohol abuse, unspecified dementia, unspecified severity without behavioral disturbances, and depression. R33's MDS dated [DATE] documents R33 has memory problems and is severely impaired for cognition of activities of daily living. R33's Care Plan with a date initiated of 7/20/2023 documents, ADL (Activities of Daily Living) with daily care need related to cognition decline, including incontinence of bowel and bladder. R33's Progress Notes dated 10/11/2024 at 12:50 PM, Note Text documents Pt (Patient) was struck in the chest with a closed fist by another resident. Pt presents No difficulty breathing, currently eating in dining area. Appetite good. Pleasant affect and easily approachable yet confused. Pt denies any pain. No obvious deformity of the chest. Lungs CTA (Clear to auscultation). Chest Excursion normal for Pt. no obvious bruising or discoloration, will continue to monitor for change. Skin intact over chest wall. R33's Progress Notes dated 10/11/2024 at 1:08 PM, documents Note Text: After resident's wheelchair became locked with his. (R28) balled up his fist and struck said resident in the chest two times. (Local Police) responded and took report. On 1/30/2025 at 2:49 PM, V29, Family of R33, stated the bottom line was that my brother was declining and becoming more forgetful. When he was involved in the incident we do not think (R33) intentional tried to hurt anyone and because of his confusion he was in the wrong place at the wrong time, accidentally bumped into someone and then was hit with a fist hand in his chest two times. (R33) did not know what was happening. It's quite sad. We moved him to a different facility hoping that if it happened again, the resident would be more understanding. 3. R1's POS dated January 2025 documents diagnoses of Paranoid Schizophrenia, anxiety disorder, cannabis abuse, depression, cognitive communication deficit. R1's MDS dated [DATE] documents R1 was cognitively intact for decision making of activities of daily living. R1's Care Plan with target date of 1/26/2024 does not address abuse. On 1/28/2025 at 4:24 PM, R1 stated, (R29) told me he wanted to f*** me in my butt until I bled. I told the staff because I don't know him and who would say something like that. They called the police and send him out, but he came right back, and he tried to approach me again, but I went and got the nurse. I don't even know him. I try and stay away from him. He is saying stuff like that to staff too. I heard him say the same thing to (V16, Licensed Practical Nurse, LPN). When he is around, I don't feel safe. I feel like he wants to fight me or hurt me. I try and keep my distance and when he approaches me, I try and get a nurse. I think he wants to hurt me. I think something is wrong with him and I just don't want him around me. He scares me. He said the same thing to a nurse, (V16). Something is not right with him. R1's Incident Report date of incident 1/21/2025, documents Verbal resident altercation was reported in the dining room. Resident (R29) spoke inappropriate comments to (R1). The incident was reported to the nurse. Nurse (V16) stayed with resident (R29) until EMS (Emergency Medical Services) and Police showed up. Resident (R29) is being sent out for a psych evaluation. MD and POA notified. More to follow pending final investigation. Upon final investigation it was noted that resident was having increased behaviors and speaking inappropriate to residents and staff even upon return. Residents was sent back from hospital and Resident was seen but Psych NP (Nurse Practitioner) and medications were changed for resident's increased behaviors. Resident was sent back out to the hospital for involuntary psych evaluation. Upon resident return he will be put on behavior monitoring for inappropriate comments, will be involved in group therapy sessions, and activities as needed. R29's POS January 2025 documents diagnoses of Schizoaffective, anxiety, depressive, and a history of substance abuse. R29's Care Plan date initiated of 10/26/2023 documents, (R29) has symptoms such as mood swings, impulsive behaviors, and attention seeking behavior related to a diagnosis of Bipolar Disorder/schizoaffective disorder, depression and ADD (Attention Deficit Disorder). He takes medication as orders. R29's Care Plan with a date initiated of 1/9/2025 under Abuse, the Goal documents, staff will monitor wellbeing of others. Resident will have zero episodes of abuse and neglect. The Care Plan does not document R29 making sexually inappropriate comments. R29's MDS dated [DATE] documents he is cognitively intact for decision making for activities of daily living. R29's Social Service Note dated 10/4/2025 at 11:14 AM, documents Note Text(*R29) is A&O x 3 (alert and orientated x 3). His BIMS (Brief Interview for Mental Status) is a 15 (cognitively intact for decision making). He has a diagnosis of Schizoaffective, anxiety, depressive, and a history of substance abuse. He is a current smoker and loves to chase the women. He was encouraged to be mindful of respecting others space, to proceed with caution. R29's Incident Report date of incident 1/21/2025, documents Verbal resident altercation was reported in the dining room. Resident (R29) spoke inappropriate comments to (R1). The incident was reported to the nurse. Nurse (V16) stayed with resident (R29) until EMS (Emergency Medical Services) and Police showed up. Resident (R29) is being sent out for a psych evaluation. MD and POA (Power of Attorney) notified. More to follow pending final investigation. Upon final investigation it was noted that resident was having increased behaviors and speaking inappropriately to residents and staff even upon return. Resident was sent back from hospital and Resident was seen but Psych NP and medications were changed for resident's increased behaviors. Resident was sent back out to the hospital for involuntary psych evaluation. Upon resident return he will be put on behavior monitoring for inappropriate comments, will be involved in group therapy sessions, and activities as needed. On 2/14/2024 at 11:33 PM, V16, Licensed Practical Nurse (LPN) stated R29 had made a comment to her as well as stating he wanting to f*** her in the butt until she bleeds, and they sent him out. 4. R23's POS for January 2025 documents diagnoses of other generalized epilepsy and epileptic syndrome. Nicotine dependence, alcohol abuse, and paranoid schizophrenia. R23's MDS dated [DATE] document R23 was moderately impaired for cognition for activities of daily living. R23's MDS documents R23 walks and is independent for most activities of daily living. R23's Care Plan date initiated of 10/1/2014. R23's Care Plan under ABUSE document: At risk for abuse and neglect r/t Seizure disorder, Major depression, Schizophrenia, CVA, Lupus, Alcohol abuse, Seizure disorder. He is noted to be verbally aggressive and difficult to redirect at times. He is noted to have history of peer-to-peer altercations. R23's Initial Incident Report dated 12/20/2024 documents, Resident to Resident altercation. Resident (R23) and Resident (R24) made contact in the smoke line to go outside. Resident (R24) pushed staff member and then went to swing on the staff member and resident (R23) intervened. Residents were immediately separated. Both residents were sent out for evaluation due to behavior, MD (Medical Doctor) and POA (Power of Attorney) notified. More to follow in final investigation. Final Report, dated 12/20/2024, documents Resident to Resident altercation. Resident (R23) and Resident (R24) made contact in the smoke line to go outside. Resident (R24) pushed staff member and then went to swing on the staff member and resident (R23) intervened. Residents were immediately separated. Both residents were sent out for evaluation due to behavior, MD and POA notified. Both residents came back from the hospital and were free of any injury. Resident care plan was updated to reflect these found behaviors. Residents have had no further altercations. On 1/31/2025 at 1:04 PM, V32 Dietary Aide stated, Yes, I remember that day (R23) hit (R24). I was helping during smoke break and all of the residents were crowded together ready to go outside and smoke. There was an ambulance trying to get through and (R24) shoved one of the residents and I told him you can't shove people and because you shoved someone you cannot smoke now, and he got mad. I reached down the cart and he swung at me and hit me pretty hard. And as I was coming up, he tried to swing at me again and (R23) grabbed him and protected me. I think I would have got hurt really bad if (R23) had not been there. (R23) did not start it, he was just protecting me. On 1/31/2025 at 1:32 PM, R23 stated he did hit (R24) but he was only protecting (V32) because (R24) was going to hurt (V32). R24's POS for January 2025 documents diagnoses of Schizophrenia, chronic obstructive pulmonary disease, unspecified speech disturbances, other specified hypoparathyroidism, cognitive communication deficit, muscle weakness, difficulty in walking, paranoid schizophrenia, and anxiety disorder. R24's MDS dated [DATE], documents R24 was cognitively intact for decision making of activities of daily living. R24's Progress Notes dated 12/20/2024 at 5:37 PM, documents Residents were lining up to go out for smoke break (R24) became agitated he pushed an aid and another resident. The resident he pushed then began to hit him and a physical fight ensued. workers managed to break them up and separated them into rooms. (R24) had a nosebleed but upon assessment vital signs were table and WNL (within normal limits), redness to nose and upper back area found upon assessment but otherwise no injuries and no complaints. The Abuse Policy dated 10/2022 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation, of property, deprivation of goods and services by staff or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriate of property, and mistreatment of residents. In order, to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order, to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.

Based on observation, interview, and record review the facility failed to provide follow-up urology care per standards of practice for 1 of 3 residents (R28) reviewed for quality of life in the sample of 51. This failure resulted in a delay of R28's scrotal surgery, ongoing unnecessary pain which affects R28's quality of life. Findings include: R28's Physician's Order Sheets for February 2025 document diagnoses of alcohol abuse, uncomplicated, chronic obstructive pulmonary disease, Chronic obstructive pulmonary disease, Type 2 diabetes without complications, Need for assistance with personal care, Hyperlipidemia, Benign prostatic hyperplasia with lower urinary tract symptoms, Hypertension, pain in unspecified knee, unsteadiness on feet, difficulty in walking muscle weakness, inflammatory disorder of scrotum. R28's Minimum Data Set (MDS) dated [DATE] documents R28 is cognitively intact for decision making of activities of daily living. R28's Care Plan under skin document, (R28) is at risk for skin complications related to surgical removal of lipoma to right upper back, resolved 2/15/2022. The Care Plan does not address any issues with his scrotum. On 2/14/2024 at 1:03 PM R28's scrotum hung down lower than the other side and appeared abnormal with swelling present in that area. On 2/14/2024 at 1:18 PM, R28 stated he had surgery on his scrotum a few years ago and they messed it up during surgery. R28 stated his testicles were together but now they are separate, and one is up, and one hangs down. R28 stated he has to be careful when he sits down because he can sit on the one that hangs down and it causes him pain and the area becomes tender. R28 stated the facility does give him pain medication for it. R28 stated he needs to get surgery to fix his scrotum really bad but has not been able to get an appointment and this has been going on for a few years now. R28's Progress Note dated 12/21/23 at 10:35 AM, documents Referral TO UROLOGY DX (diagnosis) encysted hydrocele (type of scrotal swelling that occurs when fluid collects in the thin sheath that surrounds the testicle) with history of repair last July 2023, recurrent hydrocele, Chronic, needs evaluation and treatment with urologist surgeon arrange with referral coordinator. (This surgery needed to be repeated). R28's Progress Note dated 1/10/24 at 7:38 AM, documents Arrange for clearance. Discussed with resident regarding this matter. orders were entered: The following: future surgery hydrocele repair; (R28) Surgery appointment scheduled on 2/14/2024 @ (at)1155a @ (Hospital) Instructions in PCC (Point click care) must arrive 2 hours prior to surgery. Nurse to contact Nurse practitioner Cardio for clearance for second time repair for his hydrocele surgery on [DATE]. R28's Progress Notes dated 1/24/24 at 10:43 AM, documents NP (Nurse Practitioner) cleared him to his surgery. R28's Progress Notes dated 1/25/24 at 12:06 PM, documents Spoke with Urologist due to high AIC 9.2 %, deferred his surgery at this time re-evaluate in 2 months. R28's Progress Notes dated 1/24/2024 at 6:29 AM, documents Note Text: Surgery was canceled. R28's 2025 medical record was reviewed and did not have any documentation regarding an upcoming appointment scheduled for his surgical procedure. On 2/14/2025 at 2:03 PM, V46, Social Service Director stated, I am new to this job. I have not completed my training and I am just learning. I am not sure why (R28) has not had an appointment for his surgery. I know at one time we were having issues with his insurance, and it was scheduled but then it was canceled. I am not sure why he has not had an appointment. I will look into it. We have a census of 118 residents. On 2/14/2025 at 2:03 PM, V23, Licensed Practical Nurse stated, (R28) has some issues with his scrotum and occasionally he will complain about it hurting in that area. On 2/14/2025 at 3:13 PM, V2, Director of Nursing stated, If a resident needed a follow up appointment, I would expect it to be scheduled and if there was a certain issue that it could not be scheduled I would expect staff to follow up and make sure it gets scheduled if it was indicated. On 2/14/2025 at 4:45 PM, V46, Social Service Director, stated she was not sure what happened, but she just scheduled him an appointment for an evaluation to see what he needs or should be done. On 2/21/2025 at 12:22 PM, V40, Medical Doctor of Urology stated, I did a procedure on (R28) back in July of 2023. Originally, (R28) was supposed to have it repeated because of some complications but there some issues with his blood work so it had to be delayed. We thought he would be rescheduled. I was the one who did the surgery, and we were working with the insurance company because I was the one who did the surgery. (R28) he was not in my network but then because of the delay, he must have slipped through the cracks because now too much time has elapsed, and the insurance provider will not let me bill because he is not in my network and too much time has passed. I would have thought he would have already had this procedure. We had it all fixed back in 2023 to repeat the procedure but now (R28) will need to find a new provider that is in his network. It is a shame because that is a lot of time has passed. The delay of course will affect his quality of life, some pain, maybe some inflammation. It is hard for me to say exactly because I have not put eyes on him since 2023. It can cause discomfort, pain, swelling. Nothing life threatening but it does affect his quality of life and is fixable. The Appointment and Transportation Policy dated 9/2024 documents, When a resident has an appointment outside of the facility, the staff will make the transportation arrangements, unless the responsible party chooses to make the arrangements themselves. Staff nurse or designee will call the place of the appointment to verify the date, time, and location. The staff nurse will notify the attending physician and any appropriate ancillary physicians (i.e. nephrologists) of the resident's appointment. If the resident will be missing any type of procedure or timed medication, the appropriate physician will be notified, and order received. (i.e. missed dialysis, missed IV meds, etc.) Staff nurse or designee will then call the family to see if they will be providing transportation and accompanying the resident. If the family is not making transportation arrangements, the staff nurse or designee will call the transportation company (Medicare, ambulance, etc.) to set up the date and time of pick up. The pickup time should be at least one hour prior to the appointment. If the family will not be accompanying the resident, the staff nurse or designee will inform the DON (Director of Nursing) to determine if an escort is needed for the resident. Prior to the appointment, the staff nurse or designee will gather the necessary paperwork to send with the resident to the appointment. This includes a face sheet and continuity of care document, and other requested documents. On the day of the appointment, the staff nurse will ensure that the received personal care resident and dressed appropriately for the weather. All paperwork should be given to the family or driver for the appointment. If the resident is unable to keep the appointment, it is the staff nurse responsibility to cancel the appointment and reschedule it at the earliest time. If the primary physician had arranged the appointment, the staff nurse should alert them to the schedule change. The responsible party will also be notified of any appointment that is canceled and changed.

Based on record review and interviews the facility failed to assess and treat pain and provide pain medication according to physician's order for 1 of 3 (R3) resident reviewed for pain management in a sample of 11. This failure resulted in R3 experiencing severe and unbearable pain. 10/10 on pain scale of 1-10. Findings include: R3's Admission Record, not dated, documents Unspecified Fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, Acute hematogenous osteomyelitis, left ankle foot, liver transplant failure, type 2 diabetes mellitus without complications. R3's Baseline Care Plan, dated 10/11/2024, documents Pain: 1.Focus: B. Potential for pain 2. Goal B. Resident will verbalize or acknowledge pain when questioned by staff 3. Interventions: Administer pain medications as ordered by MD B. Monitor for non verbal indicators of pain daily with care tasks and activities C. Monitor for side effects D. Provide non pharmacological interventions (i.e. back rub, aroma therapy, ice or cold packs, etc.) Fracture 1. Focus: A. Resident has limited mobility related to fracture 3. Interventions: A. Assist with repositioning as needed B. Do not lay resident on affected side Antibiotics: 1. Focus: A. Resident is receiving antibiotic therapy 3. Interventions: A. Document s/sx (signs/symptoms) related to use of the antibiotic medication and indicate effectiveness B. Encourage fluids unless contraindicated C. Notify MD for any acute changes D. Provide medications per MD order Diabetes 1. Focus: A. Resident is at risk for hypo/hyperglycemia 3. Interventions: A. Resident blood sugar and other lab values will be within acceptable parameters according to physician through next review B. Accu check as ordered C. Administer medications as ordered D. Diet as ordered E. Monitor for hypoglycemia signs and symptoms: sweating, tremors, increased heart rate, confusion, slurred speech. R3's Progress Notes, dated 10/11/2024 at 6:45 PM, documents Nurses Notes Note Text: Admit 38 yr (year) old female to rm (room) x 2 attendants. A/O (Alert and Oriented) x 3-4. Able to make needs known. Full code Diet NPO (nothing by mouth). Cont (continuous) feed Glucerna 1.5 55ml/hr (hour) (milliliters) flush. 2 assist for all transfers. Fx (fracture) to Rt (right) Humerus. No c/o pain or discomfort at this time, asking for food. Sepsis, Osteomyelitis, pneumonia, liver failure. Allergies: Clindamycin, latex, morphine, paroxetine. HR (heart rate) 65 regular. Lung sounds diminished in left upper lobe. No s/s of difficulty breathing at this time. BS (bowel sounds) + (positive) x 4 quads. Inc of B&B (bowel and bladder). 16fr Foley flowing to gravity. DVT (deep vein thrombosis) to lt (left) upper arm. PICC line in place to left upper arm. Unstageable wound to sacrum. No drsg (dressing) in place. Lt 2nd toe amputation. Resident orientated to facility, roommate and call light. Isolation precautions due to MRSA. Will follow up. R3's Progress Notes, dated 10/12/2024 1:14 AM, documents Telehealth Visit Dysphagia--okay to change glucerna 1.5 to 1.2 until able to get new pump and feeding supplement. Patient gets 55ml/hr as continuous. Nurse cannot do NGT therefore only solution is bolus feeds. Okay for 220mL q4 x2 doses and defer further bolus feeds to NP. Concerns about BG (blood glucose) and therefore needs more BG checks while on bolus feeds. R3's Progress Notes, dated 10/12/2024 at 4:13 PM, documents Resident is requesting to be sent to hospital r\t (related to) severe pain 10/10. R3's Medication Administration Record (MAR), dated 10/1/2024 to 10/31/2024, documents that R3's Levothyroxine Sodium Oral Tablet 50 MCG, Insulin NPH (Human) (Isophane) Subcutaneous Suspension 100 UNIT/ML (Insulin NPH (Human) (Isophane)), Vancomycin HCl Intravenous (Vancomycin HCl), oxycodone HCl Oral Solution 5 MG/5ML, Apixaban Oral Tablet 5 MG were not administered on 10/12/2024. No pain assessment documented in the [DATE]/11 to 10/12/2024. R3's Controlled Drug Receipt/Record/Disposition Form, not dated, documents Date Received 10/15/2024 with first dose administered 10/16/2024 at 11:00 AM. On 10/21/2024 at approximately 3:30 PM V2, Director of Nursing (DON), provide documents with list of medication in the convenience box. The documents list Levothyroxine Sodium Oral Tablet 50 MCG 16 available, Insulin NPH (Human) (Isophane) Subcutaneous Suspension 100 UNIT/ML (Insulin NPH (Human) (Isophane)) on hand in refrigerator, Vancomycin HCl Intravenous (Vancomycin HCl) was available for use, 10/11/2024 oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) 5mg tablets were available for use, and Apixaban Oral Tablet 5 MG was available for use. On 10/17/2024 at 10:45 AM R3 stated that she was admitted to the facility and within 2 days she went out to the hospital because she was not receiving care. R3 stated that the facility did not have the things she needed for her care. R3 stated that it was a mess. R3 stated that she did not get any medication. R3 stated that she was informed that her medication had not came in yet. R3 stated that she was in severe pain and could not get pain medication because there were none. R3 stated that she has a broken arm and her pain is horrible. R3 stated that she has ask for the pain medication. R3 stated that she has to keep the medication leveled or the pain is not tolerable. R3 stated that she had blood thinners and other medications that she had to take that were not there and she did not receive. R3 stated that she did not get her finger sticks and do not remember getting her insulin. R3 stated that the pain was unbearable. R3 stated that she just laid in the bed. R3 stated that any type of movement caused excruciating pain. R3 stated that she cried, screamed and begged but no relief. R3 stated that she takes a blood thinner, IV antibiotic, has a wound and she received none of it. R3 stated that they didn't have the feeding that she has. R3 stated that she received no care. On 10/21/2024 at 11:45 AM V7, Licensed Practical Nurse (LPN), stated that she came to the building at around 3:00 PM (10/12/24). V7 stated that she was getting report and she heard R3 yelling that she was in pain and wanting to go to the hospital. V7 stated that this went on for a few minutes. V7 stated that she went in the room to find out what was going on. V7 stated that R3 informed her she was in pain. V7 stated that the pain was rated at a 10 on pain scale 1 to 10 with 10 being severe and unbearable. V7 stated that R3 said she haven't had any medication all day and could not handle it anymore. V7 stated that R3 did have outward signs of pain and was in visible discomfort. V7 stated that she did not get to perform a good assessment because the paramedics showed up and R3 went out. V7 stated that it happened quick. V7 stated that she documented what she knew and that was R3 went to hospital because of pain of 10 out of 10. On 10/21/2024 at 11:55 AM V9, LPN, stated that she was nurse on the day that R3 was sent to the hospital. V9 stated that R3 did not have any medications. V9 stated that the previous nurse gave her an old vial of insulin and told her to use it for R3. V9 stated that R3 did have pain. V9 stated that she didn't have any facial grimacing, but she couldn't get comfortable. V9 stated that R3's medication was not there, and she gave her Tylenol. V9 stated that she was not sure of time, but it was between breakfast and lunch med pass. V9 stated that R3 was upset. V9 stated that R3 had not been evaluated by therapy and she was not allowing R3 to get out the bed. V9 stated that R3 was upset about it. V9 stated that she called about the meds because they were not delivered. V9 stated that there was a problem with the medication and had to be straightened out. V9 stated that she left at 3 pm and the medication was not there. V9 stated that R3 was crying and upset saying she was in pain. V9 stated that the oncoming nurse took care of it. V9 stated that she was later told that the facility had a (emergency medication system convenience box) and that she should have gotten the medications out of it. V9 stated that she is agency, and this was never told to her and that she was not aware that the facility had a (emergency medication system convenience box). On 10/21/2024 at approximately 3:30 PM V2, DON, stated that the facility has a (emergency medication system-convenience box) and when medication is not delivered than the nurses can use the medication from the (emergency medication system convenience box). V2 stated that he expects his staff to utilize the (emergency medication system convenience box) when medication is not available and call the pharmacy to check when medication will be delivered and notify the physician if necessary. The facility's Pain Management policy, dated 10/2023, documents General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence and enhance dignity and life involvement. Guideline: The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Policy: 2. Pain will be assessed at least once every shift and documented in the EMAR using the pain scale appropriate for the patient.

Based on observation, interview and record review the facility failed to ensure that residents are free from sexual abuse for 2 of 3 residents (R3, R4) reviewed for sexual abuse in the sample of 10. The failure resulted in R4 touching R3 in a sexual manner without R3's consent causing R3 to trigger memories of past sexual traumas, feelings of fear, worthless, being dirty with increased showering, and attempting to avoid R4 as he remains in the facility. The findings include: 1. R3's Care Plan, dated 4/1/2024, documents ABUSE: (R3) is at risk for abuse and neglect r/t (related to) hypertension, hld (Hyperlipidemia), COPD (Chronic Obstructive Pulmonary disease), Psychosis, anxiety, hydrocephalus, and Schizophrenia. 9/23-inappropriate behavior received. It continues 9/23- res (resident) room moved. Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings. Establish a counseling schedule with resident. Encourage the resident to verbalize/share thoughts, anxieties, fears, concerns, and general feelings. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. Review assessment information. Emphasize treatment of casual factors and/or interventions designed to moderate/reduce symptoms (make treatment of compulsive behavior, substance abuse, anger, and mental health issues available to the resident, as indicated). R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact. R3's Progress Notes, dated 9/23/2024 at 2:29 PM, documents Nurses Notes Note Text: On the night of 09/20/2024, patient (R4) entered (Room and bed of R3) where (R3) was sleeping. According to (R3), (R4), woke her up touched her leg and knee, hugged her he then proceeded and touched her genital area, (R3) told (R4) to stop. (R4) was wearing pajama pants, he then walked away after (R3) said No. Following this incident, patient (R4) has been placed on 1:1 observation to monitor his behavior and prevent further incidents. (R3) was moved to a different hall to room [ROOM NUMBER]-1 that she had previously requested, patient stated no such incident had ever happened in the facility, family was notified of the incident, Psych NP (V6) was made aware, and Md (medical doctor) was made aware. Administrator was notified of the incident. Patient had head to toe done by (V7) pupils reactive, no complains of pain or discomfort, no bruising was noted on head to toes assessment. Resident was alert and oriented x3. Patient v/s (vital signs) 117/83 (blood pressure),95 (respirations) ,98.1 (temperature in Fahrenheit),98% (blood oxygen saturation levels). Patient was referred to psych social to get assistance to dealing with traumatic events. Patient is calm and cooperative. Nurse continues to monitor patient through the shift. R3's Progress Note, dated 9/23/2024 2:56 PM, documents Nurse Practitioner Narrative/Physician Assistant Relevant Content: Therapist met with patient for ongoing psychotherapy. Patient continues to have concerns over her health and with current living situation. Patient shared with therapist that she had been awakened in the night on Friday night (9/20/24) by a male resident. Patient reports that this resident sat on her bed and touched her inappropriately. Patient states that she initially did not report it because she was afraid of being dismissed or invalidated. She states that she did report the incident to Social Services today. Patient shared with therapist how this incident brought up past trauma and abuse issues for her. Therapist provided safe space for patient to express her feelings as well as interactive feedback and emotional support. While with patient, (V1) came into the room to let patient know that she would be moved to a different hallway. Explored the themes with patient that she is innocent of any wrongdoing and that she did the right thing by speaking out. Patient appeared to be relieved to be moving to a different room where she voices, she will feel more safe. Voiced understanding and empathy for patient during a difficult time and encouraged patient toward treatment goals. Will continue with ongoing therapy twice weekly. R3's Progress Note, dated 9/30/2024, documents Relevant Content: Therapist met with patient for ongoing psychotherapy. Patient continues to have concerns over her health. Patient recently moved to a new room due to an incident with another resident. She shared concerns about the adjustment to new room/roommate including managing TV, who comes in the room, and a change in where she is allowed to take a shower. Therapist allowed for safe expression of feelings and concerns by patient. Patient and therapist continue to process feelings related to recent incident and the trauma history that has resurfaced from the incident. Continued to support and validate feelings of patient. Encouraged patient to have compassion with herself with recent incident as well as her change in room/roommate. Will continue with ongoing therapy twice weekly. On 9/23/2024 at 12:30 PM R3 stated that she was sleep in her room and at about 11:44 PM she was awakened by R4. R3 stated that R4 had his hand on the inside of her leg above her knee. R3 stated that she asked what he was doing and R4 said he was checking to see if R3 was ok. R3 stated that R4 then sat on her bed. R3 stated that R4 leaned in, hugged her, and grabbed her vaginal area. R3 stated that she had on her pajama pants. R3 stated that she felt his hand on her through the pants. R3 stated that she yelled No and R4 got up and left her room. R3 stated that she feels dirty and have started taking long showers. R3 stated that she is afraid. R3 stated that this caused her to relive childhood abuse trauma. R3 stated that R4 is still in the facility, and she goes in the opposite direction when she sees him or tries to stay away from any area. R3 stated that she has PTSD (Post Traumatic Stress Disorder) from her childhood trauma, and this just brought up all those feelings and fears. R3 stated that she did not want to be touched by R4. R3 stated that she felt uncomfortable. R3 stated that she doesn't know what is wrong with her that R4 would do that to her. R4's Care Plan, dated 5/31/2023, documents ABUSE: At risk for abuse and neglect r/t his Dx of Schizophrenia. 5/22/23 Resident was accused of inappropriate behavior with a peer. 9/23-inappropriate behavior towards another resident. It continues 9/23 1 to 1. R4's MDS, dated [DATE], documents that R4 is cognitively intact. R4's Progress Note, dated 9/23/2024 3:35 PM, documents Nurses Notes Note Text: On the night of 09/20/2024, patient (R4) entered (R3's room), where a female patient was sleeping. According to (R4) he walked into the room late at night while the lights were on. (R4) stated that he sat by the female patient's bed and noticed that she was asleep. (R4) admitted that he touched her knee and leg, which caused the female patient (R3) to wake up. R4 then gave her a hug which he states the patient requested, and afterward, he left the room. (R4) states the patient did not say anything during the encounter. (R4) denied touching patient on the genital area. (R4) expressed regret for his actions, stating that he lost control and does not know why he acted in that manner. He apologized for his behavior, acknowledging that it was inappropriate. Following this incident, patient (R4) has been placed on 1:1 observation to monitor his behavior and prevent further incidents. R4's Physician's Order, with revision date of 9/25/24, documented 1:1 observation, enhanced monitoring dt (due to) behaviors. R4's Progress Note, dated 9/24/2024 at 12:50 PM, documents Psychotropic Notes Late Entry: Note Text: Update obtained from patient and staff. Patient pleasant and cooperative with assessment. Staff report that patient recently entered a female patient's room and initiated contact with her but denied touching her genital reason but did give her a consensual hug. Patient counseled on the impropriety of the situation and counseled that he may need to be transferred to a different facility with a more separate male wing. Patient endorsed understanding of possible repercussion. Patient continues to deny SI's/HI's, appetite changes, anxiety, depression, sleep disturbances, or auditory/visual hallucinations. Patient diagnosed with paranoid schizophrenia, disorganized schizophrenia, and MDD. On 9/30/2024, at 10:40 AM and 1:15 PM, R4 was seen, and staff were providing 1:1 observation of R4. On 9/30/2024 at 11:08 AM R4 stated that he knows that he is not supposed to go in the female rooms. R4 stated that he did go in R3's room. R4 stated that the light was on. R4 stated that it was somewhere around 1100, 1130. R4 stated that there was no staff on the hall. R4 stated that there is usually staff on the hall, but it wasn't that night. R4 stated that he went into R3's room and woke her. R4 stated that he sat on the side of R3's bed. R4 stated that he hugged R3 and touched her on the inside of her leg, thigh area and knee and R3 told him to stop, and he did. R4 stated that it didn't matter what he wanted to happen she said stop and he did. R4 stated that it was his fault he shouldn't have gone in there, but he did. R4 stated that R3 was nice to him and that they did therapy at the same time, and he was attracted to R3. R3 stated that he did not touch R3's genital area, he did touch inside her leg, but it was his fault that he went into the room he should not have gone in there. On 9/30/2024 at 11:00 AM V4, Social Services Director, stated that R3 notified her of an incident. V4 stated that R3 reported the incident to her on the following Monday. V4 stated that R3 reported that the incident occurred on a Friday. V4 stated that R3 reported that it was at night and that she did not feel comfortable with discussing it with the staff in the psych social. V4 stated that R3 does come and talk with her from time to time and she has built a good rapport with R3. V4 stated that R3 is alert, oriented and able to describe events appropriately. V4 stated that R3 informed her that she was sleep in her room and was awaken by R3. V4 stated that R3 reported that R4 touched R3's leg and sat on the bed. V4 stated that R3 reported that R4 then hugged R3 and then touched her genitals. V4 stated that R3 reported that R3 said No and R4 then left the room. V4 stated that R3 stated that the touch was unwanted by R3. On 9/30/2024 at 2:43 PM V9, Psychosocial Aide, stated that she is familiar with R4. V9 stated that R4 is a sexual man and have had some issues with sexual behavior. V9 stated that she is not aware of him doing anything that is not consensual, but he does have sexual inappropriate behaviors. On 9/30/2024 at 2:57 PM V10, Psychosocial Director, stated that she was made aware of the incident on the following Monday. V10 stated that R3 did not report the event to her. V10 stated that R3 is alert and does not have a history of making up stories. V10 stated that R3 voiced that she wanted a room to move before this happened. V10 stated that she is not aware of R4 having this behavior before. On 9/30/2024 at approximately 2:15 PM V1, Administrator, stated that she could not substantiate the allegation because it's his word against hers. V1 stated that R3 reported that R4 entered room touched her leg, knee and grouped her genitals. V1 stated that R4 admitted that he went in the room, touch R4's knee and hugged R3 but denies touching R3's genitals. On 10/1/2024 at 1:20 PM V1 stated that the policy that was provided is the Abuse Prevention policy. On 10/2/2024 at 1:40 PM V5, License Social Worker, stated that R3 reported to V5 the incident on the following morning. V5 stated that R3 reported that she was sleep in her room and R4 touched her on her leg above her knee. R4 gave her a hug and then reached down to R3's pubic region. V5 stated that she was informed by R3 that she told R4 no and he left the room. V5 stated that she asked R3 why she didn't report the incident earlier and was notified by R3 that she was but when she goes to the psych social, they tell her to be quiet and go away. V5 stated that R3 voiced that she didn't think they would believe her. V5 stated that R3 reported that she did inform the V4. V5 stated that R3 does have a history of childhood trauma and abuse. V5 stated that R3 voiced that this triggered R3 and reminded her of details of the childhood abuse. V5 stated that R3 voiced she it made her feel scared. V5 stated that R3 is religious and believed that a hug that R4 gave her a while ago was R4 being friendly. V5 stated that R3 did indicate that the touch was unwanted. V5 stated that she did see R4 on that same day and R4 admitted to going in room, touching R3's leg and hugging R3 but denies touching R3's genital. V5 stated that she has not witness R4 being sexually inappropriate but have been notified by stated that R4 has had inappropriate sexual behaviors in the past. The facility's Abuse policy, dated 9/2017, documents POLICY: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CFR 483.5). Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault by a licensee, Employee, or agent (77 Ill. Adm. Code 300.330). Sexual abuse is non-consensual sexual contact of any type with a resident. (42 CFR 483.5 and 483.12 Interpretive Guidelines).

Based on interview, observation and record review, the facility failed to provide timely incontinent care to 3 of 5 residents (R2, R3, R4) reviewed for ADL (Activities of Daily Living) care in the sample of 13. This failure resulted in R2 having psychosocial harm, making her feel sad and hopeless. Findings include: 1. On 8/2/24 at 9:45 AM, R2 up in her electric wheelchair with the left leg amputated above the knee. R2 stated the other day, unsure of exact date, she had 3 bowel movements in the same incontinence brief before the staff changed her, it took the therapist to get on them to get her cleaned up so she could go to therapy. R2 stated she was independent with care before she had her leg amputated and is now dependent on the staff for care. R2 stated she does as much as she can to help them when they care for her, so they aren't doing it all by themselves. R2 stated she had skin breakdown after she was left in her feces. R2 stated this saddens her and she would never be mad or question God, but she would be okay if she just didn't wake up. R2's Face Sheet, undated, documents R2 has the following diagnosis: Need for Assistance with Personal Care, Weakness and Left Above the Knee Amputation. R2's Minimum Data Set, MDS, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R2 is cognitively intact. R2 is dependent with toileting and is incontinent of bowel & bladder. R2's Care Plan, dated 10/25/26, requires assistance with ADL needs. 2. On 8/2/24 at 11:15 AM, R3 was observed in his room in R3's bed. R3 stated he has been waiting since 7:30 AM to get cleaned up, he is wet. R3 stated nothing has changed the care is still horrible. R3's Face Sheet, undated, documents R3 has the following diagnosis: Metabolic Encephalopathy, Weakness and Overactive Bladder. R3's MDS, dated [DATE], documents R3 has a BIMS score of 15, indicating R3 is cognitively intact. R3 is dependent with toileting and occasionally incontinent of bowel and bladder. R3's Care Plan, dated 10/26/22, documents R3 requires assistance with ADL needs. 3. On 8/2/24 at 9:30 AM, R4 was observed in his room in R4's bed. R4 stated he would give this place a rating of an F for the living environment. R4 stated it can take 2 hours to get his call light answered and it's been like that for 7 months and he has told different people about it. R4 stated he isn't dry and put his call light on, but the staff are picking up trays and are busy. R4's Face Sheet, undated, documents R4 has the following diagnosis: Cerebral Infarction and Need for Assistance with Personal Care. R4's MDS, dated [DATE], documents R4 has a BIMS score of 15, indicating R4 is cognitively intact. R4 requires substantial/maximal assist with toileting/hygiene. R4's Care Plan, dated 1/6/24, documents R4 requires assistance with ADL needs. On 8/20/24 at 9:20 AM, V1 (Administrator) stated she would expect incontinent care to be provided when needed. The Incontinent Care Policy, dated 5/2015, documents incontinence care is provided to keep residents dry, comfortable and odor free as possible.

Based on interview and record review the Facility failed to ensure pain was assessed, recognizing the onset, presence, and duration of pain, and assessing the characteristics of the pain for 1 of 3 residents (R7) reviewed for pain in the sample of 36. R7 has a cancer diagnosis and verbalized being in intense pain due to lack of pain medication being available for administration. Findings include: R7's Physician Order Sheet (POS) for July 2024 documents a diagnosis of liver cell carcinoma (cancer), liver cirrhosis, human immunodeficiency virus (HIV) and migraines. R7's POS dated July 2024 document also documents an order for Oxycodone HCL oral tablet 5 milligrams (mg), Give 1 tablet by mouth every 4 hours as needed for pain) with the (start date of 4/6/2024) and d/c (discontinued date) of 7/5/2024. R7's POS dated July 2024 also documents an order for Oxycodone HCL oral tablet 5 milligrams (mg), Give 1 tablet by mouth every 4 hours as needed for pain) with the (start date of 7/5/2024). R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact for decision making of activities of daily living. R7's care plan dated 7/8/24 documents, (R7) has a problem with pain and the goal that (R7) will not experience a decline in overall function. R7's interventions for pain documents, to include to administer pain medicine and treatments as ordered, assess effectiveness of pain medication, assess pain characteristics, encourage (R7) to report any pain, monitor for nonverbal indicators of pain, and report any acute changes to the physician. On 7/16/2024 at 11:18 AM, R7 stated, I have cancer and sometimes the pain is bad, especially in the Early hours. The other night around 2:30 AM, on 7/13/24 (Saturday) I called for pain medication and was told there was only 1 pill left and the nurse would be back with the medication. The nurse did not return until around 9:30 AM to give me the medication. On Sunday the next day (7/14/24) there was still no pain medication at the facility. The facility ran out of my oxycodone which I am supposed to get when I need it. They gave me an Ibuprofen in the early hours of the day, but it just does not work the same. I was in so much pain at this point. When I get like that I can't relax and sleep. My body gets all tense, and everything hurts. At 10:15 AM I still did not receive my medication I was told they were waiting on a script. This has happened to me on several occasions, and when it happens on the weekends, forget it; I know they are not getting to do anything about my pain. They do not always give me the same nurse and one nurse will tell me my medication (oxycodone) is running low and she will tell me she placed the order. They use a lot of agency nurses. Then when I run out of medication, they tell me they tried to place the order, but they are waiting on the doctor. I ran out of pain medication and my last dose was on Friday night and I had to go all weekend without my oxycodone. I should not have to be in pain all weekend. I have cancer and the pain is so bad. When I finally get the pain medication it takes a few more days to get me back to where I need to be because the pain was so intense going without the medication. I tried to tell them, but they just ignore me and do not get my medication. My pain falls on their deaf ears. They told me they could take me to the emergency room which hopefully they could give the pain medications, but they were not sure because it was a Sunday and it was around 1 PM, and I might have to wait until Monday for a doctor. Which makes no sense, so I decided to stay here because what was the point? I am needing more pain meds and I was telling them all weekend I was in extreme pain. On 7/18/2024 at 9:45 AM, V31 (Family of R7) stated, (R7) is my brother and I live in Florida. (R7) has liver cancer and there is a tumor growing and the doctors tell us he does not have much time left. The tumor is growing and when he calls me, he talks with me and when he tells me he is so much pain, and he has been struggling with pain, he is not eating, he is not sleeping. (R7) then tells me they do not have his pain medication. It breaks my heart when he calls me and tells me he is pain is so bad and the facility has run out of his pain medication. This usually happens on the weekends, and this has happened several times. I am not sure why or what is happening that he is not getting his pain medication. It is hard to get ahold of staff on the weekends and at 2 AM in the morning. The weekends are really bad. He has a prescription for pain medicine, cancer medicine, and HIV medicine. His pain med (oxycodone) they keep running out of his script, and he goes the weekends without it. We have talked with (V1 Administrator) and (V2 Director of Nursing). They stated they have given instructions to staff, but it is still happening, and it is not getting better. There is some sort of disconnect and his scripts are not getting renewed. Is my understanding staff are putting in the script, but they are not signing off on it, so it is not getting filled. Not sure exactly on whose end that this is happening. My biggest concern is his Pain level, that is a big issue. I want him to comfortable, treated like a human being, and he should not be in pain. The facility should be making sure he is getting pain medication and kept comfortable. R7's Medication Administration Records (MAR) for July 2024 documents his last/first dose of oxycodone was documented as 7/10/2024 at 4:03 AM, and on 7/12/2024 at 8:40 AM. No oxycodone was documented as being administrated for the weekend. No oxycodone was documented as being given on 7/13/2024 and 7/14/2024. R7's progress notes dated 7/13/24 at 1:17 PM, documents, nurse has called pharmacy at this time to check the status of pain medication, new script is needed at this time, resident has been made aware, no new concerns noted. R7's progress notes dated 7/13/24 10:39 PM document that R7 complained about just not feeling well. V26 (Licensed Practical Nurse/LPN) tested resident for COVID which was negative. This nurse informed resident and he admitted that I probably just need my pain pill, it's been a while. Awaiting physician response. On 7/16/2024 at 3:32 PM, V2 (Director of Nursing) stated, We have a new physician group and (R7) ran out of medicine over the weekend. (R7) has cancer and I know he was in a lot of pain. The doctor on call said he was not comfortable writing a script for narcotics even for a few days. We asked if he could just write a script for 2 days to get him through the weekend, but he refused. We lost our regular Nurse Practitioners, so it has been tough for us getting someone in here to write scrips. I told the Medical Director and he said he sent someone to cover but the doctors and NP are not comfortable covering us over the weekends. On 7/18/2024 at 10:24 AM, V1 (Administrator) stated, Our previous pharmacy closed its door and we had to switch pharmacy companies. It came as a shock for us. They said they were having trouble finding staff and closed their doors. We switched companies and this new company is based upstate. We are having issues with physicians not wanting to call in scripts and issues with the Nurse Practitioners (NP) not coming in the building and filling scripts. Our previous NP has been out on leave, but we are hoping she will be returning soon. There have been issues with (R7) and his pain medication running out as well as other residents and their medications. R7's Medication Administration Record (MAR) for July 2024 documents for Pain Monitor and Record Q (every) Shift on 7/12/24, R7's reported a pain level of 5 (scale of 1-10) was reported on the day shift. On 7/13/24, a 4-pain level was reported by R7 on the evening shift. No pain was documented again until night shift when R7 was reported on 7/15/2024. R7's July MAR does not document he received any oxycodone from 7/12/24 (last dose at 8:40 am) until 7/17/24 at 5:25 PM. No oxycodone was documented as being administered to R7 on any weekend 7/6/2024 -7/7/2024 and 7/13/2024 -7/14/2024. On 7/19/2024 at 2:32 PM, V27 (Pharmacist Clinical Coordinator) stated (R7) had oxycodone dispensed on 7/16/2024 and there was no refill request from the facility before 7/16/2024. The pharmacy dispensed the medication the same day they received the order. The Facility Pain Policy dated 12/2024 documents, To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The Pain Management Program is based on a facility -wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. 'Pain Management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals.

Based on observation, interview, and record review, the facility failed to follow current care plan interventions/physician orders to maintain a resident's weight and to prevent significant weight loss for 1 of 8 residents (R76) reviewed for nutrition in the sample of 52. This failure resulted in R76 losing 14.84% body weight in 3 months. Findings include: R76's Face Sheet documents an original admitted [DATE]. The Face Sheet documents R76's diagnoses as Muscle Wasting and Atrophy, Cerebral Ischemia, Moderate Protein-Calorie Malnutrition, Altered Mental Status, Weakness. R76's Minimum Data Set (MDS) dated [DATE] documents R76 is moderately cognitively impaired and R76 requires touching assist with eating. R76's Care Plan updated 3/26/2024 documents Dietary: (R76) is at nutritional risk as disease progresses: schizophrenia, hypertension, hyperlipidemia, and malnutrition. R76's Care Plan Interventions, dated 6/20/23, documented Provided diet as ordered; and weight monitoring. R76's Care Plan interventions, dated 6/23/23, documented double portions at dinner; health shakes TID with meals. R76's Care Plan Intervention, dated 9/14/23, documents Provide snacks/supplements as ordered. Care Plan interventions were not updated as R76 continued to have insidious weight loss. R76's Weights and Vitals Summary On 6/7/2024 R76's weight requested. R76's weight recorded at 109#. On 3/1/2024 R76's weight was recorded at 128 pounds (#). This equals -14.84% in 3 months. R76's weights recorded as follows: 1/5/2024 139.8#, 2/5/2024 128.4#, 3/1/2024 128#, 4/3/2024 125#, 5/2/2024 115.8#, 6/7/2024 109#. R76's Physician's Order (PO), with start dated of 11/04/22 documented Regular diet, regular texture, regular liquids consistency, health shakes TID with meals. Double portions at dinner. Fortified foods all meals. R76's Physician's Order Sheet (POS) dated 3/25/2024 documents Regular diet, regular texture, regular liquids consistency, health shakes twice daily with meals. Double protein and fortified foods with meals. R76's Progress Notes, dated 5/6/2024 at 3:57PM document Nutrition: Registered Dietician review (Weight) History: Schizophrenia, vitamin D deficiency, hypertension, hyperlipidemia, altered mental status Body mass index: 66 in/ 115.8 pounds/ 18.7. Significant weight loss x 30 days, 90 days, 180 days (-7.4%, 9.8%, 21%). Diet regular, liquids consistency. Supplements: health shakes twice daily, Hi Calorie twice daily. Intake %: 76-100% Medication: divalproex sodium, folic acid, fenofibrate, risperidone, B12, Vitamin D, cetirizine HCl. Skin: intact Labs: Albumin 3.5, BUN 28, Calcium 8.3 from 3/20/24. Review Assessment: Significant weight loss x 30 days, 90 days, 180 days. Intakes 76-100% at meals. R76 continues on health shakes twice daily and HI Cal twice daily, also receives Drip intravenous nutrition therapy. Unintended weight loss related to chronic illness and significant weight loss x 30 days, 90 days, 180 days. Recommendations: Reinstate double portions at dinner and fortified foods with meals, obtain reweight. Plan: Monitor weekly on Nutrition Review meeting. R76's Physician's Orders were reviewed and there were no orders discontinuing the double portions at dinner and the fortified foods. R76's Dietary Nutritional Risk assessment dated [DATE] documents Reweigh, confirmed loss. Double proteins at dinner and fortified foods reinstated. Meal intakes 50-100%. On 6/4/2024 at 9:01 AM, V30 (Cook) stated there was fortified oatmeal for breakfast and she just adds butter and brown sugar to the regular oatmeal in place of fortified oatmeal, and that is what everyone gets who wants oatmeal. There is no fortified oatmeal. On 6/4/2024 at 9:03 AM, R76 was served the regular oatmeal, but his food ticket documented he was supposed to get fortified oatmeal. On 6/7/2024 at 12:40 PM R76 had lunch tray in room. R76 fed himself dessert and laid down. Health shake and double portion on tray and not eaten. No staff in room. No encouragement or prompting during meal. At 1:00PM tray taken from room. On 6/7/2024 at 1:00PM V18 (Certified Nursing Assistant/CNA) stated (R76) has to have a lot of encouragement to eat. He lays down and then gets back up. We can't get him to stay in the dining room. He gets up and leaves when he is in the dining room. On 6/7/2024 at 1:10PM V2 (Director of Nursing/DON) stated R76 normally eats in the dining room. If he likes the food, he will eat it. If he does not like the food, he won't eat it. On 6/7/2024 at 9:12 AM, V20 (Registered Dietician) stated, there is a difference between regular oatmeal and fortified oatmeal. The fortified cereal has extra calories, butter, sugar, and fat. The recipe should contain milk, butter as well as the sugar. I would expect any resident on fortified oatmeal to be served fortified oatmeal. It's important for a resident who experiences weight loss to be served the fortified oatmeal. If a resident has weight loss, I expect my orders to be followed and fortified oatmeal be served. On 6/7/2024 at 2:05PM V20 stated I did not have the most recent weight yet today. (R76) has a significant weight loss. He is ordered health shakes, double protein, fortified foods with meals. I would expect him to eat in the dining room and to have encouragement with eating. Facility Weight Management policy with a revision date of 10/2023 states Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week or with a physician order. Once the reweights have occurred any resident with an unexplained significant weight loss will be discussed during the weekly Nutrition Review meeting. The Director of Nursing, DON, or designee will forward dietary recommendations to the Physician or Nurse Practitioner (NP).

Based on interview and record review, the facility failed to ensure hospital discharge instructions/physician's orders were followed after readmission to maintain the resident's highest practicable physical well-being for 1 of 3 residents (R2) reviewed for quality of care in the sample of 7. This failure resulted in R2 not receiving Lokelma, a medication to treat high levels of potassium in the blood. R2 was hospitalized with elevated potassium levels, shortness of breath, chest pains, and increased heart rate. Findings include: R2's Face Sheet, undated, documented that R2 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 3, systolic heart failure, atrial fibrillation, hypertension, and ST elevation myocardial infarction. R2's Minimum Data Set (MDS), dated [DATE], documented that R2 was cognitively intact, required supervision with bed mobility, and required partial assistance with transfer. R2's Care Plan, dated 4/15/24, did not address hyperkalemia. R2's Progress Notes, dated 3/24/24 at 2:28 PM, documented that R2 complained of pain and was sent to the hospital where she was admitted with cellulitis, hyperkalemia, acute kidney injury and possible sepsis. R2's After Visit Summary, from 3/24/24-3/29/24 hospitalization , documented that hyperkalemia was the hospital problem with an order to start 10 grams sodium zirconium cyclosilicate (Lokelma) daily. R2's Physician Orders for March and April 2024 did not document an order for sodium zirconium cyclosilicate (Lokelma). R2's Medication Administration Records (MARs) for March and April of 2024 did not document an order for sodium zirconium cyclosilicate (Lokelma). R2's Progress Note, dated 4/12/24 at 7:35 PM, documented that R2 complained of shortness of breath with mild chest pains and chills, had clammy skin, and heart rate was jumping from 101-123 (beats per minutes). R2 then phoned 911 and was sent to the hospital. R2's Discharge Summary, from the 4/12/24-4/19/24 hospitalization , documented that R2 had a potassium level of 6.5 mmol/L (millimoles per liter) in the Emergency Department (ED). It also documented that R2 was admitted two weeks prior with a similar issue that resolved with Lokelma, but she never received the medication at the facility. The discharge orders also documented an order to discharge with 30-day supply of Veltassa, as the facility has confirmed they do have that medication in stock. R2's Physician Orders for March and April 2024, did not document an order for Patiromer calcium sorbitate (Veltassa). R2's MARs, for March and April 2024, did not document an order for Patiromer calcium sorbitate (Veltassa). On 4/30/24 at 8:39 AM, V9, Social Services Director/SSD, stated that she was unaware of R2 having any issues with medication coverage. On 4/30/24 at 9:20 AM, V2, Director of Nursing/DON, stated that she was unaware of R2 being on a potassium lowering medication or having any problems with medication coverage. She also stated that the nurse puts in medications orders after residents return from hospital, then the doctor looks over them to confirm, but does not always carry every medication over. On 5/1/24 at 7:45 AM, V14, Licensed Practical Nurse/LPN), stated that the nurse assigned to the resident returning to the facility, will review their hospital discharge orders and review the admission packet. She also stated that she thinks R2 was on a medication called Lokelma and was unaware of any issues with it. On 5/1/24 at 7:58 AM, V15, LPN, stated that nurses enter medication orders when residents are readmitted . She also stated that she was unaware of R2 ever being on a potassium lowering medication. On 5/1/24 at 8:45 AM, V16 , LPN, stated, I recently took over the Triple Check Process within the last couple of weeks. When residents come in, I cross check medication orders and make sure ancillary orders are added. If there is any discrepancy, I talk to (V19 Nurse Practitioner) about it. If the medication is not covered, pharmacy faxes us a notification, then I talk to (V19), and if there is no generic or alternative. I talk to (V1 Administrator) and she signs off for it. V16 also stated that she did not recall R2 being on any potassium lowering medications.

Based on observation, interview, and record review, the facility failed to prevent resident to resident altercations in 3 of 6 residents (R9, R10, R11) reviewed for abuse in the sample of 11. This failure resulted in R11 becoming fearful and not feeling safe in her environment. Findings include: 1. On 4/17/24 at 2:45 PM, R11 was observed in her room. R11 stated (R9) attacked her. R11 stated she was in room XX and (R9) was in the room next to hers. She went to use the bathroom, (R9) wasn't in there at that time and she (R11) was peeing. She (R9) pulled me off the toilet, hit me in the head and in the kidneys. R11 stated she had her panties and pants down and was bent over as (R9) was hitting her so she couldn't get away. R11 stated some lady, unsure of whom, came into the bathroom and got her (R9) off of me and this lady stood outside the bathroom door so I could go pee, but I was so shaky, I wasn't able to go until I got to my new room. R11 stated the staff moved her (R11) off that hallway and into her current room. R11 stated (R9) comes down her hallway now, hasn't tried to come in her room, but gives me a look, stares at me, staff says she (R9) goes wherever she wants to go. R11 stated she doesn't feel safe with her (R9) around. R11's Face Sheet, undated, documents R11 has the following diagnoses: Hydrocephalus, Paranoid Schizophrenia, Schizotypal Disorder, Psychosis, GAD (Generalized Anxiety Disorder), Unspecified Mood Disorder and Disorientation. R11's MDS (Minimum Data Set), dated 3/29/24, documents R11 has a BIMS (Brief Interview for Mental Status) score of 12, which indicates moderate cognitive impairment and R11 has delusions. R11's Care Plan, dated 4/1/24, documents R11 is at risk for abuse/neglect. R11's Progress Note, dated 4/10/24 at 11:20 AM, documents the following: (R11) stated that she was in the bathroom over the weekend, and she was approached by another resident (R9) while toileting. She stated that she was on the toilet with her underwear down in a seated position when she was pulled by her arm off the toilet after being told by the other resident (R9) to remove herself. When she did not comply, the other resident pulled her off. R11's Progress Note, dated 4/12/24 at 12:54 PM, documents the following: This worker spoke with resident concerning an incident she was involved in during the weekend. Resident states Yes I am the one that got attacked she threw me down on the ground and said she was going to kill me, but I am not going to let her. I had to move. This worker assured her she was in a safe place and that if she needed to talk to anyone, she could talk with this worker or any staff member or we can get her someone to talk to. 2. On 4/18/24 at 9:30 AM, R10 was observed in her room, calm and pleasant. R10 stated a couple of months ago some lady, unsure of her name, grabbed her out of her chair, she doesn't know why or understand still what really happened. R10 stated she didn't get hurt and hasn't had any further problems. R10 stated she feels safe in the facility. R10's Face Sheet, undated, documents R10 has the following diagnoses: Unspecified Psychosis. R10's MDS, dated [DATE], documents R10 has a BIMS score of 10, which indicates moderate cognitive impairment. R10's Care Plan, dated 12/19/23, documents R10 is at risk for abuse and neglect and on 2/6/24, R9 was moved off the hallway. R10's Progress Note, dated 2/6/24 at 7:49 PM, documents the following: This nurse was informed that resident was sitting in a chair waiting for smoke break when another resident (R9) approached her and told her to get up. Resident refused so she was then pushed out of the chair and landed on her right side. Resident was able to get up on her own, states that she was attacked and wanted to file charges but did not want to be sent out. This nurse assessed patient and no visible bruises were noted and police were called for report. Administrator was notified and they are their own responsible party. 3. On 4/17/24 at 9:20 AM, R9 was observed in her room, resident able to ambulate independently. R9 stated she has been at the facility for 4 years. When asked if she felt safe in the facility or had any concerns with the other residents or staff, she responded she doesn't see anyone, they're all ghosts. R9's Face Sheet, undated, documents R9 has the following diagnoses: Alcohol Abuse, Dementia, Bipolar Disorder, Schizophrenia and Anxiety Disorder. R9's MDS, dated [DATE], documents R9 has a BIMS score of 7, which indicates severe cognitive impairment. R9's Care Plan, dated 6/25/24, documents R9 is at risk for abuse and neglect. R9's Care Plan, dated 2/22/24, documents R9 has episodes of hitting others. R9's Progress Note, dated 2/6/24 at 7:56 PM, documents the following: This nurse was informed that a resident (R10) was sitting in a chair waiting for smoke break when (R9) approached her (R10) and told her to get up out of her chair. The other resident (R10) refused stating it was not her chair, (R9) then proceeded to push the resident (R10) out of the chair on to the floor. Resident was placed on 15-minute checks and spoke with the officer for report. Administrator was notified and they are their own responsible party. R9's Progress Note, dated 3/4/24 at 5:22 PM, documents the following: Resident is alert and oriented times 2-3 with periods of confusion. She is easily agitated and behaves impulsively. She endorses religious hallucinations and has some paranoid delusions. She enjoys smoke Breaks with peers. Resident likes to participate in activities that involve dancing. Resident enjoys spending time with family when they visit. She has poor insight into her mental illness and is non-compliant with her medication regimen. She has eccentric behaviors and is difficult to place with a roommate. Due to her hoarding, and threat of physical assault on housekeeping, multiple staff work to reduce her risk of harm to others to meet the hygiene standards of the facility. Resident continues to need reminders to comply with the COVID precautions. She remains a full code. R9's Progress Note, dated 4/10/24 at 11:08 AM, documents the following: This writer spoke with (R9) in regard to an incident that occurred over the weekend. She stated another resident (R11) entered the bathroom and she told her to get out. (R9) said the lady (R11) stood there and at that point she (R9) pushed her (R11) out of the bathroom because she was standing there looking at her. R9's Progress Note, dated 4/12/24 at 12:04 PM, documents the following: This worker spoke with resident concerning an incident that she was involved in over the weekend. Resident stated that she did not know what this worker was talking about and stated, that's my room you can't go in somebody else bathroom and not ask so I got her up and grabbed her friend and walked away. R9 and R10's Follow -up Investigation Report, dated 2/13/24, documents the following: Resident to resident altercation involving R9 and R10. Interview with R10 - stated she was sitting in the common area and there was an empty chair, so she sat in it. R9 came to the common area and told her that was her chair and to get out of it. When she refused R9 pushed her out of the chair. When asked if she felt safe in the facility, she stated yes. Interview with R9 - Reports that she had brought a chair to the day area to sit in. She said she left the chair to get some towels to sanitize the chair and when she got back R10 was sitting in the chair. She asked R10 to get out of the chair, when R10 refused she pushed her out of it. When asked if she intended to hurt R10, she said no. Conclusion of the investigation was verified/substantiated. R9 and R11's Abuse Investigation, dated 4/6/24, documents the following: On 4/6/24 at approximately 6:00 AM, a resident to resident allegation of abuse was reported. While R11 was using the restroom, R9 came in and grabbed R11 off the toilet by her hair and hit her several times in the head and back. Staff intervened separating residents immediately. Both residents were assessed and showed no signs of significant injury. R9 is unable to recollect any incident but is adamant that the community restroom belongs to her and anyone using it should ask for permission. R9 at times has difficulty communicating with peers when fault finding. R9 believes that her peers and/or staff are removing or messing with her items as it pertains to the bathroom. Although the incident occurred, the facility is unable to substantiate R9 intended to harm R11 but was upset by R11 using what she thought was her bathroom. On 4/18/24 at 8:33 AM, V5 (Certified Nursing Assistant/CNA), stated R9 is all over the building in the mornings and they will redirect her off of the hallway if she is bothering anyone but usually, she is just making her way throughout the facility. On 4/18/24 at 8:53 AM, V8 (Activities) stated R9 used to have a lot of behaviors but she has slowed down. On 4/18/24 at 9:20 AM, V10 (Social Services) stated R9 has behaviors off and on but not recently. V10 stated she speaks with her and is able to calm her down. On 4/18/24 at 9:35 AM, V11 (CNA) stated she has a good rapport with R9, she keeps it real with her, so if she's acting up, I'll just say now come on (R9), are they getting on your nerves, and then I'll take her outside or just sit and talk with her and she calms down. On 4/18/24 at 11:40 AM, V14 (Psychiatric Nurse Practitioner) stated the incident that occurred with R9 and R11 could exacerbate R11's Paranoid Schizophrenia. V14 stated R11 hasn't been at the facility long and she is still getting to know her, but R11 does have some behaviors and can be antagonistic and invade other's space. V14 stated R9 is alert and oriented times 4 and normally R9 is only retaliatory when defending herself or her personal space. The Abuse Policy and Prevention Program, dated 10/2022, documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review the facility failed to prevent abuse for 1 of 3 (R7) residents reviewed for abuse in a sample of 12. This failure resulted in R7 experiencing pain, being fearful, feeling trapped, unprotected, and feeling less than a man. Findings include: R7's Care Plan, dated 12/11/23, documented, ABUSE: (R7) is at risk for abuse and neglect r/t (related to) his impaired mobility. He is noted to make false allegations toward staff. 8/15/2023 Resident reported that CNA (Certified Nursing Assistant) was rough while providing care. 11/27/2023 Resident reported that a CNA was rough while providing care. It continues, Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings. Immediately report any episodes of unknown injury, abuse or change in resident's behaviors to Administrator for immediate intervention and review. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. Assure the resident that staff members are available to help, and department heads maintain an open door policy. R7's Minimum Data Set, dated dated [DATE], documented that R7 is moderately cognitively impaired. R7's Police Report, dated 3/7/2024, documented, On Thursday March 7, 2024, I (V20, Sergeant) was dispatched to (facility) in reference to Elderly Abuse. Upon arrival I exited my patrol car and walked into the lobby where I was met by an unknown black female. The female later known as (V2 Director of Nursing/DON) stated she was the staff director and she had complaints on two of her employees for elderly abuse. (V2) stated a male in room (number) later known as (R7) advised her that he was getting beat on and verbally abused by two staff members. (V2) then escorted me to room where (R7) resides at. 1 walked into room and noticed (R8) white male with what looked as if both of his legs were amputated. I then asked (R7) did he need to speak with the police. (R7) stated he did need to speak with the police because he was getting abused, and he had a witness. I then asked (R7) what happened. (R7) stated two of the nurse's aides one known as (V17) and the other one known as (V18) abused him physically and mentally. (R7) stated he needed to be changed and the female (V18) was mad that she had to do her job and started slamming him to the wall and hurting him more. (R7) stated he was yelling and telling (V18) that she was hurting him more. (R7) stated he then was asking (V18) why was she treating him like that. (R7) stated (V18) continued to ruff him up and he kept yelling for her (V18) to stop. (R7) stated that when (V17) told him to shut the f*** up because nobody has time for that bull s**t. (R7) stated he has a roommate who witness the whole thing. I then spoke with (R7's) roommate white male later known as (R8). I asked (R8) did he witness what happened to (R7). (R8) stated yes. (R8) stated he first heard some loud bumping sounds to the wall. (R8) stated he then heard (R7) stop you are hurting me. (R8) stated he then got up to see what was going on. (R8) stated he seen what the nurse was doing to (R7) by slamming him to the wall and refusing to do their job properly. (R8) stated he then told (V18) to stop what she is doing because she is hurting him. (R8) stated (V18) and (V17) then started cursing him out and telling him to shut the f*** up. (R8) stated they then left the room. (R7) stated later (V2) came in the room and he reported it to her and advised her that he wanted to make a police report. Then asked (V2) where was the two females that was in question. (V2) stated that they both are on administration leave. I provided (R7) with a report number and advised him that his report will be on file. I also advised (R7) that this matter will be turned over to our deceives division for further investigation. R7's Customer Concern and Feedback Form, dated 3/5/2024, documented, Resident reported that the CNAs were handling him rough while cleaning and drying him. Follow up: the CNAs never intended to hurt or harm the resident while turning him and providing care. His foot accidently hit the wall. On 4/8/2024 at 1:09 PM, R7 stated that he remembers what happened. R7 stated that he had his call light on for hours. R7 stated that he had his roommate go and try to get help and the staff would not come. R7 stated that when they came in the room, they were loud and yelling at him. R7 stated that V17 (CNA) and V18 (CNA) entered the room and said, What do you want. R7 stated that he informed them that he was wet and had a bowel movement. R7 stated that he told them that he had been laying in it for hours. R7 stated that they were trying to get in and out. R7 stated that he was thrown against the wall and his leg hit the wall several times. R7 stated that he informed them that it hurt but they continued and did not stop. R7 stated that they kept pushing him and each time he would hit the wall. R7 stated that he knows that he is a large guy, but this was excessive. R7 stated that he felt mistreated and abused. R7 stated that they would not listen. R7 stated that he kept saying it was hurting and nothing. R7 stated that he was being abused. R7 stated that this was the third time. R7 stated that the first two times he didn't say anything, but this was excessive. R7 stated that V2 (DON) asked him about not receiving care and he informed her of this. R7 stated that he identified V17 (CNA) and V18 (CNA) as the staff that did this. R7 stated that he was informed that those employees were currently suspended and would not be returning to the facility. R7 stated that he felt better and safe at that time. R7 stated that the V4 (Assistant Administrator) came and talk to him a couple of days later. R7 stated that he told her that he felt safe at that time because he was told that they no longer worked at the facility. R7 stated that a week or so later he was notified that they would be returning to work and stated that he was upset. R7 stated how is that? How can someone hurt you and come back? When asked if he thought the act was intentional or deliberate R7 stated that he told them that it hurt and to stop. R7 stated that they told him to shut up and kept pushing. Now if that's not intentional or deliberate. I don't know what is. R7 stated that he spoke with V2 and verified that the staff would be returning. R7 stated at the time I feared for my safety. R7 stated that he called the police that day and reported it. R7 stated that he does not feel safe at the facility. R7 stated that they are still here and can hurt him at any point hurt him. R7 stated that he feels trapped and unprotected. R7 stated that its demeaning and as a man having to depend on them and they hurt you and you can't fight back or defend your self makes you feel less than a man. R7 stated that he feels like he is going to die in this facility. On 4/8/2024 at 2:24 PM V10 (CNA) stated that R7 was alert and able to make needs known. V10 also stated that R7 can answer questions appropriately and truthful. V10 stated that R7 keeps a book with his concerns in it with dates, names, and times. On 4/8/2024 at 12:53 PM, R8 stated that he has been roommates with R7 for a while. R8 stated that he was here when the incident occurred. R8 stated that R7 had his call light on for hours. R8 stated that he went to the nurse's station several times to get help and the staff would not come and said they were not coming. R8 stated that later that day V17 (CNA) and V18 (CNA) came in the room and asked, What do you want? R8 stated that shortly after that he could hear a bumping sound and then R7 saying ouch, stop, you're hurting me. R8 stated that he got up to find out what was going on. R8 stated that there were 2 girls. One girl was standing back, not helping, talking to the other girl. The second girl was pushing R7 against the wall. R8 stated that she was trying to clean R7. R8 stated that R7 was saying that it hurt but the girl kept pushing. R8 stated she was rough. R8 stated that when he told them that it was hurting R7 he was told to shut the h*** up. R8's MDS, dated [DATE] documents that R8 is cognitively intact. On 4/8/2024 at 2:30 PM V2 (Director of Nursing) stated that on February 27, 2024, she spoke with R7 about care concerns. V2 stated that at that time R7 informed her that he does not get care. V2 stated that he has his light on for long periods of time without being answered. V2 stated that R7 informed her that when the aides come into the room, they are mad and rough with him. V2 stated that R7 informed her that V17 and V18 came to his room and cleaned him up and when they entered, they asked what did he want? V2 stated that R7 said he needed to be changed and V17 and V18 began cleaning him. V2 stated that R7 informed her that they threw him against the wall and hurt his legs. V2 stated that he told them to stop that it hurt, and they continued and did not stop. V2 stated that they kept pushing R7 against the wall and hurting him. V2 stated that she has not seen this behavior from V17 or V18. V2 stated that she has seen V18 yelling and refusing to perform care which she was suspended for. V17 stated that V17 and V18 were suspended for separate incident when she became aware of R7's concerns. V2 stated that when this issue was brought to her attention and after interviewing R8 and R7 she found them to be creditable and truthful. V2 stated that the V4 told (the administrator at the time) immediately. V2 stated that V17 and V18 had been suspended for an unrelated issue and with these abuse findings were terminated. V2 stated that the union got involved and the employees allowed to return. V2 stated that she had not spoken to or interviewed V17 and V18 until March 5 when they came in with the union representative. V2 stated that at that time V18 denied that this had occurred and V17 stated that she had not worked with R7 and had not been assigned to R7. V2 stated that V17 stated that R7 mixes her and V19 up and V19 is the staff member that works with R7. V2 stated that she did not interview V19 because R7 said that this happened on the weekend and during the week. V2 stated that she did not interview any other staff. On 4/9/2024 at 10:17 AM V4 (Assistant Administrator) stated that she was the administrator at the time of the allegation. V4 stated that she went down and talked with R7, and he said that he felt safe at that time and did not feel the need to go any further. The facility's Abuse policy, dated 9/2017, documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. It continues, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, that the individual must have intended to inflict injury or harm.

Based on interview and record review the facility failed to initiate its abuse policy and report allegations of abuse for 2 of 3 (R6, R7) residents reviewed for abuse, in a sample of 12. This failure resulted in R7 being fearful, feeling trapped, unprotected, and feeling less than a man. This failure also resulted in R6 feeling unsafe and as if no one cares. Findings include: 1. R7's Care Plan, dated 12/11/23, documented, ABUSE: (R7) is at risk for abuse and neglect r/t (related to) his impaired mobility. He is noted to make false allegations toward staff. 8/15/2023 Resident reported that CNA (Certified Nursing Assistant) was rough while providing care. 11/27/2023 Resident reported that a CNA was rough while providing care. It continues, Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings. Immediately report any episodes of unknown injury, abuse or change in resident's behaviors to Administrator for immediate intervention and review. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. Assure the resident that staff members are available to help, and department heads maintain an open door policy. R7's Minimum Data Set, dated dated [DATE], documented that R7 is moderately cognitively impaired. R7's Police Report, dated 3/7/2024, documented, On Thursday March 7, 2024, I (V20, Sergeant) was dispatched to (facility) in reference to Elderly Abuse. Upon arrival I exited my patrol car and walked into the lobby where I was met by an unknown black female. The female later known as (V2 Director of Nursing/DON) stated she was the staff director and she had complaints on two of her employees for elderly abuse. (V2) stated a male in room (number) later known as (R7) advised her that he was getting beat on and verbally abused by two staff members. (V2) then escorted me to room where (R7) resides at. 1 walked into room and noticed (R8) white male with what looked as if both of his legs were amputated. I then asked (R7) did he need to speak with the police. (R7) stated he did need to speak with the police because he was getting abused, and he had a witness. I then asked (R7) what happened. (R7) stated two of the nurse's aides one known as (V17) and the other one known as (V18) abused him physically and mentally. (R7) stated he needed to be changed and the female (V18) was mad that she had to do her job and started slamming him to the wall and hurting him more. (R7) stated he was yelling and telling (V18) that she was hurting him more. (R7) stated he then was asking (V18) why was she treating him like that. (R7) stated (V18) continued to ruff him up and he kept yelling for her (V18) to stop. (R7) stated that when (V17) told him to shut the f*** up because nobody has time for that bull s**t. (R7) stated he has a roommate who witness the whole thing. I then spoke with (R7's) roommate white male later known as (R8). I asked (R8) did he witness what happened to (R7). (R8) stated yes. (R8) stated he first heard some loud bumping sounds to the wall. (R8) stated he then heard (R7) stop you are hurting me. (R8) stated he then got up to see what was going on. (R8) stated he seen what the nurse was doing to (R7) by slamming him to the wall and refusing to do their job properly. (R8) stated he then told (V18) to stop what she is doing because she is hurting him. (R8) stated (V18) and (V17) then started cursing him out and telling him to shut the f*** up. (R8) stated they then left the room. (R7) stated later (V2) came in the room and he reported it to her and advised her that he wanted to make a police report. Then asked (V2) where was the two females that was in question. (V2) stated that they both are on administration leave. I provided (R7) with a report number and advised him that his report will be on file. I also advised (R7) that this matter will be turned over to our deceives division for further investigation. R7's Customer Concern and Feedback Form, dated 3/5/2024, documented, Resident reported that the CNAs were handling him rough while cleaning and drying him. Follow up: the CNAs never intended to hurt or harm the resident while turning him and providing care. His foot accidently hit the wall. On 4/8/2024 at 1:09 PM, R7 stated that he remembers what happened. R7 stated that he had his call light on for hours. R7 stated that he had his roommate go and try to get help and the staff would not come. R7 stated that when they came in the room, they were loud and yelling at him. R7 stated that V17 (CNA) and V18 (CNA) entered the room and said, What do you want. R7 stated that he informed them that he was wet and had a bowel movement. R7 stated that he told them that he had been laying in it for hours. R7 stated that they were trying to get in and out. R7 stated that he was thrown against the wall and his leg hit the wall several times. R7 stated that he informed them that it hurt but they continued and did not stop. R7 stated that they kept pushing him and each time he would hit the wall. R7 stated that he knows that he is a large guy, but this was excessive. R7 stated that he felt mistreated and abused. R7 stated that they would not listen. R7 stated that he kept saying it was hurting and nothing. R7 stated that he was being abused. R7 stated that this was the third time. R7 stated that the first two times he didn't say anything, but this was excessive. R7 stated that V2 (DON) asked him about not receiving care and he informed her of this. R7 stated that he identified V17 (CNA) and V18 (CNA) as the staff that did this. R7 stated that he was informed that those employees were currently suspended and would not be returning to the facility. R7 stated that he felt better and safe at that time. R7 stated that the V4 (Assistant Administrator) came and talk to him a couple of days later. R7 stated that he told her that he felt safe at that time because he was told that they no longer worked at the facility. R7 stated that a week or so later he was notified that they would be returning to work and stated that he was upset. R7 stated how is that? How can someone hurt you and come back? When asked if he thought the act was intentional or deliberate R7 stated that he told them that it hurt and to stop. R7 stated that they told him to shut up and kept pushing. Now if that's not intentional or deliberate. I don't know what is. R7 stated that he spoke with V2 and verified that the staff would be returning. R7 stated at the time I feared for my safety. R7 stated that he called the police that day and reported it. R7 stated that he does not feel safe at the facility. R7 stated that they are still here and can hurt him at any point hurt him. R7 stated that he feels trapped and unprotected. R7 stated that its demeaning and as a man having to depend on them and they hurt you and you can't fight back or defend your self makes you feel less than a man. R7 stated that he feels like he is going to die in this facility. On 4/8/2024 at 2:24 PM V10 (CNA) stated that R7 was alert and able to make needs known. V10 also stated that R7 can answer questions appropriately and truthful. V10 stated that R7 keeps a book with his concerns in it with dates, names, and times. On 4/8/2024 at 2:30 PM V2 (Director of Nursing) stated that on February 27, 2024, she spoke with R7 about care concerns. V2 stated that at that time R7 informed her that he does not get care. V2 stated that he has his light on for long periods of time without being answered. V2 stated that R7 informed her that when the aides come into the room, they are mad and rough with him. V2 stated that R7 informed her that V17 and V18 came to his room and cleaned him up and when they entered, they asked what did he want? V2 stated that R7 said he needed to be changed and V17 and V18 began cleaning him. V2 stated that R7 informed her that they threw him against the wall and hurt his legs. V2 stated that he told them to stop that it hurt, and they continued and did not stop. V2 stated that they kept pushing R7 against the wall and hurting him. V2 stated that she has not seen this behavior from V17 or V18. V2 stated that she has seen V18 yelling and refusing to perform care which she was suspended for. V17 stated that V17 and V18 were suspended for separate incident when she became aware of R7's concerns. V2 stated that when this issue was brought to her attention and after interviewing R8 and R7 she found them to be creditable and truthful. V2 stated that the V4 told (the administrator at the time) immediately. V2 stated that V17 and V18 had been suspended for an unrelated issue and with these abuse findings were terminated. V2 stated that the union got involved and the employees allowed to return. V2 stated that she had not spoken to or interviewed V17 and V18 until March 5 when they came in with the union representative. V2 stated that at that time V18 denied that this had occurred and V17 stated that she had not worked with R7 and had not been assigned to R7. V2 stated that V17 stated that R7 mixes her and V19 up and V19 is the staff member that works with R7. V2 stated that she did not interview V19 because R7 said that this happened on the weekend and during the week. V2 stated that she did not interview any other staff. On 4/9/2024 at 10:17 AM V4 (Assistant Administrator) stated that she was the administrator at the time of the allegation. V4 stated that she went down and talked with R7, and he said that he felt safe at that time and did not feel the need to go any further. 2. R6's Care Plan, dated 2/2/24, documented, ABUSE: (R6) is at risk for abuse and neglect r/t (related to) CHF (congested heart failure), weakness, malnutrition, hemiplegia and depression. It continues, Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. R6's Minimum Data Set (MDS), dated [DATE], documented that R6 was cognitively intact and required assistance from staff to complete tasks. R6's Grievance, dated 3/25/2024, documented, (R6) stated on the Friday 22nd day of march, he had a BM on himself approximately 3xs. He called for CNA at 8pm and was not serviced until 8am. Follow up (R6) refused care and was verbally abusive to any staff that tried to clean him that night. (V2 DON) present that Saturday morning and was able to get 2 female staff to clean him up. On 4/5/24 at 10:05 AM V2 (DON) stated that she had received a complaint from a state surveyor when she was at the facility doing another survey that a couple of male residents, R6 and R7, had reported to her that two female CNAs were rough with them and felt like they were abusive. V2 stated she had suspended the CNAs and did an investigation. She stated that the two CNAs were V18 and V17. V2 stated after the investigation she did feel like the allegations were substantiated and felt like the CNAs should have been terminated but the union got involved and stated that the CNAs had to be brought back, so they returned to work. V2 continued to state that she did report the allegation to the V4 (Administrator) and the surveyor also reported the allegations to the (V4), but she does not know if the Administrator reported it to the state or not. V2 stated that the investigation went on for almost 3 weeks and her investigation showed they were guilty. She stated she spoke to R7's roommate, R8, who stated staff were rough with (R7). She stated (R7) called the police himself to report the incidents. She stated when the CNAs were brought back, they were told to not have any contact with the two male residents involved. On 4/5/2024 at 10:50 AM V4 (Assistant Administrator) stated that she was the administrator at the time of the incident. She stated that she did not report the allegation because (R6) has always complained about the staff and only lets a few of them take care of him. She stated that she did talk to both of the residents at different times but did not state it was specifically about the allegation. On 4/8/2024 at 1:20 PM, R6 stated that he was not being cared for. R6 stated that his call light stays on for long periods of time and when the staff come in, they are rude and disrespectful. R6 stated that he has told them to leave the room when they are being rude. R6 stated that he prefers girls to men when it comes to his care. R6 stated that it takes them a long time to come to the room then they have an attitude when I am the one who should be mad not them. How does that work. R6 stated that it takes hours. Sometimes I lay in my own filth all night. R6 stated that when they come in, they are rough and curse you out. R6 stated that they are abusive. R6 stated that he notified V2 (DON) about it and that the staff were being verbally abusive. The facility's Abuse policy, dated 9/2017, documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. It continues, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, that the individual must have intended to inflict injury or harm. It continues, Any allegation of abuse or any incident or accident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse. As used herein, serious means any incident or accident that causes physical harm or injury to the resident. Any incident or accident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. VIII. External Reporting: 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported to the administrator and is being investigated. The report shall include the following information, if known at the time of the report: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; Type of abuse reported (physical, sexual, verbal or mental abuse, neglect, exploitation, misappropriation of resident property, unreasonable confinement or involuntary seclusion); Date, time, location and circumstances of the alleged incident; Any obvious injuries or complaints of injury; Steps the facility has taken to protect the resident. This report shall be made immediately. As used herein, the term immediately in relation to reporting abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and suspicion of a crime shall be defined as, following management of the immediate risk to the resident or residents, including the administration of necessary medical attention, and establishing the safety of the resident or residents involved or not later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause suspicion do not result in serious bodily injury. 2. Five-day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. (42 CFR 483.12}. The final investigation report shall contain the following: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; The original allegation (note day, time, location, the specific allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries} A summary of facts determined during the process of the investigation, review of medical record and interview of witnesses; Conclusion of the investigation based on known facts; The police report, if applicable; If the allegation is determined to be valid and the perpetrator is an employee, a separate sheet listing the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions, and current employment status (still working, suspended or terminated).

Based on observation, interview and record review, the facility failed to prevent resident to resident abuse for 2 of 3 residents (R5, R6) reviewed for abuse in the sample of 18. This failure resulted in R6 being sent to the hospital for evaluation of a laceration on his face and R5 being sent to jail for assaulting R6. Findings include: On 2/6/24 at 11:15 AM R6 was lying in bed in his room. He was reluctant to talk and gave short answers to questions. R6 stated R5 came into the bathroom when he was in there and tried to force him to get out. R6 stated when he would not get out, R5 hit him in the eye and then in the nose with a plunger. R6 had a small abrasion on the bridge of his nose over a purple bruise. R6 stated the staff heard him screaming at R5 to leave him alone and they came in and got him out. R6 stated R5 has threatened him verbally before but he never hit R6 before this. R6 stated this happened a few nights ago. He stated he did not know if R5 was back because the police took him to jail, but he had not seen him since the police took him away. R6's Face Sheet, printed 2/8/24, documents he has diagnoses which include Drug Induced Parkinsonism, Paranoid Schizophrenia, Depression, and Dementia. R6's Minimum Data Set (MDS) dated [DATE] documents he is moderately cognitively impaired and did not have any behaviors during the look back period for that assessment. R6's Care Plan dated 11/4/21 documents ABUSE: (R6) is at risk for abuse and neglect r/t (related to) his dx (diagnosis) of dementia. R6's Care Plan goal documents Staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect throughout next review. R6's Care Plan interventions documents Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e. (for example)., social worker, nurse, CNA (Certified Nursing Assistant), peer) and by verbalizing thoughts, needs and feelings. R6's Physician Order dated 2/4/24 documents: Triple Antibiotic Ointment 3.5/400/5000 (Neomycin-Bacitracin-Polymyxin) Apply per directions to nose topically one time a day for abrasion. R5's Face Sheet, printed 2/8/24 documents his diagnoses to include Epilepsy, Intractable with Status Epilepticus, Emphysema, Cognitive Communication Deficit, Anxiety Disorder, Unspecified Dementia, Alzheimer's with Early onset, Expressive Language Disorder, A-Fib, Bradycardia, Cannabis Use, and Traumatic Brain Injury. R5's MDS dated [DATE] documents R5 moderately cognitively impaired. R5's Care Plan, undated, documents ABUSE: (R5) is at risk for abuse and neglect r/t his impaired cognition secondary to dx of Alzheimer's and Dementia. There were three entries on this care plan of resident-to-resident altercations R5 has been involved in: 5/6/2023 Peer altercation; 6/4/23 resident was reported as the alleged perpetrator in res (resident) to res allegation; 11/5/2023 Peer reported (R5) made contact with him in chest area. R5's Care Plan intervention documents Review assessment information. Emphasize treatment of casual factors and/or interventions designed to moderate/reduce symptoms (make treatment of compulsive behavior, substance abuse, anger and mental health issues available to the resident, as indicated). Another of R5's Care Plans, undated, documents The resident has a history of substance and alcohol abuse. Problems and symptoms are manifested by recurrent hospitalization s, homelessness, and exacerbation of symptoms of mental illness. (R5) has repeatedly returned from a pass intoxicated. He admits to drinking beer and sometimes harder liquor. He denies having a problem with alcohol and does not want to seek treatment at this time. He has been educated on the impact of his use on his medical diagnoses and need to withhold medications when he is under the influence. Diagnoses: Cannabis Use, Unspecified, with other cannabis-induced disorder; Alcohol Abuse. The goal for this Care Plan documents The resident will refrain from using non-prescribed substances through the next review period. The Interventions document Implement increasingly restrictive interventions in an effort to help the resident break the addictive cycle. Interventions may include supervision while in the community, restricted independent pass privileges, implementation of money guidance and budget controls to reduce/prevent access to substance. Meet with the IDT (Interdisciplinary Team) to discuss the extent of the resident's illness. The physician may consider a referral to the psychiatrist and/or write an order restricting 'pass privileges. Work with the resident to establish a verbal or written behavioral contract specifying what is and is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances and intoxication. R5's undated Care Plan further documents LEGAL: The resident has a history of criminal behavior. The resident has demonstrated stability during the admission screening process and does not appear to present an unusual risk at this time. The IL. Dept of Public Health performed a Criminal History Analysis and determined the level of risk as low. According to the resident's history he has been convicted of criminal trespass, retail theft, unlawful use of a weapon and possession of a firearm. On 2/6/24 at 9:03 AM V1 (Administrator) stated it was reported to her that R5 had returned from an LOA (Leave of Absence) and was intoxicated. She stated he had returned from previous LOAs intoxicated before this episode. She stated typically the nurses would call his physician to see if any of his medications needed to be held due to his alcohol intake. She stated if he was having behaviors, they would send him out to the emergency room for evaluation. She stated on Saturday, February 3,2024 when he returned to the facility intoxicated, he went into the bathroom and the staff overheard a commotion and went into the bathroom and another resident, R6, told staff that R5 hit him with a plunger, but there were no witnesses and R6 had no injuries. V1 stated R6 was sent to the local emergency room for evaluation and came back that same night. V1 stated R6 had a scratch and bruising on his nose. She stated the police were notified and R5 was taken to jail, and he returned to the facility last night, 2/5/24, but was sent to the hospital this morning because he was having seizures. On 2/8/24 at 3:00 PM V23 (Psycho-Social Rehab Aide) stated R5 was in anger management group and would sometimes come to socialization groups that they have twice a day. She stated the groups did not hold his interest for very long at a time. She stated R5 is not in any type of group for his history of drug and alcohol abuse. V23 stated when R5 is not drunk he's nice to other residents, but when he is drunk, he is worrisome to everyone; he bothers staff and residents, including irritating other residents bad enough that it would cause fights between them and him. She gave the example of R18, and stated if R18 is yelling to go outside and R5 is drunk, R5 will go up and tell him to shut up or he is going to jump on him. V23 stated R5 did hit R18 sometimes. She stated if R5 is not intoxicated, R18's yelling does not bother him. V23 stated they need to stop R5 from going out on his own because he is drunk every time he comes back into the facility. On 2/9/24 at 1:07 PM V8 (Psycho-Social Rehab Coordinator) stated if R5 returns to the facility intoxicated, staff just try to get him to go lay down in his room. She stated the nurses have sent him out to the hospital and the hospital sends him right back. She stated sometimes they will send him to the Psycho-Social Rehab office, and they will let him sit with them or play checkers or something to keep him busy, so he doesn't bother anyone else. V8 stated they do not have any type of programs to address his drug or alcohol addictions. She stated they have not tried to do a contract with him to offer consequences related to his behaviors he has when he is intoxicated. On 2/12/24 at 3:42 PM V10 (Licensed Practical Nurse/LPN) stated she was the nurse taking care of R5 on the night of the incident when he hit R6. She stated several staff came to get her, telling her R5 had hit another resident in the bathroom. V10 stated when she got to the bathroom, R6 was pulling his pants up and stated, (R5) hit me. V10 stated R5 was present and stating, I didn't hit anybody. She stated the staff had already separated the residents. She stated R6 had a laceration on his nose and said R5 had hit him with a plunger. V10 stated R6 went to the hospital for evaluation and returned with no negative findings other than triple antibiotic ointment to the laceration on his nose. V10 stated the police came and arrested R5 for assault and took him from the facility. V10 stated R5 had just returned from an outing prior to the incident. She stated he had a certain walk when he was intoxicated, and she felt like he was intoxicated that evening. She stated the police officer also stated R5 appeared intoxicated. V10 stated she was usually R5's nurse on the weekends and he frequently returned from outings intoxicated. She stated he was loud when he was intoxicated, and they usually tried to direct him to his room to sleep it off, but he usually just came right back out and was loud and obnoxious, trying to tell other residents what to do. V10 stated they would try to bribe him by telling him they would send him to the hospital due to his behaviors, but he was alert and oriented x 4 and knew the EMTs (Emergency Medical Technicians) would not take him if he refused to go. V10 stated R5 went out frequently and returned intoxicated and often had to be redirected by staff, telling R5 he could not tell the other residents what to do. V10 stated when R5 is sober, he is very friendly and likes to help with straightening the dining room. She stated there are really no groups to help with alcohol or drug problems, but only social groups, and it is up to the residents if they want to go or not. V10 stated there are really no consequences for R5 when he goes out and comes back intoxicated. She stated they have had meetings before with R5 and his family but family refuse to sign him out and in because they say he can do what he wants. She stated if staff do try to keep him from going out, R5 will try and elope. She stated R5 is not seen by a psychiatrist because he doesn't have any mental illness diagnoses to her knowledge. She stated she thinks he is homeless, and he gets intoxicated and has seizures and that is why he is a resident. She stated R6 is very quiet and does not have any aggressive behaviors and has never had any problems with other residents. The facility's policy, Abuse Policy and Prevention Program, revised 10/2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Under, Establishing a Resident Sensitive Environment the policy documents, Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals or approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and updated as necessary. Under, Protection of Residents the policy documents: Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of the residents.

Based on observation, interview and record review, the facility failed to provide treatments to pressure ulcers as ordered by the physician for 2 of 2 residents (R10 and R11) reviewed for pressure ulcers in the sample of 18. This failure resulted in R10's pressure ulcer becoming infected and increasing in size. Findings include: 1.On 2/8/24 at 10:35 AM V6, Wound Nurse provided pressure ulcer care to R10's pressure ulcers on his coccyx and left ischium. V6 removed the dressing from his coccyx which was saturated with serosanguinous drainage. She cleansed his wound with wound cleanser and then applied ordered treatment of Flagyl (crushed), silver Silvadene, gentamycin, collagen powder and calcium alginate that she then covered with a foam bordered dressing. She stated this wound was improving. After washing her hands and removing the dressing from R10's left hip/ischium, there was a foul odor coming from this wound. The base of the wound had a greenish yellowing color and moderate drainage. V6 stated the odor and green color were new and she planned to notify the wound physician and see if he wanted a culture of the wound because it looked infected. V6 then cleansed the wound with wound cleanser and put the same treatment on this wound as the coccyx wound. R10 stated he cannot really feel much in his legs because he is paralyzed but stated he did feel warmth in the wound that was not usually there. R10's Face Sheet, printed 2/9/24 documents his diagnoses to include Cerebral Vascular Accident, Paraplegia, Severe Protein-Calorie Malnutrition, Need for Assist with Personal Care; Osteoarthritis, Osteomyelitis, Anxiety, Stage 3 Pressure Ulcer of Sacral Region and Left Trochanter. R10's Minimum Data Set (MDS) dated [DATE] documents R10 is alert and oriented x 3 and requires substantial assist with transfers and turning and positioning. It documents he has a colostomy and an indwelling urinary catheter. R10's Care Plan, updated 10/17/23, documents (R10) is at risk for skin complications r/t (related to) adult failure to thrive. 2/14/2020 (R10) admitted with multiple pressure ulcers. 10-16-23 Tx (treatment) orders still in place for coccyx and left ischium per (V35, Wound Physician). There was no goal or interventions included in this care plan. R10's Physician Order dated 10/24/23 documents Cleanse wound to coccyx and left ischium with wound cleanser, open Metronidazole capsule and sprinkle medication onto wound bed, apply silver sulfadiazine, collagen powder, gentamicin ointment, Dakin's-soaked calcium alginate, and cover with foam dressing BID (two times a day) and PRN (as needed) until healed. Monitor for S&S (signs and symptoms) of infection, contact MD (Medical Doctor). R10's Treatment Administration Records (TARs) were reviewed for January and February 2024 with no treatments being documented as done as ordered in the following months on the following days: February 2024: 2/3/24 AM or PM or 2/4/24 PM. January 2024 1/1/24 PM, 1/2/24 AM, 1/5/24 AM, 1/6/24 PM, 1/7/24 PM, 1/8/24 AM or PM, 1/10/24 AM or PM, 1/11/24 PM,1/12/24 AM or PM, 1/13/24 PM,1/14/24 AM or PM, 1/15/24 PM, 1/18/24 AM,1/21/24 PM,1/29/24 PM, or 1/31/24 AM. R10's Wound Physician Wound Evaluation and Management Summary reports dated 1/1/24, 1/8/24, 1/15/24, 1/29/24 and 2/5/24 were reviewed with documentation of wound deterioration of R10's left ischial pressure ulcer as evidenced by the wound increasing in size and having increased purulent drainage. The weekly wound measurements are as follows: 1/1/24: 1.1 cm (centimeters) by (x )1.2 cm x 0.5 cm 1/8/24: 1.1 cm x 1.1 cm x 0.5 cm 1/15/24: 1 cm x 1 cm x 0.5 cm 1/29/24: 2 cm x 1 cm x 0.5 cm 2/5/24: 2.6 cm x 1.8 cm x 0.5 cm R10's Physician's Order for treatment to the pressure ulcer on his left ischium remained the same (Alginate Calcium, Sodium Hypochlorite Solution (Dakin's), and Metronidazole Sprinkled twice daily with gauze island dressing with border twice daily, until 2/5/24 when V35 added Silver Sulfadiazine to the treatment. 2. On 2/8/24 at 10:07 AM V6 went in to provide pressure ulcer treatment for R11 to her stage 4 pressure ulcer to her sacrum. V6 proceeded to perform pressure ulcer treatment. R11's dressing was already off because it was soiled with feces and removed during incontinent care. V6 cleansed R11's sacral wound with wound cleanser and it started bleeding with bright red blood noted. V6 stated the wound was looking much better and was shallower as it improved. She stated R11 is followed by the wound physician. After wound was cleansed, V6 applied the treatment of calcium alginate soaked in Dakin's solution and covered with dry dressing. R11's Face Sheet printed 2/8/24 documents her diagnoses to include Malignant Neoplasm of Ureter, Long Term Use of Anticoagulant, Protein-Calorie Malnutrition, Obstructive /Reflux Uropathy, Type 2 DM (Diabetes Mellitus), Bipolar Disorder, Schizophrenia, Psychotic Disorder with Delusions, and Pressure Ulcer of Sacral Region, Stage 4. R11's Physician Order dated 2/9/24 documents: apply 1/4 strength Dakin's solution to gauze and calcium alginate to sacral wound, cover with island dressing QD (every day) and PRN every day shift for treatment and prevention of skin infection. The previous treatment dated 10/10/23 documented: apply 1/4 strength Dakin's solution to gauze and calcium alginate to sacral wound, cover with island dressing BID (twice a day) and PRN. R11's Treatment Administration Records were reviewed for February and January: Treatments were not documented as being done as ordered in the following months on the following days: February 2024: 2/3/24 AM, 2/5/24 AM and PM, 2/6/24 AM, or 2/8/24 PM; January 2024: 1/1/24 AM, 1/2/24 PM, 1/8/24 AM, 1/10/24 AM, 1/11/24 AM and PM, 1/12/24 PM, 1/14/24 PM, 1/17/24 AM, 1/18/24 PM, 1/20/24 AM, 1/21/24 PM, 1/24/24 AM, 1/27/24 PM, 1/30/24 AM, or 1/31/24 AM. On 2/12/24 at 3:30 PM V35, Wound Physician, during phone interview, stated he does not feel like R10 not getting his pressure ulcer treatments is the reason his pressure ulcer to his left ischium is getting worse. V35 stated he thinks the wound has become infected, which has happened in the past. V35 stated the pressure ulcer on his left ischium is worse because it is infected. He stated R10 is non-compliant with staying off the pressure ulcers as he will stay up in his chair for long periods of time. V35 stated sometimes he orders treatments to be done twice a day in hopes that they will actually be done once a day. V35 stated he would expect his orders to be followed but he does not think there is any negative consequences to R10's or R11's pressure ulcer treatments and wound care not being done as ordered. The facility's policy, Pressure Injuries, revised 6/2016 documents, To prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesions caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injuries, friction and shear are important contributing factors to the development of pressure injuries.

Based on observation, interview and record review, the facility failed to provide behavioral treatment and services to address the diagnoses of alcohol and/or substance abuse for 1 of 3 residents (R5) reviewed for behavioral services in the sample of 18. This failure resulted in R5 not receiving any substance abuse treatment or services. Subsequently, R5 returned from an outing intoxicated and physically assaulted R6, striking R6 in the face with a toilet plunger resulting in R6 being sent to the hospital for evaluation of a laceration on his face and R5 being taken to jail for assaulting R6. Findings include: R5's Face Sheet, printed 2/8/24 documents his diagnoses to include Epilepsy, Intractable with Status Epilepticus, Emphysema, Cognitive Communication Deficit, Anxiety Disorder, Unspecified Dementia, Alzheimer's with Early onset, Expressive Language Disorder, A-Fib, Bradycardia, Cannabis Use, and Traumatic Brain Injury. R5's Minimum Data Set, dated dated dated [DATE] documents R5 moderately cognitively impaired. R5's Care Plan, undated, documents ABUSE: (R5) is at risk for abuse and neglect r/t his impaired cognition secondary to dx of Alzheimer's and Dementia. There were three entries on this care plan of resident-to-resident altercations R5 has been involved in: 5/6/2023 Peer altercation; 6/4/23 resident was reported as the alleged perpetrator in res (resident) to res allegation; and 11/5/2023 Peer reported (R5) made contact with him in chest area. An intervention for this care plan, undated, documents Review assessment information. Emphasize treatment of casual factors and/or interventions designed to moderate/reduce symptoms (make treatment of compulsive behavior, substance abuse, anger and mental health issues available to the resident, as indicated). R5's Care Plans, undated, documents DUAL DIAGNOSIS: The resident has a history of substance and alcohol abuse. Problems and symptoms are manifested by recurrent hospitalization s, homelessness, and exacerbation of symptoms of mental illness. (R5) has repeatedly returned from a pass intoxicated. He admits to drinking beer and sometimes harder liquor. He denies having a problem with alcohol and does not want to seek treatment at this time. He has been educated on the impact of his use on his medical diagnoses and need to withhold medications when he is under the influence. Diagnoses: Cannabis Use, Unspecified, with other cannabis-induced disorder; Alcohol Abuse. The goal for this Care Plan documents The resident will refrain from using non-prescribed substances through the next review period. Interventions for this Care Plan document Implement increasingly restrictive interventions in an effort to help the resident break the addictive cycle. Interventions may include supervision while in the community, restricted independent pass privileges, implementation of money guidance and budget controls to reduce/prevent access to substance. Meet with the IDT (Interdisciplinary Team) to discuss the extent of the resident's illness. The physician may consider a referral to the psychiatrist and/or write an order restricting 'pass privileges.' Work with the resident to establish a verbal or written behavioral contract specifying what is and is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances, and intoxication. R5's undated Care Plan further documents LEGAL: The resident has a history of criminal behavior. The resident has demonstrated stability during the admission screening process and does not appear to present an unusual risk at this time. The IL. Dept of Public Health performed a Criminal History Analysis and determined the level of risk as low. According to the resident's history he has been convicted of criminal trespass, retail theft, unlawful use of a weapon and possession of a firearm. R5's Progress Notes document a history of repeated incidents of returning to the facility intoxicated after going out on leave of absences including the following: R5's Progress Note, dated 2/3/24 at 8:52 PM, documents, Several staff members came to the nurse's station to tell nurses saying this resident hit another resident in the face with a plunger in the bathroom. When approached this resident stated not doing anything to anybody. Resident seems under the impression of being intoxicated with confusion, red eyes, and a leaning walk. Police called and approached resident who then took him in the police car shortly after. R5's Social Service Progress Note dated 11/14/23 at 2:20 PM documents, Resident is A & O x 3 (Alert and oriented) with periods of confusion. Resident continues to report he is working towards moving into the community but lacks the capacity to care for himself. He is functionally illiterate and continues to need medication monitoring. He has difficulty complying with the rules of the facility as it relates to community outings and has returned intoxicated on more than one occasion. R5's Progress Note dated 11/10/23 at 11:28 PM documents, Resident noted intoxicated. Resident going throughout facility, making noises, yelling, and demanding to go out and smoke. Resident redirected to his room, upon attempt to redirect, resident continues to yell. Resident asked repeatedly to quiet down and go to personal area. Resident currently in his room at this time. Staff to continue to monitor behaviors for safety of himself and others. R5's Progress Note dated 10/30/23 at 10:27 PM documents, Res came back from the facility and said he forgot his phone at the liquor store. Minutes later the front called a code and res was outside. Res was at first refusing to come in as he wanted his phone from the liquor store. The nurse advised to call the police and ambulance. Res then came back in the building and went to his room. Ambulance and police officers came, and resident stayed in building. Resident rested for a while and then got back up to get his meds. On 2/6/24 at 11:15 AM R6 was lying in bed in his room. He was reluctant to talk and gave short answers to questions. R6 stated R5 came into the bathroom when he was in there and tried to force him to get out. R6 stated when he would not get out, R5 hit him in the eye and then in the nose with a plunger. R6 had a small abrasion on the bridge of his nose over a purple bruise. R6 stated the staff heard him screaming at R5 to leave him alone and they came in and got him out. R6 stated R5 has threatened him verbally before but he never hit R6 before this. R6 stated this happened a few nights ago. He stated he did not know if R5 was back because the police took him to jail, but he had not seen him since the police took him away. On 2/6/24 at 9:03 AM V1 (Administrator) stated it was reported to her that R5 had returned from an LOA (Leave of Absence) and was intoxicated. She stated he had returned from previous LOAs intoxicated before this episode. She stated typically the nurses would call his physician to see if any of his medications needed to be held due to his alcohol intake. She stated if he was having behaviors, they would send him out to the emergency room for evaluation. She stated on Saturday, 2/3/24 when he returned to the facility intoxicated, he went into the bathroom and the staff overheard a commotion and went into the bathroom and another resident, R6, told staff that R5 hit him with a plunger, but there were no witnesses and R6 had no injuries. V1 stated R6 was sent to the local emergency room for evaluation and came back that same night. V1 stated R6 had a scratch and bruising on his nose. She stated the police were notified and R5 was taken to jail, and he returned to the facility last night, 2/5/24, but was sent to the hospital this morning because he was having seizures. On 2/8/24 at 3:00 PM V23 (Psycho-Social Rehab Aide) stated R5 was in an anger management group and would sometimes come to socialization groups that they have twice a day. She stated the groups did not hold his interest for very long at a time. She stated R5 is not in any type of group for his history of drug and alcohol abuse. She stated there are no residents who go out to any type of AA (Alcohol Anonymous) meetings. V23 stated she thinks a few years ago, before COVID, some AA sponsors would come in and take some of the residents to meetings but stated R5 was never part of that program. V23 stated when R5 is not drunk he's nice to other residents, but when he is drunk, he is worrisome to everyone; he bothers staff and residents, including irritating other residents bad enough that it would cause fights between them and him. She gave the example of R18, and stated if R18 is yelling to go outside and R5 is drunk, R5 will go up and tell him to shut up or he is going to jump on him. V23 stated R5 did hit R18 sometimes. She stated if R5 is not intoxicated, R18's yelling does not bother him. V23 stated they need to stop R5 from going out on his own because he is drunk every time he comes back into the facility. On 2/8/24 at 3:10 PM V24 (Psycho-Social Rehab Aide) stated R5 goes out 3-4 times a week and always comes back intoxicated. She stated they have tried to revoke his walking privileges but if no one lets him out, he kicks the door open. On 2/9/24 at 1:07 PM V8 (Psycho-Social Rehab Coordinator) stated if R5 returns to the facility intoxicated, staff just try to get him to go lay down in his room. She stated the nurses have sent him out to the hospital and the hospital sends him right back. She stated sometimes they will send him to the Psycho-Social Rehab office, and they will let him sit with them or play checkers or something to keep him busy, so he doesn't bother anyone else. V8 stated they do not have any type of programs to address his drug or alcohol addictions. She stated they have not tried to do a contract with him to offer consequences related to his behaviors he has when he is intoxicated. On 2/12/24 at 3:42 PM V10 (Licensed Practical Nurse/LPN) stated she was the nurse taking care of R5 on the night of the incident when he hit R6. She stated several staff came to get her, telling her R5 had hit another resident in the bathroom. V10 stated when she got to the bathroom, R6 was pulling his pants up and stated, (R5) hit me. V10 stated R5 was present and stating, I didn't hit anybody. She stated the staff had already separated the residents. She stated R6 had a laceration on his nose and said R5 had hit him with a plunger. V10 stated R6 went to the hospital for evaluation and returned with no negative findings other than triple antibiotic ointment to the laceration on his nose. V10 stated the police came and arrested R5 for assault and took him from the facility. V10 stated R5 had just returned from an outing prior to the incident. She stated he had a certain walk when he was intoxicated, and she felt like he was intoxicated that evening. She stated the police officer also stated R5 appeared intoxicated. V10 stated she was usually R5's nurse on the weekends and he frequently returned from outings intoxicated. She stated he was loud when he was intoxicated, and they usually tried to direct him to his room to sleep it off, but he usually just came right back out and was loud and obnoxious, trying to tell other residents what to do. V10 stated they would try to bribe him by telling him they would send him to the hospital due to his behaviors, but he was alert and oriented x 4 and knew the EMTs (Emergency Medical Technicians) would not take him if he refused to go. V10 stated R5 went out frequently and returned intoxicated and often had to be redirected by staff, telling R5 he could not tell the other residents what to do. V10 stated when R5 is sober, he is very friendly and likes to help with straightening the dining room. She stated there are really no groups to help with alcohol or drug problems, but only social groups, and it is up to the residents if they want to go or not. V10 stated there are really no consequences for R5 when he goes out and comes back intoxicated. She stated they have had meetings before with R5 and his family but family refuse to sign him out and in because they say he can do what he wants. She stated if staff do try to keep him from going out, R5 will try and elope. She stated R5 is not seen by a psychiatrist because he doesn't have any mental illness diagnoses to her knowledge. She stated she thinks he is homeless, and he gets intoxicated and has seizures and that is why he is a resident. She stated R6 is very quiet and does not have any aggressive behaviors and has never had any problems with other residents. On 2/13/24 at 9:11 AM, during phone interview, V1 (Administrator) stated her regional director told her they do have a policy regarding alcohol and substance abuse, and she would be emailing it as soon as she received it. V1 stated she had reviewed R5's chart and talked to other staff and determined that R5 had not been seen by a psychiatrist for several months and he was not receiving any type of treatment for his history of alcohol abuse. The facility's policy, Residents with Substance Use Disorder, revised 1/22/23 documents, It is the policy of this facility to create an environment as safe as possible for residents with a history of substance use disorder. The policy documents the definition of Substance Use Disorder (SUD) as the recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school or home. Under Policy Explanation and Compliance Guidelines the facility documents, 1. Residents with a history of Substance Use Disorder (SUD) will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to included increased monitoring and supervision of the resident and their visitors. 2. When substance use is suspected, (in the facility or upon return from an absence from the facility), facility staff should implement the care plan interventions; these may include the notification of the resident's physician or non-physician practitioner. 3. Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek substances which could endanger his/her health or safety. 7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision. The efforts may include outside services that may include behavior health services, alcoholics or narcotics anonymous meetings, etc. as well and in-house services.

Based on interview, observation, and record review, the facility failed to provide supervision to prevent elopement for 1 of 5 residents (R1) reviewed for supervision and accident prevention in the sample of 29. This failure resulted in an Immediate Jeopardy when R1 exited the facility and was found on the ground, in a field, near a busy interstate and road. This failure has the potential to affect not only R1, but R4, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R25, who have been identified as a high risk for elopement by the facility. The Immediate Jeopardy began on 8/10/23 at 9:00 PM when R1 was last seen in the facility. R1 was found at approximately 5:00 AM on 8/11/23, lying down in a field near a busy interstate and road. R1 was brought back inside the facility, assessed, and sent out to the Emergency Department for acute medical evaluation. V1 (Administrator), V2 (Director of Nursing/DON), and V14 (Vice President of Operations and Regulatory Compliance) were notified of Immediate Jeopardy on 8/25/23 at 1:00 PM. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 8/25/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and the revisions of the elopement policy and procedures. Findings include: R1's Face Sheet documents, R1 was admitted to the facility on [DATE] with diagnoses, including Unspecified Dementia, Emphysema, Encephalopathy, Dysphagia, (Difficulty Swallowing), and Weakness. R1's Minimum Data Set, (MDS), dated [DATE] documented, R1 was severely cognitively impaired, required extensive assistance with walking, and had no exhibited wandering behavior. R1's Care Plan, initiated 12/29/2022 documents, (R1) is at a high risk for elopement. The Care Plan was last updated on 8/20/23, to include the following interventions, 8/20/23 q15, (every 15 minute), checks; Allow concerns to be expressed; Encourage resident to keep busy with activities; Monitor where abouts PRN, (as needed); Redirect resident to activities of choice or SS (Social Services) group. R1's Care Plan also documented R1 was at risk for falls related to dementia. R1's Elopement Evaluation, dated 5/17/2023, documented, R1 was at high risk of elopement. R1's next Elopement Evaluation was prior to his elopement on 8/6/2023 and documented, R1 was at low risk of elopement. R1's Elopement Evaluation following his elopement on 8/11/2023 documented, R1 was again at high risk of elopement. R1's Progress Note by V28 (Licensed Practical Nurse/LPN), on 6/19/23 at 7:25 AM documents, Resident awoke (woke), up and walked the hall and urinated in the hallway. Resident easily redirected and care provided. R1's Progress Note by V28 (LPN) on 6/25/23 at 6:01 AM documents, Resident up at nursing station most of night shift. Easily redirect able. Wonders (Wanders) unit. R1's Progress Note by V28 (LPN) on 7/8/23 at 12:18 AM documents, Resident awake, closely monitored, due to wondering (wandering) behavior. R1's Progress Note by V28 (LPN) on 8/11/2023 at 7:15 AM documents, CNA (Certified Nursing Aide) approached writer at 0345 (3:45 AM), stating that (R1) was not in his room and asked where he was. (R1) unable to express event (sic). Immediately, writer went to room and (R1) not in bed. Asked CNA assigned to (R1) and stated that when she came in at before 10:00 pm shift she asked nurse where (R1) was and stated, that the previous nurse stated, that (R1) went to hospital. Writer immediately went into nurses notes and noted that there were no notes indicated (indicating) (R1) went to hospital. Writer initiated a search of the complete facility including shower rooms and bathrooms. (R1) unfounded (not found) at that time. Writer and fell ow nurse did complete perimeter search. Ensuring all doors were alarmed and (R1) not in closed patio areas. Call placed to (V2) DON (Director of Nursing). (V2) instructed to call 911 and that she would notify (V1) Administrator and would call writer back. In the meantime, fell ow staff drove around 1 mile radius of facility including church parking lots, surrounding field and ditches on sides of the roads at 0500 (5:00 AM), (R1) noted on the grounds (sic) when completing another search. RN (Registered Nurse), DON, along with Administrative Staff assessed resident prior to (R1) getting off the ground. (R1) noted to be laying (lying) on right side in grass. ROM (Range of Motion) attempted, resident had difficulty with movement to right arm and right leg. (R1) base line is alert and orientated (oriented) to self, able to make needs known at times. (R1) hard to direct with ROM. Due to that fact, (R1) then assisted to a wheelchair and back in the building before further evaluation. R1's Emergency Department Note from (Local Hospital) dated 8/11/23 at 7:19 AM documents, this [AGE] year-old male who arrives via EMS (Emergency Medical Services) from (Facility). Apparently, this patient was found outside of the (Facility), and the confusion arises now how long he was outside. One story states 2 days and the other source states 1 hour. General appearance: cooperative, comfortable, frail appearing and appears older than stated age. Other: there are minor nontender abrasions over both shoulders anteriorly (on front side). This patient's mental and physical status has remained unchanged while in department. CT (Computed Tomography) of the neck and head are unremarkable. Patient to be discharged back to (Facility). R1's Progress Notes by V36 (LPN) on 8/11/2023 at 12:10 PM documents, (R1) returned from (Local Hospital). NNO (No New Orders) were received from hospital visit. All labs were WNL (Within Normal Limits). (R1) CT and xrays (X-rays), were negative and did not have any fractures present. (R1) is now resting in his bed at this time. The Facility's Incident Timeline dated 8/11/23 documents: 4:00 am (V2) DON received call from (V28) Charge Nurse to inform they could not locate resident (R1). 4:06 am received call from (V2) DON informing me of resident (R1) not located in facility. (V2) informed to contact Police for assistance. (V1) informed by (V2) this time, that charge nurse contacting hospitals. (V28) stated, she had directed staff to do complete head count in facility and search for resident. (V28) directed staff outside facility to search for resident. Guardian notified. 4:08 am (V1) Administrator began notifying managers of situation and requesting to assistance. 4:10 am (V35) NP (Nurse Practitioner) notified of not being able to locate. 4:15 am Police arrived at facility, police received information including picture of resident, distinguishing markings, demographics. Police assist with search. (V2) DON initiated staff interviews. 4:30 am search continues involving the immediate area outside facility and surrounding areas. 5:00 am Resident located lying on ground in adjacent grassy area, nursing assessment completed. Resident assisted to WC (wheelchair) to transport back in facility and further nursing assessment. Resident transferred to Hospital as precautionary. Police, Physician and Guardian notified. Staff remained 1:1(one on one supervision), with res(resident), until EMS (Emergency Medical Services), arrived. 12:10 pm Ret'd (Returned) from ER (emergency room ). No sig (significant injuries), 1:1 continued, Elopement Assessments for all res reviewed along with CP (Care Plan), updates as needed. Elopement Binders reviewed et (and) updated as needed. Res returned to facility 1:1 continued. On 8/24/23 at 11:56 AM, V13 (CNA) stated, she arrived at work around 9:45 PM on 8/10/22 and was doing a walk through to check on her residents, when V31 (Agency Nurse) told her R1 was in the hospital. Later in the shift, V30 (Unknown Employee) came to V13 and asked where R1 was located. V30 stated, R1 had a doctor's appointment earlier in the day, but came back to the facility afterwards. V13 stated, she went back to check with V31 (Agency Nurse), and they discovered R1 was missing. He was found at a church by the facility. V13 was helping search for him. Staff looked all through the facility and someone else finally found him outside behind the laundry area and by the church. When V13 went outside, R1 was lying on the ground and had right eye swelling. She stated, R1's tongue was sticking out of his mouth and swollen. He was on the ground and complained about his leg, but they moved him to a wheelchair. V13 stated it was light outside when they found R1 and estimates finding him at 4-5:00 AM but was unsure exactly how long they were looking for him. V13 stated, when she got to the door to go outside to check on R1 there were no alarms going off, and she assumed they had already been turned off. She stated, (R1) wasn't able to tell me what happened. I think he has dementia and is always pretty confused. On 8/24/2023 at 12:00 PM V1 (Administrator) stated, the CNA on night shift thought R1 was out of the facility for a visit. She stated the last time R1 was seen on 8/10/23 was at 10:30 PM and was later found in a grassy area near the facility by staff. On 8/24/2023 at 12:45 PM V15 (Dietary Aide) stated he has seen R1 trying to get out of the facility. On 8/24/23 at 1:14 PM, V16 (Laundry Aide) stated R1 wanders throughout the building and often stands by the doors and watches the cats outside. On 8/24/23 at 1:20 PM, V11 (CNA) stated, R1 has tried to get out of the facility before and can be combative at times. She stated someone must have shut off the alarm without checking to see if anyone was outside. On 8/24/23 at 1:58 PM, V22 (Ombudsman) stated she was not made aware of R1's elopement, but sometimes during the day they let residents on the independent side of the building go outside, and the door at the end of the Women's Hall is left unlocked. She stated, she has seen residents trying to get out of the building. On 8/24/23 at 2:18 PM, V21 (CNA) stated she remembers R1 being anxious that day and trying to get out of the facility. On 8/24/23 at 3:17 PM, V23 (CNA) stated R1 wanders around the facility and pushes on the doors. On 8/24/23 at 3:25 PM, V25 (CNA) stated R1 wanders the halls all the time and shakes the door handles. On 8/24/23 at 3:29 PM, V29 (LPN) stated R1 is very confused. On 8/25/23 at 8:30 AM, V26 (CNA) stated, R1 kept going back and forth to the door and setting off the alarm on 8/10/23. She stated, everybody watches (R1) because he is always wandering and needs to be redirected. She reported cleaning R1 up around 8:30-9:00 PM and took a break between 10:15 and 10:30 PM. R1's roommate usually likes to keep his door closed, and when she walked by around 2:30 AM she noticed R1 wasn't in there. V13 (CNA) stated, she was told he was in the hospital. I checked with the nurse (V28), and she said R1 was not on the list of hospitalized residents. I said, We've gotta find (R1). He has dementia and likes to walk. We went outside, couldn't find him anywhere. I can't remember who found him, but he was responding and talking. He said, his shoulder hurt. He was lying on his right side and that was the shoulder he complained about. (R1) had a bruise over his right eye that looked like he had fallen. He was wearing a pair of jeans; that is all I remember. He was also, wearing a diaper; we brought him in and cleaned him up. He had urinated in his diaper. I don't know how he got out. I think someone turned off the alarm and didn't look to see if he was out there. On 8/25/23 at 9:11 AM, V27 (Business Office Manager) stated, he got a call around 4:45 AM on 8/11/23 from V1. He was here by 5:00 AM and joined the search for R1. He looked at the field in back and it was starting to get light out. He came around a large mound of gravel and saw R1 lying on the ground by the back of the church building. He stated, R1 was just lying there and responded when spoken to. V27 called the nurses, and they assessed R1 and put him in a wheelchair. V27 could not recall whether R1 was wearing shoes but remembers him wearing a white shirt and jeans which were covered in grass. V27 showed surveyors where R1 was found. This was estimated to be about 250 yards from the street on which the facility resides with a speed limit of 35 mph (miles per hour), and 400 yards from Interstate 255 with a speed limit of 65 mph. On 8/25/2023 at 9:45 AM, V28 (LPN) stated, I came in 8/10/2023 at 10:45 PM. The nurse, (unknown), who gave me report was very flustered. I did not get a detailed report. There were all kinds of room changes and residents wanting my attention at the beginning of my shift. I was working with a seasoned CNA, I don't remember her name, but she was doing rounds and she said everyone was ok. Later in our shift, I'm not sure what time, a CNA asked where (R1) was. V13 said R1 was at the hospital. We saw he wasn't sent to the hospital. We immediately did a full facility check. I drove my car around and shined my lights in the grassy area. I then called the Police and the DON (V2). (R1) was found lying on his right side. We rolled him over on his back and did range of motion. We stood him up and put him in a wheelchair. The Corporate Team was here, and they assessed him. I did not do a full body assessment. R1 had on a shirt and pants. I don't know if he had shoes on or not. He complained of pain all over, but mostly on the right side. The (Local Police Department) Report dated 8/11/23 at 4:14 AM by V54 (Police Officer) documents, I, (V54), responded to (Facility) located at (Address) in reference to a missing person report. Upon arrival, I spoke with (V28), who stated, a resident by the name of (R1) had not been seen since approximately 1500hrs, (3:00 PM), on 8/10/2023. (V28) stated, when she arrived at work at 2300hrs (11:00 PM) on 8/10/2023, she was advised by the on-shift CNA (V13), that (R1) had been sent out, however, there was no chart of which hospital he was transported to or what time he left. (V28) stated, (R1) normally walks the halls, however, he has never left the facility. V28 stated, they have a receptionist normally sitting at the desk and advised her (R1) never left facility that they saw. (V28) stated, the company removed the camera system, so there was no way of seeing if he left the building. (V28) provided me with a picture of (R1) which was forwarded to my shift, in case they noticed anyone walking in the area matching the description of (R1). I requested to check (R1)'s room, at which time I was escorted to his room, where I noticed his bed was still made, and both of roommates were sleeping. As I exited the room, I spoke with (V13), who stated she came into work at 2200hrs (10:00 PM) and when she checked (R1)'s room, she noticed the bed was made, and asked the nurse she was relieving where (R1) was, and she advised he had been sent out, but nothing further. I asked the facility administrator (V1) if they wanted (R1) entered as missing, and she stated yes. I then requested dispatch enter (R1) as missing and was provided the FOLLOWING LEADS. A short time later, I was advised by dispatch (Facility) called back, and advised they located (R1) hiding in the grass behind the facility. V64 (R1's Medical Doctor) was unavailable by phone on 8/24/23 at 3:28 PM, 8/24/23 at 3:40 PM, 8/25/23 at 8:50 AM, and 8/31/23 at 9:06 AM. On 8/24/23, the facility provided the following information which identified the residents who were at risk for elopement: -R1's Elopement Evaluation dated 8/11/23 documented R1 was at high risk for elopement. -R4's Elopement Evaluation dated 8/11/23 documented R4 was at high risk for elopement. -R8's Elopement Evaluation dated 8/11/23 documented R8 was at high risk for elopement. -R9's Elopement Evaluation dated 8/11/23 documented R9 was at high risk for elopement. -R10's Elopement Evaluation dated 8/11/23 documented R10 was at high risk for elopement. -R11's Elopement Evaluation dated 8/11/23 documented R11 was at high risk for elopement. -R12's Elopement Evaluation dated 8/11/23 documented R12 was at high risk for elopement. -R13's Elopement Evaluation dated 8/11/23 documented R13 was at high risk for elopement. -R14's Elopement Evaluation dated 8/11/23 documented R14 was at high risk for elopement. -R15's Elopement Evaluation dated 8/11/23 documented R15 was at high risk for elopement. -R16's Elopement Evaluation dated 8/11/23 documented R16 was at high risk for elopement. -R17's Elopement Evaluation dated 8/11/23 documented R17 was at high risk for elopement. -R18's Elopement Evaluation dated 8/11/23 documented R18 was at high risk for elopement. -R19's Elopement Evaluation dated 8/11/23 documented R19 was at high risk for elopement. -R20's Elopement Evaluation dated 8/11/23 documented R20 was at high risk for elopement. -R21's Elopement Evaluation dated 8/11/23 documented R21 was at high risk for elopement. -R22's Elopement Evaluation dated 8/11/23 documented R22 was at high risk for elopement. -R23's Elopement Evaluation dated 8/11/23 documented R23 was at high risk for elopement. -R25's Elopement Evaluation dated 8/18/23 documented R25 was at high risk for elopement. The Facility's Elopement Policy revised 9/2021 documents, A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. Residents at risk to elope will be closely monitored. All facility staff are responsible for responding to a door/elevator alarm immediately. This response will include visual check of the immediate vicinity surrounding the door/elevator that tripped the alarm, including the stairwells and outside area. The Facility's Elopement Policy revised 8/2023 documents, Elopement is defined as a situation where a resident who cannot recognize normal dangers and hazards outside the facility leaves the facility without staff knowledge. All residents will be evaluated upon admission, quarterly, and as needed with newly identified wandering or elopement behavior. The Administrator, DON, Nursing Supervisor, Department Heads, Therapy Department, each Nursing Station, Reception and Beauty Shop, will keep the list. Facility exit doors are alarmed so that staff can secure the environment and intercede when a resident attempts to leave the facility. If no identifiable cause for the triggering alarm can be found, the following measures will be taken a. Administration will be notified. b. Account for all residents performing whole house head count. c. other steps may be taken as warranted. The state agency validated the removal of abatement by observations of exit doors to ensure they were in operating order, alarmed, and monitored, when indicated. Surveyors conducted a review of all Facility in-services. R1's medical records were reviewed for care plans and elopement assessments with no concerns. V57 (Social Service) was observed conducting enhanced supervision for R1. The Enhanced Supervision Form Monitoring Tool was reviewed for R1 and included times of observations. Surveyors reviewed Elopement Evaluations and Care Plans of residents who have been identified at risk for elopement and verified they had been updated. Employees (V23 CNA, V38 CNA, V39 LPN, V40 Housekeeper, V41 Housekeeper, V43 MDS Coordinator, V46 LPN, V44 Activity Aide, V51 CNA, V52 CNA, V55 Physical Therapy Assistant, V56 LPN, and V58 LPN) were interviewed to ensure they were aware of current policies and procedures and had been in-service. The Immediate Jeopardy that began on August 10, 2023 was removed on August 25, 2023 when the facility took the following actions to remove the immediacy. A. Identification of Residents Affected or Likely to be Affected: 1-R1 was assessed on 8/11/2023 by V2 (Director of Nursing). Resident was transferred to (local hospital) for evaluation, returning with no new orders. Resident remains in facility with implementation of enhanced supervision. Resident was placed on enhanced supervision 1:1 from 8/11/2023-8/15/2023. He was hospitalized due to unrelated medical needs 8/15-8/20/2023. Upon return 8/20/2023 resident was placed on enhanced supervision every 15 minutes. 2-Initiating reassessments for elopement risk on all residents by V46 (Infection Preventionist/Licensed Practical Nurse), V43 (Minimum Data Set/MDS Coordinator), V27 (Business Office Manager), V1 (Administrator), V47 (Admissions Director), and V48 (Activity Director) on 8/11/2023. All assessments were completed by 8/12/2023. All to be ongoing for new residents will be assessed for elopement risk and residents with newly identified exit seeking behaviors will be reassessed for elopement risk. 3-Care plans were updated with interventions to address identified risks by V1 (Administrator), V2 (Director of Nursing), V18 (Psychosocial Director) on 8/11/2023 and to be ongoing to include all new residents and as needed for newly identified exit seeking behaviors. B. Actions to Prevent Occurrence/Recurrence: 1-The [NAME] President of Regulatory Compliance and Clinical Operations, V14, reviewed and revised elopement policy and procedures on 8/11/2023. Revisions made to tailor building specific needs such code color updated to yellow, removal of electronic monitoring devices (the facility does not have electronic monitoring system), response required when cause of alarm is not immediately identified including an immediate whole house head count completed on 8/11/2023. 2-The interdisciplinary team including V1 (Administrator), V2 (Director of Nursing), V48 (Activity Director), V27 (Business Office Manager), V47 (Admissions Coordinator), V43 (Rehab/Restorative Nurse), and V46 (Infection Preventionist/LPN) educated on revised policy and procedures to be ongoing for new hires and agency staff. 3-The training will also include providing supervision/monitoring to prevent elopements, immediate head count upon recognition of missing resident and recognizing when a resident exits the facility or has newly identified exit seeking behaviors to be ongoing to include new hires and agency staff. 4-Residents exhibiting newly identified exit seeking behaviors will be placed on enhanced supervision 1:1 until interdisciplinary team and provider decide enhanced supervision can be reduced or discontinued. 5-All nursing staff will be educated on performing a whole house head count at the beginning of their shift with outgoing shift to ensure all residents are accounted for by V2 (Director of Nursing), V49 (Assistant Director of Nursing), V43 (Rehab/Restorative Nurse), V46 (IP Nurse/LPN), and V12 (Director of Staffing) on 8/25/2023. 6-Psychosocial and activities staff will be educated on the process of residents with west hall patio privileges. The west hall door will be unarmed for open patio hours from 10am-12pm and 2p-4pm daily to be completed on 8/25/2023 and ongoing for any newly hired staff by V18 (Psychosocial Director) and V48 (Activity Director). 7-Psychosocial and activities staff will be parked at the west hall patio exit door during open patio hours to provide adequate supervision of the residents initiated on 8/25/2023 and to be ongoing. 8-Emergency resident council meeting to be held on 8/25/2023 by V48 (Activity Director) to inform residents of new open patio hours the West-Hall door will be unlocked. 9-All agency staff and new hires will be educated on the above policies and processes prior to beginning their shift by V1 (Administrator), V2 (Director of Nursing), V12 (Director of Staffing) to be ongoing. 10-Safety checks of all potential exits daily to ensure they are secure. This will be done by the V37 (Maintenance Director) to be ongoing. 11-V37 (Maintenance Director) will remove access to the bypass keys for exit doors from all staff with exception of psychosocial staff. 12-V37 (Maintenance Director) will conduct elopement drills at least three (3) times a month, at different shifts to ensure compliance to be ongoing. 13-The elopement drill will be evaluated by the Administrator (V1) and any identified concern will be addressed. Additional staff training will be completed on an ongoing basis. 14-An Ad-Hoc QAPI meeting will be held weekly for four (4) weeks by the QAPI team to discuss this removal plan and identify if additional interventions are necessary to be ongoing. 15-Monitoring/auditing of ongoing education of staff for elopement policy and procedures, daily safety checks of all potential exits, and elopement drills and ongoing assessments of new residents and residents with newly identified issues regarding elopement by V1 (Administrator) will continue for a minimum of three months to be ongoing and will part of the QAPI process. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/25/2023

Based on observation, interview, and record review, the facility failed to prevent resident-to-resident physical and sexual abuse for 8 of 12 residents (R2, R8, R9, R12, R13, R14, R15 and R16) reviewed for abuse in the sample of 30. This failure resulted in an Immediate Jeopardy when the following resident-to-resident physical abuses occurred: R15 struck R12 in the head with an unknown object causing a lump to R12's head. On a later date, R15 stabbed R16 in the left chest with a paring knife causing R16 to require emergency medical services and R15 was arrested and remains police custody; and R13 hit R14 on the head with an object and on a later date, R13 stabbed R14 in the head with a pen causing R14 to require emergency medical services and R13 was sent out for psychiatric evaluation. The Immediate Jeopardy began on 5/5/23 when R15 physically abused R12 by striking him in the head with an object causing a lump. On 6/25/23, R15 and R16 got into a verbal and physical altercation and R15 stabbed R16 with a paring knife in R16's chest. V1 (Administrator), V2 (Director of Nursing), V5 (Regional Director of Operations), and V22 (Vice President of Regulatory Compliance and Clinical Operations) were notified of the Immediate Jeopardy on 7/7/23 at 1:50 PM. The surveyor confirmed by observation, interview, and record that the Immediate Jeopardy was removed on 7/12/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's policies and procedures and in-service training. Findings include: 1.R15's Face Sheet documents his diagnoses to include Asthma, Difficulty in Walking, Low Back Pain, Chronic Obstructive Pulmonary Disease (COPD), Non-Displaced Longitudinal Fracture of Left Patella, Alcohol Abuse, Anemia and Gastroesophageal Reflux Disease (GERD). R15's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented and independent with his Activities of Daily Living (ADLs). R15's Facility Incident Report documented R15 had a resident-to-resident altercation with R12 on 5/5/23 at 1:15 PM. The Facility's Incident Report, dated 5/5/23, documented Two male residents involved in an altercation. Immediately separated and assessed. Full investigation to follow. During the course of the investigation, the following facts were determined: (R12) was noted ambulating in the day area with a lump noted to his forehead. When (R12) was asked about what happened, he stated another male resident, (R15), had hit him in the head with something hard. (R12) was assessed and was noted with no other injuries or impairments. (R15) stated that (R12) had been coming into his room and threatening to take his phone and other items out of his room. (R15) admitted he struck another resident but would not admit to the item that was used during the altercation. Room searches were performed on both men's' rooms and all items of concern were removed. (R15) was placed in a group for anger management and for 15-minute checks. The two men have had no further incidents or altercations since the date of this altercation, and both have maintained their prior level of functioning. There was no documentation of what items of concern were removed from R12's and R15's rooms. R15's Care Plan, date initiated 5/30/22, document Abuse: Resident is at risk for abuse and neglect related to Chronic Obstructive Pulmonary Disease, Unspecified, and Alcohol Abuse. Resident is an Identified Offender. He has a history of peer-to-peer altercations. 6/25/23: resident to resident altercation. R15's peer to peer altercation that occurred on 5/5/23 with R12 was not documented on R15's Care Plan. There were no updated interventions after R15's resident to resident altercation with R12 on 5/5/23 until 5/30/23. These interventions include Assess resident for abuse and neglect upon admission and quarterly. Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (for example, social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings. Assure the resident that staff members are available to help, and department heads maintain an open door policy. Continue to monitor medication, ADLs, status, and behaviors. Establish a counseling schedule with resident. Encourage the resident to verbalize/share thoughts, anxieties, fears, concerns, and general feelings. Identify areas that put resident at risk. Immediately report any episodes of unknown injury, abuse, or changes in resident's behaviors to Administrator for immediate intervention and review. R15's Care Plan Focus, dated 3/30/22, documents The resident has a history of criminal behavior. The resident has demonstrated stability during the admission screening process and does not appear to present an unusual risk at this time. The Illinois Department of Public Health performed a Criminal History Analysis and made a determination regarding his level of risk. He was deemed a moderate risk. According to the resident's history he has been charged with unlawful possession of a weapon by a felon, Theft/Control/Firearm, Car Theft, and Aggravated Assault. The resident has a diagnosis of Alcohol Abuse, Uncomplicated. Interventions for this care plan include Evaluate the resident's ability to control impulses, document accordingly. Teach impulse control strategies. Follow facility protocol addressing substance abuse. If substance abuse is suspected utilize appropriate blood/urine testing, limit setting, counseling, and consequences. Review the IDPH Criminal History Analysis ([NAME]). Implement suggestions, if reasonable and appropriate. Moderate risk interventions include appropriate supervision and observation, regular monitoring, attention to behavior changes, visual monitoring if warranted and periodic reassessment. The facility's document, Facility-Reported Incident Form Initial Report dated 6/25/23 documents, On 6/25/23 at 8:25 PM Staff reported that they responded to loud voices, upon responding they observed (R15) and (R16) in verbal exchange. (R15) then was observed with small paring knife in his hand making contact with (R16's) left side rib area. The incident occurred in the doorway of Room (room number listed). (R16) sustained a small puncture wound to lower left rib area. Physician notified; new orders received to send to ER (emergency room ). Type of injury: puncture wound. The facility's Follow-up Investigation Report, dated 6/30/23, documents, under Conclusion, Staff reported that (R15) had just returned from LOA (Leave of Absence) with family, he was requesting snacks from staff at which time (R16) made a statement towards him resulting in (R16) placing hands on (R15) and giving a light push, staff saw something in (R15's) hand while swinging arm towards (R16) making contact. Residents were immediately separated, staff remained with (R15) until police, EMS (Emergency Medical Services) arrived with (R15) escorted from facility by police. Licensed nurse provided pressure to left lower rib area with pressure applied until EMS arrived. (R16) transferred to ER (emergency room ) for evaluation with no significant injury and/or treatment required, all diagnostic testing negative. (R15) medical record review reveals he has a history of Alcohol Abuse, history of homelessness, strained family relationships and BUE (Bilateral Upper Extremity) ROM (Range of Motion) loss related to weakness. (R16's) medical record review: he has poor social skills, limited coping skills which at times leads to conflict with others. History of Alcohol Abuse, inappropriate attention seeking behaviors along with maladaptive behaviors. He has a history of using loud tone when expressing frustration. (R16) has maintained his usual routine with no signs of mental anguish noted and no psychosocial distress noted. He continues to be visualized throughout facility interacting with peers, attending activities of his choice. When asked, he states, I'm fine. Police investigation ongoing, once investigation completed, addendum will be sent. R16's Hospital Records dated 6/25/23 at 9:00 PM document, Description of Mechanism: Stabbing to left chest. Review of systems: Respiratory: cough, hemoptysis, sputum, dyspnea on exertion, dyspnea at rest, wheezing. Cardiovascular: chest pain from stab; Gastrointestinal: abdominal pain left upper quadrant. Chest x-ray: Impression: Sequelae of penetrating injury in the lateral chest wall without extension into the thoracic and peritoneal cavity. Injuries: puncture wound to left chest. Plan: wound washed out and dressed. Follow up with trauma clinic as needed. R16's Face Sheet documents his diagnoses to include Major Depressive Disorder, Cutaneous Abscess of Right Hand, Osteoarthritis, Hypertension and Alcohol Abuse. R16's MDS dated [DATE] documents R16 is alert and oriented and independent with his ADLs. R16's Care Plan documents Abuse: (R16) is at risk of abuse and neglect related to history of assault leading to rib fractures and other injury prior to admission. (R16) is noted to have a history of peer-to-peer altercations. 4/4/23: peer to peer incident; 6/25/23: resident to resident altercation. On 6/29/23 at 3:15 PM R16 was lying on his bed in his room with a clean, dry, intact white gauze bandage on his left side of torso. He stated he and (R15) usually got along good and would play dominos out in the dining room with a couple of other residents. R16 stated sometimes they would have words during a game but all in fun, nothing serious. R16 stated the agency nurse was passing medications and had called his name so he went to the door to get his meds and R15 kept walking past his door, saying things about R16 arguing with the new guy and R15 was being disrespectful. R16 stated R15 came between the nurse and her cart, and the nurse yelled, He's got a knife! and then R15 stabbed him. R16 stated he went in his room and slammed the door closed. R16 stated R15 walked up the hall to the front after he stabbed him. R16 stated, He (R15) was drunk. He just came back from being out with his family. On 7/5/23 at 3:09 PM, V16 (Licensed Practical Nurse/LPN) stated, I was standing right by the double doors at the nurse's station, and I heard arguing between (R15) and (R16). Their voices were getting louder so I started walking towards them to see what was going on and try to diffuse the situation, and when I was within about two feet from them, (R15) pulled out the knife and jabbed him (R16) with it. (R16) put his hand over it and went into his room and closed the door. (R15) had the knife at his side, not trying to hide it, and started walking fast up the hall. I yelled out, He's got a knife. Call 911. He just stabbed him (R16). The other staff said, No, he's armed. We don't get involved with that. I went in to check on (R16) and he was lying on his bed with his hand over his left side, with his shirt over it, lying in the fetal position. He (R16) said, I'm fine. but he let me look at the wound. It was about 1-2 centimeters with a little bit of flesh coming out of it. It wasn't bleeding a lot by then, but there was blood on his shirt and on the floor. I put some gauze over it and held pressure on the wound until EMS arrived. I work for agency, and this was the first and last time I worked at this facility. From what some of the other staff told me, and I cannot recall their names, (R15) went out with his family and had just got back and he was drunk. Another staff told me (R15) made the statement to her, It wasn't my knife. There's no blood on it and my prints aren't on it. V16 stated the other staff told her this was unusual behavior for (R15) and that he was usually a very nice gentleman. The staff had called the police and the Administrator, and the Director of Nursing (DON) came in and did the report. 2. R13's Face Sheet documents his diagnoses to include: COPD, Diabetes Mellitus with Hyperglycemia, CVA (stroke) with Hemiparesis and Hemiplegia Affecting the Right Non-Dominant Side; Auditory Hallucinations and Schizoaffective Disorder. R13's MDS dated [DATE] documents he is alert and oriented. R13's Care Plan dated 3/13/17 documents: Abuse: At risk for abuse and neglect related to Schizoaffective Disorder, Depression, Auditory Hallucinations, history of behaviors and requires some assistance with care. He is noted to have a history of peer-to-peer altercations. 3/12/23 peer to peer altercation. 6/13/23 Peer to peer altercation. The Facility's Initial Report, dated 7/10/23 at 1:45 AM documents, under Allegation Details, Staff reported responding to loud voices, upon approaching, (R14) stated (R13) made physical contact with him. The report further documents R14 was transferred to ER for evaluation and there is no serious bodily injury or sign of mental anguish identified. Injuries described in report are as follows: Scratches, small open area. The report documents there is no known witness at this time. R13's Progress Note, dated 7/10/23, at 4:54 AM documents, Resident initiated resident to resident altercation. Residents immediately separated; local police notified. Physician notified with new orders received to send to ER for psychiatric evaluation related to physically aggressive behaviors towards peer. Behavior was not easily redirected. Staff provided 1:1 to ensure safety of patient and peers until EMS/police arrived. MD/Guardian notified. Resident going to local regional hospital. Emergency transfer discharge provided at local ER, copy provided and explained to supervisor in ER department, copy provided and explained to resident. Copy provided to resident. IDPH and ombudsman notified via email. Call placed to resident daughter/guardian with no answer, left message to return call as soon as she received message, will attempt until contact made. On 7/10/23 at 7:01 PM, V20 (emergency room /ER Nurse) stated R14 was brought to the emergency room by ambulance on 7/10/23 around 3:00 AM. V20 stated R14 told her another resident named (R13) had come into his room and punched him in the face several times and then stabbed him in the head with a pen. V20 stated R14 never really answered her as to whether R13 was his roommate or if he lived on the same hall as R14. V20 stated R14 had what appeared to be fresh injuries to his face and head including a black eye, a laceration to his left cheek over his cheekbone area and three puncture wounds to his scalp, two in front and one in the back of his head, and the puncture wounds had hematomas around them. V20 stated R14 had told this same resident (R13) has assaulted him multiple times in the past. V20 stated R14 received facial x-rays and a head Computed Tomography Scan (CT scan) to rule out facial fractures and she stated they were negative for fractures and showed the puncture wounds were superficial and did not penetrate his skull. V20 stated R14 had other injuries that appeared older, including bruises to the right side of his face, including eyebrow and cheek, upper left arm bruising, and scratches on his mid-lower back that looked like fingernails. V20 stated she attempted to call the facility to verify R14's report that he was assaulted by R13 before this. V20 stated she called the facility at least a dozen times and someone would pick up the phone and hang it back up without answering. V20 stated at about 6:00 AM a nurse (V14) answered the phone, but refused to answer any questions, and informed V20 she would have to talk to the Administrator. V20 stated (V1 Administrator) returned her call within a few minutes and she (V1) did confirm that this was not the first time R13 had assaulted R14. V20 stated V1 informed her that she had been at another hospital with R13 on that night and stated V1 informed her R13 would not be returning to the facility. V20 stated V1 informed her R13 had been on special monitoring, and she did not know why he assaulted R14 or how this protection plan failed. V20 stated R14 did not want to return to the facility, but his brother was his Power of Attorney, and they were unable to reach him by phone. V20 stated R14 was having visual hallucinations while in the emergency room , responding to his wife in the room when there was no one else in the room. V20 stated R14 was discharged back to the facility that same morning. On 7/12/23 at 9:16 PM, during phone interview, V14 (Licensed Practical Nurse/LPN) stated she was not R14's nurse on 7/10/23 but she was the first staff to respond when she heard R14 yelling out. She stated she could not understand what R14 was saying, but she ran to his room and when she entered, R14 was sitting in his wheelchair with R13 standing over him, and R13 was stabbing R14 in his head with a pen. V14 stated she yelled at R13 to stop, and he did not immediately stop but finally did without her having to lay hands on him. V14 stated she did not know how many times R13 stabbed R14 with the pen, but stated he was going at it. R14 stated other staff responded and entered R14's room and redirected R13 out of the room and he was taken to his room and kept on 1 on 1 until the ambulance arrived. V14 stated R13 did not say why he was assaulting R14, but when the EMTs (Emergency Medical Technicians), one of them reported to her that R13 stated he had assaulted R14 because R14 had thrown urine on him a month ago. V14 stated she assessed R14, and he had two puncture wounds on his head, one in front and one in back, and he also had several scratches on his face. V14 stated both R13 and R14 were sent to the hospital. She stated the incident happened around 1:40 AM. She stated there were no more behaviors between R13 and R14 before they left the facility. V14 stated she had not seen R13 have any aggression towards R14 prior to R13 attacking R14. She stated this type of behavior was over the top for R13. According to facility documents, there were two incidents when R13 physically assaulted R14 prior to the incident on 7/10/23 and are as follows: The Facility's Follow-up Investigation Report, dated 6/14/23, documents, under Conclusion: On June 13, 2023, staff responded to loud voices, upon entering room (R13) stated, He thought the back scratcher was his and when I told him it wasn't, he picked up his urinal and threw his urine at me so when he did, I reached over and made contact with his head. I didn't mean it, I just reacted to the urine being thrown this way. (R14) stated, Yeah, I threw it at him, then he got me on top of the head. Skin assessment completed on both residents with (R14) observed to have small scratch on top of head. (R14) denied pain. (R13) was immediately relocated to another room with enhanced monitoring provided. Based on complete, comprehensive investigation, facility cannot substantiate intention abuse and facility believes situation occurred, however based on interviews with both residents the situation was without any intent as (R13) reacted to situation, both residents agree that situation was a disagreement over who the back scratcher belonged to. The Facility's Facility Reported Incident Form, Initial Report dated 6/29/23 at 8:30 AM documents, Staff reported (R13) approached (R14) making physical contact. Staff witnesses stated that (R13) was sitting in the dining room waiting for meal tray, he moved away from table and approached (R14) making contact with face. Residents immediately separated; physician notified with new orders to send (R13) to ER (emergency room ) for psych evaluation. The facility's Final Report for this incident, dated 7/7/23 documents, On 6/29/23 R13 was sitting in the dining room at table during breakfast meal; R13 removed self from table and approached R14 making contact. R13 was placed on enhanced monitoring. On 7/11/23 at 9:10 AM R14 was sitting in his wheelchair in his room. R14 had small purplish-black bruises under both eyes. R14 was wearing a hat with headphones over it and declined to let his head/scalp be observed, stating, No, you don't need to look at that. I'm fine. I'm not having any pain. I don't know what happened. He's (R13) just some crazy guy who came in and beat me up in the middle of the night. R14 stated, I feel fine. I feel safe. You can go now. R14's Face Sheet documents his diagnoses to include Type 2 Diabetes Mellitus with Diabetic Retinopathy and Macular Edema; Acute Kidney Failure; Bipolar Disorder; HTN; History of Falls; and Schizophrenia. R14's MDS dated [DATE] documents he is alert and oriented. R14's Care Plan dated 4/20/22 documents: Abuse: (R14) is at risk for abuse and neglect related to impaired cognition secondary to psychiatric diagnosis. He is noted to have a court appointed guardian at this time, his brother. 6/13/23 peer to peer altercation. 3. R12's Face Sheet documents his diagnoses to include Paranoid Schizophrenia, Drug Induced Subacute Dyskinesia, Other Sexual Dysfunction Not Due to Substance or Known Physiological Condition, Anxiety Disorder, Cognitive Communication Deficit and Borderline Intellectual Functioning. R12's MDS dated [DATE] documents he is alert and oriented and requires supervision with his ADLs. R12's Care Plan dated 3/31/22 documents Abuse: At risk for abuse and neglect related to his diagnosis of Depression, Schizophrenia, and Borderline Intellectual Functioning. He has been noted to ask for items of others in a way that is not appropriate such as give me some of that. Has a history of peer-to-peer altercations. 6/22/23 Resident reported to stop resident who was independently propelling self down hall and ask her to suck his d***, while masturbating. R12's peer to peer altercation with R15 was not documented on his care plan. The Facility's Follow-up Investigation Report, dated 6/29/23, documents, under Conclusion documents On June 22, 2023, (R2) reported as she was independently propelling her electric wheelchair down the hall upon approaching (R12's) room he asked her to stop and once she did, he asked her to suck his d*** while masturbating. (R2) immediately removed herself from the situation and reported to staff. Local police were immediately notified. Physician notified with new orders to send (R12) to ER for evaluation. Complete comprehensive investigation has been completed with facility unable to substantiate abuse. Medical record review and interviews reveal (R12) has no previous behaviors of this nature. (R2) has shown no signs of mental anguish, psychosocial distress and has maintained her usual routine with her being observed in common areas interacting with peers, attending activities of her choice. (R12) remains hospitalized . R2's MDS dated [DATE] documents she is alert and oriented. R2's Care Plan dated 5/28/23 documents Abuse: (R2) is at risk for abuse and neglect related to her diagnoses of CHF (Congestive Heart Failure), history of multiple Myocardial Infarctions (MI) and multiple CVAs, Hypertension, COPD, decreased ability to complete all her care tasks on her own and requires assistance. Resident shared during assessment that she has been a victim of domestic violence, addiction in the past and diagnosis of depression. History of altercations with peers. 3/27/23 peer to peer altercation. 5/28/23 peer to peer occurrence. On 6/27/23 at 10:45 AM R2 stated R12 called her over to his room and asked her to suck his p**** while he was masturbating. R2 stated one other time he had called her over to his doorway while he was masturbating, and she was disgusted, and she turned around and left immediately. R2 stated she got angry the second time and immediately reported the incident to the Director of Nursing, who called the Administrator and R12 was sent out of the facility right away. R2 stated if they hadn't sent (R12) out of the facility, she would not have felt safe taking a shower, and would have been afraid he might come into her room at night. R2 stated she never went into R12's room and he never came into her room. R12's Progress Notes dated 6/22/23 at 11:01 PM documents, Resident 1 (R12) verbally sexually assaulted another resident. Resident 2 that was assaulted stated, I was coming down the hallway and when I got to his door, he started patting his bare private area and ask me to suck his d***. Resident 2 (R2) was extremely uncomfortable and stated that she was afraid to lay down because she was afraid that he would assault her. Resident 1 (R12) was escorted to room; staff did 1 on 1 with resident until EMS present. DON notified, EMS called and said they would be a few hours until pick up report called into (hospital) for psych evaluation, will continue to monitor. R12's Progress Notes for April, May and June 2023 were reviewed and documented four other times R12 was noted to be sexually inappropriate towards staff prior to resident-to-resident sexual abuse with R2 on 6/22/23. 4. The Facility's Follow-up Investigation Report, dated 6/23/23 documents, under, Conclusion documented On June 17, 2023 (R9) was standing next to (R8's) chair and was noted to have his hand resting under her shirt. Residents were immediately separated with (R9) being place on enhanced monitoring. R8's Face Sheet documents her diagnoses to include Adult Failure to Thrive, Weakness, Need for Assistance with Personal Care, Schizophrenia, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, and Alzheimer's Disease with Late Onset. R8's MDS dated [DATE] documents she is severely cognitively impaired. R8's Care Plan dated 10/16/19 documents, (R8) is at risk for abuse and neglect related to her impaired cognition related to diagnosis of psychosis and past TBI (traumatic brain injury) with cognitive and safety awareness deficits. 6/12/20 Involved in an altercation with a peer. R9' Face Sheet documents his diagnoses to include Alzheimer's Disease with Early Onset; Weakness; Schizoaffective Disorder, Bipolar Type; Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; Major Depressive Disorder; and Alcohol Dependence with Alcohol Induced Persisting Dementia. R9's MDS dated [DATE] documents he is severely impaired cognitively. R9's Care Plan dated 12/12/14 documents, (R9) is at risk for abuse and neglect related to Psychosis, Cerebral vascular Accident (CVA), Severe neuro-cognitive disorder, Affective Mood Disorder, Depression, Dementia, and GERD (Gastroesophageal Reflux Disease. He expresses resistance with care needs such as changing clothing and personal hygiene. Has a history of getting physical with others over cigarettes. Has a history of peer-to-peer altercations. 6/17/23 resident observed with his hand resting under another resident's shirt. On 7/14/23, at 10:02 AM, V1, Administrator, stated With (R9) I did not feel the intent was there as he just had his hand resting under her shirt and they had a relationship before and were both confused so I did not substantiate it. The facility's policy, Abuse Policy and Prevention Program 2022 dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; and implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making necessary changes to prevent future occurrences. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update, as necessary. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of residents. The Immediate Jeopardy that began on 5/5/23 was removed on 7/12/23 when the facility took the following actions to remove the immediacy: A. Identification of Residents Affected or Likely to be Affected: 1.R15 no longer resides in the facility, discharged into police custody on 6/25/2023. 2.R12 no longer resides in the facility, discharged facility on 6/23/2023. 3.R16 was assessed for trauma related events on 6/26/2023 by V5 (Region Director of Operations). Care planned interventions relating to being a victim of abuse were entered on 6/25/2023 by V5. 4.R13 no longer resides in the facility, discharged on [DATE]. 5.R14 refused assessment for trauma related events, ad hoc care plan with R14 and POA held on 7/10/2023, R14 feels safe in the facility, care plan reviewed and updated by V22 (Vice President of Regulatory Compliance and Clinical Operations), V5, and V1 on 7/10/2023. 6.All residents will be assessed for aggressive behaviors by V1, V17 (Social Service Director), to be completed on 7/7/2023, 7/10/2023 and ongoing as needed to include new residents and newly identified behaviors. 7.Through the RAP rounds (customer service interviews) with all residents, no new allegations of abuse have been identified. Rap rounds to be completed Monday through Friday by V37 (Restorative Nurse), V38 (Infection Control Nurse), V36 (Medical Records), V35 (Admission Coordinator), V55 (Business Office Manager), and V17 to be initiated on 7/12/23 and ongoing. 8.Potential admissions/referrals will be reviewed for appropriateness of admission by V35 (Admissions Coordinator) or V2 (Director of Nursing). Patients with a documented history of aggressive behaviors and any background check that identifies any potential risk factors for aggressive behaviors will not be accepted for admission completed 7/12/2023 and ongoing. 9.Care plans to be reviewed and revised as needed with implemented interventions to address resident specific behavioral needs and newly identified behaviors by V17, V36 and V37 to be ongoing. Any investigation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property occurred shall be reviewed by the facility Quality Management committee for possible changes in facility practices to ensure that similar events do not occur again. At this time, the resident specific care planned interventions will be verified in place. The investigation shall be reviewed at the next quarterly Quality Management committee meeting, or sooner, if possible, completed on 7/10/23 and ongoing [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure medication was given to a resident when on Leave of Absence (LOA) from the facility for 1 f 6 residents (R2) reviewed for significant medication error in the sample of 6. This failure resulted in R2 not receiving medications for Chronic Obstructive Pulmonary Disease (COPD) and being hospitalized with admitting diagnoses of COPD exacerbation. R2 remains in the hospital. Findings include: R2's April 2023 Physician's Order Sheet (POS) documents R2 has diagnoses of alcohol abuse with alcohol induced psychotic disorder, speech and language deficits, anxiety, asthma, bipolar disorder, chronic obstructive pulmonary disease (COPD), needs for assistance with personal care, dependence on wheelchair, partial amputation at level between left hip and knee and right hip and knee, hearing loss, and dependence on wheelchair. R2's April 2023 POS documents he was taking the following medications: albuterol sulfate HFA (Hydrofluoroalkane) 109 micrograms (mcgs)/actuation (act) aerosol solution give 1 puff every 6 hours as needed for dyspnea reacted to chronic obstructive pulmonary disease; Amiodarone HCL Tablet 200 mg (milligrams) give 1 tablet by mouth two times a day for abnormal heart rhythm. Depakote ER oral tablet extended release 24 hour 500 mg, 1 tablet my mouth one time a day related to alcohol use; Duloxetine HCL capsule 60 mg, 1 capsule one time a day related to bipolar disorder; Fluticasone Furoate inhalation 200 mcg/act 1 inhalation orally one time a day related to chronic obstructive pulmonary disease; Gabapentin 400 mg, 1 tablet once a day, Hydrocodone-Acetaminophen 5-325 mg , 1 capsule two times a day; Incruse ellipta 62.5 MCG/ACT 1 puff one time a day related to pulmonary disease; and Xarelto 20 mg by mouth one time day related to chronic atrial fibrillation. R2's Minimum Data Set (MDS) dated [DATE] document he is cognitively intact for activities of daily living and decision making. R2's MDs documents R2 receives 7 antidepressants, 7 anticoagulants and 7 diuretics for medication. R2's Care Plan with a revision date of 3/3/2023 documents Anticoagulant: (R2) is at risk for bleeding/bruising related to anticoagulation medication use due to his diagnosis of A-Fibrillation. R2's Care Plan documents (R2) has potential for altered cardiac function related to HTN (hypertension), CHF (Congestive Heart Failure). R2's Care Plan documents (R2) has potential for difficulty in breathing related to respiratory failure (COPD). R2's Social Service Notes dated 4/26/2023 at 12:51 PM, Late Entry, SSD (Social Service Director) was informed that resident went LOA (Leave of Absence) with son (V5) to return tomorrow 4/27/2023. R2's LOA form document a time of 4 PM. There is no documentation in R2's medical record that medications were sent with R2 or V5 when R2 left the facility. On 5/2/2023 at 3:12 PM, V5 (R2's Son) stated, We left the building together and I took off in my truck and my dad (R2) took off down the street in his wheelchair. I did not realize my dad was ill at the time. He said he wanted to leave so I signed him out. I am not sure how long it had been since we had last seen each other. He wanted to leave so I let him leave. I am not sure if the paper was a LOA (Leave of Absence) or AMA (Against Medical Advice). I do not remember how long (R2) was supposed to be gone. I am not sure about that. I do not remember (R2) being sent with any medications. I know they he had him take something before we left. On 5/2/2023 at 10:37 AM, V4 (R2's Daughter/Power of Attorney/POA) stated, My brother (V5) had just been recently released from prison. He had been incarcerated for a few years. Nobody from the facility called me and asked me if it was okay for my brother (V5) to sign my dad out because I would have told them absolutely not. I am the POA of my father and imagine my surprise when I get a call from one of my friends telling me they saw my father at a gas station in a completely different town than the nursing home. Nobody from the facility let me know that my father was gone or that my brother had signed him out. I do not think my brother intentionally meant my father any harm, but he just does not understand how my dad's health has declined so much. My dad does not have any legs and in the past, he was able to get around in an electric wheelchair, but he has been so sick and had such a decline that he is not the same person my brother remembers. It is dangerous for my dad to be left alone without any help. (R2) is currently at the hospital because I called around trying to find (R2). I called the bus station, and they were able to find him. (R2) was attempting to charge his wheelchair. When I saw my dad, he said he was having problems breathing and had been having issues for a few weeks now. He was just recently admitted to the hospital (January 2023) for breathing issues and has a history of needing assistance. I took him to the hospital, and he was admitted with pneumonia. (R2) is still currently at the hospital. On 5/3/2023 at 10:55 AM, R2 was in a bed at a local hospital. R2 stated, The facility gave me a pill that I took before I left but they did not send me out with any medicine or my wheelchair charger. R2 stated I got to the hospital all by myself. I was having problems breathing which I was having while I was at (Facility). R2's Social Service Notes dated 4/27/2023 at 6:22 PM, SSD received a call from resident's son today. Son expressed that resident wanted to LOA and that he signed him out. SSD explained to son that LOA paperwork was signed with a return date of today and not AMA (Against Medical Advice) paperwork. Son stated that when he and resident left the facility son got in his truck and resident went going down street in his power chair charge and son stated resident did not have his charger for his power chair. Son informed SSD that he would go looking for resident after he got off of work. R2's Hospital Records document R2 arrived at the emergency room at 4:56 PM on 4/27/23. The Record documents R2 was admitted from the emergency room to the Hospital on 4/27/2023 with a final diagnosis of COPD exacerbation. The Records document patient information was obtained primarily from patient, medical records. (R2) is a [AGE] year-old male with a history as below, who presents with complaints of SOB (shortness of breath) and abdominal distension. Patient states that he had these symptoms for the past two weeks. Patient states that he was staying at (Facility), however, his son signed him out. Patient states that he plans to live in Florida with his mother. Patient endorses a productive cough. Patient denies fever or chills. Patient states that his son signed him out and he was left on the parking lot. R2' Nurse's Notes dated 4/28/2023 at 6:34 AM, Hospital called this writer nurse (V6 Nurse) requested face sheet and medication list. This writer faxed information over to hospital (Nearby hospital). Hospital made this writer known that they did not know he arrived to the hospital but his son was aware of him being at the hospital. Nursing asked hospital what he was admitted for , and hospital made this writer aware that he came in for COPD exacerbation. Nursing will forward all information to oncoming nursing for further follow up. On 5/3/2023 at 2:03 PM, the staffing schedules of nurse's working for 4/26/2023 was requested. On 5/3/2023 at 2:32 PM, V1 (Acting Administrator) stated, (V19) was (R2's) nurse on 4/26/2023 and she would have been the one to give him his medication before he left LOA. On 5/3/2023 at 3:32 PM, V19 (Licensed Practical Nurse/LPN) stated, If a staff member came and told me my patient was LOA (Leave of Absence) I would check the Medication Administration Record with the Physician Order Sheet (POS) and make sure they have their medication for the duration of their leave, and document everything in the resident's chart. I would make sure I documented the medication was sent with the resident in the chart. I do know if I gave (R2) his medication. I am agency and not familiar with all of the residents. Nothing is ringing a bell. I will need to speak with (V1). On 5/3/2223 at 3:34 PM, V20 (LPN) stated, I am agency nurse. If someone told me a resident was leaving LOA, I would check the order, get it ready and document that I sent it out in the Nurse's Notes. I do not know who (R2) is so I could not say but I do not remember giving anyone with a double amputee medicine for LOA. On 5/3/3023 at 3:44 PM, V21 (LPN) stated I did not give (R2) any medications I was not his nurse that day. I am not sure who that was. If a staff member told me a resident was LOA, I would check the POS and determine how many days that would be gone and what medications they are going to need. I would get the medications ready, give them to the resident and document in the Nurse's Notes. On 5/3/2023 at 3:52 PM, V27 (LPN) stated, I was not (R2's) nurse so I would not have given out any medications to him. When we give out medications for LOA, we are supposed to check the POS and give out the right amount of medicine for the right amount of days. Document that the medication was given to the resident in the Nurse's Notes and document in the Medication Administration Record that the resident is in leave. On 5/5/2023 at 12:03 PM, V22 (Medical Director) stated, As far as a resident going out LOA, it would depend on the medicine and if the resident would even take the medicine. If a resident does not want to take a medicine, we cannot force them to take the medicine. As far as (R2) it is hard to say. (R2) was not competent and he does what he wants to do. I cannot say by not taking the medication it increased his risk or put him in the hospital. (R2) is not competent and is confused. (R2) is smart enough to get away but not competent enough to be able to take care of himself. The Medication Administration Policy, with a revision date of 3/2022 documents, All medications are administered appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis.

Based on interview and record review the facility failed to implement safety measures to prevent resident to resident abuse for 3 of 5 residents ( R21, R39, R110) reviewed for abuse in the sample of 47. This failure resulted in R21's repeated acts of abuse. This resulted in R110 sustaining a facial laceration, facial injury, and corneal abrasion. Findings include: 1. R21's Face Sheet, undated, documents R21 has a diagnosis of Paranoid Schizophrenia, Major Depressive Disorder (Recurrent) and Alcohol Abuse. R21's Minimum Data Set (MDS), dated [DATE], documents R21 has severe cognitive impairment. R21's Care Plan, dated 4/11/22, documents R21 is at risk for abuse/neglect, is verbally aggressive and difficult to redirect at times and has a history of peer-to-peer altercations. R21 has a history of aggressive behavior and has a past history of verbal and physical altercations and becomes easily irritated with peers. R21 has a history of criminal behavior and has been charged with aggravated battery, resisting police, criminal damage to property and assault with a deadly weapon. A state official with the Illinois Department of Public Health (IDPH) and the State Police performed a Criminal History Analysis and determined the resident to be moderate risk. R21 has the following interventions listed: 15-minute check program for increased monitoring for behavior reduction. R21's 15-minute resident monitoring sheets were reviewed with no documentation of 15-minute checks being performed 4/21/22 through 3/8/23. R21's Criminal History Analysis Security Recommendation Report, dated 11/7/14, documents R21 is at moderate risk and requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. The following specific considerations were important in arriving at the above recommendations: R21 is a [AGE] year-old male who was admitted to the nursing facility on 9/30/14. His criminal history consisted of convictions for aggravated battery, resisting a peace officer and criminal damage to property. The most recent occurred in June 2014, and he is currently on 2 years special probation. The resident interview noted he said he gets in random fights here and there, numerous arrests for battery, aggravated assault with a deadly weapon, served one year in department of corrections for assault. His diagnosis is a major psychiatric disorder, and he has a history of alcohol/drug dependence. Nursing facility staff reported satisfactory behavior since his admission except for once incident, swung his fist at another resident. Progress notes cited incidents of verbal aggression and one incident of physical aggression when he punched another resident in the arm. His compliance with psychiatric treatment and abstinence from alcohol/dry use should be closely monitored. In view of his criminal history, past and recent incidents of verbal/physical aggression and current legal circumstances, a moderate risk supervision status is recommended. In the event his psychiatric condition escalates, and additional incidents occur, a high-risk supervision status is recommended. High risk - The resident requires a single room in close proximity to the nursing station to permit ongoing visual monitoring. The level of observation should be sufficient for early detection of behavioral changes. Regular assessment is necessary to determine whether closer monitoring or more frequent individual contact is indicated. The Facility Incident Report, dated 12/11/22, documents R110 was observed striking a female staff member. R21 states that he doesn't like to see a man put their hands on a woman and he felt the need to defend the staff. R21 states he struck R110 in the face one time. R110 was noted with a laceration above his right eye and was sent to the emergency room for evaluation and treatment. Based on the facility's investigation, it is the determination that the incident did occur. R110's Hospital After Visit Summary (AVS), dated 12/11/22, documents R110 was seen in the hospital for facial injury, assault, facial laceration, and abrasion of the left cornea. The Facility Incident Report, dated 5/24/22, documents R39 became upset with a staff member for refusing to give him another resident's cigarettes. R21 states that R39 lunged at the staff member as if he was going to strike her. R21 stated that he believed R39 was going to hurt the staff member and he needed to defend her as he doesn't feel a man should hit a woman. R21 states that when he stepped between himself and the female staff member that R39 struck him in the arm. Staff state that the two residents (R21, R39) lost their balance and went to the ground. R21 states he struck R39 in the face while they were on the ground. R39 was noted to have some superficial scrapes and bruising to his face. Based on the facility's investigation, it is the determination of the facility that the incident did in fact occur. The Facility Incident Report, dated 4/6/22, document R21, R33, R35 and a past resident were gathered in the day area waiting to exit the door to smoke. While waiting in the line to go outside to smoke, the past resident bumped into R33's leg. R33 asked the past resident to move his walker from next to her leg. R33 stated that the past resident didn't move the walker, so she assumed that he did not hear her speak so she shouted at him to move. R33 stated that R21 reacted because he believed that the past resident had hurt her. R21 admits to striking the past resident and being pushed back. R21 states when he was pushed back by the past resident, he fell into the back of the wheelchair of R35, which tipped R35 onto the ground on his bottom. Based upon the investigation, it is the determination of the facility that this incident did in fact occur. R21's care plan fails to document that any new interventions were put into place after the altercations on 4/6/22, 5/24/22 or 12/11/22. The care plan also fails to document that R21 was placed in a private room, close to the nurse's station as recommended by the Criminal History Analysis Security Recommendation Report. On 3/21/23 at 2:44 PM, R21 was observed in his room, quiet, calm and was on one-on-one supervision with V13 (Certified Nurse Assistant/CNA). V13 stated she is unsure why R21 is on one-on-one supervision. R21 denied concerns with the other residents and it ain't nothin. On 3/23/23, R35 and R110 were unable to provide any details of the above incidents with R21. On 3/23/23 at 8:15 AM, V2 (Director of Nurses/DON), stated R21 is on one-on-one supervision due to an incident with another female resident. V2 stated it started in March 2023, she unsure of the exact date. V2 stated prior to this incident, R21 has not been on 15-minute checks or enhanced supervision that she is aware of. V2 stated enhanced supervision means 15-minute, 30-minute, hourly checks, more often than every 2 hours and it is determined by the interdisciplinary team if it is necessary. On 3/23/23 at 9:14 AM, V2 stated she has not been here throughout R21's admission but she is not aware of him being moved to a high-risk category related to his recent altercations. V2 stated she is not aware of him being in a private room or room close to the nurse's station since she has been at the facility. On 3/23/23 at 1:25 PM, V2 stated since she has been at the facility, they follow the recommendations of the Illinois State Police (ISP) for their identified offenders. V2 stated she was not here when R21 was admitted and was not aware of the recommendations from ISP. V2 stated they are aware now of the concerns with R21's altercations and R21 will stay on one-on-one supervision due to his resident-to-resident altercations. The Resident's Rights and Residents' Safety Enhanced Supervision Guidelines, policy, dated 7/8/20, documents these guidelines emphasize a proactive intervention promoting enhanced physical, psychosocial well-being and person-centered care while promoting resident/resident representative care participation. The facility recognizes that there may be occasions in which standard approaches of every 2-hour rounds may need to be increased to more frequent, enhanced observation. With every 15, 30, hourly checks the staff will check/observe the resident's status/whereabouts every 15 minutes, 30 minutes or hourly. The Abuse Policy and Prevention Program 2022, policy documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers ad behaviors that might lead to conflict. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendations Report into the identified offender's plan of care including the security measures listed.

Based on observation, interview and record review, the facility failed to ensure a resident's beds was positioned at a safe height to prevent falls for 1 of 4 residents (R73) reviewed for falls in the sample of 47. This failure resulted in R73 falling from her bed while it was in the high position and sustaining bilateral mandibular dislocation and a 2-centimeter laceration above her left eye that required tissue adhesive to close while at the emergency room for evaluation and treatment. Findings include: R73's Undated Face Sheet, documents she was admitted on [DATE]. R73's Fall Risk Evaluation dated 2/14/2023, documents a score of 25, a score of 10 or higher makes resident high risk for falls. R73's Quarterly Minimum Data Set (MDS), dated [DATE] documents R73 has severely impaired cognitive skills for daily decision making; requires extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene needed 2 persons physical assist. Walking did not occur during the evaluation period. R73 uses no mobility devices. R73 has had one fall since admission/entry or reentry with no injury. 10/16/20219 keep bed in lowest position and 12/19/2021 floor mats to be laid down after resident is in bed for the night with bed in lowest position. On 3/23/2023 at 8:50 AM, R73 was lying in bed with an injury to left upper eye. R73's bed was on the floor at that time. R97, R73's roommate, stated R73 fell out of bed about 10 minutes ago. R97 stated R73 fell out of bed, staff lowered her bed to the floor, it was in the high position when R73 fell out of bed. R97 stated staff in the room were upset that R73's bed wasn't in the low position. R97 stated R73 hit her head on the floor. There was a floor mat on the floor next to R73's bed. On 3/23/2023 at 9:25 AM, V24 (Certified Nursing Assistant/CNA), stated she came to work at 6:45 AM today and was assigned to R73. V24 stated she changed R73's clothes and provided incontinence care. V24 stated she was going to transfer R73 to her chair, but staff came in and told her to shower another resident, so she left the room and forgot to lower R73's bed to the floor. V24 stated staff told her R73 stated a few minutes ago that R73 fell on the floor from the bed. V24 stated she knew R73 was a fall risk, and her bed was supposed to be lowered to the floor when she is in bed. On 3/23/2023 at 9:32 AM, V27 (CNA) stated V25 (Medical Records) told her she needed help repositioning R73. V27 stated while V27 and V23 walked to R73's room, she noted the call light was on. V27 stated when V27 entered R73's room, she observed R73 was lying on the floor with her body on the floor mat and her head was off the mat, lying on the floor. V27 stated R97, R73's roommate, stated she pushed her call light because R73 just fell out of bed. V27 stated she knew R73 was a fall risk, and her bed was supposed to be lowered to the floor. V27 stated when she and V25 entered R73's room she observed R73's bed was in the high position. V27 stated after V4 (Licensed Practical Nurse/LPN), and V26 (LPN) entered R73's room and transferred R73 back to bed, she lowered the bed to the floor so R73 wouldn't get hurt anymore. V27 stated R73's bed should have never been left in the high position because she is a fall risk. V27 stated she observed blood on R73's forehead after the nurses transferred her to bed. On 3/23/2023 at 9:35 AM, V25 stated she walked by R73's room and noted her geriatric reclining chair was in the doorway. V25 stated she peeked into R73's room and noted R73's feet were hanging off the bed. V25 stated she went and got V27 (CNA) to assist her in repositioning R73. When V25 and V27 got to R73's hall, V25 noted R73's call light was on. V25 stated when she and V27 entered R73's room, R97 stated R73 just fell out of bed and R73 hit her head on the floor. V25 stated R73 was lying on the floor on her fall mat at that time. V25 stated she left R73's room and got V4 (LPN) to assess R73. V25 stated R73 is a fall risk, and her bed should have been in the low position, but it wasn't when she entered the room. V25 stated R73's bed was in the high position. V25 stated she didn't know who lowered R73's bed to the floor after she fell but that it was definitely in the high position when R73 fell out of bed. V25 stated she was upset because she is a CNA and knew R73's bed should have been in the low to the floor position and due to lack of common sense, staff left her bed in the high position and R73 is now at the hospital because of staff not doing their jobs. V25 stated she observed blood on R73's eye after the fall. On 3/23/2023 at 9:43 AM, V4 (LPN) stated V25 reported to her that R73 fell from her bed. V4 stated she entered (R73's) room and V26 (LPN) also assisted her. V4 stated she and V26 assessed R73 for injuries at that time and noted blood from her eyebrow (V4 couldn't recall which eyebrow) and V26 called the ambulance to transfer R73 to the hospital. V4 stated she couldn't recall what position R73's bed was in when she entered the room because she was focused on assessing R73 at that time. V4 stated she wasn't assigned to R73 today but that she was assisting with the fall. V4 stated she didn't know if R73 was a fall risk. On 3/23/2023 at 9:50 AM, V26 (LPN) stated staff reported R73 fell from bed. V26 stated when he entered R73's room he observed R73 lying on a fall mat next to her bed, her head was off the fall mat, and there was blood on R73's head. V26 stated he didn't know where the blood was coming from. V26 stated staff called the ambulance because R73 hit her head. V26 stated R73's roommate told V26 that R73's bed shouldn't have been in the high position. V26 stated he didn't observe the height of R73's bed at that time because he was focused on R73. V26 stated all residents are considered a fall risk at the facility. R73's Nurse's Note, dated 3/23/2023 at 8:42 AM, documents, Wound nurse reported to this nurse that resident fell from bed and has a laceration to left brow. Care provided to area by wound nurse. Neuro assessment normal for resident. Ambulance transport called. EMTS (Emergency Medical Technicians) arrived, and report given. Report given to local hospital. Resident transferred to local hospital. On 3/23/2023 at 2:40 PM, V2 (Director of Nurses/DON), stated she spoke to the emergency room staff at the local hospital, and it was reported R73 sustained a displaced bilateral temporal mandibular joint (TMJ.) V2 also stated ER staff stated they glued the laceration on R72's head. R73's Physician Order Sheet (POS), dated 3/24/2023 documents apply ice pack x 15 minutes to TMJ joint (top of lower jaw just in front of ear) 3 times daily x 3 days for reduced jaw dislocation. R73's Hospital Records, dated 3/23/2023 documents, laceration repair with tissue adhesive to left eyebrow 2 centimeters (cm) and mandibular dislocation. The Facility's policy Fall Prevention and Management dated 05/2015 documents This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. It continues under guidelines, 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall.

Based on observation, interview, and record, the facility failed to implement Registered Dietitian recommendations to improve nutritional status for 1 of 3 residents (R73) reviewed for weight loss in the sample of 47. This failure resulted in the resident having severe weight loss of 14.14% in 3 months. Findings include: R73's Undated Face Sheet, documents she was admitted to the facility 10/2/2019. R73's Weight Summary, dated 12/9/2022 documents R73 weighed 114.6 pounds. R73's Minimum Data Set (MDS), dated [DATE], documents R73 as 66 inches tall, 104 pounds. It also documents R73 has had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and is on a mechanically altered diet and therapeutic diet. R73's Care Plan documents resident at risk for complications with weight and nutrition r/t (related to) history of not eating moderate protein-calorie malnutrition third. Goal: resident will consume adequate nutrition and weight to remain stable throughout next review. Interventions: 10/7/2019 allow resident extra time to eat, allow resident to choose supplemental diet, if possible, assist resident with meals as needed, dietary consultant to determine preferred foods, give consistency of food that is easy to eat and swallow, if dessert is uneaten, offer a snack later, monitor nutritional/hydration status, monitor residents' food intake and document, monitor weight and labs. 5/10/2021 house supplement 120 milliliters (ml) TID (three times a day) 6/25/2021 appetite stimulant, 8/2/2021 fortified foods, 10/28/2021 offer snacks in between meals, 6/30/2022 assistance with all meals. There were no new progressive interventions added. R73's Physician's Order Sheet (POS) dated 2/2023, documents 1/22/2020 provide HS (night) snack q (every) evening, 6/25/2021 Megace (appetite stimulant) 20 mg (milligrams) 2 tablets BID (twice a day), 8/30/2022 hi cal (supplement) TID (three times a day) 120 ML (milligrams), 11/16/2022 regular diet pureed texture nectar thick liquids consistency, related to dysphagia, oropharyngeal phase. Fortified food TID, high calorie dessert BID, health shake TID. R73's Undated Dietary Card, documents breakfast: super cereal and nectar thick liquids. Lunch and supper: fortified mashed potatoes, nectar thick liquids, high calorie dessert. No dislikes/allergies or other documented on dietary card. Dining room south hall - feeder assistance. No health shake was documented on the dietary card. R73's Dietary Nutrition at Risk Follow Up, dated 2/2/2023, documents weight as of 2/1/2023: 106.8 pounds. ST (speech therapy) has reported that resident has decline in function and with eating and taking meds. Had a fall and brief hospitalization in January. Regular diet with fortified foods TID and high calorie dessert BID. Hi Cal, 120 mL TID, megace. Will add health shakes TID. Cont. (continue) to monitor. R73's Weight Summary, dated 2/8/2023 documents R73 weighed 105.6 pounds. R73's Dietary Nutrition at Risk Follow Up, dated 2/9/2022, documents ST has reported that resident has decline in function and with eating and taking meds. Had a fall and brief hospitalization in Jan. (January) Reg (regular) diet with fortified foods tid and high cal dessert BID. Hi Cal, 120 mL TID, Megace. Health shakes TID. Cont. to monitor R73's Weight Summary, dated 2/15/2023 documents R73 weighed 104.2 pounds. R73's POS, dated 2/15/2023 documents weekly weights. R73's Dietary Nutrition at Risk Follow Up, dated 2/16/2023, documents ST reported resident has decline in function with eating, taking meds. Reg diet with fortified foods TID and high cal dessert BID. Hi Cal, 120 mL TID, Megace. Health shakes TID. Eating 25 -100% of meals. Encourage intake and provide assistance with eating as needed. Will follow. R73's Weight Summary, dated 2/22/2023 documents R73 weighed 102.2 pounds. R73's Dietary Nutrition at Risk Follow Up, dated 2/23/2023, documents ST reported resident has decline in function with eating, taking meds. Pureed diet, nectar thickened liquids with fortified foods tid and high cal dessert BID. Hi Cal, 120 mL TID, Megace. Health shakes TID. Eating 25-100% of meals. Encourage intake and provide assistance with eating as needed. Will follow. R73's Medication Administration Record (MAR), dated 2/2023 documents staff administered hi cal 120 ml TID per physician's orders. No documentation health shakes were administered. R73's POS dated 3/2023, documents 6/25/2021 Megace 20 mg (milligrams) 2 tablets BID (twice a day), 8/30/2022 hi cal TID (three times a day) 120 ML (milligrams), 11/16/2022 regular diet pureed texture nectar thick liquids consistency, related to dysphagia, oropharyngeal phase. Fortified food TID, high calorie dessert BID and health shake TID. R73's Weight Summary, dated 3/2/2023 documents R73 weighed 98.6 pounds. R73's Dietary Nutrition at Risk Follow Up, dated 3/9/2023 documents pureed diet, nectar thickened liquids with fortified foods TID and high cal dessert BID. Hi Cal, 120 mL TID, Megace. Health shakes TID. Eating 25-100% of meals. Enc. intake and provide assistance with eating as needed. Will follow. R73's Weight Summary, dated 3/10/2023 documents R73 weighed 99.0 pounds. R73's Dietary Nutrition at Risk Follow Up, dated 3/16/2023, documents pureed diet, nectar thickened liquids with fortified foods TID, high cal dessert BID. Hi Cal, 120 mL TID, Megace. Health shakes TID. Eating 50-100% of meals. Resident being fed BF (breakfast) by CNA (Certified Nursing Assistant) this AM, tol (tolerated) well. Will follow. R73's Weight Summary, dated 3/16/2023 documents R73 weighed 98.4 pounds. R73's MAR, dated 3/2023 documents staff administered hi cal 120 ml TID per physician's orders. No documentation health shakes were administered. On 3/23/2023 at 8:50 AM, R73 was lying in bed and had a very thin appearance. The Facility's Hi Cal and Shake list, dated 3/24/2023 documents R73 received hi cal for lunch and supper. Shakes were not listed for R73. On 3/24/2023 at 11:37 AM, V34 (Licensed Practical Nurse/LPN), stated in January 2023, R73 was self-propelling in her wheelchair, smoking cigarettes and talking more. She's had a rapid decline since then. On 3/24/2023 at 12:00 PM, V35 (Cook) showed 2 cases of vanilla shakes, one case of chocolate shakes and one case of strawberry shakes. There were 50 shakes in each case. V35 stated she looked at R73's dietary card and it doesn't have health shake documented on it so she's probably not receiving them. V35 stated the dietary staff are trained to follow the residents' dietary card and so if health shakes aren't on the card, dietary staff don't know to put it on there. On 3/24/2023 at 12:52 PM, V28 (Registered Dietitian/RD), stated she expects staff to follow physician's orders and facility policies. V28 stated when she has RD recommendations it goes through nursing, they send the recommendations to the resident's physician and if he/she agrees, then it is added to the resident's current POS. V28 stated she updates the resident's dietary care plan herself and she does that weekly when there is a new intervention to add. V28 stated the resident's care plan should be updated for current dietary interventions. V28 stated when she added health shakes to a resident's diet, she would have updated the resident's care plan at that time. V28 stated she orders health shakes to resident's diet when they are losing weight. Health shakes and hi cal is not the same thing, if both supplements are ordered she expects staff to document both supplements are being administered. If there is a physician's order for the resident to receive a HS snack, she would expect staff to administer the HS snack and to document what percentage of the snack the resident ate. On 3/24/2023 at 1:16 PM V5 (Dietary Manager) stated the RD inputs dietary recommendations in the computer system and that is how they are communicated to him. The RD recommendations are then added to the residents' dietary cards and dietary staff place the items listed on the resident's dietary card on the resident's tray. If an RD recommendation is not documented on the resident's dietary card, it is not placed on the resident's tray. V5 read R73's dietary card and stated R73 doesn't have a shake listed so she wasn't receiving them, and he didn't know why R73 wasn't receiving the shake if it was ordered by the Registered Dietitian, there must be a blip in the computer system or something. V5 didn't know if R73 was losing weight, the Registered Dietitian does all the clinical stuff. On 3/24/2023 at 3:14 PM, V2 (Director of Nursing/DON), stated the facility's RD, V3 (Assistant Director of Nursing/ADON), and the restorative nurse have a NARS (Nutrition at Risk Screen) meeting weekly, and they review all the weights and assess residents that are losing weight. If there is a concerning amount of weight loss from one week to another V2 stated V3 will have staff reweigh the resident to ensure the weight is accurate. In the NARs weekly meeting, V3 and the RD add interventions to residents' care plans to ensure they don't lose weight. V2 stated she would expect a new progressive intervention to the resident's care plan when a resident is losing weight. New interventions should be added to the resident's care plan the same day of the NARS meeting takes place. V2 stated she expects residents' care plans to be updated and staff to be following the interventions on each resident's care plan. V2 wasn't aware no new progressive interventions have been added to R73 care plan since 11/2022. V2 stated she just found out today that the CNAs aren't documenting that the resident is drinking the health shake, they are documenting what percentage residents are eating per meal in 25% increments. V2 stated food related RD recommendations should be documented on the resident's dietary card, including health shakes so dietary staff know to put the health shake on the resident's meal tray. V2 didn't know why R73's health shake wasn't documented on her dietary card. The Facility's policy Weight change Policy dated 06/2015 documents It is the policy of this facility to monitor the nutritional status of all residents. Including all significant or trending patterns of weight change.

Based on interview and record review, the facility failed to administer insulin per the physician's orders for 1 of 2 (R91) residents reviewed for insulin administration in the sample of 47. This failure resulted in (R91) being admitted to the local hospital with a diagnosis of hyperglycemia. Findings include: R91's Undated Face Sheet, documents she was admitted to the facility on [DATE]. R91's Physician's Order Sheet, (POS), dated 03/23, documents diagnosis of type 2 diabetes with hyperglycemia. 01/20/23: Glargine 10 units subq (subcutaneous), every day at 9:00 AM. R91's Medication Administration Record (MAR), dated 03/23 documents a blank box dated 03/20/23 for the Glargine 10 units at 9:00 AM. R91's Nurse's Note, dated 03/21/23 at 1:22 am, documents, CNA (Certified Nurse Assistant), this CNA reported to this nurse (V14) that resident doesn't look like her normal self. Resident presents very lethargic. Blood sugar 436, 98.2 88 40 122/82 85% RA. O2 (oxygen), applied via nasal cannula O2 now at 92% 2 L (liters). Sternum rub done to resident with no arousal. This nurse (V14) called the residents POA (Power of Attorney), to update her on resident's condition. POA wants her sent to the hospital. Resident sent to local hospital. On 3/22/23 at 2:00 PM V2 (Director of Nurses/DON) stated, she expects staff to follow Physician's Orders and to document when medications including insulin was administered to the resident on the MAR. She wouldn't say what it means if the resident's MAR box is empty because she would have to investigate the specific situation first. On 03/22/23 at 12:58 PM V19 (Pharmacist) stated, she expects all medications including insulin to be administered per physician's orders. A blank box on the resident's MAR possibly means the nurse didn't document the insulin wasn't administered. V19 expects the nurse to sign off when insulin was administered. If the resident didn't receive the scheduled 9:00 AM dose of insulin on 03/20/23 that is considered a significant medication error and could have cause the hyperglycemia she experienced on the morning of 03/21/23. The Facility's Timely Administration of Insulin Policy, revised 11/17, documents administer insulin at appropriate times and document on the medication administration record the time insulin was administered. All insulins will be administered in accordance with Physician's Orders.

Based on record review, and interview the facility failed to timely identify, initiate treatment, and treat as ordered to prevent pressure ulcers for 1 of 3 residents (R89) reviewed for pressure ulcers in a sample of 61. This failure resulted in R89 developing a facility acquired unstageable pressure ulcer/injury which became infected required surgical debridement. Findings include: 1. On 5/2/22 at 2:05 PM, R89 stated that he did not have the pressure ulcer on his right ischial tuberosity when he was admitted to the facility. He stated that he got it while he was here. He stated that the Certified Nurses Assistants (CNAs) won't turn him at night. He stated that he will put his call light on, and the CNA will come and turn it off without asking what he needs. He also stated that he may not get his dressing changed for 2 or 3 days. R89's Admission Record, print date of 5/3/22, documents that R89 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R89's Minimum Data Set (MDS), dated [DATE], documents R89 is cognitively intact. R89's MDs documents he requires extensive assistance of two plus person physical assist for bed mobility, transfers, and toilet use. R89's Care Plan, dated 2/14/22, documents R89 is at risk for skin complications related to (r/t) [CONDITION(S)] weakness and reduced bed mobility related to (r/t) chronic ulcers of Bilateral lower extremities (BLE). The Care Plan documents (R89) is non-complaint with turning and re-positioning while in bed and in chair. He is able to control motorized wheelchair (w/c) to re-position himself but at times refuses to. R89's Care plan documents 3/1/22-readmitted with Stage 3 to coccyx; Coccyx and BLE resolved, 3/28/22-Unstageable to Right ischial tuberosity, and 4/30/22-readmitted from hospital with new area to scrotum. R89's Initial Skin Screen, dated 2/14/22 at 11:29 AM, documents that upon his admission to the facility, R89 had an area to his Coccyx with pink scar tissue noted, right lower leg (rear) 3-centimeter (cm) by (x) 5cm x 0.0 treatment in place, and Left lower leg (rear) 3cm x 3cm x 0.0cm treatment in place. R89's Nursing admission observation, dated of 3/1/22 at 10:44 PM, documents that when R89 returned from local hospital, he was admitted back into the facility with the following wounds: Coccyx (Wound), Right lower leg (Front, Diabetes Mellitus (DM) ulcer), Left lower leg (Front, DM ulcer), Right lower leg (Rear, DM ulcer), Left lower leg (Rear, DM ulcer). R89's Skin and Wound evaluation, dated 3/28/22, documents that R89 had a new in-house acquired, Stage 2 pressure ulcer to his Right Ischial Tuberosity (lower part of pelvis sometimes referred to as sit bone) which measured 2.4 cm x 1.1cm x 0.1cm. R89's Wound evaluation documents that the wound had 50% granulation, no eschar, 50% slough, and moderate exudate. The Merriam-Webster Medical Dictionary defines slough as a mass of dead tissue separating from an ulcer. National Pressure Injury Advisory Panel (NPIAP) website defines unstageable pressure injury as Full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 tissue injury will be revealed. There was no documentation a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/22 at 10:20 AM, V11 (Licensed Practical Nurse/LPN), stated that she found R89's right ischial tuberosity pressure ulcer while she was preforming wound care to another area on R89 on 3/28/22. She stated that she cleansed the area and placed a dry dressing to it. She stated that she waited until (Wound Consultant) came in to do wound treatments and she notified the Wound Consultants when they came in to make rounds on Wednesday 03/30/22. R89's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R89's PO, with start date of 3/31/22, documents Santyl Ointment, 250 unit/GM (gram), ([MEDICATION(S)]), apply to R ischium topically every day shift for/to promote wound healing cleanse with w/c apply Santyl, calcium alginate, and foam dressing Q day and PRN. R89's March 2022 Treatment Administration Record (TAR), documents R89 did not receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R89's TAR documented on 3/31/22, R89 received the Calcium Alginate; however, the TAR did not document the Santyl ointment was administered. R89's Skin and Wound evaluation, dated 4/5/22, documents that R89's Stage 2 pressure ulcer to his Right Ischial Tuberosity measured 2.7 cm x 1.8 cm x 0.2 cm. The Evaluation documented the pressure ulcer had 50% granulation, 50% eschar, and moderate exudate. R89's TAR documented on 4/10 and 4/11/22, R89 was out to the hospital. R89's Skin and Wound evaluation, effective date of 4/14/22, documents that the stage 2 pressure ulcer to R89's Right Ischial Tuberosity measured 2.2cm x 1.6cm x 0.3 cm. It further documents that the pressure ulcer now had 100% eschar, with moderate exudate, and seropurulent (consisting of a mixture of serum and pus) drainage. R89's Skin and Wound evaluation, dated 4/18/22, documents that the wound to R89's Right Ischial Tuberosity is now unstageable, and is measuring 3.0cm x 2.2cm x 0.3cm. It further documents that there is 10% granulation, 90% eschar, moderate exudate, serosanguineous drainage, and faint odor noted. There was no documentation R89's pressure treatment was changed at that time. R89's Skin and Wound evaluation, dated 4/25/22, documents that the wound to R89's Right Ischial Tuberosity is unstageable due to slough and/or eschar. The wound is measures 4.0cm x 2.8cm x 0.5cm. It has 20% granulation, 80% slough, moderate exudate, serosanguineous drainage, and no odor. R89's April 2022 TAR document that R89 did not receive the Calcium Alginate treatment to his right ischium because he was on leave of absence with medications. There was no documentation he received this treatment on 4/5 and 4/7/22. From 4/12/22 through 4/27/22, there is not documentation on this TAR that R89 received this treatment to his right ischial pressure ulcer. R89's Hospital Internal Medicine Report, with admitted [DATE], documented he present on 4/27/22 with a worsening right buttock decubitus ulcer. R89's Hospital Progress Note, dated 4/28/22, documented On examination, wound was grossly infected with necrotic tissue at its base. S/P status post [MEDICAL RECORD OR PHYSICIAN ORDER] R89's Hospital Discharge Orders, 5/1/22, documented he was receiving [MEDICATION(S)]-[MEDICATION(S)], tables 800-160 mg, give 1 tablet, by mouth every 12 hours for wounds. R89's Acute Care Surgery Operative Report, with procedure date of 4/28/22 documents Findings: 4.5 x 5 x 2.5cm right gluteal wound. It further documents The wound was initially debrided bluntly with gauze sponges and superficial necrotic tissue removed. Next the wound was circumferentially debrided with a combination of sharp dissection and electrocautery, carefully removing any necrotic and non-viable tissue, to achieve healthy, bleeding edges. The central portion of the wound was then debrided in a similar fashion to achieve healthy wound edges throughout. 5/4/22 10:40 AM V2 (Director of Nursing) stated that she would expect the wound nurse to contact the physician and obtain an order when she finds a new wound. She would expect the nurses to follow the treatment that was ordered. V2 stated she would expect the nurse to document any treatment orders, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility policy and procedure Skin Care Prevention, review date of 1/2022, documents General: All residents will receive appropriate care to decrease the risk of skin breakdown. Responsible party: All nursing staff. Guideline: 1. The Nursing Department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 2. Dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching [CONDITION(S)]), and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. 3. All residents will be evaluated for changes in their skin condition. It further documents 5. All residents unable to reposition themselves will be repositioned as needed, based on a person-centered approach (minimum of every 2 hours). It also documents Educate the resident and resident representative regarding pressure ulcer prevention and treatment as appropriate.

Based on record review and interviews the facility failed to provide pain medication as ordered for 3 of 3 residents (R48, R53, R116) reviewed for pain management in the sample of 61. This failure resulted in R48 and R53 experiencing pain related to medication not available at the facility. Findings include: 1. R48's Care Plan, documents PAIN: Requires pain monitoring and management r/t (related to) his healed surgical areas and h/o (history of) chest pain, PVD ([CONDITION(S)]). He is able to express his pain and discomfort to staff verbally and has medication available as needed. It also documents Administer pain meds and treatments as ordered, monitor and record. R48's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R48's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MARs also document Chart Codes 9=Other see nurses notes. The MARs do not document [MEDICATION(S)] was given and instead document 9 for 1/14/22, 1/15/22, 2/1/22 9:00 AM, 2/16/22 5 PM, 4/17/2022 9:00 AM & 5:00 PM, and 4/18/22 9 am dose. The 4/10/22 9:00 AM dose was left blank with no documentation. 8 doses of the [MEDICATION(S)] pain medication were not administered. R48's Progress notes have no documentation for 1/14/22, 1/15/22, 2/1/22, 2/16/22, 4/10/22, 4/17/22, and 4/18/22 to 4/25/22 of the reason R48 did not receive [MEDICATION(S)] on these dates. R48's Controlled Drug Receipt Record/disposition form for [MEDICATION(S)] 5 mg, dated as received in the facility on 12/27/2021, documents the last dose supplied was given on 1/13/22 at 5pm. R48's next Controlled Drug Receipt Record/disposition form for [MEDICATION(S)] 5 mg documents the date received in the facility as 1/16/2022, which means R48 did not have a supply of the medication in the facility from 1/13/22 at 5 PM until this was received on 1/16/22. It documents the first dose was given on 1/17/2022 at 9 AM and the last dose supplied was given at 1/31/2022 at 5 PM. R48's next Controlled Drug Receipt Record/disposition form for [MEDICATION(S)] 5 mg, dated 1/31/22, documents that the first dose was administered on 2/1/22 at 5PM and last dose was administered on 2/16/22 at 9 AM. R48's Controlled Drug Receipt Record/disposition form, dated 3/31/22, documents that the last dose was administered on 4/16/22 at 9 AM. R48's Controlled Drug Receipt Record/disposition form for [MEDICATION(S)] 5 mg documents the date received in the facility as 4/18/22, which means R48 did not have a supply of the medication in the facility from 4/16/22 at 9 AM until this was received on 4/18/22. It documents that the first dose of was administered on 4/19/22. On 4/26/22 at 10:30 AM, R48 stated that the facility runs out of his pain medication, and it takes a couple of days for the medication to come in. R48 stated that he does take other medication that helps with his pain. R48 stated that during the time of not receiving his pain medication his pain is increased. R48 stated that he had a lower leg amputation and at times the pain is unbearable. R48 stated that he depends on the medication to assist with his daily functions. On 4/28/22 at 10:21 AM, V9 (Licensed Practical Nurse/LPN), stated that R48 is alert and oriented. V9 stated that there have been problems with getting R48 pain pills at times. V9 stated that R48 has ran out of pain medication and she ordered it and it comes in by the next day. On 4/28/22 at 11:45 AM, V2 (Director of Nursing/DON), stated that she would expect the nurses to order the medication prior to the resident being out. V2 stated that if the medication were not here, she would expect the nurse to notify the physician and follow the physician's direction. V2 stated that if the medication is available in the convenience box, she would expect the nurse to access it and administer from there. On 5/4/22 at 12:12 PM, V9 stated that if a resident received routine medication and the medication ran out, he would experience increased pain. 2. R53's POS documents 3/4/22 [MEDICATION(S)] Capsule 5 MG *Controlled Drug* Give 1 capsule by mouth every 4 hours as needed (PRN) for moderate to severe pain. R53's Progress Notes, dated 3/5/22 at 12:12 PM, documents Nurses Notes Note Text: Returned from [CONDITION(S)]. Resident had c/o (complaint of) not having a cane and stated that he left his somewhere and needed a cane. Informed resident that we don't have canes, but I would see if PT (Physical Therapy) office had any. He threatened to call state stating we have to provide for him. He also c/o that he needed a tray and I let him know trays are coming out soon. Unable to give narcotic pain med at this time and PRN (as needed) Tylenol given. R53's Controlled Drug Receipt Record/Disposition form, dated 3/7/22 Documents [MEDICATION(S)] Cap 5 mg first dose administered 3/8/22. On 4/27/22 at 11:00 AM, R53 stated that he has a broken finger and need pain medication for it. R53 stated that he has had problem with getting his pain medication and that the facility runs out of his medication. R53 stated that it took a long time to get the medication when it was first ordered, and he was in a lot of pain. On 4/28/22 at 10:21AM V9 stated that R53 did have problems with getting his medication and was unsure what was the reason. V9 stated that R53 did not have a script (prescription) when he first came, and the physician had to be notified to get the script. V9 stated that once the script was received the pharmacy was notified and the medication was received. On 4/28/22 at 3:11 PM, V1 (Administrator) stated that R53 left the facility AMA (against medical advice), and his medication was destroyed. V1 stated that R53 came back to the facility and was readmitted . V1 stated that when readmitted R53 had orders but did not have scripts for his narcotics. 3. R116's Admission Record, not dated, list Chronic Pancreatitis and low back pain as diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R116's Care Plan, dated initiated 4/22/22, documents PAIN: (R116) Requires pain monitoring and management r/t his history of [CONDITION(S)] and Chronic Pancreatitis. It also documents Administer pain meds and treatments as ordered, monitor and record. R116's MDS documents that R116 is cognitively intact. R116's POS, dated April 22, documents [MEDICATION(S)] ER Tablet ER 12-hour Abuse Deterrent 10 mg give 1 tablet by mouth every 12 hours for moderate to severe pain. On 4/27/22 at 11:15 AM, R116 stated that the facility runs out of his medication. R116 stated that he had [CONDITION(S)] and has had hernias due to repair and has frequent pain. R116 stated that the pain is bad. R116 stated that sometimes it doesn't do any good to tell them you are in pain when they don't have the medication to give to you or won't give it to you. The facility's Pain Management Policy, review date 12/2021, documents To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to necessary comfort, exercise greater independence and enhance dignity and life involvement. It also documents Guideline: Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. It continues Pain Management is defined as a process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals.

Based on observation, interview and record review, the facility failed to provide safe, adequate Gastrostomy (G-tube) care for 1 of 1 residents (R13) reviewed for G-tubes in the sample of 47. This failure resulted in R13's G-tube being pulled out during care, requiring him to need hospitalization for surgical placement of a new G-tube. Findings include: On 3/24/21 at 12: 55 PM, R13 was observed receiving medication and a water flush through his G-tube. R13's Electronic Medical Record documents his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Minimum Data Set (MDS), dated [DATE], documents his cognitive status is severely impaired, and he is totally dependent on staff for bed mobility, transfers and eating, and that he has functional limitations in range of motion on both sides to his upper and lower extremities. R13's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Care Plan, dated 5/28/19, documents: Resident is at risk for complications related to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Progress Note, dated 2/18/21 at 6:17 PM, documents, Resident was transferred to (local hospital) via ambulance at 6:20 PM. G-tube had broken off and needs new one. This was 2 hours and 10 minutes after the MD was notified the G-tube had been pulled out. R13's Progress Note dated 2/19/21 at 6:26 AM documents, Called (local hospital) for update. Still waiting in ER (emergency room ) for room for admittance. Needs surgery consult to place G-tube as they were unable to replace existing one. On 3/25/21 at 3:00 PM V1, Administrator, presented R13's Untitled report of incident regarding R13's G-tube being pulled out, dated 2/18/21 at 6:00 PM, which documents the physician was notified of R13's G-tube being pulled out at 4:10 PM. It does not include any investigation of the cause of the incident or any new intervention to prevent it from happening again. There is no documentation of reason R13 was not sent to the hospital until 2 hours and 10 minutes after the MD was notified. R13's emergency room (ER) Records, Hospitalist History and Physical, dated 2/19/21 at 3:38 AM documents: (R13) was sent to the emergency room when he pulled out his G-tube. Patient is unable to supply any history. History is obtained from ER and nursing home records. It was unclear what time this happened. ER physician attempted to replace a G-tube and was unsuccessful. He attempted a foley placement which was also unsuccessful. R13's Hospital Records also included a Medical Doctor (MD) note, dated 2/19/21 at 12:44 PM, which documents. Assessment and Plan: Dislodged G-tube, unknown how long it has been dislodged and unable to put a replacement in directly. Plan: EGD (Esophagogastroduodenoscopy; per WebMD: An upper endoscopy is a procedure where your doctor uses a thin scope with a light and camera at its tip to look inside your upper digestive tract-- the esophagus, stomach, and first part of the small intestine, called the duodenum.) for direct visualization for placement of new tube. The procedural risks, benefits, alternatives, including the risks of complications of bleeding, infection, bowel injury or perforation, anesthesia related risks, but not limited to the above, were explained and discussed fully with the patient and all questions answered. The complications could lead to possible hospitalization , antibiotics and surgery and even remote chance of death. On 3/25/21 at 2:10 PM, V22, Licensed Practical Nurse (LPN), stated R13 cannot voluntarily move his arms or hands and he would not be able to grab his G-tube and pull it out. She stated she did not know how his G-tube got pulled out. On 3/25/21 at 2:44 PM V3, Regional Nurse, stated there would not have been an investigation of R13's G-tube being pulled out because he was sent to the hospital. On 3/25/21 at 3:05 PM, V24, Assistant Director of Nursing (ADON), stated staff should check the placement of the G-tube before turning and repositioning R13 to make sure they are not pulling on the tube. On 3/25/21 at 3:45 PM, V34, Registered Nurse (RN) stated on the day R13's G-tube came out, the CNAs (Certified Nursing Assistants) came to her and reported R13's G-tube was out. She stated the CNAs stated they were cleaning him up and he's very stiff when turning him side to side, and his G-tube somehow got tangled in his arm or hand and was pulled out. She stated when she got down to his room there was not much tube feeding formula on his bed and there was no blood. She stated she gave the CNAs education to make sure the G-tube is out of the way when they are turning R13 and now she goes down to watch them when they turn R13 so it does not get pulled out again. She stated it was carelessness that caused the tube to be pulled out. The facility's policy, Risk Management reviewed 1/2021, documents, Purpose: An event is a potentially compensable event, as determined by previous litigation analysis. All events must be reported to the insurance carrier to ensure coverage. All events must also be investigated at the direction of the General Counsel in anticipation of litigation. Event investigations will be part of the defense file and submitted to the defense counsel. Process: An event is: Level 3: Other unusual occurrences requiring additional investigation; It continues, 5. All events must have a thorough investigation/root cause analysis. The investigation may include witness statements. If statements or other documentation is created that is not included in the resident's medical record, an event file should be created. All documentation from a State Agency should also be included in this file.

Based on observation, interview and records review, the Facility failed to identify/assess and monitor for condition changes and ensure residents were given correct medications to treat chronic conditions for 2 of 3 residents (R2, R7) reviewed for change of condition in the sample of 20. This failure resulted in the hospitalization of R2 and the amputation of his right leg above his knee and R7 being admitted to the hospital for [MEDICAL CONDITION]. Findings include: 1. R2's Physician order [REDACTED]. On 6/6/18 at 5:10 PM, R2 was in the dining room in a wheelchair. R2's right leg was amputated above the knee. On 06/07/2018 at 4:40 PM, R2 stated I got my leg cut off. I was having problems because my leg was hurting me, cramping all the time. I thought my leg was getting better so it was a big shock to me when I lost my leg. I was having some breathing issues about a month before and then I started having pain in my legs. I am not sure if they did everything they could for me because I really did not want to lose my leg. I used to be able to walk before they took my leg. I miss my leg! It was a shock! R2's Progress Notes dated 04/08/2018 at 6:05 PM, documents in part, R2 was sent out to the local hospital. R2's Local Hospital Records dated 04/08/2018 document R2 had a [MEDICAL CONDITIONS] noted to his right leg. The Physician order [REDACTED]. The Group Note documented [MEDICAL CONDITION] noted right leg. Turn and Position Every 2 hours, [MEDICAL CONDITION] noted to right leg. The Record documented Discharge Status, [MEDICAL CONDITION] noted right leg. R2's Right Lower Extremity venous duplex examination dated 04/16/2018 documents, in part, Impression: Extensive right lower extremity [MEDICAL CONDITION] extending from the common femoral vein to the posterior tibial vein. R2's Local Hospital Discharge Summary dated 04/17/2018 documents, in part, Date of Discharge 04/17/2018. admitting [DIAGNOSES REDACTED]. Discharge Diagnosis: [REDACTED]. R2's physician's orders [REDACTED]. R2' Care Plan with a Review Start Date of 04/17/2018 documents [MEDICAL CONDITION]: (R2) is at risk for complications with swelling, skin issues and discomfort related to BLE (Bilateral Lower Extremity) swelling 03/12/2017. New orders for compression hose. The intervention is documented as Will demonstrate stabile fluid balance without [MEDICAL CONDITION] through next review. The Care Plan does not document how staff are to monitor R2 for [MEDICAL CONDITION] or complications related to [MEDICAL CONDITION]. https://www.nursingtimes.net/clinical-archive/haematology/the-prevention-and-treatment-of-deep-vein-[MEDICAL CONDITION]/ 7.article documents, There should be regular physical assessment of the patient's leg and advice given to patients on reporting new symptoms. It continues under Signs and symptoms, Although often asymptomatic, a number of signs and symptoms are associated with [MEDICAL CONDITION] (Gorman et al, 2000):- Calf pain and/or tenderness; - Swelling with [MEDICAL CONDITION]; - Swelling below the knee in distal [MEDICAL CONDITION] and up to the groin in proximal [MEDICAL CONDITION]; - Increased skin temperature; - Superficial venous dilation; - Cyanosis can occur with severe obstruction. Even patients with extensive venous [MEDICAL CONDITION] may have minimal leg symptoms, while pain, tenderness, and swelling of the leg may be caused by other disorders such as hematoma or Baker's cyst (Verstraete, 1997). This emphasizes the importance of risk-factor assessment and [MEDICATION NAME] measures. R2's Daily Skilled Note dated 04/17/2018 at 3:57 PM, documents R2 had 1 + (slight pitting, no visible distortion, disappears rapidly) [MEDICAL CONDITION]. The Note did note document where R2's [MEDICAL CONDITION] was located. R2's Daily Skilled Note dated 04/18/2018 at 8:57 PM, documents R2 had no [MEDICAL CONDITION] and no wounds. R2's had no Daily Skilled Notes in medical record for 4/19 and 4/20/18. R2's Daily Skilled Note dated 04/21/2018 at 3:24 PM, Daily Skilled Note dated 4/22/2018 at 5:57 PM and Daily Skilled Note dated 4/23/18 at 10:50 AM documented he had no [MEDICAL CONDITION] and no wounds. R2's Daily Skilled Note dated 04/24/2018 at 10:18 AM, documented he had 3+ [MEDICAL CONDITION] in his bilateral lower extremities. The Note documented The pit is noticeable deep and may last more than a minute; the dependent extremity looks fuller and swollen. The Note documented there was no wound that required treatment. However, the Note continued to document Bilateral lower extremities swollen and noted fluid filled blisters with some open, wound nurse evaluating. R2's Nurse's Note dated 4/24/18 at 12:42 PM, documents (V24, Physician) notified of [MEDICAL CONDITION] to bilateral lower extremity (BLE) and fluid filled blisters, new orders to start [MEDICATION NAME] 20 milligrams (mg) daily and to draw Basic Metabolic Panel (BMP) in one week. Resident aware of new orders. R2's physician's orders [REDACTED]. In addition, the POS documented [MEDICATION NAME], give 20 mg by mouth one time a day for [MEDICAL CONDITION] related to Acute Diastolic [MEDICAL CONDITION]. R2's Daily Skilled Note dated 04/25/2018 at 10:36 AM, documented he had 3+ [MEDICAL CONDITION] to his bilateral lower extremities and no wounds. The Note continued Up in w/c (wheelchair) this shift, participating with skilled therapy. Bilateral lower extremities swollen and noted fluid filled blisters. No complaints of pain or discomfort noted. Med compliant without complications. Will continue to monitor. R2's Daily Skilled Note dated 04/26/2018 at 11:13 AM, documents he had 3+ [MEDICAL CONDITION] in his bilateral lower extremities. The Note documented he had no wounds. The Note documented Up in w/c this shift, participating with skilled therapy. Bilateral lower extremities swollen. No complaints of pain or discomfort noted. Med compliant without complications. Will continue to monitor. There was no documentation regarding the status of blisters on R2's right leg or description of the right leg. R2's Daily Skilled Note dated 04/26/2018 at 8:45 PM, documents R2 had 3+ [MEDICAL CONDITION] in his bilateral lower extremities. The Note documented he had a wound that was being treated. The Note documented (R2) is up in wheelchair at this time. Respirations even and unlabored. Ate dinner in dining room without difficulty. Denies any pain/distress. There was no documentation regarding fluid filled blisters or the description of R2's legs. R2's Daily Skilled Note dated 04/27/2018 at 10:25 AM, documented R2 had 2+ [MEDICAL CONDITION] to his bilateral lower extremities. The Note documented Tx (Treatment) to LRE (Lower Right Extremity) changed per this nurse. Updated wound nurse of condition of LRE. There was no documentation of fluid blisters on this Note. R2's Daily Skilled Note dated 04/27/2018 at 11:08 PM documented R2 had no swelling or [MEDICAL CONDITION]. The Note did not address any wounds. R2's Daily Skilled Note dated 04/28/2018 at 5:58 PM, documented had 2+ [MEDICAL CONDITION] to his bilateral lower extremities. The Note documented he had no wound. The Note documented Resident alert & oriented. Propelled self to dinner in wheelchair. No respiratory distress noted. Denied pain. Safety & comfort monitoring ongoing. There was no documentation of fluid filled blisters of description of R2's leg on this Note. R2's Daily Skilled Note dated 4/29/18 at 2:26 PM documented he had 2+ [MEDICAL CONDITION] and was receiving a treatment to a wound. Under the additional comment section documented Dressing to right leg dry and intact. R2's Nurse's Note, dated 04/29/2018 at 6:40 PM, Upon removing dry dressing to right lower leg and foot noted: leg dark brown with blackening tissues to toes and heel area. Toes cool and leg with some warmth to touch. Res (Resident) denies pain, but reports he can feel nurse is touching his limb. Unable to palpitate pedal pulses. Called (V25, Advanced Practical Nurse) and made aware. Res. is to go to hospital to be followed up by (V38, Physician). The Nurse's Note documented at 7:30 PM, ambulance arrived and R2 left facility via stretcher to go Hospital for evaluation. R2's Local emergency room Visit Report dated 04/29/2018 documents in part, [AGE] year old male with extensive medical history present to Emergency Department (ED) via Emergency Medical Services (EMS) from (Facility) for care of right lower extremity pain and discoloration. Patient reports foot has been black for four days. Pain worse with movement and palpation. The General Exam documents under extremities: Limited Range of Motion, Pulse deficit, other (right foot black and cold), Skin sloughing off up to mid-calf. Circumferential line of demarcation to right upper calf. Sensation intact per patient. R2's Hospital Notes dated 04/29/2018 document R2 was seen in the emergency room for the care of right left extremity pain and discoloration; patient reports foot has been black for 4 days. Pain worse with movement and palpation. The Patient Visit Summary documents You were seen today for gangrene of foot. R2's Hospital Records also documents on 04/30/2018 at 12:00 AM, No pulse or doppler, foot cold and black, waiting return call from Vascular Hospital. Consulted vascular, patient accepted and transferred to the emergency room for further evaluation. R2's Hospital Records also document a Patient Transfer due to vascular care on 04/30/2018 at 12:21 AM to Out of State Hospital Facility. R2's Out of State Hospital Records dated 04/30/2018 document in part, Chief complaint: right lower extremity discoloration. History of Present Illness: (R2) is an [AGE] year old male who is status [REDACTED]. He presented to an outside hospital with progressive right lower extremity discoloration over the past 4 weeks. Per his nursing home he was on [MEDICATION NAME] until 04/09 and then changed to Xarelto with last dose 04/29/2018. He transferred to (Out of State Hospital) for further evaluation and treatment. At the outside hospital he was found to have a darkened pulseless, cool right lower extremity. Computed axial tomography (CT) angio was obtained that demonstrated right lower extremity. Occlusion of the right femoropopliteal bypass graft and right superficial femoral artery with no runoff to the ankle. Distal 1/3rd of right leg extremity is pulseless, black, avascular with necrosis. [AGE] year old male with history of vascular surgery to his lower extremity due to [MEDICAL CONDITIONS] present with 3 days of right lower leg, pain, swelling. On my exam, the patient has a cold and pulseless right lower extremity (RLE) just below the knee with areas of skin [MEDICAL CONDITION] and breakdown, significant smells, consistent with wet gangrene. Not septic here. Immediately discussing with vascular surgery. The Out of State Hospital Records document on 05/02/2018 R2 had an above the knee amputation to his right leg. On 06/14/2018 at 1:04 PM, V2, Director of Nursing stated pedal pulses should be documented in the Progress Notes and or Daily Skilled Notes. On 6/15/2018 at 11:45 PM, V2, Director of Nursing (DON), stated, I would expect the Daily Skilled Nursing Assessments to be completed on (R2) after he came back from the hospital. No pedal pulses were completed on (R2) because when he came back from the hospital the [MEDICAL CONDITION] was not specified where it occurred. Why would he need pedal pulses? No there is no documentation from the Wound Nurse for (R2) or pedal pulses being taken. On 06/18/2018 at 4:00 PM, V2 stated I was unaware of the site where the blood clot occurred on (R2). I am not responsible for his direct care. The nurses knew the site and I would expect nurses to access the area for redness, swelling and check the pedal pulses daily, which they were doing. On 06/15/2018 at 10:32 AM, V34, Quality Assurance Wound Nurse stated I was not treating (R2) until the blister occurred on 04/24/2018. It was not an open area nothing on (R2) was documented in the Wound Rounds. There is no documentation because it was not opened. The bandages for (R2) were more of a prevention versus a treatment. Once the blisters came I started seeing him every day up until he went out to the hospital. There was no documentation in R2's medical record regarding when V34 completed the treatment to R2's leg, what type of assessment and evaluation was completed to determine the status of the blisters and the condition of his right leg. The Facility was unable to provide any documentation verifying the Wound Care Nurse was monitoring the leg or blisters on the leg. No pedal pulses documentation or dressing changes for (R2) was available for review. On 06/15/2018 at 1:24 PM, V9, Licensed Practical Nurse (LPN) stated, Yes, those are my initials on the Hospital Discharge Sheet. The check marks are there so I do not miss any medication. As I put the medications in the computer I check them off the list. A box will pop up on the computer and you select the [DIAGNOSES REDACTED]. I am responsible for transferring the information to the computer. Next to the box the following is documented [MEDICAL CONDITION] to right leg. On 06/20/2018 at 12:00 PM, V36, Vascular Surgeon stated If (R2) had a [DIAGNOSES REDACTED]. I would expect it would take days to weeks for a foot to turn black depending on the circulation and how severe the circulation was or was not getting to the foot. As far as detecting it earlier if there was no pedal pulse I would expect (R2) to be sent out immediately for evaluation. 2. R7's current Electronic Medical Record documents a medical [DIAGNOSES REDACTED]. R7's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Give 20 mg by mouth one time a day related to Chronic Combined Systolic (Congestive) and diastolic (Congestive) Heart Failure. Order date 06/08/2017. D/C (discontinue) date 02/23/2018. R7's Progress Note, dated 2/23/2018, documents, in part, Res (resident) voices concerns of lower legs swelling. Resident has bilateral lower [MEDICAL CONDITION] +2. Call placed to on call voice mail. Awaiting call back at the time. R7's Phone Order, dated 02/23/2018, documents, [MEDICATION NAME] Tablet 40 mg ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION], Unspecific until 03/01/2018. R7's (MONTH) (YEAR) MAR, documents, in part, [MEDICATION NAME] Tablet 40 mg ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION], Unspecified until 03/01/2018. Order date 02/23/2018 D/C date 02/26/2018. R7's Note, written by V4, Nurse Practitioner (NP) dated 02/26/2018, documents Extremities: 2+ [MEDICAL CONDITION] to BLE (bilateral lower extremities). R7's New Order Form, dated 2/26/2018, documents, Continue [MEDICATION NAME] 40 mg daily through 3/5/2018. R7's (MONTH) (YEAR) MAR indicated [REDACTED]. Order date 02/26/2018. R7's (MONTH) (YEAR) MAR indicated [REDACTED]. Order date 02/26/2018. R7's Chest x-ray, dated 03/06/2018, documents, in part, Impression: [MEDICAL CONDITIONS] with mild pneumonia right lower lobe when compared with 1/6/2018. R7's Note, written by V4, dated 03/07/2018, documents, Respiratory: faint rhonchi detected in lower lobes. Extremities: 2+ [MEDICAL CONDITION] to BLE (bilateral lower extremities). Prescribe: [MEDICATION NAME] 40 mg tablet - 1 daily for 7 days, [MEDICATION NAME] 500 mg - 1 tablet for 7 days Repeat CXR ( chest x-ray) next week on 3/14/2018. R7's Nurse's Note, dated 03/07/2018 at 3:07 PM, documents, in part, Resident received N. O. (new order) for [MEDICATION NAME] 500 mg x 7 days r/t (related to) chest X-ray mild pneumonia noted. N.O. to continue [MEDICATION NAME] 40 mg for 7 days and a repeat CXR on the 14th. R7's (MONTH) (YEAR) MAR indicated [REDACTED]. Ordered 03/07/2018. R7's repeat chest x-ray ordered for 3/14/2018 was not available for review. R7's Nurse's Note, dated 03/18/2018, documents, Resident approached this writer c/o pain and swelling to both legs. Upon inspection, bilateral +2 [MEDICAL CONDITION] noted. Pedal pulses present. No c/o (complaint of) shortness of breath noted. Call placed to physician exchange. Monitoring ongoing. R7's New Order Form, dated 3/19/2018, documents, Increase [MEDICATION NAME] to 60 mg daily x 10 days then decrease to 40 mg daily thereafter. R7's (MONTH) (YEAR) MAR indicated [REDACTED]. Order date 03/19/2018 D/C date 3/19/2018. R7's MAR indicated [REDACTED]. R7's (MONTH) (YEAR) MAR indicated [REDACTED]. R7's 3/20/2018 MAR indicated [REDACTED]. Order date 03/19/2018 D/C date 03/21/2018. R7's MAR indicated [REDACTED]. R7's Nurse's Note, dated 03/20/2018, documents, in part, NP (Nurse Practitioner) wrote N.O. for [MEDICATION NAME] 60 mg x 10 & then 40 mg daily. Resident still c/o bilateral legs [MEDICAL CONDITION] +2 pitting. Observed resident labored breathing Resident states he just came back from therapy. Lung sounds crackles heard on expiration. Called placed to MD (medical doctor) resident will be sent out to local hospital for further evaluation. R7's Nurse's Note, dated 3/20/2018, documents, Resident admitted to local hospital with [MEDICAL CONDITIONS] & Pericardium Effusion. R7's Hospital Face sheet, dated 3/21/2018, documents, in part, Reason for visit: [MEDICAL CONDITION] exacerbation; pericardial effusion. R7's (MONTH) (YEAR) MAR indicated [REDACTED]. This MAR indicated [REDACTED]. On 06/14/2018 at 2:55 PM, V24, Physician, stated, When I increase [MEDICATION NAME], I will write resume original order, then order a BMP (Basic Metabolic Panel). It really depends on how the order is written. Common practice is after an increase you go back to original order. The nurses should have clarified the order. V24 further stated the fact that (R7) did not go back on his maintenance dose of [MEDICATION NAME] after the increases contributed to him being sent to the hospital. On 06/18/2018 at 1:37 PM, V4, stated, I expect staff to return to the maintenance dose after an increase of [MEDICATION NAME] or clarify the order. (R7) not receiving any [MEDICATION NAME] could have contributed to (R7) being hospitalized . On 06/18/2018 at 2:13 PM, V33, Licensed Practical Nurse, (LPN), stated, I did not enter the order to resume (R7) 20 mg of [MEDICATION NAME] after the increase of [MEDICATION NAME] because the order was not written that way. I have no idea where the order for 20 mg of [MEDICATION NAME] came from on 3/19/2018 it was on the MAR indicated [REDACTED] On 06/18/2018 at 3:15 PM, V33 stated she did not clarify that the original order for [MEDICATION NAME] should be resumed after the increase because the order was for a week and the NP would be back in house in a week. On 06/18/2018, V8, LPN, stated, If a medication dose was increased for a few days and it does not say resume the original dose, I would clarify the order. On 06/18/2018, V21, LPN, stated, When I receive an order for [REDACTED]. On 06/19/2018 at 2:30 PM, V2, Director of Nurse's/Acting Administrator stated, (V33) put the order in for [MEDICATION NAME] on 3/19/2018 as 20 mg instead of 60 mg. When (V33) realized it was put in wrong she reentered the [MEDICATION NAME] order for 60 mg to start on 3/20/2018. (R7) did not get 40 mg more of [MEDICATION NAME] on 3/19/2018. On 06/19/2018 at 3:40 PM, V2 stated, I expect staff to enter the order correctly and administer the order as prescribed. On 06/18/2018 at 2:50 PM, V4 stated, The missing 40 mg of [MEDICATION NAME] on 3/19/2018 was definitely a medication error. It is hard to say if that would have kept him out of the hospital. The facility policy and procedure Medication Ordering Requirements, dated 09/2017, documents, in part, 1. Verbal, hand-written, C[NAME] (change of condition), and telephone orders received by nursing staff must be recorded in the Electronic Medical Record. It continues, 10. After the medication order has been reviewed, all concerns, issues or questions are clarified with the prescriber before dispensing.

Based on interview and record review the facility failed to protect three of seven residents (R36, R60 and R97) reviewed for abuse in the sample of 69. R219 sexually abused these seven female residents on multiple occasions. This deficient practice has the potential to affect all 48 female residents in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 4/10/18, the Facility remains out of compliance at a severity level two as the facility continues to in-service and educate all staff on the abuse policy and evaluating the effectiveness of the abuse policies and procedures, reviews all residents for sexual inappropriate behaviors, and implement interventions to protect the residents in the facility. Findings include: 1. R219's Hospital Records, dated 04/19/2017, documents in part, History of Presenting Complaint: This is a [AGE] year old male, nursing home resident who was brought to the emergency room after he was found sexually in a compromising social position with a demented fell ow resident. At present, he denies these complaints. He does have a [DIAGNOSES REDACTED]. The Physical Examination documents in part, General: middle-aged male, robust, awake, alert, orientated x 3. The Assessment/Plan documents in part, admitted with inappropriate sexual behavior. Will refer to Psychiatry. R219's Progress Notes, dated 05/25/2017 at 2:07 PM, documents, in part, Report called in from (hospital) [DIAGNOSES REDACTED]. (R219) reportedly admitted extended amount of time due to placement issues. R219's Care Plan, dated 05/25/2017, documents R219 was admitted to this facility on 05/25/2017. R219's Care Plan documents in part, expressing inappropriate behaviors. The intervention listed is documented as continue to monitor medication, activities of daily living and behaviors. Under the [MEDICAL CONDITION] medication section, (R219) has a history of expressing inappropriate behaviors towards others. The intervention documents, monitor for changes with behaviors, when expressing inappropriate behaviors redirect and explain appropriate actions. When needed provide 1:1 monitoring. Resident has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process and is therefore considered appropriate for admission. The Goal is listed as the resident will not touch or rub any of his fell ow peers while he is a resident in the program (5/25/2017). The intervention is documented as Intervene when any inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses and behavior. The Care Plan, dated 05/25/2017, further documents in part, Focus- maladaptive behavior, Goal- The residents will not touch or rub any of his fell ow peers while he is a resident in the program. On 4/04/2018 at 3:17 PM, V3, Care Plan Nurse, reported when she initiated R219's Care Plan she probably looked at the History and Physical (H&P) that came from the hospital prior to R219's admittance on 5/25/2017, but could not remember. V3 stated, Inappropriate or maladaptive behavior could be verbal, harm to self or others, sexual. It doesn't necessarily mean sexual. V3 reported she heard nothing said about R219 being sexually inappropriate when he was admitted . V3 stated one-to-one observation is when a person is with the resident observing them. V3 reported it could be initiated by the physician or nurse. V3 reported R219 was on a 15 minute observation status for his entire stay at the facility as are all of the residents who are on Daisy Drive, which is the independent behavioral hall. V3 reported it is the responsibility of the Psycho-social Technicians on that hall to document on each resident on that hall every 15 minutes. When V3 was asked what close monitoring means, V3 stated, 15 minutes checks are close monitoring. R219's Quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS)score of 15 out of 15, indicating he was cognitively intact. The MDS documents R219 can walk in his room with staff supervision, oversight, and encouragement of cueing. R219 is documented as having physical behavioral symptoms directed towards others such as hitting, kicking, pushing, scratching, grabbing, and abusing others sexually and this is documented as occurring 1 to 3 days per week. The facility's Occurrence Investigation and Resolution Report, dated 02/12/2018 documents, in part, Our investigation has included interview of all known potential witnesses, Housekeeping staff (V10) was in the dining room and observed (R219) to be looking about himself in a suspicious manner and felt that he had reached out toward a female resident. Several other residents were also present in the dining room at this time. This housekeeper asked a male CNA who was present to observe (R219) and ensure safety while she went to report to Social Services. (R219) was then invited to the East Hall Dining Room as a precaution pending initial investigation. None of the other persons present observed inappropriate contact between (R97) and (R219). However, when asked, (R97) indicated that (R219) had touched her upper body. We were unable to question her further due to her significant cognitive impairment. We conclude from available evidence that this event did occur. (R219) has been under constant observation since the initial report. He has not been deprived of adequate socialization and freedom of movement; he has cooperated voluntarily with remaining on his hall, dining space which includes recreation/dining spaces. His guardian has agreed to support transfer to other living arrangements. The report also documented (R97) - Adult failure to thrive, Alzheimer disease, alert and oriented x 1, severely impaired (R219)- Unspecified [MEDICAL CONDITION], diffuse [MEDICAL CONDITION], alert and orientated x 3, BIMS (Brief Interview Mental Status) 15, indicating cognitively intact. The Facility's 15 minute observation checks, from 2/12/18 at 6:00 PM through 2/16/18 at 10:45 AM, documented R219 was checked every 15 minutes for inappropriate behaviors and wandering. The local police's Offense/Incident Report, dated 02/12/2018, document in part, (R219) was arrested on 02/16/2018 at 11:00 AM. (R219) was booked on 02/16/2018 at 11:00 AM. The Arrest Classification is document as FELONY. The Report also documents the date of the incident as 02/12/2018 at 4:31 PM at the facility. The Report documents a video surveillance of the incident was reviewed by V13, Police Officer, and documents the following: (R219) grabbing (R97's) left breast several times with his right hand, and (R97) attempting to slap (R219's) hand. (R97) attempting to move away from (R219) and (R219) pushes (R97's) wheelchair back to the area she just left. (R219) was grabbing and touching the breast area of (R97). I observed (R219) grabbing and touching the breast area of (R97) from the outside of her sweatshirt several times throughout the incident using my department issued camera. I later logged the video into the evidence as exhibit #1. (V2), police officer and I attempted to speak with (R97). I asked (R97) about the incident and she did not respond. (R97) mumbled something that I could not understand. I called (V15, Sergeant Police Officer) who stated he would not be making the scene and not to make an arrest at this time due to the mental health issues surrounding (R219). The Offense/Incident Police Report, dated 02/12/2018, documents the following: At approximately 4:31 PM, (R219) is seen standing next to (R97) who is sitting in a wheelchair. (R219) reaches down with his right hand and touches (R97's) left breast on the outside of her clothing. (R97) appears to try and block (R219) hands from touching her breast. (R219) appears to be continually looking around and scan the area. (R97) is seen trying to protect herself and cover herself up and pushes (R219's) hand away. (R219) swats at (R97's) hand and is also seen slapping (R97) on her left cheek area with the back if his right hand. (R219) is seen touching (R97's) left breast again and reaches inside the top of her shirt and fondles her left breast. (R97) appears to try and push (R219's) hand away. (R97) starts using her feet to pull her wheelchair away from (R219). (R219) is seen pulling (R97) back towards him, looking at the door and is seen reaching inside the top of (R97's) shirt touching her left breast. When a worker comes into the area, (R219) steps away from (R97) but moves back by her when the worker leaves the room. R219 sits down in front of (R97) partially blocking her from the view of the surveillance camera. (R219) is seen leaning forward towards (R97), the bottom of (R97's) shirt appears to keep being raised up. R97 looks like she pushed (R219's) hand away. At approximately 4:45 PM, (R219) is seen reaching for (R97's) crotch area. She pushes his hand away. (R97) is seen with her right leg crosses over her left. (R219) uncrosses (R97's) legs and appears to be touching (R97's) vaginal area through her clothing. At approximately 4:49 PM, a worker is seen entering the room and (R219) leaves the room at approximately 4:50 PM. The local police's Supplemental Report, dated 02/12/2018 at 5:13 PM, documents in part, I contacted (V9), family of (R97), and I informed her that I was assigned to investigate this case. She confirmed that she was the (R97's) surrogate for decision making. She said she was aware of what had transpired between the suspect, (R219) and her aunt (R97). She said (R219) has had problems in the past similar to what had taken place with (R97). She further advised me she was an employee of the facility and was in route to the location to have a meeting with (V1) regarding the incident. She told me she would contact me when she had further information. At approximately 10:20 AM, (V9) contacted me, and stated she had met with (V1) and the (V2), Director of Nursing of the facility. She said she wanted to pursue charges against (R219) on (R97)'s behalf. Police Report, dated 02/14/2018 at 5:13 PM, documents: On 02/14/2018, (V9) arrived at the police department and signed a Police Department Victim Protocol Form on (R97's) behalf indicating she wanted to pursue criminal charges against (R219). Additional Information: On 02/13/2018, police officer, (V13), responded to the facility to meet with (R219) and conduct an audio/video recorded interview with him regarding this investigation. Upon arrival, we spoke with (V1) and (V2). We advised them we were investigating a complaint involving (R97) and (R219) and requested to conduct an interview with (R219) regarding his involvement. The interview began at approximately 1:58 PM. (R219) was advised that everything in the room was being audio and video recorded. (R219) was advised he was not under arrest but I told him I would be reading him his Rights per Miranda. While going through the check list, (R219) said he had lived in the facility for about 6 months and shared a room with 3 other residents. The following are statements from (R219): (R219) stated he did not know (R97's) name but acknowledged her as being a woman in a wheelchair. (R219) stated he was aware that everything in the dining room was recorded. (R219) acknowledged he had reached down and touched (R97's) breast, (R219) stated he had touched (R97's) on the breast twice. (R219) acknowledged (R97) wanted him to stop when she pushed his hands away. (R219) stated he was caught touching (R97's) breast through her clothing on two occasions. (R219) stated if he was caught touching (R97's) breast that he would be talked to. (R219) stated he was touching (R97's) breast because he was trying to get with her. (R219) stated he was caught touching another woman's breast in the facility prior to the incident involving (R97). (R219) stated he likes touching peoples' breasts and it felt good to him. (R219) stated he got a little aroused when he touched (R97). (R219) stated he touched another woman's breast (unknown identify), she left the facility and he does not see her anymore. (R219) stated he believed it was wrong to touch someone if they did not want to be touched. (R219) stated he was moved from the previous facility that he lived in because of the same thing . (R219) stated he believed it was wrong to do what he did to (R97). The interview was concluded at approximately 2:21 PM. On 03/21/2018 at 1:30 PM, V1, Administrator, stated, (R219) is no longer in the building. The police came and got him, arrested him and put him in handcuffs. When asked why R219 was arrested, V1 responded I don't know. On 03/23/2018 at 9:10 AM, V1 stated, No, I am not really aware of (R219's) behavior history. I started working here on 12/01/2017 so I can only speak from 12/2017 and forward. I had some generalization that he had some behaviors that were inappropriate. The Director of Nursing (V2, DON) and I were not personally aware of (R219's) history. One instance, a single incident soon after he got here, there was an incident with an alert and oriented resident who he attempted to touch (R106). This was investigated. V1, Administrator, stated The only residents I am aware of sexually inappropriate behavior by (R219) are (R97) and (R60). There was an incident in (MONTH) with (R97) and (R219). I called the police, I wasn't aware of what they did. I have reason to believe the incident at my sister facility also was taken into investigation with the police. On 03/29/2018 at 5:01 PM, V1 stated, I was the one who had called the police regarding (R97). (R219) admitted to doing it. The police officer and I reviewed the video surveillance and saw that he had touched (R97) inappropriately in the dining room and a few days later (R219) was arrested. On 03/23/2018 at 3:18 PM, V1 stated, (V10), Housekeeper, is the one who made the initial complaint and got a hold of (V11), Psych-Social Services Coordinator. (V10) could not remember the name of the resident she was concerned about. (V10) did not talk to me. I believe she (V10) originally thought the resident was (R93) because she was not sure of the name. We (myself and police) went to the cameras. This happened in the dining room, and after viewing the camera we were able to identify (R97) and (R219's) behavior. I looked at the camera, immediately and that is when we discovered (R219) had touched (R97's) breast. I was not able to make contact with (V10) until 3 days later, and I went back to the camera to confirm that (R219) did not touch (R93), but (R219) touched (R97's) breast instead. No, (V10) did not contact me, she contacted (V11). On 4/04/2018 at 3:45 PM, V1 reported R219 was on one-to-one observation status from 2/12/2018 at 6:00 PM until he left the facility with the local police on 2/16/2018 at 10:45 AM. V1 reported this is documented on the forms entitled, 15 Minute Observation and documents the behavior for inappropriate behavior, wandering. V1 reported the one to one observation form needs to be redone to be more specific to one-to-one observation. V1 reported the facility has no policies or procedures for observation status of any resident at this time. V1 reported, Constant monitoring would essentially mean one-to-one observation monitoring. That would mean to keep them in sight. When in bed they can monitor him (R219) from the hallway. R97's Annual Minimum Data Set (MDS), dated [DATE], documents R97 was unable to complete the BIMS test and was scored as severe cognitive impairment. The MDS also documents (R97) is in a wheelchair, not steady, and only able to stabilize with staff assistance from a seated to standing position, walking and surface to surface transfers. R97's MDS does not document any behaviors. R97's Care Plan with a start date of 02/19/2018 documents R97 is at risk for abuse and neglect related to weakness, adult failure to thrive, and dementia with behaviors. The Care Plan documents she requires assistance with her care. Under communication the Care Plan documents (R97) has a communication deficit related to her minimal hearing deficit, dementia and unclear speech. She does not always understand what is being said unless speaker adjusts tone, she has to repeat statements at times. For goals under abuse it documents staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect. R97's Physician order [REDACTED]. R97's Progress Report, dated 02/12/2018 at 6:50 PM, documents in part, Resident noted being touched inappropriately by another resident. Residents were separated. Full body assessment performed by this nurse (V44, LPN). Family notified, DON and Administrator. The Progress Note does not document the name of the other resident. On 03/23/2018 at 9:40 AM, V9, Family Member of R97, stated, The facility called me and told me that they had caught (R219) on camera touching my aunt. I filed a police report and got a restraining order against (R219). I had a meeting with the Administrator (V1) about it. I just wanted to keep her safe. 2. R219's Progress Notes, dated 11/13/2017 at 12:55 PM, It was reported to Psychosocial Rehabilitation Services that (R219) was attempting to go on [MEDICATION NAME] Lane (female hall) on several occasions after hours, the staff redirected him each time he attempted to walk down the hall. I asked staff to monitor him throughout the night and report any issues to the nurses and appropriate staff members. R219's Progress Notes, dated 11/15/2017 6:38 PM, Staff had to redirect resident several times this shift not to walk on [MEDICATION NAME] Hall. Resident calm and cooperative. Spoke with resident case manager. R219's Progress Notes, dated 11/28/2017 at 3:30 PM, (R219) is a [AGE] year old male with a primary [DIAGNOSES REDACTED]. (R219) has been known to wander the halls and has to be redirected. R60's Facility Incident Report Form, dated 12/20/17, documents on 12/20/17 at 5:15 PM a reportable event was reported: date unknown and time unknown (evening or nights). The Type of Event was documented as allegation of sexual abuse (inappropriate touching) from one resident to another resident. The Facility Incident Report Form also documented while speaking to (V7), Social Service Designee (SSD), resident (R60) alleges that the above resident (R219) touched her inappropriately while in her room. The date and time is not known. Our investigation has begun. Residents are separated and will remain so: the male resident is on 1 to 1 pending transfer for a psychiatric evaluation. Notifications made to administrator, resident representatives, physicians and local police. Final report to follow within 5 days. The Facility's 2nd page of Occurrence Investigation and Resolution documented Our investigation has included an interview, at the time of her allegation (R60) indicated that (R219), who she identified by photograph, had visited her that night had uncovered her, and had been touching her between the legs. (R60) has a [DIAGNOSES REDACTED]. (R219) was visible beyond the hallway door as she stepped off the other end to bring a breakfast tray onto the hall. She (CNA) walked no more than 60 feet off the hall and 60 feet back. Returning to the hall where upon she immediately surprised (R219) in (R60's) room standing near her bed. (R60) was fully covered with the blanket in place. When she asked, why he (R219) was there. He responded that he was trying to visit a friend. The unidentified CNA stated (R60) did not seem disturbed, but she was staring at him. She asked (R60) with (R219) present did he touch you, to which she responded that he did not. The unidentified CNA then escorted (R219) off the hallway to his own room. The Video footage from the hall for the preceding 24 hours was reviewed by (V1) the administrator and the Director of Maintenance (V5). (R219) was not observed on the hall except at 8:29 AM on 12/20/17. (R219) walked onto [MEDICATION NAME] Lane from the first nurse's station at 8:29 AM and limped slowly down the hall with a mass of folded papers in his left hand. He reached the threshold of (R60's) room at 8:29 AM and went in leaving the door open. The unidentified CNA is observed to come back onto the hall at the same time and goes directly to (R60's) room at 8:29:51 after noting (R219) on the hall. She exits the room with (R219). (R60) was sent immediately to the emergency department for medical evaluation based on her allegation. Their assessment found no signs of injury or other interference. (R219) denies touching (R60). (R219) received psychological evaluation immediately following this allegation and was returned to the facility with no findings. Interdisciplinary team has reviewed both residents plan of care and made changes as appropriate. The facility form, dated 12/20/17 entitled interview with (R60) (conducted by V1, Administrator), documented spoke with resident alone in her room, requested permission to speak with her, to which she nodded yes. (R60) has limited ability to communicate verbally, but she understands what is said to her. (R60) states that there was a man in her room last night she does not know his name, but states he is ugly. When asked if anything happened, she used the word touch, and made hand motions towards her lap and groin area. She expressed she was angry and upset. The form documented (V1) collected verbal report from nursing staff as to whether any males had been observed on [MEDICATION NAME] Lane, and one resident was identified. (V1) brought pictures of a few male residents to (R60) and (R60) identified the same resident that was on the hall. R219's Progress Notes, dated 12/20/2017 at 6:22 PM, document in part, This nurse was informed that the inappropriate sexual contact allegations have been reported to him and that (V21, Psychiatrist) needed to be contacted related to situation. Resident was on 1-1 monitoring. This nurse called (V21) at 6:00 PM and informed him of the allegations and new order was given to send resident to an out of state psychiatric hospital for psychological evaluation. Resident's guardian was called at 6:06 PM and voicemail left to give nurse a call at the facility. Report was given to emergency room . At 6:20 PM the emergency medical system transported resident to psychiatric hospital. The local hospital emergency room Visit Report, dated 12/20/17, documents (R60) was sent to emergency room due to reported sexual assault, which occurred prior to 9 AM. Patient was sent to emergency room at family request. The local hospital emergency room Progress Note, dated 12/20/17 at 9:22 PM, documents Registered Nurse (RN) spoke with (V7, SSD) concerning the fact that another resident in the care facility had put their hands down the patient's (R60's) pants. The Note documented it was reported that someone walked in on the incident occurring, which is how they determined what events happened. The report documented two RN's examined R60's genital area, and no evidence of trauma or injury were present. R219's Care Plan was revised on 12/20/17 and documented Allegations were made that (R219) acted inappropriately with peer. He was immediately placed on 1:1 care with staff and sent to ER for evaluation. 12/21/17 Returned from ER with no new orders, he remains on close monitoring by staff on and off the unit. R219's Psychiatric Follow-up visit, dated 12/28/17, documented, No staff concerns. There was no documentation regarding his recent ER admit due to inappropriate behaviors. On 3/23/2018 at 9:10 AM, V1, Administrator, stated, There was an incident with (R219) and (R60). We sent (R219) out for a psychiatric evaluation on 12/20/2017. (R60) said he had touched her. (R60) was sent to the emergency room I believe to determine if it occurred. (R219) was sent out for a psychiatric evaluation to determine and get the Physician's opinion. V1 reported he was not sure if R219 was ever on any observation since admission to the facility on [DATE]. V1 stated, Once I was aware of (R219's) inappropriate behavior to women residents - The investigation with (R60) showed that (R219) didn't attempt to do anything. (R219) was observed for a period of time - direct observation at minimum until the end of the investigation. On 3/23/18 at 2:00 PM, V25, Certified Nurse's Aide (CNA), stated, I was working on Humming Bird Lane. I took one tray down [MEDICATION NAME] Lane going the back way, and as I was coming back, I saw (R219) in (R60's) room and I asked (R219) why he was in (R60's room). (R219) said I was speaking to her. (R60) said she didn't want him in her room. R60's Electronic Medical Record, dated 03/01/18, documents R60's [DIAGNOSES REDACTED]. R60's Care Plan, (revision date) dated 02/07/18, documents R60 is at risk for abuse and neglect related to cognitive deficit, amputations, and decreased mobility. R60's interventions are establishing a counseling schedule with resident, identify areas that put resident at risk, and observe the resident for signs of fear. R60's Care Plan further documents R60 is alert with a communication deficit. 3. R219's Psychiatric Evaluation form, dated 6/1/17, written by V21, Psychiatrist, documented inappropriate behaviors. R219's Progress Note, dated 06/07/2017 at 4:09 PM documents, in part, Resident is a new admit to this program. Resident is alert and oriented throughout the facility with the ability to make needs and wants known peacefully. Resident scored a perfect score with his Brief Interview Mental Status (BIMS) (cognitively intact). Resident is calm and settled with fell ow peers and staff. I talked with the resident about touching his fell ow peer arms appropriately. Resident understood and said it would not happen again. R36's Final Investigation Report documents At 8:05 PM, 06/09/2017 resident was observed in wheelchair moving through day room. Co-resident sitting on couch reached out and brushed against her breast. Resident fully clothed. Staff witnessed event. Staff interviewed immediately, counseling/discussing with male resident (R219) to be aware of his arm movement and surrounding. No injuries or further issues. On 03/29/2018 at 3:33 PM, V52, Licensed Practical Nurse (LPN), stated, I remember (R219). I remember one day he was sitting in the day area with (R36) and he reached over and put his hand over her breast and tried to fondle her breast. (R36) was confused and incoherent. She randomly rolls around. I tried to stop it and told the administrator at that time. (R219) I think had a history of [REDACTED]. R219's Care Plan was revised on 6/9/17 and documented, Sat with psychsocial staff unit it was bedtime and continued monitoring on 15 minute checks. R219's Progress Notes, dated 06/10/2017 at 1:53 PM, document, Continues one on one with staff related to inappropriate physical contact with a female resident. R219's Psychiatric Follow-up visit, dated 6/15/17, written by V21 documented Inappropriate sexual behaviors. Patient admits of his inappropriate behavior. R219's Progress Notes, dated 06/21/2017 at 1:01 PM, document in part, Social Service Director talked with resident's guardian and sister, shared resident's behaviors and a potential all male group home. R36's [DIAGNOSES REDACTED]. R36's MDS, dated [DATE], documents a BIMS score of 9 out of 15 (moderate cognitive impairment). R36's Care Plan, initiated 2/1/2017, documents, ABUSE/NEGLECT: At risk for abuse and neglect related to [MEDICAL CONDITION], Development disorder. On 03/23/2018 at 10:09 AM, V16, Licensed Practical Nurse (LPN), stated, I came in (MONTH) 17 (YEAR), and by (MONTH) I told Psychosocial Rehabilitation Coordinator (V11, former employee) and (V18, Psychosocial Service) that I was having to redirect (R219) from going into the women's rooms. I never actually saw him groping anyone, but I was always redirecting him. On 03/23/2018 at 1:30 PM, V18, Psychiatric Social Worker, stated, For the most part, (R219) stayed in his room. We kept an eye on him 1 on 1 in January. The former administrator (V22) told us to keep an eye on (R219). When the new administrator (V1) came, we brought 2 (psychiatric) technicians. Back in October, they told me (R219) likes to try and touch women. (V11, Psychosocial staff), and the old administrator (V32) were aware that (R219) was sexually inappropriate to women. On 03/23/2018 at 1:31 PM, V29, CNA, stated, When I go into the room, (R219) would say 'Hey baby.' I knew he was sexually inappropriate, and he was put out in the psychiatric social room for awhile to keep people safe. Then all of a sudden (V11), Psych-Social Services Coordinator worker put him back in the main dining room, I am not sure why he came back. On 03/23/2018 at 1:35 PM, V34, LPN, stated, (R219) was here for awhile, 3- 6 months. He lived in the independent hall- Daisy Drive. I had no problems with him. I was aware he had sexually inappropriate behaviors when he first arrived. I know at one point he was on 1:1 observations - I was told it was for his behaviors- It was in a report. Psychiatric social technicians and I would be with him during the 1:1 time. I don't know them by name. (V18, Psychiatric Social Worker) usually sat with him during meals. On 03/23/2018 at 1:50 PM, V18, Psychosocial Service, also stated (R219) stayed in his room for the most part during the day. He would usually not come out of his room until the evening and midnight shifts. (R219) would wander around when he knew there was less staff. We discussed it with staff that he knows what he is doing, and when there is no staff around. We tried to keep any eye on him. He liked to wander into other resident's room. I run groups and deal with all behaviors in the building. I was not aware of (R219's) behavior when he was first admitted . I was not aware until after the incident with (R60). R219's physician progress notes [REDACTED]. On 3/27/18 at 12:52 PM, V14, R219's Physician, stated (Current facility) has younger residents and an increased percentage of residents in wheelchairs. I remember (R219) had some history of sexual inappropriateness. Whether it was verbal or physical, I can't recall. If (R219) had physical sexual inappropriate behaviors, I would not expect him to be placed in (Current facility). On 3/28/18, at 3:00 PM, V21, R219's psychiatrist, stated, I don't remember any behaviors with regards to R219. The Facility's Abuse Prevention Facility Procedures, undated, document in part, IV. Establishing a Resident Sensitive Environment The facility desires to prevent abuse, neglect or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: As part of the resident social history evaluation and MDS (Minimum Data Set) assessment, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify problems, goals, and approaches, which would reduce the chance of abuse, neglect or mistreatment for [REDACTED].

Based on record review and interview, the facility failed to provide supervision during a meal to prevent choking, and failed to attempt cardiopulmonary resuscitation on an unconscious resident for one of 4 residents (R2) reviewed for a swallowing difficulty and a change in condition in the sample of 4. This failure resulted in R2's death from asphyxiation from a foreign body on [DATE]. Findings include: R2's EMR (electronic medical record) documents diagnoses, in part, as Oropharyngeal Dysphagia, Intellectual Disabilities, History of Gastrostomy, Aphasia and General Muscle Weakness. The annual Minimum Data Set (MDS), dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 4, which is severely impaired with cognition and decision making, and requires one person limited assistance for eating. The CAA (Care Area Assessment) for R2's nutritional status, dated [DATE], documents, in part, History of [DEVICE] (gastrostomy tube). Receives mechanical soft diet. Can feed self with set up help. Sits at feeder table to ensure she eats. Can eat fast. Monitor for choking. R2's EMR documents a physician's orders [REDACTED]. Supervision required: remind resident to take small bites/sips, reduce rate of intake and alternate food with liquid wash. Do Not Resuscitate (DNR). The Dietary Profile for R2, dated [DATE], documents, in part, Current diet order-mechanical soft. Can feed self with set up help from staff. Is eating in the dining room. At times is observed either in dining room or hall. Eats 75 to 100 percent of food. Needs supervision to remind resident to take small bites, reduce rate of intake and alternate foods with liquids. The facility's Final Incident Investigation Report, dated [DATE] at 5:37 PM, documents, (R2) was noted to be slumped over at her dinner table. (R2) is a DNR (do not resuscitate). With that in mind, staff went with the assumption that (R2) was choking. There were no visible food particles in her mouth at the start of the Heimlich maneuver. Staff began doing the Heimlich immediately, with no positive result, Staff removed (R2) from the dining area. Staff then placed her in the TV (television) room, for privacy and to continue the Heimlich. EMS (emergency medical services) had been called on the onset, and had arrived at this time. They also tried to perform the Heimlich. The EMS pronounced time of death. The Certificate of Death for R2 completed by Z6, Medical Examiner/Coroner, on [DATE] documents, in part, date of sudden death-[DATE] at 6:08 PM. Describe how injury occurred-choked on a hot dog while eating dinner. The Progress Notes, dated [DATE] at 7:03 PM, documents, in part, This nurse (E5, Licensed Practical Nurse, LPN) heard people yelling for a nurse and ran from the front nurses desk into the dining room and saw resident (R2) slumped over. Staff was doing the Heimlich maneuver. This nurse then tried doing the Heimlich maneuver and some food particles came out of resident's mouth. Resident was rushed to TV room, and staff continued to do the Heimlich maneuver to try to get foreign object out. Resident's father (Z3) was in the facility. Staff member called 911. EMS arrived to the facility and assessed (R2) and time of death was 1808 (6:08 PM). This nurse spoke with (Z2), and he stated he would sign the death certificate and that the cause of death was asphyxiation secondary to foreign body in trachea. This nurse spoke with (Z1), Coroner, and was given report on situation. He gave verbal for okay to release body to funeral home. The Prehospital Care Report Summary for R2 prepared by the EMS staff, Z4, Paramedic, dated [DATE] documents, in part, Call received: 17:52:27 (5:52 PM), On scene: 17:59:48 (5:59 PM), Patient Contact: 18:00 (6:00 PM). The Report documents R2 was unconscious, had no lung sounds, color was pale, no capillary refill, normal skin temperature and both pupils were not reactive. The Report documents R2 was in asystole (flatline) and the Glasgow Coma Scale was 3 (normal is between 3 and 15, with 3 being the worst). The Report documents R2 was dead in the field. The Report further documents, AOS (arrived on scene) to find PT (patient) unresponsive, not breathing, sitting in a chair. RN (Registered Nurse) on scene stated PT was eating dinner when she started choking. RN stated performed Heimlich on the PT and was able to get a piece of food dislodged and out of her mouth. RN stated PT was not breathing at that point and was unresponsive. RN stated she could not feel a pulse and PT is a DNR so CPR (cardio-pulmonary resuscitation) was not started. PT was placed on the cardiac monitor showing asystole in 2 leads. RN had the PT's original copy (orange) of the DNR in hand. DNR was filled out properly and all signatures. DNR was honored by EMS. RN contacted (local) county Coroner. PT was left in the care of RN. R2's DNR was signed by her and witnessed on [DATE]. The section for Comfort-Focused Treatment documents, in part, Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of [REDACTED]. R2's Care Plan, dated [DATE], documents, in part, (R2) is at risk for complications with her weight and nutrition related to her swallowing and chewing deficit. She had a [DEVICE] (gastrostomy tube) but on [DATE] [DEVICE] was pulled out and not replaced. She is receiving a mechanical soft diet and requires some assistance with her meals. Interventions-[DATE]: Supervision required. Remind (R2) to take small bites/sips, reduce rate of intake and alternate food with liquid wash. Monitor for signs/symptoms of aspiration: coughing, abnormal lung sounds, elevated temperature. Staff to provide assistance with her meals. On [DATE] at 9:40 AM, E7, Certified Nurses Aide (CNA), stated, It was a hot dog. I was in the dining room serving trays. We serve and observe residents at the same time. (R2) is a mechanical soft and always needs assistance. She feeds herself, I didn't serve her tray. She sits in the back. The hot dog-I can't say if it was cut up. My back was turned to get a tray. I heard someone say (R2) was choking. I turned and saw (R2) with her head down. I said (her name)-no response. She was moving and breathing. I assumed she was choking. I was the closest to her. I started the Heimlich on her. Some hot dog was coming up. Another CNA hollered for a nurse. (E5, LPN) came running. I grabbed her feet and we took her to the TV room and shut the door. She wasn't coughing. It happened so fast. I started crying. I loved (R2). I came out once the nurses took over. I took care of her every day. I've never known her to choke. You have to observe her and see the amount she eats. No trouble swallowing I was aware of. I never opened her mouth to look into it. I was doing the Heimlich the whole time. On [DATE] at 10:00 AM, E5 stated, I heard they needed a nurse STAT (without delay). I ran in there. (R2) was slumped in a chair. No coughing or gasping. She was bluish in color. A CNA-I don't remember who was there. I started the Heimlich, I checked her mouth. It had a little chewed up food on the side of her jaw. I removed the food and continued the Heimlich. There was me and a lot of staff. She was reclined in a high back wheelchair. I had to lean over the back of the wheelchair. At one point she took a breath. We continued until EMS came. The EMS checked for pulse-don't think she had one. They put on EKG (electrocardiogram) leads to see if she had a rhythm. There was no activity. The coroner and (Z2) did not come out (to the facility). The coroner gave authorization to release (R2) to the funeral home. I didn't see her tray. There was a lot of staff in the dining room. You have to tell (R2) to slow down when eating. It happened so suddenly. On [DATE] at 10:22 AM, E6, CNA, reported she was passing meal trays on [DATE] when she heard someone yelling and went over to help R2. E6 reported E7 was performing the Heimlich maneuver on R2 with no response. E6 reported she helped E7 take R2 to the TV room. E6 reported R2 had thrown up. E6 reported staff had to sit at the table to watch R2 eat, but she fed herself. E6 reported she did not know if any staff had been sitting with her at the time she began to choke. On [DATE] at 1:50 PM, E10, CNA, reported she was passing meal trays and had been standing and facing the service window when another CNA told me (R2) wasted a drink. E10 stated, I was standing to the side of the table where (R2) was seated. I went over there to see if she needed another drink. I walked in front of her and saw her head slumped. Her hair was falling forward. I looked down and saw some spit coming out of her mouth. I hollered for another CNA and to get a nurse. The dining room was full of CNA's. With (R2), you just watch her. She eats real fast, but can feed herself. Two or three CNA's came over, and they got the nurse (E5). A nurse or a CNA began the Heimlich maneuver. After that, I got out of the way. (R2) needs encouragement to put food in her mouth one bite at a time and not eat so fast. On [DATE] at 11:10 AM, E11, LPN, reported she responded to the call for help in the dining room during dinner on [DATE]. E11 reported when she entered the area, R2 was slumped over, and E7 was behind R2. E11 reported R2's eyes were open, and her body was jerking due to the Heimlich maneuver. E11 reported R2 was not coughing or gasping when she initially came in to the dining room. E11 reported R2 briefly became responsive, gasped for air and looked around a little. E11 reported she opened R2's mouth, did not see anything and did a finger sweep of her mouth. E11 reported there was nothing in R2's mouth, but had food on her clothes. E11 reported after R2 was moved to the TV room there was a pulse and her color was normal. E11 stated, She was still with us. E11 reported R2 again became unresponsive, and the Heimlich was again performed, with no food return. E11 reported then R2 had no pulse or respirations. E11 reported E9, LPN, checked R2's code status which was DNR. E11 reported she left the area when EMS arrived and took over. E11 reported R2 tried to shove everything in her mouth very quickly and food would spill onto her clothes. The same thing with drinks. On [DATE] at 10:55 AM, E13, Cook, reported he had prepared R2's evening meal on [DATE]. E13 stated, It was mechanical hot dog, crumbled up with bread, mashed potatoes and fruit cocktail. I don't know who served it to (R2). I was back in the kitchen preparing other trays. I didn't hear or see anything. On [DATE] at 10:49 AM, E9, LPN, reported she did not play a big part with R2 that evening, but did call 911 (emergency number) and the EMS came quickly. E9 stated, I have watched (R2) eat. She would shove food in her mouth, you had to really watch her at the dining room table, She would eat with her hands. She did not like assistance. She would get mad and pout like a child. On [DATE] at 12:35 PM, E8, CNA, reported she was in the dining room when she heard someone was choking. E8 stated, I turned around. I was facing the service window. I saw a girl trying to Heimlich her (R2), and nothing came up. (R2) was unconscious with no response. Some of the nurses came in and took her to the TV parlor area. I stayed in the dining room. I saw EMS come and go in there. (R2) always ate on her own and fed herself. She liked to eat real fast, piling food in her mouth. I didn't see anyone sitting with her that day. She was beginning to turn blue at the dining room table. On [DATE] at 3:30 PM, Z2, Physician, was asked if R2 should have had staff sit with her during meals. Z2 stated, I can't tell you off hand. She (R2) puts stuff in her mouth and forgets to chew. That's why I wrote the order like that, so she should slow down. She is more than mildly, but is moderately developmentally disabled with significant cognitive impairment. I wrote to monitor during a meal, and it's a good idea to sit there to remind her. Given the situation, they should sit with her. It happens that quickly, a tragic thing. It's hard to say if staff was negligent. My impression is they should keep an eye on her. The same thing could have happened if they were watching her, but they would have been aware sooner to help her. On [DATE] at 10:25 AM, Z4, Paramedic, reported R2 was sitting in a wheelchair, unconscious, unresponsive with no vital signs or respirations when EMS arrived on the scene [DATE]. Z4 stated, We hooked her to a monitor-in asystole, I believe. Told she had been eating, started choking and they did the Heimlich. I don't recall if they told me they did chest compressions. If she had no DNR, start CPR. Because she had a DNR, nothing we could do. Negative for removing food. There was a piece of hot dog on the floor, a small piece. Like it was cut up. (R2) had no signs of life. I don't recall if they did vital signs, The Heimlich was done. Usually you start with the Heimlich. If not effective and when they become unconscious, you do chest compressions. If no pulse and had a DNR, no chest compressions. On [DATE] at 10:35 AM, Z5, EMT (emergency medical technician), reported he also responded to the 911 call with Z4 on [DATE]. Z5 stated, We went to the private room and she (R2) was sitting in a wheelchair, unresponsive, not breathing. I could tell she choked on something, food-emesis all over her. I think there was brown emesis on the floor, if I'm not mistaken. She (R2) was obviously dead. She was a normal color-had just passed. She had started to turn cool to the touch. We placed EKG electrodes on her and confirmed she was flat lined-asystole. (Z4) called (local hospital) to report and received the time of death. We stuck around and the staff called the coroner. We helped get her in bed so her father could see her, staff had shown us a signed DNR. On [DATE] at 2:00 PM, E1, Administrator, and E2, Director of Nursing (DON), reported they could not confirm that any staff were sitting and supervising R2 during the evening meal on [DATE]. The facility's Meal Service policy and procedure, dated ,[DATE], documents, in part, Residents who require feeding or dining supervision must eat in the dining room. Residents are positioned in an upright position to prevent choking or aspiration. Residents are encouraged to eat by all facility staff, as part of the dining room supervision. The facility's Choking: Heimlich Maneuver policy and procedure, dated as reviewed ,[DATE], documents, in part, The Heimlich maneuver is performed on victims whose airway is obstructed by a foreign object. All staff trained to do the Heimlich maneuver. PR(NAME)EDURE: To identify a complete obstruction if the victim is able to speak or cough. Do not do the Heimlich maneuver on anyone who is coughing or talking. Perform thrusts until the foreign body is expelled or victim becomes unconscious. Once the victim is unconscious: Call for help. Try 2 rescue breaths, give 30 chest compressions, look for the object in the airway, if present remove. If no object present, attempt 2 rescue breaths and repeat process. Repeat sequence until resident is breathing or paramedics arrive. The web site, entitled patient.info/doctor/choking-and foreign-body-airway-airway-obstruction-fbaoand entitled Choking and Foreign Body Airway Obstruction (FBAO) documents, in part, Choking is the physiological response to sudden obstruction of the airways. FBAO causes asphyxia and is a terrifying condition, occurring very acutely, with the patient often unable to explain what is happening to them. If severe, it can result in rapid loss of consciousness and death if first aid is not undertaken quickly and successfully. Immediate recognition and response are of the utmost importance. Choking due to inhalation of a foreign body usually occurs whilst eating. Severe Obstruction-This is indicated by: The victim being able to breathe or speak/vocalize. Wheezy breath sounds. Attempts at coughing that are quiet or silent. Cyanosis and diminishing conscious level. The victim is unconscious. Choking is a risk whenever food is consumed. FBAO represents a true medical emergency in adults, with a mortality rate of just over 3 % (percent). MANAGEMENT-Adults. In severe obstruction in a conscious patient: Stand to the side and slightly behind the victim, support the chest with one hand and lean the victim well forwards. Give up to 5 back blows between the should blades with the heel of your other hand (checking after each if the obstruction has been relieved). If unsuccessful, give up to 5 abdominal thrusts. Continue alternating 5 back blows and 5 abdominal thrusts until successful or the patient becomes unconscious. In an unconscious patient: Lower to the floor. Call an ambulance immediately. Begin CPR (even if a pulse is present in the unconscious victim). The Adult First Aid/CPR/AED (Automated External Defibrillator) ready reference guide from the American Red Cross (undated), page 4 documents, in part, UNCONSCIOUS CHOKING, chest does not rise with rescue breaths. After checking the scene and the injured or ill person: 1. Give rescue breaths, re tilt the head and give another rescue breath. 2. Give 30 chest compressions. If the chest still does not rise, give 30 chest compressions. TIP: Person must be on firm, flat surface. Remove CPR breathing barrier when giving chest compressions. 3. Look for and remove object if seen. 4. Give 2 rescue breaths. If breaths do not make the chest rise-repeat steps 2 through 4. If the chest clearly rises-CHECK for breathing. Give CARE based on conditions found. CPR-No breathing. 1. Give 30 chest compressions. 2. Give 2 rescue breaths. 3. Do not stop. Continue cycles of CPR. Do not stop CPR except in one of these situations: You find obvious signs of life, such as breathing, an AED is ready to use. Another trained responder or EMS personnel take over. You are too exhausted to continue. The scene becomes unsafe.

A. Based on observation, interview and record review, the Facility failed to implement progressive interventions to prevent falls for three of six residents (R1, R10, R17) reviewed for falls in a sample 24. This failure resulted in R1 falling and being hospitalized with a right hip fracture. This failure also resulted in R10 falling and being hospitalized with a left femoral neck fracture. Findings include: 1. The Facility's Unusual Occurrence Tracking Log documents falls for R10 on 8/6/13, 8/17/13, 8/18/2013, 1/16/14, 2/10/14. R10's Incident Investigation for the fall on 2/22/14 documents the fall resulted in a fracture of the left femoral neck. On 3/20/14 at 9:30 AM, E9 and E12, both Certified Nurse Aides (CNA's), transferred R10 from his wheelchair to his bed. They explained the procedure, applied the gait belt and asked for R10 to stand for the transfer. R10's legs were bent during transfer, he did not support his weight or follow directions to stand. The Incident Investigations for R10, dated 1/16/14, 2/10/14, and 2/22/14, all document unwitnessed falls in his room with statements from R10 that he fell while trying to self transfer. The Report for the fall on 2/22/14 at 2:30 PM also documents, R10 was observed on the floor next the the bed. The 2/22/14 radiology report confirms R10 sustained a fracture of the left femoral neck. He was sent to the hospital for treatment. At 3/20/14 at 12:30 PM, an interview was conducted with E14 Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator. E14 explained she assesses each resident for fall risk upon admission to the Facility, quarterly and on significant change. R10's Fall Assessment did not have a score or value to explain his risk level. E14 explained she just uses her opinion about the "risk level" for falls based on each individual's [DIAGNOSES REDACTED]. R10's Quarterly MDS, dated [DATE], and Significant Change MDS, dated [DATE], document R10 is severely cognitively impaired. Both MDS's document R10 requires extensive assist with transferring, bathing, toileting, hygiene and his balance is such that he cannot stabilize himself without staff support and he does not ambulate. R10's Quarterly Care Plan for 11/11/13, Significant Change Care Plan for 1/9/14 and Re-entry/Significant Change Care Plan for 2/26/14 have no documentation of new safety interventions after each fall. Interventions included: 8/6/13 alarm added to R10's bed; 8/17/13 added to R10's wheelchair; 8/18/13 R10 placed on the "Orange Fall Program". The safety interventions for falls on 1/16/14 and 2/10/14 were updated dates for alarms on bed and wheelchair. The Facility's undated Think Orange Policy documents (in part), "All residents with orange name tags are a fall risk. They (the residents) cannot be left alone while in their rooms. They will be encouraged to attend activities of choice or will be closely monitored in the common areas." 2. The Incident Investigations for R1, dated 9/13/13, 11/16/13, and 11/23/13, all document unwitnessed falls in his room with statements from R1 that he fell while trying to put himself to bed. R1's fall on 11/23/13 resulted in R1 being hospitalized with a right hip fracture. R1's 11/5/13 MDS, documents (in part): R1 requires extensive assistance of 2 persons to transfer and to ambulate. R1's Falls Care Plan, last revised on 11/23/13, documents (in part): "(R1) is high risk for falls due to his Dx (diagnosis) of Dementia and his past history of frequent falls. (R1) is not safe to transfer on his own but make frequent attempts to do so. Interventions: 5/7/10 Initiate orange card program for fall prevention." In an interview on 3/25/14 at 2:00 PM, E2, Director of Nurses (DON), stated, "He (R1) is on the Orange Card Program which is they aren't supposed to be left in their rooms alone. He (R1) is one who finishes his meal quickly. Then (R1) wants to go smoke, but he must be supervised for smoking. If he (R1) can't smoke, then he is ready to go to bed. He (R1) can propel himself in the wheelchair and takes himself to his room. For those falls in November (2013), he (R1) shouldn't have been in his room unsupervised and he tried to put himself to bed." 3. On 03/20/2014 at 12:10 PM, R17 was sitting in wheel chair in dining room awaiting lunch. On 03/21/2014 at 10:25 AM, R17 was wheeling herself down the hallway. The 01/10/14 at 6:30 AM Facility Incident Investigation Report, documents R17 was found sitting on her buttocks on floor. R17 had been walking throughout the facility with a wheeled walker. R17 was not injured in this fall. The facility ordered a chest X-ray for R17. R17 was found to to have pneumonia and an antibiotic was ordered. On 01/14/2014 at 1:45 PM, the Facility Incident Investigation Report , Documents R17 was found lying on her back in the whirlpool room. R17 ambulated with her wheeled walker. An injury was not documented. The Facility documented that an oxygen saturation should be done on her three times daily. On 01/19/2014 at 7:00 PM, R17's Facility Incident Investigation Report documents R17 was found on the floor in front of dietary office on the east wing. R17 was not using her wheeled walker. R17 complained of shoulder pain, but an injury was not documented. The facility ordered a reevaluation of her gait and walker safety per Restorative Therapy. On 01/22/2014 at 9:30 PM, the Facility Incident Investigation Report documents R17 was found on the floor in the central hallway. An injury was not documented. The Facility ordered Physical therapy to evaluate and treat R17. On 01/31/2014 at 2:30 PM The Facility Incident Investigation Report documents R17 fell on her bottom ,while trying to seat herself in the dining room. An injury was not documented. The facility ordered the Activity Department to monitor R17, while she is in the dining room. On 02/02/14 at 6:20 AM The Facility Incident Investigation Report documents R17 fell , while trying to seat self in the dining room. A small abrasion was on R17's forehead. The Facility ordered a wheelchair to be used, whenever the R17 feels weak. A personal alarm was added to the wheel chair. On 03/21/2014 at 1:05 PM E 5 Licensed Practical Nurse (LPN) was interviewed concerning where oxygen saturation results are found. E5 stated "they are found on the computer." On 03/21/2014 at 1:15 PM E6 LPN was interviewed concerning the restorative and walker safety evaluation that was ordered per the Facility. E6 stated "a functional balance exam was done to see whether R17 could stand or not, but that is all I did." On 03/21/2014 at 1:10 PM E7, Activity Director, was asked if they monitored R17 for falls during meals. E7 stated "the activity department makes sure R17 has a seat in the dining room, and gives R17 a wet wipe as she leaves the dining room." On 03/21/2014 After reviewing the Care Plan interventions, for the falls dated 01/10/2014 through 02/02/2014. 01/10/2014 obtain a chest X-ray, 01/14/2014 monitor oxygen saturations three times daily, 01/19/2014 restorative is to evaluate gait and walker safety, 01/22/2014 skilled therapy to evaluate R17 ,1/31/2014 R17 is to remain with activities during mealtimes. As documented above three of these interventions were not implemented per staff. B. Based on observation, record review, and interview, the facility failed to properly assess, evaluate, and monitor the use of side rails and failed to follow the U.S. Food and Drug Administration guidelines to reduce the risk for entrapment for one of four residents (R7) reviewed for side rails in the sample of 24 and five residents (R25, R26, R27, R28 and R33) in the supplemental sample. Findings include: 1. The U.S. Food and Drug Administration (FDA) publication "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment - Guidance for Industry and FDA Staff" issued March 10, 2006 documented "To reduce the risk of head entrapment, opening in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped." The publication documented "FDA is therefore using a head breadth dimension of 120 mm (millimeters) (4 3/4 inches) as the basis for its dimensional limit recommendations." The publication documented regarding neck entrapment "To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become entrapped." The publication documented "The FDA is recommending 60 mm (2 3/8 inches) as an appropriate dimension for neck diameter." The publication documented regarding chest entrapment "The openings in a bed system should be wide enough not to trap a large chest through the openings between split rails. The FDA's dimensional limit for the chest is 12 1/2 inches." The publication documented a potential area for entrapment as "Zone 1: Within the Rail." 2. On 3/18/2014, at 1:45 PM, R7 was lying in his bed. R7's bed was equipped with an assist rail on the top left side of his bed. The assist rail was in the up position. The opened area within the rail measured 7 1/4 wide by 20 inches long. R7 has full range of motion in his upper extremities and uses the side rail for turning and repositioning. 3. On 3/19/2014, at 10:26 AM, R28 was lying in bed. R28's bed was equipped with assist rails on the top left and right sides of his bed. The assist rails were in the up position. The opened area within the rails measured 7 1/4 inch wide by 20 inches long. R28 was using the side rails for turning and repositioning in bed. 4. On 3/19/2014, at 11:17 AM, R25 was lying in bed. R25's bed was equipped with an assist rail on the top right side of her bed. The assist rails was in the up position. The opened area within the rail measured 7 1/4 wide by 20 inches long. R25 was using the side rails for turning and repositioning in bed. 5. On 3/19/2014, at 11:18 AM, R26 was lying in her bed. R26's bed was equipped with assist rails on the top left and right sides of her bed. The assist rails was in the up position. The opened area within the rails measured 7 1/4 inch wide by 20 inches long. R26 was using the side rails for turning and repositioning in bed. 6. On 3/19/2014, at 11:19 AM, R27 was lying in her bed. R27's bed was equipped with assist rails on the top left and right sides of her bed. The assist rails were in the up position. The opened area within the rails measured 7 1/4 inch wide by 20 inches long. R27 utilizes the side rails for turning and repositioning in bed. 7. On 3/19/2014, at 4:04 PM, R33 was lying in her bed. R33's bed was equipped with assist rails on the top left and right sides of her bed. The assist rails were in the up position. The opened area within the rails measured 7 1/4 inch wide by 20 inches long. R33 utilizes the side rails for turning and repositioning in bed. 8. On 3/20/2014, at 9:30 AM, an interview was conducted with E1, Administrator. E1 stated she was not aware of the FDA guidelines regarding side rail safety. E1 stated the Facility has used the "assist rails" for years.

Based on interview, observation and record review the facility failed to consistently monitor for hemoglobin and platelet levels, failed to promptly identify signs and symptoms of bleeding in the form of pinpoint rashes and bleeding of the gums, failed to promptly and accurately assess and provide interventions for hypoglycemic episodes for 4 of 8 residents (R3, R5, R7 and R12) reviewed for change in condition in the sample of 14. This failure resulted in R3 being hospitalized with critiacl laboratory values. Findings include: 1. R3's Hematology Consultation Notes dated [DATE] documents, " Reason for consult: [MEDICAL CONDITION] and [MEDICAL CONDITION]. (R3) was diagnosed with [REDACTED]. (R3) and (Z5, R3's Power of Attorney) decided on [DATE] they did not want to be treated for [REDACTED].I would recommend that a CBC be checked on a monthly basis and when (R3) becomes symptomatic or hemoglobin drops to below 7.5 be transfused with red cells. If his platelets decline to less than 10,000 or if bleeding, he should be transfused with platelets. " R3's Physician order [REDACTED]. Monthly CBC results from ,[DATE] through ,[DATE] document levels of hemoglobin and platelets were above 7.5 and 10,000 respectively. R3's Care Plan for Low Hemoglobin and Hematocrit reviewed [DATE] documents, "Interventions: Monitor for increased fatigue and signs/symptoms of bleeding; Routine lab work per MD orders; Monitor labs; Monitor for weakness and pale skin; Monitor symptomatically for [MEDICAL CONDITION] and notify MD. R3's shower sheets with their corresponding dates indicate as follows: [DATE]- No open areas, no bruising, [DATE]- No sores, [DATE]- No sores, [DATE]- Refused, [DATE]- No skin problems, [DATE]- No open areas. R3's Nurses Note dated [DATE] at 1:35 PM, documents R3 was seen and evaluated by Z1, Primary Physician, at the facility with new order to send to local hospital for evaluation of diffuse rash to all extremities spreading to face, shortness of breath, O2 sat=97% room air. R3's emergency room Report dated [DATE] documents, "Generalized body rash for days, bleeding to gums. Hemoglobin 6.8 Critical Low (13XXX,[DATE].0 grams/deciliter), Platelets 0 Critical Low(,[DATE])x10 3/ul. Hospital Discharge Summary dated [DATE] documents final Diagnoses: [REDACTED]., severe [MEDICAL CONDITIONS] of acute blood loss, diffuse petechiae skin rash, osteopenia. Overall prognosis was poor, process of recovery was very poor, family members decided for hospice care. R3 was discharged to hospice care and expired on [DATE]. In an interview on [DATE] at 11:30 AM, E2, Director of Nursing, DON, stated the nurse should call the doctor if the resident refuses any blood draw and document it in the progress notes. In an interview on [DATE] at 1:26 PM, E11, Certified Nursing Aide, CNA, stated she worked on R3's hall on [DATE] and noticed the rash on his face earlier in the day and added R3 told him it had been there for days. On [DATE] at 10:00 AM, the facility presented a written laboratory requisition form for CBC dated [DATE] with a handwritten notation, 'MD notified. Resident refused x2.' Another laboratory requisition form for CBC dated [DATE] had a notation,' Resident refused. MD notified. ' Both forms were unsigned. There is no documentation to show attempts were made in other days in January or February to ask R3 for blood draw for CBC. In an interview on [DATE] at 11:45 AM, Z3, Manager of Laboratory Services, stated any refusal for lab draw will show in the system and there were no such record for R3 on [DATE] and [DATE]. In an interview on [DATE] at 11:42 AM, Z1, R3's Physician, stated he was not aware R3 refused blood draw in January and February. Z1 added they should have been notifying him. Z1 stated he was in the facility on [DATE] to see patients but R3 was not on his list to see that day. Z1 stated it was not staff but another resident who told him to check on R3 because R3 did not look right. Z1 stated he saw R3 was clearly short of breath and had diffuse red pinpoint dots on his arms and legs. Z1 added R3 told him he had the rash for about a week. Z1 stated he ordered for R3 to be sent to the hospital right away. 2. R5's Minimum Data Set ((MDS) dated [DATE] documents R5 is independent with activities of daily living. R5's MDS dated [DATE] documents total dependence on staff for all activities of daily living. The MDS documents multiple [DIAGNOSES REDACTED]. R5's POS dated [DATE]/ through [DATE] documents medications to include: [MEDICATION NAME] 5 mg by mouth twice a day, [MEDICATION NAME] ([MEDICATION NAME]) 1 mg solution injection, as needed, give for BS less than 60, [MEDICATION NAME] 850 mg by mouth twice daily. The POS documents blood glucose monitoring twice a day. R5's Medication Administration Record [REDACTED]. R5's MAR indicated [REDACTED]. R5's Nurses Note dated [DATE] at 1:04 PM, documents, " (R5) in bed sleeping has only got up for a brief few minutes to take medication. (R5) was cleaned up and changed by staff...snoring and having rise and fall in chest. (R5) responds to sternal rub but only for a few seconds. (R5) has not eaten all day. " R5's Nurses Note dated [DATE] at 3:08 PM, documents, "CNA (Certified Nursing Aide) came to this nurse (E17, Licensed Practical Nurse, LPN)) stated resident was still in bed and that resident was shaking. This nurse took resident's blood sugar was 29. This nurse called for nursing office to come assist. This nurse got the order for [MEDICATION NAME] injections from (Z8, Nurse Practitioner). After [MEDICATION NAME] injection, BS increased to 33. Rechecked BS 5 minutes later was 26. Given another injection of [MEDICATION NAME] and BS rechecked was 56. EMS was called got order to send to local hospital. Also obtained order for Amp D50. IV started. EMS arrived and took over. In an interview on 3/ ,[DATE] at 1:15 PM, E17 stated she noticed that on [DATE] R5 was very lethargic when she gave R5 her 8 AM medications and took her blood sugar reading of 145. E17 stated R5 did not eat breakfast and she did not know if R5 had lunch. E17 added E13, Resident Technician, came up to her prior to lunch and asked her to check on R5. E17 stated R5 was snoring and responded for a few seconds to sternal rub. E17 stated she gave R5 a shot for agitation the day before and thought R5 was just catching up on sleep. E17 stated R5 would be up for days, not sleeping and then crash. E17 added at around 1 PM staff told her R5 was shaking and she went in the room and checked her blood sugar which was initially in the 20's and she administered [MEDICATION NAME] twice, started D50 intravenous and had an order for [REDACTED]. In an interview on [DATE] at 1:26 PM, E13 stated that on [DATE] at 7 AM, she received a verbal report from the night shift that R5 slept all night long and she thought it was unusual for R5 to be sleeping all night so she checked on her and tried to wake her up. E13 stated she did sternal rub and R5 would just move her arms slightly and would not wake up. E13 stated she checked on R5 every chance she got and notified E17 at least 3 times before lunch. E13 stated E17 went to see R5 around 11 AM. E13 stated E17 told her R5 got a shot the day before and was okay. E13 stated around 1:55 PM, E14, Resident Technician, noted R5 was having jerking movements and E17 was called to assess R5. In an interview on [DATE] at 9:54 AM, Z6, R5's Attending Physician in the hospital, stated R5 had prolonged [DIAGNOSES REDACTED] which resulted in [MEDICAL CONDITION]. Z6 stated what precipitated the dropping of the blood sugar was the fact that R5 was given her oral antidiabetic medications that morning and she may not have eaten anything at all. Z6 stated he would have expected the nurse to take another set of vital signs, check mental status, check her blood sugar when the resident showed signs of lethargy. R5's hospital Discharge Summary dated [DATE] documents, "Discharge Diagnoses: [REDACTED]. Hospital Course: admitted to the Intensive Care Unit from ER . Resident apparently sustained prolonged [DIAGNOSES REDACTED] which resulted in her [MEDICAL CONDITION]. A request for a gastrostomy tube to be placed for feeding and medication was performed. Her condition became stable and she was released back to the nursing home." 3. Progress Notes undated, document R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's Brief Interview of mental status (BIMS) dated [DATE], documents a score of 9 with 15 being the highest cognitive function. R7 requires extensive assistance of two staff members with activities of daily living (ADL's). Physician order [REDACTED]. According to the Medication Administration Record [REDACTED] Nurses' Notes dated [DATE] at 1:51 PM, documents R7 took oral medications without difficulty and has poor appetite. On the same day at 3:02 PM Nurse's Notes state "R7 hard to arouse, blood sugar = 28, [MEDICATION NAME] given x 2, 15 minute intervals apart. Resident awaken, blood sugar presently = 58." No further blood glucose monitoring is documented in R7's clinical record for [DATE] Nurses' Notes dated [DATE] at 6:13 AM, documents R7's "BS (Blood sugar) 22. [MEDICATION NAME] administered. BS 94 45 minutes later." On the same day at 2:24 PM documents R7 "wasn't looking right. Upon further investigation, E16 found resident to decreased in mental function. Resident was unable to make a coherent sentence." In a telephone interview on [DATE] at 3:15 PM, E16 stated he cared for R7 on [DATE] and that R7 looked worn out and that R7 said he felt tired. E16 stated that he did not monitor R7's blood glucose during shift because R7 gets routine blood glucose monitoring. R7's lab results dated [DATE] at 3:35 PM documents R7's serum glucose level as less than 31 milligrams per decilitre (mg/dl). In a telephone interview on [DATE] at 12: 30 PM, E18 stated she cared for R7 on [DATE] during the evening shift and R7's blood sugar was low maybe 50 or 60 and she (E18) got a nutritional supplement for R7 to drink. R7 drank the supplement and R7's blood sugar was brought up to 80 about an hour later but dropped back down to low 50's. E18 is unsure of the time of R7's hypoglycemic episode during her shift but thought it was close to shift change which was ,[DATE]:30 PM. E18 stated she does not recall if she documented R7's hypoglycemic episode in R7's clinical record. No documentation or further blood glucose monitoring found in R7's clinical record. 4. R12's Minimum Data Set ((MDS) dated [DATE] documents R12 is extensively dependent upon two staff members for Activities of Daily Living (ADL's) and a Brief Interview of Mental Status (BIMS) score of 8 with 15 being the highest cognitive function. R12 is a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 12:40 PM, E19 Licensed Practical Nurse, (LPN) was informed by dining staff that R12 complained of nausea and was not eating lunch. R12 was seated in her wheelchair in the dining room at the lunch table with her (R12's)lunch tray untouched. E19 wheeled R12 over to the medication cart to check for orders for nausea medicine. R12 was shaking and sweating profusely. E19 told R12 "you look tired." E19 took R12's blood glucose using a blood glucose monitoring device. R12's blood glucose reading was 66. R12 continued to sweat, soaking through her (R12's) shirt. E19 stated "she didn't eat any lunch and doesn't want any." E19 stated she was going to lay her down and change R12's shirt because it was wet with sweat. E19 gave R12 a nutritional supplement to drink and said R12 could come back out to dining room after she cooled off. When asked by E19 if she(R12) was hungry, R12 nodded yes. E19 wheeled R12 back to R12's room where she opened her window and said to R12 "you got a bit of a hot flash." E19 left R12 in her room and came back with one package of saltine crackers and carton of milk. R12 declined the milk but attempted to eat one of the crackers. E19 told R12 she would take her (R12) to the dining room but if R12 got hot again E19 would take her out of dining room. E19 then wheeled R12 out to dining area where R12 remained at her table until she was taken to her room to lie down and change shirts. R12's meal tray remained on the table untouched. On the same day, at 12:55 PM in the [MEDICATION NAME] Hall, E19 stated she was unsure of how many carbohydrates were in the nutritional supplement that was given to R12. E19 stated that R12 takes [MEDICATION NAME] mix every morning and get insulin at night and usually snacks all day but did not have any snacks today. At 1:30 PM R12 was laying in her bed with eyes closed when E 20 asked R12 if she was hungry. R12 nodded yes and E20 went to get a sack lunch. R12 just smiled when asked how she was feeling. On the same day, at 1:35 PM, E19 was at the nurses' station and stated she was going to check on R12 right now. E19 proceeded to R12's room where E20 was assisting R12 in setup of a bag lunch. E19 performed a blood glucose screen using a blood glucose monitoring device. R12's blood glucose at that time was 210. E19 stated that R12 had eaten a few bites of R12's desert during lunch and had one saltine cracker and the nutritional supplement which brought R12's blood sugar up to 210 but R12 had just gotten hot. E19 further stated it was her (E19's) professional opinion that R12 was having a hot flash and that she was in the age group to be having hot flashes. On [DATE] at 2:00 PM, during an interview with E2, DON stated that the Facility's practice in managing a hypoglycemic episode is to recheck the blood glucose to ensure results are correct. Once results are verified, residents receive a "boost" to increase blood sugar such as orange juice or snack. Staff should check physician orders [REDACTED]. E2 stated he was not aware of the hypoglycemic episode for R12 on [DATE]. E2 further stated that the Facility's Policy "Nursing Care of the Adult Diabetes Mellitus Resident" did not address management of a resident with [DIAGNOSES REDACTED] and there were no other Facility policies/procedures concerning management of [DIAGNOSES REDACTED]. The Facility's Policy "Nursing Care of the Adult Diabetes Mellitus Resident" dated [DATE] does not document interventions in treating a resident with [DIAGNOSES REDACTED].

Based on record review and interview, the facility failed to provide necessary services, failed to assess and monitor for adequate food and fluid intake, and failed to intervene timely for one (R22) of twelve residents identified with weight/nutrition concerns in the sample of 24. This failure resulted in a weight loss of 30.8 pounds (19% of body mass) in 3 months and hospitalization for severe dehydration, severe [MEDICAL CONDITION], and [MEDICAL CONDITION] secondary to dehydration for R22. Findings include: R22 has partial [DIAGNOSES REDACTED]. R22's 12/22/10 Care Plan described a Care Plan Problem for Nutrition, due to her [DIAGNOSES REDACTED]. The goal listed was to maintain adequate nutrition and show weight loss in an appropriate way...with interventions "Monitor nutritional status, monitor residents food intake and document, monitor weight and labs." The interventions also include: "Offer substitutes for uneaten food, assist resident with meals as needed." There is no Care Plan problem listed for potential for dehydration. R22's Dietary Note dated 12/22/10 documents "(R22) weighed 182.1 in November 2010; Res. weighs 189 in December 2010. No significant weight change. Res. is currently on a LCS (low concentrated sweets) pureed diet, ...fruit for dessert, skim milk BID and double vegetables. Res. is compliant. (R22) intakes 90 - 95% of all meals. Res. is currently on a snack and snack times and intakes 85 - 90%.....no current pressure sores.....does not need changes to her diet or plan at this time..." R22's Nutritional assessment dated [DATE] estimated her nutritional needs at 2075 calories, 83 grams of protein, and 2500 cc fluid per day. On 2/10/11 R22 fell in the facility and sustained a fracture. An orthopedic consultation by Z1, Physician dated 2/13/11 documented a Right Hip Subcapital Femoral Fracture, with old right [MEDICAL CONDITION] midshaft. Surgery was not recommended, and R22 returned to the nursing home on 2/13/11 to receive supportive care. R22 was placed on Hospice on 2/13/11, remained on bedrest, and totally dependent on staff for all activities of daily living. R22 needed to be fed by staff at all meals. R22's care plan for nutrition remained unchanged. R22's food intake sheets were reviewed. Her intake prior to hospitalized from [DATE] until 2/12/11 showed an average of 75 - 100% intake of all meals. After returning from the hospital on [DATE], R22's intake began to drop. On 2/13 and 2/14/11, her intake was recorded 75 - 100% for 4 meals; 51 - 75 % for 7 meals. On 2/15/11, her intake fell to 26 - 50%. From 2/15/11 until 3/5/11, R22 ate less than 25% for one or more meals on 2/17, 2/26, 2/27, 2/28, 3/1, 3/3, 3/4, and 3/5/11. R22 ate less than 50% for one or more meals on 2/15, 2/16, 3/2, and 3/3/11. R22's fluid intake is not documented. There is no documentation that R22 was offered additional food or fluids, or substitute foods during this time period. R22's Nursing Progress Notes and Hospice Notes were reviewed and contained limited documentation that nursing staff or hospice staff were reviewing her poor intake records, and offering additional interventions. The Nursing Progress Notes documented on R22's food and fluid intake on 2/15, "appetite good et fluid intake adequate", on 2/17, "lets water run out of mouth"; on 2/18, "Sm amts of food and fluids given". The Hospice Progress Notes documented on R22's food and fluid intake only on 2/15/11, "Continue on a general diet, with pureed texture and nectar thick liquids."; and on 2/28/11, "Continue on a general diet.....Appetite fair on general diet.....Feeding by staff. Previous weight 172 and present weight of 168 pounds with 5 pound loss." On 3/5/11 R22 was taken to the hospital emergency room . She was unresponsive with a temperature of 103.1, and blood pressure 94/67. emergency room records dated 3/5/11 documented she had (in part): Urinary Tract Infection with Urosepsis,[MEDICAL CONDITION] with [MEDICAL CONDITION], Severe Dehydration with acute [MEDICAL CONDITION], Severe [MEDICAL CONDITION], and Acute [MEDICAL CONDITION]. Laboratory results showed 4+ bacteria in her urine, BUN was elevated - 57 (normal 10 - 20), Creatinine was elevated - 2.9 (normal 0.5 - 1.1), Sodium was elevated 181 (135 - 145). Elevations of these levels indicate dehydration. R22 was admitted to Intensive Care On 4/26/11 during telephone interviews, E2, Director of Nursing, stated the facility nurses were aware of R22's poor food and fluid intake, but E2 was unable to provide any documentation from R22's record that indicated the nursing staff was assessing, monitoring, and providing additional interventions to address R22's poor food and fluid intake. E2 stated that R22 was on "palliative care".

Based on record review and interview the facility failed to assure that staff operated mechanical lifts properly during transfers to prevent accidents for 1(R2) of 3 resident incidents reviewed resulting in an injury, of 3 residents on sample. This failure resulted in R2 being hit in the head by the bar on the mechanical lift and sustaining a laceration to the head, requiring being transferred to the hospital for sutures. Findings include: R2, according to her February 2011 physician order [REDACTED]. The facility's investigation report states that on 3/4/2011 R2 was being transferred from her bed into her wheelchair with a mechanical lift when it tilted forward. The bar hit her on the head causing a one inch laceration. Her doctor and family were notified and she was sent to the hospital for evaluation and sutures. On 3/14/11 at 10:45 AM R2 was interviewed. She recalled the incident and said that she was being transferred using a lift when she was hit by a metal bar on the lift. She said there were two or three staff present but that she did not remember any names. E3, Certified Nursing Assistant, on 3/14/11 at 11:30 AM, stated that she was present during the transfer on 3/4/11 when R2 was injured by the mechanical lift. She said that there were four staff present in the room. They had transferred R2 from her bed into her wheelchair when they noticed she was not adjusted very well in the chair. They then lifted her again and pulled her back into her chair at the same time, causing the lift to fall forward hitting R2 in the forehead.

Based on observation, record review and interview, the facility failed to ensure 2 (R4, R19), of 5 residents reviewed for falls, on the sample of 14, be transferred safely and have a safety alarm attached with staff responding appropriately. Findings include: 1. R19's Care Plan of 5-3-11 identifies her as being at high risk for falls. The Care Plan documents R19 is limited assist of one staff for transfer and staff are to apply gait belt and wheeled walker for support during transfer. R19 was observed on 6-1-11 at 1:02PM to be transferred from her wheel chair to bed by Hospice Certified Nurse Aide, CNA. The CNA did not remove R19's wheel chair pedals prior to the transfer and did not use a gait belt or walker. In an interview with E1, Administrator, on 6-3-11 at 10:15AM, E1 stated Hospice Director had been informed of concern and the CNA has been inserviced. 2. R4's Care Plan of 4-29-11 identifies R4 as being at high risk for falls related to Cerebral Vascular Accident, weakness and requiring assistance with transfer and ambulation. The Care Plan approach, in part, is to have a personal alarm in wheel chair. On 6-1-11 at 11:15AM, R4 was observed to stand from his wheel chair and go into the bathroom by himself. R4's alarm was sounding. E9, CNA, was observed to walk by the room with a bag of soiled laundry and proceeded to take the laundry to the soiled linen room, walk up to the Nurses Station and then go respond to R4's alarm. On 6-2-11, E1 stated staff should respond to residents alarms immediately. On 6-2-11, R4 was observed to be in his room in his wheel chair with no alarm attached. E7 was in the room caring for R4's roommate. E7 was asked about R4's alarm and stated he does have an alarm. E7 came over to R4 and attached the alarm.