Every finding on record at Bria of Forest Edge

Based on observation, interviews and record review, the facility failed to ensure that a resident's (R1) left eye bruise, which was due to unknown cause, was reported to the Illinois Department of Public Health (IDPH) within two hours of discovery. This failure has affected one resident (R1) of four reviewed for abuse. Findings include:R1 is [AGE] year old with diagnosis including but not limited to: aphasia, dysphagia following cerebral infarction, functional quadriplegia, generalized anxiety disorder, major depressive disorder contracture to right hand and wrist, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side.R1's BIMS (Brief Interview of Mental Status) score dated 6/24/26 is 12, which indicates moderate cognitive impairment.On 8/18/26 at 10:30 am, R1 was observed with discoloration around his left eye as he sat in a geriatric chair near his bed with involuntary movements.At that time, R1 attempted to explain what happened to his eye, but Surveyor could only understand when R1 stated, He hit me.On 8/18/26 at 10:33 am, R2 (R1's roommate) stated the following, I know what happened to him (R1). I'm visually impaired, but I heard when he (R1) was hit. It was on the night shift last week. A Nigerian woman was standing near his bed, and I heard her (V9, Certified Nursing Assistant, CNA) say 'He touched my breast'. After that, I heard her (V9) hit him (R1) with an open hand. It was like a slap.On 8/18/26 at 10:50 am, V3 (Director of Nursing) stated the following, Last week, I believe on Tuesday (8/11/26), V7 (LPN/ Licensed Practical Nurse) reported to me (V3) that (R1) had a black eye. No report was done, because he has a history of throwing himself on the floor. The NP (Nurse Practitioner/ V15) ordered and x-ray of his face and it came back negative for any fractures.On 8/18/26 at 11:00 am, V4 (Nurse Supervisor) stated the following, I was told by (V7, LPN) that (R1) had a bruise around his eye. I didn't assess (R1). No, I didn't report it because my shift was ending. The Administrator (V1) is the abuse coordinator. I don't know what a mandated reporter is. I am not a mandated reporter. I think (V1) is a mandated reporter. I have been a nurse for eight years.On 8/18/26 at 12:53 pm, V1 (Administrator) stated the following, I have just submitted the report and initiated the abuse investigation. All of the Nigerian staff that worked on the night shift of 8/10/26 have been suspended just to be on the safe side. I want to ensure the safety of R1 and all residents. If I knew about (R1's) eye before today, I would have easily reported it and investigated. All injuries or bruises of unknown origin should always be reported to me so that I may report to the State.On 8/18/26 at 2:45 pm, V7 (LPN/ Licensed Practical Nurse) stated the following, I work part-time and I am familiar with (R1). I'm not sure of the day, but when I was there, I noticed redness underneath his left eye and immediately reported it to the DON (V3). On that day, I had heard (R1) talking to V4 (Nurse Supervisor). She then reiterated to me that R1 said that he hit his face on the headboard. I have not heard of (R1) being sexually inappropriate with staff and I have not heard anything about (R1) being hit by a staff member. R2 (R1's roommate) BIMS (Brief Interview of Mental Status) score dated 7/7/26 is 15, which indicates cognitively intact.R1's Skin Screen dated 8/14/26 documents a bruised right eye.R1's care plan dated 9/19/23 documents, R1 is vulnerable for abuse due to poor insight/ judgement, poor communication skills, poor ambulation, weakness, and present mental health diagnosis. R1's progress note dated 8/12/26 and written by V15 (Nurse Practitioner) documents the following, R1 seen at bedside lying on the floor. This is reported to be a recurrent behavior per nursing. R1 in stable condition. NAD (no abnormality detected). Left eye ecchymosis noted, x-ray pending. Facility Initial Report dated 8/18/26 documents: R1 as an alleged victim of abuse due to a bruise of unknown origin; R1 stated that he was hit in the face by staff.Facility Abuse policy dated 9/2017 documents: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of property they observe, hear about, or suspect to the administrator immediately; The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered; All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of property occurred, was alleged or suspected.

Based on observation, interviews and record review, the facility failed to conduct an investigation of potential abuse involving one resident (R1) of four reviewed for abuse. This failure has resulted in R1's left eye bruise being unaddressed for over one week after being discovered.Findings include:R1 is [AGE] year old with diagnosis including but not limited to: aphasia, dysphagia following cerebral infarction, functional quadriplegia, generalized anxiety disorder, major depressive disorder contracture to right hand and wrist, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side.R1's BIMS (Brief Interview of Mental Status) score dated 6/24/26 is 12, which indicates moderate cognitive impairment.On 8/18/26 at 10:30 am, R1 was observed with discoloration around his left eye as he sat in a geriatric chair near his bed with involuntary movements. R1 attempted to explain what happened to his eye, but Surveyor could only understand when R1 stated, He hit me.On 8/18/26 at 10:33 am, R2 (R1's roommate) stated the following, I know what happened to him (R1). I'm visually impaired, but I heard when he (R1) was hit. It was on the night shift last week. A Nigerian woman was standing near his bed, and I heard her (V9, Certified Nursing Assistant, CNA) say 'He (R1) touched my breast'. After that, I heard her (V9) hit him (R1) with an open hand. It was like a slap.On 8/18/26 at 10:50 am, V3 (Director of Nursing) stated the following, Last week, I believe on Tuesday (8/11/26), V7 (LPN/ Licensed Practical Nurse) reported to me (V3) that (R1) had a black eye. No report was done, but I asked (V7) what happened and she (V7) said that he (R1) has a history of throwing himself on the floor. That was pretty much the investigation, but I don't believe that it was documented.On 8/18/26 at 12:53 pm, V1 (Administrator) stated the following, There has not been an investigation conducted regarding (R1's) eye bruise. If I knew about (R1's) eye before today, I would have easily reported it and investigated. No on notified me of (R1's) injuries or the allegations. All injuries or bruises of unknown origin should always be reported to me so that I may report to the State and start an investigation. It is important to investigate unknown injuries and allegations of abuse in order to protect the residents and keep them from continued abuse.R2 (R1's roommate) BIMS (Brief Interview of Mental Status) score dated 7/7/26 is 15, which indicates intact cognition.R1's Skin Screen dated 8/14/26 documents a bruised right eye.R1's care plan dated 9/19/23 documents, R1 is vulnerable for abuse due to poor insight/ judgement, poor communication skills, poor ambulation, weakness, and present mental health diagnosis. R1's progress note dated 8/12/26 and written by V15 (Nurse Practitioner, NP) documents the following, R1 seen at bedside lying on the floor. This is reported to be a recurrent behavior per nursing. R1 in stable condition. NAD (no abnormality detected). Left eye ecchymosis noted, x-ray pending. Facility Initial Report dated 8/18/26 documents: R1 as an alleged victim of abuse due to a bruise of unknown origin; R1 stated that he was hit in the face by staff.Facility Abuse policy dated 9/2017 documents: This facility is committed to protecting our residents from abuse neglect, exploitation, misappropriation of property or mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of property will result in an investigation; For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source.

Based on observations, interviews and record review the facility failed to protect the resident's right to be free from physical and mental abuse by V9. This failure has affected one of four residents reviewed for abuse. Findings include:R1 is [AGE] year old with diagnosis including but not limited to: aphasia, dysphagia following cerebral infarction, functional quadriplegia, generalized anxiety disorder, major depressive disorder contracture to right hand and wrist, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side.R1's BIMS (Brief Interview of Mental Status) score dated 6/24/26 is 12, which indicates moderate cognitive impairment.During investigation on 8/18/26 at 10:30 am, R1 was observed with discoloration around his left eye as he sat in a geriatric chair near his bed.At that time, R1 attempted to explain what happened to his eye, but Surveyor could only understand when R1 stated, He hit me.On 8/18/26 at 10:33 am, R2 (R1's roommate) stated the following, I know what happened to him (R1). I'm visually impaired, but I heard when he (R1) was hit. It was on the night shift last week. A Nigerian woman was standing near his bed, and I heard her (V9, Certified Nursing Assistant, CNA) say 'He (R1) touched my breast'. After that, I heard her (V9) hit him (R1) with an open hand. It was like a slap.R2 (R1's roommate) BIMS (Brief Interview of Mental Status) score dated 7/7/26 is 15, which indicates cognitively intact. On 8/18/26 at 10:50 am, V3 (Director of Nursing) stated the following, Last week, I believe on Tuesday, V7 (LPN/ Licensed Practical Nurse) reported to me that (R1) had a black eye. The NP (Nurse Practitioner/ V15) ordered and x-ray of his face and it came back negative for any fractures.On 8/18/26 at 11:00 am, V4 (Nurse Supervisor) stated the following, I was told by (V7, LPN) that (R1) had a bruise around his eye. I didn't assess (R1). No, I didn't report it because my shift was ending.On 8/19/26 at 2:35 pm, R5 stated the following, Before (R1) had the black eye, I heard (R1) yelling on the night shift for help and a Nigerian woman went into his room yelling at him. I heard her telling him to shut up and calling him stupid. The night staff treat him like s*** and all they do is sleep.On 8/19/26 at 2:38 pm, R6 stated the following, I have pictures of (R1) lying on the floor with just a diaper (incontinence brief) on. Sometimes he is left on the floor, and the staff closes his room door when they are tired of him yelling for help.At that time, Surveyor observed pictures on R6's cellular phone of R1 lying on the floor in his room with just an incontinent brief on.On 8/20/26 at 12:20 pm V9 (CNA) stated the following, I worked with (R1) on the overnight shift on 8/10/26. (R1) agreed to get cleaned and dressed. During the process and once he was undressed, he became agitated and began to refuse care. He began to hit himself in the face and the head. He also began to kick and lift his body from the bed. I left him to attend to another person. I didn't hit (R1) or yell at him.On 8/18/26 at 2:45 pm, V7 (LPN/ Licensed Practical Nurse) stated the following, I work part-time and I am familiar with (R1). I'm not sure of the day (8/11/26), but when I worked that morning, I noticed redness underneath his left eye and immediately reported it to the DON (V3). On 8/18/26 at 3:00 pm, V10 (CNA) stated the following, I worked with R1 on Monday night (8/10/26). When I was doing my rounds after 11:00 pm, I saw him asleep in bed. I didn't notice any bruise on his (R1's) eye.On 8/20/26 at 3:40 pm, V12 (LPN) stated that she was assigned to R1 on the overnight shift of 8/10/26 and don't recall R1 having a black eye. V12 stated that although she (V12) checked on R1 and gave him medication that night (8/10/26), V9 rendered personal care to R1.R5's BIMS (Brief Interview of Mental Status) score dated 7/13/26 is 15, which indicates cognitively intact.R6's BIMS (Brief Interview of Mental Status) score dated 5/20/26 is 15, which indicates cognitively intact.R1's Skin Screen dated 8/14/26 documents a bruised right eye.R1's care plan dated 9/19/23 documents, R1 is vulnerable for abuse due to poor insight/ judgement, poor communication skills, poor ambulation, weakness, and present mental health diagnosis.Facility schedule dated 8/10/26 documents the following staff assigned to work with R1 on the overnight (11pm-7am) shift: V12 (LPN), V9 (CNA) and V10 (CNA).Facility schedule dated 8/11/26 documents, V7 (LPN) assigned to work with R1 on the day (7am-3pm) shift).Facility Abuse policy dated 9/2017 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment; this facility is committed to protecting our residents from abuse neglect, exploitation, misappropriation of property or mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on interview and record review, the facility failed to ensure that the initial physician visit was performed for a newly admitted resident which affected one resident (R1) of three residents reviewed for physician visits. Findings include: R1's Face Sheet and Census List document that R1 was admitted on [DATE] and transferred to the hospital on 2/16/26. R1's medical record revealed that V10 (Physician) did not perform an initial visit and did not fulfill the requirement of one visit every 30 days for the first 90 days. V10 did not perform any physical assessments on R1 from the time R1 was admitted to the time R1 was transferred to the hospital. All medical visits and medical assessments were performed by V8 (NP-Nurse Practitioner) and V11 (NP). On 3/11/26 at 11:30pm, a request was made for V10's visit notes for R1's visits. V3 (DON-Director of Nursing) stated that V10's notes would be provided. The facility submitted two progress notes authored by V11 and dated 12/2/25 and 1/14/26. At 12:35pm, V3 stated, Correct, there's no notes from (V10). (V10's) NP sees the patients. I'm not sure how the process goes. (V11) is the nurse practitioner for (V10). V3 confirmed that if the medical doctor sees the resident, the progress note should be in the medical record on the date that the visit is performed. On 3/11/26 at 3:30pm, V2 (Assistant Administrator) stated, We submitted what we have. We do not have any progress notes from (V10). V11 (NP) is the one that saw (R1). V2 also indicated that V10 assumed R1's medical care once R1 was in the facility and was not R1's doctor prior to her admission.The facility submitted a policy titled, Physician Services - On Call Coverage with a review date of 9/2024 which documents, in part: 5. If the physician does not make the visits required, the DON and/or Administrator are notified to attempt to contact the attending physician. 6. If the physician still does not respond, the Medical Director is notified to see the resident and contact the attending physician. 9. When the physician visits a resident, a progress note will be placed in the medical record. The facility policy does not address the time frame that newly admitted residents have to be physically assessed by the attending physician.

Based on interviews and record reviews, facility failed to follow their policy to ensure residents are free from misappropriation of property for 2 (R1, R2) out of 3 residents reviewed for abuse in a sample of 4. Findings include: On 01/10/2026 at 11:30 AM, surveyor observed R1 in her room. R1 was laying on her bed. R1 stated that people come into her room all the time. R1 stated that a few weeks back R2 came into her room while she was sleeping, unplugged her phone and took it. R1 stated that she immediately told the nurse, and the nurse got it back. R1 stated that R2 took facial pictures of himself on her phone.On 01/10/2026 at 11:35 AM, surveyor observed R2 in his room. R2 was laying on his bed. R2 stated that he doesn't go into people rooms. R2 stated that he doesn't take people's phones. R2 stated that he has never taken R1's phone. On 01/10/2026 at 12:09 PM, V2 (Director of Nursing) stated that if he sees abuse, we first protect the victim and then report it to the administrator. V2 stated that physical, financial, emotional, verbal, sexual and theft are all forms of abuse. V2 stated that abuse in-services are done at least quarterly. V2 stated that he is familiar with R1. V2 stated that he has never heard of anyone going into R2's room and taking her things. Surveyor then showed V2 a progress note from V7 (Registered Nurse). R1's progress note by V7 (12/11/2025) documents in part: R1 is alert & responsive, resident complained that a male resident came into her room and took her phone while she was sleeping. R1 was able to recover her phone from the other resident and she called the police. DON made aware and the facility security was able to deescalate the situation. Social worker will follow up. V2 stated that V7 never notified him of any theft by any resident. On 01/10/2025 at 12:28 PM and 12:30 PM, surveyor attempted to call V7 (Registered Nurse). No answer. Left voicemail with call back number. On 01/10/2026 at 12:50 PM, V1 (Administrator) stated that when it comes to abuse, his expectation for his staff is to report it to him as the abuse coordinator. V1 stated that physical, verbal, mental, seclusion, theft, sexual, and neglect are the different types of abuse. V1 stated that he knows who R1 is. V1 stated that he has not heard of any incidents of anyone taking R1's personal property. V1 stated that if he did, he would take it as an abuse and follow the abuse policy and start an investigation. Surveyor showed V1, R1's progress note from V7 on 12/11/2025. V1 stated that, based on that progress note, that incident is a form of misappropriation of property. V1 stated that he was never notified by V7 or any staff member of R2 taking R1's phone. V1 stated that he would have reported it to IDPH and started an investigation. R1's Minimum Data Sheet (MDS) Section C documents in part: R1 has a Brief Interview of Mental Survey (BIMS) of 15. R1 is cognitively intact. Facility's abuse policy (9/2017) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical, mental, 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 harm or injury. Misappropriation of resident property mean the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings or money without the resident's consent.

Based on interview and record review, facility failed to follow their policy to ensure allegation of misappropriation of resident property was immediately reported within the required time frame to the abuse coordinator and to the Illinois Department of Public Health for two (R1, R2) out of three residents reviewed for misappropriation of property in a sample of 4. Findings include:On 01/10/2026 at 11:30 AM, surveyor observed R1 in her room. R1 was laying on her bed. R1 stated that people come into her room all the time. R1 stated that a few weeks back R2 came into her room while she was sleeping. unplugged her phone and took it. R1 stated that she immediately told the nurse, and the nurse got it back. R1 stated that R2 took facial pictures of himself on her phone.On 01/10/2026 at 11:35 AM, surveyor observed R2 in his room. R2 was laying on his bed. R2 stated that he doesn't go into people rooms. R2 stated that he doesn't take people's phones. R2 stated that he has never taken R1's phone. On 01/10/2026 at 12:09 PM, V2 (Director of Nursing) stated that if he sees an abuse, we first protect the victim and then report it to the administrator. V2 stated that physical, financial, emotional, verbal, sexual and theft are all forms of abuse. V2 stated that abuse in-services are done at least quarterly. V2 stated that he is familiar with R1. V2 stated that he has never heard of anyone going into her room and taking her things. Surveyor then showed V2 a progress note from V7 (Registered Nurse). R1's progress note by V7 (12/11/2025) documents in part: R1 is alert & responsive, resident complained that a male resident bagged into her room and took her phone while she was sleeping. R1 was able to recover her phone from the other resident and she called the police. DON made aware and the facility security was able to deescalate the situation. Social worker will follow up. V2 stated that V7 never notified him of any theft by any resident. On 01/10/2025 at 12:28 PM and 12:30 PM, surveyor attempted to call V7 (Registered Nurse). No answer. Left voicemail with call back number. On 01/10/2026 at 12:50 PM, V1 (Administrator) stated that when it comes to abuse, his expectation for his staff is to report it to him as the abuse coordinator. V1 stated that physical, verbal, mental, seclusion, theft, sexual, and neglect are the different types of abuse. V1 stated that he knows who R1 is. V1 stated that he has not heard of any incidents of anyone taking R1's personal property. V1 stated that if he did, he would take it as an abuse and follow the abuse policy and start an investigation. Surveyor showed V1, R1's progress note from V7 on 12/11/2025. V1 stated that, based on that progress note, that incident is a form of misappropriation of property. V1 stated that he was never notified by V7 or any staff member of R2 taking R1's phone. V1 stated that he would have reported it to IDPH and started an investigation.R1's Minimum Data Sheet (MDS) Section C documents in part: R1 has a Brief Interview of Mental Survey (BIMS) of 15. R1 is cognitively intact. Facility's abuse policy (9/2017) documents in part: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, mistreatment or misappropriation of resident property they observe, heart about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. Reports should be documented, and a record kept of the documentation. 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 no more than two hours of the allegation of abuse. Any incident or accident that does not involve abuse and serious bodily injury shall be reported within 24 hours. The administrator will review the final written report of the investigation and forward it to the Illinois Department of Public Health within five working days of the reported incident.

Based on interview and record review, facility failed to follow their policy to ensure allegation of misappropriation of resident property was immediately investigated within the required time frame by the abuse coordinator for two (R1, R2) out of three residents reviewed for misappropriation of property in a sample of 4. Findings include: On 01/10/2026 at 11:30 AM, surveyor observed R1 in her room. R1 was laying on her bed. R1 stated that people come into her room all the time. R1 stated that a few weeks back R2 came into her room while she was sleeping. unplugged her phone and took it. R1 stated that she immediately told the nurse, and the nurse got it back. R1 stated that R2 took facial pictures of himself on her phone.On 01/10/2026 at 11:35 AM, surveyor observed R2 in his room. R2 was laying on his bed. R2 stated that he doesn't go into people rooms. R2 stated that he doesn't take people's phones. R2 stated that he has never taken R1's phone. On 01/10/2026 at 12:09 PM, V2 (Director of Nursing) stated that if he sees an abuse, we first protect the victim and then report it to the administrator. V2 stated that physical, financial, emotional, verbal, sexual and theft are all forms of abuse. V2 stated that abuse in-services are done at least quarterly. V2 stated that he is familiar with R1. V2 stated that he has never heard of anyone going into her room and taking her things. Surveyor then showed V2 a progress note from V7 (Registered Nurse). R1's progress note by V7 (12/11/2025) documents in part: R1 is alert & responsive, resident complained that a male resident bagged into her room and took her phone while she was sleeping. R1 was able to recover her phone from the other resident and she called the police. DON made aware and the facility security was able to deescalate the situation. Social worker will follow up. V2 stated that V7 never notified him of any theft by any resident. On 01/10/2025 at 12:28 PM and 12:30 PM, surveyor attempted to call V7 (Registered Nurse). No answer. Left voicemail with call back number. On 01/10/2026 at 12:50 PM, V1 (Administrator) stated that when it comes to abuse, his expectation for his staff is to report it to him as the abuse coordinator. V1 stated that physical, verbal, mental, seclusion, theft, sexual, and neglect are the different types of abuse. V1 stated that he knows who R1 is. V1 stated that he has not heard of any incidents of anyone taking R1's personal property. V1 stated that if he did, he would take it as an abuse and follow the abuse policy and start an investigation. Surveyor showed V1, R1's progress note from V7 on 12/11/2025. V1 stated that, based on that progress note, that incident is a form of misappropriation of property. V1 stated that he was never notified by V7 or any staff member of R2 taking R1's phone. V1 stated that he would have reported it to IDPH and started an investigation. R1's Minimum Data Sheet (MDS) Section C documents in part: R1 has a Brief Interview of Mental Survey (BIMS) of 15. R1 is cognitively intact. Facility's abuse policy (9/2017) documents in part: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred was alleged or suspected. All allegation involving misappropriation of resident property will result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, and anyone likely to have direct knowledge of the incident and the resident. Any written statements that have been submitted with be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed.

Based on interview and record review, the facility failed to ensure two residents (R7, R10) of five reviewed remained free from abuse in a total sample of 14. This failure resulted in R7 and R10 physically abusing each other. Findings include: R7's current face sheet documents R7's medical diagnosis to include but not limited to schizophrenia, unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, schizoaffective disorder, unspecified, major depressive disorder, recurrent, unspecified, generalized anxiety disorder, gastro-esophageal reflux disease without esophagitis, epilepsy, unspecified, not intractable, without status epilepticus, delusional disorders. R7's MDS (Minimum Data Set) section C dated [DATE], documents R7's Brief Interview for Mental Status (BIMS) as 15/15 indicating R7 has intact cognitive function. On 04/03/2025, at 11:47 AM, R7 was observed in his room sitting on his bed and was observed to be paranoid. R7 stated he does not have mental health issues and he should not be in this facility. R7 stated on 4/1/2025, R10 was roaming on the units and entering residents' rooms. R10 went to R7's room and was stealing R7's food which included crackers that were on top of R7's bedside drawer. R7 pointed where he had kept his food items. R7 stated R10 hit him on the head when he (R7) asked him (R10) to stop taking his food without permission. R7 stated, All bets were off, and he defended himself. R7 started punching R10 on the head and after punching R10 several times, R7 controlled himself and left his room because he did not want to hurt R10 anymore because they used to be friends. R7 stated there were no staff near to witness or monitor residents who wonder and enter other residents' rooms at that time. R7 stated he told staff what had happened. R7 then went back to his room and punched the TV with his right hand because he was so upset that staff did not prevent R10 from going into his room and eating/stealing his food. R7 was observed with several small cuts on the back his right fist which were healing and stated he sustained them after punching the TV; staff did not do anything about it. R7 stated he does not feel safe at the facility because staff do not round the units and there is no security on each floor, but he can defend himself. R7 stated he wanted to be discharged because he does not have a mental health issue to be living in the facility. R10 current face sheet documents R10's medical diagnosis to include but not limited to: schizoaffective disorder, unspecified, bipolar disorder, unspecified, major depressive disorder, single episode, unspecified, and insomnia due to medical condition. R10's MDS (Minimum Data Set) section C [DATE]dated documents R's Brief Interview for Mental Status (BIMS) as 15/15 indicating R10 has intact cognitive function. R10's MDS (Minimum Data Set) section C dated [DATE], documents R10's Brief Interview for Mental Status (BIMS) as 15/15 indicating R10 has intact cognitive function. On 04/03/2025, at 12:05 PM, R10 was observed walking into his room. R10 was alert and oriented to person, place, time and situation. R10 stated he and R7 were friends and on 4/1/2025 R7 told R10 that he can have some crackers that were on top of R7's drawer. R10 stated as he went to get the crackers, R7 punched R10 on the right side of his face. R10 defended himself and punched R7 on the head then R7 walked away. R10 pointed to his right side of his face and stated he did not sustain injuries and stated he did not want to talk about the incident anymore. On 04/03/2025, at 1:55 PM, V5 (Psychosocial Rehabilitative Services Director) stated on 4/1/2025, before 12:00 PM, he heard on the intercom that security was needed on the third floor. V5 rushed to the floor to see what was going on and when he got there, V5 observed R10 going into his room. Two or three staff (V5 cannot remember who) were standing outside of R7's room. V5 stated when he asked the staff what was going on, they just pointed to R7's room and did not tell R7 what was happening. V5 stated he went and spoke to R7 who stated R10 was going into R7's room and R7 asked R10 to get out of his room. V5 stated spoke to V10 who stated R7 told him (R10) to leave his room because R7 thought R10 was FBI (Federal Bureau of Investigation). V5 stated he counseled R10 not to go into other residents' rooms uninvited. V5 stated V1 (administrator) is the abuse coordinator, and all abuse allegations are reported to V1 for further investigations. V5 stated any form of abuse should be reported to V1 immediately so that it can be investigated. V5 stated he did not report to V1 or investigate further what happened because he did not witness anything and the staff who were present just pointed to R7's room. On 04/03/2025, at 3:08 PM, V1 (Administrator) stated resident to resident physical or verbal altercation is a form of abuse and residents should not verbally or physically abuse each other. V1 stated if a resident report being hit by another resident, that is a form of abuse and should be investigated and reported to IDPH (Illinois Department of Health), regardless if it happened or not, because the investigation determines what really happened. V1 stated if R7 and R10's alleged altercation had been reported to him, he would have investigated the allegation to determine what happened. R7's Social Service Note dated 4/1/2025, documents V5 was notified R10 had verbal disagreement with a male peer (R10) on his unit. Staff intervened, redirected, and counseled resident (R7) to seek staff for his concerns while making use of his coping skills. Care plan dated 02/05/2025, document's R7 displays manipulative behavior that is disruptive, insensitive, and disrespectful to staff and peers. This behavior is related to poor self-esteem, diminished self-worth, and long-standing personality (disorder) traits. R10's Social Service Note dated 4/1/2025, documents V5 was notified R10 had verbal disagreement with a male peer (R7) on his unit. Staff intervened, redirected, and counseled resident (R10) on respecting personal social boundaries with peers, to also refrain from going into peers' rooms uninvited. R10's Social Service Note dated 4/4/2025, documents R10 was observed going into another resident's belongings and took his snacks. Staff (V5) met with resident R10) to counsel him (R10) on maintaining appropriate boundaries with peers and being respectful of peer's personal space/belongings. Resident (R10) was not receptive to counsel given at this time. R10's care plan dated 8/5/2024 documents R10 is at risk for abuse due to his diagnoses, and R10 will be free from every form of abuse through the next review date of 7/27/2025. Abuse policy dated 9-2017 documents: -Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview and record review the facility failed to follow their policy and procedures to ensure (a) signage outside of the resident's room indicating Enhanced Barrier Precaution (EBP) was posted; (b) PPE (Personal Protective Equipment) was made available and accessible outside of the resident's room; (c) Position a trash can inside R2's room and near the exit for discarding PPE after removal and (d) proper PPE were worn by staff when providing high contact resident care activities to 1 (R2) resident. These failures have the potential for cross contamination to 48 residents residing on the 4th floor as of census 11/6/24 reviewed for improper nursing care. The findings include: R2's admission record showed admitted on 10/9/2024 with diagnoses not limited to Metabolic encephalopathy, Sudden visual loss, Dysphagia, Colostomy status, Hypotension, Unspecified kidney failure, Unspecified abdominal pain, Gastrostomy status. On 11/6/24 at 10:48 AM Observed R2 sitting up on wheelchair, alert and verbally responsive with confusion. V12 donned gloves and opened R2's G-tube dressing. V12 did not wear gown while providing care or use of feeding tube. No EBP signage by R2's door or wall outside of the room. Did not observe PPE supplies outside of R2's room, no trash can near the exit of the room for discarding PPE after removal. At 12:59 PM Observed V12 donned gloves and brought Jevity 1.5 8 fluid oz (ounce) and water to R2's room. V12 checked g-tube patency by auscultation. V12 checked gastric residual and aspirated a total of 360ml yellowish gastric contents. Observed V12 administered medications. V12 stated if gastric residual is more than 100ml to hold G-tube feeding. R2's G-tube feeding was not given. V12 administered 360ml gastric residual via G-tube by gravity and flushed G-tube with 135cc water. V12 was not wearing proper PPE (gown) during the whole process. At 1:12 PM V15 (Certified Nursing Assistant / CNA) stated she is working or assigned to R2 who is incontinent of bladder, requires extensive assistance with activities of daily living (ADL). V15 stated she provided incontinence care, hygiene, dressing to R2 today and donned gloves but did not wear gown because R2 is not on isolation. On 11/7/24 at 9:37 AM V24 (IP / Infection Preventionist nurse) stated V24 has been working in the facility for 4 years and as IP nurse for 2 years. V24 said Enhance Barrier Precautions / EBP is applicable for those residents with medical indwelling devices such as G-tube. It's important to make sure infection control / prevention policy and procedures are being followed by staff. V24 said for EBP there should be an order, care plan, signage on the door, and PPE supplies accessible to staff every 1-2 rooms. Staff should wear proper PPE such as gloves, gown when providing high care activities such as incontinence care, dressing, toileting, giving medications / feeding / flushing via G-tube or any hands-on activity. V24 said if staff is not wearing proper PPE during high care activities could potentially contaminate or transmit infection to other residents. EBP should have a Care plan to serve as a guidance for staff on how to care for the resident on EBP. At 10:07 AM V3 (DON / Director of Nursing / DON) stated V3 has been working in the facility for more than 2 years. V3 stated EBP should be observed for residents with G-tube. Staff is expected to wear proper PPE such as gloves and gown when providing high care activities such as Bathing, incontinence care, g-tube administration. Wearing proper PPE will protect the patient and staff, prevent cross contamination. V3 said signage indicating EBP should also be posted by resident's door as a form of communication for the staff / visitor and provide instructions to the staff regarding proper use of PPE. EBP should have a care plan and order in resident's record. PPE supplies can be placed between 1-2 rooms or accessible to staff. V3 said there are 2 nurses working on the 4th floor and if another nurse is on break the remaining nurse should cover the unit and attend to resident's needs or care. MDS dated [DATE] showed R2 was rarely or never understood. She needed substantial / maximal assistance with oral, toileting and personal hygiene, shower / bathe self, upper body dressing, lower body dressing, chair/bed and toilet transfer. Always incontinent of bowel and bladder. MDS showed feeding tube. Reviewed R2's health record did not show care plan for EBP and no order for EBP found. Facility's census dated 11/6/24 showed 48 residents residing on the 4th floor. Facility's 4th floor assignment sheet dated 11/6/24 showed 2 nurses on 1st shift. Facility's policy for Enhanced Barrier Precautions (EBP) dated 10/16/23 documented in part: Our facility employs the use of EBP to reduce transmission of MDROs to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. EBP are indicated (when contact precautions do not otherwise apply) for residents with any of the following: an indwelling medical devices regardless of MDRO status. Staff utilize gown and gloves for high-contact resident care activities when residents require EBP; high contact activities may include dressing, bathing / showering, transferring, providing hygiene, changing briefs or assisting with toileting. Device care or use: feeding tube. Post EBP signage on the door or wall outside of the resident room indicating the type of precautions and required PPE and listing high-contact resident care activities. Ensure PPE, including gowns and gloves, are available outside of the resident room. Position a trash can inside the resident room and near the exit for discarding PPE after removal.

Based on interview and record review, the facility failed to provide adequate supervision to a resident (R194) who is high risk for falls. This failure resulted in R194 sustaining a fall which required R194 to go to the local hospital due to sustaining a laceration above R194's left eyebrow, an acute interior column fracture of the C6 vertebrae without significant displacement and R194 to wear a neck brace for 8 weeks. Findings include: The facility's Initial Report to local State Agency dated 08/26/24 at 8:12 am, documents, in part R1 sustained a fall with a cut to the upper left eyebrow requiring staples. The facility's Final Report to local State Agency dated 09/02/24 at 6:46 pm, documents, in part R194 was transferred to the local hospital. R1 sustained a laceration to left eyebrow when R194 fell and hit her head on a chair in the dining room area. R194 readmitted from the local hospital with 8 stitches above the eyebrow. R194 was also diagnosed with acute interior column fracture of the C6 vertebrae without significant displacement . R194 was discharged with instructions to wear neck braces to reduce movement of the vertebrae. R194's hospital record dated 08/25/24 at 4:45 pm, documents, in part: History of Present Illness: R194 is a [AGE] year-old with history of schizophrenia, schizoaffective disorder, transferred after a fall. Patient fell off a chair and laceration on left eyebrow and struck her (R194) head . Imaging: MRI (Magnetic Resonance Imaging) Cervical Spine without contrast final result: Acute oblique-horizontal fracture of the C6 (Cervical) vertebral body extending to the ossified anterior longitudinal ligament and adjacent bridging osteophytes at C6 and C6-C7 with minimal displacement. Suspected fracture extension to the adjacent discs at C5-C6-and C6-C7 with annular tears. Wound: Musculoskeletal Immobilization Hard Collar Neck. Wound forehead right. R194's Brief Interview for Mental Status (BIMS) dated 09/12/24 shows R194 has no BIMS score and indicates R194 has memory problems. R194's Minimum Data Set (MDS) dated [DATE] shows R194 requires substantial/maximal assistance for sit to stand and Supervision or touching assistance for walking. R194's Face sheet documents R194 admitted to the facility on [DATE], discharged from the facility 09/12/24 and has a diagnosis which include but not limited to nondisplaced fracture of sixth cervical vertebra subsequent encounter for fracture with routine healing and schizoaffective disorder and bipolar type. R194 no longer resides at the facility and surveyor was unable to interview R194. On 09/30/24 at 12:40 pm, V16 (Licensed Practical Nurse, LPN) stated on 08/25/24 around 6:00 am, V16 was passing medication to residents on the sixth floor and observed V24 (Certified Nursing Assistant, CNA) ambulating R194 to the sixth-floor dining room. V16 explained V16 assumed V24 sat R194 down in the sixth-floor dining room. However, shortly after V24 left R194 in the dining room, V16 saw R194 walking from the dining room. V16 redirected R194 back to the dining room and sat R194 in a chair in the sixth-floor dining room. V16 then explained V16 continued to administer medications to residents on the sixth floor. V16 then was standing at V16 medication cart in the sixth-floor hallway slightly down from dining room area, with V16's back to the dining room area when V16 heard a loud noise. V16 stated V16 turned around and looked across the hallway and saw R194 laying on the floor in the entry way of the dining room with R194's head against the wall and the leg of another residents chair. V16 stated V16 went to assess R194 after R194's fall in the dining room and observed a laceration to R194's left eyebrow. V16 stated R194 always has a staff member walk with R194. R194 is a resident who walks fast with an unsteady gait on her (R194) toes and requires assistance from staff for safe ambulation. V16 explained on 08/25/24 prior to R194's fall, R194 was not wearing shoes when V24 (CNA) ambulated R194 to the dining room or when V16 redirected R194 to the dining room prior to R194's fall on 08/25/24. V16 stated, We try our hardest to sit and monitor the dining room but this particular day it was chaotic. I (V16) still had two people to pass medication to, so I (V16) was at my cart (referring to the medication cart) and didn't see R194 in the dining room get up. I (V16) just turned around and looked over to the dining room and saw R194 had fallen on the floor. V16 explained R194's left eye was bleeding. V16 applied a cold wet towel to R194's eye, called R194's physician (who gave orders to send R194 to the local hospital), R194's family, and V2 (Director of Nursing, DON). V16 denied R194 had lost consciousness when R194 sustained a fall on 08/25/24. V16 stated there was no staff to monitor the dining room during R194's fall and all staff was providing care to other residents. V16 explained V16 would have monitored the dining room however V16 remembered V16 still had to administer medication to other residents. When V16 was asked regarding what can happen if residents who are high risk for falls are in the dining room without any staff supervision and V16 stated, Falls and incidents can occur. On 09/30/24 at 1:03 pm, V24 (Certified Nursing Assistant, CNA) stated on 08/25/24 around 5:30 am, V24 gave R194 a bed bath, got R194 dressed and took R194 to the dining room. V24 explained V24 then sat R194 in the dining room and went to take care of another resident. When V24 was asked regarding R194's mobility, V24 explained R194 does not use any assistive devices for ambulation. V24 stated, Someone always walks with R194 to make sure R194 doesn't fall. About 15 minutes after R194 was in the dining room. I (V24) heard a loud bang noise like something hit the wall and someone fell from the dining room. V24 stated V24 rushed into the dining room and saw R194 laying on the floor and V16 (LPN) attending to R194. V24 explained V24 and V16 assisted R194 to a chair and V16 asked V24 to hold pressure to R194's eyebrow until the ambulance arrived. V24 stated R194 was not wearing shoes and R194 was wearing friction socks. When V24 was asked regarding what staff was monitoring the dining room when V24 left R194 in the dining room prior to R194's fall on 08/25/24 and V24 stated, Everyone was working at that time. I (V24) don't remember any staff in the dining room. No staff was assigned to the dining room. My (V24) job is to get up the residents and give them showers. On 10/01/24 at 10:49 am, V2 (Director of Nursing, DON) stated R194 is a resident with dementia, confused and alert to self. V2 stated R194 is to be monitored when placed in the dining room. V2 explained V2 requires staff to ambulate with R194 due to R194's leg (V2 was unable to remember which leg) is not very strong for R194's safety. On 08/25/24 V2 stated V2 received a call from V16 (LPN) that R194 stood up and started to walk and sustained a fall before the nurse could intervene. V2 explained V16 stated R194 tripped over another resident, fell , and cut R194's eye. V2 stated V2 instructed V16 to call V37 (R194's Physician) and send R194 to the hospital. V2 stated the local hospital applied sterile strips to R194's eyebrow and R194 had a X-ray showed a fracture of C6 (Cervical 6). V2 explained R194 was placed in a neck collar with orders to follow up with orthopedic surgeon in 8 weeks. V2 explained staff should be monitoring the dining room at all times when a resident who is high risk for falls is in the dining room. When V2 was asked regarding what staff was assigned to monitor the dining room on 08/25/24 during the time of R194's fall and V2 stated, I (V2) really don't know. Staff should be in the dining room to monitor the residents safety. When V2 was asked regarding what could happen if a resident who is high risk for falls is not supervised by staff in the dining room and V2 stated, There could be a fall with injury, a patient can touch another resident, residents can wander, and staff won't be able to prevent falls. When V2 was asked regarding the importance of supervising residents who are high risk for falls and V2 stated, To prevent the resident from falls and injury. On 10/01/24 at 11:05 am, V37 (R194's Physician) stated, I (V37) don't recall R194's fall on 08/25/24 but I (V37) saw her (R194) at the hospital. V37 stated V37 recalls R194 admitting to the hospital with a hairline fracture of the spine with a C (Collar) applied. When V37 was asked regarding R194's functional status and care needs at the facility, V37 explained V37 recalls R194 was not really alert with cognitive impairments and not redirectable. When V37 was asked regarding what assistance R194 required at the facility V37 stated, I (V37) don't recall how much assistance she (R194) needed. Whatever the notes reflect in her (R194's) chart is what she (R194) needs. When V37 was asked what could happen if a resident who is high risk for fall is left unsupervised and V37 stated, High risk for falls residents are going to fall. They (referring to the residents) can fall if they (referring to the residents) have an unsteady gait and an injury can be caused if they (referring to the resident) fall. R194's progress note dated 08/25/24 at 7:07 am, and authored by V16 (Licensed Practical Nurse, LPN) documents, in part: R194 walked past the writer (V16) and fell . R194 hit her (194) head on the lower part of a chair another patient was in. The writer (V26) notified ADON (Assistant Director of Nursing) DON (Director of Nursing) and left a message or the patient POA (Power of Attorney) to call the facility. The writer (V16) called 911 and set the patient out to the local hospital due to the ambulance service stating it will be a two hour wait. R194's progress note dated 08/28/24 at 11:49 am and authored by V6 (Licensed Practical Nurse, LPN) documents, in part: R194 admitted back to from the local hospital into facility accompanied by 2 EMT's (Emergency Medical Technicians) . R194 with a C (Cervical) collar brace around neck. Collar to remain in place for 8 weeks. Resident (R194) has sterile strips on laceration to tope of left eyebrow. R194's incident report dated 08/25/24 at 6:30 am, authored by V16 (LPN) documents, in part: R194 was walking and when she (R194) was behind the writer (V16). She (R194) fell hitting her (R194) head on the lower part of a chair a patient was sitting in injuring herself . Notes: R194 ambulates without any assistive device and with unsteady gait. R194 requires staff assistance to total assistance with ADL's (Activities of Daily Living). R194 was walking when she fell hitting her head on the lower part of a chair. Staff to provide morning ADL care and closely monitor resident ambulation on unit. R194's Fall Risk Assessment Evaluation dated 04/01/24 shows R194 has a Falls risk score of 19 which indicates R194 is high risk for falls. R194's Fall Risk Assessment Evaluation dated 08/27/24 shows R194 has a Falls risk score of 16 which indicates R194 is high risk for falls. R194's Fall Risk Assessment Evaluation dated 08/28/24 shows R194 has a Falls risk score of 19 which indicates R194 is high risk for falls. R194's care plan dated 08/28/24 document, in part: Focus: R194 requires the use of C collar brace to related to fracture. R194's care plan dated 10/17/23 document, in part: Focus: R194 is a high risk for falls. Interventions: R194 Velcro shoes was provided to the resident . Provide proper well-maintained footwear. The facility's document dated 08/2024 and titled Fall Prevention and Management documents, in part: General: 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 preventative strategies, and facilitate as safe an environment as possible. The facility's policy dated 09/2023 and titled Hazards and Supervision documents, in part: Policy: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .4. Monitoring and Modification - Monitoring and modification processes include: a. Ensuring interventions are implemented correctly and consistently . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. The facility's job description titled Certified Nurse's Aide documents, in part: Basic function: To provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state and federal guidelines, and as directed by your supervisor. Essential Duties: 25. Follow established safety precautions in performance of all duties. The facility's job description titled Registered Nurse/Licensed Practical Nurse documents, in part: Basic Function: Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Essential Duties: 12. Adhere to all facility and department safety policies and procedures.

Based on observation, interview and record review, the facility failed to ensure the dumpster lids were closed and free from overflowing trash. These failures have the potential to affect all 194 residents residing at the facility. Findings include: The (9/29/2024) facility census was 194 residents. On 9/29/2024 at 9:34 AM, surveyor observed the singular metal lid open for the trash compactor and 2 lids for the dumpster open. Bags of garbage, boxes, and food waste products were observed inside the dumpster and compactor. Flying insects were observed flying in the vicinity of the open compactor and dumpster. On 9/29/2024 at 9:41 AM, V19 (Regional Dietary Manager) stated the dumpster lids should be closed to prevent pests from entering the trash. V19 affirmed the trash compactor lid was broken and a work order had been completed. V19 stated the lid had been broken for about a month. V19 demonstrated the trash compactor lid was able to be shut/closed but did not latch. V19 affirmed the dumpster lids were not broken and should have been closed over the dumpster. Record review of work order dated 9/19/24 completed by V5 (Maintenance Director) documents in part dietary staff reported the trash compactor isn't latching properly. Maintenance staff called trash company for service. Record review of work order dated 9/30/24 completed by V5 documents in part the latch needs to be replaced on the garbage can (trash compactor) outside and asking for them to replace the current one we have. Call has been put out and they will be here 9/30/24. This work order was assigned the Critical priority. On 10/1/24 at 9:37 AM, surveyor observed the lid to the dumpsters open with trash and boxes preventing the lids from being closed. A large stone was observed on top of the trash compactor which adequately kept the lid to the compactor closed. V5 (Maintenance Director) stated the trash can lids should be closed at all times and staff should be putting garbage in the dumpster in a way so the lids can close properly. V5 arranged the garbage so the lids could close. V5 stated the garbage company came yesterday and stated they trash compactor couldn't be fixed and a new compactor was needed. V5 did not know when a new trash compactor would be delivered. V5 stated covering the dumpsters was important so pests do not get inside and so other objects from people in the community are not placed in the dumpsters. Facility provided policy titled, Dispose of Garbage and Refuse documents in part, .All garbage and refuse will be collected and disposed of in a safe and efficient manner .

Based on observation, interview, and record review, the facility failed to ensure the residents' ceiling was not leaking, failed to ensure the closet door was not broken, and failed to ensure the residents' bathroom has no missing ceramic tiles in effort to provide a homelike environment. These failures affected 5 (R21, R32, R50, R85, and R224) residents reviewed for homelike environment in the total sample of 77 residents. Findings include: On 09/29/2024 at 11:45am, R21, R50, and R85's ceiling was leaking. There was a big trash can used as a catch bin. On 09/29/24 at 11:46am, V8 (PRSC (Psychiatric Rehabilitation Services Coordinator) stated there is a leak coming from the ceiling and there is a garbage bin that is used as a catch basin. There are 3 residents living in this room (R21), (R50), and (R85). On 09/29/2024 at 11:48am, R85 stated, It has been like that since Friday. I (R85) don't know what to say. I (R85) don't expect my (R85) room to be with a leaking ceiling. On 09/29/24 at 11:50am, V5 (Maintenance Director) stated, I (V5) am not sure at this moment what is going on inside the room. My Assistant Maintenance (V10) put the garbage can to catch the water leak. On 10/01/2024 at 10:55am, inside R21, R50, and R85's room, the ceiling was covered with a plastic, secured with blue tape. On 10/01/2024 at 10:58am, V12 (Licensed Practice Nurse) stated there was a leak on the ceiling and they covered the ceiling with a plastic. Maintenance is supposed to fix the leak. On 10/01/2024 at 11:00am, V3 (Psych Nurse/LPN) stated we have system called TELS where we log repairs for the Maintenance Department. It is like an eMaintenance Log. This surveyor requested to print the electronic Maintenance Log. On 10/01/2024 at 11:08am, V3 presented this surveyor the eMaintenance Log and inquired if there was a work order for R21, R50, and R85's room. V3 stated there is nothing specific for R21, R50, and R85's room. On 10/01/2024 at 11:18am, V10 (Assistant Maintenance) stated, The ceiling in the room had a leak. I (V10) don't know where the leak was coming from. The CNA told me Sunday morning. I (V10) checked 4th floor to assess where the leak was coming from. Nothing was going on in 4th floor that would cause a leak to the room. Instead of busting the ceiling open, I (V10) put a garbage can to catch the water. On 10/01/2024 at 11:25am with V10 inside R21, R50, and R85's room, R85 stated, The leak started when they cleaned the vent on Friday. I (R85) don't know who these people are. On 10/01/2024 at 11:30am on the smoking area with V10, R21 stated, The ceiling in my room was leaking. I (R21) don't remember when it started leaking. On 10/01/2024 at 11:32am on the smoking area with V10, R50 stated, I (R50) think the leak started on Friday. I (R50) was not in the room when it happened, when I (R50) went up in my room, the ceiling was leaking. On 10/01/2024 at 10:12am, V2 (Director of Nursing) stated, It is not expected to have a leak on the ceiling. It is not providing a homelike environment if the ceiling is leaking. Things like that may happen but it should be fixed immediately. The staff are expected to notify the Maintenance Department, Administrator, and DON. I (V2) am not aware of the issue verbally or through a work order. If the leak was observed on Friday, the leak should be fixed already by Sunday. The leak should be fixed immediately or as soon as possible but not for days. R21's (07/23/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R21's mental status as cognitively intact. R50's (08/22/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R50's mental status as cognitively intact. R85's (08/29/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R85's mental status as cognitively intact. The (03/2024 - 10/01/2024) Work Order was reviewed; no work order for R21, R50, and R85's room. Sink in room leaking dated 09/29/2024 was for another room. The (09/29/2024) Work Order 2577 was in the common area on another floor and not in R21, R50, and R85's room. The (undated) Nursing Home Residents' Rights documented, in part Residents of nursing homes have right that are guaranteed by the federal Nursing Home Reform Law. The Law requires nursing home to promote and protect the rights of each resident and stresses individual dignity and self-determination. Right to a Dignified Existence. A homelike environment. The (undated) Resident Rights: Accommodation of Needs and Preferences and homelike Environment Policy documented, in part Policy: It is the policy of the facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The facility will provide a safe, clean, comfortable, and homelike environment. Objective. The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. Procedure: 7. The resident's environment will be maintained in a homelike manner. 41611 On 9/29/2024 at 11:00 surveyor observed a missing ceramic tile in the bathroom under the sink joining 2 rooms and R32's closet door missing the entire top half of the door. On 9/29/2024 at 11:41am R224 stated there are mice in the bathroom and they may be coming out of the hole where the tile is missing under the sink. On 9/29/2024 at 11:42am R32 said, Yes we do have mice and he reported the broken door to the CNAs who said they would let the nurse know but the door has been broken for about a week now. On 9/30/2024 at 12:35pm surveyor reviewed facility's pest control binder and on 9/23/2024 it was documented that there was a dead rodent discovered on two mice trips. On 9/30/2024 at 2:38pm V4 (Maintenance Director) stated, No the tile should not be missing, and I see a hole where their tile is missing, and the grout is dry rotted. Absolutely it is possible that mice can come in through that hole. V4 stated that there is a hole in the south wall by R224's bed that a mouse could squeeze through it. On 9/30/2024 at 2:46pm V4 stated, off the top of his head he doesn't recall being notified about the missing tile or broken door in the TELS app for maintenance issues. V4 pulled up his reports for the last 2 months so that surveyor can see that he had not received anything. V4 stated staff will also write it in the work order book. ON 9/30/2024 at 2:48pm surveyor reviewed work order book for the third floor and did not find any work order for the missing tile or broken door. On 9/30/2024 at 2:55pm V12 (Licensed Practical Nurse) stated, no she (V12) was not made aware of R32's door being broken. Preventive Maintenance Plan dated 1/2019 documents, in part, 9. Repair all ceramic tiles. Including loose or missing grout. Repair/replace as needed. Undated Job description titled Maintenance Director documents, in part, repair facility/resident property as necessary and ensure that equipment, etc. are maintained to provide safe and comfortable environment.

Based on observations, interviews and record reviews, the facility failed to ensure administration of controlled medication was documented and failed to ensure the incoming and outgoing nurses signed the Shift Change Accountability Record for Controlled Substances Forms. These failures affected R43 and all residents taking controlled medications on the 3rd floor, 4th floor B-wing, and the 6th floor B-wing. Findings include: On 09/30/2024 at 10:45am during the reconciliation of controlled medications task with V13 (Registered Nurse), R43's Controlled Drug Receipt Record/Disposition form for Tramadol 50 mg dispensed on 9/25 at 9A has a missing signature. This was pointed out to V13. V13 stated the nurse who gave the medication should signed (R43)'s form right after giving the medication to document the medication was given. On 09/29/24 at 11:37am during the Medication Storage and Labeling task with V6 (Licensed Practice Nurse) of the 3rd floor Medication Cart, there were missing signatures on 3rd floor Shift Change Accountability Record for Controlled Substances Form. This was pointed out to V6. V6 stated there are spaces in the sign in and out sheet. The incoming and outgoing nurses are supposed to sign after counting the controlled medications, so you know you handed over the correct count to the next nurse. On 09/29/2024 at 12:47pm during the Medication Storage and Labeling task with V3 (Psych Nurse/LPN) of the 6th floor B-wing medication cart, there were missing signatures on the 6th floor B-wing Shift Change Accountability Record for Controlled Substances Form. This was pointed out to V3. V3 stated there are couple of missing signatures on the sheet. The expectation is, when the outgoing and incoming nurses do the count, they are supposed to sign the accountability sheet for record keeping and tracking the reconciled medications properly. On 09/30/2024 at 10:23 am during the Medication Storage and Labeling task with V9 (Licensed Practice Nurse) of the 4th Floor B-wing medication cart, there was a missing signature on the 4th floor B-wing Shift Change Accountability Record for Controlled Substances Form. This observation was pointed out to V9 (Licensed Practice Nurse). V9 stated there is a missing signature on day 29. The outgoing nurse did not sign out. It is expected of the nurses to sign the Sheet after counting to document the count is correct. On 10/01/2024 at 10:17am, V2 (Director of Nursing) stated, I (V2) expect the staff to sign the Shift Change Accountability Record for Controlled Substances Form soon after the 2 nurses counted the controlled medications. The purpose of the accountability sheet is to ensure the controlled medications count is correct. To make sure the incoming nurse receive the correct count of the controlled medications from the outgoing nurse. On 10/01/2024 at 10:20am, V2 stated I (V2) expect the nurse to document administration of controlled medication right after the administration. The nurse is expected to sign, write how many was taken and how many medications are left in the cart. R43's (Active Order as of: 09/30/2024) Order Summary Report documented, in part Tramadol 25mg. give 25mg by mouth every 6 hours as needed for pain. Start Date: 05/20/2024. R43's (received 5/29/2024) Controlled Drug Receipt/Record/Disposition Form for Tramadol 50mg 1/2 tab has a missing signature on 9/25, 9A(am). The (undated) List of Residents on Narcotics presented to this surveyor by V2 on 10/01/2024 at 12:48pm documented there were 4 residents on 3rd floor, 4 residents on the 4th floor, and 3 residents on the 6th floor. The (09/2024) 3rd floor Shift Change Accountability Record for Controlled Substance has missing signatures on Day: 18. Shift: 2nd. Nurses initial on; Day: 18. Shift: 3rd. Nurses initial Off; Day: 22. Shift: 1st. Nurses initial On and Off; Day: 22 Shift: 2nd. Nurses initial Off; Day: 23. Shift: 1st. Nurses initial on; Day: 23. Shift: 2nd. Nurses initial Off; Day: 24 Shift: 1st. Nurses initial on; Day: 24 Shift: 2nd. Nurses initial Off; Day: 25. Shift: 1st. Nurses initial on; and Day: 25. Shift: 2nd. Nurses initial Off. The (09/2024) 4Th Floor Shift Change Accountability Record for Controlled Substance on B-Wing has a missing signature on Day: 29. Shift: 2nd. Nurses initial Off. The (09/2024) 6th Shift Change Accountability Record for Controlled Substance on B-Wing has missing signatures on Day: 22. Shift: 3rd. Nurses initial on; Day: 23 Shift: 1st. Nurses initial Off; Day: 26. Shift: 1st. Nurses initial on; Day: 26 Shift: 2nd. Nurses initial on; Day: 26 Shift: 2nd. Nurses initial Off; Day: 26. Shift: 3rd. Nurses initial Off. The (1/2024) Controlled Substance policy and procedure documented, in part General: Medications classified by the FDA (Food and Drug Administrator) as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping. Policy: 10. Controlled Substances Count Sheet. c. Signature (which includes minimum of first initial, last name and title) of nurse who administered dose. 11. All schedule II controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: d. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of the controlled substances and count sheet matches the quantity documented.

Based on observations, interviews and record reviews, the facility failed to follow Pharmacy recommendation for medication storage and failed to ensure the refrigerators were within the required temperature for proper storage of medications. These failures affected 2 (R84 and R100) residents and have the potential to affect all the residents on the 3rd and 6th floors. Findings include: On 09/29/2024 at 11:20 am during the Medication Storage and Labeling task with V6 (Licensed Practice Nurse), R84's Latanoprost eye drop was in a brown bag with sticker 'Refrigerate'. V6 checked if the bottle had been opened and stated the bottle was unopened. V6 stated the bag says 'refrigerate'. This medication should not be in the cart. It should be refrigerated to preserve the potency. On 09/29/2024 at 11:21am, R100's Latanoprost eye drop was in a brown bag. V6 checked if the bottle had been opened and stated the vial was unopened. On 09/29/2024 at 12:51pm during the 6th floor medication storage task with V4 (Licensed Practice Nurse), V4 opened the 6th floor medication room. This surveyor requested V4 to open the medication refrigerator and to check for the temperature registered on the thermometer. V4 checked the thermometer and stated temperature at 60F. There was an ice buildup on the small freezer inside of the 6th floor refrigerator. V4 stated the facility keep our unopened insulin in the refrigerator. On 09/30/2024 at 10:27 am during the Medication Storage Task with V11 (Licensed Practice Nurse) of the 4th Floor Medication Storage Room. This surveyor requested V11 to open the small refrigerator and to check the thermometer for the temperature. V11 stated the temperature is 48F. This surveyor requested to see the 4th floor refrigerator temperature log. The log documented temperature on 09/29 and 09/30 at 48F. V11 stated the facility keeps unopened insulin inside the refrigerator. The night shift checks the refrigerator daily to clean it and to check the temperature. On 10/01/2024 at 10:24am, V2 (Director of Nursing) stated, The refrigerator temperature should be within 36F to 46F. If above, staff are supposed to let maintenance know so it can be repaired. May be needing to adjust the setting. The purpose of keeping the medication storage within the required range is to keep the medications in a stable state; to keep the potency of drug in stable condition. There could be an ice buildup that is why it has to be checked to defrost the freezer. Temperature checking is daily to make sure the refrigerator in stable condition or functioning properly. On 10/01/2024 at 10:33am, V2 stated the instruction on the bag of Latanoprost from the Pharmacy to refrigerate the medication if not opened should be followed; the medication should be refrigerated for the same purpose. To follow the manufacturer's instruction which was passed on to the pharmacy for proper storage of medication. The medication will lose its potency. That is why it has to be refrigerated if not opened. R84's (Active Orders as of: 09/30/2024) Order Summary report documented, in part Diagnoses: (include but not limited to) essential hypertension. Latanoprost instill 1 drop in both eyes one time a day. Start Date: 07/10/2024. R100's (Active Orders as of: 09/30/2024) Order Summary report documented, in part Diagnoses: (include but not limited to) Glaucoma. Latanoprost instill 1 drop in both eyes at bedtime. Start Date: 02/20/2024. The (2024) 4th Floor Refrigerator Temp Log documented that on Days 29 and 30 the temperature was at 48F. The (undated) Facility provided Latanoprost Package insert documented, in part, Storage: Store unopened bottle under refrigeration at 36F to 46F. Once opened for use, it may be stored at room temperature up to 77F for 6 weeks. The (9/2022) Storage of Medications policy and procedure documented, in part, General: to provide the staff with guidance on the proper storage of medications. Storage of Medications: 9. Medications requiring refrigeration or temperature between 36F and 46F are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.

Based on interview and record review the facility failed to refer two residents R34 and R103 to the appropriate state designated authority for a new Level I PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after R34 was admitted to facility without Mental Diagnosis disclosure on the Level I PASARR and R103 diagnosed with a new mental disorder. This deficient practice affected two residents (R34 and R103) in a total sample size of 77 residents. Findings include: R34's PASSAR dated 06/28/24 documents in part, PASRR Level I Determination: No Level II Required - No SMI (Serious Mental Illness)/ID (Intellectual Disability)/RC (Related Condition). R34's admitted to the facility is 06/28/24. R34's medical diagnosis includes but are not limited to Schizoaffective Disorder, Bipolar Disorder, Brief Psychotic Disorder, Depression, Impulsiveness. Facility's policy titled PASARR dated 04/2020 documents in part, General: The PASARR screening with be provided to the facility prior to admission so that the facility can make appropriate decisions regarding care and placement .Process: 1. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program (PASARR) to the extent practicable .7. Should the resident require a PASARR update after admission, the facility will contact the state agency to update the PASARR. On 10/01/24 at 12:11pm V40 (Assistant Administrator, AA) stated, PASRR guides us (facility) with resident centered care using the diagnosis. PASARR is required to make sure that we (facility) are able to meet the needs of the residents. I (V40) am familiar with R34. R34 has mental diagnosis' and only has a level 1 PASARR. Even if the PASRR is done at the hospital, we (facility) should follow up on the accuracy of it. 50728 R103's admission record documents in part a diagnosis of major depressive disorder, recurrent (onset date 5/9/2023) and anxiety disorder (onset date 5/3/2023). R103's order summary report documents in part, R103 has active orders for bupropion HCl Oral Tablet 150 MG (Bupropion HCl) (antidepressant Medication) Give 1 tablet by mouth one time a day related to anxiety and Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) (antidepressant medication) Give 37.5 mg by mouth one time a day for Anxiety. R103's Level I PASRR (Pre-Admission Screening and Resident Review) dated 5/3/2023, documents in part, no mental health diagnosis is known or suspected for R103 and R103 does not take any mental health medications. On 10/1/2024 at 12:05 PM, V40 (Assistant Administrator) stated the social services director normally completes that PASRR assessments but the social services director is on vacation so V40 is covering. V40 affirmed V40 is familiar with the Illinois process and standards for PASRR completion. V40 reviewed R103's electronic health record and acknowledged R103 has a diagnosis of major depressive disorder and anxiety disorder. V40 reviewed R103's last PASRR (5/3/2024) and affirmed the PASRR does not identify R103's mental health diagnoses or medication use. V40 stated R130's PASRR should accurately reflect R103's health status and a new PASRR should have been completed. V40 stated PASRR assessments are important because they identify services a resident might need that is diagnosed with mental illness. Facility policy titled PASARR (effective date 4/2020), documents in part, . 7. Should the resident require a PASARR update after admissions, the facility will contact the state agency to update the PASARR .

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 resident (R136) out of 77 residents reviewed for call lights. Findings include: On 9/29/2024 at 11:53am observed R136 lying in the bed watching television, alert and oriented. Surveyor asked R136 Where is your call light pull string located? R136 stated, I don't know where my call light string is at, it's a little green string. On 9/29/2024 at 11:55am observed R136's call light string (a little green string with a clip attached on the end) hanging on top of the light fixture located above the head of R136's bed. On 9/29/2024 at 11:57am surveyor asked V4(LPN/Licensed Practical Nurse) to come into R136's room. V4 was asked, Where is R136's call light string? V4 stated the call light string is located on top of the light above R136's bed. V4 stated the call light is supposed to be within reach of the resident. On 9/29/2024 at 12:00pm surveyor observed V4(LPN/Licensed Practical Nurse) take the call light string from the top of the light fixture and clip the call light string to the right shoulder area of R136's gown. On 10/01/2024 at 11:16am V2(DON/Director of Nursing) stated the resident's call light should be in the room, within reach of the resident. V2 stated the purpose of the call light is so that the resident can signal the staff for help. R136's diagnosis includes, but are not limited to, cerebral infarction, unspecified, morbid (severe) obesity due to excess calories, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and paraplegia. R136 has a Brief Interview for Mental Status (BIMS) dated 09/05/2024 which documents that R136 has a BIMS score of 14, indicating R136's cognition is intact. The facility's policy titled Call Light Response dated 2/2017(revision date of 9?2022) documents, in part, 3. Ensure call light is within resident's reach at all times.

Based on interview and record review the facility failed to ensure staff protected one resident (R394) (out of three residents who were screened at risk for abuse) from employee to resident physical abuse. Findings include: R394's diagnosis includes but are not limited to chronic obstructive pulmonary disease with (acute) exacerbation, unspecified asthma, uncomplicated, anxiety disorder, unspecified, shortness of breath, bipolar disorder, unspecified, schizophrenia, unspecified, and dyspnea, unspecified. R394's MDS (Minimum Data Set) dated 9/19/2024 indicates a Brief Interview for Mental Status was not completed. Staff Assessment of Mental Status documents in part, C0700. Short-term Memory OK 0. Memory OK. C1000. Cognitive Skills for Daily Decision Making 0. Independent-decisions consistent/reasonable. R116's diagnosis includes but are not limited to schizophrenia, unspecified, drug induced subacute dyskinesia, major depressive disorder, recurrent, unspecified, other migraine, not intractable, with status migrainosus, and idiopathic progressive neuropathy. R116's Brief Interview for Mental Status (BIMS) dated 7/31/2024 documents R116 has a BIMS score of 15 which indicates R116's cognition is intact. On 10/03/2024 at 12:38 pm surveyor met R394 on the third floor in the hallway near the elevator. R394 alert and oriented. Surveyor and R394 went to R394's room to discuss the allegations. R394 stated, Me and my ex-roommate (R116) had a disagreement on 9/19/2024 at about 1:30pm. I owed R116 two dollars. On that day I had dropped my cellphone in the toilet, and I could not make any phone calls, so I was upset. I was trying to tell R116 about my phone situation and I would give him (R116) the two dollars later. R116 pushed me, and I fell to the floor. When I got up from the floor R116 hit me again. I picked up a chair and hit R116 with the chair. There were no witnesses to this, it was just me and R116. Staff did hear the commotion in my room from the hallway and that is when staff came into my room. Staff separated me and R116. I was told to go into the dining room on the third floor by staff. Staff escorted me into the dining room. I do not remember what staff person escorted me to the dining room. When I got to the dining room V44 (former Social Service Director) asked me to sit down. I sat down in the chair, but I wanted to ask V44 a question, so I got up out of the chair. When I got up out of the chair, V44 pushed me down to the floor and took his hand and mashed my head against the floor. I could not get V44 off me. Another manager came to pull V44 off me. This same manager pulled me up from the floor and asked me if I was okay. V44 was escorted off the third floor by another manager. The police came to the facility at about 5:30pm that day and spoke with me. The police made it clear to me that I was not in any trouble. I was shaken up bad. The police told me if I wanted to press charges it would be a civil matter. There were no residents around during the incident because the residents were told by staff to go into their rooms. I don't know if any other resident saw the incident. On 10/03/2024 at 4:38pm R48 stated on 9/19/2024 at about 1:30pm all residents in the hallways on the third floor were told to go into their rooms and remain there. R48 stated, I heard the confusion in the third-floor dining area; but I did see what was going on. On 10/03/2024 at 2:01pm V45 (LPN/Licensed Practical Nurse) stated V45 is familiar with R394. V45 stated on 9/19/2024 at about 1:30pm R394 was observed being verbally abusive towards staff on the third floor in the dining room area. V45 stated V44 (former SSD/Social Service Director) was trying to redirect R394. V45 stated R394 was not redirectable at that time. V45 stated R394 hit V44 in the face. V45 stated V44 grabbed R394 by both arms, holding both of R394's arms to the side of R394's body. V45 stated V44 and R394 were struggling and both V44 and R394 went down to the floor. V45 stated V44 was trying to do CPI (Crisis Prevention Intervention) on R394. V45 stated R394 was trying to fight V44 back and trying to get up off the floor. V45 stated R394 was able to get up from the floor and sit back in the chair in the dining room. V45 stated it did not get physical again with V44 and R394. On 10/03/2024 at 2:30pm V8 (PRSC/Psychiatric Rehab Service Coordinator) stated V8 is familiar with R394. V8 stated, I was at a care plan meeting on the second floor when the incident happened with R394 on the third floor on 09/19/2024 at about 1:30pm. When I did return to the third floor, because I am the PRSC assigned to the third floor, it seemed that things had calmed down. The nurse on the third floor informed me that R394 was yelling, screaming, and cursing at the staff. When I was able to verbally speak with R394, R394 was hard to redirect, and I could not make out what R394 was saying to me. I am trained to use CPI (Crisis Prevention Intervention) and usually we do not get to the point where we are physically touching a resident. The staff should talk with the resident to deescalate the situation first. R394 did talk with the police regarding the incident and a police report was made. R394 was sent to the hospital for evaluation. On 10/03/2024 at 3:00pm V46 (CNA/Certified Nursing Assistant) stated, I am familiar with R394. I was behind the third-floor nurse's station on 9/19/2024 between 1pm-2pm when the incident occurred with R394. R394 was being verbally aggressive and would not calm down. A Code Yellow was called by third floor staff. A Code Yellow is called when we need more staff on the floor to assist with calming down a resident. V44 (former social service director) was the first to arrive on the third floor. V44 told R394 to have a seat in the third-floor dining room. R394 did not sit down and got into V44's face and R394 hit V44 in the face. After V44 was hit in the face by R394, V44 grabbed R394's arms to hold R394's arms to the side of R394's body. R394 continued tossing his body, trying to get away from V44. At that time both R394 and V44 fell to the floor, and V44 was still holding R394's arms trying to get R394 to calm down. Next both R394 and V44 got up from the floor. It did not get physical between R394 and V44 again. R394 was still being verbally aggressive. I would not put my hands on the resident who is being verbally aggressive, I would try talk with the resident first. I was in-serviced regarding abuse on 9/20/2024, the day after the incident. On 10/03/2024 at 4:10pm V40 (Assistant Administrator) stated the incident regarding R394 occurred on 9/19/2024 in the afternoon, V40 didn't remember the exact time. V40 stated, A code yellow was called, and staff rushed to the third floor. A code yellow is called when a resident is having behaviors. I witnessed R394 displaying verbal outbursts near the nurse's station. I did not witness staff to resident physical assault. R394 did report an allegation of physical assault to me, and an investigation was started. While doing the investigation I found out V44 (former Social Services Director) tried to use CPI (Crisis Prevention Intervention) to deescalate the verbally aggression with R394. V44 did get physical with R394 I prefer staff to verbally deescalate the situation, instead of being physically aggressive. The situation between V44 and R394 could have been handled better by V44. The police were called regarding this incident and a police report was made out. On 10/03/2024 at 4:53am V1 (Administrator) stated the incident with R394 was on 9/19/2024 around 2pm. V1 stated, I was in the facility and went up to the third floor. I did not witness R394 being physically abused. R394 was stating V44(former social service director) hit me and hit R394's head against the wall. The third-floor staff told me V44 was trying to use CPI (Crisis Prevention Intervention) to deescalate V394's behaviors by holding R394's arms down by his side and this eventually led to both R394 and V44 falling to the floor. CPI skills do not require for staff to put a resident on the floor. The staff should try to verbally deescalate the situation first. Sometimes the de-escalation process can get physical, but this should be the last resort. That is why I had a problem with the way V44 did CPI. V44 should have not placed hands on R394. R394 went to the hospital for evaluation. Reviewed R394's care plan dated 10/02/2024 which documents in part, Focus: R394 Risk for Abuse, Goal: R394 will remain free from abuse through the next quarter. Facility's Abuse Prevention Program Policy dated 02/07/2017(with a revision dated of 01/30/24) documents in part, Policy: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The Residents' Rights for People in Long-term Care Facilities policy presented by the facility documents in part, you have the right to safety and good care. You must not be abused by anyone-physically, verbally, financially, or sexually. Reviewed R44's (former Social Service Director) Employee Report which documents in part, on 9/19/2024 employee was discharged for improper use of CPI (Crisis Prevention Intervention).

Based on interview and record review, the facility failed to obtain informed consent for psychotropic medication prior to administering the medication. This failure affects 1 resident (R103) in a sample of 77. Findings include: R103's admission record documents in part, the following diagnoses: major depressive disorder, recurrent and anxiety disorder. R103's Minimum Data Set (dated 8/1/2024) documents in part a brief interview of mental status summary score of 15, indicating R103 is cognitively intact. R103's order audit report documents in part, bupropion HCl Oral Tablet 150 MG (Bupropion HCl) (antidepressant Medication) Give 1 tablet by mouth one time a day related to anxiety was ordered on 5/3/2023. The dose was decreased to 100 mg on 10/1/2024. R103's order summary report documents in part, R103 has an active order for Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) (antidepressant medication) Give 37.5 mg by mouth one time a day for Anxiety, with a start date of 5/18/2024. R103's PSYCH: Consent for Psychotropic Medications (dated 5/3/2024) documents in part R103 consented to take Sertraline HCl 50 mg, QD (every day), Antidepressant (current dose of sertraline is 37.5 mg). Bupropion is not listed on the consent form. R103's medication administration record documents in part R103 received both sertraline 37.5 mg and bupropion 150 mg daily since 5/18/2024. On 10/1/2024 at 9:46 AM, R103 stated R103 was unaware R103 was taking Bupropion. R103 stated, I (R103) thought I was taking only one antidepressant medication, sertraline. I was not aware I am taking this bupropion medication. I take 2 antidepressants?. R103 affirmed R103 was not explained the risks and benefits of the medication and could not recall if anyone had ever asked for R103's consent to administer the medication. On 10/1/2024 at 9:57 AM, V3 (Psychotropic Nurse, Licensed Practical Nurse) stated residents receive psychotropic medications must consent to the medication prior to the medication being administered. V3 stated informed consent is important because the medication can change how a resident thinks. V3 affirmed Bupropion is a psychotropic antidepressant medication. V3 reviewed R103's electronic health record, active physician orders and psychotropic medication consents. V3 confirmed R103 did not consent to receiving bupropion. V3 stated R103 should have been informed of the risks and benefits of the psychotropic medication. Facility policy titled, PSYCHOTROPIC MEDICATION PROGRAM (reviewed 10/23), documents in part, GENERAL: The purpose is to promote safe and effective use of psychotropic medications .The second purpose of this process is to ensure the resident is evaluated and the indication for the medication is documented within the medical record . Also, the resident and representative are aware of the potential side effects and the facility obtains informed consent for the use of the psychotropic medication . 9. If a new order for a psychotropic medication is obtained, the resident, residents representative or POA must be informed of the risks and benefits of the medication. The facility must obtain informed consent. If the family or resident's representative is not able to sign the consent at the time of the order, a verbal consent will be obtained by the nurse and documented on a psychotropic consent form until written consent can be obtained. This form will be part of the medical record .

Based on observations, interviews, and record review the facility failed to ensure that wound care treatment was completed and documented in a timely manner for one resident (R87) in a total sample size of 77 reviewed for wound care. Findings include: R87's admission diagnoses include but not limited to hypertension, cerebrovascular disease, and furuncle unspecified. R87's Brief Interview for Mental Status (BIMS) dated 07/29/24 shows R87 has a BIMS score of 14 which indicates that R87 is cognitively intact. On 9/29/24 at 11:10 am, R87 observed in room lying in bed with a soiled undated dressing noted to the left side of R87's neck. There was a dark color drainage noted on the dressing. R87 stated that the dressing had not been changed in about three days. On 9/30/24 at 2:55 pm, surveyor observed R87 in room with same soiled dressing noted on the left side of R87's neck. R87 stated the dressing had not been changed and is the same dressing from yesterday. Surveyor requested for V26 (Wound Care Nurse) to look at R87's dressing and inquired about R87's dressing change. V26 looked at R87's dressing and stated, R87 has a cyst that drains. The dressing needs to be changed I will change it now. Surveyor inquired to V26 when was the last time it was changed because it's not dated. V26 stated, I do not date my dressing changes, it's not in the policy and the staff can look in the computer to see when the dressing was changed. R87's (Active Orders as of 10/1/24) Order summary Report documented in part, cleanse open area on left shoulder with normal saline solution and cover with a dry dressing, Monday, Wednesday, Friday, and prn (as needed) until resolved . To promote wound healing. R87's TAR Treatment Administration Record documented in part, treatment administered on 9/25/24 (Wednesday), 9/27/24 (Friday) and 9/30/24 (Monday) all dates were signed that treatment was completed. R87's Medication and Treatment Administration Audit Report documented in part, Schedule Date 9/25/24 (Wednesday) for wound care shows administration time 9/30/24 at 3:01 pm, and documented time 9/30/24 at 3:01 pm. Wound Care treatment for 9/27/24 (Friday) shows administration time 9/30/24 at 3:01 pm, and documented time 9/30/24 at 3:01 pm. On 10/1/24 at 11:02 V2 Director of Nursing (DON) stated that wound care dressing should be changed according to the doctor's order and as needed. If a dressing is soiled it should be changed to prevent infections. On 10/1/24 at 1:00 pm, Surveyor inquired to V26 (Wound Care Nurse) why was the wound care treatment on 9/25/24 and 9/27/24 not documented until 9/30/24. V26 (Wound Care Nurse) stated, I (V26) usually document after I finish the treatment. I thought I had documented on those treatments. When I went in to document the treatment for Monday, I saw that I did not document on Wednesday and Friday. I should document at the time I do the treatments and dressing changes. R87's dressing needed to be change because it was soiled and due to be changed. Surveyor inquired to V26 what could happen when a soiled dressing is not change. V26 stated that it could cause an infection. R87's (9/24/24) care plan documents in part, Focus: Has an abscess to left side of neck. Goal: area to left side of neck will remain stable/heal throughout next review. Interventions: Educate resident on the risks of infection and poor healing related to non-compliance. Facility's policy titled Dressing Application review date 9/2017, documents in part, General: Dressings are changed as ordered by the Physician or Nurse Practitioner and PRN (As Needed). Facility's job description titled (Wound Care Nurse) documents in part, Basic function: The primary purpose of Wound Care Nurse is to provide for the day-to-day care needs of the residents in a Skilled Nursing Facility Environment. Essential Duties: 18. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures.

Based on interview and record review the facility failed to refer one resident (R178) to the state agency for Preadmission Screening and Resident Review (PASRR) for rescreening before R178's Short Term Approval without Specialized Services determination's expiration date. This deficient practice affected one resident (R178) in a total sample size of 77 residents. Findings include: R178's PASRR dated 11/06/23 documents in part, PASRR Determination: Short Term Approval without Specialized Services .Date Short Term Approval Ends: February 4, 2020 .This determination allows you a limited number of days in a Medicaid-certified nursing facility .If you or your care provider thinks you need you stay after that date, a nursing facility staff member must submit a new Level I screen .The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. R178's PASRR Level I rescreen dated 06/07/24. R178's medical diagnosis' include Schizoaffective Disorder Bipolar Type, Type 2 Diabetes Mellitus, Asthma, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, Depression. On 10/01/24 at 12:11pm V40 Assistant Administrator (AA) stated, R178 PASRR was not resubmitted timely, R178 was here 4 months without the proper plan of care. Facility's policy titled PASARR dated 4/2020 documents in part, Process: 7. Should the resident require a PASARR update after admissions, the facility will contact the state agency to update the PASARR.

Based on observation, records review and interviews the facility failed to provide a safe and home like environment by not maintaining comfortable and safe temperature levels in the entire premises of the facility. This failure affected all 258 residents residing in the facility, who were all subjected to hazardous temperatures and one resident (R8) who was sent to the hospital and admitted due to hypothermia. This was identified as an Immediate Jeopardy which began on 1/16/24 at 10:30 am per (1/16/24) facility temperature log which documents a residents' rooms temperature range of 53F (Fahrenheit) to 63F. On 1/19/24 at 09:16 am V1 (Administrator) was notified of the immediate jeopardy. The facility presented a final removal plan on 1/22/24 at 4:49 am which was not approved. The facility presented a revised final removal plan on 1/23/24 at 04:59 pm which was not approved. The facility presented another revised final removal plan on 1/24/21 at 1:36 pm which was accepted/approved on 1/25/24 at 5:08 pm. The surveyor conducted additional interviews and record reviews on 1/26/24 to 1/31/24 verify the plan was implemented. The immediate jeopardy was removed on (1/24/24) based on actions from the removal plan. Findings include: On 01/16/24 at 04:00 pm surveyor arrived at the facility and noticed that there were 2 charter buses in front of the facility and in the entrance hall there were more than 15 people distributed between the reception, entrance and corridor leading onto the elevators. Everyone was wearing winter coats and jackets; some were wearing winter hats and gloves and scarfs. The temperature inside was very cold. There was a line of people coming from the elevator. After speaking with V1 (Administrator), surveyor learned that those people were residents being transferred to other facilities and staff were there to help with the transfer process. On 1/16/24 at 04:15 pm surveyor observed residents had been in process of being discharged to two other facilities due to inadequate heating. The weather forecast on 1/15/24 was 4 degrees Fahrenheit (F) with wind chills of minus 9 F. Temperatures on 1/16/24 was 5 degrees with wind chills of -5 degrees according to the weather forecast. On 1/16 24 at 04:15 pm V1 (administrator), said that on 01/15/24, around 8:30 am, it was noticed the temperature inside the building was dropping. The lack of heating was affecting all floors. The facility called a company to check the boiler and it was noticed the boiler temperature was at 130 instead of 160. V1 said the boiler malfunctioning was fixed, and the heating was restored for a while but then one of the radiator pipes burst. A plumbing company was called. The plumbing company arrived around 11am on 1/15/24, repaired the plumbing, but while they were working, other pipes burst and continued to burst because they were frozen due to the intense cold weather. V1 said, The plumbing company told me the problem would continue to occur even though they were trying to contain it. That's why I decided to evacuate all residents to other facilities. V1 said two facilities confirmed to receive residents. V1 said the census is 258 and all residents will be transferred and at this point to 2 facilities have that accepted their residents. V1 stated these two facilities will provide 150 beds to accommodate the residents. On 1/16/24 at 04:20 pm V1 said offices are located on the 1st floor; 2nd, 3rd, 4th floor is mix of skilled and non-skilled residents, but mostly skilled residents, need more assistance; 5th floor they are little more independent; 6th and 7th floor residents are independent, ambulatory and need less assistance. Copy of the census received and shows total of 258 residents. On 1/16/24 at 04:30 pm V3 (Assistant Administrator) said, The pipe burst happened initially on the second floor on (1/15/24) which caused flooding to both 2nd floor, and 1st floor. We have over 100 portable heaters that were brought in to help and they had been placed on residents' rooms to keep it warm until the heating system be repaired. The facility has also bought forced heaters and they have been placed on the floors. During facility tour surveyor noted some room did not have a portable heater in place, some other rooms had a portable heater placed in the floor unplugged. On 1/16/24 at 04:35 pm V2 (Regional Director of Operations) stated, We are implementing phase one of our emergency plan, which is to evacuate the most mobile/ independently residents first and then evacuate the ones who need more assistance, the ones on wheelchair, or not able to be transferred by bus and requires a wheelchair van for transportation. While we are doing this, I have my Chief Operating Officer (COO - V4) calling other facilities checking their availability to receive our residents. On 1/16/24 at 05:02 pm observation conducted on 2nd floor. Noticed a portable heater placed in the hallway and another one close to the nursing station. Surveyor observed water on the floor of 4 rooms. No residents observed in these rooms. At the top of the staircase that leads to the second floor, there were several black bags with debris, debris on the floor and signs of flooding. The pipe was uncovered and broken and according to the building's maintenance director V7, was where the leak started, and they had to isolate the pipe to fix it. On 1/16/24 at 5:10 pm on 3rd floor several residents observed in wheelchairs sitting in the hallway, or grouped in a room called the day room located in front of the nursing station. The residents were wearing winter clothing, such as coats, jackets, gloves, and hats. According to nurse (V6), the floor census is 47 residents. One nurse and one CNA observed working in the floor. On 1/16/24 at 05:12 pm R3 observed inside her room, sitting in a wheelchair, and noted to be wearing multiple layers. R3 stated, It's cold here and there is no heating. There is no portable heater in R3's room. Surveyor asked V6 to check R3's room to verify if there is a portable heater inside the room. V6 stated, I don't see one. On 1/16/24 at 05:15 pm noticed R4's room without a light on. R4 was in bed without a blanket, covered from the chest to the lower extremities with just a sheet. R4 kept saying, Help, help, help, black, black, back, back. R4 noted to be shivering and hunching his shoulders. R4 said he was cold, and then pointed to a wheelchair. The room was dark and cold. The room has 4 beds. A portable heater has been placed next to the R4's bed, but is not plugged in. Another portable heater found next to second bed D is plugged in. Surveyor asked V6 why the room is dark and cold and why the heater next to R4's bed is unplugged. V6 tried to plug the heater in, but the outlet was too far from the bed. V6 checked the headboard's light for all 4 beds and none of them worked. V6 said she heard that if the portable heater is plugged in, the lights above the headboard won't work properly. V3 (AADM) tried to plug in the portable heater placed close to R4's bed but was not able to. V3 stated, These are the things we have not planned. V6 unplugged the portable heater that was placed close to another bed and the lights came on. V6 said she will transfer R4 to the wheelchair but does not provide a blanket to resident. On 1/16/24 at 05:25 pm R9 was laying down in bed, wearing several layers of clothing and covered by a blanket. R9 has no roommate. Noted a portable heater placed on top of the nightstand. R9 said her son bought the heater for her yesterday because it was too cold and there is no heating in the room. R9 said the facility bought the portable heater today around 12 pm. The heater provided by facility is plugged in and placed on the top of the dresser. R9 said no one told her she will be transferred to another facility. On 1/16/24 at 05:28 pm R10 stated, They just brought the portable heater now. The heating went out during the weekend, and they should have moved us during the weekend. On 1/16/24 at 05:30 pm R5 said, They just brought this heater a few minutes ago. I'm freezing here. The heat stopped yesterday evening. I need more blankets. I've asked them, but they don't bring it. R5 was wearing 4 layers of clothing including a sweater and has one sheet and one blanket on top of her and said, and I'm still cold. On 1/16/24 at 06:00 pm there is no heating in the dining room, reception, lobby, therapy room and offices, all located on the 1st floor. Surveyor worked wearing a full set of winter clothes (heavy coat, hat, scarf). Facility's staff noted to be wearing a full set of winter clothing gloves and some of them using scarfs as well. There is no heating inside the elevators. Copy of the census received and shows total of 258 residents. On 1/16/24 the facility temperature log indicates temperatures were checked in residents' rooms, nursing station (NS), basement, Physical Therapy room, offices and dining room (PT & SO & IDNE). The temperature log shows rooms temperature were checked on intervals of about 1 hour and reflects the following: At 08:30 am temperature on rooms 702, NS and 721 were respectively 55F, 59F and 54F ; 602, NS, 620 - 55F, 57F 55F; 502, NS, 521 - 54F, 57F, 55F; 401, NS , 420 - 55F, 60F, 54F; 302, NS, 321 55F, 55F, 54F; 201,NS, 220 - 54F, 53F, 55F. At 09:40 am the temperature ranged from 59.7F on the 6th floor to 53F on 2nd floor. At 10:30 am the log reflects temperature of the following: 701 - 63F/ 720- 60F; 602- 59F/ 621- 54F; 501- 56F /520-54F; 402- 53F /419-53F; 302- 54F/ 320-53F; 202- 53 F/ 220-53 F; PT&SO& DINE (1ST floor) 51F - 52F. Facility's temperature log sheet dated 1/16/24 completed on interval of 30 minutes starting at 5 pm does not documents residents' rooms temperature, instead documents one temperature per floor (6th, 5th and 4th floor) where the residents were. The temp log reflects the following: At 5 pm 5th floor- 67.3F; 4th floor 66.1F. At 05:30 pm 5th floor - 66.4F; 4th floor 67.2F. At 6 pm 5th floor 66F; 4th floor 67.2F. At 6:30 pm 7th floor 64.1F; 6th floor 65.4F; 5th floor 66.5F. At 7 pm 7th floor 65.1F; 6th floor 68.1F; 5th floor 67.2F; 4th floor 67.9F. At 7:30 pm 6th floor 68.9 F; 5th floor 67.5F ; 4th 67.9F . The highest temperature recorded from 8 pm on 1/16/24 to 3 am on 1/17/24 on the 4th floor 71.1F. At 8 pm and 8:30 on 1/16/24 the 4th floor temperature was 61F. On 1/16/24 at 18:05 pm, noticed a crew member bringing another equipment into the facility. According to V1, it is to be installed to provide heat, because we still have to keep the building's temperature up. On 1/17/24 at 09:30 am noted 120 residents, according with census, remained at the facility with the heating system still not functionally operating. On 1/17/24 at 10:47 am 4th floor hallway north temp 57.3 degrees. At 11:08 am one resident's room on 4th floor temp was 56.6. degrees. On 1/17/24 at 01:50 pm V5 (Regional Maintenance Director) stated, The boiler malfunctioning affected the air handle system and the radiator system. The upstairs units were working at 75% capacity and warming the 7th, 6th, 5th and 4th floor. The air handles in the basement cover basement, 1st, 2nd and 3rd floor. The big units we are getting will fix the problem and they will be heating the building in 2 to 3 hours. The standing heater covers 750 square feet and we got 20 of those. The machine pumps up 80 degrees, but that does mean the rooms are 80 degrees. Forced heaters that covers 300 square feet, those are the best ones, and we have 3 of those per hall. We should have the standing heating unit, the portable heaters and the diesel fuel commercial make up air units, all working to provide heating the building so in 1:30 and 2 hours we should have everything done. On 01/17/24 at 09:40 am V1 said the heating is working on all floors, but after inspection with V7 (Maintenance Director) surveyor noted the temperature was below 71 degrees on the 4th floor. Temperature in the north corridor of the 4th floor was 57.3 degrees at 10:47 am on 01/17/24. At 11:08 a.m., the temperature in one resident's room was 56.6. degrees. On 1/17/24 at 03:02 pm Surveyor made rounds with V7 (Facility Maintenance Director). Despite all equipment brought to facility to heat up the building the temperature in residents' rooms still under the temperature required. Room temperatures were 64.9, 59.3, 63.3 63.8, 56.3, 61.9 in resident's rooms and 64.3 in the day room [ROOM NUMBER]th floor temp. The day room has one standing heating unit and two forced heaters in place. Facility entrance area temp 46.5. On 1/17/24 at 06:05 pm V1 said they were transferring residents from the 6th floor to another facility. V1 said, the boiler is working, it's just that the temperature was not holding up because the pipes burst. V1 stated, It reduced the power to keep the heat up. On 01/17/24 at 06:56 pm temperatures were 61.4, 62.8, 66.4, 60.2 degrees respectively in 4th floor residents' rooms and 68 degrees at Nursing station. On 1/18/24 at 10:47 am room's temperature checked randomly and were the following: 5th floor rooms 68.3 F, 68.1 F, 62F, 60 F, 70 F, 69.8F. 6th floor rooms 68.6F, 67.2F, 65.1F, 64.4F. On 1/18/24 progress notes documents R8 was sent to the hospital. Hospital records documents: 66.y male present to Emergency Department for evaluation. Patient brought by EMS for possible low oxygen saturation at nursing home. Per EMs the nursing home had a pipe burst and had patient was in a wheelchair sitting in the hallway. On initial assessment patient noted to be hypotensive and bradycardic. Physical exam reads: blood pressure 110/68; pulse 66' temperature 91.8 degrees. Medical decision making patient noted to be hypothermic, hypotensive, and bradycardic. Will give antibiotic and lab work. Patient placed in warming blanket. On 1/19/24 at 09:45 am R6 was in a wheelchair, fully dressed, wearing winter clothes. R6 stated, I was on the 4th floor on Monday (1/15/24), and it was cold. Cold enough to make me uncomfortable. There was no heating coming from the radiator or from the ceiling. It was very cold! I used my own blanket. On Tuesday (1/16/24) afternoon they brought the portable heater to other rooms, but never to our room. I asked V7 (maintenance director) for a heater, but he never brought one. For four days they are talking we are going to leave to another facility, and we are still here. On Tuesday (1/16/24) they put me in the room on the 6th floor that was cold and had water on the floor. I said if I am going to be in another cold room, I would prefer to stay in my room. They took me back to the 4th floor. I did not get any medicine last night. I did not get my insulin and the Keppra. I take Keppra because I have seizures. They did not check my blood sugar this morning. The nurse said she did not have the equipment to do it. They said the nurse on duty did not know where the medication was. They said they had packed the medication because we were about to leave, and the nurse didn't know where they put it. On 1/19/24 at 09:50 am R7 stated, They transferred me to 6th floor on Wednesday (1/17/24). On 1/15 and 1/16/24 the 4th floor was cold. I was fully dressed, with coat and I had to cover my head with the blanket. That's how cold it was. Everybody was wearing coat, gloves, boots and hats. It really started on Monday afternoon. The temperature was dropping. It came back a little bit and then was cut off. They told us the furnace was broken and they will bring a new one. On Tuesday they said they will transfer us. But my question is, why the let people who can walk go and left us on a wheelchair, behind? From Monday to Wednesday, when they started bringing the heating units here, we had no heating. I was transferred to this floor (6th) on Wednesday. I did not receive my medication last night. On 1/23/24 at 10:57 am V1 stated, Right now we have our residents on 6th floor, temps are between 71 and 81 F. It was checked 30 minutes ago. We are checking every 30 minutes. No residents have been sent to hospital since Friday. The resident sent to the hospital is still at the hospital. After we are able to get the entire building complete and any water damage fixed we will bring the residents back. The equipment going to ceiling through plastic tubes is to eliminate moister. We will have a meeting to discuss the progress of the work that is being done and learned about the time frame for the completion of it. On 1/23/24 at 01:30 pm surveyor made rounds with V22 (Maintenance). Random temperatures were taken on the 6th floor where 46 residents remained were 81.7 F, 83.1F, 84.4F, 85.3F, 84.9F, and 84.6F. The South hallway was 85.1F; Room in front of the nursing station (day room) north wall was 87.3 F and Nursing station was 87.3F. Residents noted to be wearing light clothes and were complaining the temperatures were now too hot. Staff no longer wearing winter clothes. Nurses and CNAs noted to be wearing scrubs only. On 01/23/24 at 3:29 pm V5 (Regional Maintenance Director) stated, The purpose of the generator that was brought into the facility (placed outside the facility) was to supply hot water that will flow to the radiator pipes and fans to create heat. The radiator's heat goes to the air coils which will push hot air through ductwork throughout the building while the pipes and coils are being repaired. V5 said the boiler was repaired, but the pipes froze, and the dampers and controls were damaged due to the cold. V5 stated the coils weren't working yet, so the 4th floor was cold. It should be done by tomorrow afternoon. The patching of the air handles should be done by Friday. Hopefully, and in the worst case, Monday. I turned off the heating as it was getting very hot on the upper floors as there is now some heat coming from the radiators as well. On 1/30/24 at 01:34 pm V15 (Attending physician) stated, I don't think this is predictable. It depends on whether the person is exposed to lower temperatures. Was the resident outside the facility? Yes, lower temperature can cause bradycardia. A body temperature of 91.8F is considered hypothermia and the resident has go to the hospital. The nursing home may provide a blanket and provide hot liquids, but this needs to be closely monitored. If the resident develops septic condition and requires treatment with antibiotics. The following corrective actions to remove the Immediate Jeopardy were taken: 6TH FLOOR TEMPERATURE: A. Temperatures are being checked in the resident rooms and resident areas on the 6th floor every 30 minutes. B. The temperatures on the 6th floor are maintained between 71 F to 81 F. HEATING SYSTEM: A. On 1/15/2024, the boiler is functional and was validated by the HVAC company. B. Per HVAC company report, the boiler supplies heat to radiators at all exterior walls in stairwells and patient rooms. The boiler also supplies heat to coils in the two air handlers. The Air handler number #1 which is located in the basement of the facility covers floors 1, 2 and 3. Air handler #2 also provided heat from the boiler is located on the 7th floor penthouse and covers floors 4,5,6 and 7. Air handler #2 also has two sets of coils. Dampers were closed to try and conserve heat and push through floors 4,5,6 and 7. C. The facility contracted HVAC company to get two (2) make up air units to pump heat to air handler #1 to push hot air into floors 1, 2 and 3. D. The facility has also procured temporary heating units on 1/15/2024. The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. On 1/19/2024, at 1:15pm, the QAPI team (which includes the Administrator, DON - director of nursing, Assistant Administrator, Maintenance), and members of the executive management team (which includes, VP of Operations, VP of Physical Plant, Chief Regulatory Compliance & Clinical Officer, VP of Policy & Education and VP of Regulatory Compliance & Clinical Services) conducted an Ad-Hoc QAPI meeting to discuss the alleged deficiency and corrective actions. The Medical Director was not able to attend the meeting in person, therefore, the Administrator notified Medical Director of the Ad-Hoc QAPI meeting minutes via telephone on 1/19/2024, at 3:15pm. B. During the Ad-Hoc QAPI meeting, the QAPI team, members of the executive management team, and the VP of Physical Plant also discussed the Heating System Mitigation Plan which was developed for the facility in response to the extreme cold outside temperatures. C. The VP of Policy and Education will provide training to the Senior Leadership of the facility, which includes the Administrator, DON and Maintenance Director. The training will include but not be limited to: 1) The responsibility of the administrator to report all incidents to IDPH in a timely manner. 2) The responsibility of the Administration to provide a safe and homelike environment to all residents. 3) Emergency Management Plan focusing extreme temperatures and facility response. 4) Preventive maintenance related to the boiler and facility heating system. This training started on 1/19/23 and was completed on 1/23/2024. To validate retention of knowledge, posttests will also be used, and the acceptable score is 100%. If the score is less than 100%, a retraining will be completed. D. Nursing Staff Education. The DON/ADON will provide training to all nurses about symptoms of hypothermia. The training will be completed on or before 1/19/2024. E. All Staff Education. After training, the Administrator, Maintenance Director, DON, ADON will also provide training to all staff about extreme cold weather protocols. The training will also include posttests and the acceptable score is 100%. Any staff who did not achieve 100% test results was provided with additional retraining from the Administrator, Maintenance Director, DON, ADON. Training on the execution of the facility's emergency evacuation plan The training started on 1/19/2024 and completed on 1/23/2024. F. All staff members who are not available and/or currently on vacation will also receive the same education upon their return to work. The Administrator/DON/ADON will provide the same training. G. Agency staff. The facility is not using agency staff at this time. If agency staff are used in the future, the facility will utilize the same process of providing the education to ensure that they (agency staff) will receive the same training as the facility staff. H. In the future, when agency is used, the Administrator/ DON/ ADON will provide similar training prior to the start of their shifts. I. An agency staff will not start the shift without finishing the training first. J. Boiler. The Administrator will review the preventive maintenance schedule with the maintenance director, focusing on boiler maintenance. The Administrator will also provide training to the maintenance director to notify the Administrator, VP of Physical Plan and VP of Operations of any concern identified with the boiler. The training will be completed on or before 1/19/2024. K. The DON/ADON/charge nurses will conduct resident assessments every two (2) hours to ensure that residents are not experiencing any sign of hypothermia. The DON/ADON/charge nurses will notify the attending physician/Nurse Practitioner (NP) of any identified concern. This started on 1/15/2024, 9:00am. L. The Maintenance Director/designee will continue to conduct temperature checks of all rooms on the 6th floor every 30 minutes until the QAPI team decides to change the frequency of temperature checks. M. The Maintenance Director/designee will continue to conduct temperature checks of all rooms in floors, 1st, 2nd, 3rd, 4th, 5th, and 7th floor every hour until the QAPI team decides to change the frequency of temperature checks. N. The residents who have been evacuated will be allowed return to the facility on ce the facility stabilizes the temperature in all floors between 71 F to 81 F for at least 24 hours. This will be discussed during an Ad-Hoc QAPI meeting. O. All results of the temperature checks, unit rounds and resident assessments will be reported to the QAPI committee. P. An Ad-hoc QAPI meeting will be held weekly to determine if additional interventions are necessary to ensure compliance. Q. The Administrator will monitor completion of this plan of removal.

Based on record review and interview the facility failed to provide supervision and failed to ensure one of four residents (R2) reviewed for abuse remained free from abuse. As a result of this failure, R2 was struck in the head (with a chair) sustained a laceration to left eyebrow and subdural hematoma due to trauma. Findings include: On 9/15/23, IDPH (Illinois Department of Public Health) received allegations R2 was hit in the head a few times by an unknown resident weeks ago and has a brain bleed. R2's (7/25/23) progress notes states writer was informed resident R2 was engaged in verbal argument with peer which led to physical altercation. Resident R2 has cut on his upper eyebrow. On 9/20/23 at 2:44pm, surveyor inquired about the (7/25/23) incident. V5 (Licensed Practical Nurse) stated, I was in the washroom when I heard commotion in the dayroom. The residents were playing cards around 1:00 am. The CNA (Certified Nursing Assistant) told me he (V19/CNA) was making rounds when it happened and the other CNA was on break. He (V19/CNA) told me that he heard a commotion and rushed down. (R2) and (R6) had a verbal altercation that led to physical altercation. (R2) had a laceration on his upper eyebrow so I cleaned it, took his vitals, and gave him pain pill because he was having a little bit of pain. V5 affirmed she did not witness the (7/25/23) incident. On 9/20/23 at 3:15pm, surveyor inquired about the (7/25/23) incident. V19 (CNA) stated, That night, I had them (residents) play cards. They (residents) were in good mood. (R2) was not there at that time. He (R2) joined them (residents) later. After an hour, it was time to do my rounds. I was on the north side of the building (far end) where they (residents) watch the TV. Surveyor inquired if V19 witnessed the (7/25/23) incident. V19 responded, I heard a commotion. (R6) had already thrown the chair on (R2). He (R6) was aggressive. He (R6) was cussing about you (R2) talk about my mom. He (R6) was difficult to calm down. (R2) got a cut on his upper eye that was bleeding. I called the nurse she came to help me. Surveyor inquired if any staff witnessed the (7/25/23) incident. V19 replied, The Nurse was in the washroom and the CNA went on a 15-minute break. It was only me on the floor at that time. R2's (9/15/23) history & physical states patient alert, oriented to place and person, able to provide history that he was hit on the head with a chair a couple weeks ago. R2's (9/15/23) head CT (Computed Tomography) affirms subdural hematomas in multiple locations. Acute/subacute bilateral subdural hematoma likely traumatic. On 9/21/23 at 1:03pm, surveyor inquired about potential harm to an (unsupervised) resident hit in the head with a chair. V22 (Medical Director) stated, There is potential for harm. There's potential for bleeding on the inside of the brain or skull fracture. Those would be the 2 things that are concerning. The (10/2022) abuse policy and prevention program states this facility desires to prevent abuse, neglect, exploitation, mistreatment, deprivation of goods and services by staff and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: staff supervision.

Based on interview and record review, the facility failed to ensure the safety of residents by not monitoring and preventing a resident (R412) from receiving and using an illegal drug for 1 (R412) out of 1 resident reviewed for incidents and accidents. This failure resulted in R412 overdosing on heroin, requiring transfer and treatment at acute hospital for treatment. Findings Include: R412's medical records show an admitted [DATE] with diagnoses including but not limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder, and Epileptic Seizures. R412's progress notes dated 7/5/23 at 7:24 PM written by V3 (Director of Nursing) shows R412 was admitted in the facility from an acute hospital with history of alcohol and drug abuse. R412's Minimum Data Set (MDS) dated [DATE] shows R412 was cognitively intact and required supervision with locomotion on and off unit. R412's care plan with date initiated on 7/6/23 shows R412 has a history of substance abuse/chemical dependency with one intervention reads to provide leisure counseling. Facility did not provide documentation R412 attended counseling. Progress notes dated 7/27/2023 at 9:36 PM written by V8 (Licensed Practical Nurse/LPN) documents in part: [R412] noted in bed lethargic unresponsive. [R412's] pupils pin point. [R412's] speech slurred and altered mental status V/S B/P 166/125, pulse 103 Temp., 98.7, O2 98, B/G 126. ADON and [V40- R412's Medical Doctor] made aware. [V40] order writer to transferred resident to (Acute) Hospital order carried out immediately. Progress notes dated 7/28/23 at 5:11 AM documents R412 was transferred to the acute hospital and was evaluated with a diagnosis of Opioid overdose. R412's hospital records dated 7/27/23 under Patient Care Report Narrative, documents in part, [R412] admitted to snorting heroin [R412] acquired in the nursing home at 2000 hours. Emergency Department Attending Note documents in part, [R412] is a 27 y.o. male who presents to the ED for presumed heroin overdose. Per EMS patient has had similar presentation in the past, went to the top floor of his nursing facility and reportedly snorted heroin. R412's AFTER VISIT SUMMARY dated 7/27/23 shows R412's diagnosis was Opiate overdose and R412 received three doses of Narcan (reverses an opioid overdose). On 8/29/23 at 11:18 AM, V8 (LPN) stated V8 was the nurse in charge for R412 the night of the incident. V8 stated R412 went down to smoke after dinner around 6:30 PM. V8 stated R412 came back on the 2nd floor (V8 does not remember the exact time). V8 noticed R412 uncomfortable, having slurred speech, and feeling weak. V8 stated V40 ordered R412 to be sent out to the hospital. V8 stated V8 does not remember if R412 went down to smoke by himself. V8 stated R412 goes down to smoke independently. At 1:07 PM, V10 (Psychiatric Rehabilitation Services Coordinator) stated smoking schedules are after breakfast, after lunch, and after supper and staff are supposed to be always watching the residents smoke. On 8/30/23 at 9:29 AM, V12 (Psychiatric Rehabilitation Services Director) stated R412 did not have an independent pass and R412 was a smoker and needed supervision when smoking. At 11:29 AM, V3 (Director of Nursing) stated R412 did not go out the evening of 7/27/23 but we have other residents go out, so I'm thinking maybe other resident got the drugs for [R412]. V3 stated if a resident has a history of drug overdose the staff should be doing an enhanced observation, meaning checking on them at least every hour. At 11:40 AM, V12 stated R412 was supposed to be placed for a Licensed Clinical Social Worker (LCSW) therapy sessions but did not get to start because R412 was only in the facility for a short period of time. V12 stated R412 had history of drug abuse and staff supposed to check on R412 at least every two hours to make sure R412 is okay. At 1:03 PM, V28 (Certified Nursing Assistant/CNA) stated V28 was the CNA in charge for R412 on 7/27/23 evening shift. V28 stated R412 was fine all day until that evening. V28 stated R412 was going up and down the elevator that night. V28 stated R412 ate dinner around 5:00 to 6:00 PM. V28 stated R412 left the floor around 6:30 PM and took the elevator by himself. V28 stated V28 did not see if R412 went down or up. V28 stated (R412) probably went to smoke and after that went to the 7th floor. V28 stated around 9:00 PM, R412 came back from the 7th floor and R412 was red, dizzy, and was out of it. V28 stated R412 told V8 that R412 came from the 7th floor. At 1:17 PM, V27 (Psychiatric Rehabilitation Services Assistant) stated V27 worked on 7/27/23 evening shift and does not remember watching R412 smoke for the evening smoke break. V27 stated there are staff watching residents smoke outside the patio but that does not last for more than one hour. V27 stated after residents' smoke, they either stay in the 1st floor dining room to play games or they go back to their floors on their own. V27 stated staff used to pick the residents up from each floor to bring downstairs to smoke but staff stopped doing after 4th of July. At 3:48 PM, V29 (R412's Family Member) stated during a phone interview R412 did not mention where R412 got the drugs. V29 stated whenever they visit R412 in the facility there are no staff that search the items they bring inside the facility. At 4:06 PM, V30 (Resident Services Assistant) stated during a phone interview V30 worked on 7/27/23 evening shift and did not see R412 went down for smoke break after dinner. V30 stated V8 called V30 to go to the 2nd floor (V30 does not remember the exact time). V30 stated when V30 went up to the 2nd floor and saw R412, R412 was not in his usual self. R412 was not feeling well, kept standing up, and falling off. V30 stated R412 could not speak clearly and looked tired and drowsy. V30 stated when residents go for smoke break, they go down and go back up on their own. The facility's policy titled; RESIDENTS' RIGHTS & RESIDENTS' SAFETY Enhanced Supervision Guidelines dated 7/8/2020 reads in part: Purpose: 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 there may be occasions in which standard approaches of Q2 hour rounds may need to be increased to more frequent, enhanced observation. Types of enhanced supervision that could be used: Q15-minute, Q30-minute, hourly checks - the staff will check observe the resident's status/whereabouts every 15 or 30 minutes, or hourly.

Based on interview and record review the facility; (A) Failed to recognize, evaluate, and address weight loss; and (B) failed to consistently implement interventions, monitor the effectiveness of interventions and revise them as necessary. This resulted in a significant weight loss [ >10% change over 6 months] for 1 [R79] of 5 [R12, R36, R70, R109] residents reviewed for nutrition in a sample of 35. Findings included: R79's clinical record indicates in part: R79 was admitted to the facility on [DATE], with medical diagnosis of schizoaffective disorder, vitamin D deficiency, anxiety disorder, Parkinson's Disease, essential hypertension, and human immunodeficiency virus. Minimum data set [MDS] dated 7/1/23 indicates R79 scored 15 on brief interview for mental status indicating R79 is cognitively intact. MDS section K dated 7/1/23, indicates R79 did not have a swallowing disorder, or dental concerns. Section K dated 7/1/23- R79 loss more than 5% or more in the past 30 days and loss 10% or more in the past 6 months. R79 was not on a physician prescribed weight loss regimen. R79's on 12/29/22 weight was 222 pounds and on 8/3/23 186 pounds. R79's physician orders: [1] Dated 5/4/23 Ensure one time per day to possibly slow weight loss progression, offer at breakfast. [2] Dated 5/4/23 House supplement one time per day - Mighty Shake with dinner. [3] Dated 8/7/23- Ensure two times a day for prevent further weight loss, offer at breakfast and lunch. R79's progress notes indicate in part: 5/4/23 at 8:35 PM, V42 [Dietitian] Note- Sig [Significant] Wt. [ weight] Change Note: -9% in 90 days (April). R79 triggered for significant weight loss. Recommended ensure shake at breakfast and mighty shake at dinner to slow weight progression. 5/24/23 at 4:38 PM V43 Note - Significant weight loss -7.6% in 30 days. R79 continued to trigger for significant weigh loss. Recommend weekly weights for four weeks due to seven-pound weight loss in 30 days. Recommend continuing ensure daily. (Interventions were the same as 5/4/23) 6/26/23 at 12:20 AM, V43 [Dietitian] Note - Weight Warning: -10% weight loss over 180 days. R79's weights reviewed in the past six months - 6 months = weight loss of 31 pound (14%), 3 months = weight loss of 20 pounds (9.5%). R79 can feed self with supervision. No swallowing or chewing problems. Recommend ensure at breakfast and mighty shake at dinner. (Interventions were the same as 5/4/23) 7/17/23 at 10:15 PM, V43 Note - Weight Warning. Weight 190 pounds. -10% weight loss over 180 days. Significant weight loss in 6 months loss 28 pounds (-12.8%) recommend ensure with breakfast, might shake at dinner. (Interventions were the same as 5/4/23 dietician note) 8/7/23 at 4:46 PM V44 [Dietitian] Note- Weight Warning. Weight 186 pounds. -10% weight loss over 180 days, compared to 2/2/23 weight of 215 pounds (-13.5%) of 29-pound weight loss. Currently, ensure at breakfast and mighty shake at dinner. Increase ensure supplement to twice a day to promote weight maintenance. R79's electron medication administration record dated 8/1/23 thru 8/31/23, documents in part: Dated 8/7/23- Ensure two times a day for prevent further weight loss offer at breakfast and lunch. -Missing administration of prescribed ensure on the following dates 8/7/23 at 12 PM 8/8/23 at 8 AM and 12 PM 8/9/23 at 8 AM and 12 PM 8/10/23 at 8 AM and 12 PM 8/11/23 at 8 AM and 12 PM R79's weight record indicates the weeks of 6/9/23, 6/16/23, and 6/23/23 no weekly weights were obtained. On 8/29/23 at 10:29 AM observed R79 resting in bed. R79 stated, I'm not doing well. I keep shaking and keep losing weight. The doctors and nurses are not doing anything about it. I have no idea how much I weigh. On 8/29/23 at 10:46 AM, surveyor requested V50 [Licensed Practical Nurse] for R79 to be weighed with surveyor present. V50 stated, We can weigh (R79) at 1PM. On 8/29/23 at 12:50 PM, surveyor reported to nursing floor. V50 stated, R79 just left the faciity on his way to the hospital due to tremors. R79 was able to feed himself, without any assistance. R79 hands would shake, but he could feed himself. On 8/30/23 at 8:35 AM, V41 [R79's Family Member] stated, R79 has been losing weight because the facility stared him on some medication and R79 began to have tremors really bad. To the point R79 had difficulty feeding himself. The food would shake off the fork or spoon not getting into his mouth. I kept telling the nurse that R79 needs feeding assistance, but they will not listen. R79 will call me and tell me they would not help him eat. The facility has not told me that R79 loss any weight, but I can tell because his clothes is falling off. The medication that was causing the tremors was discontinued. R79 was sent to the hospital due to his tremors. On 8/30/23 at 11:17 AM, V3 [Director of Nursing] stated, The dietitian makes recommendations for weekly weights. The order is placed in vital signs and the weight is completed weekly. The reason for weekly weight is to closely monitor a resident's weight loss and to prevent a significant weight loss that can occur within 30 days. If a physician's order is not signed out on the electronic medication administration record, then the medication or supplement was not given. If a resident does not receive a prescribed nutritional supplement, the resident could potentially have more weight loss. The nurse should notify the family of the weight loss. I do not have (V42) or (V43) phone numbers. They worked here through a contracted agency. On 8/31/23 at 1:15 PM, V44 [Dietitian] stated, I been working at this facility since 8/1/23 through a consultant company. R79's last weight was 186 pounds. -10% weight loss over 180 days, compared to 2/2/23 weight of 215 pounds, total of 29-pound weight loss. I increased ensure supplement to twice a day to promote weight maintenance. R79 will be re-evaluated upon return from the hospital. R79's weigh loss is probably from the progression of Parkinson's disease, which require more calorie intake due to all the involuntary movements. I have not observed R79 eat and have not received reports that he needs assistance due to shaking. The beginning of August was my first time looking over his record, I will observe R79 eating once he return from the hospital. R79's weight loss was not desired or planned. Weekly weights are ordered to develop a baseline and to prevent an accumulative weight loss that may happen in 30 days. If weekly weights are not completed it could potentially cause the resident to have a higher weight loss, because interventions were not in place to slow weight loss. The weekly weight helps the dietitian to monitor the resident closely. If a resident continues to lose weight with dietary interventions in place; the weight loss dietary interventions should be monitored, evaluated, and adjusted as necessary to prevent further weight loss and stabilize a resident weight. On 8/7/23, I increased R79's ensure supplement to twice per day. If R79 misses the prescribed ensure, he could potentially loss more weight. I do not notify family of a residents weight loss; the facility is responsible for notification. On 8/31/22 at 2:05 PM V45 [ R79's Primary Care Physician] stated, I was told about R79's weight loss two months ago and recommended for R79 to see dietitian. I do not document every single thing in my notes. I verbally tell the nursing staff. I ordered blood work but I think R79 refused. I did not document R79 refused blood work. If R79 continues to lose weight, I will order blood work and CT scan. R79 should've been placed on a calorie count to be closely monitored. I believe R79's weight loss came from contracting Covid19 earlier this year in January. If R79 is not receiving his recommended shake supplements, R79 could potentially loss more weight the supplement would not be effective. R79 weight loss was not planned. If weekly weights were ordered for R79, the facility should have taken R79's weight as ordered so the dietitian could monitor R79 weight closely, if not it could potentially cause more weight loss. R79 is under infection disease physician. R79's HIV has not progressed. The antiviral medication has been working well. I did not notify the family of R79's weight change, the nurses should complete family notification. Policy: Documented in part: Weight Change Policy dated 1/2023; -It is the policy of this facility to monitor the nutritional status of all residents, including all significant or trending patterns of weight change. -Review weights and vital dashboard for significant weight changes. -Upon identification of a newly significant weight change, the dietician, physician, and resident representative will be notified.

Based on interview and record review the facility failed to provide adequate supervision to monitor residents with aggressive behavior and those residents at risk for being abused. This affects two of six sampled residents (R6 and R10) reviewed for supervision. As a result of this failure, R10 attacked R6, a cognitive impaired resident. R6 sustained multiple injuries (black eyes, bruising, facial soft tissue swelling, and distorted nasal bones). This failure resulted in Immediate Jeopardy which began 5/25/2023 when R6 was attacked by R10 with no immediate intervention from staff. V1 (administrator) was informed of the immediate jeopardy and a template was presented on 6/29/2023. On 7/11/2023 an acceptable removal plan was received. On 07/12/2023 the surveyor confirmed by observation, interview, and record review removal plan was initiated, and immediate jeopardy was removed on 6/30/2023. However, the non-compliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R6's Admission record showed R6 was admitted to the facility on [DATE] with listed diagnosis includes but not limited to schizoaffective disorder unspecified, conversion disorder with seizures or convulsions, Unspecified psychosis not due to substance or known physiological condition, syncope and collapse, unspecified injury of face, initial encounter. R10's medical record listed diagnosis includes but not limited to Schizophrenia, seizures, unspecified Asthma, Chronic Obstructive Pulmonary Disease, Hypothyroidism, and unspecified Lack of Coordination. According to the facility abuse log report, on 05/25/23 R10 physically abused R6 by hitting R6. R6's medical record showed that R6 was sent to the local hospital. R6 sustained multiple injuries that includes the soft tissue swelling, distorted nasal bones and frontal processes left greater than right however acute on chronic fracture cannot be excluded on this exam. Correlate with physical exam. During the investigation, V23 LPN (Licensed Practical Nurse) stated she (V23) was the only staff on the floor at the time of incident resulting in a delay in responding immediately to prevent R10 from physically attacking R6 who is vulnerable and cognitively impaired and known to talk to self. R10 physically assaulted R6 because R6 did not stop talking. R6 's MDS (Minimum Data Set) an assessment tool in assessing facility resident dated 05/10/2023 scored BIMS as 08 showing that R6 has an impaired cognition. R6's care plan on abuse with last revision date of 06/24/2020 on conflict with other persons, documented interventions include staff will assure safety and provide environment with caring professionals with a revision date of 03/25/2020. R6's is care planned for monitoring for negative behavior. R6 care plan did not have specific monitoring documentation. On 6/15/23 at 12:31pm V4 (Social Services Director) stated, R6 and R10 have been cohabiting for a long time without any incident. R6 is the victim and there is no need to revise R6's care plan. On 6/21/23 at 2:41pm, V4 (SSD) stated in part that all 258 the residents residing in the facility are at risk for abuse and they should be care planned and monitored for abuse. V4 stated R6 has this behavior of blabbing (talking) to self and that is R6 baseline. R10's MDS dated [DATE] coded BIMS as 15 showing that R10 is cognitively intact. R10's medical record progress note dated 05/25/2023 timed 00:57am (12:57am), V23 LPN (Licensed Practical Nurse) documented, client (referring to R10) physically attacked roommate (referring to R6). She (R10) stated her (R6) roommate would not shut up and proceeded to attack her roommate (R6). The client (R6) has been removed from the room and placed in the dining room. She (R10) was moved to the second floor in room (***) for the remainder of the night. According to R10 medical record, R10 who has a diagnosis of Schizophrenia was not immediately sent out for enhance monitor/supervision to prevent other vulnerable resident from abuse. No supervision was documented put in place beyond what is expected for any resident. R10 with violent behavior was left with no specific supervisor after assaulting R6 on 5/25/23. R10's medical record progress note showed on 5/25/2023, V23 documentation timed 08:41am, R10 is being sent to a local hospital for psychiatric evaluation eight hours after the physically assaulting R6. R10 who has violent behavior was left with no specific supervision after assaulting R6 on 05/25/23 for approximately eight hours. R10 was not removed immediately from the facility and no documentation that supervision was put in place beyond what is expected for any resident after assaulting R6 on 05/25/23.This documentation did not show that any specific supervision was after assaulting R6 beyond what is expected for any resident. The violent attack was sent on petition to the hospital. R10 hospital ED provider Report dated 5/25/23 timed 11:34am documented, patient sent here without a partition (Petition) suggestive of any recent Acute Psychiatric issue. ER record documented R10 arrival date 5/25/23 timed 9:55am (09:55). R10's plan of care for aggression created 11/19/2021 and last interventions revised 07/23/2022. After the incident of 05/25/23 intervention added documented to refer the resident to a mental health professional including a consulting psychiatrist for evaluation if the resident's symptoms warrant further assessment or ongoing management with initiated date 05/25/2023 and created 05/26/2023. R10's mal-adaptive behavioral symptoms initial date 02/10/2022 last revised 07/23/2022. R10's plan of care did not show any documented plan of care for being at risk for abuse. R10's Screening Assessment for Indicators of Aggressive And/or Harmful Behavior dated 05/25/2023 timed 9:17pm (21:17) showed, R10 was scored at 8 indicating that R10 is at risk of aggressive behavior at this time, because R10 displayed aggressive behavior by not following the facility smoking policy. On 6/21/23 at 2:41pm, V4 (SSD) stated in part that all 258 the residents residing in the facility are at risk for abuse and they should be care planned and monitored for abuse. According to the facility Reported Incident form the incident was categorized as physical abuse, resident to resident altercation and dated 05/25/23 12:30am, documented R6 was noted with injury to her face. The report documented a review of clinical records indicated that R10 has a history of moods and behaviors that includes but not limited to poor boundary issues, attention seeking behavior, anxiety behaviors, aggression, and other socially inappropriate behaviors. Care plans and interventions have been put in place to address these behaviors. The facility concluded the allegation was not verified, unsubstantiated documenting that based on facts gathered during the investigation, staff interviews, resident interviews, and a review of R10 medical records, abuse cannot be substantiated at this time secondary to her diagnosis of severe mental illness. R10 appeared to be responding to internal stimuli as R10 believed R6 was verbally attacking her (R10). V1 (Administrator) stated during the facility investigation R6 stated that (R10) her roommate physically attacked her while in the bed. On 06/26/23 at 3:26pm, interview with R16 (roommate) regarding what R16 witnessed on 05/25/23. R16 stated R10 was hitting on R6 in bed telling R6 to shut up, R6 was shouting and screaming and R10 kept punching R6 in the face and her eyes. I was shouting for help and when no one came I went to the desk (Nurses station) to call the nurse. The nurse came and got R6 up in the chair. R16 stated R6 talk to self all the time it can gets to you when you but what can you do. 06/26/2023 at 3:35pm R14 (Roommate) stated, R10 did a number on R6, R10 kept hitting R6 on her face everywhere telling her to shut up, shut up. R14 stated R6 was shouting, R10 kept hitting her R6. R10 nearly killed R6. R14 stated, We (referring to self R14 and R16) kept on shouting for help. When no one came, (referring to staff). R16 ran out of the room shouting for the (staff). R14 stated, R6 was red in the face, the neck the hands and everywhere. R14 stated, I could not help her cause I'm afraid she (R10) will attack me (R14) too. R14 stated it took staff about five to ten minutes to separate R10 and R6. R14 stated R6 was talking to herself like she normally does day and night, it can be annoying but it does not mean anyone should put their hands on R6. At 3:37 pm, the surveyor asked whether they have reported this to anyone (referring to facility staff). Both R14 and R16 stated, Yes. R14 stated staff will tell you there's no other room but staff knows R6 talks to herself. R16 stated, But I will not punch her (R6). On 06/29/23 at 1:18pm, interview with V4 and V51 PRSD (Psychiatrist Rehabilitation Services Director) present, the surveyor asked who is responsible for making the decision on which resident can co-habit in the same room and how the resident is evaluated in making the decision. V4 stated the compatibility is based on behavior during admission assessment, taking into consideration history by reading through the admission referrals and present behaviors. V4 stated prior to this incident on 05/25/23, both R10 and R6 lived together without an incident, R6 has this baseline behavior of talking to self and that is normal for R6. The surveyor then asked both V4 and V51 that in their professional opinion with R6 behavior, BIMs of 8, is it appropriate for both R6 and R10 to co-habit in the same room. V51 stated if the resident does not come and complain there is no way to know. The surveyor asked whether with this identified baseline behavior can this make R6 susceptible to abuse. Both V4 and V51 stated Yes. Surveyor asked if R6 being physically assaulted by R10 is a form of abuse. V4 stated, Absolutely it is an abuse. V4 stated all the residents in this facility with psych diagnosis are susceptible to abuse. V4 stated that R6 's care does not need to be reviewed because R6 is the victim of physical aggression from R10 so R10's care plan was reviewed and the intervention was to review the care plan annually, quarterly, and as needed. The surveyor then showed V4 the dates on the plan of care interventions, V4 stated the intervention were not reviewed to individualize the care interventions because he (V4) did not know or think the review or revised date should be changed because both resident R6 and R10 have co-habituated in the same room without any incident. As at 07/06/23 at 4:30pm, the facility was unable to present any behavior monitoring documentation from the facility staff. The facility lacks a system to supervise / monitor residents at risk of aggressive behaviors on how often and how the facility will monitor behavior. On 7/19/23 at 10:48am, V55 NP (Nurse Practitioner) stated for any of the resident to be considered for any psych evaluation at the hospital there must be a reason and the reason is stated in the petition. If a petition paper (Petition for Involuntary/Judicial Admission) is not sent with the resident from the nursing home, there is a possibility the resident will be sent back to the facility without care because there will be no documented reason for admission. Reasons for petition can be for agitation, restlessness, safety for self and others, unstable mood, poor direction, and judgement. V55 stated R10 should have been sent to the hospital with petition on 5/25/23. When asked V55's professional opinion about the facility staffing having adequate supervision on 5/25/23 11pm to 7am shift, V55 stated the staffing for the kind of population being cared for in the facility is not adequate. The facility policy on Comprehensive Care Plan dated 10/2021 with review date 3/2023 documented in general that the facility must develop a comprehensive person - centered care plan for each resident. Responsible party listed as all staff. The policy documented in part that all care plans will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental and psychosocial needs, the comprehensive care plan should be reviewed with the resident and changes made as appropriate and it should be reviewed quarterly, annually, and with any significant changes. The facility Job Description for PRS/SSD (Psychiatrist Rehabilitation services Director/Social Services Director) presented statement of purpose documented in part that the social service worker will work with residents in the skilled nursing facility by identifying their psychosocial, mental, and emotional needs along with providing, developing and /or aiding in the access of services to meet those needs. The facility PRSC (Psychiatrist Rehabilitation Coordinator) Job Description presented documented in part that the purpose of this position is to provide group and individual psychiatric rehabilitative and case management services to adults with a history of multiple psychiatric hospitalization s and in need of long-term care stabilization: to participate with the interdisciplinary team in developing, implementing, and evaluating effective therapeutic services via facility programming. Qualification listed includes obtaining CPI certification after hire. The facility policy on Staffing with review date 9/2022 documented in part that the facility is generally to have appropriate number of staff available to meet the needs of the residents. Listed guideline includes but not limited to staff is required to review their schedule and discuss any problems regarding their schedule with their supervisor. Staffing is then increased based on the needs of the resident population. Staffing is supplemented as needed by outside agencies. The facility policy guideline titled Behavior Management with review date 9/2022 documented in part that it is the policy of the facility to manage unruly behavior of a resident in the least restrictive manor that ensures the safety of residents, employees, and family members. On 7/12/2023, the surveyor made observations, conducted interviews, and reviewed documentation to confirm the following removal plan was initiated: 1) The affected residents, R6 and R10, are not residing in the facility currently. Both R6 and R10 will not return to the facility due to family preference. 2) Social Services completed an Abuse Risk Assessment on 06/30/23. All residents were identified as being at risk for abuse and the resident care plans were updated. 3) Social Services completed a Screening Assessments for indicators of aggressive and/or harmful behaviors on 06/30/23. Six (6) residents R17, R18, R19, R20, R21 and R22 were identified as being at risk for presence of aggressive/harmful behavior. Their resident care plans were updated. 4) R17, R18, R19, R20, R21 and R22 were placed in individual rooms. 5) R17, R18, R19, R20, R21 and R22 were placed on hourly enhanced supervision rounds to observe for any new or worsening behaviors of aggression or violent behavior. This was completed on 06/30/23. 6) V1 (Administrator), V2 (Director of Nursing) and Social Services staff will conduct audits of five (5) residents weekly to ensure compliance of the Abuse Risk, and Screening Assessments for indicators of aggressive and/or harmful behaviors, care plans, and appropriateness of room placement. This was initiated on 6/30/23. 7) In-services were done by V1 (Administrator), V2 (Director of Nursing) and Social Services staff for Nurses, CNAs, Housekeeping, Activity Aides, Social Services, Dietary, Residential Services, Receptionists and Maintenance staff on how to identify vulnerable residents at risk for abuse. This was completed on 06/30/23. Agency staff and other staff not available at the time of the training are to be trained upon their return prior to the start of their first shift. 8) Facility Policy was initiated on 06/30/23 to monitor vulnerable residents that are at risk for abuse. 9) Facility Policy was implemented on 06/30/23 to ensure residents with aggressive behavior are not placed in a room with vulnerable residents. 10) The Clinical Managers/ Charge Nurses to conduct unit rounds to observe for any new or worsening behaviors at least every two hours during the week and to report the behaviors to the attending physician and/or psychiatrist and notify V1 (Administrator) and V2 (Director of Nursing) for additional interventions. This was initiated on 06/30/23 11) The MOD's Managers on Duty and /or Charge Nurse to conduct unit rounds to observe for any new or worsening behaviors at least every two hours during the weekends and to report the behaviors to the attending physician and/or psychiatrist and notify V1 (Administrator) and V2 (Director of Nursing) for additional interventions. This was initiated on 06/30/23 12) In-service by V1 (Administrator) and V2 (Director of Nursing) to V4 (Social Services Director), PRSD and Nursing Manager on room placements/ changes of residents with aggressive or violent behavior. 13) In-service of nurses and social services staff on the process of involuntary admission. Initiated on 06/30/23 14) In-service to nurses, CNAs, Housekeeping, Activity Aides, Social Services, Dietary, Residential Services, Receptionists and Maintenance staff on the facility's aggressive behavior response code Code Yellow to ensure that all resident's aggressive behavior occurrences are responded to in a timely manner. 15) Social services and residential services staff CPI trained to understand techniques for de-escalating violent and aggressive behaviors. Completed on 06/30/23. CPI training program to include Nurses, CNAs and Activity Aides initiated on 06/30/23. 16) Concerns identified and non-compliance during the monitoring activities shall be addressed immediately and discussed during QAPI meeting. The facility presented a plan of removal for the immediacy on 6/29/23. The survey team reviewed the plan of removal and was unable to accept the plan to remove the immediacy. The plan of removal was returned to the facility for revisions. The facility presented a revised plan of removal on 07/06/23, 07/09/23, 07/11/23 at 2:11am and 07/11/23 at 1:12pm. The survey team accepted the plan of removal on 07/11/23.

There are two Deficiency Practice Statements: 1) Based on interview and record review the facility failed to protect a resident from being physically abused. This affects two of six sampled residents (R6 and R10) reviewed. As a result of this failure, R10 attacked R6, a cognitive impaired resident. R6 sustained multiple injuries (black eyes, bruising, facial soft tissue swelling, and distorted nasal bones). This failure resulted in Immediate Jeopardy which began 5/25/2023 when R6 was attacked by R10 with no immediate intervention from staff. V1 (administrator) was informed of the immediate jeopardy and a template was presented on 6/29/2023. On 7/11/2023 an acceptable removal plan was received. On 07/12/2023 the surveyor confirmed by observation, interview, and record review removal plan was initiated, and immediate jeopardy was removed on 6/30/2023. However, the non-compliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R6's Admission record showed R6 was admitted to the facility on [DATE] with listed diagnosis includes but not limited to schizoaffective disorder unspecified, conversion disorder with seizures or convulsions, Unspecified psychosis not due to substance or known physiological condition, syncope and collapse, unspecified injury of face, initial encounter. R6 's MDS (Minimum Data Set) an assessment tool in assessing facility resident dated 05/10/2023, scored BIMS as 08 showing R6 has an impaired cognition. R6's care plan on abuse with last revision date of 06/24/2020 on conflict with other persons, documented interventions include staff will assure safety and provide environment with caring professionals with a revision date of 03/25/2020. R6's is care planned for monitoring for negative behavior. R6 care plan did not have specific monitoring documentation. R10's medical record listed diagnosis includes but not limited to Schizophrenia, seizures, unspecified Asthma, Chronic Obstructive Pulmonary Disease, Hypothyroidism, and unspecified Lack of Coordination. R10's MDS dated [DATE] coded BIMS as 15 showing R10 is cognitively intact. R10's plan of care did not have individualized interventions revision documented for aggressive behavior even after the incident of 5/25/23. The facility's incident report of 5/25/2023 indicated: R10 physically attacked R6, punching and hitting R6 multiple times while R6 was lying in bed. R6 was sent to the hospital and was admitted with multiple injuries including bilateral black eyes, multiple bruising on legs and arms facial soft tissue swelling and distorted nasal bones. On 06/15/23 at 12:30pm, interview with R6 regarding physical abuse, R6 stated in part, the roommate (identified as R10) jumped on her and started hitting her for no reason. R6 stated she did nothing to (R10). On 6/15/23 at 12:31pm V4 (Social Services Director) stated, R6 and R10 have been cohabiting for a long time without any incident. R6 is the victim and there is no need to revise R6's care plan. On 6/22/23 at 11:30am, V23 LPN (Licensed Practical Nurse) stated, Yes, I'm familiar with both residents. V23 stated that on 5/25/23, (R10) was walking around on the floor looking to get a dollar, asking staff and peers. Everyone told her (R10) they didn't have a dollar they could give to her (R10). V23 stated, R10 started getting upset, walking back and forth the hallway and going down to another floor and the security desk. V63 (Residential Services (security)) asked R10 to go to her room and sleep but R10 would not go to her room. Later, R10 went to her room and slammed the door. The surveyor asked whether V23 checked on the roommate so see what's going on. V23 stated, No because I was busy with another resident. V23 stated, after R10 went to the room, R16 came out of the room by the doorway yelling that R10 was hitting R6. R16 said R10 was hitting R6 in the face while in R6 was in bed. V23 called security to the floor. V23 stated the CNA (Certified Nurse's Aide) was on another floor (6th floor) giving a shower to some resident. V23 stated, I was by myself and as I ran hallway to R10's room, R16 started yelling again that R10 will injure R6. Then the security guard came and ran down the hall with me. The security guard separated them and R10 was taken to the dining area by the nurse's station. V23 stated, R6 said there was no pain but said R10 hit her. V23 said, I assessed R6 and she was okay. R6 refused to go to the hospital. When R10 was asked what happened, R10 started yelling R6 would not shut up. V23 stated, R6 talks to herself all the time, sometimes it makes no sense what she is saying. When V23 was asked about the staffing, V23 stated, It was just me and the CNA, we have been short staff lately. Normally we should have at least three staff, one nurse and two CNAs. V23 stated, Once I was aware of the situation, I assessed the resident took the vital signs and I called the managers and the NP (Nurse Practitioner) (identified as V55) who did not answer at the time. V23 stated R10 was not assessed because R10 was the one doing the hitting. V23 stated, R6 had redness around both eyes and eyeballs, they were dark red, and a purplish red color was starting to form around the eye. V23 stated, after V23 called the ADON (Assistant Director of Nurses) V42, V42 said V23 should send both R6 and R10 out, but they refused. V23 stated, the ambulance said they didn't have a car to take them out. The surveyor asked whether that was the only ambulance company the facility calls in emergency cases. V23 stated, V23 did not call another ambulance company because the only ambulance company the facility uses. At around 7:30am V23 stated she called the ambulance company again and they arrived within one hour of the call and took them (R6, R10) to the local hospital for evaluation. On 6/22/23 at 12:10pm, R10 stated in part she hit R6 because R6 kept talking and would not shut up. On 6/26/23 at 12:23pm, V4 stated an abuse is an inappropriate act toward self or others and it can be physical, sexual, verbal, or psychological. V4 stated, or putting a resident on social media, financial exploitation, and seclusion can be a form of abuse. Hitting is a form of physical abuse. When asked whether R10 hitting R6 is a form of abuse, V4 stated Absolutely. On 06/26/23 at 3:26pm, interview with R16 (roommate) regarding what R16 witnessed on 05/25/23. R16 stated R10 was hitting on R6 in bed telling R6 to shut up, R6 was shouting and screaming and R10 kept punching R6 in the face and her eyes. I was shouting for help and when no one came I went to the desk (Nurses station) to call the nurse. The nurse came and got R6 up in the chair. R16 stated R6 talks to herself often and it may annoy others at times, but there's not much that can be done about it. 06/26/2023 at 3:35pm R14 (Roommate) stated, R10 did a number on R6, R10 kept hitting R6 on her face everywhere telling her to shut up, shut up. R14 stated R6 was shouting, R10 kept hitting her R6. R10 nearly killed R6. R14 stated, We (referring to self R14 and R16) kept on shouting for help. When no one came, (referring to staff). R16 ran out of the room shouting for the (staff). R14 stated, R6 was red in the face, the neck the hands and everywhere. R14 stated, I could not help her cause I'm afraid she (R10) will attack me (R14) too. R14 stated it took staff about five to ten minutes to separate R10 and R6. R14 stated R6 was talking to herself like she normally does day and night, it can be annoying but it does not mean anyone should put their hands on R6. At 3:37 pm, the surveyor asked whether they have reported this to anyone (referring to facility staff). Both R14 and R16 stated, Yes. R14 stated staff will tell you there's no other room but staff knows R6 talks to herself. R16 stated, But I will not punch her (R6). R6's emergency record history and physical dated 05/26/23 timed 1:05am documented, R6 notably at baseline is A&O (alert and oriented). 1. Frequently talks to herself and has bruises thought to be self-inflicted. R6 was speaking loud in her room and roommate (who was identified as R10) began hitting the patient's face/neck until physically separated by staff. R6 did not lose consciousness during altercation and appeared to remain at baseline, however had significant ecchymosis and conjunctival injection in both eyes. CT facial bones without contrast dated 05/25/23 showed under impression, No clear evidence of facial fracture. Soft tissue swelling as described, distorted nasal bones and frontal processes left greater than right however acute on chronic fracture cannot be excluded on this exam. Correlate with physical exam. There is facial soft tissue swelling in this region. On 06/22/23 at 11:36A surveyor asked V23 (nurse) what should be done if an injured resident in such a situation refused to go to the hospital. V23 stated if an injured resident refused to be sent out for evaluation and treatment the resident will be petitioned out. V23 stated, Yeah (R6) should have been petitioned out to the hospital. When asked about R10 being sent to the hospital with petition for involuntary admission, V23 stated in part V23 did not send R10 with petition stating, No, I did not, I'm a new nurse. The facility policy on Comprehensive Care Plan dated 10/2021 with review date 3/2023 documented in general, the facility must develop a comprehensive person-centered care plan for each resident. Responsible party listed as all staff. The policy documented in part all care plans will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental and psychosocial needs. The comprehensive care plan should be reviewed with the resident and changes made as appropriate and it should be reviewed quarterly, annually, and when there are any significant changes. The facility abuse policy defined abuse as any physical or mental injury or sexual assault inflicted upon resident other than by accidental means. Physical abuse includes but not limited to hitting slapping. Sexual abuse includes but not limited to sexual assault, or sexual coercion non-consensual sexual contact of any type with a resident. Mental abuse includes but is not limited to humiliation. The facility policy on abuse documented in part the facility affirms the right of the facility residents to be free from abuse therefore prohibits abuse. The purpose of the policy is to assure the facility is doing all within its control to prevent occurrences of abuse includes mistreatment of residents. On 7/12/2023, the surveyor made observations, conducted interviews, and reviewed documentation to confirm the following removal plan was initiated: 1) The affected residents R6 and R10 are not residing in the facility currently. Both R6 and R10 will not return to the facility due to family preference. 2) Social Services completed an Abuse Risk Assessment on 06/30/23. All residents were identified as being at risk for abuse and the resident care plans were updated. 3) Social Services completed a Screening Assessments for indicators of aggressive and/or harmful behaviors on 06/30/23. Six (6) residents R17, R18, R19, R20, R21 and R22 were identified as being at risk for presence of aggressive/harmful behavior. Their resident care plans were updated. 4) R17, R18, R19, R20, R21 and R22 were placed in individual rooms. 5) R17, R18, R19, R20, R21 and R22 were placed on hourly enhanced supervision rounds to observe for any new or worsening behaviors of aggression or violent behavior. This was completed on 06/30/23. 6) V1 (Administrator), V2 (Director of Nursing) and Social Services staff will conduct audits of five (5) residents weekly to ensure compliance of the Abuse Risk, and Screening Assessments for indicators of aggressive and/or harmful behaviors, care plans, and appropriateness of room placement. This was initiated on 6/30/23. 7) In-services were done by V1 (Administrator), V2 (Director of Nursing) and Social Services staff for Nurses, CNAs, Housekeeping, Activity Aides, Social Services, Dietary, Residential Services, Receptionists and Maintenance staff on how to identify vulnerable residents at risk for abuse. This was completed on 06/30/23. Agency staff and other staff not available at the time of the training are to be trained upon their return prior to the start of their first shift. 8) Facility Policy was initiated on 06/30/23 to monitor vulnerable residents are at risk for abuse. 9) Facility Policy was implemented on 06/30/23 to ensure residents with aggressive behavior are not placed in a room with vulnerable residents. 10) In-service by V1 (Administrator) and V2 (Director of Nursing) to V4 (Social Services Director), PRSD and Nursing Manager on room placements/ changes of residents with aggressive or violent behavior. 11) The Clinical Managers/ Charge Nurses to conduct unit rounds to observe for any new or worsening behaviors at least every two hours during the week and to report the behaviors to the attending physician and/or psychiatrist and notify V1 (Administrator) and V2 (Director of Nursing) for additional interventions. This was initiated on 06/30/23 12) The MOD's Managers on Duty and /or Charge Nurse to conduct unit rounds to observe for any new or worsening behaviors at least every two hours during the weekends and to report the behaviors to the attending physician and/or psychiatrist and notify V1 (Administrator) and V2 (Director of Nursing) for additional interventions. This was initiated on 06/30/23 13) Concerns identified and non-compliance during the monitoring activities shall be addressed immediately and discussed during QAPI meeting. The facility presented a plan of removal for the immediacy on 6/29/23. The survey team reviewed the plan of removal and was unable to accept the plan to remove the immediacy. The plan of removal was returned to the facility for revisions. The facility presented a revised plan of removal on 07/06/23, 07/09/23, 07/11/23 at 8:32am and 07/11/23 at 1:12pm. The survey team accepted the plan of removal on 07/11/23. 2) Based on interview and record review the facility failed to protect one resident (R4) from sexual abuse. This failure affected one (R4) out of six residents reviewed. R4 was sexually abused by another resident R5. Findings include: R4's electronic medical record, admission record showed R4 is a [AGE] year-old female who was admitted to the facility 12/13/2018 with listed diagnosis information includes Schizoaffective Disorder Bipolar Type, Bipolar Disorder unspecified, Chronic fatigue unspecified and anxiety disorder. R4's hospital record dated 5/25/2023 timed 5:41pm, showed documentation R4 was admitted for evaluation after sexual assault. (R4) reported in ER (emergency room ) she was sexually assaulted at the facility. Police report was filed at the ER and Rape hotline called. On 06/15/23 at 11:50am, when asked about the incident of 5/25/23, R4 was reluctant in talking to the surveyor without any one in the room. R4 stated, I cannot trust any-one especially the opposite sex. R4 stated about one month prior 5/25/23, What happened is not so good. I still have problem having trust to talk to any male in here (referring to the facility). It is so not good at all; I was embarrassed because other roommate was in the room and to realized they know what happened to me is still embarrassing and shameful to me. I have not been the same since then. When asked what happened, R4 stated, I was in his (R5's) room watching TV and (R5) pushed me on to his (R5) bed and forced himself on me having sex with me. I could not scream because there were other people (referring to roommates) in the room, and I didn't want them to know. R4's plan of care with initiated date of 12/10/19 documented R4 is at risk for abuse due to diagnosis including bipolar disorder and poor judgement. Last revision date documented as 08/13/2020. V4 (Social Services Director), documented another intervention added with initiated date 5/25/23 and created date 05/26/2023 to document and have witness for each conversation with R4, which is not a measurable abuse preventive measure. R4 stated, I told him (R5) several times, No but he (R5) just did his thing (referring to sexual act penetration). I did not say anything right away because I was embarrassed and ashamed of what had happened to me. R4 stated, I was sent to the hospital, but I still need someone to talk to. R4 was unable to mention R5's name when talking about the alleged incident. Noted R4 finger shaking. When asked why R4 was shaking, R4 stated, I don't want to mention his name (referring to R5). On 06/15/23 at 12:06pm, R5 stated he (R5) knows who R4 is. R5 stated, I was in my room on the second floor, she (R4) came to my room to watch TV. Then we had sex. She (R4) kept coming to my room. When asked whether R4 said no to having sex with R5, R5 stated, It happened only one time, and then she (R4) said she was eight months pregnant. Then I said she can't come to my room anymore. R5 was asked again whether R4 said no to R5 regarding that one time. R5 stated, Yes, maybe. R5 kept looking out of the room. When asked about the reason for change in demeanor, R5 stated, I am just making sure V42 ADON (Assistant Director of Nurse's) (who was outside the room and by the door) could not hear all the conversation. When asked why, R5 shook his head and did not reply to the surveyor. R5's plan of care initiated 10/27/22 and with last revision date of 12/2022 showed R5 has a history of criminal behavior. Goal listed is R5 will behave in a safe manner consistent with resident conduct policies through the next review. Listed interventions with revision date 10/27/2022 includes but not limited to promoting safety, intervene when inappropriate behavior is observed. Teach impulse control strategies and communicate the resident is responsible for all actions/ behavior and must exercise control over impulses and behavior. R5's medical record progress note dated 5/25/23 timed 2:20pm (14:20) documented R5 was petitioned to the hospital for inappropriate behavior According to the facility investigation presented, R4 wrote in part, R5 forced himself on me I was watching TV (Television) in (R5)'s room. He (R5) took me against my will. I (R4) know this is partly my fault because I was in his room, but I had no idea he would do this sort of thing. Ever since this incident (R5) has been very disrespectful to me. R4's signed facility investigation statement presented documented the incident happened about one month ago. On 6/21/23 at 2:39pm to 2:45pm, V40 PRSC stated she (V40) is familiar with R4 and R5, but they are not on V40's caseload. V40 stated. I only do wellness check on the residents even if they are not on my caseload. V40 stated, R4 told me about being raped and I told my supervisor (V29 - PRSC Supervisor), who said the facility is investigating it. V40 stated on 05/29/23, V40 did a follow up on R4. V40 stated, (R4) would not want to talk about it because of her feelings about the incident. Surveyor asked what V40 meant by R4 not wanting to talk about it, V40 stated R4 will not talk about it (referring to the sexual abuse). V40 stated, R4 stated she feels safe in the facility. The surveyor asked, if forcing sexual acts on others is a form of sexual abuse. V40 stated, Yes, a 'No' is a 'No'. On 6/21/23 at 3:13pm, V29 stated V29 is familiar with R4, R4 is alert, oriented X3. V29 stated, When things don't go her (R4) way, she became agitated with false accusations. V29 stated V29 heard about the alleged sexual abuse from the staff. V29 stated, When I asked R4 about it, she said she will rather deal with a female staff. Surveyor asked about abuse protocol and whether forcing sexual acts on others is a form of abuse, V29 stated yes. On 6/21/23 at 3:27pm, V43 ADON (Assistant Administrator) stated V43 was not made aware of any abuse. V43 stated, (V1 Administrator) told me about the alleged abuse, and I called the family (R4's Mother) and told her about the incident. Surveyor asked if sexual assault is a form of abuse. V43 stated, Yes and it should be reported immediately. On 6/22/23 at 3:31pm, V50 PRSC (Psychiatrist Rehabilitation Services Coordinator) when asked whether familiar with R4, stated she (V50) really doesn't know much about R4. V50 stated R4 called the police that she was raped and then came to V50 to make V50 aware R4 had called the police. V50 stated V4 said, They (police) are on their way to the facility and asked me to go with her. That is when she (R4) said she called because she was raped. I asked her (R4) why she did not tell me sooner before the call to the police. She (R4) then said, I told someone else, the administrator. The police came and R4 then stepped outside with the police officer, I really don't know what she told the police, but the police spoke with the assistant administrator. V50 stated a police report was taken and R4 was monitored to make sure she was safe. V50 stated, R4 told (V3) Assistant Administrator that it happened about a month ago in (R5)'s room. V50 stated R4 said she was ashamed and embarrassed to talk about it because she went into R5's room not knowing she would be raped. On 6/22/23 at 3:58pm, V3 (Assistant Administrator) stated, Yes, I'm familiar with R4 and R6. I was not present when (R4) called the police department but I was made aware when the police got to the facility. I saw her (R4) talking to the police officer. The police officer informed me (R4) called alleging she was sexually abused. A report number (#JG274566) was given to me, and they said an investigator will come to the facility to investigate. V3 stated the investigator has not come yet to investigate. V3 stated R4 said it happened about a month ago on the 2nd floor between herself and (R5). V3 stated V3 believes R4 told V50 (PRSC (Psychiatrist Rehabilitation service coordinator) just before the police came. V3 stated, prior to that day V3 was not aware of the abuse and that immediately the facility investigation started and was reported to IDPH. V3 stated R4 was sent to the local hospital for treatment and was admitted . The facility abuse policy defined abuse as any physical or mental injury or sexual assault inflicted upon resident other than by accidental means. Physical abuse includes but not limited to hitting slapping. Sexual abuse includes but not limited to sexual assault, or sexual coercion non-consensual sexual contact of any type with a resident. Mental abuse includes but is not limited to humiliation. The facility policy on abuse documented in part the facility affirms the right of the facility residents to be free from abuse therefore prohibits abuse. The purpose of the policy is to assure the facility is doing all within its control to prevent occurrences of abuse includes mistreatment of residents.

Based on interview and record review, the facility failed to provide adequate nursing staff to meet residents' needs. This failure affected one sampled resident R6 reviewed for supervision. As a result, R10 attacked R6, a cognitive impaired resident, and R6 sustaining multiple injuries (black eyes, bruising, facial soft tissue swelling, and distorted nasal bones). This has the potential to affect all the resident residing on the 5th floor and all 258-resident residing at the facility. Findings include: R6's Admission record showed R6 was admitted to the facility on [DATE] with listed diagnosis includes but not limited to schizoaffective disorder unspecified, conversion disorder with seizures or convulsions, Unspecified psychosis not due to substance or known physiological condition, syncope and collapse, unspecified injury of face, initial encounter. R6 's MDS dated [DATE] scored BIMS 08 showing R6 has an impaired cognition. R6's abuse plan of care with last revision date of 06/24/2020 on conflict with other persons documented, interventions includes staff will assure safety and provide environment with caring professionals with last revision date of 03/25/2020. R10's MDS dated [DATE] coded BIMS as 15 showing R10 is cognitively intact. R10's medical record listed diagnosis includes but not limited to Schizophrenia, seizures, unspecified Asthma, Chronic Obstructive Pulmonary Disease, Hypothyroidism, and unspecified Lack of Coordination. R10's medical record progress note dated 05/25/2023 timed 00:57am (12:57am), V23 LPN (Licensed Practical Nurse) documented, client (R10) physically attacked roommate (R6). She (R10) stated her (R6) roommate would not shut up and proceeded to attack her roommate (R6). The client (R6) has been removed from the room and placed in the dining room. She (R10) was moved to the second floor in room (***) for the remainder of the night. On 6/20/23 at 2:00pm, V30 (staffing Coordinator) stated the staffing on the 5th floor at night shift (11pm to7am) should be one nurse and two aides (referring to Certified Nurse's aide). On 6/22/23 at 11:35am, V23 LPN (Licensed Practical Nurse) who was on duty on 5/25/23 stated there is usually three nursing staff, one nurse and two CNAs (Certified Nurse's aide) scheduled on the 5th floor of the facility but lately only two staff, one nurse and one nurse's aide are working. V23 stated it is difficult for one nurse and an aide (referring to CNA) to be by themselves on the floor. When asked whether these concerns have been made known to the supervisors and the administrator, V23 stated they are in-charge of the staffing. I (V23) guess they know and they are also made aware. V23 stated it was just me and a CNA so when the incident with R6 and R10 happened, I was busy doing something else and I had to wait for security to come up to help because at the time V49 (CNA) was not on the floor. V49 was busy helping to shower other residents on another floor. On 6/22/23 at 3:58pm, V1 (Administrator) stated in part the staffing on the 5th floor should be two aides and one nurse but lately the facility has been having problems with staffing. V1 stated the facility have agency staff that can be called or have other CNA work over-time but will get back to the surveyor on what really happened with staffing. V1 was asked what could happen to the residents without adequate supervision, V1 stated in part the residents' needs might not be met. In the case of fighting the resident can be injured. The facility daily schedule presented showed only one Nurse and one CNA were scheduled on 05/25/23 at 11pm to 7am and one resident services (security) staff was scheduled for the facility on 11pm to 7am shift. On 6/26/23 at 11:23am, V24 (Resident Service Director), V24 stated in part there are 9 facility security staff. On 7am to 3pm shift there are 5 scheduled, 3pm -11pm 4 are scheduled, and on nights 11pm to 7am shift 2 (two) are scheduled. Rounds are made every 30 minutes on all the floors and facility surroundings. In case there is an incident on the floor the staff, nursing staff page for security to floor. If there is a physical fight between residents, they are separated by the security. All the security staff are trained in CPI. On 6/26/23 at 11:40am, V2 DON (Director of Nurse's) stated the facility normally has three staff scheduled on the 5th floor but was not sure what happened on that day (referring to 5/25/23). V2 stated would back to surveyor on that. When asked what can happen to the resident when there is not enough staff to monitor or supervise them. V2 stated there can be incidents and residents' needs not met. On 6/22/23 at 3:01pm, V49 (CNA) stated in part, she (V49) is familiar with both resident R6 and R10. V49 stated, Yes, I was the only CNA on the floor on 5/25/23. V49 stated in part, I came in at 11:00pm (referring to resuming duty), made my rounds to make sure all the residents on the floor were okay, they were all okay. V49 stated in part, at around 12:15am, I (V49) took some of my residents to the 6th floor to take their showers. V49 stated, she stayed on the 6th floor for almost one and half hours. When V49 got back on the floor, the floor nurse on the floor (V23) LPN (Licensed Practical Nurse) told V49 there was an incident between R6 and R10. R10 has to be moved to another floor, on the 6th floor. V49 stated in part she (V49) did not see R10 physically assault R6, the nurse (V23) told V49 about it. V49 stated in part she (V49) was the only aide. V19 stated, there were supposed to be two nurse's aides on the floor and they usually have two but that day (referring to 5/25/23) it was only one nurse and one CNA. On 6/22/23 at 3:58pm, V1 (Administrator) stated in part the staffing on the 5th floor should be two aides and one nurse but lately the facility has been having problems with staffing. V1 stated the facility have agency staff can be called or have other CNA work over-time but will get back to the surveyor on what really happened with staffing. On 6/26/23 At 2:09pm V24 (Residential Services Director) stated, I thought there were two security staff (Residential Services Staff) on duty on 05/25/23 but it was only one staff. On 6/26/23 at 2:53pm, V63 (Residential Services) stated in part, I (V63) was the security staff on duty at the time on 11pm to 7am shift. I (V63) was working alone that night. On 7/12/23 at 8:50am, surveyor asked about staffing and what could happen if the facility is short staffed. V4 SSD (Social Services Director) stated in part, there will be no good supervision in case any thing happened. On 7/19/23 at 8:55am, V4 stated the floors (referring to residents residing floors) should be adequately staffed to meet residents' needs, for safety in case of resident-to-resident altercations, also not to overwhelm the staff. The surveyor asked whether the 5th floor was adequately staffed on 5/25/25 at the time R10 attacked R6. V4 stated, I (V4) just believe we (referring to the facility) can do better, that's all I am going to say about . No resident should be physically or sexually abused. Abuse is a No-No situation. On 7/19/23 at 10:03am, V3 (Assistant Administrator) stated in part, regarding staffing on 5/25/23, we (referring to the facility) can do better; we are working on it, getting adequate staffing on each floor. When asked about what can happen to residents if the facility/floor is not adequately staffed regarding resident's needs and services, V3 stated, I'm not sure on how to answer. On 7/19/23 at 10:18am, V55 NP (Nurse Practitioner) was asked whether in his (V55) professional opinion if the facility staffing on 5/25/23, 11pm to 7am shift of one nurse (V23), one CNA (V49) on the floor and only one residential services staff for the entire facility population cared for is appropriate. V55 stated, No, but that's for the management (facility management), I don't think that is an okay staffing. On 7/19/23 at 11:52am, when V1 (Administrator) was asked about staffing adequacy on 5/25/23 and about what can happen with inadequate staffing. V1 stated in part, there would be no adequate supervision for the residents and possibly the residents' needs may not be met. V1 stated, there can be increase in negative behavior with unresolved altercations and behaviors can result in injuries to themselves and others (referring to residents and staff). V1 stated on 5/25/23, I believe we had adequate staff. Then the surveyor asked if it is appropriate to have only one nurse (V23) and one CNA (V49) staff on the floor on 5/25/23. V1 stated for the facility 5th floor, it is not appropriate but depending on the census. The facility policy on Staffing with review date 9/2022 documented in part the facility is generally to have appropriate number of staff available to meet the needs of the residents. Listed guideline includes but not limited to staff is required to review their schedule and discuss any problems regarding their schedule with their supervisor. Staffing is then increased based on the needs of the resident population. Staffing is supplemented as needed by outside agencies. The facility policy guideline titled Behavior Management with review date 9/2022 documented in part it is the policy of the facility to manage unruly behavior of a resident in the least restrictive manor ensures the safety of residents, employees, and family members.

Based on observation, interviews and record reviews, the facility failed to ensure a resident (R1) was free from physical abuse in a sample of three residents reviewed for abuse. This failure to prevent abuse caused R1to have a cut on R1 face near R1's nose. Findings include: On 12/10/2022 at 12:07 pm, R1 was observed in R1's room sitting in R1's wheel chair. R1 said, on 11/26/2022, R1 went to the nursing station to get R1's medication for R1's spasms from V10 (LPN). R1 said that V10 was not happy and told R1 that R1 would get R1's medications latter. R1 said that as R1 was attempting to get into the elevator, V10 came and started pulling R1 from the elevator. R1 said V10 then balled V10 fist and hit R1 in R1's face. R1 said R1 started bleeding on the nose where R1 had a cut. R1 said a CNA saw what happened and came and separated R1 from V10 and took R1 downstairs to the social services office. R1 said R1 called the police and the police came and saw that R1 had a cut on R1 face near R1's nose. R1 said the police gave R1 a police report number. R1 is a [AGE] year-old individual with initial admitted [DATE]. R1's Brief Interview of Mental status (BIMS) dated 11/1/2022 documents: R1's score is 15/15 (meaning no cognitive deficits). R1's Activities of Daily Living (ADLs) assistance document R1 needed Limited assistance, one-person physical assist with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, personal hygiene, and supervision, setup help only with eating. R1 uses a manual wheelchair. R1's medical diagnosis include but not limited to: Paraplegia, unspecified, personal history of traumatic brain injury, other, muscle spasm. On 12/10/2022 at 2:13pm, V12 (Assistant Administrator) said R1 was trying to get on the freight elevator which is for staff, outside venders and ambulance use only. V12 said staff heard somebody moving food carts by the elevator. V10 (LPN) went to the elevator to see what was going on. V12 said V10 held R1 to prevent R1 from going into the elevator. V12 said instead of V10 holding R1's hands, V10 should have walked away and called another staff member to come assist with R1 since R1 was already upset with V10. V12 said, We had that conversation and we talked to V10 what V10 could have done differently, V12 said V10 should not have held R1's hands to try to prevent R1 from hitting V10. On 12/10/2022 at 2:48pm V13 (Certified Nurses Assistant/CNA) said that she (V13) heard a commotion by the freight elevator and went to see what was going on. V13 said V13 found R1 and V10 in a lock hold. V13 pulled them (V10 and R1) apart. V13 said V10 had a bad attitude that morning since V10 got to work. V13 said R1 had rolled up to the nursing station and asked V10 for medicine. V13 said V10 was yelling at R1 saying, I just got here. V13 said R1 then rolled R1's wheel chair towards the elevator. V10 followed R1 and tried to pull R1 from the elevator doors, when R1 resisted, V10 physically grabbed R1. R1 started using R1's leg to kick V10 so that V10 would let R1 free. V13 said V13 pulled R1 from V10 and V13 took R1 to R1's room, before escorting R1 downstairs. V13 said she (V13) changed V13's statement during facility internal investigation because V13 was afraid of retaliation by the facility for telling the truth. V6 (DON) who was present during this surveyor's interview asked V13, Which one is your statement, you keep changing your statement. V13 said You see, this is the intimidation I am talking about and I might lose my job for telling the truth. This surveyor asked V6 to let this surveyor complete the interview with V13 without interrupting the interview. V13 said after V13 took R2 downstairs V13 told V14 (Director of staffing) that V13 had seen V10 hit R1 on the face. V13 said R1 had a scratch on R1's nose, and the scratch was bleeding. On 12/10/2022 at 3:09pm, V14 (Director of staffing/CNA) said R1 and V10 had an incident. V14 stated she was acting as receptionist at the front entrance desk that morning of the incident (11/26/22). V14 said R1 was wheeled by V13 (CNA) to the reception area and R1 told V14 that V10 punched R1 on the face. V14 said she (V14) asked R1 to take off R1's mask. V14 said V14 saw fresh blood dripping down R1's nose. V14 said R1 said to her (V14), I asked V10 for my medicine and V10 threw her hands up and yelled at me and said, I just got here. R1 said after V10 yelled at him (R1), R1 rolled herself away towards the freight elevator. R1 said, V10 ran behind R1 and began pulling R1's wheel chair away from the freight elevator. R1 said she (R1) told V10 to stop pulling R1's wheelchair and R1 said that is when V10 punched R1 on the nose. On 12/10/2022 at 3:09pm, V14 stated she called V20 (Administrator) to inform V20 there was an allegation about physical abuse to R1 by V10 (LPN). V14 said V14 then called the unit to speak to V10 to find out what happened. V14 asked V10 what happened. V14 commented that V10 was rude. V14 said that V10 said, Like what? V14 said she was on the phone with V20 as she (V14) spoke to V10. Social Services notes dated 11/26/2022 documents that R1 said, V10 was aggressive to R1 when R1 tried to use the freight elevator. R1 called the police with report number JF488143. Doctor was notified. V2 (Nurse) nurses note assessment dated [DATE] documents, small cut on nose, offered R1 pain medication but R1 refused. On 12/10/22 at approximate 2:00pm, V2 said he was called to social services to perform an assessment on R1. V2 stated the local police were present in social services office taking report from R1. Facility abuse policy, no titled Policy, no date, documents; 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. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means.

Based on observations, interviews and review of records the facility failed to provide safety intervention and supervision for 2 of 2 residents (R1 and R2) reviewed for accidents and supervision. R1 sustained multiple 2nd degree [CONDITION(S)] to right hand, fingers, chest and thigh. R2 expired as a result of being discovered submerged under water in a tub at the shower room for approximately 3 to 4 hours. These failures resulted in an Immediate Jeopardy on [DATE] with the potential to affect the safety of 144 residents that requires supervision / assistance per facility form CMS 672. Findings include: R2 a [AGE] year-old female admitted with medical diagnosis to include [CONDITION(S)], seizures, [CONDITION(S)], lack of coordination, major depressive disorder, pain in unspecified joint, [CONDITION(S)] (deaf and non-speaking). Per clinical record R2 expired on [DATE]. Review of the ambulance run sheet dated [DATE], R2 found unresponsive, not breathing with obvious signs of death to include rigor mortis. According to the run sheet R2 was not defibrillated, R2 was considered dead. R2 pronounced dead in the field by the local fire department. On [DATE] at 11:21 AM surveyor accompanied V5 (Registered Nurse) to 4th floor shower/tub room near the elevator. Surveyor observed two shower/tub rooms adjacent to each other. Both rooms were labeled tub room with the same number. V5 unlocked the door using a key to open. V5 stated no one can enter if the door is locked unless the nursing staff opens the door with the key. When asked what happened with R2, V5 stated, When I arrived late today on the floor, the night shift nurse had already left, I do not know what happened to R2. V5 further stated, I do not even know the nurse who worked 11 PM to 7 AM shift and I did not receive any endorsement from the night nurse. On [DATE] at 11:26 AM V6 (Certified Nursing Assistant) stated, I was not here when it happened. The last time I saw R2 was yesterday morning when I worked 7 AM to 3 PM shift. But from what I heard, somebody left her in the bathroom by herself. I don't know if she fell in the bathroom. On [DATE] at 1:45 PM V2 (Director of Nursing) stated, We are still investigating what happened to R2 and I cannot give you any information. As for now, we don't have any names of staff or who saw R2 first when it happened. It was very busy yesterday, so I asked the nursing staff on the floor to go home and rest. I did not make any incident report, I do not think we should do any incident report until we know the cause and why R2 expired. That is why we are doing the investigation to determine if we need to report this incident. Not all death in the facility needs to be reported. Besides, we considered R2 as independent, she does things on her own and we let her be. On [DATE] at 3:24 PM V3 (Certified Nursing Assistant) stated that she was threatened by V2 (Director of Nursing) to be put to jail because she (V3) killed R2. And that there was camera footage showing her (V3) bringing R2 to the shower room. V3 stated that staff working [DATE] on 3 PM to 11 PM shift when the incident happened were V4 (CNA), V17 (CNA) and V10 (Registered Nurse). V3 added R2 was independent and able to perform activities of daily living by herself. V3 stated It is always that way, that nursing staff always left R2 in the shower room because she was independent. V3 stated that shower / tub room had been left opened during the (7AM-3 PM) shift and that it was always open every time she worked on the 4th Floor. V3 then said, she does not know what really happened to R2 on [DATE]. On [DATE] at 3:49 PM V4 (Certified Nursing Assistant) stated she was assigned to R2 when the incident happened. V4 stated she left the floor around 4 PM went down for Covid-19 testing. V4 stated she came back on the 4th floor around 5:00 PM. She (V4) was informed by V17 (Certified Nursing Assistant) that she (V17) provided towels to R2. V4 stated around 7:00 PM, V17 informed me that she found R2 was in the shower / tub room. V4 then said, When I went inside the shower / tub room, R2 was in the tub and her head was submerged in the water. The water was still running in the tub. R2 looked pale when, V10 (Registered Nurse) was called and we (V4, V17 and V10) took her out of the water. CPR was done by the nurse (V10) and water and blood came out of R2's mouth. R2 was considered by all nursing staff as independent including bathing. V4 also stated that there was no staff monitoring the shower/tub room and at least 1 of the shower / tub room's door was always left open to be used by residents. On [DATE] at 4:07 PM V10 (Registered Nurse) stated Around 7 PM I was passing medication when I heard some of the CNAs calling me to the shower room. When I entered the shower room, I saw R2 in a sitting position inside the tub with CNAs supporting her (R2) in a sitting position. We (V10, V4 and V17) took her (R2) out of the tub, and I performed CPR by doing chest compressions only. V10 was asked if an ambu-bag was used to resuscitate R2. V10 responded, No, but we have it on the crash cart. V10 was asked why only chest compression were done, V10 did not respond. V10 stated that nursing staff on the floor considers R2 as independent in her ADLs, (Activity of Daily Living) including showers or during bath. Nursing staff does not assist, supervise, or monitor R2 because she was independent. During the interview, V10 said, We (V4, V10 and V17) removed R2 from the shower room to R2's room and during that time, CPR was stopped. When asked the reason for V10's action, V10 did not answer. V1 (ADM) and V2 (DON) were asked on [DATE] at 1:25 PM, [DATE] at 1:20 PM and 3:20 PM to see footage of camera of both R1 and R2. V1 and V2 said the camera did not store information. On [DATE] at 10:25 AM, V2 (DON) asked about the shift to shift report during change of shift. V2 said It was not necessary for the outgoing staff to write a detailed account on the 24-hour report to follow up with residents' care. It was the responsibility of the oncoming nurse to find out for themselves on what happened on the previous shift. On [DATE] at 1:00 PM V18 (Maintenance Technician) measured the tub on the 4th Floor. Dimensions were as follows: inner depth 16 inches, inner width 24 inches and length 61 inches, outer height 28 .75 inches, outer width 28 .75 inches and outer length 66 inches. Both tubs have the same measurements. A resident was heard inside the shower / tub room upon knocking. After 20 minutes, R9 was came out of the shower / tub room using walker unattended. R9 was [AGE] years old, originally admitted on [DATE], with medical diagnosis that includes major depressive disorder, [CONDITION(S)] disorders. Minimum Data Set (MDS) of R9 dated [DATE] on Functional Status are as follows: 1. Transfers - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position was 1-person extensive assistance needed. 2. Walk in room and corridor - how resident walks between location in her room was 1-person limited assistance. 3. Bathing - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower. R2 needs physical help in part of bathing activity. 4. Shower / bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) was supervision or touching assistance - 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. On 10 /,d+[DATE] at 2:18 PM V17 (Certified Nursing Assistant) stated, that she was the staff who first found R2 submerged in the bathtub on her left side position at the foot of the bathtub. R2 was found with water was still running. V17 stated at the beginning of the shift, around 3:15ish PM, she gave R2 face and large/bathing towels. But she denied bringing her to the shower / tub room. V17 said it was around 6:30 PM to 7:00 PM when she saw R2 was already submerged in the water inside the tub. Per V17, R2 was independent including taking the shower and that R2 takes long showers. On [DATE] at 2:53 PM during an interview with V18 (Restorative Nurse) and V2 (Director of Nursing) V18 stated, Nursing staff on the floor should not leave resident unattended during bathing or shower. It does not matter if the resident was assessed that they need supervision, assistant or they are independent. Residents' in the shower room should not be left unattended. V2 then stated, Yes, I agree residents should not be left inside the shower room and should be checked from time to time. V2 further stated, You have to understand that R2 was assessed as needing assistance, because R2 has poor condition. Hospital Record dated [DATE] reads that R2 declined as to her ADL when she came back from the hospital. In a prior interview, with V2 (dated [DATE] at 1:45 PM) V2 stated R2 was independent. On [DATE] At 4:30 PM V24 (Medical Doctor) stated medical diagnosis does not tell whether a person needs assistance or not. It is through the facility assessment that will tell if a resident needs assistance. On [DATE] at 11:49 AM V21 (R2's sister) stated a male staff informed her that R2 expired in the shower room while taking a shower, there was no additional information mentioned. V21 also stated R2 went to the hospital recently because her health had declined. While in the hospital R2 was noted to have multiple bruising and abrasions. Nurses notes dated [DATE] documents R2 has multiple bruises and abrasions before R2 went to the hospital. On [DATE] at 2:54 PM V23 (Assistant Director of Nursing) stated she was informed on [DATE] by V26 (LPN) that R2 had multiple bruising and abrasions on different areas of her body. V23 further stated that was partly why R2 was transported to the hospital on [DATE]. Per V23 (ADON) and V2 (DON) there was no report filed to the State Agency and no investigation was done because V26 (LPN) did not do the correct assessments and they did not review V26's notes from the incident. On [DATE] at 10:50 AM V25 (Rehab Medical Doctor) stated, R2 was declining, that is the reason she was on Physical and Occupational Therapy. R2 has [CONDITION(S)] which can cause balance issues. R2 has an unsteady gait for her to get into the tub, she cannot do that without assistance. Someone needs to help her get into the tub. She may use soap to clean herself or rinse herself but for sure someone needs to help her going inside the tub. [DATE] at 2:24 PM V31 (Certified Occupational Therapy Assistant) stated he was seeing R2 on a regular basis 2 or 3 times a week. V31 said R2 was doing therapy due to safety concerns, safe transfer training, task attention and self-care. V31 said when R2 came back from the hospital she was very weak and cannot perform ADLs, R2 is not safe to go inside the tub by herself and not safe to be left alone in the shower room due to balance problem and has no safety insight or awareness. R2 requires at least contact guard assist or minimum assistance. Moreover, R2 must not be left alone or by herself in the shower room. Hospital Record for R2's discharged dated [DATE] reads: During discharge from the hospital R2 unable to sit in the wheelchair for more than ,d+[DATE] minutes. R2 continues to demonstrate deficits with strength, coordination, endurance, balance, and safety. Discharge instruction recommends R2 to continue with Physical Therapy to address functional deficits. Minimum Data Set (MDS) of R2 dated [DATE] reads: R2's Functional Status are as follows: 1. Transfers - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position was 2-person extensive assistance needed. 2. Walk in room and corridor - how resident walks between location in her room was 1-person limited assistance. 3. Locomotion on unit how the resident moves between location in her room and adjacent corridor on the same floor was 1-person extensive assist. 4. Locomotion off unit how the resident moves to and return from off-unit was 1-person limited assistance. 5. Toilet - how resident uses toilet on / off toilet was 2-person extensive assistance. 6. Bathing - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower. R2 needs physical help in part of bathing activity. 7. Balance during transitions: Moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface are all not steady, only able to stabilize with staff assistance. 8. Mobility Devices what R2 normally used was wheelchair prior device use was walker. 9. Shower / bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) was substantial / maximal assistance - Helper does more than half the effort. Helper lifts, holds trunk or limbs, and provides more the effort. R2's current quarterly Care Plan in part reads: R2 is at risk for complications related to impaired functionality. R2 requires extensive assistance with Activity of Daily Living (ADLs). R2 is at high risk for falls related to generalized weakness, observed with unsteady gait, mobility with wheelchair. Intervention includes: Staff to anticipate toileting needs / wants, observed resident's routine and personal environment, staff to assist as needed. R2 requires limited assist with daily care needs related to decrease strength, balance and endurance. Intervention includes: One assist for transfers and wheelchair for mobility. R2 has loss range of motion (ROM) to left extremities related to generalized weakness. R2 is at risk for difficulty with communication related to deaf non-speaking. V25 (Medical Doctor) notes dated [DATE] at 8:10 AM, it reads in part: R2 was having lately decline in her strength, mobility, transfer, ADL, and cognition. R2 to be kept in the facility to be managed. R2 was admitted under subacute rehab and she is currently working with PT, OT, and speech therapy. On [DATE] at 3:02 PM V35 (Medical Examiner/Forensic Pathologist) stated during examination, R2 was without injury resulting from trauma, but was found to have water in her lungs consistent with drowning. Per email dated [DATE], V1 (Administrator) informed the regional office cameras in the facility does not record. This information was provided to V1 by V42 (Corporate/IT). V1 indicated via email no written policy concerning the camera footage exist. Findings include: R1 [AGE] years old male originally admitted [DATE], with medical diagnosis that includes [CONDITION(S)], conversion disorder with [CONDITION(S)] or convulsion, dementia, and loss of hearing (deaf). Per notes dated [DATE], R1 was admitted to local hospital with multiple 2nd degrees burn. On [DATE] at 10:40 AM, R1 was observed by surveyor at local hospital. R1's right hand was wrapped V27 (Physician's Assistant) was in R1's room. R1 was awake and spoke very little. V27 wrote on paper What happened? and showed R1. R1 said, Hot water. R1 did not say anything else. R1's wound assessments dated [DATE] shows that R1 has multiple [CONDITION(S)] on various parts of his body. Specific to the following areas: right hand that measures 5.2 X 2.2 cm, right hand top 1.4 X 0.4 cm, chest 9.9 X 4.5 cm and right thigh 3.3 X 1.5 cm. On [DATE] at 12:30 PM V28 (Nurse Practitioner) stated he saw R1 before R1 was sent out to the hospital. Initially V28 stated the condition of the hands may be due to irritation or Dyshidrosis condition. V28 stated, he did a full body assessment including the chest. V28 was asked did you look at R2's chest V28 responded, Yes. V28 was then shown a picture of R2's chest V28 then stated, That is not an irritation that's a burn. V28 further stated if the hospital assessed it as [CONDITION(S)] then it's [CONDITION(S)]. On [DATE] at 2:30 PM V2 (DON) stated, We did not treat it as [CONDITION(S)], because we considered it as irritation or Dyshidrosis. When informed V28 was shown pictures of R2's chest area and the hospital assessment V2 insisted the hospital assessment of R2 was wrong and he still considers R2 diagnosis as an irritation or Dyshidrosis. V2 said, Until now I still consider it as Dyshydrosis. According to The Nurse Practitioner journal vol.43, No.11 (2018): Dyshidrosis is condition in which tiny, fluid -filled blister appears on the palm and fingers. On [DATE] at 1:10 PM V12 (CNA) stated she was the CNA for R1 on [DATE], 11PM to 7AM shift and noticed R1's hands with blisters and open areas at around 5:30 AM. V12 stated she showed R1's hands to V9 (LPN). V12 stated, V9 looked at it and said it looked like an allergic reaction. But V12 said, It looked like [CONDITION(S)]. R1's records, does not include an assessment related to R1's [CONDITION(S)]. On [DATE] at 1:30 PM V14 (CNA), stated she worked on [DATE] from 3 PM to 11 PM and gave R1 his dinner tray. V14 stated R1 was on the bed staring in space between 5:30 to 5:45 PM. R1 kept clenching his teeth and rubbed his lips and teeth with the unaffected hand. V14 said she showed R1's condition to V8 (LPN) who said, Leave him alone, he will soon snap out of it. R1's records show there was no follow up and no assessment completed for R1. Progress notes dated [DATE] at 7:28 AM, written by V9(LPN) reads: Resident received in bed asleep. Upon passing medication this morning, writer observed resident shaking and trembling. Medication given. CNA upon doing final rounds observed that resident was wet and changed resident's clothes and his bedding. CNA observed resident right hand swollen and blistered. Scarring to right thigh that appears to be healing observed. Continue to monitor On [DATE] at 12:15PM, the coffee sent to be served on the 6th floor was 144.8 degrees Fahrenheit. The coffee's temperature was taken by V30 (Dietary manager). On [DATE] at 2:10 PM, V30 said when the coffee left the kitchen, the temperature was usually between 169 to 170 degrees Fahrenheit. State Operation Manual for hot water temperature for Long Term Care: Serving Hot Water Temperatures: 120 degrees Fahrenheit / 48 degrees Celsius, the recommended temperature setting for home water heaters, skin requires five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140 F / 60 C. it takes only five seconds or less for a serious burn to occur. On [DATE] at 11:50 am observed several residents pour their own coffee from the coffee dispenser. On [DATE] at 12:20 PM, several residents including R11 and R12 said the coffee was usually hot and sometimes they could not drink it but sipped it. On [DATE] at 1:24 PM V1 and V2 DON said they have no answer to what may have happened to R1's hand. V2 said stated he spoke with staff and residents and no one knows anything. Progress note dated [DATE] at 10:50 PM, written by V23(ADON) reads: It was reported to the nurse in charge that R1 was admitted to the hospital with [CONDITION(S)], Skin Tear and 2nd Degree [CONDITION(S)]. Hospital Records dated [DATE] reads: R1 skin: Second degree [CONDITION(S)] on right hand, fingers, chest, and thigh. Minimum Data Set (MDS) of R1 dated [DATE] reads: 1. Transfers - how resident moves between surfaces including to or from: bed, chair, wheelchair, supervision and set up needed. 2. Walk in room and corridor - how resident walks between location in her room was supervision and set up needed. 3. Locomotion on unit - how the resident moves between location in her room and adjacent corridor on the same floor was supervision and set up needed. 4. Toilet - how resident uses toilet on / off toilet was 1-person limited assistance. 5. Eating - how resident eats and drinks, regardless of skill was supervision and set up needed. Incident/Accident Reports Policy dated ,d+[DATE] in part reads: The incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to-resident altercations. The facility shall send a narrative summary of each reportable accident or incident to the Department within (5) working days after report of the occurrence. If the incident or accident results in a death, after notifying law enforcement. The IDPH Regional Office must be notified by phone. A narrative summary still needs to be sent to IDPH within 5 working days of the occurrence. In addition to keeping a file of all written reports submitted, you must keep documentation of the verbal conversation with the IDPH Regional Office or IDPH Complaint Hotline, (make sure you get the name of the person you spoke with). Per V1 (Administrator) the facility does not have any policy related to prevention of accidents. [NAME] OF FOREST EDGE Illinois Department of Public Health Re: Abatement Plan of Correction for Immediacy at F689 The following plan of correction is being submitted to address the alleged finding of immediate jeopardy related to F689 Free of Accident, Hazards, Supervision, Devices. The submission of this plan of correction is not an admission of guilt or wrong doing but this plan of correction is being submitted in good faith, as required by law. This plan of correction serves as the center's credible allegation of compliance. The facility has taken the following actions to immediately abate the finding of immediate jeopardy. Immediate Action On [DATE] at approximately 8 a.m. R1 was noted with multiple 2nd degree [CONDITION(S)] to right hand, fingers, chest, and right thigh. On [DATE] at approximately 12:46 a.m. R1 was sent to the hospital for evaluation and treatment. PCP, DON, Administrator, and POA/Family notified. Investigation was initiated as to determine cause of [CONDITION(S)]. On [DATE] at approximately 6:15 p.m. R2 was found unresponsive in the shower room. CPR initiated, 911 called, and Code called. At approximately 6:45pm. R2 was pronounce dead at the scene by CPD. PCP, DON, Administrator, and POA/family notified. Investigation was initiated to determine cause of death. Education C.N.A's and nurses have been educated on ensuring that shower room doors on all resident floors are closed and locked at all times when unoccupied. All residents requiring supervision and assistance with bathing are to be supervised and assisted while in the shower room. If resident is independent, the resident must be checked on every 10 minutes. C.N.A's and nurses have been educated on completing rounds every hour on all residents requiring supervision, and to ensure stability of residents physical and mental wellbeing. C.N.A's and nurses have been educated on accessing the ADL binders on each nursing station for resident ADL status. The Director of Nursing will be responsible for educating nursing staff. Additional interventions The maintenance director will ensure that all shower/bathroom doors and locks are checked daily for proper function. The wound care nurse will perform skin checks monthly on all residents to ensure no additional alterations in skin integrity. Monitoring/Surveillance Direct observation audits will be conducted on shower/bathrooms, to ensure they are properly secured, and that locks are functioning by the DON and/or assigned clinical manager. The Audits/Observation will be conducted 1 time per shift for 14 days. The results of the Audits will then be taken to QAPI to determine future frequency. The Administrator will be responsible for ensuring the staff In-servicing and audits are completed. QAPI All audit results will be reviewed by the facility Quality Assurance Committee to determine if any further staff education or facility policy changes are needed. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Committee monthly. All above measures will be subject to review, assessment and modification. [DATE] Completion Date

Based on Observations, Interviews and Record reviews, the facility failed to assess, monitor and document change in condition for one resident (R1) of one reviewed for change in condition. This caused delay in emergency treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was hospitalized ten hours later after a change in condition was noted. Facility failed to ensure staff performed correct CPR(Cardiopulmonary Resuscitation) for one resident(R2) after being found submerged in water while in a deep soaking tub. Findings include: Record review noted R1 was [AGE] years old, originally admitted on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not speak much and R1's mental status was impaired with a Brief Interview for Mental Status (BIMS) score of 6. R1 was ambulatory with supervision. On [DATE] at 10:40am, surveyors visited R1 at the community hosptial. R1 was awake and comfortable in bed. R1, although deaf, agreed to communicate with surveyors via writing pad. R1 could speak minimally but answered questions on writing pad. R1's right hand was wrapped. V27 (Physician's Assistant) was in R1's room at the time. V27 wrote on paper questions for R1. V27 asked R1 what happened, and he said, hot water. R1 did not say anything else. R1's wound assessments dated [DATE] shows that R1 has multiple [CONDITION(S)] on different parts of his body. Specific to the following areas: right hand that measures 5.2 X 2.2 cm, right hand top 1.4 X 0.4 cm, chest 9.9 X 4.5 cm and right thigh 3.3 X 1.5 cm. V27 stated that she did not know why facility did not know how R1 received such injuries. On [DATE] at 1:25PM, V14(Certified Nursing Assistant/CNA) stated she noticed R1 did not eat his dinner on [DATE] and he stared in space and clenched his teeth while rubbing his lips with his unaffected hand. V14 said, V8 (Licensed Practical Nurse/LPN) was notified. V8 told V14,Leave him alone, he (R1) will soon snap out of it soon, There was no documentation for follow up and no assessment completed for R1 noted in R1's chart. On [DATE] at 1:10PM, V12(Certified Nursing Assistant/CNA) stated she noticed R1's hands with blisters and open areas on R1's right hand at around 5:30 AM on [DATE]. V12 said, I showed R1's hands to V9 (LPN) and V9 looked at the hand and said, it looked like an allergic reaction. But I said, it looked like [CONDITION(S)]. Nurse's Progress notes regarding R1's does not have any documented assessment or notification of family and physician for R1's injuries at that time. During review of V9's documentation on [DATE] at 7:28AM regarding R1 skin it reads: 11PM-7:00AM shift: Resident(R1) received in bed asleep. Upon passing medication this morning, writer observed resident (R1) shaking and trembling. Medication given. CNA upon doing final rounds observed that resident was wet and changed residents clothes and his bedding. CNA observed residents right hand swollen and blistered. Continue to monitor However, the above progress note written by V9 does not indicate V9, as the nurse, acknowledged resident skin injuries as reported to her by CNA and therefore, V9 did not report change in skin condition to the doctor or family. On [DATE] at 12:30 PM V28 (Nurse Practitioner) stated he saw R1 before R1 was sent out to the hospital. At first, V28 stated the condition of the hands may be due to irritation or Dyshidrosis condition. V28 stated, he did a full body assessment on R1's body. When asked. Did you ask R1 what happened. V28 said, He (R1) was in too much pain. There was no documentation that pain medication was administered to R1. Pain policy dated ,d+[DATE] documents in part: Pain management is a multidisciplinary care process that includes 1) effectively recognizing the presence of pain and 2) identifying the characteristics of pain. V28(Physician Orders) dated [DATE], Send R1 to community hospital for tremors and Dyshidrosis. According Nurse Practioner Journal, Volume 43, no. 11 (2018): dishidrosis is a condition in which tiny, fluid -filled blister appears on the palm and fingers. Hospital emergency room Record documents: R1 was received at the hospital at 2:48PM on [DATE]. However, on [DATE] at 10:50 PM, V23 (Assistant Director of Nursing) documented, It was reported to the nurse in charge that above resident was admitted to the hospital with [CONDITION(S)], Skin Tear and 2nd Degree [CONDITION(S)]. Change of Condition policy dated ,d+[DATE] documents in part: Physician or Nurse Practitioner should be notified for any Change of Condition. Incident and Accident policy(undated) documents in part: An Incident Report is completed for all accidents or incidents where there is injury or the potential to result in injury. Findings include: R2 was a [AGE] year old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . After R2 was discovered submerged in water in a deep soaking tub(depth 16 inches, width 24 inches and length 61 inches), staff failed to correctly perform CPR for R2 who expired on [DATE]. Minimum Data Set (MDS) dated [DATE] in part documents: R2 required a 2-person extensive assist with transfers in/out of tub/shower. R2 required physical assistance with bathing activity. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Current Face Sheet for R2 documents full code status. According to Nurse's progress notes dated [DATE] at 6:40pm, V10(RN) documents: At around 6:15 pm on the 6th of [DATE], I was called by the aides while I was passing medication that one of the residents was unresponsive in the shower room. I immediately rushed down to the shower room, and upon assessment, the resident had no pulse, no response to tactile or verbal stimuli, CPR was initiated, and 911 was called. Resident was pronounced dead at the scene per 'nearby police department.' On [DATE] at 4:07 PM V10 (Registered Nurse) said, During medication Pass I heard a call from other nursing staff in the shower/tub room. When I went in the shower/tub room, R2 was propped up in a sitting position inside the tub by V17(CNA) and V4(CNA). We took her (R2) out of the tub and I performed CPR by doing chest compressions only. I did not use the ambu-bag but we have it on the crash cart. V10 then stated that he with assistance of V17 and V4 transferred R2 to R2's bed. He said, CPR(chest compressions) was stopped during the change of venue. V10 did not answer when asked why chest compressions were stopped. According to American Heart Association CPR and First Aide and Emergency Cardiovascular Care article posted [DATE] reports: High Quality CPR-should be performed by anyone -including bystanders. There are five critical components: Minimize interruptions in chest compressions; Provide compressions of adequate rate and depth; avoid leaning on the victim between compressions; show proper hand placement; avoid excessive ventilation.

Based on observation interview and record review, the facility failed to administer pain medication to one (R1) of one resident with 2nd degree [CONDITION(S)] Findings Included: Per local hospital record dated 10/4/21 at 10:48pm, R1 was admitted to hospital for 2nd degree [CONDITION(S)], [CONDITION(S)]. R1 was [AGE] years old male originally admitted on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per notes dated 10/4/21, R1 was admitted to local hospital with multiple 2nd degrees [CONDITION(S)]. On 10/6/2021 at 10:40 AM, R1 was observed by surveyor at local hospital. R1's right hand was wrapped and V27 (Physician's Assistant) was in R1's room. R1 was awake and spoke very little. V27 wrote on paper what happened? and showed R1. R1 said, hot water. R1 did not say anything else. R1's wound assessments dated 10/4/21 shows that R1 has multiple [CONDITION(S)] on various parts of his body. Specific to the following areas: right hand that measures 5.2 X 2.2 cm, right hand top 1.4 X 0.4 cm, chest 9.9 X 4.5 cm and right thigh 3.3 X 1.5 cm. On 10/06/21 at 12:30 PM V28 (Nurse Practitioner) stated he saw R1 before R1 was sent out to the hospital. Initially V28 stated the condition of the hands may be due to irritation or Dyshidrosis condition. V28 stated, he did a full body assessment including the chest. V28 was asked, Did you ask him (R1) what happened? V28 said,No he was in too much pain. According to The Nurse Practitioner journal vol.43, No.11 (2018): Dyshidrosis is condition in which tiny, fluid -filled blister appears on the palm and fingers. On 10/7/21 at 1:30 PM V14 (CNA), stated she worked on 10/3/21 from 3 PM to 11 PM and R1 did not eat his (R1) dinner. V14 said,R1 was on the bed staring in space. R1 kept clenching his teeth and rubbing his lips and teeth with the unaffected hand. V8(Licensed Practical Nurse/LPN) told V14 to Leave him alone, he will soon snap out of it. On 10/7/21 at 1:10 PM V12 (CNA) stated she (V12) saw R1's hands with blisters and open areas at around 5:30 AM on 10/4/2021 and notified V9(Licensed Practical Nurse/LPN) who did nothing except to say , it looked like an allergic reaction. But V12 said, It looked like [CONDITION(S)]. V12 stated R1 was wet. V12 said it was unusual for R1 to be incontinent in bed and besides R1 trembled too. Progress notes dated 10/4/2021 at 7:28 AM, written by V9(LPN) reads: Resident received in bed asleep. Upon passing medication this morning, writer observed resident shaking and trembling. CNA upon doing final rounds observed that R1 was wet and his (R2's) linen was also wet. There was no follow up on R1's condition with family or Physician. There was no vital signs recorded for R1 at this time. On 10/4/2021 at 9:5AM, V28(Nurse Practitioner/NP) documented,judgment assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . but asymptomatic of shortness of breath, nausea pruritis and with pain of 6/10. V28 also documented the plan was to administer 2 tablets of Tylenol #3, Medication Administration Record(MAR) noted the order was written on the MAR, However, the medication was not documented as administered. Care plan for R1 dated 7/21/2021 noted problem of pain and interventions to include , Address pain promptly and report to MD of Signs and symptoms of pain Facility's policy on pain dated 9/2021 documented,Pain management is a multidisciplinary care process that includes 1) effectively recognizing the presence of pain and 2)identifying the characteristics of pain.

Based on observations, interviews and record review the facility failed to ensure staff protected a resident who was screened at risk for abuse, failed to ensure staff provided supervision to a resident displaying physically aggressive behavior and failed to timely move a resident to a different floor per facility policy after assaultive behavior was reported for two (R1 and R4) of four residents reviewed for abuse. These failures resulted in R4 physically assaulting R1 who experienced right eye and facial pain, blurry vision and light sensitivity with a hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's Admission Record documents, in part, that R1 is a [AGE] year-old with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 14 which indicates that R1 is cognitively intact. R4's Admission Record documents, in part, R4 is a [AGE] year-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE], documents a BIMS score of 13 which indicates that R4 is cognitively intact. On 8/5/21 at 12:15 pm, R1 stated that on 7/28/21 at approximately 1:00 am, R4 came into her room and punched her in the right eye. R1 stated she was awake in bed and responding to a text message on her cellular phone. R1 stated she looked up from her phone and R4 is standing next to her bed wearing a gown. R1 stated she turned her head and said, Hey (R4)! R4 then hit her in her right eye with a closed fist. R1 stated she used her stylet with her mouth to press the call light and then R4 walked out. R1 stated V12 (Licensed Practical Nurse, LPN) came into her room a few minutes later as R4 tried to come back into R1's room. R1 stated that V12 and V18 (Certified Nursing Assistant, CNA) had to pull R4 out of her (R1's) room into the hallway and that she could see R4's naked buttocks during her removal. R1 stated, Here I am, not able to move and (R4) comes in and hits me with a closed fist and says nothing. I absolutely was feeling threatened. R1 stated V12 came back into her room and R1 told V12 what happened with R4. On 8/9/21 at 4:10 pm, V12 (LPN) stated she was R1 and R4's nurse on 7/27/21 on the 11:00 pm to 7:00 am shift. V12 stated that R1 is a quadriplegic from the neck down which requires total care assistance from staff. V12 stated at the beginning of the night shift on 7/27/21, I had my eyes on R4 because when she first did rounds, R4 came up to her at the nurse's station, opened the back of her gown and spread her naked buttocks. V12 stated she redirected R4 back to her room and instructed V18 (CNA) to keep an eye on R4 since this was a new behavior. V12 stated she wanted to monitor R4 because she may do something else. On 7/28/21, approximately 2 hours after the start of her night shift, V12 stated V18 went to perform care for R7 and noted that R4 was walking from her room towards the nurse's station and then went into R1's room. V12 stated that V18 ran into R1's room after R4. V18 turned R4 out of R1's room. (V12) responded to redirect R4. V12 stated that R1 said, By the way, she (R4) hit me. V12 stated that she attended to R1 and asking her what happened with R4. V12 stated that R1 said R4 came up to her in her room and hit her in the right eye. V12 stated she assessed R1's right eye, applied a cold compress and R1 denied any pain at this time. V12 stated R4 was then one-to-one monitored by V18 (CNA) and that R4 did not come out of her room the rest of the shift. When this surveyor questioned about V12 about her authored progress note regarding R4 being combative with staff, V12 stated prior to entering R1's room, R4 tried to go on the elevator and was swinging at her (V12). V12 stated R4 was swinging with both closed fists. (V12) stated she stepped back and then redirected R4 back to her room. V12 said R4 came out of her room two more times to the nurse's station, spreading her naked buttocks. The third time (R4) came out of her room, R4 went into R1's room. In R4's Nurses Note dated 7/28/21 at 12:43 am, V12 (LPN) documented, in part, (R4) became combative with staff and was sent to her room. (R4) attempted to leave the floor and was sent back to her room again. (R4) became combative with staff. After being in her room for about ten minutes, (R4) came out and went into (R1's room) and struck (R1) in the right eye. (R4) went back in her room on her own after this encounter. Continue to monitor (R4). In R1's Nurses Note, dated 7/28/21 at 12:52 am, V12 (LPN) documented, in part, (R1) was struck by (R4) .for no reason. On 8/12/21 at 7:00 am, V18 (CNA) stated she was the only CNA on 7/27/21 from 11:00 pm to 7:00 am for R1 and R4's floor. V18 stated at the beginning of her shift at 11:00 pm, R4 was wearing a gown that wasn't fastened in the back and walked up to her at the nurse's station, then placed her head on the table and spread open her naked buttocks. V18 stated, (R4) did this for an hour repeatedly. V18 stated R4 would go back to her room with redirection, then come back out to the nurse's station or garbage can to repeat the behavior. V18 stated R4 then was attacking V12 (LPN) by hitting her in the arm with a balled up fist. V18 stated she and V12 physically escorted R4, by grabbing underneath each arm, back to her room. V18 stated that about two hours into the shift, on 7/28/21, R4 came out of her room, walked up the hallway to the nurse's station, and then R4 detoured into R1's room. V18 stated, I jumped up from the nurse's station, and V12 ran behind me. We got to R4 and she was at the foot of R1's bed. V12 then physically escorted R4 back to her room, and R1 said to me, (R4) smacked me. V18 stated that approximately one hour after this incident, R4 again jetted out into the hallway, running back towards R1's door but she ran after R4 and caught her before she reentered R1's room. V18 stated after another hour, she peeked in on R4 in her room and R4 was sleeping. V18 then she finished her other work with the other residents on the floor. On 8/5/21 at 12:15 pm, R1 stated when the morning staff came in on 7/28/21, V4 (Social Services Director) came to her (R1) and asked her what happened with R4. R1 stated she repeated the same story of R4 hitting her in the right eye. R1 said V4 informed her that he would be sending R4 out (to the hospital) and V14 (Nurse Practitioner) would be taking care of it. R1 stated she informed V4 that on 7/28/21, R1 was in her room with the door closed and even though R1 didn't see R4, she was scared. R1 stated that on 7/28/21 during the day, she hears R4 in the hallway saying, God told me to hit her (R1). R1 stated, It took me right back to the situation when she (R4) hit me. I was scared. R1 stated, (R4) had already hit me, and I can't defend myself. R1 stated she told V20 (CNA) that she was scared because the facility didn't send R4 out. R1 stated, I was traumatized all over again so I text (V2, Director of Nursing, DON). During R1's interview on 8/5/21 at 12:15 pm, this surveyor read R1's text message to V2, dated 7/28/21 at 8:29 pm. The text read, in part, I don't know if you are aware but on the 11 pm - 7 am shift, (V12) was nurse and said that (R4) said God is telling her to hit me. I am afraid that she'll come in and do worse. On 8/10/21 at 4:05 pm, V2 (DON) stated he was informed by V12 in the middle of the night on 7/28/21 that R1 had alleged that R4 hit her. V2 stated he then reported this to V1 (Administrator) who is the abuse coordinator in the facility. V2 stated he did not physically see R1 during the day on 7/28/21 and confirmed to this surveyor that he did received a text message from R1 later on 7/28/21 indicating that R1 was afraid. V2 stated the social services department helped with R4's room change. On 8/12/21 at 9:31 am, V20 (CNA) stated she was on orientation with V34 (CNA) on 7/28/21 from the 3:00 pm - 11:00 pm shift. V20 stated on this date while rendering care to R1, R1 informed her that she was afraid from an incident that occurred earlier with R4 and that she didn't want it to happen again. V20 stated that she relayed R1's feelings to the nurse (V13). On 8/5/21 at 3:05 pm, V4 (Social Services Director, SSD) stated when he arrived at the facility on 7/28/21 at 7:00 am, he began his rounds and spoke to R1 in her room. V4 stated R1 informed him of the incident with R4. V4 stated he then went to check on R4, who was fast asleep and ordered to move R4 off the floor immediately. V4 stated he checked for another room and had R4 moved off that floor on the same day (7/28/21). V4 stated staff are to intervene as soon as possible when a resident is displaying behaviors. R4's document, titled Notice of Room Transfer dated 7/29/21, indicates R4 moving rooms to another floor in the facility on 7/29/21, which contradicts V4's statement of R4 being immediately removed from R1's floor (on 7/28/21). In R4's Social Service Note dated 7/28/21 at 9:35 am, V4 documented, in part, Writer met with (R4) for a follow up. (R4) displayed delusional behavior with aggression towards (R1). (R4) verbalized hearing voices (Lord calling her) urging (R4) to hit (R1). (R4) immediately placed on 1:1 monitoring. On 8/10/21 at 12:48 pm, V14 (Nurse Practitioner, NP) stated he assessed R4 in person on 7/28/21 morning and that R4 was manic and agitated. V14 stated redirection didn't work so acute anti-psychotic medication was needed and given to R4. V14 stated R4 was verbally and physically aggressive with poor impulse control, was attempting to strike others and had already stricken R1. V14 stated since R4 was still displaying these behaviors, he (V14) was trying to prevent further behaviors from R4 by debriefing staff to take cues from R4's agitation, internal stimulation, delusional thoughts and restlessness. V14 stated if acute anti-psychotic medications are not working, he will transfer the resident out to the hospital for a psychiatric evaluation. V14 stated R4 was moved to another floor, and we started monitoring her (R4) more. On 8/5/21 12:15 pm R1 stated that on 7/29/21, the pain was persistent in her right eye, and she was sent out to the hospital where they performed radiology studies. R1 stated the hospital staff instructed her that if the right eye pain persists, to come back to the hospital. R1 stated on 8/4/21, she was experiencing right eye pain, blurry vision and light sensitivity, so she demanded to be sent back to the hospital. Per R1's request with permission provided, this surveyor reviewed R1's hospital discharge paperwork in her room. The hospital report, dated 8/4/21, listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/21 at 4:35 pm, V28 (Psychiatric Rehabilitation Services Director, PRSD) stated in the morning on 7/28/21, she went to take statements from R1 and R4 about the alleged physical assault. V28 wrote R1 and R4's statements for V1's abuse investigation. V28 stated when she interviewed R4, R4 stated she hit R1 because the Lord was calling her to do it and to do it again. V28 stated R4 was placed on one-to-one monitoring with a staff member specifically assigned that the resident. Review of the facility CNA Daily Assignment Sheets on 7/27/21 for night shift and 7/28/21 for day, evening and night shifts indicate that no staff member was assigned to R4 for one-on-one monitoring. On 8/10/21 at 11:45 am, this surveyor attempted to interview R4 about the 7/28/21 physical assault on R1; however, R4 stated that she didn't want to speak to this surveyor about it. R4's written statement, dated 7/28/21 and obtained by V28 (PRSD), documents, I hit her (R1). I feel like the Lord was contacting me so that's why I hit her (R1). I was hearing voices. The Lord was telling me to hit her. I still hear the voices. In R4's Social Service Note, dated 7/28/21 at 9:35 am, V28 (PRSD) documented: Writer met with (R4) for a follow up. (R4) displayed delusional with aggression towards peer. (R4) verbalized hearing voices (Lord calling her) urging her to hit a peer. (R4) is immediately placed on 1:1 monitoring, and charge nurse was notified. Staff will continue to follow up and note all progress. On 8/10/21 at 11:01 am, V13 (LPN) stated she worked as R1 and R4's nurse on 7/29/21 from 9:00 am to 9:00 pm. V13 stated R1 reported to her what happened overnight with R4 coming into her room and hitting R1. V13 stated on 7/28/21 at approximately 9:00 am, R4 came from her room into the day room with her gown on. V13 informed R4 that she needed to get dressed for the day. V13 stated R4 then opened the back of her gown towards her and went back to her room. V13 stated on 7/28/21 at 10:00 to 10:30 am, R4 returned to the day room with her gown on, exposing her naked backside and gestured for V13 to kiss her behind. V13 stated at that point, she told V34 (CNA) to take R4 back to her room and sit with her. V13 stated V34 left R4's room, and then R4 came back out of her room again to the day room. V13 stated she then called V14 (NP) to inform him of R4's behavior, and that V14 ordered PRN medications. V13 stated R4 laid her body on the floor of the day room with her gown on. V13 stated she called V31 (Resident Services) for assistance, and when V31 arrived R4 got up off the floor and went to her room. V13 stated she medicated R4 with the ordered anti-psychotic medications. V13 stated R4 slept through lunch and had to be woken up to eat dinner. V13 stated R4 was still residing on the same floor as R1 when she checked on her on 7/28/21 at 8:45 pm. On 8/11/21 at 3:32 pm, V34 (CNA) stated she was the CNA on R1 and R4's floor on 7/28/21 for the 7:00 am to 3:00 pm shift. V34 stated R4 was coming out of her room, pulling her hair and banging her head on the elevator door. V34 stated R4 was opening the back of her gown and spreading her naked buttocks when she was out in open view to other residents. V34 stated V13 (LPN) tried to intervene and redirected R4 back to her room, saying that she couldn't come out of her room without putting on day clothes. V34 stated R4 repeated this same behavior again out in open view of other residents. V34 stated V13 talked to R4 and walked her back to her room. V34 stated she checked on R4 every 30 to 45 minutes for monitoring because she was working with other residents on the floor. V34 stated, I was the only CNA on the floor that day. Facility document, titled Daily Schedule and dated 7/28/21, documents that V34 was the one CNA for 1st shift on the 5th floor. On 8/9/21 at 2:35 pm, V11 (Registered Nurse, RN) documented that on 7/29/21 R1 informed him she was having pain to her right eye and was requesting to be sent to the hospital. V11 stated he notified V14 (NP) about R1's pain and request, and an order was received to send R1 out to the hospital. V11 stated he prepared R1's transfer documentation, called for ambulance services and transferred R1 to the hospital. V11 stated that on 7/29/21, at the end of his shift, he moved R4 to a room on another floor in the facility. In R4's Nurses Notes dated 7/29/21 at 2:03 pm, V11 documented, in part, (R4) . transferred to 2nd floor. On 8/10/21 at 1:41 pm, after reviewing her authored documentation from 7/28/21 at 6:53 pm, V5 (Psychiatric Rehabilitation Services Coordinator, PRSC) stated she did not witness R4 move from the 4th floor to the 5th floor. V5 stated V4 informed her R4 had been transferred to the 4th floor and since R4 was assigned in her (V5's) case load, she needs to document R4's transfer. V5 stated she did not physically see R4 until she was relocated to the 2nd floor on 7/29/21. In R4's Social Service Note dated 7/28/21 at 6:53 pm, V5 (PRSC) documented: Room Change: (R4) was transferred from room [ROOM NUMBER] (A) to room [ROOM NUMBER] (D). (R4) was receptive to the room change at this time. Nursing made aware. Staff will continue to document all progress. In contradiction, V5 (PRSC) then documented in another of R4's Social Service Note, dated 7/29/21 at 1:43 pm: Room Change: (R4) was involved in a room change. (R4) was moved from room [ROOM NUMBER] (A) to room [ROOM NUMBER] (A). (R4) was receptive to the room change at this time. Nursing made aware. Staff will continue to document all progress. In R1's hospital records on 7/29/21 at 1:20 pm, V9 (Hospital Emergency Medicine Physician) documented, in part, (R1) presents with right eye/facial pain s/p being punched in the face. (R1) states 2 days ago, another resident in her nursing home punched her in the face, striking near her right eye . (R1) endorses blurred vision yesterday . notes persistent pain to her right eye and right face. On 8/11/21 at 1:31 pm V27 (LPN) stated R1 is alert, fully oriented and not able to move her extremities. V27 stated on 8/4/21, R1 complained of right eye pain and was requesting to be sent back to the hospital. V27 stated the pain location was where R4 had hit her from a previous date. V27 stated she contacted V14 (NP) who provided an order to send R1 to the hospital for further evaluation of the right eye pain. V27 stated she transferred R1 to the hospital on 8/4/21 and R1 returned back to the facility on the same day with a bottle of [MEDICATION(S)] eye drops and another medication prescription. R1's Order Summary Report documents, in part: [MEDICATION(S)] Suspension 1%. Instill 2 drops in right eye every four hours as needed for 5 days with an order dated of 8/4/21, and [MEDICATION(S)] HCl Solution 2%. Instill 1 drop in right eye two times a day for Pain until 8/14/21 with an order date of 8/8/21. R1's hospital records on 8/4/21 at 2:07 pm, V44 (Hospital Trauma Physician) documented, in part, (R1) presenting to ED with remote eye injury that occurred one week prior after being struck in the face by a fist. (R1) reports that since the injury . (R1) has been experiencing progressive blurry vision, light sensitivity, and increased pain with eye movement . Traumatic Iritis is leading diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21 at 12:48 pm, V37 (Attending Physician) stated if a resident is alleged to have assaulted another resident, the facility staff must isolate the resident and send them out to the hospital. V37 stated, There's no predictability of when a resident can physically assault another resident in a facility. V37 stated facility staff needs to do close observation of the abuser until the resident can be transferred to the hospital or to another floor. V37 stated since R4 was not sent to the hospital after the allegation of physical assault by R1, staff must monitor R4 to prevent any further harm. When this surveyor informed V37 the victim of R4's physical assault was R1, a quadriplegic resident who is fully oriented, vulnerable and not able to defend herself and then hears R4's voice in the hallway outside her door after R4 was not immediately removed off the floor, would he expect that this would cause psychosocial harm to R1? V37 stated, It's a possibility. V37 stated, If you are asking me the question if (R4) should have been transferred off the floor right away? The answer is yes. R1's Care Plan dated 2/5/20 documents, in part, a focus that R1 is vulnerable for abuse as evidenced by having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility policy dated 9/20 and titled Behavior Management, documents, in part: General: It is the policy of (the facility) to manage unruly behavior of a resident in the least restrictive manor that ensures the safety of residents, employees, and family members. Responsible Party: Nursing and Social Services. Guidelines: 1. Should a resident's behavior become abusive, hostile, assaultive or unmanageable in a way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.). Facility abuse policy, untitled and dated 9/2017, documents, in part: This facility affirms the right of our residents to be free from abuse . 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 . of residents . The facility is committed to protecting our residents for abuse . by anyone including, but not limited to, facility staff, other residents . VI. Protection of Residents: 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, but not limited to, the separation of resident.

Based on interview and record review, the facility failed to supervise and monitor a resident whom sustained fractures when she fell two different times in the facility. This failure resulted in the resident suffering a right knee fracture and a right femur fracture. This failure affects one of three residents reviewed for falls (R3) in a total sample of ten residents. Findings include: R3 is [AGE] year old female resident of the facility. R3 has the following Diagnoses: [REDACTED]. Review of R3's care plan notes that she is alert and oriented and able to make her needs known. She is a high risk for falls due to her medication, [MEDICAL CONDITION], muscle weakness, unsteady gait, and ambulating with her wheelchair. Review of the fall log notes R3 has had three falls in the facility. R3 had falls on 1/25/2020, 02/03/2020, and 06/24/2020. Progress note dated 1/25/2020, notes R3 was found lying face down on the floor in her room next to her nightstand. Her nose was bleeding and a complete body check was completed. She was noted with some swelling to her right knee. An x-ray was ordered. The x-ray noted right knee fracture. Fall intake form dated 1/25/2020, notes her predisposing factors are gait imbalance and ambulating without assistance. On 11/29/2020, at 11:13AM, V16 (Nurse) stated, I found R3 on the floor, face down. A CNA (Certified Nursing Assistant) and I came to help assess her. I sat her up and looked at her knee. It was swollen. I called the medical doctor. She was sent to a local hospital for further assessment. I monitor her because she likes to get up, move around and go to the restroom. She is wheelchair bound. The residents are monitored to make sure they are safe and that there are safety measures and precautions. Progress note dated 06/24/2020, notes R3 observed on the floor with complaint of pain to the right hip and knee. The resident stated that she was attempting to help another resident and she tripped over her wheelchair. An x-ray was completed. The x-ray notes fracture of right femur. The initial report sent to IDPH (Illinois Department of Public Health) dated 06/24/2020, notes R3 had an unwitnessed fall. The fall intake form dated 06/24/2020, notes the fall occurred in the day room. Her predisposing factors are: gait imbalance, noncompliant with safety guidelines and ambulating without assistance. On 11/29/2020, at 12:42PM, V17 (CNA) stated, my job as a CNA is to monitor residents for their safety, needs and wants. The nurse was at the nurses' station, I was in the day room. R3 slid and fell from her wheelchair. I told her not to do it, but she does what she wants. She does not listen. R3 told me that she was trying to help another resident. I do not recall if the wheelchair was locked or what she was saying. On 11/29/2020, at 10:47AM, V15 (Restorative Nurse) stated, after a resident falls, we evaluate them for what we can do to prevent future falls. In both cases of R3 falls, staff should be more proactive. She has behaviors and is not easily redirectable at times. The fall on 06/24/2020, was in the day room. She was trying to assist another resident. She was medicated and was refrained from doing what staff should be doing. Staff should be in the day room with the residents to make sure residents are monitored. The interdisciplinary team and I update the care plan and interventions after each fall. I will go up and speak with the residents and witnesses based on the information I have. I will come up with interventions. Some falls can be prevented, some cannot. But, the best way to prevent falls and fractures is by monitoring. On 11/29/2020, at 1:11PM, V13 (CNA) stated, R3 needs monitoring and rounding every two hours because she will try to get up and requires more monitoring, at times. On 11/29/2020, at 1:54PM, V12 (Nurse Practitioner) stated, R3 has fallen in the facility. Her patella fracture could be from falling. She is high risk for falls. She is alert and oriented, but has a mood disorder and finds it difficult to follow the facility protocols and does not listen to staff. R3's care plan interventions include: explain call light and assess residents ability to use it, monitor and document perceptual changes, observe for gait unsteadiness, anticipate resident's need to use the restroom, remind resident to refrain from doing the staff's job. Facility policy titled Fall Prevention and Management, dated 10/2019, notes the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe as an environment as possible.

Based on observation, interview and record review, the facility failed to provide documentation on assessment and treatment of [REDACTED]. This failure resulted in R2's wounds not being treated. The findings include On 7/11/18 at 10:54 AM on the 4th floor, R2 stated that there was a fire in the facility on 7/4/18 at 11 PM in R2's room. R2 stated that he was laying on his bed when he sees his corridor door open and a lady in a wheelchair comes into his room. R2 says he is yelling Get out, you are in the wrong room over and over. R2 says that the next thing he sees is a flicker and his mattress is on fire. R2 stated that his adult brief was also singed. R2 stated he did not think he had sustained any injury so he refused to go to the hospital. R2 stated that he was physically checked by a nurse for [MEDICAL CONDITION] does not remember who or when. R2 stated that the certified nurse aides (Certified Nurse Aide/C.N.A.) were telling him that he has a burn on the back of his right thigh but does not recall which CNAs. R2 says he has no feeling and does not feel it on the back of his thigh. R2 did attempt to show the wound and pointed to the outer aspect of his right thigh. There was a 6 inch long by 1 inch wide black jagged scar which appears old on the outside of the right thigh. At 11:18 AM, R2 is taken into his room by V17 (CNA) and V18 (Wound Nurse). R2 is assisted on to the bed by V17 and V18 so V18 can view the back of the right thigh. V18 states that it looks like a burn. There is a quarter-size burn-like circular red discoloration with the first layer of skin missing exposing the intact red discoloration on the back of the right thigh. There is no opening in the skin. V18 leaves the room to get V8 (Nurse Practitioner) to view it and obtain a treatment order. At 11:34 AM, V8 views the right thigh, V8 states it looks like a burn but not sure and puts in an order for [REDACTED]. On 7/12/18 at 9:17 AM, V3 (Director of Nursing) stated that she personally checked R2's body after the fire and saw no injury to the skin. V3 presented a form labeled Resident Body Check Sheet dated 7/4/18 documenting no reddened or open areas noted and no visible deformities. V3 was asked why this information was not in the computer. V3 stated it was very hectic at that time of the skin assessment. As for R2's resident body check sheet dated 7/10/18 for 3 PM to 11 PM shift documenting a black scabs on the side of the right thigh, V3 stated that V10 (Registered Nurse) had forgotten about R2's wound reported by V14 (C.N.A.). On 7/12/18 at 10:47 AM, V8 (Nurse Practitioner) stated that he thinks the wound on the back of the thigh is from an abrasion or open wound but not totally sure. When V8 is asked why he says the wound is open when there is no opening in the skin, V8 says that wounds start out looking red and the first layer of skin is missing as to why it is considered an open wound. V8 states he can not say for sure what type of wound it is because it is unusual. When V8 is asked about the 6 inch black scar on the outer side of the right thigh, V8 responded that he did not notice the scar-looking area above the burn-like wound. R2's resident body check sheet dated 7/4/18, 7/6/18, 7/9/18 (7 to 3 and 3 to 11 shifts) document nothing found on skin. R2's resident check sheet dated 7/10/18 for the 3 to 11 shift documents scabs on his right leg by V14 (CNA). V14 and V10 (registered nurse) both signed the sheet. This is the only place the black scar-looking wound is documented. There was no follow up with this scar-like wound. R2's Medication Administration Record [REDACTED]. There is no documentation of any skin irregularities. Review of V8's progress note dated 7/11/18 at 14:46 documents an open area to the right ischium. There is no documentation on the measurement or description of the red, circular, quarter-size mark on the back of R2's right thigh nor is there documentation addressing the 6 inch by 1 inch black, jagged scar. There was no documentation that the physician was notified of the 2 wound areas on R2. R2 is a [AGE] year old bilateral above the knee [MEDICAL CONDITION] male who was admitted to the facility on [DATE] with no re-admitted s per the minimum data sets (MDS). R2 requires extensive assistance with his activities of daily living (ADL) and has a BIMS of 11 indicating R2 is oriented per the 6/1/18 MDS. Nurses' notes 7/4/18 and 7/11/18 document R2 as oriented times three (person, place and time). R2's [DIAGNOSES REDACTED]. The 6/1/18 MDS documents one venous/vascular wound. R2 does have a history of vascular wounds per the (MONTH) (YEAR) and (MONTH) (YEAR) wound assessment detail reports. On 7/20/18 at 10:30 AM, V3 (Director of Nursing) stated that there is no documentation on the 2 wounds for R2 before 7/11/18. The facility's policy labeled Skin : Non-Pressure Ulcer documents that when a resident is identified as having a stasis ulcer, skin tear, bruise or rash, the appropriate documentation is completed. The policy does not address what the appropriate documentation would include. The facility's policy labeledSkin Care Prevention documents Dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching [DIAGNOSES REDACTED]) and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. This was not done.

Based on observation, interview and record review, the facility failed to follow the facility(s) smoking policy and ensure that smoking materials were locked in the facility designated area, and unavailable to smokers assessed to be unsafe for 1 of 3 residents (R5) reviewed for safe smoking. These failures resulted in R5 starting a mattress fire resulting in (3) residents (R4, R6, R7,) being taken to the local hospital for smoke inhalation. The facility also failed to ensure that there were assistive devices available to include grab bars to prevent falls, call lights to request assistance when there was noted debris and spills on the floor in the resident care area for 2 of 2 residents (R3, R8) requiring assistive devices for ambulation, and the facility also failed to follow the facility transfer policy and utilize a gait belt while transferring 1of 3 residents (R2) reviewed for safe transfers. Theses failures resulted in R3 being involved in fall incident and being treated at the local hospital for fractures. The findings include: On 7/12/18 at 9:35 AM, V1 (administrator) stated that R5 was the resident that started the fire per staff witnessing her leaving the room and then finding a mattress on fire. V1 stated that 2 lighters were found on R5 but not sure who found them and how R5 got the lighters. V1 stated that R5 is no longer in the facility. V1 stated that since the fire, a whole house inspection was done and numerous residents were found with lighters which were confiscated. V1 stated that no resident is to carry their own lighter or cigarettes per facility's smoking policy. V1 stated that she attempted to interview R5 but she was saying I'm too tired to talk and then began mumbling her words about her sister, money and then got very loud and yelling. R5 did calm down and apologize for yelling and then asked to be left alone. V1 presented her typed up notes that document on 7/4/18 at approximately 11:15 PM there was a fire in R2's, R4's, R6's and R7's room. The smoke alarms went off and staff responded to R2's room where R2 was on fire and staff removed R2 and his other (R4, R6 and R7) roommates from the room. Code Red and 911 were called. R4, R6 and R7 were sent to the hospital to be checked out (for smoke inhalation) and all were sent back with no injuries. R2 refused to go to hospital but was assessed and no injuries noted. R5 was found with 2 cigarette lighters in her possession which were removed and R5 placed on 1:1 monitoring until transferred to hospital. The 4th floor North hall residents were relocated to other rooms throughout the facility so the 4th floor North Unit could be cleaned. This report lacks how R5 was able to obtain the 2 lighters. Per social service note dated 5/2/18 documents R5 being found smoking in her room by nursing staff. Social service staff searched R5's room and found 2 lighters and a pack of cigarettes which were confiscated. On 7/17/18 at 1:05 PM, V19 (Psychiatric Rehabilitation Services Counselor/PRSC) stated he did the 6/27/18 smoking assessment on R5 and did not know that R5 had violated the smoking policy on 5/2/18 by smoking in her room. V19 stated that he would of marked substantial or significant problem on the 6/27/18 smoking assessment. The 6/27/18 smoking assessment documents that R5 requires supervised/controlled smoking management. The facility's smoking policy (prior to 7/4/18) documents if a resident is unable to smoke unsupervised, their smoking materials are locked in an area designated by the facility. On 7/12/18 at 10:39 AM, R3 walked into the interview using a cane. R3 stated he had sustained a fall on 4/4/18 at 5 PM in the 1st floor toilet room near the vending machines due to the floor being wet with urine and feces which he says is always in that condition. R3 stated that at that time he was using a walker. R3 stated that there are no grab bars or no call light and there is never any toilet paper, paper towels or soap. R3 stated he laid there yelling until a dietary staff member came to him. R3 stated he was sent to the hospital and had surgery on his fractured left femur and fractured left wrist. It was confirmed through incident report (4/4/18) and minimum data sets (2/13/18, 4/23/18) that R3 had fallen in the toilet room and had 2 fractures requiring surgery. R3 is oriented times three per his brief interview mental score (BIMS) of 15 in the 4/23/18 minimum data set (MDS). On 7/12/18 at 11:20 AM and 2:12 PM on the 1st floor, in the 2 resident toilet rooms off of the main dining room, both rooms were without grab bars, call light cord, toilet paper, paper towels and soap. Both toilet rooms had stale, pungent urine odors that were persistent. The floors were wet and water was pooling (2 feet by 2 feet) on the floor inside and outside the toilet room doors. The sink water was continuously running. The walls were splattered with dried, black and brown, fecal-like substances. Live gnats were present in and out the toilet rooms. The door to these toilet rooms are revolving constantly with resident after resident using the toilet rooms. At 11:20 AM, there were no wet floor signs but at 2:12 PM, the wet floor signs were present. R8 came out of the toilet room walking with a cane and almost lost her balance on the wet floor and trying to get around the wet floor signs. The facility has failed to ensure the floors in the 1st floor toilet rooms are dry and safe for walking. On 7/11/18 at 11:20 AM, in R2's room, V17 (Certified Nurse Aide/CNA) and V18 (Wound Nurse) assisted R2 on to the bed from the wheelchair by each of them putting an arm under R2's armpits and picking R2 up into the air and placing him on the bed. R2 was unable to sit upright and needed assistance with sitting up. V17 and V18 failed to ensure both wheelchair brakes were locked and failed to use a gait belt when transferring R2. V17 was wearing a gait belt around her waist. V3 (Director of Nursing) was present and informed both V17 and V18 what they failed to do correctly with R2's transfer. R2 is a bilateral above the knee [MEDICAL CONDITION] and requires extensive assistance with transfers. R2's care plan for transferring documents that the wheelchair brakes will be locked and a gait belt will be used. The facility's policy labeled How to Transfer an Individual Using a Gait Belt documents to apply the belt while individual is in a comfortable sitting position, make sure belt is tightly applied so it does not ride up or down on individual and lock brakes on equipment that individual is transferred from or to.

Based on observation, interview and record review, the facility failed to ensure that staff were present to supervise residents on the smoking patio for two of three residents (R1, R2) reviewed for abuse. This failure resulted in R1 requiring admission to the hospital for treatment of [REDACTED]. The facility also failed to implement compensatory strategies for one of three residents (R4) reviewed for Activities of Daily Living (ADLs), in the sample of six. Findings include: 1. Review of the facility's final incident report 02-19-2018 notes: Per investigation, (V4) stated he heard some noise from the smoking patio and when he approached the patio he saw R1 and R2 engaged in a physical altercation. (R2) said he was on the smoking patio with (R1) when they got into a verbal altercation about a hat which led to a physical altercation between both of them. (R2) stated that he hit (R1) with a utensil while they were engaged in the altercation. Review of R1's hospital record (Emergency Department History and Physical Note) notes R1 presented to (local hospital) with a chief complaint of getting into an altercation with another nursing home resident. Physical Exam: Abrasion above right eye. Laceration superior (2.5 cm) and inferior (1.5 cm) to the left eyebrow. Bruise on the left eyelid. Linear (5 cm) and Curved (3 cm) laceration to the frontal scalp on the left side. Total of eight staples in place. Radiology- Facial Bones/Sinus CT Scan: Acute medial and inferior wall blowout fractures on the left and comminuted [MEDICAL CONDITION] bone. Final Disposition: Full Admission Final Diagnosis: [REDACTED]. V4 (Resident Services), 03-27-2018 at 10:51 AM, 03-27-2018 at 10:35 AM) said, on the day of the incident, he left the smoking patio to bring a resident back upstairs. There was no staff present, only residents. V4 said he never saw the altercation between R1 and R2, however did hear R1 and R2 exchanging words and noted blood on R1's face. V4 said he felt that had he been present, he could have prevented the altercation between R1 and R2. 2. Review of R4's Face Sheet notes [DIAGNOSES REDACTED]. Review of R4's MDS (Minimum Data Set-02-20-2018) documents R4 is moderately impaired and requires extensive assistance of one person physical assist for eating. V7 (CNA-Certified Nursing Assistant) was observed feeding R4 lunch on 03-27-2018 at 1:33 PM. After R4 was finished eating, V7 offered R4 fluids by holding an opened mouth cup up to R4's mouth, without pausing. R4 began coughing after the fluids were offered. V7 said to R4, You drink too fast. V7 then offered thickened milk to R4 from a plastic cup, using a straw, without pausing. R4 began coughing when V7 withdrew the milk. V20 (Speech-Language Pathologist, 04-04-2018 at 2:26 PM) said staff should be alternating bites/sips, liquids/solids while monitoring rate/amount of food because of R4's impulsivity. V20 also said staff should utilize an open mouth cup rather than a straw when offering fluids to R4. V7 did not alternate small bites/sips or liquids/solids. Review of R4's Speech Progress Report (11-15-2017-11-21-2017) notes: Swallow therapy: facilitation of small bites/sips (1/2-1/3 teaspoon), facilitation of alternating bites/sips and instruction in alternating liquids/solids to increase pharyngeal clearance. Patient and Caregiver Training: Instructed nursing caregivers in compensatory strategies and safe swallow techniques in order to enable (resident) to safely consume highest level of intake with least amount of supervision with 100% carryover demonstrated by primary caregivers. R4's care plans were reviewed. There was no care plan with appropriate interventions to address R4's dysphagia.

Based on interview and record review facility failed to assist a resident during ambulation, failed to follow their policy related to gait belt usage and implement fall prevention. This applies to one of three residents (R6) reviewed for falls that needed assistance with walking. This failure resulted in R6 falling and subsequently sustained a facial fracture. Findings Include: Facility's fall prevention policy denotes 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. R6's Physical therapy evaluation dated 6-25-17 denotes medical [DIAGNOSES REDACTED]. The nursing staff has noticed a decrease in mobility since returning from the hospital. Initial assessment R6 able to maintain balance with handhold and constant minimum assist. Precautions: balance precaution includes falls. Goal will safely ambulate over changes in surface, around obstacles and in/out elevators with modified independence and none. R6's minimum (MDS) data set [DATE] section G. Functional Status: how resident walks in corridor on unit need limited assistance and one person physical assist. R6's physical therapy note dated 7-7-17 denotes level able to maintain balance with minimal assistance. R6's physical therapy note dated 7-21-17 denotes discharge summary goal not met R6 demonstrates standing balance of poor plus dynamic (able to maintain balance with minimum assistance. Ambulates safely over surfaces around obstacles with minimal assist.) Z2 (Physical Therapy Director) on 9-22-17 at 11:55 am stated R6 required minimal assist walking. Z2 stated R6 balance and gait did not change from 6-25-17 thru her discharge (7-18-17) and required hand held assist with a gait belt to ambulate. R6's nurse note dated 7-18-17 denotes aide reported while walking down the hall heard R6 fall. Asked R6 what happened stated I was trying to get some water and fell and hit head. Head to toe assessment, noted to right side of head with bleeding. Area cleansed, doctor notified and ordered to send R6 to hospital. R6's hospital record dated 7-18-17 denotes nursing home patient (R6) seen for fall complains of pain right orbit mid face. R6's hospital computed tomography scan dated 7-18-17 denotes there is comminuted mildly displaced fracture of the posterior wall of the right maxillary sinus. There is comminuted minimally displaced fracture of the lateral wall of the right orbit and also blowout fracture of right orbital floor. No evidence of intracranial hemorrhage. Medical [DIAGNOSES REDACTED]. Z3 (Doctor) on 9-22-17 at 3:15pm stated the Facial fracture that R6 sustained came from her falling. Z3 stated does not know who was supposed to be watching R6 at the time of her fall. E1 (Certified Nurse Aide) stated on 9-22-17 at 12:10 pm R6 could make her needs known. E1 stated has been working around R6 for few weeks and would see R6 walking by herself on the unit. E1 stated once R6 was woke up in the morning R6 would walk on her own. E1 stated other staff did not tell/instruct her that R6 needed assistance to walk with gait belt or hand held. E1 stated before R6 fell she was sitting in the hall way and asked for some water and told R6 to wait and went to get her some water. E1 stated while walking to get some water past another resident's room when suddenly heard a loud thumping sound. E1 stated went to the sound and saw R6 on the floor in her room lying sideways. E1 stated got the nurse and they picked R6 off the floor and the nurse assessed her. E1 stated she was never instructed to tell R6 she needed to wait for staff for assistance to walk. E2 (Restorative Nurse) on 9-22-17 at 12:50 pm stated staff should know which residents that need assistance to walk and they are to use a gait belt/hand held to assist that resident to walk. E2 stated R6 was supposed to be walked with a gait belt/hand held. E2 stated did not have to put term/intervention gait belt in R6's care plan because staff members are to know to use the gait belt with all transferring residents that need them. E2 stated if R6 was refusing gait belt it would have been documented in her nursing notes. R6's fall care plan denotes high risk for falls related to medications that may cause drowsiness and ambulates with slow unsteady gait with right eye blindness. Interventions, observe for decrease or loss of functional status and observe for gait unsteadiness. Monitor labs and meal/hydration intake. R6's nurse notes, social service note, progress notes and nurse practitioner noted for June 2017 and July 2017 have no documentation that R6 is noncompliant with gait belt or hand held assist. Facility's gait belt policy denotes gait belts are used to prevent injury of staff or residents during transfers and ambulation. Gait belts should be used by all staff when ambulating or transferring a resident. Care plan use of gait belt.

Based on observation, record review and interview, the facility failed to ensure the protection of one resident (R1) in a sample of six residents reviewed for physical abuse. This resulted in R1 requiring twelve stitches to the right upper lip, and a bruised left shoulder. The facility failed to follow their abuse policy and procedures Findings include: R1 was observed on 08/13/13 at 2:50pm in the facility conference room with several stitches and a large amount of swelling to the right upper lip and mouth area. R1 on 08/13/13 at 2:50pm stated that on the night of 8/12/13, E7 CNA (Certified Nurse ' s Assistant) physically abused him in room. " I asked (E7) for a sandwich for my roommate, when I went to give it to him, he was not in the room. So, I ate the sandwich. (E7) came into the room and stated ' you played me; I ' m going to mess you up.' The first time he hit me, I moved my head, the second time he swung and hit my mouth and he swung again and hit my shoulder. Then I went to the bathroom. I was bleeding. I went back into the room. I noticed blood all over the floor. When I was in the emergency room , the nurse there called the police. I spoke to the police in the hospital. " The incident/accident report date 08/12/13 9:20pm indicate a moderately large amount of blood was observed on floor of patient room. "I (E5 -Nurse) was told, there was altercation over a sandwich." The nurse ' s notes date 08/12/13 at 9:30pm indicates staff member came to nurse stating he had altercation with resident in room. Nurse went to room. Noting moderate amount of blood on the floor. Resident in bathroom and would not come out of washroom, immediately sent staff member off the floor. E5 (Nurse) on 08/13/13 at 3:30pm stated that the incident occurred around approximately 9:20pm on the night of 8/12/13. "I did not observe the incident, but (E7) came to me and stated he had an altercation with a patient about a sandwich. I went into room and there was a moderate to large amount of blood on the floor. (R1) was in the bathroom, I asked (R1) if he was okay and (R1) just mumbled as if he had something in his mouth. (R1) removed the face towel and he had a large laceration to his right upper lip, and inside right lip. (E7) was immediately sent off the unit. I called the shift supervisor and reported the incident. I applied first aide to (R1) and contacted physician. (R1) was transported to the emergency room . (E5) stated he did not call the police because (E4,Evening Supervisor) informed him that the police would be called by the emergency room . " E4 stated per telephone interview on 8/14/13 at 8:45am that "I didn't call the police". Surveyor asked why the police were not called. E3 (Assistant Director of Nursing) on 08/14/13 at 11:15am stated, " The administrator and the director of nursing was called." E1 (Administrator) on 08/14/13 at 11:30am stated, " We're about to fax the incident right now, review of the document indicated it was the abuse incident that occurred the night of 8/12/13." The Abuse Prevention Program and Procedure indicate: Staff supervision will be conducted on a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training and, if necessary or repeated, the facility's progressive discipline policy. The Abuse Prevention Program and Procedure (V). Internal Reporting Requirements and Identification of Allegation: If a crime, particularly involving physical or sexual abuse, is suspected, it must be reported to the state agency and local law enforcement under the following timeframes: Serious bodily injury - Immediately but not later than 2 hours after forming suspicion. All others- not later than 24 hours after forming the suspicion.

Based on observation, interview and record review facility failed to implement pressure sore prevention measures; failed to assess and treat pressure ulcer; failed to implement measures to promote healing of pressure ulcers that were already present for 2 residents (R2, R9). Findings include: 1) On 2/29/12 at 10:45 AM during initial tour observed R9 lying in bed with a strong odor of urine present in the room. At that time E10 CNA Coordinator stated she didn't know why R9 was still in bed and didn't know if he had any wounds. E10 CNA Coordinator proceeded to pull back R9 sheet to assess skin and at that time observed R9 lying in urine soaked bed with dried darker area around outer edge of wet area. Total area of urine wetness and stain extended from R9 knees to axilla. At that time also observed soiled adhesive foam dressing on Left buttock, uncovered Right ischium deep Stage 3 wound and abdominal pad dressing on Right hip. On further observation noted R9 with multiple wounds on bilateral outer feet with large fluid filled blister on Left outer and inner heel; Right heel with partially fluid filled area and partial dry firm purple red wound. Two quilted heel protectors were present sitting on R9 bedside stand. R9 initially admitted to facility in 2002 with most recent readmission 2/3/12. physician's orders [REDACTED]. On 2/29/12 at 11:05AM E11 Certified Nursing Assistant (CNA) and E12 Certified Nursing Assistant (CNA) stated that there is usually a turn schedule posted on the wall above the bed and stated that R9 should be turned and repositioned every hour. On 2/29/12 at 2:00PM E20 Wound Nurse stated "I started documenting wound assessments in the beginning of February 2012. I did assessments on every floor. The CNA does skin checks and I double back to check again. I do the Braden's." On 2/29/12 at 2:20PM E13 Licensed Practical Nurse (LPN)/Treatment Nurse stated "Me and E20 (Wound Nurse) do treatments. I kind of took over after the weekend of February 4th or 5th. I didn't change R9 dressings today, I think E20 Wound Nurse did R9". E13 (LPN) further stated "E20 Wound Nurse told me R9 was done this morning. R9 has a Stage 3 wound on his left buttock. I did the treatment yesterday. I'm still learning. It depends on redness whether we document it or not or cover it or not". On 2/29/12 at 2:55PM E21 Certified Nurse Assistant (CNA) stated "normally turn schedule is above the bed - it's not there now". On 2/29/12 at 3:15 PM observed E13 (LPN) remove soiled foam dressing from R9 Left buttock. E13 (LPN) then stated this is a new open area - it's scabbed over - it's a healing pressure wound. I put foam dressing over it yesterday". E13 (LPN) further stated "left hip is red - not blanchable. Left outer heel is a fluid filled blister, that's a pressure wound". On 2/29/12 at 3:25PM observed E13 (LPN) remove abdominal pad covering from R9 Right hip which revealed large palm-sized reddened area with dime-sized flat fluid filled center. E13 (LPN) went on to state that Right buttock/ischium wound was "unstageable" due to "dark tissue in wound". Observation of Right heel wound assessment by E13 (LPN) indicating wound measured 4 X 6 cm of eschar with deep red peri-wound area. On 2/29/12 at 3:35 PM both E20 Wound Nurse and E2 Director of Nursing (DON) stated "We don't take measurements unless the skin is broken. We're monitoring all of them - but we don't measure them". E20 Wound Nurse further stated "These marks on R9 's feet and legs could be from a lifetime. I haven't done treatments on R9 today". Care Plan dated 2/3/12 indicated impaired skin integrity due to "Buttock", no other skin impairments or wounds were identified on care plan. No interventions or treatments were in place to address multiple wounds on feet, heels or hips. Comprehensive Care Plan for Nutrition with goal date of 3/15/12 did not address nutrition interventions for wounds or skin impairment. Most recent Nutritional Assessment by a Registered Dietician was dated 6/1/10. Most recent Nutritional Assessment and Progress Note by a Diet Technician was dated 12/08/11. No Nutrition Assessments were available after most recent readmission of 2/3/12. On 3/2/12 at 1:05PM Z5(RD) Registered Dietician stated "I don't recall whether I was notified when R9 was readmitted on [DATE]rd. I talked to the facility yesterday, I don't have my records with me. I couldn't say when I was notified about R9 status". POS dated 2/3/12 to 2/29/12 indicated to Apply Zinc Oxide to buttock and cover with dressing after cleansing with Saline. No other skin/wound treatment orders were present prior to 2/29/12. Discharge wound assessments from hospital dated 2/2/12 indicated excoriation with patches of breakdown Left buttock: non-pressure ulcer and bilateral heels dry, peeling and cracked: non-pressure ulcer. On 3/2/12 at 2:40PM E20 stated "R9 was transferred to the hospital last night due to shortness of breath. He's no longer in the facility". 2) Closed record review states R2 is a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set ((MDS) dated [DATE] shows lower extremities impairment, non-weight bearing, impaired mobility and indwelling urinary catheter. R2 is scored having no pressure sores. Nursing Admission Skin assessment dated [DATE] shows a total of 7 pressure sores to Sacrum, Buttocks, both heels and left foot: three Stage III, one Stage II, three unstageable. Braden Scale dated 5/6/11 and 5/13/11 shows R2 at 'moderate risk' for skin breakdown, however, R2 was scored as no impairment in sensory perception despite lower extremities paralysis. Pressure ulcer prevention measures include inspection of skin every shift, pressure reduction mattress, weekly wound assessment. Wound assessment and treatment were rendered on 5/6/11 and 5/13/12 with documentation showing no change in wounds status. Nursing notes dated 5/17/11 states R2's Sacral wounds (2) were noted with dark colored, brown and green drainage, with distinct foul odor. R2 was sent out to hospital and admitted . R2 returned to the facility on [DATE] on intravenous antibiotics administered via a peripherally inserted central catheter (PICC line). Nursing psychosocial assessment states R2 was in an anxious mood. There was no evidence to support a comprehensive skin assessment being done. Braden scale was scored at '23', signifying no risk for skin breakdown. The Braden scale was inaccurately done. R2 was scored as having no impairment in sensory perception, rarely moist, walks frequently, no limitations in mobility and no apparent problem with friction and shearing. Nursing 72 hour admission charting 3pm to 11pm shift on 5/27/11 shows R2 being out on pass. Nursing notes dated 5/27/11, 11pm to 7am states R2 out on pass; 5/28/11, 2:50pm, R2 out on pass. There is no documentation to support R2 ever returning from pass. Social service notes dated 5/26/11 shows documentation of R2's re-admission to the facility. There are no subsequent social service note, no discharge summary. Facility Pressure Risk Assessment Policy and Procedure For all Residents dated 2/29/12 indicates the facility is to do a systemic, ongoing wound assessment on all wounds in order to determine the response to nursing care and treatment modalities. Policy procedures also include presence of all wounds, ulcers and other skin abnormalities on admission and then weekly by a licensed nurse for all wounds, ulcers and impairments in skin integrity. Facility Pressure Ulcer Prevention Policy dated 2/29/12 indicates 'A nutritional evaluation should be completed on all residents in order to maintain skin integrity and prevent pressure ulcer development.