Every finding on record at Chalet Living & Rehab

Based on interview and record review, the facility failed to accommodate R3's needs and preferences related to self administration of blood glucose monitoring supplies. This deficient practice affected one (R3) of three residents reviewed for medical equipment.Findings Include:R3's Minimum Data Set assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. R3's comprehensive care plan, initiated on 2/20/22, states in part: I requested and was assessed as able to safely self medicate meds/insulin/mounjaro. Review of R3's physician orders dated 6/10/26 shows orders for Microlet Lancets, (Brand name) blood glucose monitoring kit, and (Brand Name) Test Strips, all ordered for unsupervised self administration three times daily. Review of progress notes from 6/10/26 through 8/19/26 revealed no documentation that the ordered equipment was provided to R3, nor any documentation indicating staff followed up with R3's health insurance regarding coverage for the ordered supplies.On 8/19/26 at 10:50 AM, Surveyor observed R3 to be alert and oriented to person, place, and time, sitting upright on her bed. R3 stated that she does not have a manual blood glucose monitor and currently uses a continuous glucose monitor (CGM). R3 stated that she takes insulin and prefers to have a manual glucometer available. R3 stated that she had provided all necessary information to V15 (Assistant Director of Nursing/ADON). R3 stated that in April she received an insurance notice indicating that the (Brand Name) meter kit, test strips, and Microlet lancets would be covered and could be sent to her. According to R3, V15 informed her that the facility's pharmacy would not cover the items and entered a different order in her records, which she stated was incorrect. R3 stated that she sent the insurance information to V15 in May and no follow up was done. R3 stated that on May 29th, V2 (Executive Director) informed her that her insurance was not covering the items. R3 reported this was not accurate, as her insurance will provide the items as long as the required scripts are submitted. R3 stated that she provided a copy of the insurance letter to V18 (R3's Nurse Practitioner), and together they entered the orders into (Name of Pharmacy), which is the application her insurance uses. R3 stated that her nurse entered the correct order into her chart on 6/10/26. R3 further explained that her insurance requires to send scripts from the facility in order to send the glucometer, lancets, and test strips she uses, but the facility never submitted the required scripts. R3 stated, I don't have it yet because they haven't sent the script to my insurance. R3 stated that she does not use the glucometer provided by the facility and stated, They don't have a proper system here. They did not even try to call my insurance and follow up.On 8/19/26 at 12:27 PM, a phone interview was conducted with V16 (R3's Health Insurance Agent). V16 stated that she could not discuss any details regarding R3's prescriptions due to HIPAA (Health Insurance Portability and Accountability Act of 1996) requirements. However, V16 confirmed that the (Brand Name) blood glucose monitoring device, test strips, and Microlet lancets were not listed among R3's active prescriptions or orders. V16 stated that the facility would need to submit pre authorization scripts from R3's physician in order to begin the ordering process for those items, and that the documents were never sent.On 8/19/26 at 12:46 PM, V15 (ADON) stated that R3 uses a continuous glucose monitoring (CGM) sensor and does not perform traditional finger stick blood glucose checks. According to V15, R3 requested specific test strips and a glucometer; however, the pharmacy did not deliver the items. V15 stated that he had already discussed the issue with R3 and informed her that the facility had its own brand available, but R3 declined to use it, preferring the brand for which the order had been entered. V15 explained that the pharmacy would not supply R3's preferred brand. V15 stated that the facility had not received any information regarding the need to send a prescription, and the script was never submitted to R3's insurance because R3 had not requested it. When asked what follow up the facility completed after learning that the pharmacy would not cover the requested items, V15 stated that he spoke with R3 and asked if she wanted the glucose monitoring supplies the facility typically provides, but R3 declined. V15 also stated he was not aware that R3's insurance required scripts from the facility.On 8/20/26 at 11:38 AM, V2 (Executive Director) stated that he first became aware of R3's concern regarding the blood glucose machine yesterday and had no prior knowledge of the issue. V2 explained that R3 often prefers items to be personalized, but he does not know whether her insurance denied the request. V2 stated that he does not recall speaking with R3 specifically about the blood glucose machine, although he has discussed some of her medications with her.The facility's Residents' Rights (undated) reads in part: You have the right to participate in your own care. Your facility must make reasonable arrangements to meet your needs and choices.

Based on observation, interview, and record review the facility failed to provide food at an appetizing temperature. These failures have the potential to affect all 195 residents receiving food prepared in the facility's kitchen. Findings include:On 05/26/26 at 11:28 AM, observed V32(Chef) take temperatures of the lunch food on the tray line using a digital thermometer with the results as follows: Pork Chop (161 degrees Fahrenheit), [NAME] Beans (172 degrees F), [NAME] (147 degrees F), Mechanical Soft Pork Chop (145 degrees F), Pureed Pork Chop (141 degrees F), Pureed [NAME] (145 degreed F), Pureed [NAME] Beans (131 degrees F).On 05/26/26 at 11:35 AM, during tray line service observed V32 pulling plates from a stack of ceramic and melamine plates on the side of the tray line. The plates were not heated and there was no heated pellet system in place. V32 stated we don't do that here. Surveyor observed each plate of food being covered with a dome lid.On 05/26/26 at 12:01 PM, surveyor tasted the pureed rice, pureed green beans, and pureed pork on the tray line. All the pureed food tasted lukewarm, not hot, it was not palatable.On 05/26/26 at 12:11 PM, V33 (Culinary Development Specialist) stated the tray line holding temperatures should be at least 135 degrees F but the aim is for the holding temperatures to be 150-155 degrees with the understanding that the temperature of the food will drop as soon as the food is put on the plate and transported from the kitchen to the nursing unit. V33 stated the temperature of the food when it is served to the residents should be at last 135 degrees F. V33 stated if the temperature of food on the tray line is below 150 degrees it should be reheated in the kitchen before being put on a plate and delivered to the residents. V33 stated the facility does not own a heated palate system. V33 stated food that is 145 degrees put on a cold plate, with no heating system means that once that food reaches the resident it may not be the 135 degrees F temperature that the kitchen aims for.On 05/26/26 at 12:25 PM, surveyor requested a test tray. At 12:40 PM, the test tray food was plated on the tray line. At 12:42 PM, test tray left the kitchen in a closed cart. At 12:43 PM, test tray arrived on the unit and staff began distributing the meal trays.On 05/26/26 at 12:55 PM, after the last tray from the cart was passed out V33 began to take the temperatures of the food on the test tray using the same digital thermometer V32 used in the kitchen. V33 took the temperatures and read the results out loud as follows: Pork Chop (115 degrees F), [NAME] Beans (97 degrees F), [NAME] (100 degrees F).On 05/26/26 at 12:57 PM - 12:58 PM, surveyor tasted all the food items on the test tray. All the food tasted cold, and bland. The food was not appealing or palatable.On 05/26/26 at 12:59 PM - 1:02 PM, V33 tasted the food and stated the rice tasted cold, the green beans were not hot or warm, and the pork was not hot, it tasted dry. V33 stated these are not acceptable temperatures because all the food tasted cold. V33 stated if that food was served to him, he would ask for it to be reheated.On 05/26/26 at 1:05 PM, R16 stated for lunch he was served a pork chop, green beans and rice. R16 stated the temperature of the food was cold, not hot and he wished it had been hotter. R16 stated he could ask for them to reheat the food but the staff is not going to be able to do that for everyone and they are busy so he just ate the cold food.R16's Diagnosis Includes But Not Limited To Essential (Primary) Hypertension, Opioid Dependence With Unspecified Opioid-Induced Disorder, Alcohol Use, Insomnia, Major Depressive Disorder, Non-Pressure Chronic Ulcer Of Other Part Of Right Lower Leg With Other Specified Severity, Acute Hepatitis C Without Hepatic Coma. R16's MDS (Minimum Data Set) dated 04/28/26 indicates intact cognition.On 05/26/26 at 1:14 PM, R17 stated the food is always cold. R17 stated she has learned to eat cold food because it is always served that way. R17 stated she buys delivery food because she is hungry, and the delivery food arrives hotter than the food from the kitchen. R17 stated the food always arrives cold, it is a problem here. R17 stated the pork chop, rice and green beans were cold. R17 stated if the food was hotter, she may have eaten more of it. R17 stated she has asked to get her food reheated but sometimes the staff are too busy and they do not do it. R17 stated her only issues are with the food, it's really terrible here. R17 stated maybe the food would taste better if it was served hot.R17 diagnosis includes but not limited to Presence Of Aortocoronary Bypass Graft, Paroxysmal Atrial Fibrillation, Neoplasm Of Unspecified Behavior Of Respiratory System, Essential (Primary) Hypertension, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Malignant Neoplasm Of Unspecified Part Of Unspecified Bronchus Or Lung, Chronic Systolic (Congestive) Heart Failure, Mild Dementia. R17's MDS dated [DATE] indicates mildly impaired cognition.On 05/26/26 at 12:33 PM, R18 stated the food here is always cold! R18 stated it is not even a little warm, it is cold every day, every meal! R18 stated the only time the food is warm is when the state is in the building. R18 stated this morning her breakfast was warm, so she knew that someone from the state was in the building even before she met anyone from the state. R18 stated she gets tired having to eat cold food and the food is not appealing when it is cold and that is why she started buying snacks for herself to eat in case she cannot eat what is served to her because it is too cold. She stated she has to ask the CNAs (Certified Nursing Assistants) if they can reheat her food but they are so busy all the time they do not have the time. R18 stated she is trying to save up money for a microwave so she can heat up her food. R18 stated she really just wishes the kitchen would improve things for the residents here because everyone should be receiving warm food, not cold.R18 diagnosis includes but not limited to Essential (Primary) Hypertension, Adult Failure To Thrive, Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Gastro-Esophageal Reflux Disease Without Esophagitis, Unilateral Primary Osteoarthritis, Right Knee, Bipolar Disorder, Current Episode Depressed, Moderate, Generalized Anxiety Disorder, Other Lack Of Coordination, Abnormal Posture. R18's MDS dated [DATE] indicates intact cognition.On 05/28/26 at 10:01 AM, V31 (Food Service Director) stated the temperature of the food should be between 145 -160 degrees F when it reaches the resident. V31 stated it is important for the food temperature to be maintained so the food will be enjoyed by the residents. V31 stated if the food is not served at the right temperature, it will affect how the food tastes and if they are not satisfied with the meal they may not eat it. V31 stated the residents need the nutrients and food to nourish them so it is important for them to be able to eat the food. V31 stated if the food temperatures are on the low end of the range or below 135 degrees F on the tray line the food should be reheated before being served/plated. V31 stated she wants the food as hot as possible before being sent up to the units because the temperature will start to drop as soon as it is plated. If the food is served below 135 degrees F in the kitchen there is no way the temperature could reach 145 degrees F when it reaches the resident.On 05/28/26 at 2:28 PM, V51 (Consulting Registered Dietitian) stated the holding temperature of the food being put on the tray line should be at least 165 degrees F and the temperature at point of service (when served to the resident) for hot food should not be below 135 degrees F. V51 stated the hot food should be hot for residents satisfaction and safety. V51 stated hot food that is served cold may not be palatable or appetizing to the resident and the residents will probably not want to eat food that is cold which could negatively impact the residents overall intake. After reviewing the holding temperatures from 05/26/26 lunch V51 stated the regular pork chops, regular rice, pureed pork, pureed rice and pureed green beans should have been heated to at least 165 degrees F. V51 stated if the holding food temperatures are below the desired range then the temperature of the food when it reaches the resident will be even lower and hot food that is served cold may not be palatable or appetizing for the resident.Facility provided document titled, Resident Info Report dated 05/26/26 listing 197 residents with their diet orders. The report indicates two of these residents receive nothing by mouth (NPO).Facility provided policy titled, Food Quality and Palatability dated 02/19/25 which documents in part, it is the center policy that food is prepared by methods that conserve nutritive value, flavor and appearance. Food is palatable, attractive and served at a safe and appetizing temperature.Facility provided copy of document titled, Food Temperature and Evaluation Log Lunch dated 05/26/26 which documents in part, Pork Chops (161 degrees F), [NAME] (147 degrees F), [NAME] Beans (172 degrees F), Pureed Pork (141 degrees F), Pureed [NAME] (145 degrees F), Pureed [NAME] Beans (131 degrees F).Facility provided document titled Chef Job Description (undated) which documents in part, a successful Chef will be able to prepare meals in accordance with planned menu that are palatable, appetizing in appearance.

Based on interview and record review, the facility failed to follow a resident's comprehensive care plan to ensure side rails were provided for positioning and turning in bed mobility movement and led to R2's fall incident on 4/7/26. This failure affected one (R2) of five residents reviewed for improper nursing care. The findings include:R2's admission record/face sheet shows admission date on 4/3/2026 with diagnoses not limited to Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Essential (primary) hypertension, Hypothyroidism, Obstructive sleep apnea, Atherosclerotic heart disease of native coronary artery, Hyperlipidemia, Gastro-esophageal reflux disease, Gout, Spinal stenosis, Lumbago with sciatica, Morbid (severe) obesity, Bilateral primary osteoarthritis of knee, Generalized anxiety disorder. MDS (Minimum Data Set) dated 4/9/26 shows R2's cognition is intact. On 5/26/26 at 10:29AM Observed R2 resting in bed on moderate high back rest, on bariatric bed with both side rails up, alert and oriented x 3, verbally responsive. He stated that on 4/7/26, early morning about to change shift, he turned to his side and rolled over from bed to the floor. R2 stated he did not have bed or side rails so there was nothing to grab or to hold on when he turned on his side.On 5/26/26 at 11:42AM V17 (Certified Nursing Assistant/CNA) stated that on 4/7/26, R2 tried to turn on his side and rolled over from the bed to the floor. She said there were no side or bed rails in place so there was nothing that R2 could grab or hold on to when he was turning on the side. She stated she informed V19 (Nurse) right away and asked R2 what happened. R2 stated I lost my way when turning on the side. V17 stated R2 was using Bariatric bed, there was no side rails in placed at the time of the fall. On 5/26/26 at 1:43PM V19 (Licensed Practical Nurse/LPN) stated she was the assigned nurse for R2 on 4/7/26 around 5AM, V17 (CNA) called her and saw R2 lying on the floor. She stated she assessed R2 and there was no injury. R2 stated he was turning/moving to his side and rolled over from bed to the floor. V19 stated there were no side/bed rails. She stated bed rails help residents to move from side to side so not to fall from bed. V19 stated if there were bed rails in place, R2's fall may be prevented. On 5/27/26 at 11:05AM V45 (Fall Nurse/LPN) stated R2 had a fall incident on 4/7/26. She stated R2 rolled over from bed to the floor. V45 stated she spoke with R2 and stated he does not have a side rail to hold on that's why he rolled over from the bed to the floor. V45 stated when she saw R2 upon admission there was no side or bed rails in place. She stated if the side or bed rails were provided as stated in R2's care plan this fall could have been prevented. V45 stated R2 was assessed as high risk for fall.On 5/28/26 at 9:35AM V2 (Director of Nursing) stated R2 had a Fall incident on 4/7/26, 11-7 shift, CNA was providing care to R2's roommate and heard R2's bed racking. He stated R2 rolled over from the bed to the floor and CNA called the nurse, assessment done by nurse and there was no injury. He stated he spoke with R2, and he stated he rolled over from bed to the floor because there were no bed/side rails to hold or grab on. V2 stated bed or side rails are used to help residents in turning or repositioning when in bed. V2 stated possibly R2's fall could have been prevented if bed/side rails were provided.R2's Fall risk evaluation dated 4/3/26 shows in part: high risk for fall.R2's POS (Physician Order Sheet) shows order not limited to: May use 2 partial side rails for transfer and bed Mobility. Order date 4/3/26.R2's Side rail evaluation dated 4/3/26 shows in part: Side rail half-length rails. R2 uses side rails as an enabler during bed mobility and repositioning.Care plan dated 4/6/26 shows in part: R2 is at risk for falls related to unsteady gaitCare plan dated 4/6/26 shows in part: R2 may need to use two partial rails to enhance functional independence, to become more self-sufficient in: Positioning and turning. In-bed mobility movement, getting up.Facility's fall occurrence policy dated 6/30/25 shows in part: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions.Facility's Side Rail policy dated 7/3/25 shows in part: If the alternative devices failed to assist the resident in repositioning, the resident will be assessed for the use of side rails, to determine risk for entrapment and other potential danger to the resident.

Based on interview and record review, the facility failed to ensure medications were checked for accuracy prior to administration to a resident. This failure affected one (R4) of six residents reviewed for medication administration. Findings Include:R4's clinical records show an admission date of 4/3/20 with included diagnoses but not limited to obstructive sleep apnea, morbid obesity, and vitamin d deficiency. R4's Minimum Data Set, dated [DATE] shows a BIMS (Brief Interview for Mental Status) of 15 which means R4 is cognitively intact. R4's comprehensive care plan reads in part: [R4] was assessed as able to safely self-medicate (date initiated: 2/20/2022). One intervention includes: Nurse will monitor and counsel resident as necessary regarding proper medication administration.On 5/27/26 at 11:21 AM, R4 stated that on second shift medication pass around 5:00 PM, V20 (Registered Nurse/RN) provided her medications on 5/8/26 to 5/10/26, including 50,000 units of Vitamin D, but she is prescribed to take 5,000 units. R4 stated the capsules appeared much larger than usual and reports not seeing the medication container at that time. R4 stated she did not take the medications and told V20 that he made a mistake providing the wrong dosage. R4 stated V20 took the medications back. R4 further stated she does not take Tramadol; however, on 5/9/26 V20 allegedly gave R4 Tramadol along with her routine medications. R4 stated seeing all medications in the medication cup and later identifying a medication left at bedside as Tramadol after searching online. R4 stated she did not take the Tramadol. R4 stated the concern was brought to V24 (Assistant Director of Nursing/ADON) attention on Monday (5/11/26), and V24 reportedly confirmed the medication was Tramadol.On 5/26/26 at 12:09 PM, V24 (ADON) stated R4 can self-administer her own medications. V24 stated R4 informed him that V20 (RN) entered her room and provided Tramadol and an incorrect dosage of Vitamin D. R4 reportedly showed V24 a picture on her phone. V24 stated V20 retrieved the medications and provided the correct medications afterward. V24 reports the incident occurred while he was not present in the facility. V24 stated he reported the incident to V2 (Director of Nursing/DON), and V2 counseled V20, who stated [V20] became distracted by another resident while doing medication pass. V24 confirmed R4 did not take the medications and V20 acknowledged the mistake providing her the wrong medications.On 5/26/26 at 12:27 PM, V2 (DON) stated he counseled V20 (RN) because he was expected to administer the correct medications to the residents. V2 stated that V20 reported to him that he became distracted while administering medications to another resident receiving Tramadol. V2 stated V20 mistakenly attempted to give the medications to R4 before the error was identified and corrected. V20 then returned and provided the correct medications. V2 stated R4 did not report concerns regarding Vitamin D. V2 stated nursing staff are expected to verify physician orders and ensure correct medications are administered to the correct resident. V2 stated nurses are required to follow the medication administration rights, including right medication, right patient, right dosage, right frequency, right time, and right procedure. V2 stated if the wrong medication is administered and ingested by the resident, nurses are expected to notify the physician and follow physician orders. V2 stated V20 is currently out of the country on vacation.Surveyor attempted to contact V20 and left messages on 5/26/26, 5/27/26, and 5/28/26 but did not return calls.V20's INSERVICE/TRAINING SIGN IN SHEET dated 5/11/26 presented by V2 shows V20 was educated on administering right medications to residents at all times.The facility's Medication Pass policy dated 7/2/25 reads in part: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.

Based on interview and record review, the facility failed to follow residents' physician order to ensure foley catheters are cleaned every shift in order to prevent infection for 2 (R13, R14) out of 3 residents reviewed for urinary catheter care in a sample of 15.Findings include:On 04/14/2026 at 1:05 PM, R13 was observed in his room. R13 stated he doesn't think any foley catheter care was done for him today.On 04/14/2026 at 1:07 PM, R14 was observed in his room. R14 stated that the staff did not do any foley catheter care on him today.On 04/14/2026 at 1:30 PM, V7 (Registered Nurse/RN) stated that nurses are the ones who do catheter care for urostomies and indwelling foley catheters. V7 stated that the urostomy care is done once a day and done by the night shift nurse. V7 stated that she is the nurse for R14. V7 stated that she didn't do R14's catheter care because night shift is the one who takes care of it. V7 stated that wound care nurses also take care of R14's foley catheter care.On 04/14/2026 at 1:45 PM, V14 (2nd floor RN supervisor) stated that he is R13's nurse for today. V14 stated that he doesn't do R13's catheter care because the night shift nurse does foley care. V14 stated that he didn't do R13's foley catheter care. V14 stated that all he is expected to do is record the output.On 04/14/2026 at 1:50 PM, V6 (Wound Nurse) stated that R14 does have a foley. V6 stated that she doesn't do the foley catheter care for residents during wound care. V6 stated that foley catheter care is to be completed by the nurse in charge of that resident. V6 stated that she didn't do R14's foley catheter care today. On 04/15/2026 at 11:20 AM, V6 (Wound Nurse) stated that foley catheter care is defined by cleaning around the insertion site, making sure the foley bag is clean, not on the floor and making sure there is no obstruction. V6 stated that Certified Nursing Assistants (CNA) only does measurement and output. Nurses in charge of the resident, do the cleaning and checks for irrigation. V6 stated that she did not clean R13 and R14's foley catheter care yesterday or today. On 04/15/2026 at 12:31 PM, V18 (Director of Nursing/DON) stated that foley catheter care consists of making sure the area of insertion of the indwelling catheter is clean with no discharge. That is why it is important to clean it regularly. If it is not cleaned regularly, the resident is prone to infection. V18 stated that R13 has an indwelling catheter. V18 stated that R13 is on antibiotics because he had an infection resulting in abscess on his penis near the insertion site. V18 stated that he is not sure how R13 had an infection on his penis. V18 stated that not performing foley catheter care can have the potential to increase the risk of infection. V18 stated that he is not sure if R14 and R13 had their foley catheter care done.Surveyor showed V6 (Wound Nurse) R13 and R14's treatment administration record. V6 stated that it is her initials documented for foley catheter care for 04/14/2026 and 04/16/2026. Surveyor then asked her, why she charted R13 and R14's treatment administration record under foley catheter care when she said she didn't perform foley catheter care.V6 responded, Oh I'm sorry, I was mistaken. I thought you meant changing the catheter.R13's physician order sheet documents in part: Catheter care every shiftR14's physician order sheet documents in part: Catheter care every shift.R13's treatment administration record for 04/2026 documents in part: On 04/14/2026 and 04/15/2026, it shows V6's initials as completed order.R14's treatment administration record for 04/2026 documents in part: On 04/14/2026 and 04/15/2026, it shows V6's initials as completed order.R13's progress note by nurse on duty on 3/23/2026 documents in part: R13 observed with purulent discharge from penis. Doctor assessed the patient at the bedside. New orders received for CBC, BMP, Urology consult, and initiation of antibiotics for 14 days. Writer carried out the order and notified R13's power of attorney.R13's progress note by V6 on 3/25/2026 documents in part: R13 was seen by wound nurse practitioner for wound assessment and evaluation. R13 has an ongoing surgical wound to left groin area, site is stable. R13 was also seen for an Abscess to penis area. Site has moderate purulent exudate, full thickness, A reopened stage 3 pressure injury to coccyx. Order given to apply Mupirocin ointment to penis abscess daily and Hydrocolloid to area 3 times a week. R13 on Doxycycline Hyclate tablet 100mg, twice a day for 14 days for abscess infection. All orders verified and carried out as ordered. Will continue to treat his wounds as needed.R13's progress note by nurse practitioner on 3/25/2026 documents in part: Location: PenisPrimary Etiology: Abscess. Stage/Severity: Partial Thickness. Wound Status: New. Odor Post Cleansing: Malodorous. Size: 1.7 cm x 0.4 cm x 0.1 cm. Calculated area is 0.68 sq cm. Wound Base: 100% epithelial , 0% slough. Exposed Tissues: Epithelium. Wound Edges: Attached. Peri-wound: Intact, Fragile. Exudate: Moderate amount of SeropurulentRequested foley catheter care procedure/policy. V18 (DON) stated that they do not have a policy regarding specifically catheter care.

Based on review of record and interview, the facility failed to accurately document on residents' treatment administration record tasks that were not done for 2 (R13, R14) out of 14 residents reviewed for resident records. Findings include: On 04/14/2026 at 1:05 PM, R13 was observed in his room. R13 stated he doesn't think any foley catheter care was done for him today.On 04/14/2026 at 1:07 PM, R14 was observed in his room. R14 stated that the staff did not do any foley catheter care on him today.On 04/14/2026 at 1:30 PM, V7 (Registered Nurse/RN) stated that nurses are the ones who do catheter care for urostomies and indwelling foley catheters. V7 stated that the urostomy care is one once a day and done by the night shift nurse. V7 stated that she is the nurse for R14. V7 stated that she didn't do R14's catheter care because night shift is the one who takes care of it. V7 stated that wound care nurses also take care of R14's foley catheter care.On 04/14/2026 at 1:45 PM, V14 (2nd floor RN supervisor) stated that he is R13's nurse for today. V14 stated that he doesn't do R13's catheter care because the night shift nurse does foley care. V14 stated that he didn't do R13's foley catheter care. V14 stated that all he is expected to do is record the output.On 04/14/2026 at 1:50 PM, V6 (Wound Nurse) stated that R14 does have a foley. V6 stated that she doesn't do the foley catheter care for residents during wound care. V6 stated that foley catheter care is to be completed by the nurse in charge of that resident. V6 stated that she didn't do R14's foley catheter care today.On 04/14/2026 at 2:17 PM, V18 (Director of Nursing/DON) stated his expectations of his nurses is to follow through on the doctors' orders for any medication and treatment orders and documented accordingly.On 04/15/2026 at 11:20 AM, V6 (Wound Nurse) stated that foley catheter care is defined by cleaning around the insertion site, making sure the Foley bag is clean, not on the floor and making sure there is no obstruction. V6 stated that Certified Nursing Assistants (CNA) only does measurement and output. Nurses in charge of the resident, do the cleaning and checks for irrigation. V6 stated that she did not do foley catheter care for R13 and R14 yesterday or today.Surveyor showed V6 (Wound Nurse) R13 and R14's treatment administration record for the month of April 2026. V6 stated that it is her initials documented for foley catheter care for 04/14/2026 and 04/16/2026. Surveyor then asked her, why she charted R13 and R14's treatment administration record under foley catheter care when she said she didn't perform foley catheter care. V6 responded, Oh I'm sorry, I was mistaken. I thought you meant changing the catheter.Reviewed R13 Minimum Data Sheet Section C. R13 has a Brief Interview of Mental Status (BIMS) of 11. R13 is moderately cognitively intact. Reviewed R14 Minimum Data Sheet Section C. R14 has a Brief Interview of Mental Status (BIMS) of 15. R14 is cognitively intact. R13's physician order sheet documents in part: Catheter care every shiftR14's physician order sheet documents in part: Catheter care every shift.R13's treatment administration record for 04/2026 documents in part: On 04/14/2026 and 04/15/2026, it shows V6's initials as completed order. R14's treatment administration record for 04/2026 documents in part: On 04/14/2026 and 04/15/2026, it shows V6's initials as completed order. CMS Medicaid Documentation for Medical Professionals policy (12/2015) documents in part:Medical professionals are in the business of helping their patients. Patients are their priority, whether the professional is a physician, pharmacist, nurse, therapist, or any of the many other types of medical professionals. Meeting ongoing patient needs such as furnishing and coordinating necessary medical services is impossible without documenting each patient encounter completely, accurately, and in a timely manner. Documentation is often the communication tool used by and between medical professionals. Records not properly documented with all relevant and important facts can prevent the next provider from furnishing sufficient services. The outcome can result in erratic or even dangerous treatment and cause unintended complications. While meeting patient needs is the most important reason for documenting services, it is not the only one. Another reason for documenting medical services includes complying with Federal and State laws.

Based on observation and interview, the facility failed to ensure resident's urostomy bag was off the floor for 1 (R7) out of 3 residents reviewed for infection control in a sample of 15.Findings include:On 04/14/2026 at 11:30 AM, surveyor observed R7 in R7's room. R7 was awake and alert. R7 stated that she thinks her bag is on the floor. R7 stated that she doesn't know how it got there. R7's bag was observed on the floor.Surveyor asked V7 (Registered Nurse) to come into R7's room. V7 observed R7's bag on the floor. V7 stated that R7's bag should not be on the floor because it can cause infections.On 04/14/2026 at 2:17 PM, V18 (Director of Nursing) stated that he is the infection preventionist as well. V18 stated that the foley bag should not be on the ground but instead hanging on the bed. V18 stated that the bag should be hanging to prevent infection. V18 stated that the bag on the ground can lead to infection.Reviewed R7 Minimum Data Sheet Section C. R7 has a Brief Interview of Mental Status (BIMS) of 12. R7 is cognitively intact.Center for Disease Control catheter policy documents in part: Keep the urine bag off the floor.Requested foley catheter care procedure/policy. V18 stated that they do not have a policy regarding specifically catheter care.

Based on observation, interview and record review, the facility failed to ensure that one resident (R1) was free of sexual abuse from a resident (R4) with a known history of requesting sexual favors from other residents, behavioral symptoms, and history of battery. This failure affected 1 of 3 residents reviewed for abuse and resulted in R1 feeling fearful, uncomfortable, and crying.Findings include:The immediate jeopardy began on 02/02/26 when the facility failed to ensure R1 was free from sexual abuse by R4. The Administrator (V1), Executive Director (V2) and Assistant Administrator (V3) were notified of the immediate jeopardy on 03/16/26 at 10:28am. The facility submitted an abatement plan on 03/17/26 at 12:18pm; a revised plan on 03/17/26 at 5:09pm; and on 3/18/26 at11:29am. None of these plans were approved. The facility submitted a revised abatement plan on 03/18/26 at 1:27pm. This plan was accepted on 03/18/26 at 5:00pm. The surveyor confirmed by onsite observation, record review, and interview that the immediacy was removed on 3/18/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's admission date to the facility is 02/02/2026.R1's medical diagnoses include but are not limited to bipolar disorder, essential hypertension, autistic disorder, drug induced subacute dyskinesia.R1's care plan dated 02/04/26 documents in part, Presence of abuse and neglect factors. The resident presents with a difficult or troubled past secondary to severe mental illness. She presents with risk factors r/t (related to) acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history and present mental health symptoms. The resident will remain safe, free of mistreatment through the next review. Establish guidelines regarding visiting if persons interested in visiting have a history of inappropriate and/or maladaptive behavior towards the resident. Provide supervision during visits as necessary.R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 9, indicating R1's cognition is moderately impaired.R4's medical diagnoses include but are not limited to chronic obstructive pulmonary disease, restlessness and agitation, schizoaffective disorder bipolar type, generalized anxiety disorder.R4's MDS dated [DATE] has a BIMS score of 15, indicating R4's cognition is intact. R4's care plan dated 01/22/26 documents in part, Sexually Oriented Behavior. I exhibit sexually inappropriate behavioral symptoms which may be r/t (related to) history of substance abuse/dependency, lack of self-respect, poor self-worth, feelings of inadequacy, feeling angry and out of control, attempting to manipulate others by making them feel uncomfortable, making crude, sexually oriented, profane or suggestive remarks. I will comply with staff redirection and behave in a safe and respectful manner through next review. Implement limit setting. Specify appropriate versus inappropriate behavior, acceptable partner and taking precautions. If I tries/try to touch inappropriately, place your hand over me and gently (but firmly) push it down and away. Intervene. On 03/09/26 at 12:41pm R3 (R1's roommate) stated that she observed R4 entering their bedroom. R3 stated that R4 walked to R1's side of the bedroom and R3 overheard R4 ask R1 for sexual favors. R3 stated that she asked R1 if she was okay but R3 stated that she did not hear R1 say anything. R3 stated that she then heard some wet noise and what sounded like some sexual sounds. R3 stated that she told R4 that he needed to leave and R4 stated to give him a minute. R3 stated that after some time had passed, R3 observed R4 adjusting his pants and leaving the room. R3 stated that R1 informed her that she did not say anything while R4 was at R1's bedside because R1 was afraid to speak. On 03/09/25 at 1:44pm R1 stated that on the day of her admission to the facility, R4 approached R1 asking if R1 was new to the facility. R1 stated that she informed R4 that she had just arrived at the facility. R1 stated that R4 asked R1 her room number and R1 informed R4 of the room that she had been assigned. R1 stated that later that night, she was lying in bed and R4 entered her room. R1 stated that initially R4 was just standing and talking, but then R4 sat on R1's bed and began to rub on R1's leg. R1 stated that she asked R1 to stop but R4 continued to rub her leg. R1 stated that R4 then asked R1 for sexual favors and R1 told R4 no. R1 stated that R4 then unzipped his pants, exposed himself, began rubbing his penis, while continuing to rub R1's leg. R1 stated that she thought that R4 would harm her if she screamed, so R1 just continued to lay in bed until R4 was done. R1 stated that after R4 finished pleasing himself, R4 relieved himself on R1's bed. R1 stated that she then got up and ran out of the room to the nurse's station and informed the nursing staff of what just took place. R1 stated that she is afraid that it will happen again. R1 stated that every time she entered her room she would cry. R1 stated that the facility moved her to another room. Surveyor observed R1 visibly shaken and crying during the interview with R1. R1's progress note dated 02/02/26 documents in part, Resident alert and oriented x(times)3 walked up to the nurses' station and informed the nursing staff that a male resident had entered her room and got inappropriate with her. Resident immediately assessed. R4's progress note dated 02/02/26 documents in part, It was reported to this charge nurse that resident had an inappropriate interaction with another resident. Resident was placed on 1:1 monitor and will be sent to the hospital for psych evaluation. Administration and MD (medical doctor) notified. On 03/09/26 at 2:25pm the facility's video monitoring was observed with V2 (Executive Director). Surveyor observed video surveillance of R4 entering R1's bedroom on 02/02/26 at 9:43pm. R1 observed leaving R1's bedroom and walking to the nurse's station at 10:13pm. R4 observed leaving out of R1's bedroom and walking towards the back hallway at 10:14pm. On 03/09/26 at 3:31pm V16 (Licensed Practical Nurse/LPN) stated that when she returned from lunch, she was informed that R4 had inappropriately touched R1. V16 stated at that time she went to assess R1 and found R1 sitting with R3 (R1's roommate) being consoled. V16 stated she observed R1 crying and in emotional distress. V16 stated that R1 informed her that R4 came into her room, exposed and pleasured himself while rubbing R1's leg. V16 stated that R1 informed her that R4 ejaculated on R1's sheets. V16 stated that she removed the sheets and placed them in a bag that was later taken away by the police. V16 stated that the police informed her not to touch anything next time. On 03/09/26 at 3:47pm V17 (Certified Nursing Assistant/CNA) stated that she was not present on the nursing unit when R4 entered R1's bedroom. V17 stated that she was informed by R1 that R4 entered her room and V17 asked R1 why she didn't call for help. V17 stated that when she returned to the unit, she sat in the corner by the elevator. V17 stated that she would not have seen R4 enter R1's room from where she was sitting even if she was on the unit because R4 entered R1's room from the back hallway. On 03/10/26 at 11:23am V11 (Social Service/SS) stated that another resident had accused R4 of being sexually inappropriate with her a few weeks before the incident that occurred between R1 and R4. V11 stated that after R4 had become sexually inappropriate with another resident, she informed the nursing staff to monitor R4 more closely and to make sure that R4 stays in his room at night. V11 stated that R4 would sleep all day and liked to be up all night. V11 stated that because of R4's sexually inappropriate behavior with another resident, R4 needed to be monitored closely. V11 stated that R4 should not have been in other residents' rooms. V11 stated that R4 being in another resident's room posed a risk of any kind of abuse including verbal and sexual. V11 stated that R4's behaviors made it unknown what he would do and if he would cause harm to anyone in any kind of way. V11 stated that she received a call on 02/02/26 during the night to come back to the facility immediately. V11 stated that when she arrived at the facility, she was informed by the nurse to go to speak to R1. V11 stated that when she entered R1's bedroom, R1 was in distress, rocking back and forth and crying. On 03/10/26 at 12:11pm R7 stated that she was friends with R4. R7 stated that R4 started to ask her (R7) for sexual favors. R7 stated that she told R4 no, but R4 continued to ask her (R7) for sexual favors. R7 stated that when R4 wouldn't stop, R7 went to administration and asked if someone could speak to R4 about leaving her alone because R4 is trying to pressure R7 into having sex. R4's progress note dated 01/22/26 documents in part, SS (Social Service) met with resident upon report that resident was engaging in inappropriate behaviors r/t (related to) attempting to obtain favors for personal gain. SS provided education regarding appropriate boundaries and expectations within the facility and discussed potential consequences should such behaviors continue. Resident was informed of facility policies and expectations for respectful and appropriate interactions with staff and peers. Resident verbalized understanding of the information provided. Staff will continue to monitor resident behavior and provide redirection and support as needed. Care plan implemented, refer to as needed. On 03/10/26 at 3:00pm V2 (Executive Director) stated that R7 had asked V2 for help by asking R4 to leave her alone. V2 stated that R7 stated that R4 keeps hitting on her and R7 didn't want R4 around her. V2 stated that he explained to R4 that no means no. V2 stated that R7 stated that R4 keeps offering R7 marijuana for favors. V2 stated that he never asked what kind of favors R4 was asking for. V2 stated that he didn't want to know what kind of favors R4 was asking for, he just handled the incident. V2 stated that he informed R4 that the police would be involved if R4 continued with his behavior. V2 stated that the night of the incident between R1 and R4, V2 was called to come back to the facility. V2 stated that he was informed by the nurse that R4 had entered R1's bedroom and touched R1 inappropriately. V2 stated that he was informed that R4 had ejaculated on R1's bed so he went to examine R1's bed sheets. V2 stated that he was informed by V16 (LPN) that she had removed R1's sheets and placed them in the laundry chute. V2 stated that he went to the laundry room to retrieve the sheets and examined the sheets with gloves on. V2 stated that the police scolded him for touching the sheets. V2 stated that R4 left the facility the night of the incident in handcuffs escorted out by the police. R4's document titled District Pretrial Release Conditions dated 02/02/26 documents in part, offense: Battery-Physical Contact. On 03/11/26 at 11:55am V11 (Social Service) stated that the facility uses the resident's BIMS (Brief Interview for Mental Status) score as part of the assessment when evaluating residents for sexual appropriateness. V11 stated that a sexual relationship is not consensual if the residents' BIMS are not on the same cognitive levels. V11 stated that R1 and R4 were definitely not on the same cognitive level.On 03/16/26 at 9:50am V24 (Psychiatrist) stated that the facility did not make him aware that R4 was making inappropriate sexual advances towards other residents. V24 stated that R4 was already sexually preoccupied. V24 stated that R4 would always make off brand comments about women. V24 stated that R4 would make comments about what he would like to do to women. R4's Criminal History Analysis Security Recommendation Report dated 11/07/25 documents in part, The information provided and reviewed supports the following risk assessment and security recommendation for the resident named below: Moderate Risk: The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. Facility's policy titled Abuse and Retaliation Policy revised 01/29/26 documents in part, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. Types of Abuse and Examples: 5. Sexual: Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Even if there is capacity to give consent, consent obtained through intimidation, coercion or fear is considered sexual abuse. Must be reported examples in the SOM includes:. Forced observation of masturbation, or pornography. Forced, coerced or extorted sexual activity. Sexual abuse also includes non-consensual sexual relationship between residents or a consensual relationship involving a resident/s who wants the sexual relationship but has no cognitive ability to make a consent. 7 steps In Abuse Prevention: This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting/Response. Prevention: Have procedures to: Identify, correct and intervene in situations in which abuse, neglect, exploitation, retaliation and/or misappropriation of resident properly is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Facility's Residents' Rights pamphlet dated 07/2024 documents in part, As a long-term care facility resident in Illinois, you are guaranteed certain privileges according to rights, protections and State and Federal law. You have the right to. Safety and good care. You must not be abused by anyone - physically, verbally, mentally, financially or sexually. The Immediate Jeopardy began on 2/2/26, and was removed on 03/18/2026, when the facility took the following actions to remove the immediacy:1.) Resident R4 was discharged on 2/3/2026 and is no longer a resident in the facility. 2.) Resident R1 remains a resident in the facility and has been assessed for abuse risk identifying resident as high risk for abuse on 2/3/2026 and abuse care plan was initiated. Resident R1 was reassessed for abuse risk on 3/16/2026 and care plan has been reviewed. 3.) All current residents were reassessed for abuse risk using Screen for Abuse & Neglect UDA on 3/16/2026 and each resident's abuse care plan has been reviewed. The Abuse UDA is completed on all new admissions within 72 hours of admission as well as Quarterly and Annually and as needed. The Abuse UDA is completed by the Social Services Department.4.) There are 18 residents identified on 3/16/2026 with a history of sexually inappropriate behaviors. A list was created, and this list is being provided to 2nd,3rd & 4th floors in a binder at the nursing station for identification and reference. This list will be updated as needed such as when there is a change in status, discharge/change in condition, as well as when a new sexually inappropriate behavior is identified or when a sexually inappropriate behavior is identified during the admissions process. This list will also be reviewed at least weekly on Mondays. The Social Services Department is responsible for updating this list. Avenues in which the facility utilizes to determine a resident's history of sexually inappropriate behaviors include Background Check Process (prior to admission), CHIRP (post-admission), and Social Services Assessment. 5.) Nursing Staff (Nurses and CNAs) including Social Services were In-serviced regarding the list of residents with sexually inappropriate behaviors to aid in identification of residents exhibiting sexually inappropriate behaviors so that it is reported immediately to the nurse supervisor and/or social service supervisor on call. Residents identified as exhibiting sexually inappropriate behaviors will be monitored every 2 hours by Nursing, Social Services and other designee and will document verification on the monitoring tracker which is in the Residents Exhibiting Sexual Abuse Binder (SIB Binder) located at each nursing station. All newly hired nurses, CNAs, and Social Service workers will be in-serviced on the processes pertaining to the List of Residents Identified with Sexually Inappropriate behaviors prior to his/her start date by HR Director. All contracted workers will be in-serviced on Abuse, including Reporting, by Administrator/Designee. The Chalet team changed back the monitoring time from 1 hour to every 2 hours in that it's a new protocol where before there was not a specific designated SIB Binder and Tracking Tool for the specific behavior of Sexually Inappropriate Behavior and felt that 2 hours was a much more reasonable time element where the process could be ultimately sustained in order to ensure continuous compliance. 6.) A protocol was created to provide various avenues in which the facility can use to determine a resident's consent. All current residents were reassessed for cognitive ability to consent using the Brief Interview for Mental Status UDA on 3/16/2026. Social Services Department is responsible.7.) An audit was completed to identify the residents who are currently taking part in an intimate relationship. There are 6 residents who have been identified and who have consented to having an intimate relationship within the facility. These 6 residents have been assessed by Social Services team as being able to consent based on their BIMS Score. The residents' care plan for intimate relationships has been reviewed and updated on 3/16/2026. These Care plans are completed by the Social Services Department. These residents will be monitored by Social Services staff weekly to ensure that he/she still consents to taking part in his/her respective intimate relationship. This list will be updated weekly and as necessary. 8.) Facility employees were in-serviced on Abuse policy with emphasis on Sexual Abuse and this in-service was completed on 2/3/26 and on 2/4/26. Another all-in-house In-service was also conducted on Abuse Policy with emphasis on identifying and reporting inappropriate sexual behaviors on 3/16/2026. 9.) A QA Audit Tool was developed to monitor residents identified with sexually inappropriate behaviors to ensure that identification and reporting is done immediately. This audit will be completed 3x/week x12 weeks by the Social Services Department/Designee. This Audit was initiated on 3/16/2026.10.) A QA Audit tool was developed to monitor residents who have been identified and who have consented to having intimate relationships to ensure these residents continue to consent and are care planned. This audit will be completed 3x/week x 12 weeks by the Social Services Department/Designee. This Audit was initiated on 3/16/2026.11.) Results and trends from this QA Audit will be discussed by the Assistant Administrator in the monthly QAPI Meeting until resolution. A QAPI meeting is being held today 3/16/2026 to discuss the Abatement plan. 12.) The Medical Director was made aware of this abatement plan and is in agreement on 3/16/2026.

Based on interview and record reviews, the facility failed to follow their policy and provide an adequate number of staff to meet resident needs based on their facility assessment. This has the potential to affect all 194 residents residing in the facility. Findings include: On 01/07/2026 at 1:54PM, V15 (Scheduling Coordinator) states she has been the scheduling coordinator for two years and she makes the schedule for the CNAs only. V15 states V4 (Director of Nursing/DON) makes the schedule for the nurses. V15 states for the day and evening shift, the facility should have 5 CNAs for the 4th floor, 5 CNAs for the 3rd floor, and 4 CNAs for the 2nd floor. V15 states for the night shift, the facility should have 3 CNAs for all floors of the facility. V15 states the facility does not use agency staffing to supplement staffing in the facility. V15 states she has not received any concerns related to lack of nursing staff. V15 states she staff according to a budget provided to her by the facility. V15 states she was told that she could staff 15 CNAs for the morning and evenings and 9 CNAs for the night shift. V15 state she is unaware of the staffing budget and is unaware of the minimum staffing requirements for the facility. On 01/07/2026 at 2:08PM V4 (DON) states he is responsible for staffing for the nurses in the facility. V4 states the facility does not use agency staffing to supplement facility staffing. V4 states he always ensures to staff 2 nurses on each floor for each shift. V4 states he staffs for a total of 18 per day in the facility. V4 states he always staff 18 nurses a day and never fall below the minimum of 18 nurses per day to work in the facility. V4 states the total number of CNAs that the facility staffs on a daily basis are 37 per day. V4 states he is not aware of low nursing staffing on the weekends. V4 states he is not responsible for submitting the facility's payroll-based journal/PBJ information for employee staffing. Facility nursing staff time punch reports reviewed for nurses and CNAs from 07/01/2025 to 09/30/2025 for weekend shifts. The nursing staff time reports documents that out of the 26 weekend days reviewed, there were 26 days that did not meet the minimum requirements of 18 nurses and 37 CNAs per V15 (Scheduling Coordinator) and facility assessment. CMS (Centers for Medicare & Medicaid Services) PBJ (Payroll Based Journal) Report for facility's Fiscal Quarter 4 2025 (July 1 - September 30) documents in part that the facility triggered for excessively low weekend staffing.Facility assessment dated [DATE] documents in part a staffing of two nurses per shift per each floor, five CNAs (Certified Nurse Aides) for morning shift, five CNAs during evening shift, and three CNAs during night shift for each floor of the facility. The facility has a total of three floors and three shifts per day, so this equals approximately 39 CNAs per day. The facility assessment also documented that they staff for 13 CNAs per day, which was contradictory to what the other portion of the facility assessment stated regarding approximately 39 CNAs to be staffed daily. The facility assessment regarding the 13 CNAs per day also contradicts what the staffing scheduler and DON said the total CNA staffing should be (Approximately 37 CNAs daily).Facility policy dated 07/03/2025 titled Staffing documents in part, It is the facility's policy to provide adequate staff to meet the needs of the residents which is the requirement under the federal regulations. The facility will provide 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care.

Based on observation, interview, and record review, the facility failed to follow their Storage of Medications policy and store medications in locked compartments for 1 of 6 medication carts. This has the potential to affect all 36 residents receiving medication from team one medication cart. Findings IncludeOn 1/6/26 at 9:26 AM observed V14 (Licensed Practical Nurse/LPN) prepared R34's medications and walked away from medication cart unlocked and out of sight. On 1/6/26 at 9:35 AM, observed V14 prepared R131's medications and walked away from medication cart unlocked and out of sight. On 1/6/26 at 9:45 AM observed V14 prepared R122's medications and walked away from medication cart unlocked and out of sight. On 1/6/26 at 9:50AM observed V14 prepared R144's medications and walked away from medication cart unlocked and out of sight. On 1/6/26 at 10:10 AM observed V14 prepared R107's medications and walked away from medication cart unlocked, left medication on top of the cart and out of sight. On 1/6/26 at 10:22 AM V14 (LPN) stated, I forgot to lock the medication cart, I was not focused. Whenever, I walk away from the medication cart there should not be any medication on top of the cart, another resident or unlicensed person could have taken the medication or went into the medication cart. On 1/6/26 at 11:15 AM, V5 (Assistant Director of Nursing) stated, The medication cart should aways stay locked when the nurse is not utilizing the cart. If the cart is not locked and the licensed nurse is not present another resident or any unlicensed personnel could take medication that could potentially harm them. Policy documented in part: Controlled Substance Prescriptions: dated 8/2020.Security and Record KeepingControlled substance, medications are stored at the facility under double lock or as required by state regulations, separate from all other medications and counted at each change of custody. The medication nurse on duty maintains possession of a key for controlled medications. Medication Pass dated 7/2/25.After medication is administered to each resident, sign the medication administration records that it was given. Storage of Medications Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to follow portion sizes listed on spreadsheets. These failures have the potential to affect the five residents receiving pureed diets and 163 residents receiving regular consistency diets of food prepared in the facility's kitchen. Findings Include:On 01/07/26 at 10:25 AM, during pureed food preparation V27 (Cook) stated she will be preparing pureed chicken, pureed vegetables, and pureed rice today for lunch. V27 stated she will be making eight portions of pureed food. Observed metal container with individual pieces of cooked chicken breast inside. V27 used tongs to put eight pieces of the chicken breast into the commercial blender and then added two cups of measured chicken broth and turned on the blender to reach desired pureed consistency. Surveyor noted many leftover pieces of cooked chicken inside the metal container.On 01/07/26 at 10:29 AM, observed V27 transfer the pureed chicken to a metal container, cover with foil and put into the oven to reheat before the lunch tray line started.On 01/07/26 at 10:34 AM, surveyor asked V27 to weigh out one of the pieces of cooked chicken breast used to make the pureed chicken. V27 retrieved a digital scale and placed a piece of plastic wrap over the digital scale and then tarred the scale before she added one piece of the cooked chicken breast. Surveyor observed the digital scale to read 2.5-ounces. V27 said, I need to make more pureed chicken because the portion should be 3 ounces. V27 indicated that she had not weighed out the cooked chicken breast prior to the surveyor's request.On 01/07/26 at 10:38 AM, observed V27 add six pieces of cooked chicken breast to the commercial blender, add one cup of chicken broth and turned on the machine to puree chicken to appropriate consistency.On 01/07/26 at 10:45 AM, V26 (Food Service Director) stated since V27 made the extra pureed chicken the residents will get the correct portion of 3-ounces of pureed chicken. V26 noted that if the surveyor had not requested for the chicken to be weighed the residents on pureed diet would have received 2.5 ounces of pureed chicken instead of 3 ounces of chicken.On 01/07/26 at 11:20 AM, the lunch tray line started. Observed V27 reading the meal tickets and plating food. For residents on regular diet consistency V27 was giving them one piece of chicken. Surveyor noted that the pieces of chicken being put on the resident's plate appeared small.On 01/07/26 at 11:29 AM, as the tray line was running observed V27 select one chicken thigh using tongs and placed it on a plate with rice and vegetables for a resident. Right before the plate was going to put into the food cart the surveyor asked V27 to remove the chicken thigh from the plate and weigh that piece of chicken. V27 placed the chicken thigh on a separate plate and gave it to the surveyor. The surveyor then asked for someone to weight the chicken thigh.On 01/07/26 at 11:32 AM, V26 placed a piece of plastic wrap on the digital scale, tarred the scale and then added the chicken thigh given to the surveyor by V27. V26 stated the reading on the scale was 2.4 ounces (including the bones and skin). Surveyor asked V26 to remove the bones and skin from the piece of chicken and reweigh the edible pieces of the chicken. V26 did as instructed, retarred the digital scale and placed the edible pieces of chicken back on the scale (no bones, no skin). Surveyor observed the scale to read 1.4 ounces. V26 stated the reading on the scale was 1.4 ounces.On 01/07/26 at 11:38 AM, V26 checked the Diet Guide Sheet and stated the portion of chicken served should be 3 ounces. V26 stated they will need to give the residents extra portions of chicken for the residents to get the 3 ounces of chicken required.On 01/07/25 at 4:00 PM, V25 (Registered Dietitian) stated the Diet Guide Sheets should be followed by the kitchen. V25 stated this is important so that the residents receive the correct items in the correct consistency based on their diet order and that the portions are followed so that they can receive the correct amount of nutrition including calories, protein, vitamins/minerals. V25 stated for the lunch served today on 01/07/26 the regular diet orders should receive 3 ounces of chicken, and the pureed diets should receive #8 scoop (4 ounces) of pureed chicken because that is what is listed on the Diet Guide Sheets. V25 stated the pureed portion is more than the regular portion (4 ounces versus 3 ounces) because of the added liquid needing to puree the item to the correct consistency. V25 stated she was made aware of the issue at lunch with the chicken used to prepare the pureed chicken being 2.5 ounces instead of 3 ounces and the chicken for the regular diets being less than the 3-ounces. V25 acknowledged that if the surveyor had not asked for the chicken to be weighed the residents may not have received the correct portion and therefore not gotten enough nutritional value out of what they received for that meal. V25 stated the 3 ounces chicken should be edible protein (excluding bones and skins). V25 stated if the edible part of the chicken served to regular diets was 1.4 ounces on the scale than that was wrong because it should have been 3 ounces. V25 stated some of the residents complain about the portions being small, it depends on the resident and their situation. V25 stated milk is provided upon request, otherwise it is not automatically added to trays at meals.Facility provided Diet Tally Report dated 01/07/26 which documents five residents on pureed textured diet and 163 residents on a regular textured diet. Facility provided document titled Diet Guide Sheet for Wednesday (Day 18) which documents in part for lunch pureed diets to receive pureed oven fried chicken #8 scoop and regular diets to receive 3 ounces oven fried chicken.Facility provided kitchen policy titled, Menus dated 02/19/25 which documents in part, it is the center policy that menus are planned in advance, and to meet the nutritional needs of the residents/patients, will be developed utilizing an established national guideline and menus are served as written, unless changed in response to preference, unavailability of an item or a special meal.Facility provided document titled [NAME] Job Profile undated which documents in part, job responsibilities include but not limited to prepare and cook flavorful, yet visually appealing meals following standardized recipes, nutritional guidelines, and resident dietary needs.

Based on interview and record review the facility failed to ensure an allegation of abuse was reported to the state surveying agency, within two hours of notification of the abuse allegation for 1 (R44) resident reviewed for abuse in a sample of 35.Findings Include:R44 has diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Abnormalities of Gait and Mobility, Anxiety Disorders, Depressive Episodes, Other Psychoactive Substance Abuse, Essential (Primary) Hypertension and Other Recurrent Depressive Disorders. R44's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate impairment. R44's Care Plan document in part: Focus: History of Suspected Abuse/Neglect The resident's comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase his/her susceptibility to abuse/neglect. A history and/or personality that draws him/her into unhealthy, even abusive, relationships., Behavior that might be characterized as provoking, antagonizing, disrespectful, angry, insensitive, and/or annoying, Behavioral symptoms, Difficulty in adjustment and generalized mood distress.R44's letter addressed to V1 (Administrator) or V2 (Executive Director) dated Sunday (01/04/26) 05:10 PM document in part: the certified nurse assistant who delivers food to my side was hostile to my roommate regarding her asking to be changed. I asked the certified nurse assistant not to yell at R37 like that and how she would feel in R37's shoes. V17 (Certified Nurse Assistant) told me to shut up and mind my own business. I told her to get out of my way I was going to the front desk. V17 blocked me and my cart, refusing to move and continued ranting. I said get out of our room, to which she said if I tried to get by her, she'd throw me out the window. I got by V17 when she moved to the door and told the nurse. V17 pushed pass me bumping me. I got in the elevator and came to send you this letter. I told her she'll get fired for threatening a patient! Please take action this shouldn't happen. I'm a nervous wreck! I'm literally shaking.On 01/06/26 at 12:29 PM R44 stated Two days ago (01/04/25), a certified nurse assistant (V17 Certified Nurse Assistant) that work 3 pm came into my room at around 5 pm to give the dinner tray. The certified nurse assistant was African American. She was supposed to come change R37 but said that she will come back in a couple hours. I told her (V17) would she like to lay in her urine. She (V17) said get out my face, f**k you. She (V17) would not let me pass to leave the room and threatened to throw me out the window. She (V17) scared the hell out of me, and I was shaking like a leaf. I tried to get her name, but no one would tell me her name. Abuse does not need to be on the job at least show compassion because I have heart problems. I went to the nurse station and told the nurse. There was two other people at the nurse station. I then got on the elevator, went down stair to report it. I was explaining to the receptionist what happened, and she was so understanding. The receptionist gave me a pen/paper, I wrote a letter, and the receptionist put it in the administrator mailbox. I told V2 (Executive Director) and V6 (Social Worker).On 01/06/26 at 01:44 PM V6 (Social Worker) stated R44 complained to me that a staff member was very abusive, and I reported it to V2 (Executive Director).On 01/06/26 at 02:21 PM V2 (Executive Director) stated I was upstairs doing other things and a whole lot of stuff was going on yesterday when R44 interrupted me. I took time to speak to R44 and she had a generalized story that a certified nurse assistant (V17) came in to take care of her roommate when her (R44) and the certified nurse assistant (V17) got into a confrontation. R44 said the certified nurse assistant (V17) was in the room, dropped off food and R37 had to be changed. R44 described the certified nurse assistant as wearing a wig and is heavyset. I checked the schedule, and the certified nurse assistant was here this morning. The certified nurse assistant (V17) said I have to finish passing out food and R44 started yelling at her. I did the reportable as soon as V6 (Social Worker) told me about it today. R44 is care planned because she gets involved in other resident care. R44 said the certified nurse assistant threatened her. I got the letter that R44 wrote this morning, it was in my mailbox. I would consider that as abuse and I probably should have reported it yesterday. I thought R44 was having psychosis based off her care plan.On 01/06/26 at 03:23 PM V2 (Executive Director) stated I don't take abuse lightly and should have reported the abuse allegation yesterday (01/05/26).01/07/26 at 10:23 AM V6 (Social Worker) stated R44 came to my office to talk to me yesterday (01/06/26) morning. R44 said one certified nurse assistant had talked to her in an incorrect way. I immediately let V2 (Executive Director) know, and he handled it from there. R44 did not tell me the exact date that it happened. R44 said she was not comfortable the way the certified nurse assistant talked to her.On 01/07/26 at 11:29 AM per telephone interview V7 (Receptionist) stated On 01/04/26 I worked a double. R44 came downstairs in the evening. R44 complained and asked when the administrator is going to be here. I told R44 I can I get them a note and R44 asked for pen and paper to leave the note. R44 complained something about the nursing staff. R44 said someone threatened to push her out the window then she went and sat down to write the letter. I put the letter in the administrator mailbox. Surveyor asked V7 would that have been considered an allegation of abuse. V7 responded that is like a threat. The way R44 expressed it, if it true and if she felt threatened, I guess that is abuse. If there is an allegation or I witness abuse I would contact the administrator. I did not follow protocol. I probably dropped the ball because I felt it was more of a complaint.On 01/07/26 at 02:20 PM Per telephone interview V17 (Certified Nurse Assistant) stated I worked on the second floor 01/04/26 on the 3-11 PM shift. I did patient care and passed meal trays. I was passing trays going toward R44's room and saw the call light on. I dropped off the meal tray and said R44 that's your meal tray. It was 05:30 PM and I asked R37 if she wanted me to change her (R37) but she wanted to eat and said come back at six. R44 said that is a breach of the contract, you don't have to time R37. I asked R44 can you mind your business. R44 got her walker and was hitting on me on my leg. I asked R44 what have I done to her. R44 said I am going to fire you. I never experienced this character from R44, and I never said I was going to throw her out the window. I was surprised at how R44 was pushing me with her walker. R44 was passing the nurse station and went downstairs. R44 reported me that I said that I was going to throw her out the window. I did not do anything or say anything to R44. When R44 was passing the nurse station she told me to look for another job.On 01/09/26 08:01 AM per telephone interview V20 (Certified Nurse Assistant) stated On Sunday 01/04/26 R44 said to V17 (Certified Nurse Assistant) that she was going to report and fire V17 when she came to the elevator. V17 said that she did not do anything to R44.Reportable dated 01/06/26 12:10 PM document in part: Subject R44 and staff. Abuse Report Initial Form: Allegation Type: Verbal/Mental. Information about when the facility became aware of the incident: 01/06/26 10:30 AM. Name of staff who 1st became aware of the incident: V1 (Administrator). Alleged Victim: R44. Alleged perpetrator: Unknown. Allegation Details: On 01/06/26 R44 spoke to Administrator. A few nights ago, a C.N.A. (Certified Nurse Assistant) on the 2nd shift was being rude to me and telling me not to get involved I other patients care.In-service Attendance Training dated 01/06/26 document in part: Topic: Timely reporting of Abuse, Identifying Abuse, Abuse Policy, (7) Key Components of Abuse, Abuse Types, Review of Abuse Scenarios, Review of Specific Reportable Prioritizing and Investigating.In-service Attendance Training dated 01/06/26 document in part: Topic: Abuse and Neglect Policy and Procedure, Timely reporting, Identifying Abuse and (7) Key Components of Abuse and Neglect Prevention.In-service Attendance Training dated 01/07/26 document in part: Topic: Abuse and Neglect and Policy and Procedure, Timely reporting, Identifying Abuse, (7) Key Components of Abuse, Neglect and Prevention.Policy:Titled Abuse and Neglect revised 06/26/25 document in part: it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention abuse and timely and thorough investigations of allegations. If abuse/neglect is suspected the facility will: 1: Take immediate steps to assure the protection of the resident(s). 2. Notify the appropriate/designated organization/authority (IDPH) that an investigation is being initiated immediately following interventions for the resident's safety. VI. Protection: Have procedures to: Employee(s) accused must be suspended pending investigation. V11. Reporting/Response. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee. All allegations of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.

Based on interview and record review the facility failed to initiate an investigate immediately of an allegation of Abuse for 1 (R44) resident reviewed for abuse in a sample of 35. Findings Include:R44 has diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Abnormalities of Gait and Mobility, Anxiety Disorders, Depressive Episodes, Other Psychoactive Substance Abuse, Essential (Primary) Hypertension and Other Recurrent Depressive Disorders. R44's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate impairment. R44's Care Plan document in part: Focus: History of Suspected Abuse/Neglect The resident's comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase his/her susceptibility to abuse/neglect. A history and/or personality that draws him/her into unhealthy, even abusive, relationships., Behavior that might be characterized as provoking, antagonizing, disrespectful, angry, insensitive, and/or annoying, Behavioral symptoms, Difficulty in adjustment and generalized mood distress. R44's letter addressed to V1 (Administrator) or V2 (Executive Director) dated Sunday (01/04/26) 05:10 PM document in part: the certified nurse assistant who delivers food to my side was hostile to my roommate regarding her asking to be changed. I asked the certified nurse assistant not to yell at R37 like that and how she would feel in R37's shoes. V17 (Certified Nurse Assistant) told me to shut up and mind my own business. I told her to get out of my way I was going to the front desk. V17 blocked me and my cart, refusing to move and continued ranting. I said get out of our room, to which she said if I tried to get by her, she'd throw me out the window. I got by V17 when she moved to the door and told the nurse. V17 pushed pass me bumping me. I got in the elevator and came to send you this letter. I told her she'll get fired for threatening a patient! Please take action this shouldn't happen. I'm a nervous wreck! I'm literally shaking. On 01/06/26 at 12:29 PM R44 stated two days ago (01/04/25), a certified nurse assistant (V17 Certified Nurse Assistant) that work 3 pm came into my room at around 5 pm to give the dinner tray. The certified nurse assistant was African American. She was supposed to come change R37 but said that she will come back in a couple hours. I told her (V17) would she like to lay in her urine. She (V17) said get out my face, f**k you. She (V17) would not let me pass to leave the room and threatened to throw me out the window. She (V17) scared the hell out of me, and I was shaking like a leaf. I tried to get her name, but no one would tell me her name. Abuse does not need to be on the job at least show compassion because I have heart problems. I went to the nurse station and told the nurse. There was two other people at the nurse station. I then got on the elevator, went down stair to report it. I was explaining to the receptionist what happened, and she was so understanding. The receptionist gave me a pen/paper, I wrote a letter, and the receptionist put it in the administrator mailbox. I told V2 (Executive Director) and V6 (Social Worker). On 01/06/26 at 01:44 PM V6 (Social Worker) stated R44 complained to me that a staff member was very abusive, and I reported it to V2 (Executive Director). On 01/06/26 at 02:21 PM V2 (Executive Director) stated I was upstairs doing other things and a whole lot of stuff was going on yesterday when R44 interrupted me. I took time to speak to R44 and she had a generalized story that a certified nurse assistant (V17) came in to take care of her roommate when her (R44) and the certified nurse assistant (V17) got into a confrontation. R44 said the certified nurse assistant (V17) was in the room, dropped off food and R37 had to be changed. R44 described the certified nurse assistant as wearing a wig and is heavyset. I checked the schedule, and the certified nurse assistant was here this morning. The certified nurse assistant (V17) said I have to finish passing out food and R44 started yelling at her. I did the reportable as soon as V6 (Social Worker) told me about it today. R44 is care planned because she gets involved in other resident care. R44 said the certified nurse assistant threatened her. I got the letter that R44 wrote this morning, it was in my mailbox. I would consider that as abuse and I probably should have reported it yesterday. I thought R44 was having psychosis based off her care plan. On 01/06/26 at 03:23 PM V2 (Executive Director) stated I don't take abuse lightly and should have reported the abuse allegation yesterday (01/05/26). 01/07/26 at 10:23 AM V6 (Social Worker) stated R44 came to my office to talk to me yesterday (01/06/26) morning. R44 said one certified nurse assistant had talked to her in an incorrect way. I immediately let V2 (Executive Director) know, and he handled it from there. R44 did not tell me the exact date that it happened. R44 said she was not comfortable the way the certified nurse assistant talked to her. On 01/07/26 at 11:29 AM per telephone interview V7 (Receptionist) stated On 01/04/26 I worked a double. R44 came downstairs in the evening. R44 complained and asked when the administrator is going to be here. I told R44 I can I get them a note and R44 asked for pen and paper to leave the note. R44 complained something about the nursing staff. R44 said someone threatened to push her out the window then she went and sat down to write the letter. I put the letter in the administrator mailbox. Surveyor asked V7 would that have been considered an allegation of abuse. V7 responded that is like a threat. The way R44 expressed it, if it true and if she felt threatened, I guess that is abuse. If there is an allegation or I witness abuse I would contact the administrator. I did not follow protocol. I probably dropped the ball because I felt it was more of a complaint. On 01/07/26 at 02:20 PM Per telephone interview V17 (Certified Nurse Assistant) stated I worked on the second floor 01/04/26 on the 3-11 PM shift. I did patient care and passed meal trays. I was passing trays going toward R44's room and saw the call light on. I dropped off the meal tray and said R44 that's your meal tray. It was 05:30 PM and I asked R37 if she wanted me to change her (R37) but she wanted to eat and said come back at six. R44 said that is a breach of the contract, you don't have to time R37. I asked R44 can you mind your business. R44 got her walker and was hitting on me on my leg. I asked R44 what have I done to her. R44 said I am going to fire you. I never experienced this character from R44, and I never said I was going to throw her out the window. I was surprised at how R44 was pushing me with her walker. R44 was passing the nurse station and went downstairs. R44 reported me that I said that I was going to throw her out the window. I did not do anything or say anything to R44. When R44 was passing the nurse station she told me to look for another job. On 01/09/26 08:01 AM per telephone interview V20 (Certified Nurse Assistant) stated On Sunday 01/04/26 R44 said to V17 (Certified Nurse Assistant) that she was going to report and fire V17 when she came to the elevator. V17 said that she did not do anything to R44. Reportable dated 01/06/26 12:10 PM document in part: Subject R44 and staff. Abuse Report Initial Form: Allegation Type: Verbal/Mental. Information about when the facility became aware of the incident: 01/06/26 10:30 AM. Name of staff who 1st became aware of the incident: V1 (Administrator). Alleged Victim: R44. Alleged perpetrator: Unknown. Allegation Details: On 01/06/26 R44 spoke to Administrator. A few nights ago, a C.N.A. (Certified Nurse Assistant) on the 2nd shift was being rude to me and telling me not to get involved I other patients care. The allegation of Abuse happened on 01/04/26 and was reported to V7 (Receptionist) by R44. V7 failed to report the allegation of abuse to the abuse coordinator. The Abuse Coordinator is V1 (Administrator) however V2 (Executive Director) spoke with R44 on 01/05/26 concerning the abuse allegation and failed to submit an Initial Reportable or start an investigation until V6 (Social Worker) reported the alleged abuse to him (V2) on 01/06/26. V17 (Certified Nurse Assistant) did not work on 01/05/26 but was assigned to the unit in which R44 resides on 01/06/26. On 01/06/26 V2 identified the perpetrator as V17 after which time V17 was suspended and sent home pending the outcome of the investigation. The facility started to in-service the staff concerning abuse/abuse reporting/abuse investigating on 01/06/26. In-service Attendance Training dated 01/06/26 document in part: Topic: Timely reporting of Abuse, Identifying Abuse, Abuse Policy, (7) Key Components of Abuse, Abuse Types, Review of Abuse Scenarios, Review of Specific Reportable Prioritizing and Investigating. In-service Attendance Training dated 01/06/26 document in part: Topic: Abuse and Neglect Policy and Procedure, Timely reporting, Identifying Abuse and (7) Key Components of Abuse and Neglect Prevention. In-service Attendance Training dated 01/07/26 document in part: Topic: Abuse and Neglect and Policy and Procedure, Timely reporting, Identifying Abuse, (7) Key Components of Abuse, Neglect and Prevention.Policy:Titled Abuse and Neglect revised 06/26/25 document in part: it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention abuse and timely and thorough investigations of allegations. If abuse/neglect is suspected the facility will: 1: Take immediate steps to assure the protection of the resident(s). 2. Notify the appropriate/designated organization/authority (IDPH) that an investigation is being initiated immediately following interventions for the resident's safety. 3. Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses. VI. Protection: Have procedures to: Employee(s) accused must be suspended pending investigation. V11. If the Administrator is not present, the report must be made to the Administrator's designee. All allegations of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.

Based on interviews and record reviews, the facility failed to refer a resident (R18) who was later identified with a mental disorder to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 resident. Findings include: R18's 7/17/2024 Notice of PASRR (Preadmission Screening and Resident Review) Level I Screen Outcome documents in part no level II required due to R18 not having a severe mental illness, intellectual disability or related condition. There was no mental health diagnosis known or suspected and no mental health medications during the assessment. R18's admission Record documents in part an initial/original admit date of 7/25/2024. It documents in part a diagnosis of schizoaffective disorder (onset 1/17/2025). V33's (Psychiatrist) 8/08/2024 12:57 PM progress note for R18 documents in part: Diagnosis: Schizoaffective [diagnosis], depressed type. Past Psychiatric History: Schizoaffective. V33 wrote historical medication to include lithium. V33 wrote to add Seroquel (antipsychotic) 50 milligrams at night to R18's medications. On 1/07/2026 at 1:18 PM, V8 (Nurse Consultant) stated R18 did not have the diagnosis of schizoaffective disorder during admission. V8 stated R18's hospital and referral paperwork also did not contain the diagnosis for R18. Requested R18's Level II PASARR. V8 stated facility did not resubmit for a Level II PASARR; therefore, R18 did not have one. On 1/07/2026 at 3:13 PM, V11 (Admissions Director) stated R18's initial PASRR Level I was done at the hospital prior to admission. V11 stated if there was a new diagnosis of schizoaffective disorder or if the diagnosis was missed during the first assessment, R18 should have gotten a new PASARR. Facility's Pre-admission Screening and Resident Review (PASARR) Policy (adopted 7/16/2025) documents in part: If the referring hospital fails to submit any information showing the psychiatric disorders/diagnoses, substance use history, and mental health medications in the referral information to the facility and the facility suspects a MD [mental disability] or ID [intellectual disability], the facility will notify the appropriate state-designated mental health or intellectual disability authority by requesting a PASSAR screening via AssessmentPro (Apro). The facility will notify the appropriate state-designated mental health or intellectual disability authority by requesting a PASSAR screening via AssessmentPro (Apro), if a new psychiatric diagnosis under MD or ID is added by a physician.

Based on interview and record review, the facility failed to refer a resident to the appropriate state-designated authority for a new Level II PASARR evaluation and determination with known mental illness for two (R11, R14) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35 residents reviewed. Findings include: R11's Facesheet documents that R11 was admitted to the facility on [DATE] with diagnoses not limited to bipolar disorder, current episode depressed, severe, with psychotic features, post-traumatic stress disorder, chronic R11's PASARR screening dated 06/09/2024 documents that R11 does not require a level II PASARR due to no SMI (severe mental illness)/ID (intellectual disability)/ RC (related concerns). R14's face sheet documents that R14 was admitted to the facility on [DATE] with admission diagnoses not limited to Schizoaffective Disorder, Bipolar Type, Other Recurrent Depressive Disorders, Mild Neurocognitive Disorder Due to Known Physiological Condition without Behavioral Disturbance. R14's Order Summary Report dated 01/07/26 indicates in part that R14 is receiving Aripiprazole for psychosis 10 mg tablet one time a day. R14's Care Plan Report documents in part R14 has a diagnosis and history of severe mental illness and requires psychotropic medication. R14's PASARR screening dated 02/13/2023 documents in part, you do not have a mental health condition requiring evaluation through the PASRR process. If a change occurs suggesting that you do have a mental health, intellectual or developmental disability, then further evaluation through the PASRR process will be needed. You do not require further evaluation through the PASRR process. Your depression and confusion are noted. However, you have not been diagnosed with a serious mental illness. It is noted that you do not currently take any medication for your mental health. The current focus of your care is treatment of your medical conditions and planning for your care after you leave the hospital. The only DSM diagnoses listed on R14's Illinois PASRR Summary of Findings is Depression. No other DSM diagnoses included. On 01/07/2026 at 3:07PM, V11 (Admissions Director) states he has been working at the facility for 2.5 years and is responsible for performing the PASARR screenings for the residents. V11 states he checks the screening agency's website every day to check to see if there are any screenings that requires his attention. V11 states he is responsible for entering the resident's information, such as medications and diagnoses, into the screening agency's website. V11 states usually, the hospital completes a resident's PASARR prior to the facility admitting the resident to the facility. V11 states he is unsure of who is responsible for ensuring that resident's PASARR information is accurate prior to admitting the resident to the facility. V11 states a PASARR Level II is needed for a resident if the resident has a severe mental illness/SMI diagnosis. V11 states the determination for a Level II PASARR screening is based off of the results of the Level I PASARR screening. V11 states once he enters the resident's information, the screening agency will alert him if a resident requires a Level II PASARR screening. V11 states if information is entered into the resident's Level I PASARR screening incorrectly, then this can result in the PASSAR screening results being incorrect, which requires a new screening to be completed. V11 states R11's current PASARR screening is inaccurate and requires a new PASARR screening to be completed due to R11's severe mental health diagnosis. Facility policy dated 07/16/2025 titled Preadmission Screening and Resident Review (PASARR) Policy documents in part, A PASARR level II is required to be done prior to admission if the PASARR Level I is positive for MD/mental disorder or ID/intellectual disability. PASRR Level I screen is to be completed before the individual is admitted to the facility. If it is not completed by the sending institution, it should be completed upon admission, or as soon as practicable thereafter.

Based on observation, interview, and record review, the facility failed to follow facility smoking protocol to ensure that smoking materials are not kept by the resident in their room. This failure has the potential to affect 1 (R109) resident reviewed for smoking in a total sample of 35.Findings include:On 01/06/2026 at 11:28 AM, observed R109 lying on his bed in his room. R109 said, I smoke cigars. R109 stated he does not keep a lighter in his room and that someone outside lights his cigars for him. R109 stated that he keeps his cigars in his coat pocket. On 01/06/2026 at 11:30 PM, observed R109 walk to his closet and remove his coat. R109 then reached into his coat pocket and pulled out a box filled with brown cigarettes/cigars. R109 then reached back into his coat pocket and pulled out an additional 8-10 brown cigarettes/cigars. On 01/07/26 at 1:45 PM, V22 (Activity Aide) stated cigarettes/cigars are stored at the front desk and the residents are only allowed to have smoking materials on them when they are out at smoke break. V22 stated they are not allowed to take them (smoking materials) back on the nursing unit, everything is returned to the front desk. V22 stated even if a resident is allowed to smoke independently, they must still return their lighter and cigarettes/cigars to the front desk when they come back into the building.On 01/07/26 at 1:52 PM, V9 (Receptionist) stated there are four smoke breaks per day and he is involved in the 9AM and 1PM smoke breaks. V9 stated residents who have their own cigarettes store them in individual boxes kept behind the receptionist desk. V9 stated if a resident does not have their own cigarette, then he will give them a house stocked cigarette. V9 stated after the residents are done smoking, they come back to the receptionist desk and drop off their smoking material for storage. V9 stated none of the residents are allowed to have cigarettes/cigars and/or a lighter on their person due to safety reasons.On 01/07/26 at 2:11 PM, V23 (Social Worker) stated when a resident gets admitted the social service department assesses if the resident smokes or not. V23 stated through the smoking assessment it is determined if the resident can smoke independently or require supervised smoking breaks. V23 stated smoking on the patio is supervised because a staff is always monitoring those smoke breaks. V23 stated the facility does not allow lighters, cigarettes/cigars or e-cigarettes in the resident rooms and all smoking materials are kept at the front desk for safety concerns. V23 stated residents are not allowed to keep any smoking materials in their room. V23 stated R109 is complaint with the smoking rules, and she has not been made aware of any non-compliance issues with R109.On 01/07/26 at 2:29 PM, V23 went into R109's room and found inside R109's coat pocket a box of cigarettes/cigars, three additional unused cigarettes/cigars and six used cigarettes/cigars of various lengths. V23 stated R109 should not have these cigarettes/cigars in his room for safety reasons/concerns.R109's diagnosis included but not limited to Metabolic Encephalopathy, Bipolar Disorder, Unspecified Dementia, Cocaine Abuse, Schizophrenia, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Auditory Hallucinations, Tobacco Use, Alcohol Use, Altered Mental Status.R109's MDS (Minimum Data Set) dated 10/22/25 indicates severely impaired cognition with BIMS (Brief Interview for Mental Status) 03 out of 15.R109's care plan report includes smoking care plan which documents (R109) is a smoker and expresses the desire to smoke at this facility. Interventions include but not limited to explain the consequences of smoking, this includes removal of all smoking materials and only being allowed to smoke when supervised.Smoking Behavior Agreement dated 10/17/25 signed by R109 indicating the resident agrees to the smoking policy. R109's Smoking Program Evaluation dated 10/17/25 which documented Resident is considered a safe smoker and may use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking.Facility provided document titled, Smoking Policy dated 07/03/25 which documents in part, facility staff may keep the residents smoking materials when not being used by the resident.

Based on observation, interview, and record review the facility failed to maintain accurate records of usage and accountability for controlled substances on 1 of 6 medication carts for two (R201, R154) out of seven residents reviewed for medication storage. Findings Include: On 1/6/26 at 10:21AM, during the narcotic reconciliation count with V14 (Licensed Practical Nurse/LPN) on team's one cart, R201's Controlled Drug Administration Record Sheet documented seven (7) tablets were available. R201's medication blister card had six (6) tablets of Lorazepam 2mg. R154's Controlled Drug Administration Record Sheet documented twenty-nine (29) tablets. R154's medication card had twenty-eight (28) tablets of clonazepam 1mg. On 1/6/26 at 10:33 AM, V14 (LPN) stated, I gave R201's medication around 7:45 AM or 8:00 AM, I am not sure of the exact time. I gave 154's medication around 8:15 AM. I was trying to hurry up and pass my morning medications. I know I was sign out the medication after I administered the narcotic. Om 1/6/26 at 11:10 AM, V5 (Assistant Director of Nursing) stated, After the nurse administers medication, they are required to immediately sign out that medication on the appropriate documents. Controlled substance needs to sign out on the controlled medication sheet for a quick reference when a resident received the narcotic and narcotic accountability. Policy documented in part: Controlled Substance Prescriptions: dated 8/2020.Security and Record KeepingControlled substance, medications are stored at the facility under double lock or as required by state regulations, separate from all other medications and counted at each change of custody. The medication nurse on duty maintains possession of a key for controlled medications. Medication Pass dated 7/2/25.After medication is administered to each resident, sign the medication administration records that it was given.

Based on observation, interview and record review, the facility failed to provide nectar thickened water as ordered by the physician and failed to follow the meal ticket for one resident (R49) in a total sample of 35.Findings Include: On 01/06/2026 at 11:54 PM, during lunch meal rounds observed R49 sitting in bed eating from his lunch tray. R49 had already consumed the main entree and was in the process of beginning to eat the mashed potato and cooked cabbage. The cooked cabbage had various thickness of strands of cabbage surrounded by a thin liquid pooling around the outside edges of the cabbage. It appeared as if the liquid used in the cooking process had separated from the cabbage. The cooked cabbage was not pureed. Observed a closed container of nectar thick apple juice on R49's tray and next to his meal tray was a large pitcher filled 1/3 full of ice and water. Observed R49 continue to eat the mashed potato and the cooked cabbage. Then, observed R49 put down his fork, remove the lid from the nectar thick apple juice container and drink the entire container of juice all at one time. R49 then proceeded to cough multiple times. R49 stated he likes to drink water and points to the pitcher next to his meal tray. R49 stated the staff put the ice in there and fill it with water. Then, R49 picked up the water pitcher, took a small sip from the straw and proceeded to cough again.On 01/06/26 at 11:56 PM, observed R49's meal ticket on the side of his meal tray which listed his diet order as Mechanical Altered/Ground, Nectar and listed in part for R49 to receive puree seasoned cabbage. On 01/06/26 at 11:58 AM, V30 (Registered Nurse) stated R49 is on nectar thick liquids because he has swallowing problems and is at risk for aspiration. V30 stated R49 gets water by himself from the bathroom. V30 observed R49's water pitcher filled 1/3 with ice. V30 stated the residents are not allowed to get ice by themselves, only the staff have access to the ice.On 01/6/26 at 12:06 PM, V31 (Certified Nursing Assistant) stated she is taking care of R49 today. V31 stated he is on nectar thick liquids which means he cannot tolerate thin liquids like the other residents so thickened liquids are sent for him on his meal tray. V31 stated she is the one who filled up R49's pitcher with ice and water this morning. V31 stated she is not able to thicken R49's water, that is only something the nurse care do, the CNAs are not allowed to do that. V31 viewed R49's water pitcher filled with ice and water and stated that water in the pitcher is not thickened.On 01/06/26 at 12:13 PM, V25 (Registered Dietitian) stated for residents on mechanical soft diets the consistency of the vegetable served is dependent what vegetable it is. V25 stated in some cases the vegetable may be pureed even if the resident is on a mechanical soft diet. V25 stated this is done to keep it safer for the residents. V25 stated the kitchen staff should follow the meal ticket and provide the food items in the consistency listed. V25 stated if the meal ticket says R49 should have received pureed cabbage then that is what he should have received. V25 stated if a resident is on nectar thick liquids, they should not have a pitcher of ice and water at the bedside because that is a thin liquid and places the resident at risk for aspiration. V25 stated because ice melts at room temperature it is considered to be a thin liquid and should not be provided to residents on nectar thick liquids. V25 stated water provided to residents on thickened liquids should be thickened to nectar consistency with no ice.On 01/07/26 at 2:35 PM, V24 (Speech Language Pathologist) stated she has been covering the facility since July 2025 and has been a Speech Language Pathologist for 20 years. V24 stated she last saw R49 in July 2025 at which time R49 was referred for a possible solid upgrade from mechanical soft to regular consistency. V24 stated at that time R49 he was already on a mechanical soft diet with nectar thick liquids. V24 stated R49 has been on this diet due to his diagnosis of COPD. V24 stated for some residents with COPD like R49 it means their swallowing can become dis-coordinated meaning sometimes the airway does not close off as it normally should when you swallow, or the airway closing can be sluggish. V24 stated during her bedside swallowing evaluation in July 2025 she could not establish a safe way to upgrade R49's diet consistency because R49 was very impulsive and eating large amounts of food at a fast pace. V24 stated R49 has some cognitive deficits which did not make him a good candidate for education. V24 stated her recommendation was for R49 to continue a mechanical soft diet with nectar thick liquids. V24 stated thin liquids move too quickly and are harder to control. This is especially true if a resident like R49 who lacks awareness of their own abilities gulps or takes large sips of liquids, which can overwhelm their system. V24 stated nectar thick liquids are heavier and thicker and therefore moves slower through the swallowing system. V24 stated nectar thick liquids have a thicker viscosity which is why it is easier for people to swallow thickened liquids than thin liquids like water. V24 stated ice is a thin liquid because it melts to a thin liquid. V24 stated based on her bedside evaluation in July 2025 R49 should be receiving all liquids thickened to nectar consistency including water and should not have a water pitcher within his reach because he runs the risk of aspiration which has the potential to cause pneumonia. V24 stated yesterday, 01/06/25 afternoon the facility asked her to see R49 because staff found R49 drinking thin liquids. V24 stated she came to the facility yesterday afternoon and did an evaluation on R49 with water and determined that he would be allowed to have non-thickened water in between his meals, not with his meals. V24 stated the order to allow R49 water between meals was entered into R49's electronic health record (EHR) on 01/06/26 at 3:30 PM. V24 stated prior to this time R49 should not have been allowed to drink water/ice that was not thickened to nectar consistency because the doctor's order at the time the surveyor observed R49 eating lunch was for him to only receive nectar thickened liquids. V24 stated the kitchen should be following what is printed on the meal ticket. V24 stated strands of cooked cabbage even if cooked that has some thin liquid in it could be harder for R49 to chew/swallow. V24 stated if his meal ticket stated R49 should receive pureed cabbage that would be the safer option for R49 and that is what should have been served to him. V24 stated it is possible R49 could have swallowed finely ground small pieces of cooked cabbage if it was served with a gravy. V24 stated otherwise R49 should have received the pureed cabbage as printed on his meal ticket.On 01/07/26 at 3:55 PM, V25 stated on 01/06/26 when the surveyor observed R49 eating lunch R49 had an order for nectar thick liquids, and he should not have received or had access to ice or water (non-thickened). V25 stated prior to yesterday she was not made aware that R49 was non-complaint with water, otherwise she would have added that to his nutrition care plan.R49 diagnosis includes but not limited to Chronic Obstructive Pulmonary Disease, Dysphagia, Oropharyngeal Phase. R49's MDS (Minimum Data Set) dated 10/09/25 reveals R49 is severely cognitively impaired and requires a mechanically altered diet and complains of difficulty or pain with swallowing.R49's Order Summary Sheet dated 01/07/26 documents in part, diet order as mechanical soft texture, nectar thick liquids consistency order date 08/01/24.R49's Speech Therapy Discharge summary dated [DATE] documents in part aspiration precautions, soft/nectar thick liquids diet.R49's meal ticket dated 01/06/26, lunch listed mechanical altered/ground, nectar at the top of the meal ticket and listed in part pureed seasoned cabbage.R49's nutrition care plan initiated 03/22/22 documents in part, R49 risk to potentially choke or aspirate food or liquids and interventions include but not limited to prepare/serve the resident's nutritional diet as ordered. Prescribed diet is mechanical soft, nectar thick.Facility provided document titled, Diet Guide Sheet printed 01/07/2026, 9:02 AM which documents in part for Tuesday (Day 17) lunch mechanical altered/ground diet (to receive) pureed season cabbage.Facility provided kitchen policy titled, Thickened Liquids dated 10/01/25 which documents in part, thickened liquids will be made available to meet the nutritional and fluid needs of residents with dysphagia as ordered, to ensure residents receive thickened liquids meeting swallowing and food items that are liquid at room temperature must be thickened to desired consistency.Facility provided kitchen policy titled, Therapeutic Diets dated October 2019 which documents in part, it is the center policy to insure (ensure) that all residents have a diet order, including regular, therapeutic, and texture modified, prescribed by the attending physician, physician extender or credentialed practitioner in accordance with applicable regulatory guidelines.

Based on interview and record review, the facility failed to provide mail services to residents on Saturdays. This has the potential to affect all 194 residents residing in the facility. Findings include: On 01/07/2026 at 10:34AM, during the resident council group meeting, R121, R144, and R186 states there is no mail delivered to the residents on Saturdays. Residents state when mail is first delivered, it is first checked by the front office, then the front office gives it to the receptionist, and then the receptionist gives it to the activity department, and then the activity department is who delivers mail to the residents. Residents state they have to wait until the weekdays to get their mail at the facility. Residents state sometimes their mail is opened when they receive it. On 01/07/2026 at 10:45AM, V9 (Receptionist) states he has been working at the facility for two to three years and states he only works at the facility Monday through Friday. V9 states when mail is delivered to the facility for the residents, he places the mail in a bin in the front office room. V9 states someone from the front office comes to the facility twice a week on Wednesdays, Thursdays, or Fridays to sort through the mail and disperse it to the residents. V9 states he does not work in the facility on the weekends and is not sure if mail is delivered to residents on the weekends. On 01/07/2026 at 1:33PM, V13 (Activity Director) states he has been working at the facility for one to two years and oversee 4 activity aides. V13 states 3 activity aides work Monday through Friday, and 1 activity aide works on the weekends. V13 states the activity aide scheduled to work on the weekends does not distribute the resident's mail to them. V13 states the protocol that is followed when resident mail is delivered is as follows: The receptionist places resident's mail inside a room at the front office, the mail is kept there until the front office sorts through it, once the front office sorts through it, the resident's mail is then given back to the receptionist. The activity aides pick up the resident mail from the receptionist desk and gives it to the residents. V13 states he was told by the front office that if residents receive mail, do not distribute it and hold it until Monday. V13 states on Mondays, there are more people in the front office to distribute the resident's mail. V13 states once the receptionist collects the resident's mail, the activity department has to wait for V11 (Admissions Director) or another front office staff member to distribute the resident's mail. V13 states the staff asks the residents to open their mail in front of staff in order to make sure there is no contraband delivered in the mail. V13 states mail is distributed to the residents approximately three days during the week. V13 states if residents inquire about their mail, then he directs them to the front office. V13 states sometimes when mail is given to the activity department, there is some mail that is opened already but the front office staff explains why it is opened already. V13 states the activity department then have the residents sign that they have received their mail. Facility census dated 01/06/2026 documents that a total of 194 residents reside in the facility. Long Term Care Ombudsman Program Residents' Rights dated 11/2018 documents in part, Your facility must deliver and send your mail promptly. Your facility may not open your mail without your permission.

Based on interview and record review, the facility failed to ensure a resident positive with Covid-19 was quarantined for 10 days prior to cohorting with a non-positive Covid-19 resident to prevent the spread of Covid-19 virus. This failure affected 2 (R2 and R4) residents reviewed for infection control in the total sample of 4 residents. Findings include: R2's admission Record documented that R2's diagnoses (include but not limited to) attention-deficit hyperactivity disorder, generalized anxiety disorder, and secondary hypertensionR2's census list documented that R2 was in the current room since 02/23/2023. R4's admission Record documented that R4's diagnoses (include but not limited to) covid-19, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and vascular dementia. R4's census list documented that R4 was initially admitted on [DATE] and was moved to R2's room on 08/31/2025. R4's (08/27/2025) Hospital Record documented, in part Collection Time: 08/22/2025 COVID/FLU/RSV (respiratory syncytial virus) panel. Result SARS-COV-2 by PCR (polymerase chain reaction). Value: Detected. Ref(erence) Range: Not detected. R4's (08/28/2025) care plan documented, in part is on strict Droplet/CONTACT PRECAUTIONS related to covid 19. Infection will be resolved or controlled. Maintain contact isolation precaution in accordance with Centers for Disease Control (CDC) guidelines. On 09/12/2025 at 4:03pm, V2 (Assistant Director of Nursing/ADON) stated the facility has to isolate the resident for 10 days from the day the resident tested positive with Covid-19. If the resident tested positive on 08/22/2025, she (R4) should be out of the isolation on 09/01/2025. The purpose of quarantining a resident for 10 days is to control the spread of infection. The Covid positive resident should not be cohorted with a resident who is not Covid 19 positive if not yet quarantined for 10 days. Technically, the facility would want to isolate a resident if they have covid to prevent the spread of covid 19. V2 stated he will not cohort the resident who is not covid positive with a resident who tested positive with Covid-19 because the resident who is not positive can get it.On 09/12/2025 at 4:25pm, V22 (Infection Preventionist/Licensed Practical Nurse) stated the expectation is to quarantine a covid positive resident for 10 days; from the day the resident tested positive. If a resident tested positive on 8/22/2025, the resident should be on quarantine from 8/22 to 8/31 then on 9/1/25, the resident can cohort with another resident. She should not be moved to another room on 8/31 because she (R4) has not completed the quarantine days yet. She can cohort with another resident on 9/1/2025. On 09/12/2025 at 4:52pm, V8 (Assistant Administrator) stated he miscalculated the count and thought that on the 10th day of isolation she (R4) could come off isolation.The (07/16/2025) Preventing and Controlling Acute Respiratory Illness Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Skilled Care documented, in part This guidance replaces previous COVID-19 disease-specific guidance. It is based on the CDC's guidance for the control of respiratory illnesses, including COVID-19, influenza, and other respiratory illnesses, in health care settings. Recommended Precautions for Common Respiratory Viruses. RESPIRATORY VIRUS: COVID-19. TYPE OF PRECAUTION: Contact precautions, N95, and eye protection. COVID 19 Duration of Isolation and quarantine. COVID POSITIVE RESIDENT'S ISOLATION GUIDANCE: Asymptomatic. Isolation Required: 10 Days. Day 0 = day of swabbing.

Based on interview and record review, the facility failed to supervise, monitor, and develop an effective plan to prevent residents with known histories of substance abuse from obtaining illicit drugs while in the facility for three of three residents (R1, R4, R5) reviewed for opioid use. These failures resulted in R1, R4, and R5 obtaining illicit drugs and having suspected overdoses while not being able to leave the facility on pass. R1, R4, and R5 did not leave the facility, nor did they have community passes in their care plans. Findings include: R1 experienced a suspected opioid overdose on 1/17/25, requiring administration of Narcan (medication used to reverse the effects of opioids) at the facility with evaluation and treatment in local emergency department. R4 experienced a suspected opioid overdose on 12/22/24 requiring evaluation and treatment in the local emergency department. R4 experienced a second suspected opioid overdose on 1/17/25, requiring administration of Narcan. R5 was sent to the local hospital for evaluation of seizure activity on 2/5/25. R5 required urgent endotracheal intubation (inserting a tube into the windpipe) for airway protection; used syringe was found at R5's bedside. The immediate jeopardy began on 12/22/24, when R4 had a suspected opioid overdose. The Administrator, Assistant Administrator, Director of Nursing, and Nurse Consultant were notified of the immediate jeopardy on 3/13/25 at 12:24 PM. An abatement plan was provided on 3/17/25 at 4:52 PM. This plan was sent back for corrections. An abatement plan was provided on 3/18/25 at 1:54 PM. This plan was sent back for corrections. An abatement plan was provided on 3/19/25 at 1:21 PM. This plan was returned for corrections. An abatement plan was provided on 3/19/25 at 8:32 PM. This plan was sent back for corrections. An abatement plan was received on 3/20/25 at 2:43 PM. This plan was sent back for corrections. An abatement plan was received on 3/20/25 at 3:15 PM. This plan was sent back for corrections. An abatement plan was received on 3/20/25 at 3:48 PM. This abatement plan was accepted on 3/20/25 at 3:50 PM. Based on observation, interview, and record review, the immediacy was removed on 3/20/25. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. 1). R1's medical record (Face Sheet) documents R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: (Idiopathic) Normal Pressure Hydrocephalus, Opioid Abuse, Uncomplicated; Nicotine Dependence, Unspecified, Uncomplicated; and Post Traumatic Stress Disorder, Chronic. R1's MDS (Minimum Data Set, 12/9/24) documents a BIMS (Brief Interview for Mental Status) of 12 indicating moderate cognitive impairment. On 1/17/25 at 8:58 PM, R1's progress note documents in part, the attention of the nurse was called by the assigned CNA (Certified Nursing Assistant) stating that the resident seems unresponsive when called by name. The resident was observed unresponsive with slow breathing, small, constricted pinpoint pupils. Due to history of opioid use, the resident seems to be exhibiting symptoms of opioid use. Two Narcan shots were given nasally. After 30 minutes, the resident became responsive. 911 was called and R1 was transferred to the (local hospital emergency department). On 1/17/25 at 9:24 PM, R1's emergency room record documents in part, patient brought in from nursing home via EMS (Emergency Medical Services), for altered mental status. Per EMS report patient was lethargic on arrival. Patient was given Narcan with prompt return to baseline and he was endorsing using heroin today. On 1/17/25 (no time) R1's ambulance run sheet documents in part, staff (nursing home) reports patient was noted lethargic and was given 4 mgs (milligrams) of Narcan with improvement back to baseline. Patient admits to getting heroin from a fell ow resident. On 1/17/25, facility's incident report documents in part, (R1) was observed unresponsive/suspected overdose. Two sprays of Narcan were given. Security searched the resident's room and found nothing. (R1) unable to go out on pass. The visitor logs were checked for three days, and no visitors were found. The resident said he bought a $20.00 bag of heroin but would not say where he got it from. On 2/28/25 at 12:16 PM, R1 observed awake/alert, reclining in recliner chair. R1 said he bought a $20.00 bag of heroin from R4 with money he received from his trust fund. R4 came to R1's room at night to give R1 the heroin. R1 said the last time he used heroin was about three weeks ago when he had to go to the hospital and then several weeks prior to that but he did not get ill the first time. R1 informed the surveyor that he would not have used heroin if he had received Suboxone (Buprenorphine/Naloxone-a medicine to treat dependence on opioid (narcotic) drugs such as heroin or morphine in drug addicts) and if programming for his drug abuse/use had been available to him. R1 said he does not go out on pass. On 2/26/25 at 12:52 PM via telephone, V8 (Registered Nurse/RN) said my two CNAs (Certified Nursing Assistants) called me to tell me that R1 was not responding. I went in there and called him by his name. He wasn't responding to verbal or tactile stimuli. I know he has history of drug abuse. I called my supervisor, V9 (Nursing Supervisor) and he did the same thing. V9 grabbed the crash cart, gave him a dose of Narcan, then a second dose of Narcan. He started to come back gradually. We called 911. Before they came, he was fully awake. He was telling 911 that he didn't want to go to the hospital. V9 asked him what happened. R1 said I don't know. I don't know. He would not tell me what he took. He had never done this before. He did receive Suboxone when he was first admitted in June 2024, and I can't say why it was discontinued. He doesn't get methadone. V8 stated we need to keep talking to him, to see what he's thinking about, to keep him from using again. On 3/4/2025, at 9:51 AM, V2 (Director of Nursing/DON) said, R1's Suboxone was discontinued on 12/12/2024. One of the nurses told me they could no longer get prescriptions for the medication. When R1 was admitted , the prescription was provided by a hospital physician and an outside pharmacy continued to supply. The pharmacy reached out to the hospital physician and was informed they would no longer prescribe the Suboxone. R1 had leftover Suboxone that the (Social Service Agency) was holding for him; they brought it to the facility. We reached out to V23 (R1's Physician/Medical Director), he said he would prescribe the Suboxone. Normally when they are discharged from the hospital a referral has been made for follow up with addiction clinic. I heard there was an insurance issue, I can't remember what the issue was. We haven't been able to find a clinic for him; we have been looking. If Suboxone was not continued, the resident might go through withdrawal. They would probably want to use (illicit drugs). They probably would use. On 3/4/25 at 12:58 PM via telephone, V23 (R1's Physician/Medical Director) said, I have written prescriptions for Suboxone. It's not my preference to prescribe Suboxone. I don't want to get involved. I told them (facility) they should send R1 to a clinic. On 3/4/25 at 1:54 PM via telephone, V21 (Hospital Liaison) I'm at the hospitals. I follow up on referrals. As long as we can accommodate their needs, we will take residents who have a history of substance abuse. I can't think of any recent residents who were not accepted for admission. We wouldn't accept residents who had recently used illicit drugs. We wouldn't accept someone who uses heroin. On 3/4/25 at 11:24 AM, V19 (Social Service Director) said, R1 does not go out to the addiction clinic. I haven't sent anything for him. Yes, he should go to addiction clinic as he has past substance abuse history. Order Review Report documents the following orders for R1: - Buprenorphine HCl-Naloxone HCl Sublingual Film 8-2 MG (milligrams), Give 1 film sublingually (under the tongue) every 12 hours for pain. Order date: 6/10/24. Start date: 6/12/24. End date: 6/19/24. -Buprenorphine HCl-Naloxone HCl Sublingual Film 8-2 MG, Give 1 film sublingually (under the tongue) every 12 hours for pain. Order date: 6/19/24. Start date: 6/19/24. End date: 12/12/24. -Naloxone HCl Nasal Liquid 4 MG/0.1ML (milliliter), One spray in both nostrils as needed for Opioid overdose. Order date: 6/10/24. Start date: 6/11/24. Substance Abuse/Chemical Dependency Disorders care plan (initiated/created 6/22/24, revised 3/3/25) documents R1 has a history of substance abuse/chemical dependency. R1 has a history of opioid use. Goals include R1 will complete the first step of the Alcoholics Anonymous program by admitting that he is powerless over alcohol by the next review; will refrain from using non-prescribed substances through the next review; and will comply with the intake procedures of a substance abuse treatment program (i.e. hospital, clinic-based, mental health agency or Alcoholics Anonymous by the next care plan review. All goals revised 1/8/25). Interventions include, implement increasingly restrictive interventions in an effort to help the resident break the addictive cycle. Interventions may include supervision while in the community, restricted independent pass privileges, implementation of money guidance and budget controls to reduce/prevent access to substances; meet with the IDT (Interdisciplinary Team) to discuss the extent of the resident's illness. The physician may not consider a referral to the psychiatrist and/or write an order restricting pass privileges; present the resident with a list of substance abuse treatment programs. Confront the resident concerning the illness and the self-destructive path. Focus on getting past denial by reciting the facts associated with Alcoholism (i.e. Alcoholism is a disease which will end in death if it is not treated. A significant percentage of Alcoholics are able to enter treatment and gain sobriety. The first step is admitting that one is in fact, Alcoholic); provide leisure counseling to the resident to help him use free tine in productive, not destructive ways; and work with the resident to establish a verbal or written behavioral contract specifying what is and is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances and intoxication. All interventions created on 6/22/24. Revisions were made on 3/3/25 after complaint investigation initiated on 2/21/25. History of substance abuse and R1 has overdosed in the past care plan (initiated/created 2/27/25). Goals include R1 will remain drug free and abide by facility smoking policies and procedures; will meet with the facility psychotherapist to express emotions and feelings. Initiated/created 2/27/25. Intervention includes work with the resident to develop long-term goals focused on maintaining sobriety, building healthy coping mechanisms, and avoiding situations that may trigger relapse. Initiated/created 2/27/25, after complaint investigation initiated on 2/21/25. Substance Abuse/Opioid care plan (initiated/created 3/2/25) documents R1 has a history of improperly using and abusing substances. R1 has poorly developed the ability to control impulses. This has led R1 to engage in narcotic seeking behaviors that include drug abuse. Education has been provided on the negative effects that substance (abuse) has on health, mental health, and psychosocial well-being. Education has been provided on abstaining from using substance. A referral has been made to psychological services to address addictions with substance, underlying reasons for addiction and substance use, ineffective coping mechanisms, and to learn to engage in healthy activities and employ healthy strategies to better cope with stress and anxiety and to not return to using substance. Goals include R1 will be open-minded to interventions that promote abstinence for using substance, will refrain from using substance, and work with social services/psychotherapist to address substance use/abuse. Interventions include, establish a verbal or written behavioral agreement specifying what is and what is not allowed. Make sure R1 is aware of the rules prohibiting use of illicit substances; work with the interdisciplinary team to discuss the extent of my illness. Refer R1 to the psychiatrist and clinical psychologist as indicated; and approach R1 concerning his illness and the self-destructive path that he is on. Focus on getting him past denial by reciting the facts associated with substance abuse (i.e. substance abuse is a disease which will end in death if it is not treated and that a significant percentage of persons who abuse substance are able to enter treatment and gain sobriety. Encourage R1 to take the first steps by admitting that he is in fact a substance abuser so that he may get the help and assistance that he needs. All goals and interventions created 3/2/25, after complaint investigation initiated on 2/21/25. No care plan specifically addressing independent out on pass was found. 2). R4's medical record (Face Sheet) documents in part, R4 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Cerebral Infarction Due to Embolism of Left Anterior Cerebral Artery, Opioid Abuse with Intoxication, Unspecified; Other Schizophrenia, and Other Bipolar Disorder. MDS (Minimum Data Set, 12/5/24) documents a BIMS (Brief Interview for Mental Status) of 9 indicating moderate cognitive impairment. On 12/23/24 at 12:02 AM, R4's progress note documents in part, writer was alerted by CNA (Certified Nursing Assistant) and resident('s) roommate that resident appeared to be shaking uncontrollably. Nurse immediately ran to resident's bedside and was noted to be extremely diaphoretic, with pinpoint pupils non-reactive to light and accommodation. Resident visually shaking and lethargic. R4 was going in and out of consciousness. R4 immediately stated, I didn't take anything! Vitals taken immediately and noted in (electronic medical record). V2 (Director of Nursing) and physician were contacted. The physician was phoned with a new order to send R4 out 911. R4 walked out with the fire department and EMT (Emergency Medical Services) to the (local hospital). On 12/22/24 at 11:37 PM, R4's emergency room record documents in part, per report given to RN (Registered Nurse), patient was using drugs at his nursing home, so they called EMS. He (patient) told EMS he was using a little bit of heroin. On 12/22/24, (no time), R4's ambulance run sheet documents in part, patient stated he was using heroin in his room when the nurse walked in. Patient states he's a habitual user and did not get to use much before he was caught. On 12/23/24, the facility's incident report documents resident (R4) was found shaking uncontrollably. At the time drugs were not suspected. When the resident returned it was noted that the hospital stated Narcan was used. Security was notified and searched his room for drugs. Visitor logs were checked, and no visitors were noted. Resident does not have OOP (out on pass) privileges. On 1/17/25 at 11:20 PM, R4's progress note documents in part, writer was alerted by CNA that (R1) was lying on the floor, observed with drug overdose. R4 was noted to be extremely diaphoretic, with (pinpoint) pupils non-reactive to light. Resident observed lethargic. Naloxone 4mg nasal spray was (given). (R1) (transferred) to bed. After 30 minutes, the resident was observed smoking in the bathroom. When staff asked him why his smoking in the bathroom, resident was very aggressive toward staff. V22 (R4's Former Physician) notify (notified) with order to (send) him to (local hospital) for further evaluation. On 1/18/25 at 8:00 AM, R4's progress note documents in part, (R1) had some behaviors on the previous shift (11:00 PM-7:00 AM). He was noted with some respiratory distress as a result of a drug overdose. V22 (R4's Former Physician) was notified with an order to petition (R4) to the local hospital. On 1/17/2025, facility's incident report documents resident (R4) was observed unresponsive/suspected overdose. Two sprays of Narcan were given. The resident was sent out to the hospital. V12 (Security Guard) searched the resident's room and found nothing. Resident was discharged from the hospital to another nursing home. Visitor logs were checked for (R4). There were no visitors for the resident. Resident did not have OOP (out on pass) privileges. On 1/19/2025, at 9:34 AM, R4's hospital record documents in part, (R4) is [AGE] years old with past medical history significant for cerebrovascular accident with some aphasia as residual with underlying schizophrenia and bipolar disorders and hypertension with history of cognitive communication deficits secondary to underlying stroke and history of alcohol abuse and narcotic abuse brought to the emergency room by ambulance for agitations and they wanted to be evaluated. Evidently patient had episode of unresponsiveness most likely secondary to narcotic overdose with good response to Narcan. Evidently patient has Narcan and medication list and patient has history of opioid overdose. Presence of Abuse and Neglect Factors care plan (created 10/2/24/revised 10/5/24) documents R4 presents with a difficult or troubled past secondary to severe mental illness. He presents with risk factors related to abuse and neglect, due to his psychiatric history and present mental health symptoms, and substance abuse history. Goals include R4 will remain safe, free of mistreatment through next review R4 will be treated with respect, dignity, and reside in the facility from of mistreatment. Interventions include but are not limited to review assessment information. Emphasize treatment of causal factors and/or interventions designed to moderate/reduce symptoms (male treatment of compulsive behavior, substance abuse, anger and mental heal issues available to R4, as indicated). All goals and interventions created on 10/2/24, revised on 10/5/24. No care plans specifically addressing R4's illicit drug use/abuse history or independent out on pass were found. On 2/28/25 at 11:25 AM, via telephone, R4 denied using or selling drugs while at facility. I did not receive counseling at facility, even if it was available, I wouldn't have been interested. 3) R5's medical record (Face Sheet) documents R5 is a [AGE] year-old admitted to the facility on [DATE], with diagnoses including but not limited to: Hypertensive Chronic Kidney Disease with Stage 1 Through Stage 4 Chronic Kidney Disease, or Unspecified Chronic Kidney Disease; Opioid Dependence with Intoxication, Uncomplicated; Acute Hepatitis C Without Hepatic Coma, and Adjustment Disorder. R5's MDS (Minimum Data Set, 11/18/24) documents a BIMS (Brief Interview for Mental Status) of 15 indicating intact cognitive function. On 2/5/25, at 10:03 AM, R5's progress note documents in part, at beginning of shift, resident was noted in the bed sleeping. At approximately 7:30 AM, the resident got the writer's attention. She was requesting to go to the hospital. Writer asked why but resident refused to give any further information. Writer assessed the resident. The resident was not in any distress at this time. The physician was notified with an order to send the resident to the hospital. On 2/5/25 at 10:40 AM, R5's progress note documents in part, at approximately 10:30 AM, writer was making rounds noted resident having seizures that lasted a second. 911 was called. 911 crew arrived; resident was picked up by 911 crew at approximately 10:48 AM. R5 was taken to the hospital for further evaluation. On 2/5/25 (no time), R5's ambulance run sheet documents in part, per staff patient was witnessed to have a convulsive seizure lasting approximately one minute while in bed. Staff report finding a needle and syringe in bed with patient and patient has history of opioid dependence. On 2/5/25 at 2:52 PM, R5's emergency room record documents R5 required urgent endotracheal intubation (inserting a tube into the windpipe) for airway protection. On 2/5/25, facility's incident report documents in part, resident requesting to go to hospital due to seizures. When cleaning the room, the nurses found two syringes, one empty, one used. The visitor log was checked; resident had visitor in lobby. Suspected visitor gave her the drugs. Resident was put on supervised pass. Outside Pass Privilege (Mental Health Client) care plan (initiated/created 1/17/25, revised 2/5/25) documents in part, (R5) does not appear capable of limited IOOP (Independent Out on Pass). The resident (R5) has history of substance abuse and exhibits drug-seeking behavior care plan (initiated/created 2/5/25). Goal: Reduce drug-seeking behavior and promote recovery-focused care. Interventions include but are not limited to staff will prevent access to unauthorized substances. Goals and interventions initiated/created 2/5/25. Substance abuse care plan (initiated/created 2/27/25, revised 3/3/25) documents R5 has a history of substance abuse and has overdosed in the past. R5 has a history of opioid use and is receiving methadone as medication assisted treatment to address her substance use. Goals include: R5 will meet with the facility psychotherapist to discuss emotions. Interventions include work with the resident to develop long term goals focused on maintaining sobriety, building healthy coping skills, and avoiding situations that may trigger relapse. Goals and interventions were initiated/created on 2/27/25, after complaint investigation initiated on 2/21/25. On 2/27/25 at 3:30 PM, R5 said it is not difficult for residents to get drugs in the facility. There is no plan in the facility on how to handle drug use before and after. There was a resident on 4th floor that overdosed twice. The resident came up to me on several occasions and asked if I had stuff (drugs). I am on Methadone and Suboxone. There are only two residents on methadone in the facility. There are no meetings or programs. If there was a narcotic anonymous or addiction assistance, I would attend. On 3/4/25 at 12:34 PM, V25 (Psychotherapist) said to be honest, I did not get to see R1 for individual therapy. I saw him once in group on 1/27/25. I met once with R4, he declined services (group/individual therapy). I have not seen R5 at all. Based on observation, interview, and record review, the immediacy was removed on 3/20/2025. The facility took the following steps remove the immediacy: 1.) On 3/13/25 the Administrator and Assistant Administrators were in-serviced and educated on doing a thorough investigation by the [NAME] President of Operations and Nurse consultant. (See Exhibit AA In-Service on thorough investigation). 2.) On 3/13/25 the Administrator and Assistant Administrators reviewed and investigated the incidents thoroughly and concluded that the following occurred: First, all four incidents were reviewed in order to look for common factors. The chief common factor noted was related to information received from multiple residents with substance abuse history who came forward and named the same resident as the individual who provided heroin on multiple occasions to residents in the facility. Upon further review, this same individual's CHIRP/police background check completed upon admission showed that he had a history of distribution. Upon discovering this evidence, it was found out that this resident was no longer in the facility and had discharged to the community with assistance of (name of state program) on 2/28/2025. Upon discharge, this resident admitted to the Security Guard that he was dealing heroin. Since this resident's discharge on 2/28/2025 there have been no further incidents of illicit drug use noted. 3a.) Regarding the post-investigation. First, Leadership team interviewed each employee of the facility and asked them whether they were aware of any individuals, staff, or resident, who have been distributing illicit drugs within the facility. (See Exhibit 1-Employee Substance Abuse Attestation Form). This was completed from 3/13/25 through 3/17/25. 3b.) Secondly, Leadership team interviewed all residents with a history of substance abuse and interviewed them on whether they were aware of any individuals, staff or residents who have been distributing illicit substances within the facility. This was done on 3/13/25 and 3/14/25. (See Exhibit 2-Resident Substance Abuse Attestation Form). 3c.) Thirdly, background checks were pulled and reviewed for all residents within the facility identified with a history of substance abuse to identify whether he/she had a history of dealing drugs. If a hit was found, the Substance Abuse Care Plan would be amended to include a history of distributing drugs. (See Exhibit 3 - A -Substance Abuse Care Plan/History of Drug Distribution & Exhibit 3-B Chirp in Process - Held). This Background Check Review Process relating to verifying whether an individual had a history of distributing illicit drugs prior to entering facility will be an ongoing process where it will be noted on the Care Plan after every new admission. 3d.) Fourth, a form was created listing all residents with a history of substance abuse and will be reviewed weekly by the Social Services team and Leadership to ensure that all on this list are being compliant with substance abuse protocols. A list of residents with a history of substance abuse will be placed in each nursing station and updated weekly. (See Exhibit 4-Security Committee Form Exhibit 5- A Residents with History of Substance Abuse List). 3e.) The facility will conduct a QA Audit designed to ensure comprehensive and through investigation of any illicit drug distribution, promoting safety, accountability and transparency. These audits will be conducted by the Administrator and Assistant Administrators. This QA audit was initiated on 3/14/25 and will be conducted when there is any suspicion of illicit drug use or an allegation of illicit drug distribution. (See Exhibit 5-B QA Tool For Investigation of Illicit Drug Use or Distribution) 4.) Package Security Procedure: On 3/13/25 Administrator, Assistant Administrators, and IDT collaborated and began to look at protocol to prevent dangerous items from entering the facility. The purpose of this protocol is to prevent dangerous items from being delivered or dropped off to residents in the facility through the mail system or individuals. On packages arriving to the facility by U.S. Mail, Fed Ex, etc., the Receptionist/Security will check the package in at the Front Desk. After the package is received the Receptionist/Security places the item in a secured office adjacent to the Front Desk area where only the Front Desk, Security, and Leadership have access. Receptionist/Security staff will then inform Activities Staff/Representative that there is a resident package that has arrived and is being placed in the secured office area. Activity staff/representative will then pick up the package and deliver it to the resident where he/she will be asked to open it in front of them. (See Exhibit 6- Mail Log) Once the package has been determined to be safe and free of any contraband, the Activity staff/Representative will enter the package into Mail Log for tracking. If the package is not considered to be safe, Security personnel will be called to the location and will gather up the package where it will be placed in a secure location. For packages/items delivered by individuals as opposed to the mail system, the family member/other will be required to open the package in front of the Security Guard where it will be inspected for contraband. Once the package is cleared, the family member/other will receive the package back and can continue with their visit. 4a.) Security, Activities, and Front Office staff were in-serviced on being able to identify specific types of unauthorized items which includes illicit substances to optimally prevent illicit substances from entering the facility. In-servicing of Security, Activities, and Front Office Staff was completed by the Assistant Administrator. (See Exhibit 7A- Visitor Package Tracking Log and Exhibit 7B-In-Service on Package Security Procedure / Mail Log (Residents & Visitors)/IOOP Procedure) (Exhibit 7C-Prohibited Items List) 4b.) All residents were informed Activities staff/Designee of this new process on 3/14/25. (See Exhibit 8- Resident In-Service Sheet regarding Package Security Procedure) 4c.) This process will be posted at the Front Desk to make visitors aware of this process when they bring in packages for residents. (See Exhibit 9-Package Security Procedure Posting) 4d.) This process will be reviewed at the emergency Resident Council Meeting on 3/17/25 and monthly thereafter for 3 months (See Exhibit 10A-Resident Council Agenda for March 17, 2025, and Exhibit 10B - Resident Council Sign in sheet) 4e.) All new admissions will be informed of the Package Security Procedure upon Admission by Admissions Director/Designee. (See Exhibit 11-QA Tool verifying Admissions Director/Designee reviewed and presented new admission with Package Security Procedure) 4f.) The facility conducted a QA Audit 2x/weekly x 12 weeks to ensure new admissions were aware of the Package Security Procedure and the process is being implemented and followed as recommended. This audit will be conducted by the Assistant Administrator or designee. This QA started on 3/14/25. 5.) Independent/Community Out on Pass Protocol Relating to All Residents and A focus on Residents with A History of Substance Abuse. The purpose of this protocol is to prevent all residents, including those with a history of substance abuse, and visitors from bringing illegal substances into the facility upon returning from out on pass. 5a.) On 3/19/25 Administrator, Assistant Administrators, and IDT collaborated and began to review protocol to prevent all residents, including those with a history of substance abuse, and visitors from bringing illegal substances into the facility after returning from out on pass. 5b.) A sign will be placed in a predominant location in the Front Lobby Area notifying all residents, while out on pass, and visitors entering the facility not to bring illicit substances into the facility and if they are suspected/caught they will be subject to police intervention. (See Exhibit AB Front Desk Poster) 5c.) In order to remind All Residents, including those with a History of Substance Abuse, not to bring illicit substances into the facility when going out on pass, a statement will be boldly printed on the bottom of the resident out on pass log stating that if he/she brings illicit substances back into the facility, they will be subject to restricted out on pass and or immediate police intervention. The Posting will also be in immediate view of the Reception Desk to further remind a resident of the repercussions of bringing illicit substances into the facility. If a resident is caught in the facility utilizing or distributing illicit drugs on more than one occasion, he or she will be reported to the police as well as Involuntarily discharged to promote the safety of both residents, visitors, and staff. (See Exhibit AC Resident Out on Pass Log) 5d.) A destination section is located on the Resident Out on Pass Log in order for the resident to declare each time he/she goes Out on Pass. It will be the responsibility of Security/Front Desk staff to ensure that this section is consistently and accurately filled out and in the Destination Section. (See Exhibit AC Resident Out on Pass Log) 5e.) To prevent residents and visitors, who do not have a documented history of substance use from bringing illicit substances into the facility, the Security Team/Front Desk Staff will strongly request any visitor or resident en [TRUNCATED]

Based on record review and interviews the facility failed to assess and address multiple significant weight loss and provide supplements for 1 (R1) out of 3 residents reviewed for nutrition and dietary services. These failures resulted to 1 resident (R1) significant weight loss, decline from moderate to severe protein malnutrition and recommendation for gastrostomy tube insertion. Findings include: R1 was [AGE] years old male resident, initially admitted on [DATE]. R1's medical diagnosis includes the following Pancytopenia and acute kidney failure. Per R1's record, he was discharged on [DATE]. Weight Summary record of R1 documents multiple significant weight loss: R1's recorded weight documents significant weight loss on the following dates: R1's weight dated 5/16/2023 - 114.8 LBS (pounds) compared to 5/24/2023 94.6 LBS there was a decrease of -20.2 LBS or -17.6% weight loss for a period of 8 days. Weights on 7/7/2023 110.7 LBS to 8/7/2023 103.1 LBS comparison there was a decrease of -8.0 LBS or 7.2% weight loss for a period of 30 days. And weights on 2/9/2024 106.2 LBS to 2/16/2024 94.6 LBS comparison there was a decrease of -11.6 LBS or -10.92% weight for a period of 7 days or 1 week. R1's nutritional supplement under physician's order are as follows: House supplement was ordered to start on 8/7/2023 with instruction to give two times a day. From 5/24/2023 to 8/7/2023 R1 has no order for supplement despite -20.2 LBS or -17.6% weight loss for a period of 8 days. House supplement order was changed to (nutritional supplement) 1 carton two times a day on 11/17/2023 until 12/26/2023. On 12/26/2023 (nutritional supplement) 1 carton supplement was increased to three times a day until 2/24/2024 due to R1's discharge to hospital. On R1's MAR (medication administration record) that documents (nutritional supplement) 1 carton food supplement was not received by R1 and was coded as DR (drug refused) from 12/26/2023 to 2/23/2024 for a period of 59 days. No alternative supplement was documented due to R1 refusal. R1's nutritional care plan was initiated on 4/25/2023 after R1 was admitted in the facility. Although R1 weights that were recorded that document significant weight loss, care plan was not reviewed. On 12/26/2023, when V12 (Registered Dietitian) initiated a separate care plan related to R1's weight loss. V12 documents that R1 sustained significant weight loss and continues to meet criteria for severe protein calorie malnutrition. As compared to V27 (Medical Doctor) initial assessment dated [DATE] in the progress notes that documents R1 has moderate protein malnutrition. R1's status declined to severe protein malnutrition. V12's care plan intervention for significant weight loss is to provide dietary supplements as order: (Nutritional supplement) 1 carton three times a day. Care plan was not reviewed after the initial date of 12/26/2023. And R1 continued to refuse (nutritional supplement) almost every day from 12/26/2023 to 2/23/2024. R1's progress notes dated 2/23/2024 by V24 (Licensed Practical Nurse) document that R1 has had a change in condition with poor appetite and weakness. Per care plan meeting with R1's family, the placement of a gastric tube was suggested. V28 (Medical Doctor) was informed and ordered to send R1 to hospital emergency room for possible gastrostomy feeding tube insertion. On 3/13/2024 at 9:35 AM, V12 (Registered Dietitian) stated when he took over R1's case he had a poor appetite. (Nutritional supplement) 1 carton was ordered to be given as his supplement. (Nutritional supplement) is very important because R1 eats food very slow that sometimes it takes a long time. V12 said, R1's mealtime last forever to eat. (Nutritional supplement) is very important because of the way R1 eats food. It takes forever and can last for 2 hours. We change the supplement to (nutritional supplement) because it has more calories than other supplements. V12 said after seeing R1's (nutritional supplement) documentation that almost every day R1 was not receiving (nutritional supplement) from 12/26/2023 to 2/23/2024, V12 said, Oh, that's a lot of days. V12 was asked due to R1's not receiving supplement does it contribute to R1's significant weight loss? V12 said there are other ways to give supplement. Like we did calorie count and other interventions. Review of R1's full physician order does not document calorie count. On 3/14/2024 at 9:46 AM, V18 (Director of Nursing) stated I don't know if he was assisted to eat during meals, I don't remember if we did a calorie count. I can't remember if he was receiving any supplement. Every time I see him, he is on the wheelchair. I cannot remember if he refuses medications or supplements. V18 stated that DR initial on the MAR (Medication Administration Record) means Drug Refuse. V18 said, That means it was offered and resident refused.

Based on observation, interviews and record reviews, the facility failed to provide adequate supervision for 1 confused resident (R19) who is a high fall risk out of a sample of 36 residents reviewed for falls. This failure resulted in R19 sustaining a displaced bilateral nasal bone and anterior osseous nasal septal fracture. Findings Include: R19 was reviewed as a closed record. R19 was sent to the hospital on 2/19/24. R19's clinical record documents in part: R19 is a [AGE] year-old with the medical diagnosis of metabolic encephalopathy, need for assistance with personal care, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, adult failure to thrive, retention of urine, pleural effusion, myocardial infarction, fracture of nasal bones, subsequent encounter for fracture with routine healing, fall, subsequent encounter, secondary hypertension, chronic obstructive pulmonary disease, chronic kidney disease, stage 3a, retinopathy of prematurity, stage 2, unspecified eye, schizoaffective disorder, bipolar type, bipolar disorder, current episode mixed, moderate, major depressive disorder, spinal stenosis, schizophrenia, personal history of transient ischemic attack (TIA), and cerebral infarction, asthma, chronic obstructive pulmonary disease, and fusion of spine cervical region. R19's Minimum Data Set (MDS) dated [DATE], Brief Interview score (8) indicates R19 is cognitively impaired. R19's Fall Risk Evaluation dated 1/27/24, Section J form effective as of 4/25/23. Revised/Effective 11/14/23. documents in part the following for R19: Display a memory problem, and R19 is not able to walk even with the assistance and/or assistive device. R19 scored (15), indicates R19 is a high fall risk. R19's Hospital After Visit Discharge Summary dated 1/27/24 documents in part: Diagnosis-Fall initial encounter with displaced bilateral nasal bone and anterior osseous nasal septal fractures. R19's care plan dated 11/21/2023, documents the following in part: R19 is a high fall risk, the following falls noted. 12/9/23 R19 went to the basement and fell of walker rollator, while trying to get a soda. Intervention: No fall intervention noted on fall care plan. 1/27/24 R19 was observed on the floor next to his bed with a bruise on his nose. R19 sent to hospital and diagnosis with a displaced bilateral nasal bone and anterior osseous nasal septal fracture. Intervention input on care plan on 1/29/24: R19 was moved to a closer room near the nursing station. 2/5/24 R19 fell outside smoking on patio. Intervention input on care plan on 2/9/24: Schedule one to one smoking. 10/18/21 R19 is using protective head gear, soft helmet to prevent head injury due to recent fall as a result of a seizure. R19 is occasionally noncompliant with the usage. Encourage R19 to use helmet for safety measures 8/23/22. Replace helmet as needed. Staff to ensure helmet is on daily. Staff to redirect R19 when he removes helmet. R19 progress notes document in part: V29 (Licensed Practical Nurse) nurse note: On 12/9/23 at 11:57 PM, Incident Summary: Prior to fall incident R19 was last seen by this nurse (V29) in his room lying on his bed after dinner was served. Writer (V29) received call from receptionist that R19 was in the basement on the floor. Upon trying to go downstairs to basement to assess resident, R19 came upstairs with rollator. R19 states I slipped off my rollator, while I was trying to buy a soda in the basement, but I did not hit my head. R19 was taken back to his room. Head to toe assessment done, no visible injuries noted this time. R19 denies any pain currently. Able to move all extremities without difficulty. Physician made and family made aware. V23 (Licensed Practical Nurse) nurse note: On 1/18/2024 10:10 AM, Change of Condition (SBAR) Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: R19 noted with period of confusion, AMS (altered mental status), and suspect Pneumonia. V25 (Nurse Practitioner) assess R19 with order to send R19 to the hospital. VS Taken BP (blood pressure) 116/83, T(temperature) 97.3, P (pulse) 77,02 SAT (oxygen saturation) 95% (room air), R (respiratory) 18. R19's family made aware by V25. Report given to hospital nurse and ambulance transport dispatch. (R19 was noted confused) V23 (Licensed Practical Nurse) nurse note: On 1/26/2024 at 9:18AM, Admit/Readmit Follow Up Note Note Text: R19 in his room in bed comfortable, who appears stable, alert, and oriented x 1-2 confuse at times this time, with no SOB (shortness of breath) and or any discomfort. Bed at the lowest position with call light in place. Vital signs taken and recorded. Plan of care ongoing. (R19 was noted confused) V42 (Restorative Nurse) Note: On 1/26/2024 at 1:35 PM, R19 noted with history of repeated falls, has poor balance and poor safety awareness, decrease functional mobility but, does not call for assistance from staff when it comes to complete ADL task. R19 is able to note the urge to void but has difficulty to go to toilet self. Endorsed to Therapy. V24 (Licensed Practical Nurse) nurse note: On 1/27/24 at 11:54 AM, Incident Summary: Prior to the incident R19 was lying in the bed watching TV, while he was in bed, bed on the lowest position, call light placed within easy reach about 10 minutes later, the staff came to notify the writer (V24) that R19 was sitting on the floor with no witness. On assessment R19 noted with bruise on the top of his nose but was able to move all extremities with no pain, on enquiry R19 was unable to express himself, R19 was just mumbling words. Vital signs done as follows T:97.8, RR:20, PR:86, B/P:142/98 and 02 Sat:96% on room air. No loss of consciousness, R19 was able to get back in bed with a mechanical lift with the help of two staff. V25 (Nurse Practitioner) notified, V25 gave order to send the R19 to hospital emergency room for further evaluation. R19's family and V3 (Director of Nursing) made aware. V25 (Nurse Practitioner) note: On 1/29/2024 at (Medical Professional Progress Note) Reason: 1/27/2024, R19 was admitted to hospital for status post fall, with laceration and fracture. R19 was discharged same day with diagnosis of minimally displaced bilateral nasal bone and anterior osseous nasal septal fracture. R19's Incident Final Report dated 2/2/24 documents in part: -R19 is a [AGE] year-old male, alert, and oriented X2 with BIM score of 11 of out 15. On 1/27/24 at 10:12 AM, V24 noted R19 on the floor in a sitting position in his room. Note a bruise on the bridge of the nose. R19 was not able to tell what happened. There is no change in mental status from baseline. Prior to incident R19 was lying in bed watching TV. The bed was at its lowest position and call light in reach. R19 sent to hospital for evaluation and diagnosis of open fracture of nasal bone. (R19's Minimum Data Set (MDS) dated [DATE], Brief Interview score (8) indicates R19 is cognitively impaired. R19's progress notes documented change/decline in mental status on 1/18/24, and 1/26/24 prior to fall on 1/27/24). On 2/21/24 at 1:22 PM, V24 (Licensed Practical Nurse) stated, I was R19's nurse on 1/27/24 when he fell . Ever since R19 was positive for Covid on 1/1/24 he had a decline in his mental status. R19 was very confused, weak, unsteady on his feet and could not walk anymore. R19 needed close monitoring and supervision. Due to R19 being so confused prior to his fall on 1/27/24, R19 had a bed and wheelchair alarm, low bed, and mats on the floor next to his bed, and call light in reach. However, R19 was so confused he did not know how to place on his call light for assistance. Nursing staff had to monitor R19 very closely. Prior to R19's fall on 1/27/24, I saw him in bed resting watching TV. I went down the hall passing medications to other residents. Approximately 30 to 40 minutes later I heard his bed alarm sound off. By the time I got to R19's room, he was on the floor mat next to his bed trying to get himself up off the floor very confused, he could not tell me what happened, which was his normal mental status for a several weeks. I called for assistance, completed body assessment, vital signs and noted a cut open area on his nose that was starting to bleed and bruise. R19 was not wearing a helmet. I have not seen any helmet R19 was to wear. I cleaned up R19 nose, and he was lifted off the floor with several staff and the use of the mechanical lift. I notified V25, V3, and R19 family of incident and the order from V25 to send R19 to the hospital for evaluation. After that fall, R19 room was moved closer to the nursing station for close monitoring and supervision. R19 use to be a smoker, but to him being so confused, R19 was not going outside to smoke anymore. On 2/21/2 at 11:27 AM, V27 (Certified Nursing Assistant/CNA) stated, I was R19's CNA when he fell on [DATE]. R19 was very confused, on 1/27/24, after breakfast, R19 was wet and needed to be cleaned up and changed. I changed R19's under brief and linen, he continued to rest in bed. Around an hour later, V24 called out for assistance, because R19 was on the floor. R19 was lying down on the floor next to his bed trying to get up off the floor. No there was no floor mats in R19 room or next to his bed. V24 and I used the mechanical lift to assist R19 back into the bed. R19 did not have on a helmet, I never seen R19 with a helmet on his head or in his room, I do not know anything about a helmet. On 2/21/24 at 2:54 PM, V26 (Licensed Practical Nurse) stated, I was R19's nurse when he fell on [DATE]. R19 is confused and hard to redirect. R19 has a bed and wheelchair alarm and need extensive assistance the ADL care. R19 kept getting out of bed and his wheelchair, but he was so confused, he did not know to place on his call light. R19 need close monitoring and supervision. On 2/5/24, I was passing out medications and V49 (Security/Smoke Monitor) pushed R19 to me. V49 said R19 was downstairs smoking on the patio and slipped out his wheelchair onto the ground. V49 assisted R19 back into his wheelchair and brought him to me. I assessed R19, no injures was noted. I phoned V25, V3 and R19's family to notify all regarding fall. I do not know how R19 got into his wheelchair and down to the smoke patio. I was passing medications out to other residents. I cannot provide one to one monitoring to R19. Fall interventions for R19 is wheelchair/bed alarm, low bed, call light in reach and floor mats. R19 does not wear a helmet, and I have not seen any helmet on R19 or in his room. On 2/21/24 at 3:30 PM, V30 (CNA) stated, I was R19 CNA on 2/5/24 when he fell . I checked on R19 and he was in bed sleeping. I went to assist another resident. I was told by V26 that R19 went downstairs to smoke and fell on the outside patio. R19 is very confused sometimes he is not coherent, a high fall risk and disorientated. R19 needs close monitoring and supervision. Most of the time R19 is not re-directable. R19 fall interventions are wheelchair/bed alarm, low bed, and side rails. I have not seen any floor mats or a helmet. I did not know R19 needs to wear a safety helmet. I have never saw any helmet in his room or on his head. I had to assist my other residents and could not continuously monitor R19, he needs one to one monitoring. On 2/21/24 at 1:36 PM, V49 (Security/Smoke Monitor) stated, R19 was outside on the smoke patio smoking when he got up and slipped out of his wheelchair. R19 was trying to get up off the ground, so I assisted him back into his wheelchair and took him to his nurse V26. On 2/21/24 at 2:24 PM, V25 (Nurse Practitioner) stated, I no longer work for the facility since 2/12/24. I was R19's nurse practitioner and very familiar with him. R19 tested positive for covid around the end of December 2023, that when there was a rapid noticeable decline with R19's mental and medical status. R19 was hospitalized twice after covid, not eating, or drinking, and had several falls. I recommended to nursing administration for R19 to have side rails, floor mats, and someone to sit with R19. The facility did place side rails on the bed; however, I never saw any floor mats. The fall dated 1/27/24 when R19 fell out the bed, the injury was avoidable. R19 would not have sustained a displaced bilateral nasal bone and anterior osseous nasal septal fracture if the floor mats were down next to the bed. R19 was not walking anymore since December 2023, the floor mats would not have been contraindicated. R19's fall on 2/5/24 was avoidable. Due to the fact if R19 was adequately supervised, he would not have been able to go down and outside to the smoke patio and fell , without the staff knowing he was off the nursing floor. I have never seen R19 with a safety helmet on his head or in his room. On 2/21/24 at 11:28 AM, V28 (Psychotropic/Fall Nurse) stated, I investigate the falls and develop fall interventions for each fall that happens in the facility. If a fall occurs on the weekend or when I am off work the fall intervention is not developed or placed int the care plan until I return to work. A fall intervention is developed and placed in the care plan to prevent another fall from occurring. R19 has a total of 10 falls since his admission (8/31/17). The most recent falls in 2023 and 2024 were on 12/9/23, 1/27/24, and 2/5/24. On 12/9/23 R19 had used his rolling walker and went to the basement to buy a soda out the machine. R19 was sitting on the rolling walker and leaned over to get the soda and fell on to the floor. There is no fall intervention entered in the fall care plan for 12/9/23, I am not sure what happened, I thought I entered the fall intervention. On 1/27/24 R19 was observed on the floor next to his bed with a bruise on his nosed. R19 sent to hospital and diagnosis with a displaced bilateral nasal bone and anterior osseous nasal septal fracture. The fall intervention was moved R19 to a closer room near the nursing station, I placed in the fall intervention in the care plan on 1/29/24 due to the fall was on a Saturday. On 2/5/24, R19 fell outside smoking on patio. The fall intervention was to schedule R19 one to one for smoking. I entered the fall intervention in the care plan on 2/9/24, I do not remember why I was late assessing R19's fall and developing a fall intervention. When a fall intervention is not developed soon as possible it leaves the resident susceptible to another fall, due to no fall intervention in place for the nursing staff to review to prevent another fall for occurring. R19 was readmitted back to the facility on [DATE] evening. On 2/22/24 at 11:22 AM, surveyor and V23 observed R19 in bed. R19' bed was in high position approximately 3 1/2 feet high, up to V23's waist. No floor mats, and safety helmet noted. V23 (Licensed Practical nurse) stated, The hospice nurse recently left. R19's bed should not be this high, and I will call for floor mats. On 2/22/24 at 12:18 PM, V3 (Director of Nursing) stated, R19 is confused, and a high fall risk. Fall interventions for R19 are floor mats, low bed, bed alarm, and moved him close to nurse station. R19 need close monitoring, that is why he was move close to the nurse station. V28 is the facility fall nurse. V23 investigates, develop fall interventions, and update the resident care plan. A fall intervention needs to be place in the care plan soon as possible, so nursing staff is able to review the plan of care, to assist with prevention further falls. Policy- Fall Occurrence dated 7/17/23 document in part: -It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are re-evaluated and revised as necessary. -The nurse may immediately start interventions to address falls in the unit, even prior to the falls coordinator investigation. -The fall coordinator will add the intervention in the resident's care plan. -The interventions will be re-evaluated and revised as necessary.

Based on observation , interview, and record review , the facility failed to ensure a resident is free from physical abuse. This failure affected 1 ( R5) of 4 ( R2,R3,R4 and R5) residents reviewed for abuse which resulted in a bruise around the right wrist after being physically restrained. Findings include : R5's diagnosis includes Spina Bifida , Anemia in Chronic Kidney Disease , Chronic Kidney Disease stage 4 , Schizoaffective Disorder , Bipolar Disorder , Type 2 Diabetes Mellitus and Paraplegia. R5 was first admitted to the facility on [DATE]. R5 has a BIMS ( Brief Interview of Mental Status ) of 9/15. R5 is care planned for including resisting care which includes refusing blood draws and exams. ( Initiated 5/1/17). R5 receives medications including Aspirin EC Tablet Delayed Release 81 MG 1-tab po 1 time a day for supplement. On 2/27/23 at 11:05 AM, R5 was observed in her room in bed with a faded/yellowed bruise on her right upper wrist. The bruise was plainly visible most prominently on top of wrist and continued faintly around the entire wrist. On 2/27/23 at 11:05 AM, R5 stated I got the bruise on my right wrist because V3 (Director of Nursing/DON) was holding my wrists down when they were trying to get blood from me. I am not afraid of him I just didn't want a needle in my arm. V3 and the lab person took the blood anyway. I didn't say anything because I didn't want V3 to get in trouble. On 2/27/23 at 11:09 AM, V3 (DON) stated about two weeks ago I had to assist the lab person draw a blood from R5. R5 was combative and swinging her arms. After trying to redirect her I had to hold R5's wrist down so we could get the sample. I was not aware of R5 getting any bruise on her. On 2/27/23 1:38PM V5 ( Registered Nurse ) stated I take care of R5. I never noticed any bruising on R5's arm. This is the first time I observed the bruise. She never said anything about staff holding her down to me. On 2/28/23 at 10:57AM V7 ( Phlebotomist ) stated per phone: On 2/16/23 I went to facility and needed to do a blood draw from R5. R5 refused and I left the room and notified staff. V3 (DON) told me to go back in room because it was really important to get a blood draw. V3 was in the room restraining R5. R5 was screaming, yelling, and spitting. V3 continued to restrain her by her wrist. I did the blood draw even though she clearly did not give consent for the procedure. On 3/1/23 at 11:14AM, V13 (Wound Care Nurse) stated R5 was assessed for wounds on 2/27/23. During the wound care assessments R5 was observed with old, faded discoloration bruises to right arm and upper arms and both legs. The faded bruise was all around the right wrist. On 3/1/23 at 10:45 AM, V12 (Physician) stated I am familiar with R5 . I am her doctor. She has many diagnosis conditions. She has Diabetes and Kidney Disease with low platelet count. R5 is not eating well. She is on aspirin. These conditions could have contributed to the bruising. The bruise on her right wrist could have been caused by moderate pressure but I am not sure on how that occurred. I wasn't there. There have been times before when R5 has refused blood draws. The staff has let me know and I talk to her . This time I was not aware that R5 refused the blood draw. This is the first time I was aware. Review of R5's progress notes does not show any documentation of the incident on 2/16/23 showing any blood draw refusal or R5's bruising on her wrist . Review of R5's 2/27/23 skin evaluation shows a full routine head to toe skin assessment was performed and showed old ,faded discoloration bruises to right arm and upper arms and both legs. No other skin issues noted at this time. Facility policy titled Abuse and Neglect , reviewed 10/24/22 shows Policy Statement : It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse , corporal punishment , misappropriation of property , exploitation , neglect , or mistreatment. Definitions of Abuse , Neglect , Exploitation , & Abuse Coordinator Abuse : Abuse is the willful infliction of mistreatment , injury , unreasonable confinement , intimidation, or punishment. Abuse assumes intent to harm , but inadvertent or careless behavior done deliberately that results in harm may be considered abuse.

Based on interview and record review, the facility failed to accurately assess and implement appropriate interventions for a resident with history of falls for one of three residents (R6) reviewed for falls. This deficient practice resulted in R6 falling and sustaining a subdural hematoma (brain hemorrhage). Findings include: R6's medical record (Face Sheet, Minimum Data Set) documents R6 is a cognitively moderately impaired [AGE] year old with diagnoses including but not limited to: Dementia, Lack of Coordination, Abnormal Posture, [CONDITION(S)] Disorder, and [CONDITION(S)] Disorder. R6 is frequently incontinent of bladder and bowel and requires extensive assistance of one person for toilet use. Physical Medicine and Rehabilitation Initial Note dated 5/15/2021 at 1:44 PM documents R6 was admitted to local hospital on 2/22/2021 status post multiple falls. During this hospitalization , R6 required sitter (via video monitoring) due to impulsive behavior. Incident Summary (Progress Note) dated 10/3/2021 at 6:30 PM documents prior to resident's fall, resident was lying in bed. All of the sudden heard noise coming from resident's room. Writer immediately went to resident's room and noticed resident on the floor next to bed on his right side. While assessing resident, writer noticed urine on the floor. Resident sustained laceration to right eyebrow. Resident unable to describe what happened. Body assessment done from head to toe. Noticed laceration to right eyebrow. Resident assisted to bed with two assistants. General Progress Note dated 10/4/2021 at 10:15 AM documents R6 was admitted to Intensive Care Unit at local hospital with diagnosis of subdural hematoma. On 10/7/2021 at 3:32 PM, V7 (Certified Nursing Assistant/CNA) said, R6 looked unsteady; anytime we saw R6 up, we would immediately get a wheelchair, would wait for direction from nurse (leave at nurse's station or put to bed). We would try to get R6 into the wheelchair. R6 was not easily redirected. On 10/7/2021 at 5:42 PM, V8 (CNA) described R6 as back and forth to their bed (wouldn't sit still). On 10/7/2021 at 5:50 PM, V9 (CNA) said R6 was unstable or unsteady on R6's feet, that R6 needed assistance with ambulation. V9 said R6 would get up on their own. On 10/8/2021 at 10:35 AM, V10 (Licensed Practical Nurse/LPN) said, I heard a noise. I went to investigate; R6 was on the floor on the right side. R6 had a laceration to the right side of R6's head. I noticed urine on the floor. On 10/7/2021 at 5:22 PM, V11 (LPN) said, R6 needs constant monitoring, R6 is constantly getting up from R6's bed, walking to nurse's station then back to bed. R6 is very difficult to re-direct. R6 doesn't want to be told what to do. On 10/8/2021 at 4:00 PM, V12 (Fall Coordinator) said, When I read this (Incident Progress Note), what comes to my mind (root cause analysis), it could be a result of the urine on the floor. Care plan (initiated 4/22/2021) documents R6 is at high risk for falls related to [CONDITION(S)] disorder, [CONDITION(S)] disorder, [CONDITION(S)], and Dementia. Interventions: I prefer to keep all items like water pitcher, tissue box, urinal, etc., within reach; Please avoid repositioning the furniture in my room; Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like the staff to address my needs with a prompt response to all requests for assistance. Care plan does not address resident's past medical history of multiple falls or impulsivity.

Based on interviews and record reviews, the facility failed to have restorative services evaluate a resident's community safety skills post fall in the community. This affected 1 out of 3 residents (R2) reviewed for improper nursing care. This failure resulted in R2 having another fall in the community resulting in a right femur fracture. Findings include: Review of R2's comprehensive care plan reads R2 uses a motorized wheelchair due to [DIAGNOSES REDACTED]. It continues to read that R2 is weak and has decreased functional mobility and poor balance. Progress note dated 9/24/19 4:08 PM written by V7 (Social Service Designee) reads R2 had a fall while out in the community. R2's independent out on pass was revoked and R2 was placed on 72 hours observation post fall. Progress note dated 9/27/19 1:48 PM written by V7 reads R2 wanted to regain independent out on pass privileges. V7 wrote to refer to restorative for evaluation. On 10/24/19 at 11:22 AM, V7 stated she referred R2 to V9 (Restorative Nurse). Progress notes do not read that R2 was evaluated and cleared by V9 for independent out on pass after 9/27/19 but prior to 9/28/19. On 10/24/19 at 1:23 PM, V2 (Nurse Consultant) stated the facility does not have a restorative assessment for R2. V2 stated V9 did not complete an assessment. V2 stated V7 communicated the referral the evening of 9/27/19. V2 stated R2 went out on pass the morning of 9/28/19. Progress note dated 9/28/19 4:52 PM written by V6 (Nurse) reads R2 had another fall while out on pass the morning of 9/28/19. R2 got up from (R2's) motorized wheelchair and ambulated. While ambulating, R2 tripped and injured right lower extremity. On 10/23/19 at 1:19 PM, V6 stated R2 returned to the facility complaining of inability to walk and severe right leg pain. V6 stated she informed the doctor and sent R2 to the hospital for evaluation. Review of hospital records read R2 sustained a right femur fracture that required an open reduction internal fixation. On 10/24/19 at 12:33 PM, V10 (Nurse Practitioner) stated it was necessary for R2 to have a re-evaluation by restorative services. V10 stated R2 should have first been monitored and evaluated within the facility premises. V10 stated restorative services needed to re-evaluate R2 for safety precautions. V10 stated if R2 was deemed safe to be out in the community independently by social services and restorative services, she would have reinstated R2's independent out on pass. Review of R2's comprehensive care plan reads R2 is at risk for falls related to current medication use, poor safety awareness and disease process. Care plan interventions include Restorative Nursing Program evaluation and treatment as indicated. Comprehensive care plan also has a care plan that reads R2 is at risk for falls related to psychoactive drug use, impaired mobility, and impaired balance. Interventions include The resident needs to be evaluated for appropriate adaptive equipment or devices as needed. Re-evaluate as needed for continued appropriateness. Facility policy titled 'Pass Privilege Policy' last revised 8/02/19 reads: It is the policy of the facility to ensure that residents are safe to have out on pass privileges.

Based on interview and record review, the facility failed to monitor bowel movements and evaluate the resident's response to preventative efforts and treatment to avoid fecal impaction which affected one resident (R4) of 5 residents reviewed for bowel movements in a sample of 5 residents. This failure resulted in R4's emergent transfer to the hospital for treatment for [REDACTED]. Findings include: R4 is a [AGE] year old resident originally admitted to the facility on [DATE] for long term skilled nursing and rehabilitation. Facility face sheet dated 7/31/17 with [DIAGNOSES REDACTED]. R4's Care Plan initiated 8/18/16 with target date of 5/15/17 states in part, Focus: The resident is on [MEDICATION NAME] therapy related to constipation; Goal: The resident will be free of discomfort and/or adverse reactions to this medication; Interventions: Administer medication as order, relay side effects to MD immediately; If resident is diabetic [MEDICATION NAME] may alter blood sugar levels; Monitor and record bowel movements, include size, color and consistency; Notify MD and/or nurse of any of the following side effects, should they persist or worsen: Gas, bloating, burping, stomach rumbling/pain, nausea, cramping; Notify MD immediately should serious side effects occur: rash, itching/swelling, severe dizziness, trouble breathing, diarrhea, vomiting, muscle cramps/weakness, irregular heartbeat, mental/mood changes, [MEDICAL CONDITION]. R4's additional Care Plan initiated 8/3/15 (revisions on 8/18/16 and 5/8/16) and target date of 5/15/17, states in part, Focus: The resident is at risk for constipation related to decreased mobility, medication side effects. Goal: The resident will pass soft, formed stool at the preferred frequency of every 2-3 days through the review date. Interventions: Follow facility bowel protocol for bowel management; Monitor medications for side effects of constipation. Keep physician informed of any problems; Monitor/document/report to MD as needed signs/symptoms of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, [MEDICAL CONDITION] (slow, low pulse). Abdominal distension, vomiting; Bowel sounds, diaphoresis, abdomen: tenderness, guarding, rigidity, fecal impaction. MDS (Minimum Data Set) dated 4/24/17 (Section H for Bowel and Bladder) show R4's Bowel Continence scored at a 2 for frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). This same MDS section shows R4 not on a formal toileting program used to manage the resident's bowel continence and also lists R4 as not having constipation. R4's Facility flowsheet dated 4/1/17 through 7/2/17 titled BM Report show the following: April 4th through April 7th (four days) and from April 13th through April 17th (five days), R4 did not have a bowel movement recorded. In May, R4's BM Report shows that from May 1st through May 9th (nine days) and from May 18th through May23rd (six days), (R4) had no bowel movement recorded. In June, R4's BM Report shows from June 5th through June 10th (six days) and June 15th through June 19th (five days) with no bowel movements recorded. From June 30th up to R4's discharge of 7/2/17 to the hospital emergency room , there were no bowel movements recorded. Interview with E2 (DON-Director of Nursing) on 8/2/17 at 11:20 AM states in part, I've been the DON for about a week but the company is all the same with same procedures. (E2 was transferred from sister facility) Asked about the BM Reports, E2 struggled to answer but stated, It looks like report when resident has bowel movement but I can't be sure. Asked what his expectation of his staff, E2 stated, I expect that the C.N.A's notify the nurses who will notify the MD if residents are experiencing long periods with no bowel movements. As a nurse, I would check for fecal impaction and I could do manual removal of the fecal impaction. We should be doing this first. Interview with E3 (ADON-Assistant Director of Nursing) on 8/2/17 at 11:20 AM states in part, I've been the ADON for 7 to 8 months here and prior to that I worked three years as a floor nurse, so yes I'm very familiar with our forms and systems. Asked about the facility BM Report, E2 stated, I don't know the BM Report or what those numbers mean. We don't fill those out. I think the C.N.A.s do but they should be reporting it to the nurses. Interview with E5 (Restorative Director LPN-Licensed Practical Nurse) on 8/2/17 at 11:40AM states in part, I've been the Restorative Director since February 2017. Prior to that I was a floor nurse since 2014. Asked to interpret the facility bowel flowsheets E5 stated, The zero (0) means there was no bowel movement that day; the M means a medium sized bowel movement and 1 means they had one bowel movement, and so on. The initial below it is the initial of the C.N.A.(certified nurse aide). Asked what happens to this information, E5 stated, The C.N.A.s will mark it down on their shift and they should be telling the nurses. Facility progress notes dated 7/2/17 at 10:00 AM written by E6 states in part, Upon routine rounds, resident complained of abdominal pain on a scale of 8/10 and throwing up since yesterday. Assessment done, noted distended abdomen, rigid and hard on touch. Coffee ground emesis noted in a cup in moderate amount. Resident not in any respiratory distress. Alert and oriented, able to verbalize needs. PRN [MEDICATION NAME] given for pain. Vital signs.MD notified, with order to send resident to hospital ER. Order noted and carried out. At 11:10 AM, E6 documents, Ambulance called with estimated time of arrival 20 minutes. At 11:30 AM E6 documents, Resident was taken to hospital on a stretcher, accompanied by two male crew. Endorse to 3-11 nurse to follow up with disposition. Further review of facility progress notes show no other documentation related to R4's constipation nor nursing interventions to address R4 continuous nonmovement of her bowels. Interview with E6 (RN-Registered Nurse) on 8/2/17 at 2:00PM states in part, Yes I am the nurse that sent (R4) to the hospital. I got an order to send her. She had coffee ground emesis. She told me she was throwing up since yesterday but I don't know how many times. (R4) had it in a cup and showed me. Asked if she received any nursing endorsements from the previous shifts about (R4), E6 stated, No they didn't report anything to me. Asked if she assessed (R4), E6 stated, Yes, I took her vitals. Asked what else she did, I checked her bowel sounds and they were present. Asked if she did any other assessment prior to contacting the doctor, E6 stated, No sir, I called the doctor right away. Asked if she knew when (R4) had her last bowel movement E6 responded, No sir, I didn't ask her. Asked if the nursing aides mentioned anything to her about when her last bowel movement was, E6 responded, No, they didn't tell me anything. Facility policy and procedure dated May 5, 2015 titled, Bowel and Bladder Retraining Program states in part, It is the policy of this facility to provide the resident the bowel and bladder program interventions as appropriate in order to help the resident regain the ability to control the bowel and bladder excretory functions. Procedures: Restorative nurse shall complete and review the resident's bowel and bladder evaluation and treatment plan to assess appropriateness and potential; Bowel and Bladder Training Program interventions shall be incorporated into the residents' plan of care; Nurse shall evaluate the resident's diet. Encourage fluid intake and to increase roughage in the diet unless contraindicated; Nurse shall encourage the resident to establish a structured schedule in toileting such as 2-3 hours, upon waking, before each meal, after a nap; Times or scheduled toileting approaches shall be indicted in the care plan; Provide assistance in toileting; encourage resident to the bathroom/toilet or use a bedside commode if appropriate; The Bladder and Bowel Retraining program shall be evaluated and adjusted at least weekly until a pattern has been established. 7/2/17 Hospital emergency department notes show R4 arriving in the Emergency Department at 12:07 PM by ambulance with chief complaint of Emesis (vomitus), nausea, and abdominal pain with abdomen distended and rigid. Hospital emergency department notes authored by Z1 (Emergency Department Doctor #1) on 7/2/17 at 12:31 PM states in part, There is significant amount of stool present in the distal sigmoid colon and rectum with distention of the rectum up to 9.1 centimeters. Large colonic stool burden present in the cecum, ascending colon, and descending colon. There is [MEDICATION NAME] distention of the [MEDICATION NAME] colon up to approximately 5.5 centimeters. Multiple non-distended fluid-filled loops of small bowel present. The stomach is distended with fluid and ingested material. There is reflux of fluid into the distal esophagus which is distended with fluid. Very large colonic stool burden particularly in the distal sigmoid colon and rectum compatible with a fecal impaction. Z1 denotes R4's Diagnosis: [REDACTED]. Z2 (Emergency Department Doctor #2) wrote on 7/2/17 at 4:22 PM, Endorsed by AM physician. On exam, [MEDICAL CONDITION] (rapid heart rate), appears hypovolemic and endorses pain. Abdomen distended with typany concerning for bowel obstruction. Surveyor contacted Z2 on 8/2/17 at 2:30 PM and read over the notes to refresh Z2's memory of his examination of (R4). Telephone interview with Z2 states in part, The abdominal distension doesn't happen overnight. Fecal impaction is a gradual event and can be prevented if the nursing home monitored her bowel movements, hydrated her, utilized preventative stool softeners, etc. which obviously they did not do as (R4) had extensive fecal matter in her entire colon and cecum (beginning of the large intestine). Attempted to call Z3 (attending physician) on 8/2/17 and 8/3/17 but no return call was received. Interview on 8/3/17 at 12:25 PM with Z9 (Nurse Practitioner), states in part, I do see (R4); she is one of my residents and I'm familiar with her. I asked for (R4) when I came to visit and the nurses told me she was sent to the hospital. (R4) is bed bound and the nurses would usually say if they have a bowel movement. They (the nurses) have to make sure she is moving her bowels and they have to know how often. You have to be a little concerned especially with somebody like her. If she did not have a bowel movement for 48 hours you can ask her if you can give her something to help her go to the bathroom. As a nurse you can ask me or the doctor to order a K.U.B. (lab test to assess the organs of urinary and gastrointestinal systems used to diagnose urinary disorders and causes of abdominal pain). The nurses have to tell me what's going on and I take action. They should have done that with (R4) that should have been caught if she was having that long period of no bowel movements.

Based on observations, interviews and record reviews the facility failed to ensure one of 20 sampled residents (R5) was protected from abuse in a sampled 20, reviewed for abuse. The lack of supervision and monitoring for R5, who is cognitively impaired, resulted in sexual assault by another resident (R6). R5 had known behaviors that put her at risk for being abused and the facility failed to have interventions in place for preventing abuse. Immediate Jeopardy was identified on 7/20/13 when R5 was sexually assaulted by R6. On 8/12/13 at 9:45AM, E1(Assistant Administrator), E2 (Director of Nursing/DON) and E8(Administrator) were informed of the Immediate Jeopardy. Findings Include: R5 is a [AGE] year old female admitted to facility on 8/24/12 with [DIAGNOSES REDACTED]., Asthma, Difficulty walking and [MEDICAL CONDITION] per POS (Physician Order Sheet) dated 12/24/12. MDS (Minimum Data Set) dated 6/21/13 denotes R5 speech score is 2, (indicating no speech); makes self-understood score is 3 (indicating rarely/never understands); understanding verbal content score is 2 (indicating sometimes understood). Cognitive Patterns score is 1 denoting memory problems; cognitive skills for Daily Decision Making score is 3 (indicating severely impaired). Signs and Symptoms of [MEDICAL CONDITION] score is 2 (indicating behavior fluctuates). R5's behaviors consist of wandering into other resident rooms and getting into empty/unoccupied beds, taking her clothes off, walking up close to others, and staring at others. Documentation and interviews over the course of the survey from family, nurses, CNA ' s (Certified Nursing assistants), physicians, psychiatrists and social services indicated that R5 should have been monitored closely because of these at risk behaviors. On 8/09/13 at approximately 4:40PM, Z4 (Family member of R5), stated that R5 was severely cognitively impaired. She wanders and has been doing it for quite some time. Z4 stated that R5 does not talk and she visits R5 two to three times per month. "R5 could not consent for sex because she would not know what the person is talking about. She just stares." Z4 stated that about 3 months ago she was visiting R5 and saw her standing in a man's room as she was getting off the elevator. Z4 said she went to the room and asked the man what R5 was doing in his room but got no answer. Z4 said she did not know why they (staff) wanted to change R5's room so she would be closer to the nursing station. Nursing admission assessment dated [DATE] remarks that R5 was non-communicative and has wandering behaviors. Nurses notes on 8/25/12 remarks about incident where R5 was in a male room. "They were yelling at her telling her to get out". Incident report dated 9/16/12 remarks that R5 was abused. R5 was physically assaulted by another resident while on patio on September 16, 2012 where she sustained scratches to the face. Care Plan dated 12/29/12 indicates R5 had fading bruises on arms and right lateral thigh. Social Services Quarter Care Plan note dated 4/04/13 remarks that R5 was observed wandering and pacing throughout 4th floor. "She is alert but often does not respond to staff prompts. Resident is often non-responsive to others and may stare at people. This staring sometimes upsets peers who are not familiar with R5 and she needs redirection from this behavior. She has history of wandering into other ' s room. Often R5 is heard or seen laughing which may be a response to internal stimuli". Per Nursing note dated 6/30/13, R5 was found with bruise on the upper right eye lid. Documentation states "no injury noted and no red eye noted, denies pain, continue monitoring, vital signs taken, given oral medications, endorsed to next shift". Wandering Behavior Care Plan dated 7/20/13 remarks resident wanders into other resident's rooms. Care Plan does not address resident taking her clothes off, getting close to and staring at peers inappropriately. There is no Care Plan addressing R5's history of physical abuse or being at high risk for abuse after assault incident on 7/20/13. According to incident report dated 7/21/13, R5 is a [AGE] year old female who was sexually assaulted by another R6 (male resident) on the 7/20/13 at approximately 6:00PM. E3 (CNA-Certified Nursing Assistant) entered R6's room to pick up dinner trays. When she pulled back privacy curtain, she saw R6 standing at side of the bed with his pants down. He hurriedly proceeded to pull his pants up as she entered the space. E3 saw R5 lying supine in his bed with her pants and diaper pulled down. On 8/08/13 at approximately 10:30AM E2 (DON - Director of Nursing) said she interviewed R6 and said he/R6 fondled her clitoris but did not have sexual intercourse with R5. On 8/07/13 at approximately 1:45PM, E1 (Assistant administrator) corroborated the same accounts of the sexual assault incident on 7/20/13 involving R5 and R6. E1 indicated Resident's physicians, families, police and State Agency were notified and indicated residents were placed on close observation monitoring. E1 stated that E2 in the facility and knew more details about the incident. On 8/07/13 at approximately 2:00PM, E2 said there were no physician orders for R6 or R5 in the charts regarding one to one monitoring, sending the residents out to hospital for evaluation, pass privileges for R6, or discontinuing monitoring for R6. E2 said she forgot to write down the telephone orders of 7/20/13 and 7/21/13. On 8/07/13 at approximately 2:30PM, E2 discussed the events that occurred on 7/20/13 and 7/21/13. R6 was maintained on 1:1 and transferred to another unit immediately following the incident. Resident's doctors were notified of incident and R6 ' s doctor said to keep R6 on close monitoring. E2 said, during interview with R6, he said he did not have sexual intercourse with R5, he just fondled her clitoris and said "go ahead and call the police, I will tell the police the same thing I told you". R6 said he did have sex in [AGE] years. Resident's families were notified. Police were notified and came to facility and interviewed both residents. On 8/07/13 at approximately 3:45PM, E3 said R5 had a look of shock on her face and her eyes were wide open; looked fearful. E3 said she was shocked to see this and yelled out to nurse for help as she pulled up R5's pants. Nurse's came to room to help. E3 indicated that the room housed three males and that roommates were not present during the time of the incident. The nurses attended to R6 and she escorted R5 back to her room. E3 said she remained on 1:1 with R5 until she was sent to E.R.(emergency room ) about two hours later. R5 interviewed by female police before being sent to E.R. E3 said R5 usually does not talk at all but eventually talked to nurse in E.R. about incident and was confused. First she said she did not consent to sex and then stated she said yes to sex, but appeared confused and fearful during the conversations. E3 said she was not present when actual rape kit was done by the doctor. On 8/07/13 at 4:25PM, E4 (Social Services) said she was in facility on the day after the incident, 7/21/13, and that R6 was out of facility on pass when she arrived. E4 said R6's wife had called the facility and spoke with her about R6's being paranoid and fearful of returning to facility because of Police asking him questions the day before. The wife said she did not know what to do. E4 said she told the wife she could bring him back to facility for admission to hospital for psychiatric evaluation or she could take R6 to the closest E.R. E4 stated she left work that evening before R6 and his wife returned to facility. Observation on 8/07/13 at approximately 5:15PM, R5 was in the dayroom sitting with E3 awaiting the dinner meal. R5 sat with her head hanging down at times; impulsive movements were noted, i.e., standing up suddenly. R5 could not answer any questions. On 8/07/13 at approximately 5:15PM, E8 (Medication nurse) she stated that R5 does not talk, appears "zombie like". "She needs redirection at times. I float to different units and was endorsed that R5 was on close monitoring". On 8/08/13 at 2:00PM, R5 observed walking down the hall with E16. R5's pants and diaper were falling down. E2 was made aware. On 8/08/13 at 2:25PM, E2 stated, " Maybe we could get R5 some clothes that button up from the back so she will not take them off. " On 8/08/13 at 4:00PM, Z1 (Attending Physician) stated that he was notified by nurses of incident on 7/20/13 and that R5 was sent to emergency room for evaluation with close monitoring. Z1 said that this was uncharacteristic of both residents, and that R5 has to be watched and needed more supervision; "staff should monitor closely". Z1 stated that R6 just recovering from medical issues and was weak. Z1 said he was surprised about the incident. Z1 stated he was not aware R6 went out on pass the next day. On 8/08/13 at approximately 4:30PM, Z2 (Psychiatrist) stated he was very surprised to hear about the assault incident of R5 and R6 because it has never happened before with either of them. Z2 indicated that when notified he ordered for R6 to be placed on close monitoring and he was relocated to another unit. Z2 indicated he was not aware resident went out on pass with wife the following day. On 8/09/13 at 10:15AM Z3 (Attending Physician of R5) indicated he was notified of incident on 7/20/13 and followed protocol for R5 to be sent out to hospital for evaluation and no forced trauma was found. He stated that R6 had no aggressive behaviors prior to incident and had no previous acts documented. Hospital History and Physical record dated 7/20/13 remarks that R5 received vaginal examination performed, rape-kit applied and [MEDICATION NAME] antibiotic treatments were given by mouth. Also, Labs were drawn [MEDICAL CONDITION].[MEDICAL CONDITION] and C. Patient is denying pain, vaginal discharge, vaginal bleeding, and other concerns. Right and left adnexum displays no mass, no tenderness, and no fullness. No rash or tenderness to labia. There are no foreign body around the vagina. She will intermittently answer questions, but has a very [MEDICATION NAME] affect. R5 remains in facility at this time and she is maintained on one to one monitoring for wandering behaviors into resident rooms, taking off her clothes, walking close up to people and staring. R5 continues to require constant redirection as she attempts to enter into rooms of other residents. Her room is located in the back corridor of the secured unit where two rooms down from her room are three rooms of male residents. The Immediate Jeopardy was removed on August 12, 2013 at 5:30PM. The facility still remains out of compliance at a Severity and Scope-Level 2. The facility needs to allow time to complete staff training and Nursing in- services, and to evaluate the effectiveness of the revised policies/protocols/monitoring and assessments for residents who wander and are at risk for physical and sexual abuse. The facility took the following measures to reduce the Immediate Jeopardy to severity Level 2. 1. Residents were immediately separated by the Nurse and DON on 7/20/13 2. R5 was immediately assessed by the nurse following the allegation 3. R6 was immediately transferred to another floor 4. R5 and R6 were supervised by staff 1:1 immediately following the allegation 5. Attending physician, psychiatrist, and family notified for both residents on 7/20/13 at 7:15pm and 8pm. 6. Local police notified on 7/20/13 at 8:30pm; came to the facility interviewed residents. 7. State Agency notified of allegation 7/21/13; final report submitted on 7/25/13. 8. Ombudsman (C. Reid) notified of allegation on 7/23/13 and given all details of incident and investigation. 9. R5 sent to hospital on [DATE] for evaluation; was placed on close monitoring upon return to the facility and presently. 10. R6 was given a 30 day discharge notice on 7/2`1/13 by Acting Administrator. 11 on 7/22/13 at 12:30am, R6 was sent to the local hospital for evaluation. Resident did not return to facility. 12. All employees were re-educated by Administration and the Director of Nursing on the Facility's abuse and neglect policy and on Resident Rights beginning 7/21 to present. 13. All residents were reassessed for risk for potential abuse by Social Services on 7/21/1314. Resident care plans were also reviewed and updated. 14. All residents identified as wanderer's were reassessed by Social Services and care plans were updated. 15. The abuse and neglect policy and Resident Rights were reviewed with all residents on 8/12/13 by the Activity Director. 16. Facility conducts weekly Behavior Monitoring Meeting. Social Service leads the meetings with input from designated nursing staff. 17. Facility conducts weekly Abuse meetings led by the Administrator with department heads attending. (Meetings held 7/26, 8/2, 8/9 and 8/12/13) 18. For QA (Quality Assurance) purposes, Nurse Manager or Social Services director will do a random observation of 6 residents assessed as wanderers once per shift per day. Evaluator will do this at varied times to ensure that behaviors are being monitored and addressed appropriately. This will continue to be discussed weekly at the Behavior meetings and monthly QA meetings. This will be on-going. 19. Abuse policy updated 8/2/13 for revised screening employees procedure, clarification on bruises and injuries of unknown origin, protecting residents during investigation, and reporting. Update again on 8/12/13 for emphasis on immediacy of reporting.

Based on observations, interviews and record reviews the facility failed to supervise one resident (R5) with wandering behavior out of 8 residents sampled reviewed for this behavior, in the sample of 20. This resulted in the resident (R5) being sexually assaulted during the evening of 7/20/13. R5, a severely cognitively impaired resident, wandered into a male resident's room and was found by a CNA (Certified Nursing assistant) lying in bed with her pants and brief removed. Because the facility staff were not aware that R5 had wandered into another residents room, and did not closely monitor and supervise the resident for this behavior, an Immediate Jeopardy was identified as beginning on 7/20/13. On 8/12/13 at 9:45AM, E8(Assistant Administrator), E2 (Director of Nursing - DON) and E1(Assistant Administrator) were notified of the Immediate Jeopardy. Findings Include: R5 is a [AGE] year old female admitted to facility on 8/24/12 with [DIAGNOSES REDACTED]., Asthma, Difficulty walking and [DIAGNOSES REDACTED] per POS (Physician Order Sheet) dated 12/24/12. MDS (Minimum Data Set) dated 6/21/13 denotes R5 speech score is 2, (indicating no speech); makes self-understood score is 3 (indicating rarely/never understands); understanding verbal content score is 2 (indicating sometimes understood). Cognitive Patterns score is 1 denoting memory problems; cognitive skills for Daily Decision Making score is 3 (indicating severely impaired). Signs and Symptoms of Delirium score is 2 (indicating behavior fluctuates). R5's behaviors consist of wandering into other resident rooms and getting into empty/unoccupied beds, taking her clothes off, walking up close to others, and staring at others. Documentation and interviews over the course of the survey from family, nurses, CNA ' s (Certified Nursing assistants), physicians, psychiatrists and social services indicated that R5 should have been monitored closely because of these at risk behaviors. On 8/09/13 at approximately 4:40PM, Z4 (Family member of R5), stated that R5 was severely cognitively impaired. She wanders and has been doing it for quite some time. Z4 stated that R5 does not talk and she visits R5 two to three times per month. "R5 could not consent for sex because she would know what the person is talking about. She just stares." Z4 stated that about 3 months ago she was visiting R5 and saw her standing in a man ' s room as she was getting off the elevator. Z4 said she went to the room and asked the man what R5 was doing in his room but got no answer. Z4 said she did not know why they (staff) wanted to change R5 ' s room so she would be closer to the nursing station. Nursing admission assessment dated [DATE] remarks that R5 was non-communicative and has wandering behaviors. Nurses notes on 8/25/12 remarks about incident where R5 was in a male room. "They were yelling at her telling her to get out". Incident report dated 9/16/12 remarks that R5 was abused. R5 was physically assaulted by another resident while on patio on September 16, 2012 where she sustained scratches to the face. Care Plan dated 12/29/12 indicates R5 had fading bruises on arms and right lateral thigh. Social Services Quarter Care Plan note dated 4/04/13 remarks that R5 was observed wandering and pacing throughout 4th floor. "She is alert but often does not respond to staff prompts. Resident is often non-responsive to others and may stare at people. This staring sometimes upsets peers who are not familiar with R5 and she needs redirection from this behavior. She has history of wandering into other ' s room. Often R5 is heard or seen laughing which may be a response to internal stimuli". Per Nursing note dated 6/30/13, R5 was found with bruise on the upper right eye lid. Documentation states "no injury noted and no red eye noted, denies pain, continue monitoring, vital signs taken, given oral medications, endorsed to next shift". Wandering Behavior Care Plan dated 7/20/13 remarks resident wanders into other resident's rooms. Care Plan does not address resident taking her clothes off, getting close to and staring at peers inappropriately. There is no Care Plan addressing R5's history of physical abuse or being at high risk for abuse after assault incident on 7/20/13. According to incident report dated 7/21/13, R5 is a [AGE] year old female who was sexually assaulted by another R6 (male resident) on the 7/20/13 at approximately 6:00PM. E3 (CNA-Certified Nursing Assistant) entered R6's room to pick up dinner trays. When she pulled back privacy curtain, she saw R6 standing at side of the bed with his pants down. He hurriedly proceeded to pull his pants up as she entered the space. E3 saw R5 lying supine in his bed with her pants and diaper pulled down. On 8/08/13 at approximately 10:30AM E2 (DON - Director of Nursing) said she interviewed R6 and said he/R6 fondled her clitoris but did not have sexual intercourse with R5. On 8/07/13 at approximately 1:45PM, E1 (Assistant administrator) corroborated the same accounts of the sexual assault incident on 7/20/13 involving R5 and R6. E1 indicated Resident's physicians, families, police and State Agency were notified and indicated residents were placed on close observation monitoring. E1 stated that E2 in the facility and knew more details about the incident. On 8/07/13 at approximately 2:00PM, E2 said there were no physician orders for R6 or R5 in the charts regarding one to one monitoring, sending the residents out to hospital for evaluation, pass privileges for R6, or discontinuing monitoring for R6. E2 said she forgot to write down the telephone orders of 7/20/13 and 7/21/13. On 8/07/13 at approximately 2:30PM, E2 discussed the events that occurred on 7/20/13 and 7/21/13. R6 was maintained on 1:1 and transferred to another unit immediately following the incident. Resident's doctors were notified of incident and R6 ' s doctor said to keep R6 on close monitoring. E2 said, during interview with R6, he said he did not have sexual intercourse with R5, he just fondled her clitoris and said "go ahead and call the police, I will tell the police the same thing I told you". R6 said he did have sex in [AGE] years. Resident's families were notified. Police were notified and came to facility and interviewed both residents. On 8/07/13 at approximately 3:45PM, E3 said R5 had a look of shock on her face and her eyes were wide open; looked fearful. E3 said she was shocked to see this and yelled out to nurse for help as she pulled up R5's pants. Nurse's came to room to help. E3 indicated that the room housed three males and that roommates were not present during the time of the incident. The nurses attended to R6 and she escorted R5 back to her room. E3 said she remained on 1:1 with R5 until she was sent to E.R.(emergency room ) about two hours later. R5 interviewed by female police before being sent to E.R. E3 said R5 usually does not talk at all but eventually talked to nurse in E.R. about incident and was confused. First she said she did not consent to sex and then stated she said yes to sex, but appeared confused and fearful during the conversations. E3 said she was not present when actual rape kit was done by the doctor. On 8/07/13 at 4:25PM, E4 (Social Services) said she was in facility on the day after the incident, 7/21/13, and that R6 was out of facility on pass when she arrived. E4 said R6's wife had called the facility and spoke with her about R6's being paranoid and fearful of returning to facility because of Police asking him questions the day before. The wife said she did not know what to do. E4 said she told the wife she could bring him back to facility for admission to hospital for psychiatric evaluation or she could take R6 to the closest E.R. E4 stated she left work that evening before R6 and his wife returned to facility. Observation on 8/07/13 at approximately 5:15PM, R5 was in the dayroom sitting with E3 awaiting the dinner meal. R5 sat with her head hanging down at times; impulsive movements were noted, i.e., standing up suddenly. R5 could not answer any questions. On 8/07/13 at approximately 5:15PM, E8 (Medication nurse) she stated that R5 does not talk, appears "zombie like". "She needs redirection at times. I float to different units and was endorsed that R5 was on close monitoring". On 8/08/13 at 2:00PM, R5 observed walking down the hall with E16. R5's pants and diaper were falling down. E2 was made aware. On 8/08/13 at 2:25PM, E2 stated, " Maybe we could get R5 some clothes that button up from the back so she will not take them off. " On 8/08/13 at 4:00PM, Z1 (Attending Physician) stated that he was notified by nurses of incident on 7/20/13 and that R5 was sent to emergency room for evaluation with close monitoring. Z1 said that this was uncharacteristic of both residents, and that R5 has to be watched and needed more supervision; "staff should monitor closely". Z1 stated that R6 just recovering from medical issues and was weak. Z1 said he was surprised about the incident. Z1 stated he was not aware R6 went out on pass the next day. On 8/08/13 at approximately 4:30PM, Z2 (Psychiatrist) stated he was very surprised to hear about the assault incident of R5 and R6 because it has never happened before with either of them. Z2 indicated that when notified he ordered for R6 to be placed on close monitoring and he was relocated to another unit. Z2 indicated he was not aware resident went out on pass with wife the following day. On 8/09/13 at 10:15AM Z3 (Attending Physician of R5) indicated he was notified of incident on 7/20/13 and followed protocol for R5 to be sent out to hospital for evaluation and no forced trauma was found. He stated that R6 had no aggressive behaviors prior to incident and had no previous acts documented. Hospital History and Physical record dated 7/20/13 remarks that R5 received vaginal examination performed, rape-kit applied and prophylactic antibiotic treatments were given by mouth. Also, Labs were drawn for HIV, Hepatitis B and C. Patient is denying pain, vaginal discharge, vaginal bleeding, and other concerns. Right and left adnexum displays no mass, no tenderness, and no fullness. No rash or tenderness to labia. There are no foreign body around the vagina. She will intermittently answer questions, but has a very blunted affect. R5 remains in facility at this time and she is maintained on one to one monitoring for wandering behaviors into resident rooms, taking off her clothes, walking close up to people and staring. R5 continues to require constant redirection as she attempts to enter into rooms of other residents. Her room is located in the back corridor of the secured unit where two rooms down from her room are three rooms of male residents. The Immediate Jeopardy was removed on August 12, 2013 at 5:30PM. The facility still remains out of compliance at a Severity and Scope-Level 2. The facility needs to allow time to complete staff training and Nursing in- services, and to evaluate the effectiveness of the revised policies/protocols/monitoring and assessments for residents who wander and are at risk for physical and sexual abuse. The facility took the following measures to reduce the Immediate Jeopardy to severity Level 2. 1. Residents were immediately separated by the Nurse and DON on 7/20/13 2. R5 was immediately assessed by the nurse following the allegation 3. R6 was immediately transferred to another floor 4. R5 and R6 were supervised by staff 1:1 immediately following the allegation 5. Attending physician, psychiatrist, and family notified for both residents on 7/20/13 at 7:15pm and 8pm. 6. Local police notified on 7/20/13 at 8:30pm; came to the facility interviewed residents. 7. State Agency notified of allegation 7/21/13; final report submitted on 7/25/13. 8. Ombudsman (C. Reid) notified of allegation on 7/23/13 and given all details of incident and investigation. 9. R5 sent to hospital on [DATE] for evaluation; was placed on close monitoring upon return to the facility and presently. 10. R6 was given a 30 day discharge notice on 7/2`1/13 by Acting Administrator. 11 on 7/22/13 at 12:30am, R6 was sent to the local hospital for evaluation. Resident did not return to facility. 12. All employees were re-educated by Administration and the Director of Nursing on the Facility's abuse and neglect policy and on Resident Rights beginning 7/21 to present. 13. All residents were reassessed for risk for potential abuse by Social Services on 7/21/1314. Resident care plans were also reviewed and updated. 14. All residents identified as wanderer's were reassessed by Social Services and care plans were updated. 15. The abuse and neglect policy and Resident Rights were reviewed with all residents on 8/12/13 by the Activity Director. 16. Facility conducts weekly Behavior Monitoring Meeting. Social Service leads the meetings with input from designated nursing staff. 17. Facility conducts weekly Abuse meetings led by the Administrator with department heads attending. (Meetings held 7/26, 8/2, 8/9 and 8/12/13) 18. For QA (Quality Assurance) purposes, Nurse Manager or Social Services director will do a random observation of 6 residents assessed as wanderers once per shift per day. Evaluator will do this at varied times to ensure that behaviors are being monitored and addressed appropriately. This will continue to be discussed weekly at the Behavior meetings and monthly QA meetings. This will be on-going. 19. Abuse policy updated 8/2/13 for revised screening employees procedure, clarification on bruises and injuries of unknown origin, protecting residents during investigation, and reporting. Update again on 8/12/13 for emphasis on immediacy of reporting.