Every finding on record at Citadel of Skokie, The

Based on observation, interview, and record review, the facility failed to have a call light accessible for residents. This applies to 5 of 5 residents (R1, R2, R3, R4 & R5) reviewed for call light accessibility in a sample of 5.The findings include:1.R1 is a [AGE] year-old male admitted on [DATE], having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 1/21/26 at 9:45 AM, R1's call light was observed with around four meters of call light string trapped under the wheelchair wheel, and was unable to trigger the call.On 1/21/26 at 9:45 AM, R1 stated, My call light is not working. The call string is too long and is trapped somewhere, and I can't trigger the call.On 1/21/26 at 10:00 AM, V3 cleared the long call light string, which was under the wheelchair, and got it for R1. V3 stated, The call light should be accessible to the resident, and the resident should be able to use it. The call light is too long and was stuck among the wheelchair wheels.2.R2 is a [AGE] year-old female admitted on [DATE] and having a severe cognitive impairment as per the MDS dated [DATE].On 1/21/26 at 10:02 AM, R2 was observed in bed A in her room, and her call light string was observed in bed B.On 1/21/26 at 10:04 AM, observed V5 (Licensed Practical Nurse / LPN) pick up the call light string from bed B to R1 in bed A. V5 stated that the call light should be available for residents to call for help.3.R3 is a [AGE] year-old female admitted on [DATE], having moderate cognitive impairment as per the MDS dated [DATE].On 1/21/26 at 10:05 AM, R3 was observed in her bed with the call light on the floor, and R3 stated that she couldn't access the call light.4.R4 is a [AGE] year-old female with cognition intact as per the MDS dated [DATE].On 1/21/26, at 10:05 AM, R4 was observed in her room with a broken call light string on the wall. The string was observed to be only one foot long and was unable to reach out to R4.On 1/21/26 at 10:10 AM, V6 (Registered Nurse/RN) stated that the call light should be accessible to residents, and she would tell the maintenance to replace the broken string.5.R5 is a [AGE] year-old female admitted with cognition intact as per the MDS dated [DATE].On 1/21/26 at 10:20 AM, R5 was observed in her bed with a call light hanging from the wall. R5 stated that her call light is not hooked up to her bed to call.On 1/21/26 at 10:50 AM, V2 (Director of Nursing / DON) stated that the call light should be accessible to residents to call for help.The facility presented an undated call light policy document:Policy: In order to ensure resident's needs are promptly identified and met, the facility will utilize a resident call light system. The staff will respond to resident's request and needs as identified.Procedure:5. Place the call light where the resident can reach it.

Based on observation, interview and record review, the facility failed to follow their Oxygen Administration Policy. Facility failed to follow physician's order for oxygen administration. This deficient practice affects one resident (R8) of three residents reviewed for oxygen administration in a total sample of 23.Findings Include On 11/18/25 at 10:15AM, observed R8 in bed, oxygen concentrator at bedside. Oxygen concentrator is set to 3L (Liters) per minute via nasal cannula.On 11/18/25 at 11:00AM, observed and confirmed with V5 (Nurse) that R8's oxygen setting is at 3L per minute. V5 also stated that R8 is on continuous oxygen administration at 3L per minute.R8 is a [AGE] year-old male resident under hospice care for diagnosis of COPD (Chronic Obstructive Pulmonary Disease) started on 7/18/25.Physician order sheet reviewed. Order for Oxygen at 1 liter per minute per nasal cannula continuously with an order start date of 9/5/25.11/20/25 at 10AM, V2 DON (Director of Nursing) stated that the expectation is for the nurses to follow the physician order for oxygen administrator. Stated that if the oxygen needs to be increased, the nurse should call the attending physician and get an order for it.Oxygen Administration Policy with a revised date of October 2010, reads in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to follow its call light policy by not having the call light within reach. This applies to 1 of 2 residents (R77) reviewed for accommodation of needs in a sample of 23. The findings include:R77 is a [AGE] year-old female having severely impaired cognition as per the Minimum Data Set (MDS) dated [DATE]. On 11/18/25 at 12:54 PM, the writer heard from the hallway that R77 was screaming for a spoon to eat her lunch with her door closed. On 11/18/25 at 12:55 PM, R77 was observed in her bed with a lunch tray, and a call light was found on the floor. R77 stated, I need a spoon. I don't know where my call light is. On 11/18/25 at 12:57 PM, V4 (Certified Nursing Assistant/CNA) brought a disposable spoon for R77, retrieved the call light from the floor, placed it within reach for R77, and stated, The call light should be accessible for residents, and I don't know what happened. On 11/20/25 at 9:40 AM, V2 (Director of Nursing/DON) stated that the call light should always be within reach of residents to call for assistance and that she will in-service staff on the call light policy. A review of R77's care plan documented that R77 was care planned for risk of falls, with interventions including ensuring the resident's call light is within reach and encouraging the resident to use it for assistance. The resident needs a prompt response to all requests for assistance. A review of the facility presented the call light policy (revised March 2018) statement document: In order to ensure residents' needs are promptly identified and met, the facility will utilize a resident call light system. The staff will respond to residents' requests and needs as identified.Procedure:5. Place the call light where the resident can always reach it.

Based on observation, interview, and record review, the facility failed to develop and implement wound prevention interventions for a resident (R16) with a recent progression in dementia before a wound developed and failed to ensure pressure reduction devices were applied as ordered after the development of a pressure wound for one out of five residents reviewed for pressure ulcers in a total sample of 23. This failure resulted in R16 developing a blister to the right heel and stage one pressure injury to the right lateral foot. Findings Include: R16 is a [AGE] year old with the following diagnosis: dementia and Parkinson's disease. Due to R16's mental status, R16 could not be interviewed. On 11/20/25 at 2:23PM, V7 (CNA) stated R16 should have heel protector boots on at all times while in bed to prevent the foot wounds from getting worse. V7 reported R16 has been losing weight but does not know the cause. V7 stated the heel protectors were recently ordered within the last two weeks. V7 was unaware is R16 is at risk for developing pressure ulcers. On 11/20/25 at 2:27PM, R16 was in bed without the heel protectors on R16's feet. V8 (R16's care giver) was sitting at the bed side. V8 stated V8 assisted R16 back to bed around 2PM but didn't put the heel protectors on because it is too hard to put them on. V8 reported being hired by R16's family to sit with R16 from four to eight hours a day for four to five days a week. V8 stated R16 has recently had a mental decline and has been less mobile the last month even with therapy services and now needs assistance with repositioning in bed. V8 reported R16 had a blister develop to the right heel within the last one to two weeks. No other pressure redistribution/relieving devices were on R16's bed. On 11/20/25 at 2:33PM, V9 (Nurse) stated R16 has a dark red colored blister to the right heel that is about the size of a quarter. V9 reported V9 would need to check the chart but R16 could possibly be at risk for developing wounds due to being chairfast and incontinent. V9 stated R16 has had weight loss that is from an unknown cause. V9 reported wound prevention interventions are put in the computer by the wound care nurse and the staff nurses check off the interventions are in place on the Medication Administration Record and/or Treatment Administration Record (TAR). V9 stated the wound treatments need to be checked off on the TAR so prove the treatment was completed. V9 reported the heel protectors should be on at all times while R16 is in bed. V9 stated nurses and CNAs are responsible for making sure wound interventions are in place during rounds. V9 was unable to answer why R16 didn't have the heel protectors on at this time and reported V8 was at the bedside. On 11/20/25 at 2:40PM, V10 (Wound Care Coordinator) stated R16 currently has a blister to the right heel and a stage I to the right lateral foot. V10 reported R16 now needs assistance in bed because R16 is not moving in bed as much for about the last two weeks. V10 stated R16's dementia has progressed and now R16 is more confused and needs more assistance with ADL (activities of daily living) care. V10 reported the wounds were found on 11/10/25. V10 stated R16 has been being followed by the dietitian for a decrease in oral intake and weight loss. V10 stated if a resident isn't eating as much or getting the correct amount of protein then they are more prone to wound development. V10 reported while in bed R16 should have heel protectors in place at all times for off loading and should be being turned ever two hours. V10 denied having an order for the heel protectors in place before the wounds developed because R16 was moving around more. When asked if any interventions were put in place for wound prevention after the dementia progression was noticed, V10 stated they were focused on dietary interventions. V10 reported it is the nurses, CNAs, and wound care nurse's responsibility to check during rounds to make sure the heel protectors are in place when R16 is in bed. V10 denied that it is the care givers responsibility to put the heel protectors on and reported V8 is only there to monitor R16. V10 stated a score of 14 on the Braden scale indicates a resident is at moderate risk for developing wounds. V10 denied having any new laboratory levels completed since R16's decline. V10 reported a resident qualifies for a pressure reducing mattress if they need assistance with turning/repositioning in bed and if they have redness on their sacral area. When asked if R16 qualifies for a pressure reducing mattress now, V10 stated yes because R16 has had a decline. When asked why R16 hasn't had the pressure reducing mattress in place already since staff knew about the decline, V10 reported V10 will call the physician to get the order now. On 11/20/25 at 3:12PM, V1 (Administrator) stated R16 has had a recent progression in dementia which had led to an overall decline within the last two weeks. On 11/21/25 at 10:32PM, V13 (Wound Nurse Practitioner) stated V13 saw R16 last week after a referral. V13 reported the heel blister to the right foot is likely due to wearing inserts that were too hard in the shoe and from friction. V13 stated R16 has a history of Parkinson's disease, dementia, is incontinent, and muscle weakness, which puts R16 at risk for developing wounds. V13 was unaware of R16's weight loss or nutritional status, but reported poor nutrition is a big factor in developing wounds. V13 stated V10 overseas the whole picture of the wound healing process where V13 cares for the wound through assessment and providing treatments. V13 reported interventions should include incontinence care, soft shoe inserts, turning from side to side went in bed, and heal protectors to help offload when in bed.The Braden Scale dated 10/2/25 documents a score of 15 indicating R16 is at risk for developing wounds due to being very moist, very limited mobility, walks occasionally, has a slightly limited sensory, has adequate nutrition, and friction and sheer are a potential problem.A Skin/Wound note dated 11/10/25 documents upon skin check, a blister was noted to the right heel and a skin alteration to the right lateral foot. The nurse practitioner was notified and a treatment order was obtained and carried out.The Braden Scale dated 11/10/25 documents a score of 14 indicating R16 is at a moderate risk for developing pressure ulcers. R16's activity level was changed from walk occasionally to chair fast which increased R16's score.The Physician Order Sheet documents offloading device on feet while in bed every shift for wound prevention was ordered on 11/13/25. A low air loss mattress was ordered on 11/20/25. Wound care treatments to the right lateral foot and right heel were ordered on 11/10/25. The weights document R16 has had a 36.5 pound weight loss from 04/2025 through 11/2025. The last three months of dietary notes reviewed and document the weight loss is likely multifactorial from an increase in energy expenditure from tremors, feeding difficulty, and underlying disease process. A Nutrition note dated 10/15/25 documents R16 has had a 17.33% significant weight loss over the past six months. R16 has mild anemia and is at risk for poor nutrition. The weight loss is likely multifactorial. R16 remains at risk for malnutrition given significant prior weight loss, borderline anemia and is a skin breakdown risk. Goal is to prevent further weight loss and skin breakdown.The Wound Assessment Details Report dated 11/17/25 documents the right heel wound is classified as a blister that was identified on 11/10/25. The wound was facility acquired. Skin is intact. The wound measures 2.2 cm x 3 cm by unknown. Interventions include to wear offloading devices on feet while in bed. The Wound Assessment Details report dated 11/17/25 documents the right lateral foot wound is classified as a stage 1 pressure ulceration that was identified on 11/10/25. The wound was facility acquired. The wound is 50% intact skin with 50% non-blanchable redness. The wound measures 7.5 cm x 1.2 cm by unknown.The Wound Nurse Practitioner note dated 11/17/25 documents the primary care physician requested R16 to be seen by the wound care nurse practitioner for skin alterations/lesions. R16 has a wound to the right heel that is classified as a blister. R16 is deconditioned with multiple medical problems and risk factors that may cause wound worsening, delayed healing, infection, or new wound formation. Plan is to complete treatment as ordered, offload, and continue with skin alteration prevention protocol of the facility. The right heel blister measures 3 cm x 3.5 cm x 0. The skin is intact.The Pressure Ulcer Unavoidability Screen dated 11/11/25 documents R16 has a pressure ulcer to the right lateral foot and a blister to the right heel. R16 is up in the chair daily and has a caregiver that spends a few hours with R16. R16 has had changes in weight and is being followed by the dietitian. There is no score or statements in this screen indicating why the right heel and right lateral foot wounds were unavoidable. The Care Plan dated 11/10/25 documents R16 has an actual skin breakdown related to blister on the right heel and a stage one on the right lateral foot. Interventions include protect heels and provide new soft shoe per wound physician recommendation. There is no documentation of any care plan or interventions that were put in place before R16 developed the wounds to the right foot and heel even though R16 was at risk based on the Braden scale score and the Nutrition noted on 10/15/25 identifying R16's significant weight loss, noting a goal to prevent skin breakdown. The Treatment Administration Record (TAR) dated 11/2025 documents the ordered right heel and right lateral foot wound care treatment were not completed on 11/19/25. The box for this day was not checked off on the TAR as having been completed.The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as five (severe cognitive impairment). Section GG of the MDS indicates R16 uses a wheelchair for a mobility device. R16 needs supervision/touching assistance with bed mobility and partial/moderate assistance with transfers. Walking wasn't not attempted due to medical condition or safety concerns. Section M of the MDS documents R16 is at risk for developing pressure ulcers but does not currently have any unhealed pressure ulcers. Recommended treatments for this time are pressure reducing device for chair and bed.The policy titled, Prevention of Pressure Ulcers/Injuries, that is undated documents, Purpose: the purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors in interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk assessment: 1. Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Prevention:. Mobility/repositioning: 1. Choose a frequency for repositioning based on the resident's mobility, the support service and use, skin condition and tolerance, and the resident's stated preferences .4. Reposition more frequently as needed, based on the condition of the skin and the residence comfort. 5. Encourage residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Support surfaces and pressure distribution: Select appropriate support services based on the resident's mobility, continence, skin, moisture and perfusion, body size, weight, and overall risk factors

Based on interview and record review, the facility failed to obtain a physician's order to remove an indwelling urinary catheter for a resident diagnosed with urinary retention and failed to review a resident's hospital records upon admission for the diagnosis and follow up care for the indwelling urinary catheter. These failures affected one (R1) of four residents reviewed for improper nursing care. This failure resulted in R1 developing abnormal lab values with urinary retention and UTI (Urinary Tract Infection), subsequently requiring hospitalization . Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to Persistent Atrial Fibrillation, Influenza A, Dementia, Myocardial Infarction, Hypertension on admission 3/31/25 and Elevated [NAME] Blood Cell Count on 4/3/25. R1's comprehensive assessment section C cognitive status dated 4/7/2025 documents a brief interview for mental status score of 3/15. This score indicates R1 has severe cognitive impairment. During observations in the facility on 4/15/25, R1 was not in the facility during the investigation. R1 was admitted to the hospital per review of the facility census and electronic medical record on 4/10/25 due to abnormal lab results for BUN (Blood Urea Nitrogen) 99 mg/dl (milligrams/deciliter). This is significantly elevated and considered a serious indicator of kidney dysfunction or other health issues. The normal range for the BUN is 7-20 mg/dl. R1 was admitted for a UTI (urinary tract infection). On 4/15/25 at 11:24 AM, V4 Licensed Practical Nurse (LPN) was inquired of R1's care. V4 said, R1 had some abnormal labs. When I took care of him, he didn't have a urinary catheter. His BUN was high 99. He was already on an antibiotic for Leukocytosis (elevated white blood cell count). He was on Amoxicillin then the Nurse Practitioner (NP) switched it to Cipro. On April 3rd his admission labs included a UA (urinalysis) and C&S (culture and sensitivity) due to abnormalities as a prophylactic. He was transferred to the hospital on April 10th, it was due to his Leukocytosis. Haven't heard anything yet from the hospital. On 4/16/25 at 10:17 AM, V2 Director of Nursing (DON) was inquired of V7 Assistant Director of Nursing (ADON) for interview regarding R1's 4/1/25 progress note on removing his urinary catheter. V2 said, V7 is the ADON, she's out of the country on vacation right now. On 4/16/25 at 12:05 PM, V2 DON was inquired of R1's hospital discharge instructions related to the urinary catheter and V7 ADON removing R1's urinary catheter on 4/1/25. V2 said, R1 was to follow up with urology in a week. Our receptionist schedules all the appointments. She's not a nurse. The receptionist scheduled him to see urology on May 12th at 9:40 AM. I'd have to find out with her why it was for that date. I gave her the hospital follow up instructions to set up the appointment with urology. V7 ADON and I follow up with the appointments. The receptionist sends us an email when she makes the appointments, and we discuss it in our morning meetings. I wasn't able to check on this or the urgency of his appointment. V2 DON said, I reviewed the transition of care documents, and I wasn't able to locate a diagnosis for the catheter. V8 RN Registered Nurse took R1's admission report from the hospital. I see she put he had urinary retention with a foley (indwelling) catheter. I missed the page on the transition of care document. R1 was on a foley catheter because of his urinary retention. Based on his diagnosis and clinical document his catheter was not to be removed. I reviewed the POS (physician order sheets) and there was no order from the doctor to discontinue the catheter. It requires to have a physician order to discontinue it. There was a medical diagnosis, we should have reviewed his hospital documents thoroughly. We should have got an order from the doctor or NP (nurse practitioner) before discontinuing the catheter. R1's medical records were reviewed. On 3/31/25 at 7:35 PM, R1 was admitted to the facility with a urinary catheter in place from the hospital. On 4/1/25 at 11:47 AM, R1 was seen by the internal medicine nurse practitioner in the facility. The nurse practitioner did not document R1's urinary catheter during her assessment. The documentation states in part- Urinary: no dysuria (painful urination), hematuria (blood in urine). Reviewed: labs/hospital records/chart/ allergies/meds/MD (medical doctor) and nursing notes. On 4/1/25 at 1:15 PM, V7 ADON's progress note documents the following: Resident foley catheter discontinued for no qualifying diagnosis. R1's physician orders from 3/31/25 to 4/10/25 do not document an order to remove his urinary catheter. Review of V8 RN's 3/31/25 hospital admission report documents a significant medical history of urinary retention with foley catheter 16 F (French) in place. R1's discharge instructions reason for hospital stay state in part: you had urinary retention, and a catheter was placed. You should follow up with Urology as an outpatient. You were started on Doxazosin to treat enlarged prostate. Your next steps- schedule an appointment with V9 Urology Medical Doctor (MD) as soon as possible for a visit in one week for hospital follow up and management of urinary retention. Review of R1's physician order sheets documents Doxazosin Mesylate 1 tablet by mouth one time a day for HTN ordered 3/31/25. The medication can be used to treat urinary problems caused by an enlarged prostate. It can also treat high blood pressure when used alone or in combination with other medications. R1's transition of care form dated 3/31/25 documents contact information for follow up providers. V9 MD is listed to schedule an appointment as soon as possible for a visit in one week for hospital follow up and management of urinary retention. V9's address and phone number are listed. Active drain: urinary catheter placement date 3/20/25. Reason for foley catheter maintenance: acute urinary retention: bladder outlet obstruction, or neurogenic bladder. V9 MD's consultant recommendation documents- would recommend discharge home with foley (indwelling) catheter. Would recommend follow up with urology. Patient may need to have chronic foley (indwelling) catheter versus surgical insertion of suprapubic tube. He has multiple medical problems and may not benefit from transurethral resection of bladder outlet obstruction. Detailed hospitalization summary states in part: Urinary Retention foley catheter placed 3/20 and adjusted based on 3/29 CT (computed tomography) scan. Started doxazosin (as it can be crushed). Urology consulted: plan to discharge with foley catheter and will need outpatient follow up with urology V9 MD or colleague. V2 DON confirmed R1 was not seen by V9 MD as ordered 1 week after being discharged from the hospital. There is no documentation the facility notified V9 MD that R1's urinary catheter was removed by V7 ADON on 4/1/25. On 4/3/25 at 1:32 PM, R1's nurse practitioner ordered a stat (immediate) urine analysis and culture/sensitivity. On 4/4/25 at 8:49 PM, R1's urine test results document- antimicrobial resistance and urinary bacteria. R1's nurse practitioner was informed with no new orders received. The laboratory report documents urinary bacteria- Pseudomonas Aeruginosa and Citrobacter Freundii. On 4/7/2025 at 11:39 AM, R1 was assessed by his nurse practitioner regarding the urine test results. The nurse practitioner documents the following- Internal Medicine Progress Note CC/ reason for visit: UTI/leukocytosis Assessment and Plan: #. UTI: - UA/CS with Pseudomonas aeruginosa and Citrobacter Freundii. To start Cipro 500mg BID x 5 days. On 4/10/25 R1 was transferred to the hospital via ambulance for abnormal lab results. R1's 4/10/25 emergency room provider notes state in part: HPI History of present illness- R1 presents with abnormal labs. According to paperwork he had blood drawn today and revealed that his creatinine increased from 4 to 1 from last week. Patient currently being treated for urinary tract infection with Ciprofloxacin which he started a few days ago. Medical decision making: R1 presents with a urinary tract infection, questionable altered mental status as well as increased creatinine on outpatient labs. We did perform a bladder scan which revealed 1400 ml (milliliters) of purulent (containing or producing pus, a thick yellowish fluid that indicates infection) urine in the patient's bladder. This was removed with a foley catheter however appeared to be similar to frank pus. (Clear and evident presence of pus, a thick, usually yellow or greenish fluid, in a wound or other area of the body. It's a sign that the area is infected, indicating the body's immune system is actively fighting an infection.) R1 remains hospitalized at this time. R1's nephrology consult note, during hospitalization dated 4/12/25 documents, HPI: presented from his Nursing Home for increase in his Creatinine levels from a week ago. During recent hospitalization ,d+[DATE] - 3/21 for lethargy secondary to sepsis to influenza and aspiration pneumonia, course was complicated by Acute Kidney Injury and urinary retention, where a foley was placed. Urology recommending discharge home with Foley Catheter, follow- up with urology, and chronic Foley versus surgical insertion of suprapubic tube. UA (urinalysis) was unable to be completed due to purulent urine, though it did show extensive neutrophils and bacteria, foley catheter is in place, but the bladder was distended on CT, also with new bolateral (sic) hydronephrosis. On 4/17/25 at 8:25 AM, call placed to V9 MD's office for interview. Message left with staff, awaiting return call. On 4/17/25 at 11:31 AM, received a return call from V9 MD's office that V9 is in surgery and another staff will attempt to return the call. During course of survey, facility failed to provide requested policies. National Institute of Health (December 2019) documents (in part) Urinary retention is a condition in which you cannot empty all the urine from your bladder. Urinary retention can be acute-a sudden inability to urinate, or chronic-a gradual inability to completely empty the bladder of urine. Urinary retention results from either a blockage that partially or fully prevents Treatments for urinary retention may include draining the bladder Administrative Code TITLE 68: Professions And Occupations (January 4, 2021) Professional Responsibility includes making decisions and judgments requiring use of knowledge acquired by completion of an approved program for licensure as a practical, professional or advanced practice registered nurse.

Based on interview and record review the facility failed to provide care and services according to accepted standards of practice by failing to obtain a physician's order to remove an indwelling urinary catheter for a resident diagnosed with urinary retention and failed to review a resident's hospital records upon admission for the diagnosis and follow up care for an indwelling urinary catheter. These failures affected one (R1) of four residents reviewed for improper nursing care. Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to Persistent Atrial Fibrillation, Influenza A, Dementia, Myocardial Infarction, Hypertension on admission 3/31/25 and Elevated [NAME] Blood Cell Count on 4/3/25. R1's comprehensive assessment section C cognitive status dated 4/7/2025 documents a brief interview for mental status score of 3/15. This score indicates R1 has severe cognitive impairment. During observations in the facility on 4/15/25, R1 was not in the facility during the investigation. R1 was admitted to the hospital on 4/10/25 due to abnormal lab results for BUN (Blood Urea Nitrogen) and UTI (urinary tract infection). On 4/15/25 at 11:24 AM, V4 Licensed Practical Nurse (LPN) was inquired of R1's care. V4 said, when I took care of him, he didn't have a urinary catheter. On 4/16/25 at 10:17 AM, V2 Director of Nursing (DON) was inquired of V7 Assistant Director of Nursing (ADON) for interview regarding R1's 4/1/25 progress note on removing his urinary catheter. V2 said, V7 is the ADON, she's out of the country on vacation right now. On 4/16/25 at 12:05 PM, V2 was inquired of R1's hospital discharge instructions related to the urinary catheter and V7 removing R1's urinary catheter on 4/1/25. V8 RN Registered Nurse took R1's admission report from the hospital. I see she put he had urinary retention with a foley (indwelling) catheter. I missed the page on the transition of care document. R1 had a foley catheter because of his urinary retention. Based on his diagnosis and clinical document his catheter was not to be removed. I reviewed the POS (physician order sheets) and there was no order from the doctor to discontinue the catheter. It requires to have a physician order to discontinue it. There was a medical diagnosis, we should have reviewed his hospital documents thoroughly. We should have got an order from the doctor or NP (nurse practitioner) before discontinuing the catheter. R1's medical records were reviewed. On 3/31/25 at 7:35 PM, R1 was admitted to the facility with a urinary catheter in place from the hospital. On 4/1/25 at 1:15 PM, V7 ADON's progress note documents the following: Resident foley catheter discontinued for no qualifying diagnosis. R1's physician orders from 3/31/25 to 4/10/25 do not document an order to remove his urinary catheter. Review of V8 RN's 3/31/25 hospital admission report documents a significant medical history of urinary retention with foley catheter 16 F (French) in place. R1's discharge instructions reason for hospital stay state in part: you had urinary retention, and a catheter was placed. You should follow up with Urology as an outpatient. You were started on Doxazosin to treat enlarged prostate. Your next steps- schedule an appointment with V9 Urology MD (Medical Doctor) as soon as possible for a visit in one week for hospital follow up and management of urinary retention. Active drain: urinary catheter placement date 3/20/25. Reason for foley catheter maintenance: acute urinary retention: bladder outlet obstruction, or neurogenic bladder. V9 MD's consultant recommendation documents- would recommend discharge home with foley (indwelling) catheter. Would recommend follow up with urology. Patient may need to have chronic foley (indwelling) catheter versus surgical insertion of suprapubic tube. Detailed hospitalization summary states in part: Urinary Retention foley catheter placed 3/20 and adjusted based on 3/29 CT (computed tomography) scan. Started doxazosin (as it can be crushed). Urology consulted: plan to discharge with foley catheter and will need outpatient follow up with urology V9 MD or colleague. V2 DON confirmed R1 was not seen by V9 MD as ordered 1 week after being discharged from the hospital. There is no documentation the facility notified V9 MD that R1's urinary catheter was removed by V7 ADON on 4/1/25. The facility failed to document R1's urinary retention from his transition of care forms dated 3/31/25. V7 ADON failed to review R1's 3/31/25 hospital discharge forms and transition of care forms that document R1's urinary retention and treatment with the urinary catheter prior to removing his catheter. V7 did not obtain a physician's order to discontinue R1's urinary catheter. During course of survey, the facility failed to provide requested facility policies.

Based on observation, interviews, and record review, the facility failed to ensure R93 was not verbally abusive toward three of 18 residents (R6, R25, and R53) present in the facility dining area. Findings include: R6 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Traumatic Subdural Hemorrhage without Loss of Consciousness, Unspecified Visual Disturbance, Bipolar Disorder, and Schizoaffective Disorder. R25 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus, Malignant Neoplasm of Prostate, Personal History of Transient Ischemic Attack (TIA), Paranoid Schizophrenia, and Major Depressive Disorder. R52 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant side, Vascular Dementia, and Major Depressive Disorder. R93 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Psychosis, Chronic Obstructive Pulmonary Disease, Hypertension, Alcohol Abuse, Nicotine Dependence, and Anxiety Disorder. On10/28/2024, and 10/29/2020 between 12:00PM and 12:15PM, in the 2nd Floor Dining Area, multiple residents were observed during lunchtime meal in-service and were not being monitored by any facility staff. While residents were eating R93 was being verbally aggressive, yelling and making hand gestures and no staff came to monitor, supervise or redirect the aggressive behavior being displayed towards others. On 10/28/24 at 12:29 PM there were 18 residents in the second floor dining room. Staff monitoring intermittently, coming in and out of the dining room. On 10/28/24 between 12:32 PM and 12:37 PM R93 was observed cussing, screaming, and shouting profanities at R6, R25, and R53 and remaining fell ow residents in the dining room with no intervention from staff. At12:37 PM R93 removed herself from the dining room, just to return to continue to sit at the dining room table. On 10/28/24 at 12:37 PM V10 (Certified Nurse Assistant) stated, R93 does it (screams at fell ow residents) all the time, they (fell ow residents) are used to it. I don't want to come in to work for that, when enough is going to be enough. I've never seen R93 get into a physical altercation with anyone, but she came up to me, threatened me with a fist and cussed at me. On 10/30/24 at 02:06 PM, V1 (Administrator/Abuse Prevention Coordinator) stated, my role as a abuse prevention coordinator consists of two parts, to make sure staff knows what abuse is, and to make sure reporting and investigation is conducted immediately. Staff received abuse related education during every annual skill fair training and upon hire. Every new employee gets in depth abuse training. Every facility abuse allegation is investigated thoroughly. Most common abuse occurring in the facility are physical and verbal. Verbal abuse is when one resident yells or curses at another resident. If staff witnesses verbal abuse occurrence, they should separate residents and provide monitoring to both, perpetrator, and a victim. Next, staff should call me, and then I continue with the abuse complete the investigation. V1 not aware of verbal abuse occurrence witnessed by the surveyor, staff did not report verbal abuse occurrence to V1. The facility Abuse Prevention Program (no date) reads in part, As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on observation, interview, and record review, the facility failed to administer medications per facility policy for one of two residents (R40) reviewed for medication administration on the total sample of 42. Findings include: R40 admitted to the facility on [DATE] with diagnosis including but not limited to Type Diabetes Mellitus, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Major Depressive Disorder, and Schizophrenia. On 10/29/24 at 08:41 AM, during R40's medication administration V12 (Licensed Practical Nurse) left the medication cup with 15 scheduled medications. V12 (LPN) stated, I let her take medications and go in and out of the room to monitor. I checked R40's vital signs this morning, her blood pressure was 110/58 and pulse 76. I will hold R40's medications for high blood pressure because R40's blood pressure is on the lower side. I usually wait and then recheck the vital signs later and give R40 her high blood pressure medications. On 10/29/24 at 10:50 AM R84 appeared angry, and stated she was told to go back to her room because state regulatory agency is in the building. R84 stated to the surveyor that her medications are left at the bedside and she is never told to go to her room and be monitored during medication administration, things are different during this week because surveyors are here. On 10/29/24 at 10:55 AM, clarified with V12 (LPN) whether R84's statement related to medication administration is correct, V12 (LPN) affirmed that that's what she told R84. V12 (LPN) stated that she gives the cup of medications to R84, and she should not have done that. On 10/29/24 at 01:40 PM during follow up with V12 (LPN) regarding medication administration for R40 earlier that day, V12 (LPN) stated, I left medications on R40's nightstand. That was a mistake. I usually give it to her in the hallway. I have to catch her before she goes to have a cigarette because then she is not back until 11a. I rechecked R40's blood pressure and pulse and gave her four high blood pressure medications that I held this morning, but I don't know if she took any of her medications because they were all left at the bedside. On 10/30/24 at 12:23 PM V2 (Director of Nursing) stated, during medication administration, nurses are expected to give medications no more than an hour before or an hour after the scheduled time. Nurse should also observe to make sure that a resident took their medication. It is not appropriate to leave medications at the bedside for the resident to self-administer unless resident has self-administration assessment and is deemed as appropriate. Neither R40 or R84 have the self-administration assessment; therefore, they are not appropriate to take medication by themselves and should always be monitored during medication administration process. There are parameters for high blood pressure medications established by the physician. Before administering those, the nurse should always check residents' vital signs, including blood pressure and pulse, and check against the parameters to make sure high blood pressure medications are appropriate to administer. If the vital signs are within parameters, the nurse should administer high blood pressure medications. R40's MAR (medication administration record) documents R40 received 9:00 AM dose for Actos Oral Tablet 45 MG, Ascorbic Acid Tablet 500 MG, Centrum Ultra Womens Oral Tablet, [NAME] Oil Capsule 500 MG, Latuda Oral Tablet 20 MG, LORazepam Oral Tablet 0.5 MG, Losartan Potassium Tablet 100 MG, Montelukast Sodium Tablet 10 MG, UTI-Stat Oral Liquid, Vitamin B Complex Tablet, Vitamin D3 Capsule 125 MCG, Vitamin E-400 Capsule, Benadryl Allergy Oral Tablet 25 MG, Benztropine Mesylate Oral Tablet 0.5 MG, Ferrous Sulfate Tablet 325 (65 Fe) MG, cloNIDine HCl Oral Tablet 0.2 MG, hydroCHLOROthiazide Tablet 25 MG, Calcium Carbonate Tablet Chewable 500 MG, and hydrALAZINE HCl Oral Tablet 25 MG. V12 (LPN) unsure if R40 took any or all of her scheduled 9:00 AM medications. R40's physician orders show R40 to receive: - Actos Oral Tablet 45 MG (Pioglitazone HCl) Give 1 tablet by mouth one time a day for DIABETES - Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for Supplement - Centrum Ultra Womens Oral Tablet (Multiple Vitamins w/Minerals) Give 1 tablet by mouth one time a day for Supplement - [NAME] Oil Capsule 500 MG Give 1 capsule by mouth one time a day for supplementation - Latuda Oral Tablet 20 MG (Lurasidone HCl) Give 1 tablet by mouth one time a day related to SCHIZOPHRENIA - LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day for anxiety - Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for Hypertension Hold if SBP (systolic blood pressure) is below 100 and HR (heart rate) below 60 - Montelukast Sodium Tablet 10 MG Give 1 tablet by mouth one time a day for asthma - UTI-Stat Oral Liquid (Cranberry- Vitamin C-Inulin) Give 30 ml by mouth one time a day for UTI Prophylaxis -Vitamin B Complex Tablet (B Complex Vitamins) Give 1 tablet by mouth one time a day for Supplementation - Vitamin D3 Capsule 125 MCG (5000 UT) (Cholecalciferol) Give 2 tablet by mouth one time a day for low vit d level - Vitamin E-400 Capsule (Vitamin E) Give 1 capsule by mouth one time a day for Supplement for 30 Days - Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth two times a day for allergies - Benztropine Mesylate Oral Tablet 0.5 MG (Benztropine Mesylate) Give 1 tablet by mouth every 12 hours for EPS - cloNIDine HCl Oral Tablet 0.2 MG (Clonidine HCl) Give 1 tablet by mouth two times a day for HTN Hold if SBP is below 100 - Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth two times a day for supplementation - hydroCHLOROthiazide Tablet 25 MG Give 1 tablet by mouth two times a day for HTN/edema Hold if sbp is below 100 - Calcium Carbonate Tablet Chewable 500 MG Give 2 tablet by mouth with meals for GERD -hydrALAZINE HCl Oral Tablet 25 MG (Hydralazine HCl) Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION The facility pharmacy Medication Administration policy dated July 2024 reads in part, Medications are administered in accordance with written orders of the attending physician; Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with facility procedures for self-administration of medications; If a dose of regularly scheduled medication is withheld, refused, or given at other time than the scheduled time, the MAR should reflect documentation as to the reason medication could not be administered. Tips for Safe Medication Administration: Administer medications and remain with resident while medication is swollen.

Based on observations, interviews, and record review the facility failed to provide consistent monitoring and supervision for a verbally aggressive resident (R93) throughout the entire lunchtime meal in-service in the second floor dining room. This failure affects three of eighteen residents (R6, R25 and R52,) in which R93 was verbally aggressive toward while staff was not monitoring R93. The Findings include: R25 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus, Malignant Neoplasm of Prostate, Personal History of Transient Ischemic Attack (TIA), Paranoid Schizophrenia, and Major Depressive Disorder. R6 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Traumatic Subdural Hemorrhage without Loss of Consciousness, Unspecified Visual Disturbance, Bipolar Disorder, and Schizoaffective Disorder. R52 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant side, Vascular Dementia, and Major Depressive Disorder. R93 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Psychosis, Chronic Obstructive Pulmonary Disease, Hypertension, Alcohol Abuse, Nicotine Dependence, and Anxiety Disorder. R25's care plan dated 10/07/2024 includes (but not limited to): Abuse, Neglect, Trauma factors I do not present with unusual or uncommon factors for mistreatment, victimization or exploitation. I am an adult living with schizophrenia, MDD and cognitive loss. I have a legal guardian. My awareness of person, place, time, situation is poor. My care partners recognize that long term care admission may represent and/or rekindle trauma secondary to feelings of loss of control, loss of autonomy and I am considered a vulnerable, older adult in need of 24-hour care. I appreciate the compassion and sensitivity I am afforded in this setting. During observations on 10/28/2024, and 10/29/2020 between 12:00PM and 12:15PM, in the 2nd Floor Dining Area, multiple residents were observed during lunchtime meal in-service and were not being monitored by any facility staff. While residents were eating R93 was being verbally aggressive, yelling and making hand gestures and no staff came to monitor, supervise or redirect the aggressive behavior being displayed towards others. On 10/28/2024 at 12:52 during an interview with V10 (Certified Nursing Assistant/CNA), V10 said they all monitor the dining room, that no one is specifically assigned to the dining area. They will rotate shifts to make sure they cover and watch the dining area. On 10/29/2024 at 9:10AM during an interview with V9 (Activities Director), V9 said staff will usually rotate and cover the dining area. He is not aware if anyone is scheduled to just monitor the residents during mealtimes. On 10/29/2024 at 9:20AM during an interview with V7 (Licensed Practical Nurse/LPN), V7 said nurses will assist the certified nursing assistants and rotate to cover the dining area. She said there's no set schedule for staff to monitor the dining area. On 10/29/2024 at 9:30AM during an interview with V3 (Assistant Director of Nursing), V3 said Certified Nursing Assistants/CNA's will rotate days to cover the dining area. She said no one's specifically assigned or scheduled to monitor residents during mealtimes. V3 said the aids will determine their own schedule for coverage and nurses will usually assist when they are available. On 10/30/2024 at 9:30AM during an interview with V2 (Director of Nursing), V2 said all facility staff including managers should monitor residents in the dining area while eating. He said while certified nursing assistants are passing out trays to residents in their rooms managers should go to assigned areas to help monitor dining areas. Facility policy titled, Safety and Supervision of Residents (July 2017) includes: Individualized, Resident-Centered Approach to Safety. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Facility Job Description for Certified Nursing Assistant (CNA) includes but not limited to Job Summary: The Certified Nursing Assistant (CNA) helps patients/residents with comprehensive health care needs under the supervision of a nurse. The CNA assists patients/residents with activities of daily living to include bathing, dressing, eating, grooming, toileting and exercising. This role is also responsible for the successful transfer of residents to and from activities. Duties/Responsibilities: Notes and communicates patient/resident behaviors and changes in mood.

Based on interview and a record review, the facility failed to prevent an incident of staff to resident sexual assault and inappropriate exposure. This affected one of three residents (R1) reviewed for sexual assault and inappropriate exposure. This failure resulted in V6 forcibly pushing R1 down onto her back, grabbing her breast, undoing his clothing and exposed his penis to attempting to rape R1. R1 said, she felt hurt and wished for death. R1 said, she felt victimized, traumatized, and feared for her safety. The Immediate Jeopardy began on 04/09/24 when V6 exposed his penis and sexually assaulted R1. V1 (Administrator), V2 (Director of Nursing) and V14 (Chief Operating Officer) was notified of the Immediate Jeopardy on 04/18/24 at 11:40AM. The surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 04/18/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the interventions implemented. Findings Include: R1 was diagnosed with Huntington's disease. Brief interview for mental status dated 02/27/24 documents a score of thirteen which indicates cognitively intact. Screening Assessment to determine abuse/neglect dated 2/21/24 and 4/9/24 documents: a score of (0-2) low risk (risk measure for likelihood of previous/recent mistreatment and psychosocial/psychological symptoms related to history of abuse and or neglect.) On 4/11/24 at 1:08PM, V3 (CNA-Certified Nursing Assistant) said, R1 was her usually self after her lunch. V3 said, she went to lunch and returned, R1 was acting funny, terrible in her chair, moving like she was upset. R1 was anxious. R1 moves all the time based on her disease but R1 was moving more than normal. On 4/11/24 at 2:38PM, V2 (DON) said, he saw R1 after she mentioned the word rape. V2 said, normally R1 is very quiet. V2 said, that was the first time he saw R1 having that much anxiety. On 4/11/24 at 2:55PM, V1 (Administrator) said, he was informed by the V5 (nurse). R1 said, something about rape. R1 never used that language before. V1 said, he spoke with R1. R1 was sitting on the bed crying. R1 said, rape, black man. R1 couldn't give any more detail. V1 said, V6 was identified as that black male after reviewing the video footage. V1 said, V6 reported, he did his rounds and then checked on residents he has not seen throughout the day. V1 said, R1 threw a shoe at V6. V6 left the room, unable to determine why R1 threw the shoe. V1 said, maybe R1 was triggered by a past life event. On 4/11/24 3:15PM, V4 (CNA) said, R1 was agitated. V4 said, she worked with R1 in the past but has never seen R1 like that before. On 04/12/24 at 2:49PM, R1 was assessed to be alert and oriented to person, place and time. R1 was observed visibly distraught, crying, anxious and agitated. R1 said, while crying, red face, snot sniffling and increased body movement which included hitting bilateral heels hard on the floor multiple times, V6 came into her room and started to massage her shoulders. V6 forcibly pushed her down on her back by the shoulders, grabbed her breast on top of her clothing, undid his clothing and exposed his penis and tried to force her to have sex. R1 said, she couldn't yell. R1 said, she hit V6 with her phone then V6 left her room. R1 said, V6 tried to rape her. R1 said, she was hurt and would have rather death instead of being raped. R1 said, she felt victimized, traumatized and feared for her safety. On 4/12/24 at 10:06AM, V8 (Family) said, while crying, to watch R1 die from a debilitating disease is one thing but to watch R1 live through almost being raped and victimized was another level of trauma. R1 could not scream due her Huntington's disease. R1 reported, while in the hospital it would have been easier for her to die than to be raped. On 4/16/24 at 10:58AM, V6 (CNA) said, V6 said, he was compelled to check on R1 because he had not seen R1 in about a week to a week in a half. V6 said, he was concerned about R1. V6 said, it bother him to not see certain residents. V6 said, when he returned from an escort, ten of his residents were soaked in urine. V6 said, he did not report the ten residents to the nurse. V6 said, he changed five residents, then realized he had not seen R1 or R5. V6 said, he went into R1 and R5's room. R5 was sleeping/breathing. V6 said, he walked to R1's bed, R1 was sleeping, not moving and really still. V6 said, he stood in R1's room for one to two minutes to ensure R1 was breathing. R6 said, he had no idea who was R1's assigned CNA. V6 said, he did not notify the nurse when he thought R1 wasn't breathing. V6 said, after one to two minutes he saw R1 breathing he knew she was okay. V6 said, no one asked him to check on R1. V6 said, he was suspended pending an investigation for something, but not sure exactly what. V6 said, abuse should always be reported to V1 or the nurse immediately. Sexual, physical, mental, emotional, financial, involuntary seclusion and verbal are all forms of abuse. V6 said, he was not sure which abuse he was accused of but plan to stay away from all of them. V6 said, since he returned to work he did not have any training and nothing was newly implemented related to his suspension. V6 said, R1 did not throw a shoe at him. On 4/16/24 at 3:12pm, V9 (Nurse) said, R1 was alert and oriented to person, place and time. R1 has never made any false allegations. Health status note dated 4/9/24 documents: Around 3:07PM, nurse on duty observed the resident (R1) being wheeled by two female CNAs in the hallway to the nursing station. Resident was noted to restless and holding her phone with the flash light on. Resident was then approached and asked what is wrong with her but she kept swinging her arms. She was asked if she wanted the nurse to turn off the flash light and she nodded. Afterwards, resident was still noted to be anxious and was again asked if she wanted the nurse to call her son. Resident nodded and the nurse proceeded to call her son but to no avail. Resident was again asked if what is wrong with her and she made an allegation. V1 and V2 was called right away and they went check on the resident. One to one supervision for safety provided. Body assessment and police called. Facility reportable dated 4/9/24 documents: It was reported to V1 (Administrator) that R1 is alleging black male rape. Police were contacted and came to follow up on resident statement. Camera footage reviewed: One employee that entered room for a few minutes with door open has been suspended pending investigation. Police report dated 4/9/24 documents: R1 said, she was raped by a male/black (M/B) about one hour ago. Reviewed video briefly which showed at 1434 hours (2:34PM), a M/B, large build, afro style hair, full facial hair, and wearing all black entered R1's room. At 1438 hours (2:38PM), the M/B subject exits the room. At 1439 hours (2:39PM), R1 exits the room and then walks to a wheel chair. Hospital papers dated 4/9/24 documents: Assault was exposure and an attempt. Video seen on 4/16/24 at 1:15 pm shows V6 was observed entering R1's room whose door was open at 14:34:25 and coming out at 14:38:38 while pulling the door behind him which did not close completely. Abuse Policy dated 12/2020 documents: Our resident have the right to be free from abuse. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. Sexual abuse id defined as non-consensual sexual contact of any type with a resident. The Immediate Jeopardy that began on 04.09.24 was removed on 04.18.24 when the facility took the following actions to remove the immediacy. On April 18th, 2024, a State Surveyor informed the Administrator that an Immediate Jeopardy had been issued for Citadel of Skokie under F600. This abatement plan is being submitted without any prior knowledge of what specifically the Illinois Department of Public Health surveyor's citations will be. The following Plan of Abatement shall also serve as the Facility's written credible allegation of compliance that will be achieved by stated date of completion. Submission of this Plan of Abatement does not constitute in any way an admission of any facts and/or conclusions of law reflected in the alleged deficiencies, nor does it constitute a waiver of the Facility's right to contest the deficiencies and/or any remedies imposed as a result of this or future surveys. The facility reserves the right to contest the survey findings and the immediate jeopardy as allowed by applicable law and rules. The facility abatement plan includes the following: April 9th, 2024 Incident On April 9th, 2024 Facility Administrator was informed that R1 reported black man rape. In response, on that same day, April 9, 2024, the Administrator initiated action consistent with its abuse policy including: Initiating a comprehensive abuse investigation Notifying police immediately. Police came to facility and viewed the facility video footage and interviewed R1. R1 was sent to (local) hospital for evaluation. R1 was seen and assessed at the hospital and refused a complete rape kit. R1 had a partial rape kit done. R1 did change her initial statement to exposed his self to me. R1 was not admitted and was sent to another facility the next day. R1 has not returned to the facility. Identifying and suspending the alleged employee pending investigation. Employee was suspended from April 9, 2024 until the conclusion of the investigation. The investigation as complete by April 11, 2024. Because the investigation could not substantiate that the alleged sexual abuse occurred, employee returned to work April 16, 2024 after Administrator confirmed employee was up to date on his abuse in-service training, including the in-service training referenced below that employee received on April 11, 2024. (No further allegations of sexual abuse were made or received between April 16 - April 18. Employee was suspended April 18 and subsequently terminated for an issue unrelated to the instant sexual abuse allegations.) Notifying the Resident ' s MD (physician) and family. Sending an initial report to (state agency) on 4/9/2024 Sending a final report to (state agency) on 4/11/2024 Administrator completed a comprehensive abuse investigation that included: Interview of facility employees. Administrator interviewed all employees who were observed to be near/outside the room at the time of the alleged incident and none heard, saw, or observed anything inappropriate from resident ' s room. All other employees were interviewed about their knowledge and experience with the alleged perpetrator and no employees have heard, seen, or otherwise observed anything inappropriate about the alleged perpetrator. Interview of facility residents. No residents reported any inappropriate treatment or contact by staff, including the alleged perpetrator. Review of video footage. Video footage that showed employee [NAME] enter R1's room for approx. 3-4 minutes with door left open and exiting R1 ' s room. Administrator reviewed R1's statements about the alleged incident. Completion Date: 04-09-24 On April 10 and April 11, 2024, Administrator met with corporate office to review Administrator's investigation where it was confirmed that abuse allegation could not be substantiated. Legal counsel confirmed unsubstantiated investigation was insufficient to support employee termination. (Should this reviewer have questions about this determination, we request you meet with our legal counsel for a discussion.) Completion Date: 04-11-2024 On April 9, 2024, Administrator, DON, Regional Nurse began educating all employees on the facility's abuse /neglect policy with emphasis on sexual abuse-physical-reporting. All employees on duty received education before their shift ended. The remaining facility employees have been educated before to their next scheduled shift and education will continue until 100% of facility employees have been educated. The Administration will be at the facility to conduct education at the start of their shifts. Completion Date: 04-19-2024 The Facility Quality Assurance team (which includes Administrator, Director of Nursing, Medical Director, and Facility Directors met on April 18, 2024 to review R1's incident and will meet monthly to review abuse and neglect policies related to sexual abuse. DON will conduct ongoing audits including any risk management reports to ensure compliance once week on each shift for the next 60 days. QAPI will discuss and revise ABUSE policy as needed through the QAPI process. Completion Date: 04-19-2024 Facility SSD (Social Service Director) audited all resident records on April 18 and April 19, 2024 to ensure all residents have an up-to-date abuse assessment. Completion Date: 04-19-2024 R1 was discharged to another facility 4/10/24. Facility has confirmed R1 is stable according to emergency room report dated 4/9/24. Completion Date: 4-19-2024

Based on interview and record review the facility failed to have effective system in place to prevent a resident from leaving the facility unauthorized on two different occasions. This affected one of three residents (R1) reviewed for supervision and elopement. This failure resulted in R1 being buzzed out of the facility with a visitor without staff knowledge on 01/05/24, and R1 able to leave the facility without staff knowledge on 03/11/24 after a staff member failed to ensure the door was closed securely after entering. The Immediate Jeopardy began on 01/05/2024 when R1 left out the facility when V14 buzzed visitors out of the facility and was found disorient and falling on the ground by local police, R1 also left the faciity on [DATE] and found disoriented and falling on the ground by the local police. V12 (Administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on 03/21/2024 at 9:16 am. The surveyor confirmed by onsite observation, interview and record review the immediacy was removed on 3/22/24 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the education and in-service training. Findings include: R1 face sheet shows diagnosis of unspecified dementia, severe with other behavioral disturbance. R1 MDS (Minimum Data Set) dated 2/21/24 denotes in part section C for cognitive patterns a BIMS (Brief Interview Mental Status) of 2 (cognitively impaired). Police report dated January 5, 2024, denotes in part on 05 January 24 at approximately 2:11pm hours, I (officer) was dispatched to the (street name) intersection for a public fall on the northeast corner. Upon arrival, I spoke with (fire department) who stated a passing motorist (V2- concern citizen), noticed an elderly male, later identified as R1, walking eastbound on the north sidewalk. V2 stated the male was walking with an unsteady and unbalanced walk and stated he continued to watch the male because he thought R1 was going to fall. V2 stated as R1 turned to go north on the sidewalk, he lost his balance and fell on to the grass parkway. V2 stated he could not tell if R1 lost his footing and fell or if he tripped over the sidewalk. V2 stopped his car and checked on R1. I contacted (police department) Communications and advised them to send an Evidence Technician. E.T. (Officer) arrived on location and photographed the scene and R1. See his report for further. Transported R1 to (local) Hospital for treatment as they could not determine who the male was or his injuries. The elderly male could not provide a name or if he was uninjured. Once at Hospital, he was seen by the emergency room staff and (physician name). I was unable to speak with R1 as he only spoke Spanish. R1 stated to the emergency room nurses, that he was not injured and was transported to the emergency room by the ambulance. While I (officer) was on scene at (the location of the fall), employees from the (nursing facility), stopped and asked if we had seen one of their residents, but did not provide a description. I advised them the ambulance took an elderly male to the hospital, but the male would not provide a name. It was later determined R1 was a walk away from the (nursing facility). The (nursing facility) was contacted, and they arrived to pick up R1. The employees from the (nursing facility) requested R1 be checked out by the hospital staff. Police report dated 3/11/24 denotes in part, on 11 March 2024, at 8:24 hours, I (Officer) was dispatched to the north entrance area of (store name) on (street name) for a report of a public fall. (Local police department) Communications received a call from V15 (concern citizen), stating she was with an elderly male who seems disoriented and appeared to have fallen. Upon arrival, I briefly spoke with V15 who advised she was driving (west bound) on (street name) when she observed an elderly male with a walker on the parkway area of the sidewalk. She pulled into the (store name) lot and assisted the elderly male up and called (local police department). The area was the grass between the sidewalk and (street name). The elderly male was identified as (R1 name). R1 was unable to explain where he had fallen. (R1) did not have any visible injuries on his person. (R1) was wearing a fleece jacket which the right elbow part of the jacket appeared to have grass debris. R1 was unable to answer (local fire departments) questions and was transported to (local) Hospital. The parkway area of the sidewalk had no objects that may have caused R1 to fall. R1 was walking with a walker and appears to have trouble walking due to his medical illness/age. R1 had no visible injuries. (R1) did not have any identification on his person and (local fire department) recognized R1 due to a previous public fall, RD #24-00110. Per the report, (R1) was a patient at (local) nursing (facility), (facility address). I went to (nursing facility) and spoke with the front desk receptionist who advised R1 was a patient. She briefly spoke with the nurse in charge who advised they did not know that (R1) had left the property. I advised staff that R1 had fallen and was taken to (local) Hospital. I spoke with Director of Nursing, (V10) (number listed) who was advised of the incident and stated he was going to review camera footage to see how R1 was able to leave the property. I went to (local) Hospital emergency room #1 and spoke with R1 in Spanish. (R1) stated the following: (R1) was going for a walk and advised he has trouble walking. He did not want to walk on the sidewalk as it was dirty, so he began to walk on the grass. R1 lost his balance as he was walking on the grass with his walker and fell . (R1) advised he was walking on (street name) and advised they just repaved the road, so he was unfamiliar with the street. I advised (R1) he was not on (street name) and not in Chicago. I spoke with R1's daughter/emergency contact, (V1- R1 family) via (telephone) (number listed). V1 stated the following: I advised V1 of the incident and the status of R1. V1 advised R1 has dementia and should not be walking alone. V1 was frustrated that the nursing staff did not notice R1 had left the property. V1 advised R1 has left the nursing home unsupervised approximately three (3) different times. R1 advised she was on her way to Hospital. I provided (nursing facility) and V1 with a incident referral card. On 3/12/24 at 3:24pm V1 (R1 family) said she was R1 power of attorney, V1 said R1 has dementia and uses a walker for ambulation. V1 said R1 should not be out of the facility alone and unsupervised. V1 said she did not give permission for R1 to leave the facility on 1/5/24 and 3/11/24. V1 said the police notified her that R1 was found on 3/11/24 and she rushed to the hospital to see R1. V1 said R1 left the facility a total of 2 times. V1 said R1 does not wear a wander guard band. On 3/14/24 at 10:29am R1 observed resting in bed, awake, alert, orient to name, R1 observed to speak Spanish language. V4 (Registered Nurse) assisted with translation, R1 said he left the facility, R1 said he did hear the door alarms. R1 said no one was at the front desk. R1 complain of pain in his back. R1 laid in the bed to get some rest. Facility incident report labeled unwitnessed fall, dated 1/5/24 at 3:11pm am denotes in part, R1 name, incident location outside. Resident was observed kneeling on the ground. Thorough physical assessment done, no injury, denied hitting head, full range of motion to all extremities. Resident unable to give description. Head to toe and pain assessment done, denied pain complaints, 911 was called. Resident taken to (hospital emergency room ) for further medical evaluation. Taken to hospital Y. Mental status orientated to person. Facility incident report labeled other, dated 3/11/24 at 8:25am denotes in part, R1 name, incident location out of facility, Resident went out to walk outside and was picked up by the (local) police officer (name noted) Resident was taken to (local) hospital for evaluation. Resident description I was just walking. Immediate action, taken to ER (emergency room ). DON (Director of nursing) and administrator went to see resident right away. He was resting well in bed. He denied pain, no objective signs of pain or discomfort, no facial grimacing, moaning, etc. taken to hospital Y. Mental status, orientated to person, orientated to place. Agency /person notified family member and nurse practitioner. On 3/14/24 at 11:43am V10 (Director of nursing) said R1 did not elope from the facility on 3/11/24 and that R1 went for a walk. V10 said R1 did not inform any staff at the facility that he was going for a walk, V10 said the staff did not know R1 was going for a walk, V10 said R1 did not have an order to leave the facility unsupervised and go for a walk. V10 said he do not know where R1 was going walk to. V10 said he do not know if R1 is at risk for elopement and he will get back to the surveyor. On 3/15/24 at 1:47pm during a follow up interview, V10 said R1 was at risk for elopement. V10 said R1 eloped from the facility twice. V10 said on 1/5/24 he received notification from a staff member that the neighboring facility notified them (male staff member) that the fire department had picked a male up from the ground. V10 said himself and a staff member went to the scene and the police informed them that the male was sent to the hospital. V10 said himself and the staff member went to the hospital and identified that R1 was the resident that the fire department had picked up from the ground. V10 said on 1/5/24 the receptionist pressed the button to allow visitor to leave the facility and R1 left the facility behind the visitors. V10 said the receptionist was not at the front desk monitoring the entry door but instead was sitting behind the nurse's station on the first floor when she pressed the button. V10 said she pressed the button and sat back down; she did not look to see who was leaving the facility. V10 said the receptionist did not see R3 leave behind the visitors. V10 said the receptionist should be at the front desk/ front lobby monitoring that area and door. V10 said the interventions was to monitor R1. V10 said on 3/11/24 R1 left the facility after V3 (CNA- Certified Nursing Assistant) entered the facility. V10 said the door has a delay before it locks. V10 said he watched the video. V10 was asked why didn't V3 redirect R1 front the front lobby area as mentioned in the care plan. V10 said V3 was a newer CNA, and she did not know R1 well, she did not know R1 was an elopement risk. V10 said R1 daughter did contact him on 3/11/24 and express her concerns of R1 leaving the facility unsupervised, V10 said R1 daughter said, what if my father had been hit by a car. V10 did not give response when asked if the monitoring was effective if R1 was able to leave the facility on 3/11/24. Observation of the Nurse station, there is a green square button located on the wall behind the nurse station. V26 (CNA) observed to press this button when door alarm sound. V26 (nursing aide) said this button is used to unlock the front door and to shut the door alarm off. On 3/14/24 at 1:41pm V3 (CNA-Certified Nursing assistant) said on 3/11/24 she came inside the facility, she saw R1 in the front lobby, R1 had his jacket on and R1 had his walker, R1 was standing between the door and the front desk (V3 drew a picture demonstrating R1 position). V3 said she greeted R1 and went downstairs to punch in for the day. V3 did not respond when asked if she was aware that R1 was an elopement risk. V3 denied redirecting R1 from the front lobby area when she observed him with his jacket on. V3 said there were no staff in the front lobby on 3/11/24. V3 did not give response when asked about her understanding of elopement risk, and how do she know who are the residents that are at risk for elopement. Review of V3 timecard denotes V3 punched in at 8:09am on 3/11/24. On 3/15/24 at 10:09am, V7 (social worker) said R1 is at risk for elopement. V7 said R1 cannot go out of the facility without supervision. V7 said R1 has dementia, poor safety awareness, unsteady gait, and is at risk for falls. V7 said R1 cannot go out without supervision for safety reason. V7 said due to R1 dementia, R1 may not know how to return to the facility, R1 may not know how to contact his family and or the facility, R1 may not be able to cross the street safely. V7 said R1 eloped from the facility on January 5, 2024, and recently on 3/11/24. R1 elopement risk assessment dated [DATE] reviewed with V7. V7 said she completed R1 elopement risk assessments and may have documented in error that R1 did not have history of elopement. V7 said she checked No for is the resident considered to be at risk and no for elopement risk because R1 behavior had slowed down from going to the front lobby area. V7 said the elopement risk assessment helps with identifying residents that are at risk for elopement. V7 said the information is used to develop a care plan and interventions to prevent elopement. V7 said R1 elopement risk assessment is not accurate, it does not reflect that R1 is at risk for elopement. V7 said R1 assessment should be answered accurately, so that interventions can be put in place to help prevent R1 from getting out of the facility. V7 said she has observed R1 with exit seeking behaviors like standing around the door, looking around to see if people are going to leave out. V7 said sometimes she monitor the front door, and she have observed R1 with exit seeking behaviors. On 3/14/24 at 11:43am V12 (Administrator) said the facility video camera was not available for surveyor to review. During a follow up interview, on 3/15/24 at 11:14am V12 (Administrator) said he reviewed the facility video and observed R1 leave the facility with his walker on 3/11/24 after V3 entered the facility. V12 said the police notified the facility that R1 was found in the community. V12 said the department was not notified of R1 elopement on 1/5/24 or the elopement on 3/11/24. V12 said he thought the police would report the elopement to the state agency. V12 said the police do not work for the facility. V12 said he should have reported R1 elopement to the State agency (IDPH). On 3/14/24 at 10:32am V13 (Receptionist) said she was running late on 3/11/24, and she was not in the facility monitoring the front desk. V13 said the residents that are at risk for elopement have pictures in the computer, V13 said everyone that monitor the front desk don't have a login for the computer. V13 was asked how the staff will know who are at risk for elopement if they don't have access to the pictures in the computer. V13 said she's trying to start a folder for the pictures. On 3/21/24 at 11:11am V24 (Medical Doctor) said the facility made him aware that R1 left the facility, V24 was made aware of survey findings that on January 5, 2024, a staff member buzzed out a visitor and R1 left behind the visitor and on 3/11/24 R1 left the facility after a staff member entered the facility before the door locked per facility. V24 said he was not there, maybe staff wasn't paying attention. V24 said it's an unfortunate situation. V24 said the facility mention something about a wander guard, he's not sure. V24 said the elopement could have been avoided. On 3/21/24 at 12:16pm V22 (Nurse Practitioner) said R1 is on her caseload, V22 said she sees R1 for routine visits, V22 said she was not aware of R1 elopement on 1/5/24, the facility did not make her aware, V22 was made aware of survey findings related to R1 elopement on January 5, 2024. V22 and the facility made her aware of the 3/11/24 elopement on 3/14/24. V22 said the facility told her that a staff member heard the alarm sounding, or something. V22 said she was not aware that the police found R1 in the community and notified the facility that R1 was out of the facility. V22 said the facility should have made her aware of both elopements. V22 said she request R1 to have a wander guard bracelet. V22 said she did not see anything in R1 notes about the elopements. R1 community survival assessment dated [DATE] denotes in-part, the resident is sufficiently alert, oriented, coherent, and knowledgeable allowing him/her to be considered for independent outside pass privileges, No is checked. Conclusion, the resident does not appear to be capable of unsupervised outside pass privileges at this time. The resident cannot have unsupervised outside pass privileges, at this time. Signed by V7 (social services). R1 elopement risk assessment dated [DATE] denotes in-part, R1 name, score 3, is the resident cognitively impaired with impaired decision-making skill, yes is checked. Does the resident have diagnosis /symptoms of any of the following: dementia, Alzheimer's, yes is checked. Does resident ambulate independently with or without assistive devices including wheelchair, yes is checked. Does the resident have a history of elopement from home or facility, no is checked. Is the resident having difficulty accepting placement, no is checked. Does the resident verbally express a desire to go home, no is checked. Does the resident pace expressing a desire to locate a family member, no is checked. Has the resident been observed standing at the exit door waiting for someone to let them out, or verbalized a plan to exit, no is checked. Total score (a score of 5 or more is considered to be at risk for elopement). Is resident considered to be at risk, no is checked. Elopement risk, 4 is checked for not at risk. Observation of the first-floor nurses' station, the nurse's station has a high countertop, when sitting behind the nurse's station, the person must come to a standing position to see who is exiting the front door, which is greater than 15 feet away. R1 plan of care with initiated date of 3/11/24 denotes in part resident (R1) is high risk for wandering/elopement identified, resident safety will be maintained will not leave facility unattended through next review. Close monitoring of residents whereabouts at least hourly. Provide resident picture at reception desk and at nurse station. Engage resident on all floor activities to redirect/divert attention to deescalate elopement ideas. Encourage family visits as often as needed. Involve family to help redirect resident in a meaningful conversation to mitigate unsafe notion to leave unattended. Ensure doors are secured alarmed. R1 plan of care for cognitive loss dated 5/3/2023 revised on 3/11/24 denotes in part, I (R1) am an older adult functioning with dementia. I may respond coherently at times, other times I may display cognitive challenges. My concentration and attention-span may be affected. I have reduced cognitive processing speed and deficits in executive functions such as abstract reasoning, planning, problem solving, impaired conversational skills, and lack of initiation. My strengths include my enjoyment of physical movement, exercise (including walking) and keeping busy. I have periods of lucidity and greater awareness. I will accept interventions to avoid complications/decline concerning my cognitive loss and I will be provided care/activities/interventions to help strengthen and promote my cognitive skills. Emphasize keeping R1 busy and engaged. Review his favorite and preferred activities which often include movement, exercise, physical tasks; solicit additional ideas for engagement from his family. Offer opportunities to 'move with music.' Cue, reorient and supervise as needed. R1 plan of care for falls denotes in part, R1 is at risk for falls r/t (related /to) gait/balance problems, poor communication/comprehension, unaware of safety needs. Facility policy titled Wandering, Unsafe Resident revised dated of 8/2014 denotes in part the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at risk individual for potentially correctable risk factors related to unsafe wandering. The resident care plan will indicate the residents is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included. Facility policy titled Care plans, comprehensive person centered with revised date of 12/2016 denotes in part a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Incorporate identified problem areas, incorporate risk factors associated with identified problems. The Immediacy Jeopardy that began on 01/05/24 was removed on 03/22/24 when the facility took the following actions to remove the immediacy. January 5, 2024 Incident On January 5th Facility V12 Administrator educated V14 on the elopement policy. V12 Administrator has verbal discussion with receptionist at the time to confirm understanding of elopement policy, including door buzzer process: 1. When door alarm is activated- go outside and check surroundings to identify root cause, if you do not actually see who activated alarm. 2. Ensure door closes and alarm activates prior to leaving door unattended. 3. Do not buzz any resident out of facility unless you 100% know who the resident is and that they have permission to leave premises. 4. Immediately respond to all alarms and assist residents back into facility. 5. Always stop and ask visitors if a resident is walking with them- where are they going and confirm with Nurse that they have properly signed out prior to allowing them to leave. V 14 Receptionist involving in the incident resigned. No other reports or incidents of residents able to exit with visitors/staff with other reception staff. Completion Date: 1/5/24 R1 was seen and assessed at the hospital. R1 was not admitted and returned to the facility the same day. Upon his return, Facility recommended relocation to second floor where Wander guard could be implemented. Family declined and preferred R1 remain on first floor. Educated on risks. Behavior monitoring completed every shift for R1 throughout January, February, and March. Neuro checks were implemented upon return to facility for close assessment for 72 hours. Completion Date: 1/5/24 On January 5th, 2024, V19 Maintenance Assistant, V19 performed a check of all facility doors and alarms to confirm they were working, secure and in good operation. Maintenance department performed weekly checks thereafter with no issues identified. Completion Date: 1/5/24 March 15, 2024, Incident R1 has been assessed with care plan updated to address elopement risk. Facility recommended relocation to second floor where Wander guard can be implemented immediately. Family declined and preferred R1 remain on first floor. Educated on risks and care plan update. R1 was placed on close monitoring 15 min checks, hourly checks, close monitoring. Facility resident head count conducted and confirmed all residents were accounted for on 03-11-24. Completion Date: 3/15/24 All facility staff: Nursing, activities, housekeeping, dietary, Bus driver. Maintenance staff, office staff, are educated annually on elopement policy and procedure, and safety and supervision of residents. Training has been reviewed and confirmed to have been up to date for all staff. Completion Date: 3/15/24 All Facility staff including all receptionists were trained on: elopement risk binder kept at facility reception desk/nurses' station desk. R1 as elopement risk as identified in the elopement risk binder. door buzzer system and procedures to prevent residents from exiting and preventing unauthorized entries. ensuring residents are not near/trying to access doors when staff enter exit. All training was completed with open discussion among participants to maximize participation and demonstrate understanding. Completion Date: 3/15/24 Facility V 12 Administrator, V 20 Corporate Nurse Consultant/Nurse Administration and V11 Chief Operating Officer /Chief Nursing Officer immediately educated all facility employees on the following topics: 1. Elopement procedures, including securing doors to prevent unauthorized exits-facility and the door buzzer system process. 2. Elopement policy including reporting/proper notification policy and Identification of high-risk elopement residents through the use of the elopement risk binder that identifies high risk elopement risk residents at the receptionist /nurse's stations. 3. Policy and procedure to immediately notify nursing supervisor/designee when new exit seeking behaviors or high-risk behaviors are identified so that: a. Nursing supervisor/designee will assess behaviors. b. Nursing supervisor/designee will investigate root cause of behaviors. c. Elopement assessment and community survival skills will be reassessed. d. IDT will implement new interventions. 4. Facility V10 and V 12 will be the facility designees that will be responsible for staff training and evaluation of staff knowledge of elopement policies/procedures/door buzzer system/exiting doors with visitors. The education was completed between 3/11/24 and 3/15/24 for all facility staff. All training was completed with open discussion among participants to maximize participation and demonstrate understanding. Completion Date: 3/15/24 The Facility Quality Assurance team, which includes V12 Administrator, V10 Director of Nursing, V21 Medical Director, and Facility Directors met on 3/15/24 to review R1's incident and then will meet monthly to review Elopement policies and reporting, door buzzer, and exiting door with visitors. V20 will conduct ongoing audits including any risk management reports to ensure compliance once week on each shift for the next 60 days. QAPI will discuss and revise elopement policy as needed through the QAPI process. Completion Date: 3/15/24 All residents receive comprehensive assessments on admission and annually thereafter. All residents are assessed as needed for condition change, and when exit seeking behaviors or high-risk behaviors are identified. R1 is the only exit-seeking resident on the first floor. Completion Date: 3/15/24 Facility has audited all resident records to ensure all residents have an up-to-date elopement risk assessment and community survival assessment. Completion Date: 3/15/24 V19 Director of Maintenance or designee is performing door checks 3-5 times a week to ensure doors secured per facility policy/procedure. Completion Date: 3/15/24 All staff education provided and 1:1 V3 training provided on elopement policy and procedures- Identification of high-risk elopement risk residents through the assessment and the use of elopement risk binder process. Door buzzer process-door entry/exit closure/locking after being entered by staff/or visitor's process. Facility did not employ agency workers during this timeframe. If in the future agency is used, they will receive training prior to working their shift by V10 Director of Nursing or V12 Administrator. Staff that were on vacation received training via phone. Staff that were out sick received training via phone. If staff are unable to be contacted, they will receive training prior to next scheduled day of work by V10 Director of Nursing or V12 Administrator. All new facility employees will be trained during orientation process. Completion Date: 3/15/24 Quality Assurance meeting held 3-15-24 to review elopement issue and interventions. QA tool implemented for monitoring processes. Completion Date: 3/15/24 New Wander guard system was quoted 3/15/24 and will be installed and tested upon receipt. Completed installation confirmed that it's working on 3/22/24. Wander guard applied to R1. Completion Date: 3/15/24 Door egress delay was changed from 18 second delay to 5 second delay to prevent residents from using doors after staff enter/exit. During hours that receptionist is not clocked in at facility. The first floor Charge Nurse and first floor staff will monitor entrance. Completion Date: 3/15/24 Elopement books confirmed to be up to date including door buzzer/alarm and in place at reception desk. R1 is only elopement risk on the first floor and all receptionists familiar with R1 to watch for exit seeking. V7 Social Services Director will oversee new admissions risk elopement assessments and the assignment of wander guards. Completion Date: 3/15/24

Based on interview and record review the facility failed to follow the order of the primary care provider by not ordering a STAT Xray after a fall incident. This affected one of three residents (R4) reviewed for following the physician orders. This failure resulted in a 13-hour delay in R4 having an Xray conducted subsequently resulting in a diagnosis of 5 right side rib fractures and an acute fracture of right elbow. Findings include: R4 care plan shows diagnosis of intervertebral disc degeneration lumbar region, bipolar disorder, history of falling, pain in the right elbow, repeated falls, fracture of one rib left side, multiple fracture of ribs right side an issue for close fracture, multiple fracture of ribs left side initial encounter for closed fracture, displaced fracture of right radius encounter for closed fracture with routine healing, presence of orthopedic , difficulty walking, need for assistance with personal care. On 3/29/24 R4 observed alert and orient to person, place, time. Facility incident report titled witnessed fall, dated 1/18/24 at 6:45pm, R4 name noted, location: front lobby, person preparing report V16 (Nurse). Resident demand to stay at the porch for a few minutes to get some fresh air writer instructed resident that due to weather condition it would be better if he can wait until tomorrow when the weather gets better. Resident demand and yell at the nurse stating that he is not a prisoner and all he needs to get just 5 minutes to get some fresh air. Resident wore jacket and with appropriate shoes. Nurse assisted resident on his way out to the porch when he lost his balance and fell on his bottom with his right hand on the floor in attempt to abort the fall at the main entrance. Head to toe assessment done able to move all extremities without difficulty. Resident was instructed to stay put until staff can get the wheelchair, but he stood up immediately saying that he is fine. Resident did not hit his head. Vital signs 121/68, pulse 72, R18, temp 97.5. Resident stated that he lost his balance and fell on his bottom. Hand to toe assessment done. Vital signs taken DON, PCP (primary care provider) and are all informed. R4 sister. Injuries observed at time of incident right hand palm and other location. Pain level 6 alert ambulatory without assistance. Mental status alert to person orientated to situation, orientated to place, orientated to time, PEARLA (pupils, equal, round, reactive light accommodation). Predisposing physiological factors history of falls, other impulsive behavior. Witnesses; V16. Agencies notified DON (Director of nursing), physician and family member. Notes 1/19/24 per investigation resident fall is because he was trying to get into the door with the nurse behind him and as he opened the door lost balance and fell . Resident is always in a rush doing things in he's very impulsive. R4 progress notes date 1/18/24 at 9:02pm denotes in-part V24 (physician) gave an order of Xray of right elbow and right rib as per resident complain of pain on his body parts. Xray was ordered to (radiology provider) (name noted). R4 physician progress notes dated 1/19/24 at 10:30am denotes in-part, CC (chief complaint), s/p (status/post) fall, pain management, anxiety, HTN (hypertension), old rib fracture. Seen an examine per patients request. The resident approached the writer in the hallway and reported that he had a fall on 1/18. According to the patient he wanted to go outside to the porch that day to get some fresh air he was rushing lost his balance then fell and landed on his butt. PCP (primary care physician) was notified per record and ordered STAT X-ray of right elbow pending result. Today patient c/o (complain of) (R) right-side pain. Stat CXR (chest X-ray) order pending results. Informed NOD (nurse on duty) to administer pain medications and re-counsel resident on fall precaution. R4 progress notes dated 1/19/24 at 1:34pm denotes in-part receive resident in his room post fall monitoring, check vitals within normal limits. Complaining of right elbow and right rib pain, given Norco as ordered. X-ray already ordered; NP (Nurse Practitioner) seen the resident. New order for chest X-ray, order carry out. Called (radiology provider) and confirmed the order. Resident is resting in his bed now, comfortable, all needs attended. Call light within reach continue to monitor. R4 progress notes dated 1/20/24 at 12:08am denotes in-part receive resident in bed complaining of severe pain to right rib and right elbow related to recent fall. Medicated for pain and effective X-ray order and done. Result of X-ray receive at 7:30 PM. Resident has fractured to right rib and right elbow. (Doctor) notified and order to send resident to the hospital resident his sister Don were informed nurse call ambulance and will arrive in 45 to 90 minutes but later on (ambulance company name) called and the ambulance will be late for 2 hours. Nurse canceled and called 911. DON agreed. Resident picked up by 911 at 11:55pm. R4 emergency room records dated 1/20/24, arrival time 12:04am, [AGE] year-old male presents with right rib and right elbow pain for 1 day. CT chest 1/20/24 acute nondisplaced right rib fractures are noted including the right lateral sixth, right posterior lateral seventh, right posterior lateral 8th right posterior lateral 9th and right posterior lateral 10th rib. Xray right elbow there is an acute fracture nondisplaced fracture of the radial neck, trace right hemothorax. R4 emergency room triage note denotes in-part patient arriving via (local) Emergency Medical Services, patient is from (nursing facility), patient is alert and orient X3, c/o right elbow and right rib pain. RN (Registered Nurse) at (nursing facility), states patient had a witnessed, mechanical fall yesterday, and landed on right elbow and right rib. Patient X-rays done, fracture of right elbow, and right rib, so sent to ER (emergency room ). Patient work of breathing, SPO2 (oxygen), RR (respiratory rate) WNL (within normal limits). A/P (assessment/plan) R4 is [AGE] year old male with past medical history of HTN, HLD, hypothyroidism, schizoaffective disorder who lives at citadel now admitted after sustaining a fall to right side and has nondisplaced R (right) 6/10 rib fracture and L (left) min displaced 7-9 ribs. Pain poorly controlled and limiting mobility. Breathing well on room air. Chest well moderate. Transferred to [NAME] park hospital for further management. R4 radiology results report dated 1/19/24 at 5:48pm completed by (portable Xray company name) denotes right elbow 2 views, impression: suspected acute radial head fracture with associated small effusion hardware fixation of the proximal ulna is anatomic. Right ribs 2 views, impression: acute right-side fracture of the 7th and 8th posterolateral ribs. On 3/29/24 at 4:51pm V24 (Physician) said whenever there's a fall and the resident complain of pain the facility should order a STAT Xray. V24 said he don't recall all the details of R4 fall, but he does remember the facility mentioning something about R4 falling and the was a fracture to the left rib. On 3/29/24 at 11:26am V16 (RN-registered Nurse) said she was R4 nurse on 1/18/24. V16 said R4 wanted to go outside to get some fresh air, V16 said she was telling R4 that it was cold, V16 said R4 wanted to go any, V4 said she was walking behind R4 because R4 is fall risk. V16 said R4 fell in the foyer when R4 lost his balance, V16 said there was a visitor coming inside when R4 was going out of the building. V16 said the visitor gave way to R4 (the visitor allowed R4 to pass). V16 said R4 fell , R4 did hit his right side slightly on the radiator, and landing on his buttock. V16 said she don't recall who the visitor was, V16 said the visitor did not body slam R4, the visitor did not touch R4, V16 said the visitor gave way to R4. V16 said R4 fell when he lost his balance. V16 said she don't know why she did not document that R4 hit his right side on the radiator when he fell . V16 said R4 did complain of pain in his hand. V16 said after the fall R4 stood up, but she got R4 a wheelchair. V16 said she assessed R4 for injuries and R4 complained that his hand hurt. V16 said she did give R4 pain medication, she notified the doctor and R4 family. On 4/2/24 at 9:22am V16 said V20 (physician) gave orders for R4 to have an Xray, V16 said she don't recall if the orders were for STAT Xray. V16 said she did not call the physician back to clarify if he would like a STAT Xray when R4 observed with complaints of pain to the right-side rib pain. Review of R4 physician order sheet there were no Xray orders noted in the electronic records dated for 1/18/2024. On 4/2/24 V10 (Director of Nursing) said the facility nurses know what to do if there's a delay in a STAT Xray. V10 said when the nurse receives an order for a routine Xray, from the physician or Nurse practitioner the Nurse should input the orders in the electronic records within 2 hours of receiving the order and if the order is for a STAT Xray the nurse should put the order in the electronic system right away. V10 explains the Xray orders go directly to the radiology company for review. V10 said R4 received medication for the right-side rib pain at the facility. V10 said he was aware that R4 was diagnosed with five right-side rib fractures and an acute fracture to the right elbow at the hospital. V10 said if the resident pain level is under 8 he expects a routine Xray to be completed, V10 said if the resident pain level is 8 or higher he expects a STAT Xray to be completed. V10 said ordering a STAT vs routine Xray also depends on the physician. On 4/2/24 at 9:22am V25 (XRAY COMPANY Rep) said the company received a Xray order for R4 on 1/19/24 at 10:24am as a routine order, V25 said R4 routine Xray exam was upgraded to STAT at 5:19pm on 1/19/24 and the company was onsite to complete the Xray for R4 at 5:20pm. V25 explained that a STAT Xray will be completed with results within 4-5 hours and a routine Xray will be completed with results within 24 hours. V25 said he does not have any Xray orders for R4 for 1/18/24. V25 said the company notice that the exam times have been showing as 12:00 midnight, V25 said R4 Xray was not complete at 12:00 midnight as shown on the report. Review of R4 order audit denotes in-part date 1/19/24 at 10:23am, chest two views. On 1/19/24 at 5:07pm right ribs, unilateral, (with) posteroanterior chest, 3+ views. R4 pain evaluation dated 1/18/24 at 6:46pm completed by V16 denotes in-part resident is able to understand and be understood regarding their pain, pain score 5, location right elbow and right iliac crest, characteristics of current pain: intermittent pattern. Facility policy titled Physician Orders with revised date of February 2019 denotes in-part all orders including medications and treatments labs and ancillary orders must be ordered by a licensed physician or nurse practitioner. All orders will be consistent with principles of safe and effective writing order. All orders will be processed and carried out by nursing service personnel as soon as the order has been received. The nursing staff member who took the order or the one assigned to the resident is responsible to transcribe the order. Transcribing orders include writing new orders on the medication administration record or treatment administration record or completing laboratory test request dietary notification form or ancillary notification to inform others of the change in order as necessary for facilities in EHR (electronic health record) orders must be properly entered into the computer and attached to appropriate flow sheets IE medication treatment or lab flow sheet. Facility Radiology contract with agreement date denotes in-part duties and obligations of facility will promptly schedule the patient service per the providers ordering procedure provider will in service facility on ordering procedure. On 4/2/24 at 8:41am V12 (administrator) presents the radiology contract for (radiology provider), stating he alternates between companies.

Based on observation, interview, and record review, the facility failed to follow enteral feeding administration physician order for 1 (R3) of 3 residents reviewed for enteral tube feed management in the sample of 4. Findings include: R3 is a [AGE] year old female admitted to the facility 12/10/2021 with diagnosis including but not limited to Dementia; (Osteo)Arthritis; Cardiomyopathy; Cerebral Infarction; Hyperlipidemia; Primary Hypertension; Epilepsy; and Gastrostomy Status. On 02/27/2024 at 11:40 AM Surveyor observed ongoing enteral feeding. Label reads in part, Jevity 1.2 cal, start date: 2/27/24 2:30 AM, rate: 65 ml/hr (milliliters/hour). Enteral feeding pump infusion rate observed to be set at 50 ml/hr. R3's Physician Order dated 01/11/2024 reads in part, Jevity 1.2 at 70 ml/hr x 16 hours/day. On 02/27/2024 at 11:40 AM Surveyor asked V4 (Registered Nurse) to verify R3's enteral feed order due to discrepancy between label and infusion pump, V4 (RN) checked R3's physician order and said, It should be 70ml/hr. It has been 50 ml/hr for years and no one told me that there was a change. It must have changed recently. Surveyor asked about importance of following enteral tube physician order, V4 (RN) stated, It is important to follow enteral feeding orders for residents' proper nutrition. Surveyor asked who monitors accuracy of enteral feeding with residents' order, V4 (RN) stated, We (nurses) monitor enteral feeding and on day shift (7:00 AM - 3:00 PM), but all feeding tube care and enteral feeding set up is done on night shift. I didn't notice enteral feeding rate discrepancy. I don't look at all orders for all residents every day. If there are any changes, we supposed to communicate them on the 24-hour report. On 02/28/2024 at 12:04 PM Surveyor interviewed V2 (Director of Nursing) who related the following in summary: I would expect nurses to follow most recent residents' orders. Surveyor asked why it is important to adhere to physician's order, V2 (DON) stated, To make sure, residents get adequate nutrition. Additionally, nurse should inform the doctor about any discovered discrepancy. Facility Enteral Tube Feeding via Continuous Pump policy dated 11/2022 reads in part, Check the enteral nutrition label against the order before administration. Check the following information: Rate of administration (ml/hr). Refer to facility procedures for hang times and administration set changes. Check the label on the enteral formula against the physician order.

Based on observation, interview, and record review, the facility failed to follow their food service and safety policies by not ensuring refrigerated foods were properly stored; food items in the cooler not labeled and dated; foods not removed from the cooler after disposal date; and not maintaining proper general cleanliness and organization in the kitchen. These failures have the potential to affect all residents who reside in the facility and receive services from the kitchen. Findings include: The following observations were conducted in the facility kitchen on [DATE] from 9:50 AM to 10:40 AM: At 9:55AM with V8 (Cook) the walk-in cooler was observed to have five heads of putrid lettuce, moldy tomatoes stored in a box, an opened package of corn tortillas with no date, four boiled eggs in bowls (undated), personal beverages, an undated bowl of cooked mashed potato, two packages of undated opened lunch meat; one plastic container labeled strawberry preserves [DATE] opening with discard date [DATE], the container was noted with red syrup and black fuzzy spots. A plastic container of tuna salad dated [DATE] that looked dry in some areas and very white in others- V8 said this was expired and removed it from the cooler. On a tray was ready to cook items including: three raw hamburger patties, three hot dogs, and four chicken tenders were placed on a tray. V8 said they would be prepared as alternates for lunch. V8 said that it was okay to have the foods on the same tray uncooked because the foods were on foil sheets and not touching. One uncooked ham was on the second rack not contained, and underneath was a tray of ready to eat foods prepared for lunch service, which included fruit trays and fresh salads. V8 said, the ham was thawing for a later date, and moved the fruit and salad to be on the same level as the thawing meat. Outside of the cooler, a plastic container of onions was found under the meat thawing sink, when V8 opened the cover, flies were noted inside. Two soup base bucket containers were also found under the prep table. At 10:09 AM, V9 Dietary Aid was seen placing clean plates in the warming box which had visible crumbs and other food debris. V14 Dietary Aid was seen washing some dishes in the three compartment sink, which did not appear to have any sanitizer in it. The solution container as seen under the sink appeared to be almost empty of pink liquid and when V8 pushed the dispenser, nothing came out. V8 then poured the small content remaining in the bottle directly into the sink. V9 was asked to test the solution and when they tried the testing strips, there was no color change. V9 said, this would indicate that there was not enough solution diluted in the water to provide proper sanitization. V14 was noted wiping a prep table with towels from a sanitation bucket. V9 tested the solution and the color did not change on the strip. On [DATE] at 11:37 AM V7 Dietary Manager said, the cooks should monitor the integrity of the foods and the stock individual and myself will make sure it is organized. Cross contamination, infection control and food safety would be of concern if the foods were not maintained. Meats can be thawed under running water or pulled and put into the refrigerator. Should the meat be in the fridge, it would be on top of a pan so that nothing can drip down underneath. Anything that needs to be cooked to a higher temperature would be on the bottom of the cooler racks because if it was being stored on top, we have risk of it dripping down which could cause cross contamination. The cooks should be cleaning the shelves out regularly. Generally, the person who stocks is picking up the mats and cleaning the floor of the cooler and they are also responsible for cleaning the wall and the shelves. Produce that is rotting or moldy should be thrown away. I would have them date tuna salad for only three days, which is typical for prepared foods and any leftovers. We use a Quaternary sanitizer. The dispenser over the sink is calibrated to dispense the proper amount of solution and then we test it before washing the dishes to be sure it is appropriate part per milliliter. No one has made any complaints about the sanitizer not working. This is the same solution is used for the buckets, dispensed from the same pump. Food and Nutrition Services Policies were reviewed and all policies were reviewed ,d+[DATE] : Storage of Refrigerated Foods- Policy: Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Food in the refrigerator is covered, labeled and dated with a used by date. Raw food is stored below cooked food, or ready to eat food. Refrigerated Food- Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as Day 1. Manual sanitizing in Three-Compartment Sink: Policy: A sink with three compartments is used for manually washing, rising and sanitizing utensils and equipment that can be submerged. It may also be used for tableware. After washing and rinsing utensils or equipment are sanitized in the third sink by immersion in either: Hot water or chemical sanitizing solution used according to manufacturer's instruction. The most common chemical sanitizers are chlorine, iodine and quaternary ammonia. The manufacturer's label is referenced for the appropriate concentration of the sanitizing solution and for length of submersion time. A test strip is used to accurately determine the concentration of the sanitizing solution. The strip is dipped into the sanitizing solution and held for the seconds specified on the test kit. Once removed from the sanitizing solution, the strip is compared to the color on the char. If the color is not within the correct rang, adjustment is made until the sanitizing solution is the correct concentration.

Based on observation, interviews, and record reviews, the facility failed to administer medications as ordered. There were 25 opportunities with two errors resulting in 8% medication error rate. These failures applies to one (R65) resident observed during the medication administration on the sample list of 51. Findings include: R65 admitted in the facility on 09/01/22 with diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease; Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy without Macular Edema; Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified; Other Specified Diabetes Mellitus with Diabetic Nephropathy; and Other Chronic Pancreatitis. POS (Physician Order Sheet) dated recorded: 05/22/23: Creon Oral Capsule Delayed Release Particles 12000-38000 unit (Pancrelipase Lipase-Protease-Amylase) give one capsule by mouth with meals. 08/09/23: Insulin Lispro Injection Solution 100 unit/ml (unit per milliliters) inject 2 units subcutaneously in the morning. On 11/19/23 at 11:35 AM, V4 (Licensed Practical Nurse, LPN) was observed preparing R65's 9 AM medications. V4 stated, It's the morning medications that I am passing right now. All of R65's scheduled morning medications were prepared except Creon and Insulin Lispro. V4 was asked why she did not prepare Creon and Insulin Lispro. V4 stated, This medicine (pertaining to Creon) has to be taken with meals. I have not given this medication this morning. I did not give Insulin this morning, too. During medication administration, R65 verbalized, No, I have not taken the Creon this breakfast and she (V4) did not give me the Insulin this morning. On 11/19/23 at 12:30 PM, V5 (Registered Nurse, RN) and V6 (RN) both stated that all residents' medications are administered between the 8 AM to 8:30 AM for the scheduled 9 AM medication time. V5 stated, We pass medications between 8 to 8:30 in the morning, an hour before and an hour after. Medication time is 9 AM. V6 also verbalized, Breakfast is 8 AM. Morning shift starts at 7 AM to 3 PM. By 10:00 AM, medication pass should be done, ideally. V4 was asked regarding medication pass for today (11/19/23). V4 replied, Medication pass is at 9 AM, an hour before or an hour after. I came in at 7 AM. End of medpass should be at 10 AM. I was late in giving medpass today. I only come on weekends and not used into these residents. I know, 10:30 AM medpass is late. On 11/20/23 01:40 PM, V2 (Director of Nursing) was asked regarding medication administration. V2 stated, Medpass times for daily dosing is 9AM; 6AM for stomach medications or thyroid medications. For twice a day medications, it would be 9 AM and 5 PM. Three times a day is 9 AM -1 PM -5 PM. If medication is in the morning, it should be given by 9 AM, an hour before and an hour after. 11:00 AM medpass is considered late. I do expect that staff assess residents and inform doctors. With medication orders with meals, it should be given with meals or with foods. Facility's policy titled, Administering Medications dated December 2022 documented in part but not limited to the following: Policy: Medications shall be administered in a safe and timely manner, and as prescribed. Procedure: 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure that a resident who required transmission based precautions was placed on contact isolation after readmitting from the hospital. This failure applied to one (R307) of one resident reviewed for infection control on the sample list of 51. Findings include: R307 originally admitted to the facility on [DATE], was sent to the hospital on 11/1/23, and readmitted to the facility on [DATE]. R307 was admitted back to the facility with multiple diagnoses including but not limited to the following: sepsis due to E. Coli, bacteremia, acute cholecystitis, and ESBL (Extended-spectrum beta-lactamases) resistance. On 11/19/23 at 10:45AM, R307 was observed to not be on isolation. No isolation signs or personal protective equipment (PPE's) noted outside of R307's room. Observed V10 (Licensed Practical Nurse) walk in to room while not wearing any PPE's. On 11/20/23 at 12:40PM, V12 (Registered Nurse) was interviewed regarding R307. V12 said R307 readmitted to the facility on Saturday evening, (11/18/23). R307 has ESBL bacteremia in his blood and should have been on isolation upon readmitting from the hospital. V12 said when a resident is on contact isolation, the staff should be wearing proper PPE's to help prevent the spread of infection. This includes a gown, gloves, and a mask and should be worn every time they enter the room. At 1:10PM, V3 (Assistant Director of Nursing/Infection Preventionist) was interviewed regarding R307 and isolation procedures. V3 said R307 readmitted to the facility 11/18/23, however was not placed on isolation until the afternoon of 11/19/23. I reviewed his hospital records on 11/19/23 and realized he should be on isolation. Typically the admitting nurse should review the hospital records and let the housekeeping staff know. There are housekeepers here on the weekends and they have access to the isolation bins and signs. Hospital records dated 11/1/23-11/18/23 indicate resident currently is being treated for sepsis due to ESBL bacteremia. Facility policy titled Isolation-Initiating Transmission-Based Precautions with revision date of October 2018 states in part but not limited to the following: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrive for admission with symptoms of an infection, or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Procedure: Determine the appropriate notification on the room entrance door and ensures that protective equipment is maintained outside the resident's room.

Based on observations, interviews, and record reviews, the facility failed to inform residents individually and through postings of their grievance process and procedures including contact information of the grievance official, reasonable expected time frame for reviewing and responding to grievances, the right to obtain a written decision regarding his or her grievance, and the contact information of independent entities such as the state agency with whom grievances may be filed. This failure has the potential to affect all residents residing in the facility. Findings include: On 11/20/23 from 02:09 PM - 2:30 PM R2, R7, R10, R17, R18, R41, R47, R49, R53, and R63 reported they have not been informed about the procedure of filling a grievance at the facility. On 11/21/23 at 10:52 AM Observed only one sign with information on the facility's grievance procedure on the facility's lower level board area near the elevators in an area not easily observed by staff or visitors. Observed there were no other grievance procedure signs posted anywhere else in the facility. On 11/21/23 at 10:56 AM V1 (Administrator) stated residents are informed of the facility's grievance procedures through the admissions packet and through signage. On 11/21/23 11:55 AM V1 (Administrator) stated he understood the concern regarding posting and education of the facility's grievance procedures. V1 stated he will address this moving forward. Resident council meeting reports from June - November 2023 do not document a review of the facility's grievance procedures. The facility's admission packet reviewed 11/21/2023 does not include information about the facility's grievance procedures.

Based on observations, interviews, and record reviews, the facility failed to post a notice of availability and failed to provide access for residents to the most recent Federal or State Survey conducted and any subsequent plans of correction. This failure has the potential to affect all residents residing in the facility. Findings include: On 11/20/23 from 02:09 PM - 2:30 PM R2, R7, R10, R17, R18, R41, R47, R49, R53, and R63 reported they have not been informed about having access to the results of the state survey nor have seen the survey results anywhere in the facility. On 11/21/23 at 10:48 AM Observed no signage throughout the facility regarding where to view the survey results. V13 (Receptionist) stated she wasn't sure where the survey results binder is. Observed the survey results not available for viewing anywhere in the facility. On 11/21/23 at 10:56 AM V1 (Administrator) stated the survey binder may be located in the receptionist area. V1 stated any postings regarding the survey binder may be in the receptionist area. V1 stated the survey binder is likely outdated. Observed V1 and V13 (Receptionist) could not locate the survey binder in the reception area. On 11/21/23 11:55 AM V1 (Administrator) stated he located the survey binder in his office and advised he would ensure the binder is placed in a visible area.

Based on interview and record review, the facility failed to provide readmission for 1 (R3) of 3 residents reviewed for transfer/discharge notice in the sample after R3 was ready to return to the facitlty, after being transferred to the hospital for evaluation. Findings include: R3's medical records document R3 was admitted to the facility on [DATE] and discharged on the following day on 6/21/2023. On 8/7/23 at 9:55 AM, V1 (Administrator) and V2 Director of Nursing (DON) stated, We were not able to even admit R3 into the facility and we discharged him that same evening because he became agitated and hit staff. We transferred him to the hospital for a psychological evaluation. He never returned to us because he came from another facility, so R3 should go back to the previous facility, not ours. On 8/8/23, V2 (DON) on 10:30 AM stated, I misspoke yesterday, we were able to admit R3 because it does show the nurse admitted the resident into the facility. (R3) had to be transferred to the hospital because he became physically combative with staff and he punched a nurse in the stomach and he bit one of the CNA's in the arm. Surveyor asked if R3 was presented with an emergency discharge notice in writing or if a power of attorney was provided the form, V2 stated I don't think that was done. On 8/10/23 at 12:15 PM, V1 (Administrator) stated, We did not provide an involuntary discharge notice to R3. On 8/10/23 at 12:17 PM, V2 (DON) stated, We did not give R3 a notice because we did a 911 emergency discharge to the hospital because the resident was not appropriate for the facility due to his behaviors. Surveyor asked if he was originally assessed as appropriate and did the facility admit him to the facility as appropriate, V2 stated, Yes we did. On 8/9/23 at 10:30 AM V8 (R3's family member) stated that when he was told by the facility to pick up R3's personal belongings he saw plenty of open beds to readmit R3 but was told that they were full and refused to hold R3's bed for readmission back to the facility. V8 indicated that when R3 was in the hospital, they had difficulty finding placement for him because no one would accept him, but the facility should not have banned him from going back since they knew he was a dementia resident with behavioral issues. V8 stated the facility should have known how to manage the behavior instead of just kicking (R3) out. On 8/10/23 at 12:30 PM, V6 Minimum Data Set (MDS nurse) stated, The DON (V2) should have assessed R3 as appropriate for the facility to begin with. They accepted R3 and admitted him to the facility so if he was no longer appropriate for the facility, he should have been given IVD (involuntary discharge) notice. The facility's policy dated December 2016 titled transfer or Discharge Emergency documents, Emergency transfers or discharges may be necessary to protect the health and/or well-being of the residents. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.

Based on interview and record review the facility failed to implement its Abuse prevention policy by failure to formulate an abuse prevention care plan for residents who are at risk for abuse. The facility also failed to update the abuse assessment and care plan after an abuse allegation and investigation was made. This deficiency affects two (R1 and R2) of three residents reviewed for Abuse prevention program. Findings include: R1 is admitted on [DATE] with diagnosis listed in part but not limited to Bipolar disorder, Schizoaffective disorder, Post traumatic stress disorder. Admission abuse/neglect assessment done on 5/3/23 indicated she is at risk for abuse due to psychiatric history or present mental health diagnosis and history of or presence of behaviors such as provoking, aggressive manner, manipulative, derogatory, disrespectful, obnoxious, abhorrent, insensitive, attention-seeking and or otherwise abrasive/inappropriate behavior. Physician order sheet indicated that she is on every shift behavioral monitoring. Care plan indicates that she has mental health challenges due to diagnosis of Schizophrenia and Bipolar disorder. No abuse prevention care plan formulated. Abuse assessment and care plan were not updated after allegation of mental abuse made by R1. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Attention deficit hyperactivity disorder, Dementia with psychotic disturbance, Major depression, General anxiety disorder, Opioid dependence. Abuse assessment done on 7/4/22 did not indicate history of substance abuse, psychiatric history and present mental health diagnosis, diagnosis of depression. Care plan indicates that she is confused she thought she was living in a basement. She has medical comorbidities with delirium. She has called 911 system when medical emergency does not exit. She is impulsive calling 911 and thinking she was trapped in the basement and wanted the responders to take her home. She is anxious and upset during her stay and sometimes respond by screaming. She became increasingly agitated and unable to regulate behavior. She has abuse/neglect /trauma factors. Abuse assessment and care plan were not updated after allegation of mental abuse made by V17 Family member and R2. On 5/23/23 at 9:54am Informed V1 Administrator and V2 Director of Nursing (DON) of R1 and R2's complaint allegations of mental abuse. R1 reported that CNAs yelled and made fun of her during incontinence care. V17 Family member of R2 reported that CNAs told R2 that she stinks. Both denied complaint allegation of R1 and R2. Both said that they have not heard R1 and R2 complaint or reported the said allegations. On 5/23/23 at 10:38am, Observed R2 lying on bed. She is alert and responsive with period of confusion. R2 said that CNA told her that she and her feet stinks. She cannot identify the CNA by name or appearance and unable to give the date /time of the incident occurrence. On 5/23/23 at 11:21am, Observed R1 up in wheelchair in her room. She is alert and responsive but with period of confusion. She said that CNAs yelled at her and made fun of her during incontinence care. She said it happened last Sunday night. She cannot give name and description of CNAs. On 5/23/23 at 2:30pm, V1 Administrator presented abuse allegation incident report submitted to IDPH for R1 and R2. On 5/24/23 at 1:16pm V7 Social Service Director (SSD) said that she does the abuse assessment for the residents in the building. She said, Abuse/neglect is done upon admission, annually, significant change and as needed if there is allegation of abuse. Abuse prevention care plan if the resident is at risk for abuse based on abuse assessment. Informed V7 that R1's admission abuse assessment done on 5/3/23 indicated she is at risk for abuse due to psychiatric history or present mental health diagnosis and history of or presence of behaviors such as provoking, aggressive manner, manipulative, derogatory, disrespectful, obnoxious, abhorrent, insensitive, attention-seeking and or otherwise abrasive/inappropriate behavior. But no abuse prevention care plan is formulated. Informed V7 that R2's abuse assessment done on 7/4/22 did not indicated history of substance abuse, psychiatric history and present mental health diagnosis, diagnosis of depression of R2. Informed V7 that both R1 and R2's abuse assessment and abuse care plan were not updated after an allegation of abuse were reported and investigated. V7 said, she is aware that R1 and R2 have abuse allegations presented against the facility and V1 submitted abuse allegation incident report to IDPH. V7 said, she did not complete abuse assessment and update abuse prevention care plan for both R1 and R2. V7 said, she thought V1 is taking care it. V7 said, she is responsible for completing resident's abuse assessment and formulating abuse care plan prevention. V7 said, she is waiting for the instruction from V1 to update abuse assessment and care plan for both R1 and R2. On 5/24/23 at 2:05pm Informed both V2 DON and V19 Nurse Consultant of above concerns. Both said that abuse assessment should be completed accurately. Both said that abuse prevention care plan should be formulated to resident who triggered at risk for abuse assessment. Both said that V7 SSD should updated both R1 and R2 abuse assessment and abuse prevention care plan. Facility's policy on Abuse Prevention program indicates: Policy interpretation and implementation: 3. Develop and implement policies and procedures to aid in our facility in preventing abuse, neglect, or mistreatment of our residents. Facility's policy on Abuse prevention program indicates: IV. Establishing a resident sensitive environment Resident assessment: as part of the resident's life history in the admission assessment and as needed, comprehensive care plan and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation mistreatment, history of trauma or misappropriation of resident property, which have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.

Based on observations, interviews, and record review, this facility failed to identify an emergent situation and immediately activate the 911 system. This affected 1 of 3 residents (R1) reviewed for activating 911 in an acute change in condition. This failure resulted in a 30-minute delay in 911 being called and R1 being transported to the local hospital for emergent treatment. Findings include: On [DATE] at 11:45am, this surveyor observed R1's room was located near the nurses' station with a telephone. The oxygen storage room is located between R1's room and the nurses' station. On [DATE] at 1:50pm, V3 NP (nurse practitioner) stated that V3 is familiar with R1. V3 stated that R1 was alert and oriented x 0. V3 stated that V3 reviewed R1's medical record on [DATE] when V3 arrived at this facility. V3 stated V3 would not have waited 30 minutes to recheck R1's oxygen saturation level. V3 stated V3 did not realize R1 was not sent out to hospital immediately. V3 stated any changes in a resident's oxygen saturation level, heart rate, and blood pressure is an emergent situation and R1 should have been transported immediately at 5:28am when R1's oxygen saturation level was 64%. On [DATE] at 7:00am, V7 CNA (certified nurse aide) stated that V7 was familiar with R1. V7 stated that V7 did not work at this facility on [DATE] 11:00pm until [DATE] 7:00am. When questioned reason V7's name was on staffing sheet [DATE], V7 did not know but insisted V7 did not work overnight on [DATE]. Review of this facility's staffing sheet, dated [DATE], notes V7 worked on R1's nursing unit 11:00pm until 7:00am ,d+[DATE]. Review of V7's timecard punches notes V7 clocked in to work on [DATE] at 3:24pm and clocked out on [DATE] at 7:28am. On [DATE] at 7:45am, V6 RN (registered nurse) stated that she does not recall the details of the events of [DATE]. V6 reviewed V6's documentation on [DATE]. V6 stated that when V6 assessed R1 at 5:28am and noted R1's oxygen saturation level was 64%, V6 applied oxygen at 5 liters via non-rebreather mask. V6 stated that V6 called EMS 911 immediately. When questioned further regarding time documented noting at 5:59am EMS 911 was called, V6 stated that V6 called another nurse to assess R1 and then V6 had to go to the oxygen storage room to obtain oxygen cannister. When questioned reason it took 31 minutes to get another nurse and oxygen, V6 did not respond. On [DATE] at 1:00pm, V2 DON (director of nursing) stated that V6 RN called EMS immediately when R1's blood pressure was ,d+[DATE] at 5:59am. V2 stated that when a resident's oxygen level is low, the nurse should apply oxygen and recheck the oxygen saturation level in ,d+[DATE] minutes. V2 stated that R1's oxygen saturation level was 64% at 5:28am, V6 applied oxygen via a non-rebreather mask and R1's oxygen saturation level came up to 71%. V2 stated that when V6 obtained blood pressure ,d+[DATE], V6 called EMS immediately. V2 stated that with some medical conditions, an oxygen saturation level of 64% is normal. When asked to identify those medical conditions, V2 did not respond. When asked to identify which of R1's medical condition(s) would one see oxygen saturation levels normally 64%, V2 did not respond. V2 stated that this facility does not have a policy or protocol for oxygen saturation level monitoring. V2 stated that oxygen saturation level monitoring is a nursing standard of care. Review of R1's medical record notes R1 was admitted on [DATE] with diagnoses including: traumatic brain injury, paraplegia, dysphagia, non-traumatic intracerebral bleed, generalized muscle weakness, right elbow contracture, seizures, and hypertensive heart disease. Review of R1's medical record, dated [DATE], V6 RN noted: resumed duty at 10:56 pm, R1 in bed sleeping, 1:00am R1 was sleeping, vital signs as follows: blood pressure ,d+[DATE], temperature 98.4 degrees, pulse 78, respirations 20 breaths/minute, oxygen saturation level 96% on room air, 3:00am R1 was sleepy, 5:28am observed R1 with difficulty in breathing, vital signs checked: oxygen saturation level 64% Room air, pulse 92, blood pressure ,d+[DATE], respirations 22 breaths/minute, raised head of bed, oxygen 5 liters via non-breather mask given and oxygen saturation level was 71 %. R1 also was sweating. At 5:59am, called 911 and they arrived at the facility at 6:10 am, departed facility at 6:20 am. R1's gown changed, incontinence brief changed and R1 was cleaned. Addendum: vital signs taken at 5:28am were as follows: oxygen saturation level 64% room air, pulse 84, blood pressure ,d+[DATE], respirations 22 breaths/minute. Vital signs taken before calling 911: blood pressure ,d+[DATE], respirations 22 , pulse 92, oxygen saturation level 71% with 5 liters of oxygen on non-breather mask. Review of R1's EMS 911 run sheet, dated [DATE], notes EMS was contacted at 6:01am for a resident with low oxygen saturation level. Upon EMS arrival at R1's bedside at 6:08am, crew found R1 in hospital bed unresponsive with agonal respirations. R1 had cyanosis to lips. R1's skin hot and cyanotic, lung sound diminished throughout, and vital signs: blood pressure-unable to obtain, respirations 8/minute weak/agonal, heart rate 60 beats/minute, and oxygen saturation level 71% on room air. At 6:13am, R1's blood pressure was ,d+[DATE], heart rate 50 beats/minute, respirations 12/minute, and oxygen saturation level 94% with oxygen/bag valve mask. EMS left facility with R1 at 6:18:22am and arrived at the hospital at 6:18:53am. Review of R1's hospital record, dated [DATE], notes R1 arrived to the emergency unresponsive. R1's vital signs: oxygen saturation level 94% via oxygen/bag valve mask, without respirations, blood pressure ,d+[DATE], no pulses palpated--believed to be false read while arm was being manipulated for IV (intravenous) access, cyanotic, pale, and fixed dilated pupils. CPR (cardiopulmonary resuscitation) initiated. R1 was pronounced dead at 6:44am. Review of this facility's change in a resident's condition or status policy, revised ,d+[DATE], notes the nurse will notify the resident's physician when there has been a significant change in resident's condition and there is a need to transfer the resident to a hospital. A significant change of condition is a major decline in the resident's status that will not resolve itself without intervention by staff. Review of this facility's pulse oximetry policy, revised ,d+[DATE], notes assess the resident for the following signs and symptoms of impaired oxygen saturation: altered respirations, difficulty breathing, cyanotic appearance of nail beds, lips, skin, mucous membranes, restlessness, and/or loss of consciousness. Review of the national library of medicine, oxygen saturation, dated [DATE], notes oxygen saturation is an essential element of patient care. Oxygen is tightly regulated within the body because hypoxemia can lead to many acute adverse effects on individual organ systems. These include the brain, heart, and kidneys. Oxygen saturation is a measure of how much hemoglobin is currently bound to oxygen compared to how much hemoglobin remains unbound. The use of pulse oximetry has become a standard of care in medicine. It is often regarded as a fifth vital sign. Pulse oximetry can provide a rapid tool to assess oxygenation accurately. It is particularly useful in emergencies. Cyanosis (bluish discoloration) may not develop until oxygen saturation reaches about 67%. The generally accepted standard is that a normal resting oxygen saturation of less than 95% is considered abnormal. Therefore, it remains vital to observe patients for the clinical markers of hypoxemia. The brain is the most sensitive organ, and visual, cognitive, and electroencephalographic changes develop when the oxygen saturation level is less than 80% to 85%. All healthcare workers, including nurses, should be familiar with pulse oximetry. Pulse oximetry is an accurate measurement of the patient's overall oxygen saturation.

Based on observation, interview and record review, the facility failed to assess and treat new pressure sores for 1 resident in the sample (R10), and failed to follow the manufacturer's directions for the use of a low air loss mattress and failed to reposition 1 resident in the sample (R1). This failure resulted in R1's pressure sore increasing in size. Findings Include 1. On 12/27/11 at 10:15am during initial tour R10 was transferred into a wheel chair. At 2:40pm, R10 was transferred back into bed. R10 was intermittently observed not able to reposition self to relieve pressure on the buttocks. The facility identified R10 has having pressure ulcer. R10 was also observed on 12/28 and 12/29 to be up in the wheelchair during the same time period and not repositioned to relieve pressure. E4 ADON (Assistant Director of Nursing) was questioned for clarification whether R10 has a pressure ulcer, and E4 replied that the pressure ulcers have healed. Upon observation on 12/27/11, R10 was noted to have two new open skin sites on the right buttocks. E4 (ADON) acknowledged that they are new and was asked to measure the site and stage them if applicable. E4 measured first site on the right buttocks as 2cm (centimeter) x 2.2cm and stage it as stage II ulcers. The second site on the right buttocks measured 0.4cm x 1cm and was staged as stage II pressure ulcer with reddened surrounding area of 8cm x 4.8cm staged as stage I . On the left buttocks an area of redness noted and measured 7.4cm x 6cm and was staged as stage I. At 3:30pm 12/27/11 the redness and open area on both buttocks remain the same, E4 stated the physician will be notified to get a new order for treatment. On 12/28/11 at about 9:15am, Z2 (Wound care Physician) acknowledged that the original site of pressure ulcer healed and these are new sites that were just reported late last night 12/27/11, Z1 noted in R10 's wound care assessment and progress note dated 12/7/11 that the right buttocks pressure ulcer size " remains closed. " On 12/27/11 R10 ' s care plan did not address the new site of pressure ulcer. R10 ' s MDS score for transfer is 3/3 and for bed mobility 3/2. 2. Per observation and facility records, R1 has a stage II pressure sore on her right buttock. The resident was observed lying on a low air loss mattress on 12/27 (2:30pm), 12/28 (9:30am), 12/29/11 (2:25pm) and 1/3/11 (10:50am). R1 had a sheet on the mattress, 2 cloth pads under her, and a cloth diaper on during all of these observations. E4 and E31 (CNA's - Certified Nursing Assistants) performed incontinence care on the resident on 12/28 at 9:30am and placed the same amount of linen on the bed/resident as stated above. E22 was asked on 12/28/11 at 10am if there was any information available about the use of R1's bed, and she stated that all they had on the floor was the delivery receipt. A search of the Manufacturer's Specifications for this brand of bed documents the following regarding use of linens: "Limit to 1 bed sheet and only breathable incontinence pads. Waterproof cover is moisture vapor permeable." Observations on 12/28 at 12N and 2pm, 12/29 at 11am & 3pm, 12/29 at 2.23pm, and 1/3/12 at 1pm also showed that the resident was lying on her back. No repositioning of R1 was observed. R1's pressure sore and wound records show that the area on the right buttock re-opened on 11/26/11 and measured 3.0cm x 2.0cm. The following measurements are documented weekly by the nursing staff or wound physician: -11/30 - 2.0cm x 3.0cm -12/7/11 - 1.5cm x 2.4cm -12/14/11 - 1.5cm x 2.4cm -12/21/11 - 0.4cm x 0.7cm -12/28/11 - 0.8cm x 1.2cm -12/31/11 - 6.0cm x 1.5cm The wound was remeasured by E22 (nurse) upon request on 1/3/12 at 12:30pm. It was measured at 5.4cm x 1.3cm. E22 stated that the wounds are measured every Friday by the nurses. According to these measurements, the wound increased dramatically from 12/28 to 1/3/12. No documentation was found to address the increase in size or the possible causes for it. A document titled "Skin Care Do's and Don't" was presented by the facility. Under "Do's" - Do notify the treatment or the charge nurse of any redness or skin breakdown. -Do turn and reposition residents at least every 2 hours. Under "Don'ts" -Don't place multiple layers of sheets and underpads beneath residents. "Less is best" -Don't leave residents in a chair for more than one hour without repositioning them.