Every finding on record at Claridge Healthcare Center

Based on interview and record review, the facility failed to ensure a resident (R2) did not physically abuse other residents for three of nine residents (R1, R2, R3) reviewed for abuse in the sample of nine.The findings include: 1.R2's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, convulsions, and wedge compression fractures. R2's UCIA report dated 7/10/23 shows there was a hit on his record. R2 is an identified offender with possession of a firearm in public, unlawful use of a weapon, and possession of cannabis. R2's Minimum Data Set (MDS) dated [DATE] shows he is not cognitively intact, exhibits verbal behavioral symptoms directed toward others, and is independent with walking. R2's Care Plan initiated 6/12/26 shows R2 could be at risk for abuse/due to psychotic and mood disorders. 1/5/26 resident to resident altercation was reported. Update 6/15/26 resident had an altercation with his roommate and accused him of stealing his remote and was physically aggressive. R2 has a behavior problem, easily gets upset and agitated. May become physically and verbally aggressive. 2.R3's admission Record shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anemia, muscle weakness, adult failure to thrive, and abnormalities of gait and mobility. R3's MDS dated [DATE] shows R3 is rarely/never understood. R3 has rejected cares and has verbal behavioral symptoms directed towards others. R3 does not ambulate. R3's Care Plan revised on 6/12/26 shows R3 was hospitalized [DATE] after receiving a physical attack from another male resident and on 1/5/26 a resident to resident altercation occurred. The facility's Final Incident Investigation Report shows on 1/3/26, R3 was in R2's room in R2's bed and was using the remote control. R2 went into his room to get R3 out of his bed, and they started to fight each other. They both ended up on the floor. R3 was noted to have purple discoloration to both eyes, his left ear, with superficial scratch marks to the left side of his face and superficial abrasion to his left collar bone area. R2 complained of pain and swelling to his right hand. On 6/24/26 at 10:54 AM, V3 (Assistant Director of Nursing/ADON) said R2 had an altercation with R3 because R3 was in R2's bed. V3 said that R3 went to the hospital because R3 had bruising around his eyes. V2 complained of pain and swelling to his right hand. 3. R1's admission Record shows he was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, heart disease, toxic encephalopathy, heart failure, and cellulitis. R1's MDS dated [DATE] shows he is not cognitively intact. R1 had no behavioral symptoms. The county's Sheriff's Office report dated 6/13/26 shows the offense was battery/cause bodily harm. R2 was listed as the offender and R1 was listed as the victim. Narrative: On 6/13/26 at approximately 10:31 PM, I [deputy name] was dispatched to a delayed battery at [facility name]. Dispatch received a call from a staff member, [V11 RN] that two residents got into an argument at 9:55 PM. One roommate struck the other. Upon my arrival, I activated my body worn camera and spoke with [V11]. He told me that two people in the nursing home stay in the same room together. I went to speak with [R1] and he stated that [R2] was upset about the remote. [R1] had a bruise above his right eye. [R2] was now in a different room away from [R1]. [R2] appeared to have poor mental capacity and did not understand what exactly was going on. Battery citations were not issued due to the mental capacity of [R2]. On 6/24/26 at 10:24 AM, V9 (Certified Nursing Assistant/CNA) said R2 has a history of hitting people. V9 said that R2 has hit 2-3 different residents. It's horrible. The administration moved R2 to the 3rd floor of the facility. V9 said she worries about her other resident's safety. V9 said that R2 had been aggressive with staff before. V9 said that staff distance themselves when R2 is angry. V9 said that R2 has always been like that. On 6/24/26 at 2:06 PM, V11 (Registered Nurse/RN) said he was at the nurses' station when R2 came up to him and said he needed a television remote. V11 said that R2 told V11 that R1 stole the remote. V11 said he and R2 went into R1 and R2's room to look for the remote. V11 said that R2 went over to R1's side of the room and started punching R1 while R1 was asleep in bed. V11 said he pulled R2 away from R1. V11 said R1's face bruised right away and had a bump to his head. V11 said that R2 denied hitting R1 when the police came later that evening. V11 said that R2 had hit a resident before. V11 said he always watches R2 because he does not want it to happen again. V11 said that R2 is violent. On 6/24/26 at 1:42 PM, V6 Social Services Assistant said R1 is Spanish speaking but can understand English. V6 said that R1 keeps to himself and is very friendly. V6 said that R2 visits other floors often. V6 said that R2 has a history of aggression with other residents. V6 said that it is safer for R2 to be in a room by himself. On 6/24/26 at 1:27 PM, V8 RN said R1 is a very quiet resident. R1 has no negative behaviors and does not yell. V8 said R2 is quiet but can get irritated. You don't know when he is going to get irritated. R2 has never been physical with staff but has been physical with other residents. V8 said she does not know what triggers R2. On 6/24/26 at 2:14 PM, V5 CNA said R2 is a very aggressive resident. V5 said R2 has always been aggressive. V5 said that staff kind of leave R2 alone so he doesn't get mad. V5 said that R2 has gotten aggressive with other people before. V5 said the other residents are not safe in the facility with R2 in the facility. On 6/25/26 at 12:31 PM, V12 Social Services Director said R2 has dementia and has had episodes where he gets angry and agitated. R2 can be unpredictable. V12 said she talked to R2 after the incident with R2 and R1. V12 said that R2 told her that R1 took his tv remote. V12 said that R2 told her, This is how black folks take care of things. V12 said that R1 is calm and quiet, he does not provoke anyone. V12 said that R1 is not someone who would start a fight with people. V12 said she does not have control over room changes. V12 said she told V2 (Director of Nursing/DON) that R2 must be kept in a private room because his behavior is unpredictable. V12 said she did tell V2 V12's recommendation of R2 needing a private room, but V2 has the final decision. (R2 is not in a private room-but R2's roommate was hospitalized during this investigation).R1's Progress Notes dated 6/14/26 at 6:57 AM show R1 returned to the facility from the emergency room. Bruising and swelling present to right forehead. R2's Social Service Note dated 6/15/26 at 8:52 PM shows, resident had an altercation with his roommate over a missing remote and it was unprovoked. Following the event, resident denied hitting his roommate despite staff observation of the incident. He is in a private room until further notice with increased supervision from staff. R1 was observed on 6/24/26 sitting in his wheelchair. There was bruising noted to the right side of his face. The Facility's Abuse Prevention Program dated 7/3/12 shows, This facility desires to prevent abuse, neglect, and theft by establishing a resident sensitive and resident secure environment. This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its resident, and has attempted to establish a resident sensitive and resident secure environment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility.

Based on observation, interview and record review the facility failed to ensure a severely cognitively impaired resident with a known history of wandering and exit seeking behaviors was supervised to prevent elopement. This failure resulted in R1 eloping from a secure unit through her 2nd floor window and plummeting to the ground below. R1 was found approximately 20 feet from her window with her personal belongings scattered outside on the ground. R1 was sent to the local hospital sustaining multiple fractures, C1 fracture, Pneumothorax and a Subarachnoid and Subdural Hemorrhage (brain bleed). The Immediate Jeopardy began on 6/6/26 when R1 could not be located in the facility. R1 eloped from a secured unit out her 2nd floor window and plummeted to the ground below. At 11:25 PM, R1 was found approximately 20 feet from her window with her personal belongings scattered outside on the ground. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 6/10/26 at 11:10 AM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 6/11/26, however noncompliance remains at Level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's face sheet shows she is [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's, unspecified psychosis, dementia unspecified severity with agitation, major depressive disorder. R1's preadmission records show she was hospitalized on [DATE] for wandering in the neighborhood with inappropriate behavior. Since arriving she is pacing back and forth, looking to exit out of the building. R1's EHR (Electronic Health Records) shows she wants to go home and was pointing to the window and says she lives near. R1's preadmission Psychiatric Evaluation dated 5/4/26 shows she is Korean speaking female who has increasing agitation and aggressiveness. She started leaving the home in the middle of the night, becoming very disorganized and quite labile. She started endangering herself as a consequence of her behavior. She has become delusional and quite dysphoric. She thinks she is endangered, and someone is trying to harm her. R1 has a past history of bipolar disorder, major neurocognitive disorder, Alzheimer's and anxiety. She has had 2 known psychiatric hospitalizations. These preadmission records were sent to the facility dated 5/22/26 to be reviewed prior to admission. R1's Incident Report dated 6/6/26 shows on 6/6/26 at 10:50 PM, R1 was not located in her room. A building search was conducted inside and outside of the building. R1 was found by staff on the ground outside of the building in the yard underneath her 2nd floor bedroom window. R1 was brought back to her room by staff, 911 emergency services were contacted and sent to local hospital. (R1's) behaviors included, restless, unable to make needs, known, memory impairment, history of wandering and wants to go home. R1 admitted with the diagnosis of critical polytrauma. R1's hospital records dated 6/6/26 show R1 presented as a Level 1 trauma after falling approximately 20 feet from a second-floor window and sustained multiple injuries to her body. R1 sustained C1 fracture, T3 bust fracture (severe injury where the vertebra loses height in both the front and the back. Typically caused by high energy trauma like a car accident or severe fall), right anterior 3-8 rib fractures, left 4-7 fracture, pneumothorax, pelvic fracture, and right adrenal hemorrhage. R1's Elopement Risk dated 6/4/26 shows she is at risk for elopement and had exit seeking behaviors. She has a history of elopement/attempted an elopement while at home, verbally expressing the desire to go home/or stayed near an exit door, wanders, has the physical ability to leave the building, becomes easily agitated/confused/disoriented and shows poor judgment.On 6/9/26 at 9:25 AM, V2 (Director of Nursing) showed this surveyor R1's broken screen from her window. The top of the screen was completely ripped off with the screen part hanging down. R1's room was located on the 2nd floor, the measurement from her window to the ground floor was approximately 25 feet. A chair was located next to the windowsill. An awning style window with hinges on the bottom and opens from the top measured 15 inches in width when opened. R1's personal clothing was scattered on her bed with grass clippings. On 6/9/26 at 9:10 AM, V2 (DON) said on 6/6/26, she was in the facility and received a call from V4 (Registered Nurse-RN) they could not locate R1. V2 said she went upstairs, and they started searching for R1 and could not find her. The night shift arrived and started looking outside for her. R1 was found lying on the ground outside where her room was. R1's clothes and blanket were outside on the ground. She was lying on her right side complaining of pain and short of breath. R1's window screen was torn and that's the only way she got out through the window. V2 said she saw R1 when she made rounds at 9:30 PM. R1 was a new admit and had been at the facility for two days. R1 wandered, she was looking for an exit and repeated she wanted to go. R1 needed to be supervised frequently due to her behavior, but she did not think R1 would go out the window. On 6/6/26 at 10:32 AM, V4 (RN) said she was R1's nurse on 6/6/26 when she eloped. R1 was confused, delusional and had exit seeking behaviors during her shift. She was trying to exit through the emergency doors and trying to get off the elevator. Ever since her admission she had been exit seeking, it was bad. She saw R1 last about 8:30 PM when she was sitting at the nurse's desk. V2 came to floor around 9:30 PM, made rounds and said R1 was okay in her room. At the end of shift, she was making rounds with the CNA and that's when they could not locate R1. We searched everywhere in the facility and could not find her then we notified V2. Staff found her outside lying on the ground floor outside of her room. R1 was alert to self, complaining of upper chest pain and she was sent out to the local hospital. R1 was very suspicious, paranoid and we would have her sit at the nurse's station because she needed a lot of supervision. R1 was upset, she was at the facility and wanted to leave. She kept on asking the same questions repeatedly, she was difficult to re-direct and wanted to leave. She did not get much information in report about her past behaviors. R1 needed frequent checks, and we watched her and stayed with her when we could. On 6/9/26 at 11:06 AM, V5 (Licensed Practical Nurse-LPN) said she was R1's nurse during the day shift on 6/5/26 and 6/6/26. R1 was confused, she had exit seeking behaviors and was trying to leave through the exit doors and elevator. V5 said she tried to keep R1 at the nurse's station due to her behavior. R1 had a history of eloping and was at risk of eloping. R1 needed to be monitored closely she told the CNAs to check on her frequently. R1 knew this was place was not her home and that her daughter placed her here. Her will was so strong to get out of here. On 6/9/26 at 11:23 AM, V9 (Certified Nursing Assistant-CNA) said on 6/6/26 she was CNA on 1st and 2nd shift. She said she saw R1 last around 8:00 PM near the nurse's station. She did not know R1 was at risk for eloping or needed frequent checks. She saw R1 grab her clothing and looking to exit off the 2nd floor. R1 wanted to leave, and she told her No and reported to nursing. She said V2 asked her to monitor R1, she could not supervise her because she had other residents to take care off, it was very busy that day. On 6/10/26 at 11:42 AM, V9 (CNA) said on 6/6/26 she was the CNA on 1st and 2nd shift. R1 was newer resident, every time she would grab her clothes and was trying to leave off the elevator. She was trying to leave multiple times, it was reported to her this was her normal behavior. There was no direction to supervise her frequently. On 6/9/26 at 1:45 PM, V6 (RN) said on 6/6/26 he arrived at work on 3rd shift at 11:00 PM, they were trying to find R1. We looked outside and she was found at the back of the building lying on her right side on the floor below her room. R1 was in a lot of pain, she was complaining of chest and head pain. R1's screen was busted, I think she jumped out of the window. If a resident has exit seeking behaviors they need increased supervision, notify the physician and sometimes they require 1:1 supervision. On 6/9/26 at 1:16 PM, V11 (R1's Physician) said R1 has dementia, confused and had a history of exit seeking. She had a similar situation for a couple of months trying to leave a previous nursing home. She tried to leave through a window before, he recalls when reviewing her medical records. Then she was in patient psych for a couple of months and was placed on antipsychotic medications. Staff did not report to me she was exit seeking. If she showed signs of exit seeking, she would require increased supervision. On 6/9/26 at 1:24 PM, V12 (Medical Director) R1 sustained multiple fractures, brain bleed and pneumothorax from falling out of the 2nd story window. R1 is confused, has dementia and he would expect staff to increase supervision and redirect when a resident has exit seeking behaviors. On 6/10/26 at 11:10 AM, V2 (DON) said she was not aware of R1's history of elopement and she did not review R1's past medical history. R1 required 1:1 supervision for safety. R1's nurses note dated 6/5/26 documents (R1) is confused and is looking for an exit. R1's physician progress note dated 6/5/26 documents she has a prior psych hospitalization for dementia and confusion, after she was found wandering in the parking lot of her apartment complex.R1 was sent to an extended long term care facility became aggressive and sent to psych hospital.she was found wandering again and sent to psych hospital. She became aggressive at the place trying to get out of the building.She is placing around and asking to discharge planning. She has poor insight, severe psychosis.monitor behavior. R1's current care plan initiated on 6/4/26 shows she is an elopement risk, could be at risk due to pacing and may require monitoring. She has a history of elopement. Interventions include conducting functional assessments to identify triggers and purposes of elopement. Increase supervision during known high-risk times and locations. Arrange environment to reduce opportunities of elopement. Provide structured activities. R1's care plan also shows she has the potential for verbal and physical aggression related to anger and poor impulse control. R1 has impaired cognitive function related to dementia. The facility's undated Elopement/Missing Resident Policy and Procedure States, The elopement risk assessment will be completed upon admission and quarterly and with the changes of condition.a care plan will be developed and updated.staff members will make random checks to verify residents are in the facility. If the event of a missing resident, the nurse on duty shall announce CODE BLACK; notify the administrator and the Director of Nursing. The facility's undated Wandering & Exit Seeking Policy states, The purpose of this policy is to reduce the risk of elopement and ensure individual safety through prevention, supervision, and intervention strategies. Possible triggers: The individual may attempt to elope when: Experiencing anxiety or frustration.Wanting to go home, seeking family.Warning signs: Pacing unable to redirect, Expressing wanting to leave, seeking an exit, Increased agitation.Supervision plan: Level of supervision required, Keep resident in line of sight, Keep resident at arm's length. The facility presented an abatement plan to remove the Immediacy on 6/10/26. The survey team reviewed the abatement plan and was unable to accept the abatement plan to remove the Immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 6/11/26. The Immediate Jeopardy that began on 6/6/26 was removed on 6/11/26 when the facility took the following actions. Facility plans for removal for Immediate Jeopardy related to failure to ensure a severely cognitively impaired resident with a known history of wandering and exit seeking behaviors were supervised to prevent elopement. 1.The facility Policy and Procedure for Exit Seeking / Wandering Behavior will be used to reduce the risk of Unauthorized Departure / Elopement and ensure safety through prevention, supervision and intervention for residents seeking unsupervised exit from the facility. This policy will be initiated on 6/11/26.2.R1. Social Service Unauthorized Departure / Elopement Risk Assessment has been completed on 6/10/26. R1 Care plan has been updated on 6/10/26. Upon return R1 will have a room change from room [ROOM NUMBER] to room [ROOM NUMBER] (closer to nursing station) to close monitor. Upon R1 return from the hospital, R1 will be reassessed by the psychiatrist NP for any adjustment in medication. R1 will be placed on hourly safety visual checks. If R1 behavior of exit seeking escalates the visual checks will be adjusted to 30 min intervals. If R1 is seen with increased agitation and pacing 1:1 attention will be provided. 3.All residents will be reviewed, and The Unauthorized Departure / Elopement Risk Assessment will be updated by the Social Service Department by 6/19/26. Residents with Elopement Risk will be monitored on an individualized basis dependent on their risk assessment. Social Service will do continued training for all staff on elopement risk residents and any changes to the care plan will be completed at the time the elopement risk book is updated with any changes in residents' appearance and condition. This will be completed by 6/19/26.4.On 6/11/26, In-services began on the Dementia Wandering and Exit Seeking Plan to educate all staff including nursing (Nurses and CNAs), Administration, Front Desk, Dietary, Activities, Housekeeping, Maintenance and Laundry. The above staff will continue to be in-serviced on the following Dementia Wandering and Exit Seeking Plan. The 2nd floor staff will continue to monitor the elevator and the emergency exit doors. All staff will be in service prior to the start of their shift, via group in-service or one on one in-service, given by Nursing Administration. When a resident begins to experience increased exit seeking behaviors the nurse on the floor will notify the front desk, the Physician and the psychiatrist NP.All in-servicing will be completed by 6/15/26. 5.Effective today, random audits of all sign-in logs for the elevator, emergency exit doors on the unit, hourly check, and agitation exit seeking behavior will be done daily by the [NAME] or her designee this process will continue for three months to ensure the procedure is being completed. The Medical Director has been informed and will be involved in Quality Assurance. Progress will be reviewed and discussed at the quality assurance meeting to ensure corrections are achieved and permanent.

Based on interview and record review, the facility failed to ensure the administrator provided the necessary oversight and management to ensure the facility operated effectively for the health, safety and well-being of all residents. This applies to all residents residing in the facility. The findings include: The facility census dated 6/9/26 shows 77 residents residing in the facility. This surveyor was in the facility on site from 6/9/26 to 6/11/26. On 6/9/26 at 3:00 PM, V1 was notified of the serious concern of R1 eloping from her 2nd story window and sustaining serious injuries. V1 was not aware of R1's history of eloping and asked to define an abatement plan. V1 was not present on 6/10/26 when the Immediate Jeopardy-IJ was declared for a resident eloping out of a 2nd story window and sustaining several fractures, C1 fracture, pneumothorax and brain bleed. On 6/11/26, V1 was not present and nor involved composing the removal plan and oversight during the Immediate Jeopardy. On 6/10/26 at 2:00 PM, V3 (ADON) said V1 was not coming in today and she was working on the removal plan for the IJ. On 6/11/26 at 10:00 AM, V3 (ADON) said V1 was not coming in today. He is not involved with the removal plan. V3 said this is the facility's third IJ for elopement in one year. The facility's previous IJ was in March 2026. The facility's undated Job Description Administration states, The Administrator is responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and physical management of the facility, residents, employees and equipment in way the purpose of the facility shall be established and maintained in accordance with established policies.

Based on interview and record review the facility failed to review and update the Facility Assessment annually to ensure it accurately reflects the needs for its residents. This applies to all residents residing in the facility. The findings include: The facility census dated 6/9/26 shows 77 residents residing in the facility. The Facility's Assessment was last revised and updated 7/31/23. Approximately three years without the assessment being reviewed or revised. On 6/10/26 at 2:00 PM, V3 (ADON) said V1 (Administrator) is responsible for updating and reviewing the facility assessment annually. V3 confirmed the assessment has not been updated or reviewed since 2023. V3 added the facility does not have a policy on Facility Assessment. On 6/10/26 and 6/11/26, V1 was not available at the facility to be interviewed. On 6/15/26 at 12:00 PM, V1 said he thought the facility assessment was reviewed last year.

Based on interview and record review the facility failed to immediately activate emergency medical services (EMS) for a resident who fell approximately 20 feet from a second story window and failed to ensure the resident remained immobilized and inappropriately moved the resident prior to receiving the necessary care and services. This applies to 1 of 5 residents (R1) reviewed for necessary care and services. The findings include: R1's face sheet shows she is [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's, unspecified Psychosis, Dementia unspecified severity with agitation, Major Depressive Disorder. R1's Incident Report dated 6/6/26 shows on 6/6/26 at 10:50 PM, R1 was not located in her room. A building search was conducted inside and outside of the building. R1 was found by staff on the ground outside of the building in the yard underneath her 2nd floor bedroom window. R1 was brought back to her room by staff, 911 emergency services were contacted and sent to local hospital. R1's hospital records dated 6/6/26 show R1 presented as a Level 1 trauma after falling approximately 20 feet from a second-floor window and sustained multiple injuries to her body. R1 sustained C1 fracture, T3 bust fracture (severe injury where the vertebra loses height in both the front and the back. Typically caused by high energy trauma like a car accident or severe fall), right anterior 3-8 rib fractures, left 4-7 fracture, pneumothorax, pelvic fracture, and right adrenal hemorrhage. On 6/9/26 at 9:10 AM, V2 (Director of Nursing-DON) said on 6/6/26, she was in the facility and received a call from V4 (Registered Nurse-RN) they could not locate R1. V2 said she went upstairs and they started searching for R1 and could not find her. The night shift arrived and started looking outside for her. R1 was found lying on the ground outside where her room was. She was lying on her right side complaining of pain and short of breath. V2 said she told the staff to move her and get her back to her room. V2 said the staff rolled her on a blanket and carried her on the blanket back to her room on the 2nd floor. On 6/9/26 at 1:45 PM, V6 (RN) said on 6/6/26 he arrived at work on 3rd shift at 11:00 PM, they were trying to find R1. We looked outside and she was found at the back of the building lying on her right side on the ground below her room. V6 said I was not sure what happened and said we should call the ambulance. We need to call 911. V6 said V2 (DON) told the staff to move R1 back in her room. We rolled her on the blanket and carried her back to her room. R1 was complaining of pain to her chest and head. After they moved her upstairs then 911 was called. He (V6) did not think moving her was a good idea, it could cause more injury to the resident. On 6/10/26 at 11:12 AM, V3 (ADON) said a fall like that you should not move the resident. You could make the injuries worse. I almost fell out of my chair when I heard they moved her. On 6/10/26 at 11:30 AM, V2 (DON) said I should have not moved R1, but I was not thinking. V6 told me we should not move R1 and call 911 first. I was not thinking, it was a big mistake. When the paramedics came, she reported to them R1 was moved. On 6/9/26 at 1:24 PM, V12 (Medical Director) R1 sustained multiple fractures, brain bleed and Pneumothorax from falling out of the 2nd story window. She is lucky she did not sustain any permanent injuries. Residents should not be moved after a fall it could cause serious injuries. R1's nurses note dated 6/5/26 documents R1 was found outside on facility grounds. Staff brought her back to bed then called 911. The facility's undated Falls/Incidents Prevention Policy states, It is our goal to promote resident safety and independence and to prevent life threatening dangers of falls.Upon discovering a resident's fall, staff will summon the nurse on duty who will assess the resident and determine the next action.the assessment will include a complete head to toe exam including vital signs, neurological checks and observation of any bleeding, pain, loss of consciousness, deformity, swelling.and/other indications of first aid is needed. If needed, first aid will be given immediately and procedure for utilizing 911 or activating emergency medical system will be followed.a resident whose head is stuck in a way should be sent to the ER.

Based on observation, interview, and record review, the facility failed to ensure a resident with a history of elopement and identified as high risk for elopement was provided adequate supervision to prevent elopement and failed to ensure an exit door alarm was alarmed. This failure resulted in R1 eloping from the facility without being witnessed on 3/11/26 being found about 1.6 miles away having crossed three busy heavily traveled roads. This applies to 1 of 3 residents (R1) reviewed for safety supervision in the sample of 3. This failure resulted in immediate jeopardy. The Immediate Jeopardy began on 3/11/26 when staff were unable to locate R1. V1 (Administrator) was notified of Immediate Jeopardy on 3/17/26 at 3:15 PM. This surveyor confirmed by interview and record review that Immediate Jeopardy was removed on 3/19/26 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:On 3/17/26 at 9:40 AM, V3 (Assistant Director of Nursing) said R1 eloped from the facility on 3/11/26 and had a history of eloping from the facility doing so in September of 2025. R1 resided on the second floor that was a locked unit and a card key was needed to use the elevator. V3 added that no one witnessed R1 exiting the building and they were not sure how he exited the building. V3 said she thought R1 entered the elevator when someone exited the elevator while the doors were still open. V3 added that no door alarms were noted alarming around the time R1 eloped. A facility incident report with an occurrence date of 3/11/26 showed the following: R1 was last seen on 3/11/26 at 11:30 AM, a certified nursing assistant went to get R1 at 11:50 AM, the certified nursing assistant could not find R1, a facility search was done and R1 was not located. The same document showed 911 was called and the sheriff department found R1 at 1:27 PM (1 hour and 37 minutes after R1 was noted as missing) on route 176. On 3/17/26 at 10:41 AM, V5 (Registered Nurse) said on 3/11/26 at 11:50 AM V6 (Certified Nursing Assistant) went to get R1 for lunch and R1 could not be found. V5 said they searched the facility, including outside of the facility, and they were unable to locate R1. V5 said during the search she checked the basement exit door and it did not alarm. V5 added that she thought R1 got on the elevator when someone exited the elevator while the elevator doors were still open. V5 said she did not hear any door alarms prior to noticing R1 was missing. V5 said R1 was wearing pants and a windbreaker. R1's progress note dated 3/11/26 entered by V5 showed the facility was searched and R1 was not found. The same note showed the basement exit door did not alarm when opened.On 3/17/26 at 10:48 AM, V6 confirmed on 3/11/26 at 11:50 AM she went to get R1 from his room and could not find R1. R1 said she did not hear any door alarms around the time frame R1 eloped.On 3/17/26 at 10:59 AM, V9 (Receptionist) said on 3/11/26 he was at the main desk on the ground floor that faces the elevator doors and did not see R1 exit the elevator or the main exit. V9 added that he did not hear any door alarms around the time frame R1 eloping.A Sheriff's Office Field Case Report dated 3/11/26 showed R1 went missing from the facility on 3/11/26 at 11:30 AM. A local oil change shop called saying a man matching R1's description had been at the shop and seemed, .confused. The same report indicated R1 was wearing a windbreaker jacket, and it was 33 degrees Fahrenheit outside. The report showed R1 was found at a scrap metal facility. On 3/17/26 at 12:05 PM, V8 (local Oil Change Shop Employee) said a man matching R1's description arrived at their oil change shop on 3/11/26 around 11:50 AM. V8 said R1 seemed confused as he did not know where he was and was asking for directions to a town. V8 said R1 was not dressed for the cold weather as R1 had on a windbreaker, t-shirt, jeans, and shoes. V8 said R1 wandered off and they called 911. The National Weather Service website showed on 3/11/26 at 11:51 AM the temperature was 34 degrees Fahrenheit. On 3/17/26 at 1:10 PM, V7 (Police Officer) said R1 was found at a scrap metal recycling center (1.6 miles away from the facility). V7 said for R1 to get to the location where R1 was found, R1 had to of crossed three busy roadways that are heavily traveled. V7 added that R1 was taken to the hospital and evaluated for cold exposure. R1's hospital discharge paperwork dated 3/11/26 showed he was evaluated in the emergency room for cold exposure. On 3/17/26 at 11:50 AM, V10 (R1's Doctor) said R1 was confused and if R1 leaves the facility R1 should have someone with him as he needed supervision for safety reasons. On 3/17/26 at 12:26 PM, R1 said he did not remember going outside on 3/11/26. R1 added he never goes outside. R1 was confused as he was unable to say where he was or give the date/time. R1's Care Plan printed on 3/17/26 showed he eloped from the facility on 9/7/25, 3/11/26, and was at risk for elopement. The care plan also showed R1 was at risk for falls, had impaired cognitive functions/dementia, impaired thought processes/decision making with poor short term and long-term memory loss. R1's elopement care plan showed R1 will not leave the facility unattended without staff supervision. R1's Elopement Risk Evaluation done on 12/28/25 showed R1 was at risk for eloping.A facility assessment done on 12/21/25 showed R1s cognitive status was severe impairment.R1's Psychiatrist Physician Note dated 3/8/26 showed R1had a history of auditory hallucinations.On 3/17/26 at 11:53 AM, V4 (Maintenance) checked the basement exit door (the same door V5 said did not alarm when V5 was searching for R1 on 3/11/26). The alarm did not activate when the door was opened by V4. V4 said someone must have turned off the alarm and the alarm should have been activated. V4 said he was not aware the exit door alarm was not alarmed on 3/11/26. The facility presented an abatement plan to remove the immediacy on 3/19/26 at 10:03 AM. The abatement plan was reviewed and was unable to be accepted. The abatement plan was returned to the facility for revisions on 3/19/26 at 11:40 AM. The facility presented a revised abatement plan on 3/19/26 at 12:58 PM. The abatement plan was reviewed and accepted on 3/19/26 at 1:47 PM. The Immediate Jeopardy that began on 3/11/26 was removed on 3/19/26 when the facility took the following actions to remove the immediacy: 1. The facility policy on Elopement Risk: The Policy and Procedure for Elopement Risk residents will be used to identify the potential for residents to exit unsupervised from the facility. The Elopement Risk Assessment will be completed by Social Service Department upon admission, quarterly and with change of condition. This policy was revised on 3/17/262. R1 Social Service Unauthorized Departure / Elopement Risk Assessment has been done on 3/11/26. R1 Care plan was updated on 3/11/26. On 3/12/26 R1 was re-assed by the psychiatrist NP increased R1 medication (olanzapine) to twice a day. On 3/12/26 R1. had a room change from room [ROOM NUMBER] to room [ROOM NUMBER] (closer to nursing station) to closely monitor. On 3/12/26 R1 was placed on hourly safety checks.3. All residents at risk will be reviewed and a revision of the Elopement Book and care plan update will be completed by the Social Service Department. Residents with Elopement Risk will be monitored on an individualized basis dependent on their risk assessment. Social Service will do continued training for all staff on elopement risk residents and any changes to the care plan will be completed at the time the elopement risk book is updated with any changes in residents' appearance and condition. This was completed on 3/19/26.4. Starting on 3/19/26 2nd floor staff will alternate desk coverage to monitor the elevator to prevent residents from entering the elevator. On the 2nd floor, staff will be required to fill in the sign-in /sign-out sheet to ensure the area is covered 24 hrs a day indefinitely. The floor nurse will be assigned to check the emergency exit doors to ensure they are working properly by opening the door and hearing the alarm, then re-set the alarm door with the key this action will be done 2 times per shift. If the emergency doors do not sound, the floor nurse will be responsible for notifying the Maintenance Department immediately. All exit doors to the outside will be tested daily by Maintenance Department to ensure the exit doors are armed and will sound when opened.5. On 3/19/26, In-services began on the updated Elopement Risk Policy and Procedures and the Elopement Risk Book to educate all staff including nursing (Nurses and CNAs), Administration, Front Desk, Dietary, Activities, Housekeeping, Maintenance and Laundry. The above staff will continue to be in-serviced on following the Elopement Risk policy and procedures, the Elopement Risk Book and the plan for 2nd floor staff monitoring the elevator, the emergency exit doors and the exit doors to the outside. This will be completed prior to the start of their shift, via group in-service or one on one in-service, given by nursing administration. All in-servicing will be completed by 3/25/26.6. Effective today random audits of the all sign-in logs for the elevator, emergency exit doors on the unit and exit doors to the outside will be completed daily by the DON or her designee this process will continue for three months to ensure the procedure is being completed. The Medical Director has been informed and will be involved in the Quality Assurance. Progress will be reviewed and discussed at the quality assurance meeting to ensure corrections are achieved and permanent.

Based on interview and record review the facility failed to treat a resident with dignity and respect for1 of 4 residents (R1) reviewed for dignity in the sample of 4. The findings include:On 1/14/26 at 10 AM, R1 was in her room alert and pleasant. R1 said she gets scared, and it causes her anxiety when someone yells and screams at her. My husband was abusive, yelling and screaming triggers me to be anxious. R1 said when V5 (Registered Nurse) talks to her, V5 sounded like V5 (RN) was screaming and yelling. Also, R1 found out that her physician was at the nursing home. V5 (RN) said because of your mammogram appointment, you missed your visit from your doctor. R1 said V5's statement did not sit well with her-, I am a cancer survivor, I had to go to my mammogram appointments. R1 said she complained to V5 about her feet hurting due to bone spurs, V5 responded there's always something wrong with you. R1 said V5 make her feel like she did not matter.On 1/14/26 at 11 AM, V5 stated to this surveyor, Even if you don't tell me the name, this is (R1), she had said to me before you scream and yell at me but this was my normal voice, what can I do? I have told R1, if she had an issue with me to tell the DON. (V2) V5 also confirmed that she told R1, she did not see her doctor because she was out for her mammogram appointment. V5 said she was aware R1 was a cancer survivor but did not know that R1 was offended by his comment. V5 said R1 has a lot of complaints about the staff. I told R1, you are alert, you can tell your complaints to the DON yourself. V5 said R1 was alert and can speak for herself. On 1/14/26 at 12 PM, V3 (Assistant Director of Nursing) said V5 had a high-pitched voice, V5 might not realize how his voice was coming across to R1. V3 also said V5 has a bubbly personality not sure if R1 was ok with that. V3 said all residents should be treated with respect.The facility policy on Dignity (undated) documents, this facility will promote care for residents in a manner and in environment that maintain or enhances each resident's self-esteem and self-worth.

Based on interview and record review the facility failed to ensure a resident went to her outpatient medical appointment for 1 of 3 residents (R1) reviewed for medical appointments in the sample of 4.The findings include:A Hospital document entitled After Visit Summary dated 11/13/25 show R1 had surgical pathology of esophagogastroduodenoscopy (EGD). The results show, - Cratered ulcer in the middle third of the esophagus. Due to severe ulceration and peeling appearance of the ulceration, scope and dilatation was deferred. The document continues, Repeat EGD with interventional Gastroenterologist (G1) in 4 weeks.A progress notes dated 11/26/25 documents, R1's EGD return appointment was scheduled for 12/10/25 at 9:45 AM.On 1/14/26 at 10:15 AM, R1 stated she had been having issues with swallowing, I feel there's something here (pointing to her neck.) R1 said her G1 doctor has been trying to figure things out. R1 said she had gone through testing and was supposed to have a return appointment last 12/10/25 for repeat EGD. The appointment was cancelled by this Nursing Home due to no escort meaning no staff available to go with her. R1 said she was upset about it; it delayed her treatment. R1 said while she was having issues with swallowing, she had to wait more than a month for her repeat EGD due to no staff available to go with her. The appointment was moved tomorrow (1/15/26.)On 1/14/26 at 11: 15 AM, V7 (Registered Nurse) said due to no available escort, R1's appointment had to be cancelled. V5 said she called the Gastroenterology office, explained the situation. R1's appointment was moved to 1/15/26 (tomorrow) more than a month from the original appointment of 12/10/25. V5 said We can only do 1 medical appointment per day with escort here at this facility due to no staff available to escort. On 1/14/26 at 11:52 AM, V6 (Receptionist) said due to no staff available we can only do 1 medical appointment daily, that was an instruction from the DON. (V2)On 1/14/26 at 1:30 PM, V2 said she will work with staff to see who were willing to go with residents to escort when necessary medical appointments come up like R1's EGD.

Based on observation, interview and record review the facility failed to ensure a resident did not elope from the facility's locked unit, failed to update the list of residents at risk for elopement, and failed to update a resident's care plan after an elopement for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include:On 1/5/26 at 10:32 AM, R1 was standing in the common area near the elevator talking loudly. The elevator door was opening frequently, and staff/visitors were entering and exiting. The staff had to use a fob to request the elevator. At 11:40 AM, this surveyor requested to see the list of residents at risk for elopement from V10 (Licensed Practical Nurse). V10 said that there is usually a list hanging at the nurse's station, but she could not find it. V10 then found a binder and opened it up and there was an elopement risk list inside the binder. The list was last updated on 11/19/25 and R1 was not on the list. V10 wrote R1's name on the list. R1's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of schizophrenia, anxiety and depression.R1's Hospital History and Physical dated 11/27/25 shows, Upon examination, patient is irritable, racial slurs. States she is here because I wanted to go to the store, I called my husband, and he said I could go but they wouldn't let me at the nursing home, so I tried to leave anyway. Delusions and paranoia are present.R1's Social Service Note dated 12/2/25 shows, Resident is a [AGE] year-old female, who is ambulatory.Resident was noted aggressive, with threats, gestures and behaviors for at least 2-3 hours on the unit this evening and she is considered to be at high risk for leaving the facility unattended.R1's Incident Note dated 12/12/25 at 9:20 AM shows, Staff were alerted that resident had left the building unauthorized. Staff went to catch up to the resident one staff by walking, and two staff took their car to follow her. Staff were able to catch up to her at the first stop sign.On 1/5/26 at 10:30 AM, V8 (Receptionist) said that on 12/12/25 at 9:00 AM, V9 (Certified Nursing Assistant) and R1 came down to the 1st floor for smoke break. V8 said that R1 did not have any cigarettes at reception so V9 and R1 returned to the second floor to retrieve them. V8 said that a short time later, R1 arrived at the reception area unattended. V8 said that R1 asked him for a cigarette, and he told her that he did not have any. V8 said that he paged the 2nd floor staff to come down and get R1 but R1 exited the building through the front door before they arrived. V8 said that he called for help and V4 (Administrative Assistant) responded and went after R1. On 1/5/26 at 10:12 AM, V7 (Maintenance) said that he heard that R1 had left the building, so he started running after her. V7 said that he caught up to R1 when she was already out of the parking lot and almost to the first stop sign on the road (approximately 0.2 miles). V7 said that he tried to convince R1 to return to the facility, but she would not and said that she was going to court. V7 said that he continued to walk with her until the police arrived (approximately 0.8 miles from the facility).On 1/5/26 at 10:19 AM, V6 (Registered Nurse) said that on 12/12/25, she was working as the nurse on the second floor. V6 said that she typically does not work the second floor, so she was not familiar with R1. V6 said that right before R1 eloped, she saw R1 talking to V11 (Psychiatric Nurse Practitioner). V6 said that she was passing medications and V8 called her and said that R1 was on the first floor. V6 said that she is not sure how R1 got to the first floor. On 1/5/26 at 10:55 AM, V9 (Certified Nursing Assistant) said that on 12/12/25, she brought R1 and another resident down to the first floor to smoke but they both did not have any cigarettes, so she brought them back up to the second floor and continued taking care of other residents. V9 said that she then heard that R1 had left the facility. V9 said that she does not know how R1 got to the first floor on her own. On 1/5/26 at 11:00 AM, V10 (Licensed Practical Nurse) said that R1 is only allowed to go off of the second floor with a staff member. V10 said that the elevator requires a fob to be used from the second floor. V10 said that there is usually a staff member at the nurse's station watching to ensure that residents do not enter the elevator without a staff member. V10 said that if she has to leave the nurse's station, she will get another staff member to sit at the station to watch the elevator. V10 said that R1 is at risk for elopement and is not in touch with reality.On 1/5/26 at 12:54 PM, V2 (Director of Nursing) said that all residents have an elopement assessment done upon admission and if they are at risk for elopement, they place them on the second floor. V2 said that the second floor is a locked unit, and residents should not be able to exit the unit without staff assistance. V2 said that a staff member should be present at the nurse's station at all times to ensure that residents do not get on the elevator unattended. On 1/5/26 at 1:01 PM, V3 (Assistant Director of Nursing) said that the second floor is the locked unit, and residents should not be able to exit the floor without a staff member. V3 said that she is not sure how R1 got on the elevator on her own. V10 said that they try and have a staff member watching the elevator and keep the residents who are at risk for elopement away from the elevator and involved in an activity. At 2:11 PM, V10 said that after an elopement, the resident's care plan should be updated by social services. V10 reviewed R1's Care Plan and said that she did not see an update after R1 eloped. V10 said that an in-service was not done after R1's elopement.On 1/5/26 at 1:34 PM, V11 (Psychiatric Nurse Practitioner) said that R1 is at risk for elopement. V11 said that on 12/12/25 she saw R1 and was walking the unit and talking with her. V11 said that after she was done on the second floor, a nurse used their fob to open the elevator, and she went to the third floor. V11 said that R1 was in the common area near the elevator when she left the second floor. V11 said that she was on the third floor for some time before she heard that R1 had left the facility. R1's Elopement Risk Evaluation dated 12/2/25 shows that she is at risk for elopement.R1's Care Plan printed on 1/5/26 shows that R1 is an elopement risk/wanderer related to history of attempts to leave facility unattended, impaired safety awareness, wanders aimlessly and is extremely unhappy being in a nursing home. R1's elopement interventions include disguise exits, distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. All interventions were initiated on 12/2/25. No additional interventions were added after her elopement on 12/12/25.The list titled Residents with Risk for Elopement/Wandering was provided. The list was last updated on 11/19/25 and had 13 residents listed. R1 was not listed on the list. The facility's undated Missing Person/Elopement Policy shows, Safety of all residents is the primary care standard at [Facility]. Precautions, procedures, staff and visitor education have been put in place to maximize resident safety. A Resident Elopement form and a thorough investigation will be completed by the Nurse Manager. He or she is responsible to instruct staff on precautions and safety measures to be taken. The responsible nurse manager will attend the committee meeting to further review the incident and to develop a plan to prevent recurrence. In-service will be conducted on the day of the elopement occurrence to implement safeguards against repeated occurrences.The facility's Elopement/Missing Resident Policy revised on 9/12/25 shows, The elopement risk assessment will be competed upon admission, quarterly and with change of condition by social service department. A care plan will be developed and updated upon admission, quarterly and with change of condition by the social service department. Social Services or their designee will In-service and inform all staff members of any residents at risk for elopement and will be updated on any new interventions and any new residents added to the elopement book.

Based on observation, interview, and record review the facility failed to implement interventions for a resident at risk for elopement to elope from the facility. These failures resulted in R1 eloping from the facility and being found walking in the road of a heavily traveled highway. This applies to one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/7/25 when staff were unable to locate R1 inside the facility. V2 (Director of Nurses) was notified of the Immediate Jeopardy on 9/12/25 at 9:50 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/12/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training. Findings IncludeThe facility's initial incident report sent to the IDPH (Illinois Department of Public Health) showed R1 was observed through a window in the facility parking lot on 9/7/25 at approximately 8:00 AM. Staff went outside to look for the resident and were unable to locate the resident. The report showed staff called the local police department at 8:16 AM. The report showed R1 was found by local police and returned to the facility at 9:55 AM. R1's face sheet printed on 9/11/25 showed diagnoses including but not limited to psychosis, malnutrition, physiological condition, insomnia, and need for personal care. The same face sheet showed R1 has resided on the second floor of the dementia unit since admission in May of 2024. R1's facility assessment dated [DATE] showed severe cognitive impairment and the ability to walk independently with staff supervision. R1's elopement risk assessment dated [DATE] showed R1 was not physically able to leave the building and was not confused or disoriented (conflicts with the facility assessment). On 9/11/25 at 9:45 AM, R1 was seated in an upright chair in the hallway, directly outside of his room. R1 was pleasantly confused and could not provide any details regarding his elopement. R1 answered yes or no to all questions in a nonsense manner. On 9/11/25 at 9:50 AM, V3 (Licensed Practical Nurse) stated R1 recently went onto the elevator alone and went outside. V3 stated he was trying to look for his mother. The elevator has a key card needed to open the doors but sometimes it doesn't work if the battery is low. V3 said sometimes the doors don't close right away and residents can slip out onto the elevator. V3 said we try to always have someone right by the doors to watch for that. I guess no one was watching the day R1 got out. On 9/11/25 at 10:00 AM, V1 (DON-Director of Nurses) stated she was at the facility the morning R1eloped. R1 said the second-floor nurse (V4) called her and said R1 was observed by V5 (CNA-Certified Nurse Aide) alone outside. V1 said she ran outside but did not see any sign of R1. V1 said she drove her car around the neighborhood then called 911 about 15 minutes later. V1 said R1 can walk without assistance, does not understand English, and is very confused. V1 said she spoke with a local police officer at a nearby gas station. She was told they were in the process of searching the neighborhood for R1 too, so she returned to the facility. V1 said she began looking inside parked cars and came upon a visitor sitting in his car. V1 said the visitor told her he saw a resident come outside and walk behind the building, toward a wooded area. V1 said she searched there and still could not locate R1. V1 said multiple police officers and dogs arrived and continued to search the area. V1 said she received a phone call approximately one hour and forty minutes later that R1 had been found. V1 said the second-floor dementia unit is a locked unit and everyone needs a key card to activate the security pad for the elevator. The security pad was not working last Sunday (9/7) and that is the only way R1 could have got outside. It has been broken a couple of weeks now. V1 said currently, she sits at the nurse's station and watches the elevator when staff aren't there. V1 said she should have been watching the elevator when R1 got out, but she was up and down on other floors that morning. The visitor that observed R1 wandering in the parking lot was attempted to be interviewed but could not be reached during this survey. On 9/11/24 at 10:52 AM, V4 (RN-Registered Nurse) stated she was notified that R1 was outside of the building alone by V5 (CNA) during the breakfast meal on 9/7/25. V4 stated she ran to a window and saw R1 wandering in the parking lot. V4 said she immediately called the DON and reported the elopement. V4 said no one was watching the second-floor elevator or the first-floor front desk. V4 stated the elevator usually needs a key card to open the doors but it hasn't been working for a few weeks. V4 said there is usually a receptionist at the front door, but no one was working that day. V4 said we are supposed to have someone watching the doors to keep residents from getting out. V4 said R1 must have just pushed the elevator, got on, and walked out the front door all by himself. R1 is not fully alert or oriented. He does not speak English and only understands yes or no questions. On 9/11/25 at 11:08 AM, V5 (CNA) said she was feeding a resident breakfast on Sunday in a second-floor room when she looked out the window and observed R1 outside. V5 said she immediately notified V4 (RN). V5 said R1 appeared confused and was wandering around the parking lot. V5 said the key card for the second-floor elevator hasn't been working for a while. On 9/11/25 at 11:25 AM, V2 (Assistant Director of Nurses) stated she was just arriving to the facility on Sunday when the police were leaving. V2 said she was told R1 had got out and the police eventually located him near the intersection of a large, local hospital. V2 said she did the incident investigation and interviewed R1with a translator. R1 said he was trying to find his mother. V2 said R1 is on a lot of psychiatric medications and has a pretty low cognitive status. V2 said her investigation results showed R1 opened the elevator and got on it alone. V2 said she was sure he was able to get on it alone. V2 verified the key card was not working and hadn't worked for almost a month. V2 said a front desk person doesn't start until 9 AM each day and the front door is unlocked around 6 or 7 AM daily. On 9/11/25 at 11:45 AM, V6 (Elevator Security Vendor) stated he has worked on the facility's second floor card access system for years. V6 said he was at the facility a few weeks ago and told staff the system has failed. It is a 30 plus year old system and it can't be patched back together anymore. V6 said the electronic key card system control board can't be repaired anymore. V6 said he repeatedly sent a quote for a new system and never heard anything back until this past Sunday (9/7, day of the elopement). That was when his emails were finally acknowledged, and they agreed to go ahead to fix the system. V6 said right now the second-floor elevator is a fail safe set up which means it will still open when the key card is not working. That prevents anyone from getting trapped in case of an emergency. V6 said right now, anyone can get on or off that elevator. There is no security system in place. V6 said we are still waiting on the parts to be shipped in. The facility provided a quotation invoice dated 8/18/25 from V6's security company. The quote stated, Replace card access system that controls the elevator buttons on the 2nd floor and the stairwell door on that floor. System has to be designed as fail safe. Needs to be interfaced with the existing fire alarm system for emergency release. The quote was blank under the client signature date section. The facility provided a receipt dated 9/9/25 (two days after R1 eloped) showing a downpayment for the 2nd floor elevator was processed by V6's security company. On 9/11/25 at 1:00 PM, V7 (Maintenance Staff) stated the second-floor security pad hasn't been working for a couple of weeks now. V7 said an outside company does all the repairs on that. The outside company has been notified, and the part is on order. It won't be here for several more days. On 9/12/25 at 10:57 AM, V9 (local police officer) stated he got a call on 9/7/25 related to a missing elderly person from the subject facility. It was reported the resident had dementia. V9 said he responded to the call along with several colleagues. The DON (V1) said she called us about 10 to 15 minutes after realizing the resident was missing. V9 said they checked the immediate area with trained dogs. V9 said he went inside and asked V1 how did this happen. V1 answered the missing resident resides on the second floor and the security pad system was broke. She was in the process of trying to get it fixed. V9 said R1 was only found after a random passerby saw him walking in the road. She thought he looked confused or lost so she called the local police department and reported it. That police department responded to the area and sent out notice of a missing person too. V9 said that is when we realized that sounded like our guy. V9 said he took R1 back to the subject facility and V1 confirmed his identity. V9 stated there was no one manning the front desk and he could not find any staff when he initially arrived. V9 stated he rode the elevator up to the second floor with V1. At no time did V1 need a key card to operate the elevator up or back down. V9 stated fellow co-workers mentioned later to him that they have responded to calls in the past at the same facility. Co-workers said they have never needed anything special to go on or off the dementia unit floor. V9 said there are railroad tracks right behind the facility that run all the way parallel to the busy highway, where R1 was found. V9 said they were so worried R1 may be hit by a train that they called the railroad line and confirmed none were scheduled for that day. V9 said the area where R1 eventually was found was by the same tracks. V9 said R1 was found in the road walking the wrong way in traffic. The road is a heavily traveled four lane highway. V9 stated it is the facility's job to keep these people safe and if someone gets out like that, they are not doing their job. The local police department's report dated 9/7/25 and authored by V9 stated R1 was located at 9:35 AM and the exact address of the intersection was provided in the report. The report showed R1 was walking southbound IN the northbound lanes. A google map search from the facility to the intersection showed it was an approximately two-mile walk. On 9/11/25 and 9/12/25, this surveyor was able to freely exit the second-floor dementia unit during the entire survey without using any key card security device. R1's care plan showed a focus area for risk for wandering/elopement due to an elopement event on 9/7/25. The initiation date and interventions were dated 9/8/25. The facility's undated Missing Person/Elopement Policy states: Safety of all residents is the primary care standard at (subject facility). Impaired judgement, perception, and thought processes of cognitively impaired persons make the residents at a higher risk for elopement into unsupervised or unsafe areas. Precautions, procedures, staff, and visitor education have been put in place to maximize resident safety. The Immediate Jeopardy that began on 9/7/25 was removed on 9/12/25 when the facility took the following actions: 1. The facility policy on Elopement Risk: The Policy and Procedure for Elopement Risk residents will be used to identify the potential for residents to exit unsupervised from the facility. The Elopement Risk Assessment will be completed by Social Service Department upon admission, quarterly and with change of condition. This policy has been revised on September 12, 2025. 2. R1. Social Service Unauthorized Departure / Elopement Risk Assessment has been done on 9/8/2025. R1 had a room change to room [ROOM NUMBER] (closer to nursing station) to close monitor. On 9/7/2025, R1 was placed on hourly safety checks. 3. All residents at risk will be reviewed and a revision of the Elopement Book and care plan update will be completed by the Social Service Department. Residents with Elopement Risk will be monitored on an individualized basis dependent on their risk assessment. Social Service will do continued education for all staff on elopement risk residents and any changes to the care plan will be done at the time the elopement risk book is updated with any changes in residents' appearance and condition. This will be completed by September 16, 2025.4. Starting today nonscheduled floor staff have been assigned to stay at the 2nd floor desk to monitor the elevator and to prevent residents from entering the elevator. The nonscheduled staff will be required to fill in a sign-in sheet to ensure the area is covered 24 hours a day. This process will continue until the repair of the elevator safety system has been completed. The elevator repair time is estimated for the week of September 15, 2025. 5. On September 12, 2025, in-services began on the Elopement Risk policy and procedures and elopement risk book to educate all staff including nursing (Nurses and CNAs), Administration, Front Desk, Dietary, Activities, Housekeeping, Maintenance and Laundry. The above staff will continue to be in-serviced on following the Elopement Risk policy and procedures, the Elopement Risk book, and the plan for nonscheduled staff monitoring the elevator. This will be completed prior to the start of their shift, via group in-service or one on one in-service, by nursing administration. All in-servicing will be completed by September 16, 2025.6. Effective today random audits of the sign-in logs will be completed every shift by the DON or her designee. This process will continue until the elevator security system is fixed. The Medical Director has been informed and will be involved in the Quality Assurance. Progress will be reviewed and discussed at the quality assurance meeting to ensure corrections are achieved and permanent.

Based on interview and record review the facility failed to ensure a resident was free from resident-to-resident physical abuse for 1 of 7 residents (R4) reviewed for abuse in the sample of 7. Findings Include:On 9/2/25 at 12:50 PM, V3 (Assistant Director of Nursing) said there was an altercation that had just occurred between two residents {R4 and R5} and one of the residents was punched in the face and was just sent to the hospital because he had a small laceration on the side of his eye.R4's face sheet shows he has diagnoses including Alzheimer's disease, muscle weakness and abnormality of gait and mobility. R4's active care plan last revised on 7/8/25 shows he is alert but confused and forgetful, uses a wheelchair for mobility and his primary language is Spanish. The same care plan also shows that R4 is at risk for abuse due to wandering behaviors and having a cognitive impairment, dementia, with a language barrier. Interventions listed in R4's care plan is for redirecting his behaviors and engaging him in activities.R5's facesheet shows he has a diagnosis of dementia. R5's care plan initiated 7/21/25 shows he is ambulatory and alert but forgetful at times.A Nurses Progress note completed on 9/2/25 at 3:55 PM, by V12 (Registered Nurse) states, resident had physical contact with another resident, separated right away, noted bleeding to his face, completed entire physical exam, 1 cm laceration noted on left temple. sent resident to {local hospital} via ambulance at 12:45 PM.A Social Services note completed by V9 (Social Worker) on 9/2/25 at 5:07 PM states, Around 12:10 pm, this writer responded to a call for help from {R5's} room made by CNA (Certified Nursing Assistant) (V13). Upon arrival, this writer observed that the resident {R4} was being physical attacked by another resident {R5} on the floor. CNA and maintenance staff were attempting to separate the residents, this writer also intervened, but the aggressor continued hitting until staff successfully separated them and moved each resident to different rooms.On 9/2/25 at 1:17 PM, V12 said around 12:10 PM she heard screaming and ran towards the sound and found R4 and R5 in a physical altercation and R4 was being hit by R5. V12 said R4 has wandering behaviors and propels himself into other resident rooms all the time. V12 said both residents have dementia, and R4 also has a language barrier so he does not always understand what people are saying to him.On 9/2/25 at 1:22 PM, V13 said she heard yelling and when she got to the room, she found R4 and R5 in an altercation and grabbing at each other and she yelled for help. V13 said she attempted to separate the residents and did not physically see R5 hit R4 but R4 had blood on the side of his face after. V13 said R4 does wander around the unit in his wheelchair and needs redirecting. On 9/2/25 at 1:25 PM, V14 (Lake County Sheriff Officer) was interviewing R5 and came out of the room and said from what he gathered happened was that R4 had went into R5's room and was going through drawers. R5 wanted R4 out of his room and was yelling for him to get out of here, R4 did not leave and R5 ended up hitting R4. V14 said R4 then grabbed R5's shirt and it continued to escalate.On 9/2/25 at 1:27 PM, R5 said he hit R4 because he would not leave his room. R5 said he comes into the room all the time and this time he was not leaving so I hit him yes, and I meant to.On 9/2/25 at 1:30 PM, R7 (R5's roommate) said he did not see the altercation happen because he was at lunch, but he heard the yelling. R7 said the other guy (R4) comes into our room all the time and eats jelly off my nightstand, usually he leaves on his own. An incident/occurrence report form dated 9/2/25 shows that R4 returned to the facility on 9/2/25 at 4:00 PM, he was stable and had steri strips to his left temple, the local hospital had completed a CT/computed tomography scan of the spine and head which were negative for any bleed or fractures, R4 did not require sutures to the laceration. Hospital documents show R4 was diagnosed with a facial contusion. On 9/3/25 at 8:45 AM, R4 was sitting in the dining area at a table, his left eye was dark purple and very bruised around the eye socket. The sclera of his eye was red in color, and he had several steri strips to the outer temporal area of the left eye. R4 said, I am okay. When this surveyor attempted to talk to him. He also said no when asked if his eye was hurting him. On 9/3/25 at 8:47 AM, V20 (CNA) said she was here the day prior when the altercation happened. V20 said staff were in the dining room feeding residents and V5 came into the room saying someone needs to get him out of my room. V20 said she told another CNA to go see what was going on and the next thing she knows it had escalated, and they were fighting. V20 said R4 goes in and out of the other resident rooms frequently but will usually come right out because he is confused about which room is his.On 9/3/25 at 11:07 AM, V1 (Administrator) said when a resident hits another resident it is abuse.The facility provided Abuse Prevention Program policy last revised on 7/30/12 shows that the facility will prevent abuse, neglect and theft by establishing a sensitive and secure environment and all residents have the right to be free from abuse. The policy describes physical abuse as hitting, slapping, pinching, kicking or controlling behaviors.

Based on interview and record review the facility failed to ensure a resident was free from misappropriation of resident property for 1 of 4 residents (R1) reviewed for misappropriation in the sample of 7. Findings Include:An Illinois Department of Public Health Investigation Report completed by V3 (Assistant Director of Nursing) on 8/21/25 shows that R1 had reported that $300 was missing from her wallet. The report shows that R1 had taken a nap between 1:30-5:00 PM and when she woke up to take her medication, she noticed her wallet was not secured and the envelope she had inside it with her money was gone. The report shows that R1 is alert and oriented x 4 and cooperative.A Nursing Progress Note completed by V17 (Registered Nurse) on 8/20/25 at 10:30 PM for R1 states, Resident reported to nursing assistant that she lost $300.00 between 1 PM and 5 PM. R1's Social Service Notes for 8/21/25 show that V9 (Social Worker) went to meet with R1 on 8/21/25 at 9:30 AM, a room search was completed, and the money was not located. The police were contacted and came to the facility to interview the resident. A second social service note completed by V22 (Social Worker) on 8/21/25 at 8:18 PM, shows that R1 told V22 that she seldom leaves her room, and her wallet was inside her walker. V22s note shows R1 said she takes her walker everywhere with her even to the bathroom. R1 did not verbalize any suspects to V22 based on the progress note. On 9/2/25 at 8:38 AM, R1 was in her room, her walker which has a seat you can lift and store items underneath it was at her bedside. The top drawer of her dresser was noted to have a silver lock on it. R1 told this surveyor that she is very hard of hearing, and she must read lips to communicate. She said on 8/20/25 she had her wallet closed and inside her walker hidden under some other items she keeps in there. R1 had approximately $300.00 inside and she knows exactly what denominations of bills they were 3- $50.00 dollar bills, 4- $20.00 dollar bills, 3- 5.00 bills and a few $1.00 bills. R1 said she had taken money out of her account back in May to go out with her niece and she also takes $30.00 a month out of the account managed by the facility. R1 also said she had received $50.00 cash in the mail from her cousin for her recent birthday. R1 said she has not been out of the facility beside one doctor appointment since May 2025. R1 said she had taken a nap on 8/20/25 from about 1-5 PM. When she woke up, she noticed that the side of her walker seemed to be bulging out, so she opened the storage seat and her wallet, which was buried under other items, was sticking out and not closed. R1 said she opened the wallet up and all that was left was $3.00. R1 said she immediately panicked and began looking for her CNA that evening (V19), but V19 was on break so she waited for her to return from break and then told her about her missing money. R1 also said she seldom leaves her room and if she does her walker goes with her. R1 said she does have a locked drawer, but she had been keeping the wallet in her walker because nothing like this has ever happened before and she was too trusting. R1 was interviewed again by this surveyor on 9/3/25 at 10:20 AM and she described all the same events with her missing money.On 9/2/25 at 3:10 PM, V19 said R1 did report to her that she had money missing from her wallet. V19 confirmed that R1 seldom leaves her room and if she does her walker goes with her. V19 said R1 is alert and oriented and hard of hearing and if she is asleep, she would not hear someone enter her room. V19 said on the floor R1 resides on they do not have wandering residents. V19 said she went and told her nurse (V17) that evening about the missing money. On 9/3/25 at 8:08 AM, V11 (Administrator Assistant/ Business Office) said I did give money to R1 and brought in a transaction report showing R1's account that the facility manages. The report showed that R1 had taken out cash withdrawals of $30 on 5/6/25, 6/30/25, 7/4/25 and 8/21/25 and a cash withdrawal of $150 on 5/20/25. V11 said she encourages residents to not keep that much cash on them and knew that R1 had taken $150.00 out in May to go shopping with family so she waited until right before they were going to go to give her the money. V11 verified it was possible for R1 to have had that much cash on her possession. On 9/3/25 at 8:15 AM, V3 said she was alerted to R1's missing money on 8/21/25 and they did do a room search and the money was not located. V3 said R1 is deaf and does read lips and if someone came into her room while she was asleep, she would not hear them. V3 confirmed that R1 does not go out of the facility very often and that she is alert and oriented. V3 also confirmed when she interviewed R1 on 8/21/25 that her account of what cash she had, and the events matched what R1 reported to this surveyor. On 9/3/25 at 11:07 AM, V1 (Administrator) said they encourage residents to not have that much cash on them. V1 said he is highly upset that R1 had her cash taken from her and that they facility does not have cameras to identify who may have done it.The facility provided Abuse Prevention Program policy last revised on 7/30/2012 shows residents have the right to be free from misappropriation/theft and any missing money should be treated as theft until there are clear indications the property was mislaid or lost by means other than theft.

Based on interview and record review the facility failed to ensure the abuse coordinator was immediately notified of an allegation of misappropriation of resident property for 1 of 5 residents (R1) reviewed for abuse reporting in the sample of 7. Findings Include:An Illinois Department of Public Health Investigation Report completed by V3 (Assistant Director of Nursing) on 8/21/25 shows that R1 had reported that $300 was missing from her wallet.A Nursing Progress Note completed by V17 (Registered Nurse) on 8/20/25 at 10:30 PM for R1 states, Resident reported to nursing assistant that she lost $300.00 between 1 PM and 5 PM. On 9/2/25 at 3:10 PM, V19 said R1 did report to her that she had money missing from her wallet. V19 said she went and told her nurse (V17) that evening about the missing money. On 9/2/25 at 12:45 PM, V3 said she was not alerted to R1's missing money until 8/21/25 and when an allegation is made staff should notify an administrator or V1(Administrator and abuse coordinator) immediately. On 9/2/25 at 3:02 PM, V17 said he was alerted by a CNA, V19 the evening of 8/20/25 that R1 had money missing from her wallet but it was getting late in the evening, so he did not call anyone he just left a message to pass on in report to have social services see her the next day. V17 said he knows that you should call the abuse coordinator right away for any abuse allegations, but he thought they should wait to see if the money turns up. On 9/3/25 at 11:07 AM, V1 (Administrator) said staff are required to report to the abuse coordinator or a member of management who would then call the abuse coordinator immediately for any allegations of theft, misappropriation, abuse etc. V1 said waiting until the next day is not acceptable. The facility provided Abuse Prevention Program policy last revised 7/30/2012 shows that any allegations of abuse or mistreatment including misappropriation of property should be reported to a supervisor who should immediately report it to the administrator.

Based on observation, interview and record review the facility failed to have a system in place for monitoring resident room temperatures during hot weather. This applies to 4 of 5 residents (R1-R4) reviewed for comfortable room temperatures in the sample of 5. The findings include: On 6/24/25 at 9:20 AM V2 (Director of Nursing) stated, I have a guy that comes everyday to check on the temperatures but with this heat it just can't keep up. He is here now. I have pictures. V2 then showed Surveyor a picture, with no date or time, of a thermometer on the wall at the nurse's station on the second floor. The picture shows the thermometer at 70 degrees Fahrenheit (F). On 6/24/25 at 9:40 AM V5 (Heating and Cooling Representative) stated, I come in every morning at 7 AM to check. There are 2 condensers and there seems to be an obstruction in one of them- one of the condensers is not as cold as it should be. I ordered the parts, but it will take 2-3 days to get them. Then it is a 2-day job to fix it. It is blowing cold air but not cold enough. One is 50 degrees (F) and the other is about 65 degrees (F). V2 stated, We turned on the AC (Air Conditioning) about 2 weeks ago. It was working fine. We have not seen any temperatures of 80 or 90 degrees (F). We are not checking room temperatures. We just have the thermometers at the nurse's stations. Yesterday morning we noticed it was hot. I went through and turned on all the units (in the rooms) because they were all off. We have not been recording the temperature checks. On 6/24/25 at 9:45 AM the thermometer on the third floor read 74 degrees F. There was a digital thermometer next to it showing 78 degrees F. On 6/24/25 at 9:50 AM R1 stated, It is too hot and very humid. I think with this heat the AC is struggling to keep up. At 9:55 AM R2 stated, I get cold at night but sometimes it is really hot. They are good about giving us water. The temperature really varies. At 10:00 AM V6 (Registered Nurse) stated, The temperature is definitely better today than it was the last few days. At 10:05 AM R3 stated, Maybe a little hot in here, but they got the fans and it is better than yesterday. On 6/24/25 at 10:10 AM the thermometer on the second floor read 70 degrees F. (Same as the picture). The second floor felt cooler than the third floor. The humidity level felt high and the whole building feels damp. At 10:20 AM R4 stated, It is a little warm in here sometimes but I'm from Texas so it is ok. On 6/24/25 at 11:00 AM V8 (Admissions Director) stated, I bought a thermometer a long time ago when I was doing the life safety stuff. Let me see if I can find it. V8 returned with a digital thermometer with a long cord and a probe at the end. Surveyor took thermometer to rooms on the second floor and the temperature stayed at 78.8 degrees F with 45% humidity. On 6/24/25 at 11:45 AM V4 (Maintenance) stated, I have been here for 2 years- helping maintenance. About 2-3 months on my own. I'm not doing air temperature checks- not recording building temps. I don't have a thermometer to check the air temps. Residents and staff have been complaining. I put the fans out. The guy comes and checks the AC in the morning. Asked what temperature he thinks the building should be at V4 stated, 78 degrees (F). On 6/24/25 at 12:45 PM V3 (Assistant Director of Nursing) stated, I looked at the emergency plan yesterday. If it gets too hot, I would follow the direction of the Administrator (V1). I could not make the decisions myself. I have not seen (V1) yet today. We have a hot weather plan- I know the high-risk residents would be anyone with a respiratory illness. Yesterday it was warm on the third floor, so I closed all the drapes, removed sweaters and blankets and made sure all the units were on. The facility policy titled Maintenance Services dated 3/20/25 states, The Maintenance Department is responsible for maintaining the building, grounds and equipment in a safe and operable manner always. The facility policy titled Hot Weather Policy and Procedure states, The following measures are to be taken during periods of excessive heat and/or in the event of a failure in the facility air cooling system to assure the comfort and safety of the residents in the facility. Neither of these policies addresses the need for monitoring and recording the temperatures in the building during days of excessively high heat.

Based on observation, interview, and record review the facility failed to protect a resident (R1) from physical abuse by another resident (R2). This applies to 2 of 5 residents (R1, R2) reviewed for physical abuse in the sample of 5. The findings include: R1's Facesheet shows that R1 has diagnoses that include, but are not limited to, dementia and insomnia. R2's Facesheet shows that R2 has diagnoses that include, but are not limited to, psychosis, major depressive disorder, and insomnia. R1's Minimum Data Set (MDS) Section C dated 11/17/24 shows R1 scored a five out of fifteen on his brief interview for mental status (BIMS), indicating severe cognitive impairment. On 12/31/24 at 9:10 AM, R1 was in R1's room, lying in bed half asleep and half watching the television. R1 stated he was not in pain and that he did not have bruising on his torso area. R1 was unable to recall the 12/23/24 incident but appeared pleasant and had his needs met. On 12/31/24 at 9:50 AM, R3 stated that R2 typically eats his breakfast and returns to R2's room when finished. R3 also said that this was the first time that R2 has ever shown any signs of aggression towards staff or residents. On 12/23/24, just after breakfast in the dining room on the second floor, R3 noticed R2 was pacing from his table to another table in the dining room, and out and down the hallway and back. R3 stated that as R1 entered the dining room through the main entrance, that's when R2 ran towards R1, kicked R1 to the ground, and kicked him approximately five times to R1's torso. R3 and staff shouted at R2 to stop and R2 stopped kicking R1 and returned to R2's table. On 12/31/24 at 10:00 AM, V6 (Housekeeping) stated she was in the hallway just outside of the second-floor dining room when the incident occurred. V6 stated she witnessed R2 shove R1 to the ground and started kicking R1. V6 yelled at the residents to stop and yelled for staff to come help. V6 stated V3 (Assistant Director of Nursing) came down the hall and when V6 arrived, R2 had already stopped kicking R1. On 12/31/24 at 8:30 AM, V3 stated R1 and R2 were separated immediately and both were assessed by staff. V3 personally assessed R1 and stated he had no injuries, no bruising, and R1 could not recall what had happened. For precautions, V3 moved R1 to the third floor approximately 30 minutes after the incident. R2 was difficult to redirect after being separated and was eventually discharged to a behavioral health hospital on 12/23/24 and as of 12/31/24, R2 was still at the behavioral health hospital. R2's monthly Psychiatrist Physician Notes with dates of 12/3/24, 11/5/24, and 10/8/24, all show that R2 had no previous signs of irritability or aggressive behaviors towards others. On 12/31/24 at 8:51 AM, V4 (Social Services) said that she has not known R2 to be aggressive towards staff or residents prior to the incident on 12/23/24. On 12/31/24 at 12:26 PM, V9 (Medical Director) stated it is his expectation that residents are to be free from physical abuse within the facility. V9 stated that there was no physical harm done to R1 from the reports received by staff at the facility. Facility Abuse Prevention Program Facility Policy states, This facility affirms the right of our residents to be free from abuse, neglect, misappropriate of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident which applies to 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for abuse in a sample of 7. This failure resulted in R1 sustaining a right hip fracture. The findings include: 1. R1's Facesheet printed on 8/12/24 showed R1 to be a [AGE] year-old male admitted to the facility with diagnoses which include: metabolic encephalopathy, hemiplegia (right sided), vascular dementia, cerebral infarction. R2's Facesheet printed on 8/12/24 showed R2 to be an [AGE] year-old male admitted to the facility with diagnoses which include: dementia and Alzheimer's disease. The facility's Final Incident Report dated 8/4/24 showed R1 and another male (R2) had an altercation on 7/31/24. It is noted R1 and R2 have dementia and cognitive deficits. R1 approached R2 who was sitting in a chair. R1 attempted to get R2 to move from the chair. R2 stood up and struck R1 in the face. R1 them fell back onto the floor. On 8/12/24 at 1:00 PM, R6 stated, A few of us (residents) were in the dining room area before breakfast time. (R2) was sitting in (R1's) spot. (R1) gets upset when other residents are sitting in his chair. (R1) nudged (R2), waved his hands to (R2) to get away. (R2) stood up and punched (R1) in the face. (R1) fell back on the floor. On 8/12/24 at 2:00 PM, R7 stated, When (R1) walked into the dining room (R1) got upset. We (residents) do not have assigned seats, but (R1) has his chair he sits in all the time. (R1) walked up to (R2), (R1) tapped (R2) on the arm, and (R2) punched (R1) in the face. (R1) fell back on the floor and landed on his butt. On 8/13/24 at 11:00 AM, V3 (Assistant Director of Nursing) stated R1 initially had no signs of injury. After the incident R1 was placed in a wheelchair at the table for breakfast. At the end of breakfast V10 (Certified Nursing Assistant/CNA) came and asked me to look at R1. V3 stated R1 usually ambulates by himself with no assistance. At that time R1 was having difficulty standing up and bearing weight on his right leg. V3 stated when R1's leg was moved R1 winced in pain. V3 stated R1 was sent out to the hospital. R1's Hospital Records showed he was admitted on [DATE] with a right hip fracture after having an altercation with another resident. These records showed R1 needed to have hip surgery to repair the fracture. On 8/12/24 at 9:20 AM, V2 (Director of Nursing/DON) showed this writer R1's right hip which had a dressing covering a surgical site. 2. The Facility's Final Incident report dated showed R3 was waiting for bingo to start in the 3rd floor dining room. R3 asked a male resident (R2) if he could move because he was sitting in her chair. This report showed R2 got upset and struck R3 in the face and arm. The Report was filled out and completed by V3. On 8/12/24 at 11:45 AM, R3 stated she was in the dining room to play bingo. 'The Chinese guy' (R2) was sitting in my chair. I leaned over to ask him if he could move. (R2) swung at me and hit me in my face and arm. R3 stated she immediately went to V7 (Registered Nurse/RN) about it. R3 stated she was upset at the time but is fine now. On 8/12/24 at 12:35 PM, V7 (RN) stated R3 came out of the dining room yelling the Chinese guy hit her in the face and arm. V7 stated she went to check the dining room. (R6) and (R7) told me (R2) hit (R1). On 8/12/24 at 2:00 PM, R7 stated, A while ago we were waiting to start bingo. (R2) was sitting in a chair by the wall. (R3) came in and started yelling at (R2). (R2) started swinging at (R3). R7 stated she was not sure where R2 hit R3. R3's back was to her. R3 then left the dining room yelling for V7. On 8/12/24 at 9:20 AM, attempted to interview R2 with V2 (DON) as a translator. R2 only speaks Korean. R2 stated he does not remember hitting anyone. 3. R5's Facesheet printed on 8/12/24 showed R5 to be a [AGE] year-old male resident admitted to the facility with diagnoses which include: dementia, traumatic subdural hemorrhage, and unspecified psychosis. R4's Facesheet printed on 8/12/24 showed R4 to be a [AGE] year-old male with diagnoses which include: dementia, unspecific psychosis, and major depressive disorder. The facility's Incident Report dated 7/10/24 showed R5 was found sitting on the floor outside another resident's room (R4). R5 had a laceration above his left eye. This Report showed R4 stated R5 tried to come into his room. R4 stated he pushed R5 out of his room, R5 stumbled, and hit the doorway as he fell . This report showed R5 sustained a laceration to his left eyebrow approximately 2 centimeters long. R4's emergency room report dated 7/16/24 showed R4 was treated for a laceration repair. On 8/13/24 at 9:30 AM R5 was sitting in the dining room. R5 had a reddish scar above his left eyebrow. The facility's Abuse Policy dated 7/3/12 showed the facility affirms the rights of the residents to be free from abuse.

Based on interview and record review the facility failed to notify law enforcement when an allegation of physical abuse occurred which applies to 4 of 4 residents (R1, R2, R4, R5) reviewed for abuse notification in a sample of 7. The finding include: 1. The facility's Final Incident Report dated 8/4/24 showed R1 and another male (R2) had an altercation on 7/31/24. It is noted R1 and R2 have dementia and cognitive deficits. R1 approached R2 who was sitting in a chair. R1 attempted to get R2 to move from the chair. R2 stood up and struck R1 in the face. R1 then fell back onto the floor. This report showed the police were not contacted after both residents' families declined to contact them. R1's Hospital Records showed he was admitted on [DATE] with a right hip fracture after having an altercation with another resident. These records showed R1 needed to have hip surgery to repair the fracture. 2. The facility's Incident Report dated 7/10/24 showed R5 was found sitting on the floor outside another resident's room (R4). R5 had a laceration above his left eye. This Report showed R4 stated R5 tried to come into his room. R4 stated he pushed R5 out of his room, R5 stumbled, and hit the doorway as he fell . This report showed R5 sustained a laceration to his left eyebrow approximately 2 centimeters long. This report showed R5's family declined to have the police called. R4's emergency room report dated 7/16/24 showed R4 was treated for a laceration repair. On 8/13/24 at 11:30 AM, V3 (Assistant Director of Nursing) stated she believed the police did not have to be called if the families did not want to contact them (press charges). V3 stated a resident hitting another resident and causing a fracture is considered a serious injury. The police should have been contacted. R1 and R5's medical record showed no indication law enforcement was notified after receiving an injury from being struck or pushed physically by another resident.

Based on observation, interview, and record review, the facility failed to ensure dietary staff were supervised and trained by a qualified dietary manager resulting in R6, R53, R21, and R65 receiving incorrect physician prescribed diets and resulted in R6 choking, requiring the Heimlich maneuver. R6 required hospitalization for aspiration pneumonia and remains at risk for further episodes of choking and aspiration due to continuing receiving the incorrect diet. This failure applies to 4 of 4 residents (R6, R53, R21, and R65) reviewed for mechanical soft diets in the sample of 20. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE], when the facility failed to ensure residents were served a mechanically soft diet as prescribed by their physician. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:30 PM. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE]; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On [DATE] at 2:05 PM, V4 (Food Service Manager/FSM) stated he has been in his role as food service manager for about three years. V4 only has a food protection manager certification that has expired. V4 is not a certified dietary manager. V4 has not begun the process of signing up to take the certified dietary manager coursework as of [DATE]. V4 stated that he doesn't always know exactly what to do in his position. There isn't someone on site at all times for him to refer to when he has questions. V4's provided food protection manager certification shows an expiration date of [DATE]. On [DATE] at 10:37 AM, V7 (Registered Dietitian/RD) stated that she is contracted to provide 16 hours at the facility per month which mainly includes conducting resident nutrition assessments. V7 has never attended a face-to-face staff meeting with all of the dietary staff but has provided printed information for the staff to review. On [DATE] at 8:44 AM, V9 (Cook) stated she has worked here for about eight years. V9 was trained by V4 (FSM) and former cooks on the job. V9 has a current food protection manager certification. V9 stated that a mechanical soft diet is prepared using a knife and cutting the item into bite-size pieces, roughly the size of the fingernail on a pinky finger. V9 does not use any type of machine or device to prepare the mechanical soft diet. V9 stated chopped meats, cooked vegetables, canned fruit, and fresh fruit are allowed on a mechanical soft diet. V9 stated V7 (RD) does not come to the kitchen and V9 has not received training from V7. Per V9, the most recent in-service provided by V4 was a few months ago and covered being careful to send the correct foods for each resident. On [DATE] at 9:03 AM, V8 (Dietary Aide) stated he reads all of the diet cards during service and notifies the chef as to what to put on each plate. A mechanical soft diet is signified by a green sticker on the diet card. Mechanical soft diets are to receive soft and chopped foods, roughly the size of the fingernail on a pinky finger. V8 stated that residents receiving a mechanical soft diet can receive a lettuce salad as long as the contents of the salad are chopped finely, similar in size to the chopped meats. If tomatoes are a part of the salad, those need to be chopped up as well; they cannot be large pieces. Facility provided dietary staff certificates indicate that V10 (Dietary Aide), V11 (Dietary Aide), V13 (Dietary Aide), and V14 (Dietary Aide) do not have current food handler's certifications. V12's (Cook) Food Protection Manager's certificate has an expiration date of [DATE] and is not currently active. R6's current diet card shows R6 should receive a mechanical soft diet. R6's progress note dated [DATE] shows, Writer was called to R6's room, resident was choking. 911 was called. Heimlich maneuver was performed, a piece of tomato was expelled. On [DATE] at 1:02 PM, V5 (LPN) stated that at the time of the choking event, R6 was lying in bed. V5 was called into R6's room by V6 (Certified Nursing Assistant (CNA)). When V5 entered R6's room, R6 was purple and could not speak. V5 initiated the Heimlich maneuver on R6 and a tomato piece, approximately the size of a quarter, came flying out. V5 stated R6 was receiving a mechanical soft diet on [DATE] and is still on a mechanical soft diet. R6's progress note dated [DATE] shows, Resident readmitted from local hospital via local paramedics. He was on IV (intravenous) antibiotics to treat aspirated pneumonia while at local hospital . On minced moist diet with thin liquid . Facility served menu for [DATE] shows the meal served for the day includes a tomato wedge, pesto chicken salad, potato chips, marinated cucumber and onion salad, pudding with whipped topping, and a dinner roll. Facility diet spreadsheet for [DATE] shows that a mechanical soft diet should have received a diced tomato rather than a full tomato wedge. On [DATE] at the noon meal, R6 received ham cut into cubes, a baked potato with the skin, spinach, and fresh cantaloupe cut into chunks. On [DATE] at the noon meal, R6 received meat lasagna, California blend vegetables, garlic bread, and apple slices. R53's physician order sheet dated [DATE] shows R53 is on a general diet with mechanical soft texture. On [DATE] at the noon meal, R53 received a whole hot dog on a bun, spinach, and fresh cantaloupe cut into chunks. On [DATE] at 1:43 PM, V7 stated that a hot dog is absolutely not appropriate for a resident on a mechanical soft diet. R21's current diet card reads, mech soft (mechanical soft). On [DATE] at the noon meal, R21 received ham cut into cubes, a baked potato with skin, spinach, and fresh cantaloupe cut into chunks. On [DATE] at the noon meal, R21 received meat lasagna, California blend vegetables, garlic bread, and apple slices. R65's physician order sheet dated [DATE] shows R65 is on a general diet with mechanical soft texture. R65's current diet card reads, Regular diet (with no texture modifications). On [DATE] at the noon meal, R65 received a slice of ham, a baked potato with skin, spinach, and fresh cantaloupe. On [DATE] at the noon meal, R65 received meat lasagna, California blend vegetables, garlic bread, and apple slices. On [DATE] at 1:43 PM, V7 (RD) stated that ham would not be the best option for a resident on a mechanical soft diet. The cut-up squares could be a choking problem. She would also recommend they not serve fresh fruit unless they could guarantee it is soft enough for them to eat. Facility diet spreadsheet for [DATE] shows mechanical soft residents should have received ground ham and a chopped baked potato without the skin. On [DATE] at 1:20 PM, V4 (FSM) said the staff should follow the diet spread sheet for altered diets. On [DATE] at 1:13 PM, V29 (Medical Director) stated, They definitely should be serving what is ordered for the resident's diets. Facility Food and Nutrition Services Diets and Diet Orders, Mechanical Soft Diet policy dated 2017 states, . Procedure: The texture may be altered by one of the following methods: Unless otherwise indicated, meat and meat substitutes will be mechanically ground On [DATE] at 10:40 AM, V29 (Medical Director) stated that he was not familiar with what qualifications a dietary manager requires and he also did not know that V4 (FSM) did not possess the proper qualifications. Facility provided job description for Director of Food and Nutrition Services dated 2018 states, Qualifications: Certified in food safety through an American National Standards Institute (ANSI) accredited course and has one of the following qualifications: Registered Dietitian, Licensed or Certified Dietitian, Certified Dietary Manager . The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on [DATE] and the survey team accepted the abatement plan on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position as of [DATE]. The current Supervisor (V4) will attend a class dated [DATE], to renew his Food Safety Manager Certificate. All other dietary staff files will be audited for compliance with the current Food Handler's Certification by Human Resources (V17) by [DATE]. The Certified Dietary Manager (CDM) (V31) has started the training for dietary staff on [DATE]. The Registered Dietitian (V7) will continue with the training for proper production and serving of mechanical soft diets on [DATE]. This process will be completed by [DATE]. The CDM (V31) will supervise food service production. 2. Enhanced Training Programs: As of [DATE] In-servicing and training have begun for dietary staff by the CDM (V31) on providing diet as ordered, communication protocol, review diet, and update orders, in-servicing will continue until all dietary staff is trained before starting their next shift. The ADON (V3) started in-servicing nursing staff on [DATE] on monitoring dietary cards to ensure correct food consistency is being served; in-servicing will continue until all nursing staff is trained by [DATE]. We are enhancing our current training programs to ensure all dietary staff receive continuous education on a yearly basis for food safety, nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted Registered Dietitian (V7) or her designee. 3. Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by the CDM (V31) and our contracted Registered Dietitian (V7) this process will be started on [DATE] and continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee. 4. Regular Audits and Monitoring: To prevent future occurrences, we will establish a random weekly audit of 3 meals a week for 90 days done by the CDM (V31); this audit will be focused on food consistency matching the dietary card. This procedure will help us monitor for compliance, identify potential issues early, and take corrective actions promptly. Results will be reported at QA meeting to ensure ongoing compliance.

I. Based on observation, interview, and record review the facility failed to ensure residents with a history for choking and at risk for choking were served the correct physician prescribed diets. This failure resulted in R6 choking, requiring the Heimlich maneuver, going to the hospital, and being treated for aspiration pneumonia. R6 returned to the facility and continued to be served the incorrect diet putting him at risk to choke again. The facility also failed to ensure R21, R53, and R65 were served the correct physician prescribed diets putting them at risk to choke. This applies to 4 of 20 residents (R6, R21, R53, R65) reviewed for menus in the sample of 20. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/22/24 when the facility failed to ensure residents were served a mechanically soft diet as prescribed by their physician. V1 Administrator was notified of the Immediate Jeopardy on 6/4/24. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/6/24 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and staffing levels. The findings include: 1. R6's progress notes dated 4/22/24 shows, Writer was called to R6's room, resident was choking. 911 was called. Heimlich maneuver was performed, a piece of tomato was expelled. R6's local hospital records dated 4/22/24 shows, Medical Screening Exam: s/p (status post) reported witnessed chocking [SIC (statement is correct)] event earlier today at 1846 (6:46 PM). Local fire department called by SNF (skilled nursing facility) for witnessed event, Heimlich maneuver perform and fully resolved/signed off at the scene. R6's progress notes dated 4/28/24 shows, Resident readmitted from local hospital via local paramedics. He was on iv antibiotics to treat aspirated pneumonia while at local hospital . On minced moist diet with thin liquid . On 6/3/24 at 1:02 PM, V5 Licensed Practical Nurse (LPN) stated, R6 was lying in bed when he choked. It was dinner time, and the CNA (certified nursing assistant/V6) called her into R6's room. R6 was purple and couldn't speak when V5 LPN got into the room. She did the Heimlich maneuver on him and a quarter size tomato came flying out. She couldn't remember what was for dinner that night only that he choked on a tomato. She also stated, his diet has not changed and was on a mechanical soft diet at the time when he choked. The dinner menu for 4/22/24 (the day R6 choked) shows, tomato wedge, pesto chicken salad, potato chips, marinated cucumber and onion salad, pudding with whipped topping and a dinner roll. The spreadsheet for mechanical soft diet shows, tomato wedge (diced (garnish)) . On 6/3/24 at 1:43 PM, V7 Dietitian stated, ham would not be the best option for a resident on a mechanical soft diet. The cut-up squares could be a choking problem. She would also recommend they steer away from fresh fruit unless they could guarantee it is soft enough for them to eat. On 6/4/24 at 9:03 AM, V8 Dietary Aide stated, residents on a mechanical soft diet can receive a salad if it is chopped fine and the tomato is cut small. They should not receive large pieces of tomato. Mechanical soft diets should be soft and chopped up to about the size of a pinky nail. On 6/2/24, at the noon meal, R6 was served a slice of ham cut into cubes, a baked potato with skin, spinach and fresh cantaloupe cut into chunks. R6 has no teeth. On 6/3/24, at the noon meal, R6 was served meat lasagna, California blend vegetables, garlic bread and apple slices. R6's physician order sheet dated 4/28/24 shows, Regular diet, soft & bite sized texture, regular/thin consistency minced and moist diet/thin liquid for dysphagia. The menu for 6/2/24, at the noon meal shows, orange glazed ham, baked potatoes with sour cream, seasoned spinach, fresh fruit mix and dinner roll. The spreadsheet for mechanical soft diet shows, orange glazed ham: grnd (ground), baked potato: no skin/chopped/add [NAME] (margarine (butter)). The spreadsheet does not show what mixed fruit should be for a mechanical soft diet. The menu for 6/3/24, at the noon meal shows, home style meat lasagna, Italian blend vegetables, fresh fruit and garlic bread. The spreadsheet for mechanical soft diet shows, they can have what is on the menu however it shows they were to get pineapple with the noon meal instead of fresh fruit. The spreadsheet does not show what a mechanical soft diet should get instead of sliced apples. R6's diet card shows, mechanical soft diet. On 6/4/24 at 1:13 PM, V29 (R6's physician/Medical Director) stated, he was aware of him choking during dinner. They definitely should be serving what is ordered for the resident's diets. R6's medical record does not show any evaluations by a speech therapist for diet recommendations. 2. On 6/2/24, at the noon meal, R53 was served a whole hot dog on a bun, spinach and fresh cantaloupe cut into chunks. R53 also has no teeth and was having a hard time eating the hot dog and cantaloupe. On 6/3/24, at the noon meal, R53 was served meat lasagna, California blend vegetables, garlic bread and apple slices. R53 was having a hard time eating the apple slices. R53's physician order sheet dated October 1, 2023, shows, General diet, Mechanical Soft texture, Regular/Thin consistency. On 6/3/24 at 1:43 PM, V7 Dietitian stated, A hot dog was absolutely not appropriate for a resident on a mechanical soft diet. R53's current diet card shows, regular diet (not the prescribed diet). 3. On 6/2/24, at the noon meal, R21 was served a slice of ham cut into cubes, a baked potato with skin, spinach and fresh cantaloupe cut into chunks. On 6/3/24, at the noon meal, R21 was served meat lasagna, California blend vegetables, garlic bread and apple slices. R21's physician order sheet dated October 1, 2023, shows, NAS (no added salt) diet, Mechanical Soft texture. R21's current diet card shows, mech soft (mechanical soft). 4. On 6/2/24, at the noon meal, R65 was served a slice of ham, a baked potato with skin, spinach, and fresh cantaloupe. On 6/3/24, at the noon meal, R65 was served meat lasagna, California blend vegetables, garlic bread and apple slices. R65's physician order sheet dated October 1, 2024, shows, General diet, Mechanical Soft texture, Regular/Thin consistency. R65's current diet card shows, Regular diet (not the prescribed diet). On 6/3/24 at 1:20 PM, V4 Dietary Manager stated, they follow the spreadsheet for altered diets (mechanically soft diets). The facility's food and nutrition services diets and diet orders policy dated 2017 shows, Diet Standardization: Policy: Food and nutrition services will serve standard diets which correspond to the diet columns on the menu spreadsheet and are based on the nutrition manual for healthcare communities . Procedure: Examples of standard diet orders may include: Mechanical soft: The texture and consistency of the general/regular or therapeutic diet is modified. Food maybe served as ground or chopped. Whole food may only be served if it is soft in consistency. The facility's food and nutrition services diets and diet orders, mechanical soft diet policy dated 2017 shows, Policy: Food will be provided in a form designed to meet individual needs. The highest practicable level of eating will be provided. The texture of the food may be altered to mechanical soft consistency. Procedure: The texture may be altered by one of the following methods: Unless otherwise indicated, meat and meat substitutes will be mechanically ground. Plain fish fillet may be flaked. Meat loaf without hard crust and soft casseroles may be served intact. Foods commonly avoided are fibrous raw vegetables (such as celery, radishes, cauliflower, broccoli, etc.), whole kernel corn and nuts. If individual tolerance allows, meat and meat substitutes can by chopped by hand. This will be indicated on the tray card. The facility presented an abatement plan to remove the immediacy on June 5, 2024. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on June 5, 2023, and the survey team accepted the abatement plan on June 6, 2024. The Immediate Jeopardy that began on April 22, 2024, was removed on June 6, 2024, when the facility took the following actions to remove the immediacy: 1. Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position as of 06/04/24. The current Supervisor (V4) will attend a class dated 08/19/24, to renew his Food Safety Manager Certificate. All other dietary staff files will be audited for compliance with the current Food Handler's Certification by Human Resources (V17) by June 5, 2024. The CDM (V31) has started the training for dietary staff on 06/05/24. The Registered Dietitian (V7) will continue with the training for proper production and serving of mechanical soft diets on 06/06/24. This process will be completed by 06/06/24. The CDM (V31) will supervise food service production. 2. Enhanced Training Programs: As of 6/5/24 In-servicing and training have begun for dietary staff by the CDM (V31) on providing diet as ordered, communication protocol, review diet, and update orders, in servicing will continue until all dietary staff is trained before starting their next shift. The ADON (V3) started in-servicing nursing staff on 06/05/24 on monitoring dietary cards to ensure correct food consistency is being served, in servicing will continue until all nursing staff is trained by 6/13/24. We are enhancing our current training programs to ensure all dietary staff receive continuous education on a yearly basis for food safety, nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted Registered Dietitian (V7) or her designee. 3. Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by the CDM (V31) and our contracted Registered Dietitian (V7) this process will be started on 6/6/24 and continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee. 4. Regular Audits and Monitoring: To prevent future occurrences, we will establish a Random weekly audit of 3 meals a week for 90 days done by the CDM (V31), this audit will be focused on food consistency matching the dietary card. This procedure will help us monitor for compliance, identify potential issues early, and take corrective actions promptly. Results will be reported at QA meeting to ensure ongoing compliance. 47552 II. Based on observation, interview, and record review the facility failed to ensure residents receiving a regular texture diet received a 3-ounce (oz) portion of sliced ham for the noon meal on 6/2/24. This applies to 4 of 4 residents (R44, R75, R84, R45) reviewed for menus in the sample of 20. The findings include: Facility provided Dietary Type Report shows that R44, R75, R84, and R45 all receive a regular texture diet. On 6/2/24 at 11:27 AM, V12 (Cook) was placing a single slice of sliced ham on each plate receiving a regular texture diet. The slices of ham appeared small. The slices were approximately one quarter inch thick and the size of a three inch by five-inch index card or smaller. On 6/2/24 at 12:10 PM, V12 finished plating all meals and none of the residents received additional ham during normal meal service. On 6/2/24 at 12:37 PM, facility provided test tray was received and the portion of ham was similar to the sizes served during lunch. On 6/2/24 at 12:54 PM, V4 (Dietary Manager) used a calibrated food scale to weigh the ham slice provided on the test tray. The ham slice weighed 1.75 ozs (ounces), providing approximately 88 calories and 11 grams (g) protein. V4 stated the residents were to receive a 3 oz portion of ham, which would provide approximately 150 calories and 20g protein. Residents received approximately 60 calories and 9g less protein than the written menu. On 6/2/24 at 12:55 PM, V9 (Cook) confirmed that V12 cut the ham into slices to serve for lunch on 6/2/24. Facility Diet Spreadsheet shows the portion size for the regular texture diet is to receive a 3 oz portion of ham. On 6/2/24 1:47 PM, R44 said there are sometimes he receives enough food, but he stated the ham received on 6/2/24 was small and he was still hungry after lunch. On 6/2/24 at 1:58 PM, R84 state that he believes the portion sizes served are small. On 6/3/24 at 9:05 AM, R75 stated that she does not believe the food portions served are always large enough. R75 was unable to eat the ham on 6/2/24 and was still hungry after the end of the meal. R75 stated there have been other times that she was still hungry after meals and this was not the first time.

Based on interview and record review the facility failed to ensure the Registered Dietician was immediately notified of a significant weight loss for a resident receiving enteral feedings. This failure resulted in a delay in a resident (R24) being assessed by the dietician to implement interventions to prevent further weight loss. The facility failed to ensure weekly weights were completed for a resident (R1) on enteral feedings with insidious weight loss. This applies to 2 of 3 residents (R24, R1) reviewed for enteral feedings in the sample of 20. The findings include: 1. R24's active care plan shows he requires enteral feedings through a Gastrostomy tube (G tube). Hospital records from a local community hospital show he was hospitalized from 2/28/24 through 3/12/24 for placement of a gastrostomy tube. R24's nutritional assessment completed by V7 (Registered Dietician/RD) on 3/25/24 show he was readmitted from the hospital with tube feeding orders for a continuous tube feeding of Glucerna 1.2 at 60 (ml) milliliters per hour. These orders were changed by V7, at the request of the facility, to bolus feedings QID (four times a day). R24's weight summary shows on 4/1/24, R24's weight was 101.0 lbs. (pounds). On 4/4/24 R24's weight was 91 pounds, a 10 lb., 9.9% weight loss in 4 days. On 4/15/24, R24's weight had dropped from 91 lbs. to 87.8 lbs, another 3.2 lbs in 11 days. R1's nursing progress notes do not show that V7(RD) or V29 (R24's Physician and Medical Director) were notified of R24's significant weight loss. A Nutrition/Dietary note completed by V7 (RD) on 4/29/24 shows, Patient with significant weight loss noted, 10% in 1 month, Discussed with RN will change to a continuous tube feeding to meet the needs of the patient. A physician's order dated 4/29/24 shows R24's tube feeding was changed from bolus to a continuous feeding of Glucerna 1.2 at 50 ml. per hour. On 6/4/24 at 10:32 AM, V7 (RD) stated she is only at the facility 16 hours per month. V7 stated she is not immediately notified of weight loss as she finds out by notes left in her mailbox when she comes to the facility. V7 stated she could not recall exactly when she was told of R24's weight loss but she did not see him until 4/29/24 so she assumes it was that day. R24 stated she made immediate changes to the tube feeding orders to be a continuous feeding to try to prevent further weight loss. On 6/5/24 at 7:50 AM, V2 (Director of Nursing) stated she was aware of R24's weight loss and she expects the nurses to call the Dietician and Physician right away for significant weight loss and to chart that in the resident's medical record. V2 stated she was not aware that V7 (RD) was only contracted to come to the facility 2 times per month. On 6/5/24 at 10:35 AM, V29 (R24's Physician) stated he was notified of R24's weight loss but not sure of the date. V29 stated he was also unaware that the nursing staff were only leaving notes in the mailbox for V7 (RD) and not calling her to notify her of significant weight loss. V29 state they will have to fix that process because the Registered Dietician should be notified immediately. On 6/5/24 at 11:41 AM, V16 (Registered Nurse/RN) stated they do not call the Dietician directly they let V3 (Assistant Director of Nursing) know and then put a note in the Dieticians mailbox. V16 stated they should call the residents physician who usually tells them to notify the Dietician. The facility provided Weight Monitoring policy dated 2017 describes significant weight loss as 5% in one month, 7.5% in 3 months, and 10% in 6 months. The policy shows that the physician and dietician should be notified but fails to indicate a time frame. 2. R1's Medication Administration Record shows he receives enteral feedings via a G-tube of Jevity 1.2, 300 ml at breakfast and lunch, and 600 ml. at dinner. R1's 2/12/24 Nutrition note completed by V7 (RD) shows the resident has had a significant weight loss of 8% in 6 months and she recommended weekly weights for 4 weeks to monitor his weight. R1's Weight Summary report shows on 2/5/24 he weighed 132.0 lbs. but, no further weight is documented until 3/12/24. One month after V7 ordered weekly weights for R24. On 6/4/24 at 10:32 AM, V7 (RD) stated R1 has a history of refusing the bolus feedings so he can consume his regular diet order. V7 stated she ordered the weekly weights to keep track of his weight and she expects the facility to do the weights when it is ordered. The facility provided Weight Monitoring policy dated 2017 describes significant weight loss as 5% in one month, 7.5% in 3 months, and 10% in 6 months. The policy shows that the physician and dietician should be notified but fails to indicate a time frame. The policy additional shows that a client's body weight is monitored to maintain acceptable parameters of nutritional status.

Based on observation, interview and record review the facility failed to set up a urology appointment for a resident with a suprapubic urinary catheter for (R46) 1 of 4 residents reviewed for urinary catheters in the sample of 20. This failure resulted in R46 suffering from catheter pain, leaking, urinary blockages and infections requiring emergency treatments. The findings include: R46's Minimum Data Set assessment dated [DATE] shows that her cognition is intact, and she has an indwelling urinary catheter. On 7/10/23 at 1:58 PM, the back of R46's pants were wet. R46 said that she has a catheter that causes her constant pain, leaking and burning. R46 said that she is supposed to be seeing a Urologist, but she is waiting on the nurses to set up an appointment. R46's Nursing notes on 1/29/23 indicates, Resident c/o (complains of) painful burning upon urination and the suprapubic catheter leaking. Noted sediment inside the suprapubic catheter tubing with scant amt (amount) of urine noted called [Urogynecologist] ok to change the catheter and monitor .attempted to change suprapubic catheter and when balloon deflated unable to pull tube out met with much resistance spoke to [Urogynecology Nurse] .she is also aware that she has an appointment February 1 . R46's Nursing note on 2/1/23 shows, Unable to make appointment due to no transportation Will make new date . On 2/5/23 R46's Nursing note indicates, Writer reported from a CNA that resident's adult brief was wet with urine when she cleaned the resident no urine output in the bag. On 2/8/23 R46's Nursing note indicates that the resident complains of moderate pain to suprapubic catheter and vaginal area .[primary doctor] made aware with N.O (Nursing Orders) carried out. Report given to nurse at [local hospital] resident admitted for UTI (urinary tract infection). No notes were found that her Urogynecology appointment was rescheduled. R46's Nurses note dated 2/28/23 indicates, Tried to flush suprapubic catheter. Unable to flush, urine has been leaking out from urethra Sent patient to [Local Hospital]. R46's Nurses note dated 3/11/23 indicates, Urine leaking out through urethra, tried to flush suprapubic cath but blocked send resident out to [Local Hospital] R46's Nurses note dated 3/12/23 indicates that she came back from the hospital after getting her catheter changed with new antibiotic orders for a urinary tract infection. R46's Nurses note dated 4/8/23 indicates that she complained of blood in her urine, her incontinence brief was saturated with pinkish urine. R46's Nurses note dated 4/11/23 indicates, Unable to flush suprapubic catheter. Urine leaking out through urethra. Resident sent to [Local Hospital]. R46's Nurses note dated 5/12/23 shows, Suprapubic cath unable to flush. Urine has been leaking out through urethra for few days. Informed [Physician]. Resident went to [Local Hospital]. R46's Nurses note dated 6/23/23 shows, Resident need to change suprapubic catheter and c/o low abd (abdominal) pain. Called [Doctor] and received order to send to ER (emergency room ) Returned from [local hospital] without change suprapubic catheter, endorse to tomorrow to make appointment (Urology). R46's Nurses note dated 6/23/23 shows, Called [Urology] office to make appointment, they said they need to fill out [SIC] some paperwork. Will fax to us and remind them need to see MD within 2-4 days. R46's Nurses note dated 6/30/23 shows, Still waiting for picture ID from former home, and they said they mailed already. R46's Nursing Notes do not document that she had a clinic visit with a Urologist from 1/29/23 to 7/12/23. R46's Discharge Instructions from the hospital dated 6/23/23 show that she was diagnosed with a urinary tract infection and needs to see a Urologist in 2-4 days. On 7/11/23 at 10:25 AM, V7 (Registered Nurse) said that R46 has been to the emergency room multiple times to get her catheter changed due to pain and leaking. V7 said that every time she comes back, they say that she needs to see a Urologist in 2-4 days, but we are waiting on getting a photo ID from her previous facility before we can send the paperwork. On 7/11/23 at 10:30 AM, R46 said that her catheter is very uncomfortable and painful. R46 said that it makes her cry sometimes and when she is sent to the hospital, all they do is say to see the Urologist. This surveyor asked R46 if she had a photo ID, and the resident took it out of her wallet and gave it to this surveyor. R46 said that no one at the facility has ever asked her for her ID. R46 said if she would have been asked, she would have given it to them. On 7/12/23 at 1:35 PM, V16 (R46's Physician] said that he is not aware of any current issues that R46 is having regarding her catheter. V16 said that he knows that she has had issues in the past and was sent to the hospital and she should have had a follow up with a Urologist. V16 said that he is not sure if she has seen a Urologist, but he would assume she had seen one in the hospital. On 7/12/23 at 12:11 PM, V3 (Assistant Director of Nursing) said that she is not sure why R46 has not seen the Urologist yet.

Based on interview and record review the facility failed to provide for a resident's safety dependent on staff for care. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 10. This failure resulted in R1 sustaining four fractured bones. The findings include: R1's Admission Record (Face Sheet) dated 9/6/22 showed R1's original admitted was 5/31/2015 with diagnoses to include: a stroke with paralysis affecting her dominant side; [CONDITION(S)] ([CONDITION(S)]); and [CONDITION(S)] (A-Fib, rapid and irregular heart rate.) R1's 7/10/22 Minimum Data Set (MDS) showed she had short and long-term memory problems. The MDS showed she required extensive assistance from two staff for Bed Mobility (turning and positioning in bed.) The MDS showed R1 was totally dependent on two staff for transfers between her bed and chair. R1's Risk for Fall care plan, dated 7/10/22, showed she was a mechanical (crane type) lift transfer, and she uses her wheelchair for mobility. R1's Patient Transfer and Referral Record from 8/30/22 showed at 8:00 AM and 9:00 AM R1 was pale and not feeling well. The record showed R1 had refused breakfast. (Record was signed by V12 Registered Nurse, RN) R1's 8/30/22 at 8:00 AM Nurse's Note showed, the nurse received R1 up in her wheelchair. The note showed R1 requested to return to bed and she was transferred by staff. (No mention of resident being pale or not feeling well.) R1's 8/30/22 at 9:15 AM Nurse's Note showed, Resident in bed, looks pale, refused breakfast, noticed not her usual self. C/O (complains of) pain, when asked where, just pointed all over .remains pale .order to transfer resident to [local area hospital]. R1's 8/30/22 at 9:45 AM Nurse's Note showed she was transferred to a local area hospital. R1's 8/30/22 at 3:15 PM Nurse's Note showed the facility was notified by the hospital that R1 would be admitted for a left femur (thigh bone) fracture, urinary tract infection, and dehydration. On 9/1/22 at 1:10 PM, V12 RN stated she had told the day shift CNA/certified nursing assistant that R1 was not feeling well and R1 wanted to go to bed. V12 stated she did not assist with the transfer from her wheelchair to the bed. V12 stated when the ambulance personnel arrived, she was called to the room. V12 stated R1's legs were uncovered, and her left leg was turned to the side and touching the bed (externally rotated.) V12 stated, .it didn't look right. V12 stated the right leg was externally rotated as well; however, at the time she believed it was due to R1's stroke and her right side being the affected side. V12 stated she had not noted or assessed for external rotation prior to R1's transfer. V12 stated she has worked at the facility for [AGE] years and has not aware of R1 ever having a fall. V12 stated R1 never attempts to get up without assistance. On 9/6/22 at 1:35 PM, V15 Orthopedic Surgeon stated R1 had sustained 4 fractures in total: left femur, right femur, right tibia (shin), and right humerus (right upper arm bone.) The facilities working schedule for R1's floor showed V10, and V11 Certified Nursing Assistants (CNA) worked a double shift from 3:00 PM on 8/29/22 until 7:00 AM on 8/30/22. The schedule showed V10 and V11 were the only assigned CNA's to R1's floor during that time period. On 9/2/22 at 2:25 PM, V10 stated when she arrived for her shift on 8/29/22 R1 was already in bed, and per R1's preference, R1 was not transferred out of bed until 5:30 AM on 8/30/22. V10 stated V13 RN had assisted with the transfer the morning of 8/30/22. (On 9/6/22 at 3:10 PM, V10 retracted this statement and stated V11 had assisted with the transfer.) V10 denied any incident with R1 during her shift. On 9/2/22 at 2:55 PM, V11 stated she was assigned to the opposite side of R1's floor. V11 stated she did not see R1 until after dinner that evening. V11 stated she assisted with R1's transfer the morning of 8/30/22. V11 denied knowledge of any incident occurring during her shift starting on 8/29/22. V11 stated she was 100 percent certain V13 RN assisted with R1's transfer as well as V10 on 8/30/22. V11 stated she is not aware of R1 ever having a fall; if R1 fell , she would not be able to get up on her own; and R1 does not attempt to transfer herself. On 9/1/22 at 12:05 PM, V13 stated R1 had no issues during the night that she was aware of. V13 stated R1 was in her wheelchair at 6:30 AM when she passed R1 her morning medication. V13 stated R1 was at her baseline. V13 stated she was certain she did not assist with R1's transfer the morning 8/30/22. The facilities working schedule showed V7, V8, and V9 were the day shift CNA's assigned to R1's floor on 8/30/22. The schedule also showed V12 was R1's nurse. On 9/1/22 at 11:45 AM, V9 CNA stated .She (R1) was already up when I punched in at 7:00 AM. (V12) came up to me right after I punched in, and she said she (R1) looked pale and wanted to go to bed. She's not normally a good eater but she will eat something, that day she ate nothing (for breakfast.) I went right to (R1's) room. She was crying. She does a lot of crying, especially when she wants to go to bed, but that day she was in pain and crying more than usual. I asked her if she was having pain and she shook her head yes. I didn't ask her where the pain was, but she would not have been able to tell me if I did ask her. I put her in bed with (mechanical lift.) Normally she will move a lot during the transfer but that day she wasn't, and she was crying even more during the transfer which made me think she was having pain during the transfer . V9 denied any incident or falls during his time with R1 on 8/30/22. V9 stated R1 does not attempt to get up on her own; he has never known R1 to fall; and if R1 fell she would not be able to get up without assistance. On 9/1/22 at 1:00 PM, V8 CNA stated she assisted with the transfer of R1 from her wheelchair back to bed on the morning of 8/30/22. V8 stated, .She (R1) complained of pain but didn't say where the pain was .she was more pale that morning . On 9/1/22 at 11:38 AM, V7 CNA stated the morning of 8/30/22 he notified V12 that R1 appeared pale. V7 stated, She (R1) knows better than to get up on her own . On 9/6/22 at 1:35 PM, V15 Orthopedic Surgeon stated when he assessed R1 he noted the right leg was swollen in addition to the left leg. V15 stated, R1 was found to have two fractures in the right leg. V15 stated, R1 also had significant bruising to her right arm and imaging of that arm showed a fourth fracture of the humerus bone. V15 stated, I'm pretty certain these fractures were not due to her pathology (her diagnoses.) I could see maybe one fracture but not that many all at once. They are all acute (recent) fractures, I would say they occurred within a week of me seeing them. I don't really see a way that she could have had these fractures without having pain from the moment she got them. She does have some [CONDITION(S)] (weakening of the bone) but these fractures are not due to her pathology. V15 stated that if R1 is unable to put herself back in bed after a fall and she is unable to transfer herself, I cannot imagine any way that she would have caused these injuries to herself, and I cannot imagine a way that these injuries occurred outside the presence of staff. V15 stated, We see this many and types of fractures on people that are in bad automobile accidents or falls from great heights, given her age it would not have needed to be that severe but would have been due to trauma. Maybe a fall from a wheelchair. It could have been a drop from a [mechanical crane type lift], if the [lift] was high enough .these injuries would have been painful from the moment they occurred. V15 stated, R1 could not have sustained this many injuries during a normal and safe transfer. The facilities Monitoring Flow Sheet for Incidents showed from 6/3/22 through 8/30/22 no documented falls for R1. R1's Nurses Notes from 4/23/22 to 8/30/22 showed no documented falls. R1's 8/23/22 weekly skin assessment showed, skin intact. R1's August Medication Administration Record showed no documented pain for the month. R1's as needed pain medication, acetaminophen, was not documented as being given for the month of August.

Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was supervised while seated in a shower chair for one of three residents reviewed for falls in the sample of three. This failure resulted in R2 falling from the shower chair sustaining sutures to her forehead. The findings include: R2's computerized face sheet showed [DIAGNOSES REDACTED]. R2's facility assessment dated [DATE] showed R2 is severely cognitively impaired and requires total staff assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The assessment also showed R2 has both upper and lower body impairments. On 3/10/21 at 11:00 AM, R2 was lying in bed and lightly sleeping. R2 had yellowish-purplish bruising around both of her eyes and they were swollen shut. The left eye bruising was the size of a golf ball. R2's right eye bruising was completely covering the eye and extending up into her forehead, covering an area the size of a soda can. R2 had multiple stitches over the right eye in the shape of a letter L, which was the size of a large egg. The stitches had dark, black scabbing over them. R2 moaned softly when spoken to but was unable to speak clearly, or understand questions. V1 (Director of Nurses) was present in the room and lifted R2's bedding to expose her legs and abdomen. R2 began suddenly shaking and trembling in her arms and legs. V1 stated, Yes that is normal for her. She routinely has tremors due to her [MEDICAL CONDITION]. R2's tremors continued throughout the entire observation. On 3/10/21 at 10:00 AM, V3 (Licensed Practical Nurse) stated R2 is bed bound, non-verbal, and not alert to her surroundings. V3 said R2 has tremors that come on sudden and quick. V3 said R2 should be continually supervised if she is not lying down in bed or reclined in a high back wheelchair. V3 said R2 has no upper body trunk control and is non-weight bearing. On 3/10/21 at 11:20 AM, V4 (Certified Nurse Aide) stated she was working the 11 PM to 7AM shift the morning of 3/6/21. V4 said R2 was transferred into a shower chair next to her bed at around 6:45 AM. V4 said she left the resident room to pick up clean linens. V4 said when she returned R2 was lying face down on the floor and bleeding from her head. V4 said R2 shakes a lot and it has been increasing lately. V4 said the shaking especially increases during cares and when medications are given. V4 said R2 needs full care and a lot of supervision. R2's local hospital emergency room medical record stated, (R2) brought in by EMS from nursing home for unwitnessed fall. Per EMS, patient was found on the floor. Patient hit the corner of the dresser and sustained [MEDICAL CONDITION]. The emergency room record stated, first assessed on 3/6/21, present on hospital admission, right forehead anterior, full thickness laceration. R2's facility re-admitting assessment dated [DATE] showed, 3/6/21 s/p (status [REDACTED].#8 sutures (eight). The facility's undated Falls Prevention Policy states, It is our goal to promote resident safety, and independence and to prevent the life threatening dangers of falls.

Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding isolation of new admissions and re- admissions to the facility that were under investigation for possible exposure to COVID-19 for four of four residents (R191, R291, R1, R50) reviewed for transmission based precautions in the sample of 18. This failure has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on February 25, 2021 when R191 was admitted to the facility and not placed on transmission-based precautions. The Immediate Jeopardy was identified on 3/1/2021. V1 Administrator was informed of the Immediate Jeopardy on 3/3/21. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/3/21; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R191's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/1/21 there was no transmission-based precautions sign nor was there any PPE (Personal Protective Equipment) near the room. There were no orders for transmission-based precautions. 2. R291's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for transmission-based precautions. On 3/1/2021 at 9:32 AM, V2 DON (Director of Nursing) said (R291) came to the facility last night. We need to set him up for quarantine. There was no sign on the door to indicate any transmission-based precautions on R291's bedroom door, nor was there any PPE near his room. At 10:17 AM on 3/01/21, V6 CNA was in R291's room making his bed. R291 did not have a mask on. V6 had a face shield and KN95 on while in R291's room. V6 did not have a gown on. On 3/1/21 at 11:45 AM, there was a contact precaution sign on R291's door but no PPE was visible. 3. R1's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nurse's notes dated 2/24/21 show R1 went out to the hospital via ambulance for chest pain. R1's Nurse's Admitting Assessment shows R1 was readmitted to the facility on [DATE]. There are no orders for transmission-based precautions. On 3/1/21 there was no transmission-based precautions sign nor was there any PPE (Personal Protective Equipment) near the room. 4. R50's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse's notes dated 2/26/21 at 6:30 PM shows R50 was transferred to the local hospital via ambulance. R50 returned to the facility on [DATE] at 1:00 AM. R50's Lab Reports shows he was last tested for Covid-19 on 1/28/21. There are no orders for transmission-based precautions. On 3/1/21 there was no transmission-based precautions sign nor was there any PPE (Personal Protective Equipment) near the room. On 3/1/2021 at 9:39 AM, V4 RN (Registered Nurse) said there were no residents that were on transmission-based precautions on her floor. At 9:45 AM, V5 CNA (Certified Nursing Assistant) said there were no residents on transmission-based precautions on her floor. At 9:50 AM, V3 ADON/IP (Assistant Director of Nursing/Infection Preventionist) said there currently were no residents on transmission-based precautions and the newest admission was (R191). On 03/01/21 at 11:04 AM, V6 CNA said if a resident is on isolation, staff should be wearing gowns, shoe coverings, face shield, and gloves. On 03/02/21 at 9:03 AM, V3 said people under investigation (PUI) means a resident is showing signs and symptoms of COVID-19. V3 said they have never put new admissions or re-admissions on transmission-based precautions. They are placed on observation only which means staff observe them for any signs and/or symptoms of COVID-19. V3 stated the facility usually tests the residents for COVID-19 upon admission. V3 said if a readmitted resident gets tested negative for COVID-19 in the hospital, then they are not placed on transmission-based precautions. V3 said R191 was admitted on [DATE] but not tested until 3/1/21; R291 was admitted on [DATE] but not tested until 3/1/21, R1 was tested for COVID-19 at the hospital on 2/24/21 but was not readmitted to the facility until 2/26/21, and R50 went to the local emergency roiagnom on [DATE] but was not tested for COVID-19 at the hospital nor at the facility. R191, R291, R1, and R50 were never placed on transmission-based precautions upon admission or re-admission. The facility's Admissions of Residents during the COVID-19 pandemic policy effective 4/17/2020, shows all hospitalized patients should be assessed for COVID-19 prior to transfer to a skilled or intermediate care facility. If a test is not indicated per CDC testing criteria, and the patient has no clinical concern for COVID-19, new and returning residents may be discharged to a skilled long-term care facility. However, the facility needs to put the resident on droplet/contact precautions for 14 days. The Centers for Disease Control Preparing for Covid-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions updated 11/20/2020 shows, HCP (Healthcare personnel) should wear an N95 or higher-level respiratory, eye protection, gloves, and gown when caring for new admissions and readmissions. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. The Post Vaccine Considerations for Residents update on 12/13/2020 shows, Because information is currently lacking on vaccine effectiveness in the general population; the resultant reduction in disease, severity, or transmission; or the duration of protection, residents and healthcare personnel should continue to follow all current infection prevention and control recommendations to protect themselves and others from [CONDITION(S)]-COV-2 infection, regardless of their vaccination status. 2. On 03/01/2021 at 9:47AM, V4 (RN) Registered Nurse was wearing a N95 mask over a surgical Mask. V4 RN was the nurse for R1 and R291 a new admission. At 11:14AM, V15 Activity Aid was wearing a surgical mask under a N95 mask. On 03/01/21 at 9:47AM, V4 RN said, we have in-services on PPE, and we do return demonstration in front of V3-Infection Control Nurse. We were not fit tested for the N95 masks. I heard a news media policy that said we should double mask. On 03/01/21 at 11:14AM, V15-Activity Aid said, I was trained by the CNA-Certified Nursing Assistant manager and the Director of Activities on proper PPE use. 03/03/21 at 10:49 AM, V3 -Infection Control nurse said, wearing a surgical mask under a N95 mask could impair the fit of the N95 mask. The facility's undated policy PPE donning/doffing options for LTCFs during Cluster of COVID-19 Infections shows, if using a respirator, perform a Seal Check. The manufacturers N95 Direction for Application dated 12/11/2019 shows, a pictorial demonstration of the N95 mask application showing the mask being applied to a bare face that is absent of facial hair or a mask. The explanation for Figure 10 shows, continue to adjust the respirator and secure the edges until you feel you have achieved a good facial fit. Now perform a Fit Check. Check FACIAL SEAL to assure proper fit, adjust nose piece if there is air leakage around the nose. Reposition head bands to secure FACIAL SEAL around edges of respirator. Before use, the wearer must be trained by the employer in proper respirator use in accordance with applicable safety and health standards. Intended Use: N95 Particulate Filter Respirator and Surgical Mask is intended for use by operating room personnel and other health care workers to protect both patients and health care workers from transfer of microorganisms, blood and body fluids and airborne particulate materials. Follow all instructions and warnings on the use of this respirator, obtain a PROPER FIT, and wear during all times of exposure. Failure to do so will reduce respirator effectiveness and user protection and may result in sickness or death. The Immediate Jeopardy that began on February 25, 2021 was removed on March 3, 2021, when the facility took the following actions to remove the immediacy: 1. Revised admission policies and procedures to ensure all new admissions, hospital and emergency room returns, will be quarantined and proper PPE will be worn by staff when caring for these residents. 2. PPE equipment was placed outside of rooms for residents on quarantine/isolation. 3. In-servicing will be done by the Director of Nursing for all staff on: proper resident co-horting, proper use of PPE, and education on what residents are required to be on quarantine according to the CDC guidelines. This will begin immediately, and no staff will be allowed to work until this is completed. 4. All staff will be in-serviced by the DON and Administrative Assistant on proper PPE usage with required return demonstrations from staff. This will begin immediately and will be expected to be completed for all staff by March 10, 2021. Random spot checks will be done on every shift daily by the DON. 5. The DON and Administrative Assistant will monitor the CDC website daily for any changes needing to be implemented to facility policy and procedures and staff will be informed of all changes.

Based on observation, interview and record review the facility failed to supervise R1 who is high risk for elopement. The facility failed to ensure corridor doors and exit doors were alarmed and functioning. The facility failed to accurately assess a resident at risk for elopement and have staff knowledgeable in elopement risk precautions. These failures contributed to R1 leaving the dementia unit and premises, unknown to staff for a period of approximately three hours on (MONTH) 3, 2019. R1 was found by a passersby when she fell on a busy 4 lane highway, 0.4 miles from the facility. These failures resulted in an immediate jeopardy. The immediate jeopardy started on (MONTH) 3, 2019, when R1 eloped from a locked dementia unit and off the premises without staff knowledge. On (MONTH) 16, 2019, V1 Administrator was informed of the immediate jeopardy. The immediacy was removed on (MONTH) 16, 2019. While immediate actions were taken by the facility, the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 7 residents (R1) reviewed for safety and supervision in the sample of 7. The findings include: 1. R1's face sheet shows she was residing on a locked dementia unit on the second floor. The face sheet lists [DIAGNOSES REDACTED]. R1's incident report dated (MONTH) 3, 2019 at 3:00 PM shows, police stated the resident (R1) was seen by two co-workers trying to cross the street. The drivers (concerned citizens) stopped, after they saw R1 fall in the street, and called 911. The facility's incident report statement from V18 activity staff dated (MONTH) 3, 2019 shows, after V18 activity staff got off work and was driving home she saw police blocking the roadway at 43 &[NAME]Avenue. She saw R1 with the police officer and paramedics. V18 called the facility and spoke with V6 Activity Director and told her what was happening. V6 told her to stop and go tell the police officer that R1 belongs at the facility. V18 did that and then remained with R1 to translate for her. She asked her if she had any pain or injuries. R1 told her she was fine. V18 did see some light bleeding on R1's face. The local hospital's emergency department history of present illness form for R1 dated (MONTH) 3, 2019 shows, Patient is an [AGE] year old female, history of dementia, hypertension, [MEDICAL CONDITION], presenting brought in by emergency medical services after eloping from nursing home, wandering the street. Patient was last seen at 12 noon, was found in street at 2:54 PM . The local fire department report for R1 dated (MONTH) 3, 2019 shows, local ambulance was called for an [AGE] year old female who had fallen. Upon arrival the patient was on the side of the road with good Samaritans and local sheriffs that had helped the patient out of the road way. The police told crew that the patient had fallen in the middle of the road when witnesses stopped to help her out of the road, witnesses told crew that patient was walking across the road when the patient fell then they had helped her across the road, they held up patient (R1) due to her having weakness. Patient (R1) assessed and moved to stretcher, she did not speak English. Patient did have an abrasion to her left cheek, a laceration to her upper and lower left side of lips as well as left hand and knee pain. A worker (activity staff) from nursing home which the patient had left stopped and told crew where she was from and that the patient has dementia. The patient was from facility and was supposed to be unable to leave the facility on her own. Crew made contact with nursing home which supplied the patient's information and sent interpreter with patient . The local hospital's history and physical dated (MONTH) 4, 2019 for R1 shows, Chief Complaint: Facial injury and confusion. History of present illness: R1 is a [AGE] year old female who has a past medical history of [REDACTED]. She speaks only Korean and speaks it very fast per interpreter however she is very confused but at her baseline per son who was present only temporarily at the bedside. While in ED she was noted to have facial injury c/o (complained of) mild amount of periorbital ecchymosis to the left cheek as well as a small abrasion. On (MONTH) 5, 2019 at 11:13 PM, V13 Receptionist stated, he saw R1 downstairs on (MONTH) 3, 2019 around 12:25 PM. He tried to explain to her that she needed to be upstairs but because R1 is Korean speaking, she did not understand him. He put her in the elevator alone and sent her back upstairs. V13 said he called the nurse on the second floor (V7 Licensed Practical Nurse) and told him that R1 was coming back upstairs on the elevator alone. This was the last time he saw R1 at 12:25 PM. This was the second time she had come downstairs that day. V13 stated the first time R1 came down stairs was around 10:00 AM and (V14 Human Resources) saw her at that time and took her back upstairs. He stated, some of the residents went out on an outing with activities. I saw them (the other residents) coming back from the activity. I didn't see her at that time. If I saw her I would have stopped her. I know she is one that is trying to leave. On (MONTH) 10, 2019 at 4:11 PM, V2 Director of Nursing stated, V13 Receptionist should not have put R1 in the elevator alone. He should have called for someone to go with R1 back upstairs. On (MONTH) 5, 2019 at 11:31 AM, V14 Human Resources stated, I took her (R1) back upstairs in the morning around 9:00 AM on (MONTH) 3, 2019. She came down here. I was sitting at the receptionist desk at the computer and saw her. I followed her and asked, Where are you going? and she said she was going to her son's house. I told her he was on his way here and that it was kind of chilly outside. Then I took her back upstairs. The day before, Monday (September 2, 2019) she (R1) came down here and was really upset. She was walking really fast, so I went out with her and walked with her down the street. Then I brought her back to the facility and took her back upstairs. V14 stated, she didn't know how R1 was getting downstairs, the elevator, I think? On (MONTH) 5, 2019 at 9:30 AM, V7 Licensed Practical Nurse (LPN) stated, the staff told me R1 was a wanderer and had a history of [REDACTED]. On (MONTH) 3, 2019, R1 was seen by two drivers trying to cross the 4 lane busy highway. R1 tripped and sustained bruises to her left eyebrow and upper lip. The police came. I am not sure how R1 got off the unit. Around lunch time, V13 receptionist called him and said he was sending R1 upstairs from the first floor in the elevator alone. He told V17 Certified Nursing Assistant (CNA) to get R1 off of the elevator. On (MONTH) 9, 2019 at 10:08 AM, V17 CNA stated, on (MONTH) 3, 2019 V7 LPN told him that R1 was coming back up on the elevator. He stated he got R1 off the elevator and put R1 back on second floor. That was the last time he saw R1. V17 CNA said that he told V7 LPN that R1 was not at the noon meal. V7 LPN told him, R1 went out to Walmart with activities. On (MONTH) 5, 2019 at 11:37 AM, V6 Activity Director stated, I told V1 administrator, V2 Director of Nursing (DON), and V11 dietary manager on (MONTH) 3, 2019 which residents were going out on an outing and won't have lunch here. V7 LPN is a new nurse here and he doesn't know that the dementia unit residents do not go out on outside activities. On (MONTH) 5, 2019 at 10:58 AM, V3 Assistant Director of Nursing (ADON) stated, The resident (R1) got out on (MONTH) 3, 2019 and nobody really knew. V3 said that she thought R1 could have gotten out of the building by the backdoor by the laundry room which was not alarmed or R1 went out the front door. That day we had an activity outing and I don't know if R1 went with them. V3 stated, R1 had gotten out of the building before and normally we get R1 before she leaves the parking lot. On (MONTH) 5, 2019 at 9:40 AM, on the second floor, the corridor door on the south hallway that leads to a stairwell, had a locked linen cart pushed in between the door frame. V2 DON stated, I don't know why the cart was in front of the door. V2 moved the linen cart and opened door. The alarm did not sound. This door opens to a stairwell which goes down to the first floor. One door opens directly outside to the front of the building and another door to the first floor hallway. The stairwell continues on down into the basement. V2 called for V8 maintenance to help with the door alarm. He confirmed the door alarm was not working. V8 stated, the residents on the second floor continually open that door and may have worn out the batteries on the alarm. The facility's alarm door random checklist taped on the door documents the door was last checked on (MONTH) 18, 2019 and that the door was working. V8 stated he checks the doors weekly but confirmed that (MONTH) 18, 2019 was the last time he checked the door alarm. On (MONTH) 5, 2019 at 10:27 AM, in the basement, the back door by the laundry room did not alarm when the door was opened. This doorway leads to the parking lot on the side of facility and to the front of the building. On (MONTH) 5, 2019 at 10:32 AM, V9 dietary staff stated, he worked in laundry on Tuesday (MONTH) 3, 2019 when R1 eloped from the building. He turned the alarm off (the back door by the laundry room) because a delivery was coming. It's normal to leave the door unalarmed because of deliveries. He stated, he never turned the alarm back on after the delivery. On (MONTH) 5, 2019 at 11:45 AM, V11 dietary manager stated, on (MONTH) 3, 2019 he was at the front desk/reception area and saw United Parcel Service go to the back of the building. I called V9 and told him to unlock the door. He stated that was around 1:00/1:15 PM. He added, V9 never re-set the alarm after the delivery. R1's nursing notes on (MONTH) 7, (MONTH) 10, (MONTH) 11, (MONTH) 19, and (MONTH) 21, 2019 shows, R1 making multiple attempts to get into the elevator. On (MONTH) 10, 2019 R1 opened the south hallway door on the second floor. R1's nursing elopement risk assessment dated (MONTH) 20, 2019 shows, R1 is not at risk for elopement. R1's social service elopement risk assessment dated (MONTH) 27, 2019 shows, she is a moderate risk. Resident has dementia [DIAGNOSES REDACTED]. She has the potential risk for elopement. Requires a 24-7 supervision and assistance at this time. The care plan for R1 dated (MONTH) 20, (YEAR) shows, Focus: The resident has a communication problem r/t (related to) language barrier. Has poor comprehension. Has confusion. Primary language is Korean. The care plan for R1 dated (MONTH) 27, (YEAR) shows, Focus: The resident is an elopement risk/wanderer r/t disoriented to place, history of attempts to leave facility unattended, impaired safety awareness. Paces on unit and will attempt to follow the visitors into the elevator. On (MONTH) 9, 2019 at 12:25 PM, V19 primary care physician for R1 stated, R1 has dementia and she doesn't make good choices regarding her safety. On (MONTH) 5, 2019 at 12:30 PM, R1 returned to the facility from the hospital after eloping from the facility on (MONTH) 3, 2019. She was walking independently in her room, making her bed. She had an abrasion on her swollen left eye. Her left upper lip was swollen with an abrasion. There was bruising to both of her arms and hands. With an interpreter this surveyor asked R1 how she got her bruises on her arms and her face. R1 stated, no idea. On (MONTH) 5, 2019 at 12:30 PM, V5 CNA working on the second floor dementia unit, was only able to identify 3 out of 7 residents identified as high risk for elopement. The facility's exit doors policy (no date) shows, Policy: It is the policy of this facility to maintain resident and employee safety. Exit doors are to be monitored or alarmed at all times. Procedure: 1. All exit door are to be alarmed or monitored at all times. 2. Alarms on all outside doors other than the front door and the kitchen/service door are to be on at all times. Alarms may be temporarily disarmed in order to use exit doors for entrance or discharge from the facility if personnel are present to monitor the door. Through observation, interview and record review on (MONTH) 16, 2019 the surveyor confirmed the facility took the following actions to remove the immediacy. 1. The facility policy on Elopement Risk was reviewed and revised on (MONTH) 5, 2019. The elopement risk assessment will be completed on admission, quarterly, and when the resident has a change in condition. 2. In-service training on elopement risk policy and procedures began on (MONTH) 5, 2019 and continued through completion on (MONTH) 16, 2019. All staff including nursing, administration, front desk reception, dietary, activities, housekeeping, maintenance and laundry were included. Any staff who were not in attendance for any reason will not be allowed to return to work until they have completed the training. This training was presented by nursing administration. 3. On (MONTH) 16, 2019 all residents identified as at risk were reviewed and the elopement book was updated. Residents identified as at risk have had monitoring interventions on their care plans based on their risk assessment identifiers. 4. On (MONTH) 16, 2019 the facility put into place a monitoring check flowsheet for R1. This will be continued for 1 month to determine a pattern of behavior. R1's careplan interventions were updated based on her elopment risk behaviors. 5. The second floor South door alarm was fixed and re-alarmed on (MONTH) 5, 2019 after becoming aware the alarm was not functioning. The Maintenance Director is responsible to check all alarmed doors at the start and finish of his shift. 6. On (MONTH) 16, 2019 the Kitchen staff were educated regarding the receiving door next to the kitchen must be reset any time a delivery is received. The staff who open the door for the delivery will be responsible to ensure the door is reset and armed after the delivery is complete.

Based on interview and record review the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) when a resident (R1) had no vital signs or respirations. The facility failed to ensure staff could identify a residents' code status. The facility failed to verify the presence of a resident's (R1) advance directives. The facility failed to ensure nursing staff were certified in CPR. The facility failed to ensure a resident's advance directives matched a resident's physician order (R10-R14). These failures contributed to a delay in cardiopulmonary resuscitation (CPR) due to staff being unable to quickly verify R1's code status, on (MONTH) 30, 2019, after R1 sustained an unwitnessed [MEDICAL CONDITION]. R1 was hospitalized and subsequently expired on (MONTH) 4, 2019. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 30, 2019 at 7:20 PM when CPR was not immediately initiated on R1 after R1 was found pulseless and not breathing by facility staff. On (MONTH) 22, 2019 at 9:30 AM, V1 Administrator was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 24, 2019. While immediate actions were taken by the facility, the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 6 of 8 residents (R1, R10, R11, R12, R13, R14) reviewed for advanced directives in the sample of 17. The findings include: R1's Admission Record printed (MONTH) 16, 2019 showed R1 was initially admitted to the facility on (MONTH) 17, 2014 with a readmitted (MONTH) 11, (YEAR). R1's Care Plan dated (MONTH) 3, (YEAR) showed R1 had no advanced directives. R1's Physician Order Sheet dated (MONTH) 1, 2019 showed R1 was a Full Code. R1's Nurse's Note dated (MONTH) 30, 2019 at 7:00 PM showed R1 was eating dinner in her room. At 7:20 PM, R1 was found unresponsive by staff, not breathing and with no pulse, in her room. This nurse's note showed CPR (cardiopulmonary resuscitation) was not initiated by staff on R1 until 7:25 PM, five minutes after R1 was found pulseless and not breathing. R1 was transferred to a local hospital via ambulance at 7:50 PM on (MONTH) 30, 2019. On (MONTH) 16, 2019 at 4:00 PM, V11(POA/power of attorney for R1) stated, After the incident (on (MONTH) 30, 2019), (R1) never returned to the facility. She never regained consciousness. She had no brain activity and couldn't breath off the ventilator so we took her off the ventilator on (MONTH) 4 (2019) and she died . R1's Ambulance report dated (MONTH) 30, 2019 showed upon arrival of the ambulance crew at the facility, R1 was unresponsive with CPR in progress. This report showed, Patient had obvious airway obstruction with food in her airway . R1's Hospital Record dated (MONTH) 1, 2019 showed, Patient is a [AGE] year old female who was admitted post [MEDICAL CONDITION]. Now intubated in the ICU (intensive care unit). EEG (echoencephalograph/study for brain activity) has shown generalized slowing and is consistent with severe generalized [MEDICAL CONDITION] with minimal activity .Likely an [MEDICAL CONDITIONS] .Patient remains unresponsive. Patient at this time is not responding to stimuli, has fixed and dilated pupils, and has no reflexes .there is no meaningful activity on EEG . R1's Hospital Record dated (MONTH) 4, 2019 showed, Family meeting with POA (power of attorney) and medical staff held .Plan for terminal extubation today. On (MONTH) 16, 2019 at 12:30 PM, V12 Certified Nursing Assistant stated on (MONTH) 30, 2019, she entered R1's room and found R1 unresponsive. V12 stated, (R1) was pale and her eyes were closed. I shook her and she didn't respond. I didn't check for a pulse or if she was breathing. I ran out of the room, down the hall, to the nurse's station to get the nurse. I didn't think about checking for a pulse or starting CPR on (R1). I just wanted to get the nurse. I was scared. I froze . V12 CNA stated, It was about ,[DATE] minutes from when I found (R1) like that and the nurse (V13) came in. V12 CNA also stated she was CPR certified. On (MONTH) 16, 2019 at 3:00 PM, V13 Registered Nurse (RN) stated on (MONTH) 30, 2019, he was at the nurse's station when a CNA came to get me about (R1). I went into (R1's) room, she had no pulse and wasn't breathing. She was blue. She had food on her gown and under her chin. When V13 was asked why CPR was not initiated immediately on R1, V13 stated, I didn't know if she was a full code or not so I left the room. I went back to the nurse's station to check (R1's) chart. No one had started CPR on (R1) yet. I went through her chart and couldn't find an advanced directive or the POLST (Physician Order's for Life Sustaining Treatment) form which is usually in the front of the chart. I looked through her physician orders and saw the order for a full code. I called a code blue over head, ran back to R1's room and staff started CPR on her . On (MONTH) 16, 2019 at 1:40 PM, V5 Registered Nurse (RN) stated on (MONTH) 30, 2019, she did CPR on R1 after she (R1) had choked. V5 stated, When I entered (R1's) room, no one was doing CPR or the [MEDICATION NAME] on (R1). She had food coming out of her mouth and on her gown. I opened her mouth and pulled food out of her mouth. She didn't have a pulse. I heard the code blue page overhead. As (V13) came running back into the room, I started CPR I don't know why CPR wasn't started right away on (R1) . On (MONTH) 16, 2019, V5 RN and V13 RN each stated there was no quick way to identify which residents were full codes versus DNR's (do not resuscitate) at the facility. V5 RN and V13 RN each stated if they were unsure of a resident's code status, they would have to look in the resident's written medical record, kept at the nurse's station, for verification. On (MONTH) 18, 2019 at 10:30 AM, V3 Assistant Director of Nursing (ADON) stated, We have no quick way to identify residents that are full codes versus DNR's. There is nothing in the resident's rooms to quickly identify this. The nurse would have to go to the nurse's station and look in the chart for a DNR sticker and the POLST form. On (MONTH) 16, 2019 at 11:25 AM, V3 ADON and V4 Nurse Consultant each stated if a resident is a full code (not a DNR), CPR should be started immediately if the resident is pulseless and staff should yell for help. On (MONTH) 22, 2019 at 9:15 AM, V3 ADON stated, All nursing staff which includes nurses and CNAs are to be CPR certified. If a CNA finds a resident pulseless and not breathing, they should yell for help and start CPR immediately. On (MONTH) 18, 2019 at 10:05 AM, V16 Physician stated, Residents that are found pulseless and apneic (not breathing) should have CPR started on them immediately if they are a full code. Any delay in CPR can cause an increase in morbidity and mortality. A delay can lead to an increase in bad outcomes which can include an [MEDICAL CONDITIONS] or never getting a pulse back. On (MONTH) 16, 2019 at 11:25 AM, V3 ADON and V4 Nurse Consultant each stated they were unable to find a POLST form in R1's medical record. V3 ADON stated, Our social services makes sure the POLST form gets completed as soon as possible once a resident is admitted and puts them in the chart. On (MONTH) 16, 2019 at 4:00 PM, V11 (POA for R1) stated, I was never asked to sign any advanced directive forms for (R1). When (R1) was admitted to the facility years ago, she was of sound mind so I advised them to speak with her. She wanted to be a full code, not a DNR. When she was readmitted last fall (2018), I was contacted by someone at the facility, I don't remember her name, and was told we needed to discuss (R1's) code status. I again asked for her to speak with (R1) about this and said we can all talk about this the next time I visited with (R1). No one ever brought this up to me again or approached me about signing any advanced directive forms when I was at the facility. I was never emailed any advance directive forms to sign. On (MONTH) 17, 2019 at 8:00AM, V15 Social Services stated, I don't know why a POLST form was never completed on (R1). We start trying to get the POLST forms completed as soon as possible after a resident is admitted . We want to get the advanced directives confirmed immediately so if the resident is cognitively intact, we approach the resident and have them sign the form. If they aren't, we approach the POA to sign the form. R1's Social Service note dated (MONTH) 5, 2019 showed, Resident has POAHC (power of attorney for health care/V11). This writer left a voicemail for POAHC to educate on POLST form. When V15 Social Services was asked if she followed up with V11 (R1's POA) regarding the voicemail left for V11 on (MONTH) 5, 2019, V15 stated, I'm not sure. R10's Admission Record printed (MONTH) 24, 2019 showed R10 was admitted on (MONTH) 21, (YEAR) and listed no code status for R10. The facility's No POLST List dated (MONTH) 24, 2019 showed R10 had no completed POLST form in his chart. R10's Physician Orders dated (MONTH) 1, 2019 showed no physician order for [REDACTED].>R11's Admission Record printed (MONTH) 24, 2019 showed R11 was admitted on (MONTH) 26, (YEAR) and listed R11 as a DNR. R11's Physician Orders dated (MONTH) 1, 2019, showed R11 was a full code. R12's Physician Orders dated (MONTH) 1, 2019 showed R12 was admitted on (MONTH) 19, 2019 and R12 was a full code. R12's POLST form dated (MONTH) 27, (YEAR) showed R12 was a DNR. R13's Physician Orders dated (MONTH) 1, 2019 showed R13 was admitted on (MONTH) 17, (YEAR) and R13 was a full code. R13's POLST form dated (MONTH) 14, (YEAR) showed R13 was a DNR. R14's Physician Orders dated (MONTH) 1, 2019 showed R14 was admitted on (MONTH) 12, (YEAR) and R14 was a full code. R14's POLST form dated (MONTH) 4, (YEAR) showed R14 was a DNR. On (MONTH) 24, 2019 at 10:30 AM, V2 DON stated she did not know why R10-R14's POLST forms were missing or not matching each residents physician orders. V2 stated, Social Services does the POLST forms. I should have made sure they were matching. V2 also stated the facility had no process in place to verify or check that each resident's POLST form and physicians order for advance directive matched. The facility Nurses Form 2019 and CNA Form 2019, both dated (MONTH) 24, 2019, showed V4 RN, V17 RN, V18 RN, and V,[DATE] CNA's had no valid CPR certification. On (MONTH) 24, 2019 at 10:24 AM, V2 Director of Nursing (DON) stated the facility had no process in place to ensure all nursing staff were current in CPR. V2 stated she was not aware there were facility nursing staff without current CPR certification. The facility's Cardiopulmonary Resuscitation (CPR) Policy dated (MONTH) 2010 showed, Cardiopulmonary Resuscitation (CPR) will be initiated on all patients, employees or visitors for whom this intervention is indicated. Cardiopulmonary Resuscitation will be initiated by any member of the Nursing Department who has been trained in this procedure. The facility's Advance Directives Policy dated (MONTH) 26, 2014 showed, Upon Admission: A. Designated staff will review Advance Directive options and the Statement on Illinois Law addressing Advance Directives and Life Sustaining Treatment with the resident and/or representative .An Advance Directive form (as provided by the healthcare facility) will be completed with resident and/or legal representative to verify treatment options as well as code status (full code vs. DNR using the POLST document) . The facility's CNA Job Description, RN Job Description, and LPN Job Description each dated (MONTH) 2019 showed each must have valid CPR certification. Through observation, interview and record review on (MONTH) 24, 2019, the surveyor confirmed the facility took the following steps to remove the immediacy. 1. The facility policy on Advanced Directive Life Sustaining Treatment and End of Life Care: Policy and Procedure was revised to immediately identify a resident's code status. The name tag on each resident's door was color coded to identify each resident's code status. For residents that are DNR, their door name plate is color coded in hot pink. For residents that are full codes, their name plate is color coded in white. a. Inservices began to educate all staff including nursing (nurses and CNAs), dietary, activities, and housekeeping on (MONTH) 23, 2019, on the revised policy related to Advanced Directive Life Sustaining Treatment and End of Life Care. The above staff will be in-serviced on the revised policy changes immediately, prior to providing patient care, via group in-service or one on one in-service, by nursing administration. This education will be completed by (MONTH) 3, 2019. 2. A new facility policy on POLST Form/Advanced Directives was established. This policy was created to ensure each resident has a completed POLST form along with a physician order to quickly identify a resident's code status. a. Effective immediately, the facility's Social Service Department is reviewing every resident's medical record to ensure each resident has a completed POLST form and a physician's order verifying each resident's code status. A review of every resident's medical record will be completed by (MONTH) 3, 2019, to ensure each resident has a completed POLST form with a matching physician's order to identify each resident's code status. b. Effective immediately, the POLST form will be part of a resident's admission paperwork. Social Services will be responsible for educating residents and families on the form. Social Services will be responsible for ensuring a POLST form is completed on each new resident within 2 weeks of their admitted . c. In-services began to educate all staff including nursing staff and social services on (MONTH) 23, 2019, on the new policy related to POLST Forms/Advanced Directives. The above staff will be in-serviced on the above policy changes immediately, prior to providing patient care, via group inservice or one on one in-service, by nursing administration. This education will be completed by (MONTH) 3, 2019. 3. Starting Monday, (MONTH) 29, 2019, nursing administration will randomly select 5 residents' charts to verify the presence of a signed POLST Form and a matching physician order on each resident's code status.

Based on observation, record review and interview the facility failed to thoroughly evaluate fall risk factors, develop a fall plan of care with specific and individualized interventions and have nurse call cord accessible and monitor a resident (R2) to prevent from falling when she was ambulating unassisted by staff. The facility also failed to ensure the toilet hand rail arm rests are not broken and free from potential for skin tear hazard. As a result R2 fell multiple times (2/19/13, 6/5/13 and 7/3/13). When R2 fell on [DATE], she sustained fracture of her right hip. This is for one of four residents in the sample of 18 residents evaluated for falls and six residents (R19 through R24) from out side of the sample whose toilet hand rail arm rests were broken with sharp edges exposed. Findings include: On 7/17/13 at 10:30 am R2 called / yelled with sounds that was in foreign language (Korean). The yelling was audible from the hallway where R2's room was. Upon entering R2's room, her nurse call cord was observed at the foot of the bed between side wall and her bed. The cord was too short for R2 to reach and call for help. R2 responded by pointing to her right hip with a grimace on her face. E10 (Nurse) came to interpret Korean for R2's expressions. R2 complained of pain to her right hip. E10 stated she would give R2 her pain medication. The facility documented the following falls for R2: (1) On 2/19/13 R2 was found lying face down with walker on top of her, not talking, speaks Korean, sustained 5 cm wide circle bump to forehead. There is no evaluation to show how R2 fell . The facility did not modify interventions to prevent future falls. The facility did not develop a fall care plan for R2 until 5/2/13. E2 (Director of Nurses) stated there may be a fall care plan in the thinned record, but did not present any fall care plan for review other than the one of 5/2/13. (2) On 6/5/13 at 9:50 pm R2 was found lying on the floor on her right side complaining of low back pain and right leg pain. On 6/6/13 at 8:50 pm the facility became aware of R2's X-Ray result, which showed she sustained fracture to her right hip and femur. The facility did not conduct a comprehensive evaluation to show why and how R2 fell . The intervention added to the plan of care was to use bed alarm during the night. (3) On 7/3/13 at 9:00 pm R2 was found on floor lying on her back, according to her room-mate she was trying to help her get on the wheel chair and R2 slid from the chair. There was no intervention to show how the facility will prevent such future occurrence. R2's fall risk evaluations ((3/7/13, 6/5/13 and 6/10/13) indicated she is at high risk for falls. The risk factors indicated in the evaluation are: Change in Mental Status, History of Falls, Age and Medications. The facility did not further evaluate these risk factors to develop fall prevention care plan with specific and individualized interventions. The facility undated fall protocol showed the comprehensive falls assessment must be done on every resident on admission and on readmission and after each fall. The facility did not follow their fall prevention protocol for R2's falls. R2's 5/2/13 fall prevention care plan interventions are not specific to the risk factors identified in the fall risk evaluation. The examples of non-specific interventions are: (a) Instruct resident to ask for assistance prior to attempting to transfer to walk. It is not clear how the facility will ensure R2 who has memory impairment will follow the instruction. On 7/18/13 at 2:05 pm R2 exhibited memory problems (could not recall incidents of falling, day or time of the day). (b) Place the call light within easy reach and encourage to use it prior to attempting to transfer or walk. R2's Nurse call cord was not accessible on 7/17/13 at 10:30 am and 7/18/13 at 11:30 am. On 7/18/13 at 12:15 pm E3 (Nurse) verified the Nurse call cord was at the foot of R2's bed. (c) make sure environment is free from hazard such as poorly arranged furniture. On 7/18/13 at 1:45 pm E2 stated R2 had cluttered furniture at the time of R2's fall on 6/5/13 and her extra furniture was sent to her home. This intervention was not noted in R2's plan of care. (d) Implement fall precaution procedures per protocol. The facility also did not follow their fall protocol by not conducting comprehensive evaluation of R2's fall and by not developing and implementing individualized and specific interventions to prevent and monitor R2 from falling. On 7/19/13 at 1:45 pm Z1 (Physician) stated R2 is non-compliant in seeking assistance. She (R2) thinks she can get up and walk and she also does not use the walker. Z1 also stated what you do under these circumstances, is to provide close supervision if not one to one monitoring. There was no documentation to show if R2 and her family were educated about the risks of unassisted ambulation. There is also no documentation to show if the facility educated staff about the extent of monitoring especially when R2 is non-compliant and speaks foreign language. On 7/18/13 at 2:00 pm during the environmental tour, the toilet hand rails plastic arm rests for the residents from R19 through R24 were cracked and sharp plastic edges were exposed. The toilet hand rail metal legs were two inches above the ground level. The cracked plastic arm rest on toilet hand rails has the potential to cause skin tears and or lacerations. The second floor dining room wall corner metal frame is exposed with sharp edges ten inches long. The exposure was at four feet above the ground level. Any one walking along the corner could get hurt from metal sharpness. E4 (Maintenance Director) stated he has to patch it. Resident's chairs movement must have scraped the metal frame.

A. Based on observations, interviews and record reviews, the facility failed to: -Identify and analyze all the risk factors and causes of residents' falls; -Monitor the effectiveness of the interventions and change the interventions as necessary to prevent recurrence of falls; -Provide adequate supervision/monitoring to prevent further falls. This applies to three of five residents (R1, R2 and R5) reviewed for falls in the sample 20. These failures resulted in R1 sustaining a subdural hematoma after experiencing a fall on 4/26/12. R2 sustained a hip fracture after a fall on 4/4/12 and, R5 was sent to the emergency room for evaluation of swelling about 9cm x 9cm with pain to the back of head after she fell backward on 3/11/12. Findings include: 1. R1's [DIAGNOSES REDACTED]. R1 is ambulatory. The fall risk evaluation dated 12/25/11 assesses R1 as "at risk for falls." Review of facility incident reports denote R1 having the following multiple falls: On 3/18/12-R1 noted sitting on the floor outside of her room. On the left side of her head was a "laceration 6 centimeters x 4 cm with moderate amount of bleeding from her head, bruise on bridge of nose and forehead." R1 alert and verbally responsive. R1 was sent to hospital and returned with staples to head. Care Plan interventions included: Hourly checks. On 4/6/12 at 7:55 AM "R 1 was found lying on the floor on her left side. Roommate stated she tripped on the roommates walker. Sustained a bruise on left cheek bone. R1 physician/family notified. Neuro checks were done. Corrective actions: Will monitor." On 4/6/12 at 9:00 AM, "R1 was found lying on the floor in the north hallway with slight nosebleed. Pressure applied and ice compress applied. Facility investigation denotes R1 was in dining room after breakfast and followed another resident out of the dining room. On 4/7/12 corrective actions chair alarm." Also on 4/6/12 at 9:20 AM, "R1 while being toileted by the staff, R1 stood up from the toilet and CNA was unable to catch her. R1 was sent out to hospital for evaluation and was admitted for hypotension and leukocytosis." Nurse notes dated 4/26/12 at 5:45 PM denote R1 was found walking in hallway by nurses station with hand behind head. Laceration noted back of head 4 cm long oozing blood. Taken to room. Pressure applied. Neuro checks taken PERL (pupils equal and reactive). Body check done skin intact, no bruises noted. Blood Pressure 130/70, heart rate 100, respiration 20. Motrin given for pain. R1 complain of pain to head in R1's native language. R1's physician was notified and R1 was sent out to hospital for evaluation and R1 was admitted to hospital with [DIAGNOSES REDACTED]. Incident report of 5/6/12, R1 was found laying on floor side of bed on right side. Bump noted right side of forehead. R1 did not require hospitalization . Incident report did not denote if bed alarm was on or sounded. Corrective actions included close monitoring of resident and Keep Bed/Chair monitor on at all times. On 6/11/12 at 11:15 AM, R1 was observed sitting in a chair off on the side of the dining room. There was no chair alarm in place, and only 1 staff member was present in the room during activities with 12 other residents. R1 was not in direct visual view of the staff person. 2. R2 is deaf and mute and has difficulty understanding, and is difficult to understand according to the 4/4/12 Minimum Data Sets (MDS) assessments. R2 also has poor vision according to the Vision Function care plan dated 4/7/12. R2 sustained a hip fracture following a fall at the facility on 4/4/12, according to documentation in the nursing notes dated 4/19/12. R2 was re-admitted to the facility on [DATE] status [REDACTED]. R2 was sent to the hospital and admitted with Syncope according to the nursing notes dated 5/4/12. R2 was re-admitted to the facility on [DATE] at 2:45 PM, and fell again at 3:20 PM, according to the nursing notes dated 5/8/12 (timed 2:45 PM and 3:20 PM). R2 fell again on 5/9/12 at 6:00 PM, according to the nursing notes dated 5/9/12. R2 fell again on 6/12/12 at 11:00 AM and sustained a cut to the bridge of his nose, according to the nursing notes. On 6/11/12 at 3:08 PM, R2 was sitting in his wheelchair in his room. R2's chair alarm was not attached to him. On 6/11/12 at 3:10 PM, E9 (CNA) stated that R2 knows how to un-clip his alarm. R2's Fall Risk care plan dated 4/7/12 denotes an intervention to apply chair-bed alarm. The care plan does not address R2's behavior of removing his chair alarm. The care plan also lists an intervention to conduct safety checks every hour. The facility's Resident Safety Check log (June 2012) lacks documentation that R2 was checked every hour on 6/12/12 between 7:00 AM and 3:00 PM. (R2 sustained a fall on 6/12/12 at 11:00 AM). On 6/13/12 at 2:15 PM, R2's Resident Safety Check log was reviewed. There was no documentation regarding R2's safety checks for the hours between 7:00 AM and 2:00 PM. On 6/13/12 at 2:30 PM, E2 (DON) stated that staff should document at the time that they checked R2 to insure his safety, not at the end of the shift. On 6/12/12 at 9:17 AM, R2 was in the physical therapy room in the lower level. R2 was seated on a chair and was using the pulley machine. Two other residents were using equipment in the room. No staff were present in the room. 3) R5 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Occurrence Log listed R5 was noted with following incidents: - 1/16/2012 at 6:30 PM - R5 in her room, reported falling to the floor by R25 (R5's husband and roommate). Staff encouraged R5 to ask for assistance for ambulation . - 3/11/12 at 8:55 A.M. - R5 while in her room, felt dizzy and fell backwards. " (R5) lying on the floor on her left side facing closet and close to the sofa. (R5) complaint of pain to back of her head. Noted swelling about 9 cm x 9 cm (size of a baseball) to the right side back of head with redness and purple color. " R5 sent to the hospital's emergency room precipitated by the fall incident . R5 was later returned to facility on same day. - 3/17/12 at 1:45 P.M. - R5 reported fall by the nurse' station. "(R5) got up from wheelchair and slowly bend down to the floor and lay down." - 3/20/2012 at 2 A.M. - R5 reported found sitting on the floor. "(R5) found on the floor, positioned right by the bed. (R5) alert, confused, no injury. Probable cause of fall: (R5) confused , try to get up. (R5) was sent to the hospital." The plan of care for falls indicated the following interventions : -"7/11/2011 - instruct resident in proper use of any appliance or device to aid balance. Encourage the resident to use the appliance /device as instructed." - "Instruct resident to ask for assistance prior to attempting to transfer or walk." -" Provide ambulation and strengthening exercise" -"Implement fall precautions procedures per protocol" Added interventions were as follows: 1/16/2012- " Every hour check" 1/17/2012 - " Rehab program for safety transfer" There were no revised interventions or modification for fall interventions when R5 had further falls on 3/11, 3/17 and 3/20/2012. E6( Registered Nurse) and E7 (CNA - certified nurse assistant) stated on 6/13/2012 at 12:30 P.M. that R5 stays in her room with R25 and do not go out of the room for activity except for meals. E2 (Director of Nursing) stated on 6/13/2012 at 12:35 P.M. that there was no documentation for rehab program because most likely R5 had refused and will not leave room without R25. The Facility policy titled, " Resident Fall Protocol" requires that with each fall the care plan interventions will be reviewed for their effectiveness and modified as appropriate to reduce hazards and risk to the residents. R5 MDS (minimum Data Set) dated 1/19/2012 and 4/19/2012 indicated that R5 was assessed requiring supervision for transfer and ambulation. During lunch observation on 6/12/2012, R5 got up unassisted from the dining room chair, ambulated without staff assistance and supervision. R5 ambulated without assistive device, R5 walked towards the hallway to catch up with R25. R5 finally caught up with R25 and then proceeded to propel R25's wheelchair towards their room. On 6/13/2012 at around 12:35 A.M., R5 was observed ambulating and also propelling R25's wheelchair. There was no staff supervision as observed. B. Based on observation and interview the facility failed to ensure a safe environment for residents. This failure has the potential to affect most of the 96 residents residing at the facility. The findings include: There are no grab bars in either of the 2 women's bathrooms in the lower level per observations on 6/13/12. On 6/13/12 at 10:30 AM, E12 (Restorative CNA) stated that female residents use the women's washroom when they come down to the physical therapy room to receive therapy. E12 said that most of the residents are brought down to the therapy room for restorative therapy. On 6/13/12 the soiled utility room located on the 2nd floor was unlocked. An unlocked laundry chute is located in this room. Ambulatory confused residents with Dementia reside on the second floor. On 6/11/12 at 10:55 AM, R28 was sitting in his room. R28 stated that he hit his shin on the bed crank and he was in pain. The bed crank was noted sticking out into the room. A CNA entered the room at this time and adjusted the bed crank so that it was not sticking out. The CNA said that the bed crank should have been pushed in after the bed was adjusted.

Based on observation and interview the facility failed to ensure a safe environment for residents living on a secured Dementia Unit. This is for 5 residents (R39, R40, R41, R42 and R43) in the supplemental sample. The findings include: On 7/31/12 at 11:25 AM on the 2nd floor Dementia Unit, both doors leading to the soiled utility room door were unlocked and easily accessed. An unlocked laundry chute is located inside the utility room and presents a danger to confused residents. The laundry chute is easy to open. There were no staff in the soiled utility room. At 11:30 AM on the 2nd floor Dementia Unit the janitor's closet door was easily opened. A plastic glove was shoved inside of the striker plate opening to keep the door from locking. An unlocked garbage chute is located inside the janitor's closet and presents a danger to confused residents. There were no staff inside the janitor's closet or in the hallway. E2 (Director of Nursing) was called to witness the unlocked doors. E2 stated the janitor's closet door should be locked and that a glove should never be shoved inside the opening. E2 said the soiled utility room doors have locks and they should be locked. R39, R40, R41, R42 and R43 are confused residents who reside on the Dementia Unit and are known wanderers, according to E2 and E3 (Nurse on Dementia Unit).

Based on observation, record review, and interview the facility failed to conduct a comprehensive assessment and analyze pressure sore risk factors, failed to indicate why R3 developed a pressure sore in the facility, failed to provide and implement individualized interventions, and monitor the impact of the intervention to promote healing and/or prevent development of pressure sore, and failed to identify whether the facility acquired pressure sore was avoidable or unavoidable. This is for 1 residents out of 2 (R3) reviewed for pressure sore/decubitus ulcer in the sample of 20. This failure resulted in R3's development of a facility acquired Stage II pressure ulcer on her right sacrum and coccyx. Findings Include: On 8/22/11 the facility presented a list of pressure sores in which it was identified that R3 acquired a Stage II pressure sore to her right sacrum and a Stage II pressure sore to the coccyx on 8/5/11. R3 ' s Resident Admission Information documents R3 as [AGE] years old who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/22/11 at 11:55 am, and on 8/23/11 at 10:55 am, R3 was observed sitting on an end chair without any pressure relieving device. On 8/24/11 at around 10:50 am E3 (ADON) stated that Z1 (Wound Care Physician) saw R3 last night (8/23/11) and R3 ' s pressure sore was healed. On 8/24/11 at 12:20 PM R3 ' s skin was checked, a Stage II pressure sore was noted on the right sacral area. E3 stated that the area was closed and it opened up again. There was no pressure relieving device on R3 ' s wheelchair and/or on the end chair. E3 verified that R3 usually sits on the end chair while in her room. E3 found the pressure relieving cushion in R3 ' s closet. On 8/24/11 at 12:24 PM E3 stated that R3 refused the pressure relieving cushion and R3 last used the cushion in the month of May. E3 verified that no other alternative was offered to R3. R3 ' s " Decubitus Assessment " dated 8/2/11 documents a score of " 15 " which shows that R3 is a " High Risk " to develop pressure sore. A review of R3 ' s clinical record showed that there was no assessment for the pressure sore acquired on 8/5/11. R3 ' s current care plan did not address R3 ' s acquired pressure sore on 8/5/11. The review of R3's clinical record also showed that there was no documentation about when and who identified R3's pressure sore that was acquired on 8/5/11 and these were confirmed by E3 on 8/24/11 at around 12:28 PM. On 8/25/11 at 9:50 am R3 ' s skin was checked again, two stage II pressure sore were observed, one pressure sore measuring 3.1 centimeter (cm) X 1.4 cm on the coccyx and another pressure sore measuring 1.3 cm X 1 cm. No pressure relieving device was noted on end chair. R3 ' s current care plan was reviewed again, the care plan did not address R3's pressure sore which was acquired on 8/24/11, and this was confirmed by E3 on 8/25/11 at around 10:05 am. The facility ' s policy and procedure titled " Pressure Ulcer Prevention "documents..." Based on the result of the Pressure Ulcer Risk assessment, all residents AT-RISK for pressure ulcer development will receive a documented daily visual inspection of their skin by the RN/LPN or CNA delivering care ... " A review of R3's clinical record showed that there was no documented daily skin inspection done and this was confirmed by E3 on 8/25/11 at around 10:00 am. Based on observation, record review, resident and staff interview, the facility failed assess and to provide care to prevent the development of additional pressures for 1 of 3 residents (R5) in a sample of 20. Findings include: R5 [DIAGNOSES REDACTED]. R5 is incontinent of bladder and bowel and totally dependent on staff for all activities of daily living. R5 is assessed high risk for pressure ulcers and has history of healed ulcers to sacral area and heels. During skin check on R5 with E3 (treatment nurse) on 8/23/11, R5 complained of pain to left groin area. R5 stated the area has been hurting for a couple of days. E3 released R5's diaper and E3 stated R5's left groin area is red and raw. R5's diaper was dry. An order to apply Calmasyn cream to groin and inner bilateral thigh every shift and prn (as necessary) was obtained on 8/23/11. R5's care plan for skin breakdown included interventions to provide clean/dry skin condition, protective skin care and to apply lotion daily.