Every finding on record at Good Samaritan Home

Based on observation, interview, and record review the facility failed to implement an initial care plan on admission to prevent pressure ulcers, failed to implement pressure relieving interventions to prevent the development of pressure ulcers, failed to initiate a pressure ulcer care plan as soon as a pressure ulcer was identified, and failed to obtain a treatment as soon as a pressure ulcer was identified for one resident of four residents (R79) reviewed for pressure ulcers in the sample of 37. These failures resulted in R79 developing two stage two facility acquired pressure ulcers.Findings include:The Skin Care Protocol: Prevention and Treatment policy dated 2/14/2025 documents The facility will ensure that a resident who enters the facility without pressure injury does not develop a pressure injury unless the individual's clinical condition demonstrates that the pressure injury was unavoidable. The facility will further ensure that a resident having pressure injury receives necessary treatment and services which promote healing, prevent infection, and prevent new injury from developing. Procedure 1. Upon admission/readmission, the charged nurse will document the presence of all marks, scars, rashes, pressure injuries, moles, bruises, etc.(etcetera) in the designated space in the admission Assessment under observations in (computer program). 3. Upon admission/readmission, the charged nurse will complete the Braden Pressure Ulcer Risk Assessment under observations in (computer program). Based on the risk category indicated, the charged nurse will implement the respective risk protocol. 4. Within seventy-two hours following admission/readmission the Resident Care Coordinator will review the admission Assessment and Braden Pressure Ulcer Risk Assessment for implementation of risk protocol, review treatment orders, and refer to the Nursing Program Coordinator or start Initial Pressure Sore event in (computer program). 6. The Resident Care Coordinator or Nursing Program Coordinator will review and update the Braden Pressure Ulcer Risk Assessment quarterly and upon finding of new pressure injury. Risk Assessment Process 1. Risk Assessment Definitions a. Braden Scale for Prediction of Pressure Sore Risk will be used to identify residents who are at increasing risk for acquiring a pressure injury. The Braden Scale will be completed upon admission, quarterly and upon identification of a new pressure injury. b. If the resident has a new or existing pressure injury, including stage I, the resident shall be considered High Risk. 3. At Risk Protocol (Braden Score 15-18) b. If using wheelchair for mobility, obtain cushion from the therapy department. c. Obtain order for house barrier cream to be applied during incontinence care to minimize the effects of urine and feces. d. Repositioning of residents who are unable or not inclined to self-reposition every 2 (two) hours in lying position and every hour when in seated position. The Initial Care Plan policy dated 5/23/2022 documents The initial care plan will be used to communicate the resident care needs on admission. This form will be completed and placed in the care plan book until the admission care plan is developed following completion of the MDS (Minimum Data Set Assessment) and care plan meeting.The Resident Care Planning policy dated 3/21/19 documents Each resident has a Resident Care Plan that is current, individualized, and consistent with the medical regimen. The plan of care is initiated within 48 hours after admission by using the Initial Care Plan. A care plan will be initiated at the time a pressure injury or skin alteration is identified and will include prevention strategies as well as treatment plans.R79's Face Sheet documents that R79 is an [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease/COPD, and Pneumonia.R79's Braden Scale Pressure Risk assessment dated [DATE] at 3:48 PM, documents that R79 scored a 17 indicating R79 was at risk for the development of pressure ulcers.R79's admission Evaluation dated 1/30/26 at 4:40 PM, documents that R79's cognition level was independent with decision making, R79 made herself understood, and R79 required a one person assist for activities of daily living, bed mobility, and transfers. The same Evaluation documents R79 was continent of bladder/bowel, R79 had no redness, rashes, lesions, or excoriations, R79 had no verbal complaints of pain, and R79 had no pressure ulcers.R79's Initial Care Plan dated 1/30/26 does not include any pressure relieving interventions to prevent R79 from developing pressure ulcers.R79's Skin Integrity Report printed 2/24/26 at 3:16 PM documents that a stage two pressure ulcer was discovered on R79's right buttock on 2/6/26 at 1:30 PM. The wound measured 3 centimeters (cm) by 3 cm x 0.1 cm with a scant amount of serous drainage causing mild pain. R79's Skin Integrity Report printed 2/24/26 at 3:16 PM documents that a stage two pressure ulcer was discovered on R79's left buttock on 2/6/26 at 1:30 PM. The wound measured 2.5 cm by 3.5 cm with blistered skin still intact causing mild pain. R79's Nursing Note dated 2/6/26 at 1:38 PM written by V16/Infection Preventionist/Registered Nurse/RN documents that R79's buttock was assessed and R79 had a stage two ruptured blister observed to R79s right buttocks that measures 3 cm by 3 cm by 0.1 cm and R79 had a stage two partial thickness wound to her left buttocks that measured 2.5 cm by 3.5 cm.R79's Treatment Administration Record documents to cleanse with soap and water the stage two deroofed blister and apply Xeroform (medicated wound dressing) dressing to the wound bed, cover with sacral optifoam (foam dressing) and change on shower days and as needed (if it starts draining start Calcium Alginate). If stage two intact blister opens apply the same treatment once a day on Wednesday and Saturday. Start Date 2/8/26.On 2/25/26 R79 was sent to the hospital for respiratory issues and was not in the facility for the wounds to be observed by this surveyor.R79's current Care Plan was not updated with documentation of R79's pressure ulcers or pressure ulcer interventions until 2/9/26.On 2/23/26 at 10:30 AM, R79 was sitting in her wheelchair next to her bed with her eyes closed. R79 was sitting with direct pressure on her buttocks with no offloading of pressure. R79 stated that she has a couple of sores on her bottom that she got since coming to the facility.On 2/23/26 at 11:57 AM, V28/R79's Family Member stated that she got a call from the facility that R79 had developed a wound on her buttock. V28 also stated (R79) has had to wait up to 45 minutes for (R79's) call light to be answered and that is a long time when you have to use the bathroom. I'm sure that is not good for getting sores if your left sitting in a wet (disposable brief).On 2/24/26 at 11:43 AM, R79 was sitting in her wheelchair next to her bed visiting with V29/R79's Family Member. V29 stated I don't know what to think about (R79's) care. (R79) came to the facility three weeks ago for therapy and (R79's) health has been steadily declining. On 2/24/26 at 1:59 PM, V3/Assistant Director of Nursing verified that R79 was admitted to the facility on [DATE] and did not have a pressure ulcer but now has two stage two pressure ulcers on R79's buttocks. V3 also verified that R79 scored a 17 on the Braden Scale meaning R79 was at risk for developing a pressure ulcer. V3 stated that there were no pressure relieving interventions on R79's baseline care plan and there should have been. V3 also stated that the pressure ulcers were identified on 2/6/26 and a pressure ulcer care plan was not initiated with interventions until 2/9/26. On 2/25/26 at 12:55 PM V25 (Nurse Practitioner) stated R79's wounds to the buttock were caused by pressure. V25 also verified she is not sure if the facility implemented pressure relieving interventions prior to the development of pressure ulcers.On 2/25/26 at 9:38 AM, V16/Infection Preventionist/RN stated that R79 has two stage two ulcers that were caused by pressure. The wounds were identified on 2/6/26 and treatment was not started until 2/8/26.

Based on Observation, Interview and Record Review, the facility failed to provide a resident with adequate supervision and assistance with footwear to prevent a fall and conduct a thorough investigation with staff interviews after a resident suffered a fall with fracture for one of two residents (R7). This failure resulted in R7's footwear being worn unsafely, and R7 suffering an unwitnessed fall, experiencing swelling and pain in her right wrist and resulting in a distal radius bone fracture requiring cast application.Findings include:The facility's Program for Reduction of Falls Risk policy, dated 4/9/25, documents As part of the program for the prevention of falls, all newly admitted residents and those residents experiencing a change in function will be assessed for the risk of falls. The care plan will indicate that the resident is at risk for falls and provide interventions for fall prevention. Purpose: to enable staff to recognize those residents who have been found to be at increased risk for falls, implement interventions to reduce the risk of resident falls and ultimately prevent resident falls. If the resident is found to be at risk, the individual who has completed the assessment will initiate a care plan for prevention of falls or update the existing care plan. The appropriate fall prevention interventions will be selected on the basis of the individualized needs of the resident.R7's current Care Plan, dated 12/30/25, documents R7 is [AGE] years old and has diagnoses including Alzheimer's disease, Anxiety, Chronic Respiratory failure and Age-related Macular Degeneration. This care plan documents I require varying levels of assist due to Alzheimer's disease, COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure and macular degeneration. Approach: Observe frequently and place in supervised area when I am out of bed and restless (start date 7/8/25). This care plan also documents I am at risk for falls due to Dementia, Alzheimer's, COPD, Chronic hypoxia, and Nonexecutive age related macular degeneration. Approach: I wear non-skid shoes/socks, increased staff supervision with intensity based on my needs (both started 7/8/25). This same care plan also documents I am limited in my ability to dress/undress self, related to macular degeneration, weakness and COPD. Approach: provide me consistent amount of oversight and encouragement with occasional cueing and physical assistance, provide me step by step instructions during dressing (both started 7/8/25).On 2/23/26 at 10:50 AM, R7 was sitting in a wheelchair in front of the 600 hall nurses' station. R7 was pleasantly confused with conversation and denied any history of falling.On 2/25/26 at 11:05 AM, R7 was sitting in a wheelchair in front of the 600 hall nurses' station with her eyes closed.R7's Minimum Data Set assessment, dated 7/3/25, documents R7 has moderately impaired cognition and requires supervision/touching assistance with putting on and taking off footwear.R7's Safety Fall Event, dated 8/26/25, documents on 8/25/25 at 9:13 PM R7 suffered an unwitnessed fall in her room. This event documents the last time R7 was seen prior to falling, was at 7:30 PM while headed to her room after an activity (1 hour and 45 minutes prior to the fall). This event also documents R7's shoes were not worn properly, the backs of the shoe were pressed down as if they had been slipped on and R7 exhibited pain and swelling in her right wrist. This same event form also documents measures put in place after the fall: educated resident to no longer slide her shoes on with the backs flat to the sole. We (staff) can assist with putting on her shoes properly, so her feet stay in the shoes.R7's nursing progress note, dated 8/26/25 at 7:51 AM, documents Right wrist swollen, warm to the touch, blue/black bruising present with deformity. (R7) states pain level four out of ten while positioning to elevate with ice.R7's nursing progress note, dated 8/26/25 at 12:40 PM, documents R7 returned from the orthopedic walk-in clinic with a diagnosis of a right distal radius fracture requiring a cast that was applied in the office.On 2/25/26 at 11:29 AM, V2 (Director of Nursing) stated I do not have a complete fall investigation with witness statements for (R7's) fall on 8/25/25. I know she went to get an x-ray of her wrist the next day and had a wrist fracture. (R7) is forgetful, she can be conversated with, but she may not remember what was discussed. I know (R7's) shoes were not on correctly at the time she fell, and she does have confusion off and on. Educating her would not be very effective. V2 confirmed staff should always assist R7 with applying and removing her shoes and that R7 requires frequent supervision as part of her fall prevention plan.

Based on observation and interview, the facility failed to ensure that the dishwashing machine was effectively sanitizing dishes. This failure have the potential to affect all 91 residents in the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 2/24/26 and signed by V2/Director of Nursing documents 91 residents reside within the facility.The facility's Pot/Pan Machine and Dish Machine Supervisor Policy, documents Policy: It is the policy of the food service department that the department supervisor or designees will check the temperature of the dish machine and pot and pan machine during the breakfast, noon, and evening meals. The acceptable temperature of the manifold is 160 degrees Fahrenheit. Heat stickers will be used to ensure that the dish machine and pot and pan machine are reaching acceptable temperatures. A sticker will be collected and logged once per meal. The sticker will turn black when the final rinse is at the proper temperature. If the sticker does not turn black, this should be noted, and the service company notified.This Dishwasher Manufacturer Instructions, dated 8/22/19, documents the final rinse temp should be 180 degrees to 195 degrees Fahrenheit.The Dishwasher Temperature Sensor Label Package Instructions documents How to use: Attach to the thickest clean dry dish, place labeled dish/utensil in dishwasher and run dishwasher, read label (Label should turn from silver to black when surface temperature reaches rated temperature, remove label and attach to dishwasher documentation.The Dishwasher Companies Beverage Chemical and Equipment Department Dishwasher Instructions, un-dated, document's Temperature Sanitation Failure: If the conveyor dish machine is not achieving proper temperature sanitation of a minimum of 180 degrees on the Final Rinse, the chemical sanitation pump will need to be engaged. To engage the sanitizer, pump the switch on the dispenser will need to be turned on and run to ensure that it is pumping correctly. The booster heater located on the top of the dish machine should be turned off while using chemical sanitation. Next the chemical sanitation will need to be tested to ensure that chemical sanitation is taking place. To do this you will need a chlorine test strip. Place the test strip in the fine mist spray of the final rinse at the outgoing side of the machine. The test strip will need to be between 50-150PPM (Parts per Million) to be legally sanitizing. If the test strip reads above or below the required PPM, please stop using the machine.The Chemical Sanitation Strip Package Instructions document Dip paper in quaternary solution (Not Foam Surface), for 10 seconds. Don't shake. Compare colors at once. Testing solution should be between 65-75 degrees Fahrenheit.On 2/23/26 at 9:21 AM, breakfast dishes were being washed through the back dishwasher. While the dishes were going through the dishwasher, V5/Dietary Manager stated the back dishwasher was a high temperature dish machine and the final rinse should reach a surface temperature of 180 degrees Fahrenheit. As the dishes were flowing through the dish machine, V5 placed a dishwasher temperature sensor label on a plate and ran the strip through the dishwasher. V5 stated if the strip turns black it would indicate the minimum temperature of 180 degrees Fahrenheit had been reached. As the plate with the strip came out, the strip did not turn black, indicating the final rinse did not reach 180 degrees Fahrenheit. V5 stated that the facility has had issues with this dish machine in the past and sometimes the water does not reach the appropriate final rinse temperature but requested to run a different temperature sensor label through the dish machine to ensure the label was working properly. V5 placed another strip on a plate and ran it through the dish machine to double check. The plate came out with the strip, and the strip still did not turn black indicating the appropriate final rinse had not reached 180 degrees Fahrenheit. V5 indicated that since the machine has had issues in the past, the dishwasher manufacturer placed a low temperature chemical dispenser to use if the final rinse was not reaching the proper temperature. V5 then turned off the booster heater and flipped the machine over to dispense the appropriate chemical sanitation during the final rinse. V5 ran four loads of dirty dishes through the dish machine and tested the chemical sanitation with a chlorine strip as directed by the manufacturer. During those four loads the strip never changed color to indicate the sanitation was at the proper sanitation level. V5 placed strips on the plates after they came through the dish machine and held the sanitation strip in the spraying water during which the plates were coming out and verified the strip was still not reading the appropriate sanitation level and was not even changing color. V5 stated they will have to notify the dish machine company to let them know the issues.On 2/24/26 at 11:45 AM, V5/Dietary Manager verified that the facility's dishwasher is used for all dirty dishes from the facility

Based on interview and record review, the facility failed to prevent abuse for two of four residents (R16 and R41) reviewed for abuse in a sample of 37.Findings include:The facility's Abuse Prevention Program Policy, dated 6/19/21, documents Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, exploitation, and any physician or chemical restraints not required to treat the resident's symptoms. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. Definitions: the following definitions are based on federal and state laws, regulations, and interpretive guidelines. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology, this also includes deprivation by an individual, including a caretaker, or goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish.The Final Investigation Report sent to the State Agency for R16 and R41 dated 2/20/26, documents, Based on witness interviews, witnesses report (R16) was sitting in her wheelchair next to her side table in the common area. (R41) attempted to walk past the side table and kicked the wheelchair, making contact with (R16's) leg. In response, (R16) struck (R41) in the face with the back of her hand.R16's Face Sheet documents R16 is an [AGE] year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Dementia and Cognitive Communication Deficit.R16's MDS (Minimum Data Set) Assessment, dated 2/19/26, documents R16 is severely cognitively impaired.R41's Face Sheet documents R41 is a [AGE] year-old female who was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Dementia (with mood disturbance), Agitation, Anxiety, and Restlessness.R41's MDS, dated [DATE], documents R41 is severely cognitively impaired.R16's Progress Note, dated 2/17/26, documents It was reported to this nurse (V27/LPN/Licensed Practical Nurse) that (R16) experienced a resident altercation with another resident (identified as (R41). It was reported that (R16) was sleeping in the common area when (R41) rolled up in her wheelchair and started kicking (R16). (R16) then woke up and smacked (R41) across the face. (R16) then kicked (R41) another time.R41's Progress Noted, dated 2/17/26, documents (R41) noted to have exit seeking behaviors after lunch today and became very aggressive with staff and other residents. Staff attempted to redirect (R41) and help with ADLS (Activities of Daily Living) in attempt to help with behaviors, but all attempts were non-effective. (R41) then started to calm down and was sitting in the common area where she then unprovoked started kicking (R16). (R16) then retaliated by smacking (R41) in the face. (R41) then kicked (R16) again. (R16) and (R41) then were separated by staff and are continuing to be separated to keep the situation deescalated.On 2/25/26 at 11:41 AM V12/Housekeeper stated, Around a week or so ago I witnessed (R41) dosing off in her wheelchair when (R16) wheeled up to (R41) and kicked (R41) and was yelling at (R41). As soon as (R16) kicked (R41), (R41) smacked (R16) on the right side of (R16's) face like hit (R16). V12 stated, (V11/Non-Certified Nursing Personnel) separated (R16) and (R41) right after the incident occurred.On 2/25/26 at 12:32PM, V11/Non-Certified Nursing Assistant stated, I witnessed (R16) and (R41) get into a physical altercation. (R16) was sitting in her wheelchair with her eyes closed in front of the nursing desk, when (R41) wheeled up in her wheelchair to (R16) and began kicking (R16) in her legs. (R41) moved back a little in her wheelchair after she was kicked. (R41) then tried to squeeze by (R16) and a bedside table and couldn't fit so (R4) started kicking (R16) again. After (R16) was kicked again, (R16) smacked (R41) across (R41's) cheek. I was finally able to separate (R16) and (R41). V11 stated that R41 kicking R16 and R16 smacking R41 was intentional.

Based on observation, interview, and record review the facility failed to document an appropriate diagnosis and target behaviors to warrant the use of antipsychotic medications, failed to implement behavioral interventions prior to increasing an antipsychotic medication dose, and failed to perform antipsychotic assessments for two of four residents (R10 and R52) reviewed for chemical restraints in the sample of 37.Findings include: The facility's Medication Monitoring Psychotropic Drug Management Program Policy dated 3/11/19 documents, Psychotropic drugs refer to drugs which are used for anti-psychotic, anti-depressant, anti-manic, sedative-hypnotic and/or anti-anxiety purposes and which are intended to control mood, mental status, or behavior of the resident. Residents taking psychotropic drugs will have a specific diagnosis/condition for use of this drug noted on the Accumulative Diagnosis list. The specific behavior that warrants the use of this drug will be documented on the Care Plan, and Behavior Monitoring. To continue with an order for an antipsychotic medication the resident must have documented prior non-pharmacological interventions used, an appropriate diagnosis and appropriate target behaviors for antipsychotic med use. If this is not available, then the licensed nurse will proceed with getting the order discontinued or begin with the GDR (Gradual Dose Reduction) process with the goal of discontinuing the medication. Each resident in program will be reassessed at least quarterly (90 days) with progress or lack of it noted. For any resident using psychotropic medications, other than sedatives/hypnotics, there will be an attempt at dose reduction of psychotropic medications and/or attempts of alternative behavioral interventions in two separate quarters at least one month apart and then annually thereafter. For any resident using sedatives/hypnotics an attempt at dose reduction will be made at least quarterly for the duration of therapy unless clinically contraindicated. This will be so noted in clinical records. If attempts are clinically contraindicated it will also be noted in the clinical record. Psychotropic medications should not be administered for the purpose of discipline or staff convenience and when not required to treat the resident's medical condition. Behavior requiring medication intervention will be documented on each resident for at least 72 hours before a routine psychotropic medication is started and daily thereafter. 1.R52's PASRR (Preadmission Screening and Resident Review) Level I Screen dated 7/25/24 documents R52 had no indication or diagnosis of a mental illness prior to admission to the facility. R52's MDS (Minimum Data Set) assessment dated [DATE] documents R52 is severely cognitively impaired, has no behaviors, receives anti-psychotic medications daily, and had no gradual dose reduction attempted. R52's Physician's Order dated 4/6/25 documents R52 was receiving Risperdal (antipsychotic medication) 0.5 mg (milligrams) twice daily for the diagnosis of Unspecified Dementia, unspecified severity, with agitation. R52's Physician's Order documents R52's Risperdal was reduced to 0.25 mg twice daily on 10/27/25. R52's Progress Notes dated 12/30/25 documents a hospice nurse stated R52's family reported R52 was making delusional statements and assaulting staff, therefore a physician's order was received to increase R52's Risperdal back to 0.5 mg twice daily. R52's Electronic Health Record between 10/27/25 (date of reduction Risperdal) through 12/30/25 (date of increase of Risperdal) does not include documentation of R52 having an increase in behaviors of assaulting staff or making delusional statements, or documentation of R52 receiving non-pharmacological interventions to address behaviors of assaulting staff or making delusional statements prior to R52's increase in the Risperdal. R52's current Physician Order Report documents R52's Risperdal was increased back to 0.5 mg twice a day on 12/30/25 for the diagnosis of Unspecified Dementia, unspecified severity, with agitation. R52's Pharmacy GDR Recommendations signed by V17 (R52's Physician) and dated 2/4/25, 8/6/25, and 10/27/25 document V17 rejected R52's pharmacy GDR recommendations due to R52 being stable and receiving hospice services. R52's Medication Administration Records dated 8/1/25 through 2/23/26 document R52's target behavior for the use of Risperidone is Delusions as evidenced by making statement that did not happen such as staff is poisoning R52. These same Medication Administration Records dated 8/1/25 through 2/23/26 document R52 has only had three behaviors of this type within this timeframe. No other behaviors were documented during this timeframe. R52's Electronic Health Record dated 4/6/25 through 2/25/26 does not include any antipsychotic drug evaluations. On 2/23/26 at 10:00 AM R52 was sitting in a recliner in her room, sleeping. On 2/23/26 at 10:05 AM V14 (LPN/Licensed Practical Nurse) stated, (R52) gets confused and sleeps a lot. (R52) doesn't have any physical behaviors. On 2/23/26 at 10:10 AM V15 (CNA/Certified Nursing Assistant) stated, (R52) has Dementia and tries to get up herself and has anxiety. (R52) doesn't have any physical behaviors. On 2/25/26 at 1:00 PM V3 (Assistant Director of Nursing) verified R52 does not have documented behaviors or a diagnosis to justify the use of Risperdal or the increase in Risperdal on 12/30/25. On 2/25/26 at 1:30 PM V2 (Director of Nursing) verified the facility does not perform antipsychotic drug evaluations. 2. On 2/24/26 at 9:45 AM, R10 was observed sitting in his wheelchair self-propelling in the hallway by the nurse's station. R10 was pleasant, and no behavior was observed. R10's census documents R10 admitted to the facility 11/25/24. R10's Physician Order dated 1/2/25 documented a new order for Seroquel 25 milligrams (mg) one time daily for Vascular Dementia with Psychotic Disturbance. R10's Physician Orders dated 6/6/25 documented an order for Seroquel (antipsychotic medication)12.5 mg at noon daily for Delusions and Agitation. R10's Electronic Health Record dated 1/2/25 through 2/25/26 does not include any antipsychotic drug evaluations. R10's current comprehensive care plan does not include documented target behaviors, no measurable description of paranoia, agitation, or delusions, no documented non-pharmacological interventions attempted prior to or in conjunction with psychotropic medication use, and no individualized behavioral monitoring interventions for the use of R10's Seroquel. On 2/25/26 at 1:00 PM, V3 (Assistant Director of Nursing) stated R10 was initially started on Seroquel for paranoia and behaviors toward staff. V3 confirmed R10's initial care plan for Mood and Psychotropic drug use was initiated on 12/4/24 and confirmed the care plan did not include target behaviors or non-pharmacological interventions. V3 further stated we do not complete evaluations prior to a resident starting on an anti-psychotic medication. V3 stated Nurse Practioners who come to the facility will write the order for anti-psychotic medications based upon what the staff tell them about any behaviors, but the facility does not complete an assessment first.

Based on Interview and Record review, the facility failed to report a bruise of unknown origin to the facility's abuse coordinator and the state agency and report an allegation of misappropriation of jewelry to the state agency for two of four residents (R82, R84) reviewed for abuse in the sample of 37.Findings include:The facility's Abuse Prevention Program policy, dated 6/19/21, documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, exploitation, and any physical or chemical restraints not required to treat the resident's symptoms. The facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: Identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences; and filing accurate and timely investigative reports. This policy also documents Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator immediately. Supervisors shall immediately inform the administrator or in the absence of the administrator, the person in charge of the facility, of all reports of incidents, allegations or suspicion of potential abuse, neglect or misappropriation of property. Upon learning of the report, the administrator, or in the absence of the administrator, the person in charge of the facility, shall initiate an incident investigation. Any reasonable suspicion of a crime against a resident or individual receiving care from the facility, including but not limited to alleged violations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property must be reported to the state agency and local law enforcement under the following timeframes: allegation of neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury, not later than 24 hours after forming the suspicion. Reports should be documents and a record kept of the documentation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator. 1. R84's current Care Plan, dated 12/10/25, documents R84 is [AGE] years old with diagnoses of Depression, Anxiety, Parkinson's disease and is wheelchair dependent. This care plan documents I am at risk for abuse/neglect based on comprehensive assessment as evidenced by requiring extensive assist with some ADLs (activities of daily living). Report any incident of abuse to the administrator immediately. R84's nursing progress note, dated 1/16/26 at 11:37 PM, documents (R84) noted to have healing bruise, inner left thigh (lower), (R84) denies pain or discomfort at this time. Vital signs stable. Will continue to monitor, call light within reach. R84's current electronic medical record does not document any administration notification or reporting of R84's thigh bruise to the facility's abuse coordinator or the state agency. On 2/25/26 at 11:10 AM, V22 (Licensed Practical Nurse) confirmed R84 sometimes will have new areas or skin tears on her arms due to self-propelling her wheelchair and moving on her own. V22 stated If the injury discovered is an area that isn't a common location such as the thigh, (V1, Administrator) should be called and we would open a new event in the computer, and (V2, Director of Nursing and V1) would do an investigation. On 2/25/26 at 11:29 AM, V2 (Director of Nursing) stated, I was not notified of (R84) having a bruise to her thigh. I would expect the nursing staff to notify me and/or V1 (Administrator) and I would initiate an investigation to determine the source. Staff are educated to notify V1 and then I do the investigation. V2 confirmed R84's injury is in a location that is not typical and that a report for injury of unknown source was not sent to the state agency. 2. R82's Grievance/Concerns/Missing Item Form dated 1/30/26 documents R82's silver cross necklace is missing. This form further documents R82's room has been searched, as well as other resident rooms, handrails, under and inside furniture in common areas, shower room, chapel and social room, laundry, and lost and found. Facility was unable to locate R82's necklace. This same form documents V26 (R82's Family Member) was notified by the facility and V26 stated he was appreciative of them searching and requested a phone call if found. R82's Current Care plan documents R82 has Dementia and is cognitively impaired. On 2/25/26 at 1:40 PM V26 (R82's Family Member) stated, I noticed one day that (R82) was missing a silver cross necklace. (R82) wore that necklace every day and it was sentimental. I am not sure what happened to the necklace. I reported it as missing. On 2/25/26 at 1:15 PM, V1 (Administrator) stated she was aware of the missing necklace but did not report to the state agency that R82 had a missing necklace.

Based on Interview and Record review, the facility failed to complete an abuse investigation for an injury of unknown origin and misappropriation of jewelry for two of four residents (R82, R84) reviewed for abuse in the sample of 37.Findings include: The facility's Abuse Prevention Program policy, dated 6/19/21, documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, exploitation, and any physical or chemical restraints not required to treat the resident's symptoms. The facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: Identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences; and filing accurate and timely investigative reports. This policy also documents Upon learning of the report, the administrator, or in the absence of the administrator, the person in charge of the facility, shall initiate an incident investigation. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect or misappropriation will result in an abuse investigation. For any other incident or pattern involving reasonable cause to suspect abuse, neglect or misappropriation, the administrator will appoint a person to gather further facts prior to making a determination to conduct an abuse investigation. An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (such as, the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. 1. R84's current Care Plan, dated 12/10/25, documents R84 is [AGE] years old with diagnoses of Depression, Anxiety, Parkinson's disease and is wheelchair dependent. This care plan documents I am at risk for abuse/neglect based on comprehensive assessment as evidenced by requiring extensive assist with some ADLs (activities of daily living). R84's nursing progress note, dated 1/16/26 at 11:37 PM, documents (R84) noted to have healing bruise, inner left thigh (lower), (R84) denies pain or discomfort at this time. Vital signs stable. Will continue to monitor, call light within reach. R84's current electronic medical record does not document any further investigation, observation or notification of R84's bruise to her thigh. On 2/25/26 at 11:10 AM, V22 (Licensed Practical Nurse) confirmed R84 sometimes will have new areas or skin tears on her arms due to self-propelling her wheelchair and moving on her own. V22 stated If the injury discovered is an area that isn't a common location such as the thigh, (V1, Administrator) should be called and we would open a new event in the computer, and (V2, Director of Nursing and V1) would do an investigation. On 2/25/26 at 11:29 Am, V2 (Director of Nursing) stated, I was not notified of her having a bruise to her thigh. I would expect the nursing staff to notify me and/or V1 (Administrator) and I would initiate an investigation to determine the source. Staff are educated to notify V1 and then I will do an investigation. They (staff) would also open an event in the computer to document the injury and monitor and there is not one opened. I do not have an investigation for this bruise that was discovered in January (2026). V2 confirmed R84's injury is in a location that is not typical and should be investigated as an injury of unknown source. 2. R82's Grievance/Concerns/Missing Item Form dated 1/30/26 documents R82's silver cross necklace is missing. This form further documents R82's room has been searched, as well as other resident rooms, handrails, under and inside furniture in common areas, shower room, chapel and social room, laundry, and lost and found. Facility was unable to locate R82's necklace. On 2/25/26 at 1:40 PM V26 (R82's Family Member) stated, I noticed one day that (R82) was missing a silver cross necklace. (R82) wore that necklace every day and it was sentimental. I am not sure what happened to the necklace. I reported it as missing. R82's current electronic medical record does not document an investigation, staff interviews or a resolution for R82's missing necklace. On 2/25/26 at 1:15 PM, V1 (Administrator) stated she was aware of the missing necklace but did not investigate that it was missing.

Based on record review and interview the facility failed to submit a discharge MDS (Minimum Data Set) Assessment after residents were discharged from the facility for two of two residents (R40 and R90) reviewed for Accuracy of Assessments in the sample of 37.Findings include:The Minimum Data Set Policy undated documents, Policy: Assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument User Manual. Assessments include but are not limited to admission Assessment, Annual Assessment, Significant Change in Status Assessment, Significant Correction, Discharge Assessment, and Re-entry. Completed assessments are maintained in the resident's active medical record. All MDS assessments and discharge records ae completed and electronically encoded into the facility's MDS information system and transmitted to CMS (Centers for Medicare and Medicaid Services) Assessment Submission and Processing system in accordance with current regulation governing the transmission of MDS data.1.R40's Progress Notes document R40 passed away while in the facility on 11/24/25.R40's Electronic Health Record and MDS Tracking Log does not include evidence of the submission of a Discharge MDS being completed after R40's death.2.R90's Progress Notes document R90 was discharged from the facility to another facility on 10/2/25.R90's Electronic Health Record and MDS Tracking Log does not include evidence of the submission of a Discharge MDS being completed after R90's discharge.On 2/25/26 V2 (Director of Nursing) verified V24 (MDS Coordinator) was supposed to submit an MDS Assessment whenever a resident is discharged from the facility. V2 verified R40 and R90's Discharge MDS's were never completed or submitted.

Based on interview and record review, the facility failed to ensure a resident received a new PASRR (Pre-admission Screen and Resident Review) Level I screening and referral for Level II evaluation following a significant change in condition, including the addition of a psychiatric diagnosis and initiation of psychotropic medication, for one (R10) of three residents reviewed for PASRR compliance in the sample list of 37. Findings include: R10's PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome dated 11/22/24 documented that a disability was not present because: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted.R10's Physician Order dated 1/2/25 documented an order for Seroquel 25 milligrams (mg) one time daily for Vascular Dementia with Psychotic Disturbance.R10's Physician Orders dated 6/6/25 documented an order for Seroquel 12.5 mg at noon daily for Delusions and Agitation.On 2/25/2026 at 1:00 PM, V3 (Assistant Director of Nursing) stated R10 was initially started on Seroquel for paranoia and behaviors toward staff. V3 stated she could not find documentation of behaviors toward other residents or self.On 2/25/2026 at 11:53 AM, V3 stated she was not aware that a new PASRR needed to be completed when a psychiatric diagnosis was added and psychotropic medications were initiated after admission. V3 stated Social Services typically handles PASRR screening upon admission, but the facility was not aware that a new PASRR must be submitted when a new psychiatric diagnosis is added to the resident's medical record. V3 confirmed that new PASRR screenings are not being completed under these circumstances.R10's clinical record revealed no evidence that the facility submitted a new PASRR Level I screen or referred R10 for a Level II evaluation following the addition of a psychiatric diagnosis and initiation of psychotropic medication.The facility's Pre-admission Screening and Resident Review (PASRR) Policy updated 12/7/22 did not contain guidance requiring staff to complete a new PASRR screening when a new psychiatric diagnosis is added following admission.

Based on observation, record review, and interview, the facility failed to revise and update the comprehensive care plan to reflect significant changes in condition, including the addition of new psychiatric diagnoses, initiation of psychotropic medication, identification of target behaviors, and implementation of non-pharmacological interventions for one (R10) of five residents reviewed in a sample of 37.Findings include:The facility's undated Resident Care Planning Policy documents each resident has a Resident Care Plan that is current, individualized, and consistent with the medical regimen. Following Interdisciplinary Care conferences, occurring within 21 days after admission, and every 90 days thereafter, the nurse coordinates the Resident Care Plan for all disciplines by updating goals and actions that were discussed. Between Interdisciplinary Conferences, each discipline adds activities to the Resident Care Plan when initiated and discontinues activities when completed.On 2/24/26 at 9:45 AM, R10 was observed sitting in his wheelchair self-propelling in the hallway by the nurse's station. R10 was pleasant, and no behavior was observed.R10's census documents R10 admitted to the facility 11/25/24.R10's Physician Order dated 1/2/25 documented an order for Seroquel 25 milligrams (mg) one time daily for Vascular Dementia with Psychotic Disturbance.R10's Physician Orders dated 6/6/25 documented an order for Seroquel 12.5 mg at noon daily for Delusions and Agitation.R10's current comprehensive care plan revealed: no documented target behaviors, no measurable description of paranoia, agitation, or delusions, no documented non-pharmacological interventions attempted prior to or in conjunction with psychotropic medication use, No individualized behavioral monitoring interventionsReview of R10's Medical Diagnosis List documented: Depression (12/16/24), Anxiety Disorder (3/3/25), Restlessness and agitation (5/30/25), Vascular Dementia with Psychotic Disturbance (1/2/25), Unspecified severe Dementia with Psychotic Disturbance (10/29/25).On 2/25/26 at 1:00 PM, V3 (Assistant Director of Nursing) stated R10 was initially started on Seroquel for paranoia and behaviors toward staff. V3 confirmed R10's initial care plan for Mood and Psychotropic drug use was initiated on 12/4/24 and confirmed the care plan did not include target behaviors or non-pharmacological interventions. V3 stated the care plan should be revised with changes and should include non-pharmacological interventions and targeted behaviors.

Based on observation, interview, and record review the facility failed to properly store a nebulizer mask and implement a care plan for oxygen/nebulizer use for one of one resident (R1) reviewed for oxygen in the sample of 37.Findings include:The Nebulizer Medication Administration policy dated 2/4/2020 documents Nebulizer therapy aids bronchial hygiene by restoring and maintaining mucus blanket continuity; hydrating dried, retained secretions; promoting expectoration of secretions and humidifying inspired oxygen; and delivering medications. Cleaning and Maintenance; 5. Store tubing and nebulizer equipment in storage bag between uses.The Initial Care Plan policy dated 5/23/2022 documents The initial care plan will be used to communicate the resident care needs on admission. This form will be completed and placed in the care plan book until the admission care plan is developed following completion of the MDS (Minimum Data Set Assessment) and care plan meeting.The Resident Care Planning policy dated 3/21/19 documents Each resident has a Resident Care Plan that is current, individualized, and consistent with the medical regimen. The plan of care is initiated within 48 hours after admission by using the Initial Care Plan.R1's Face Sheet documents that R1 is a [AGE] year-old that admitted to the facility on [DATE] with diagnoses which included Pneumonia, Chronic Diastolic (Congestive) Heart Failure, Shortness of Breath, and Wheezing.R1's Physician Order Report for February 2026 documents an order dated 2/6/26 for oxygen at 2L/liters as needed and Albuterol Sulfate nebulization 2.5 mg (milligrams) /3 ml (milliliters) one vial three times a day.The Initial Care Plan dated 2/6/26 for Respiratory: Goal-Maintain Airway and Oxygen Levels documents NA (Not Applicable) for oxygen and nebulizer treatments.R1's current Care Plan does not include a care plan for oxygen or nebulizer treatments.On 2/23/26 at 10:20 AM, R1 was sitting in her wheelchair in her room wearing oxygen. R1's nebulizer mask was on the bedside table and was not stored in a bag.On 2/23/26 at 12:10 PM, R1 was sitting in her room wearing oxygen and the nebulizer mask was still on the bedside table not in the storage bag.On 2/23/26 at 12:12 PM V10/Certified Nursing Assistant verified R1's nebulizer mask was not stored in a bag. V10 stated that it is to be cleaned and stored in the plastic bag. V10 stated that the nurses take care of the nebulizer treatments and masks. On 2/24/26 at 8:45 AM V2/Director of Nursing stated that nebulizer masks are to be kept in a plastic storage bag any time they are not in use. On 2/24/26 at 1:47 PM, V3/Assistant Director of Nursing verified that there was not an initial care plan for R1's oxygen or nebulizer treatments but there should have been. V3 also verified that R1's current care plan did not have anything about R1's oxygen or nebulizer treatments.

Based on observation, interview, and record review the facility failed to ensure a multidose vial of lidocaine and multidose insulin pen were labeled with resident identifiers and labeled when opening for two of 19 residents (R1 and R11) reviewed for medication storage and labeling in the sample of 37.Findings include:The facility's Storage of Medications Policy (undated) documents, All centrally stored prescription medications must be labeled and maintained in compliance with applicable state and federal laws. Each label must include the resident's name, the medication name, strength, and quantity. Insulin will be stored in the refrigerator in the medication room or in the medication cart if refrigerator is not required. Each vial is marked with date the medication was opened.R11's current Physician Order Report documents, Start Date 1/2/26 Insulin Lispro 100 units/ml (milliliter) per sliding scale every day before meals and at bedtime for the diagnoses of Type II Diabetes Mellitus.On 2/23/26 at 9:20 AM the medication cart located on the 500-hallway identified as [NAME] Gardens contained an opened half-used Lispro (Insulin) injector pen 100/ml that did not have a date when opened or a label identifying the resident the Lispro injector pen was being used for. On 2/23/26 at 9:30 AM the medication room located on the 500-hallway identified as [NAME] Gardens had an opened multi-dose vial of Lidocaine HCL (Hydrochloride) 1 % (percent) 50mg (milligram)/5ml located on top of the medication room counter. This Lidocaine HCL 1 % vial did not have a date when opened or a label identifying the resident the Lidocaine was being used for.On 2/23/26 at 9:32 AM V13 (RN/Registered Nurse) stated she had used the open bottle of Lidocaine for R1, and the bottle of Lidocaine was not labeled with R1's name or the date that it was opened. V13 also verified the open Lispro injector pen was being used for R11 and did not have a label with R11's name or the date the injector pen was opened.On 2/24/26 at 11:00 AM V3 (Assistant Director of Nursing) stated all medication multi-dose vials and insulin multi-dose injector pens should be labeled with the dates they are open, residents' names, and expiration dates.

Based on interview, observation, and record review, the facility failed to implement standard infection control precautions, failed to apply a gown prior to providing high-contact care for a resident with a wound, and failed to perform hand hygiene during incontinence care for one of one resident reviewed (R12) for Infection control Precautions in the sample of (37). Findings include:The Enhanced Barrier Precautions Sign, undated, documents Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities- Dressing, Bathing/Showering, Transferring, Changing Lines, Providing Hygiene, Changing Briefs or Assisting with Toileting, Device Care or Use: Central Line, Urinary Catheter, Feeding Tube, Tracheostomy, Wound Care (any skin opening requiring a dressing).The Enhanced Barrier Precautions, dated 5/1/20, documents Definition: EBP (Enhanced Barrier Precautions) expand the use of PPE (Personal Protective Equipment) beyond situations in which exposure to blood and body fluids is anticipate, and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's (Multidrug-Resistant Organisms) to staff hands and clothing. Because EBP's do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be a longer-term approach to managing individuals colonized with targeted pathogens. Procedure: 1. All barriers as indicated in Standard Precautions, plus: C. Examples of high-contact resident care activities requiring gown and glove use for EBP include: Dressing, Bathing/Showering, Transferring, Providing Hygiene, Changing Linens, Changing Briefs or Assisting with Toileting, Device Care or Use: Central Line, Urinary Catheter, Feeding Tube, Tracheostomy/Ventilator, Wound Care: any skin opening requiring a dressing.The facility's Incontinence/Perineal Care Policy, dated 10/16/14, documents, Definition: Prolonged exposure to urine and feces produces excessive hydration of the skin that causes increased friction, increased skin permeability, increased microbial flora, and increases the PH (Potential of Hydrogen) of the skin. All these factors compromise skin integrity. Policy: Procedure: Female Resident: 6. Clean the rectal area. Clean from the vagina to the anus with one stroke. Repeat until the area is clean. Use a clean portion of the rag for each stroke. Use as many washcloths as needed. 7. Rinse the rectal area with a washcloth. Stroke from vagina to the anus. Repeat the steps using a different part of the washcloth for each stroke. 8. Pat the area dry with the towel. 9. Remove soiled gloves, wash hands, and don (put on) clean gloves. 11. Apply incontinent pad.On 2/25/26 at 10:45 AM R12 was lying in her bed. V8/Licensed Practical Nurse provide pressure ulcer treatment to R12's coccyx and did not wear a gown. R12 has a stage two pressure wound to her coccyx. V8 stated I did not wear a gown during (R12's) wound care because I was told this time we did not have to. The last time (R12) had the same wound in the same area we had to, so I am not sure why we don't this time.On 2/25/26 at 10:50 AM V20/CNA (Certified Nursing Assistant) was preparing to perform incontinent care for R12. V20 donned gloves but did not put on a gown. V20 proceeded to wash (R12's) groin area. Using the same soiled gloves, V20 placed a new adult brief on R12, pulled R12's pants up, and repositioned R12 in the bed. V20 stated, I thought I should have worn a gown while providing care to (R12) since (R12) has an opened wound, but I was told not to wear one. I should have removed my gloves and washed my hands before placing a new brief on (R12), pulling (R12's) pants up, and repositioning (R12) in bed.On 2/25/26 at 11:15 AM V16/Infection Preventionist stated R12 was not placed in EBP due to R12's wound being a stage two, having no slough, and not looking infected. V16 verified the wound is open and the staff should be utilizing clean techniques while performing wound and incontinence care.

Based on interview and record review, the facility failed to ensure a resident was provided timely provider notifications to ensure medical intervention was received with an acute change in condition for one of four residents (R1) reviewed for change in condition in the sample of four. This failure resulted in R1 experiencing a delay in evaluation and treatment while experiencing an acute ischemic stroke.Findings include:The facility's Change in Resident Condition Policy, dated 10/8/24, documents, Standard: The attending physician, resident representative, and RCC (Resident Care Coordinator) will be notified of any change in the condition of a resident. Policy: A significant change in a resident's condition must be relayed to the physician, resident, representative, RCC, and DON (Director of Nursing) or ADON (Assistant Director of Nursing) timely. Procedure: 2. Any significant change in a resident's condition must be immediately relayed by phone to the attending physician and the resident representative. In addition, notify the supervisor, RCC, DON, or ADON. A significant change in condition is a major decline in a resident's status that will not normally resolve itself without interventions. A significant change in condition may include but not be limited to the following: B. Emergent Situations: Symptoms such as chest pain, loss of consciousness, or other signs or symptoms of heart attack or stroke that may signify a significant change. Sudden unexpected decline in a resident's condition. 4. Call the physician or provider on-call for questions, concerns, or any significant change in condition.R1's Face Sheet documents R1 is an [AGE] year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Postprocedural hemorrhage of right eye and adnexa following other procedure, Repeated Falls, Tinea Pedis, and Encephalopathy.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 is cognitively intact and requires supervision or touching assistance with ambulation, sitting to standing, and transfers. This same MDS documents R1 has no impairments to R1's upper or lower extremities.R1's Care Plan, dated 7/8/25, documents, Problem Start Date: 07/08/2025 ADLs (Activities of Daily Livings) Functional Status/Rehabilitation Potential: (R1) requires varying levels of assist d/t (due to) Weakness, Ataxia and Edema. Approach Start Date: 07/08/2025 Report any further deterioration in status to physician.R1's Progress Note, dated 9/11/25 and signed by V9/Agency LPN (Licensed Practical Nurse), documents, (R1) was complaining of left leg weakness and vision problems. (R1) was seen yesterday by (V4/R1's Nurse Practitioner) for these issues. (R1) weakness increased with left leg, needing assistance to transfer to the bathroom. Vital Signs in normal range, ask (R1) if she was in pain, dizzy, or having headache, (R1) voiced no, but her vision was not good and left leg weak. (R1) ate well both meals talking well, took (R1) to the bathroom and to chair to elevate legs, (R1) took a nap. Checked on (R1) her head was down to neck and looked uncomfortable in chair, (R1) woke up and complaints of pain in neck. (R1) asked to go the bathroom (R1's) left arm was flaccid, (R1) transferred two assists. (R1) request to be seen. This same progress documents V10/Nurse Practitioner was notified and gave an order to send R1 to local emergency room.R1's local ED (Emergency Department) Note, dated 9/11/25, documents, Chief Complaint: Stroke-Like Symptoms. (R1) is an [AGE] year-old who presents to the ED with complaints of stroke-like symptoms that began today. (R1) reports waking up with vision problems and requiring assistance to go to the bathroom. This same ED Note documents, Critical Findings: Acute Ischemic Stroke. Admit to Hospital.R1's Hospital Discharge Orders and Summary, dated 9/14/25, documents, Admitting Diagnoses: Left-Sided Weakness and Stroke.On 9/18/25 at 11:46 AM, R1 stated a day or two before being admitted to the hospital on [DATE], R1 experienced changes in vision and reported having leg cramps. A Nurse Practitioner, identified as V4, reportedly saw R1 the day before R1's hospital admission and initiated new orders. The day of R1's hospital admission, before lunch, R1 reported her vision changes became more severe, and developed weakness to her left leg. R1 used her call light because she was too weak to transfer on her own and had to use the bathroom. R1 stated, Two staff members had to assist me to the bathroom. I could not move my left leg and I reported my vision was getting worse. R1 reported a nurse, identified as V9/Agency LPN, came down and assessed R1 and told R1, V4/Nurse Practitioner, had previously assessed R1 the day prior, so V9 was just going to monitor R1. R1 stated, I went to lunch and my vision was getting worse and my left leg was extremely weak. Again, (V9) told me (V4) had just seen me the day prior, so she pushed me down to my room, assisted me to my recliner, and elevated my legs. (V9) told me to try and rest. Around two to three hours later, I put back on my call light to get help with using the bathroom. At this time, I was unable to move my left leg, my left arm, and could hardly see. It took two staff members to assist me to the bathroom once again. (V9) finally sent me out to the ED.On 9/18/25 at 1:27 PM, V11/CNA (Certified Nursing Assistant) stated she was working with R1 on 9/11/25, the day R1 was sent out to the local hospital. V11 stated, (R1) did not complain of anything early that morning. Right before lunch (R1) had turned on her call light. (V12) and I went to (R1's) room and (R1) was visibly upset saying she needed to use the bathroom. (R1) expressed to me that something was wrong with her vision and her left leg. (R1) was complaining of weakness on her left side and could not physically lift her left leg. (V12) and I assisted (R1) to the bathroom. As we stood (R1) up to hold on to the grab bars in the bathroom, (V12) and I had to manipulate (R1's) left leg to get her positioned correctly to sit on the toilet. (R1) was unable to move her left leg which was out of character for (R1). V11 expressed R1 never utilizes her call light or asks for assistance. V11 reported she notified V9/Agency LPN to let her know about the new concerns with R1, V9 came to examine R1 and stated since V4 had already seen her the day prior, V9 would just monitor R1. V11 stated, I did express to (V9) that something was not right with (R1) and that (R1) never requires assistance.On 9/18/25 at 1:35 PM, V9/Agency LPN verified she was the nurse taking care of R1 on 9/11/25, the day R1 was sent to the local hospital. V9 stated, Before lunch I was called to (R1's) room. (R1) was complaining of her left leg being weak and having some vision trouble. (R1) required more assistance at that time to go to the bathroom. I had read (R1's) notes and (V4) had been in to see her the day prior for leg cramps and vision changes. I let (R1) know that and told (R1) I would monitor her. I did not call a physician at that time. (R1) ate lunch fine but was still complaining of some vision changes and left leg weakness. I let (R1) know that (V4) had written an order for (R1) to see an ophthalmologist again, and that I would push (R1) to her room and assist her withing propping her leg up in the recliner and told (R1) to try and rest. When (R1) woke up around 3:00 PM, (R1) was complaining of neck pain. (R1) was talking fine and responding fine but stated her left leg didn't feel right. I called (V12/CNA) to assist me with taking (R1) to the bathroom. At that time (R1's) mobility decreased even more. I then called (V10/Nurse Practitioner) at that time and got (R1) sent out to the local hospital. V9 reported when V9 typed R1's assessments in R1's progress note, V9 did not document correct times of when R1 was complaining of everything. V9 verified she typed everything that occurred throughout the day in one progress note right before she sent R1 out to the local hospital. V9 confirmed she should have documented R1's events throughout the day as they occurred at the correct times.On 9/19/25 at 10:43 AM V12/CNA stated, I was getting resident's up for lunch, when (R1) had put on her call light sometime between 11:00 AM and 11:30 AM. It was weird that (R1) had her call light on because (R1) is independent and never uses her call light. (V11/CNA) and I both went down to (R1's) room. (R1) was saying her eyes were bothering her, (R1) couldn't see how she normally could, and that (R1) couldn't really move her left leg. (R1) stated she was needing to go to the bathroom. (V11) and I assisted (R1) to the bathroom. When (V11) and I assisted (R1) up to the grab bar in the bathroom, (R1) could hardly move her left leg and (V11) and I had to help guide it, to get (R1) on the toilet. (V11) went and got (V9/Agency LPN) because something was not right with (R1). (R1) never requires assistance. (V9) came to (R1's) room, but basically just told (R1) that (V4/R1's Nurse Practitioner) was already aware from the day prior and that (V9) would just monitor (R1). I am not sure how (R1) got back to her room after lunch because I was called to work on a different unit for a few hours. When I got back to the floor (V9) had asked me if I could come to (R1's) room and help (V9) assist (R1) to the bathroom. This was around 3:00 PM. When I got to (R1's) room (R1) stated she now was unable to move her left arm. I believe right after that is when (V9) got (R1) sent out to the hospital.On 9/18/25 at 12:39 PM, V4/R1's Nurse Practitioner stated she saw R1 on 9/10/25 at the facility. R1 told V4 she was having cramps in her legs, and it was worse at night along with vision changes. V4 stated she did initiate orders for V4, but at that time didn't see any stroke-like symptoms. V4 stated, (R1) could move her left leg up and down when I had seen her and had no problems with weakness. I did initiate orders for (R1's) complaints of leg cramps. I would have expected the facility to notify (V17/R1's Physician) or myself right away if (R1's) if (R1) was experiencing increased weakness or required more assistance with ADL's (Activities of Daily Living).On 9/19/25 at 10:02 AM, V2/Director of Nursing verified she would have expected a nurse to notify the resident's provider immediately with any significant changes in a resident's condition like R1 was experiencing on 9/11/25 when R1 first was requiring more assistance with ADL's and complaining of increased weakness and more severe vision changes.

Based on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions for 2 (R1 and R3) of 3 residents reviewed for wound care in a total sample of 5. Findings Include:The facility's undated Enhanced Barrier Precautions policy documents: It is the policy of the facility to use Enhanced Barrier Precautions in addition to standard precautions as a method of infection control, requiring the use of gown and gloves in situations of high-contact resident care. Definition: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms. EBP requires gown and glove use during high-contact resident care activities and prevents the spread of infection to and among residents and staff. EBP will also be initiated for all residents with indwelling medical devices such as, but not limited to central lines, urinary catheters, feeding tubes and tracheostomies. A peripheral intravenous line (not peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. Resident with wounds such as but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers will also be placed on EBP. In addition to following Standard Precautions, gowns and gloves should be worn during the following: Wound care; any skin opening requiring a dressing. 1.R1's medical record indicates R1 was admitted [DATE], with diagnosis to include but not limited to atherosclerosis of native arteries with intermittent claudication bilateral lower extremities, chronic kidney disease, and hypertension. On 7/17/25 at 9:30 AM, V5 (Registered Nurse) performed R1's wound care as ordered by the physician. V5 only wore gloves during wound care. During the cares, V5 stated R1 is not on Enhanced Barrier Precautions because R1's wound drainage has never seeped through the dressing, and R1 has never been diagnosed with a MDRO (Multi-drug Resistant Organism).2.R3's Medical Record documents she was admitted in 6/13/25, with diagnosis to include but not limited to systemic scleroderma. R3 was admitted with two pin point open areas between her 3rd and 4th toes on the right foot. On 7/17/25 at 10:15 AM, V5 (Registered Nurse) performed R3's scheduled wound care as ordered by the physician. V5 only wore gloves during the wound care. During the cares, V5 stated R3 was not in Enhanced Barrier Precautions because the drainage from her wound has never soaked through her primary dressing,On 7/17/25 at 11:45 AM, V2 (Director of Nursing) confirmed EBP (Enhanced Barrier Precautions) should be used with every resident who has a wound, regardless of the drainage being contained by the dressing or not.

Based on record review and interview, the facility failed to provide documentation by a physician regarding the basis of a resident's involuntary discharge with indications for why a resident should not return to the facility following hospitalization , what resident needs could not be met at the facility, what the facility's efforts were to meet those needs, and the specific services the receiving facility could provide to meet the needs of the resident which could not be met at the facility for one of three residents (R1) reviewed for involuntary discharge in the sample of four. Findings include: R1's Progress Notes, dated 8-31-24 at 4:00 PM, document R1 was sent to the emergency room by ambulance due to R1 having combative behaviors, threatening staff and (V10/R1's Family Member), hallucinating, and having increased paranoia. R1's Progress Notes, dated 9-1-24 at 2:16 AM, document R1 was being admitted to the hospital for treatment of a urinary tract infection and chronic kidney disease. R1's Progress Notes, dated 9-12-24 at 3:00 PM and signed by V4/Admission's Coordinator, document, Admissions: Spoke with (V1/Administrator) and (V2/Director of Nursing) about (R1's) possible return to (the facility). They (V1 and V2) feel that (R1's) condition has changed to a point that our staff can no longer meet (R1's) needs. Notified (V8/Hospital Case Manager) and (V10) that (R1) cannot return to (the facility) due to his condition changing to a point that our staff can no longer meet (R1's) needs. (R1) will be discharged from (the facility) to the hospital effective today 9-12-24. R1's Medical Record and Physician's Orders, dated 8-31-24 to 10-26-24, do not include documentation by V17/R1's Physician regarding the basis of R1's involuntary discharge with the indications for why R1 should not return to the facility following hospitalization , what needs of R1 could not be met at the facility, what the facility's efforts were to meet R1's needs, and the specific services the receiving facility could provide to meet R1's needs of which could not be met at the facility. On 10-25-24 at 11:05 AM, V9 (Nurse Practitioner) stated, I cover for (V17/R1's Primary Physician). I was not consulted by the facility when the facility decided not to let (R1) come back. I know (V17) was not consulted, either therefore there was no documentation by (V17) or myself of why the facility could not meet (R1's) needs. I did not know the decision was being made to not re-admit (R1) back to the facility. On 10-25-24 at 1:30 PM, V1 (Administrator) verified the facility does not have an involuntary discharge policy and did not receive an order or get documentation by V17/R1's Physician regarding the basis of R1's involuntary discharge with the indications for why R1 should not return to the facility following hospitalization , what needs of R1 could not be met at the facility, what the facility's efforts were to meet R1's needs, and the specific services the receiving facility could provide to meet R1's needs of which could not be met at the facility. V1 stated, I did not know we (the facility) need to have documentation by the physician in (R1's) record with the reason for (R1's) discharge with the needs the facility could not meet.

Based on record review and interview, the facility failed to notify the resident, resident's representative, and the Ombudsman in writing of the reasons for discharge for one of three residents (R1) reviewed for involuntary discharge notice in the sample of four. Findings include: The Ombudsman's Residents' 'Rights for People in Long-Term Care Facilities policy, dated 11/2018, documents, You have the right to keep living in your facility. You must be given written notice if your facility wants you to move from the facility. The notice must: tell you why your facility wants you to move; tell you how to appeal the decision to the Illinois Department of Public Health; and provide a stamped and addressed envelope for you to mail your appeal in. R1's Progress Notes, dated 8-31-24 at 4:00 PM, document R1 was sent to the emergency room by ambulance due to R1 having combative behaviors, threatening staff and (V10/R1's Family Member), hallucinating, and having increased paranoia. R1's Progress Notes, dated 9-1-24 at 2:16 AM, document R1 was being admitted to the hospital for treatment of a urinary tract infection and chronic kidney disease. R1's Progress Notes, dated 9-12-24 at 3:00 PM and signed by V4/Admission's Coordinator, document, Admissions: Spoke with (V1/Administrator) and (V2/Director of Nursing) about (R1's) possible return to (the facility). They (V1 and V2) feel that (R1's) condition has changed to a point that our staff can no longer meet (R1's) needs. Notified (V8/Hospital Case Manager) and (V10) that (R1) cannot return to (the facility) due to (R1's) condition changing to a point that our staff can no longer meet (R1's) needs. (R1) will be discharged from (the facility) to the hospital effective today 9-12-24. R1's Medical Record, dated 8-31-24 to 10-26-24, does not include documentation of R1, V10/R1's Family Member, or V16/Ombudsman being given a notice of discharge regarding the basis of R1's involuntary discharge with the indications of why R1 should not return to the facility following hospitalization , what needs of R1 could not be met at the facility, what the facility's efforts were to meet R1's needs, and the specific services the receiving facility could provide to meet R1's needs of which could not be met at the facility. On 10-25-24 at 11:28 AM, V10 (R1's Family Member) stated, I was not provided a written notice of (R1's) discharge from the facility. On 10-25-24 at 1:30 PM, V1 (Administrator) verified the facility did not provide R1, V10/R1's Family Member, or V16/Ombudsman a notice of discharge regarding the basis of R1's involuntary discharge with the indications for why R1 should not return to the facility following hospitalization , what needs of R1 could not be met at the facility, what the facility's efforts were to meet R1's needs, and the specific services the receiving facility could provide to meet R1's needs of which could not be met at the facility. On 10-25-24 at 4:00 PM, V16/Ombudsman, stated, The facility never notified me that they were refusing to re-admit (R1) back to the facility from the hospital. I should have received a written notice. It is important that I get a notice so I can meet with the resident and the resident's family to ensure they know their appeal rights and I can help to ensure (R1) gets proper placement at another facility to meet his needs.

Based on record review and interview, the facility failed to provide a bed hold notice to a resident and a resident's representative upon transfer to the hospital for one of three residents (R1) reviewed for bed hold notice in the sample of four. Findings include: The facility's Bed Hold and Readmission Policy, dated 10-26-18, documents, Purpose: The primary purpose of the policy for bed hold and readmission to (the facility) is to establish uniform guidelines for the resident, family member, or legal representative in the event a resident is transferred to a hospital, to another level of care, or takes a leave of absence from the home. A written copy of the bed-hold policy will be provided to the resident at the time of transfer for hospitalization or therapeutic leave. R1's Progress Notes, dated 8-31-24, document R1 was sent to the emergency room and admitted to the hospital. R1's Medical Record does not include documentation of a bed hold noticed being given to R1 nor (V10/R1's Family Member) after R1 was sent to the hospital on 8-31-24. On 10-25-24 at 11:28 AM, V10 (R1's Family Member) stated, Me and (R1) were not given a bed hold notice when (R1) was sent to the hospital on 8-31-24. I do not even know what that notice is about. On 10-26-24 at 10:15 AM, V2 (Director of Nursing) stated, We (the facility) did not send a bed hold notice to (V10) and there is no documentation in (R1's) medical record of the facility giving (R1) a bed hold notice.

Based on observation, interview, and record review, the facility failed to use the Heat Stickers to ensure dishes reach the correct/required surface temperature when in the rinse cycle in the dish machine and failed to have staff wash hands with soap and water as required between handling dirty dishes and clean dishes in the dish room. This has the potential to affect all 101 residents living in the facility. Findings: 1. The document, Dish Machine Temperature Recording for Food Service Staff Policy, 4/2024, states, It is the policy of the Food Service Department that the acceptable wash temperature (should be) 150 - 165 degrees Fahrenheit (F) and the acceptable rinse temperature is 180 degrees F or above. Any temperature reading below 150 degrees F wash, or 180 degrees F rinse should be noted, and a department supervisor or designee notified. On 8/12/24 at 10:55 AM, V5, Assistant Dietary Manager, stated, We do not use the Surface Temperature Stickers for the dish machine. You (Illinois Department of Public Health (IDPH) Surveyor) had me get the (surface temperature stickers) last time, and I ended up throwing them away because they became outdated. Writer inquired if the surface temperature stickers were being used as required after the IDPH surveyor was last at the facility. V5 did not respond to the question stating, I've been told that we do not need to use the surface temperature stickers. I put a thermometer in the rack and send it through the dish machine. If it registers 160 degrees F, then it's okay. V15, Dietary Manager, has a calculation that shows the temperatures reach what they should. Writer explained without using the surface temperature stickers, it would be unknown if they reached the appropriate surface level of heat for dishes, utensils, glasses, etc . V5 stated, No one else requires the surface temperature stickers to be used. Why do you? I will get (V15) to explain that we don't need the surface temperature stickers. When V15 was asked about this issue, V15 stated, Yes the surface temperature stickers should be used, and I will order them right away. 2. The document, Handwashing, dated 2/2024, states, Proper handwashing technique is used for the prevention of transmission of infectious diseases. A policy for when it is required to wash hands when in the kitchen was requested. The facility states that they do not have a specific policy of when to wash hands, including when staff are using the dish machine. On 8/12/24 at 11:05 AM, V6, Dietary Aide, was observed putting dirty dishes and equipment into racks and sending the soiled dishes through the dishwasher. V6 then reached up, got a squirt out of the sanitation solution container that is affixed to the wall next to the dishwasher and above the area where the dirty dishes are racked. V6 rubbed his hands together and then proceeded to take clean dishes and other clean equipment out of the just washed items in the racks and put them on a cart to be taken into the kitchen. V6 stated. Yes, I always use the sanitation solution. On 8/12/24 at 11:10 AM, V5, Assistant Dietary Manager, stated, I noticed that they didn't have a handwashing sink in the dish room, but use the sanitizer solution when I started working here. I was told that a hand washing sink would not be put in the dish room. Staff should go into the kitchen and wash their hands between handling the dirty dishes and clean dishes. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671, dated 8/12/24, signed by V2, Director of Nursing, documents 101 residents currently reside within the facility.

Based on record review and interview, the facility failed to report bruises of unknown origin to the State Agency for two of two residents (R35 and R81) reviewed for abuse in the sample of 34. Findings include: Abuse Prevention Program Facility Policy, dated 6/19/2021, documents, Internal Reporting Requirements and identification of Allegations: Any reasonable suspicion of a crime against a resident or individual receiving care from the facility, including but not limited to, alleged violations of abuse, neglect, exploitation of mistreatment including injuries of unknown source and misappropriation of resident property must be reported to the state survey agency (IDPH/Illinois Department of Public Health) under the following time frames: Alleged Abuse or Serious Bodily Injury - Immediately but no later than 2 (two) hours after forming the suspicion. Allegation of neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury -not later than 24 hours after forming the suspicion. Reports should be documented in a record kept of the documentation. An injury should be classified as an injury of unknown source when both the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g. (for example), the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injury overtime. 1. R35's MDS (Minimum Data Set) Assessment, dated 6-7-24, documents R35 is severely cognitively impaired. R35's Progress Notes, dated 7-21-24 at 1:59 PM, documents, While taking (R35) to the bathroom noted a ten cm (centimeter) round dark purple bruise to rt (right) hip. possibly from bumping on shower chair or bars on toilet. R35's Progress Notes, dated 4-8-24 at 5:36 AM, documents, (R35) was provided (a) shower this am and a bruise on left inner thigh (was found) measuring nine inches by eight inches was noted. Area is dark blue/black in color. (R35) states that it does not hurt. R35's Event Report, dated 4-8-24 and signed by V8 (LPN/Licensed Practical Nurse), documents, Bruise to left inner thigh. Was event witnessed? No. Color black, blue. Size nine cm (centimeters) by eight inches. R35's Event Report, dated 7-21-24 at 1:58 PM and signed by V7 (LPN/Licensed Practical Nurse/LPN), documents, Dark purple bruise to right hip 10 cm round. Was event witnessed? No. R35's Medical Record does not include R35's bruises of unknown origin found on 4-8-24 or 7-21-24 being reported to IDPH (Illinois Department of Public Health) On 08/13/24 at 1:30 PM V2 (Director of Nursing/DON) stated, Both of (R35's) bruises were unwitnessed. I did not report (R35's) bruises of unknown origin to the state (IDPH). 32875 2. R81's current electronic Medical Record documents R81 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Parkinson's Disease with Dyskinesia, Dementia, Malignant Neoplasm of Uterine Adnexa, Depression, Polyneuropathy, and Anxiety. R81's MDS Assessment, dated 6/10/24, documents R81 has a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate cognitive impairment. R81's Nursing Note written by V9/Licensed Practical Nurse/LPN, dated 7/18/24 at 9:46 AM, documents, CNA (Certified Nursing Assistant) came to this nurse and said (R81) has a dark purple bruise on back of right leg, bruising with redness on rt (right) upper leg, and several discoloration areas on both of (R81's) arms. R81's Event Report, dated 7/18/24 at 9:54 AM and signed by V9 (LPN/Licensed Practical Nurse/LPN), documents, Right leg bruise is three cm/centimeters by two cm, upper right leg five cm by three cm, and several two cm discolorations to both arms. The bruises are purplish black and reddish blue in color with mild pain. Was event witnessed? No. Residents Statement Doesn't know how it happened. On 8/14/24 at 1:15 PM, V2, Director of Nursing/DON stated she does not know how R81 got the bruises to her legs and arms, but assumes it was from when a family member helped R81 to the bathroom. V2 also stated there was no notification sent to the State Agency to report the bruises on R81.

Based on observation, interview, and record review, the facility failed to respond immediately to a sounding exit door alarm, failed to adequately supervise a known wandering resident (R8), failed to re-assess R8 as high risk for elopement once R8 started to exit seek, failed to develop and implement interventions and plan of care to address R8's exit-seeking behaviors after R8 attempted to exit seek, and failed investigate and report R8's elopement thoroughly for one of three residents (R8) reviewed for elopement in the sample of 41. These failures resulted in R8, a severely cognitively impaired resident with the diagnosis of Dementia, eloping from the facility approximately 70 feet from the facility, falling, and being found on the curb next to the road, after attempting to exit the building earlier that evening on 6-7-23. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8-19-23, the facility remains out of compliance at a severity Level II as the facility continues to investigate R8's elopement on June 7, 2023, and provide a final report to IDPH within five days, provide in-servicing to all staff on R8's elopement interventions and the facility's Elopement Policy, including the Administrator/V11 upon her return to the facility on [DATE], residents are assessed quarterly and with a change in condition or when exhibiting exit seeking behavior for elopement risk, and each exit-seeking episode by residents will be audited by V13 (Compliance Officer) and re-education will be provided and disciplinary action for noncompliance will be given as necessary. Findings of all audits and re-education will be reported to the QAA (Quality Assurance Assessment) committee and the compliance committee on a quarterly basis and reviewed monthly by the QAPI (Quality Assurance and Performance Improvement) committee. Findings include: The facility's Resident Elopement Policy, dated 6-12-18, documents, Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. All staff are responsible. Missing resident shall be defined as a resident who has left the main building without signing him/herself out of the facility. Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility: Door alarms on facility exits, code alert bracelet, staff supervision of facility exits, and pictures of residents at risk for elopement will be kept at the front desk for quick identification. Elopement assessment will be done on admission, quarterly, and change in condition which puts them at risk for elopement. Residents at risk for impaired safety awareness and wandering as well as elopement shall be identified by the elopement assessment and interventions documented in the individual plan of care. Residents at risk for elopement shall be identified on the Resident Watch List with accompanying photograph as well as in the clinical record, The list shall be updated whenever new resident safety issues are identified. Photographs of each resident are located in the Medication Administration Record, face sheet, and front receptionist desk. When responding to an exterior door alarm: If a resident is found leaving the building, attempt to prevent departure. After assessing resident's behavior, nursing administration will determine the need for ever 15 minute/ever one hour documented checks. Care plan session will be held to review/modify care plan approach. Procedures for missing resident and/or elopements: Notify the Administrator. R8's Physician's Order Sheets, dated 8-1-23 through 8-31-23, document R8 has the diagnoses of Dementia without behavioral disturbance, Psychotic Disturbances, Mood Disturbance, and Anxiety. R8's MDS (Minimum Data Set) Assessment, dated 6-26-23, documents R8 is severely cognitively impaired and requires supervision of one staff physical assistance for locomotion of and on the unit and walking in his room and in the corridor, and requires extensive assistance of one person physical assistance for transfers. R8's PASRR (Preadmission Screening and Resident Review), dated 4-2-22, documents, You know who you are but you do not know where you are, why the time, or date. You are not able to focus and our mood changes a lot. You need supervision. R8's Event Report, dated 6-7-23 at 5:30 PM, and signed by V3 (RN/Registered Nurse) documents, Resident was found between double doors of the east exit of Eastbrook Lane (floor within facility). Combativeness and resisting redirection from staff prior to elopement. New onset of agitation and confusion. Immediate measures taken-returned resident to room. Interventions ineffective. R8's Progress Notes, dated 6-7-23 at 5:30 PM and signed by V3 (RN/Registered Nurse), document, (R8) attempted to leave through the east door on Eastbrook Lane (floor within facility). (R8) stopped and escorted back to his room. (R8) was not using his walker at the time. (R8) stated that he wanted to get his keys out (of) his car. Nurse and CNA (Certified Nursing Assistant/V8) re-directed him. Nurse grabbed walker and nurse and CNA (V8) escorted him back to his room. R8's Event Reports, dated 6-7-23 at 7:00 PM and signed by V3, documents, (R8) exited through the south side door on Eastbrook. (R8) was found by road next to cottage at about 7:00 PM. Combativeness, elopement attempts, and resisting redirection from staff behaviors exhibited prior to elopement. New onset of agitation, resistiveness, and restlessness. Resident was laying on ground next to road by cottages on his side. He was picking flowers in the grass. R8's Progress notes, dated 6-7-23 at 7:05 PM and signed by V3, documents, (R8) has an unwitnessed fall following an elopement. (R8) exited the unit through the south door of (facility unit). (R8) was found laying on his side in the grass with his walker next to him. He has no complaints of pain. Assessment showed no injuries. (R8) was wearing shoes in good repair and was using his walker. (R8) was found by nurse and CNA (Certified Nursing Assistant) (V8) who used (mechanical lift) to get (R8) off the ground and into his wheelchair. Placed resident next to nurses station and placed on 15 minute checks. R8 did not have a comprehensive care plan developed regarding R8's wandering, exit-seeking, or elopement until 7-3-23 (26 days after R8's elopement). R8 did not have an elopement risk assessment completed once R8 started exhibiting exit-seeking behaviors, as directed by the facility's resident elopement policy, until 6-21-23 (14 days after R8's elopement). On 08/14/23 at 10:44 AM, R8 was in his bed. R8 was unable to answer where he was, what time of day it was, or what day it was. On 8-14-23 at 2:10 PM, V3 (RN) stated, On 6-7-23, (R8) has having behaviors and trying to exit-seek. (R8) had exited around 5:30 PM and was found between the double doors of the east exit. (R8) was confused and combative and did not have his walker. I had to get his walker and take (R8) back to his room. I left for supper break and told the CNA's to keep a close eye on (R8) because he was trying to exit-seek. When I came back from the supper break, I heard the end of the south side door alarm going off. None of the staff were responding to the alarm. I went and answered the alarm and asked the staff where (R8) was. Nobody knew where (R8) was. I went outside and found (R8) outside by the road, laying on the curb, between the two cottage buildings. (R8) had fell (sic) to the ground with his walker beside him. I got him up and helped him back inside. I did not notify the Administrator (V11) or Director of Nursing (V1) of (R8's) elopement. On 8-15-23 at 11:45 AM, V7 (CNA) stated, I was on break when (R8) went outside unattended on 6-7-23. I did not know (R8) had tried to exit earlier that night. I am not sure who found (R8) outside or if anything was done to monitor (R8) afterwards. On 8-15-23 at 12:15 PM, V8 (Agency CNA) stated, I was working contract at the facility and did not know (R8) very well. I did not know (R8) had tried to exit-seek earlier that night (on 6-7-23). (V3/RN) did not tell me that (R8) had tried to exit earlier, and did not tell me to monitor (R8) closely. Sometime around 7:00 PM, (V3) yelled at me and said she needed help because (R8) was outside and had fell (sic). I went outside with (V3) and (R8) had fell over the curb and was laying on the curb by the road. Me and (V3) had to use the mechanical lift to get (R8) back up off the ground and into a wheelchair. (R8) was not hurt. I wheeled (R8) back into the building. I am not aware of (R8) being put on 15 minute checks afterwards. I did not hear the exit-alarm sounding when (R8) went outside because I was in a room with another resident. On 8-15-23 at 12:40 PM, V9 (CNA) stated, On 6-7-23 I came to work at 6:30 PM. I did not know (R8) had try to exit earlier that night (on 6-7-23). I heard an alarm going off and thought it was the alarm where the residents who smoke go outside. I did not realize (R8) had eloped. On 8-14-23 at 2:00 PM, V2 (Director of Nursing) stated, I did not report to IDPH (Illinois Department of Public Health) when (R8) eloped. I was not told that (R8) had gotten outside unattended, so no investigation was done. I only was told (R8) had tried to exit. There were no exit-seeking or elopement interventions implemented or an elopement risk assessment completed once (R8) started to exit-seek on 6-7-23. The Immediate Jeopardy was identified to have started on June 7, 2023, when the facility failed to provide adequate supervision and implement elopement interventions after R8 was found attempting to exit-seek around 5:30 PM and then later that night around 7:00 PM R8 eloped from the facility approximately 70 feet from the facility, falling, and being found on the curb next to the road, unattended by staff. V1 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 8-16-23 at 12:10 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. All staff who were working 8-16-23 through 8-19-23 were educated by V14 (Education Coordinator) on the facility's Elopement Policy including assessing residents for elopement risk, response to alarms and elopement attempts and when to implement elopement interventions once the resident starts to exit-seek, and R8's specific elopement interventions including moving R8 to a room near the nurses station, doing hourly rounding of R8's location, applying an electronic monitoring bracelet to R8's ankle, and including R8's name on the facility's elopement risk list. 2. V14 educated V15 (Associate Administrator), V1 (DON), and V2 (Assistant Director of Nursing/ADON) regarding the Resident Elopement Policy including assessing residents for elopement risk, investigation and reporting requirements, response to an elopement attempt/when to implement elopement interventions once the resident starts to exit-seek, and reviewed R8's elopement interventions. 3. V1 (DON) submitted an initial report to IDPH regarding R8's elopement. 4. V1 (DON), V2 (ADON) and V12 (Resident Care Coordinator) reviewed R8's elopement interventions, and R8's elopement care plan was updated on 8-16-23 to include moving R8 to a room near the nurses' station, doing hourly rounding of R8's location, applying an electronic monitoring bracelet to R8's ankle, and including R8's name on the facility's elopement risk list. 5. All residents at risk for elopement were placed on hourly staff monitoring and nurses documented the rounding on the electronic medication administration records.

Based on observation, interview, and record review, the facility failed to ensure the facility's COVID-19 (Coronavirus Disease 2019) Infection Prevention and Control Program policy was followed, failed to screen all staff for COVID-19 symptoms before the start of their scheduled shifts, filed to remove symptomatic employees from work immediately, failed to test and quarantine employees who had symptoms of COVID-19 immediately, and failed isolate residents who were unvaccinated or not up to date with the COVID-19 vaccination immediately after exposure to COVID-19 positive employees. These failure affected 24 of 24 residents (R4, R7, R12, R20, R22, R26, R38, R45, R49, R51, R63, R64, R72, R83, R85, R87, R88, R90, R91, R93, R94, R100, R107, R256) reviewed for COVID-19 infection control procedures in the sample of 60. These failures resulted in numerous symptomatic COVID-19 positive staff working directly with residents, resulting in an outbreak of COVID-19 within the facility and 24 residents developing symptomatic COVID-19 (a severe acute respiratory syndrome). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9-8-22, the facility remains out of compliance at a severity Level II as the facility continues to screen and audit to ensure employees screen prior to their shift for COVID-19, test employees and residents who are symptomatic for COVID-19 immediately, remove employees from the facility immediately who have symptoms of COVID-19, isolate residents who are not up to date with the COVID-19 vaccination or are unvaccinated and have direct contact with anyone who is COVID-19 positive, in-service staff on the facility's COVID-19 Infection Prevention and Control Program policy, and report audits/findings to the Quality Assurance Committee monthly. Findings include: The facility's COVID-19 Infection Prevention and Control Program policy, dated 3-22-22, documents, Description: (The facility) has developed a COVID-19 infection prevention and control program to decrease the risk of residents and staff becoming infected with [CONDITION(S)]-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), the virus that causes COVID-19. Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting, requires aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. Policy: It is the policy of (the facility) to implement COVID-19 infection prevention and control policies and procedures under the recommendation and guidance of the Centers for Disease Control and Prevention (CDC), (State agency), and the (Local Health Department/ACHD) to decrease the risk of COVID-19 transmission to our residents. Leadership Responsibilities: Administrative Leadership- Responsibilities: to develop, implement, and oversee the facility COVID-19 Infection Prevention and Control policies and procedures, to stay current on changes and updates to any provided guidance from the state and federal governing authorities to delegate facility departmental tasks to adhere to changes in restrictions and infection control precautions, to communicate with ACHD and governing authorities as needed and requested. B. Nursing Leadership- Responsibilities: to oversee and implement COVID-19 Infection Prevention and Control policies and procedures for all direct care staff, to stay current on changes and updates to any provided guidance from the state and federal governing authorities requested, review and store all infection control logs for staff screenings, resident screenings, and infection totals, to ensure an appropriate amount of Personal Protective Equipment (PPE) is available, report infection control information in the daily standup meetings, and as necessary. Testing Plan and Response Strategy: The occurrence and frequency of all future testing will be based upon the results of facility testing, changes in the surrounding community, and the current requirements of state and federal authorities. All future testing will be completed using a contracted testing laboratory (PCR/Polymerase Chain Reaction testing) and/or point-of-care testing. Although PCR testing remains the gold standard for testing, point-of-care antigen (rapid) testing is acceptable. A. When to test: Symptomatic residents and/or staff regardless of vaccination status (testing should take place immediately.) D. Confirmed Positive Tests: If COVID-19 testing results in positive cases of COVID-19 amongst staff and/or residents, the appropriate protocols will be followed to decrease the spread of illness. All confirmed cases will be reported to ACHD and CDC. Employees- Any employee who tests positive or is suspicious for having COVID-19 will immediately leave the facility and follow the instructions from their medical provider and/or health department. E. Facility Response to a Positive Test (Investigation): Affected Neighborhoods (exposed)- If resident is asymptomatic and not up to date and are considered to be a close contact to the individual who tested positive, room quarantine for 14 days even if testing negative. Staff should wear full PPE (Personal Protective Equipment) when providing care to this resident (N95, eye protection, gown, and gloves). Interventions: Employee Screenings- Employees will need to screen at the beginning of each shift using a checklist-based screening protocol in written format. All symptomatic employees must be immediately removed from the resident area, receive a [CONDITION(S)]-CoV-2 rapid test, and sent home. If rapid antigen test is positive, please see confirmed positive tests for employees for further guidance. If rapid antigen test is negative, employee must receive a confirmatory [CONDITION(S)]-CoV-2 PCR (Polymerase Chain Reaction) test and will be restricted from work pending result. Screenings will check for COVID-19 infection criteria in accordance with the CDC. Vaccinations and Vaccine Boosters: COVID-19 vaccinations and vaccine boosters will be offered to all consenting and eligible employees and residents onsite at scheduled dates and times through the [NAME] County Health Department. Additional vaccination locations will be shared with employees as they become available. (The facility) will continue to provide educations and promote the vaccination to all staff, residents, and families who are not up to date. The CDC COVID-19 Data Tracker, dated 8-29-22 through 9-6-22, documents COVID-19 Community Level of contracting COVID-19 as High for [NAME] County Illinois (the county the facility is within). The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2-2-22, documents, Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: A positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus Two) symptoms of COVID-19, close contact with someone with [CONDITION(S)]-CoV-2 infection, or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2. The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus two) Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities website, dated 2-2-22, documents, Manage residents who had close contact with someone with [CONDITION(S)]-CoV-2 Infection: Residents who are not up to date with all recommended COVID-19 (Coronavirus Disease 2019) vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP (Health Care Personnel) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure if they do not develop symptoms. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. 1. R88's Face Sheet, dated 6-30-22, documents R88 is an [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R88's Progress Notes, dated 6-22-22, document, Unit: [NAME] Center. (R88) having symptoms of coughing, clear nasal drainage, and complaints of sore throat, and having weakness. Negative COVID test and us (the facility) sending off a PCR COVID test. Doctor gave orders for Mucinex and Tussin. R88's COVID-19 Antigen Test, dated 6-23-22, documents R88 tested positive for COVID-19. 2. R26's Face Sheet, dated 8-25-16, documents R26 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's COVID-19 Antigen Test, dated 6-26-22, documents R26 tested positive for COVID-19. R26's Progress Notes, dated 6-27-22 at 3:05 PM, document R26 developed symptoms of a runny nose and cough. 3. R91's Face Sheet, dated 10-28-21, documents R91 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's COVID-19 Positive Log documents R91 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-26-22 of loose stools and malaise, and tested positive for COVID on 6-26-22. R91's COVID-19 Antigen Test, dated 6-26-22, documents R91 tested positive for COVID-19. 4. R20's Face Sheet, dated 3-4-22, documents R20 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's COVID-19 Positive Log documents R20 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-26-22 of a cough and congestion, and tested positive for COVID-19 on 6-26-22. R20's COVID-19 Antigen Test, dated 6-26-22, documents R20 tested positive for COVID-19. 5. R72's Face Sheet, dated 12-13-18, documents R72 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R72 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-27-22 of diarrhea and non-productive cough, and tested positive for COVID-19 on 6-27-22. R72's COVID-19 Antigen Test, dated 6-27-22, documents R72 tested positive for COVID-19. 6. R45's Face Sheet, dated 2-19-18, documents R45 is a [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R45 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-27-22 of runny nose and non-productive cough, and tested positive for COVID-19 on 6-27.22. R45's COVID-19 Antigen Test, dated 6-27-22, documents R45 tested positive for COVID-19. 7. R7's Face Sheet, dated 1-2-19, documents R7 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R7 resided on [NAME] Center hallway, and developed symptoms of COVID-19 on 6-27-22 of cough, and tested positive for COVID-19 on 6-27-22. R7's COVID-19 Antigen Test, dated 6-27-22, documents R7 tested positive for COVID-19. 8. R64's Face Sheet, dated 6-16-17, documents R64 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R64 resided on Eastbrook Lane, and tested positive for COVID-19 on 6-27-22. R64's COVID-19 Antigen Test, dated 6-27-22, documents R64 tested positive for COVID-19. 9. R22's Face Sheet, dated 12-08-21, documents R22 is an [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R22 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 6-29-22 of body aches, and tested positive for COVID-19 on 6-29-22. R22's COVID-19 Antigen Test, dated 6-29-22, documents R22 tested positive for COVID-19. 10. R107's Face Sheet, dated 7-15-21, documents R107 is an [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R107 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 7-05-22 of cough and sneezing, and tested positive for COVID-19 on 7-05-22. R107's COVID-19 Antigen Test, dated 7-05-22, documents R107 tested positive for COVID-19. 11. R63's Face Sheet, dated 6-09-22, documents R63 is a [AGE] year-old, with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R63 resided on [NAME] Gardens hallway, and tested positive for COVID-19 on 7-07-22. R63's COVID-19 Antigen test, dated 7-06-22, documents R63 tested positive for COVID-19. 12. R256's Face Sheet, dated 6-22-22, documents R256 is an [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R256 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 7-05-22 of cough and congestion, and tested positive for COVID-19 on 7-07-22. R256's COVID-19 Antigen Test, dated 7-07-22, documents R256 tested positive for COVID-19. 13. R51's Face Sheet, dated 4-20-21, documents R51 is a [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R51 resided on [NAME] Center hallway, and developed symptoms of COVID-19 on 7-05-2022 of being fatigued and confused, and tested positive for COVID-19 on 7-08-2022. R51's COVID-19 Antigen test, dated 7-07-22, documents R51 tested positive for COVID-19. 14. R49's Face Sheet, dated 4-13-21, documents R49 is an [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R49 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 7-09-2022 of confusion, runny nose, weakness, and fatigue, and tested positive for COVID-19 on 7-09-22. R49's COVID-19 Antigen Test, dated 7-9-22, documents R49 tested positive for COVID-19. 15. R83's Face Sheet, documents R83 is a [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R83 resided on [NAME] Brown hallway, and developed symptoms of COVID-19 on 7-13-2022 of congestion and fever, and tested positive for COVID-19 on 7-14-22. R83's COVID-19 Antigen Test, dated 7-14-22, documents R83 tested positive for COVID-19. 16. R100's Face Sheet, dated 7-15-2021, documents R100 is an [AGE] year-old, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R100 resided on [NAME] Brown hallway, and developed symptoms of COVID-19 on 7-16-22 of cough, nausea, and not feeling well, and tested positive for COVID-19 on 7-16-22. R100's COVID-19 Antigen Test, dated 7-16-22, documents R100 tested positive for COVID-19. 17. R38's Face Sheet, dated 6-21-22, documents R38 is a [AGE] year-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R38 resided on [NAME] Brown hallway, and developed symptoms of COVID-19 on 7-16-22 of sore throat and congestion, and tested positive for COVID-19 on 7-16-22. R38's COVID-19 Antigen Test, dated 7-16-22, documents R38 tested positive for COVID-19. 18. R4's Face Sheet, dated 1-23-20, documents R4 is a [AGE] year-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R4 resided on [NAME] Brown hallway, and developed symptoms of COVID-19 on 7-19-22 of hoarseness and cough, and tested positive for COVID-19 on 7-19-22. R4's COVID-19 Antigen Test, dated 7-19-22, documents R4 tested positive for COVID-19. 19. R85's Face Sheet, dated 7-30-21, documents R85 is an [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R85 resided on [NAME] Brown hallway, and developed symptoms of COVID-19 on 7-19-22 of runny nose and fatigue, and tested positive for COVID-19 on 7-19-22. R85's COVID-19 Antigen Test, dated 7-19-22, documents R85 tested positive for COVID-19. 20. R12's Face Sheet, dated 9-07-21, documents R12 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R12 resided on Eastbrook Lane hallway, and developed symptoms of COVID-19 on 7-26-22 of fever and diarrhea, and tested positive for COVID-19 on 7-26-22. R12's COVID-19 Antigen Test, dated 7-26-22, documents R12 tested positive for COVID-19. 21. R87's Face Sheet, dated 11-21-19, documents R87 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R87 resided on Eastbrook Lane hallway, and developed symptoms of COVID-19 on 8-02-22 of headache and nausea, and tested positive for COVID-19 on 8-02-22. R87's COVID-19 Antigen Test, dated 8-02-22, documents R87 tested positive for COVID-19. 22. R93's Face Sheet, dated 8-03-22, documents R93 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R93 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 8-02-22 of sore throat, and tested positive for COVID-19 on 8-03-22. R93's COVID-19 Antigen Test, dated 8-03-22, documents R93 tested positive for COVID-19. 23. R90's Face Sheet, dated 11-27-20, documents R90 is a [AGE] year-old, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R90 resided on Eastbrook Lane hallway, and developed symptoms of COVID-19 on 8-15-22 of headache and cough, and tested positive for COVID-19 on 8-15-2022. R90's COVID-19 Antigen Test, dated 8-15-22, documents R90 tested positive for COVID-19. 24. On 8-29-22 at 1:56 PM, R94 was sitting in a contact isolation private room on the Sunny Dale hallway. R94 stated, I still do not feel the greatest. I am still weak. R94's Face Sheet, dated 8-24-22, documents R94 is an [AGE] year-old ,with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facilities COVID-19 Positive Log documents R94 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 8-21-2022 of shortness of breath, and tested positive for COVID-19 on 8-22-22. R94's COVID-19 Antigen Test, dated 8-22-22, documents R94 tested positive for COVID-19. V5's (Registered Nurse/RN) Timecard Summary documents V5 worked on the [NAME] Center hallways from 8:24 AM through 4:00 PM on 6-21-22, and 8:32 AM to 4:28 PM on 6-20-22. The facility's COVID-19 Employee Tracking Log documents V5 developed symptoms of COVID-19 on 6-21-22 of a headache, runny nose, cough, and fever, exposed the [NAME] Center residents on 6-20-22 and 6-21-22, and did not test for COVID-19 until 6-22-22. V5's COVID-19 Antigen Testing form, dated 6-22-22, documents V5 tested positive for COVID-19 on 6-22-22 at 7:30 AM. V6's (CNA/Certified Nursing Assistant) Timecard Summary documents V6 worked on the [NAME] Center hallways from 6:08 AM through 2:31 PM on 6-21-22, and 6:06 AM through 10:12 AM on 6-23-22. V6's COVID-19 Self Employee Screening, dated 6-21-22 and 6-23-22 at 6:00 AM, documents V6 had no signs/symptoms of COVID-19. The facility's COVID-19 Employee Tracking Log documents V6 developed symptoms of COVID-19 on 6-21-22 of a cough, runny nose, and cough, exposed the [NAME] Center residents on 6-20-22, 6-21-22, and 6-23-22, and did not test for COVID-19 until 6-23-22. V6's COVID-19 Antigen Testing form, dated 6-23-22, documents V6 tested positive for COVID-19 on 6-23-22 at 10:00 AM. On 9-1-22 at 9:00 AM, V6 stated, I had a stuffy nose and cough a few days before I tested positive for COVID. I did take a rapid COVID test, and it was negative. I did not know I had to take a PCR test or quarantine while I had symptoms. My supervisors did not tell me that I could not work with symptoms. V7's (LPN/Licensed Practical Nurse) Timecard Summary documents V7 worked on the [NAME] Gardens hallways from 6:24 PM through 9:13 PM on 6-26-22. The facility's COVID-19 Employee Tracking Log documents V7 developed symptoms of COVID-19 on 6-26-22 of fever and body ache, and exposed the [NAME] Center hallway residents on 6-26-22. V7's COVID-19 Antigen Testing form, dated 6-26-22, documents V7 tested positive for COVID-19 on 6-26-22 at 7:30 PM. On 9-1-22 at 11:15 AM, V3 (Assistant Director of Nursing) stated, (V7) did not complete a pre-screening for COVID-19 symptoms before her shift on 6-26-22. V8's (Non-Certified Assistant) Timecard Summary documents V8 worked on the [NAME] Gardens hallways from 6:25 AM through 3:30 PM on 6-26-22, and 6:25 AM through 6:45 AM on 6-27-22. V8's COVID-19 Self Employee Screening, dated 6-25-22, 6-26-22, and 6-27-22 at 6:30 AM, documents V8 had no signs/symptoms of COVID-19. The facility's COVID-19 Employee Tracking Log documents V8 developed symptoms of COVID-19 on 6-24-22 of sneezing and body aches, and exposed the [NAME] Gardens hallway residents on 6-25-22 and 6-26-22. V8's COVID-19 Antigen Testing form, dated 6-27-22, documents V8 tested positive for COVID-19 on 6-27-22 at 6:50 AM. On 9-1-22 at 1:30 PM, V8 stated, I did work with the residents on [NAME] Gardens while I was having body aches and sneezing. I sneezed like 30 times, but did not think anything about it. I thought it was allergies. I was never told to do a PCR test or to quarantine until my symptoms were gone. V9's (CNA) Timecard Summary documents V9 worked on the Eastbrook Lane hallways on 6-24-22 from 6:32 PM until 7:12 AM on 6-25-2022. The facilities COVID-19 Employee Tracking Log documents V9 developed symptoms of COVID-19 on 6-25-22 of sore throat, body aches, and headache, and exposed Eastbrook Lane hallways on 6-24-22. V9's COVID-19 Antigen Testing form, dated 6-28-22, documents V9 tested positive for COVID-19 on 6-28 at 1:52 PM. On 9-1-22 at 11:15 AM, V3 (Assistant Director of Nursing/ADON) stated, (V9) did not complete a prescreening for COVID-19 symptoms before her shifts on 6-24-22 and 6-25-22. V10's (Housekeeper) Timecard Summary documents V10 worked on the [NAME] Gardens hallways on 6-30-22 from 6:56 AM until 3:30 PM. V10's COVID-19 Self Employee Screening, dated 6-30-2022 at 5:00 AM, documents V10 had no signs/symptoms of COVID-19. The facilities COVID-19 Employee Tracking Log documents V10 developed symptoms of COVID-19 on 6-30-22 of fever and cough, and exposed [NAME] Gardens hallways on 6-30-22. V10's COVID-19 Antigen Testing form, dated 7-01-22, documents V10 tested positive for COVID-19 on 7-01-2022 at 12:26 PM. On 9-1-22 at 1:45 PM ,V10 stated, I had a fever and cough that I got during my shift on 6-30-22. I tried to make it through work, and then I went to the hospital the next morning and was tested for COVID and was positive. V11's (CNA) Timecard Summary documents V11 worked on the [NAME] Gardens hallways on 7-03-22 from 02:03 AM until 11:54 AM. The facilities COVID-19 Employee Tracking Log documents V11 developed symptoms of COVID-19 on 7-03-2022 of runny nose and cough, and exposed [NAME] Gardens hallways on 7-03-2022. V11's COVID-19 Antigen testing form, dated 7-03-2022, documents V11 tested positive for COVID-19 on 7-03-22 at 11:50 AM. On 9-1-22 at 11:15 AM, V3 stated, (V11) did not complete a prescreening for COVID-19 symptoms before her shift on 7-03-22. V12's (CNA) Timecard Summary documents V12 worked on the Eastbrook Lane hallways on 6-29-22 from 6:30 PM until 6-30-22 at 7:15 AM, 6-30-22 from 6:26 PM until 7-01-22 7:00 AM, and 7-01-2022 from 10:30 PM until 7-02-2022 at 6:00 AM. The facilities COVID-19 Employee Tracking Log documents V12 developed symptoms of COVID-19 on 6-28-2022 of cough, sore throat, and double ear infection, and last exposed Eastbrook Lane hallways on 7-02-22. V12's COVID Antigen testing form, dated 7-02-22, documents V12 tested positive for COVID-19 on 7-02-22 at 6:00 AM. On 9-1-22 at 11:15 AM, V3 stated, (V12) did not complete a prescreening for COVID-19 symptoms before her shift on 7-01-22 and 7-02-22. (V12) worked with COVID-19 symptoms on 6-29-22, 6-30-22, 7-01-22, and 7-02-22, exposing all the residents on Eastbrook Lane hallway to COVID-19. On 9-1-22 at 11:52 AM, V12 stated, I had a cough and sore throat for several days before I tested positive for COVID. I worked with the residents while I had symptoms. I did not know I had to quarantine or do a PCR test. I do not remember doing a prescreening for COVID symptoms before my shifts. V13's (Non-Certified Assistant) Timecard summary documents V13 worked on the Southern Court hallways on 7-05-22 from 6:32 AM until 3:04 PM, 7-07-22 from 6:32 AM until 2:30 PM, and 7-09-22 from 6:25 AM until 7:17 AM. The facilities COVID-19 Employee Tracking log documents V13 developed symptoms of COVID-19 on 7-07-22 of sore throat, headache, runny nose, and cough, and exposed Southern Court hallways on 7-05-22, 7-06-22, 7-07-22, and 7-09-22. V13's COVID-19 Antigen testing form, dated 7-09-22, documents V13 tested positive for COVID-19 on 7-09-22 at 7:15 AM. On 9-1-22 at 11:15 AM, V3 stated, (V13) did not complete a prescreening for COVID-19 symptoms before her shifts on 7-05-22, 7-07-22, and 7-09-22. On 9-1-22 at 11:50 AM, V13 stated, I did not think anything about my symptoms of a headache, sore throat, or sinus drainage. I never knew I had to report those symptoms to the facility or do a prescreening for COVID before my shifts. I did work with the residents on Southern Court when I had these symptoms. V14's (CNA) Timecard Summary documents V14 worked on the Eastbrook Lane hallways from 5:58 AM through 2:31 PM on 7-9-22, 5:58 AM through 2:35 PM on 7-10-22, and worked the [NAME] Brown hallways from 5:55 AM through 2:30 PM on 7-11-22. The facility's COVID-19 Employee Tracking Log documents V14 developed symptoms of COVID-19 on 7-10-22 of a cough and congestion, and exposed the Eastbrook Lane hallway residents on 7-9-22 and 7-10-22, and [NAME] Brown hallway residents on 7-11-22. V14's COVID-19 Antigen Testing form, dated 7-11-22, documents V14 tested positive for COVID-19 on 7-11-22 at 8:42 AM. On 9-1-22 at 11:15 AM, V3 stated, (V14) did not complete a pre-screening for COVID-19 symptoms before her shifts on 7-9-22, 7-10-22, or 7-11-22. V17's (Dietary Aide) Timecard log documents V17 worked on the Eastbrook Lane hallways on 7-21-22 from 3:49 PM to 8:02 PM, and 7-22-2022 from 3:54 PM to 8:00 PM. V17's COVID-19 Self Employee screening, dated 7-21-22 and 7-22-22 at 4:00 PM, was incomplete and did not include whether V19 had signs/symptoms of COVID-19. The facilities COVID-19 Employee Tracking log documents V17 developed symptoms of COVID-19 on 7-21-22 of sore throat/headache, and exposed Eastbrook Lane hallways on 7-21-22 and 7-22-22. V17's COVID-19 Antigen testing form, dated 7-23-2022, documents V17 tested positive for COVID-19 on 7-23-2022. On 9-1-22 at 4:24 PM, V17 stated, I did not always fill out the prescreening for COVID every day before my shifts. I worked when I had a sore throat, headache, and runny nose. I thought I just had a cold. I did not report my symptoms to anybody. I did end up testing positive for COVID. On 9-2-22 at 1:00 PM, V3 (Assistant Director of Nursing) provided a list of the following residents who are either unvaccinated or not up to date with their COVID-19 boosters (R4, R7, R20, R26, R38, R45, R51, R63, R64, R72, R83, R88, R90, R91, R93, and R100). On 8-31-22 at 12:30 PM, V3 (Assistant Director of Nursing) stated, I oversee the COVID-19 policy and procedures. The outbreak of the COVID-19 virus with the [NAME] Center residents started with (V5/RN) and (V6/CNA), the outbreak of COVID-19 with the [NAME] Gardens residents started with (V11 CNA), the outbreak of COVID-19 with the Eastbrook Lane residents started with (V17/Dietary Aide), and the outbreak of COVID-19 with the [NAME] Brown residents started with (V14/CNA). (V5, V6, V11, V14, V17) worked with the residents while having symptoms of COVID-19. I do not know why (V5, V6, V11, V14, V17) did not report that they were having symptoms. All employees are to screen themselves for COVID-19 before the start of their shifts every day. Not all staff have been screening themselves prior to their shifts. I do not think anybody is monitoring to make sure staff are prescreening for symptoms before their shifts. The staff have been in-serviced that they are to report to their supervisor immediately if they have signs and symptoms of COVID-19, and not work with the residents. Employees who have symptoms of COVID-19 are supposed to rapid test immediately for COVID-19. If the employee is negative by rapid testing, the employee must submit a PCR (Polymerase Chain Reaction) test for COVID-19 and quarantine until they receive the result of the PCR. I did not know that residents who are unvaccinated or not up to date with the COVID-19 vaccination are to be isolated once coming into contact with anyone symptomatic or testing positive of COVID-19. (R

Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcers, maintain pressure relieving equipment, complete and document daily skin checks, and identify pressure ulcers in a timely manner for two of four residents (R80, R111) reviewed for pressure ulcers in the sample of 49. These failures resulted in R80 developing a Stage three pressure ulcer to the right scapula and R111 developing an unstageable pressure ulcer to the right heel. Findings include 1. On 11/3/21 at 9:54 AM, a pressure wound was observed on R80's right scapula. While the dressing was being changed, R80 complained of pain. The wound was approximately the size of a quarter and was open. R80's Minimum Data Set assessment, dated 9/28/21, documents R80 requires extensive assistance of two staff for bed mobility. R80 currently has a Stage three pressure ulcer, and did not have any pressure ulcers when admitted . R80's current Care Plan documents R80 is at increased risk for pressure injuries related to immobility. R80's Braden Scale, dated 4/6/21, documents R80's mobility is very limited, and R80 is at risk for developing pressure sores. R80's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (R80) reports her back does hurt at times and repositioning helps. R80's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/3/21 at 10:11 AM, V5 (Nursing Progress Coordinator/Wound Nurse) stated (R80) has a chronic pressure ulcer on (R80's) right scapula. Unfortunately, it (the wound) was acquired here. (R80) had a low air loss mattress and it got unplugged so it was flatter than it should have been. The wound was unstageable when it was discovered because it had eschar covering it. When the eschar was removed it was determined to be a Stage three. On 11/4/21 at 8:30 AM, V3 (Assistant Director of Nursing) stated, I'm not proud of it, but (R80) acquired it (pressure ulcer) here. I thought that (R80) got the pressure ulcer because the air mattress got unplugged but I think it may have been malfunctioning. We have found it (air mattress) unplugged a few times and had to plug it back in because (R80's) roommate pushes her bed over and unplugs the air mattress for (R80). 2. On 11/2/21 at 10:00 AM, R111 was sitting in R111's wheelchair with lift boots on. R111 was complaining of pain to R111's right heel. R111 stated, It feels like daggers are sticking in my foot. On 11/2/21, V10 (LPN/Licensed Practical Nurse) stated, (R111) has an open area to his right heel that is from pressure and is unstageable. On 11/3/21, during wound care, R111 had an open area to R111's right heel slightly larger than quarter size. R111's MDS/Minimum Data Set Assessment, dated 7/18/21, documents R111 has a BIMS/Brief Interview for Mental Status score of 04 (cognitively impaired), requires extensive assist of two staff with bed mobility and transfers, and has an unstageable pressure ulcer. R111's Pressure Ulcer care plan, dated 10/21/21, documents R111 is at risk for pressure ulcers related to immobility, incontinence and poor nutrition. On 7/4/21, R111's Pressure Ulcer care plan documented (R111) has an unstageable pressure area to Right heel. R111's Progress notes, dated 07/04/2021, documents, CNA (Certified Nursing Assistant) reported to this nurse (V11/LPN) about right heel with an area present to it. Area has black center cover to it with edges having pink skin surrounding. Size: 4.2 cm (centimeters) x 4.5 cm. R111's Event Report (Weekly Pressure Sore Report), dated 7/4/21 and documented by (V11), documents unstageable black scab that has pulled away from edge of wound to right heel, wound has foul odor, and R111 has weight loss and ill fitting footwear. This same report documents R111's pressure wound measures 4.2 cm. x 4.5 cm. R111's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/21 at 8:45 AM, V2 stated, Yes the staff should have identified R111's pressure ulcer to his right heel before it was unstageable. V2 also stated, There is no documentation of daily skin checks for R111 and daily skin checks were obviously not done or they would have found it sooner. The Facility Skin Care Protocol: Prevention and Treatment documents, The facility will ensure that a resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition demonstrates that the pressure injury was unavoidable. The facility will further ensure that a resident having pressure injury receives necessary treatment and services to promote healing, prevent infection, and prevent new injury from developing. Ongoing Assessment Process: The resident's skin will be inspected daily by direct staff and any changes shall be brought immediately to the attention of the charge nurse. The National Pressure Ulcer Advisory Panel's Pressure Injury Prevention Points, dated 4/16, documents, Inspect the skin at least daily for signs of pressure injury, especially nonblanchable [CONDITION(S)].

Based on observation, interview, and record review the facility failed to implement their abuse policy and remove an alleged perpetrator (V5/Chaplain) from direct contact with residents after an allegation of abuse was made, failed to identify a pattern of allegations involving the alleged perpetrator (V5), failed to interview other residents that had contact with the alleged perpetrator (V5), failed to evaluate/assess the residents for safety following the abuse allegations, and failed to prevent further abuse from occurring for one of four residents (R1) reviewed for sexual abuse allegations in the sample of seven. These failures resulted in V5 having continued access to all residents in the facility following several allegations of abuse, resulting in V5 sexually assaulting R1 on [DATE], causing R1 ineffective coping and emotional distress. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Level 2 as the facility continues to educate all staff on the abuse policy, holds a Quality Assurance meeting to determine who will be responsible for ensuring residents and staff are interviewed with each abuse allegation, who will investigate abuse allegations, and how to track patterns to prevent further abuse. The facility will also conduct ongoing interviews and assessments of all residents for potential of abuse or episodes of suspected abuse Findings include: The facility's Abuse Prevention Program Policy dated [DATE] documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This facility is committed to protecting our residents from abuse by anyone including facility staff. The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be removed from contact with that resident during the course of the investigation. The resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering placement, considering his or her safety, as well as the safety of other residents and employees of the facility. Employees of this facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the Administrator. Once notified, the Administrator will begin an investigation or appoint a person to take charge of the investigation. The investigator will follow the Resident Protection Investigation Procedures that contain specific investigation paths depending on the nature of the allegation, and procedures for investigation, interview parameters, and reporting requirement. Upon receipt of an allegation, the Administrator will notify the following agencies immediately: Illinois Department of Public Health (IDPH) and the Elder Services Office/Local Police Department. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation will be sent to IDPH. The facility's Resident Protection Investigation Procedure dated [DATE] documents, Investigation Procedures include interviews with the residents, interviews with staff members having direct contact with the resident and accused individual, interviews with the resident's roommate, family members, visitors or others within the vicinity of the incident, interviews with other residents that have regular contact with the accused, and interviews with other employees that have regular contact with the accused. Obtain written interviews for all statements. V5's Director of Pastoral Services Job Description Dated [DATE] and signed by V5 on [DATE] documents, The primary purpose of your job position is to provide pastoral care, religious support and services to residents, family members, and employees. Working Conditions: Works throughout the facility. Moves intermittently during working hours. Works beyond normal working hours and on weekends and holidays, when necessary. The facility's Centers for Medicare and Medicaid Services Form 802 Matrix for Providers dated [DATE] and signed by V2 (Director of Nursing) documents 148 residents reside in the facility. 1. On [DATE] at 11:05 AM, R1 was sitting in a chair in her room. R1 knew the day of the week, her name, and that she resided in a nursing facility. R1 stated with tears in her eyes, Last week (V5/Chaplain) came into my room to ask me questions. When I stood up, (V5) grabbed my left breast under my shirt and shook it. I am very upset about it. (V5) touched my breast for about two minutes and then left the room. During this time, R1 raised her shirt and shook her own left breast, demonstrating what V5 had done to her. R1's Clinical Record includes a Spiritual Care Assessment that was done on [DATE] and signed by V5 as the staff member that completed the assessment. V2's (Director Of Nursing) written statement dated [DATE], documents, Went with (V4/Police Detective) to speak with (R1). (V4) asked (R1) what had happened. (R1) was tearful. (R1) stated they (R1 and V5) stood up and (V5) lifted (R1's) shirt and grabbed (R1's) breast for about two minutes. (R1) reported that (V5) was the person that did it. (V5) was suspended. V2's Abuse investigation regarding R1's allegation does not include other resident or employee interviews to determine if any other residents experienced or witnessed abuse in regards to V5 or any other staff member. R1's Progress Note/assessment dated [DATE] and signed by V6 (Nurse Practitioner) documents, (R1) is an [AGE] year old female who is seen today at the request of staff for concerns expressed to them by another resident indicating that (R1) had an encounter last week that (R1) described as being a sexual assault in nature. When asked about the encounter, (R1) drops her head into her hands and begins crying. (R1) states she was in her room with the individual (V5). (R1) stood up and when (R1) was standing, (V5) reached under (R1's) shirt touching (R1's) left breast for what (R1) described at that time as being for two minutes. (R1) then shoved (V5) away. (R1) does have a history of Dementia and a recent BIMS (Brief Interview of Mental Status) was reviewed. (R1's) description in all accounts remained the same and (R1's) obvious distress illustrated by tearfulness and comments that (R1) would never forget the incident were noted. (R1) states that she had never had an encounter with a male in the past. Primary [DIAGNOSES REDACTED]. New orders to consult with (outside facility) behavioral health for assistance with coping due to ineffective coping. V5's Employee Counseling Record dated [DATE] documents, You (V5) have the option of resigning or being terminated effective immediately based on the fact the investigation of the allegation is being referred to the State Attorney's Office to review for possible charges and that Illinois Department of Public Health will be conducting an investigation. This same record documents V5 signed to resign immediately on [DATE]. V5's Employee Separation Report dated [DATE] documents V5 was hired on [DATE] and was terminated from employment on [DATE]. On [DATE] at 10:05 AM V4 (Police Detective) stated, I was informed on Thursday ([DATE]) that (R1) had made an allegation of sexual abuse against (V5/Chaplain). I went to the facility that day to do my investigation. I am pretty confident that abuse occurred because (R1's) statements were consistent. (R1) was pretty shaken up and crying when talking to me. (R1) also lifted her shirt and demonstrated (V5) grabbing her breast. I am turning over my report to the State's Attorney. The facility has not contacted me in the past about any other allegations of sexual abuse regarding (V5). On [DATE] at 1:40 PM V6 (Nurse Practitioner) stated, When I met with (R1) on Thursday ([DATE]), (R1) burst into tears and said a preacher came into (R1's) room. (R1) informed me that (V5) had lifted up her shirt and rubbed her breast. The abuse officer and V2 met with her with me also. R1 was consistent. I believe that what (R1) reported to me was factual and the allegation had occurred. No prior history of her making allegations. I have been coming to the facility since October, (YEAR) and my nurse had heard of something like this occurring before with V5, but I am not exactly sure what that was. I referred (R1) to a licensed clinical worker because (R1) had a [DIAGNOSES REDACTED]. On [DATE] at 12:30 PM V17 (R1's Power of Attorney) stated, (R1) reported to me that the preacher (V5) felt her up and raised her blouse and felt her breast. (R1) is of sound mind to know if someone would do this to (R1). (R1) has a good mind and would not make it up that (V5) pulled up her blouse and felt her breast. (R1) would have known who did that to her. (R1) was crying when she told me. I hated it that (R1) needed to stay at the facility. (R1) has been very upset over this. I have been told that (V5) no longer works at the facility, so I am glad about that. I lived with (R1) for [AGE] years and (R1) had never made up any accusations against anyone else. (R1) was admitted to the facility because she could no longer drive due to her [MEDICAL CONDITION]. On [DATE] at 10:15 AM, V2 (Director Of Nursing) stated, (V1/Administrator) assigned me as the primary staff member to do the investigation into (R1's) allegation of abuse that occurred from (V5). I did not interview any other residents during this investigation to determine if they had experienced or witnessed abuse of any type. I only interviewed the staff/residents that reported the alleged abuse of (R1). 2. On [DATE] at 10:15 AM V15 (Social Service Director) stated, Sometime last summer (2018), (R5) had reported that a guy came in her room with a mask on (like one for an isolation room) that sounded and looked like (V5/Chaplain). (R5) reported that (V5) was grabbing her breasts. I know (V1/Administrator) and (V2/Director of Nursing) were made aware of the situation. (V5) had drove the van for the youth volunteers at night late the week that (R5) had made the allegation. (V5) had came back after midnight the night he drove the volunteers which I thought was very suspicious. On [DATE] at 12:00 PM V16 (LPN/Licensed Practical Nurse) stated, Sometime around (MONTH) 2nd or 3rd, (YEAR) (R5) was very uncomfortable and upset and told me that (V5) came into her room at night and something happened. (R5) would not tell me what happened because she did not want to get (V5) in trouble and said she did not want me to look at (V5) any different. I immediately reported (R5) feeling uncomfortable to (V2) and (V1). I was scared to leave (R5) alone because she lived on the sheltered care unit where there are no staff unless one of the resident's use their call light. (V5) enters and exits the door of the sheltered care unit to get to his office. I also knew that (V5) had driven a bus one of the nights of the same week (R5) had stated (V5) had came into her room. (V5) did not get back from that bus trip until the middle of night. On [DATE] at 11:20 AM V1 (Administrator) stated, (R5) kept telling me (unsure of the date) that (V5) came into her room and sat on her bed and attempted to kiss her. She kept saying I hope it is just a dream. I did not do an abuse investigation or report the allegation to the police or state agency. I know (V5) drove a group of volunteers in our van and am not sure of when they returned. I know now that I should have reported and investigated this allegation. (V5) was not suspended pending investigation after this allegation, no investigation was completed and no report was sent to the state agency. There is no documentation about (R5's) allegation. (R5) is expired now. On [DATE] at 10:45 AM V2 (Director Of Nursing) stated, (R5) reported a masked man had touched her breasts and the voice sounded familiar. We looked into it. This was late at night. We did not do an abuse investigation at that time. (R5) reported this sometime last summer. Was not on isolation. (R5) knew it was (V5) by the voice. (V5) was the Chaplain and had access to all residents that reside in the nursing facility, sheltered care facility, and the assisted living facility. (V5) was not suspended pending investigation. (R5's) allegations are not documented in (R5's) record. R5's Medical Record and the facility's abuse investigation records do not include any documentation of the allegation of sexual abuse R5 had made against V5, or an evaluation of R5's condition to determine the most suitable therapy, care approaches, and placement, considering placement, considering his or her safety, as well as the safety of other residents and employees of the facility (as stated in the facility's abuse policy). R5's Transfer Form dated [DATE] documents R5 was alert, orientated, and follows instructions. R5's Progress Notes documents R5 passed away while in skilled care at the facility on [DATE]. 3. Additional allegation on typed statement written by V22/LPN (Licensed Practical Nurse) dated [DATE] documents that R6 (residing in Sheltered Care at that time) reported that on [DATE] V5 had touched her shoulder and neck and started touching her breasts above her bra. R6's Final Abuse Investigation dated [DATE] and signed by V2 documents R6's allegation was unsubstantiated based on V5 stating that he had only met with R6 in the hallway on [DATE] and not in R6's room. V2's abuse investigations regarding R6 does not include other resident or employee interviews to determine if any other residents experienced or witnessed abuse in regards to V5 and do not include interviews to determine if staff witnessed V5 with R6 during the time of the allegation. This investigation only includes interviews from staff that R6 had reported the allegation to and V5. 4. Additional allegation documented in R7's progress note dated [DATE] documents R7 reported that V5 raped her. V2's Final Abuse Investigation documents R7's allegations of abuse was unsubstantiated due to allegation having no supporting evidence. V2's abuse investigations regarding R7 does not include other resident or employee interviews to determine if any other residents experienced or witnessed abuse in regards to V5 and do not include interviews to determine if staff witnessed V5 with R7 during the time of the allegation. This investigation only includes interviews from staff that R7 reported the allegation to and V5. On [DATE] at 2:35 PM, V2 stated that she and the Administrator did not identify a pattern of allegations made against V5 until this last (fourth) allegation was made regarding R1. V2 also stated, I think we (facility staff) trusted him (V5) too much. The Immediate Jeopardy was identified on [DATE] at 10:30 A.M. to have begun on [DATE] when R5 reported V5 had sexually abused R5 and the facility failed to implement their abuse policy and remove an alleged perpetrator (V5/Chaplain) from direct contact with residents after an allegation of abuse was made, failed to identify a pattern of allegations involving the alleged perpetrator (V5/Chaplain), failed to interview other residents that had contact with the alleged perpetrator (V5), failed to evaluate/assess the residents for safety following the abuse allegations, and failed to prevent further abuse from occurring of another resident (R1). V1 (Administrator), V2 (Director of Nursing), V23 (Assistant Director of Nursing), and V24 (Assistant Administrator) were notified of the Immediate Jeopardy on [DATE] at 10:40 A.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The alleged perpetrator (V5) was suspended and subsequently resigned on Friday, [DATE] and is barred from the facility. 2. A comprehensive investigation of the allegation made by R1 was initiated on [DATE] at 3:51 PM by the facility. 3. The allegation related to R1 has been reported to the Illinois Department of Public Health [DATE] at 12:27 PM. 4. The allegation related to R1 was reported to the local police department [DATE] at 12:25 PM. 5. A final report was submitted to the Illinois Department of Public Health on [DATE] at 7:45 AM. 6. The resident's family and physician of R1 were notified of the allegation on [DATE] at 10:45 AM. 7. R1 was evaluated by a nurse practitioner on [DATE] and assessed by her attending physician on [DATE]. R1 was seen by an outside agency on [DATE] for counseling. 8. The facility policy on abuse will be circulated to all staff [DATE]. 9. All staff are receiving immediate in-servicing on the facility abuse policy. V25 (Consultant) will be conducting education and this will be recorded. Re-education will be expected to be completed by [DATE]. V23 (Assistant Director of Nursing) will oversee compliance. Any employee not compliant by this day will not be allowed to return to work until they are in compliance. 10. The facility's Quality Assurance Committee will meet [DATE] to determine who will be responsible for ensuring that residents and staff are interviewed with each allegation, who will investigate and prevent further abuse and track patterns of further abuse. 10. V1 (Administrator) and V24 (Assistant Administrator) will receive one-on-one training from facility legal counsel on [DATE] at 1:00 PM. 11. V1, V2, and all department heads will receive abuse training from the regional ombudsmen and V4 (Elder Services Officer) on [DATE] at 3:30 PM. 12. All residents will be interviewed and assessed for potential of abuse or episodes of suspected abuse by Monday, [DATE]. Interviews will be conducted by department supervisors and the social service department.

Based on observation, record review, and interview the facility failed to protect a resident (R1) from being sexually abused by a staff member (V5/Chaplain) for one of four abuse allegations reviewed. This failure resulted in R1 suffering ineffective coping and emotional distress following the sexual abuse. Findings include: The facility's Abuse Prevention Program Policy dated 03-25-13 documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This facility is committed to protecting our residents from abuse by anyone including facility staff. On 6-10-19 at 11:05 AM, R1 was sitting in a chair in her room. R1 knew the day of the week, her name, and that she resided in a nursing facility. R1 stated with tears in her eyes, Last week (V5/Chaplain) came into my room to ask me questions. When I stood up, (V5) grabbed my left breast under my shirt and shook it. I am very upset about it. (V5) touched my breast for about two minutes and then left the room. During this time, R1 raised her shirt and shook her own left breast, demonstrating what V5 had done to her. R1's Clinical Record includes a Spiritual Care Assessment that was done on 5-31-19 and signed by V5 as the staff member that completed the assessment. V2's (Director Of Nursing) written statement dated 6-6-19, documents, (I) went with (V4/Police Detective) to speak with (R1). (V4) asked (R1) what had happened. (R1) was tearful. (R1) stated they (R1 and V5) stood up and (V5) lifted (R1's) shirt and grabbed (R1's) breast for about two minutes. (R1) reported that (V5) was the person that did it. R1's Progress Note/assessment dated [DATE] and signed by V6 (Nurse Practitioner) documents, (R1) is an [AGE] year old female who is seen today at the request of staff for concerns expressed to them by another resident indicating that (R1) had an encounter last week that (R1) described as being a sexual assault in nature. When asked about the encounter, (R1) drops her head into her hands and begins crying. (R1) states she was in her room with the individual (V5). (R1) stood up and when (R1) was standing, (V5) reached under (R1's) shirt touching (R1's) left breast for what (R1) described at that time as being for two minutes. (R1's) description in all accounts remained the same and (R1's) obvious distress illustrated by tearfulness and comments that (R1) would never forget the incident were noted. Primary [DIAGNOSES REDACTED]. New orders to consult with (outside facility) behavioral health for assistance with coping due to ineffective coping. V5's Employee Counseling Record dated 6-7-19 documents, You (V5) have the option of resigning or being terminated effective immediately based on the fact the investigation of the allegation is being referred to the State Attorney's Office to review for possible charges and that the Illinois Department of Public Health will be conducting an investigation. On 6-10-19 at 10:05 AM V4 (Police Detective) stated, I am pretty confident that abuse occurred because (R1's) statements were consistent. (R1) was pretty shaken up and crying when talking to me. (R1) also lifted her shirt and demonstrated (V5) grabbing her breast. On 6-10-19 at 1:40 PM V6 (Nurse Practitioner) stated, When I met with (R1) on Thursday (6-6-19), (R1) burst into tears and said a preacher came into (R1's) room. (R1) informed me that (V5) had lifted up her shirt and rubbed her breast. I believe that what (R1) reported to me was factual and the allegation had occurred. On 6-11-19 at 12:30 PM V17 (R1's Power of Attorney) stated, (R1) reported to me that the preacher (V5) felt her up and raised her blouse and felt her breast. (R1) is of sound mind to know if someone would do this to (R1). (R1) has a good mind and would not make it up that (V5) pulled up her blouse and felt her breast. (R1) would have known who did that to her. (R1) was crying when she told me. I hated it that (R1) needed to stay at the facility. (R1) has been very upset over this. On 6-12-19 at 10:15 AM, V2 (Director Of Nursing) stated, (V1/Administrator) assigned me as the primary staff member to do the investigation into (R1's) allegation of abuse that occurred from (V5). After investigating this allegation, I am substantiating this allegations as probable sexual abuse. On 6-12-19 at 2:35, PM V2 (Director of Nursing) stated that allegations of sexual abuse have been made against V5 from three other residents (R5, R6, R7) and that V2 and V1 (Administrator) did not identify a pattern of sexual allegations made against V5 until after R1 had already been sexually abused.

Based on interview and record review the facility failed to ensure supervision was provided as was instructed on the fall prevention care plan for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 falling, while not being supervised, and sustaining a Subdural Hematoma and a potential Intraparenchymal Hemorrhage, requiring hospitalization . Findings include: A Program for Reduction of Falls Risk policy dated 7/23/15 states, If a resident is found to be at risk, the individual who has completed the assessment will initiate a care plan for prevention of falls. The appropriate fall prevention interventions will be selected on the basis of the individualized needs of the resident. R1's Initial/Admission Fall Risk assessment dated [DATE] documents that R1 has the fall risk factors of: disoriented to person, place, and situation, is incontinent, has a psychiatric or cognitive condition causing [MEDICAL CONDITION], decline in cognitive skills, [MEDICAL CONDITIONS], or other Dementia. This same assessment concludes that R1's risk factors put R1 at high risk for falls. R1's Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is hearing and vision impaired without hearing aids or glasses, is severely cognitively impaired with inattention, disorganized thinking, and requires extensive assistance of two people for transfers, walking in the corridor, and toileting. This same MDS documents that R1 is not steady and only able to stabilize herself with staff assistance while walking, moving from a seated to a standing position, turning around, and for surface-to-surface transfers, This MDS further documents that R1 has [DIAGNOSES REDACTED]. R1's fall investigations dated 2/7/19 to 2/20/19 document that R1 had nine falls during that time period. R1's fall investigation dated 2/17/19 documents that R1 fell from a recliner while seated in the common area and also while exhibiting the symptoms of agitation, anxiety, restlessness and resistiveness. This same fall investigation documents that after R1's fall the facility took the immediate action of providing 1:1 supervision to prevent future falls. R1's care plan intervention dated 2/17/19 also documents that the intervention of 1:1 supervision was initiated on that date. R1's fall investigation dated 2/20/19 and signed by V4 (Unit Coordinator) documents that R1 had an unwitnessed fall in the common area at 6:00a.m. on that date. This same investigation documents that when R1 was found on the floor, R1 had a, Large golf ball (sized) bump noted on right side of temple. Area was open and bleeding. (R1) was unable to form sentences that made sense and pupils were uneven. R1's nurse's notes dated 2/20/19 at 6:01a.m. documents that on that date, This nurse was alerted by CNA (Certified Nurse Aide) that (R1) had gotten up from the recliner at nurses station and had fallen on the floor. R1's hospital History and Physical physician's progress note dated as dictated 2/21/19 states, (R1) has had nine falls in the last week or so. (R1) presented to the ER (emergency room ) after a fall yesterday morning, on (MONTH) 20. She fell while walking in the hall. Unclear as to how she fell but it appears to be a mechanical fall. When she did fall, she fell forward and suffered a right parietal scalp laceration and bleeding. After the fall, she was somewhat difficult to arouse. She was taken to the emergency room at that time. CT (Computed Tomography) scan done in the emergency room showed a Subdural hemorrhage, 7mm(millimeters) in size, with some mass effect as well. There was also high density foci noted within the right frontal lobe which could be consistent with a potential Intraparenchymal hemorrhage as well. Since her fall, (R1) has been extremely lethargic and unarousable. This same progress note documents that R1 was referred to hospice care for comfort measures. On 2/26/19 at 11:25a.m. V4 verified that R1's fall prevention intervention implemented following R1's fall on 2/17/19 was 1:1 supervision. V4 also verified that R1 was not receiving 1:1 supervision resulting in an unwitnessed fall on 2/20/19.

Noncompliance resulted in two deficient practices. A. Based on observation, interview and record review the facility failed to recognize environmental hazards, provide adequate supervision to residents while on a facility outing, and failed to provide clear instructions for boarding facility transportation which resulted in an accident with injury for one of three residents (R1) reviewed for falls in the sample of three. As a result of these failures, R1 fractured both her legs and bones in her face. Findings include: 1. A facility incident report dated 6-13-12 at 1:15p.m. documents that R1 fell from a wheelchair and sustained "bilateral femur fractures and facial fractures." On 7-10-12 at 9:40a.m. E2 (Associate Administrator) stated that on 6-13-12 the facility was having a picnic at a shelter in a local park. E2 stated that she was assisting residents to get on the buses to return to the facility when she "heard something" and turned to see that R1 had just fallen down some steps while in a wheelchair. E2 stated that she thought R1 had propelled her wheelchair too close to the stairs and that the wheelchair fell down the steps throwing R1 forward from the wheelchair. A physician's orders [REDACTED]. The POS also documents [REDACTED]. An annual Minimum Data Set (MDS) indicates that R1 has inattention and disorganized thinking which fluctuates. A care plan dated 4-18-12 documents that R1 needs, "extensive to total assist with ADL's (activities of daily living) due to impaired physical mobility and cognitive impairment." The care plan also documents that R1 has "a problem hearing," when in a group setting. The care plan further indicates for staff to seat R1, "near the speaker when in a group setting. Staff is to make sure,"R1 is "hearing what they are doing and explain all procedures before performing." The care plan also instructs for "staff to be sure and stand in front of, " R1 "when speaking to," R1, "face," R1 "while speaking using eye-to-eye contact," and "give clear and simple direction." On 7-10-12 at 10:30a.m. E4 (Social Services Director) stated that "It was a big shelter house," where the picnic was held. "There's a two stair entry way and a wheelchair ramp." E4 stated that she was cleaning and removing table cloths in the shelter when she heard someone shout, " No (R1), you can't go that way!" E4 stated that R1, "purposely went forward onto the stairs, thinking she could go down the stairs, but fell ." On 7-10-12 at 1:05p.m. E6 (Clinical Services Administrator) stated that " We were loading people into the vans. I was on the wheelchair ramp. I heard, 'No, you can't do that!' I turned around and saw (R1). Her first two wheelchair wheels were tipped onto the first step (to the picnic shelter). The rear wheels were still on the shelter (floor). The oxygen tubing was stretched and (R1) was face first on the concrete." On 7-11-12 at 9:45a.m. E9 (Certified Nurse Aide) stated that during the facility picnic " I had my back turned to everyone because I was taking a resident to the van. I heard everyone yell and I turned and she (R1) was falling." E9 stated that she couldn't remember hearing an announcement that the picnic was over or that staff would assist residents to the facility vans. E9 stated that "we were cleaning up and the residents may have realized it was time to go." E9 stated that "we" were taking the ambulatory residents to the buses first, " because we could get five ambulatory residents and five wheelchair residents on a bus at the same time." E9 stated that of the nine archways and two doors to the shelter, only one was blocked off with a buffet table. E9 also stated that she had thought during the picnic that "they should have put caution tape or chairs around," the arches to keep residents away from the stairs. E9 also stated that the residents in wheelchairs were not taken to the buses in any particular order. E9 stated that after R1 fell and left in the ambulance, facility staff decided to start supervising the stairs leading onto the shelter. E9 stated that staff also moved the remaining residents into the center of the shelter to avoid another accident. On 7-11-12 at 9:20a.m. E2(Associate Administrator) stated that she didn't remember hearing a formalized announcement that the picnic was over and that it was time for residents to return to the facility. E2 also stated that she didn't remember having a formalized plan on how residents would be guided from the shelter, down the wheelchair ramp, and onto the buses. E2 stated that during the picnic when staff "saw that a resident looked ready or maybe getting restless," to leave, they (staff) would help that resident go down the wheelchair ramp to board the bus to return to the facility. E2 was unable to state how many staff members and volunteers were assigned to the picnic to assist with resident care but stated that she thought there were "at least 20." E2 agreed with E9's statement that after R1 left in the ambulance, facility staff decided to supervise the stairs leading onto the shelter and that staff also moved the remaining residents into the center of the shelter to avoid another accident. On 7-11-12 at 10:00a.m. Z1(A resident from the independent living cottages) stated that during the picnic, buses arrived to return residents to the facility. Z1 stated, "They had loaded the first batch. We were all in the shelter waiting for our turn. I guess she (R1) decided she didn't want to wait and she went to the stairs and went down. I think she didn't realize there were steps there." Z1 stated that there was, "no announcement I don't think. It was an assumption on our part because the buses pulled up and they started cleaning up." Z1 stated that there were no barriers around the openings to the stairs at the shelter and " we were all pretty close to the edge." Z1 stated that after R1 fell , "several of the girls working for the home stood in front of the steps so no one else could do what (R1) did." On 7-11-12 at 11:15a.m. E10 (Activities Director) stated that the facility had been using the same shelter for resident outings "for a long time." E10 stated that " the program team," consisting of facility supervisory staff, meet periodically to plan big events and "select a site." E10 stated the program team had selected the shelter in the park because "we've used that pavilion before because there is a restroom there." E10 stated that the program team has, "discussed parks in the past and drove there and assessed if it is wheelchair accessible and if there is a restroom for wheelchairs." E10 was unaware if the shelter at the park had been evaluated for being a potential accident hazard to residents. E10 stated that all residents were invited to the picnic and that approximately 120 residents attended. E10 stated that as the picnic was concluding, no formalized announcement was made for residents to begin boarding the buses. E10 indicated that there are some residents "who are impatient and when they want to go, they want to go now!" E10 stated that she has "a mental list of people who are impatient and want to go first," but had no specific plan outlined for staff to know which residents should board the buses first. On 7-11-12 at 7:15a.m. the area in the park where the facility held the picnic was noted to have a four sided shelter which has ten archway entrances and two doorways. Each archway and door has two steps to climb in order to get onto the shelter. The two steps equal a height of approximately 16 inches. There is also one wheelchair ramp located on the front of the shelter which has one access point from the far left of the shelter. On 7-10-12 at 10:30a.m. E4 (Social Services Director) stated that " anyone who knows (R1)," knows, " she acts on impulse," and stated that there "are concerns with safety issues." E4 also stated that when R1 " wants something, she wants it now." On 7-11-12 at 10:25a.m. E3 (Director of Nursing) stated that R1 can be impulsive and impatient. On 7-11-12 at 9:45a.m. E9 (Certified Nurse Aide) stated that "I've taken care of this resident before and she's kind of impatient." On 7-10-12 at 11:20a.m. E5 (Resident Care Coordinator) stated that R1 has contractures to her hands and can only self propel her wheelchair short distances. B. Based on interview and record review the facility failed to perform root cause analysis after resident falls, failed to implement new interventions for fall prevention, and failed to evaluate the effectiveness of fall prevention interventions for three of three residents (R1, R2, R3) reviewed for falls in the sample of three. Findings include: 1. On 7-10-12 at 9:40a.m. E2 (Associate Administrator) stated that on 6-13-12 R1 was attending a facility picnic at a local park when R1 rolled her wheelchair off the steps of a pavilion throwing R1 from the wheelchair and onto the sidewalk. A facility incident report dated 6-13-12 at 1:15p.m. documents that R1 fell from a wheelchair and sustained "bilateral femur fractures and facial fractures." The incident report does not document a root cause analysis was performed to determine why R1 rolled the wheelchair onto the steps of the pavilion. The incident report's "Conclusion/Summary" section was left blank and there were no fall prevention interventions documented as being initiated. A care plan dated 4-18-12 was not updated to include R1's fall on 6-13-12 and no fall prevention interventions had been added. 2. A facility incident summary report dated 9-23-11 to 7-10-12 documents that R2 has fallen 30 times. The incident summary documents that R2 has fallen six times since the onset of a care plan dated 3-15-12 and fallen one time since the onset of a care plan dated 6-14-12. R2's care plans dated 3-15-12 and 6-14-12 do not document any of the six falls nor do they document any additional fall prevention interventions. The incident summaries and the care plans do not document the effectiveness of the fall prevention interventions that were already in place. POS dated 7-01-12 to 7-31-12 indicates that R2 has [DIAGNOSES REDACTED]. The POS also indicates R2 has medications which include: Bystolic 10mg (milligrams) daily, Diltiazem 60mg at bedtime, and Calcium 600mg daily. On 7-11-12 at 8:35a.m. E11 (Care Coordinator) stated that she doesn't document every fall on the care plan and only adds fall interventions to a care plan if she "makes any changes to the current (fall) interventions." 3. Facility incident summary reports dated 9-23-11 to 7-10-12 document that R3 has fallen 29 times. The incident reports do not contain root cause analysis for R3's falls and do not evaluate the effectiveness of the fall prevention interventions that were already in place. Quarterly MDS dated [DATE] documents that R3 has moderate cognitive impairment and minimal depression. The MDS also documents that R3 requires supervision for activities of daily living (ADLs) such as transferring, ambulation, dressing, and hygiene. At 3:20p.m. E7 (Licensed Practical Nurse) stated that R3 has a chair and bed alarm in place but that R3 is able to remove those alarms. E7 stated that R3 usually falls while trying to get out of bed and while trying to take himself to the bathroom. E7 also stated that R3 has an electronic wrist band which alarms if R3 tries to get on the elevator or opens a door to leave the unit where he lives. On 7-11-12 at 10:30a.m. E2 (Director of Nursing) stated that the facility does document a summary of falls each month when a resident has two or more falls in a month. A fall summary dated 9/11 which summarizes R3's falls on 9-02-11 and 9-15-11 does not contain a root cause analysis or an evaluation of the effectiveness of the fall interventions that were in place. There was no fall summary provided for R3's six falls occurring between 11-06-11 and 11-30-11. R3's 1/12 fall summary report includes 11 falls dating from 12-29-11 to 1-18-12. The fall summary does not include a root cause analysis for five of the six falls. The 1/12 fall summary does not include an evaluation of the effectiveness of the fall prevention interventions that were already in place. E2 did not provide fall summaries for R3's eight falls occurring after 1-18-12. A care plan dated 5-24-12 does document the addition of R3's falls on 6-10-12 and 6-29-12 but does not document any additional fall prevention interventions. The care plan also does not document an evaluation of the effectiveness of the interventions that were already in place.