Every finding on record at Henry Rehab and Nursing

Based on observation, interview and record review the Facility failed to promptly respond and resolve Resident Council concerns in a timely manner for five of five Residents (R1, R2, R31, R40 and R41) reviewed for Resident Council concerns in a sample of 28.Findings include:The Facility Resident and Family Concerns and Grievances Policy, revised 10/5/23, documents: prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with Federal and State statutes and regulations; Facility is committed to ensure the continued provision of such exceptional care and services and has established grievance process to address Resident and family member concerns or dissatisfaction about the Facility provision of care and services; should a Resident require assistance in voicing a grievance the Facility associates shall provide needed assistance; the management or supervisory staff will commence a formal investigation of the grievance as is practicable; and will follow-up with Resident or their family/guardian within 72 hours of the filing of the grievance; the Facility will advise the Resident of the outcome of the grievance investigation and will provide the Resident with a written Grievance Decision (date of grievance, summary statement, steps take to investigate grievance, whether the grievance was confirmed or not confirmed, corrective action and the date the decision was issued); and in the event the Facility cannot resolve the grievance within 30 calendar days, the Facility will notify the Resident or their family/guardian of the estimated completion date of the resolution.The Resident Right for People in Long-Term Care Policy, dated 11/2018, documents: the Facility must provide services to keep your physical and mental health at their highest practicable levels; must be safe, clean, comfortable and homelike; and you have a right to complain to your Facility and get a prompt response and you may not be threatened or punished in any way for asserting your rights.Facility Resident Council Minutes, dated 1/13/26, document unresolved concerns with V1's (Administrator) response times to Resident Council Grievances, more frequent water passing, dietary meal trays being left in rooms, bed making, nursing staff conversing too much and not being attentive and not explaining what is being done while providing care, cleaning/sweeping of floors, chicken too hard to cut or chew, brown gravy put-on everything. The Minutes document that V1 does not handle concerns in a timely fashion.Facility Resident Council Minutes, dated 3/10/2026, document unresolved issues with call light response, water needs on meal trays, sweeping/mopping of floors in rooms, cold hall/room and dining room trays, meal service time, pork/chicken is too tough, no condiments, too many mashed potato and gravy and supper meals unsatisfactory.The Facility Resident Council Minutes, dated 4/14/26m documents unresolved issues with nursing department not returning after answering a call light, call light response time, sweeping/mopping of rooms, no condiments when needed and still running out, nursing phone usage, smoking breaks for employees, laundry not returned on time, dietary concerns with food amount and choice (potato and vegetable variety).The Facility Grievance Report, dated 12/15/25 through 5/12/26, documents concerns and unresolved issues with responses on concerns should be done quicker, soup/crackers are not a meal alone, chicken patties too hard to cut, brown gravy used to cover up food, served too much rice and potato, sweeping floor before mopping and not cleaning against walls, water passing and bed making, meal trays left in room, Certified Nursing Assistants horseplaying and conversing too much and not being attentive, smoking times, quicker response to concerns, unresolved issues from last month (1/14/26), meal carts sitting too long in hallway before trays are passed, drinks on dinner trays, nails not trimmed on shower days, cold meals on halls and in dining room, call light response, unavailable alternative meal choice, running out of condiments and laundry concerns.On 5/13/26 at 9:45 am, R1, R2, R31, R40 and R41/Resident Council President were in resident council group meeting and stated that: Dietary concerns are not addressed or rectified, stating that meal portions are too small, meat is very hard to cut and is tough; snacks are terrible and the only snacks provided are graham crackers & a package of peanut butter crackers, no pudding, yogurt or milk is served with them. R41 stated when R41 went to the kitchen once and asked for peanut butter crackers and V6 (Dietary Manager) said, you can only get one, and R1, R2, R31 and R40 all voiced this same concern. R1, R2, R31, R40 and R41 verified that many concerns have been voiced at many Resident Council Resident Meetings, and many go unresolved and that the same complaints and concerns have all been voiced repeatedly and are not rectified. Also, in the Resident Council group meeting concerns with the kitchen running out of cracker for soup and R2 stated, we have been served graham crackers with our soup because they have run out of saltines.On 5/13/26 at 9:45 am, R1, R2, R31, R40 and R41 all voiced complaints with cold food, dinner meal consisting of only soup and small lettuce salad, R2 stating, They think a small little cup of soup and just a plain lettuce salad consists of a meal. They call a small little bowl of lettuce a salad, nothing else on it, no tomato or carrot or anything. Also, R40 and R41 stated the evening room tray meal is served in their room, while they are on a Facility designated smoking time is cold when they return to their rooms and the timing of the smoking breaks and mealtimes do not work out and need to be looked at. R1, R2, R30, R40 and R41 also verified that call lights are answered and shut off, without anyone helping and when requesting toileting or water they say the Certified Nursing Assistants say they are too busy with other residents and can't help right now or will help when they are done with other things or we are understaffed and I will be back when I can.On 5/13/26 at 9:45 am, R1, R2, R31, R40 and R41 verified that V6 (Dietary Manager) always gives the answer that I have to follow the menu provided and does not respond to the grievances. On 5/13/26 at 9:45 am, R2, R3 and R40 stated they received a shower today and their bed linens were not changed and all stated that bedding is not always changed on our bath days, which is twice a week.On 5/13/26 at 9:45 am, R41 stated, My roommate's bed is not always changed when it is soiled with urine and even when I ask for it to be changed because of the odor they do not do it. Then when I am eating my meals in my room, I have to eat near the open window, to keep me from feeling sick from the smell.On 5/14/26 at 9:22 am, R41's (Resident Council President) bed linens had a dark brown debris area (approximately four inches by 4 inches) and a moderate amount of food debris/crumbs. R1 stated, They hardly ever change my sheets when they should, and I have asked them to do many times. We have got a lot of complaints in Resident Council about this also. We have the same concerns month after month and the management does not follow through on our complaints and sometimes, we never even hear anything back, or they say, 'oh we will look into that, and they do not care. I feel like administration just does not care.On 5/14/26, V1 (Administrator) stated, We may need to work on getting all departments on board and work together on our grievances. We probably need to make some improvements, so we do not get the same issues over and over.

Based on observation, interview and record review the Facility failed to follow a care planned dysphagia diet intervention and monitor/supervise one of 15 Residents (R7) reviewed for diets in a sample of 28. Findings include:The Facility Aspiration Precautions Policy, revised 2/11/26, documents: it is the policy of this Facility that Residents will be identified when they are at risk for aspiration and that the plan of care will reflect appropriate interventions; any resident identified as an aspiration risk will be placed on Aspiration Precautions protocol; Aspiration Precaution protocol may include interventions determined by a Speech and Language Pathologist and Physician; Aspiration Precautions will be noted on the resident plan of care; staff responsible for feeding will be knowledgeable of emergency procedures; resident will be in view of staff for meals and nourishments unless otherwise specified in the plan of care; and resident will be monitored for changes in their condition that would require further evaluation and intervention.R7's current Care Plan documents: Regular diet, Dysphagia Advanced texture; Aspiration precautions related to diet texture alteration and dysphagia; alteration in visual abilities; altered oral/dental health related to missing teeth; swallowing difficulty related to complaints of difficulty or pain with swallowing and to monitor/document/report difficulty swallowing, holding food in mouth, prolonged swallow time, repeated swallows per bite, coughing, throat clearing, drooling or pocketing food in mouth; has alteration in ability to care for self and needs assistance due to dementia; and supervision with eating. On 5/12/26 at 11:01 am, upon entry to R7's room, R7 was sitting on a bedside chair consuming a breakfast meal (scrambled eggs with cheese, oatmeal, toast and milk). R7 was unsupervised and no staff were monitoring R7. On 5/12/26 at 11:20 am, R7 was consuming the breakfast meal and was unsupervised.On 5/12/26 at 11:04 am, while eating the breakfast tray, R7 stated, I am eating my breakfast but it is cold. R7 could not verify monitoring by a staff member.On 5/14/26 at 1:00 pm, V2 (Director of Nursing) stated, A resident with a dysphagia diet should be with a staff member while they eat, so they can be monitored for choking.

Based on observation, interview and record review the facility failed to develop comprehensive care plans for three residents (R6, R22, R31) identified as requiring Contact Precautions of five residents reviewed for Transmission Based Precautions in a total sample of 22. FINDINGS INCLUDE: The facility policy, entitled Comprehensive Care Plan Policy, dated 6/25/2020, documents: An individualized comprehensive care plan that include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems. R6's current Physicians Order Summary Report indicates R6 has diagnoses to include ESBL (Extended Spectrum Beta Lactamase Resistance and Urinary Tract Infection (UTI) and indicates R6 has Infection Precautions-Contact for ESBL in urine. (date initiated 5/16/24). R22's current Physicians Order Summary Report indicates R22 has diagnoses to include ESBL (Extended Spectrum Beta Lactamase Resistance and Urinary Incontinence and indicates R22 requires Contact Isolation (date initiated 2/6/25). R31's current Physicians Order Summary Report indicates R31 has diagnoses to include ESBL (Extended Spectrum Beta Lactamase Resistance, Malignant Neoplasm of Unspecified Kidney, UTI, Acute Pyelonephritis, Hydronephrosis with Renal and Ureteral Calculus Obstruction and indicates R31 has Infection Precautions-Contact Isolation every shift for ESBL of urine. (date initiated 6/13/24). On 4/15/25 and 4/16/25, R6 and R22's room (roommates) and R31's room was noted to have a Contact Precaution sign posted on the door to R6/R22 and R31's rooms. R6's current Care Plan indicates R6 currently has an alteration to Genitourinary system due to UTI related to antibiotic (Gentamycin) - end date 5/27/24. Date Initiated: 05/17/2024 Revision on: 05/20/2024 R6's care plan does not include a Focus/Problem area for Contact Isolation or identify ESBL as the organism requiring transmission based precautions. R22's current Care Plan indicates R22 is at risk for urinary incontinence but does not include a Focus/Problem area for Contact Isolation or identify ESBL as the organism requiring transmission based precautions. R31's current Care Plan indicates R31 has an alteration to her Genitourinary system due to ESBL. Care Plan intervention indicates R31 has Enhanced Barrier Precautions (EBP) in place. On 4/17/25, at 9:30 am, V1/Administrator, confirmed the facility currently does not have an MDS (Minimum Data Set)/Care Plan Coordinator. On 4/17/25, at 9:35 am, V1 and V3/ADON (Assistant Director of Nursing)/IP (Infection Preventionist) both acknowledged the care plans should have been developed to include problem area of transmission based precautions and appropriate interventions. On 4/17/25 V3 confirmed R31 remains in Contact Precautions-not EBP and the care plan needs to be corrected.

Based on observation, interview, and record review the facility failed to obtain smoking agreements and collect smoking paraphernalia for two (R1, R15) of two residents reviewed for smoking in a sample of 22. Findings include: The facility policy and procedure titled, Smoking, revised October 1, 2024, documents, Policy- To ensure compliance with regulatory guidelines and safety protocols, the Facility prohibits smoking except for in specifically designated areas. To protect the safety of other residents and employees, the use of medical oxygen is prohibited in smoking areas. Residents deemed to need assistance to smoke should have this designation noted in the care plan. For purposes of this policy, electronic cigarettes Ce-cigarettes, pipes, cigars, and similar paraphernalia are to be treated as cigarettes. Procedure- 1. B. Residents are not permitted to have any smoking paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Nursing staff should maintain records of residents' property and distribute it accordingly. Nursing staff are required to confirm the resident's status in the smoking log before distributing smoking materials to the resident. Residents who have been determined to require supervision must be actively supervised by a staff member while in the designated smoking area. E. Residents must sign a Smoking Agreement as part of the admission process. Smoking Agreements should be amended and re-signed when the resident's smoking status has changed. R1's Admission Record documents R1's date of admission to the facility was 2/26/25 and her diagnoses on admission included: Cerebral Infarction, Major depressive Disorder Recurrent, Insomnia, Depression, Anxiety, Hyperlipidemia, Myocardial Infarction Type 2, and Type 2 Diabetes. R1's Minimum Data Set assessment, dated 3/6/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 13/15 indicating cognition intact. R1's Smoking Evaluation Assessment, dated 3/4/25, documents that R1 is a smoker. R1's current Care Plan documents R1 is a smoker and Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station or med cart. On 4/15/25 at 1:51pm, R1 stated, I (R1) am a smoker. R1 also stated, I keep my smoking materials with me or in the top drawer of my husbands (R15) dresser in his room. R1's cigarette pack and lighter observed in R1's shirt pocket at this time. R15's Admission Record documents R15's date of admission to the facility was 9/5/24 and his diagnoses on admission included: Cerebral Infarction, Metabolic Encephalopathy, Sepsis, Osteomyelitis, and Nicotine Dependence. R15's Minimum Data Set assessment, dated 3/11/25, documents R15 has a BIMS score of 13/15, indicating cognition intact. R15's Smoking Evaluation Assessment, dated 9/6/24, documents that R15 is a smoker. R15's current Care Plan documents R15 is a smoker and Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station or med cart. On 4/15/25 at 10:53am, R15 stated, I am a smoker and I keep my cigarettes and lighter in the top drawer of the nightstand over there under the television set. R15's cigarette pack and lighter noted in top drawer of nightstand at this time. On 4/16/25 at 10:39am, R1 and R15's cigarettes and lighters observed in R15's nightstand, top drawer. R1 and R15 also stated they do not remember signing a smoking agreement on admission. On 4/16/25 at 11:00am, V5 (Licensed Practical Nurse/LPN) stated, There is no designated smoking times for residents, they go when they want if there is staff available to take them. Resident smoking supplies are kept at the nurses station. V5 (LPN) verified that smoking supplies were not at nurses' station and stated, They are usually kept here but I didn't work yesterday so I'm not sure where they are. On 4/17/25 at 10:00am, V5 (LPN) verified that R1 and R15's cigarettes and lighter were in R15's bedside table, top drawer and V5 (LPN) stated, they (cigarettes and lighter) should be kept at the nurse's station. On 4/17/25 at 10:14am, V1 (Administrator) stated, resident's cigarettes and lighters are to be kept at the nurse's station when they are not smoking. On 4/17/25 at 11:30am, V1 (Administrator) stated, Resident smoking agreement is a new form added when policy was revised in October of 2024 and has not been updated in our system. So, neither of our smokers (R1 and R15) have signed one.

Based on interview, observation, and record review the facility failed to attempt gradual dose reduction for one resident (R15) of five residents reviewed for unnecessary medications in a sample of 22. Findings include: The facility's Policy and Procedure, titled Psychotropic Gradual Dose Reduction (GDR), revised 11/5/19, documents, Policy statement- It is the policy of this facility that residents who use psychotropic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue the use of these medications. Policy Interpretation and Implementation- 1. Residents who use psychotropic drugs will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. 4. Our drug reduction program consists of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether. Inquiries concerning drug reductions should be referred to the pharmacist, attending physician, psychiatrist, and/or to the director of nursing. The facility policy, entitled Psychotropic Medication Management, dated 12/4/2019, documents: Documentation within the clinical record to support one or more of the following diagnosis: Schizophrenia, Delusional Disorder, Organic mental syndromes (now called delirium, dementia, and amnesia and other cognitive disorders) with associated psychotic and/or agitated behaviors. 1. R15's admission Record documents R15's date of admission to the facility was 9/5/24 and his diagnoses on admission included: Cerebral Infarction, Metabolic Encephalopathy, Sepsis, Osteomyelitis, Other Specified Depressive Episodes, Anxiety Disorder, and Nicotine Dependence. R15's Minimum Data Set assessment, dated 3/11/25, Section C documents R15 has a BIMS score of 13/15, indicating cognition intact, Section E documents no behaviors exhibited, and Section N documents R15 currently takes Antidepressant Medications. R15's Physician Orders, dated 9/5/24, documents R15 takes Bupropion HCL ER (XL) Extended Release 24 Hour 300 milligram (mg) tablet (antidepressant) give one tablet by mouth one time a day related to Other Specified Depressive Episodes and Escitalopram Oxalate/Lexapro 20 mg tablet (antidepressant) give 20 mg by mouth one time a day for antidepressant. R15's current care plan documents R15 receives antidepressant medications for Depression and has an alteration in behavior related to depression. R15's Psychotropic Medication Monitoring Assessment, dated 9/5/24, documents R15 takes antidepressant medications of Bupropion ER (Extended Release) 300 mg daily and Escitalopram 20 mg daily. R15's Behavior- Depression/Withdrawn task documents no behaviors from 3/20/25 to 4/17/25. R15's psychiatry note, dated 2/15/25, documents, Gradual Dose Reduction (GDR) Lexapro/Escitalopram (antidepressant) 20 mg to 15 mg daily for depression. Continue Bupropion HCL ER (Extended Release) 300 mg daily for depression. R15's psychiatry note, dated 3/12/25, documents, GDR of Lexapro from 20 mg to 15 mg daily for depression recommended last session but patient is still on Lexapro 20 mg by mouth (po) daily. On 4/15/25, 4/16/25, and 4/17/25 R15 observed on several occasions calmly sitting in his wheelchair in room watching television. On 4/16/25 at 2:09 pm, V6 (Social Service Director/SSD) stated, The Director of Nursing/DON, Assistant Director of Nursing/ADON, and me (V6) get the psychiatry notes emailed to us. I (V6) document visit in the nurses' notes and nursing takes care of the recommendations for Gradual Dose Reductions/GDR's. On 4/16/25 at 2:10 pm, V1 (Administrator) stated, The Director of Nursing/DON monitors psychotropic medications and Gradual Dose Reductions/GDR's. The DON sends recommendations from psychiatric services to the facilities Nurse Practitioner to approve or decline, then documents response and changes orders if approved. On 4/17/25 at 9:54 am, V1 (Administrator) verified that on 2/15/25 psychiatry recommended to decrease R15's Escitalopram (antidepressant) from 20 milligrams(mg) daily to 15 mg daily and recommendation was not sent to Nurse Practitioner to approve or decline.

Based on interview and record review the facility failed to provide a Hospice created Care Plan, visit communication notes and to designate in writing a facility Hospice Coordinator for one resident (R28) of three residents reviewed for Hospice in the sample of 22. FINDINGS INCLUDE: Facility Policy Hospice Care, dated 11/5/2019, document: This facility will work in coordination with the contracted Hospice agency to provide a safe continuum of care for the resident's end of life. Nursing Facility Hospice, General Inpatient And Respite Care Services Agreement, dated 7/13/21, documents: Services to be Provided by Hospice: Hospice will develop, at the time a resident of the Facility is admitted into Hospice's program, a Plan of Care for the management and palliation of the resident's terminal illness. The Plan of Care will identify the care and services that are needed and will specifically identify which provider is responsible for providing respective functions that have been agreed upon and included in the Plan of Care. The Plan of Care will be updated as often as the patient condition requires, but no less frequently than every fifteen (15) calendar days. A copy of each updated Plan of Care will be furnished to the Facility upon each update, but no less frequently than every fifteen (15) days. Hospice will furnish a copy of each Hospice patient's Plan of Care to the Facility at the time of the resident's admission into the Hospice program. On 4/16/25, at 3:00 pm, V4/Business Office Manger and V9/Registered Nurse were unable to find the Hospice Company Care Plan at the nurses station where they both stated it would be kept. V4 stated That particular Hospice Company does not leave communication notes They haven't left them for a long time. No Hospice communication notes were found in R28's electronic medical record or in the binders at nurse station designated for the Hospice Company. There was no designation in writing found indicating who was the facility Hospice Coordinator.

Based on interview and record review, the facility failed to follow its policy of implementing care plan interventions to prevent the further decline of pressure ulcers, for one of three residents R100 reviewed for pressure ulcers, in a sample of 31. FINDINGS INCLUDE: The facility policy, Skin Prevention, Assessment and Treatment, dated (revised) May 2, 2022 directs staff, Purpose: To identify factors that place the residents at risk for the development of pressure ulcers; To implement appropriate interventions to prevent the development of clinically avoidable wounds; To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; To promote healing of existing pressure ulcers. Residents identified as high risk should be addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented. Care Plan interventions include: Wound Consultant review; Registered Dietician review; Nutritional supplement; Encourage or turn and reposition on a resident centered time frame (approximately every 2 hours); Use pillows, pads, etc. to aide in positioning, cushion bony prominence's and elevate heels off surface; Encourage activities such as range of motion, ambulation and exercises as tolerated; Practice good transfer techniques to avoid friction and shearing; Keep linens clean and wrinkle free; Keep skin clean and dry; Incontinent care after each incontinent episode; Provide pressure relieving device or cushion on surfaces as indicated; Inspect skin daily for reddened areas or breakdown; Monitor cast, braces, splints and compression bandages for skin irritation; Encourage to maintain adequate nutrition and hydration; Showers at least two times weekly; Nails maintained to promote cleanliness, prevent infection and enhance sense of wellbeing; Arm sleeves, leg protectors; Pad frequently bumped areas. Wounds are treated and based on the etiology of the wound. R100's March 2024 Physician Order Sheet documents that R100 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, Urinary Tract Infection, Malignant Neoplasm of the Rectum and Diarrhea. R100's Nursing Admission Assessment, dated 3/23/24 and signed by V5/Licensed Practical Nurse includes the following Skin Issues, Left ear, Pressure, 1.3 CM (Centimeters) X 0.3 CM, Stage 1; Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1 and Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1. No Admission Care Plan to address R100's admission skin conditions and interventions to prevent further deterioration of R100's skin, is present in R100's medical record. R100's Care Plan, dated 3/25/24 includes no focus area to address R100's newly acquired pressure ulcer, or interventions to prevent further deterioration of R100's skin. The facility Weekly Wound Tracking Log, dated 3/25/24 documents, (R100) Pressure wound, Right Buttock, Stage 2, 2.5 CM X 1.5 CM X 0.1 CM, Open (area). On 4/2/2024 at 1:00 P.M., V4/Care Plan Coordinator verified R100's current Care Plan did not address (R100's) pressure ulcer or include interventions to prevent further deterioration of R100's skin. On 4/2/24 at 2:40 P.M., V5/Licensed Practical Nurse verified no admission care plan to address (R100's) skin condition on admission was developed.

Based on record review and interview, it was determined the facility failed to ensure weights were obtained as ordered for 1 of 1 (R10) resident reviewed for Heart Failure in a sample of 31 residents. Findings include: The Minimum Data Set (MDS) section I documents R10 has an active diagnosis of Heart Failure. The current care plan documents R10 has an alteration to my cardiac system and to monitor vital signs as ordered and PRN (as needed); expect weight fluctuations due to edema and diuretics (medication that helps reduce fluid in the body). On 3/11/24, the Physician ordered weights to be conducted daily. Daily weights were not conducted in March 2024, 6 of 20 days. On 4/2/24 at 2:00 PM, V2 (Director of Nurses) stated R10's weights were not recorded daily and should have been.

Based on observation, interview and record review the facility failed to document target behaviors to warrant the use of Seroquel (antipsychotic medication) for one of two residents (R14) reviewed for antipsychotic medications in the sample of 31. Findings include: The facility's Psychotropic Medication Management policy, dated 12/4/19, documents Purpose to provide guidance for the psychopharmacologic drug treatment for a resident with specific conditions, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record. An assessment must be conducted to identify specific behaviors/ symptoms, potential causative factors and recommendations for managing identified behaviors. The physician should evaluate use of antipsychotic medication use if one or more of the following is/are the only indication: Wandering, Poor self-care, Restlessness, Impaired Memory, Anxiety, Depression (without psychotic features), Insomnia, Unsociability, Indifference to surroundings, Fidgeting, Nervousness, Uncooperativeness or Agitated behaviors which do not represent danger to the resident or others. On 4/1/24 at 10:30 AM R14 was sitting in a wheelchair in her room. R14 was pleasantly confused with conversation and unable to answer questions. R14 was not displaying any behaviors. On 4/1/24 at 12:00 PM R14 was sitting in dining room at a table being assisted by staff with her meal. R14 was not displaying any behaviors. On 4/3/24 at 9:45 AM R14 was sitting in her wheelchair in the activity room watching a movie. R14 was not observed displaying any behaviors. R14's current Physician Order Sheet, dated 4/3/24, documents R14 has an order for Quetiapine Fumarate (Seroquel, antipsychotic medication) 25 milligrams by mouth one times daily related to psychotic disorder with delusions due to known physiological condition. This same order sheets also documents an order for Quetiapine Fumarate 50 milligrams by mouth in the evening related to psychotic disorder with delusions due to known physiological condition. R14's current Care Plan, dated 3/9/23, documents I currently have acute confusion episodes or delirium due to Dementia and psychotic disorder. I currently have an alteration in my behavior status related to Dementia/Anxiety/Insomnia/Psychotic Disorder with Delusions. (R14) often wants to speak to her mother and believes staff/residents are her sisters/children. Has a history of being agitated/yelling out/grabbing/pushing staff during cares. It can be very difficult to redirect resident when she is agitated. R14's electronic behavior monitoring, dated 3/4/24-4/1/24, documents R14 is being monitored daily for behaviors of Agitation/ Restlessness/ Anxious, Confusion/disorganized thinking, Cursing, Depression/withdrawn, Delusion. On 4/03/24 at 9:35 AM, V7 (Certified Nursing Assistant) stated (R14) mostly has been sleepy lately. She is newly on palliative care. When (R14) does display behaviors, they are of being resistive with cares. She is not a harm to other residents at all. On 4/03/24 at 9:40 AM, V8 (Licensed Practical Nurse) stated (R14) typically is just resistive to care at times. She can be sassy, her symptoms are that of Dementia. (R14) has no behaviors towards other residents. On 4/03/24 at 11:54 AM, V2 (Director of Nursing) Confirmed R14's behaviors that are being tracked are those of agitation, restlessness, confusion/disorganized thinking, cursing, depression/withdrawn, and delusion. V2 stated R14's delusions are often thinking staff are family/parents and confirmed R14 is not at risk of harming herself or other residents. V2 confirmed R14's behaviors being tracked are not psychotic in nature and relate back to her diagnosis of dementia.

Based on observation, record review and interview, the facility failed to ensure Personal Protective Equipment was utilized and hand hygiene was performed for 3 of 6 residents (R10, R22 and R27) reviewed for Infection Control Practices in a sample of 31. Findings include: The Hand Washing policy dated 11/5/19, documented Hands should be washed before resident care, after resident care. The Enhanced Barrier Precautions policy dated 3/27/24, documented Are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or patient's environment. In addition to residents who have an infection or colonization with CDC (Center for Disease Control)-targeted or other epidemiologically important MDRO when contact precautions do not apply. Hand Washing. R10 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Atrial Fibrillation, history of Urinary Tract Infection (UTI) with Multi-Drug Resistant Organism and Acute Respiratory Failure. On 2/14/24, R10's Physician ordered Contact CDC Isolation Precautions d/t (due to) ESBL (Extended-Spectrum beta-lactamase/multi-drug resistant organism) Urine. On 4/2/24 at 12:00 PM, (R10) was observed to have a Contact Precautions and Enhanced Barrier Precautions signage posted on the door. On 4/2/24 at 12:00 PM, V6 (Certified Nurse Aide/CNA) was observed assisting R10 with meal setup. V6 was observed to not have any personnel protective equipment donned; exited R10's room without conducting hand hygiene; entered R22's room and assisted R22 and R27 with setting up their meals; exited the room without conducting hand hygiene; re-entered R10's room and exited without conducting hand hygiene and then entered the staff lounge. On 4/2/24 at 12:20 PM, V2 (Director of Nursing) stated V6 should have donned a gown and gloves while providing care for R10 and conducted hand hygiene before and after exiting room [ROOM NUMBER] and 411.

Based interview and record review, the facility failed to provide daily housekeeping cleaning services for one resident (R1) of four residents reviewed for housekeeping in a sample of four. Findings include: The facility's Resident Rights Policy and Procedure, Undated, documents: Purpose: To ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. IX. Safe environment. Each resident has a right to a safe clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. The facility shall provide: A. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. B. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility's Effective Plan for Housekeeping Policy, dated 3/23/23, documents: It is the policy of this facility to provide a clean and sanitary environment. 1. The housekeeping staff will keep the building clean, safe and in orderly condition. This includes all rooms, corridors, attics, basements and storage areas. The facility's Resident Council Minutes, dated 11/14/23, documents: Housekeeping/laundry: All halls say on weekend their hall or rooms don't get cleaned all the time. The facility's Resident Council Minutes, dated 12/12/23, documents: Housekeeping: Rooms are not cleaned on weekends, certain housekeepers. The facility's Resident Council Minutes, dated 1/9/24, documents: Housekeeping: Need toilets to be cleaned, some housekeepers don't even bring cleaner in with them. Would like to see rooms and bathrooms cleaned. R1's Suggestion/Complaint/Grievance Form, Dated 10/20/23, documents: (My/R1's) room hasn't been cleaned by Housekeeping since October 17, 2023. They have been outside my room every day, sometimes twice, to clean the rooms adjacent to mine but not mine. R1's Suggestion/Complaint/Grievance Form, Dated 10/20/23, also documents in Section 1 that V17 Housekeeping/Laundry Supervisor spoke with V16 Housekeeping and V9 Housekeeping and both staff admitted to not cleaning (R1's) room. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) On 1/25/24 at 1:05pm, V9 Housekeeping stated that she remembers that one day she was called away to clean another's resident's bathroom; and that she did not go back to clean R1's room. On 1/24/25 at 1:35pm, V16 Housekeeping, stated she cleans rooms five days a week at the facility, and stated that on one occasion (cannot recall the date), (R1's) room did not get cleaned. V16 stated, This was an oversight on my part. On 1/24/25 at 1:38pm, V17 Housekeeping/Laundry Supervisor stated that all rooms at the facility should be cleaned each day. V17 stated, I talked to my staff to make sure they got (R1's) room each day; they (Housekeeping Staff) have a check off list to use after cleaning each room but they do not always use the check off list but are supposed to.

Based on observation, interview and record review the Facility failed to provide hygiene care (showers) for four (R6, R18, R30 and R36) of 16 Residents reviewed for hygiene in a sample of 22. Findings include: Facility Shower Care Policy and Procedure, revised 11/24/20, documents that it is the practice of this Facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Facility Shower Schedule, effective 3/1/2012, documents that all Residents residing in the Facility are scheduled to receive a shower twice a week. Facility Certified Nursing Assistant Job Description, documents: this position is to assist the nurses in the providing of Resident care primarily in the area of daily living routine; must be physically and mentally capable of performing routine, repetitive job duties; knowledge of State and Federal Regulations; carry out assignments for resident care including bathing and grooming; and be responsible for the well-being and nursing care of all residents assigned to his/her unit while on duty. Facility Resident Council Minutes, dated 1/10/23, document: showers (100 Hall) still not being done, they are told by staff that they are short of help; feel nurses spend too much time at nurse's desk; showers (400 Hall) said their showers are better they at least get one shower a week. Facility Resident Council Minutes, dated 5/9/23, document issues with showers on Second Shift, Residents are told they are too short on staff to do them. Facility Resident Council Minutes, dated 6/13/23, document issues with showers on second shift are not being done on regular basis and that V2 (Director of Nursing) has talked to staff and shower audits are also in place and being tracked. Facility Resident Council Minutes, dated 7/11/23, document that showers again have not been done in a timely fashion and that Residents feel that more staff is needed. R30's Minimum Data Set/MDS, Section G, dated 5/21/23, documents that R30 requires staff assistance with bathing. R30's current Care Plan documents, requires extensive assistance of one to two staff to provide showers (two times a week) and as necessary. R36's Minimum Data Set/MDS, Section G, dated 7/20/23, documents that R36 requires staff assistance with bathing. R6's Current Comprehensive Assessment indicates R6 is cognitively intact and able to make all needs known. R6's current Care Plan indicates R6 requires assistance with ADL's (Activities of Daily Living). On 7/27/23, at 1:30 pm, R6 stated, I do not always get my showers and that the CNA's will tell me that they do not have enough time to give them because there is not enough staff. R6's CNA (Certified Nursing Assistant) Task Documentation, dated 7/2023, indicates R6 was admitted on [DATE] and did not receive a shower on 7/25/23. R18's Current Comprehensive Assessment indicates R18 has moderate cognitive impairments. R18's current Care Plan indicates R18 requires assistance with ADL's (Activity of Daily Living) including showering/bathing. R18's CNA (Certified Nursing Assistant) Task Documentation, dated 7/2023, indicates R18 was admitted to the facility 2/23/23, and received one shower on 7/6/23. On 7/25/23, at 8:19 am, R36, with oily and unkempt hair, stated, I do not remember when my showers are, and I do not remember the last time I got one. I do not think I get them all the time when I am supposed to. On 7/26/23, at 9:50 am (during Resident Group Meeting), R24 (Resident Council [NAME] President) stated, There was a problem with the nurses not helping to cover the hallways when the CNA's were in giving showers, so the showers were not getting done all the time and there were not enough CNA's to give showers. On 7/26/23, at 8:15 am, R195 stated, I am the Resident Council President and there are many people, in the meetings, that complain about not getting their showers when they are scheduled. This has been going on for a few months, we keep complaining and nothing is ever done. I am supposed to get my showers on Monday and Thursday evening, but I do not get them. I like my showers right before I go to bed, and I definitely do not get my showers when they are scheduled. On 7/26/23, at 9:15 am, V4 (Ombudsman) stated, At this Facility, I get concerns over the Residents not receiving their showers and this has been ongoing for a few months. I think the Facility has trouble and issues with second shift staff. On 7/26/23, at 1:20 pm, V2 (Director of Nursing) stated, I know that we have had issues with showers, but we have less CNA's (Certified Nursing Assistants) on second shift, and we need more help, but it is hard finding second shift CNA's. I am looking specifically just for a shower aide. I do not have any documentation showing that (R30 and R36) got their twice a week showers. 30899

Based on interview and record review the facility failed to offer bedtime snacks to six of nine residents (R7, R24, R37, R38, R41, R195) who attended the Resident group meeting in the sample of 22. Findings include: Facility Policy/Nutritional Snacks and Supplements, dated 11/5/2019, documents: Nutritional supplements are available, and will be provided for all appropriate residents by the nursing staff; bedtime snacks will be offered daily; and the nursing staff will deliver the supplements/snacks to residents. The Facility Week at a Glance Dietary Menu, dated Spring/Summer 2023, documents fruit drink, assorted snacks, cookies, and crackers as the Evening Snack. Facility Resident Council Minutes, dated 1/10/23, documents, snacks are available in kitchenette, behind nurses' station, you need to ask for them if not offered. Facility Resident Council Minutes, dated 3/14/23, documents, still not receiving their nighttime snacks (they need to ask for snack if they do not receive one) and still no nighttime snacks. On 7/26/23, at 9:45 am, R7, R24, R37, R38, R41 and R195 (Resident Council President) stated they were never offered snacks at bedtime and were not aware there were snacks available. All six residents stated they would like a snack to be offered and acknowledged it is a long time between dinner and breakfast and a snack would be helpful. On 7/25/23, at 8:19 am, R36 stated, I do not ever remember getting offered a snack at night. On 7/26/23, at 8:15 am, R195 stated, I am the Resident Council President and I have heard complaints that other Resident's do not get offered a snack at night. They do not offer me a snack at night either, and I would like them to ask me if I want one. On 7/26/23, at 9:50 am, V6 (Activity Director) stated they had been short staffed on evening shift and may not have had time to pass out snacks. On 7/27/23, at 2:05 pm, V7, CNA (Certified Nurse Assistant) stated she was just arriving for work as she works the evening shift. V7 stated, sometimes there are snacks available, but not always V7 stated, sometimes staff have to go to the Memory Care Unit to get snacks if a resident asks for them. V7 also stated the staff do not offer snacks, Residents have to ask for them. On 7/27/23, at 10:20 am, V3 (Dietary Manager) stated, The Dietary Cook is responsible for bringing out the nighttime snacks and delivering them to the nurses station. Then, at night, it is the CNA's responsibility to offer and pass them to the Residents. We always send out nutritional snacks for the Diabetics, but it is the responsibility of the Nursing Staff to deliver them and offer snacks to other Resident's, with food from the pantry by the Nurse's Station. On 7/27/23, at 10:10 am, V2 (Director of Nursing) stated, Dietary delivers a tub of snacks at the Nurse's Station and the CNA's (Certified Nursing Assistant's) are responsible for delivering the snacks. We do not offer each individual resident a snack, there is a snack schedule, and each Resident has to be on the list to receive a snack, such as Diabetics. If they are not on the list, the Residents can always ask for a snack, but the CNA's do not offer each individual Resident a snack every night. I have been working on the snack delivery over the last months. I have trouble hiring CNAs on second shift and now I have hired a few more, so hopefully everything on second shift will get better. We have less CNAs on second shift, and we need more help, but it is hard finding second shift CNA's. 33975

Based on interview and record review the facility failed to identify potential triggers for one resident (R35) of five residents reviewed for PTSD (Post Traumatic Stress Disorder) in a total sample of 22. Findings Include: The Facility's Trauma-Centered Care Policy dated, 11/12015, documents It is the policy of this facility that we will create and maintain a safe, calm, and secure environment with supportive care, a system-wide understanding of trauma prevalence and impact, recovery and trauma specific service as needed, and recovery-focused services. As approach that appreciated healing is possible, trauma informed care engages people with histories of trauma, recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. This approach seeks to shift the paradigm from one that asks What's wrong with you? to one that asks, What has happened to you? Every part of a trauma-informed system's organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking service. The Facility's Trauma-Centered Care policy also documents the facility routinely assist residents to develop a plan that is designed to prevent and manage a crisis. All staff directly involved in the resident's treatment is informed about the resident plan and how they can support it. The facility has a system in place to identify and implement policies, procedures, environmental conditions, activities, social climate, documentation and treatment practices that promote a safe and secure environment in order to reduce the likelihood of re-dramatization or re-victimization. R35's undated care plan documents I experienced a traumatic event in my past. childhood trauma and physical abuse. R35's care plan does not include any triggers or approaches for R35. On 7/27/23 at 9:30 AM V2 (RN DON) stated That (Care Plan) should include approaches specific to (R35's) specific triggers which are also not on the care plan and should be.

Based on record review and interview, the facility failed to serve an appropriate non-emergent involuntary discharge and allow the resident and resident's family time to appeal the notice, for one of three residents (R1) reviewed for discharge in the sample of four. This failure resulted in R1 being removed from his environment and suffering psychosocial harm that any reasonable person would after being placed over four and half hours away from his family and friends without notice. Findings include: The facility's Transfer/ Discharge policy, dated 11/5/19, documents The interdisciplinary team and or physician, in consult with the resident or his/her power of attorney (POA) for healthcare, may recommend transfers or discharges. All resident transfers and discharges from this facility require notification and/or authorization of the resident or his/her POA for healthcare, and his/her primary physician. In cases of emergencies the nurse on duty may initiate transfer to a hospital or medical center as resident's status and condition warrants it. The National Institute on Aging online article titled Changes in Intimacy and Sexuality in Alzheimer's Disease, dated 5/17/17 and located at www.nia.nih.gov, documents Hypersexuality: Sometimes, people with Alzheimer's disease are overly interested in sex. This is called hypersexuality. The person may masturbate a lot and try to seduce others. These behaviors are symptoms of the disease and don't always mean that the person wants to have sex. R1's Admission record documents R1 was admitted to the facility on [DATE] with a principal diagnosis of Alzheimer's Disease. R1's recent Minimum Data Set assessment, dated 4/7/23, documents R1 suffers severe cognitive impairment and requires extensive assistance of one person to transfer, walk and move around the facility in a wheelchair. R1's Care Plan, dated 2/6/23, documents (R1) does both independent and group activities. Staff will observe and not leave (R1) unattended during activities. R1's Care Plan, dated 12/26/22, documents (R1) has expressed sexual desires. R1's Plan of Care, dated 4/21/23 documents (R1) is at risk for wandering/elopement and (R1's) safety will be monitored every shift by all staff. Interventions: One on one monitoring as necessary, initiated 4/21/23. Targeted one on one supervision, initiated 4/28/23. R1's Care Plan, dated 12/26/23, documents I currently have an alteration in my behavior status related to Alzheimer's, impaired memory/thinking, and increased sexual drive and may exhibit behaviors such as increased confusion, making inappropriate comments or physically attempting to touch staff and residents; will masturbate and is unable to comprehend or remember appropriate behaviors due to his diagnoses. (R1) does get agitated at times with staff and other residents. R1's Progress Note, dated 5/25/23, document at 11:00 AM IDT (Interdisciplinary Team) met to discuss the physical assault (R1) attempted with a CNA (Certified Nursing Assistant, V11) during transfer and recommends the resident be discharged to accepting facility for the safety of other residents. R1's Progress Note, dated 5/25/23, documents Administrator (V1) met with resident to discuss the events happening this morning with Activity Director (V15) present. Involuntary discharge was explained and issued to the resident. Resident did not have any questions or concerns. R1's Notice of Involuntary Transfer or Discharge and opportunity for Hearing for Nursing Home Residents, dated 5/25/23, documents R1 is to be an Emergency transfer or Discharge due to the safety of individuals in this facility is endangered. On 6/7/23 at 2:09 PM, V11 (Certified Nursing Assistant, CNA) stated The day of the incident, I went in to get (R1) up and when I went to stand him, his hand was out and (R1) tried to kiss me but did not make contact. I got him to the dining room, and I let activities know his behavior and I told the nurse (V7, Licensed Practical Nurse). On 6/7/23 at 11:34 AM, V8 (CNA) stated I was on the hall with (V11) when she came out of (R1's) room and said (R1) tried to kiss me. That sometimes was a behavior for him. I hadn't seen him try to do that in the last month or so and I did work with (R1) a lot. For his last couple days (in the facility) he was basically one on one monitoring. On 6/7/23 at 11:20 AM, V7 (Licensed Practical Nurse) confirmed being the nurse for R1 on the day he was discharged . V7 stated (R1) was back in his room after breakfast. The CNA (V11) saw (R1) up in his room and asked if she could help him back to his chair. (R1) held his hand out to (V11) and pulled her in and tried to kiss her, no contact was made. (V11) came out and told me while I was doing medications and I told her make sure to chart it and don't go back in the room without a buddy. I got done with medication pass and was called into (V1's) office and was asked why I didn't report him being sexual inappropriate to them immediately. I said (R1) was not inappropriate to another resident. We as staff are on our own if we get hit or abused. We worry about the residents. I had no idea (R1) was being taken out of here (the facility). I came back the next day and (R1) was gone. I didn't consider the situation an emergency. His wife (R4) is also a resident here. On 6/7/23 at 12:15 AM, V6 (R1's Family Friend) stated I have called and talked to (R1) since he's been discharged . (R1's) first day he was so confused and didn't know how he got there and why he was there. He said they had a room that (R4, R1's spouse) could come to. (R4) doesn't want to move that far away. We (Friends and Family) don't want that either. It's sinful to take someone who has dementia that far away, over four and a half hours. (R1) is originally from the Peoria area. On 6/7/23 at 1:20 PM, V12 (R1's family member/ Power of Attorney) stated I am an international airline pilot. I see a statement from (the facility) and of course don't always open the bills right away. Enclosed in one of those was the notice of Involuntary Discharge. I had no idea that was coming. The fact that we didn't talk is the problem. I live in Atlanta. It read that the date he was transferred was the date the letter was signed. I was a part of the admission process. They told me they would provide extra care and as things progressed, they would just up the care with (R1). I was under no direction that they were going to not care for (R1). They have people in the facility in much worse condition than (R1) and so I knew if they are caring for them, they can care for an [AGE] year-old man with severe Alzheimer's. The receiving facility (he transferred to) was just as shocked as me, they didn't know why he was there. I want him back in the facility with his wife (R4). (R4) and (R1) were inseparable. They had vacation houses together. (R4) and (R1) were always together. I just got the sense that they (the facility) were not going to be bothered with (R1's) behaviors. You can't handle this (Hypersexual) old man who's frail and can't get up without help? (R1's) not strong and they are trained to handle him. He is not mean. Inappropriate, maybe, but not uncontrollable. I just want (R1) back there in (the facility). They (R4 and R1) are wondering where each other are. On 6/8/23 at 10:10 AM, V13 (R1's Physician) stated I was aware of the discharge. I did not hear the details (of the incident) but just that (R1) assaulted a staff member. I did not know (R1) was issued with emergency status discharge. I had no idea they were moving that quickly or trying to get (R1) out that same day. I do not know why it was escalated that quickly, given the situation was not emergent. I was not aware it was an emergency discharge. On 6/8/23 at 12:10 PM, R4 was sitting in her room reading. R4 stated she knows her spouse (R1) has been transferred far away and she knows the situation but of course she'd rather be in the building together. R4 stated We've have been married a long time and it's a sad situation. (R1) would rather be in the same residence as me too. On 6/8/23 at 1:00 PM, V1 (Administrator) stated Our basis on reasoning for discharging (R1) was because he made the action of a physical altercation. He didn't make contact but made a physical attempt at a CNA (V11). At that point he no longer was just a verbal threat, he took a step-in action to be physical. He is in an all-male hallway in a smaller facility. He was transferred to the facility that would accept him. I think it's like four hours from here. He was taken that day because it was urgent to get him right out of here with those behaviors. He did not require emergency services or hospitalization .

Based on record review and interview, the facility failed to provide adequate dementia care to a resident with a diagnosis of Alzheimer's disease for one of three residents (R1) reviewed for dementia care in the sample of four. This failure resulted in R1 being removed from his environment after displaying a care planned behavior of dementia and suffering psychosocial harm that any reasonable person would after being placed over four and half hours away from his family and friends. Findings include: The facility's Care of Resident with Dementia Guidelines, dated 11/5/22, documents Provide care and support in a way that is respectful, preserves the residents identity, and maintains dignity. Understand the resident's behaviors and aggression and try to understand what may be the causative factor. Remain calm and provide a supportive approach that is individualized to the resident. Understand that behaviors have meanings and is a means to communicate a possible unmet need. Approach is everything. Caregivers can cause a behavior if we don't use the right approach. A resident with dementia can misunderstand what us happening and perceive activities of daily living (ADL) care as traumatic and/or frightening, resulting in resistance to care. Work with the resident to complete ADL tasks using creative approaches to help reduce resistance. Aggressive behaviors may be verbal or physical. They can occur suddenly, with no apparent reason, or result from a frustrating situation. While aggression can be hard to cope with, understanding that the person with Alzheimer's or dementia is not acting this way on purpose can help. The facility's Facility Assessment, dated 5/12/23, documents the facility is able to provide care for residents with the following diagnoses, including but not limited to: Impaired cognition, Mental disorder, Anxiety, Behavior that needs Intervention, Alzheimer's Disease and Non-Alzheimer's dementia. The facility's Resident Census and Conditions of Residents, dated 6/7/23 and signed by V14 (Minimum Data Set assessment Coordinator) documents 29 residents reside in the facility with a diagnosis of Dementia and 21 residents reside with Behavioral Healthcare needs. The National Institute on Aging online article titled Changes in Intimacy and Sexuality in Alzheimer's Disease, dated 5/17/17 and located at www.nia.nih.gov, documents Hypersexuality: Sometimes, people with Alzheimer's disease are overly interested in sex. This is called hypersexuality. The person may masturbate a lot and try to seduce others. These behaviors are symptoms of the disease and don't always mean that the person wants to have sex. R1's Admission record documents R1 was admitted to the facility on [DATE] with a principal diagnosis of Alzheimer's Disease. R1's recent Minimum Data Set assessment, dated 4/7/23, documents R1 suffers severe cognitive impairment and requires extensive assistance of one person to transfer, walk and move around the facility in a wheelchair. R1's Care Plan, dated 2/6/23, documents (R1) does both independent and group activities. Staff will observe and not leave (R1) unattended during activities. R1's Care Plan, dated 12/26/22, documents (R1) has expressed sexual desires. R1's Plan of Care, dated 4/21/23 documents (R1) is at risk for wandering/elopement and (R1's) safety will be monitored every shift by all staff. Interventions: One on one monitoring as necessary, initiated 4/21/23. Targeted one on one supervision, initiated 4/28/23. R1's Care Plan, dated 12/26/23, documents I currently have an alteration in my behavior status related to Alzheimer's, impaired memory/thinking, and increased sexual drive and may exhibit behaviors such as increased confusion, making inappropriate comments or physically attempting to touch staff and residents; will masturbate and is unable to comprehend or remember appropriate behaviors due to his diagnoses. (R1) does get agitated at times with staff and other residents. R1's Progress Note, dated 5/25/23, document at 11:00 AM IDT (Interdisciplinary Team) met to discuss the physical assault (R1) attempted with a CNA (Certified Nursing Assistant, V11) during transfer and recommends the resident be discharged to accepting facility for the safety of other residents. R1's Progress Note, dated 5/25/23, documents Administrator (V1) met with resident to discuss the events happening this morning with Activity Director (V15) present. Involuntary discharge was explained and issued to the resident. Resident did not have any questions or concerns. On 6/7/23 at 2:09 PM, V11 (Certified Nursing Assistant, CNA) stated The day of the incident, I went in to get (R1) up and when I went to stand him, his hand was out and (R1) tried to kiss me but did not make contact. I got him to the dining room, and I let activities know his behavior and I told the nurse (V7, Licensed Practical Nurse). On 6/7/23 at 11:34 AM, V8 (CNA) stated I was on the hall with (V11) when she came out of (R1's) room and said (R1) tried to kiss me. That sometimes was a behavior for him. I hadn't seen him try to do that in the last month or so and I did work with (R1) a lot. For his last couple days (in the facility) he was basically one on one monitoring. On 6/7/23 at 11:20 AM, V7 (Licensed Practical Nurse) confirmed being the nurse for R1 on the day he was discharged . V7 stated (R1) was back in his room after breakfast. The CNA (V11) saw (R1) up in his room and asked if she could help him back to his chair. (R1) held his hand out to (V11) and pulled her in and tried to kiss her, no contact was made. (V11) came out and told me while I was doing medications and I told her make sure to chart it and don't go back in the room without a buddy. I got done with medication pass and was called into (V1's) office and was asked why I didn't report him being sexual inappropriate to them immediately. I said (R1) was not inappropriate to another resident. We as staff are on our own if we get hit or abused. We worry about the residents. I had no idea (R1) was being taken out of here (the facility). I came back the next day and (R1) was gone. I didn't consider the situation an emergency. His wife (R4) is also a resident here. On 6/7/23 at 12:15 AM, V6 (R1's Family Friend) stated I have called and talked to (R1) since he's been discharged . (R1's) first day he was so confused and didn't know how he got there and why he was there. He said they had a room that (R4, R1's spouse) could come to. (R4) doesn't want to move that far away. We (Friends and Family) don't want that either. It's sinful to take someone who has dementia that far away, over four and a half hours. (R1) is originally from the Peoria area. On 6/7/23 at 1:20 PM, V12 (R1's family member/ Power of Attorney) stated I was a part of the admission process. They (the facility) told me they would provide extra care and as things progressed, they would just up the care with (R1). I was under no direction that they were going to not care for (R1). They have people in the facility in much worse condition than (R1) and so I knew if they are caring for them, they can care for an [AGE] year-old man with severe Alzheimer's. (R4, spouse) and (R1) were inseparable. They had vacation houses together. (R4) and (R1) were always together. I just got the sense that they (the facility) were not going to be bothered with (R1's) behaviors. You can't handle this (Hypersexual) old man who's frail and can't get up without help? (R1's) not strong and they are trained to handle him. He is not mean. Inappropriate, maybe, but not uncontrollable. I just want (R1) back there in (the facility). They (R4 and R1) are wondering where each other are. On 6/8/23 at 10:10 AM, V13 (R1's Physician) confirmed that hypersexual behaviors can be a symptom of Alzheimer's and dementia. V13 stated We started (R1) on an antidepressant and tried to isolate him away from those vulnerable. It (R1's behaviors) escalated to an encounter with a staff member. I did not hear the details but that he assaulted a staff member. I had no idea they were moving that quickly or trying to get (R1) out that same day. I do not know why it was escalated that quickly, given the situation was not emergent. On 6/8/23 at 12:10 PM, R4 was sitting in her room reading. R4 stated she knows her spouse (R1) has been transferred far away and she knows the situation but of course she'd rather be in the building together. R4 stated We've have been married a long time and it's a sad situation. (R1) would rather be in the same residence as me too. On 6/7/23 at 10:30 AM, V1 (Administrator) stated So on the 25th (of May) is when the incident occurred. (R1) had been making verbal comments to staff prior and we were monitoring that. When it escalated to (R1) reaching out physically (towards staff), not just verbal we issued the involuntary discharge. (R1) was not making any comments or reaching out to other residents. Since April he hasn't had any resident-to-resident incidents. On 6/8/23 at 1:00 PM, V1 (Administrator) stated Our basis on reasoning for discharging (R1) was because he made the action of a physical altercation. He didn't make contact but made a physical attempt at a CNA (V11). At that point he no longer was just a verbal threat, he took a step-in action to be physical. He is in an all-male hallway in a smaller facility. He was transferred to the facility that would accept him. I think it's like four hours from here. He was taken that day because it was urgent to get him right out of here with those behaviors.

Based on observation, interview and record review, the facility failed to supervise a resident (R1) to ensure residents were protected from non-consensual sexual abuse; failed to complete monitoring documentation of a resident with known sexual behaviors and failed to protect vulnerable cognitively impaired residents (R2 and R4) without the mental capacity to consent to sexual activity from sexual abuse for two of eight residents (R2 and R4) reviewed for abuse in the sample of ten. These failures resulted in R1 engaging in non-consensual inappropriate sexual behavior with R2 and R4. On [DATE], R1 was found with R1's hands down the front of R4's pants. On [DATE], R1 was found with R1's hands massaging R2's groin/vaginal area. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to in-service current staff and newly hired staff on R1's sexual behaviors and interventions; in-service current staff and newly hired staff on the newly implemented electronic behavior tracking records; and monitor the effectiveness of implemented interventions to protect other residents from R1's sexual behaviors. Findings include: The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2022, states, Purpose: To ensure that all of (name of skilled nursing facility) residents are free from abuse, neglect, misappropriation of their property and exploitation. Policy: The facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation as defined in this policy. Procedure: III. The Facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to: c. Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing. The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, dated 2022, states, To facilitate efforts to prevent, detect, treat, intervene in and prosecute elder abuse, neglect and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect and exploitation. I. Definitions: C. Abuse. a. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. c. Instances of abuse of all residents, irrespective of any mental or physical condition, that cause physical harm, pain or mental anguish. This includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. i. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual mist have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. There may be some situations in which the psychosocial outcome to the resident may be difficult to determine or incongruent with what would be expected. In these situations, it is appropriate to consider how a reasonable person in the resident's circumstances would be impacted by the incident. k. Abuse includes unwanted sexual contact, which includes but is not limited to: 1. Unwanted touching of the breasts or perineal area; 2. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal and non-verbal cues; 3. Sexual activities where one resident indicates that the activity is unwanted through verbal and non-verbal cues 4. Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown; 8. Other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis to include but limited to: Alzheimer's Disease. R1's Minimum Data Set/MDS Assessment, dated [DATE], documents: R1 with moderate cognitive impairment; R1 requires supervision of one person physical assist to ambulate throughout the facility; R1 uses a walker to ambulate; and R1 is not steady with ambulation but is able to stabilize without staff assistance. R1's Order Recap Report for the dates [DATE]-[DATE], documents orders for: Aripiprazole Tablet Five mg/milligram, Give 0.5 (half) tablet by mouth one time a day for sexual drive for seven days with an order start date of [DATE] and a discontinue date of [DATE]; Aripiprazole Tablet Five mg/milligram, Give 0.5 (half) tablet by mouth one time a day for sexual behaviors with an order start date of [DATE] and an order end date of [DATE]; Escitalopram Oxalate Tablet 10 (ten) mg Give one tablet by mouth one time a day for Depression; sexual urges with an order start date of [DATE] and a discontinue date of [DATE]; and Escitalopram Oxalate Tablet 20 MG Give one tablet by mouth one time a day for sexual urges with an order start date of [DATE] and no end date. R1's Care Plan documents the following: Focused area with an initiation date of [DATE] that R1 has an alteration in R1's behavior status related to Alzheimer's, Impaired memory/thinking and Increased sexual drive; R1 may exhibit behaviors such as: increased confusion, making inappropriate comments or physically attempting to touch staff, hospice staff, residents; R1 may be unable to comprehend or remember appropriate behavior due to R1's diagnoses; R1 gets agitated at times with staff and other residents; a goal that R1 will not engage in inappropriate sexual behavior; Interventions are documented as My (R1's) behaviors will be monitored every shift and documented with an initiation date of [DATE]; Intervene as Necessary to protect safety of others; R1 has expressed sexual desires with an initiation date of [DATE] and documents interventions as Intervene when risk, resident safety, or the safety of others is involved; Lexapro per MAR (Medication Administration Record) to control sexual urges with a revision date of [DATE]; and R1 is on Psychotropic Medications due to R1's sexual urges; R1's medication was increased on [DATE] for an unusual occurrence on [DATE]. R1's Nursing Progress Note, dated [DATE] at 3:00 PM, states, Sitting out here across from desk. Other resident (unknown) out here as well. He (R1) pulled penis out and started masturbating. Resident (R1) was directed to stop and could do this behavior in his room. R1's Nursing Progress Note on [DATE] at 1:54 PM documents a new order for Abilify 2.5 milligrams by mouth was received for sexual behaviors from V15 (R1's Hospice Physician). On [DATE] and [DATE], R1's room was located in the middle of the 400 resident hallway. R7's (female) room was at the end of the 400 hallway and R8's (female) room was directly across the hallway from R1's room. On [DATE] at 1:35 PM and [DATE] at 2:35 PM, R1 was observed in R1's room. R1's room was located at the very end of the 400 resident hallway, immediately before the outside exit door and furthest from the Nurse's Station. R7's (female) room was located directly across the hall from R1's room. 1. R4's Facesheet documents R4 admitted to the facility on [DATE] with a diagnosis of Schizophrenia. R4's Care Plan documents the following: R4 is at high risk for Wandering/Elopement; safety will be monitored every shift by all staff; history of wandering, refusal of cares, insomnia, disorganized speech or behavior, difficulty with concentration, compulsive, slowness in activity, delusions, hallucinations; impaired safety awareness and will get close to other residents; and alteration to cognition. R4's Minimum Data Set/MDS Assessment, dated [DATE], contains a Brief Interview of Mental Status which documents R4 with severe cognitive impairment. On [DATE] at 10:29 AM, R4 was observed wandering aimlessly around the facility's Memory Care Unit. R4 was unable to answer questions due to R4's mental status. The facility's Serious Injury Incident Report, dated [DATE], documents this report as an initial and final report that on [DATE] at 11:15 AM, R1 and R4 were in a resident to resident altercation. This same report documents R1 as the perpetrator, R4 as the victim and V8/CNA/Certified Nursing Assistant as a witness. This report states, (V8) alerted (V2/Director of Nursing) that (R1) appeared to have his hand in (R4's) sweatpants. (R1) was sitting at his table in the dining room and (R4) was standing in front of (R1). (V8) separated (R1 and R4) immediately and notified (V2). R1's Nursing Progress Note on [DATE] at 12:31 PM, states, Hospice/POA/Power Of Attorney/MD/Medical Doctor notified of (R1's) sexual drive change. (R1) monitored in room at this time. Confusion noted. New order received for Abilify x (times) one week to control sexual drive. R1's Nursing Progress Note on [DATE] at 12:26 PM documents R1's room was moved due to inappropriate behaviors. V8's written statement, dated [DATE], states, I went to do personal cares on an (unknown) resident in their room. I had (R4) sitting in a chair in TV/Television Room. (R1) was in the dining room. When I came out of the (unknown) resident's room, I heard (R4) saying, 'No Daddy, No Daddy.' When I got to the dining room, (R1) was in his chair still. (R4) was standing in front of (R1) and (R1) had his hand down in (R4's) sweatpants. I said, '(R1) stop. Go to your room.' I took (R4) to the TV room and called (V2) immediately. R1's MDS/Minimum Data Set/Care Plan Note on [DATE] at 11:15 AM, states, Root Cause: (R4 and R1) both have impaired memory, safety awareness, and impaired decision making capability. Intervention: Separated immediately. (R1 and R4) assessed. New order for (R1) to start Abilify times one week trial for sexual drive/behavioral change. (R1) given more privacy and relocated (off of Memory Care Unit). Continue to monitor behaviors and location as able. On [DATE] at 12:10 PM, V8 stated that on [DATE], V8 walked out of an (unknown) residents room after providing cares and noticed that R1 had R1's hand at least up to the wrist down inside the front of R4's sweatpants. V8 stated it was unknown if R1 was inside R4's incontinence brief/underwear or not. V8 stated, I heard (R4) saying, 'No daddy. No daddy, stop. Daddy stop.' V8 stated that R4 is confused and wanders throughout the memory care unit. V8 stated that since R1 had admitted to the facility, R1 was having increased behaviors of masturbating. V8 stated that while V8 was providing cares in the unknown resident's room, no other staff members were present on the Memory Care Unit providing supervision of the residents, including R1 and R4. 2. R2's Facesheet documents R2 admitted to the facility on [DATE] with diagnoses to include but not limited to: Severe Vascular Dementia; Disorientation; and Wheelchair Dependency. R2's Minimum Data Set/MDS Assessment, dated [DATE], contains a Brief Interview of Mental Status which documents R2 with severe cognitive impairment. R2's Care Plan documents R2 is at risk for behavior symptoms related to Dementia; is difficult to redirect at times of behaviors; Attempts to assist other resident's with cares and difficult to educate and redirect due to cognitive impairment. R1's Nursing Progress Note on [DATE] at 10:15 PM, states, (R1) was inappropriately groping another resident (R2). Both residents (R1 and R2) separated and (R1) brought down the hall to be observed by staff. R2's Nursing Progress Note on [DATE] at 10:23 PM, states, (R2) unaware of unusual occurrence. Unable to recall or describe. (R2) had sling positioned in chair, ready to be transferred into bed for evening. Brief, long pants intact. The facility's Serious Injury Incident Report, dated [DATE], documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on [DATE] at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4). V5's written statement, dated [DATE], states, I (V5) was at the nurse's station charting before dinner was served. I looked over and noticed (R2) sitting still next to (R1). I sat up to see what they were doing and I noticed (R1) had his hand on (R2's) vaginal area over (R2's) pants massaging the area. Once I realized what was happening between them, I stood up and removed (R2) from the area, while my co-worker (V6) started to remove (R1). Once (R2) was out of the area, (V5 and V6) told (R1) that behavior was inappropriate and moved him away from other female residents and had him sit in the hallway to eat dinner. Both (V5 and V6) informed our nurse (V4). V6's written statement, (undated) but has an electronic stamp [DATE], states, Last night ([DATE]) I was sitting at the desk charting, when the incident happened. I could not see it happen. Another CNA (V5) seen it. We approached (R1) and said, 'We don't do that, keep your hands to yourself, please.' (R1) was laughing in response and said 'ok'. (R1) was taken down the hall to his room. (R1) finished supper and was (assisted) into bed. V4's written statement (undated) states, The CNA (V5) came and got me and told me that (R1) had his hands in (R2's) lap grabbing her. We brought the resident (R1) down the hall closer to staff to be monitored. On [DATE] at 10:41 PM per telephone interview due to third shift hours, V4 stated that V5 had reported to V4 that R1 was being inappropriate with R2 and R1 had touched R2 near R2's vaginal area. V4 stated that R1 was known to masturbate publicly throughout the facility. R1's Nursing Progress Note on [DATE] at 1:44 PM, states, Verbal consent received for increase in dose of Lexapro to treat sexual urges/behavioral issues. Continue to monitor behaviors. V14's (R1's Nurse Practitioner) Progress Note, dated [DATE], states, (R1) was having sexual behaviors and masturbating in public. (R1) has also had some inappropriate behaviors toward other residents. Two weeks ago, I changed (R1) from Abilify to Lexapro. Then two weeks later (R1) was increased from 10 milligrams/mg to 20 mg daily. On [DATE] at 3:27 PM, V5 (Certified Nursing Assistant) stated, (On [DATE]) I was sitting at the Nurse's desk. We keep a balloon on (R2's) wheelchair to help keep track of (R2) because (R2) is so mobile. I noticed (R2's) balloon was not moving which was not normal for (R2), so I sat up to see what (R2) was doing. That's when I noticed that (R1) had his hands in (R2's) pubic region and was massaging the area. We immediately separated the residents and I reported it to my nurse right away. I don't like to think about that happening to (R2). On [DATE] at 11:03 AM, V1 (Administrator) stated that R1 all of a sudden started masturbating in random places throughout the facility not long after R1 admitted to the facility. V1 stated that R1 has inappropriately touched two residents; R1 had put R1's hand down the front of R4's pants and R1 touched R2's lap area. On [DATE] at 11:12 AM, V2 (Director of Nursing) stated that on [DATE], around 9:00 or 10:00 in the morning, V2 was reviewing progress note charting from the night before ([DATE]). V2 stated that V2 found a note charted by V4, that R1 had inappropriately groped R2. V2 stated that V2 discussed the incident with the staff members who confirmed the incident. V2 stated that R1 had inappropriately touched another resident (R4) one other time when R1 touched R4's private area back in [DATE] when R1 was a resident on the Memory Care Unit. V2 stated that R1 was placed on psychotropic medications to help manage R1's sexual urges. As of [DATE], R1's medical record did not contain any behavior tracking logs for [DATE] or [DATE]. R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form is blank on the dates [DATE]-[DATE]. On [DATE], it is documented a behavior occurred one time. R1's behavior tracking log for February 2023 states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form documents behaviors occurred on the following dates either all or half the shift: [DATE]; [DATE]; [DATE]-[DATE]; [DATE]; [DATE]; and [DATE]-[DATE]. The following dates are documented that interventions were not effective: [DATE]; [DATE]; [DATE]; and [DATE] and [DATE]. The following dates are documented that interventions were effective and then R1 reverted back to the same behavior: [DATE]-[DATE]; [DATE]-[DATE]. No new or updated interventions are documented as being attempted or implemented. R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form documents behaviors occurred on the following dates: [DATE]-[DATE] four times and [DATE] three times with interventions documented as not being effective. No new/different interventions are documented as being attempted or implemented. R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form does not document monitoring of R1's behaviors on [DATE]-[DATE], as these areas are blank. R1's Social Service Behavior Summary dated [DATE] at 12:23 PM, states, SSD/Social Service Director (V16) gathered January's behavior charting. (R1 displayed physical behaviors throughout the month randomly, charting was rarely completed. SSD will continue to follow. In-services were completed and charting should be completed better for this month. R1's Social Service Behavior Summary dated [DATE] at 12:02 PM, states, SSD gathered February's behavior charting. (R1) displayed physical behaviors half the month with interventions working half the time. Verbal behaviors were displayed a couple days with interventions working. SSD will continue to follow. R1's Social Service Behavior Summary dated [DATE] at 10:44 AM, states, SSD gathered March's behavior charting. (R1) did display physical behaviors with interventions working occasionally, verbal behaviors were displayed the same as well as the interventions. Interventions generally revert back d/t (due to) his Dementia. SSD will follow. On [DATE] at 3:30 PM, V2 (Director of Nursing) verified no behavior tracking logs for R1 could be provided for [DATE] or [DATE]. V2 verified the first behavior tracking for R1 was initiated on [DATE]. V2 verified no documentation could be provided to indicate increased monitoring or supervision such as 15 minute checks being initiated for R1 after R1's [DATE] or [DATE] incidents. On [DATE] at 8:51 AM, V2 stated, I would have expected 15 minute checks to have been implemented for (R1) for at least 24 hours after R1's ([DATE] and [DATE]) incidents. It's hard to check on someone every 15 minutes especially when it gets very busy. I feel like being on 15 minute checks too long, the staff gets desensitized to them. As of [DATE], R1's medical record did not document 15 minute checks or other increased monitoring was ever completed for R1 after R1's [DATE] or [DATE] resident to resident incidents. The Immediate Jeopardy began on [DATE] when R1, who has known sexually inappropriate behaviors, engaged in non-consensual inappropriate sexual behavior with R2. R1 was found massaging R2's perineal/groin area with R1's hand. On [DATE], R1 was found with R1's hand down the front of R4's pants. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 9:53 AM. The facility submitted the original Abatement Plan for F600 to the State Agency on [DATE] at 5:14 PM. Revisions was requested on [DATE] at 10:03 AM; 2:51 PM; and 5:02 PM. An amended Abatement Plan was submitted and accepted on [DATE]. On [DATE], the immediacy was not able to be removed because the facility failed to monitor and document R1's behavior each shift as stated in the facility's Abatement Plan and on R1's Care plan and failed to provide documentation that 1:1 monitoring for R1 or R2 was completed after R1 and R2's [DATE] resident to resident incident as stated in the facility's Abatement Plan. An amended Abatement Plan was submitted and accepted on [DATE] at 11:18 AM. On [DATE] the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: R1 and R2 were immediately separated and assessed following the [DATE] incident. R2 has expired and is unable to be interviewed/observed. V16/Social Service Director, V1/Administrator and V2/Director of Nursing had 1:1 visit with R1 and then R2 separately to discuss and assess concerns, needs, feelings - determined both R1 and R2 unaware of situation with no recall of occurrence. On [DATE], V2/Director of Nursing/DON implemented motion alarm at R1's doorway to assist staff in monitoring R1's location. Observations made on [DATE]-[DATE] and ,d+[DATE] and [DATE] note motion sensor alarm in place and in functioning working order in R1's room. On [DATE], R1's Lexapro ordered for sexual urges was increased from 10 milligrams/mg to 20 mg daily by V13/R1's Physician. All staff educated on appropriate use of R1's motion alarm, completed by V2/DON. [DATE], Behavior Status Review completed by V3/Assistant Director of Nursing. Medication adjustments continue to be effective, As of [DATE], Behavior tracking was initiated in the facility's electronic charting system to help differentiate between R1's different targeted behaviors. On [DATE] and [DATE], R1 was seen by the Psychiatry Company for an initial evaluation and subsequent visit. On [DATE], Non-pharmacological interventions: offer book to read, turn on music, distraction (games/puzzles), offer assistance to activity room to play bingo added to R1's Care Plan by V2/DON. All staff educated on Abuse Policy including preventing abuse on [DATE], done by V2/Director of Nursing and V1/Administrator. All staff notified verbally and/or by mass communication of R1's plan of care on [DATE] by V1 and V2. [DATE], Audit tool created by V1 to ensure care plans are updated with effective interventions and staff aware of any changes, weekly times four, then monthly times four, then as needed based on QAPI (Quality Assurance and Performance Improvement) Team recommendations.

Based on interview and record review, the facility failed to immediately report an allegation of sexual abuse to the Administrator/Abuse Coordinator for one (R1 and R2) of five allegations of abuse reviewed. Findings include: The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, dated 2022, states, B. The Facility has a duty to report all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violations pursuant to 42 CFR 483.12(c). B. Alleged violations under 42 CFR 483.1(c) a. Immediately (for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) but not later than: i. Two hours if the alleged violation involves abuse or results in serious bodily injury. ii. 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. k. Abuse includes unwanted sexual contact, which includes but is not limited to: 1. Unwanted touching of the breasts or perineal area; 2. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal and non-verbal cues; 3. Sexual activities where one resident indicates that the activity is unwanted through verbal and non-verbal cues 4. Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown; 8. Other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident. R1's Nursing Progress Note on 3/7/2023 at 10:15 PM, states, (R1) was inappropriately groping another resident (R2). Both residents (R1 and R2) separated and (R1) brought down the hall to be observed by staff. The facility's Serious Injury Incident Report, dated 3/8/23, documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on 3/7/23 at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4). V5's written statement, dated 3/7/23, states, I (V5) was at the nurse's station charting before dinner was served. I looked over and noticed (R2) sitting still next to (R1). I sat up to see what they were doing and I noticed (R1) had his hand on (R2's) vaginal area over her pants massaging the area. Once I realized what was happening between them, I stood up and removed (R2) from the area, while my co-worker (V6) started to remove (R1). Once (R2) was out of the area, (V5 and V6) told (R1) that behavior was inappropriate and moved him away from other female residents and had him sit in the hallway to eat dinner. Both (V5 and V6) informed our nurse (V4). On 3/28/23 at 10:41 PM per telephone interview due to third shift hours, V4 stated that V5 had reported to V4 that R1 was being inappropriate with R2 and had touched R2 near R2's vaginal area. V4 denied that V4 reported R1 and R2's incident to V1/Administrator/Abuse Coordinator. V4 stated, I charted a progress note and kept an eye on (R1). I did not report it to anyone. They told me the next day that I should have reported the incident immediately. On 3/29/23 at 3:27 PM, V5 (Certified Nursing Assistant) stated, (On 3/7/23) I was sitting at the Nurse's desk. We keep a balloon on (R2's) wheelchair to help keep track of (R2) because (R2) is so mobile. I noticed (R2's) balloon was not moving which was not normal for (R2), so I sat up to see what (R2) was doing. That's when I noticed that (R1) had his hands in (R2's) pubic region and was massaging the area. We immediately separated the residents and I reported it to my nurse right away. I don't like to think about that happening to (R2). V5 stated, I told my nurse about it and that's it. We were in-serviced that this should have been reported to (V1) immediately. On 3/28/23 at 11:12 AM, V2 (Director of Nursing) stated that on 3/8/23, around 9:00 or 10:00 in the morning, V2 was reviewing 24 hour charting from the night before (3/7/23). V2 stated that V2 found a note charted by V4, that R1 had inappropriately groped R2. V2 stated that V2 discussed the incident with the staff members who confirmed the incident occurred between R1 and R2. V2 stated that this incident should have immediately been reported to V1 and it was not. On 3/28/23 at 11:03 AM, V1 (Administrator) stated that staff did not immediately report R1 touching R2 inappropriately on 3/7/23 and should have. We started in-servicing on that right away. The facility's In-Service Sign-In Sheets, dated 3/9/23 and 3/10/23 documents the audience as All Staff and the topic as: Abuse Reporting; Abuse Prevention; Recognizing Abuse. The attached in-service sheet, dated and initialed by V1 on 3/9/23 states, Any abuse allegations need to be reported to (V1/Administrator/Abuse Coordinator). We only have two hours to report. Example: Inappropriate behaviors sexual or touching needs to be reported. Resident to resident needs to be reported. If you need to separate two residents, call me (V1). We know who has triggers. Move them before the incident happens, get them something to do. Take them to activities. Sit with them for a moment. Ask them to walk with you or go for a ride in wheelchair. These are things that need to happen before an incident occurs. Be proactive verses reactive.

Based on interview and record review, the facility failed to revise a resident's plan of care for one of eight residents (R1) reviewed for care plans in the sample of eight. Findings include: The facility's Comprehensive Care Plan policy, revised 6/25/20, states, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes. 5. Care Plans are revised as changes in the resident's condition dictate. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis to include but not limited to: Alzheimer's Disease. R1's current Order Recap Report documents an order for Escitalopram Oxalate 20 milligram tablet daily for sexual urges with an order start date of 3/11/23 and no end date. The facility's Serious Injury Incident Report, dated 12/23/22, documents this report as an initial and final report that on 12/23/22 at 11:15 AM, R1 and R4 were in a resident to resident altercation. This same report documents R1 as the perpetrator, R4 as the victim and V8/CNA/Certified Nursing Assistant as a witness. This report states, (V8) alerted (V2/Director of Nursing) that (R1) appeared to have his hand in (R4's) sweatpants. (R1) was sitting at his table in the dining room and (R4) was standing in front of (R1). (V8) separated (R1 and R4) immediately and notified (V2). The facility's Serious Injury Incident Report, dated 3/8/23, documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on 3/7/23 at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4). R1's Care Plan documents the following: Focused area with an initiation date of 12/23/22 that R1 has an alteration in R1's behavior status related to Alzheimer's, Impaired memory/thinking and Increased sexual drive; R1 may exhibit behaviors such as: increased confusion, making inappropriate comments or physically attempting to touch staff, hospice staff, residents; R1 may be unable to comprehend or remember appropriate behavior due to R1's diagnoses; R1 gets agitated at times with staff and other residents; a goal that R1 will not engage in inappropriate sexual behavior; Interventions are documented as My (R1's) behaviors will be monitored every shift and documented with an initiation date of 12/23/22; Intervene as Necessary to protect safety of others; R1 has expressed sexual desires with an initiation date of 12/26/22 and documents interventions as Intervene when risk, resident safety, or the safety of others is involved; Lexapro per MAR (Medication Administration Record) to control sexual urges with a revision date of 3/10/23; and R1 is on Psychotropic Medications due to R1's sexual urges; R1's medication was increased on 3/10/23 for an unusual occurrence on 3/7/23. On 4/14/23 at 2:21 PM, V17 (Activity Director) stated that R1 is an active participant in activities/groups. V17 stated that R1 is invited to attend activities the same as the other residents and that R1 is not on 1:1 activities. V17 stated, (R1) isn't treated differently than any other resident as far activities goes. V17 stated that V17 is aware that R1 has a history of sexually inappropriate behaviors. V17 stated that V17 does not leave R1 alone in activities, V17 puts R1 at group activities with other male residents, and V17 has staff assist R1 to and from activities when needed. V17 stated these extra interventions for R1 should be documented on R1's Care Plan and stated that they are not. V17 stated, I will add them now. As of 4/14/23 at 12:30 PM, R1's Care Plan did not document interventions to protect other resident's from R1's sexual behavior during Activities.

Based on observation, interview and record review, the facility failed to safely transfer a resident according to their plan of care for one of three residents (R6) reviewed for accidents and supervision in the sample of ten. Findings include: The facility's Fall Reduction Policy, revised 11/5/19, states, Purpose: To provide an environment that remains as free of accident hazards as possible; To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. The facility's Safe Patient Mobility Policy, revised 11/5/19, states, Policy: All lifting, positioning and moving of patients will be done within a defined standard of care for the overall safety of the patient and the health care worker. Purpose: The purpose is to outline a specific standard for lifting, positioning and moving of patients safely and appropriately to prevent injury to healthcare workers and patients. Practice: It is the responsibility of employees to take reasonable care of their own safety, as well as that of their co-workers and patients during patient handling activities. It is preferable that two employees will be present during a transfer to stabilize and support the patient whenever possible to maintain safety. Procedure: b. Patient Lift/ Transfer Procedure: 1. Patient mobility needs are assessed upon admission, prior to performing a lift/transfer/move, every eight hours and on an on-going basis as needed. Types of transferring devices and amount of assistance required will be determined, documented and communicated to all employees taking care of the patient. 2. Prior to using a mechanical lift or transfer device, ensure proper planning for the lift/transfer has been accomplished and request assistance as applicable for any difficult lift/transfer. 3. Have proper equipment or personnel on hand and ensure everyone involved in the task understands his or her role in the transfer, lift, or move. R6's Facesheet documents R6 admitted to the facility on [DATE] with diagnoses to include but not limited to: Unspecified Abnormalities of Gait and Mobility; Unspecified Lack of Coordination; Cognitive Communication Deficit; Morbid (Severe) Obesity; Muscle Weakness (Generalized); and Repeated Falls. R6's current Order Summary Report documents orders for Mechanical Lift for Transfers (Brand Name of Total Mechanical Lift) with an order start date of 4/14/23; Monitor Site Hematoma Back of Head/Scalp every shift with an order start date of 4/19/23; Post fall monitoring every shift for three days-if any new injuries post fall place an order for the area of concern and do a progress note with an order start date of 4/19/23; and Eliquis (Anticoagulant) Tablet 2.5 milligram by mouth twice a day for DVT/Deep Vein Thrombosis prevention with an order start date of 10/27/22. R6's Quarterly Minimum Data Set/MDS Assessment, dated 3/11/23, documents R6 with the following: moderately impaired cognition; requires extensive assistance of two plus persons physical assist for bed mobility, transfers, and toilet use; and when moving from a seated to standing position and moving on and off the toilet, R6 is not steady and only able to stabilize with staff assistance. R6's Fall Risk Assessment, dated 1/7/23, documents R6 as a moderate fall risk. R6's current Care Plan documents R6 has had an actual fall due to unaware of safety needs. Falls are documented on 9/24/22, 10/7/22, 10/10/22, 10/14/22, 10/31/22 and 4/18/23. This same Care Plan states, 4/18/23-fall in room; Hematoma to scalp and documents R6 with an alteration to cognition due to memory loss and cognitive communication deficit. R6's Nursing Progress Note on 12/15/22 at 7:26 PM documents R6 lost consciousness when R6 stood up with two staff member assist. R6's Nursing Progress Note on 4/18/23 at 2:42 PM documents R6 fell to the floor and sustained a goose egg to the back of R6's head. R6's Physical Therapy Recertification, Progress Report and Updated Therapy Plan, dated 11/4/22 documents staff provides 100% (percent) assistance for transfers and states, (R6) Difficulty performing transfers d/t (due to) reduced safety awareness, weakness and cognitive status and (R6) unable to perform supported standing d/t LE (lower extremity) weakness, cognitive status and motivation. This same report states, Patient Progress: (R6) Presenting difficulty with improving standing tolerance and functional mobility d/t patient motivation and cognitive status. (R6) frequently is confused and resistive with treatment. Remaining Impairments: Balance Deficits; Decreased Safety Awareness; Strength Impairments; Safety Awareness Deficits; and Postural Alignment/Control. R6's POC (Point of Care) Response History, dated 4/14/23-4/21/23, states, Task: ADL (Activity of Daily Living)-Transferring (Brand Name of Total Mechanical Lift). The dates 4/14/23-4/15/23 and 4/17/23-4/18/23 documents a sit to stand lift was used with two plus persons physical assist. The facility's Incident by Incident Type Report, dated 1/21/23-4/21/23, documents on 4/18/23 at 2:30 PM, R6 sustained a staff assisted fall with injury incident. R6's Incident Report, dated 4/18/23 at 2:30 PM, documents the incident occurred in R6's bedroom. This report states, Nursing Description: (R6) on floor. Lying on his right side Had been transferring with the sit to stand lift. (R6) c/o (complained of) feeling dizzy and then slumped while in lift. (R6's) feet at the base of the lift/his head at the foot of his bed. CNA (Certified Nursing Assistant/V20) said (R6's) head hit the edge of foot board, she (V20) put her hand out to attempt to buffer it. Resident Description: I felt dizzy. Other Info: Was in lift became dizzy and slumped, causing fall. Witnesses: (V20/CNA) 4/18/23 (R6) transferring with sit to stand lift. All of a sudden (R6) slumped down causing to fall. (R6) hit his head on the foot board. I attempted to buffer him hitting his head by putting my hand out onto the foot board. V20's written statement, dated 4/18/23, states, I had (R6) strapped into the sit to stand sitting on the toilet. I lifted (R6) up in the lift to wipe his bottom. (R6) had been talking and alert. As soon as I started to pull the resident's brief and pants up, he stopped talking and began sliding down in the lift. I tried to get (R6) to the wheelchair but then decided it was safer to lower resident to the floor when I couldn't make it to the chair. I had my hands on his back and under his neck as I lowered him to the ground. (R6) started jerking and hit his head off the ground when I was lowering him. V18's (Licensed Practical Nurse) written statement, dated 4/19/23, states, (R6) fell on [DATE] at 2:30 PM. I responded to the call for a nurse. Upon entering (R6's) room, (R6) was lying on his right side, his head at the foot of his bed, his feet at the base of the sit to stand lift. (R6) was talking and his face flushed. He felt a little sweaty but not cool or clammy. Neuro (Neurological) checks and vital signs and his responses were normal limits. (R6) had a small goose egg on the back of his head. (R6) denied having any pain. On 4/25/23 at 12:58 PM, V3 (Assistant Director of Nursing) that V3 was recently updating residents' transfer status on the Physician Order Sheets. V3 verified that V3 entered R6 to be a total mechanical lift. V3 stated at one point (R6) was either sit to stand or a total lift but (R6) has gotten weaker. V3 stated after R6's 4/18/23 fall, V19 (Physical Therapist) verified R6 should remain a total mechanical lift for transfers. On 4/25/23 at 1:25 PM, V20 stated, I picked up a 2:00 PM-10:00 PM shift on 4/18/23. I usually work nights. Right at shift change, (R6) had to go to the bathroom. I got report from the day shift CNA and then she was pulled away to go with another aide. I went in (R6's) room and got him hooked up to the lift. I got (R6) to the toilet and then about five minutes later, (R6) had his call light on to get off the toilet. Everyone was giving shift change report or busy. I couldn't find my partner and (R6) was getting agitated, so I went into (R6's) bathroom by myself. We were having a conversation, I was getting him wiped up and pulling his pants up. (R6) then stopped talking. I pulled the lift out of the doorway to get behind (R6) and I was trying to turn the lift to get to (R6's) chair. (R6) was unresponsive and not talking to me. (R6) was sliding down out of the sling and I was having a hard time getting (R6) to the wheelchair. There was no where to go, so I tried to lower (R6) to the ground. (R6's) arms were above (R6's) head and he was sliding through. I was scared his shoulders were going to dislocate, so I lowered the arms of the lift to the halfway down position and then (R6) slid right through. I was trying to lower (R6) gently but (R6) is a very big guy and the fall wasn't graceful at all. (R6) hit his head on the floor. At this time, V20 stated that V20 would check with the previous CNA, the nurse or the POC (Point of Care) charting to see how a resident transfers. V20 verified that V20 should have had two staff members to transfer R6 and to provide after toilet cares. On 4/25/23 at 1:38 PM, V19 (Physical Therapist) stated that due to R6's cognition status, safety awareness and weakness, R6 should have two staff members present for all mechanical lift transfers and verified R6 should remain a total mechanical lift for all transfers. On 4/21/23 at 2:37 PM, V9 (CNA) stated that R6 should have two staff members present during R6's transfers. V9 stated, (R6) was standing for too long, passed out and slid out of the sling. For exactly that reason, is why you should always have two people. (R6) is a big guy and it's too much to do alone. On 4/21/23 at 2:42 PM, R6 was sitting in a wheelchair in R6's bedroom. R6 stated, They told me what happened. I blacked out. I have a sore spot on my (right) elbow and a bump to the back of my head. At this time, R6 rubbed the left posterior portion of R6's head and stated, It's hurts but it gets better each day. On 4/21/23 at 2:48 PM, V18 (Licensed Practical Nurse) stated that V18 was R6's nurse on 4/18/23 when R6 fell out of the sit to stand sling. V18 stated, (V20) said (R6) slumped and she couldn't hold him up. (V20) said (R6) hit the back of his head during the fall. There was a goose egg to the back of (R6's) head. He was talking when I entered the room. His face was flushed. I notified (R6's) physician. We didn't' send him out. At this time, V18 stated that two staff members should be present for all of R6's transfers. V18 stated, After (R6's 4/18/23) fall, the DON (V2/Director of Nursing) was in-servicing everyone on using two staff members for lift transfers. On 4/21/23 at 3:05 PM, V2 (Director of Nursing) stated that for residents who use the sit to stand, they must be able to bare their own weight and stand. Two staff members are used ideally.

Based on interview and record review, the facility failed to identify and respond to the change in condition for one resident (R1) of three residents reviewed for change in condition. This failure resulted in a lack of adequate oxygenation for over two hours with subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Physician Order Sheet indicates R1 was admitted to the facility 1/11/22 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Progress Note dated 1/20/22 at 9:28am indicates R1's oxygen saturation level was noted to be 86-87% at that time (while working with therapy). This note indicates R1 was placed on 2L (liters) of oxygen and oxygen saturation level increased to 95%. Progress Note on 1/21/22 at 1:26pm indicates staff notified Physician - via fax - of R1's decreased oxygen saturation levels and (as needed) oxygen placement. Note indicates a request was made for oxygen administration as needed with parameters. No physician orders for oxygen administration were found or presented to initiate oxygen therapy for R1 prior to 1/29/22. Weights and Vitals Summary dated 1/11/22 to 1/28/22 indicates on 1/28/22 at 9:39pm, R1's oxygen saturation level was 80% on oxygen via nasal cannula. Nurse Progress Note dated 1/29/22 at 1:00am indicates Noted at (12:00am) during cares that resident (R1) is unresponsive to any physical or verbal stimuli. (R1) has not opened (R1's) eyes, no verbal or physical response; blood pressure 155/44, pulse 75 and irregular, respirations 20 - labored pursed lips; SPO2 (oxygen saturation level) 80% on Room Air; temperature 98 (oral). Note indicates PCP (Primary Care Physician) paged and notified of decline; order for (as needed) oxygen use. Applied (oxygen) at 3L per nasal cannula and SPO2 89%. Will allow body to adjust and bump to 4L per nasal cannula if needed. POA (Power of Attorney) notified of deterioration and will call this nurse back to decide if family wants to send R1 to ED (Emergency Department) for evaluation or keep at facility and keep comfortable. On 2/9/22 at 3:10pm V4 (Licensed Practical Nurse/LPN) stated that she did not receive any information about R1 during shift report that indicated R1 was wasn't doing well or that R1's SPO2 earlier in the evening was 80%. On 2/10/22 at 11:30am V5 (LPN) stated that at 7:30pm (on 1/28/22) she received report from the previous nurse, counted narcotics then made brief rounds to check on her assigned residents. V5 stated that she just briefly looked in on each resident to make sure they weren't on the floor and were still breathing. V5 stated that R1 was in bed and the lights were off in the room. V5 could not recall whether R1 was wearing oxygen. V5 stated that after her rounds she went over to another resident unit and spent the rest of the evening - from approximately 8:00pm to 10:30pm - passing medications on that unit. V5 stated she did not go back to R1's unit until after 11:00pm when she was helping V4 (LPN) make calls regarding transfer of R1 to the hospital. V5 stated that the residents on R1's unit are monitored by one CNA (Certified Nurse Assistant) while the nurses primarily stay at the main nurses station. V5 stated she would have assessed R1 if she had known R1's SPO2 was only 80%. On 2/9/22 at 12:30pm V6 (Certified Nurse Assistant/CNA) stated she started her shift (on 1/28/22) at 6:00pm and that R1 was in bed when she made her first rounds. V6 stated that later in the shift she took R1's vitals and R1's SPO2 was 80% with oxygen. V6 stated that R1 was breathing ok but knew that 80% was a low reading so she called the main nurses' station and reported R1's oxygen level to whoever the nurse was that answered the phone. V6 stated that the nurse told her R1 should be Ok as long as R1 had oxygen on. V6 stated, I should've insisted a nurse come down to look at (R1). V6 stated that when V4 (LPN) came on at 11:00pm, she didn't like how R1 looked and wanted to send R1 to the hospital. No assessments or documentation was found or presented to indicate R1 had been assessed/monitored between 9:39pm on 1/28/22 when SPO2 was documented as 80% on oxygen and 12:00am on 1/29/22 when R1's SPO2 was documented at 80% on Room Air. On 2/10/22 at 1:30pm V7 (Physician/Medical Director) stated that 80% oxygen saturation is significantly low and should receive immediate treatment. V7 stated for someone who does not normally have a low saturation level - like with a chronic condition - a low oxygen saturation indicates a change in condition. V7 stated that he should have been notified on 1/28/22 when R1's SPO2 was found to be 80%. V7 stated that the brain is not getting enough oxygen at 80% and R1 would have been hypoxic. Hospital Records dated 1/29/22 indicates R1 arrived at the hospital via EMS (Emergency Medical Services) at 2:47am (on that date). Hospital Emergency Department Decision Making Note dated 1/29/22 indicates R1 was found by facility nursing staff at 11:00pm with AMS (Altered Mental Status) and was noted to be hypoglycemic and hypoxic en route to the hospital. Note indicates R1 Hypoxic - requiring 5L (liters) oxygen via nasal cannula for O2 (oxygen) SAT (saturation) greater than 90%. Hospital records dated 1/29/22 indicates R1's Primary Encounter diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Emergency Department Notes dated 2/1/22 at 10:32am indicates R1 was seen and examined on 1/29/22 with increasingly altered mental status for two hours prior to EMS being called. Facility Policy/Change In Condition Procedure dated 9/21/20 documents: The following guidelines will be utilized as appropriate to each situation and change in condition: Full assessment by nursing staff including but not limited to: a. Full vitals (temperature, pulse, respirations, blood pressure and SPO2) b. Level of consciousness; c. Respiratory status including lung sounds; d. Abdomen including last bowel movement and urine properties; e. Functional status f. Pain g. Glucometer test if diabetic or decrease in level of consciousness. Notify Physician and give assessment information. Facility Policy/Oxygen Administration and Storage dated 11/5/20 documents: Emergency Oxygen Administration. It is the nurse's responsibility to provide emergency administration of oxygen when it is necessary for the care of the resident. As a guideline, a beginning flow rate of 2L/minute and adjust according to oxygen saturation levels which should be kept above 90% unless otherwise ordered by a Physician. Pulse Oximetry: Residents who have oxygen orders should have oxygen saturation levels measured by Oximetry. The Physician should be notified of any concerns identified with oxygen titration needs so the Physician may determine a need to change the order to best meet the resident's oxygen needs. Procedure: 1. In cases of emergency oxygen may be administered as a nursing intervention until a Physician order may be obtained. 16. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: a. Signs or symptoms of cyanosis (i.e., blue tone to skin and [MEDICATION(S)] membranes); b. Signs or symptoms of [CONDITION(S)] (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); c. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); d. Vital signs; e. Lung sounds f. Arterial blood gases and oxygen saturation, if applicable.

Based on interview and record review, the facility failed to provide oxygen therapy and failed to assess respiratory status for one resident (R1) of three residents reviewed for oxygen therapy.This failure resulted in a lack of adequate oxygenation for over two hours with subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Physician Order Sheet indicates R1 was admitted to the facility 1/11/22 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Progress Note dated 1/20/22 at 9:28am indicates R1's oxygen saturation level was noted to be 86-87% at that time (while working with therapy). Note indicates R1 was placed on 2L (liters) of oxygen and oxygen saturation level increased to 95%. Progress Note on 1/21/22 at 1:26pm indicates staff notified Physician - via fax - of R1's decreased oxygen saturation levels and (as needed) oxygen placement. This note indicates a request was made for an oxygen administration as needed with parameters. Fax request dated 1/21/22 at 1:45pm indicates V7 (Physician/Medical Director) was notified of R1's oxygen saturation level on 1/20/22 and that oxygen was placed (at that time) on R1 at 2L as needed. Request was made to obtain orders for oxygen 2L (as needed) with parameters. Note included that R1 has a history of lung cancer. Requested was approved by V7 (Physician) and sent back to the facility on [DATE] at 2:17pm. No Physician orders were found or presented to initiate oxygen therapy for R1 until 1/29/22. On 2/9/22 at 2:45pm V2 (Interim Director of Nursing) and V3 (ADON/Assistant Director of Nursing) stated that only emergency oxygen therapy can be administered without an order. V2 and V3 stated that oxygen should not be administered without a Physician's order that includes flow rate and parameters. V2 stated that she was aware a request was made to get oxygen orders on 1/20/22 but was not aware the order did not get transcribed. On 2/9/22 at 3:04pm V4 (Licensed Practical Nurse/LPN) stated that (on 1/29/22 at 12:00am) R1 didn't look right and R1's oxygen saturation level was low. V4 stated there was an oxygen concentrator in R1's room but when she went to check R1's orders there wasn't an oxygen order. V4 stated that she notified R1's Physician at that time and obtained order Oxygen at 2 - 4L per minute via NC (nasal cannula) as needed to keep (oxygen saturation) at 90% or above. Weights and Vitals Summary dated 1/11/22 to 1/28/22 indicates on 1/28/22 at 9:39pm, R1's oxygen saturation level was 80% on oxygen via nasal cannula. R1's Care Plan did not address Oxygen therapy or low oxygen saturation levels. On 2/10/22 at 1:30pm, V7 (Physician/Medical Director) stated that 80% oxygen saturation is significantly low and should receive immediate treatment. V7 stated for someone who does not normally have a low saturation level - like with a chronic condition - a low oxygen saturation indicates a change in condition. V7 stated that he should have been notified on 1/28/22 when R1's SPO2 was found to be 80%. V7 stated that the brain is not getting enough oxygen at 80% and R1 would have been hypoxic. Hospital Records dated 1/29/22 indicates R1 arrived at the hospital via EMS (Emergency Medical Services) at 2:47am (on that date). Hospital Emergency Department Decision Making Note dated 1/29/22 indicates R1 was found by facility nursing staff at 11:00pm with AMS (Altered Mental Status) and was noted to be hypoglycemic and hypoxic en route to the hospital. Note indicates R1 Hypoxic - requiring 5L (liters) oxygen via nasal cannula for O2 (oxygen) SAT (saturation) greater than 90%. Hospital records dated 1/29/22 indicates R1's Primary Encounter diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Emergency Department Notes dated 2/1/22 at 10:32am indicates R1 was seen and examined on 1/29/22 with increasingly altered mental status for two hours prior to EMS being called. Facility Policy/Oxygen Administration and Storage dated 11/5/20 documents: Emergency Oxygen Administration: It is the nurse's responsibility to provide emergency administration of oxygen when it is necessary for the care of the resident. As a guideline, a beginning flow rate of 2L/minute and adjust according to oxygen saturation levels which should be kept above 90% unless otherwise ordered by a Physician. Pulse Oximetry: Residents who have oxygen orders should have oxygen saturation levels measured by Oximetry. The Physician should be notified of any concerns identified with oxygen titration needs so the Physician may determine a need to change the order to best meet the resident's oxygen needs. Procedure: 1. In cases of emergency, oxygen may be administered as a nursing intervention until a Physician order may be obtained. 16. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: a. Signs or symptoms of cyanosis (i.e., blue tone to skin and [MEDICATION(S)] membranes); b. Signs or symptoms of [CONDITION(S)] (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); c. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); d. Vital signs; e. Lung sounds f. Arterial blood gases and oxygen saturation, if applicable.

Based on interview and record review, the facility failed to ensure resident safety during wheelchair positioning for one resident of three residents (R3) reviewed for accidents in a sample of five. This failure resulted in R3 sustaining a fall from R3's wheelchair leading to a subsequent subdural hematoma and death. Findings include: The facility's Falls Practice Guide, dated 2011, documents Purpose: The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. This guide continues with Overview: Falls among elderly patients are a common source of both high injury severity and mortality, much more so than in younger patients. Of the elderly who fall, 20 to 30 percent suffer moderate to severe injuries such as hip fractures or head traumas that reduce mobility and independence and increase the risk of premature death. R3's Progress Note, dated 3-14-21 at 3:30am by V9 (Registered Nurse/RN), documents This writer was in (Room number) changing a wound (vacuum) dressing, upon exiting room, heard a loud noise and then heard CNA (Certified Nursing Assistant) yelling out for help. Observed Patient (R3) on ground with knees bent upwards towards the midline in a sitting position with wheelchair underneath resident and CNA kneeling next to resident. CNA states that she was assisting with increasing comfort and elevated bilateral lower extremities onto a chair and the wheelchair had then fallen backwards. Clothes and shoes properly fitted and on. Resident had just been toileted prior to event. CNA states that resident had shown signs of increased anxiety, restlessness, and was attempting to get out of bed per self and CNA had made decision to assist resident to nurses' station for closer observation. This same Progress note continues to state that R3 was transferred to a hospital of R3's family's request. R3's Progress Note, dated 3-14-21, documents the hospital called and reported R3 had a head bleed. R3's Annual Minimum Data Set/MDS assessment, dated 1-28-21 documents R3 is severely cognitively impaired; has diagnoses of Dementia with Behavioral Disturbance and Anxiety; needs extensive assist with two staff members for bed mobility and transfers; is only able to stabilize with staff assistance for all type of transfers including surface to surface transfers, due to R3's imbalance during transitions and walking; and has a functional limitation in range of motion with impairment to bilateral lower extremities. On 4-15-21 at 12:15pm, V1 (Administrator) stated On 3-14-21, (R3) was restless, so for better comfort V7 (CNA) brought (R3) to the nurse's station and raised (R3's) legs up to put them on a chair. (R3's) wheelchair had an anti-sling device on the bottom and a cushion for comfort and skin which brought (R3) up further and raised (R3's) point of gravity. The back of the chair came to (R3's) mid back so (R3) was top heavy. (R3's) center of gravity was too high. On 4-15-21 at 12:18pm, V2 (Director of Nursing/DON) stated It didn't matter if the wheelchair was locked or unlocked - the problem was (R3's) center of gravity. On 4-15-21, at 2:20pm, V8 (Physical Therapist) stated that R3's wheelchair had not been assessed; R3 was mostly ambulatory but was receiving therapy for a decline. V8 stated that to position R3 for comfort I would have used leg rests and would not have propped his legs up on a chair. On 4-15-21 at 2:49pm, V7 (CNA) stated the following: (R3) was restless and attempting to get out of bed so I brought (R3) to the nurse's station to keep an eye on (R3). I wanted to raise (R3's) feet up to make (R3) more comfortable so I lifted both of (R3's) feet at the same time to place them on a chair and (R3) fell right over backwards and hit (R3's) head on the floor. I did not lock (R3's) brakes and I thought that maybe if I had it may not have tipped. (R3) is a stiff sitter. I didn't tell (R3) to lean back and I'm not sure if (R3) did because it all happened so fast. (R3) sits high in the wheelchair and has a wedge (anti-sling) and a cushion under (R3) for comfort. There were no witnesses. I should have put the brakes on. It all happened so fast but when we did the re-enactment, I recalled that I had not (put the brakes on). Normally I would brake a wheelchair when a resident is placed out by the nurse's station to be watched. (R3) was very restless and I brought (R3) out to the nurse's station so (R3) wouldn't fall out of bed and then I caused (R3's) fall. R3's Fall investigation, dated 3-14-21, documents by V2 (DON) that (R3's) wheelchair was used for re-enactment. It was observed that when (R3's) legs were raised for repositioning that if (R3) reclined or leaned back that the wheelchair tipped backward very easily. Current wheelchair does not have anti-tip device on it. Wheelchair back from top of cushion to top of wheelchair back measures leaving approximately 8-10 inches of resident's upper body not supported by wheelchair back. In an attempt to make (R3) more comfortable by elevating (R3's) legs, unfortunately changed (R3's) center of gravity and when (R3) leaned as to recline the wheelchair tipped causing the fall. On 4-19-21 at 8:05am, V10 (R3's Physician) stated that the injuries R3 sustained from the fall on 3-14-21 would have increased (R3's) risk of death. R3's State of Illinois Certificate of Death Worksheet documents R3's date of death as 3-21-21 with the following causes of death a. Acute Hypoxic Respiratory Failure due to b. Subdural Hemorrhage due to c. Ground level fall.

Based on observation, interview and record review, the facility failed to attempt a reduction for two of ten residents (R8, R15) reviewed for antipsychotic medication in a sample of seventeen. R8 has developed an inability to sit or lay still in bed to rest. R8 is in constant motion and has developed a large abrasion to right back due to this constant motion. This failure resulted in the decline of R8 ability to function normally. R15 is unable to stay awake to eat or participate in activities. Findings include: 1. The Physicians' Order sheet dated 7/1/11-7/31/11 documents that R8 is an [AGE] year-old-female with [DIAGNOSES REDACTED]. The nursing notes dated 11/8/09-1/2010 document that R8 was independently ambulatory on admission. R8 was documented with behaviors of yelling out, verbally abusive, resistive to care (hitting, pinching and slapping) on admission 11/8/09. The physician order [REDACTED]. The [MEDICATION NAME] was increased to 0.5mg twice a day on 12/28/09 for these same behaviors. The physician order [REDACTED]. The physician order [REDACTED]. The physician order [REDACTED]. The [MEDICAL CONDITION] Medication Use form dated 5/9/11 presented as a quarterly review of the [MEDICAL CONDITION] medication documents that R8 receives antipsychotic, antianxiety and antidepressant medication. According to this form, the possible adverse consequences of antidepressants that R8 displays are anxiety, nervousness, fidgety or restless and Somnolence. The possible adverse consequences of antipsychotics that R8 displays are: inability to sit still (Akathesia) and falls. This quarterly form assesses R8 with a decline in cognition/communication. The Abnormal Involuntary Movement Scale (AIMS) dated 3/20/10, 7/8/10, 12/9/10, 3/2/11 and 6/28/11 document that R8 has abnormal involuntary movements of the lips and perioral area. It does not address the constant movement of the trunk or extremities. On 7/26/11 at 11:00 AM, R8 was seated in a low tilted reclining chair in the day area where other residents were playing trivia. R8 was in constant motion, hips thrusting forward, trunk movement, arms, wrists and hands, rocking twisting, squirming, pelvic gyrations. At 11:30 AM, R8 was seated at the dining room table in the same chair with plastic blocks in front of her. R8 was moaning, rocking back and forth in the chair. At 1:00 PM, R8 was in bed rolling from side to side. At 1:30 PM, R8's head was hanging over the side of the low bed. R8 did not rest while in bed, but continued with constant motion. At 2:30 PM R8 was seated in the low, reclining chair moaning, in constant motion. On 7/27/11 at 9:30 AM, R8 was seated in this same chair in the day area rocking back and forth in constant motion. On 7/26/11 at 2:00 PM, E14 (Director of Care Delivery) removed a clear occlusive dressing from R8's back. E14 stated that R8 had shearing from her continuous motion (rocking back and forth) in the low reclining chair. The Behavior Symptom Tracking Tool dated 4/24/11 through 6/17/11 document the behaviors being tracked for the antipsychotic medication are: 1. PM anxiety, 2. Restless, 3. nonstop talking, 4. resists care, 5. inability to sit still, 6. pain discomfort, and 7. incontinence. The behaviors of 2, 3, 5 are charted approximately thirteen times a month, with the behavior 6 (pain, discomfort) added in the month of June. and charted approximately thirteen times in that month. The Behavior Symptom Tracking Tool dated 6/18/11 through 7/25/11 document the behaviors being monitored are: 1. restlessness, 2. non stop talking, 3. inability to sit still, and behavioral pain/discomfort. The behaviors of 1, 2, 3, 4 are charted as observed sixteen times in June and ten times in July. There is no documentation on these behavior tracking forms quantifying the occurrence of the behaviors. The forms do not indicate what shift the behaviors occurred on in order to track the behaviors as being improved or worsening in order to adjust or discontinue the medication. On 7/28/11 at 9:30 AM, E2 stated that R8 does not see a psychiatrist. R8's medication is ordered by her primary care physician. E2 stated that they have not considered that the constant motion could be an adverse side effect of the medication. E2 stated that they consider it a behavior. E2 stated they have decreased the [MEDICATION NAME] because of lethargy, but increased it back in approximately two weeks. E2 stated that they have never discontinued the [MEDICATION NAME] to evaluate whether the constant motion could be a possible adverse side effect (Akathesia) of the [MEDICATION NAME]. On 7/26/11 at 3:00 PM, E14 stated that there are no pharmacy consults to review for R8. E14 stated that the Physician only sends them back to the facility if he wants to change the medication. E14 stated that there is no clinical justification for the use of [MEDICATION NAME], no attempt at reduction since 6/10 or discontinuation of the [MEDICATION NAME] in the presence of possible adverse side effects (constant motion). On 7/26/11 at 3:30 PM, E14 provided one Pharmacy Consultation Report dated Nov. 1 2010 through November 24, 2010 asking to consider a gradual dose reduction for [MEDICATION NAME]. The attending physician declined the recommendation stating "patient doing very well as is. See no good reason to change treatment." The Drug Information Handbook for Nursing 2007 documents that The Warning/Precautions for [MEDICATION NAME] are: "Elderly patients with dementia-related behavioral disorder treated with atypical antipsychotics are at an increased risk of [MEDICAL CONDITION] adverse events and death compared to placebo. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. The Adverse Reactions to the Central Nervous system are: Sedation, dizziness, restlessness, dystonic reactions, tardive dyskinesia, [DIAGNOSES REDACTED], altered central temperature regulation, nervousness, fatigue, somnolence, hallucination, tremor hypoesthesia, akathesia. 2. According to the POS dated 7/1/11 through 7/31/11, R15 was admitted to this facility on 7/18/11 with [DIAGNOSES REDACTED]. R15 is receiving [MEDICATION NAME] 1mg every night, [MEDICATION NAME] 0.5mg three times a day, [MEDICATION NAME] 250mg at night, [MEDICATION NAME] 5 mg at night, [MEDICATION NAME] 5/325mg three times a day and Tylenol 650mg every 4 hours as needed. The care plan dated 7/27/11 documents that R15 is at risk for adverse effects related to: use of antipsychotic medication, [MEDICATION NAME]; use of antianxiety medication, [MEDICATION NAME]. There are no behaviors documented or being monitored for the use of the antipsychotic medication. One of the goals is: will have medication dose reduction/ elimination as indicated. The interventions are: Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs, Observe for and report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation, ability, lethargy, complaints of dizziness, tremors, etc. On 7/26/11 at 12:00PM, R15 was seated at the dining table with food in front of her, head drooped forward with eyes closed. R15 was hard to arouse when staff tried to waken her to eat. R15 would eat two bites and fall back asleep. This continued throughout the noon meal. On 7/27/11 at 9:30 AM, R15 was asleep in wheelchair in day area at activities. Staff touched R15's shoulder shaking gently, called R15's name several times before R15 responded and opened her eyes. R15 immediately closed her eyes again with her head drooping forward. This continued throughout the activity until 11:00 AM. From 11:00 AM until 12:00PM., R15 was asleep in the wheelchair in the day area. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 7/28/11 at 9:30 AM, E2 stated that she didn't know if it is the [MEDICATION NAME] or the pain medication causing R15's lethargy. E2 stated that R15's family member said not to mess with the [MEDICATION NAME], but did not say what behaviors were being treated. There are no behavior monitoring sheets in the behavior log for R15. The current care plan dated 7/27/11 does not address any behaviors that requires the use of [MEDICATION NAME]. The current care plan documents to observe for and report to physician signs of adverse reactions. On 7/28/11 at 9:30 AM, E2 stated that the physician was not notified of any adverse reactions. The Drug Information Handbook for Nursing 2007 documents that The Warning/Precautions for [MEDICATION NAME] are: "Elderly patients with dementia-related behavioral disorder treated with atypical antipsychotics are at an increased risk of [MEDICAL CONDITION] adverse events and death compared to placebo. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. The Adverse Reactions to the Central Nervous system are: Sedation, dizziness, restlessness, dystonic reactions, tardive dyskinesia, [DIAGNOSES REDACTED], altered central temperature regulation, nervousness, fatigue, somnolence, hallucination, tremor hypoesthesia, akathesia.