Every finding on record at Jerseyville NSG & Rehab Center

Based on interview and record review, the facility failed to provide proper assistance during a transfer for 1 of 3 (R16) residents reviewed for falls in a sample of 24. This failure resulted in R16 falling, sustaining laceration requiring staples.Findings include:R16's Care Plan, last review/revised date 5/19/2026, documents Problem: Dependent Transfers with 1 assist. Problem: Resident participates in facility transfer program. Requires both verbal and physical cues from staff r/t (related to ) alteration in mobility, unsteady balance and cognitive status.R16's Minimum Data Set, dated [DATE] documents that R16 requires Substantial/maximal assistance to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and transfer from the bed-to-chair.R16'S Transfer Assessment, completed dated/time 05/25/2026 07:29, documents USE GAIT BELT WITH 2 ASSIST WITH ALL TRANSFERS.R16's Fall Risk Assessment, dated 5/25/2026, documents that R15 is high risk for falls.R16's Safety Events - EVENT - Fall and Investigation report, dated 6/4/2026, documents that on 6/3/2026 at 6:30 AM R15 experienced a fall. It documents that R15 was in the recliner prior to fall. R15 obtained a laceration and experienced pain. Conclusion with root cause: Aide was attempting to transfer patient with gait belt in place. Patient's feet got twisted, and patient stated his legs gave out and patient fell to floor.V19's written statement, dated 6/3/2026, documents To whom it may concern, around 7 AM I went into (R16's) room to get him up for the day. I put his shoes and gait belt on, sat him on the side of the bed. We counted to 3 and stood up. He turned a little to the left then he took a head dive to the floor. I tried to brace his fall. I then called for (V31) to report fall.R16's Progress Note, dated 06/03/2026 at 7:05 AM, documents that Res (Resident) sent out to (local) ER (emergency room).R16's (Local) Hospital Emergency Documentation, dated 6/3/2026 at 8:38 AM, documents diagnosis for today's visit: Fall, Skin tear upper extremity and scalp laceration. R16's Progress Note, dated 06/03/2026 at 9:13 AM Res returned from (Local) ER via stretcher accompanied by two EMT's (Emergency Medical Technician). Res transferred to bed by the EMT's-res hardly able to stand and unable to move his feet in any direction to assist with transfer. Res has five staples to laceration left temple area with a small open area to proximal end and a larger opened, sheared like area below staples. Res has dressing in place held in place by kerlix wrapped around head. VSS (vital signs stable). T (temperature)-98.2 P (pulse)-72 R (respirations)-20 BP (blood pressure)-118/72 O2-unable to obtain due to fingers bilaterally being very cold. A&O (alert and orientated) x 4. Skin w/d (warm and dry).R16's Physical Therapy Discharge summary, dated documents Skilled Interventions Provided: Skilled treatment interventions included instructing and training patient in safe transfer techniques in order to improve mobility and decrease falls within pt's room. Progress & Response to Treatment: Patient's functional abilities have progressed as a result of skilled interventions. Team Communication/Collaboration: Reviewed patient's plan of treatment and treatment services with interdisciplinary team members. Functional Reach - Forward Direction = 3 inches (predictive of falls). On 8/4/2026 at 1:05 PM R16 stated that he remembers the fall. R16 stated that it was early in the morning. R16 stated that there was someone in the room helping him get dressed. R16 stated that he stood up and went down. R16 stated that girl did not have a hold of him. R16 stated that he reached for the chair and he went down hitting his head on the floor. R16 stated that if they had a hold of him don't think I would have hit so hard. R16 stated that he felt the blood running down his face. R16 stated that he did experience pain to his head and all over his body. When asked if he could rate his pain R16 stated No, but it hurt a lot. On 8/4/2026 at 7:45 AM V31, Licensed Practical Nurse, stated that she was notified of the fall by V19, Certified Nurse Assistant. V31 stated that she applied light pressure to R16's head. V31 stated that V2 (Director of Nurses) took over after that.On 8/4/2026 at 9:52 AM V19 stated she was there when R16 fell. V19 stated that she went into the room. Cleaned R16 up. V19 stated that she sat R16 on the side of the bed and applied the gait belt. V19 stated that she then assisted R16 to stand. V19 stated that she had her hand on R16's lower back and a hold of R16's right hand, did not have a hold of gait belt. V19 stated that R16 turned slightly and went down. V19 stated that it startled her because she had never had anyone fall on her. V19 stated that R16 legs are wobbly and have had some issues in the past with balance. On 8/4/2026 at approximately at 11:50 AM V7, Physical Therapy, stated that Forward Direction = 3 inches (predictive of falls) indicates risk for falls. 3 inches is not good. On 8/4/2026 at 1:36 PM V4, CNA, stated that R16 was a 1-person transfer. V4 stated that during the transfers R16 would lean forward and balance was not good. V4 stated that once he started going forward, he would keep going. Transfer not safe. On 8/4/2026 at 2:06 PM V2, Director of Nursing, stated that R16 was a 2-person transfer. V2 stated that she expected R16 to be transferred as a 2 person. V2 stated that in her opinion if R16 would have been transferred correctly, utilizing 2 staff in transfer, it would have prevented the fall. The facility's Safe Lifting and Movement of Residents policy, dated July 2017, documents that It is the policy of [NAME] Healthcare to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.The facility's Fall Prevention policy, dated March 15, 2018, documents that Policy: It is the policy of [NAME] Healthcare to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. We will develop a culture of safety to provide the Quality of Care and preventive services for each individual resident. Our Quality Assurance Program will monitor the program to assure ongoing effectiveness. Fall Prevention Program Components: The fall Prevention Program includes the following components: 1. Methods to identify risk factors. Risk will be determined by the Charge nurse and IDT (Interdisciplinary Team) when completing the Plan of Care based on: a. Fall Risk Score b. Resident Transfer Assessment c. History of Falls d. medical condition which directly impacts on equilibrium and/or ambulation. e. Medication Review f. Discussion of individual circumstances. It also documents Physical Capability: 5. Developing a Care Plan a. Areas of concern are based on initial Risk assessment, MDS and any additional assessments. b. Care Plan should address why the resident is at risk for falls and interventions by the staff to prevent falls. c. Interventions tell the staff if the resident is independent with ambulation/mobility, if the resident requires one/two assist with transfers/ambulation.

Based on observation, interview and record review the facility failed to provided showers twice a week for 4 of 5 residents (R6, R13, R15 and R19) reviewed for bathing in the sample of 24.Findings include: 1 R6's shower sheet dated 4/10/2026, and 4/17/2026 fails to document R6 received a shower. Shower sheet is blank but does have signatures of CNA and nurse. R6's Minimum Data Sheet (MDS) dated [DATE] documents R6 is cognitively intact with a Behavioral Interview of Mental Status (BIMS) of 14. R6's MDS documents R6 is dependent on staff for bathing. R6's undated face sheet documents a diagnosis in part of osteomyelitis of Left foot and ankle, end stage renal disease and morbid obesity. R6's care plan dated 12/28/2025 documents R6 is dependent on nursing for all aspects of care related to impaired mobility and functional limitations in Range of Motion (ROM) R6's care plan documents intervention dated 12/28/2025 to provide daily care. 2 On 7/28/2026 at 9:38AM R13 stated he does not always get his showers. R13's undated face sheet documents in part a diagnosis of acquired absence of left leg below the knee (LAKA). R13's MDS dated [DATE] documents a BIMS of 15. R13's MDS documents R13 requires substantial/maximal assistance for personal hygiene, bathing and toileting. R13's care plan dated 10/11/2026 documents R13 needs limited assistance for activities of daily living related to LAKA; decreased mobility. R13's care plan dated 10/11/2026 documents limited assistance of ADL (Activities of Daily Living) related to LAKA, decreased mobility and limited functional ability. R13's care plan documents assist as needed with ADLs. R13's shower record/skin audit is blank for 6/18/2036 7/20/2026,7/27/2026, 3. R19's shower sheets dated 7/11/2026 is blank with exception of CNA (Certified Nurse Aide) and nurse signature On 7/28/2026 at 1:14PM R19 in his room in his wheelchair. R19 stated his shower day is Wednesday and Saturday. R19 stated if the shower girl is not on duty, he does not get a shower. R19's John Hopkins Fall Risk, dated 7/15/2026, documents that R19 has no cognition issues. R19's MDS dated [DATE] documents R19 requires substantial/maximal assist with personal hygiene, dressing showers and toileting. R19's care plan dated 7/13/2025 documents Activities of Daily Living (ADL) functional with limitations. R19's care plan documents assist with shower and shampoo as per schedule. On 8/3/2026 at 8:43AM, V2 DON stated if a shower aide is on duty, the shower aide is to provide showers. V2 stated if there is no shower aide the staff assigned to the hall are to provide the shower. V2 stated due to complaints of residents not getting showers she has instructed staff if a resident refuses a shower the resident is to sign the shower sheet. On 8/4/2026 at 10:30AM V2 DON stated she would expect residents to be provided a shower twice a week. V2 stated if the shower sheet is blank, she would assume the resident did not receive a shower. 4. R15's Care Plan, dated 3/19/26, documents that Approach: Activities of Daily Living: I am (independent) of all activities of daily living. (OR) Overall I require (supervision, limited, extensive, dependent) assistance with oral care; (supervision, limited, extensive, dependent) with bathing; (supervision, limited, extensive, dependent) with grooming; (supervision, limited, extensive, dependent) with eating; (supervision, limited, extensive, dependent) with toileting; (supervision, limited, extensive, dependent) with dressing;(supervision, limited, extensive, dependent) with mobility. I will need (support, assistance) to have my personal care needs met while supporting my strengths and personal goals. R15's Minimum Data Set, dated [DATE], documents that R15 is severely cognitively impaired with short and long-term memory problems. It also documents that R15 is dependent on staff for all adl's (activities of daily living). On 7/30/26 8:30 AM R15's Shower Record Skin Audits were reviewed. No showers were provided on 6/12, 6/29, and 7/3/2026. As of 08/03/2026 at 12:39 PM no additional shower documentation provided. On 7/29/2026 at approximately 11:50 AM V23, Certified Nurse Assistant (CNA), stated that R15 was hospice and hospice provided R15's showers. V23 stated that R15's showers were not provided by the facility. On 7/28/2026 at 9:00 AM V14, R15's family, stated that R15's showers were scheduled Monday and Fridays. V14 stated that to get R15 a shower was like pulling teeth. V14 stated R15 would lay in his own filth and the staff would do nothing. V14 stated that she would have to raise hell to get the shower completed. V14 stated that V14 visited frequently, several times a day. V14 stated that if the staff needed help V14 would do so. V14 stated that there were missed scheduled showers. V14 stated that she would complain, and the shower was then given at that time. V14 stated that what if she didn't know or didn't complain. R15 would not have been cleaned. On 7/30/2026 at 11:05 AM V2, Director of Nursing, stated that R15's Care Plan is not a true reflection of the level of care R15 required. The facility's Bathing a Resident policy, dated July 2014, documents that Policy: It is the policy of [NAME] Healthcare that residents will receive a shower/bath will be scheduled regularly and prn (as needed). It also documents that Procedure: 23. Document the date of the shower and any abnormalities noted on the Bath/Shower Completion Form.

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented for 4 of 4 (R2, R3, R4, R5) residents reviewed for infection control in a sample of 24.Findings include: 1. On 7/27/2026 at 9:15 AM observed R2's, R3's, R4's and R5's shared bathroom. Observed a large amount of dried brown stool on the floor, toilet seat, down the front of toilet, dried stool on the sink, both door frames, both entry doors and walls. Observed 3 bath blankets on the floor with large brown circles. Observed dried stool coming out of the bathroom into R3's and R5's room. Observed multiple flies flying around the bathroom, landing on the dried stool. The flies then flew out of the bathroom into R2's, R3's, R4's and R5's rooms landing on the R2's, R3's, R4's, and R5's bed, bedside dressers and overbed table. Observed very small, black, slender-bodied flying insects with long legs and thread-like antennae flying and crawling around the bathroom. On 7/27/2026 at 9:36 AM V4, Certified Nurse Assistant (CNA), identified the insect as a gnat. V4 stated that the bathroom has been this way for about 2 weeks. V4 stated that the gnats are horrible and fly into the residents' rooms from this bathroom. Observed V4 walk in and out of the bathroom. Stepping on the dried stool on floor and walking about R3's and R5's room. On 7/27/2026 at 10:04 AM observed V3, Maintenance Director, cleaning R2's, R3's, R4's and R5's bathroom. V3 stated that he should have cleaned up the bathroom before now. V3 stated that he is the only maintenance, and it takes time to get to everything. V3 stated that he has had problems with the toilet for months. V3 stated that he has snaked it 3 or 4 times and it works for a while then it gets messed up again. V3 stated that some residents use too much paper and cause it to back up in the room.On 8/3/2026 at 11:20 AM V2, Director of Nursing, V2 stated that she was notified that the shared bathroom was a mess last Friday. V2 stated that she is not sure why the bathroom was left in that condition. V2 stated that it should have been cleaned up immediately. V2 stated that it is the aide's responsibility to clean up the stool then housekeeping comes in and sanitize. V2 stated that this is not a reflection of the organization's commitment to prudent infection prevention and control measures. V2 stated that it does not promote the concept of compassionate, common-sense resident and patient care, and doesn't emphasis cleanliness or infection prevention strategies.2. R3's Face Sheet, not dated, documents R3 was admitted on [DATE]. It lists the following diagnosis Unspecified dementia, unspecified severity, with agitation, Major depressive disorder, recurrent, severe with psychotic symptoms, Essential hypertension, Unspecified hearing loss, unspecified ear, Exocrine pancreatic insufficiency, Urgency of urination, panic disorder and Generalized anxiety disorder.R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is moderately cognitively impaired, require partial/moderate assistance with toileting hygiene. R3's Social Services - Social Worker Assessment 2023, dated 07/08/2026 at 3:27 PM, documents that R3 is alert but somewhat disorientated.On 7/27/2026 observed handwritten yellow sign, dated 7/26/2026, documents that Toilet Still Broken. Running sink Cause Overflow taped to R3's and R5's bathroom door.On 7/27/2026 at 9:13 AM observed R3 attempting to enter the bathroom in room. R3 opened the door and attempted to enter. R3 stated that she needed to have a bowel movement. R3 stated that she really needs to go but it doesn't look good in there.On 7/27/2026 at 9:36 AM V4 stated that R3 is alert and forgetful. V4 stated that R3 can tell you that the bathroom is broken and then forgets and tries to use it. V4 stated that R3 has dementia and forgets things. V4 stated that R3 does try to use the bathroom. V4 stated that they usually put a chair in front of the door to keep R3 from going into the bathroom.On 7/27/2026 at 10:04 AM V3 stated that R3 has memory problems and forgets that the bathroom does not work. V3 stated that R3 goes in the bathroom and tries to use it.3. R4's MDS, dated [DATE], documents that R4 is cognitively intact.On 7/27/2026 at 9:08 AM observed 2 handwritten yellow signs. 1 sign dated 6/13/2026, DO NOT USE SINK OR Toilet. Needs Fixed. The other sign, dated 7/26/2026, documents that Toilet Still Broken. Running sink Cause Overflow taped to R2's and R5's bathroom door. A large commode is positioned in front of bathroom door.On 7/27/2026 at 9:08 AM R4 stated that the bathroom toilet has been broken and unusable for months. R4 stated that the bugs come from under the door and through the cracks. R4 stated that its horrible. R4 stated that flies, gnats and roaches come out of there (bathroom). R4 stated Look right there pointing to bathroom door frame. Multiple gnats coming through space in door frame. R4 stated that she is more worried about the residents that share the bathroom. R4 stated that they are forgetful and use that bathroom and it (the bathroom) is in horrible condition.4. R2's MDS, dated [DATE], documents that R2 is moderately cognitively impaired.R2's Progress Notes, dated 7/16/2026, documents that R2 is alert and oriented x 2-3.On 7/28/2026 at 8:36 AM R2 stated that she does not use the bathroom. R2 stated that the girls would open the door. The odor, the flies and gnats would come into the room. R2 stated that there were so many. R2 stated that they would be on the bed, table and food at times. R2 stated that she would have to fan them away but that it didn't work because they would be right back. R2 stated that the odor from the bathroom was bad but when the girls opened the door it was strong and offensive. R2 stated that who wants bugs that's on poop on your food. Disgusting. It's not clean. The girls would track the poop into the room. It's horrible. R2 stated that she is not able to clean it but would not allow it in her home.On 7/28/2026 at 8:37 AM V13, Registered Nurse (RN), stated that R2 is alert and oriented. V13 stated that R2 is able to communicate appropriately. V13 stated that she is not aware of R2 having behaviors of making up stories.5. R5's Face Sheet, not dated, documents that R5 was admitted on [DATE] and currently resides on 200 halls in room [ROOM NUMBER] bed A. It also documents the following diagnosis: Parkinson's disease without dyskinesia, Hyperlipidemia, Other chronic pain, Allergic rhinitis, Diarrhea, Acquired absence of right breast and nipple, open wound of right breast, subsequent encounter, specified eating disorder, Gastro-esophageal reflux disease without esophagitis, Zoster without complications, Constipation, unspecified, Overactive bladder, Type 2 diabetes mellitus without complications, Personal history of COVID-19, Unspecified dementia, unspecified severity, with agitation, Violent behavior, Essential) hypertension, I97.2 Postmastectomy lymphedema syndrome, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, Personal history of urinary (tract) infections, Alzheimer's disease, unspecified information.R5's MDS, dated [DATE], documents that R5 is always incontinent of bowel and bladder and requires partial/moderate assistance.On 7/27/2026 at 9:36 AM V4 stated that R5 is incontinent. V4 stated that they use the shared bathroom to toilet and provide incontinent care for R5. The facility's Infection Prevention and Control Program Policies and Procedures: General Statement, dated August 2018, documents that the organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies.

Based on observation, interview and record review, the facility failed to maintain the the shared bathroom in clean and good repair for 4 of 4 (R2, R3, R4, R5) residents reviewed for physical environment in a sample of 24. Findings include: 1. On 7/27/2026 at 9:15 AM observed R2's, R3's, R4's and R5's shared bathroom. Observed a large amount of dried brown stool on the floor, toilet seat, down the front of toilet, dried stool on the sink, both door frames, both entry doors and walls. Observed 3 bath blankets on the floor with large brown circles. Observed dried stool coming out of the bathroom into R3's and R5's room. Observed multiple flies flying around the bathroom, landing on the dried stool. The flies then flew out of the bathroom into R2's, R3's, R4's and R5's rooms landing on the R2's, R3's, R4's, and R5's bed, bedside dressers and overbed table. Observed very small, black, slender-bodied flying insects with long legs and thread-like antennae flying and crawling around the bathroom. On 7/27/2026 at 9:36 AM V4, Certified Nurse Assistant (CNA), identified the insect as a gnat. V4 stated that the bathroom has been this way for about 2 weeks. V4 stated that the gnats are horrible and fly into the residents' rooms from this bathroom.On 7/27/2026 at 10:04 AM observed V3, Maintenance Director, cleaning R2's, R3's, R4's and R5's bathroom. V3 stated that he should have cleaned up the bathroom before now. V3 stated that he is the only maintenance, and it takes time to get to everything. V3 stated that he has had problems with the toilet for months. V3 stated that he has snaked it 3 or 4 times and it works for a while then it gets messed up again. V3 stated that some residents use too much paper and cause it to back up in the room.On 8/3/2026 at 11:20 AM V2, Director of Nursing, stated that the shared bathroom was not in clean and good repair. 2. R3's Face Sheet, not dated, documents R3 was admitted on [DATE]. It lists the following diagnosis Unspecified dementia, unspecified severity, with agitation, Major depressive disorder, recurrent, severe with psychotic symptoms, Essential hypertension, Unspecified hearing loss, unspecified ear, Exocrine pancreatic insufficiency, Urgency of urination, panic disorder and Generalized anxiety disorder.R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is moderately cognitively impaired, require partial/moderate assistance with toileting hygiene. R3's Social Services - Social Worker Assessment 2023, dated 07/08/2026 at 3:27 PM, documents that R3 is alert but somewhat disorientated.On 7/27/2026 at 9:12 AM observed handwritten yellow sign, dated 7/26/2026, documents that Toilet Still Broken. Running sink Cause Overflow taped to R3's and R5's bathroom door.On 7/27/2026 at 9:13 AM observed R3 attempting to enter the bathroom in room. R3 opened the door and attempted to enter. R3 stated that she needed to have a bowel movement. R3 stated that she really needs to go but it doesn't look good in there.On 7/27/2026 at 9:36 AM V4 stated that R3 is alert and forgetful. V4 stated that R3 can tell you that the bathroom is broken and then forgets and tries to use it. V4 stated that R3 has dementia and forgets things. V4 stated that R3 does try to use the bathroom. V4 stated that they usually put a chair in front of the door to keep R3 from going into the bathroom.On 7/27/2026 at 10:04 AM V3 stated that R3 has memory problems and forgets that the bathroom does not work. V3 stated that R3 goes in the bathroom and tries to use it.3. R4's MDS, dated [DATE], documents that R4 is cognitively intact.On 7/27/2026 at 9:08 AM observed 2 handwritten yellow signs. 1 sign dated 6/13/2026, DO NOT USE SINK OR Toilet. Needs Fixed. The other sign, dated 7/26/2026, documents that Toilet Still Broken. Running sink Cause Overflow taped to R2's and R5's bathroom door. A large commode is positioned in front of bathroom door.On 7/27/2026 at 9:08 AM R4 stated that the bathroom toilet has been broken and unusable for months. R4 stated that the bugs come from under the door and through the cracks. R4 stated that it's horrible. R4 stated that flies, gnats and roaches come out of there (bathroom). R4 stated Look right there pointing to bathroom door frame. Multiple gnats coming through space in door frame. R4 stated that she is more worried about the residents that share the bathroom. R4 stated that they are forgetful and use that bathroom and it (the bathroom) is in horrible condition.4. R2's MDS, dated [DATE], documents that R2 is moderately cognitively impaired.R2's Progress Notes, dated 7/16/2026, documents that R2 is alert and oriented x 2-3.On 7/28/2026 at 8:36 AM R2 stated that she does not use the bathroom. R2 stated that the girls would open the door. The odor, the flies and gnats would come into the room. R2 stated that there were so many. R2 stated that they would be on the bed, table and food at times. R2 stated that she would have to fan them away but that it didn't work because they would be right back. R2 stated that the odor from the bathroom was bad but when the girls opened the door it was strong and offensive. R2 stated that who wants bugs that's on poop on your food. Disgusting. It's not clean. The girls would track the poop into the room. It's horrible. R2 stated that she is not able to clean it but would not allow it in her home.On 7/28/2026 at 8:37 AM V13, Registered Nurse (RN), stated that R2 is alert and oriented. V13 stated that R2 is able to communicate appropriately. V13 stated that she is not aware of R2 having behaviors of making up stories.5. R5's Face Sheet, not dated, documents that R5 was admitted on [DATE] and currently resides on 200 halls in room [ROOM NUMBER] bed A. It also documents the following diagnosis: Parkinson's disease without dyskinesia, Hyperlipidemia, Other chronic pain, Allergic rhinitis, Diarrhea, Acquired absence of right breast and nipple, open wound of right breast, subsequent encounter, specified eating disorder, Gastro-esophageal reflux disease without esophagitis, Zoster without complications, Constipation, unspecified, Overactive bladder, Type 2 diabetes mellitus without complications, Personal history of COVID-19, Unspecified dementia, unspecified severity, with agitation, Violent behavior, Essential) hypertension, I97.2 Postmastectomy lymphedema syndrome, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, Personal history of urinary (tract) infections, Alzheimer's disease, unspecified information.R5's MDS, dated [DATE], documents that R5 is always incontinent of bowel and bladder and requires partial/moderate assistance.On 7/27/2026 at 9:36 AM V4 stated that R5 is incontinent. V4 stated that they use the shared bathroom to toilet and provide incontinent care for R5. The facility's Long-Term Care Facility Maintenance and Repair Policy, not dated, documents that 1. Policy Statement (facility) is committed to maintaining a safe, clean, functional, and comfortable environment for residents, staff, and visitors. All facility equipment, utilities, structural elements and grounds will be maintained in safe operating condition and in compliance with federal state and local regulations.

Based on interview and record review the facility failed to ensure safe and appropriate discharge plan for 1 of 3 (R15) residents reviewed for discharge in a sample of 24. R15's Care Plan, not dated, does not address R15's discharge plans.R15's Progress Note, dated 07/05/2026 at 1:40 PM, documents that Resident's daughter here to take him home. All appropriate paperwork reviewed with and signed by resident's daughter, verbal understanding expressed. All medications reviewed with and given to resident's daughter, verbal understanding expressed of when medication is due, and reason for taking medication. Resident's daughter told to call with any questions and concerns. Resident lifted into daughter's van by 3 staff members.On 7/28/2026 at 1:46 PM R15's discharge plan and summary requested. As of 8/4/2026 at 3:00 PM the facility had not provided R15's discharge plan and or summary. On 7/28/2026 at 1:40 PM V15, Social Service Director, stated that she cannot say what the reason for R15's discharge. V15 stated that there was family conflict regarding the care for R15. V15 stated that she was not at the facility when R15 was discharged . V15 stated that R15 was discharged on a weekend. V15 stated that during the time of the discharge the discharge plan and summary was not complete or in place. V15 stated that last week the form was found and the summary was incomplete.On 7/28/2026 at 1:53 PM V12, Registered Nurse, stated that she discharged R15 home with family. V12 stated that at the time of the discharge V12 did not have the discharge plan or summary. V12 stated that she contacted V15, and the plan was not found. V12 stated that she provided the family with a form and had the daughter sign and V12 signed. V12 stated that normally there is a plan and summary that is created with each department's documentation. V12 stated that this information is reviewed with the family and residents. V12 stated that they did not have a plan or summary at the time of discharge.On 8/3/2026 at 11:20 AM V2, Director of Nursing, stated that during the discharge usually the Social Service would provide a discharge form, and each department would fill out their section. V2 stated that this form is usually reviewed with the family at discharge. V2 stated that the form has a small area for nursing. V2 stated because of this the CCD (Continuity of Care Document) is printed and attached to the summary. Both forms are reviewed with the family with verbalizing of understanding. V2 stated that the discharge plan, summary and CCD are reviewed with the family at discharge. V2 stated that the CCD is not reviewed or given alone, it is to be reviewed and given with the summary not in its (plan and summary) place.The facility's Discharge Summary and Plan policy, dated October 2017, documents that When a resident's discharge is anticipated or the resident expresses an interest in receiving information about returning to the community, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment and to avoid unnecessary delays in resident's discharge or transfer. Procedure 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/MR, etc.), a discharge summary and a post-discharge plan will be developed by the Interdisciplinary Team which will assist the resident to adjust to his or her new living environment. The plan is an ongoing process and discharge plan is updated as needed to reflect changes. The plan will consider caregiver/support person availability and the capacity and capability to perform the required care. 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. Medically defined condition, diagnosis, and prior medical history (medical history before entering the facility and current medical diagnoses, including any history of mental retardation and current mental illness); b. Medical status measurement (objective measurements of a resident's physical and mental abilities including, but not limited to, information on vital signs, clinical laboratory values, or diagnostic tests); c. Physical and mental functional status (ability to perform activities of daily living including bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems. Includes determining the resident's need for staff assistance and assistive devices or equipment to maintain or improve functional abilities and the resident's ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility); course of illness/treatment or therapy and pertinent lab, radiology, and consultation results. d. Sensory and physical impairments (neurological, or muscular deficits; for example, a decrease in vision and hearing, paralysis, and bladder incontinence); Nutritional status and requirements (weight, height, hematological and biochemical assessment, clinical observations of nutrition, nutritional intake, resident eating habits and preferences, and dietary restrictions); f. Special treatments or procedures (treatments and procedures that are not part of basic services provided; for example, treatment for pressure sores, sterile special, naso-gastric feedings, specialized rehabilitation services, and respiratory care); g. Mental and psychosocial status (the resident's ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); h. Discharge potential (the expectation of discharging the resident from the facility within the next three months); i. Dental condition (Dentures); j. Activities potential (the resident's ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being. Activity pursuits refer to any activity outside of ADLs which a person pursues in order to obtain a sense of well-being. Includes activities which provide benefits in the areas of self-esteem, pleasure, comfort, health education, creativity, success, and financial or emotional independence, and the resident's normal everyday routines and lifetime preferences); k. Rehabilitation potential (the ability to improve independence in functional status through restorative care programs); Course of therapy l. Cognitive status (the resident's ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and m. Drug therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). Includes pre and post discharge medication reconciliation 3. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and identifies specific resident needs after discharge such as personal care, sterile dressings, and physical therapy as well as describes the resident/caregiver education needs and ability to meet care needs after discharge. Include goals of care, preferences for care, how resident will access these services and how care should be coordinated if continuing treatment involves multiple caregivers. Referrals to local contract agencies will be documented and the plan of care will be updated to reflect the response to these contacts. If the resident expresses an interest in returning to the community and the discharge is not feasible, the SSD will document who made that determination and the reasons for the decision. 4. The Social Services Department will review the final plan with the patient/resident and family before the discharge is to take place. A copy of the post-discharge plan and summary will be provided to the resident and receiving facility, and a copy will be filed in the resident's medical records. A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the of the resident or resident's representative.

Based on interview and record review the facility failed to follow order for preparation for procedure for 1 of 2 residents (R6) reviewed for fistula gram in the sample of 24.findings include: 1 On 7/29/2026 at 2:00PM V20 Licensed Practical Nurse (LPN) stated R6 was to be NPO (nothing by mouth) for a fistula flush. V20 stated R6 goes out of town for procedure. R6's progress noted dated 4/2/2026 documents back from kidney dr. appointment July 21 to have fistula flushed. NPO 6 hours prior to the procedure. On 7/29/2026 at 3:02PM V28 administrative assistant [NAME] returned call and stated the procedure is a fistula gram and R6 is required to be NPO. On 7/29/2026 at 3:16PM V3 maintenance director stated he previously also provided transport to appointments. V3 stated he did take R6 to an appointment over line in her arm on 4/2/2026. V3 stated when they got to the appointment it had to be rescheduled as R6 had eaten. V3 stated it was rescheduled at that time for July. R6's progress note dated 04/02/2026 at 8:35AM documents R6 out with staff to kidney dr at Florissant MO.R6's progress note dated 4/2/2026 at 11:02AM documents R6 returned from Kidney doctor. July 21, 26 app (appointment) set up for 9:30am be there 30 min s early. NPO 6 hours before procedure. Transportation set per staff. R6's care plan date, edited 4/2/2026 documents R6 is at risk for complications related to end stage renal disease. On 8/4/2026 at 2:06PM V2, Director of Nursing (DON) stated she would expect physician orders to be followed The facility policy Obtaining and Following Physician orders dated, revised 2017 documents It is the policy of the facility that physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgment think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified.

Based on observation, interview and record review the facility failed to provide complete incontinent care for 1 of 3 (R18) residents reviewed for incontinent care in the sample of 24.Findings include: 1 On 7/29/2026 at 12:082:08PM V19 Certified Nursing Assistant (CNA) entered R18's room for skin check. R18 in bed on back with breakfast tray still on bedside table. V24 CNA entered room. V24 then left room to get supplies as all V19 had was an incontinent brief. With R18 on his back V19 with gloved hands undid incontinent brief and rolled brief forward towards R18's scrotum. R18's incontinent brief wet as verified by V19 CNA. R18's brief wrinkled with dark yellow urine stains in brief. V24 CNA took 2 towels in place in bathroom sink ran water on them and squirted bath wash on one towel. V24 CNA wrung towels out. V24 CNA handed towels to V19. V19 then with gloved hand took wet towel and wiped down left groin, then right groin then place towel in trash bag. V19 then took antifungal powder and sprinkled in bilateral groins. V19 was not informed which towel had soap. No visible soap when swiped bilateral groin. R18 was not rinsed. V19 did not cleanse scrotum or penis or pull foreskin back. R18 was then turned on his side toward the wall with wet towel wipes from front to back with one swipe and disposed of towel did not cleanse inner thighs or buttocks. did not rinse or dry. R18's Minimum Data Set (MDS) dated [DATE] documents R18 is cognitively intact with a Behavioral Interview of Mental Status (BIMS) of 14. R18's MDS document R18 is dependent on staff for toileting, and personal hygiene. On 8/3/2026 at 9:50AM V29 CNA stated when providing incontinent care all areas are to be cleansed, rinsed and dried. V29 CNA stated when cleansing a male resident, the penis and scrotum are to be cleansed. On 8/3/2026 at 11:21AM V2 Director of Nursing (DON) stated when providing incontinent care, she would expect staff to use foaming no rinse cleanser instead of soap in bathroom. V2 stated she would expect staff to provide complete incontinent care. The facility policy Perineal Care dated, revision 2012 documents the purposes of this procedure is to provide cleanliness, and comfort to the resident, to prevent infections and, and to observe the resident's skin condition. The policy documents Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure; wash basin, towels, washcloth, soap (or other authorized cleansing agent); and personal protective equipment (e.g. gowns, gloves, mask etc. as needed.)The policy documents: Steps in the procedure: Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached, wash and dry your hands thoroughly, fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside, put on gloves. The policy documents For a Male Resident: wet washcloth and apply soap or skin cleansing agent, wash perineal area starting with urethra and working outward, retract foreskin of the uncircumcised male, wash and rinse urethral area using a circular motion, continue to wash the the perineal including the penis, scrotum and inner thighs. Do not use the same washcloth or water to clean the urethra. Thoroughly rinse the perineal area in same order, using fresh water and c or assist the resident to turn on his side with his upper leg slightly bent, if able, rinse washcloth and apply soap or skin cleansing agent, wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus and the buttock, dry area thoroughly.

Based on interview and record review the facility failed to administer medication as ordered for 2 of 5 residents (R6 and R7) reviewed for medication administration in the sample of 24. Findings include: 1 R6's Medication Administration Record (MAR) dated 5/1/2026- 5/31/2026 documents vancomycin 125mg (milligram) capsule every 6 hours. R6's MAR document 5/7/2026 at 1800 not administered drug item not available, 5/8/2026 00:00 not administered drug item not available, 5/8/2026 12:00 not administered: resident unavailable. Buspirone 7.5mg twice a day MAR documents on 5/19/2026 8:30 not administered resident not available, 5/20/2026 8:30 resident not available, 5/20/26 8:30 and 16:30 not administered, resident not available., 5/21/2026 medication not administered resident not available. R6's Minimum Data Set (MDS) sated 6/19/2026 documents R6 is cognitively intact with a Behavioral interview of Mental Status (BIMS) of 14. 2 On 7/27/2026 at 1:00PM R7 stated a few months ago she was not getting her night medications as a new nurse was not giving them to her. R7 stated that nurse is no longer at the facility. R7's MDS dated [DATE] documents R7 is cognitively intact with a BIMs of 13. R7's MAR dated 5/1/2026-5/31/2026 documents doxycycline 100 mg 0800. R7's MAR documents 5/7/2026 not administered: resident not available. 5/25/2026 not administered: Drug item unavailable.R7's MAR dated 7/1/2026-7/29/2026 document alprazolam 0.25 mg i tablet oral 0800 and 1600. R7's Mar documents on 7/3/2026 08 not administered: drug item not available,7/5/2026 1600 not administered: other comment: resident sleeping, 7/21/2026 1600 not administered: drug item unavailable: awaiting refill from pharmacy On 7/29/2026 at 10:57AM V20 Licensed Practical Nurse (LPN) stated she was aware of residents complaining of not getting their medications. V20 stated it was evening medications and stated complaints were pretty much for any resident who could tell you. V20 stated they either did not get them at all or it may be 2:00AM. V20 stated that nurse does not work here anymore, she got fired. V20 stated if resident refuses medication it is to be marked refused on MAR. V21's termination record form documents V21 documents V21 terminated 7/22/2026. The form documents date of hire 6/18/2026. The termination form documents description of infraction; loitering or loafing during work hours, failing to meet work productivity expectations, failing to perform job duties. The form documents not performing med (medication) pass in a timely manner, not performing wound treatments as ordered as scheduled, not responding to resident needs. On 7/29/2026 at 9:56AM V1, Administrator stated she would expect medications to be administered as ordered.The facility policy Medication Administration dated, revision June, 20026 documents to administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. The policy documents identify the resident, explain to resident type of medication to be administered. Give the resident the medication. The policy documents if medication is ordered but not present, call the pharmacy or supervisor to obtain the medication.

Based on observation, interview, and record review, the Facility failed to ensure nutritional interventions were in place to prevent weight loss for 1 of 3 residents (R40) reviewed for nutrition in the sample of 34. This failure resulted in R40 losing 13.6% body weight over four months which is significant and undesirable.Findings include: 1-R40's Face Sheet documents R40 was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition. R40's Minimum Data Set (MDS) dated [DATE] documented R40 was moderately cognitively impaired, used wheelchair, required setup or clean-up assistance with eating, and had no or unknown weight loss. R40's Vitals Results document R40 weighed 98.4 pounds (lbs) on 12/8/25, 91.0 lbs on 2/6/26, 93.0 lbs on 3/17/26, and 85.0 lbs on 4/3/26. The document correlates R40's 4/3/26 weight with a Body Mass Index (BMI) of 15.55. R40's Physician Order dated 3/7/26 documents mechanical soft diet with double protein portions and peanut butter sandwiches between meals with 120 mL (milliliters) Med Pass three times daily. R40's Care Plan last revised 3/24/26 documents double protein portions and supplements will be given as ordered. On 4/22/26 at 8:12 AM, V11, Dietary Manager, scraped the pan of scrambled eggs from the steam table to place nearly a full scoop of eggs on R40's plate. V11 was able to get a partial second scoop that was approximately one third full. R40 was the last resident served, and the pan of eggs was completely empty. On 4/22/26 at 8:13 AM, V11 stated it is uncommon for the Facility to run out of food. On 4/22/26 at 12:44 PM, R40 was sitting up in bed in her room visiting with V13, Licensed Practical Nurse (LPN). R40's gown had fallen down on the left side, revealing wasting of the shoulder and clavicle, as well as temporal wasting on her face. V13 stated R40's lunch was just delivered, but R40 did not want to eat anything right then. R40's tray contained a meal card dated 4/22/26 documenting R40 was on a mechanical soft diet with double protein portions. V13 lifted the cover of R40's plate which contained one cabbage roll, a slice of bread, and mixed vegetables. V13 stated this tray does not contain double protein and she does not believe R40 usually gets double protein portions. V13 stated R40 does not receive a Med Pass supplement. R40's Medication Administration Record (MAR) for 1/1/26-4/23/26 does not document Med Pass was ever administered. On 4/23/26 at 9:07 AM, V2, Director of Nursing (DON), stated there is no documentation that R40 received Med Pass because it was entered as a general order, rather than a medication order, and thus was not prompting nurses to administer. She stated some nurses may not be aware of the order. R40's 4/17/26 Progress Note by V19, Registered Dietitian (RD), documents R40 was reviewed for weight variance with 8.6% weight loss over 17 days and 14.1% weight loss over 150 days. The recommendation was to continue current interventions which included (Med Pass) three times daily and double protein portions. On 4/23/26 at 10:35 AM, V19 stated the purpose of Med Pass is to add extra calories and protein for residents who are not eating well and should be documented on the MAR. R40's BMI (Body Mass Index) was 17.0 a few months ago, and now it is 15.0. There are many factors that can affect weight, but if a resident did not get Med Pass or double portions it could be a contributing factor to weight loss. Residents having significant weight loss without the use of a GLP (Glucagon-like peptide) or diuretic is not really warranted. On 4/23/26 at 2:37 PM, V19 stated R40's BMI is not necessarily ideal as evidenced by the orders for interventions to provide additional calories and protein to her oral intake. On 4/23/26 at 3:10 PM, V1, Administrator, stated she expects the Facility to follow food service policies and physician prescribed orders. The Facility's Weight Management Program Policy revised February 2024 documents, It is the policy of (Facility Company) to manage resident weight through prevention, assessment, and implementation and evaluation of interventions.

Based on observation, interview, and record review, the facility failed to accurately date a vial of Tuberculin solution to determine the expiration date. This has the potential to affect all 54 residents living in the facility.Findings Include:On 4/21/2026 at 2:14 PM the facility's medication room was observed with V3, Licensed Practical Nurse (LPN). An open, partially used multi-dose vial of Tuberculin (TB) Purified Protein Derivative Diluted/Aplisol 5TU/0.1mL noted in a House Stock bin in the medication refrigerator with no open date on the vial or medication box. V3 stated the vial is a stock vial of TB solution the facility uses, and she is unsure how long the vial has been open due to the vial not having an open date written on it. V3 stated once a vial is open, the vial should have the date it was opened written on it.On 4/22/2026 at 8:54 AM V1, Administrator, stated the vial of TB serum is for resident use. V1 stated all multi-dose vials including insulin and Tuberculin are expected to be dated with the date opened. On 4/22/2026 at 10:45 AM V2, Director of Nursing, stated the vial of TB solution is a multi-dose vial the facility uses for all the residents. V2 stated she expects staff to label the vial with the date opened and once opened, the vial is good for 30 days.The Aplisol Solution Package Insert Prescribing Information as of November 2013 documents Dosage and Administration: Aplisol vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than 30 days should be discarded.The Facility's Storage of Medications Policy Date Revised 5/1/2018 documents Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: in a multi-dose injectable vial, an ophthalmic medication, an item for which the manufacturer has specified a usable life after opening. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the [NAME] stickers to affix contain bother a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 4/21/26 documents there are 54 residents living in the facility.

Based on observation, interview, and record review, the Facility failed to store and prepare foods in a manner that prevents potential contamination. This has the potential to affect all 54 residents living in the Facility.Findings include: On 4/21/26 at 8:20 AM, in the dry storage room there was an empty box of oatmeal cream pies on the floor. There was a box of bananas on a shelf containing several black bananas. There were areas of dark, dirty spots on the floor. The deep freeze had a box of garlic bread that was opened, but was not resealed upon opening, leaving the contents inside open to air. On 4/21/26 at 8:22 AM, in the larger storage room with the pipes, there was a window fan that was covered in dust. The fan was blowing directly toward a rack with crockpots and roasting pans approximately one foot away. There was a significant layer of dust on all the pipes running through the room and generalized brown/black dirt on the floor. There were eight food storage containers stacked on the floor underneath the window with the dusty fan in operation. The deep freezer in the room had a plastic bag with round items that was tied up in a knot, but was not labeled or dated. The freezer labeled Freezer 4 contained a box of cooked egg patties above a box of corn on the cob. There was a bag of garlic bread tied into a knot on the bottom shelf with no label or date. The freezer labeled Freezer 3 contained a box of uncooked beef patties on the shelf above a box of omelets and a box of canadian bacon. On 4/22/26 at 8:18 AM, V11, Dietary Manager, stated she was written up for the window fan blowing in dust when local health dept was here about a month ago. It was cleaned, so she was unsure why the dust has built up again so fast. She stated she went through the kitchen yesterday after the surveyor visited and threw away everything that was not labeled or dated. On 4/23/26 at 3:10 PM, V1, Administrator, stated she expects the Facility to follow its food storage policies. The Facility's Dry Storage Areas Policy revised January 2012 documents dry storage areas will be kept neat, orderly, and in a condition which protects foods in a safe and sanitary manner. Items will be stored at least six inches off the floor. Floors will be swept daily and mopped at least weekly. Cans and dried goods will be dated with the date they were received and date they were opened. The Facility's Food and Supply Storage Policy revised January 2012 documents all foods will be covered, labeled, and dated with an expiration date. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 4/21/26 documents there are 54 residents living in the Facility.

Based on interview and record review the facility failed to provide a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other residents in the facility. This failure has potential to affect the 54 residents in the facility.Findings include:R26's EMR (Electronic Medical Records undated documents that the resident was admitted to the facility on [DATE].R26's Wound Culture dated 3/13/26 documents Heavy Methicillin-Resistant Staphylococcus aureus.R35's EMR undated documents that the resident was admitted to the facility on [DATE].R35's Urine Culture dated 2/12/26 documents Proteus miralilis Extended Spectrum Beta Lactamase.R49's EMR undated documents that the resident was admitted to the facility on [DATE].R49's Skin, Hair, Nails Fungus Culture dated 11/14/25 documents Candida auris.Facility's Infection Control binder for January, February, and March of 2026 does not document what organisms the residents have in the facility. The highlighter areas in the binder are not names of organisms.On 4/22/26 at 9:28 AM, V2, DON (Director of Nursing) stated that the infection control binder is used to identify the organisms in the facility.On 4/24/26 at 9:26 AM, V1, Administrator and V2, DON stated that they share the role of Infection Control Preventionist. They stated that the facility tracks the infections in the building by highlighting the infections in the infection control binder. They also write the infection on a dry erase board in the DON's office, and they can print a report in the computer system. V2 stated that most of the time the ER will send the urine culture back with residents that are diagnosed with a UTI.Facility's Infection Control policy dated July 2017 documents It is the policy of (facility) to make every effort to prevent the spread of infection in the facility. Procedure; 2. To identify true infections, track and trend infection data, the facility will utilize the Infection Criteria Checklist form and the Infection Control log.Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 4/21/26 documents a census of 54 residents.

Based on interview and record review the facility failed to timely answer call lights for 2 of 2 (R7, R60) residents reviewed for resident rights in a sample of 34.Findings Include:1. R7's Undated Face Sheet documents R7 an admission date of 10/3/2025 and has a medical diagnosis including End Stage Renal Disease, Type 2 Diabetes Mellitus, Chronic Pain, Obsessive-Compulsive Disorder, Peripheral Vascular Disease, Unspecified injury of right forearm, and Acute pulmonary edema.R7's Minimum Data Set (MDS) dated [DATE] documents R7 is moderately cognitively impaired, is always incontinent of bladder and bowel, and requires substantial/maximal assistance with toileting hygiene, sitting to standing, and chair/bed to chair transfers.R7's Care Plan Edited 4/2/2026 documents Problem: R7 is at risk for skin breakdown or pressure ulcers related to decreased mobility. Interventions dated 12/18/2025 documents Keep skin clean and dry as possible and keep linen clean and dry as much as possible.2. R60 Undated Face Sheet documents an admission date of 2/1/2024 and has a medical diagnosis of Hypertension, Type 2 Diabetes Mellitus, Cervicalgia, and Abnormalities of Gait and Mobility.R60's MDS dated [DATE] documents R60 is cognitively intact, uses a wheelchair, needs substantial/maximal assistance with toileting hygiene, sitting to standing, and chair/bed to chair transfers.On 4/23/2026 at 11:15 AM R7 stated this past Tuesday night she was in bed and informed the nursing staff that she wanted to get up for supper. R7 stated she was informed by V3, Registered Nurse, if she wanted to get up now then she would not be able to go back down to bed until after 9:00 PM and when staff were done taking care of everyone else. R7 stated she was sitting in her chair, and she had an accident in her chair. R7 stated she pushed her call light for staff to come help her. R7 stated she sat in her chair with wet and dirty for 2 hours before staff came into her room. R7 stated she was crying and screaming in pain because she had to sit in her own bm for 2 hours. R7 stated staff should not treat her like that and she was in pain and then became angry because staff would not help her. R7 stated her roommate R60 called the phone at the nurse's station for staff to come to help, and no one would answer the phone. R7 stated she called her daughter and was crying to her daughter on the phone due to the pain and sitting in her accident. R7 stated staff came to her room [ROOM NUMBER] hours later, because her son-in-law called the facility. R7 stated the Certified Nursing Assistants (CNAs) would not help her sooner because they were abiding by V3's orders. On 4/23/2026 at 2:10PM V5, Certified Nursing Assistant, CNA, stated On the evening of 4/21/2026 at 5:45PM R7 wanted to get up and it was right before supper. I know she had just been laid down at 2:00PM. I asked V3, Registered Nurse, RN, if it was ok to get R7 up and V3 said Yes but to explain to R7 that she may not be able to get back to bed immediately after dinner. We must be in the dining room until the last resident is finished eating and then we take the residents back to their rooms. As V22 and I were pushing residents to their rooms R7, and her roommate were saying R7 wanted put back to bed. I was trying to explain to R7 that we wouldn't be able to put her back to bed until 7:15PM. R7 started screaming at V22 and me and cussing at us. We were able to put her back to bed at around 7:50PM.On 4/23/2026 at 1:45PM V3, Registered Nurse, RN, stated On 4/21/2025 right before supper V5, Certified Nursing Assistant, CNA, and V22, CNA, came to ask me if R7 could get up in the chair at that time. I said Yes but to explain to R7 that she may not be able to go back to bed immediately after dinner because the CNAs must be in the dining room. I don't know if she ended up getting up or not.On 4/23/2026 at 3:00PM V22, Certified Nursing Assistant, CNA, stated R7 wanted to get up right after dinner. We told R7 that we could get her up but that it would be a while before we could put her back to bed. We got her up around 5:45PM. Right after she had finished eating R7 was asking to be put back to bed. We told her we had to stay in the dining room until all the residents were finished. R7 started screaming and cussing at us and saying she had pooped herself. We got her back to bed around 7:50PM. On 4/23/2026 at 11:23 AM R7 stated she had an incident last night where she was having a panic attack and could not breathe, so she pressed her light. R7 stated staff were not coming to answer her light so her roommate R60 called the nurse's station phone. R60 stated V20, CNA, and V21, Licensed Practical Nurse (LPN), came into her and R7's room and V21 assessed R7. V60 stated V20 told her that she should only call the nurse's station for emergencies and her and R7 are just crying wolf. V60 stated she will only call the nurse's station when herself or R7 have to wait a long time for staff to answer their call lights. R60 stated she has had to wait over a half hour for staff to answer her call light. On 4/23/2026 at 3:28 PM, V20, CNA, stated he was walking by the nurse's station on 4/22/2026 and the phone rang, and it was R7's roommate, R60. V20 stated R60 said R7 needed a nurse, so V21 and I both walked down to her room. V20 stated we helped pull R7 up in bed and then V21 got R7's O2 saturation and started assessing her. V20 stated the call light was on at that time but did not know how long it had been on since he was not working on that hall. R7's Progress Note dated 4/22/2026 at11:49 PM documents Res tearful this evening. Roommate called facility phone stating R7 having trouble breathing. Upon assessment res tearful, Resp even and unlabored. Res pulled up in bed and (head of bed) HOB elevated. R7 calm and states she feels better after being pulled up in bed.The Facility's Resident Council minutes dated 1/14/26 documents Follow-up to concerns from last meeting: call light wait time.The Facility's Resident Council minutes dated 2/11/2026 documents Follow-up to concerns from last meeting: call light wait time. Nursing: call light.The Facility's Grievance/Concern/Complaint Form dated 2/11/26 documents call lights not being answered in a timely manner. The Facility's Undated Timeliness of Care Policy (Long-Term Care) Policy Standard of Timeliness: Response to Call Lights/Requests-Immediate acknowledgement: within 1-3 minutes. In-person response: within 5-10 minutes. Urgent requests (pain, toileting, distress): priority response (less than or equal to 5 minutes) Toileting & Activities of Daily Living (ADL) Assistance-Unscheduled requests: within 5-10 minutes.The Facility's Answering the Call Light Policy Revised July 2014 documents Answer the resident's call as soon as possible.

Based on observation, interview and record review, the Facility failed to provide food in a form to meet needs for 1 of 1 residents (R39) reviewed for nutritional services in the sample of 34.Findings include: 1-R39's Face Sheet documents R39 was admitted to the facility on [DATE]. R39's Diet Order dated 11/14/25 documents pureed diet. R39's Breakfast Meal Ticket dated 4/22/26 documents R39 is on a pureed diet. On 4/22/26 at 8:03 AM, V11, Dietary Manager, placed a bowl of regular oatmeal on the tray with R39's meal ticket. On 4/22/26 at 8:13 AM, V11 stated they have always given regular oatmeal to the pureed diets. On 4/22/26 at 8:18 AM, V11 stated she checked the pureed recipe and the oatmeal is supposed to be broken down with liquid added, so she will inform her staff of that. On 4/23/26 at 11:01 AM, V19, Registered Dietitian (RD), stated she would defer all questions to the menu spreadsheets to ensure diets are followed correctly. The Facility's Pureed Breakfast Menu for 4/22/26 documents the hot cereal is pureed. On 4/23/26 at 3:10 PM, V1, Administrator, stated she expects the Facility to follow its approved menus and follow recipes. The Facility's Consistency Modified Diets Policy revised December 2024 documents the pureed diet consists of pureed, homogenous, and cohesive foods, and foods should be pudding-like. Any foods that require mastication are excluded.

Based on interview and record review the facility failed to develop and implement protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic for 2 of 4 (R28, R37) residents investigated for infection control in a sample of 30.Findings include:1.R28's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R28's MDS (Minimum Data Set) dated 3/28/26 documents that the resident is rarely/never understood and unable to provide a BIMS (Brief Interview for Mental Status. The MDS documents that the resident is dependent for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident is always incontinent of bladder.R28's ER (Emergency Room) paperwork dated 1/22/26 does not document a culture and sensitivity report for her UTI (urinary tract infection).R28's Physician Order dated 1/23/26 documents cefdinir 300 mg capsule Every 12 Hours.R28's Progress Note dated 1/23/26 at 10:13 AM documents Patient had ER visit 1/22/2026. Returned with orders for ABT (antibiotic) to treat UTI. Patient was up for breakfast this morning, ate well. No complaints noted.2.R37's EMR undated documents that the resident was admitted to the facility on [DATE].R37's MDS dated [DATE] documents that the resident is rarely/never understood and unable to provide a BIMS. The MDS documents that the resident requires partial/moderate assistance for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident is occasionally incontinent of bladder.R37's Urine Culture dated 2/18/26 documents Final report: 20,000 - 30,000 cfu/mL (colony-forming unit/milliliter) Yeast.R37's ER paperwork dated 2/20/26 documents UA with possible UTI, urine culture pending. -continue Cefdinir x 4 days. No Urine Culture noted in the ER paperwork.R37's Physician Order dated 2/23/26 documents Cefdinir 300 MG Capsule; TAKE 1 CAPSULE BY MOUTH TWICE DAILY X 4 DAYS (DX: UTI).On 4/24/26 at 9:26 AM, V2, DON (Director of Nursing) stated that most of the time the ER with send the culture back with resident if the resident is diagnosed with a UTI.Facility's Antibiotic Stewardship - Review and Surveillance Antibiotic Use and Outcomes policy dated October 2017 documents Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (1) the organism is not susceptible to antibiotic chosen; (2) the organism is susceptible to narrower spectrum antibiotics; (4) Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics.

Based on interviews, observations, and record reviews the facility failed to evaluate, implement and monitor effectiveness of fall interventions to prevent falls for 1 out of 3 residents (R2); reviewed for accident hazards/supervision/devices in a sample of 4. This failure resulted in R2 sustaining depressed skull, orbital, maxillary and temporal fractures, a scalp laceration, a subdural hematoma, a subarachnoid hematoma and an intraparenchymal hematoma of the brain. Findings include:R2's Face Sheet documented she was admitted to the facility on [DATE] and was discharged on [DATE] with diagnosis of, in part, dementia with agitation, history of falling, hypothyroidism, and anxiety disorder.R2's Minimum Data Set (MDS) dated [DATE] documented she was rarely/never understood and her cognitive skills were severely impaired. It continued to document that R2 required the use of a wheelchair, substantial/maximal assistance from staff to stand, and partial/moderate assistance to sit up on the side of the bed from a lying position.R2's Care Plan started on [DATE] documented she was at risk for injuries related to history of falls secondary to unsteady gait and the interventions added to this care plan included: ([DATE]) use proper assistive device wheelchair/walker as needed, rest periods as needed, proper footwear as indicated, invite/escort to activities of choice as tolerated as desired, cues/redirect as needed, clutter free environment, call light within reach while in room and remind resident to call for assistance as needed; ([DATE]) staff will have the tv on when she is laid down in bed; ([DATE]) bed/chair alarm placed on residents bed and wheelchair, however, this was already care planned on [DATE] in a separate care plan; and ([DATE]) staff will place bed in lowest position and place a fall mat beside the residents bed.R2's Progress Note from her admission date on [DATE] at 8:00 PM, documented R2 was at the facility for reoccurring falls. R2's Fall Risk Assessments dated [DATE], [DATE], [DATE] and [DATE] all documented she was a high fall risk.The facility's Fall Report documented R2 fell on [DATE], [DATE] and [DATE].The facility's Fall Investigation Report dated [DATE] documented R2 received an injury to her head, and the root cause was R2 wanting to watch tv (television) and that staff will have the tv on when R2 is laid down in bed. The report also included a progress note dated [DATE] documenting R2 had an alarm in place to her wheelchair. The facility's Fall Investigation Report dated [DATE] documented R2 received an injury to her head and arm then sent to the ER (emergency room). The report documented the root cause was R2 trying to stand and for bed/chair alarm to be placed on her bed and wheelchair. The report documented a progress note stating R2 had been sitting in her wheelchair with seatbelt on and had a contusion to her head that was bleeding out onto the floor. The report concluded that R2 was evaluated at the ER, scans were normal, and she sustained a contusion to her head. The facility's Fall Investigation Report dated [DATE] documented R2 had an injury to her head and was bleeding. The report documented the root cause of R2's fall was attempting to get out of bed without assistance and that staff will place bed in lowest position with fall mat beside it. The facility's Investigation Narrative Summary initiated on [DATE] documented V5 certified nursing assistant (CNA) and V6 (CNA) put R2 in her bed from 1:45-1:50 PM. At 1:50 PM, V3 (CNA) walked down the hall and saw R2 lying on her left side on the floor with a puddle of blood under her head, 911 was called and EMS (emergency medical services) arrived at 2:00 PM. All responsible parties were notified. On [DATE] the facility was informed that R2 had expired at the hospital on [DATE]. On [DATE] at 2:16 PM, V1 (Administrator) and V2 (Director of nursing/DON) presented video footage of R2's hallway prior to, during and after her fall on [DATE]. The facility's video footage documented the following: on [DATE] at 12:45 PM, V5 (CNA) wheeled R2 into her room. At 12:47 PM, V6 entered R2's room also. At 12:53 PM, V5 exited R2's room and seconds later V6 (CNA) exited. At 1:10 PM, V10 (Activities Director) entered R2's room and exited at 1:11 PM. At 1:43 PM, V3 (CNA) walked by R2's room and then entered it; V1 stated this was when R2 was found after falling.R2's Emergency Department Records dated [DATE] documented R2's assessment/plan included: fall, scalp laceration, depressed skull fracture, orbital fracture, subdural hematoma, subarachnoid hematoma, intraparenchymal hematoma of brain, maxillary fracture and temporal bone fracture. R2's Intensive Care Hospital Note dated [DATE] documented, admitted with severe TBI (Traumatic Brain Injury) and altered mental status superimposed on chronic neurocognitive disorder. Concern for impending uncal herniation syndrome. After discussion with family, transitioned to comfort-oriented care.On [DATE] at 11:27 AM, V8 (ER Nurse) stated R2 presented to her emergency department with an abrasion to her forehead, her nose was bleeding, both eyes swollen and purple from bruising. V8 stated the facility claimed R2 was found lying on the ground in her blood from falling out of her bed but the paramedics said her bed was in the lowest position. V8 stated the extent of R2's injuries does not match up with falling from a short distance. V8 stated R2 was flown to a larger hospital to get more care because they couldn't close up the laceration and she had a brain bleed, skull fracture and orbital fracture. On [DATE] at 8:25 AM, V3 (CNA) stated she saw R2 on the floor the day she fell. V3 stated she was walking by her room and just noticed her in a puddle of blood. V3 stated it looked like R2 was trying to get out of bed without assistance which was common for her to do. V3 stated R2 had alarms on her chair and bed but they weren't going off when she fell. V3 stated R2 did have a fall mat and when she is in her wheelchair a lap belt is used. V3 stated R2's bed was in low position, and she was a high fall risk. V3 stated stars are placed by resident names outside their doors to indicate they are high fall risk also.On [DATE] at 8:55 AM, R2's room did not have a star next to her name.On [DATE] at 8:58 AM, V4 (Registered Nurse/RN) stated R2 was mostly confused, sometimes combative and was able to scoot herself around in her wheelchair. V4 stated R2 would sometimes use her call light or yell out if she needed something. V4 stated R2 was a high fall risk, and she could not get herself out of bed safely. V4 stated R2 had a belt to wear in her wheelchair too.On [DATE] at 10:39 AM, V2 (DON) stated when R2 fell, she heard the CNA yelling and when she got to the room R2 was on the floor. V2 stated she got down on the floor and assessed R2 who was responding to her appropriately and admitted she fell. V2 stated R2 was on her left side with half her body on the fall mat, the upper half on the floor. V2 stated the bed alarm was still on R2's bed but R2 would turn it off. V2 stated they had the fall mat and bed in low position care planned for her falls. V2 stated the bed alarm was not going off at the time.On [DATE] at 11:37 AM, V5 (CNA) stated she took care of R2 the day she fell, and she was acting like her normal self. V5 stated R2 was getting tired, so she took her back to her room to lay down and cleaned her up too. V5 stated she put R2's bed alarm in place and she had her fall mat. V5 stated before she left R2's room, she had her eyes closed and looked like she was falling asleep. V5 stated 3-5 minutes later she heard another CNA yelling after finding R2 on the ground. V5 stated R2 liked to get up without assist and she'd fallen in the hallway once prior from her wheelchair. V5 stated after her fall in the wheelchair a belt was added for R2 to wear, and she always had a wheelchair alarm. V5 stated she would take R2 on walks or keep her in front of the nurse's station for distraction and supervision. V5 stated R2 would let them know typically if she needed something. V5 stated after R2 fell she saw blood on the floor and her face.On [DATE] at 12:03 PM, V6 (CNA) while in R2's room, stated after lunch R2 was laid down right away, she was cleaned and in bed with her alarm and fall mat in place along with her call light in reach. V6 stated it was 2-3 minutes after she'd left the room before she heard screaming. V6 stated when she responded to R2's room after she fell, R2 was not on the fall mat. V6 stated R2 must have wiggled herself to the foot of her bed to get out of it. V6 stated R2's bed was in the lowest position. V6 stated R2's bed legs were approximately a foot elevated from the floor at the lowest. R2's bed was approximately 12 inches above the ground, not including her mattress and the floor was tile. V6 stated R2 was completely out of range of the fall mat from where she fell. V6 stated R2 doesn't remember she can't walk by herself and was forgetful. V6 stated when R2 fell, the bed alarm was not going off, but it was in place. V6 stated they would keep R2 up at the nurse's station for more supervision because she was constantly trying to get up. V6 stated R2's hall is the heaviest hall with multiple fall risk residents on it.On [DATE] at 1:18 PM, V7 (Paramedic) stated he responded to R2's fall. V7 stated when he entered R2's room, her bed was closest to the door and to the right side with the foot of her bed to the right of the doorway. V7 stated R2 was lying on her left side and had a lot of blood on her, she was moaning and had purposeful movements with her eyes open but was not speaking. V7 stated he thinks R2's bed was in a lower setting and couldn't remember if there was a fall mat or not, but no alarms were going off when he arrived. V7 stated R2 was actively bleeding, and her hair was saturated with blood. V7 stated they had to use a blanket to pick her up off the floor. On [DATE] at 1:42 PM, V5 (CNA) stated R2 did not have her television on [DATE] after she laid her down for her nap, she was too tired.On [DATE] at 1:43 PM, V6 (CNA) stated R2 didn't have tv on after lunch on [DATE], she was tired.On [DATE] at 12:33 PM, V3 (CNA) stated R2 did not have the tv on in her room on [DATE] when she found her, there was a light on, and she was wearing non-slip socks.On [DATE] at 1:44 PM, V9 (Care Plan Coordinator/RN) stated she created R2's care plan putting in an original plan for falls and updating it with every fall after. V9 stated R2 had a self-release belt as a fall intervention that should have been added at the same time her bed and chair alarms were, but she couldn't see it was actually added. V9 stated she and V2 follow up on the effectiveness of the interventions. V9 stated R2 knew how to turn the bed/chair alarms off, she would grab the box and turn it off. V9 stated the belt was typically, effective for R2 and while in bed having the tv on was important for distraction because there weren't any eyes on her in there and the belt was only for her wheelchair. V9 stated R2 would be placed by the nurse's station, along with things to keep her distracted like snacks. V9 stated when R2 fell, half of her body was on the fall mat and the upper half was on the floor. V9 stated R2 also had a side rail on her bed to help her with rolling.On [DATE] at 12:36 PM, V10 (Activities Director) stated she had gone into R2's room to pass out activities information but she appeared to be sleeping having her eyes closed on [DATE]. V10 stated she couldn't recall if R2's roommate was in the room at the time or if the tv was on or not. V10 stated R2 liked to color and would attend activities a lot. V10 stated she wasn't sure if R2 could turn her alarms off or not. V10 stated R2 was initially irritable when she admitted and didn't like to be alone but eventually, she was content with being in her wheelchair. V10 stated R2 had been spending too much time in bed.On [DATE] at 10:10 AM, V2 (DON) stated R2 would turn her bed alarm off, she did that a lot. V2 stated we didn't have this documented, but we were doing 15-minute checks on R2 while she was ever in bed, she was the only one we had to do that on, otherwise we would have her more supervised and up at the nurse's station. V2 stated R2's only major health concern was that she didn't have fingers or toes, so we wanted to keep her safe. V2 stated the bed alarm was not an effective intervention for R2, the alarm was only effective when used in her wheelchair. V2 stated in agreement that R2 already had use of bed and chair alarms in place prior to her fall [DATE], it would not have been a new intervention. V2 stated in agreement that R2's bed had already been put in low position with a fall mat in place prior to her fall on [DATE] and that it wasn't added to her care plan interventions until after the fall. V2 stated maybe they could have put the alarm box inside R2's bedside table to keep her from turning it off.On [DATE] at 11:50 AM, V11 (Medical Director) stated his main concern for R2 was preventing falls. V11 stated he hadn't seen R2 yet but was scheduled to see her this month. V11 stated in his clinical expertise, a TSH (thyrotropin) level of 34 and having hypothyroidism would not have an effect on the risk of falls. V11 stated he would expect staff to be following the fall risk care plan interventions if they were able to do so. V11 stated he would expect interventions to be progressive and resident centered, if R2 was able to turn off the alarm, he would expect the facility to attempt to prevent her from being able to do so by hiding it. V11 stated if the fall risk interventions were not being followed and they were previously working, it could pose a higher risk for R2 to fall.On [DATE] at 2:18 PM, V2 (DON) stated the facility did not have an alarm policy but they did have guidelines for Personal Alarms. The Personal Alarms guidelines (undated) documented bed exit alarms are often used as an intervention for fall reduction programs, but they are not always used effectively. It continued to document it is important that when placing an alarm to consider many reports describe patients deliberately deactivating their alarms and may not be appropriate.The facility's Falls Management Policy dated [DATE] documented it is the policy of the facility to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions.

The facility failed to ensure its door alarms were loud enough to be heard from areas away from the 200 hall exit door and its outside gait latch was in working order to prevent elopement in 1 of 4 residents (R2) reviewed for elopement in the sample of 4. This led to R2 eloping from the facility, which is located on a busy intersection and approximately 100 yards from an active railroad track. The Immediate Jeopardy began on 8/22/25, when R2 eloped from the facility. On 9/16/25 at 10:45 AM, V1, Administrator, and V2, DON, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 9/16/25 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include:On 9/16/25 at 8:20 AM, this surveyor went to the 100/300 nurse's station and V7 activated the 200-hall door alarm, it could not be heard from the 100/300 hall nurse's station until approximately 20 feet down the 200 hallway, and when it was heard, the surveyor was unable to discern what type of alarm it was. On 9/16/25 at 8:00 AM, 8:20 AM, and 8:29 AM, there were no staff observed at the 200 hall nurses' station next to the 200-hall exit door. There was only one therapy staff in the building, and she was at the front of the building in the main dining room, not near the 200-hall exit door or the 200-hall nurses' station. R2's Progress Note, dated 8/22/25 at 7:16 PM, documents the following: Writer and (V3, R2's Son) were down 300 hall looking for patient as another resident told us she had come past desk and went down 300. Room search did not come up with patient. As writer and son rounded 100/300 nurses' desk, writer heard alarm going off from 200/400. (V3), writer, and (V6, CNA (Certified Nursing Assistant) started running. Writer and (V3) went out 200-hall door, (V6) went to 400 south to search for patient. Writer searched courtyard, to the outside of fence to front parking lot not locating resident. When writer entered front door, nursing staff was calling writer STAT to 200/400 hall doors. Another patient's family member stated they saw resident behind the building walking down the street. Writer, (V3), and 2 CNA staff took off running to patient. Samaritan was standing with patient. (V3) got truck from parking lot and drove over. (V3) and writer picked patient up and placed in passenger seat of truck. DON notified. POA (Power of Attorney) present. Full body check done. Patient has no open areas or areas of concern.R2's Progress Note, dated 9/3/25 at 2:32 PM, documents the following: This nurse spoke to (V3), who stated he was going to discharge his mother home to his house on 9/5/25. (V3) stated he feels that if he takes her home, she would be safer, and he wouldn't have to worry about her. (V3) stated he didn't feel safe with the facilities back fence being open. I let (V3) know I understand, and we would do what we could to make the transition for this resident to go home as successful as possible.R2's Progress Note, dated 9/5/25 at 2:22 PM, documents the following: (V3) and his wife in building to discharge patient home. Medications and treatment order gone over with POA, he understood. Orders printed individually for POA to take to pharmacy to fill. Medications were sent with patient, including Nystatin powder. POA wants patient to continue to see (V10, R2's Physician). Phone number was provided. Discharge instructions were gone over and POA understood. All belongings sent with patient.R2's MDS (Minimum Data Set), 7/9/25, documents R2 has severe cognitive impairment and ambulates with supervision.R2's Care Plan, dated 8/22/25, documents the following: Resident got out of the facility via 200-hall door. Staff placed resident on 15-minute checks. Starting 8/25/25, resident placed on 30-minute checks. R2's Elopement Assessment, dated 8/22/25, documents R2 is ambulatory, independent with wheelchair mobility, has cognitive impairment, and a history of wandering - elopement care plan initiated. R2's Elopement Investigation, dated 8/22/25 at 7:35 PM, documents the following: Patient got out the 200-hall door. Patient was found by another patient's family member on the street behind the facility. No behaviors prior to elopement. No changes in mental status. Contributing factors - Alzheimer's Disease, Dementia. No mood indicators present. Recent event, trauma, new diagnosis or other stressors/losses. Recent change in medications or new medications added. Abnormal lab values in the past 30 days. Immediate intervention - 15-minute checks. Interventions effective.The Final Report to IDPH (Illinois Department of Public Health), dated 8/22/25, documents the following: On 8/22/25, R2 exited the facility without staff knowledge while her son was visiting in the building. Staff immediately initiated the elopement protocol, and the resident was located nearby and safely returned to the facility without injury. The resident was assessed by nursing staff, family and Physician were notified, the care plan was updated, staff were re-educated on elopement prevention, door/alarm systems were verified to be functioning. Resident remains safe in the facility with enhanced monitoring in place. On 9/12/25 at 11:20 AM, V3, R2's Son, stated on that Friday 8/22/25, he had come to the facility to pick up R2's laundry, he saw R2 in the hallway, he went into her room, gathered her laundry and changed her bedding. V3 stated when he came out of R2's room he did not see her. V3 stated he went out and put R2's clothes in his truck and came back inside the facility. V3 stated he asked V4, LPN (Licensed Practical Nurse), where R2 was, they looked for her but could not find her. V3 stated he was going to the nurse's station by the door R2 exited out of and heard the alarm screaming. V3 stated the alarm could not be heard from the 100/300 hall nurse's station until he came closer to the 200-hall door exit. V3 stated he and V4 went outside to the fenced in courtyard and did not see her. A young lady called and stated the facility had a patient out on the road behind the facility. V3 stated they went to that area and R2 was standing in the road in front of a vehicle, where two ladies were with R2. V3 stated he tried to get R2 to walk back to the facility, but she was so weak, he had to go and get his truck from the parking lot, drive it to where R2 was and physically place her in the truck. V3 stated the gate to the fenced in area outside the 200-hall door was not locked or latched. V3 stated when he asked about this, he was told that they could not lock/latch it because it was illegal due to it preventing residents from exiting in the event of a fire. V3 stated he had decided at that time to take R2 home to live with him, they had several care concerns, and this just placed it over the top. V3 stated prior to R2 getting out of the building she was in the hospital with a UTI (Urinary Tract Infection) and was very weak. V3 stated since R2 had been at home with him and his wife, her skin has cleared up and she is doing great. V3 stated he believes R2 had tried to go out with the smokers before and they put one of them ankle bracelets on her.On 9/12/25 at 1:10 PM, V2, DON, stated V3 was at the facility visiting R2 and was gathering her dirty laundry. V2 stated V3 took R2's clothes out to his truck in the parking lot, came back to R2's room and she was not in her room. V2 stated V3 notified V4, and a resident stated she had just seen R2 on the 300 hallway, so they were headed down that hallway, then they heard the 200 hall exit door alarm sounding so they went to that door, looked outside and didn't see anyone. V2 stated V3 and V4 then went out the courtyard gait outside the 200 hall exit door, to the left towards the front of the building, didn't see her. V2 stated a family member told them she was at the back of the facility. V2 stated they found her at the back of the facility, R2 couldn't make it back into the building so V3 got his truck and drove her back to the facility. V2 stated R2 was being treated for a UTI at the time she eloped. V2 stated it was determined that it was approximately 3 minutes from the time R2 was missing, until she was found. V2 stated R2 did not have any injuries. V2 stated R2 was normally confused but hadn't exited or attempted to exit the building prior to 8/22/25, that she is aware of. V2 denied concerns with the alarms, she can hear it from her office, which is located across from the 100/300 hall nurse's station. V2 stated the latch to the courtyard gait off of the 200 hall exit door was broken and has been fixed. V2 stated V3 asked her why it wasn't latched, and she told him because they weren't required to.On 9/12/25 at 2:08 PM, V4, LPN, stated R2 had been in the hospital, was weak, and was using her wheelchair. V4 stated the morning of 8/22/25, R2 was doing much better, she was using her walker and going to activities. V4 stated she had just finished her evening med pass, unsure of exact time, and V3 had come into the facility and stopped at the 100/300 hall nurse's station where she was and they were talking about how well R2 was doing, V3 stated they talked about 2-3 minutes as they were walking down the 200 hall towards R2's room with R2 walking in front of them. V2 stated V3 went into R2's room, did his thing, getting R2's laundry/linen. V3 then came out of R2's room and said, I guess mom disappeared on me. At that same time there was a resident sitting there and said R2 had just headed down the 300 hall, so V3 and V4, went to the 300 hall, searched every room, the dining room and were heading back towards the 200 hallway and when they reached a little ways down the 200 hall where the ice machine is, they started to hear an alarm but couldn't tell where it was coming from. V4 stated the alarm was not sounding normally, it wasn't loud at all, and she couldn't hear it until she got closer to the 200-hall door exit. V4 stated V3 was with her the entire time. On their way to the 200-hall door, V6, CNA, was on the hallway passing out meal trays, V4 told V6, R2 was missing and instructed her to go down the 400 hallway and then outside that door to search. V4 stated she and V3 went out and searched the courtyard along the fence line heading towards the front parking lot, front of the facility, they made it to the front entrance and as they were coming back into the facility, she heard staffing paging her over the intercom and she was told a family member stated R2 was on the street behind the facility. When V3 and V4 got to R2, she was with V6, a bystander and there was a USPS van that had pulled into the street to block any traffic from getting through. V4 stated R2 had not made any attempts to exit prior to that. V4 stated R2 would make comments that her car was out in the parking lot, and she needed to go to it and they would tell her, V3 has your car and R2 would say okay but would never try to exit the building or go towards the doors. V4 stated she is not sure how long the 200 hall exit door alarm was sounding because she couldn't hear it from the 100/300 hall nurses' station until she went down the 200 hall, it was not sounding loud enough to hear it. V4 stated she isn't sure how long it was from when R2 was missing until she was found. On 9/16/25 at 8:20 AM, V7, Maintenance Director, stated the 200-hall door alarm was acting up yesterday 9/15/25 and it had to be reset, but is working fine now. V7 stated they are changing the door alarms to an audible voice instead of a beeping noise that will state over the intercom which door alarm is sounding. V7 thinks this is to be installed next week. V7 stated he tests the alarms routinely and denied any problems with them. On 9/16/25 at 8:25 AM, V1, Administrator, acknowledged that the 200-hall door alarm could not be heard from the 100/300 hall nurse's station. V1 stated they have a nurse stationed at the 200 hall nurses' station at all times, so the alarm can be heard. V1 stated if the nurse isn't at the 200 hall nurses' station, they have therapy control it, the department managers do rounds, and the CNAs should be cautious and aware. V1 stated there isn't a lot of time in between when staff aren't there. On 9/16/25 at 1:33 PM, V10, R2's Physician, stated R2 is confused and has Alzheimer's Disease, the plan would not be to have her outside by herself. V10 stated V3 was at the facility and then went outside, so this could have caused R2 to go searching for V3. V10 stated R2 was found and returned to the facility pretty quickly.The Elopement Prevention Policy, dated 5/16/24, documents the following: It is the policy of this facility to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. A licensed nurse will complete the Elopement Risk Assessment upon admission to the facility. An interim plan of care for minimizing the risk for elopement will be initiated upon the risk determination. Revision of the Elopement Risk Assessment will be completed quarterly, upon a resident's significant change of condition, when elopement behaviors occur and as needed, determined by the IDT (Interdisciplinary Team). The Immediate Jeopardy that began on 8/22/25 was removed on 9/16/25, when the facility took the following actions to remove the immediacy:IMMEDIATE JEOPARDY REMOVAL OF IMMEDIACY PLANDeficiency Summary:The facility failed to ensure door alarms were loud enough to be heard from nursing stations and failed to ensure the exit gate latch was in working order to prevent elopement. This resulted in R2, with a diagnosis of Alzheimer's Disease, eloping from the facility and being found in the roadway, creating risk for serious harm.1. Corrective Action for Residents Affected R2 was immediately returned safely to the facility and assessed for injury by nursing staff; no injuries were noted. Completed on 8/22/2025 V4, LPN. Thorough body assessment completed for any injury 8/22/2025 V4, LPN. The physician and family were notified immediately of the incident. 8/22/2025 V4, LPN. All door alarms were checked 8/22/2025 V4, LPN and 9/16/2025 V7, Maintenance Director. All facility gates were checked 8/22/2025 V4, LPN and 9/16/2025 V7, Maintenance Director. Door alarms checked by outside vendor All components for the door monitor voice announcement system ordered on August 28th. 2. Identification of Other Residents at Risk Elopement observations for residents at risk were completed: care plans reviewed and if updated if needed. 9/16/2025 V2, DON. All exit doors and alarms were tested for sound, function, and audibility from all nursing stations; any malfunctioning or inaudible alarms were immediately ordered to be repaired or replaced. 9/16/2025 V7, Maintenance Director. All exterior gate latches were inspected and repaired to ensure secure closure. 8/26/2025 V7, Maintenance Director.3. Systemic Changes to Prevent Recurrence Staff will be positioned by the door alarm until scheduled maintenance is completed. All components for the door monitor voice announcement system are assembled, programmed, and ready to install. This will be interconnected to the 200/400 Patio door to this new system. The installation of this system is scheduled for tomorrow, September 17. A policy review of missing residents completed without any changes 9/16/2025 V1, Administrator Policy review on elopement policy without any revision 9/16/2025 V1 Administrator A policy review of door alarm policy reviewed without any revision 9/16/2025 V1, Administrator Education provided to all staff (nursing, maintenance, ancillary staff) on elopement policy, missing resident policy and door alarm policy on 9/16/2025, including response procedures when an alarm sounds. V2, DON, V1, Administrator and V15, Dietary Manager.4. Monitoring to Ensure Compliance Administrator or designee will conduct weekly audits of door alarm function and audibility for four weeks, then monthly for three months. Maintenance Director will maintain daily door alarm checks when on duty Results will be reported monthly to the QAPI committee for review and ongoing oversight. Any alarm malfunction identified will result in immediate repair and staff re-education if necessary.5. Completion Date All corrective actions will be completed 9/16/2025

Based on interview and record review, the facility failed to ensure its courtyard gait latch was in proper working order when reviewing for mechanical equipment in working order. This failure has the potential to affect all 50 residents residing in the facility.Findings Include:On 9/12/25 at 11:20 AM, V3, R2's Son, stated on that Friday 8/22/25, R2 had exited the facility without staff and he and V4, LPN (Licensed Practical Nurse) went outside to the fenced in courtyard and did not see her. A young lady called and stated the facility had a patient out on the road behind the facility. V3 stated the courtyard gate to the fenced in area outside the 200-hall door was not locked or latched. V3 stated when he asked about this, he was told that they could not lock/latch it because it was illegal because it could prevent residents from exiting in the event of a fire. V3 stated he had decided at that time to take R2 home to live with him, they had several care concerns and this just placed it over the top. On 9/12/25 at 1:10 PM, V2, DON (Director of Nurses), stated the latch to the gait off of the 200-hall exit door was broken and has been fixed. V2 stated V3 asked her why it wasn't latched, and she told him because they weren't required to.R2's Progress Note, dated 9/3/25 at 2:32 PM, documents the following: This nurse spoke to (V3), and he stated he was going to discharge his mother home to his house on 9/5/25. (V3) stated he feels that if he takes her home, she would be safer, and he wouldn't have to worry about her. (V3) stated he didn't feel safe with the facilities back fence being open.The Safety and Supervision of Residents Policy, dated 12/31/25, documents the following: Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified in an ongoing basis through a combination of employee training, employee monitoring, and reporting processes, reviews of safety and incident/accident report, and a facility-wide commitment to safety at all levels of the organization.The Resident Census Report, dated 9/12/25, documents there are 50 residents residing in the facility.

Based on Interview, and Record Review the facility failed to timely report and treat a change in condition for 1 (R3) of 3 residents reviewed for change in condition in the sample of 5. This resulted in R3 experiencing an increase in pain and not being seen by a physician and diagnosed with a pubic fracture for 8 days. Findings include: R3's admission Record, not dated, documents an admission date of 10/28/2022. Diagnosis include Displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, Emphysema, Aneurysm of the Descending Thoracic Aorta, Dementia, Tremors. R3's Minimum Data Set, dated [DATE], documents R3 is severely cognitively impaired. R3 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R3's Care Plan updated 5/8/2025, documents Problem: R3 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, iron deficiency anemia, and poor safety awareness related to a BIMS of 8, up ad lib in facility with walker. Falls 7/20/23, 09/27/2023, 12/1/23, 12/19/24, 12/23/24,1/3/25, 2/18/25, 3/13/25 and 3/31/25. Interventions include: Staff to toilet resident every 2 hours and as needed. (R3) has an alarm which sounds reminding resident not to stand without assist and staff aware (R3) is standing and to provide assistance. R3 to wear no skid socks to bed to prevent sliding on the mat when getting out of bed. Encourage R3 to take frequent rest periods and staff to provide stand by assist when ambulating with walker. Encourage R3 to utilize walker when ambulating. R3 struggles with her sleep pattern, medication review for any changes. Attempt to keep bathroom light on and leave bathroom door open. Place R3 in common areas for increased supervision. Therapy to evaluate and treat for strengthening and balance. Approach: engage in activities when noted wandering to prevent further falls. Approach: educate staff on R3's need for increased assistance at times. Place on Walk to Dine program. Approach: Clock place in R3's room to show the R3 what time it is. Approach: Staff to have a discussion with daughter regarding hip protectors and a helmet. Approach: Night light placed in resident's room to assist with vision during night hours. (R3) Care Plan documents Problem: R3 is cognitively impaired related to unspecified dementia, mild, with anxiety, unspecified abnormalities of gait and mobility, Muscle weakness (generalized). Interventions include Approach: Simple YES/NO questions and commands Approach: Allow ample time for resident to respond. R3's Incident Report, dated 3/13/2025 at 11:30 AM documents that R3 had fall in the hallway causing a laceration to R3's left 5th finger, and unwitnessed fall 3/30/2025. R3's Progress note, dated 03/13/2025 at 11:30 AM, documents Res sitting in w/c at nurses station; res stood up on own and immediately fell. Res landed on right side. Fall was witnessed by staff member who was down the hall and tried to get to resident but could not reach her in time. Staff member states res did not hit her head. Res denies pain with ROM to all extremities. Res assisted into wheelchair with assist of gait belt and two CNA's. Res has a small laceration to top and towards medial aspect of left fifth finger. It measures 1.8 cm l x 0.2 cm w. Area cleansed, steri-stripped and dry dressing applied. Res states finger hurts. VSS (vital signs). R3's progress Notes, dated 03/13/2025 at 11:46 AM, documents (V8), Physician, informed of res fall landing on right side; sustained a laceration to top left fifth finger which was cleansed, steri-stripped and covered with a dry dressing. VSS. 1226: New orders received for x-ray of left hand and wrist. Daughter (V9) called and informed of new orders. R3's Progress Note, dated 3/13/2025 at 11:12 PM Resident receiving therapy services for generalized weakness and fatigue following L (left) hip fx (fracture). Resident afebrile and has c/o pain or discomfort this shift. Resident is TTWB (toe touch weight bearing) and noncompliant due to dementia. All meds taken whole. Fluids offered and encouraged. Resident transfers with a 1 assist and requires assistance with ADLs. On f/u (follow up) post fall today. No changes in LOC. Family notified of x-ray results. Asked to see report tomorrow. Hearing aides are locked in top of nurse cart. Resident lying in bed asleep at this time with bed lowest position and call light in reach. R3's Progress Note, dated 03/18/2025 at 10:01 PM Resident's daughter states that since the last fall, her mother has c/o right hip pain when she transfers, sits, or stands. I told her we could order a right hip x-ray, and she states she wants to wait another night to see if it improves. She also states resident has an ortho appointment about the left hip fracture, and maybe she can get them to x-ray her right hip as well. R3's Progress Notes, dated 03/21/2025 at 4:04 PM Patient returned from appointment with (V15), daughter here reporting to this nurse that patient has right hip fracture. DON and admin made aware. Dr office is faxing paperwork from visit. R3's Orthopedic Office Clinical Notes, dated 3/21/2025, documents that Chief Complaint: 3-month status post left hip fracture, daughter with patient today and states she is having pain in right side today and not showing signs of left side being painful anymore. fell on right side 8 days ago. History of present Illness: 8 days ago, she had a fall, falling backward landing on buttock and right hip. Since then, she complains of pain along the lateral aspect of the right hip as well as in the gluteal fold of the right buttock. She has discomfort with lowering down to a seated position and has increased pain especially when seated on a firm surface such as a toilet seat. She denies any increased groin or anterior thigh discomfort but does not lateral hip pain. Physical Exam: She has stiffness with passive internal and external rotation. There is lateral hip soreness to palpation and stiffness to passive range of motion of the right knee. She is neurovascularly intact in the right lower extremity. There is some discomfort with resisted hip extension and some mild discomfort with passive hip flexion. Assessment/Plan: 1 Inferior pubic ramus fracture. Xray of the right hip may indicated nondisplaced inferior pubic ramus fracture. We would like her to be protective weight bearing that she does. She may require an additional person for assist to minimize fall risk and she would be at risk for worsening fracture position if she has another trauma. May benefit from use of donut type cushion to offload some weight from the ischial tuberosity when seated. Avoidance of low chairs can be helpful to can be helpful to minimize stress to this area and the use of a high-rise commode may be a benefit to her to minimize symptoms as well. R3's Progress Notes, dated 03/22/2025 at 9:51 PM Resident was up before dinner, and then family here and took resident to her room after dinner. She did try to stand a few times but was redirected. She has a left hip fracture and a right hip fracture. No c/o pain as long as she is sitting. She receives scheduled Tylenol for pain at 4PM. R3's Progress Note, dated 03/24/2025 at 7:45 AM, documents that Report received of results of right and left hip x-ray done while at (V15) on 3/21/25 which shows no new fracture of either hip. Also states on right hip x-ray-status post right hip intramedullary rod and dynamic hip screw fixation across the intertrochanteric femur fracture-hardware appears well positioned without failure or complications. On left hip x-ray also states unchanged position of a mildly displaced greater trochanter fracture. R3's Progress Note, 03/27/2025 at 4:55 AM, documents that resident has been up all night sitting at the nurse's station with her chair alarm in place. Continues to try to stand up and self-transfer. PRN Tylenol given as resident seems uncomfortable. Staff with multiple attempts to redirect. Currently sitting in w/c at nurse's station. R3's 03/31/2025 at 2:53 AM At 0000, after hearing a noise down the hall, staff found resident sitting on her bottom on the floor between her bed and the wall with her back and head resting against the wall and her legs up on the bed. She was moaning saying her head was hurting and rubbing her right thigh with her hand. There was a little redness to the back of her head, but no open skin noted. Writer attempted to complete neuro assessments, but resident wouldn't open eyes and is HO so unable to respond to verbal commands. Initial BP was 154/86. Pulse 63. Temp 97.7.96% on RA. Resp (respirations) 20. Resident assisted back into bed. For approximately 5-10 seconds, resident's whole body started shaking. Staff continued obtaining vitals and stayed by resident's side while writer called daughter/POA (0020) and 911 (0026). Resident left via EMS at approximately 0045. Face sheet, POLST, and bed hold policy sent with. Report called to nurse at (Local Hospital) ED. Daughter to meet resident at (local hospital). (V18), FNP-BC, notified. R3's Orthopedic Clinical Note, dated 3/31/2025, documents that Chief Complaint: Right Pubic Ramus Fracture Follow up. Returns in regard to her inferior pubic ramus fracture on the right side. She was seen on March 21 and diagnosed at that time with the inferior pubic ramus fracture as she had previously had a fall at her facility. She sustained another fall around March 30 that was not witnessed. seen at emergency room with x-rays of the right hip that showed no acute changes. Her family stated that she complains of pain in the lateral aspect of the hip and rubs that area. They are concerned about her decline due to lack of activity secondary to her fractures she has been contending with. Physical Exam: There is some tenderness with palpation of the lateral aspect of the hip overlying the greater trochanter. She has tightness to passive hip internal and external rotation. On 6/2/2025 at 2:15 PM V9, R3's daughter, stated that her mother has had about 11 falls within the last 6 months. R3 stated that the staff do not listen when she voices concerns or observations she has for her mother. V9 stated that she is at the facility at least daily but mostly twice a day. V9 stated that on March 13th her mother had a fall. V9 stated that she was informed that her mother stood up and then fell to the ground hard. V9 stated that her mother complained of pain to her hand and an Xray was performed. V9 stated that she helps with her mother's care which consists of eating, transfers, walking, and toileting. V9 stated that after the fall she reported to the nurse that her mother was having pain when she sits on the toilet and when she gets off. V9 stated that she was disregarded and told that her mother had a recent fall and that R3 would have pain. V9 stated that she was aware that her mother would have pain, but this was different. V9 stated that she told the nurses and the CNAs. V9 stated that this went on for several days. V9 stated that she spoke to a nurse not sure her name about this and finally someone listened. V9 stated that they talked about R3's upcoming ortho appointment and getting them to do the xray. V9 stated that she never refused an xray. V9 stated that no one was doing anything so I thought the orthopedic would. V9 stated that they went to the appointment on March 1st and xrays were done. V9 stated that the doctor came in and showed her the film and pointed out the fracture to R3's pelvis. V9 stated that she notified the facility about the fracture and they were not surprised. V9 stated that he mother experienced increased pain during this time. V9 stated that her mother's cognition is poor and she can't always say that she is in pain but she stands up and she grabs you and hits at you when trying to put her on and take her off the toilet. On 6/4/2025 at 11:37 AM V7, CNA, stated that she takes care of R3 frequently. V7 stated that R3 has had multiple falls. V7 stated that they all run together. V7 stated that R3 does not voice pain but does winces and is more agitated and combative when sitting on and standing up from toilet. V7 stated but when standing up from the chair she will stand straight up and does not appear to be in pain, but you can't really tell. V7 stated that V9 would voice that she notices R3 was having pain. V7 stated that R3 has had a lot of fall she would be having pain. On 6/4/2025 at 12:10 PM V11, RN, stated that V9 did voice that R3 was having pain. V11 stated that she told V9 that R3 had just had a fall and would have pain. V11 stated that R3 was receiving Tylenol routinely. V11 stated that she informed V9 that she could get a xray but didn't think that it would show anything and that the pain was related to the fall. V11 stated that V9 would continue to talk about R3 having pain. V11 stated that V9 informed her that R3 had a follow up appointment with the ortho for her left hip fracture and would have them do the xray. V11 stated that she agreed, and this became the plan. V11 stated that R3 did have pain. V11 stated that R3 had a fall and with her age this would cause her to have pain. V11 stated that she did not notify the physician. On 6/4/2025 at approximately 3:00 PM V8 stated that he was not notified of R3's increase pain or pubis fracture. V8 stated that the facility is usually pretty good about notifying him of changes of condition. On 6/4/2025 at 3:35 PM V17, CNA, stated that R3 is confused and it is hard to tell if she is having pain. V17 stated that she will pop up out of a chair and does not appear to have pain but will be combative when trying to sit her on or the toilet or down in her chair. V17 stated that she feels R3 is in pain when being combative. On 6/10/2025 at 1:43 PM V2, Director of Nursing, stated that R3 is challenging and that they are trying to keep R3 safe. V2 stated that there has been some resistance with interventions. V2 stated that they were not initially aware of the pelvic fracture. V2 stated that the information was not given in report and the documents didn't come with R3. V2 stated that they requested the documents. V2 stated that in that time frame R3 fell again. V2 stated that she would expect her nurses to notify the physician of changes in conditions. Facility did not provide change in condition policy.

Based on Interview, and Record Review the facility failed to assure fall interventions were in place for 1 (R3) of 3 residents reviewed for falls in the sample of 5. Findings include: R3's admission Record, not dated, documents an admission date of 10/28/2022. Diagnosis include Displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, Emphysema, Aneurysm of the Descending Thoracic Aorta, Dementia, Tremors. R3's Minimum Data Set,, dated 2/19/2025, documents R3 is severely cognitively impaired. R3 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R3's Care Plan updated 5/8/2025, documents Problem: R3 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, iron deficiency anemia, and poor safety awareness related to a BIMS of 8, up ad lib in facility with walker. Falls 7/20/23, 09/27/2023, 12/1/23, 12/19/24, 12/23/24,1/3/25, 2/18/25, 3/13/25 and 3/31/25. Interventions include: Staff to toilet resident every 2 hours and as needed. (R3) has an alarm which sounds reminding resident not to stand without assist and staff aware (R3) is standing and to provide assistance. R3 to wear no skid socks to bed to prevent sliding on the mat when getting out of bed. Encourage R3 to take frequent rest periods and staff to provide stand by assist when ambulating with walker. Encourage R3 to utilize walker when ambulating. R3 struggles with her sleep pattern, medication review for any changes. Attempt to keep bathroom light on and leave bathroom door open. Place R3 in common areas for increased supervision. Therapy to evaluate and treat for strengthening and balance. Approach: engage in activities when noted wandering to prevent further falls. Approach: educate staff on R3's need for increased assistance at times. Place on Walk to Dine program. Approach: Clock place in R3's room to show the R3 what time it is. Approach: Staff to have a discussion with daughter regarding hip protectors and a helmet. Approach: Night light placed in resident's room to assist with vision during night hours. It also documents Problem: R3 is cognitively impaired related to unspecified dementia, mild, with anxiety, unspecified abnormalities of gait and mobility, Muscle weakness (generalized). Interventions include Approach: Simple YES/NO questions and commands Approach: Allow ample time for resident to respond. R3's Incident Report, dated 4/17/2025, documents that R3 had an unwitnessed fall in her room. Root Cause and Conclusion Resident woke up and attempted to get out of bed without assistance and fell to floor. Staff reeducated on putting the chair alarm under resident when she gets in the bed. R3's Physician Order Sheet, documents 1/3/2025 bed/chair alarm at all times. R3's Progress Notes, dated 04/17/2025 8:45 PM, [Recorded as Late Entry on 04/18/20250 12:25 AM] , documents Resident had an unwitnessed fall at approximately 2045 in bedroom. Appeared resident attempted to get out of bed and fell to the floor. Roommate heard her fall and told the CNA who then came and got the nurse. Resident was found sitting onfall mat with legs straight out in front of her. Upon initial assessment, resident had a laceration to R pinky finger that was bleeding. No other injuries observed. VS were WNL (within normal limits) for resident. Resident was incontinent of urine at time of fall. Grips equal bialt (bilateral). Pupils equal and reactive. Transferred to w/c (wheelchair) with a 2 assist and reassessed. changes in LOC. Resident brought out to nurse's station for close monitoring. Cleansed and bandaged laceration to R pinky finger. C/o (complains of)) pain in R hand. PRN (as needed) pain meds (medication) given. On 6/4/2025 at 11:37 AM V7 stated that R3 has a bed and chair alarm. V7 stated that there has been times that she has had to go put in on her because it was not there. V7 stated that the alarm is supposed to be on her when she is in the chair and the bed. On 6/4/2025 at approximately 2:50 PM V1, Administrator, stated that V2 is on vacation, and he is not aware of what staff member it was. V1 stated that he expects the interventions to be in place. On 6/4/2025 at 3:35 PM V17 stated that R3 always has an alarm in place. V17 stated that the alarm is to be in place in the chair and bed. On 6/10/2024 at 1:43 PM V2, Director of Nursing, stated that the bed alarm was not in place at the time of the fall and the CNA was reeducated. The facility did not provide fall pevention policy.

Based on Interview, and Record Review, the facility failed to provide progressive fall interventions and to complete a fall investigation for 1(R28) of 2 residents in the sample of 21.This failure resulted in R28 sustaining a displaced fracture of greater trochanter of left femur. Findings include: R28 documents an admitted [DATE]. Diagnosis include Displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, Emphysema, Aneurysm of the Descending Thoracic Aorta, Dementia, Tremors. R28's Minimum Data Set, MDS, dated [DATE] documents R28 is severely cognitively impaired. R28 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R28's Care Plan updated 1/1/2025 documents Problem: R28 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, iron deficiency anemia, and poor safety awareness, up ad lib in facility with walker. Falls 7/20/23, 09/27/2023, 12/1/23, 12/8/23 atb initiated fall 2/10/24 fall 3/6.24. Interventions include: Staff to toilet resident every 2 hours and as needed. R28 to wear no skid socks to bed to prevent sliding on the mat when getting out of bed. Encourage R28 to take frequent rest periods and staff to provide stand by assist when ambulating with walker. Encourage R28 to utilize walker when ambulating. R28 struggles with her sleep pattern, medication review for any changes. Attempt to keep bathroom light on and leave bathroom door open. Place R28 in common areas for increased supervision. Therapy to evaluate and treat for strengthening and balance. Approach: engage in activities when noted wandering to prevent further falls. Approach: educate staff on R28's need for increased assistance at times. Place on Walk to Dine program. Approach: Clock place in R28's room to show the R28 what time it is. Approach: Staff to have a discussion with daughter regarding hip protectors and a helmet. Approach: Night light placed in resident's room to assist with vision during night hours. R28's Care Plan updated 1/1/2025 documents Problem: [NAME] is cognitively impaired related to unspecified dementia, mild, with anxiety, unspecified abnormalities of gait and mobility, Muscle weakness (generalized). Interventions include Approach: Simple YES/NO questions and commands Approach: Allow ample time for resident to respond. R28's fall risk assessment dated [DATE] documents R28 is at high risk for falls. R28's progress notes dated 12/19/2024 at 11:00AM documents POA (Power of Attorney) had R28 ambulate to nurses' station and brought to this writer's attention that R28 has abrasion/bruised area to left forehead and an area into left hairline and that R28 complains of pain to head and to left upper hip down into left upper thigh and left foot slightly rotated inwards. States R28 was sitting on toilet when she first got here and when she went to assist R28 up, R28 started complaining of pain left hip and had a difficult time getting up. V2, Director of Nusing/DON, made aware and assessed R28 also. Origin/time of fall unknown at this time. R28 unable to say when or how she fell due to mental status. Will send R28 to local hospital evaluation. R28's progress notes dated 12/19/2024 at 1:07PM documents Received call from staff nurse at local hospital and she states that R28 will be returning to facility. She states everything was negative and they did the following: Cat Scan of head and cervical spine without contrast; Xray of the chest, left femur, pelvis and left shoulder. R28's fall report conclusion with root cause dated 12/19/2024 documents R28 coming out of restroom tripped over her walker and fell into roommate's wardrobe. R28 sent to local hospital for evaluation and treatment. R28 given pain medications for hip pain. R28's care plan does not document new interventions for falls occurring on 12/19/2024, 12/23/2024, and 12/27/2024. R28's progress notes dated 12/20/2024 at 2:36PM documents R28 is resting in low bed with eyes closed. No signs of pain or discomfort noted. Bruising/abrasion remains to L forehead/hairline. Staff assist with toileting during night. R28 does get up without assist at times and walks around room without walker. Reminders to use call light for assistance. Staff checking on R28 frequently during night and every 2hrs. Call light in reach. R28's progress notes dated 12/23/2024 at 2:26AM CNA (Certified Nursing Assistant) called this writer to R28's room she was s found lying on the bathroom floor on her back with her hands behind her head, no new injury bruising continues to right arm and some areas on forehead. No new injury noted. Lifting R28 off floor she begins to yell and resist care. While sitting on bed resident begins to shake all over will not respond to questions when asked by nurse. R28 transported to local hospital by ambulance. Parties notified. R28's fall event conclusions with root cause dated 12/23/2024 documents R28 attempting to take self to restroom. Sent to local hospital for evaluation and treatment. Staff requests urinalysis order. R28's progress notes dated 12/23/2024 at 3:16PM documents follow up from fall 12/23/2024. No injuries and range of motion within normal limits. No complaints of pain, discomfort or facial expressions. R28's progress notes dated 12/26/2024 at 8:42PM R28 displaying difficulty with ambulation and transfer this shift as well as bruising to the left hip and thigh area and complaints of pain. Daughter expressed concerns to this writer that no x-rays were completed when R28 was sent to the local hospital on 12/23/2024. Call placed to on call physician. This writer expressed family concerns to Physician. Orders to X-ray left hip leg and ankle. Order placed with bio tech x-ray. R28's progress notes dated 12/27/2024 at 5:22PM documents R28 found sitting on wheelchair pedals. Roommate stated she sat on her pedals hanging onto the arms of the wheelchair. No new bruises noted at this time. R28 offer any complaints of pain, discomfort, or facial expressions. Parties notified. R28's fall event does not documents fall on 12/27/2024. R28's progress notes dated 12/28/2024 at 10:41PM documents R28 has a broken Trochanter left hip. Daughter wants her to see Physician who will not be available until after New Year according to daughter. Suggested she see local physician and she states she wants her to wait and see her Physician delaying treatment. In the meantime, resident is getting worse, and having more pain. R28's progress notes dated 12/28/2024 at 11:35PM documents R28 noted with increased pain to left hip. R28 guarding L leg. On call Physician notified of L hip xray results. New order noted to send R28 to local hospital for evaluation and treatment. POA notified. V2 notified. 911 called for transport. On 2/26/25 at 10:12 AM, V2, DON, stated she does not think the hip fracture was attributed to the 12/23 fall and thinks they have an investigation on the unknown injury and will try to locate it. On 2/26/25 at 10:53 AM, V2, DON, stated she fell on ,d+[DATE] and they did not Xray her at the hospital. We had been trying to keep her in her chair because she was getting some medication for pain but her daughter kept walking her and would complain of pain so that is why we ordered the x-ray on 12/27. There were no falls in between those days. Any change of plane would be a fall. There should be an intervention after every fall or incident, and they should be on the care plan. On 2/26/25 at 11:08 AM, V2 provided pain evaluation. No pain documented from 12/23/25 until 12/27/25. Unsure whether there were staff interviews to determine what happened but will look for them. On 2/27/2025 at 3:10PM V18, Regional Director, stated Any change of plane should be considered a fall. Facility fall policy with a revision date of 7/2017 states It is the policy of (Facility) to assess and manage resident falls through prevention, investigation, and implementation, and evaluation of intervention. The definition of a fall refers to unintentionally coming to rest on the found, floor, and other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evident suggesting otherwise, when a resident is observed on the floor, a fall is considered to have occurred.

Based on observation, interview and record review, the facility failed to obtain monthly weights on 2 of 3 residents (R13, R41), reviewed for nutrition in the sample of 21.This failure resulted in R13 having a significant weight loss of 15.6% from 11/8/24 to 2/26/25. Findings include: 1. On 2/26/25 at 8:43 AM, R13 was sitting in a specialty chair in the dining room. She appeared thin with observable temporal wasting and did not respond when spoken to. V10, Certified Nursing Assistant (CNA), stated R13 has to be fed by staff. R13's Face Sheet documents R13 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, depression, and pain. R13's Minimum Data Set (MDS) dated [DATE] documented R13 was severely cognitively impaired, ambulated via wheelchair, required substantial assistance with eating, was on mechanically altered diet, and had no or unknown weight loss. R13's Care Plan revised 2/11/24 documents R13 is at risk for hydration problems, dehydration, constipation, and urinary tract infection related to communication deficit, poor intakes, diagnoses of heart disease and hypothyroidism, and vitamin deficiency. The goal was for R13 to remain free of malnutrition as evidenced by labs, weight monitoring and intake monitoring through review date. The approach was weigh monthly and as needed and record. If weight changes 5% in one month, 7.5% in three months, or 10% in six months, notify provider and family. R13's Physician Order dated 7/25/24 documents mechanical soft diet with pureed meat. R13's Physician Order dated 5/2/23 documents nutritional supplement twice daily due to weight loss history. R13's 11/8/24 weight measured 153.2 pounds (lbs). R13's 2/26/25 weight measured 129.0 lbs. A 15.6% weight loss from 11/8/24. R13 had no recorded weights for December 2024 or January 2025. 2. On 2/25/25 at 1:50 PM, R41 appeared thin and stated since he has been on isolation for COVID-19, he doesn't get his meals until later than normal, it is cold by the time it gets to him and the meat tastes horrible. R41 stated he isn't sure if he has lost any weight but has been trying to gain weight. R41 stated he has not been weighed recently. R41's Face Sheet, undated, documents R41 has a diagnosis of Moderate Protein Calorie Malnutrition. R41's Minimum Data Set (MDS), dated [DATE], documents R41 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R41 is cognitively intact and requires set up with eating. R41's Care Plan, dated 11/7/24, documents R41 is at risk for weight loss with an intervention to monitor and record weight. R41's Physician Order Sheet (POS), documents an order, dated 11/6/24, to weigh R41 monthly. R41's Weight Records, document the last recorded weight was on 12/14/24 and R41 weighed 160.8 lbs (pounds). R41's weight on 11/6/24 was 160.8 lbs. R41's weight on 10/14/24 was 168.6 lbs. R41's Progress Note, dated 11/6/24 at 11:49 AM, documents the following: IDT (Interdisciplinary Team) met regarding resident weights. Resident is noted to have a significant weight change of 10% in 180 days. Resident had medication changes in September which could have contributed to weight loss. Resident tis stable at this time. Chart review completed, medications reviewed, diet and intakes reviewed. Will continue to monitor with monthly weights. MD (Medical Doctor) and family notified. R41's Progress Note, dated 11/12/24 at 3:14 PM, documents the following: Quarterly dietary progress note, resident has had some weight loss, not significant. Has a past history of not coming to the dining room and eating. Currently comes to the dining room and consumes 75-100% of all meals. Feeds himself in the dining room. Non-diabetic. On 2/26/25 at 1:20 PM, V5, Certified Nursing Assistant (CNA), stated the Facility's scale was broken for about six weeks, and the replacement did not arrive until a few days ago. On 2/26/25 at 1:44 PM, V19, Registered Dietitian (RD), stated she uses the Electronic Health Record (EHR) to obtain resident weights and monitors residents monthly for weight loss. She stated, There were no weights done for January, and that is a problem. People might already be losing weight, and we don't know it, and they could be malnourished. Last time I was there, some residents had not been weighed in December either. I would expect weights to be done monthly unless they have CHF (Congestive Heart Failure). I don't see any documentation that residents have been refusing (weights). If I had seen (R13)'s weight loss, I would have first requested a reweight (to ensure accuracy), and then I would have seen what I could do for her. If (R13) went from 153.2 lbs to 129.2 lbs, that is 15.6% weight loss, and that's a problem. On 2/26/25 at 1:44 PM, V19, Registered Dietician, stated she visits the facility once per month, she runs a report that shows her any new admits, weight loss, and other concerns like skin. V19 stated there were no weights done for January 2025 and that is a problem. V19 stated she has contacted the facility about it. V19 stated people might already be losing weight and they don't know it and they could be malnourished. V19 stated the last time she at the facility, there were some residents that had not been weighed in December either. V19 stated she would expect weights to be done monthly. V19 stated the facility is supposedly getting a new scale. On 2/27/25 at 3:16 PM, V1, Administrator, stated, Residents are always weighed upon admission, and then monthly unless other factors and requirements that necessitate them to be weighed daily or weekly. The Facility's Weighing and Measuring the Resident Policy revised 8/2014 documents, The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Monthly weights are to be obtained by the 8th of the month. Weight is usually measured upon admission and readmission weekly x 4 weeks and then monthly during the resident's stay. The Facility's Nutritional Assessments Policy revised 1/2012 documents, All residents who experience significant or undesirable weight loss shall be assessed for nutritional status and required intervention by the registered, licensed dietitian. A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for improvement of medical status. Weights shall be reported to the RDLD (Registered Dietitian, Licensed Dietitian) for review and assessment. Residents shall be weighed and weights reported monthly to RDLD. 45947

Based on interview and record review, the facility failed to protect residents from sexual abuse for 2 of 5 residents (R3, R4) reviewed for abuse in the sample of 15. This failure resulted in immediate jeopardy on 7/31/24 when the facility first identified the sexual behaviors between R3 and R4 and failed to put interventions in place to ensure every effort was taken to protect R3. This failure resulted in R4 displaying sexual behaviors towards R3, including fondling her breasts, placing his hand in her pants and R3 and R4 observed in R4's room, both with their pants and underwear down and R4 kneeling in front of R3. R3 and R4 have moderate cognitive impairment and the inability to consent to sexual relations. The Immediate Jeopardy began on 7/31/24, when the facility first identified the sexual behaviors between R3 and R4 and failed to put interventions in place to ensure every effort was taken to protect R3. On 10/9/24 at 12:35 PM, V1, Administrator, V2, DON (Director of Nurses), V25, BOM (Business Office Manager), and V26, Regional Director, were notified of the immediate jeopardy. The surveyor confirmed by observation, interview and record review, the immediate jeopardy was removed on 10/10/24, but remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The Facility Reported Incident, dated 9/20/24, documents that on 9/19/24 at 8:00 PM, an allegation of a resident-to-resident altercation involving R3 and R4 was made. The initial and final report dated, 9/20/24, documents that R3 and R4 both have a diagnosis of Dementia and have POA (Power of Attorney) decision makers. The Incident report documented R3 and R4 have been in a relationship, holding hands, kissing, staff encouraged to keep out of each other's rooms. On 9/19/24, R3 was noted in R4's room with pants down and R4 on top of R3. Both POAs made aware. Both are okay with the relationship if consensual. Care plan updated. R3's Face Sheet, undated documents R3 has the following diagnosis: Other Symptoms and Signs Involving Cognitive Functions and Awareness, Major Depressive Disorder, Amnesia, and Altered Mental Status. R3's MDS (Minimum Data Set), dated 7/1/24, documents R3 has a BIMS (Brief Interview for Mental Status) score of 8, indicating R3 has moderate cognitive impairment. R3's Care Plan, dated 7/23/24, documents the following: Resident is exhibiting problems as seen by cursing, hitting, grabbing others, rummaging, making disruptive sounds, screaming at others, wandering, looking for a boyfriend-has a relationship with another male resident. POA aware. There are no interventions in place to prevent R3 from sexual abuse or acts. R3's Abuse Screener, dated 9/24/24, documents that R3 is at risk for abuse and care planning is required. R3's Progress Note, dated 7/31/24 at 3:13 PM, documents the following: (V15, R3's Daughter) was notified that resident has been going in and out of men's rooms and will rub their legs or shoulders. Informed her that one of the male resident's entered her room and CNA (Certified Nurse's Assistant) observed him with his hand down her shirt. He was immediately removed from her room. Daughter informed of room move to (new room). Daughter's only response was ok, thank you. R3's Progress Note, dated 7/31/24 at 3:36 PM, documents the following: Administrator notified of situation with male patient earlier. R3's Progress Note, dated 8/28/24 at 2:12 PM, documents the following: Resident sitting in common area prior to lunch time, resident had sexual behaviors with a male resident, this was reported to this nurse from activity department. Administrator aware, she is care planned with this type of behavior and is to be in common area with conversation with a male resident. SSD (Social Service Director) has had conversation with POA about this behavior prior. Resident is resting in bed at this time, her mood is pleasant. R3's Progress Note, dated 8/31/24 at 2:58 PM, documents the following: Resident had sexual behaviors with another male resident this shift, she was in common area near nurses' station or resting in bed. PRN (As Needed) Ativan administered after lunch due to resident paranoid and yelling at nursing staff to quit talking about her. She was up in wheelchair for meals, appetite and fluid intake fair. She had to be redirected multiple times this shift due to following male resident in hallways. She is A&O (Alert and Oriented) times 1. Still awaiting return call from POA. She agitated and yelling at roommate for her treatment being on at night and not getting along. Administrator has been notified of her not getting along with roommates. R3's Progress Note, dated 9/19/24 at 6:40 PM, documents the following: Notified (V16, R3's Daughter) that (R3) was in (R4's) recliner with her underwear and pants down, and (R4) was on top of her with his pants off. (V16) said she would notify her sister. R3's Progress Note, dated 9/20/24 at 10:34 AM, documents the following: Family called and made aware of event that happened with another resident. Family is ok with the situation as long as resident doesn't mind. R3 considers the other male resident (R4) her boyfriend. Staff will continue to encourage them to remain in public and not alone. R3's Progress Note, dated 9/26/24 at 8:17 PM, documents the following: Resident found in males' room on the floor. They both had their pants down. They were assisted up and separated. Resident is on fall precautions, she is confused and stands up to walk back to male's room. They are closely monitored, but they find a way. R3's Progress Note, dated 9/28/24 at 3:41 PM, documents the following: 11:30 AM, called to dining room from dietary staff. Reported another male resident had his hand down in her pants touching her. Upon entering, seen male resident remove his hands from her pants. She was removed from the situation and taken back to her room. Resident upset and voiced that's my husband, why can't we be together. Resident redirected, no trauma present. Body assessment completed as much as possible, no areas of concern noted. Resident did not want this nurse to assess skin. Administrator notified via phone, she voiced to have residents eat in separate dining rooms. 11:48 AM, On Call MD (Medical Doctor) notified, NNO (No New Orders) received. 11:50 AM, POA notified by phone, left VM (Voicemail). She did return call at around 12:45 PM and was notified of above sexual encounter, she voiced understanding, notified resident will try to be separated from other male resident. R3's Progress Note, dated 9/28/24 at 10:27 PM, documents the following: Resident attempted to go to males room, she tries to stand and walk, She punched this nurse in the stomach and scratched my arm which needed cleaned and a band aid applied. Male resident comes looking for her and they have sexual behaviors and then he goes to his room and wants nothing to do with her till their next sexual encounter. Female resident is hard to redirect and gets very physical and aggressive. R4's Face Sheet, undated, documents R4 has the following diagnosis: Senile Degeneration of the Brain and Dementia. R4's MDS, dated [DATE], documents R4 has a BIMS score of 8, indicating he has moderate cognitive impairment. R4's Care Plan, dated 8/5/24, documents the following: Resident exhibiting problems as seen by wandering, pacing, public sexual acts self-directed, sexually inappropriate behavior toward others; has a relationship with another female resident. POA aware with an intervention that R4 is not allowed in room alone with a female resident. R4's Progress Note, dated 7/31/24 at 3:28 PM, documents the following: Resident's daughter in law notified that resident was observed in a female's room with his hand down the front of her shirt. Informed that resident was immediately removed from the situation and taken back to his room and instructed him that he could not go back into her room or another female's room. Informed that the female was moved to a different hall. POA states, Oh my, I just can't believe this-this does not even seem like him at all. POA states she will be in tomorrow to speak with resident. Administrator has been informed of above aforementioned also. R4's Progress Note, dated 8/4/24 at 2:57 PM, documents the following: Patient is attempting to get another female patient to come into his room. Patient redirected to his room at this time. R4's Progress Note, dated 8/5/24 at 2:58 PM, documents the following: Patient educated on not provoking female patients to follow him to his room. Educated on other patient having dementia and not being able to make decisions on her own. R4's Progress Note, dated 8/18/24 at 4:04 PM, documents the following: Resident was found kissing a female resident today in the dining room. This resident was removed from area and walked him down to his room to initiate a 1 and 1. A warning was initiated. Resident understood and acknowledged. R4's Progress Note, dated 8/22/24 at 1:49 PM, documents the following: Resident continues to have sexual behaviors with another female resident. POA made aware of this. Staff to ensure that both residents are not alone in room. They must be present with staff to monitor. Will continue to monitor situation. R4's Progress Note, dated 8/22/24 at 4:20 PM, documents the following: Resident continues on hospice with no change in status. Resident has sat in common area in front of desk with his female friend who is also a resident here. CNA reports that resident noted to have his hand on her leg above the knee underneath her skirt and this issue was immediately addressed and resident removed his hand. Resident then went back to his room. Resident making comments to female resident that he would like to take her to bed to, which she did not reply. Resident currently in his room. R4's Progress Note, dated 8/25/24 at 2:57 PM, documents the following: Resident remains under the care of hospice with no change in status noted. Resident has been ambulating up and down halls with a slow, steady gait with walker. Resident frequently sits in common area in front of nurse's station talking with female resident. Resident noted earlier to be following female resident into her room and he was redirected. Informed resident they need to stay in common area and resident compliant. R4's Progress Note, dated 8/28/24 at 3:42 PM, documents the following: Resident remains under the care of hospice with no change in status noted. Resident ambulates up and down hallway frequently throughout the day looking for his female friend. They sit in common area and resident will make sexual suggestions and female resident just sits and smiles at him. Administrator aware and this is care planned. Family also aware. R4's Progress Note, dated 8/31/24 at 11:45 AM, documents the following: Patient walks up and down hallway looking for female friend/patient. Makes gestures to female to come with him to his room. Patient is redirected to either sit in common area with friend or go back to room alone. R4's Progress Note, dated 9/19/24 at 6:36 PM, documents the following: Notified POA that female (R3) was in (R4's) recliner and had her underwear and pants pulled down, and (R4) was on top of her with his pants off. (R4's) bilateral knees had abrasions. Cleansed with wound cleanser and applied mupirocin and dressings. Administrator is aware. R4's Progress Note, dated 9/20/24 at 10:37 AM, documents the following: POA made aware of relationship with another female resident. They voiced no concerns at this time and understands that they have a relationship with each other. R4's Progress Note, dated 9/26/24 at 8:12 PM, documents the following: Resident remains on hospice. Resident and a female resident were in room on the floor with their pants down. They were assisted up, dressed, and separated. Even though they are closely monitored, they find a way. R4's Progress Note, dated 9/28/24 at 11:36 AM, documents the following: Patient observed in dining room with his hands on another patient's vagina. Patients were separated at this time. 1137- nurse manager on call notified. 1145- Admin notified, 1148- Doctor on call made aware. POA updated on situation. POA stated it was female initiating contact. Updated on things patient says to female trying to get her to go in his room. R4's Progress Note, dated 9/29/24 at 12:42 PM, documents the following: Patient's POA in facility and stated she was taking patient out of facility and that he would not be returning. On 10/3/24 at 4:30 AM, V5, LPN (Licensed Practical Nurse) stated she was not here when the alleged sexual abuse occurred between R3 and R4 but had heard about it. V5 confirmed that R3 was R4's girlfriend. On 10/3/24 at 11:40 AM, V8, CNA, stated she did not witness the sexual interaction between R3 and R4. V8 stated R3 likes to leave her hallway to seek out R4 and is unable to be redirected. V8 stated R4 is consistently stating that R4 is her (R3's) husband and she will have the staff from R4's hall come and get her, telling her that R3 won't leave R4's hallway. On 10/3/24 at 11:55 AM, V17, RN (Registered Nurse), stated she was in the dining room when a CNA called her stating that there was a problem with R3 and R4. V17 stated upon entering R4's room, R3 was observed sitting in the recliner with her pants and underwear down, R4 was on his knees on the floor by R3 with his pants and underwear down. V17 stated R3 and R4 seemed embarrassed by the incident. V17 stated R4 was complaining of knee pain, so she had him sit on the floor and he had abrasions to both knees that she cleaned and applied bandages to. V17 stated that neither R3 or R4 stated what happened and she (V17) did not know if penetration had occurred, and she did not witness the sexual interaction between them. V17 stated she assessed R3, and she was smiling, acting silly and didn't have any complaints of pain or areas of trauma noted. V18 stated after the incident, she notified V1, Administrator, R3 and R4's family but did not notify either resident's physician or local law enforcement. V17 stated she spoke with V16, R3's Responsible Party/Daughter, who apologized for her mom's behavior but didn't give any instructions or voice concerns to her. V17 stated this type of behavior is not a common thing for R3 or R4. V17 stated R3 would pursue R4, followed him wherever he was at but neither resident ever displayed any behaviors like this before. On 10/3/24 at 12:30 PM, V2, Director of Nursing, DON, stated she does not have any investigation on R3 or R4 other than the one on 9/19/24. On 10/3/24 at 1:45 PM, V2 stated there have not been any events, investigations regarding R3 or R4's sexual behaviors. V2 stated they have just been putting progress notes in, they tried to do the right thing and would notify their MD and POA. On 10/3/24 at 3:15 PM, V15, R3's Representative/Daughter, stated the facility has called her a couple of times regarding R3 another male resident (R4), but she feels as though it isn't R3 that is instigating these behaviors, it is R4. V15 stated she told the facility it was okay for R3 and R4 to spend time together in the hallway, but she did not give permission for any type of sexual encounters or advances. V15 stated the first time she was notified of anything, she was told that R4 was in R3's room, R3 was in bed and R4 was fondling R3's breasts, unsure of the date. V15 stated the next time, she was notified, she was told that R3 was in R4 and both residents were partially undressed, R3 had just a top on and that they (facility staff) didn't think anything happened between them. The next time V15 was notified was recently that both residents were in the dining room and R4 pulled R3's underwear down and was touching her. V15 stated R4 looks like R3's late husband and R3 thinks R4 is her husband and even calls R4 her late husband's name. V15 stated R3 has declined over the past 6 months and isn't with it or able to make her own decisions. V15 stated all R3 would tell her was she (R3) and R4 had been naughty, but it is because R3 believes R4 is her husband. V15 stated if R3 knew that wasn't her husband, she would have been embarrassed by those incidents occurring and she wouldn't have done them. On 10/4/24 at 7:45 AM, V2 stated she has only observed R3 and R4 together, talking and holding hands. V2 stated R3 and R4's families were notified each time they were doing more than that, and the families told the facility to let it play out. V2 stated R4's Daughter, got tired of the facility calling her about the sexual behaviors, she came and got him and took him home. V2 stated the staff provided privacy for R3 and R4 when they would have sexual encounters. V2 stated R3 and R4's BIMS were not high enough to give consent but R3 and R4's families were okay with it. V2 stated R3 would often say she just loved R4, and both of their families were aware of the sexual encounters and R3's family just wanted her to be happy. V2 stated she never spoke with either R3 or R4's family so she isn't sure if either one said it was okay for R3 and R4 to perform sexual acts with one another. V2 stated she and V1, Administrator, decided it was time to report it and believed they were doing it right by documenting it in the progress notes. V2 stated they did train and told the staff to keep R3 and R4 apart, it was hard, and it wasn't what R3 or R4 wanted. V2 stated they made an activity center and would take R3 to that and she enjoyed that but when staff would find R3 and R4 together performing sexual acts, they would provide privacy for them. V2 stated both R3 and R4's physician was aware. V2 stated either the Nurse Practitioner or the Physician was notified of the incident on 9/19/24 but local law enforcement was not notified. V2 stated R3 was not sent to the hospital or examined to see if sexual penetration had occurred, the nurse did do a physical assessment and didn't notice any injuries. V2 stated it was reported that R4 was on top of R3 with both of their pants and underwear down but when staff went into the room, R4 was on his knees and couldn't get up off the floor. On 10/4/24 at 9:50 AM, V20, Medical Director and R3 and R4 Physician, stated he was aware of the boyfriend/girlfriend situation with R3 and R4. V20 stated that both R3 and R4 had confusion but were consenting and he was told by the facility that both R3 and R4's families were okay with their relationship. V20 stated he was notified of the incident on 9/19/24 and opted not to send R3 or R4 to the hospital. V20 stated that knowing they were both consenting adults and their families were okay with their relationship, he would have only sent them out if they had displayed signs or symptoms of an STD (Sexually Transmitted Disease), which was highly unlikely. On 10/9/24 at 9:35 AM, V1, Administrator, R3 and R4 had a relationship and were hard to keep apart. V1 stated knew they had to keep them apart, so they kept a close eye on them, and they weren't to be in each other's room alone. V1 stated R4 was alert and oriented times 2 and R3's confusion came and went. V1 stated R4 ambulated with a walker and R3 was in a wheelchair and could propel herself. V1 stated the relationship started out with them just holding hands and kissing. V1 stated they notified both R3 and R4's family. V1 stated the report that was submitted on 9/19/24 to (State Agency), she wasn't sure who to report as the victim/perpetrator because both wanted it. V1 stated R3 referred to R4 as her boyfriend and would say that she loved him. V1 stated R4 referred to R3 as his girlfriend and neither resident sought out other residents, it was just each other. V1 stated even though R3 and R4 had Dementia, staff would still tell them they couldn't be alone with each other and had to be in public. V1 stated the staff tried their best to divert them. V1 stated there were only two incidents where they were caught with their pants down, the first was when they were in R4's room and R3 was in the recliner and both R3 and R4 had their pants and underwear off. V1 stated the other incident occurred after that incident and R3 and R4 were found in R4's room, on the floor with their pants and underwear off. V1 stated both resident's families were aware, they did not give permission for R3 and R4 to have sex, but they could have a companion. V1 stated it was never witnessed whether or not actual penetration occurred. V1 stated they would let the family know what was going on with R3 and R4 and they (the facility) assumed they were okay with it. V1 stated after the last incident, R4's family discharged him from the facility, and she isn't sure if it was because they got tired of all the phone calls regarding R4's behavior or of the relationship between R3 and R4. V1 stated neither R3 nor R4 had the cognitive capacity to consent to a sexual relationship. V1 stated only the incident on 9/19/24 was reported to (State Agency) and it was not reported to local law enforcement because they didn't know if it was abuse or not. V1 stated after the incident on 9/19/24, they had R3 and R4 on different hallways, they were not allowed to be in any room, including the dining room alone, they were not on one-on-one observation, but staff watched them and tried to keep them separated. The Abuse Prevention Program Policy, dated 9/29/22, documents the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Protection of Residents: The facility will take steps to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and will immediately take appropriate steps to remediate the non-compliance and protect residents from additional abuse. Residents who allegedly mistreated another resident will be removed from the situation and will have limited contact with the targeted individual during the course of the investigation. Residents have the right to engage in sexual activity. If the facility has reason to believe or suspect that a resident does not have the capacity for consent, the facility must take steps to ensure the resident is protected from abuse and must evaluate the resident's capacity for consent. The facility must revise the resident's care plan if the resident's medical, nursing, physical, mental, psychosocial needs or preferences change as a result of an incident of abuse. The Immediate Jeopardy that began on 7/31/24 was removed on 10/10/24, when the facility took the following actions to remove the immediacy: Proposed Removal Plan: Other Residents with Potential to be affected by the Immediate Jeopardy Incident: All residents identified as a risk for abuse are vulnerable due to diagnosis, decreased cognition, communication deficit, or physical mobility function. Staff Identified: All staff in the facility are identified as responsible for residents' safety. Immediate Changes to Facility Systems: The facility needs to take the following immediate action to prevent the risk of abuse: 1. R3 room move to the 200 Hall. R4 room remained on the 300 Hall. The move was completed on 7/31/2024 2. R3 and R4 were both care planned to maintain supervision when in public areas together. R3 and R4 were care plans to not be in either person's room together. This was completed on 7/23/24 by MDS Coordinator. 3. R4 was discharged home on 9/29/24 via AMA per POA. 4. The Abuse Assessment was completed 10/09/2024 for all residents to determine if the resident is at risk of abuse or displays behaviors that would be indicative of potential abuse occurring completed by V1, Administrator. 5. All residents identified as at risk for abuse had a care plan developed with interventions to prevent occurrence of abuse completed by V1, Administrator. 6. The Administrator, Director of Nursing, and the MDS Coordinator assessed all residents to determine if any other residents were having sexual relationship in the facility. No other resident identified as having a sexual relationship with any resident completed on 10/9/24 7. The Director of Nursing and/or designee educated all staff on what to do when a resident is at risk for abuse or displays behaviors that would be indicative of potential abuse occurring which was completed on 10/9/2024. 8. Education will be ongoing to ensure that no employee works prior to receiving education by the Director of Nursing 9. Education will be provided to all new hires prior to working by the Director of Nursing. 10. The Director of Nursing, Administrator and/or Social Service Director will assess residents BIMS score for the ability to consent to relationships. If unable to consent, the POA or decision maker will be notified and care plan updated. Ongoing Monitoring Review of all policies regarding staff obligations to prevent and report resident abuse, neglect, and theft, as well as what staff are to do if they see, hear or suspect resident abuse, neglect, or theft. At 3:15 PM 10/9/2024, all staff working in the facility were in-service on the facility abuse/neglect and reporting process. The Administrator and/or designee will ensure all staff are educated on Abuse/Neglect Policy and Procedures prior to working. The Administrator will ensure all audits are reported to the QA committee.

Based on interview and record review, the facility failed to provide supervision/monitoring to prevent an elopement for 1 of 6 residents (R5) reviewed for supervision to prevent elopement in the sample of 15. This failure resulted in Immediate Jeopardy on 9/20/24 when R5, eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM and returned to the facility. The Immediate Jeopardy began on 9/20/24, when R5 eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM and was returned to the facility. On 10/9/24 at 12:35 PM, V1, Administrator, V2, DON (Director of Nurses), V25, BOM (Business Office Manager), and V26, Regional Director, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 10/10/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The Facility Reported Incident Investigation, dated 9/24/24, documents the following: On 9/20/24 at 6:00 AM, R5 eloped from the facility. R5 has a BIMS (Brief Interview for Mental Status) Score of 11, which indicates moderate cognitive impairment. R5's POA (Power of Attorney) states that he does have confusion and forgetfulness most days. Staff did rounds at 3:00 AM and went back for another round at 5:00 AM, when they noticed R5 was not in his room. Staff completed an outside and inside perimeter sweep with no findings. They call the DON (Director of Nurses) and Administrator and notified the local police. R5 was noted behind the building in the parking lot by a passerby, who brought R5 back to the facility. Staff stated that the door alarm was not activated and later found that another resident had turned the alarm off. An assessment was completed upon return with no injuries noted. R5's POA was made aware. R5 was moved to a room closer to the nurse's station, the door code was changed and R5 was placed on 15-minute checks for 24 hours. Initial report 9/20/24 - Resident unable to recall why he left. Written statement by V7, LPN (Licensed Practical Nurse), undated, aide alerted me at 5:40 AM, that patient wasn't in room, we then began to check all the room but were unsuccessful with finding patient in building. We then went outside and walked around the whole building, meeting each other multiple times. After not finding outside, aide called supervisors to see what step to take. Police were then contacted. We then went outside again to look when a truck pulled up and patient was inside the vehicle. The man stated that resident flagged him down in the back parking lot by 200/400 hall exit. When resident returned to building and asked where he had been, resident stated he didn't know how he got outside, nor for how long he had been out there. The POA was contacted unsuccessfully. Also, vital signs and head to toe assessment were completed with no findings and normal vitals. Written statement by V8, CNA (Certified Nurse's Assistant), undated, at approximately 5:55 AM - 6:00 AM, I was doing rounds and was approached by the charge nurse who stated she was attempting to locate a resident from 4 south. I stopped what I was doing and immediately began to search. Written statement by V9, CNA, undated, I went back to 400 South at around 2:30 AM, after I got back from lunch, then went back there at around 5:30 AM, R5 was there at around 2:30 AM sleeping and at around 5:30 AM was missing. Written statement by V10, [NAME] by, undated, I was driving down (street name) at about 6:20 AM when I saw R5 standing at the corner of (street name) and (street name), waving his arms to get my attention. I pulled over to assist R5. After asking R5 a couple of questions, I was approached by staff of the facility. I then drove R5 to the front of the building where I helped him out of the truck and to the front doors where we entered the building and after entering the building, I then handed R5 off to a staff member on duty. The facility is located on a main highway, heavily trafficked area, less than a half mile from train tracks that are currently in use by the railroad. R5's Face Sheet, undated, documents R5 has the following diagnoses: Displaced Fracture of the Right Foot, Dementia, Abnormalities of Gait and Mobility, Hearing Loss, Diabetes, Hypertension, Giddiness and Dizziness. R5's Minimum Data Set (MDS), dated [DATE], documents R5 has a BIMS score of 12, indicating R5 has moderate cognitive impairment. R5's Elopement Assessment, dated 9/13/24, documents the following: R5 is ambulatory, is a new admission who has made statements questioning the need to be here, displays behavior that may indicate an attempt to leave, body language, etc., that an elopement may be forthcoming. Elopement care plan to be initiated. R5's Progress Note, dated 9/14/24 at 3:00 AM, documents the following: Resident slept most of the night without issues. Resident was restless and attempting to get out of bed most of the evening requiring one to one care until he went to sleep. Alert and oriented to self, time, and situation. Able to communicate needs, appetite and fluid intake is good. Resident asked for cigarette and ash tray, I advised res (resident) that there is no smoking inside the facility, resident does not have own supply of cigarettes. R5's Care Plan, dated 9/17/24, documents R5 is cognitively impaired due to Dementia with interventions for a wander guard as needed and to observe whereabouts. R5's Progress Note, dated 9/20/24 at 6:34 AM, documents the following: At 5:40 am aide alerted me that resident was not in his room and that she checked his room and the rooms on the hall. We then went outside and walk the entire building without success of locating resident. At this time all personnel was alerted and police were contacted. When outside a truck pulled up with resident in car stating that the resident was outside in the area of 200/400 by smoking area. When resident returned the resident didn't know why he was outside or how he got out. Head to toe assessment completed with no open areas, scrapes, or abrasions Pain level is 0 out of 10, vs (vital signs) - b/p (blood pressure)- 132/64 p (pulse)-58 o2 (oxygen saturation level) - 96% t (temperatures) -96.8. POA (Power of Attorney) was called but didn't answer a voicemail was left. Resident is now sitting at nurse's station. R5's Progress Note, dated 9/20/24 at 10:58 AM, documents the following: DON (Director of Nursing) and Administrator spoke with (POA) contact 1, who came to the facility to see the resident. (POA) did state she didn't listen to the message we left for her. We explained the resident did get out of the facility and another resident turned off the door alarm. We explained a head to toe assessment was completed, he was showered, and the steps we are taking for the safety of this resident. (POA) stated he was always trying to get out at home and did get out at the last facility he was in by climbing out of a window. (POA) stated she understood and had no questions or concerns. R5's Progress Note, dated 9/20/24 at 11:09 AM, documents the following: Resident got a room move today, from (previous room to new room), due to safety reasons, family was made aware. Resident will continue to be monitored; any changes will be made in next care plan meeting. On 10/3/24 at 4:25 AM, V4, CNA, stated 2 CNAs and 1 nurse is not enough staff for 47 residents. V4 stated it's hard to get the call lights answered, care provided and to supervise the residents. On 10/3/24 at 4:30 AM, V5, Licensed Practical Nurse, LPN, stated the layout of the building is a problem because the residents are scattered, not in one area making it very difficult, impossible to supervise them. V5 stated they all answer call lights, but if they are at the front nurse's station (100/200/300 hall), you can't hear the call lights going off on the 400-hall until you get to that nurse's station, so if someone needs help, you might not know it. On 10/3/24 at 4:35 AM, V6, CNA, stated there aren't a lot of residents on the 400-hall but the 200-hall is a heavy hall. V6 stated it is just him, another CNA and nurse working. V6 stated that is not enough staff and there are a few unruly residents and residents that are up and moving about so if they are dealing with one of those residents, they can't supervise the other ones, it's very difficult to manage. V6 stated if he is on the 100, 200 or 300-halls, he can't hear the call lights on the 400-hall so he tries to be by the nurse's station so he can hear them. V6 stated R5 was independent, strong willed, doesn't really need help. On 10/3/24 at 8:00 AM, V11, MDS Coordinator, stated they do not have any residents currently at risk for elopement. On 10/3/24 at 4:05 PM, V9, CNA, stated she was not the aide assigned to R5 but all the CNAs care for all the residents. V9 stated she checked on R5 at around 2:30 AM, he was sleeping, when she went back to check on him around 5:30 AM, he was nowhere to be found. V9 said she notified the nurse. V9 stated there were no alarms going off. V9 stated V10, [NAME] by, is also V2, DON's, son, was on his way to work and saw R5, who was waving him down. V10 placed R5 in his truck and drove him to the facility and walked him back into the facility. V9 stated R5 was fine, had no injuries, and was fully dressed with a coat and shoes on. V9 stated R5 was alert for the most part until he returned to the facility and couldn't remember how he got out of the facility or why he left the facility, couldn't remember anything. V9 stated she knew R5 could walk with assistance but didn't know he could walk like that. On 10/3/24 at 4:10 PM, V8, CNA, stated she was working when R5 eloped. V8 stated it was a weird situation, she had just done rounds. R5 was there and then she went to do final rounds around 5:30 AM - 6:00 AM and he was gone. V8 stated her and V9, CNA, were working the halls together. V8 did the round at 3 AM and V9 did the round at 5:30 AM and notified her (V8) that R5 was gone. V8 stated she looked everywhere and couldn't find R5, so she called the police, she was freaking out because he couldn't be found, and she wasn't going to wait for anyone else to call. V8 stated a community member (V10, [NAME] by) is somehow familiar with the facility, was on his way to work and R5 flagged him down so he (V10) brought R5 back to the facility and walked him inside. V8 stated when R5 returned to the facility he was lethargic, didn't know what he was doing or what was going on. V8 stated normally V5 isn't that confused but is never alert and oriented x 2 or 3. V8 stated she normally works evening shift but stays over for nights at times and staffing on nights is horrible, there isn't enough staff to supervise the residents or do what they need to do. V8 stated if there would have been more staff, she doesn't believe the incident with R5 would have happened. On 10/4/24 at 7:45 AM, V2, DON, stated when staff went to check on R5, it disturbed him and woke him up, so he got up, changed out of his pajamas into regular clothes, put a coat and shoes on and left the facility. V2 stated the door alarm did go off and another resident, who comes in later at night, turned off the alarm when it was sounding, and she believes the CNA thought the other CNA turned it off, so they didn't check to make sure none of the residents had gone out. V2 stated she watched the cameras, and it shows the CNA going into R5's room to do a check and R5 wasn't there. V2 stated she doesn't remember when R2 exited the facility, she wrote it down but isn't sure where it is at. V2 stated the CNA then called V1, Administrator, herself (V2), and the local police department. V2 stated R5 was already back in the building by the time she arrived at the facility. V2 stated V10, [NAME] by, is her (V2's) son, he was on his way to work and R5 was waving him down, so he (V10) pulled over and R5 told him he needed help, upon further questioning, V5 told V10 that he didn't know where he was going but he was from the home right there, pointing to the facility, so V10 brought R5 back to the facility. V2 stated afterwards V21, R5's Significant Other, told her that R5 had busted out a window at another facility to get out and R5 would often try to leave while he was at home so V21 had alarms placed on the doors so he couldn't go out on his own. V2 stated they did not know this until after R5 eloped on 9/20/24. V2 stated R5 would often tell V21 that he wanted to go home but she isn't aware of him making any prior elopement attempts while in the facility. V2 stated R5 was alert and oriented x 2, sometimes he was fine, other times he was confused. V2 stated R5 was on the back half of the 400 hall and after the elopement, he was moved to the 300-hall to a room next to the nurse's station. On 10/4/24 at 8:10 AM, V7, LPN, stated she was working when R5 eloped from the facility. V7 stated the CNAs checked on him around 4:30 AM - 5:00 AM, and R5 was in bed, asleep. V7 stated when the CNA went back into the room around 6:00 AM to get R5 up for the day, he wasn't in his room. V7 stated the staff looked for him inside and outside of the building but did not see him. V7 stated after that a car pulled up, V10, [NAME] by/V2's son, and stated R5 was out there at the smoking gait, and he picked him up. V7 stated she is not aware of any alarms going off on the 400 hall doors but the residents on that hall know the door code because their families come in often and they go in and out that door. V7 stated she isn't sure if R5 was trying to go out and smoke because he used to smoke but recently V21 told the facility he couldn't smoke anymore. V7 stated R5 told her, he didn't know where he was going and R5 isn't capable of knowing the door code to get out. V7 stated R5 didn't have any injuries and was fully dressed with a coat and shoes on. V7 stated R5 was alert and oriented x 2-3 and had no prior attempts to elope that she is aware of. On 10/4/24 at 9:50 AM, V20, R5's Physician, stated R5 had a fractured foot, was wheelchair bound and in a boot for the fracture, or so they thought. V20 stated R5 got out of the facility because 1 busy body resident turned the alarm off when R5 went out, if that resident hadn't done that, R5 wouldn't have gotten out and that just set off a cascade of effects. V20 stated R5 had periods of confusion. On 10/8/24 at 9:25 AM, V1, Administrator, stated the current elopement binder is not up to date and staff doesn't look at it anyway. V1 stated she has hung up instruction sheets at the nurse's station on what to do if they have a missing resident. V1 stated after R5 eloped, they looked at the residents that were at risk and determined they were no longer at risk. V1 stated they determined this by reviewing the resident's information. The surveyor asked if there were new elopement assessments completed to determine they were no longer at risk and V11, MDS Coordinator/Care Plan Coordinator, stated he believes so but would check to make sure. V11 stated the residents are assessed for elopement risk upon admission and then quarterly. On 10/8/24 at 1:58 PM, V18, LPN, stated she knows a resident is at risk for elopement by looking in the elopement binder at the nurse's station. On 10/9/24 at 9:35 AM, V1, Administrator, stated R5 was at the facility for skilled care due to a fractured foot and was non-weight bearing, wore a boot and staff thought he was a 2-assist, and he went along with it. V1 stated he was placed in a room on the 400-hall because that is where they put their rehab to home residents because the rooms are bigger. V1 stated on 9/20/24, the CNA, did rounds and stated R5 was in bed sleeping at that time, it was determined when the CNA went into the room to do rounds, the CNA, inadvertently woke R5 up and that is why he got up and dressed for the day. V1 stated at approximately 5:00 AM, the CNA went in to do the last round and R5 was gone and panic set in. After interviewing staff and residents, the CNA that was assigned to R5's hallway, went to help the other CNA in another resident's room, during that time, R5 went out the 400-hall exit door, setting off the alarm and R12, annoyed by the alarm, got up in his wheelchair, went to the exit door and shut off the alarm using the door code. V1 stated the CNAs on that hallway never heard the alarm because they were in a resident's room on a different hallway and R12 turned the alarm off before they came out of the room. V1 stated R12 could have told staff that he turned the alarm off but chose not to. V1 stated when R5 was returned to the facility, he was immediately moved to a room on the 300-hallway, where more residents and staff were. V1 stated R5 was more engaged on that hall due to more residents and staff and did not try to elope again. V1 stated all the door alarm codes were changed at that time. V1 stated R5 was alert and oriented x 2 with confusion. V1 stated after R5 eloped, V21, R5's Significant Other, told the facility that when R5 was at home, she had alarms on all the exit doors because he would try to get out at night. V1 stated the staff didn't know R5 could walk. The Elopement Prevention Policy, dated January 2018, documents the following: It is the policy of this facility to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention will be established in the plan of care to minimize the risk for elopement. Any resident assessed to be at risk for elopement will have their photograph and basic identifying information placed in a special folder or binder to be maintained in a designated location. Responsibility for updating the folder/binder shall be assigned to a designated staff member by the administrator. Communication of interventions will be made to direct care staff through exposure to the resident's plan of care and periodic review and disclosure of the contents of the elopement binder. The Missing Resident Policy, dated November 2017, documents the following: It is the policy of the facility that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to: door alarms, personal door alarm activation devices, staff intervention, staff education regarding response to door alarms, and the resident interventions. A resident shall be defined as missing when the initial reasonable search of the facility interior and immediate grounds has not rendered physical evidence of the resident's person; there exists no evidence of the resident's whereabouts upon examination of documents including but not limited to the medical record, calendar of events and sign out books/sheets and after questioning of facility staff and residents evidence of whereabouts remain uncertain. The Immediate Jeopardy that began on 9/20/24 was removed on 10/10/24, when the facility took the following actions to remove the immediacy: Proposed Removal Plan: Other Residents with Potential to be affected by the Immediate Jeopardy Incident: All residents identified as a risk per facility elopement risk screening. Staff Identified: All staff in the facility are identified as responsible for residents' safety. Immediate Changes to Facility Systems: The facility needs to take the following immediate action to prevent the risk of abuse: 1. R5 was immediately placed on 15-minute checks and moved to the 200 Hall for closer supervision on 9/20/2024 upon his return at 6:20. 2. R5's care plan was reviewed and updated to reflect interventions regarding elopement risk by the MDS Coordinator on 9/20/24 3. R5 was discharged home on 9/27/24 with R5's, emergency contact. 4. The Elopement Assessment was completed on all residents 10/09/2024 by V1, Administrator. 5. All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Code Yellow Binder by V1, Administrator, on 10/9/24 6. All staff were in-service on the facilities Elopement Prevention Policy to reflect on what to do in the event of a missing person which was completed on 10/09/24. All staff Education will be ongoing to ensure that no one works prior to being in-service by the Director of Nursing. 7. All policies and procedures related to elopement and missing person were reviewed to ensure appropriate by V26, Regional Director and V1, Administrator. 8. The Maintenance Director audited all exit door to ensure alarms are functioning properly. 9. Door alarm code was changed on 9/20/24 and staff in serviced by the maintenance director on new code and not giving out the code to family members or residents the same day. Ongoing Monitoring Social Service Director and/or designee will audit the Elopement Risk Assessment upon admission to the facility, quarterly, and during a significant change to ensure any resident identified as at risk will be placed in the Code Yellow binder and the resident care plan are up to date with appropriate intervention. The Maintenance Director and/or designee with audit door alarm weekly to ensure functioning. The Administrator will ensure all audits are reported to QA committee.

Based on interview and record review, the facility failed to investigate allegations of potential abuse to prevent further sexual abuse for 2 of 5 residents (R3, R4) reviewed for investigating/implementing interventions to prevent further abuse in the sample of 15. This failure resulted in R4 displaying sexual behaviors towards R3, including fondling her breasts, placing his hand in her pants and R3 and R4 observed in R4's room, both with their pants and underwear down and R4 kneeling in front of R3. R3 and R4 have moderate cognitive impairment and the inability to consent to sexual relations. Findings include: R3's Face Sheet, undated documents R3 has the following diagnosis: Other Symptoms and Signs Involving Cognitive Functions and Awareness, Major Depressive Disorder, Amnesia, and Altered Mental Status. R3's Abuse Screener, dated 9/24/24, documents that R3 is at risk for abuse and care planning is required. R3's Progress Note, dated 7/31/24 at 3:13 PM, documents the following: (V15, R3's Daughter) was notified that resident has been going in and out of men's rooms and will rub their legs or shoulders. Informed her that one of the male resident's entered her room and CNA (Certified Nurse's Assistant) observed him with his hand down her shirt. He was immediately removed from her room. Daughter informed of room move to 223-A. Daughter's only response was ok, thank you. R3's Progress Note, dated 8/31/24 at 2:58 PM, documents the following: Resident had sexual behaviors with another male resident this shift, she was in common area near nurse's station or resting in bed. PRN (As Needed) Ativan administered after lunch due to resident paranoid and yelling at nursing staff to quit talking about her. She was up in wheelchair for meals, appetite and fluid intake fair. She had to be redirected multiple times this shift due to following male resident in hallways. She is A&O (Alert and Oriented) times 1. Still awaiting return call from POA. She agitated and yelling at roommate for her treatment being on at night and not getting along. Administrator has been notified of her not getting along with roommates. R3's Progress Note, dated 9/19/24 at 6:40 PM, documents the following: Notified (V16, R3's Daughter) that (R3) was in (R4's) recliner with her underwear and pants down, and (R4) was on top of her with his pants off. (V16) said she would notify her sister. R3's Progress Note, dated 9/26/24 at 8:17 PM, documents the following: Resident found in males room on the floor. They both had their pants down. They were assisted up and separated. Resident is on fall precautions, she is confused and stands up to walk back to male's room. They are closely monitored, but they find a way. R3's Progress Note, dated 9/28/24 at 3:41 PM, documents the following: 11:30 AM, called to dining room from dietary staff. Reported another male resident had his hand down in her pants touching her. Upon entering, seen male resident remove his hands from her pants. She was removed from the situation and taken back to her room. Resident upset and voiced that's my husband, why can't we be together. Resident redirected, no trauma present. Body assessment completed as much as possible, no areas of concern noted. Resident did not want this nurse to assess skin. Administrator notified via phone, she voiced to have residents eat in separate dining rooms. 11:48 AM, On Call MD (Medical Doctor) notified, NNO (No New Orders) received. 11:50 AM, POA notified by phone, left VM (Voicemail). She did return call at around 12:45 PM and was notified of above sexual encounter, she voiced understanding, and notified resident will try to be separated from other male resident. R4's Face Sheet, undated, documents R4 has the following diagnosis: Senile Degeneration of the Brain and Dementia. R4's MDS, dated [DATE], documents R4 has a BIMS score of 8, indicating he has moderate cognitive impairment. R4's Progress Note, dated 7/31/24 at 3:28 PM, documents the following: Resident's daughter in law notified that resident was observed in a female's room with his hand down the front of her shirt. Informed that resident was immediately removed from the situation and taken back to his room and instructed him that he could not go back into her room or another female's room. Informed that the female was moved to a different hall. POA(Power of Attorney) states, Oh my, I just can't believe this-this does not even seem like him at all. POA states she will be in tomorrow to speak with resident. Administrator has been informed of above aforementioned also. R4's Progress Note, dated 8/18/24 at 4:04 PM, documents the following: Resident was found kissing a female resident today in the dining room. This resident was removed from area and walked him down to his room to initiate a 1 and 1. A warning was initiated. Resident understood and acknowledged. R4's Progress Note, dated 8/22/24 at 4:20 PM, documents the following: Resident continues on hospice with no change in status. Resident has sat in common area in front of desk with his female friend who is also a resident here. CNA reports that resident noted to have his hand on her leg above the knee underneath her skirt and this issue was immediately addressed and resident removed his hand. Resident then went back to his room. Resident making comments to female resident that he would like to take her to bed to, which she did not reply. Resident currently in his room. R4's Progress Note, dated 9/26/24 at 8:12 PM, documents the following: Resident remains on hospice. Resident and a female resident were in room on the floor with their pants down. They were assisted up, dressed and separated. Even though they are closely monitored, they find a way. R4's Progress Note, dated 9/28/24 at 11:36 AM, documents the following: Patient observed in dining room with his hands on another patients vagina. Patients were separated at this time. 1137- nurse manager on call notified. 1145- Admin notified, 1148- Doctor on call made aware. POA updated on situation. POA stated it was female initiating contact. Updated on things patient says to female trying to get her to go in his room. On 10/3/24 at 12:30 PM, V2, (Director of Nursing/ DON), stated she does not have any investigation on R3 or R4 other than the one on 9/19/24. On 10/3/24 at 1:45 PM, V2, DON, stated there have not been any events, investigations regarding R3 or R4's sexual behaviors. V2 stated they have just been putting progress notes in, they tried to do the right thing and would notify their MD and POA. The Abuse Prevention Program Policy, dated 9/29/22, documents the following: Any incident or allegation of abuse, neglect, or misappropriation will result in an abuse investigation.

Based on observation, interview, and record review, the facility failed to implement a system to track and trend infections, failed to implement a system for testing for the spread of COVID-19, and failed to implement infection control procedures including isolation precautions and personal protective equipment (PPE) to prevent the spread of COVID-19. These failures resulted in 23 residents developing COVID-19, including 5 residents (R37, R51, R207, R208, and R209) who expired after becoming positive with COVID-19. Two residents (R19, and R40), and one staff member (V27, Certified Nursing Assistant/CNA) are currently positive with COVID-19. These failures have the potential to affect all 52 residents in the facility. The Immediate Jeopardy began on [DATE], when R35 developed COVID-19 and the facility failed to conduct testing and surveillance to prevent the spread of COVID-19. Subsequently, 22 other residents have developed COVID-19. Although the facility tested those with COVID-19 symptoms, the facility did not conduct testing for all residents and health care personnel identified as close contacts twice a week as per CDC guidance after these residents were diagnosed . Subsequently, R51 was diagnosed with COVID and expired on [DATE] with COVID and Congestive Heart Failure (CHF), R207 was diagnosed with COVID and expired on [DATE] with COVID, R209 was diagnosed with COVID and expired on [DATE] with Heart Disease, R208 was diagnosed with COVID and expired on [DATE] with Pneumonia and COVID, R37 was sent to the hospital and diagnosed with COVID on [DATE] and expired on [DATE]. On [DATE] at 2:15 PM, V2, Director of Nurses (DON), stated at the time R35 tested positive for COVID-19, there was no contact tracing done with residents or employees. On [DATE] at 8:53 AM, V1, Administrator, V2, Director of Nursing, and V3, MDS Nurse/Infection Control Nurse, V4, Business Office Manager/Admissions, and V37, Regional Director of Operations and Clinical Services (via phone), were notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time was needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1.Upon entrance into the building on [DATE] through [DATE], there was no signage on the doors indicating any of the residents had COVID-19 or were on contact isolation. On [DATE], the facility provided a list of 18 residents in the facility including R13, R34, R18, R25, R17, R6, R207, R208, R42, R47, R32, R31, R3, R209, R7, R22, R2, and R210 who were positive with COVID-19 from [DATE] through [DATE], and no contact tracing or further testing was completed. During the investigation, there were three more residents (R35, R37, and R51) who were noted to have COVID-19 in the facility during that same time frame. 2. R35's Face Sheet, undated, documents, R35 was admitted on [DATE], with diagnoses of Atrial Fibrillation and right sided heart failure. R35's Nurses Note, dated [DATE] 11:59 PM, documents, Res c/o (complaint of) new onset generalized weakness. Writer tested res (resident) for COVID and res is positive. Droplet isolation precautions initiated. Res assisted to bathroom and to bed. Educated res (resident) to use call light for assistance during NOC (night). V/S (vital sign) @ 98.3, 47, 18, ,d+[DATE], Sp02 (oxygen saturation) 96% ORA (on room air). NP (Nurse Practitioner) notified via fax. Left message for POA (Power of Attorney) to call facility. DON (Director of Nurses) notified. 44967 3. R207's Face Sheet, undated, documents R207 was admitted to the facility on [DATE], with diagnoses of fracture of unspecified part of neck of right femur, COVID-19 acute respiratory disease, depression, hypertension (HTN), chronic kidney disease-stage 3, and cerebral infarction. R207's Nursing Note, dated [DATE] at 8:56 AM, documented, Patient has excess nasal drainage with cough noted in dining room. Brought out of dining room and tested for COVID, patient was positive at this time. POA (Power of Attorney) was notified. NP (Nurse Practitioner) was notified and responded with orders for anti-viral Lagevrio 200mg give 4 caps BID (twice daily) x 5 days, ASA 81mg daily x 30 days from positive test, vital signs every shift x 10 days, and Mucinex 600mg BID x 10 days. Lungs are clear at this time. 97.8 89 18 ,d+[DATE]. 93%. R207's Nursing Note, dated [DATE] at 6:29 PM, documented, Resident looks really bad. Fingertips blue, not eating and drinking. Notified son of situation. Resident refused to take medication. R207's Nursing Note, dated [DATE] at 9:21 PM, documented, Resident was found by CNA approx. 6:30pm stated that resident looked really bad and his fingertips were blue, and resident was not eating and drinking for dinner. CNA states that the previous nurse was notified prior. the nurse prior then notified POA son of resident change in condition. Resident is currently COVID +, upon assessing resident, resident appears to be uncomfortable and anxious, cyanotic at the lips and nailbeds, this nurse immediately obtained VS (vital signs) as a result, resident VS were unstable Spo2 84% RA (room air) resident immediately placed on 2L O2 with HOB (head of bed) elevated for comfort, HR (heart rate) ranging ,d+[DATE], Temp. 98.3, unable to access B/P (blood pressure) at this hour. Son is at bedside and is made aware of resident being on comfort care, notified the on call MD (medical doctor) for reinstatement of PRN (as needed) Lorazepam 2mg/mL 0.25mL Q 4hr d/t (due to) anxiousness and Morphine Sulfate 5 mg/0.25ml PRN Q 4hrs for pain. MD returned call with okay to reinstate PRNs. Son made aware. R207's Nursing Note, dated [DATE] at 9:58 PM, documented, Called to room per CNA. Resident observed with no vital signs of life. No pulse or respirations noted. No heart or lung sounds on ausc. (auscultated) MD notified. Coroner, notified. POA notified. Administrator and nurse manager on call notified. New order received to release remains to (funeral home) in (nearby town). Postmortem care provided. R207's Death Certificate, dated [DATE], documents R207's cause of death was Palliative Care, CVA (cerebral vascular accident), and COVID-19. 4. R208's Face Sheet, undated, documented R208 was admitted to the facility on [DATE],3 with diagnoses of Chronic obstructive pulmonary disease (COPD), Pneumonia, COVID-19 acute respiratory disease, Dysphagia, Emphysema, Congested Heart Failure (CHF), Atherosclerotic heart disease (ASHD), and HTN. R208's Nursing Note, dated [DATE] at 8:41 AM, documented, Patient had coughing episode in dining room, patient was taken out of dining room, where nasal congested was noted in excess patient expressed, he did not feel well. Patient was tested for COVID at this time, positive results. Lungs are congested. POA updated at this time. NP was notified and responded with orders to monitor vitals every shift, ASA 81mg x 30 days from positive date, anti-viral Lagevrio 200mg give 4 caps BID x 5 days and contact isolation x 10 days. 97.8 89 18 ,d+[DATE] 94%. R208's Nursing Note, dated [DATE] at 10:59 AM, documented, 0820 called to residents room, res was moaning, HOB elevated, respirations labored at 26 resp (respirations) per min. SPO2 78%, res had removed O2 from nose, placed back into place, at 4L/NC due to SOB (shortness of breath), spo2 83%. Lungs diminished in bilateral lower lobes, unable to assess upper lobes accurately due to res moaning. Wet cough present. Lips dry, res did continue to ask for a drink, he drank 120ml of water. 0845 911 notified of need of transfer and DON notified. 0850 Daughter notified. 0915 (local hospital) Ambulance service arrived, res transferred from bed onto stretcher using sheet. Res continued to pull O2 off and mask. 0920 Report called to RN at (local hospital) ER (emergency room ), ED (emergency department) form, med list, face sheet, and POLST (Physician Orders for Life-Sustaining Treatment) form sent with EMTS (emergency medical technicians) R208's Nursing Note, dated [DATE] at 2:15 PM, documented, 1245 Res returned from (local hospital) ER via ambulance, res was on RA (room air) upon arriving, respirations are even and unlabored, res was moaning, but would answer when asked questions. VS 97.8 80 20 ,d+[DATE], unable to obtain a pulse ox with finger monitor. New orders: Decadron 6mg 1 tab PO (orally) daily x 5 days; to start on ,d+[DATE] and Augmentin 875mg 1 tab PO Q12h x 7 days for chronic bronchitis. Staff assisting res with lunch. R208's Nursing Note, dated [DATE] at 10:29 PM, documented, Standing comfort orders noted in MAR (medication administration record). R208's Nursing Note, dated [DATE] at 6:01 AM, documented, Upon entering residents room, resident appeared to be in an uncomfortable state with chest rise and fall equal bilaterally, POA at bedside for support. resident was due for schedule Morphine Sulfate. and Lorazepam at this hour, resident appearing to show s/sx (signs/symptoms) of distress with respiration of ,d+[DATE] that plummet to ,d+[DATE] while attempting to obtain vitals, Resident took last breath before administering schedule medication, while this nurse was at bedside, POA present in facility at the time of resident expiring. after assessing resident for 5 minutes resident is showing no signs of life or respiratory effort, has no palpable carotid pulse, has no heart sounds on auscultation, no respiratory sounds on auscultation, absence of pupillary reflexes and corneal reflex, and absence of motor response to supra-orbital pressure. This nurse provided privacy and notified [NAME] funeral home per family, corner notified, and MD notified. [SIC] R208's Death Certificate, dated [DATE], documented that R208's Cause of Death was Pneumonia, COPD, and COVID-19. 5.R209's Face Sheet, undated, documented that R209 was admitted to the facility on [DATE], with diagnoses of Chronic ischemic heart disease, atrial fibrillation, Sick sinus syndrome, Peripheral vascular disease, and stage 1 through stage 4 chronic kidney disease. R209's Nursing Note, dated [DATE] at 11:30 AM, documented, Patient continues with poor appetite. Congested cough noted. Patient roommate positive for COVID. Patient tested and came positive as well. Patient currently on (local hospice). POA and (local hospice) notified of positive test and symptoms. No new orders at this time from (local hospice). Nurse will be in today to see patient. COVID orders per facility will be placed at this time. Vital signs every shift, droplet precautions. R209's Nursing Note, dated [DATE] at 10:36 AM, documented, 10:19 Called to residents room, res expired, no HR, BP, or respirations noted. 10:25 This nurse called POA and notified of res expired, she voiced no one would be coming to facility due to her herself having COVID. She confirmed (funeral home in nearby town) is whom they would be using. 10:36 Called placed to (local hospice), care notified of res expired at 10:19. Nurse is to be returning phone call. R209's Death Certificate, dated [DATE], documents R209's Cause of Death Ischemic Heart Disease. 32874 6. R37's face sheet, undated, documents a diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute respiratory failure, personal history of COVID-19. R37's progress notes, dated [DATE] at 3:43, documented, Resident observed with shortness of breath (SOB), congestion and wet lungs sounds, SP02 ,d+[DATE]% on 2liters of 02 per nasal cannula, Notes document nebulization treatment administered and SPO2 dropped to 50's. Head of bed elevated. Medical Doctor notified and POA notified. New order notes to send resident to emergency room for evaluation and treatment 911 called. R37's notes, dated [DATE] at 10:20, documented, Call placed to hospital for updates, notes document resident is COVID positive. Progress notes, dated [DATE] at 11:15, documented, Hospital called and gave report resident passed away. R37's hospital emergency room report, dated [DATE], documented, Date of service at 08:43 with reason for admission hypoxic respiratory failure/copd exacerbation. Chief complaint history and physical, dated date of service [DATE], documented, (R37) with a past medical history of COPD, congestive heart failure was brought to the ER by Emergency Medical Services (EMS) for complaints of shortness of breath and increased somnolence. (R37's) Emergency Report (ER) documents in the ED (R37) was found to be tachypneic sating low on room air. It continues, Treated with BIPAP, albuterol nebulizing treatment. Documents given one dose of diuretic. Despite Bipap treatment the patient continued to desat down into the 80%. Documents DNR/DNI. It continues, (R37) was then transferred to ICU on airborne isolation for further management. R37's notes documented throughout the morning, the patient became increasingly somnolent and when she would fall asleep, she would desaturate to ,d+[DATE]%. R37's report also documented when she was roused and coached by the nurse, her 02 sats would improve to the low 90% and this was needed with increased frequency. R37's death certificate documented R37 expired on [DATE] with the following diagnosis, Respiratory Arrest, Chronic Obstructive Pulmonary Disease (COPD) and COVID. 7. R51's face sheet, undated, documents a diagnosis of acute or chronic diastolic (congestive) heart failure (primary admission) and pneumonia. R51's progress notes, dated [DATE] at 6:28, documented, Resident had sudden onset of Shortness of breath (SOB) RN raised head of bed 45 degrees, resident still could not catch breath. It continues, RN put resident on 2L (liters) of 02 per nasal cannula for comfort., resident subside right away and requested to keep o2 on. R51's progress notes, dated [DATE] at 12:22. Documented, (R51) will have a room move today, resident will be moving 230-b-308a due to positive covid isolation. Documents will continue to monitor. Any changes will be made next care plan meeting. [DATE] at 12:42 PM, R51's progress notes, documented, Nurse Practitioner (NP) here, new order to obtain covid test due to decline and SOB. Progress notes documents COVID test completed, positive results noted. Progress notes documents droplet isolation, Lagevrio 200 milligram(mg), give 4 caps by mouth (po) twice a day (bid) x 5 days Mucinex Extended Release (ER) 60mg 1 tab po x 10 days. R51's Progress notes document lungs have rubs to bilateral upper lobes 02 in place at 2l per nasal canula (nc). R51's notes, dated [DATE] at 3:00PM, documented, (R51) complained of SOB, requested a breathing treatment, this RN administered prn treatment per electronic medical record (emar). It continued, Resident stated treatment was effective and she is breathing much better. Resident is currently on 2 liters of 02, hob elevated, 02 sat is 94%, and lungs have rubs to bilateral upper lobes 02 in place at 2l nc. R51's notes, dated [DATE] at 15:00, documented, Resident on covid isolation, respirations even and unlabored. lying quietly in bed at present time. no acute distress noted this shift, daughter will be taking mom home tomorrow. R51's progress notes, dated [DATE] at 16:39, documented, Lungs diminished bilaterally; resident has congested sounding cough that's occasionally productive of cream colored phlegm. Progress notes, dated [DATE] at 10:05 AM, documented, CNA states upon entering room to get resident dressed, resident not to have any respiration. Resident expired at this time. R51's death certificate, dated [DATE], documented the cause of death as Congestive Heart Failure (CHF) Fractured Humerus, and COVID. 8.R40's Face Sheet, undated, documented that R40 was admitted on [DATE], and has diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, Cardiac Arrhythmia and Type 2 Diabetes. R40's Physician Orders documented, Start date of [DATE] Droplet Isolation. Start date of [DATE] Ipratropium - Albuterol solution for nebulization; 0.5 mg (milligram) - 3 mg; amount 1 vial; inhalation. every 6 hours. dx (diagnosis) 2019- nCov (covid). Start date of [DATE] End date of [DATE] Lagevrio capsule 200 mg; amount 4 caps (capsules) Twice a Day. Dx 2019 nCov. Mucinex tablet extended release 12 hour; 600 mg; amount 1 tab; oral Twice a day. R40's Nurses Note, dated [DATE] 1:31 PM, documented, Patient has complaints of congestion and cough. Patient lungs have bilateral crackles. SP02 (oxygenation saturation)-95% on RA (room air). NP (Nurse Practitioner) gave orders to obtain covid swab. COVID swab done x 3 swabs, all positive. Patient is being moved and droplet isolation precautions will be in place. New orders received for lagevrio 200mg, give 4 caps BID x 5 days, mucinex 600mg BID x 7 days, and duonebs q (every) 6hrs while awake. POA (Power of Attorney) made aware of diagnosis and room move. R40's Nurses Note, dated [DATE] 2:06 PM, documents, Resident had a temp. room move, due to positive covid isolation, family was made aware, resident moved from 234b-302a, resident will continue to be monitored, any changes will be in next care plan meeting. 9. R19's most current undated face sheet documents diagnoses of acute respiratory disease, Chronic obstructive pulmonary disease, and mild intermittent asthma. R19's care plan, dated [DATE], documented R19 has a tested positive for COVID-19. R19's care plan documents this places R19 at higher risk for severe illness. R19's progress notes, dated [DATE] at 20:09, documents R19 positive for COVID-19. R19's progress notes, dated [DATE], documents R19 is on antibiotics for pneumonia. On [DATE] at 10:05 AM, V31, Housekeeper, entered R19's room, which has isolation cart outside room and sign on door for transmission-based precautions. V31 did not sanitize hands prior to entering R19's room or don any Personal Protective equipment (PPE). V31 then exited room and did not sanitize hands, V31 then walked down hall and got floor sign from cart and sit out in hallway. On [DATE], V31 stated he is expected to don PPE prior to entering and isolation room. 10.On [DATE] at 8:45 AM, V16, Regional Nurse stated V27, Certified Nursing Assistant (CNA) tested positive for Covid 19 on [DATE] at home and positive at clinic on [DATE]. V16 stated V27 worked at the facility on [DATE] and returned to work at the facility on [DATE]. V27's employee timecard, dated [DATE]- [DATE], documents V27 worked 7:55AM -9:56PM on [DATE]. V27's timecard documents V27's next day of work as [DATE] at 5:29AM. V16, Regional Nurse stated she would have expected V27, CNA, to remain off work for 10 days. The facility was unable to provide any documentation the facility had implemented any type of contact tracing. On [DATE] at 9:57 AM, V3, MDS/ Infection Control Nurse, stated he started employment at the facility on [DATE]. V3 continued to state he has taken the infection control modules for certification, but he has not taken the test as he had not had time. V3 stated on [DATE], all residents and staff at the facility were tested and there were no positive cases of COVID-19. V3 stated all employees on duty were tested , and all employees who were not on duty will be tested prior to their shift. V3 stated he has not been in contact with the local health department regarding COVID 19 infection. V3 stated he has a roster of all employees, and is tracking testing on that roster. V3 stated he also has a list of all residents. V3 stated when R40 tested positive, he had a roommate, R47, and he did not test R47. V3 stated V4, Business Office Manager, put the current signage on the front door, which still does not document there is COVID-19 in the building. On [DATE] at 9:18 AM, per telephone interview, V34, Jersey County Health Department Infection Control Nurse, stated she has not been contacted by anyone at the facility, or made aware of any COVID-19 infection. V34 stated if the health department would have been contacted, she would have provided them a copy of the current IDPH guidance. V34 stated she would have discussed with the facility to provide additional staff education regarding handwashing. V34 stated signage on the door at entry should document the facility has COVID-19 in the building so visitors could be made aware of infection in the building. V34 stated she would expect the facility to be testing twice a week until no positives for 2 incubation periods. V34 stated the facility should be maintaining a line list of COVID-19 positive residents and submitting to the list to the health department on a weekly basis. V34 stated staff should be wearing gown, gloves, N95 masks, and face shield/or goggles when entering a COVID 19 positive room. On [DATE] at 10:58 AM, V2, Director of Nursing, stated she had not reached out to the local health department regarding COVID-19 infection. The QA meeting summary documented there was an Interdisciplinary Team (IDT) meeting held on [DATE], at 2:51PM, and a discussion was held with V36, Medical Director, regarding staffing, integrating new referral/admission processes, new lab process, but there was no documentation in regard to the COVID-19 outbreak at the facility recently. The facility policy, Screening: Residents, Health Care Personnel and Residents, dated [DATE], documented, The facility will put into place measures and processes to inform residents, visitors, and health care peroneal of recommended actions to prevent the transmission of COVID-19. It continues, The facility will post visual alerts at entrances and other strategic areas that include instructions about current infection prevention and control recommendations. This includes when to use source control and when to perform hand hygiene. It continues, Visitors- visual prompts will be posted to ensure visitors are aware of when their visitations should be limited or deferred including when they are infectious or potentially infectious or until they have met the health care criteria to end isolation to preserve the safety of the residents. It continues, Visitors should defer visits for the following: they have a positive viral test for SARS-COV-2, they have symptoms of COVID-19, they have close contact with someone with SARS-COV-2 infection, they have been in a situation that put them at high risk for transmission until 10 days after close contact. The facility policy, Healthcare Personnel Work Restrictions, dated [DATE], documented, The facility will implement appropriate work restrictions for Healthcare Personnel according to current regulatory guidance. It continues, Healthcare personnel with confirmed Covid-19 return to work criteria Covid 19 documents confirmed infection are excluded from work and may return to work based on the severity of their illness. The facility policy, Covid-19 testing plan, dated [DATE], documented, The facility will implement a testing plan to assist in preventing the transmission of COVID-19. The policy documents testing is required in the following instances: residents who are symptomatic regardless of vaccination status even if symptoms are mild as soon as possible, asymptomatic residents and health care personnel with close contract or higher risk exposure with someone with SARS_COV-2 infection (serial testing: series of 3 viral tests). It continues, If the facility is in outbreak status (immediately and twice weekly or very ,d+[DATE] days until no more positive cases for 14 days. The facility's Infection Prevention and Control Program Policies and Procedures: General Statement, dated ,d+[DATE], documented, The organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidenced based approaches to infection prevention. The infection prevention and control program: Investigates, controls, and prevents infections in the organization. Decides what procedures, such as isolation, should be applied to the individual resident/patient. Maintains a record of incidents and corrective actions related to infections. Has written procedures as a basis of determination for isolation (transmission based precautions) to help prevent the spread of infection. Has an employee health directive to prevent the spread of communicable diseases through work restriction and hand hygiene. The Immediate Jeopardy that began on [DATE], and was removed on [DATE], when the facility took the following actions: 1. V40, Medical Records, notified the facility's Medical Director, V36, of the Immediate Jeopardy. 2. Facility infection control policies were reviewed by Regional Nurse, V37, and V1, Administrator, to ensure it is acceptable with Standards of Practice and CDC Guidelines. 3. On [DATE], V2, DON, and V3, MDS Nurse, immediately assessed and tested all residents for COVID-19, and then tested all staff members immediately or prior to their next working shift for COVID-19. 4. On [DATE], V38, Corporate Infection Preventionist Nurse, trained V1, Administrator, V2, DON, V3, MDS Nurse, V4, Business Office Manager, and V22, ADON, on Vaccine and Reporting Policy, Screening of Resident and Healthcare Personal Policy, COVID-19 Plan Policy, Management of Residents with confirmed and suspected COVID-19 infection and transmittal-based precautions policy, and Healthcare personal work restriction policy. 5. On [DATE], all staff members were educated, via in-service, email, or phone call, by V1, V2, V4, and V38, regarding the facility's policy on COVID-19 required testing and monitoring including biweekly testing during outbreak status for staff and residents initiated on [DATE] and/or prior to the next working shift. No staff will be allowed to begin their scheduled shift prior to being educated in accordance with these policies and procedures. 1. Vaccine and Reporting Policy. 2. Screening of resident and healthcare personal policy. 3. COVID-19 testing plan policy. 4. Management of residents with confirmed and suspected COVID-19 infection and transmittal-based precautions policy. 5. Healthcare personal work restriction policy. 6. V3, MDS Nurse/Infection Preventionist, will review COVID testing log bi-weekly to ensure completion according to CDC guidelines and facility policy for four weeks and again when outbreak status occurs in the facility. 7. V38, Corporate Infection Preventionist, will be reviewing V3's audits upon completion. On [DATE], the survey team validated the removal of the immediacy by interviewing V14, LPN, V37, CNA, V39, CNA, V15, RN, V40 Medical Records Director, V41, Housekeeping Supervisor, V13, Activities Director, and V18, Cook, about the in-services they received related to the following policies and procedures: 1. Vaccine and Reporting Policy. 2. Screening of resident and healthcare personal policy. 3. COVID-19 testing plan policy. 4. Management of residents with confirmed and suspected COVID-19 infection and transmittal-based precautions policy. 5. Healthcare personal work restriction policy. The completed facility audits, in-services and policies were reviewed.

Based on observation, interview, and record review, the facility failed to assess/monitor, provide treatments as ordered, and provide pressure relief to prevent pressure ulcers for 1 of 2 residents (R30) reviewed for pressure ulcers in the sample of 52. This failure resulted in R30 developing two facility acquired unstageable pressure ulcers to R30's left and right heels, and a Stage II pressure ulcer to his buttocks. Findings include: R30's Face Sheet, undated, documents R30 was admitted on [DATE], and has diagnoses of left femur fracture and hypertension. R30's Minimum Data Set (MDS), dated [DATE], documents R30 is moderately cognitively impaired and requires substantial / maximal assistance for staff for activities of daily living and mobility. R30's Braden Assessment, dated 1/12/24, documents R30 is a mild risk for developing pressure ulcers. R30 did not have an updated Braden Assessment after her return from the hospital on 1/27/24 with a fractured left hip. R30's Physician Orders, dated 1/28/24 - 2/28/24, documents, Heel protectors at all times. Start date of 2/1/24. R30's Physician Order Report, dated 1/28/24 - 2/28/24, documents, Start date of 2/27/24. Cleanse R (right) heel with wc (wound cleanser), apply betadine and LOTA (leave open to air). R30's Treatment Administration Record, documents, Start date of 2/9/24. Discontinue date of 2/22/24. Cleanse R (right) heel with wc (wound cleanser), apply betadine and LOTA (leave open to air). R30's February 2024 Treatment Administration Record did not document a treatment for R30's right heel pressure ulcer from 2/23/24 through 2/28/24. R30's Nurse's Note, dated 02/01/2024 at 1:27 PM, documents, 0900 This nurse assisting with res (resident) care, removed (anti-embolism stockings) due to soiled, noted a purple fluid filled blister to left heel, measuring 9 cm x 8 cm, no drainage present, blister intact. Heel protectors put into place, new order to skin prep blister TID (three times daily) and PRN (as needed), monitor for blister opening. Right buttock has sheering area noted measuring 4 cm x 1.5 cm, pink in center, no drainage present, new order to apply barrier cream TID and PRN for incontinence, monitor for worsening. (V33, Nurse Practitioner) NP notified. Res has no pain when asked. There was no documentation regarding a pressure ulcer to R30's right heel. R30's Wound Note, written by V17, Wound Doctor, dated 2/22/24, documents, Site 1 Unstageable (due to necrosis) of the right heel full thickness pressure ulcer measuring 4 x 3.5 with thick adherent black necrotic tissue 100%. Recommendations: Float Heels in Bed'; Off- Load Wound; Multipodus boot to use when out of bed. Dressing Treatment Plan: Primary Dressing Betadine apply once daily for 30 days. Site 2 Unstageable (due to necrosis) pressure ulcer of the left heel full thickness pressure ulcer measuring 5 x 5 x 0.1 cm. with 95% thick adherent black necrotic tissue and 5% granulation tissue. The progress of this wound and the context surrounding the progress were considered in great depth today. Reviewed off-loading surfaces and discussed surfaces care plan. Recommend upgrading off-loading devices in bed and/ or chair. Recommendations: Off-Load Wound; Float heels in bed; Pressure Off- Loading Boot; Multipodus boot when out of bed. Dressing Treatment Plan Primary Dressing. Gauze island w/ bdr (with border) apply once daily for 30 days. Betadine apply daily for 30 days. To heel eschar.; Leptospermun honey (medi - honey) once daily for 30 days: To granulating area. Site 3 Stage 2 Pressure Ulcer of the buttocks, measuring 3 x 1 x 0.1 cm, no exudate, open areas with dermis. Dressing Treatment Plan Primary Dressing House barrier cream apply twice daily and as needed for 23 days. R30's Nurse's Note, dated 02/23/2024 at 10:05, documents, Resident seen by wound physician. New order received: Cleanse wound with wound cleanser, apply betadine to eschar, medihoney to granulating area, cover with dry dressing. Resident and family aware of new orders. The Nurse's Note did not document which pressure sore was receiving the new treatment. R30's Nurse's Note, dated 02/27/2024 at 11:56, documents, Routine wound care being provided. Barrier cream no longer effective to area to L buttock due to drainage. (V17, Wound Doctor) notified, and new order received to cleanse wound to L (left) buttock with wound cleanser, apply calcium alginate and dry drsg (dressing) q (every) d (day)and prn. Resident and POA (Power of Attorney) aware of new orders. Wound measurements 1.1cm x 0.9cm at this time, scant to moderate amount of serosanguinous drainage noted. Updates noted in wound management. R30's Nurse's Note, dated 02/27/2024 at 17:57, documents, New order placed per (V17). to Cleanse area to R (right) heel, apply Betadine and LOTA q daily. Resident and POA aware. R30's Wound Note, written by V17, dated 2/29/24, documents no changes to R30's heel pressure ulcers, R30 left buttock pressure ulcer has moderate serous exudate and 60% dermis and subcutaneous tissue, and the wound progress of not at goal. On 2/26/24 at 12:00 PM, R30 was sitting up in wheelchair with no heel protectors on. On 2/27/24 at 8:53 AM, R30 was sitting up in wheelchair in room with no heel protectors on just slipper socks. On 2/27/24 at 12:03 PM, R30 was sitting in wheelchair with heel protectors on. On 2/28/24 at 8:25 AM, R30 was sitting in wheelchair with no heel protectors on. On 2/27/24 at 10:50 AM, V14, Licensed Practical Nurse and V15, Registered Nurse, entered R30's room to provide pressure ulcer treatment to R30's left heel. V14 and V15 stated R30 had a pressure ulcer on his left heel, a shear area to his upper buttock, and the upper buttock just gets barrier cream. V14 removed the old left heel dressing. The dressing had yellowish brown drainage on it. The wound was cleansed with normal saline. The pressure ulcer was approximately 5.5 centimeters (cm) x 5 cm. An area at the top of the wound has a wound bed that is a small area of granulation tissue. The rest of the pressure ulcer was necrotic, hard, and black. The wound was treated with medihoney and betadine, then a dry dressing and gauze. R30 then was rolled onto his right side and his incontinent brief was removed. R30 had a pressure area approximately 3 cm x 1 cm. The wound bed is white. The brief had yellow drainage where the pressure area was. V14 stated she will put barrier cream on it. V15 who saw the wound stated, It's a Stage 2 pressure ulcer now. We need to let IV2, Director of Nursing/DON) know so she can look at it. V14 did not observe or treat the pressure ulcer on R30's right heel. On 2/27/24 at 11:15 AM, V2 stated she did look at R30's buttocks; the wound had worsened and she was going to call the wound doctor and get a doctor's order. V2 did not mention R30's pressure ulcer to right heel at that time. On 2/27/24 at 3:15 PM, V2 entered R30's room to look at R30's right heel. R30's was lying in bed. R30 did not have heel protectors on. R30's right sock was removed. R30's right heel pressure ulcer is approximately 4 cm x 3 cm. The pressure ulcer is necrotic, hard, and black. On 2/27/24 at 1:10 PM, V14, Licensed Practical Nurse/LPN, stated she was unaware R30 had a pressure ulcer on the right heel because she reviewed the orders before she did his treatment earlier, and there was no order for R30's right heel. On 02/27/24 at 1:20 PM, V2 stated R30 should have an order for Betadine daily for the right heel unless she accidently deleted it. On 2/27/24 at 3:15 PM, V2 stated R30 did get the heel pressure ulcers while in the facility. V2 stated, After he came back from the hospital because of a broken left hip, (R30) laid on his back with his heels on the mattress and staff were kinda afraid of his left leg because the hip was broken. The policy Wound Management Program, dated 2/26/21, documents, the facility will assess residents weekly for current skin conditions. The facility provided document What is a pressure Ulcer, undated, which documents, Pressure ulcers develop when there is injury to the skin and underlying tissue due to pressure for an extended period of time. This constant pressure reduces the blood supply to that area, preventing the delivery of vital nutrients and oxygen. Pressure ulcers most commonly occur in patients confined to a wheelchair or a bed. It continues, What can I do to prevent a pressure ulcer? Reposition yourself while in bed at least every 2 hours, in a chair at least every hour. Elevate you heels off the bed using a pillow under your lower legs.

Based on observation, interview and record review, the facility failed to provide foot care, including providing current treatment and consulting with a Podiatrist for further treatment, for 1 of 1 resident (R31) reviewed for foot care in the sample of 52. This failure caused R31 to be in severe pain and have a severely reddened, swollen, and very tender fourth toe and/or foot for a long period of time. Findings include: R31's Face Sheet, undated, documents R31 was admitted to the facility on [DATE], and has diagnoses of arthritis, left hip, corns and callosities. R31's Care Plan, revised 1/10/24, documents R31 has potential/actual impairment to skin integrity related to, hypertension, history of falling, unspecified abnormalities of gait and mobility, tremor, dementia, anxiety, ambulates without assistants, fragile skin due to natural aging process. The Care Plan Approach, revised on 10/2/23, documents Weekly skin checks per licensed nurse. Document skin check in EMR (electronic medical record). 2) Treatment as per orders. The Care Plan Approach documented staff should report any red or open areas to the charge nurse. R31's Minimum Data Set (MDS), dated [DATE], documents R31 has a severe cognitive impairment, uses a wheelchair as a mobility device, is dependent on staff for sit-to-stand, and tub/shower transfers, requires substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility, chair/bed-to-chair transfers, and toilet transfer. R31's Podiatry Note, dated 3/9/23, documents, Apply skin prep to 4th toe left foot QID (four times a day) X 4 weeks or longer until healed, no shoe B/L (bilateral/left) feet, cut a hole in left shoe. R31's Physician Order, dated 8/15/23, documents, Patient has corn on Left 4th toe. Make sure she will be seen by Podiatrist at facility when he comes next. See if there is a way, he can give nurses order between visits to keep corn under control. R31's Physician Order, dated 11/24/23, documents Check Left foot 4th toe q shift. Cleanse with wound cleanser and apply betadine/ Band-Aid to skin corn. Every Shift. This order was Discontinued on 2/12/24 by V5, Registered Nurse/RN. R31's Nursing Note, dated 1/19/24 at 8:04 AM, documents, Resident had a scheduled Care Plan 01-17-2024 with family. All concerns were addressed, family was happy with all care, resident will continue to be monitored, any changes will be made in next Care Plan meeting. There were no wound notes seen in R31's electronic medical record. R31's Medication Administration Record (MAR), dated 2/1/24 through 2/29/24, documents Check Left foot 4th toe q (every) shift. Cleanse with wound cleanser and apply betadine / Band-Aid to skin corn. Every Shift. This has not been signed off as completed since 2/11/24. On 2/26/24 at 9:10 AM, R31 was sitting in chair with her shoes and socks on. R31 stated her toes hurt when she touches them on anything, and especially when the staff are putting her shoes and socks on. R31's left shoe does not have a hole in it and is securely tied to R31's foot. On 2/27/24 9:55 AM, V12, R31's Daughter, stated, I visit my mom (R31) twice a day. Mom has a sore on one of her toes on left foot. I take pictures of it and check it every time I come in, and I can tell you that no one is doing anything with it. I had a Care Plan meeting and brought this to their attention, and still nothing is being done. I brought it up to the MDS Nurse (V3), and he said it looks like the treatment is getting done because it is charted, but I assure you, nothing is getting done. I have watched staff put mom's shoes on and she cries in pain every time. I am here to put mom to bed in the evening and her toe never has a band-aid on it or has been treated with Betadine, which I thought they were supposed to be doing. On 2/28/24 at 9:40 AM, V12 stated R31 was seen a year ago by a podiatrist and has not been seen since. V12 took off R31's left shoe and sock to show R31's left toes. Upon taking off her shoe and sock, R31 was grimacing in pain. R31 accidently hit her toes on the footrest of her wheelchair and grimaced and said Ouch. R31's left fourth toe was very crusty, swollen, red and painful to touch. The surrounding toes were also reddened, swollen, dry and crusty. On 2/28/24 at 9:45 AM, V3, MDS Nurse, stated Yes, (R31) is supposed to get a band-aid on her toe daily and I assumed it was getting done. On 2/28/24 at 9:50 AM, V2, Director of Nursing (DON), was brought into R31's room to see R31's toe, along with V12. V2 stated, It definitely looks tender. I wasn't involved in the Care Plan meeting and have not been told about (R31's) toe. No one has left me notes about it, and I haven't seen anything noted about it in her chart. The old ADON (Assistant Director of Nursing) was doing wounds on the day shift, and he no longer does that, and works the evenings now. I am the one doing wounds now, and I knew nothing about (R31's) toe. I know every wound in the facility and I am not sure that (R31's) toe is a wound, it is not open, just dried up. I will have the wound doctor see (R31) tomorrow to make sure we get the right treatment for her. Her toe looks like it does because it has not been treated. R31's Nursing Note, dated 2/28/24 at 10:20 AM, documents, NP (Nurse Practitioner) notified that daughter requesting res (resident) to have tx (treatment) again to corn on right fourth toe of cleansing with wound cleanser, applying Betadine and covering with band-aid. New orders received for this from NP who also inquired if daughter would like a referral for consult to (V32, Podiatrist) at (local hospital) and daughter stated she would. R31's Nursing Note, dated 2/28/24, at 10:30 AM, documents Left fourth toe cleansed with wound cleanser, betadine applied and covered with band-aid. No opened or draining areas noted. Res has hard, raised corn from mid-left side of toe which daughter states res has had for a long time-that she used to put betadine on it for a few days at a time when she took care of resident at home. No redness or warmth noted to left fourth toe or surrounding area. Res voices no c/o's pain during treatment. On 2/28/24 at 11:25 AM, V5, Registered Nurse (RN), stated, I was the one who discontinued (R31's) order for the treatment to her toe. I discontinued the order because it had been going on for a long time without any changes. No, I don't think she has been seen by a physician for her foot since the last time. The facility's Wound Management Program, dated 2/26/21, documents, It is the policy of (this facility) to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions. Procedure: 1. The facility is provided with Wound Care Protocols. These are to be utilized to assist in the care and treatment of wounds. This reference tool can be placed in the front of the treatment administration record book or the weekly skin assessment book. Physician orders should be obtained and followed for each resident.

Based on observation, interview, and record review, the facility failed to put progressive interventions in place and provide supervision to prevent falls for 2 of 3 residents (R30, R31) reviewed for falls. This failure resulted in R30 falling and sustaining a fractured hip, and R31 falling and sustaining a fractured arm. Findings include: 1.R30's Face Sheet, undated, documents R30 was admitted to the facility on [DATE], with diagnoses of Pneumonia, Hypertension and Shortness of Breath. R30's Nurse's Note, dated 01/04/2024 at 1:33 PM, documents, Patient arrived via (local) Emergency Medical Services with 2 attendants. Patient was in ER (emergency room ) for two days, diagnosis fall. Patient had multiple unwitnessed falls at home. R30's Fall Risk Assessment, dated 1/4/24, documents R30 is a high fall risk. R30's Care Plan, initiated on 1/4/24, documented R30 was at risk for falls related to generalized weakness, forgets limitations, hearing impaired, unsteady gait, and occasional incontinence, Pathological fracture, left femur edited on 2/11/24. The Care Plan approaches, dated 1/4/24, were created by V2, Director of Nursing (DON). The Care Plan approaches were as follows: Use proper assistive device wheelchair/walker as needed; Rest periods as needed, Observe for safety; invite/escort to activities of choice as tolerated as desired; and Cues/redirect as needed. These approaches were entered into R30's Care Plan on 1/29/24. R30's Care Plan approach, dated 1/4/24, created by V2 on 2/7/24 documented, Call light within reach while in room and remind resident to call for assistance as needed, and clutter free environment. These approaches were entered into the Care Plan on 2/7/24. R30's Nurse's Note, dated 01/21/2024 at 10:46 PM, documents, CNA (Certified Nurse) witnessed resident on knees on the floor in the praying position sitting upright. resident stated he needed blue jeans, resident had grippy socks on at time of fall. Upon RN (Registered Nurse) assessment resident was at normal baseline, vitals noted all WNL's (within normal limits) in fall event, resident had no s/s (signs/symptoms) of pain/discomfort at this time. resident had no visible bruising/skin alterations at this time. POA (Power of Attorney) called, voicemail was left at 9:10 pm, DON/MD (Director of Nurses / Medical Doctor) notified. R30's Event Report for fall on 1/21/24, documented, Conclusion with root cause: Root cause analysis suggests resident was cold and trying to get warm by getting blankets. R30's Nurse's Note, dated 01/26/2024 01:30, documents, Called to room per CNA. Res observed laying on left side in front of personal bathroom. Bed in low position. Grippy socks on. Incont (incontinent) of BM (bowel movement). Res A&O (alert and orientated) x 2. Neuro (neurological) check WNL (within normal limit). Grips equal and strong. L (left) knee rotated inward. Complaining of moderate L hip pain and requesting to go to hospital. On call, (V35, Medical Doctor), notified and gave new order to send res to ER for eval (evaluation) and tx (treatment). R30's Nurse's Note, dated 01/26/2024 07:17, documents, (local hospital) called and reported that patient has left hip fx (fracture), CT (cat scan) done of head due to latent hematoma that presented at hospital, it was negative. R30's Hospital Discharge Summary, dated 1/27/24, documents, Left hip fracture s/p (status post) surgical repair. R30's Fall and Investigation Event Report, dated 1/29/24, documents, Conclusion with root cause: Res (resident) up without assist and was incont (incontinent) of BM (bowel movement). R30's Care Plan approaches, start date of 1/26/24, created by V2 on 1/29/24, documented PT/OT (Physical Therapy/Occupational Therapy) to eval (evalutate) and treat; and call light reminder sign placed in resident room. There was no documentation of what type of supervision R30 needed by staff in the care plan. R30's Care Plan was not updated until 1/29/24 by V2 and documented, Staff to encourage and offer toileting and give additional blankets while in bed for warmth. In the medical record, there was no documentation that he facility reassessed R30 for need for supervision to prevent falls. R30's Nurse's Note, dated 02/01/2024 at 1:31 PM, documents, 1130 Res visually observed with knees on floor, in kneeling position with upper half of body on bed. Res assisted back into bed with 2x staff, LLE (left lower extremity) stable during transfer. PROM WNL (passive range of motion within normal limits), res denies pain to LLE or pain anywhere. No rotation noted to LLE. Pedal pulse present. Res incontinent of bladder, grippy socks with heel protectors in place, bed was in low position. No injuries noted. VS (vital signs) noted. Res did not have call light on, spoke with ST (speech therapy) whom is working with res for cognition, she is going to provide a visual aide sign for reminder of call for resident. (V33, Nurse Practitioner) notified. Res had been toileted approximately 1hr prior to this event. 1245p Res up in w/c (wheelchair) for lunch, ate 50% and drank fluids, propels self in hallway. Res denies pain when asked. R30's Care Plan was not updated after this fall. R30's Nurse's Note, dated 02/04/2024 10:44 AM, documents, Writer called to patient's room, patient observed on bedside mat on knees with bed in lowest position and upper body leaning onto bed. Patient stated that he put self in that position to relieve hip pain. Patient states he is not hurt did not fall onto floor, slid onto knees. ROM in WNL for this patient. 98.2 (temperature) 70 (pulse) 18 (respirations) 32/68 (blood pressure) 96% (oxygen saturation level) on RA (room air), Pain medication given at this time. Patient is sitting at nurses' station at this time. R30's Nurse's Note, dated 02/05/2024 10:29 AM, documents, IDT (Interdisciplinary Team) team met and reviewed falls. (R30) is at risk for falls r/t (related to): Generalized weakness, forgets limitations, hearing impaired, unsteady gait, and occasional incontinence, Pathological fracture, left femur. (R30) has had multiple falls: unwitnessed fall 1/21/24 unwitnessed fall 1/26/24 unwitnessed fall 2/1/24 unwitnessed fall 2/4/24. Discussed resident attempting self-transfer out of bed often, raised edge mattress placed on bed. Family updated. Fall mat remains in place to reduce injury. Call light reminder sign in place to remind resident to call for assistance with transfers. R30's Fall and Investigation Event Report, dated 2/7/24, documents, Conclusion with root cause: Resident forgets to call for assistance. Fall mat placed beside bed to reduce harm if resident attempts to get out of bed. R30's Care Plan approach, with start date of 2/4/24, created by V2 on 2/7/24 documented, Raised edge mattress placed on bed. There was no documentation regarding fall mat. On 3/7/24 at 9:52 AM, V20, Certified Nurse Aide, CNA, stated she took care of R30 before he fell , and he had got sick to his stomach and vomit on himself. V20 stated, The next day when I came back to work, they told me he had fallen and broke his hip. I think he didn't feel good and was trying to get up. He was confused but he would get himself up. At that time, he did not have any fall prevention interventions those did not go into place until after he broke his hip. 44967 2. R31's Face Sheet, undated, documents R31 was admitted to the facility on [DATE], with the diagnoses of Displaced fracture of coronoid process of right ulna, subsequent encounter for closed fracture with routine healing, dislocation of right ulna-humeral joint, dementia, anxiety, emphysema, dysphagia, vertigo, perforation of tympanic membrane, left ear, hearing loss, bilateral, arthritis, left hip, and a history of falling. R31's Care Plan, dated 10/28/22, documents R31 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, and poor safety awareness related to Basic Interview for Mental Status (BIMS) of 8, up ad lib in facility with walker. The Care Plan documents R31 fell on [DATE], 9/27/23, 12/1/23, 12/8/23, and an unwitnessed fall on 2/10/24. Care Plan approaches with approach start dates are as follows: (2/10/24) Place resident in common areas for increased supervision; (2/10/24), Physical Therapy (PT)/Occupational Therapy (OT) to evaluate and treat; (12/8/23) Continue with antibiotic for ear infection, ear Infection contributes to poor balance; (12/1/23) Encourage resident to take frequent rest periods and staff to provide stand by assist when ambulating with walker; (10/17/23) Ensure the resident has on proper footwear such as non-skid socks or rubber sole shoes, (9/27/23) Staff to check on resident hourly; (7/23/23) Alarm declined by resident and Power of Attorney (POA) due to possible agitation; (7/21/23) Medication review, Norco discontinued, (7/20/23) R31 refuses to utilize gait belt with ambulation, education provided to resident and POA, and place visual reminder in room and verbally remind as needed to utilize walker for ambulation; (3/17/23) R31 may not report when she falls, daughter to assist in reporting to staff if fall is indicated, is up ad lib with walker, attempt to keep clear path and remove obstacles as needed to promote safety, encourage R31 to utilize walker when ambulating; (11/13/22) Attempt to keep bathroom light on and leave bathroom door open, and (10/28/22) Increased staff supervision as needed, keep frequently used items within reach, keep floor free of clutter, utilize half side rails as indicated, assessment and treatment for postural/orthostatic hypotension with falls, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, implement exercise program that targets strength, gait and balance. R31's Admission Fall Risk Assessment, dated 10/29/22, documents R31 is a high fall risk. R31's Fall Risk Assessment, dated 1/3/24, documents R31 is a high fall risk. R31's Fall Risk Assessment, dated 2/10/24, documents R31 is a high fall risk. R31's MDS, dated [DATE], documents R31 has a severe cognitive impairment and is dependent on staff for sit-to-stand and tub/shower transfer, requires substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility. R31's Fall Investigation, dated 12/1/23, documents, Description: Unwitnessed Fall in resident's room. What was resident doing just prior to fall? Sitting up in chair in room. Pain observation: Yes, mild pain to right hip. Interventions: Analgesics, rest, reminders to use call light. Conclusion with root cause: Resident wandering in hallway and around room and redirected frequently during NOC (hours sleep). Resident standing at window looking out blinds several times tonight looking at the rain. Found on floor in front of window with walker in use at time of fall. Treatments: Monitor for latent injuries related to recent fall. Evaluation Notes: Resident is a [AGE] year-old female who becomes weak at times. Encourage resident to frequent rest periods and staff to provide stand by assist when ambulating. R31's Fall Investigation, dated 12/8/23, documents, Description: Unwitnessed fall in resident's room. What was resident doing just prior to fall? Resting per bed. Pain observation - Yes to wrist. Positioning of extremities: Skin tear to left posterior wrist. Interventions: First Aid. POA refused interventions offered - no interventions used. Conclusion with root cause: Resident has an ear infection which contributes to balance issues. Continue on ABT (antibiotics). Evaluation Note: Continue with ABT for ear infection which as cause balance issues. R31's Fall Investigation, dated 2/10/24, documents, Description: Unwitnessed fall in resident's room. What was resident doing just prior to fall? Sitting in chair in room. Location of injury: Upper extremity - RUE (right upper extremity). Positioning of extremities: LROM (limited range of motion) to RUE - resident will not move due to pain. Possible contributing factors: Recent change in medications - placed on ABT (antibiotics) for left ear infection recently 12/9/23. Interventions: Sent to (local hospital emergency room - returned with fracture and arm sling. Conclusion with root cause: Resident has had frequent ear infections which may affect balance and a-fib. Resident has fractures to RUE. PT (Physical Therapy)/OT (Occupational Therapy) to evaluate. Will place resident in common areas for increased supervision. will follow up with (V30, Orthopedic Physician) (ortho on 2/15). Evaluation: Resident seen by NP. R arm remains bruised and swollen. Will follow up with (V30) on 2/15. R31's Nursing Note, dated 2/10/24 at 2:52 PM, documents [Recorded as Late Entry on 02/12/2024 03:30] Nurse called to resident room at 1552 (3:52 PM). (R31) observed in floor lying flat on back with head up against bathroom door. Nurse completed full assessment; no visible injuries noted. Resident c/o (complained of) moderate to severe pain to R (right) arm. LROM (limited range of motion) noted. No obvious injury to area, but resident unable to move R upper extremity and tearful. Full ROM (range of motion) noted to BLE (bilateral lower extremity), no internal or external rotation noted. CNA and this nurse remained at bedside. Neuros WNL (within normal limit) for resident baseline. VSS (vital signs stable). R31's Nursing Note, dated 2/10/24 at 10:46 PM, documents, Resident returned back from ER with Family. Dx (diagnosis) of dislocated shoulder joint and fractures of the coronoid process and radial head/neck are noted. Resident has sling to right arm. Had several doses of Morphine in ER with last dose at 10pm. She is to follow up with (V30, Orthopedic Physician) on Monday and continue with Tylenol for pain. Family here and requested a tray for (R31). Given at this time. R31's Nursing Note, dated 2/13/24 at 10:02 AM, documents, Res (resident) was a 1 x assist for transfer this AM, confusion noted. Right arm in sling, right hand has edema noted, radial pulse present, Ace wrap in place to right arm with soft splint. Ace wrap removed from lower portion and rewrapped due to it was tight. Res has f/u (follow up) on 2/15 at 14:00 per NP (Nurse Practitioner). NP to be in this afternoon to round on resident, notified of edema. Pillow and blanket rolled up to for positioning of right arm and elevated. Res (resident) c/o (complained of) pain to right arm this AM, took scheduled Tylenol. R31's MDS/Change in Condition, dated 2/21/24, documents R31 has a severe cognitive impairment and is dependent on staff for sit-to-stand, and tub/shower transfer, requires substantial/maximal assistance of staff for all other Activities of Daily Living (ADLs). R31's Nursing Note, dated 2/29/24 at 7:42 AM, documents, Resident sitting up in wheelchair. Band-aid in place to L 4th toe, tx (treatment) completed early am by noc (night) nurse. Brace in place to R arm r/t fx (fracture). Pulses present/neurovascular WNL. No c/o pain or distress noted. Resident requires stand-by assist for transfers/ambulating to bathroom, remains continent most of the time. Alert to self, confused to time and place and requires frequent redirection. Family here at this time to visit. Cont (continue) with therapy as ordered. Awaiting wound consult with (V32, MD). On 2/26/24 at 9:10 AM, R31 was sitting in a chair in her room with no staff present in the room. R31's call light was seen on the bed and not within reach of R31, restroom door is closed, sign posted Always remember walker. There was no other way to determine if R31 is a fall risk was seen. On 2/27/24 9:55 AM, R31's Daughter, stated, I visit my mom (R31) twice a day. She has been here over a year now. Mom has fallen about six times since she's been here. The biggest one was when they found her on the floor, it looked like she was coming out of her restroom and landed on her right side. She dislocated her elbow and fractured it in two places. They sent her to ER (emergency room ) and then back with a brace. Due to her medical conditions, they did not want to do surgery. They did place mom by the nurse's desk at one time, but that was just as bad, because there is no one there to watch her either. On 2/27/24 at 2:25 PM, R31 was sitting in her chair by bed, wheelchair next to her, walker next to wheelchair, no staff seen in or around her room. R31 was not visible by anyone unless passing the room. R31's restroom door was closed, no other fall interventions noted. R31 was not seen in the common areas for increased supervision. On 2/29/24 at 7:45 AM, R31 was walking around her room without using her walker or wheelchair while trying to hold onto the bed and wheelchair during her walk, with no staff present in room. R31's call light was tied to the bedrail. On 3/4/24 at 9:05 AM, R31 sitting in her chair in her room by herself. R31's wheelchair was by bed approximately two feet away. R31's call light was tied to bedrail and not within reach of R31. There was now a star on R31's name plate that was not there previously. On 3/4/24 at 2:45 PM, V20, CNA, and V11, CNA, both stated they are not sure what the stars on the resident name plate means. V11 thought it had something to do with toileting of the residents. V20 stated the main problem at the facility is with communication, and in all the meetings, she tells the nurses and the DON that they need to communicate with the CNAs about who is a fall risk, and what we are doing with them. V20 stated R31 always falls, and she is not sure what interventions are in place to keep her from falling. The facility's Fall Prevention Management Policy, dated 3/15/18, documents, It is the policy of (this facility) to have a fall prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. We will develop a culture of safety to provide the Quality of Care and preventive services for each individual resident. Our Quality Assurance Program will monitor the program to assure ongoing effectiveness. Fall Prevention Program Components: 2. A visual prompt is placed on the name plaque by the entrance to the resident's room. This system provides staff a visual alert to monitor those at risk for falls. Standards: 2. A Fall Risk Assessment will be performed at least quarterly and after any fall incident. Standard Fall/Safety Precautions: 7. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or chair and provide care as assigned with the plan of care.

Based on interview and record review, the facility failed to keep residents free from attempted and misappropriation of money, related to a staff member trying, and getting money from residents, for 2 of 3 residents (R1, R3) reviewed for misappropriation in a sample of 8. This failure resulted in R1 having money stolen from his account and R1 now feels unsafe and can't trust staff. This failure also resulted in R3 having staff attempting to withdraw money from his account, and now he feels angry at staff. Findings include: 1. R1's Minimum Data Set, dated dated [DATE], documents R1 is cognitively intact. R1's check number 2686, dated 04/22/23, documents Pay to: V6, Certified Nursing Assistant, in the amount of $2000.00. with a memo: Loan. R1's written statement, dated 05/22/23, documents he had not given any employee money, or a check, to cash for their personal use. The staff must have gotten it out of his bag, in his book, in his nightstand, but he never saw them. He keeps some checks in his room in a bag in his drawer. He is missing checks, not sure how much, but his POA (Power of Attorney), and lawyer would be returning, and would let him know the amount. On 05/24/2023 at 9:00 AM, V1, Administrator, stated she was made aware of R3 voicing his money had been taken. V1 stated R3 had identified V6. V1 stated R3 and V7, R3's sister, notified her V7 attempted to remove money from the account per cash app and was denied. R3 and V7 stated she was notified of ATM (Automated Teller Machine) withdrawls that R3 denies doing and giving permission to anyone. R3 and V7 did not have any written proof of the withdrawls. V1 stated V7 was going to get the bank statements and bring them back to the facility. V1 stated V7 has not done so at this time. V1 stated the police were called and that they were told, without an amount they could not investigate it. V1 stated she interviewed V6. V6 admitted to taking $200 dollars from the ATM, for R3, per his request. V1 stated V6 said she gave the money to R3, but no one saw her. V6 stated this happened 2 months prior. V1 stated she can't, at this time, say V6 stole money from R3. V1 stated either way, V6 was in the wrong, and should not have used R3's card for any reason. V1 stated she became aware of another incident of R1 having a check removed from his check book and money taken from his account. The check was out of sequence, and did not look like R1's handwriting. V1 stated she was aware R1 had checks at the facility. V1 stated the checks were in his drawer, next to his bed, under some items. V1 stated to retrieve the checks you would have to dig and get them. V1 stated they had a copy of the check. V1 stated the police were called, and a report was filed, and she had interviewed R1, and he denied giving his check book to anyone. V1 stated R1 is alert and aware of his surroundings, and knows what's going on. V1 stated the checks were written in a different handwriting than the other checks. On 05/24/23 at 8:50 AM, R1 stated initially, he did not know there was any money taken out of his account. R1 stated he was notified by his POA (Power of Attorney), V5. V5 writes his checks and pays his bills. V5 brought a cashed check to him that was written to V6, CNA. R1 stated they looked through his check book and were able to find where the check was removed, which was out of sequence. R1 stated he did not write a check to anyone; he doesn't write his checks. R1 stated if he would have written the check, then he would have taken the check off the top. The check was not cashed at his bank, the check was cashed at the bank across the street from the facility, and that was not his bank. R1 stated this is not the first time he has had money stolen. R1 stated the facility found the money on the bus. R1 stated he doesn't feel safe and can't trust the staff and stated, How do you live like that? On 05/24/23 at 8:55 AM, V5, R1's POA, stated he noticed there was money missing from R1's account, when he went to pay his bills. V5 stated he notified the bank, and was then notified of a check written to V6 for $2000.00. V5 stated R1 is alert and knows what's going on. R1 has not written his own check in a long time. V5 stated he was not made aware of any check R1 would have written, and that the handwriting was different. That's when he notified the facility, and reported it to the police. On 05/25/2023 at 9:25 AM, V4, CNA, stated R1 is alert and knows what is going on. 2. R3's MDS, dated [DATE], documents R3 is cognitively intact. R3's written statement, dated 05/18/2023, documents his sister called the bank and the bank said there were several withdrawls from his account, and he didn't do them. It documents V6 tried to move money and was denied, but thinks she took money out of the ATM (Automated Teller Machine). It documents he knows who V6 is, and she works the night shift at the facility. It documents he has given his PIN (Personal Identification Number) number to his roommate who goes to the store for him. It documents he is not aware how someone could have gotten his PIN. On 05/24/2023 at 9:06 AM, R3 stated he is a resident at the facility, and has been here for some time, and he has a debit card he keeps at the facility. R3 stated V6, CNA, stole money from him, and he is not sure of the amount, but is aware she, (V6), took the money. R3 stated V6 went to the ATM (Automated Teller Machine) across the street, and took up to $200 dollars out of his account twice. He did not give V6 permission to take or use his debit card. R3 stated he did not give V6 the PIN number, and is unsure how she got it. R3 stated his phone was missing for some time, and his phone had his banking information in it, including his PIN number to his card. R3 stated, The staff looked for the phone and no one could find it. Then miraculously, (V6) located the phone on my dresser. R3 stated he was notified V6 attempted to remove money from his account using Cash app. R3 stated he does not have a Cash app account. R3 stated he has given his card and PIN number to his roommate because he gets things for him, but his roommate brings him a receipt. R3 stated he wants to press charges and they have called the police, but was unable to file a report, because R3 didn't know the amount taken. R3 stated he has asked the staff to help him buy things because he doesn't usually get out of the facility. On 05/25/2023 at 11:33 AM, V7, R3's sister, stated she had gotten R3's bank card from him to go and get money to pay his bills. V7 stated the balance on the account was a little over $300 dollars. V7 stated she notified R3 of this, and he said this was a mistake, and he had well over $1000 in the bank. V7 stated when she spoke with the bank, she was notified of several withdraws around 5:00 AM and 6:00 AM. V7 stated she was also notified V6 attempted to transfer money from R3's account to her account on 04/24/23 and 04/26/23. V7 stated the bank denied both transactions. V7 stated she was waiting for the bank to send the statements. On 05/25/23 at 1:30 PM, R6 stated R6 and R3 are roommates. R6 stated R3 has given him his card to go to the store and get some things. R6 stated R3 doesn't go anywhere. R6 stated R3 did give him his PIN number. R6 stated when he uses the card, it is because R3 has given it to him, and has asked him to get him something. R6 stated he always brings a receipt back. R6 stated he has never shared R3's PIN number and has never been to a bank for R3. On 05/26/2023 at 2:32 PM, V6, CNA, stated she had worked at the facility and took care of both R1 and R3. V6 stated she had not stolen any money from a resident. V6 stated R3 gave her his card and PIN number, and told her to go to the bank and withdraw money for him, and she did. V6 stated she felt bad for R3 because he had asked several people, and they would not do it, so she did. V6 stated she did not try to transfer any money from R3's account with a cash app, because she does not have a cash app account. V6 stated she knew she shouldn't have done it, but she did. V6 stated she has never received a loan from any resident. When asked if she cashed a check from R1, V6 would not answer, and ended the phone call. The facility's Abuse policy, dated September 29, 2022, documents Misappropriation of resident property: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use if a resident's belongings or money without the resident's consent.

Based on observation, interview, and record review, the facility failed to investigate a resident-to-resident altercation, failed to assess a resident after a resident-to-resident altercation, and failed to keep a resident safe from resident-to-resident altercations for 3 of 3 residents (R1, R2 and R4) in a sample of 5. This failure resulted in R2 pulling R4's hair, and R2 pulling R1 halfway out of bed. R1 sustained a bruise on her left lower extremity. Findings include: 1. R2's Undated Face Sheet documents, she was admitted to the facility on [DATE] with diagnoses including depression, dementia with mood disturbance, and anxiety. R2's Minimum Data Set, (MDS), dated [DATE], documents moderately cognitively impaired, behavioral symptom presence & frequency: physical and verbal behavioral symptoms (hitting, kicking, pushing, scratching, grabbing, threatening others, screaming at others and cursing at others) directed toward others occurred daily other behavioral symptoms (physical symptoms such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming/disruptive sounds) not directed toward other occurred daily. Behavioral symptoms: no impact on resident or others. Change in behavior or other symptoms resident's current behavior status was documented: worse. R2's Care Plan, dated 3/30/2023, documents, behavioral symptoms: resident exhibiting problems as seen by wandering, verbally abusive, screaming, making disruptive sounds, grabbing and cursing. Goal: Resident will have behavior improve as seen by decreased episodes of. Approaches: encourage family support and/or involvement, encourage resident to keep involvement in activities of choice, encourage resident to vent feelings/fears/frustrations PRN, (when needed), notify MD, (Physician), as needed, observe involvement in activity, provide meds as ordered and monitor effectiveness, psychiatric consult as needed, 1:1 visits as needed for reassurance, call light within reach while in room, check for pain, observe for changes in appetite/signs of withdrawal/ crying and tearfulness decreases in social interactions and changes in routine. R2's Behavioral Analysis Report, dated 4/6/2023 at 10:43 PM, by V9, Certified Nurse Assistant, (CNA), documented scratched a CNA, pulled R4's hair, and tried to pull R1 out of bed. R2's Resident Progress Notes, dated 4/2023, no resident-to-resident altercations documented. On 4/20/2023 at 11:37 AM, R2 lay in bed with the bed lowest to the floor. R2 was awake and calm at the time of the interview. R2 stated she gets mad at staff and residents from time-to-time because, she's just crazy in that way. R2 recalled pulling R4's hair while in the dining room one day because R4 wouldn't shut up. R2 recalled she didn't pull any of R1's hair out, but, she did pull R4's hair, so she would stop talking. R2 denied pulling her roommate, R1, out of bed. Review of the Facility's Resident Room Roster, dated 4/20/2023, documents R1 and R2 are roommates. 2. R1's Undated Face Sheet, documents she was admitted to the facility on [DATE], diagnoses include Alzheimer's disease, cognitive communication deficit, need for assistance with personal care and psychosis. R1's MDS, dated [DATE], documents she is severely cognitively impaired. Delirium symptoms of inattention, disorganized thinking and altered level of consciousness behavior present, fluctuates. No behaviors impact resident or others. R1's Undated Care Plan doesn't address she is at risk for abuse. R1's Resident Progress Note, dated 4/6/2023, no progress notes documented regarding R2 pulling R1 out of bed, or if R1 was assessed by a nurse for injury after staff observed R2 pulling on R1's lower extremities, pulling her out of bed. R1's Resident Progress Noted, dated 4/7/2023 at 2:51 AM, by V21, LPN (Licensed Practical Nurse), documents, Noted a 4.5 x 2 hematoma to L, (left), calf. No c/o, (complaint of), pain or facial grimacing during assessment. Resting in bed in lowest position. Call light within reach. Will continue to monitor. NP, (Nurse Practitioner), and ADON, (Assistant Director of Nurses), notified. Will have day shift notified POA, (Power of Attorney.) On 4/20/2023 at 3:00 PM, R1 was observed sitting in her wheelchair near the dining room. R1 didn't respond to IDPH (Illinois Department of Public Health) surveyor's questions. R1 was not interviewable. On 4/21/2023 at 11:16 AM, V8, LPN, pulled up R1's left pant leg and measured a bruise on R1's left lower calf 5 centimeters, (cm), by 1.3 cm. V8 stated the bruise was purple and black in color. 3. R4's Undated Face Sheet, documents she was admitted to the facility on [DATE], with diagnoses including dementia, psychotic/mood disturbance and anxiety. R4's Undated Care Plan documents psychosocial well-being resident at risk of abuse, related to diagnosis of dementia. Goal: resident will remain abuse free until next review. Approaches: all staff to monitor resident for signs and symptoms of abuse. R4's Resident Progress Note, dated 4/6/2023, no progress notes documented regarding R2 pulling R4's hair. R4's MDS, dated [DATE], documents she is moderately cognitively impaired and has verbal behavioral symptoms, (hitting, kicking, pushing, scratching and grabbing), directed towards others 1 to 3 days. Behavioral symptoms: no impact on resident or others. Change in behavior or other symptoms: same. On 4/20/2023 at 3:30 PM, R4 was observed sitting in her wheelchair near the dining room. R4 didn't respond to IDPH surveyor's questions. R4 was not interviewable. On 4/20/2023 at 10:30 AM, V1, Administrator, stated they had two residents get into an altercation over Bingo card a few weeks ago, but there hadn't been any other resident-to-resident altercations in April 2023 that she was aware of. On 4/20/2023 at 12:06 PM, V2, Director of Nursing (DON), stated, 2 residents had an altercation in the activity room over a card game a few weeks ago, but there hasn't been any other resident to resident altercations other than that incident. No residents have a history of being physically aggressive with other residents at the facility. The Facility's Daily Staffing Sheet, dated 4/6/2023, documented V10, CNA (Certified Nursing Assistant), was assigned to 200 hall evening shift which included R1, R2 and R4. On 4/20/2023 at 3:02 PM, V10, CNA, stated she works evening shift from 2:30 PM to 10:30 PM at the facility, and is often assigned to R2. R2 has behaviors and yells at her roommate, R1, often and makes her cry. One evening a few weeks ago, V10 recalled she was assigned to R2 and R2 was out of sorts. R2 always yells at staff and residents, especially her roommate (R1) but, this evening R2 was really agitated. V10 attempted to sit with R2 that shift, but she had to take care of other residents as well. At one point, she went to check on R2, and found her pulling R4's hair while R4 lay in bed. V10 redirected R2 at that time, and recalled R4 stated, I think she thought I wore a wig! V10 propelled R2 to the 200-hall nurse's station and went to assist other residents. A few minutes later, she witnessed R2 pulling her roommate, (R1), halfway out of bed. R1 was yelling, Stop! Stop! Stop! V10 ran into the room and redirected R2 from pulling on R1's lower extremities. V10 stated, she reported R2's behaviors to V14, LPN, but she didn't see her go down and check the residents. V10 stated after she redirected R2, she noted a large dark purple bruise on R1's left lower extremity, calf area. V10 stated for some reason she couldn't document resident behaviors in the computer that night, so when midnight shift got there, she asked another CNA, (name unknown), to document the incident in CNA charting. V10 stated she was upset this incident occurred because no one did anything about R2 yelling at R1 prior to the incident, and R1 has dementia and can't speak up for herself, but she doesn't serve to be yelled at and hurt by R2. On 4/20/2023 at 1:46 PM, V9, CNA, stated she works midnight shift at the facility from 10:30 PM to 7:00 AM. V9 stated about a week ago, she received CNA report from V10, CNA, and V10 told her R2 thought R4 was wearing a wig and pulled R4's hair. The same evening R2 pulled her roommate, (R1), out of bed, causing a bruise to R1's left lower leg. V9 stated R2 has aggressive behaviors and yells at residents all the time. V9 stated she reported R2's behavior to an agency nurse, (name unknown), but didn't think anything was done about it because, R1 and R2 are still roommates. V9 stated she documented the incident in the CNA charting for V10 because she is an agency CNA and doesn't have computer access. Although she didn't witness the incident, she documented it for V10. The Facility's Daily Staffing Sheet, dated 4/6/2023, V14, LPN, was assigned to 200 hall evening shift, which included R1, R2 and R4. On 4/20/2023 at 3:30 PM, V14, LPN, stated she works evening shift from 2:00 PM to 11:00 PM at the facility, and is often assigned to R2. R2 has a lot of behaviors including yelling at staff and residents. V14 witnessed R2 yelling and degrading R1 often and stated, they [NAME] a lot. No staff reported R2 pulled R4's hair, or that R2 pulled R1 out of bed. If staff reported that incident, I would have assessed all resident involved and documented the incident in the nurse's notes. V14 never witnessed R2 be physical with other residents. The Facility's Daily Staffing Sheet, dated 4/6/2023, documents V3, Assistant Director of Nursing, (ADON), was clinical on-call. On 4/21/2023 at 11:00 AM V3, ADON stated no one reported R2 pulled R4's hair or R2 pulled R1 out of bed. It was V3's understanding the bruise on R2's left lower extremity was identified on 4/7/2023, and it was from her wheelchair. When there is a resident-to-resident altercation staff are expected to call the clinical on-call to let them know what occurred to ensure an investigation is started immediately if needed. On 4/21/2023 at 11:25 AM, V2, DON stated, When a new bruise was assessed, I expect staff who initially see the bruise to report it to a nurse. When staff observe a resident-to-resident altercation, staff should immediately separate the residents and ensure they are safe, then notify the charge nurse. The charge nurse is responsible for opening an event and documenting what occurred. The charge nurse should assess all residents involved in the altercation for injuries immediately, so they know the residents are ok. The charge nurse is expected to document the incident in all involved residents' medical records what exactly occurred and if any injuries were sustained. The charge nurse should call (V1, Administrator) and (V3, ADON), and if there is an injury the charge nurse should notify the provider of the resident that got injured. CNAs document resident behavior in the computer but, it is all check off, CNAs can't type free text notes in the computer. V2 read R2's Behavior Analysis Report, dated 4/6/2023, and stated she wasn't aware R2 pulled R4's hair or that R2 pulled R1 out of bed. It was V2's understanding the bruise on R1's left lower extremity came from her footrest, but it could have been from R2 pulling on her, that is why she expects the charge nurse to assess residents after an altercation, to ensure there are no injuries sustained. V2 expected the charge nurse to obtain written statements from staff regarding what occurred because, resident to resident incidents is considered abuse and she wants to ensure staff are protecting the residents. V2 stated, she expects staff to follow the facility's abuse policy and procedure. On 4/21/2023 at 12:00 PM, V1 stated no one reported R2 pulled R4's hair, or that R2 pulled R1 out of bed. V1 stated staff should have notified the charge nurse and the charge nurse should have assessed all residents involved for injury and notified herself, V2, and V3, and an investigation should have been started immediately. On 4/21/2023 at 2:10 PM, V22, Family Nurse Practitioner, stated, (R2) has physical and verbal behaviors, and she is followed by a psychiatrist. (R2) has advanced dementia and grabs, hit and yells at staff and residents. Approximately 2 weeks ago a nurse, (name unknown), reported to her that (R2) grabbed (R1's) leg and (R1) sustained a bruise. V22 stated, The facility staff knew about it because a nurse told me about it; I assumed it was investigated. V22 stated she wasn't told R2 attempted to pull R1 out of bed, or R2 pulled R4's hair; she would have notified R2's psychiatrist because she can't do anything else for R2 other than to drug her, and that could cause R2 to fall. V22 expected facility staff to follow the abuse policy and investigate the resident-to-resident altercation when it occurred. The CNA should have reported the incident to the charge nurse, who should have assessed all residents immediately and documented in each resident's medical record what occurred and if any injuries were sustained. The Facility's Abuse Prevention Program, revised 9/29/2022, documents employees are required to report any incident, allegation or suspicion of potential abuse they observe, hear about or suspect immediately to the administrator. Upon learning of the report, the administrator shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on facility incident report the appearance of suspicious bruises. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation, and reporting to the administrator. If the resident complains of physical injuries, or if resident harm is suspected, the resident's physician will be contacted for further instructions. The facility will take steps to prevent further potential abuse while the investigation is in progress and will immediately take appropriate steps to remediate the non-compliance and protect residents from additional abuse. Residents who allegedly mistreated another resident will be removed from the situation and will have limited contact with the targeted individual during the course of investigation. The accused resident's condition shall be immediately evaluated to determine most suitable therapy, care approaches and placement, considering his/her safety, as well as the safety of other residents and employees of the facility. Any willful action that results in physical injury, mental anguish or pain must be reported. Internal investigation of abuse: all incidents will be documented, whether or not abuse occurred, was alleged or suspected. Any incidents or allegation involving abuse will result in an abuse investigation. Any other incident or pattern involving reasonable cause to suspect abuse, will result in an abuse investigation. The facility shall immediately contact local law enforcement authorities in the following situations: physical abuse involving physical injury inflicted on a resident by another resident.

Based on interview and record review, the Facility failed to respond to call lights in a timely to address residents' needs for 7 of 18 residents (R2, R5, R17, R19, R22, R32, R36) reviewed for dignity in the sample of 40. Findings include: 1. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact. On 3/29/23 at 10:00 AM, R22 stated, I feel ignored at times. We have to wait a long time on call lights, and they always say, Let me check on that and you never see them again. I have learned that if I use the (call) light in the bathroom they come a lot faster than (if I use) the one on the bed. 2. R19's MDS, dated [DATE], documents R19 is cognitively intact. On 3/29/23 at 10:00 AM during the Resident Council Meeting, R19 stated he has to wait a long time for help when he presses his call light. 3. R5's MDS, dated [DATE], documents R5 is cognitively intact. On 3/29/23 at 10:00 AM during the Resident Council Meeting, R5 stated there are often long waits when she presses her call light. 4. R17's MDS, dated [DATE], documents R17 is moderately cognitively impaired. On 3/28/23 at 12:10 PM, R17 stated the facility needs more staff, especially at night. R17 further stated she feels call light waits are too long, and she previously sat on the pot for a long time waiting for someone to come help her. The facility's Resident Council Minutes, dated 3/8/2023, documents call lights are not being answered. The Facility's Resident Council Mintues, dated 2/8/2023, documents not answering call lights. On 3/30/23 at 1:12 PM, V2, Director of Nursing (DON), stated, I would expect call lights to be answered as soon as possible. On 3/30/23 at 1:14 PM, V3, Assistant Director of Nursing (ADON), stated, Call lights really should be answered immediately, but that doesn't always happen. We do a pretty good job during the day, but we don't have as much staff at night, so sometimes they do have to wait for a little while. 32874 5. On 3/27/2023 at 8:45 AM, R2 stated call lights are not answered timely. R2's MDS, dated [DATE], documents R2 is moderately impaired cognitively. 6. On 3/27/2023 at 9:45 AM, R32 stated it can take a while for call lights to be answered. R32's MDS, dated [DATE], documents R32 is moderately cognitively impaired. 33112 7. R36's MDS, dated [DATE], documents R36 is cognitively intact. On 3/27/23 at 9:50 AM, R36 stated, Sometimes it takes a long time for someone to answer my light. It seems the evening shift is the worst. Sometimes they don't even come. The Facility's Answering the Call Light Policy, revised June 2020, documents, The purpose of this procedure is to respond to the resident's requests and needs. Answer the resident's call as soon as possible. Be courteous in answering the resident's call. It continues, If you have promised the resident you will return with an item or information, do so promptly.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent sexual abuse in 1 of 3 residents, (R2), reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused by R3. This failure has the potential to affect all 31 vulnerable residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32 and R33.) This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified to have begun on 10/9/22 when the facility failed to provide adequate supervision to prevent the sexual abuse of R2 by R3. V4 and V11 witnessed R3 in front of R2, rubbing his hands between R2's legs. The Immediate Jeopardy was identified on 10/12/22. On 10/12/22 at 12:00 PM, V1, Administrator, was notified of this Immediate Jeopardy. The surveyor confirmed through observations, record review, and interview, that the Immediate Jeopardy was removed on 10/13/22, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-servicing training. Findings include: On 10/11/22 at 7:40 AM, V4, Agency Registered Nurse, (RN), stated she is the one that initiated the report on R3, while she was working the 100/300 hallway on 10/9/22. V4 stated she was getting prepped for the noon med pass, a family member came to me and said, there's a man touching her and pointed to the sitting area. (R2) was on the couch fully clothed, with an (incontinence brief) on and (R3) had his hands between R2's legs and was rubbing in an up and down motion. I called (V1, Administrator) and he told me the protocol. I called the doctor (R3's) and he put (R3) on one on ones and then we moved him, (R3), to room (another resident room). We sent her (R2) out to the hospital for a rape kit. I'm not sure who the family member was that told me, she was heading out to the patio with her mother. I was told yesterday (10/10/22) that he was on one on ones, then this morning he's on 15 minutes checks when out of his room due to staffing. He (R3) was to be closely monitored prior to this incident. V4 was unable to state what close monitoring meant or entailed. V4 stated, she is the only nurse with one Certified Nursing Assistant, (CNA) on R3's hallway (400 hall). V4 stated there weren't any staff members on the hallway that she saw when she observed the incident on 10/9/22 involving R2 and R3. On 10/11/22 at 8:10 AM, V2, Director of Nursing, (DON), stated, It was reported on Sunday (10/9/22) that when (R3) came back from smoke break, the CNA was letting the other residents in, and (R3) was going down the 200 hallway to his room on the 100 hallway. (R2) was laying on the couch in the sitting area, off the 200 hallway, and (R3) was touching her (R2), outside of her clothing. A family member, (unsure of whom), reported it to the nurse. V4 stated she was not here when the incident occurred, so she is not sure if R3 was being closely observed. V2 stated R3 was moved to room (another resident room), and placed on one-on-ones while awake and 15-minute checks when sleeping, and isn't to be taking any smoke breaks with other residents. V2 stated, (R3) is to eat in the dining room with one-on-one supervision. The one-on-one observations were changed to 15-minute checks throughout the night. When asked how the staff are doing one-on-one supervision with R3 this morning, when there is only 1 CNA on the hall, V2 stated, There's supposed to be another CNA coming down here. V2 stated they have cameras in the building, but the sitting room area is not captured on the camera. V2 stated, I'm trying to get that couch removed, because she (R2) likes to lay on it. V2 left and came back stating another CNA was on her way down to do one-on-one observations with R3. On 10/11/22 at 8:25 AM, V1, Administrator, stated he received a call on Sunday (10/9/22) that a family member had witnessed (R3) rubbing (R2's) vagina. (R2) was fully clothed at the time. (R2) was sent to the emergency room for an evaluation. (R3) was put on one-on-one supervision. V1 stated prior to incident on 10/9/22, R3 was on 15-minute checks. On 10/11/22 at 10:30 AM, V8, Agency CNA, stated she took the residents out to smoke prior to the alleged incident that took place on 10/9/22, between 10 AM and 11 AM. V8 stated she had let R3 back in the building, but didn't witness anything. V8 stated she was then told that she had to take over V15, CNA's, assignment because V15 had to go provide one on one care with R3. V8 was told one of the residents with the same first name as R3 was messing with R2. V8 stated she did not look to see if there were other staff members around. On 10/11/22 at 11:07 AM, V11, R6's family, stated she was at the facility on 10/9/22, visiting with R6, and as her and R6 were coming up the 200 hallway, heading towards the front patio, she observed R2 lying on the couch and an unknown male was in front of R2, rubbing his hands between R2's legs. V11 stated she does not know who the male is, or if he is a visitor or resident. V11 stated she immediately reported it to the first person she saw, which was a staff member coming around the corner to the right of where they were, unsure of whom the staff member was. V11 stated the staff member went directly to the sitting area, so family and resident, (R6 and V11), went on out onto the patio. V11 stated she has not observed anything like this before when in the facility. V11 stated she (V11) and R6 often visit with R2 when she is sitting/laying on the couch. V11 stated, (R2) lays on that couch 'a lot.' V11 stated she did not see any staff on the 200 hall or by the sitting area, until she reported the incident, and staff was coming around the corner on the (100 hallway), which was around the corner where the sitting room could not be seen. R3's Face Sheet, undated, documents R3 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's Minimum Data Set (MDS), dated [DATE], documents R3 has severe cognitive impairment, requires an extensive assist of two with transfers and supervision with locomotion on the unit. R3's Care Plan, dated 8/14/22, documents R3 has sexual behavioral symptoms towards female residents with an intervention, dated 9/19/22, with a discontinuation date of 10/9/22, to be monitored by all staff to prevent him from entering female resident rooms or being alone unobserved in hallways, resident on 15-minute checks and allow distance in seating other residents around R3, divert resident's behavior by moving him away from females. The intervention, dated 10/9/22, documents R3 was placed on one-on-one supervision, while awake and 15-minute checks while in bed. Resident is not able to self-transfer out of bed and was moved to room [ROOM NUMBER] close to nurse's station. R3 had the intervention added on 9/19/22 to be monitored by all staff to prevent him from entering female resident rooms or being alone unobserved in hallways, due to a history of sexual behaviors towards female residents. R3 was placed on one-on-one observations on 10/9/22 as an intervention due to the sexual abuse that occurred on 10/9/22 involving R2. R3's Progress Notes document the following: 10/9/22 at 12:27PM by (V4, RN), at approximately 10:40 AM, this nurse was notified by a passing family member that the resident was touching another resident. (V4) went to observe a resident laying on a couch on 200 hall with her legs closed, clothes on while (R3) sat in his wheelchair, reaching between her legs with his hand in motion. (V4) immediately told the resident to stop and removed him from the area in his wheelchair. The Administrator was called and notify of the behaviors observed, between (R3) and (R2). (V4) was informed to call the residents' involved families, and the doctor to report incident. (V4, nurse) called the doctors exchange at 10:59 AM and received a call back at approximately 11:06 AM, who gave an order to place the resident initiating the inappropriate touching on one on-one supervision. POA contacted with no answer. Voice mail left asking for callback. DON notified this (V4) to call the local police department to file a report of sexual assault, this nurse called the local police department at approximately 11:18 AM, told them of incident and report number given 75, officer on the scene at 11:42 AM to get further information and notified V4 he would also go to emergency room to attempt to gather further information from the victim. DON also wants the resident to be sent to the local emergency room for sexual assault evaluation; 10/09/2022 at 1:37 PM, (V4, Nurse), was notified the doctor placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He is one-on-one when awake and 15-min checks when in bed, due to being unable to accommodate one-on-one, because of staffing shortage. Nurse's and CNA's on this unit were not able to provide one-on-one observation, while (R3) was up in wheelchair, but did complete 15-min checks. Nurse was not able to stay on unit due to passing medications on other end of building. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Event for Combative/Aggressive Behavior, dated 10/9/22 at 12:30 PM, documents the following: Describe behavior exhibited: At approximately 10:54 AM ,This nurse was notified by a passing family member, that a resident looked to be touching on another resident, this nurse observed (R3) sitting in his wheelchair in front of (R2) who was laying on a couch on hall 200 her legs were closed and resident was fully dressed, (R3's) hand was in motion between the legs of (R2), this nurse approached the resident told him to stop the behavior and he immediately did and allowed this nurse to remove him from the area. (R2) continued laying on the couch. Resident was touched inappropriately by the other resident and will need a sexual assault evaluation done by local police department, as well as the emergency room . Prior to the incident, (R3) was outside smoking with peers in his wheelchair then wheeling down the hall. (R2) was up walking around requiring frequent redirection from entering other residents rooms and entering places designated for staff; Was resident or others injured during the behavioral episode: yes; Describe resident/others injured: Residents peer was touched inappropriately without consent; Describe resident's activity before aggressive/combative behavior began: Resident was seen looking for the nurse to get cigarettes to smoke. On 10/11/22 at 8:05 AM, R3 was observed, and is alert to self only. R3 denied being sexually inappropriate or touching other residents inappropriately. R3 stated he doesn't know why he was moved to his current room. R2's Face Sheet, undated, documents R2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS, dated [DATE], documents R2 has severe cognitive impairment. R2's Care Plan, dated 9/26/22, documents R2 is at risk for abuse/neglect. R2's Progress Notes document the following: 10/9/22 at 12:14 PM by (V4, RN): At approximately 10:40 AM this nurse was notified by a passing family member that the resident was being touched by another resident, this nurse went to observe resident laying on a couch on 200 hall with her legs closed, clothes on while another resident sat in his wheelchair directly in front of her reaching between her legs outside of her clothing with his hand in motion in her private areas. This nurse immediately told the resident to stop and removed him from the area in his wheelchair. The resident is unable to state what was occurring or given any further insight of the situation, she is alert to herself and unaware of surroundings. Resident was last seen by staff walking around in the hall requiring redirection for wandering into rooms and the dining room while it was being cleaned. Administrator was called to notify him of the behaviors observed. This nurse was informed to call the residents involved families, and the doctor to report incidents. This nurse called the doctors exchange at 10:59 AM and received a call back at approximately 11:06 AM who gave an order to place the resident initiating the inappropriate touching on one on one. POA notified at 11:15 AM of the incident. POA was also called back at 11:54 AM to give permission to send to the emergency room for a sexual assault evaluation. DON notified this nurse to call the local police department to file a report of sexual assault. This nurse called the local police department at approximately 11:18 AM, told them of incident and report number given 75, officer on the scene at 11:42 AM to get further information and notified this nurse he would also go to emergency room to attempt to gather further information from the victim. DON also wants the resident to be sent to the local emergency room for sexual assault evaluation; 10/9/22 at 2:06 PM by (V4, RN), POA called back to the facility inquiring about what precautions would be done to ensure that the resident would be free from this happening again. This nurse reassured family that she would be under close observation upon her return from the hospital and the offender was being watched as well. This nurse gave phone numbers to family to call office staff and inquire about the specifics of precautions taken to ensure safety; 10/09/2022 at 5:37 PM Resident has returned to facility from emergency room via ambulance accompanied by two attendants. No new orders. Resident has been wandering from room to 200 hall sitting area and dining room. Denies pain and discomfort. No signs or symptoms of acute distress noted. Frequent checks. The police report by V21, Police Officer, dated 10/9/22, documents, On Sunday 10/9/22 at approximately 11:36 AM, I was dispatched to (facility) in reference to a report of sexual assault. Upon arrival, I spoke with (V4, RN), who states a visitor observed a patient with what appeared to be his hands between a female patient's legs. (V4) stated she responded to the area, and observed (R2), lying on her back on a couch in a common area. (R3), sitting in front of the couch in a wheelchair, with his hands between (R2's) legs. (V4) states (R2) was fully clothed and wearing an adult diaper. (V4) stated she wheeled (R3) back to his room where he is being monitored by a certified nurse's assistant (CNA). (V4) stated both (R2) and (R3) have a declined mental ability, subjects will not be able to recall the situation. The facility Initial IDPH, (Illinois Department of Public Health), Incident and/or Abuse Notification, documents on 10/9/22 at 10:55 AM, staff reports allegation of possible resident to resident inappropriate sexual contact between (R2) and (R3). Residents separated immediately. Administrator notified immediately. Final report to follow. The facility Final IDPH Incident and/or Abuse Notification, with an incident date of 10/9/22, documents Based on the results of the investigation, facility was able to substantiate abuse related to inappropriate sexual touching. Care plans updated, chart and medication review completed. MD and POA's notified. Both Residents remain in facility. Both residents have continued daily routines with no s/s of mental anguish or behaviors out of the normal. On 10/11/22 at 8:22 AM, V5, CNA, stated she is providing one-on-ones with R3 today. V5 stated she thinks she is to stay with R3 unless another staff member is with him. V5 stated she was off this weekend (10/8/22 & 10/9/22), so she is not aware of any incidents that occurred during that time. V5 stated prior to the incident on 10/9/22, R3 was supposed to be separated from other female residents. On 10/11/11 at 9:50 AM, V15, CNA, stated she was told on 10/9/22, unsure of exact time, that she had to go provide one on one care with R3. V15 stated she was told, unsure of exact time, R3 was observed touching R2, so he was moved from the 100 hall to room (another resident room). V15 stated prior to this incident, R3 was on 15-minute checks, and they were to keep an eye on him. V15 stated R3 has been in trouble for this before. V15 stated she did not witness the incident that occurred on 10/9/22. On 10/11/22 at 11:03 AM, V6, Agency RN, stated it was only her and one CNA working on the 400 hallway for the PM-1 shift on 10/10/22. V6 stated the 100/300 hall nurse didn't show up for her shift, so she (V6) had to pass medications for the 100/300 and 400 hallways. V6 stated there was only the 1 CNA on the 400 hall, I can guarantee, he (R3) did not have eyes on him the whole time. I was told by the DON, (V2), to change him, (R3), from one-on-one care continuously, to only when out of his room, because of staffing and he was in and out of his room and up and down the hallways. On 10/11/22 at 11:40 AM, V2, DON, stated on 10/10/22, the evening shift nurse did not show up for her shift. V16, CNA, was supposed to provide one-on-one with R3 on the evening shift but left. V2 stated either V12, CNA, V14, CNA, or V18, CNA, would have been providing one on one care with R3 on the evening shift 10/10/22. On 10/11/22 at 12:33 PM, V18, Agency CNA, stated she did not provide one on one care with R3 on 10/10/22. The time card reports were reviewed for 10/10/22, 2 PM to 10 PM shift, and documents the following staff were working during that time frame: V22 CNA 2:23 PM - 10:40 PM; V23 CNA 11:18 AM - 6:09 PM; V24 RN 6:48 AM - 4:33 PM; V17 LPN 6:42 AM - 4:06 PM; V25 LPN 7:37 AM - 4:00 PM; V12 Agency CNA 1 PM - 11:30 PM; V26 Agency CNA 2:30 PM - 4:30 PM; V27 Agency CNA 2:30 PM - 10:30 PM; V18 Agency CNA 2:30 PM - 11 PM; V14 Agency CNA 2:15 PM - 10:30 PM; V6 RN 2 PM - 11 PM; V28 LPN 4 PM - 11 PM, V2 DON 2 PM - 6 PM. The timecard reports show after 6:09 PM, there were 5 CNAs,1 RN and 1 LPN on duty. The facility Immediate Jeopardy Removal of Immediacy Plan, dated 9/26/22, documents R3 had two prior sexual abuse allegations with female residents prior to the incident that occurred on 10/9/22 with R2. The plan goes on to document that education will be ongoing to ensure that no one works prior to being in-serviced, including agency staff on care plans and the facility abuse policy. On 10/12/22 at 8:30 AM, V1, Administrator, provided surveyor with a list of vulnerable residents. The list includes: R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32 and R33. This includes a total of 31 residents. The facility floor plan was reviewed and shows the following: the smoking area where R3 would have been let back into the building on 10/9/22 just prior to the abuse with R2 is at the northwest corner of the building. The sitting area where the abuse occurred is located at the outer corner of the northwest side of the building. R3 would have passed approximately 9 rooms to get to the sitting area with no staff observing R3. The surveyors confirmed through observation, interview, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1.Re-Inservice all staff regarding R3's care plan interventions and 1:1 status. a. All direct care staff have been re-inserviced on where to find all residents care plan interventions and R3's care plan interventions by (V2), RN, DON, (V35), Housekeeping/Laundry Supervisor, (V36), Activity Director, (V31), Executive Assistant, (V37), Dietary Manager, (V38), SSD, (V39), Therapy Director, on 10/12/2022 b. All staff have been in-serviced on R3's 1:1 means and how to provide 1:1 by (V2), RN, DON, (V35), Housekeeping/Laundry Supervisor, (V36), Activity Director, (V31), Executive Assistant, (V37), Dietary Manager, (V38), SSD, (V39), Therapy Director, on 10/12/2022. All supervision during awake hours and in on 15-minute checks while he is in bed as he is not able to get himself out of bed. c. Education will be ongoing to ensure no one works prior to being in-serviced. Facility to also educate any agency staff upon entering the facility, prior to beginning work as well as a read and sign in-service is placed at the nurses desk for direct care staff to read and sign. d.R3 has been issued a 30-day involuntary discharge and remains on 1:1 by assigned staff member until such new placement has been found, to protect all 31 identified female residents, and any other resident who may be vulnerable or affected by R3's alleged sexual behaviors. DON or designee to monitor 15-min checks are completed on the required sheet and 1:1 assignment is given on staffing sheet. e. R3 has had a psychosocial assessment completed with no new outcomes identified by V1, Administrator on 10/12/22. R3 has had another medication adjustment from [MEDICATION(S)] 25mg daily to [MEDICATION(S)] 25mg BID on 10/10/2022 by (V40), Psychiatrist. f. R2 has had a new trauma assessment completed with no new outcomes with no new identified issues or Psychosocial outcomes on 10/09/2022 by (V1), Administrator. All facility abuse and reporting policies have been reviewed by (V30), RN, Director of Operations, and are in compliance with the statues they apply to, no revisions were made at this time. The Abuse Prevention Program policy, dated 12/16/2016, documents staff will identify residents with increased vulnerability for abuse, neglect, or mistreatment or have needs and behaviors that lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches that would reduce the chances of abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to prevent sexual abuse for 3 of 7 residents (R1, R2, R3) reviewed for abuse in the sample of 35. The failure to prevent sexual abuse resulted in an Immediate Jeopardy to the health and safety of R1 and R2. Due to R1's and R2's vulnerabilities and diagnoses, this increases the likelihood for physical and psychosocial harm related to abuse. This failure has the potential to affect all 34 female residents (R1, R2, R4-R35) who have [NAME] identified by the facility as being vulnerable due to diagnoses, decreased cognition, communication deficit, or physical mobility function. The Immediate Jeopardy was identified to have begun on 8/14/22 when R3 masturbated, exposed his genitals to R1, and asked her to touch his penis. On 8/20/22, V5 witnessed R3 in R2's room with his hand inside R2's vagina. The Immediate Jeopardy was identified on 9/23/22. On 9/23/22 at 2:15 PM, V1, Administrator, was notified of this Immediate Jeopardy. The surveyor confirmed through observations, record review, and interview, that the Immediate Jeopardy was removed on 9/26/22, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-servicing training. Findings include: R3's MDS, dated [DATE], documents a brief interview of mental status of 7, indicating severely impaired cognition. The MDS documents R3 needs extensive assist with Activities of daily living. The MDS documents R3 needs supervision with locomotion on the unit. R3's undated Face Sheet documents R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R3's Care plan for Category: Behaviors documents, (R3) has sexual behavioral symptoms toward females. With the Goal: Resident (R3) will not harm others secondary to sexually abusive behavior. Approaches dated 8/14/22 include: Allow distance in seating other residents around resident (R3). Assess whether the sexual behavior endangers or places vulnerable females at risk. Intervene if necessary. Divert resident's behavior by moving him away from females. Obtain a psych consult/psychosocial therapy. Praise resident when behavior is appropriate. Remove resident from group activities when behavior is unacceptable. Seat resident where constant/near constant observation is possible, Set expectations and limits for [NAME]. When resident becomes sexually abusive or exhibits inappropriate conduct, keep distance between resident and other staff, other female residents, visitors. 1. R1's Care Plan, dated 10/10/19, documents R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Minimum Data Set (MDS), dated [DATE], documents R1 has a Brief Interview of Mental Status score of 7, indicating severe cognitive impairment. The MDS documents R1 requires extensive assist from staff for Activities of daily living. R1's MDS documents she is always incontinent. The facility's Initial Incident Report regarding R1 and R3, for incident dated 8/14/22, submitted by V1 to IDPH on 8/14/22, documented the incident was Inappropriate Conduct. The Report documented, Staff reports possible resident to resident altercation. Resident separated immediately. Administrator notified immediately. The Facility's Final Report regarding the incident between R1 and R3, for incident dated 8/14/22, submitted by V1 to IDPH on 8/19/2022, documented (R1) was sitting in the hallway when (R3) wheeled up to (R1) and exposed himself to her and requested that she make contact with his private area. No actual contact was made between (R1) and (R3). Residents were immediately separated. Residents were residing on the same hallway 3 doors apart and (R3) was moved to a different hallway. Nursing did witness. Nursing completed assessment with no injuries noted. R1's Progress Note, dated 8/14/22 at 11:48 AM, documents, Patient was in hall sitting in chair outside of room, as this is where she sits a lot of the time. Male patient approached patient chair and proceeded to expose himself to patient. Patient turned head the other way and did not entertain said male patient. No contact was made between patients. When asked what had occurred patient (R1) responded with, he (R3) exposed himself and wanted me to touch his penis. The staff is on alert to ensure patient to patient interaction does not occur between the two. POA (Power of Attorney) was updated on situation and intervention. R1's Progress note, dated 8/15/22 at 12:58 PM, documents, Resident has been acting out in the dining hall, aggravate other residents, clapping her hands, resident was redirected, was given something to keep hands busy, resident continues to do the behavior. R1's Progress note, dated 8/16/22 at 11:40 AM, documents, Resident continues to have her behaviors in dining hall, of clapping of the hands, resident will continue to be monitored, any changes will be made in next care plan meeting. Resident had no other complaints or concerns, happy with her care. Resident was up and eating her lunch. R1's Progress notes dated prior to 8/14/22 noted no new or worsening behaviors. On 9/21/22 at 12:00 PM, V12, Licensed Practical Nurse (LPN), stated she witnessed an act of sexual abuse against R1 from R3. V12 stated R3's room was moved, and staff were instructed to escort R3 from his room to the smoking area and back. V12 stated on 8/14/22, she was at her med cart down the hallway where R3 and R1 were sitting separately in the hallway. V12 stated she left her med cart and went down the hall to take a phone call. V12 stated when she returned to the hallway, she came up on R3 with his back to her, and R3 was facing R1. R3 had his penis and scrotum out of his pants and was touching them. V12 stated she heard R3 ask R1 to touch his penis. V12 stated R1 was facing away from R3 and did not respond to R3's question. V12 stated she separated R1 and R3 and took R3 to his room. V12 said she educated R3 on his right to masturbate in the privacy of his own room. V12 states (R3) is pretty with it. He knows all the staff's names and knows when and where to go to smoke. V12 stated she returned to R1, and R1 stated he had his private parts exposed and wanted me to touch them. V12 states she asked R1 if R3 had touched her and R1 stated no. V12 stated she notified V1, Administrator, and moved R3 to a different room. V12 stated she notified Powers of Attorney (POAs) for both residents, but did not notify the doctors. V12 stated she was upset about the occurrence, as she feels R3 is in his right mind, and R3 purposefully targeted R1 because R1 is not cognitively intact, and R3 performed the sexual abuse act during the moment V12 had stepped away from supervision. On 9/20/22 at 2:00 PM, V1, Administrator, stated he only had the initial and final report that he submitted to Illinois Department of Public Health for his investigation of R3 and R1 incident dated 8/14/22. V1 stated he had no interviews with staff and residents, or other documentation about this investigation. 2. R2's undated Face Sheet documents R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS, dated [DATE], documents a brief interview of mental status of 11, indicating moderately impaired cognition. It also documents R2 is dependent for activities of daily living and has a catheter. In an interview with R2 on 9/21/22 at 10:00 AM, R2 is not able to speak. Nods head yes or no. On 9/20/22 at 11:30 AM, V5, Certified Nursing assistant (CNA), stated on 8/20/22 around 8-8:30 PM, she witnessed R3 in R2's room. V5 stated R3 was in his wheelchair on the left side of R2's bed. V5 stated R3 had his hand in R2's vagina. V5 stated R2 was not resisting. V5 stated she told R3 to stop it, and removed R3 from the room. V5 stated R2 stuck her middle finger up in the air. V5 stated she covered R2 back up, and took R3 to the nurse station and told him to wait there. V5 stated V5 then told V6, Registered Nurse (RN), what she had witnessed. V5 stated she told V6 that V1, Administrator, needed to be called. V5 stated she took R3 to his room, and cleaned his hand up. V5 stated R3 had a small amount of bowel movement (BM) on his hands. V5 stated she then went back to R2's room and cleaned R2 up. V5 stated R2 did not have a brief on at the time of this occurrence. V5 stated she asked V6 if she told V1 what had happened, and V6 replied she had talked to V1. V5 stated she told V13, CNA, during rounds at shift change what had happened. V5 stated she did not notify or speak to V1 until 9/19/22. On 9/28/22 at 2:50P M, V1 stated neither R2 nor R3 have any documentation in the progress notes for 8/20/22. On 9/23/22 at 11:20 AM, V5 stated she did not speak with V1 on 8/20/22. V5 stated the first time she spoke to V1 about the sexual abuse allegation was on 9/19/22. V5 stated she didn't think she was supposed to call V1. V5 stated she was not aware of where to find V1's phone number to call him. V5 stated she has been suspended. On 9/21/22 at 2:00 PM, V13, CNA, stated on 8/20/22, V5, CNA, told her she had witnessed R3 with his fingers in R2's vagina. V13 stated V5 told her V1 was aware of this. V13 stated V5 told her to try to keep R3 away from R2. On 9/20/22 at 1:30 PM, V6, RN, stated she was outside on break when V5 came outside and said she needed a nurse. V6 stated V5 told her R3 was in R2's room and had his hand on her blanket. V6 stated she interviewed R2, and R2 stuck her middle finger in the air, and started shaking her finger at V6. V6 stated R2 was covered up with her blanket and had an incontinent brief on. V6 stated, (V5) said I had to call (V1) and I said (R3) putting his hands on (R2's) blanket is not abuse. V6 stated she did notify V1 of R3 being in R2's room and having his hand on R2's blanket. V6 stated V5 stated R3 is not to be in the female patients' rooms. On 9/20/22 at 9:30 AM, V1, Administrator, stated 3 weeks ago (no date given) he received a phone call from the RN (V6), stating R3 was in R2's room, and he was touching the bed/blanket, but did not physically touch R2. V1 stated staff intervened and removed R3 from R2's room. V1 stated he did not report anything because there was no allegation of abuse because R3 did not touch R2. V1 stated now the allegation has changed to R3 putting his fingers in R2's vagina. V1 stated he didn't know why the story had changed now. V1 stated R2's story has changed multiple times. The facility's Initial Incident Report regarding R2 and R3, for incident dated 9/19/22, submitted by V1 to IDPH on 9/19/22, documents alleged resident to resident inappropriate sexual contact for R2 and R3. The Final IDPH Incident and/or Abuse Notification regarding R3 and R2, undated for incident of 9/19/2022, submitted to IDPH on 9/27/2022, documents the conclusion: staff reported possible resident to resident inappropriate sexual contact between (R3) and (R2). Staff reported that it was said by rumor that (R3) was in (R2's) room in his wheelchair sitting next to (R2's) bed and had his fingers in her vagina. Upon further investigation the incident allegedly occurred on 8/20/2022. Nurse reported on 8/20/2022 to Administrator that (R3) was in (R2) room and was found to have his hand on top of her blanket and not that any sexual contact had occurred. Residents were residing on the same hallway, (R3) was moved to a different hallway. (R3) was placed on closer watch and staff instructed to keep him out of female resident's rooms. No reporting of this incident occurred due to the incident not being a reportable event. Nursing completed assessment with no injuries noted. Upon interviewing (R3) about the incident on the night of 8/20/2022, he said nothing occurred. (R2) was interviewed on the night of 8/20/2022 by the nurse on duty and flipped the nurse off while being questioned and shook her head no, that nothing happened and yes that she was okay. Interviews completed with staff working the evening of 8/20/2022, one CNA changed her story from 8/20/2022 and now reports on 9/19/2022 that in fact (R2) did have his fingers in R2's Vagina, she removed him from the room and cleaned his hands and returned to R2 to clean her up. CNA was asked why she had changed her story and CNA did not have response, only that she didn't change her story. Other staff interviewed only heard 2nd hand hearsay of the event. Police were notified of this incident and a report was completed by the (Local) Police Department. Resident sent out to (Local) Hospital on 9/24/2022 for a rape kit, results returned with 0 indications of assault. R2 was questioned a total of 4 times with each time resulting in a different response, 2 of the times resident said R3 was only in her room and no contact was made, times 3 and 4 once with daughter and once with police, R2 responded with 2 additional different answers. The first different answer was that R3 touched her stomach and breast, the second different answer with the police officer present was that R3 only touched her left leg. R3's Care plan for Category: Behaviors documents, (R3) has sexual behavioral symptoms toward females. With the Goal: Resident (R3) will not harm others secondary to sexually abusive behavior. Approaches, dated 9/20/22, include: R3 to be monitored by all staff to prevent him from entering female resident rooms or being alone unobserved in hallway. R3 was moved to room (number) close to nurses' station. On 9/21/22 at 09:20 AM, R3 was observed propelling himself in his wheelchair in the hallway unattended, staff active in hallway. On 9/21/22 at 11:40 AM, R3 was alone in his room playing cards. On 9/21/22 at 2:25 PM, R3 was observed propelling himself in his wheelchair to dining room. R3 noted sitting at table in dining with other male residents. Staff present in dining room. On 9/23/22 at 11:40 AM, R3 was observed propelling self in hallway unattended, staff present at nurses station. On 9/20/22 at 10:15 AM, V4, R2's Daughter, stated yesterday she had received a phone call from V10, facility CNA, and is R2's son. V4 stated V10 was told by V13, CNA, R3 had his hands in R2's pants several weeks ago. V4 stated she spoke with V1, Administrator, after hearing this, and V1 told V4 he was only aware of R3 having his hand on R2's bed. V4 stated she came into the facility and spoke with R2 and V3, Marketing/Admissions, and R2 indicated R3 has touched her breast and thigh. V4 said she spoke with V5, CNA, and V5 said she had reported it to V13 weeks ago. V4 stated this is not the first occurrence of R3 touching other females. V4 stated V1 doesn't know anything. On 9/21/22 at 12:00 PM, V12, Licensed Practical Nurse (LPN), stated on the morning of 9/19/22, V10 told her of the occurrence between R3 and R2, so she reported it to V3, Marketing/Admissions. On 9/20/22 at 10:30 AM, V3, Marketing/Admissions, stated on 9/19/22, V12, LPN, informed her she had heard from V10, facility CNA and is R2's son, R3 had touched R2 inappropriately, and V10 wanted to know what had happened. V3 stated she immediately went to V1, Administrator, and informed V1 of the allegation. V3 then interviewed R2. V3 stated R2 had had a stroke and speaks very little, and uses hand gestures to communicate. V3 stated R2 shook her head no when asked if R3 had touched her. V3 then interviewed R2 again with V10 present, at which time, R2 shook her head no when asked if R3 had touched her. V3 then interviewed R2 with V4, R2's daughter present, and R2 gestured R3 had touched her from the waist up to her breast. Local police department were notified, and police officer came to facility and interviewed R2 with V3 present. R2 indicated by gestures this time R3 had touched her thigh. On 9/21/22 at 10:15 AM, V7, CNA, stated she has not witnessed any sexual behaviors from R3. V7 stated the only intervention to address R3 was to have R3 was moved to a different room after the occurrence with R1. On 9/21/22 at 10:30 AM, V8, CNA, stated she has not witnessed any sexual behaviors from R3. V8 stated R3 was moved to a different room after the occurrence with R1, and they were supposed to monitor R3 and ensure he is not going into other residents' rooms. V8 stated R2 will ask for her curtain to be pulled, or put her covers over her head if she sees R3. V8 stated R3 has been known to touch other staff on the buttocks. V8 states R3 is very cognitive, R3 knows the staff by name, and knows when and where to go when he wants to smoke. On 9/21/22 at 10:40 AM, V9, CNA, stated she has not witnessed any sexual behaviors from R3. V9 stated R3 was moved to a different room after the occurrence with R1. V9 stated they are supposed to keep R3 from wandering into other rooms by re-directing him. On 9/21/22 at 11:00 AM, V10 stated he has not witnessed any sexual behaviors from R3, but he is aware of an incident between R3 and R1. V10 stated R3 was moved to a different room after the occurrence with R1, and they were supposed to keep R3 away from R1. V10 stated V13 asked him on the morning of 9/19/22 what had happened with the situation between R3 and R2. V10 stated V13 told him R3 had been witnessed in R2's room with R3's fingers in R2's vagina by V5 several weeks ago. V10 stated he called V4 and informed her. V10 stated V13 said V5 reported it to V1. V10 stated R2 was doing good in therapy when she first got here, but in the last few weeks R2 has not been doing as well. V10 stated R2 has just shut down; R2 tears up a lot now. V10 stated, (R2) has had a change in her behavior over the last two and half weeks, she isn't as interested in her nieces as she used to be, she used to cuddle with them, and she doesn't want anything to do with them. V10 states R2 isn't eating or speaking like she did a couple of weeks ago, V10 believes these changes are due to the occurrence with R3. On 9/21/22 at 11:45 AM, V11, CNA, stated she has not witnessed any sexual behaviors from R3. V11 stated the only interventions to address R3's behavior was to have R3 was moved to a different room after the occurrence with R1. On 9/21/22 at 2:30 PM, V1 states the interventions that were put in place after the 8/14/22 incident with R3 and R1 included staff to monitor resident closely, if R3 is in hallway they are to monitor him, room moves, and to re-direct him. V1 states staff are to engage R3 in activities to keep him active. V1 states they have done a medication review, and updated the doctor on 9/19, and on 9/20/22 doctor ordered new medication. V1 stated the staff member that witnesses the abuse is to call him, but they are allowed to use the chain of command to notify him also. V1 stated he did not speak with V5 on 8/20/22. V1 stated he had a conversation with the POA of R3 on 9/21/22, and informed him the sexually inappropriate behavior could lead to a discussion about alternative placement for R3. On 9/23/22 at 11:00 , V1 stated he is not aware of any assessment of R3s sexual behavior that has been completed for vulnerable females who are at risk, as stated in R3's care plan dated 8/14/22. V1 stated he did speak with V5 on 8/20/22, and V5 stated R3 had only touched R2's blankets, but V5 felt like R3 was working on being inappropriate with R2. V1 stated his final report on the 8/14/22 report was unsubstantiated because they could not determine R3 had intent to sexually abuse R1. V1 stated there has been no changes to R1's or R2's behaviors. On 9/28/22 at 2:50 PM, V1, Administrator, states they have 34 residents identified as vulnerable related to R3's sexual behaviors. V1 sates they are all female residents who have a cognitive impairment, communication deficit and/or physical limitations. V1 gave surveyor a list of residents who are identified as R1, R2 and R4 through R35. The Resident Information Report labeled List of Female Residents Cognitively Impaired, Communication Deficit, and Physical Limitations provided by V1 on 9/28/22 lists R1, R2, and R4-R35. The facility's Abuse Prevention Program policy and procedure, revised 12/16/2016, documents definitions, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It continues, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. It also documents, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It documents the definition Sexual abuse is non-consensual sexual contact of any type with a resident. It also documents, 6. Protection of Residents The facility will take steps to prevent further potential abuse, neglect exploitation, or mistreatment while the investigation is in progress a. Residents who allegedly mistreated another resident will be removed the situation and have limited contact with the targeted individual during the course of investigation. The accused resident's condition shall be immediately evaluated to determine most suitable therapy, car approaches, and placement, considering his/her safely, as well as the safety of other residents and employees of the facility. The surveyors confirmed through observation, interview, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. Conduct a thorough investigation regarding R3's sexual abuse of R1, R2 and all other potentially affected residents. a. V1, Administrator completed investigation filed on 9/26/2022. b. Interviews were conducted on 9/25/2022 with staff by V20, Activity Director, and residents by V23, Social Services Director (SSD) to determine awareness of any other abuse situations. 2. Ensure all residents affected by R3's sexual abuse are safe and are assessed/monitored for effects due to abuse. Psychosocial/trauma informed care assessments were completed by V3, Executive Assistant and V23, SSD on 9/25/2022. 15 minute checks were implemented for R3 on 9/24/2022. 3. Ensure all treatments/provision are implemented to provide for R3's victims and care plans are revised if needed. Care plans were reviewed and revised if necessary based on the comprehensive assessments by V2, Director of Nursing (DON) on 9/25/2022. 4. Ensure all staff are in-serviced on revisions of care plans. Direct care staff have been in-serviced on care plans and where to locate them by V20, Activities Director on 9/25/2022. a. Education will be ongoing to ensure that no one works prior to being in-serviced including agency staff. 5. Review and revise all abuse policies regarding investigation, prevention and protection and ensure appropriated corrective action is taken if abuse occurs. Facility abuse policy has been reviewed by V18, Regional Director of Operation on 9/23/2022, and is in alignment with current standards of practice. 6. All staff are in-serviced on the revision of abuse policies. All staff have been re-educated on the facility abuse policy by V1, Administrator, on 9/23/2022. New signage posted throughout the facility directing staff to contact Administrator with any and all abuse allegations or reports of abuse by V1, Administrator on 9/23/2022. Education will be ongoing to ensure that no one works prior to being in-serviced. All agency staff in-serviced by their agencies upon hire. Facility to also educate any agency staff upon entering the facility, prior to beginning work. Education Plan: Review of all policies regarding staff obligations to prevent and report resident abuse, neglect, and theft, as well as what staff are to do if they see, hear or suspect resident abuse, neglect, or theft. At 5:15 PM 9/23/2022, all staff either working in the facility or by phone, were in-serviced on the facility abuse/neglect policy and reporting. All staff will be trained upon hire at orientation and quarterly for 1 year regarding resident abuse/neglect policy. V1, Administrator, or facility designee will ensure all staff are trained on these policies and procedures. V1, Facility Administrator, has been re-educated on the facility policy regarding reporting of suspected/abuse, proper investigations, and the supervision policy by the V18, Director of Operations, on 9/23/2022.

Based on interview and record review, the facility failed to thoroughly investigate, and protect other residents by preventing further abuse for 3 of 7 residents (R1, R2, R3) reviewed for abuse in the sample of 35. This failure resulted in an Immediate Jeopardy, when the facility failed to thoroughly investigate and prevent further abuse after R3 masturbated, exposed his genitals to R1, and asked her to touch his penis. The Immediate Jeopardy was identified to have begun on 8/14/22 when the facility failed to thoroughly investigate and prevent further abuse after R3 masturbated, exposed his genitals to R1, and asked her to touch his penis. On 8/20/22, V5 witnessed R3 in R2's room with his hand inside R2's vagina. This failure has the potential to affect all 34 female residents (R1, R2, R4-R35) who have identified by the facility as being vulnerable due to diagnoses, decreased cognition, communication deficit or physical mobility function. The Immediate Jeopardy was identified on 9/23/22. On 9/23/22 at 2:15 PM, V1, Administrator, was notified of this Immediate Jeopardy. The surveyor confirmed through observations, record review, and interview, that the Immediate Jeopardy was removed on 9/26/22, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-servicing training. Findings include: 1. R1's Progress note, dated 8/14/22 at 11:48 AM, documents, Patient was in hall sitting in chair outside of room, as this is where she sits a lot of the time. Male patient approached patient chair and proceeded to expose himself to patient. Patient turned head the other way and did not entertain said male patient. No contact was made between patients. When asked what had occurred patient (R1) responded with, he (R3) exposed himself and wanted me to touch his penis. The staff is on alert to ensure patient to patient interaction does not occur between the two. POA (Power of Attorney) was updated on situation and intervention. The facility's Initial Incident Report regarding R1 and R3, for incident dated 8/14/22, submitted by V1 to IDPH on 8/14/22, documented the incident was Inappropriate Conduct. The Report documented Staff reports possible resident to resident altercation. Resident separated immediately. Administrator notified immediately. The Facility's Final Report regarding the incident between R1 and R3, for incident dated 8/14/22, submitted by V1 to IDPH on 8/19/2022 documented (R1) was sitting in the hallway when (R3) wheeled up to (R1) and exposed himself to her and requested that she make contact with his private area. No actual contact was made between (R1) and (R3). Residents were immediately separated. Residents were residing on the same hallway 3 doors apart and (R3) was moved to a different hallway. Nursing did witness. Nursing completed assessment with no injuries noted. On 9/20/22 at 2:00 PM, V1, Administrator, stated he only had the initial and final report he submitted to Illinois Department of Public Health (IDPH) for his investigation of R3 and R1 incident, dated 8/14/22. V1 stated he had no interviews with staff and residents or other documentation about this investigation. On 9/21/22 at 12:00 PM, V12, Licensed Practical Nurse (LPN), stated she witnessed an act of sexual abuse against R1 from R3. V12 stated R3's room was moved, and staff were instructed to escort R3 from his room to the smoking area and back. V12 stated on 8/14/22, she was at her med cart down the hallway, where R3 and R1 were sitting separately in the hallway. V12 stated she left her med cart and went down the hall to take a phone call. V12 stated when she returned to the hallway, she came up on R3 with his back to her and R3 was facing R1. R3 had his penis and scrotum out of his pants and was touching them. V12 stated she heard R3 ask R1 to touch his penis. V12 stated R1 was facing away from R3, and did not respond to R3's question. V12 stated she separated R1 and R3 and took R3 to his room. V12 said she educated R3 on his right to masturbate in the privacy of his own room. V12 states (R3) is pretty with it. He knows all the staff's names and knows when and where to go to smoke. V12 stated she returned to R1 and R1 stated that he had his private parts exposed and wanted me to touch them. V12 states she asked R1 if R3 had touched her and R1 stated no. V12 stated she notified V1, Administrator, and moved R3 to a different room. V12 stated she notified POAs for both residents, but did not notify the doctors. V12 stated she was upset about the occurrence as she feels R3 is in his right mind, and R3 purposefully targeted R1 because R1 is not cognitively intact, and R3 performed the sexual abuse act during the moment V12 had stepped away from supervision. R3's Care plan for Category: Behaviors documents, (R3) has sexual behavioral symptoms toward females. With the Goal: Resident (R3) will not harm others secondary to sexually abusive behavior. Approaches, dated 8/14/22 include: Allow distance in seating other residents around resident. Assess whether the sexual behavior endangers or places vulnerable females at risk. Intervene if necessary. Divert resident's behavior by moving him away from females. Obtain a psych consult/psychosocial therapy. Praise resident when behavior is appropriate. Remove resident from group activities when behavior is unacceptable. Seat resident where constant/near constant observation is possible, Set expectations and limits for (R3). When resident becomes sexually abusive or exhibits inappropriate conduct, keep distance between resident and other staff, other female residents, visitors. 2. The facility's Initial Incident Report regarding R2 and R3, for incident dated 9/19/22, submitted by V1 to IDPH on 9/19/22, documents alleged resident to resident inappropriate sexual contact for R2 and R3. The Final IDPH Incident and/or Abuse Notification regarding R3 and R2, undated for incident of 9/19/2022, submitted to IDPH on 9/27/2022, documents the conclusion: staff reported possible resident to resident inappropriate sexual contact between (R3) and (R2). Staff reported that it was said by rumor that (R3) was in (R2's) room in his wheelchair sitting next to (R2's) bed and had his fingers in her vagina. Upon further investigation the incident allegedly occurred on 8/20/2022. Nurse reported on 8/20/2022 to Administrator that (R3) was in (R2) room and was found to have his hand on top of her blanket and not that any sexual contact had occurred. Residents were residing on the same hallway, (R3) was moved to a different hallway. (R3) was placed on closer watch and staff instructed to keep him out of female resident's rooms. No reporting of this incident occurred, due to the incident not being a reportable event. Nursing completed assessment with no injuries noted. Upon interviewing (R3) about the incident on the night of 8/20/2022, he said nothing occurred. (R2) was interviewed on the night of 8/20/2022 by the nurse on duty and flipped the nurse off while being questioned and shook her head no, that nothing happened and yes that she was okay. Interviews completed with staff working the evening of 8/20/2022, one CNA changed her story from 8/20/2022 and now reports on 9/19/2022 that in fact (R2) did have his fingers in R2's Vagina, she removed him from the room and cleaned his hands and returned to R2 to clean her up. CNA was asked why she had changed her story and CNA did not have response, only that she didn't change her story. Other staff interviewed only heard 2nd hand hearsay of the event. Police were notified of this incident and a report was completed by the (local) Police Department. Resident sent out to (local) Hospital on 9/24/2022 for a rape kit, results returned with 0 indications of assault. R2 was questioned a total of 4 times with each time resulting in a different response, 2 of the times resident said R3 was only in her room and no contact was made, times 3 and 4 once with daughter and once with police, R2 responded with 2 additional different answers. The first different answer was that R3 touched her stomach and breast, the second different answer with the police officer present was that R3 only touched her left leg. On 9/20/22 at 11:30 AM, V5, Certified Nursing assistant (CNA), stated on 8/20/22 around 8-8:30 PM, she witnessed R3 in R2's room. V5 stated R3 was in his wheelchair on the left side of R2's bed. V5 stated R3 had his hand in R2's vagina. R2 was not resisting. V5 stated she told R3 to stop it, and removed R3 from the room. V5 stated R2 stuck her middle finger up in the air. V5 stated she covered R2 back up, and took R3 to the nurse's station, and told him to wait there. V5 stated V5 then told V6, Registered Nurse (RN), what she had witnessed. V5 stated she told V6 that V1, Administrator, needed to be called. V5 stated she took R3 to his room and cleaned his hand up. V5 stated R3 had a small amount of bowel movement (BM) on his hands. V5 stated she then went back to R2s room and cleaned R2 up. V5 stated R2 did not have a brief on at the time of this occurrence. V5 stated she asked V6 if she told V1 what had happened, and V6 replied she had talked to V1. V5 stated she told V13, CNA, during rounds at shift change what had happened. V5 stated she did not notify or speak to V1 until 9/19/22. On 9/23/22 at 11:20 AM, V5 stated she did not speak with V1, Administrator, on 8/20/22. V5 stated the first time that she spoke to V1 about the sexual abuse allegation was on 9/19/22. V5 stated she didn't think she was supposed to call V1. V5 stated she was not aware of where to find V1's phone number to call him. V5 stated she has been suspended. On 9/28/22 at 2:50 PM, V1 states neither R2 nor R3 have any documentation in the progress notes for 8/20/22. On 9/21/22 at 2:00 PM, V13, CNA, stated on 8/20/22, V5, CNA, told her she had witnessed R3 with his fingers in R2's vagina. V13 stated V5 told her V1 was aware of this. V13 stated V5 told her to try to keep R3 away from R2. On 9/20/22 at 1:30 PM, V6, RN, stated she was outside on break when V5 came outside and said she needed a nurse. V6 stated V5 told her R3 was in R2's room and had his hand on her blanket. V6 stated she interviewed R2 and R2 stuck her middle finger in the air, and started shaking her finger at V6. V6 stated R2 was covered up with her blanket, and had an incontinent brief on. V6 stated, (V5) said I had to call (V1) and I said (R3) putting his hands on (R2's) blanket is not abuse. V6 stated she did notify V1 of R3 being in R2's room and having his hand on R2's blanket. V6 stated V5 stated R3 is not to be in the female patients' rooms. On 9/20/22 at 9:30 AM, V1, Administrator, stated 3 weeks ago (no date given), he received a phone call from the V6, RN, stating R3 was in R2's room and he was touching the bed/blanket, but did not physically touch R2. V1 stated staff intervened and removed R3 from R2's room. V1 stated he did not report anything, because there was no allegation of abuse, because R3 did not touch R2. V1 stated now the allegation has changed to R3 putting his fingers in R2's vagina. V1 stated he didn't know why the story had changed now. V1 stated R2's story has changed multiple times. On 9/21/22 at 11:00 AM, V10 stated he has not witnessed any sexual behaviors from R3, but he is aware of an incident between R3 and R1. V10 stated R3 was moved to a different room after the occurrence with R1, and they were supposed to keep R3 away from R1. V10 stated V13 asked him on the morning of 9/19/22 what had happened with the situation between R3 and R2. V10 stated V13 told him R3 had been witnessed in R2s room with R3s fingers in R2s vagina by V5 several weeks ago. V10 stated he called V4 and informed her. V10 stated V13 said V5 reported it to V1. On 9/20/22 at 10:15 AM, V4, R2's Daughter, stated yesterday she had received a phone call from V10, facility CNA, and is R2's son. V4 stated that V10 was told by V13, CNA, R3 had his hands in R2's pants several weeks ago. V4 stated she spoke with V1, Administrator, after hearing this, and V1 told V4 that he was only aware of R3 having his hand on R2's bed. V4 stated she came into the facility and spoke with R2 and V3, Marketing/Admissions, and R2 indicated R3 has touched her breast and thigh. V4 said she spoke with V5, CNA, and V5 said she had reported it to V13 weeks ago. V4 stated this is not the first occurrence of R3 touching other females. V4 stated that V1 doesn't know anything. R3's Care plan interventions, dated 9/20/22, documents R3 to be monitored by all staff to prevent him from entering female resident rooms or being alone unobserved in hallway. R3 was moved to room (number) close to nurses' station. On 9/21/22 at 09:20 AM, R3 was observed propelling himself in his wheelchair in the hallway unattended, staff active in hallway. On 9/21/22 at 11:40 AM, R3 was alone in his room playing cards. On 9/21/22 at 2:25 PM, R3 was observed propelling himself in his wheelchair to dining room. R3 noted sitting at table in dining with other male residents. Staff present in dining room. On 9/23/22 at 11:40 AM, R3 was observed propelling self in hallway unattended, staff present at nurses station. On 9/21/22 at 12:00 PM, V12, LPN, stated on the morning of 9/19/22 V10 told her of the occurrence between R3 and R2 so she reported it to V3, Marketing/Admissions. On 9/20/22 at 10:30 AM, V3, Marketing/Admissions, stated on 9/19/22, V12, LPN, informed her she had heard from V10, facility CNA, and is R2's son, R3 had touched R2 inappropriately and V10 wanted to know what had happened. V3 stated she immediately went to V1, Administrator, and informed V1 of the allegation. V3 then interviewed R2. V3 stated R2 had had a stroke, and speaks very little, and uses hand gestures to communicate. V3 stated R2 shook her head no when asked if R3 had touched her. V3 then interviewed R2 again with V10 present, at which time, R2 shook her head no when asked if R3 had touched her. V3 then interviewed R2 with V4, R2's daughter present, and R2 gestured R3 had touched her from the waist up to her breast. Local police department were notified, and police officer came to facility and interviewed R2 with V3 present. R2 indicated by gestures this time R3 had touched her thigh. On 9/21/22 at 2:30 PM, V1 states the interventions that were put in place after the 8/14/22 incident with R3 and R1 included: staff to monitor resident closely, if R3 is in hallway they are to monitor him, room moves and to re-direct him. V1 states staff are to engage R3 in activities to keep him active. V1 states they have done a medication review, and updated doctor on 9/19 and on 9/20/22 doctor ordered new medication. V1 stated the staff member that witnesses the abuse is to call him, but they are allowed to use the chain of command to notify him also. V1 stated he did not speak with V5 on 8/20/22. V1 stated he had a conversation with the POA of R3 on 9/21/22, and informed him the sexually inappropriate behavior could lead to a discussion about alternative placement for R3. On 9/23/22 at 11:00 AM, V1 stated he is not aware of any assessment of R3s sexual behavior that has been completed for vulnerable females who are at risk, as stated in R3s care plan dated 8/14/22. V1 stated he did speak with V5 on 8/20/22 and V5 stated R3 had only touched R2s blankets, but V5 felt like R3 was working on being inappropriate with R2. V1 stated his final report on the 8/14/22 report was unsubstantiated, because they could not determine R3 had intent to sexually abuse R1. V1 stated there has been no changes to R1's or R2's behaviors. On 9/28/22 at 2:50 PM, V1, Administrator, states they have 34 residents identified as vulnerable related to R3's sexual behaviors. V1 states they are all female residents who have a cognitive impairment, communication deficit and/or physical limitations. V1 gave surveyor a list of residents who are identified as R1, R2 and R4 through R35. The Resident Information Report labeled List of Female Residents Cognitively Impaired, Communication Deficit, and Physical Limitations provided by V1 on 9/28/22 lists R1, R2, and R4-R35. The facility's Abuse Prevention Program policy and procedure, revise 12/16/2016, documents, 6. Protection of Residents The facility will take steps to prevent further potential abuse, neglect exploitation, or mistreatment while the investigation is in progress a. Residents who allegedly mistreated another resident will be removed the situation and have limited contact with the targeted individual during the course of investigation. The accused resident's condition shall be immediately evaluated to determine most suitable therapy, car approaches, and placement, considering his/her safely, as well as the safety of other residents and employees of the facility. It continues, 7. Internal investigation of abuse, neglect or misappropriation allegations and response. a. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. b. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. c. Any other incident or pattern involving 'reasonable cause to suspect abuse, neglect, or misappropriation', will result in an abuse investigation. It also documents, under d. Confidentiality. After a conclusion of the investigation, internal reports, interviews, and witness statements shall be release only with the permission of the administrator or the facility attorney. Under f. Final Abuse Investigation Report, documents, Attach a summary of all interviews conducted, with names, addresses, phone number and willingness to testify of all witnesses. The surveyors confirmed through observation, interview, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. Conduct a thorough investigation regarding R3's sexual abuse of R1, R2 and all other potentially affected residents. a. V1, Administrator, completed investigation files on 9/26/2022. b. Interviews were conducted on 9/25/2022 with staff by V20, Activity Director, and residents by V23, Social Services Director (SSD) to determine awareness of any other abuse situations. 2. Ensure all residents affected by R3's sexual abuse are safe and are assessed/monitored for effects due to abuse. Psychosocial/trauma informed care assessments were completed by V3, Executive Assistant and V23, SSD on 9/25/2022. 15 minute checks were implemented for R3 on 9/24/2022. 3. Ensure all treatments/provision are implemented to provide for R3's victims and care plans are revised if needed. Care plans were reviewed and revised if necessary based on the comprehensive assessments by V2, Director of Nursing (DON) on 9/25/2022. 4. Ensure all staff are in-serviced on revisions of care plans. Direct care staff have been in-serviced on care plans and where to locate them by V20, Activities Director on 9/25/2022. a. Education will be ongoing to ensure that no one works prior to being in-serviced including agency staff. 5. Review and revise all abuse policies regarding investigation, prevention and protection and ensure appropriated corrective action is taken if abuse occurs. Facility abuse policy has been reviewed by V18, Regional Director of Operation on 9/23/2022, and is in alignment with current standards of practice. 6. All staff are in-serviced on the revision of abuse policies. All staff have been re-educated on the facility abuse policy by V1, Administrator, on 9/23/2022. New signage posted throughout the facility directing staff to contact Administrator with any and all abuse allegations or reports of abuse by V1, Administrator, on 9/23/2022. Education will be ongoing to ensure that no one works prior to being in-serviced. All agency staff in-serviced by their agencies upon hire. Facility to also educate any agency staff upon entering the facility, prior to beginning work. Education Plan: Review of all policies regarding staff obligations to prevent and report resident abuse, neglect, and theft, as well as what staff are to do if they see, hear or suspect resident abuse, neglect, or theft. At 5:15 PM 9/23/2022, all staff either working in the facility or by phone, were in-serviced on the facility abuse/neglect policy and reporting. All staff will be trained upon hire at orientation and quarterly for 1 year regarding resident abuse/neglect policy. V1, Administrator or facility designee will ensure all staff are trained on these policies and procedures. V1, Facility Administrator has been re-educated on the facility policy regarding reporting of suspected/abuse, proper investigations, and the supervision policy by the V18, Director of Operations on 9/23/2022.

Based on interview and record review, the facility failed to perform a complete neurological assessment after a head injury for 1 of 3 residents (R11) reviewed for quality of care in the sample of 48. This failure resulted in a delay in the [DIAGNOSES REDACTED]. Findings includes: R11's Resident Progress Note, dated 11/24/2019 at 4:00 AM, documents, Resident was found on the floor sitting in water (not urine). Bruising noted to her left side, left side of her head from hitting it on the bedside table on the way down. Swelling is also noted to her left hand. R11's resident post fall investigation form, dated 11/24/2019, documents, Resident stated she did hit her head so neuro checks were started. R11's November 2019 Physician order [REDACTED]. R11's Neurological (Neuro) Assessment, dated 11/24/2019 from 4:00 AM to 1:00 PM, showed incomplete documentation. The facility did not follow the Neurological Assessment key to indicate the assessment of and changes in R11's neurological status. The Neuro assessment provided by the facility did not document R11's pupil size, reaction to light, and the extremity assessment. R11's scheduled 3:00 PM assessment was blank documenting, Out to ER (emergency room ) although R11's Resident progress notes, dated 11/24/2019 at 4:50 PM, indicates that R11 was in the building. R11's Resident Progress notes, dated 11/24/19 at 4:50 PM, documents, Husband in doorway looking into hallway, needing help. Resident has to use the bathroom. Attempted to transfer resident with left side arm flaccid and left leg not responding. Went out and got help. Two CNA's (Certified Nursing Assistants) and writer assisted resident to toilet, resident unable to keep her balance on toilet. Right wrist noted to be bruised with knot on it. Call placed to primary physician with physician on call asking for x-ray, per family's request. Writer not familiar with this resident, but CNA states this is a change for her. R11's Resident Progress Notes, dated 11/24/2019 at 9:15 PM, documents, Spoke with staff at local hospital and (R11) was transferred to (a Metropolitan Hospital) with the [DIAGNOSES REDACTED]. R11's Nursing Home Follow Up from the Hospital, dated 12/6/2019, documents Patient suffered a fall early Sunday morning on 11/24/2019. Family visited her that day and noticed she was more lethargic and was not as talkative as usual. Her husband fed her dinner that day and noticed food was falling out of her mouth. A CT (Computed Tomography) scan of the head showed a right intraparenchymal hemorrhage. Patient was noted to have left sided weakness and left facial droop. Lists head injury with [MEDICAL CONDITION] -with unconsciousness of unspecified duration as part of assessment. Patient states she isn't doing well and is sore all over. Patient complains of back pain, constipation and headaches mostly behind her ears. R11's CT Scan of her head, performed at local hospital on [DATE], showed large acute [MEDICAL CONDITION] of the right basal ganglia region. Bleed measures at least 4.3 x 3.0 cm (centimeter) in size. There is approximately 1 cm right to left sided shift of the brain. On 3/2/20 at 10:10 AM, V12, CNA, stated , (R11) used to ambulate 1 assist with walker. Toilet 1 assist. Now she is a mechanical lift since coming back from the hospital. We put her on the bed pan now. We don't take her to the bathroom. Before, we didn't put her walker in reach because we didn't want her to fall. On 3/2/2020 at 3:00 PM, V21, Medical Director, stated, I would expect the nurses to perform a complete assessment including the pupil size and reaction and extremities and document it. As this would have caught a change in condition. On 3/2/2020 at 3:45 PM, V27, R11's husband, stated, She had a bad fall and since then she can't do anything for herself. Her left arm has a lot of pain when its moved. She uses the machine to get up now. She can't sit in her recliner like she used to. She really liked that. They feed her or I do when I'm here. That fall was really bad. She lays in the bed and sleeps more. We came here together and she has to stay. On 3/2/2020 at 4:03 PM, V2, Director of Nursing (DON), stated, The Neuro checks are incomplete. They should be totally completed showing the pupil size and reaction and extremity assessment. Its done that way to make sure there is no injury to the resident and (to) find any neurological change in conditions. If the nurses would have completed the Neuro checks per the instructions above, then they would have noticed the change in condition before the evening. 3/3/2020 at 1:20 PM, V1, Administrator, stated, That performing the assessment and finding the brain bleed early would decrease the injury. https://www.mayoclinic.org/diseases-conditions/intracranial-hematoma/symptoms-causes/syc- 145 documents, An intracranial hematoma is a collection of blood within the skull, most commonly caused by rupture of a blood vessel within the brain or from trauma such as a car accident or fall. The blood collection can be within the brain tissue or underneath the skull, pressing on the brain. Although some head injuries - such as one that causes only a brief lapse of consciousness (concussion) - can be minor, an intracranial hematoma is potentially life-threatening. It usually requires immediate treatment, often surgery to remove the blood. It also documents, Symptoms- You might develop signs and symptoms of an intracranial hematoma right after a blow to your head, or they may take weeks or longer to appear. You might seem fine after a head injury, a period called the lucid interval. However, with time, pressure on your brain increases, producing some or all of the following signs and symptoms: Increasing headache, Vomiting, Drowsiness and progressive loss of consciousness, Dizziness, Confusion, Unequal pupil size, Slurred speech. As more blood fills your brain or the narrow space between your brain and skull, other signs and symptoms may become apparent, such as: Lethargy, [MEDICAL CONDITION], Unconsciousness. It further documents, Seek immediate medical attention after a blow to the head if you: Lose consciousness, Have a persistent headache, Have difficulties such as vomiting, weakness, blurred vision, unsteadiness. If signs and symptoms aren't immediately evident after a blow to the head, watch for physical, mental and emotional changes. For example, if someone seems fine after a blow to the head and can talk but later becomes unconscious, seek immediate medical care. It continues, If you're an older adult - especially if you're taking an anticoagulant or an antiplatelet drug, such as aspirin - even mild head trauma can cause a hematoma. The Facility Falls Management, dated 2017, documents It is the policy to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. If a fall is unwitnessed or resident has evidence of head injury, complete neurological assessment per protocol.

Deficiency at this level requires two deficient practice statements. A. Based on interview and record review, the facility failed to offer, re-evaluate the need, and monitor and track when pneumococcal vaccines are and can be given for 3 or 27 residents (R62, R13, and R42) reviewed for the pneumococcal vaccine in the sample of 48. This failure resulted in R62 going to the emergency room and being diagnosed with [REDACTED]. B. Based on interview and record review, the facility failed to administer pneumococcal vaccines to 24 for 27 residents (R4, R7, R8, R9, R12, R14, R17, R18, R20, R22, R23, R36, R39, R40, R43, R54, R55, R56, R58, R59, R71, R72, R76, R77) reviewed for the pneumococcal vaccine in the sample of 48. Findings include: A. 1. R62's Face Sheet, not dated, documents R62 was admitted to the facility on [DATE] and has a birthdate of 8/26/1935. R62's [DIAGNOSES REDACTED]. R62's Pneumococcal Vaccine record, dated 3/31/2016, documents Pneumococcal Vaccine was administered on 3/31/2016. The facility was not able to provide documentation that R62 was offered or received Prevnar 13. R62's nurses notes, dated 1/30/20 at 1:16 AM, document, in part, resident had a change in condition, not responding to staff and was sent out to the local ER for evaluation and treatment. R62's nurses notes, dated 1/30/2020 at 10:51 AM, document, Resident returned at 8 am this morning. With new orders of [MEDICATION NAME] 750mg IV every Q 24hrs x7 days. Check comprehensive metabolic panel (CMP) this afternoon. 22 gauge needle in left hand. R62's ER discharge records, dated 1/30/20, documents, in part, [DIAGNOSES REDACTED]. Bacterial pneumonia. [MEDICAL CONDITION]. Mild [MEDICAL CONDITION]. Chest X-Ray results document IMPRESSION: Opacity at the left lung base reflects pleural effusion, atelectasis, consolidation/pneumonia. On 2/27/20 at 12:15 PM, V3, Assistant Director Of Nursing (ADON), stated, (R62) never received the prevnar 13, or if she did we cannot find it. A. 2. R13's hospital notes, dated 9/1/2019, documents that R13 's [DIAGNOSES REDACTED]. R13's Patient Transfer Form, dated 9/6/2019, documents that R13 was administered Prevnar 13 vaccine 0.5cc [MEDICATION NAME] on 9/2/2019 while at the hospital. The facility has no documentation in regards to R13's Pneumococcal vaccinations. The facility did not offer any pneumococcal vaccines. R13's Face sheet, dated 9/6/2019, documents that R13 is [AGE] years old. R13's Face sheet documents that R13 primary admission to the facility due to pneumonia. A. 3. R42's Face Sheets documents that R42 was admitted to the facility on [DATE]. R42's records does not document that R42 was offered the pneumococcal immunization. R42's Face Sheet documents that R42 is [AGE] years old. B. 23 residents (R4, R7, R8, R9, R12, R14, R17, R18, R20, R22, R23, R36, R39, R40, R43, R54, R56, R58, R59, R71, R72, R76, R77) or their guardians, signed consents to receive the pneumococcal pneumonia vaccine, of which, not one of the residents received the pneumococcal vaccine deemed appropriate for them depending on their immunization history. On 2/26/2020 at 12:15PM, V2, DON, stated that she had delegated the immunizations to someone else. V2 stated that for any new admissions the consents were to be included in admission packet. V2 stated this process did not occur for new admissions. On 3/02/2020 at 8:30AM, V2, Director of Nurses (DON), stated, I am in charge of the immunization program at the facility. We ask resident, family, or if the resident came from the hospital, what pneumonia shot they got. We don't have a Vaccination Log at this time, but we are trying to get on track now. The past administrator, (V22) sent out a mass mailing of consents and vaccine information sheets (VIS) for the flu, and 02/03/2020 the consents came back. (V23, Secretary), just highlighted the residents who needed the flu vaccine and gave it to (V24, License Practical Nurse) who works night shift and she was going to start giving the flu shots. This is how the pneumonia vaccines got missed. Prior to that when there is a new resident being admitted , I assumed the floor nurses or admissions were asking if they (the resident) had received the flu and pneumonia vaccines and if the hadn't received it was offered. V2, DON, continued to state, The education part for the pneumonia vaccine is on the consent form that they had received it. On 03/03/2020 at 7:55 AM, V25, License Practical Nurse (LPN), stated that she does not know who or when residents need the pneumonia vaccine and has no idea on who takes care of it. On 03/03/2020 at 8:00 AM, V26, LPN, stated, The admission note should have it (pneumonia vaccine information) in it. Usually, when the paperwork is given to the department heads and they will let us know who needs the (pneumonia) vaccine. The facility's Pneumococcal Vaccine Policy, dated 12/2016, documents, It is the policy of Helia Healthcare that all residents are protected from incident of pneumonia by obtaining pneumococcal vaccines, if desired, per CDC (Centers for Disease Control and Prevention) guidelines. It continues to document, Procedure: 1. Upon admission, the facility will attempt to determine when the last pneumococcal vaccine was received by the resident, if at all and whether the vaccine was a PCV13 (Prevnar) or a PPSV23 ([MEDICATION NAME]). PCV13 is recommended for all adults [AGE] years or older, and people 6 years or older with certain risk factor. PPSV23 is recommended for all adults who are [AGE] years or older and for people 2 through [AGE] years old who are at high risk for pneumococcal disease. 2. Immunization information will be recorded on the Vaccination Log. 3. Before offering the resident pneumococcal vaccination, the resident or their legal guardian shall receive education about the benefits and potential side effects of the vaccination. 4. Each resident will be offered vaccination unless the immunization is medically contraindicated, has been refused or the resident has already been immunized. If the resident desires vaccination they must sign a Vaccination Authorization Form. 5. If the resident has never had a pneumococcal vaccine, and desires one, it will be administered by the nursing department and recorded on the Vaccination Log according to the schedule listed below. 6. If the resident cannot recall when they received the last dose and the facility is unable to determine this information from other sources, (medical records, family, etc.) and the resident desires the pneumococcal vaccine, it will be administered by the nursing department and recorded on the Vaccination Log according to the schedule below. 7. Documentation in the medical record shall include that the resident or the legal guardian was provided education regarding the benefits and potential side effects of the vaccination and that the resident received the immunization, it was medically contraindicated or refused. According to CDC's Advisory Committee on Immunization Practices (ACIP), the following new recommendations were released June 26, 2019. PCV13 is a shared decision between residents and their provider, for all immunocompetent adults> 65 who have not previously received the vaccine. All adults > 65 should receive a dose of PPSV23 ([MEDICATION NAME] 23). The two vaccines should not be co-administered but should be given at least 1 year apart. Pneumococcal Pneumonia Guide, undated, documents, NO vaccinations received. (Then) Adults [AGE] years of age or older who have not previously received any pneumococcal vaccines should receive PCV13 followed by a dose of PPSV23greater or equal to twelve months later. If a dose of PPSV23 cannot be given during this time window, it should be administered later. PCV13 and PPSV23 should not be administered on the same day. For some immunocompromised residents (See High Risk Pneumococcal Revaccination Guide) the PPSV23 should be given greater than 8 weeks after receiving the PCV13. UNCERTAIN if any vaccination was received. (Then) Adults [AGE] years of age or older who have not previously received any pneumococcal vaccines or whose previous history is unknown should receive a dose of PPSV23 greater or equal to twelve months later. For some immunocompromised residents (See High Risk Pneumococcal Revaccination Guide) the [MEDICATION NAME] 23 should be given greater or equal to 8 weeks after receiving the Prevnar13. UNABLE TO DETERMINE if PCV13 or PPSV23 was received. (Then) Adults [AGE] years of age or older whose previous history of obtaining PCV13 or PPSV23 is unable to be determined should receive a dose of PCV 13 first, followed later by a dose of PPSV23 greater or equal to twelve months later. For some immunocompromised residents (See High Risk Pneumococcal Revaccination Guide) the [MEDICATION NAME] 23 should be given greater or equal to 8 weeks after receiving the Prevnar13. RECEIVED PCV13 (Then) Adults [AGE] years of age or older that received a dose of PCV13 may receive a dose of PPSV23 greater or equal to twelve months later. If a dose of PPSV23 cannot be given during this time window, it should be administered later. RECEIVED PPSV23. (Then) Adults [AGE] years of age or older who have not received PCV13 and who have previously received one or more doses of PPSV23 should receive a dose of PCV13. The dose of PCV13 should be given greater or equal to 1 year after receipt of the most recent PPSV23 dose. RECEIVED BOTH PCV13 & PPSV23. (Then) See attached table for those that meet the requirement for an additional vaccine. PCV13 = Prevnar13 PPSV23 = [MEDICATION NAME] 23. Above are the recommendations of the Center for Disease Control (CDC) for all adults [AGE] years of age or older. For revaccination recommendations in high risk residents see table attached. Review of the Centers for Disease Control and Prevention (CDC) publication with a review date of 9/18/19 titled Adults: Protect Yourself with Pneumococcal Vaccines specified Many adults may be at increased risk for pneumococcal disease .Two vaccines provide protection against this serious and sometimes deadly disease .Each year in the United States, pneumococcal disease kills thousands of adults. Thousands more end up in the hospital because of pneumococcal disease. It can cause severe infections of the lungs (pneumonia) blood steam (bacteremia) and lining of the brain and spinal cord (meningitis) .However, some can be deadly, especially for adults [AGE] years or older: Pneumococcal pneumonia kills about 1 in 20 older adults who get it (and) pneumococcal bacteremia kills about 1 in 6 older adults who get it. Vaccines are the best way to prevent pneumococcal disease .When the bacteria spread into other parts of the body, it can lead to (pneumonia, bacteremia, and meningitis). These illnesses can be deadly, especially for: Adults [AGE] years or older, people with chronic health conditions (and) people whose immune systems are weakened by disease or medicine (immunocompromised) .Pneumococcal disease is contagious .Pneumococcal bacteria spread from person to person through coughing, sneezing, and close contact. People can carry the bacteria in their nose and throat without being sick and spread the bacteria to others . Review of the new immunization guidelines dated June 2019 TABLE 2. Policy options* for use of pneumococcal vaccines in adults aged [AGE] years presented for a vote and considerations by the Advisory Committee on Immunization Practices (ACIP), June 2019 revealed . BOX. Considerations for shared clinical decision-making regarding use of 13- valent pneumococcal conjugate vaccine (PCV13) in adults aged [AGE] years PCV13 is a safe and effective vaccine for older adults .The remaining risk is a function of each individual patient's risk for exposure to PCV13 serotypes and the influence of underlying medical conditions on the patient's risk for developing pneumococcal disease if exposure occurs. The following adults aged [AGE] years are potentially at increased risk for exposure to PCV13 serotypes and might attain higher than average benefit from PCV13 vaccination, and providers/practices caring for many patients in these groups may consider regularly offering PCV13 to their patients aged [AGE] years who have not previously received PCV13: Persons residing in nursing homes or other long-term care facilities .

Based on interview, observation, and record review, the facility failed to implement interventions and provide supervision to prevent falls for 2 of 10 residents (R1, R2) reviewed for falls in the sample of 16. This failure resulted in R1 sustaining a laceration to her right eye brow requiring 8 sutures, and R2 receiving a right [MEDICAL CONDITION] that required surgery. Findings include: 1. R2's Face Sheet, dated April, (YEAR), documents R2 was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS), dated [DATE], documented R2 having a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. The MDS further documents R2 requiring assist with transfers, locomotion on and off the unit, and identifies R2 as being unsteady and only able to stabilize with staff assistance for balance and walking. R2's Physician order [REDACTED]. R2's initial Fall Risk Assessment, dated 4/17/18, documented in part, R2 having had 3 or more falls in the past 3 months. R2's Fall Risk assessment dated [DATE], documented in part, a score of zero, indicating R2 not having any falls in the past 3 months. R2's Fall Risk assessment dated [DATE], documents R2 having a score of 2, indicating 1 to 2 falls in the past 3 months. R2's Incident/Occurrence Report, dated 4/28/18 at 5:10 AM, documented R2 was found sitting on floor next to bed, with her incontinent brief removed. The Incident Report also documented interventions in part, Canoe mattress for residents bed and more frequent checks. R2's Care Plan does not reflect an intervention for R2's fall of 4/28/18 until 5/1/18, which does not include frequent checks. R2's Incident/Occurrence Report, dated 5/20/18 at 7:19 PM, documents R2 was witnessed on floor during evening dining hour. The report also documents, R2 was assisted back to bed. The Report further documents R2's family and physician were notified of the incident. R2's Pain Assessment, dated 5/20/18, documents R2 having a pain rating of 2, with the description of hurt, and location of her right leg. R2's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MAR further documents R2 may receive [MEDICATION NAME] 650 mg one suppository per rectum as needed every 4 to 6 hours for pain. The MAR indicated [REDACTED]. R2's Progress Note, dated 5/21/18 at 4:40 AM, documented that R2 notified staff that her incontinent brief was wet. The note also documented, when CNA (Certified Nursing Assistant) attempted to change resident, resident began screaming in pain and holding right leg, hip area. The note further stated R2 was noted to have external rotation with shorting noted to her right leg, and resident protecting her right leg. R2's Progress Note, dated 5/21/18 at 11:06 AM, documents in part, (R2) was admitted with hip and pelvic fracture. Will be receiving surgery on 5/22/18. R2's Incident/Occurrence Report new interventions, dated 5/22/18, documented, Anti roll backs installed on wheelchair. On 5/29/18 at 3:00 PM, V15 and V16, CNA's, were attempting to transfer R2 from the bed to bathroom, and R2 began to stand without assist. V15 and V16 redirected R2 to not stand up from bed until assisted. V15 and V16 stated they care for R2 on a frequent basis when working and that R2 continues to self transfers at times. On 5/29/18 at 3:15 PM, V17, CNA, stated she was assisting residents within the central dining room on 5/20/18 around 6:30 to 7:30 PM, when she observed R2 sitting on the floor. V17 stated she informed V8, Licensed Practical Nurse (LPN), of the incident. On 5/30/18 at 10:15 AM, V8, LPN, stated during the 5/20/18 incident, R2 was assisted back into her wheelchair. V8 further stated she performed an assessment and re-located R2 to front of nurse's station. V8 stated she did perform a total body assessment and obtained vital signs, but did not document it. On 5/30/18 at 9:35 AM, V14, LPN, stated R2 self transfers without requesting assistance even prior to right [MEDICAL CONDITION]. On 5/29/18 at 9:25 AM, V3, LPN, stated the new frequent check intervention for R2's fall of 4/28/18, could not be presented for review, as it was not documented. On 5/30/18 at 11:50 AM, V3, LPN, stated she was aware R2's Care Plan having an intervention of frequent checks for R2's initial fall on 4/28/18, and being the only intervention prior to the incident of 5/20/18, in which R2 sustained a right [MEDICAL CONDITION]. On 5/31/18 at 2:15 PM, V3, LPN, stated she was aware of R2 having a Left [MEDICAL CONDITION] prior to admission to facility on 4/17/18. 2. R1's Care Plan, dated 1/30/2018, documented in part, R1 being admitted to the facility for skilled nursing and therapy services, with contributing factors including, fractured pubis, dementia, anxiety. R1's Care Plan, edited on 4/18/2018, documented in part, Problem: Psychoactive medication (R1) receives psychoactive med to treat anxiety and depression, placing her at risk for significant side effects from med. Monitor for dizziness; (sig) lightheadedness. R1's Care Plan, edited on 5/15/2018, documented in part, (R1) is at risk for falls or trauma, r/t (related to) unsteady balance, and use of multiple meds & dx (diagnoses) which include: hx (history) of falls prior to facility admit, use of psych (psychotic) medications. R1's POS, dated 1/30/18, documented R1 having received an order for [REDACTED]. The Falls Details Report, dated 3/3/18 at 5:45 AM and 3/22/18 at 6:15 AM, documented R1 was visually observed on floor, in her room. Interventions listed for 3/3/18 was to lower R1's bed and Res (resident) was advised on the importance of using call light for help. R1's MDS, dated [DATE], documented a BIMS score of 4, indicating severely impaired cognition. The MDS also documents R1 requiring extensive assistance of two for toileting and bed mobility, transfers, and uses a wheelchair for mode of transportation. The MDS further documented R1 having limitations to her lower extremity (hip, knee, ankle, foot), being unsteady and only able to stabilize with staff assistance for balance and walking, and being frequently incontinent. R1's Care Plan, edited 4/18/2018, documented R1's approaches in part as, Assure safety prior leaving room, and place any requested or anticipated item in esy (sig) reach, such as, not limited to: bedside table. R1's Incident/Occurrence Report, dated 5/10/18 at 6:00 AM, documented in part, Noted Res laying on Rt (right) side, with incident occurring in her room. The Report further documented R1 was unable to participate in a pain assessment due to dementia. The Detailed Incident Summary, dated 5/11/18 at 3:15 PM for incident occurring 5/10/18, documented in part, (R1) was found laying on the floor next to bed. Resident was on her landing strip next to her bed, however she had struck her head on a night stand next to her bed. Resident stated 'she needed to go to the bathroom.' BM (bowel movement) on the floor when fall occurred. Ambulance called for laceration to right eyebrow. The Summary was authored by V2, Director of Nursing (DON). R1's Progress Notes Report, dated 5/10/18 at 10:30 AM, documented in part, ER (emergency room ) called to notify res received 8 sutures to laceration above right eye. R1's Progress Notes Report, dated 5/17/2018 at 1:13 PM, documented R1 had 8 sutures removed. On 5/30/18 at 5:50 PM, R1 was sitting in the dining room eating her dinner, with her legs crossed eating fish and drinking from her cup during the evening meal. On 6/1/18 at 11:10 AM, R1 was sitting in her wheelchair in her room, and was pleasantly confused. She had bruising and a scar noted to the right upper corner of her eye, and the bruising appeared to be resolving. She was unable to answer how she sustained the injury to her eye, and was not able to utilize her call light when asked if she could use the light. On 5/31/18 at 2:00 PM, V3, LPN, stated after R1's fall of 5/10/18, the facility implemented having R1 be one of the first residents up in the morning, to have staff toilet her upon rising, hourly bed checks from 9:00 PM until 6:00 AM, as well as moving her environment so as to not have the bedside table next to her bed. V3 further stated the facility did not have documented frequent checks, but that facility is now ensuring the hourly checks are documented. On 5/31/18 at 8:55 AM, V20, Physician for R2 and on-call physician for R1, stated he would expect the facility to follow interventions implemented for fall prevention for residents. The Facility's Incident Report Tracking and Analysis policy and procedure, dated (MONTH) 2014, documents in part, Policy: It is the policy that incidents will be tracked and analyzed for trends and patterns to aide in preventing future reoccurrences. It continues under Procedure: 8. The tracking log, and analysis sheets should be retained so it can be analyzed for patterns or trends. Look for patterns in the time of day. It further documents, 10. Once the analysis is completed an action plan is created to address any patterns. On an individual basis, the resident with numerous falls is referred to the Fall Program for intervention. The Facility's Falls Management policy and procedure,dated (MONTH) (YEAR), documents in part, It is the policy to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. Unless there is evidence suggesting otherwise, when a resident is observed on the floor, a fall is considered to have occurred. iv. Action Taken - list any steps that were taken after the fall to care for the resident. The Facility's Fall Program policy and procedure, dated (MONTH) 2014, documents in part, Policy. The Program is designed to decrease the number of falls in the facility. An episode where a resident lost his/her balance is considered a fall. The risk for fall will be addressed on the resident's plan of care and discussed with the interdisciplinary team. It continues, 6. Each resident on the program will be monitored to ensure: and continues, b. Pathways in the room are clear and free of clutter. 7. Facility staff will assist in monitoring residents. The Facility's Facility Self Report policy and procedure, dated (MONTH) 2014, documents in part, 7. The reporting facility's documentation must include the following information: and continues, c. A description of the resident(s) injury. d. What corrective action the facility has taken to prevent the incident from reoccurring.

Based on record review and interview, the facility failed develop an individualized care plan to address the needs of the resident and the risks identified for 1 of 23 residents (R37) reviewed for care planning in the sample of 36. This failure resulted in R37's fall sustaining a Subdural Hematoma and subsequent death. Findings include: R37's physician's orders [REDACTED]. It also document medications to include [MEDICATION NAME] 75 mg (milligrams), take one tablet by mouth daily and Aspirin 81 mg, take one tablet daily. R37's Fall Risk Assessment, dated [DATE], documented R37 was at High Risk for falls. It also documented R37's Level of Consciousness/Mental status as disoriented and has a history of ,[DATE] falls in the past 3 months. R37's Minimum Data Set (MDS), dated [DATE], documented R37 required Limited assistance of 1 person physical assist for transfers and ambulation. It also documented, R37 as not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking and Surface-to-surface transfer. R37's Care plan, initiated [DATE], documented (Resident) is at risk for falls or trauma, r/t (related to) unsteady balance, and use of multiple meds & Dx's (diagnoses) which include:weakness and low endurance. R37's Care plan does not document the MDS assessment of requiring limited assistance of 1 person physical assist for transfers and ambulation or R37's use of Anticoagulation medications and the risks. The facility's Serious Incident Report, dated [DATE], documented R37 was found on R37's bathroom floor, on R37's hands and knees with a raised hematoma above left eyebrow, alert, but unable to explain what happened because of R37's confusion. The Clinical Report-Physicians/Mid Levels from the local hospital, documented R37 was seen at the hospital by V14, Hospital Physician, on [DATE] at 10:17 PM. A Computer Tomography Scan (CT-scan) done on [DATE] at 10:44 PM, read by V13, Hospital Radiologist, documented, Summary: 1. Extensive right acute subdural hematome with maximal thickness of 9 mm (millimeters) in the right temporal regions. There is mild mass effect with no midline shift. On [DATE] at 10:15 AM, V11, Primary Care Physician, stated R37's Alzheimer's was fairly well progressed. V11 stated the reason R37 was admitted to the Nursing Home was R37 needed help and supervision. V11 stated R37 had strength, R37's major problem was R37's cognition. V11 stated there was nothing that could have been done for R37's bleeding. V11 stated R37 was sent back to the facility on comfort measures and subsequently died . V11 stated The fact that (R37) got up and fell , lead to (R37's) death. R37 was on blood thinners for A-Fib ([MEDICAL CONDITION] Fibrillation) which increased (R37's) risk for bleeding. The facility's Policy and Procedure, Falls and Fall Risk, managing, revised (MONTH) 2007, documents, in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview and record review the facility failed to provide safe transfers, supervision and interventions to prevent fall for 3 of 6 residents (R37, R45, R366) reviewed for falls and transfers in the sample of 36. This failure resulted in R37's fall sustaining a Subdural hematoma and subsequent death. This failure also resulted in R45 receiving a serious injury requiring 15 sutures to her right anterior lower leg. Findings include: 1. R37's physician's orders [REDACTED]. It also document medications to include [MEDICATION NAME] 75 mg (milligrams), take one tablet by mouth daily and Aspirin 81 mg, take one tablet daily. R37's Fall Risk Assessment, dated [DATE], documented R37 was at High Risk for falls. It also documented R37's Level of Consciousness/Mental status as disoriented and has a history of ,[DATE] falls in the past 3 months. R37's Minimum Data Set (MDS), dated [DATE], documented R37 required Limited assistance of 1 person physical assist for transfers and ambulation. It also documented, R37 as not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking and Surface-to-surface transfer. R37's Care plan, initiated [DATE], documented (Resident) is at risk for falls or trauma, r/t (related to) unsteady balance, and use of multiple meds & Dx's (diagnoses) which include: weakness and low endurance. R37's Care plan does not document the MDS assessment of requiring limited assistance of 1 person physical assist for transfers and ambulation or R37's use of Anticoagulation medications and the risks. The facility's Serious Incident Report, dated [DATE], documented R37 was found on her bathroom floor, on R37's hands and knees with a raised hematoma above left eyebrow, alert, but unable to explain what happened because of R37's confusion. The Clinical Report-Physicians/Mid Levels from the local hospital, documented R37 was seen at the hospital by V14, Hospital Physician, on [DATE] at 10:17 PM. A Computer Tomography Scan (CT-scan) done on [DATE] at 10:44 PM, read by V13, Hospital Radiologist, documented, Summary: 1. Extensive right acute subdural hematome with maximal thickness of 9 mm (millimeters) in the right temporal regions. There is mild mass effect with no midline shift. On [DATE] at 10:15 AM, V11, Primary Care Physician, stated R37's Alzheimer's was fairly well progressed. V11 stated the reason R37 was admitted to the Nursing Home was R37 needed help and supervision. V11 stated R37 had strength, R37's major problem was R37's cognition. V11 stated there was nothing that could have been done for R37's bleeding. V11 stated R37 was sent back to the facility on comfort measures and subsequently died . V11 stated The fact that R37 got up and fell , lead to R37's death. R37 was on blood thinners for A-Fib ([MEDICAL CONDITION] Fibrillation) which increased r37's risk for bleeding. The facility's Policy and Procedure, Falls and Fall Risk, managing, revised (MONTH) 2007, documents, in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. R45's Progress Notes, dated [DATE] 5:20 AM, document, called to resident's room, noted 18 cm (centimeter) laceration to R (right) lower leg caused during transfer, pressure dressing applied, ambulance notified at 5:40 AM. R45's Progress Notes, dated [DATE] at 12:27 PM, documents resident returned to the facility received 15 stitches and Tetanus injection. Disciplinary Action, dated [DATE], documents V33, Certified Nursing Assistant (CNA), did not follow the safe patient handling and Keep Me Safe Policy and Procedure that resulted in a resident injury. On [DATE] 02:20 PM, R45 was sitting in a chair with a dressing to the lower right anterior leg. V3, Assistant Director of Nursing (ADON) removed the dressing to show 15 sutures on R45's Right anterior lower leg. V3 stated that R45 has restless legs that spasm and R45's leg got caught in the opening of the wheel chair. V3 stated R45's legs have done that since admission, and does not know if R45 has a [DIAGNOSES REDACTED]. R45's Care Plan, dated [DATE], documents in part that R45 has a [DIAGNOSES REDACTED]. R45's Care Plan, dated [DATE], documents R45 is at risk for falls or trauma related to unsteady balance. R45's Care Plan documents intervention Keep Me Safe Transfer Status; 2 staff assist with gait belt. R45's Care Plan, dated [DATE] and edited [DATE], documents that R45 is at risk for falls or trauma related to unsteady balance, Keep Me Safe status changed to mechanical lift with 2 staff assist, interventions include mechanical lift x 2 assist. R45's Care Plan does not document anything about R45's restless legs, spasms or interventions to deal with them during care and transfers. R45's MDS, dated [DATE], documents that R45 requires extensive assistance and two plus physical assistance for transfers. On [DATE] 10:30 AM, when asked if R45's MDS documents that R45 requires assistance of 2 for transfers, would he expect them to use 2 staff? V11, R45's physician, stated, I would expect them to try to do it. On 3 /,[DATE] 02:34 PM, V8, CNA, and V9, CNA, transferred R45 from R45's chair to the bed using a mechanical lift. V8 stood back and did not assist with transferring R45 from the chair to the bed. V9 transferred R45 from the chair to the bed. At no time during the transfer did staff have hands on the sling while R45 was in the air. V9 stated R45 was now a mechanical lift transfer because midnights were getting R45 up and cut R45's leg on wheelchair. On [DATE] at 10:30 AM, V3, Assistant Director of Nursing (ADON), stated the policy on transferring with a mechanical lift is always to use 2 staff. The Facility's Lifting Machine, Using a Portable, Policy and procedure, dated, revised (MONTH) 2010, documents the portable lift can be used by one nursing assistant if the resident can participate in the lifting procedure, if not, two CNA will be required to perform the procedure. The Electric Mobile Patient Lift User Manual, dated 2013, documents it is recommended that two assistants be used for all lifting preparation and transferring to/from procedures. 3. On [DATE] 11:15 AM, R366 sitting in R366's wheelchair stating needs to go to the bathroom. R366 states R366 had been up since therapy got R366 up this morning. V23, CNA and V28, CNA came into room. V23 stated the nurse said assist of 2 for R366's transfer status. V23 pushed R366 in wheel chair into bathroom and put a gait belt around R366's waist. V28 asked R366 which leg was hurt. R366 told V28, R366's right hip. V23 and V28 both stated that therapy had got R366 up this morning. V23 and V28 tried to stand R366 using a gait belt. V28 told R366 to put R366's right foot on V28's foot and to press on V28's foot. R366 was unable to do and complained of pain. V23 stated V23 would go get therapy. V29, Doctor of Physical Therapy (DOPT), and V30, Certified Occupation Therapy Assistant (COTA), came in. V29 stated they had gotten R366 up around 9:00 AM. V30 stated a walker is to be used with 2 assist transfer and toe touch weight bearing on right foot. V30 stated they do an inservice and train staff, but stated V23 and V28 had not been trained. V30 stated V30 had put a note in the facility computer system. R366's Minimum Data Set ((MDS) dated [DATE] documents that R366 requires extensive assistance and two plus physical assistance for transfers. R366's Progress notes, dated On [DATE] at 2:05 PM documents that R366 found lying on floor and complaining of right hip pain, and R366 sent to the hospital by ambulance. R366's notes dated [DATE] at 10:22 PM, documents R366 fractured right hip and scheduled for surgery on [DATE]. The Hospital Discharge Instructions, dated [DATE], documents Activity Instructions of 25% Weight Bearing with walker at all times x 2 weeks. On [DATE] at 2:40 PM, V1, Administrator, stated V1 would expect staff to know how to transfer a resident upon return from the hospital.

Based on record review and interview, the facility failed to provide safe transfers with the use of a gait belt for 1 resident (R2) of three residents reviewed for falls in the sample of 3. This failure resulted in R2's fall sustaining a right hip fracture requiring surgical repair. This Past Non Compliance occurred on 8/11/17. On 8/11/17, the facility took disciplinary action against E4, Certified Nurse's Aide (CNA) and conducted a validation competency screen regarding transfers on E4. On 8/11/17, the facility reviewed the Safe Patient Handling Policy, dated January 2017 and all nursing staff were in serviced on this policy. At that time, the facility implemented random Validation competency screens on all CNAs regarding transfers skills. Validation competency screens began on 8/11/17 and are on-going to ensure compliance. Findings include: R2's Minimum Data Set (MDS), dated [DATE], documents that R2 has a Brief Interview for Mental Status (BIMS) score of 3 which indicates severe cognitive impairment. R2's MDS also documents that R2 requires extensive assistance and one person physical assistance with bed mobility and transfers. R2's Fall Risk Assessment, dated 10/4/16, 1/3/17, 4/5/17, and 7/3/17 document R2 as high risk for falls. R2's Care Plan, dated 7/6/16, documents R2 requires staff assistance for transfers related to alteration in mobility, unsteady balance and cognitive impairments. R2's Care Plan documents under the Approach section to gather all supplies for task, including gait belt. To place gait belt around R2's waist. After gait belt is secured around R2's waist to place walker in front of R2 and to have R2 to push up from surface. R2's Care Plan also documents that R2 is at risk for fall related to unsteady balance. E4's, Certified Nursing Assistant (CNA), undated Employee Witness Statement documents that E4 went to put R2 in her recliner, locked the wheelchair, had a hold of R2 by left side and arm, the wheel chair did move and R2's foot slid on floor and R2 fell on her right hip on the floor. On 10/4/17 at 11:15 AM in an interview regarding R2's fall on 8/11/17, E4 stated that she did not use a gait belt and that she had admitted that to the facility. E4 stated that she did try to catch R2. E4 stated it is the facility policy to use gait belts. E4's Employee Disciplinary Action form, dated 8/11/17, documents, in part, did not apply gait belt during resident transfer from W/C (wheelchair) to recliner resulting in a resident injury. R2's X-ray report, dated 8/11/17, documents that examination of the pelvis and right hip reveals an essentially nondisplaced right intertrochanteric hip fracture. R2's Operative Report, dated 8/11/17, documents that R2 had her right hip pinned. On 10/4/2017 at 2:30 PM, E1, Administrator, stated that she would expect staff to use a gait belt when transferring residents. Multiple attempts to contact the physician were unsuccessful. The facility Safe Patient Handling Program, revised January 2017, documents gait/transfer belts where deemed appropriate will be used when manual assistance is required for ambulation and transfer activities. On 8/11/17, the facility reviewed the above policy. The In-Service Training Record, dated 8/11/17, documented the training topic as Safe Patient Handling & Please Keep Me Safe. All Nursing staff signed this in-service sheet. On 8/11/17, E4 and multiple staff were given validation of competency skills check on transfers. On 10/12/17, E1 stated that random validation of competency skills check will be conducted on all nursing staff to ensure compliance.

Based on record observation, record review and interview, the facility failed to prevent a fall from a wheelchair while pushing a resident from a dialysis provider for one of 4 residents (R3) reviewed for falls and safety during transport in the sample of 10. This failure resulted in R3 sustaining fractures of the cervical spine, nose and 2 ribs, with traumatic subdural hematoma, subarachnoid hemorrhage and facial and right elbow lacerations. Findings include: The ECR (electronic clinical record) for R3 documents diagnoses, in part, as Chronic Pain, End Stage Renal Disease with Renal Dialysis, Weakness, History of Deep Vein Thrombosis of Lower Extremity and CHF (Congestive Heart Failure). The Minimum Data Set ((MDS) dated [DATE], documents R3 has a BIMS score (Brief Interview of Mental Status) of 15, with no impairment in cognition, requires extensive assistance with transfers, does not ambulate, has limited range of motion in all 4 extremities and has unsteady balance, that only stabilizes with staff assistance. The MDS documents R3 uses a wheelchair for her mode of transportation. The Occurrence Report, dated [DATE] at 4:30 PM, documents R3 fell over face first from the wheelchair, hitting her face on the concrete sidewalk as E3, Certified Nurses Aide (CNA) was pushing her down a downward sloping sidewalk in front of the nearby general store. The Occurrence Report documents 911 was called, and R3 was transported to the local hospital for evaluation and treatment. On [DATE] at 10:40 AM, Z1, Manager of the general store played the video, dated [DATE], with images that the store's camera had taken and recorded on [DATE] at 4:29 PM of the front of the store and the main entrance/exit. This video documents E3 was pushing R3 on the sidewalk past the front entrance door of the store. R3 was in a wheelchair with no foot pedals, and her head and body were covered with a blanket. E3 had both hands on the handgrips of the wheelchair as she was pushing and guiding R3 down the sidewalk. As the sidewalk began to slope downward, R3's wheelchair moved a little faster, and at 4:30 PM R3 rapidly pitched forward from the wheelchair and landed face first onto the concrete sidewalk. R3's wheelchair was on top of her. A customer approached R3 and covered her with a blanket, as E3 left the area. R3 remained on the sidewalk in the same position. The video documents at 4:33 PM on [DATE], Z1 came out of the front entrance. At 4:37 PM, an ambulance and a local police officer arrives at the scene. The first responders, with help from others that had approached R3, turned R3 over onto a backboard. No cervical collar was applied before R3 was lifted by the ambulance staff and placed into the waiting ambulance at 4:39 PM. The video documents the ambulance carrying R3 left the parking lot in front of the general store at 4:40 PM. On [DATE], at 10:40 AM, Z1 reported he did not witness R3's fall, but was there to assist afterward. Z1 stated, in part, She (R3) hit her head. There is a black stain on the sidewalk from bleeding from her face. There was a lot of blood. I put cat litter on it to soak it up. When I came out, she was still on her face .The staff were talking to her (R3), and she was responsive. I don't think there were any foot pedals on the wheelchair. By the time I got there, an ambulance got called. Two ladies from the nursing home (facility) came to watch the video. One was the Administrator, (E1). A customer covered (R3). The staff person (E3) had left briefly. There was no snow or ice on the sidewalk. (Z3) of the (local) police also arrived. On [DATE] at 11:08 AM, the sidewalk near the front entrance to the general store had a large dark substance mixed with cat litter staining the sidewalk. At that time, Z1 identified it as the blood stain left by R3. Before the stain, the sidewalk began to slope downward and there was a large 8 to 10 inch wide and 1 inch deep, open area in the right side of the crack, where the concrete had eroded away, leaving a hole. On [DATE] at 2:25 PM, E3, CNA stated, in part, (R3) had a scarf around her neck. It was cold and windy. I asked her if she wanted me to cover her face, and she said yes. I covered her (R3) face-blanket up to the hood with fuzz around it, and tucked the edge of the blanket under her legs. I wheeled her down the sidewalk. We got between the (general store) and (grocery store). The sidewalk inclined-slanted downward. (R3's) wheelchair began going faster. I leaned back to slow down the wheelchair. (R3) started to lean forward and fell out of the wheelchair. She is a bigger lady. I couldn't see due to being in back of the wheelchair. There were no foot pedals on the wheelchair. I started to panic. A lady jumped out of a truck, and said she would stay with (R3). I ran to the facility for help and came back. A man had 911 on the phone. A nurse, (E5, Registered Nurse, RN) came over. I was freaked out. She said you need to calm down, and I came back (to the facility). She was not knocked out and was talking. She (R3) said the ground was cold and wanted to get off of it. I just saw blood on the sidewalk. I work evenings and normally, I just go and get them (from dialysis). I have gotten her (R3) a couple times before. On [DATE] at 2:10 PM, E5, RN stated, in part, A staff member said she was on the ground. I got there and between (general store) and (grocery store), (R3) was between the two. She was laying on the sidewalk face down-head was turned to the left. All I could see was blood on the concrete. She (R3) was talking and wanted to get up off of the sidewalk. She said she was cold. The store manager called 911. I knew (E4, RN) and I couldn't get her up by ourselves. She is a large lady and uses a mechanical lift. (E4) took her pulse. The ambulance arrived quickly. I moved the wheelchair over and the (urinary) catheter bag was still connected to the wheelchair. (R3's) feet were still under the wheelchair. She was placed on a backboard. No cervical collar was applied. We all lifted (R3) to the stretcher to the ambulance. I sent her glasses with her. One of the lenses came out. The glasses had blood on them. On [DATE] at 1:53 PM, E4 was interviewed and told the same story as E5. E4 reported the facility has transported residents to and back from the nearby dialysis center by wheelchair for the 2 years she has been employed at the facility. The local ambulance record for R3 dated [DATE] at 4:38 PM, documents, in part, Patient (pt) complaining of pain to her chin, neck and head. Pt had about 1,000 ml (milliliter) of blood loss on the ground. Pt was log rolled onto backboard. Unable to get a c-collar in place due to size of patient's neck. Pt was starting to spit up blood and airway was starting to become compromised. The local hospital emergency department (ED) record documents R3 arrived at 4:55 PM on [DATE]. The ED record documents, in part, Patient has noted forehead avulsion, right elbow skin tear and pain reported to neck, head and chin. Pain all reported at ,[DATE]. The ED record documents R3 was air lifted via medical helicopter to a hospital that provided a higher level of care on [DATE] at 6:55 PM. The History and Physical (H&P) for R3 from the local hospital, dated [DATE] at 5:18 PM, documents, in part, Patient (R3) sustained a large 4 X 2 cm (centimeter) V shaped laceration to right frontal area, small laceration to upper tip of nose, skin tear to right elbow. Patient complains of intractable pain to neck, head and chin. Bilateral raccoon appearance of eyes. The CT (computed tomography) of R3's head, dated [DATE] at 11:32 PM, documents, small amount of acute subarachnoid and subdural hemorrhage involving the frontal lobes. Cervical CT-Type 2 dens fracture which should be considered unstable. The fx (fracture) displacement as a risk for vertebral artery injury to which could be better assessed with [REDACTED]. CT face-nasal fx, small densities in the post nasopharynx. Condition-critical. The H&P, dated [DATE], from the second hospital R3 was transferred for a higher level of care documents R3 also sustained, Nondisplaced right fifth through ninth anterior rib fractures. R3's Discharge Report from this hospital documents R3 left the faciity on [DATE] at 10:43 AM by ambulance to a hospital based rehabilitation unit. On [DATE] at 4:03 PM Z2, Physician reported he was aware of R3's fall with numerous fractures and injuries. Z2 reported he knew R3 expired on [DATE]. Z2 stated, in part, Her (R3) renal functioning was very brittle. I had discussed a probable malignancy of the left upper chest that was found with a screening for cataract surgery with her and her family in [DATE]. They did not want chemotherapy. There was trouble keeping her blood counts up. She was not in good health. I don't know the cause of death. Personally, if the fall contributed to her death, she would have died sooner. R3's Care Plan, dated [DATE], documents in part, Resident is at risk for falls or trauma related to unsteady balance and use of multiple meds (medications). Receives hemodialysis 3 times weekly and receives narcotic pain management. Transfers are 2 assist with (mechanical lift) and verbal/physical cues. If injury should occur, alert family and physician as soon as possible, administering first aide as indicated. She has varying ability to participate in ADL's (activities of daily living), noted more after dialysis treatments. On [DATE] at 12:06 PM, E2, Director of Nursing (DON) reported the facility had no protocol or policy and procedure for transporting residents to the dialysis center in the strip mall that is behind the facility until after R3's fall on [DATE]. The State Of Illinois Certificate of Death Worksheet, certified on [DATE], documented Describe How Injury Occurred: Decedent was in wheelchair that overturned at her extended care facility. R3 ' s Death Certificated documented the Cause of Death as Complications of Cervical and Rib Fractures. The facility's policy and procedure, dated ,[DATE] and entitled, 'Falls and Fall Risk, Managing' documents, in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, record review and interview, the facility failed to initiate a safety intervention to prevent a fall during a shower for 1 of 6 residents (R1), reviewed for falls in the sample of 12. This failure resulted in R1 sustaining a cervical fracture and was sent to the hospital for evaluation and treatment. Findings include: The ECR (electronic clinical record) for R1 documents diagnoses, in part, of Morbid Obesity, Arthropathy, Obstructive [DIAGNOSES REDACTED] with a Right Ventricular Shunt, Ataxia and Dementia. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is moderately impaired with cognition and requires extensive assistance of 2 staff for transfers, is nonambulatory and has unsteady balance for sitting and surface to surface transfers. The Fall Risk Assessment, dated 8/09/2016 documents R1 is a high risk for falls. On 9/23/2016 at 1:50 PM, R1 was seated in a recliner, wearing a cervical collar to her neck. R1 was tall and morbidly obese. A sit to stand mechanical lift was near her bed. A sensor pad alarm was attached to the recliner. R1 stated, I had an accident with, I don't know. I didn't fall. I broke a bone in my neck about 3 weeks ago. I wear the neck brace all the time. R1 reported she uses a sit to stand mechanical lift for transfers. The Fall Details Report, completed by E9, Registered Nurse (RN), dated 8/19/2016 at 3:00 AM, documents R1 fell on her buttocks in the shower room from the shower chair, with no bruising, redness, injury or complaints of pain. The Occurrence Report completed by E9 at the same time, documents Z3, Physician, was notified by fax at 3:00 AM. The Message Form sent to Z3 on 8/19/2016 is dated 8/19/2016, but has no time documented or fax confirmation. The Report sent to the Department via fax on 8/19/2016 at 2:34 PM, documents Z3 was notified at 7:00 AM on 8/19/2016 about R1's fall. The Report documents that on 8/19/2016 at 10:00 AM, R1 had bruising to the left side of back of the head and neck, and was sent to the local hospital for evaluation and admitted with a cervical fracture (C2) and a UTI (urinary tract infection). The Neurological Assessment Form for 8/2016, R1 documents the facility began neurological checks for R1 at 5:30 AM with complaints of a headache. The Progress Notes Report for R1, dated 8/19/2016 at 4:24 AM by E9 documents, in part, (3:00 AM) resident up in shower room with CNA (Certified Nurses Aide), fell to floor. No injury noted, no bruising, no redness noted, denies hitting head, VSS (vital signs stable). Returned to bed. There is no documentation Z3 was notified. The Progress Notes Report for R1, dated 8/19/2016 at 6:56 AM, by E9 documents in part, (5:30 AM) resident complained of headache, Tylenol given, neuro (neurological) checks negative, perrl (pupils equal, reactive to light) 6 mm (millimeter), grips equal, moves all extremities. Alert and oriented times on. (6:25 AM) POA (power of attorney) notified of fall, shunt checked, Some ropey areas, but others soft, mushy. Neuro checks unchanged. There is no documentation Z3 was notified. The Progress Notes Report for R1 by E16, Licensed Practical Nurse (LPN), dated 8/19/2016 at 10:08 AM, documents, in part, (R1) has bruise/bump to left side of crown of head, Complaints of headache and neck pain. POA called, raised concern due to patient's shunt placed in right side of head. This nurse did full neuro assessment. Shunt was assessed. The Progress Notes Report for R1 by E16, on 8/19/2016 at 10:08 AM, documents, in part, POA wants (R1) to be sent to ER (emergency room ) to check placement of shunt and address neck pain from previous fall. This nurse left message with (Z3) to make aware of family request. The CT (computerized tomography) of R1's cervical spine, dated 8/19/2016 at 12:20 PM, documents, in part, The examination reveals transverse fractures through the pedicels of C2 bilaterally. This effectively separates the anterior and posterior elements at C2. This therefore, would be classified as an unstable fracture. On 9/28/2016 at 2:00 PM, E5, CNA, reported she was across the hall from the 100 hall shower room, when she heard a loud noise and went into the hall to investigate. E5 stated, I noticed the 100 hall shower door was open with legs sticking out. I went around the door and saw (R1) laying on the floor with a walker across her chest. (E7, CNA) was straddled over (R1). (E7) said (R1) fell . E5 reported she, E7 and E17, CNA used a mechanical lift to get R1 off of the floor and took her to her room. On 9/28/2016 at 3:20 PM, E7 reported when she had done a bed check on R1 she found stool everywhere. E7 stated, I got her up with a walker. There was no gait belt on her. (R1) went from the bed to the shower chair. No shoes. The crash pad on the floor was full of stool. I covered (R1) and wheeled her to the closest shower, the 100 hall shower stall. I washed and rinsed her hair, and got (R1) washed off. She fell out of the shower chair when I was shutting the water off. I didn't leave her. The door was open. I called out for help. Another CNA, (E5) and (E17) came by. I refused to pick her up with a gait belt. The nurse (E9) came down after (E17) went and got him to evaluate her. (R1) had no complaint of pain or crying. Her bottom bounced when she hit the floor. She didn't holler. It was an unfortunate accident that happened. The seat was plastic, a vinyl covered soft foam. It's slippery when wet. On 9/29/2016 at 9:37 AM, E17, CNA, stated, I saw the 100 hall shower room door open and light on. I went to see why the door was open. (R1) was on the floor already. (R1) was alert, (E7) was in the room with her. (E9), the nurse said it was ok to get her up. I was one that helped her down the hallway in the mechanical lift. I know that's the wrong way to transport somebody. I did help put (R1) in bed from the lift. She wasn't hurt and no complaints of pain. On 9/29/2016 at 8:45 AM, E2, Director of Nursing (DON), stated, (R1) had a foam seat, vinyl covered on the shower chair, The CNA (E7) failed to have the seat belt fastened. That's why (R1) slid out. On 9/29/2016 at 2:56 PM, E9 stated, I remember she fell in the shower. She was bed when I saw her. One of the aides told me she fell . Don't remember who-one of the ones who was on a different hall. She had no loss of consciousness. The shower aide said she didn't think she hit her head. I didn't know she had shunt in her head until after I talked to the daughter/POA. I checked it. I did neuro checks when she complained of a headache. I faxed (Z3). I don't remember the time. It was in the notes or on the fax. If there is no injury, I just fax the doctor. If there is an injury, I would have call the doctor on call. I went to her room to assess her, not the shower room. She was already in bed. I think they are supposed to wait until the nurse gets there to assess before moving a resident. Rolling her in bed or moving her could have caused harm. On 9/29/2016 at 5:43 PM, Z3 reported he could not remember much about R1's fall on 8/19/2016, but R1 has always been a high risk for falls due to her history of [DIAGNOSES REDACTED] and unsteady gait. A Summary Report of Meeting, dated 8/19/2016, documents, in part, All shower chairs are equipped with seat belts. When a resident is in the shower chair, the seat belt must be fastened. R1's Care Plan, updated 9/17/2016, documents, in part, Is at risk for falls or trauma related to unsteady balance, and use of multiple meds (medications) and [DIAGNOSES REDACTED]. Approach-Follow Keep Me Safe Transfer Status: sit to stand lift with 2 assist with belt and leg strap donned. The Keep Me Safe Screen for R1, dated 8/04/2015, documents a transfer status as Assist of 2 with a gait belt. Patient requires verbal cues and extra time to process 1 step command during transfers to step from/to wheelchair/bed/recliner. The Keep Me Safe Screen for R1, dated 8/24/2016, documents, in part, Prior transfer status: 2 assist with walker. New transfer status: 2 assist with sit to stand (mechanical lift). On 9/29/2016 at 4:20 PM, E1, Administrator, reported they currently could not find the policy or procedure for the use of a shower chair. On 9/29/2016 at 12:30 PM, E2 reported the facility's policy and procedure for the use of mechanical lifts is called the Please Keep Me Safe Program. The Please Keep Me Safe Program documents, in part, Definition: A program designed to ensure a safe environment of care for our residents during resident handling and movement. Handling and movement includes: repositioning, lifting/lowering, pushing/pulling, carrying or turning, holding and supporting, The facility will have adjustable equipment/technology available for the health care worker to facilitate safe work practice. The program focuses on a culture of safety and consists of education, intervention, monitoring and communication. 2 person assist-Resident requires physical assistance of 2 people with the use of a gait belt and verbal cues to ensure a safe transfer, Resident is able to bear weight. All CNA's and Nurses will be instructed in and demonstrate competence with resident handling, mobility and transfers prior to their first day of direct care with the residents. The Employee Disciplinary Action for E7, dated 8/22/2016, documents, in part, Specific Infraction-Category I, # (number) 19-Violation of safety rules. On 8/19/2016, did not apply safety belt on resident during shower. Resident slid out of shower chair resulting in resident injury.

Based on interview and record review, the facility failed to assess/monitor and intervene for prevent a serious medical condition/[DIAGNOSES REDACTED] following a medication error for one of 3 residents (R1) reviewed for sliding scale insulin in the sample of 5. This failure resulted in R1 exhibiting sweating, being cool to touch, and a blood sugar level of 22 on [DATE] at 11:10 am. R1 expired at 12:29 pm on [DATE]. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and monitor the efficacy of the training received. Findings include: 1. The Admission Report documents R1 to have been admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. R1's physician's orders [REDACTED]. Parameters for the sliding scale were included in the physician's orders [REDACTED]. The Facility's Incident Report, dated [DATE], and Electronic Medication Administration Record (eMAR), on [DATE] at 6:00 AM, documented E3, Licensed Practical Nurse (LPN) did blood glucose monitoring on R1 which was 121. According to the Sliding Scale parameters in the physician's orders [REDACTED]. E3 documented on the eMAR that she gave 25 units. The Progress Notes do not reflect this information. R1's Progress Notes dated [DATE] written by E4 LPN document that at 9:29 AM, R1 was unable to take morning medication due to lethargy, alert to verbal stimuli, skin was dry and warm to touch. At 10:36 AM, E4 documented that she went to assess the patient and status was unchanged, skin warm and dry to touch, responded to verbal stimuli by opening and closing eyes when talked to . At 11:10 AM, E4 documented that R1's wife called her into the room because patient was cool to touch and sweating through gown and sheets. Blood sugar registered "L" (Low) on accu-check. E4 documented R1's physician, Z1 was called and an order for [REDACTED]. The Progress note continued that the blood sugar came up to 22 and that after the physician was informed, ordered [MEDICATION NAME] Intravenously (IV) STAT (Immediately.) The progress note documents EMT's (Emergency Medical Technician's) were called to start the IV with multiple attempts to get the IV started. E4 documented R1's time of death as 12:29pm. On [DATE] at 1:55pm, E4 confirmed that she received report from E3 the morning of [DATE] at approximately 7:00 am and had been told by E3 that R1 received 20 units of Insulin. E4 stated that during report, E3 explained that the order was for 100 units but given R1's decline in condition, she (E3) thought that was too much so she decided to give 20 units. E4 stated she did not recheck for order or question the Insulin given R1 as she was unfamiliar with R1's care but did stated E3 seemed sure that R1's was suppose to get 100 units. On [DATE] at 10:50 am, E4 stated that she had did not check the order until R1's wife asked how much insulin he had been given that morning. E4 stated she checked the EMAR and saw that R1 should have not gotten any according to the sliding scale and that E3 actually documented 25 units given. E4 stated she told Z1 that R1 had received 25 units at 6:00 AM that morning when she called him at 11:10 am. E4 stated she did not question E3 adjusting R1's insulin and did not recheck the order because E3 was very confident that he should have gotten the 100 units. E3 also stated she was told at 8:30am that morning that R1 did not eat any breakfast. E3 stated she did not do any glucose monitoring earlier that morning. On [DATE], at 10:00 AM, Z1 that he was not made aware of the Insulin error until later that morning when he ordered the [MEDICATION NAME] but had he known, he would have implemented hypoglycemic treatment. Z1 stated it was just a medication error and that R1 [MEDICAL CONDITION], had decided to discontinue [MEDICAL TREATMENT], had not had it in 4 days, and he had just signed orders for Hospice care that morning. Z1 stated R1 would soon have expired anyway adding that this "tipped him over the edge." The Facility's Policy entitled "Adverse Consequences and Medication Errors" documents that residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. The policy continues to document that examples of medication errors to be monitored include wrong dose (e.g. [MEDICATION NAME] 12 ml ordered, [MEDICATION NAME] 2 ml given.) The Immediate Jeopardy was identified to have begun on [DATE] at 6:00 AM, when E3 administered 25 unitls of [MEDICATION NAME] to R1 in error. E1, Administrator and E2, Director of Nursing (DON), were notified of the Immediate Jeopardy on [DATE] at 2:40pm. On [DATE] and [DATE], the surveyor confirmed through interview, observation and record review, that the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE], E7, Corporate Nurse Consultant reviewed the policy and procedures on Change of Condition in a Resident's Condition or status, Administering Medications, Procedures to administer subcutaneous medication and adverse consequences and medication errors. 2. On [DATE], E7 inserviced all licensed staff on the policy and procedures of following physician's orders [REDACTED]. and prompt follow-up to the physician. 3. All residents have the potential to be affected by the alleged deficient practice. All residents were reviewed for change of conditions including residents on insulin sliding scales. 4. The following systemic measures have been implemented to ensure the alleged deficient practice does not recur: A) The DON/Designee will make random checks of EMAR to ensure documentation of medication administration according to physician's orders [REDACTED]. B) The DON/Designee will review the 24 hour nursing report and check documentation to ensure prompt physician notification and orders are being transcribed and administered accordingly. C) The DON/Designee will make random medication pass observations. 4. The following Quality Assurance programs have been implemented to ensure the alleged deficient practice does not recur: A) The DON/Designee will continue to review the 24 hour nursing report to ensure continued compliance. B) The DON/Designee will continue to make random medication pass observations to ensure continued compliance. C) The DON will report concerns to the Administrator through the Quality Assurance process.

Based on record review and interview, the Facility failed to provide timely treatment for [REDACTED]. This failure resulted in R1 being hospitalized with urosepsis. Finding include: R1 was originally admitted to the facility on [DATE] with diagnoses, in part of Acute [MEDICAL CONDITION] and Anxiety. R1's 5/19/11 plan of care documents that R1 was "At risk for problems of constipation, urinary tract infection [MEDICAL CONDITION] and dehydration. She has a [DIAGNOSES REDACTED]. The interventions for this problem includes "report to physician for adjustment if necessary. Monitor of signs and symptoms of UTI - fever, frequency, dysuria, hematuria, incontinence, flank or abdominal pain, urgency, confusion, foul odor or dark color to urine". R1's nurses notes document that on "5/7/11, cloudy yellow urine. Dr. notified. Orders received to [MEDICATION NAME] milligrams twice a day for 5 days and update physician with urinalysis results". R1's laboratory urinalysis dated 5/9/11 documents "colony count >100,000/Milliliter (ML) gram negative bacillus - [DIAGNOSES REDACTED] pneumoniae and Escherichia coliform". Nurses notes document that R1's physician was notified of the urinalysis results on 5/9/11, and the following order was obtained: "Continue Cipro, start [MEDICATION NAME] 100 milligrams twice a day for 10 days". R1's nurses notes document the following: "6/1/11, 2:00 PM, resident having increased confusion, dysuria and strong urine odor. New order for urinalysis (UA), and Culture and Sensitivity (C & S)". 5:00 PM, given [MEDICATION NAME] 0.5 milligrams intramuscularly in left ventral gluteal area due to physical aggression". "6/2/11, 7:00 AM - 3:00 PM shift, very aggravated, angry. Feels as if everyone is trying to get her. Tried multiple times to obtain UA. Resident screamed and said "you are not touching me!" 6/3/11, 7:00 AM - 3:00 PM shift, "Very verbally abusive and screaming at staff this morning." 6/4/11, 7:00 AM, "Certified Nurses Aide's (CNA's) came to this writer stating R1 continues to be confused. R1 needing incontinent care. This writer went to assess resident - very confused, very foul smelling urine, dark in color. Spoke to R1's Power of Attorney who said to send R1 to the emergency room . 11:00 AM, emergency room called - resident admitted to hospital with decreased Hemoglobin , UTI and pneumonia". Interview on 6/8/11 at 1:20PM with E4, Registered Nurse (RN), and E4 stated that she was the nurse on duty on 6/1/11 who contacted R1's primary care physician, and obtained an order for [REDACTED]. E4 said that R1 was very combative and would not let me near her. E4 stated I did not call the Doctor, and notify him that we did not get the urine sample as they were going to try and get it on the next shift, and I passed it on to the evening nurse. Interview with E1, Administrator and E3, Assistant Director of Nursing, on 6/8/11 at 1:35PM, and both stated that R1 has been a resident of the Facility 3-4 times in the past. During R1's most recent admission, the staff have noted that she has had an increase in behaviors and paranoia. E1 and E3 both said that R1 is extremely sensitive to medication as she has liver and renal damage from a previous Tylenol overdose. E1 and E3 both confirmed that the urine sample was not obtained for R1, and R1's physician was not contacted. R1's History and Physical from the hospital dated 6/5/11 documents "Diagnosis: [REDACTED]. Hospital laboratory "Urine Culture" shows "colony count >100,000/ML gram negative bacillus, escherichia coliform".

Based on record review and interview, it was determined that the facility failed to ensure 1(R3) of 2 residents reviewed for falls, had side rails that were securely fastened. This failure resulted in R3 falling out of bed and sustaining a hematoma to the forehead, a subacute frontal lobe hemorrhage and hospitalization . The findings include: R3 was admitted to the facility on [DATE] with diagnoses, in part, of cerebral vascular accident with left hemiparesis, gastrostomy tube, dysphagia, and deep vein thrombosis. R3 receives Coumadin and aspirin. R3 had orders for full side rails to be up while in bed. On 1/18/11, the nursing notes and incident report dated 1/18/11, documented that R3 had been put into bed with both full side rails up by E5 and E7, Certified Nurse Aides. The incident report states R3 was positioned on her left side with both rails up. R3 was found on the floor, face down, between the bed and the wall. The siderail on her left side was down. The investigation noted that R3 could use her right hand and when she grasped the left side rail it came down and she "slid" between the bed and the wall. The investigation noted that maintenance and nursing checked the side rail and both were working "which indicates that siderail on residents left side was not totally engaged when it was raised". E2, Director of Nursing, confirmed the investigation report on 2/24/11. E2 stated on 2/24/11 that the side rail was not pulled and locked. E2 stated R3 could use her right hand and when she grasped the rail it must have come down. E2 stated R3 slid out of the bed and was sent to the local hospital. A CT (Computerized Tomography) showed a subacute bleed and R3 was sent to a large metropolitan hospital. The subacute bleed was resolving on its own and R3 returned to the facility on [DATE]. E2 didn't think R3 had fallen as she didn't have any lacerations. E2 confirmed that R3 couldn't put the rail down herself and the rail was working properly. E2 confirmed E5 and E7 were disciplined. E5 stated on 2/24/11 that she had helped put R3 in bed and had raised the rails. E5 stated she felt the rails were secure when she left. About 15 minutes later R3 was on the floor. E5 thought R3 had grabbed the rail with her right hand and jarred the rail loose. E5 stated R3 had a little bruise on her forehead. E5 confirmed that the rail was working properly after the fall. The emergency room report from the local hospital noted R3 "reportedly fell out of bed onto abd (abdomen) struck head". The [DIAGNOSES REDACTED]. R3 was transferred to a large metropolitan hospital by ambulance. The "CT Head Noncontrast" report noted under the "impression "1) Subacute parenchymal hemorrhage of the right frontal lobe 2) Old large infarct of the right frontal lobe...". R3's Neurology exam, from the second hospital, noted the chief complaint as "Fall & Intracranial bleeding".