Every finding on record at Landmark of Itasca Rehabilitation and Nursing Cent

Based on observation, interview, and record review, the facility failed to have a system in place to provide sufficient food to meet the daily nutritional requirements of residents and serve the facility planned/approved menu.This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/18/26 at 11:58 AM when the facility failed to maintain two days' worth of food supplies on hand, failed to purchase food in quantities/quality to be able to serve all residents the planned, palatable menu, and failed to have sufficient food to serve double portions and dietary supplements to residents with recent significant weight loss.This applies to 14 of 14 residents (R11, R15, R16, R21, R22, R23, R24, R25, R27, R28, R30, R31, R32, and R33) reviewed for residents with significant weight loss and has the potential to apply to all 125 residents on oral diets at the facility.V1 (Administrator), V2 (Director of Nursing), and V10 (Regional Director of Operations) were notified of the Immediate Jeopardy on 5/22/26 at 2:57 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 5/27/26 at 9:03 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and plan implementation.The findings include: 1. Facility Daily Census, dated 5/18/26, shows the facility resident census was 127. Facility document provided on 5/28/26 shows two residents had physician orders for NPO (no food by mouth). On 5/18/26 at 2:40 PM, V10 (Regional Director of Operations) stated the facility was budgeted to spend $6.40 per person per day for food/beverage/nutritional supplements. At a census of 127 residents, the facility was providing approximately $5690 per week for food/beverage/nutritional supplement purchases to be provided by the kitchen. On 5/18/2026, at 9:53 AM V3 (Food Service Manager) stated he was allotted $5500 for his weekly food purchases. V3 said he was unable to purchase all the weekly menu items required to serve the facility approved weekly menus. V3 stated he received a delivery every Wednesday and by the next delivery was usually running low on food. V3 stated he felt he usually had menu entrees but not specific fruits so he would change the fruits served to fruits he had on hand at the end of the week. V3 stated the facility was serving chicken tenders at lunch that day instead of the planned corned beef because the corned beef was too expensive for his weekly food budget. V3 also said because he doesn't have enough funds, he can only purchase one case of hamburgers instead of two. Hamburgers are listed on the Always Available Menu as a substitution offered to residents. V3 stated one case of hamburgers is insufficient to provide the weekly meal substitutions when the planned meal was not palatable for residents to eat.Food delivery order, delivered 5/13/26, showed V3 spent $5616.87 on food purchases from the food vendor for the week. On 5/19/26 at 10:43 AM with V15 (Corporate Food Service), an inventory of the kitchen refrigerator and freezers showed minimal amounts of protein foods available in stock in the kitchen for residents. V15 stated there was no more than 2 days of protein tops - that's pushing it.On 5/21/26, V16 (Dietitian) stated during her scheduled visits to the facility she reported to V3 (Food Service Manager), V1 (Administrator), and V17 (Regional Director of Food Service) that residents were consistently not receiving food/double portions/nutritional supplements/nutritional interventions as ordered by the physician and V16 was told the food purchases were limited by budgetary constraints. V16 stated the kitchen regularly maintained very little food on hand and should always maintain no less than three days of emergency food - including for those residents with nutrition interventions such as double portions. V16 stated she recommended nutrition interventions for residents such as nutrition supplements, added food items (ice cream/yogurt/pudding) and double portions of meals for residents who experienced significant/insidious weight loss, protein malnutrition, or were at risk of experiencing either. V16 stated the following residents were receiving nutrition supplements and/or double portions due to a history of significant weight loss, protein malnutrition or to aid in meeting their nutritional requirements at meals: R11, R15, R16, R17, R18, R19, R21, R22, R23, R22, R24, R25, R26, R27, R28, R29, and R36. V16 stated she witnessed the kitchen not serving all the nutrition interventions listed on resident meal tickets as required. V16 stated the facility kitchen was consistently running out of nutrition supplements, cottage cheese, yogurt, ice cream, pudding, always available menu alternative foods, and between meal snacks for dementia residents. 2. Facility Weight Change Report, dated November 2025 to May 2026, shows R15, R16, R21-R24, R27, R28, R30-R33 all experienced significant weight loss. Review of the residents' May 2026 POS (Physician Order Sheet) showed all the residents had physician orders for double portions of foods at one or more meals as nutrition interventions to prevent further weight loss. On 5/19/2026, at 11:35 AM, during lunch meal service, V6 (Dietary Aide) served a single 8-ounce portion of chili to R35. V20 (Dietary Aide- Tray line Checker) asked V6 if the serving provided was a double portion and V6 motioned to put the serving on R35's tray. V20 questioned V6 again asked if the serving was a double portion, and V6 again stated yes and indicated V20 should put the chili on R35's tray. After prompting a third time, V6 acknowledged the serving was not a double portion and provided R35 with a second 8-ounce portion of chili. At 11:50 AM, V6 was observed to be serving less than a full ladle of chili to some residents. After prompting, V6 resumed serving full 8-ounce portions of chili to residents. At 11:53 AM, R37 was served a chef salad with small amounts of cheese, diced meat, and diced egg. The meat/cheese/egg was removed and weighed separately and weighed less than 2 ounces total which was verified by V4 (Traveling Cook). At 12:35 PM, the tray line ran out of cornbread and the remaining residents were provided dinner rolls. At 12:48 PM, the tray line ran out of chili with seven residents not served their meals- three of whom (R6, R11 and R36) all required double portions. The kitchen staff began grilling chicken breasts and looking for other food items to serve to the remaining seven residents. The remaining seven residents were all served foods other than the planned menu for lunch. R6 was initially served a single portion of food and after prompting was served two entrees. During observations of the lunch tray line, R6, R11, R15, R17, R18, R35 and R37 were not served double portions of their meal items per their tray ticket instructions. On 5/27/26 at 3:27 PM, V23 (Corporate Menu Registered Dietitian) and V24 (Corporate Menu Registered Dietitian) stated they plan the menus for the facility using Dietary Guidelines for Americans and each entree at lunch and dinner provided three ounces of protein per serving- including the chili served at lunch on 5/19/26. V24 stated double portions of entrees would require six ounces of protein per serving. V23 stated if the menu is changed at the facility after she approves the facility menu, the menu is no longer approved by her and the dietitian at the facility would be responsible for approving the changes. On 5/21/26 at 2:27 PM, V16 (Dietitian) stated R11, R15, R16, R21, R22, R23, R24, R25, R27, R28, R30, R31, R32, and R33 were all supposed to receive nutrition interventions of double portions or nutritional supplements to encourage nutritional intake at meals and improve nutritional status. V16 stated R11 received double portions because he had a significant weight loss previously and R15 recently required increased protein intake due to her compromised nutritional status. V16 stated R16 experienced recent significant weight loss and because R16 did not like nutritional supplements, R16 was to have received double portions for breakfast, extra sandwiches at lunch and dinner, and yogurt with all meals to prevent further significant weight loss. V16 stated R21 was to have received double portions and house supplements to prevent further significant weight loss. R22 has dementia and walks constantly so he was to receive double portions. R24 had a physician order for double portions because he experienced significant weight loss. R23 experienced significant weight loss in March 2026, and double portions at breakfast were implemented to help meet his total caloric needs. R25 received nutritional supplements because she did not regularly eat food. R27 experienced significant weight loss and only liked chocolate nutritional supplements. R28 required health shakes to maintain weight after losing weight at the hospital and needing to gain back the weight. R30 was a large person wishing to lose weight but required more food than a regular diet to prevent significant weight loss due to his size and being a picky eater. V16 stated R31 required double egg/meat because she experienced protein malnutrition. R32 experienced significant weight loss in April 2025 and was receiving multiple supplements and double meat/egg to stabilize her weight. V16 stated R33 had dementia, had a history of weight loss, and wasted much of his food when he ate so he required double portions and supplements to ensure he ate enough each day to prevent weight loss.R27's Weights and Vitals Summary, printed 5/21/26, shows on 5/19/26, R27 experienced a significant 10% weight loss (20.6 pounds) in six months and 7.5% weight loss (12 pounds) in three months. The POS, printed 5/21/26, shows R27 had physician a physician order dated 5/11/2026, for chocolate health shakes with all meals and double meat/egg at breakfast, and an order dated 5/15/2026, for Glucerna shakes three times a day.Nutrition note, dated 5/25/26, shows R27 experienced significant 7.5% weight loss (12 pounds) in 3 months and 10% weight loss (20.6 pounds) in 6 months. The note shows R27 was recently hospitalized and experienced weight loss related to chronic inadequate oral intake. The note shows R27 received chocolate health shakes with all meals and double meat/egg at breakfast to discourage further weight loss.Weights and Vitals Summary, printed 5/26/26, shows on 12/5/25, R11 experienced a significant weight loss of 10% (26.8 pounds). Review of R11's nutrition notes dated 7/10/2025 to 12/5/2025, and R11's physician order dated 3/24/25, shows R11 was to be provided with multiple nutritional supplements, double portions at breakfast and lunch, and meat sandwiches at bedtime, to prevent significant weight loss and stabilize R11's weights.On 5/19/26 at 12:59 PM, R15 was observed at lunch with only one serving of chili on her tray. V19 (Family) stated R15 never received double portions at lunch as ordered and he said he visited R15 every day at lunch. R15's POS, printed on 5/20/26, shows R15 had physician orders (dated 5/1/26) for double egg/meat/protein servings at breakfast and lunch. Weights and Vitals Summary, printed on 5/20/26, shows R15 experienced significant weight loss of 13 pounds between 1/2026 and 3/2026. On 5/19/26 at 12:58 PM, R16 was sitting in the dining room for lunch. There was no yogurt or sandwich provided on R16's lunch tray. Nutrition note, dated 5/18/26, shows that R16 experienced significant weight loss of 7.5% in 3 months (15.6 pounds) and 10% in 6 months (20.6 pounds). The note shows R16 refused oral nutrition supplements and R16 was to receive double portions at breakfast, an extra sandwich at lunch and dinner, and yogurt at all meals to increase calories offered to R16. The POS, printed on 5/20/26, shows R16 had a physician order (dated 5/1/26) for double portions at breakfast, extra sandwich at lunch and dinner, and yogurt at all meals. Review of R16's weights showed R16 experienced significant weight loss of 10% in April 2026. R21's POS, printed on 5/20/26, shows R21 had a physician order (dated 4/9/26) for health shakes at all meals and double portions at breakfast. Weights and Vitals Summary, printed 5/20/26, shows R21 experienced significant weight loss of 10% on 12/10/25 after losing 15 lbs. in six months. Nutrition note, dated 4/24/26, shows R21 experienced another significant unintended weight loss of 5% in one month (a loss of 8.8 pounds) and nutrition supplements were added. Nutrition note, dated 5/8/26, shows R21 experienced further weight loss of 5% in one month (a loss of 7.8 pounds) and R21 was placed on double portions at breakfast to prevent further weight loss. Weights and Vitals Summary, printed on 5/20/26, shows R22 experienced a 5% significant weight loss (6.2 pounds) in one month. The documented weights show R22 lost 10 pounds in 6 months. Nutrition note, dated 5/8/26, shows R22 had a good appetite and was asking for extra meal portions. The nutrition note shows R22 was also to receive nutritional supplements in addition to double portions at all meals to prevent further weight loss. R22's body mass index was 16.4 indicating he was under-weight.On 5/19/26 at 9:54 AM, R23 stated he did not receive double portions at breakfasts. R23 stated he experienced weight loss and was not sure what caused the weight loss. R23 stated he would eat double portions at meals if they were served to him. Review of R23's weights show R23 lost an additional 5.4 pounds since 2/7/26 and lost a total of 18 pounds in one year. Nutrition note, dated 2/13/26, shows R23 was placed on double portions at breakfast by the dietitian due to a significant weight loss of 5% in one month despite a good appetite. The note shows R23's estimated calorie needs were 2715 calories a day. On 5/19/26 at 10:16 AM, R24 stated he never felt like he received enough food at any meal, and he never received double portions at breakfast. R24 stated about 50% of the time he did not receive what was on the facility's planned menu for that day. Nutrition note, dated 4/20/26, shows R24 experienced 10% weight loss in 6 months. The note shows R24 required 2690 kcals and 70 g of protein a day to meet his estimated nutritional needs. R24 was to receive double portions at breakfast and nutrition supplements to prevent further weight loss. Weights and Vitals Summary, printed on 5/20/2026, shows R24 experienced a significant weight loss 11.2 % (37.8 pounds) from 11/5/2025 to 5/6/2026. R25's nutrition note, dated 5/8/26, shows R25 experienced a significant 5% weight loss of 12.2 pounds in one month and R25 was to receive health shakes and yogurt at breakfast. Nutrition note, dated 3/11/26, shows R25 experienced significant weight losses of 5% in one month (12.8 pounds), 7.5% in three months (17 pounds) and 10% in six months (17 pounds). Weights and Vitals Summary, printed on 5/21/26, shows on 5/19/26, R25 experienced 10% significant weight loss in six months (a loss of 17 pounds) and 7.5% significant weight loss in 3 months (a loss of 12.8 pounds). R25's weights show she lost a total of 25 pounds in 12 months. R25's POS, printed on 5/21/26, shows R25 had physician order dated 1/6/25 for yogurt at breakfast and health shakes with all meals, an order dated 1/23/2025 for Ensure three times a day, and an order dated 5/21/2026 for MedPass 2.0 supplement three times a day. R28's Weights and Vitals Summary, printed 5/21/26, shows on 11/27/25, R28 experienced a 10% weight loss (16.6 pounds) and on 4/7/26 she experienced a significant weight loss of 7% (11 pounds) in one month. Nutrition note, dated 3/20/26, shows R28 was to receive double portions at breakfast and nutrition supplements to stabilize recent significant weight loss due to hospitalizations and more nutritional supplements were added through nursing at that time to prevent further significant weight loss. The POS, printed 5/21/26, shows R28 had a physician order (3/17/26) for health shakes, and fortified cereal, and double portions at breakfast.R30's Weights and Vitals Summary, printed 5/26/26, shows R30 experienced significant weight loss on 12/9/25 of 7.5% (25 pounds) in three months and on 5/6/26 experienced another significant weight loss of 10% (29 pounds) in six months. Nutrition note, dated 5/18/26, shows R30 experienced significant weight loss due to a desire to lose weight and episodes of meal refusals. Review of nutrition notes show V16 provided education on safe / healthy weight loss and offered R30 double portions at meals to encourage intake of foods to prevent further significant weight loss. R31's Nutrition note, dated 3/27/26, shows R31 experienced significant 5% weight loss (11 pounds) in one month and 7.5% weight loss (15 pounds) in three months related to inadequate oral intake and refusals of various nutritional supplements. The note shows R31 was offered double portions at breakfast to encourage oral intake and R31 was previously on total parental nutrition during hospitalization. R32's Nutrition note, dated 4/26/26, shows R32 experienced a significant weight loss of 10% (20.6 pounds) in 6 months and R32 was to receive double portions and nutritional supplements due to a history of significant weight loss, weight fluctuations, varied oral intake and the goal of maintaining R32's weight. Weights and Vitals Summary, dated 5/26/26, shows R32 lost 20 pounds from 11/5/25 to 4/4/26. The POS, dated 5/26/26, shows a physician order (dated 3/27/25) for double meat/egg at breakfast and multiple nutritional supplements ordered by the physician. R33's Weights and Vitals Summary, dated 5/26/26, shows on 12/10/25 R33 experienced a significant 10% weight loss (22 pounds) over 6 months and another significant 10% weight loss (22.8 pounds) on 2/9/26 over six months. Nutrition notes, dated 2/23/36, show R33 was to receive nutritional supplements and double portions at meals to prevent further weight loss and R33 required 2414 calories a day to stabilize his weight. The POS, printed on 5/26/26, shows R33 had physician orders for double portions and nutritional supplements. 3. Review of R17's, R21's, R25's, R26's, R27's, R28's, and R29's May 2026 POS (Physician Order Sheets) showed the residents all had orders for nutritional supplements for either breakfast, lunch, or both meals served by the kitchen. Review of Facility 6-month Weight Change Report dated November 2026 to May 2026 showed the following residents who experienced significant weight loss: R21, R25, R27, and R28. On 5/20/26 at 10:21 AM, V6 (Dietary Aide) stated the kitchen ran out of nutritional supplements for residents who were to receive them at breakfast that morning and would not receive them at lunch because the food delivery was not expected to arrive until 3:00 PM that afternoon. V6 stated the facility purchased more yogurt for only R1 but there was no yogurt for any other residents who required yogurt during their meals until the next delivery. V6 stated there were residents who required yogurt at breakfast that did not receive yogurt that morning. V6 stated there was no cottage cheese and no lactose free milk available in the kitchen. V6 stated R8 had not received lactose free milk in two weeks because it was not available in the kitchen. On 5/19/26 at 10:36 AM, V3 (Food Service Director) stated they were going to serve sherbert instead of nutritional supplements at lunch for those residents who required health supplements because they were out of stock. V3 stated the kitchen was also out of stock of yogurt and cottage cheese. Review of manufacturer product information for the nutritional supplements and the sherbet served as a substitute shows the sherbet contained less protein than the nutritional supplements the residents were supposed to receive.On 5/19/26, R21 stated he sometimes received nutrition supplements but not at every meal. The POS, printed 5/20/26, shows R21 had a physician order for nutritional supplements, all meals, double portions at breakfast, and pudding at lunch and dinner. 4. On 5/18/26 at 10:19 AM, R1 stated the residents have no idea what they had for dinner the night prior. R2 stated they had some type of ground meat and not fajita meat. R1 showed a picture of the dinner served the night prior which looked like ground beef crumbles mixed with cooked, chopped green pepper and a side of refried beans. There was no rice evident on her plate. R1 and R38 stated they did not receive the rice for dinner. R38 stated, I wouldn't know if I got fajitas! I got something I chewed on and I got very little I know that! R1 and R39 stated often what is shown on the menu was not served to the residents. R1 and R2 stated the day prior the facility ran out of hamburgers as meal substitutions. R1 stated she had not received her yogurts recently during her meals and was told the facility ran out of yogurt. On 5/18/26 at 10:48 AM, V6 (Dietary Aide) stated the kitchen often ran out of hamburgers for resident requested substitutions. V6 stated the hamburgers were offered on the always available menu provided to residents if they would like substitutions during meals. On 5/18/26 at 11:00 AM, V4 (Contract Cook) stated the facility did not have burgers to serve residents if requested from the Always Available Menu. On 5/18/26 at 10:47 AM, V3 (Food Service Manager) was removing the posted Always Available Menu at the entrance of the first-floor dining room. The Always Available Menu included cheeseburgers and hamburgers. At 10:58 AM, V3 stated there were 2 servings of cottage cheese remaining in the refrigerator. V3 stated cottage cheese and fruit plate is typically requested/served to residents as a substitute at meals despite not being listed on the Always Available menu. On 5/18/26 at 10:46 AM, V5 (Food Service Director) stated the kitchen ran out of hamburgers for substitutes on Friday, 10/15/26. V5 stated the kitchen used Philly beef strips to make fajitas for dinner the previous night.On 5/18/26 at 11:03 AM, V7 (Family) stated R1 did not receive her daily yogurt that morning and was told the facility ran out of yogurt. V7 stated the facility also often ran out of items offered on the Always Available Menu list. On 5/18/26 at 12:28 PM, V9 (Registered Nurse) stated R1 was not served yogurt on her breakfast or lunch trays per her tray ticket instructions. V9 stated she went to the administrative office and took yogurt from the refrigerator which was left over from a staff party the week prior. V9 stated R1 had not received yogurt per her tray ticket instructions for two days or more. On 5/18/26 at 11:58 AM, the kitchen had no yogurt in the refrigerator and V3 stated the facility ran out of yogurt. 5. On 5/18/26 at 11:55 AM, R3 stated she required plant-based milk and her son regularly purchased and provides it to the kitchen for R3. R3 stated her son brought a large container to the facility on 5/14/26 which should have lasted two weeks but was already used up. R3 stated the facility frequently served R3's private milk to residents requiring lactose-free milk because the facility often ran out of lactose free milk. R3 stated the facility ran out of lactose -free milk since 5/16/26 and the facility also often ran out of hamburgers, salads, and juices.On 5/19/26 during lunch, R3 did not receive milk at lunch. V22 (CNA) stated R3 was supposed to have her plant-based milk every lunch but the kitchen ran out of lactose free milk days ago and they gave R3's milk to R8 because R8 should receive lactose free milk. Review of the dining room milk supplies showed only regular milks and no lactose free or plan-based milk. At 12:21 PM, R8 stated she was supposed to receive lactose free milk, but the facility often runs out. R8 stated the kitchen was out of lactose free milk for days and the staff gave R3's milk to R8 which upset R8 because R3's family purchased her milk. On 5/18/26 at 12:25 PM, V12 (CNA) stated the facility usually ran out of R3's plant-based milk, hamburgers, cottage cheese, sugar substitutes, and salad dressings. On 5/19/26 at 12:23 PM, V3 stated the facility had no lactose free milk and had no plant-based milk that was supplied by R3's family. V3 stated he was aware R3's milk was utilized to serve to other residents.6. On 5/18/26 at 10:46 AM, V5 (Cook) stated there was no corned beef for lunch's planned menu. V5 stated there was no cottage cheese because V3 only orders one tub of cottage cheese for the week and the residents require two tubs per week. V3 stated when they serve meals, the staff often run out of meat and other foods during service. On 5/18/26 at 12:00 PM, during lunch in the kitchen, chicken tenders were served instead of corned beef per the planned menus. The chicken tenders were piled high above the top of a 8-inch steamtable pan and covered with clear plastic film. The breading on the chicken tenders was soggy and wet. The chicken tenders tasted wet. R7 stated the kitchen served some of the menu items but they run out of food at meals such as pasta shells. R7 stated, That makes me feel hungry! R7 stated they gave her bread when she was not served pasta shells. On 5/18/26 during lunch, R4 and R5 stated they would have rather had corned beef. R5 stated the kitchen served chicken very often. R6 stated the quality of the food has diminished and the kitchen often ran out of sugar substitutes. On 5/18/26 at 12:33 PM during lunch on the second floor, R9 stated the prior week the residents were served a chicken patty so hard they could not cut it. R10 stated she never was chicken like the chicken patty served the week prior. R9 and R10 stated they were not aware they were supposed to have been served corned beef for lunch because the kitchen only posted daily menus the morning of, or the night prior, the meals were served and not a week prior. R10 stated the last time they were served corned beef was on St. Patrick's Day and it was chewy and inedible. R10 stated all the residents were served chicken and the facility often ran out of hamburgers, yogurt, and cottage cheese. R10 stated the foods served have become inedible and substandard. R9 stated the meat felt like you were chewing on rubber. R11 stated the chicken patty served last week was like a hockey puck- when I used a knife, it sounded like a saw was going threw it - it made buzzing noises as I cut back and forth! V13 (Restorative CNA) stated the residents complain that the meat is overcooked, hard, dry, and do not eat it. V13 stated the residents complain the kitchen runs out of food, especially yogurt. On 5/19/26 at 10:08 AM, R42 stated he was served chicken patties on a bun that were so hard he could not chew them. R42 stated the facility did not serve what was planned on the menu. R42 stated he did not know if the facility was running out of food or if the staff did not know how to cook. R42 stated he was given ground beef for fajitas, no tortillas and instead a piece of bread. R42 stated he was served no rice and no beans during the fajita meal. R42 stated when he received rice, the rice was undercooked and hard. On 5/22/26 at 9:19 AM, R47 stated, We were supposed to have chicken and beef fajitas the other night - I got a tortilla with hamburger and chopped green pepper. I am the last person who gets a tray - room [ROOM NUMBER]. Sometimes I don't even get a tray. Or a tray comes with something that was not on the menu. They are out of foods like hamburgers and hot dogs on the substitute menu. We can be out of sugar and creamer for a week! Several times a week we don't see the menu item on our trays in that hall because they run out of food. On 5/22/26 at 2:20 PM, R44 (Resident Council President) stated, We save food for last at resident council because there are so many complaints. The change to this food company was a mistake and I am afraid they are running out of food. They only get a delivery one time a week and run out of food. They tell people they don't have food when the people ask for food. They say they are out of it, or they don't have it. It happened to me when I asked for a lunch meat sandwich and oranges and bananas. The chili was like water. The beef and chicken fajitas was not whole meat pieces - it was ground beef - some residents got bread, and some got tortillas. It makes us think we were running out of food - we run out of cheeseburgers and other foods. They tell us they ran out. It's concerning that people aren't getting the nutrients they need. Sometimes we feel like we won't be fed - It's scary. It's gotten way worse and now we run out of food more! .It makes me feel not heard and has been happening for the last 6 months. They don't order enough food, and it scares me. We should have more than enough money. We had chicken patties that were hockey pucks. Most people did not eat that meal. I brought it to the kitchen and said it was inedible. It's depressing! It makes us feel like we are an inconvenience to have here. It's exhausting, aggravating, and depressing. We talked about it in resident council, and nothing is done about it. People ask why we even meet because it only got worse! Family members come and ask the facility why their residents are ordering food from outside! On 5/19/26 at 1:12 PM, R11 was observed during lunch with one serving of chicken breast and a dinner roll. R11 stated he was supposed to receive double portions of chili and cornbread. R11 stated, Does that look good!? R11 stated the food was not good at the facility and R11 did not receive what was on the menu. R11 stated he asked for a ham sandwich instead of what he was served.On 5/19/26 at 1:15 PM, R6 was observed eating his lunch which consisted of a hot dog, a scoop of egg salad, and mashed potatoes. R6 stated, I like egg salad but not seven days a week. I don't know why I get it seven days a week. Egg salad 7 days a week is too often! R6's tray ticket showed R6 liked egg salad and disliked grilled chicken breast. On 5/22/26 at 2:10 PM, R8 stated, The food is nasty! I can't eat it! I throw up! I don't know how some can eat it. It's nasty. And it's been going on forever. I'm losing weight because I can't eat it. I am very disgusted. Disgusted with it! It makes me angry since I've been here! I got in their face and said you have to give us choices! R8 stated she was not allowed to ask for a grilled cheese sandwich substitute when she did not like her meals and was told she had to ask for a substitute by 4:00 PM but saw two other residents receiving substitutes. R8 stated the hamburgers were hard and dry like they were cooked and left over for two days, and the grilled cheese sandwiches were hard and dry like they were left over. R8 stated the residents talked about how bad food service was consistently but no improvements were made. On 5/22/26 at 3:48 PM, R45 stated at lunch she did not receive the same fish everyone else received. R45 stated other residents got 4 fish sticks and R45 got something with a very hard crust and thin gray fish she could not cut with a knife. R45 stated she picked off a piece of it and it tasted terrible, so she did not eat it. R45 stated two other residents received the same entree as R45 and those residents did not eat the entrees. R45 stated, It makes me feel like I am worthless. At least 1/3 of the time it is not edible. They get the cheapest of everything. The hard boiled eggs taste fake! .They have given peanut butter sandwiches that were less than you would put butter on a bread. They do run out of a lot of food. Yogurt, cottage cheese, orange juice, hamburgers for substitutions, salad dressing - sometimes they give plain lettuce with no dressing and say they run out of it. They run out of scrambled eggs. We will get a sausage patty and a piece of toast. That's it. I ask for yogurt daily and they took it off my meal ticket and never give me yogurt. They give me fruit loops instead of cooked cereal which I ask for. The CNAs know I want the cooked cereal so they may get it off another resident's tray. They refuse to put any preferences on my menu. They took tea off that was on there. Last week they had tacos beef which I wanted - with fried rice and corn but they gave me grilled cheese and something else and I didn't ask for a substitute. I eat in my room. They serve us second to the last in halls. I think they run out of food, and they give me something different. They did today! I couldn't eat it. They gave it to a few other people.

Based on interview and record review, the facility failed to administer a food service operation in a manner to provide adequate quality/quantities of food to residents of the facility. This applies to all 125 residents receiving oral diets at the facility.The findings include: Facility Daily Census, dated 5/18/26, shows the facility resident census was 127.Facility document provided 5/28/26 shows two residents had physician orders for NPO (no food by mouth).On 5/18/26 at 2:40 PM, V10 (Regional Director of Operations) stated the facility was budgeted to spend $6.40 per person per day. At a census of 127 residents, the facility was providing approximately $5690 per week for food/beverage/nutritional supplement purchases provided by the kitchen.On 5/18/2026, at 9:53 AM V3 (Food Service Manager) V3 stated he was allotted $5500 for his weekly food purchases, and he was unable to purchase all the weekly menu items required to serve the facility approved weekly menus. V3 stated he received a delivery every Wednesday and was usually running low on food by the next food delivery. V3 stated he felt he usually had menu entrees but not specific fruits so he would change the fruits served to fruits he had on hand at the end of the week. V3 stated the facility was serving chicken tenders at lunch that day instead of the planned corned beef because the corned beef was too expensive for his weekly food budget. V3 said he can only afford to order one case instead of two cases of hamburgers a week (which were listed on the Always Available Menu for substitutions offered to residents) due to lack of funds. V3 stated one case of hamburgers was insufficient to provide the weekly requested meal substitutions when the planned meal was not palatable for residents to eat. Food delivery order, delivered 5/13/26, showed V3 spent $5616.87 on food purchases from the food vendor for the week. On 5/19/26 at 10:43 PM with V15 (Corporate Food Service), an inventory of the kitchen refrigerator and freezers showed minimal amounts of protein foods available in stock in the kitchen for residents. V15 stated there was no more than 2 days of protein tops - that's pushing it.On 5/21/26, V16 (Dietitian) stated during her scheduled visits to the facility she reported to V3 (Food Service Manager), V1 (Administrator), and V17 (Regional Director of Food Service) that residents were consistently not receiving food/double portions/nutritional supplements/nutritional interventions as ordered by the physician and V16 was told the food purchases were limited by budgetary constraints. V16 stated the kitchen regularly maintained very little food on hand and should always maintain no less than three days of emergency food - including for those residents with nutrition interventions such as double portions. V16 stated she recommended nutrition interventions for residents such as nutrition supplements, added food items (ice cream/yogurt/pudding) and double portions of meals for residents who experienced significant/insidious weight loss, protein malnutrition, or were at risk of experiencing either. V16 stated the following residents were receiving nutrition supplements and/or double portions due to a history of significant weight loss, protein malnutrition or to aid in meeting their nutritional requirements at meals: R11, R15, R16, R17, R18, R19, R21, R22, R23, R22, R24, R25, R26, R27, R28, R29, and R36. V16 stated she witnessed the kitchen not serving all of the nutritional interventions listed on resident meal tickets as required. V16 stated the facility kitchen was consistently running out of food items such as nutrition supplements, cottage cheese, yogurt, ice cream, pudding, always available menu alternative foods, and between meal snacks for dementia residents.On 5/22/26 at 2:57 PM, V10 (Regional Director of Operations) asked V1 (Administrator) if he was aware of V16's concerns the facility was not purchasing enough food. V1 stated he was aware of the concerns and spoke to V17 (Regional Director of Food Service) regarding the concerns and was told they were constrained by the budget for their food purchases.On 5/19/26 during lunch, the facility failed to serve double portions to several residents (R6, R11, R15, R17, R18, R35, and R37) per their tray tickets and ran out of the chili entree and bread rolls with seven residents not yet served their lunches.On 5/18/26 at 10:46 AM, V5 (Cook) stated the staff often ran out of meat and other foods during meal service at the facility.Facility Weight Change Report, dated November 2025 to May 2026, shows R15, R16, R21-R24, R27, R28, R30-R33 all experienced significant weight loss. Review of the residents' May 2026 POS showed all of the residents had physician orders for double portions of foods at one or more meals as nutrition interventions to prevent further weight loss.On 5/19/26 during lunch service, R16 was not served her extra sandwich at lunch per her physician diet order, R23 stated he did not receive double portions at breakfasts per his meal ticket, R21 stated he did not always receive his nutritional supplements on his meal trays, and R24 stated he did not receive enough food at meals and never received double portions at breakfast per his meal ticket.On 5/18/26 at 11:58 AM, the kitchen had no yogurt in the refrigerator and V3 stated the facility ran out of yogurt.On 5/20/26, V6 (Dietary Aide) stated the kitchen ran out of nutritional supplements that morning and would not have any nutritional supplements for residents at lunch. V6 stated the facility also ran out of yogurt and several residents did not receive yogurt that morning. V6 stated the facility was also out of cottage cheese and lactose free milk (which they had not had on hand for two weeks.) On 5/18/26 at 10:48 AM, V6 (Dietary Aide) stated the kitchen often ran out of hamburgers for resident substitutions. V5 (Food Service Director) stated the kitchen ran out of hamburgers for substitutions on Friday, 5/15/26. On 5/18/26 at 11:55 AM, R3 stated the facility used her privately purchased plant-based milk to serve to residents who required lactose free milk when the kitchen ran out of lactose free milk. On 5/18/26 at 12:25 PM, V12 (CNA) stated the facility usually ran out of R3's plant based milk, hamburgers, cottage cheese, sugar substitutes, and salad dressings. On 5/22/26 at 9:19 AM, R47 stated she was the last resident to receive a tray at meals and sometimes she did not even receive a meal tray during meals. R47 stated several times a week she did not receive items that were listed on the menu and suspected the facility ran out of food by the end of meal service. On 5/18/26 during resident interviews, R1, R4, R5, R9, R38, all expressed concerns regarding the quality of the food, and some residents expressed concerns about the facility ran out of food during meal service.On 5/19/26 at 10:08 AM, R42 expressed concerns that the facility was running out of food and stated he was not served items at meals that were listed on the menus.

Based on observation, interview and record review, the facility failed to provide activities as scheduled on the posted activities calendar. This applies to 4 of 4 residents (R1, R2, R3, R48) reviewed for activities in a sample of 48.The findings include: Resident Activity Assessments show R1 (4/12/26), R2 (2/10/26), R3(4/29/25), and R48 (4/12/26) all enjoyed participation in various activities including religious services.R1, R2, R3 and R48's activities care plans show the residents both had strong activity participation including engaging in a variety of small and large group activities. R1, R2 and R48's interventions include developing an activity plan centering around the residents' interests and reminding the residents of program schedules. R3's interventions show interventions include reminding R3 about program schedules. Activities calendar, dated May 2026, shows on 5/18/26 Musical Exercise was to begin at 10:00 AM, Chronicles at 10:30 AM, Meditation at 11:00 AM, and at 11:30 AM Fresh Air. The Activity calendar, dated 5/18/26, shows at 2:00 PM Frisbee Tic-Tac-Oh No! and at 3:00 PM Playing Outdoor Games were scheduled as afternoon activities. The calendar also shows Religious Services were to be held every Sunday of the month at 10:30 AM and Catholic mas was to be held at 10:30 AM every Friday of the month. The calendar also shows the facility was to have Game Night activities every 6:00 PM every Tuesday. On 5/18/26 at 10:30 AM, no activity was being conducted in the first floor dining room and Musical Exercise was being organized to begin. R1, R2, R3, and R48 were in attendance. At 11:36 AM, the music exercise activity concluded and V11 (Activities Aide) stated they would not do the meditation or fresh air as scheduled on the activities calendar and the residents were to next go to lunch. V11 stated she passed out paper Chronical pamphlets to residents with their menus while residents in the dining room were attending the Musical Exercise activity. V11 stated she did not review Chronicles with the residents in the first floor dining room. V11 stated she was the only activities aid working in the facility at that time. R1 stated the residents were not given the option to do meditation or go outside that morning. V11 stated R1 and R2 did not like meditation and R1 responded that some residents did enjoy meditation R1 stated the facility no longer provided religious services that were scheduled weekly on the activities calendar. V11 stated a resident performs a bible study on the second floor at 10:30 AM on Fridays and a priest comes to the facility to give communion on the first Friday of each month. R1 stated a resident led a religious ceremony weekly, but there were no religious services conducted by the facility. R2 stated the religious services were still listed on the calendar but they had not been performed in a long time. R3 stated she liked to attend religious services when they were held. R48 stated someone performed a religious services approximately five weeks ago and he attended but they were not offered since not since. No meditation or fresh air activities were performed on the morning of 5/18/26 as per the planned activity calendar. On 5/18/26 at 11:55 AM, R3 stated she is unable to attend religious services unless her son picked her up and drove her to mass at a church. R3 stated she would prefer to do religious services at the facility as per the calendar, but they have not been offered. R3 stated the facility previously had religious services weekly but stopped. On 5/18/26 at 2:22 PM, R1 was sitting alone in the first floor dining room and stated she was told residents were going to go outside to play beanbag toss. At 2:27 PM, R48 and R2 were sitting outside on the back patio, and no activity was in progress. At 2:40 PM no activity was being conducted at the facility. On 5/18/26 at 12:55 PM, a sign posted in the facility elevator announced a bible study was available every Sunday at 10:00 AM in the second floor dining room and non-denominational religious services were available Sundays at 10:30 AM on the first floor. On 5/18/26, V1 (Administrator) stated a man performed a religious study on the second floor that morning but was not sure of the content of the activity. On 5/18/26 at 11:03 Am, V7 (Family) stated the activity calendar shows on Tuesday and Thursday nights there were activities scheduled, and the facility did not provide the activities. V7 stated they have religious ceremonies on the activities calendars, but no services were provided other than a resident playing a bible study on their phone. V7 stated recently one individual comes once a month to provide residents communion. V7 stated the activities aides sometimes are tasked with taking smokers out on smoking activities and there is only one activity aide at the facility to do both activities and smoking. On 5/28/26 at 6:45 Pm, V25 (Activities Aide) stated the residents have been disappointed for a couple of months since religious services were canceled on Sundays. V25 stated R1, R2, and R48 all regularly attended religious services. On 5/19/26 at 10:32 /PM, V27 (Activities Director) stated she needed to adjust the calendar because they no longer offer religious services every Friday and now offer them only one Friday a month. V27 stated she was not aware of Sunday services not happening and needed to investigate. V27 stated she was also unaware the time was changed for Music Exercise at 10:00 AM. V27 stated she was aware R1, R2, R3, and R48 regularly attended the Sunday religious services. V27 stated the activities staff and administration have to coordinate running activities and taking smokers out for cigarettes every day at 9:00 AM, 1:00 PM and 3:00 PM. V27 stated she just returned part time to work at the facility, and she had one full time staff who works on the dementia unit, V11 who is full time, and two part time staff.Review of the 5/2026 worked Activity Schedule shows on 5/8/26, 5/12/26, 5/22/26 there was only one activity aide scheduled at the facility who worked from 9:00 AM to 5:00 PM. Review of the worked schedules showed only one Tuesday (5/12/26) in May was an activities staff scheduled beyond 5:00 PM to conduct the scheduled 6:00 PM Game Night every Tuesday.Resident grievance, dated 2/20/26, shows R1 expressed concern there were no activities and were waiting for someone to perform activities of Catholic Church that had not occurred in months.Resident council meeting minutes, dated 4/15/26, show the residents expressed concerns regarding not having consistency in evening activities. Activity Department Program Policy, undated, shows, It is our policy to provide a competent variety of therapeutic recreation opportunities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psycho-social well-being needs of each individual resident. There shall be sufficient number of staff members to ensure the implementation of a consistent, diversified and beneficial program. A full weekly program shall be carried out by the staff.

Based on interview and record review, the facility failed to ensure residents were free from physical abuse by employees. This applies to 2 of 3 residents (R3 and R4) reviewed for abuse in a sample of 10.R3's EMR (Electronic Medical Record) showed R3's diagnoses, including dementia, Alzheimer's disease, psychosis, mental disorder, schizophrenia, bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder. The writer made multiple attempts from 04/21/2026 to 04/24/2026 to speak with R3, but R3 refused to speak. R3's MDS (Minimum Data Set) dated 04/03/2026 showed that R3's cognition is intact and she is independent in her activities of daily living.R1's care plan dated 03/24/2026 showed R3 will remain safe, will be treated with respect and dignity, and reside in the facility free of mistreatment, including abuse/neglect.The facility's Abuse Prevention Program dated 02/2019 showed that the policy of the facility is to prohibit and prevent abuse against a resident in the facility.On 04/28/2026 at 9:02, V29 (Receptionist) stated that on 04/03/2026, around 7:00 PM, she was near the residents' area by the kitchen, and R3 came by looking for food or coffee. V29 said she witnessed V17 (Dietary Aide) yelling, pushing, and swearing at R3, and then he closed the kitchen door. V29 said R3 came to her, said V17 hurt her, and then V29 took R3 to the front desk, gave some cereal, and notified V6 (Social Service Assistant), V30 (Registered Nurse) who were in the building, and V1(Administrator).On 04/28/2026 at 12:56 PM, V27 (Social Service Assistant) said she was about to leave around 7:00 PM. V27 said V29 told her that she witnessed R3 asking V17 for food, that V17 was yelling, pushing R3 away from the door out of the kitchen, and that R3 was crying. V27 said she told V29 to report to the administrator. V6 said all residents have the right to be free from abuse.On 04/28/2026 at 1:49 PM, V3 (Assistant Director of Nursing) said V1 asked her to assist nurses in following up on the incident, and V1 conducted the investigation. On 04/28/2026 at 1:02 PM, V30 (Registered Nurse) said V29 (Receptionist) called her and made her aware of what had happened. Another nurse came to the receptionist area, assessed R3 for pain and/or injury, and called the police. The local police came and met with R3. V3 and V30 said all residents have the right to be free from abuse.On 04/28/2026 at 10:00 AM, V1 (Administrator) said he completed the investigation based on the information he received and stated that V17 is loud by nature and did not think abuse happened. V1 acknowledges that residents have the right to be free from abuse.2. The EMR (Electronic Medical Record) showed R4 has diagnoses, that includes depression, chronic obstructive pulmonary disease, and gastroesophageal reflux disease. MDS (Minimum Data Set) dated 03/29/2026 showed that R4's cognition is intact and that she is independent in her daily activities. On 04/23/2026 at 10:56 AM, R4 said that on 12/03/2025, when she returned from dinner, R9 whose room is next door and shares a bathroom with her, told her that V26 (Certified Nursing Assistant) had taken her dishes, which R4 had left on the bathroom sink. R4 said when she spoke to V26, she hit her with a garbage bag. R4 said she called the police, and they came to the facility. The next day, V1 (Administrator) spoke with her and did nothing about it.R4's nursing progress notes dated 12/03/2025 showed that the nurse on duty observed R4 confronting V26 about taking R4's cup and bowel and separated them. A few minutes later, the police arrived at the facility and told the nurse that R4 had called the police, alleging that V26 had hit R4 with a garbage bag. V26 made V1 (Administrator) and V2 (Director of Nursing) aware.On 04/24/2026 at 2:30 PM, R9 said she witnessed V26 hitting R4 with a garbage bag. R9's EMR (Electronic Medical Record) showed R9 diagnoses, including bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder. The MDS (Minimum Data Set) dated 01/30/2026 showed R9's cognition was intact and that she was independent in her activities of daily living.On 02/23/2026, around 12:00 PM, the writer asked V1 for the incident report, and V1 said he hadn't investigated or reported the incident because he didn't see any significant concerns. V1 said after reviewing the progress notes now, he should have reported, investigated, and planned care appropriately.04/23/2026 at 12:30 PM, V2 (Director of Nursing) stated V1 is the abuse coordinator and that she was unaware that the investigation had not been completed.The facility's policy titled Abuse Prevention Program in part defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish to a resident.

Based on interviews and record reviews, the facility failed to implement the facility's abuse prevention program policy that prohibits and prevents abuse, investigates allegations of abuse, protects residents during investigation, and reports abuse. This applies to 1 of 3 residents (R4) reviewed for abuse in a sample of 10.On 04/23/2026 at 10:56 AM, R4 said that on 12/03/2025, when she returned from dinner, R9, whose room is next door and shares the bathroom, told her that V26 (Certified Nursing Assistant) had taken her dishes, which R4 had left on the bathroom sink. R4 said that when she spoke to V26, she hit her with a garbage bag. R4 said she called the police, who came to the facility. The next day, V1 (Administrator) spoke with her and did nothing about it.R4's EMR (Electronic Medical Record) showed R4 has diagnoses, that included depression, chronic obstructive pulmonary disease, and gastroesophageal reflux disease. R4's MDS (Minimum Data Set) dated 03/29/2026 showed R4's cognition is intact and that she is independent in her daily activities. On 04/24/2026 at 2:30 PM, R9 said she witnessed V26 hitting R4 with a garbage bag.R9's EMR showed R9's diagnoses included bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder. R9's MDS dated [DATE] showed that R9's cognition was intact and that she was independent in her activities of daily living.On 02/23/2026, at 12:00 PM, this writer asked V1 (Administrator/Abuse Coordinator) if he reported this incident. V1 said he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the facility's definition of abuse. V1 acknowledged the incident was not reported to IDPH until 04/22/2026 and indicated an internal investigation had been initiated. V1 said V26 (CNA) continued to work after the allegation an investigation had not been initiated.On 04/24/2026, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) stated the facility overlooked the incident and the abuse allegation should have been addressed in a timely manner. The facility's policy titled Abuse Prevention Program with a revised date of 01/2019 in part showed the facility will not tolerate resident incidents of abuse, the policy will define how the investigations of abuse allegations will be conducted, outline the process of reporting, investigating, and arriving at a conclusion of allegations.

Based on the interview and record review, the facility failed to implement policies and procedures to investigate and report employee abuse to the State Agency and to protect a resident from further abuse by the alleged employee. This applies to 1 of 3 (R4) residents reviewed for abuse in a sample of 10.On 04/23/2026 at 10:56 AM, R4 said that on 12/03/2025, when she returned from dinner, R9, whose room is next door and shares the bathroom, told her that V26 (Certified Nursing Assistant) had taken her dishes, which R4 had left on the bathroom sink. R4 said when she questioned V26, she hit her with a garbage bag. R4 said she called the police, who came to the facility. The next day, R4 said V1 (Administrator) spoke with her about the incident and did nothing about it. R4 said V26 is still working, and if she did the same thing to V26, the facility would have sent her to the hospital for evaluation, but nothing happened to V26. R4 said that if she thinks about it, she gets very upset.R4's EMR (Electronic Medical Record) showed R4 has diagnoses that included depression, chronic obstructive pulmonary disease, and gastroesophageal reflux disease.R4's MDS (Minimum Data Set) dated 03/29/2026, showed R4's cognition is intact and that she is independent in her daily activities.On 04/24/2026 at 2:30 PM, R9 said she witnessed V26 hitting R4 with a garbage bag.R9's EMR (Electronic Medical Record) shows R9's diagnoses, including bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder.R9's MDS (Minimum Data Set) dated 01/30/2026 showed that R9's cognition is intact and she is independent in her activities of daily living.On 02/23/2026, at 12:00 PM, this writer asked V1(Administrator/Abuse Coordinator), if he reported the incident to the Illinois Department of Public Health (IDPH). V1 said he did not report the incident at that time because he did not believe it met the facility's definition of abuse. V1 acknowledged the incident was not reported to IDPH until 04/22/2026 and indicated an internal investigation had been initiated.On 04/24/2026, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) stated that the facility overlooked the incident and that the abuse allegation should have been addressed. V2 and V3 said the employee should have been removed from the facility until the investigation was completed. V2 and V3 said the facility should have updated care plans and that the incident should have been reported in a timely manner. The facility's policy titled Abuse Prevention Program with a revised date of 01/2019 in part showed the facility will report, identify, investigate, remove the employees from the facility during investigation, complete the final investigation within five working days after the review of medical records, personnel records of employees, interview with residents and employees and addressing in quality Performance Improvement Approach, and updating intervention in care plans.

Based on record review and interview, the facility failed to ensure that an allegation of an employee abusing residents was thoroughly investigated and that corrective action was taken. This applies to 1 of 3 residents (R3) reviewed for abuse in a sample of 10.R3's EMR (Electronic Medical Record) showed R3 has diagnoses that included dementia, Alzheimer's disease, psychosis, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder.R3's MDS (Minimum Data Set) dated 04/03/2026 showed that R3's cognition is intact and that she is independent in her activities of daily living.R3's care plan dated 03/24/2026 showed R3 will remain safe, will be treated with respect and dignity, and reside in the facility free of mistreatment, including abuse/neglect.The writer made multiple attempts from 04/21/2026 to 04/24/2026 to speak with R3, but R3 refused to speak. V2 (Director of Nursing) and V3 (Assistant Director of Nursing) said R3 tends not to speak; however, she makes her needs known.On 04/28/2026 at 9:02, V29 (Receptionist) stated that on 04/03/2026, around 7:00 PM, she was near the residents' area by the kitchen, and R3 came by looking for food or coffee. V29 said she witnessed V17 (Dietary Aide) yelling, pushing, and swearing at R3, then closing the kitchen door. V29 said R3 came to her, said V17 hurt her, and then V29 took R3 to the front desk, gave some cereal, and notified V6 (Social Service Assistant) and V30 (Registered Nurse), who were in the building, and the V1(Administrator)On 04/28/2026 at 12:56 PM, V27 (Social Service Assistant) said she was about to leave around 7:00 PM. V27 said V29 told her that V17 was yelling, pushing R3 away from the kitchen door, and that R3 was crying. V27 said she told V29 to report to the administrator. V6 said all residents have the right to be free from abuse.On 04/28/2026 at 1:49 PM, V3 (Assistant Director of Nursing) stated that V1 (Administrator) asked her to assist the nurses in following up on the incident, and V1 conducted the investigation. On 04/28/2026 at 1:02 PM, V30 (Registered Nurse) said V29 called him to report the incident. V30 said staff then got R3 to the unit, assessed for pain/injury/bruise and then called the police, who came to the facility and met with R3. V30 said R3 complained of pain and refused medication. V3 and V30 said all residents have the right to be free from abuse.On 04/28/2026 at 10:00 AM, V1 (Administrator) stated that V17 (Dietary Aide) is loud by nature and that he did not think abuse occurred.V1 stated that he completed the investigation based on the information he received and acknowledged that residents have the right to be free from abuse.The review of the incident report dated 04/06/2026 lacked the witness's factual statement and signature. V17 was suspended during the investigation, and the incident was not substantiated; no corrective actions were taken.The facility's Abuse Prevention Program, dated 02/2019, in part stated that the final report shall include facts determined during the investigation and a conclusion based on those facts. Policy further stated that the administrator or Director of Nursing shall review the findings of the investigation and determine whether any further training or corrective action is needed to prevent further actions.

Based on observation, interview, and record review, the facility failed to provide meaningful activities to residents. This applies to 4 of 4 residents (R2, R3, R7, R10) who were reviewed for activities in a sample of 10.The findings include:1. On 04/07/26 at 10:49 AM, R2 said the facility has had less activities because the activity manager was on leave of absence. R2 said the facility did not have game nights or movie nights anymore.R2's face sheet showed she had diagnoses including multiple sclerosis, acquired hemolytic anemia, cardiac arrhythmia, atrial fibrillation, ataxia, peripheral vascular diseases, hyperlipidemia, vitamin D deficiency, foot drop on right & left foot, stage 2 chronic kidney disease, nutritional deficiency, weakness, acute bronchitis due to rhinovirus, osteoporosis, hypothyroidism, constipation, skin changes, major depressive disorder, and hypotension. R2's MDS (Minimum Data Set) dated 01/02/26 showed R2 was cognitively intact. On 04/01/26 at 8:29 AM, V28 (Family Member) said there were no activities being held in the evenings since the director was sick and they only had three part-timers. V28 said there were no activity staff on the 2nd floor so there were no activities happening on the 2nd floor. V28 said there was always an activity aid at the facility, but they had multiple jobs to get done like smoking time and also needed to get the residents for the activities. 2. On 04/01/26 at 12:45 PM, R3 said the frequency of activities had decreased because the director of activities went on maternity leave. R3 said it was three to four weeks where they did not have as many activities. R3 said some other staff can substitute, but not all of them knew how to turn the television on to get the games. R3 said there were no evening activities such as game nights or movie nights since the activity director was so sick. R3's face sheet showed she was admitted to the facility with diagnoses including need for assistance with personal care, gastro-esophageal reflux disease, unspecified psychosis, dementia, anxiety disorder, and weakness. R3's MDS dated [DATE] showed R3 was cognitively intact.3. On 04/02/26 at 3:09 PM, R7 said the activities department did not always have staff in the facility and they had not done movie nights or game nights because there were no staff available to do so. R7 said the activity director was off for a while. R7's face sheet showed she was admitted to the facility with diagnoses including primary osteoarthritis, weakness, acute and chronic kidney failure, anxiety disorder, and adult failure to thrive. R7's MDS dated [DATE] showed R7 was cognitively intact.4. On 04/02/26 at 2:47 PM, R10 said they had not had movie night in a while. R10's face sheet showed she was admitted to the facility with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, weakness, major depressive disorder, dysphagia, bell's palsy, schizophrenia, and generalized anxiety disorder. R10's MDS dated [DATE] showed R10 was cognitively intact. On 04/02/26 at 2:37 PM, V14 (Activity Aide) said she worked on Thursdays and Saturdays from 9 AM to 5 PM. V14 said she was not sure if anyone was staying in the evenings for game nights or movie nights. On 04/03/26 at 10:32 AM, V20 (Activity Aide) said she worked Mondays, Wednesdays, Fridays, Saturdays, and Sundays from 9 AM to 5 PM. V20 said the activity director was on maternity leave. V20 said they have not started the movie nights or game nights because they are trying to figure out what schedule works for everyone. On 04/07/26 at 2:05 PM, V35 (Activity Aide) said she worked Tuesdays, Saturdays, and Sundays from 9 AM to 4 PM. V35 said she was not aware there were any evening activities happening as all the activity aids left the facility by 5 PM during the week. V35 said if the facility was not holding game nights or movie nights, they should not be posting the events on the activity calendar. V35 said it had been between 1.5 to 2 months since they had game nights or movie nights. On 04/07/26 at 2:53 PM, V34 (Social Services Assistant) said she had been helping the activity department since the director went on maternity leave. V34 said she worked Monday through Friday from 10 AM and ended her shift between 6-8 PM, depending on the need. V34 said she did not do any of the nighttime activities with the residents. V34 said 04/06/26 was the first time they had done a movie night in a long time. V34 said there was an ad in the paper to hire another activity aide. At 3 PM, V34 said generally after 4-5 PM, it was independent time for the residents. On 04/07/26 at 3:13 PM, V1 (Administrator) said the events they post on the calendar should be carried out. V1 said if an event was cancelled or switched to another day, they should notify the residents that it was not being done. The facility's March Activity Calendar showed movie nights should have been offered every Monday and game nights should have been offered every Thursday. The facility's Guidelines for Activities policy dated 07/23/23 showed Activities refers to any endeavor, other than routine, ADLS (Activities of Daily Living) in which a resident participates that is intended to enhance his/her sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include but are not limited to activities that promote self-esteem, pleasure, comfort, education, creativity, success and independence.It is the policy of the facility to ensure that each resident's interests and needs are identified and that an ongoing program of activities that is designed to appeal to his/her interests and to enhance the resident's highest practicable level of physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to obtain consent from a resident or POA (Power of Attorney) prior to taking pictures of the resident. This applies to 1 of 3 residents (R1) reviewed for resident rights in a sample of 8.The findings include:On 04/01/26 at 3:20 PM, V27 (Family Member) said she was in a meeting with staff from the facility when she noticed a picture of R1 was in the documents held by the staff. V27 said R1's picture was taken of her while she was asleep. V27 said that R1 would never have been ok with the picture taken as R1 always had her hair combed and makeup done and R1 would have been very upset if she had seen the picture. V27 said she had not consented to the facility to take pictures of R1. V27 said she wanted the picture removed and the facility took another picture of R1.On 04/03/26 at 12:53 PM, V22 (Human Resources Director/Business Office Manager) said she had a meeting with V27 and was reviewing the documents with her when V27 saw R1's picture on her face sheet. V22 said V27 became upset with the picture taken as R1 was sleeping in the picture. V22 said it was a bad picture. V22 said per the admission director, there was a photograph consent form in the admission packet which should have been filled out prior to taking pictures. V22 said R1 was not able to consent if she had a POA in place. V22 said a picture of a sleeping resident would not be considered consent.On 04/03/26 at 12 PM, V3 (Dementia Coordinator) said there was a photo release form which needed to be signed prior to taking a picture for the EMR. V3 said this form was usually signed during the admission process. V3 said if a resident was sleeping in the picture, consent was probably not given. V3 said the family brought R1's picture to her attention and the photograph was immediately taken down and V3 retook everyone's picture to ensure they were appropriate. On 04/03/26 at 1:10 PM, V23 (Social Services Director) said pictures taken for the EMR would need consent. V23 said the residents or families also had the right to refuse the picture being taken. V23 said there was usually a consent form for photography in the admission packet provided to the residents or families. V23 said if a resident was sleeping in the picture, it would not show consent was given. On 04/03/26 at 1:40 PM, V1 (Administrator) said the admission packet contained the photographic authorization release form which would address the picture for the medical record. V1 said the release form would need to be signed prior to taking the picture for the medical record. V1 said staff should not take pictures of residents while they are sleeping. V1 said even a picture of a resident where they did not look their best would prompt a retake. V1 said the activity department usually took pictures of the residents. At 2:33 PM, V1 provided R1's admission packet with the photographic authorization release form and said they missed the part that said no to taking pictures.R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses including dementia, type 2 diabetes mellitus, unspecified psychosis, weakness, and need for assistance with personal care. R1's MDS (Minimum Data Set) dated 01/16/26 showed R1 had moderate cognitive impairment. The facility's Concern Form dated 03/23/26 showed [R1]'s picture was taken twice without authorization. 1 picture was taken in her sleep.The facility's Photographic Authorization Release Form dated 01/21/26 showed I, [blank space] authorize Facility its agents and their representatives, to take photographs, slides and videotapes of me for medical and advertising purposes. In addition, I authorize the use of these images, without compensation to me, for the following specific purposes: In the office photo album for prospective patients, in office seminars for prospective patients, On our web site and social media pages, In print advertisements, On television. to which the POA had selected No to all of the above.

Based on interview and record review, the facility failed to arrange and provide transportation for out of facility nephrology medical appointments for residents.This applies to 6 of 6 residents (R1, R8, R9, R10, R11, and R12) reviewed for appointments in a sample of 12. Findings included: On 02/06/2026 at 10; 00 AM, a review of the resident appointment calendar showed that R1, R8, R9, R10, R11, and R12 had nephrology appointments on 02/05/2025 at 11:15 AM that were canceled.On 02/06/2026 at 12; 00 PM, V2 (Director of Nursing) said that all the residents were scheduled to go together by bus to the appointment on 02/05/2026, but the bus was not ready at the repair shop. V2 said the staff from the record department who arranged the appointment schedule were out due to vacation and sickness, and that transportation was to be arranged 72 hours before the appointment.The facility provided an Auto Clinic repair receipt indicating that the facility bus had been in a repair shop since 01/27/2026, with a fuel pump failure causing very low fuel pressure. The report showed that insufficient fuel pressure can lead to hard start, sudden starting, loss of power, sudden stalling while driving, and an increased risk of an accident. The report further showed that the Auto Clinic could not be repaired and that repairs need to be done to a heavy truck repair facility. 1. On 02/06/2025 at 10:15 AM, R1 said she is upset because the facility cancelled her appointment with the kidney doctor on 02/05/2026 due to not having transportation, and the bus has been in the repair shop for a while. R1 was a [AGE] year-old female with a diagnoses including hypertensive kidney disease, diabetes type 2 diabetes, urinary tract infection, and anxiety disorder. R1's MDS (Minimum Data Set) dated 11/07/2025 showed R1's cognition was intact and required supervision from one staff for activities of daily living. The appointment was made on 12/04/2025.2. On 02/06/2025 at 01:30 PM, R8 said he had canceled his quarterly follow-up appointment with the kidney doctor because the facility's bus was in a repair shop for a while. R8 was a [AGE] year-old male with diagnoses including chronic kidney disease, hypertensive heart failure, anemia, and benign prostate hyperplasia. R8's Minimum Data Set quarterly assessment dated [DATE] showed R8's cognition was intact and required supervision from one staff for activities of daily living. The appointment was made on 12/11/2025.3. On 02/06/2025 at 1:48 PM, R9 was in bed and not interviewable.R9 was an [AGE] year-old male with diagnoses including obstructive and reflux uropathy, urinary tract infection, diabetes type 2 diabetes, retention of urine, and dementia. R9's MDS (Minimum Data Set) dated 01/12/2026 showed R9's cognition was severely impaired and required one to two staff assistance for activities of daily living. The appointment was made on 12/18/2025.4. On 02/06/2025 at 2:02 PM, R10 was in bed and not interviewable.R10 was a [AGE] year-old male with diagnoses including hypertensive heart disease, type 2 diabetes, and dementia. R10's MDS dated [DATE] showed R10's cognition was severely impaired and required one to two staff assistance for activities of daily living. The appointment was made on 12/11/2025.5. On 02/06/2025 at 2:30 PM, R11 said his kidney appointment was cancelled because the bus was not available to transfer residents.R11 was an [AGE] year-old male with diagnoses including chronic kidney disease, type 2 diabetes, hypertensive heart disease, and peripheral vascular disease. R11's MDS dated [DATE] showed R11's cognition was intact and required supervision from one staff for activities of daily living. The appointment was made on 01/29/2026.6. On 02/06/2025 at 3:30 PM, R12 was in the hallway in a wheelchair and not interviewable.R12 was a [AGE] year-old female with diagnoses including transplant kidney status, urinary tract infection, dementia, and Alzheimer's disease. R12's MDS (Minimum Data Set) dated 01/23/2026 showed R12's cognition was severely impaired and required staff assistance for activities of daily living. The appointment was made on 12/04/2025.On 02/06/2025 at 12:00 PM and on 02/07/2025 at 2:00 PM, V2 stated that the facility should have arranged transportation, either by coordinating with the family or a transportation company. V2 also said the facility should have assigned a designee since the person arranging transportation was out sick. On 02/07/2025 at 2:00 PM, V1 (Administrator) acknowledged the failure.

Based on interview and record review the facility failed to treat residents with dignity and respect for 1 of 4 residents (R1) reviewed for resident's rights in the sample of 15.The findings include:On 1/16/26 at 9:25 AM, R1 said this incident had happened a couple of weeks ago but it still bothers R1 up to this time. R1 said, V7 (Certified Nursing Assistant- CNA) came to her room and spoke to her very inappropriately. V7 (CNA) stated, I believe you love me; you know that you love me. R1 said she did not like that statement, that was not a right way to talk to a patient like me, not fair at all. R1 said she called her sister. R1 said she still sees V7 working at the facility.On 1/16/26 at 9:21 AM V13 (R1's POA/sister) said V7 (CNA) making that statement should not be allowed at all at the Nursing Home. V13 said she called the Police on the CNA (V7) On 1/16/26 at 11 AM, V7 (CNA) confirmed he made those statements to R1 you know you love me. But that V7 was just joking. V7 said the Police came and spoke to him. The Police believed that he was joking but was told not to do that again. V7 said the DON (Director of Nursing) spoke to him 1:1, that I should be careful of the things I was saying to the residents. Residents are to be treated with respect.On 1/16/26 at 10;10 AM, V2 (Director of Nursing) said staff were expected to always be respectful and professional. Avoid making jokes so statements will not be misinterpreted. Residents are to be treated with dignity and respect.The facility policy on Dignity (undated) documents, Dignity, as an extension of appropriate interactions between staff and residents: 1, staff will always be polite and respectful. Note: Residents are to have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or not understand what is being said or done by others.

Based on observation, interview, and record review, the facility failed to identify and assess a pressure wound prior to it becoming a Stage III wound for 1 of 5 residents (R2) reviewed for pressure ulcers in the sample of 15. The findings include:On 1/17/26 at 11:10 AM, V16, Wound Care Nurse, was observed as she provided wound treatment to R2's coccyx. R2 had an open area to his coccyx. R2's buttocks were not reddened and did not have any open areas.On 1/17/26 at 1:19 PM, V16, Wound Care Nurse, said R2's coccyx wound was first identified 12/30/25. The wound was a Stage III pressure wound to his coccyx. V16 said R2's coccyx pressure wound was acquired in the facility. V16 said it had yellow slough and was not sure why it was not found sooner. V16 said it (healing) was difficult at first because R2 did not like his low air loss mattress, and he was only moving when staff moved him.On 1/17/26 at 11:40 AM, V8, Certified Nursing Assistant (CNA) said it's important she informs V16 and the (floor) nurse about any changes in the residents' skin right away.R2's Admission/readmission Alteration in Skin Integrity form dated 12/17/25 shows R2 has no open areas or skin breakdown. R2's Weekly Wound Evaluation dated 12/18/25 shows R2 has blanchable redness to his buttocks with no open areas present. No redness or open areas were noted to his coccyx. No open areas or skin breakdown was noted. The document shows a Stage I pressure ulcer that has non-blanchable redness. Non-blanchable redness was not noted to R2's skin. R2's Weekly Wound Evaluation dated 1/2/26 shows R2 was found to have a Stage III pressure injury (In-house acquired) to his coccyx on 12/30/25. The wound had a moderate amount of thin, watery, serous drainage yellow slough and a resident pain rating of an eight (8). R2's Wound Physician's note dated 12/30/25 shows R2 has a Stage III pressure wound of his coccyx which was reported on 12/30/25. R2's Braden Scale(s) for Predicting Pressure Sore Risk dated 12/17/25, 12/25/25, 1/2/26 and 1/9/26 all show R2 is a low risk. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact and has no rejection of care behaviors.The facility's Guidelines for Prevention/Treatment of Pressure Injuries (dated 10/9/23) show that a Risk Assessment is considered the starting point for prevention of pressure injury. The earlier any risk factors can be identified, the more quickly they can be addressed. The at risk resident must be identified because they can develop a pressure injury within hours of the onset of pressure. CNAs should immediately report any new skin concern, or complaint of a painful area of skin to the nurse for assessment.

Based on observation, interview, and record review, the facility failed to implement and/or follow Enhanced Barrier Precautions (EBP) for 2 of 3 residents (R2 and R5) reviewed for infection control in the sample of 15.The findings include:On 1/17/26 at 10:15 AM, V16, Wound Care Nurse, said R2 has a sacral pressure ulcer (Stage III). On 1/17/26 at 11:10 AM, V16 approached R2's room to provide wound treatment. R2's room had no EBP sign nor PPE (Personal Protective Equipment) bin outside his room. V16 did not don a gown prior to entering R2's room. V16 was observed providing wound care to R2's coccyx without a gown.On 1/17/26 at 9:42 AM, V8, Certified Nursing Assistant (CNA), entered R5's room without a gown to change R5's brief. R5's room had an EBP sign on her door and a PPE bin outside her room.On 1/17/26 at 12:50 PM, V2, Director of Nursing (DON), said any resident with wounds or a history of MDROs (multidrug resistant organism) needs to be on EBP. A sign will be placed on their door indicating the type of isolation and the PPE. V2 said the PPE needs to be put on and hand hygiene done before entering the room to do resident care and needs to be removed prior to exiting room. V2 said EBP requires a gown and gloves when providing direct patient care such as incontinence care and wound care.R2's admission Record shows he has a Stage 3 pressure ulcer of his sacral region. R2's Order Summary Report dated 1/16/26 shows R2 has an active order written on 1/2/26 for daily and as needed wound care to his coccyx.R5's Order Summary Report dated 1/16/26 shows R5 has an active order written on 1/2/26 for EBP for ESBL (a MDRO) in her urine.

Based on observation, interview and record review the facility failed to ensure resident's mail was not opened prior to delivering it to the resident. This applies to 2 of 9 residents (R7 and R13) reviewed for resident rights in the sample of 14. The findings include: On 1/12/26 at 9:10AM (R7) was in his room sitting on his bed. R7 stated, Sometimes my mail is open. I got a check a couple months ago, and V1(Administrator) brought it to me and told me I got a check and had me sign it and then the money went into my account. It was from some State check for some missing/ lost property. It was $88. I don't know who opened it, but (V1) brought it to me.On 1/12/26 at 11:35AM R13 was lying on her bed in her room. R13 stated, I have had my mail opened for me. It was from Social Security. They cashed it and then said the check didn't go through right away. It was for $25. It eventually got put into my account. It was a couple months ago. Activities brought me the open envelope and (V5- Business Office Manager) brought me the check and asked me to sign it and about 2 weeks later it was in my account. I had to threaten the police on them because it was taking so long to get my money. R13 showed a piece of mail with her name on it that she said was open when it was given to her. There was no facility name on the letter. The letter was clearly opened with a letter opener and slit open cleanly across the top of the envelope. On 1/12/26 at 10:45AM V5 stated, Reception receives the mail and they separate it and give activities anything that is not (Medicaid) mail. I open the ones that have (Facility Name) on them. They are usually Medicaid applications or denials or statements. V5 pulled 2 unopened pieces of mail from the table behind her. One was addressed to the facility, and one was addressed to a resident. Both envelopes looked like they came from the same place (Medicaid). V5 stated, I have not sorted these yet, but this one will go to the resident and this one I will open. I do not open any resident mail. It has to have the facility name on it. We never hold mail for any reason. If it needs to go to a resident, then I either give it back to reception or give it to activities or if I see the resident then I might just hand it to them.On 1/12/26 at 11:11 AM V6 (Activities Director) stated, Mail goes to the business office, bills and stuff, and all the cards and gifts and things go to activities. We deliver mail 6 days a week. The front desk gives it to us, but the bills and the medical bills all stay with the business office. I have never delivered that to residents.The facility policy entitled Resident Mail Delivery dated 5/1/11 states, Purpose: To ensure that all residents receive mail unopened and in a timely manner upon delivery of the mail from the United States Postal Service to the Facility.

Based on observation, interview, and record review the facility failed to ensure a resident received yogurt with breakfast per resident preference. This applies to 1 of 8 residents reviewed for dietary services in the sample of 14. The findings include: R1's Facesheet shows R1 has a diagnosis of osteoporosis. On 1/12/26 at 8:45 AM, a case of six bulk 5 pound tubs of yogurt were in the walk in cooler in the kitchen. Five of the tubs were unopened and one was opened. V7 (Interim Food Service Director) said one case of yogurt typically lasts the facility about a week and it is an item that residents must request to receive.R1's Dietary Progress Note from 5/19/23 shows R1 prefers milk and yogurt with meals. R1's breakfast tray ticket for 1/12/26 shows R1 is to receive plain yogurt daily. On 1/12/26 at 9:20 AM, R1 said R1 started ordering yogurt at all meals to encourage optimal calcium levels after R1 was diagnosed with osteoporosis. R1 did not receive yogurt with breakfast. R1 said staff told R1 that they were waiting on a shipment because they were out of yogurt. R1 said most, if not all kitchen staff, know that R1 likes yogurt. On 1/12/26 at 11:15 AM, V8 (Dietary Aide) said when serving on the tray line, tray tickets will state either in the middle or bottom items that residents request or need as daily items. V8 said R1 is to receive yogurt daily. V8 said dietary aides on the tray line are responsible for getting and providing yogurt dished into bowls for resident trays at meals. Facility Dietary Preferences, Nutritional Requirements, and Portion Management policy dated 10/30/25 states, The facility will make every reasonable effort to accommodate each resident's cultural, religious, and personal dietary preferences while ensuring that all meals meet the resident's nutritional requirements as determined through comprehensive assessment and care planning.

Based on observation, interview, and record review, the facility failed to ensure that residents who are dependent on the facility for ADLs (Activities of Daily Living) such as feeding, dressing, and incontinence care are provided the necessary assistance in a timely manner.This applies to 5 of 5 residents (R8, R9, R10, R11, and R12) reviewed for ADLs in the sample of 12.The Findings include:On December 6, 2025, 9:53 AM to 12:48 PM, R8, R9, R10, and R11 were continuously observed sitting in dining room. They were not checked for incontinence during this time.1. R9's admission record showed R9 to be [AGE] years old with diagnoses that include chronic obstructive pulmonary disease, type 2 diabetes mellitus, dementia, anemia, major depressive disorder with severe psychotic disturbance, anxiety disorder, and fall. R9's MDS (Minimum Data Set) dated September 25, 2025 showed R9 to be dependent on staff for all ADL care. On December 6, 2025 at 11:26 AM, V25 (R9's family member) stated she is at the facility visiting R9 once a week and the facility staff do not check R9 for incontinence for more than 2 - 3 hour. V25 stated, They don't have enough help. V25 stated sometimes she comes, and it is 10 or 11AM and R9 is still in bed and her hands are dirty. On December 6, 2025 at 1:37 PM, V24 (Certified Nursing assistant, CNA) took R9 to her room to be changed. R9's incontinence brief was soaking wet from front to back, and R9 had a bowel movement. 2. R8's admission record showed R8 to be [AGE] years old with diagnoses that included displaced fracture of second cervical vertebra, osteoarthritis, left shoulder, dementia, Rheumatoid arthritis, anxiety disorder, psychosis, major depression weakness, difficulty in walking, and need for assistance with personal care. R8's MDS dated [DATE] showed R8 required substantial maximal assistance for toilet transfers.On December 6, 2025 at 1:54 PM, V22 (CNA) and V23 (CNA) took R8 to the restroom. 3. R10's admission record showed R10 to be [AGE] years old with diagnoses that include senile degeneration of brain, atrioventricular block, second degree, dementia, type 2 diabetes mellitus, difficulty in walking, need for assistance with personal care, weakness, and abnormalities of gait and mobility. R10's MDS dated [DATE] showed he was dependent on staff for eating. R10's care plan showed R10 had a self-care deficit and requires assistance with transfers and toileting. On December 6, 2025 at 12:10 PM, R10 was sitting in the dining room at a table alone with a bowl of chili, corn bread, and fruit on his tray in front of him. R10 was eating the chili with his bare hands by sticking his fingers in the chili grabbing some and then putting it in his mouth. V5 (Licensed Practical Nurse, LPN) was feeding R8 at another table to the left and in front of R10. There was no other staff in the room. There was silverware on R10's tray. At 12:16 PM, R10 picked up the bowl of chili and started drinking it rapidly and started coughing vigorously. V5 then turned around and walked over to R10 and put a spoon in his food and said, It's not for drinking, use your spoon. V5 then went back to feeding R8. At 12:21 PM, V24 (CNA) came and sat with R10 and began feeding him. On December 6, 2025 at 12:48 PM, V23 and V24 took R10 to the bathroom to be checked for incontinence.4. R11 admission record showed R11 to be [AGE] years old with diagnoses that include dementia with severe psychotic disturbance, type 2 diabetes, osteoarthritis, epilepsy, difficulty walking, unsteadiness on feet, weakness, and need for assistance with personal care. R11's MDS dated [DATE] showed she required substantial/maximum assistance with toileting hygiene and transfer. On December 6, 2025 at 2:00 PM, V24 took R11 to her room to be changed. 5. R12 face sheet showed R12 to be [AGE] years old with diagnoses that include dementia, sarcopenia, hypertensive heart disease, violent behavior, major depressive disorder, aphasia, unspecified psychosis, weakness, and need for assistance with personal care. R12 had an active care plan that showed he had a self-care deficit with impaired grooming abilities. R12's MDS dated [DATE] showed R12 is dependent on staff for lower body dressing and toileting. On December 6, 2025 at 11:35 AM, R12 was near the nurse's station and had a brown substance on his left fingers and under his fingernails and on the left side of his gray jogger pants. The brown substance ran laterally down the left leg of R12's gray jogger pants and was about a half inch wide and about 5-6 inches long.On December 6, 2025 at 11:39 AM, V23 and V24 took R12 into bathroom.On December 6, 2025 at 11:44 AM, V23 came out of the restroom and stated her and V24 were helping R12 use the restroom. V24 then exited the restroom with R12. V24 stated R12's incontinence brief was changed and R12 now has a clean one on. V24 stated R12 had a bowel movement. V24 stated R12 dug in his incontinence brief with his hand and wiped stool on his pants. V24 was cleaning R12 fingers with wet disposable clothes. A brown substance could still be seen on R12' s fingers/nails. V22 and V23 took R12 to his room and emerged about 1 minute later along with R12. R12 sat at the nursing station and now the brown substance was partially removed but R12's grey jogger pants were wet where the stain was. The wetness was about 2 inches wide and 6 inches long. On December 6, 2025 at 11:51 AM, V22 stated V23 tried to wipe the brown stain off R12's gray jogger pants. V22 repeated (R12) wipes his hands on his pants. V22 stated that they can change R12's pants. V23 and V22 then took R12 into his room. R12 came out at 11:54 AM with black pants on instead of grey pants. On December 6, 2025 at 2:23 PM, V2 (Director of Nursing) stated staff should be checking residents every 2 hours and as needed for incontinence to protect them from developing wounds, so that they don't sit in a soiled incontinence brief, and to ensure they are clean and dry. V2 stated that resident's clothing should be changed if they are dirty or have feces on them. The facility's feeding assistance guidelines dated March 27, 2023 showed that feeding assistance will be completed according to the individual needs.The facility's guidelines for incontinence care policy showed the following: frequency of incontinence care depends on bladder diary results and/or routine minimal every 2 hours checks as well as care planning.

Based on observations, interviews and record review, the facility failed to provide a substantial evening snack when the mealtimes exceed 14 hours per resident.This applies to all residents that receive foods prepared in the facility kitchen.The findings include:Facility Data sheet dated November 18, 2025, showed that there was a census of 126 residents in the facility. Facility provided information that there was one resident on NPO (nothing by mouth) status.Facility Mealtimes chart showed as follows:Breakfast: 2 North Unit -7:45 AM - 8:00 AM, 2 South Unit 8:00 AM - 8:15 AM, 2 Main Unit 8:15 AM -8:25 AM, Main Dining room [ROOM NUMBER]:25 AM - 8:40 AM, 1 South Unit 8:40 AM - 8:55 AM, 1 North Unit 8:55AM-9:10 AM.Dinner: 2 North Unit -4:45 PM - 5:00 PM, 2 South Unit 5:00 PM - 5:15 PM, 2 Main Unit 5:15 PM -5:25 PM, Main Dining room [ROOM NUMBER]:25 PM - 5:35 PM, 1 South Unit 5:35 PM - 5:45 PM, 1 North Unit 5:45 PM-5:55 PM.This showed that there was a 15-hour duration between the dinner and breakfast meal.On November 18, 2025, and November 19, 2025, between 8:30 AM-4:00 PM, multiple residents (R1, R2, R8 R9, R10, R13) stated that they do not receive a bedtime snack after the dinner meal.On November 18, 2025, at 4:11 PM, V11(Regional Dietary Manager) stated the facility sends cookies or graham crackers and Kool aide with the dietary staff to each unit around 6:30 PM when they go to collect the dinner meal trays. V11 stated the dietary staff put the snacks at the nurse's station. V11 stated he sends about 20-30 cookies per unit and that residents who want snacks get it from the nurse's station. V11 stated only 5 residents receive a labeled hs (evening) snack consisting of half a sandwich and these are mainly for the diabetic residents.On November 20, 2025, at 11:47 AM, V31 (Dietitian) stated the facility does not give a nourishing snack at bedtime currently. V31 stated if the time exceeds 14 hours between the dinner and breakfast meal, a substantial snack should be given.Facility policy and procedure titled Meal Snack Hours and Frequency (revised August 15, 2023) included: Policy-The facility provides three meals daily at regular times comparable to normal mealtimes in the community. The facility will also offer an evening snack to the residents. Meals and snacks will be served in a timely manner.Procedure: 4. As long as the facility is serving the evening meal and the breakfast meal 14 hours apart (or less), a nourishing snack if offered to all residents not on diets prohibiting bedtime nourishment. A nourishing snack is defined as a verbal offering of items, single or in combination, from the basic food groups. The facility will choose the snacks that are served at bedtime. However, the dietary manager, RD [Registered Dietitian] or DTR [Diet Technician] will solicit input from the residents and/or the resident council.5. If the time span between the evening meal and the next day's breakfast meal exceeds 14 hours, the facility is required to provide a substantial evening meal. A substantial evening meal is defined as offering three or more menu items at one time, one of which includes a high-quality protein, such as meat, fish, eggs, or cheese. The meal represents no less than 20% of the day's nutritional requirement.

Based on observation, interview, and record review the facility failed to implement an effective pest control program and failed to respond to sightings of rodent excrement, and dead and live rodents. The facility failed to take measures to eradicate and contain rodents including patching holes in walls, informing pest control vendor of rodent sightings, provide effective room cleaning, and staff failed to notify the Administrator of any evidence of pest or rodent presence in accordance with facility policy. This has the potential to affect all 126 residents who reside in the facility as reported on the Facility Data Sheet, dated November 18, 2025, completed by V1 (Administrator). The findings include:On November 18, 2024, at 10:34 AM, V24 (Pest Control Vendor Employee) stated he visits the facility weekly. V24 stated mice can enter a structure through a hole the size of a dime or under a door if there is enough space to see light. V24 stated he had instructed V22 (Maintenance Supervisor) to patch all holes in walls and that had not been completed yet. V24 stated last week on his visit there was a dead mouse found under a dining room table in the second-floor dining room.On November 18, 2025, at 10 :38 AM, V22 stated he had not completed patching all the holes on the second floor yet.On November 18, 2025, at 11:27 AM, V22 stated staff inform him of maintenance needs either by verbally telling him when he is in the building or entering the information into the TELS system. V22 stated for urgent needs the TELS system sends a notification to his phone.On November 18, 2025, at 2:48 PM, tour with V22, on the second-floor memory care dining room there was an approximate 3 inch hole seen under the heating vent around the pipe that runs into the wall.On November 18, 2025, at 2:54 PM tour with V22, inside the second-floor memory care unit soiled utility room closet, there was a hole approximately 2 inches under the bottom shelf along the wall around the heating pipe. V22 stated he had not finished patching all the holes yet.On November 19, 2025, at 10:10 AM in R9's room, on the first floor, V28 (Housekeeping Supervisor) and V22 moved the bed away from the wall. V22 shined a light behind the bed and observed small brown rice sized substance on the floor that V22 stated were mice droppings. V28 then shined the light to observe the same floor under the bed and described the substance on the floor as mouse droppings.R9's MDS dated [DATE], showed R9 was cognitively intact and required assistance with ADL's including supervision with eating, oral hygiene, bed mobility and transfer, partial assistance with upper body dressing and personal hygiene and substantial assistance with lower body dressing, bathing, and toileting, On November 18, 2025, at 3:37 PM, R9 stated over the past 6 months he had caught 9 mice in a mouse trap in his room. R9 stated on Saturday November 15, 2025, he and V6 (CNA) noticed a foul odor in his room. R9 stated they found a dead mouse under his bed. R9 stated V6 removed it and put it in a plastic garbage bag and removed it from the facility.On November 20,2025, at 1:01 PM, V6 stated she did notice a foul odor in R9's room on November 15, 2025, during the 3PM to 11PM shift and convinced R9 to take a shower. V6 stated while making R9's bed, she lifted the mattress to place the sheet and noticed the dead mouse under the bed. V6 stated R9 pulled the mouse from under his bed using his Reacher. V6 stated based on the smell and appearance of the mouse carcass, it looked like an adult mouse, and she thought it had been there for about 4-5 days. V6 stated she did not inform V22 or V1 because it was about 10:30 PM and R9 told her he would report it to V1 in the morning. V6 stated she had worked in the facility for about a year and did not know what a TELS system was. V6 stated she thought the nurse would write the finding of the mouse in the shift report, pass it on in the report and that V22 would be informed the next day. V6 stated she had seen live mice around the building and stated the mice usually come out in the evening shift and can be seen running out of the vents on the second floor or by the walls in various rooms on the first floor. V6 stated everyone knows there are mice around here and nobody, especially the owner does anything about it.On November 18, 2025, at 4:00PM, V8 (LPN) who works the 1 south unit with V6, stated he has seen live mice on the unit on occasion but does not remember where exactly or when and did not recall if he reported the sighting or not.On November 18, 2025, at 4:08 PM, V1 stated he was unaware and had not been informed of the dead mouse found in R9's room on Saturday November 15, 2025. V1 stated the last report of mice in the building he was aware of was around 6 months ago. V1 stated if staff see live or dead mice or mice droppings, they should report the sighting to V1.Review of the pest vendor reports showed there were mice seen in R9's room and the room was treated for mice on June 26, 2025. R9's room was not checked again for rodents in the reports reviewed through November 18, 2025.On November 19, 2025, at 1:15 PM, V42 (Regional Director) stated if evidence exists of the presence of rodents mitigation steps should be taken immediately.The facility's policy titled Guidelines for Pest Control (Policy), dated October 31, 2025, showed It is the policy of the facility to ensure that an effective pest control program is in place. An effective pest control program is defined as measures to eradicate and contain common household pests, including mice. The Maintenance staff and all other staff will be cognizant of the necessity to maintain a clean, safe, and comfortable, homelike environment that is free of pests or rodents. Upon sighting of any pest or rodent or any evidence of a pest or rodent by any person in the facility, the Administrator will be notified.

Based on observations interview and record review, the facility failed to serve meals at required meal temperatures and appearance/consistency for palatability. This applies to all residents that receive foods prepared in the facility kitchen.The findings include: Facility Data sheet dated November 18, 2025, showed there was a census of 126 residents in the facility. Facility provided information there was one resident on NPO status.1. The Week at a glance menu (Week 3) for dinner meal on November 17, 2025, included hot dog with hot dog bun.On November 17, 2025, at 4:27 PM, the dinner meal items were on the steam table in the facility kitchen and V3 (Cook) stated they were ready for meal service at 4:45 PM and he has already taken the food temperatures of the meal items. On request, V30 (Regional Dietary Director) measured the food temperatures at the steam table and showed as follows in degrees Fahrenheit. Mechanical Soft hot dog=110.4, Pureed hot dog =129.7.2. The Week at a glance menu (Week 3) for breakfast meal on November 18, 2025, included Western egg casserole and hot cereal.On November 18, 2025, at around 8:30 AM, during breakfast meal service, it was noted the room trays served for the residents first floor did not have hot plates/thermal pellets and only had an insulated dome cover over the plate. The hot cereal did not have a lid. These meal trays were placed in a rolling cart and covered with a plastic liner.On November 19, 2025, at 8:54 AM, V37 who was passing out food trays out to the residents in 1 South unit from the food cart stated, They (Dietary Staff) sometimes give us coffee is clear and not even black. They only give plastic plates in the evening. How can the food stay warm?On November 19, 2025, at 9:04 AM, the food temperatures were monitored from a test tray by V11 (Regional Dietary Manager) prior to passing out all the meal trays in the 1 South unit. The Western egg casserole and hot cereal measured 120 degrees Fahrenheit. V11 remarked if the meal temperatures were taken after the room trays were passed out it will be below 110 degrees Fahrenheit. V11 stated, We do not have enough hot plates for this site. V11 added they run out of plates and utensils as its probably still in the resident's room and not returned to the kitchen. 3. The Week at a glance menu (Week 3) for lunch meal on November 18, 2025, included beef stroganoff with egg noodles and broccoli florets.On November 18, 2025, starting at starting at 12:10 PM, the lunch meal service was observed in the facility kitchen. The beef stroganoff with egg noodles mixture appeared like mushy with overcooked noodles and shredded beef. The broccoli appeared also overcooked and dull green in appearance.On November 20, 2025, at 11:47 AM, V31 (Dietitian) stated the meal temperatures at the steam table should be 135-140 degrees Fahrenheit and palatability of foods served should be at least 125 degrees Fahrenheit.Facility undated policy and procedure titled Food Temperature Management at Bedside/Table-side ServiceIncluded: Purpose- To ensure patient safety and quality of care by maintaining food temperatures in accordance with CMS guidelines and Food Code, while prioritizing palatability and timely reheating practices.1.Temperature Standards: Initial Serving Temperatures (Staring Point)- The recommended starting temperature for hot foods at bedside/table-side service should begin at 135 degrees Fahrenheit (57 degrees Centigrade) or higher.3. Palatability consideration: In addition to meeting specific temperature targets, all hot foods must be prepared and served in a manner remains palatable (e.g., texture, moisture, aroma, and appearance suitable for immediate consumption).4. Time/Temperature Control Standards: If any hot food item drops below 125 degrees Fahrenheit at bedside/table side, it must be reheated promptly to reach 165 degrees Fahrenheit before serving to the patient.Facility policy and procedure titled (reviewed June 27, 2023) Palatability and Nutritive Value included:Policy: Food will be prepared, held, and served in a manner preserves nutritive value and palatability.Procedure: 1. Hot foods will be held at temperatures 135 degrees or above.4. Best efforts will be made to present hot and cold foods at point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary.5. Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council minutes.

Based on observations interview and record review, the facility failed to provide portions as shown on the menu spreadsheet.This applies to all residents that receive foods prepared in the facility kitchen.The findings include: Facility Data sheet dated November 18, 2025, showed there was a census of 126 residents in the facility. Facility provided information there was one resident on NPO (nothing by mouth) status.1. The Week at a glance menu (Week 3) for dinner meal on November 17, 2025, included hot dog with hot dog bun, potato wedges, green peas, baked cookie. The extension spread sheet for the same meal showed to serve pureed potatoes (#12 scoop) for pureed diets. On November 17, 2025, at 4:27 PM, the dinner meal items were on the steam table in the facility kitchen and V3 (Cook) stated they were ready for meal service at 4:45 PM and he has already taken the food temperatures of the meal items. It was noted pureed potatoes or mashed potatoes were not prepared. On enquiry what the residents on pureed diets are getting, V30 (Regional Dietary Director), who was at the steam table, stated the pureed diets are getting pureed hot dog, pureed bread and pureed green peas. When asked why the pureed diets are not getting pureed potatoes, V30 stated V3 prepared the meal. V30 then directed V3 to make mashed potatoes for the pureed diets.Facility scoop equivalents guidance showed #12 scoop =1/3 cup.2. The Week at a glance menu (Week 3) for breakfast meal on November 18, 2025, included Western egg casserole. The extension spread sheet for the same meal showed to serve 1 slice of Western egg casserole for Regular and Mechanical soft diets. Additional serving instruction included the Western egg casserole prepared in a 6 x (times) 4 [inches] hotel pan to be sliced into 24 pieces.On November 18, 2025, starting at 7:35 AM, during the breakfast meal service in facility kitchen, the Western egg casserole prepared in a pan was cut into 40 slices and the residents on Regular and mechanical soft diets were served 1 slice each (except for around 8 residents who received boiled eggs or scrambled eggs per choice). When this pan was completed, another pan containing Western egg casserole was cut into 35 slices was placed on the steam table and the residents on Regular and mechanical soft diets were served 1 slice each. V32 (Cook), who was seen cutting the prepared sheet pan of Western egg casserole, stated the pan is 6 x 4 [inches]. When showed the directions on the menu extension sheet for slicing the Western egg casserole into 24 pieces, V30 stated, I don't know why I cut it into 35 and 40 slices.3. The Week at a glance menu (Week 3) for lunch meal on November 18, 2025, included beef stroganoff with egg noodles and broccoli florets. The extension spread sheet for the same meal showed to serve 4 oz (ounces) of beef stroganoff over 6 oz egg noodles (total 10 oz) for Regular diet, 2 #8 scoops of pureed beef stroganoff with egg noodles.On November 18, 2025, starting at 12:10PM, during the lunch meal service in the facility kitchen, the residents on Regular diets received an 8 oz ladle portion of beef stroganoff and noodle mixture. The residents on pureed diets received one #8 scoop of pureed beef stroganoff with egg noodles mixture. When V30 (Regional Dietary Director), who was at the steam table, was asked why the residents on Regular and pureed diets received the same instead of what is shown on the menu extension sheet, V30 stated the facility does not have a 10 oz scoop. V30 added the server should have served one 8 oz ladle and a little more using the same ladle for regular diets and the pureed diets should have received 2 #8 scoops.It was noted towards the at the end of the lunch meal service, the facility ran out of beef stroganoff with egg noodles and broccoli, and 6 residents (R5, R37, R38, R39, R40, R41) received a hamburger on bun with mashed potatoes and no additional vegetables. On November 18, 2025, at 8:47 AM, V25 (Certified Nursing Assistant) who was passing out meal trays in the 1 South unit stated, If the resident asks for second portion, they (dietary staff) say we don't have enough. That's not right. The food is for the residents. On November 20, 2025, at 11:47 AM, V31 (Dietitian) stated the menu is preplanned and approved by dietitian of the new company oversees the kitchen. V31 stated the facility should follow the diet extension sheets and recipes to meet the requirements of calories and proteins for the meal. Facility scoop Conversions and Measurements guidance showed #12 scoop =1/3 cup, #8 = 1/2 cup. Facility Diet Order Listing printed on November 19, 2025, showed there were 13 residents on pureed diets, 28 residents on mechanical soft diets and 85 residents on Regular diets.

Based on observation, interview and record review the facility failed to ensure a resident with a history of elopement was appropriately assessed and/or monitored to prevent elopement, failed to identify and assess residents who actively seek exits or display elopement behaviors, failed to ensure all exit doors/windows were secured/monitored, failed to promptly/effectively respond to triggered door alarms and perform a resident head count, and failed to maintain a current list of residents at risk for elopement at the front door exit per facility policy and resident care plans. The Immediate Jeopardy began on 11/4/25 at approximately 10:20 PM when R1 removed window lock hardware, tied bed sheets together, and repelled out of a second-floor window of the facility with temperatures at approximately 55-56 degrees Fahrenheit. R1 was found the morning of 11/7/25 approximately 10 miles away in the parking lot of an assisted living facility from which R1 previously eloped. The failure also had the likely serious adverse outcome of additional residents eloping from the facility. The Administrator was notified of the Immediate Jeopardy on 11/12/25 at 2:00 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 11/13/25 at 12:32 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction. This failure applies to 10 of 10 residents (R1-R10) reviewed for elopement in a sample of 10.The findings include: 1. Face sheet, printed 11/13/25, shows R1 was admitted to the facility on [DATE] and R1's diagnoses included an unspecified injury of the head, mild cognitive impairment, chronic kidney disease stage 3, congestive heart failure, dysphagia, unsteadiness on feet, weakness, need for assistance with personal care, and cardiac pacemaker.Pre-admission hospital records, dated 10/7/25, shows R1 left his assisted living facility alone at 4:00 AM with a cart and then hit his head against a concrete wall. The note shows R1 was seen by psychiatry during his hospitalization who deemed R1 to be lacking in decisional capacity.Hospital Record Psychiatry Consult Note, dated 10/5/25, shows, [Patient] presently lacks medical decision-making capacity. He is fully oriented at time of evaluation but is unable to discuss anything about treatment or disposition plan for him since he's been in the hospital. He has poor insight and does not have an appropriate understanding of his limitations in his ability to care for himself independently and believes that he can care for himself completely independently, expressing desire to go to work on a farm in southern Illinois. Patient unable to appropriately discuss his chronic medical issues or the medications he typically takes. He denies having been diagnosed with anything psychiatrically though his friend reported past [diagnosis] of bipolar disorder. Patient is tangential and hyperverbal during evaluation. Suspect mild cognitive decline/early dementia. Patient has primary neurocognitive disorder. Facility Wander Risk Assessment, dated 10/14/25, shows R1 was at high risk for wandering.Elopement risk assessment dated [DATE] and completed by V5 (LPN- Licensed Practical Nurse), shows R1 was assessed as not exhibiting wandering or pacing behaviors, as having the ability to be mobile without assistance from staff, and as having no history of elopement in the prior three months.On 11/7/25 at 11:02 AM, V5 (LPN - Licensed Practical Nurse) stated on 10/12/25 at approximately 9:30 PM R1 packed all his belongings, placed them by the locked exit of the memory care unit, and stated he wanted to leave. V5 stated he attempted to redirect R1 but was unable to do so. V5 stated he called R1's physician and obtained an order for Haldol to calm R1 down but R1 remained upset he was on the memory care unit and wanted to leave. V5 stated he reported the incident to V2 (Director of Nursing) and V16 (Assistant Director of Nursing) as well as the next shift nurse V6 (RN-Registered Nurse). Progress notes, dated 10/12/25 and written by V5, show R1 attempted to elope after packing his belongings and putting them by the door of the locked memory care unit. The note shows R1 was provided a new order for Haldol as needed due to agitation and sitting at the nursing station with all of his belongings.Behavior Monitoring records, dated 10/12/25, failed to show R1 had any wandering or elopement behaviors.On 11/7/25 at 1:28 PM, V6 (Registered Nurse) stated she was notified at approximately 12:30 AM on 11/5/25 by V10 (CNA) that R1's window was open, R1's window lock was removed, and the window could open 1.5 feet. V6 stated there were sheets tied into a rope with knots and one end of the sheet rope was attached to the foot of the bedside drawer which was located close to the open window. V6 stated the rope of sheets led to the ground. V6 stated R1's personal possessions were removed from the room and there were pillows placed under R1's bed linens resembling a body sleeping in the bed. V6 stated there were no alarms alarming in the facility at the time she observed R1 was no longer in his room. V6 stated she was not aware that R1 had a history of elopement from his prior facility or that he attempted to elope from the facility on 10/12/25.On 11/7/25 at 7:48 AM, V15 (Police) stated the police were notified on 11/5/25 at 12:38 AM that R1 was missing from the facility. V15 stated a search was initiated, including 10 bloodhounds and 2 [NAME], and R1 was tracked to a local train station. V15 stated he had no further leads as to R1's whereabouts.Video footage of R1's elopement, dated 11/4/25 at 10:23 PM, shows R1 climbing down the side of the facility utilizing bed sheets and carrying belongings. The video shows R1 walked north in the courtyard until out of sight and then did not reappear in any of the cameras. On 11/6/25 at 12:37 PM, V9 (Dementia Care Coordinator) stated R1 removed the left window lock to exit the window when he eloped. V9 stated he witnessed a screw sitting near the window and sheets wadded up on the windowsill when he arrived the next morning. V9 stated he was unaware of R1's prior attempts to elope until 11/5/25 when staff informed him R1 packed his belongings and attempted to leave through the locked unit door.On 11/10/25 at 2:04 PM, V11 (Maintenance) stated on 10/21/25 he received a text from a nurse asking V11 to replace R1's missing right window lock early in the morning V11 stated he replaced the right lock and ensured the left lock was in place on the window. V11 stated he was not aware R1 eloped from his prior facility and if he were aware, he would have spoken with V1 and V3 regarding the missing window lock in R1's room to request more supervision for R1. On 11/7/25 at 12:59 PM, V3 (Social Services Director) stated she was not aware of any prior attempts by R1 to elope from the dementia unite including R1's 10/12/25 attempt to leave the unit. V3 stated R1 was never placed at risk for elopement and was never placed in the elopement binder located at the reception desk and never received an electronic wander guard.On 11/6/25 at1:28 PM, V14 (VP Clinical), V10 (Consultant) and V1 (Administrator) stated R1 was not considered an elopement risk while at the facility and was never included in the facility elopement binder provided to the receptionist.On 11/7/25 at 10:50 AM, V1 stated R1 was found at the assisted living facility in which R1 resided prior to living at the current facility. On 11/7/25 at 11:16 AM, V15 (Police) stated when he found R1 in the parking lot of R1's prior assisted living facility, R1 was disoriented and was sent to the hospital.Hospital records, dated 11/7/25, show .feet are dirty from being on the road for the last 2 days. Reportedly jumped out of a second story window to escape his living facility, though he used bedsheet to let himself down. Per external chart review, was seen by psychiatry last month, deemed to be non-decisional and thus was placed in this facility.On 11/6/25 at 11:10 AM, V1 (Administrator) stated he did not file a reportable incident because there had not been any reports of injury to R1. 2. Elopement risk binder located at the front door reception desk of the facility, observed on 11/6/25, 11/7/25, 11/10/25, showed only 6 residents, (R4, R5, R6, R7, R8 and R10) were identified at the facility as at risk for elopement. On 11/6/25 at 1:05 PM, V2 (Director of Nursing) provided a list of only 5 residents in the facility who were identified as exit seeking which included R4-R8. On 11/6/25 at 11:25 AM, V7 (Housekeeping) propped external door open to dispose of trash, left view of door for minutes while door alarm was alarming, and no staff were present. At 11:27 PM, V3 (Social Services) arrived at the door which was still propped open and alarming. V7 closed the door but the alarm continued to sound. V11 (Maintenance) arrived and turned off the door alarm. V3 and V11 left the external door area without looking outside for residents who may have eloped. On 11/6/25 at 11:55 AM, V1 (Administrator), V2 (Director of Nursing), V3 (Social Services), V8 (Consultant) and V13 (MDS) all stated there were no concerns regarding potential elopements or regarding missing residents that morning. At 12:18 PM, V1 and V8 (Consultant) both stated there were no concerns regarding potential elopements or regarding missing residents that morning.On 11/7/25 at 11:56 AM, V3 (Social Services) stated if a door alarm sounds, staff are to go outside and search for a resident. V3 stated if no resident is seen outside, the staff are responsible for performing a resident head count to check for all residents in the building. V3 stated if a resident is identified as missing, the staff were to overhead page a Code 99 for staff to begin searching for the missing resident.Face sheet, printed 11/13/25, shows R4's diagnosis included anxiety, insomnia, and unsteadiness on feet. MDS, dated [DATE], shows R4's cognition was severely compromised. Elopement Risk Review, dated 11/5/25, shows R4 was at high risk for elopement.Face sheet, printed 11/13/25, shows R5's diagnoses included psychosis, depression, anxiety, schizoaffective disorder, bipolar disorder and dementia. MDS, dated [DATE], shows R5's cognition was intact. Elopement Risk Review, dated 11/5/25, shows R5 was at risk for elopement.Face sheet, printed 11/13/25, shows R6's diagnoses included hemiplegia and hemiparesis following cerebral infarction, dementia, depression, and falls. MDS, dated [DATE], shows R6's cognition was severely impaired. Elopement Risk Review, dated 11/5/25, shows R6 was at high risk for elopement. Face sheet, printed 11/13/25, shows R7's diagnoses included dementia, depression, weakness, difficulty walking, anxiety, bipolar disorder, and a history of falling. MDS, dated [DATE], shows R7's cognition was severely impaired. Elopement Risk Review, dated 11/5/25, shows R7 was at high risk for elopement.Face sheet, printed 11/13/25, shows R8's diagnoses included Alzheimer's disease, dementia, kidney transplant status, schizoaffective disorder bipolar type, hallucinations, weakness, unsteadiness on feet, depression, dementia, and anxiety. MDS, dated [DATE], shows R8's cognition was severely compromised. Elopement Risk Review, dated 11/5/25, shows R8 was at high risk for elopement. 3. Face sheet, printed 11/13/25, shows R9's diagnoses included dementia, schizoaffective disorder, weakness, cognitive communication deficit, unsteadiness on feet, history of falling, and need for assistance with personal care. MDS, dated [DATE], shows R9's cognition was severely impaired. Elopement Risk Assessment, dated 11/5/25, shows R9 did not pace or wander, did not try to get outdoors or perceive the need to be somewhere else, had no history of elopement, and was not at risk for elopement. Wandering Care Plan, initiated/revised 2/26/25, shows R9 demonstrated movement behavior that may be interpreted as wandering, pacing or roaming related to dementia. The care plan shows R9 became agitated, oppositional and combative when redirected or exit-seeking. The care plan shows, post a picture of the resident at/near the front desk and/or nursing station in a discrete place identifying possible elopement risk. Implement 'preventative' intervention strategies: Make rounds/room checks per facility protocol to minimize chance of unauthorized leave. Use/apply electronic monitoring device with appropriate consent.On 11/10/25 at 12:20 PM on the locked memory care unit, R9 independently walked through the halls and toward the locked exit of the memory care unit. R9 attempted to follow V18 (Speech Language Pathologist) through the exit door of the dementia unit. V18 attempted to redirect R9 back into the unit and out of the doorway and then quickly exited through the door closing the door behind her. R9 continued to stand at the door looking at the door until staff removed R9 from the area. On 11/10/25 at 12:27 PM, V9 (Dementia Care Coordinator) stated if staff witnesses a resident attempted to exit the door of the locked dementia unit, the staff should redirect the resident and inform V9 of the behavior. V9 stated the resident should then be reassessed for elopement risk. V9 stated he was unaware R2 attempted to push the dementia unit door open recently. Review of R9's clinical record as of 11/12/25 at 10:00 AM, showed R9 was not reassessed for elopement risk since his last risk assessment on 11/5/25.4. Face sheet, printed 11/14/25, shows R2's diagnoses included dementia, weakness, difficulty walking and unsteadiness on feet, insomnia and restlessness and agitation. MDS, dated [DATE], shows R2's cognition was severely impaired. Wandering Risk Scale, dated 10/15/25, shows R2 wandered in the past month, had a history of wandering, could move without assistance while in a wheelchair, and was at high risk for wandering.Face sheet, printed 11/13/25, shows R3 had diagnoses which included metabolic encephalopathy, depression, dementia, unsteadiness on feet, weakness, need for assistance with personal care, and suicidal ideations. MDS, dated [DATE], shows R3's cognition was severely impaired. Wandering Risk Scale, dated 8/8/25, shows R3 had no history of wandering, can move without assistance while in a wheelchair, had no reported episodes of wandering in the past 6 months, and was at low risk for wandering at the time of the assessment.Elopement Risk Reviews, both dated 11/5/25, show both R2 and R3 had no history of elopement attempts in the past three months, did not try to get outdoors or perceive the need to leave, accepted their nursing home placement, and were at low risk for elopement. On 11/7/25 at 3:39 PM, V17 (LPN- Licensed Practical Nurse) stated R2 was known to try to leave the locked memory care unit and R2 attempted to exit through the dementia unit door even that day. V17 also stated she was aware of R3 also pushing on the memory care unit exit doors to attempt to leave. As of 11/10/25 at 12:36 PM, R2 and R3 were not reassessed for elopement since 11/5/25 and not included on the list of residents at risk for elopement at the reception desk.On 11/10/25 at 3:14 PM with V2 (DON), V17 again stated R2 tried to exit the dementia unit locked door on 11/7/25 V17 stated she had to retrieve R2 before he left the unit. V17 also stated R3 also attempts to push the locked memory care door open at times. V2 stated V17 should have reported the elopement attempts to her supervisor. 5. R10's care plan shows R10 had diagnoses which included mild cognitive impairment, bipolar disorder, dementia, delusional disorders, psychosis, and mood disturbance and anxiety. Elopement Prevention Program Care Plan, initiated 5/13/22 and updated 8/4/23, shows R10 demonstrated behavior that may be interpreted as wandering, pacing, or roaming related to diagnoses of schizophrenia. The care plan shows R10 attempted to leave the facility without a responsible escort, paced, and roamed or wandered in and out of peer's rooms. The care plan shows, Implement 'preventative' intervention strategies: Post a picture of the resident at/near the front desk and/or nursing station in a discrete place identifying possible elopement risk. Notify staff of risk potential.Elopement assessment, dated 11/5/25, shows R10 has a history of elopement, is currently wearing a wander guard, face sheet and resident's picture place din binders on each unit. Facility document Exit Seeking Residents, provided on 11/6/24 and 11/12/25, show R10 was not identified as an exit seeking resident.Review of the resident elopement risk binder located at the front door reception desk of the facility, observed on 11/6/25, showed 6 residents (R4-R8 and R10) were identified by the facility as at risk for elopement.Forest View Nursing & Rehabilitation Center Policy and Procedure Regarding Missing Residents and Elopement, undated and provided with the facility elopement binder on 11/6/25 at 2:00 PM, showed, All door alarms will be tested and documented daily. At no time will any door alarm be deactivated without direct visual supervision of the exit. The individual responsible for turning the alarm off will be responsible for resetting the alarm. All residents shall be assessed for behaviors that place them at risk of elopement utilizing an elopement risk assessment upon admission, quarterly, annually and upon significant change of condition. Any resident identified to be at risk of elopement will be placed on a resident at Risk List which shall be posted at each nurses' station and at the reception area. The At-Risk List will be updated whenever a new resident safety concern is identified. Residents with identified elopement risk will be documented in the resident's plan of care. Should an alarm on one of the exits to the outside of the facility sound, staff will immediately respond to determine the cause of the alarm. After the facility staff investigate an exit door and no reason can be found for the sounding of the alarm, staff will be informed of the possible elopement, and a facility head count will be initiated. The Director of Nursing or designee shall coordinate the accounting of all residents. After all residents are accounted for and the cause of the alarm is undetermined, the Director of Nursing or designee will continue to reasonable investigation to determine the cause of the alarm. In the event a resident s discovered missing, the following procedures shall be followed: .report to the State Department of Health if the incident meets reportable criteria. Should a resident attempt an elopement, a review of the individualized care plan will be completed for identified changes. The facility presented an abatement plan to remove the Immediacy on 11/12/25 at 4:02 PM. The survey team was unable to accept the plan to remove the Immediacy. The abatement plan was returned to the facility for revisions.The facility presented an abatement plan to remove the Immediacy on 11/12/25 at 5:22 PM. The survey team was unable to accept the plan to remove the Immediacy. The abatement plan was returned to the facility for revisions.The facility presented an abatement plan to remove the Immediacy on 11/13/25 at 11:28 AM. The survey team was unable to accept the plan to remove the Immediacy. The abatement plan was returned to the facility for revisions.The facility presented an abatement plan to remove the Immediacy on 11/13/25 at 12:32 PM and the survey team accepted the abatement plan on 11/13/25 at 12:32 PM. The Immediate Jeopardy that began on 11/4/25 at 10:20 PM was removed on 11/13/25 at 12:32 PM when the facility took the following actions to remove the immediacy: Resident #1 no longer resided in facility. Residents R2 - R9 were reassessed for elopement risk by Social Services and DON; interventions were added to care plans on 11/12/25 All exit doors and windows were immediately checked and secured by Maintenance; window hardware was replaced or reinforced with tamper-proof locks. Resident head counts and census verification were conducted by Charge Nurse and DON immediately; all residents were confirmed present. Elopement risk list was updated and placed at front reception and nurse's stations. All staff were in-serviced on elopement protocol, alarm response, and head-count procedure on 11/11/25. Facility-wide audit was completed by the DON on 11/12/25 to identify any residents exhibiting exit-seeking behaviors. Environmental rounds will be completed twice daily to confirm window locks and alarm integrity by Administrator, Maintenance Director, or Maintenance assistant. Reception desk binder will be updated with a list of elopement-risk residents. Alarm response protocol: immediate head count and documentation is required after response to door alarms with no identifiable cause. Nurses and Social Services were trained on how to accurately complete the elopement assessment by outside Social Services Consulting group on 11/13/25. Initial Elopement Risk Assessment will be completed by nursing, and assessments by social services reviewed and supervised by Social Services Consulting completed upon admission, quarterly, significant change, or any observed exit-seeking behavior. Staff training will be integrated into new-hire orientation and annual in-services; includes training for elopement vs wandering risk and interventions. Elopement binder will be updated by social service consultant based on results of elopement risk assessment. Binder reviewed by Administrator/DON weekly x 4 weeks, then monthly x3 months. Facility to complete elopement drills weekly for all shift by Social Services consultant, Administrator and DON. Results of drills to be reviewed Administrator/DON. QA Committee to audit 5 elopement-risk residents weekly x 4 weeks, then monthly x 3 months for compliance with interventions and monitoring DON/Social Services Consultant to review all elopement risk assessments completed weekly for 90 days and report findings in QAPI. Maintenance to conduct weekly door alarm and window lock checks and log results.

Based on interview and record review the facility failed to provide the necessary monitoring and supervision for a resident with a history of suicidal ideation and a history of obtaining knives. The facility also failed to have a system in place to accurately screen residents for suicide risk in a timely manner, and ensure residents with suicide risk were identified, and interventions were put in place. This failure resulted in R1 sustaining self-inflicted stab wounds and expiring at the facility from apparent suicide. This failure resulted in Immediate Jeopardy when the facility lacked interventions and processes to protect a resident with a history of suicidal ideation from keeping sharp knives in his room and sustaining self-inflicted stab wounds and expiring from apparent suicide. The Immediate Jeopardy began on [DATE], at approximately 6:00 AM when R1 was found expired in his bed by facility staff with stab wounds to his chest. The Administrator was notified of the IJ on [DATE], at 3:14 PM. This applies to 14 of 14 residents (R1, R5 - R17) reviewed for suicidal ideation in the sample of 17. The findings include:1. The EMR (Electronic Medical Record) shows R1 was a [AGE] year-old male resident admitted to the facility on [DATE]. The EMR continues to show R1 expired at the facility on [DATE]. R1 had multiple diagnoses including heart failure, non-traumatic subacute subdural hemorrhage, aortic stenosis, hypertensive heart disease, morbid obesity, Type 2 diabetes, atrial fibrillation, major depressive disorder, pyloric stenosis, right shoulder osteoarthritis, acute respiratory failure, history of venous thrombosis, and acute kidney failure.R1's MDS (Minimum Data Set) dated [DATE] shows R1 was cognitively intact, required supervision with eating, substantial/maximal assistance with oral and personal hygiene, and was dependent on facility staff for all other ADLs (Activities of Daily Living). R1 was always incontinent of bowel and bladder. R1's MDS continues to show R1 was feeling down, depressed, or hopeless, and had trouble sleeping nearly every day.The EMR shows R1's hospital paperwork dated [DATE], shows multiple active problems including suicidal ideation.The facility's final incident report submitted to the State Agency on [DATE] shows, On [DATE] at approximately 5:45 AM, staff discovered [R1] unresponsive and without vital signs. Blood was observed on his body and the floor beneath his bed. Emergency medical services (911) were immediately contacted, and [R1] was pronounced dead at 6:45 AM. A comprehensive investigation was completed, including staff interviews, medical record review, and collaboration with law enforcement and the coroner's office. Based on the findings: there is no evidence of foul play. The findings are consistent with self-harm, and the cause of death has been determined to be suicide. On [DATE] at 10;18 AM, V6 (RN-Registered Nurse) said, I had [R1] the night of the incident. I checked on [R1] two times. I didn't notice anything wrong with him. I went in there to check his blood sugar around 5:30 or 6:00 AM and when I went in there, I was shocked. I saw [R1's] mouth open, and the oxygen tubing wasn't in his nose, and I was thinking he passed away from removing the oxygen. I couldn't check his blood sugar because he was pale and cyanotic. There was a lot of blood, and when we opened the sheets, I was panicking looking at the blood. I couldn't even see where it was coming from, and I was thinking it looked like a crime or something. I opened the blanket and there was blood by the incontinence brief. Blood was everywhere, and then when I moved to the other side by the window, I was about to collapse because I was so scared from the amount of blood on the floor. Then the other CNA (Certified Nursing Assistant) was searching and found two knives and there were blood stains on the knives. I called 911 and [V2] (DON-Director of Nursing). There was a lot of blood on his chest. I was scared to touch him, and I could see it coming from the left side of his chest. I asked the roommate if he noticed something. Last year, I had him and they said I had to send him out because he was going to kill himself with a plastic bag. We had him on one-to-one supervision, and then we searched, and we found knives. We removed the knives from his room, and he was mad at me for taking his things. I was surprised the hospital sent him back when that happened. I did not wake [R1] up on the night of [DATE] because he would get mad at me if I would wake him up. His roommate gets mad too. There's a person who visits, his friend. Maybe [R1] bought the knives or asked the lady to bring him knives. He likes to cut his fruits.On [DATE] at 1:57 PM, V3 (CNA) said, I was doing my last rounds on my unit on [DATE]. I saw [V7] (CNA) coming towards me, and he said [R1] passed away. I wasn't aware of how he had passed, and when I saw the blood on him, I saw two knives on the bedside table. They were wrapped in white paper towels. There were two knives. One with a black handle with a stainless-steel pointed tip, and then there was a smaller knife, and it was a light blue color and it was also pointed. [R1] was covered with blood on his chest and down his left-hand side of his body, and there was a puddle of blood on the floor. I wasn't able to see the puddle of blood on the floor when I entered the room because it was between the bed and wall by the window. The puddle was at least two feet in diameter. I work night shift and mostly everyone is in bed, and they don't come out of their room.On [DATE], at 1:37 PM, V4 (RN) said, I am usually assigned to [R1's] unit. In May of this year, [R1] had knives in his room.On [DATE], at 3:32 PM, V4 documented, Resident's friend came today to visit resident. Resident's knives (3 pieces) were given to the friend as per agreement with resident. SS (Social Services) aware.The facility does not have documentation to show R1 received education regarding keeping sharp knives in his room. The facility does not have documentation to show R1's room was searched for sharp objects at any time during the duration of his stay at the facility. On [DATE] at 12:27 PM, V15 (Psychiatric NP-Nurse Practitioner) said, I saw [R1] about two weeks before the incident of [DATE]. [R1] has always been dismissive. He always refuses evaluation and says he is not depressed and doesn't need me. I know from the staff he said he was depressed. He had not fired me yet, and never said he didn't want my services, but never entertained me to get enough information from him. He wasn't really completely open with me. I was just told [R1] committed suicide by using a knife. I can't imagine how he was able to do that. When I asked, they said he stabbed himself in the chest. I tried to start him on medications for depression, but he refused. He does not entertain my questions. I would never assume he was not suicidal. No staff told me that he kept sharp knives in his room. Because of his history of suicidal ideation, I would ask them to take them away because I would be afraid, he would harm himself. In my opinion, I would say you should not let someone keep a sharp knife in their room. People who attempted one or two times are likely to be successful on their other attempts.Local police department documentation dated [DATE], shows the date of R1's incident as [DATE]. V16 (Police Officer) documented, I went into [R1's] room and observed [R1] deceased with a large puddle of what appeared to be blood underneath his bed. [V6] RN stated in summary and not verbatim that: She is the night nurse and [R1] is her patient. She started her shift at 2315 (11:15 PM) on [DATE]. She checked on [R1] at approximately 0000 (midnight) and did not notice anything out of the usual. She did her rounds at approximately 0430 (4:30 AM), and [R1] appeared to be sleeping with his mouth closed. At approximately 0600 (6:00 AM) [V6] realized that [R1] had not paged nurses to his room to assist with anything as he typically does every day of the week. [V6] went to his room to check on him which is when she found him with his mouth open, not breathing, and cold to the touch. [V6] then realized there was blood on [R1's] body and blood on the ground and called 911 and asked her CNA to assist in trying to determine what had happened [V7] (CNA) and [V6] began to check [R1's] body and noticed what appeared to be cut marks on [R1's] legs. [V6] and [V7] then uncovered [R1's] body with his blanket and exited the room. [V6] stated that throughout her shift overnight she did not see anyone enter or exit [R1's] room or hear any unusual noises throughout the night. The nursing staff stated that in the past [R1] was caught with a knife in his room which is not allowed at the facility. The knife was confiscated. The facility then began to monitor packaged that [R1] received via mail. It was stated that on 2 separate occasions, [R1] had ordered a knife from [online retailer]. The knives were confiscated and never given to [R1]. The nurses confirmed that the knives that were wrapped in paper towel on the tray were there prior to their arrival and were left untouched. On [DATE] an autopsy was done on [R1]. The knives that were located on scene were used by the medical examiners to determine if the wounds may have been from the knives. The medical examiners stated that the wounds were consistent to that of the knives located. [R1's] bed is located in a tight corner in the room, with little room to maneuver for someone standing. It would not be feasible for anyone to enter that corner and leave wounds on [R1] that were consistent with the wounds found on the left side of his chest. There were no signs of blood spatter, or any indication of a struggle observed while on scene. Toxicology and coroner's report to follow.Pictures obtained by the local police of R1's room showed two large knives as described in the police report, as well as a third knife, on R1's bedside table. The third knife was orange in color and appeared to be a paring knife. The police evidence pictures also showed what appeared to be three cuts on R1's skin on his right upper thigh, and three cuts on R1's skin on his left upper thigh, as well as at least two stab wounds to R1's chest.On [DATE] at 10:01 AM, V5 (Deputy Coroner) said, R1's autopsy was completed, but official results have not been released due to pending toxicology results, which take approximately 8 to 12 weeks. V5 said, The preliminary cause of [R1's] death is apparent suicide. There were several places he had stab wounds. As of right now, it is being investigated as an apparent suicide. The death certificate will be available in approximately 8 to 12 weeks.The facility's Screening Assessment for Evaluating Self-Harm/Suicide Risk shows instructions for completing the screening tool. The assessment tool is used for evaluating self-harm/suicide risk quickly, in a standardized format for all residents to identify individuals who may be at risk. The screening tool category entitled Assessment shows 10 different questions, including resident age, history of previous suicide attempts and/or verbalization about ending his/her life, history of psychiatric/mental health problems, substance abuse, disturbed relationships, social isolation, chronic behaviors, and post-traumatic stress disorder. The assessment tool automatically generates a severity score based on the answers to the questions and categorizes them as: 0-5 Minimal or low risk, 6-15 Moderate risk, 16-20 Greater than moderate risk, and 21-30 High risk. The tool shows a blank box where the screener fills in the severity score and based on the severity score chooses the recommendations and outcome for the resident.The facility completed one screening assessment for evaluating R1's self-harm/suicide risk for the entirety of his stay at the facility. V12 (SSD-Social Service Director) completed the suicide risk screening on [DATE]. The screening assessment shows R1 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R1's risk assessment score to 4 and indicated R1 was minimal/low risk instead of the moderate risk score obtained by using the screening tool. The facility does not have any documentation to show R1's self-harm/suicide risk screening assessment was repeated quarterly or as needed with condition changes for the duration of his stay at the facility.The State of Illinois Petition for Involuntary/Judicial admission for R1, dated [DATE] shows R1 was in need of immediate hospitalization for the prevention of harm. I base the foregoing assertion on the following: [R1] is a [AGE] year-old male with a diagnosis of major depressive disorder. Resident expressed SI (Suicidal Ideation), stating that he is going to put a plastic bag over his head until he expires. Resident is in danger to self. V12 (SSD) is shown as the witness to the incident. R1 was sent to the local hospital and returned to the facility on [DATE] with no indication for inpatient psychiatric admission.The State of Illinois Petition for Involuntary/Judicial admission for R1, dated [DATE], and signed by V12 (SSD) shows R1 was in need of immediate hospitalization for the prevention of harm. I base the foregoing assertion on the following: [R1] is a [AGE] year-old male with a diagnosis of major depressive disorder. Our Human Resource Manager went to meet with [R1] to give him some paperwork and [R1] stated he is going to kill himself. [R1] has a noted history of SI. Resident is in danger to self.The facility does not have documentation to show R1 was rescreened for self-harm/suicide risk following R1's threats of suicide on [DATE] or [DATE]. On [DATE] at 3:44 PM, V12 (SSD) said self-harm/suicide risk screening assessments should be completed on every resident quarterly.On [DATE] at 3:10 PM, V12 admitted she changed R1's suicide risk assessment score from a moderate risk score of 6 to a low risk for suicide score of 4 when she completed R1's suicide risk screening on [DATE]. V12 said residents' care plan interventions are determined after completing the suicide risk screening. V12 continued to say she did not know why she did not screen R1 for suicide risk quarterly or following R1's threats of suicide. R1's care plans were reviewed. R1's care plan for history of self-harmful and self-mutilation ideations (thoughts) and/or behavior was initiated on [DATE]. Multiple interventions were initiated on [DATE] including: As warranted, conduct random room safety checks, personal wellness check. As warranted, conduct a room check/search, and remove any sharp objects or similar contraband (razor blades, razors, knives, scissors, hammer, nails, screwdriver, screws, needles, etc.). As warranted, conduct a room check/search and remove any other objects (in the opinion of the health care professionals) may pose a threat to safety.On [DATE], at 3:44 PM, V12 (SSD) said, the words as warranted in R1's care plan meant if he verbalized suicidal ideations, those actions would be implemented. On [DATE] at 11:21 AM, V1 (Administrator) and V2 (DON) were interviewed together. V2 said the facility's Self-harm/Suicide Risk Screening Assessment should be done for every resident upon admission to the facility, quarterly, and as needed. V2 continued to say as warranted in R1's care plan would mean as needed with his permission, and if R1 refused to have his room searched, facility staff should document the refusal. V1 said, there were no plans in place for scheduled searches of R1's room for contraband. The facility does not have any documentation to show safety checks were conducted of R1's room, including checking for sharp objects.2. R5's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R5 had a moderate risk of self-harm/suicide with a numeric score of 7. V12 changed R5's risk assessment score to 4 and indicated R5 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R5's risk screening scores for the screenings dated [DATE], [DATE], [DATE], February 4, 2025, [DATE], [DATE], and [DATE]. The facility does not have care plans in place to address R5's moderate risk for self-harm/suicide risk.3. R6's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R6 had a moderate risk of self-harm/suicide with a numeric score of 7. V12 changed R6's risk assessment score to 3 and indicated R6 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R6's risk screening scores for the screenings dated [DATE], and [DATE]. The facility does not have care plans in place to address R6's moderate risk for self-harm/suicide risk.4. R7's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R7 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R7's risk assessment score to 3 and indicated R7 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R7's risk screening scores for the screenings dated February 13, 2024, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility does not have care plans in place to address R7's moderate risk for self-harm/suicide risk.5. R8's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R8 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R8's risk assessment score to 5 and indicated R8 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The facility does not have documentation to show R8 was screened for self-harm/suicide for the period of [DATE] to [DATE]. The EMR shows V12 also lowered R8's risk screening score for the screening dated [DATE] from 6 (moderate risk) to 5 (low risk). The facility does not have care plans in place to address R8's moderate risk for self-harm/suicide risk.6. R9's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R9 had a moderate risk of self-harm/suicide with a numeric score of 8. The facility does not have documentation to show R9 was screened for self-harm/suicide for the period of February 9, 2024 to [DATE]. R9's suicide risk screening dated on February 9, 2024 shows R9 scored 8 (moderate risk of suicide). The facility does not have care plans in place to address R9's moderate risk for self-harm/suicide risk.7. R10's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R10 had a moderate risk of self-harm/suicide with a numeric score of 7. The EMR shows the previous suicide risk screening completed for R10 was on [DATE], and R10 scored moderate risk for suicide. The facility does not have care plans in place to address R10's moderate risk for self-harm/suicide risk.8. R11's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R11 had a moderate risk of self-harm/suicide with a numeric score of 7. The EMR shows the previous suicide risk screening completed for R11 was on [DATE], and R11 scored moderate risk for suicide. The facility does not have care plans in place to address R11's moderate risk for self-harm/suicide risk.9. R12's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R12 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R12's risk assessment score to 5 and indicated R12 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R12's risk screening score for the screening dated [DATE] from 6 (moderate risk) to 5 (low risk). The facility does not have care plans in place to address R12's moderate risk for self-harm/suicide risk.10. R13's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the suicide risk screening. The screening assessment shows R13 had a moderate risk of self-harm/suicide with a numeric score of 8. V12 changed R13's risk assessment score to 3 and indicated R13 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R13's risk screening score for the screening dated [DATE] from 8 (moderate risk) to 3 (low risk). The facility does not have care plans in place to address R13's moderate risk for self-harm/suicide risk.11. R14's self-harm/suicide risk assessment screening was completed on [DATE] by V17 (SW-Social Worker). The screening assessment shows R14 had a moderate risk of self-harm/suicide with a numeric score of 6. V17 changed R14's risk assessment score to 4 and indicated R14 was at minimal/low risk instead of the moderate risk. The EMR shows the previous suicide risk screening completed for R14 was [DATE] and V12 changed R14's risk assessment score from 7 (moderate risk) to 5 (low risk). The facility does not have care plans in place to address R14's moderate risk for self-harm/suicide risk.12. R15's self-harm/suicide risk assessment screening was completed on [DATE]. V17 (SW) completed the suicide risk screening. The screening assessment shows R15 had a moderate risk of self-harm/suicide with a numeric score of 6. V17 changed R15's risk assessment score to 3 and indicated R15 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The EMR shows V12 also lowered R15's risk screening score for the screening dated February 13, 2025 from 6 (moderate risk) to 3 (low risk). The facility does not have care plans in place to address R15's moderate risk for self-harm/suicide risk.13. R16's self-harm/suicide risk assessment screening was completed on [DATE]. V17 (SW) completed the screening. The screening assessment shows R16 had a moderate risk of self-harm/suicide with a numeric score of 7. The facility does not have documentation to show the self-harm/suicide risk assessment was completed from [DATE] to [DATE]. R16's self-harm/suicide risk assessment score on [DATE] was 7 (moderate risk). The facility does not have care plans in place to address R16's moderate risk for self-harm/suicide risk.14. R17's self-harm/suicide risk assessment screening was completed on [DATE]. V12 (SSD) completed the screening. The screening assessment shows R17 had a moderate risk of self-harm/suicide with a numeric score of 6. V12 changed R17's risk assessment score to 3 and indicated R17 was at minimal/low risk instead of the moderate risk score obtained by using the screening tool. The facility does not have documentation to show the self-harm/suicide risk assessment was completed from [DATE] to [DATE]. R17's self-harm/suicide risk assessment score on [DATE] was 6 (moderate risk). V12 changed the score from 6 (moderate risk) to 3 (low risk). The facility does not have care plans in place to address R17's moderate risk for self-harm/suicide risk.The facility presented an abatement plan to remove the Immediacy on [DATE], at 8:08 AM. The survey team was unable to accept the plan to remove the Immediacy. The abatement plan was returned to the facility for revisions.The facility presented an abatement plan to remove the Immediacy on [DATE], at 9:57 AM. The survey team was unable to accept the plan to remove the Immediacy. The abatement plan was returned to the facility for revisions.The facility presented an abatement plan to remove the Immediacy on [DATE], at 10:32 AM and the survey team accepted the abatement plan on [DATE], at 10:40 AM. The Immediate Jeopardy that began on [DATE], at approximately 6:00 AM was removed on [DATE], at 10:40 AM when the facility took the following actions to remove the immediacy:R5 - R17's suicide risk screening has been reviewed, reassessed and revised.R5 - R17's Care plans were audited to ensure appropriate interventions are in place and were updated as necessary.All residents' self-harm care plans were reviewed and updated as necessary by Social Service Director (SSD), MDS coordinator and or designee.The facility identified no other residents who were at risk of self-harm and had a significant history of obtaining knives or other potential weapons identified via audit /record review. Furthermore, of those residents who did have a suicide ideation/verbalization there were no significant findings identified via room search, placing them at risk for self-harm.All residents' suicide risk screenings were audited and updated as necessaryAll residents self-harm care plans were reviewed and updated where necessary.SSD/designee is responsible for completing suicide risk screening assessments and have been in-serviced on [DATE], by V20 (Consultant Social Worker), V21 (RNC-Regional Nurse Consultant) completing self-harm/suicide risk screening assessments accurately, including properly recording the assessment score, completing timely and accurately with appropriate, individualized interventions in place. Suicide risk assessments need to be completed upon admission, quarterly, upon significant changes, and as needed.The facility created a process to address the results of the self-harm/suicide risk screening assessment to ensure recommendations from the screening, and measurable care plan interventions are put in place to instruct staff on how to keep residents safe. The facility created a policy and guidelines to the self-harm/suicide risk assessment and implemented on [DATE].Nursing staff were in-serviced by DON/ADON (Director of Nursing/Assistant Director of Nursing) starting on [DATE], and will complete on [DATE], to ensure that residents with suicidal ideation will be monitored every shift under behavior monitoring and will be documented in the EMR (Electronic Medical Record). Residents with a history of obtaining sharp objects will have room searches conducted during angel rounds as permitted by residents or POA (Power of Attorney).Beginning [DATE], an audit tool will be completed by Administrator, DON and or ADON on every resident upon admission, re-admission, quarterly and with significant changes to ensure that suicide risk screening assessments are completed accurately with appropriate individualized care plans as follows: Three times a week for the first two weeks, two times a week for two weeks, one time week for two weeks, and one time a month for two months.QAPI (Quality Assurance Performance Improvement) Committee, which meets monthly, will review for compliance, and determine that compliance has been met. An emergency QAPI meeting was held on [DATE], and attended by the Medical Director and interdisciplinary team.

Based on observation, interview, and record review, the facility failed to ensure a resident with a healed pressure ulcer on the buttock received care to prevent the pressure ulcer from reopening. and failed to ensure the resident received nutritional interventions to promote wound healing. This failure resulted in R38 developing a stage 3 facility acquired pressure ulcer. This applies to 1 of 3 residents (R38) reviewed for pressure ulcers in the sample of 25. The findings include: The EMR (Electronic Medical Record) showed R38 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia, bipolar disorder, deformity of the right and left hand, and intellectual disabilities. R38's MDS (Minimum Data Set) dated February 28, 2025, showed R38 had severe cognitive impairment and was dependent on facility staff for eating. The MDS showed R38 had a weight loss of 5% (percent) in the last month or loss of 10% or more in the last six months, and not on a physician-prescribed weight-loss program. R38's care plans for at risk for skin alteration dated July 23, 2024, and April 29, 2025, showed multiple interventions dated July 23, 2024, and April 29, 2025, including Nutritional Supplements per dietician recommendations. On April 29, 2025, at 11:51 AM, V23 (Wound Nurse) said R38 has a facility acquired pressure ulcer which reopened this week. V23 said R38 has not been eating well which could be why her pressure ulcer reopened. V23 removed R38's dressing and R38 had an opened reddened area on the left buttock. V23 said R38's pressure ulcer had healed on April 16, 2025, but reopened this week. A wound note dated April 29, 2025, by V29 (Wound Doctor) showed R38 had a stage III pressure ulcer of the left buttock measuring 3 cm (centimeters) by 3 cm by 0.1 cm. On April 29, 2025, at 12:36 PM, R38 was sitting in the dining room with a lunch tray of pureed food, chocolate pudding, and cranberry juice. On April 29, 2025, at 12:48 PM, V28 (LPN/Licensed Practical Nurse) was feeding R38 lunch. V28 said the pureed food, pudding, and cranberry juice was R38's complete lunch. R38's tray did not include a frozen nutritional supplement or ice cream. On April 30, 2025, at 9:26 AM, V25 (CNA/Certified Nursing Assistant) was feeding R38 breakfast. V25 said R38's breakfast was pureed food, sugar free pudding, and cranberry juice. V25 said R38 doesn't eat much at meals but will always eat her pudding. R38's meal ticket showed R38 was to receive whole milk and a frozen nutritional supplement. R38's tray did not include whole milk, a frozen nutritional supplement, or ice cream. On April 30, 2025, at 12:12 PM, R38 was in the dining room with V14 (POA/Power of Attorney). R38's tray was delivered and V5 (Food Service Manager) said R38's lunch tray was pureed rice, pureed chicken, pureed broccoli, and pudding. V5 said all residents on pureed diets get pudding for dessert. V5 said a frozen nutritional supplement is like ice cream. R38's meal ticket showed frozen nutritional supplement. R38's meal tray did not include a frozen nutritional supplement or ice cream. On April 30, 2025, at 1:10 PM, V24 (R38's Physician) said his expectation would be for facility staff to give residents nutritional supplements as ordered by the provider. V24 said malnutrition would contribute to R38's pressure ulcer reopening. On March 19, 2025, R38 weighed 94 pounds. On April 22, 2025, R38 weighed 86.6 pounds which is a 7.87% (percent) weight loss in one month. On April 30, 2025, at 1:38 PM, V2 (DON/Director of Nursing) said facility staff should be giving residents dietary supplements as ordered by the provider. V2 said frozen nutritional supplements come from the kitchen staff when meal trays are being assembled. V2 said R38 should be getting the frozen nutritional supplement especially since R38 likes sweets and will usually eat her sweets at meals. V2 said pudding is not the same as the frozen nutritional supplement because the frozen nutritional supplement is more nutritious. V2 said facility staff documentation showing R38 received a frozen nutritional supplement on April 29, 2025, at lunch and on April 30, 2025, at breakfast and lunch would be incorrect since the frozen nutritional supplement was not on R38's meal tray. The facility's policy titled Guidelines for Prevention/Treatment of Pressure Injuries (Part of the SWAT- Skin Weight Assessment Team Program) dated October 9, 2023, showed Purpose: It is the intent of the facility to recognize the following information and to act on it in such a way as to practice evidence-based recommendations for the prevention/treatment of pressure injuries to the residents who reside in the facility. Objectives: In accordance with Federal Regulations and based on resident assessment, the facility will ensure: 1) A resident receives care, consistent with professional standards of practice; to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and 2) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Note: the second point will be addressed in Guidelines for Addressing Pressure Injuries. Facts: Pressure injuries are significant health issues and one of the biggest challenges for long-term care facilities on a day-to day basis. Preventing pressure injuries is a challenge to care givers in the long-term care industry. The epidemiology of pressure injuries varies by clinical setting. Every effort should be made to prevent a pressure injury from developing. Pressure injuries can interfere with the resident's function and recovery, especially if complicated by pain and/or infection. The presence of pressure injuries is used as a 'marker' of poor overall prognosis and can contribute to premature mortality in some residents. Further, the development of stage 3 and/or stage 4 pressure injuries is considered by the Joint Commission as a patient safety event . Multidisciplinary Concern: Many clinicians believe that pressure injury prevention is not only the responsibility of nursing, but also of the entire healthcare system. Therefore, prevention of pressure injuries requires multidisciplinary collaboration. Risk Factors: Not all risk factors are fully modifiable or can be completely addressed. Some risk factors such as permanent lack of sensation to an area may not be modified. Some potentially modifiable risk factors such as malnutrition or uncontrolled blood sugar levels may take some time to correct. Others such as 'pressure' can be modified promptly. Examples of identified risk factors for development of pressure ulcer/pressure injury include but are not limited to: .Under nutrition, malnutrition, and hydration deficits . The presence of a previously healed pressure ulcer/pressure injury. The history of an pressure ulcer/pressure injury, its origin, treatment, its stages (if known), is important assessment information since areas of healed stage 3 or stage 4 pressure ulcers/pressure injuries are more likely to have recurrent breakdown . Strategies for Pressure Injury Prevention based on NPIAP's (National Pressure Injury Advisory Panel's) 'Pressure Injury Prevention Points' . 3) Nutrition and Weight Loss and Hydration- residents who live in an institution are at risk for undernutrition. Adequate nutrition provides the body with vital energy and building blocks for all of the body's structures and processes. Any organ or body system may require additional energy or structural materials for repair or function. The skin is the body's largest organ. Skin may affect and may be affected by other body processes and organs. Skin condition affects overall body function therefore the presence of skin breakdown may be the most visible indication of a health issue . Residents who are receiving oral, enteral, and parenteral nutrition will need this intake evaluated regularly to ensure adequacy of nutritional needs being met. Supplemental nutrition will be recommended by the Registered Dietician will be presented timely to the physician to be addressed. Weight loss- significant, unintended weight loss may indicate under-nutrition or worsening health status. Weight stability (in the absence of fluid excess or loss) is a useful indicator of overall calorie balance. Severely impaired organs (heart, lungs, kidneys, liver, etc.) may not be able to utilize nutrients effectively. A resident with a pressure ulcer/pressure injury who continues to lose weight either needs additional caloric intake or correction (when possible) of conditions that are creating a hypermetabolic state .

Based on observation, interview, and record review, the facility failed to implement physician orders for dietary supplements to prevent further weight loss in a resident with significant weight loss. This failure resulted in R38 experiencing significant weight loss ( 7.87% weight loss in one month and10.72% weight loss in six months). This applies to 1 of 3 residents (R38) reviewed for nutrition in the sample of 25. The findings include: The EMR (Electronic Medical Record) showed R38 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia, bipolar disorder, deformity of the right and left hand, and intellectual disabilities. R38's MDS (Minimum Data Set) dated February 28, 2025, showed R38 had severe cognitive impairment and was dependent on facility staff for eating. The MDS showed R38 had a weight loss of 5% (percent) in the last month or loss of 10% or more in the last six months, not on a physician-prescribed weight-loss program. R38's Order Summary Report dated April 30, 2025, showed an order dated April 18, 2025, for [Frozen nutritional supplement] three times a day for dietary supplement. R38's diet order dated March 10, 2025, showed, Ice cream with meals. On April 29, 2025, at 12:36 PM, R38 was sitting in the dining room with a lunch tray of pureed food, chocolate pudding, and cranberry juice. On April 29, 2025, at 12:48 PM, V28 (LPN/Licensed Practical Nurse) was feeding R38 lunch. V28 said the pureed food, pudding, and cranberry juice was R38's complete lunch. R38's tray did not include a frozen nutritional supplement or ice cream. On April 30, 2025, at 9:26 AM, V25 (CNA/Certified Nursing Assistant) was feeding R38 breakfast. V25 said R38's breakfast was pureed food, sugar free pudding, and cranberry juice. V25 said R38 doesn't eat much at meals but will always eat her pudding. R38's meal ticket showed R38 was to receive whole milk and a frozen nutritional supplement. R38's tray did not include whole milk, a frozen nutritional supplement, or ice cream. On April 30, 2025, at 12:12 PM, R38 was in the dining room with V14 (POA/Power of Attorney). R38's tray was delivered and V5 (Food Service Manager) said R38's lunch tray was pureed rice, pureed chicken, pureed broccoli, and pudding. V5 said all residents on pureed diets get pudding for dessert. V5 said a frozen nutritional supplement is like ice cream. R38's meal ticket showed frozen nutritional supplement. R38's meal tray did not include a frozen nutritional supplement or ice cream. On April 30, 2025, at 9:48 AM, V5 said the facility has frozen nutritional supplements and nutritional shakes. V5 showed the frozen nutritional supplement in the facility's freezer in the kitchen. On March 19, 2025, R38 weighed 94 pounds. On April 22, 2025, R38 weighed 86.6 pounds which is a 7.87% (percent) weight loss in one month. On October 28, 2024, R38 weighed 97 pounds. On April 22, 2025, R38 weighed 86.6 pounds, which is a 10.72% weight loss in six months. On April 29, 2025, at 12:12 PM, V11 (Dietician) said R38 has experienced significant weight loss and interventions put in place to prevent further weight loss were adding supplements to R38's meals. A nutrition note dated February 27, 2025, at 11:01 AM, by V11 showed .Diet and supplements resumed. Calorie counts initiated. No reported edema. Resident is fed/assisted at meals with reported varied oral intake, 25-75% of meals. Supplements provides extra 750 calories per day. On mirtazapine since November 6, 2024, for appetite. Plan/Recommendations: Continue current interventions and nutritional management. Continue meal supplements- health shakes with meals of frozen nutritional treat, fortified oatmeal . On April 29, 2025, at 11:51 AM, V23 (Wound Nurse) said R38 has a facility acquired pressure ulcer which reopened this week. V23 said R38 has not been eating well which could be why her pressure ulcer reopened. On April 30, 2025, at 1:10 PM, V24 (R38's Physician) said his expectation would be for facility staff to give residents nutritional supplements as ordered by the provider. V24 said R38 not receiving her nutritional supplements as ordered could contribute to R38's ongoing weight loss. On April 30, 2025, at 1:38 PM, V2 (DON/Director of Nursing) said facility staff should be giving residents dietary supplements as ordered by the provider. V2 said frozen nutritional supplements come from the kitchen staff when meal trays are being assembled. V2 said R38 should be getting the frozen nutritional supplement especially since R38 likes sweets and will usually eat her sweets at meals. V2 said pudding is not the same as the frozen nutritional supplement because the frozen nutritional supplement is more nutritious. V2 said facility staff documentation showing R38 received a frozen nutritional supplement on April 29, 2025, at lunch and on April 30, 2025, at breakfast and lunch would be incorrect since the frozen nutritional supplement was not on R38's meal tray. R38's nutrition care plan dated February 4, 2025, showed, The resident may be at risk for weight loss related to: reduced ability to feed self, chewing problems, clinical diagnosis and/or expression of depression resulting in loss of appetite, poor ability to communicate, other: diagnoses of type 2 diabetes mellitus, acquired deformity both right and left hand, unspecified intellectual disabilities, anemia, disorder of adrenal gland, personal history malignant neoplasm of breast, vitamin D deficiency, gastroesophageal reflux disease, anxiety, bipolar, hyperlipidemia. Present weight 101 pounds: ideal body weight is 125 pounds, plus or minus 10% . The care plan continued to show multiple interventions dated February 4, 2025, including Provide dietary supplements, as ordered. The facility's policy titled SWAT (Skin Weight Assessment Team) Program dated October 9, 2023, showed Meeting Guidance: Purpose: To identify residents who are at nutritional risk for weight loss and or who are at risk for skin breakdown and the development of PU/PI (Pressure Ulcers/Pressure Injuries). Further, to address and monitor those residents who already have identified deficits with either weight loss and/or skin breakdown. Intent: It is the intent of the facility to assess the nutritional status as well as the skin condition status of each resident and to timely address any issues or any potential for issues related to weight and/or skin. The SWAT Team will monitor residents who meet the criteria (listed later) on a weekly basis to ensure that measures are in place to avoid weight loss in 'at risk' for weight loss residents; as well as to avoid skin breakdown in residents 'at risk' for skin breakdown based on their medical assessments and overall health status . The team will appropriately determine clinical and dietary interventions to best address each individual resident's needs based on observation, assessment, and review . Indications Determining Implementation of SWAT Monitoring: 5% or more (undesirable) weight change in 30 days, 10% or more (undesirable) weight change in 180 days, open area(s) Stage II or greater (upon discovery) . Procedure: . 5) Interventions decided upon by the team will be recorded on the individual resident monitoring record form. The appropriate disciplines will address interventions determined by the team and recorded on each resident's form(s). Interventions requiring a physician's order, will have that order obtained. Any new interventions will be added to the resident's care plan. CNA assignment information will be updated as indicated .

Based on interview and record review, the facility failed to safely transfer a resident utilizing a mechanical lift as per facility policy. This failure resulted in R1 experiencing pain and discomfort related to numerous facial fractures, a left periorbital hematoma, nondisplaced fracture of C2, left frontal subdural hematoma along the left frontal convexity, and hemorrhage within the bilateral maxillary and bilateral sphenoid sinus caused by the fall. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 6. The findings include: Face sheet, dated [DATE], shows R1's diagnoses included fall, fracture of facial bones, traumatic hemorrhage of cerebrum, dementia, and Alzheimer's disease. MDS (Minimum Data Set), dated [DATE], shows R1's cognition was severely impaired and R1 was dependent on staff for transfers. Review of R1's care plans showed R1 was at increased risk for falls related to cognitive impairments, decreased safety awareness, impulsiveness, decreased strength/endurance, use of anti-psychotropic medications, behavioral problems, and Alzheimer's. The care plan shows R1 was totally dependent on staff for transfers. Final Incident Report, dated [DATE], shows on [DATE] R1 was a hospice resident who fell from a mechanical lift during a transfer performed by V5 (Certified Nursing Assistant). The report shows R1 accidentally slid off the mechanical lift and fell on the floor. The report shows V5 attempted to stop the fall but also fell on the floor with the resident. When staff responded to the scene, they found both R1 and V5 were on the floor. The report shows R1 landed on the floor and sustained upper body injury. R1 was sent via 911 to the emergency department for evaluation and treatment. The investigation shows R1 sustained facial fractures, base dens fracture, nondisplaced fracture of C2, and a left frontal subdural hematoma resulting from the mechanical lift transfer performed by V5. The report shows R1 expired. Witness statement, dated [DATE], shows V5 stated, That day I dressed and gave [R1] AM care and during that time the hospice nurse [V4] was in the room. I proceeded to prepare [R1] to transfer in the reclining chair and at that time the nurse stepped out of the room. I had [R1] in the [mechanical lift] for transfer. She began to be spastic and leaned forward. When I noticed this, I immediately ran under the lift to catcher. I was unable to cradle her, and we both fell on the floor. We fell on the floor, and she was on top of me. I think she hit her left side on the floor. After this I screamed for help, and someone came in the room and staff came in and helped. Hospital CT (Computed Tomography) scans, dated [DATE], show R1 experienced the following as a result of her fall: 1. CT Maxillofacial: R1 had numerous fractures were noted throughout the facial bones. There was a mildly displaced fracture through the roof of sphenoid sinus, likely the source of patient's pneumocephalus. There was a fracture through the left superolateral orbital rim with mild comminution of the left lateral orbital wall and a nondisplaced fracture through the left medial orbital wall extending to the left frontal process of maxillary bone. There was a mildly displaced fracture through the lateral wall of the left maxillary sinus and a minimally displaced fracture of the right inferolateral maxillary sinus wall. R1 had a moderately displaced fracture of the left zygomatic arch and there was a nondisplaced fracture through the left maxillary floor. 2. CT cervical spine: R1 had a nondisplaced fracture of C2 at the junction of the odontoid peg and base. 3. CT Head: R1 had a left frontal subdural hematoma along left frontal convexity measuring up to 0.8 centimeters 4. CT Paranasal Sinus: R1 had a hemorrhage within the bilateral maxillary and bilateral sphenoid sinus. 5. CT Orbits: R1 had a left periorbital hematoma. On [DATE] at 3:16 PM, V10 (Physician) stated R1's injuries were the result of her fall and not a result of any other clinical conditions R1 was experiencing. On [DATE] at 10:13 AM, V2 (Director of Nursing) stated at the time of R1's fall, V5 decided to transfer R1 by herself utilizing a mechanical lift. V2 stated it was her expectation that facility residents have two staff assisting with all mechanical lift transfers. V2 stated when she entered the room at the time of the incident, R1 and V5 were on the floor and there were only three of the four slings attached to the mechanical lift. V2 stated it was possible that V5 did not attach the slings properly to the mechanical lift. V2 stated she inspected the mechanical lift and sling, and no concerns were identified. On [DATE] at 11:03 AM, V4 (Hospice Registered Nurse Case Manager) stated she initially left R1's room while V5 was performing care for R1. V4 stated she was seeing a different resident in the facility when R1 fell . V4 stated she was called to the room and saw R1 and V5 on the floor. V4 stated R1 was bleeding on her left eyebrow and from R1's nose and V4 attempted to control the bleeding. V4 stated V5 independently attempted to transfer R1 using a mechanical lift and R1 fell . V4 stated one of the four sling straps was hanging from the mechanical lift and the other three remained hooked on the lift. Witness statement, dated [DATE], shows V4 stated at the time of the incident V4 responded to R1's room, R1 and V5 were lying on the floor. R1 was bleeding from her eyebrow and nose, and only three of the four sling straps were attached to the mechanical lift next to R1's bed. On [DATE] at 12:01 PM, V3 (Hospice Clinical Supervisor) stated she interviewed V4 and V5 and determined V5 attempted to transfer R1 independently utilizing a mechanical lift and R1 fell . V3 stated it was her expectation that two staff be present when transferring residents utilizing mechanical lifts. On [DATE] at 8:19 AM, V8 (Licensed Practical Nurse) stated she was called to R1's room and saw R1 lying on the floor of her room and V5 sitting on the floor. V8 stated she examined R1's injuries and R1 was bleeding from an open laceration on her left eyebrow and R1's eyebrow bone was exposed. V8 stated R1 could not verbally express pain but was showing face grimacing. V8 stated she asked V5 what happened and V5 stated R1 fell when she slipped out of the mechanical lift sling. V8 stated V5 attempted to catch R1 but V5 also fell . Witness statement, dated [DATE], shows V8 stated she was called to R1's room, R1 and V5 were sitting on the floor, and V5 stated R1 slipped from the mechanical lift sling. V5 tried to catch R1, and R1 fell to the floor. The statement shows V8 stated one of the three straps was not attached to the mechanical lift at R1's bedside. Witness statement, dated [DATE], shows V6 (CNA) stated at the time of the incident he witnessed R1 and V5 on the floor, R1 was bleeding from her face, and one of the sling straps was hanging from the mechanical lift and three straps were still attached to the mechanical lift. The statement shows V6 asked V5 what happened and V5 responded that R1 fell . Progress note, dated [DATE], shows R1 returned from the hospital with multiple skin discolorations on her left orbital area with bandages to her left upper eyebrow. The progress note shows R1 vomited twice, and an antiemetic was provided. Hospice note, dated [DATE], shows V10 (Physician) approved continuous care for pain control, agitation, dyspnea, and nausea/vomiting after fall from [mechanical] lift and confirmed R1 had fractures to her face and a hematoma of her brain. Progress note, dated [DATE], shows R1 had bluish-purplish discoloration on her left and right periorbital areas with swelling and bandages to her left upper eyebrow. The progress note shows the hospice service increased the morphine provided to R1. Progress note, dated [DATE], shows R1 was unresponsive to verbal cues but responsive to tactile stimuli. Progress note, dated [DATE], shows R1's face was covered in bruises, was swollen, and was showing drainage. Progress note, dated [DATE], shows R1 expired. Mechanical Lift Transfer Policy and Procedure, revised [DATE], shows, Purpose: To assure that all residents that are assessed to require extensive assistance high (with minimal to no ability to bear weight of bilateral lower extremities) and/or total assistance in transfer are transferred safely with no injury to resident or care handler. The operating of the lift requires a minimum of two trained operators

Based on interview and record review the facility failed to use the proper equipment to transfer a resident resulting in a left femur fracture that required surgical repair. This applies to 1 of 2 (R7) residents reviewed for hospitalization s in a sample of 32. Findings include: R7 was originally admitted to the facility on [DATE]. R7 has diagnoses that includes diabetes, obesity, anxiety, major depressive disorder, weakness, Parkinson's disease. R7 has previous documented fractures bimalleolar (ankle) fracture of lower leg (9/22/20) and a nondisplaced fracture the fifth metatarsal (foot) bone (7/1/23). R7's MDS (Minimum Data Set) dated 2/12/24 shows she is cognitively intact with a BIMS (Brief interview for Mental Status) score of 15. R7 is dependent on staff assistance for toileting, transfers, and repositioning. R7's care plan dated 2/29/24 documents current transfer needs of total assistance of two staff using a patient lift due to due to a femur fracture. On 4/10/24 at 1:56 PM, R7 stated she broke her leg while staff were transferring her to bed. R7 stated staff were supposed to use the sit-to-stand to transfer her but used a gait belt. R7 stated they now must use a patient lift to transfer her. Review of nursing progress notes documents on 2/5/24 R7 was transferred to the hospital emergency department for further evaluation and treatment due to a left acute femoral neck fracture. On 4/11/24 at 11:58 AM, V19 LPN (Licensed Practical Nurse) stated she recalled when R7 suffered a femur break. V19 stated V21 CNA. (Certified Nursing Assistant) asked her to assist in transferring R7 back to bed. V19 stated a few hours later R7 complained of left hip pain. V19 stated they used a gait belt to transfer R7 back to bed. V19 stated she did not know R7 was supposed to use the sit to stand for transfers until after the occurrence. R7's physical therapy discharge summary dated 7/26/23 documents for safe transfer techniques using sit to stand up lift transfers and safety precautions in order to preserve current level of function. On 04/11/24 at 2:59 PM, V2 ADON (Assistant Director of Nursing) stated R7 was transferred using a stand and pivot to the bed. V2 stated, If staff are supposed to use the sit to stand to transfer it is a problem not using the correct transfer mode. If the pivot is too intense it could contribute to the break. Staff should be following the proper transfer to assure residents are not injured. The mode of transfer is in the EMR (Electronic Medical Record) for staff to reference. Staff should reference the transfer mode before transferring the resident. On 04/12/24 at 9:34 AM, V20 stated she ordered an Xray for R7 when a nurse called and stated R7 had complaints of pain. The Xray results showed R7 had a left femur fracture and was sent out to the hospital. R7's fracture resulted in her having a surgery to repair the fracture. V20 stated R7 has decreased bone density making her bones more fragile and prone to break. V20 stated it is important to handle residents with decreased bone density carefully because they are at risk for fractures. Transferring someone with decreased bone density incorrectly could contribute to a fracture. V21 CNA was not able to be reached for interview during this survey. The facility initial investigation report prepared by V19 dated 2/4/24 at 10:00 PM documents R7 was assisted back to by V19 and V21 using a turn and pivot at which point R7's leg twisted. R7 complained of pain immediately complained of left hip pain when she was assisted to lay down. Witness interviews from the facility investigation showed V21 CNA stated she and V19 LPN transferred R7 back to bed using a stand and pivot. During the transfer R7's leg twisted. R7 complained of pain when V21 lifted her leg to assisted her to lay down. On 2/9/24 the facility investigation documents R7 denied having had any falls. R7 stated the fracture occurred during transfer by staff. R7 stated she had pain when her left leg twisted during the transfer. R7's physical therapy evaluation and plan of treatment for aftercare following joint replacement surgery dated 2/9/24 new recommendation for transfers is now the use of a mechanical patient lift. The facility policy and procedure, Sit to Stand Lift, dated 10/10/11 states the purpose is to assure that all residents that are assessed to require extensive high assistance in transfer are transferred safely with no injury to resident or care handler.

Based on observation, interview, and record review, the facility failed to ensure physical abuse did not occur for a resident (R1) with a known history of physical aggression. This failure resulted in (R1) grabbing (R4) around the neck, throwing him to the ground, and R4 hitting his head on the floor. (R4) was transferred to a local hospital for evaluation of a head injury. This failure has the potential to affect all residents in the building as R1 is ambulatory throughout all units of facility and accesses the elevator independently. The findings include: The Immediate Jeopardy began on 12/30/23 when R1 grabbed R4 around the neck and threw R4 on the floor, resulting in R4 being sent to the hospital for evaluation of head injury. V1 (Administrator) was notified of the Immediate Jeopardy on 1/4/24 at 9:00AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/4/24, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The facility's resident roster dated 1/3/24 showed 132 residents currently residing in the building. R1's electronic face sheet printed on 1/4/24 showed R1 has diagnoses including but not limited to alcohol abuse, bipolar disorder, anxiety disorder, and schizoaffective disorder. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment, ambulates independently, and experiences verbal behaviors directed towards others that significantly disrupt care or living environment. R1's physician's orders for December 2023 showed R1 receives Quetiapine 400mg at bedtime for bipolar disorder. R1's physician's orders for December 2023 showed, 1:1 supervision until 12/2/23. R1's State Police background check dated 10/23/23 showed R1 has a history of aggravated battery in 2023. R1's nursing progress notes showed, 10/24/23 Yelling and screaming at staff and residents. Using foul language. Shouting loud in the hallway. 11/4/23 Resident at lunch time was yelling at staff, using foul language and racial slurs. This writer told resident to go to his room and relax, he refused at first and continued to yell at staff. After ten mins redirected resident to his room. Informed psych physician, he ordered one time dose of Haldol. Resident refused the one-time dose of Haldol. 11/30/23 Nurse Practitioner notified about resident behavior of agitation, verbal aggression, altered mental status, and appears to be intoxicated. With new orders to hold medications for the next 24 hours, alcohol/drug test, hold green pass and 1:1 supervision for the next 72 hour. Orders carried out. 11/30/23 This writer was informed that resident was verbally abusive/aggressive and agitated to staff member. This writer noted resident ambulating towards his room. Resident shows possible signs and symptoms of intoxication: slurred speech, abnormal gait, increased agitation/irritability and verbally abusive. Resident remained in his room afterwards. This writer was informed by other facility staff members that resident was observed carrying a bottle of alcohol that he disposed in a garbage bin outside the premises prior to coming inside the facility. Required assessment and education due to possible interaction with his medication and alcohol was refused by resident. Resident immediately became aggressive. Resident started speaking profane language to this writer, got up from his bed and stated, Do you want me to get you out of this room? as resident started approaching this writer. Boundary was set and resident was reminded of possible consequences of threatening and assault. 911 was called in regard to resident's increasing aggressive behavior and agitation. Nurse Practitioner aware of above. New orders were received. Resident was informed regarding orders to hold his medication for 24 hours, to hold green pass privilege, and alcohol testing. Resident then immediately got extremely upset and agitated, yelling and cussing at this writer stating I don't give a f***. I am not a drug addict! I am gonna do whatever I wanna do. Get the f*** out of here! This writer thanked resident for his time and exited his room. 12/30/23 This resident (R1) came to the nurse's station talking loud to this writer. When another resident told him to 'Stop it, what are you doing?', resident (R1) got upset, went to another resident (R4) who was sitting on the chair, grabbed his neck and threw him to the ground hitting the back of his (R4) head on the floor. Writer intervened, stopped the fight & separated the 2 residents (R1 and R4). Physician ordered to send resident (R4) out to hospital. Police came & took resident (R1) to hospital. After a few hours resident (R1) was brought back to the facility escorted by police officer, per police officer resident (R1) refused to be hospitalized & refused to be moved to another room. (No further progress notes were entered into R1's records until after surveyor entered facility on 1/3/24). R1's psychiatric progress note dated 10/29/23 showed, Patient is alert to self, person, time, place and situation. Behavior Manifestations: agitated, demanding, alcohol abuse, verbally aggressive. Patient is easily distracted and has flight of ideas. Patient is depressed. anxious, and angry/hostile .Patient has a diagnosis of Bipolar Disorder, Schizoaffective Disorder, alcohol abuse, and anxiety disorder, patient is verbally aggressive toward staff members, calls them names and will swear at them, when trying to meet with patient he stated get the F out of here, he does not need to be seen and was stating that the staff at facility all are horrible and that I should not listen to them. When trying to redirect patient he slammed the door in my face laughing .staff continue to monitor for any changes in behaviors/moods, staff to call psych physician if behaviors increase. On 1/3/24 at 9:34AM, R1 stated, I remember the incident with (R4). A few days before the incident he elbowed me and charged at me, but nobody saw it. On Saturday (12/30/23), he (R4) came at me again and I put him in a headlock and threw him to the ground. The cops came and we shook hands and now we are good. There's nothing else to say about it. That's all that happened, and I feel bad about it but it is what it is. R1's behavior monitoring for December 2023 showed R1 experienced behaviors throughout all 3 shifts on 12 different occasions during the entire month. R1 has no behaviors documented on his behavior monitoring for 12/30/23. On 1/3/23 at 9:46AM, R2 stated, (R1) is very nasty to the staff here. I hear him yelling and threatening people all the time. I heard what happened with him and (R4) and it doesn't surprise me. That guy is a loose cannon, and we can all see that. It's just a matter of time before he does something worse. On 1/3/24 at 9:55AM, R4 stated, I had to move rooms because they told me I had to. That big guy knocked me out and took me to the ground. My body still hurts, and I had to go to the hospital because of what he did to me. I had a collar around my neck at the hospital and could barely breathe. The whole event was so uncomfortable, and I hope I never have to go through anything like that again. (R4 has no cognitive impairment) R4's local hospital records dated 12/30/23 showed, Diagnosis: Minor head injury. On 1/3/24 at 11:04AM, V5 (Social services director) stated, I have known (R1) for years from a different facility. He can get very loud and verbal, but he can also be a nice guy. I have talked to him about counseling, and he initially declined but now he signed a behavioral contract today (1/3/24) stating that he will get counseling. He does always apologize after altercations because he knows exactly what he is doing. Usually after an altercation the staff will do 1:1 with him and then eventually he comes off of it. We always restart it after any altercations though. We did assign him a roommate yesterday because he seems to be okay with it. I guess we will see how it goes. I heard (R1) and (R4) had words prior to this most recent altercation but I don't think any new interventions were put in place. On 1/3/23 at 9:45AM, R5 stated, I had a verbal altercation with (R1) before during smoking time outside recently. We argued back and forth until it ended in both of us yelling obscenities at one another. No physical confrontations were made. I was told about the incident between (R1) and (R4) and heard (R1) was escorted out by police in handcuffs. I just avoid (R1). I don't feel like staff seem to be doing much since (R1) has been verbally abusing staff and residents since he got here a few months ago. (R5 has no cognitive impairment) On 1/3/23 at 10:20AM, R6 stated, I believe the cops have been called upwards of 7 total times on (R1) since his admission. I do not feel safe in the facility with (R1) here and would feel safer if he were not in the facility. (R6 has no cognitive impairment) On 1/3/23 at 10:20AM, R7 stated, (R6) and I have known (R1) for about 5 years from another facility. (R1) was the same way then as he is now. He was always getting into verbal and/or physical altercations. I heard from staff that on 12/30 (R1) had choked a guy out and the guy got sent to the hospital and (R1) got arrested but he was brought back to the facility shortly after .(R1) is always making comments to (R6) and others in the facility. When staff witness it, they do break things up and prevent it from escalating further. I know that sometimes they put (R1) on a 1:1 where a staff member is put outside his door to make sure he doesn't cause any issues. (R1) frequently comes down to the first floor to go out the front entrance and smoke. I do not feel safe in the facility with (R1) still present and would definitely feel safer if he was not here. (R7 has no cognitive impairment) On 1/3/24 at 11:00AM, R8 stated, I do not feel safe in the facility; not just because of (R1) but he is a big factor in it. (R8 has no cognitive impairment) On 1/4/24 at 9:24AM, V6 (Registered Nurse) stated, (R1) is pleasant as long as he gets what he wants. When you start to push him to try to convince him to do something that's when he gets verbally aggressive. A month or so ago, I tried to send him out because he came back to the facility appearing intoxicated and he wouldn't go to the hospital. He stood up and started to come towards me, so we called the cops. The cops couldn't do anything because he refused to leave and hadn't hurt anyone. (R1) apologized to me the next day and he knows exactly what he's doing when he has these behaviors. From the first day he came here the staff have all felt he shouldn't be here. He is a loose cannon for lack of a better word. He is verbally abusive to staff all the time. One day he's fine with you and the next day he is cussing you out. We have a resident on this unit that yells a lot and (R1) yells at him to shut up. He completely disregards his pass privileges and does what he wants. One time he had a green pass and we saw him throw an empty liquor bottle in the trash outside and the previous administrator did nothing. I then went and told (R1) he was on a red pass, and he told me to F off and left the building. I told administration not to accept him to our facility because I know of him, and they took him anyway. (R1) was given a green pass before he even got admitted into the building and we could assess him. I worry about the other resident's safety every day. (R1) can flip so easily that it's hard to know when something will happen. He does not need the services of a nursing home. All we do is feed him and give him medications. Every time he comes off of 1:1 and gets his pass back he does the same outbursts. I'm afraid he might really hurt someone. We didn't do anything differently with (R1) after this most recent altercation that I am aware of. They just put him on 1:1 yesterday. On 1/4/24 at 9:41AM, R1 stated, I hope I'm not in trouble. Sometimes I get in trouble when I drink, and I feel bad about that. I don't mean to hurt anyone. I know what I'm doing is bad and I'm sorry and won't do it anymore. On 1/4/24 at 10:11AM, V1 (Administrator) and R1 were interviewed. V1 said he gave R1 a 30-day involuntary discharge notice. V1 stated, Even with a red pass, we are unable to ensure other residents are safe in the building with (R1) here. On 12/9/23, (R1) had a red pass and left anyway and went and bought liquor. (R1) was arrested on 12/30/23 but the cops just took him to the police station until he calmed down and then brought him back because he refused to go to the hospital. (R4's) family is not pressing charges against (R1). We thought we were doing everything right and keeping other residents safe, but it appears we are not able to ensure everyone's safety even when (R1) has a red pass. R1 stated, I went and bought the alcohol and hid some in my room. I was intoxicated on 12/30/23 when the incident happened with (R4). I haven't been telling the whole truth and I'm sorry about that. On 1/4/24 at 1:05PM, V9 (Certified Nursing Assistant) stated, I was working the day the altercation occurred. When I was leaving the unit, (R1) was arguing with the nurse and I was leaving to get ice and then I looked back and saw (R1) grab (R4's) neck and throw him on the floor. I ran to them and asked (R1) what happened, and he backed away and kept saying nothing happened. (R4) kept saying the back of his head was hurting so he got sent to the emergency room . The police arrived and were making sure they were separated. They asked (R1) what happened, and he kept saying nothing happened. The police took him and then brought him back awhile later. When (R1) came back to the facility he was taunting all of the staff like he was trying to get us to do something to him. We didn't have to do any extra checks or anything, but he kept trying to get a reaction out of all of us. I feel he is a major safety risk to the residents and even the staff. He has had a lot of verbal behaviors and tries to intimidate other residents by yelling at them. He acts like he owns the place. All I can say is he is in the wrong facility. He shouldn't be here. The facility's policy titled, Abuse Prevention Program dated 3/1/21 showed, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility . The facility's policy undated titled, Outside Community Pass Privileges Policy showed, Many individuals admitted to the facility have a medical need requiring clinical supervision, a history of chemical addiction or other psychiatric problems. Because of a combination of mental health, physical problems and behavior that can result in harm, certain residents may not be appropriate for independent pass privilege .Furthermore, the resident is acknowledging that he/she will follow all physician orders, will contact the facility if any change occurs in their physical or mental condition and the individual agrees to follow the treatment recommendations and plan of care formulated by the facility .1. Newly admitted residents will be placed on a 14-day observation period for proper monitoring of medical needs .b. once the resident is assessed, he/she will be placed on a pass status: GREEN PASS- resident who may go out in the community independently and return within curfew hours .RED PASS- residents who have violated facility policy or a resident who cannot go out in the community independently due to cognitive inabilities, degree and severity of mental illness, addiction history and present addictive behaviors .ability to follow rules and procedures .14. Pass Revocation. a. first offense- outside pass privileges will be suspended for a 2-week period with a behavioral monitoring tool .if a resident is able to follow facility policy and procedures during their restriction period, they will be able to obtain green pass status after their 2-week period is completed. Appropriate intervention will be implemented .b. second offense- outside pass privileges will be suspended for a 30-day period with a behavioral monitoring tool. A behavioral contract will be formulated for the resident and will be presented to the resident and Responsible Party outlining specific areas where the resident needs to comply with facility policy. R1 was given his green pass prior to being assessed upon admission. R1's green pass was only revoked for 72 hours instead of 2 weeks on 11/30/23 after showing signs of intoxication and refusing an alcohol test. R1 was able to leave the facility independently on 12/9/23 to obtain alcohol. The Immediate Jeopardy that began on 12/30/23 was removed on 1/4/24 when the facility took the following actions to remove the immediacy. ABATEMENT PLAN January 4, 2024 R1 Resident will be on 1:1 direct supervision until he is discharged from the facility. 1:1 supervision initiated 1/3/24. Resident issued an involuntary discharge on 1/4/24 due to the risk of compromised safety of others at the facility. At this time of this report, R1 is in agreement to move and is not planning to appeal the notice. Care plan revised on 1/4/24 to include wellness visits three times per week by social services or nursing staff until discharge. Also, to be included in care plan, monitoring of any trigger behavior for R1 such as non-compliance, disruptive verbalization/noise, inappropriate verbalization, inappropriate gestures, agitation, emotional dysregulation, aggression, intoxication. Resident residing in private room, as of 1/3/24. Resident will be encouraged to meet with counselor weekly. Resident seen on 1/3/24. Resident assessed by nurse practitioner and psychiatrist on 1/4/23. Both are in agreement with the interventions and plan. R4 Was relocated to a separate floor on 12/30/23. Care plan revised 1/4/24 to include wellness visits, 3 times per week, from nursing or social services staff. Also, to be included, monitoring of any aggressive behavior. R6, R7, and R8 Discussed safety strategies the facility has implemented to ensure safety of residents. Wellbeing check will continue 3 times per week until R1 is discharged . Wellbeing check How other residents of the facility were identified to potentially be affected. Guardian angel rounds were completed for all residents, assessing feelings of safety and identifying signs and symptoms of abuse. Guardian Angel Rounds forms updated to include questions to prompt these responses. Residents identified as risk during these rounds will be supported by well-being checks, social service designee and nursing. Residents identified as having a history of aggression have had care plans reviewed and updated as necessary. Training On 1/4/24 the facility Administrator initiated education for all staff of the abuse policy and procedure. On 1/4/24, the facility Administrator initiated training for all staff on identifying triggering behaviors for any resident. On 1/4/24, the nurse consultant provided a training on the Facility Community Pass Privileges Policy to all department heads. The Administrator initiated training for all staff on the Facility Community Pass Privileges. Education will be completed on 1/5/24. New employees will be educated on the Abuse Policy and Procedure and identifying triggering behaviors during orientation prior to working on the floor. In case staffing agency is use, they will also be educated prior to their work shift. QAA/QAPI Upon notification of alleged verbally or physical aggression, the social service director or designee, will ensure an intervention is implemented. Upon any new admission or readmission with a history of physical aggression will be assessed and care plan updated by the social service director or designee. Beginning 1/4/24 audit tools will be reviewed 3 times a week for 2 weeks, then, beginning 1/18/24 for 2 times a week for 2 weeks, and then weekly, for 2 weeks, culminating on 2/1/24. QAPI committee which meets monthly will review for compliance and determine that compliance has been meet. An emergency QAPI was held on 1/4/24 and attended by medical director and Interdisciplinary team. On 1/4/24, a review of the facility's in-service documentation showed 54% of the facility's staff members were educated regarding the facility's abuse policy, out on pass policy, and behavior management. The remainder of staff and any new agency staff will be educated prior to the start of their next shift. Interviews with staff working on 1/4/24 showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan.

Based on observation, interview and record review, the facility failed to ensure a resident, R1 was free from physical abuse from another resident, R11. The facility failed to implement interventions to keep R1 free from further abuse by R11 and the facility failed to implement a treatment plan to keep other residents safe from R11's behaviors. This applies to one (R1) of seven residents reviewed for physical abuse in a sample of 16. This failure has the potential to affect the other 24 residents residing in this unit with R11. This unit is the facility's Dementia Unit cares for residents at risk for abuse related to their cognitive impairment and inability to verbalize needs. The Immediate Jeopardy began on July 14, 2023, at 7:00 A.M. when R1 reported she was physically attacked by R11 on 7/14/2023. V1(Administrator) failed to implement the facility's abuse policy and procedure and take measures. V1 (Administrator), V2 (Director of Nursing-DON), V 15 (Corporate Nurse Consultant) and V24 (Regional Chief Operating Officer) were notified of the Immediate Jeopardy on August 9, 2023, at 10:50 A.M. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed on August 11, 2023, at 11:30 A.M., but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EMR (Electronic Medical Record) showed R1's original admission to the facility was on 5/3/2018. R1 was readmitted on [DATE]. R1 was discharged home on 7/26/2023 because R1's family refused for R1 to return to the facility. R1, an [AGE] year-old and with multiple diagnoses including Parkinson's Disease, neurological deficits, repeated falls, difficulty in walking, muscle weakness, unsteadiness of feet, hypothyroidism, major depression, vitamin D deficiency, GERD (gastro-esophageal reflux disease) and displaced fracture of lateral end of the left clavicle. The EMR shows R1, while at the facility was in in the designated dementia unit. R1 was transferred to new room at 12:00PM 7/14/2023. R1's new room was located across the hallway from her previous room. Then, on 7/23/2023, (9 days after the reported physical attack from R11), R1 was moved to the first floor. R1 had verbalized to V9 (Social Service Director) she was afraid in the dementia unit where R11 resides. The MDS (Minimum Data Set) assessment dated [DATE], showed R1 required extensive assistance from staff for toilet use, transfers, ambulation inside/outside of her room, personal hygiene, eating, dressing, and bed mobility. R1's primary mode of locomotion was a wheelchair. The MDS shows R1 was assessed with having trouble in falling asleep, trouble concentrating on things, and she moves and speaks so slow it is noticeable to others. R1 was assessed with no negative behavior. The progress notes show R1 was alert, oriented and verbally responsive. R1 was noted with forgetfulness at times and periods of being impulsive and attempting to stand without asking for assistance. The facility provided Spanish speaking staff to educate R1 on asking for assistance in standing and mobility. On 8/7/2023 at 11:13 A.M. V3 (ADON/Assistant Director of Nursing) said that on 7/14/2023, around 7:30 A.M., V5(RN/Registered Nurse) informed her R1 said she was attacked in the shared bathroom. This bathroom was used by both R1 and R11. V3 said after the daily meeting with the department managers including V1 (Administrator), V4 stated she informed team of R1's allegation of being physically attacked. V3 said she was told to just transfer R1 to the adjacent room. V3 said there was no abuse investigation started regarding R1's allegation of being physically attacked. On 8/7/2023 at 12:15 P.M., V5 (Registered Nurse/RN) said his regular assignment is in the dementia unit as a full-time day nurse. V5 said he knows his residents well including R1 and R11. V5 said R1 had a ritual of getting up from bed or wheelchair in her room and goes by herself to the bathroom shared with (R11). V5 added R1 and R11 share the same bathroom. V5 said R1 was slow and would spend 25 to 30 minutes in the bathroom. V5 said R11 was demanding, very inpatient, easily frustrated, and angry. V5 added R11 is very territorial of the shared bathroom and her room. According to V5, R11 would get mad and yell at R1 for using the shared bathroom. V5 stated R11 would become angry and frustrated with R1 since R1 moved slow and spoke Spanish and little English. V5 said on that 7/14/2023 at 7:00 A.M., R1 was sitting in her wheelchair in the dining room. V5 said it was the night shift staff that gets R1 up for breakfast. V5 said when R1 saw him, R1 started to wave her hand for V5 to come to her. As V5 approached R1, V5 said R1 told him, I was pushed, kicked, and attacked by (R11) in the bathroom early this morning. (R11) attacked me for using the bathroom. V5 added though R1 speaks mostly Spanish, R1 speaks minimal English and with sign gestures, R1 was able to communicate. V5 said R1 was alert and knew what had happened. V5 said she immediately informed V3 (Assistant Director of Nursing) of the allegation of physical abuse V5 reported and stated a physical assessment was not completed on R1. V5 said during the time R1 was talking to him regarding being attacked by R11, V6 (CNA/Certified Nurse Assistant/Spanish speaking staff) came and heard what R1 reported to V5. V5 said, (R1) was very lucky she got away from (R11). (R11) was very inpatient, doesn't want others using the shared bathroom, pushes and yells and she will not wait for (R1) to be done using the bathroom. Maybe next time, (R1) won't be lucky to get away from her (R11). (R1) was a very frail, tiny, shy lady and (R11) was a large built, intimidating and a bully. V5 said around noon on 7/14/2023, he was told by V3 to move R1 to another room, which was just across the hall. V5 confirmed there were no in-services, no investigations done regarding the incident between R1 and R11. V5 said he was only asked about R1's unexplained bruise when there was a state surveyor in the facility on 7/24/2023. V5 said there was no special plan of care regarding monitoring of R1 and R11 after the incident. V5 added R11 acts out without provocation and is ambulatory and freely roams around the Dementia Unit. V5 said 27 residents on the unit are severely cognitively impaired and cannot verbalized their needs and are at risk for abuse from three residents (R11, R14 and R15) with psychiatric illnesses V5 stated the other residents are frail and have severely impaired cognition and are at risk for abuse. On 8/7/2023 at 12:52 P.M., V6 (CNA) said he speaks Spanish fluently. V6 said he is regularly scheduled in the dementia unit for the day shift. V6 said he came to V5 and R1 on 7/14/2023 around 7:00 A.M. when R1 told V5 she was being attacked, pushed, and kicked by R11 in the shared bathroom during the early morning hours of 7/14/2023. V6 added he was not interviewed about the incident between R1 and R11 nor was he provided any training after the incident. Both V5 and V6 said R1 was reliable with her statement. While R1 was informing them what R11 did to her, R1 had pointed R11's permanent seat assignment in the dining room. V5 and V6 said R1, The woman who always seat at the end of this table was the one who had hit me this morning. V5 and V6 had confirmed the woman R1 was referring to was R11. On 8/7/2023 at 1:34 P.M., V4 (Dementia Coordinator) said she was not aware of the physical altercations between R1 and R11. V4 added the facility initiated an investigation after notified by R1's family of the bruises noted on home visit 7/18/2023. V4 said R1's family took R1 home and found large bruises on R1's left shoulder, arm, forearm and R1 had difficulty raising her left arm. V4 said R1's family had called and reported to her about this unexplained injury/bruises on 7/18/2023 at 5:30 P.M. R1's family asked, What happened to my mom? Why does she have big bruises on the left shoulder, left upper back shoulder, upper arm, left forearm and left side of her face (cheekbone)? V4 said she immediately called V3, and they started an investigation regarding the unexplained bruises. V4 confirmed she was not aware of R1's allegation from 7/14/2023 and was unaware of any investigation. V4 confirmed R11's behaviors of being impatient, angry, and territorial which leads to anger towards other residents. V4 added R11 is very controlling about the shared bathroom. V4 said R1's family had sent pictures of R1 when she was informed on 7/18/2023. V4 said R1's pictures showed huge yellowish-greenish bruises surrounding the left upper side of her body including shoulder, arm, and face. V4 said there was no special monitoring regarding R11's behavior after the incident. On 8/7/2023 at 1:08PM, V9 (Social Service Director) stated she did wellness checks on R1 after the family complaint of bruising. According to V9, R1 was still complaining of pain. On 8/7/2023 at 3:54 P.M., V17 (LPN, worked on 7/15/2023 for day and evening shift and on 7/16/2023 for the evening shift) said no report was given to him regarding the physical attack by R11 on R1, only the bruises when it was discovered by family on 7/18/2023. V17 said he was not asked for an investigation regarding these incidents. V17 said on 7/25/2023, sometime in the afternoon, he was asked to call for ambulance for (R11) to be taken to the hospital for evaluation. V17 stated he was not given a report on R11, just told to call for medical transport. According to V17 the ER (emergency room ) nurse called about R11's behavior and R11 mentioned killing but the hospital was unsure if R11 meant herself or another person. R11 was transferred to a psychiatric hospital. There were no in-services received regarding this, no special monitoring for R11, just to check for side effects for the psychotropic medications given. V17 said R11 is always demanding and when staff does not give at once what she wanted, R11 will get angry and yell. V18 (LPN-Nurse), V19 (Nurse Aide), V20 (RN-Nurse) and V21 (LPN-Nurse) all work the Dementia Unit and were all interviewed about the incident between R1 and R11. V18, V19, V20 and V21 all stated they were not interviewed about the reported abuse between R1 and R11 and none of the staff was aware of R1's allegation. Staff was unaware of any behavior monitoring of or interventions for R11. On 8/7/2023 at 4:33 P.M., V22 (CNA, worked on 7/18/2023 for day shift) said after lunch that day when she was getting R1 ready for a family visit, she noted a large bruise on R1's left shoulder, armpit, back and chest area. V22 stated the color was somewhat greenish yellow, like a fading bruise and R1 could not raise her arm. V22 stated she reported this to (V23, LPN). V14 (LPN, worked 7/19/2023 evening shift) was interviewed on 8/7/2023 at 4:50PM and stated that on 7/19/2023 at 7:45 PM, R1 returned to the facility with her daughter. V14 said R1's family was very upset about what happened to R1. The family wanted to know what caused the large bruises on R1. V14 said she notified (V8, ANP-Nurse Practitioner) and an x-ray of the left shoulder was done. V14 said the result was an acute fracture of the left clavicle. On 8/7/2023 at 3:31 P.M., V1 (Administrator) said the physical abuse on 7/14/2023 was not investigated. V1 added, I heard something happened in the bathroom of (R1 and R11) but I did not think much about it, did not follow up on it, nor investigation was done. I should have investigated it, so I would have known the cause and to monitor (R1's) injury and (R11) monitoring for potentially taking advantage of other residents. The facility submitted an initial incident report to the department 7/18/2023 with a final report dated 7/20/2023. The report does not include R1's allegation of R11's physical abuse. The facility concluded, the injury to the right clavicle was self-inflicted. R1's injury was to the left clavicle. The facility did not submit any investigation regarding R1's allegation of abuse by R11 nor was this information included in the incident report of 7/10/2023. On 8/7/2023 at 4:54 P.M., V8 (ANP-Advanced Practice Nurse) said she was informed on 7/19/2023 R1 had large bruises greenish yellowish in color around left armpit, left shoulder, arm and forearm. V8 said she had ordered an X-ray and the result was an acute fracture of the left clavicle. V8 said she examines R1 one to two times a week. V8 added R1, basically speaks Spanish but was able to verbalize her needs. Although R1 was forgetful, R1 was reliable with her statement. V8 said based on (R1's) injuries she sustained on the left side of her body, (R1) was correct when she said she was pushed by (R11) since (R11) was on R1's right side. V8 said, You do not pull somebody toward you if you are upset, you push them away from you, this makes more sense that (R1) was pushed from her right side and landed on her left side, and it showed from her sustained injuries. V8 said the fracture was caused from a trauma, was not pathological and just did not happen on its own. On 8/7/2023 at 10:30 A.M. together with V2 (Director of Nursing), V3 (Assistant Director of Nursing), V4 (Dementia Care Coordinator), and V5 (RN-Nurse), the shared bathroom was noted with a handwashing porcelain sink next to the toilet. R1 was pushed from the right onto the sink which injured her left clavicle. R1 reported she was pushed in the bathroom on 7/14/2023 causing the injuries to the left side of the body. During this observation, R11 came rushing to her room and immediately went to the bathroom. R11 immediately closed bathroom door on R1's side, and then quickly closed and slammed bathroom door from her (R11's) side of her room. R11 did this very quickly as to be protecting her territory before the surveyor was able to get out of the bathroom. R11 said, I need my privacy. The distance from R11's bathroom door to the toilet seat was 22 inches. It was observed R11's roommate bed was empty. V4, and V5 said R13 was R11's roommate. V4 and V5 said R13 stays in the dining room all day, so it does not bother R11. R13 was observed sitting in her wheelchair in the dining room. R13 was leaning on the table, and she was asleep. Meantime, R12 was observed in bed, and said I do not use the bathroom anyway, they just change my diaper. The EMR shows R11 a [AGE] year-old female with diagnoses of schizophrenia, heart failure, unspecified dementia with unspecified severity, paranoid schizophrenia, pseudobulbar affect, other psychotic disorder, and paranoid schizophrenia. R11 was admitted originally admitted to the facility on [DATE]. The care plan dated 8/17/2023 shows a history of maladaptive behavioral symptoms related to diagnosis of chronic mental illness, depressive disorder, and agitation. The 9/12/2022 care plan history shows R11 still expresses maladaptive behavioral symptoms related to diagnosis of chronic mental illness, a depressive disorder, agitated, and has been using unfriendly language to her other peers. R11 exhibits verbally abusive behavior when agitated. R11 will be verbally abusive, yell at others, make threats, swear, and make demeaning statements. In addition, R11 can become frustrated when others interfere with her daily routine. The care plan shows no specific interventions or plan of care to monitor and prevent aggressive behavior. On 8/8/2023 at from 3:10 P.M. through 3:20 P.M., R11 was observed sitting in a regular chair in the dining room. There was a Bingo activity going on. V25 (Activity Aide) left the residents unsupervised including R11, who was seated elbow to elbow with another residents. V25 said no one told her of any monitoring regarding R11. V25 was not aware of the physical abuse occurred 7/14/2023. During this time, V22, V17 and V5 said R13 was only moved to another room today (8/8/23) in the morning. R11's door was closed at this time. The facility's abuse policy dated 2/11/2011 shows: It is the policy of this facility to prevent resident from abuse, neglect, mistreatment, and misappropriation of property. The policy shows when an employee or agent becomes aware of abuse or neglect, the abuse policy and procedure should be implemented immediately. The policy shows for the protection of other residents, if the perpetuator is a resident, then this resident should be evaluated immediately to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. The policy shows any incident or allegation involving abuse or mistreatment will result in abuse investigation. The Immediate Jeopardy began on July 14,2023, was removed on August 11,2023, when the facility took the following actions to remove the immediacy. -R1 was discharged home on 7/26/2023 with family. -R11 was sent to the hospital on 7/25/2023, returned to the facility on [DATE] was placed in a private room and was monitored each shift by nursing staff for any signs of aggressive behavior for 72 hours and was discontinued because resident did not display any aggressive behaviors. -R11 was relocated outside the dementia unit with alert residents and provided 1:1 monitoring by C.N.A or facility staff on 8/10/2023. Staff assigned will be educated to monitor any signs and symptoms of aggression and intervention to prevent any further aggression towards other residents and to report immediately supervisor. Resident will continue 1:1 monitoring until no behavior of aggression towards others were noted. -R11's behavior monitoring form was revised by the facility on 8/11/2023 as the behavior form used on 8/10/2023 did not include the behavior observed rather it asked where R11's location was. -R11's care plan was revised 8/10/2023 to include wellness visits, 5 times per week, from nursing or social services staff. Also, to be included, monitoring of any aggressive behavior. -V1 was terminated by the governing body and no longer is employed by the facility. -The facility's interim Administrator received education on the abuse policy and procedure on 7/19/2023 by RNC. -Physical, clinical (limited ROM, pain, skin alteration such as skin tear, bruises, redness) and mental (change in mood, fearfulness, withdrawal, isolation) assessment were conducted for all residents on the memory care unit initiated at 8/9/2023 with no further observations noted related to abuse. -The facility Administrator initiated staff education of the abuse policy and procedure on 7/19/2023. -On 8/9/2023, the Administrator educated the IDT (Interdisciplinary Team) on the abuse policy and procedure, to ensure a resident is free from physical abuse from another resident, implement interventions to keep free from further abuse and implement a treatment plan to keep other residents safe. -On 8/9/2023, all staff currently work at the building were educated with a follow up test by the Administrator, Director of Nursing, Assistant Director of Nursing, and the IDT on following: 1. Abuse Policy 2. Abuse reporting, Abuse Prevention 3. Thoroughly investigate alleged abuse 4. Prevent further abuse or mistreatment from occurring. 5. Implement training after an allegation of physical abuse. 6. Place intervention in place to prevent additional abuse from happening related to a reported physical abuse. 7. Any alleged, witnessed, and suspected abuse, a. Intervene, stop separate alleged perpetrator, place on additional monitoring or one to one. b. Notify your immediate supervisor. c. Report to your Administrator (Abuse Coordinator) and Director of Nursing immediately. d. Follow directive of Administrator or DON e. Complete a skin check and head to toe assessment, screen for any injuries. f. Complete an incident report. -Acting Administrator was educated on 8/10/23 about facility's abuse policy and procedure. Education will be completed on 8/11/2023. -New employees will be educated on the Abuse Policy and Procedure during orientation prior to going on the floor. In case staffing agency is use, they will also be educated prior to going on the floor. New resident coming into the facility will be reviewed by Social Service for any history of aggressive behaviors and will be seen by Psych services and interventions will be in place to address and monitor behaviors. QAA/QAPI Upon notification of alleged physical abuse, the Administrator or designee, will ensure an allegation of physical abuse is fully investigated, staff are educated on the abuse policy and action is taken to prevent additional abuse. Beginning 8/10/23 audit tools will be reviewed 3 times a week for 2 weeks, then, beginning 8/25/23 for 2 times a week for 2 weeks for 3 months culminating on 9/25/23. QAPI committee which meets monthly will review for compliance and determine that compliance has been meet. An emergency QAPI was held on 8/9/23 and attended by medical director and Interdisciplinary team. -The facility submitted forms labeled as exhibits that shows its current implementation and monitoring for abatement plan.

Based on observation, interview and record review, the facility failed to investigate alleged physical abuse to prevent further abuse or mistreatment from occurring. The facility failed to validate physical abuse and implement training after an allegation of physical abuse. The facility failed to take action to prevent additional abuse from happening related to a reported physical abuse between R1 and R11. This applies to one (R1) of seven residents reviewed for physical abuse in a sample of 16. This failure has the potential to affect the other 24 residents residing in this unit with R11. This unit is the facility's Dementia Unit cares for residents at risk for abuse related to their cognitive impairment and inability to verbalize needs. The Immediate Jeopardy began on July 14, 2023, at 7:00 A.M. when R1 reported she was physically attacked by R11 on 7/14/2023. V1(Administrator) failed to implement the facility's abuse policy and procedure and take measures. V1 (Administrator), V2 (Director of Nursing-DON), V 15 (Corporate Nurse Consultant) and V24 (Regional Chief Operating Officer) were notified of the Immediate Jeopardy on August 9, 2023, at 10:50 A.M. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed on August 11, 2023, at 11:30 A.M., but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EMR (Electronic Medical Record) showed R1's original admission to the facility was on 5/3/2018. R1 was readmitted on [DATE]. R1 was discharged home on 7/26/2023 because R1's family refused for R1 to return to the facility. R1, an [AGE] year-old and with multiple diagnoses including Parkinson's Disease, neurological deficits, repeated falls, difficulty in walking, muscle weakness, unsteadiness of feet, hypothyroidism, major depression, vitamin D deficiency, GERD (gastro-esophageal reflux disease) and displaced fracture of lateral end of the left clavicle. The EMR shows R1, while at the facility was in in the designated dementia unit. R1 was transferred to new room at 12:00PM 7/14/2023. R1's new room was located across the hallway from her previous room. Then, on 7/23/2023, (9 days after the reported physical attack from R11), R1 was moved to the first floor. R1 had verbalized to V9 (Social Service Director) she was afraid in the dementia unit where R11 resides. The MDS (Minimum Data Set) assessment dated [DATE], showed R1 required extensive assistance from staff for toilet use, transfers, ambulation inside/outside of her room, personal hygiene, eating, dressing, and bed mobility. R1's primary mode of locomotion was a wheelchair. The MDS shows R1 was assessed with having trouble in falling asleep, trouble concentrating on things, and she moves and speaks so slow it is noticeable to others. R1 was assessed with no negative behavior. The progress notes show R1 was alert, oriented and verbally responsive. R1 was noted with forgetfulness at times and periods of being impulsive and attempting to stand without asking for assistance. The facility provided Spanish speaking staff to educate R1 on asking for assistance in standing and mobility. On 8/7/2023 at 11:13 A.M. V3 (ADON/Assistant Director of Nursing) said that on 7/14/2023, around 7:30 A.M., V5(RN/Registered Nurse) informed her R1 said she was attacked in the shared bathroom. This bathroom was used by both R1 and R11. V3 said after the daily meeting with the department managers including V1 (Administrator), V4 stated she informed team of R1's allegation of being physically attacked. V3 said she was told to just transfer R1 to the adjacent room. V3 said there was no abuse investigation started regarding R1's allegation of being physically attacked. On 8/7/2023 at 12:15 P.M., V5 (Registered Nurse/RN) said his regular assignment is in the dementia unit as a full-time day nurse. V5 said he knows his residents well including R1 and R11. V5 said R1 had a ritual of getting up from bed or wheelchair in her room and goes by herself to the bathroom shared with (R11). V5 added R1 and R11 share the same bathroom. V5 said R1 was slow and would spend 25 to 30 minutes in the bathroom. V5 said R11 was demanding, very inpatient, easily frustrated, and angry. V5 added R11 is very territorial of the shared bathroom and her room. According to V5, R11 would get mad and yell at R1 for using the shared bathroom. V5 stated R11 would become angry and frustrated with R1 since R1 moved slow and spoke Spanish and little English. V5 said on that 7/14/2023 at 7:00 A.M., R1 was sitting in her wheelchair in the dining room. V5 said it was the night shift staff that gets R1 up for breakfast. V5 said when R1 saw him, R1 started to wave her hand for V5 to come to her. As V5 approached R1, V5 said R1 told him, I was pushed, kicked, and attacked by (R11) in the bathroom early this morning. (R11) attacked me for using the bathroom. V5 added though R1 speaks mostly Spanish, R1 speaks minimal English and with sign gestures, R1 was able to communicate. V5 said R1 was alert and knew what had happened. V5 said she immediately informed V3 (Assistant Director of Nursing) of the allegation of physical abuse V5 reported and stated a physical assessment was not completed on R1. V5 said during the time R1 was talking to him regarding being attacked by R11, V6 (CNA/Certified Nurse Assistant/Spanish speaking staff) came and heard what R1 reported to V5. V5 confirmed that there were no in-services, no investigation done regarding the incident between R1 and R11. V5 said that he was only asked about R1's unexplained bruise when there was a state surveyor came to the facility on [DATE]. V5 also said that there was no special plan of care regarding monitoring of R1 and R11 after the incident. On 8/7/2023 at 12:52 P.M., V6 (CNA) said he speaks Spanish fluently. V6 said he is regularly scheduled in the dementia unit for the day shift. V6 said he came to V5 and R1 on 7/14/2023 around 7:00 A.M. when R1 told V5 she was being attacked, pushed, and kicked by R11 in the shared bathroom during the early morning hours of 7/14/2023. V6 added he was not interviewed about the incident between R1 and R11 nor was he provided any training after the incident. Both V5 and V6 said R1 was reliable with her statement. While R1 was informing them what R11 did to her, R1 had pointed R11's permanent seat assignment in the dining room. V5 and V6 said R1, The woman who always seat at the end of this table was the one who had hit me this morning. V5 and V6 had confirmed the woman R1 was referring to was R11. On 8/7/2023 at 1:34 P.M., V4 (Dementia Coordinator) said she was not aware of the physical altercations between R1 and R11. V4 added the facility initiated an investigation after notified by R1's family of the bruises noted on home visit 7/18/2023. V4 said R1's family took R1 home and found large bruises on R1's left shoulder, arm, forearm and R1 had difficulty raising her left arm. V4 said R1's family had called and reported to her about this unexplained injury/bruises on 7/18/2023 at 5:30 P.M. R1's family asked, What happened to my mom? Why does she have big bruises on the left shoulder, left upper back shoulder, upper arm, left forearm and left side of her face (cheekbone)? V4 said she immediately called V3, and they started an investigation regarding the unexplained bruises. V4 confirmed she was not aware of R1's allegation from 7/14/2023 and was unaware of any investigation. V4 confirmed R11's behaviors of being impatient, angry, and territorial which leads to anger towards other residents. V4 added R11 is very controlling about the shared bathroom. V4 said R1's family had sent pictures of R1 when she was informed on 7/18/2023. V4 said R1's pictures showed huge yellowish-greenish bruises surrounding the left upper side of her body including shoulder, arm, and face. V4 said there was no special monitoring regarding R11's behavior after the incident. On 8/7/2023 at 1:08PM, V9 (Social Service Director) stated she did wellness checks on R1 after the family complaint of bruising. According to V9, R1 was still complaining of pain. On 8/7/2023 at 3:54 P.M., V17 (LPN, worked on 7/15/2023 for day and evening shift and on 7/16/2023 for the evening shift) said no report was given to him regarding the physical attack by R11 on R1, only the bruises when it was discovered by family on 7/18/2023. V17 said he was not asked for an investigation regarding these incidents. V17 said on 7/25/2023, sometime in the afternoon, he was asked to call for ambulance for (R11) to be taken to the hospital for evaluation. V18 (LPN-Nurse), V19 (Nurse Aide), V20 (RN-Nurse) and V21 (LPN-Nurse) all work the Dementia Unit and were all interviewed about the incident between R1 and R11. V18, V19, V20 and V21 all stated they were not interviewed about the reported abuse between R1 and R11 and none of the staff was aware of R1's allegation. Staff was unaware of any behavior monitoring of or interventions for R11. On 8/7/2023 at 4:33 P.M., V22 (CNA, worked on 7/18/2023 for day shift) said after lunch that day when she was getting R1 ready for a family visit, she noted a large bruise on R1's left shoulder, armpit, back and chest area. V22 stated the color was somewhat greenish yellow, like a fading bruise and R1 could not raise her arm. V22 stated she reported this to (V23, LPN). V23 was not available for interview during the survey. V14 (LPN, worked 7/19/2023 evening shift) was interviewed on 8/7/2023 at 4:50PM and stated that on 7/19/2023 at 7:45 PM, R1 returned to the facility with her daughter. V14 said R1's family was very upset about what happened to R1. The family wanted to know what caused the large bruises on R1. V14 said she notified (V8, ANP-Nurse Practitioner) and an x-ray of the left shoulder was done. V14 said the result was an acute fracture of the left clavicle. On 8/7/2023 at 4:54 P.M., V8 (ANP-Advanced Practice Nurse) said she was informed on 7/19/2023 R1 had large bruises greenish yellowish in color around left armpit, left shoulder, arm and forearm. V8 said she had ordered an X-ray and the result was an acute fracture of the left clavicle. V8 said she examines R1 one to two times a week. V8 added R1, basically speaks Spanish but was able to verbalize her needs. Although R1 was forgetful, R1 was reliable with her statement. V8 said based on (R1's) injuries she sustained on the left side of her body, (R1) was correct when she said she was pushed by (R11) since (R11) was on R1's right side. V8 said, You do not pull somebody toward you if you are upset, you push them away from you, this makes more sense that (R1) was pushed from her right side and landed on her left side, and it showed from her sustained injuries. V8 said the fracture was caused from a trauma, was not pathological and just did not happen on its own. On 8/7/2023 at 3:31 P.M., V1 (Administrator) said the physical abuse on 7/14/2023 was not investigated. V1 added, I heard something happened in the bathroom of (R1 and R11) but I did not think much about it, did not follow up on it, nor investigation was done. I should have investigated it, so I would have known the cause and to monitor (R1's) injury and (R11) monitoring for potentially taking advantage of other residents. The facility submitted an initial incident report to the department 7/18/2023 with a final report dated 7/20/2023. The report does not include R1's allegation of R11's physical abuse. The facility concluded, the injury to the right clavicle was self-inflicted. R1's injury was to the left clavicle. The facility did not submit any investigation regarding R1's allegation of abuse by R11 nor was this information included in the incident report of 7/10/2023. The facility's abuse policy dated 2/11/2011 shows: It is the policy of this facility to prevent resident from abuse, neglect, mistreatment, and misappropriation of property. The policy shows when an employee or agent becomes aware of abuse or neglect, the abuse policy and procedure should be implemented immediately. The policy shows for the protection of other residents, if the perpetuator is a resident, then this resident should be evaluated immediately to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. The policy shows any incident or allegation involving abuse or mistreatment will result in abuse investigation. The Immediate Jeopardy began on July 14,2023, was removed on August 11,2023, when the facility took the following actions to remove the immediacy. -R1 was discharged home on 7/26/2023 with family. -R11 was sent to the hospital on 7/25/2023, returned to the facility on [DATE] was placed in a private room and was monitored each shift by nursing staff for any signs of aggressive behavior for 72 hours and was discontinued because resident did not display any aggressive behaviors. -R11 was relocated outside the dementia unit with alert residents and provided 1:1 monitoring by C.N.A or facility staff on 8/10/2023. Staff assigned will be educated to monitor any signs and symptoms of aggression and intervention to prevent any further aggression towards other residents and to report immediately supervisor. Resident will continue 1:1 monitoring until no behavior of aggression towards others were noted. -R11's behavior monitoring form was revised by the facility on 8/11/2023 as the behavior form used on 8/10/2023 did not include the behavior observed rather it asked where R11's location was. -R11's care plan was revised 8/10/2023 to include wellness visits, 5 times per week, from nursing or social services staff. Also, to be included, monitoring of any aggressive behavior. -V1 was terminate by the governing body and no longer is employed by the facility. -The facility's interim Administrator received education on the abuse policy and procedure on 7/19/2023 by RNC. -Physical, clinical (limited ROM, pain, skin alteration such as skin tear, bruises, redness) and mental (change in mood, fearfulness, withdrawal, isolation) assessment were conducted for all residents on the memory care unit initiated at 8/9/2023 with no further observations noted related to abuse. -The facility Administrator initiated staff education of the abuse policy and procedure on 7/19/2023. -On 8/9/2023, the Administrator educated the IDT (Interdisciplinary Team) on the abuse policy and procedure, to ensure a resident is free from physical abuse from another resident, implement interventions to keep free from further abuse and implement a treatment plan to keep other residents safe. -On 8/9/2023, all staff currently work at the building were educated with a follow up test by the Administrator, Director of Nursing, Assistant Director of Nursing, and the IDT on following: 1. Abuse Policy 2. Abuse reporting, Abuse Prevention 3. Thoroughly investigate alleged abuse 4. Prevent further abuse or mistreatment from occurring. 5. Implement training after an allegation of physical abuse. 6. Place intervention in place to prevent additional abuse from happening related to a reported physical abuse. 7. Any alleged, witnessed, and suspected abuse, a. Intervene, stop separate alleged perpetrator, place on additional monitoring or one to one. b. Notify your immediate supervisor. c. Report to your Administrator (Abuse Coordinator) and Director of Nursing immediately. d. Follow directive of Administrator or DON e. Complete a skin check and head to toe assessment, screen for any injuries. f. Complete an incident report. -Acting Administrator was educated on 8/10/23 about facility's abuse policy and procedure. Education will be completed on 8/11/2023. -New employees will be educated on the Abuse Policy and Procedure during orientation prior to going on the floor. In case staffing agency is use, they will also be educated prior to going on the floor. New resident coming into the facility will be reviewed by Social Service for any history of aggressive behaviors and will be seen by Psych services and interventions will be in place to address and monitor behaviors. QAA/QAPI Upon notification of alleged physical abuse, the Administrator or designee, will ensure an allegation of physical abuse is fully investigated, staff are educated on the abuse policy and action is taken to prevent additional abuse. Beginning 8/10/23 audit tools will be reviewed 3 times a week for 2 weeks, then, beginning 8/25/23 for 2 times a week for 2 weeks for 3 months culminating on 9/25/23. QAPI committee which meets monthly will review for compliance and determine that compliance has been meet. An emergency QAPI was held on 8/9/23 and attended by medical director and Interdisciplinary team. -The facility submitted forms labeled as exhibits that shows its current implementation and monitoring for abatement plan. 32935

Based on interview and record review, the facility failed to thoroughly assess and monitor a resident a resident's condition after an allegation of physical abuse. This failure resulted a delay of treatment of 4 days for R1's acute fractured left clavicle. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 16. The findings include: The EMR (Electronic Medical Record) showed R1's original admission to the facility was on 5/3/2018. R1 was readmitted on [DATE]. R1 was discharged home on 7/26/2023 because R1's family refused for R1 to return to the facility. R1, an [AGE] year-old and with multiple diagnoses including Parkinson's Disease, neurological deficits, repeated falls, difficulty in walking, muscle weakness, unsteadiness of feet, hypothyroidism, major depression, vitamin D deficiency, GERD (gastro-esophageal reflux disease) and displaced fracture of lateral end of the left clavicle. The EMR shows R1, while at the facility was in in the designated dementia unit. R1 was transferred to new room at 12:00PM 7/14/2023. R1's new room was located across the hallway from her previous room. Then, on 7/23/2023, (9 days after the reported physical attack from R11), R1 was moved to the first floor. R1 had verbalized to V9 (Social Service Director) she was afraid in the dementia unit where R11 resides. The MDS (Minimum Data Set) assessment dated [DATE], showed R1 required extensive assistance from staff for toilet use, transfers, ambulation inside/outside of her room, personal hygiene, eating, dressing, and bed mobility. R1's primary mode of locomotion was a wheelchair. The MDS shows R1 was assessed with having trouble in falling asleep, trouble concentrating on things, and she moves and speaks so slow it is noticeable to others. R1 was assessed with no negative behavior. The progress notes show R1 was alert, oriented and verbally responsive. R1 was noted with forgetfulness at times and periods of being impulsive and attempting to stand without asking for assistance. The facility provided Spanish speaking staff to educate R1 on asking for assistance in standing and mobility. On 8/7/2023 at 11:13 A.M. V3 (ADON/Assistant Director of Nursing) said that on 7/14/2023, around 7:30 A.M., V5(RN/Registered Nurse) informed her R1 said she was attacked in the shared bathroom. This bathroom was used by both R1 and R11. V3 said after the daily meeting with the department managers including V1 (Administrator), V4 stated she informed team of R1's allegation of being physically attacked. V3 said she was told to just transfer R1 to the adjacent room. V3 said there was no abuse investigation started regarding R1's allegation of being physically attacked. On 8/7/2023 at 12:15 P.M., V5 (Registered Nurse/RN) said his regular assignment is in the dementia unit as a full-time day nurse. V5 said he knows his residents well including R1 and R11. V5 said R1 had a ritual of getting up from bed or wheelchair in her room and goes by herself to the bathroom shared with (R11). V5 added R1 and R11 share the same bathroom. V5 said R1 was slow and would spend 25 to 30 minutes in the bathroom. V5 said R11 was demanding, very inpatient, easily frustrated, and angry. V5 added R11 is very territorial of the shared bathroom and her room. According to V5, R11 would get mad and yell at R1 for using the shared bathroom. V5 stated R11 would become angry and frustrated with R1 since R1 moved slow and spoke Spanish and little English. V5 said on that 7/14/2023 at 7:00 A.M., R1 was sitting in her wheelchair in the dining room. V5 said it was the night shift staff that gets R1 up for breakfast. V5 said when R1 saw him, R1 started to wave her hand for V5 to come to her. As V5 approached R1, V5 said R1 told him, I was pushed, kicked, and attacked by (R11) in the bathroom early this morning. (R11) attacked me for using the bathroom. V5 added though R1 speaks mostly Spanish, R1 speaks minimal English and with sign gestures, R1 was able to communicate. V5 said R1 was alert and knew what had happened. V5 said she immediately informed V3 (Assistant Director of Nursing) of the allegation of physical abuse V5 reported and stated a physical assessment was not completed on R1. V5 said during the time R1 was talking to him regarding being attacked by R11, V6 (CNA/Certified Nurse Assistant/Spanish speaking staff) came and heard what R1 reported to V5. V5 confirmed that there were no in-services, no investigation done regarding the incident between R1 and R11. V5 said that he was only asked about R1's unexplained bruise when there was a state surveyor came to the facility on [DATE]. V5 also said that there was no special plan of care regarding monitoring of R1 and R11 after the incident. On 8/7/2023 at 12:52 P.M., V6 (CNA) said he speaks Spanish fluently. V6 said he is regularly scheduled in the dementia unit for the day shift. V6 said he came to V5 and R1 on 7/14/2023 around 7:00 A.M. when R1 told V5 she was being attacked, pushed, and kicked by R11 in the shared bathroom during the early morning hours of 7/14/2023. V6 added he was not interviewed about the incident between R1 and R11 nor was he provided any training after the incident. Both V5 and V6 said R1 was reliable with her statement. While R1 was informing them what R11 did to her, R1 had pointed R11's permanent seat assignment in the dining room. V5 and V6 said R1, The woman who always seat at the end of this table was the one who had hit me this morning. V5 and V6 had confirmed the woman R1 was referring to was R11. On 8/7/2023 at 1:34 P.M., V4 (Dementia Coordinator) said she was not aware of the physical altercations between R1 and R11. V4 added the facility initiated an investigation after notified by R1's family of the bruises noted on home visit 7/18/2023. V4 said R1's family took R1 home and found large bruises on R1's left shoulder, arm, forearm and R1 had difficulty raising her left arm. V4 said R1's family had called and reported to her about this unexplained injury/bruises on 7/18/2023 at 5:30 P.M. R1's family asked, What happened to my mom? Why does she have big bruises on the left shoulder, left upper back shoulder, upper arm, left forearm and left side of her face (cheekbone)? V4 said she immediately called V3, and they started an investigation regarding the unexplained bruises. V4 confirmed she was not aware of R1's allegation from 7/14/2023 and was unaware of any investigation. V4 confirmed R11's behaviors of being impatient, angry, and territorial which leads to anger towards other residents. V4 added R11 is very controlling about the shared bathroom. V4 said R1's family had sent pictures of R1 when she was informed on 7/18/2023. V4 said R1's pictures showed huge yellowish-greenish bruises surrounding the left upper side of her body including shoulder, arm, and face. On 8/7/2023 at 1:08PM, V9 (Social Service Director) stated she did wellness checks on R1 after the family complaint of bruising. According to V9, R1 was still complaining of pain. On 8/7/2023 at 3:54 P.M., V17 (LPN, worked on 7/15/2023 for day and evening shift and on 7/16/2023 for the evening n shift) said no report was given to him regarding the physical attack by R11 to R1. Only the bruises when it was discovered by family on 7/18/2023. V17 also said he was not asked for an investigation regarding these incidents. V18 (LPN-Nurse), V19 (Nurse Aide), V20 (RN-Nurse) and V21 (LPN-Nurse) all work the Dementia Unit and were all interviewed about the incident between R1 and R11. V18, V19, V20 and V21 all stated that they were not interviewed about the reported abuse between R1 and R11 and none of the staff was aware of R1's allegation. On 8/7/2023 at 4:33 P.M., V22 (CNA, worked on 7/18/2023 for day shift) said after lunch that day when she was getting R1 ready for a family visit, she noted a large bruise on R1's left shoulder, armpit, back and chest area. V22 stated the color was somewhat greenish yellow, like a fading bruise and R1 could not raise her arm. V22 stated she reported this to (V23, LPN). V14 (LPN, worked 7/19/2023 evening shift) was interviewed on 8/7/2023 at 4:50PM and stated that on 7/19/2023 at 7:45 PM, R1 returned to the facility with her daughter. V14 said R1's family was very upset about what happened to R1. The family wanted to know what caused the large bruises on R1. V14 said she notified (V8, ANP-Nurse Practitioner) and an x-ray of the left shoulder was done. V14 said the result was an acute fracture of the left clavicle. On 8/7/2023 at 3:31 P.M., V1 (Administrator) said the physical abuse on 7/14/2023 was not investigated. V1 added, I heard something happened in the bathroom of (R1 and R11) but I did not think much about it, did not follow up on it, nor investigation was done. I should have investigated it, so I would have known the cause and to monitor (R1's) injury and (R11) monitoring for potentially taking advantage of other residents. On 8/7/2023 at 4:54 P.M., V8 (ANP-Advanced Practice Nurse) said she was informed on 7/19/2023 R1 had large bruises greenish yellowish in color around left armpit, left shoulder, arm and forearm. V8 said she had ordered an X-ray and the result was an acute fracture of the left clavicle. V8 said she examines R1 one to two times a week. V8 added R1, basically speaks Spanish but was able to verbalize her needs. Although R1 was forgetful, R1 was reliable with her statement. V8 said based on (R1's) injuries she sustained on the left side of her body, (R1) was correct when she said she was pushed by (R11) since (R11) was on R1's right side. V8 said, You do not pull somebody toward you if you are upset, you push them away from you, this makes more sense that (R1) was pushed from her right side and landed on her left side, and it showed from her sustained injuries. V8 said the fracture was caused from a trauma, was not pathological and just did not happen on its own. The progress notes shows that there was no documentation from 7/10 through 18 of 2023 to show R1 was monitored nor assessed after R1 had said she was physically attacked by R11. The undated facility policy for Accident/Incident Reporting shows .10. Documentation of the resident's physical and mental status will be completed each shift following a minimum of 72 hours.

Based on interview and record review, the facility failed to assist a resident with obtaining financial assistance. This failure resulted in psychosocial harm when R1 felt withdrawn and anxious leading to R1 seeking referrals to other facilities. This applies to 1 of 3 residents (R1) reviewed for resident funds in a sample of 3. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including: cerebral infarction, hemiplegia and hemiparesis affecting the left side, peripheral vascular disease, bipolar disorder, depression, suicidal ideations, and hypertension. R1's MDS (Minimum Data Set) dated December 9, 2022, showed R1 was cognitively intact and required limited assistance of one facility staff for toilet use, transferring between surfaces, and personal hygiene. On December 27, 2022, at 11:17 AM, R1 said, I came to the facility in February this year. I told the facility right away that I was not receiving my Social Security and needed help getting it. In September, I called the Social Security office and was told I needed my doctor to submit paper work to show I was still disabled. I told this to [V3-Business Office Manager] and she said medical records deals with that. No body helped me with the paperwork. The last time I told the facility I had concerns about my Social Security and asked for help from facility staff was on November 25, 2022. I was hoping to get some money in time for Christmas for my grandchildren. Nobody has helped me. On December 28, 2022, at 1:57 PM, R1 said, When the facility was not helping me, I felt anxious and wanted to leave this facility. I asked them to send out referrals to other facilities because I wanted to go to a facility where someone would help me. I was upset because I watched other people get their money and I did not get any. I feel like the facility walks all over me. I have been withdrawn and do not participate in activities because I cannot trust the facility. Thirty dollars is not a lot of money, but it is better than no money and it means a lot to me. On December 27, 2022, at 10:01 AM, V3 (BOM/Business Office Manager) said, [R1] is supposed to be getting 30 dollars a month, but he does not have any funds in Social Security, it depends on how long a person has been working. [R1] can call Social Security and ask them, but there are not any funds left for him. On December 27, 2022, at 3:34 PM, V7 (Social Services Director) said, [V3] is the only staff member who deals with the residents' disability and Social Security. [V3] has never asked for help with getting a resident Social Security or disability. I do not deal with any of the residents' Social Security. On December 28, 2022, at 10:02 AM, V3 said R1 has a pass to go out independently in the community. V3 continued to say since R1 had this pass then R1 could go the Social Security office himself to figure out his Social Security. On December 28, 2022, at 10:55 AM, V7 said, [V3] needed to ask Social Security about reapplying or doing a redetermination of [R1]'s Social Security. [R1] should be receiving 30 dollars a month from Social Security. On December 28, 2022, at 11:41 AM, V1 (Administrator) said, It is only 30 dollars. There is a priority with getting a resident's money for someone receiving 1000 dollars a month versus someone who is only receiving 30 dollars a month. [R1] has a history of drug use so we would prioritize a resident who is more responsible than [R1]. We are his representative payee so we get to decide how he uses his money and if he gets the 30 dollars a month. On December 28, 2022, at 12:22 PM, V7 said, [R1]'s Social Security could have been reapplied for months ago, when he was first admitted to the facility. The facility's documents titled Grievance Tracking Log, for the period of September 1, 2022, to December 27, 2022, did not show any documentation from facility staff about R1's Social Security concerns. The documentation also does not show any resolution for R1's Social Security concerns. R1's Social Security documentation titled, Social Security Administration, Supplemental Security Income, Important Information., dated September 19, 2022, showed, no payment has been made at this time.

Based on observation, interview, and record review, the facility failed to protect R1, a severely cognitively impaired resident from sexual abuse by R2 a male resident with a history of inappropriate sexual activity. The facility also failed to implement a plan to prevent further abuse to R1 once R2's behavior was identified. This applies to R1 a severely cognitively impaired female resident who was unable to give consent for sexual activity by R2. This resulted in an Immediate Jeopardy. The IJ (Immediate Jeopardy) was noted to begin in May of 2022, when R2 was found kissing and hugging R1 while both were lying in R1's bed. V2 (Director of Nursing) was notified of the IJ (Immediate Jeopardy) on 8/30/2022 at 10:21 A.M. The surveyor confirmed by interview and record review that IJ was removed on 9/1/2022 at 12:00 Noon, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EMR (Electronic Medical Record) shows R1, an 84 -year-old female and was admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) dated 5/18/2022 and 8/16/2022, shows R1 BIMS (Brief Interview Mental Status) score of 6/15 (very severe impairment in cognition). The MDS also shows that R1 had exhibited mood behavior of feeling down, trouble falling asleep, trouble concentrating on things and moving or speaking slowly. The MDS further shows that R1 requires limited assistance with 1-person physical assistance for bed mobility, transfer, dressing, toilet, and hygiene. R1 requires supervision for walking in and out of her room. The psychiatrist's notes dated 10/9/2021, 11/21/2021, 12/05/2021 shows the same assessment that shows R1 is oriented to self, with confusion and easily distracted with flight of ideas. The Social Service Notes dated 11/16/2021, 2/6/2022, 5/16/2022, 8/14/2022 shows R1's quarterly assessments by the social service which shows the same and described R1, a female diagnosed with dementia, major depressive disorder, anxiety, and delusional disorder, alert, stable, able to make her needs known and ambulates on unit independently. The notes shows that R1's BIMS score of 6/15, which indicates symptoms with severe impaired cognition. Further review of social service notes shows that on 12/6/2021 that R1's family was informed that R1 be moving to 2N (designated Dementia Unit) today since R1 has been seeking exit areas and (R1) needed to go find her white cat. The facility's sexual allegation report dated 8/22/2022 shows that V4 (Nurse Practitioner) reported to V1 (Administrator) an allegation of sexual abuse by R2 on R1. The hospital ED (Emergency Department) Record dated 8/22/2022 at 11:03 P.M., shows R1's reason for visit was sexual assault. There was no further documentation regarding R1's visit from the hospital. R1 had returned to the facility early morning of 8/23/2022. The nurse' progress notes shows that on 8/22/2022 at 10:09 A.M., R1 was sent to the hospital for further evaluation in relation to allegations of unwanted physical contact. R1's family member made aware, and V4 (Nurse Practitioner). On 8/23/2022 at 2:30 A.M., R1 came back to facility. On 8/26/2022 at 11:14 A.M., V4 (R1's Nurse Practitioner) said that on 8/22/2022, a resident's family member informed V4 that R2 sexually assaulted R1, in R1's room, and that R2's pants were pulled down. V4 said that she immediately informed V1 (Administrator) and sent R1 to the hospital for evaluation. V4 said that there were no signs of rape when R1 was evaluated at the hospital since it was undetermined as when the alleged sexual assault happened. V4 stated that according to the resident's family member, this sexual abuse had been going on for quite some time. V4 said that both R1 and R2 are her patients. V4 described R1 as pleasantly confused, is not aware of what is going on, is not aware enough to protect herself from abuse and is not able to provide her consent for sexual activity. V4 added that R2 is male resident who is alert, no mental history, and is aware of what he was doing, alert and oriented times 4. R3 was the roommate of R1 from January 2022 until August 11, 2022. R3 is an alert and oriented female resident who was interviewed on 8/26/2022 at 11:30 A.M. R3 stated that almost every day around 8:00 P.M. to 9:00 P.M., R2 would sneak into the room. R3 described R2 as being smart and would take advantage of the time when nursing staff was passing medications, giving showers, picking up dinner trays or helping other residents go to bed. R3 said she would get startled when R2 came into her room since she was either sleeping or watching TV. R3 added that she would notice R2 suddenly just standing inside their room. R3 said she gets awaken with overpowering smell of R2's cologne. R3 also said that R2 also wears his cranberry colored silk pajama every time R2 comes into their room. R3 also said that with a loud tone of voice, R2 would say to her It is my right to visit my friend (R1), so do not complain. R3 also said that R2 would pull the privacy curtain every time he is with R1, on R1's side of their room. R3 also added that R2 spent long hours with R1 in their room and does not know what they were doing since the curtain was closed and she also turned her TV on, so she did not hear anything. R3 said that R1, is very isolative, withdrawn and does not really believe she understands what R2 is doing to her. R3 added that she tried to ignore it, but all the staff know what is going on between R1 and R2. R3 went on to add to talk to V16 (Nurse) and other staff members since they know what is going on between R1 and R2. According to R3, R2 spent long hours with R1 who cannot say anything, is confused and does not know what is going on. V17 (CNA/Certified Nurse Assistant) was interviewed on August 26, 2022, at 7:00PM. V17 stated that sometime around the end of May 2022, she saw someone lying in R1's bed wearing cranberry-colored pajamas and the privacy curtain was partially pulled. V17 stated that R1 did not own that colored pajamas so she went to check on R1. V17 stated that R2 was in R1's bed and R2 was kissing R1 while R2's arms were on top of R1's breast and chest area. According to V17, R1 was passive, confused and not aware of what was going on and R2 kept kissing R1 and telling R1, you are so pretty, I love you, I really love you. V17 stated she told R2 to stop and ran out of the room to get the charge nurse (V16). V17 reported everything to V16 and told V16 that R2 was abusing R1 because of R1's impaired judgement. V16 (Nurse) was interviewed on August 26, 2022, at 7:30PM. V16 stated that sometime around the end of May 2022 V17 informed him that R1 and R2 were in bed together. V16 described seeing R2 lying in bed next to R1 with R2's arms on top of R1's breast area and R2's right knee on top of R1's lower extremities. V16 stated that R1 was awake but not responding and was unaware of what was happening. V16 also stated that R1 was confused and R2 took advantage of her. V16 stated that R2 was pretending to be asleep. V16 then called V1 (Administrator) and V1 told V16, okay, just keep an eye on him (R2). V16 indicated that he was surprised about V1's response since it is not always feasible to keep any eye on R2 because of the number of residents they need to care for. V16 described R2 as sneaking, since he would take advantage of the time when staff were too busy to go into R1's room. On 8/27/2022 at 10:45 A.M., V19 (CNA) said that he had seen several occasions when R2 was lying in bed or sitting at edge of R1's bed while R1 was lying in bed. V19 said that (R1) is confused and cannot give consent for sexual activity, and for (R2) sitting on (R1's) bed is inappropriate especially that (R1) was lying in bed and does not know any difference. V19 said that this had occurred from June, July, and August 2022. V19 said that he thought that this inappropriate sexual manner was already reported to V1 but was wondering why it is still an ongoing issue with R2 going to R1's room, with no further plan or supervision. On 8/27/2022 at 11:00 A.M., V18 (Registered Nurse) said that on 8/10/2022 around 8:30 P.M., R2 was sitting at R1's bed while R1 was lying down. V18 said that this is sexual abuse, because (R1) cannot give consent, is confused and (R2) was taking advantage of R1 that was sexual in nature. V18 said that she immediately called V1 and reported the sexual abuse. V18 said she also informed V2 (Director of Nursing) via text. V18 said she was surprised that V1's response was Okay. On 8/27/2022 at 11:30 A.M., V2 stated that V18 had texted her on 8/10/2022 that R2 was sexually inappropriate with R1. V2 said that R2 was sitting in R1's bed while R1 was lying down, and privacy curtain was pulled. V2 said that they instructed V18 to report to V1. V2 also said that the facility did not have a plan for monitoring, supervising, including possible treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 said there was no investigation done after she was made aware of the 8/10/2022 incident. V2 said that also aside from moving R2 the next day to the second floor, the plan of care had no revisions regarding how R2 would be monitored to ensure protection of R1 and other female residents who are cognitively impaired. On 8/27/2022 at 11:45 A.M., V20 (Nurse) said that R2 is alert and oriented times 4. V20 said that R2 likes women, he always says to R13 that she is his wife and that R13 was upset about being called his wife. V20 also said that R12, who is ambulatory, and is deaf, always spends time in R2's room, and they close the door. They stayed there for hours, and sign postage made by (R2) not to enter the room and always knock. V20 said that I don't know what they do there the inside room, but I guess that R12 knows what she was doing. V20 also said that R2 moves freely about and comes and goes out of his room. On 8/26/2022 at 12:30 P.M. and on 8/27/2022 at 9:30 A.M., R1 was observed in her room on the second floor. R1 was observed flipping pages of her book non-stop and was not trying to find a page. There were times that R1 just stared blankly with a flat affect. When asked how she was doing, R1 said, I don't know, I don't know, I don't know. On 8/26/2022 at 1:00 P.M., R2 was in his private room on the first floor. R2 said that he was alleged of inappropriate sexual behavior. R2 said that I will never do that, I am very active, socializing with other residents planning a concert for the Labor Day. I keep myself busy planning what songs for the concert and busy with my paintings. On 8/27/2022 at 10:00 A.M., R2 denied going to R1's room. Later in the interview, R2 suddenly changed his statement and said Yes, I go to her (R1's) room, nothing else. R2 was ambulating with a steady gait when observed walking inside his room. On 8/27/2022 at 2:00 P.M., V1(Administrator) said that she was notified by V16 (Nurse) sometime in May of 2022 and V20 (Nurse) in August 2022 regarding R2 being sexually inappropriate to R1. V1 said that she did not investigate these allegations of sexual abuse not until V4 had informed her on 8/22/2022. On 8/28/2022 at 1:50 P.M., V2 said that all the sexual abuse allegations were reported to V1. V2 added that the reported sexual allegations made since May of 2022 and August 10,2022 were not investigated and were missed, and she had informed staff to let her know any allegations of abuse. The EMR shows that R2, a 63-year, old male admitted to the facility on [DATE]. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . diabetes mellitus, major depressive disorder, unspecified [CONDITION(S)], and [CONDITION(S)]. The MDS dated [DATE] and 7/22/2022 shows R2's BIMS score of 15/15 indicating that R2 is cognitively intact. R2 had no range of motion impairment. R1's and R2's care plan were reviewed. The sexual abuse/sexually inappropriate behavior were not addressed. There were no interventions how R2 would be monitored to ensure R1, and other confused female residents were kept safe and free from abuse from R2. The EMR for both R1 and R2 including the nurses' notes, psychiatrist notes /physician notes, social services notes show no documentation regarding these sexual advances made by R2 to R1. The facility's policy for abuse latest revision date of 1/2019 shows: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented .Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility .This policy will define how the investigation of abuse allegations and mistreatment or crimes will be conducted and outline the process of reporting, investigating, and arriving at a conclusion or disposition of the allegation. Inquiries concerning abuse reporting and investigations will be referred to the Administrator and/or the Director of Nursing. The Administrator or DON shall review the findings of the investigation and determine if further training or other corrective action is needed to prevent future occurrences. The Immediate Jeopardy that began in May of 2022, was removed on 9/1/2022 when the facility took the following actions to remove the immediacy: 1. R1 was relocated to secured dementia unit with close monitoring on 8/30/22. R1's Care plan was revised on 8/31/22 to include wellness visits five times per week by social services or nursing staff. Also, to be included in care plan, monitoring of any behavior/side effects of R2's inappropriate touching to include anxiety, restlessness, self-isolation and crying. R1 will be seen by psychological services weekly, starting on 8/31/22 2. R2 is on a 1:1 supervision started on 8/30/22 until he is discharged from the facility. Resident received an IVD (Involuntary Discharge Notice) due to lack of payment which will end on 9/19/22. On 8/27/22, Social Services spoke with R2 regarding boundaries and no physical contact with R1. R2's Care plan was revised on 8/31/22 to include monitoring of any behavior to include not touching any female resident unless given permission; not allowed to go into female resident rooms. R2 will be seen by psychological services weekly, starting on 8/31/22. R2 signed behavior contract on 8/30/22, regarding inappropriate behavior with female confused residents. 3. How other residents of the facility were identified to potentially be affected: The facility conducted skin assessments for all residents with BIMS score of 7 or less for to assess for any allegation or sign of abuse. This began on 8/30/22 and will be completed 9/1/22. The facility interviewed female residents with a BIMS score of 8 to determine if R2 had any inappropriate behavior towards them. 4. Training: All staff will be educated by DON and Regional Consultant on 8/30/22 and will be completed on 9/1/22. The following will be reviewed and discussed: Abuse Policy with emphasis on different types to include sexual abuse: (any of the following scenarios, against the resident's will or the will of the resident's representative) a) If an allegation is reported to the administrator, please notify DON also immediately. b) If no outcome is observed from reporting notify Regional Director of Operation or Regional Nurse consultant c) Staff to communicate to Regional Director of Operations if abuse allegations are not reported or handled per facility's abuse policy. d) Staff to monitor R1 and R2's behavior. What should you do if you find a confused resident inappropriately touch or visited by another alert cognitively intact resident? a) Immediately intervene to provide resident safety and separate resident. b) Immediately assess resident head to toe for any injury or harm to include emotional upset c) Notify the Abuse Coordinator for further guidance and instruction-Abuse Policy will be implemented. d) Staff to communicate to Regional Director of Operations if abuse allegations are not reported or handled per facility's abuse policy. e) Staff to monitor R1 and R2's behavior. 5. QAA/QAPI Audit tools will be reviewed 3 times a week for 2 weeks beginning 9/1/2022, then 2 times a week for 2 weeks for 3 months (9/15/2022) and then QAPI committee which meets monthly will review for compliance and determine that compliance has been meet (9/29/2022). An emergency QAPI was held and attended by medical director and Interdisciplinary team.

Based on observation, interview, and record review, the facility failed to implement their abuse policy by not investigating, reporting, protecting a confused female resident from sexual abuse by a male resident with known history of sexually inappropriate behavior. This applies to 1 of 1 resident (R1) who was severely cognitively impaired female resident who was unable to give consent to R2 for sexual activity. This resulted in an Immediate Jeopardy. The IJ (Immediate Jeopardy) began in May of 2022, when R2 was found kissing and hugging R1 while both were lying in R1's bed. V2 (Director of Nursing) was notified of the IJ (Immediate Jeopardy) on 8/30/2021 at 10:21 A.M. The surveyor confirmed by interview and record review that IJ was removed on 9/1/2022 at 12:00 Noon, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EMR (Electronic Medical Record) shows R1, an [AGE] year-old female and was admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) dated 5/18/2022 and 8/16/2022, shows R1 BIMS (Brief Interview Mental Status) score of 6/15 (very severe impairment in cognition). The MDS also shows that R1 had exhibited mood behavior of feeling down, trouble feeling asleep, trouble concentrating on things and moving or speaking slowly. The MDS further shows that R1 requires limited assistance with 1-person physical assistance for bed mobility, transfer, dressing, toilet, and hygiene. R1 requires supervision for walking in and out of her room. The psychiatrist's notes dated 10/9/2021, 11/21/2021, 12/05/2021 shows the same assessment that R1 is oriented to self, with confusion and easily distracted with flight of ideas. The Social Service Notes dated 11/16/2021, 2/6/2022, 5/16/2022, 8/14/2022 shows R1's quarterly assessments by the social service which shows the same and described R1, a female diagnosed with dementia, major depressive disorder, anxiety, and delusional disorder, alert, stable, able to make her needs known and ambulates on unit independently. The notes shows that R1's BIMS score of 6/15, which indicates symptoms with severe impaired cognition. Further review of social service notes shows that on 12/6/2021 R1's family was informed that R1would be moving to 2N (designated Dementia Unit) today since R1 has been seeking exit areas and (R1) needed to go find her white cat. The EMR shows that R2, is a 63-year, old male admitted to the facility on [DATE]. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] and 7/22/2022 shows R2's BIMS score of 15/15 indicating that R2 is cognitively intact. R2 had no range of motion impairment. The facility's sexual allegation report dated 8/22/2022 shows that V4 (Nurse Practitioner) reported to V1 (Administrator) an allegation of sexual abuse by R2 to R1. The hospital ED (Emergency Department) Record dated 8/22/2022 at 11:03 P.M., shows R1's reason for visit was sexual assault. There was no further documentation regarding R1's visit from the hospital. R1 had returned to the facility early morning of 8/23/2022. The nurse' progress notes shows that on 8/22/2022 at 10:09 A.M., R1 was sent to the hospital for further evaluation in relation to allegations of unwanted physical contact. R1's family member made aware, and V4 (Nurse Practitioner). On 8/23/2022 at 2:30 A.M., R1 came back to facility. On 8/26/2022 at 11:14 A.M., V4 (R1's Nurse Practitioner) said that on 8/22/2022, a resident's family member informed V4 that R2 had sexually assaulted R1, in R1's room, and that R2's pants were pulled down. V4 said that she immediately informed V1 (Administrator) and sent R1 to the hospital for evaluation. V4 said that there were no signs of rape when R1 was evaluated at the hospital since it was undetermined as when the alleged sexual assault happened. V4 stated that according to the resident's family member, this sexual abuse had been going on for quite some time. V4 said that both R1 and R2 are her patients. V4 described R1 as pleasantly confused, is not aware of what is going on, is not aware enough to protect herself from abuse and is not able to provide her consent for sexual activity. V4 added that R2 is male resident who is alert, no mental history, and is aware of what he was doing, alert and oriented times 4. R3 was the roommate of R1 from January 2022 until August 11, 2022. R3 is an alert and oriented female resident and was interviewed on 8/26/2022 at 11:30 A.M. R3 stated that almost every day around 8:00 P.M. to 9:00 P.M., R2 would sneak into the room. R3 described R2 as being smart and would take advantage of the time when nursing staff were passing medications, giving showers, picking up dinner trays or helping other residents go to bed. R3 said she would get startled when R2 came into her room since she was either sleeping or watching TV. R3 added that she would notice R2 suddenly just standing inside their room. R3 said she gets awaken with overpowering smell of R2's cologne. R3 also said that R2 also wears his cranberry colored silk pajama every time R2 comes into their room. R3 also said that with a loud tone of voice, R2 would say to her It is my right to visit my friend (R1), so do not complain. R3 also said that R2 would pull the privacy curtain every time he is with R1, on R1's side of their room. R3 also added that R2 spent long hours with R1 in their room and does not know what they were doing since the curtain was closed and she also turned her TV on, so she did not hear anything. R3 said that R1, is very isolative, withdrawn and R3 does not really believe she understands what R2 is doing to her. R3 added that she tried to ignore it, but all the staff know what is going on between R1 and R2. R3 went on to add to talk to V16 (Nurse) and other staff members since they know what is going on between R1 and R2. According to R3, R2 spent long hours with R1 who cannot say anything, is confused and does not know what is going on. V17 (CNA/Certified Nurse Assistant) was interviewed on August 26, 2022, at 7:00PM. V17 stated that sometime around the end of May 2022, she saw someone lying in R1's bed wearing cranberry-colored pajamas and the privacy curtain was partially pulled. V17 stated that R1 did not own that colored pajamas so she went to check on R1. V17 stated that R2 was in R1's bed and R2 was kissing R1 while R2's arms were on top of R1's breast and chest area. According to V17, R1 was passive, confused and not aware of what was going on and R2 kept kissing R1 and telling R1, you are so pretty, I love you, I really love you. V17 stated she told R2 to stop and ran out of the room to get the charge nurse (V16). V17 reported everything to V16 and told V16 that R2 was abusing R1 because of R1's impaired judgement. V16 (Nurse) was interviewed on August 26, 2022, at 7:30PM. V16 stated that sometime around the end of May 2022 that V17 informed him that R1 and R2 were in bed together. V16 described seeing R2 lying in bed next to R1 with R2's arms on top of R1's breast area and R2's right knee on top of R1's lower extremities. V16 stated that R1 was awake but not responding and was unaware of what was happening. V16 also stated that R1 was confused and R2 took advantage of her. V16 stated that R2 was pretending to be asleep. V16 then called V1 (Administrator) and V1 told V16, okay, just keep an eye on him (R2). V16 indicated that he was surprised about V1's response since it is not always feasible to keep any eye on R2 because of the number of residents they need to care for. V16 described R2 as sneaking since he would take advantage of the time when staff was busy to go into R1's room. On 8/27/2022 at 10:45 A.M., V19 (CNA) said that he had seen several occasions when R2 was lying in bed or sitting at edge of R1's bed while R1 was lying in bed. V19 said that (R1) is confused and cannot give consent for sexual activity, and for (R2) sitting on (R1's) bed is inappropriate especially that (R1) was lying in bed and does not know any difference. V19 said that this had occurred from June, July, and August 2022. V19 said that he thought that this inappropriate sexual manner was already reported to V1 but was wondering why it still was an ongoing issue with R2 going to R1's room, with no further plan or supervision. On 8/27/2022 at 11:00 A.M., V18 (Registered Nurse) said that on 8/10/2022 around 8:30 P.M., R2 was sitting at R1's bed while R1 was lying down. V18 said that this is sexual abuse, because (R1) cannot give consent, is confused and (R2) was taking advantage of R1 that was sexual in nature. V18 said that she immediately called V1 and reported the sexual abuse. V18 said she also informed V2 (Director of Nursing) via text. V18 said she was surprised that V1's response was Okay. On 8/27/2022 at 11:30 A.M., V2 stated that V18 had texted her on 8/10/2022 that R2 was sexually inappropriate with R1. V2 said that R2 was sitting in R1's bed while R1 was lying down, and the privacy curtain was pulled. V2 said they instructed V18 to report to V1. V2 also said that the facility did not have a plan for monitoring, supervising, including possible treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 said there was no investigation done after she was made aware of the 8/10/2022 incident. V2 also said aside from moving R2 the next day to the second floor, the plan of care had no revisions regarding how R2 would be monitored to ensure protection of R1 and other female residents who are cognitively impaired. On 8/27/2022 at 11:45 A.M., V20 (Nurse) said that R2 is alert and oriented times 4. V20 said that R2 likes women, he always says to R13 that she is his wife and that R13 was upset about being called his wife. V20 also said that R12, who is ambulatory, and is deaf, always spends time with in R2's room, and they close the door. They stayed there for hours, and sign postage made by (R2) not to enter the room and always knock. V20 said that I don't know what they do there inside room, but I guess that R12 knows what she was doing. V20 also said that R2 moves freely about and comes and goes out of his room. On 8/26/2022 at 12:30 P.M. and on 8/27/2022 at 9:30 A.M., R1 was observed in her room on the second floor. R1 was observed flipping pages of her book non-stop and was not trying to find a page. There were times that R1 just stare blankly with flat affect. When asked how she was doing, R1 said, I don't know, I don't know, I don't know. On 8/28/2022 at 1:50 P.M., V2 said that all the sexual abuse allegations were reported to V1. V2 added that the reported sexual allegations made since May of 2022 and August 10,2022 were not investigated and were missed, she had informed staff to let her know any allegations of abuse. There was no evidence that any of these allegations were investigated or reported to the state agency. R1's and R2's care plan was reviewed. The sexual abuse/sexually inappropriate behavior were not addressed. There were no interventions how R2 would be monitored to ensure R1, and other confused female residents were kept safe and free from abuse from R2. The EMR for both R1 and R2 including the nurses' notes, psychiatrist notes /physician notes, social services notes show no documentation regarding these sexual advances made by R2 to R1 The facility's policy for abuse latest revision date of 1/2019 shows: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented .Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility .This policy will define how the investigation of abuse allegations and mistreatment or crimes will be conducted and outline the process of reporting, investigating, and arriving at a conclusion or disposition of the allegation. Inquiries concerning abuse reporting and investigations will be referred to the Administrator and/or the Director of Nursing. The Administrator or DON shall review the findings of the investigation and determine if further training or other corrective action is needed to prevent future occurrences. The Immediate Jeopardy that began in May of 2022, was removed on 9/1/2022 when the facility took the following actions to remove the immediacy: 1. R1 was relocated to secured dementia unit with close monitoring on 8/30/22. R1's Care plan was revised on 8/31/22 to include wellness visits five times per week by social services or nursing staff. Also, to be included in care plan, monitoring of any behavior/side effects of R2's inappropriate touching to include anxiety, restlessness, self-isolation and crying. R1 will be seen by psychological services weekly, starting on 8/31/22 2. R2 is on a 1:1 supervision started on 8/30/22 until he is discharged from the facility. Resident received an IVD (Involuntary Discharge Notice) due to lack of payment which will end on 9/19/22. On 8/27/22, Social Services spoke with R2 regarding boundaries and no physical contact with R1. R2's Care plan was revised on 8/31/22 to include monitoring of any behavior to include not touching any female resident unless given permission; not allowed to go into female resident rooms. R2 will be seen by psychological services weekly, starting on 8/31/22. R2 signed behavior contract on 8/30/22, regarding inappropriate behavior with female confused residents. 3. How other residents of the facility were identified to potentially be affected: The facility conducted skin assessments for all residents with BIMS score of 7 or less for to assess for any allegation or sign of abuse. This began on 8/30/22 and will be completed 9/1/22. The facility interviewed female residents with a BIMS score of 8 to determine if R2 had any inappropriate behavior towards them. 4. Training: All staff will be educated by DON and Regional Consultant on 8/30/22 and will be completed on 9/1/22. The following will be reviewed and discussed: Abuse Policy with emphasis on different types to include sexual abuse: (any of the following scenarios, against the resident's will or the will of the resident's representative) a) If an allegation is reported to the administrator, please notify DON also immediately. b) If no outcome is observed from reporting notify Regional Director of Operation or Regional Nurse consultant c) Staff to communicate to Regional Director of Operations if abuse allegations are not reported or handled per facility's abuse policy. d) Staff to monitor R1 and R2's behavior. What should you do if you find a confused resident inappropriately touch or visited by another alert cognitively intact resident? a) Immediately intervene to provide resident safety and separate resident b) Immediately assess resident head to toe for any injury or harm to include emotional upset c) Notify the Abuse Coordinator for further guidance and instruction-Abuse Policy will be implemented. d) Staff to communicate to Regional Director of Operations if abuse allegations are not reported or handled per facility's abuse policy. e) Staff to monitor R1 and R2's behavior. 5. QAA/QAPI Audit tools will be reviewed 3 times a week for 2 weeks beginning 9/1/2022, then 2 times a week for 2 weeks for 3 months (9/15/2022) and then QAPI committee which meets monthly will review for compliance and determine that compliance has been meet (9/29/2022). An emergency QAPI was held and attended by medical director and Interdisciplinary team.

Based on Record Review and Interview the facility neglected to develop and/or follow policies to ensure residents receive medications ordered by physicians, and care of residents with fever and infection. This failure resulted in the worsening of R3's infection, R3 required hospitalization in the Intensive Care Unit and needed mechanical ventilation. As a result of these failures an Immediate Jeopardy was identified on 7/23/13 at 3:15pm. E1 (Administrator) and E2 (DON) were informed on 7/23/13 at 4:50pm. The Immediate Jeopardy began on 7/4/23 at 6:00am, when R3 was due to receive the first dose of Meropenem (Antibiotic). While the Immediacy was removed on 7/23/13 at 10:30pm, the facility remains out of compliance at a Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the implementation of staff training and the revised policies and procedures. This applies to 1 of 9 residents (R3) reviewed for infections in the sample of 9. The Findings Include: R3 was first admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing note dated for 6/25/13 documents that R3 is in on tube feeding with nothing by mouth, unable to communicate, alert, and confused. This note also shows that R3's temperature was 99.0 degrees F (Fahrenheit) on 6/25/13 at 5:00pm. The nursing note for 6/27/13 at 6:00pm shows that R3 had a temperature of 104.4. R3 was sent to the community hospital emergency room and subsequently was admitted with [DIAGNOSES REDACTED]. On 7/3/13 at 6:00pm R3 was readmitted to the facility. The [DIAGNOSES REDACTED]. The Physician order [REDACTED]. E6 (Registered Nurse, RN) timed the doses to start on 7/4/13 for 6:00am, 2:00pm, and 10:00pm. E6 reported R3's vital signs as blood pressure of 110/68, pulse being very high at 150 beats per minute, respiratory rate of 20, oxygen saturation of 99 % on three liters of oxygen per nasal cannula, and a temperature of 97.7 F. There is no documentation of the physician being notified of the Pulse. A review of R3 ' s Medication Administration Record showed that no doses of Meropenem were given until 7/7/13 at 6:00am (3 days later). On 7/22/13 at 11:05am E7 (Registered Nurse, RN) stated, "I was working on 7/6/14 on the three to eleven shift on 2 north. I administered the IV (Intravenous) Meropenem for R3. The assigned nurse for R3 was a LPN (Licensed Practical Nurse) and only a RN can administer IV's. I forgot to sign it off on the Medication Administration Sheet. R3 was feverish and the LPN told me it was R3's first dose of the Meropenem. It was about 10:00pm." The review of R3's MAR and staff interview showed that R3 did not get 8 doses of the ordered Meropenem. On 7/23/13 at 11:50am, E12, (RN who worked on 7/4/13, 11-7 shift) stated, "I didn't have the drug. R3's first dose was due at 6:00am. I called the pharmacy and they told me the drug needed to be authorized by the facility. I endorsed it to the next shift as it was two o'clock in the morning. I know we are supposed to call the DON but it was 2:00am." On 7/17/13 at 1:45pm, E9 (Registered Nurse, RN) stated, "On the morning of 7/4/13, I called the pharmacy to see where the Meropenem was. They faxed me a sheet the DON (Director of Nurses) needed to sign. I went to the DON's office. The DON was not there and the ADON (Assistant Director of nursing) told me to leave it on the DON's desk. On 7/5/13 around 11:30 to 12:00pm I still did not have the Meropenem. I called the pharmacy but I did not call the DON. The pharmacy said the form was still not signed." On 7/10/13 at 2:20pm, E2 (Director of Nurses, DON) was unable to give a specific timeline as to the delay in obtaining the drug. E2 stated, "I found out on 7/4/13 that the drug needed a signed document to authorize payment for the drug as R3's insurance would not pay for the drug. I am not sure exactly when the drug was sent over. I do know that on 7/6/13, E13 (RN) called and told me the drug was not available. This was in the morning. I told E13 to sign the paper and fax the sheet and call the pharmacy." On 7/10/13 at 3:10pm, E2 confirmed that there was no policy and procedure for ordering and receiving medication requiring prior authorization. The facility's policy and procedure titled " Unavailable Medications, Medication Shortage " dated 7/08/13 does not address how to obtain medications requiring prior authorization. On 7/11/13 at 10:20am, Z2 (Pharmaceutical Representative) stated, "We faxed an authorization to the facility on [DATE] that needed to be signed by the Director of Nurses, or facility staff authorized to sign for this drug as it was not covered by his insurance. Nothing was faxed back. On 7/6/13 we finally got the authorization signed and sent back to us at around 3:30pm. This order (Meropenem) was then sent out at 5:20pm on 7/6/13." On 7/18/13 at 10:44am Z4 (R3's Neurologist) stated, "The infection did worsen his neurologic status. If he did not get the ordered antibiotics (Meropenem) this did not help his infection." On 7/18/13 at 10:45am, Z5 (R3's Epidemiologist) stated, "Missing that many doses of Meropenem certainly worsened his infection. R3's prognosis is poor and R3 is now a Hospice patient with comfort care only. " On 7/18/13 at 11:00am Z1 (R3's Attending Physician) stated, "I did not know R3 missed 8 doses. I would have wanted to know right away if the temperature was too high. I would expect that a resident with a fever and infection at nursing home to have vital signs assessed at least once every shift. Vital Signs should also be assessed more frequently if needed. I think that the missing doses of the Meropenem worsened the infection for R3. The Meropenem was more for the Pseudomonas in the lungs causing the infection. " A review of R3's MAR and Nurse's Notes showed no documentation of vital signs on 7/5/13 for days, evening, and night shift. There were no vital signs documented for 7/6/13 for the day and night shift. On 7/7/13 no vital signs were documented until 5:00pm. At 10:20 pm R3 was noted to have temperature of 107 degrees F. R3 was given cold sponge and Tylenol suppository. At 10:45 pm 911 was called. The assessment record from the emergency room (ER) of the local/community hospital dated 7/7/13 showed R3 arrived in the ER at 11:48 pm. R3's initial temperature was 108.5 degrees F. R3 was admitted to the Intensive Care Unit (ICU) where R3 required artificial ventilation. R3's admitting progress note also showed that R3 had labored respirations and required non-rebreather mask. On 7/22/13 at 3:30pm, E6 (Registered Nurse RN, who worked 3-11 shift on 7/5/13) stated, "It was around 10:00pm when I called the physician to report a high white blood count. The doctor wanted to know what the vital signs were. I went to take the vitals and R3's temperature was 107 axillary. At 10:20 pm I called the doctor and he ordered to send R3 to the emergency room . I went and cooled him off with a sponge bath, gave Tylenol, and started R3's Meropenem. At 10:45pm, I called 911. I was able to get his temperature down to 100.6 axillary but it came back up to 106.0 axillary. I was afraid R3 would have convulsions". The facility ' s policy and procedure titled "Fever/Infection" dated October 2010 does not provide any guidance regarding the frequency of monitoring and assessing residents admitted with infection and fever. The policy and procedure does provide any guidance when the physician should be notified and what to do with a febrile resident. On 7/23/13 the surveyor confirmed through interview and record review the facility took the following actions to remove the immediacy of the situation: 1.) Policies and Procedures were reviewed and updated for Resident's change of condition, Assessment of Fever and Infection, Ordering and receiving medication requiring prior authorization. 2.) The Policy and Procedure for ordering and receiving medication requiring authorization included that a three day supply any medication will be dispensed from the pharmacy while information is being obtained for prior approval of the medication. 3.) The Policy and Procedure for Fever/Infection included that the facility nurse will assess a resident with a suspected infection and will document significant findings. The Nurse will utilize Interact Fever pathway in the assessment process which includes vital signs that are outside the normal parameters for the resident and may indicate that vital signs to be taken more often, such as 2 to 4 hours depending on the degree of change. 4.) An In-service has been conducted to review all above mentioned policy and procedures. All staff will be in-serviced prior to the start of their next shift until there is 100 % compliance.

Based on record review and interview the facility failed to monitor and provide timely care for a resident with an infection. The facility failed to monitor vital signs which contributed to the resident's symptoms worsening. These failures resulted in R3 needing hospitalization in an Intensive Care Unit with a temperature of 108.5 degrees Fahrenheit and requiring mechanical ventilation. As a result of these failures an Immediate Jeopardy was identified on 7/23/13 at 3:15pm. E1 (Administrator) and E2 (DON) were informed on 7/23/13 at 4:50pm. The Immediate Jeopardy began on 7/4/23 at 6:00am; when R3 was due to receive the first dose of Meropenem (Antibiotic). While the Immediacy was removed on 7/23/13 at 10:30pm, the facility remains out of compliance at a Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the implementation of staff training and the revised policies and procedures. This applies to 1 of 9 residents (R3) reviewed for infections in the sample of 9. The Findings Include: R3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Nursing note dated 6/25/13 documents that R3 is in on a tube feeding with nothing by mouth, is unable to communicate, is alert, and is confused. R3's body temperature was 99.0 degrees F (Fahrenheit) on 6/25/13 at 5:00 pm. The nursing note for 6/27/13 at 6:00pm shows that R3 had a temperature of 104.4 degrees F axillary. R3 was given a sponge bath and Rescue 8 (ambulance) was called. The 6/27/13 nursing note for this date at 10:10pm shows that R3 was admitted to a community hospital with [DIAGNOSES REDACTED]. The nursing note for 7/3/13 at 6:00pm shows that R3 was readmitted to the facility. The [DIAGNOSES REDACTED]. The Physician order [REDACTED]. On 7/3/13 at 6:00pm E6, RN (Registered Nurse) timed the doses of Meropenem to start on 7/4/13 for 6:00am, 2:00pm, and 10:00pm. On 7/3/13 at 6:00pm the admitting nurse E6, RN reported R3's vital signs as a blood pressure of 110/68, pulse being very high at 150 beats per minute, respiratory rate of 20, oxygen saturation of 99 % on three liters of oxygen per nasal cannula, and a temperature of 97.7 F. No documentation was in R3's record of the physician being notified of the Pulse. The Medication Administration Record for 7/3/13 through 7/7/13 shows that the first dose of Meropenem was to be administered starting 7/4/13 at 6:00am. The first dose that was signed off by a nurse was not until 7/7/13 at 6:00am (3 days later). On 7/22/13 at 11:05am, E7, RN (Registered Nurse) stated, "I was working on 7/6/14 on the three to eleven shift on 2 north. I administered the IV (Intravenous) Meropenem for R3. The assigned nurse for R3 was a LPN (Licensed Practical Nurse) and only a RN can administer IV's. I forgot to sign it off on the Medication Administration Sheet. R3 was feverish and the LPN told me it was R3's first dose of the Meropenem. It was about 10:00pm." The review of R3's MAR and staff interview showed that R3 did not get 8 doses of the ordered Meropenem. On 7/23/13 at 12:05pm, E12, (RN, who worked 11-7 shift on 7/4/13) stated, "I worked on the fourth (7/4/13). R3's first dose was due at 6:00am. I didn't have the antibiotic to give. I called the Pharmacy and they told me I needed authorization. I endorsed it to the next shift as it was two o'clock in the morning. I know we are supposed to call the DON but it was 2:00 am. I have too many residents. I have to prioritize my work. R3's Temperature was 100.0 degrees at around 2:00am. I gave Tylenol to R3. There were no other problems for the night. " On 7/17/13 at 1:45pm, E9 (Registered Nurse, RN, who worked 7-3 shift on 7/4/13) stated, "On the morning of 7/4/13, I called the pharmacy to see where the Meropenem was. They faxed me a sheet the DON needed to sign. I went to the DON's office. The DON was not there and the ADON (Assistant Director of nursing) told me to leave it on the DON's desk. On 7/5/13 around 11:30 to 12:00pm I still did not have the Meropenem. I called the pharmacy but I did not call the DON. The pharmacy said the form was still not signed." On 7/10/13 at 2:20pm, E2, DON (Director of Nurses) was unable to give a specific timeline as to the delay in obtaining the drug. E2 stated, "I found out on 7/4/13 that the drug needed a signed document to authorize payment for the drug, as R3's insurance would not pay for the drug. I am not sure exactly when the drug was sent over. I do know that on 7/6/13, E13 (RN) called and told me the drug was not available. This was in the morning. I told E13 to sign the paper and fax the sheet and call the pharmacy." On 7/11/13 at 10:20am, Z2 pharmaceutical representative stated, "We faxed an authorization to the facility on [DATE] that needed to be signed by the Director of Nursing, or facility staff authorized to sign for this drug, as it was not covered by his insurance. Nothing was ever faxed back. On 7/6/13 we finally got the authorization signed and sent back to us at around 3:30pm. This order was then sent out at 5:20pm on 7/6/13." On 7/4/13 through 7/7/13, R3's nursing notes and July 2013 Medication Administration Record (MAR) showed no documentation of vital signs on 7/5/13 for the day, evening or night shifts. No vital signs were documented for 7/6/13 for the day or night shift. On 7/7/13 no vital signs were documented until after 5:00pm when the nursing note shows that R3's temperature was 107.0 F. R3's nursing note for 9:50pm was written and crossed out with the word error written. The next nursing note written for 7/7/13 started at 5:00pm and did not clearly show the time that the assessment/actions occurred. R3's nursing note says that on 7/7/13 at 5:00pm, "Temp checked 99.3". "At 10:20PM returned to reassess resident and noted blood pressure 140/90, pulse 140, Temperature 107.0 F. Cold sponge applied, Tylenol suppository given." R3's nursing note documents that at 10:20pm the physician was "made aware". At 10:45pm 911 was called, and a report was given to the emergency room nurse at the community hospital. On 7/22/13 at 3:30pm, E6 (Registered Nurse RN) stated, "It was around 10:00pm when I called the physician to report a high white blood count. (The Normal Value of a White Blood Count is 5,000 to 10,000) R3's White Blood count on 7/7/13 was very high (around 27,000). The doctor wanted to know what the vital signs were. I went to take the vitals and R3's temperature was 107 axillary. At 10:20 pm I called the doctor and he ordered to send R3 to the emergency room . I went and cooled him off with a sponge bath, gave Tylenol, and started R3's Meropenem. At 10:45pm, I called 911. I was able to get his temperature down to 100.6 axillary but it came back up to 106.0 axillary. I was afraid R3 would have convulsions." On 7/10/13 at 2:30pm, E5 (Certified Nursing Assistant CNA) stated, "It was around 8:00 or 9:00pm that I noticed R3 was hot. R3 was moving around a lot and was very sweaty. It was around 9:00 or 9:30pm that two other nurses and myself gave R3 a sponge bath." The assessment record from the emergency room of the local/community hospital dated 7/7/13 showed that R3 arrived in the emergency room (ER) at 11:48 pm. R3's initial temperature recorded in the ER was 108.5 degrees F. R3 was admitted to the intensive care unit with a [DIAGNOSES REDACTED]. R3 needed to be intubated and continues to require intensive care service. R3 remained in the intensive care unit from 7/8/13 until 7/17/13. On 7/10/13 at 4:00pm, Z1 (R3 ' s Attending Physician) stated, "I would have liked to have known right away if R3's temperature was 107. We estimate that he missed at least six doses of the antibiotic. This certainly would have worsened his infection." On 7/18/13 at 11:00am Z1 stated, "I did not know R3 missed 8 doses. I would have wanted to know right away if the temperature was too high. I would expect that a resident with a fever and infection at nursing home to have vital signs assessed at least once every shift. Vital Signs should also be assessed more frequently if needed. Now R3 is getting close to his baseline mental status, but he is a Do Not Resuscitate, and is on comfort care only." On 7/23/13 the surveyor confirmed through interview and record review the facility took the following actions to remove the immediacy of the situation: 1.) Policies and Procedures were reviewed and updated for Resident's change of condition, Assessment of Fever and Infection, Ordering and receiving medication requiring prior authorization. 2.) The Policy and Procedure for ordering and receiving medication requiring authorization included that a three day supply any medication will be dispensed from the pharmacy while information is being obtained for prior approval of the medication. 3.) The Policy and Procedure for Fever/Infection included that the facility nurse will assess a resident with a suspected infection and will document significant findings. The Nurse will utilize Interact Fever pathway in the assessment process which includes vital signs that are outside the normal parameters for the resident and may indicate that vital signs to be taken more often, such as 2 to 4 hours depending on the degree of change. 4.) An In-service has been conducted to review all above mentioned policy and procedures. All staff will be in-serviced prior to the start of their next shift until there is 100 % compliance.

Based on observation, record review and interview, the facility failed to supervise residents, revise specific interventions to prevent further falls and failed to implement facility's policy for safe transfer. This is for 7 of 8 residents reviewed for falls in the sample of 18 (R3, R4, R6, R8, R11, R14 and R16 ). The facility also failed to lock and supervise treatment and respiratory carts. The treatment cart contained multiple medications/ointments and the respiratory cart contained breathing treatment medications. This failure resulted in R14 sustaining an impacted intertrochanteric basocervical fracture of the proximal left femur with some varus deformity at the fracture site. R14 was sent to the hospital with a [DIAGNOSES REDACTED]. R11 sustained laceration that required sutures at the hospital due to a fall on 3/20/2013. Findings include: 1. R14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R14 had multiple falls for the period of 4 months from 12/11/13 to 04/12/13. Most of the falls occurred while R14 was in the facility's Television room, unsupervised where she was found on the floor. - on 4/12/13 at 4:50 AM, R14 was sleeping in the recliner chair in the TV room. CNA left R14 to take a break and left the R14 unsupervised. Alarm was heard and R14 was discovered on the floor. The Nurse's notes dated 04/12/13 at 4:40 AM documented that R14 was assessed immediately showing left hip/femur pain. Ice placed on the area and Tylenol 650 mg was given. There was no documented ROM (Range of Motion) assessment. Despite her complaint of pain and without checking her ROM, R14 was assisted to the washroom at 5:15 AM. At 6:15 AM, the physician was notified and stat Left femur/hip X-ray was ordered to rule out fracture. There were no nursing documentation of R14's condition until 4:00 PM which showed that R14 was awake and sitting up in the wheelchair. R14 complained of left hip/leg pain upon movement. The Stat X ray was not done until 3:30 PM. Norco 5/325 mg was given for pain. This indicated that R14 was in pain but facility staff continued to move R14, assisted her to the bathroom and got her up in the wheelchair. X ray report dated 4/12/13 showed an impacted intertrochanteric and basocervical fracture of the proximal femur with some deformity at the fracture site. R14 was sent to the hospital. On 05/07/13 at 12:20 PM, E16 (Nurse) stated, "I was at the nursing station, R14 was sitting in the couch inside the TV room. I heard the alarm went off and found resident on the floor. R14 was not visible in the TV room and there was no staff present in the TV room when R14 was found on the floor. The resident just had their dinner and the CNA (former employee) said she just transferred R14 from the wheelchair to the couch. The 2 other CNAs were in the dining room to bring residents back to the unit." During telephone interview on 05/08/13 at 1:25 PM, E40 (CNA) stated, "I was sitting with R14 in the TV room. R14 was sitting on the couch. I went out to the nursing station to tell my nurse that I am going on my break. The nurse said okay. I went outside of the building to smoke cigarette for about 5- 10 minutes. When I came back, R14 was already on the floor. I am the only CNA on that floor and there was a nurse and 1 nurse orientee. The nurse knows that I was watching R14. I am usually with her when R14 is up. I try not to leave R14 because I don't want R14 to have a fall." The facility was aware that R14 had fall episodes when unsupervised and often when placed in the TV room. Care plan addressed the falls with the same approaches that have not worked as R14 continued to fall when not supervised. The facility continued to leave R14 unsupervised which resulted to more fall incidents and injury to R14 including a hip fracture and a visit to the emergency room . The facility failed to provide proper handling of R14 as they transferred her to the chair, to bed, assisted her to go to the bathroom and up in the wheelchair after a fall despite resident's complaint of hip and leg pain. These procedures were done without waiting to see whether R14 had a fracture and while R14 was in pain from 4:15 AM to 4:40 PM on 4/12/13. 2. R11 had multiple [DIAGNOSES REDACTED]. R11 was an [AGE] year old with original admission to the facility on [DATE]. R11 had been hosptalized on [DATE] and readmitted back to facility on 4/18/2013. Review of latest MDS (Minimum Data Set) dated 4/25/2013 showed that R11 scored 7= severely impaired for BIMS (Brief Interview for mental Status). R11 also required total assistance for hygiene and bed mobility with 1 person physical assist. On 5/6/13 at 11:15 A.M., R11 was observed in bed, alert, responsive and confused. Review of current fall risk assessment showed R11 scored as high risk for fall. Review of the facility incident reports indicated that R11 had fallen 5 times from 6/24/2012 to 3/20/2013. The reports were as follow: - 6/24/2012 (5:30 A.M.) - R11 was up and tried sitting on the bed. The bed wheels were not locked and the bed moved. R11 missed the bed and fell on the floor. - 8/13/2012 (7:45 A.M.) - R11 was ambulating to dining room from TV room and had slipped on a 12 inches x 12 inches area of wet floor. The written intervention for this fall incident indicated " (R11) has cognitive limitations, language barrier and functional limitations. Remind (R11) to walk with caution in slow pace on the wet floor." - 12/13/2012 (6:00 P.M.)- R11 was sitting on the bathroom floor. R11 attempted to self transfer to the wheelchair after toiletting , but the wheelchair rolled away and R11 ended on the floor. Incident investigation showed that intervention was to educate R11 to lock wheelchair brakes. - 2/12/2013 (3:00 P.M.) -" (R11) found on the floor in sitting position in the TV room. (R11) fell over while asleep on his wheelchair." - 3/20/13 (11:30 P.M.) - R11 found lying on the floor with bleeding forehead. R11 sustained laceration that measures 2.4 cm x 0.4 cm . R11 was monitored, however, continued to have small to moderate bleeding for period of 8 hours. R11 was sent to the hospital at 7 A.M. to suture the lacerated forehead. Review of the conclusion of facility's fall investigation dated 3/20/2013 showed that "(R11) has periods of agitation with impulsive behaviors, tried to get up from bed without asking for assistance." As indicated above, R11 had cognitive impairment, confusion, language barrier, functional limitations, with periods of agitation and impulsive behavior. The current care plan showed no specific intervention how to monitor and supervise R11 to prevent further fall. As a result of this failure, R11 sustained laceration from the fall of 3/20/2013. The facility failed to provide a hazard free environment by ensuring that bed and wheelchair wheels were locked and that the floor was maintained dry. 3. R8 is a [AGE] year-old with [DIAGNOSES REDACTED]. Hospital records printed 3/22/13 indicate R8 has a history of fall. Review of the facility incident reports indicate R8 had fallen 12 times from 6/9/12 - 3/21/13 as follows: - 6/9/12 (10:00 AM) - slipped off wheelchair (w/c) while attempting to reach in closet. No injury. - 6/11/12 (7:00 PM) - fell off w/c while attempting to reach for TV on the floor. Family brought in a TV and put the facility TV on the floor. No injury. - 6/12/12 (5:30 PM) - fell off the bed while trying to reach for her socks. No injury. - 6/13/12 (1:00 PM) - tried to transfer from w/c to bed without assistance. No injury - 9/26/12 (5:20 AM) - fell off the bed while trying to pick up shoes from the floor. No injury. - 10/18/12 (4:10 AM) - staff eased resident to floor as resident was found sliding off her bed. No injury. -1/2/13 (6:35 AM) - leaned forward from the w/c with lap cushion. Resident fell along with w/c and lap cushion attached. No injury. - 2/3/13 (2:15 AM) - found on the floor mattress. Left buttock and hip area reddened. - 2/7/13 (lunchtime) - CNA (Certified Nursing Assistant) took off lap cushion for lunch in the dining room. R8 fell on her knees and hit forehead on the wall after CNA left resident to attend to other residents. Slight redness to forehead. - 2/13/13 (10:45 PM) - found on the floor on her knees. No injury. - 3/5/13 (3:45 AM) - found on the floor mattress. No injury. - 3/21/13 (7:30 PM) - found in the dining room hallway in w/c lying on her side with the w/c and lap cushion still attached. Left eyebrow has bruise and was swollen. Resident was sent to the hospital for evaluation. CT scan and x-ray results were negative. Incident of 3/21/13 investigation interview with nurse E20 (Nurse) state that E20 was at 2 Main (outside of Alzheimer Unit) passing medications when the incident occurred. R8 was sent to the hospital due to bruise and swelling of left eyebrow. No evidence found to indicate report was sent to the state survey agency. Summary and conclusion report on the fall incident of 3/21/13 indicate that it did not warrant to send report to the survey agency since there was no negative outcome. Staff interviewed in the Alzheimer Unit on 5/5/13, 5/6/13, 5/7/13 all stated additional help was needed. On several occasions, the nurses could not be found in the unit. When asked where they were, the nurses said they also had to cover Rooms 215 - 221 (11 beds) outside of the Alzheimer Unit. On 5/8/13 at 10:10 AM on a telephone interview, Z2 (Family Member) of a resident in the Alzheimer Unit stated approximately 2-3 months ago, the evening staff would not show up. Other staff would be assigned to the unit and these staff had "no idea" about the residents. Z2 state that the nurse "goes between units" and there would be no nurse available. Z2 state that the Alzheimer unit is not properly staffed. 4. R4 was a [AGE] year old with multiple [DIAGNOSES REDACTED]. Review of latest MDS (Minimum Data Set) dated 4/5/2013 and 1/3/2013 showed that R4 was assessed as 2/2 for ambulation and transfers( limited assistance with 1 person physical assistance) . Review of incident report dated 3/28/2013 indicated that R4 fell due to improper transfer. The incident report indicated that E42 (CNA- Certified Nurse Assistant) did not use gait belt during the transfer. The report also indicated that E42 attempted to transfer R4 twice and lifted R4's belt and pants instead of using the gait belt. Review of facility policy indicated that "Gait Belt usage is mandatory for all resident handling." 5. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of incident/accident report indicated that R3 had several falls on the following dates: On 02/20/13 at 6:00 PM, R3 was seated on the wheelchair in the dining room and a crashing sound was heard by a CNA and R3 was found on the floor. On 05/07/13 at 3:10 PM, E26 (CNA) stated, "I was putting another resident back in bed and heard a sound. I went out of the room and went to the dining room and saw R3 lying on the floor. Dinner is about to start. There were 2 CNA (E26 and E27 ) in the unit. E27 was coming out from the farther section of the 2 Main unit. We are in the process of bringing residents to the dining room and there was no staff in the dining room." According to E7's documented statement report dated 2/20/13, E7 was passing medications and was informed by a CNA that R3 was on the floor. On 03/07/13 at 10:30 AM, R3 was sitting in reclining chair and was found again on the floor in the dining room. On 05/07/13 at 11:30 AM, E29 (CNA) stated, "I was pushing a resident towards the dining room and the other CNA was in the hallway. I heard the alarm, went to the dining room and saw R3 on the floor. There was no staff in the dining room then I called the nurse." On 03/14/13 at 2:30 AM, R3 was found on the floor next to bed. On 03/26/13 at 1:40 AM, R3 was found again on the floor next to bed. On 03/28/13 at 12:30 AM, 04/28/13 at 3 PM and 05/03/13 at 3:20 PM was noted again on the floor mat in the room. On 05/08/13 at 1:35 PM, E30 (CNA) stated, "I was doing my rounds, and R3's alarm was going on and off and making noise. R3 was in bed getting restless. R3 was halfway trying to get out of bed and then I went out of the room, went to get another and the mechanical to get up R3. When I came back to the room R3 was already on the floor." 6. Review of the Accident/Incident Reports from 4/14/12 to the present, R6 had 7 fall episodes on 6/11/12, 9/1/12, 10/17/12, 1/25/13, 2/16/13, 2/20/13 and 4/20/13. On 6/11/12 at 5:15 AM, R6 was walking to the bathroom and slipped due to the wet floor. R6 complained of right shoulder pain. Cold compress was applied to the site. R6 was sent to the hospital. MRI (Magnetic Radioactive Imaging) showed right shoulder dislocation. 7. Review of the Accident/Incident Reports indicated that R16 had multiple falls on 5/23/12, 6/5/12, 8/28/12 & 1/4/13. On 6/5/12 at 12:30 PM, R16 was assisted to the toilet by E41 (CNA -Certified Nursing Assistant) and left the room. Another CNA (former employee) saw R16 trying to stand up from the toilet and almost fell . The CNA grabbed the resident's arm and called for help. The staff nurse came and both staff assisted CNA back to bed. No incident report was written for the near fall until 6/6/13 when R16's right ankle showed large bruise and R16's complained of right ankle pain. The X Ray of the left lower extremity showed fracture of distal fibula right side. On 8/28/12, R16 got out of bed unassisted and fell on the floor, bed alarm, mattress and bed bolster came off. On 1/413 at 11:40 PM, R16 was found on the mattress floor by the bedside, sitting down. 8. On 5/5/13 at 8:00 PM by 1 North Unit hallway, the second drawer of the respiratory cart was observed fully opened. There were 4 full boxes of Ipratropium inhalation medications in the drawer. There was no visual control of the cart for at least 15 minutes. No staff was present. E23 (Respiratory Therapist) came out from an identified isolation room at 8:15 PM. E23 stated that she opened the cart to get some respiratory supplies. 9. On 05/06/13 at 12:15 PM, the treatment cart in 1 North Unit was observed parked in the hallway near the nursing station unlocked and unattended. E37 (Nurse) was informed of the above mentioned finding.

Based on observation, interview and record review, the facility failed to consistently monitor, comprehensively assess, identify and follow plan of care to prevent the development of facility acquired pressure ulcers. This applies to 2 of 4 residents (R10 and R11) reviewed for pressure sores in the sample of 18. As a result of this failure, R10 developed stage II pressure sore which became unstageable in 21 days. R11 developed a deep tissue injury related to a pressure on the left hip and a stage 2 pressure sore characterized by a blood filled blister on the left outer ankle and a fluid filled blister on the left forefinger around the knuckle. Findings include: 1. R10 has [DIAGNOSES REDACTED]. R10 is totally dependent on staff for all ADL (Activities Daily Care) care and is mostly in bed. Review of Weekly Wound Documentation dated 01/14/13 showed "Nurse notified of open sore to the sacral area. Assessment completed, Stage II noted, measured and documented. Z6 ( Physician) notified with new orders received and carried out. Family notified. Dietary notified of new pressure sore ulcer awaiting recommendation." The facility's initial wound assessment on 01/14/13 described the wound as L (length) 1.2 cm x W ( Width ) 1.2 cm x D (Depth) 0.1 cm, stage II, superficial wound bed, surrounding area intact and with scanty drainage. On 05/08/13 at 11 AM E3 ( Nurse Consultant ) acknowledged that the documentation for weekly wound assessment for R10's for January 22 and January 29, 2013 were missing. E3 further stated that there was no documentation to show that the wound was unavoidable. The facility did not initiate care plan when R10 developed stage II pressure on 01/14/13. On 02/04/13, the Skin Alteration Record described the sacral wound as bigger with the measurement as L-2. 2 cm x W- 2 cm D- 0.2 cm unstageable, 100 percent slough. The wound was described as Necrotic-eschar, black in wound 100 %. Wound care evaluation by the Wound Doctor on 02/04/13 also described the sacral wound as L- 2cm x W- 2 cm with 0.2 depth unstageable, Eschar/necrosis 100 percent with minimal serous exudate. Treatment order for the pressure sore on 01/14/13 " Cleanse sacral with NSS ( Normal Saline Solution), apply collagen dressing, cover with [MEDICATION NAME]. Change QOD (every other day) and PRN ( as needed) until healed. On 02/04/13 the treatment order was changed to apply Santyl & [MEDICATION NAME] ointment and cover with foam dressing and PRN. March TAR (Treatment Assessment Record) showed that the box was left blank on March 30 and 31, 2013 meaning treatment on the sacral area were not done. R10's care plan for pressure sore was initiated on 02/4/13 when the pressure sore was already unstageable. On 05/07/13 at 1 PM, E28 (wound nurse) indicated that she was new in the facility and did not know how the pressure sore developed. 2) R11 has [DIAGNOSES REDACTED]. R11 was an [AGE] year old with original admission to the facility on [DATE]. R11 had been hosptalized on [DATE] and readmitted back to facility on 4/18/2013. Review of latest MDS (Minimum Data Set) dated 4/25/2013 showed that R11 scored 7= severely impaired for BIMS (Brief Interview for mental Status). R11 also required total assistance for hygiene and bed mobility with 1 person physical assist. Review of "Wound Care Evaluation" dated 4/29/2013 showed that R11 had multiple wounds due to multiple risk factors for skin breakdown. This evaluation also included that R11 be turned and repositioned in bed every 1-2 hours and be checked for skin breakdown daily. During wound dressing change observation on 5/6/2013 at 11:15 A.M. with E16 (Wound Treatment Nurse) and E18 (Restorative Aide), R11 was in bed, alert and responsive. R11 was partially turned to his left side and left buttock was touching the bed . There was a sensor alarm pad made of vinyl plastic that was placed directly underneath R11's buttocks. There was a bed sheet in between the vinyl sensor pad and R11's buttocks. E16 informed E18 that R11's plastic vinyl sensor pad should not be placed directly underneath the sacral /buttocks/ ischium area as this could cause more pressure/friction to the existing pressure sores. R11 was noted with multiple pressure sores on the following areas: - upper outer area of the right ear around the cartilage - unstageable pressure sore with eschar on the sacrum - unstageable pressure sore covered mostly with slough on the left ischium - stage 2 pressure sore on the right buttock - unstageable pressure sore with eschar on the scrotum - unstageable pressure sore with eschar on the right heel - left hip pressure ulcer, with reddish /purplish discoloration - stage 2 bloody fluid filled blister on the left outer ankle - fluid filled blister on the left forefinger around the knuckle During this observation, E16 stated that she was not aware of the existence of the pressure sores on the left hip, left ankle and the blister on the left forefinger. E18 stated that she was not aware of the existence of these pressure sores (left hip,left ankle and left forefinger) during the perineal care approximately 30 minutes prior to the dressing change. There were no assessements and treatments to these unidentified sores. Review of current "Ongoing Skin Alteration Record" showed the following wound assessments: - right outer ear with 1.3 cm in length; width 0.3 cm, depth 0.1 with scant exudate acquired at the facility on 5/4/2013 - left ischium with 7.2 cm in length, 7.3 cm in width and 0.3 cm in depth assessed on 4/29/2013 as unstageable pressure sore with eschar with moderate exudate - right buttock stage 2 pressure sore with 2 cm. in length, 1 cm width, and depth of 0.1 cm. - pressure sore on the scrotum with 2 cm. width, 1 cm. length and 0.1 cm in depth, eschar with scanty serous exudate as assessed on 4/29/2013 - unstageable pressure ulcer on the right heel with 4 cm. in length and 3 cm. in width During the initial tour on 5/5/2013 at 12:30 P.M., there was a "Repositioning Schedule" posted above R11's headboard. The repositioning schedule was as follows: -10 A.M. facing window(R11's left side) -12 noon facing door(R11's right side) - 2 P.M., facing window - 4 P.M., facing door - 6 P.M., facing window R11 was observed in bed on 5/5/2013, lying on his left side facing the window at 12:30 P.M., 2:10 P.M., 4:00 P.M. and 6:15 P.M. On 5/8/2013 at 4:50 P.M., E17(CNA- Certified Nurse Assistant) stated that R11 was supposed to be turned at 12 noon on 5/5/2013. E17 said that she was not able to turn R11 at 12 noon and only repositioned R11 at 1:30 P.M. (facing the window) because E17 was attending other residents during lunch time in the main dining room. This indicated that R11's turning and repositioning schedule was not followed. Review of current plan of care indicated that R11 be turned and repositioned every 1-2 hours for pressure relief. This plan is to prevent development of new pressure sores and worsening of the existing sores. R11's record also showed that there was no current comprehensive nutritional assessment to ensure that optimal nutritional intervention for wound healing was in placed. E3(Nurse Consultant) acknowledged this concern on 5/8/2013 during the daily status meeting. -

Based on observations, interviews and record reviews, the facility failed to provide supervision to two residents (R2 and R3) that were identified as at risk for falls, and failed to assess, analyze the circumstances, develop interventions, and re-evaluate for the effectiveness of interventions after each residents (R2 and R3) experienced falls in the facility. This applies to two residents (R2 and R3) in a sample of three residents, who are at high risk for falls. This failure resulted in R2 who sustained a cut to his upper lip which required evaluation and treatment at the local hospital and R3 sustained a laceration to the back of her head requiring 5 staples to close the wound at a local hospital. Findings include: 1. R3 was interviewed in her room on 1/31/2012. R3 was alert and anxious about her health. R3 stated that she recently fell in the facility. R3 said, "I needed 5 stables to close the wound to the back of my head." The nurse (E6), who took care of R3 on 1/25/2013, was interviewed by phone on 2/05/2013 at 11:40 AM. E6 indicated that staff did not witness R3's fall. E6 stated that she was on the second floor (R3 resides on the first floor) with a nurse, who was in orientation. E6 reported that the night nurse has to also take care of residents on the first and second floor. But, E11 was in room, providing care to another resident. E6 said E11 called her and told her to come down to the first floor. E6 stated: "We went down because we got the idea something happened. When we got there she (R3) was on the floor. E6 told me she (E11) was helping someone in another room. She (E11) came out and R3 was screaming. (E6 reported that R3 had a habit of not using her call light and usually yell for staff assistance.) E11 went to her (R3) room and found her on the floor. R3 had turned herself in bed and fell on the floor." E6 reported that R3 was not at risk for falls. E6 indicated she knew this because R3 had no fall prevention measures in place. E6 said, "If someone is at risk for falls, they have chair and bed alarms and mats on the floor. R3 had nothing (no preventive measures in place.)." E6 described R3 as being unable to walk and stand by herself. E6 also described R3 as often having severe drops in her blood sugar level usually at night. The restorative nurse (E12) was interviewed on 2/05/2013 at 2:35 PM. E12 stated that R3 was assessed at risk for falls when she was admitted to the facility. The facility MDS coordinator (E8) was interviewed on 2/05/2013 at 2:09 PM. E8 reported that no fall prevention measures were put in place for R3 until after she (R3) fell on [DATE]. E8 said that R3 had a star placed on her (R3's) door name tag to alert staff that R3 was at risk for falling, and attached to her wheel chair. E8 was observed to go to R3's room to look for the star. But, no star was observed attached to R3's door name tag or wheel chair. E8 stated that she could not explain why the alert to staff was not in place for R3. On 2/05/2013, E9 (acting director of nursing) was interviewed. E9 reported that the previous director of nursing did not complete a comprehensive fall assessment with an analysis for R3. Review of the Facility Admission/Readmission Departmental Notification Assessment, dated 12/28/2012, documented that R3 was admitted to the facility with the following Diagnosis: [REDACTED]. R3 is a [AGE] year old female. In the area " Special Risk Precaution and Equipment/Program needs upon Admission/Readmission *Nursing Department ", R3 was documented at high Risk for fall. However, the area for "Requires the following interventions " was left blank. No interventions were identified to address R3's risk for falls. R3's MDS (Minimum Data Set) Assessment, dated 1/10/2013, documented that R3 had a fall with fracture in the last three months and was at risk for falls. The Care Area Assessment (CAAR) for R3 documented that R3 triggered for risk to fall. R3 was assessed to have multiple factors that could cause her to fall; such as: unsteady gait, position change/transition-balance difficulty, balance problems, uncontrolled diabetes, and loss of arm and leg movements. R3's CAAR documented the need for R3 to have: "fall precautions in place to prevent future injury" The CAAR also directed staff to develop and "continue with care plan" for R3's fall. Review of R3's care plan had documentation that on 1/07/2013, R3's risk for fall was a focus of concern in her care. However, R3's care plan lacks specific staff interventions or use of safety devices to prevent R3 from falling. R3's MDS identify factors that put her at risk for falls, but the care plan had no interventions/approaches addressing these factors. One of the approaches was not appropriate for R3, and directed staff to have R3 uses her call light. But, staff reported that R3 would yell to call staff and did not use her call light. Review of the facility's Incident Reports were difficult because on 1/31/2013, the administrator (E1) stated that the director of nursing (E2) had taken them (6 months of the facility's incident reports) home along with the Accident/Incident Tracking record. When the records became available, the tracking record was not complete. There was an incident report documenting that R3 had fallen in the facility. Review of this Incident Report, dated 1/25/2013, documents the following: 1/25/2012 at 4 AM, "Resident (R3) was on the floor in supine position in her room." A review of R3's Comprehensive Assessment, date 1/25/2013, was not completed. The following areas were left blank: "Root Cause as why the fall incident happened. Previous Interventions put in Place. Were the previous interventions effective?" The follow up to R3's fall on 1/25/2013, or the "Follow-Up Meeting" Form had no documentation of an interdisciplinary team getting together to analyze and develop a plan of care to address R3's fall. Review of the facility's Fall Program Guidelines had documentation instructing staff to do the following: "5. Resident identified to be a fall risk will have an identified symbol placed on the doorway by the resident name, on the wheelchair (If applicable), and on the mobility assistive device (if applicable). 6. Resident's identified as fall risk will have an individualized care plan to address the contributing factors that place them at risk, goals to prevent falls/injury, and interventions/approaches to promote safety of the residents ... ." This policy was not being followed in the care of R3. Review of the facility Accident/Incident Reporting Policy documented the following instruction for staff: "12. A more extensive investigation procedure is required for the following occurrences: ...Fall with injury." But, this was not done after R3's fall occurrence on 1/25/2013. 2. Review of the facility's Accident and Incident Report, dated 10/26/2012 at 2:40 PM, documented the following: "Nurse heard an alarm and also resident calling for help immediately went to that room and resident is on the floor ..." R2 cut his lip on a garbage can that was near him. R2 was sent to the hospital for evaluation and treatment. Review of R2's Admission Face Sheet document that R2 is a [AGE] year old male with [DIAGNOSES REDACTED]. Review of R2's plan of care documented that R2 is at risk for fall and this is a focus in his care. One of the nursing care approaches was documented as: "8/10/2012 Educate wife to leave armrest and footrest of wheel chair up for safety. 8/10/2012 Staff to check resident for all safety appliances after wife leaves resident in the room." However, staff failed to ensure safety device was applied appropriately when the resident fell on [DATE]. The nurse working the day that R2 fell was interviewed on 2/05/2013. E7 stated, "During the day at 2:45 PM, I was at the nursing station and heard an alarm. R2 was on the floor on his left side with facial bleeding on the upper lip." E7 reported that R2 was sent to the hospital for evaluation and treatment. The MDS coordinator (E8) was interviewed on 2/05/2013. E8 stated that R2 had been on fall precautions for a long time. E8 said that R2 needs the use of his arm rest and foot rest to prevent him from falling forward. But, E8 said that the CNA on 10/26/2012 did not ensure that the leg rest was used as required on 10/26/2012.