Every finding on record at Marigold Rehabilitation and Health Care Center

Based on record review and interview, the facility failed to protect a resident from resident-to-resident physical abuse for one of four residents (R3) reviewed for abuse in the sample of five.Findings include:The facility's Abuse Prevention and Prohibition Policy dated 11/2025 documents, Residents must not be subjected to abuse by anyone, but not limited to, facility staff, other residents, consultants, staff of other agencies, family members, legal guardians, friends, or other individuals. The resident has the right to be free from verbal, mental, sexual, exploitation or physical abuse.R3's current admission Record documents R3 has diagnoses of Severe Dementia, Alzheimer's Disease, and Chronic Pain.R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is severely cognitively impaired.R4's current admission Record documents R4 has diagnoses of Alzheimer's Disease, Impulsiveness, and Moderate Dementia.R4's MDS assessment dated [DATE] documents R4 is severely cognitively impaired and has physical behaviors directed towards other four to six times per week.R4's current Care Plan documents R4 has behaviors of being physically and verbally aggressive.On 7/31/26 at 12:40 PM V12 (CNA/Certified Nursing Assistant) stated, Around a month ago (unknown date) I was working during the day shift. (R4) has went up to (R3) in the hallway and grabbed (R3) by the wrist and was squeezing (R3's) wrist. (R4) gets aggressive. (R3) was yelling out for help and had a reddened area to her wrist. I do not recall what wrist. I got (V2/Director of Nursing) to help and try to calm (R4) down. It is hard to keep an eye on all of the residents on this unit.On 7/31/26 at 12:45 PM V2 stated, Around a month ago, (V12) came and got me to help with (R3 and R4). (R4) was agitated and had lashed out at (R3). (R4) had grabbed and squeezed (R3's) wrist and did not want to let go. I reported this to (V1/Administrator) immediately as physical abuse.On 7/31/26 at 2:00 PM V1 (Administrator) stated, (R4) squeezing (R3's) wrist would be considered physical abuse.

Based on record review and interview, the facility failed to report an allegation of resident-to-resident physical abuse to the State Agency and failed to submit a final report of the investigation to the State Agency within five working days of the occurrence for two of four residents (R3 and R4) reviewed for abuse in the sample of five.Findings include:The facility's Abuse Prevention and Prohibition Policy dated 11/2025 documents, Reporting: The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. The allegation will be reported no later than two hours, or per state regulations, after the allegation is made. The investigation report will be complete and summarized the investigation within five business days. Complete final report and submit to the requires agencies. Maintain the report in a locked file in the Administrator's office.On 7/31/26 at 12:40 PM V12 (CNA/Certified Nursing Assistant) stated, Around a month ago (unknown date) I was working during the day shift. (R4) has went up to (R3) in the hallway and grabbed (R3) by the wrist and was squeezing (R3's) wrist. (R4) gets aggressive. (R3) was yelling out for help and had a reddened area to her wrist. I do not recall what wrist. I got (V2/Director of Nursing) to help and try to calm (R4) down.On 7/31/26 at 12:45 PM V2 stated, Around a month ago, (V12) came and got me to help with (R3 and R4). (R4) was agitated and had lashed out at (R3). (R4) had grabbed and squeezed (R3's) wrist and did not want to let go. I reported this to (V1/Administrator) immediately as physical abuse.The facility's Abuse Investigations and R3 and R4's Electronic Health Records were reviewed and do not include a final investigation or evidence of the State Agency notification of the allegation of (R4) getting aggressive and squeezing (R3's) wrist.On 7/31/26 at 2:00 PM V1 (Administrator) stated, (R4) squeezing (R3's) wrist would be considered physical abuse. I do not recall anyone reporting this to me. V1 verified the facility has not notified the State Agency or submitted a final investigation to the State Agency regarding allegation involving R3 and R4.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse for two of four residents (R3 and R4) reviewed for abuse in the sample of five.Findings include:The facility's Abuse Prevention and Prohibition Policy dated 11/2025 documents, Investigation: The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action.On 7/31/26 at 12:40 PM V12 (CNA/Certified Nursing Assistant) stated, Around a month ago (unknown date) I was working during the day shift. (R4) has went up to (R3) in the hallway and grabbed (R3) by the wrist and was squeezing (R3's) wrist. (R4) gets aggressive. (R3) was yelling out for help and had a reddened area to her wrist. I do not recall what wrist. I got (V2/Director of Nursing) to help and try to calm (R4) down.On 7/31/26 at 12:45 PM V2 stated, Around a month ago, (V12) came and got me to help with (R3 and R4). (R4) was agitated and had lashed out at (R3). (R4) had grabbed and squeezed (R3's) wrist and did not want to let go. I reported this to (V1/Administrator) immediately as physical abuse.The facility's Abuse Investigations and R3 and R4's Electronic Health Records were reviewed and do not include an investigation of the allegation of (R4) getting aggressive and squeezing (R3's) wrist.On 7/31/26 at 2:00 PM V1 (Administrator) stated, (R4) squeezing (R3's) wrist would be considered physical abuse V1 verified an investigation has not been conducted regarding R4 allegedly getting aggressive with R3 and squeezing R3's wrist.

Based on observation, interview, and record review, the facility failed to prevent physical and verbal abuse from happening for five (R1, R2, R4, R5 and R6) of five residents reviewed for abuse in a sample of six. The physical abuse on 3/9/26 between R1 and R2 resulted in R1getting a black eye and ear laceration, and R2 getting a fat lip.Findings include:Facility Abuse, Prevention, and Prohibition Policy, dated November 2025, documents Each resident has the right to be free from abuse. Residents must not be subject to abuse by anyone, including but not limited to staff, and other residents. This facility prohibits mistreatment, neglect, or abuse of residents. Resident to resident abuse includes the term willful. The word willful means that the individuals action was deliberate regardless of whether the individual intended to inflict injury or harm.1.R4 and R5's Final State Report, dated 2/24/26, documents on 2/27/26 R4 reported to facility staff that V10 CNA/Certified Nurse Aide verbally abused R5 in her room. R5 is unable to state if she feels abused due to her cognitive status. V10 admits to being overwhelmed with the amount of work she was assigned. R4 states he has felt V10 has been rude to him when providing care. V10 doesn't take enough time when working with him and felt V10 was rude to other residents. V14 LPN MDS/Minimum data Set stated V10 did appear to be overwhelmed in the performance of her duties. With the potential of (V10) being agitated or stressed while on duty, and thereby allowing any negative occurrence to take place, the facility has chosen not to return her to employment.V10's employee file documents V10 CNA was hired 8/26/24 with a termination 2/27/26 for: Corrective action form dated 2/17/26 (V10) displayed a level of discourteousness towards a facility resident that was out of bounds for normal interactions especially with facility residents. Termination of employment (not eligible for rehire). Educated for dementia care and abuse on 2/26/25.Signed facility resident rights and preventing abuse on 9/13/24 which includes preventing mental, physical, verbal abuse.On 4/17/26 at 3:15PM, V14 LPN MDS/Licensed Practical Nurse Minimum Data Set stated, I was called to (R4) room, and he said (R5) was yelling stop and (V10 CNA) said be quiet and get out of bed. That same day (R4) felt (V10) was rough with him for cares, he felt she was aggressive and loud speaking. I was the nurse working on the hallway that night, I called (V19 Prior Administrator) about (V10) and (V10) was clocked and walked out of the building. I felt (V15) was overwhelmed because she was anxious, agitated, and short tempered.2.R2's electronic nurses note, dated 3/9/26 at 2:06am V9 LPN, documents (R2) was observed in (R1's) bed physically restraining him by his wrist holding him to the bed. (R1) was yelling for help and (R2) was not redirectable. 911 was called. (R2) was given Haldol in the buttocks. (R2) was sent to the hospital for evaluation of his behavior. Police were present.R2's Nurses note, dated 3/9/26 at 2:30AM by V3 DON/Director of Nursing, documents (R2) was heard screaming in his room; (R2) was observed holding (R1's) wrists down pinning him to the bed and screaming in his face; (R2) was insisting (R1) had a gun and was going to hurt him and the staff; staff were able to get (R2) to let go of (R1); (R2) was not able to be redirected; (R2 was given Haldol IM/Intramuscular but it was not successful; and (R2) sent to the ER/emergency room for further evaluation at the hospital.R1's electronic nurses note, dated 3/9/26 at 2:30AM by V3 DON documents (R2) was observed on top of (R1) screaming in his face and saying (R1) had a gun and was going to hurt everyone. Staff was able to get (R2) off (R1) and out of the room. Staff remained in the doorway so (R2) could not get into the room with (R1), and once (R2) was sent out of the nursing home (R1) was able to lay back down and rest.R1's electronic skin notes, dated 3/9/26 at 10:24AM by V15 LPN, documents New skin issue to right eye. Below right eye, above cheek bone bruising, wound acquired in house on 3/9/26. Length 3cm/centimeters by width 5cm. On 3/9/26 at 12:14PM, V15 documents new skin issue right ear. Length 1.58cm by width 2.5cm and area 3.17 (cm2).R1 and R2's final State Report, dated 3/13/26, documents on 3/9/26 in residents' room a physical interaction between R1 and R2 took place. Redness noted to skin for both residents where they had come into physical contact with each other. R2 was noted to have a cut on his lip and scratch by his left eye. R1 was noted to have redness around the area of his wrists. V9 LPN/Licensed Practical Nurse stated R2 was lying over R1 holding on to R1's wrists and wouldn't let go. V7 CNA/Certified Nurse Aid working on the unit confirmed V9 facts.On 4/17/26 at 12:15PM, R1 was alert, in a manual wheelchair, unable to answer questions/confused, jumbled speech, and was talking/muttering to himself. R1's right eye had a moon shaped bruise purple/pink underneath eye, and his left eye purple under eye extends to cheek which has a greenish colored bruise.On 4/17/26 at 12:15 PM, R2 was in the dining room, alert, got up and walked independently to the hallway, confused, grabbing stuff off the food cart, unable to answer questions, and very busy walking around with staff attempting to redirect and required many attempts at redirection.On 4/17/26 at 12:15PM, V20 Memory Care Supervisor stated (R2) is hard to redirect and keep busy.On 4/17/26 at 12:30PM, V18 CNA stated (R2) has hallucinations; (R1 and R2) were roommates; (R2) talks but not a lot and he is hard to understand; not sure what exactly happened that day just what I was told by the CNA.On 4/17/26 at 12:40PM, V17 CNA stated (R1) [NAME] and talks to himself a lot all the time.On 4/17/26 at 12:50PM, V18 CNA stated (R1's) left eye was black and (R2) had a fat lip. What I understood was (R2) was holding (R1) down, they were going at it fighting. (R2) was really hard to re-direct, he still takes coaxing. (R2) sometimes freaks out and runs for the door to get out and pound on the door.On 4/17/26 at 3:00PM, V12 RN stated R2 has a history of running into doors and hitting unprovoked.3. R2's Final State Report, dated 3/11/26, documents Alzheimer's/Dementia Care Area of Facility on 3/4/26 V12 RN ADON/Assistant Director of Nursing communicated to V19 Prior Administrator V13 CNA had spoken inappropriately to residents on the Alzheimer's/Dementia Care Area. The residents living in that area are unable to state if they felt verbally abused due to their cognitive status. V12 RN ADON reported she felt V13 CNA had communicated with the residents in a concerning tone. V20 Supervisor of Alzheimer's/Dementia Unit stated V13 appeared to be overwhelmed in the performance of her duties. V17 CNA stated V13 did display a feeling of being overwhelmed and stressed which appeared to be caused by her workload. With the potential of (V13) being agitated or stressed while on duty, and thereby allowing any negative occurrence to take place, the facility has chosen not to return her to employment.V13's employee file documents V13 PTA/Physical Therapy and CNA last day worked was 3/4/26. V13 signed facility resident rights and preventing abuse on 2/12/24 which includes preventing mental, physical, verbal abuse.On 4/17/26 at 3:00PM, V12 RN stated Me and (V14 LPN) walked (V13 PTA/Physical Therapy Aid) out on 3/4/26, I was the ADON at the time. I was walking back to the memory care unit and staff said, You have got to do something about her she is yelling. When I went back to the unit V13 had her voice raised. (R2) was standing there and lots of other residents.4. R2's electronic nurses note, dated 3/24/26 at 1:15PM by V16 RN/Registered Nurse, documents CNA informed me that (R2) had grabbed (R6's) left arm and would not let go.R2 and R6's Final State Report, dated 3/31/26, documents on 3/24/26 on the Alzheimer's/Dementia Care Area of Facility a physical interaction between (R6) and (R2) took place in the Alzheimers/Dementia Care area. V16 RN was a witness to the interaction stated (R2) grabbed (R6's) left arm. V17 and V18 both CNAs confirmed V16's report.

Based on observation, interview, and record review the facility failed to transcribe a residents physician order appropriately for one (R2) of eight residents reviewed for medication administration in a sample of 10. This failure resulted in R2 not receiving his anti-neoplastic medication for three days. Findings include:The facility's Medication Administration Policy for Senior Living, undated, documents not in its entirety, Adherence to this Medication Administration Policy is essential to ensure the well-being and safety of our residents. All staff members are expected to follow these guidelines strictly and to report any issues or deviations from the policy. Continuous improvement and open communication are encouraged to uphold best practices in medication administration. This policy applies to all staff members involved in the administration of medication, including nurses, and any other designated personnel who are certified or licensed to pass medications in the state that they are practicing on. 1. All medication orders must be prescribed by a licensed healthcare professional and documented accurately in the resident's medical records.3. Any changes in medication orders must be documented in the resident's medical record.Recording and Reporting: 2. Any errors, omissions, or incidents related to medication administration must be documented I the clinical record & reported as per facility policy.Quality Assurance: 1. Regular audits and inspections of the medication administration process should be conducted to identify areas for improvement and ensure compliance with policies and procedures. 2. Any identified concerns, or incidents, should be properly investigated, documented, and addressed to prevent recurrence. R2's admission Record documents R2's admitted to the facility on [DATE] and R2's diagnoses on admission include but not limited to Unspecified Fracture of Shaft of Left Tibia, Subsequent Encounter for Closed Fracture with routine healing, Malignant Neoplasm of Prostate, Anemia, Gastro-Esophageal Reflux Disease without Esophagitis, Essential (Primary) Hypertension, Morbid (severe) Obesity due to excess calories, Malignant Pleural Effusion, and Secondary Malignant Neoplasm of Bone. R2's Minimum Data Set assessment dated [DATE] documents R2 has a Brief Interview for Mental Status score of 15/15, indicating cognition intact. R2's hospital discharge orders dated 2/9/26 documents R2 has an order for Abiraterone (anti-neoplastic) 250mg (milligrams) oral tablet: 4 tabs (tablets) orally once a day on an empty stomach. No stop date indicated. R2's Medication Administration Record (MAR) dated 2/1/26-2/28/26 documents an order for Abiraterone Acetate (anti-neoplastic) Oral Tablet 250mg (milligrams) give 4 tablets by mouth one time a day for take with prednisone (steroid)- chemo until 2/24/26 on an empty stomach. MAR also documents that R2 did not receive Abiraterone on 2/25/26, 2/26/26, and 2/27/26 and an order was started on 2/28/26 for Abiraterone Acetate Oral Tablet 250mg give 4 tablets by mouth in the morning related to Malignant Neoplasm of Prostate; Malignant Pleural Effusion in bottle in drawer. On 3/20/26 at 10:30am, V10 (R2's Family) who stated R2 admitted to the facility around 2/12/26 due to sustaining a left ankle fracture. R2 was sent there as they were the only facility that would take him due to her cancer medication, but he has missed several days because nurses keep telling R2 that it is not on his orders to give. V10 stated R2 is to take this medication for the rest of his life due to Stage 3 Prostate Cancer. Not sure exactly how many days he has missed and when but stated R2 would know because he has been keeping track. On 3/20/26 at 2:40pm, R2 stated he has had several days that he has not received his cancer medication; the nurses tell R2 there is no order for it, or they do not have any available. R2 stated he brought in his bottle from home that had a 4-day supply and had it renewed just after he got here. R2 stated it is not one specific nurse because he rarely has the same nurse due to the facility using agency staff. R2 also stated he was told he cannot miss taking it as his prostate cancer has spread to his bones. On 3/24/26 at 8:50am, V15 (Licensed Practical Nurse/Wound Nurse) and V3 (Assistant Director of Nursing) who verified that R2's transcribed orders for Abiraterone show a stop date of 2/24/26. V15 verified she transcribed R2's medication order for Abiraterone (anti-neoplastic) on admission to the facility and V15 also verified that R2's hospital discharge orders did not contain a stop date for the use of his Abiraterone. V15 stated, I'm not sure where that came from. It's not on his hospital discharge order and there is no script in his chart. On 3/24/26 at 9:08am, V16 (Licensed Practical Nurse) who stated, I only changed R2's administration time from 8am to 6am because he (R2) told me that he usually takes it before breakfast at home on an empty stomach. The stop date was already on the order. On 3/24/26 at 2:51pm, V28 (Former Director of Nursing) who stated that R2 voiced concerns that the nurse, could not remember who or what date specifically, would not give R2 his cancer medication because there was not an order for it. V28 stated she re-instated the order as it should never have been stopped. R2 refused to take it that day as it was too late in the day but did resume it the next day.

Based on observation, interview and record review, the facility failed to ensure a resident was free from neglect, as evidenced by the failure to provide goods and services necessary to avoid physical harm for one of three residents (R1), reviewed for medications, in a sample of three. The facility failed to administer prescribed medications to R1 in accordance with physician orders. R1's medical record revealed that multiple medications were not administered as prescribed, no timely notification to the physician and no implementation of appropriate interventions. As a result of the facility's failure to provide necessary care and services, R1 experienced a decline in condition and subsequently expired. The failure to administer prescribed medications and to respond appropriately constituted neglect and resulted in actual harm and death to the resident. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on [DATE] when R1 was admitted to the facility from a local hospital, after a prolonged hospitalization for respiratory and cardiac failure, with physician ordered medications and treatments to begin at 4:00 P.M.V1 (Administrator) and V2 (Interim Director of Nurses) were notified of the Immediate Jeopardy on [DATE] at 9:50 A.M.While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include: The facility policy, Abuse Prevention and Prohibition policy dated [DATE] documents, This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.The (undated) facility Medication Availability policy, directs staff to, On admission, using Quick (computerized program), admit the resident to the facility. Enter allergies. enter physician orders within one hour of the resident entering the facility. make sure the correct date and time are entered. If after 4:00 pm, call the pharmacy notifying them of a new admission- ask to speak to a pharmacist. Review with the pharmacist which medications you will need until the next scheduled delivery. Administer meds (medications) from the EDK (emergency drug kit or convivence kit). For meds not in the EDK, request pharmacy send STAT (immediately) or use their back up pharmacy to get them to the facility. Document administration of the medication in EMAR (Electronic Medication Administration Record).The (facility pharmacy) posted Hours of Operation and Cutoff Times form, located at the facility East Wing nurse's station directs staff, Order Cutoff Times: Monday - Friday New Orders by 4:00 PM and Saturday New Orders by 1:00 PM. STAT SAFE: The stat safe is an automated dispensing cabinet that will allow nurses access to doses of specific medication. Inventory can be customized.The (facility) STAT Safe Inventory List, dated (last update) [DATE] includes some of the following medications, Albuterol (Bronchodilator) Nebulizer Solution, Fluoxetine (Anti-depressant) 20 MG (Milligram) tablet, Prednisone (Corticosteroid) 10 MG tablet, Simvastatin (Statin) 10 MG tablet, Spironolactone (Diuretic) 25 MG tablet, Torsemide (Diuretic) 20 MG tablet, Ipratropium (Bronchodilator) Nebulizer Solution.R1's facility admission Record documents that R1 was admitted to the facility on [DATE] from a local hospital with the following diagnoses: Acute on Chronic Respiratory Failure with Hypercapnia, Acute Respiratory distress, Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Cor Pulmonal.R1's (Hospital) After Visit Summary documents that R1 was hospitalized from [DATE] until [DATE] and includes the following physician orders: Oxygen at 5 liters per nasal cannula continuously. Upon admission, R1 had new physician orders to start the following medications: Acetazolamide (Carbonic anhydrase inhibitor used for edema in heart failure); Clonazepam (Benzodiazepine); Ipratropium-Albuterol (Bronchodilator); Prednisone (Corticosteroid) start [DATE], Fluticasone (Corticosteroid) start [DATE]. R1 also had a physician's order to continue the following medications: Albuterol (Bronchodilator); Cyanocobalamin (Supplement); Folic Acid (Supplement) and MiraLAX (Laxative). R1 also had a physician's order to continue taking Aspirin; Budeson- Glycopyrrolate- Formoterol (Bronchodilator); Fluoxetine (Antidepressant); Guaifenesin (Mucolytic); Pantoprazole (Proton Pump Inhibitor); and Simvastatin (Statin). R1's Daily Skilled Nursing Note on [DATE] at 2:30 P.M. document, (R1) is alert and has short term memory problem. (R1) does not have delusions, does not hallucinate, and decision making is not impaired. Signs of delirium: none. (R1) has the following sensory or speech issues: wears glasses. (R1) has the following indicators of a mood issue: none. (R1) has the following behavioral issues: none. (R1) has the following skin issues: Scattered bruising to abdomen and extremities. (R1) is incontinent of bladder. Bowel sounds are normal, has normal bowel movements, is incontinent of bowel. Apical pulse is regular, radial pulse is regular. (R1) is experiencing the following cardiovascular issues: none. (R1) has no edema. Respiratory Status- (R1) is experiencing the following breathing issues: SOB (Short of Breath) at times. (R1) Has SOB while lying flat, has shortness of breath on exertion, does not have shortness of breath or trouble breathing when sitting at rest. Lung sounds: Clear. (R1) does not have a cough and requires the following respiratory support Bi-pap and neb (nebulizer) treatments with O2 (oxygen).R1's Nursing Progress Notes, dated [DATE] at 12:32 P.M., and signed by V5/Licensed Practical Nurse document, Nurse went into (R1's) room to administer medications at 11:39 A.M. (R1) appeared that breathing had ceased. No audible heart tones; no pulse and no visual signs of life noted. DON (V2/Interim Director of Nurse) verified (R1) had expired. Staff had last talked to (R1) approximately 15 minutes prior. (R1) had several complex medical diagnoses, including respiratory failure. R1's October Physician Order Sheet includes the following medications: Enteric Coated Aspirin 81 MG daily at 8AM, Cyanocobalamin 500 MCG (Micrograms) daily at 8AM, Docusate Sodium 100 MG daily at 8AM, Ferrous Sulfate 325 MG daily at 8AM, Fluoxetine 20 MG daily at 8AM, Fluticasone Nasal Suspension daily at 8AM, Folic Acid 1 MG daily at 8AM, Prednisone 5 MG daily at 8AM, Protonix 40 MG daily at 5AM, Simvastatin 40 MG daily at 8PM, Spironolactone 25 MG daily at 8AM, Vitamin D3 1000 Units daily at 8AM, Acetazolamide 250 MG twice daily at 8AM and 4PM, AR formoterol Inhalation Nebulization Solution twice daily at 8AM and 4PM, Breztri Aerosphere Inhalation twice daily at 8AM and 4PM, Clonazepam 0.5 MG twice daily at 8AM and 4PM, Guaifenesin ER (Extended Release) 600 MG twice daily at 8AM and 8PM, Hydroxychloroquine 200 MG twice daily at 8AM and 4 PM, Torsemide 40 MG twice daily at 8AM and 4PM, Ipratropium-Albuterol Inhalation Solution via Nebulization four times daily at 8AM, 12PM, 4PM and 8PM.R1's [DATE] Medication Administration Record documents that R1 did not receive Aspirin, Cyanocobalamin, Docusate Sodium, Ferrous Sulfate, Fluoxetine, Fluticasone, Folic Acid, Prednisone, Spironolactone (Diuretic), Vitamin D3 (Supplement), Acetazolamide, Budeson- Glycopyrrolate- Formoterol, Clonazepam, Hydroxychloroquine (Anti-rheumatic), Torsemide (Diuretic), or Ipratropium-Albuterol on [DATE] or [DATE] at 8AM, 12PM or 4PM., as documented by V5/Licensed Practical Nurse as unavailable. No documentation that the missed medication doses was escalated to facility nurse management staff or that R1's physician was notified that R1 had missed physician ordered medications on [DATE] and [DATE] is present in R1's medical record.On [DATE] at 11:33 A.M., a locked, electronic medication dispensing machine was located in the East Wing Medication Room. A list of medications available in the machine was present, and included Albuterol (Bronchodilator) Nebulizer Solution, Fluoxetine (Anti-depressant) 20 MG (Milligram) tablet, Prednisone (Corticosteroid) 10 MG tablet, Simvastatin (Statin) 10 MG tablet, Spironolactone (Diuretic) 25 MG tablet, Torsemide (Diuretic) 20 MG tablet, Ipratropium (Bronchodilator) Nebulizer Solution. On [DATE] at 1:04 P.M., V5/Licensed Practical Nurse stated she has been an employee of the facility for the past 8 years as a Licensed Practical Nurse. States when a new admission comes to the facility, V8/Minimum Data Set Assessment Coordinator or V9/Assistant Director of Nurses put the orders into the computer. States pharmacy delivery of medications is made between 8 PM to 10 PM each day, except Saturday or Sunday when delivery is usually late afternoon. States if a resident is admitted prior to that, their medications should be delivered that evening. States the facility also has a locked medication cart that contains many different medications. If a resident runs out of medicine or is a new admission and their medications aren't in the facility yet, a nurse can call the pharmacy, and they will give you a code to unlock the machine to pull the medications needed. States she worked on [DATE] and 23, 2025 and that R1's medications had not arrived from the pharmacy. States R1 did not receive medications on those dates. Unable to recall if medications had been placed on hold. States on [DATE] around 11:30 A.M. the CNAs (Certified Nursing Assistants) had gone into R1's room to deliver his noon meal tray and found him deceased . States they came and got her and she assessed R1 and found him without a pulse or respirations. On [DATE] at 1:26 P.M., V10/Medical Doctor stated he was R1's primary physician. States R1's medications, including multiple diuretics, nebulizer treatments and steroids should never have been placed on hold. States R1 should have received his medications, as ordered by the physician. Unable to state if R1 not receiving his medications led to his death on [DATE], but stated it is a very good possibility. Stated it definitely hurt R1's medical condition. Stated his expectation of the facility is that a resident's medications are available on the evening of admission, or he should be notified to modify the treatment plan for a resident. Further stated he was not notified by nursing staff on [DATE], [DATE] or [DATE] that R1's medications were not available. On [DATE] at 2:42 P.M., V7/Advanced Practice Nurse stated she doesn't specifically recall giving an order to hold R1's medications until available. Stated her expectation is that medications should be available upon admission, or the facility should have a means to obtain medications swiftly via a local pharmacy or an in-house electronic dispensing machine. V7 stated she would not expect medications to be unavailable for 48 hours and she or V10/Medical Doctor should have been made aware of the extended time delay in obtaining R1's medications. Stated she was not notified by the facility that R1 did not receive his ordered medications on [DATE], [DATE] or [DATE]. Stated if she had been notified, a new treatment plan could have been implemented for R1 or R1 would have been sent back to the hospital to receive treatment. On [DATE] at 9:08 A.M., V13/Critical Care Pharmacist stated the delivery slip for the facility documents that the following medications were delivered for R1 on [DATE] at 11:18 PM, Arformoterol Inhalation, Acetazolamide, Enoxaparin and Budesonide. V13 stated the Enoxaparin and Budesonide were discontinued on [DATE]. Stated on [DATE] at 12:21 AM, the following medications for R1 were delivered: Torsemide, Spironolactone, Simvastatin, Prednisone, Pantoprazole, Ipratropium-Albuterol Inhalation, Hydroxychloroquine, Fluticasone, Fluoxetine, Breztri and Albuterol. On [DATE] at 11:03 A.M., V2/Interim Director of Nurses stated she was not informed by any nurse that R1's medications were not available or given to him as ordered by the physician. At that time, V2 verified that R1 did not receive physician ordered medications on [DATE], [DATE] or [DATE] including Aspirin on [DATE] and [DATE]; Cyanocobalamin on [DATE] and [DATE]; Docusate Sodium on [DATE] and [DATE]; Ferrous Sulfate, Fluoxetine, Fluticasone, Folic Acid, Prednisone, Spironolactone (Diuretic), Vitamin D3 (Supplement), Acetazolamide, Budeson- Glycopyrrolate- Formoterol, Clonazepam, Hydroxychloroquine (Anti-rheumatic), Torsemide (Diuretic), or Ipratropium-Albuterol on [DATE] or [DATE].On [DATE] at 11:17 A.M., V5/Licensed Practical Nurse stated she did not get medications for R1 from the facility electronic medication dispensing machine on [DATE] or [DATE]. Stated she did not notify R1's physician that he had not received any medications including his breathing treatments, diuretics, medication for heart failure or his prednisone. Stated she doesn't know why she did not administer R1's Diamox or Breztri Inhaler on [DATE] or at 8:00 AM on [DATE] despite them being delivered by the pharmacy on [DATE]. Stated she was busy and was going into R1's room at 11:39 AM when R1 was found deceased . Also stated she did not notify nursing management of R1's missing medications on [DATE], [DATE] or at 8:00 AM on [DATE]. R1's (State) Certificate of Death documents R1's Cause of Death as Acute on Chronic Congestive Heart Failure, Acute on Chronic Diastolic Heart Failure with Significant Conditions Contributing to Death as Chronic Obstructive Pulmonary Disease.On [DATE] the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:On [DATE] Director of Nursing has reviewed all residents that are receiving prescribed medications as ordered.On [DATE] Director of Nursing has reviewed all residents, and no residents have been identified to having missed any doses of prescribed medications.On [DATE] All licensed nurses have been educated by the Director of Nursing and provided access on how to obtain unavailable medications from the facilities emergency medication kit (stat safe) On [DATE] Regional Nurse Consultant educated Director of Nursing on medication administration/availability. And as part of QA activities weekly match back audits are completed for med availability. All new admits should be reviewed to ensure their medications are available and orders in place using the checklist. Which is reviewed daily during clinical QA meeting. Licensed Nursing Staff including V5 were educated by Director of Nursing on [DATE] or prior to working their next scheduled shift on the following:Adherence to physician orders Residents should be assessed timely and documentation completed, and the Physician should be notified in the event an ordered medication dose is missed.Facility Nursing Administration notified immediately of any medication administration issue.Facility Abuse and Neglect Policy related to administering prescribed medications to avoid physical harm to residentsAn audit has been created on [DATE] by the Director of Nursing to ensure compliance with medication administration and availability, assessment and documentation, physician notification and escalation to nursing administration and staff knowledge of facility medication administration standards to avoid physical harm to residents.Director of Nursing or designee will conduct an audit of 3 licensed nurses 3 times per week for 8 weeks to ensure compliance with medication administration standards.Administrator or designee will conduct an audit of 3 licensed nurses 3 times per week for 8 weeks to ensure compliance with medication administration standards to avoid physical harm to residents. Completion date [DATE]

Based on interview and record review, the facility failed to ensure that a resident received prescribed medications in accordance with physician orders, resulting in a failure to provide necessary care and services to attain or maintain the resident's highest practicable physical well-being, for 1 of 3 residents (R1) reviewed for medications, in a sample of 3. The facility failed to administer prescribed medications to R1 as ordered over multiple days. R1's medical record review revealed that the medications were ordered to be administered routinely; however, documentation showed missed doses without evidence of physician notification, or appropriate intervention. Staff interviews confirmed that missed medications were not escalated to nursing leadership or the attending physician. As a result of the failure to administer prescribed medications and the lack of timely assessment and intervention, R1 experienced a decline in condition and subsequently expired. The facility's failure to follow physician orders and provide appropriate monitoring and response placed R1 at risk for serious harm and resulted in actual harm and death.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on [DATE] when R1 was admitted to the facility from a local hospital, after a prolonged hospitalization for respiratory and cardiac failure, with physician ordered medications and treatments to begin at 4:00 P.M.V1 (Administrator) and V2 (Interim Director of Nurses) were notified of the Immediate Jeopardy on [DATE] at 9:50 A.M.While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The (undated) facility Medication Availability policy, directs staff to, On admission, using Quick (computerized program), admit the resident to the facility. Enter allergies. enter physician orders within one hour of the resident entering the facility. make sure the correct date and time are entered. If after 4:00 pm, call the pharmacy notifying them of a new admission- ask to speak to a pharmacist. Review with the pharmacist which medications you will need until the next scheduled delivery. Administer meds (medications) from the EDK (emergency drug kit or convivence kit). For meds not in the EDK, request pharmacy send STAT (immediately) or use their back up pharmacy to get them to the facility. Document administration of the medication in EMAR (Electronic Medication Administration Record).The (facility pharmacy) posted Hours of Operation and Cutoff Times form, located at the facility East Wing nurse's station directs staff, Order Cutoff Times: Monday - Friday New Orders by 4:00 PM and Saturday New Orders by 1:00 PM. STAT SAFE: The stat safe is an automated dispensing cabinet that will allow nurses access to doses of specific medication. Inventory can be customized.The (facility) STAT Safe Inventory List, dated (last update) [DATE] includes some of the following medications, Albuterol (Bronchodilator) Nebulizer Solution, Fluoxetine (Anti-depressant) 20 MG (Milligram) tablet, Prednisone (Corticosteroid) 10 MG tablet, Simvastatin (Statin) 10 MG tablet, Spironolactone (Diuretic) 25 MG tablet, Torsemide (Diuretic) 20 MG tablet, Ipratropium (Bronchodilator) Nebulizer Solution.R1's facility admission Record documents that R1 was admitted to the facility on [DATE] from a local hospital with the following diagnoses: Acute on Chronic Respiratory Failure with Hypercapnia, Acute Respiratory distress, Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Cor Pulmonal.R1's (Hospital) After Visit Summary documents that R1 was hospitalized from [DATE] until [DATE] and includes the following physician orders: Oxygen at 5 liters per nasal cannula continuously. Upon admission, R1 had new physician orders to start the following medications: Acetazolamide (Carbonic anhydrase inhibitor used for edema in heart failure); Clonazepam (Benzodiazepine); Ipratropium-Albuterol (Bronchodilator); Prednisone (Corticosteroid) start [DATE], Fluticasone (Corticosteroid) start [DATE]. R1 also had a physician's order to continue the following medications: Albuterol (Bronchodilator); Cyanocobalamin (Supplement); Folic Acid (Supplement) and MiraLAX (Laxative). R1 also had a physician's order to continue taking Aspirin; Budeson- Glycopyrrolate- Formoterol (Bronchodilator); Fluoxetine (Antidepressant); Guaifenesin (Mucolytic); Pantoprazole (Proton Pump Inhibitor); and Simvastatin (Statin). R1's Daily Skilled Nursing Note on [DATE] at 2:30 P.M. document, (R1) is alert and has short term memory problem. (R1) does not have delusions, does not hallucinate, and decision making is not impaired. Signs of delirium: none. (R1) has the following sensory or speech issues: wears glasses. (R1) has the following indicators of a mood issue: none. (R1) has the following behavioral issues: none. (R1) has the following skin issues: Scattered bruising to abdomen and extremities. (R1) is incontinent of bladder. Bowel sounds are normal, has normal bowel movements, is incontinent of bowel. Apical pulse is regular, radial pulse is regular. (R1) is experiencing the following cardiovascular issues: none. (R1) has no edema. Respiratory Status- (R1) is experiencing the following breathing issues: SOB (Short of Breath) at times. (R1) Has SOB while lying flat, has shortness of breath on exertion, does not have shortness of breath or trouble breathing when sitting at rest. Lung sounds: Clear. (R1) does not have a cough and requires the following respiratory support Bi-pap and neb (nebulizer) treatments with O2 (oxygen).R1's Nursing Progress Notes, dated [DATE] at 12:32 P.M. and signed by V5/Licensed Practical Nurse document, Nurse went into (R1's) room to administer medications at 1139 A.M. (R1) appeared that breathing had ceased. No audible heart tones; no pulse and no visual signs of life noted. DON (V2/Interim Director of Nurse) verified (R1) had expired. Staff had last talked to (R1) approximately 15 minutes prior. (R1) had several complex medical diagnoses, including respiratory failure. R1's October Physician Order Sheet includes the following medications: Enteric Coated Aspirin 81 MG daily at 8AM, Cyanocobalamin 500 MCG (Micrograms) daily at 8AM, Docusate Sodium 100 MG daily at 8AM, Ferrous Sulfate 325 MG daily at 8AM, Fluoxetine 20 MG daily at 8AM, Fluticasone Nasal Suspension daily at 8AM, Folic Acid 1 MG daily at 8AM, Prednisone 5 MG daily at 8AM, Protonix 40 MG daily at 5AM, Simvastatin 40 MG daily at 8PM, Spironolactone 25 MG daily at 8AM, Vitamin D3 1000 Units daily at 8AM, Acetazolamide 250 MG twice daily at 8AM and 4PM, AR formoterol Inhalation Nebulization Solution twice daily at 8AM and 4PM, Breztri Aerosphere Inhalation twice daily at 8AM and 4PM, Clonazepam 0.5 MG twice daily at 8AM and 4PM, Guaifenesin ER (Extended Release) 600 MG twice daily at 8AM and 8PM, Hydroxychloroquine 200 MG twice daily at 8AM and 4 PM, Torsemide 40 MG twice daily at 8AM and 4PM, Ipratropium-Albuterol Inhalation Solution via Nebulization four times daily at 8AM, 12PM, 4PM and 8PM.R1's [DATE] Medication Administration Record documents that R1 did not receive Aspirin, Cyanocobalamin, Docusate Sodium, Ferrous Sulfate, Fluoxetine, Fluticasone, Folic Acid, Prednisone, Spironolactone (Diuretic), Vitamin D3 (Supplement), Acetazolamide, Budeson- Glycopyrrolate- Formoterol, Clonazepam, Hydroxychloroquine (Anti-rheumatic), Torsemide (Diuretic), or Ipratropium-Albuterol on [DATE] or [DATE] at 8AM, 12PM or 4PM., as documented by V5/Licensed Practical Nurse as unavailable. No documentation that the missed medication doses was escalated to facility nurse management staff or that R1's physician was notified that R1 had missed physician ordered medications on [DATE] and [DATE] is present in R1's medical record.On [DATE] at 11:33 A.M., a locked, electronic medication dispensing machine was located in the East Wing Medication Room. A list of medications available in the machine was present, and included Albuterol (Bronchodilator) Nebulizer Solution, Fluoxetine (Anti-depressant) 20 MG (Milligram) tablet, Prednisone (Corticosteroid) 10 MG tablet, Simvastatin (Statin) 10 MG tablet, Spironolactone (Diuretic) 25 MG tablet, Torsemide (Diuretic) 20 MG tablet, Ipratropium (Bronchodilator) Nebulizer Solution. On [DATE] at 1:04 P.M., V5/Licensed Practical Nurse stated she has been an employee of the facility for the past 8 years as a Licensed Practical Nurse. States when a new admission comes to the facility, V8/Minimum Data Set Assessment Coordinator or V9/Assistant Director of Nurses put the orders into the computer. States pharmacy delivery of medications is made between 8 PM to 10 PM each day, except Saturday or Sunday when delivery is usually late afternoon. States if a resident is admitted prior to that, their medications should be delivered that evening. States the facility also has a locked medication cart that contains many different medications. If a resident runs out of medicine or is a new admission and their medications aren't in the facility yet, a nurse can call the pharmacy, and they will give you a code to unlock the machine to pull the medications needed. States she worked on [DATE] and 23, 2025 and that R1's medications had not arrived from the pharmacy. States R1 did not receive medications on those dates. Unable to recall if medications had been placed on hold. States on [DATE] around 11:30 A.M. the CNAs (Certified Nursing Assistants) had gone into R1's room to deliver his noon meal tray and found him deceased . States they came and got her and she assessed R1 and found him without a pulse or respirations. On [DATE] at 1:26 P.M., V10/Medical Doctor stated he was R1's primary physician. States R1's medications, including multiple diuretics, nebulizer treatments and steroids should never have been placed on hold. States R1 should have received his medications, as ordered by the physician. Unable to state if R1 not receiving his medications led to his death on [DATE], but stated it is a very good possibility. Stated it definitely hurt R1's medical condition. Stated his expectation of the facility is that a resident's medications are available on the evening of admission, or he should be notified to modify the treatment plan for a resident. Further stated he was not notified by nursing staff on [DATE], [DATE] or [DATE] that R1's medications were not available. On [DATE] at 2:42 P.M., V7/Advanced Practice Nurse stated she doesn't specifically recall giving an order to hold R1's medications until available. Stated her expectation is that medications should be available upon admission, or the facility should have a means to obtain medications swiftly via a local pharmacy or an in-house electronic dispensing machine. V7 stated she would not expect medications to be unavailable for 48 hours and she or V10/Medical Doctor should have been made aware of the extended time delay in obtaining R1's medications. Stated she was not notified by the facility that R1 did not receive his ordered medications on [DATE], [DATE] or [DATE]. Stated if she had been notified, a new treatment plan could have been implemented for R1 or R1 would have been sent back to the hospital to receive treatment. On [DATE] at 9:08 A.M., V13/Critical Care Pharmacist stated the delivery slip for the facility documents that the following medications were delivered for R1 on [DATE] at 11:18 PM, Arformoterol Inhalation, Acetazolamide, Enoxaparin and Budesonide. V13 stated the Enoxaparin and Budesonide were discontinued on [DATE]. Stated on [DATE] at 12:21 AM, the following medications for R1 were delivered: Torsemide, Spironolactone, Simvastatin, Prednisone, Pantoprazole, Ipratropium-Albuterol Inhalation, Hydroxychloroquine, Fluticasone, Fluoxetine, Breztri and Albuterol. On [DATE] at 11:03 A.M., V2/Interim Director of Nurses stated she was not informed by any nurse that R1's medications were not available or given to him as ordered by the physician. At that time, V2 verified that R1 did not receive physician ordered medications on [DATE], [DATE] or [DATE] including Aspirin on [DATE] and [DATE]; Cyanocobalamin on [DATE] and [DATE]; Docusate Sodium on [DATE] and [DATE]; Ferrous Sulfate, Fluoxetine, Fluticasone, Folic Acid, Prednisone, Spironolactone (Diuretic), Vitamin D3 (Supplement), Acetazolamide, Budeson- Glycopyrrolate- Formoterol, Clonazepam, Hydroxychloroquine (Anti-rheumatic), Torsemide (Diuretic), or Ipratropium-Albuterol on [DATE] or [DATE].On [DATE] at 11:17 A.M., V5/Licensed Practical Nurse stated she did not get medications for R1 from the facility electronic medication dispensing machine on [DATE] or [DATE]. Stated she did not notify R1's physician that he had not received any medications including his breathing treatments, diuretics, medication for heart failure or his prednisone. Stated she doesn't know why she did not administer R1's Diamox or Breztri Inhaler on [DATE] or at 8:00 AM on [DATE] despite them being delivered by the pharmacy on [DATE]. Stated she was busy and was going into R1's room at 11:39 AM when R1 was found deceased . Also stated she did not notify nursing management of R1's missing medications on [DATE], [DATE] or at 8:00 AM on [DATE]. R1's (State) Certificate of Death documents R1's Cause of Death as Acute on Chronic Congestive Heart Failure, Acute on Chronic Diastolic Heart Failure with Significant Conditions Contributing to Death as Chronic Obstructive Pulmonary Disease.On [DATE] the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:On [DATE] Director of Nursing has reviewed all residents that are receiving prescribed medications as ordered.On [DATE] Director of Nursing has reviewed all residents, and no residents have been identified to having missed any doses of prescribed medications.On [DATE] All licensed nurses have been educated by the Director of Nursing and provided access on how to obtain unavailable medications from the facilities emergency medication kit (stat safe) On [DATE] Regional Nurse Consultant educated Director of Nursing on medication administration/availability. And as part of QA activities weekly match back audits are completed for med availability. All new admits should be reviewed to ensure their medications are available and orders in place using the checklist. Which is reviewed daily during clinical QA meeting. Licensed Nursing Staff including V5 were educated by Director of Nursing on [DATE] or prior to working their next scheduled shift on the following:Adherence to physician orders Residents should be assessed timely and documentation completed, and the Physician should be notified in the event an ordered medication dose is missed.Facility Nursing Administration notified immediately of any medication administration issue.An audit has been created on [DATE] by the Director of Nursing to ensure compliance with medication administration and availability, assessment and documentation, physician notification and escalation to nursing administration.Director of Nursing or designee will conduct an audit of 3 licensed nurses 3 times per week for 8 weeks to ensure compliance with medication administration standards. Completion date [DATE]

Based on interview and record review, the facility failed to maintain an accurate medical record for three of three residents (R1, R2 and R3) reviewed for accuracy of medical records, in a sample of 3. Findings include:1.R1's facility Face Sheet documents that R1 was admitted to the facility on [DATE]. R1's Nursing Progress Notes, dated 10/21/2025 document, 10/21/2025 at (6:19 P.M.) V7 (Advanced Practice Nurse) was notified that (R1) is (a) new admit and medications are not available at this time. (V7) gave order to hold medications that are unavailable.A review of R1's Physician Order Sheet, dated October 2025 does not include a signed physician order to hold R1's medications.2. R2's facility Face Sheet documents that R2 was admitted to the facility on [DATE].R2's Nursing Progress Notes, dated 10/23/2025 at 9:23 A.M. document, Received (physician's) order to hold Abilify, Trelogy and Jardiance until delivery pharmacy contacted to verify for delivery for this evening and all orders are being filled for drop off this evening.A review of R2's Physician Order Sheet, dated October 2025 does not include a signed physician order to hold R2's medications.3. R3's facility face Sheet documents that R3 was admitted to the facility on [DATE].R3's Nursing Progress Notes, dated 10/24/2025 at 9:26 A.M. document, (R3's) medications on hold til (until) available. Was able to get PRN (As needed) Ultram and Lasix out of backup. PCP (V10/Medical Doctor) aware that meds (medications) are on hold. On 01/05/2026 at 2:40 P.M., V2/Interim Director of Nurses verified R1, R2 and R3's electronic medical records contained no signed physician's order to hold R1, R2 or R3's medications that were unavailable. At that time, V2/DON stated the standard of practice that the facility follows for physician's orders is if a licensed nurse obtains a telephone order or a verbal order from a physician, there must be a signed physician order to back it up. At that time V2/DON confirmed that without a signed physician's order, a telephone order or a verbal order was insufficient and void.

Based on record review and interview, the facility failed to ensure a resident remained free from physical abuse. This failure affects one of three residents (R1) reviewed for abuse in a total sample of three residents. This failure resulted in R1 being pushed by R2, causing R1 to fall to the floor after losing R1's balance.Findings include: The facility policy, entitled Abuse, Prevention, & Prohibition Policy, dated 12/2024, documents: 3. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. 4. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. R1's Electronic Medical Record/EMR document R1's diagnosis to include: Dementia with psychotic disturbance, chronic obstructive pulmonary disease, type two diabetes mellitus, hyperlipidemia, hypertension, major depressive disorder, vitamin B deficiency, peripheral vascular disease, and primary osteoarthritis.R1 resides on a locked dementia unit and R1 is not cognitively intact-with a Brief Interview for Mental Status of 1/15. R1 ambulates without assistance.R1's EMR documentation, entitled Risk Management document, Date of Incident 8/10/25 6:45 p.m., V6 [Certified Nursing Assistant] came over to get nurse and expressed that an incident between two residents had just occurred. V6 stated that [R2] shoved [R1] and caused [R1] to lose balance and fall on the floor onto buttock. V6 and V7 [CNA] expressed that [R1] kept bothering [R2] and had to be removed twice from getting too close into [R2's] space.R2's EMR document R2's diagnosis to include: Dementia with Anxiety, Chronic Obstructive Pulmonary Disease, Urinary Tract Infection, Hypertension, Iron Deficiency, Gastroesophageal Reflux Disease, Anxiety, Major Depressive Disorder, Hyperlipidemia, Depression, Obesity, Diverticulitis, Gout, Congestive Heart Failure, Benign Prostatic Hyperplasia, Congenital Hiatus Hernia, and Spinal Stenosis.R2 resides on a locked dementia unit and R2 is not cognitively intact-with a Brief Interview for Mental Status as 0/15. R2 ambulates in a wheelchair.R2's EMR documentation, entitled Risk Management documents, Date of Incident 8/10/25 6:45 p.m., V6 came over to get nurse and expressed that an incident between two residents had just occurred. V6 CNA stated that [R2] shoved [R1] and caused [R1] to lose balance and fall on the floor onto buttock. Both V6 and V7 expressed that the [R1] kept bothering [R2] and had to be removed twice from getting too close into [R2's] space. On 9/25/25, at 10:00 a.m., V6/Certified Nursing Assistant-CNA confirmed: observing the incident with R1 and R2; R1 initially walked up the R2 in the hallway and entered R2's personal space; R1 was redirected; R1 then approached R2 a second time in the day room; R2 then pushed R1 and R1 lost her balance and fell; the V11 Licensed Practical Nurse was down the hall, on the dementia unit, when the incident occurred; and R2 does not even like staff to enter R2's personal space when talking to R2. On 9/25/25, at 11:05 a.m., V9/CNA confirmed R1 will often enter the personal space of other residents and R1 would then have to be redirected; and R2 only gets aggressive during ADL's/Activities of Daily Living or with someone he doesn't know.

Based on observation, interview, and record review the facility failed to obtain the proper equipment to ensure a resident received showers at least once weekly and was weighed at least once monthly for one of three residents (R2) reviewed for accommodation of needs in the sample of three. These failures resulted in a resident with the diagnoses of Morbid Obesity not receiving a shower for over two years, resulting in R2 having increasing depression and feeling disgusting, smelly, and dirty.Findings include:The Facility Assessment Tool dated 3/19/25 documents, Diseases/Conditions: Morbid Obesity. Services and care we offer based on our resident's needs. The facility provides services for the residents we care for. The residents' care is based on their individual needs and preferences and is reflected in the individual's care plan. The cares and services are distributed by category. Activities of daily living bathing: Bathing and Showers. Physical Environment and building plant needs: Ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents. Physical Equipment: Bath benches, shower chairs, bathroom safety bars, bathing tubs, scales, bed scales.The facility's Weight Assessment and Intervention policy dated 12/2024, The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly. Weights will be recorded in the individual's medical record.The facility's Activities of Daily Living Policy, undated, documents, This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrates that the decline was unavoidable, including Bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating, and communication.R2's admission Record documents R2 is a [AGE] year-old admitted to the facility 10/20/22 with the diagnoses of Depression, Morbid Obesity, Adult Failure to Thrive, Hoarding Disorder, and Attention-Deficit Hyperactivity Disorder.R2's Current Care Plan documents, Behavior Problem: Has signs/symptoms of depression. Withdrawn. BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 04/13/2023 BATHING/SHOWERING: (R2) requires extensive assistance by one staff with bathing/showering (bathing/showering on scheduled days and as necessary. (Mechanical Lift) and two assist for transfers to shower chair. Encourage (R2) to wash upper body. Date Initiated: 04/13/2023.R2's MDS (Minimum Data Set) dated 6/19/25 documents R2 is dependent on staff for showers/bathing and needs partial/moderate assistance of staff for personal hygiene. This same Assessment documents R2's Mood Score at a 10 indicating R2 suffers moderate depression.R2's BIMS (Brief Interview for Mental Status) dated 8/18/25 documents R2 is cognitively intact.R2's Weights and Vitals Summary dated 1/2025 documents R2's most recent weight obtained was 293 pounds.R2's Grievance dated 5/8/25 documents, I (R2) have had difficulty with my bath/hair and getting (a) head to toe bath plus my hair shampooed since the CNAs (Certified Nursing Assistants) have been switched halls. I am not consistently getting a full bath and my hair shampooed. I would like to discuss a shower plan at a care plan meeting with (V14/Ombudsman) to support me (R2). Please let me (R2) know a date and time that we (the facility) can meet, and I will coordinate with the ombudsman.On 8/18/25 at 10:30 AM R2 was lying in a bariatric bed. R2 was morbidly obese and had stringy, oily hair. R2 stated, I feel very disgusting, smelly, and dirty. I have lived here over two years and have never been able to take a shower. The staff tried once, and I could not fit through the shower room door while on the shower chair, and my wheelchair will not fit through the shower room doorway. I am getting further and further depressed from being in this room every day and never getting a shower. I get bed baths, and my hair only gets washed maybe six out of the 12 times I get a bed bath. How would you (this surveyor) feel if you never could get a shower? I have asked over and over and filled out a grievance about at least getting my hair washed and nobody ever gets back to me. I do not get weighed monthly because the scale on the (mechanical lift) broke.On 8/18/25 at 10:10 AM V3 (LPN/Licensed Practical Nurse) stated, We (the facility) do not have a shower room that can accommodate (R2). (R2) requires a large shower bench and cannot fit through the shower doorways. Anytime the staff try, (R2's) legs scrape on the doorway of the shower room. The doorway to the shower rooms needs to be wider in order to fit (R2), or (R2) needs a different shower chair.On 8/18/25 at 10:20 AM V4 (CNA/Certified Nursing Assistant) stated, I have worked here four years and have always taken care of (R2). (R2) cannot fit through the shower room doors, so we have to give (R2's) bed baths. We used to not have a (mechanical lift) that would work for (R2's) weight. We have a lift that works for (R2) now. (R2) has never been able to get a shower. The last time we tried to wheel (R2) into the shower room, (R2's) legs scraped on the doorway. The shower chair with (R2) sitting on it does not fit through the shower doorway. Over two years ago there was a shower chair that worked for (R2), but it broke, and we (the facility) have never gotten a new shower chair that would work for (R2). I have never tried to use a (mechanical lift) to get (R2) into the shower room. I did not think about using a (mechanical lift).On 8/18/25 at 10:30 AM V5 (CNA) was providing personal cares to (R2). V5 stated, I always give (R2) bed baths because (R2) cannot fit through the shower room doorways. I have never tried to give (R2) a shower and have never tried a (mechanical lift) to get (R2) into the shower rooms. I just always assumed I was supposed to give (R2) bed baths since (R2) cannot fit into the shower rooms.On 8/18/25 at 2:10 PM V11 (CNA) and V12 (CNA) verified R2 does not get showers due to having no way to get R2 into the shower room.On 8/19/25 at 9:30 AM V14 (Ombudsman) stated, After (R2) wrote the grievance on 5/8/25, I immediately handed it to (V15/Prior Administrator) who was in (V16's/Director of Nurse's) office at the time. I discussed with (V15) and (V16) the need to have a care plan meeting with (R2) to discuss (R2's) concerns. At that time (V15) told me that the care plan coordinator was out of the building, and he would get back to (R2) and myself with a day and time for a care plan meeting. I have never heard anything back. I have been dealing with all different managers for the last two years about (R2) not being able to get a shower. (R2) is very upset that she cannot even get a shower and not get her hair washed. The staff cannot get (R2) into the shower room as the doorway is not big enough and the facility does not have a shower chair that will fit threw the shower room doorway. On 8/19/25 at 11:15 AM V1 (Administrator) stated, I was not made aware about (R2's) grievance from 5/8/25. (R2) should be offered a shower at least once a week and the facility should have the proper equipment and shower rooms to accommodate (R2) being able to get a shower at least once a week or whenever she wants. (R2) not receiving a shower for over two years is ridiculous and unacceptable. The staff have not been weighing (R2) monthly. I guess because the (mechanical lift) scale is broke.On 8/19/25 at 12:15 PM V2 (Director of Nursing) stated, The facility does not have a scale that can weigh (R2). I just found this out yesterday. All residents should be weighed at least once monthly unless a physician's order indicates a resident should be weighed more than monthly. (R2) has not had a monthly weight since January 2025.

Based on observation, record review, and interview the facility failed to honor a resident's request to conduct a care plan meeting with the ombudsman present for one of three residents (R2) reviewed for resident rights in the sample of three.Findings include:The Facility Assessment Tool dated 3/19/25 documents, The residents' care is based on their individual needs and preferences and is reflected in the individual's care plan. Provide person-centered/directed care: Psycho/social/spiritual support: Build relationship with resident/get to know him/her/engage resident in conversation, offer and assist resident and family caregivers (or other proxy as appropriate) to be involved in person-centered care planning and advance care planning.R2's BIMS (Brief Interview for Mental Status) dated 8/18/25 documents R2 is cognitively intact.R2's Grievance dated 5/8/25 documents, I (R2) have had difficulty with (my) bath/hair and getting (a) head to toe bath plus my hair shampooed since the CNAs (Certified Nursing Assistant) have been switched halls. I am not consistently getting a full bath and my hair shampooed. I would like to discuss a shower plan at a care plan meeting with (V14/Ombudsman) to support me (R2). Please let me (R2) know a date and time that we (the facility) can meet, and I will coordinate with the ombudsman.R2's Electronic Health Record dated 5/8/25 (date of grievance) through 8/19/25 does not include documentation of a care plan meeting being conducted with R2, the facility staff, and the ombudsman.On 8/18/25 at 10:30 AM R2 was lying in a bariatric bed. R2's hair appeared oily and stringy. R2 stated, Nobody listens to me around here. I am trying to find somewhere else to accept me. I asked (V15/Prior Administrator) over and over to have a care plan meeting with the ombudsman present and no one has ever set up a meeting for me. I have told almost all the staff here that I want a meeting with the ombudsman so I can have a witness and be heard.On 8/19/25 at 9:30 AM V14 (Ombudsman) stated, After (R2) wrote the grievance on 5/8/25, I immediately handed it to (V15/Prior Administrator) who was in (V16's/Director of Nurse's) office at the time. I discussed with (V15) and (V16) the need to have a care plan meeting with (R2) to discuss (R2's) concerns. At that time (V15) told me that the care plan coordinator was out of the building, and he would get back to (R2) and myself with a day and time for a care plan meeting. I have never heard anything back.On 8/19/25 at 11:00 AM V1 (Administrator) verified R2 has not had a care plan meeting with the ombudsman present.On 8/18/25 at 11:38 AM V9 (Social Service Director) stated, I have worked here for two years and have never been told that (R2) would like a care plan meeting with the Ombudsman present. I am responsible for scheduling care plan meetings.

Based on observation, interview, and record review the facility failed to protect a resident with severely impaired cognition from resident-to-resident sexual abuse and failed to protect a resident from resident-to-resident physical abuse for four of four residents (R26, R35, R42, R62) reviewed for abuse in the sample of 38. This failure resulted in R35 a cognitively intact resident sexually assaulting R42 a cognitively impaired resident, on more than one occasion. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 4/7/25 when R35 entered R42's room and sexually assaulted her within the facility. V2 (Director of Nursing) and V26 (Regional Nurse) were notified of the Immediate Jeopardy on 7/24/25 at 4:10 PM. While the immediacy was removed on 7/25/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse, Prevention, and Prohibition Policy, undated, documents Statement of Intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect, or abuse of resident. This also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of property. Resident behaviors will be monitored for changes, which trigger abusive behaviors. The facility will reassess care plan interventions on a regular basis. Intervention strategies based on resident screenings will be implemented to prevent occurrences of abuse. Definitions: Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. R42's current Care Plan, dated 1/6/25, documents R42 has diagnoses including but not limited to dementia, poor safety awareness, confusion, Bipolar disorder, Schizoaffective, depression and anxiety. This care plan does not address any plans of care regarding R42 being at risk for or a victim of Abuse or interventions to protect R42 from being abused. R42's current Minimum Data Set assessment dated [DATE], documents R42 has severe cognitive impairment. On 7/22/2025 at 10:40 AM, R42 sitting in her room in a wheelchair with a mechanical lift sling under her. R42 stated (when asked if she has had any incidents with other residents coming into her room or touching her) There was something, but I can't remember. R42 was tearful at moments and confused with conversation. On 7/22/2025 at 10:45 AM V9 (Licensed Practical Nurse) confirmed she was working in April when R35 was observed inappropriately touching R42. V9 stated April 2025 would have been the first incident where (R35) was in (R42's) room with his hands on her stomach and breast area with her breasts exposed. There was a second incident, but I do not know what time of day or who was working. I know that the second incident was the same allegation of basically fondling. I heard through chatter of staff that it happened a second time, I believe in May 2025. On 7/22/25 at 11:30 AM, V12 (Certified Nursing Assistant) confirmed she was working and a witness when R35 was found in R42's room. V12 stated I was the one who saw (R35) in (R42's) room back in April (2025) inappropriately touching her. I was walking by and saw (R35) had his hand in (R42's) shirt under her breast area and was rubbing her back and forth. I think we put (R35) on 15-minute checks, I am not sure for how long. V12 confirmed R42 has severely impaired memory and is not able to recall events or provide any history. R35's Minimum Data Set assessment, dated 7/10/25, documents R35 is cognitively intact. R42 and R35's Incident investigation, dated 4/12/25, documents R35 and R42 were involved in a resident-to-resident altercation. The incident final report, dated 4/18/25, documents R35 was rubbing R42's abdomen after being asked by her to do so. This report documents The facility has taken the following actions based on the facts and conclusions of the investigation: (R35) was educated on asking staff for assistance instead of helping residents himself. On 7/23/25 at 9:10 AM, V9 (Licensed Practical Nurse) stated When I was working on 4/7/25, (R35) was observed touching (R42). (R42) had her shirt above the breast. Her breasts and abdomen were exposed. (R35) was groping her inappropriately and she was exposed. The door was open. (R35) didn't care, he was just in there quick and (V12) happened to be walking by and witnessed what was going on. He was groping her inappropriately and she was exposed. It was not just rubbing her belly. On 7/23/25 at 11:00 AM, V15 (Licensed Practical Nurse) stated I just started working in the facility in June or maybe May 2025, but no earlier. I came in one day and asked why (R35) was on 15-minute checks, when I got report. I was told it was because (R35) had his hand in (R42's) brief and pants. (V1, Administrator) and (V2, Director of Nursing) were aware because they are the ones who originally said for staff to do 15-minute checks with (R35). R42's nursing progress notes, risk management notes, care plan and assessments do not document any incidents of sexual abuse, touching of R42's private areas or interventions to alert staff to the incident occurring between R42 and R35 in April or May 2025. R35''s electronic medical record, dated 3/1/25-7/24/25, does not document that R35 has had sexual abuse allegations and does not document interventions or notes make staff aware of this behavior. On 7/23/25 at 3:00 PM, V1 (Administrator) and V2 (Director of Nursing) confirmed that R35's medical record does not document risk management notes or assessments for R35 to document why he was placed on 15-minute checks starting on 4/7/25. V2 stated the reason they started them is because of the incident with R42. On 7/24/25 at 1:30 PM, V2 confirmed R35 can ambulate around the building and that R35's medical record does not document appropriate measure to alert staff of his need for supervision. 2. R26 and R62's Final Five-Day Reported Incident to Illinois Department of Public Health, dated 6/17/25, documents (R26) was being repositioned, and (R26) reached over and hit (R62) on her shoulder. R26's Face Sheet documents R26 is a [AGE] year-old-female with the following but not limited to diagnosis: Alzheimer's disease with late onset, Dementia with mood disturbance, Bipolar Disorder, Mood disorder due to known physiological condition with depressive features. R26's current Care Plan documents (R26) has a behavior problem: physical aggression towards staff (triggers: overstimulation and increased noise levels and moving too quickly with cares) verbal aggression towards staff/peers (triggers: overstimulation, increased noise levels and moving too quickly with cares) signs and symptoms anxiety-restlessness (triggers: unsure of her surroundings and not being able to fully understand what is going on around her) signs and symptoms depression-crying/tearfulness (triggers: wanting to go home) hallucinations/delusional thinking/psychotic features (triggers: not understanding what is going on around her and overstimulation). R62's Face Sheet documents R62 is a [AGE] year-old-female with the following but not limited to diagnoses: Essential (Primary) Hypertension, Pure Hypercholesterolemia. R62's MDS (Minimum Data Set) Assessment, dated 6/11/25, documents R62 is cognitively intact. R62's Progress Note dated 6/9/2025 at 9:21 PM and signed by V22 (Registered Nurse) documents, The writer was notified by the CNA (identified as V13/Certified Nursing Assistant) that at 1630 the (R62) was hit on her right shoulder by the roommate (identified as R26). On 7/21/2025 at 10:09 AM, R62 stated R26 is known to be verbally and physically aggressive with staff while they are doing cares. R62 stated (R26) was in her bed, the staff turned (R26) towards me while I was sitting in my recliner chair and (R26) hit me in the shoulder. On 7/22/2025 at 9:15 AM, V2 (Director of Nursing) stated (R26) is known to be physically aggressive during cares. On 7/22/2025 at 10 AM, V13 (Certified Nurse Assistant) stated, While I was performing (R26's) incontinence cares, I turned (R26) over in bed during incontinence care and (R26) reached over and hit (R62) on her shoulder when (R62) was sitting in her recliner. (R62) then got up using her wheeled walker and walked out of the room. On 7/30/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R42 has received skin, pain, and trauma assessments, and their care plan was reviewed and updated as appropriate by social services director (V29), MDS coordinator (V10), and facility nursing staff on 7/25/25 2. 1:1 supervision on R35 has been implemented 7/24/25 to provide safety and adequate supervision for abuse for a period of 72hr and may be extended if results of psychiatric and medication review determine need. Social Services to meet with R35 and R42 for any trauma related concerns. 1:1 continues at this time Monday 7/28/2025 and will be reevaluated on Friday 8/1/2025 3. R35 had psychiatric evaluation and was completed by facility contracted psychiatric provider on 7/25/25. Facility medical director completed medication review on 7/25/25. 4. Administrator (V1), Director of Nursing (V2), Assistant Director of Nursing (ADON, V30), Housekeeping Supervisor (V43) were educated on Abuse and Neglect Policy and Procedure with special focus on sexual abuse identification and reporting by Regional Clinical Nurse (V26) Friday 7/25/2025 5. Agency and routine employees were/will be educated by the Regional Nurse (V26) or designee on the abuse policy and process of reporting abuse allegations with special focus on sexual abuse identification and reporting currently working when issue was reported or before to be completed by 8/1/2025 6. Agency staff and new employees will be educated by ADON (V30) or designee on the abuse policy and process of reporting abuse allegations prior to working the floor. The Director of Nursing (V2) or designee will be responsible for this education before working. Completion date 7/25/25

Based on observation, record review and interview the facility failed to post grievance/complaint procedures in a prominent location throughout the facility and promptly address resident grievances. This has the potential to affect all 67 residents residing in the facility. Findings include: The Resident Grievance Process-Senior Living Policy, undated, documents Policy: Utilization of the grievance form offers residents, families, or resident representatives an opportunity to make written accounts of their concerns utilizing the grievance form. Any resident or their representative may complete a grievance concerning his or her treatment, medical care, safety, or other issues without fear of reprisal of any type. The Administrator/Executive director will act as the community designated grievance official. The Administrator, with the assistance of the Social Service Designee, will be responsible for the oversight of the grievance process. Each grievance will be investigated an addressed with a response. The actual response may be completed be a department head and will be reviewed by the Administrator. Procedure: Grievance forms are to be located throughout the community at all nurse's stations and the front desks. The Social Services Designee or the employee responsible for the process will take a copy of all open grievance forms to the daily morning/Quality Assurance meeting for review by the Administrator/Executive Director will ensure grievances are addressed and resolved within a five-day time frame and outcome communicated to the person originating the grievance. Th appropriate department head will investigate grievances, document findings, and then return the grievance form to the Social Services Designee or the employee responsible for the grievance procedure. R21's Grievance, dated 5/8/25, documents, I have had difficulty with getting a full head to toe bath and my hair shampooed. I would like to discuss a shower plan at a care plan meeting with the Ombudsman there to support me. I would also like to discuss call lights not being answered in a timely manner by staff, staff not having access to needed supplies needed on a regular basis. Please let me know a date and time when we can meet and I'll coordinate with the Ombudsman This same grievance does not document steps of investigation, summary/findings, or recommendations/actions taken. On 7/21/2025 at 10:29 AM, R21 was in her room, in her bed, and in a pleasant mood. R21 stated I have had a lot of issues and I have tried to voice them by filing a grievance. (V3/Ombudsman) assisted me in completing one on 5/8/2025. R21 stated that V5 (Activities Director) is in charge of grievances but V5 is not helpful because it is her way or the highway. This is why I asked V3 to help me fill out the grievance on 5/8/25. On 7/21/2025 at 12:16 PM, V3 (Ombudsman) stated R21 asked V3 to assist her in writing a grievance on May 8th, 2025. V3 stated I took a picture of the grievance before I handed the grievance to the (V1 (Administrator) because the facility has stated before they never received the grievances. V3 stated the main request that R21 wanted to accomplish was a care plan meeting where I would attend with her. V3 stated V1 had told her that V21 (MDS) was gone on medical leave, and he would get back to her, and he has yet to get back to her. On 7/21/2025 at 3:06 PM, V5 (Activities Director) stated (V1) had (R21's) 5/8/2025 grievance and just gave it to me last week. I have not started this grievance. On 7/22/2025 at 11:00 AM, V1 stated Once (V3) handed me the grievance, I explained that (V21) was out due to (R21) wanting to have a care plan meeting. I have not documented anywhere that I have addressed (R21's) grievance or spoke to the (V3) regarding setting up a care plan meeting. V1 confirmed this grievance was not investigated and there is no resolution. On 7/22/25 at 10:06 AM during resident council meeting R2, R3, R24, R33, R35, R44, R51, R59, R67 all stated that they do not know where or how to file a grievance. On 7/22/25 at 10:09 AM R21 and R59 stated they (the facility) does not follow up with grievances promptly or at all sometimes. On 7/22/25 at 12:36 PM a tour was conducted with V1/Administrator asking V1 to show where the prominent location(s) are for the grievance procedure in the building. V1 verified there was not a posted grievance procedure in any prominent locations around the building. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/22/25 and signed by V1/Administrator documents 67 residents currently reside within the facility.

Based on Interview and Record review the facility failed to report an allegation of resident-to-resident sexual abuse to the local police department and report allegations of sexual abuse and physical abuse timely to the State Agency for four of four residents (R26, R35, R42, R62) reviewed for abuse in the sample of 38.Findings include: The facility's Abuse, Prevention, and Prohibition Policy, dated 12/2024, documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse Prohibition Program: The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. Reporting/Response: The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence. An employee or agent or any covered individual will make or cause a report to be made to law enforcement and the facility. The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or caused a report to be made to the mandated state agency per reporting criteria. Such reports may also be made to local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of the allegations of abuse or neglect, or the Administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than two hours, or per state regulations, after the allegation is made. This policy also documents Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Sexual abuse is defined as non-consensual sexual contact of any type with a resident.1. On 7/23/25 at 9:10 AM, V9 (Licensed Practical Nurse) stated When I was working on 4/7/25, (R35) was observed touching (R42). (R42) had her shirt above the breast. Her breasts and abdomen were exposed. (R35) was groping her inappropriately and she was exposed.R42 and R35's Incident investigation, dated 4/12/25 and completed by V1 (Administrator), documents an initial report of a resident-to-resident altercation was sent to the State Agency on 4/12/25 (five days after the allegation was reported to V1). R42 and R35's final Incident Report, dated 4/18/25, documents a final report was sent to the State Agency on 4/18/25 (11 days after the allegation was reported.) R42 and R35's electronic medical records, risk management notes and incident investigation do not document that local law enforcement was notified of the alleged sexual abuse between R35 and R42 in April 2025.On 7/24/25 at 1:30 PM, V1 (Administrator) confirmed that the initial abuse report for R42 and R35 was sent to the state agency five days after the allegation took place and that local law enforcement was never notified of the sexual abuse allegation.2. The facility's State Preliminary Incident Investigation Report dated 6/10/2025 documents a resident-to-resident altercation between R26 and R62.R62's Progress Note dated 6/9/2025 at 9:21 PM and signed by V22 (Registered Nurse) documents, The writer was notified by (V13/Certified Nurse Assistant) that at 4:30pm (R62) was hit on her right shoulder by (R26). (V13) reported that during cares, she was turning (R26) onto her left when (R26) extended her right hand and hit (R62) who was sitting in the recliner by the bed. (R62's) right shoulder skin check was done and no bruises, skin tear or injury noted. (R62) complained of right shoulder pain which she rated as 3/10. Ice pack was applied. (V1/(Administrator), on-call nurse, and both Power of Attorney's were notified. Physician was notified by fax. Will continue to monitor.On 7/22/2025 at 10 AM, V13 (Certified Nurse Assistant) stated, While I was performing (R26's) incontinence cares, I turned (R26) over in bed during incontinence care and (R26) reached over and hit (R62) on her shoulder when (R62) was sitting in her recliner. (R62) then got up using her wheeled walker and walked out of the room.On 7/22/2025, V1 (Administrator) confirmed he did not report within the 2-hour window. V1 stated, The resident-to-resident altercation between (R26) and (R62) happened on 6/9/25 not 6/10/25. I didn't report the incident to the state agency until 6/10/25. I wasn't aware I had to report it within two hours.

Based on observation, interview and record review the facility failed to ensure a resident was assessed following an alleged fall for 1 of 3 residents (R1) reviewed for fall assessments in the sample of 3. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including severe dementia without behavioral disturbance, anxiety and depression. R1's 4/18/25 Resident Assessment and Care Screening documents R1 to have moderate cognitive impairment. On 6/13/25 at 9:50 AM, R1 was observed lying in bed, alert and confused. She was unable to answer questions with any clear answers. She was wearing a hospital gown, and had an indwelling urinary catheter. Her room was located on the dementia unit. The facility's 5/9/25 final incident investigation report documents on 4/29/25 R1 was observed sitting on the floor in her room leaning against her bed. R1 stated she had fallen, and was unable to recall how she fell. The report shows V4 and V5 Certified Nursing Assistants (CNA's) reported to V6 Licensed Practical Nurse (LPN) R1 had fallen out of bed. The report shows V6 sent R1 to the emergency room for evaluation. On 6/13/25 at 12:15 PM, V4 said she was working on the west wing when V5 came out of the dementia unit asking for help with R1, because she was on the floor. V4 said V5 notified V6 of the incident at same time. She said V6 asked what had happened, and then told them to get R1 up and put her back into bed. V6 did not go to assess R1 at that time. V4 said R1 was moved from the floor to the bed, but could not recall what time this had occurred. Then just before the end of the shift at 6:00 AM, V6 said R1 was being sent out to the emergency room. The ED (Emergency Department) record for R1 shows the date and time of service to be 4/29/25 at 7:18 AM. The chief complaint was a fall, and R1 had complaints of mid back pain and right rib pain. The discharge assessment and clinical impression shows closed fractures of the 8th and 9th ribs on the right side. R1's 4/29/25 Nursing Progress Notes show she was transported back from the emergency department (ED) at 11:16 AM, and was received by V12 LPN. The progress notes do not show evidence of a fall incident, resident assessment, or documentation of notifications or what time R1 was sent out to the ED. On 6/13/25 at 11:30 AM, V12 LPN said on the morning of 4/29/25, she relieved V6 and received in report R1 had been sent out for evaluation due to behaviors. She was not given report of any fall. V12 said when she reviewed R1's notes, there was nothing charted. She said V6 should have charted the fall, and an assessment with vital signs. She should have noted if there was any head injury and range of motion. V12 said she found out about the fall when the emergency room called to let her know R1 had fractured ribs. On 6/13/25 at 10:37 AM, V3 Assistant Director of Nursing (ADON) said when a resident has a fall, the nurse should immediately assess the resident for any injury or possibility of injury and if the resident needs to be sent out to the ED. She said the nurse should document in the progress notes the assessment, what occurred, and what immediate interventions should be put in place to prevent further falls. She said the importance of the documentation is for staff to know what is going on with the residents. The facility's 4/29/25 policy for Post Fall Procedure documents Post Fall: After a resident fall, they must be stabilized by the nursing staff. A fall risk evaluation must be completed by the charge nurse. A detailed progress note must be documented in the resident's record, including root cause analysis, resident provider notification, resident representative notification, details of injury if present, new intervention, pertinent statement, and any other details surrounding the resident fall.

Based on Interview and Record Review the facility failed to provide effective administrative oversight to ensure residents on Medicaid receive a Personal Needs Allowances, assistance with supplemental income financial applications, transfer payment assistance and ensure a resident's personal funds were not charged for Medicaid covered services. This failure has the potential to affect all 68 residents residing in the facility. Findings include: The facility's Administrator/ Executive Director job description (undated), documents The Administrator oversees the day to day operations of the facility to meet state and federal regulations and supervises all department managers to ensure the facility is in compliance. The Administrator is responsible for the delivery of clinical services integrated with business plans while meeting or exceeding quality, clinical and utilization standards, performance measures, and financial productivity objectives. Ensures premier customer service while facilitates resolutions of resident care issues. Responsibilities: Acts as the compliance office for the facility. Ensures center compliance with all federal, state and company regulations and policies. Ensures that all practices and policies are carried out in the highest ethical manner. Ensures the highest quality in standard of care and services provided. Oversees completion of forms, reports, etcetera, including state licensure reports, monthly financial reports, (state agency) or department of labor surveys, plans of correction, responses to corporate requests, replies to residents' council, and others as needed. Reviews and signs accounting records, incident/ accident reports, resident fund reconciliation, and resident funds approval; provides facility related data/ information responsive to the company needs. The facility's Business Office Coordinator job description (undated), documents Responsible for the overall management of business office activities in accordance with current applicable federal, state, and local standard guidelines and regulations, and as directed by the administrator. Responsible for coordinating with the Central [NAME] Office on managing insurance payments, including private, Medicare, Medicaid and other managed care; managing refunds for accounts receivable, and maintaining appropriate logs and reports, not limited to, resident funds, census records, and case accounts. Responsibilities: Manages all business functions including but not limited to accounts receivable, accounts payable, resident trust finds and other assigned duties. Ensures the financial systems are accurate, efficient, and in accordance with professional accounting practices and governmental regulations. Manages insurance payments of Medicare, Medicaid, private insurance, HMOs (Health Maintenance Organizations) and hospice billing; verifies payor source; posting payments to various systems; ensures critical deadlines are met. Ensures timely receipts of all payments. Makes monthly phone calls to responsible parties regarding missing payments; submits Medicaid applications and completes timely follow up on pending cases; enters admission packets into the electronic system within seven days of admission. Maintain monthly logs for outstanding admission packets, new admissions, verifications and pending cases; maintains Medicaid pending and pending admission log. Implements and monitors the facility's established system for receiving, depositing, withdrawing and accounting for resident funds and ensures that resident funds are available for the resident or their authorized representative in accordance with established procedures; conducts monthly audit to ensure process is followed. Obtains information from admissions and assures accuracy and completeness. The facility's Admissions Coordinator job description (undated), documents Responsibilities: Ensure financial verification is accurate and complete before the resident is admitted to the facility thus assisting in reducing accounts receivable. Conducts admission process of signing in and explaining admission policies to residents and their families. Ensures a smooth transition is achieved and that all paperwork is complete upon admission. Emphasizes financial arrangements and responsibilities. The Medicaid's Personal Needs Allowance (PNA) for Nursing Home Residents article, dated 1/13/25 and located at www.medicaidplanningassistance.org/personal-needs-allowance, documents Medicaid's Personal Needs Allowance (PNA) is the amount of monthly income a Medicaid-funded nursing home resident can keep of their personal income. Since room, board, and medical care are covered by Medicaid, the majority of one's income must go towards the cost of nursing home-care as a Share of Cost/Patient Liability. The PNA is intended to cover the nursing home resident's personal expenses, which are not covered by Medicaid. This may include, but is not limited to haircuts, vitamins, clothing, magazines, and vending machine snacks. Under certain circumstances, if a nursing home resident does not have their own monthly income, the Personal Needs Allowance is provided by the state in which one resides. The facility's Financial Responsibility Agreement, dated 10/2023, documents Residents who are eligible for Medicaid will not be charged for any medical or personal supplies that are routinely supplied to all residents in accordance to state guidelines. R2's current electronic medical record documents R2 was admitted to the facility on [DATE] and R2's stay is being paid for by Medicaid, since admission. On 4/21/25 at 10:15 AM, R2 stated she moved to the facility close to a year ago. R2 stated On April 28th I will be a year without getting my social security. I am on Medicaid, and I think I have some insurance and I have no money to my name. If I want a haircut or shoes, or just to go shopping, I can't because I have no money. The only time I have cash is if I win bingo and I might get a dollar or a dollar and a half, and then I have a friend from church who has given me some money for things like shoes. R2's Monthly recorded trust registry dated 11/1/24, documents on 11/1/24 R2's personal trust balance was $1,159.50. This registry documents on 11/12/24, $1086.20 was deducted for R and B (Room and Board) payment. This registry documents three deductions for shopping and one credit of $13.77 for a final balance on 12/1/24 of $32.07. R2's Monthly recorded trust registry, dated 1/1/25, documents R2's account balance was $16.01 and recorded a withdrawal of $16.00 for shopping on 1/7/25. R2's Monthly recorded trust registries, dated 2/1/25, 3/1/25 and 4/1/25 all document R2's trust account balance is $0.01. R2's [NAME] statement, dated 3/31/25, documents R2's account was credited $217.24 on 3/5/25 and R2's total amount due to the facility is $15,413.76. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) confirmed R2's stay is being paid for by Medicaid and R2 has a current trust balance of one cent. V4 stated (R2) has Medicaid for insurance and room and board is also paid from her social security. (R2) has not been getting social security checks or her 60 dollar personal needs allowance each month due to the checks not being delivered here and the facility not being set as her payee. Those checks are just piling up at the social security office. (R2) does have an additional income that is coming to us that is a little over 200 dollars each month. I think that is from an old pension or retirement income. That amount is credited to her bill and does not withhold her 60 dollar monthly allowance. Nothing has been added to (R2's) trust for personal spending from that retirement income. (R2) came here with a check from her past facility and it was the money she had in her trust account. (R2) is owed the 60 dollar monthly amount of money for the past year and the over 1000 dollars that we took from her trust in November 2024. That was onetime payment. (R2) has a family members (V12 and V12's spouse, V13) who get (R2's) billing accounts and I am sure that viewing large, owed balances is overwhelming. (V13) is (R2's) financial POA (Power of Attorney) and told me to deduct (R2's) room and board from November, out of (R2's) personal trust money. But that money is all gone because it has not had any deposits since (R2) has lived here. The facility's Medicaid list (undated), provided by V3 (Licensed Practical Nurse/Assistant Director of Nursing) on 4/22/25, documents R5 was admitted to the facility on [DATE], R6 was admitted to the facility on [DATE] and R7 was admitted to the facility on [DATE]. This list documents all three residents have a payer source of Medicaid. R5, R6 and R7's current electronic medical records document all three residents are under the age of 65. On 4/22/25 at 10:15 AM, V1 (Administrator) provided blank trust balance forms, dated 2/1/25-4/1/25, for R5, R6, and R7 and V1 stated They (R5, R6, R7) do not have any monthly balance due to having no income, so these residents do not receive a monthly Personal Needs Allowance (PNA). On 4/22/25 at 10:35 AM, V8 (Corporate Educator) stated When residents come to the facility they have to have some kind of income. There are very few cases where they don't have any income at all. It would be the Business Office Manager and Social Services who would be responsible for assisting the residents to get the SSI (Supplemental Security Income) after being admitted . On 4/22/25 at 11:00 AM, V9 (Corporate Medicaid Compliance Manager) stated SSI has to be applied for separately. For Illinois, when a resident applies and under age [AGE], if they are not receiving disability and they have no source of income we (the facility) would pursue disability, and they would make a decision. The resident would be entitled to SSI and then they would get a PNA (Personal Needs Allowance). It's not an automatic when they are admitted on Medicaid. What should be done is that we (the facility) pursue the SSI application. The facility should want to make sure they start the disability process and that is usually started through Social Services. If we have a resident living (in the facility) long term and they are not getting SSI, they (social services) can start paperwork for disability. On 4/22/25 at 11:11 AM, V5 (Social Services) stated she has been in the job position for about one year. V5 stated I have not done any SSI or Disability assistance applications. On 4/22/25 at 11:38 AM, V4 (Business Office Manager, BOM) confirmed she has been working in the job position for approximately two years. V4 stated I haven't ever helped a resident apply for SSI or Disability. I do the financial agreement on admission and the contract is done by Social Services. (R5, R6 and R7) have been here a while and all have a zero liability. So, they receive no additional funds or personal allowance monthly. I am not sure how to see if they have ever applied for SSI or Disability. I guess we would need to talk to the Medicaid office case managers, but I haven't done that for anyone. On 4/22/25 at 3:25 PM V1 (Administrator) stated On admission the BOM does the financial checks to ensure payer source, and those things are accurate. There isn't generally anyone else overseeing the payments through corporate. We just do the financial check and see that they have a payer source. We (the facility) do have a monthly AR (Accounts Receivable) call with myself, the BOM (V4) and a corporate representative, related to private pay, liability and making sure all of those things are coming through correctly. I can't speak to any time prior to October 2024 when I started. I was not aware that (R2) was receiving income aside from the social security checks (that haven't been delivered). I didn't know (R2) had any trust money transferred here from her (previous nursing home) account or that we deducted room and board from those personal funds account. (R2) came here before I did, and I was not aware that happened. (R2) came to me once, early on (unknown date). She told me she was concerned about her social security not coming here and that's when I was made aware of a possible issue, but only recently realized it is still an issue. The combination of BOM and Social Services would be the people assisting residents with SSI and Disability. I have not had to encounter anyone needing it, so we have not done any of that. I am not aware of anything related to residents needing additional funding or lacking personal needs allowances. If they don't have any liability, then we would need to reach out to them and see if they need signed up for SSI or Disability. I don't have the documentation to show when residents were talked to or that this concern has been addressed. V1 confirmed that the facility has a large population of Medicaid funded residents and that at any time a residents could face a need to be placed on Medicaid services for facility payment. The facility's (undated) Resident Roster provided on 4/21/25 and verified by V1 (Administrator), documents 68 residents reside in the facility.

Based on Interview and Record Review, the facility failed to provide a resident with state funded payment transfer assistance and social services to ensure medical and personal state aid payments were accurately delivered for over eleven months and ensure residents currently receiving Medicaid are applying for financial services to allow an opportunity for a monthly personal needs allowance to be provided for four of seven residents (R2, R5, R6, R7) reviewed for Personal Funds and [NAME] in the sample of seven. Findings include: The facility's Social Services Assistant job description (undated), documents Responsible to assist Social Service Coordinator and Social Workers in providing medically related social services so that each resident may attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. Promotes a climate, policies and routines that enable residents to maximize their individuality, independence and dignity. Services will be provided in accordance with Federal, State and Local regulations and governing agencies. Responsibilities: Makes appropriate referrals to other consultants, community agencies, or center departments in order to facilitate the resident/resident's optimal use of resources, and to promote increased level of psycho-social functioning as planned by the Social Service Coordinator or Social Worker. Aids with the resident/resident's admission to assure a smooth transition; meets with resident/resident's and families as needed to provide information and facilitate adjustment. The facility's Admissions Coordinator job description (undated), documents Responsibilities: Ensure financial verification is accurate and complete before the resident is admitted to the facility thus assisting in reducing accounts receivable. Conducts admission process of signing in and explaining admission policies to residents and their families. Ensures a smooth transition is achieved and that all paperwork is complete upon admission. Emphasizes financial arrangements and responsibilities. The facility's Business Office Coordinator job description (undated), documents Responsible for the overall management of business office activities in accordance with current applicable federal, state, and local standard guidelines and regulations, and as directed by the administrator. Responsible for coordinating with the Central [NAME] Office on managing insurance payments, including private, Medicare, Medicaid and other managed care; managing refunds for accounts receivable, and maintaining appropriate logs and reports, not limited to, resident funds, census records, and case accounts. Responsibilities: Manages all business functions including but not limited to accounts receivable, accounts payable, resident trust finds and other assigned duties. Ensures the financial systems are accurate, efficient, and in accordance with professional accounting practices and governmental regulations. Manages insurance payments of Medicare, Medicaid, private insurance, HMOs (Health Maintenance Organizations) and hospice billing; verifies payor source; posting payments to various systems; ensures critical deadlines are met. Ensures timely receipts of all payments. Makes monthly phone calls to responsible parties regarding missing payments; submits Medicaid applications and completes timely follow up on pending cases; enters admission packets into the electronic system within seven days of admission. Maintain monthly logs for outstanding admission packets, new admissions, verifications and pending cases; maintains Medicaid pending and pending admission log. Implements and monitors the facility's established system for receiving, depositing, withdrawing and accounting for resident funds and ensures that resident funds are available for the resident or their authorized representative in accordance with established procedures; conducts monthly audit to ensure process is followed. Obtains information from admissions and assures accuracy and completeness. The Medicaid's Personal Needs Allowance (PNA) for Nursing Home Residents article, dated 1/13/25 and located at www.medicaidplanningassistance.org/personal-needs-allowance, documents Medicaid's Personal Needs Allowance (PNA) is the amount of monthly income a Medicaid-funded nursing home resident can keep of their personal income. Since room, board, and medical care are covered by Medicaid, the majority of one's income must go towards the cost of nursing home-care as a Share of Cost/Patient Liability. The PNA is intended to cover the nursing home resident's personal expenses, which are not covered by Medicaid. This may include, but is not limited to haircuts, vitamins, clothing, magazines, and vending machine snacks. Under certain circumstances, if a nursing home resident does not have their own monthly income, the Personal Needs Allowance is provided by the state in which one resides. 1. R2's current electronic medical record documents R2's stay is being paid for by Medicaid, since admission. R2's current Care Plan, dated 3/11/25, documents R2 was admitted to the facility on [DATE] with Diagnoses of Bipolar Disorder without Psychotic features and Borderline Intellectual Functioning. This same care plan documents (R2) is alert and oriented. She is able to state wants and needs. (R2) requires training for community living skills. She has impairments with self-maintenance, social functioning, work related skills, and community living skills. Diagnosis: Bipolar. On 4/21/25 at 10:15 AM, R2 stated she moved to the facility close to a year ago. R2 stated On April 28th I will be a year without getting my social security. I am on Medicaid and I think I have some insurance and I have no money to my name. If I want a haircut or shoes, or just to go shopping, I can't because I have no money. The only time I have cash is if I win bingo and I might get a dollar or a dollar and a half, and then I have a friend from church who has given me some money for things like shoes. R2's Monthly recorded trust registries, dated 2/1/25, 3/1/25 and 4/1/25 all document R2's trust account balance is $0.01 with zero transactions or deposits throughout the three month period. R2's [NAME] statement, dated 3/31/25, documents R2's total amount due to the facility is $15,413.76. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) stated (R2) has Medicaid for insurance and room and board is paid from her social security and a small retirement income. When (R2) came here the prior nursing home was her payee for social security. (R2's) not been getting her personal needs allowance of 60 each month. (R2) has a family member (V12) who gets her billing accounts but not the checks because those are piling up at the social security office. They (social security) needs to switch over and list (the facility) as her payee so her checks can be sent here. On 4/22/25 at 10:35, V8 (Corporate Educator) stated We (the facility) can apply for rep (representative) payee and then we are the one receiving the payments from social security. This would be the BOM (Business Office Manager's) job to apply for rep payee. (R2) does have a resident liability. I think this error may have been discovered after the fact, after (new facility ownership) took over from (prior ownership). (R2) should be getting her $60 each month added to her personal funds. 2. The facility's Medicaid list (undated), provided by V3 (Licensed Practical Nurse/Assistant Director of Nursing) on 4/22/25, documents R5 was admitted to the facility on [DATE], R6 was admitted to the facility on [DATE] and R7 was admitted to the facility on [DATE]. This list documents all three residents have a payer source of Medicaid. R5, R6 and R7's current electronic medical records document all three residents are under the age of 65. On 4/22/25 at 10:15 AM, V1 (Administrator) provided blank trust balance forms, dated 2/1/25-4/1/25, for R5, R6, and R7 and V1 stated They (R5, R6, R7) do not have any monthly balance due to having no income, so these residents do not receive a monthly Personal Needs Allowance (PNA). On 4/22/25 at 10:35 AM, V8 (Corporate Educator) stated When residents come to the facility they have to have some kind of income. There are very few cases where they don't have any income at all. It would be the Business Office Manager and Social Services who would be responsible for assisting the residents to get the SSI (Supplemental Security Income) after being admitted . On 4/22/25 at 11:00 AM, V9 (Corporate Medicaid Compliance Manager) stated SSI has to be applied for separately. For Illinois, when a resident applies and under age [AGE], if they are not receiving disability and they have no source of income we (the facility) would pursue disability, and they would make a decision. The resident would be entitled to SSI and then they would get a PNA (Personal Needs Allowance). It's not an automatic when they are admitted on Medicaid. What should be done is that we (the facility) pursue the SSI application. The facility should want to make sure they start the disability process and that is usually started through Social Services. If we have a resident living (in the facility) long term and they are not getting SSI, they (social services) can start paperwork for disability. On 4/22/25 at 11:11 AM, V5 (Social Services) stated she has been in the job position for about one year. V5 stated I have not done any SSI or Disability assistance applications. I know the Business Office Manager gets asked about those things. I assist on admissions as well and act as the Admissions Coordinator. I make sure residents have a payer source that we can accept. Going over the Medicaid list is also part of my admissions duty. On 4/22/25 at 11:38 AM, V4 (Business Office Manager, BOM) confirmed she has been working in the job position for approximately two years. V4 stated I haven't ever helped a resident apply for SSI or Disability. I do the financial agreement on admission and the contract is done by Social Services. (R5, R6 and R7) have been here a while and all have a zero liability. So, they receive no additional funds or personal allowance monthly. I am not sure how to see if they have ever applied for SSI or Disability. I guess we would need to talk to the Medicaid office case managers, but I haven't done that for anyone. On 4/22/25 at 3:25 PM V1 (Administrator) stated On admission the BOM does the financial checks to ensure payer source, and those things are accurate. The combination of BOM and Social Services would do the assisting residents with SSI and Disability. I have not had to encounter it, so we have done any of that. Residents can come and ask and they would be assisted. If they don't have any liability, then we would need to reach out to them and see if they need signed up for SSI or Disability. I don't have the documentation to show when residents were talked to or that this concern has been addressed.

Based on interview and record review the facility failed to ensure a resident's personal funds were not charged for covered services while receiving Medicaid benefits for one of seven residents (R2) reviewed for billing in the sample of seven. Findings include: The facility's Financial Responsibility Agreement, dated 10/2023, documents Residents who are eligible for Medicaid will not be charged for any medical or personal supplies that are routinely supplied to all residents in accordance to state guidelines. The Medicaid's Personal Needs Allowance (PNA) for Nursing Home Residents article, dated 1/13/25 and located at www.medicaidplanningassistance.org/personal-needs-allowance, documents Medicaid's Personal Needs Allowance (PNA) is the amount of monthly income a Medicaid-funded nursing home resident can keep of their personal income. Since room, board, and medical care are covered by Medicaid, the majority of one's income must go towards the cost of nursing homecare as a Share of Cost/Patient Liability. The PNA is intended to cover the nursing home resident's personal expenses, which are not covered by Medicaid. This may include, but is not limited to haircuts, vitamins, clothing, magazines, and vending machine snacks. Under certain circumstances, if a nursing home resident does not have their own monthly income, the Personal Needs Allowance is provided by the state in which one resides. This same article documents A resident's Personal Needs Allowance cannot be used towards items and/or services paid for by Medicaid. For instance, federal regulations require the nursing home to provide the resident (at no charge) with basic personal hygiene items, such as a toothbrush, toothpaste, dental floss, denture adhesive and cleaner, shampoo, bath soap, deodorant, moisturizing lotion, comb, razors, incontinence supplies, and tissues. If a resident chooses to purchase a specific brand that is not provided by the nursing home, their Personal Needs Allowance can be used. R2's current electronic medical record documents R2 was admitted to the facility on [DATE] and R2's stay is being paid for by Medicaid, since admission. On 4/21/25 at 10:15 AM, R2 stated she moved to the facility close to a year ago. R2 stated On April 28th I will be a year without getting my social security. I am on Medicaid, and I think I have some insurance and I have no money to my name. If I want a haircut or shoes, or just to go shopping, I can't because I have no money. The only time I have cash is if I win bingo and I might get a dollar or a dollar and a half, and then I have a friend from church who has given me some money for things like shoes. R2's Monthly recorded trust registry dated 11/1/24, documents on 11/1/24 R2's personal trust balance was $1,159.50. This registry documents on 11/12/24, $1086.20 was deducted for R and B (Room and Board) payment. This registry documents three deductions for shopping and one credit of $13.77 for a final balance on 12/1/24 of $32.07. R2's Monthly recorded trust registry, dated 1/1/25, documents R2's account balance was $16.01 and recorded a withdrawal of $16.00 for shopping on 1/7/25. R2's Monthly recorded trust registries, dated 2/1/25, 3/1/25 and 4/1/25 all document R2's trust account balance is $0.01. R2's [NAME] statement, dated 3/31/25, documents R2's account was credited $217.24 on 3/5/25 and R2's total amount due to the facility is $15,413.76. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) confirmed R2's stay is being paid for by Medicaid and R2 has a current trust balance of one cent. V4 stated (R2) has Medicaid for insurance and room and board is also paid from her social security. (R2) has not been getting social security checks or her 60 dollar personal needs allowance each month due to the checks not being delivered here and the facility not being set as her payee. Those checks are just piling up at the social security office. (R2) does have an additional income that is coming to us that is a little over 200 dollars each month. I think that is from an old pension or retirement income. That amount is credited to her bill and does not withhold her 60 dollar monthly allowance. Nothing has been added to (R2's) trust for personal spending from that retirement income. (R2) came here with a check from her past facility and that was all of the money she had in her trust account. (R2) is owed the 60 dollar monthly amount of money for the past year and the over 1000 dollars that we took from her trust in November 2024. That was onetime payment. (R2) has family members (V12 and V12's spouse, V13) who get (R2's) billing accounts and I am sure that viewing large, owed balances is overwhelming. (V13) is (R2's) financial POA (Power of Attorney) and told me to deduct (R2's) room and board from November, out of (R2's) personal trust money. But that money is now all gone because it has not had any deposits since (R2) has lived here.

Based on observation, interview and record review, the facility failed to deliver resident mail, unopened and without being read, to one of four residents (R1) reviewed for mail delivery in the sample of seven. Findings include: The facility's Resident Rights policy, dated 12/2024, documents Each resident residing in this community has the right and will be afforded the right to dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. It is the responsibility of all who work in this community, including employees of the community and any others who provide services to the residents of the community, to advocate and protect the rights of each resident. This same policy documents Resident rights include but are not limited to: Privacy and confidentiality. Privacy in sending and receiving mail. R1's current Care Plan, dated 4/8/24, documents R1 was admitted to the facility on [DATE]. This Care Plan also documents (R1) has suffered a traumatic life event of husband's death, requiring support and intervention. Triggers include: date of husband's death, approaching holiday's, people talking about his death, church services because husband was a reverend. Date initiated, 12/11/2024. On 4/21/25 at 10:30 AM, R1 was sitting in wheelchair in her room. At this time R1 stated A few weeks ago I was delivered two envelopes that were addressed to me and they were both opened before I got them. The Business Office Manager (V4) brought me the two envelopes and they were both life insurance checks from (V14, R1's late spouse) passing away in November. (V4) said that she opened my letters by accident but if she did that, then why did she open both of them? I have not had any other mail delivered opened, but both of these envelopes were. On 4/21/25 at 11:20 AM, V11 (R1's Family Member) stated We (family members) do all the banking for (R1) and none of it is managed by the facility or (V4). When I called (V4) after the mail was delivered to (R1) already opened, I asked her why she opened it and she said it doesn't matter. The envelope said (company) Life Insurance and only was addressed to (R1), not the facility so (V4) knew these envelopes contained checks. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) confirmed in March 2024, she opened two pieces of mail that were addressed to R1. V4 stated (R1) received life insurance checks and I opened those. I had the envelope upside down, and I opened both envelopes. They were addressed to (R1) and it was just her name, not the facility. I am the one who receives all of the resident mail and see that it gets delivered. (V7, Activity Director) gives the mail to residents once it is sorted by me. On 4/22/25 at 9:35 AM, V7 stated I deliver mail for all of the residents. I get the mail from (V4). If something is addressed to the facility sometimes, I have had to open it only due the fact that there is no resident name on the outside. In which case I then take it to the resident and will show them that the outside of the envelope does not have a name on it. When I get the mail from (V4) it is sealed. V7 confirmed resident mail should be delivered to the residents still sealed and only opened if requested by the resident.

Based on observation, record review and interview, the facility failed to follow its policy and ensure sanitary handling of food items during mealtimes. This failure has the potential to affect all 75 residents who reside in the facility. Findings include: The Facility's Hand Washing and Glove Usage Policy, undated, documents: All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines. 5. Gloves are to be used whenever direct food contact is required. The facility's Infection Prevention and Control Manual Standard Precautions Gloves Policy, dated 2019, documents: Purposes: 3. To reduce the likelihood that healthcare workers will transmit their endogenous microbial flora to residents. On 8/20/24 at 11:40 am, V16 (Certified Nursing Assistant/CNA) prepared food trays for all residents residing in the facility. V16 (CNA) removed bread from a plastic bag on a meal tray with V16's bare hands, placed the bread in V16's left hand and used a knife to butter the bread, cut the bread in half, and then placed the bread back on the meal tray with the rest of the food items. No gloving or handwashing was performed. On 8/20/24 at 11:40 am, V16 CNA stated, No, we are not supposed to touch bread or the food with our bare hands. On 8/20/24 at 11:45 am, V17 (Activities) stated, I do not touch the food; we are not supposed to touch the food with our bare hands. On 8/20/24 at 11:55 am, V18 (Licensed Practical Nurse/LPN) stated, Staff should have gloves on if touching residents' food. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form, dated 8/20/24, documents 75 residents reside in the facility.

Based on observation, interview, and record review the facility failed to prevent abuse for four of seven residents (R9, R10, R11, and R12) from resident-to-resident physical abuse and failed to prevent resident-to-resident sexual abuse for one resident (R3) reviewed for abuse in the sample of 26. These failures resulted in R3 physically assaulting R11 by hitting R11 in the left arm, R3 physically assaulting R10 by shoving R10 down to the ground resulting in R10 having a contusion of the scalp and severe pain requiring an emergency room visit, R3 punching R9 in the face, and R3 throwing water on R12. These failures also resulted in R4 sexually assaulting R3 by putting his left hand down R3's pants and briefs when R3 went into R4's room. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7/6/24 the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The Abuse, Prevention and Prohibition Policy dated 1/24 documents Statement of Intent Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The resident must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property. Resident behaviors will be monitored for changes, which trigger abusive behaviors. The facility will reassess care plan interventions on a regular basis. Intervention strategies based on resident screenings will be implemented to prevent occurrences of abuse. 1. R3's Face Sheet documents R3 was admitted to the facility on [DATE]. This same form documents the following, but not limited to, diagnoses: Unspecified Dementia and Major Depressive Disorder. R3's MDS (Minimum Data Set) assessment dated [DATE], documents, R3 is severely cognitively impaired, has delusions and behaviors of physical and verbal aggression that impacts others, wanders and significantly intrudes on the privacy or activities of others, wanders and is at significant risk of getting to a potentially dangerous place, is at significant risk for physical illness or injury, puts others at significant risk of physical injury, and significantly intrudes on the privacy or activity of others. R3's Care Plan dated 6/25/24, documents R3 has behaviors of being verbally aggressive towards staff, being physically aggressive with others, and is known to wander into other residents' rooms. This same care plan does not include interventions addressing R3 shoving down R11. R3's Behavior Note written by V4/Licensed Practical Nurse/LPN dated 3/30/24 at 1:26 PM, documents (R3) was in the room when CNA (Certified Nursing Assistant) attempted to redirect (R3) out of the room. (R3) became agitated/verbally aggressive and started swinging at CNA. (R3) told CNA to get out. (R3) then came out of the room and went down the hall and asked another resident (R11) to help (R3) and (R3) then punched and shook another resident (R11) on left arm. R3's AIMs (Assessment Intercommunicate Management) dated 3/30/24 documents that R3 appears to have been involved in an altercation with a peer (R11). Just prior to the time of the event R3 appears to have been in another resident's room. V32/CNA stated R3 was in another room and V32 attempted to redirect R3 and R3 became aggressive. The incident happened in the hallway. R3 has a history of physical aggression towards staff and other residents at other nursing (facilities). R11's current computerized medical record, documents R11 is an [AGE] year old female that admitted to the facility on [DATE] with diagnoses which included Dementia, with Psychotic Disturbance, Depressive Disorder, and Chronic Obstructive Pulmonary Disease. R11's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, indicating (severe cognitive impairment). R11's Nursing Note written by V4/LPN dated 3/30/24 at 1:41 PM, documents, CNA reported that another resident (R3) came up to (R11) and asked (R11) to help (R3) then proceeded to hit (R11) in the left arm and shake (R11's) arm. CNA was able to intervene. Voice mail left for administrator at 1:11 PM d/t (due to) no answer. On 7/2/2024 at 9:04 AM, V32/Agency CNA stated, I haven't worked at (the facility) for a few months. When I was working at (the facility) there was a resident (R3) who was swinging on everyone that day. (R3) punched and shook (R11's) left arm. (R3) was swinging her arms so hard, she even swung herself to the floor. (R3) was being very aggressive and trying to punch everyone. On 6/30/24 at 3:15 PM, V25/R11's Power of Attorney/POA stated that earlier this year she was notified that R11 was hit in the back of the head and shook by another resident (unidentified). V25 asked if R11 had done anything to the resident to provoke the incident. V25 was told No, (R11) did not do anything to the other resident. 2. The Final Report sent to the (State agency) dated 5/21/24 at 8:06 AM, documents that on 5/16/24 R10 BIMs/Brief Interview of Mental Status of 15 (indicating cognition intact) and R3 BIMs of 0 (indicating severe cognitive impairment) had a verbal altercation. Witness statements stated that they heard R10 yelling at R3 What are you doing. Get out of here. Before staff could intervene, R3 pushed R10 and R10 fell hitting her head. This event happened as R10 was leaving the bathroom. R10 was assessed with no injuries but was sent to the Emergency Department for an evaluation due to hitting her head. R3's Behavior Note written by V18/LPN dated 5/16/24, at 4:27 PM, documents (R3) is agitated. (R3) was yelling and pushing (V18). (R3) tried shutting the door on (V18). (R3) is refusing to allow roommate (identified as R10) into (R3's) room. (V18) talked calmly to (R3) and (R3) calmed down. (R10) asked CNA to get something out of room. (R3) placed hands on the CNA and was pushing and yelling at the CNA and trying to shut the door on the CNA. (R3) reached out to scratch CNA on the face. (V18) stepped in and asked (R3) to stop and remove her hands from the CNA. (R3) did. Then (R3) became angry and yelling at (V18). (R3) was raising her hand to scratch or hit (V18). (V18) and CNA left the room. R3's Behavior Note written by V18/LPN dated 5/16/24 at 5:05 PM, documents (R3's) roommate (identified as R10) was in the bathroom. There was an altercation between (R3) and (R10). (R10) ended up on the floor in the adjoining room. (R10) stated she bumped her head on floor. R3's current Care Plan does not include interventions addressing R3 shoving R10 down. R10's current computerized medical record, documents R10 is an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis which Dementia, Depression, Essential (Primary) Hypertension, and End Stage Renal Disease. R10's MDS (Minimum Data Set) assessment dated [DATE], documents a BIMS (Brief Interview for Mental Status) Score of 9/15, indicating moderate cognitive impairment. R10's AIMS dated 5/16/24 and signed by V18/LPN documents that R10 had an unwitnessed change in plane at approximately 5:05 PM on 5/16/24. Just prior to the time of the event R10 appears to have been using the bathroom in her room. R10's account of the event is R10 stated her roommate (identified as R3) was standing in the doorway. The next thing R10 remembered was them arguing and R10 ending up on the floor. Staff responded when R10 was yelling for help. R10 stated her only pain was the bump on the back of her head. V18/LPN sent R10 to the local ED (Emergency Department) because of a golf ball size bump on the back of R10's head. R10's Nursing Note dated 5/16/24 at 5:1 PM written by V18/LPN documents, (R10) sent to the hospital because of golf ball sized bump on back of head from incident and right pupil not responding to light. R10's ED (Emergency Department) discharge note dated 5/16/24 documents, Primary Diagnosis: Contusion of scalp. Reason for Visit: Assault Victim and Neck Pain. (R10) here from (the facility). (R10) was hit by her roommate (R3) causing (R10) to fall to the ground. (R10) hit the back of her head. Originally not complaining of any pain but EMS (Emergency Medical Services) reports that in route (R10) started to complain of head and neck pain. C-collar applied. Trauma: Reports headache and neck pain. Neck Pain: associated symptoms- headache. R10's Statement dated 5/17/24 documents another resident (identified as R3) pushed R10 down. R10 was standing in the bathroom doorway talking to someone in the next room. R10's roommate (R3) came up and pushed R10 down. V4/LPN Written Statement dated 5/20/24 about the incident between R3 and R10 documents that R3 gets upset/agitated upon redirection and/or others raising their voice at R3. R3 is difficult to redirect. R10 raises her voice loudly and will yell out to others Why are you in there? What are you doing? Get out of there. On 6/30/24 at 10:19 AM, R10 stated, I don't remember what exactly happened. I just know someone pushed me down and my neck and head were hurting. I went to the hospital. On 7/1/24 at 10:27 AM, V20/R10's POA stated that she was told R10's roommate (R3) pushed R10 and R10 fell hitting her head and was sent to the hospital. (R3) would take R10's clothes. After R10 was pushed and hit her head R10 was moved to another room. R10 is not able to express herself now. V20 was asked how R10 would have felt about being pushed by someone when R10's cognition was intact. V20 stated that R10 had a rough childhood and R10 would have been aggravated and upset. On 7/1/2024 at 4:08 PM V18/LPN stated, I did not witness the altercation between (R3) and (R10), but (R10) was cognitively intact then. (R10) told me (R3) was trying go in the bathroom where (R10) was, (R10) was telling (R3) to get out and (R3) went up to (R10) and shoved her down. 3. The Final Report sent to the (State agency) dated 6/18/24 at 2:53 PM, documents that V12/Certified Nursing Assistant/CNA alerted nursing staff that R9 reported that R3 Punched (R9) in the face and told R9 to get out of bed. R9 was assessed and there were no apparent injuries. Conclusion: R3 got in roommate R9's bed. R3 wanted R9 to get out of the bed due to R3 thinking it was her bed. Neither resident remembers the event after it occurred. R3's Nursing Note written by V26/LPN dated 6/14/24 at 5:38 AM, documents CNA alerted (V26) that (R3) had punched (R3's) roommate (R9) in the face and told her to get out of bed. CNA separated the residents from each other and (R3) laid down in (R9's) bed. (V26) with another nurse was able to get (R3) to her own bed with no altercation. R3's current Care Plan dated 6/25/24 does not include interventions addressing R3 punching R9. R9's current computerized medical record, documents R9 is a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis which included Osteoarthritis, Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, Dementia, Delusional Disorder, and Alzheimer's Disease. R9's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, indicating severe cognitive impairment. R9's Progress Note dated 6/14/24 at 5:42 AM written by V26/LPN documents that a CNA alerted V26/LPN that R9 had been punched in the right side of her face. R9 stated that R3 punched R9 in the face and told R9 to get out of bed. The CNA separated the R3 and R9 and R3 then laid down in R9's bed. V12/CNA Written Statement dated 6/14/24 documents that R3 was in her roommate (R9's) bed. R9 wanted R3 to get out of R9's bed. R3 hit R9 in the face. On 6/30/24 at 7:34 PM, V19/R9's POA stated that she was told R9 was hit in the jaw by R9's roommate (identified as R3). The facility moved the roommate (R3) to another room. There were several times before the incident happened when V19 went to visit R9, and the roommate (R3) would be in R9's bed or messing with R9's clothes. V19 also stated I would start to say something to the roommate (R3) and (R9) would say Oh, no, leave (R3) alone its ok. V19 was asked if she thought R9 was afraid of R3. V19 stated That's very possible. I know (R9) never wanted me to say anything to her roommate (R3) and (R9) was not that way with anyone else. On 7/2/24 at 9:06 AM an attempt was made to contact V12/CNA with no answer or return call back. 4. R3's Nursing Note written by V4/LPN dated 6/19/24 at 5:22 PM, documents (R3) threw a partial glass of water on another resident (R12). (R3) keeps trying to get more water to throw on staff and other residents. R3's current Care Plan dated 6/25/24 does not include interventions addressing R3 throwing water on R12. R12's current computerized medical record, documents R12 is an [AGE] year old male that admitted to the facility on [DATE] with diagnosis which included Alzheimer's, Dementia, and Essential (Primary) Hypertension. R12's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 9/15, indicating moderate cognitive impairment. R12's current computerized medical record, documents no evidence of the incident between R3 and R12 on 6/19/24. On 6/29/24 at 2:00 PM V4 stated, I was here on 6/19/24 when (V13/CNA) came and told me (R3) threw a half glass of water on (R12). I reported it to the (V1/Administrator) immediately. (V1) told me it was not abuse and it was just a behavior and to document on it. I received an order for Haldol (antipsychotic) because (R3) was throwing on staff as well and trying to take the water pitcher off my nursing cart. (R3) kept getting water other places as well and was trying to throw it on everyone. We (the staff) were having a hard time re-directing and getting (R3's) behavior to stop. 5. The Final Report sent to the (State agency) dated 6/10/24 at 3:16 PM, documents Incident Description CNA walking by (R4's) room and saw (R4) sitting in recliner leaning over toward (R3), (R3) was laying in (R4's) bed) CNA went into (R4's) room to remove (R4's) hand from inside (R3's) pants. (R3) and (R4) were immediately separated. Resident and staff interviews completed. (R3) wanders and had gone into (R4's) room to lay in (R4's) bed. (R3) was laying on her side with her back to the door talking to (R4) when the staff went into separate them. (R3) was upset and didn't want to leave the room. (R3's) Care Plan updated to reflect aggression when trying to re-direct and wanders in rooms. (R3) to be monitored closely while wandering. (R4) to be monitored for inappropriate sexual behaviors. Medication for (R3) was adjusted to assist with agitation. R4's current computerized medical record, documents R4 is a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis which included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder. R4's MDS (Minimum Data Set) dated 4/22/24 documents a BIMS (Brief Interview for Mental Status) Score of 00/15, indicating (severe cognitive impairment). This same MDS documents R4 has no upper or lower extremity impairment, uses a wheelchair or walker for mobility, and requires supervision for ADL's (Activities of Daily Living). R4's Progress Note written V18/Agency LPN dated 6/4/24 at 3:00 PM, documents, CNA's stated (R4) was in the chair next to the bed. A female resident (R3) was lying in the bed next to the chair. (R4) leaned over and had his hand down the front of the female resident (R3) pants. R3's Behavior Note dated written by V4/ LPN dated 6/4/24 at 6:33 AM, documents (R3) is wandering and rummaging in others (other residents) rooms. R3's Nursing Note written by V18/LPN dated 6/4/24 at 3:00 PM, documents CNAs stated (R3) was lying in another resident's bed. A male resident (R4) was sitting in the chair next to the bed. (R4) leaned over and had his hand down the front of (R3's) pants. V18 notified V1/Administrator and V29/Unit Manager. Written Witness Statement by V16/Agency CNA dated 6/4/24, documents At 2:40 PM while doing rounds, we enter (R4's) room to find (R4) leaning over (R3) while (R3) was laying on bed. (R4) drew his hand back and sat up and closed his eyes. We instructed (R3) to get up and come out for snack. (R3) resisted. We stepped outside door. We peeked back in room to find (R4) leaned over again with his hands down (R3's) pants. At that point we helped (R3) put her shoes on and guided (R3) to the TV (television) room. Written Witness Statement by V13/CNA dated 6/4/24, documents that at 2:40 PM while doing afternoon rounds V13 entered R4's room to find R4 leaning over R3 while R3 was lying in a bed. As R4 set up R4 drew his hand back and closed his eyes. R3 was asked to please get up and R3 resisted. V13 stepped outside R4's room to figure a plan to get R3 out of R4's room. V13 looked back in the room to find R4 leaned over again with his hand down R3's pants. R3's shoes were put on her and R3 was taken out of R4's room. The incident was reported to the unit nurse immediately. Written Witness Statement by V4/LPN dated 6/10/24 documents that R3 wanders and roams in and out of multiple rooms. R3 is difficult to redirect and come can become verbally and physically aggressive. On 6/28/24 at 3:00 PM V13/CNA stated, (R3) wandered into (R4's) room and laid down in (R4's) roommate's bed. I had noticed (R3) in (R4's) room so (V16/Agency CNA) and I entered (R4's) room. When (V16) and I entered the room was in the recliner leaning over to the bed (R3) was lying in. I immediately noticed (R4) jerk his hand away from (R3) and sat up in the recliner. (V16) and I attempted to re-direct (R3) out of the room. (R3) started kicking and slapping us, so I just said let's leave (R3) alone because we are not going to be able to get (R3) out when she is agitated. When (V16) and I got past the doorway to (R4's) room we turned around in the doorway and noticed (R4) was leaning over the bed (from the recliner) where (R3) was laying and had his left hand underneath her pants touching (R3's) private area. (V16) and I then immediately entered the room and was able to immediately separate them and get (R3) out of the room. On 6/30/24 at 10:00, V16/Agency CNA stated, (V13/CNA) was training me the night the incident occurred between (R3) and (R4). That was my first night working at the facility and it was just us two for CNA's back on the unit. We walked into the room because we saw (R3) laying in (R4's) roommates' bed, and it was not her room. When I walked in the room (R4) was in the recliner leaning over by (R3). (R4) immediately pulled his hand back from (R3) when we walked into the room. I did not see where (R4's) hand was at that time. (V13) and I tried to remove (R3), but she was being aggressive. (V13) and I decided to leave the room to figure out a plan because (R3) was being aggressive. When (V13) and I got past the doorway we turned around and (V13) and I saw (R4's) left hand down (R3's) pants and underpants. (V13) and I went back in the room and (R4) removed his hand from her underpants again. We then removed (R3) from the room. On 6/29/24 at 4:06 PM, V14/R4's POA stated she was told something about R3 pants but did not remember exactly what it was about. V14 also stated We (R4's Family) have had to run (R3) out of (R4's) room several times. On 6/29/24 at 1:57 PM, V13/R3's POA was asked if he had been notified about R3 being in R4's room and R4 had his hands in R3's pants. V13 stated I was not. V13 was asked if he had any idea how R3 would feel about the incident happening and V13 stated I have no idea. V13 also stated I feel bad that it happened, but I don't know what can be done to prevent it. On 6/28/2024 at 3:35 PM, R3 was ambulating independently down the hallway on the locked unit towards the double doors that go out to the other hallways. R3 was exit seeking and observed to be agitated. R3 was kicking and punching at the doors. R3 then turned around and was ambulating down the hallways past other residents. No CNA or Nurses were observed in the hallway during that time. On 6/29/2024 at 1:00 PM, R3 was in her room asleep in her roommate's bed. On 6/30/24 at 11:00 AM V2/Director of Nursing/DON verified no new interventions were put in place to prevent R3 from abusing residents. V2/DON stated, I do not see where (R3's) care plan addresses her resident-to-resident altercations with (R9, R10, R11, or R12) or interventions. On 6/30/24 at 12:00 PM, V1/Administrator stated, The facility staff should not leave someone alone if they are experiencing aggression but should remove other resident's away from that person during that time to prevent abuse from happening. The Immediate Jeopardy started on 3-30-24 at 1:26 PM when R3 physically assaulted R11 by punching and shaking R11's left arm. V1/Administrator, V2/Director of Nursing, and V34/Regional Director of Operations were notified of the Immediate Jeopardy on 7-2-24 at 12:43 PM. This surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 7/2/24 V34/Regional Director of Operations in-serviced V1/Administrator on the facility's Abuse Policy on what constitutes abuse, how to prevent it and providing adequate supervision to prevent abuse 2. On 7/2/24 V34/Regional Director of Operations in-serviced V1/Administrator was in-serviced on Dementia care. 3. On 7/2/24 all residents were reviewed by the Interdisciplinary Team to assess their potential to be abusive towards other residents. 4. On 7/2/24 All residents' care plans were reviewed by the Interdisciplinary Team to ensure that all abusive behaviors are addressed, and interventions are reflected to prevent further abusive behaviors. 5. R3's electronic medical record documents R3 has been on 1:1 supervision 24 hours per day from 7/2/24 to 7/6/24. 6. On 7/2/24 R3's care plan was updated with new intervention to address pain, overstimulation aggression towards peers. 7. On 7-2-24 R4's care plan was reviewed by the Interdisciplinary Team and interventions were updated to address inappropriate sexual behavior. 8. Agency staff verified they have been given access to the electric health care record since 7/2/24. 9. On 7/5/24 V1/Administrator interviewed five staff members to audit their understanding on the abuse policy of what constitutes abuse, preventing abuse, providing adequate supervision to prevent abuse and Dementia Care. 10. On 7/5/24 V1/Administrator audited three resident care plans for interventions in place to prevent abuse. 11. On 7/3/24 the Interdisciplinary Team documented on a QA (Quality Assurance) form their review of residents with new abusive behaviors and interventions to prevent abuse. No residents were identified as having new abusive behaviors. On 7/5/24 at 10:00 AM V35/Agency Registered Nurse (RN) stated she has not been in-serviced regarding abuse or dementia from (the facility). V35/RN sated, I would report abuse to the state or Director of Nursing. On 7/5/24 at 10:07 AM V1/Administrator verified that V35/Agency RN had not been in-serviced on the Abuse and Dementia policies. Due to all staff not being in-serviced on Abuse and Dementia policies prior to their shift the facility's abatement plan was not completely executed on 7/2/24 as documented by the facility. Therefor the immediacy could not be removed on 7/2/24. On 7/6/24 the facility completed all measures on the abatement plan, including providing in-servicing all of the staff on abuse and dementia policies. Therefor the abatement plan could be approved on 7/6/24.

Based on record review and interviews the facility failed to provide a safe resident transfer for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling on 11/2/2023, hitting the back of R1's head, requiring transfer to the local hospital. R1 sustained a 2-centimeter (cm) laceration to the back of R1's head requiring staples, head pain and a subdural hematoma. Findings Include: R1 has the following diagnosis: Cerebrovascular disease with a stroke, Chronic Atrial Fibrillation, Heart Failure, Weakness, COPD (Chronic Obstructive Pulmonary Disease.) R1's Fall Risk Evaluation dated 6/26/2023, documents the following: Gait/Balance 1.) Balance problem while standing 2.) Balance problem while walking 3.) Decrease muscular coordination. On 11/15/2023 at 8:05AM, R1 was alert and able to answer questions appropriately. R1 is sitting in the main dining room eating breakfast. R1 stated I am doing ok and feeling better. On 11/15/2023 at 8:25AM R1 stated, V4 was trying to put me to bed when I stood up my legs gave out. My head hit the bedside table, then I fell to the ground hitting the floor. V4/CNA (Certified Nursing Assistant) did not use a gait belt on me. I probably would be ok if she did. R1's Nurses Notes, dated 11/2/2023, documents, V4/CNA (Certified Nursing Assistant) called V3/LPN (Licensed Practical Nurse) to R1's room. Upon assessment R1 noted lying on her back on the floor with bilateral legs extended. Blood noted from back of head. R1 had a laceration approximately 2cm (centimeter) x 2cm in the back of her head. AROM (active range of motion), pupils equal and reactive to light, R1 complained of head pain. V4/CNA attempted to transfer R1 and while resident was standing V4/CNA turned to grab a washcloth and R1 fell sideways to the left. 911 called immediately. R1's Tele Hospitalist Initial Note, dated 11/3/2023, documents the following, R1 is a [AGE] year-old female presented on 11/2/2023. Had a mechanical fall transferring from wheelchair to bed. Hit her head and sustained a laceration. CT (computed tomography) scan showed a small subdural hematoma. R1 has been awake and alert. R1's CT scan of the head, dated 11/2/203, documents the following: Impression. Head CT: Subtle subdural hematoma with focal thickening and slight hyper attenuation along the cerebral falx. On 11/15/2023 at 8:17AM V2/Director of Nurses stated, I know that V4/CNA was getting R1 up to go the bathroom and R1's knees buckled. R1 fell sideways and hit her head on the bedside table, then fell on the floor sustaining a laceration to the back of the head. I did not interview the resident, but I got this statement of occurrences from V4 who was transferring her. Yes, I do expect all staff that are helping a resident transfer or ambulate to use a gait belt. On 11/15/2023 at 9:04AM V3/LPN (Licensed Practical Nurse) stated, V4 had just taken R1 down the hall to take R1 to her room and put R1 to bed. Then, I was summons to R1's room by V4 because R1 had fallen and was on the floor. When I entered the room R1 was lying next to her bed with her legs extended out and a pool of blood underneath her head. V4 stated she was transferring R1 to bed and went to grab a washcloth from the bedside table and R1 fell . No, I did not see a gait belt on R1. On 11/15/2023 at 2:45PM V4/CNA stated, I was getting R1 ready for bed. When R1 stood up on her feet her legs weakened and gave out and R1 fell hitting her head on the bedside table then landed on the floor and again hit her head. I turned around to get a depend off the bed side table and that was when R1 fell . I had a gait belt around her, but only one had was under the gait belt. When I called for the nurse, I hurried and removed the gait belt because R1 was already on the floor. R1 had blood coming from her head. On 11/15/2023 at 12:49PM V5/LPN (Licensed Practical Nurse) MDS (Minimum Data Set) Coordinator. stated,R1 is an extensive assist of one or two. R1 is alert and she knows what is going on with her. I asked R1 what had happened, R1 said that she was standing up and V4/CNA was getting R1 ready for bed and her legs gave out. R1 hit her head on bed side table then R1 landed on the floor hitting her head again. I asked R1 if V4 had applied the gait belt around her waist and R1 said No! On 11/15/2023 at 1:28PM V6/CNA stated, I am familiar with R1. I always use a gait belt when I transfer R1 because she is weak and unsteady on her feet due to the stroke she had back in June. R1 knows what she is talking about, and she would know if we were not using the gait belt. R1 will tell you she does not want to fall. On 11/15/2023 at 1:34PM V7/CNA stated, I use a gait belt anytime a resident needs assistance with ambulation or transfers. R1 is one resident that is getting stronger, but a gait belt still needs to be used. `

Based on interview and record review the facility failed to prevent physical abuse due to the lack of supervision of a known wanderer for one of three residents (R2) reviewed for abuse in a sample of three. This resulted in R2 receiving a scratch to his forehead and a black eye. Findings include: The facility's Abuse Prevention Program Policy dated 1/2019, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by: Identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriations of resident property. Dementia management and resident abuse prevention. This facility is committed to protecting our residents from abuse by anyone including: but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members of legal guardians, friends, or any other individuals. R1's POS/Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS/Minimum Data Set assessment dated [DATE], documents R1 has a BIMS/Brief Interview of Mental Status of 04 (cognitively impaired). This same MDS documents R1 transfers and ambulates independently with supervision. R1's progress notes dated 9/19/22 and signed by V11 (LPN/Licensed Practical Nurse) documents, Another resident (R2) wandered into this resident room and this resident (R1) hit the resident (R2) in the face with his fist. Resident educated that this type of behavior is not acceptable. Residents were separated at this time. POA/Power of Attorney was notified of incident. Nurse manager notified of incident. Administrator notified of incident. MD (Medical Director) was notified and gave orders for [MEDICATION(S)] 10 mg IM (intramuscular) one time only. R1's progress notes from 9/19/22 to 10/31/22 document R1 is on 15 minute checks since the altercation. R2's POS dated 10/31/22 documents R2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This same POS documents R2 is receiving [MEDICATION(S)] daily for Dementia with Behavior Disturbances. R2's MDS dated [DATE], documents R2 is severely cognitively impaired and ambulates independently with supervision and wanders daily. R2's current plan of care dated 3/22/22, documents, Impaired Cognition related to Dementia, he has dementia with behavior disturbance. He wanders, has verbal aggression, inattention and disorganized thinking. This same plan of care documents, Resident requires use of Psychotic Medicine to manage mood and/or behavior issues, tracking in place for delusional thinking, hallucinations, psychotic features, wanders, verbally aggressive towards others, and puts self on floor/lays on floor. R2's progress notes dated 9/19/2022 and signed by V13/LPN, documents, (R2) was struck by another resident in the face. Resident received a scratch to the middle of his forehead and area under his right eye is purple in color. (R2) had wandered into the other resident's room and that resident stated he punched him because he was defending himself. Both residents were separated. Neuro (Neurological) checks initiated and WNL/Within Normal Limits. MD (Medical Director) notified of incident and was okay with us continuing neuro checks and monitoring for changes. Administrator notified. nurse manager notified. POA (Power of Attorney) notified. R2's progress notes dated 9/10/2022, documents, In and out of everyone's room in everyone's bed won't stay in his own room. The facility's IDPH (Illinois Department of Public Health) Notification Form dated 9/23/22 and signed by V2 (Director of Nursing) documents on 9/19/22, R1, [AGE] year old male resident, BIMS of 4 noted to strike R2, [AGE] year old male resident BIMS of 99 (cognitive impaired). Residents were immediately separated and redirected. R2 entered room unannounced. R2 received a skin tear to middle of forehead and discoloration under right eye. New intervention for R2 redirected him to common areas as needed, provide activities of choice as needed, monitor skin tear and discoloration for s/s (sign and symptoms) pain, swelling, infection and discoloration until healed. New intervention for R1 [MEDICATION(S)] immediately for agitation, medication review, due to recent medication changes. Plan of care updated accordingly, staff aware, no further incidents noted. On 10/31/22 at 10:55 am, R1 stated he had an altercation with another resident. R1 stated, he broke in my room and I beat the hell out of him. He is old enough to know better and I got on top of it real quick. I got several good licks on him and would take him on right now to be honest with ya. See my class ring. I caught him on his right eye, I think he still has a scar. On 10/31/22 at 11:53 am, V6/LPN stated, (R2) wanders up and down the halls and goes in to other residents rooms. I think (R1) thought (R2) walked in to try and hurt him. We keep everyone out of (R1's) room. On 11/1/22, at 4:32 pm., V11 stated, I was one of the nurses called to the incident. When I walked in the room (R2) was sitting in (R1's) recliner crying and had an immediate black eye and an area on his forehead. (R2) wanders around the unit and into other residents rooms and sometimes lays on their beds. On 11/1/22, at 4:49 pm., V12 (CNA/Certified Nursing Assistant) stated, I was walking down the hall and (R1) came out of his room and asked him what was the matter. (R1) said I hit him. (R2) was sitting in the recliner crying with a purple eye. (R2) does wander into other residents rooms and will get in their beds.

Based on observation, record review, and interview the facility failed to implement daily skin checks, obtain treatment orders once a pressure ulcer was identified, implement pressure relieving interventions, and provide timely turning and repositioning for one of four residents (R90) reviewed for pressure ulcers in a sample of 33. These failures resulted in R90 developing a facility-acquired, painful stage three pressure ulcer that worsened to a non-stageable pressure ulcer and required surgical debridement (removal of necrotic (dead) tissue and establish the margins of living tissue) on three separate occasions. Findings include: The National Pressure Ulcer Advisory Panel Pressure Injury Prevention Points dated 04/2016 documents, Turn and reposition all individuals at risk for pressure injury, avoid positioning the individual on the body areas with the pressure injury, and reposition weak or immobile residents in the chair every hour. All residents at high risk of pressure ulcer risk perform skin checks daily. The facility's Pressure Sore Prevention Guidelines dated 01/2018 documents, It is the facility's policy adequate interventions for the prevention of pressure ulcers for residents who are identified as high or moderate risk for skin breakdown as determined by the Braden Scale (Pressure Ulcer Risk Assessment). High Risk Interventions include: Daily skin checks, turning and re-positioning every two hours (Turning and re-positioning may be more than every two hours for high risk, if indicated). Care Plan entry. Skin risk and appropriate interventions are to be placed on the care plan. If despite interventions a pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further preventions of pressure ulcers. Any resident scoring a high or moderate risk for skin breakdown will have daily scheduled skin checks on the treatment record. Skin checks will be completed and documented by the nurse. R90's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R90's MDS's (Minimum Data Set) Assessments dated 5-7-21 and 6-30-21 document R90 is cognitively intact, requires extensive physical assistance of two staff for bed mobility, and is totally dependent on two staff for toileting. R90's MDS assessment dated [DATE] documents R90 has one unstageable pressure ulcer that was acquired within the facility. R90's Braden Scale for Predicting Pressure Ulcer Risk dated 5-7-21 and 6-30-21 document R90 is High risk for development of pressure ulcers. R90's Shower/Abnormal Skin Report dated 5-5-21 and signed by V8 (CNA/Certified Nursing Assistant) and V10 (Licensed Practical Nurse/LPN) documents R90 had a sore spot to the right buttock. R90's Nurse's Notes dated 5-5-21 and signed by V10 document, (R90) received shower this shift with no new skin issues noted. R90's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R90's Nurse's Notes dated 5-21-21 document (R90) seen by (V9/Wound Physician) for new wound on right buttock. Stage three 0.5 x 1.0 x 0.3 cm (centimeters). (V9) ordered [MEDICATION(S)] (Occlusive dressing). Orders processed. R90's Wound Evaluation and Management Summary dated 5-21-21 and signed by V9 (Wound Physician) documents, (R90) has a stage three pressure wound of the right buttock for at least one day in duration. There is light serosanguinous (bloody yellowish) exudate (drainage). Etiology: Pressure. Wound size 0.5 x 1 x 0.3 cm (centimeters). Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommendations: Reposition per facility protocol; Off-load wound; Turn side to side and front to back in bed every one to two hours as able; Limit sitting to 30 minutes. Asked that the dietician revisit nutritional status. R90's Wound Evaluation and Management Summary dated 6-17-21 and signed by V9 documents, Stage three pressure wound of the right buttock documents, Etiology: Pressure. Wound size 2.0 x 4 x 0.1 cm. Wound progress: Deteriorated. Procedure to (right buttock pressure ulcer) Surgical Excisional Debridement. Recommendations: Reposition per facility protocol; Off-load wound; Turn side to side and front to back in bed every one to two hours as able; Limit sitting to 30 minutes. R90's Wound Evaluation and Management Summary dated 6-24-21 and signed by V9 documents, Unstageable wound of the right buttock documents, Etiology: Pressure. Stage: Unstageable Necrosis (dead tissue). Wound size 0.5 x 1.5 x non-measurable cm. Slough (yellow soft dead tissue) 50 percent. Procedure (right buttock pressure ulcer) Surgical Excisional Debridement. Recommendations: Reposition per facility protocol; Off-load wound; Turn side to side and front to back in bed every one to two hours as able; Limit sitting to 30 minutes. R90's Wound Evaluation and Management Summary dated 7-1-21 and signed by V9 documents, Unstageable wound of the right buttock documents, Etiology: Pressure. Stage: Unstageable Necrosis. Wound size 0.5 x 1.0 x non-measurable cm. Slough 70 percent. Procedure to (right buttock pressure ulcer) Surgical Excisional Debridement. Recommendations: Reposition per facility protocol; Off-load wound; Turn side to side and front to back in bed every one to two hours as able; Limit sitting to 30 minutes. R90's Pressure Ulcer Care Plan dated 5-20-21 does not include the pressure relieving interventions recommended by V9 to off load R90's pressure ulcer to the right buttock and limit R90's sitting to 30 minutes. On 07/11/21 from 11:30 AM through 1:15 PM, R90 was sitting in the dining room in a wheelchair with a mechanical lift sling underneath her. R90's right buttock pressure ulcer area was not off-loaded. On 07/12/21 at 09:11 AM to 11:00 AM, R90 was lying in bed, on her back with no offloading to the pressure ulcer on her right buttock. R90 stated, The sore on my butt was caused from the staff not turning me enough. I cannot turn myself to get off of my butt. The sore really hurts. On 07/12/21 at 11:22 AM V8 (Certified Nursing Assistant/CNA) and V7 (Licensed Practical Nurse/LPN) turned R90 to her left side. R90's right buttock pressure ulcer measured approximately 0.4 cm x 0.5 cm x 0.2 cm with 50 percent dark brownish/purple tissue within the wound. V7 applied a new occlusive dressing. R90 stated, Ouch. Ouch. while her pressure ulcer was being cleansed and the treatment was applied. On 07/13/21 at 10:10 AM V10 (LPN) stated, I did not see that (R90) had a sore spot on her buttock according to (R90's) shower skin report. I should have assessed the area, called the physician, and filled out the necessary paperwork. On 07/12/21 at 01:50 PM V3 (Assistant Director of Nursing) stated, On 5-5-21, the staff should have filled out a newly acquired skin issue sheet when (R90's) wound was identified, and the physician should have been notified for a treatment order. Then the staff should have put (R90) on the list to see V9 (Wound Physician). The staff should have recognized the pressure ulcer on 5-5-21 and obtained a treatment on 5-5-21 for the right buttock. (R90's) wound to the right buttock was due to pressure. The staff should be offloading (R90) off of the right buttock as much as possible. (R90's) interventions as documented on (V9's) wound evaluations to off-load the wound and limit (R90's) sitting to 30 minutes has not been added as interventions to (R90's) pressure ulcer care plan. (R90) is at a high risk for pressure ulcer development according to her Braden Scale assessment and she should have had daily skin checks before and after her pressure ulcer developed. This did not happen. (R90) has only been getting weekly skin checks.

Based on record review and interview, the facility failed to ensure an indwelling urinary drainage tube was passed into the bladder prior to inflation of the tube's retention balloon which serves to hold the drainage system in place at the base of the urinary bladder for one of three residents (R1) reviewed for catheter care in a sample of three. This failure resulted in resident experiencing discomfort during placement and removal and bleeding from the urinary tract which required treatment and evaluation at a local emergency roiagnom on [DATE] and 12/27/18. Findings include: On 01/02/19 at 10:00 a.m., R1 was awake but not able to verbalize or indicate understanding of conversation. R1 had a indwelling urinary catheter (a flexible tubing and collection system that drains urine from the bladder and is kept in place with an inflatable balloon) in place, draining amber color urine. R1's Physician order [REDACTED]. Physician order [REDACTED]. A policy titled Catheterizations (Brand Name) Catheter Insertion dated 2/18 states: 3. For male resident, insert the catheter approximately six to three inches into the urethra to obtain a flow of urine. 4. Insert the catheter approximately one more inch after the urine flow starts. 5. Using the indicated amount of fluid on the catheter, plus four to five cc's (cubic centimeter), inflate the balloon of the catheter. 6. Once the balloon is inflated, gently pull back on the catheter to ensure placement. A policy titled (Brand name) Catheter Removal dated 02/2018 states: Use the syringe to remove the fluid from the balloon of the catheter. Never cut the tubing to remove the fluid of the balloon. A (YEAR) publication titled Clinical Practice Guidelines - Adult Male Catheterizations published by the Society of Urologic Nurses and Associates states: Procedure: Gently advance the catheter and, with experience, you can feel the natural resistance offered as the catheter traverses (travels through) the external sphincter (a ring of muscle to guard or close an opening). Ask the patient to take slow, deep breaths to help relax him and allow easier catheter passage. Be sure to advance the catheter to the Y level created by the balloon filling and urinary drainage ports to assure the balloon is within the bladder. If resistance is met, do not attempt forceful catheter insertion. Apply continuous, gentle pressure and ask the patient to take slow, deep breaths to help relax. Another helpful tip is to instruct the patient to try to void when you feel resistance. This will sometimes open the sphincter, allowing the catheter to pass. ·Urine flow should begin and the catheter balloon should be inflated with sterile water to the amount specified on the catheter. Over or underinflating may occlude the drainage holes. Do not inflate the balloon until urine flow is noted. Difficult Catheterizations: Urethral strictures, false passages, (prostate) enlargement, and post-surgical bladder neck contractures can make urethral catheterization difficult and may require the services of a urologist. If there is any question as to the location of the catheter (no return of urine), do not inflate the balloon. It may be best to remove the catheter and consult the urologist or leave the catheter and have a supervisor, nurse practitioner/advanced practice nurse, or urologist verify placement. R1's Nurses' Notes, written by V8 (Licensed Practical Nurse) (LPN) on 12/25/18, state, (R1) due for monthly (indwelling urinary) catheter (tubing and collection system that drains urine from the bladder) change with assistance of other nurse and Certified Nursing Assistant (CNA) due to (R1's) grabbing and resisting care, previous catheter balloon deflated with 10 cubic centimeter (cc) normal saline (NS) obtained. Some resistance noted upon removal and small amount of blood noted from urethra (duct which removes urine from the body). (R1) moaning and grimacing during removal. New (size and type of catheter) 10 cc bulb inflated to check for leaks and proper function prior to insertion. Using sterile technique, penis cleansed with [MEDICATION NAME] (an antiseptic) swabs. Catheter inserted and advanced with no urine return. (R1) yelling per (R1's) norm during cares. Catheter pulled back slightly and advanced again with still no urine return. Ten cc (catheter) bulb inflated with some resistance. Monitored catheter bag for several minutes with still no urine return. Attempted to deflate bulb with much resistance and only a few (cc's of NS) able to be withdrawn. Asked another nurse in building for assistance. A 12/25/18 Nurses' Note entry written by V9 (LPN) states, (R1's) catheter balloon would not deflate to remove the catheter. A new catheter was used to see if the port (where NS is injected to inflate the retention balloon) for the catheter's balloon could be cut so it may be removed; which was successful. (R1's) catheter balloon port was cut, thus allowing the balloon to deflate and (the) catheter (to) be removed. Upon removal there was a moderate to severe amount of blood loss. Pressure was applied to penile area to reduce blood loss. 911 was called immediately. Emergency Department notes from the local hospital dated 12/25/18 state, (R1) arrives via ambulance (from nursing home). (Nursing home staff) reportedly had difficulty removing catheter after deflating the balloon. They relate they cut the port and drained the (normal) saline to deflate the balloon. When they pulled the catheter out (R1) had large amount of bright red bleeding. Per EMS (Emergency Management Services) there was large amount of blood at the nursing home. Catheter removed by (nursing home) staff with difficulty subsequently with gross hematuria. Patient on [MEDICATION NAME] due to (blood clots in legs and lungs). (Urinary Catheter) inserted without difficulty. (R1) began bleeding profusely from penis. Pressure applied to penis to stop bleeding. A local Ambulance Report dated 12/25/18 states, Dispatched emergent for (R1). (R1) with profuse bleeding from penis. Per Nursing Home staff they where changing urinary catheter when they did not get any urine return they removed the new catheter and noted that (R1)had began bleeding profusely from (the) penis. EMS arrived to find to find (R1) lying in bed with nursing staff at (R1's) side. (R1's) bedding is saturated with bright red blood. Noted blood actively flowing from urethra. Look as if there would be between 700 to 1000 cc's of blood. Also noted deflating hub of the old urinary catheter to be cut. (R1) non-verbal per norm. (R1) seemed to be in pain, moaning and rolling back and forth. On 01/03/19 at 2:38 p.m., V8 (LPN) stated on 12/25/18 R1 was due for a routine change of the indwelling urinary catheter. V8 stated, (R1) was on antibiotics for a urinary tract infection [MEDICAL CONDITION]. I deflated the catheter balloon and as I was pulling it out it got tighter but it came out completely deflated and intact. There were a couple small drops of blood. I inflated the bulb (on the new catheter tubing) to make sure there were no leaks in the bulb, then deflated it and did the normal procedure. There was no urine so I advanced the catheter a little further and there was still no urine. I thought maybe the bladder was just empty. So I went ahead and inflated the balloon. I had a little trouble inflating it. I thought it was just me. I waited for several minutes and there was no urine return. I deflated the bulb and no more than 2 cc's came back. Then I got another nurse to help (V9 LPN) came and (V9) was only able to withdraw 2 cc's from the bulb. Still through this whole process there was no urine (in the tubing or drainage bag). (V9 LPN) went and got another catheter and checked to see if the balloon port could be cut. When the port was cut and the catheter was removed blood started gushing out of (R1's) penis. When asked what V8's training was regarding catheter insertion, V8 (LPN) stated, I was taught when I insert the catheter I should get urine return. Regarding inflating R1's catheter balloon without getting a urine return, V8 (LPN) stated, I should have removed it and tried again later. On 01/03/19 at 11:10 a.m., V9 (LPN) stated, When they came to get me the information I got was that (R1) hadn't voided (emptied the bladder) in a long time. That it was time for (R1's) monthly catheter change and there was no urine return. (V8 LPN) had already put the new one (catheter) in and there was no urine return and the balloon was already inflated. I tugged on it (the catheter tubing) to make sure it was there (the bottom of the bladder). There was no urine in the catheter bag. There was no urine return. I felt like I should get it (the catheter) out of there. I was concerned about possible perforation of the bladder. When we couldn't get the normal saline out of the balloon we knew something was wrong with the port of the balloon. I went and got another catheter to see if the balloon port could be cut. I filled up the balloon and cut the port and it did deflate so I cut (R1's) port and the balloon deflated. The catheter projected out and all the blood behind it came projecting out. We called 911. (R1) was on a blood thinner. I put pressure on (R1's) penis with a blanket. I was concerned about (R1) being on [MEDICATION NAME] and a potential bladder rupture. V9 (LPN) stated V9 would not inflate a indwelling catheter balloon unless there was a urine return when the catheter was inserted. When asked if R1 was uncomfortable prior to and during the catheter removal, V9 (LPN) stated: Without a doubt. It (the catheter) came right out of there, it projected. (R1) had a facial grimace and (R1's) jaw was clenched. (R1's) fist were closed. (R1) was definitely having discomfort. On 01/02/19 at 1:20 p.m., V4 (Registered Nurse) (RN) stated if V4 was replacing a indwelling urinary catheter and there was no urine flow when the catheter was inserted, V4 would not inflate the catheter but check to see if the catheter was far enough in (out of the urethra and into the bladder) and if no return then I would take the whole thing out and either try again or call the doctor. If there was no urine return I wouldn't inflate the balloon. On 01/02/19 at 1:05 p.m., V7 (R1's Attending Physician) reported changing an indwelling catheter monthly and as needed is standard protocol. V7 stated, In the hospital, they have bladder scanners to check the bladder but that is equipment we do not have available here. When a catheter is put in there should at least be some urine. (R1) has healthy kidneys so (R1) should be putting out urine. There should be urine (when catheter is changed). On 01/03/19 at 1:25 p.m., V2 (DON - Director of Nursing) reported V2 did not read V8's (LPN) 12/25/18 Nurses' Note regarding R1's catheter placement. V2 reported V2 only read V9's (LPN) note, therefore V2 was not aware V8 (LPN) did not get urine return when changing R1's indwelling urinary catheter and inflated the catheter balloon without confirmation the catheter was properly placed in R1's bladder. Regarding catheterizations, V2 stated, I've never not had a urine return when I have catheterized a patient. Emergency Department notes from the local hospital dated 12/27/18 document R1 returned to the Emergency Department on 12/27/18 with hematuria (blood in the urine) with blood clots. The Emergency Department notes state: (Nursing home staff) stated (R1) has large amounts of (blood) clots coming from around (urinary) catheter at the urinary meatus (opening where urine exits the body). Stated (R1) had been seen here a couple days ago for similar symptoms. Urine appears consistent with Urinary Tract Infection [MEDICAL CONDITION]. Will give a dose of Keflex (antibiotic). discharged with an outpatient course of Keflex.

Based on observation, interview, and record review, the facility failed to obtain a physician ordered treatment when a pressure ulcer was identified, remove a feces soiled dressing, and follow a physician prescribed treatment order for two of three residents (R2, R3) reviewed for pressure ulcers in the sample of three. These failures resulted in R2's pressure ulcer worsening from a Stage three to unstageable. Findings include: The facility's Decubitus/Pressure Area policy, dated 5/2007, documents, Notify the physician for treatment orders. The physician's orders [REDACTED]. The order must have specific frequencies; Initiate physician order [REDACTED]. National Pressure Ulcer Advisory Panel's Pressure Injury Stages, dated 4/2016, documents, Stage 3 Pressure Injury: Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. National Pressure Ulcer Advisory Panel's Prevention and treatment of [REDACTED]. The guide also documents, Change the wound dressing if feces seep beneath the dressing. 1. R2's Weekly Wound Tracking, dated 4/5/18, documents that R2 has a Stage three facility acquired pressure ulcer to R2's coccyx that was discovered on 4/3/18 and it measures 1.8 cm (centimeters) x 0.2 cm x 0.4 cm. R2's physician's orders [REDACTED]. 4/10/18. On 4/10/18 at 3:30 p.m., V5 (Licensed Practical Nurse) stated that she identified the pressure ulcer on 4/3/18, but she did not obtain a physician ordered treatment for [REDACTED]. On 4/9/18 at 11:25 a.m., R2 was incontinent of bowel. V9 (Certified Nursing Assistant-CNA) and V10 (CNA) provided incontinent care to R2. R2 had a border gauze dressing in place to R2's coccyx at this time. With R2 being incontinent, the lower one third of the dressing was covered in brown feces and was pulled away from the skin. A wound with depth was observable underneath the soiled area of the dressing. V9 and V10 proceeded to put an adult brief on R2, redress him, and transfer R2 into R2's wheel chair with the soiled dressing still in place. On 4/9/18 at 1:30 p.m. V11 (Licensed Practical Nurse) was walking out of R2's room, and stated that she just changed R2's pressure ulcer dressing because it was soiled. V11 also stated that (V9 and V10) notified V11 that (R2's) dressing was soiled before lunch, but she just got it changed. On 4/10/18 at 11:40 a.m., V3 (Assistant Director of Nursing) stated, If a dressing is soiled it should be changed right away. The CNAs, if they notice it, tell their nurse, and the nurse should change it immediately. (R2) should not have gotten up until his dressing was changed. On 4/10/18 at 1:25 p.m., An abdominal pad dressing was removed from R2's coccyx area. R2 had a round open area with depth to R2's coccyx area. The wound bed of this pressure ulcer was 100% covered with black/grey tissue (eschar/necrotic). This black/grey tissue was all along the wound edges also. V4 (Licensed Practical Nurse) was present and measured R2's wound. The wound was 4 cm x 2.5 cm, and she was unable to determine the depth due to the black/grey tissue covering the wound bed. On 4/10/18 at 1:40 p.m., V4 (Licensed Practical Nurse) stated, When we found the pressure ulcer last week it was only a Stage three, and there was no black tissue. The pressure ulcer has worsened since we found it last week. V4 stated R2's pressure ulcer would now be unstageable. On 4/10/18 at 5:00 p.m., V6 (R2's Physician Assistant) stated, Not getting an order for [REDACTED]. 2. On 4/9/18 at 11:15 a.m., R3 was lying in bed. R3 stated, I have a sore on my bottom, but I don't think I have a bandage on it. They never take care of it. The facility's Monthly Wound Tracking Report, dated 4/5/18, documents that R3 has a facility acquired Stage one pressure ulcer to R3's left buttock that measures 0.3 cm x 0.2 cm x 0.1 cm. R3's physician's orders [REDACTED]. On 4/9/18 at 1:15 p.m., V17 (Licensed Practical Nurse) removed R3's adult incontinent brief. R3 had a round shallow open area to R3's left buttock that was uncovered with no dressing covering the wound. V17 stated that R3 had not had a dressing in place since her shower at 9:30 a.m. that morning. V17 also stated that the wound was a Stage two pressure ulcer. On 4/10/18 at 11:40 a.m., V3 (Assistant Director of Nursing) stated, If the staff knew (R3's) dressing was off during her shower, the nurse should have gotten a new one on no later than when (R3) got back to her room to get dressed after the shower.

Based on observation, interview, and record review, the facility failed to protect one resident (R1) from abuse by a staff member. R1 was physically abused by E15 (Certified Nursing Assistant) causing facial injury and bruising which required hospitalization . R1 was one of three residents reviewed for abuse in a sample of three. Findings include: R1's Physician order [REDACTED]. R1's (Corporate Name) Inquiry/Referral Form, dated [DATE], documents R1 has a criminal history for fighting. The transferring hospital (for R1) document, entitled Shift Review Report ,dated [DATE] to [DATE], documents R1 needed a 1:1 sitter at R1's bedside daily-due to: a history of hitting; for safety; restlessness; and will throw arms and legs over side-rails. R1's Nursing Admission Assessment, dated [DATE], documents: R1 was admitted [DATE], at 4:15 p.m.; and R1 had bruises on R1's abdomen and both arms. R1's Social Service Progress Notes, dated: [DATE], document R1 was admitted from a hospital, located in another town; [DATE], R1 is Easily annoyed/short tempered/verbally aggressive/Physically aggressive-hits staff/rejects care/ and requires 24-hour care/supervision; [DATE] (wrong date written-actual date was [DATE] as R1 was at a psychiatric hospital from [DATE] until [DATE]), R1 was readmitted from a psychiatric hospital; [DATE], family requested R1 be transferred to a facility closer to them; [DATE], R1 was transferred to a local hospital; and [DATE], R1 was discharged from the local hospital to another long-term care facility. R1's Nurses Notes, dated [DATE] to [DATE], document: [DATE] R1 admitted to the facility; [DATE]-much confusion and difficult to redirect; [DATE]-1:1 care due to safety concerns; [DATE]-Verbally aggressive with staff/requiring constant supervision and continues to be restless and unable to keep in bed or wheelchair; [DATE]- restless, agitated, and aggressive; [DATE]-combative with staff at times; [DATE]-combative during cares, continues to be agitated, requires close supervision, aggressive, hitting and spitting at staff, sent to local hospital and returned 5 hours later; [DATE]-confused, combative, hitting staff, sent to local hospital and returned 4 hours later; [DATE]-agitated, difficult to redirect, requires 1:1 supervision most of the time, aggressive and combative; [DATE]-pinching staff, increased aggression, requires constant supervision; [DATE]-combative with staff and physically/verbally aggressive during cares; hitting staff, aggressive with staff during cares, close monitoring required, combative in dining room, threw spoon at visitor; [DATE]-restless, agitated, 1:1 required, hitting, kicking, biting, throwing things, sent to local hospital and returned 5 hours later; [DATE]-sent to local hospital for admission to the psych unit for failure to thrive due to significant weight loss (admit weight 216 and current weight 190 pounds), no appropriate beds sent to second local hospital (where R1 was involuntarily admitted to a psychiatric unit at a third hospital); [DATE]-R1 readmitted to the facility, from the psychiatric hospital/ low bed with mat on the floor; [DATE]-crawling in and out of bed, 1:1 for safety, not cooperative, unable to follow simple instructions, continuously attempting to roll off the floor mat; [DATE]- crawled out of bed several times, unable to redirect, not able to follow simple commands, 1:1 most of the time; and [DATE]-not able to follow simple directions. R1's Behavior Monitoring Record, dated ,[DATE], documents seven resident behaviors to monitor for: Restless, Rejecting Activities for Daily Living, Transferring self, Verbally aggressive, Physically aggressive, Socially inappropriate, and easily annoyed/short tempered. This document, which also listed interventions, was not filled out, although Nursing Notes document some behaviors listed. R1's Resident transfer Form documents: [DATE] send to local hospital emergency room due to behaviors-aggressive behavior, hitting, disrobing, up and down constantly (fall risk); [DATE] sent to local hospital due to combative, confused, will not eat; [DATE] send to local hospital due to combative, keeps trying to get up without assist, crawls on the floor, confused, kicking, biting, punching, does not sleep, behaviors at all times, and will not eat; and [DATE] send to local hospital to eval and treat (for alleged abuse). On [DATE], from 5:00 a.m. to 5:50 a.m., Nursing Notes, written by E4 (Licensed Practical Nurse), documents: CNA (Certified Nursing Assistant) (identified in the local police department Offense Report as E16) reported that (R1) has a nose bleed; (R1) laying face down in bed with bright red blood noted to the pillow under (R1's) face; (R1's) bridge of nose swollen; bruising to bilateral sides of (R1's) neck; and the medical doctor and nurse manager notified/will continue to monitor. On [DATE], at 7:30 a.m., Nursing notes indicate R1 was sent to a local hospital. R1 was never readmitted back to the facility, but was admitted at a facility, in a nearby town, where R1 expired on [DATE]. On [DATE], at 7:35 a.m., E4 verified the nursing notes were written by E4-during E4's shift. E4 stated that E4 was R1's nurse from [DATE]/10:00 p.m. to [DATE] at 6:00 a.m. E4 stated, (R1) kept repeating-he (referring to E15 (certified nursing assistant)) choked me and punched me in the nose. E4 stated, (R1's) comments were not written down in the nursing notes. The Discharge Summary, dated [DATE], from the hospital in which R1 was sent (on [DATE]) due to alleged abuse, documents: Primary Diagnosis: [REDACTED]. R1 was transferred to a different long term care facility on [DATE]. On [DATE], at 8:50 a.m., Facility document, entitled, Fax Worksheet/Incident Report Form, documents an (initial alleged) abuse investigation was initiated (for R1) and faxed to the State Agency. The report form documents, resident with injuries-sent to ER (emergency room )-police notified-investigation initiated-two employees (E15/E16 both certified nursing assistants) suspended. The local police department investigation was completed by Z1 (Police Officer). In Z1's Offense Report, Z1 documented that E15 and E16 were the suspects in the alleged abuse. Z1's Offense Report also documents: E4 confirming E15 and E16 are good friends and that even though (E15) was not assigned to the wing (R1) was in, it is not uncommon for (E15) to be in the same wing (E16) is working; The Offense Report, documents that during the recorded audio/video interview (of Z1 and E16), (E16) advised (R1) rolls out of bed a lot and (E15) went in to (R1's) room three different times to put (R1) back in bed .twice (E15) was in (R1's) room alone; On [DATE], (E15) was arrested; During E15's audio/video recorded interrogation, E15 stated (E15) did lift (R1) by the neck and put (R1) into bed; E15 then admitted that (E15) does have anger problems, and that (E15) got mad at (R1), and choked (R1) while (R1) was on the bed; and (E15) advised (E15) did not constrict (E15's) hand, but the (E15) did push (E15's) weight down on (R1's) neck while (R1) was in bed. Photographs were taken, of R1's bruising, by Z1 and at the local hospital. Photographs confirm R1 had bruising to both sides of R1's neck and bruising (and swelling) to R1's nose. Photographs reflect: R1's nose was completely bruised and swollen; the right side of R1's neck had a dark red bruise approximately the size (and resemblance) of an adult's thumb; the left side of R1's neck had dark red bruising the size (and resemblance) of four adult fingers (from the right hand); and both of R1's knees had dark bruising completely covering R1's knees. On [DATE], an untitled document, prepared by E2, documents, During the investigation process and in correlation with the (city) Police Department investigation, a determination was made to term(inate) both employees (E15/E16). On [DATE], at 9:50 a.m., E2 stated, To better protect R1, nurses should have been more in charge.

Based on interview and record review, facility staff failed to address a known mechanical failure with the facility van lift, failed to follow the facility van driver protocol and report it to the administrator and failed to follow the manufacturer's recommendations for servicing the wheelchair van lift, all of which had the potential to affect 10 residents (R1 to R9 and R11) reviewed for safety in the sample of 10 who use the small van for transportation needs.These failures also resulted in R1 falling from the van lift, sustaining a head injury which resulted in death. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. FINDINGS INCLUDE: The Operator's Manual for the facility's wheelchair van lift, dated (revised [DATE]) includes the following information: Operation Notes and Details-Warning! Discontinue lift use immediately if any lift component does not operate properly. Failure to do so may result in serious bodily injury and/or property damage. Outer Barrier: This spring-loaded roll stop provides a ramp for wheelchair loading and unloading at ground level. When the platform lowers fully to ground level, the roll stop activation feet automatically unfold (rotate) the barrier to the ramp position (fully loaded). Although the outer barrier is lift-powered, the activation of the barrier is controlled by the lift operator (attendant). Pressing the DOWN switch unfolds the barrier. The outer barrier is spring-loaded to automatically fold (rotate) to the vertical position when the UP switch is pressed. As the activation feet lift off the ground, the torsion springs rotate the barrier to the vertical position. Discontinue lift operation immediately if the barrier does not operate properly. Maintenance and Lubrication: Proper maintenance is necessary to ensure safe, troublefree operation. Inspecting the lift for any wear, damage or other abnormal conditions should be a part of all transit agencies's daily service program. Simple inspections can detect potential problems. The maintenance and lubrication procedures specified in the following schedule must be performed by a (manufacturer) authorized service representative at the scheduled intervals according to the number of cycles. All listed inspection, lubrication and maintenance procedures should be repeated at '750 cycle' intervals following the scheduled '4500 Cycles' maintenance. These intervals are a general guideline for scheduling maintenance procedures and will vary according to use and conditions. Lifts exposed to severe conditions (weather, environment, contamination, heavy usage, ect.) may require inspection and maintenance procedures to be performed more often than specified. A facility incident report dated [DATE] sent to the State Agency regional office indicates that R1 fell off the wheelchair lift of the facility van at 10 AM while at the local hospital where R1 had a dialysis appointment. The report states that while the Certified Nurses Assistant (CNA) was locking R1 ' s wheelchair on the lift, the bar on the lift bumped into (R1 ' s) wheelchair. The report indicates that R1 then fell off the lift, was taken to the local hospital ' s emergency department, and then later transferred from there to a hospital trauma center out of town. A facility document sent to the State Agency regional office on [DATE], signed by the Administrator (E1) and entitled Follow up report to event of [DATE] states under the Description of Event section: Resident (R1) was transported to dialysis center per facility van. The resident was being transported in a wheelchair. The transportation CNA placed the resident on the wheelchair lift and had locked one of the wheelchair wheels. As so sic (she) was attempting to lock the other wheelchair wheel, the lift malfunctioned and the flap that prevents the wheelchair from rolling off released. The wheelchair rolled off the lift and resident (R1) fell . Head injury resulted from the fall. The transportation CNA immediately called 911. (Paramedics) arrived and resident was transported to the hospital. This document states under the Investigation of Events section: Facility van was immediately removed from service for review and remains out of service. The document states under the Conclusion section: At this time it is felt that the resident fall resulted due to equipment failure. R1's Physicians Order Sheet, dated [DATE] include the following Diagnoses: [REDACTED]. R1's current care plan, dated [DATE] includes the following problems: Dialysis for chronic renal failure. Dialysis schedule three times a week. Facility transports to dialysis. On [DATE] at 9:05 A.M., E3 (Certified Nursing Assistant) CNA stated, On Saturday ([DATE]), around 9:30 (in the morning) I loaded R1 first, then R2 into the little van. I opened the back doors, unfolded the lift and lowered the lift with a button. Every once in awhile the button sticks and you have to keep pushing it to release it to lower it to the ground. I got both loaded and went to the dialysis at (the local hospital). I opened the back door, unfolded the lift, went in the side door to check (R2). I lowered (R2) down, the lift worked fine. I got (R2) off the lift and onto the sidewalk. I raised the lift back up. There is a flap on the end of the lift that is supposed to be up when you take the lift up. It stayed down and I pushed it back up, with my hand. I unstrapped the seat belt and the straps on the floor. I pushed (R1) onto the lift. I locked (R1)'s wheelchair brake. Every once in awhile, the lift will jerk. It jerked and the flap fell down and (R1)'s (wheel) chair fell backwards. That is about two feet. (R1) fell and hit the back of (R1)'s head. I had my cell phone on me, so I called 911. There is a covering over the wires and sometimes (other) transporters don't cover it. I always try to make sure it is covered. It has stuck on me probably three times. I have told (E6 Transportation Coordinator) and (E5 Maintenance Director) . (E5) has tried to fix it, but it eventually breaks again. On [DATE] at 10:45 A.M., E4 (Alzheimer's Coordinator) stated, Saturday August eighth was the last time I drove the (facility) van. Lately, I drive the van one to two times a month. Every now and then the button sticks and the lift kind of jumps. It has been going on for a couple of months. I have told (E5 Maintenance Director) about it, and (E6 Transportation Coordinator) . (E5) fixes things on it. (E5) tries. On [DATE] at 11:05 A.M., E5 (Maintenance Director) stated, On the little van, I have worked on the lift. I am not certified or have additional training from the lift company to work on the lift. Some of the springs weren't functioning, I replaced them. The last time I worked on the lift was two to three months ago. We changed the controller on that van about a year ago. The actual control box had to be fixed. There is a problem with the computer that operates the lift. (E6 Transportation Coordinator) and E3 (Certified Nursing Assistant) told me about it, this past week. I don't write things down when someone tells me things are broke. I keep it in my head. On [DATE] at 11:20 A.M., E6 (Transportation Coordinator) stated, I drove it (the van) to the corporate office and the corporate van person looked at it. We unfolded the lift and lowered it to the ground, but when we raised it back up, we noticed the flap did not go up. The spring was broke. You could see it. On [DATE] at 12 noon, E8 (CNA) stated, It has been approximately two weeks, around [DATE]th, since I have driven the facility van to transfer residents. The flap on the lift has not been working properly, the flap on the lift does not properly go up when the lift goes up. I have to look to see that the flap has gone up. If flap does not go up, I manually lift the flap up and flap will click in place. I do not drive the van on a daily basis so, I did not report the malfunction of the lift. When I drove the van last I manually put the flap up myself with my hands, it has been at least two weeks since it has not been working correctly. On [DATE] at 2:45 PM E1 (Administrator) stated I received a call from E3 (CNA) (Certified Nurses Aide) regarding the [DATE] incident with R1 and the malfunction of the van lift. E3 stated, I got R2 off the van first and placed him under the canopy the transfer went fine. R1 then was placed on lift, then I locked one brake on wheelchair, then went to lock second brake on wheelchair and the back of the lift ( flap) had fallen down and wheelchair had rolled out with R1 falling to ground hitting the back of her head. E1 stated, No, I am not aware of any malfunctions in the past or currently, I have not been made aware of any problems with the flap on the lift, nor am I aware that the drivers knew the flap was broken. A list dated [DATE] provided by E6 of residents who are in wheelchairs and use the facility van for transportation listed residents R1 to R9 and R11. On [DATE] at 8:30 A.M. R2 stated, I have been here since 2012. I go to dialysis three times a week. I am transported via facility van. In regards to the incident on [DATE], I had been taken off of the van. I was on the ground, under the canopy. I saw (R1) being pushed by (E3 Certified Nursing Assistant) onto the lift. I saw (R1) fall and hit (R1)'s head. The wiring in the van is faulty. It's over-used. Every time you push the button on the lift, you have to keep pushing the button. That has been broke for three years. Everybody knows it's broke. The administrator (E1) knows about it. They can't afford to fix it. When they push the button, it jerks you back up to the starting position. Every time something happens with the van, they borrow a van from somewhere else. When they bring it back, it still doesn't work right. It's always broke. we were riding in it one day and it caught on fire, not that long ago. Supposedly they fixed it, but it's not. It's still broke. On [DATE] at 9:30 A.M., R3 stated, I go to dialysis three days a week. I usually go by the facility van, in my wheel chair. There is one lady that drives the van, that scares me. She says she doesn't do it very often and you can tell. She is very unsure of herself. I don't feel safe when she is driving. I know the button on the controller sticks at times and the lift jerks you. On [DATE] at 10:30 A.M., R5 stated, I go to the doctors to get treatments. I ride in the van in my wheel chair. Something is wrong with the button on the lift, it jerks. It causes you to jump. On [DATE] at 10:40 A.M. R6 stated, I don't like the van, if I am in pain the van is bad and rickety, it shakes too much causes me more pain. And there is problems with the lift, it goes up and I am in the wheelchair it gets stuck in the air, they do something to the button makes it go up the rest of there way or down. Sometimes I do get scared of riding the van. E5 (Maintenance Supervisor) stated on [DATE] at 9:07 AM that the wheelchair lift for the small facility van used for transporting residents to medical appointments has experienced mechanical problems since the facility received the van from a sister facility about two years ago. E5 said that approximately one year ago, the lift had electronic problems in which the lift would stop on the way down. E5 said that the lift was repaired at the lift service company at that time. E5 said that two to three months ago, the lift ' s platform barrier flap, which is supposed to flip up in a vertical position as the platform is raised off the ground, moved up slowly and did not lock into place as quick as normal. E5 said that he replaced a spring on the barrier flap at that time, and it worked normally after that. E5 stated that the purpose of the barrier flap on the platform is to prevent a patient ' s wheelchair from rolling off the lift when the platform is raised off the ground. E5 stated that about one to two weeks ago, a facility van driver (whom he could not recall) informed him that the lift ' s barrier flap was not raising up into the vertical position as it normally does, but moved up slowly. E5 said that he did not work on the lift or send the lift to the lift service company at that time. E5 said that he told the van drivers at that time to bump it (barrier flap) back up. E5 stated that E6 (Transportation Coordinator) inspects the two facility vans once monthly using the Van Safety Checklist, but that the checklist does not address an inspection of the van ' s lift. E5 stated that the facility vans are inspected twice a year for the State required vehicle safety check, but that this inspection does not include an inspection of the lift. E5 said that it has been approximately one year since the van lift was serviced at lift service company. E3 clarified on [DATE] at 9:45 AM that when E3 rolled R1 onto the lift platform at the back of the van last Saturday, R1 was facing towards E3. E3 said that E3 locked the right brake on R1 ' s wheelchair, and as E3 was reaching in front of R1 to lock the left brake on the wheelchair, the lift platform jerked, causing the platform barrier flap to fall down. E3 said that R1 and her wheelchair then started to roll backwards. E3 said that E3 tried to grab the front of the wheelchair, but it had happened too fast, and R1 was already rolling off the platform. E6 stated on [DATE] at 10:35 AM that E6 or E5 do a monthly inspection of the two facility vans, and that E6 checks the lifts on the vans as well. E6 said that there is no place though on the monthly van inspection sheets to document this. E6 also said that there is no other document to note E6 ' s lift inspection either. On [DATE] at 8:50 A.M., Z1 (Service Technician for the facility's van lift) stated, I have further training on van lifts through (the van lift manufacturer). E9 (Corporate Information Technologist) dropped this van off last Monday ([DATE]). (E9) said it had been involved in an incident. When I checked the lift over, I noticed on the barrier flap, one of the feet that releases and holds it in place when it is going up and down, was missing. It was laying on the floor of the van. On [DATE] at 10:05 A.M., Z2 (Customer Experience Manager for van lift manufacturer) stated, (This) series lift is a commercial grade lift that have been certified by the National Highway Transporation Safety Association. The roll stop latch at the end of the lift is a safety mechanism to prevent unintended wheel chair roll-away. On [DATE] at 11:10 A.M., Z3 (R1's son) stated, Right after (R1) was transferred to (Trauma Center), (R1) was still conscious and able to hold a conversation. (R1) said one of (R1)'s wheel chair brakes was locked and then (R1) felt something jerk and somehow (R1) rolled off of the lift. (R1) also said the stop at the end of the lift was broken for sometime. On [DATE], E6 (Transportation Coordinator) provided a list of facility approved van drivers. Included in the list are E3 (CNA), E4 (Alzheimer's Director), E5 (Maintenance Director), E6 (Transportation Coordinator), E7 (Activity Director) and E8, E10 and E11 (all CNAs). The facility form, titled Mandatory Van Safety Demonstration In-service dated [DATE] and signed by E3, E4, E5, E6, E7, E8, E10 and E11 includes the following statement,Employee understands that it is their responsibility to report any maintenance concerns with the (company) van to their Administrator immediately. The facility form, titled Van Safety Checklist dated monthly from [DATE] through [DATE] and signed by E6 (Transportation Coordinator) includes the following areas that are inspected: seat belts, lights, glass, heater/defroster, windshield wipers, steering, horn, brakes, parking brake, muffler, tires, oil change and transmission/differential. On [DATE] at 11:20 A.M., E6 (Transportation Coordinator) stated, We do a monthly inspection on the van that is documented. Either myself or (E5 Maintenance Director) does the inspection. (E1 Administrator) keeps the documentation of those inspections. The van safety checklist does not include checking the lift. An invoice, dated [DATE] for the 2006 facility van includes the following information, Replaced the broken magnets on the outer barrier latch. An invoice, dated [DATE] for the 2006 facility van includes the following information, The lift was disassembled when it was brought in for service. The lift would keep going up and fold itself in when the button was pressed. An invoice, dated [DATE] for the 2006 facility van includes the following information: Lift involved in accident. Foot missing on drivers side, outer barrier latch. R1's emergency room Report, dated [DATE] includes the following Brain Computerized Tomography report, Impression: Right Frontal and Interhemispheric Subdural Hematoma. Interhemispheric Subarachnoid Hemorrhage. Mild Leftward 4 MM (millimeter) Midline Shift. and the following Disposition, Transfer ordered to (Regional Trauma Hospital) for higher level of care. R1's trauma center hospital discharge summary dated [DATE] at 11:29 AM authored by Z4 (trauma center hospital APN/Advanced Practice Nurse) states the following under the Hospital Course section: (R1) was initially admitted after fall with SDH (Subdural hematoma), SAH (Subarachnoid hemorrage). She lives in a nursing home and was in her normal state of health and was getting ready to be transported to dialysis. She was in her wheelchair in a lift being transported onto the van when the back bar of the lift broke. Her wheelchair fell off of the lift from its highest point and she fell backwards. She hit the back of her head. The people present report no loss of consciousness. She was transported to (the local hospital) where the head CT showed a small frontal SDH and interhemispheric SDH. Neurosurgery did not recommend any surgical interventions at that time. She appeared to be at her baseline mental status immediately after the fall. Her mental status acutely declined the morning of [DATE]th, with acutely worsening left sided weakness and right sided gaze. Repeat head CT showed minimal shift to the left and increasing hemorrhage. She was transferred to the ICU (Intensive Care Unit) and did have an ileus that was being managed by the surgeons via NG (Nasogastric) tube for bowel rest. However, she continued to neurologically decline over the 18th. She progressively required more oxygen support over the 18th. Son was called and discussed the progression of his mother's care. He changed her code status back to her previous one of DNR comfort, but not active comfort measures. Over the night of the ,[DATE]th she continued to decline and then goals were changed to comfort measures only. She expired at 1040 (AM). Z4 (trauma hospital APN/Advanced Practice Nurse) confirmed on [DATE] at 9:10 AM that R1's death was directly related to the recent fall and resulting brain injury. The Immediate Jeopardy was identified at approximately 9:30 AM on [DATE] to have begun on [DATE] when E8 last drove the lift van and observed that the lift's barrier flap was not working properly. E1 and E12 (Corporate Nurse) were notified of the Immediate Jeopardy on [DATE] at approximately 10 AM. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: · As of [DATE], facility van was removed from service and remains out of service. · On [DATE], the facility van was taken by the Transportation C.N.A. to the Corporate Office. Corporate provided the facility with another van for use. The facility van was taken to the lift service company for inspection. · [DATE], facility began in-servicing all approved van drivers on safe operation and functioning of the lift and all safety devices. In-servicing was conducted by the Transportation CNA driver, Maintenance Supervisor and Administrator. · [DATE]; the facility has instituted a Wheelchair Lift Maintenance Policy; all approved van drivers have been in serviced on this Policy, in-servicing was conducted by Administrator and the Regional Corporate Nurse · On [DATE] Corporate has revised the Van Safety Checklist to include safety checks of the Van Lift, these safety checks will be completed for every trip/transport. Approved van drivers have been in serviced on the revised Van Safety Checklist and by Administrator and the Regional Corporate Nurse. Van approved drivers will review the Manufacturer Manual for Facility Van Lift. · On [DATE] all van drivers and Maintenance Supervisors that did not follow Van Policy Procedure related to the facility van have been disciplined. · On [DATE]; all approved van drivers have been re-in-serviced on the Van Safety Usage Guide/Policy Procedures, including reporting of all safety concerns or problems identified and that the van will be taken out of service immediately, the Administrator will be notified and the van will remain out of service until it is inspected by a certified/authorized technician. This in-service was conducted by the Administrator and the Regional Corporate Nurse with the assistance of the C.N.A./Transportation Driver. · The facility will continue to in-service approved van drivers in accordance with the Van Safety Policy and Procedures. Any new approved van drivers will have training and in servicing as per Van Safety Policy and Procedures prior to using the van.