Every finding on record at North Aurora Living & Rehab CTR

Based on interview and record review, the facility failed to ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medications doses as ordered by the physician. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for pharmacy services in the sample of 4.The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, major depressive disorder, attention-deficit hyperactivity disorder, and borderline personality disorder. R1's MDS (Minimum Data Set) dated June 17, 2026, showed R1 was cognitively intact. R1's Physician Orders dated June 25, 2026, showed an order dated March 28, 2025, for diclofenac sodium 75 mg (milligram), delayed release, give one tablet by oral route two times per day. R1's April 2026 MAR (Medication Administration Record) showed on April 10, 2026, R1 did not receive the 9:00 AM dose of diclofenac. V8 (LPN/Licensed Practical Nurse) documented the reason as Other: awaiting delivery. R1's May 2026 MAR showed on May 31, 2026, R1 did not receive the 9:00 AM dose of diclofenac. V7 (LPN) documented the reason as Other: pending delivery. On June 24, 2026, at 12:26 PM, R1 said the facility has run out of his medications multiple times. R1 said most recently it was his diclofenac. R1 said when he misses doses of diclofenac it makes it difficult to ambulate. On June 24, 2026, at 2:58 PM, V3 (ADON/Assistant Director of Nursing) said sometimes staff reorder R1's medications from pharmacy too early and pharmacy won't refill the medication. V3 said the facility is not notified the medication refill request cannot be fulfilled due to the request coming too early. V3 said another request has to be sent but the facility is unaware the first request was denied. V3 said R1 has missed medications due to pharmacy not refilling his medications. V3 said a resident's scheduled medication should not be missed and it should be reordered so the refill comes before a dose is missed. 2. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, depression, and anxiety disorder. R2's MDS dated [DATE], showed R2 was cognitively intact. R2's Physician Orders dated June 25, 2026, showed an order dated May 19, 2026, for clonazepam 0.5 mg tablet, give one tablet by oral route two times per day. R2's June 2026 MAR showed on June 22, 2026, R2 did not receive the 9:00 AM dose of clonazepam. V9 (RN/Registered Nurse) documented the reason the medication was not given as Other: medication on order awaiting delivery. On June 25, 2026, at 8:47 AM, R2 said the facility has run out of one of his medications and he missed a dose of the medication. 3. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia, dementia, and atrial fibrillation. R3's MDS dated [DATE], showed R3 was cognitively intact. R3's Physician Orders dated June 25, 2026, showed an order dated September 23, 2025, for lorazepam 1 mg tablet, give one tablet by oral route once daily at bedtime. R3's June 2026 MAR showed on June 19, 2026, R3 did not receive the 9:00 PM dose of lorazepam. V10 (LPN) documented the reason as Other: Reordered. 4. R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease with dyskinesia, schizoaffective disorder, and drug induced subacute dyskinesia. R4's MDS dated [DATE], showed R4 was cognitively intact. R4's Physician Orders dated June 25, 2026, showed an order dated February 13, 2026, for [Valbenzapine] 60 mg capsule, give one capsule by oral route once daily at bedtime. R4's June 2026 MAR showed on June 17, 2026, R4 did not receive the 9:00 PM dose of Valbenzapine. V11 (LPN) documented the reason as Other: Pharmacy to deliver. The MAR continued to show on June 19, 2026, R4 did not receive the 9:00 PM dose of Valbenzapine. V12 (RN) documented the reason as Other: pharmacy yet to deliver. On June 24, 2026, at 3:40 PM, V2 (DON/Director of Nursing) said the facility is not being made aware by the pharmacy when medication refill requests are being denied and then residents run out of medications. V2 said it is important for residents to receive their scheduled medications, and they should not miss medication doses.

Based on observation, interview and record review, the facility failed to sanitize dishes during dishwashing procedure.This applies to all 99 residents that received meals prepared and served in the facility kitchen. The findings include: The CMS-671 Form dated December 1, 2025, showed the facility census was 99 residents. Facility provided information that the facility has no residents on NPO (nothing by mouth) status. On December 01, 2025, starting at 9:35 AM, during initial tour of kitchen the following observations were made:In the dry storage area, there were two dented cans placed on shelving with other cans. One of these dented can's contained Marinara sauce (6 lbs./pounds, 9 oz/ounces) with delivery date October 31, 2025, and the other dented can contained cut waxed beans (6 lbs., 5 oz) with delivery date November 12, 2025.In the kitchen, V13 (Dietary Aide) was washing dishes in the dish machine. When asked if the dish machine was a high temperature or low temperature machine, V13 stated she is not sure and that she checks the sanitation using a test strip. On request, V13 tested the sanitizer well of the dish machine with a chlorine test strip and it remained white color which showed ten on the test strip color scale. V13 stated the test strip should be 100 (ppm/parts per million) with color showing dark purple. When asked if she had tested the dish machine prior to washing the breakfast dishes, V13 stated she did and the test strip had shown white color, and she then changed the three containers (wash detergent, rinse and sanitizer) that was at the bottom of the dish machine. V13 added that she did not have a chance to report it to the V12 (Dietary Manager) as she (V12) had just come in a little while ago. A test strip was run two more times through the dish machine and the color remained white and V12 was notified of the same. Chlorine Sanitizer Test Procedure for Low Temperature Dish Machine showed that test strip range should be 50-100 ppm. Facility Policy and Procedure (Revised June 6) titled Receiving included: Policy: It is the policy of the [facility] that all food and supplies received from the vendor are delivered to the Food Service Department and shall be checked by the Food service Manager or designee. This is to ensure compliance with specifications and prices on the invoices. Procedure: 9. If after delivery, damaged product is found, the Food Service Manager or designee contact the vendor immediately, so that it can be picked up and credited on the next delivery. Facility Policy and Procedure (revised October 9) titled Ware-washing -Dish machine included:Policy: It is the policy of [facility] that utensils and dishes washed by mechanical dishwasher will be cleaned and sanitized.Procedure: 3. For Low Temperature Dish machine (temperature of wash water shall not be less than 120 degrees Fahrenheit), before washing anything, use a test strip to check the sanitizer level a. For chlorine sanitizers, the level should be 50-100 ppm.

Based on interview and record review, the facility failed to implement their water management program plan, failed to conduct risk assessment to identify high risk areas, failed to document description of the facility's water system, and failed to implement control measures to prevent Legionella and other opportunistic waterborne pathogens spread within the facility's water system.This applies to all 99 residents who reside at the facility.The findings include:Form CMS (Centers for Medicare and Medicaid Services)-671 (Long Term Care facility application for Medicare and Medicaid) dated December 1, 2025, showed the facility had a total census of 99 residents.During the survey, the facility did not have documentation to show water flow schematics of the facility and did not have documentation of an assessment identifying where high-risk water flow areas were in the facility. The facility did not have documented risk assessments or control measures established to handle potential hazards. The facility did not have a plan in place to assess, mitigate risk, and/or monitor for Legionella and other waterborne pathogens.On December 2, 2025, at 12:32 PM, V1 (Administrator) stated the water management program is maintained by the maintenance director. V1 said he is unsure of the components of the water management program.On December 2, 2025, at 12:55 PM V8 (Maintenance Director) said he did not have a plan in place to assess or monitor for Legionella. V8 said he is not aware of documentation needed for the facility water management program. V8 said V7 (Housekeeping Director) would have more information on the management program.On December 2, 2025, at 12:57 PM, V7 said he has been working at the facility for years and is unsure of all components of water management program and testing protocols.On December 2, 2025, at 2:13 PM, V8 said he was unable to provide documentation regarding facility water management program. V8 said he doesn't have schematics that describes the facility water system. V8 said he doesn't have a facility water management plan that includes the required risk assessment to determine where Legionella and other waterborne pathogens could grow and spread. V8 said he has not established risk assessments or control measures that could address potential hazards.On December 3, 2025, at 10:07 AM, V3 (Assisted Director of Nursing/ Infection Prevention Nurse) said he doesn't handle water management program and that V1 should know everything about the program.The facilities water management program policy dated October 1, 2020, showed the maintenance director will maintain documentation that describes the facility's water system. A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. The risk assessment will be completed by facility leadership and the Infections Prevention with collaboration from the other facility members such as maintenance employee, risk and quality management staff. Based on the risk assessment, control measures will be established to address potential hazards.

Based on observation, interview and record review, the facility failed to provide behavioral health services to residents with SMI (severe mental illness).This applies to 4 of 4 residents (R4, R12, R85 and R97) reviewed for behavioral health services in the sample of 23.The findings include:1. R12 was admitted to the facility on [DATE]. R12 had multiple diagnoses including severe bipolar disorder with psychotic features, recurrent severe major depressive disorder without psychotic features, attention-deficit hyperactivity disorder and suicidal ideations, based on the face sheet. R12 is [AGE] years old. R12's admission MDS (minimum data set) dated October 22, 2025, showed the resident was cognitively intact. The MDS showed R12 had no functional limitation in range of motion, and he required supervision from the staff with his ADLs (activities of daily living). Further review of the same MDS showed R12's primary SMI (severe mental illness) diagnosis are recurrent major depression and bipolar disorder I mixed, manic and depressed. On December 1, 2025 at 11:01 AM, R12 was in bed and was awaken from his nap. R12 claimed he does not attend any in-house or outside psychosocial program. According to R12 he spends most of his days reading and taking naps. On December 2, 2025 at 9:52 AM, R12 was in bed and was awaken when he heard the knocking on the door, claimed he was napping. R12 was asked what his plans were for the day. R12 responded later he wants to read a book inside his room, walk outside for fresh air and eat his meals. R12 plans to be discharged from the facility to the community and he wanted to live with his family when his medications are stable and when his physician thinks he can function outside of the facility safely. According to R12, he does not attend any psychosocial and/or behavioral health services/groups at the facility or outside of the facility. R12 stated he wants to join any group at the facility to discuss programs to learn how to manage and cope with stress and behavior symptom, manage money, and talk to someone on a one-on-one basis to discuss his feelings to be able to manage his behaviors. During the same interview, R12 stated since his admission at the facility he had spoken to V4 (PRSD, Psychiatric Rehabilitation Service Director/SS, Social Service) once. At 1:26 PM, R12 was in bed and was awaken from his nap, when he heard the knocking on his door. R12 stated he will go outside to walk around or read a book later. On December 3, 2025 at 10:03 PM, R12 was reading a book inside the solarium. R12's PASRR (Preadmission Screening and Resident Review) summary of findings dated October 16, 2025 showed the resident had serious mental illness. The PASRR summary showed, You are in need of support for your medical and mental health care, You are not able to care for yourself in the community at this time and You said your long-term goal is to have your own apartment. It was documented, A nursing home will be able to provide you with the medical care you need and make sure your mental health needs are being met. The PASRR summary of findings listed multiple services and/or supports needed to be provided to R12, under rehabilitative services including, Consistent implementation during resident's daily routine and across settings, of systematic plans which are designed to change inappropriate behaviors. You would benefit from taking part in social activities to help with depression and anxiety. You would benefit from creating a daily routine or schedule you could follow at the nursing facility. Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. It was documented the above service and/or support was selected because, You may benefit from programs, such as skilled therapies, designed to improve your ability to complete daily skills and tasks, and improve your overall independence and health. Another rehabilitative services needed to be provided to R12 included, crisis intervention services plan, You would benefit from crisis intervention planning to prevent behaviors and thoughts impact you safety and individual, group and family psychotherapy, You would benefit from individual counselling to help improve your mental well-being, adjust to the changes in your health, and help you learn new coping strategies for managing your mental health symptoms. You would benefit from group therapy to better understand behaviors related to your mental health, practice coping skills, and promote personal strength and flexibility. R12's Social Services-Psychosocial history addendum completed by the facility on October 22, 2025 showed the resident was oriented with guarded behaviors when in social situations. Under the rehabilitation and discharge potential it showed, Refer to individual psychotherapy. Under the client interests and strengths, it showed in-part, skill development needs and problem areas for which the resident expresses interest in receiving psychiatric rehab, resident's beliefs and confidence in his capacity to develop increased skills and independence, and willingness to participate in recommended treatment. Under the brief life skills assessment, it showed R12 had decreased skills related to social skills, community living and symptom management. The same social service-psychosocial history addendum showed R12's rehabilitation focus are basic skills training and supports with opportunities for community integration, coping/support/ adjustment, social skills/behavior management, orientation/connections, psychotherapy, empowerment/self-esteem, community living and symptom management. It was documented R12 needed one-on one intervention in the areas of coping/support/ adjustment, psychotherapy, symptom management, orientation/connections and community living. Review of the facility's behavioral health/psychotherapy services provided at the facility showed R12's name was not on the list to receive one-on one behavioral health service from an outside licensed social worker. R12's name was not on the list to receive group or one-on one behavioral health services/psychosocial programs provided by an outside company. However, R12's name was included on the list to receive one-on one with the psychologist. On December 2, 2025 at 3:00 PM, V6 (SSD (Social Service Director)) was asked to provide documentation regarding R12's one-on one with the psychologist. At 3:45 PM, V6 presented documentation from the psychologist showing R12 was seen on October 17 and November 11, 2025 for 20 minutes each time. The psychologist documented, I did this as a courtesy because my understanding was, he had no insurance that would pay for my services. V6 confirmed R12 had received one-on-one with the psychologist only twice since admission, and no further visits thereafter due to insurance issues. On December 3, 2025 at V4 (PRSD/SS) stated she is the case manager to R12. V4 stated she had referred R12 for one-on-one with the psychologist, however, she was not informed the psychologist had seen the resident only twice since admission and stopped due to insurance issues. V4 acknowledged R12 does not receive one-on-one behavioral health service from an outside licensed social worker at the facility and R12 does not receive group or one-on one behavioral health services/psychosocial programs at the facility which are provided by an outside company. During the same interview, V4 was asked if she had provided any one-on-one discussions with R12 to address the resident's identified rehabilitation focus as identified on the resident's social service-psychosocial history addendum. V4 stated she had no documentation of any one-on-one she had with R12. According to V4, she would check in with R12 to ask how he was doing and if he needed anything. 2. R85 was admitted to the facility on [DATE]. R85 had multiple diagnoses including, schizoaffective disorder depressive type, major depressive disorder and generalized anxiety disorder, based on the face sheet. R85 is [AGE] years old. R85's admission MDS dated [DATE], showed the resident was cognitively intact. The MDS showed R85 had no functional limitation in range of motion, and she required supervision from the staff with her ADLs. Further review of the same MDS showed R85's primary SMI diagnosis was schizoaffective disorder. On December 1, 2025 at 10:51 AM, R85 was in bed. Stated she was taking a nap. According to R85 she does not attend any psychosocial rehab/program in-house or outside the facility. R85 stated she does not do much at the facility, she just takes naps, eat and smoke. On December 2, 2025 at 9:58 AM, R85 was in bed awake and oriented. R85 was staring at the ceiling. R85 was asked what her plans are for the day, and she responded, Nothing really, I might take my shower today, take naps and eat my meals. R85 added she might go outside to smoke, if she has any cigarette left inside the facility's smoking cart. R85 stated she does not attend any psychosocial and/or behavioral health services/groups at the facility or outside of the facility. R85 stated when her Physician thinks she can be discharged to the community, she plans to live with her family. During the same interview, R85 stated she is currently on probation because she got incarcerated due to drugs. At 1:24 PM, R85 was in bed sleeping. On December 3, 2025 at 10:00 AM, R85 was in bed and was awaken by the knocking on the door. R85 stated she was taking a nap and she had no planned activity for the day. R85's PASRR summary of findings dated September 18. 2025 showed the resident has serious mental health condition. The PASRR summary showed, You are in need of nursing home for rehabilitation. The summary under PASRR determination Explanation showed, You are diagnosed with mood affective disorder which significantly impacts your daily life. You may benefit from medication management and psychiatric support. The PASRR summary of findings listed multiple services and/or supports needed to be provided to R85, under rehabilitative services including, Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. It was documented the above service and/or support was selected because, You may benefit from programs to teach daily living skills to help improve independence. Another rehabilitative service needed to be provided to R85 included Individual, group, and family psychotherapy. You may benefit from psychotherapy to decrease mental health symptoms and develop healthy coping skills. R85's Social Services-Psychosocial history addendum completed by the facility on October 7, 2025 showed the resident was alert and oriented to all aspects and was able to communicate herself effectively and can engage in conversation. Under the rehabilitation and discharge potential it showed R85 plans to return home with her mother when she is mentally stable, and her court issues are resolved. Under the client interests and strengths showed in-part, skill development needs and problem areas for which the resident expresses interest in receiving psychiatric rehab, resident's beliefs and confidence in her capacity to develop increased skills and independence and willingness to participate in recommended treatment. Under the brief life skills assessment, it showed R85 had decreased skills related to self-maintenance, community living, occupational skills, symptom management and substance abuse management. The same social service-psychosocial history addendum showed R85's rehabilitation focus is to provide one-on-one intervention related to coping/support/adjustment, psychotherapy, substance abuse treatment, empowerment/self-esteem, self-maintenance and symptom management. On December 2, 2025 at 12:47 PM, V14 (Social Service/Case Manager) stated R85 is depressed with suicidal ideation. R85 was homeless and currently on probation in this State for mental health concerns. V14 stated since R85's admission at the facility, the resident was not assigned to attend the group or one-on-one psychosocial and/or behavioral health services provided in-house by an outside company. During the same interview V14 was asked if she had provided one-on one intervention to R85 to address the resident's identified rehabilitation focus as identified on the resident's social service-psychosocial history addendum. V14 responded, she was not sure, and she will check R85's EMR (electronic medical records). At 1:30 PM, V14 presented one documentation of a one-on one discussion with R85 dated October 3, 2025, addressing the resident's adjustment to the facility. V14 acknowledged there are no other one-on one discussion/intervention documented to address R85's mental health rehabilitation focus areas, since admission, except on October 3, 2025. Review of the facility's behavioral health/psychotherapy services provided at the facility showed R85's name was not on the list to receive one-on one behavioral health service from an outside licensed social worker. R85's name was not on the list to receive one-on one with the psychologist and R85's name was not on the list to receive group or one-on one behavioral health services/psychosocial programs provided by an outside company. On December 2, 2025 at 2:00 PM, V4 (PRSD/Social Service) stated she just started a women's psychosocial group to meet every Thursdays at 3:00 PM until 3:45 PM. V4 stated R85 attended the first women's psychosocial group on November 20, 2025. V4 presented the attendance sheet for the women's psychosocial group held on November 20, 2025 at 3:00 PM. The said group was attended by eight residents, including R85. On December 2, 2025 at 4:10 PM, V6 (Social Service Director) confirmed based on the facility's behavioral health and psychotherapy services program listing, R85 does not receive any one-on-one with the outside licensed social worker. R85 does not receive one-on one with the psychologist and R85 does not receive either group or one-on one behavioral health services/psychosocial programs in-house, provided by an outside company. 3. R97 face sheet showed R97 was [AGE] years old and was admitted to the facility on [DATE], with the diagnoses of schizophrenia, essential hypertension, and unspecified asthma. The MDS dated [DATE], showed R97 was cognitively intact. R97's PASRR level II screening dated October 10, 2025, showed R97 may choose to live in a nursing facility now but should return to the community (home or residential center) when your medical condition improves. The screening also showed R97 previously worked as an EMT and used to participate in [NAME] arts and playing basketball and managing finances are important to R97. The screening showed the services R97 needed to return to the community included one to one with psychiatrist and/or social worker to assist R97 to learn about the symptoms of mental illness, manage medications, and educate R97 on strategies to cope with symptoms. The screening showed additional services need to return to the community included socialization groups or programs, regular follow up by psychiatrist, case management services could provide assistance and support, coordinate services and provide discharge planning. The screening to approve Nursing facility services was short term and expires on January 8, 2026. R97's Social Services -Psych Social History Addendum dated September 17, 2025, showed R97 needed intensive skills in training and supports with an increasing focus on community integration through group intervention for coping/support/adjustment, social skills /behavior management, orientation/connections, psychotherapy, self-maintenance, symptom management, and medication education. On December 1 and 2, 2025, R97 stayed in his room and came out for meals and went back to his room. On December 3, 2025, at 11:20 AM, V6 (Social Services Director & R97s case manager) stated R97 does not go to groups and often stays in his room, only coming out for meals. V6 stated she is unsure about R97's medication education and R97 could benefit from symptom management education. V6 stated R97 has delusions and hallucinations. V6 stated R97 does not have an incentive program in place to encourage participation, but R97 may benefit from an incentive program to participate. V6 stated R97's goal is to get a job and an apartment and R97 needs assistance to obtain his identification documents to proceed to get a job. V6 stated the facility's program for groups such as symptom and medication management are under development with their consultant and currently not available to residents. V6 stated residents could sit in on the ADAPT program groups if they desire. On December 3, 2025, at 11:30 AM, V21 (ADAPT program manager) stated R97 had not attended any of the scheduled groups available on the calendar and is not part of the ADAPT program. 4. R4 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, hallucinations, unspecified, insomnia, and hypertension. R4's MDS dated [DATE], showed R4 was cognitively intact. On December 1, 2025, 10:21 AM, R4 was alert and oriented in her room sitting on top of her bed. R4 was observed with long facial hair on her upper lip and chin. R4 stated she does her own grooming and bathing without staff assistance. R4 stated she does not go to activities except on rare occasion and does not attend any psychosocial groups and primarily stays in her room playing games on her phone and comes out of her room only to eat her meals. R4's PASRR level II screening dated September 10, 2025, showed R4 would benefit from medication monitoring and education, participating from programs targeted to improve daily living activities and self-care tasks, and would benefit from structured social activities to promote healthy social interactions and moods and decrease social isolation. The screening also showed R4 had been hospitalized on [DATE], for thoughts of self-harm and had an unstable living situation and lacked family support and anticipated stay was long term. R4's Social Services-Psych Social Addendum, assessment dated [DATE], showed R4 was in need of Basic skills training and support with opportunities for community integration, using a one-to-one approach in the topic areas of coping/support/adjustment, psychotherapy, empowerment self-esteem, symptom management, and medication management. On December 3, 2025, 11:35 AM, V4 (PRSD R4's case manager) stated R4 was supposed to start attending the new women's group however R4 had not attended the group yet just started on November 20, 2025. V4 stated R4 does exhibit symptoms of anxiety and worrying about her roommate and expresses unrealistic worry and concerns. V4 stated R4 is aware of her overgrown facial hair and does let the hair grow to a certain length before she asks for a razor and to be assisted with the removal of her facial hair. V4 stated R4 struggles with her peers due to the long facial hair and her style of dress, her peers thought she was a male instead of a female. V4 stated R4 could benefit from symptom management for anxiety and self-care training. V4 was unable to provide any documentation of one to one intervention sessions being provided to R4. On December 3, 2025, at 11:30 AM, V21 (ADAPT program manager) stated R4 had not attended any of the scheduled groups available on the calendar and is not part of the ADAPT program. The facility's policy titled Behavior Management Symptom Evaluation Policy, dated January 2019, showed Introduction.It is the policy and philosophy of this long term care organization to enable each resident to engage in quality of life opportunities to the best of his or her ability.group therapy is generally the preferred treatment methodology.Behavior interventions .are individualized, non-pharmacological approaches to care are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical, or psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure that resident bathroom had a clean and working toilet. This applies to 2 of 3 residents (R78 and R91) reviewed for environmental concerns in the sample of 23. The findings include: On December 1, 2025, at 1:15pm both R78 and R91 were lying on their beds in their room. R78 and R91 were alert and oriented. R78 pointed towards a sign posted on the bathroom door that read, Temporarily Out of Order. R78 said the toilet has not been working for a few weeks. R78 stated, The toilet does not flush and whatever is in there just sits there. Eventually it may go down but the next time you try to flush it again it won't flush. R78 said the sign was put on the door last week by the maintenance staff who said they would fix it. R91 said the toilet had been broken for about three weeks. R91 said that maintenance was informed again at the resident council meeting on November 25, 2025. The note was placed after resident council, but the toilet was still not fixed. R91 said they have been using different restrooms throughout the facility for the past few weeks. This is not the first issue regarding the toilet. According to R78 the toilet needed to be fixed a few months ago because it was leaking. On December 2, 2025, 12:20pm V8 (Maintenance) said he was made aware of toilet not working during resident council meeting on November 25,2025. V8 did not fix or replace toilet when notified on November 25, 2025. V8 instructed R78 and R91 to use community bathrooms until toilet was fixed and placed sign on door. R78 and R91 did not have a functional toilet in their room from November 25, 2025, to December 2, 2025. V8 said that because residents informed him directly during the resident council meeting there was no work order put in place for the malfunction. Review of resident council minutes from November 25, 2025, did not show discussion of the non-functional toilet or plan for repair. Council minutes stated, Maintenance is making sure residents' rooms are kept up in order.On December 3. 2025 at 10:35am V1 (Administrator) stated communication for maintenance concerns need improvement. V1 said in instances of a non-functioning toilet, repairs should be made immediately. Supplies can be purchased same day from the local home improvement store. V1 said he had attended the resident council meeting on November 25, 2025, and heard R91 voice concerns to V8 regarding the toilet and that it should have been repaired sooner. V1 said both residents should have been offered the chance to move to a new room. If they did not want to move, they should have been informed to use community facilities temporarily while repairs were made the same day.

Based on observation, interview and record review, the facility failed to repair a gap between the outside wall and the air conditioner unit on the exterior wall in a residents room, that caused cold air from the outside to flow directly into the room and failed to implement a system to notify maintenance staff of needed repairs.This applies to 1 of 3 resident (R31) reviewed for environmental concern in the sample of 23.The findings include: R31's medical record showed R31 was [AGE] years old. R31 was admitted to the facility on [DATE]. R31 had multiple diagnoses including schizophrenia, alcohol induced psychosis, anxiety disorder and nicotine dependence unspecified. R31's MDS (Minimum Data Set) dated October 29, 2025, showed R31 was cognitively intact. On December 1, 2025, at 10:33 AM, there was a gap in the exterior wall, on the left side, next to the air conditioner in R31's room and the parking lot was visible through the gap. The room was noted to be chilly, and a breeze was noted coming from the gap. R31 stated he thought the gap had been there for about a month and stated it was a little chilly in the room. R97 (R31's roommate) was observed fully dressed lying under the blankets in bed. V9 (Housekeeper) entered the room at 10:40 AM and stated she had worked in the facility for about 3 months and this room was one of her primary assignments and stated she had not noticed the gap in the wall prior to the observation today. On December 2, 2025, 10:40 AM, V7 (Housekeeping Supervisor) stated V9 had informed him yesterday of the gap in the wall in R31's room and prior to yesterday he was unaware of it. On December 2, 2025, 10:49 AM, V8 (Maintenance Director) stated he was unaware of the gap in the exterior wall in R31's room prior to yesterday. V8 stated there is a maintenance request form that staff or residents can fill out and leave in the mailbox outside V8's office door. There was no record of a maintenance request form completed for the gap in the wall in R31's room. V8 stated the last maintenance request form he had received was dated October 7, 2025. On December 3, 2025, 11:26 AM, V8 stated he put a new air conditioner unit in R31's room around the end of summer but could not remember exactly when he had installed it and did not have any record regarding the installation date. V8 stated prior to the onset of cold weather, he checks all the windows in all resident rooms to be sure they are closed to prevent any drafts because some residents open their windows from the top. V8 stated again he had not been aware or saw the gap in the exterior wall adjacent to the air conditioner unit prior to being informed on Monday December 1, 2025. On December 2, 2025, 12:04 PM, V1 (Administrator) stated there was no facility policy regarding reporting maintenance issues or requesting repairs. V1 also stated residents can tell staff and staff can complete the maintenance request form on their behalf. V1 stated the expectation is for staff to request needed repairs on the maintenance request form and he is unsure why staff stopped using the form.

Based on interview and record review, the facility failed to meet the requirements for an emergency involuntary transfer and did not allow the resident to return to the facility.This applies to 1 of 3 residents (R1) reviewed for involuntary discharge in the sample of 3.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, bipolar disorder, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. The EMR continued to show R1 was transferred to the local hospital on July 7, 2025, and did not return to the facility.R1's MDS (Minimum Data Set) dated June 17, 2025, showed R1 was cognitively intact, and R1 required partial assistance from facility staff for eating, oral hygiene, toileting hygiene, and personal hygiene. On July 15, 2025, at 2:54 PM, V2 (DON/Director of Nursing) said on July 7, 2025, R1 asked V2 for more food and V2 instructed R1 he already a double portion meal. V2 said she told R1 the doctor allowed double portions but R1 could not have extra snacks. V2 said R1 started cursing and then started trying to exit the facility. V2 said staff followed R1 out of the facility and R1 hopped a fence and went into the street. V2 said R1 grabbed a piece of wood about 12 inches long and threatened to kill staff or himself. V2 said she called emergency services, and the police showed up in two to three minutes. V2 said this started at about 1:15 PM, and R1 left for the hospital in the ambulance around 3:00 PM. V2 said when R1 was about to leave in the ambulance, she handed paramedics multiple copies of R1's Petition for Involuntary/Judicial admission and the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents. V2 said on the same day around 7:00 PM, an ambulance company showed up to the facility with R1. V2 said the nurse on duty called V2 and V2 spoke with the ambulance drivers and told them R1 had been involuntarily discharged from the facility. V2 said she told the ambulance company to send R1 back to the hospital because R1 had been involuntarily discharged from the facility. V2 said she spoke with the emergency room charge nurse and was told R1 was cleared by their psychiatrist to be discharged from the hospital. V2 said she told the emergency room charge nurse R1 had been involuntarily discharged from the facility and needed to go back to the hospital. V2 said after some time, the ambulance company took R1 back to the local hospital.On July 15, 2025, at 4:09 PM, V1 (Administrator) said he spoke with R1's case worker at the hospital on July 11, 2025, and informed her R1 had been involuntarily discharged from the facility and could not return. V1 said the facility does not have a policy for involuntary discharge, the facility follows the regulations for involuntary discharge.R1's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated July 7, 2025, showed Emergency Transfer or discharge: Yes. Federal Proceeding. The facility admits private-pay and Medicare or Medicaid residents and is federally-certified and state licensed, or this facility admits only Medicare or Medicaid residents and is federally funded. This facility seeks to transfer or discharge you pursuant to the regulations of the Health Care Financing Administration for states and long-term care facilities, 42 CFR 483.15 ('federal regulations'). As recorded in your clinical record in accordance with Section 483.15 (c) of the federal regulations, the reason for this proposed transfer or discharge is: the safety of individuals in this facility in endangered, 483.15 (c)(1)(i)(C).A progress note dated July 14, 2025, at 10:55 AM, by V1 showed On Friday, July 11, 2025, [V10 (Hospital Social Worker)] from [local hospital] contacted [the facility] that [R1] will be returning to [the facility]. This writer informed [V10] that [the facility] served involuntary discharge to [R1] on July 7, 2025, and we can't take [R1] back due to the threat and risk he posed on himself and the other residents here at [the facility]. Writer informed [V10] that proper involuntary discharge documents were sent with ambulance with two copies. Resident 'own guardian,' physician and ombudsman have been notified. [V10] said that she needs a copy of the emergency eviction order notice. Writer explained that nursing home regulations doesn't have emergency eviction notice order and that regulation doesn't apply in nursing home. Writer informed [V10] that [R1]'s psychiatrist at [a different hospital] are willing to accept [R1]. Writer also informed [V10] that [a different nursing home] is willing to accept [R1]. Writer informed [V10] that [the facility] can and will send [R1]'s belongings either to [local hospital or to any place [R1] will go to. [V10] said that my information are incorrect. I explained that I am following the nursing home regulations and the conversation ended.A progress note dated July 14, 2025, at 2:37 PM, by V1 showed [V4 (Ombudsman)] called writer today regarding [R1]. [V4] said that she spoke to [V10] today, July 14, 2025. [V4] said that [V10] informed her that [R1] is coming back to [the facility]. I informed [V4] that is incorrect and [the facility] is not accepting [R1] back. I informed [V4] that [the facility] informed [V10] that we are not taking [R1] back since July 7, 2025. I explained to [V4] that involuntary discharge papers have been sent to paramedics, hospital, [V10], and [V4] on July 7, 2025. [V4] said that resident have a right for appeal and hearing and I confirmed that it is the resident's right to appeal within 10 days. [V4] mentioned that she have never been in process of involuntary discharge before. I guided [V4] that [V5 (Facility Lawyer)]'s contact information is listed in the involuntary discharge documents. [V4] said she will call [V5]. A progress note dated July 16, 2025, at 11:07 AM, by V7 (Psychiatric Nurse Practitioner) showed Staff observed patient to be increasingly agitated throughout that day (July 7, 2025), noted verbal outbursts and pacing behavior. The patient expressed paranoid thoughts and demonstrated poor impulse control, asking for food from other residents. Later the patient became physically agitated and exited the facility without authorization. During the episode, he posed a significant risk to himself, to other residents with the nursing home, and to individuals in the surrounding community including the nearby school. Local authorities were contacted to assist in ensuring the safety of the patient and others. No injuries were reported. In my professional opinion, this patient continued to demonstrate severe psychiatric instability with escalating agitation and poor judgement. His behavior presented an ongoing safety risk that exceeded the capacity of the facility to manage safely. His uncontrolled psychiatric symptoms needed an immediate psychiatric transfer. This writer recommended sending the patient to a locked inpatient behavioral health facility for further evaluations and stabilization. Nursing and interdisciplinary team coordinated with appropriate facilities to ensure a safe and timely transfer. On July 16, 2025, at 12:08 PM, V7 said in her progress note dated July 16, 2025, she is referring to the incident with R1 that occurred on July 7, 2025. V7 said R1 needed to be stabilized in the hospital before returning to the facility. V7 said she did not receive communication from the hospital and does not know if R1 has stabilized while at the hospital. V7 said she is unable to say if R1 was appropriate for an involuntary discharge from the facility. As on July 16, 2025, at 4:00 PM, R1's medical record did not have documentation to support the facility's continued refusal to allow R1 to return to the facility following multiple days of inpatient hospitalization. The facility did not have documentation to show R1 continued to be a danger to the safety of individuals in the facility at the time of the hospital's multiple attempts to have R1 readmitted to the facility.On July 17, 2025, at 10:53 AM, V4 said R1 would have liked to have returned to the facility.

Based on interview and record review, the facility failed to prevent the physical abuse of residents per facility policy. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in a sample of 3. The findings include: Face sheet, dated 4/17/25, shows R1's diagnoses included Schizoaffective disorder, bipolar type, anxiety disorder, attention-deficit hyperactivity disorder, Major depression disorder, insomnia, obesity, and chronic obstructive pulmonary disease. MDS (Minimum Data Set), dated 3/17/25, shows R1 was cognitively intact. Face sheet, dated 4/17/25, shows R2's diagnoses included dementia with other behavioral disturbance, schizophrenia, difficulty walking, unsteadiness on feet, weakness, foot drop, abnormality of gait and mobility, disorganized schizophrenia, major depressive disorder, and insomnia. MDS, dated [DATE], shows R2 was cognitively intact. Facility Final Incident Investigation Report, dated 4/15/25, shows on 4/12 25 at 10:10 PM, R2 entered the community bathroom where R1 was taking a shower. R1 told R2 to get out of the bathroom and R2 ignored R1's request. R1 did not pull a call light for staff to assist and R2 bumped R1's shower chair in which R1 was sitting. R1 began yelling at R2 to leave but R2 would not leave. R1 dried himself off and attempted to leave the bathroom when R2 began harassing R1 and R2 threw his urinal full of urine at R1. R1 became upset and struck R2 on the back of the head and left the bathroom. R1 slipped on the urine while leaving the bathroom and landed on his buttocks. When interviewed, R2 stated he did not remember why he did not leave the bathroom when R1 asked him to do so. The residents were separated and both were placed on 1:1 monitoring by staff. V1 (Administrator) and 911 was called. The residents were assessed and no physical concerns were identified. R1 was sent to the hospital for a psych evaluation and returned to the facility. The allegation of abuse was substantiated. On 4/17/25 at 11:30 AM, R1 stated he was taking a shower in the shower room and R2 came into the room while R1 was naked. R1 stated he yelled at R2 to leave the shower room but R2 would not leave. R1 stated eventually R2 left and R1 dried off, dressed, and walked out into the hall and saw R2. R1 stated he hit R2 and R2 threw urine at R1 which caused R1 to slip and fall to the floor. R1 stated he was not injured in the incident. On 4/17/25 at 11:45 AM, when asked about R2's altercation with R1, R2 stated, It's over and done with. R2 stated he was not hurt during the incident with R1. On 4/17/25 at 10:40 AM, V3 (Registered Nurse) stated she heard yelling while at the nursing station and saw R2 sitting by his room door in his wheelchair holding his urinal which contained urine. V3 asked if R2 needed to use the bathroom and he would not reply. V3 stated V4 (CNA - Certified Nursing Assistant) also asked R2 if he could assist and R2 wound not reply to V4. V3 stated she and V4 were not yet aware R1 and R2 were arguing prior. V3 stated R1 came out of the bathroom, looked left and right, and began punching R2. V3 stated she tried to intervene but R1 was too large to remove from the area. V3 stated she called for staff to assist and the staff attempted to break up R1 and R2 but R1 was very strong and was resisting. V3 while she called 911, R2 dumped his urinal on R1, R1 slipped on the urine on the floor and fell . V3 stated while staff were attempting to separate the residents, R1 flipped R2's wheelchair while R2 was in the wheelchair. V3 stated the two residents were eventually separated and no injuries were identified. Both residents were placed with 1:1 supervision and R1 was involuntarily petitioned to the hospital for aggressive behavior. V3 stated neither of the residents were injured. On 4/17/25 at 6:43 PM, V4 stated he heard yelling and realized it was coming from a shower room with two residents in the room. V4 stated the residents exited the shower room and V4 thought the residents were fine until R2 threw urine from his urinal on R1 and R1 began hitting R2. V4 stated he was able to separate the residents and there were no injuries. Progress notes, dated 4/12/25, shows R2 went to the bathroom to dump his urinal and R1 was already using the bathroom. R1 told R2 to get out of the bathroom but R2 refused. The note shows that R1 hit R2 because R2 would not leave the bathroom. The note shows R2 was assessed for injury and no concerns were identified. The note shows 911 was called and R2 refused to go to the hospital. Progress note, dated 4/13/25, shows close monitoring and assessment of R2 continued until he was involuntarily sent to the hospital related to his aggressive behavior. Progress notes, dated 4/13/25, show R1 was using the bathroom to shower and R2 walked into the bathroom. The progress note shows R1 told R2 to leave the bathroom but R2 refused. R1 stated he hit R2 because R2 refused to leave the bathroom. The note shows R2 dumped urine from his urinal on to R1 which made R1 fall on the floor. The note shows the residents were separated and R1 was placed on 1:1 supervision until he left the hospital. Facility Abuse Prevention Policy, dated 10/24/22, shows, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect exploitation, misappropriation of property and mistreatment of residents . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident

Based on interview and record review the facility failed to safely transfer a resident (R1) with the use of a mechanical lift. This failure resulted in the resident falling and sustaining fractures to the right hip, left pelvis, pubic bone, and lumbar vertebra. This applies to 1 of 3 residents (R1) reviewed for accidents. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including generalized edema, chronic pain, impaired mobility, and generalized weakness. R1's MDS (Minimum Data Sheets) dated 3/19/2025 shows R1 was dependent on staff for transfers and required the use of a mechanical lift. On 4/07/2025 at 11:25 AM, V6 (Certified Nurse Assistant/CNA) was interviewed regarding R1's fall incident on 3/31/2025. V6 said she secured R1's sling to the mechanical lift to transfer him from the bed to his wheelchair. V6 said V4 (CNA) then came to the room and stood behind R1's wheelchair as she started to operate the lift. V6 said she started to maneuver the machine as V4 remained behind the wheelchair (not within close reach of R1). V6 said she then started to turn the machine when the sling's lower left strap suddenly ripped and R1 fell to the floor. V6 said R1's sling was worn out from overuse because it had not been replaced since R1's admission. On 4/07/2025 at 9:45 AM, V4 (CNA) said she was asked to assist V6 with R1's transfer on 3/31/2025. V4 said that when she arrived at R1's room V6 had already connected R1's sling to the lift. V4 said she positioned herself behind R1's wheelchair (not within close reach of R1) to receive him while V6 started to maneuver the machine. V4 said R1 fell as V6 started to turn the machine because the sling's lower left strap ripped. V4 said they were unable to respond quickly to reduce R1's fall impact from the mechanical lift. On 4/07/2025 at 2:00 PM, V2 (Director of Nursing/DON) said she responded to R1's fall incident. V2 said R1 had to be transferred to the hospital because he was complaining of pain to his back, legs, and elbows. V2 said she interviewed V6 and V4 after the incident and assessed R1's sling. V2 said the sling's lower left and right straps were ripped completely in half. V2 said she had concluded that R1's fall was because the sling's straps were frayed causing them to rip during R1's transfer. V2 continued to say R1's sling appeared worn out from overuse. V2 said R1's sling should have been inspected before being used and tossed because it was unsafe for use. V2 also said she expects both staff members to be actively assisting with mechanical lift transfers to ensure safe transferring and be able aid in an emergency. On 4/07/2025 at 3:00 PM, V12 (Nurse Practitioner/NP) said R1 required total assistance with mobility and transfers. V12 said R1 required the use of the mechanical lift for transfers and expected the staff to be trained on how to safely use the lifting equipment to ensure safe transfers. V12 also said the facility was expected to maintain operable lifting equipment based on policy or manufacturing guidelines to ensure residents were provided with safe equipment. R1's Care Plan Activity Report with a review date of 1/03/2025, showed R1 was at risk for falls and required staff assistance with transfers. R1's transfer focus problem had multiple interventions, including Assist with safe transfers as recommended: [Mechanical] lift and 2-person assist, Provide equipment for transfers: [Mechanical] lift, and Utilize mechanical lifts as appropriate. R1's progress note dated 3/31/2025 shows At about 1140, the writer was notified that the resident had a witnessed fall during transfer with a [Mechanical] life from bed to wheelchair .Resident complained of pain 7/10 on his legs, back, and elbows .911 was called and they arrived and took him out to [Hospital] ER. R1's Accident Investigation Form dated 3/31/2025, shows R1's fall occurred because the sling broke. The form said the sling should have been inspected before being used to transfer R1 on 3/31/2025. R1's Fall Incident Final Report dated 4/04/2025 shows During the [Mechanical] lift transfer, resident suddenly fell to the ground on his buttocks .The CNA who navigated the resident stated that the fall happened so quickly that she didn't have time to reach to reduce the impact .Upon further investigations, both bottom loops of the sling were fray apart. R1's hospital notes dated 3/31/2025 shows R1 was brought from nursing facility for evaluation of a fall. Reportedly the [Mechanical] lift broke and he was dropped on the ground. Patient reports pain in his neck, back, hip, and legs. Pain is constant, worse with movement. Images showed closed right acetabular fracture; Fracture of left ischium, Pubic bone fracture, Fracture of the transverse process of lumbar vertebra. The facility's policy titled Hydraulic Lift dated 08/2024, shows Purpose To enable two staff to lift and move a resident safely, with little effort as possible. The policy does not provide instructions on equipment checks before use, including slings. The facility's policy titled Resident Supervision Policy dated 07/2024, shows To ensure the facility provides an environment that is free from accident and hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accident. The facility's provided [Mechanical] lift manufacture's document titled Manual/Electric Portable Patient Lift undated, said Transferring to a Wheelchair . [Company] recommends that two assistants be used for all lifting preparations, transferring from and transferring to procedures .Maintenance .SLINGS AND HARDWARE CHECK ALL SLING ATTACHMENTS each time it is used to ensure proper connection and patient safety. Inspect sling material for wear. Inspect strap for wear.

Based on interview and record review, the facility failed to follow manufacturer's maintenance recommendations for the safe use of a mechanical lift-sling transferring device. This applies to 1 of 3 (R1) residents reviewed for transfer equipment. Findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including generalized edema, chronic pain, impaired mobility, and generalized weakness. R1's MDS (Minimum Data Sheets) dated 3/19/2025 shows R1 was dependent on staff for transfers and required the use of a mechanical lift. On 4/07/2025 at 11:25 AM, V6 (Certified Nurse Assistant/CNA) said on 3/31/2025 she and V4 (CNA) transferred R1 from the bed to his wheelchair. V6 said she secured R1's sling to the mechanical lift. V6 said she then started to maneuver and turn the machine when the sling's lower left strap suddenly ripped and R1 fell on the floor. V6 said R1's sling was worn out from overuse because it had not been replaced since R1's admission. On 4/07/2025 at 9:45 AM, V4 (CNA) said she was asked to assist V6 with R1's mechanical lift transfer on 3/31/2025. V4 said R1 fell as V6 started to turn the machine because the sling's lower left strap ripped. V4 said they were unable to respond quickly to reduce R1's fall impact from the mechanical lift. V4 said R1's sling was old and worn out from overuse. V4 said R1's sling had not been replaced for years. On 4/07/2025 at 2:00 PM, V2 (Director of Nursing/DON) said she responded to R1's fall incident. V2 said she interviewed V6 and V4 after the incident and assessed R1's sling. V2 said the sling's lower left and right straps were ripped completely in half. V2 said she had concluded that R1's fall was because the sling's straps were frayed causing them to rip during R1's transfer. V2 continued to say R1's sling appeared worn out from overuse. V2 said R1's sling should have been inspected before being used and tossed because it was unsafe for use. V2 said the facility did not have a policy for maintaining lift sling equipment. V2 said she was not aware of the sling's manufacturing service life recommendations. On 4/07/2025 at 3:00 PM, V12 (Nurse Practitioner/NP) said R1 required the use of the mechanical lift for transfers. V12 said the facility was expected to maintain operable lifting equipment based on policy or manufacturing guidelines to ensure residents were provided with safe equipment. R1's Care Plan Activity Report with a review date of 1/03/2025, showed R1 was at risk for falls and required staff assistance with transfers. R1's transfer focus problem had multiple interventions, including Assist with safe transfers as recommended: [Mechanical] lift and 2-person assist, Provide equipment for transfers: [Mechanical] lift, and Utilize mechanical lifts as appropriate. R1's Accident Investigation Form dated 3/31/2025, shows R1's fall occurred because the sling broke. The form said the sling should have been inspected before being used to transfer R1 on 3/31/2025. R1's Fall Incident Final Report dated 4/04/2025 shows During the [Mechanical] lift transfer, resident suddenly fell to the ground on his buttocks .The CNA who navigated the resident stated that the fall happened so quickly that she didn't have time to reach to reduce the impact .Upon further investigations, both bottom loops of the sling were fray apart. The facility's policy titled Resident Supervision Policy dated 07/2024, shows To ensure the facility provides an environment that is free from accident and hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accident. The [Mechanical] lift's manufacturer's document titled Patient Slings undated, said SPECIAL NOTES .Service Life The expected service life is thirteen (13) months for this product, provided the product is used in accordance with the intended use as set out in this document .General Guidelines After each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately.

Based on interview and record review the facility failed to schedule a follow up doctor appointment for 1 of 3 residents (R1) reviewed for quality of care in the sample of 10. The findings include: R1's Face Sheet showed a diagnosis of stress fracture of the left radius. On 3/27/25 at 9:50 AM, V6 (R1's Mother) said R1 broke her arm, and the facility did not schedule R1's follow up appointment. On 3/27/25 at 9:30 AM, V4 (Transportation Scheduler) said she schedules residents follow up appointments. V4 said R1's last orthopedic appointment was on 2/25/25 and R1 was taken by the facility's ADAPT (Psychosocial Rehabilitation) staff. V4 said R1 did not have a follow up orthopedic appointment scheduled. On 3/27/25 at 10:50 AM, V8 (Program Director for ADAPT) said an ADAPT staff took R1 to the orthopedic appointment on 2/25/25. V8 said the after visit summary paperwork indicated R1 was to have a follow up appointment scheduled on the week of March 17th. V8 said the after visit summary was given to V3 (Registered Nurse). On 3/27/25 at 10:55 AM, V3 said R1 was to have a follow up orthopedic appointment around March 17th. V3 said he was not sure if the appointment was scheduled and the after visit summary was given to V4. On 3/27/25 at 11:05 AM, V4 said she just received R1's after visit summary paper work from the 2/25/25 office visit and is now aware R1 needed a follow up appointment scheduled. V4 said she was unsure why R1's appointment was not scheduled. R1's orthopedic After Visit Summary dated 2/25/25 showed, Please make an appointment in 3 weeks for a follow up. The week of March 17th. R1's Progress Note dated 2/25/25 entered by V3 showed R1 returned from an orthopedic appointment, and R1 was to return to the orthopedic office around March 17th.

Based on interview and record review the facility failed to maintain an accurate and complete medical record after discharge for 1 of 3 residents (R2) reviewed for medical records in the sample of 10. The findings include: R2's face sheet printed on 3/27/25 show R2 was admitted to the facility last 5/2/24 with diagnoses of depression and cellulitis. (discharged [DATE]) A document of Authorization for Disclosure of Protected Health Information (PHI) dated 2/27/25 requesting R2's entire medical record dated May 2, 2024 (date of admit) to [DATE] (date of discharge) On 3/27/25 at 1:44 PM, R2 said she discharged last December. She had requested her medical records from the facility last month (February). R2 said she got some records but it was not complete. R2 said she was told they have no more access to her records due to a new system R2 said she was wanting a copy of her complete medical records including her doctor's notes and list of medications to review. One of the things she was wanting to review was her antibiotics prescribed to her to treat her cellulitis. R2 said she was at the facility again this week still following up her records that she had requested last February. On 3/27/25 at 10:30 AM, V12 (Medical record staff) said R2 had requested a copy of her medical records. But we cannot provide her complete records since I do not have any access to PCC. (previous electronic health record system-EHR). V12 said she gave R2 a copy of what was in R2's paper chart that included old records. Another request from R2 of Authorization for Disclosure of PHI dated 3/26/25 requesting NP notes and Psychiatric Notes. On 3/27/25 at 9:15 AM V5 (Social Worker) said R2 was at the facility this week still looking and requesting for more medical records. She was specific with psych notes and NP notes. V5 said there were some psych notes that were emailed to her from the Doctor's office so she gave R2 copies of those records. On On 3/27/25 at 10:30 AM, V2 (Director of Nursing) said the facility used to have PCC. Then when we have new owners and they have changed the (EHR) system to Sigma Care. If we have to refer to old records for information we cannot do that since we have no access like physician order sheets, progress notes, MAR, MDS and careplans of discharged residents. On 3/27/25 at 1PM, V1 (Administrator) said he knew that residents records should be kept years after they are discharged . V1 said the new owner is coordinating with the old owners to gain access to PCC.

Based on interview and record review the facility failed to protect a resident's rights to be free from sexual and physical abuse by another resident in accordance with facility policy. This applies to 2 of 5 residents (R2 and R5) reviewed for abuse in the sample of 8. This failure resulted in psychological harm to R2 and R5. Both R2 and R5 expressed being scared of their peer who was the perpetrator of the abuse. The findings include: 1). R2's EMR (Electronic Medical Record) showed R2 was [AGE] years old, admitted to the facility on [DATE], with diagnoses of schizoaffective disorder, bipolar type, and tachycardia. On January 3, 2024, at 4:06 PM, R2 stated on December 9, 2024, a female peer R1, came to his room uninvited and would not leave when asked. R1 was a [AGE] year-old female. R2 stated while he was escorting R1 out of his room, while they were both walking toward the door, R1 turned and grabbed R2's genitals through his clothing. R2 stated he pushed R1's hand away. R2 stated he felt scared because after R1 left his room, R1 remained in the hallway outside R2's room and kept staring at him. R2 stated he did not know what R1 would try to do next. R2 stated on previous days, R1 had been following him in the facility and came to his room uninvited at different times, while he was brushing his teeth or laying in his bed at different days and times. R2 stated he felt uncomfortable and felt weirded out because R1 was an old lady and R2 was trying to nicely ask R1 to leave him alone. R2 stated he went to report to V8 (Activity Director) after R1 had touched him inappropriately on December 9, 2024. R2 stated when he saw R1 in the common day room on December 12, 2024, R2 wanted the police to be called to ensure R1 would not follow him and try to grab him again. R2 stated he was scared R1 would try and grab him again. On January 2, 2025, at 4:06 PM, V4 (Police Detective) stated the police officer came to the facility on [DATE], at the request of R2. V4 stated R1 admitted to grabbing R2. V4 stated R2 declined to press criminal charges against R1. 2). R5 EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, psychotic disorder with delusions, type 2 diabetes, chronic obstructive pulmonary disease, foot drop, right foot, essential hypertension, hyperlipidemia, and dry eye syndrome of unspecified lacrimal gland. R5's MDS (Minimum Data Set) dated October 21,2024 showed R5 was cognitively intact. On December 31, 2024, at 4:35 PM, R5 stated she was scared of a male peer, R3. R5 stated about a week ago, while R5 was sitting in the day room, she was startled awake by R3 who had slapped her in the face for no reason. R5 stated she told staff the next day she wanted to be discharged from the facility to get away from R3. R5 stated she told staff she was scared to live in a place that had residents hit people for no reason. R3's medical record showed a progress note written by V2 (Director of Nursing) dated December 17, 2024, that showed R3 had raised a hand towards a female peer, and the female peer had a red mark on her cheek. V2 identified the female peer as R5. R5 stated R3 had slapped her while she was resting on the couch in the day room. R5's medical record showed a progress note written by V6 (Social Services Director) on December 18, 2024, that showed R5 was requesting discharge from the facility. There was no assessment in R5's medical record of R5's reddened cheek or any injury after December 17, 2024, and no assessment of reason R5 was requesting a discharge from the facility. The facility's policy titled Illinois Abuse Prevention Policy showed .The facility is committed to protecting our residents from abuse .by anyone including but not limited to facility staff, other residents .Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means .the term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review the facility failed to report one incident of resident-to-resident physical abuse to local law enforcement in accordance with facility policy. This applies to 1 of 5 residents (R4) reviewed for abuse in the sample of 8. The findings include: R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, bipolar disorder, chronic obstructive pulmonary disease, generalized anxiety disorder, impulsiveness, Tourette's disorder, type 2 diabetes, and neuralgia and neuritis. R4's MDS dated [DATE], showed R4 was cognitively intact. On December 31, 2024, during the entrance conference all resident-to-resident incident investigations for the past three months was requested. V1 (Administrator) provided one incident investigation dated December 13, 2024. involving R1 and R2. V1 stated there was an incident involving R3 and R4 being in a physical altercation last week but he did not have an investigation report and did not report the incident to local law enforcement. On January 2, 2025, at 2:25 PM, V7 (Restorative Aide) stated on December 24, 2024, around 6:30 AM, V7 heard loud noises coming from the TV lounge and went to the area and found R3 and R4 in a physical altercation. On January 2, 2025, at 11:25 AM, R4 stated when he was in the TV lounge playing his hand-held video game, R3 approached him and hit R4 in the face and walked away. R4 stated that R3 did not say anything prior to or at the time R3 hit R4. R4 stated he got up and followed R3 and asked R3 why did you just hit me? R4 stated R3 turned around and lunged at R4 and R4 stated they then hit each other. R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, chronic obstructive pulmonary disease, bipolar disorder, gastro esophageal reflux disease, unspecified osteoarthritis, diabetes mellitus with unspecified complications, and hypertension. R3's MDS (Minimum Data Set) dated December 9, 2024, showed R3 was cognitively intact. R3's and R4's medical records did not contain any documentation of resident assessment of physical or mental condition in response to the incident on December 24, 2024. V1 did not provide an investigation report or copy of the police report when requested regarding the incident on December 24, 2024, involving R3 and R4. The facility's policy titled Illinois Abuse Prevention Policy dated October 24, 2022, showed VIII External Reporting .Informing local law enforcement the facility shall also contact local law enforcement authorities in the following situations: physical abuse involving physical injury inflicted on a resident by another resident .when there is reasonable suspicion of a crime .if there is reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury then a report to local law enforcement as soon as possible but within 24 hours of when the suspicion was formed.

Based on interview and record review the facility failed to report two incidents of resident-to-resident physical abuse to the State Agency in accordance with facility policy. This applies to 2 of 5 (R4, and R5) residents reviewed for abuse in the sample of 8. The findings include: R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, chronic obstructive pulmonary disease, bipolar disorder, gastro esophageal reflux disease, unspecified osteoarthritis, diabetes mellitus with unspecified complications, and hypertension. R3's MDS (Minimum Data Set) dated December 9, 2024, showed R3 was cognitively intact. R5's EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, psychotic disorder with delusions, type 2 diabetes, chronic obstructive pulmonary disease, foot drop, right foot, essential hypertension, hyperlipidemia, and dry eye syndrome of unspecified lacrimal gland. R5's MDS dated [DATE] showed R5 was cognitively intact. R3's progress note written by V2 (Director of Nursing) showed R3 had a raised hand over R5 and R5 had a reddened cheek, while they were both in the dayroom on December 17, 2024. The incident was witnessed by V11 (CNA). On December 31, 2024, at 2:50 PM a request for the incident report and the assessment following the incident between R3 and R5 was requested from V2. V2 stated there was no incident report and no assessment of R5 following the incident. On December 31, 2024, at 4:45 PM, R5 stated she was resting on the couch in the lounge with her eyes closed when R3 slapped her in the face for an unknown reason. R5 stated she was scared of R3 and wanted to discharge from the facility as a result. On December 31, 2024, at 3:34 PM, V1 (Administrator) stated he does not have an incident report of the altercation between R3 and R5 on December 17, 2024, and stated he did not report the incident to the State Agency. R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, bipolar disorder, chronic obstructive pulmonary disease, generalized anxiety disorder, impulsiveness, Tourette's disorder, type 2 diabetes, and neuralgia and neuritis. R4's MDS dated [DATE], showed R4 was cognitively intact. On January 2, 2025, at 11:25 AM, R4 stated when he was in the TV lounge playing his hand-held video game, R3 approached him and hit R4 in the face and walked away. R4 stated that R3 did not say anything prior to or at the time R3 hit R4. R4 stated he got up and followed R3 and asked R3 why did you just hit me? R4 stated R3 turned around and lunged at R4 and R4 stated they then hit each other. On January 2, 2025, at 2:25 PM, V7 (Restorative Aide) stated on December 24, 2024, around 6:30 AM, V7 heard loud noises coming from the TV lounge and went to the area and found R3 and R4 in a physical altercation. V7 stated they separated in response to V7's verbal redirection. V7 stated she instructed R3 to go to his room and R3 did. V10 (LPN) documented on December 24, 2024, at 7:10 AM that R3 was transferred to the hospital. There was no assessment in the progress notes of either R3's or R4's physical condition or mood in response to the incident on December 24, 2024. On December 31, 2024, at the entrance conference all resident-to-resident altercations incident reports were requested from V1 (Administrator) for the past three months. V1 provided one incident involving R1 and R2 dated December 13, 2024. V1 stated there had been an incident of a physical fight last week between R3 and R4, but he did not report the incident to the state agency or the local police. V1 stated he probably should have reported the incident between R3 and R4 because it was abuse. The facility's policy titled Illinois Abuse Prevention Policy, dated October 24, 2022 showed V . report to the state survey agency any allegation of abuse, neglect .and to local law enforcement or other state agency if they have a suspicion that a crime has been committed .reports will be documented and a record kept of the documentation .any allegation of abuse or any incident that results in serious bodily injury will be reported immediately .or within 24 hours .VIII External Reporting 1. Initial reporting of Allegations. When an allegation of abuse exploitation, neglect, mistreatment .has been made the administrator or designee shall notify the department of Public Health's Regional Office immediately by telephone or fax.

Based on interview and record review the facility failed to investigate two incidents of resident-to-resident physical abuse in accordance with facility policy. This applies to 3 of 5 residents (R3, R4, and R5) reviewed for abuse in the sample of 8. The findings include: On December 31, 2024, during the entrance conference all resident-to-resident incident investigations for the past three months was requested. V1 (Administrator) provided one incident investigation dated December 13, 2024. involving R1 and R2. V1 stated there was an incident involving R3 and R4 being in a physical altercation last week but did not have an investigation report. On December 31, 2024, at 2:50 PM, V2 (Director of Nursing) identified a physical altercation between R3 and R5 that occurred on December 17, 2024, but stated there was no incident report. V1 stated there were no incident investigation reports for December 24, 2024, involving R3 and R4 and no incident investigation report for the incident on December 17, 2024, involving R3 and R5. R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, chronic obstructive pulmonary disease, bipolar disorder, gastro esophageal reflux disease, unspecified osteoarthritis, diabetes mellitus with unspecified complications, and hypertension. R3's MDS (Minimum Data Set) dated December 9, 2024, showed R3 was cognitively intact. R5's EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, psychotic disorder with delusions, type 2 diabetes, chronic obstructive pulmonary disease, foot drop, right foot, essential hypertension, hyperlipidemia, and dry eye syndrome of unspecified lacrimal gland. R5's MDS dated [DATE] showed R5 was cognitively intact. On December 31, 2024, at 4:45 PM, R5 stated she was resting on the couch in the lounge with her eyes closed when R3 slapped her in the face for an unknown reason. R3's progress note written by V2 (Director of Nursing) showed R3 had a raised hand over R5 and R5 had a reddened cheek, while they were both in the dayroom on December 17, 2024. R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, bipolar disorder, chronic obstructive pulmonary disease, generalized anxiety disorder, impulsiveness, Tourette's disorder, type 2 diabetes, and neuralgia and neuritis. R4's MDS dated [DATE], showed R4 was cognitively intact. On January 2, 2025, at 11:25 AM, R4 stated when he was in the TV lounge playing his hand-held video game, R3 approached him and hit R4 in the face and walked away. R4 stated that R3 did not say anything prior to or at the time R3 hit R4. R4 stated he got up and followed R3 and asked R3 why did you just hit me? R4 stated R3 turned around and lunged at R4 and R4 stated they then hit each other. On January 2, 2025, at 2:25 PM, V7 (Restorative Aide) stated on December 24, 2024, around 6:30 AM, V7 heard loud noises coming from the TV lounge and went to the area and found R3 and R4 in a physical altercation. V7 stated they separated in response to V7's verbal redirection. V7 stated she instructed R3 to go to his room and R3 did. R3's progress note dated December 24, 2024, at 7:10 AM showed R3 was transferred to the hospital after the altercation with R4. The facility's policy titled Illinois Abuse Prevention Policy dated October 24, 2022, showed .VII .2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation .VIII 2. Five-day final investigation report within 5 working days the report of the occurrence, a complete written report of the conclusion of the investigation including steps the facility has taken in response to the allegation will be sent to the Department of Public Health. The final investigation report shall contain the following: Name age, diagnosis .original allegation .summary of the facts .conclusion of the facts .police report .

Based on observation, interview, and record review, the facility failed to follow the administration guidelines while administering eye drops. The facility also failed to obtain an uncontaminated blood sample for blood glucose monitoring. This applies to 2 of 9 residents (R24 and R46) reviewed for medication pass observation. The Findings Include: 1 R46 is a [AGE] year-old female admitted on [DATE]. A record review on R46's physician order sheet (POS) document Refresh eye drops, one drops each eye three times a day. On 11/13/24 at 01:22 PM, R46 was observed in her room sitting on her chair, and V4 (Licensed Practical Nurse/LPN) administered eye drops to R46's right eye while sitting on the chair. V4 pulled R46's right corner of the right upper eyelid and administered eye drops (Refresh) to the right eyeball. The eye drops fell on the eyeball and dripped onto her cheeks. On 11/14/24 at 9:23 AM, V2 (DON-Director of Nursing) stated the eye drop should have been instilled into the lower eyelid by pulling it down. The facility presented the Eye Drop Administration procedure dated 11/2020, documented: With a gloved finger, gently pull-down lower eyelids to form a pouch while instructing the resident to look up. Place the other hand against the resident's forehead to steady. Hold the inverted medication bottle between the thumb and index finger and press gently to instill the prescribed number of drops into the pouch near the outer corner of the eye. If the resident blinks or drops lands on the cheek, repeat administration. 2. R24 is a [AGE] year-old female admitted with an admitting diagnosis, including type 2 diabetes. On 11/13/24 at 10:44 AM, observed V5(LPN) checking R24's blood glucose level after cleansing the right middle finger. V5 discarded the first drop using an alcohol wipe and didn't wait for air to dry the wetness from the alcohol wipe to collect the blood specimen. The blood glucose check resulted in a reading of 160. On 11/13/24 at 11:10 AM, V5 stated that she should have used gauze to wipe off the first drop of blood. She continued that using an alcohol wipe to discard the first drop can alter the blood glucose reading. On 11/13/24 at 11:00 AM, V2 added that the nurse shouldn't use an alcohol wipe to discard the first drop of blood, as it can alter the blood glucose reading.

Based on observation, interview, and record review, the facility failed to securely store medications by having them at the bedside and failed to discard expired medications from the medication cart. The facility also failed to label and date insulin vials after initial use. This applied to 3 of 3 residents (R1, R16, and R50) reviewed for medication storage and label/date in a sample of 19. The Findings Include: 1 R1 is a [AGE] year-old male admitted with an admitting diagnosis, including type 2 diabetes. On 11/13/24 at 11:04 AM, V6 (Licensed Practical Nurse/LPN) was unable to locate the insulin (Novolin R) vial to administer the scheduled 10 units of insulin to R1. V6 opened a new insulin vial to administer 10 units of insulin to R1's left shoulder and put the vial back into the medication cart without labeling the vial with an open date. On 11/13/24 at 1:20 PM, observed V6's medication cart with V2 (Director of Nursing) and the Novolin R insulin vial was observed without having an open date. On 11/13/24 at 1:25 PM, V6 stated that she should label the insulin vial with an open date. On 11/14/24 at 09:23 AM, V2 (Director of Nurse/DON) stated that the insulin vial should have an open date. A review of the facility-presented policy on vials and ampules of injectable medications revised on the November 2020 document: Expiration Date: Unopened vials expire on the manufacture's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on multidose vials on the vial label or an accessory label affixed for that purpose. At a minimum the date opened must be recorded. 2 On 11/14/24 at 11:23 AM, during medication cart (middle cart) check with V8 (Registered Nurse), observed Brimonidine and Timolol eye drops for R16 with an open date 10/13/24. On 11/14/24 at 11:25 AM, V8 stated that those eye drops were expired and that she would remove them from the medication cart. According to our policy, ophthalmic products are good for only 28 days once they are opened. A review of the facility presented Medication Storage Guidance document: Date when opened and discard unused portion after 28 days or in accordance with the manufacturer's recommendations or facility policy. On 11/14/24 at 11:45 AM, V2 stated that nurses are supposed to check expired medications in the medication cart and should have discarded the expired medications. 46409 3. On November 12, 2024 at 10:43 AM, there was a yellow, ovular pill in a medication cup sitting on R13's (R50's roommates') bookshelf. R50 was not in his room and R13 was sleeping in his bed. On November 12, 2024 at 12:48 PM, the yellow, ovular pill was sitting on the bookshelf. On November 13, 2024 at 11:52 AM, the yellow, ovular pill was sitting on the bookshelf. R50 was sleeping in his room, and R13 said it was his bookshelf but not his medicine. R13 said the medicine belonged to his roommate and had been there since yesterday. R50's face sheet showed he was admitted to the facility with diagnoses including hypothyroidism, bipolar disorder, depressive disorder, and anxiety disorder. R50's MDS (Minimum Data Set) dated September 9, 2024, showed R50 was cognitively intact. R50's EMR (Electronic Medical Record) did not show an assessment to store medications at the bedside, and his POS (Physician Order Sheet) also did not show an order for resident to keep medications at the bedside. On November 14, 2024 at 9:25 AM, V7 (RN/Registered Nurse) said none of the residents were allowed to keep medications at the bedside. V7 said if she went to pass medications and the resident was not in his room, she would take it back to the cart. V7 said she needed to be present when the resident took the medications. V7 said if a resident asked to keep medications at the bedside, she would tell them they have to take the medications with a nurse present and would not be allowed to keep it at bedside. On November 14, 2024 at 9:28 AM, V5 (LPN/Licensed Practical Nurse) said she only had one resident who was allowed to keep medicine at the bedside. V5 said if she went to pass medications and the resident was not in his room, she would take the medicine back as they were not allowed to leave it in their room. V5 said the nurses have to watch the residents take their medications. On November 13, 2024 at 1:13 PM, V2 (DON/Director of Nursing) said the nurses have to observe the residents to make sure they are taking their medications. V2 said if the resident was sleeping, if the resident had orders to leave medications at bedside, then only would the nurse be allowed to keep it at the bedside. V2 said if there weren't any orders, they would not be allowed to keep it at bedside. V2 also said the nurses should not leave medications at bedside if the resident was not in his room. V2 said if the medications were left at bedside, other residents can come and take the medications as the facility was a psychiatric facility. V2 said none of the residents were allowed to store medications at the bedside. The facility's Storage of Medications Policy dated November 2020 shows Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interview and record review, the facility failed to provide influenza and pneumonia vaccines to residents residing in the facility. This applies to 3 of 5 residents (R1, R59, R70) reviewed for immunizations in a sample of 19. The findings include: On November 14, 2024 at 9:34 AM, V2 (DON/Director of Nursing/Infection Preventionist) said they had a vaccine day prior to her starting as the DON of the facility and was unable to speak to why all the residents did not have their vaccines. V2 said she was not sure if the residents came to the previous DON and requested vaccines instead of the facility offering the vaccines to all the residents. 1. R1's immunization record was reviewed. On November 14, 2024 at 11:09 AM, V2 presented a consent form for the influenza vaccine, which showed R1 consented to receiving the influenza vaccine on November 13, 2024 (during the survey). V2 also presented a consent form to receive the pneumococcal vaccine, dated November 13, 2024 (during the survey). R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pneumonia, chronic respiratory failure, type 2 diabetes mellitus, pneumonia, hypertension, and asthma. 2. R59's immunization records were reviewed. On November 14, 2024 at 11:07 AM, V2 presented consent forms for the influenza vaccine and pneumococcal vaccine. R59's consent forms dated November 13, 2024 (during the survey) showed she agreed to receiving both vaccines. R59's face sheet showed she was admitted to the facility on [DATE] with diagnoses including hydrocephalus, type 2 diabetes mellitus, weakness, mood disorder, blastomycosis, hypertension, and osteoarthritis. 3. R70's immunization records were reviewed. On November 14, 2024 at 11:10 AM, V2 presented consent forms for the influenza vaccine and the pneumococcal vaccine. R70's consent forms dated November 13, 2024 (during the survey) showed she agreed to receiving the vaccines. R70's face sheet showed she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, type 2 diabetes mellitus, hypertension, hypothyroidism, and major depressive disorder. The facility's undated Immunization policy showed In order to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumococcal pneumonia, it is the policy of this facility to offer influenza and pneumococcal vaccinations to all residents.

Based on observation, interview and record review, the facility failed to initiate CPR (Cardiopulmonary Resuscitation) for a resident (R1) with full code status (attempt CPR). The facility also failed to have a system in place to ensure that Advance Directives are completed timely and available to direct care staff. These failures resulted in R1 not receiving CPR and expiring at the facility. These failures have the potential to affect all residents residing in the facility. The [DATE], Facility Data Sheet showed 96 residents reside at the facility. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE], when R1 was found not breathing and no CPR was initiated. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE], at 9:50 AM. Findings include: 1. R1's Admission Record dated [DATE] documents R1 as an [AGE] year-old with diagnoses that include bipolar disorder, dementia, and schizoaffective disorder. On [DATE], R1's paper chart included a green Practitioner Order for Life-Sustaining Treatment (POLST) form dated [DATE], and signed by V14 (R1's Physician and facility Medical Director). The POLST included R1's signature and in Box A, the option for Attempt Resuscitation/CPR (Selecting CPR means Full Treatment .) was checked. R1's Clinical Physician Order Report dated [DATE] shows an order dated [DATE] for R1 to be a full code (attempt CPR) but this order was discontinued on [DATE]. R1's Order Recap Report ,d+[DATE]-[DATE] does not show a current order for R1's code status. R1's Electronic Medical Record (EMR) shows a Progress Note dated [DATE] documenting V14 (Medical Director) provided an order for a hospice evaluation due to R1's refusal to eat and failure to thrive. R1's Hospice Telephone Verbal Order form dated [DATE] shows R1 was admitted to hospice with a primary diagnosis of dementia on this date. There is no indication of a code status on this document. R1's EMR Progress Note completed by V5 (Nurse) on [DATE] from 8:21 PM showed CNA (Certified Nursing Assistant) has reported to the writer about or around maybe later 5:20 PM that the resident has passed away .No vital and no pulse. On [DATE] at 12:10 PM V5 (Nurse) stated she was assigned as R1's nurse on [DATE] between 7 AM- 7 PM. V5 stated she was instructed at the beginning of her shift that R1 was on hospice and had a Do Not Resuscitate (DNR [do not attempt CPR]) order. V5 stated on [DATE], R1 was acting as usual, stayed in bed and ate minimally. V5 stated she works many places as an agency nurse and is not sure what the process is at the facility to verify advanced directives. V5 stated around 4 PM, a nurse from hospice (V9) came into the facility and she and V9 went into R1's room together. V5 stated V9 informed her that R1 was beginning to transition. V5 stated around 5 PM, R1 was unchanged, and then sometime between 5:,d+[DATE]pm, a Nursing Assistant (V6) reported to her R1 was no longer breathing. V5 stated she assessed R1 and after taking vitals and confirming R1 was not breathing, she went to find R1's chart and notified V2 (Director of Nursing) that R1 had passed. V5 confirmed she did not notify V2 that she was unable to verify R1's code status and she did not initiate CPR. V5 stated when she entered the room, V1 (Administrator) was present and instructed her to call hospice to clarify her advanced directives, which she did. V5 stated after speaking with V8 (Hospice Nurse), he told V5 he would call her back. V5 stated, I left [R1] with the workers in the back. I was in charge of the patient but [V1] was in charge of me. I waited in the nurse's station as I was instructed to do. I was in the nurse's station until I got a call back. I then had another resident with an issue, so I handled that .I thought [V2 (Director of Nursing)] was with [R1] .Nobody is administering CPR and we are calling hospice, so I assumed she was a DNR. Later, I was told there was a DNR in process but it was not complete. Then I called the paramedics, 911, and assumed the people in the back initiated CPR. I did notify the people in the back that she was a full code. We all came back to the room; paramedics were back there then and were working on her when I got back to the room. V5 confirmed that at the time she discovered R1 had no vital signs, she was still unsure of R1's advanced directives because she was unable to find the chart where the POLST form is supposed to be located. On [DATE] at 7:47 AM, V4 (Nurse) stated he overheard a Nursing Assistant report to V5 that R1 doesn't look good. V5 requested V4's assistance with obtaining a blood pressure cuff and pulse oximeter which V4 stated he provided to V5, then went to attend to another resident. V4 stated at some point after this interaction he took a call from an unknown hospice nurse who reported to V4 that he was in the process of changing R1's full code status to a DNR. V4 stated this unknown hospice nurse was frustrated as to why the POLST form had not been completed. V4 could not indicate when he became aware that R1 had passed and was a full code. V4 stated he did not perform CPR at any time during this incident. On [DATE] at 12:47 PM, V3 (Nurse) stated that around 7 PM on [DATE], she saw V5 in the hallway and she asked for help, stating it is an emergency. V3 stated she ran down the hallway and asked what was going on, and V5 responded, Apparently we were supposed to start CPR two hours ago, and that V5 was instructed to call 911. V3 stated CPR was not started until the paramedics arrived. On [DATE] at 2:36 PM, V6 (Nursing Assistant) stated he found R1 non-responsive between 5:,d+[DATE]:20 PM and notified V5. V6 confirmed he did not perform CPR, stating V5 did not give him instructions to perform CPR. V5 stated he was instructed to perform postmortem care for R1, which he did, and completed care with the assistance of V7 (Nursing Assistant). V6 stated about an hour later, the paramedics arrived. The Reporting Officer statement from the [DATE], local Police Department's preliminary Case Report Summary showed .On [DATE] at 18:57 [6:57 PM] .responded .for deceased patient at [facility address]. Due to some uncertainty, dispatch clarified that this was not an in-progress emergency, rather the patient, [R1] .had been deceased for some time. This document shows the timeline obtained by the officers during interviews conducted with the witnesses on [DATE] as follows: R1 was discovered deceased between 5:,d+[DATE]:20 PM by V6 (Nursing Assistant), who then alerted V5 (Nurse). V5 stated to the officer she then spent the time between discovering R1 was deceased up to the time 911 was contacted at 6:57 PM attempting to locate R1's DNR paperwork, contacting hospice, and the state guardian. V2's (Director of Nursing) interview identified her at the facility at approximately 6 PM to pay her respects then she left. V4 (Nurse) stated he became aware of the situation between ,d+[DATE]:30 PM after notification by V5, who had indicated she was in the process of contacting hospice. V8 (Hospice Nurse) reported to the officer that he spoke with V5 at approximately 6:25 PM and advised V5 to call 911 because no DNR was in place. V3's (Nurse) statement to the officer identified she was notified of R1's status at approximately 7 PM. This report shows a hospital physician provided a time of death to the paramedics as 7:20 PM. On [DATE], at 12:05 PM, V2 (Director of Nursing) stated V5 (Nurse) is an Agency nurse, and she works at the facility a lot. V2 stated V5 notified her that R1 had expired. V2 stated she asked her if hospice had been notified and she said yes. V2 stated CPR was not done. V2 stated that once a resident is admitted to hospice services, hospice takes over. V2 stated the facility still provides standard care. V2 stated if hospice says a resident is a full code, the resident is a full code, adding R1 was a full code in our chart. V2 stated R1 expired, and CPR was not performed, adding If a full code, CPR should have been done. V2 re-iterated if there is no DNR, you initiate CPR. On [DATE] at 9:45 AM, V10 (R1's State Guardian) confirmed she was aware of R1's decline and as of [DATE] had been communicating with hospice regarding advanced directives. V10 stated that on [DATE] at 2:05 AM, she received an email from V8 (Hospice Nurse) regarding R1's change in status and concerns that R1's advanced directives at that time showed R1 as a full code. V10 stated she then spoke with the hospice company again on [DATE] at 9:17 AM and reviewed the required process as a State Guardian to consider changing R1's code status. V10 stated the process includes an initial form with supporting documentation signed by two doctors. V10 stated once this information is received, a POLST form can be signed by her as a resident's guardian. V10 stated, I cannot change a resident's status without knowing their wishes. On [DATE] 6:57 PM, V22 (Deputy Coroner) stated an autopsy was planned but it was later decided not to after reviewing R1's comorbidities and speaking with V10 (R1's Guardian) and finding out a DNR was in process but apparently not valid yet because the physician information and signature were not completed. V22 stated, My concern is nobody started CPR. That is basic nursing. Without a valid DNR order she should have been provided emergency interventions and CPR. I am not sure what they were thinking. I understand there was some confusion but without a valid DNR, she is a full code. In section 2.1 Admission to Hospice Program under Article II: Services to be Provided by Hospice in the facility's Nursing Facility Hospice Services Agreement, it showed (c) Hospice shall notify Nursing Facility whether a resident is authorized for admission as a Patient and shall be responsible for obtaining all necessary admission forms, consents, and election statements from the Resident or, where applicable, the Resident's representative. The Article does not refer to hospice being responsible for obtaining a POLST form. R1's hospice Informed Consents/Election of Benefits Form was stamped and signed by R1's State Guardian and hospice company on [DATE], and it does not mention the completion of a POLST form. R1's Circuit Court Letters of Office Guardianship of a Disabled Person dated [DATE] documents R1 as a disabled person totally without capacity per physician and therefore ordered a plenary guardian of person. 2. On [DATE] at 2:13 PM V1 (Administrator) stated advanced directives are initiated at admission. If a resident does not have a POLST in place upon admission, we implement the process and obtain one. POLST forms are obtained by a joint effort between nursing and social services. All residents should have a POLST form in their paper chart and a physician order indicating their code status in the Electronic Medical Record (EMR). A review of R5-R17, and R19's paper charts on [DATE], did not find a completed POLST form in their chart. The Admission Record shows R17 admitted to the facility on [DATE]. R17's Order Summary Report dated [DATE] did not include an order indicating code status. The Admission Record shows R10 admitted to the facility on [DATE]. R10's Order Summary Report dated [DATE] found an order dated [DATE] for a full code. The Admission Record shows R16 admitted to the facility on [DATE]. R16's Order Summary Report dated [DATE] found an order dated [DATE] for a full code. The Admission Record shows R5 admitted to the facility on [DATE]. R5's Order Summary Report dated [DATE] found an order dated [DATE] for a full code. The Admission Record shows R9 admitted to the facility on [DATE]. R9's Order Summary Report dated [DATE] found an order dated [DATE] for a full code. The Admission Record shows R11 admitted to the facility on [DATE]. R11's Order Summary Report dated [DATE] found an order dated [DATE] for a full code. On [DATE] at 12:15 PM, V20 (Social Services) stated the last Social Service Director that was here would review the POLST forms. V20 stated, We have had a lot of 'hiccups' since transferring to PCC (Electronic Medical Records System) and I do not have access to fix it .We are running into hiccups when we compare the (paper) charts with PCC. It has been an ongoing issue, including the face sheet (Admission Record) not always being accurate . V20 stated V1 has requested access for Social Services approximately ,d+[DATE].5 months prior in order to correct issues identified with inconsistent information in PCC, and access has not been granted as of this date. On [DATE] at 1:20 PM, V21 (Social Service Director) stated she began employment at the facility [DATE]. When asked what her role is in the initiation of advanced directives, V21 responded with, I would think that I should be involved in advanced directives and code status initiation and changes. On [DATE] at 11:35 AM, V2 (Director of Nursing) stated the facility process for the completion of POLST forms is that V14 (Medical Director) comes in every Thursday, so if a POLST form needs to be signed, we let him know when he comes in. V2 stated Social Services will try to get POLST forms done as soon as possible and in an acceptable amount of time. V2 further stated that if it is an emergency, the facility will fax the POLST form to V14, but if not an emergency, it can be held until Thursdays. V2 stated that in early May, an audit of POLST forms was done and updated. On [DATE] at 1:05 PM, V1 (Administrator) stated that she was aware a recent audit was done by V2 and V25 (Assistant Director of Nursing) in May. V1 stated that physician orders are entered into the EMR by Nursing and Social Service does not have access to make changes. V2 confirmed inconsistent information related to advanced directives has been an ongoing issue at the facility since PCC was initiated last June. V1 stated she has asked the facility corporate office to give additional access to some staff and she has also requested the ability to scan documents into PCC. The Advanced Directive Policy dated [DATE] documents the following: The Patient Self Determination Act states that individuals have the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state and federal legislation relating to advance directives. Procedure: 1. At the time of admission each resident, POA (Power of Attorney), guardian or responsible party shall be given written information regarding resident rights and advance directive. At this time, each resident /responsible party will be requested to furnish this facility with copies of all existing advance directives. 2. The day of admission to this facility, the Social Service Designee, Administrator or designee at admission shall meet with the resident/responsible party to review existing advance directives. 3. After confirming the accuracy of provided documents with the resident/responsible party, the document will be sent for appropriate signatures. No order for No Code or DNR shall be effective until the Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form is signed by resident/responsible party and physician order is received and documented. 4. Any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Advance directives specifying full code/Attempt Resuscitation/CPR, or the absence of determination shall be recorded as a Full Code. Those residents indicating Do Not Attempt Resuscitation/DNR shall be recorded as a DNR. Code status shall also be recorded on the resident's Physician Order Sheet. 6. In cases where a legal guardian has been appointed by the court, and the resident is without decisional making capabilities or a qualifying condition, the guardian must seek court authorization for consent for a DNR. Until this consent is obtained, the resident shall be considered without advance directives. 8. Any advance directive will be reviewed quarterly with the interdisciplinary team and the resident/responsible party. Advance directives may be reviewed more frequently as condition warrants. 9. Implementation of a code is as follows: i) Direct and Non-Direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. ii) The nurse shall be summoned to respond, and upon review of chart documents determine code status. iii) The nurse shall evaluate the code status and notify appropriate staff for task assignment. If CPR is indicated only certified personnel shall administer CPR. iv) Activation of the Emergency Medical System shall be initiated, or the ambulance service notified. The physician shall also be notified to inform him/her of the resident condition. v) Upon completion of notifications and necessary paperwork, the nurse shall relieve those performing CPR. The appropriate certified staff will continue until the emergency medical team arrives and takes over. vi) The emergency medical team trained in advanced life support shall then assume charge of the situation. The nurse shall follow the direction on the emergency medical team, until transport of the resident out of the facility. 10. Once CPR is initiated in this facility, the staff trained in CPR shall continue until: i) The resident is revived. ii) The emergency medical team has arrived and assumed care iii) The physician gives an order to stop CPR The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: A. All staff were in-serviced on Advance Directive policy, Emergency Management policy, Change in Condition policy, and the location of binders made available at the nurses' station to direct care staff with all POLST/codes status for each resident. B. All agency were in-serviced on the Advance directive policy, Changes in Condition policy and the location of code status in binder. C. All staff were in-serviced on the process of how to get information of residents advance directives and code status. D. An audit of all residents POLST forms was conducted. For the residents with no current POLST the Social Service Director initiated the process for up to date POLST. E. Binders made available at the nurses' station to all staff with all POLST/codes status for each resident. Social Service will monitor and maintain the binders. F. A QA meeting was conducted [DATE] and the medical director was in agreeance with plan of correction. G. All agency staff will be in-serviced by the DON/Designee on code status/POLST/Change on condition upon hire. H. All facility staff will be in-serviced on code status/POLST/Change in condition by the DON/Designee upon hire, quarterly, and annually. I. Social Service Director/DON/Designee will review new resident's code status once weekly for 4 weeks to ensure POLST form is completed. J. Social Service Director/DON/Designee will review all code status/POLST forms once monthly for 3 months to ensure compliance. K. Social Service Director/Designee will review PCC code status and POLST binder once daily for 3 months, once weekly for 3 months and then quarterly thereafter. Results will be submitted and reviewed during QAPI meetings. L. Social Service Director/DON/Designee will review all residents changing to hospice to ensure code status/POLST in place once weekly for 3 months and then quarterly thereafter. M. Social service/Designee to audit both binders once weekly for 3 months and then quarterly thereafter.

Based on record review and interview, the facility failed to ensure staff used the wheelchair's footrests during transportation. This failure resulted in R4 falling from the wheelchair to the floor sustaining a forehead laceration and transfer to the emergency department. This Applies to 1 of 3 residents (R4) reviewed for falls and accidents in a sample of 10. A care plan revised on 04/24/2024 showed that R4 has risk factors that require monitoring and intervention to reduce the potential for self-injury. The updated care plan on 06/19/2024 instructed staff to instruct and help R4 use footrests when he is in his wheelchair. The MDS (Minimum Data Set), dated 05/27/2024, showed that R4 was cognitively severely impaired and dependent and required substantial assistance for ADLs, requiring two or more staff members to complete activities such as transfers, dressing, personal hygiene, bathing and ambulation or walking required moderate to partial assistance, and activity was not attempted. A review of R4's face sheet showed R4 was an [AGE] year-old admitted to the facility initially on 11/25/2023 with diagnoses including cerebral infarction, vascular dementia with behavioral problem psychosis, depression, and cardiac diseases. On 06/25/2024 at 11:30 AM, R4 was in a specialized chair and awake and minimally interviewable. R4 said while V11(Certified Nursing Assistant) was wheeling him in a wheelchair, he stepped his feet on the floor. Nursing progress notes and post-fall assessment dated [DATE] at different times showed R1 was confused due to dementia, R4 had forehead laceration, new onset of pain observed, complained of headache with a pain level of 6/10, and was sent to the hospital, and returned to the facility same day with two inches of stitches on the left side of the forehead and black and bluish discolorations under residents' eyes. On 06/26/2024 at 11:49 AM, V11 (Certified Nursing Assistant) said he was wheeling R4 in his wheelchair to his room from the dining hall after breakfast, and R4 braked his wheelchair by putting his feet on the floor and fell out of the wheelchair and onto the floor. V11 said all residents should have footrest while wheeling, and he did not attach the footrest to the wheelchair at the time of R4's transfer to his room. V11 said from now on, he will ensure residents will have footrests while transferring and further said, That is a big lesson for me. On 06/25/2024 at 12:00 PM, V2 (Director of Nursing) said staff should ensure residents' feet are rested on the footrest during any transport in a wheelchair.

Based on observation, interview, and record review, the facility failed to ensure a resident with a history of falls was provided hourly rounding as ordered by the physician and failed to implement new, individualized fall risk interventions for residents who experienced falls, to prevent further falls. This failure resulted in R1 experiencing an unwitnessed fall at the facility and sustaining a subdural hematoma and R2 falling and sustaining a laceration requiring closure with sutures. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for resident injury in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on March 6, 2024 at 6:50 AM due to abdominal distention and did not return to the facility. R1 had multiple diagnoses including, bipolar type schizoaffective disorder, COPD (Chronic Obstructive Pulmonary Disease), insomnia, dementia, mixed anxiety disorders, asthma, overactive bladder, and other disorders of the brain. R1's MDS (Minimum Data Set) dated February 8, 2024 shows R1 was rarely/never understood and had moderate cognitive impairment for daily decision making. R1 required supervision with eating and locomotion of 50 feet with a manual wheelchair. R1 required partial/moderate assistance with oral hygiene and locomotion of 150 feet with a manual wheelchair. R1 was dependent on facility staff for toilet and personal hygiene, bathing, bed mobility, dressing, and transfers between surfaces. R1 was frequently incontinent of bowel and bladder. On March 8, 2024 at 1:00 PM, V4 (LPN-Licensed Practical Nurse) documented R1 had an unwitnessed fall on March 6, 2024 at 00:00 (12:00 AM). The facility's initial report to IDPH (Illinois Department of Public Health) dated March 12, 2024 shows R1 sustained a fall on approximately March 6, 2024 at approximately 12:00 AM. The initial report continues to show: Facility was notified that [R1] was admitted for abdominal distension and acute cystitis. The hospital notified the facility days later that test results showed [R1] had a subdural hematoma. Investigation initiated, final report to follow in five days. On March 6, 2024 at 7:37 AM, V10 (Hospital Physician) documented: [R1] is cooperative, she has bruising to her right eye, bruising to her face, bruising to the anterior chest . On March 6, 2024 at 3:10 PM, V9 (Hospital Physician) documented: [R1] has unintelligible speech. Was noted to have multiple bruises on the right side of her body which includes forehead, eyes, shoulder, forearm, axillary region . R1's CT scan of the head, performed on March 7, 2024 at 10:55 AM shows: Findings indicating holohemispheric acute subdural hematoma formation along the right cerebral hemisphere measuring up to 10 mm (millimeters) in diameter. There is localized mass effect with 3 mm of leftward midline shift. There are also subdural blood products layering along the right temporalis as well as with the right parafalcine regions posteriorly On March 12, 2024 at 11:56 AM, V2 (DON-Director of Nursing) said, R1 had a caregiver/sitter in her room from 11:00 AM to 7:00 PM. She was constantly trying to get up and was not able to walk. Her lower extremities were weak, and she still believed that she could walk. She tried to get up multiple times from the bed and the chair. She needs someone with her one on one. She needs someone with her most of the time. If she is sleeping, she is fine. We got word from the hospital that [R1] had a subdural hematoma. I set up the investigation right away. My conclusion was that she had an unwitnessed fall here that resulted in a subdural hematoma. On March 13, 2024 at 11:16 AM, V8 (NP-Nurse Practitioner) said, [R1] had two falls in February. She has fallen in the past and has had multiple falls and has been sent to the emergency room for falling. She is very impulsive. She has no safety awareness. I was told she had bruising on her eye, and I ordered an X-ray and neuro checks around the clock. They never told me she had a fall. She is always found on the floor crawling. [V2] (DON) did notify me that [R1] had a subdural hematoma after she got to the hospital. A subdural hematoma is caused by hitting your head. Obviously this was something unwitnessed. She just came to us from a skilled nursing facility and already had two falls. R1's fall care plan initiated on February 3, 2024 shows R1 had an actual fall related to medication side effects, weakness, debility, poor safety awareness and impulsivity. Interventions dated February 3, 2024 include, CNA to provide frequent rounding (checks) on resident throughout the AM, PM, and night shift for safety. An intervention initiated February 13, 2024 shows: Resident receives oral anticoagulant or NSAID (Non-Steroidal Anti-Inflammatory Drug), evaluate for bleeding/bruising post-fall. The facility does not have documentation to show frequent rounding or checks were being done for R1. The EMR shows the following physician order for R1 dated February 2, 2024 and discontinued on March 7, 2024 due to R1's hospitalization : Start date: 2/2/2024 0400 (4:00 AM) Resident on frequent rounding. Every hour for safety precaution r/l (related) to fall risk. Frequency: Every hour. Schedule type: Every day. The facility does not have documentation to show hourly rounding was being done as ordered by the physician. On March 13, 2024 at 2:55 AM, the EMR was reviewed with V3 (ADON-Assistant Director of Nursing). V3 acknowledged there is an order in R1's medical record to do hourly rounding due to frequent falls that was initiated on February 2, 2024. V3 (ADON) said, the order was entered incorrectly and was not visible to the nursing staff. The nurse who received the order entered it incorrectly. Because of the way she entered the order, the nursing staff would not have been able to see the order and were not aware they should have been rounding on [R1] and documenting they did so. 2. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including pressure ulcer of the left heel, Wernicke's encephalopathy, seizures, weakness, psychotic disorder, other disorders of the brain, alcohol dependence with alcohol-induced anxiety, muscle weakness, and nicotine dependence. R2's MDS dated [DATE] shows R2 has significant cognitive impairment, uses a wheelchair for locomotion, is able to eat with setup help, requires substantial/maximal assistance with oral hygiene, bed mobility, and transfers between surfaces, and is dependent on facility staff for toilet hygiene, showering/bathing, dressing, and personal hygiene. R2 is frequently incontinent of urine, and occasionally incontinent of stool. On March 13, 2024 at 10:44 AM, R2 was sitting up in his wheelchair in the hallway of the facility. R2 was wearing shoes on both feet that were untied and loose on his feet, with his heels out of both shoes and resting on the top of the back of his shoes. R2 had a visible scar on the right side of this upper forehead. R2 touched the scar when asked about it and said he fell and hit his head. The facility's initial report to IDPH dated March 4, 2024 shows R2 was observed on the floor in his room, lying on his right side. Licensed nurse assessed for injuries and a laceration was noted to the head. R2 was sent to the hospital for evaluation and treatment. Hospital records dated March 4, 2024 at 4:04 PM show R2 was seen in the emergency room of the local hospital for a laceration to the forehead. R2 received sutures and hospital discharge instructions show the sutures were to be removed after seven days. On March 13, 2024 at 11:16 AM, V8 (NP) said R2 received sutures on his forehead after he fell at the facility. [R2] is impulsive and has to be redirected due to his behavior and for poor safety awareness. The fall caused the laceration, and he needed stitches. Facility documentation also shows R2 sustained a fall on February 13, 2024 at 7:20 PM after R2 was found on the floor next to his bed, and on March 4, 2024 at 12:20 PM when R2 had an unwitnessed fall and was found next to his bed. R2's care plans show a fall care plan initiated August 9, 2023. No new fall interventions have been added to R2's care plan since December 26, 2023. On March 13, 2024 at 1:17 PM, V2 (DON) acknowledged R2's care plan does not show any new interventions to prevent falls and said, Our interventions include sending out a package for skilled nursing facility placement and requesting he be put on hospice, but his brother is not ready for that. V2 was unable to answer how those interventions would protect R2 from falling or sustaining injury related to falling if R2's family was unwilling to place him on hospice or if skilled nursing facility placement was not imminent. 3. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including Huntington's disease, difficulty walking, weakness, mild cognitive impairment, dementia, and bipolar disorder with psychotic features. R3's MDS dated [DATE] shows R3 has severe cognitive impairment, is able to eat independently, is able to roll left to right in bed independently but is dependent on facility staff for all other bed mobility and toilet hygiene, showering/bathing, dressing, personal hygiene, and transfers between surfaces. R3 is always incontinent of bowel and bladder. On March 13, 2024 at 10:46 AM, R3 was sitting in a wheelchair in a TV room outside of V2's (DON) and V3's (ADON) office. V2 and V3 were not present in their office. Seven other residents were present in the TV room with R3. No facility staff were present. R3's locked wheelchair was pushed up against a table. The table was pushed up against a wall. R3 had continuous jerky, involuntary movements. R3 was continuously observed fidgeting in her wheelchair. No facility staff came to the room to observe R3. At 11:04 AM, R3 was forcefully pushing her locked wheelchair away from the table with her hands. R3 was placing her feet on the floor and attempting to stand using her hands and arms and the support of the wheelchair to stand. R3 used a motion of throwing her body weight backwards into her wheelchair. The action of doing this made it possible for R3 to move her wheelchair approximately four feet away from the table. R3 was able to lean forward without any staff present and without staff intervention. R4 was sitting in the same room as R3. R4 started yelling at R3 to sit down! No staff were present to discourage R3's behavior of attempting to stand and pushing her wheelchair away from the table. On February 17, 2024 at 6:40 PM, V12 (RN) documented a fall incident for R3: Just prior to/at the time of the event [R3] appears to have been up on her wheelchair, watching TV in the TV room. Witness to the event includes: another resident. [R3] was trying to pick her shoes on the floor when resident suddenly slid out of the wheelchair. R3 did not sustain an injury. On January 20, 2024 at 8:25 AM, V12 (RN) documented a fall incident for R3: Just prior to/at the time of the event, [R3] appears to have just finished eating her breakfast. Witness to the event includes CNAs. At around 8:25 AM [R3] stood up and tripped over the footrest. The EMR does not show R3 has a care plan specific to falls. R3's care plan entitled Resident has risk factors that require monitoring and intervention to reduce potential for self-injury was initiated on July 31, 2023. As of March 12, 2024, R3's care plan interventions had not been updated following her two most recent falls with new interventions to prevent falls. The facility's policy entitled Fall Prevention, revised 11/10/18 shows: Policy: To provide for resident safety and to minimize injuries related to falls; decreases falls and still honor each resident's wishes/desires for maximum independence and mobility.5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on interview and record review, the facility failed to supervise a newly admitted male resident (R4) with known hyper-sexual behaviors resulting in R4 entering 5 female residents' rooms (R1, R2, R3, R5, R6), sexually abusing (R1), and getting into bed with R2 and touching her shoulder. This applies to 5 of 5 residents (R1, R2, R3, R5, R6) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 31, 2023 at 11:45 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on November 1, 2023, but non- compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, cerebral palsy and mild cognitive impairment of uncertain or unknown etiology. R1's MDS (Minimum Data Set) dated August 8, 2023 shows R1 is cognitively intact, requires supervision with dressing, locomotion off the unit, and eating, limited assistance with bathing and personal hygiene, and is independent with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. On October 26, 2023 at 9:34 AM, R1 was sitting in her room. R1 said, We got a new resident (R4) and he tried to kiss me the other night (October 13, 2023). He tried to kiss me, and I said I don't know you! I cannot kiss someone I don't know! I was so scared. I am so afraid he is going to come back in my room. He tried to touch me all over. He put his hand up my shirt and touched my breasts. I hollered for help, and he ran out of the room. It was on Friday (October 13, 2023) around 2:00 AM. I couldn't sleep for a while because I was scared. No one came in my room to help me. The next morning, I told [V5] (Activity Director) around 10:00 AM. She asked me what was wrong with me because I wasn't smiling. I told her I almost got raped last night. On October 26, 2023 at 9:29 AM, R5 was lying in her bed, in the room she shares with R1. R5 said, [R4] came into our room two times during that night (October 13, 2023). Around 2:00 AM, he got near to [R1's] bed and was asking her for a kiss. I heard everything. The second time he came in I told him she's asleep get out of our room, and he left the room. The EMR shows R5 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, mild cognitive impairment, autistic disorder, and diabetes. R5's MDS dated [DATE] shows R5 is cognitively intact. On October 26, 2023 at 10:35 AM, R3 was sitting in her bed in the room she shares with R6. R3 said, [R4] came in our room twice that night. I asked what he was doing. He left and someone came and said he shouldn't be in our room. He tried to go over and see my roommate (R6), but she was sleeping. On October 26, 2023 at 10:43 AM, R2 said, There was a tall black man in my room. He was new to our building and just came that day. I was sound asleep and woke up to [R4] fondling my shoulder. I swatted at him, and I told him to leave, and he left. I did not tell anyone until the next day. The facility's final report to the state agency dated October 19, 2023 shows: Summary: On October 13, 2023 approximately around 2:30 AM, [R4] went into [R2's] room and got into her bed and startled her. [R4] later went into [R1's] room and sat on her bed waking her up as well. The nurse on duty was informed about [R4] going into their rooms and he told him to go back to his room when he was observed by the doorway. [R1] reported to staff on the next shift that when [R4] was in her room he woke her up and touched her. [R1] was assessed for injuries none were noted. Investigation: When interview by the police and Administrator; [R2] stated she was more startled when she realized someone was in her bed. She stated that [R4] did not say anything to her and he just left her room. She told her nurse that [R4] was in her room and she was fine. The nurse on duty (V9) (RN-Registered Nurse) stated that when [R2] told him what occurred he went to look for the resident that [R2] described to him. Later on, [V9] (RN) saw [R4] in the doorway of another resident he told [R4] to return to his room. [R1] stated that when [R4] came into her room and woke her up he asked her if he could kiss her, and she said no. [R4] then asked her to look at his phone and then reached over and touched her. [R1] asked him to stop and leave the room. [R1's] roommate, [R5] was also interviewed and said she heard what [R4] said to [R1] and when [R1] asked [R4] to leave the room; [R5] also asked [R4] to leave the room. [R5] said she went back to sleep after this occurred and forgot to tell anyone about what she witnessed. [R4] did admit that he got into [R2's] bed because he thought she was someone else. [R4] also stated that he did go to [R1's] room after leaving [R2's] room. [R4] admitted waking [R1] up asking her for a kiss and touching her. [R4] stated that [R1] said it was okay for him to touch her. [V9] (RN) was also interviewed and stated that [R1] did not inform him of the event with [R4]. Conclusion: It was determined that [R4] did go into [R2's] bedroom and got into bed with her. And it was also determined that [R4] also went to [R1's] room and got into bed with her and touched her. [R1] was assessed and there were no injuries she also confirmed that she was not in any pain or hurt. [R4] was monitored one on one after the investigation was initiated until he left the facility. The police returned to the facility after the event was filed and removed [R4] from the facility and took him to the local police department. [R2] and [R1's] care plans have been reviewed. Staff will continue to monitor both [R1] and [R2] for any concerns they may have. [R1] and [R2] both reported that they feel comfortable in the facility. On October 26, 2023 at 11:04 AM, V1 (Administrator) said, I found out about the incidents with [R4] around 10:30 AM on October 13, 2023. Around 10:30 AM, we put [R4] on one-to-one monitoring, and the police were notified around 11:15 AM, and took the resident into custody around 4:00 PM. [R1] said he sat on her bed and touched her. [R2] said he got into bed with her. [R3] said she talked to [R4] the night before, that he went in her room, but nothing sexual happened. We were told he could walk around, and he would ask girls if he could kiss them. Not all of the staff were made aware of his kissing tendencies. The EMR shows R4 was admitted to the facility on [DATE]. The EMR continues to show R4 was discharged on [DATE] with local police department. V8's (NP-Nurse Practitioner) documentation created October 14, 2023 shows R4 had multiple diagnoses including schizophrenia and asthma. R4's MDS was not completed at the time of this investigation. The facility does not have documentation to show they had an interim care plan or any other type of care plan in place addressing R4's hyper-sexual behaviors, this was confirmed by V1 (Administrator) on October 31, 2023 at 9:14 AM. [Psychiatric Hospital) documentation dated September 23, 2023 at 2:24 PM shows: [R4] is a [AGE] year-old male admitted to [Psychiatric Hospital] voluntarily. Chief complaint from intake: I was high on weed oil and I was trying to talk to a girl in the room. I was trying to kiss her and touch her butt. I tried to kiss her. Patient is a [AGE] year-old male admitted to [Psychiatric Hospital] voluntarily for acute psychosis. Patient reportedly had walked into another resident's room in his nursing home with intent to physically assault them. Patient has been hypersexual, inappropriately touching nursing home staff, and sexually aggressive towards emergency medical services staff. UDS (Urine Drug Screen) positive for cannabis. Patient began masturbating in front of the sitters at the emergency department and was unable to be redirected. Patient has been seen responding to internal stimuli. He has disorganized and tangential thought process. He has a history of schizophrenia and has been non-compliant with his medications. Nursing home reports that patient has been decompensating due to refusing to comply with treatment. Patient presents with auditory and visual hallucinations, paranoia, disorganization, and flight of ideas. Patient states that he has been very paranoid lately. Patient has cognitive delay. Patient's mother is POA (Power of Attorney) and guardian. Patient demonstrates poor insight into illness, poor judgment, and poor impulse control. Patient is on SAO (Sexually Acting Out) precautions. Patient requires inpatient hospitalization for safety and stabilization. On October 26 2023 at 9:47 AM, V5 (Activity Director) and V6 (Social Worker) were sitting in their office. V5 said, I came into work on Friday, October 13, 2023, and [R1] wanted to talk to me and she came back here to my office. She said the new guy (R4) came in and touched on her, feeling on her breasts, and I reported it to [V1] (Administrator). He was a new admission, 24 to 48 hours or so. Corporate screens the individuals before they come to us. We used to be part of a team where we reviewed the paperwork and decided if the person was a good fit for our facility, but now Corporate makes those decisions and we are not given any information about the residents. We were not told about him before he came. We were not asked to put a plan in place to monitor [R4] or anything to protect the other residents. We got the information after he arrived. When we were able to look at his history and saw about his history of trying to kiss other residents and sexually grabbing staff members from other facilities, we were like woah! We never had a meeting to discuss him before he came or any precautions we should have taken. It was all a big surprise after the sexual abuse happened. V6 (Social Worker) said, We were not told about [R4's] psychiatric diagnosis or his history of trying to kiss residents, or sexually acting out at previous facilities before he came to the facility. One minute he was not at the facility, and the next minute he was. There was nothing put in place to protect the residents from [R4]. We didn't even know about it until it was too late. The decision was made by Corporate to take this resident. We would have said he was not appropriate for our facility. Once he had sexually abused a resident the night of October 13, 2023, then I heard about it from [V1] (Administrator) that morning. He ended up in our office as a one-to-one observation resident late in the morning on October 13, 2023. When we left at 3:00 or 3:30 PM, we took him up to [V1's] (Administrator) office and he had to sit with her. He was very agitated sitting with us and did not want to be watched so closely. We never had a team meeting before [R4] came to the facility to decide if he was appropriate. After he was admitted , he was in the hallway, wandering all over the place. We ourselves did not go around to interview other people to see if it happened to anyone else. If we would have known he was sexually active, we could have protected our residents. The facility's 3 Day Assignment Sheet, provided by the facility on October 26, 2023 shows. V18 (RN), V19 (LPN-Licensed Practical Nurse), V7 (Nurse), V9 (RN), and V8 (CNA-Certified Nursing Assistant) worked at the facility on October 12 and 13, 2023. On October 26, 2023 at 1:34 PM, V18 (RN) said, [V10] (Director of Psychosocial Services) told me [R4] was a wanderer. I did not know he had sexual behaviors that needed to be monitored. On October 26, 2023 at 1:37 PM, V19 (LPN) said, No one told me to keep an eye on [R4] or monitor his behaviors. He was a touchy, feely guy. On October 26, 2023 at 3:12 PM, V7 (Nurse) said, I admitted [R4] on October 12, 2023 towards the end of my shift around 2:00 PM. He had just gotten here, and I was getting ready to go home. I did not receive a report from the previous facility. I briefly looked at the paperwork from his previous facility and saw he had some sexual behaviors, so I gave the information to the next nurse and told her what I read. [V1] (Administrator) or [V2] (DON) never told me anything about the resident I was going to be taking care of. There was no plan in place to keep an eye on him. On October 26, 2023 at 9:15 AM, V8 (CNA) said, I worked from 3:30 PM to 11:30 PM on October 12, 2023. [R4] came to the facility around 2:30 PM. No one told us we had to keep an eye on him. He was walking all around the facility, during my shift, pacing and pacing. I was never told to keep an extra eye on him. I did not know anything about his background. On October 30, 2023 at 3:41 PM, V20 (CNA) said, I was not told anything about [R4's] behaviors or to keep an eye on him when he came to the facility. I worked from 2:00 PM to 10:00 PM on October 12, 2023, the day he was admitted , and the following morning as well. On October 30, 2023 at 3:45 PM, V21 (CNA) said, I was working on the morning shift the day [R4] was admitted (October 12, 2023). He came towards the end of my shift. I was not told anything about his behaviors or to follow him around. On October 30, 2023 at 3:49 PM, V22 (CNA) said, I worked on the 2:00 PM to 10:00 PM shift on October 12, 2023. [R4] came to the facility around 2:00 PM. I was not assigned to watch him or anything. No one told me he had sexual behaviors. On October 30, 2023 at 4:05 PM, V24 (CNA) said, I was working at the facility on Thursday, October 12, 2023. [R4] was admitted that day. We had a COVID outbreak that day and I was helping to move residents around to different rooms. I was never told about [R4] having sexual behaviors or that I had to observe him and report any concerns. On October 26, 2023 at 2:15 PM, V9 (RN) said, After midnight, I came out from the nurse's station, and I see this guy (R4) outside the door of [R1]. His room was across the hall from hers, and I said what are you doing there, because the door was cracked open, and it is usually always closed. He moved away from the door, and I said go back to your room. I closed [R1's] door. I did not check on [R1] or [R5]. [R4] was a new admit, and I did not know him or anything about him. I told the other nurse working with me that night that the new resident was wandering around. After a while, [R1] and [R5] tried to use the toilet and they asked me to watch them because there is a guy that is looking at them. I did not know that night that he touched the resident's breasts. I told [V1] (Administrator) the next morning that maybe she could move the guy because he kept looking into the female resident's rooms. He kept wandering around. About an hour after that, another lady, [R2] woke up and said a man came in her room and scared her. She said I just woke up and he was there. I said okay, I'll tell [V1] (Administrator) in the morning about this. I saw him go in [R3's] room too. I said you should stay in your own room, and he said she's my friend. I said you should not go around, and he said if you keep on following me, I need privacy too. I am not sure about his mental capacity. He was admitted on the other side of the building, and I did not get report on him. Nobody told me about him having a history of sexual abuse. Administration did not give me any warning. On October 26, 2023 at 12:35 PM, V10 (Director of Psychosocial Rehab) said, We did not want to take this guy (R4), we could not meet his needs. [V11] (Regional Marketing Director) and [V12] (Corporate Hospital Liaison) said they were at [psychiatric hospital]. He [V11] put in an email and said we needed to do this as a favor. I tried to explain to him we could not take this guy. I emailed the owner of the company. [R4's] referral was awful, and he was not stable. [V11] (Regional Marketing Director) overrode us and said we had to take him. I am very upset with them. They keep sending us people and we are next to a grade school. We asked for a denial and [V11] said it was a favor. They told [V1] (Administrator) that she cannot deny his referral. An email thread provided by V1 (Administrator) on October 26, 2023 shows: On October 5, 2023 at 8:16 AM, V12 (Hospital Liaison) sent an email to V1 (Administrator), V2 (DON), and V11 (Regional Marketing Director), as well as others. The email shows: [R4] is slow to respond and has a cognitive deficit. He was aware why he was at the [Psychiatric Hospital]. I did not have the referral yet and the C/M (Case Manager) did share some info with b/4 (before) I did the bedside. He stated he went into a girl's room and tried to kiss her. I asked him if she wanted to be kissed. He said that she didn't like it too much . He is African American, and he states to me that he wants to go in facility where there is a majority of white people. He stated that male staff do not respect him and would prefer white female CNAs and white female nurses. Diagnoses, 160 pounds, bipolar disorder severe w/psychosis, schizophrenia. On October 5, 2023 at 10:39 AM, V1 (Administrator) responded to V11 (Regional Marketing Director), V12 (Hospital Liaison), and V2 (DON), I'm concerned about this referral and his request for a staff of a different gender and race. Most of my CNAs are African American, Latino, African, and Filipino, same thing with my nurses. I don't want him trying to kiss some of our residents that cannot tell him no. On October 5, 2023 at 2:43 PM, V11 (Regional Marketing Director) responded to V1, V2, and V12, Is patient ambulatory? To which V12 (Hospital Liaison) responded at 2:48 PM, Yes. On October 5,2 023 at 3:00 PM, V11 (Regional Marketing Director) replied to V12 (Hospital Liaison), V1 (Administrator), and V2 (DON), Proceed with admission. Spoke with [V1] via phone at 1459 (2:59 PM). On October 26, 2023 at 3:11 PM, V1 (Administrator) said, I told corporate I did not think he was appropriate for our facility. They told me I had to take him and that was that. On October 30, 2023 at 10:53 AM, V1 (Administrator) said they did not do any advance planning for R4's admission to the facility to ensure residents would be kept safe. In this instance, Corporate told me we had to take the resident, but did not give us any tools or ideas on how we should take care of him. On October 30, 2023 at 11:11 AM, V17 (Psychiatrist) said, The way you protect other residents from a resident with [R4's] history is don't admit a guy like that! I would not have admitted him in the first place because of his history. I saw him on October 13, 2023 via telehealth, and I was aware he already crawled into bed with some female residents. I could not even talk to him about it. He would not engage in an interview. This facility is not set up to take care of psychiatric patients like [R4]. I have been told by [V10] (Director of Social Services) that the facility does not have programming in place. Each time a patient like [R4] has a psychotic exacerbation, it changes their brain chemistry, and they are less likely to respond to their medications. He is a very sick man. The decision to accept him at the facility was made higher up in the corporate ladder. I know the staff at the facility did not want him. I was never asked for suggestions or involved in any advance planning on how to handle him once he got there so other residents were protected from his behaviors. The Immediate Jeopardy began on October 12, 2023. The facility presented a removal plan to remove the immediacy on October 31, 2023 at 4:01 PM. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan to remove the immediacy on November 1, 2023 at 9:49 AM. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan to remove the immediacy on November 1, 2023 at 12:27 PM, and the survey team accepted the removal plan on November 1, 2023 at 12:34 PM. The Immediate Jeopardy was removed on November 1, 2023 when the facility took the following actions to remove the immediacy. On October 31, 2023, the following was initiated: 1. The Administrator, Director of Nursing, Social Services, Regional Clinical Director, and Hospital Liaison will establish a plan for notifying staff of new resident's behaviors which will impact other residents right to privacy, safety, and freedom from abuse. Resident Bio form to be used for new resident admissions. 2. The Administrator, Director of Nursing, Social Services, Regional Clinical Director and Hospital Liaison will have an individualized plan for any new resident requiring individual centered interventions to ensure the residents are appropriately supervised upon admission. 3. Direct care staff will be in-serviced prior to and upon admission of a new resident and given a plan to ensure that staff are aware of resident's behaviors which would impact other residents' right to privacy, safety, and freedom from abuse. Information will be provided in the Agency staffing binder. Completion date: November 2, 2023. The following systemic measures have been implemented to ensure all alleged deficient practices do not recur: A) The facility will notify staff of any needed plans in place for residents who are high risk for interventions. Facility will have resident centered interventions put in place to supervise and prevent residents from being abused. Residents will be monitored for behaviors and reported immediately to Administrator/Director of Nursing. B) Facility will inform direct care staff of new residents' history before and upon admission with Resident Bio For Quality Assurance (QA) Measures: Administrator/Director of Nursing/Designee will monitor compliance through the QA process as new residents are admitted on e time a week for 3 months. Administrator/Director of Nursing/Designee will contact additional assistance from the physician, and [Corporate] Management as needed. The Quality Assurance team including the Regional Clinical Manager will monitor compliance through the quarterly Quality Assurance meetings by reviewing the audit tool.

Based on interview and record review, the facility failed to ensure a female resident was protected from a male resident with a known history of hyper-sexual behaviors resulting in the sexual abuse of 1 female resident (R1). This applies to 1 of 5 residents (R1) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 31, 2023 at 11:45 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on November 1, 2023, but non- compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, cerebral palsy and mild cognitive impairment of uncertain or unknown etiology. R1's MDS (Minimum Data Set) dated August 8, 2023 shows R1 is cognitively intact, requires supervision with dressing, locomotion off the unit, and eating, limited assistance with bathing and personal hygiene, and is independent with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. On October 26, 2023 at 9:34 AM, R1 was sitting in her room. R1 said, We got a new resident (R4) and he tried to kiss me the other night (October 13, 2023). He tried to kiss me, and I said I don't know you! I cannot kiss someone I don't know! I was so scared. I am so afraid he is going to come back in my room. He tried to touch me all over. He put his hand up my shirt and touched my breasts. I hollered for help, and he ran out of the room. It was on Friday (October 13, 2023) around 2:00 AM. I couldn't sleep for a while because I was scared. No one came in my room to help me. The next morning, I told [V5] (Activity Director) around 10:00 AM. She asked me what was wrong with me because I wasn't smiling. I told her I almost got raped last night. During the interview with R1, R1 kept interrupting the conversation, standing up, and walking down the hallway, saying she needed to walk to the front of the building and ask the V1 (Administrator) if there was any chance R4 would return to the facility. The local police department's Case Summary Report printed October 26, 2023 at 2:41 PM shows the following documentation by V16 (Police Officer): On Friday, October 13, 2023, at approximately 1158 (11:58 AM) hours, I, [V16] (Police Officer) responded to [the facility] for a reported criminal sexual abuse incident that occurred earlier in the day - approximately 0200 hours (2:00 AM).I began interviewing [R1] who was observed to be in distress and crying. [R1] stated that a male entered her room around 0200 hrs (hours) and woke her up by sitting on her bed. She was sleeping while laying on her right side. The male said, hey, and showed her something on his phone. [R1] said she was like, what the F are you doing in my room, and the male proceeded to start touch her. [R1] indicated physically that her breasts were being touched and later described the act as rubbing. Per [R1], the male then asks for a kiss, and would she be his girlfriend, and she tells him to leave. [R1] stated that her roommate [R5] was awake as she began to call for help and instructed her to get help. As [R5] began to respond, the male ran out of the room [R1] reported being very shaken up after the incident and could not stop crying. She reported she had not eaten because she was afraid to see the male. I asked if any force was used or if she was threatened when this happened. [R1] stated that she forced his face away when the male attempted to kiss her. When asked if the two have interacted previously, [R1] stated the male followed her around 10:00 PM to the shower-room and said she looked sexy in her robe The local police department's Case Summary report continues to show V16 (Police Officer) interviewed R4. The report shows: I asked [R4] if he was doing anything this morning, early this morning, and he replied he was felt on a girl's nipples . I asked [R4] what happened after he entered [R1's] room. [R4] stated he was trying to have sex with her and was in the mood to have sex. He followed that statement by saying he does not think that is normal and that he knows better.When asked what he showed [R1] on his phone, [R4] replied that he showed her the time. [R4] stated [R1] asked for the time and he told her it was 1:53 (AM). I asked what interrupted him in the room, and he said that her roommate [R5] kept saying that [R1] was asleep, and he was trying to get to it and have sex. [R4] said he could see that she was not asleep and did not want to argue about it.I asked again if he was in any other rooms, and he stated he was. [R4] said he was, and he saw a teenage black girl, but did not want to have sex anymore and was going to be good. [V1] (Administrator) asked [R4] if he made it a habit to have sex with people he does not know. [R4] replied, that was his M.O. (Modus Operandi). On October 26, 2023 at 9:29 AM, R5 was lying in her bed, in the room she shares with R1. R5 said, [R4] came into our room two times during that night (October 13, 2023). Around 2:00 AM, he got near to [R1's] bed and was asking her for a kiss. I heard everything. The second time he came in I told him she's asleep get out of our room, and he left the room. The EMR shows R5 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, mild cognitive impairment, autistic disorder, and diabetes. R5's MDS dated [DATE] shows R5 is cognitively intact. On October 26, 2023 at 10:35 AM, R3 was sitting in her bed in the room she shares with R6. R3 said, [R4] came in our room twice that night. I asked what he was doing. He left and someone came and said he shouldn't be in our room. He tried to go over and see my roommate (R6), but she was sleeping. On October 26, 2023 at 10:43 AM, R2 said, There was a tall black man in my room. He was new to our building and just came that day. I was sound asleep and woke up to [R4] fondling my shoulder. I swatted at him, and I told him to leave, and he left. I did not tell anyone until the next day. The facility's final report to the state agency dated October 19, 2023 shows: Summary: On October 13, 2023 approximately around 2:30 AM, [R4] went into [R2's] room and got into her bed and startled her. [R4] later went into [R1's] room and sat on her bed waking her up as well. The nurse on duty was informed about [R4] going into their rooms and he told him to go back to his room when he was observed by the doorway. [R1] reported to staff on the next shift that when [R4] was in her room he woke her up and touched her. [R1] was assessed for injuries none were noted. Investigation: When interview by the police and Administrator; [R2] stated she was more startled when she realized someone was in her bed. She stated that [R4] did not say anything to her and he just left her room. She told her nurse that [R4] was in her room and she was fine. The nurse on duty (V9) (RN-Registered Nurse) stated that when [R2] told him what occurred he went to look for the resident that [R2] described to him. Later on, [V9] (RN) saw [R4] in the doorway of another resident he told [R4] to return to his room. [R1] stated that when [R4] came into her room and woke her up he asked her if he could kiss her, and she said no. [R4] then asked her to look at his phone and then reached over and touched her. [R1] asked him to stop and leave the room. [R1's] roommate, [R5] was also interviewed and said she heard what [R4] said to [R1] and when [R1] asked [R4] to leave the room; [R5] also asked [R4] to leave the room. [R5] said she went back to sleep after this occurred and forgot to tell anyone about what she witnessed. [R4] did admit that he got into [R2's] bed because he thought she was someone else. [R4] also stated that he did go to [R1's] room after leaving [R2's] room. [R4] admitted waking [R1] up asking her for a kiss and touching her. [R4] stated that [R1] said it was okay for him to touch her. [V9] (RN) was also interviewed and stated that [R1] did not inform him of the event with [R4]. Conclusion: It was determined that [R4] did go into [R2's] bedroom and got into bed with her. And it was also determined that [R4] also went to [R1's] room and got into bed with her and touched her. [R1] was assessed and there were no injuries she also confirmed that she was not in any pain or hurt. [R4] was monitored one on one after the investigation was initiated until he left the facility. The police returned to the facility after the event was filed and removed [R4] from the facility and took him to the local police department. [R2] and [R1's] care plans have been reviewed. Staff will continue to monitor both [R1] and [R2] for any concerns they may have. [R1] and [R2] both reported that they feel comfortable in the facility. On October 26, 2023 at 11:04 AM, V1 (Administrator) said, I found out about the incidents with [R4] around 10:30 AM on October 13, 2023. Around 10:30 AM, we put [R4] on one-to-one monitoring, and the police were notified around 11:15 AM, and took the resident into custody around 4:00 PM. [R1] said he sat on her bed and touched her. [R2] said he got into bed with her. [R3] said she talked to [R4] the night before, that he went in her room, but nothing sexual happened. We were told he could walk around, and he would ask girls if he could kiss them. Not all of the staff were made aware of his kissing tendencies. The EMR shows R4 was admitted to the facility on [DATE]. The EMR continues to show R4 was discharged on [DATE] with local police department. V8's (NP-Nurse Practitioner) documentation created October 14, 2023 shows R4 had multiple diagnoses including schizophrenia and asthma. R4's MDS was not completed at the time of this investigation. [Psychiatric Hospital) documentation dated September 23, 2023 at 2:24 PM shows: [R4] is a [AGE] year-old male admitted to [Psychiatric Hospital] voluntarily. Chief complaint from intake: I was high on weed oil and I was trying to talk to a girl in the room. I was trying to kiss her and touch her butt. I tried to kiss her. Patient is a [AGE] year-old male admitted to [Psychiatric Hospital] voluntarily for acute psychosis. Patient reportedly had walked into another resident's room in his nursing home with intent to physically assault them. Patient has been hypersexual, inappropriately touching nursing home staff, and sexually aggressive towards emergency medical services staff. UDS (Urine Drug Screen) positive for cannabis. Patient began masturbating in front of the sitters at the emergency department and was unable to be redirected. Patient has been seen responding to internal stimuli. He has disorganized and tangential thought process. He has a history of schizophrenia and has been non-compliant with his medications. Nursing home reports that patient has been decompensating due to refusing to comply with treatment. Patient presents with auditory and visual hallucinations, paranoia, disorganization, and flight of ideas. Patient states that he has been very paranoid lately. Patient has cognitive delay. Patient's mother is POA (Power of Attorney) and guardian. Patient demonstrates poor insight into illness, poor judgment, and poor impulse control. Patient is on SAO (Sexually Acting Out) precautions. Patient requires inpatient hospitalization for safety and stabilization. On October 26 2023 at 9:47 AM, V5 (Activity Director) and V6 (Social Worker) were sitting in their office. V5 said, I came into work on Friday, October 13, 2023, and [R1] wanted to talk to me and she came back here to my office. She said the new guy (R4) came in and touched on her, feeling on her breasts, and I reported it to [V1] (Administrator). He was a new admission, 24 to 48 hours or so. Corporate screens the individuals before they come to us. We used to be part of a team where we reviewed the paperwork and decided if the person was a good fit for our facility, but now Corporate makes those decisions and we are not given any information about the residents. We were not told about him before he came. We were not asked to put a plan in place to monitor [R4] or anything to protect the other residents. We got the information after he arrived. When we were able to look at his history and saw about his history of trying to kiss other residents and sexually grabbing staff members from other facilities, we were like woah! We never had a meeting to discuss him before he came or any precautions we should have taken. It was all a big surprise after the sexual abuse happened. V6 (Social Worker) said, We were not told about [R4's] psychiatric diagnosis or his history of trying to kiss residents, or sexually acting out at previous facilities before he came to the facility. One minute he was not at the facility, and the next minute he was. There was nothing put in place to protect the residents from [R4]. We didn't even know about it until it was too late. The decision was made by Corporate to take this resident. We would have said he was not appropriate for our facility. Once he had sexually abused a resident the night of October 13, 2023, then I heard about it from [V1] (Administrator) that morning. He ended up in our office as a one-to-one observation resident late in the morning on October 13, 2023. When we left at 3:00 or 3:30 PM, we took him up to [V1's] (Administrator) office and he had to sit with her. He was very agitated sitting with us and did not want to be watched so closely. We never had a team meeting before [R4] came to the facility to decide if he was appropriate. After he was admitted , he was in the hallway, wandering all over the place. We ourselves did not go around to interview other people to see if it happened to anyone else. If we would have known he was sexually active, we could have protected our residents. On October 26, 2023 at 3:12 PM, V7 (Nurse) said, I admitted [R4] on October 12, 2023 towards the end of my shift around 2:00 PM. He had just gotten here, and I was getting ready to go home. I did not receive a report from the previous facility. I briefly looked at the paperwork from his previous facility and saw he had some sexual behaviors, so I gave the information to the next nurse and told her what I read. [V1] (Administrator) or [V2] (DON) never told me anything about the resident I was going to be taking care of. There was no plan in place to keep an eye on him. On October 26, 2023 at 9:15 AM, V8 (CNA-Certified Nursing Assistant) said, I worked from 3:30 PM to 11:30 PM on October 12, 2023. [R4] came to the facility around 2:30 PM. No one told us we had to keep an eye on him. He was walking all around the facility, during my shift, pacing and pacing. I was never told to keep an extra eye on him. I did not know anything about his background. On October 26, 2023 at 2:15 PM, V9 (RN) said, After midnight, I came out from the nurse's station, and I see this guy (R4) outside the door of [R1]. His room was across the hall from hers, and I said what are you doing there, because the door was cracked open, and it is usually always closed. He moved away from the door, and I said go back to your room. I closed [R1's] door. I did not check on [R1] or [R5]. [R4] was a new admit, and I did not know him or anything about him. I told the other nurse working with me that night that the new resident was wandering around. After a while, [R1] and [R5] tried to use the toilet and they asked me to watch them because there is a guy that is looking at them. I did not know that night that he touched the resident's breasts. I told [V1] (Administrator) the next morning that maybe she could move the guy because he kept looking into the female resident's rooms. He kept wandering around. About an hour after that, another lady, [R2] woke up and said a man came in her room and scared her. She said I just woke up and he was there. I said okay, I'll tell [V1] (Administrator) in the morning about this. I saw him go in [R3's] room too. I said you should stay in your own room, and he said she's my friend. I said you should not go around, and he said if you keep on following me, I need privacy too. I am not sure about his mental capacity. He was admitted on the other side of the building, and I did not get report on him. Nobody told me about him having a history of sexual abuse. Administration did not give me any warning. On October 26, 2023 at 12:35 PM, V10 (Director of Psychosocial Rehab) said, We did not want to take this guy (R4), we could not meet his needs. [V11] (Regional Marketing Director) and [V12] (Corporate Hospital Liaison) said they were at [psychiatric hospital]. He put in an email and said we needed to do this as a favor. I tried to explain to him we could not take this guy. I emailed the owner of the company. [R4's] referral was awful, and he was not stable. [V11] (Regional Marketing Director) overrode us and said we had to take him. I am very upset with them. They keep sending us people and we are next to a grade school. We asked for a denial and [V11] said it was a favor. They told [V1] (Administrator) that she cannot deny his referral. An email thread provided by V1 (Administrator) on October 26, 2023 shows: On October 5, 2023 at 8:16 AM, V12 (Hospital Liaison) sent an email to V1 (Administrator), V2 (DON), and V11 (Regional Marketing Director), as well as others. The email shows: [R4] is slow to respond and has a cognitive deficit. He was aware why he was at the [Psychiatric Hospital]. I did not have the referral yet and the C/M (Case Manager) did share some info with b/4 (before) I did the bedside. He stated he went into a girl's room and tried to kiss her. I asked him if she wanted to be kissed. He said that she didn't like it too much. I talked to him about consent and that going forward if he feels he wants to kiss someone he needs to ask that person before he does it. I also told him that if he came to the facility and liked a girl there and wanted to kiss her that before he acted on it that he needed to talk to the nurse or S/W (Social Worker) at the facility and tell them that was what he wanted to do so they could help him in knowing what to do next. I asked him if that was something he could do and he said yes. Then he said that he no longer has interest in girls. He is aware that he will have a shared room. He is a smoker, so I informed him of our smoking rules - which he states is understood. He told me he did have a THC vape pen - which his mother bought for him while he was OOP (Out on Pass). He stated he tried to buy it, but since he did not have his ID he could not buy it, so he asked his mom, and she bought it for him. He receives SSI/SSD (Social Security/Disability) but is unsure how much he receives. He is aware that he will need to turn it over to the facility and would be interested in starting a resident trust fund. He is African American, and he states to me that he wants to go in facility where there is a majority of white people. He stated that male staff do not respect him and would prefer white female CNAs and white female nurses. Diagnoses, 160 pounds, bipolar disorder severe w/psychosis, schizophrenia. On October 5, 2023 at 10:39 AM, V1 (Administrator) responded to V11 (Regional Marketing Director), V12 (Hospital Liaison), and V2 (DON), I'm concerned about this referral and his request for a staff of a different gender and race. Most of my CNAs are African American, Latino, African, and Filipino, same thing with my nurses. I don't want him trying to kiss some of our residents that cannot tell him no. On October 5, 2023 at 2:43 PM, V11 (Regional Marketing Director) responded to V1, V2, and V12, Is patient ambulatory? To which V12 (Hospital Liaison) responded at 2:48 PM, Yes. On October 5, 2023 at 3:00 PM, V11 (Regional Marketing Director) replied to V12 (Hospital Liaison), V1 (Administrator), and V2 (DON), Proceed with admission. Spoke with [V1] via phone at 1459 (2:59 PM). On October 26, 2023 at 3:11 PM, V1 (Administrator) said, I told corporate I did not think he was appropriate for our facility. They told me I had to take him and that was that. On October 30, 2023 at 11:11 AM, V17 (Psychiatrist) said, The way you protect other residents from a resident with [R4's] history is don't admit a guy like that! I would not have admitted him in the first place because of his history. I saw him on October 13, 2023 via telehealth, and I was aware he already crawled into bed with some female residents. I could not even talk to him about it. He would not engage in an interview. This facility is not set up to take care of psychiatric patients like [R4]. I have been told by [V10] (Director of Psycho-Social Rehab) that the facility does not have programming in place. Each time a patient like [R4] has a psychotic exacerbation, it changes their brain chemistry, and they are less likely to respond to their medications. He is a very sick man. The decision to accept him at the facility was made higher up in the corporate ladder. I know the staff at the facility did not want him. I was never asked for suggestions or involved in any advance planning on how to handle him once he got there so other residents were protected from his behaviors. The local county Judicial Circuit Court records show R4 was charged on or about 10/13/2023 with committing the following offenses: Aggravated Criminal Sexual Abuse to Handicapped Victim, Aggravated Battery to Pregnant or Handicapped Person, Criminal Sexual Abuse Unable to Give Consent, and Battery Makes Physical Contact. The facility's policy entitled Abuse Prevention Program revised 11/28/2016 shows: Policy: 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 this 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 . The following definitions are based on federal and state laws, regulations, and interpretive guidelines.Sexual Abuse is non-consensual sexual contact of any type with a resident. The Immediate Jeopardy began on October 12, 2023. The facility presented a removal plan to remove the immediacy on October 31, 2023 at 4:01 PM. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan to remove the immediacy on November 1, 2023 at 9:49 AM. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan to remove the immediacy on November 1, 2023 at 11:57 AM, and the survey team accepted the removal plan on November 1, 2023 at 12:34 PM. The Immediate Jeopardy was removed on November 1, 2023 when the facility took the following actions to remove the immediacy. On October 31, 2023, the following was initiated: 1. The Administrator, Director of Nursing, Social Services, Regional Clinical Director, and Hospital Liaison will establish a plan for evaluating a resident's acceptability to the facility clinically. Admission Criteria checklist to be used going forward for new referrals to determine if individualized plans are needed. {Attachment} 2. R4 no longer resides at the facility. R1 placed a restraining order against R4. R1 still resides at the facility. R2, R3, and R5 still reside at the facility with no negative outcomes; facility will provide additional counseling if needed. 3. The Administrator, Director of Nursing, Social Services, and Hospital Liaison will have an individualized plan for any new resident requiring individual centered interventions to be put into place upon admission. 4. Clinical staff will be in-serviced prior and upon admission of any history information needed in order to provide care to a new admission that requires interventions. Administrator/Director of Nursing/Designee will complete education regarding the new process for clinical staff in person or via phone. Information will be provided in the Agency staffing binder. Completion date: November 2, 2023. The following systemic measures have been implemented to ensure all alleged deficient practices do not recur: A) Residents who are high risk for behaviors will have resident centered interventions put in place to prohibit and prevent residents from being abused. B) Facility will inform direct care staff of incoming residents' history upon admission. For Quality Assurance (QA) Measures: Administrator/Director of Nursing/Designee will monitor compliance through the QA process on all new residents admitted to the facility on e time a week for 3 months. Administrator/ Director of Nursing/Designee will contact additional assistance from the physician, and [Corporate] management as needed. The Quality Assurance team including the Regional Clinical Manager will monitor compliance through the quarterly Quality Assurance meetings by reviewing the audit tool {Attachment}.

Based on interview and record review, the facility failed to obtain weekly weights, failed to monitor and review for weight loss, and failed to make recommendations for nutritional support for 1 resident (R90) that resulted in a severe weight loss of 23.83% (percent) over 4 months and required an 8-day hospitalization for treatment of rhabdomyolysis and hypokalemia. The facility also failed to complete a quarterly dietary assessment for 1 resident (R33) with a history of significant weight loss. Four residents were reviewed for weight loss in the sample of 20. The Immediate Jeopardy began on 5/5/23 when R90's weight decreased by 11.4% in one month and the physician/nurse practitioner (NP) were not notified and V3 Dietitian, did not identify or address the significant weight loss until 5/22/23. V1, Administrator, was notified of the Immediate Jeopardy on 10/3/23 at 9:38 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 10/4/23 at 1:25 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. According to www.CDC.gov, Rhabdomyolysis is a serious medical condition that can be fatal or result in permanent disability [that] occurs when damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death. According to www.merckmanuals.com, A low potassium level can make muscles feel weak, cramp, twitch, or even become paralyzed, and abnormal heart rhythms may develop Potassium is needed for cells, muscles, and nerves to function correctly. On 9/27/23 at 9:05 AM, V3, Dietitian, said she goes to the facility every month and reviews the residents' weights. If a significant weight loss is identified, she starts treatment with a supplement and initiates weekly weights. V3 said she would definitely investigate a resident with significant weight loss and would follow up the next month once weight loss was identified. V3 said she would notice the weight loss when it first starts and would document each month when a resident triggers for weight loss. V3 said she looks at the weight reports every month and addresses any area of concern. On 10/3/23 at 11:57 AM, V3, Dietitian, said even if she recommends weekly weights, she still follows up at her next monthly visit. If the resident continues to lose weight with the weekly weights, the facility would need to contact the physician directly for those concerns. V3 said there was no weight recorded in June 2023 for R90. V3 said it is up to the facility to initiate her recommendations. V3 said she does not contact the physician directly and does not collaborate with the physician, she gives her recommendations to the dietary manager and the Director of Nursing, and they pass her recommendations to the physician. On 9/27/23 at 10:31 AM, V8, Nurse Practitioner (NP), said, I'm sure she (R90) went into rhabdomyolysis due to her poor intake. V8 said R90's poor intake of food and fluids likely caused her low potassium. A Physician's Order dated 5/25/23 started R90 on Remeron (an antidepressant medication) 15 milligrams (mg) at bedtime. A Physician's Order dated 6/23/23 increased R90's Remeron to 30 mg at bedtime. A Physician's Order dated 7/5/23 decreased R90's Remeron to 15 mg at bedtime. On 10/3/23 at 6:18 PM, V17, Psychiatrist, said when a resident is put on Remeron, which is an anti-depressant, the increased appetite will happen right away, within a week or two. V17 said Remeron is not really an appetite stimulant, that is just a side effect of the medication. V17 said if the Remeron did not increase R90's appetite, they need to go to the primary care provider (physician or NP) and try other medications or consult with the Dietitian for other interventions. On 10/3/23 at 12:18 PM, V9, Dietary Manager, said the Dietitian makes recommendations for residents with weight loss and relays them to her. V9 said she then gives the recommendations to the DON and the Administrator, and one of them give the recommendation to the nurse. The nurse is supposed to fax them to the doctor. V9 said once the doctor gives an order, they relay the order to her so she can implement whatever recommendations are ordered. V9 said if weekly weights are recommended, she would tell the CNAs to obtain the weights. V9 said she keeps track of residents on weekly weights on the Weekly Weight Meeting Report which she keeps in the kitchen. V9 said she will email the Dietitian about residents with weight loss. Copies of the emails between V9 and the Dietitian were requested, and none were provided. On 5/22/23 (no time) the Registered Dietitian, V3, documented R90's weight at 171 pounds which was a decrease of 11.40% (percent) in 30 days. V3 recommended weekly weights for four weeks. R90's Weekly Weight Meeting Report shows the resident weighed: 193.0 pounds on 4/5/23. 171.0 pounds on 5/5/23 (11.40% weight loss). 165.0 pounds on 5/28/23 (an additional weight loss of 3.51% in 23 days). R90's Weights and Vitals Summary dated 9/27/23 shows the next time R90 was weighed was on 7/6/23 and she weighed 147 pounds (a further weight loss of 14.04%). R90 lost 23.83% of her body weight in four months. R90's Weekly Weight Meeting Reports show her average food intake was: 100% for the weeks of 4/5/23 and 4/12/23. 75% for the weeks of 4/19/23 and 4/27/23. 25-50% for the weeks of 5/3/23 and 5/10/23. 25% for the weeks of 5/28/23, 6/1/23, and 6/8/23. No other intake records were provided for R90. R90's Physician's Orders (printed 9/27/23) show R90 had blood work ordered for 6/17/23, and an order to send R90 to the ER for evaluation due to critical labs on 6/27/23. R90's laboratory results from 6/27/23 show a critically low potassium level (hypokalemia) of (2.7 mEq/L). R90's Health Status Notes dated 6/27/23 between the hours of 2:12 PM and 8:35 PM, show nursing contacted R90's Nurse Practitioner, V8, with critical lab results, an order was received to send R90 to the emergency room (ER), and R90 was admitted to the hospital with a diagnosis of rhabdomyolysis. R90's Health Status Note dated 6/28/23 at 12:28 PM shows the nurse on duty received a call from the dietitian at the hospital regarding R90's diet and weight as she noticed a tremendous weight decline and advised the facility to give R90 meal supplements to manage the weight per dietitian orders. R90's Health Status Note dated 7/5/23 at 1:37 PM shows R90 returned from the hospital for re-admission to the facility. . R90's Physician/Practitioner note dated 7/7/23 at 9:06 AM shows R90 was seen following her hospitalization for altered mental status, hypokalemia, rhabdomyolysis, and urinary retention. R90's diet beginning 6/1/23 was a regular diet, regular texture, regular/thin consistency and no meal supplements were ordered between 5/5/23 and 9/26/23. R90's Electronic Medical Record shows no Dietitian Review or dietary notes between 5/22/23 and 7/31/23. Medical records from R90's hospitalization include a History and Physical (H&P) Exam dated 6/27/23 which shows she presented with altered mental status (AMS). Her potassium in the ER was 2.3 mEq/L, she received Intravenous (IV) potassium, an anti-anxiety medication, and two liters of IV fluids. The H&P shows R90's altered mental status was complicated by dehydration and electrolyte abnormalities. The H&P shows an Assessment and Plan included, but is not limited to, the following medical conditions: Hyponatremia (low sodium) dehydration, metabolic acidosis likely due to dehydration, hypokalemia due to low oral intake, and rhabdomyolysis with the plan to recheck lab work, give IV hydration, and to monitor her vital signs (blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation levels). R90's Discharge Instructions from her hospitalization dated 7/5/23 show R90 was sent back to the skilled nursing facility on 7/5/23. R90's Minimum Data Set (MDS) dated [DATE] shows she has moderate cognitive impairment. R90's Admission Record printed 9/26/23 for her 7/5/23 readmission to the facility shows her diagnoses include, but are not limited to, major depressive disorder, anxiety disorder, obsessive compulsive disorder, eating disorder, rhabdomyolysis, affective mood disorder, hypokalemia (low potassium), and altered mental status. R90's current care plan provided by the facility shows R90 has cognitive loss including poor decision making, impulsivity, memory loss, inattentiveness, and distractibility. R90 has impaired cognitive function/dementia or impaired thought processes and need guidance and support to make decisions. The facility's Resident Weight Monitoring Policy (Revised last on 3/19) shows it is the policy of the facility that resident weights are recorded and monitored at least monthly, if the monthly weight shows a significant change in 30 days (i.e. 5% gain or loss (+/-) the resident will be re-weighed. The dietician shall review and document all significant weight changes (i.e. +/- 5% in one month, +/- 7.5% in three months, +/- 10% in six months), along with any recommended nutritional interventions in the dietary progress notes in the medical record monthly. The same policy also shows residents readmitted to the facility will be weighed weekly for at least four weeks. The Immediate Jeopardy that began on 5/5/23 was removed on 10/4/23 when the facility: 1. Reviewed the residents' paper and electronic charts and recommended dietary supplements for R90. 2. In-serviced staff on the facility's weight policy. 3. In-serviced nursing staff on reporting all weight changes that trigger to the Registered Dietician (RD) and resident physician. 4. In-serviced the Dietary Manager on reporting all new admissions and weight changes that trigger to the Registered Dietician and recording weekly weights in the electronic medical record so it can be monitored and reviewed. 5. Implementing weekly weight meetings (attended by the dietary manager/designee, Director of Nursing (DON), Administrator, Social Service designee, MDS Coordinator, and a designee from the corporate staff) whereby residents who are on weekly weights will be weighed and discussed and any interventions/updates needed will be relayed to the physician and RD for any changes that are needed. 6. Administrator will monitor compliance via audit tool once a week for three months. 7. Administrator, DON, Regional Clinical Manager, and Dietary Manager will review the weight loss reports weekly for recommendations or changes. 8. Administrator/DON will contact additional assistance from the physician as needed. 9. The Quality Assurance (QA) team, including the Regional Clinical Manager, will monitor compliance through the quarterly QA meetings by reviewing the audit tool. 37232 2. R33's Weight Summary report showed on 4/5/23 R33 weighed 267 pounds (lbs) and on 5/5/23 weighed 251 lbs (a significant weight loss of 6.3% in one month). On 09/26/23 at 9:55 AM, there were no documented quarterly dietary assessments found in R33's electronic medical record. R33's quarterly assessments were requested from V1 (Administrator). On 09/26/23 at 11:40 AM, V1 provided dietary quarterly assessments from R33's paper chart. The last documented quarterly assessment from the paper chart was dated 1/4/23. On 09/26/23 at 12:07 PM, V1 was asked if there were more recent dietary assessments for R33. V1 deferred to V9 (Dietary Manager). On 09/26/23 at 12:12 PM, V9 said R33's dietary quarterly assessment was due in July. V9 showed in R33's electronic medical record there was a dietary quarterly assessment dated [DATE]. When the document was open it had a lock date of 09/26/23 at 10:33 AM. V9 said the quarterly assessment that was dated 7/4/23 was done on 9/26/23. R33's Dietary Admission/Quarterly Evaluation assessment dated [DATE] had a most recent weight from 9/12/23 (two months after the evaluation was dated) and a most recent height from 8/3/23 (one month after the evaluation was dated). On 09/27/23 at 09:08 AM, V3 (Dietitian) said quarterly assessments are done by the dietary manager and should be done every 3 months. The facility's Resident Weight Monitoring policy revised 3/19 showed, The Food Service Manager and interdisciplinary team review the resident's weights and nutritional status, and make recommendations for interventions.

Based on interview and record review, the facility failed to ensure licensed nurses were always present in the building to care for residents. For a period of over 12 hours, on August 14, 2022 from 10:42 AM until 11:00 PM the facility did not have licensed nursing staff in the building. On August 14, 2022, this failure resulted in 19 residents (R1, R4-R21) not receiving their physician-ordered medications due to the lack of a licensed nurse, including cardiac and blood pressure medications, diabetes and insulin medications, diuretic medications, blood thinners, antipsychotic medications, and anti-[CONDITION(S)] medications. There is a history of noncompliance in which this facility was cited for lack of staff on January 13, 2022 and March 1, 2022 that affected all residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on August 14, 2022 at 10:42 AM when the facility was without a licensed nurse working in the building. The Immediate Jeopardy was identified on August 24, 2022. V1 (Administrator) and V22 (Administrator in Training) were notified of the Immediate Jeopardy on August 25, 2022 at 10:45 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was not removed at the time of exit. This applies to all 87 residents residing in the facility. The findings include: The Facility Data Sheet dated August 23, 2022 shows the facility census as 87 residents. On August 24, 2022 at 9:10 AM, V1 (Administrator) said, I work as the Administrator and the Staffing Coordinator. We do not have a DON (Director of Nursing) or ADON (Assistant Director of Nursing). For a census of 87 residents, we should have three nurses working on the AM shift (7:00 AM to 3:30 PM), three nurses working on the PM shift (3:30 PM to 11:30 PM), and two nurses working on the night shift (11:00 PM to 7:30 AM), plus a DON and an ADON. On August 14, 2022 (Sunday) we had a census of 90 residents. One resident was out on pass, leaving 89 residents in the building. We had 20 residents (R4, R14, R21-R38) in isolation due to positive Covid-19 test results. We did have a period of time, on August 14, 2022, where we did not have licensed nursing staff in the building. I would have to check the timecards to see exactly how long there were no nurses in the building. The facility's timecards for August 14, 2022 show V11 (RN-Registered Nurse) worked from 11:07 PM on August 13, 2022 to 10:42 AM on August 14, 2022, and V14 (LPN-Licensed Practical Nurse) worked from 12:37 AM on August 14, 2022 to 8:49 AM on August 14, 2022. The facility did not have timecards or documentation to show any licensed nursing staff worked on August 14, 2022 from 10:42 AM to 11:00 PM. The facility's 3-Day Assignment sheet dated August 13, 14, and 15, 2022 shows no licensed nursing staff were scheduled to work on the AM and PM shift on August 14, 2022. On August 24, 2022 at 9:10 AM, V1 (Administrator) said she was unable to find any nursing staff to work the AM and PM shifts, leaving the facility without any scheduled nursing staff for two shifts. On August 24, 2022 at 12:10 PM, V1 (Administrator) said, We did not have a strategy to determine which of the 89 residents should receive their medications on August 14, 2022. The night nurses stayed over to give some of the medications, but we did not actually sit and strategize to see if there were residents with more serious medications like insulin or cardiac medications versus residents with multivitamins. I did not notify the physicians of the residents who missed their medications. I did have V15 (Social Services) come to help from 11:53 AM to 6:42 PM, and V16 (SSD-Social Service Director) came in to help from 9:13 AM to 2:53 PM, but they are not nurses and cannot pass medications. V7 (Certified Nursing Assistant/CNA) worked from 6:06 AM to 2:00 PM, and V8 (Certified Nursing Assistant/CNA) worked from 5:54 AM to 2:03 PM. Then V10 (Certified Nursing Assistant/CNA) worked from 2:32 PM to 9:51 PM, V17 (Certified Nursing Assistant/CNA) worked a double shift from 2:37 PM to 5:50 AM, and V19 (Certified Nursing Assistant/CNA) worked a double shift from 3:10 PM to 5:58 AM, but they are not nurses. I also came into the facility to help from about noon to 11:00 PM. I am not a nurse. V1 continued to say the facility has not had a DON since about February 2022, and does not have an ADON, a MDS (Minimum Data Set) Nurse, an Infection Control Nurse, or a staffing coordinator. On August 24, 2022 at 12:54 PM, V7 (CNA) said, We did not have a nurse for most of our morning shift, on August 14, 2022. We did the best we could that day. The residents knew there was no nurse that day, and they just knew they had to wait to get their medications because there was no nurse to take care of them. That is what we told them when they asked us. On August 24, 2022 at 1:07 PM, V8 (CNA) said, I worked on Sunday, August 14 from 6:00 AM to 2:00 PM. There were no nurses in the building for most of my shift. I had at least 15 residents in the Covid Unit that needed help with meals being delivered to them. We did the best we could, what can I say? We tried to feed them and keep them changed. I was asked by residents where their medications were. All I could tell them was, there was no nurse to give them their medications. If someone needed help for a change in condition, or if the Covid people became short of breath or something, I would not have known what to do. There were no nurses here. The CMS (Centers for Medicare and Medicaid Services) CMS-2567, Statement of Deficiencies and Plan of Correction form, dated January 13, 2022 shows the facility was cited for lack of staff (F725) on January 13, 2022. The facility did not have a licensed nurse in the building to care for residents on December 26, 2021 (Sunday) from midnight until 6:00 AM. This failure had the potential to affect 88 residents living in the facility at the time. The CMS-2567 dated March 1, 2022 shows the facility was cited for lack of staff (F725) on March 1, 2022. The facility did not have a licensed nurse in the building to care for residents on February 13, 2022 (Sunday) from 10:41 AM to 3:00 PM, and February 27, 2022 (Sunday) from 10:00 AM to 2:30 PM. This failure had the potential to affect 87 residents living in the facility at the time. The August 2022 MARs (Medication Administration Records), dated August 1 to August 31, 2022 show the following residents did not receive their physician-ordered medications on August 14, 2022: R1's face sheet dated August 9, 2022 shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (diuretic) 1 mg. (Milligrams) at 9:00 AM [MEDICATION(S)] (antidepressant) 60 mg. at 9:00 AM Potassium (electrolyte) 10 meq. (Milliequivalents) at 9:00 AM [MEDICATION(S)] (antipsychotic) 1 mg. at 12:00 PM [MEDICATION(S)] (anticonvulsant) 150 mg. at 5:00 PM [MEDICATION(S)] (psychiatric medication) 300 mg. at 8:00 PM [MEDICATION(S)] ER (ER-Extended Release) 450 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (anti-diabetic) 100 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (beta-blocker) 40 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (antihypertensive/sedative) 0.1 mg. at 9:00 AM, 12:00 PM, and 5:00 PM [MEDICATION(S)] (antihistamine/anxiety) 50 mg. at 11:00 AM and 5:00 PM [MEDICATION(S)] 2 mg. at 8:00 PM Blood sugar check at 11:00 AM, 5:00 PM and 8:00 PM R4's face sheet dated August 25, 2022 shows R4 was admitted to the facility in March 2010. R4 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (pain medication) 50 mg. at 9:00 AM and 5:00 PM. R4's pain assessment every shift was not done on August 14, 2022. Paxlovid (Coronavirus treatment) 300 mg. at 9:00 AM and 5:00 PM. R5's face sheet dated August 25, 2022 shows R5 was admitted to the facility in November 2015. R5 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (cognition enhancing medication) 5 mg. at 9:00 AM [MEDICATION(S)] (antihistamine/anxiety medication) 50 mg. at 9:00 AM and 5:00 PM Trazadone (antidepressant) 100 mg. at 8:00 PM [MEDICATION(S)] ([CONDITION(S)]/[CONDITION(S)]/depression medication) 150 mg. at 8:00 PM [MEDICATION(S)] (anticonvulsant) 500 mg. at 9:00 AM and 5:00 PM R6's face sheet dated August 25, 2022 shows R6 was admitted to the facility in October 2005. R6 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 60 mg. at 9:00 AM [MEDICATION(S)] (ACE inhibitor/blood pressure) 20 mg. at 9:00 AM [MEDICATION(S)] (sedative) 1 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] ER ([CONDITION(S)]/[CONDITION(S)] medication) 500 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] 250 mg. at 12:00 PM [MEDICATION(S)] 50 mg. at 9:00 AM [MEDICATION(S)] (antipsychotic) 10 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (antipsychotic) 3 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] ([MEDICATION(S)]) 5 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] 5 mg. at 8:00 PM R7's face sheet dated August 25, 2022 shows R7 was admitted to the facility in May 2011. R7 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Blood glucose monitoring at 8:00 PM Sliding scale [MEDICATION(S)] insulin at 8:00 PM based on glucose monitoring [MEDICATION(S)] insulin 33 units at bedtime [MEDICATION(S)] (dyskinesia medication) 80 mg. at 9:00 AM Potassium Chloride ER 20 meq. At 9:00 AM [MEDICATION(S)] (antidepressant) 100 mg. 5:00 PM [MEDICATION(S)] ([CONDITION(S)] medication) 1 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (anticonvulsant) 0.25 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] ER 500 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (anticonvulsant) 300 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (Alzheimer's medication) 10 mg. at 9:00 AM and 5:00 PM Carbid-[MEDICATION(S)] ([CONDITION(S)] medication) 25/100 mg. tablets, take two tablets at 9:00 AM, 1:00 PM, and 5:00 PM [MEDICATION(S)] (antibiotic) 100 mg. at 9:00 AM and 5:00 PM R8's face sheet dated August 25, 2022 shows R8 was admitted to the facility in December 2015. R8 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 20 mg. at 9:00 AM. The facility does not have documentation to show R8's blood pressure was checked to determine if the medication should be administered as ordered. [MEDICATION(S)] (beta blocker/cardiac medication) ER 100 mg. at 9:00 AM. The facility does not have documentation to show R8's blood pressure or pulse rate was checked to determine if the medication should be administered as ordered. [MEDICATION(S)] 2 mg. at 9:00 AM and 8:00 PM [MEDICATION(S)] (antipsychotic) 4 mg. at 9:00 AM and 8:00 PM R9's face sheet dated August 25, 2022 shows R9 was admitted to the facility in November 2019. R9 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (hypothyroid medication) 75 mcg. at 7:00 AM [MEDICATION(S)] ER 500 mg. at 9:00 AM and 5:00 PM R10's face sheet dated August 25, 2022 shows R10 was admitted to the facility in January 2013. R10 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Blood glucose monitoring twice daily at 4:00 PM [MEDICATION(S)] (depression/anxiety medication) 5 mg. at 9:00 AM [MEDICATION(S)] (ACE inhibitor/cardiac medication) 10 mg. at 9:00 AM [MEDICATION(S)] 0.5 mg. at 9:00 AM [MEDICATION(S)] 1000 mg. at 9:00 AM [MEDICATION(S)] 5 mg. at 9:00 AM [MEDICATION(S)] 500 mg. at 9:00 AM R11's face sheet dated August 25, 2022 shows R11 was admitted to the facility in May 2012. R11 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (hypertension medication) 5 mg. at 9:00 AM [MEDICATION(S)] (diuretic) 20 mg. at 9:00 AM [MEDICATION(S)] sodium (asthma medication) 10 mg. at 9:00 AM [MEDICATION(S)] 20 mg. at 9:00 AM [MEDICATION(S)] 1000 mg. at 9:00 AM R12's face sheet dated August 25, 2022 shows R12 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Blood glucose monitoring twice daily at 4:00 PM [MEDICATION(S)] 75/25 (insulin) 25 units sq (subcutaneous) at 5:00 PM [MEDICATION(S)] (blood thinner) 75 mg. at 9:00 AM [MEDICATION(S)] ER 12.5 mg. at 9:00 am R13's face sheet dated August 25, 2022 shows R13 was admitted to the facility in August 2013. R13 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 5 mg. at 9:00 AM [MEDICATION(S)] 5 mg. at 9:00 AM [MEDICATION(S)] ER (bladder incontinence) 50 mg. at 9:00 AM Potassium Chloride ER 40 meq. at 9:00 AM [MEDICATION(S)] 150 mg. at 9:00 AM [MEDICATION(S)] 2 mg. at 1:00 PM [MEDICATION(S)] 2 mg. at 9:00 AM [MEDICATION(S)] 200 mg. at 8:00 AM [MEDICATION(S)] ER 500 mg. at 9:00 AM and 1:00 PM R14's face sheet dated August 25, 2022 shows R14 was admitted to the facility in January 2017. R14 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] [MEDICATION(S)] 25 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] (depression medication) 15 mg. at 8:00 PM R15's face sheet dated August 25, 2022 shows R15 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 20 mg. at 9:00 AM [MEDICATION(S)] (depression/anxiety medication) 50 mg. at 8:00 PM Loratadine (antihistamine) 10 mg at 8:00 PM [MEDICATION(S)] 0.5 mg. at 8:00 PM [MEDICATION(S)] ER 75 mg. at 9:00 AM R16's face sheet dated August 25, 2022 shows R16 was admitted to the facility in September 2014. R16 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Blood glucose monitoring twice a day at 4:00 PM [MEDICATION(S)] insulin 30 units sq. at bedtime [MEDICATION(S)] (involuntary movement medication) 18 mg. at 9:00 AM [MEDICATION(S)] 20 mg. at 9:00 AM [MEDICATION(S)] 20 mg. at 9:00 AM Loratadine 10 mg. at 9:00 AM [MEDICATION(S)] (bladder relaxant) ER 5 mg. at 9:00 AM [MEDICATION(S)] (anticonvulsant) 250 mg. at 9:00 AM [MEDICATION(S)] 30 mg. at 9:00 AM [MEDICATION(S)] 10 mg. at 9:00 AM [MEDICATION(S)] 1000 mg. at 9:00 AM [MEDICATION(S)] (sedative) 0.25 at 9:00 AM and 1:00 PM R17's face sheet dated August 25, 2022 shows R17 was admitted to the facility in July 2009. R17 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (mood treatment) 20-10 mg. at 9:00 AM [MEDICATION(S)] 300 mg. at 9:00 AM and 1:00 PM R18's face sheet dated August 25, 2022 shows R18 was admitted to the facility in June 2015. R18 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (anticonvulsant) 200 mg. at 9:00 AM [MEDICATION(S)] 20-10 mg. at 9:00 AM Carbid-[MEDICATION(S)] 25/100 mg. tablet, 2 tablets at 9:00 AM and 1:00 PM R19's face sheet dated August 25, 2022 shows R19 was admitted to the facility in April 2010. R19 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 2.5 mg. at 9:00 AM [MEDICATION(S)] (Beta blocker/cardiac medication) 50 mg. at 9:00 AM [MEDICATION(S)] 20 mg. at 9:00 AM [MEDICATION(S)] ER 15 mg. at 9:00 AM [MEDICATION(S)] 1000 mg. at 9:00 AM [MEDICATION(S)] 2 mg. at 8:00 AM [MEDICATION(S)] 250 mg. at 8:00 PM [MEDICATION(S)] (anticonvulsant) 200 mg. at 9:00 AM and 5:00 PM Sodium Chloride (electrolyte) 1 gram at 9:00 AM and 5:00 PM [MEDICATION(S)] 10 mg. at 8:00 PM [MEDICATION(S)] 10 mg. at 8:00 PM [MEDICATION(S)] 0.5 mg. at 8:00 PM R20's face sheet dated August 25, 2022 shows R20 was admitted to the facility in July 2017. R20 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (antipsychotic) 40 mg. at 5:00 PM [MEDICATION(S)] 1 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] 0.2 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] 25 mg. at 9:00 AM and 5:00 PM [MEDICATION(S)] 300 mg. at 9:00 AM, 1:00 PM, and 5:00 PM [MEDICATION(S)] (sedative) 1 mg. at 1:00 PM and 5:00 PM [MEDICATION(S)] (antipsychotic) 100 mg. at 8:00 PM [MEDICATION(S)] 50 mg. at 8:00 PM R21's face sheet dated August 25, 2022 shows R21 was admitted to the facility in October 2012. R21 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Aspirin 325 mg. at 9:00 AM [MEDICATION(S)] 1 mg. at 8:00 AM [MEDICATION(S)] (cardiac/blood pressure medication) 24-hour ER 180 mg. at 8:00 AM [MEDICATION(S)] 20 mg. at 8:00 AM [MEDICATION(S)] 300 mg. at 8:00 AM Potassium Chloride ER 40 meq. At 8:00 AM [MEDICATION(S)] (diuretic) 25 mg. at 8:00 AM On August 24, 2022 at 3:22 PM, V20 (Physician) said, I was not aware no nurses were in the building on August 14, 2022. I was never notified any of my residents did not receive their medications. This is the first I am hearing of it. It would be concerning to me if they did not receive their medications as ordered. There could be problems with residents not receiving their insulin or experiencing high blood pressure if they did not receive their blood pressure medicine. On August 24, 2022 at 3:29 PM, V21 (NP-Nurse Practitioner) said, I was not notified residents did not receive their medications on August 14, 2022 due to a lack of staff. The facility's Facility Assessment Tool, dated August 23, 2022, shows, Staffing Plan: Staffing is based on the needs of the residents. These needs are discussed daily in our clinical management meeting. Staff: Licensed Nurses (LN): RN, LPN, LVN (Licensed Vocational Nurse) providing direct care: Plan: DON: 1, ADON: 1, 2-3 RN per day, 1-2 LPN one to two per shift. The facility undated policy entitled, Nurse Staffing shows: Policy: It is the policy of [the facility] to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. The Immediate Jeopardy that began on August 14, 2022 was not removed at the time of the survey exit because the facility failed to provide a removal plan to show licensed nursing staff will be present in the facility at all times.

Based on interview, and record review, the facility failed to monitor, and prevent a resident with a history of elopement from leaving the facility unwitnessed,= and without supervision. This failure resulted in Immediate Jeopardy. The immediate jeopardy was noted to begin on January 4, 2021 during the morning shift when R1 could not be found in the facility. This failure applies to 1 of 4 residents (R1) reviewed for supervision in the sample of 4. V1 (Administrator) and V8 (Social Service Director) were notified of the Immediate Jeopardy on January 21, 2021 at 4:05 PM. V1 was provided with the Immediate Jeopardy Template outlining the failures. Although the immediacy was removed on January 27, 2021 at 12:16 PM, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies and procedures and Quality Assurance monitoring. The findings include: R1 was admitted on [DATE] with diagnoses including [CONDITION(S)] disorder [CONDITION(S)] type, anxiety disorder, major vascular neurocognitive disorder with behavioral disturbance, dementia, hypertension and GERD (Gastroesophageal Reflux Disease), according to the medical records. The MDS (Minimum Data Set) dated 11/5/2020 showed a BIMS (Brief Interview for Mental Status) score of 3 (severe cognitive impairment). V12's (Psychologist) psychological evaluation dated 6/9/2020 shows R1 has a history of multiple elopement attempts from prior facilities where he resided. R1's neurocognitive test results dated 6/9/2020 show, his neurocognitive impairments suggest he requires 24-hour supervision in order to ensure his safety, and security. 2 .Thus, he does not appear to have the capacity to go into the community independently without supervision, or escorted accompaniment. Out on Pass privileges for this resident are not recommended. 5 He does not appear capable of making reasonable and well thought out decisions that are within his best interest. V15's (Psychiatrist) progress notes dated 12/25/2020 show R1 was seen via telehealth. On 1/21/2021 at 8:18 AM, V15 stated R1 needed 24-hour supervision and whatever it takes to keep R1 safe. The facility's final incident report sent to the state survey agency dated 1/9/2021, showed R1 was missing from the facility on 1/4/2021 at approximately 7:00 PM. Police Summary Case Report dated 1/5/2021 shows that on 1/5/2021 (day after R1 eloped), at 10:00 AM, V1 (Administrator) reported R1 as missing to the local police since 1/4/2021 but was found at the nearby local hospital. The report also shows V11 (Police Officer) called the hospital and spoke to the charge nurse for the emergency room . The nurse told V11 (Police Officer) R1 was walking along I-88 and was brought into the ER by a passerby around 0930 hrs (9:30 AM) on 01/04/21. The Nurse stated R1 was admitted to the hospital for having an altered mental status as well as other symptoms regarding being cold. According to the Weather Underground Website (wunderground.com), the temperature in North Aurora, IL on 01/04/2021 from 6:07 AM - 10:09 AM was 25 degrees Fahrenheit. On 01/14/2021 at 1:55 PM, V11 (Police Officer) stated he did not go to the hospital to see R1 but was informed that R1 was found walking along I-88 but had no information on the exact location. (I-88 is an interstate highway which is approximately 3 miles from the facility). On 01/12/2021 at 1:25 PM, V2 (Registered Nurse/RN) stated that on 01/04/2021, he was the nurse assigned to R1 during the morning shift (7:00 AM- 3:30 PM). V2 stated he was passing medications from approximately 7:00 AM - 9:00 AM and did not see R1 throughout the medication (med) pass. V2 stated R1 would normally be in his room or walking in the hallways. V2 stated he did not look for R1 after he finished administering the other residents' medications. V2 was asked if he looked for R1 to give his scheduled 12:00 PM medication, V2 stated he did not look for, nor see R1 throughout his shift. V2 stated he did not give R1 any of his scheduled medications during his shift. V2 stated it was a busy shift and he completely forgot about R1. V2 stated he left the facility at 2:00 PM on 01/04/2021. V2 stated that at approximately 8:00 PM on 01/04/2021, V7 (Nurse) who was working the evening shift called him to ask if he knew R1's whereabouts. V2 stated it was only at this time that he realized he had not seen R1 all day. On 01/12/2021 at 4:00 PM, V7 (Nurse) stated he worked the evening shift on 01/04/2021 and was assigned to care for R1. V7 stated he arrived at 3:00 PM and made rounds. He did not see R1 at that time. V7 stated he began passing medications at 4:00 PM and was unable to find R1 at that time. V7 stated when he finished giving medications to the other residents, he looked for R1. V7 stated when he could not find R1 in the facility, he alerted all the other nurses, and CNAs (Certified Nursing Assistant) in the other hallways at approximately 6:30 PM. Everyone searched for R1 but was unable to find him. V7 stated he called V1 (Administrator) at that time to notify her that R1 was missing. V7 stated V1 instructed him to drive around the neighborhood to search. V7 stated he drove around the neighborhood for about 10-15 minutes and returned to the facility, unable to find R1. V7 called and reported back to V1 that he was unable to find R1. V7 stated V1 (Administrator) and V8 (Social Service Director) arrived at the facility and took over locating R1. V7 stated he also called V2 (Nurse), who worked the morning shift on 01/04/2021 to ask what happened to R1 and V2 did not know. On 01/12/2021 at 2:30 PM on a telephone interview, V4 (Certified Nursing Assistant/CNA) stated she was employed by an agency and worked on 01/04/2021 at the facility during the morning shift. V4 stated she started at 6:00 AM and was assigned to care for R1. V4 stated she began the shift by getting the dependent residents to the dining room for breakfast and at some point, she saw R1 speed walking towards her in the middle hallway. V4 was unable to provide the specific time when she last saw R1. V4 stated R1 eats his breakfast in his room and usually, goes back to sleep afterwards. V4 stated she was busy providing care to the other residents that she was not aware that R1 was missing. V4 was asked how often she made rounds. V4 was unable to give a specific frequency but stated that she walks through the hallways often. On 01/12/2021 at 2:00 PM, V17 (CNA) stated she would see R1 walking in hallways 2 and 3. V17 stated R1 needed prompting to keep his mask on and when it's time to eat. V17 stated there was no required frequency when to do rounds. On 01/19/2021 at 10:25 AM, V1 (Administrator) stated there was no facility policy and procedure on making rounds. V1 stated due to the psychiatric diagnoses of residents, they would become suspicious if staff would make rounds consistently. V1 stated V2 (RN) should have caught sooner that R1 was not in the facility. V1 stated that on 01/04/2021 at night, it was V8 (Social Service Director) who called and discovered that R1 was admitted to the hospital. On 01/12/2021 at 2:10 PM, V3 (PRSD/Psychiatric Rehabilitation Services Director) stated R1 had been restless prior to elopement due to dementia, which was worsening. V3 further stated she saw behavior in R1 she had not seen before related to dementia. On 01/12/2021 at 3:00 PM, V6 (PRSC/Psychiatric Rehabilitation Services Counselor) stated R1 has the diagnosis of dementia and has a history of elopement. V6 stated they are looking at guardianship for R1 due to cognitive decline. As an example, she used to be able to instruct R1 to go to his room and put on his shoes and he was able to follow direction. Currently, if instructed the same, R1 would wear other residents' shoes. V6 said she asked R1 how he left the faciity on [DATE], R1 was only able to point at the different colored tiles in the hallway and did not say anything regarding the elopement. V6 further stated a care plan for elopement should also be initiated. According to R1's nurses' progress notes dated 04/09/2020, R1 was up all night trying to exit the building and stated he wanted to leave. R1 was able to be redirected. On 01/13/2021 at 10:20 AM, V8 (Social Service Director) presented a handwritten, undated, unsigned care plan on elopement. V8 stated he added history of elopement in the handwritten elopement care plan on 01/04/2021 but was unable to provide the original care plan to determine if an elopement care plan was initiated. V8 stated he assessed R1 at the hospital along with V6 (PRSC) prior to the original admission on 04/01/2020. V8 stated there was no documentation of this evaluation in R1's medical records. V8 stated that during hospitalization just prior to admission to the facility on [DATE], R1 got out of the hospital unit where he was admitted and went to another unit. V8 stated R1 at that time, walked in the room hunched at a 45 degree angle, mobility was poor, unable to walk more than a few feet and was unable to stand erect. V8 stated he did not think R1 would be an elopement risk. V8 stated R1 was very pleasant towards him. R1 was quiet, isolative and calm with certain residents and staff. R1 walked up and down the hallways more as he became acclimated to the facility. V8 stated R1 has a history of trying to open an exit door at least a couple of times (not sure which door) and was redirectable. V8 stated that when he was informed on the night of 01/04/2021 that R1 was missing, he made a phone call to the nearest local hospital at approximately 7:45 PM and found out that R1 had been admitted at that hospital. V8 stated that on 01/04/2021, he went to the facility afterwards and was at the facility from 8:00 PM until midnight. V8 stated he and V1 (Administrator) reviewed the videotape recorded on 01/04/2021 from 5:30 AM - 10:30 AM. V8 stated the camera did not capture R1 walking out due to coverage outage and inconsistent video. On 01/13/2021 at 12:50 PM, the videos was reviewed in V1's (Administrator) office. V1 stated she went back to the facility on [DATE] before 10:00 PM after being notified that R1 was missing. V1 stated she reviewed the videos with V8 (Social Service Director) starting on 01/03/2021. V1 stated she last saw R1 in the facility on 01/03/2021 during the evening shift. Taping from 01/04/2021 at 6:20 AM was reviewed, which showed staff throwing out garbage. There were many missing frames and difficult to find exhibits. The pictures were blurry, choppy and not labeled to be able to determine areas that were monitored. V1 stated the system was old and would wipe off the previous days' sequence. V1 stated the time stamped was an hour early because of the time change. V1 stated they were not able to identify from the videos how R1 left the facility. On 01/21/2021 at 10:20 AM, V16 (Nurse) stated she worked on 01/03/2021 during the night shift and the last time she saw R1 was before breakfast on 01/04/2021 at 7:30 AM. V16 stated he was wearing sweatpants and a dark long sleeve top. On 01/13/2021 at 1:25 PM, V9 (Business Office Manager) stated, generally, since her office was closest to the front door, she was the one who answers when the front doorbell rings. V14 (Transportation Driver) who shares office with her will also answer the doorbell. V9 stated a code is needed to go out of the front door. V9 stated she received a text message from V1 (Administrator) on 01/04/2021 at approximately 10:00 PM to call back. V9 stated she did not see the message until the following morning on 01/05/2021 at 5:45 AM. V9 stated she has no observation of how R1 left the facility. The Emergency Department Physician Report documentation showed R1 was examined on 01/04/2021 at 09:51 (9:51 AM). R1 was brought in by EMS (Emergency Medical Service) after being found wandering outside. When asked why he was wandering outside and where he was going, R1 stated, I don't know. R1 reported he lived with his sister. The physician's impressions were altered mental status, elevated troponin, [CONDITION(S)], [CONDITION(S)], and leukocytosis. The [CONDITION(S)] was treated with [MEDICATION(S)]. Documentation showed R1 requires intensive medical treatment, as an inpatient, to prevent further deterioration of condition, as there is an increase risk of morbidity/mortality associated with the patient's medical condition. The physician recommended admission to telemetry. The Nurses' Progress Notes dated 01//06/2021 at 13:55 (1:55 PM) showed R1 was readmitted to the facility. R1 was alert and oriented x 1-2. Through observation, record review, and interviews conducted on January 28, 2021, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: 1. The following corrective action for the alleged deficient practice has been achieved by implementation of the following: A. The staff was in-serviced in regards to Elopement Prevention (attachment A) Started on January 4, 2021 and ended on January 7, 2021. In-service was conducted by V1. Education shall be provided to all staff upon hire and intervals through the year. B. A resident check was completed on January 4, 2021 immediately initiated missing resident policy (this was clarified with the facility, according to the facility a head count was done). C. Agency staff was in-serviced and the facility will continue to in-service new agency staff, prior to the beginning of shift. D. R1's elopement risk assessment has been reviewed and updated to reflect the current needs of the resident on January 26, 2021. (Attachment C) E. R1's care plan was updated on January 6, 2021 (Attachment D) F. R1 has had fifteen minute checks implemented on January 6, 2021 and will go on for four weeks. R1 was hospitalized on [DATE] and returned to the facility on [DATE]. Fifteen minute checks were resumed upon R1's readmission to the facility (Attachment B). On February 19th, March 19th, and April 19th, the QA Committee will review to determine if a gradual reduction of monitoring is needed if R1 is still exit seeking. The QA Committee will use input from the nursing staff and will evaluate the need for continued monitoring and will review care plan interventions for effectiveness. Investigation was initiated to identify opportunities for improvement on January 5, 2021 (this was clarified with the facility; according to the facility, an investigation was done to find out how R1 left the facility. When asked, V1 stated as of now they do not know which door R1 exited from.) G. Door alarm codes were immediately changed for all exit doors on January 4, 2021. 2. 4 of 4 residents have the potential to be affected by the alleged deficient practice. 3. The following systematic measures have been implemented to ensure the alleged deficient practice does not recur: A. Any resident assessed to be at high risk for elopement will have their photograph and basic identifying information placed in a special folder to be maintained at the nurse's station. Staff will be provided with a listing of residents at high risk for elopement. B. Staff will conduct visual checks every two hours on R2, R3, and R4 starting on January 27, 2021 and will be reassessed by the QA Committee to determine a gradual reduction on February 19th, March 19th, and April 19th. Any high risk resident will be promptly and courteously escorted back to the appropriate nursing unit, activity room, dining area or resident room when noted to be near an exit door. C. Revision of the Elopement Risk Assessment will be completed quarterly, after an isolated elopement attempt, monthly for residents who attempt elopement more than 5 times per week, upon a resident's significant change in condition and as needed, determined by the QA Committee. 4. The following Quality Assurance programs have been implemented to ensure continued compliance: A. QA Committee will assure compliance through Quality Assurance process. Social Service Director and/or Designee will review tool {Resident Monitoring- 15 minute} daily for compliance for R1. This monitoring started on January 6, 2021 and will be reassessed on February 19th, March 19th, and April 19th to evaluate the need for continued monitoring. Social Service Director and/or Designee will review two hour monitoring for R2, R3, and R4 starting on January 27, 2021 daily. The QA Committee and will review on February 19th, March 19th, and April 19th to evaluate the need for continued monitoring for R2, R3, and R4.

Based on observation, interview, and record review the facility failed to monitor and supervise a cognitively impaired resident who was left in the uncovered outside patio, being exposed to direct sunlight and heat. This failure resulted in R1 needing to be sent out to the local hospital emergency room for treatment of [REDACTED]. R1 was admitted to the local hospital with a [DIAGNOSES REDACTED]. This applies to 1 of 3 residents (R1) reviewed for incident reports. The findings include: R1 has [DIAGNOSES REDACTED]. The MDS (minimum data set) dated 07/23/19 shows that R1 has severe cognitive impairment, requiring limited assistance with one staff assistance with dressing, personal hygiene and bathing. R1's current care plan goal showed that R1 continue to need 24-hour supervision. The facility's SBAR (situation background assessment request) communication form dated 08/03/19 showed: Situation: The change in condition, symptoms, or signs observed and evaluated, R1 was non-responsive. Vital signs: Blood pressure - 108/54 pulse - 136 respiratory rate - 24 temperature - 105.4 Resident evaluation: - mental status evaluation - decreased level of consciousness, unresponsiveness - functional, behavioral and respiratory evaluation - unresponsiveness, - skin evaluation - skin hot to touch - neurological evaluation - decreased level of consciousness Appearance: Non-responsive, breathing labored, skin hot to touch. Nurses notes for additional information on the change of condition: On Observed resident unresponsive with labored breathing. Resident sitting on a patio chair outside. Resident wearing pants and winter [NAME]et. Resident brought inside, placed in his bed, his clothing was removed. Towels with cold water and ice was placed all over his body. 911 was called and resident was transported to the hospital emergency room . Physician and POA (power of attorney) aware. Paramedics record showed that on 08/03/19 they responded to a call via 911. The record showed that the patient (R1) was unresponsive and breathing. R1 was laying on his bed with [MEDICAL CONDITION] of both legs, NRB (non-rebreather mask) on. R1 in his underwear with towels soaked in cold water and ice on his body. Nursing home staff had a thermometer in R1 armpit that was reading 104 degrees. Nursing home staff stated that they found R1 outside unresponsive and he was wearing a winter coat and pants and they believe he was outside all day. R1 was moved to the ambulance where additional medical treatment was given. Hospital emergency department report dated 08/03/19 showed: This is a [AGE] year old male with a medical history of [REDACTED]. He is currently staying in the nursing home and was found outside in the sun wearing full winter clothing. He was not acting like his usual self so EMS (emergency medical service) was called. Patient is no verbal, history limited Impression: primary impression heat stroke. Rectal temperature 102.2, history suggestive of heat stroke Cardiovascular exam - [MEDICAL CONDITION]/>Hospital History and physical exam dated 08/04/19 showed: Chief complaint: altered mental status History of present illness: Patient is a [AGE] year old gentleman with no medical problems who is a resident at a local nursing facility who was found outside the facility in his winter clothes, weak and confused. The patient was brought to the emergency room and found to be hyperthermic possibly secondary to heat stroke. He is unable to elaborate on details the history. Assessment and plan: Altered mental status likely secondary to toxic metabolic etiology such perhaps dehydration and heat stroke versus new pneumonia. Plan to admit for careful hydration and monitoring. The nurses notes dated 08/03/19 at 4:45 PM showed: Observed resident unresponsive with labored breathing sitting on the patio chair outside on the patio. Resident wearing pants and winter [NAME]et. Resident was placed in wheel chair and brought back to his bed. Staff removed all his clothing, towels with cold water and ice applied all over his body. Body warm to touch. Oxygen with non- rebreather mask applied Oxygen saturation at 97%. Vital signs: Temperature 105.4, pulse 136, respiratory rate 24, blood pressure 108/54. 911 was called. At 5:04 PM, 911 came to transport resident to hospital. V6 (physician) was called and made aware of resident condition. At 5:30 PM Administration and POA was also made aware of resident condition. At 8:42 PM placed a call to the hospital ER and resident is admitted with heat stroke. On 08/07/19 at 11:28 AM V3 (nurse 7AM - 3 PM) stated I was the day nurse of R1 that day (08/03/19). R1 likes to go outside the patio/courtyard/smoking area. After meals the patio/courtyard is open. If there is an activity going on, or during meal times they do not allow the resident to go out on the patio. During smoking times there is an activity staff, or a CNA assign to supervise the residents. R1 walks around and comes to get his medications. R1 did not have any untoward behavior that day (08/03/19). When V3 was asked they track their residents, V3 replied, there is no set standard or rules. On 08/08/19 at 10:04 PM, V11 CNA (certified nursing assistant) stated I was the morning CNA for R1 that day (08/03/19) and that he (R1) was fine and acting normal. R1 walks around and had lunch at 11 AM (first seating). I was assigned to the cigarettes cart that day (08/03/19). On 8/3/19 at 1:30 PM I noticed R1 had a cigarette and was wearing pants and winter coat. Residents were out on the patio for about 15 to 20 minutes. I saw R1 come back inside the facility between 1:45 PM - 1:50 PM. I saw R1 in the dining room around 1:45 PM. I left the door closed but not locked. The residents are able to go in and out to the patio. My shift ended at 2PM. On 8/7/2019 at 2:30 PM V7 (Certified Nurse's aide) stated The hours I work are 2 - 10PM. When I get here I make sure what assignment I have and then check on all my residents. V7 added that on 8/3/2019, V7 was in charge of the cigarette cart. V7 stated that she did not see R1 until 4 PM, which not unusual since he paces through the facility. V7 stated, I didn't think anything of it because that is his norm. At 4 PM during cigarette rounds I saw R1 on the patio sitting in a chair slumped over in the sun with his winter coat on. I went over to him and asked if he wanted a cigarette he mumbled. I went back in the facility and started passing drinks out for the dinner meal. At 4:45 V10(Certified Nurse Aide) went out on patio to get residents ready for dinner and noted R1 sitting in chair slumped over and not responding. V4 (Registered nurse) was alerted to the emergency by V10. V10 and V4 brought R1 back into facility placed him in bed and called 911. On 8/7/2019 at 1:00 PM V10 (Certified Nurse's aide) stated I was making rounds on the patio and getting the residents in the dining area for dinner when I noted R1 sitting in a chair slumped over. I proceeded to him and tried to arouse him, but he was unresponsive. I went inside and told R4 (Registered Nurse) there was an emergency on the patio. V4 and I brought R1 inside and placed him in his bed, proceeded to remove all his clothing and place towels with cold water and ice over his body. 911 was called by another staff member but I don't remember who did that. I don't know how long R1 was outside, but he was hot and sweating. On 08/07/19 at 12:48 PM V4 (3PM -11PM nurse) stated on 08/03/19 at around 4:30 PM they are about to serve the dinner and V10 CNA went to check on the residents in the outside patio and found R1 sitting on the chair by the wall. V4 said that she was in the dining room and V10 called her and found R1 in the outside patio unresponsive. V4 said that she was trying to arouse R1 but he was unresponsive and R1 had labored breathing. V4 said that V12 (nurse) came and someone brought the wheel chair, and wheeled R1 back to his room, and put him to back to bed. R1 was wearing pants and a winter [NAME]et. V4 stated that they took all R1's clothing off and put cold towels, and ice on R1's face, legs and arms. V4 continued and stated that R1 was hot to touch. V4 said that one of the staff was taking vital signs and V3 (nurse) was putting ice on his armpit and trying to arouse R1 and 911 was called. V4 said that after preparing all the papers she went back to R1's room and the nurses (V3, V12) was still with R1 putting ice on R1's body and R1 was still unresponsive. V3 took R1's temperature and it was 105/axillary. The paramedics came and R1 was still unresponsive and they took over. I did not see R1 on that day (08/03/19) prior to the incident. V4 was asked how they track their residents. V4 said that residents do not stay in their room, wander around in the TV room, solarium and by the vending machines they do not stay in one place. When there is an incident the staff fills out an SBAR assessment, they do not have incidents reports at the facility so on 8/3/2019 I filled out the SBAR assessment. On 8/3/2019 it was a warm and humid day. On 08/07/19 at 10:40 AM V1 (Administrator) stated that the residents are free to go out to the patio with no supervision unless its smoking time then they have supervision. V1 said that once the door is open they can go in and out unless weather permitting. V1 continued and stated that the staff need to check on R1 couple of times because he paces through the hallways. On 08/07/19 at 2:40 PM V5 (Activity director) stated that the patio door is always open unless it is meal times, activities, or severe weather condition. On 08/08/19 at 9:32 PM V6 (Physician) was asked his expectation from the staff for supervising a resident and how long should a resident be out in the sun. V6 stated it depends upon the temperature. V6 was told that day (08/03/19) when R1 was found the temperature was 87 - 89 degrees and humid. V6 said residents should not be outside for long periods of time and staff should keep an eye on residents for safety. Facility's job description for certified nursing assistant showed: Job summary: Working under the direction of the staff nurses, the certified nurses aide provides personal care and assistance to residents to assure their safety and comfort. Responsibilities: b. provides for the safety and security needs of the residents by making frequents round checks on residents and responding to the resident's call for assistance in a timely and appropriate manner. August 2019 activity calendar showed that on 08/03/19 (Saturday) that there was no scheduled activity on that day (08/03/19) and all the other Saturdays were just for leisure time. Facility's smoking times showed: 10 AM, 1:30 PM, 4 PM, 7:30 PM, 9:30 PM Meal time schedule: Breakfast time: first serving - 7 AM second serving - 8 AM Lunch time: first serving - 11 AM second serving - 12 PM supper time: first serving - 5 PM second serving - 6 PM Facility's patio door notification sign showed that the patio door will be open daily from 9 AM to 10 PM. It will be locked for all meals, activities and severe weather conditions.

Based on observation, interview, and record review, the facility failed to protect a resident from physical abuse. This situation resulted in R1 recieving a nose contusion and psycho-social harm of fearfullness of the threat of further harm. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 6. The findings include: POS (Physician order [REDACTED]. MDS (Minimum Data Set), dated (MONTH) 1, (YEAR), shows R1's cognitive status as modified independence. On (MONTH) 12, (YEAR) at 10:00 AM, R1 stated that while he was lying in bed sleeping, R1's radio alarm turned on and began making noise. R1 stated R2's room was close to R1's room. R1 stated R2 entered R1's room, began punching R1 in R1's face without warning, and caused injury to R1's nose and R1's nose to bleed. R1 stated he was sent to the hospital for examination of his injuries. R1 stated the episode was the second of two times R2 had punched R1 in the face at the facility. R1 stated he felt the facility was not addressing/punishing R2 for hitting R1 to prevent further attacks. On (MONTH) 13, (YEAR) at 12:15 PM, R1 stated, I have a fear, but there is nothing I can do about it! He (R2) sits behind me and he could do anything! He could probably break my neck. I just try to accept it. R1 also stated he felt like V2 (Former Administrator) was not doing anything to protect R1. Nursing notes, dated (MONTH) 4, (YEAR) at 11:45 PM, show, Incident, see SBAR. Nursing notes, dated (MONTH) 5, (YEAR) at 12:30 AM, show R1 was transported by ambulance to the hospital. Hospital Emergency Department summary, dated (MONTH) 5, (YEAR) at 1:41 AM, shows R1 was examined for a nose contusion. Face sheet, dated (MONTH) 23, (YEAR), shows R2's [DIAGNOSES REDACTED]. MDS, dated (MONTH) 19, (YEAR), shows R2 was cognitively intact. On (MONTH) 13, (YEAR) at 9:58 AM, R2 stated at the time of the altercation with R1, R1's radio was making noise and the noise bothered R2. R2 stated because the radio volume was high, I hit him. R2 stated he said nothing to R1 prior to hitting R1. R2 stated he did not first ask R1 to turn down the radio. R2 also stated he hit R1 one additional time in (MONTH) (YEAR) when R1 and R2 were roommates. R2 stated he hit R1 in (MONTH) after asking R1 to turn down R1's radio. R2 stated during both altercations R2 hit R1 first. R2 stated he and R1 are supposed to be separated at all times since the incident (MONTH) 4, (YEAR). Social Service documentation, dated (MONTH) 6, (YEAR), shows V10 attended a care plan for R1 and a decision to move R1's room across the building, and away from R2, was made at that time. The note shows R1 was very angry with V10 and V10 reassigned R1 a new case worker. The note shows, R1 and R2 are now on opposite sides of facility and should have minimal contact. As of (MONTH) 13, (YEAR), no further documentation was available in R1's clinical record indicating R1 had any follow up assessment after the incident with R2. Facility Investigation: Resident to Resident Altercation, dated (MONTH) 6, (YEAR), shows, Conclusion: R2 became upset when R1 was playing his radio too loud. R2 then entered R1's room and struck him in his face. R1 and R2 were both sent out for evaluation. R1 and R2 returned to the facility and were both calm R1's room was moved and no other incidents have occurred. R1 and R2 don't get along and R2 has been directed to stay away from R1. A police report was filed by V13 (Police Officer). On (MONTH) 13, (YEAR) at 1:58 PM, V10 (Social Services Director) stated since the (MONTH) 4, (YEAR) altercation, V10 witnessed an incident of R1 screaming at R2 in the dining room on (MONTH) 5, (YEAR). On (MONTH) 13, (YEAR) at 11:18 AM in the main dining room during the first of two lunch seatings, R1 sat eating his lunch at the table next to R2 who was sitting eating his lunch. R2 finished his lunch, stood up, took his walker, and walked past R1 who was still sitting and eating his lunch. At 11:25 AM, V11 (CNA - Certified Nursing Assistant) was the only CNA in the dining room with the dining residents and was standing at the kitchen window across the dining room from R1 and R2. V11 stated she was not beem made aware of any residents who should not interact together in the dining room. At 11:18 AM, V12 (Dietary Aide) stated all residents sit at assigned tables in assigned seats. V12 showed a resident tray card which had the table and dining seating assigned to the resident. On (MONTH) 13, (YEAR) at 2:45 PM, V1 (Administrator) stated R1 and R2 should not be seated near each other at meals. Facility Abuse Prevention Program Policy, dated Nonmember 28, (YEAR), shows, This facility affirms the right of our residents to be free from abuse This will be done by: Immediately protecting residents involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property' promptly and aggressively, and making the necessary changes to prevent future occurrences

Based on observation, interview and record review, the facility failed to provide supervision/monitoring for one resident, identified with unsafe smoking behaviors. This failure resulted in the resident being unsupervised, falling on the patio, sustaining a fractured knee, and crawling to get help from staff in the middle of the night. This applies to 1 of 3 residents (R2) reviewed for falls in the sample of 7 residents. The findings include: Review of R2's Face Sheet showed R2 is a [AGE] year old, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R2 has a recent [DIAGNOSES REDACTED]. Review of R2's Incident Report, dated January 12, 2017, showed: 3 AM (R2) Location of Incident: Outside Patio (R2) complained of pain to his knee. (R2) was unable to ambulate, which was a change of condition. MD notified and sent to emergency room with x-ray revealing an acute comminuted and displaced fracture through the Patella of Left Knee. Type of Incident: Fall Type of Injury: Fracture Review of R2's Diagnostic Imaging Services, dated January 12, 2017, showed the following: Exam: x ray Knee Bilateral History Knee Pain, fall on ice Impression: Comminuted, displaced fracture through the left patella with retraction of fragments Review of R2's nursing notes, dated January 12, 2017 at 3 AM, showed the following: (R2) seen sitting on floor by door States, I fell on my knees outside smoking patio Review of R2's Smoking Assessment, dated June 12, 2016 showed the following: Comprehensive Evaluation Results, Unable to follow directions - Poor Safety Awareness - Behavior Evaluation Results .- Aggressive and disruptive - The Inter disciplinary Team determines the above named resident may smoke under the following condition: Supervised Review of R2's care plan, dated June 20, 2015 continued to April 2017, showed R2 at risk because of behaviors and needing supervision. The nursing interventions were for R2 to be monitored while smoking to prevent R2 from picking up cigarette butts off the ground and smoking cigarettes until his fingers were burned. Review of the facility's Smoking Policy, undated, showed the following: Supervised Smoking Times 10 AM, 1:30 PM, 4 PM, 7 PM and assigned staff member will be observing residents while they smoke. Residents will be observed within close visual proximity. If staff do not physically want to be on the patio they can observe from the patio door but must be in place until the last smoker is finished Another area of concern in R2's care plan, dated August 12, 2015 continued to April 2017, showed: Self care deficit-needs supervision and/or assistance to complete quality activities of daily living, as well as verbal cues. Alert and oriented residents were interviewed in their rooms. The residents reported that staff were not always available to assist residents who needed to be supervised in the area of the outside patio/courtyard used for smoking. On March 01, 2017 at 3:36 PM, R6 was interviewed in his room. R6 said prior to R2's incident, we (residents) could go out into the courtyard and smoke anytime at night, because the patio door was unlocked, and staff were not always outside to supervise. R6 also complained that the night shift staff was not always helpful or available for residents. R4 was interviewed on March 1, 2017 at 3 PM. R4 said before R2 fell , we (independent smokers) could go out and smoke anytime and staff did not always provide supervision during the smoking times to prevent R2 from picking up cigarette butts and smoking unsupervised. R4 said R2 would stand over you and beg for cigarettes. R4 stated staff did not provide R2 with the supervision he needed and made her think staff was unorganized. R7 was interviewed on March 2, 2017 at 3:49 PM. R7 complained that staff did not always supervise residents who needed it at night or be readily available when help was needed. R7 stated sometimes the patio door to the courtyard was left unopened so residents could smoke and staff were not always there to supervise R2 from picking up butts. On March 01, 2017 at 3:29 PM, R5 was interviewed in her room. R5 stated before the incident with R2, staff left the patio door open at night so the independent smoker could go out at anytime and smoke. R5 said sometimes staff was not present to supervise residents. R5 stated she is an independent smoker, but staff did not want R2 smoking outside by himself. R5 said R2 picks up butts and smokes until his fingers get nasty and black. R5 stated R2 is always begging for cigarettes, and she (R5) is tired of his behavior. R5 stated she was in the dining room talking with another guy at 2 or 2:30 AM the morning R2 fell on the patio. R5 said she could not sleep, so she was up talking to another resident in the day room. R5 stated staff were not present and were doing rounds. R5 said it was dark outside and she did not see what happened. But, R5 stated I saw R2 crawling into the building. R5 stated R2 could not stand, so I told him to do nothing and the other resident went to get the nurse (E8). R5 said E8 came and checked R2 out, and I learned R2 broke his knee cap. E8 was interviewed on February 28, 2018 at 4 PM. E8 said she was the nurse on duty when R2 fell . E8 stated the patio door is locked at 10 PM, and then the door is opened at 1 AM, so the independent smokers can go out to smoke. E8 said the CNA's (Certified Nursing Aides) should monitor the residents while they are smoking to ensure they (residents) do not share cigarettes or fight. E8 stated R2 is an independent smoker and could go out that night of the incident and smoke independently. E8 said I think one of the CNA's told me R2 had fallen. E8 stated she found R2 on the floor by the patio door and saw R2's leg was not in the right position and I knew he (R2) had a fracture. E16, CNA was interviewed on March 2, 2017 at 4:45 AM. E16 stated she (E16) was R2's CNA the night of R2's fell . E16 said she was doing rounds and was unaware of what happened to R2 until another CNA told her R2 had fallen. E16 described R2 as alert, but sometimes wanders at night, R2 walk around but mainly sits in the dining room. E16 said I think R2 was one of the residents who would be out there when the door to the patio would be picked. E16 stated some of the residents would pick the lock to the patio door at night and go out to smoke unsupervised. E16 said I think R2 was one of the residents who would go outside when the door was picked. E16 stated I know the residents picked the lock because it (the door) would be locked, and all of a sudden the door would be unlocked and residents are outside on the patio smoking. E16 said this went on for awhile, the residents were told not to go out there, but a lot of the time residents would be out there smoking unsupervised. E16 stated the independent smokers had cigarettes, and the supervised smokers were not allowed to carry their own cigarettes, and residents with cigarettes were allowed to smoke. E16 said we use to have a list identifying the smokers needing supervision, but I have not seen that list in a long time. Interview with E14, CNA on March 2, 2017 at 5:05 AM stated she was working the night R2 fell , but I have no idea what happened to him, because I was doing rounds. E14 said I heard someone say R2 fell . E14 said when I went to see what happened other staff members were assisting R2. E14 said the door should have been locked, but the residents were able to pick the lock and go out smoking during the night shift. E14 was unsure if R2 was an independent smoker on the night he fell , or up to the time of this interview on March 2, 2017. E14 stated if residents have cigarettes they can go out and smoke, and that is how we can tell if residents are independent smokers. E7 was the other nurse on duty the night R2 fell . E7 was interviewed at 11 AM on March 1, 2017. E7 said it was maintenance or another resident that told me R2 had fallen. E7 said when he got to the dining room R2 was on the floor by the patio door. E7 stated R2 told me he had fallen outside in the courtyard and crawled into the building. E7 said R2 had a coat on because of the outside temperature, but he could not recall how cold it was outside. E7 stated at the time of R2's fall the patio door was left opened to allow the independent smoker to go outside into the courtyard to smoke. E4 is the nurse, who took care of R2 after he fell . E4 was interviewed on February 28, 2017 at 12:08 PM. E4 said R2 fell during the night shift and I took care of him on the day shift. E4 said R2 was an independent smoker because he could walk, but needs supervision now because he uses a wheel chair and cannot walk now. E4 said R2 may have fallen in the courtyard that night because resident use to pick the patio lock and the other residents would follow them outside to smoke. E4 stated R2 did not keep cigarettes on him, but residents share. E4 said I think the camera showed R2 tried to get up, but fell again. E4 stated he heard another resident shared a cigarette with R2 while he was on the ground then went into the facility to report the incident to the nurse. E4 said the patio door should have been locked and residents supervised that night because of the cold weather. E4 also said it was reported that R2 slipped on ice that night while in the courtyard. E15, CNA who works the night shift was interviewed on March 2, 2017 at 8:46 AM. E15 stated we only have a few independent smokers, but she was unsure if R2 was one of the independent smokers. E15 said there use to be a note saying R2 was not allowed to smoke because R2 would shake the ash tray can for cigarette butts, but that note is gone. E15 said we were never told who is an independent smoker, but we know because we worked with the resident for a long time. On March 1, 2017 E9, CNA stated that she usually worked evening and night shift. E9 stated that R2 would go out to smoke on the patio and would not listen. E9 said if R2 is not supervised he will go out with the independent smokers, get a cigarette from another resident, or pick up butts. E9 said when residents pick the lock; R2 would follow them outside to smoke and would not listen. E9 stated that the activity director was responsible for running the smoker program and letting us know who can smoke independently. On March 1, 2017 at 2:08 PM E8, Activity Director said she's been responsible for the facility's smoking program for the last 9 years. E18 stated the smoking rules have always been the same for residents to have scheduled and supervised smoking breaks for the last 9 years, we just have not enforced it consistently. E8 said according to the facility's smoking policy staff should be monitoring the residents as they smoke on the patio, but when R2 fell , the residents were going out on the patio at night smoking unsupervised. E8 stated R2 needs to be supervised because R2 will wander at night on to the patio to smoke unsupervised with the independent smokers. E8 stated R2 always wants to smoke and will try to go into the courtyard and smoke with the independent smokers anytime he (R2) sees the (independent smokers go out). On March 2, 2017 at 1:14 PM E20, PRSC (Psychiatric Rehab Service Counselor) stated that R2 used to be on my case load but is currently working with another PRSC. E20 stated I assessed R2 on June 12, 2016 to have deficits in self maintenance, community living, social and cognitive impairments. E20 said R2 sometimes is in his own world, needs cueing and supervision to maintain activities of daily living. E20 stated R2 is not a safe smoker because R2 will pick up butts, share cigarettes of others and smoke cigarettes till they burn and turn his finger tips black and brown. E20 said she talked to the nursing staff about this behavior because R2 is a diabetic and any injury to his skin or development of a wound would impact his health. E20 stated R2 is always trying to get outside on the patio to smoke without supervision with the independent smoker, and needs monitoring and supervision to manage this behavior. E19, PRSC was interviewed on March 2, 2017 at 1:34 PM. E19 said R2 needs to be supervised and does not have the capabilities to safely smoke independently. E19 stated R2 has burned his fingers in the past from smoking and attempts to smoke unsupervised. On March 3, 2017 Z1 (Psychiatrist for RS) stated that his (R2) PRSC would address and identify the interventions needed to monitor and supervise R2 while smoking, because they work with him daily. During Daily Status Meetings on March 3, 2017 and March 7, 2017, the administrative staff (E1/administrator and E2/director of nursing) was informed of concerns that nursing staff were not providing consistent monitoring/supervision of R2 who wanders around the building at night with possible unsafe behaviors. E1 said he reviewed the video tape of R2's fall and said R2 slipped and was not smoking. E1 gave no explanation of possible reason R2 was outside so early in the morning. E1 stated he observed on the video tape there was no witness to R2's fall, nor did E1 identify any staff being present in the courtyard coming to assist R2 after he fell on the ground. E1 said the patio door to the courtyard was left unlocked for the residents who smoke independently. E1 also said that one of the residents may have picked the lock and that is how R2 may have gotten out to the patio. E1 did not provide any evidence or identify any method staff used to monitor/supervise R2 who had behaviors (such: as picking up cigarette butts off the ground, shaking ash can for butts, irritating peers by begging, taking, or sharing cigarettes with the independent smokers) on a cold winter morning.

Based on observation, interview, and record review the facility failed to protect a resident from being physically abused by a staff on 10/6/2012, This failure resulted in an Immediate Jeopardy. On 3/26/13 at 5:27 pm, E1 (Administrator), E20 (DON) and E21 (ADON) were notified of the Immediate Jeopardy. The Immediate Jeopardy began on 10/6/12 at 6:47 pm when E3 (Certified Nursing Assistant, CNA) slapped R1 in the face. The immediacy was removed on 3/26/13 at 8:55 pm. The facility remains out of compliance at a Severity Level 2 due to the need to monitor and evaluate the effectiveness of the revised policies and procedures, assessments of residents and education of staff for abuse prevention. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings Include: R1 was a [AGE] year old resident, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Sheet. On 3/27/13 at 4:20 pm E1 (Administrator) stated R1 was sent to a local hospital on [DATE] and was readmitted to the facility on [DATE] at around 5:00 pm. The facility's investigation report shows on October 6th at 7:00 pm R1 was in the dining room while E4 (Housekeeper) was cleaning the dining room after the evening meal. E4 stated R1 had rolled herself out to the dining room. E3 (Certified Nursing Assistant, CNA) yelled R1 ' s name three times. E3 approached R1 who was sitting in her wheelchair. E3 struck R1 with open hands on both sides of her face and placed her hand over R1's mouth. R1 pulled E3's hands away and E3 took R1 out of the dining room. The report also documented E2 (Housekeeping/Laundry Supervisor) notified E1 (Administrator) of this abuse allegation on 10/7/12 at 3:20 pm and E3 was immediately removed from the schedule. E4 (Housekeeper) reported the physical abuse on 10/7/12 at 2:00 pm to E19 (Nurse). On 3/26/13 at 3:35 pm a video of the above mentioned incident was reviewed with E1. The video showed R1 was sitting in the dining room in her wheelchair dressed in a hospital gown. E4 was wiping the tables. E3 approached R1 from the back and with her right hand slapped R1 on her right cheek. R1 raised her right hand to protect herself and E3 slapped R1's hand. E3 then wheeled R1 to her room. The video showed E4 was seen observing this incident. The time registered on the video when E3 slapped R1 was 18:46:51 (approximately 6:47 pm). A review of E3's timecard report dated 10/6/12 showed E3 punched out at 9:53 pm. E13 (Nurse) was interviewed on 3/26/13 at around 12:36 pm. E13 stated on 10/6/12 E3 worked her whole shift, until around 10:00 pm. On 3/26/13 at 3:40 pm E2 was interviewed. E2 stated on 10/7/12 at 2:00 pm E4 told E19 (Nurse) about the allegation of physical abuse. E19 called him and stated E4 had something very important and he should come into the facility. So he came into the facility. E4 told E2 she saw E3 hitting R1. E2 then looked at the video tape and called E1. E2 stated he notified E1 at 3:20 pm. E2 further stated he saw E3 pulling into the parking lot so he told her she could not come into the building. E2 also stated he asked E4 why she did not report the physical abuse immediately and E4 told E2 she was scared of E3, as E3 had threatened another housekeeping staff 6 to 7 months ago. On 10/12/12 at 3:00 pm E4 said on 10/6/12 (Saturday) she started work about 2:15 pm. Around 7:00 pm she was cleaning tables in the dining room after dinner. E4 said she heard E3 yell out R1's name, and said "come here" three times, and then she hit her. E4 said she was afraid to report this while E3 was in the building. She was afraid of retaliation by the CNA, E3. The facility ' s policy and procedure dated 3/5/2009 and titled " Abuse Prevention Program " under the subheading of " Orientation and Training of Employees " documented " During orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs; Staff obligation to prevent and to immediately report abuse, neglect and theft to supervisory personnel ... " The same policy and procedure under the subheading of " Protection of Residents " documented " The facility will take steps to prevent mistreatment while the investigation is under way ... Employees of this facility who have been accused of mistreatment will be immediately removed from resident contact until the results of the investigation has been reviewed by the administrator or designee. Employees accused of alleged mistreatment shall not complete their shift as a direct care provider to residents ... " The facility failed to follow their policy by not immediately reporting physical abuse by a staff member to a resident to the supervisor/administrator and by allowing the accused staff to complete her shift as a direct care provider to the residents. On 3/26/2013 the surveyor confirmed the facility took the following actions to remove the immediacy of the situation 1. An In-service has been conducted to review all policy and procedures for the Abuse and Neglect. These in-services will be conducted by the Administrator or designee for current staff on duty and prior to next scheduled shift with shift starting at 10:00 pm, 5:00 am, 6:00 am, 8:00 pm, and 2:00 pm shifts. All staff will be in-serviced prior to working in direct patient care. Then semi-annually in-services will be conducted to review abuse and Neglect with staff. 2. An in-service will be conducted with staff to review signs of stress and burnout. This in-service will be done semi-annually. Social Services will be completing forms that prescreen risks for violence with all residents in the building. It will assess a residents risk at low, moderate and high. This information will be reviewed on a quarterly basis with the IDT team for 6 months.

Based on interview and record review the facility neglected to follow its policy and procedure by not taking action to place R1 on a hard surface and initiate artificial respirations, neglected to attempt to open the airway, neglected to give rescue breaths and neglected to give chest compressions while waiting for emergency response services (911) to arrive for R1 who was found unresponsive in her room on [DATE]. These failures caused R1 to suffer [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. An Immediate Jeopardy was identified on [DATE] at 5:27 pm. The Immediate Jeopardy began on [DATE] at 6:50PM when R1 was found unresponsive. The E1 (Administrator) was informed on [DATE] at 5:27 pm. The Immediacy was removed on [DATE] at 8:55 pm. The facility remains out of compliance at a Severity Level 2 due to the need to monitor and evaluate the effectiveness of the revised policies and procedures, assessments of residents and education of staff when finding someone unresponsive. This applies to 1 of 6 residents ( R1) reviewed for advance directives in the sample of 6. The findings include: R1's advanced directive in record dated [DATE] indicates she does want her life prolonged, meaning she is a full code. According to nursing notes of [DATE], R1 was in her room at 6:50 PM being fed by the CNA (E3) when she passed out. 911 was called, oxygen was given, and Cardiopulmonary Resuscitation (CPR) was initiated when the paramedics arrived. Telephone interviews with E13 LPN (licensed practical nurse) in the afternoon of [DATE] and [DATE] confirm she went to R1's room on [DATE] when called by E3 (CNA.). E13 said she found a lot of pureed food in R1's mouth, found a towel and attempted to remove food with her finger and then a towel. E13 said she could not remember if a blood pressure was taken, could not say if any respirations were counted or present, however E13 said E19 (LPN) was present and helping to get vitals from R1. E13 said she removed R1's gown because it was dirty with food. R1 was on oxygen, and had a pulse ox of 97. R1 was not removed from her wheel chair during this time. E13 said that she was surprised that E3 was feeding R1, because E3 had told E13 that R1 did not want to eat. E13 said she told E3 that if R1 said she does not want to eat that is OK don't force her. E19 LPN was interviewed in person on [DATE] and on the telephone on [DATE]. E19 said she assisted in the room with R1 after 911 had been called. E19 said she proceeded to R1's room when called to help, where she saw R1 slumped over in her wheel chair. E19 performed a check of R1's blood sugar which was 128; saw some food around her mouth. E19 said she did not pick up any respirations, does not remember her breathing, could not say any blood pressure was taken. E19 said R1 was unresponsive, meaning that she did not answer when her name was called, she was quiet. E19 said that R1 had a weak pulse. R1 remained in her wheel chair, by the time they got ready to put R1 in bed the ambulance came. In an interview with E13 on [DATE] at 12:38pm , she stated that when R1 was found to be unresponsive, not breathing with pureed food in her mouth, the possibility of using a suction machine to remove pureed food did not enter her mind. The EMS (emergency medical service) incident report of [DATE] indicates when they arrived in R1's room at 6:58 PM R1 was sitting upright in her wheel chair with staff present, unresponsive. R1 was not breathing and had no pulse; the paramedics initiated CPR after transferring R1 to a cot, started compressions and intubation. R1 was given [MEDICATION NAME] intravenous; this report indicates R1's response was improved with normal sinus heart rate. Vomit was noted in the Endo Tracheal (ET) tube which was suctioned and cleared of debris. In route R1 began attempting to breathe on own, slightly fighting the tube. Police report #,[DATE] has statements written on [DATE] from four employees who responded to the emergency (EMS call) at this facility on [DATE]. This report included: The central dispatch request stated " female, unconscious, and breathing in her wheelchair " . The patient (R1) was in her assigned room sitting upright, head back, unresponsive at the time of arrival. Three representatives from the facility were present gathered around R1's wheelchair, no CPR or other life preserving / saving efforts were observed. When asked, staff seemed unable to answer any questions regarding R1 and events leading to the incident. An EMS employee began asking the staff questions while assisting R1 - EMS said they " didn't feel a pulse. The staff standing in front of the wheelchair said " I didn't' get a pulse either. " Another staff member was heard saying to this co-worker " It's Okay, it's not your fault. " R1 was quickly moved out of wheelchair and onto a cot. Advance life support interventions were started. An airway was secured and during intubation a brown mush in the back of her mouth and upper airway was noticed. Intubation was completed. During ventilation the brown substance was seen inside the tube. When R1 arrived at the hospital she had a palpable carotid pulse, measurable blood pressure, showing normal sinus rhythm on the monitor and was beginning to fight her ET tube. The hospital record shows R1 was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. R1 was transferred to a long term care ventilator facility. The physician assessment note upon discharge [DATE] indicates R1 had [MEDICAL CONDITION] un-witnessed; severe [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], acute [MEDICAL CONDITIONS] aspiration, tracheotomy with a poor prognosis. The facility's policy and procedure dated ,[DATE] titled " Cardiopulmonary Resuscitation " documented " ...The following procedure shall be directed by a licensed nurse in the event of cardiac distress: ...4. If respirations are nonexistent or cease, place resident on a hard surface (floor or back board) and initiate artificial respirations. a. Position resident on back on hard surface. b. Open the airway by chin lift and remove any foreign objects/dentures. c. Give rescue breaths or provide respirations through an ambu bag ...5. If pulse is absent, initiate artificial circulation/chest compression 6. Continue CPR until a. Advanced life support systems are available ...7. Document all observations and occurrences in the medical record ... " On [DATE] the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the immediacy of the situation: 1. An In-service has been conducted with licensed nurses by the DON, ADON or Designee to review proper procedures for CPR and choking emergencies including medical assessment. The crash cart/emergency cart items have been reviewed on proper usage along with its location with ongoing monitoring in place. In-services for current staff completed and continue in-service prior to next schedule shift. The shifts for CNAs are at 10:00 pm, 6:00 am, and 2:00 pm and Nurses are 11:00 pm, 7:00 am, and 3:00 pm. All nursing staff will be in-serviced prior to working in direct patient care. A mock survey will be done 1 X monthly for 3 months to ensure compliance. The data collected will be reviewed at the next Quality Assurance meeting. 2. The emergency cart has all appropriate equipment on it in proper working condition. An oxygen tank has been added to the cart along with a working suction pump on [DATE].

Based on observation, interview and record review the facility failed to assess a resident who was identified as a full code and was found in cardiopulmonary distress. The facility failed to initiate basic life support (establishing airway, initiating cardiopulmonary resuscitation) when resident was found unresponsive on [DATE]. This failure caused R1 to have [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. These failures resulted in an Immediate Jeopardy. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy began at 6:50PM when R1 became unresponsive on [DATE]. On [DATE] at 5:27 pm to E1 (Administrator), E20 (DON) and E21 (ADON) were notified of the Immediate Jeopardy. While the immediacy was removed on [DATE] at 8:55 pm the facility remains out of compliance at a Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures, education of staff for identifying and assessing residents who are in cardiopulmonary distress and education of staff regarding initiating basic life support. This applies to 1 of 6 residents (R1) reviewed for advanced directives in the sample of 6. The findings Include: A speech therapy swallowing evaluation dated [DATE] shows R1 has a swallowing disorder with dysphasia. R1 has risk of aspiration, aspiration pneumonia, choking and delayed or slow swallow reflex. R1 was a [AGE] year old resident, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Sheet. On [DATE] at around 4:20 pm E1 (Administrator) stated R1 was sent to the local hospital on [DATE]. R1 was readmitted to the facility on [DATE] at around 5:00 pm. E13 (Nurse) was interviewed on [DATE] at 12:38 pm. E13 stated resident (R1) was readmitted to the facility from the local hospital on [DATE] at around 5:00 pm. R1 was alert oriented X 3. She was put into bed by the ambulance staff. R1's skin was checked, R1 had no issues. At 5:50 pm E3 (CNA) was asked to get R1 up for dinner. E3 came out of R1's room and stated R1 did not want to eat as she ate at the hospital. E13 said, "E3 told me twice R1 did want to eat, so I told her if she does not want to eat do not force her. I was about to start R1's readmission process like calling the doctor to verify the order I heard E3 screaming my name. It was around 6:50 pm. I went into R1's room, R1 was sitting in her wheelchair with her head forward and she was unresponsive. Her mouth was full of food. She had food all over, food was drooling from her mouth. I was surprised E3 was feeding her. I said how come you are feeding her now. I saw the tray in the room. E3 said nothing and was shaking " . I told E3 to call 911 right away. I called another Nurse (E17) and with the towel I tied to remove the food from her mouth. It was a lot of food. You do not know whether the resident was not swallowing and the CNA was feeding her. R1's mouth was full of food. I gave her oxygen via the nasal cannula at 4 L / Minute. We then removed R1's gown as she was dirty. We were going to lay her down on to the floor and paramedics came in." E13 further stated when you see lot of food the first thing we think is Aspiration and Choking. If it is choking we have to do [MEDICATION NAME], since the food was pureed it did not cross my mind she was choking. She said, "We do have an emergency kit. We have mask and stuff for suctioning. I did not suction her. I felt her radial pulse. Sometime I could feel it and sometimes I could not feel it. I did not see her chest going up and down. CPR was not started. Paramedics started the CPR. " E13 also stated the rescue breathing was not done because she had food in her mouth. R1 was quiet and calm. E13 stated " It was 7 minutes from the time E3 called my name and the Paramedics arrived. " The Police report included statements from Paramedics (Z4, Z5, and Z6). Z4 documented that on [DATE] R1 was in her room sitting upright, head back and unresponsive. R1 was pulseless. The report says, "Three representatives from the facility were present at our time of arrival. No CPR or other Life Preserving/Saving efforts were observed by me at the time our arrival. CPR was initiated by the paramedics." Z5 documented on [DATE] R1 was seated in the wheelchair. R1 had her head back and appeared unresponsive. Z6 began asking questions while assessing the resident. Z6 checked for a pulse and stated he did not feel a pulse. The staff responded " neither did we " . R1 was moved out of the wheelchair onto a cot and Advanced Life Saving (ALS) interventions were started. Z5 began securing R1's airway and during intubation noticed a brown mush in the back of her mouth and upper airway. The brown mush was described as " mashed potatoes with gravy " . Z6 documented on [DATE] they were dispatched at 6:52 pm. When he arrived in R1's room he saw staff gathered around the resident. The resident was sitting upright in her wheelchair, her head was back and she was unresponsive. R1 did not respond to verbal or painful stimuli. Z6 was unable to palpate R1's carotid and radial pulse and while informing his coworkers (other paramedics) he did feel a pulse. At that time the staff member in front of R1's wheelchair said ' I didn ' t get a pulse either. " Z6 asked that staff member to move, as she was moving Z6 heard another staff member telling her, " It's okay, it's not your fault. " R1 was moved from the wheelchair to the cot and interventions were started. The report from the local fire department dated [DATE] documented they received the call at 6:52 pm. Upon arrival to the facility at 6:57 pm R1 was unresponsive and pulseless and CPR was initiated. [MEDICAL CONDITION] prior to the arrival of the EMS (Emergency Medical Services). The etiology of [MEDICAL CONDITION] " Respiratory " , estimated time of arrest " ,[DATE] minutes " R1's hospital records were reviewed. The consultation report dated [DATE] documented R1 was found to be unresponsive and paramedics were called in. There was possibility of aspiration and she was found to be in a pulseless situation with full cardiopulmonary arrest The Critical Care Medicine (CCM) Note dated [DATE] documented R1 was found unresponsive in her room by EMS. R1 had acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. R1 had severe [MEDICAL CONDITION], [MEDICAL CONDITIONS] secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION] probably secondary to aspiration. On [DATE] at 4:00pm Z7 (R1's Attending Physician) when asked, stated anoxia would cause brain damage and the longer the anoxia persist the damage would be worst. Z7 further added if R1 aspirated any food then the cause of the [MEDICAL CONDITION] would be respiratory. American Heart Association 2010 Guidelines documented, " ... The purpose of CRP is to bring oxygen to the victim's lungs and to keep blood circulation so oxygen gets to every part of the body. When a person is deprived of oxygen, permanent brain damage can begin in as little as four minutes and death can follow only minutes later. So the main objective is to intervene as soon as possible. Table below represents the likelihood of brain damage or death and typical timing after the heart stopping 0 to 4 minutes after exhibiting symptoms - Chances of Brain Damage Minimal 4 to 6 minutes after exhibiting symptoms - Chances of Brain Damage Possible 6 to 10 minutes after exhibiting symptoms - Chances of Brain Damage Likely Greater than 10 minutes - Chances of Brain Death Likely. " The facility's policy and procedure dated ,[DATE] titled " Cardiopulmonary Resuscitation " documented " ...The following procedure shall be directed by a licensed nurse in the event of cardiac distress: ...4. If respirations are non existent or cease, place resident on a hard surface (floor or back board) and initiate artificial respirations. a. Position resident on back on hard surface. b. Open the airway by chin lift and remove any foreign objects/dentures. c. Give rescue breaths or provide respirations through an ambu bag ...5. If pulse is absent, initiate artificial circulation/chest compression 6. Continue CPR until a. Advanced life support systems are available ...7. Document all observations and occurrences in the medical record ... " On [DATE] at 1:22 pm the Emergency Cart/Crash Cart was observed with E13 and E20 (DON). The cart was covered with a red mesh plastic cover. When the cover was removed the cart was very dusty. The cart had two suction machines with only one suction canister. E20 was asked to show whether the suction machine was working. At 1:37 pm E20 tried to get the suction machine to work. When asked how do we know that the suction machine is functioning E20 replied " I don't know how. I don't know where the tubing goes. " At 1:45 pm E21 (ADON) tried to hook up the tubing to the suction and she stated " there are missing parts. " When asked whether there was a functioning suction machine, E21 stated " No, we have to order the parts. " A review of the Emergency cart Checklist showed there was no [MEDICATION NAME] (suction tip) or airway on the cart. There was no oxygen tank on or by the cart. E20 stated the oxygen tank is in the oxygen room. The oxygen room was checked with E20. The oxygen tank in the portable stand was observed to be empty and this was verified by E20. There was no oxygen set up. E20 when asked stated " It was here, I don't know where it is. " E20 was asked who was responsible to check the Emergency cart. E20 stated it was checked by the Nurse on the Night Shift. E20 showed the January and February 2013's Emergency Cart Checklist. E20 was made aware the Emergency Cart Checklist was not consistently filled. E20 replied " I know " . When asked to show the checklist for [DATE], she stated " They did not do it " . At 4:40 pm E21 brought the Emergency Cart Checklist for [DATE]. The checklist was reviewed along with the [DATE] staffing schedule. At 4:42 pm E21 verified that the signature on the checklist from [DATE] to [DATE] was that of E20. E21 also stated " It is the DON ' s signature and she (E20) said she filled them. " On [DATE] the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the immediacy of the situation: 1. An In-service has been conducted with licensed nurses by the DON, ADON or Designee to review proper procedures for CPR and choking emergencies including medical assessment. The crash cart/emergency cart items have been reviewed on proper usage along with its location with on going monitoring in place. In-services for current staff completed and continue in-service prior to next schedule shift. The shifts for CNAs are at 10:00 pm, 6:00 am, and 2:00 pm and Nurses are 11:00 pm, 7:00 am, and 3:00 pm. All nursing staff will be in-serviced. A mock survey will be done 1X monthly for 3 months to ensure compliance. The data collected will be reviewed at the next Quality Assurance meeting. 2. The emergency cart has all appropriate equipment on it in proper working condition. An oxygen tank has been added to the cart along with a working suction pump on [DATE] .