Every finding on record at Park View Rehab Center

Based on interview and record review, the facility failed to protect a resident (R2) from physical abuse from another resident (R3). This failure affected one (R2) out 3 residents reviewed for abuse.Findings include:R2's Electronic Health Record (EHR) documents R2 has diagnoses including but not limited to Toxic Encephalopathy, Chronic Kidney Disease, Stage 3a, Alcoholic Hepatitis with Ascites, Hyperglycemia, and Schizophrenia.R2 has a Brief Interview of Mental Status score of 09 that indicates moderate cognition impairment.R2's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors (SS), dated 8/16/2026, documents 4. History or recent episode of aggressive/agitated behavior (aggression towards others including destruction of property, fire setting, or other violent acts and/or noncompliance with medications, treatment regimen, resisting care=2 (Substantial or Significant Problem).R2's care plan focus Abuse, dated 8/16/2026 by V11 (Psychiatric Rehabilitation Service Director), documents R2 comprehensive assessment reveals hx (history) of suspected abuse &/or neglect or factors that may increase his/her susceptibility to abuse/neglect. The resident demonstrates: Difficulty in adjustment & generalized mood distress. Symptoms may be manifested by: verbal expressions of distress., Difficulty in adjustment & generalized mood distress. Symptoms may be manifested by: behavioral symptoms., Behavior that might be characterized as provoking, antagonizing, disrespectful, angry, insensitive, &/or annoying.R3's Electronic Health Record (EHR) documents R3 had diagnoses including but not limited to Diabetes Mellitus, Paranoid Schizophrenia, Hypertension, Blindness Right Eye, Major Depressive Disorder, and Unsteadiness on Feet.R3 has a Brief Interview of Mental Status score of 09 that indicates moderate cognition impairment.R3's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors (SS), dated 8/16/2026, documents 4. History or recent episode of aggressive/agitated behavior (aggression towards others including destruction of property, fire setting, or other violent acts and/or noncompliance with medications, treatment regimen, resisting care=2 (Substantial or Significant Problem).R3's care plan focus (Abuse), dated 8/16/2026, documents R3 has hx of suspected abuse Symptoms may be manifested by verbal expressions of distress. Difficulty in adjustment & generalized mood distress. Symptoms may be manifested by: observable signs of distress., Difficulty in adjustment & generalized mood distress. Symptoms may be manifested by: behavioral symptoms., Behavior that might be characterized as provoking, antagonizing, disrespectful, angry, insensitive, &/or annoying.Nursing staff schedule, dated 8/15/2026, documents V10 (Licensed Practical Nurse) was assigned to provide care to R2 and R3 and V11 (Certified Nursing Assistant-CNA) was assigned to R3, and V13 (CNA) was assigned to R2.On 8/28/2026 at 12:01pm, R2 statedR3 jumped on him because he (R2) was sitting in the doorway of the bedroom. R2 stated R3 did not break his finger but broke his fingernail trying to defend himself.On 8/28/2026 at 12:32pm, R3 stated he does not recall a physical altercation with R2 and does not recall speaking with the police.On 8/28/2026 at 2:54pm, V12 (Certified Nursing Assistant-CNA) stated, I was doing rounds and was walking back from the nurse's station when I heard arguing, so I went to where I heard the arguing, and it was (R2) and (R3). (R3) was standing up behind (R2) who was in his wheelchair. Both residents were closer to the doorway. V12 stated he could not really hear what they were saying and he just heard name calling. V12 stated he stepped in between R2 and R3 and called for V13 (CNA) to get the nurse. V12 stated he could see R2's finger or hand was bleeding. On 8/28/2026 at 3:07pm, V13 (CNA) stated, I was two rooms down and across the hall providing care to another resident when I heard someone who having an elevated conversation. I went to make sure everything was ok and (V12), the other CNA, was already addressing the issue. (R3) was standing to the right behind (R2), and (R2) was in the doorway so no one could get past (R2). (R2) was sitting in the doorway waiting on her (V13) to provide incontinence care. (R2) said (R3) was trying to push past him to leave the room and started hitting him (R2). V13 stated she had just spoken to R2 about 10 minutes prior to the incident and told R2, who was sitting in his room, that she would change R2 (provide incontinence care) once she was done with another resident.On 8/28/2026 at 3:17pm, V10 (Licensed Practical Nurse-LPN) said, I was told by (V11, CNA) that (R2) was sitting in the middle of the doorway and (R3) was trying to leave the room and (R2) was in the way. R2 told her that he was sitting in the doorway waiting for V13 to change him when R3 got up and was trying to push past him out of the room. R2 said R3 started hitting him and he (R2) broke his fingernail down to the nail bed trying to defend himself. V10 stated she cleaned R2 left hand and fingernails and covered it with a band aid, called the V1 (Administrator), V3 (Director of Nursing), doctor, and residents family member and friend. R2's progress note, dated 8/16/2026 at 03:39am by V10 (LPN), documents, reported to the writer (V10), that the resident (R2) had a physical altercation with his roommate (R3). He (R2) was blocking the doorway, and his peer (R3) attempted to remove him (R2) from the doorway, causing him (R2) to strike out which led to him (R2) breaking his left middle fingernail.R3's progress note, dated 8/16/2026 at 2:15am by V10 (LPN) documents, reported to the writer (V10), that the resident (R3) had a physical altercation with his roommate (R2). He (R3) attempted to remove his peer (R2) from the doorway of their room, causing the peer (R2) to strike out which led to a broken fingernail.On 8/29/2026 at 1:17pm, V3 (Director of Nursing) stated the facility's abuse policy's purpose to ensure the residents are not being abused and that they are safe and that all protocols were used to keep the residents safe. V3 also said, No, we (facility staff) did not protect (R2), but we cannot predict when a resident will have behaviors.On 8/29/2026 at 2:14pm, V1 (Administrator) stated the purpose of the abuse policy to make sure staff are educated and keep the residents safe. V1 also stated, yes, it was a failure on our part, but we cannot anticipate when something is going to trigger a resident that causes them to put their hands on another resident.Undated Abuse Policy documents, this facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse of residents.

Based on interview and record review, the facility failed to affirm the right of one (R5) resident to be free from physical abuse. The deficient practice resulted in actual harm when R5 sustained nondisplaced fracture of the distal tip of the nasal bones. The findings include:R5's admission record / face sheet shows admit date on 3/28/22, with diagnoses not limited to Bipolar disorder, Hyperlipidemia, Other asthma, Paranoid schizophrenia, Depression, Fracture of nasal bones, Vitamin d deficiency, Type 2 diabetes mellitus. MDS (Minimum Data Set), dated 1/15/26, shows R5's cognition is moderately impaired.On 5/3/26 At 10:32AM, R5 was sitting up on wheelchair, alert, and verbally responsive. R5 stated R6 struck / hit him with closed fist on the face and nose inside the bathroom. He said there was a little bleeding on his nose and there were scratches on his face. R5 stated his nose was hurt. He stated he was scared and fearful because his arm was pulled and R6 tried to choke him inside the bathroom. R5 stated he was yelling / screaming for help and staff came to help him right away. R5 stated they took picture or X-ray of his face and nose then he went for doctor's appointment.On 5/3/26 At 11:09AM, V12 (CNA / Certified Nursing Assistant) stated he was working on 2/2/26, around morning time, R5 was using a bathroom by the nurse's station when R6 entered the bathroom. He said he did not know what happened inside the bathroom, but he heard R5 was screaming, and he attended immediately and saw R5 and R6 inside the bathroom. He said both R5 and R6 were separated right away. He said he called the nurse (V19) right away. V12 stated, R5 claimed R6 hit / struck him on the face. On 5/3/26 at 12:40PM, V17 (PRSD / Psychiatric Rehabilitation Services Director) stated he was informed about the incident between R5 and R6 last February 2026. He stated R5 was in the bathroom and R6 came inside the bathroom. V17 stated R5 claiming that he was struck on the face then pulled his arm and R6 was the perpetrator. He stated R6 was sent out to the hospital. V17 stated x-ray was done in the facility as ordered for R5. V17 stated striking and pulling is an example of physical abuse allegation and it was reported to the Administrator right away.On 5/4/26 at 9:12AM, V19 (LPN / Licensed Practical Nurse) stated she received an abuse allegation in February 2026 between R5 and R6. V19 staff reported to her that R5 was in the bathroom right next to the nurse's station when R6 punched or hit R5 on the face and his nose and pulled R5's arm. V19 stated she assessed R5 right away and observed scratches on his face and nose. She said there was slight bleeding on R5's nose, R5 was scared and fearful. Both residents were separated and informed V1 about the physical abuse allegation. V19 stated X-ray was done in the facility and result revealed fracture of the nose. She stated R6 was transferred to the hospital. V19 stated the following day after the incident, there was some redness and bruising on R5's nasal area. On 5/4/26 At 9:49AM V22 (PA / Physician Assistant) stated he was informed about the physical altercation between R5 and another resident in the facility. He stated he was not aware of the details of physical altercation incident. He stated x-ray was ordered for R5 and result revealed nondisplaced nasal fracture. V22 stated no treatment for nondisplaced nasal fracture, it will heal by itself and treated with pain medication. V22 stated nondisplaced fracture could happen if there is trauma like punching or hitting on the face or nose. He stated hitting or punching is an example of physical assault or abuse between resident to resident.On 5/4/26 at 10:01AM, V13 (ADON / Assistant Director of Nursing) stated she was informed by staff that R6 hit R5 on the face / nasal area in the bathroom. She stated she saw R5 after the incident and his face was a little red. She stated X-ray was done as ordered for R5 in the facility and result revealed fracture on the tip of the nose. V13 stated the incident between R5 and R6 was an example of physical abuse allegation. On 5/4/26 At 11:22AM, V1 (Administrator) stated she received an abuse allegation between R5 and R6. She stated the nurse reported to her that R5 and R6 engaged in physical altercation in the bathroom by the nurse's station. V1 stated R5 claimed R6 punched him on the nose. Both residents were immediately separated. V1 stated R5 had superficial scratches on the nose. When asked what happened, R5 said while in the toilet R6 walked in the bathroom and struck him on the nose. V1 stated staff reported the incident to her because it was identified as an abuse allegation. She stated X-ray ordered and was completed for R5 and result revealed distal fracture on the nose. She stated the incident between R5 and R6 was investigated thoroughly and was reported to state agency. V1 stated abuse allegation was substantiated. V1 stated it is the facility's goal and Resident rights that they should be free from abuse. R5's Nursing Progress Note, dated 2/2/2026, shows: (R5) stated that a co-resident struck him in the face with a closed fist unprovoked in a common bathroom. Both residents were separated. Noted 2 scratches to the right facial area. MD (Medical Doctor) made aware with orders for X-Ray of Nasal and Facial area. Called (city) Police informed of the incident (city) Police here, Report (#).R5's police report, dated 2/2/26, shows: Battery simple between R5 and R6. R5's x-ray exam of nasal bones, dated 2/2/26, findings shows: Examination reveals nondisplaced fracture of the distal tip of the nasal bones. R5's PRN (as needed) Medication, dated 2/3/2026, shows: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for mild to moderate pain 1-5 (650 mg). Complaint of Nasal Pain.R5's final incident investigation report, dated 2/7/26, shows: On 2/2/26, V19 reported to the administrator that R5 alleged he was struck in the face by R6. The facility determined R5 was utilizing the communal restroom on the 1st floor near the nurse's station. R6 entered the restroom and an altercation ensued. Staff in the unit heard a commotion, went to investigate the situation and observed both R5 and R6 in the common restroom. R5 reported R6 struck him in the face with a closed fist unprovoked. R5 was assessed and observed with superficial scratches on his nose, there was no swelling, bruising or discoloration noted. Xray was ordered by physician, and results reveal a nondisplaced fracture of the distal tip of the nasal bone. The police were contacted. Based on the known facts from medical record review and interviews, the conclusions have been determined about the allegation: Abuse and is Substantiated. V22's Physician Progress Note, dated 2/12/2026 14:46, shows: NASAL FRACTURE: x-ray of facial bones on 2/2/26 showed a nondisplaced fracture of distal tip on nasal bone. Tylenol prn for pain. ENT eval as outpatient ordered.Facility's Abuse Prevention and Reporting policy, dated 2/2/26, shows: This facility affirms the right of our residents to be free from abuse. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.Facility's Residents' Rights for people in long term care facilities policy, dated 11/18, shows: Your rights to safety. You must not be abused - physically.

Based on interview and record review, the facility failed to provide appropriate supervision for one (R2) resident who was identified at risk for elopement and requires supervision with community access. The findings include: R2's admission record / face sheet shows admission date on 1/12/26, with diagnoses not limited to Acute respiratory failure with hypoxia, Biliary acute pancreatitis without necrosis or infection, Other pulmonary embolism without acute cor pulmonale, Generalized anxiety disorder, Insomnia, Major depressive disorder, Essential (primary) hypertension, Extrapyramidal and movement disorder, Gastro-esophageal reflux disease, Alcohol dependence, Opioid dependence, Other chronic pain, Obstructive and reflux uropathy, History of falling, Muscle weakness (generalized), Other abnormalities of gait and mobility, Unsteadiness on feet, Encephalopathy, Gastrointestinal hemorrhage, and Other psychoactive substance abuse. R2's MDS (Minimum Data Set), dated 1/19/2026, showed R2 cognition was intact. On 2/11/26 At 10:55AM, R2 was up and about, ambulatory, alert and oriented x 3, verbally responsive. He said on 1/14/26, around evening time, it was already dark outside, he left the facility unauthorized. He stated nobody told him that he was in Chicago, and he did not feel safe. He said he had paranoia because of his history of taking drugs. He said he did not feel safe / comfortable in the facility, and he thought somebody was after him, so he exited the facility without telling the staff. R2 said staff were behind him and saying you can't leave the facility. He said it was after dinner when he left the facility. He said the staff were closely monitoring him and were on him because he wanted to leave. R2 said he told staff they couldn't hold him and left the facility. He said he thought there was an alarm going off when he left the facility. He said he was not sure which floor the alarm went off. R2 said he thought there was a female facility staff running after him and probably could not catch him because he was running as fast as he could. He said he did not realize that he was Chicago, and it was very cold outside, raining ice / snowy. He said he was wearing the same type of clothes he is wearing today when he left the facility. He said he was wearing a sweater, pants, and shoes with no socks. Observed R2 wearing gray sweater, pants, and shoes. R2 said his sweater was not a winter jacket and should have had a coat over it. He said he walked outside of the facility for a while and when he noticed that he was hit by ice / snow, he felt very cold. He said he was walking and running a little bit. R2 said he was maybe a couple blocks or about a half mile away from the facility and saw an apartment building. He said he sat in the lobby of the apartment building to shelter because he felt very cold already. R2 said he was not in the proper state of mind. He said he felt his mind was telling him that people around him were trying to hurt him and wanted to leave the facility. R2 said he was walking and running for about an hour in the cold. He said he probably was running as fast as he could to leave the facility. R2 said he was in the lobby of the apartment maybe for more than 2 hours to shelter, then a random person helped him and called the police. He said 2 policemen came, called an ambulance, and he was brought to the hospital. R2 said there was some bruising on his left foot, pain medicine (Tylenol) was given, compression wrap was applied on his foot, and nonskid socks were provided in the hospital. R2 said he stayed in the ER for about 2 hours. He said female staff from the facility came and brought him back to the facility. R2 said it was cold and probably when he was running, he twisted his left leg and there was bruising. He thought the alarm went off; he heard a sound by the stairwell that he used when he exited the facility. He said maybe the staff got tired of him trying to get him to stay in the facility. He said nobody was watching him when he left the facility. There was a male staff working in the facility and was trying to stop him as much as he could. R2 said maybe if a male staff had run after him, then maybe he would have been caught. He said he was limping because he twisted his left leg. On 2/11/26 At 3:03PM, V18 (Certified Nursing Assistant / CNA) said she has been working in the facility in July 2024 and was mostly assigned on the 1st and 2nd floor. She said on 1/14/26, she was working on the 2nd floor but was not assigned to R2. V18 said when she arrived at 3 PM on 1/14/26, she noticed R2 was walking from hallway to hallway, dining room to his room. She said R2 was trying to escape using the back door through the stairwells and was redirected by V30 (Social Service staff). R2 was brought back to his room. V18 said after smoke break around 6:35PM, upon entering the 1st floor, the stairwell alarm went off, she went outside of the facility to see if there were any residents outside and did not see anybody, so the alarm was turned off, and she came back to the floor. V18 said she was coming to the 2nd floor using stairwell from the first floor when she saw V13 (Nurse on duty) who told her R2 ran out of the building. She stated V13 told her she was chasing after R2 but R2 did not want to go back to the facility. V18 said there is always 1 staff watching the day room and hallway; CNA rotates hourly to do hallway / dining room watch. V18 said most CNAs / staff went outside of the facility and searched for R2 for more than 2 hours. She said it was very cold outside, and it was snowy.On 2/11/26 At 3:28PM, V19 (CNA) said he has been working in the facility for more 6 years and regularly assigned on the 2nd floor. He said he had worked with R2. V19 said he was working on 1/14/26 but he was not assigned with R2. He said after dinnertime, around 5:50PM - 6PM, R2 was restless, walking / pacing back and forth in the unit hallway, from one end to another end. He said he was coming out from the shower room after giving shower to a resident and heard the alarm go off on the back door of the 2nd floor stairwell and heard V13 (Nurse on duty) saying R2's name going out of the door. He said V13 followed R2 out of the door by the stairwell. V19 stated he could not leave his resident in the hallway, so he put the resident in bed. V19 said he saw V13 come back after putting resident in bed and told him that she could not find R2. V19 said he went out with another CNA (V24) to search for R2 using his car but did not find R2. He said he had been searching for more than two hours. V19 said it was very cold outside, and it was snowing that night. There was overhead paging that resident had eloped, he heard it when he was in the room putting resident to bed after shower. He said there should be staff monitoring the hallway and dining room all the time. V19 said CNA rotates hourly to watch dining and hallway. He said R2 went through the back door stairwell because the alarm went off. Even if there was a staff monitoring the hallway at that time, R2 would have left and would not be caught because he was fast. V19 said there were 4 CNAs and 1 nurse working in the unit on 1/14/26. On 2/11/26 At 4:00PM, V17 (CNA) said she has been working in the facility for almost 3 years and most of the time assigned on the 2nd floor. She said she was assigned to R2 on 1/14/26. After dinner time around 6PM, R2 was observed in and out of his room. V17 said R2 was observed walking back and forth hallway to hallway, dining to his room around 5:30PM - 6PM. She said that same day on 1/14/26, R2 was trying to get out of the building at around 4-5PM, was trying to get out of the stairwell back door. V17 stated R2 pushed the 2nd floor back door and the alarm went off. R2 was redirected by V30 (SS staff) and was brought back to this room. V17 said CNA rotates hourly to watch dining room and hallway continuously. She said it was not her time to monitor the hallway when R2 left the facility. V17 said during that time she was attending to one of the residents in their room. She said when she came out of resident's room, V18 (CNA) told her R2 went out of the facility. She said she did not hear any alarm go off, maybe because she was inside the resident's room, but she heard there was overhead elopement paging. V17 said V13 (nurse on duty) came back to the facility from outside search and did not find R2. She said V13 ran after R2 but did not allow V13 to bring R2 back to the facility. She said they could not force R2 to go back to the facility. V17 said all the staff went out to search for R2. She said they were searching for R2 for more than 2-3 hours. V17 said that day / night was very cold and snowing. On 2/11/26 at 4:27PM, V24 (CNA) stated she has been working in the facility for about 2 years in the facility and mostly assigned on the 2nd floor. She said there is always a staff / CNA continuously watching or monitoring dining room and hallway. V24 said CNA rotates hourly to watch dining and hallway. She said on 1/14/26, she was not assigned to R2 but was working on the 2nd floor. V24 said she was taking vital signs for one of the residents in the room, she heard an overhead paging for elopement code, maybe around after dinner time. She came out of the room and was informed that R2 had left the building and could not be located. V24 said V13 went after or chasing R2 outside of the building and R2 did not want to go back to the facility. She said V13 was not wearing coat, and she was freezing so she came back to the facility to inform them to search for R2. V24 said they searched for R2 around the facility and outside of the facility. It was very cold and snowy at that time. She said she went out 2 times to search for R2 for about 2-3 hours and could not find him. On 2/11/26 At 4:40PM, V13 (LPN / Licensed Practical Nurse) stated she started working in the facility in October 2025 and regularly assigned on the 2nd floor. She said there is always at least 1 staff continuously monitoring dining/ hallway. She said CNAs rotate hourly to watch dining and hallway. V13 said if she is doing med pass in the hallway then CNA can do something else. She said on 1/14/26, before dinner time, R2 was trying to get out of the back door on the 2nd floor, and she could not remember if the alarm went off. V13 said V30 (SS) redirected him to his room and was settled in the room. She said around dinner time, R2 was pacing or walking back and forth in the hallway, room and dining room. V13 said there was no CNA watching the hallway because she was passing medication in the hallway. She said after dinner time around 6:30PM, she was giving medication in the room to one of the residents and heard V19 (CNA) telling R2 stop, where are you going?. V13 said she went outside and heard the alarm go off by 2nd floor back door. V19 was in the hallway standing by linen cart. She said she ran out after R2. V13 said R2 was running by the stairwell then another alarm on the 1st floor went off. V13 said she went outside to the alley, and she was not wearing any coat / jacket. She said she saw R2 wearing a sweater, pants, sneakers. R2 was not wearing appropriate clothes for the cold weather. V13 said she told R2 to come back, and he said NO and then ran away. V13 said she followed him just to find out where he was going to tell staff where R2 was heading. She said she tried to hold R2, but he pulled back and R2 said don't touch me and ran away. V13 said she went back to the facility because she was not wearing a jacket at that time, and it was very cold and snowing. V13 said upon coming back to the facility, there was a group of staff at the back door searching for R2. She said she told the staff which way R2 was going and staff searched for him. V13 said she called V28 (ADON / Assistant Director of Nursing) while she was outside chasing R2 and V28 called the reception. She said she was outside when they announced the elopement code. V13 said staff had searched for 2-3 times; came back around 10PM. She said R2 was missing for more than 2hours; she informed family and Physician. V13 stated she called the police as soon as she could not find R2. V13 said there were 4 CNAs and 1 nurse working on 2nd floor on 1/14/26.On 2/17/26 at 10:39AM, V28 (ADON / Assistant Director of Nursing) said on 1/14/26 around 6:30pm, she received a call from V13 informing her R2 had left the building and V13 was chasing him. She said V13 could not catch R2 and could not be found. V28 stated she called the facility to initiate elopement code. She said CNAs were searching for R2. V28 said V1 (Administrator) was also informed. She said they called the police and did police report. V28 said they also called nearby hospitals but R2 was not found. She said around 9-10PM, she received a call from V1 that police found R2 and was sent to the hospital. She said R2 was brought back to the facility around 11PM. V28 said staff are expected to monitor and watch hallway and dining room hourly to quickly assist/help residents with needs, for safety purposes or if a resident is attempting to leave the facility to redirect them right away.On 2/17/26 At 11:40AM, V30 (Social Service staff / PRSC / Psychiatric Rehabilitation Social Services Coordinator, CNA) said he has been working with R2. He said on 1/14/26 around 4-5PM, R2 attempted to leave the back door through the stairwell and the alarm went off. V30 said he was able to redirect R2 and was brought back to this room, stay calm and collected in his room. He said R2 was assessed as elopement risk. V30 said R2 was talking about leaving the facility, he was educated if he wanted to be discharged to follow the protocol so he can be properly discharged from the facility. He said R2 was also asking about the police station. V30 said at around 6:30PM, he was about to leave the facility when he heard an elopement code through overhead paging system. He said R2 left the facility unauthorized, the nurse ran after him. V30 stated he helped search for R2, he checked at the police station as R2 mentioned earlier during their conversation. He also checked the stores / establishments nearby, it was cold outside, and it was snowy. V30 said he looked inside the business establishment; maybe R2 was seeking for shelter. He said he did not find R2. He said R2 was found after he left the facility. V30 said he received a text message R2 was found around 10-11PM. He said he saw R2 the following day on 1/15/26. R2 regretted running away / eloping because it was very cold that night. V30 stated R2 was outside for too long, it was cold. R2 was not wearing winter coat; he was not wearing appropriate clothes for the weather. On 2/18/26 at 9:25AM, V34 (Physician) was interviewed via phone and said R2 is one of his residents in the facility. He stated he saw R2 but could not remember when; R2 is stable. V34 said he was informed by staff regarding R2's elopement incident on 1/14/26. He said nobody would suspect R2 would elope, it was a spontaneous incident, staff followed him but could catch him. V34 said the resident could leave AMA (against medical advice) with informed consent. He said staff could be compassionate with their needs, listen to their needs / customer needs, and give them reassurance that they would be taking care of in the facility. V34 said elopement usually happens within 2-3 days within their admission. V34 said there was no warning sign of R2's elopement. He said R2 was evaluated in the ER, don't think he needed more medical intervention. V34 said R2 with history of depression, psychiatrist is seeing him. He said this is a learning experience, learning over what else facility can do to prevent this incident from happening again. V34 said listen to the residents, saying we care about you, do not single out resident. He said simple words - helps a lot. V34 said R2 leaving the facility unauthorized during wintertime / cold weather could potentially sustain frost bite and hypothermia. V34 said there was no report of frost bite or hypothermia from the hospital and R2 was able to go back to the facility safely.On 2/18/26 At 9:47AM, V2 (DON / Director of Nursing) said she was on vacation at the time of the incident on 1/14/26. She said she read R2's progress notes and she spoke with V13 regarding the incident. She said R2 was wandering to another resident's room, and she was not aware R2 had attempted to leave the floor / unit prior to elopement on 1/14/26. V2 said she interviewed V13 (nurse on duty) regarding R2's incident on 1/14/26. V13 was passing medication in resident's room and heard CNA saying STOP to R2. V13 immediately came out of the room and saw R2 going out by the back door stairwell. She said the alarm went off and V13 ran down the stairs and followed R2, but she lost him because he was running. V13 was not wearing a coat / jacket. V2 said she didn't believe R2 had on proper clothes for the winter. V2 said V13 called ADON while she was still out of the building. When V13 came back to the facility, the CNA started to search for the resident, the administrator, MD, R2's sister, and police were informed. The police found him maybe about 2 hours later and transferred R2 to hospital for evaluation and he came back to the facility. She said V1 (Administrator) picked up R2 in the hospital. There was no hospital records provided during discharge. She said Potential risk of R2's unauthorized departure from the facility, he could sustain hypothermia, frost bite. On 2/18/26 At 10:46AM, V1 (ADMINISTRATOR) stated she has been working in the facility since 2013 as a CNA, she worked her way up and transitioned into an administrator role in 2020. She said on 1/14/26 at 6:30PM, she was at home and received a call from the ADON informing her that the nurse on duty had called her that R2 had left the facility via 2nd floor stairwell and exited back door. She said the nurse was in pursuit of him going down (name) Street. V1 said Elopement Code was initiated so staff members went outside to locate R2. She said some staff were in cars, and some were on foot. V1 said she notified ADON that she was on her way to the facility and instructed them to call the police. She said she started searching the area on her way to the facility, driving around to locate R2. V1 said she had just arrived at the facility when the police called to inform her R2 was found. She said R2 was found just about quarter to half miles away from the facility. V1 said the police informed her they would take R2 to hospital and she told them she would meet R2 at the hospital. V1 said R2 was found about 2.5 to 3 hours after he left the facility unauthorized. She said she went to the hospital and picked up R2, stayed for a while due to R2 still being evaluated in the ER (Emergency Room). V1 said they came back to the facility about 11-11:30PM. She said she drove R2 back to the facility. She said there was no apparent injury when she saw R2 in the hospital. V1 said R2 was wearing sweater with a hood, it was cold outside, and his clothes were not appropriate for the cold weather. She said routine checks or evaluation were done in the ER with no information about frost bites or hypothermia. V1 said R2 left the facility unauthorized, there was no indication that he would elope that day. She said she was not aware R2 had already attempted to leave the facility, and staff was able to redirect him before the elopement incident.R2's Elopement risk review, dated 1/13/26, reviewed and showed: The resident is at risk for elopementR2's Community Survival Skills, dated 1/13/26, reviewed and showed: The resident does not appear to be capable of unsupervised outside pass privileges at this time. Social Service will conduct more assessment to determine resident's community access level.Nursing Progress Note, dated 1/13/2026 18:39, showed: R2 remains alert to self and requires constant redirection due to wandering the halls and entering other residents' rooms.Nursing Progress Note, dated 1/14/2026 23:36, showed: R2 returned from hospital, and asked where he was going and why did he leave? R2 states, he doesn't know where he was going, and he just wanted to get out of here.Care plan, dated 1/18/26, showed: R2 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming. Symptoms are manifested by: Attempting to leave the facility without a responsible escort (elopement), Pacing, roaming or wandering in and out of peers' rooms., Engaging in theme behavior, believes he/she is in another time & place with specific responsibilities. R2 is an ELOPEMENT RISK.Care plan, dated 1/14/2026, showed : R2 expresses the desire to receive an outside, independent pass. R2 requires the support of a long-term care facility secondary to: A substance abuse disorder. R2's Community Access Level-SUPERVISION. R2 can access the community and patio with family and staff.Police report, dated 1/14/26, showed: Name of person missing: R2. Date / time of occurrence: 1/14/26 at 6:30PM.Hospital records, dated 1/14/26, showed: (R2) who is in nursing home for multiple issues stemming from alcoholism. (R2) was admitted to nursing home 2 days ago. This morning, he left nursing home and got confused, asked police to help him and they brought him here. The staff from nursing home also arrived and can take him back. (R2) states he has been walking outside today in shoes without socks and has pain to medial aspect of right foot. On exam he has some callous to right great toe medial and slight skin redness. No sign of infection or frostbite. (R2) was given socks, Tylenol, Flexeril and sent back to nursing home with staff.Facility's elopement binder kept in the reception room reviewed. R2 was included in elopement risk, dated 1/13/2, with R2's picture and face sheet. Facility's policy on Elopement prevention and location of missing residents, dated January 2013, showed: It is the policy of this facility to provide appropriate supervision to each individual. Residents are routinely assessed for cognitive impairment, behavior symptoms or other conditions that may place the person at risk for elopement. Elopement - unauthorized departure from the residence by an individual with cognitive impairment when such behavior is likely to result in some type of harm. Residents identified as being at risk should only leave the facility when accompanied by a responsible individual.

Based on interviews and records review, the facility failed to ensure three (R4, R6, R13) of seven residents reviewed remained free from physical and mental abuse in a sample of 14.Findings Include: 1.Facility Reported Incident Report, sent to Illinois Department of Public Health (IDPH), initial dated 10/24/2025, final dated 10/29/2025, related to R4 and R6 documents: Based on the known facts from medical records review and interviews, the following conclusions have been determined about the original allegation: Abuse is substantiated.On 01/29/2026 at 2:20PM, V1(Administrator) stated on 10/24/2025, V1 was notified by nursing staff (no names provided), R4 was verbally aggressive and loud towards R6, telling R6 to turn off his music playing from R6's phone. R6 pushed R4 on R4's face for being verbally aggressive towards him. R4's provider gave orders for R4 to be sent to the hospital for aggressive behavior. R4 refused, police were called, R4 was sent to a psychiatric hospital for evaluation related to aggressive behavior. V1 stated staff are supposed to keep residents safe and free of any form of abuse. V1 further stated verbal aggression and pushing are a form of abuse. V1 conducted investigations on what happened and concluded abuse happened between R4 and R6. R4 is a [AGE] year-old individual whose current face sheet documents R4 medical conditions to include but not limited to depression, unspecified, schizophrenia, unspecified, alcohol use, unspecified with intoxication, unspecified. MDS (Minimum Data Set) section C, dated 12/16/25, documents R4's Brief Interview for Mental Status (BIMS) as 15/15, indicating R4 has intact cognitive abilities. R4 is a closed record and was not residing in the facility during this investigation.R4's nursing progress note, dated 10/24/2025, documents R4 stated to staff his roommate (R6) pushed him. V6(Licensed Practical Nurse) heard R4 in the hallway having a verbal disagreement with co residents. Residents became aggressive, agitated, and combative. R6 is a [AGE] year-old individual whose current face sheet documents R6 medical conditions to include but not limited to: bipolar disorder, unspecified, type 2 diabetes mellitus without complications. MDS (Minimum Data Set) section C, dated 12/3/25, documents R6's Brief Interview for Mental Status (BIMS) as 15/15, indicating R6 has intact cognitive abilities.On 01/27/2026 at 12:08PM, R6 stated he got into a confrontation with R4 when R4 tried snatch R6's phone as R6 was listening to music, stating the phone was his (R4's). R6 pushed R4 away and told him to get away from him. R6 stated he and R4 cursed each other. Staff came and separated them. R4 was moved out of the room he shared with R6. R6's progress notes, dated 10/24/2025, documents R6 told V6(Licensed Practical Nurse) that he pushed R4 because R4 came on R6's side of the room and threatened to break his phone and started verbally abusing him. Police notified. Chicago Police made aware of Incident.On 01/28/2026 at 12:36PM, V8 (Licensed Practical Nurse-LPN) stated on 10/24/2025, she heard a disagreement between R4 and R6. R6 told V8 that he had pushed R4 after R4 threatened R6 and told him he was going to break his phone. R6 stated R4 she went to check to check what was going on. R4 stated R6 he was playing music on his phone, and it was not loud. R6 stated R4 was verbally abusing R6. V8 went to R4 and R6's room and heard R6's music at a normal sound, it was not loud at all. V8 stated she notified police who come to the facility to investigate. On 01/28/2026 at 3:40PM, V12 (Social Services Director) stated the incident between R4 and R6 occurred on 10/24/2025. V12 works only one Sunday of the month; V12 learned about the altercation on 10/27/2025 when he returned to work. V12 stated R4 and R6 used to be roommates. V12 stated he was informed by nursing (Does not remember who) that R6 had reported there was a verbal confrontation between R4 and R6. R4 was yelling and cursing at R6, R4 was approaching R6, so R6 pushed R4 away from him. V12 stated R4 and R6 were separated, R4 sent to the hospital for further evaluation. R6 was moved to another room. Both R4 and R6 are ambulatory and do not use assistive devices. V12 stated its not ok for residents to push each other. Residents are supposed to be monitored by staff and interventions taken before residents' resident issues can escalate to aggression. V12 stated when R6 pushed R4, that is a form of abuse. R4 abused R6 when R4 cursed at R6. V12 stated staff are responsible of making sure residents are safe in the facility. V12 stated he met with R6 on 10/27/2025 and R6 stated he did not like being verbally abused by R4. V12 stated R4 was sent to the hospital on [DATE] and come back on 11/13/2025. V12 met with R4 on 11/17/2025. R4 stated he did not like it when R6 pushed him. V12 further said residents should feel safe in the facility since it's their home.Social services progress, note dated 11/17/2025, documents R4 returned to the facility after being sent out to a near hospital for getting into a physical altercation on 10/24/2025 with R6. 2.R13's current face sheet documents R13 medical conditions to include but not limited to: deaf nonspeaking, not elsewhere classified, unspecified psychosis not due to a substance or known physiological condition, schizophrenia, unspecified. MDS (Minimum Data Set) section C -Cognitive abilities, dated 10/27/25, 1/15/26, Brief Interview for Mental Status (BIMS) is not scored/documented.On 01/28/2026 at 4:17PM, V8 (Licensed Practical Nurse) stated R13 is deaf and communicates staff with staff writing down questions that include yes or no. R13 reads the questions and answers by writing down the answers or shaking his head yes or no. R13 read questions asking him if he has been hit by R4. R13 nodded his head yes that R4 hit him, but he did not hit R4. R4 nodded yes that he was afraid and hurt when R4 hit him. R13 feels safe at the facility.R13's nursing progress notes, dated 1/2/2026, documents R4 stated R13 kicked him on the left leg. Abuse Prevention Program-Policy, dated 1/20, documents: -Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means. -Verbal abuse is the use of oral, written, of gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of an individual's age, ability to comprehend or disability.

Based on interview and record review the facility failed to protect the residents rights to be free from physical abuse by residents. This failure affected 3 (R4, R6, and R12) residents and resulted in R6 sustaining a nasal bone fracture and subdural hematoma. Findings Include: 1.R6's Face Sheet, dated 1/23/2026, documents diagnoses of but not limited to Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter, Unspecified Injury of Head- Subsequent Encounter, Fracture of Nasal Bones-Subsequent Encounter for Fracture with Routine Healing, Acute Embolism and Thrombosis of Unspecified Vein, Schizophrenia, and bipolar disorder. R6's Minimum Data Set Section C, dated 11/19/2025, documents a BIMS (Brief Interview Mental Status) Score is 15, which indicates an intact cognition. R6's Care Plan, dated 11/20/2025, documents a focus for Nasal Bone Fracture, dated 1/22/2026; Potential for complications related to subdural hematoma-Acute Head Injury dated 1/22/2025; and resident's comprehensive assessment reveals history of suspected abuse and or neglect or factors that may increase his susceptibility of abuse- Incident 1/18/2026 R6 was involved in a physical altercation with a co-peer R9, initial date initiated 6/23/2025 and date revised on 1/21/2026. IDPH (Illinois Department of Public Health) Reportable, dated 1/18/2026, documents the initial incident report was made to IDPH at 5:18 am, and the IDPH Final Incident Report, dated 1/23/2026 at 1:04 pm, documents abuse was substantiated. R6's Progress Note, dated 1/18/2026 at 4:46 pm, documents, admitted at (local) Hospital with the Diagnosis of Subdual Hematoma. R6's Discharge Summary from (local) Hospital, dated 1/21/2026, documents, Page #22-23, Small focal left frontal subarachnoid clot appears new or more evident.There is left periorbital and pre-septal soft tissue swelling. Left ocular lens replacement. There is a right nasal bone fracture evident. R6's Progress Note, dated 1/21/2026 6:49 pm, documents, resident returned to the facility from the hospital at 1600 hours via ambulance on a stretcher. Hospital discharge diagnoses include subdural hematoma and stenosis of the left carotid artery. Upon arrival, resident noted to have left eye markedly reddened with visible blood and clotted blood present around the surrounding tissues. Facial appearance consistent with recent trauma. Resident level of consciousness assessed; resident awake and responsive at time of admission. Vital signs obtained upon arrival and documented. No active external bleeding noted at this time. Resident denied pain at this time. Family and attending physician have been notified of resident return. Hospital discharge paperwork reviewed; medication reconciled per doctor's instructions. Resident is comfortably on bed, call light within reach. Continues monitoring planned with emphasis on neurological status, vision changes, pain and safety. R9's Face Sheet, dated 1/23/2026, documents diagnoses of but not limited to Undifferentiated Somatoform Disorder, Anxiety Disorder-Unspecified, Insomnia-Unspecified, and Schizophrenia-Unspecified. R9's Minimum Data Set Section C, dated 10/25/2025, documents a BIMS (Brief Interview Mental Status) Score is 15, which indicates an intact cognition. R9's Minimum Data Set Section E, dated October 27, 2025, documents behaviors of hallucinations and delusions but no physical behavior directed towards others. R9's Care Plan, dated 10/28/2025, documents a focus of the resident displays socially inappropriate & maladaptive behavior related to: A mental illness diagnosis(es)., Anger, agitated depression., Feeling inadequate, inferior., Feeling vulnerable, powerless. Date Initiated: 11/15/2023. R9's Care Plan, dated 10/28/2025, documents a focus of the resident expresses maladaptive behavioral symptoms related to: A diagnosis of chronic mental illness., Disorganized, chaotic and/or decompensating behavior (e.g., poor contact with reality, hallucinations, delusions)., The resident's problems/symptoms are manifested by: Hallucinations (Specify- auditory, visual, tactile, olfactory, taste, command hallucinations), The resident's problems/symptoms are manifested by: Delusions (Specify paranoid, grandiose, irrational/bizarre thoughts, inability to perceive reality Date Initiated: 11/15/2023. R9's Progress Noted, dated 1/18/2026 at 10:07 pm, documents physician notified and Note Text: Staff informed the writer regarding resident's behavior. Resident hit another resident. It resulted to injuries of (R6), ending up in ICU. The resident's behavior which is volatile and explosive post danger to other residents. He was sent out to St [NAME] Hospital and was given notice of involuntary discharge. R9's Progress Note, dated 1/18/2026 at 4:24 pm, documents Note Text: admitted to the Hospital with the Diagnosis of Schizophrenia. On 1/18/2026 at 12:07 pm, R6 stated he went to R9's room to borrow a cigarette lighter so that he could take a smoke. R6 stated R9 told him that he (R9) did not have a lighter. R6 stated he went back to his room and a few minutes later R9 entered his room. R6 stated R9 asked R6 where his cigarettes were. R6 stated he informed R9 he did not have R9's cigarettes. R6 stated R9 punched him in the face, and he fell on his bed. R6 stated R9 continued to punch him repeatedly with a closed fist but can't recall how many times R9 punched him. R6 stated he never lost consciousness. R6 stated he feels safe in the facility since R9 has been discharged . R6 stated he sees his Social Worker and Therapist regarding the incident. R6 stated the Abuse Coordinator is V1 (Administrator) and he knows how to report abuse to V1 and the Ombudsmen. On 1/23/26 at 12:42 PM, V12 (Psychiatric Rehabilitation Services Coordinator-(PRSC) stated he heard about the physical altercation incident between R6 and R9 as manager on duty that Sunday morning, in which R6 was already hospitalized . V12 stated R6 received counseling regarding the physical altercation and injury he sustained on 1/18/2026. V12 stated R6 stated he felt safe in the facility. V12 stated when there is a physical altercation, both residents involved are separated and further guidance is obtained, and the family is informed. V12 stated R9 had two prior incidents with another peer, though not as severe as the incident with R9 and R6. V12 stated R9 was involuntarily discharged from the facility because of his behavior. On 1/23/2026 at 1:59 pm, V17 (Registered Nurse) stated he was at the nursing station completing documentation when he heard a loud noise. V17 stated he rushed down the hallway and notice R9 leaving out or R6's room. V17 stated as he entered R6's room he noticed R6 lying on the bed with his face covered in blood. V17 stated R6 informed him that R9 came into his room and began punching him (R6) in the face. V17 stated R9 had broken some shelves in the nursing station on the third floor in the past but R9 has improved his behavior since then. V17 stated when residents exhibit aggressive behavior they are placed on one-on-one monitoring and a psychiatric evaluation may be needed. V17 stated R8 was not on one-on-one monitoring at the time of the altercation. On 1/23/2026 at 2:30 pm, V20 (Certified Nurse's Assistant) stated most of the time, R9 is in bed sleeping and when he wants something he asks politely. V20 stated other staff had stated R9 displayed aggressive behavior on the second floor in the past. V20 stated when residents exhibit aggressive behavior, the staff is trained in Crisis Prevention Intervention (CPI) to de-escalate the resident. V20 stated the staff who works the night shift should be monitoring the hallway during throughout the night to make sure residents aren't wandering in other residents' rooms when they are sleeping. On 1/23/2026 at 3:02 pm, V2 (Assistant Administrator) stated she heard about the incident between R6 and R9. V2 stated she was surprised R9 had a physical altercation with another resident because when R9 has outbursts he usually will go outside or come and talk to V2 or V12 (Psychiatric Rehabilitation Services Coordinator-(PRSC). V2 stated R9 is redirectable, and staff are supposed to monitor the hallways throughout the night to ensure residents are not wandering in other residents' room. V2 stated the purpose of staff monitoring the hallway is to make sure residents are safe. V2 stated residents does not have a smoking time at 3 o'clock or 4 o'clock am. On 01/23/2026 at 3:13pm, V1 (Administrator) stated it is not expected of residents to be physically abused by another resident while they are at the facility because the facility must keep the residents safe. V1 stated she is the Abuse Coordinator. On 1/23/2026 at 4:41 pm, V22 (Medical Doctor) stated he was informed of the altercation between R6 and R9 and reviewed R6's record but did not recall all of the specifics. V22 stated his normal practice is to send the resident who exhibits aggressive combative behavior to the hospital for a psychiatric evaluation and send the affected resident to the hospital for a medical evaluation. V22 stated the facility is not a psychiatric long term care facility although the facility has a mix of resident with more behavioral health need than other facilities. V22 stated abuse is not an expectation and behaviors should be managed to maintain safety. 2.R4's admission Record documented R4's diagnoses (include but not limited to) schizophrenia, hypertension, and unsteadiness on feet. R4's (01/20/2026) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15., indicating R4's mental status as cognitively intact. R5's admission Record documented R5's diagnoses (include but not limited to) schizophrenia, asthma, and schizoaffective disorder. R5's (09/05/2025) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03., indicating R5's mental status as severely impaired. R5's census list documented R5 was admitted to the facility on [DATE] on the second floor and was discharge on [DATE]. R5 was sent to the hospital on [DATE]. R4's (11/06/2025) Final Incident Investigation Report Form documented, Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: [X] Abuse is [x]SUBSTANT1ATED, as follows. On 11/06/25, (V15 – Licensed Practical Nurse/ LPN) reported to administration a resident (R4) was STRUCK in the face by another resident (R5). Upon further investigation it was determined (R4) exited the dining room and was sitting in the hallway when (R5) walked out of her room and struck him in the face with her hand, unprovoked. R4's (11/06/2025) Progress note documented, Resident was sitting in the hallway when another resident came out of her room and suddenly smacked the resident on the face. Writer responded to the incident immediately by assessing the resident. No redness or swelling noted at this time. Authored by: (V13) LPN. R4's (11/07/2025) Counselling Session documented, It was reported to Social Services Director that resident was hit by co-peer (R5) on 11-6-25. On 01/23/2026 at 3:25pm, V13 (Licensed Practice Nurse) stated she was the nurse working on 11/06/2025 when the incident between them (R4 and R5) happened. V13 stated she was getting medication for a resident when she heard R4 yelling stop hitting me. V13 stated she saw R5 standing close to R4 making a fist. V13 stated she separated the two residents. V13 stated R4 reported to her that R5 hit him (R4) in the face. V13 stated she called the police and notified the psych doctor and the primary care physician. The importance of calling the psych doctor is to get an order to send resident for psych evaluation. It is not an expectation for resident to be abused by another resident. Residents have rights to live free from abuse. 3.R12's admission Record documented R12's diagnoses (include but not limited to) osteoarthritis, hypertension, and psychosis. R12's (11/03/2025) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15., indicating R12's mental status as cognitively intact. R12's (11/04/2025) Final Incident Investigation Report Form documented, Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: [X] Abuse Is [x]SUBSTANTIATED as follows (summarize facts obtained during investigation): On 11/4/2025 resident (R12) alleged she was struck in the face by another (R5). Upon further investigation it was determined that while (R12) was inside the public restroom (R5) was walking past. When the restroom door opened (R5) was startled and started swinging her arms and struck (R12) in the face. Staff present on the unit intervened immediately and separated the residents. The resident's physician was made aware of the allegation. Subsequently, (R5) was sent to the hospital for evaluation per physician orders. R5's (Date Range: 10/31/2025 – 11/10/2025) Progress notes documented, 11/04/2025. The nurse was on the phone by the nursing station and suddenly She heard (R12) saying don't hit me. (R12) is just outside the nurse station, (R5) is by the door of the bathroom which is beside the nurse station. She ran immediately and she saw (R5) picking up her bag and she went inside the bathroom. (R12) is around 1 meter away from (R5). When she asked (R12) where she was hit she said on her face. Authored by: V14 LPN. 11/04/2025 Counselling Session. It was reported to Social Services Director that resident allegedly hit co-peer (R12). Authored by: V12 PRSD. 11/06/2025. (R5) without event or provocation hit co peer on his face. Staff immediately attempting to remove (R5) from the area using verbal cues and positioning their bodies between the residents. (R5) then became physically aggressive towards staff attempting to kick, punch and spit on them. Authored by: V3 DON. There was no physician notification when R5 hit R12. On 01/24/2026 at 12:44pm, V11 (Infection Preventionist/RN) stated she worked the floor on 11/04/2025 during the 3pm-11pm shift. She was on the phone with a hospital, sending a resident out, when she heard (R12) say don't hit me. She asked R12 where she got hit and R12 said she was hit on the face. On 01/23/2026, R4 and R12 both stated they did not remember the incidents. On 01/23/2026 at 11:45am, V1 (Administrator) stated she substantiated both allegations of physical abuse between R4 and R5 and between R12 and R5 based on the nature of the incidents and statements from the residents. If the allegations of abuse are substantiated it means abuse happened. On 01/23/2026 at 3:13pm, V1(Administrator) stated, It is not expected of residents to be physically abused by another resident while they are at the facility because the facility has to keep the residents safe. The (undated) Residents' Rights for People in Long-Term Care Facilities documented, As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. You must not be abused physically, neglected, or exploited by anyone-financially, physically, verbally, mentally or sexually. Your facility must provide services to keep your physical and mental health at their highest practicable levels. The (undated) Abuse Prevention Program Policy documented, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. DEFINITIONS: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental mean. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to notify the resident's physician of allegation of abuse. This failure affected 2 (R5, and R12) residents reviewed for abuse in the total sample of 16 residents.Findings include: 1.R12's admission Record documented R12's diagnoses (include but not limited to) osteoarthritis, hypertension, and psychosis. R12's (11/03/2025) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15., indicating R12's mental status as cognitively intact. R12's census list documented R12's actual admission date was on 06/01/2015 and has been residing on the second floor since 06/28/2022. R12's (11/04/2025) Final Incident Investigation Report Form documented, Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: [X] Abuse Is [x]SUBSTANTIATED as follows (summarize facts obtained during investigation): On 11/4/2025 resident (R12) alleged she was struck in the face by another (R5). Upon further investigation it was determined that while (R12) was inside the public restroom (R5) was walking past. When the restroom door opened (R5) was startled and started swinging her arms and struck (R12) in the face. Staff present on the unit intervened immediately and separated the residents. The resident's physician was made aware of the allegation. Subsequently, (R5) was sent to the hospital for evaluation per physician orders. R12's (11/01/2025 - 11/15/2025) Progress Notes documented, in part 11/04/2025. The nurse was on the phone by the nursing station and suddenly She heard (R12) saying don't hit me. (R12) is just outside the nurse station, (R5) is by the door of the bathroom which is beside the nurse station. She ran immediately and she saw (R5) picking up her bag and she went inside the bathroom. (R12) is around 1 meter away from (R5). When she asked (R12) where she was hit she said on her face. Authored by: V14 LPN. 11/04/2025. Counselling Session. It was reported to Social Services Director that resident (R5) allegedly hit co-peer (R12). Authored by: V12 (PRSD). On 01/24/2026 at 12:44pm, V11 (Infection Preventionist/RN) stated she worked the floor on 11/04/2025 during the 3pm-11pm shift. She was on the phone with a hospital, sending a resident out, when she heard R12 say don't hit me. She asked her where she got hit and she said she was hit in the face. V11 stated she already called the police and informed (V1 - Administrator) that she was busy, and she would not be able to complete the abuse protocol for R5 and R12. V11 stated she (V1) instructed (V14 - Licensed Practical Nurse/LPN) to complete the abuse protocol. Abuse protocol includes calling the family and doctor for both alleged victim and perpetrator. The importance of calling the doctor of the alleged victim is to inform the doctor of the incident, to get an order to send for medical evaluation, or to monitor the resident at the facility. The importance of calling the doctor of the alleged perpetrator is to inform the doctor of what happened, get an order to send the resident for psych evaluation, or get an order to place resident on supervision 1:1. V11 stated she did not call the family and doctor of both alleged victim and perpetrator. On 01/24/2026 at 12:57pm, V14 (Licensed Practice Nurse) stated she did not receive an instruction from V1 to complete the abuse protocol for R5 and R12. V14 stated she did not call the family or doctor of both residents. On 01/23/2026 at 11:11am, V12 (PRSC (Psychiatric Rehabilitation Services Director) stated he documented on the progress note that R12 was hit by R5 on 11/04/2025. If a resident made an allegation of physical abuse, the psychiatrist should be called. V12 stated he was not 100% sure if the psychiatrist was called. V12 stated the reason why the psychiatrist should be called because the resident was physically aggressive toward a resident, and they can order to send to the perpetrator to the hospital for psych evaluation. If the nurse did call the psychiatrist, then the nurse should document it in the electronic health record.On 01/23/2026 at 11:16am, V12, PRSD, stated no notification was done for the psychiatrist. R5's physical aggression towards R4 on 11/06/2025 could have been prevented if the nurse called the psychiatrist when she allegedly hit her R12 on 11/04/2025. On 01/23/2026 at 11:45am, V1 stated it was reported to her by R12 that she was hit by another resident, and she submitted a reportable to IDPH (Illinois Department of Public Health). V1 stated, Anytime the residents were struck by another resident, the facility has to immediately start abuse protocol. Abuse protocol includes separating the individuals, putting them on behavior monitoring, and notifying physician and emergency contact person. Nursing staff are expected to document the notifications in electronic health record, and to follow the physician's order, if they have order to send to psych facility for psych evaluation or for medication adjustment. If not documented, if means the staff failed to follow abuse protocol. Doctor should be notified immediately. Right away. V1 stated the allegation of physical abuse between R4 and R5 on 11/06/2025 could have been prevented if the doctor was notified when R5 hit R12 on 11/04/2025.On 01/23/2026 at 3:13pm, V1(Administrator) reviewed R12's 11/04/2025 reportable which read Subsequently, (R5) was sent to the hospital for evaluation per physician orders. V1 also reviewed R5's census list which indicated R5 was not sent to the hospital on [DATE]. V1 stated, Staff should be calling the doctor to get an order to send the alleged perpetrator to the hospital for psych evaluation. That is part of the facility abuse protocol.On 01/24/2026 at 2:10am, V1 (Administrator) stated she spoke with the nurse (V14 - LPN) on the phone and was notified there is an abuse allegation between R5 and R12 and instructed V14 and to follow abuse protocol. V1 stated the abuse protocol includes separating both residents, calling the primary contact of both residents, calling the physician of both residents, and calling the police. V1 stated the purpose of calling the doctor of both residents is to get an order; maybe to put the resident on close monitoring or give PRN (as needed) medication or to send the residents out. V1 stated if notification of the doctor was not documented, it means it did not happen. The (undated) Abuse Prevention Program Policy documented, in part Residents have the right to be free from abuse. DEFINITIONS: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental mean. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Abuse Prevention Program Facility Procedures. V. Protection of ResidentsThe facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. IV. INVESTIGATIONAs soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation ofresident property, or exploitation, the administrator or designee will initiate an investigation intothe allegation which may include the following elements: Physicians will be notified of any incident, and any medical treatment will be done as ordered. V. Reporting & RESPONSE. A. Representative and Physician. The administrator or designee will notify the resident's representative and physician of the alleged incident and the investigation.

F564Based on interview and record review, the facility failed to ensure residents had full and equal visitation privileges consistent with resident preferences. This affected one resident (R1) in the sample reviewed for visitation privileges. Findings include:R1's Minimum Data Set (MDS), dated [DATE], shows R1 is cognitively intact. She was admitted to the facility on [DATE] with diagnoses including but not limited to adult failure to thrive, encounter for surgical aftercare following surgery on the digestive system, ileostomy status, morbid severe obesity due to excess calories, need for assistance with personal care, irritable bowel syndrome, and unspecified open wound, right thigh. On 9/18/25 at 9:02 AM, V3 (R1's Friend) stated she visited R1 in her room on Monday around 2:50 PM, and R3 (R1's Roommate) screamed at her to get out of the room because she thought she was a funeral director. V7 (Certified Nursing Assistant/CNA), V8 (Licensed Practical Nurse/LPN) and other staff came into the room and told her to leave the room, andV1 (Assistant Administrator) will get back to her, but she did not get back to her. She has not been in the facility since the incident to visit R1, and she does not know why the facility will not allow her to visit her best friend.On 9/18/25 at 9:20 AM, R1 was in her bed, and stated she has been in the facility for few months. A few days ago (9/15/25), V3 visited her, as she does once a week. R3 told her to leave because she does not like her, and R1 is angry that her right to receive her visitor was violated. V3 is her best friend, she helps to reload her link card, buy groceries, and do her laundry because she cannot get out of bed. V3 has not been in the facility since, but she wants her to visit because it is her right.On 9/18/25 at 9:26 AM, R3 stated she has been in the facility for twenty-six years. On Monday around 3pm, V3 came to visit R1, and she told her to leave the room because she is a funeral director, and she does not want her to give her funeral. V10 (Social Services Director) came to tell her she should voice her concerns to staff instead of yelling at R1's visitor, and she listened to him. R3 also stated V3 left the room, and she has not been back since to visit R1.On 9/18/25 at 12:57 PM, V7 (Certified Nursing Assitant/CNA) stated he has been in the facility for thirteen years. On Monday 9/15/25, almost at the end of the morning shift, a former resident, V3, came to visit R1. He heard R3 yelling. She told V3 to leave her room. V6, V7, and V8 (Licensed Practical Nurse/LPN) told V3 leave R1's room, and V3 left R1's room immediately. V7 also stated the facility allows visitors in the rooms, and it is the right of R1, and another resident to receive visitor. On 9/18/25 at 1:11 PM, via telephone, V8 (Licensed Practical Nurse/LPN) stated he has been in the facility for ten years. On 9/15/25, he heard R3 telling V3, who came to visit R1, to get out of her room. V2 (Assistant Director of Nursing/ADON), V8, V10 (Social Services Director), and other staff escorted V3 out of R1's room, but R1 was upset for sending her visitor out of her room. V8 also stated, We did not allow (V3) to go into (R1's) room, but (R1) has the right to see/receive her visitor in her room.: He is not sure if V3 went down to see V1 to talk about the incident.On 9/18/25 at 1:35 PM, V10 (Social Services Director) stated he has been in the facility over seven years. On Monday 9/15/25 at about 2:30 PM, he was informedR3 was upset, and she wanted V3, who was visiting R1, to leave the shared room. V3 left the room; he offered reality orientation that R1 is bed bound, she is allowed to have a visitor in her room. V10 also stated R1 has equal right to receive visitor, even when R3 did not accept V3 in the shared room. The facility should have made another alternative arrangement for R1 to see V3 instead of sending V3 away. On 9/18/25 at 2:21 PM, V1 (Assistant Administrator) stated she has been in the facility since August 25th, 2025. She did not tell V3 she would like to speak with her about the incident. She did not tell R1 to call V3 to continue with her visitation, and R1 has equal right as well to receive visitor in her room. V2 (Assistant Director of Nursing/ADON), V4 (Certified Nursing assistant/CNA), V5 (Registered Nurse/RN), V6 (LPN), and V9 (CNA) all stated R1 has equal right to receive her visitor. Progress Notes, dated 9/15/25, documents: Staff assisted visitor (V3) out of the (R1's) room.Policy on Residents Rights, dated January/2016, documents: To exercise his or her rights as a resident of the facility. Visitation Policy, undated, documents: (1) Therefore, the resident is permitted to have visitors as he/she permits.

Based on interview and record review, the facility failed to provide adequate weekend staff for the facility. The facility's weekend short staffing has the potential to affect all 116 residents residing in the facility.Findings Include:On 9/11/25 at 11:30 AM, V15, Assistant Director of Nursing, stated, During the third quarter of April 1,2025 to June 30,2025, the facility was short staff sometimes on the weekends, mainly due to call offs. The nursing staffing schedules are as follows:First floor day, evening and night shift; There is one nurse and two certified nurse assistants [CNA].Second floor day and evening; There is one nurse and four CNA's, night shift one nurse and two CNA's.Third floor day, evening, and night shift; There is one nurse and two CNAs on all shifts.On 9/11/25 at 11:50 AM, V15 the nurse staffing schedules for April to June were reviewed. V15 stated the following:4/5/25: First floor third shift there was one certified aide, [two was needed].4/6/25: First floor third shift there was one certified aide, [two was needed].4/12/25: First Floor second shift was three certified aides [ three was needed]. First Floor third shift one certified aide [two was needed].5/10/25: Second floor first shift was three certified aides [ four was needed]. First floor, third shift was one certified aide [two was needed].5/11/25 First floor day shift was one certified aide [two was needed], move one of the first-floor aides to the second floor and the first floor was short. Second shift moved one aide to the second floor again but left the first floor short an aide. Second floor, second shift there were three aides [four was needed].5/25/25: Second floor, second shift there were three aides [Four was needed].First floor third shift there was one aide, [there were two needed].6/7/25: Second floor, day shift there was three aides [four was needed].6/14/25: Second floor, second shift there were three aides [four was needed].First floor, third shift there was one aide [two was needed].6/15/25: Second floor, second shift there was three aides [four was needed].First floor, third shift there was one aide, [two was needed].6/21/25: Second floor, second shift there was three aides [four was needed].6/28/25: Second floor, first shift there were three aides [four was needed].First floor third shift was one aide, [two was needed].6/29/25: Second floor, first shift there was three aides [four was needed].On 9/11/25 at 12:01 PM, V15 stated, I move Certified Nurse Assistants around to cover the floors much as possible, due to call offs. During the time period of April 2025 to June 2025 the facility was short staffed 12 times on the weekends.On 9/1125 at 2:24 PM V1 [Administrator] stated, The facility does not have a staffing policy.

Based on observation, interview, and record review, the facility failed to label and date stored food; failed to cover and label open food; and failed prepare food in a clean area. These failures have the potential to affect all 114 residents receiving food prepared for the nursing skilled facility.Findings include:On 9/9/25 at 9:21 AM, during initial kitchen tour with V11 [Dietary Manager], the following items were found in walk-in refrigerator:Observed open plastic bag with undated with open sandwich baggie, cheese, and yogurt. V11 stated, That belongs to an employee. It was not in here earlier; I will remove it. Employee personal items should not be in the walk-in cooler, it potentially could cause cross contamination.On 9/9/25 at 9:30 AM, during initial kitchen tour with V11 [Dietary Manager], the following items were found in walk-in freezer: open uncovered to environment box of turkey breakfast sausage sitting in an open plastic bag with no open nor expiration date. V11 stated, The food is to be covered dated, with a label including an expiration date once the package is opened to prevent cross contamination and possible food borne illness.On 9/9/25 at 9:45AM, V11 [Dietary Manager], surveyor observed the following:Garbage can in the kitchen that was not in use was filled with garbage without lid in the food preparation area. The floor had multiple open drank cartons of milk, napkins, food crumbs, and bread on the floor throughout the kitchen. Two bags of filled garbage was siting on the floor. V11 [Dietary Manager] stated, All garbage cans should always have a lid on. Once the garbage is full of garbage, the staff need to take out the garbage. Garbage cans not covered could potentially cause cross contamination and food borne illness.Policy documents in part:Food Safety and Sanitation dated 2017.Refrigerated food prepared in the healthcare community is labeled with the date to discard or used by date. If opened the food item is labeled with date opened an date which is discard or use by.Labeling and Dating Foods dated 2021.Date the items opened and the date by which the item should be discarded or use by date,

Based on observation, interview, and record review, facility failed to ensure corridor handrails used by residents are firmly secured on all floors (1st, 2nd and 3rd). These failures have the potential to affect all 116 residents in the facility.Findings include: On 09/10/2025 at 10:26 AM with V12 (Maintenance Manager) on the 2nd floor, a total of 4 handrails were identified as loose. V12 took out brown hard plastic cover using screwdriver to tighten the screws. After placing back the cover, 1 out 3 handrail was still loose upon placing slight pressure. With V12 on the 3rd floor, 4 handrails were identified as loose. V12 took hard brown cover using the same method to tighten the screws. V12 stated that he does not have any documentation that he checked equipment including corridor handrails. Surveyor and V12 went to 1st floor and identified 2 loose handrails, 1 of which cover detached to its base that can easily remove after applying pressure. V12 stated that he checked last Monday but failed to identify loose handrails. All floors occupied by residents were seen to have handrails that are not completely secure.Facility provided Preventative Maintenance Program, dated 07/25, documents purpose to conduct regular environment tours/safety audits to identify areas of concern within the facility. Preventative Maintenance Program will review the following areas during random rounds that includes handrails present and in working conditions.

Based on interview and record review, the facility failed to a.) ensure physician orders for Advanced Directives were obtained and railed to ensure Advanced Directives were properly documented and accessible for 4 (R1, R8, R11, R12) residents reviewed for advance directives in a sample of 25.Findings Include:1.R1 was admitted to the facility on [DATE], with diagnoses not limited to Nonspecific Abnormal Finding of Lung Field, Pain In Right Leg, Primary Osteoarthritis, Aortic Aneurysm of Unspecified Site, Unspecified Psychosis, Auditory Hallucinations, Encephalopathy, Elevated [NAME] Blood Cell Count, Dysphagia, Pneumonia, Gastrointestinal Hemorrhage, Essential (Primary) Hypertension, Pressure Ulcer of Left Hip, Stage 3, Pressure Ulcer of Left Buttock, Stage 3, Chronic Kidney Disease, Stage 5, Altered Mental Status, Metabolic Encephalopathy, Hypothyroidism, Rhabdomyolysis, Benign Neoplasm of Cerebral Meninges, Acute Respiratory Failure with Hypoxia, Anemia and Schizoaffective Disorder.R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate resident is rarely/never understood.Review of R1's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE], documents: CPR (Cardiopulmonary Resuscitation): Attempt cardiopulmonary resuscitation. Full Treatment.Review of R1's Order Summary Report, dated [DATE], has no order for Advanced Directive (Code Status).R1's care plan documents: Focus: Pursuant to resident rights & the individual's desire to retain control & autonomy over his/her health care decisions, the individual has: Executed a FULL CODE/CPR ADMINISTERED. Date Initiated: [DATE] Revision on: [DATE]. Goal: R1 wishes for FULL CODE/CPR ADMINISTERED status as specified in his/her advance directive documents will be honored & clearly delineated in the medical record in compliance with state law, (goal is on-going) Date Initiated: [DATE] Revision on: [DATE]. Interventions: The resident &/or responsible party has been provided a copy of the facility's policy to implement advanced directives, resident's rights to accept or refuse medical or surgical treatment, and at the individual option, formulate advance directives. Date Initiated: [DATE]. Continue to educate the resident about his/her options addressing life sustaining care throughout the stay as long as the individual remains coherent & able to understand this information. Date Initiated: [DATE].2.R8 was admitted to the facility on [DATE], with diagnoses not limited to Functional Dyspepsia, Suicidal Ideations, Chest Pain, Seizures, Gastro-Esophageal Reflux Disease, Vitamin D Deficiency, Schizoaffective Disorder, Pain in Left Lower Leg, Morbid (Severe) Obesity, Lymphedema, Major Depressive Disorder, Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Asthma, Polyneuropathy, Polyosteoarthritis, Acute and Subacute Hepatic Failure, Fibromyalgia, Chronic Respiratory Failure with Hypercapnia, Obstructive Sleep Apnea, Overactive Bladder, Localized Swelling, Mass and Lump, Lower Limb, Bilateral and Glycogen Storage Disease.R8's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response.Review of R8's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE], documents: CPR: Attempt cardiopulmonary resuscitation. Full Treatment.Review of R8's Order Summary Report, dated [DATE], has no order for Advanced Directive (Code Status).R8's Care Plan documents: Focus: Pursuant to resident rights & the individual's desire to retain control & autonomy over his/her health care decisions, the individual has: Executed a FULL CODE/CPR ADMINISTERED. Date Initiated: [DATE]. Goal: R8 wishes for FULL CODE/CPR ADMINISTERED status as specified in his/her advance directive documents will be honored & clearly delineated in the medical record in compliance with state law, (goal is on-going) Date Initiated: [DATE]. Interventions: The resident &/or responsible party has been provided a copy of the facility's policy to implement advanced directives, resident's rights to accept or refuse medical or surgical treatment, and at the individual option, formulate advance directives. Date Initiated: [DATE]. Continue to educate the resident about his/her options addressing life sustaining care throughout the stay as long as the individual remains coherent & able to understand this information.3.R11 was admitted to the facility on [DATE], with diagnoses not limited to Seizures, Bilateral Primary Osteoarthritis of Knee, Essential (Primary) Hypertension, Hypothyroidism, Vitamin D Deficiency, Constipation, Insomnia, Hypokalemia, History of Falling, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Muscle Weakness (Generalized), Morbid (Severe) Obesity and Schizoaffective Disorder.R11's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14, indicating intact cognitive response.Review of R11's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE], documents: CPR: Attempt cardiopulmonary resuscitation.Review of R11's Order Summary Report, dated [DATE], has no order for Advanced Directive (Code Status).R11's Care Plan documents: Focus: Pursuant to resident rights & the individual's desire to retain control & autonomy over his/her health care decisions, the individual has: Executed a FULL CODE/CPR ADMINISTERED. Date Initiated: [DATE]. Goal: R11 wishes for FULL CODE/CPR ADMINISTERED status as specified in his/her advance directive documents will be honored & clearly delineated in the medical record in compliance with state law, (goal is on-going): Date Initiated: [DATE] Revision on: [DATE]. Interventions: The resident &/or responsible party has been provided a copy of the facility's policy to implement advanced directives, resident's rights to accept or refuse medical or surgical treatment, and at the individual option, formulate advance directives. Date Initiated: [DATE]. Continue to educate the resident about his/her options addressing life sustaining care throughout the stay as long as the individual remains coherent & able to understand this information. Date Initiated: [DATE].4.R12 was admitted to the facility on [DATE], with diagnoses not limited to Atrial Fibrillation, Decreased [NAME] Blood Cell Count, Obesity, Bipolar Disorder, Major Depressive Disorder, Insomnia, History of Falling, Muscle Weakness, r Abnormalities of Gait and Mobility and Unsteadiness on Feet.R12's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. Review of R12's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE],documents: CPR: Attempt cardiopulmonary resuscitation. Full Treatment. Review of R12's Order Summary Report, dated [DATE], has no order for Advanced Directive (Code Status).R12's Care Plan documents: Focus: Pursuant to resident rights & the individual's desire to retain control & autonomy over his/her health care decisions, the individual has: Executed a FULL CODE/CPR ADMINISTERED. Date Initiated: [DATE]. Goal: The resident's wishes for FULL CODE/CPR ADMINISTERED status as specified in his/her advance directive documents will be honored & clearly delineated in the medical record in compliance with state law, (goal is on-going): Date Initiated: [DATE]. Interventions: The resident &/or responsible party has been provided a copy of the facility's policy to implement advanced directives, resident's rights to accept or refuse medical or surgical treatment, and at the individual option, formulate advance directives. Date Initiated: [DATE]. Continue to educate the resident about his/her options addressing life sustaining care throughout the stay as long as the individual remains coherent & able to understand this information. Date Initiated: [DATE].On [DATE] at 09:13 AM, V2 (Director of Nursing) stated, If nothing came from the hospital for the resident for a resident's Advanced Directives, they are a full code. The nurse will transcribe the resident as a full code until the family or resident deem, they want to have some type of POLST. There is supposed to be an order in the resident medical record if they are a full code or DNR (Do Not Resuscitate). If the resident doesn't have an order and there is a change in condition, and they (resident) did not come with a POLST form, we would initiate the code process. If a resident is a DNR and the Advanced Directives order is not entered, there is a potential the resident wishes won't be granted. Maybe the resident did not want any lifesaving or intubation; we would not have followed the wishes of the resident and family.On [DATE] at 09:46 AM, V2 (Director of Nursing) stated, The Social Service Department gets the POLST information, and the nurse enters the order.Policy:Titled Advance Directives, dated 07/25, documents: Purpose: To establish guidelines to assure each resident is provided information on advance directives. Policy: It is the policy of this facility to allow the resident or authorized legal representative to make decisions regarding health care as well as refusal of service. Standards: 3. The resident, legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advance Directive, as recognized under state law, has been executed. Documentation concerning this inquiry and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall then be included in the resident's medical record in the Social Service Progress notes. 9. A written physician's order is required in response to the resident's Advanced Directive(s). Physician's orders shall be specific and address each Advanced Directive(s). 12. Advanced Directive(s) shall be addressed on the resident's plan of care, physician progress notes, and physician's orders and in Social Service Progress Notes.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. This affected five (R1, R11, R30, R107, R110) out of nine residents during medication administration task. The facility had six errors out of 25 opportunities, resulting in a 24% medication error rate.Findings include:1.R107's 'Order Summary Report' and 'Medication Administration Record' document in part: RisperDAL Oral Tablet (Risperidone) Give 1.25 mg by mouth in the morning related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE.On 9/09/2025 at 9:52 AM, V6 (Nurse) prepared R107's medications. V6 read R107's Medication Administration Record (MAR) on the laptop. V6 stated R107 was scheduled to receive Risperidone (Risperdal) 1.25 MG (Milligram) every morning. V6 pulled out two different unit-dose blister packs/bingo cards for R107's Risperidone. One blister pack read Risperidone Tab 3 MG take 1/2 tablet (1.5 MG) by mouth at bedtime. Each individual slot contained half tablets (1.5 MG dosing). The other blister pack read Risperidone tab 0.25 MG with instructions to take 1 tablet by mouth daily - give [with] 1 MG (total dose = 1.25 MG). V6 popped out two half tablets from the first blister pack (1.5 MG + 1.5 MG = 3 MG) and one 0.25 MG tablet from the other blister pack (totaling 3.25 MG of Risperidone). V6 popped the three tablets into the medicine cup with all the other morning medications for R107. V6 put away the rest of the medications and started cleaning up the medication cart. V6 stated V6 will administer the medications to R107. V6 was asked to review R107's orders and Risperidone blister packs. After reviewing the order, V6 removed a Risperidone 1/2 tablet (1.5 MG). The total in the cup was now 1.75 MG (1.5 MG + 0.25 MG). At a9:58 AM, V2 (Director of Nursing) was near the nurses' station. V2 motioned for V3 (Infection Preventionist) to assist. V3 instructed V6 to hold Risperidone until V2 and V6 obtained the correct dosage from the electronic medication dispensing system. 2.R11's 'Order Summary Report' and 'Medication Administration Record (MAR)' documents: Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 25 mg by mouth one time a day for [Hypertension] related to ESSENTIAL (PRIMARY) HYPERTENSION. There were no parameters to hold the medication.R11's 'Care Plan Report' documentsR11 is at risk for elevated blood pressure related to hypertension (last revised 1/22/2025). Interventions include to administer medications as ordered by the doctor (initiated 1/22/2025). On 9/09/2025 at 10:20 AM, V6 prepared R11's medications. One of the medications included Metoprolol Succinate ER (Extended Release) 25 MG (blood pressure medicine) and Lamotrigine 200 MG (given for anxiety). At 10:29 AM, V6 went into R11's room and checked R11's blood pressure via an electronic blood pressure machine to R11's right wrist. V2 (Director of Nursing), who was standing at the doorway, stated there was no parameters for the blood pressure medicine. V2 stated it was okay for V6 to administer the Metoprolol. R11's blood pressure was 98/63, with a heart rate of 85 beats per minute. At 10:32 AM, V6 stated V6 will not administer the Metoprolol to R11 because the blood pressure was low. V6 stated, It's for hypertension [high blood pressure] and I don't want [R11] to bottom out. V6 stated V6 will put in a progress note to read that it did not apply. R11 took the other morning medications at 10:32 AM. At 10:37 AM, V6 stated R11's morning medication pass was complete and proceeded to administer medications to other residents. V6 did not call to inform R11's physician about not administering Metoprolol.R11's MAR documents V6 charted '9' under the 9/09/2025 9:00 AM dose meaning Other / See Nurse Notes. R11's orders and MAR also document: LamoTRIgine Oral Tablet 200 MG (Lamotrigine) Give 1 tablet by mouth every 12 hours for antianxiety. The MAR documents it was due at 9:00 AM. V6 administered the medication at 10:32 AM. R11's progress note, dated 9/9/2025, 10:34 AM reads dna hypotension (low blood pressure). V6 stated 'dna' stood for 'did not apply.'On 9/09/2025 at 10:41 AM, V4 (Physician) stated no one called to inform V4 about R11's blood pressure or holding the morning dose of Metoprolol. V4 stated the nurses need to inform V4 when they are holding or not administering a medication because it is a complicated decision. V4 stated V4 will need to trend R11's blood pressures, heart rates, and symptoms in the last three to four days prior to deciding whether to hold the Metoprolol Succinate ER or change it. When asked about R107's Risperidone, V4 stated it 'definitely' would not be good if the nurse increased the dosage and administered more than what was ordered. V4 stated R107 would have increased sedation and systemic slowing.3.R1's 'Order Summary Report' documents Sucralfate Oral Suspension 1 GM (Gram)/10 ML (Sucralfate) Give 10 ml by mouth three times a day related to GASTROINTESTINAL HEMORRHAGE.R1's 'Care Plan Report' documents R1 has gastritis and duodenitis (initiated 9/05/2025). Intervention initiated on 9/05/2025 documents in part to administer medications per physician orders. On 9/10/2025 at 12:03 PM, V13 (Nurse) prepared R1's noon medications. One of the medications was Sucralfate 100 MG / ML (milliliter) oral suspension. V13 stated the order was for 1 gram / 10 ML of Sucralfate. V13 held a medication cup in the air and poured the medication into the medicine cup. The medication when held in the air was at the 10 ML mark; however, when V13 placed the medicine cup on top of the medication cart, the medicine cup read 15 ML. At 12:10 PM, V13 went into the room and told R1 which medications V13 had prepared. V13 was asked to review Sucralfate medicine cup on a flat, stable surface. V13 took out 5 ML and administered 10 ML to R1. 3.On 9/10/2025 at 12:19 PM, V13 prepared medications for R110. V13 did not locate R110's blister pack for Hydroxyzine in the medication cart or medication room. V13 stated V13 administered the last pill from the blister pack in the morning. V13 reordered it from pharmacy via the electronic medical record. V13 then went to R110's room. V13 informed R110 the Hydroxyzine was not in the medicine cup, but V13 had reordered it from pharmacy. V13 informed R110 that pharmacy will deliver it in the evening and R110 will get it during the evening dose. V13 checked 9 in the MAR, and stated V13 will let the oncoming nurse know the medication was not there, but it was reordered. V13 stated R110's medication pass was complete and proceeded to prepare another resident's medications. V13 did not inform R110's physician the medication was not available. 4.R30's 'Order Audit Report' documents: Simethicone Tablet 80 MG Give 2 tablet by mouth three times a day for bloating, give with meals.On 9/10/2025 at 12:32 PM, V13 prepared R30's noon medications. Reading off the MAR on the computer, V13 stated R30 was scheduled to get two Simethicone 80 mg chewable tablets. V13 stated it was a house stock medicine and pulled a bottle of Simethicone on the top right drawer of the medication cart. V13 stated there were two pills left in the bottle, which was exactly how many R30 needed. The bottle read Simethicone 125 MG tablets. V13 was notified of the dosage difference. V13 stated V13 did not notice the dosage difference. V13 searched the medication cart, medication room, and facility stock on the other floors. At 1:12 PM, V13 stated the facility did not have Simethicone 80 MG in the building. V13 stated V13 did administer two pills from the same bottle during morning administration. V13 stated V13did not know the dosage was different. On 9/10/2025 at 11:37 AM, V2 (Director of Nursing) stated the nurses are to administer medications based on the doctors' orders. V2 stated residents' rights with medications include the right patient, right medication, right dosage, right route, and right time. V2 stated nurses have one hour before and one hour after the scheduled time to administer the medications. V2 stated the nurses should reorder medications when they are running low so that there is ample medications and no issues with administration. V2 stated the pharmacy can deliver medications when needed as long as the nurses reorder them. V2 also stated if a nurse holds or does not administer a medication, the nurse is supposed to inform the physician. Facility's 'Medication Administration Policy' (8/15) documents: Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with professional standards for two of two storage rooms reviewed, and one of two medications carts reviewed for medication storage and labeling.Findings include:On 9/09/2025 at 10:50 AM, V15 (Assistant Director of Nursing) reviewed the third-floor medication cart. V15 stated it contained medications for all 38 residents in the unit. In the second drawer on the left side, the second slot from the left had one white pill with number 211 etched on it. It was loose on the bottom of the drawer and not in its original packaging. There was also another loose white pill on the bottom of the fourth slot with I 125 etched on it. On the right side of the medication cart, the second drawer contained house stock medication bottles. There was a bottle of Loratadine 10 MG (milligram) tablets. The bottle read an expiration date of 02/25 (February 2025). In the same drawer, there was also a bottle of Bisacodyl 5 MG tablets. The expiration month was not legible but it expires in 2025 ( /25). At 11:08 AM, V15 stated [V15] could not read the expiration month. V15 stated if we can't read the date, then facility should treat it as expired. On 9/09/2025 at 11:09 AM, V15 reviewed the third-floor medication room. The top left cabinet had multiple house stock medications. There was a bottle of Loratadine 10 MG tablets that expired August 2025 (08/25). There was also a bottle of Oyster Shell Calcium 250 MG tablets that expired July 2025 (07/25). The medication refrigerator had four 8-oz (ounce) nutritional supplement drinks. They were next to a box of Bisacodyl suppositories and insulin pens. On 9/09/2025 at 2:27 PM, V5 (Nurse) stated there were 38 residents on the first floor. At 2:37 PM, V5 reviewed the first-floor medication room. The medication refrigerator had two 8-oz nutritional supplement drinks. They were near suppositories and insulin pens.On 9/10/2025 at 11:33 AM, V2 (Director of Nursing) stated all nurses are responsible for their own medication carts and rooms, but the Sunday night-shift nurses are primarily responsible for checking them. V2 stated the Sunday night-shift nurses are supposed to look for loose pills and expired medications. V2 stated all nurses can do it, but it is a designated role for Sunday nights. On 9/11/2025 at 9:11 AM, V2 stated only medications should be stored in the medication fridge.Facility's 'Medication Administration Policy' (8/15) documentst: Expired medication may not be administered to the resident. Return the medication to the pharmacy for a new supply. Facility's 'Medication Disposal Policy' (2/14) documentst: Most non-controlled substances will be returned to pharmacy. Facility's 'Medication Storage' and 'Medication Disposal Policy' were not specific about protocols/procedures regarding medications not in original packaging and keeping only medications in the medication refrigerator.

Based on observations, interviews, and record reviews, the facility failed to provide hand splints for one resident (R31) out of a total sample of 25 residents.Findings include:R31's 'admission Record' documents a primary diagnosis of rheumatoid arthritis.On 9/09/2025 at 12:40 PM, R31 was sitting at the side of the bed. R31 was oriented to person, place, date, and situation. R31's left fingers were closed inward. R31 stated both hands had weakness, but it is worse on the left. R31 stated R31 is able to spread left fingers open with right hand. R31 stated the nurses and Certified Nurse Aides used to apply bilateral hand splints during the day, but not anymore. R31 stated the facility did a deep clean close to a year ago, and R31's hand splints disappeared. R31 suspected staff must have thrown them out by mistake. R31 informed staff, but they never replaced them. R31's 'Order Summary Report' documents R31 may wear splint to bilateral upper extremities as tolerated and as needed for comfort (active since 10/10/2023).R31's 'Care Plan Report' documents R31 has orthoses (brace/splint) related to rheumatoid arthritis (revised 4/14/2024). Intervention includes Educate on the importance of wearing splint/brace (revised 10/05/2023) and Monitor splint for cleanliness, need for refitting, repair or fit as needed (revised 10/05/2023).R31's 2025 progress notes prior to the survey did not mention hand splints or braces. No mention of hand braces or splints under the ADL (Activities of Daily Living) tasks in the electronic medical records. On 9/10/2025 at 9:10 AM, V5 (Nurse) stated V5 works with R31 on most days of the week. V5 stated V5 has been taking care of R31 since resident has been residing on the first floor. V5 stated R31 does not have any hand splints. V5 stated R31 had them years ago, but none this year. On 9/10/2025 at 10:03 AM, V7 (Restorative Nurse) stated the facility did not reorder the hand splints/braces until date of the survey. On 9/10/2025 at 10:29 AM, V9 (Certified Nurse Aide-CNA) stated V9 takes care of R31 for most days of the week, since R31 moved to the first floor. V9 stated R31 is not able to hold open the left fingers all the time. V9 stated left fingers are closing inward. V9 stated R31 hasn't had hand splints/braces for more than a year. On 9/10/2025 at 10:38 AM, V10 (Psychiatric Rehabilitation Services Coordinator) stated V10 has worked with R31 for less than half a year. When V10 does morning rounds, V10 hasn't seen R31 with hand splints. On 9/10/2025 at 11:45 AM, V2 (Director of Nursing) stated when making rounds, V2 hasn't seen hand splints/braces on R31. Facility's 'Splints/Braces/Devices' policy (11/17) documents: Resident with the following conditions, but not limited to, may be eligible for evaluation: (a) weak or absent muscle strength. Nursing/Restorative will document the application of the splint/brace/device on the appropriate facility ADL form.

Based on observation, interview, and record review. the facility failed to provide sufficient notification of SNF - ABN (Skilled Nursing Facility - Advance Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) to 3 out of 3 residents (R19, R98 and R112). These failures affect 3 residents (R19, R98 and R112) in exercising their rights and options afforded by notification procedure.Findings include: On 09/10/2025 at 12:28 PM, the facility submitted the following information to residents discharged within the last six (6) months that includes R19, R98, and R122: R19 remained in the facility. Medicare Part A skilled services episode start date: 08/01/2025. Last covered day of Part A service: 08/29/2025. R98 remained in the facility. Medicare Part A skilled services episode start date: 06/03/2025. Last covered day of Part A service: 09/10/2025. R122 discharged to home. Medicare Part A skilled services episode start date: 03/30/2025. Last covered day of Part A service: 05/30/2025. R19's, R98's, and R122's SNF-ABN and NOMNC were not signed by residents for the same reason; refused to sign due to paranoia. All forms (SNF-ABN and NOMNC) of R19, R98, and R122 were signed and witnessed by V7 (Restorative Nurse/MDS Coordinator) and V18 (Psychiatric Rehab Services Director/PRSD). On 09/10/2025 at 12:56 PM, V7 stated confirmed he and V18 signed all SNF-ABN and NOMNC forms. V7 stated it was V18 who explained to residents regarding notification of SNF-ABN and NOMNC. V7 stated he does not know much about insurance. On 09/10/2025 at 1:13 PM, V18 (PRSD) stated, NOMNC is provided at least 2 to 3 days before resident discharged to therapy or Medicare part A. After discharged to Medicare part A, it will basically stop covering therapy. Notice is given 2 to 3 days early to let resident appeal. I have no documentation under Social Service notes that education was provided to R19, R98, and R122. Paranoia means a resident fear, 'it may be because of fear of signing.' V18 stated by not signing of notices (SNF - ABN (Skilled Nursing Facility - Advance Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage), residents will not be able to avail their options provided by those notices. On 09/10/2025 at 2:57 PM, R19 was seen in her room, after seeing both (SNF - ABN (Skilled Nursing Facility - Advance Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) forms. R19 stated, I don't even know what that is, my identity was stolen. R19 look at both forms multiple times but was unable to recognize either form. On 09/10/2025 at 3:05 PM in the dining room, after seeing both forms (SNF - ABN (Skilled Nursing Facility - Advance Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage), R98 stated, I don't know what that is. As long as I am covered with Medicare and Medicaid, I will be all right. CMS-10123 Form Instructions for Notice of Medicare Provider Non-Coverage documents a Medicare provider must give a completed copy of this notice to beneficiaries receiving services from skilled nursing facilities (SNFs). Providers will note that the notice must be validly delivered. Valid delivery means that the beneficiary must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The beneficiary must be able to understand that he or she may appeal the termination decision. If the beneficiary is not able to comprehend the contents of the notice, it must be delivered to and signed by a representative. CMS-10095 Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) documents a Medicare health provider must give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to enrollees receiving skilled nursing. The notice must be validly delivered. Valid delivery means that the enrollee must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The enrollee must be able to understand that he or she may appeal the termination decision. If the enrollee is not able to comprehend the contents of the notice, it must be delivered to and signed by a representative.

Based on interview and record review, the facility failed to ensure qualified personnel submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for one resident (R7) out of a total sample of 25 residents.Findings include:R7's admission Record documents diagnoses of post-traumatic stress disorder (PTSD) (onset 9/04/2015), anxiety disorder (onset 11/03/2011), and alcohol dependence (onset 11/03/2011).R7's 4/14/2022 'Illinois PASRR Level I Form' does not include R7's diagnosis of PTSD. The 'Level I Attestation and Signature' box documents V17 (Office Tech / former Assistant Administrator) filled out the form. The 'Level I Attestation and Signature' box documents: By checking this box, I attest that I have reviewed all information contained herein and that I take responsibility for the completeness and accuracy of information reported throughout this submission. I attest that I am a health care professional working in a clinical capacity for this provider. I understand that approved submitters include clinical professionals such as nurses, [Licensed Practical Nurses], social workers (with a [Bachelor of Science] degree or higher), physicians, or home health agency clinical staff. Social service staff are not required to be licensed to submit information. I understand that administrative staff are not permitted to submit clinical information to [company name retracted].I understand that Illinois PASRR considers knowingly submitting inaccurate, incomplete or misleading Level I information to be Medicaid fraud, and I have completed this form to the best of my knowledge.On 9/10/2025 at 3:06 PM, V17 stated V17 has done residents' PASARRs in the past, including R7's form, but now V18 (Psychiatric Rehabilitation Services Director) primarily does them. When asked about qualifications, V17 stated V17 was the former Assistant Administrator. V17 stated V17 was not licensed, was not a Social Worker, and was not clinical in any capacity. On 9/10/2025 at 3:10 PM, V18 stated filling out the PASRR Level I Form involves inputting the resident's demographics, diagnoses, medications, and behaviors like hallucinations, delusions, or suicidal ideations. V18 stated it also involves reviewing the resident's history and physical from the doctors' progress notes and care plans to input all the necessary information in the form. V18 stated if a resident has a diagnosis of PTSD, it should be documented on their PASRR Level I Form. Facility's 'Pre-admission Screening and Resident Review (PASRR)' policy documents: It is the policy of this facility to comply with Federal, State and the appointed screening agency, [company name retracted], in standards addressing the PASRR assessment/screening process.

Based on observation, interview, and record review, the facility failed to follow professional standards and administer medications in a timely manner for two (R11 and R31) out of a total sample of 10 residents reviewed for medication times.Findings include: 1.On 9/09/2025 at approximately 10:20 AM, V6 (Licensed Practical Nurse) prepared R11's morning medications. These included Hydroxyzine Pamoate (given for restless leg syndrome), Lamotrigine (antianxiety), Levetiracetam (anticonvulsant), Metoprolol Succinate Extended Release (for high blood pressure), and Potassium Chloride (for low potassium). At 10:32 AM, V6 stated V6 will not administer the Metoprolol because R11's blood pressure was low. R11 took the other morning medications at 10:32 AM. R11's 'Medication Administration Record (MAR)' documents R11's morning medications are to be given at 9:00 AM. R11's 'Medication Admin Audit Report' documents on 9/03/2025, R11's morning medications were also administered late. R11's received the 9:00 AM medications at 12:08 PM. On 9/04/2025, R11 received the morning medications at 10:57 AM. On 9/08/2025, R11 received the morning medications at 12:40 PM. 2.On 9/09/2025 at 12:44 PM, R31 stated there were incidents a week to two weeks ago in which a new nurse gave R31's evening medications late. R31 stated nurses usually give R31's evening medications an hour after dinner. R31 stated during the mentioned incidents, it was almost 11:00 PM, and R31 still hadn't received the evening medications. R31's current MAR documents R31 is to receive Haloperidol (for agitation) and Vitamin C (supplement) at 5:00 PM. R31 is also to receive Donepezil Hydrochloride (for dementia) at 9:00 PM.R31's 'Medication Admin Audit Report' documents in August, R31 had Naproxen (for pain) and Vitamin C scheduled at 5:00 PM. On 8/06/2025, R31 received the medications at 7:03 PM. On 8/07/2025, R31 received the medications at 6:25 PM. On 8/09/2025, R31 received the medications around 8:28 PM. On 8/12/2025, R31 was no longer receiving Naproxen in the evening; however, R31 remained scheduled to receive Vitamin C at 5:00 PM. On this evening, R31 received it at 9:34 PM. There were multiple evenings afterwards in which staff administered it late (8/13/2025, 8/15/2025 - 8/17/2025, 8/20/2025, 8/21/2025, 8/23/2025 - 8/25/2025).R31's 'Medication Admin Audit Report' also documents in August, R31 had Donepezil Hydrochloride and Haloperidol scheduled at 9:00 PM. On 08/07/2025, R31 received the medications at 10:22 PM. On 8/20/2025, R31 received them at 11:14 PM. R31's 'Medication Admin Audit Report' documents on 8/26/2025, R31's 5:00 PM medications were now Vitamin C and Haloperidol. On this evening, R31 received them late at 8:01 PM. R31 also received them late on 8/27/2025 - 8/29/2025, 9/02/2025 - 9/04/2025, and 9/06/2025 with the latest one being at 8:45 PM on 8/29/2025. On 9/10/2025 at 11:23 AM, V2 (Director of Nursing) stated V24 (outside Social Worker) spoke with facility staff at the end of August to report R31 had complained about late or missing evening medications. V2 stated with some of the new nurses such as V13 and V25, it's possible medications were given late, since the residents were new to them. V2 stated all nurses were in-serviced on medication timeliness to make sure medications are administered within one hour before or one hour after the scheduled time. Facility's 'Medication Administration Policy' (8/15) documents: Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.

Based on observation, interview, and record review, the facility failed to follow policy for self-urethral catheterization on obtaining physician order and failed to provide documentation a urinary catheter was being changed for 1 out of 1 resident (R5) for a total sample of 25 residents. R5 is [AGE] years old, initially admitted on [DATE]. R4 medical diagnosis includes paraplegia, flaccid neuropathic bladder, and neuromuscular dysfunction of the bladder. On 09/09/2025 at 11:28 AM, R5 was seen in his room sitting on his bed. In front was his wheelchair with the urinary catheter bag attached. R5 was alert and verbally able to express thoughts well. R5 has a BIMS (Brief Interview for Mental Status) score of 15 on last MDS review, dated 07/30/2025, which indicates resident cognition is intact. R5 said, I change my own catheter, somebody taught me when I was on the street. R5 pointed to the box full or urinary catheter supplies including urinary catheter. On 09/11/2025 at 10:54 AM, V2 (Director of Nursing) clarified R5 has a urinary catheter to correct physician order written on R5's record. Physician order documents (urinary catheter), suprapubic, Condom catheters. V2 stated R5 has (urinary) catheter. V2 stated R5 is able to change (urinary) catheter. Requested to V2 that V2 provides physician order, assessment, care plan for self-performance of urinary catheter, and policy on changing urinary catheter. On 09/11/2025 at 01:12 PM, V2 stated R5 does not have physician order to perform self-catheterization. V2 said, I cannot remember when (R5) started performing self-catheterization. V2 stated there is no documentation for physician order or clinical notes R5's urinary catheter was being changed. Self-Urethral (Intermittent) Catheterization policy, dated 05/14, reads, physician ordered self-catheterization is considered a clean rather than sterile procedure. Urinary catheter insertion kit (size ordered by physician). Resident will be provided with a sterile catheter every 24 hours. Licensed nurse will assess the resident's tolerance and assist in resolving needs. V2 stated that this is the only policy for self-catheterization.

Based on observation, interview, and record review, the facility failed to assess and provide a plan of care for the use of enteral feeding and failed to ensure a resident received enteral nutrition feedings via G-tube per physician orders for 3 out of 3 residents (R4, R60, R95) out of a total of 25 residents reviewed for enteral feeding. Findings include: 1.R4 [AGE] years old, initially admitted on [DATE]. R4 medical diagnosis includes encounter for attention to gastronomy as primary diagnosis, dated 11/30/2023. V23 dietary notes, dated 01/23/2025, documents R4 is consuming 76% of all meals per review. V23 recommend hold enteral feeding. Diet order: general/regular diet, regular texture, thin consistency. R4 feeds self with set up and occasional assistance. By mouth intake more than 76%. On 09/09/2025 at 10:53 AM, R4 was seen in her room. R4 showed her gastronomy tube. R4 said, Tube feeding needs to be cut off. I am tired of this thing. On 09/11/2025 at 09:46 AM, V2 (Director of Nursing) stated R4 does not use tube feeding for nutrition purposes. V2 stated R4 eats by mouth and does not use G-Tube (gastronomy tube). V2 stated the only thing R4 uses her gastronomy tube for is medication administration. V2 said R4 refuses her medication; that is the reason the gastronomy tube is necessary. V2 was asked if there was an assessment or care plan to address the concern on refusal of medication. V2 stated she is not sure if there was a care plan or assessment. V2 said, I have to look it up. On 09/11/2025 at 9:52 AM, V23 (Registered Dietitian) stated G-tube feeding of R4 was put on hold because R4 is obese. V23 stated, Right now it is not necessary because (R4) put on some weight. Super-stable weight. V23 state the last time R4 was assessed was on January 23, 2025. V23 stated R4 currently is on no concentrated sweet (NCS) regular thin liquid diet. V23 said, She can tolerate a regular diet. V23 said, Tomorrow we will have a meeting; we will decide going forward. V23 stated since R4 weight remains stable, it is only necessary to have enteral feeding if medication is being refused. On 09/11/2025 at 1:12 PM, V2 stated there is no care plan for R4 refusing medication by mouth. V2 said, I cannot find a care plan that (R4) is refusing medication to show it is necessary to have G-tube. I will check if we have policy regarding medical necessity to have G Tube. V2 stated there is no policy related to determination of necessity for resident to have enteral feeding. V2 provided procedures on gastronomy site care and tube feeding related to infection prevention. 2. On 09/09/2025 at 12:10PM, V6 (Licensed Practical Nurse/LPN) states she has been working at the facility for approximately 1 week and is orientating under V19's (LPN) preceptorship. R60's physician order sheet/POS, documents, Glucerna 1.2 @ 65 cc hr. x 18 hr. 1200- 0600 start date 09/02/2025. R60's care plan documents, Provide diet as ordered. Infuse feeding as ordered on the POS. On 09/09/2025 at 12:12PM, V19 (LPN) states he has been working at the facility for approximately 9 years, and has 2 residents (identified as R60 and R95) who require g-tube feedings. V19 states he usually starts the g-tube feedings for both residents around 12:00PM every day. On 09/09/2025 at 1:09PM, R60 was lying in bed in her room in a supine position with head of bed elevated at 45 degrees. An enteral feeding pump adjacent to R60's bed. Enteral feeding pump observed turned off, and R60's enteral tube feeding or tube feeding equipment was not seen. On 09/10/2025 at 1:20PM, R60 was lying in bed in her room. An enteral feeding pump adjacent to R60's bed. Enteral feeding pump was observed turned off and R60's enteral tube feeding or tube feeding equipment was not seen. 3.R95's POS documents, Jevity 1.5 at 65 cc/hr. x 20 hours up at 1200pm off at 8am. R95's care plan documents, Infuse feeding as ordered on the POS. On 09/10/2025 at 1:17PM, R95's enteral feeding container was labeled as follows: Jevity 1.5 1000ml dated 09/10/2025 at 12:00PM and rate of 65ml per hour. R95's enteral feeding pump observed with a rate of infusion set to 75ml/hour; enteral feeding was infusing. On 09/10/2025 at 1:23PM, V13, Registered Nurse/RN, stated she is responsible for caring for R60 and R95 today. V13 was asked about R60's enteral feeding scheduled start time. V13 stated she believes R60's enteral feeding is scheduled for a start time of 2:00PM. V13 was made aware of R95's enteral infusion rate on the feeding pump. V13 stated she programmed R95's enteral feeding pump, but must have put the incorrect infusion rate. V19, Licensed Practical Nurse/LPN was then observed decreasing the infusion rate on R95's enteral feeding pump to 65ml/hour. V13 stated if R95's enteral feeding is not infused per physician's orders, there is a chance R95's enteral feeding can infuse too fast and cause her to become too full or to aspirate. On 09/10/2025 at 1:29M, V13 was observed at the nurses' station with R60's electronic health record/EHR on the computer. V13 stated R60's enteral feeding order documents R60's feeding should be infusing every day from 12:00PM-6:00AM. V13 stated if R60's enteral feedings are not infused per physician orders, R60 could potentially not have her nutritional needs met and then lose weight. Facility's policy, undated, titled Physician Orders documents, 2. Any orders given by Physician are carried out.

Based on interview and record review, the facility failed to report and investigate a misappropriation of property allegation for one (R2) of four residents reviewed for abuse in a sample of five. Findings include:On 08/24/2025 at 11:14 AM, R2 stated, I am the federal police. R2 stated he is missing a clock radio. R2 stated it was stolen, sold out in the street. R2 stated, I have no idea who stole it. R2 stated the police told R2 that they will recover it, but they didn't. R2 stated he informed the staff. R2 stated the police came here last week.On 08/24/2025 at 12:30 PM, R4 stated the police came to knock on R4's door and they asked R4 if any altercations or situations happened between R2 and R4. R4 stated he denied anything happened. R4 stated this happened last week, during the evening shift. On 08/24/2025 at 12:35 PM, V4 (Licensed Practical Nurse) stated R2 called the police last week because R2 was calling to complain about someone on the third floor. V4 stated the police officers went to the third floor, and they never asked V4 any questions, nor did they request R2's face sheet. V4 stated she went to R2 to ask R2 why R2 called the police, and R2 told V4 someone took something that belonged to R2 but did not voice any names or what item it was. V4 stated R2 did not make any sense, and the police just walked out. V4 stated this should have been documented in R2's electronic medication record for continuity of care. V4 stated V1 (Administrator) was not made aware. V4 stated V1 is the Abuse Coordinator. V4 stated she didn't think it was abuse related because the lack of details to R2's allegation. V4 stated she understands it should have been reported.On 08/24/2025 at 1:48 PM, V1 (Administrator) stated, All allegations of abuse must be reported to myself, who is the Abuse Coordinator immediately and verbally. Once it is reported to me, I have two hours to send the preliminary report to the State Agency, and I immediately get started on the investigation. If a resident alleges that someone took something from them, and called the police, that would be a possible allegation of abuse (misappropriation of property). V1 stated despite of a lack of details of an allegation made, staff must report it to V1. V1 stated it can be either a concern or possible allegation of abuse. V1 stated she was not made aware of any of the allegations, and she is just being made aware of this. V1 stated she was not made aware the police came to facility last week. V1 stated, I take everything seriously, and I don't downplay allegations due to (R2's) conditions. It should have been reported to me.R4's MDS/Minimum Data Set Section C, dated 06/11/2025, documents R4 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating R4 is cognitively intact. R2's MDS/Minimum Data Set Section C, dated 07/24/2025, documents R2 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating R2 is cognitively intact.No documentation regarding R2 calling the police and reporting an allegation of misappropriation of property noted in R2's electronic medical record. Facility document, not dated, documents: abuse prevention program facility procedures. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator, or an immediate supervisor who must then immediately report it to the administrator.

Based on interview and record review, the facility failed to ensure four of ten residents (R2, R3, R7, and R9) were free from abuse. This failure affected R2, R3, R7, and R9 who were physically hit, pushed, and punched by peers. As a result of this failure, R3 was hit, pushed, and punched, and sustained a laceration to the forehead requiring 8 stitches. Findings include: 1.R3's admission Record documented date of admission to the facility as 02/01/2024, with diagnoses that includes but not limited to Schizophrenia unspecified, bipolar disorder unspecified, depression unspecified, insomnia, obstructive sleep apnea (adult) (pediatric), history of falling, muscle weakness (Generalized), unsteadiness on feet, and other abnormalities of gait and mobility. R4's admission Record documented R4 was admitted to the facility on [DATE]; diagnoses includes but not limited to Depression unspecified, insomnia unspecified, unspecified psychosis not due to a substance or known physiological condition and asthma. R3 and R4 had a resident-resident physical attack that resulted into R3 being sent to the hospital due to fall injury from R4 hitting, slapping, and pushing R3. R3 fell on a transferring lifting device, causing a laceration to the forehead over the left eyebrow. On 05/14/25 at 11:49 am, R4 was observed on the 1st floor of the facility in the room preparing to go out on planned consultation. R4 stated, On 4/22/202, (R3) came to my room to steal my (snacks) and was going through my stuff. We (R3 and R4) were on the same floor. They (facility) moved me down here (1st floor) after I came back from the hospital. I pushed (R3) and hit her, because she was stealing from me; she came from her room to my room stealing. R4 stated when she pushed R3, R3 fell and hit her head on the (transfer lifting Device) in the hallway. (R3) started bleeding from the head, and I think they (staff) said she had some stiches from the hospital. At the time of physical contact, there was no staff around; I did not know I pushed her so hard. R3's medical record showed documentation R3 was sent to the hospital and returned to the facility with eight (8) stiches to the upper left eyebrow. On 05/14/25 at 2:44pm, R3 was observed in the room eating with redness noted on the left side of the forehead over the eyebrow, healing well, with no open wound or drainage. R3 was not willing to talk about the incident of 4/22/2025. According to R3's electronic health record (EHR), R3 was sent to the hospital on 4/22/25, and received 8 stiches to the forehead. On 05/14/25 at 12:49pm, V8, LPN (Licensed Practical Nurse/Wound care Nurse), stated, I am familiar with (R3) and (R4). I was not on the floor when it happened, but I was on the 3rd floor. The staff on the 2nd floor called me. I saw (R3) laying on the floor, with blood coming from upper left eye eyelid. They had already called the ambulance to pick up (R3). I applied pressure to the site and cleaned it. (R3) came back to the facility with 8 stitches. Hitting, pushing, or slapping another resident either by staff or peers, is a form of physical abuse. (V1, Administrator) V2, (Director of Nursing), Social Services, and the physician should be notified. On 05/14/25 at 2:58 pm, V1 (Administrator) stated, There was no witness to what happened. (V6, LPN/Licensed Practical Nurse), who was in charge at the time of 04/22/25 incident, no longer works at the facility. (R3) and (R4) were sent to the hospital for evaluation. Upon (R4's) return to the facility, (R4) was moved to the 1st floor. V1 acknowledged hitting, slapping, pushing, and any physical contact, is a form of physical abuse. V1 stated that was why the incident was treated as abuse. 2. On 05/21/25 at 12:58 PM, R2 was observed on the 1st floor of the facility ambulating around. R2 stated, (R1) came (wandered) into me room and hit me. I was in my room, and I did not do anything to (R1); he just came to my room and hit me. I have been in the hospital. Those hurt. On 05/14 /25 at 12:04pm, V10, LPN (Licensed Practical Nurse) stated, (R1) needs constant redirection, so (R1) has needs to be monitored. The last time I saw (R1), he was in the dining room, and I was at the nurse's station. We tend to monitor (R1) on a 1:1 (one to one staff monitoring). I did not see (R1) when he passed the nurse's station; I really don't know when (R1) passed by me. All I heard was some commotion down the east hallway. (R2) said (R1) came to his room and hit him. This behavior is part of why we monitor (R1) closely. (V11, Certified Nursing Assistant/ CNA) was assigned to both residents. At the time of incident, (V11) was on lunch break; I am not sure where she was, but I know (V11) was not on the floor. I was at the nurse's station, but I did not see the altercation. Both (R)1 and (R2) are in the hospital. The facility protocol for staff coverage when the staff assigned is not on the floor is we mainly monitor the dining room when the resident is in there. I helped in monitoring the floor, but I could not tell you how (R1) got past me. (R1) needs close monitoring. Yes, hitting, pushing, or slapping another resident either by staff or peers is a form of abuse, and it must be reported immediately to (V1, Administrator), who is the Abuse Coordinator. On 05/14/25 at 12:21pm, V11 CNA (Certified Nurse's Aide) stated, I am familiar with both (R1 and R2). I was not on the floor when they had the problem (Physical altercation). I was taking the lunch cart downstairs around 12ish (12:00pm or 1:00pm). When I was going off the floor, I did not know where the Nurse was, maybe in the nurse's medication room, so the nurse was not informed that I was going off the floor. When I left, there were other CNA's that can watch over my residents. When I got back to the floor, I saw management staff (V1 and V2) on the floor, and I was told both (R1 and R2) had a fight. Yes, hitting, pushing, or slapping another resident either by staff or peers is a form of physical abuse. 3.Facility Investigation Report of the incident of 05/09/25 documented R8 hit R7 in the back of the head while lining up to go for a smoke break with staff. V1 (Administrator) documented based on the known facts from medical record review and interviews the following conclusions have been determined about the original allegations, and checked abuse column. Police contacted event (#). Plan of care for R7 and R8 reviewed and updated. R7's admission Record showed admission date as 03/28/2022, with diagnoses that includes but not limited to Bipolar disorder, Paranoid schizophrenia and anxiety disorder. R8's admission Record showed admission date as 03/30/2025, with diagnoses that includes but not limited to Effusion right knee, Bacteremia, Cutaneous abscess of right upper limb, Type2 diabetes mellitus with foot ulcer, long term use of antibiotics and unsteady gait. On 05/21/25 at 10:05am, V5 (Certified Nurse's Aide) stated, On 05/09/25, we are getting ready for smoke break, and I was arranging the residents' wheelchairs against the wall in the hallway on the 1st floor. I heard a commotion behind, as I turned around and it was (R7) and (R8). (R7) said (R8) hit him in the back of his head. I immediately removed (R8) to other side in the hallway at the nurse's station. I told (V1, Administrator) about what happened. (R8) said (R7) was repositioning his wheelchair, and the wheelchair touched his foot. It is not appropriate for a resident to physically hit another resident. Yes, hitting, pushing, slapping, kicking, touching like pinching another resident is a form of physical abuse. On 05/21/25 at 10:55am, R7 was in the room in a wheelchair. R7 stated what he can remember about the incident of 05/09/2025 is (R8) hit me touching his head, I'm okay now. It hurts (referring to when it happened). On 05/21/25 at 11:16 am, R8 stated R7 wheeled the wheelchair into his leg, and it hurt him, and he felt pain on his leg. R8 stated he should not have hit R7, and let the facility staff handle it, but he reacted out of pain from the leg wound. V8 (Wound Care Nurse), who was present at the time of interview, stated R8 has a diabetic wound on the lower extremities. On 05/21/25 at 12:37 pm, V17, NP (Nurse Practitioner), stated, Many of these residents are confused and they have mental issues; they don't always know what they are doing, so it is difficult to say it is an abuse. When asked what abuse is and to give example of physical abuse and whether hitting, pushing, slapping another resident is a form of abuse, V17 did not answer. 4. R10's Progress note showed V9's, LPN (Licensed Practical nurse), documentation, dated 05/12/2025 timed 10:56am, indicating R10 was physically aggressive toward staff, throwing water on staff landing on other residents that was sitting by R10. R10 was screaming, yelling, and talking to self, and was not redirectable. Physician notified and gave order to send R9 to the hospital for psych (psychiatric) evaluation. While R10 was waiting to be sent out, R10 was placed on one-to-one monitoring. On the same day at 2:58pm, V9 documented R10 physically attacked R9, who was the roommate. On 05/15/25 at 1:43 pm, V16, PRSC (Psychiatrist Rehabilitation Service Coordinator), stated, On the day of the incident on 05/12/25, (R9) was responding to internal stimuli (hearing voices, was noted pacing in the hallway and talking to himself). (R10) was placed on 1:1 for behavior monitoring for throwing water on peers in the dining room and staff, and was uncontrollable. While we were in his room, the roommate, (R9), came into the room to pick up his books from his bed, and as (R9) was bending over to pick up the books, (R10) jumped up and hit (R9) and shuffled (R9). (R9) fell and laid on his bed. This happened around 1:30 pm. (R9) did not know he was not to come into the room. I called for help, and (R9) was immediately removed from the room to the nurse's station. (R10) was then moved to the Social Services office until he was taken by ambulance to the hospital. (R9) did not know he was not to come to the room. (R10) has not returned to the facility. On 05/22/25 at 12:37 pm, V20, PRSD (Psychiatrist Rehabilitation Services Director), stated Abuse is a harm toward resident, and it can be verbal, physical, mental, financial, misusing of resident property, and can also be isolating a resident. Physical abuse can be hitting, pushing, slapping, kicking, touching like pinching another resident is a form of physical abuse. A resident is assigned one to one supervision because the resident is having behavior problem, and by being on one to one, is to make sure the resident has no contact with anyone else (other resident) to cause them harm and to protect them from others harming them. In case of (R9) and (R10), (R10) was acting out; he should have been separated from the roommate, because there is a potential for harm. (R10) should have been in a separate space like the patio or another space before been transported transporting to the hospital. The facility policy on Abuse Prevention Program documented residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Physical abuse is infliction of injury on a resident that occurs other than accidental means and that requires medical attention. Physical abuse includes but not limited to hitting, slapping pinching, and kicking. The policy under protection of residents documented that residents who allegedly mistreat another resident will be removed from contact with other resident during the cause of the investigation. The facility policy on Behavior Management for Agitated Behavior, presented with no date, documented targeted behavior includes agitated behavior, which represents danger to self and others, due to Alzheimer's disease with anxiety, dementia, mental illness or other illnesses. Interventions listed includes but not limited to removing the resident from problem area and separate from others when necessary. Approaches to use when encountering a potential violent resident includes but not limited to moving other residents out of the area.

Based on interview and record review, the facility failed to use extensive assistance of two staff members during a manual bed-to-wheelchair transfer for one resident (R2) out of three residents reviewed for resident injury and falls. This failure resulted in R2 falling in the facility on 09/17/2024, during a manual bed-to-wheelchair transfer, sustaining a head injury and requiring four staples to the head. Findings include: R2s' Facesheet documents R2 has diagnoses not limited to: Diffuse traumatic brain injury with loss of consciousness, muscle spasm, other seizures, history of falling, and weakness. R2's MDS/Minimum Data Set, dated dated [DATE], documents R2 does not score on the BIMS/Brief Interview for Mental Status, and indicates R2 has memory problems. R2s' MDS documents R2 requires substantial/maximal assistance with chair/bed-to-chair transfer and sit to stand transfer. R2s' MDS documents R2 has impairments to upper and lower extremities on both sides. R2s' MDS documents R2 ambulates via wheelchair and is incontinent of bowel and bladder. R2s' care plan, dated 07/06/2024, documents R2 has an ADL/Activities of Daily Living Self Care Performance with Functional Deficit for transfers related to diagnosis of weakness to the upper and lower extremities. Interventions include to use gait belt for safety. R2s' Fall risk assessment, dated 07/27/2024, documents R2 is at high risk for falls. R2s' fall risk assessment documents R2 is unable to independently come to a standing position, R2 exhibits loss of balance while standing, and R2 has a decrease in muscle coordination. R2s' facility reported incident, dated 09/18/2024, documents R2 hit the right side of her head in the facility while being transferred from her bed to her wheelchair. Nursing progress note, dated 09/17/2024, written by V6 (Registered Nurse/RN) documents, Writer was informed by the staff that (R2) fell and hit her head on the nightstand. Writer went to see (R2) in the room. A full body was assessment done. Resident noted with a small laceration on the right temple. Writer notified NP (Nurse practitioner) and an order was given to send the resident to the local hospital for medical evaluation. Writer started neuro checks, vitals were taken, and the affected area was clean and covered with dry dressing. Resident was given PRN/as needed for pain as per MAR/medication administration record. Vitals were taken and were normal. Nursing Service and Administrator made aware. At 4:50 PM, writer scheduled ambulance for transportation. At 5:30 PM, R2 was transferred to the hospital. R2 left in stable condition. Nursing progress note, dated 09/18/2024, documents, (R2) returned to the facility from hospital with 4 staples and a bandage above the right eyebrow. Discharge instructions were to provide wound care, keep head elevated, and no limitations on wt./weight bearing. (R2) was placed in bed and safety measures were implemented. Vitals are normal. R2s' hospital records, dated 09/17/2024, documents R2 was evaluated in the hospital on 09/17/2024, and diagnosed with a scalp laceration. R2s' care plan, dated 10/04/2024, documents R2 was sent to the hospital for evaluation and treatment on 9-17-24. R2 returned to facility with 4 staples above the right eyebrow on 9-18-24. On 11/30/2024 at 9:56 AM, R2 was observed fully dressed sitting in a wheelchair inside the second-floor dayroom. R2 was not interviewable and unable to make her needs known. On 11/30/2024 at 2:20 PM, V6 (Registered Nurse/RN) stated on 09/17/2024, she remembers R2 sitting in the second-floor dayroom and needed her incontinence brief changed. V6 stated two CNAs (identified as V9/CNA and V10/CNA) took R2 to her room so they could provide incontinence care for R2. V6 stated, (R2) is a two-person assist with transfers, which is why two CNAs were present to assist (R2). V6 stated she did not witness R2 fall, but was informed V10 was in the shower room and V9 was standing next to R2. V6 stated R2 attempted to stand up and lost her balance, and V9 tried to catch R2. V6 stated, (V9) was unable to catch (R2) from falling on the floor and (R2) hit her head on the nightstand. V6 stated she believes the incident occurred during the process of trying to transfer R2 and transport her back to the day room after they had finished changing R2s' incontinence brief. V6 stated, (R2) has history of falling. (R2) sits on the bed and starts jerking her legs, attempting to wiggle herself out of the bed. V6 stated V10 (Certified Nursing Assistant/CNA) was the CNA assigned to care for R2 on 09/17/2024. V6 stated she was made aware of R2s' injury when V9 (CNA) came to get her in the dayroom and told her R2 fell and hit her forehead. V6 stated she immediately went to assess and assist R2. V6 stated when she arrived, she saw R2 was sitting on the bed and had some bleeding on her head. V6 stated she called the DON/Director of Nursing, the Administrator, and R2s' doctor to make them aware. V6 stated R2s' doctor ordered to send R2 to the hospital for evaluation. V6 stated she then cleaned R2s' wound and applied a dry protective dressing. On 12/01/2024 at 10:47 AM, V10 (Certified Nursing Assistant/CNA) stated she was responsible for caring for R2 on 09/17/2024. V10 stated R2 was located in the day room on 09/17/2024, and needed her incontinence brief changed. V10 stated R2 is a two-person assist, so V10 asked another CNA (identified as V9/CNA) to assist her with changing R2. V10 stated R2 was transported to her room via wheelchair and placed inside of her room. V10 stated she immediately went to the bathroom to prepare towels and warm the water to provide incontinence care for R2. V10 stated she was inside of the bathroom for approximately six minutes. V10 stated V9 stayed with R2 while V10 was inside of the bathroom. V10 stated once she finished in the bathroom, she went inside of R2s' room and saw R2 on the bed and a little blood on the floor at the bedside. V10 stated she asked what happened, and V9 told her R2 fell . V10 stated she did not witness R2 fall or what occurred, because she was in the bathroom. V10 stated she then stayed with R2 while V9 went to inform the nurse R2 had fall and was bleeding. V10 stated she began to clean the blood up off of the floor and also saw R2 had a little blood on her forehead. V10 stated she never touched R2, did not witness what happened, or why R2 was bleeding. V10 stated once the nurse arrived (identified as V6/RN), V6 examined the cut on R2 and asked what happened. V10 stated she informed V6 that she was not there and did not see what happened. V10 stated V9 informed V6 that R2 fell . On 12/01/2024 at 1:21 PM, V10 (Certified Nursing Assistant/CNA) stated she can't remember exactly who transported R2 to her room, but R2 was transported to her room via wheelchair and placed inside of her room. V10 stated during this time, incontinence care had not occurred for R2 yet, and she went inside the bathroom to prepare towels and warm water. V10 stated when she returned to R2s' room, she saw R2 sitting on the bed bleeding and V10 is unaware of how R2 got onto the bed. On 12/01/2024 at 11:08 AM, V9 (CNA) stated he was not the CNA assigned to care for R2 on 09/17/2024. V9 stated R2 is a two-person assist with transfers, and was asked by V10 (CNA) to assist her with transferring R2 and incontinence care for R2. V9 stated he has provided care for R2 on previous occasions and is familiar with R2. V9 stated he stayed with R2 while V10 went to the bathroom. V9 initially stated he was helping R2 from the bed to the wheelchair, when R2 hit her head on the nightstand. Upon further interview, V9 stated he was positioned directly in front of R2, holding R2 by the shirt, while R2 was sitting on the bed. V9 stated he was waiting for V10 to come back from the bathroom so he could transfer R2 from the bed to the wheelchair. V9 stated, That's when (R2) suddenly reached out to the nightstand and bumped her head on the nightstand. V9 stated R2 got up and tried to reach towards the nightstand. He lost his grip on her and R2 fell . V9 stated it happened all of a sudden because he didn't know that (R2) would do that. V9 stated R2 moves back and forth while in the sitting position and does not sit still. V9 stated V10 entered the room and he and V10 sat R2 on the bed. V9 stated that's when they both realized that R2 was bleeding. V9 stated he then went to report the incident to the nurse (identified as V6/RN). V9 stated sometimes he uses a gait belt to transfer residents, but not every time. V9 stated if he does not have another staff member to assist him right away with a two-person assist and staff are busy, then he uses a gait belt to transfer the residents by himself. V9 stated he does this when the facility is short staffed. On 12/01/24 at 1:54PM, V9 (CNA) stated when he arrived to R2s' room to assist V10, R2 was already inside of R2s' room sitting in her wheelchair. V9 stated he and V10 then transferred R2 from the wheelchair to the bed. V9 stated he and V10 immediately began incontinence care for R2. V9 stated the towels and the water were already located inside of R2s' room, soaking in water inside a bin. V9 stated his role was to take off R2s' diaper, clean her, and assist to transfer her back to the wheelchair. V9 stated V10 was going back and forth to the bathroom exchanging water, washing her hands, and bringing the bin back. V9 stated incontinence care was provided for R2 prior to V10 going to the bathroom for the first time. V9 stated R2 fell after incontinence care was provided and while he was waiting on V10 to return back from the bathroom. V9 stated at this time, R2 was sitting on the bed fully dressed because he and V10 had provided incontinence care and fully dressed R2. V9 stated he was only waiting on V10 so that he could get assistance with transferring R2 from the bed to the wheelchair and take her back to the dayroom. On 12/01/2024 at 11:48 AM, V12 (Restorative Nurse/Fall Coordinator/LPN), stated he is familiar with R2.(R2) is an extensive to total care assist with ADL/Activities of Daily Living care. For transfers, (R2) needs at least a two-person assist due to her history of seizures and traumatic brain injury. (R2) ambulates via wheelchair and should be in a wheelchair when (R2) is not walking. (R2) also has an abnormal posture and muscle spasms. (R2) tends to stand up and has issues with safety awareness. (R2) wiggles around and still thinks she can do everything on her own, but she can't. V12 stated he is aware of the incident involving R2s' head injury. V12 stated he was made aware one of the CNAs (identified as V9/CNA) tried to transfer R2 by themself, and R2 fell and hit her head. V12 stated, (R2) had a wound on her head and was sent out to the hospital for evaluation. (V9) was not supposed to transfer (R2) by himself. (V9) was supposed to ask for help from another staff member to transfer (R2), especially since (V9) has a smaller weight/frame size than (R2). V12 stated a proper bed to wheelchair transfer should be as follows: one staff member standing in front of the resident and places a gait belt on the resident. The other staff member should be positioned on the other side of the resident to help move the resident from the bed to the wheelchair. V12 stated during a two-person transfer procedure, it is not acceptable for one staff member to leave the room. V12 stated R2 has spasms and always requires two people for transfers because of how R2 moves her body. V12 stated R2 is a high risk for falls. Facility policy undated, titled Supervision and Safety documents, 9. Staff to decrease safety risk hazards as much as possible. Facility policy undated, titled Lifting/Transfers documents, Purpose: To promote comfort, maintain good body alignment, decrease the complications related to immobility, and decrease the possibility of injury to the resident. 4. Transferring a resident with injuries, pain or dementia can cause anxiety. The procedure should be done carefully while providing support and reassurance to the resident. Facility policy undated, titled Limited Lifting Resident Handling Policy documents, 9. Use of gait belt for all physical assist transfers is mandatory. Facility policy undated 01/12/2024, titled Fall Prevention Program documents, The Fall Prevention Program includes the following components: 10. Care plan incorporates: a. Identification of all risk/issue. c. Preventative measures. Standard Fall/Safety Precautions for all Residents: 12. Transfer conveyances shall be used to transfer residents in accordance with the plan of care.

Based on observation, interview, and record review, the facility failed to ensure that a resident (R1) was free from sexual abuse and mental anguish. This failure affected R1 who experienced sexual abuse and mental anguish in form of another resident exposing themselves to R1 in the facility elevator. Findings include: R1's medical record admission record showed R1 was originally admitted to the facility on [DATE], and latest admission was dated 01/01/24, with diagnoses that includes but not limited to Pneumonia, unspecified organism, hypokalemia, muscle wasting, unsteady on feet, presence of intraocular lens, anxiety disorder, insomnia, ileus unspecified, and essential hypertension. R1's MDS (minimum Data Set), dated 04/04/24, showed BIMS (Brief Interview for Mental Status) score of 10, showing R1 is cognitively impaired. R2's medical record admission record showed R2 was admitted to the facility on [DATE], with diagnoses that includes but not limited to schizoaffective disorder unspecified, Type 2 diabetes mellitus without complications, unspecified convulsions, other depressive episodes, and hypokalemia. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score of 12 shows R2 is cognitively impaired. According to facility reported incident on 06/10/24, R1 alleged that R2 exposed self to R1 while in the elevator and after the facility investigation, based on the facts from their review from the resident medical record and interviews, the facility concluded the allegation was substantiated. Both R1 and R2 were placed on 1:1 supervision, R1 was transferred to another floor, and R2 later was transferred to a local hospital for Psychiatrist evaluation. On 06/17/24 at 10:00am, V3, LPN (Licensed Practical Nurse), stated R1 has moved to the 1st floor, separating R1 from R2, and was placed on 1:1 supervision and nearer to the nursing station. On 06/17/24 at 10:08am, R1 observed in the room crying. R1 stated, I am punished for what happened to me. I'm the one not able to visit my friends on my floor. I have friends on my floor that I cannot see. I am afraid because (R2) is still living on the floor and I cannot go upstairs. (Crying). I don't go for activities because I am afraid, I might find (R2) there. (R2) exposed himself to me in the elevator, and all the time, (R2) stands over me on my bed and in my doorway. And anywhere I go, (R2) can go too. When asked about whom this was reported to by name, R1 could not remember, but stated R2 was the only resident in the elevator during the incident of 06/10/24. R1 stated R1 felt being punished for what happened. On 06/17 at 10:28am, V4, LPN (Licensed Practical Nurse), stated, (R2) reported to one of the staff, (V13, CNA Certified Nurse's Aide) that (R2) had exposed himself to (R1) in the elevator. As soon as (V13) told me, I reported it to the Administrator. (R2) was placed on 1:1 right away. I called the psychiatrist and orders were given to send (R2) to the (local hospital) for psychiatrist evaluation. (R1) was put on 1:1 until the time (R1) went to the hospital. (R1) is no longer on the floor; she is now on the 1st floor. (R1) was moved to the 1st floor the same day (R1) was put on 1:1 supervision. V4 acknowledged exposing oneself to another intentionally is a form of abuse. On 06/18/24 at 10:13am, V13, CNA (Certified Nurse's Aide), stated, On 06/10/24, (R1) and (R2) told me about the incident. R1 stated that (R2) exposed himself to (R1) in the elevator, and (R2) said (R2) exposed self in the elevator. (R1) was the only resident in the elevator. V13 stated it was not a normal thing for R2 to go about exposing self to another resident (referring to peers). When asked whether exposing oneself to another resident is form of abuse. V13 stated, Yes, it is a form of sexual abuse. On 6/18/24 at 10:27am, V15, PRSD (Social Services Director), stated he was not in the facility at the time of incident of 06/10/24, but was told that R2 had walked up to R1's room and made inappropriate comments. V15 stated he was able to talk with R1, but R2 has been sent to the hospital. The surveyor asked V15 whether exposing oneself to another person/resident can be a form of sexual abuse. V15 stated, Yes. On 6/18/24 at 10:48am, V14 (Assistant Director of Nursing) stated, (R1) came to me and told me that (R2) had pulled his pants down and exposed himself to (R1) in the elevator and said, 'come and get it'. V14 stated R1 was visibly shaking, upset, and crying. V14 stated the Nurse Practitioner and family were notified. (V17, NP/Nurse Practitioner) ordered some psychotropic medication to calm (R1) down, and consent was taken over the phone from the family member. The surveyor asked whether intentionally exposing oneself to another can be form of sexual abuse. V14 stated, Yes and it can also be a dignity and resident rights issue. R1's medical record showed that Risperdal 1mg, Buspar 5mg, and Vistaril 25mg was ordered for R1. On 6/18/24 at 12:47pm, V2, DON (Director of Nursing) stated, It could be deemed sexual abuse depending on the intent and nature of the resident psychologically. V2 acknowledge the incident between R1 and R2 is a form of sexual abuse. On 6/18/24 at12:50pm, V1 stated, Exposing oneself to another, yes can be a form of abuse, depending on the intent and when it makes resident uncomfortable. The incident with (R1) and (R2) was a form of abuse, and that was why it was reported immediately. On 06/20/24 at 1:35pm, V17 stated, I cannot remember whether they (referring to the facility Nurse) told me or not, to be honest with you. V17 stated he was familiar with R1. When asked about what the nurse told V17 happened to R1 before ordering the medication, V17 stated, I forgot already. The facility policy on Abuse Prevention Program documented the facility affirms that the facility resident has the right to be free from abuse. Abuse is defined as the willful infliction of injury that includes but not limited to mental anguish, and sexual abuse includes but not limited to sexual harassment. The facility policy on Resident Rights presented with last revision, dated 2/24, documented employees shall offer all residents privacy and treat all residents with respect and dignity. To provide an environment of care that supports a positive self-image.

Based on interview and record review, the facility failed to follow its policy on abuse for one (R1) resident of three reviewed. This deficiency led to R1 being punched by R2 on the top of his head, and R1 suffered a laceration requiring/receiving two staples. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual, admitted to the facility on [DATE], and his medical diagnosis include but not limited to: chronic obstructive pulmonary disease, unspecified, aphasia, dysphagia, oropharyngeal phase, hemiplegia, unspecified affecting unspecified side. R1's MDS (Minimum Data Set) Section C - Cognitive Patterns-BIMS (Brief Interview for Mental Status), dated 2/21/24, documents R1's BIMS is 15/15, indicating R1 has intact cognation, and R1's MDS section E- behavior documents R1 does not exhibit behavioral issues. R2's current face sheet documents R2 is a [AGE] year old individual, admitted to the facility on [DATE], and his medical diagnosis include but not limited to disorganized schizophrenia, auditory hallucinations, anxiety disorder, unspecified, depression, unspecified. R2's MDS (Minimum Data Set), Section C-Cognitive Patterns, dated 02/05/2024, does not score R2's BIMS (Brief interview for Mental status). R2's MDS section E-Behavior documents R2's behaviors as hallucinations, delusions, and physical behavioral symptoms directed to others such as hitting, kicking, pushing, threatening others, screaming, and cursing at others, occurred one to three days. R1's Nursing Progress notes, dated 1/24/2024 14:20, documents V7(Registered Nurse-RN) was at the nurse's station at about 2:00pm doing her charting, when it was reported by another resident, (R9) that R1 had been punched in the head by R2. V7 immediately rushed to the resident's room and found him sitting in his wheelchair with minimal bleeding on the right side of his head. R1 was assessed, he was noticed to have a minor cut on the right side of his head, and was able to communicate with hand gestures that he was punched in the head while sitting in his chair. R1 was sent to community hospital for further assessment. R1's Nursing Progress Notes, dated 1/24/2024 at 22:11, documents, (R1) returned safely nearby hospital with 3 staples to top middle back of head, and said he has headache and Tylenol given, will monitor for effectiveness. R1's hospital records dated 1/24/2023 documents: -You (R1) were seen and evaluated here in the emergency department after you were punched in the head and suffered a laceration over the back your head. -Staples were placed. -Please follow up in 10 days to have the stables removed with your primary care doctor or here in the emergency department. Police report number, dated 01/24/2024, documents: -AGG(Aggressive) Battery. Name of victim- R1 R2's progress notes, dated 01/24/2024 at 15:09, R2 punched another resident(R1) in the head which lead to minimal bleeding. Facility reported Incident Report (FRI-Final), dated 1/30/2024, documents V7 reported to administration that R1 was observed bleeding from the back of his head, was assessed and was noted to have a laceration. R1 stated he was hit in the head by R1. Both R1 and R2 were sent to the nearby hospital, and R1 come back to the facility with two staples top mid back of the head. The FRI further documents based on the known factors from medical records and interviews, the following conclusions have been determined about the original allegations: Abuse. On 3/26/2024 at 10:36am, R1 stated R2 hit him on the top of his head as he was sitting in his room, and pointed to the top of his head, stating he bled when R2 hit him, and he was taken to the hospital and received two stitches. R1 stated he did not provoke R2 before R2 hit him, and R2 just walked in and hit him. R1 said he did not like it when R2 hit him, and he felt pain in his head. On 03/26/2024 at 10:47am, V7 (Registered Nurse) said she was the nurse on duty when R2 hit R1 unprovoked. V7 stated she was completing her charting at the nursing station, when R9 alerted her that R1 was bleeding on the head. V7 stated she rushed to R1's room and found R1 bleeding from a small laceration on the head, and R2 had punched R1 on the head with no provocation. V7 stated she assessed R1 and called V14 (Wound Care Nurse/LPN), who came and assessed R1 and put a dressing on R1's laceration on the head. V7 stated she then notified R1 and R2's providers and both residents were sent to nearby hospitals for further evaluations. V7 stated R1 received 2 staples on the head and returned to the facility. V7 stated R2 has a history of violence such as punching walls, and other residents feared him. V7 stated residents are not allowed to hit each other and hitting is a form of mental and physical abuse. On 3/27/2024 at 9:52am V14(Licensed practical Nurse-LPN/Wound Care) stated on the day R1 was punched by R2, V7 called him to the unit to assess R1, and V14 went to R1's room and found him bleeding from the right side of the top of his head. V14 stated he assessed R1, and saw R1 had a laceration on the scalp, therefore V14 cleaned the laceration with normal saline, applied pressure then wrapped it with gauze, and R1 was to the hospital for further evaluation and treatment. V14 stated residents are supposed to be kept safe in the facility and not be hit by peers or staff. V14 stated hitting is physical aggression/abuse and should not happen in the facility. On 03/27/2024 at 10:43am, V3(Director of Nursing) stated residents cannot hit each other because residents have to be free of injury, but sometimes residents might hit someone unwillingly because of their diagnosis, but resident had a right to be free of physical abuse. On 3/27/2024 at 12:38pm, V18 (Social Services Director) stated R1 has never shown physical aggression, and R1 stated he was sitting in his wheelchair in his room, R2 come from the back and hit him on the head with his hand. V18 said R1 told him he (R1) was upset about the incident. V18 stated residents are not supposed to hit each other because that is abuse, and it can affect the resident emotionally and physically. On 03/27/2024 at 1:18pm, R9 was observed in the hallway walking towards his room. R9 is alert and oriented to person, place, time, and situation. R9's BIMS score, dated 1/10/2024, documents R9's BIMS as 15/15, indicating R9's cognation is intact. R9 stated on the day R2 hit R1, he was in the room with R1 and R2 come to the room and hit R1 on the head with his (R2) knuckle, and R1 suffered a cut and was bleeding. R9 stated he went and informed V7(Registered Nurse) of what happened. On 03/27/2024 at 3:15pm, V1 (Administrator) stated she is the Abuse Coordinator and residents are not supposed to hit each other because hitting is a form of physical abuse, and it can lead to physical injury and the victim (resident) can be severely impacted mentally, and cognitively by being abused. Facility policy titled: ABUSE PREVENTION PROGRAM-POLICY, dated 1/20, documents: -The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual, or physical abuse, corporal punishment, and involuntary seclusion. The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated. - Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.

Based on interview and record review, the facility failed to provide supervision, failed to ensure that staff intervene timely, and failed to prevent a physical altercation for two of four residents (R3, R4) reviewed for abuse. These failures resulted in R4 sustaining a right eye abrasion. Findings include: The Preliminary Incident Investigation Report, dated 11/11/23, states Nurse reported R3 and R4 engaged in a physical altercation. R4's incident report, dated 11/11/23, states, writer heard a noise in the dining when passing medication. On reaching there resident and a co-resident were engaged in altercation. Resident alleged that co-resident hit him when dragging chair with him. Injuries observed at time of incident: right eye abrasion. No witnesses found. R4's progress notes, dated 11/11/23, state, writer heard a noise in the dining when passing medication. On reaching there resident and a co-resident were engaged in altercation. Writer separated both residents to prevent further physical aggression. Noted a little bleeding from residents right upper eye region. Order received from doctor to send resident to hospital. R4's diagnoses include vascular dementia, Parkinson's disease, slowness, poor responsiveness, and reduced mobility. R4's BIMS (Brief Interview for Mental Status), dated 12/22/23, determined a score of 9 (moderate impairment) inattention is continuously present. On 1/29/24 at 2:30 PM, surveyor attempted to interview R4; however he refused to respond. R3's progress note, dated 11/11/23, states resident alleged co-resident first hit him, and he had to hit him back. R3's diagnoses include schizophrenia, bipolar disorder. R3's BIMS (Brief Interview Mental Status), dated 11/9/23, determined a score of 15 (cognitively intact). On 1/29/24 at 2:09 PM, R3 stated, I was straightening up the dayroom chairs. I moved the chair next to his (R4) table, he snatched it and almost hit me in the chin. He grabbed the chair, dropped it, hit me with his right hand, and I hit him with my left hand. Consequences led to consequences he (R4) hit me (R3), and I (R3) hit him (R4). That was it. R3 affirmed they struck each other in the face. R3 affirmed staff intervened after the altercation occurred. On 2/1/24 at 11:54 AM, V1 (Administrator) stated, I received a call from the nurse on duty (V13/Registered Nurse) who told me the residents had a altercation in the dining room. He (V13) said he heard a commotion, and they were going back and forth about the TV. (R4) started maneuvering chairs and changed the station, (R3) got up to change the station and they made contact while trying to change the station at the same time. Surveyor inquired about R3 and R4's contact V1 responded They hit each others hand or so while trying to change the station back. The nurse (V13) was passing medication and the CNA (Certified Nursing Assistant) was rounding at the time. The expectation is to do frequent rounds on dining room and the units. On 2/1/24 at 10:04 AM, surveyor inquired about potential harm to a resident that is hit in the face V12 (Medical Director) stated, It could be local injuries, possible fracture, or bleeding. The (undated) abuse prevention program states: This facility affirms the right of our residents to be free from abuse. Establishing a resident sensitive environment will be accomplished by a comprehensive quality management approach involving staff supervision. On a regular basis, supervisors will monitor the ability of the staff to meet the needs or residents, staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur.

Based on observation, interview, and record review, the facility failed to implement care plan interventions, failed to repair equipment, and failed to ensure staff transfer residents safely for one of four residents (R1) reviewed for incidents/accidents. These failures resulted in R1 sustaining a right lower leg laceration on 12/4/23, which required 11 staples to repair. Findings include: R1's diagnoses include dementia, cognitive communication deficit, weakness, and need for assistance with personal care. R1's BIMS (Brief Interview Mental Status), dated 12/22/23, states resident was unable to complete the interview. R1's cognitive skills for daily decision making are severely impaired. R1's functional assessment, dated 12/22/23, affirms substantial/maximal assistance is required for chair to bed transfer. R1's care plan states, dated 11/3/23, documents ADL (Activities of Daily Living) Self Care Performance Deficit, Intervention: resident requires assistance when transferring (10/3/23) Resident demonstrates cognitive impairment related to diagnosis of Alzheimer's disease symptoms are manifested by becoming agitated during care and resisting necessary assistance. Intervention: If the resident is agitated or becomes agitated during care, back off and try to calm the resident with soothing words. If the resident remains agitated tell him that you'll come back when he is feeling better. R1's progress notes, dated 12/4/23, state, Writer was informed by the CNA (Certified Nursing Assistant) that resident's right lower leg is bleeding. Noted laceration (around 2 inches in length) on the side of the right lower leg. Resident assisted back to bed. Nurse Practitioner notified ordered to send to hospital for wound stitching. CNA together with the other CNA said that they were trying to transfer the resident back to bed, but the resident was refusing and fighting back, his leg scraped the screw of the bed. 12/5/23 Received resident from emergency room . Right leg assessed and 11 staples present. R1's management incident investigation, dated 12/4/26 (typographical error), states: Does resident have a history of falls? Yes. Has resident been identified as a fall risk? Yes. Does resident display poor coordination/unsteady gait? Yes. Potential contributing factors: Alzheimer's disease/Dementia, foreign objects in pathway, resistive to care. Possible interventions for consideration according to classifications for falls, bruises, skin tears: Other: Bed with screw sticking out was fixed by maintenance. All beds in facility were checked for safety. Resident room was changed closer to nursing station as resident is also a fall risk. Assess for need of transfer aids was not selected. R1's initial skin assessment, dated 12/5/23, includes right lateral, lower leg surgical wound 5.2 x 0.2 x (not measurable) centimeters. Probable cause of the skin alteration: trauma. V10's 12/5/23 8:40 AM, typewritten Witness Statement includes the following: Was the resident resisting care when you were transferring the patient? Yes. How did you transfer the patient? Both of us hold (sic) the patient arms so he do not hit us because he was struggling. What happened? Resident appeared to bumped his leg (sic) on the screw of the bed when we were transferring the patient. V11's 12/5/23 11:25 A, typewritten Witness Statement includes the following: Was the resident resisting care when you were transferring the patient? Yes. How did you transfer the patient? Both of us hold (sic) the patient arms so he do not hit us because he was struggling. What happened? Resident appeared to bumped (sic) his leg on the screw of the bed when we were transferring the patient. On 1/29/24 at 2:35 PM, V6 (CNA) was observed assisting R1 with repositioning in bed after transfer from the wheelchair. R1 was clearly unable to reposition himself. V6 stated, I had (V7/Wound Care Nurse) help me; however, a gait belt was not observed in the room and/or on R1. R1 stated, I ain't doing good both my knees hurt and my neck. Surveyor inquired how R1 injured his leg R1 replied, I don't know nothing. He was bringing it off the bum, you could see he was standing there; however was unable to clarify what this meant. On 1/29/24 at 2:41 PM, V7 (Wound Care Nurse) stated, He's (R1) oriented times 2, he's confused and he's aggressive. Surveyor inquired how R1 is transferred. V7 responded 2 person assist. Surveyor inquired how R1 injured his leg. V7 replied, They (staff) just said that during transfer he got injured. He was sent to the hospital and came back with the staples. I think it was like 9 (staples). On 1/30/24 at 2:29 PM, V9 (Restorative Nurse) stated, He's (R1) times 1; he doesn't know where he is, or the date, the time, or the year. He's very non-compliant with care. He's very combative so we use 2 person with toileting, dressing, transfers, grooming. There's a care plan there that is ADL's that said he needs a lot of motivation and need assistance with transfer, dressing and grooming-- all the ADL's except for eating. If the resident is refusing, we talk to Social Service for him to be involved, and talk to the resident. If that doesn't work, the family can talk to him by phone, but the resident is confused so it might not be working for that one. So, I would say encouragement, but it takes a long time, but eventually he will do it. Surveyor inquired how R1 transfers from the wheelchair to bed. V9 stated, Extensive assist, 2 person. Also, it's much better for you to use a gait belt. On 1/30/24 at 3:15 PM, surveyor inquired if R1 can stand. V2 (Director of Nursing) replied, With assistance. Surveyor inquired how staff transfer R1 from the wheelchair to the bed or vice versa. V2 stated, So the CNAS when I saw him (R1), they (CNAs) actually have one person hold him and have the other one put him (R1) in the bed. One person was trying to guide him (R1) and the other person was trying to put him in the bed so he doesn't strike out. Surveyor inquired about R1's (12/4/23) incident which resulted in serious injury. V2 responded, The patient (R1) has a laceration on the right leg. According to the CNAs when they were transferring the patient (R1) he was aggressive, and his leg accidentally hit the screw on the side of the bed. It was a bolt on the bed that was loose, and it hit his leg. He was sent to the hospital and came back; unfortunately there was some staples there. Surveyor inquired what the CNAS should have done if R1 was aggressive. V2 replied, They should have at least try to calm him down first and wait till he's not aggressive to put him back to bed. I told the maintenance the same day, please check the bed, and he came right away. I looked at the bed and there's probably maybe an inch screw that was fixed. On 1/31/24 at 11:44 AM, V8 (Registered Nurse) stated, He's (R1) alert and oriented times 1 to himself only. He's usually in the wheelchair, needs 2 man assist from bed to wheelchair or wheelchair to bed. Surveyor inquired about R1's 12/4/23 incident. V8 responded, I heard a call light and went there to his room. I saw blood so I asked them (V10/CNA & V11/CNA) what happen, they said they were trying to transfer him and he was trying to fight. He wanted to stay up late. I think it was some bolt or something that scratched his leg. Surveyor inquired where R1 was located when V8 entered R1's room. V8 replied, He was actually on his bed at that time sitting. Surveyor inquired how staff transferred R1 to bed. V8 stated, I don't know if they (V10 & V11) used the (mechanical lift) that time or they transferred him (R1) with the belt. On 1/31/24 at 12:57 AM, surveyor inquired how V10 and V11's statements were verbatim if interviewed on separate occasions V2 (DON/Director of Nursing) affirmed V10 and V11 were interviewed via phone and signed typewritten statements (documented by V2). On 2/1/24 at 10:59 AM,V12 (Medical Director) stated, The patient should be calmed down before you do something, that's what it should be if that's what the care plan is telling you to do. If the patient is too aggressive, they (staff) need to call the physician. The Supervision and Safety policy, dated 3/15, states safety risks and environmental hazards are identified on an ongoing basis through employee training conducted upon hire, annually and as needed. The Fall Prevention policy , dated 2/28/14, states malfunctioning equipment will be immediately reported to maintenance for repair or removed from service. Transfer conveyances shall be used to transfer residents in accordance with the plan of care.

Based on interview and record review, the facility failed to adequately supervise a resident (R126). This failure resulted in R126 eloping from the facility from the patio area. R126 has not returned to the facility. This was identified as an Immediate Jeopardy which began on 7/10/23, when R126 eloped from the facility under no staff supervision. On 10/6/23 at 3:32 PM, the Administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy began on 7/10/23, and was removed on 10/12/23. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings include: R126 was viewed as a closed record. R126's 10/5/23 facesheet documents R126 diagnoses not limited to: Type 2 diabetes mellitus, anemia, schizophrenia, history of falling, and depression. R126 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R126 was cognitively intact. R126's care plan, initiated 3/9/23, documents: The resident demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming related to the diagnosis of, (left blank,) and problems understanding the immediate environment. Symptoms are manifested by attempting to leave the facility without a responsible escort (elopement). The resident is a new admission and not familiar with his/her environment. Resident has a history of alcohol and drug abuse. Interventions included: Implement preventative intervention strategies: assess for potential elopement/unauthorized departure risk, post a picture of the resident at/near the front desk and/or nursing station in a discrete place identifying possible elopement risk. Notify staff of risk potential. R126's Community Survival Skills Assessment (SS), 7/5/23, documents: Recommendations: The resident does not appear to be capable of unsupervised outside pass privileges at this time. Comments: Residents Community Access Level is 2-patio only. No physician order was found on R126 's Physician Order Summary, 10/5/23, for Level two (patio only) unsupervised pass privilege. On 7/10/23, R126 was on the facility patio with no staff supervision, and eloped from the facility. Progress note, dated 7/10/23 at 4:20 PM, states at approximately 4:15 PM, R125 was noted to not be in the building. A missing person report was filed with CPD (Chicago Police Department) on 7/10/23. R126 had an elopement from the facility on 1/22, during a previous admission in the facility and did not return. R126 was then readmitted to the facility on [DATE]. Progress note, dated 3/9/23 at 1:03 PM, states R126 is a former resident of the facility, with a history of elopement and drug abuse. Progress note, dated 1/11/22 at 4:38 PM, states R126 noted out of facility and cannot be found. Progress note, dated 1/11/22 at 5:41 PM, states Police Officer here to make a missing person report. On 10/05/23 at 11:22 AM, V13 (Psychiatric Rehab Services Director/PRSD) stated, (R126) eloped 7/10/23. (R126) was on the patio, and (R126) left the patio. (R126's) community access was level two, so (R126) could access the patio unsupervised to go out to smoke. (R126) could go to the patio, but not off grounds to smoke. Level two and three can go out to smoke outside of the smoke break times. There is no supervision because they are higher functioning. I called hospitals, nursing did a missing person report with CPD (Chicago Police Department). I called family. According to (V25, R126's family member), (R126) was seen by family in the community post elopement. Aside from calling hospitals, family, and notifying CPD, and notifying the Ombudsman, there is not more the facility can do. Residents are evaluated on components such as being cognitively aware, medication compliant, ADL (activities of daily living) compliance, free of aggressive behavior, need to know the facility address, phone number and neighborhood, ambulation, and previous elopement. A community skills assessment is completed every three months, and as needed. Factors we question are if there is a history of substance abuse and elopement. Increasing residents' community access levels is discussed/decided by committee/interdisciplinary team, nursing, therapy, and administration, social service. If there are no reservations, then we ask for the order from the physician. If there is a concern, we ask for the physician's input. There should be orders for level two and level three from the physician. V13 was asked to locate the physician order for R126's level two privilege. V13 confirmed there is no order for R126's level two privilege in the electronic charting. V13 stated, (R126) was a resident before and eloped that time as well, on 1/11/22. I spoke with administration about allowing (R126's) level two patio access, even though (R126) was an elopement risk. On 10/5/23 at 1:03PM, V25 (R126's family member) stated, (R126) is not living with me. I don't think (R126) has somewhere to live. I do not have a phone number for (R126). My kids give (R126) money when they see (R126). I think (R126) is on the street, homeless, and has no income. (R126) drinks alcohol heavily. On 10/5/23 at 4:00 PM, V1 (Administrator) stated, (R126) left the facility. (R126) went out on a designated smoke break, not sure which break, and did not return from smoke break. Smoke breaks are supervised by three to four staff members. Staff told me (R126) walked off. They did not tell me they saw (R126) walk off. No one tried to stop or encourage (R126) to return. There were two different admissions/occasions (R126) left the facility. A code was called to search for (R126). Staff searched inside and outside in the neighboring areas where staff think (R126) frequents. The Police and Physician were notified that (R126) left the facility. Family was contacted. The family told us that (R126) frequents a store on (street name). Family and (V27, Receptionist) saw (R126), not sure of the date. I notified the police of where family said (R126) was, and I believe they closed out the missing person report. (V27) asked (R126) to come back, and (R126) didn't. For safety and elopement risk, the resident is interviewed upon admission, a care plan meeting with Social Service, care plan coordinator, nursing, all disciplines, is held to discuss resident risks, behaviors. Assessments are conducted by social service for community survival, BIMS (Brief Interview for Mental Status) score, alert, and oriented status. The resident is monitored for behaviors. (R126) had no behaviors when (R126) came in at level one. After a time period, (R126) was assessed for level two. We discuss in morning meetings, the IDT (Interdisciplinary Team), nursing, Social Service, all disciplines if the resident is appropriate to move up from level one. (R126) was discussed and determined to be appropriate. According to regulations and facility policy, we have to assess residents when appropriate for increases, services have to be individualized and have to accommodate their needs. ( R126) was doing good, so we thought (R126) would be ok. With level two, residents do not have to have supervision to go to the patio. They have patio access and then come back to check in every hour. With level two, residents are not to go past the patio. If the resident is a level two and they are alert and oriented and can survive in the community on their own, then they may be given permission to go to other areas/places/store, access to the community. The Receptionist checks all residents in and out. The resident did not have to sign a pass/paper. Level twos let the front desk know they are going to the patio. The front desk checks them in when they come back in. Generally, they stop at the front desk and check back in. Level twos go out for one-hour increments at a time. The patio is not monitored, level twos can be out by themselves. The patio is a gated area, but it is not locked. My definition of elopement is a resident is not alert, oriented, does not have community skills to survive outside of the facility. (R126) did not elope; (R126) left. (R126) has left the facility before on a prior admission. When (R126) left 7/23, it was an authorized leave, so no it was not reported. (R126) left on (R126's) own accord to the community. On 10/5/23 at 4:50 PM, V27 (Receptionist) stated, I saw (R126) while I was on the bus. I don't remember when I saw (R126). I thought (R126) was out on pass. I did not know that (R126) left the facility. I saw (R126) about four times on (street name) and (street name) and at a store on (street name), before I knew (R126) left the facility. After seeing (R126) in the community about four times, I called ()V1 to ask if (R126) was out on pass. (V1) said, 'No (R126) is a runaway.' (V1) told me if I see (R126) again to call the police, because (R126) was a runaway. I have not seen (R126) recently. On 10/6/2023 at 9:45 AM, V1 (Administrator) stated she was mistaken in V1's previous interview. V1 stated, (R126) was on the patio when (R126) left. I am not sure what (R126) was doing on the patio, smoking, or getting some air. No one was monitoring (R126). (R126) was not outside with the smokers. (R126) was not on a designated smoke break. Staff did rounds, and (R126) wasn't seen. A code was initiated to search for (R126). Staff searched inside and outside of the building. V1 stated it was implemented recently that residents have to obtain a pass to go to the patio. This system was not in place in July. On 10/6/23 at 10:15 AM, V13 (PRSD) stated, (R126) had to have left the patio area around 2 PM. The gap between the monitored smoking breaks. On level two, patio only, the resident is not supposed to leave the patio area. The process is to notify nursing that they are going to the patio. They have to stop at the front desk to notify the receptionist that they are going out. The front desk will sign them out. They go out in hour increments. They can go out for an hour, then they come back in the building. They have to be in the building for an hour before they can go back outside. The front desk has a list of which residents is on which level. The receptionist has a list to sign of the residents that go out and what time they go out. When the resident comes back in the building, the receptionist signs the list that the resident is back in the building. The process was upgraded in September. The new process is that the residents would get a pass from their nurse with the nurse's signature, which specifies the time the resident left, and the place they are going/destination. For level two, going to the patio, for level three, where they are going in the community. The pass is given to the front desk receptionist. The receptionist then signs a list that indicates when the resident leaves the building, which is the same time that is written on the pass received from their charge nurse, to keep the resident from falsifying the pass. The level two and three can only leave the building without supervision with a signed pass from their charge nurse. Level two can stay out in hour increments, not monitored. The patio has two entrances from the ramp and street that are not locked. The back entrance is locked. (R126) eloped the facility on a previous admission in 1/2022. When (R126) was here in 2022, (R126) was in a wheelchair. The second time(R126) was higher functioning, alert, and oriented times three, BIMS (Brief Interview for Mental Status) 15, inquiring about level increase, due to wanting to smoke independently. It was discussed with Interdisciplinary team about the level increase, even though there was a history of unauthorized departure. Pass level increase was granted per administration, because we did not want to restrict rights, so (R126) was granted level two. On 10/6/23 at 12:50 PM, V13 (PRSD) stated, For high elopement risk residents, we do an assessment every three months or as needed, and there is a care plan to coordinate with that assessment that they are high risk for elopement. They are monitored with supervision. Staff is made aware, discussed with Interdisciplinary Team, it's charted in the resident's chart that they are high risk for elopement, it's care planned, and there is a Social Service binder at each nursing station and at the front desk with a list of elopement risk residents. On 10/6/23 at 1:08 PM, V21 (Wound Care nurse) stated, I was (R126's) nurse when (R126) left in July. That was the second time I'm aware that (R126) left the facility. Both discharges were not planned. The facility doesn't like to restrict resident rights. They monitor and when compliant residents get more privilege. (R126) was on level two; (R126) could only go to the patio, spend about 30 minutes to an hour, and then come back in. If the resident is independent, follow rules, is alert and oriented, they go to level three, and can go to the community. (R126's) room was on the third floor. I was not aware (R126) went outside to the patio. (R126) was supposed to let me know (R126) was going outside. The receptionist checks the residents that go out and come back in, checks them out and in. I don't know how much time passed before it was noticed that (R126) was not in the building. The receptionist told me (R126) was not in the building. A code was called to start checking the residents. We did not find (R126) in the building. I called (V25). (V25) told me (R126) might be around (street name). I drove up to (street name) to search. I did not see (R126). I called the police when I came back from the search. (R126) did not take belongings, medications, or anything at all. The facility was not able to provide sign in/out documents from the front desk/receptionist for 7/10/23. Facility Elopement Risk Assessment policy, 5/14, documents: 2. Risk factors that will be assess include the following: b. Pre-admission or history of elopement, i. Diagnosis of Alzheimer's, Dementia, Schizophrenia, Brain Injury. Facility Supervision and Safety policy, 3/15, documents: 4. Resident supervision is a core component to resident safety. 5. The type and frequency of supervision is determined by the individual resident assessment needs. Facility Community Access Standards policy, 9/13/23, documents: 2. Decisions regarding pass privileges, including, independent privileges or being accompanied by a responsible individual are determined by physician's orders, therapy/restorative for mobility and social services assessments. 8. Pass Privileges Levels, Level 2 Patio Only: (Restricted Pass) Resident allowed out to the patio independently with written pass from nursing or social services or floor monitors and signing out at the front desk ensuring that resident is medication compliant. Residents are allowed patio access one hour at a time starting after morning medication is distributed until 8pm. Residents' curfew is 8pm. 12. All residents who wish to access the community must have a doctor's order. Plan of Abatement: Elopement/Supervision *All rooms in facility all units were searched by Facility Staff immediately upon inability to locate resident at 4:15pm on July 10, 2023. *Visual head count done throughout facility to ensure all other residents were present on July 10, 2023. *Staff were immediately dispatched to walk the facility grounds in search for resident on July 10, 2023. *Responsible Family Member, Police, NP and Physician notified on July 10, 2023. * Family Member (Sister) reported seeing resident in her neighborhood on July 10, 2023. *On July 11, 2023 multiple hospitals were contacted in an effort to locate resident. *On October 6, 2023, the facility began re-educating the Staff on Elopement Precaution and Prevention. Focus of re-education: Elopement Policy Exit door alarm system testing. System alert response Elopement Risk binders Wanders/Exit Seekers supervision Pass Privileges System *Maintenance Director retested all door alarm systems to ensure proper functioning. Will continue to maintain testing log minimal weekly. *Activities, Nursing, and Social Services will supervise all patio outings for elopement risk residents. Staff will be staged at top of ramp on porch, at bottom of ramp at the entrance/exit gate, and physically on patio area for monitoring and elopement prevention. *Elopement assessment on all residents have been updated by Director of Nursing , Nurse Consultant, and Infection Preventionist Nurse, with help from other Nurse Managers. Future assessments will be completed on admission and updated minimally quarterly by Social Service Director. Assessments will be discussed during baseline and quarterly care conferences with IDT to ensure accuracy *Elopement Risk Binder was updated by Social Service Director (SSD) with list created from updated Elopement Risk Assessments. *Community Access Assessments were updated by SSD for all identified elopement risk residents. These were reviewed with IDT for accuracy. *As of October 10, 2023, facility is eliminating Level 2 program: Unsupervised patio access. Facility will have Level 1: Supervision with Staff and/or Family and Level 3: Independent Community Access. Pass Privilege policy was updated. *All residents have proper orders for community level access. *Regional Director reeducated upper management (Director of Nursing, Assistant Administrator, Administrator , Nurse Consultant, Social Service Director) on reporting to proper authorities (including Illinois Department of Public Health) any elopements. *All staff who are currently on vacation will be reeducated upon their return. *Any contractual staff will be in- serviced on the above policies and requirements. *All new hires will be educated during the orientation process. Administrator will be responsible for overall compliance to plan of correction in conjunction with Social Service Director by monitoring and updating elopement assessments and binders as needed, and Maintenance Director by reviewing the testing logs weekly and self-testing the system minimally weekly. Based on residents requiring community supervision while on the patio who are elopement risk, Activities, Nursing and Social Service will complete log of exit from and reentry to facility daily, upon each event. SSD will maintain these logs. The Quality Assurance Quality Improvement Team meets monthly. This event will also be brought to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly. The facility presented a removal plan on 10/6/23 at 7:33 PM that could not be accepted. The facility sent a revised plan on 10/10/23 at 3:07 PM that could not be accepted. The facility sent another revision on 10/10/23 at 4:20 PM. The facility's removal plan was accepted on 10/11/23 at 1:41 PM. The surveyor conducted additional interviews and record review on 10/12/23 to verify the plan was implemented. The Immediate Jeopardy was removed on 10/12/23, based on actions from the removal plan.

Based on interview and record review, the facility failed to report to IDPH (Illinois Department of Public Health) when a resident (R126) was known to have eloped from the facility. Findings include: R126 was viewed as a closed record. R126's 10/5/23 facesheet documents R126 diagnoses not limited to: Type 2 diabetes mellitus, anemia, schizophrenia, history of falling, and depression. R126 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R126 was cognitively intact. R126's care plan, initiated 3/9/23, documents: The resident demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming related to the diagnosis of, (left blank,) and problems understanding the immediate environment. Symptoms are manifested by attempting to leave the facility without a responsible escort (elopement). The resident is a new admission and not familiar with his/her environment. Resident has a history of alcohol and drug abuse. Interventions included: Implement preventative intervention strategies: assess for potential elopement/unauthorized departure risk, post a picture of the resident at/near the front desk and/or nursing station in a discrete place identifying possible elopement risk. Notify staff of risk potential. R126's Community Survival Skills Assessment (SS), dated 7/5/23, documents: Recommendations: The resident does not appear to be capable of unsupervised outside pass privileges at this time. Comments: Residents Community Access Level is 2-patio only. On 7/10/23, R126 was on the facility patio with no staff supervision and eloped from the facility. Progress note, dated 7/10/23 at 4:20 PM, states at approximately 4:15 PM, R125 was noted to not be in the building. A missing person report was filed with CPD (Chicago Police Department) on 7/10/23. R126 had an elopement from the facility 1/22 during a previous admission in the facility and did not return. R126 was then readmitted to the facility on [DATE]. Progress noted, dated 3/9/23 at 1:03 PM, states R126 is a former resident of the facility, with a history of elopement and drug abuse. On 10/05/23 at 11:22 AM, V13 (Psychiatric Rehab Services Director/PRSD) stated, (R126) eloped 7/10/23. (R126) was on the patio and (R126) left the patio. (R126's) community access was level two, so (R126) could access the patio unsupervised to go out to smoke. (R126) could go to the patio, but not off grounds, to smoke. Level two and three can go out to smoke outside of the smoke break times. There is no supervision because they are higher functioning. I called hospitals; nursing did a missing person report with CPD (Chicago Police Department). I called family. According to (V25, R126's family member), (R126) was seen by family in the community post elopement. Aside from calling hospitals, family, and notifying CPD, and notifying the Ombudsman, there is nothing more the facility can do. Residents are evaluated on components such as being cognitively aware, medication compliant, ADL (activities of daily living) compliance, free of aggressive behavior, need to know the facility address, phone number and neighborhood, ambulation, and previous elopement. A community skills assessment is completed every three months and as needed. Factors we question are if there is a history of substance abuse and elopement. Increasing residents' community access levels is discussed/decided by committee/interdisciplinary team, nursing, therapy and administration, social service. If there are no reservations, then we ask for the order from the physician. If there is a concern, we ask for the physician's input. On 10/5/23 at 4:00 PM, V1 (Administrator) stated, (R126) left the facility. (R126) went out on a designated smoke break, not sure which break, and did not return from smoke break. Smoke breaks are supervised by three to four staff members. Staff told me (R126) walked off. They did not tell me they saw (R126) walk off. No one tried to stop or encourage (R126) to return. There were two different admissions/occasions (R126) left the facility. A code was called to search for (R126). Staff searched inside and outside in the neighboring areas where staff think (R126) frequents. The Police and Physician were notified that (R126) left the facility. Family was contacted. The family told us that (R126) frequents a store on (street name). Family and (V27, Receptionist) saw (R126), not sure of the date. I notified the police of where family said (R126) was, and I believe they closed out the missing person report. (V27) asked (R126) to come back, and (R126) didn't. Level twos go out for one-hour increments at a time. The patio is not monitored; level twos can be out by themselves. The patio is a gated area, but it is not locked. My definition of elopement is a resident is not alert, oriented, does not have community skills to survive outside of the facility. (R126) did not elope; (R126) left. (R126) has left the facility before on a prior admission. When (R126) left 7/23, it was an unauthorized leave, so no, it was not reported. (R126) left on (R126's) own accord to the community. On 10/5/23 at 4:50 PM, V27 (Receptionist) stated, I saw (R126) while I was on the bus. I don't remember when I saw (R126). I thought (R126) was out on pass. I did not know that R126 left the facility. I saw (R126) about four times on (street name) and (street name)) and at a store on (street name), before I knew (R126) left the facility. After seeing (R126) in the community about four times, I called (V1) to ask if (R126) was out on pass. (V1) said, 'No (R126) is a runaway.' (V1) told me if I see (R126) again to call the police, because (R126) was a runaway. I have not seen (R126) recently. On 10/6/2023 at 9:45 AM, V1 (Administrator) stated she was mistaken in V1's previous interview. V1 stated, (R126) was on the patio when (R126) left. I'm not sure what (R126) was doing on the patio, smoking, or getting some air. No one was monitoring (R126). (R126) was not outside with the smokers. (R126) was not on a designated smoke break. Staff did rounds, and (R126) wasn't seen. A code was initiated to search for (R126). Staff searched inside and outside of the building. V1 stated it was implemented recently that residents have to obtain a pass to go to the patio. This system was not in place in July. On 10/6/23 at 10:15 AM, V13 (PRSD) stated, (R126) had to have left the patio area around 2 PM. The gap between the monitored smoking breaks. On level two, patio only, the resident is not supposed to leave the patio area. On 10/6/23 at 1:08 PM, V21 (Wound Care nurse) stated, I was (R126's) nurse when (R126) left in July. That was the second time I'm aware that (R126) left the facility. Both discharges were not planned. The facility doesn't like to restrict resident rights. They monitor, and when compliant, residents get more privileges. (R126) was on level two; (R126) could only go to the patio, spend about 30 minutes to an hour, and then come back in. If the resident is independent, follow rules, is alert and oriented, they go to level three, and can go to the community. (R126's) room was on the third floor. I was not aware (R126) went outside to the patio. (R126) was supposed to let me know (R126) was going outside. The receptionist checks the residents that go out and come back in, checks them out and in. I don't know how much time passed before it was noticed that (R126) was not in the building. The receptionist told me (R126) was not in the building. A code was called to start checking the residents. We did not find (R126) in the building. I called (V25, R126's Family Member). (V25) told me (R126) might be around (street name). I drove up to (street name) to search. I did not see (R126). I called the police when I came back from the search. (R126) did not take belongings, medications, or anything at all. The facility was not able to provide sign in/out documents from the front desk/receptionist for 7/10/23. Facility Unusual Occurrence Report Form, 1/20, documents: Unusual occurrence is any unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, [NAME], or related administrative matters. Serious incident is any incident or accident that has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents resulting in injury requiring the services of physician, hospital, or police, or other service provider on an emergency basis and/or requiring the services of the coroner of fire department shall be reported to the Department of Public Health within 24 hours of the incident or accident. Notification shall also be made by a phone call to the Departments Regional Office or if the facility is unable to contact the Regional Office, via fax or the Departments toll-free complaint number. A narrative summary of each serious accident or incident occurrence shall be sent to the Department within seven days after the occurrence. Facility Elopement Risk Assessment policy, 5/14, documents: 2. Risk factors that will be assess include the following: b. Pre-admission or history of elopement, i. Diagnosis of Alzheimer's, Dementia, Schizophrenia, Brain Injury. Facility Supervision and Safety policy, 3/15, documents: 4. Resident supervision is a core component to resident safety. 5. The type and frequency of supervision is determined by the individual resident assessment needs. Facility Community Access Standards policy, 9/13/23, documents: 2. Decisions regarding pass privileges, including, independent privileges or being accompanied by a responsible individual are determined by physician's orders, therapy/restorative for mobility and social services assessments. 8. Pass Privileges Levels, Level 2 Patio Only: (Restricted Pass) Resident allowed out to the patio independently with written pass from nursing or social services or floor monitors and signing out at the front desk ensuring that resident is medication compliant. Residents are allowed patio access one hour at a time starting after morning medication is distributed until 8pm. Residents' curfew is 8pm. 12. All residents who wish to access the community must have a doctor's order.

Based on interview and record review, the facility failed to protect one resident (R2) from mental abuse in a sample of three residents (R1, R2, R3) reviewed for abuse. This deficient practice resulted in R2 feeling belittled by staff. Findings include: R2's Admission Record documented R2's diagnoses includes, but is not limited to morbid obesity and pain in right and left lower legs. R2's Census list documented R2 was admitted on [DATE]. R2's (06/10/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R2' mental status as cognitively intact. Section G. Functional Status. I. Toilet use- how resident uses the toilet, commode, bedpan, or urinal; transfer on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjust clothes. 3/3 coding Extensive assistance/two + persons physical assist. On 06/20/2023 at 12:16pm, R2 stated, I need to wait for staff on the 11pm -7am shift to answer the call light. (V13 Certified Nursing Assistant), he is harsh. It is the tone of voice. When he answers the call light, he asks me What do you want? He was loud and harsh. He told me if you (R2) don't want to be here (referring to facility) you can transfer to another facility. He thinks I use the call light often, but I don't. He asked me why I did not let the evening shift change me, and I said, Because I don't have to pee at that time. R2 further stated, A few times, he took the call light from me. This surveyor inquired how R2 felt with the treatment R2 received from V13. R2 stated, He was saying he is better than I am. I feel like he did not want to provide care to me. He is kinda of abusive. R2 stated, A few days ago, the night shift nurse (V14 - Licensed Practice Nurse) asked me why I used the call light often. V14 said, I use it (referring to call light) like a toy. R7's Admission Record documented, in part Diagnosis Information. Schizoaffective Disorder. R7's Census list documented R7 was admitted on [DATE] in a room adjacent to R2's room. R7's (06/16/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R7's mental status as cognitively intact. On 06/21/2023 at 1:30pm, R7 stated, I know (R2). She needs a lot of help. She uses the wheelchair. At night, I could hear her yelling 'help, help', for about half a minute. Then it would stop. Some of the staff are kinda of mean. I don't want to get on their bad side. For the most part they (staff) are doing their job, but they (staff) talk in a loud mean tone of voice. R10's Admission Record documented R10 diagnoses include but not limited to Schizoaffective Disorder. R10's Census list documented R10 had a room change on 06/09/2023, to a room across from R2's room. R10's (06/07/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R10's mental status as cognitively intact. R2's (06/19/2023) Nursing Progress Note documented, in part At 0120 (1:20am), the resident called the light and the nurse answered the call light and ask the resident why are you calling the light frequently (sic)? Authored by V21 (Licensed Practice Nurse). On 06/21/2023 at 1:55pm, R10 stated, It is like every night. I could hear her (R2) screaming for help. This surveyor inquired how she (R10) knew it was (R2). R10 stated, She is the only one in that room who can scream loud like that. Her roommates (R4 and R11) can't talk loudly, they mumble. She calls for help when she gets wet. I don't think they (staff) want to change her. She uses the call light. I could hear the sound of the call light when it is on. When they come in her room, it is during the 11pm-7am shift. I heard the staff say 'what do you want?' And I heard her (R2) say 'I am wet'. I do hear the call light and the staff would come and ask her what she wants. It is insulting; they are supposed to do their job. I heard them talking about her in the hallway. I heard staff criticizing her.about how she uses the call light. They (staff) were saying 'She is not wet or anything. She always uses the call light for nothing.' On 06/22/2023 at 8:57am, V14 stated, We have abuse in service once to twice month, or several times a month. Surveyor inquired what training have you received related to abuse prevention, reporting abuse, and the facility's abuse policy and procedures? V14 stated,Types, neglect, verbal, isolation, sexual abuse. Misappropriation of resident's funds. Remove the person from the situation and take a statement, remove from alleged perpetrator to prevent further abuse. V14 stated, Sometimes I would answer the call light. I just ask her (R2) what she needs. Usually, she wants a diaper change, and I will get the assigned CNA (Certified Nursing Assistant). On 06/22/2023 at 9:07am, V14 (LPN) stated, I never told a resident they were toying with their call light. (R2) told me that she was never changed. I asked her what time she put the call light, on and what time did she ask. I don't remember what she said. I asked the CNA why she was not changed. The CNA just said 'she told you she was not changed?' I don't remember the name of the CNA. It was like 5 in the morning, but they did change her. There are always two CNAs in the room because of a lot accusation with several residents. I don't want them to be accused (of something). I had another CNA go with the assigned CNA. She complained to me about the staff removing the call light. I don't remember when. I am not usually there, so I will not know. If staff asked her what do you want? I will not know. 'Can I help you?' that is what I would say. Asking 'What do you want'; I don't think it is appropriate. I think it is more appropriate to say 'do you need something?' On 06/22/2023 at 9:30am, V13 (Certified Nursing Assistant) stated, She is getting me mixed up with somebody else that night. On this particular night, when she reported to the nurse that her call light was taken by staff, the staff who she was referring to was (V22 -CNA). On 06/22/2023 at 9:59am, V13 stated, The CNAs are normally pretty good, nice to her (R2), but sometimes it could get irritating with the constant thing. This surveyor inquired what V13 meant by irritating. V13 stated, I think sometimes it gets irritating, like the pressure of taking care of everybody, and maybe the CNAs come in with their personal problems. Survyeor asked, what training have you received related to abuse prevention, reporting abuse, and the facility's abuse policy and procedures? V13 stated, We always have abuse training; if anything happened, we have to report it. Types of abuse are mental abuse, physical, emotional, verbal, imposing with power, violence. On 06/22/2023 at 10:18am, V16 (PRSD - Psychiatric Rehabilitation Services Director) stated, I assessed her (R2) behavior. She is combative, argumentative, with poor listening skills. Unfortunately, she does not have any psyche (psychaitric) diagnosis at this time. She is displaying a lot of behaviors that warrants psych diagnosis, attention seeking. She is not displaying any patience. We had a care conference with her yesterday (06/21/2023). We (facility) told her things we can do to make her experience better. She said things never happened on other shifts, except for the night shift. The negative experience she's having, happened on the night shift. She feels in certain ways talked down to by the CNA. Every time she pulls her call light, the CNAs do answer. The amount of time she is pulling her call light is a large number. She (R2), pulling the call light, is a bit extreme. She is frequently pulling the call light. and it is documented in the charting. Surveyor inquired what is expected of staff when answering the call light? V16 stated, Staff should see what the resident needs. Surveyor inquired if it is expected of staff to ask the resident 'why are you pulling the call light frequently? V16 stated, No, but they can ask 'how can I help you? Surveyor inquired why V16 stated, No. V16 stated, Because the CNA still needs to address the resident with respect. So, the response 'how can I help' is better than 'what do you need? or 'what do you want?. This surveyor inquired if appropriate for staff to ask the resident why are you pulling the call light frequently? V16 stated, No, the staff is expected to respect the resident. It is a question, but it can be asked in a different way. It depends on how often the resident frequently pulling the call light. If pulling it every 5 minutes, that seems to be an issue. When the CNA is there, they can address the issue the first time when the call light was pulled. The resident is perceived pulling the call light every 2-3 minutes, that seems excessive, don't you think? When the CNA enters the room, the CNA can ask 'How may I help you?' or 'What assistance do you need?' Surveyor inquired if R2 has the capability of feeling insulted or disrespected. V16 stated, Anyone can feel insulted. It is subjective. It depends on her perspective. I can't say how someone is feeling if I am not there. I can't speak for someone on how they feel. This surveyor inquired if R2 felt being talked down to by the CNA, is it an affirmation R2 had a capability of feeling insulted or disrespected? V16 stated, Yes. On 06/22/2023 at 10:58am, surveyor asked V22 (CNA) what training have you received related to abuse prevention, reporting abuse, and the facility's abuse policy and procedures? V22 stated, We have abuse training 3-4 weeks ago. Types of abuse are physical, mental, financial. Report to the nurse. Try to stop abuse and inform the administrator immediately. On 06/22/2023 at 10:41am, at 11:32am, and at 2:33pm, surveyor called V21 to no avail. The (undated) facility floor plan indicated R2's room was adjacent to R7's room and across R10's room. The (undated) Facility provided Policy and Procedure titled Call Light documented, in part Purpose: to respond to residents request and needs in a timely and courteous manner. Policy: All call lights will be answered within 3 to 5 minutes. Standards: 1. All resident shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. 4. Request shall be responded to in a courteous and professional manner. Procedure. 1. Answer light (signal) promptly. 2. Be courteous when entering room. 4. listen to resident's request. Do not make him feel that you are too busy to help. The (undated) Abuse Prevention Program - Policy documented, in part Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Purpose: the purpose of this policy and the abuse prevention program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by: immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by a license, employee or agent. Mental abuse is also the use of verbal or nonverbal conduct which causes or has the potential to cause the resident experience humiliation, intimidation, fear, shame, agitation, or degradation. This includes but is not limited to harassing a resident; mocking, insulting, or ridiculing; yelling or hovering over a resident, the indent intimidate; threats of deprivation; and isolation.

Based on observation, interview and record review, the facility failed to ensure a resident was safe in the environment and failed to provide resident-centered monitoring and supervision for one resident (R2)with Diagnosis of Severe Dementia, known for wandering and confusion out of three residents reviewed for abuse. This failure reulted in R2 wandering, being found in found in a male residet's bed and possibly engaging in sexual activity. Findings include: R2's room and R4's room were located down the hall and not in view from nursing station at the time of the incident. R4 was documented as sexually active and known to have history inappropriate sexual behaviors towards staff and female residents. According to incident report dated 5/26/21, R2, [AGE] year old female was alleged to be sexually assaulted by another resident, male (R4), [AGE] years old, on 5/26/21 at 7:45pm. R2 was noticed to be missing from her room by V4 (Staff Nurse) After nurse looked in multiple residents rooms for R2, R2 was located in R4's bed. Both residents were undressed. R2 was calm, quiet, as nurse assisted her out of bed and dressed her. V11 (CNA) worked on unit night of 5/26/2021. V11 observed residents in the room, but standing up, at the time she arrived. R2 was sent to community hospital ER for evaluation and treatment per doctors order. R4 was discharged to community hospital on 5/27/2021 for evaluation. The facility began an immediate investigation. According to the Investigation report, Staff and Resident interviews were conducted on 5/26/21: V11 (CNA) provided statement indicating she did not see residents in the bed together when she arrived to the room but commented they were met naked, R2, standing by head of the bed, and R4, at foot of the bed facing the door. V11 stated that before the incident, she was at the nursing station charting while V4 was off the floor , Upon V4's return to the unit, V4 went to check on R2 and discovered she was not in her bed. V11 stated she and V4 began doing room checks and located R2 in R4's room. Note: Times of event are not provided in the written statements. According to the Investigation report, V4 provided statement, she entered R4's room and observed R4 on top of R2 and coming to a standing position. R2 was laying on the bed disrobed, calm and quiet. I dressed the resident (R2) and took her from the room. R4 was partially disrobed with only a T-shirt on. R4 was asked what happened to you? R4 replied, She(R2) came into my room I was laying in the bed. She started taking off her clothes. We talked, she said she wanted me. R4 was asked what happened next R4 replied, We was about to have sex. I was trying to put a condom on, but the nurse knocked on the door and came in the room. R4 was asked, What did you have on? R4 replied, I had my shirt on, she had her clothes off. R4 was asked, What happened next? R4 replied, The nurse and the CNA came in the room and took the lady out. R4 was asked, Did you and R2 have sexual intercourse? R4 replied, We did not have sex. R2 was interviewed on 5/26/21, R2 was asked, How are you doing? R2 replied, I am fine. R2 was asked, Did you go into a man's room? R2 was silent. R2 was asked, How did you end up in R4's room? R2 replied, I don't know. R2 was asked, What were you doing? R2 replied, talking. R2 was asked, Who were you talking to? R2 replied, My son(name) called, R2 was asked, Did you talk to R4, too? R2 repeats she talked to her son. R2 was asked, Did anyone hurt you? R2 replied, No, I am fine. Everybody is fine. R2 was asked, Do you feel safe? R2 replied, Yes, I am fine. R2 was asked, Did anyone touch you? R2 continues to repeat I'm fine and stated I'll talk to you later. During a phone interview on 6/18/21with surveyor, at 10:20am, V5(Family member of R2) stated, he was shocked, felt extremely guilty and was in emotional pain when he found out that his mother (R2) was sexually assaulted by another resident at the nursing home. He stated that his family members blamed him because he had made the decision to place R2 there. V5 stated he lives in Florida but his 3 other siblings live in Illinois. He stated that the nursing home is far away from where the siblings live and they are not physically capable of visiting R2 due to distance. V5 stated he wants the mother to be in a facility closer to the siblings because they are concerned for her safety. V5 said, My mother is indigent, has no funds other than Medicaid, Medicare and we can't afford to place her in another home. It would cost money to do that, we don't have the financial means for that. I don't know how to do that, don't know who to talk to about getting her into another nursing home. I'm very worried about my mother's safety. I'm 800 miles away and there is on so much I can do. I have a family here to manage and work a 9 to 5 job. I can't just jump on a plane and fly there to look for a better nursing home for her. My siblings aren't able to do that either but they demand that I do something about it because I'm able to make decisions that they are not capable of making. It's a lot of pressure on me. I don't want my mother in that facility but they told me that the resident that assaulted her was removed from the facility so I agreed that she could return there due to not having another place to go to. V6(City Police Officer) called on 6-18-21 at 2:37PM, regarding R2 and R4. Left voice message for return call regarding report. V6 did not return call during survey investigation. According to R2's MDS(Minimum Data Sheet) dated 6/08/21, BIMS(Brief Mental Status Interview) score R2's score is 1 out of 15, indicating very low cognitive function. B. Inattention: Behavior present, Fluctuates (comes and goes, changes in severity); C. Disorganized thinking 2. Behavior present, fluctuates(comes and goes, changes in severity). Social Services note for R2 dated 5/19/21 at 9:40am, documents R2 BIMS score is 3(very low cognitive function on scale of 00-15). Diagnoses: [CONDITION(S)], Dementia, Aggressive Behavior, [CONDITION(S)], Recent history of aggressive behavior and non-compliant with medications. Resident has history of increased agitation and outburst of aggression. Resident is alert and oriented to herself with bursts of confusion/forgetfulness. Current Face Sheet for R4 documents: R4 was admitted to facility on 1/09/2020 with diagnoses to include: Paranoid [CONDITION(S)], [CONDITION(S)], Violent behavior, Inadequate Social Skills, [CONDITION(S)], Pain, Fracture of Base of First Metacarpal bone. Need for assistance with personal care. V7 (PRSD/Psychosocial- Rehab Service Director) progress note for R4 dated 04/07/2021 at 2:14pm documents: 1:1 COUNSELING SESSION: It was reported to Social Services that resident(R4) was making inappropriate comments towards female staff. Writer counseled resident in regards to respecting female staff members and maintaining appropriate boundaries with staff. Resident was receptive. At this time, resident is calm, no agitation, no aggression. Social Services will continue to monitor and update the residents progress. V7 progress note dated 5/10/21 at 1:18 pm for R4 documents: PRSD spoke with resident in regard to engaging in consensual sexual behavior. Writer conducted Resident Sexuality Assessment. Residents BIMS score is currently 15 (on scale of 00-15) high cognitive function. Writer educated resident in engaging in consensual sexual behavior, utilizing condoms, practicing safe sex, identifying potential STD's and what to do if he discovers he has a sexual transmitted disease. Resident was receptive. Writer notified resident he can receive condoms from the Social Services office. Social Services will continue to monitor and update resident's progress. V7 progress notes dated 5/25/21 at documents: Resident(R4) was previously assessed for the [NAME] Decree Transition Program. Resident received a NOT RECOMMENDED for program. The determination was made by a qualified professional of the Comprehensive Program. It is recommended that resident work on maintaining appropriate personal and sexual boundaries with staff and peers, improve management of personal care and hygiene and increase awareness and understanding of the impact of symptoms on interaction and communication with staff and peers. Resident is aware of goals set out for him by the program. Resident will be re-evaluated in 6 months. Social Services will continue to monitor and update the resident's progress. On 6-19-21 at 1:15pm, R2 was resting in bed. R2 agreed to talk with surveyor. R2 stated she felt safe here. When asked about sexual assault, R2 replied, I changed my mind. Resident motioned that she did not want to talk about the incident. R2 began suddenly taking off her top as she sat on her bed. At this time, V10(CNA) entered the room and immediately began redirecting R2 and putting on her top. V10 said, She is confused, very quiet. I don't know anything about her (R2) being sexually assaulted. I was off from work. They said it happened on the 3-11pm shift, not too long ago. The other resident(R4) is no longer here. Behavioral Care Plan initiated on 2/15/2021, updated on 6/19/21 for R2: documents impart: Resident displays behavioral symptoms related to: Severe mental illness, Dementia of Alzheimer's type or other dementia. Resident with tendency to undress herself. Interventions: Staff to redirect resident to put on her clothes and offer her assistance. Intervene when any inappropriate behavior is observed. Communicate that the resident is responsible for exercising control over impulses & behavior(social skills training). Refer resident to consulting psychiatrist for a psychiatric evaluation, as warranted. On 6/19/21 at 3:00pm, V2(Assistant Administrator) stated that V4 and V11 were not working and provided their phone numbers. Surveyor attempted to conduct phone Interview with V4 and V11 at approximately 3:25pm regarding incident, left voice message with V4 and V11 but they failed to return call. V2 made a call to both V4 and V11 but they did not answer or return calls. According to R2's current Face Sheet, resident is [AGE] year old female initially admitted to Nursing facility on 02/14/21 from community hospital with diagnoses: [CONDITION(S)], Dementia without behavioral disturbances, DM, [CONDITION(S)], [CONDITION(S)], CHF/Heart Disease, History of COVID-19, [CONDITION(S)]. Nurses admission noted dated 02/14/21 documents, resident was in hospital for acute [CONDITION(S)] and aggressive behaviors. From 02/15/21 to 06/18/21, it is frequently document in nurse's notes, Resident required constant redirection supervision; Resident alert and oriented 1-2 with period of confusion and forgetfulness. V4 Nurse notes dated 5/27/2021 at 00:05(midnight) documents, Resident(R2) observed in male resident's(R4) bed, disrobed with male resident on top of her. Resident (R2) is alert and oriented x1 and unable to give consent. Residents were separated immediately and both placed on 1:1 supervision. Documents vital signs stable. Doctor, DON and Family member notified. City police notified and police report completed. Doctor gave order to send resident to ER for evaluation for this incident and fall incident. R2's Hospital records dated 5/27/2021 admitting diagnoses to include: Contusion of Left wrist; Urinary Tract Infection without hematuria; PVD(Peripheral Vascular Disease) DM, [CONDITION(S)], History of open heart surgery. Impaired ADL's and self-care. Diagnoses: [CONDITION(S)], Congestive Cardiac Failure, [CONDITION(S)], Coronary Artery Disease, COVID-19, High cholesterol, Uncomplicated senile dementia. R2's Hospital History and Physical(H&P) notes dated 5/27/21 documents impart: Resident is a 73 y/o female with a past medical history of significant dementia(baseline only oriented to name) who was admitted on [DATE] after a witnessed incident at her residence nursing home and subsequent concern for sexual assault. She complained of pain but the staff placed her in her bed. They went to check on her 15 minutes later and found her in with another male resident with no pants,on top of her while she was laying fully nude on her back. The male resident immediately jumped off of her. Resident remained calmly on the bed and had no complaints after the incident. Her son, is her medical decision maker, and is requesting a full rape kit. Hospital H&P(History and Physical) dated 5/27/21 documents R2 vital signs were stable. When asked why the patient is in the ED she expressed that she does not know why. When asked if anybody tried to hurt her tonight she said, No, not that I know of. HIV was non-reactive and UA significant for glucose greater than 500, 3-5 erythrocytes, and 11-25 leukocytes. She was given 1000mg PO [MEDICATION(S)] and 500mg IM and [MEDICATION(S)] for GC prophylaxis. As well as, 2000mg [MEDICATION(S)] for trichamonas prophylaxis. Hospital POS(Physician orders, documents R2's medication includes: [MEDICATION(S)] 5 mg/IM injection once; [MEDICATION(S)](Zyprexa) 10mg prn for agitation-5/27/21; [MEDICATION(S)] 7.5mg nightly p.o.; Divalproex(Depakote) 500mg 3 times daily-oral for start 5/27/21; Detrose injection 12.5mg as needed for Hypoglycemia; [MEDICATION(S)].(Lovenox) 40mg subcutaneous abdomen at 1700 5/27/21; Insulin glargine(Lantus) injection 32 units subcataneously nightly-2100; [MEDICATION(S)](Zithromax) 1,000 mg once p.o. sexually transmitted infection. [MEDICATION(S)] (Rocephin) 500mg lidocine HCL(Xylocaine) 1% for IM(intramuscular Injection) once.-5/27/21-inidication: Sexually transmitted Infection. [MEDICATION(S)](Rocephin) once IV; give slow IV push over 2 to 5 minutes. [MEDICATION(S)](Flagyl) tablet 2,000 mg once p.o. Nurses note dated 5/28/21 at 15:29(3:29pm) documents, R2 readmitted from community hospital after sexual encounter with male per DX UTI abt(antibiotic treatment) [MEDICATION(S)] 500mg po twice daily. Nurses notes dated 5/28/21 at 21:59(9:59pm) R2 redirected as needed from entering other rooms by staff. Will continue to monitor. Call light within reach. On 6/19/21 at approximately 4:00pm,V2 (DON) stated that the hospital told her that the rape kit was performed on R2 but results will not come back for months. At 5:00pm, V2 said, Every shift there's four CNA s scheduled and one Nurse. They are to do rounds every two hours but I tell them to do rounds every hour to make sure residents are safe and for fall precautions. Supervision and Safety Policy dated 3/15 documents in part: Our facility-oriented approach to safety addresses risks for groups of residents such as wanderers, behaviors, aggressiveness, confusion, etc. Safety risks and environmental hazard are identified on an ongoing basis through employee training conducted upon hire, annually and as needed. Staff will use various resources to identify resident risk factors. Resident supervision is a core component to resident safety. The type and frequency of supervision is determined by the individual resident assessment needs. Staff to intervene immediately whenever an unfavorable event between residents, staff or visitors is noticed. Staff to decrease safety risk factors as much as possible. Staff to make visual rounds on residents minimally every two hours and more often if necessary based on resident's assessment needs.

Based on interview and record review, the facility failed to supervise and prevent an impaired resident from obtaining a severe injury that required surgery. This failure resulted in one of three residents (R6) obtaining a femur fracture that required extensive surgery to repair the fracture, in a total sample of eight residents. Findings include: R6 is an expired resident. R6 was a [AGE] year old male resident of the facility. R6's [DIAGNOSES REDACTED]. R6's BIMS (Brief Interview of Mental Status) notes that he is alerted and oriented, but has impairments with focusing and understanding questions and thoughts. R6 has disorganized thinking. The behavior is continuously present. R6 is also an extensive one person assist when transferring or ambulating. Fall risk review dated [DATE], [DATE], and [DATE], notes that R6 is high risk for falls. X-ray dated [DATE], notes R6 has acute complete intertrochanteric fracture present with displacement resulting in varus angulation. Review of R6's progress notes document the following: On [DATE], it was reported to staff that R6 was observed getting on his knees and laying on the floor intentionally. R6 was assessed from head to toe. No visible injury noted. Resident educated that if he feels sleepy he should lay in his bed. On [DATE], it was reported to social services by the 2nd floor charge nurse that R6 continues to place himself on the floor. Staff spoke to him in regards to his behavior. He stated that he gets tired and he wants to lay down. Staff suggested to R6 to lay in his bed or sit in a chair, not on the floor when he is feeling tired. On [DATE], it was reported to staff that the resident was observed getting on his knees and laying on the floor intentionally. R6 was assessed from head to toe. No skin breakdown or visual injury noted. Resident was educated that if he feels sleepy, he can lay down on his bed. On [DATE], staff reported that R6 stated that he fell on the floor while trying to reach his bed. On assessment, no visual injury noted. R6 complained of right knee pain on a ,[DATE] pain scale. Physician and nurse practitioner notified. X-ordered. At 9:47PM, a CNA (Certified Nursing Assistant) reported to a nurse that R6 was reported to be on his knees when rounds were made. Nurse went to the room immediately and observed the resident on the floor on his knees. Resident was then placed to bed with a two person assist. On [DATE], R6 x-ray reveals an acute complete intertrochanteric [MEDICAL CONDITION] femur. The right leg was immobilized and R6 was transferred to a local hospital. On [DATE], R6 returned to the facility from a local hospital. Surgical wound noted to right hip with a total of 25 staples which is intact and covered with an abdominal pad. On [DATE], R6 was seen by V14 (Medical Doctor). Progress note documents that R6 fell on his knees which resulted in a stress [MEDICAL CONDITION] neck (head of femur bone). Nursing management report dated [DATE], notes that R6 does not always ask for assistance and he gets confused. He has poor impulse control. Care plan dated [DATE], notes if the resident becomes preoccupied by his hallucinations and/or thoughts, simply remind him that he is in a safe and secure environment and staff will protect him. R6 is noted with poor communication and comprehension and has impulsive behavior. In-service staff for frequent monitoring; every two hours and as needed. On [DATE], at 4:00PM, V9 (Restorative Nurse) stated, R6 was a high fall risk. On [DATE], at 10:15PM, V10 (Nurse) stated, R6 normally falls. He was a fall risk. I was right at the nurses' station when they called me and told me that he was on the floor. R6 stated that he slipped and fell . He used to be in the wheelchair. During my shift, he was walking to the bathroom. All residents are required to use the call light. Anytime they need assistance, we encourage them to pull the call light. R6 was very delusional. He has a lot of behavioral issues and he had to be continuously redirected. On [DATE], at 8:38AM, V12 (CNA) stated, R6 is confused. R6 is limited assistance to total care. R6 had a lot of behaviors. R6 had to be watched closely. He needed to be watched closely because he liked to get up and move a lot. On [DATE], at 8:52AM, V13 (CNA) stated, Sometimes his care was different. He was limited care and he became extensive assistance. R6 required close monitoring. He had times were he was paranoid because his eyes would shift and he would question everything we did. At times, he could be redirected, but he had a lot of anger. When he had the anger, he was not redirect able. He was defiant. He needed supervision. On [DATE], at 9:42AM, V14 stated R6 had dementia. He did not call for assistance and he had a fall. I require my staff to monitor my residents every two to three hours, especially if they have dementia. His fall required surgery to fix the fracture.

Based on interview and record review, the facility failed to follow their Abuse Prevention Policy in not preventing a physical altercation resulting in allegation of physical abuse for two residents (R1, R2) of three residents reviewed for abuse. This failure resulted in one resident ( R2) sustaining a left lateral tibial plateau fracture requiring hospitalization . Findings Include: R1 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R2 is a [AGE] year old resident with [DIAGNOSES REDACTED]. The facility Final Incident Report sent to IDPH (Illinois Department of Public Health ) dated 10/10/18 documents on 10/3/18 at 8:33 AM a physical altercation took place between two residents (R1, R2). R1 was the aggressor, R2 was sent to the hospital for evaluation and it was determined that R2 required treatment for [REDACTED]. 10/3/18 at 8:51 by V8 LPN (Licensed Practical Nurse) Progress Note: Resident was hit by another resident ; immediate intervention was done resident; neurological checks initiated - no loss of consciousness and remains at baseline orientation; VS (vital signs) BP (blood pressure)= 98/70 ; P(pulse)=82 ; T= 96 Oxygen Saturation= 95% . Head to toe assessment with ROM (range of motion) impaired to Left Knee with c/o pain in attempt to assess - area immobilized, Emergency medical services (911) activated and arrived to transport to hospital via stretcher. MD paged; DON and Administrator aware; Guardian called back . Resident was sent to St.(NAME)Hospital. Will follow up for resident status . On 10/26/18 at 11:30 AM, R2 stated: I was walking down the hall, R1 bumped into me, I said watch where you are going. I don't remember after that. I do remember being on the ground, R1 kicked me. I don't remember who came to help, I don't remember much. On 10/26/18 at 1:00 PM R1, stated through interpreter V9 ,Physician Assistant (PA), they bumped each other. R2 tried to hit me, I was trying to defend myself and R2 fell . R2 got in my way, they started to fight. I hurt my wrist a little, ok now. On 10/25/18 at 2:20 PM, V7 ,Restorative Aide, stated : They (R1, R2) passed me in the hall, I turned back around, they were swinging their fists at each other. R1 hit first. I was holding R1 and R1 got away and hit R2 again and R2 fell . I told the receptionist to call a code. V5, Social Service Director, came after R2 fell . The nurse came and assessed R2. On 10/25/18 at 2:00 PM V1, Administrator/Abuse Coordinator, stated; It happened on the first floor just past the Nursing Station. I was coming through the entrance, they were walking side by side from the Dining Room. R1 crossed over in front of R2 and R2 said f*** you. R1 hit R2 in the lip then R2 fell down into the shower room. We kept R2 down on the floor until the nurse came. They were both sent out for evaluation. On 10/25/18, V5, Social Service Director, stated; I was in the first floor Conference Room, I heard a commotion, R2 was on the floor, R1 was on top of R2, hitting him. We separated them. I had another Social Service staff sit with R1 in his/her room. R1 was always on a 1 on 1 until sent out to the hospital. Since (MONTH) (2018) ,when I started ,R2 has not shown any physical aggression. There were no verbal behaviors for either. R1 did have some physical aggressiveness before July, earlier this year. R1 is in the smoking cessation, symptoms behavioral management and social skills groups. R1's attendance is sporadic. R1 does get one to one counseling when he/she doesn't attend group. The facility Abuse Prevention Policy documents; This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. 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 harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.