Every finding on record at Pinckneyville Nursing & Rehab

Based on observation, interview, and record review the facility failed to ensure incontinence care was provided timely for 1 of 1 (R13) resident reviewed for dignity in the sample of 28. Findings Include: R13's admission Record with a print date of 03/25/2026 documents R13 was admitted to the facility on [DATE] with diagnoses that include spastic hemiplegia, dementia, lack of coordination, muscle weakness, and history of traumatic brain injury. R13's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 07, indicating a severe cognitive deficit. This same MDS documents R13 is dependent on staff for toileting. R13's current Care Plan documents a Focus area of Self-care deficit r/t (related to) Seizures, Hemiplegia, lack of coordination. Date Initiated: 4/5/2025. This Focus area includes the interventions of, Assist with toileting and showers/bath. Date Initiated: 04/05/2025.On 3/23/26 at 12:07 PM, R13 was sitting in a reclining chair in the dining room, waiting for lunch to be served. There was fluid puddled (approximately 2 feet by 1 feet) on the floor, under the seat of his chair, with a smaller area on the floor near the front of his chair. V3 (Certified Nursing Assistant/CNA) approached R13 with his meal tray and started setting it up to assist him with eating his meal. This surveyor asked V3 (CNA) what the fluid under R13's chair was. V3 left the table and went to the dining room serving window. V3 returned to R13's table and began wheeling him down the hall. This surveyor asked V3 where she was taking R13 and she stated she was going to change him. This surveyor obtained R13's permission to observe care. V2 (Director of Nurses/DON) joined V3 in R13's room. R13 was transferred to his bed via mechanical lift using current standards of practice. The chair had pooling fluid in the seat, and the mechanical lift pad was wet. R13's pants and incontinence brief were removed. The brief was saturated with urine and was dark yellow/brown in color. On this same day and time, V3 stated she was R13's CNA for the day and was responsible for providing his care. V3 stated she had last checked and changed R13 around 8 am. V3 then stated, no, it was 9 am. When asked how often R13 should be checked and changed, V2 (Director of Nurses/DON) stated, every two hours. When asked why R13 wasn't checked and changed prior to the surveyor bringing the incontinence episode to their attention, V3 stated she had to give a shower to another resident, and it took longer than she thought it would. The facility Activities of Daily Living (ADLs), Supporting policy dated 3/2018 documents, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on Interview, record review, and observation the facility failed to properly check gastrostomy tube placement per professional standards of practice for 1 of 1 (R21) resident reviewed for tube feeding in a sample of 28.The Findings include: R21's admission Record documents an admission date of 03/09/26, with diagnoses in part of gastrostomy status, dysphagia, type 2 diabetes mellitus, and need for assistance with personal care. R21's Minimum Data Set (MDS) dated [DATE] documents in Section C. a Brief Interview for Mental Status (BIMS) score of 00 which indicates severely impaired cognition. Section GG documents eating as dependent. Section K documents feeding tube (e.g. nasogastric or abdominal tube) as yes. R21's undated Care Plan documents a focus area of I require tube feeding Depression, Dysphagia with documented interventions of: Check for tube placement and gastric content/residual volume per facility protocol and record. R21's Order Summary documents an order dated 03/24/26 to flush peg tube with 90mL (Milliliter) Q4 (every 4 hours) during day and after each feeding at night. Every 4 hours verify correct placement via auscultation before administration. On 03/25/26 at 12:12PM, V5 (Licensed Practical Nurse) was observed performing R21's physician ordered water flush and placement check to gastrostomy tube (G-Tube). V5 had a syringe of 15 ml of air in a piston syringe, and she put a stethoscope next to the insertion site of the G-Tube. V5 then pushed the 15 ml of air into the G-Tube, and she stated that the G-Tube was in place. V5 then removed the piston syringe from the G-Tube and then placed 90 mL of water into the tube. V5 was not observed checking for gastric contents prior to flushing the G-Tube.On 03/25/26 at 12:13PM, V5 stated that checking placement of a G-Tube is to use 15 mL of air and listening for the air to make a sound. V5 stated that this is the current policy for checking placement of a G-Tube at the facility. On 03/25/26 at 1:35PM, V2 (Director of Nursing/DON) stated that the facility policy does state to check placement of G-Tube with up to 15ml of air and listen for the growl or rumbling/bubbling sound. V2 stated that the facility does not have a newer policy other than the policy to check placement with air. The facility policy titled Confirming Placement of Feeding Tubes with a revised date of November 2018 documents under Purpose The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feeding, flushing, or medications. Under the section To Confirm Placement of an Existing Feeding Tube at the Bedside it documents 1. Draw up 5-15ml of air into the syringe and attach to the extension set attached to the resident. using a stethoscope, listen over the left side of the abdomen above the waist. When you inject the air, you should hear a Growl or rumbling/bubbling sound as the air goes in.

Based on observation, interview and record review the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms for 4 of 4 residents (R12, R15, R19, and R20) reviewed for room size in a sample of 28. Findings include: On 3/24/26 at 10:18 AM, R12 and R20's shared room appeared smaller in size and held two beds, two nightstands, two over the bed tables, and a dresser built into an alcove area. There was space to navigate about the room. On 3/25/26 at 9:50 AM, R12 denied any concerns with the size of his room.On 3/24/26 at 10:22 AM, R15 and R19's shared room appeared smaller in size and held two beds, two nightstands, two over the bed tables, one wheelchair, and a dresser built into an alcove that did not affect the living area. There was room to navigate about the space. On 3/26/26 at 11:26 AM, R15 denied concerns with the size of his room.On 3/26/26 at 11:26 AM, V6 (Family Member) denied concerns with the size of R19's room.During a facility tour on 03/24/2026 at 10:18 AM, V4 (Chief Operating Officer) was asked to measure R12, R15, R19, and R20's rooms. V4 used a measuring tape to measure the length and width of the rooms and both rooms measured at 12.5 feet by 12 feet which was equivalent to 150 square feet/75 feet per resident bed. The measurement did not include the closet or built in dresser area. On 3/26/26 at 12:00 PM, V4 stated that all rooms on hall A and B do not meet the requirement of having 80 square feet per resident. V4 verified those rooms included 1-10, 20- 31. V4 stated that all residents are notified upon admission of the room sizes. V4 stated that all the rooms on A and B hall that don't meet the requirement for 80 square feet are certified for Medicaid residents.The facility Floor Plan provided by the facility documents rooms 1-10, 20-31 are all waivered rooms for size.

Based on interview and record review the facility failed to initiate the process to timely obtain a prescription medication for 1 of 3 residents (R1) reviewed for medications in the sample of 7.This past noncompliance occurred from 7/27/25 and 7/28/25.Findings include:R1's admission Record documents an admission date of 6/20/25, a discharge date of 7/28/25, and listed diagnoses including hypertension, chronic obstructive pulmonary disease (COPD), unspecified, other cerebral infarction due to occlusion or stenosis of small artery, other specified symptoms and signs involving the circulatory and respiratory systems, bradycardia, unspecified, cerebral infarction, unspecified, and peripheral vascular disease.R1's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 4, indicating that R1 had severe cognitive impairment.R1's Care Plan documented R1 had COPD and a history of a recent Cerebral Vascular Accident (Stroke). Both focus areas have interventions including giving medications as ordered by the physician.R1's Physician's Order Sheet documented an order for Diltiazem HCI (hydrochloride) Oral Tablet 120 MG (Diltiazem HCI) Give 3 tablets by mouth one time a day for a fib (Atrial fibrillation), hold if pulse under 70. This order documented a start date of 7/27/26.R1's Medication Administration Record (MAR) for July 2025 documented on 7/27/25, R1 was administered Diltiazem HCI Oral Tablet 360mg by V4 (Licensed Practical Nurse/LPN), the area where the pulse is to be recorded is marked n/a. On 7/28/25, this MAR further documents that R1 was not administered her dose of Diltiazem because she was hospitalized .R1's Progress Notes document on 7/28/25 at 9:13am, CNAs (Certified Nursing Assistants) alerted this nurse that resident is SOB (Short of Breath). Upon entering room, resident appears to have labored breathing. O2 (oxygen) at 87% on 3L (Liters) via nasal cannula. Pulse irregular, jumping from 50/60 to 160/170. (Name of Medical Doctor/V5) called at 0834 and gave orders for resident to be sent to ED (Emergency Department) for further evaluation.R1's medical records from the local hospital emergency room dated 7/28/25 at 9:35am, documents the following: .Patient complains of palpitations and shortness of breath that started this morning. Patient was admitted to this hospital Friday for pneumonia and apparently while on the floor she developed atrial fibrillation with rapid ventricular response. She was discharged on Saturday with Cardizem ordered for rate control. Apparently, she did not receive it because the nursing home did not have it available over the weekend. Patient was given Cardizem 15 mg IV (intravenously) push en route by EMS without the accompanying infusion. She had a normal heart rate upon arrival however prior to initiation of the Cardizem infusion her ventricular rate increased to the 120s. She denies any chest pain or fevers .On 8/7/25 at 7:57am, V3 (Licensed Practical Nurse/LPN) stated she was the nurse that sent R1 to the Emergency Room. She stated she was in the middle of medication pass when the aides alerted her that R1 was short of breath and her pulse was all over the place. V3 stated she had not yet administered R1's medications so she went to pull them from the emergency kit and there was only one pill, and it was 180mg. V3 stated R1's dose was 360mg. V3 stated she went to assess R1 and immediately contacted the doctor and sent her to the emergency room. V3 stated she was not sure if the emergency kit had been accessed the day before.On 8/7/25 at 8:30am, V4 (LPN) stated she could not recall how she obtained the medication to administer R1's dose of Diltiazem on 7/27/25 or if she administered it. V4 stated she would not mark that the medication was administered on 7/27/25 unless she gave it. V4 stated if the patient's card was not yet delivered, she would access the emergency kit. V4 stated if she was not able to obtain a resident's medication, she would contact the Physician for further instructions or orders.On 8/7/25 at 9:37am, V5 (Physician) stated missing one dose of Diltiazem can be critical for a patient. V5 stated this medication does not work as effectively as other drugs of the same class. V5 stated he could not say for sure that it directly caused R1's hospitalization because R1 was already in bad shape, but this is not a medication that should ever be missed. V5 stated he wasn't contacted by anyone from the facility about R1 until she was sent to the emergency room on 7/28/25.On 8/7/25 at 10:19am, V8 (Family Member) stated R1 was discharged from the hospital (to the facility) on Saturday 7/26/25. V8 stated R1 was released while still in A-fib (atrial fibrillation), that was the reason that her dose was so high. V8 stated when she met R1 at the emergency room (on 7/28/25), the ambulance driver and the nurse both told her that she had not received the medication since she was previously discharged . V8 stated they (paramedics) gave her the medication she missed intravenously in the ambulance and then they gave her another medication. V8 stated when V9 (family member) went to collect R1's things, two staff members, V1 (Administrator) and V2 (Director of Nursing) both stopped her and continued to apologize and state that they were so sorry that all of this had happened. V8 stated they openly admitted they did not give the medication to R1.On 8/7/25 at 11:24am, V6 (Pharmacy Technician) stated they received an order for R1's medication on 7/26/25 after 1pm, which is when they close, and it was delivered on 7/28/25 the next business day they were open. V6 stated they have an after-hours back up pharmacy and if they needed something, they could contact them. V6 stated if staff take something from the facility emergency kit, there is a log inside of it and the facility is to contact the pharmacy and let them know they have to refill it. V6 confirmed that there was no communication from the facility regarding this medication being taken from the emergency kit.On 8/7/25 at 11:44pm, V7 (Pharmacy Supervisor) stated they do keep Diltiazem in the emergency kit at the facility, but they only keep 180mg because it is not a very often needed drug and R1's dose was outside of normal dosage. V7 stated R1's dose was 360mg. V7 stated there is a backup pharmacy that the facility can call if they need medications after hours. V7 confirmed there were no call outs to the backup pharmacy that weekend.On 8/7/25 at 11:58am, V2 (Director of Nursing/DON) stated if they did not have a resident's medication in house, the expectation would be for nursing staff to follow facility protocol on obtaining the resident's medications. V2 stated if nursing staff were unable to obtain a resident's medication, they should contact the physician.Facility policy titled, Medication ordering and receiving from the pharmacy, IC5: Emergency pharmacy service and emergency kits, with an effective date of 06/01/23 documents the following under procedure, The charge nurse.3) Ascertains whether the ordered medication is contained in the emergency kit by referring to the list of contents posted on the box. 4) If the medication is not available, calls the pharmacy, using the after-hours emergency number(s) if necessary .Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box or from (Name of Pharmacy), or the third-party emergency pharmacy.Prior to the survey date, the facility took the following actions to correct the noncompliance:1. The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 7/28/25 with V1 (Administrator), V2 (DON), V10 (Medical Director), V11 (Dietary Manager), and V12 (Regional Nurse) in attendance. The facility QAPI agenda/meeting template documents 1. Immediate Re-Education with all nursing staff related to proper MD (Medical Director) notification. 2. Immediate Re-Education with all nursing staff related to the correct process when medication is not available to give including proper notification to pharmacy of medication that is needed. 3. A QA tool has been created to monitor effectiveness to ensure compliance to promote improved quality performance.2. In-service/Education documentation shows that all facility nurses were educated on change in condition or status-proper MD notification and Pharmacy notification. Hospital discharge report form to completed by Nurse receiving report on new admit/readmit and given to DON. If medications are not on hand or available in E-kit, must call pharmacy for E-Run and Notify DON and MD. This in-service was completed on 7/28/25.3. QA Audit Tool documents daily audits were performed from 7/28-8/5 and will continue through 8/8. Progress notes, 24 hour reports, changes in condition or significant events noted and physician notification were audited by V1 (Administrator) V2 (DON).

Based on interview and record review, the facility failed to provide the services of a Registered Nurse for 8 consecutive hours per day seven days per week. This failure has the potential to affect all 42 residents living in the facility. Findings Include: On 04/10/25 at 9:57AM V6 (Licensed Practical Nurse/LPN) stated that most of the time the facility does have a Registered Nurse for 8 consecutive hours a day seven days a week. V6 stated that V2 (Director of Nursing/DON) usually works Monday-Friday, and he covers the Registered Nurse coverage during the week. V6 stated that V4 (Registered Nurse/RN) works every other Saturday on the floor. V6 stated that she doesn't think that they have Registered Nurse coverage on Sunday's. On 04/10/25 at 11:40AM V7 (LPN) stated that the facility does not have Registered Nurse coverage 8 consecutive hours a day seven days a week. V7 stated that on her weekend that she works there in no Registered Nurse coverage on Saturday or Sunday. V7 stated that her next weekend to work is on 04/12/25 and 04/13/25. V7 stated that V4 (RN) does not work her weekend either day. On 04/10/25 at 11:45AM V5 (LPN) stated that V2 (DON) has worked a couple of Saturdays along with V4 (RN). V5 stated that the facility does not have RN coverage for 8 consecutive hours seven days a week. On 04/10/25 at 12:30PM V1 (Administrator) stated that the facility does not have RN coverage for 8 consecutive hours seven days a week. V1 said that V2 (DON) and V4 (RN) do try to cover the floor often for the RN coverage, but they do have days that are not covered. V1 stated the facility is working on obtaining RN coverage for 8 consecutive hours seven days a week. V1 stated they are trying to hire more RN's at this time. Review of the Nursing Schedule from 02/26/25-04/09/25 documents no RN coverage was provided at the facility on 03/01, 03/02, 03/09, 03/15, 03/16, 03/23, 03/29, 03/30, and 04/06. The facility policy titled Staffing (undated) documents under policy interpretation and implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. RN coverage will be provided 8 hours per day, 7 days per week. If RN coverage is not available for direct care staffing, LPN will cover with RN on call to assess and assist as needed. The Resident List Report dated 04/07/25, documents there are 42 residents living in the facility.

Based on observation, interview and record review the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms for 4 of 4 residents (R5, R9, R31, R35) reviewed for room size in a sample of 32 . Findings include: Observation on 4/09/25 at 11:20AM revealed R31 and R9 shared a bedroom. It was a smaller sized bedroom with two beds, two nightstands, two over the bed tables, a regular sized wheelchair, and one reclining massage chair and had limited area to move around inside the room. A built-in dresser was observed in the room as well, but did not affect the living area. Observation on 04/09/25 at 11:35AM revealed R35 and R5 shared a bedroom. It was a smaller sized bedroom with two beds, two nightstands, two over the bed tables, one wheelchair, a reclining massage chair and had limited area to move around inside the room. A built-in dresser was observed in the room as well, but did not affect the living area. During a tour with V8 (Maintenance Supervisor) on 04/09/25 at 11:20AM, V8 was asked to measure R31, R9, R35 and R5's bedroom sizes. V8 used a measuring tape to measure the length and width of R35 and R5's bedroom and stated, 12.5 [feet] by 12 [feet] [which was equivalent to 150 square feet/75 feet per resident bed]. The measurement did not include the closet or built in dresser area. At approximately 11:35AM, V8 measured R31 and R9's bedroom and stated, 12.5 [feet] by 12 [feet] [which was equivalent to 150 square feet/75 feet per resident bed]. The measurement did not include the closet or built in dresser area. During an interview on 04/09/25 at 11:45AM with V3 (Director of Nursing), when asked about the size required for two-resident bedroom, V3 stated, The room has to be over 80 (square feet each) for two residents. On 04/09/25 at 11:45AM, V1 (Administrator) stated that all rooms on A hall and B hall do not meet the requirement of having 80 square feet per resident. V1 verified those rooms included 1-10, 20-28 and rooms [ROOM NUMBERS]. V1 stated that all residents are notified upon admission of the room sizes. V1 stated that all the rooms on A and B hall that don't meet the requirement for 80 square feet are dually certified for Medicare or Medicaid residents. On 04/09/25 at 12:00PM, R31 and R9 both stated they had no problems with their rooms and had enough space in their rooms. On 04/09/25 at 12:30PM, V11 (Family Member) stated that R35 has no problems with the size of his room and that she thinks that they have enough space in the room. V11 said that R35 is in a wheelchair and staff must use a mechanical lift on him to get him out of the wheelchair and bed and they have no problems with using the mechanical lift in the room. Facility Floor Plan provided by the facility documents rooms 1-10, 20-28 and rooms [ROOM NUMBERS] are all waivered rooms for size.

Based on interviews, observations, and record review the facility failed to implement surveillance measures to detect, treat, and prevent the spread of potential scabies infestation for 7 of 9 residents (R1, R2, R3, R4, R5, R6, and R7) reviewed for infection control in a sample of 9. This failure resulted in R1 experiencing intense itching for over 1 month resulting in signs and symptoms of distress of crying, facial grimacing, and experiencing a loss of appetite. This failure has the potential to affect all 41 residents residing in the facility. Findings include: 1.R1's Admission Record documents an admitted [DATE] including diagnoses of Anxiety, Anorexia, Hyperlipidemia, Alzheimer's Disease, and Dementia. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 1 indicating R1 has severe cognitive impairment. R1's Care Plan documents a risk for alteration in skin integrity dated 2/24/2024 with interventions including: Medication for complaint of itching to be given as ordered by MD (physician) dated 9/18/24, referred to (name of local dermatology office) dated 10/11/24, and MD update about current skin status new orders received see Physician's Order Sheets (POS) for orders dated 10/16/2024. On 11/1/2024 at 9:38AM, V5 (Licensed Practical Nurse/LPN) stated we have a few people with rashes. V5 stated R1 has had a rash for a long time, and we just can't figure out what it is. V5 stated R1 has been on Prednisone at least 3 times and many different creams and nothing seems to help. V5 stated we even changed her laundry soap and her body wash, and nothing has really helped. V5 stated she scratches all the time. It is sad and I wish we knew what it was. V5 stated it is a peculiar rash and I don't think it is scabies, but I am not sure. On 11/1/2024 at 10:30AM V2 (Director of Nursing) stated they have not done a 100% skin audit on all the residents in the facility yet. V2 stated none of the residents have been seen by a Dermatologist yet. V2 stated he wasn't sure what R1's rash was from, but she has been treated with Prednisone several times and different creams with not really any relief. V2 stated that V4 (Medical Director) came in and ordered Permethrin (Scabicide/Pediculicide cream) and that helped the most. V2 stated he was the facilities Infection Preventionist. V2 stated the rashes are not on the Infection Control log as he didn't know he needed to keep those on the logs and the nurses usually add stuff to the Infection Control log electronically. V2 stated he only keeps infections treated with antibiotics on the log. V2 was asked how he tracks the rashes if they are not on the log and he replied good point. On 11/1/2024 at 10:36AM, V4 (Medical Director) stated he has looked at a couple rashes and one of the resident's (R1) he ordered Permethrin treatment. V4 stated it is kind of a toss-up with R1 and the rash has some characteristics of possibly scabies so that is why I ordered the Permethrin cream. V4 stated he has not had much luck with skin scrapings as it a hit and miss kind of thing. V4 stated even Dermatologist do not do a lot of skin scrapings anymore because they are not always accurate. Sometimes we just treat with Permethrin to see if it makes a difference. One possibility to do when you have numerous rashes is to treat everyone with Permethrin. V4 stated he would be coming to the facility, and he wanted to look at the residents with rashes. On 11/1/2024 at 11:00AM, V5 (Licensed Practical Nurse) stated skin checks should be done daily on anyone with a rash. V5 stated she knows that they tried different body washes and detergents on R1, and nothing seems to help. V5 stated R1 was the first one she knew of with this rash. V5 stated V15 (Certified Nurse Assistant/CNA) had a rash but the staff member went to the doctor and the doctor stated it was viral. On 11/1/2024 at 2:10PM, V12 (Laundry Staff) stated the facility has not changed laundry soap in a very long time. V12 stated no resident's laundry is being done in special soap at this time. V12 stated 2 weeks ago we did do R1's laundry separate and with a different soap, but we are not doing that anymore. V12 stated she has not seen any signs of bed bugs but was told R1 had scabies, but she didn't know how accurate that information was. On 11/1/2024 at 2:35PM, V4 (Medical Director) entered the facility and checked residents with rashes. V4 met with V2 (Director of Nursing) and this surveyor and stated he feels R1, R2, R3, R4 and R5 need to be treated with Permethrin because R1 was treated and has shown improvement and he wants her treated again. V4 stated there are characteristics of scabies but he would not do scrapings as those are never definite. V4 stated with rashes that have spread through the facility, then treatment of Permethrin is not harmful to the residents, it is best to treat and monitor and if the rashes improve then we know we did the right treatment. V2 stated he felt like at this time it is best to treat just the ones with rashes and that he would conduct a complete skin check of everyone and anyone else with a rash will be included in the treatment plan. V4 stated the beds linens and clothing would also need to wash in hot water and dried in a hot drier. V2 stated he understood. On 11/1/2024 at 9:48AM, R1 was observed lying in bed scratching upon entering room. R1 was scratching her arms, chest and abdomen. V2 (Director of Nursing) at bedside. A rash to R1's arms, chest, abdomen and back were observed. There were small areas with tiny scabs noted on R1's arms, chest, back, and abdomen with linear lines noted between some of the small areas. Scratch marks were also observed mostly to both sides of R1's back with bleeding noted. There was blood noted under R1's fingernails. R1 is alert with confusion noted. On 11/1/2024 at 11:30AM, R1 was observed walking up and down the halls and was scratching her arms and chest. R1 was observed with a grimace on her face as she was scratching her arms. Blood was observed to R1's arms, fingertips, and under fingernails. On 11/7/2024 at 12:50PM, V2 was observed assessing R1 and R1's rash was observed to be improved from 11/1/2024. V2 stated the linear lines are even faded away. There was no bleeding noted or scratching upon observation. R1 was observed sleeping upon entering the room. R1's Progress Notes document the following: 9/18/2024: rash all over, itching and crying. Prednisone 20mg x 2 days then 10mg x 4 days. Benadryl 25mg every 6 hours as needed. 10/3/2024: Prednisone 10mg x 3 days, wash laundry in hypoallergenic soap, if not cured make appointment to office for biopsy. 10/11/2024 at 2:09PM: (V3 Medical Doctor) sent referral to (name of local dermatology office). 10/11/2024 at 1:39PM: Resident red scabs all over torso, face, arms, and thighs. Resident continues to scratch herself all over and crying while lying in bed. Residents' appetite poor due to discomfort. Orders to discontinue Remeron and increase Prednisone to 40mg daily x 4 days then 20mg every day for 4 days then 10mg every day for 8 days and 5 mg for 8 days. 10/16/2024 at 10:20 AM: spoke with (V4 Medical Director) regarding resident being itchy all over body. Ordered Permethrin 5% cream to body for 8 hours. 10/18/2024: order with Prednisone titrate has to be restarted due to pharmacy sending card with medications tonight, unaware of why card was sent tonight when order was obtained 10/11/2024. Order restarted so that resident can receive all proper doses per physician instructions 40 mg everyday x 4 days, 20mg everyday x 8 days, 10mg everyday x 8 days, 5mg everyday x 8 days. 10/24/2024 at 7:18 AM: Prednisone 20mg daily x 4 days. 11/1/2024: Permethrin Cream ordered per (V4). 1st application upon receipt from pharmacy. Shower the following day. Repeat process in 1 week. POA (Power of Attorney) aware. 11/5/2024: Prednisone again 20mg x 8 days. R1's weekly skin checks titled Skin Check Weekly and PRN (As Needed) document the following: 9/17/2024: rash all over arms, legs, and back (not new). 9/23/2024: red non raised rash chest. 9/30/2024: red rash over torso, arms, and legs. 10/14/2024: rash all over body. 10/22/2024: rash and scratch marks all over body. R1's Treatment Administration Record (TAR) dated 10/1/24-10/31/24 documents the administration of Permethrin cream on 10/16/24. R1's Physician's Note authored by V3 (Physician) and dated 10/24/24 documents Has had a rash but It has Improved quite a bit. The same note further documents The patient has only faint areas of previous excoriation on the upper arms and chest. No active rash. She is finishing Prednisone now. R1's TAR dated 11/1/2024-11/30/2024 documents the administration of Permethrin cream on 11/1/2024. 2. R2's Admission Record documents an admitted [DATE] and includes diagnoses of Dementia, Alzheimer's Disease, Anxiety, and Depression. R2's MDS dated [DATE] documents a BIMS score of 99, indicating that R2 was unable to complete the interview. On 11/1/2024 at 10:20AM, R2 was noted sitting up in a Geriatric Chair in her room with V7 (family member) at bedside. R2 was observed scratching her arms and chest. R2 had small, scabbed areas all over her arms and upper chest. R2 was unable to answer any questions asked. R2's Progress Notes documented the following: 11/1/2024 at 10:21 AM: husband noted rash. V4 notified and ordered Prednisone. 11/1/2024 at 5:57 PM Permethrin Creme ordered. 11/3/2024 at 1:36AM: Permethrin creme applied. On 11/7/2024 at 11:06 AM, V7 (family member) stated R2 received the treatment on Saturday night, and she is much better now, and the itching has subsided, and the rash is improving except under R2's arms and he understands those are hard places to reach. V7 stated you can see the areas that were not covered with the treatment. While in R2's room V2 told V7 that R2 would receive a second treatment and they will make sure and get those areas covered better with the treatment. V7 was appreciative and stated he is just glad she is getting better as she was miserable. V2 stated her rash is much improved since the treatment of Permethrin. 3. R3's Admission Record documents an admitted [DATE] and includes diagnoses of Alzheimer Disease, Hypoglycemia, Diabetes Mellitus type 2, Major Depressive Disorder, and Anxiety. R3's MDS dated [DATE] includes a BIMS score of 00, indicating R3 has severe cognition impairment. On 11/1/2024 at 9:50AM, R3 was assessed by V2 (Director of Nursing) and an observation of a rash was noted to arms and abdomen with worse rash noted to left arm. R3 observed scratching the left arm with slight bleeding noted. All areas with small scabs and linear lines were noted between some of the areas to the abdomen. The lines were noted to be shiny in color in the light. There are red bins inside room and protective equipment in the bins outside the door of R3's room. V2 stated that R3 is on Enhanced Barrier Precautions (EBP) due to R3 having a wound. R3's Progress Note dated 11/1/2024 at 5:57 PM, documents orders for Permethrin Creme. R3's November 2024 TAR documented the order for Permethrin cream and was initialed as being administered on 11/1/2024. On 11/7/2024 at 12:51PM, R3 was observed being assessed by V2 and improvement was noted to the rash. V2 asked if R3 was still itching and R3 stated No but R3 was observed to have some confusion. V2 stated her rash is finally fading away. There was no further scratching observed. The Midnight Census Report dated 11/1/24 documents that R3 resides in the same room as R1. 4. R4's Admission Record documents an admitted [DATE] and includes diagnoses of Unspecified Dementia, Alzheimer Disease, Anxiety, and Anemia. R4's MDS dated [DATE] documents a BIMS score of 00, indicating R4 has severe cognition impairment. On 11/1/2024 at 10:22 AM, R4 was observed sitting up in a wheelchair scratching her arms and both arms were noted to have small scabs and open areas noted with some linear marks along with scratch marks. The areas were noted to have some bleeding with blood noted under fingernails. R4 is confused and was unable to answer any questions. On 11/1/2024 at 12:10PM, V2 said he was not aware of R4 having a rash to her arms. R4's document titled Treatment Administration Record dated 11/1/2024-11/30/2024, documents Permethrin Creme was administered on 11/1/2024. On 11/7/2024 at 12:55PM, V2 was observed assessing R4's rash. R4's rash was observed to be fading and no scratching noted. V2 stated she is much improved. The Midnight Census Report dated 11/1/24 document that R2 and R4 reside in the same room. 5. R5's Admission Record documents an admitted [DATE] and includes diagnoses of Alzheimer Disease, Anxiety, Unspecified Dementia, Major Depressive Disorder, and Hypertension. R5's MDS dated [DATE] includes a BIMS score of 00, indicating R5 has severe cognitive impairment. On 11/1/2024 at 2:35 PM, V4 was observed assessing residents including R5. R5 had a rash observed to arms, abdomen and back, arms are noted to be the areas with scratches and bleeding. Several scattered scabbed areas noted to R5's abdomen, back, and arms. R5's TAR dated 11/1/2024-11/30/2024 documents Permethrin cream was administered on 11/1/2024. On 11/7/2024 at 9:33AM, V2 stated a skin scraping was done on R5 and sent to the local hospital. V2 stated the scraping was done by V4 (Medical Director). V2 stated he scraped 3 separate areas. V2 stated he has called the local hospital to see if the results were back and they were not completed yet as it was a send out specimen and can take up to 6 days to get the results. V2 stated R5 did not receive the Permethrin cream treatment until 11/4/2024 due to waiting on scrapings of skin. On 11/7/2024 at 12:58PM, V2 was observed assessing R5 right after a shower. A rash was observed to R5's arms and abdomen and are still red in color with scabs noted. V2 stated R5 did not get treated with Permethrin until 11/4/2024 due to waiting until after skin scrapes were completed. R5's room was not observed to have any isolation bins or signs posted. On 11/8/2024 at 1:05PM, V2 stated he just checked, and the lab reported to him that R5's lab requisition was filled out wrong as the diagnosis on the requisition had rash instead of scabies and the wrong stain was used but it would be run to see if it will result. On 11/11/2024 at 2:48PM, V2 stated he still did not have results from the lab. V2 was asked about R5's Treatment Administration Record documenting the Permethrin cream being administered on 11/1/2024 which was before the scrapings were obtained. V2 stated I don't know why they did that and maybe they charted it wrong but V2 stated he would look into that matter. V2 stated we held R5's Permethrin treatment for the reason of getting the scrapings so the results would be more accurate. R5's lab report with a print date of 11/11/24 documents that the specimen received was a skin scraping from the abdomen and ordered test was a fungal stain with no fungus observed. There were no ordered test or results for a skin scraping to detect scabies documented on R5's lab report. 6. R6's Admission Record documents an admitted [DATE] including diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Legal Blindness, Dysphagia, and Depression. R6's MDS dated [DATE] includes a BIMS score of 00, indicating R6 has severe cognition impairment. On 11/7/2024 at 9:33AM, V2 stated they completed the 100 % skin audit on all residents and added 2 more residents, R6 and R7, to the list of residents having rashes. V2 stated that R6 and R7 were added to the list for treatment with Permethrin. R6's Progress Note dated 11/1/2024 documents orders for Permethrin 5% cream. R6's TAR dated 11/1/2024-11/30/2024 documents Permethrin cream was administered on 11/1/2024 at 8:00PM. On 11/7/2024 at 12:45 PM, V2 stated R6 received Permethrin treatment and R6's rash looks much better now. A rash was observed to R6's abdomen and arms with noted scattered small scabs. No scratching noted. 7. R7's Admission Record documents an admitted [DATE] and includes diagnoses of Anxiety Disorder, Unspecified Dementia, Dysphagia, Anorexia, Anemia and Hypertension. R7's MDS dated [DATE] documents a BIMS score of 00, indicating R7 has severe cognitive impairment. R7's TAR dated 11/1/2024-11/30/2024 documents that Permethrin cream was administered on 11/1/2024. On 11/7/2024 at 12:47PM, V2 was observed assessing R7 and a rash was noted to R7's abdomen, arms and back. R7's rash was observed to have tiny scabs on both arms. V2 stated that R7 has received the Permethrin cream treatment as well. V2 stated R7's rash looks much better now. The Midnight Census Report dated 11/1/24 documents that R5 and R7 reside in the same room. On 11/7/2024 at 11:12AM, V2 was asked if any of the residents were separated due to rash and he stated No because all the ones with a rash had a roommate with the rash except one and that resident is in a room by himself. On 11/7/2024 at 11:26AM, V4 (Medical Director) stated with the improvement of the rashes I believe we are heading in the right direction. V4 stated he ordered for the residents to have a second treatment in a week to make sure all areas get treatment applied and to make sure this is taken care of. On 11/7/2024 at 12:00PM, V2 stated none of the residents with rashes were placed on Contact Isolation. V2 stated he instructed the staff to send all the clothes that the residents had on and the bed linens to laundry to be washed separately and in hot water. V2 stated none of the residents' clothes in their closest was rewashed or bagged up. On 11/7/2024 at 1:08PM, V15 (Certified Nurse Assistant/CNA) stated she had a rash, but it wasn't the same as what the residents have, and her doctor stated her rash was from a virus. V15 stated the residents have had this rash for more than a week that she knows of. V15 stated she was aware of 2 staff CNA's that had the same rash as the residents, but they no longer work there. V15 stated they have been gone for a couple of weeks now. V15 stated we had another resident with a rash, but she has passed away. V15 stated she worked this past weekend on 11/2/24 and 11/3/2024 and none of the residents were on Contact Isolation precautions and we were not told to bag or separate their laundry. V15 stated I have noticed this rash is spreading around the facility and there are 2 halls now with residents with rashes. On 11/7/2024 at 1:15 PM, V8 (Laundry) stated she did not work this past weekend. V8 stated R1's clothes were separated 2-3 weeks ago before her treatment, she believes it was before the 18th of October. V8 stated she worked on 11/4/2024 and there was no separate laundry for any of the resident and has not been this week. V8 stated she was told a few weeks back that R1 had scabies and that was why we was doing her laundry separate. On 11/7/2024 at 1:34PM, V16 (Licensed Practical Nurse) stated the rashes she has seen have been on the residents' arms and torso and some of the residents were scratching and scratching bad. V16 stated Permethrin cream was applied on the night shift. V16 stated she was not aware of any staff with rashes. V16 stated skins checks are being done either daily or weekly on the ones with a rash. V16 stated she does her skin checks on shower days which are twice a week. V16 stated there was another resident with a rash but she passed away a while back. On 11/7/2024 at 2:11PM, V12 (Laundry) stated she worked 11/2/2024 from 6AM to 6PM and she did not do any laundry separate or was told to do anything extra like hot water or dry clothes on high heat. V12 said the only laundry done separate is the ones on Enhanced Barrier Precautions and they have been doing those for a while. V12 stated that is the only laundry received in red bags. V12 stated R2, R4, R5, R6 and R7's clothes were done as normal with everyone else's. V12 stated R1 and R3's clothes are always in a red bag together as R3 is on Enhanced Barrier Precautions and they just wash those 2 together as they are roommates. On 11/7/2024 at 2:25PM, V18 (Licensed Practical Nurse) stated she worked Saturday 11/2/2024 from 6AM to 6PM and she knew the treatment had not been done yet as the medicine had not been delivered yet. V18 stated no residents were on Contact Isolation precautions that she was aware of. V18 stated she was not aware that the clothes and bed linens had to be washed in hot water after the treatment either. V18 stated she knows R1 and R3's laundry is always done together as R3 is on Enhanced Barrier Precautions for a wound. On 11/7/2024 at 2:43 PM, V19 (Licensed Practical Nurse) stated she was not sure what the rashes are, but she did work this past weekend 11/2/2024 and 11/3/2024 6AM-6PM. V19 stated the treatments were done on 11/2/2024 on the night shift. V19 stated nobody receiving the treatment was on Contact Isolation except R1 and R3 and they are on precautions for Enhanced Barrier Precautions for a wound on R3 and they are roommates. V19 stated she wasn't aware of any laundry on the others being done separately or with hot water. On 11/7/2024 at 3:30PM, V20 (Laundry and Housekeeping Supervisor) stated she worked on Sunday 11/3/2024. V20 stated she was working in laundry and there were no isolation bags that had come to laundry on 11/3/2024. V20 stated there were no instructions given to us about washing anything in hot water and high dryer heat. V20 stated the beds for R2, R4, R5, R6, and R7 were not stripped and sent to laundry either. V20 stated the beds would have needed to be cleaned thoroughly too but they were not done as they were not instructed to do so. V20 stated for a while they were doing R1's laundry in a special soap and separate from others but we haven't done that in a while. The facility Infection Surveillance Monthly Report dated 11/1/24 documents for R2 and R5 under the Other Infection Category with an infection onset date of 9/30/24. Under Status it documents closed (10/8/24)-resolved There is no documentation or description of what type of infection that R2 or R5 had on the report. There is no documentation of R1, R3, R4, R6, or R7 on the Infection Surveillance Monthly Report of having an infection under the Other Infection Category or Skin and Soft Tissue Infection Category. The facility policy titled Surveillance for Infections (revision date September 2017) documents that the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 3. Infections that will be included in routine surveillance include those with: d. Pathogens associated with serious outbreaks (e.g., invasive Streptococcus Group A, acute hepatitis, norovirus, scabies, and influenzas.) The facility policy titled Scabies Identification, Treatment and Environmental Cleaning (revision date August 2016), documents under General Guideline, 6. Scabies is spread by skin-to-skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. 7. Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings, although scrapings are preferred. 8. Affected residents should remain on Contact Precautions until 24 hours (24) after treatment . 11 . A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved. 12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing as established by the facility's infection and exposure control programs. Under the section titled Environmental Control: Typical Scabies it documents 1. Place residents with typical scabies on contact precautions during the treatment period; 24 hours after application of 5% permethrin cream or 24 hours after last application of scabicides requiring more than one application .4. Place bed linens, towels and clothing used by an affected person during the 4 days prior to initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for at I0-20 minutes. 5. Use the hot cycle of the dryer for at least I0-20 minutes. 6. Place non-washable blankets and articles in a plastic bag for at least 72 hours. These items can also be dry cleaned or tumbled in a hot dryer for 20 minutes. 7. Change all bed linens, towels and clothes daily. 8. Disinfect multiple residents-use items, such as walking belts, blood pressure cuffs, stethoscopes, wheelchairs, etc., before using on other residents. 9. Discard all creams, lotions or ointments used prior to effective treatment. I0. Vacuum mattresses, upholstered furniture and carpeting. Wrap vacuum cleaner bag in a plastic bag and discard. a. General cleaning and thorough vacuuming of furniture, mattresses or rug is recommended. b. Fumigation is not necessary. 11 . For non-fabric items, routine disinfection procedures are adequate. The facility policy titled Isolation- Initiating Transmission-Based Precautions (revision date October 2018) documents 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor notifies the Infection Preventionist and the resident's Attending Physician for evaluation of appropriate Transmission-Based Precautions. The Center for Disease Control (CDC) website (https://www.cdc.gov/scabies/php/public-health-strategy/index.html) documents under the section titled Prevention that Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). New patients/residents and employees should be screened carefully and evaluated for any skin conditions that could be compatible with scabies . When there is concern for scabies in a person, skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Appropriate isolation and infection control practices (e.g., gloves, gowns, avoidance of direct skin-to-skin contact, etc.) should be used when providing hands-on care to patients/residents who might have scabies. Epidemiologic and clinical information about patients/residents with confirmed and suspected scabies should be collected and used for systematic review in order to facilitate early identification of and response to potential outbreaks. The Midnight Census Report dated 11/1/24 documents that there are 41 residents that reside in the facility.

Based on interview and record review the facility failed to follow physician's orders for 1 of 7 residents (R1) reviewed for quality of care in a sample of 9. Findings include: R1's Admission Record documented an admitted [DATE] with diagnoses including Anxiety, Anorexia, Hyperlipidemia, Alzheimer's Disease, and Dementia. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 1, indicating R1 has severe cognitive impairment. R1's Care Plan documents a risk for alteration in skin integrity dated 2/24/2024 with interventions including: Medication for complaint of itching to be given as ordered by MD (physician) dated 9/18/24 and referred to (name of local dermatology clinic) dated 10/11/24. R1's Progress Notes document the following: 9/18/2024: rash all over, itching and crying. Prednisone 20mg x 2 days then 10mg x 4 days. Benadryl 25mg every 6 hours as needed. 10/3/2024: Prednisone 10mg x 3 days, wash laundry in hypoallergenic soap, if not cured make appointment to office for biopsy. 10/11/2024 at 2:09PM: V3 (Medical Doctor) sent referral to (name of local dermatology clinic). On 11/1/2024 at 9:48AM, R1 was observed lying in bed scratching upon entering room. R1 was scratching her arms, chest and abdomen. V2 (Director of Nursing) was observed at R1's bedside. A rash was observed to R1's arms, chest, abdomen and back. There were small areas with pinpoint scabs noted on R1's arms, chest, back, and abdomen with linear lines noted between some of the small areas. There were scratch marks also noted mostly on both sides of R1's back with bleeding noted. Blood noted under R1's fingernails. R1 is alert with confusion. On 11/1/2024 at 11:30AM, R1 was observed walking up and down the halls and was scratching her arms and chest. R1 was observed with a grimace on her face as she was scratching her arms. Blood was noted to R1's arms, fingernails, and fingertips. On 11/7/2024 at 2:55PM, the records from the Dermatology referral were requested V2 (Director of Nursing/DON) and V2 stated I will look but I didn't know about that. On 11/11/2024 at 2:48PM, V2 stated there is no record of R1 going to the dermatologist. V2 said that R1 did not go to the dermatologist as the nurses thought V3 was going to make the arrangements for the appointment. V2 stated it is a miscommunication with the orders. V2 was asked about the biopsy that was noted to be done if the rash was not cured as documented in R1's Progress Note dated 10/3/24. V2 stated he didn't know anything about that. V2 stated well that did not happen either again a miscommunication. V2 said he doesn't think V3 has an office to do this procedure and doesn't know the specifics on what office the note is referring to.

Based on interview, observation, and record review, the facility failed to ensure residents were free from peer to peer sexual abuse by (R1) for 3 of 11 residents (R2, R3, R7) reviewed for peer to peer sexual abuse in a sample of 11. This failure resulted in R2, R3, and R7, all of whom are cognitively impaired and incapable of giving informed consent to sexual activity, witnessing masturbation, being touched on the breasts and genitals, and having unsolicited sexual comments directed toward them. These actions would cause a reasonable person to experience feelings of fear, embarrassment, anger, and shame. The Immediate Jeopardy began on 9/23/24 when R1 touched R2's breast, and a plan for effective supervision and monitoring of R1's behavior was not implemented. R1 subsequently went on to sexually abuse R3, and R7. V1, Administrator, was notified of the Immediate Jeopardy on 10/22/24 at 9:03am. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 10/22/24. Findings include: R1's Admission Record documented an admitted [DATE] and listed diagnoses including Atrial Fibrillation, Adjustment Disorder, Alzheimer's Disease, and Chronic Viral Hepatitis C. R1's Minimum Data Set (MDS) dated [DATE] documented that R1 has moderate deficits in cognition and ambulates independently. 1. An Illinois Department of Public Health (IDPH) Final Report dated 10/4/24 stated, On 9/23/24 at approximately 12:55pm this afternoon, (V1, Administrator) notified that resident (R1) made unwanted contact toward resident (R2) It was witnessed by (V13, Licensed Practical Nurse/LPN), that R1 lifted the shirt of R2 and touched her breast. Residents were immediately separated, and (V1) was notified. Nurse assessment completed, noting no issues. (R2) was interviewed, and she could not give any details of such incident and states she doesn't know what we were talking about. (V1) and (V4, Social Services Designee), interviewed (R1) with his sister present and (R1) reports not remembering this and that he doesn't touch women that way. His roommate, (R5) was interviewed, and he stated he could hold a conversation with (R1) on certain days and on other days he does not make any sense. Conference with (V14, R1's Physician) and a thorough chart review, assessment, and medication review was completed. (V14) decided to make changes to (R1's) medications. (V14) feels that (R1's) medication changes need time to become therapeutic. (V4) will meet with (R1) three times a week to facilitate and guide socially appropriate conversations and behaviors between residents and keeping him engaged in a meaningful activity. (R1)'s behaviors will continue to be monitored, and (V14) will review on an ongoing basis to determine if any changes need to be made. One to one activity with (R1) will be increased. (V4) will meet with (R2) 2 times weekly for 2 weeks to ensure she does not experience any adverse effects and continues to feel safe at the facility. Both residents are doing well at this time and have had no adverse effects from this incident. (V14), Police, and Ombudsman all notified of this conclusion. R2's Admission Record documented an admitted [DATE] and listed diagnoses including Alzheimer's Disease and Diabetes Type 2. R2's MDS dated [DATE] documented that R2 is severely cognitively impaired and requires a wheelchair for mobility. R2's Care Plan dated 9/23/24 documented a problem area, I received unwanted contact by a male resident. Due to my cognition, I have no recollection and remain at baseline cognition and mood, with a corresponding intervention, Keep me and other resident involved in incident in safe distance from each other. On 10/16/24 8:55am, R2, who was alert only to herself, was observed self-propelling in her wheelchair in the hallway outside her room. On 10/16/24 at 9:45am, V5, family member of R2, stated, A nurse called him 2 1/2 weeks ago and said a male resident had touched (R2)'s breast. V5 stated before she developed Dementia, R2, Would never have put up with being treated that way. She would have been extremely upset. 2. An IDPH Final Report dated 10/4/24 stated, On 9/27/24 at approximately 2:55pm, (V1) notified that (R1) made unwanted contact toward resident (R3) It was witnessed by (V13), (R1) was hugging (R3) in the hall and then (R1) grabbed (R3)'s breast. Residents were immediately separated and (V1) was notified. Nurse assessment completed noting no issues. (R3) was interviewed, and she could not give any details of such incident and states she doesn't know what we are talking about. (R1) was sent to (a local hospital) for a psychological evaluation. (R1) received evaluation form (local counseling center) and he did not meet the requirements (for inpatient psychiatric referral). (Counseling center) wants to do outpatient therapy. Labs for (R1) were positive for Covid and Marijuana. (V4) will continue to meet with (R1) three times a week to facilitate and guide socially appropriate conversations and behaviors between residents and keeping (R1) engaged in a meaningful activity. (R1's) behaviors will continue to be monitored, and (V14) will review on an ongoing basis to determine if any changes need to be made. (V4) will meet with (R3) two times weekly for two weeks to ensure she does not experience any adverse effects and continues to feel safe at the facility. R3's Admission Record documented an admitted [DATE] and listed diagnoses including Unspecified Dementia and Diabetes Type 2. R3's MDS dated [DATE] documented that R3 is moderately cognitively impaired, is ambulatory, and wanders daily. R3's Care Plan dated 9/27/24 documented a problem area, I received unwanted contact from another resident. I remain at baseline for cognition and mood. No distress noted, with a corresponding intervention, Keep me and other resident at a safe distance from each other. On 10/15/24 at 9:10am, R3 was observed ambulating in the hallway. R3 was alert only to herself. On 10/18/24 at 10:20am, V12, family member of R3, stated he was called on 9/27/24 and told that a male resident had grabbed R3's breast. V12 stated he was told they were going to send R1 out for psychiatric treatment, and that's the last he heard of it. V12 stated he was never informed about a male resident trying to lift R3's shirt on 9/26/24. V12 stated had R3 not been confused, She would have been very upset and probably would have socked him in the jaw, she never would have tolerated behavior like that. 3. On 10/11/24 at 3:05pm, V10, CNA, stated that sometime during the week of 9/29/24, R1 started displaying a behavior of lying on his bed, unclothed, masturbating, with the door open. V10 stated one day that week, date unknown, she had to redirect him every few minutes to close the door, but when she walked away, he would open it again. V10 stated R7 was ambulating by R1's room, and R1 had the door open again. V10 stated R7 looked into the room as she walked by and R1 made sexual comments directed at R7 and encouraged R7 to enter the room and engage in sexual activity. V10 stated she redirected both residents, and that R7 was upset. V10 stated she reported this to her charge nurse, she cannot remember whom, and that person went to V1's office to report the incident. V10 stated that to her knowledge, R1 was not at any time placed on 15-minute checks or one to one monitoring. V10 stated that R1 was ambulatory and fast moving, Especially when we only have 2 CNAs for the whole building, let alone did we not have extra staff to do one on one (monitoring) with him. I felt (R1) was dangerous to be around our female residents, many of them are confused and can't consent (to sexual activity) and they are too weak to fight him off. R7's Admission Record documented an admitted [DATE] and listed diagnoses including Unspecified Dementia. R7's MDS dated [DATE] documented that R7 is severely cognitively impaired and ambulates independently. R7's Care Plan dated 8/30/24 documented a problem area, The resident is an elopement risk/wanderer, with a corresponding intervention, Redirect resident to another area. There were no problem areas related to unwanted sexual contact from other residents. On 10/16/24 at 2pm, R7 was observed ambulating in the hall. R7 was alert only to herself. On 10/16/24 at 3:55pm, V7, family member of R7, stated he was unaware of the incident on the week of 9/29/24 between R7 and R1. V7 stated R7 is very confused and has Dementia. V7 stated if R7 was not confused, she would have been upset and embarrassed when the incident occurred. R1's Physicians Orders for September 2024 documented the following: Increased supervision every 15 minutes, order date 9/24/24. Citalopram 20mg. (milligrams) give one tablet at bedtime, start date 9/24/24. Citalopram (increase to) 30 mg give one tablet at bedtime, order date 9/27/24. Quetiapine 25mg. one tablet at bedtime, order date 9/13/24. Quetiapine 25mg. (increase to) two tablets at bedtime, order date 9/24/24. Quetiapine 25mg. (add) one tablet every morning, order date 9/27/24. A Physicians Progress Note dated 9/24/24, authored by V14, stated, New resident to nursing home. He has a history of Dementia, Depression, recent Renal Insufficiency, Hypertension, GERD (Gastro-Esophageal Reflux) Hyperlipidemia, Gout, Atrial Fibrillation. Has been having issues in the nursing home since arriving inappropriately touched a female patient. Plan: Citalopram 20 mg. daily with Seroquel 50mg. daily for depression. and to control inappropriate sexual activity. R1's Current Care Plan last revised 10/11/24 documented, I am demonstrating inappropriate behaviors, exposing privates to female workers, making inappropriate comments to female workers, masturbating in doorway of room, walking around refusing to wear pants, exposing self, etc., with a date initiated as 9/24/24. Interventions/Tasks include: 10/10/2024 Resident was transferred to (regional psychiatric inpatient facility, ER). 10/9/24 Denied admittance by (Gero psych regional hospital). 9/23/24 Medication changes by MD. Family approved. 9/27/24 Resident was sent to (local hospital ER) for evaluation. Returned 9/28/24 positive for Covid. Psych Eval done from (local mental health center) and recommended outpatient therapy with (health agency). Care plan meeting held with POA 10/7/2024 related to inappropriate behaviors. POA wants to do Medication changes first. Denied admittance to (behavioral health inpatient facility): Date initiated 10/9/24. Increased supervision: Date initiated 9/24/24. Referral was sent to (regional psychiatric inpatient facility): Date initiated 10/9/24. R1's Nursing Progress Notes documented the following: 9/23/24: Resident was observed inappropriately lifting a residents shirt and touching her breast. Resident is being kept away from female resident at this time. 9/24/24: Sexually inappropriate toward staff. 9/24/24: This AM staff was in residents room changing bed linens. Staff glanced over and resident was masturbating. Staff redirected resident to close his curtain and the door for privacy. 9/26/24: Resident sitting at nurses station. (R3) was standing next to resident. Resident attempted to lift (R3's) shirt while this writer was walking back up to the desk. Behavior was stopped. 9/27/24: Resident was seen hugging (R3). Staff was telling resident to stop touching her. Resident proceeded to grab (R3's) breast. He was also telling her that he is her husband. Resident was redirected to his room; he is now in his bed resting. 9/27/24: Per (V2, Director of Nurses), send to ER for psychiatric evaluation. 9/28/24: Resident arrived back at the facility at 11:10 from (ER). Resident tested positive for Covid and is on isolation. Resident also tested positive for marijuana. POA (Power of Attorney) believes he used substances before coming to facility. Resident arrived at facility on 9/13/24 so it still could be in his system. Resident received a psychiatric eval from (local mental health center), he did not meet requirements (for inpatient treatment) but they would like to do outpatient therapy with him. Must call Monday to schedule a follow up appointment to be scheduled after patient is off isolation Resident stated that he is depressed from being in the nursing home and not having his dog. Resident stated that he understands that his behaviors have not been right, and he will not treat other residents inappropriately. Order to increase Citalopram, spoke with (V14) and POA, order placed. (V14) would also like a second dose of Seroquel 25 milligrams given in the morning. Order placed. 10/6/24: This nurse took resident his evening meds when resident was noted to be masturbating. Resident stated, 'Give me some pu**y' This nurse explained to resident that behavior was inappropriate. 10/7/24: Activity Director was helping pass breakfast trays and went into this resident's room, resident told Activity Director to lay down in bed so he could feel her breast, admin went into residents room and told resident that behavior was inappropriate. This nurse contacted POA, POA will be coming to facility to have meeting with administrative staff. 10/7/24: (V1 and V4) had a care plan meeting with this residents POA. We discussed the inappropriate sexual behaviors this resident had been exhibiting. POA decided she wanted to try and change a couple of medications first. We informed the nurses on shift of what POA had decided to do. We discussed with POA about how this behavior is highly inappropriate and the next steps if it continues. POA said whatever we had to do; they were ok with. Resident will be monitored on this medication to see if behaviors decline. 10/7/24: ST (Speech Therapist) attempted to see patient for therapy in room with Occupational Therapy present during therapy attempt. Patient refused treatment and said he 'wanted to have fun' and exposed groin area to therapists and began masturbation. Therapists attempted to redirect patient with no success and patient educated on appropriate behavior during therapy interventions. Administrator and nursing staff notified of this interaction. 10/7/24: Resident has been inappropriate with staff all day. Every time a staff walks past his room or into his room he begins to masturbate in front of them. Stands in his doorway doing the same in front of female residents. We have attempted to keep door closed but resident keeps opening door and masturbating. He has tried to touch staff in sexual ways, and we are keeping certain residents away from him R/T (related to) other incidents. MD was notified and awaiting reply. 10/7/24: Resident was walking in hallway in gown flashing female staff members with his penis and buttocks. This nurse and another CNA went to redirect resident and informed him he needed to be covering himself up with pants when walking through the hallways. Resident went back into room, laid down on his bed and starting masturbating while this nurse and other CNA were in room. 10/8/24: Resident continues to come out into doorway of room masturbating, asking all female CNAs to come closer to him. Redirection has continued to fail. 10/9/24: Resident has been awake almost the entire shift. Resident has been in and out of his room with no pants on holding his penis numerous times. Resident has stated to female CNA, 'come here, you want to f**k' and touched another female CNA on the butt. Resident has been redirected back to room to put pants on but will not comply. Continues to go into female rooms. 10/9/24: This nurse was in residents room trying to get him to put pants on, resident then said, 'You should be scared of me. Show me your t**s, a**, and pu**y.' Nurse finished assisting resident with putting his pants on and left the room. 10/9/24: CNA reported to DON that this resident was in the hallway asking for a specific female resident. CNA redirected resident to his room. 10/9/24: CNA informed DON that resident came out of his room completely naked and was quickly redirected and instructed to put his clothes back on. 10/10/24: Called and gave report about resident to (regional psychiatric inpatient facility). 10/10/24: (V1 and V4) transported this resident to (regional psychiatric inpatient facility). Review of R1's 15 Minute Checks Log Documents showed the following: 9/23/24: No documentation. 9/24/24: No documentation. 9/25/24: Checked every 15 minutes. 9/26/24: Checked every 15 minutes. 9/27/24: Checked every 15 minutes. 9/28/24: No documentation from 3:45pm to 6:00pm. 9/29/24: No documentation from 2:15pm to 6:00pm. 9/30/24: No documentation. 10/1/24: No documentation from 6:15am to 6:00pm. 10/2/24: No documentation from 6:15am to 5:45pm. 10/3/24: No documentation from 6:15am to 6:00pm. 10/4/24: No documentation. 10/5/24: No documentation. 10/6/24: No documentation. 10/7/24: No documentation. 10/8/24: No documentation from 6:15am to 5:45pm. 10/9/24: No documentation. 10/10/24: No documentation. There was no documentation in R1's record to indicate he had received one to one monitoring. On 10/11/24 at 2:30pm V8, Certified Nursing Assistant (CNA), stated she was aware from reports of other staff that R1 had sexual acting out behavior toward female peers, but she had never personally witnessed it. V8 stated R1 was ambulatory, wanders, and was confused at times. V8 stated R1 frequently had to be redirected from getting into peers rooms. V8 stated she was not aware of R1 ever being put on 15-minute checks or one to one monitoring. V8 stated, We just tried to watch him as best as we could. On 10/11/24 at 2:55pm, V9, CNA, stated on numerous occasions, R1 would come out of his room naked with an erection and require redirection. V9 stated R1 was, Very ambulatory, and very fast, and sometimes we didn't have enough staff to keep up with him. V9 stated to her knowledge, R1 was never on one to one monitoring. V9 stated she thinks after one of R1's episodes of acting out he was placed on 15-minute checks for 24 hours. V9 stated interventions for R1's behavior were to, Redirect him as best they could with snacks or activities. On 10/15/24 at 9:50am, R5 was alert and oriented. R5 stated he was previously roommates with R1. R5 stated maybe a month ago, R3 wandered into their room, and R1 was asking her to come over to his bed, but R3 wandered back out. R5 stated he doesn't recall telling staff about it, and he could not say for sure why R1 beckoned R3 to the bed. R5 stated R1 was moved to a different room, shortly after, but at no time had R5 ever seen staff with R1 one to one or doing frequent checks with him. R5 then stated, I think they tried to keep an eye on him as best they could, and I heard them frequently holler at him to stop. R5 stated there are only a few men on A hall where R5's room is, most are confused or bedridden females. R5 stated R1 was, At times totally with it, but other times really confused. R5 stated one night about midnight, a couple of weeks ago maybe, he saw R1 standing in the A hall at the end closest to the dining room, no staff were present. R5 stated it looked like he was stalking somebody or hiding, he was up against the wall, with his palms flat to the wall, like he was trying to go unnoticed. R5 stated, I said (R1) what are you doing, and he said, I'm lost and need to go to the bathroom, so I showed him where it was, but he already knew where the bathroom was. At that time they had already moved him from my room to one across the hall. R5 stated he did not inform staff of this incident. R5 stated R1 had also been frequently walking out of his room naked despite staff redirecting him. On 10/15/24 at 2:10 pm, V4 (Social Services Designee) stated when R1 was initially admitted to the facility, he did not display any behaviors. V4 stated the first episode staff had witnessed was on 9/23/24 when R1 touched R2's breast. V4 stated she attempted meeting with R1 after this incident, but he was sexually suggestive and could not be redirected. After the 9/27/24 incident when R1 grabbed R3's breast, V4 stated she started seeking inpatient psychiatric placement for R1 but received several denials as, since he was not suicidal or homicidal, he was not appropriate for that level of care. When asked about behavior interventions for R1, V4 stated, We tried to redirect him, offer food or drinks, and tried to check on him every 15 minutes. But we didn't have enough staff to watch him honestly. He would sneak out of his room when the CNAs weren't watching him. V4 stated at one point we did have a male receptionist sit outside his door, over a weekend, but couldn't remember which weekend. V4 stated when R1 was admitted to a psychiatric unit on 10/10/24, V4 and V1 transported him in the facility van, while R1 masturbated and made sexual comments the entire trip and could not be redirected. V4 stated she has met with R2 and R3 and completed trauma assessments on each one, and they have shown no signs of after affects from the abuse. On 10/16/24 at 10:05am, V1 confirmed she is the facility's Abuse Coordinator. V1 stated nobody reported the incident the week of 9/29/24 with R7 walking by R1's room and him masturbating and beckoning her in. When asked if anything had been done to try to assess the scope of R1's potential victims, V1 stated she was only aware of R2 and R3. V1 stated when staff witness or hear about abuse, they are to report it to her immediately. On 10/16/24 at 1:25pm, V1 stated that after V13 reported the incident between R1 and R2 on 9/23/24 she notified all staff that R1 and R2 were to be kept apart and if seen together, to take them to their respective rooms. V1 stated V14 changed some of R1's psychotropic medications in response to the incident, and Staff tried to check on (R1) every 15 minutes. V1 stated when the second incident took place on 9/27/24, R1 was sent to the emergency room and was deflected for inpatient admission. V1 stated while there R1, tested positive for marijuana and Covid, and upon his return, was put in a room by himself on isolation. V1 stated, We tried to have staff sit outside his door if we had enough staff, sometimes we had extra staff who could do this, and sometimes not. Otherwise, staff tried to keep an eye on him every 15 minutes. V1 stated R1 was sent to a psychiatric inpatient unit on 10/10/24 and will not be allowed to return to the facility as he is not appropriate for the facility due to his behavior. On 10/24/24 at 9:25am, V14 stated he began taking care of R1 when R1 was admitted to the facility. V14 stated when staff made him aware of R1's sexual acting out behaviors, he had tried adjusting some of R1's psychotropic medications, but the behavior continued and R1 was placed inpatient for psychiatric treatment, where he remains. V14 stated R1 has proved to be inappropriate to be a resident at the facility due to his behaviors. V14 stated R1 was confused at times, but his behavior seemed manipulative in that he seemed aware enough to target confused residents. On 10/22/24 at 10:25am, V13 (LPN) stated that on 9/23/24, she saw R2, who is alert only to self, self-propelling in her wheelchair toward R1. After a few seconds she realized they were too close to each other, so she walked over to intervene and saw R1 taking his hand out from under R2's shirt. V13 stated R2 did not display any reaction. V13 stated she went to V1, Administrator, and reported what she saw. V13 stated she and V1 reviewed security camera footage which clearly showed R1 first placing his hand on R2's breast on top of R2's clothing, and then reaching under R2's shirt and touching R2's breast. V13 stated she had never witnessed any previous peer to peer behavior from R1, although he was verbally sexually inappropriate with staff. V13 stated she thinks after that, R1 was then placed on every 15-minute checks, for how long, she was not sure. V13 stated on 9/26/24, she witnessed R1 attempt to lift R3's shirt. V13 stated the residents were redirected, but she did not report this to V1 as potential abuse. V13 stated on 9/27/24, she witnessed R1 hug R3, and V15, LPN, who was close by, could see from where V15 was standing that R1 had touched R3's breast. V13 stated R3 is alert only to herself. V13 stated V13 and V15 reported the incident to V1, and the intervention to prevent further contact between the two was to move R3 to a different hall, and staff were told by V1 to, Keep an eye on the two of them to make sure they weren't together. V13 stated R1 was masturbating in his room frequently with the door open and would leave his room unclothed and had to be redirected. V13 stated she thought at some point a support staff member had been assigned to sit outside R1's doorway for one shift. V13 stated, We didn't have enough staff to keep (R1) away from female residents. V13 stated she told V1, Administrator, that R1 needed one to one monitoring, and V1 said they didn't have enough staff for that, And we should just try our best to watch him. V13 stated there are frequently two nurses and two CNAs on day shift (6am to 6pm) for the whole building of 40 plus residents. V13 stated CNA's are quitting because they are tired of working short staffed, and V13 stated she put in her two week notice today. V13 stated, (R1) posed a threat to our female residents, it made me feel awful to know we couldn't do enough to protect them, and it's part of the reason I'm leaving. The facility's Abuse Prevention Policy dated 8/16/19 documented, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. The Immediate Jeopardy that began on 9/23/24 was removed on 10/22/24 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review: The Facility has implemented and educated staff on its Abuse Policy, including effective, individualized interventions for all residents displaying inappropriate sexual behavior. All staff and department heads have been educated to ensure if there are reports of inappropriate sexual behaviors, they are to be immediately reported to their Administrator and individualized interventions need to be put in place to prevent further altercations. Education was provided by the Director of Operations (V17), and Regional Clinical Director, (V18). In-servicing was started on 10/11/24 with education ongoing. All licensed staff will be educated prior to their next shift. This will be reviewed and verified daily for 2 weeks, and then weekly for 2 months by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide reeducation if deficiencies are recognized. All audits and verifications will be provided to QA team. The facility has incorporated effective monitoring of residents with sexually inappropriate behaviors to ensure all residents remain free of resident to resident abuse. R1 was discharged to a Regional Hospital on 10/10/24. Education for effective monitoring of inappropriate behaviors was provided on 10/11/24 by the Director of Operations and Director of Nursing. All staff will be educated prior to their next shift. This will be reviewed and verified daily for 2 weeks, and then weekly for 2 months by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide re-education if deficiencies are recognized. All audits and verifications will be provided to QA team. All reportables for the past 3 months have been reviewed to ensure there are effective interventions in place and care plans are updated. (10/16/24) This was completed on 10/22/24. R2, (9/24/24) R3 (10/10/24) and R7 (10/16/24) have all had trauma assessments completed and phyco-social follow-up. No negative results noted. This was completed on 10/22/24. This will be reviewed and verified daily for 2 weeks, and then weekly for 2 months by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide re-education if deficiencies are recognized. All audits and verifications will be provided to QA team. The next meeting of the QA Committee is 10/29/24. The QA team was notified of the Immediate Jeopardy on 10/22/24 and the abatement plan that was put into place. The QA team will review the results of the audits, as referenced above, once per week for two weeks, then monthly for two months, to ensure the plan of correction is effective. The next meeting of the QA Committee is 10/29/24.

Based on interview and record review, the facility failed to notify the resident's representatives of peer to peer sexual abuse for two of 11 residents (R3, R7) reviewed for representative notification in the sample of 11. Findings include: R1's Admission Record documented an admitted [DATE] and listed Diagnoses including Atrial Fibrillation, Adjustment Disorder, Alzheimer's Disease, and Chronic Viral Hepatitis C. R1's Minimum Data Set (MDS) dated [DATE] documented that R1 had moderate deficits in cognition, had no deficits in range of motion, and ambulated independently. R1's Care Plan dated 10/11/24 documented, I am demonstrating inappropriate behaviors, exposing privates to female workers, making inappropriate comments to female workers, masturbating in doorway of room, walking around refusing to wear pants ,exposing self, etcetera. 1. R3's Admission Record documented an admitted [DATE], listed V12 as POA (Power of Attorney), and listed diagnoses including Unspecified Dementia and Diabetes Type 2. R3's MDS (Minimum Data Set) dated 9/18/24 documented that R3 is moderately cognitively impaired and is ambulatory with supervision or touching assistance. R1's Nursing Progress Notes dated 9/26/24, authored by V13, Licensed Practical Nurse, stated,(R1) sitting at nurses station, resident (R3) was standing next to (R1). (R1) attempted to lift (R3) shirt while this writer was walking back up to desk. Behavior was stopped. There was no documentation in either R1 or R3's record that the incident had been reported to V12. On 10/18/24 at 10:20am, V12 stated he was never informed about a male resident trying to lift R3's shirt on 9/26/24. On 10/22/24 at 10:25am ,V13 stated on 9/26/24, she witnessed R1 attempt to lift up R3's shirt. V13 stated she did not report this to V1 as potential sexual abuse, and V12 was not notified. On 10/16/24 at 1:25pm, V1 stated she was not made aware of the 9/26/24 incident as per the Nurses Notes, so an Abuse Investigation was not initiated and V12 was not notified. 2. R7's Admission Record documented an admitted [DATE], listed V7 as Responsible Party/Emergency Contact, and listed diagnoses including Unspecified Dementia. R7's MDS dated [DATE] documented that R7 is severely cognitively impaired and ambulated independently. On 10/11/24 at 3:05pm, V10, Certified Nursing Assistant (CNA), stated that sometime during the week of 9/29/24, R1 started displaying a behavior of lying on his bed, unclothed, masturbating, with the door open. V10 stated one day during that week, date unknown, she had to redirect R1 every few minutes to close the door, but when she walked away he would open it again. V10 stated R7 was ambulating by R1's room, and R1 had the door open again. V10 stated R7 looked into the room as she walked by and R1 made sexual comments directed at R7 and beckoned R7 to come into the room and engage in sexual activity. V10 stated R7 was visibly upset. V10 stated she re-directed both residents and informed her charge nurse what happened, and stated she cannot remember who the charge nurse was that day. V10 stated she believes the charge nurse went to V1's (Administrator) office to inform her of the incident. There was no documentation in either R1 or R7's chart documenting the above referenced incident on the week of 9/29/24, nor any documentation that V7 was notified. On 10/16/24 at 10:05am, V1 confirmed she is the facility's Abuse Coordinator. V1 stated staff did not report the incident the week of 9/29/24 with R7 walking by R1's room as stated above. V1 stated she therefore would not have notified V7. V1 stated when staff witness or hear about abuse they are to report it to her immediately, and the POA is notified. On 10/16/24 at 3:55pm, V7 stated he was unaware of the incident on the week of 9/29/24 as per V10's report. The facility's undated Resident Notification of Changes Guide Policy stated, A facility must immediately inform the resident; Consult with the resident's Physician; And notify, consistent with his or her authority, the residents representative(s) when there is, A. An accident involving the resident which results in injury and has the potential for requiring Physician intervention. B. A significant change in the residents physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life threatening condition or clinical complications.

Based on interview and record review, the facility failed to report peer to peer sexual abuse to the Administrator for three residents (R1, R3, R7) of eleven residents reviewed for abuse in the sample of eleven. Findings include: 1. R1's Nursing Progress Notes dated 9/26/24, authored by V13, Licensed Practical Nurse, stated,(R1) sitting at nurses station, resident (R3) was standing next to (R1). (R1) attempted to lift (R3) shirt while this writer was walking back up to desk. Behavior was stopped. There was no documentation in either R1 or R3's record that the incident had been reported to the facility's Abuse Coordinator, nor investigated. R1's Admission Record documented an admitted [DATE] and listed Diagnoses including Atrial Fibrillation, Adjustment Disorder, Alzheimer's Disease, and Chronic Viral Hepatitis C. R1's Minimum Data Set (MDS) dated [DATE] documented that R1 had moderate deficits in cognition, had no deficits in range of motion, and ambulated independently. R1's Care Plan revised 10/11/24 documented, I am demonstrating inappropriate behaviors, exposing privates to female workers, making inappropriate comments to female workers, masturbating in doorway of room, walking around refusing to wear pants,exposing self, etcetera. R3's Admission Record documented an admitted [DATE] and listed diagnoses including Unspecified Dementia and Diabetes Type 2. R3's MDS dated [DATE] documented that R3 is moderately cognitively impaired and is ambulatory with supervision or touching assistance. On 10/16/24 at 1:25pm, V1, Administrator stated V1 stated she was not made aware of the 9/26/24 incident where R1 attempted to lift R3's shirt, so an Abuse Investigation was not initiated. On 10/22/24 at 10:25am V13 stated on 9/26/24, she witnessed R1 attempt to lift up R3's shirt. V13 stated she did not report this to V1 as potential sexual abuse. V13 stated abuse should be immediately reported to V1. 2. On 10/11/24 at 3:05pm, V10, Certified Nursing Assistant, stated that sometime during the week of 9/29/24, R1 started displaying a behavior of lying on his bed, unclothed, masturbating, with the door open. V10 stated one day, date unknown, she had to redirect him every few minutes to close the door, but when she walked away he would open it again. V10 stated R7 was ambulating by R1's room, and R1 had the door open again. V10 stated R7 looked into the room as she walked by and R1 made sexual comments directed at R7 and beckoned R7 to come into the room and engage in sexual activity. V10 stated she redirected both residents and informed her charge nurse what happened, and stated she cannot remember who the charge nurse was that day. V10 stated she believes the charge nurse went to V1's office to inform her of the incident. R7's Admission Record documented an admitted [DATE] and listed diagnoses including Unspecified Dementia. R7's MDS dated [DATE] documented that R7 is severely cognitively impaired and ambulates independently. On 10/16/24 at 10:05am, V1, Administrator confirmed she is the facility's Abuse Coordinator. V1 stated nobody told her about the incident the week of 9/29/24 with R7 walking by R1's room as stated above. V1 stated when staff witness or hear about abuse they are to report it to her immediately. The facility's Abuse Prevention Policy dated 8/16/19 documented, V. Internal Reporting Requirement and Identification of Crimes of Abuse. Employees are required to report any incident, allegation or suspicion of crime or potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator.

Based on interview and record review, the facility failed to provide effective behavior interventions for 1 of 11 residents (R1) reviewed for behaviors in the sample of 11. Findings include: R1's Admission Record documented an admitted [DATE] and listed Diagnoses including Atrial Fibrillation, Adjustment Disorder, Alzheimer's Disease, and Chronic Viral Hepatitis C. R1's Minimum Data Set (MDS) dated [DATE] documented that R1 has moderate deficits in cognition, and ambulates independently. An Illinois Department of Public Health (IDPH) Final Report dated 10/4/24 stated, On 9/23/24 at approximately 12:55pm this afternoon, (V1, Administrator) notified that resident (R1) made unwanted contact toward resident (R2) It was witnessed by (V13, Licensed Practical Nurse/LPN), that R1 lifted the shirt of R2 and touched her breast. Residents were immediately separated, and (V1) was notified. Nurse assessment completed, noting no issues. (R2) was interviewed, and she could not give any details of such incident and states she doesn't know what we were talking about. (V1) and (V4, Social Services Designee), interviewed (R1) with his sister present and (R1) reports not remembering this and that he doesn't touch women that way. His roommate, (R5) was interviewed, and he stated he could hold a conversation with (R1) on certain days and on other days he does not make any sense. Conference with (V14, R1's Physician) and a thorough chart review, assessment, and medication review was completed. (V14) decided to make changes to (R1's) medications. (V14) feels that (R1's) medication changes need time to become therapeutic. (V4) will meet with (R1) three times a week to facilitate and guide socially appropriate conversations and behaviors between residents and keeping him engaged in a meaningful activity. (R1)'s behaviors will continue to be monitored, and (V14) will review on an ongoing basis to determine if any changes need to be made. One to one activity with (R1) will be increased. (V4) will meet with (R2) 2 times weekly for 2 weeks to ensure she does not experience any adverse effects and continues to feel safe at the facility. Both residents are doing well at this time and have had no adverse effects from this incident. (V14), Police, and Ombudsman all notified of this conclusion. An IDPH Final Report dated 10/4/24 stated, On 9/27/24 at approximately 2:55pm, (V1) notified that (R1) made unwanted contact toward resident (R3) It was witnessed by (V13), (R1) was hugging (R3) in the hall and then (R1) grabbed (R3)'s breast. Residents were immediately separated and (V1) was notified. Nurse assessment completed noting no issues. (R3) was interviewed, and she could not give any details of such incident and states she doesn't know what we are talking about. (R1) was sent to (a local hospital) for a psychological evaluation. (R1) received evaluation form (local counseling center) and he did not meet the requirements (for inpatient psychiatric referral). (Counseling center) wants to do outpatient therapy. Labs for (R1) were positive for Covid and Marijuana. (V4) will continue to meet with (R1) three times a week to facilitate and guide socially appropriate conversations and behaviors between residents and keeping (R1) engaged in a meaningful activity. (R1's) behaviors will continue to be monitored, and (V14) will review on an ongoing basis to determine if any changes need to be made. (V4) will meet with (R3) two times weekly for two weeks to ensure she does not experience any adverse effects and continues to feel safe at the facility. An IDPH Final Report dated 10/17/24 stated, On 10/9/24 at approximately 4:00pm this afternoon, (V1) notified that (R1) made unwanted contact toward (R6). No injuries noted to either resident. On October 10th 2024 at 6:30pm, (R1) was sent to (inpatient psychiatric facility) via the facility van for a psychological evaluation. (R1) is still an inpatient of (inpatient psychiatric facility) at the time of this final report. R1's Physicians Orders for September 2024 documented the following: Increased supervision every 15 minutes, order date 9/24/24. Citalopram 20mg. (milligrams) give one tablet at bedtime, start date 9/24/24. Citalopram (increase to) 30 mg give one tablet at bedtime, order date 9/27/24. Quetiapine 25mg. one tablet at bedtime, order date 9/13/24. Quetiapine 25mg. (increase to) two tablets at bedtime, order date 9/24/24. Quetiapine 25mg. (add) one tablet every morning, order date 9/27/24. A Physicians Progress Note dated 9/24/24, authored by V14, stated, New resident to nursing home. He has a history of Dementia, Depression, recent Renal Insufficiency, Hypertension, GERD (Gastro-Esophageal Reflux) Hyperlipidemia, Gout, Atrial Fibrillation. Has been having issues in the nursing home since arriving inappropriately touched a female patient. Plan: Citalopram 20 mg. daily with Seroquel 50mg. daily for depression. and to control inappropriate sexual activity. R1's Current Care Plan last revised 10/11/24 documented, I am demonstrating inappropriate behaviors, exposing privates to female workers, making inappropriate comments to female workers, masturbating in doorway of room, walking around refusing to wear pants, exposing self, etc, with a date initiated as 9/24/24. Interventions/Tasks include: 10/10/2024 Resident was transferred to (regional psychiatric inpatient facility, ER). 10/9/24 Denied admittance by (geropsych regional hospital). 9/23/24 Medication change by MD. Family approved. 9/27/24 Resident was sent to (local hospital ER) for evaluation. Returned 9/28/24 positive for Covid. Psych Eval done from (local mental health center) and recommended outpatient therapy with (health agency). Care plan meeting held with POA 10/7/2024 related to inappropriate behaviors. POA wants to do Medication changes first. Denied admittance to (behavioral health inpatient facility): Date initiated 10/9/24. Increased supervision: Date initiated 9/24/24. Referral was sent to (regional psychiatric inpatient facility): Date initiated 10/9/24. R1's Nursing Progress Notes documented the following: 9/23/24: Resident was observed inappropriately lifting a residents shirt and touching her breast. Resident is being kept away from female resident at this time. 9/24/24: Sexually inappropriate toward staff. 9/24/24: This AM staff was in residents room changing bed linens. Staff glanced over and resident was masturbating. Staff redirected resident to close his curtain and the door for privacy. 9/26/24: Resident sitting at nurses station. (R3) was standing next to resident. Resident attempted to lift (R3's) shirt while this writer was walking back up to the desk. Behavior was stopped. 9/27/24: Resident was seen hugging (R3). Staff was telling resident to stop touching her. Resident proceeded to grab (R3's) breast. He was also telling her that he is her husband. Resident was redirected to his room, he is now in his bed resting. 9/27/24: Per (V2, Director of Nurses), send to ER for psychiatric evaluation. 9/28/24: Resident arrived back at the facility at 11:10 from (ER). Resident tested positive for Covid and is on isolation. Resident also tested positive for marijuana. POA (Power of Attorney) believes he used substances before coming to facility. Resident arrived at facility on 9/13/24 so it still could be in his system. Resident received a psychiatric eval from (local mental health center), he did not meet requirements (for inpatient treatment) but they would like to do outpatient therapy with him. Must call Monday to schedule a follow up appointment to be scheduled after patient is off isolation Resident stated that he is depressed from being in the nursing home and not having his dog. Resident stated that he understands that his behaviors have not been right and he will not treat other residents inappropriately. Order to increase Citalopram, spoke with (V14) and POA, order placed. (V14) would also like a second dose of Seroquel 25 milligrams given in the morning. Order placed. 10/6/24: This nurse took resident his evening meds when resident was noted to be masturbating. Resident stated, 'Give me some pu**y' This nurse explained to resident that behavior was inappropriate. 10/7/24: Activity Director was helping pass breakfast trays and went into this resident's room, resident told Activity Director to lay down in bed so he could feel her breast, admin went into residents room and told resident that behavior was inappropriate. This nurse contacted POA, POA will be coming to facility to have meeting with administrative staff. 10/7/24: (V1 and V4) had a care plan meeting with this residents POA. We discussed the inappropriate sexual behaviors this resident had been exhibiting. POA decided she wanted to try and change a couple of medications first. We informed the nurses on shift of what POA had decided to do. We discussed with POA about how this behavior is highly inappropriate and the next steps if it continues. POA said whatever we had to do, they were ok with. Resident will be monitored on this medication to see if behaviors decline. 10/7/24: ST (Speech Therapist) attempted to see patient for therapy in room with Occupational Therapy present during therapy attempt. Patient refused treatment and said he 'wanted to have fun' and exposed groin area to therapists and began masturbation. Therapists attempted to redirect patient with no success and patient educated on appropriate behavior during therapy interventions. Administrator and nursing staff notified of this interaction. 10/7/24: Resident has been inappropriate with staff all day. Everytime a staff walks past his room or into his room he begins to masturbate in front of them. Stands in his doorway doing the same in front of female residents. We have attempted to keep door closed but resident keeps opening door and masturbating. He has tried to touch staff in sexual ways and we are keeping certain residents away from him R/T (related to) other incidents. MD was notified and awaiting reply. 10/7/24: Resident was walking in hallway in gown flashing female staff members with his penis and buttocks. This nurse and another CNA went to redirect resident and informed him he needed to be covering himself up with pants when walking through the hallways. Resident went back into room, laid down on his bed and starting masturbating while this nurse and other CNA were in room. 10/8/24: Resident continues to come out into doorway of room masturbating, asking all female CNAs to come closer to him. Redirection has continued to fail. 10/9/24: Resident has been awake almost the entire shift. Resident has been in and out of his room with no pants on holding his penis numerous times. Resident has stated to female CNA, 'come here, you want to f**k' and touched another female CNA on the butt. Resident has been redirected back to room to put pants on but will not comply. Continues to go into female rooms. 10/9/24: This nurse was in residents room trying to get him to put pants on, resident then said, 'You should be scared of me. Show me your t**s, a**, and pu**y.' Nurse finished assisting resident with putting his pants on and left the room. 10/9/24: CNA reported to DON that this resident was in the hallway asking for a specific female resident. CNA redirected resident to his room. 10/9/24: CNA informed DON that resident came out of his room completely naked and was quickly redirected and instructed to put his clothes back on. 10/9/24: This resident was seen by (V23, Laundry Aid) touching (R6) in perineal area above pants. (V23) redirected resident out of room. 10/10/24: Called and gave report about resident to (regional psychiatric inpatient facility). 10/10/24: (V1 and V4) transported this resident to (regional psychiatric inpatient facility). Review of R1's 15 Minute Checks Log Documents showed the following: 9/23/24: No documentation. 9/24/24: No documentation. 9/25/24: Checked every 15 minutes. 9/26/24: Checked every 15 minutes. 9/27/24: Checked every 15 minutes. 9/28/24: No documentation from 3:45pm to 6:00pm. 9/29/24: No documentation from 2:15pm to 6:00pm. 9/30/24: No documentation. 10/1/24: No documentation from 6:15am to 6:00pm. 10/2/24: No documentation from 6:15am to 5:45pm. 10/3/24: No documentation from 6:15am to 6:00pm. 10/4/24: No documentation. 10/5/24: No documentation. 10/6/24: No documentation. 10/7/24: No documentation. 10/8/24: No documentation from 6:15am to 5:45pm. 10/9/24: No documentation. 10/10/24: No documentation. There was no documentation in R1's record to indicate he had received one to one monitoring. On 10/11/24 at 2:30pm V8, Certified Nursing Assistant (CNA), stated she was aware from reports of other staff that R1 had sexual acting out behavior toward female peers, but she had never personally witnessed it. V8 stated R1 was ambulatory, wanders, and was confused at times. V8 stated R1 frequently had to be redirected from getting into peers rooms. V8 stated she was not aware of R1 ever being put on 15 minute checks or one to one monitoring. V8 stated, We just tried to watch him as best as we could. On 10/11/24 at 2:55pm, V9, CNA, stated on numerous occasions, R1 would come out of his room naked with an erection and require redirection. V9 stated R1 was, Very ambulatory, and very fast, and sometimes we didn't have enough staff to keep up with him. V9 stated to her knowledge, R1 was never on one to one monitoring. V9 stated she thinks after one of R1's episodes of acting out he was placed on 15-minute checks for 24 hours. V9 stated interventions for R1's behavior were to, Redirect him as best they could with snacks or activities. On 10/11/24 at 3:05pm, V10, CNA, stated that sometime during the week of 9/29/24, R1 started displaying a behavior of lying on his bed, unclothed, masturbating, with the door open. V10 stated one day that week, date unknown, she had to redirect him every few minutes to close the door, but when she walked away he would open it again. V10 stated R7 was ambulating by R1's room, and R1 had the door open again. V10 stated R7 looked into the room as she walked by and R1 made sexual comments directed at R7 and encouraged R7 to enter the room and engage in sexual activity. V10 stated she redirected both residents, and that R7 was upset. V10 stated she reported this to her charge nurse, she cannot remember whom, and that person went to V1's office to report the incident. V10 stated that to her knowledge, R1 was not at any time placed on 15-minute checks or one to one monitoring. V10 stated that R1 was ambulatory and fast moving, Especially when we only have 2 CNAs for the whole building, let alone did we not have extra staff to do one on one (monitoring) with him. I felt (R1) was dangerous to be around our female residents, many of them are confused and can't consent (to sexual activity) and they are too weak to fight him off. On 10/15/24 at 9:50am, R5 was alert and oriented. R5 stated he was previously roommates with R1. R5 stated maybe a month ago, R3 wandered into their room, and R1 was asking her to come over to his bed, but R3 wandered back out. R5 stated he doesn't recall telling staff about it, and he could not say for sure why R1 beckoned R3 to the bed. R5 stated R1 was moved to a different room, shortly after, but at no time had R5 ever seen staff with R1 one to one or doing frequent checks with him. R5 then stated, I think they tried to keep an eye on him as best they could, and I heard them frequently holler at him to stop. R5 stated there are only a few men on A hall where R5's room is, most are confused or bedridden females. R5 stated R1 was, At times totally with it, but other times really confused. R5 stated one night about midnight, a couple of weeks ago maybe, he saw R1 standing in the A hall at the end closest to the dining room, no staff were present. R5 stated it looked like he was stalking somebody or hiding, he was up against the wall, with his palms flat to the wall, like he was trying to go unnoticed. R5 stated, I said (R1) what are you doing, and he said, I'm lost and need to go to the bathroom, so I showed him where it was, but he already knew where the bathroom was. At that time they had already moved him from my room to one across the hall. R5 stated he did not inform staff of this incident. R5 stated R1 had also been frequently walking out of his room naked despite staff redirecting him. On 10/15/24 at 2:10 pm, V4 (Social Services Designee) stated when R1 was initially admitted to the facility, he did not display any behaviors. V4 stated the first episode staff had witnessed was on 9/23/24 when R1 touched R2's breast. V4 stated she attempted meeting with R1 after this incident, but he was sexually suggestive and could not be redirected. After the 9/27/24 incident when R1 grabbed R3's breast, V4 stated she started seeking inpatient psychiatric placement for R1 but received several denials as, since he was not suicidal or homicidal, he was not appropriate for that level of care. When asked about behavior interventions for R1, V4 stated, We tried to redirect him, offer food or drinks, and tried to check on him every 15 minutes. But we didn't have enough staff to watch him honestly. He would sneak out of his room when the CNAs weren't watching him. V4 stated at one point we did have a male receptionist sit outside his door, over a weekend, but couldn't remember which weekend. V4 stated when R1 was admitted to a psychiatric unit on 10/10/24, V4 and V1 transported him in the facility van, while R1 masturbated and made sexual comments the entire trip and could not be redirected. V4 stated she has met with R2, R3, and R6 and completed trauma assessments on each one, and they have shown no signs of after affects from the abuse. On 10/16/24 at 1:25pm, V1 stated that after V13 reported the incident between R1 and R2 on 9/23/24 she notified all staff that R1 and R2 were to be kept apart and if seen together, to take them to their respective rooms. V1 stated V14 changed some of R1's psychotropic medications in response to the incident, and, Staff tried to check on (R1) every 15 minutes. V1 stated when the second incident took place on 9/27/24, R1 was sent to the emergency room and was deflected for inpatient admission. V1 stated while there R1, tested positive for marijuana and Covid, and upon his return, was put in a room by himself on isolation. V1 stated, We tried to have staff sit outside his door if we had enough staff, sometimes we had extra staff who could do this, and sometimes not. Otherwise, staff tried to keep an eye on him every 15 minutes. V1 stated R1 was sent to a psychiatric inpatient unit on 10/10/24, and will not be allowed to return to the facility as he is not appropriate for the facility due to his behavior. On 10/24/24 at 9:25am, V14 stated he began taking care of R1 when R1 was admitted to the facility. V14 stated when staff made him aware of R1's sexual acting out behaviors, he had tried adjusting some of R1's psychotropic medications, but the behavior continued and R1 was placed inpatient for psychiatric treatment, where he remains. V14 stated R1 has proved to be inappropriate to be a resident at the facility due to his behaviors. V14 stated R1 was confused at times, but his behavior seemed manipulative in that he seemed aware enough to target confused residents. On 10/22/24 at 10:25am, V13 (LPN) stated that on 9/23/24, she saw R2, who is alert only to self, self-propelling in her wheelchair toward R1. After a few seconds she realized they were too close to each other, so she walked over to intervene and saw R1 taking his hand out from under R2's shirt. V13 stated R2 did not display any reaction. V13 stated she went to V1, Administrator, and reported what she saw. V13 stated she and V1 reviewed security camera footage which clearly showed R1 first placing his hand on R2's breast on top of R2's clothing, and then reaching under R2's shirt and touching R2's breast. V13 stated she had never witnessed any previous peer to peer behavior from R1, although he was verbally sexually inappropriate with staff. V13 stated she thinks after that, R1 was then placed on every 15-minute checks, for how long, she was not sure. V13 stated on 9/26/24, she witnessed R1 attempt to lift R3's shirt. V13 stated the residents were redirected, but she did not report this to V1 as potential abuse. V13 stated on 9/27/24, she witnessed R1 hug R3, and V15, LPN, who was close by, could see from where V15 was standing that R1 had touched R3's breast. V13 stated R3 is alert only to herself. V13 stated V13 and V15 reported the incident to V1, and the intervention to prevent further contact between the two was to move R3 to a different hall, and staff were told by V1 to, Keep an eye on the two of them to make sure they weren't together. V13 stated R1 was masturbating in his room frequently with the door open, and would leave his room unclothed and had to be redirected. V13 stated she thought at some point a support staff member had been assigned to sit outside R1's doorway for one shift. V13 stated, We didn't have enough staff to keep (R1) away from female residents. V13 stated she told V1, Administrator, that R1 needed one to one monitoring, and V1 said they didn't have enough staff for that, And we should just try our best to watch him. V13 stated there are frequently two nurses and two CNAs on day shift (6am to 6pm) for the whole building of 40 plus residents. V13 stated CNA's are quitting because they are tired of working short staffed, and V13 stated she put in her two week notice today. V13 stated, (R1) posed a threat to our female residents, it made me feel awful to know we couldn't do enough to protect them, and it's part of the reason I'm leaving. On 10/23/24 at 1:50pm,V23 stated on 10/9/24 she was going room to room check for laundry and witnessed R1 in R6's room. V23 stated R1 was rubbing R6's crotch area over top of her clothing, and R1 was not wearing pants. V23 stated this was reported to V1. The facility's Behavioral Assessment, Intervention and Monitoring Policy dated March 2019 stated, The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm.

Based on observation, interview and record review, the facility failed to provide a sufficient amount of staff to ensure residents receive showers, and assistance with care. These failures have the potential to affect all 45 residents living in the facility. Findings include: Resident Matrix dated 10/2/2004 documents there are 45 residents living in the facility. 1. On 10/3/24 at 2:39pm, R5 stated his care is pretty good here. R5 stated he wasn't sure if he got showers like he was supposed to, but they keep him clean. R5 stated they need some more staff badly. R5 stated they are a little slow on the lights, but it is more of an issue at night. R5 stated if you are in the bathroom, the staff are quick to respond, but the regular room lights not so much. R5 stated he is supposed to call for help to transfer, especially to the bathroom, but sometimes he just can't wait on them any longer. R5 stated he even has a sign in his bathroom that says he should call for help. R5 stated he did have a recent fall, he was trying to transfer out of his bed to go to the bathroom and slid in between the bed and chair. R5 stated he was not injured, and it has happened multiple times before. R5's admission record documents an admitted [DATE] with diagnoses in part; abnormalities of gait and mobility, dermatitis, insomnia, chronic pain syndrome, vitamin D deficiency, muscle weakness and constipation. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating that R5 is cognitively intact. R5's MDS documents in section GG- R5's current care plan documents that R5 is at risk for falls and is to ask for staff assistance with toileting. An incident report in R5's medical record for an unwitnessed fall on 09/26/24, documents that R5 slipped trying to get out of bed. R5's Order Summary Report documents R5's shower days are Tuesdays and Fridays. R5 has a document titled Skin Observation: Comprehensive shower review for Tuesday 9/3/24 and Thursday 9/12/24 (refusal). No documentation of showers or refusals were found for the following shower days; Fri 9/5, Tues 9/10, Tues 9/17, Fri 9/19, Tues 9/24, Fri 9/28. 2. R4's admission record documents an admitted [DATE], with diagnoses in part; Alzheimer's disease, late onset, Unspecified dementia, depression, dizziness, delusional disorders and vertigo. R4's current care plan documents that she is at risk for falls, has behaviors and is totally dependent on staff for Completing ADL's. R4's shower days documented in is Summary Order Report are Wednesdays and Saturdays. R4 has a document titled Skin Observation: Comprehensive shower review for Saturday 9/14/24 (bed bath) and Saturday 9/28/24. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat, 9/7, Wed 9/11, Wed 9/18, Sat 9/21, Wed 9/25. 3. R6's admission record documents an admitted [DATE] with diagnoses in part cognitive communication deficit, abnormalities of gait and mobility, need for assistance with personal care, unsteadiness on feet, vascular dementia, osteoarthritis and muscle weakness. R6's Minimum Data Set (MDS) dated [DATE], documents a Brief interview for mental status (BIMS) of 2, indicating that R6 is severely cognitively impaired. Section GG documents R6 requires assistance for transfers and is dependent on staff for Toileting hygiene and bathing. R6's Order Summary Report documents R6's shower days are Wednesday and Saturday. R6 has a document titled Skin Observation: Comprehensive shower review for Wed 9/4, Wed 9/11, Sat 9/14, Wed 9/18 and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Sat 9/7, Sat 9/21, Weds 9/25. 4. R7's admission record documents an admitted [DATE] with diagnoses in part; urinary tract infection, acute kidney failure, osteoarthritis, urinary incontinence and pain in unspecified joint. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief interview for mental status (BIMS) of 00, indicating that R7 is severely cognitively impaired. Section GG documents that R7 requires assistance with toileting hygiene and showering/bathing, dressing and personal hygiene. R7's Order Summary Report documents R7's shower days are Wednesday and Saturday. R7 has a document titled Skin Observation: Comprehensive shower review for Fri 9/13, Sat 9/14, and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat 9/7, Wed 9/18, Sat 9/21 and Wed 9/25. R7's progress notes document the following, 10/2/2024 2:47pm, SHOWER EVERY WEDNESDAY, SATURDAY. one time a day every Wed, Sat for STANDING ORDER. Bed bath short staffed. On 10/2/2024 at 9;03am, R7 was observed sitting in her chair, in clean dry clothing, her hair appeared dirty and unkept and she was only wearing one sock. On 10/2/24 at 9:08am, R1 who was alert to person place and time stated her care is fine. She stated she feels like it takes a little longer to get help, but they take great care of her here. On 10/02/24 at 1:05pm, R3 stated she was looking for someone to help her. R3 stated she's always trying to find someone to help her. R3 appeared to be alert to person only. On 10/2/24 at 1:06pm, R2 who was alert to person, place and time stated the staff here tries to help him as much as they can. R2 stated sometimes it takes them a little while to get to him, but they do a good job helping him. R2 stated there's not a lot of them to go around. On 10/2/24 at 1:13pm, R8 who was alert to person, place and time stated, you don't want to ask me about the staff. R8 stated they are always busy. On 10/2/24 at 9:11am, V3 (Licensed Practical Nurse/LPN) stated lately on a normal day they only have three CNA's (Certified Nursing Assistant) but sometimes they only have two. V3 stated it has been a problem for a while, but it's definitely gotten worse since COVID has hit the building. V3 stated that there are 12 or 13 residents who require total assistance with meals and a lot of residents with behaviors who require one on one supervision. V3 stated it's just hard for the CNA's to get everything done let alone with all that on top of it. V3 stated she can usually assist the CNA's with some of their duties and still complete her own. But everyone is stretched thin right now and any little bump in the road can change that. V3 stated that V1 (Administrator) and V5 (Social Services Director) are always out on the floor helping them as much as they can, V2 (DON) not so much. V3 stated she had mentioned to V1 about how another facility offers incentive bonuses or sign on bonuses and she had spoken with several people in corporate and it never went anywhere. On 10/2/24 at 9:21am, V6 (CNA) stated lately she has been the only CNA to show up the past three mornings, midnights does stay and help though, So does V1 and V5. V6 stated they barely get breaks and if they get a lunch, it usually isn't until 2 or 3pm, her shifts are 6a-6p. V6 stated at this moment there are only 2 CNA's that are assigned to the floor in the building. V6 stated they barely have time to give showers, that they have been having to wash people up in bed. V6 stated that they make sure that everyone is clean though. V6 stated they are supposed to complete shower sheets for showers and refusals. V6 stated that V1 and V5 were always on the floor trying to help them. On 10/2/24 at 12:56pm, V3 and V4 were observed trying to make calls to get staff to cover the next shift. V3 and V4 stated that residents have scheduled shower days and staff are expected to fill out shower sheets when they give residents a shower and for a refusal. On 10/2/24 at 1:29pm, V1 (Administrator) stated she tries to do what she can to get more staff in here. V1 stated from what she has heard from staff about other facilities, their wages are not competitive to bring in new staff or retain current staff. On 10/3/24 at 10:49am, V7 (CNA) stated most days it is hard to get everything done. V7 stated there are several days she has worked the A hall by herself, she stated that hallway is the heaviest hallway and many of the residents often require the assistance of two people. V7 stated there are a lot of people in the building that require lots of assistance and plenty of people with behaviors. V7 stated she was not here for the past two weeks, but it just keeps getting worse and worse. V7 stated V1 (Administrator) and V5 (Social Services Director) are always trying to help how they can. V7 stated V2 (Director of Nursing/DON) will not leave the office unless he has a question for someone. V7 stated if you ask V2 for help, he will tell you to go find a CNA. V7 stated V2 will not even help the nurses. On 10/3/24 at 10:51am, V8 (CNA) stated they are always short staffed, it just keeps getting worse. V8 stated she is a PRN (as needed) employee, and they are constantly calling her to cover shifts. V8 stated that it is hard to complete job duties but that they try to make sure everyone is clean and taken care of the best we can. On 10/3/24 at 11:00am, V9 (Family Member) stated they do not have enough CNA's to go around here. V9 stated on two occasions, R9 sat for over 4 hours in wet pants. V9 stated both times she left and alerted staff to it and when she came back he was still in the same wet pants. V9 stated that the CNA's do all that they can, she stated they will literally bend over backwards for us but there just is not enough to go around. V9 stated that if it wasn't for her children, she would have already moved R9. V9 stated in the beginning of his stay in August, she did not feel like he was very clean. But now she has no complaints about it, his face and hair look clean everyday she comes in, she stated she wishes incontinence care was a little better. On 10/3/24 at 2:00pm, it was observed that there were only 2 CNA's in the building and on the floor. On 10/2/24 at 2:10pm, V1 stated that there is no policy specific to call ins. V1 stated it is a known practice that it is all hands on deck, management, and everyone, we do our best to try to call people in, but everyone has something going on or they are tired. A review of Nursing and CNA schedules from 09/11-10/08 revealed instances where there were only 2 CNA's on the floor for two or more hours on the following days; 9/20, 10/01, 10/3. There was only one CNA on the floor on 9/30 from 6:00am to 2:00pm.

Based on interview, observation, and record review, the facility failed to provide dependent residents timely ADL (Activities of Daily Living) assistance for 5 of 7 residents (R4, R5, R6, R7, R9) reviewed for ADL assistance in the sample of 9. Findings include: 1. R4's admission record documents an admitted [DATE], with diagnoses in part; Alzheimer's disease, late onset, Unspecified dementia, depression, dizziness, delusional disorders and vertigo. R4's Minimum Data Set (MDS) dated [DATE], records a Brief Interview for Mental Status (BIMS) of 9, indicating that R4 is mildly cognitively impaired. R4's current care plan documents that she is at risk for falls, has behaviors and is totally dependent on staff for Completing ADL's. On 10/02/2024 at 9:16am, an attempt to interview R4 was made and R4 was not interviewable. R4's shower days documented in is Summary Order Report are Wednesdays and Saturdays. R4 has a document titled Skin Observation: Comprehensive shower review for Saturday 9/14/24 (bed bath) and Saturday 9/28/24. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat, 9/7, Wed 9/11, Wed 9/18, Sat 9/21, Wed 9/25. 2. R5's admission record documents an admitted [DATE] with diagnoses in part; abnormalities of gait and mobility, dermatitis, insomnia, chronic pain syndrome, vitamin D deficiency, muscle weakness and constipation. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating that R5 is cognitively intact. Section GG documents he is independent with toileting hygiene and bathing but requires assistance with transferring. R5's current care plan documents that R5 is at risk for falls and is to ask for staff assistance with toileting. R5's Order Summary Report documents R5's shower days are Tuesdays and Fridays. R5 has a document titled Skin Observation: Comprehensive shower review for Tuesday 9/3/24 and Thursday 9/12/24 (refusal). No documentation of showers or refusals were found for the following shower days; Fri 9/5, Tues 9/10, Tues 9/17, Fri 9/19, Tues 9/24, Fri 9/28. On 10/3/24 at 2:39pm, R5 stated his care is pretty good here. R5 stated he wasn't sure if he got showers like he was supposed to, but they keep him clean. R5 stated they need some more staff badly. R5 stated they are a little slow on the lights, but it is more of an issue at night. R5 stated if you are in the bathroom, the staff are quick to respond, but the regular room lights not so much. R5 stated he is supposed to call for help to transfer, especially to the bathroom, but sometimes he just can't wait on them any longer. R5 stated he even has a sign in his bathroom that says he should call for help. R5 stated he did have a recent fall, he was trying to transfer out of his bed to go to the bathroom and slid in between the bed and chair. R5 stated he was not injured, and it has happened multiple times before. An incident report in R5's medical record for an unwitnessed fall on 09/26/24, documents that R5 slipped trying to get out of bed. 3. R6's admission record documents an admitted [DATE] with diagnoses in part cognitive communication deficit, abnormalities of gait and mobility, need for assistance with personal care, unsteadiness on feet, vascular dementia, osteoarthritis and muscle weakness. R6's Minimum Data Set (MDS) dated [DATE], documents a Brief interview for mental status (BIMS) of 2, indicating that R6 is severely cognitively impaired. Section GG documents R6 requires assistance for transfers and is dependent on staff for Toileting hygiene and bathing. R6's Order Summary Report documents R6's shower days are Wednesday and Saturday. R6 has a document titled Skin Observation: Comprehensive shower review for Wed 9/4, Wed 9/11, Sat 9/14, Wed 9/18 and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Sat 9/7, Sat 9/21, Weds 9/25. 4. R7's admission record documents an admitted [DATE] with diagnoses in part; urinary tract infection, acute kidney failure, osteoarthritis, urinary incontinence and pain in unspecified joint. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief interview for mental status (BIMS) of 00, indicating that R7 is severely cognitively impaired. Section GG documents that R7 requires assistance with toileting hygiene and showering/bathing, dressing and personal hygiene. R7's Order Summary Report documents R7's shower days are Wednesday and Saturday. R7 has a document titled Skin Observation: Comprehensive shower review for Fri 9/13, Sat 9/14, and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat 9/7, Wed 9/18, Sat 9/21 and Wed 9/25. R7's progress notes document the following, 10/2/2024 2:47pm, SHOWER EVERY WEDNESDAY, SATURDAY. one time a day every Wed, Sat for STANDING ORDER. Bed bath short staffed. On 10/92/2024 at 9;03am, R7 was observed sitting in her chair, in clean dry clothing, her hair appeared dirty and unkept and she was only wearing one sock. 5. On 10/3/24 at 11:00am, V9 (Family Member) stated they do not have enough CNA's to go around here. V9 stated on two occasions, R9 sat for over 4 hours in wet pants. V9 stated both times she left and alerted staff to it and when she came back, he was still in the same wet pants. V9 stated that the CNA's do all that they can, she stated they will literally bend over backwards for us but there just is not enough to go around. V9 stated that if it wasn't for her children, she would have already moved R9. V9 stated in the beginning of his stay in August, she did not feel like he was very clean. But now she has no complaints about that, his face and hair look clean everyday she comes in, she stated she wishes incontinence care was a little better. On 10/2/24 at 9:10am, V3 (Licensed Practical Nurse/LPN) stated lately on a normal day they only have three CNA's (Certified Nursing Assistant) but sometimes they only have two. V3 stated it has been a problem for a while, but it's definitely gotten worse since COVID has hit the building. V3 stated that there are 12 or 13 residents who require total assistance with meals and a lot of residents with behaviors who require one on one supervision. V3 stated it's just hard for the CNA's to get everything done with all that on top of it. V3 stated she can usually assist the CNA's with some of their duties and still complete her own, but everyone is stretched thin right now and any little bump in the road can change that. V3 stated that V1 (Administrator) and V5 (Social Services Director) are always out on the floor helping them as much as they can. On 10/2/24 at 9:21am, V6 (CNA) stated lately she has been the only CNA to show up the past three mornings. V6 stated midnights does stay and help though, so does V1 and V5. V6 stated at this moment there are only 2 CNA's that are assigned to the floor in the building. V6 stated they barely have time to give showers, that they have been having to wash people up in bed. V6 stated that they make sure that everyone is clean though. V6 stated they are supposed to complete shower sheets for showers and refusals. V6 stated that V1 and V5 were always on the floor trying to help them. On 10/2/24 at 10:18am, V1 (Administrator) stated that last week was a rough week for CNA's for sure. V1 stated that staff are expected to finish charting, even if they have to stay over, but that patient care comes first. V1 stated at the end of the day, the floor staff has been at it all day for several days and just want to go home. V1 stated showers are to be done twice a week and the scheduled days are in their orders, shower sheets are to be completed. On 10/2/24 at 12:56pm, V3 (LPN) and V4 (LPN) were observed trying to make calls to get staff to cover the next shift. V3 and V4 stated that residents have scheduled shower days and staff are expected to fill out shower sheets when they give residents a shower and for a refusal. On 10/3/24 at 10:49am, V7 (CNA) stated most days it is hard to get everything done. V7 stated there are several days she has worked the A hall by herself, she stated that hallway is the heaviest hallway and many of the residents often require the assistance of two people. V7 stated there are a lot of people in the building that require lots of assistance and plenty of people with behaviors. V7 stated she was not here for the past two weeks, but it just keeps getting worse and worse. V7 stated V1 (Administrator) and V5 (Social Services Director) are always trying to help how they can. V7 stated V2 (Director of Nursing/DON) will not leave the office unless he has a question for someone. V7 stated if you ask V2 for help, he will tell you to go find a CNA. V7 stated V2 will not even help the nurses. On 10/3/24 at 10:51am, V8 (CNA) stated they are always short staffed, it just keeps getting worse. V8 stated she is a PRN (as needed) employee, and they are constantly calling her to cover shifts. V8 stated that it is hard to complete job duties but that they try to make sure everyone is clean and taken care of the best we can. Facility policy titled Bath, Shower/Tub with a revision date of February 2018 documents the following under documentation, If a resident refused the shower/tub bath, the reason(s) why and the intervention taken. It is to be reported to the supervisor if the resident refuses.

Based on observation, interview, and record review, the facility failed to ensure privacy was maintained during personal care services for 2 of 2 residents (R11 and R40) reviewed for privacy in the sample of 25. Findings include: 1. R11's Face Sheet, dated 03/21/24 documents R11 was admitted to the facility on [DATE] with a diagnosis of diagnosis documents Spondylolysis, lumbar region, Depression, unspecified, Hyperlipidemia, unspecified, Benign prostatic hyperplasia without lower urinary tract symptoms, Chronic obstructive pulmonary disease, Anxiety disorder, Hereditary and idiopathic neuropathy, Essential (primary) hypertension, Weakness, Repeated falls, and Obstructive and reflux uropathy. R11's Current Care Plan, documents R11 requires assistance for all ADL'S (Activities of Daily Living) with a start date of 03/09/23, interventions include Refer to Occupational Therapy to work on ADL (Activities of Daily Living) re-training, give verbal cues to help prompt, break tasks up into smaller steps, and allow rest breaks between tasks. R11's Minimum Data Set (MDS), dated [DATE], documents R11 has a Brief interview for Mental Status (BIMS) of 15 which indicates R11 is cognitively intact and is dependent on staff for transfers, toileting, dressing, and personal hygiene. R11 has an indwelling catheter and is always incontinent of bowel. On 03/19/24 at 9:49AM, R11 stated he doesn't like that he doesn't have a privacy curtain in between him and his roommate. R11 said he does have a curtain to block the outside people from looking in but doesn't have anything to separate him and his roommate. R11 said when he gets his bed baths that his roommate can see everything. R11 said that V11 (Housekeeper) told him that the track is broken to the curtain, so she removed the curtain, so the track does not fall down. R11 stated that it doesn't embarrass him when he takes a bed bath in the room and his roommate is in there but that it is more annoying that he must take a bed bath with him in there. On 03/19/24 at 9:52AM while in R11's room it was noted that the track in the middle of the room was hanging down with no curtain on it. On 03/20/24 at 1:15PM, V11 stated that she took down the privacy curtain in R11's room around February, because the track was falling, and the curtain was dragging on the ground. V11 said that she did notify V10 (Maintenance) about taking the track coming off the ceiling and that she removed the curtain. V11 said that V10 told her that he would work on it when he can. V11 said that is the only curtain that she has removed. V11 said there are several other tracks that are coming loose, and she has notified V10 about them. V11 stated she was unaware if V10 has taken care of those tracks or not yet. 2. R40's Face sheet, dated 03/21/24, documents R40 was admitted to the facility on [DATE] with a diagnosis of Cellulitis, unspecified, Personal history of other venous thrombosis and embolism, Opioid abuse, uncomplicated, Generalized anxiety disorder, Other idiopathic peripheral autonomic neuropathy, and Depression. R40's Current Care Plan, documents Self Care deficit with a start date of 10/27/22 with interventions of: assist with ambulation, transfers, and locomotion as needed, assist with dressing/undressing, assist with meals prn (as needed), assist with oral/dental hygiene, and encourage resident to perform self-care if able. R40's Minimum Data Set, dated dated [DATE], documents that R40 has cognitive impairment and is dependent on staff for toileting, transfers, dressing, and bathing. R40 is always incontinent of bowel and bladder. On 03/19/24 at 12:50 PM, R40 who was alert and oriented to person place and time during interview stated that he hasn't had a curtain that divides him from his roommate the entire time he has been in that room. R40 was unsure how long he has been in his current room. R40 said he doesn't have any privacy. R40 said that they perform care on him when his roommate is in the room. R40 said it annoys him that he can't have any privacy. R40 said they don't do anything that allows him privacy when they perform care on him. R40 said that his roommate just sits over there on his bed while he receives care. On 03/19/24 at 12:52PM, while in R40's room there was no curtain track in the room between R40's bed and his roommate bed. There was a curtain that wraps around the door and the window, but nothing in between the two residents in the room to allow privacy for them. On 03/20/24 at 1:30PM, V10 who stated that he was aware that he had a track down in R40's room. V10 said that he ordered a new track and curtain for R40's room and he was supposed to be putting that track and curtain up today. V10 said he wasn't sure how long the track and curtain had been missing from the ceiling in R40's room he thought maybe a couple of days or so. V10 said that he didn't know that R11's curtain was removed, until he observed the curtain being down. V10 said he had forgot V11 did notify him that the track was coming down in R11's and V11 removed the curtain. V10 said that he will work on putting a screw in the track in R11's room and getting it fixed so they can put a curtain back up. On 03/21/24 at 10:30AM, V3 (Director of Operations) provided the maintenance logbook with no evidence of work order for curtain and track repair to R11 and R40's rooms. No evidence noted in maintenance logbook for repair request. Facility Policy Confidentiality of Information and Personal Privacy with a revision date of October 2017 documents under Policy statement Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation states in part: The facility will strive to protect the resident's privacy regarding his and her: medical treatment and personal care.

Based on interview and record review the facility failed to timely perform quarterly Minimum Data Set (MDS) assessments for one of one resident (R149) reviewed for MDS assessments in a sample of 25. Findings include: R149 Face Sheet documents an admitted [DATE] with diagnosis including: Depression, Atrial fibrillation, Anxiety, Disorder, Type 2 Diabetes Mellitus, Dementia, and Bipolar Disorder. R149's Electronic Health Records documents there was a quarterly Minimum Data Sheet (MDS) done on 10/20/23. R149's EHR also documents that R149 had a readmission MDS for the date of 12/19/23 that was not signed and dated until 3/18/24 and then a new quarterly MDS that was signed and dated 3/19/24. On 03/20/24 at 1:10 PM when asked about why R149 had not had an updated readmission and quarterly MDS conducted V3 (Regional Administrator) stated they missed an MDS assessment and is put in the system now, but it will be late. On 03/21/24 at 9:50 AM, V14 (MDS/Care Plan Coordinator) stated, they had missed the quarterly MDS assessment for R149, R149 should have had another quarterly done around 01/20/24 she believes. V14 stated they missed an assessment for R149.

Based on interview, record review and observations, the facility failed to prominently post the daily nurse staffing data which includes the facility's name, date, census and the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This failure has the potential to affect all 47 residents who reside at this facility. Findings included: On 3/18/2024 at 11:00am and 1:00pm, the facility was observed to not have a Daily Nurse Staffing data sheet posted in a prominent place readily accessible to residents and visitors. On 3/19/2024 at 1:25pm, V1 (Administrator) said Daily Nurse Staffing Data is posted at the nurse's station. On 3/19/2024 at 1:30pm, Daily Nurse Staffing Data sheet was not posted at the facility's nurse station. On 3/19/2024 at 1:30pm, V4 (Licensed Practical Nurse/LPN) was sitting at the nurse's station and asked to point out where the Daily Nurse Staffing Data sheet was posted. V4 pointed to a sheet of paper on a clip board behind the nurse's station. The undated paper was titled Nurse Daily Assignment Sheet. V4 (LPN) said the paper she pointed to did not include a current date, current resident census, the facility's name, the total number of licensed and unlicensed staff or the actual hours worked per shift of the licensed and unlicensed staff. V4 said the administration used to post the daily nurse staffing data sheet up in the dining room, but she has not seen this for several months. On 3/19/2024 at 2:15pm, V1 said the form titled Nurse Daily Assignment Sheet is what she is calling the Daily Nurse Staffing Data sheet. V1 said she had never posted a Daily Nurse Staffing sheet since she became administrator at this facility, and she has been the Administrator of this facility since 10/9/2023. On 3/20/2024 at 8:45am and 1:00pm, the facility was observed to not have a Daily Nurse Staffing data sheet posted in a prominent place readily accessible to residents and visitors. A facility document titled Census List and dated 3/20/2024 documents 47 residents reside at this facility.

Based on observation, interview and record review the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms. This failure affects four of four residents ( R12, R5, R29 and R45) reviewed for environment in the sample of 25. Findings include: Observation on 3/20/2024 at 2:30pm revealed R12 and R5 shared a bedroom. It was a smaller sized bedroom with two beds, two bedside tables, an arm chair, an over the bed table, a geriatric wheelchair and had limited area to move around inside the room. A built in dresser was observed in the room as well, but did not affect the living area. Observations on 3/20/2024 at 2:35pm revealed R29 and R45 shared a bedroom. It was a smaller sized bedroom with two beds, two bedside tables, an arm chair, an over the bed table, two wheelchairs and had limited area to move around inside the room. A built in dresser was observed in the room as well, but did not affect the living area. During a tour with V3 (Director of Operations) on 3/21/2024 at 10:15am, V3 was asked to measure R12, R5, R29 and R45's bedroom sizes. V3 used a measuring tape to measure the length and width of R12 and R5's bedroom and stated, 12.6 by 12 [feet] [which was equivalent to 151.2 square feet/75.6 feet per resident bed]. The measurement did not include the closet, toilet room and built in dresser area. At approximately 10:17am, V3 measured R29 and R45's bedroom and stated, 12.6 by 12 [feet] [which was equivalent to 151.2 square feet/75 feet per resident bed]. The measurement did not include the closet, toilet room and built in dresser area. During an interview on 3/21/2024 at 10:20am with V3, when asked about the size required for two-resident bedroom, V3 stated, The room has to be over 80 [square feet each] for two residents. On 3/21/24 at 11:00 AM when V3 was asked if residents were notified during admission that many of the rooms in the facility did not meet the requirement of having 80 square feet per resident V3 stated he was unsure if it was in the contract but stated that residents were told verbally that rooms on the A Hall and B Hall were a little smaller. V3 stated that when a Medicare resident was admitted normally there were admitted to one of the rooms that met the size requirement and moved later on to a Medicaid only or private pay room which were smaller rooms. V3 stated there are only 2 single person rooms in the facility.

Based on interview and record review, the facility failed to keep a resident free of physical restraints for 1 (R1) of 5 residents reviewed for physical restraints in the sample of 9. This failure resulted in R1 being tied down in a wheelchair with a bath blanket for an undisclosed amount of time. An independent reasonable person would respond to being restrained to a wheelchair with feelings of fear, anxiety, frustration, agitation, and humiliation. This past non-compliance occurred between 10/12/23 and 10/13/23. The Findings include: R1's Face Sheet dated 10/23/2023 documents R1 being admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, recurrent, unspecified, Frontotemporal dementia, Barrett's esophagus with dysplasia, unspecified, Type 2 diabetes mellitus without complications, Obstructive sleep apnea (adult) (pediatric), Need for assistance with personal care, Unspecified osteoarthritis, unspecified site, Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, Dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. R1's Minimum Data Set (MDS) dated [DATE], documents Section C, Brief Interview for Mental Status (BIMS) score is 2, severely, impaired, cognition, Section GG, Independent with bed mobility, transfers, toileting, ambulating, eating, supervision with touching assistance with dressing. R1's Physician's Order dated for the month of October 2023 does not list any restraint ordered for R1. On 10/24/2023, at 6:30 AM, V5, (Certified Nurse Aide /CNA) stated that she worked the night of 10/12/2023. V5 stated that when she came on her shift, she noticed R1 sitting up at the nurse's station. V5 stated that he was sitting there calmly, not trying to get up. V5 stated she went about her shift and noticed R1 appeared to be looking tired. V5 stated that she asked him to come with her and she would help him get ready for bed. V5 stated R1 usually walks independently but was not getting up from his wheelchair. V5 stated that she went over to R1 and took the blanket off him and noticed there was another blanket underneath. V5 stated that she tried to take that blanket off R1, but noticed it was tied down to the wheelchair. V5 stated that it took her about 2 minutes or so to get the bath blanket untied from the wheelchair.V5 stated that V10 (CNA) came up to her and asked, Why are you putting R1 to bed?, I was coming to do it. V5 stated that she asked V10, Who tied this blanket down on R1's wheelchair? V5 stated that she told V10, We can't tie any resident down. V5 stated that V10 stated to her, I can't chase him around all night, What are we supposed to do?. V5 stated that she went up to V8, (Licensed Practical Nurse /LPN) and reported to her that she found R1 tied down with a bath blanket to his wheelchair. V5 stated that V8 just looked at her and stated, Ok. V5 stated that after she put R1 to bed, he stayed in bed and slept all night. V5 stated that when V6 (LPN) came on her shift the next morning, she reported to her that she found R1 tied down with a bath blanket to his wheelchair. V5 stated that V6 stated she would notify V1 (Administrator) and V2 (Director of Nursing/DON). On 10/23/2023, at 11:05 AM, V6 (LPN) stated that she worked 10/13/2023 on day shift. V6 stated that V5 (CNA) reported to her that when she was putting R1 to bed last night, she noticed that R1 was tied down with bath blanket in his wheelchair. V6 stated that she reported this to V1 (Administrator) right away. On 10/23/2023, at 12:00 PM, V1 (Administrator) stated that it was reported to her on 10/13/2023 that R1 was found to be tied down with a bath blanket in his wheelchair, the night before. V1 stated that an investigation was initiated, all proper notifications were made (Power of Attorney, Police Department, Primary Physician, & Ombudsman). V1 stated that R1's skin was assessed and there were no injuries noted. V1 stated that it was founded that V10 (CNA) had tied R1 down with a bath blanket in his wheelchair. V1 stated that V10 was immediately suspended and later terminated for not following policies and procedures for LTC facilities. V1 stated that all staff were in-serviced on Use of Restraint/Reporting of Reasonable Suspicion of a Crime. On 10/23/2023, at 9:45 AM, attempted to contact V10 (CNA) by phone but was unable to get in contact with him. The facility's final investigation report dated 10/17/2023 documents in parts . It was reported on 10/13/2023 that V10 (CNA) had tied R1 in a wheelchair using a bath blanket around 6:30 PM the night before. Nurse assessment completed on R1, and no injuries were noted. V10 was suspended until further investigation. V12 (Family), Local Police Department, V13 (Primary Physician) and Ombudsman were notified. On 10/13/2023, V1 (Administrator) interviewed V5 (CNA), and she stated when she came on shift at 10:00 PM, 10/12/2023, she walked down the hall to the nurse's station, as she approached the nurse's station, she saw R1 and another resident sitting along the wall. V5 stated that R1 was not trying to get up, he was just minding his own business with a blanket draped across him. V5 started to get him out of the wheelchair and noticed he was not moving. V5 asked R1 what was wrong, and he just looked at her, that is when V5 noticed another blanket was still across his waist. V5 tried to pull it off and realized someone tied R1 to the wheelchair with a bath blanket prior to her coming on shift. V10 (CNA) walked by and stood in the doorway to R1's room and asked, What are you doing? V10 stated multiple times he was going to lay R1 down. V5 walked back down the hallway and told V10 that she doesn't know who did that to R1, but it was not ok. V5 went to the nurse's station and told the charge nurse, V8 (LPN). V5 stated that V8 just looked at her and said, Ok. V5 waited until day shift nurses got to the facility and told V6 (LPN) what had happened and V6 stated she would let the Director of Nursing know. V1 was notified of this incident on 10/13/2023, at 8:45 AM. V1 notified V12 (Family), V13 (Primary Physician), Local Police, and Ombudsman. A facility wide In-Service was conducted on Use of Restraints and Reporting of Reasonable Suspicion of a Crime in a Long-Term care facility .After further investigation, we find that V10 (CNA) needs to be terminated for not following policies and procedures for Long-Term care facilities. There was no restraint assessment included in R1's Clinical Records to indicate the use of bath blankets as a restraint. The facility's policy, Use of Restraints, dated April 2017, documents under Policy Statement: Restraints should only be used to treat the resident's medical symptoms and never for discipline or for staff convenience, or for the prevention of falls. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: b. Tucking sheets so tightly that a bed-bound resident cannot move; c. Placing a resident in a chair that prevents the resident from rising; 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that might improve the symptoms; 9. Restraints shall only be used upon a written order from the physician and after obtaining a consent from the resident and or/representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint and the period of time for the use of the restraint. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 10/13/23. In attendance - V1, V2. 2. Measures that were put into place/systematic changes to ensure the deficient practice does not recur: V1 and V2 (DON) provided in-service to all facility staff regarding Restraint Usage/Reporting of Reasonable Suspicion of a Crime on 10/13/23. 3. Plan to monitor performance to ensure solutions are sustained: Restraint audits to be conducted daily by V1 & V2. The first complete facility audit was completed on 10/13/23.

Based on interview and record review, the facility failed to report an allegation of abuse immediately to the Administrator for 1 of 3 residents (R1) reviewed for abuse in the sample of 9. This past non-compliance occurred between 10/12/23 and 10/13/23. The Findings include: R1's Face Sheet dated 10/23/2023 documents being admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, recurrent, unspecified, Frontotemporal dementia, Barrett's esophagus with dysplasia, unspecified, Type 2 diabetes mellitus without complications, Obstructive sleep apnea (adult) (pediatric), Need for assistance with personal care, Unspecified osteoarthritis, unspecified site, Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, Dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. R1's Minimum Data Set (MDS) dated [DATE], documents Section C, Brief Interview for Mental Status (BIMS) score is 2, severely, impaired, cognition, Section GG, Independent with bed mobility, transfers, toileting, ambulating, eating, supervision with touching assistance with dressing. On 10/24/2023, at 6:30 AM, V5, Certified Nurse Aide (CNA) stated that she worked the night of 10/12/2023. V5 stated that when she came on her shift, she noticed R1 sitting up at the nurse's station. V5 stated that he was sitting there calmly, not trying to get up. V5 stated she went about her shift and noticed R1 appeared to be looking tired. V5 stated that she asked him to come with her and she would help him get ready for bed. V5 stated R1 usually walks independently but was not getting up from his wheelchair. V5 stated that she went over to R1 and took the blanket off him and noticed there was another blanket underneath. V5 stated that she tried to take that blanket off R1, but noticed it was tied down to the wheelchair. V5 stated that it took her about 2 minutes or so to get the bath blanket untied from the wheelchair V5 stated that V10 (CNA) came up to her and asked, Why are you putting R1 to bed?, I was coming to do it. V5 stated that she asked V10, Who tied this blanket down on R1's wheelchair? V5 stated that she told V10, We can't tie any resident down. V5 stated that V10 stated to her, I can't chase him around all night, What are we supposed to do? V5 stated that she went up to V8 (Licensed Practical Nurse /LPN) and reported to her that she found R1 tied down with a bath blanket to his wheelchair. V5 stated that V8 just looked at her and stated, Ok. V5 stated that when V6 (LPN) came on her shift the next morning, she reported to her that she found R1 tied down with a bath blanket to his wheelchair. V5 stated that V6 stated she would notify V1 (Administrator) and V2 (Director of Nursing/DON). On 10/23/2023, at 11:05 AM, V6 (LPN) stated that she worked 10/13/2023 on day shift. V6 stated that V5 (CNA) reported to her that when she was putting R1 to bed last night, she noticed that R1 was tied down with bath blanket in his wheelchair. V6 stated that she reported this to V1 (Administrator) right away. On 10/23/2023, at 12:00 PM, V1 (Administrator) stated that it was reported to her on 10/13/2023 that R1 was found to be tied down with a bath blanket in his wheelchair, the night before. V1 stated that at that time an investigation was initiated, all proper notifications were made (Power of Attorney, Police Department, Primary Physician, & Ombudsman). The facility's final investigation report dated 10/17/2023 documents in part . It was reported on 10/13/2023 that V10 (CNA) had tied R1 in a wheelchair using a bath blanket around 6:30 PM the night before . V5 went to the nurse's station and told the charge nurse, V8 (LPN). V5 stated that V8 just looked at her and said, Ok. V5 waited until day shift nurses got to the facility and told V6 (LPN) what had happened and V6 stated she would let the Director of Nursing know. V1 was notified of this incident on 10/13/2023, at 8:45 AM. The facility's undated policy Reporting of Reasonable Suspicion of a Crime in a Long-Term Care Facility documents in part under: What should be reported and to whom: All alleged violations involving mistreatment, neglect, sexual, or abuse, including injuries of unknown source and misappropriation of resident property are to be reported immediately to the administrator. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 10/13/23. In attendance - V1, V2. 2. Measure put into place/systematic changes to ensure the deficient practice does not recur: V1 and V2 (DON) provided in-service to all facility staff regarding Restraint Usage/Reporting of Reasonable Suspicion of a Crime dated 10/13/2023. 3. Plan to monitor performance to ensure solutions are sustained: Reporting/Notification audits to be conducted daily by V1 & V2. The first complete reporting/notification audit was completed on 10/13/23.

Based on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R1) reviewed for accidents in the sample of 6. This failure resulted in R1 sustaining a fall from R1's wheelchair that resulted in R1 receiving a laceration to left (side) forehead, left eye lid ecchymosis, left infraorbital skin tear, as well as some left forehead skin tears. The findings include: R1's undated Face sheet documents that R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Alzheimer's Disease, unspecified dementia (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety), abnormal posture, muscle weakness, history of falling, and other lack of coordination. R2's MDS (Minimum Data Set) dated 2/24/23 documents that R1 has a BIMS (Brief Interview of Mental Status) of 04 which indicates that R1 has severe cognitive impairment. The same MDS documents under Section GG that R1 uses a wheelchair for mobility. Section GG also notes that R1 requires partial/moderate assistance to wheel 50 feet with two turns and partial/moderate assistance to wheel 150 feet. R1's Physical Therapy Plan of Care dated 2/17/23 documents the reason for referral as recent diagnosis of Urinary Tract Infection (UTI) and falls. Under the section titled Initial Assessment it documents that R1 has a functional deficit of mobility with the use of a wheelchair (WC)/ scooter: wheel 50 feet with 2 turns and R1's current level of functioning as Partial/moderate assistance, helper lifts, holds or supports trunk or limbs, but provides less than half the effort. R1's facility Incident Report to the Illinois Department of Public Health (IDPH) dated 3/31/23 labeled Initial Report and Final Report documents under the section Initial Status that on 3/31/23 at approx. (approximately) 9:00 AM while at the hospital, Certified Nurse's Aide (CNA) was pushing resident in wheelchair when wheelchair wheels came into contact with the 'American's with Disabilities Act (ADA) truncated surface tile' causing the wheelchair to tip forward and resident to fall out of wheelchair. Hospital staff was alerted, and resident was immediately taken to the emergency room (ER) at (name of hospital) for evaluation and treatment. The report further documents that report received from (hospital staff member) at (name of hospital) at approx. 1:15 pm stating resident received 5 sutures to head wound. Computed Tomography (CT) of head and neck negative. The same report documents under the section Conclusion that All staff will be educated on either going around the ADA Truncated surface tiles or turning the wheelchair around and going in reverse over the tiles when encountered. R1 will have front anti-tippers applied to her wheelchair. R1's emergency room Physician Chart, dated 3/31/23, documents under additional information that a medical emergency called patient (PT) on ground outside fell out of wheelchair (W/C) while being pushed into hospital for appointment. The emergency room Physician chart further documents under Physical Exam that R1 had a laceration on left (side) of forehead measuring 4.5cm (centimeters). R1 also had left eye lid ecchymosis, left infraorbital skin tear as well as some left forehead skin tears. The same document under Procedure that a repair of the laceration was completed using a one-layer closure. Length of the laceration repair was 4.5 cm, was closed with 4-0 nylon (sutures). R1's Care Plan documents a Care Plan category of fall and a history of falling with a start date of 12/2/22 with documented interventions of remind to ask staff for assistance with ambulation, assist of 1 staff member for ambulation, and monitor for changes in condition that may warrant increased supervision/assistance, notify physician. R1's Care Plan documents an intervention dated 1/19/23 of resident wheelchair will be placed close to resident as a visual clue to have resident ask for assistance. R1's Care Plan also documents a Care Plan category of Fall from W/C while being transported to an appointment with a start date of 3/31/23. Interventions documented include monitor bruising on R1's face and report to physician as needed, when transporting resident pull resident from behind when going over a bump, in-service to train staff on proper transportation of resident. The same care plan notes an intervention with a start date of 4/1/23 for foot pedals to be used at all times during transport. On 4/18/23 at 9:45am, V1 (Administrator) said she completed the investigation on the incident on 3/31/23 involving R1 falling from her wheelchair when out of the facility going to an appointment. V1 said that R1 had an appointment at the hospital for a Doppler study. V3 (CNA/Certified Nurse Assistant) took her to the appointment. V1 said that V3 was pushing R1 in the wheelchair and hit the ADA (Americans with Disabilities Act) truncated surface tile and the wheels stopped causing R1 to fall out of the wheelchair. V1 said that R1's family was there when the incident occurred but is not sure if he witnessed the incident or not. V1 said that V3 was very upset over the incident. V1 said that R1 was taken into the emergency room at the hospital and received stitches and also had some bruising to her face. V1 said she is not sure if V3 had the footrests on the wheelchair or not. On 4/18/21 at 10:20am, V3 (CNA) said she was taking R1 to an appointment at the hospital. V3 said she parked in the handicap parking in the front of the parking lot. V3 said she made it to the end of the sidewalk where there were red things for vision impaired. V3 said she hit the bumps with the wheelchair, and it made the wheelchair stop and R1 fell forward out of the chair. V3 said it happened so fast she could not catch (R1) from falling. V3 said that there was no way she could go around the red things due to the curbs. V3 was crying and said she does not know why she didn't put the footrests on the wheelchair. V3 said she knew to use them but just forgot. V3 said she came in just to take R1 to the appointment. V3 said the hospital staff got on her also for not using footrests on the wheelchair. V3 said the accident was like in slow motion and she couldn't stop it. On 4/18/23 at 3:45pm, this surveyor went to the hospital location where R1's fall incident occurred. The particular sidewalk where the fall occurred was observed to connect the parking lot area to the roadway area where patient/transport vehicles drop off near the hospital entrance. This area of the sidewalk was noted to have a decline of approximately 4 - 6 inches with truncated ADA tiles at the end of the sidewalk just before the roadway. Video surveillance footage provided by the hospital was reviewed. The surveillance footage dated 3/31/23 with a time stamp of 9:11 AM, shows V3 pushing R1 in a wheelchair on the sidewalk near the hospital entrance. As the wheelchair descended through the ADA truncated tiles onto the smooth roadway/ concrete surface, R1's left foot, followed by the right foot, are observed dropping and coming into contact with the concrete surface approximately 1 to 2 feet past the ADA truncated tile. R1 is then observed falling forward out of her wheelchair onto the concrete surface. There are no foot plates or foot rests observed on R1's wheelchair in the surveillance footage. On 4/18/23 at 10:40am, V5 (LPN/Licensed Practical Nurse) said she would expect staff to use a footrest when taking a resident out of the facility unless they are independent. On 4/18/21 at 10:50am, V4 (CNA/Certified Nurse Assistant) said if a resident does not really use their feet, she would use a footrest on the wheelchair when taking a resident out of the facility. On 4/18/23 at 10:45am, V6 (LPN/Licensed Practical Nurse) said she would expect that staff would use a footrest on the wheelchair when transporting a resident out of the facility. On 4/18/23 at 12:05pm, V8 (CNA/Certified Nurse Assistant) said that he would use footrests when he takes a resident out of the facility. On 4/18/23 at 2:15pm, V10 (family member of R1) said he volunteers and drives a golf cart around the parking lot of the local hospital. V10 said he was aware R1 had an appointment for a Doppler and went to where they parked. V10 said that the staff got R1 out of the back of the van and began pushing her on the sidewalk. V10 said he asked the staff if they needed any help, and they said no. V10 said he turned his head for a minute and when he looked back over, R1 had fallen forward out of the wheelchair and was bleeding. V10 said hospital staff came out and took her in for treatment. V10 said that from where they parked the car, it was maybe 50 feet to the entrance. V10 said there were bumps for the Disabilities Act and the wheels of the wheelchair like locked and she fell forward. V10 said that some days R1 is more with it and can tell you what she had for lunch, and then other times she cannot. V10 said that he and his brother had talked the evening after the accident about footrests on the wheelchair. V10 said he went to the facility the next day and talked with the Social Service person (V7) and told them he would like them to use footrests on her wheelchair. V10 said that R1 does not like them, and he told V7 that if they agitated R1, they could turn them to the side. V10 said he has been to the facility every day since the accident and the footrests have been on her wheelchair. On 4/19/23 at 10:06am, V13 (emergency room Director at local hospital) said that she and another nurse were on duty on 3/31/23 and went outside to where R1 was on the ground and assessed R1. V13 said they brought R1 on a gurney back into the ER (emergency room ). V13 said that the staff with R1 was visibly upset and crying. V13 said that she noticed that staff did not have foot pedals on the wheelchair when pushing her. V13 said she talked to staff about using foot pedals when taking a resident out of the facility. V13 said that she told them how a resident's foot can drop and also cause an accident and to always use the footrest. Observations were made at various times during the day on 4/18/23, R1 was noted to have footrests on her wheelchair and did not appear to have anxiety about them being on her chair. Attempts to interview R1 were unsuccessful due to R1's impaired cognition.

Based on observation, interview, and record review, the facility failed to recognize/prevent the development of pressure ulcers, initiate and implement measures to promote healing, and report a decline to the physician for 1 (R37) of 1 resident reviewed for pressure ulcers in a sample of 45. This failure resulted in R37 acquiring an open pressure ulcer on his left buttock and three new open pressure areas on his right buttock. The Findings Include: R37's Resident Diagnosis/History Sheet documents an original admission date of [DATE] with the following [DIAGNOSES REDACTED]. The facility report titled, Braden Risk assessment dated [DATE] documents R37 is a minimal risk for developing pressure sores; R37 is rarely moist, walks frequently outside/inside his room; has no mobility limitations (makes major changes and frequent changes in position without assistance). However, R37's quarterly MDS dated [DATE] documents the following in part - R37 requires extensive one person assist with bed mobility, transfer, and personal hygiene, totally dependent for bathing requiring a one person assist, with surface to surface transfer between bed/chair/wheelchair as not steady and only able to stabilize with human assistance. R37's Care Plan dated 08/24/18 documents he is at risk for skin breakdown with the only interventions as follows - weekly skin assessments, CNA (Certified Nursing Assistant) to report skin issues to nurses, follow-up with physician as needed, and medications as ordered. R37's Care Plan dated 08/24/18 also documents skin is to be observed daily for irritation and redness due to occasional urinary incontinence. R37's record contained no documentation of daily skin observations being made or interventions that were implemented to prevent further skin breakdown for R37. On 02/27/20 at 11:30 AM, an observation was made with V2 (Director of Nursing - DON) and V5 (Minimum Data Set) Coordinator. R37 required a 2 person assist to stand from a seated position. R37's left buttock was observed to have an open area with serosanguinous drainage present. R37's right buttock was observed to have three small open areas, red and irritated in appearance, with sanguinous fluid present. During this observation, R37 appeared weak with difficulty maintaining a standing position. The facility wound assessment report dated 2/19/20 documents R37 was out of the facility from 02/17/20 thru 02/18/20. The facility wound assessment documents redness to R37's buttocks and barrier cream applied; excoriation to R37's left buttock with the cause as moisture; with the wound description as red or darker pink, moderate irritation. The assessment documents V6 (primary care physician) was notified on 2/19/20 with treatments pending. On 02/27/20 at 11:35 AM, when asked if R37's left buttock wound was the same wound V2 described in the 02/19/20 Wound Assessment Report, V2 stated it was the same wound. When asked if the wound was open or closed on 02/19/20, V2 replied, It was closed. When asked if R37's pending treatment orders status documented in this same wound assessment had been followed up on and/or treatment started, V2 stated, No, they had not. V2 further stated the three open areas observed on R37's right buttock were not there before. When asked what before meant, V2 stated, he had a catheter from the hospital I took out on 02/23/20, and they weren't there. R37's (MONTH) 2020 POS - (physician's orders [REDACTED]. R37's (MONTH) 2020 TAR (Treatment Administration Record) contains no documentation that treatment was started for R37's left or right buttock wound. On 02/28/20 at 8:50 AM, V9 (CNA) stated when she toileted R37 on 02/26/20 she observed a sore on each buttock that looked like they needed something on them. V9 stated she reported this to V7 (Registered Nurse - RN). On 02/28/20 at 9:20 AM, V7 (RN) stated she does not remember if a CNA told her R37 had a sore on each buttock on 02/26/20 and there is no documentation regarding this. On 02/28/20 at 10:50 AM, V6 (Primary Care Physician - PCP) stated he had no knowledge of the facility notifying him on 02/19/20 regarding R37's left buttock, nor was he aware a wound treatment order had been requested. When V6 was told R37 was assessed by the facility on 02/19/20 to have a moderately irritated, closed area to his left buttock and upon observation on 02/27/20, R37 was observed to have an open wound to left buttock with three small open areas on his right buttock, V6 stated, This is a problem. By not following through and ensuring treatment was started, the wound was not given a chance to improve and the fact there are areas on the right buttock now is an issue. A facility policy titled, Prevention of Pressure Ulcers/Injuries dated Revised (MONTH) (YEAR) documents the following in part - Purpose: .to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation - Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 4. Inspect skin on a daily basis when performing or assisting with personal care or ADL's (Activities of Daily Living). Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.