Every finding on record at River View Rehab Center

Based on interview and record review the facility failed to protect a resident from sexual abuse for (R4). This failure affected (R4 &R5) reviewed for sexual abuse in the sample of 7.The findings include:R4's facility assessment dated [DATE] shows R4 has no cognitive impairment. R5's facility assessment dated [DATE] shows R5 is moderately cognitively impaired. The Facility Reported Incident (FRI) sent to the state agency dated 4/20/26 with date of report as 4/14/26, documents: Allegation: Sexual Abuse, Abuse was substantiated. The FRI documents that R5 touched R4 inappropriately. R4 was sent to the hospital for physical exam and R5 was sent for psychiatric evaluation. R4 was also moved to another floor. The report also shows that R4 said R5 touched her breast, denied touching her lower part, and they did not have sex. R5 stated he did not do anything wrong.On 4/24/26 at 10 AM, R4 was sitting in her wheelchair alert and pleasant in the common area. R4 stated a couple of weeks ago, I woke up with [R5] kissing me all over my face while rubbing his hands on both of my breasts. I immediately screamed at him get the f--k out of my room! R4 said she recalled being so angry at that time, about it. Since then, she has been moved to first floor. R5 had not attempted to go near her. On 4/24/26 at 10:15 AM, R5 was in his room lying in bed with his eyes closed. When this surveyor asked to speak to R5. R5 stated if this was about the incident 9 days ago, he was not going to talk about it, he will not admit or deny to anything, he had spoken to the police, and that was the end of that, besides it was an old issue.On 4/24/26 at 12:07 PM, V5 (Psyche Rehab Staff) said R4 came to her on 4/14/26 and said R5 groped'' her. R5 was rubbing her breast while kissing her. R4 said she woke up to R5 offering me cigarettes so he could touch me, I kicked him out of my room, get out! V5 said this was sexual abuse so she reported the incident to the Social Service Director (SSD-V7) and Administrator (V1) immediately. On 4/24/26 at 11:23 AM, V4 (Registered Nurse-RN) said she was the Nurse working on 4/14/26. V4 said she was the nurse of R4 and R5. V4 said V2 (Director of Nursing) informed her to transfer R5 to a psych unit, that R5 had touched R4 inappropriately. R4 was being moved to first floor. R4 was also being sent to the hospital for medical exams. R4 was sent to a local hospital. R5 was sent to the psych unit by petition.On 4/2/26 at 11:38, V2 (Director of Nursing-DON) said it was reported to her that R5 touched R4 inappropriately. V2 said R5 was sent out for psych eval and R4 was sent to the local hospital for evaluation. R4 and R5 were discharged back to the facility. R4 was moved from 2nd floor to first floor away from R5. R4 is wheelchair bound. R5 is up and about independently. Both R4 and R5 were being monitored closely.R4's hospital records dated 4/14/26 timed at 1:46 PM show, you had general checkup today, you are being discharged . No new orders noted.R5's progress notes dated 4/14/26 timed at 5:29 PM show, R5 was being sent back to the facility after a psych eval was completed.On 4/24/26 at 11: 31 AM, (V7) Social Service Director) SSD said she was the one who completed the abuse investigation when R4 reported that R5 entered her room, kissed her, and R5 rubbed both of her breast. R4 demonstrated the contact by using a rubbing motion with her right hand pointing to both of her breasts. V7 (SSD) said R4 noticed R5 was giving her cigarettes prior to the incident and being extra helpful to her by pushing her around in her wheelchair. The investigation resulted in sexual abuse being substantiated. R4 and R5 are now on different floors. It was important for residents to feel safe. Abuse of any kind was not tolerated at the facility.The facility policy on Abuse Prevention and Reporting (undated) documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect exploitation, misappropriation of property and mistreatment of residents. This will be done by: .Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Sexual abuse includes but not limited to sexual harassment sexual coercion or sexual assault including non-consensual to non-competent to consent sexual activity. Sexual abuse is nonconsensual sexual contact of any type with resident. Sexual abuse includes but not limited to, unwanted intimate touching of any kind specially shows of breasts and perennial area.

Based on observation, interview and record review, the facility failed to prevent the physical and verbal abuse of residents at the facility for five of six residents (R1, R2, R4, R5, and R6 ) reviewed for abuse in a sample of 9. This failure resulted in R6 experiencing psychosocial harm, feeling unsafe and expressing desire to leave the facility. The findings include: 1. MDS, dated [DATE], shows R1's cognition was moderately impaired.MDS, dated [DATE], shows R2's cognition was intact.On 3/30/26 at 11:40 PM, R2 stated while she and R1 were laying in their beds R2 [NAME] water on R1 to wake her up because R1 was antagonizing R2 throughout that day and telling R2 that R1 was going to send her to jail. R2 stated R1 then began hitting R2 on the left side of her face / head/ chin. R2 stated her head still hurt from being hit and that she had multiple prior surgeries on her head. R2 stated she was hit by R1 during the altercation and identified her left temple, left cheek, left side of her chin, and along both sides of her face as areas that were hit by R1. R2 stated R1 also bit her on her third and fourth fingers and pulled back her fingernail. R2 stated a nurse came in and stopped R1 from hitting R2. On 3/30/26 at 12:11 PM, R1 stated she woke up wet and did not know why and then realized R2 threw water on her when R1 was asleep. R1 stated she hit R2 three times after R2 hit R1. R1 stated R2 also hit R1 in the face causing visible bruising area above R1's right eyebrow and one across the bridge of R1's nose at the time of the altercation.On 3/30/26 at 12:29 PM, V3 (Registered Nurse - RN) stated she heard a commotion from R1 and R2's room and went to investigate. V3 stated when she entered R1 and R2's room during the altercation, she was focused on R1 standing without assistance, was concerned R1 was going to fall, and called for help but did not see the residents hit each other. V3 stated R1 was wet and she saw a mark on R1's face but was unsure if the mark was caused by an altercation. V3 stated she did not see the mark on R1's face prior to the altercation. V3 stated she did not see any injuries on R2.Hospital Emergency Department Note regarding R2, dated 3/7/26, shows, Presenting with left hand swelling / pain right facial scratches, and right hand bite marks after an altercation with her roommate. According to the petition filled out by nursing home, patient poured a cup of water on her roommate which started the altercation. Patient also complaining of facial pain in her cheeks due to being punched. EXAM. HEAD Small abrasion to right cheek. Patient complains of tenderness to bilateral cheeks upon palpation. Right hand: 1 mm superficial skin flap abrasion to right 4th dorsal middle phalanx. No bleeding. Dried blood underneath right 3rd fingernail. Fingernail intact. Patient with tiny superficial wound to finger that she says is from a human bite. Treated with local wound care and bacitracin. Review of nursing progress notes, dated 3/7/26 and 3/8/26, fail to show documentation of any injuries sustained by R1 or R2 during their altercation on 3/7/26. Physician Progress notes, dated 3/8/26, shows, [R2] has a tiny scratch along her jaw.Tiny superficial scratch noted along the jaw/face area following altercation with roommate, no bleeding, drainage, or signs of infection.Final Incident Investigation Report Form regarding the 3/7/26 incident, shows R2 alleged R1 was threatening to take R2 to jail so R2 threw water on R1. The report shows R1 approached her and began swatting at her and [R2] pushed [R1]. The investigation interviews show R1 denied hitting or being hit by R2. The report shows the facility did not substantiate the allegation of resident physical abuse. The final report fails to show if R2 was asked if she was hit or if she was injured. The report indicated a full head to toe assessment was completed to assess for resident injury, but no documentation of R1 or R2's injuries were identified in the facility clinical record other than the facility physician and emergency department notes. The investigation failed to show review of the hospital records or physical/skin assessments of R2 to identify any injuries. On 4/1/26 at 10:30 AM, V3 (PRSD - Psychiatric Rehabilitation Services Director) stated she did not review the physician reports regarding R1 and R2's altercation and usually uses the resident interviews to determine if abuse was substantiated. After reviewing the emergency department documentation for R2, V3 stated if she had reviewed the documentation at the time of the investigation she would have substantiated that abuse did occur between R1 and R2 on 3/7/26. V3 stated she utilized the word swatting as meaning attempting to hit and that neither R1 or R2 used the word swatting during the investigation. V3 stated she could not remember if she asked R2 if R1 made contact with R2 when R2 was swatting. V3 was also not confident if she asked R2 if R2 was injured during the incident. V3 stated she was not aware of any pain to R2's face or any bite marks or blood was identified on R2's hands at the hospital as she did not review the hospital documentation during the investigation. On 4/1/26 at 3:15 PM, V1 (Administrator) stated he was aware that R2 hit R1 during the altercation but V1 thought that the altercation was not an incident of abuse because R2 had dementia. 2. MDS, dated [DATE], shows R4's cognition was intact. MDS, dated [DATE], shows R5's cognition was intact. Final Incident Report Form shows on 3/23/26 R5 alleged R4 pushed R5 and scratched her face because R4 did not like R5. The report shows R4 alleged that R5 pulled R4's hair but R5 denied pulling R4's hair. The investigation fails to include a physical assessment of any injuries to R5's face. The report shows V5 (Marketing) reported she witnessed R4 having her hand wrapped around R5's hair, V6 (CNA- Certified Nursing Assistant) stated she witnessed the two residents come off the elevator and noticed R5 had a scratch on her face and V7 (Monitor) witnessed R5 push R4 and R4 reached and grabbed R5's hair. R9 reported he saw R4 try to swing at R5 and pull R5's hair. R7 stated he saw a scratch on R5's face after the incident. R8 stated he witnessed R4 try to pull R5 back into the elevator. The report shows the allegation of abuse was substantiated. Involuntary petition, dated 3/23/26, shows R4 was involuntarily admitted to the hospital due to becoming physically aggressive toward another resident and pulling the resident's hair. On 3/30/26 at 12:05 PM, R5 stated she and R4 were the only residents in the elevator when R4 reached up and scratched R5's face while she was standing next to R4 in her wheelchair. R5 stated she still had marks from the altercation and pointed to a faint red superficial streak on R5's left cheek perpendicular to the side of R5's mouth. The streaks measured approximately one inch long. R5 pointed to another faint red streak perpendicular to her jaw line approximately one inch long. R5 stated R4 yelled F***ing [NAME] Rican B****! when R4 reached up and attacked her. On 3/31/26 at 11:00 AM, R4 stated R5 attacked her out of nowhere. R4 had several superficial scratch marks on her right inner forearm. R4 stated she was not sure why the altercation occurred. R4 stated R5 being [NAME] Rican had nothing to do with the altercation and R4 stated she scratched and pulled R5's hair. On 3/31/26 at 11:09 AM, R8 stated he witnessed R4 trying to pull R5 backwards when they were fighting.Physician progress note, dated 3/24/26, shows R5 had a right side superficial facial scratch from an altercation the day prior. Nursing progress note, dated 3/23/26, shows R5 had an altercation with a resident resulting in a scratch on the left side of her face. Physician progress note, dated 3/24/26, shows R4 was seen regarding her behaviors and ongoing medication refusals. The note shows R4 sustained a small scratch to her right hand. The note shows the facility staff were to Continue behavior watch and close nursing supervision. 3. MDS, dated [DATE], shows R6's cognition was intact.Preliminary Incident Investigation Report Form, dated 3/30/26, shows R4 and R6 were involved in a physical altercation in which both residents scratched each other, and the investigation was pending. On 3/31/26 at 11:27 AM and 3:30 PM, R6 stated she was trying to exit the elevator and R4 was blocking the elevator door. R6 stated when she tried to move past R4, R4 backed up into R6 and prevented her from exiting. R6 stated she again attempted to exit and R4 again backed into R6. R6 stated she hit R4's arm lightly and told her to stop. R6 stated R4 grabbed R6's arm and began to scratch R6. R6 had several scratches on her right arm located above her wrist (approximately one inch long), above her right inner elbow (four small scratches in a row with the two outside scratches both having longer scratches approximately two inches in length), mid upper arm above her inner elbow (three superficial abrasions), on the side of her right upper arm (a bruise with a scab over a scrape approximately two inches long), and under her upper arm (a dark purple bruise approximately two inches long.) R6 stated R4 was a bully and that R4 purposely backed up into R6 before, and R6 wanted to press charges against R4. R6 stated she no longer felt safe in the facility and felt R4 did not have the right to physically or verbally abuse her. R6 stated she was in a previous physical altercation with R4 over a year ago and that R4 continues to make verbal insults, shows (R6) her middle finger, and antagonizes (R6). On 3/31/26 at 11:00 AM, R4 stated R6 attacked her out of no where and was not sure why the altercation occurred.Nursing Progress Note, dated 3/30/26, shows R4 had an altercation with a resident and had minor scratches on her right forearm with no bleeding noted. Nursing progress notes, dated 3/31/26, show R6 had partial thickness lines of dried fibrinous exudates on bilateral arms length of 0.5 to 1.8 cm. The record shows R6 received physician orders for topical antibiotics. The progress notes show R6 verbalized the wounds were a result of a scratch. The progress notes show R6 expressed a desire to leave the facility. On 3/31/26 at 11:09 AM, R8 stated R4 bullied R6 at the facility for some time and he witnessed the two fighting and tried to break them up. R8 stated R6 was trying to step off the elevator and R4 tried to push her way through R6. R8 stated R6 became very upset and exploded like she could not take it anymore. She just let go and blew up.Abuse Prevention and Reporting document, undated, shows, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: .Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. The term 'willful' in the definition of abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. An example of deliberate ('willful') action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview and record review the facility failed to report resident injuries sustained during altercations and perform thorough investigations of resident abuse allegations. This applies to 4 of 4 residents (R1, R2, R4, R5) reviewed for abuse in a sample of 9. The findings include: 1. MDS, dated [DATE], shows R1's cognition was moderately impaired.MDS, dated [DATE], shows R2's cognition was intact.On 3/30/26 at 11:40 PM, R2 stated during an altercation R2 threw water on R1 and R1 then began hitting R2 on the left side of her face / head/ chin. R2 identified her left temple, left cheek, left side of her chin, and along both sides of her face as areas that were hit by R1. R2 stated R1 also bit her on her third and fourth fingers and pulled back her fingernail. On 3/30/26 at 12:11 PM, R1 stated during the altercation she hit R2 three times after R2 hit R1. R1 stated R2 also hit R1 in the face causing visible bruising area above R1's right eyebrow and one across the bridge of R1's nose at the time of the altercation.On 3/30/26 at 12:29 PM, V3 (Registered Nurse - RN) stated R1 was wet and she saw a mark on R1's face but was unsure if the mark was caused by an altercation. V3 stated she did not see the mark on R1's face prior to the altercation. V3 stated she did not see any injuries on R2.Hospital Emergency Department Note regarding R2, dated 3/7/26, shows, Presenting with left hand swelling / pain right facial scratches, and right hand bite marks after an altercation with her roommate. According to the petition filled out by nursing home, patient poured a cup of water on her roommate which started the altercation. Patient also complaining of facial pain in her cheeks due to being punched. EXAM. HEAD Small abrasion to right cheek. Patient complains of tenderness to bilateral cheeks upon palpation. Right hand: 1 mm superficial skin flap abrasion to right 4th dorsal middle phalanx. No bleeding. Dried blood underneath right 3rd fingernail. Fingernail intact. Patient with tiny superficial wound to finger that she says is from a human bite. Treated with local wound care and bacitracin. Review of nursing progress notes, dated 3/7/26 and 3/8/26, fail to show documentation of any injuries sustained by R1 or R2 during their altercation on 3/7/26.Physician Progress notes, dated 3/8/26, shows, [R2] has a tiny scratch along her jaw.Tiny superficial scratch noted along the jaw/face area following altercation with roommate, no bleeding, drainage, or signs of infection.Final Incident Investigation Report Form regarding the 3/7/26 altercation between R1 and R2, shows R1 approached her and began swatting at her and [R2] pushed [R1]. The investigation interviews show R1 denied hitting or being hit by R2 but fails to show if R2 was asked if she was hit or if she was injured. The report indicated a full head to toe assessment was completed to assess for resident injuries, but no documentation of R1 or R2's injuries were included in the report. The investigation failed to show review of the hospital records or facility physical/skin assessments of R2 to identify any injuries sustained during the altercation. On 4/1/26 at 10:30 AM, V3 (PRSD - Psychiatric Rehabilitation Services Director) stated she did not review the physician reports regarding R1 and R2's altercation and usually uses the resident interviews to determine if abuse was substantiated. V3 stated she was not aware that any pain to R2's face or any bite marks or blood was identified on R2's hands at the hospital as she did not review the hospital documentation during the investigation. After reviewing the emergency department documentation for R2, V3 stated if she had reviewed the documentation at the time of the investigation she would have substantiated that abuse did occur between R1 and R2 on 3/7/26. V3 stated she utilized the word swatting as meaning attempting to hit and that neither R1 or R2 used the word swatting during the investigation. V3 stated she could not remember if she asked R2 if R1 made contact with R2 when R2 was swatting. V3 was also not confident if she asked R2 if R2 was injured during the incident. Abuse Prevention and Reporting document, undated, shows, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: .Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. The Administrator or Designee will initiate an investigation to the allegation which may include (1) interviewing all persons who may have knowledge (2) Review medical records, review of all circumstances surrounding the incident. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. The initial report to Department of Public Health shall include the following information, if known at the time of the report: .Any obvious injurie or complaints of injury. 2. MDS, dated [DATE], shows R4's cognition was intact. MDS, dated [DATE], shows R5's cognition was intact. Final Incident Report Form shows on 3/23/26 R5 alleged R4 pushed R5 and scratched her face. The report shows V6 (CNA- Certified Nursing Assistant) stated she witnessed R5 had a scratch on her face. The report shows R7 stated he saw a scratch on R5's face after the incident. The investigation fails to include a physical assessment of any injuries to R5's face or R4's arm. On 3/30/26 at 12:05 PM, R5 stated during the altercation, R4 reached up and scratched R5's face. R5 stated she still had marks from the altercation and pointed to a faint red superficial streak on R5's left cheek perpendicular to the side of R5's mouth. The streaks measured approximately one inch long. R5 pointed to another faint red streak perpendicular to her jaw line approximately one inch long. On 3/31/26 at 11:00 AM, R4 stated R5 attacked her and R4 had several superficial scratch marks on her right inner forearm. R4 stated she scratched and pulled R5's hair. Nursing progress note, dated 3/23/26, shows R5 had an altercation with a resident resulting in a scratch on the left side of her face. Physician progress note, dated 3/24/26, shows R5 had a right side superficial facial scratch from an altercation the day prior. Physician progress note, dated 3/24/26, shows R4 sustained a small scratch to her right hand.

Based on interview and record review, the facility to prevent abuse between two residents, resulting in R2 requiring an emergency room evaluation and sustaining bleeding above the eye, lip and bruising to the temple area. This applies to 2 of 5 residents (R1, R2) reviewed for abuse in a sample of 5. The findings include: R1 and R2's final incident report to IDPH (Illinois Department of Public Health) shows the following: (R1) stated that (R2) jumped at him because he was talking to himself. (R1) reported that (R2) threw an object at him but doesn't recall what the object was. (R1) stated that he and (R2) started tussling and that he was defending himself. (R1) acknowledges that he talks to himself and tends to swear. (R1) stated that he is aware of this behavior and is currently waiting for his medication to be adjusted. (R2) stated that (R1) was swearing at him and calling him derogatory names. (R2) stated he had water in his cup and poured it on (R1). (R2) stated that (R1) then began hitting him. Staff immediately intervened and separated both residents. (R2) also reported that he later learned that (R1) talks to himself and understands that (R1)'s derogatory statements were not directed towards him. (R1) was moved to another room. Both residents were educated to remain separated from each other. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation.On 2/24/26 at 10:50 AM, R1 stated that he had a fight with R2. He said R2 attacked him. He said he has had schizophrenia for 20 years. He was listening to his voices and talking back to them in his room. R2 got annoyed at him and threw a cup at him which had some liquid inside. He stated that he punched R2 because R2 punched him. He said he was trying to hold him back. They both fell in the hallway. Staff separated them. They changed R1 to a different room.R1's face sheet shows the following diagnoses: Bipolar Disorder current episode depressed, severe with psychotic features and suicidal ideations. R1's MDS (Minimum Data Set) dated 1/18/26 shows that he is cognitively intact. R1's care plan dated 1/13/26 with a focus of abuse/neglect/exploitation trauma shows a goal that he will be treated with respect, dignity, and reside in the facility free of mistreatment (i.e., abuse/neglect) through next review. R1's care plan dated 2/12/26 shows a focus of hallucinations where he experiences auditory and visual hallucinations, which may lead to confusion and agitation.R1's progress note dated 2/9/26 at 11:40 PM, Around 8:38 PM, informed by co-nurse that this resident and his roommate had altercation in room. Co nurse separated both residents. Skin alteration noted. First aid treatment given, refused going to the hospital for evaluation despite educating and encouraging. 911 was called. R1's progress note dated 2/10/26 at 12:36 AM shows, (R1) is currently in a different room separated from the roommate. Noted a scratch on the right eyelid, scratch on the right chin and two big scratches on the right forearm. (R1) is still refusing to go to the hospital.On 2/24/26 at 4:26 PM, R2 stated that he was watching TV (Television) in his room. R1 was also watching TV on his side of the room. He was also laughing and talking to his voices. R2 got annoyed and told him if he could keep it down. R1 then walked over to R2's side of the room and got in his face. R2 told R1 to back up. Then R1 threw water at R2. R1 hit the side of his head. He received a black eye because R1 gave him a few swings. Then R1pushed him on the floor and he got on top of him and punched him. R2 stated he had to go to the hospital.R2's face sheet shows the following diagnoses: major depressive disorder, recurrent severe without psychotic features, suicidal ideations, and alcohol abuse, uncomplicated. R2's MDS dated [DATE] shows he is cognitively intact. R2's care plan dated 7/24/25 shows he has a history of criminal behavior. R2's care plan dated 7/25/25 with a focus of abuse/neglect has a goal that he will be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect).R2's progress notes show the following: On 2/9/26 at 11:28 PM, Around 8:38 PM, informed by co-nurse that this resident and his roommate had an altercation in the room. Co-nurse separated both residents. This RN immediately assessed the resident. First aid treatment was given to his right arm. 911 was called.(R2) sent to hospital for evaluation via 911. On 2/10/26 at 12:25 AM, (R2) back from the hospital. Bruising on the left temple and dry dressing to the right forearm.On 2/24/16 at 10:16 AM, V2 (DON-Director of Nursing) stated that R1 had said that R2 jumped at him because R1 was talking to himself, which is part of illness. R1 reported that R2 threw an object at him. He couldn't recall what it was. They were the only ones their room. R1 stated he and R2 started tussling and he was defending himself. R2 said that R1 was swearing at him and called him derogatory names. R2 stated he had water in his cup and poured it on R1. R2 then stated R1 then began hitting him. Both R1 and R2 were separated. R1 was removed and placed in a different hallway on the same floor. R2 was sent to the ER (Emergency Room) for evaluation. R1 refused to go to the hospital. V2 stated, We did our investigation, and the allegation of abuse was substantiated. Yes, it's our job to prevent abuse here.On 2/24/26 at 12:05 PM, V1 (Administrator) stated that R1 talks to himself. R2 got annoyed and threw some kind of liquid at him. Both of them were separated. V1 stated, Based on our investigation, abuse occurred. It's our job to prevent abuse.On 2/24/26 at 3:10 PM, V4 (RN-Registered Nurse) stated that he worked on 2/9/26 when the incident between R1 and R2 happened. He said he was not their assigned nurse. V14 (RN-Registered Nurse) was their assigned nurse but she was attending to another resident. V4 stated he saw R2 in the corner of the hallway lying on the floor while R1 was on top of him hitting the face of R2. V14 rushed to them and calmed R1 and told him to stop hitting R2. He stated the rest of the staff came and separated them. When he asked R1 why he was hitting R2. He said it was self-defense. V4 told V14 what happened, and she took care of the rest. R2 was sent to the hospital.On 2/24/26 at 3:42 PM, V12 (CNA-Certified Nursing Assistant) stated he didn't see R1 and R2 in their room. He heard a commotion and saw them yelling at each other in the hallway. He saw R1 yelling at R2, but he didn't see them hitting at that moment. He saw R2 was on the floor. He stated he didn't know what actually happened for them to be fighting. V12 helped R1 move to new room. He stated that R2 had some bleeding above his eye and above his lip. R2 was transferred to the hospital.On 2/24/26 at 3:59 PM, V13 (CNA) said she heard some yelling. She saw R2 on the floor and R1 was on top of him. They were punching and fighting with each other. She stated the nurses and CNA's came and helped separate them. R1 was moved to another room. Facility's abuse policy titled Abuse Prevention and Reporting (Undated) shows: Guidelines: This facility affirms the right our residents to be free from abuse, neglect.and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse.Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. A resident to resident altercation should be reviewed as a potential situation of abuse.

Based on interview and record review, the facility failed to prevent a resident from being abused by another resident in accordance with facility policy. This applies to 1 of 5 resident (R5) reviewed for abuse in the sample of 9. The findings include:The facility filed a report dated January 12, 2026, to the department that described an incident between R8 and R5. The report showed on January 11, 2026, while in their shared room, R8 hit R5 on the forehead without provocation. R8's EMR (Electronic Medical Record) showed R8 was admitted to the facility on [DATE], and was discharged from the facility on January 15, 2026. R8 had multiple diagnoses including major depressive disorder severe with psychotic symptoms, alcohol and cocaine abuse, chronic obstructive pulmonary disease, and asthma. R5's EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, chronic obstructive pulmonary disease, history of malignant neoplasm of the breast, history of healed femur fracture, history of alcohol abuse, cannabis abuse and anxiety disorder. On February 11, 2026, at 2:30 PM, R5 stated prior to the altercation R5 and R8 were friends and shared a room. R5 stated on January 11, 2026, when R8 came back from community pass R8 was talking loudly and seemed anxious. R5 stated since she and R8 were friends, R5 thought she would be able to calm R8 down. R5 stated she went to the doorway of the bathroom to talk to R8. R5 recalled as R8 came out of the bathroom R8 reached out and pulled R5's hair and hit her on the forehead. R5 stated she quickly left the room and went to get staff assistance. R5 stated she was surprised by R8 and upset by R8's actions. R5 stated she was not injured by R8. On February 10, 2026, at 11:30 AM, V1 (Administrator) stated the incident between R5 and R8 was substantiated for abuse. The facility reported an incident on January 11, 2026, between R5 and R8. An altercation with R8 was the perpetrator and R5 was the victim. R8 was discharged from the facility on January 15, 2026. The incident was investigated and reported as required to the department. R5 stated what R8 did was a surprise to everyone, both staff and R5. R5 stated R5 was a CNA and there was nothing the facility could have done differently to prevent the incident. The facility report indicated abuse was substantiated and that R8 had been discharged from the facility. R5 had no injury related to the incident. The facility's policy titled Abuse Prevention and Reporting dated February 2, 2026, showed the facility affirms the rights of the residents to be free from abuse and establish an environment that promotes resident safety and security.

Based on interviews and record reviews, the facility failed to protect R2's right to be free of abuse from another resident. This applies to 1 of 4 residents (R2) reviewed for physical abuse.The findings include:The facility's Incident Report to IDPH (Illinois Department of Public Health) on 11/14/2025 showed that on 11/10/2025, R3 grabbed R2 by the neck, and the local police were called.On 12/27/2028 at 12:10 PM, R2 said when R3 came to R8/R9's room to see R9, R8 (R9's roommate and R2's girlfriend) told him to get out. R2 stated when he tried to intervene, R3 got upset and punched him in the neck.R2's Face Sheet showed R2 had been residing at the facility since 03/17/2017 with mental health diagnoses including schizoaffective disorder, depressive type, personality disorder, schizophrenia, post-traumatic stress disorder, disorder of psychological development, and suicidal ideation. R2's MDS (Minimum Data Set) dated 12/17/2025 showed R2's cognition is intact. On 12/28/2025 at 1:00 PM, R3 said he went to see R9 in the room, and R8 told him to get out of the room. R3 acknowledged R2 was present and when R2 tried to intervene, R3 got upset and hit R3 on the neck. R3 said he was sent to the hospital for evaluation and that his pass privileges were revoked.R3's Face Sheet showed R3 had been residing at the facility since 10/22/2025 with mental health diagnoses including schizoaffective disorder, anxiety disorder with depressed mood, and adjustment disorder. On 12/28/2025 at 3:30 PM, V9 (Registered Nurse) stated that staff told her R3 was aggressive and pushed R2 by the neck. V9 said the social worker intervened and separated them, and R3 was sent to the hospital for psychiatric evaluations. On 12/28/2025 at 3:00 PM, V1 (Administrator) said that, upon investigation, the incident was substantiated. V1 said the facility failed to provide a safe environment free from abuse for R2. V1 said it is the facility's policy to maintain a secure environment for residents and to ensure they are free from abuse by residents and staff.The facility's Abuse policy dated 01/2020 in part showed that the residents have a right to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment.

Based on interview and record review, the facility failed to assess for, report, and document a resident's acquired pressure wounds prior to the wounds becoming unstageable.This failure resulted in R3 acquiring unstageable pressure injuries to the sacrum measuring 8 x 7 x 0.1 cm (centimeters, measuring length x width x depth) and right medial heel measuring 5.5 x 6 cm x unknown depth.This applies to 1 of 3 residents (R3) reviewed for pressure injuries. The findings include:R3's EMR (Electronic Medical Record) said he was admitted to the facility on [DATE] with multiple diagnoses, including paraplegia, degenerative disease of the nervous system, hereditary and idiopathic neuropathy, neuromuscular dysfunction of the bladder, presence of urogenital implant, ataxia, and impaired mobility. R3's EMR said he was dependent on staff for his ADLs (activities of daily living) care needs, including for toileting and transfers. The EMR said R3 was incontinent of bowel and required substantial staff physical assistance with his transfers. R3's admission Braden scale assessment dated [DATE] said he was at risk for pressure injuries, although R3's 5/2/2025 MDS (Minimal Data Set) said based on his clinical assessments and his Braden Scale, he was not at risk for development of pressure injuries and had none present during the look-back period.On 11/17/2025 at 1:15 PM, V9 (R3's Family Member) said R3 was transferred to the facility because his progressive neuromuscular dysfunction disorder required him to need staff assistance with his care, including toileting and transfers. V9 said R3 had a history of pressure injuries to his hip area and right heel prior to admitting to the facility. V9 said she was informed weeks after he admitted that he had acquired extensive wounds to the sacral area and right heel. V9 said R3 was transferred to the hospital on 5/26/2025 and then went to another facility. V9 said R3 was currently receiving ongoing aggressive treatment for his acquired pressure injuries at the facility. On 11/17/2025 at 12 PM, V11 (Wound Care Nurse/WCN) said she was aware of R3's history of pressure injuries prior to admission. V11 said on 5/19/2025, when assessing R3's healed left buttock non-pressure wound, she identified a new wound on his sacral-coccyx area. V11 said the wound was full-thickness and measured 7.6 x 6.8 x 0.1 cm with moderate serous exudate. V11 said she did not classify R3's wound type and did not document the wound's tissue because she wanted to have V16 (Wound Physician) assess R3 on 5/22/2025. V11 continued to say R3 was dependent on staff for his toileting hygiene and, at times was incontinent of bowel. V11 said staff was expected to assess resident's skin daily during care and report any abnormalities to prevent further skin complications. V11 said R3's sacral wound was not reported prior to her identifying it on 5/19/2025.On 11/17/2025 at 11 AM, V19 (Wound Physician) said he assessed R3 on 5/22/2025 and staged his sacral pressure wound as unstageable due to the necrotic tissue present. V19 said the wound measured 8 x 7 x 0.1 cm and had 40% thick necrotic tissue and required debridement. V19 said he then assessed R3's skin and identified a new wound to his right medial heel. V19 said the wound was also unstageable and presented as DTI (deep tissue injury) with a blood-filled blister. V19 said R3's right heel measured 5.5 x 6 cm x unknown depth. V19 said skin breakdown on residents at risk should be identified early to aid in preventing potential deterioration. V19 said he expected the facility staff to follow their pressure injury prevention and wound assessment policy to ensure residents at risk could be managed appropriately. R3's comprehensive care plan did not indicate he was at risk for skin breakdown prior to 5/19/2025. The care plan was updated on 5/19/2025 to indicate R3 had new facility-acquired wounds to his sacrum on 5/19/2025 and right medial heel on 5/22/2025. R3's ADL report from 5/01/2025-5/26/2025 showed he required limited to extensive assistance with his toileting needs. R3's Bath and Skin Report Sheet for May 2025 showed his weekly (every 7 days) comprehensive skin check was last done on 5/12/2025. The following scheduled skin assessment on 5/19/2025 was not documented.R3's Treatment Nurse Initial Skin Alteration Review (Wound Nurse) report dated 5/19/2025 said R3 had a new facility identified open wound to his coccyx area. The wound measured 7.6 x 6.8 x 0.1 cm. The assessment did not indicate the type of wound and the type of tissue present.R3's Specialty Physician Initial Wound Evaluation and Management Summary report dated 5/22/2025 said R3 had a facility-acquired unstageable (due to necrosis) sacrum full thickness wound. The wound had 40% necrotic tissue with moderate serous drainage and measured 8 x 7 x 0.1 cm. The report also said R3 had another facility acquired unstageable DTI of the right medial heel undetermined thickness wound. The wound measured 5.5 x 6 cm x unknown depth due to blood blood-filled blister. The facility's policy titled Pressure Injury and Skin Condition Assessment Policy, dated 09/2016, said the policy was established to provide guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring interventions were implemented. The policy said each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the Charge Nurse, who will perform the initial assessment. Skin notifications include redness/swelling, blisters, skin discoloration, bleeding, wound drainage, any type of lesion, and changes in skin temperature. The policy said that at the earliest sign of pressure injury or other skin breakdown, and initial assessment and documentation, should be completed in the resident's clinical record. A licensed nurse was responsible for assessing, measuring, and recording pressure wounds in the Wound Assessment Form. The form documentation should include the site, stage of the pressure ulcer, and a comprehensive description of the wound.

Based on interview and record review, the facility failed to follow their policy for an involuntary discharge. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 3. The findings include:R1's EMR (Electronic Medical Record) showed R1 had multiple diagnoses including chronic obstructive pulmonary disease, schizophrenia, and altered mental status. R1's Admission/readmission Screener by V5 (RN/Registered Nurse) dated September 8, 2025, showed R1 was admitted to the facility from a hospital on September 8, 2025. On September 22, 2025, at 9:44 AM, V2 (DON/Director of Nursing) said on September 8, 2025, R1 came to the facility from a hospital. V2 said once R1 was transferred to the facility, R1 exhibited behaviors. V2 said they knew they could not keep R1 in the facility for the safety of the other residents. V2 said R1 was transported to the local hospital but the plan was for him to be sent to the original hospital R1 came from. V2 said R1 returned to the facility in the same day and was sent back out to the local hospital. V2 said R1 spent a week at the local hospital when the facility received a phone call that R1 was returning to the facility. V2 said R1 came back to the facility and arrangements were made for R1 to be sent to the original hospital he came from. V2 said R1 was not issued any involuntary discharge paperwork. On September 22, 2025, at 10:00 AM, V3 (Assistant Administrator) said V3 evaluated R1 at the hospital the week before R1 came to the facility. V3 said R1 was very cooperative when she met R1. V3 said arrangements were made for R1 to be admitted to the facility on [DATE]. V3 said R1 arrived at the facility on September 8 in an ambulance in soft restraints. V3 said the ambulance crew assisted with transferring R1 into his bed in the facility. V3 said once R1 was in the facility he started having behaviors and V3 called the hospital R1 came from and told them the facility could not care for R1. V3 said facility staff monitored R1 while waiting for an ambulance to come to transport R1 back to the hospital he came from. V3 said the ambulance crew was instructed to take R1 back to the original hospital, but R1 was too aggressive so the ambulance transported R1 to the local hospital. V3 said R1 was transferred back to the facility a few hours later and V3 said another ambulance was arranged to send R1 back to the original hospital. V3 said R1 was transported to the local hospital a second time. V3 said she asked the local hospital to stabilize R1 and then transfer him to the original hospital, but was told they were not able to do that. V3 said R1 stayed at the local hospital for about a week and then the facility received a call R1 was being sent back to the facility. V3 said the facility could not care for R1 because he was a safety risk to the other residents. V3 said R1 returned to the facility and transportation was arranged for R1 to be sent to the original hospital. V3 said the original hospital was not happy but V3 told them the facility could not care for R1. V3 said the facility did not complete involuntary discharge paperwork for R1 because he wasn't in the facility for very long. On September 22, 2025, at 12:18 PM, V5 (RN/Registered Nurse) said she was R1's nurse when he first came to the facility on September 8, 2025. V5 said she did an admission assessment on R1 including obtaining his vital signs. V5 said R1 was having behaviors and was difficult to manage. V5 said V3 told V5 R1 was not a good fit for the facility so the admission process stopped for R1. V5 said another nurse had already assisted V5 with entering R1's admission orders. On September 22, 2025, at 3:03 PM, V7 (PRSD/Psychiatric Rehabilitation Services Director) said she assisted with monitoring R1 when he returned from the local hospital on the evening of September 8, 2025. V7 said R1 was in the facility for a few hours because V7 stayed after her shift for about two hours to monitor R1 while they waited for an ambulance to take R1 back to the hospital. V7 said when R1 returned to the facility a week later on September 16, 2025, V7 also monitored R1 while they waited for an ambulance to transport R1 back to the original hospital. On September 22, 2025, at 4:13 PM, V6 (RN) said she was R1's nurse when he returned from the local hospital in the evening of September 8, 2025. V6 said R1 came back to the facility but V6 was told they were not readmitting R1 and he was to be sent back to the original hospital. V6 said R1 was still having behaviors and V6 obtained the order from the psychiatrist to have R1 sent back to the hospital. V6 said the ambulance was supposed to take R1 back to the original hospital but the ambulance crew said R1 was too aggressive so they had to take R1 to the local hospital. A progress note dated September 8, 2025, at 12:38 PM, by V5 (RN) showed Resident arrived to the facility from [original hospital] with two EMTs (Emergency Medical Technicians) via stretcher. Resident is alert but disoriented at times to place and time. He uses a wheelchair for mobility due to poor gait and is able to use walker in the room. Resident has a diagnosis of schizophrenia and mild intellectual disability. He was observed talking to himself out loud at time of admission. Upon admission assessment towards resident, resident made a sexual inappropriate comment towards writer. The writer immediately informed the Assistant Administrator. The resident was also observed spitting on the window. Vitals taken 98.2 temperature, 148/87 blood pressure, 99% (percent) pulse oximetry room air, 99 heart rate. Psychiatric nurse practitioner, [Physician] and Nurse Practitioner were informed of new admit. A progress note dated September 8, 2025, at 4:45 PM, by V6 showed Resident arrived back from [local hospital] Emergency Room, via [ambulance company] stretcher. Ordered to be transferred to [original hospital] emergency room for psychiatric per nurse practitioner. Resident refused all assessments stated 'Get out [expletive],' when attempting to ask questions. Arrived from hospital without belongings or clothing on. In room on one to one until transferring back out. Calm and cooperative at this time. A progress note dated September 8, 2025, at 6:50 PM, by V6 showed Resident aggressive towards co residents and staff, yelling, threatening and swinging fists. Told writer 'I will [expletive] you when I get back baby and I'm coming back for you sent [local hospital] emergency room via [ambulance company] on stretcher. [Ambulance company] was unable to take the resident to [original hospital] due to needing to restrain the resident because of aggressive behavior swinging and spitting at ambulance drivers. No signs/symptoms of pain or distress upon leaving, no belongings to send, bed hold not in place, refused vitals and skin assessment. A progress note dated September 8, 2025, at 7:02 PM, by V11 (Restorative Nurse) showed Resident was admitted into facility for a short-period of time. Functional ability assessments was conducted with information gathered from therapist, floor nurse, and CNAs (Certified Nursing Assistants). Upon admission, resident demonstrated significant aggressive behaviors that were challenging to manage. Following a comprehensive evaluation, it was determined that resident required a higher level of care than the facility could provide. Resident was promptly transferred back to the hospital for further assessment and treatment. On September 22, 2025, at 3:56 PM, V1 (Administrator) said the facility should have followed the facility's policy and completed the proper paperwork and documentation for R1's involuntary discharge. The facility does not have documentation to show R1 or R1's representative was issued a notice in writing regarding R1 not being allowed to return to the facility. R1's medical record does not show a physician documented the reason for R1's discharge was due to the safety of others was endangered. The facility's undated policy titled Involuntary Discharge or Transfer showed A. The facility will provide proper procedure and notification of an involuntary transfer or discharge pursuant to the regulations of the Health Care Financing Administration for States and long term care facilities, 42 CFR 483.12 (federal regulations); and State rules and regulations. B. Procedure: Reason For Transfer or discharge: 1. A resident can be transferred or discharged from the facility based on one of the following reasons: a. The resident's welfare cannot be met at the facility. b. The resident's health has improved sufficiently and the resident no longer needs the services provided by the facility. c. The health and/or safety of individuals in the facility are endangered. This would include residents, facility staff, or facility visitors. d. The resident has failed after reasonable and appropriate notice, to pay for a stay at the facility. Notification and Documentation: 2. Residents, family members, surrogate, and representative must be notified of the transfer and the reasons for the transfer. This notice must be provided in writing thirty days prior to transfer or as soon as practicable in a language and manner understood. As soon as practicable would depend on the reason for the transfer which would include the endangerment; urgent medical needs; or the resident has resided in the facility for less than thirty days. The transfer or discharge shall be discussed with the resident, resident's representative, and person or agency responsible for the resident's placement in the facility. The following forms and documentation will be completed: a. The resident's record must include the (1) reason for the transfer/discharge, (2) needs that cannot be met by the facility, steps taken to meet those needs, and needs that can be met by new facility as documented by resident's physician. Documentation in the notice must (1) demonstrate the condition which warrants the transfer, (2) effective discharged /transferred (4) name, mailing address and phone number of the person responsible for supervising the transfer, (5) name, mailing address, email address and phone number of the Office of the State Long Term Care facility Ombudsman and (6) is the person has intellectual/developmental disabilities or serious mental illness, the name, mailing address, email address and phone number of Equip for Equality. b. The resident's physician must document in the record the reason for discharge is either the resident's welfare cannot be met or the resident's health has improved sufficiently; or any physician can document in the resident's record when the safety of other individuals are endangered. c. The explanation and discussion of the transfer or discharge with the resident and his representative shall be summarized in the resident record. d. the Illinois Department of Public Health (IDPH) prescribed form entitled 'Notice of Involuntary Transfer or Discharge and Opportunity for a Hearing' must be completed and given to the resident with a copy placed in the resident record. Additional copies must be sent by registered or certified mail to the Illinois Department of Public Health, the resident's representative, the Illinois Department of Public aid if applicable, State Long Term Care Ombudsman or Equip for Equality. This information must be documented in the record with corresponding notation of the information having been provided to the resident and appropriate individuals/agencies listed above. The notice to IDPH should be addressed to the Regional Health Officer in the region where the facility is located. Reminders: 5. a. All forms/notices must be accurate and complete. b. Copies of all forms/notices must be placed in the resident record and sent to the appropriate agencies c. The resident's record must include descriptive ongoing documentation to demonstrate the need for transfer/discharge. d. The resident record should include descriptive documentation of all actions taken with dates and times. The record should include all attempts to assist the resident in the transfer/discharge. e. The resident's record should include all attempts made through care planning or other means to assess the resident's needs prior to issuing a thirty day notice. f. The IDPH prescribed form titled 'Notice of Involuntary Transfer or Discharge and Opportunity for a Hearing' includes the required information identifying the Long Term Care Ombudsman and agency responsible for the protection and advocacy of the developmentally disabled or mentally ill. This information needs to be explained at the time of issuing the thirty day notice with corresponding documentation in the resident's record. g. The resident should be offered counseling services with the corresponding documentation placed in the record. f. The facility shall assist the resident in the arranging alternative living arrangements. All assistance will be documented in the resident record.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who need assistance. This applies to 4 of 4 residents (R26, R29, R53, and R59) reviewed for ADL's in a sample of 37. The findings include:1. On 9/03/2025 at 8:22 AM, R29 had a beard and mustache. He stated he wanted to be shaved. He said the CNAs (Certified Nursing Assistants) have no time to shave him. He preferred to be clean shaven.R29's face sheet shows diagnoses of bipolar disorder, anxiety disorder, major depressive disorder, and Parkinsonism. R29's MDS (Minimum Data Set) dated 6/11/25 shows that he has moderate cognitive impairment and needs partial/moderate assistance with personal hygiene. R29's care plan dated 7/24/25 shows that he has a self care deficit and requires assistance with ADL's to maintain the highest possible level of functioning.2. On 9/03/2025 at 8:39 AM, R53 had hair on her chin and above her lip. She said she wants to be shaved.R53's face sheet shows diagnoses of major depressive disorder. R53's MDS dated [DATE] shows that she is cognitively intact and needs set up or clean up assistance with personal hygiene. R53's care plan dated 8/7/25 shows that she has a self care deficit and requires assistance with ADL's to maintain the highest possible level of functioning.3. On 9/3/25 at 8:40 AM, R26 had long fingernails in both hands with a black substance underneath. R26 said she wanted her nails to be cut. She stated that the CNAs usually do it, but they were too busy the last time she asked.R26's face sheet shows diagnoses of major depressive disorder, recurrent severe without psychotic features, anxiety disorder, and Parkinsonism, unspecified. R26's MDS dated [DATE] shows that she is cognitively intact and needs supervision or touching assistance with personal hygiene. R26's care plan dated 12/13/24 shows she has a self-care deficit and requires assistance with ADL's to maintain the highest possible level of functioning.4. On 9/03/2025 at 8:50 AM, R59 had a beard and wanted to be shaved. He said staff are too busy to shave it for him.R59's face sheet shows diagnoses of bipolar disorder, unspecified, paranoid schizophrenia and generalized anxiety disorder. R59's MDS dated [DATE] shows that he is cognitively intact and needs setup or clean-up assistance with personal hygiene. R59's care plan dated 6/14/24 shows he has a self-care deficit and requires assistance with ADL's to maintain the highest possible level of functioning.On 9/04/2025 at 9:11 AM, V2 (DON-Director of Nursing) stated that CNA's are responsible for doing ADL's such as shaving and nail care during showers and as needed.Facility's policy titled ADL's (4/14/25) shows: To preserve ADL function, promote independence, and increase self-esteem and dignity. Interventions: Grooming-Maintaining personal hygiene including shaving and self-manicure (safety awareness with nail care) .

Based on observation, interview and record review, the facility failed to safely store medications.This applies to 5 of 5 residents (R23, R75, R80, R89, and R140) reviewed for medication storage in a sample of 37. The findings include: 1.On 9/2/25 at 11:22 AM R89 was observed resting in bed and said he had not been feeling well. A pill cup with medications was noted on his bedside table. At 11:26 AM R89's nurse, V7 (RN/Registered Nurse) entered R89's room and R89 told V7 he was still waiting for his cough medicine. R89 replied to V7, what about the pills? and pointed to the cup of pills left on the bedside table. On 9/2/25 at 11:29 AM V7 said the pills in the cup were all of R89's scheduled 10 AM medications that V7 left at R89's bedside. R89's MAR (Medications Administration Record) shows his 10 AM medications on 9/2/25 and reasons for taking each medication include: Clopidogrel/Plavix for heart arrhythmia, Furosemide/Lasix for high blood pressure, Loratidine for allergies, multivitamin, folic acid for supplement, Gabapentin/Neurontin for lumbar radiculopathy, Metoprolol for high blood pressure, and Venlafaxine for anxiety disorder. On 9/4/25 at 12:24 PM V7 (RN) said he should not have left medications at R89's bedside during medication pass because another resident could enter the room and consume those medications or the resident could end up not taking the medications until a later/off schedule time and it would be too close to the next medication administration time. V7 said if he brings medications in to a resident and they say they do not want to medications at that time, he should remove the medications from the resident's room and come back later to administer them. On 9/4/25 at 12:53 PM, V2 (DON/Director of Nursing) said medications should never be left at a resident's bedside because of safety reasons: we want to make sure no other resident will pick up the medications and take it for themselves and also that the medications are taken by the intended resident at the scheduled time. V2 said there are extra risks of dangerous side effects from the medications if taken by the wrong resident, such as bleeding with Plavix and low blood pressure with Metoprolol or Lasix. V2 also said the efficacy, or effectiveness of the medications will not be as good if the intended resident takes the medications later than scheduled. The facility's policy titled, Medication Administration Policy dated 8/15 states, Policy: I. Level of Responsibility: Medication Storage Areas (medication room, medication cart, and treatment cart) must be locked when not in use by authorized personnel .II. Administration of Medications: Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. 2. On 9/2/25 at 10:57 AM, R75 had a bottle of antifungal powder in front of his TV. He said he puts it on his feet as needed. R75's POS (Physician Order Sheet) had no order for antifungal Powder. 3. On 9/2/25 at 10:05, R80 said she is recovering from respiratory infection. She had nasal spray on top of her drawers. She said the nurses do not want to keep it at their cart because she gets saliva and mucus on it when she uses it. R80 also had a bottle of antacid on her bedside on the right side of her bed. R80's POS shows an order for Nasal Suspension. One spray in both nostrils two times a day for allergies and antacid tablet chewable 500 mg, give two tablets by mouth every six hours as needed for heartburn. 4. On 9/2/25 at 11:10 AM, R140 had an albuterol inhaler on bedside table on left side of his bed. He said he uses it when he needs to when he has a hard time breathing. R140's POS shows an order for Albuterol Sulfate Inhalation Aerosol Powder Breath activated. 2 puffs, inhale orally every four hours as needed for shortness of breath. On 9/4/25 at 9:09 AM, V2 (DON-Director of Nursing) said medications should be kept in the medication room or medication cart where it can be locked. She said she does not know of any resident who can keep medication by the bedside. 5. On 9/02/2025 at 11:20 AM, on R23's bedside table, there was a tube of 1 oz (ounce) antifungal Cream 1% and a tube of 0.5 fluid oz of Medi-honey. R23 was not in her room. On 9/3/25 at 8:25 AM, R23 was in her room. R23 stated, Someone dropped of the antifungal cream here. I don't know whose it is. I don't use it. R23 stated the Medi-honey has been there for a while and she uses it for the wrinkles on her hands. R23's MDS (Minimum Data Set) dated 8/8/25 shows she is moderately impaired in cognition. Review of R23's POS (Physician Order Sheet) shows she has no orders for the antifungal or Medi-honey. Facility's Policy on Medication Administration dated 8/15 states the following: 1. Level of Responsibility Medication Storage Areas (medication room, medication cart, and treatment cart) must be locked when not in use by authorized personnel. This includes medications delivered from Consulting Pharmacy, brought in by Resident and/or Family or mail order delivery. All medications must be properly labeled with resident's name, dosage and frequency. Medications labeled Refrigerate must be kept in refrigerator. Multi-use vials and house stock liquids must be dated when opened. Authorized personnel include licensed nurse and the facility's pharmacists. Any other individual needing access to a medication storage area must be supervised by an authorized person while in the medication area.

Based on observation, interview and record review, the facility failed to provide an appropriate size bed to meet resident needs. This applies to 1 of 3 residents (R70) reviewed in a sample of 37.The findings include: On 9/2/25 at 1 1:38 AM, R70 was lying in bed in bed with an overhead trapeze (mobility device made of metal) hanging above his head. R70's bed was perpendicular to the bed of his roommate (R69), who happens to be his mother. The right side of R70's bed was flush against the wall with his feet facing R69. R70's feet were pressed against the footboard and, the right side of his face and body was pressed against the wall. R70 stated, look at me, I'm pinned against this wall; I don't have enough space to turn. I'm too tall for this bed. R70 stated he had requested for his bed to be positioned parallel to R69's so they could talk, and he could watch television without having to turn his neck. He also stated that he is a big guy and had previously requested a bigger (longer and wider) bed. According to R70, he also requested that his overhead trapeze be removed, and that side rails or enablers be placed for easier bed mobility. He explained that he is unable to sit up in bed because the trapeze hits his face when he is upright. At the time of observation, R70's bed was elevated at approximately 45 degrees, and the overhead trapeze was about three inches away from his head. R70's care plan, reviewed on 9/2/25, directs staff to utilize person-centered care models that afford (R70) as much initiative, control, and self-determination as possible to address his physical, psychological, and social needs. Care plan interventions dated 6/5/25 include: 1) Elevate the head of the bed to a 90-degree angle (to prevent shortness of breath related to his asthma diagnosis); 2) Encourage correct positioning (to promote comfort and to prevent muscle and joint strain); and 3) Offload R70's heels (to prevent pressure injury). At the time of the survey, R70's EMR (Electronic Medical Record) did not reflect behaviors or refusal of interventions. The EMR showed his weight as 240.6 lbs. (pounds) taken on 9/1/25 and a height of 74 inches (entered on 6/4/25).On 9/4/25 at 11:45 AM, V2 (Director of Nursing) stated that the facility does not have a specific policy outlining criteria for when to provide residents with bariatric beds. V2 explained that, since the facility does not use specific height or weight parameters, residents are provided with bariatric beds on a case-by-case basis. V2 stated she had just come from R70's room and, based on her assessment a few minutes ago, R70's current bed was appropriate for his height and weight. According to V2, R70 did not require a different type of bed-whether longer, wider, or both-at this time. V2 and V3 (Assistant Director of Nursing) were unable to provide the actual measurements or manufacturer's guidelines for R70's bed.On 9/4/25 at 12:52 PM, R70 was lying in bed while watching television. A label located on the lower left side of the bed listed the manufacturer as Basic American Products, with serial number 12020004833 and model number [PHONE NUMBER]-064020. The model specifications reflect a total bed length of 76 inches. R70's height is documented as 74 inches, providing approximately 2 inches of clearance.

Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment. This applies to 1 of 1 resident (R179) reviewed for environment in a sample of 37. The findings include:On 9/03/2025 at 8:55 AM, R179 stated, My window is broken, the bottom half part. Do you see all the sharp pieces? R179 stated that the window has been broken for the past 2 years. He stated that he told everyone, but no one has done anything. R179 stated he used to feed the birds, but because of the broken glass he doesn't want to cut his hands. R179's MDS (Minimum Data Set) dated 8/20/25 shows that he is cognitively intact. R179's window had a broken bottom half with jagged and sharp edges where the damaged glass was exposed. There was a piece of cardboard on it.On 9/03/2025 at 11:57 AM, V4 (Maintenance Director) stated he has been working in the facility for two years. He stated he didn't see a work order for R179. V4 stated that R179 never told him anything about his window being broken. V4 stated, It might have been broken before I got here. On 9/3/25 at 12:10 PM, V4 stated that he talked to one of the housekeepers. He said that housekeeper told the housekeeping director about the broken window a week ago but failed to tell him.Facility's policy titled Preventative Maintenance Program (4/21/21) shows: 3. Preventative Maintenance Program will review the following areas during random rounds: 5. All facility areas are kept clean and in safe condition.

Based on observation, interview, and record review, the facility failed to ensure residents received oxygen therapy as ordered by physician.This applies to 2 of 3 residents (R130 and R69) reviewed for respiratory care in a sample of 37. The findings include: 1.R130's Face Sheet shows a primary admission diagnosis of Chronic Obstructive Pulmonary Disease. R130 also has diagnoses of dependence on supplemental oxygen and congestive heart failure. R130's MDS (Minimum Data Set) dated 8/6/25 shows her cognition is intact. On 9/2/25 at 10:51 AM, R130 was observed using 4 liters of oxygen per nasal cannula connected to oxygen concentrator. R130's oxygen concentrator had the humidifier water and canister, but it did not have any tubing connecting the humidifier to the oxygen. R130 said the staff have not given her the tubing for the humidifier and told her they do not have the tubing. On 9/3/25 at 3:01 PM, R130 was again observed wearing her 4 liters of oxygen, off the concentrator, without any humidity. It was noted the humidifier canister was no longer on the concentrator and R130 said she still was not provided the tubing to connect the humidity to the concentrator. R130 said she had connected her nasal cannula to the humidifier instead of the oxygen concentrator in the past, and because she did not have the correct tubing, she was not getting any oxygen. On 9/4/25 at 12:24 PM, V7 (RN/Registered Nurse) said if a resident has a physician's order for humidified oxygen, they should be receiving it. V7 said R130 did not have her oxygen humidified because he did not know she had an order for humidified oxygen. V7 said the facility does not have respiratory therapists, the nurses do all of the respiratory therapy, but he was not sure were to obtain the tubing to attach the humidifier to the oxygen concentrator. On 9/4/25 at 12:53 PM, V2 (DON/Director of Nursing) said if the physician's order shows humidified oxygen, the resident should be getting their oxygen humidified. V2 said if the resident needs humidity and they are not getting it, they can get nasal dryness and irritation. R130's Care Plan dated 11/21/24 states R130 has altered respiratory function secondary to Chronic Obstructive Pulmonary Disease (COPD) and OSA (Obstructive Sleep Apnea). Interventions include administer oxygen continuously as ordered by physician. R130's POS (Physican Order Sheet) shows order dated 8/22/24 for oxygen 4 liters per minute humidified to keep oxygen saturation above 92%. The facility's policy titled, Oxygen Therapy dated 9/19 states, Objective: To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues.Procedure: 1. Explain procedure to patient and bring equipment to bedside.5. Try to keep patient as comfortable as possible.8. Give oxygen per physician order. 2. R69's face sheet shows diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, R69's MDS dated [DATE] shows her cognition is intact. R69's POS (Physician Order Sheet) shows an order for oxygen at 3 liters per minute via nasal cannula as needed to keep oxygen saturation above 92%. On 9/2/25 at 11:30 AM, R69 was lying in bed watching television and receiving oxygen via nasal cannula at 5 liters per minute. The nasal cannula tubing was connected directly to the oxygen concentrator without a humidifier or adaptor. R69 stated that the higher flow of oxygen dries out her nose and affects her sinuses. She also stated that staff increases her oxygen flow rate from 3 liters to 5 liters per minute when she feels short of breath. On 9/4/25 at 11:50 AM, V2 said oxygen settings are based on physician orders as stated in the POS and humidifiers should be used for oxygen rates that are 5 liters per minute or more.

Based on interview and record review, the facility failed to assist a resident in obtaining emergency dental services.This applies to 1 of 3 residents (R34) reviewed for dental services in a sample of 37.Findings include:On 9/02/2025 at 11:00 AM, R34 said he had ongoing right molar pain, 9 out of 10. R34 said he started to experience tooth problems in February 2025, when his tooth began to chip off. R34 said during his routine dental visit in February 2025, he was informed he needed a root canal extraction procedure to manage his tooth pain. R34 said his tooth was now more chipped and causing him more discomfort, especially when eating. R34 said he continuously tried to follow up with V6 (Social Worker) for assistance with his dental referral and was still waiting to receive an update.On 9/04/2025 at 11:00 AM, V6 (Social Worker) said he was responsible with assisting residents who required outside dental referral services, including for tooth extractions. V6 said he was informed in February 2025, regarding R34's needed dental procedure. V6 said based on R34's Medicaid insurance provider, he had difficulty assisting him with his dental care needs. V6 said he stopped assisting R34 because he was unsure how else to assist him with his referral. V6 said he asked R34 to contact his insurance directly for further assistance. V6 said he did not document in R34's EMR (Electronic Medical Record) regarding his dental referral attempts. V6 said he also did not discuss R34's dental needs with V1. On 9/03/2025 at 2:40 PM, V1 (Administrator) said all residents should be assisted with their dental services, including with outside specialty referrals regardless of their payer source. V1 said if needed, the facility was able to assist residents financially with their needed dental procedures to ensure they received proper oral care management. R34's Order Summary Report dated 9/04/2025 showed an active order for May receive services of.dental.and any other specialist as deemed necessary initiated on 10/24/2024.R34's infectious disease progress note dated 2/25/2025, said followed for dental procedure ppx. Patient was seen by dentist who prescribed him abx Amoxicillin 500mg TID x 7 days for right lower tooth infection, needing root canal pending insurance approval. Patient tolerating abx well, however pain still persistent. Patient has PRN Norco available for pain relief. Tooth chipped.Patient needs to follow up with the dentist for root canal.R34's EMR did not show any further progress notes regarding the facility staff following up or assisting him with his dental care needs. R34's EMR also did not include his dental consultation assessment report from February 2025 with his tooth extraction referral.The facility's policy titled Routine Dental Care undated, said Policy Statement Each resident will receive routine dental care. 1. The nursing care staff will conduct ongoing oral health assessments to assure that each resident receives adequate oral hygiene. 2. The attending physician will be notified of a resident's need for dental treatment and order dental consultation as appropriate. 3. The attending physician will include, as a part of his/her initial medical assessment an assessment of the resident's dental needs. Findings will be included in the resident's medical record.

Based on observation, interview, and record review, the facility failed to remove expired food items from resident refrigerators and failed to provide a thermometer.This applies to 3 of 5 residents (R75, R110, and R181) reviewed in a sample of 37.The findings include: On 9/2/25 at 10:00 AM, initial tour of the first floor was conducted. The following observations were made: 1. On 9/2/25 at 10:57 AM, R75's fridge had two 15 oz cups of peach in his fridge. The peach cups expired on June 14, 2025. He said it is the cleaning lady who checks his fridge but is not done daily. 2. On 9/2/25 at 12:21 PM, R110's fridge had expired half consumed vegan cream cheese. The vegan cream cheese expired on 5/15/25. She said she has not seen any staff cleaning her fridge in days. On 09/3/25 at 12:21 PM, V5 (Housekeeping Director) said housekeepers are responsible for keeping the refrigerators clean. She said housekeepers should clean the refrigerators every day and dispose of expired foods. She said all expired foods should be thrown away for safety reasons. On 9/4/25 at 9:09 AM, V2 (DON-Director of Nursing) said it is the housekeeper's responsibility to clean the fridge and to get rid of expired food items. Facility's policy titled Food Brought in by Family or Visitors Personal Refrigerators (2017) documents: Refrigerators are cleaned regularly to maintain a safe and sanitary environment for food storage. Refrigerated foods that have been opened or left-over foods that are stored in the refrigerator will be marked with use-by date. The use-by date is six days from the day the food was opened or the day the left-over food was put in the refrigerator. Perishable foods are discarded on the sixth day after preparation/opening or on the expiration date. Facility's Policy titled Food Storage-Outside Sources (1/19) documents: : 3. Staff will be responsible for checking resident personal refrigerator daily for proper labeling, temperature recording and storage maintaining 34-40 degrees. 4. Facility staff will monitor resident rooms, resident personal refrigerators, unit pantries as well as facility refrigerators and freezers for food and beverage disposal needs for safety. 3. On 9/2/25 at 10:28 AM, R181's fridge had one 8 oz carton of milk and one 6 oz carton of Mighty Shake (fortified nutritional supplement). Both cartons had smudged expiration dates that were illegible. The contents of both cartons appeared white and curdled. There was no thermometer inside his fridge R181 said the facility does not check the temperature or contents of his refrigerator.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure resulted in R2 experiencing a right medial orbital (eye socket) wall blowout fracture when R1 became physically aggressive towards R2. This applies to 1 of 3 residents (R1) reviewed for resident-to-resident abuse in the sample of 5. The findings include: The facility's Final Incident Investigation Report Form submitted to IDPH (Illinois Department of Public Health) on May 9, 2025 shows, The incident happened on May 3, 2025 at 11:00 PM. The incident was reported to abuse coordinator by [V6] (RN-Registered Nurse), and a preliminary report was sent. The alleged perpetrator is [R1], and the alleged victim is [R2]. It was reported that [R1] was physically aggressive towards [R2]. [R1] was sent out for psych evaluation and [R2] was sent out for medical evaluation. The local police were called and on site. Although there were plans for [R1] to be sent out for psych evaluation, he was arrested instead. When [R2] came back from the hospital, hospital records indicate that [R2] has a fracture of the medial wall of the right orbit. [R1] was released from [local county jail] but has a court order that he isn't allowed within 900 feet of the facility Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: With the available information, this incident is substantiated. Abuse is substantiated as follows: [R2] stated that [R1] came to his room and was swearing and calling [R2] racial slurs. [R1] left, then came back and slammed [R2's] door. Then he was swearing and using racial slurs towards [R2]. [R1] got up in [R2's] face and proceeded to hit [R2] across the face. [R2] hit the ground. Then [R1] got on top of [R2] and held him by his neck while swearing, yelling, and using racial slurs towards [R2]. A nurse/CNA (Certified Nursing Assistant) came rushing in the room and that is when [R1] stopped being physically aggressive towards [R2] and being distress by claiming that he was the victim. [R2] states his nose still hurts from the incident, and he is afraid [R1] will come back and hurt him again. [R2] stated prior to the incident [R1] was texting him; using racial slurs and threatening that he would hurt him. [R1] was upset with someone that isn't a resident at the facility and he was upset that [R2] would not provide him with this person's phone number, even though he told [R1] that he had nothing to do with situation. R2's hospital records dated May 3, 2025 at 11:51 PM show the following CT (Computed Tomography) scan results: CT of R2's face shows a right medial orbital wall blowout fracture. Patient has no entrapment on exam or visual field deficits. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 left the faciity on [DATE] in the custody of the police, following a physical altercation with another resident, and did not return to the facility. R1 had multiple diagnoses including, ischemic heart disease, hypertension, low back pain, rheumatoid arthritis of the left knee, gout, anxiety disorder, PTSD (Post-Traumatic Stress Disorder), and heart disease. R1's MDS (Minimum Data Set) dated March 5, 2025 shows R1 was cognitively intact, required setup with personal hygiene, and was independent with all other ADLs (Activities of Daily Living). R1 was always continent of bowel and bladder. The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, Type 2 diabetes, gastritis, cocaine abuse, cannabis abuse, schizophrenia, encephalopathy, alcohol abuse, bipolar disorder, and asthma. R2's MDS dated [DATE] shows R2 is cognitively intact, is independent with eating, requires setup assistance with oral hygiene and bed mobility, and supervision with all other ADLs. R2 is always continent of bowel and bladder. On May 14, 2025 at 10:37 AM, R2 was lying in bed in his room. The window shades were drawn, and the room was dimly lit. R2 did not wake up when his name was called or while speaking to R5 (R2's roommate). On May 14, 2025 at 1:17 PM, R2 was lying in bed in his room. R2 did not have any visible facial bruising or swelling. R2 denied vision problems. R2 said, On Saturday night (May 3, 2025), [R1] was upset about someone else, and he took it out on me. He argues a lot to get his point across. He was texting me from his room and saying he was coming down to my room. I told him not to, that it was late at night, around 11:00 PM, and I was already trying to sleep for the night. He came into my room and called me the N word. I yelled at him to get out of my room. He choked me and punched me in the face, and I fell from my bed to [R5's] side of the room, and [R5] tried to break things up. The CNA heard it all happening through the wall from next door and came running in. They sent me to the hospital, and I got a scan of my head and that's how they found the broken eye socket. I am very afraid he will come back to the facility and do the same thing to me again. He always broke the rules, so what is to stop him from breaking the rules and coming back here? I am afraid to go outside of the facility because he might come here and he knows where I like to go, so I haven't gone out. On May 14, 2025 at 1:25 PM, R5 came to R2's room and said he is R2's roommate and was present on May 3, 2025 when R1 came to the room and was physically aggressive with R2. R5 said he heard R1 yelling at R2 and saw R1 hit R2. On May 14, 2025 at 12:53 PM, V7 (LPN-Licensed Practical Nurse) said, I was the night shift nurse taking care of [R2]. The incident happened at change of shift. We were doing report and the CNA alerted me that something had happened between [R1] and [R2]. I did not see any visible injury. I called the police to help with the incident, and also the physician. The police called the paramedics for backup, and they took [R2] to the hospital. On May 14, 2025 at 3:09 PM, V6 (RN) said, I was working the afternoon shift on May 3, 2025. I was caring for [R1]. It was change of shift when the incident happened, and I was still at the facility. I gave [R1] medication at 11:00 PM, and then I went to the medication room. I was setting up my cart for the next shift, and they came and told me there was an incident. They took [R1] out of the facility in handcuffs. On May 14, 2025 at 5:22 PM, V10 (CNA) said, I normally work night shift, and I pick up afternoon shifts quite often. I was working afternoon shift that day (May 3, 2025). I was watching [R1]. He was talking to someone at the nurse's station, and he went down [R2's] hallway. We have to keep an eye on him, but not make it obvious because he got mad when we followed him. I went to go check on my residents one last time and I was in the room next to [R2's] room, where [R1] had just entered. All of a sudden, I heard what sounded like a body being slammed against the wall and hit the floor. I ran into that room and caught the end of the altercation. We got [R1] to leave the room, and I stayed outside of the room to make sure [R1] didn't go back in the room. Someone else called the police. On May 14, 2025 at 1:06 PM, V8 (NP-Nurse Practitioner) said, she was familiar with R2. V8 said, The orbital fracture was as a result of the altercation. V8 continued to say she attempted to examine R2 following his hospitalization for the injury sustained following the physical altercation, but R2 was sleeping at the time of her visit and did not wake up to be examined. The facility's undated Abuse Prevention Program Policy, number 71146759.3 shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Definition: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, direct care staff member failed to follow the facility's policy and procedures and immediately notify the nurse after a resident fall. This failure led to a delay of assessment by the nursing staff for the resident within the required time frame. This applies to 1of 3 residents (R1) reviewed for falls in a sample of 8. The findings include: On 4/16/25 at 10:13 AM, V4 (CNA-Certified Nursing Assistant) stated, On 4/7/25 between 10 AM to 10:15 AM, I brought (R1) to the shower room in his wheelchair. I put him on the shower chair. I had (R1) stand up and grab the handlebars. I scrubbed his back and butt with soap and a washcloth. Then I told (R1) to sit back down on his shower chair. Within 1 to 2 seconds, (R1) slides off. I picked him up and put him back on the chair. I asked (R1), does it hurt. He said no and that he has no pain. There were no injuries. I continued the shower. I asked (R1) if he wants me to tell anyone. (R1) said, Na, don't tell anyone right away. I dried him and put him in his gown and wheeled him back to his room. When I got to his room, I dressed (R1) in his regular clothes. I again asked him if he's okay and he said Yeah, I'm okay. I said do you want me to tell anyone about the fall. He said no. I forgot the name of the nurse who was working that day. I didn't tell the nurse. I should have reported it to her because she needed to assess him. I left his room and went to take care of my other residents. After work, I had class. V2 (DON-Director of Nursing) called me on the phone. She asked me what happened with (R1) in the shower room. I told her (R1) fell . She asked me why I didn't tell the nurse. She said she has to discipline me and she wrote me up. I know I should have reported the fall to the nurse. On 4/16/25 at 10:47 AM, V1 (Administrator) stated, (V4) should have reported (R1)'s fall to the nurse right away. (V4) has to call the nurse and she has to do the assessment before he can be picked up from the floor. In the evening, (R1) told (V12--R1's sister) about the fall that happened in morning shift when she came to visit him. Then (V12) told the evening nurse (V6-RN/Registered Nurse) about the fall. (V6) then did the assessment. There were no injuries. On 4/16/25 at 11:20 AM, R1 stated, (V4) gave me a shower. I was sitting on the shower bench. I stood up and grabbed the bar. (V4) scrubbed me with soap. Then I sat down in the middle of the bench. I sprayed myself with water. I think I may have dozed off. I slid off the bench. (V4) tried to pick him up. Then he put me back on the bench. He told me if I was gonna say anything to anyone. I said no. No nurse came and saw me in the morning. Then in the evening I told my sister (V12). Then she told the nurse. I don't know her name. The nursed asked me my name. They didn't do any vitals. I had no pain or injuries. On 4/16/25 at 12:06 PM, V6 (RN) stated, I worked on 4/7/25. I picked up a shift and started at 3 PM. The morning nurse never told me that (R1) fell because (V4) never told her about the fall. After I was done with the medication pass, (V12-R1's sister) came to the nursing station and wanted to talk to me. She told me that (R1) told her that he fell in the morning. I told her that the morning nurse never told me that. I checked the risk management in the computer to see if a fall happened. Nothing was there. I went to (R1)'s room. I asked (R1) what happened. He told me that he fell . I assessed him. (R1) told me that he didn't want to make a big deal about it and that's why he didn't tell the nurse. He told me he landed on his buttocks. He said (V4) helped or assisted him back to the chair. He was confused and and then said he thought (V4) pushed him. He had no pain during the time of the fall and when I assessed him. He had no injuries. When I gave (R1) his medication and checked his blood sugar at 4 PM, he didn't tell me anything about the fall then. I then notified nurse practitioner and the psychiatric nurse practitioner, (V1) and (V2). Yes, when a resident has a fall, the CNA has to report it to the nurse right away. On 4/16/25 at 12:40 PM, V7 (RN) stated, I worked in the morning on Monday 4/7/25 on the 400 unit from 7 AM To 3:30 PM. I was the nurse for (R1). (V4) was my CNA and he was assigned to (R1). (V4) never told me that (R1) fell . (R1) never told me that he fell also. If a resident falls, the CNA or whoever saw the fall has to call the nurse immediately. The nurse has to watch and see the position of the resident. The nurse has to assess for pain and range of motion. On 4/16/25 at 2:33 PM, V2 (DON-Director of Nursing) stated, (V4) was supposed to leave (R1) on the floor for safety reason when he fell in the shower room. Then he was supposed to inform the nurse, so the nurse could assess (R1) and determine if he could be safely transferred back to the shower chair and then his wheelchair. I talked to him on the phone. He told me that (R1) fell in the shower room, but he never reported it to the nurse. I did counseling over the phone. On 4/16/25 at 2:48 PM, V3 (ADON-Assistant Director of Nursing) stated she did a disciplinary with V4). She confirmed that V4 should have notified the nurse right away after the fall. V3 submitted the corrective action form dated 4/11/25 for V4. It shows he received counseling for not reporting a fall incident to the nurse in a timely manner and that it was an informal warning. R1's face sheet shows diagnoses of: cerebral infarction, adjustment disorder with depressed mood, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1's MDS (Minimum Data Set) dated 2/19/25 shows a BIMS (Brief Interview for Mental Status) score of 12 which means moderate cognitive impairment. R1 has impairments on one side of his upper and lower extremities. For showers, R1 was assessed as a 3, which means he needs partial/moderate assistance. For tub/shower transfer, he was assessed as a 2, which means he needs substantial/maximal assistance. R1's care plan dated 12/4/24 shows he is at risk for falls related to used of antidepressants, decreased safety awareness, and left sided weakness. Intervention: Anticipate and intervene to prevent recurrence. R1's progress notes and incident report dated 4/7/25 shows the following: Writer reported by (R1)'s sister that (R1) had fall this morning in 300 hall shower room. Per CNA who was with giving shower to (R1), CNA was soaping (R1)'s back while (R1) was standing and holding the grab bar. (R1) proceeded to sit down on the shower chair and slid off the chair because (R1) was not seated right and was still soapy. (R1) told CNA to pick him up from the floor and continue with the shower and not make a big deal about it. (R1) stated, After applying soap, I slid off from my wheelchair and landed on my buttocks, assigned CNA assisted me back to wheelchair. I didn't report it to my morning nurse. (R1) doesn't remember the exact time of fall incident. Writer assessed (R1) from head to toe with limited range of motion in lower and upper extremities; left side weakness as per usual due to CVA, denied hitting his head, no injuries were noted. Denied any pain and discomfort. Vitals done .Reminded (R1) to ask for help if needed and pull the call light for help. Facility's policy titled Falls (Undated) shows: Observed or unobserved and reported by staff member. Licensed nurse should conduct assessment immediately, including events leading up to the fall to determine when possible and causative factors 1. Observe positioning and overall conditioning. If head and neck are bent forward or backward in an extreme degree, do not move until seen by a physician .CNA: 1. Call for nurse and stay with resident. 3. Do not move.

Based on observation, interview and record review the facility failed to ensure residents were free from mental abuse for 3 of 8 residents (R2, R3, R6) reviewed for abuse in the sample of 14. This failure resulted in R2 feeling fearful of R1 and socially isolating due to R1's threats against him. This failure resulted in R6 suffering mental anguish related to R1's threats to physically harm and kill R6. This failure resulted in R3 being fearful of physical and mental retaliation from R1. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/17/25 when R2 reported to V1 Administrator that sometime late February (2025) R1 had threatened to kill him. These failures resulted in R2, R3, and R6 experiencing psychosocial harm. The Immediate Jeopardy was identified on 3/31/25. V1 Administrator was notified of the Immediate Jeopardy on 3/31/25. This surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 3/31/25 however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: An initial facility abuse investigation report dated 3/17/25 showed R2 reported to V1 Administrator that R1 had threatened to kill and strangle him if R2 told facility staff that R1 had sold R2 marijuana. The final facility abuse investigation report dated 3/24/25 showed, on 3/18/25, R6 reported to V1 Administrator that R1 had offered R6 drugs in the facility. When R6 refused the drugs from R1, R1 became angry and told R6 that he would knock out his teeth if R6 reported to anyone that R1 had offered him drugs. R6 stated R1 threatened to break R6's neck and throw you out the window to make it look like a suicide. Per the report, R6 stated, on another occasion, R1 came into R6's room and told R6, I will kill you if you snitch on me. I have no one to lose. I will kill you and make it look like you are having a seizure. The final facility abuse investigation report showed, on 3/18/25, R3 reported to V1 Administrator that he too was afraid of R1. R3 stated R1 hid alcohol bottles in R3's room. R3 stated R1 is very threatening and intimidating. I don't want to be here if he is here. Once he threatened to beat me . I am terrified and want to be left alone . He (R1) knows a lot of people on the street, if he finds out I can get killed easily. The report showed R3 was visibly shaking, when speaking about R1, to V1 Administrator on 3/18/25. The facility's final abuse investigation report dated 3/24/25 showed abuse was substantiated related to the actions of R1. A police report was filed. R1's Admission Record showed R1 was admitted to the facility on [DATE] for rehabilitation therapy services due to his diagnosis of low back pain. R1's current care plan showed R1 was cognitively intact, ambulatory, and needed no staff assistance to complete his activities of daily living. The plan showed R1 had a history of verbally aggressive behaviors towards others. The plan showed R1 was an identified offender due to his criminal history of attempted armed violence. R1's progress and nursing notes dated November 2024-March 2025 were reviewed. These notes showed multiple documented episodes of R1 having alcohol, drugs, and drug paraphernalia in the facility. The notes showed incidents of R1 being verbally aggressive and threatening towards residents and staff. The notes showed incidents of R1 repeatedly disobeying facility rules and leaving the facility despite his community pass privileges being revoked due to his behaviors. They showed multiple incidents of the local police being called to the facility due to R1's behaviors. A note dated 2/6/25 showed the facility served R1 a 30-day discharge notice due to his behaviors and R1 no longer needing skilled nursing services. R1 appealed his discharge. A note dated 3/3/25 showed a coat, belonging to R1, was found in the facility containing 9 bags of marijuana, a scale and a pipe. A note dated 3/11/25 showed R1 was sent to a local behavioral health hospital due to R1 threatening to shoot V1 Administrator and V2 Assistant Administrator. R1 was allowed to return to the facility on [DATE] pending the appeal related to his discharge. Upon return from the hospital, R1's notes dated 3/20/25-3/31/25 showed R1's behaviors continued. On 3/21/25, R1 walked out of the facility and did not return until noon on 3/22/25. On 3/23/25, R1 was verbally aggressive with staff. On 3/23/25, it was reported to facility staff that R1 had been smoking crack with another resident. On 3/25/25, R1 was found in another resident's room. R1 took food from the resident's room, and left. On 3/27/25 at 8:45 AM, R1 was in his room, lying in bed. R1 denied selling drugs to any residents in the facility. When this surveyor asked R1 about his interactions with R2 and if he had ever threatened R2, R1 began to get upset and his voice became louder. He immediately stood up from his bed, took a step towards this surveyor and stated, I have already told this story before. I already talked to the police. R1's voice continued to raise his voice as he spoke. R1 began walking towards the door of his room. R1 very loudly asked this surveyor to leave his room. This surveyor exited R1's room. 1. R2's Admission Record dated 12/5/24 showed R2 was admitted to the facility with diagnoses of autism, developmental delays and a heart transplant. R2's admission nurse practitioner note dated 12/30/24 showed R2 was cognitively intact. On 3/27/25 at 8:30 AM, R2 was in his room, lying in bed, with the lights off. R2 stated R1 threatened to kill R2 sometime in late February if I snitched and told anyone where I got my pot (marijuana) from. R2 stated he had bought marijuana from R1 in February. R1 stated, After I bought pot from him, there were a couple of times when (R1) would just come into my room (unannounced). I was definitely scared of him then. He never asked to come in my room . after that, I finally told on him because I was angry from what he said to me and I was also a little scared of him . Now that (R1) is back from the hospital, I just stay away from him. I stay in my room to avoid him. I know he has other people (residents) watching me so he knows who I talk to. I am still a little scared of him . On 3/27/25, V5 Social Services stated R2 had reported to V5 in the past that R2 did not feel safe around R1 because R1 had threatened to choke him (R2) out if R2 told anyone he bought marijuana from R1. V5 stated when R1 returned from the hospital, R2 reported feeling afraid because of (R1). (R2) has been spending more time in his room to avoid conflicts . V5 stated, (R1) is very intimidating. He becomes verbally aggressive. Staff are afraid he will hit them if they try to enforce the rules. I worry that (R1) will attack me or other staff . I don't feel comfortable with (R1) and he intimidates me. The dilemma is that we don't know what to do with him when he acts out other than call the police . A social service noted for R2, dated 3/25/25, showed R2 reported to social services that a co-resident came into his room when he wasn't present and the he doesn't want this co-resident to come into his room anymore . On 3/27/25 at 12:27 PM, V4 Social Services was asked about the resident referenced in R2's social service note dated 3/25/25. V4 stated, The resident in (R2's) room was (R1). (R2) came to me and told me that the day before (3/24/25), (R2) walked into his room and found (R1) standing in his room, talking to (R2's) roommate. (R2) reported to me that he immediately felt uncomfortable and walked back out of his room. I think he was a little fearful when he saw (R1) in his room. Since his return from the hospital, we try to monitor where (R1) is at when he is in the building but he goes where he wants. We have tried to revoke (R1's) community pass privileges due to his behaviors but he doesn't care. He feels like he's above the rules and leaves anyway. On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/17/25, R2 reported to V1 that R1 had threatened to kill R2 if he told anyone R1 had sold him marijuana. V1 stated all staff and many residents are afraid of R1 due to his behaviors. V1 stated, We were finally able to send (R1) out to the hospital after he threatened to kill me, (V2 Assistant Administrator), and our families but he was allowed to return. When he came back, we tried to put him (R1) in a private room, but he refused. We tried to move him to a room on the first floor, but he refused. We revoked his community pass privileges but he doesn't care, he still leaves the facility. We try to monitor where he is every hour that he is in the facility . V1 stated facility staff are afraid to enforce the facility's rules with R1 because they are afraid he will try to hurt and physically assault them. 2. On 3/27/25 at 10:45 AM, R6 was asked about his interactions with R1. R6 was initially hesitant to speak with this surveyor, stating, I don't want to get involved. If I say something, there is nothing you can do. I already made my statement (during the abuse investigation) . R6 continued to talk and then stated he had been threatened by R1 in the past. R6 stated, One night, when he (R1) wasn't sober, he came into my room and threatened to break my neck and throw me out a window. He said he could break my neck and tell staff it was a seizure since there is no cameras in my room. I started yelling and a CNA (certified nursing assistant) came and got him out of my room . Many residents are afraid of him. He has power and no one can stop him. He is big and intimidates people . It would be better if he left and never came back. The police just bring him back and he does whatever he wants . (R1) has said before he can leave people crippled in a wheelchair or a vegetable, what are they waiting for? Someone to die or get hurt? On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/18/25, R6 reported to V1 that he was scared of R1 because R1 had threatened to break R6's neck. 3. On 3/27/25 at 11:10 AM, R3 refused to speak to this surveyor about R1. On 3/27/25 at 11:10 AM, R4 stated R3 won't come down and talk to you guys because he's fearful of his safety. (R1) is big and has threatened (R3) before. I have seen (R1) drinking (alcohol) in (R3's) room before. (R3) is timid and shy .He doesn't want to get beat up by (R1) . R4 stated she was the resident that reported R1 had threatened to kill V1 Administrator and V2 Assistant Administrator. R4 stated, (R1) was pissed off because he thought (V2) was trying to get him kicked out of the facility. He told me that he could be sitting in a bar and have someone shoot (V1) and (V2) and their families so I reported that to (V2). R4 stated she has seen R1 smoke weed and drink alcohol in the facility. A social service note dated 3/19/25 for R3 showed, Resident is upset and scared that a co-resident (R1) got admitted back to the facility . On 3/31/25 at 10:24 AM, V7 Social Services was asked about the note she documented on 3/19/25 for R3. V7 stated R3 said he was scared because R1 had been readmitted to the facility. On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/18/25, (R3) told me he felt terrible. He said he was afraid of (R1). He said (R1) was very threatening. He said (R1) hides alcohol and drugs in (R3's) room. (R3) can't tell on him because (R3) is scared of him. On 3/27/25 at 10:20 AM, V2 Assistant Administrator stated, I spoke with (R3). He told me he is afraid of (R1). (R3) said his room is where (R1) hides his drugs and alcohol. (R3) is afraid that if he snitches and tells on (R1), (R1) will have people come and get (R3) and kill him .(R4) came to me and told me (R1) threatened to kill me and my family . Since then, I don't stay home alone . V2 became tearful during the interview. V2 stated, We are all afraid that (R1) is back. We are sitting ducks right now . On 3/27/25 at 1:00 PM, V6 Psychiatric Nurse Practitioner stated he has been treating R1 for a mood disorder but recently also for substance abuse and his threatening behaviors. V6 stated, (R1) doesn't follow the rules. When staff try to enforce the rules, he gets upset and starts threatening staff and residents. It's a big deal. That is why we sent him to the hospital and then he was allowed to come back. He's threatened to hurt staff and residents. I am very concerned about his behaviors. His behaviors are worsening. I am not sure if that's related to his substance abuse or there is something else going on. Staff and residents are fearful of him. He is a risk. His homicidal threats are a big deal. The facility's Abuse Prevention-Program Policy revised 2/26/25 showed, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident . Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Mental abuse is also the use of verbal or nonverbal contact which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . The facility presented an abatement plan to remove the immediacy on 3/31/25. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on 3/31/25. The abatement plan was returned to the facility for revisions. The facility presented a third revised abatement plan on 3/31/25 and the survey team accepted the abatement plan on 3/31/25. The Immediate Jeopardy that began on 3/17/25 was removed on 3/31/25 when the facility took the following actions to remove the immediacy: 1. On 3/31/25, R1 was placed on 1:1 monitoring. 2. On 3/31/25, the police will be called for assistance every time R1 violates community restriction. R1 will be discharged in 10 days per court order. 3. On 3/31/25, an order of protection will be filed on R1, by R2, R3, and R6 pending their consent. 4. On 3/31/25, recent abuse in-services/education will be continued on all newly hired employees and agency nurses. 5. On 3/31/25, the resident admission process was reviewed with the Admissions Director and Social Services and will be implemented per facility guideline. It will ensure that resident background checks are being completed on time. The background checks will also be reviewed to ensure that appropriate interventions are put into place for the safety of all residents. 6. On 3/31/25, it was decided that should a resident become noncompliant with facility protocols and guidelines, the resident will be counseled by staff. If the resident continues to be noncompliant, he/she will be sent out for psychiatric evaluation and will be served a 30-day discharge notice as deemed appropriate. Should he/she become harmful to other residents, he/she will be placed on 1:1 monitoring. V1 Administrator will be responsible for overall compliance to the plan of correction in conjunction with the Social Services Director by making sure that the above plan is being implemented. A QA (quality assurance) will be used to monitor for compliance by checking if the monitoring sheet is followed. The Quality Assurance/Quality Improvement (QAQI) Team meets monthly. The event will also be brought to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly.

Based on interview and record review the facility failed to follow their abuse policy by not completing pre-admission screening of residents to ensure resident safety for 6 of 6 residents (R4, R10, R11, R12, R13, R1) reviewed in the sample of 14. The failure has the potential to affect all 179 residents in the facility. The findings include: The Facility Data Sheet form dated 3/27/25 showed a resident census of 179. 1. R4's Admission Record showed R4 was admitted to the facility on [DATE]. R4's electronic medical records dated 2/19/25-3/31/25 showed no IDOC (Illinois Department of Corrections), Illinois Sex Offender Registry, or National Sex Offender Registry website checks had been completed on R4. 2. R10's Admission Record showed R10 was admitted to the facility on [DATE]. R10's National Sex Offender Registry check was not completed until 3/31/25. 3. R11's Admission Record showed R11 was admitted to the facility on [DATE]. R11's electronic medical records dated 3/17/25-3/31/25 showed no IDOC, Illinois Sex Offender Registry, or National Sex Offender Registry website checks had been completed on R11. 4. R12's Admission Record showed R12 was admitted to the facility on [DATE]. R12's electronic medical records dated 1/27/25-3/31/25 showed no IDOC, Illinois Sex Offender Registry, or National Sex Offender Registry website checks had been completed on R12. R12's Criminal History Information Response Process (CHIRP) report dated 1/27/25 showed R12 was an identified offender due to his convictions of aggravated battery resulting in great bodily harm, theft, possession of drug paraphernalia, criminal damage to state property, and resisting a peace officer. R12's fingerprint-based criminal history background check was not completed until 2/4/25. 5. R13's Admission Record showed R13 was admitted to the facility on [DATE]. R13's National Sex Offender Registry check was not completed until 3/31/25. R13's CHIRP dated 1/8/25 showed R13 was an identified offender due to his convictions of obstructing justice, theft, deceptive practice, resisting a peace officer, and endangering life/health of a child. R13's fingerprint-based criminal history background check was not completed until 2/4/25. On 3/31/25 at 11:00 AM, V1 Administrator stated, A CHIRP should be run on a resident within 24 hours of their admission. If the CHIRP shows the resident is an identified offender, fingerprints should be ordered and done on that resident immediately. V1 Administrator stated all criminal history background checks, for newly admitted residents, are to be completed within 24 hours of a resident's admission. On 3/31/25 at 11:05 AM, V7 Social Services stated the ISP, IDOC, and National Sex Offender Registry website checks had never been completed on R4, R11, or R12. V7 she had just completed the National Sex Offender Registry website checks on R10 and R13 today (3/31/25). 6. R1's Admission Record showed R1 was admitted to the facility on [DATE]. R1's, name based, Criminal History Information Response Process report (CHIRP) dated 9/19/24 showed R1 was an identified offender due to his conviction of attempted armed violence. R1's fingerprint-based criminal history background check was completed on 9/26/24. An email dated 11/18/24 from the State Identified Offenders program showed the program had received all of the required information on R1 to process his criminal analysis security report. The email stated if the facility did not receive R1's security report within 45 days of the email, the facility was to contact the State police. On 3/31/25 at 8:04 AM, V1 Administrator stated the facility had never received the results of R1's criminal analysis security report from November 2024. V1 stated, We don't know if (R1) is a low, medium, or high risk identified offender. I don't think we ever followed up on this. V1 stated it was important for the facility to know the risk level, for any identified offender resident in the facility, so they can initiate an appropriate care plan for the offender and safety interventions for residents as needed. The facility's Resident Background Checks policy dated October 2024 showed, When a resident is admitted to the facility, an electronic name-based background check must be ordered within 24 hours . If the background check response contains convictions that match the Identified Offender offenses, the resident is an identified offender . Once the facility determines the resident is an Identified Offender, the facility must arrange for the resident to undergo a live scan State and FBI (national) fingerprint-based Fee Applicant criminal history check within 72 hours . The facility's Abuse Prevention Program-Policy revised 2/26/25 showed, The residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment . The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by: conducting pre-employment screening of employees and pre-admission screening of residents .

Based on interview and record review the facility failed to initiate discharge planning for 1 of 3 residents (R1) reviewed for discharge planning in the sample of 14. The findings include: R1's admission Record showed R1 was admitted to the facility on [DATE] for rehabilitation therapy services due to his diagnosis of low back pain. R1's current care plan showed R1 was cognitively intact, ambulatory, and needed no staff assistance to complete his activities of daily living. R1's progress and nursing notes dated November 2024-March 2025 were reviewed. These notes showed multiple documented episodes of R1 having alcohol, drugs, and drug paraphernalia in the facility. The notes showed incidents of R1 being verbally aggressive and threatening towards residents and staff. The notes showed incidents of R1 repeatedly disobeying facility rules and leaving the facility despite his community pass privileges being revoked due to his behaviors. They showed multiple incidents of the local police being called to the facility due to R1's behaviors. A note dated 2/6/25 showed the facility served R1 a 30-day discharge notice due to his behaviors and R1 no longer needing skilled nursing cares. R1 appealed his discharge. R1's physician progress note dated 2/26/25 showed, The resident has demonstrated sufficient stability and independence in their current condition, with no ongoing medical needs requiring skilled nursing services. (R1) is now safe and capable of transitioning to the PAD program (program for homeless persons)/shelter. The resident no longer requires the specialized care provided by a skilled nursing facility and is suitable for the next level of care. R1's social service notes dated 2/6/25-3/31/25 were reviewed. These notes showed no documentation of any discharging planning for R1, including no referrals for R1's placement after his discharge or documentation of R1's discharge needs or goals. On 3/27/25 at 8:45 AM, this surveyor attempted to interview R1 in his room. R1 became verbally aggressive towards this surveyor. R1 asked this surveyor to leave his room and surveyor exited R1's room. This surveyor was unable to interview R1 on his discharge plans or goals. On 3/31/25 at 12:03 PM, V4 Social Services stated he was R1's case worker in the facility. V4 stated he had not initiated any discharge planning for R1. V4 stated he had not made any referrals for R1's placement after being discharged from the facility. V4 stated he had not done any discharge planning for R1 because R1 had not expressed any desire to leave. On 3/31/25 at 11:55 AM, V5 Social Services stated had not initiated any discharge planning for R1. V5 stated social services is responsible for discharge planning, however, social services does not begin discharge planning for a resident until we know a discharge plan is in place. On 3/31/25 at 10:24 AM, V7 Social Services stated she had not initiated any discharge planning for R1 because he doesn't want to leave. V7 stated if a resident is issued a 30-day discharge notice, we should help that resident find placement for when he is discharged . The facility's Discharge/Transfer of Resident policy dated November 2018 showed, Purpose: To provide safe departure from the facility. To provide continuity of care and treatment . Procedure: Explain discharge procedure to resident and family . Inform all departments of anticipated and actual discharge .

Based on observations, interviews, and record reviews, the facility failed to: 1. Protect a resident's right to be free of sexual and mental abuse from staff and other residents. This failure resulted in R1 being inappropriately touched by V8 (CNA-Certified Nursing Assistant) in the shower and being subjected (verbally and via phone message) to inappropriate and lewd comments of a sexual nature about R1's body. This failure also resulted in R1 being exposed to R6, who formerly sexually abused R1. R6 was in close proximity to R1 without supervision. These failures caused R1 to experience emotional distress and feel unsafe in the facility and caused her to discharge herself AMA (against medical advice). 2. Protect a resident's right to be free from physical abuse by a resident and failed to protect residents from further abuse from the abusive resident. This failure resulted in R5 hitting R7, R5 hitting R4 twice within two days, and R5 hitting R6 between [DATE] and [DATE]. This failure also resulted in R2 being hit by R3. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R1 was sexually and mentally abused by V8. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 9:45 AM. The surveyor confirmed by observation, interviews, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the interventions and in-service training. This applies to 5 of 5 residents (R1, R2, R4, R6, and R7) reviewed for abuse in a sample of 16. The findings include: 1. Facility Final Investigation Report Form, submitted [DATE], shows the facility substantiated that R6 sexually abused R1. R1's Face sheet, dated [DATE], shows R1's diagnoses include Huntington's disease, major depressive disorder, and suicide ideation and attempt. The face sheet shows R1 was admitted to the facility on [DATE] and discharged on [DATE]. MDS (Minimum Data Set), dated [DATE], shows R1 was cognitively intact and required supervision or touching assistance for bathing, hygiene, and lower body dressing. Face sheet, dated [DATE], shows R6's diagnoses include alcohol abuse, depression, and chronic obstructive pulmonary disease. MDS, dated [DATE], shows R6 was cognitively intact and was able to independently ambulate. Care plan, initiated [DATE], shows R6 was admitted to the facility with a history of a Class 4 felony, was at moderate risk, and requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Care plan, initiated [DATE], shows R6 is to remain on his designated floor (2nd floor) and is not to enter other residents' rooms. [R6] will be escorted to and from floors if he is to participate in the designated smoke times, attend activities or go to therapy. Interventions include educating the resident on appropriate behavior redirect resident if seen on the first floor other than to smoke or participate in activities and monitor resident when in community areas to make sure actions are appropriate. 2. Facility Final Incident Investigation Report Form, provided [DATE], shows the facility substantiated R1 was abused by V8. The report shows the abuse occurred on [DATE] and R1 left the facility AMA on [DATE] at approximately 10:30 PM. Facility abuse investigation documents show V8 was interviewed and stated he assisted R1 with a shower, stood outside her curtain, assisted R1 as she stumbled, and then only washed her back and lower legs for R1. V8 denied touching R1 in inappropriate ways. V8 stated he and R1 connected on Facebook on [DATE] and messaged each other on the application. On [DATE] at 9:56 AM, V4 (PRSC- Psychiatric Rehabilitation Services Coordinator) stated R1 showed her a message from V8 on R1's phone regarding V8 becoming sexually aroused when V8 was near R1. V4 stated she was shocked and felt the messages were very inappropriate. V4 stated R1 told her that R1 kept the conversation going via the messages because she wanted proof of how V8 was talking to R1. On [DATE], V3 (assistant admininstrator) stated she was informed on [DATE] that V8 was messaging R1 via phone in a sexual nature. V3 stated she interviewed R1, R1 read V3 some of the messages, and V3 read messages which showed V8 was referring to becoming sexually aroused when he saw R1. V3 stated, I saw enough- they were very concerning. V3 stated by the time the police arrived, V8 deleted the messages on the messaging application. On [DATE] at 1:13 PM with V25 (R1's Friend), stated, R1 stated V8 would often bring R1 food from outside the facility including the day V8 inappropriately touched R1. R1 stated, Then as we were showering, he ended up washing my [internal reproductive area] and then my [buttocks]. R1 stated she almost fell prior in the shower and V8 steadied her but then continued washing areas of R1's body that she did not need assistance washing. R1 stated V8 never asked if he could wash R1's body. R1 stated after the shower R1 and V8 were in R1's room and V8 stated, Nice butt. R1 stated V8 stated, Could I tell you something without getting fired? You have a really nice butt and nice boobs. R1 stated after the comments, V8 asked to connect on Facebook with R1 and V8 used R1's phone to add V8 as her friend. R1 stated at that time they were sitting next to each other in her room and V8 stated, He told me how cute I was, that I had a cute butt and boobs again, and then he left. R1 stated V8 later messaged R1 telling her that V8 was sexually aroused, suggested he could have sexual intercourse with her while she was in the shower, and referenced the size of his sexual organ. R1 stated all of the administrative staff left the facility because it was late on a Sunday, so R1 reported the interactions the next day to V4 (PRSC- Psychiatric Rehabilitation Services Coordinator). R1 stated she showed V4 and V3 (Assistant Administrator) the messages from V8 before V8 deleted the messages on the application. R1 stated she didn't initially mention her concerns about the shower because R1 thought V8 was helping her but after R1 told her children about the interaction, they told R1 no staff should be helping her in the shower and R1 was capable of washing herself even if she became off balance. R1 stated she told V26 (Restorative CNA) about V8 washing her peri area in the shower and R1 stated V26 told R1 that R1 did not need assistance from staff to perform those tasks. R1 stated V26 never washed R1's peri area in all the times V26 provided R1 assistance in the shower. R1 stated she experienced prior sexual assault at the facility by a resident and stated, Hence I am no longer there. I am not safe at all at that facility Nobody asked me if I felt safe at the facility this time. I had friends come and get me on Tuesday because I don't feel safe! On [DATE] at 3:15 PM, V26 (Restorative CNA) stated R1 could independently wash herself in the shower. V26 stated R1 could sit on a shower bench and wash all of their body in the shower. V26 stated R1 only needed supervision to help her get set up and regulate the water temperature in the shower. V26 stated she assisted R1 with a shower on [DATE] and R1 did not require assistance to physically wash R1. On [DATE] at 11:54 AM, V23 (R1's Daughter) stated R1 was sexually assaulted at the facility in the past and V23 stated R1 was sexually abused a second time by facility staff. V23 stated the facility staff did not need to assist R1 to walk to the shower but recently a male CNA was allowed to wash her body and her privates. V23 stated on [DATE] at 12:44 AM, R1 messaged V23 stating she had to report a male CNA because he helped R1 in the shower and made verbal and written sexual comments toward R1 via phone, and suggested R1 allow V8 have sexual intercourse while being showered by V8. R1 identified the staff as V8. V23 stated she called the facility at approximately 2:15 PM on [DATE] and spoke to V4 (PRSC- Psychiatric Rehabilitation Services Coordinator). V23 stated she told V4 she was aware of V8 sexually messaging R1 as well as touching R1 inappropriately in the shower. V23 stated she called the police at 2:30 PM to report the allegation that V8 touched R1 inappropriately in the shower and the inappropriate messages because V4 stated they were not going to call the police but instead would handle it in house. V23 stated she pulled R1 out of the facility and sent R1 to the hospital to be examined on [DATE]. On [DATE] at 12:53 PM, V24 (R1's Friend) stated she was with R1 at the hospital on [DATE] and R1 told the staff V8 asked R1 if she needed help with her shower and R1 told him she did not because she was fully capable of washing herself. V24 stated R1 told the staff V8 proceeded to wash her vaginal and buttocks areas which shocked R1. V24 stated on [DATE] evening, R1 messaged V24 stating V8 made verbal sexual comments toward R1. On [DATE] at 4:00 PM, V9 (Police Officer) stated V3 told her that V3 did see some of the messages and described the messages as very disturbing. At 7:00 PM, V9 stated V8 came to the police station to do an interview but would not speak with the police officers and requested a lawyer. On [DATE] at 11:15 AM, V5 PRSD (Psychiatric Rehabilitation Services Director) stated she spoke with V8 who stated he stood outside the shower curtain during R1's shower until R1 stumbled. V8 stated he helped R1 and then helped R1 wash her legs and back. V5 stated V8 was very short with his answers and not forthcoming. On [DATE] at 9:15 AM. V1 (Administrator) stated on [DATE] he received report that R1 alleged V8 (CNA) sent sexual messages via phone to R1. V1 stated the messages included phrases such as you are hot or you are sexy. V1 stated when he asked to see the messages, the messages were deleted. V1 stated he spoke with V8 who admitted to messaging R1 but denied ever physically touching R1. V1 stated V8 resigned from facility employment. V1 stated later in the day on [DATE], R1 contacted V1 and informed V1 she spoke with her daughter who informed R1 that V8 assisting R1 in the shower was sexual abuse because R1 did not require physical assistance with her showers. V1 stated R1 told V1 that V8 unnecessarily wiped R1's peri area and buttocks during her shower. On [DATE] at 12:38 PM with V27 (R1's Friend), stated, R1 stated since R6 sexually abused R1, R1 experienced R6 in close physical proximity and unsupervised to her several times and as recent as [DATE]. R1 stated, I was freaked out and stated she told a staff member. R1 stated R6 would visit the table at which she was sitting for approximately 10 minutes and talk to all of the residents at the table other than her. R1 stated R6 at times pushed a resident around the first floor in his wheelchair unsupervised where she resided. R1 stated R6 was not supposed to be on the first floor and was supposed to remain on the second floor where he resided because of the sexual abuse she experienced by R6. R1 stated R6 came down to the first floor unsupervised other than during designated smoking breaks. On [DATE], V23 (R1's Daughter) stated R1 messaged her on [DATE] at 11:25 AM telling V23 that R6 was walking by R1. V23 stated R1 pressed charges against R6 last year after R6 sexually assaulted her and R1 recently went to court on the case and there was an upcoming court date in April of 2025. V23 stated R1 left the facility because R1 was not safe at the facility. On [DATE] at 1:13 PM with V25 (R1's Friend), R1 stated she was sexually assaulted by R6 the prior year and she was in disbelief she was sexually assaulted again the facility recently by staff. R1 stated she no longer felt safe at the facility because she experienced sexual abuse twice and she chose to discharge AMA from the facility to a friend's home until she could find a different facility in which to live. On [DATE] at 3:55 PM, R6 stated he travels up and downstairs by himself to smoke breaks at the facility. On [DATE] at 1:35 PM on the first floor, R6 walked off the elevator with female resident and independently walked into the dining room. R6 then began walking around the dining room talking to residents with no direct supervision from staff. V28 (Social Services) was sitting at a table with a resident engaged 1:1 in an interview of the resident. R6 stood at R14's table talking to residents with no direct supervision and then walked to R9's table and then back to R14's table. At 1:40 PM, an announcement was made overhead the facility that the smoking patio would be opened in five minutes. R6 continued to walk around the dining room speaking to R9 and other residents. There were 11 females and 11 males in the dining room in addition to R6. On [DATE] at 9:45 AM, V1 stated R6 did not need any kind of supervision at the facility. V1 stated R6 was moved to the second floor because of his isolated behavior of sexual abuse toward R1 (which was substantiated) and to reduce interactions with R1 when the incident was new. V1 stated he did not deny R6 was coming down to the first floor unsupervised. On [DATE] at 3:47 PM, V31 (CNA- Certified Nursing Assistant) stated R6 travels back and forth on the elevator to the first floor independently without supervision. On [DATE] at 3:45 PM, V30 (Registered Nurse) stated R6 was not allowed to go downstairs due to an incident a year ago which was why R6 was moved to the second floor. V30 stated R6 did travel back and forth on the elevator without an escort to the first floor. 2. Face sheet, dated [DATE], shows R5's diagnoses included Huntington's disease and mood disorder. R5 was admitted to the facility on [DATE]. MDS, dated [DATE], shows R5 was cognitively intact and R5 was able to propel in a wheelchair once set up in the wheelchair. Care plan, dated [DATE], shows R5 was admitted to the facility on [DATE] with a criminal history of violating an order of protection and domestic battery. Approaches include, Review of my past behavior and evaluate the potential for me to engage in inappropriate / high risk behavior, provide R5 with supportive group intervention and/or 1:1 via a qualified provider, to promote safety intervene when I am observed to be engaging in inappropriate behavior, teach me impulse control strategies and communicate to me that I am responsible for all my actions/behavior and must therefore exercise control over my impulses and behavior. Care plan, dated [DATE], shows R5 had a history of a hit and run accident and may have flashbacks, become upset, and become aggressive verbally and physically with staff. Care plan, dated [DATE], shows R5 was observed with manipulative behaviors and approaches included providing educations to not fabricate stories, perform check-ins with residents, and providing 1:1 interaction with R5 to help find solutions towards issues. Behavioral care plan, initiated [DATE], shows R5 displayed verbal and physical aggressive behaviors toward others, uncontrolled behavior outbursts and requires the use of non-pharmacological and pharmacological interventions to address and mitigate behaviors. Interventions included Social Services will continue to educate resident on aggressive behaviors and encourage resident to utilize healthier ways to communicate thoughts and feelings. Social services will work with resident to establish better communication and mechanisms. Delusions/paranoia care plan, dated [DATE], shows R5 was diagnosed with Huntington's disease and believes everyone is making fun of his disability. Interventions include psychiatric management, minimizing risk factors through interventions such as assessment, team, consultation, supervision, observation, structured environment, peer-buddy system, contracting and medication management. Other interventions include teaching stress/anxiety management techniques, discussing benefits of therapy with physicians, encouraging resident to follow mental health treatment plans and encouraging resident to attend groups. Illinois State Police report, dated [DATE], shows R5 was convicted of domestic battery/bodily harm, revisiting a peace officer, criminal trespassing, possession of drug paraphernalia, manufacturing/delivering controlled substances. Facility Final Incident Investigation Report Form, dated [DATE], shows on [DATE] R5 stood up and attempted to hit R7 in the face. The report shows R5 was sent to the hospital and R7 declined to press charges. The report shows R5 has a history of dwelling in the past which leads him to become physically aggressive with co-residents. The report shows R5 was educated on the facility policy and proper way of communicating. R7 was educated on the proper way to speak to his co-residents. Investigation witness statement, shows R7 reported R5 repeatedly came into R7's room and when R7 asked if R5 had a problem, R5 stood up and started punching R7. The statement shows R7 covered his head while R5 swung but R5 missed which caused R7 to fall. Investigation witness statement shows V17 (Registered Nurse) heard R7 was calling R5 the n word and R7 told R5 to get away from R7. The statement shows R5 stood, leaned into R7 and hit him in the left side of the face. The statement shows R7 pushed R5 off of him and R5 lost his balance and fell . Investigation witness statement shows V11 (Registered Nurse) saw R7 and R5 arguing, R5 stood and hit R7, and R5 fell to the floor. The report shows the facility did not substantiate the abuse because R5 stood up from his wheelchair and attempted to hit [R7], but has an unsteady gait, which caused him to lose balance and fall into [R7]. Nursing note, dated [DATE], shows, Writer was standing near nursing station, turned around to note this resident standing up and using profanity towards a co-resident. As soon as writer began to approach the situation, this resident stood up, leaned into co-resident and was physically aggressive. Co-resident pushed this resident to the ground. The writer and other staff members separated the resident from each other. On [DATE] at 2:59 PM, R7 stated he had a previous altercation with R5 approximately a year ago when the two were roommates and R5 hit (R7) in the head several times. R7 stated the most recent altercation happened a few weeks ago when R5 hit him in the head several times and R7 stated he had several knots on his head. Social Services note, dated [DATE], shows the PRSD was informed that R5 and another co-resident got into a physical altercation by the nursing station, R5 hit another co-resident, and R5 was being sent out for a psychiatric evaluation. Social Services note, dated [DATE], shows R5 got in a physical altercation with co-resident as resident claimed that this co-resident had insulted him. PRSC explained to resident that he cannot get physical with co-residents whatsoever. PRSC explained to resident that if he has an issue with co-resident, he must find a PRSC to intervene. Resident was therefore educated on facility policy and proper communication. Will continue to monitor. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. Progress note, dated [DATE], shows R5 angrily knocked on R7's door to get in, entered R7's room, and knocked R7's belongings around the room and was verbally aggressive. The note shows R5 hit R7 the day prior and R5 was told to stay away from R7. The progress notes show R5 was sent to the hospital for evaluation and returned the same day to the facility. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. 3. Face sheet, dated [DATE], shows R4's diagnoses included schizoaffective disorder, epilepsy, convulsions, post-traumatic stress disorder, and cocaine/cannabis abuse. MDS, dated [DATE], shows R4 was cognitively intact and could independently ambulate at the facility. Care plan note, dated [DATE], shows R4 was reported to be making inappropriate remarks, becoming aggressive with staff, and verbally aggressive with co-residents. Care plan notes, dated [DATE], show R4 experiences auditory and visual hallucinations and paranoia when discussing his symptoms. Progress note, dated [DATE], shows R5 was in a second physical altercation at the facility. The note shows, Writer was notified that [R5] was fighting with other resident at the end of the hallway 400. We proceeded to separate them, assess them, and place them in different areas. I notified [Psych Nurse Practitioner], who ordered to send the resident to the [Psychiatric Hospital] for a psychiatric evaluation Facility Final Incident Investigation Report form, submitted [DATE], shows on [DATE] in the 400 hallway, R5 stood up and hit R4 in the face after R4 was speaking with V14 (Housekeeping). V14's statement shows R4 did nothing to provoke R5 to hit R4 and V14 was hit during the altercation. The investigation shows R4 stated R5 caught R4 off guard and R5 smacked [R4] on the lips. The investigation showed R4 was protecting his head because of his seizures and was trying to run away but was not able to do so because of his clinical condition. The statement shows staff assisted to stop R5 and staff assisted R4 up off the floor and took him upstairs. The report shows R4 was educated not to go to the first floor, R5 was sent to the hospital for a psychological evaluation, local police were called, and R5 was educated on facility policies and the proper way of communicating. The report shows the facility substantiated R5 physically abused R4. Progress notes, dated [DATE], shows R5 was sent to the psychiatric hospital and returned to the facility the same day. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. Social Services note, dated [DATE], shows R4 was reported to have called a co-resident in a wheelchair a vegetable. The note shows R4 had a history of bullying co-residents and was told he could not bully residents. Social Services note, dated [DATE], shows R4 was educated to stay away from R5 and R4 was encouraged to stay on the second floor during meal times. The note shows R4 verbalized understanding. 4. Progress notes, dated [DATE], show R5 was in a third physical altercation at the facility (R5's second altercation with R4 within two days), 911 was called, the police and fire department arrived at the facility and R5 was escorted from the facility by the police. The progress notes show R5 was being involuntarily admitted to the psychiatric hospital with diagnoses including aggression/mood disorder. Facility Final Incident Investigation Report Form, dated [DATE], shows on [DATE] at approximately 7:40 AM, R5 again hit R4 which was witnessed by staff. Witness statement by V15 (Registered Nurse) shows R5 suddenly got up from his wheelchair and pushed [R4] against the wall, [R4] hit his head to the wall and fell on the floor. [V15] immediately ran towards and separated [R5] from [R4], [R4] was on the floor, he was unconscious [V11] called 911 while we were monitoring[R4]. R5's statement stated R4 was picking on R5 so R5 got up from his wheelchair to try to hit [R4] but lost his balance and grabbed onto his sweatshirt instead to gain back balance. R4's statement shows R4 briefly spoke to R5 when he walked past R5 with nice words and when walking away from R5 R5 pulled his sweatshirt and fell to the floor, and R4 thought he fell to the floor because he had a seizure. Investigation witness statement by V11 (Nurse) shows V11 saw R5 and R4 next to each other and V11 immediately told R4 to move. The statement shows R4 began to walk away and then R5 suddenly got up from his chair and tried to walk toward R4 but because of R5's disease R5 fell . The witness statement shows R4 had a seizure and the police removed R5. The report summary shows the facility concluded that the allegation of physical abuse by R5 was substantiated. The report shows R4 was educated to keep his distance from R5, was told not wander to the first floor during mealtimes and wait until mealtimes are over to go to the first floor. The report shows R5 was educated to not use physical violence towards co-resident and to speak to case workers to resolve issues with residents. The report shows R5 believed people are against him and residents make fun of him even if they are not. R5 was sent to the hospital for psychological evaluation and returned to the facility, the residents were separated by floors, and plans were made to move R5 to a private room. On [DATE] at 11:27 AM, V16 (PRSC) stated R5 felt like residents like R4 make fun of R5's disability and that was why R5 hit R4. Social Services Note, dated [DATE], shows, Resident is no longer a part of the work program due to numerous aggressive incidents in past week. Progress note, dated [DATE], shows the facility spoke with [V12 (Psychiatrist)] to place [R5] in a different nursing due to increase aggressive behaviors. [V12] is working with hospital caseworkers to find a appropriate placement. Progress note, dated [DATE], shows R5 was readmitted to the facility from the psychiatric hospital. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. 5. Progress note, dated [DATE], shows R5 was in a fourth physical altercation at the facility with a co-resident in the back patio of the facility. Facility Final Incident Investigation Report Form, submitted [DATE], shows the facility substantiated the allegation that R5 physically abused R6. The report shows R6 was punched unprovoked by R5 and the altercation was witnessed by R8-R11. Witness statements shows R8 stated he intervened to try to prevent R5 from hitting a staff member and fell , R9 was talking to R6 and R5 began hitting R6 without provocation, R10 stated R5 got up and grabbed R6, and R11 stated R5 got out of his chair and swung at R6. Staff witness statements show V18 (Activities) stated R5 started swinging at R6 and R8 tried to intervene. On [DATE], V22 (Hospital Case Manager), stated when R5 was admitted to the hospital emergency department, there was no medical necessity to admit R5 to the hospital, but the facility would not allow R5 to return to the facility. V22 stated R5 reported to hospital staff that he was constantly being placed near a resident that constantly bullied and harassed him and R5 felt like he needed to defend himself. V22 stated while R5 had been in the hospital R5 had not shown any aggression. V22 stated, While he has been at the hospital, he has been fine. Maybe they aren't moving him away from this person like he is asking! Hospital Nurse Practitioner note, dated [DATE], shows, R5 was previously admitted to the inpatient psychiatric unit between [DATE] and [DATE]. The note shows R5 was returned to the emergency roiagnom on [DATE] with the facility stating he was not welcome back to the facility. The note shows R5 was discharged previously from the facility to a different hospital for the same reason and returned to the facility at that time. During this admission, R5 was unable to be admitted to inpatient psychiatry due to not meeting criteria. The note shows the facility stated R5 was aggressive and injured six other residents and the facility would not allow him to return. On ,d+[DATE] at 12:30 PM, V12 (Physician) stated when R5 arrived at the hospital R5 was appropriate and there was no sign of aggression from R5. V12 stated there was no reason to admit R5 to the hospital however the hospital was forced to take R5 because the facility would not accept R5 back. 6. MDS, dated [DATE], shows R2 was cognitively intact. Review of R2's care plan showed no concerns with aggressive behaviors. MDS, dated [DATE], shows R3 was cognitively intact. Care plan, initiated [DATE], shows R3 displayed verbal aggressive behaviors toward others, uncontrolled outbursts, and changes his story to make himself look like the victim. On [DATE] at 3:30 PM, R3 stated he was attempting to wake his friend, who was sleeping on a table, so he began banging on the table. R2 told R3 he was going to go to the hospital and R2 hit R3. R3 stated he was hit first by R2, but R3 hit him back. On [DATE] at 3:00 PM R2 stated R3 began messing with a resident and R3 threw a punch at R2. R2 had a healed scratch on his left upper cheek. R2 stated if he had not slipped, he would have fought back and hit R3. Social Services note, dated [DATE], shows at 3:55 PM in the first-floor dining room, R3 was having a conversation with another co-resident when he alleged another resident interrupted him. R3 alleged that the other resident then punched R3 in the side of the head and R3 responded by punching him and knocking him to the ground and then hit him again. Final Incident Investigation Report Form, dated [DATE], shows on [DATE] R3 hit R2 after a verbal argument in the first-floor dining room. The Form shows V6 (Registered Nurse) witnessed the end of the occurrence and R2 sustained a scratch on his left check. The report shows the police were called, R3 was sent to the hospital for a psychiatric evaluation, and R2 was treated at the facility. The Form shows R3 was educated on not using physical violence toward other residents and the facility substantiated R2 was physically abused by R3. Abuse Prevention Program - Policy, dated [DATE], shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents including verbal, mental, sexual or physical abuse .The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means Abuse is also the willful infliction of injury Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention Sexual abuse is non-consensual sexual contact of any type with a resident Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by a licensee, employee or agent. Mental abuse is also the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation Facility Abuse Prevention Training Program, dated [DATE], shows, .Protection - The facility will remove any alleged perpetrator(s) of abuse or neglect from any further contact with residents pending an investigation . If the perpetrator is a resident, the residents will be separated from the alleged victim The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE], and the survey team accepted the abatement plan on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. - On [DATE] R5 was given an immediate discharge to St [NAME] Hospital, R5 no longer a resident of River View. - On [DATE], R6 was reassessed on Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors (Sexual Misconduct) and educated on Appropriate behavior. O [TRUNCATED]

Based on interview and record review, the facility failed to protect R1 from physical abuse from R2. This failure resulted in R1 needing emergency medical care and treatment after R1 was assaulted by R2. This applies to 1 of 5 residents (R1) reviewed for abuse. The findings include: The Electronic Health Record (EHR) showed that R1 had diagnoses including Schizophrenia, Bipolar, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE] showed R1's cognition intact. The EHR showed that R2 had a diagnosis of paranoid schizophrenia. The MDS dated [DATE] showed R2's mental status of inattention and disorganized thinking behavior fluctuated and would come and go with changes in severity. The Brief Interview for Mental Status could not be completed. A care plan showed R2 was an Identified Offender with interventions including closer supervision and more frequent observation than standard or routine for most residents in an open facility. 1. A Facility Reported Incident reportable dated 9/12/24 documented a physical altercation between R1 and R2. On 9/25/24 at 9:40 AM, R1 was observed in his room with a small, glued laceration on the outer edge of his left eyebrow. R1 stated, he had a fight with R2 approximately a week ago. R1 didn't know why R2 hit him. R2 said there was urine on the floor in the bathroom. When R1 said there wasn't, R2 started hitting him. R1 went to the nurse's station to tell the nurse. R1 was sent to the hospital for a small left eyebrow laceration which was glued in the hospital and had a right eyebrow skin tear. On 9/25/24 at 3:46 PM, V5 (Registered Nurse/RN) stated that she was the night nurse on 9/12/24 caring for both R1 and R2 when R2 hit R1. R1 came to the nurse's station with blood on his forehead, a left eyebrow laceration and a right eye eyebrow scratch. R2 accused R1 of urinating on the bathroom floor. R1 was sent to the hospital and returned before the end of my shift with his left eyebrow laceration glued. V5 stated R2 has had an altercation with staff of pushing or slapping them. R2 has pushed me with both his both hands on my shoulder when V5 was trying to give R2's medication. V5 also stated R2's behavior is unpredictable and V5 would instruct the CNAs to check on R2 for aggressive behaviors. V5 stated all the residents should be monitored for their behaviors every two-to-three hour with no specific timing on how often they should be monitored. V5 said there was no extra monitoring for someone being readmitted from the hospital after having behavior issues. On 9/26/24 at 11:21 AM, V20 (CNA) stated he was on break and the incident was already happened when V20 came back from break. V20 was told R2 walk up to R1 and punched R1. R2 was aggressive at times, and he hit a CNA (V6) in his face. On 9/25/24 at 3:20 PM, V15 (CNA) stated on 9/12/24, R1 came to the nurse's station and said his roommate R2 punched him. V15 saw a cut on his R1's left eye, right lip and right forehead. V15 stated R2 was not right in the head. V15 was not aware of having any previous incidents/altercations with other residents or staff. V15 also stated R2 was not on any special supervision/monitoring than any other residents. V15 added that R2 did not have any special supervision or monitoring. On 9/26/24 at 10:25 AM, V7 (Nurse Practitioner/NP) stated R2 was very psychotic. V7 said for the last few weeks, R2 has refused to talk to V7. V7 stated R2 has decompensated significantly and probably required a higher level of care and supervision. On 9/26/24 at 3:30 PM, V22 (CNA) stated R2 can be aggressive at times and sometimes he threw his trays, slam the trays on the rack, and take the hand sanitizers off from the wall. V22 said they monitor residents every two hours. V22 said he doesn't know of any residents who need more frequent supervision except for those who need one-to-one monitoring. On 9/26/24 at 3:00 PM, V17 (RN) stated R2 was not able to be redirected all the time when he does have behaviors. V17 said R2 was laughing, singing, and making noises to be distracting to other residents. Sometimes R2 would throw water on the floor. V17 also stated R2's cognition was moderately impaired and wasn't aware of any care plan with interventions to monitor R2's behaviors more frequently than other residents. On 9/26/24 at 2:24 PM, V23 (Psychiatric Rehab Services Coordinator/PRSC) stated R2 has had an incident of aggressive behavior; most recently with R1. R2's behavior has been escalating over the past several months. V23 also stated R2 sometimes acknowledge what we were said to him about his behaviors and respond O.K, but V23 doesn't know if R2 understands what he is agreeing to. 2. A Nursing Progress Notes by V8 (RN) dated 7/15/24 at 12:55 AM, documented that R2 was walking in the hallway with no underpants on; V8 was trying to persuade the resident to wear a gown, but he refused. R2 walked to a co-resident sitting in the dining area and attempted to kiss the co-resident. V8 tried to re-direct the resident, and the resident took his shirt off and was completely naked. The resident walked into the 2500 hallway and entered one of the resident's rooms. Staff tried to stop him from entering the room; then, he punched the male CNA (V6) in the face. On 9/26/24 at 3:10 PM, V8 (RN) stated that she saw the incident where R2 was going to kiss R5 on 7/15/24. On 9/26/24 at 3:50 PM, V6 (CNA) stated that on 7/15/24 at around midnight, R2 hit him in V6's face when V6 prevent him to enter another resident's room. The facility's Abuse Prevention Program Policy dated 11/22/2017 includes: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.

Based on interview and record review, the facility failed to have a process in place to ensure agency staff receive abuse training during orientation to the facility as shown in the facility's Abuse Prevention Training Program. This failure resulted in V3 (Agency LPN-Licensed Professional Nurse) working at the facility without receiving abuse training and physically abusing R1. This failure has the potential to affect all 156 residents residing in the facility. The Immediate Jeopardy began on January 7, 2024 when V3 (Agency LPN) worked at the facility without receiving abuse training and physically abused R1. V1 (Administrator) was notified of the Immediate Jeopardy on January 25, 2024 at 2:12 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on January 25, 2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The Facility Data Sheet dated January 22, 2024 shows the resident census as 156 residents. On January 22, 2024 at 10:00 AM, R1 was sitting in a chair in her room. R1 said she was physically abused by V3 (Agency LPN) on January 7, 2024. R1 said, It started over medications that I normally get at 8:00 AM. It was 1:00 in the afternoon, and I had not received my medications for the day. [V10] (CNA-Certified Nursing Assistant) said we had a temporary nurse, and she was sitting in the lobby area at the nurse's station, and if you wanted your medications, you had to line up for the medications, and those who could not line up were disregarded. It is my preference to take my medications in my room. I walk with a cane, and it is hard for me to walk to the nurse's station. Also, I am a high risk for falls, so I usually stay in my room all day. When I stand up I get dizzy and I fall easily, so I did not walk to the nurse's station to get my medications. At 2:00 PM, [V3] (Agency LPN) finally came to my room with my morning medications. She came to the doorway and said, Come and get your medications. She said it very rudely. I did not get up, so she then said, Did you hear me say come get your medications? Come and get them! I told her she needed to bring the medications to me. She handed me the medications and turned to leave the room. I was yelling to her that some of my medications were missing. She continued walking out of the room and slammed the door. I got up after she did not come back and stood in the doorway of my room. When she came out of the room across the hall, she looked at me and made another smart remark. I threw my pills down and she ran up in my face, pointing at my face and yelling at me. She was shaking her hand at me with a pointed finger and hitting the tip of my nose with her finger. I said stop hitting my nose and I put my hand up to block her from hitting my nose. When I made that motion, she grabbed my hair and my hands and threw me down to the floor and hit me. She said, Are you going to stop? Are your going to stop? She was screaming loudly and trying to make people think I was attacking her. I have never seen [V3] working at this facility before. She left me there in the room and walked out. I went over to my telephone and called 911. I explained to the operator that I had been attacked and where I was at. She assured me the police were on their way. [V10] (CNA) could back up the problems we were having with getting our medications that day, but she did not witness the altercation. [V11] (CNA) came and saw me crying when it was all over. I told the police I wanted to press charges because [V3] threw me to the floor by the hair. The police kept asking me if I wanted to go the hospital, and I said no. I had just been in the hospital recently, and the last place I wanted to go was the hospital. Later in the evening I had chest pain, and I went to the hospital. The paramedics said my blood pressure was over 200. I went to the hospital and came back the same night. It happened two weeks ago, and I still have some neck pain, back pain, and a headache. On January 23, 2024 at 2:45 PM, V3 (Agency LPN) said, The first time I worked at the facility was around December 31, 2023. The second time was on January 7, 2024. I did not receive any abuse training from the facility. I did not receive any training from the facility regarding dealing with resident behaviors. They never pointed out an agency binder or did any education with me. When you come into a facility, they give you an assignment, and they put you to work. The EMR (Electronic Medical Record) shows R1 is [AGE] years old and was admitted to the facility on [DATE]. R1 has multiple diagnoses including, acute respiratory failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), cerebral infarction, heart disease, traumatic subarachnoid hemorrhage, muscle weakness, cognitive communication deficit, abnormal gait and mobility, lack of coordination, abnormal posture, need for assistance with personal care, falls, hypertension, anxiety disorder, and major depressive disorder. R1's MDS (Minimum Data Set) dated January 4, 2024 shows R1 is cognitively intact, has a lower extremity functional limitation in range of motion on one side and uses a cane for mobility. R1 is able to eat and dress her upper body independently, requires supervision with transfers between surfaces and walking, and partial/moderate assistance with oral hygiene, toilet hygiene, showering, lower body dressing, and personal hygiene. R1 is occasionally incontinent of bowel and bladder. The facility's undated Final Incident Investigation Report Form, received by the State Agency on January 12, 2024 shows: Upon further investigations, the incident was substantiated as the nurse [V3] (Agency LPN) was acting unprofessional to a point that it escalated this incident where the resident (R1) needs to be physically controlled and lowered down to floor for her safety. The police, NP/MD (Nurse Practitioner/Medical Doctor) and family members were informed, and the Resident was assessed by the nurses for injuries and was sent to the local hospital for evaluation. No injury was noted. The Final Incident Investigation Report Form continues to show the facility substantiated R1 was abused by V3 (Agency LPN). On January 22, 2024 at 9:24 AM, and on January 22, 2024 at 3:54 PM, V1 (Administrator) said, We do not train agency staff on abuse. That is done by the agency. On January 23, 2024 at 9:32 AM, V15 (Staffing Coordinator) said the facility continues to use agency staff, including nurses and CNAs to fill staffing shortages. On January 24, 2024 at 6:28 PM, V1 (Administrator) said V3 (Agency LPN) worked at the facility on December 31, 2023 from 11:00 PM to 7:00 AM and on January 7, 2024 from 9:45 AM to 3:00 PM. The facility does not have documentation to show the facility provided abuse training to V3 (Agency LPN). On January 23, 2024 at 3:34 PM, V2 (DON-Director of Nursing) said agency staff are given an orientation upon entering the facility, and the facility does not have formal abuse training for agency staff prior to caring for residents. We do not have training binders on the units specifically for agency staff. We do abuse in-services sometimes, but for agency we mostly teach them who to report to. Agency staff should know how to handle these situations. We are told by the agencies that they are trained individuals. On January 23, 2024 at 1:38 PM, V6 (Regional [NAME] President-Staffing Agency) said, Our company is basically a computer portal where facilities can look for staff who are willing to work. The facilities post their needs, and staff reply and pick up the shifts. The staff are not employed by us. We do criminal background checks and make sure they are licensed if they need to be, but that is it. We do not train the staff. It is the responsibility of the facility to educate the staff regarding abuse training. We tell our buildings to in-service them on abuse and neglect, have that packet, and have them sign it and keep a soft copy in your facility. We do not keep that information. We leave that to the facility to train for abuse. The Client Service Agreement between the staffing agency and the facility, signed by V1 (Administrator) on September 22, 2022 shows the facility is named as the Client: Whereas [staffing agency] is a software company that provides a technology platform for healthcare facilities/healthcare service companies and self-employed or independent contractor health care service providers (hereinafter known as Professional Providers) to find one another for the purposes of engaging in a business-to-business arrangement whereby the two may contract for services needed by the healthcare Client . 5.0 Client Responsibilities: 5.3 Client acknowledges and agrees that it will comply with all applicable healthcare laws and regulations, including but not limited to, the provision of personal protective equipment (PPE) and posters The facility's policy entitled; Abuse Prevention Training Program adopted 1/20 shows: D. Orientation and Training: During orientation and annually thereafter, staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source, exploitation, and misappropriation of property. On an annual basis, supervisory personnel will also receive training on their obligations under law when receiving an allegation of abuse, exploitation, neglect, or misappropriation of resident property, and how to monitor and correct inappropriate or insensitive staff actions, words or body language. The Abuse Prevention Training Program continues to show multiple handouts. Handout C: Causes, Prevention and Management of Angry or Agitated Resident Behaviors shows: Predict and prevent the situation, if possible, by recognizing situations that may bring on a violent outburst. Respond to the person's needs or distract the person's attention with an activity. If a person becomes aggressive, assess the situation, your role, and the effect on the person and other people in the area. Never threaten a person. When reacting to an aggressive person, always respond in a calm, but determined manner. Speak slowly and make eye contact with the person. Remind the person of who you are and of his or her behavior. If possible, keep your arms at your side, but be prepared to protect yourself if the person becomes violent. Be sure that you stand between the person and the door, if possible. The facility's Abuse Prevention Training program continues to show Handout E: Abuse Prevention Training Program Post Test with ten true and false questions. The facility's policy entitled; Abuse Prevention Program - Policy adopted 1/20 shows: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Immediate Jeopardy that began on January 7, 2024 was removed on January 25, 2024 when the facility took the following actions to remove the immediacy: On January 7, 2024, once the abuse allegation was reported, V3 (Agency LPN) was removed immediately from residents' presence and sent home pending investigation, but subsequently arrested in the parking lot by the local police, who were called by the facility. On January 7, 2024, resident was examined by Charge Nurse who notified the Attending Physician and transferred resident to the local hospital for evaluation of injuries. She returned to facility the same evening. On January 7, 2024, Charge Nurse notified V18 (Daughter of R1) of incident and need for hospital visit. On January 8, 2024, R1 was examined in facility by V17 (NP-Nurse Practitioner). On January 25, 2024, the facility began re-educating the current staff, including agency staff on abuse prevention. This re-education will continue until all staff have been re-educated by January 27, 2024. Focus of re-education includes: Managing residents with behaviors/agitation Abuse Burn-out Identifying triggers Screening Types Reporting Investigating Consequences/Discipline Post-Test Beginning January 25, 2024 and ongoing, all future staff, including agency staff, will be mandated to receive abuse training from Administrator or Designee prior to caring for residents. Training will include the information listed above. Beginning January 25, 2024 and ongoing, all future agency nurses will be mandated to arrive at facility prior to start of their shift for general orientation. Beginning January 25, 2024 and ongoing, Human Resources Director will obtain the healthcare background check and license lookup on all future agency staff nurses prior to starting orientation. As of January 25, 2024 and ongoing, R1 is being followed by in-house caseworkers and Social Service Department. R1's pain is continually being managed by medication as prescribed by Attending Physician. On January 26, 2024, R1 was seen by the psychiatrist. V1 (Administrator) will be responsible for overall compliance to plan of correction in conjunction with V2 (DON) by actively participating in the general orientation process, ensuring all mandated in-services are completed prior to resident care. The general orientation checklist and abuse post-test will be maintained in the employees' files for future reference. The QAQI (Quality Assurance Quality Improvement) Team meets monthly. This event will also be brought to the next monthly QAQI Team meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by V3 (Agency LPN-Licensed Practical Nurse). This failure resulted in R1 experiencing physical abuse by a staff member (V3). This applies to 1 of 3 residents (R1) reviewed for staff-to-resident abuse in the sample of 3. The Immediate Jeopardy began on January 7, 2024 when V3 (Agency LPN) worked at the facility without receiving abuse training and physically abused R1. V1 (Administrator) was notified of the Immediate Jeopardy on January 25, 2024 at 2:12 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on January 25, 2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On January 22, 2024 at 10:00 AM, R1 was sitting in a chair in her room. R1 said she was physically abused by V3 (Agency LPN) on January 7, 2024. R1 said, It started over medications that I normally get at 8:00 AM. It was 1:00 in the afternoon, and I had not received my medications for the day. [V10] (CNA-Certified Nursing Assistant) said we had a temporary nurse, and she was sitting in the lobby area at the nurse's station, and if you wanted your medications, you had to line up for the medications, and those who could not line up were disregarded. It is my preference to take my medications in my room. I walk with a cane, and it is hard for me to walk to the nurse's station. Also, I am a high risk for falls, so I usually stay in my room all day. When I stand up I get dizzy and I fall easily, so I did not walk to the nurse's station to get my medications. At 2:00 PM, [V3] (Agency LPN) finally came to my room with my morning medications. She came to the doorway and said, Come and get your medications. She said it very rudely. I did not get up, so she then said, Did you hear me say come get your medications? Come and get them! I told her she needed to bring the medications to me. She handed me the medications and turned to leave the room. I was yelling to her that some of my medications were missing. She continued walking out of the room and slammed the door. I got up after she did not come back and stood in the doorway of my room. When she came out of the room across the hall, she looked at me and made another smart remark. I threw my pills down and she ran up in my face, pointing at my face and yelling at me. She was shaking her hand at me with a pointed finger and hitting the tip of my nose with her finger. I said stop hitting my nose and I put my hand up to block her from hitting my nose. When I made that motion, she grabbed my hair and my hands and threw me down to the floor and hit me. She said, Are you going to stop? Are your going to stop? She was screaming it loudly and trying to make people think I was attacking her. I have never seen [V3] working at this facility before. She left me there in the room and walked out. I went over to my telephone and called 911. I explained to the operator that I had been attacked and where I was at. She assured me the police were on their way. [V10] (CNA) could back up the problems we were having with getting our medications that day, but she did not witness the altercation. [V11] (CNA) came and saw me crying when it was all over. I told the police I wanted to press charges because [V3] threw me to the floor by the hair. The police kept asking me if I wanted to go the hospital, and I said no. I had just been in the hospital recently, and the last place I wanted to go was the hospital. Later in the evening I had chest pain, and I went to the hospital. The paramedics said my blood pressure was over 200. I went to the hospital and came back the same night. It happened two weeks ago, and I still have some neck pain, back pain, and a headache. On January 23, 2024 at 2:45 PM, V3 (Agency LPN) said, The first time I worked at the facility was around December 31, 2023. The second time was on January 7, 2024. I did not receive any abuse training from the facility. I did not receive any training from the facility regarding dealing with resident behaviors. They never pointed out an agency binder or did any education with me. When you come into a facility, they give you an assignment, and they put you to work. I know when you are working at a facility with residents with mental illness, you are at risk as a caregiver. I learned some techniques to restrain residents, not to hurt the person. As you restrain them, you are putting them in a compromising position. [R1] was aggressive and combative. She struck me and she grabbed me by the hair. I said she should let go and she did not. This was all because she was not happy with her medications. My main thought was to get her loose. I know I cannot hit her, but I don't want to be hurt either. Earlier she was verbally aggressive towards me. I walked away, closed the door, and went about my business. I did not call the doctor. I did not ask another nurse to help me or to give [R1] her pills. [R1] came out of the room and threw her pills. I asked her, Why did you throw your pills? That's your health. She struck me in the face and pulled me in. She got my hair, and I asked her to let go. I grabbed both of her hands over my head, while lowering her down to the ground. Once I got her down to the floor I put her hands on her chest and held them there and I said I am going to let go of your hands if you promise to let go. I asked her if she wanted me to help her get up, and she said no. I left the room and went and gave medications to two other residents. Then I went to the bathroom to fix my hair. I went over to the nurse's station and said what do I do, [R1] just attacked me, and the nurse said she didn't know. Before I could ask what to do, the resident had called 911 and the police were there. This is normal for these type of residents to curse at you and call you names. This is a psych facility. I did not see [R1's] diagnoses so I don't know if she has any psychiatric issues. No one gave me a heads up about the resident and if she had behaviors. All of this was because of her medications. On January 22, 2024 at 10:45 AM, V8 (RN-Registered Nurse) said, [R1] has never tried to hit me. She cannot chase anyone down. There are times she will refuse her medications but will take them later. She will say I prefer later. On January 22, 2024 at 10:49 AM, R2 said, [V3] did not give me my medications. She said they weren't important. She only gave me one pill. When I asked for my other medications, she had a lousy attitude and said I would be last. On January 22, 2024 at 10:55 AM, R3 said, [V3] had an attitude. Usually, the nurses go room to room to give medications. She came to work around 9:00 AM. She said, You have to line up at the medication cart,, do you see these other people, they are all in line, you have to wait. I asked for medication, and she gave me attitude. On January 22, 2024 at 12:48 PM, V9 (CNA-Certified Nursing Assistant) said, I saw [V3] (Agency LPN) was rude to the residents and wasn't very respectful. She was that way to everybody, all of the residents. She was irritated. She kept giving a reason why she was busy. I have never seen [R1] get physical and grab someone's hair. She really does not come out of her room. She cannot run after anyone. She uses a cane. On January 22, 2024 at 1:06 PM, V10 (CNA) said, I worked here that day. It was a busy day. We were short a CNA, and that nurse (V3) came late. I never met [V3] before. It would be out of character for [R1] to hit someone. She can be angry but be respectful. She can use her words sometimes, and say she's upset. She has a limp and walks with a cane. [V3] (Agency LPN) was expecting the residents to come to the desk to get their medications. I was actually on my break when the incident happened. When I got back, a police officer was here. I saw [R1] right after the incident. She was bawling and said, I don't know why she would do this to me. She told me that [V3] pulled her hair and pushed her on the ground. [R2] was asking for anti-nausea medication and [V3] was rude and said you have to hold on, you have to give me a second. On January 22, 2024 at 1:26 PM, V11 (CNA) said, I was here that day (January 7, 2024). That was my assigned hallway. I was on my lunch break. I did not hear about it until I came back. When I came back, there was an ambulance, and the police were here. [R1] called me over and told me what happened. She said the nurse tried to give her medicine and [R1] told [V3] (Agency LPN) she had waited quite some time and the nurse got upset, and [R1] threw her medication. I was surprised because [R1] has never been rude or aggressive towards me. I have never seen her hit or scratch someone. She was crying. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, acute respiratory failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), cerebral infarction, heart disease, traumatic subarachnoid hemorrhage, muscle weakness, cognitive communication deficit, abnormal gait and mobility, lack of coordination, abnormal posture, need for assistance with personal care, falls, hypertension, anxiety disorder, and major depressive disorder. R1's MDS (Minimum Data Set) dated January 4, 2024 shows R1 is cognitively intact, has a lower extremity functional limitation in range of motion on one side and uses a cane for mobility. R1 is able to eat and dress her upper body independently, requires supervision with transfers between surfaces and walking, and partial/moderate assistance with oral hygiene, toilet hygiene, showering, lower body dressing, and personal hygiene. R1 is occasionally incontinent of bowel and bladder. R1's care plan, initiated July 24, 2023, shows R1 is high risk to be susceptible to abuse and/or neglect. This is determined by the resident's comprehensive assessment revealing a history of abuse, resident's physical and mental condition and/or compromised medical health. Interventions initiated on July 24, 2023 include: Assure resident that she is in a safe and secure environment with caring professionals to help, assure resident that staff members are here to help, explain that psychological adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse and/or CNA) and by verbalizing thoughts, needs, and feelings. Observe resident for signs of fear and insecurity during delivery of care. Take steps to calm resident to make her feel safe. The facility's undated Final Incident Investigation Report Form, received by the State Agency on January 12, 2024 shows: Upon further investigations, the incident was substantiated as the nurse [V3] (Agency LPN) was acting unprofessional to a point that it escalated this incident where the resident (R1) needs to be physically controlled and lowered down to floor for her safety. The police, NP/MD (Nurse Practitioner/Medical Doctor) and family members were informed, and the Resident was assessed by the nurses for injuries and was sent to the local hospital for evaluation. No injury was noted. The Final Incident Investigation Report Form continues to show the facility substantiated R1 was abused by V3 (Agency LPN). The local police department Field Case Report dated January 7, 2024 shows, On arrival, I went to [R1's room]. [R1] was crying, incredibly emotional, and unable to speak clearly. [R1] had a red mark on her left cheek, which appeared to be bleeding . On January 22, 2024 at 3:37 PM, V12 (Police Officer) said, We arrested [V3] (Agency LPN). I was present for the arrest part. [V3] was charged with aggravated battery. It was because she hit the resident. Aggravated means because the victim was over 65 or disabled. [V14] (Police Officer) must have had probable cause to arrest [V3]. There had to be video surveillance or marks on the victim (R1). I am reading the notes of the police report. [R1] had a red mark on her left cheek which appeared to be bleeding. In the report it is noted [V3] had called a supervisor and told the supervisor she had engaged physically with [R1] because of some aggression. It says [V3] had also stated she had to go hands-on after a scuffle with the patient. The probable cause would have been the admission of the physicality of the incident, the marks on the victim, and advised to pursue charges. On January 22, 2024 at 9:24 AM, and on January 22, 2024 at 3:54 PM, V1 (Administrator) said, R1 does not have a history of violent outbursts or attacking staff or residents. V1 continued to say the facility does not have behavior tracking for R1. V1 said, I substantiated the allegation as physical abuse based on the interview, and that [V3] physically held [R1] and put her down on the ground. On January 25, 2024 at 10:29 AM, V17 (NP-Nurse Practitioner) said she examined R1 on January 8, 2024. V17 said, I am familiar with [R1]. I have never known her to be physically aggressive with anyone. When I saw her she complained of scalp and neck soreness. I documented the resident had a neck sprain based on what [R1] was saying. No resident should be abused while residing in a facility. The facility's policy entitled; Abuse Prevention Program - Policy adopted 1/20 shows: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Immediate Jeopardy that began on January 7, 2024 was removed on January 25, 2024 when the facility took the following actions to remove the immediacy: On January 7, 2024, once the abuse allegation was reported, V3 (Agency LPN) was removed immediately from residents' presence and sent home pending investigation, but subsequently arrested in the parking lot by the local police, who were called by the facility. On January 7, 2024, resident was examined by Charge Nurse who notified the Attending Physician and transferred resident to the local hospital for evaluation of injuries. She returned to facility the same evening. On January 7, 2024, Charge Nurse notified V18 (Daughter of R1) of incident and need for hospital visit. On January 8, 2024, R1 was examined in facility by V17 (NP-Nurse Practitioner). On January 25, 2024, the facility began re-educating the current staff, including agency staff on abuse prevention. This re-education will continue until all staff have been re-educated by January 27, 2024. Focus of re-education includes: Managing residents with behaviors/agitation Abuse Burn-out Identifying triggers Screening Types Reporting Investigating Consequences/Discipline Post-Test Beginning January 25, 2024 and ongoing, all future staff, including agency staff, will be mandated to receive abuse training from Administrator or Designee prior to caring for residents. Training will include the information listed above. Beginning January 25, 2024 and ongoing, all future agency nurses will be mandated to arrive at facility prior to start of their shift for general orientation. Beginning January 25, 2024 and ongoing, Human Resources Director will obtain the healthcare background check and license lookup on all future agency staff nurses prior to starting orientation. As of January 25, 2024 and ongoing, R1 is being followed by in-house caseworkers and Social Service Department. R1's pain is continually being managed by medication as prescribed by Attending Physician. On January 26, 2024, R1 was seen by the psychiatrist. V1 (Administrator) will be responsible for overall compliance to plan of correction in conjunction with V2 (DON) by actively participating in the general orientation process, ensuring all mandated in-services are completed prior to resident care. The general orientation checklist and abuse post-test will be maintained in the employees' files for future reference. The QAQI (Quality Assurance Quality Improvement) Team meets monthly. This event will also be brought to the next monthly QAQI Team meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly.

Based on interview and record review, the facility failed to implement their policy to thoroughly investigate an allegation of employee to resident sexual abuse. The facility also failed to investigate an allegation of resident-to-resident abuse. This failure resulted in R1 reporting V3 (Maintenance Director) sexually abused R1 and the facility not conducting a thorough investigation including assessing R1 for injuries and immediately contacting emergency services. This has the ability to affect all 139 residents residing in the facility. This failure resulted in Immediate Jeopardy on June 7, 2023, when the facility failed to implement their abuse policy for sexual abuse, and unsubstantiated an allegation of abuse prior to completing a thorough investigation. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on June 22, 2023, at 9:53 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on June 23, 2023, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and abuse investigations are being reviewed. The findings include: The Facility Data Sheet dated June 20, 2023 shows the facility's census of 139 residents. 1. R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, anxiety, and hypertension. R1's MDS (Minimum Data Set) dated May 10, 2023, shows R1 is cognitively intact. The facility's Final Incident Investigation Report Form submitted to IDPH (Illinois Department of Public Health) on June 12, 2023, shows Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: Abuse is unsubstantiated, as follows: [R1] states that maintenance man, [V3 (Maintenance Director)] dropped off a bed and wheelchair to her room. After the bed and wheelchair, [R1] stated [V3] walked over to the bed where she was laying and touched her breast and kissed her on the lips. [R1] pushed [V3] away and told him to stop but says [V3] tried kissing her another time but was unsuccessful. [V3] then walked out of the room. PRSD (Psychiatric Rehabilitation Services Director) conducted an internal investigation and found no other residents or staff that accuse [V3] of being sexually inappropriate with them. There were no reported injuries and no witnesses to the occurrence. [V3] denies all claims that he was inappropriate with [R1]. The report continues to show a full head to toe assessment was not completed, R1's physician was not notified of the allegation, and R1 was not offered or received counseling/social services. On June 20, 2023, at 3:50 PM, R1 said, On June 7, 2023, I was laying on my bed. Someone knocked at the door and I said come in. I thought it would be the nurse. [V3] came in and asked if he could put a bed and wheelchair in my room, and I said sure because that part of the room is not my space. He brought them in the room, and I was laying on my bed listening to music. I looked over and he was standing by the curtain and was just staring at me. I asked him what he wanted. He then came over and touched my breasts and kissed me. I told him to stop and was pushing him away. I told him if he didn't stop, I would scream, then he left the room. I was so scared and nervous. I eventually got up and looked out my door and saw [V8 (NP/Nurse Practitioner)] so I asked her to come in my room. I told her what happened. I felt bad and started crying because I was sexually abused when I was little. [V8] asked if she could tell [V6 (Social Services Director)] and I said that was fine. [V6] talked to me and the police came. The police asked me if I wanted to press charges and I said yes. They let me know I will have to see him in court. I don't want to see him in court, but I want to press charges. Nobody from social services has been meeting with me. I am hoping [V3] does not come back because I am scared. I haven't seen him since it happened, but I don't know if he is coming back so I am always looking around for him. The bed and the chair in the room are a constant reminder of [V3] and I wish they could be out of my room. I told [V6] I was scared. I leave the facility on pass more often now because I am scared to be here. I told them it felt like he was in here for 15 minutes, but I wasn't paying attention to the time because I was pushing him away. There is not a clock in my room, and I couldn't look at my phone to see what time it was because I was using both of my hands to push him away. It might have only been two minutes, but to me it felt like 15 minutes or even longer. Nobody looked at me for injuries or asked if I wanted to go to the hospital. I lived in this facility two to three years ago and [V3] bothered me then. He touched me a couple years ago, and I told a staff member then, but nothing happened so that is why I left the facility. The facility does not have documentation to show an investigation was completed for R1's abuse allegation from her previous admission in the facility. On June 21, 2023, at 10:20 AM, V8 (NP) said, I have been seeing [R1] because she is in therapy for leg pain. On June 7, 2023, I was in the hallway and [R1] said she wanted to talk to me. We went to her room and we were talking. At the end of our conversation, [R1] became teary eyed and said someone is bothering her and came into her room and touched her. I asked who touched her and she said [V3]. I have seen [V3], but I have never talked to him. She knew he was the head of maintenance and knew him from the last time she was here. I encouraged her to talk to the social workers, but [R1] said her case manager was a guy and she was uncomfortable with that. I told [R1] she could speak with [V6], but [R1] said nothing is going to happen if she tells them. It seemed like she wasn't going to talk about it, so I asked permission to talk to [V6]. I went straight to [V6]'s office and told her what happened. I only examined her leg while we were in her room because she has neuropathy, I did not do a head-to-toe assessment. I see [R1] once or twice a week. [R1] has never made allegations like this before to me. She is cognitively intact. On June 20, 2023, at 1:10 PM, V6 (Social Services Director) said, I was told about [R1]'s abuse allegation by [V8]. I started talking to a few staff and other residents. I looked at the security camera footage to see if the story correlated. [R1] had told us at first that [V3] was in her room for 15 minutes, but the camera showed it was two minutes. That was the only discrepancy in her story. I had called the [local police] and they came out soon after I called. I do not think [V3] should come back to work in this facility. [R1] is here for a heart condition and diabetes. [R1] is not here for mental health issues. She is very alert and aware and independent. The other residents I interviewed for the investigation are scattered between the first and second floor. I just made a random selection of residents. I chose some residents that are alert and aware, I tried to get a variety of residents. There have been previous allegations against [V3] in the past, one by a staff member and one by [R9] this past December. The allegation by [R9] came out unsubstantiated because it was in the resident room and there was no other proof, no roommate, and no video footage of it happening. [R1]'s allegation is unsubstantiated because we could not find any hard proof evidence of sexual abuse occurring. After the allegation by [R9], [V3] was told not to go into resident rooms alone, but I don't know if he was following that. [V3] was by himself the day he went into [R1]'s room. On June 21, 2023, at 12:30 PM, V6 said, I went to [V1]'s office around noon on June 7 to notify him about [R1]'s allegation. After I spoke with [V1], I went to speak with [R1], but she was eating lunch, so I let her finish lunch. I spoke with [R1] in her room after she finished lunch. On June 21, 2023, at 2:22 PM, V6 said, I would assume one of the nurses assessed [R1] following her allegation, but I am not sure if anyone did. I wrote in the report [R1] had no injuries because she told me she did not have any injuries. I am not sure if the nurses checked [R1]. This allegation would have been substantiated if there was video evidence or a witness of it. I don't think unsubstantiated means it didn't happen, but there is no concrete proof to show it did happen. When I finish my final investigation reports, I send them to [V1] to review, he gives me the go ahead to submit the report to IDPH. I called the non-emergency police number to report [R1]'s allegation. We did not call an ambulance. I typed the interviews I conducted with the staff and residents. I interviewed three case workers, three CNAs (Certified Nursing Assistants) working the day of the incident. I also interviewed the receptionist, she is the one sitting behind the glass at the front door. The last person I interviewed was the scheduler, she works upstairs, but walks around the facility a lot. I never interviewed [V7(LPN/Licensed Practical Nurse)], [R1]'s nurse at the time of the incident. Before I started working here, there was an incident with a nurse and [V3]. [V3] attempted to kiss her in a storage or supply room. The nurse does not work here anymore. On June 20, 2023, at 3:03 PM, V3 said I usually take [V14 (Maintenance)] in resident rooms with me, but I needed to move this bed right away, so I went in without him. I was told before to have someone go in resident rooms with me. It was because of the previous abuse allegation with another resident that I was supposed to have someone with me when I was going into resident rooms. On June 20, 2023, at 3:11 PM, V1 (Administrator) said [V3] was told be careful with female residents. [R1]'s abuse allegation was unsubstantiated because we do not have any witnesses. [R1] did say [V3] was in her room for more than 15 minutes, but it was about two minutes. The abuse allegation was unsubstantiated because of the time discrepancy. I have not brought [V3] back to work because I did not feel comfortable. Just because the allegation was unsubstantiated doesn't mean it didn't happen. I cannot substantiate abuse based on just one statement. On June 21, 2023, at 1:37 PM, V13 (Police Officer) said, This allegation is considered battery, and [R1] is pressing charges against [V3]. I got to the facility on [DATE], at about 2:45 PM. I arrived shortly after they called the police department. They waited hours to call, they usually call right away. On June 21, 2023, at 10:45 AM, V9 (NP) said, I was not aware of [R1]'s allegation of sexual abuse. This is the first I am hearing about this. I saw her last week. Nobody from the facility contacted me about this. [R1] is cognitively intact. [R1] has never made allegations about anybody. [R1] does not regularly make false statements. On June 21, 2023, at 10:52 AM, V10 (Physician) said, I am [R1]'s physician. I am unaware of [R1]'s sexual abuse allegations. I would expect the facility to inform me of this. I have not heard from anyone from the facility. It is my expectation [R1] is free from abuse. Her wellbeing is my priority. On June 21, 2023, at 2:07 PM, V2 (DON) said, I was only a part of the second questioning during the investigation. That was before the final report was submitted. I spoke with [R1] with [V6] on June 12, 2023. I did not perform a physical assessment on [R1]. I do not think anyone assessed [R1]. On June 20, 2023, at 12:58 PM, V7 (LPN) said, I was not aware of [R1]'s abuse allegation until [R1] told me about it days later. I was [R1]'s nurse on June 7, 2023. I was never interviewed by anyone about [R1]'s allegation. I did not perform a head-to-toe assessment of [R1] on June 7, 2023. On June 20, 2023, at 3:47 PM, V12 (RN/Registered Nurse) said, I am unaware of the allegation of abuse regarding [R1] and [V3]. I have only heard rumors. I was [R1]'s nurse on June 7, 2023 for second shift. I did not do a head-to-toe assessment on [R1] on June 7, 2023 because she did not require one. The facility does not have documentation to show a facility staff member completed a head-to-toe assessment of R1 following her allegation of sexual abuse. The facility does not have documentation to show R1's primary physician was notified of her sexual abuse allegation. On June 26, 2023, at 4:33 PM, V1 said V3's job duties included maintenance throughout the entire building. The facility's job description for maintenance director, signed by V3 on February 11, 2020, shows main duties of assuring proper maintenance throughout the facility including resident rooms. Facility documentation shows V6 interviewed 16 residents on June 8, 2023 between 1:00 PM and 2:00 PM and June 9, 2023, from 10:45 AM to 11:30 AM. The EMR shows two of the residents interviewed (R10 and R11) are male residents residing on the second floor of the facility (R1 resides on the first floor of the facility). R3 was interviewed on June 8, 2023. R3's MDS dated [DATE], shows R3 has moderate cognitive impairment. R12 was interviewed on June 9, 2023. R12's MDS dated [DATE] shows R12 has moderate cognitive impairment. R13 was interviewed on June 8, 2023. R13's MDS dated [DATE], shows R13 has moderate cognitive impairment, and has inattention and disorganized thinking. R14 was interviewed on June 8, 2023. R14's MDS dated [DATE], shows R14 has moderately impaired cognitive skills for daily decision making, and has short term and long term memory problems. 2. R4's EMR shows a progress note dated June 13, 2023, at 2:42 PM, by V11. V11 documented, Resident is being accused by another resident of entering room without authorization and kissing same resident without consent (spoke to co-resident about issue). PRSC (Psychiatric Rehabilitation Services Coordinator) attempted to speak to resident about issue but refused to talk. Will continue to work on issue. On June 21, 2023, at 11:11 AM, R3 said, [R4] came into my room and kissed me when I didn't want him to. I told a social worker about it. On June 20, 2023 at 4:49 PM, V6 said, I am unaware of [R3] saying [R4] kissed her. [V11] never reported that to me. This is something that would be investigated. On June 21, 2023, at 12:16 PM, V11 (Case Worker) said, My director told me is [R4] was going into [R3]'s room and we didn't know why. On June 13, I went to [R3] and she said [R4] would come into her room and give her snacks. The part we found inappropriate was [R4] would kiss [R3] and it had been going on for a while. I reported this to [V6] on either June 13 or the day after. I informed [V6] because I didn't want it to become a bigger issue. I am not aware if anything has been put in place to ensure this doesn't happen again. On June 21, 2023, at 2:21 PM, V6 said, I don't remember [V11] telling me about [R3] and [R4]. I don't remember this coming up. I have not started an investigation on this. As of June 22, 2023, at 9:53 AM, the facility does not have documentation to show an investigation was initiated or a report was sent to IDPH regarding R4 kissing R3. R3's EMR shows R3 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia, insomnia, and asthma. R3's MDS dated [DATE], shows R3 has moderate cognitive impairment. R4's EMR shows R4 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia and hypothyroidism. R4's MDS dated [DATE], shows R4 is cognitively intact. R4's Identified Offender care plan dated on December 29, 2021, shows [R4] is a [AGE] year old male who admitted on [DATE]. Criminal history consisted of convictions for criminal trespass/remain on land; and unlawful window peeping. He was sentenced to 12 months conditional discharge. He is diagnosed with a major psychiatric disorder and has a history of alcohol/drug abuse. Facility personnel reported no incidents of aggression since admission, although, he has hallucinations, becomes easily agitated, and may be difficult to redirect. His compliance with psychiatric treatment and abstinence from alcohol/drug use should be closely monitored. In view of his psychiatric condition, frequent agitation, and current legal circumstances (conditional discharge) a moderate risk supervision status is recommended. When discharged , the identified offender program will be notified. The care plan continues to show multiple interventions dated December 29, 2021, including, [R4] is determined to be a moderate risk and requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on the time limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. 3. R5's EMR shows R5 was admitted to the facility on [DATE], with multiple diagnoses including: lung cancer, diabetes with chronic kidney disease, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. R5's MDS dated [DATE], shows R5 is cognitively intact The facility's undated Final Incident Investigation Report Form submitted to IDPH on May 12, 2023, completed by V6 shows, The incident happened on 5/10/2023 at approximately 1:00 PM in the resident's room. The alleged perpetrator is [V16 (CNA)]. The report was written on 5/10/2023 at approximately 2:00 PM after PRSD was made aware of allegation. There are no witnesses to the occurrence and no injuries were noted. Resident stated that [V16] yelled at her to 'be patient' and kicked over her trash can. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: Verbal abuse is unsubstantiated as follows: Upon investigation it was found that [V16] did not kick [R5]'s garbage can or yell at her. [R5] pulled her call light because she needed to use the bathroom. [V16] answered resident's call like and asked what she could do to help her. [V16] helped resident use the bathroom and asked if there was anything else she could do. Resident stated no and [V16] then grabbed the trash can to throw things away and walked out of the room. PRSD did not see trash can spilled over on floor when talking to resident about incident and no one heard [V16] yelling . On June 26, 2023, at 9:46 AM, V6 said, I was really busy, and didn't have time for investigating [R5]'s allegation. I know I am supposed to do interviews, but I did not have the time. The facility does not have documentation to show staff were interviewed during the investigation of R5's allegation. 4. R6's EMR shows R6 was admitted to the facility on [DATE], with multiple diagnoses including: major depressive disorder, schizoaffective disorder, and hypertension. The EMR continues to show R6 was discharged from the facility on May 31, 2023. R6's MDS dated [DATE], shows R6 is cognitively intact. The facility's undated Final Incident Investigation Report Form submitted to IDPH on January 21, 2023, completed by V6 shows, Resident reported the allegation on Tuesday 1/17/2023 at approximately 1:00 PM to [V6]. Time of report was 1:40 PM. Time of the incident is unknown. The incident happened in the resident's room. The alleged perpetrator is a staff member, [V16]. There were no other witnesses to this incident and no injuries noted. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: mistreatment is unsubstantiated, as follows: [R6] stated that staff member, [V16], was verbally inappropriate with her in her room. [V16] walked into resident's room and noticed a strong scent of urine. [V16] then asked [R6] if she wet herself. [R6] replied confirming she urinated her pants. [V16] asked [R6] why she wet herself and stated that she was not able to go to the bathroom on her own. [R6] did not reply so [V16] started to change resident. While CNA was changing [R6], she started to urinate again. [V16] again explained to [R6] that she is capable of using the bathroom on her own and was unsure why she was urinating all over herself. [V16] denied being disrespectful to [R6]. CNA was trying to educate resident on being independent and there was a misunderstanding in communication. [V16] has been educated on professionalism and using appropriate language when talking to residents . On June 26, 2023, at 9:46 AM, V6 said, In January, I did not know I was supposed to be conducting interviews during investigations. The facility does not have documentation to show interviews were conducted during the investigation of R6's allegation. The facility's Abuse Prevention Program - Toolkit dated November 17, 2017, shows, Investigation Procedures: Regardless of the specific nature of the allegation (physical, sexual, verbal/mental abuse, theft, neglect, unreasonable confinement/involuntary seclusion or exploitation), the investigation shall consist of: . Interview of staff members having contact with the alleged victim and alleged perpetrator during the period of the alleged incident; If the alleged perpetrator is an employee, interview of the other residents the alleged perpetrator provided care on the same shift as the alleged incident; If the alleged perpetrator is an employee, interview of other employees who worked the same shift of the alleged incident . Sexual Abuse Incident Response Guide Definition: Sexual abuse is non-consensual contact of any type with a resident. Determine if the allegation involves verbal sexual harassment or physical sexual contact with or without penetration. If the allegation involves verbal sexual harassment, refer to the Verbal Abuse Investigative Path. If an allegation of sexual contact is involved: Immediately contact local law enforcement authorities (e.g. telephoning 911 where available) as required in Section 300.695 in the following situations: for sexual abuse- sexual penetration, intentional sexual touching or fondling, or sexual exploitation; or for sexual abuse of a resident by a staff member, another resident, or a visitor. Call an ambulance provider and move the survivor, as quickly as possible, to a private environment to ensure privacy and ensure safety while waiting for emergency or law enforcement personnel to arrive . If the facts do not indicate that sexual contact occurred after a thorough investigation, proceed to submit the Final Incident Investigation Report. Document the specific reasons sexual harassment or sexual contact is not suspected. Ensure notification to the Department of Public Health within two hours of the report . The facility's undated Abuse Prevention Program Facility Procedures shows, . V. Internal Reporting Requirements and Identification of Allegations Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator. Or an immediate supervisor who must then immediately report it to the administrator . VI. Internal Investigation of Abuse, Neglect or Misappropriation Allegations and Response 1. All incidents will be documents, whether or not abuse occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect or misappropriation will result in an abuse investigation . The Immediate Jeopardy that began on June 7, 2023, was removed on June 23, 2023, when the facility took the following actions to remove the immediacy: On June 22, 2023, re-education was immediately started with facility staff members on abuse policy, identifying abuse, reporting abuse, and keeping professional relationship with residents and coworkers. Re-education included: Assess and Identify residents at risk for Abuse. Completion date: 6/22/2023 Report any form of abuse and any suspicious behaviors of staff members or residents immediately to the administrator or the designee. Completion Date: 6/22/2023 Administrator, Assistant Administrator, DON, ADON (Assistant Director of Nursing) and PRSD were in-serviced by Corporate Legal Advisor on prevention, identification, reporting and thorough investigation of abuse. Completion Date: 6/22/2023 V3 was immediately suspended on the day of incident 6/08/2023 and remains off the schedule. He will be terminated. Completion Date:6/22/2023 An initial report was submitted to IDPH regarding abuse allegation on R4. R4 was sent to ER for psychiatric evaluation. Completion Date: 6/22/2023 A QA (Quality Assurance) tool was developed to monitor that there's no further abuse and that a thorough investigation is being done for every abuse allegation. QA tool will be used daily for 30 days then weekly for 3 months. QA will do 5 resident random interviews daily to identify behaviors. After 3 months facility will reevaluate the need of frequency and need for continuation of the QA tool. This QA tool will be done by Administrator or designee. In the case of an abuse allegation, the Administrator or designee will do the investigation and the VP of Operations or Director of Clinical Services will do the QA of specific abuse allegation before submission of final report to IDPH to ensure that thorough investigation of abuse allegation is being done. Date: 6/22/2023 This education will be conducted by Assistant Administrator, ADON and PRSD to staff members and agency staff and will be completed by the end of 06/22/2023. Administrator/assist administrator will in-service all staff members including off-hour staff members and agency staff. Anyone not reached out today will be in-serviced prior to their next schedule and will be ongoing. Abuse in-service will continue to be presented during the orientation period for all new hires and agency staff. Administrator will be responsible for the overall compliance of this plan of correction in conjunction with PRSD and Assistant Administrator. The Quality Assurance Quality Improvement Team meets monthly, in addition to the Emergency QA addressing prevention, identification, reporting and thorough investigation of abuse which was done today 6/22/2023. This event will also be brought to the next monthly Quality Assurance / Quality Improvement meeting for discussion and possible re-evaluation to determine any needed revisions to policy and/or interventions. If revisions of the policy and/or interventions are needed at that time, they will be made accordingly.

Based on observation, interview, and record review, the facility failed to protect a resident from abuse perpetrated by a facility staff member. This applies to 1 of 3 residents (R1) who were reviewed for abuse in the sample of 8. As a result of this failure, R1 was exposed to abusive behaviors from V4 (PRSC - Psychiatric Rehabilitation Services Coordinator). The IJ (Immediate Jeopardy) began on 1/6/22 at 7:40 PM when R1 was sexually abused by V4. The IJ was identified on January 21, 2022. V1 (Administrator) and V2 (Director of Nursing) were notified of the IJ on 1/31/22 at 10:38 AM. V1 was provided with the IJ Template outlining the failures. The surveyor confirmed by interview and record review that IJ was removed on 1/31/22, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: Face sheet, dated 1/14/22, shows R1 was admitted to the facility on [DATE], was [AGE] years old, and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's psychology note, dated 12/14/21, shows R1 stated she had significant difficulty with short term memory and, for that reason, is kept safe by the facility and her freedom of movement outside the facility is significantly restricted. The psychology exam showed R1 had marginal judgement, marginal impulse control, and impaired insight. R1's behavior note dated 9/14/21, shows Resident continues to have cognitive and memory impairments. Resident oftentimes confuses how long she has been at the facility, stating clothing is missing even though it is in her room, asking questions of why she is here and that she needs to go home to her son ([Department of Children and Family Services] has custody). Elopement Risk Review dated 12/19/21, shows R1 becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e . would not be able to safely care for him/herself outside the facility .) On 1/14/22 at 11:06 AM, V10 (PRSC) stated R1 reported to her on 1/11/22 she was having a relationship with V4. V10 stated R1 reported she and V4 would kiss in V4's office and when V4 took R1 on smoking breaks. V10 stated on the day R1 reported to the staff she was having a relationship with V4, V10 reported to V6 (PRSC) and V12 (PRSC) that V4 joked around about thinking R1 was cute and wanting to have a relationship with R1. V10 stated V4 was flirty with staff and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . At 12:28 PM, V10 stated that on the day prior to R1 reporting her relationship with V4, V4 had asked V10, What would you say or what would you do if I told you I found [R1] attractive and she found me attractive? V10 stated the next day she discussed V4's comments with V6 and V9 (PRSC) and they agreed to report the comments to V1 (Administrator), when R1 appeared and reported her relationship with V4. V10 stated she reported R1's allegations to V3 (Assistant Administrator). On 1/14/22 at 10:07 AM, V6 (PRSC) stated R1 reported to V6 that R1 and V4 had kissed, but R1 could not remember when. R1 reported the incident happened while she was smoking outside and V4 was supervising her smoking because she was on smoking restrictions. R1 told V6 that V4 would take R1 to the North side of the building. V6 stated R1 reported V4 also kissed R1 during online classes she attended under V4's supervision. V6 stated she told V1 (Administrator) and V3 (Assistant Administrator) immediately. V6 stated a Police Officer arrived the prior day to retrieve video footage from the facility. V6 also stated R1 told V6 the relationship was consensual and R1 informed the police she did not want to press charges. V6 stated the Officer told V6 the actions were not criminal and there was nothing the police could do. On 1/21/22 at 11:48 AM during facility video surveillance review with V1 (Administrator) and V14 (Psychiatric Rehabilitation Services Director, PRSD), the facility video footage from Camera 9 (dated 1/6/22) showed the following: - At 7:37 PM-7:40 PM, R1 and V4 (PRSC) appeared in view of the facility camera located outside the building and above the Northeast exit door of the building. R1 began to smoke a cigarette and V4 began hugging R1 from behind by placing the front of his body up against R1's back of her body while placing V4's arms around the front of R1's body. V4 occasionally placed his nose in R1's hair and stroked R1's hair with his hand. Occasionally, V4 briefly loosened his grip on R1, and once stepped away placing his hands in his pocket, however quickly reconnected in a hug. -At 7:40 PM, V4 released his hands from hugging R1 from behind, turned R1 around to face V4, and began to hug R1 closely as they faced each other. V4 began stroking R1's hair and appeared to kiss R1 on the left side of her head while holding R1 in a tight frontal hug embrace. V4 then leaned his head to the left and kissed R1 while continuing to hold R1 in a hug. -At 7:41 PM, V4 began kissing R1 on the lips in a deep kiss [MEDICATION(S)] until 7:41 PM at which time they disengaged and continued their face-to-face hug. At 7:42 V4 began kissing R1 again and re-embraced, placing each of their chins on the other's shoulder. V4 again leaned back and kissed R1 quickly on the mouth and then quickly released R1 while looking toward the street and quickly stepped away from R1 while placing his hand in his pockets. Seconds later, V4 stood behind R1 and placed his hands on R1's arms while placing his face against the left side of R1's head and occasionally kissing R1. V4 hugged R1 from behind until 7:44 PM. -At 7:44 PM, V4 briefly let go of R1 but reconnected hugging R1 from behind but occasionally released R1 while looking toward the street. R1 continued to smoke and talk with V4 while being hugged. -At 7:49 PM, V4 and R1 faced each other as V4 leaned toward R1 and kissed her on the mouth twice. V4 then placed his hand on the back of R1's head and pulled her head toward V4's chest. V4 released R1 and the two stood independently near each other, then walked out of camera view. On 1/21/22 at 11:48 AM and following video review, V1 (Administrator) stated he did not think what he witnessed on the video between R1 and V4 was abuse because R1 could make her own decisions. V14 (PRSD) also stated she did not think she witnessed abuse in the video, but stated she would have to think about it. As of 1/31/22 at 10:06 AM, the facility had not submitted any further update regarding the investigation of R1's allegation she and V4 had a relationship at the facility. On 1/14/22 at 10:30 AM, R1 stated, He just kissed me, that's it. R1 stated V4 kissed her while sitting in chairs across from one another inside the facility but could not specifically remember further details. R1 stated .my memory is all over the place I can't tell you a timeline! R1 could not describe if the kiss occurred a month, a week, or a day ago. Originally, R1 stated she could not remember if she and V4 only kissed once, but then stated they kissed outside while she was having a cigarette. R1 stated she was not sure how long the kissing had gone on and could not remember she told staff about her kissing V4. R1 stated she was unsure why her kissing V4 was being discussed. On 1/24/22 at 9:08 AM, V8 (Psychiatrist) stated he could not determine if R1 was able to consent to a relationship and that R1 needed a neuropsychological evaluation to determine her ability to consent. V8 stated R1's alcoholic dementia was most likely mild and V8 did not believe R1 could manage her medications independently or live on her own without assistance with cognitive functions. On 1/24/22 at 3:22 PM, V13 (Psychologist) stated R1 had areas of cognitive impairment. V13 stated, Clearly she is not cognitively intact. Is the extent of her cognitive impairment to the extent that she could be seduced by a staff? It is certainly possible. On 1/24/22 at 11:18 AM, V15 (Primary Physician) stated because of R1's complications, R1 would require a neurocognitive evaluation to determine her cognitive status. Facility Abuse Prevention Policy, adopted 1/2020, shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion The IJ that began on January 6, 2022 was removed on January 31, 2022 when the facility took the following actions to remove the immediacy. 1) On January 31st, 2022, re-education was immediately started with facility staff which includes CNAs, Nurses, and all other staff on abuse policy, identifying abuse, reporting abuse, and keeping professional relationship with residents and coworkers and that the relationship between staff and the residents are considered as abuse. Re-education included: Assess and Identify residents at risk for Abuse and report any form of abuse and any suspicious behaviors of staff or residents immediately to the administrator or the designee. This education will be for all staff completed by the end of 01/31/2022, staff not reached will be inserviced prior to their next schedule. The education will be ongoing and presented during the orientation period for all future new hires. 2) Administrator, assistant administrator, DON and PRSD were inserviced by Vice President of clinical services on identification and reporting abuse including staff/resident relationship. This was completed on 1/31/2022. 3). Abuse was substantiated and reported to IDPH (Illinois Department of Public Health) on 1/31/2022, employee (V4) does not work at the facility as of 1/11/2022. 4) A QA (Quality Assurance) tool was developed to monitor that there's no further abuse, QA tools will be used daily 30 days then weekly for 3 months, QA will do 5 resident random interviews daily to identify staff behaviors. After 3 months facility will reevaluate the need of frequency and need for continuation of the QA tool. 5) Administrator will be responsible for the overall compliance to this plan of correction in conjunction with PRSD and Assistant Administrator. 6) The Quality Assurance Quality Improvement Team meets monthly. This event will also be brought to the next monthly Quality Assurance Quality Improvement meeting for discussion and possible re-evaluation to determine any needed revisions to policy and/or interventions. If revisions of the policy and/or interventions are needed at that time, they will be made accordingly.

Based on observation, interview and record review, the facility failed to protect a resident from mental abuse when an unauthorized video of R3 was posted to social media by staff members. Using the reasonable person concept, this failure resulted in mental abuse to R3 due to the demeaning and humiliating nature of the video. This applies to 1 of 3 residents (R3) reviewed for abuse in a sample of 25. The findings include: R3's Electronic Health Record (EHR) showed R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS (Minimum Data Set) dated 5/19/2021 showed she was severely, cognitively impaired. The same MDS showed R3 needs extensive assistance from staff for her activities of daily living, such as eating, dressing, and moving in bed. On 06/14/2021 at 1:10 PM, V20 (Psychosocial Rehab Services Coordinator/PRSC) stated he was R3's social services coordinator. V20 said R3 has dementia, has a lot of hallucinations, was hard to redirect, and was very confused. V20 said the most lucid response he has heard from R3 was when she said thank you after she was complimented. V20 said R3 usually only makes comments that are totally unrelated to what anyone was talking about. On 06/08/2021 at 5:15 PM, R3 was sitting in a wheelchair near the nurse's station. A staff member was sitting next to R3, reminding her to sit down. R3 appeared confused and spoke words that were out of context for the situation. On 06/09/2021 at 3:56 PM, R3 was sitting at nursing station with V15, (Certified Nursing Assistant/CNA), sitting next to her. R3 did not respond to the surveyor when she said hello or asked her how she was doing. R3 looked away, in a different direction. On 06/10/2021 at 9:32 AM, V16 RN (Registered Nurse from Agency) stated that after completing medication pass on the evening of 04/24/2021, she had seen a video of R3 on a social media site that had been posted by V15 (CNA). V16 said she immediately recorded the video and showed it to V14 (PRSC). On 06/09/2021 at 4:06 PM, V14 (PRSC) said she saw the video of R3 and contacted R3's family members. V14 stated R3's family was disappointed and discouraged and hoped those CNAs would not take care of R3 any longer. The video was viewed by the surveyor. The video showed V13 (CNA) holding up R3's left arm with her (V13's) own right arm. R3 was in bed,wearing a hospital gown. V13 held R3's left hand up in the air and manually jiggled the loose skin and tissue on the back of R3's upper arm with V13's hand. V13 then let go of the back of R3's upper arm, then swung R3's arm back and forth so R3's skin and tissue were seen swinging back and forth. A caption was included below the video that read Don't leave your family members with her, she plays with their skin, . The caption was followed by three emojis (two loudly crying face emoji and a hand emoji). An emoji is a pictogram used in elctronic messages to depict an emotion. According to Dictionary.com and [NAME] Dictionary, the Loudly Crying Face emoji , indicates laughter and can mean to be laughing extremely hard over something. The emojis are used to indicate a joke. On 06/09/2021 at 3:03 PM, V13 (CNA) said she went to help V15 (CNA) because sometimes R3 will become aggressive and grab the staff members arms. V13 said R3 was talking about her appearance saying, How did I get so old? and was playing with the skin on her arm. V13 said they (V13 and V15) were joking around with R3. V13 gave R3 kisses on the arm while V15 took a video, posting it to (social media site). V13 said one of the nurses had seen it and had showed the video to V3 (Psych/Rehab Social Services Director/PRSD). On 06/09/2021 at 4:51 PM, V3 (Psychosocial Rehab Services Director) stated V16 (Agency RN) reported that V13 (CNA) and V15 (CNA) were inappropriate with the R3 on 04/24/2021. When describing the video, V3 stated It was just the resident's arm. Nobody has the video, it disappeared. V3 stated she saw the video the night it was posted and R3's son and dughter-in-law were notified. V3 stated They were upset, they wanted to know what was going to be done, and if the CNAs were going to be disciplined. V3 said the facility does have a social media policy separate from the abuse prevention policy. V3 was unsure what the social media policy said, but staff members are not supposed to be using their phones in the facility. V3 said The video did not have anything to identify the resident or the facility. It was just an arm. On 06/09/2021 at 5:17 PM, V1 (Administrator) and V2 (Director of Nursing/DON) stated they had received the video of R3 with V13 (CNA) and V15 (CNA). V1 and V2 said they knew it was R3 because the CNAs admitted it was R3, but R3's face was not in the video. R3 would be unidentifiable On 06/14/2021 at 11:09 AM, V24 (Medical Doctor/MD, Medical Director) stated she was unaware of the incident of a video being posted to social media involving R3. V24 said That is not right. V24 stated she would expect the facility to take action against the CNAs right away. V24 said It is the patient's right to privacy, to not have a video. There is no excuse for that. Even if the person is not alert. They are not allowed to do that. They should not be doing that. At 11:57 AM, V24 said This is unforgiveable. I am feeling very terrible about this. What if this was me or my family member, I would want action taken right away. Or if it happened to one of their family members? On 06/15/2021 at 5:02 PM, V2 (DON) stated she didn't know why the Allegation of Abuse report did not mention R3 had a video recorded and posted to social media. When asked if it was her or her family member would V2 be ok with someone videotaping them in this manner and posting it to social media. V2 said No, I would not be ok with it. On 06/16/2021 at 3:54 PM, V1 (Administrator) said he did not have an answer to why the Allegation of Abuse Report sent to IDPH did not mention there was a video taken and posted to social media. V1 said he had asked them to delete the video right away . The facility did an internal investigation. V1 did not feel the CNAs should be recording any residents. V1 stated he didn't know how he would react and couldn't say how he would feel if it happened to himself or a family member. On 06/10/2021 at 7:07 PM, V18 (Police Officer) said he was notified by the staff at the facility regarding a video of a resident and CNA posted to social media. V18 said he spoke with R3's dughter-in-law who was upset and had wanted a full investigation. The initial and final Incident Investigation Report Form for an Allegation of Abuse sent to Illinois Department of Public Health (IDPH), completed by V3 (PRSD), did not mention R3 had been videotaped and the videoposted to social media. The facility found the Abuse Allegation to be unsubstantiated. The facility's undated Abuse Prevention Program- Facility Policy described mental abuse as includes, but is not limited to, humiliation, harassment or offensive physical contact . The policy does not address protecting resident privacy or prohibiting mental abuse related to photographs and audio/video recording posted to social media sites by facility staff. The facility's undated Social Media Policy show .although not an exclusive list, some specific examples of prohibited social media . include posting commentary, content, or images that are defamatory, pornographic, proprietary, harassing . The policy further showed Employees are not to publish, post or release any information that is considered confidential or not public . Employee personal phones cannot be used to take resident photos or any photos of the patient care area .

Based on observation, interview and record review, the facility failed to ensure the safety of a resident by not implementing interventions for a resident (R1) with a history of dysphagia and impulsive eating. This failure resulted in R1 choking during a meal, requiring CPR, and subsequent hospitalization . R1 expired in the hospital on (MONTH) 31, 2019, from aspiration pneumonia related to the choking incident. The facility failed to supervise a resident at risk for aspiration during meals. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 25, 2019 when R1 choked during a meal. On (MONTH) 12, 2019 at 10:00 AM, V1 Administrator was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 12, 2019. While the immediacy was removed, the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 3 of 3 residents (R1-R3) reviewed for safety and supervision in the sample of 3. The findings include: 1. R1's Speech Therapy Evaluation and Plan of Treatment dated (MONTH) 25, 2019 showed R1 was at risk for aspirating food and liquids related to her [DIAGNOSES REDACTED]. The evaluation showed R1 received a mechanical soft diet with nectar thickened liquids. Swallowing interventions for R1 included education of staff members to ensure R1's oral intake rate was controlled to facilitate R1's swallowing of food. A Swallowing Precautions for (R1) staff education checklist provided by V6 Speech Therapist (ST) showed, 5. Patient can feed herself to encourage self-feeding; however, make sure she goes slowly and that she has swallowed what's in her mouth before next bite/sip . R1's Progress Note dated (MONTH) 25, 2019 at 8:45 PM showed a nurse was called to R1's room by a CNA (Certified Nursing Assistant) because R1 was not looking good after the CNA noticed R1 was having trouble swallowing. The nurse found R1 looking pale with a faint carotid pulse. The nurse began CPR on R1 while another nurse suctioned ground meat from R1's mouth. At 8:52, EMS (emergency services/911) arrived at the facility and found R1 to be pulseless and continued CPR with emergent transport to a local hospital. R1's EMS report dated (MONTH) 25, 2019 showed when EMS arrived at the facility, R1 was pulseless. CPR was continued as EMS checked patient's airway and small particles of food were found. R1's Emergency Department Physician Report dated (MONTH) 25, 2019 showed, Impression; [MEDICAL CONDITION] related to choking and pneumonia. The report showed R1 presented to the hospital, intubated and unconscious after going into [MEDICAL CONDITION] following choking on food 30 minutes ago. R1 was admitted to the intensive care unit (ICU) in critical condition. R1's Report dated (MONTH) 28, 2019 showed R1 was discharged from the ICU, with withdrawal of treatment per R1's family, and placed on hospice care in the hospital due to R1 remaining unresponsive with a poor prognosis. An EEG (electroencephalogram/brain activity test) study completed on R1 on (MONTH) 26, 2019 showed R1 was markedly abnormal with findings of an [MEDICAL CONDITIONS] with poor prognosis. R1's Certificate of Death Worksheet showed R1 expired in the hospital on (MONTH) 31, 2019 with her cause of death as Complication from Aspiration of Food Bolus. On (MONTH) 6, 2019 at 9:40 AM, V4, Certified Nurse Assistant,stated she was the CNA caring for R1 on (MONTH) 25, 2019. V4 stated she was aware R1 was at risk for aspiration. V4 stated, Around 8:00PM, I gave (R1) her food and noticed she was eating fast so I asked her to slow down. She didn't, so I tried to feed her but she wouldn't let me. I let her eat (leaving the food tray in front of R1). I started to notice she wasn't looking good, she was having trouble swallowing and her breathing sounded funny. I gave her drinks of her (thickened) water to try to help get her food down. (R1) continue to look bad so I went and got a CNA, (V12). (V12) came into (R1's) room and got some food out of (R1's) mouth and told me to go get the nurse. I went and got the nurse and she came in and started CPR on (R1) . I didn't think she was choking. V4 stated she did not check R1's mouth for food, suction R1's mouth, attempt abdominal thrusts/[MEDICATION NAME] maneuver, or check to see if R1 had a pulse at any time during the incident. V4 stated from the time R1 started to develop trouble swallowing to the time the nurse entered R1's room was about ,[DATE] minutes. R4 stated she was CPR certified which included receiving education on the interventions and treatment for [REDACTED]. On (MONTH) 6, 2019 at 3:05 PM, V12, CNA ,stated, I was sitting at the nurse's station charting that night ([DATE]) when (V4,CNA) came and got me. She asked me to come into (R1's) room because (R1) wasn't looking good. I went into (R1's) room, she was sitting up in her wheelchair, with food coming out of her mouth. She was pale and was having trouble breathing, her breathing was noisy. I told (V4, CNA) to go get the nurse. The nurse came in right away but by that time, (R1) had become unconscious and the nurse started CPR right away. On (MONTH) 6, 2019 at 11:20 AM, V5, Registered Nurse (RN) stated V12 ,CNA notified her on the evening of (MONTH) 25, 2019 that (R1) wasn't looking good. I went into (R1's) room and within two seconds, she had become unconscious and didn't have a pulse so I started CPR on her right away. On (MONTH) 6, 2019 at 10:15 AM, V6, Speech Therapist stated, (R1's) aspiration risk is directly related to her eating too fast. She was impulsive, with a tendency to eat too fast. She needed 1:1 supervision with eating and constant cueing and reminders to slow down. We would allow her to try and feed herself. If she started eating too fast and wasn't following the cues, staff knew to take over and feed her. If she started showing signs of choking, trouble swallowing, or was eating too fast, they were to pull the food away from her, check for pocketing of food, and notify the nurse immediately. You don't continue to feed her or give her something to drink. All the staff know this and have been in-serviced on how to feed (R1) because she was such an aspiration risk. On (MONTH) 6, 2019 at 12:00 PM, V3, Nurse Practitioner stated R1 was at risk for aspiration and needed supervision with eating due to her impulsivity. V3 stated, If a resident developed difficulty swallowing or choked while eating, staff should immediately stop feeding the resident, pull the food away from the resident, and notify the nurse immediately. (V4, CNA) should have gotten the nurse immediately when (R1) started to have trouble swallowing. V3 stated the expectation is that nursing staff can identify when a resident is choking and emergently intervene as needed. V3 stated any delay in intervening when a resident is choking, can lead to death, [MEDICAL CONDITION], and/or lack of oxygen to the brain. On (MONTH) 6, 2019 at 12:10 PM, V2, Director of Nursing (DON) stated R1 was at risk for aspiration especially when she fed herself because she had a tendency to eat too fast. V2 stated if a resident began choking or had trouble swallowing while eating, nursing staff are to stop feeding the resident, remove the food, do the [MEDICATION NAME] if needed, and get the nurse right away. V2 stated all of the nursing staff are CPR certified and have been trained on the [MEDICATION NAME] maneuver. The facility's Emergency Care Policy dated (MONTH) 2014 showed, Principles of Emergency Management: To preserve life .1. Maintain a patent airway, employing resuscitation measures, if necessary . The policy showed, Choking 1. Follow American Heart Association procedure using abdominal thrusts . Through observation, interview and record review on (MONTH) 12, 2019, the surveyor confirmed the facility took the following steps to remove the immediacy: 1) There are 12 residents on mechanical soft and 4 residents on pureed diets. On (MONTH) 7, 2019, all mechanically altered diets were reviewed for accuracy by the Food Service Supervisor. 2) On (MONTH) 7, 2019, re-education was immediately started with facility staff which includes CNA's, Nurses and all other staff involved in feeding of residents by DON and designated staff. Re-education included: Identify residents at risk for choking/aspiration, their diets and their specific feeding instructions. Completion date: [DATE] Speech Therapy Department identified residents with specific feeding recommendations. Staff was educated the feeding instructions and the specific instructions are laminated and attached to their diet cards for easy referral every meal time. Those instructions are also incorporated in the care plans. Completion date: [DATE] Review of requirement to check diet cards and compare to meal prepared before serving. Completion date: [DATE] Review of proper method for feeding residents who need assistance. Completion date: [DATE] Review of emergency procedures with emphasis on identifying choking incidents. Completion date: [DATE] Review of importance of close monitoring during dining experience for resident changes in condition. Completion date: [DATE] Review that any incorrect diet is to be sent back to kitchen for correction. Tray servers are not to attempt corrections themselves. Completion date: [DATE] Review signs and symptoms for choking or difficulty swallowing while eating. Completion date: [DATE] The above education for all staff will be completed by the end of [DATE] and also presented during the orientation period for all future new hires. Any remaining staff, not present today, will be in-serviced prior to their next working schedule. 3) The Quality Assurance/Quality Improvement Team meets monthly. This event will also be brought to the next Quality Assurance/Quality Improvement meeting for discussion and possible re-evaluation to determine any needed revisions to policy and/or interventions. If revisions of the policy and/or interventions are needed at that time, they will be made accordingly. 2. R2's admission record dated [DATE] showed R2 had multiple [DIAGNOSES REDACTED]. R2's (MONTH) 23, 2019, facility assessment showed that R2 is cognitively impaired and required supervision of one person when eating. R2's physician order [REDACTED]. The Care Plan for R2 dated [DATE] showed R2 had dysphagia with a related goal that R2 will not have signs of coughing/choking during oral intake through next review. Interventions included encourage her to eat her meals in the dining room, but when she refuses, due to her paranoia, serve her tray in her room, observe for swallow safety while she eats, and have in upright position for all oral intake; observe for coughing/signs of choking during meals. The Speech Therapy Discharge Summary dated [DATE] written by V6, Speech Language Pathologist showed R2 was to receive distant supervision for oral intake. It recommended R2 eat in dining room for general supervision; it was not recommended that R2 eat alone in her room due to choking/aspiration risk. On [DATE] at 8:15 AM, R2 was seated in her room, in her wheelchair, eating breakfast. R2's breakfast included eggs, toast, pears, oatmeal, thickened apple juice, and thickened milk. She was alone in her room with no staff and no staff in the hallway near her room. On [DATE] at 12:30 PM, R2 was seated in her room with her lunch tray in front of her, eating. V10 was exiting R2's room. V10, Rehab Aide, said R2 normally eats by herself in her room. On [DATE] at 12:40 PM V6, Speech Language Pathologist, said that she had previously seen and treated R2 but hasn't for a while. She said that R2 frequently refused to go to the dining room to eat and had combative tendencies. V6 said that R2 should be supervised and should not be alone when eating. 3. R3's admission face sheet dated [DATE] showed R3 had multiple [DIAGNOSES REDACTED]. R3's facility assessment dated (MONTH) 23, 2019 showed R3 required supervision when eating. R3's physician order [REDACTED]. A physician order [REDACTED]. if resident is still coughing while eating after the completion of the antibiotic for pneumonia on [DATE]. A physician order [REDACTED]. The Care Plan for R3 dated [DATE] showed interventions for R3's dysphagia included strict aspiration precaution; have in upright position for all oral intake; observe for signs of coughing or choking while eating and drinking; report problems to MD. On [DATE] at 8:00 AM, R3 was seated in his wheelchair in the dining room eating breakfast and coughed several times. V8 CNA (Certified Nursing Assistant) asked R3 if he was ok; R3 said yes. R3 continued to cough while pushing himself away from the table, across the dining room, and exited the dining room, still coughing. On [DATE] at 11:30 AM, V8 said that he remembers R3 coughing at breakfast this morning and he did report the incident to V11 RN (Registered Nurse). On [DATE] at 11:35 AM, V11(RN) states that she was notified of R3 coughing during breakfast but did not report it to the physician. V11 said that she did not notify the MD because R3 still has three days left of his antibiotic, and the physician order [REDACTED]. V11 said that she is not aware of R3's Care Plan. On [DATE] at 11:40 AM V9, MDS/Care Plan Nurse, said that R3's Care Plan was last updated [DATE]. V9 said that the Care Plan intervention is in place for any instances when R3 starts coughing while eating. The physician order [REDACTED]. On [DATE] at 12:20 PM V3 Nurse Practitioner states that if R3 was coughing during breakfast, it should be reported to her, or if Speech Therapy is there, (like she was that day) it should be reported directly to Speech Therapy. On [DATE] at 12:40 PM V6 said that she has not seen R3 in years, but he does have a history of dysphagia. V6 said that no staff had notified her that R3 was coughing when eating. She said that any problems including coughing, choking, not eating, or any change at all in the dining room should be reported to her. The facility's Aspiration Precautions policy dated ,[DATE] states .3. If aspiration is suspected, the nurse will monitor the resident's temperature and lung sounds and report abnormal findings to the physician. 4. Speech Therapist is to be notified for possible screen and/or evaluation.

Based on observation, interview, and record review the facility failed to conduct a comprehensive assessment to identify the root cause for the development of R 11 and R 10 ' s facility acquired pressure injuries and failed to develop a person-centered plan of care to address the promotion of healing and the prevention of additional skin alteration. The facility failed to develop and implement a specific repositioning plan for R 11 and to follow R 11 ' s care plan intervention to provide pressure-relieving mattress. These failures resulted in R 11 acquiring Stage 3 pressure injury on the left ischium, Stage 2 on the anterior aspect of the right buttocks and a Deep Tissue Pressure Injury on the posterior aspect of R 11 ' s right buttocks that the facility was not aware of. R10 acquired a stage 2 pressure injury to the sacrum and a stage 3 pressure injury to the left thigh. This applies to 2 of 3 residents (R 11 and R 10) reviewed for pressure injury in the sample of 11. The findings include: The facility pressure ulcers/wounds sheet for January 1, 2017 showed R 11 acquired a Stage 3 pressure injury on the left ischium initially noted on December 7, 2016. On January 10, 2017 at 1:00 PM, R 11 was in bed sleeping positioned on his left side. At 2:00 PM R 11 remains in the same position, no positioning device was noted. At 2:05 PM, E 15 (Nurse) stated that R 11 has a pressure ulcer on the left ischium/buttocks. E 15 and E 16 (Certified Nursing Assistant) showed R 11 has altered skin and noted with multiple open areas ( left ischium, sacrum and right buttocks ) and discoloration on the right buttocks. There was no dressing noted on these areas. R 11 ' s order summary report dated January 11, 2017 showed an order to apply wound dressing ([MEDICATION NAME] pad) to R 11 ' s sacrum and left ischium. On January 10, 2017 at 2:40 PM, E 14 (Treatment Nurse) and E 17 (Certified Nursing Assistant) were observed during skin assessment. E 14 identified, described, and provided measurement on the following areas of skin alteration: (1) Acquired Stage 3 pressure injury on the left ischium measured at 0.6 cm X 0.5 cm X 0.2 cm (initially noted on December 7, 2016). (2) Stage 2 pressure injury (admitted with) on the sacrum measuring 0.5 cm X 0.3 cm X 0.1 cm (3) New area of Stage 2 pressure injury on the right buttocks measuring 0.2 cm X 0.2 cm X 0.1 cm (4) New area of Deep Tissue Pressure Injury (Deep purple discoloration) on the posterior aspect of the right buttocks measured at 3.5 cm X 1.0 cm. E 14 stated, I was not aware about these areas on his right buttocks (Stage 2 and Deep Tissue Pressure Injury). No one told me about these. I do not know why his wounds have no dressing (on the left ischium and the sacrum), probably it fell off. E 14 also acknowledged that R 11 has no positioning device while in bed and on a regular bariatric mattress only. E 14 was unable to present a root cause analysis for the development of R 11 ' s Stage 3 pressure injury on the sacrum. R 11 ' s skin care plan dated October 24, 2016 (page 4 of 7) presented by E 14 on January 11, 2017 at 11:00 AM showed an interventions that were not followed/implemented: (1.) Administer treatments as ordered. (2.) Inform the resident/family/care givers of any new area of skin breakdown. (3.) Monitor dressing to ensure it is intact and adhering. Report loose dressings to treatment nurse. (4.) The resident requires pressure relieving mattress On January 11, 2016 at 3:20 PM, E 20 (3-11 shift Certified Nursing Assistant) explained, He (R11) cannot reposition himself, he needs assistance with all of his activities of daily living ' s with at least 2 person. He usually gets up at around 8:00 or 9:00 AM then we (3-11 shift) put him back to bed around 4:30 or around 5:30 PM. On January12, 2017 at 12:20 PM via phone, Z3 (Nurse Practitioner) stated, No I was not informed that he (R 11) has a new pressure ulcers (injuries), they usually inform me but not about this. I was even there yesterday. To avoid wounds from developing of course they cannot leave him in bed or in chair for too long and he needs to stay off of those areas. Absolutely he needs a specialty mattress to relieve the pressure. R 10 ' s weekly skin alteration review for November 7, 2016, documents that R 10 acquired a Stage 3 pressure injury on the left thigh measured at 0.5 cm X 0.5 cm X 0.1 cm. This area worsened on December 5, 2016, increased in size to 2.0 cm X 3.0 cm X 0.1 cm documented with presence of black eschar at 20 % and stringy yellow slough at 30%. R 10 ' s pressure injury on the left thigh was not addressed on the care plan presented by E14 on January 10, 2017. In addition, R10 was noted on November 29, 2016 to acquire a Stage 2 pressure injury on the sacrum measured at 2.2 cm X 2.2 cm X 0.1 cm. E14 (Treatment Nurse) stated on January 10, 2017 at 12:00 PM that the facility has not analyzed R 10 ' s root cause for the development of these two areas of pressure injuries. E 14 also expressed that the interventions for R 10 ' s skin alteration care plan was not specific to R 10's identified needs, and E14 confirmed that the sacral and the left thigh pressure injuries were not care planned.

Based on observation interview and record review, the facility failed to assess and monitor and provide treatment and services in a timely manner to a resident with an acute humeral fracture. This failure resulted in a worsening of the fracture and increased pain for the resident. This applies to 1 of 2 (R1) residents reviewed for falls with injury in the sample of 28 residents. The facility also failed to have an effective communication system with the [MEDICAL TREATMENT] center to coordinate care pre and post [MEDICAL TREATMENT]. This applies to 2 of 2 (R10 and R24) residents reviewed for [MEDICAL TREATMENT] in a total sample of 28. The findings include: On 10/20/15 at 10:30 AM R1 was sitting in a wheel chair with his left arm on a pillow with visible swelling of the hand and wrist. R1 stated he was in a lot of pain. R1 stated he broke his arm and it throbs like a tooth ache. R1 also stated he was supposed to go to the orthopedic doctor for follow up but they keep canceling the appointments and has not seen an orthopedic doctor since he broke his arm. R1 feels his pain is not managed at all. On 10/20/15 and 10/21/15 R1 did not have a sling on his arm. R1 said he had a sling after the initial fracture but when he went to the hospital (for a non-fracture related issue) he came back to the facility without the sling. R1's nursing notes indicate R1 was sent out on 10/14/15 and returned on 10/16/15. R1 stated the sling made it more comfortable for him and helped ease the pain. R1's nursing notes were reviewed for September and October 2015 and there is no mention of R1 refusing to wear the sling. There are several nurses notes documenting R1's sling was on when he first returned from the hospital on [DATE]. R1's nursing incident note of note of 9/29/15 states R1 was observed lying on the floor on his left side with his left arm underneath. Assessment done, no visible injury noted. R1 complained of pain of 9 out of 10 when passive range of motion performed on his left arm. Physician ordered to send to ER for evaluation and treatment. R1 returned from hospital the same day with a sling on his left arm. The X-ray results dated 9/29/15 show R1 had a nondisplaced fracture through the left humeral neck. The emergency department report dated 9/29/15 states R1 should follow up with physician in seven to ten days. The nursing note of 10/6/15 (seven days post fall) documents the staff nurse reminded and informed R1's physician of the follow up with the Orthopedic doctor. The nurse documented the physician will talk with the scheduler. The nursing notes dated 10/20/15 documents that the transport did not show up for R1's ortho appointment. On 10/21/15 at 1:00 AM E6 (appointment scheduler) stated that a new appointment had been made for 10/27/15. On 10/22/15 at 1:30 PM, R1 stated that his pain is at 8 out of 10 and his arm throbs like a tooth ache. R1 said he hasn't had his sling since he came back from the hospital on [DATE]. On 10/22/15 at 1:30 PM, E8 (staff nurse) caring for R1 said that R1 did not complain of pain, and there was no swelling of his arm. When E8 looked at his arm she did say it was swollen. E8 stated the assessment for R1's arm would be in the nursing notes. E8 stated she would call Z1 (Nurse Practitioner) to evaluate R1. R1's nursing notes were reviewed for September and October 2015 and there was no assessment for R1's arm. There was no mention of circulation, motion or sensation of the affected arm. There is no documentation of any pain relieving measures such as applying ice or elevation of the arm. There is no documentation to show that R1's primary physician was notified of the delay in orthopedic treatment and if any treatments needed to be put in place until R1 could be seen by the orthopedic doctor. On 10/22/15 at 2:15 PM Z1 stated that she was not aware that R1 had swelling to the affected arm/hand and increased pain. Z1 also stated she was not aware that R1 was without a sling for any period of time and she was also not aware that R1 had missed the orthopedic appointment. Z1 stated she will assess R1, order another X-ray and increase his pain medication. The X-ray report dated 10/22/15 documents a change in R1's fracture from non displaced to displaced. The X-ray showed there is an acute or subacute minimally displaced fracture through the left humeral neck. The distal fragment is displaced laterally by 4-5 mm and is impacted onto the humeral head by approximately 13 mm. This was not evident on the initial X-ray done on 9/29/15. On 10/23/15 at 10:44 AM, Z1 documented the X-ray results from 10/2215 were reviewed and R1 will be sent out to the emergency room stat for possible casting and the orthopedic consult is pending. R1's care plan reviewed on 10/21/15 does not have any mention of his humeral fracture, what kind of care is needed, limitations R1 may have and ways to reduce pain. There is no mention of immobilizing the arm, what the arm should be mobilized with and for what period of time it needed to be mobilized. 1. R10 has a medical history of [REDACTED]. On 10/21/15 at 9:30 AM, E5 (LPN, Licensed Practical Nurse) stated R10 goes out to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays. E5 stated a communication sheet is sent to [MEDICAL TREATMENT] and then it is returned with the resident and scanned into the computer. E5 was only able to locate one communication document from [MEDICAL TREATMENT] for February and one for March of 2015. On 10/21/15 at 3:00 PM, E2 (DON) confirmed there were no other [MEDICAL TREATMENT] communication sheets. The October 2015 nursing notes only document about R10's pain medication. There are no nursing notes concerning [MEDICAL TREATMENT] or any assessments pre or post [MEDICAL TREATMENT]. R10's documented weights under weights in the electronic medical record shows only one day documented as a [MEDICAL TREATMENT] weight (9/25/15) but it is unclear if it is a pre or post [MEDICAL TREATMENT] weight. The undated facility policy titled, Care of [MEDICAL TREATMENT] Resident, documents, Correlation of services will be established between the [MEDICAL TREATMENT] team and the facility staff. R24 has a medical history of [REDACTED]. There are sporadic [MEDICAL TREATMENT] communication sheets for R24. There is one in August 2015 and none for September 2015 and three for October 2015. On 10/23/15 E2 stated there is a system to send a communication sheet with the resident to the facility, but residents not always bring the sheet with them to the facility. E2 said here after the nurse will follow up with the [MEDICAL TREATMENT] center if the resident did not bring the communication sheet.

Based on observation, interview and record review the facility failed to identify, assess and develop a plan for unplanned weight loss. This failure resulted in one resident, R21 sustaining a significant weight loss without facility knowledge or interventions to prevent additional weight loss. This applies to one resident (R21) out of 15 residents reviewed for weight and nutrition from a total sample of 29. The findings include: R21's admission face sheet shows [DIAGNOSES REDACTED]. R21's September physician order [REDACTED]. On 09/10/2014 at 2:40pm R21's weight was 92.0 pounds using the sitting scale by E10 (Certified Nurse's Aide). E7 was present during the weight. R21's weight record shows the following weights: Date: 06/11/2014 Weight: 110 pounds Date: 06/18/2014 Weight: 94.40 pounds Date: 07/01/2014 Weight: 108 pounds Date: 08/01/2014 Weight: 108 pounds Date: 08/27/2014 Weight: 89 pounds Date: 09/03/2014 Weight: 88.6 pounds There was a weight loss of (19.4 pounds) 17.96% in one month from 08/01/2014 to 09/03/2014. R21 ' s last nutritional note/assessment was noted in the electronic medical record dated 2-25-14 as a " late entry " . No documentation or assessment of R21 could be located during the chart review since the 2-25-14 entry. The weight loss noted from August 1 to August 27 of 19 pounds was not assessed by the facility. On 09/10/2014 at 11:30am E6 (Registered Dietician) stated that she was not aware of any weight loss for R21. E6 stated that she has not seen R21 for a nutritional assessment prior to today's visit since her weight had been stable for the past six months. E6 stated that she visits the facility approximately four times a month and her last two visits to the facility were on 08/20/2014 and 08/27/2014. E6 stated that when the facility identifies a weight loss they should notify her right away. On 09/09/2014 at 12:50pm R21 was in the first floor dining room during lunch. R21 was observed folding a slice of bread and then taking a small bite out of it. R21 would then set the bread down and occasionally pick up a fork and move the food around on the plate. R21 picked up the bread again folded it several times and took another small bite. R21 then stacked two food bowls with food remaining in them on top of her slice of ham on the plate. At 12:58pm E8(Certified Nurse's Aide) removed R21's lunch dishes to the soiled tray cart. E8 stated that she was not aware of any eating or weight issues with R21. E8 also stated that R21 usually eats about 25% of lunch meals. On 09/10/2014 at 8:30am E21 stated that she thinks she ate breakfast already but cannot remember what she ate. On 09/10/2014 at 12:05pm R21 was sitting in the first floor dining room during lunch. R21 was observed moving food, which consisted of noodles and Swedish meatballs, around on her plate with a fork. R21 also picked up a breadstick, buttered it, looked at it, then set it back down on her plate. R21 drank from a cup and then moved the food around on her plate again, picked up the bread stick then placed it back down. At approximately 12:30pm E9 (Certified Nurse's Aide) removed R21's tray of food from the table and placed it on the soiled tray cart. E9 stated that R21 meal intake depends on how her mood is that day, some days being better than others. E9 stated that the nurse's aides will document how much the residents eat. When E9 was asked how much R21 consumed for lunch, she stated that she would have to look at her tray to determine it. E9 then went to the soiled meal cart and removed R21's tray. E9 stated that she would estimate that R21 ate 40% of her meal since a couple of meatballs and a couple of grapes were eaten. The meatballs were slightly separated on the plate. The noodles and the vegetables were untouched. On 09/10/2014 at approximately 1:30pm E7(Assistant Director of Nursing) stated that the nurse's aides should use the Dietary Intake Guide posted in the facility to assess how much the resident had consumed. The Dietary Intake Guide indicates that overestimating the resident's total consumption is a common error, especially when food is pushed around the tray. The Dietary Intake Guide shows that the meal intake would be recorded at 0% if the resident consumed only one or two bites of each item. E7 stated that if there are weight discrepancies a reweigh should be done. E7 said that if there is a significant weight loss then the facility would notify the doctor and the dietician. On 09/10/2014 at 2:50pm E11(Licensed Practical Nurse) stated that she had not noticed any changes with R21. E11 said that she makes sure that the residents are eating by making sure that they are in the dining room. She said that the nurse's aides usually assess how much food the resident's are eating. E12 (Certified Nurse's Aide) said that R21 needs reminders to get up and eat but R21 is independent in eating and doesn't need assistance. E12 said that the nurse's aides record the meal consumption but they do not record if the resident had consumed or refused any health shakes or supplements. On 09/10/2014 at 2:55pm E7 was asked for copies of R21's last monthly meal intake record. On 09/10/2014 at approximately 3:00pm E3 (Director of Nursing) confirmed the request for R21's last monthly meal intake record. The meal intake record was not received. The facilities Weight Management Policy dated 06/2012 shows that all significant or trending weight changes must be investigated by the facility to determine the possible cause, determine the plan of action, document the investigation and notify the physician and responsible party. The policy also shows that an evaluation of significant weight change form will be completed any time there is a noted significant or trending weight fluctuation and referred to the dietician.