Every finding on record at Sunset Rehabilitation and Health Care

Based on observation, interview, and record review, the facility failed to ensure a resident was properly secured during transportation, conduct pre-trip safety inspections prior to transporting a resident in the facility van, conduct transportation van inspections, prevent staff from placing personal items on a resident's wheelchair, and ensure facility transportation staff were educated on driver safety training for one of three residents (R1) reviewed for accidents in a sample of 11. These failures resulted in R1's wheelchair tipping backward during transport on 7/3/26, requiring emergency hospital treatment, causing R1 excruciating pain, and R1 sustaining an acute nondisplaced fracture at the anterolateral aspect of the right ninth rib.Findings include:The facility's Rear Conversion Transportation Van Manual, undated, documents, Safety Precautions: All wheelchairs must be facing forward and be properly secured. Seating Securement: Instructions for Use- 1. Place wheelchair in the vehicle facing forward and in a suitable position. 2. Preselect a position on the wheelchair to attach the hook and a position on the floor to attach the floor latch end of the strap. 3. Release the buckle latch on the strap. With the buckle released, pull the webbing to create enough slack so that the restrain belt can be attached to the floor and the wheelchair. 4. Connect the floor latch to the pre-selected location on the floor track by pushing the fitting with even pressure into the track and slide the fitting in one direction until spring loaded latch drops into place. Pull on the strap to make sure it is secure. 5. Find the handhold strap and pull it to tighten the strap. Make sure there are no twists or knots in the strap. 6. Lock buckle by pushing down until the buckle latch locks into place. 7. Repeat the procedure for each of the four designated positions.The Facility's Dodge Grand Caravan 2019 Owner's Manual documents, Warning: A frayed or torn belt could rip apart in a collision and leave you with no protection. Inspect the belt system periodically, checking for cuts, frays, or loose parts.The facility's Driver Safety Training Form documents, Section 2. Rules and Responsibilities- All passengers, including wheelchair-bound residents, will always be secured and appropriately restrained in the vehicle, per the manufacturer's instructions and guidelines.R1's admission Record documents R1 is an [AGE] year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Dementia, Major Depressive Disorder, Age-Related Osteoporosis, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, and Chronic Kidney Disease.R1's MDS (Minimum Data Set) Assessment, dated 6/18/26, documents R1 is moderately cognitively intact, and requires supervision or touching assistance with most ADLs (Activities of Daily Living).R1's Final State Reportable, dated 7/9/26, documents, Date and Location of Incident: 7/3/26 at 3:30 PM during transportation. Brief Description of Incident: (R1) complains of pain to right shoulder, neck and back during transportation following an appointment. (R1) sent to the emergency room for further evaluation noting non-displaced 9th right rib fracture. This same Reportable documents, Disposition: After thorough investigation it was determined that the root cause was the front strap disengaged during transportation. Upon initial nursing assessment, (R1) was compliant and reported pain to right shoulder, neck and back. R1's Progress Note, dated 7/3/26 and signed by V2/DON (Director of Nursing), documents, During transportation back to facility from appointment, (R1's) wheelchair unlatched in the front and (R1) rolled backwards in the van. (R1) stated she hit her right shoulder but did not hit her head. Upon returning to facility, full body assessment was completed and resident subsequently c/o neck and mid back pain. Pain medication administered. The decision was made to send (R1) to the Emergency Department for evaluation and treatment.R1's emergency room Note, dated 7/3/26, documents, History of Present Illness: Chief Complaint- Fall. Initial Comments- (R1) an [AGE] year-old female here via EMS (Emergency Medical Services) for injuries sustained from a fall. (R1) was in her wheelchair. (R1) was being wheeled up into wheelchair when (R1) fell from the wheelchair that accidentally tipped over. (R1) landed on her right side. (R1) has pain to the right rib cage and mid back. Hurts to move and hurts to breathe. Review of Systems: Musculoskeletal: Neck pain, Joint pain, and Joint Swelling. This same emergency room Note documents, Chest X-Ray interpretation: 2. Acute nondisplaced fracture at the anterolateral aspect of the ninth rib. Clinical Impression- Fall, Rib Fracture.R1's Order Summary Report, dated 7/3/26, documents R1 has the following Physician Order: Start date: Hydrocodone-Acetaminophen Tablet 5-325 milligrams give one tablet by mouth every eight hours as needed for pain due to fractured rib.R1's Physician Progress Note, dated 7/5/26 and signed by V12/R1's Nurse Practitioner, documents. Patient Name: (R1) Chief Complaint: My (R1's) ribs hurt when I breathe. History of Present Illness: (R1) is a female patient presenting after a fall from her wheelchair yesterday afternoon that resulted in a confirmed rib fracture on hospital X-ray. (R1) reports she is unsure if her wheelchair was strapped into the van prior to the incident and does not recall whether she was hooked up, which may be relevant for fall risk. She reports 10/10 pleuritic pain in the posterior rib region, worsened by deep inspiration. (R1) was given pain medication in the Emergency Department and requests additional analgesia today; current order is every 8 hours as needed. (R1) endorses subjective shortness of breath and states she must keep making myself breathe. (R1) has an incentive spirometer and was instructed today to perform 10 repetitions multiple times per day to prevent atelectasis. This same Progress Note documents, Review of Systems: Constitutional: No fevers, Respiratory: Positive for shortness of breath associated with rib pain, Musculoskeletal: Positive for severe rib pain rated 10/10, Gastrointestinal: Reports alternating diarrhea and constipation; currently passing hard pellet-like stools; rectal soreness. Objective- Physical Exam: General: Patient in obvious discomfort.R1's Progress Note, dated 7/13/26 and signed by V13/LPN (Licensed Practical Nurse), documents, Gave Tylenol as needed for comfort due rib fracture states it feels a little better.The facility's QAPI (Quality Assurance and Performance Improvement) Corrective Summary, dated 7/3/26, and prepared by V1/Administrator, documents, F689 Free of Accident Hazards/Supervision/Devices, F921 Safe/Functional/Sanitary/Comfortable Environment. Problem/Noncompliance Identified- The facility identified vulnerabilities in its Resident Transportation Safety. The facility identified a past noncompliance related to resident transportation safety after an incident in which a resident sustained an injury during transport in the facility van. During transport, (R1's) wheelchair restraint and/or occupant safety belt became unsecured, resulting in (R1) shifting from a safe position and sustaining an injury. Root Cause Analysis: Front strap disengaged and Improper wheelchair securement.The facility's Reeducation Memo, dated 7/6/26, documents, Employee Name: (V4/Transportation Driver). Date of incident: 7/3/26. Section 2. Areas of Concern- Resident safety while operating facility van. Section 3. Reeducation Topics Covered- V4 educated to overall resident safety while operating facility van transporting residents to and from appointments/resident shopping trips and resident outings.On 7/13/26 at 12:44 PM, R1 stated, A few weeks ago, I was in an accident while being driven back from an appointment in the facility van. I was sitting in my wheelchair in the back of the van. The driver came to a stop, and when the van started moving again, I flipped completely backward in my chair. I started screaming for help. The driver, (V4/Transportation Aide), stopped, came to the back, and picked the wheelchair back up with me still in it. Once we got back to the facility, someone laid me down. I was in so much pain that they sent me to the hospital, where I found out I had a broken rib. Even now, my pain is sometimes a 10 out of 10 because of it. I don't know for sure if all four of the floor straps were hooked to my wheelchair, but I know that I didn't have a seatbelt over me or the chair.On 7/13/26 at 12:59 PM, V4/Transportation Aide, stated, While transporting (R1) back from a nearby medical appointment a few weeks ago, I secured the wheelchair in the facility van with two floor straps (one front, one rear) and locked the wheels. I did not place the lap belt on (R1) because it pinches residents at times. I thought, given the short distance, it would be ok. Upon accelerating from a complete stop at a stop sign, the front floor strap mount detached from the vehicle floor. This caused (R1's) wheelchair to tip backward completely. I immediately pulled over, picked (R1's) wheelchair back up with (R1) in it, and transported them directly back to the facility. (R1) was stating she was in pain. V4 stated he had hung his own heavy backpack on the handles of R1's wheelchair before loading R1 into the van. V4 noted if he had secured R1 with the lap belt, the wheelchair likely would not have flipped backward. V4 acknowledged the combination of the heavy backpack and securing only two of the four required floor straps allowed the front strap to detach from the floor, causing the wheelchair to tip backward. Additionally, V4 stated van safety checks were not being performed before trips-or at all-because he was managing all appointments and responsibilities by himself.On 7/13/26 at 1:25 PM, the facility's van was observed with V9/CNA (Certified Nursing Assistant) Supervisor. The van had four floor latches, two being in front of the wheelchair on the left and right side, and two being in the back of the wheelchair on the left and right. The floor latches each have a retractable hook that latches to the frame of the wheelchair. A lap belt was then observed that extends from the side of the van to the seat belt latch on the floor. During this observation, V9 stated all four floor latches should be secured to the wheelchair when transporting a resident along with the lap belt fastened through the wheelchair and out the other side of the wheelchair. V9 stated, If (R1's) wheelchair had been secured with the lap belt I do not believe the wheelchair could have tipped backwards.On 7/13/26 at 1:36 PM, V1/Administrator, stated prior to the 7/3/26 incident, no facility staff had been trained on properly securing wheelchairs in the facility's transport van. V1 noted her investigation revealed the right front floor latch had disengaged from the floor while secured to resident R1's wheelchair during transit. V1 stated V4/Transportation Aide failed to latch all four floor latches to R1's wheelchair, opting to latch only the front right and back left positions. V1 was also aware the van's lap belt was not fastened during R1's transport. V1 affirmed all four floor latches, alongside the lap belt, should have been fully secured to R1's wheelchair, that doing so likely would have prevented R1's wheelchair from tipping backward, even if a single latch had disengaged. V1 reported later it was discovered V4 had placed a personal bookbag on the back handle of R1's wheelchair, which was unauthorized, and may have caused a weight imbalance that contributed to the wheelchair tipping. V1 stated there was no record of any pre-trip safety checks being conducted and acknowledged there should have been.

Based on interview and record review, the facility failed to prevent abuse for one resident (R8) of three residents reviewed for abuse in a sample of eleven. Findings include: The Abuse, Prevention and Prohibition Policy, dated 02/2026, documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, or other individuals. This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate ( willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements and his/her body movements impact a resident who is nearby.The Initial State Report sent to Illinois Department of Public Health/IDPH prepared by V7/Prior Interim Administrator, dated 5/20/26, documents, Staff observed (R10) have physical contact with (R8).The Police Incident Report, dated 5/20/26 at 8:16 PM, documents the incident happened on 5/19/26 about 5:00 PM in the dining room. There was resident to resident physical abuse when R10 struck R8 with a closed fist in the jaw. R8's computerized Medical Record documents R8 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Heart Failure, Anxiety, and Seizures.R8's MDS (Minimum Data Set) assessment, dated 6/5/26, documents a BIMS (Brief Interview for Mental Status) of 6, indicating (severe cognitive impairment). R8 uses a wheelchair, is dependent on staff for activities of daily living, toileting, and transfers.On 7/13/26 at 1:40 PM, R8 was lying in bed. R8 was asked if he was ever hit by another resident. R8 stated he did not remember. R8 was asked if he would like to be hit by another resident and R8 stated, I wouldn't like that.R10's computerized Medical Record documents R10 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Alcohol Dependence with Withdrawal Delirium, Depression, and Anxiety. R10 was discharged on 7/2/26.R10's MDS (Minimum Data Set) assessment, dated 5/27/26, documents a BIMS (Brief Interview for Mental Status) of 13, indicating (cognition intact). R10 has no upper or lower extremity impairment, uses a wheelchair, requires supervision for ADLs, bed mobility, transfers, and partial assistance for toileting. R10 has verbal behaviors and behaviors directed towards others one to three times.On 7/15/26 at 1:11 PM, an attempt was made to contact R10. V16/R10's Family Member answered and stated R10 was not available to be interviewed. V16 also stated he did remember hearing R10 say he had got into a fight with someone at the facility but V16 had no other details.On 7/13/26 at 1:34 PM, V4/Certified Nursing Assistant/CNA stated she saw R10 hit R8 in the face but does not know the date. V4 stated it was in the dining room at supper time around 6:00 PM when R8 and R10 were arguing, then R10 punched R8 in the face. R10 hit R8 on the right side of R8's face with a closed fist. R8 said, Hey, he (R10) hit me. R8 did not like being hit. V4 stated, I took (R10) away from (R8) and told (V15/Registered Nurse) what happened. (R10) was yelling, Go ahead and arrest me. I would rather go to jail then be here.On 7/15/26 at 10:53 AM, V15/Registered Nurse stated she did not remember the date, but she heard R8 and R10 arguing during supper. V15 stated, I told them to stop arguing. (R10) said, I'm gonna (sic) beat the F*** out of him (R8). I told (R10) to go to his room. I did not know that (R10) hit (R8) so I didn't document it or do an assessment on either of the residents. The next day I got a call from work that (V4/CNA) had reported that (R10) hit (R8).On 7/15/26 at 12:50 PM, V9/CNA Supervisor stated on 5/20/26 around 1:30 PM, V4/CNA reported the day before (5/19/26) R10 punched R8 in the face. R8 kept saying, Coffee, coffee, coffee and R10 told R8 if R8 said coffee one more time I will punch you and R10 did hit R8.

Based on interview and record review, the facility staff failed to report abuse immediately to the Administrator and the Administrator failed to report the abuse within two hours to the State Agency for 1 of 3 residents (R8) reviewed in the sample of eleven. Findings include:The Abuse, Prevention and Prohibition Policy, dated 02/2026, documents, Investigation: Resident abuse must be reported immediately to the Administrator. All alleged violations including abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegations of abuse or neglect, or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than two hours, or per state regulation, after the allegation is made. Reporting/Response: The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or is her designated representative in the administrator's absence. Any employee or agent or any covered individual will make or cause a report to be made to law enforcement and the facility. The facility administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. Such reports may also be made to the local law enforcement agency in the same manner.The Police Incident Report, dated 5/20/26 at 8:16 PM, documents the incident happened on 5/19/26 about 5:00 PM in the dining room. There was resident to resident physical abuse when R10 struck R8 with a closed fist in the jaw. On 7/13/26 at 1:34 PM, V4/Certified Nursing Assistant/CNA stated she saw R10 hit R8 in the face but does not know the date. V4 stated it was in the dining room at supper time around 6:00 PM when R8 and R10 were arguing then R10 punched R8 in the face. R10 hit R8 on the right side of R8's face with a closed fist. R8 said, Hey, he (R10) hit me. R8 did not like being hit. V4 stated, I took (R10) away from (R8) and told (V15/Registered Nurse) what happened. (R10) was yelling, Go ahead and arrest me. I would rather go to jail then be here. (V15) did not assess (R8) but I looked at (R8's) face and did not see any injury. I was in the wrong because I forgot to call the Administrator to report the abuse. The next day when I came to work, I reported the abuse.On 7/14/26 at 10:26 AM, V14/Administrator stated the abuse should have been reported immediately to the Abuse Coordinator and reported to the State Agency within two hours.On 7/15/26 at 10:53 AM, V15/Registered Nurse stated she did not remember the date, but she heard R8 and R10 arguing during supper. V15 stated, I told them to stop arguing. (R10) said I'm gonna beat the F*** out of him (R8). I told (R10) to go to his room. I did not know that (R10) hit (R8) so I didn't document it or do an assessment on either of the residents. The next day I got a call from work that (V4/CNA) had reported that (R10) hit (R8). (V4) and I were both suspended while the investigation was done because we did not report it. On 7/15/26 at 12:43 PM, V7/Prior Interim Administrator stated he was told about the incident between R8 and R10 on 5/20/26. V4/CNA said it had happened on 5/19/26 but she did not report it until the following afternoon. V7 also stated, (V4) should have reported the abuse immediately.On 7/15/26 at 12:50 PM, V9/CNA Supervisor statedon 5/20/26 around 1:30 PM, V4/CNA reported the day before (5/19/26) R10 punched R8 in the face. R8 kept saying Coffee, coffee, coffee and R10 told R8 if R8 said coffee one more time I will punch you. and R10 did hit R8. V4 was suspended for not reporting the incident timely. V9 also stated, I was not with (V7/Prior Interim Administrator) when he interviewed (V4). The Time Report for the period of 5/17/26 to 5/23/26 documents V6/CNA and V15/RN both worked on 5/19/26. V15 did not work any other days during that week. The Initial State Report sent to Illinois Department of Public Health/IDPH prepared by V7/Prior Interim Administrator, dated 5/20/26, documents, Staff observed (R10) have physical contact with (R8). Both residents were separated immediately, and a head-to-toe body assessment was completed on (R8). (R10) had been placed on 1:1 supervision. The Initial Report does not document the date or time that the abuse occurred.R8's Skin Check, dated 5/20/26, documents the skin check was completed on 5/20/26 at 5:40 PM.The Initial Report e (electronic) -mail sent to IDPH documents the report was sent on 5/20/26 at 8:29 PM.

Based on interview and record review, the facility failed to implement their Abuse Policy to thoroughly investigate an allegation of resident-to-resident abuse and failed to update the Care Plan for two of three residents (R8 and R10) reviewed for investigating abuse in the sample of eleven.Findings include:The facility's Abuse Prevention and Reporting policy, dated 09/2024, documents, Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Witnesses will be asked to assist with completing statements if indicated. Complete a thorough investigation. Two management staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated.The Police Incident Report, dated 5/20/26 at 8:16 PM, documents the incident happened on 5/19/26 about 5:00 PM in the dining room. There was resident to resident physical abuse when R10 struck R8 with a closed fist in the jaw. On 7/13/26 at 1:34 PM, V4/Certified Nursing Assistant/CNA stated she saw R10 hit R8 in the face but does not know the date. V4 stated it was in the dining room at supper time around 6:00 PM when R8 and R10 were arguing then R10 punched R8 in the face. R10 hit R8 on the right side of R8's face with a closed fist. R8 said, Hey, he (R10) hit me. R8 did not like being hit. V4 stated, I took (R10) away from (R8) and told (V15/Registered Nurse) what happened. (R10) was yelling, Go ahead and arrest me. I would rather go to jail then be here. (V15) did not assess (R8) but I looked at (R8's) face and did not see any injury. I was in the wrong because I forgot to call the Administrator to report the abuse. The next day when I came to work, I reported the abuse.On 7/14/26 at 10:26 AM, V14/Administrator stated she did not find a written statement from V6/CNA or V15/RN about the abuse incident between R8 and R10. V14 also stated the abuse should have been reported immediately to the Abuse Coordinator and reported to the State Agency within two hours. The incident should have been documented in the nursing notes, an assessment of the residents should have been made immediately on the day of the incident, and the care plan should have been updated. V14 stated there are to be two management staff during an interview for abuse.On 7/15/26 at 10:53 AM, V15/Registered Nurse stated she did not remember the date, but she heard R8 and R10 arguing during supper. V15 stated, I told them to stop arguing. (R10) said I'm gonna (sic) beat the F*** out of him (R8). I told (R10) to go to his room. I did not know that (R10) hit (R8) so I didn't document it or do an assessment on either of the residents. The next day I got a call from work that (V4/CNA) had reported that (R10) hit (R8). (V4) and I were both suspended while the investigation was done because we did not report it. On 7/15/26 at 12:43 PM, V7/Prior Interim Administrator, stated he was told about the incident between R8 and R10 on 5/20/26. V7 also stated, I did not have (V4/CNA) do a written statement, but I generally do. (V9/CNA Supervisor) was with me when I interviewed (V4). I did not know that (R10) hit (R8). I thought (R10) grabbed (R8's) face.On 7/15/26 at 12:50 PM, V9/CNA Supervisor stated on 5/20/26 around 1:30 PM, V4/CNA reported the day before (5/19/26) R10 punched R8 in the face. R8 kept saying, Coffee, coffee, coffee and R10 told R8 if R8 said coffee one more time I will punch you. and R10 did hit R8. V4 was suspended for not reporting the incident timely. V9 also stated, I was not with (V7/Prior Interim Administrator) when he interviewed (V4). The Initial Report sent to the State Agency, dated 5/20/2026, does not document the date or time that the abuse occurred. The same report documents, Staff observed (R10) have physical contact with (R8). Both residents were separated immediately, and a head-to-toe body assessment was completed on (R8). (R10) had been placed on 1:1 supervision.The Final Report sent to the State Agency, dated 5/27/26, documents the date of the incident as 5/21/26. The same report documents, (V6/Certified Nursing Assistant/CNA) states she was assisting another resident in the dining room. When (V6) saw (R10) reach out and grab the face of (R8), (V6) states she separated both residents immediately. Upon a thorough review of medical records and resident and staff interviews, the facility is unable to substantiate abuse towards (R8). Care plan will be revised and updated as needed. There was no documentation that V15/Registered Nurse was interviewed. R8's Care Plan does not include a plan of care for abuse and was not updated after the abuse incident between R8 and R10. R10's Care Plan does not include a plan of care for abuse and was not updated after the abuse incident between R8 and R10.

Based on interview and record review, the facility failed to follow therapeutic diet orders for one resident (R1) of 4 reviewed for therapeutic diets in a total sample of eight. Therapeutic Diet Policy, dated 12/2024, documents, Therapeutic diets shall be prescribed by the Attending Physician. The admission Policy, dated 12/2024, documents Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least Type of diet. R1's Electronic Health Record documents R1 was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus, Dementia, Chronic Obstructive Pulmonary Disease, and Hypertension. R1's Hospital Discharge orders, dated 4/20/26, documents R1's diet order as Carbohydrate Controlled Diet. R1's Physician's Order in the Electronic Health Record, dated 4/20/26, documents R1's diet order as Regular diet. R1's Physician's Order, dated 5/5/26, documents R1's diet was changed to Consistent Carbohydrate Diet. On 6/18/26 at 12:36 PM, V2 (Director of Nursing) reported the facility should follow the diet order on the hospital discharge orders. V2 verified R1's diet order was not put in the Physician's Orders correctly on 4/20/26 and R1 did not receive the correct diet until 5/5/26.

Based on record review and interview, the facility failed to notify the resident and the resident's representative when the facility changed a resident's primary physician choice for one of three residents (R1) reviewed for Resident Rights in the sample of eightFindings include:The facility's Resident Rights Policy, dated 12/24, documents, Each resident will have autonomy and choice, to the maximum extent possible, about how each resident wishes to live his/her everyday life and receipt of care, subject to the community's policies and procedures as long as those policies so not violate any requirement. Resident rights include but are not limited to: Choose a physician and treatment and participate in decisions and care planning.R1's admission Orders, dated 4/2/24, document V11 (Physician) was R1's Primary Care Physician on admission.R1's Electronic Health Record documents the facility switched R1's Primary Care Physician from V11 to V12 (Medical Director) in May 2025 (unknown day). R1's Electronic Health Record documents V12 continued to provide orders and/or physician visits in May, June, July, and August 2025.On 12/5/25 at 10:24 AM, V6 (R1's Family Member) stated, I was not notified, and neither was (V7/R1's Representative) that (R1's) physician was changed. I did not want (R1's) physician to be changed. (R1) had always had (V11) as his primary physician.On 12/5/25 at 10:50 AM, V9 (ADON/Assistant Director of Nursing) stated, (V12/Medical Director) took over cares for (R1) on May 19, 2025.On 12/5/25 at 11:00 AM, V1 (Administrator) verified R1's electronic health record does not include evidence of R1 or (V7/R1's Power of Attorney) being notified of R1's physician changing on 5/19/25 from V11 (R1's Primary Care Physician) to V12 (Medical Director). V1 also stated the facility hired V12 as their Medical Director in May 2025 and decided to switch all of the residents' physicians over to V12.On 12/6/25 at 10:00 AM, V7 (R1's Representative) stated, I was never informed in writing or verbally that (R1's) physician was changing. I would have never agreed to switch (R1) from V11 to V12.

Based on observation, interview, and record review, the facility failed to adequately supervise a resident while handling a hot beverage and failed to have a policy regarding the use and supervision of hot beverages for one of three residents (R1) reviewed for accidents in the sample of three. These failures resulted in R1 sustaining a burn to the right thigh after spilling a hot beverage in his lap.This past noncompliance occurred on October 20, 2025 and was corrected the same day.Findings include: R1's admission Record documents R1's date of admission to the facility was 10/21/18, and his diagnoses on admission include Chronic Obstructive Pulmonary Disease, Seizures, Personal History of Transient Ischemic Attack, and Cerebral Infarction without Residual Deficits, and Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, or Anxiety. R1's Minimum Data Set Assessment, dated 9/5/25, documents R1 has moderately impaired cognition, requires a manual wheelchair for mobility, and is dependent with bathing, grooming, transfers, and mobility throughout the facility in his wheelchair. R1's care plan documents R1 can move self around the facility with supervision only, and prior to 10/20/25, had no intervention for a cup with lid for coffee. The facility's report to the local State Agency for R1, dated 10/20/25, documents R1 experienced a potential burn to bilateral thighs and R (right) knee after spilling coffee on his lap. R1's Final Report, dated 10/21/25, documents R1 inadvertently spilled his coffee onto his lap due to unsteadiness while attempting to self-propel in his wheelchair, Tx (treatment) orders to be followed and areas to be monitored for any new changes. (R1) to be seen by Facility Wound Dr (Doctor) during next rounds, and implemented a Hot Beverage Policy. R1's progress notes, dated 10/20/25 at 8:47am, document, Resident given coffee by kitchen staff without lid. Order received to apply Silvadene topically to bilateral thighs BID (twice a day) and PRN (as needed). Resident (R1) will no longer receive hot beverages without a lid, and a cup holder will be added to his wheelchair. R1's progress notes also document on 10/21/25 at 9:44am documents, Blisters have opened. Treatment orders have changed to apply nonadherent dressing and paper tape. R1's wound doctor note, Wound Assessment and Plan, dated 1/22/25, documents right thigh burn, second degree measuring 2.5cm (centimeter) in length, 3 cm in width, and 0.1cm in depth with peri wound showing maceration. On 10/31/25 at 10:55 am, R1 was noted to be lying on his back in bed with covers pulled up to his bare chest watching television. R1 was in no distress. When asked about spilling coffee R1 stated, I remember that. I burned myself. R1 pulled down blankets and points to two quarter sized pink areas on his inner right thigh and stated, That's what happened. R1 denies discomfort to site and could not remember if he uses a cup with a lid. On 10/31/25 at 11:07 am, V3 (Dietary Manager) stated the facility initiated a new Hot Beverage and Soup Policy after R1's incident with spilled coffee. On 10/31/25 at 1:30 pm, V1 (Administrator) stated R1 had spilled coffee in his lap on 10/20/25, when he tried to hold onto the cup and wheel his wheelchair down the hallway, spilling coffee on his lap, causing a burn to his right thigh area. V1 (Administrator) also verified the facility did not have a Hot Beverage Policy in place prior to R1's incident. On 10/31/25 at 3:10 pm, V7 (Assistant Director of Nursing/ADON) stated V7 was standing in the front foyer by the reception desk when R1 wheeled his wheelchair by her and started heading up the ramped hallway toward his room, when she heard R1 yell out an explicit word. V7 immediately went to him to see what was going on and noted he had spilled his coffee into his lap. V7 (ADON) immediately assisted R1 to his room where his pants were removed, and it was noted he had reddened area to his thighs and groin area. V7 (ADON) did not recall seeing R1 with coffee as he went by her. On 11/4/25 at 10:32 am, V1 (Administrator) confirmed she sees R1 with coffee frequently. V1 also confirmed R1 has impaired cognition and safety awareness. On 11/4/25, V14 (Certified Nursing Assistant/CNA) stated, I do not feel he is safe to have coffee without a lid and staff should have carried it for him. V14 (CNA) also verified R1 has poor safety awareness. On 11/4/25 at 10:50 am, V6 (Licensed Practical Nurse/LPN) stated she feels R1 is not safe with coffee. He tilts his cup in his lap when he is wheeling the halls in his wheelchair. On 11/4/25 at 11:00 am, V2 (Director of Nursing/DON) stated, I don't think anyone is safe with an open cup of coffee. The following corrective actions were implemented to correct the noncompliance for those residents found to have been affected by the alleged deficient practice.The facility Administrator made notification to the department per the regulations on 10/20/25.The facility adopted Hot Beverage Policy.R1 resides at the facility, and the facility QA Team reviewed/revised the care plan on 10/20/25.The Facility Administrator and Divisional VP of Clinical implemented an Ad Hoc QAPI tool on 10/20/25 to ensure Plan of Correction is effective and deficiency remains corrected.The facility Administrator and DON In-Serviced staff regarding the facility's Hot Beverage Policy & Procedure. All beverages rechecked using food-safe thermometers to ensure serving at 130 degrees before being served to the residents. Dietary is responsible for ensuring coffee and hot water are not leaving the kitchen until the temperature is 130 degrees, this includes hot beverages for activities. All residents have the potential to be affected by the alleged deficient practice. However, due to the implementation of the above corrective action, alleged deficient practice will not recur.A systemic review of the facility systems, including Hot Beverage Policy & Procedure. This review found that all procedure(s) are in compliance with State and Federal guidelines. No further changes are required.The following Quality Assurance programs have been implemented to ensure continued compliance.The Quality Assurance Committee will ensure compliance through the internal Quality Assurance Process. The facility dietary manager is to record daily temperature checks for beverages and maintain logs for review in addition to daily checklist. The facility DON is to complete weekly observation audits for 4 weeks and then monthly for 3 months to ensure compliance with beverage temperature policy. Noncompliance findings to be discussed in QAPI meetings monthly until sustained compliance for 90 days. Concerns about the progress of the implementation of the Hot Beverage Policy & Procedure will be discussed in the QA Morning meetings for immediate resolution. The ongoing progress will be reviewed quarterly during the QA meetings. The DON or Designee will educate newly hired dietary staff on Hot Beverage Policy & Procedures.

Based on interview and record review, the facility failed to provide post-fall assessments, identify injury, and thoroughly investigate incidents to identify the root cause and implement interventions to potentially prevent further events per policy for 2 of 3 residents (R1, R3) reviewed for falls in a sample of 6.Findings include:The Skilled Nurse Facility Post Fall Workflow policy, dated 5/2025, documents after a resident falls, they must be stabilized by the nursing staff. If the fall was unwitnessed, no matter their orientation status, the neuro (neurological) policy must be followed and completed. Staff must complete root cause analysis to determine why the resident fell and an appropriate immediate intervention must be placed and updated on the resident's care plan. The resident provider and representative must be notified of the resident's fall. A Fall Risk Assessment must be completed. A detailed Progress Note must be documented in the resident's record, including root cause analysis, resident provider notification, resident representative notification, details of injury and any other details surrounding the resident's fall. Post-fall documentation must be done every shift for 72 hours following the fall.The Skilled Fall Policy, dated 5/2025, documents every resident will receive a fall risk assessment after every fall. Each resident who experiences a fall will be treated and assessed adequately treat any current injuries and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. After each fall, an occurrence report will be completed, root cause will be determined, and interventions will be implemented. A fall is defined as unintentional change in position coming to a rest on the ground, floor or next lower surface. An intercepted fall occurs when a resident would have fallen if the fall had not been intercepted by another person. This is still considered a fall.The Fall Investigation Guidelines for Quality Assurance only, dated 1/11/22, documents the step of the occurrence to review such as to review Progress Notes, were skin issues identified, were neuro checks initiated, anticoagulants, diagnostic test ordered, care plan interventions, fall assessments, pain assessment, responsible party and physician notification was conducted.The Neurological Assessment policy, dated 12/2024, documents Neurological assessments will be completed following an unwitnessed fall. Neurological assessments will be done every 15 minutes for the first hour, then every 30 minutes times two, every hour times six, every four hours times four, every eight hours times six for a total of 72 hours.The Charting and Documentation policy, reviewed 6/2020, documents to chart all pertinent changes in a resident's condition, as well as routine observations. Documents circumstances surrounding the accident/incident, where it took place, date and time it occurred, name of witnesses and their account of incident, residents account of incident, time physician was notified, date and time family was notified, condition of resident, pertinent observations and document every shift for 72 hours post-accident/incident. Document behaviors or change in behaviors using facts and describe symptoms. 1. R1 was admitted on [DATE], with diagnoses of Schizophrenia, Cystitis without Hematuria, Abnormal Liver function Studies, Rhabdomyolysis, and Sciatica. R1's current care plan documents R1 has impaired cognitive function and thought process related to Dementia and impaired decision making, at risk for falls related to physical status and poor safety awareness and is dependent on staff for Activities of Daily Living. R1's Minimum Data Set (MDS), dated [DATE] section C0500, documents R1 had a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment).V3's (Licensed Practical Nurse) Progress Notes, dated 10/24/25 at 9:34 PM (fall occurred between 3:30 PM and 4:00 PM), documents V3 was notified by CNA (V11, CNA/Certified Nurse Aide) that R1 was found lying on the floor next to her bed. R1 complained of mild pain to her right leg and was noted to have a scratch to the back of her right thigh with scant amounts of blood noted. Full body assessment completed, neuro checks initiated and were within normal limits, range of motion intact, moves all extremities without difficulty. Transferred resident from floor to her bed by mechanical lift. New treatment orders were to apply skin prep to area every shift until healed. V3's Progress Note, dated 10/24/25 at 4:55 PM (documented as a late entry on 10/26/25 at 8:38 PM), documents R1 had a new skin tear on her rear right thigh that measured 0.02 centimeters (CM) in length, 0.5 cm in depth and 0.01 cm in width. A film/membrane dressing with dry dressing applied.V11's (Licensed Practical Nurse) Progress Note, dated 10/25/25 at 7:15 AM, documents R1's right leg had decreased range of motion, pain from previous fall (10/24/25), physician was notified and an order for a stat x-ray of right hip and leg was obtained. At 9:03 AM, V11 cancelled the stat x-ray and sent R1 to the hospital via ambulance due to rotation of right leg, hematoma to right leg and swelling. At 11:57 AM, R1 returned to the facility with a diagnosis of right tibia and fibula (bones in the lower leg) fractures.The Emergency Department notes, dated 10/25/25, documents R1 sustained a right tibia and fibula fracture, a knee immobilizer was placed, Norco every six hours as needed for pain was ordered and a follow-up appointment with the Orthopedic Physician was scheduled for 10/27/25.The Electronic Health Record documents the Post Fall Assessment was conducted on 10/25/25 at 10:41 PM and on 10/26/25 at 1:41 PM. The record lacked documentation that post fall assessments and neurological checks were conducted per policy. A Fall Risk Assessment scored at an 11.0 was conducted on 10/24/25 at 12:13 PM, prior to R1's fall, and again on 10/25/25 at 5:01 PM which scored a 15.0 both scores indicate R1 was at high risk for falls.The Fall log documents R1 sustained an unwitnessed fall on 6/12/25, 9/30/25 and 10/24/25.R1's current Care Plan did not include new interventions related to skin integrity post fall on 10/24/25; new Safety/Fall interventions were not initiated post the 9/30/25 fall; Safety/Fall interventions were revised on 10/27/25 to include frequent checks from staff; and Pain interventions were revised on 10/29/25, 5 days after R1's fall, to include to administer pain medications as ordered.The Medication Administration Record (MAR) did not include that Acetaminophen was administered on 10/24/25 as reported by V3. R1 was administered Acetaminophen on 10/25/25 and 10/26/25 as ordered for pain management. The record lacked documentation the Norco (Narcotic for pain management) order from the Emergency Department on 10/25/25 was reconciled into the electronic medical record and made available for R1's pain management. The Medication Administration Record (MAR) documents on 10/27/25 the Orthopedic Physician ordered Norco to be administered every six hours as needed for pain. The MAR documents a Physician's order to complete a post-fall note every shift for the next three days was obtained on 10/7/25, 3 days post R1's fall. Neither the October 2025 Medication Administration Record nor the Treatment Administration Record indicated a new order for R1's skin tear was obtained or conducted post fall on 10/24/25.On 10/28/25 at 2:05 PM, V4 (Certified Nurse Aide) and 10/29/25 at 10:38 AM, V11 (Certified Nurse Aide) stated R1 was complaining of right leg pain and was bleeding from a cut on the back of her upper thigh post fall on 10/24/25. V4 stated upon notifying V3 (Licensed Practical Nurse) that R1 had fallen, V3 instructed V4 to mechanically lift R1 back to bed without a nurse's assessment.On 10/29/25 at 11:45 AM, V20 (Primary Care Physician) stated the facility usually calls directly and V20 did receive a notification that R1 fell although there were no injuries or complaints sustained. No order for wound care was given due to no injuries reported. On 10/29/25 at 10:00 AM, V12 (Licensed Practical Nurse) stated when she notified V19 (R1's Power of Attorney) that R1 was being transferred to the hospital post fall, V19 stated he was unaware R1 had fallen and was not notified.On 10/29/25 at 11:24 AM, V19 (R1's Power of Attorney) stated the facility did not notify him on 10/24/24 regarding R1's fall, neither was a message left on his answering machine. The facility did notify him on 10/25/25 that R1 was going to the hospital due to a fall the previous night, was called again about the report of a fractured leg and then again when R1 returned to the facility from the Hospital.On 10/30/25 at 11:00 AM, V3 (Licensed Practical Nurse) stated she was working on another floor when notified about R1's fall by V11 (Certified Nurse Aide/CNA). V11 stated R1's fall was unwitnessed and there was a scratch of her leg. V3 told V11 she would assess R1 after she finished three other things. V3 then stated she was informed by V5 (Licensed Practical Nurse/LPN) that she laid eyes on R1 and was ok. V3 stated she instructed V5 to mechanically lift R1 back to bed and she had not conducted a full body assessment. V3 stated neuro checks were not completed per policy because she didn't have neurological deficits, although agreed per policy they should've been conducted. V3 stated it was a busy day and she was covering other floors. V3 had to stay after her shift to complete documentation. V3 stated she notified V20 (Primary Care Physician) and left a message for V19 (R1's Power of Attorney) but wasn't sure about the time of notifications or if the notifications were documented. V3 stated the unwitnessed fall protocol is to do a full body assessment and initiate neuro checks for 72 hours post fall, notify the physician, power of attorney and report it to the supervisor. Within the electronic medical record (EMR) there is a Risk Management section to enter the fall into. The entry into the Risk Management section generates post-fall assessments to be entered in the EHR's Progress Notes every shift. I gave (R1) Tylenol because that's what I do when someone falls. V3 was unable to state why the Tylenol administration was not documented. On 10/29/25 at 12:45 PM, V2 (DON/Director of Nursing) stated when a resident falls, the Nurse on duty is to assess the resident right away, before the resident can be moved or transferred to bed or wheelchair. If the Nurse assesses there is an injury requiring Emergency transport, the resident is not moved and will remain on the floor until the ambulance arrives. V2 stated her investigation concluded on 10/24/25 at 6:00 PM, V27 (Licensed Practical Nurse) came on shift and did a head-to-toe post-fall assessment.During interviews on 10/28/25 and 10/29/25, V4 (CNA), V10 (CNA), V11 (CNA) and V21 (CNA) were unaware that new intervention were care planned post R1's fall on 10/24/25 to prevent R1 from a repeat fall.On 10/30/25 at 1:45 PM, V1 (Administrator) agreed R1 did not have a full body assessment prior to being placed back to bed via mechanical lift post fall, post fall assessments and neurological checks were not conducted per policy, the record lacked documentation the Power of Attorney was notified of R1's fall, a thorough pain assessment nor the administration of Acetaminophen was documented as given per V3's interview, the pain medication prescribed by the Emergency Department Physician was not reconciled as an active order and available for use as needed, no order for wound care was given due to no injuries reported, the care plan did not include new interventions related to skin integrity post fall on 10/24/25; new Safety/Fall interventions were not initiated post the 9/30/25 fall; Safety/Fall interventions were revised on 10/27/25 to include frequent checks from staff, 3 days post fall; and Pain interventions were revised on 10/29/25, 5 days after R1's fall, to include to administer pain medications as ordered. V1 stated the investigation consisted of direct care staff interviews only. V1 was unaware that staff were not informed of the new interventions (frequent checks) put into place post R1's fall.2. R3 was admitted on [DATE] with diagnoses of Schizophrenia, Diabetes Mellitus with Neuropathy, Urine Retention, Congestive Heart Failure, Osteoarthritis, COPD, Depression, Anxiety Disorder, and Traumatic Brain Injury.The current care plan documents R3 has limited physical mobility related to weakness and deconditioning. R3 can walk with a walker as tolerated with stand by assistance; behavior problem of fidgeting; resistive to Activities of Daily Living (ADL) cares; monitor for attention seeking behaviors and putting self on the floor.The Fall log documents R3 sustained a fall on 10/22/25 with hospitalization.R3's Progress Note documents R3 was hospitalized on [DATE] and returned to the facility on [DATE].On 10/28/25 at 3:30 PM, V23 (Certified Nurse Aide/CNA) stated on 10/24/25 while trying to take R3 to the shower, R3 went down on both knees. V23 stated R3 likes to put himself on the floor and I don't think he had an injury, but it wasn't assessed by the nurse (V3) who also witnessed the change of plane.10/28/25 at 3:45 PM, V24 (Certified Nurse Aide) stated R3 fell and hit hard in the dining room on 10/24/25 between 4:00 PM-5:00 PM. V23 and V24 did the vital signs and assessed R3 because V3 (Licensed Practical Nurse) left and never came back.On 10/30/25 at 11:00 AM, V3 (LPN) stated R3 did have a change of plane in the dining room on 10/24/25 and a post fall assessment was not conducted, nor was a Risk Management Incident report initiated, the physician nor the family were notified and follow assessments were not conducted because she considered the change of plane to be intentional related to behaviors and not a fall. V3 stated she did not document R3's behaviors because behaviors do not need to be documented. V3 stated she was aware that R3 had returned from the hospital the same day and was actively undergoing treatment for Sepsis (a life-threatening medical emergency caused by your body's overwhelming response to an infection).On 10/29/25 at 9:11 AM, V5 (Licensed Practical Nurse/LPN) stated R3 is her brother and was not notified that a change of plane occurred on 10/24/25.10/30/25 at 8:53 AM, V2 (Director of Nursing/DON) stated she was unaware R3 had a change of plane on 10/242/5. V2 stated R3 can ambulate independently although it's not encouraged and will sit on the floor when he wants to. V2 stated after interviewing V3, V3 felt R3's change of plane was a behavior issue and not a fall.On 10/30/25 at 1:45 PM, V1 (Administrator) agreed a thorough investigation had not been conducted after R1's fall to determine the root cause. V1 stated R3's change of plane should have been documented and reported so an investigation could have been conducted to assist in identifying the root cause.

Based on record review and interview, the facility failed to report an allegation of abuse to the Administrator for one resident (R2) of three residents reviewed for abuse in a total sample of three.FINDINGS INCLUDE:The facility policy, entitled ABUSE, PREVENTION AND PROHIBITION POLICY, not dated, documents: The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence; and the facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action.R2's Electronic Medical Record/EMR Progress Notes documents on 6/28/25 at 8:44 AM, R2 had someone call V5/Registered Nurse to report CNAs (Certified Nursing Assistants) hurt R2.On 8/8/25, at 12:00 p.m., V5/Registered Nurse confirmed her progress note dated 6/28/25 at 8:44 a.m.; R2 told V5 that V7 Certified Nursing Assistant/CNA and V8/CNA hurt her with washcloths; V5 reported the incident to V4/Director of Nursing.On 8/8/25, at 12:15 p.m., V4 (Director of Nursing) confirmed, I was told hours later of the alleged incident regarding the two CNAs who R2 alleged hurt R2, and V4 did not report the incident.On 8/8/25, at 11:30 a.m., V1/Administrator and V2/Interim Administrator confirmed the 6/28/25 allegation was not reported to V1 or V2.

Based on interview and record review, the facility failed to investigate allegations of abuse thoroughly for one (R1) of one residents reviewed for physical abuse in a sample of seven. Findings include: The facility's policy titled Abuse, Prevention and Prohibition, dated 03/2025, documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process. Initiate investigation including initial reporting to all required agencies. A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. Interview the resident if they are cognitively able to answer questions in a private setting free from any intimidating factors. Request that a staff member who has special rapport participate if possible. If the resident is not interviewable, question the roommate and any family or friends who visit frequently with completion of a questionnaire. Social Services (designee) will complete a Trauma Informed Care assessment and provide follow-up care regardless if allegation is substantiated. Complete and summarize the investigation within five business days. Review outcome of investigation report with the Regional Nurse. Notify the employee in question of their reinstatement or termination. Complete final report and submit to required agencies. Maintain the report in a locked file in the Administrator office. This must be kept private and confidential. R1's Admission Record documents the R1's date of admission to the facility was 6/8/23, and her diagnoses on admission include Cerebral Palsy, Hypothyroidism, and Cerebrovascular Disease. R1's Minimum Data Set assessment, dated 4/23/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 14/15, indicating cognition intact. On 4/10/25, R1 reported to V6 (Case Manager for [NAME]) that a staff member placed a sock in her mouth. On 5/27/25 at 9:30am, R1 stated about a month ago, a female Certified Nursing Assistant/CNA (V4) was helping a male CNA (V3) put R1 on a bed pan. She (R1) did not recall what was being said, but a nurse came to the door and V4 (CNA) placed a sock in R1's mouth to keep her (R1) from telling the nurse something about V3 (CNA). R1 stated, I think she thought I was going to tell on the black guy. R1 stated she pulled the sock from her mouth and V4 (CNA) placed it back in her mouth and held it there for a bit, but unsure of how long. On 5/28/25 at 8:15am, V1/Administrator stated, I was notified of the allegation by (V6's Case Manager for insurance company) that R1 reported a Certified Nursing Assistant/CNA had placed a sock in (R1's) mouth. I immediately went down and spoke with (R1), who told me that (V4, CNA) did not physically place a sock in her mouth. (R1) stated to me that she had called (V3, CNA) a lazy N word when he had left the room, and (V4, CNA) told her to 'put a sock in it, we do not use words like that here, that will hurt feelings.' V1 (Administrator) also stated R1 stated she (R1) was not afraid of V3 or V4 (both CNA's) and she felt safe in the facility. V4 (CNA) was suspended pending investigation, and was told she could return to work. On 5/28/25 at 9:50am, V1 (Administrator) spoke with R1. R1 told V1 at this time, V4 (Certified Nursing Assistant/CNA) had physically placed the sock in her mouth and would not verify what was stated in previous conversation with V1. On 5/28/25 at 12:45pm, V1 (Administrator) stated he only spoke with R1, V3 (Certified Nursing Assistant/CNA), and V4 (CNA) regarding the allegation, but did not write down formal statements. V1 also verified he did not obtain staff interviews, other resident interviews, or have R1 assessed for injury by nursing and Social Services. V1 did not do a subsequent Trauma assessment during the investigation, but will re-start the investigation due to R1 changing her story back to the sock being physically placed in her mouth. V1 stated, You're right, my investigation was lacking.

Based on interview and record review, the facility failed to perform ongoing clinical assessments for a resident experiencing an acute medical condition (R1); one of four residents reviewed for clinical assessment, in a sample of four. FINDINGS INCLUDE: The (undated) facility policy, Nursing Documentation Guidelines directs staff, Three-day documentation on every shift is required on all new admissions/readmissions. R1's hospital Discharge Summary form, dated 02/05/2025 documents, admitted : 01/30/2025. Past medical history of COPD (Chronic Obstructive Pulmonary Disease), Asthma, Diabetes Mellitus, Chronic Kidney Disease presents to the ED (Emergency Department) with 1 to 2 days of decreased appetite, shortness of breath and wheezing. (R1) did test positive for Influenza A. On admission (R1) continued to be mostly nonverbal however did attempt to speak with family and speech was very garbled. (R1) does have slight right sided upper extremity weakness and significant right lower extremity weakness. Head CT (Computerized Tomography) was obtained which does show acute to subacute left occipital lobe and left anterior cerebral artery distribution cerebrovascular infarction. (R1) was evaluated by (Speech Therapy) and placed on a pureed diet with nectar thick consistency. R1's facility Admission Record documents R1 was admitted to the facility on [DATE], with the following diagnoses: Cerebral Infarction, Dysphasia, Aphasia, Diabetes Mellitus, Chronic Kidney Disease and Influenza A. R1's facility Nursing Admission Assessment form, dated 02/05/2025 documents, (R1) alert, unable to determine orientation, difficulty being understood, unsteady gait, poor balance, short- and long-term memory problems, withdrawn, poor appetite, anxious, lung sounds with wheezes and crackles, incontinent of bowel and bladder. R1's Nursing Progress Notes, dated 2/5/2025 at 10:32 A.M. document, admitted to room, (R1) via hospital. Alert with confusion, incontinent of bowel and bladder, PT/OT/ST (Physical Therapy, Occupational Therapy and Speech Therapy) to eval (evaluate) and treat. Will remain in isolation precautions due to influenza. R1's Nursing Progress Notes, dated 2/7/2025 at 4:37 P.M. document, (R1) transferred to local hospital ER (emergency room ) via ambulance d/t (due to) decreased SpO2% (oxygen level), AMS (Altered Mental Status)/slow to respond, elevated temp (temperature). All parties notified. No other nursing assessments or nursing progress notes are documented in R1's electronic medical record after of 2/5/25 at 10:32 A.M. until 2/7/25 at 4:37 P.M. On 3/18/2025 at 2:03 P.M., V2/Director of Nurses (DON) stated when a resident is admitted to the facility as a skilled level resident, facility staff are to document every shift, under the assessment tab in PCC (Point Click Care), a Skilled Documentation/Skilled Care Assessment form for each resident. At that time, V2/DON confirmed no skilled documentation form was present on R1's electronic medical record for 2/6/25 and 2/7/25. V2/DON stated, Just recently we realized the nurses weren't performing nursing assessments and documenting a resident's ongoing medical condition. We (V6/Assistant Director of Nurses and myself) have since educated all facility staff on this issue. At this time, V2 stated when a resident is transferred to the hospital, a complete nursing assessment is performed on a resident, and the results are documented in a resident's medical record via an E Interact Transfer Form.

Based on observation, interview, and record review, the facility failed to provide the correct textured diet to one of four residents (R1), a resident with a documented diagnosis of dysphasia, in a sample of four. FINDINGS INCLUDE: The (undated) facility policy, Therapeutic and Mechanically Altered Diets, directs staff, It is the policy of (facility) that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietician. A therapeutic diet is a diet ordered to manage problematic health conditions. A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake. Examples include soft diets, pureed foods and ground meat. Diets for residents that only take liquids that have been thickened are included in this definition. A physician's order is written for all diets including therapeutic and mechanically altered diets. R1's hospital Discharge Summary form, dated 02/05/2025, documents, admitted : 01/30/2025. Past medical history of COPD (Chronic Obstructive Pulmonary Disease), Asthma, Diabetes Mellitus, Chronic Kidney Disease presents to the ED (Emergency Department) with 1 to 2 days of decreased appetite, shortness of breath and wheezing. (R1) did test positive for Influenza A. On admission (R1) continued to be mostly nonverbal however did attempt to speak with family and speech was very garbled. (R1) does have slight right sided upper extremity weakness and significant right lower extremity weakness. Head CT (Computerized Tomography) was obtained which does show acute to subacute left occipital lobe and left anterior cerebral artery distribution cerebrovascular infarction. (R1) was evaluated by (Speech Therapy) and placed on a pureed diet with nectar thick consistency. R1's facility Admission Record documents R1 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Dysphasia, Aphasia, Diabetes Mellitus, Chronic Kidney Disease and Influenza A. R1's Physician Order Sheet, dated 02/05/2025, includes the following physician order: Low Concentrated Sweets diet. Pureed texture, Nectar thick (Liquids) consistency, for Dysphasia. R1's facility Diet Order Form, dated 02/05/2025 and signed by V6/Assistant Director of Nurses, documents, Pureed diet, Nectar thick liquids. On 3/18/2025 at 12:29 P.M., V8/R1's POA (Power of Attorney) stated she is R1's granddaughter and his POA. V8 stated she lived with (R1) and provided care for him. She called the ambulance on 1/30/25 due to R1 not moving and being unable to speak. R1 was admitted to local hospital with a stroke and was unable to speak clearly or swallow correctly. V8 stated the family made the decision to admit R1 to the facility as they were no longer able to care for (R1) and he required PT (Physical Therapy), OT (Occupational Therapy), and Speech Therapy. R1 was transferred to the facility on [DATE] around 10:30 in the morning and she and her boyfriend arrived around 11:00 AM that morning. Within an hour of her arrival, staff brought in a meal tray that consisted of two pieces of whole white bread with some diced meat and shredded cheese on top, applesauce, regular consistency cranberry juice and regular consistency water. V8 stated at that time, they were face timing with V7/R1's daughter. V8 stated R1 acted very thirsty and picked up the cranberry juice and began drinking. R1 then picked up the sandwich and began eating and swallowing, and immediately began choking. V8 stated her boyfriend put his finger down R1's throat to dislodge the bolus of food. At that time, V7 noticed, via face time, R1's tray of food contained the wrong diet and wrong consistency of fluids. V8 grabbed R1's tray of food and went to the nurse's station and spoke with V9/Licensed Practical Nurse (LPN). V8 stated V9/LPN looked through R1's medical records and realized R1 had been provided the wrong diet and wrong consistency of fluids. On 3/18/20205 at 1:16 P.M., V9/Licensed Practical Nurse stated, When a resident is admitted , the transfer sheet contains a diet. I fill out a diet slip and hand it to someone in dietary. (R1) was on a pureed diet and thickened liquids. (R1) came to us very sick and had recently had a stroke. (R1) was admitted late morning (2/5/25). At lunchtime that day, his granddaughter (V8) brought his tray to me, and I knew right away (R1) had gotten the wrong diet. It wasn't pureed with thickened liquids, like it was supposed to be. (R1) had eaten some of the sandwich and had drunk quite a bit of the fluids.

Based on observation, interview, and record review, the facility failed to keep a clean and sanitary kitchen; dispose of outdated food; date and label opened food items; include thaw dates for supplements; correctly cool down potentially hazardous food and keep a log of the temperatures; and label and date food storage containers holding bulk food stuffs.This has the potential to affect all 75 residents living in the facility. Findings: 1. The document Kitchen Sanitation, dated 10/2020, states, It is the policy of this facility to comply with public health standards and local and state sanitation regulations. The Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. The Dietary Sanitation Quality Assurance Review shall be used as a tool to monitor compliance with sanitation standards and identify which areas need corrective action. The Food Service Manager will develop a cleaning schedule for the department and ensure that dietary employees complete cleaning tasks as scheduled. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen and specify which chemical and personal protective equipment should be used for each task. The document Dietary Sanitation, Quality Assurance Review, dated 10/2020, states, Hand washing sink clean. Disposable towels, hot water available. Cooling log is accurate. Ensure food and non-food contact surfaces are easily cleanable including shelves and drawers and carts. Equipment is clean and in safe working order: Oven/Stove; Microwave; Mixer; Ice Machine. Range hoods are free of dust/grease. Refrigerator - shelves/floor/ceiling clean; no indication of spills. All food is covered; containers are labeled with contents, date opened and date to discard. Supplements have thaw and expiration date; Foods are stored in airtight containers and labeled if not in original container. Vents and pipes are clean. Ceilings and walls are clean; floors and baseboards are clean. The document, In-place Equipment, dated 4/2013, states, It is the policy of this facility that in-place equipment and surfaces that cannot be cleaned and sanitized by a mechanical dishwasher or 3-compartment sink will be cleaned and sanitized by using an appropriate wiping cloth and solution. Remove visible debris off of in-place equipment or surface with use of soap and water solution. Rinse detergent from equipment. Wipe in-place equipment or surface with sanitizing solution. Allow in-place equipment or surface to air dry. On 11/18/24 at 9:45 AM, the area under the pass-through window over the steam table wells had a large buildup of black dust, grease/grime, crumbs/food debris, and splashes of unknown origin. The microwave, sitting on a food preparation table (next to the steam table), had dried food particles and splashes of unknown origin on its inside ceiling. Under this table were four large storage bins, with dried food debris and liquid splashes of unknown origin on the lids, front, and sides. These held flour, sugar, brown sugar, and oats. There were no labels identifying the contents of the bins. Food carts used to transport resident trays had splashes on the outside and inside of the carts. The burners and on the metal wall behind the stove burners had old food splatters; the pull-out grease tray under the burners had blackened substance, crumbs. The pull-out grease tray under the grill had two to three inches of old black grease and food particles. The baffles and pipes over the stove and range had a thick visible dust covering; the pipes behind this appliance also had thick visible dust build up. The ovens under the stove and grill had layers of grease on the outside and the handle to the oven was sticky with grease. The inside of the ovens had blackened food debris. The convection oven next to this area had windows opaque from layers of dried grease and food splashes on the inside and outside of the doors. Blackened food particles and splashes were on the inside of the oven and on the wire shelves. Several food racks around the kitchen held various items, food, dishes, utensils, etc. (etcetera) or all had food debris and liquids of unknown origin on the bottom from and the side rungs. Portable coolers, stored directly on the floor, had layers of dust and debris. The windowsill and frame, wall, and floors throughout the kitchen had splashes of food and liquid items of unknown origin. The inside of the reach-in refrigerator and walk-in refrigerator had splashes on the walls, wire racks, and bottom and floor. In the stockrooms, a non-institutional container, no label to identify its contents, with a lid that was dusty with splashes of food/liquids of unknown origin held a substance used to thicken beverages and food items. Three-tiered food transport carts had old splashes of food and liquids of unknown origin. V9, Dietary Manager, confirmed observations, stating, Looks like we have a lot of cleaning to do. The document Prevention of Food Contamination, states, It is the policy of this facility that all food shall be handled and prepared to prevent contamination against dirt, odor, bacteria, etc. Store all food according to package directions or standardized guidelines. The document Hazard Analysis Critical Control Point, dated 10/2020, states, It is the policy of this facility to use a procedure to prevent the outbreak of any food borne illness. Protect foods during storage to prevent contamination. Foods are not exposed to pipes. Foods will be tightly covered or in a sealed container. Container must be labeled and dated. Rapidly cool all cooked foods to an internal temperature of 70 degrees Fahrenheit (F) or below within two hours and 41 degrees F within four hours. Label all cooling foods with appropriate log record to track cooling procedure. 2. The document Storage, dated 10/2020, states, Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food. All items will be dated upon receipt. Store leftovers in covered, labeled, and dated containers under refrigeration or frozen. Clean up all debris dropped on the floor immediately. The document Refrigerator and Freezer Storage, dated 10/2014, states, Any item placed in the refrigerator and freezer must be covered, labeled, and dated with a date-marking system that tracks when to discard perishable foods. [NAME] container with name of item. [NAME] the date that the original container is opened or date of preparation. Label refrigerated, potentially hazardous food prepared with the day/date by which the food shall be consumed or discarded (maximum of seven days from time of preparation). Clean up any spills immediately. Designated dietary employee is to check, pull and throw away any potentially hazardous foods that have been in the refrigerator for seven days. On 11/18/24 at 10:05 AM, the walk-in refrigerator held the following: a large deep pan of barbeque pork dated 11/17/24; a large deep pan of Swiss steak, dated 11/16/24; A large pan of lemon pudding dated 11/16/24; a larger pan of vanilla pudding dated 11/17/24; A pan of mixed fruit, dated 11/01/24, an opened container of a whipped topping, no open date. V9, Dietary Manager, was unable to clarify if the dates on the food items were the date to use or to discard. None of the items had a label identifying this information. This cooler also held an eight ounce container of black icing, partially used, no open date; two squeeze bottles of unknown substance, one pink, one aqua colored, covered with mold; an eight ounce package of block cheddar cheese, with the use by date of 12/07/23; a five ounce package of [NAME] Cheese with a sell by date of 9/02/23; 250 ml (milliliter) container of a supplement, expiration date of 8/01/24; two opened 36 ounce containers of thickened liquid, half used, no open date; Beverage container of apple juice, 1/4 full, dated 11/19/24; Beverage container of cranberry juice, 1/3 full, dated 11/11/24. The reach-in refrigerator held the following: 14 squeeze bottles, used, with splashes/sticky substance on the outside and dried substance on the top squirt spout did not have labels or dates; two small bowls containing unknown substance without labels; two Styrofoam glasses of unknown substance, no labels; 2 1/2 pounds of sliced American cheese, no open date or label; a five pound container of whipped margarine (1/8 full), a five pound package of shredded cheddar cheese (1/2 full), a five pound package of Parmesan cheese, a half-gallon container with a cup of applesauce; two gallon jars of coleslaw sauce (one 1/2 full) (one 3/4 full), a gallon of red dressing, a gallon of 1000 island dressing, a gallon of dill pickles, a gallon of mustard, none of these items had open dates or labels; a small storage bag containing 1/2 pound of lunchmeat dated 11/06/24. V9 stated, I will tell staff to put labels on the food. On the bottom shelf of a food preparation table next to the reach-in refrigerator a tray contained two bottles of red food coloring, one bottle of green food color, two bottles of vanilla extract and a five-pound container of baking powder. All had been opened, all had dust, food stains on them, none had open dates or labels. V9 stated, We don't use those very often. 3. The document Food Thawing, dated 10/2020, states, It is the policy of this facility that all food requiring thawing before serving must be thawed in a manner that avoids placing the food in the danger zone. All items placed in the refrigerator to thaw, including oral nutrition supplements, must be labeled with the thaw date. On 11/18/24 at 9:50 AM, a case (48 cartons) of a supplement thawing in the walk-in refrigerator. There was no thaw date on the case. V9, Dietary Manager, stated, I didn't know they needed to be dated. The document Food Cooling, dated 3/2018, states, It is the policy of this facility the Time Temperature Control for Safety (TCS) foods will be cooled properly to prevent the outbreak of food borne illness. Hot foods will be cooled to the proper temperature using a two-stage cooling process. Stage 1: Cool foods from 135 degrees Fahrenheit (F) to 70 degrees F within 2 hours. Stage 2: Cool foods from 70 degrees F to 41 degrees F or below within four hours (total of six hours). If food has not been cooled to 70 degrees F or below within the first two hours, the food needs to be thrown out or reheated one time only to 165 degrees F and held for 15 seconds. The cooling process will start overusing an alternate method to cool from what failed initially. If the food does not reach 70 degrees F or below the second time the food item must be discarded. Use the Food Cooling Log for Temperature monitoring and recording. The Dietary Manager will review and monitor the Food Cooling process and log for completion. The Dietary Manager will maintain records of the Food Cooling logs for one year. The document Food Cooling Log, dated 9/2024 through 11/2024, states, Record temperatures of potentially hazardous foods during cooling process. Food Item; start time; start temperature; time and temperature within two hours (below 70 degrees F); Time and Temperature within four more hours (below 41 degrees F); Corrective Action, if necessary. On 11/18/24 at 10:15 AM, the Food Cooling Log was reviewed. Twelve potentially hazardous foods were listed on the form: 9/05/24, Ham; 9/11/24, Chicken Dumpling; 9/24/24 Meatloaf; 9/26/24, Turkey; 9/28/24, Goulash; 9/30/24, Mixed Vegetables; 10/07/24, Hamburger; 10/22/24, Meatloaf; 11/07/24, Ham; 11/10/24, Turkey; 11/14/24, Roast Beef. Each item had the exact same start time of 12:00 PM; the exact same start temperature of 65 degrees Fahrenheit (F); the exact same temperature for the Time and Temperature within two hours (below 70 degrees F), of 65-degree F. Only one food item, ham from 9/05/24, had a temperature recorded for time and temperature within four more hours (below 41 degrees F), of 35 degrees F. Nothing else recorded on the form. V9, Dietary Manager, stated, No, the form isn't filled out as it should be. V9 agreed it was unusual that all the times, temperatures were exactly the same on the form. 4. The document Equipment, Temperatures, dated 9/2008, states, It is the policy of this facility that all refrigerator and freezers shall be monitored regularly to ensure that they are working properly and to correct any mechanical difficulties quickly. On 11/18/24 at 10:10 AM, the walk-in freezer was dripping a clear colorless substance from a hole 36 inches by 24 inches, no cover/grate over it. A large deep pan was catching the substance. An accumulation of ice was on the rack and floor under the area. The walk-in refrigerator also had a clear colorless substance dripping out of its ceiling grate onto the containers of food items below it, pooling on their tin foil coverings. A container of whipped topping had the liquid pooled on its lid and a paper case containing whipped topping was saturated with the liquid. The automatic paper towel machine by the hand washing sink did not work and no paper towels were by the sink. The water faucet was difficult to turn on and could not be totally turned off, water continuing to run out of the faucet. A floor drain, opposite of the hand washing sink, protruded to the edge of the above counter and did not have a grate over the 12 by 10-inch hole. V9, Dietary Manager, stated, We keep the large containers in both the walk-ins to catch the water. There's been some problems, but they fixed it. There's a grate for the floor drain. I'm not sure where it is now. 5. The document Ice Machine, dated 10/2017, states, It is the policy of this facility to assure that ice is handled in a clean, sanitary manner. The ice machine should be kept clean at all times. The ice machine is cleaned and sanitized on a regular basis. Refer to the manufacturer's cleaning procedure and recommendation. The document Ice Machine Operator Use and Care Manual, dated 6/1999, states, Clean and sanitize the ice machine. If required, an extremely dirty ice machine may be taken apart for cleaning and sanitizing. Refer to Sanitizing Procedure. Use sanitizer to remove algae or slime. Periodic cleaning must be performed on adjacent surface areas not contacted by the water distribution system. If the bin requires sanitizing, remove all the ice and sanitize it. On 11/18/24 at 9:35 AM the following observations were made: a three-drawer plastic storage unit, non-institutional, holding utensils and various kitchen items, sat by the kitchen door. The unit had splashes of unknown liquids and food debris on the top, sides and front. Wheels were attached to only one side of the unit, making it sit on a slant; the bottom right side bottom drawer was smashed/cracked, gapping open, sitting directly on the floor with items inside the drawer exposed to contamination. Water coming from the floor by the ice machine was seeping toward the storage unit. The ice machine had mineral deposits on the exterior and interior. The interior area where ice passes from where it is made into the well for ice storage has a lip across the width of the machine. This contained a black/brown/pink unknown slime appearing substance. V9, Dietary Manager, confirmed the observations. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671, dated 11/18/24, signed by V11, Business Office Manager, documents 75 residents currently reside within the facility.

Based on record review and interview, the facility failed to ensure a residents Physician Orders matched their Practitioner Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for one of 24 residents (R66) reviewed for Advanced Directives in the sample of 37. Findings include: The facility's DNR (Do Not Resuscitate) Policy, dated [DATE], documents, Purpose: To offer facility guidance on do not resuscitate orders. Policy: Our facility will not use cardiopulmonary resuscitation and related emergency measure to maintain life functions on a resident when there is DNR Order in effect. Interpretation and Implementation: 1. Do not resuscitate orders on the physician's order sheet maintained in the resident's medical record. 2. A DNR order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State Law). R66's Physician Orders, dated ,d+[DATE], documents Code Status: [DATE]- Full Code. R66's Illinois Department of Public Health Uniform (POLST), dated [DATE], and signed by V16/R66's Power of Attorney, V8/Medical Director, and V4/Care Plan Coordinator, documents R66 is a DNR, with selective treatment only. On [DATE] at 12:50 PM, V13/Assistant Director of Nursing verified R66's [DATE] Physician Order Sheet documents R66 is a full code, and R66's POLST form documents R66 is a DNR. V13 stated, I am responsible to ensure the Physician Orders match the POLST form. I must have missed it on (R66's) November Physician Orders. The POLST form and current Physician Orders should always match.

Based on observation, interview and record review, the facility failed to follow a dietician's recommendation for weight loss, provide a resident with a physician ordered calorie supplement, implement a care plan for weight loss and complete physician ordered weekly weights for two of four residents (R43, R66) reviewed for nutrition in the sample of 37. Findings include: The facility's Weight Assessment and Intervention Policy, dated 7/1/2023, documents Policy statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation: Weight Assessment- 1. The nursing staff will measure residents' weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in the resident's medical record. 5. Any weight change of five percent or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. 6. The Dietitian will review the Weight Record at least monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not he criteria for significant weight change has been met. 7. The threshold for significant unplanned and undesired weigh loss will be based on the following criteria (where percentage of body weight loss= (usual weight-actual weight)/ (usual weight) times 100): a. 1 month- five percent weight loss is significant; greater that 5 percent is severe. B. 3 months- 7.5% weight loss is significant; greater that 7.5 percent is severe. C. 6 months 10% weight loss is significant; greater that 10% is severe. 1. R66's 2024 Weight Record documents R66's weight in May 2024 was 153 pounds and R66's weight in November 2024 was 130 pounds, which is a 15.03 percent weight loss in a 6 month period. R66's Request for Diet Change, dated 9/26/24, and signed by V21/Dietitian, documents, Summary: Regular mechanical diet, on Magic Cup two times per day, weight decrease past 30 days, Recommend Med Pass (calorie supplement) for nutrition needs. Refer PRN (as needed.) Comments: Weight Progress Note- Please change diet to: Med Pass 60cc (cubic centimeters) two times per day. This same request was documented as received by V8/R66's Physician on 10/24/24, and signed as agreed by V8/R66's Physician on 10/28/24. R66's Request for Diet Change, dated 10/16/24, and signed by V21/Dietitian, documents, Summary: Weight at 136 pounds. Magic cup is given, diet okay for needs, (R66) paces and burns calories throughout the day. Recommend Med Pass 90cc three times per day. Comments: Weight Progress Note- Please change diet to Med Pass 90 cc three times per day. This same request was documented as received by V8/R66's Physician on 10/24/24, and signed as agreed by V8/R66's Physician on 10/28/24. R66's Physician Order Sheets, dated September, October, and November 2024, do not document an order for Med Pass 60cc to be given two times per day, or an order change for Med Pass 90cc to be given three times per day. On 11/20/24 at 11:45 AM, R66 was on the dementia unit sitting in the dining room. R66 was being assisted with eating by V20/CNA (Certified Nursing Assistant). V20/CNA verified R66 requires assistance with eating. On 11/20/24 at 1:00 PM, V13/ADON (Assistant Director of Nursing) stated, (V21/Dietitian) comes in around twice a month and writes dietary recommendations for the residents who need it. When (V21) fills out the dietary recommendation forms, (V9/Dietary Manager) will send the recommendations to the resident's appropriate Physician. When the Physician sends back the dietary recommendation stating if they agree with the recommendation or not, the nurses will then process the order. I am not sure how (R66's) dietary recommendation dated 9/26/24 and 10/16/24 never got processed by the nurses. On 11/20/24 at 12:30 PM, V9/Dietary Manager verified R66's dietary recommendations, dated 9/26/24 and 10/16/24, did not get sent to V8/R66's Physician until 10/24/24. V9 stated, I was on maternity leave in September 2024, so I didn't send any dietary recommendations until I was back to work in October 2024. I don't know who was filling in for me when I was gone, but I sent both of (R66's) dietary recommendations from September and October 2024 to (V8/R66's Physician) when I got back. V9 also verified at this time R66 does not have a care plan for unplanned weight loss and R66 should have. On 11/20/24 at 1:05 PM, V2/Director of Nursing verified R66's dietary recommendations, dated 9/26/24 and 10/16/24 and signed on 10/28/24 by V8/R66's Physician, never got processed by the nurses. V2 verified R66 has not been receiving Med Pass as recommended by the Dietician for the months of September, October, and November 2024. V2 stated, Any dietary recommendation should be sent to the doctors right away and then followed up on to ensure the facility has received the recommendation back from the doctor and that the order gets processed. We (the facility) will work on a better process. I am not sure how (R66's) signed dietary recommendations got missed but it should not have. 38396 2. R43's Physician Order Sheet, dated 11/2024, documents R43 was admitted to the facility on [DATE], with a Gastric tube (supplemental internal feeding tube) and diagnoses of Dehydration, Severe Protein Calorie Malnutrition and Hypernatremia. This same Physician order sheet documents R43 is to have Weekly Weights. R43's Monthly Weight and Vitals record documents one recorded weight for October of 112.8 pounds. R43's Medication Administration Record (MAR), dated October 2024, documents weekly weight should be done between 6 AM and 2 PM one time per week. This same administration record does not document any weights recorded for R43 for the entire month of October. On 11/21/24 at 10:00 AM, V2 (Director of Nursing) and V13 (Assistant Director of Nursing) confirmed R43's weights were not recorded weekly during October, and stated they do not have documentation to reflect that any weekly weights were ever completed for R43.

Based on observation, interview, and record review, the facility failed to date oxygen tubing, place an oxygen sign on resident doors, and ensure a nebulizer facemask and tubing was changed weekly for three of three residents (R5, R34, R56) reviewed for oxygen therapy in the sample of 37. Findings include: The Oxygen Administration Policy revised 3/17/22, documents, To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Oxygen therapy will be administered to the resident upon the written order of a licensed physician or may be given in an emergent life-sustaining situation without an order, until an order may be obtained by a licensed physician. It will be administered by way of an oxygen mask, nasal cannula and/or a nasal catheter. Procedure: 5. Place the Oxygen in Use sign on the outside of the room entrance door. Tubing will be changed and dated weekly. 1. R5's Admission Record documents R5 was admitted on [DATE] with diagnoses which included Morbid (Severe) Obesity, Paroxysmal Atrial Fibrillation, Type 2 Diabetes Mellitus, Fibromyalgia, and Heart Failure. R5's Minimum Data Set/MDS Assessment, dated 10/11/24, documents R5 has a BIMs/Brief Interview of Mental Status of 15 (cognition intact). R5's Physician Orders for November 2024 documents Oxygen at 4 liters/minute per nasal cannula (dated 6/4/24). Change Oxygen Tubing weekly (dated 7/28/24). R5's current Care Plan documents Cardiac - diagnosis of Congestive Heart Failure. Monitor oxygen saturation every shift if with dyspnea, administer oxygen therapy per Physician Orders. On 11/18/24 at 1:43 PM, R5 was lying bed with her oxygen tubing next to the side of R5's pillow. R5 stated she does not always wear the oxygen, but keeps it close in case she needs it. The tubing was not dated. R5 stated there is no certain day the oxygen tubing is changed. R5 did not remember when the oxygen tubing was last changed. On 11/18/24 at 11:48 AM, there was no oxygen sign on R5's door. R5's Treatment Administration Record for November 2024 documents oxygen at 4 liters/minute per nasal cannula and to change oxygen tubing weekly. The last time the tubing was documented as being changed was 11/10/24. 2. R56's Admission Record documents R56 was admitted on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Fluid Overload, Morbid (Severe) Obesity, Hyperlipidemia, and Essential (Primary) Hypertension. R56's Minimum Data Set/MDS Assessment, dated 9/18/24, documents R56 has a BIMs/Brief Interview of Mental Status of 15 (cognition intact). R56's Physician Orders for November 2024 documents Oxygen at 5 liters/minute per nasal cannula (dated 4/30/24). R56's current Care Plan documents R56 has altered respiratory status/difficulty breathing related to Morbid Obesity and Chronic Obstructive Pulmonary Disease. On 11/18/24 at 11:26 AM, R56 was sitting in the dining room wearing oxygen. There was no date on the oxygen tubing. R56 stated she thinks the tubing was changed yesterday. They change the tubing at least every week or two. On 11/18/24 at 11:48 AM, there was no oxygen sign on R5's door. R56's Treatment Administration Record for November 2024 does not document the last time R56's oxygen tubing was changed. On 11/18/24 at 11:48 AM, V19/Licensed Practical Nurse/LPN verified that R5 and R56 are both on oxygen but neither have an oxygen sign on their door. On 11/20/24 at 12:50 PM, V13/Assistant Director of Nursing stated, The oxygen tubing should be labeled when it is changed. The tubing should be changed weekly and there should be a sign on the resident's door warning of oxygen use. 38396 3. R34's Physician Order Sheet, dated 11/2024, documents an order for Albuterol 0.083% nebulizer solution to give three milliliters per nebulizer every four hours as needed for wheezing. On 11/18/24 at 11:40 AM, R34 was in his room sitting on the edge of his bed. At this time ,V12 (Licensed Practical Nurse) administered R34's Albuterol nebulizer breathing treatment, and placed the nebulizer face mask over R34's face. This mask documented a date of 10/4/24. V12 verified the date and stated the date on the mask would be when the tubing and mask was changed. On 11/21/24 at 10:15 AM, V2 (Director of Nursing) stated resident's Oxygen and Nebulizer equipment, such as tubing, face masks and cannulas, should be changed weekly and dated to reflect the change. V2 verified the 10/4/24 date on R34's mask was over a month ago and stated, They (staff) should be changing those weekly.

Based on observation, interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) of Olanzapine (Antipsychotic medication) for one of three residents (R34) reviewed for antipsychotic medications in the sample of 37. Findings include: The facility's Psychotropic Medication Policy, dated 11/28/17, documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: For excessive duration. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. Reductions shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the regulatory guidelines for such. The facility's Reduction of Psychotropic Medications Protocol policy, dated 8/22/18, documents, Residents who must receive psychotropic medications are to be maintained at the safest, lowest dosage necessary to control the resident's condition. Theses medications (psychotropic) shall be used when deemed necessary by each resident attending physician and/or psychiatric consultant. Each resident will be maintained on as low dosage of these medications as possible. Dosage reductions may be attempted whenever the resident's behavior patterns indicate to the attending physician that a dosage reduction may be appropriate. R34's Physician Order Sheet, dated 11/2024, documents R34 is to receive Olanzapine five milligrams every morning and Olanzapine five milligrams every other bedtime alternating with Olanzapine ten milligrams every other bedtime. On 11/18/24 at 11:40 AM, R34 was sitting in his room on the edge of his bed, completing a respiratory breathing treatment. R34 was cooperative with facility staff and was not displaying any behaviors. On 11/19/24 at 10:15 AM, R34 was in his room siting in bed. R34 denied having any complaints, stated he attends activities when he chooses, and was pleasant with conversation. R34 was not displaying any behaviors. R34's Behavior Tracking Sheets, dated 1/1/24-10/31/24, documents R34 is being monitored for paranoid thoughts/behaviors for the use of Olanzapine. These behavior tracking sheets over nine consecutive months document R34 has had zero episodes of paranoid thoughts/behaviors in nine months. R34's (Behavioral Health service) Psychiatric Note, dated 10/25/24, documents R34 is currently [AGE] years old and was diagnosed with Bipolar Disorder in 1980. This note also documents R34's behaviors upon examination are as follows: Appearance is consistent with chronological age. Calm, cooperative, pleasant. Clear speech, adequate attention and good judgment. This Psychiatric note documents a GDR of R34's medications is Clinically contraindicated at this juncture. On 11/21/24 at 10:10 AM, V13 (Assistant Director of Nursing) confirmed R34 has not had a GDR of his Olanzapine in the past year. V13 stated, We just started with a new psychiatric service in September, 2024. I am not sure why they didn't reduce it in October. (R34) has not had an Olanzapine reduction in the last twelve months.

Based on observation, interview, and record review, the facility failed to change gloves and perform hand hygiene while providing incontinent care and implement Enhanced Barrier Precautions (EBP) for a resident with an open wound, for two of 18 residents (R5, R56) reviewed for infection control in the sample of 37. Findings include: The Incontinence Care Policy, dated 7/1/23, documents, To provide guidelines to all nursing staff for providing proper incontinence care in order to clean skin clean, dry, free of irritation and odor. All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. The Enhanced Barrier Precautions, dated 7/13/23, documents, Purpose: To reduce transmission of multi-drug-resistant organisms/MDRO (Multi-Drug Resistant Organisms). Enhanced Barrier Precautions should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change, Indwelling Medical Devices, Infection or colonized with a MDRO. Enhance Barrier Precautions require use of a gown and gloves during high contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a residence room when high contact resident care activities are bundled together. Outside of a resident's room, EBP should be followed when performing transfers in the shower/assisting with shower and when assisting a resident with toileting and common restrooms. High-contact care activities include Dressing, Bathing/Showering, Transfers (when bundled with other high- contact resident care activities), Hygiene, Changing linens, Changing briefs or Toileting, Caring for medical devices (central lines, urinary catheters, feeding tubes, tracheotomies, drainage tubes, end ports), Wound care (pressure ulcers, diabetic ulcers, unhealed surgical wounds, chronic venous stasis wounds), and Skilled Therapies. Procedure 1. Educate staff on EBP. 2. Identify residents with an infection or colonized with a MDRO, residents with medical devices or chronic wounds that do not require contact precautions. 3. Review Contact precautions to ensure that Enhanced Barrier Precautions are appropriate. Post approved EBP signage that indicates high-contact activities. 4. Ensure that disposable or washable isolation gowns and gloves are available to HCP (Health Care Providers), where high- contact resident care activities may be required. 5. Keep a container or hamper inside resident's room for HCP to dispose of PPE (Personal Protective Equipment). 1. R5's Admission Record documents R5 was admitted on [DATE], with diagnoses which included Morbid (Severe) Obesity, Paroxysmal Atrial Fibrillation, Type 2 Diabetes Mellitus, Fibromyalgia, and Heart Failure. R5's Minimum Data Set/MDS Assessment, dated 10/11/24, documents R5 has a BIMs/Brief Interview of Mental Status of 15 (cognition intact). R5 is dependent on staff for toileting and occasionally incontinent of bowel and bladder. R5's current Care Plan documents Continence - Alteration in Bladder Elimination as related to incontinence. Give proper hygiene for incontinence. On 11/18/24 at 1:09 PM, V17/Certified Nursing Assistant/CNA and V18/CNA provided incontinent care for R5. R5 was incontinent of bowel and bladder. V17 removed the soiled disposable brief, then cleaned R5's vaginal area and buttocks. R5 had runny liquid stool. V17 then applied the clean disposable brief. V17 did not change her gloves or do any hand hygiene during the incontinent care. On 11/20/24 at 12:46 PM, V13/Assistant Director of Nursing stated during incontinent care, staff should be washing/sanitizing their hands and changing their gloves when going from the dirty disposable brief to the clean disposable brief. 2. R56's Admission Record documents R56 was admitted on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Fluid Overload, Morbid (Severe) Obesity, Hyperlipidemia, and Essential (Primary) Hypertension. R56's Minimum Data Set/MDS Assessment, dated 9/18/24, documents R56 has a BIMs/Brief Interview of Mental Status of 15 (cognition intact). R56's Physician Orders for November 2024 documents Right Abdominal Area - Cleanse, pat dry and apply Hydrogel with Collagen and cover daily (dated 11/15/24). Left Lateral Outer Ankle - Cleanse, pat dry, apply collagen matrix dressing and cover with dry dressing on Tuesday, Thursday, and Saturday. Right Lateral Outer Ankle - Cleanse, pat dry, apply collagen matrix dressing, and cover with dry dressing on Tuesday, Thursday, and Saturday. R56's Wound Assessment and Plan written by V15/Wound Physician, dated 11/19/24, documents R56 has an abdominal wound which started on 11/13/24. Description of Wound- Full Thickness: with Fat Layer Exposed. Measuring 0.5 cm/centimeters by 0.8 cm by 0.1 cm. Left Ankle Lateral Malleolus which started on 8/13/24. Description of Wound Full Thickness: with Fat Layer Exposed. Measuring 0.7 cm by 0.7 cm by 0.1 cm. Right Ankle Lateral Malleolus which started on 8/13/24. Description of Wound 0.7 cm by 1 cm X 0.1 cm. On 11/19/24 at 12:51 AM, R56 was sitting on her bed waiting for V3/Wound Nurse and V15/Wound Physician to check her wounds. R56 stated she has a wound on her abdomen and a wound on the outside of each ankle. R56 also stated none of the staff wear gowns when providing care, or when doing a dressing change. There was not any Personal Protective Equipment outside of R56's door, and no sign on R56's room that R56 was in Enhanced Barrier Precautions. On 11/19/24 at 12:51 PM, V15/Wound Physician went into R56's room to assess R56's wounds. V15 did not wear a gown while assessing R56's wounds. V15 removed the dressing from R56's abdomen that had a small amount of drainage on the dressing. V15 measured the wound. V15 then removed the stocking from R56's left ankle. The wound did not have a dressing on it. V15 measured the wound to the left ankle. V15 then removed the dressing from R56's right ankle and measured it. On 11/19/24 at 12:56 PM, V3/Infection Preventionist/Wound Nurse came in to put dressings on R56's wounds. V3 was wearing gloves but no gown. V3 applied dressings to all three wounds. On 11/20/24 at 12:54 PM, V13/Assistant Director of Nursing verified R56 was not in Enhanced Barrier Precautions. V13 stated that R56's wounds were not pressure ulcers. V13 also stated she did not know all wounds required a resident to be in EBP. On 11/20/24 at 2:56 PM, V3/Wound Nurse stated V2/Director of Nursing explained to V3 that R56 should have been in EBP due to her wounds.

Based on record review and interview, the facility failed to formulate Advanced Directives on admission and document current Advanced Directives within the care plan and within the physician's order sheets for five of six residents (R1, R3, R5, R9, and R10) reviewed for advanced directives in the sample of 13. These failures resulted in facility staff failing to provide CPR (Cardiopulmonary Resuscitation) to a resident (R1) with no Advanced Directive, who was found unresponsive in his room. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Advance Directives Policy, dated [DATE], documents, Purpose: To provide guidance to staff on the expectation of respecting wishes with regards to Advance Directives and compliance with state and federal regulations. Responsibility: It is the responsibility of the Social Service Department/Administrator to know the regulations/policies and ensure all appropriate staff are aware. Procedure: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3 If the residents are incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicated that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Advance Directive-a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provision of healthcare when the individual is incapacitated. Life-Sustaining Treatment-treatment that, based on reasonable medical judgment, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but on those that are considered palliative or comfort measures. 20. The Director of Nursing or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The facility's CPR (Cardiopulomary Resuscitation) policy, dated [DATE] documents, Policy: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support including defibrillation, for victims of sudden cardiac arrest. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Emergency Procedure: If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. Instruct a staff member to activate the emergency response system and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic lift support sequence of events. Continue with CPR until emergency medical personnel arrive. 1. R1's Nurse's Notes, dated [DATE] at 4:40 PM, and signed by V23 (LPN/Licensed Practical Nurse) document R1 was admitted to the facility on a stretcher via emergency medical transfer on three liter of oxygen being delivered by nasal cannula. R1's Cumulative Diagnosis Log documents R1's diagnoses are Weakness, Hypertension, Atrial Fibrillation, Cerebrovascular Disease, Diabetes Mellitus Type II, Congestive Heart Failure, Acute Kidney Injury, Atrial Flutter, and Chronic Pain. R1's IDPH (Illinois Department of Public Health) Practitioner Order for Life-Sustaining Treatment (POLST) Form located within R1's medical record is incomplete and does not indicate R1's Advanced Directives. R1's Medical Record does not include a baseline plan of care or physician's order that indicates R1's Advanced Directives. R1's Nurse's Notes, dated [DATE] at 12:30 AM, and signed by V30 (Agency Registered Nurse/RN) documents R1's oxygen was not on and had to be re-applied. R1's Nurse's Notes, dated [DATE] at 3:15 AM, and signed by V30 documents R1 was found in his room with no heartbeat and was cold to touch. This same note documents a second nurse confirmed R1 was deceased . R1's Medical Record does not include any documentation of 911 being called or CPR being initiated once R1 was found with no heartbeat. On [DATE] at 9:00 AM, V16 (R1's Family Member) stated, (R1) always told us he wanted to be brought back (resuscitated) at least three times. It was a shock that (R1) passed away so quickly. (R1) was alert enough to tell the staff if he wanted CPR or not. On [DATE] at 9:20 AM, V24 (Registered Nurse/RN) stated, On [DATE] around 3:00 AM, (V21/Nursing Assistant) got me and said (R1) had passed away and (V30) needed me to verify with (V30) that (R1) had no pulse or respirations. I confirmed with (V30) that (R1) was deceased . No one had performed CPR. (V30) stated (R1) did not have Advanced Directives in his chart and (V30) did not know if (R1) was a full code or DNR. 911 was not called either. On [DATE] at 10:00 AM, V29, Care Plan Coordinator, stated, (R1's) care plan and medical record did not have Advanced Directives. Since there were no Advanced Directives, (V30) should have performed CPR and called 911 when (R1) was found without a pulse or respirations. The admitting nurse (V22, Licensed Practical Nurse/LPN) admitted (R1) and was responsible for formulating (R1's) Advanced Directives and care planning (R1's) Advanced Directives. (V22) did not get (R1's) Advanced Directives completed or care planned. On [DATE], V6 (Assistant Director of Nursing/ADON) stated, (V30) should have done CPR when she found (R1) had died . On [DATE] at 10:20 AM, V23 (LPN) stated, When (R1) was admitted on [DATE], the hospital nurse gave me report and told me (R1) was a full code. I did not know it was my responsibility as a floor nurse to do (R1's) Advanced Directives or care plan. I did not complete (R1's) advanced directives or care plan. (V30) should have done CPR when she found (R1) deceased since there were no Advanced Directives in the chart. If there is not an order for a resident to be a DNR, the nurse should always perform CPR no matter what. (R1) was alert and orientated enough to make his own decisions. On [DATE] at 4:55 PM, V21 (CNA/Certified Nursing Assistant) stated, On [DATE], (R2) came out of (R1's) room around 3:00 AM, and said the room and (R1) was really cold. I had saw (sic) (R1) around 12:30 AM and he had taken his oxygen off. When I went into (R1's) room he had no pulse or respirations. I immediately got (V30) and (V30) had confirmed that (R1) had passed away. No one performed CPR or called 911. I do not have access to (R1's) chart, so I did not know if (R1) was a full code or DNR. I figured that was up to the nurse to decide. On [DATE] at 11:20 AM, V30 (Agency RN) stated, (R2) had gotten (sic) (V20) and said her and (R1's) room was freezing because of the air being on high and (R1) was cold. (V20, Certified Nursing Assistant/CNA) came and got me around 3:00 AM ([DATE]) and said (R1) was cold and she thought (R1) had died . I went into (R1's) room and he had no pulse or respirations and was cold to touch. (R1) had been taking his oxygen off that night. I had put (R1's) oxygen back on around 12:30 AM. Every time (R1) took his oxygen off, his pulse ox (oximetry) would go down to 70 to 80 percent. I did not see (R1) again after 12:30 AM until (V20) found (R1) deceased . I looked in the chart and (R1) did not have Advanced Directives or a care plan to show whether or not (R1) was a DNR or full code. I did not do CPR as (R1) was gone and did not have Advanced Directives. I have no idea how long (R1) had been gone. I did not call 911. I had another nurse (V24) come down and verify with me that (R1) had passed away. I called the family and (R1) was transported to the funeral home later on. When I found (R1) he was cold, but I did not notice rigor mortis setting in yet. I could still move (R1's) extremities and (R1's) mouth was shut. (R1) was not stiff and I did not notice any blood pooling. It was very frustrating and a hot mess at the facility. When (V24) came down, (V24) told me that she though (R1) was ready to go (die) and that is why I did not do CPR. If I knew (R1) was a full code I would have performed CPR. 2. R3's Admission Record documents R3 was admitted on [DATE]. R3's POLST Form, dated [DATE], documents, Do Not Attempt Resuscitation/DNR) if (R3) has no pulse. R3's Physician's Order Sheets and Baseline Care plan, dated [DATE] through [DATE], do not include R3's Advanced Directives choice of DNR. 3. R5's POLST Form, dated ,d+[DATE] -24, documents, Do Not Attempt Resuscitation/DNR) if (R5) has no pulse. R5's Physician's Order Sheets, dated [DATE] through [DATE], document, Code Status: Full Code. R5's Care Plan, dated [DATE] through [DATE] (date of R5's death), documents, Resident has chosen Advanced Directives. Resident chooses to be a full code in the event of cardiac arrest. 4. R9's Admission Record documents R9 was admitted on [DATE]. R9's POLST Form, dated [DATE], documents, Full Code. Attempt CPR if no pulse. R9's current Care Plan does include R9's Advanced Directives of R9's wishes to be a full code. 5. R10's Admission Record documents R10 was admitted on [DATE]. R10's IDPH POLST Form located within R10's medical record is incomplete and does not indicate R10's Advanced Directives. R10's Baseline Care plan, dated [DATE] through [DATE], does not include R10's Advanced Directives. On [DATE] at 1:00 PM, V13 (Social Service Director/SSD) stated, I have never had anything to do with the resident's Advanced Directives. I have never been responsible for making sure the residents have Advanced Directives. On [DATE] at 2:00 PM, V1 (Administrator) confirmed R3's care plan and physician's order sheets do not document R3's Advanced Directives, R9's care plan does not include R9's Advanced Directives, and R10 has not had Advanced Directives formulated or documented in R10's medical record. On [DATE] at 11:42 AM, V6 (Assistant Director of Nursing/ADON) verified R5's Care Plan was not updated with R5's DNR Advanced Directives. The Immediate Jeopardy started on [DATE] at 3:15 AM when V30 failed to provide CPR to R1, who had no formulated advance directive, when R1 was found unresponsive in his room. V1 (Administrator) and V6 (ADON) were notified of the Immediate Jeopardy on [DATE] at 1:55 PM. On [DATE], the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE], V6/ADON, V13/SSD, and V29/MDS Coordinator checked all of the resident's Advanced Directives, care plans, and physician order sheets to ensure the documents coincided, including R1, R3, R5, R9, and R10. 2. V1 and V6 in-serviced all clinical staff, including agency staff, on the facility's Advanced Directives Policy on [DATE] and continue to educate all staff prior to the start of their next shift. 3. V1 and V6 in serviced all clinical staff, including agency staff, on the facility's CPR Policy on [DATE] and continue to educate all staff prior to the start of their next shift. CPR Policy Education - Clinical Staff 4. V2 (Director of Nursing) and V13 audited all new resident admissions to ensure all residents were offered Advanced Directives upon admission, and all Advanced Directives were correct within all new residents' medical records. 5. On [DATE], the facility's Medical Director was notified of the non-compliance and a Quality Assurance meeting was held to ensure auditing of all residents 'medical records for advance directives were complete.

Based on record review, observation, and interview, the facility failed to perform pressure ulcer risk assessments as directed by the facility's policy, failed to perform daily skin checks, failed to develop and implement pressure relieving interventions, failed to develop a pressure ulcer care plan, failed to assess a pressure ulcer weekly, and failed to perform pressure ulcer treatments as directed by the physician for one of two residents (R7) reviewed for pressure ulcer development in the sample of 13. These failures resulted in R7's right and left heel pressure ulcers deteriorating from stage one pressure ulcers to an unstageable pressure ulcer to the right heel and a stage three pressure ulcer to the left heel. Findings include: The facility's Preventative Skin Care policy, dated 01/2018, documents, It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. Procedures: 1. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly times four then will be reassessed at least quarterly and/or as needed. 5. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two hours. 6. Special mattresses and/or cushions will be used on any resident identified as being at high risk for potential skin breakdown. 7. Pillows and/or bath blankets may be used between two skin surfaces or to slightly elevate bony prominences/pressure areas off the mattress. Pressure relieving devices may be used to protected heels and elbows. The Pressure Sore Prevention Guidelines policy, dated 01/2018, documents, Policy: It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. Responsibility: all nursing staff and the dietary manager. Interventions/Comments for High-Risk residents. Special Mattress/Specify type of mattress on the Care Plan. Daily Skin Checks/follow protocol for coding skin conditions. Interventions/Comments for High or Moderate Risk residents: Turn and reposition every two hours. Turning and positioning may be more often than every two hours for high risk, if indicated. Care Plan Entry/Skin risk and appropriate interventions are to be placed on the Care Plan. If despite interventions a pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of Pressure Ulcers. Interventions/Comments as needed for High or Moderate Risk residents. Positioning Devices/Devices while in chair or in bed as needed to maintain turning. Specify on Care Plan. Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse. The facility's Skin Condition Monitoring Policy, dated 01/2018, documents, Policy: It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. Procedure: 1. Upon notification of a skin lesion, wound, or other skin abnormality, the nurse will assess and document the finding in the nurses' notes and complete a QA (Quality Assurance) for newly acquired skin condition. 2. The nurse will then implement the following procedure: Type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed, and stop date, if needed. 4. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: Characteristic, size, shape, depth, odor, color, and presence of granulation tissue or necrotic tissue. Treatment and response to treatment. Prevention techniques that are in use for the resident. The facility's Decubitus Care/Pressure Areas policy, dated 01/2018, documents, Policy: It is the policy of the facility to ensure a proper treatment program has been instituted and is closely monitored to promote the healing of any pressure ulcer. Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation Form. The assessment must include characteristics and treatment and response to treatment. The facility's Turning and Repositioning Program policy, dated 01/2018, documents, Purpose: To ensure residents at risk for pressure ulcers are turned and positioned per the plan of care in an organized system. Procedure:Turning schedule will occur as indicated by the resident's plan of care. R7's Braden Scales for Predicting Pressure Ulcer Risk, dated 3-14-24 and 3-27-24, document R7 was at high risk of developing pressure ulcers. These same Braden Scales for Predicting Pressure Ulcer Risks document R7 did not have a pressure relieving cushion to his chair, was not on a turning and repositioning program, was not having his heels floated, did not have elbow or heel protectors, and was not using positioning devices such as pillows, cushions, etc. R7's Medical Record does not include any further Braden Scales for Predicting Pressure Ulcer Risk Assessments since 3-27-24. R7's MDS (Minimum Data Set) Assessments, dated 3-27-24 and 5-9-24, document R7 had no pressure ulcers and was at risk for developing pressure ulcers. R7's Treatment Administration Records (TARs) and Physician's Order Sheets (POSs) dated 3-16-24 through 7-31-24 document, Daily skin check. Weekly skin documentation on back of TAR. R7's TARs, dated 3-16-24 through 7-31-24, document R7 did not receive daily skin checks on 24 days during this timeframe. R7's TARs, dated 3-16-24 through 7-31-24, do not include documentation of weekly skin checks being completed weekly except for one time on 4-10-24. R7's Recertification Hospice Plan of Care, dated 7-19-24, documents, Noted significant skin breakdown. Skin breakdown is significant and progressing rapidly. Communication with floor nurse was made related to assistance by facility staff in keeping (R7) clean, hydrated, and repositioned. May increase visits if (R7) continues to have skin breakdown. R7's Hospice Care Coordination Progress Note, dated 6-14-24, documents, Heels starting to look a little reddish. R7's Abnormal Skin Report, dated 6-24-24, documents R7's bilateral heels were red. R7's Physician's Orders and Treatment Administration Records, dated 6-24-24 through 7-31-24, document, Skin Prep (Preparation) to bilateral heels every shift. R7's TARs, dated 6-24-24 through 7-31-24, documents R7's physician ordered skin prep treatment every shift to both heels was not completed 82 times within this time frame. R7's Physician Order, dated 6-18-24, documents, (R7) to be turned and re-positioned every two hours due to skin breakdown. Please document and initial. R7's Medical Record, dated 6-18-24 through 8-1-24, does not include documentation of R7 being turned and reposition every two hours as ordered by R7's physician. R7's TARs, dated 7-16-24 through 7-31-24, document, Apply mepilex to left heel change every three days. R7's TARs, dated 7-16-24 through 7-31-24, document R7's mepilex treatment to the left heel was not completed two times during this timeframe. R7's Hospice Care Coordination Progress Note, dated 8-1-24, documents, Right foot heel (pressure wound) continues to decline. Current measurement six cm (centimeters) round and completely covered in eschar (dead tissue/If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/injury). New orders per doctor for right foot (heel) to change dressing daily and to cleanse area, pat dry and apply Santyl (debriding cream) and cover with a four-by-four gauze and wrap with rolled gauze and continue to wear protective boots. Left foot (heel) three cm round and wound bed is pink and beefy (stage three pressure ulcer/full thickness skin loss). Change dressing daily. The facility's Wound Tracking Reports (used to assess the characteristics and size of wounds weekly), dated 7-1-24 through 7-31-24, do not include R1's wound characteristics or size to the bilateral heels. R7's Medical Record does not include an assessment of R7's wound characteristics or measurements to R7's bilateral heel pressure ulcers since first identified on 6-14-24, except for one assessment of R7's bilateral heel wounds performed by hospice services on 8-1-24. R7's current Care Plan does not address R7's pressure ulcers to the left or right heels since development on 6-14-24 and does not include pressure relieving interventions. On 7-27-24 at 10:00 AM, R7 was lying in bed with bilateral heels laying directly on the bed. R7 did not have on heel protecting boots. R7's right heel and left heel did not have dressings, leaving R7's right and left heel pressure ulcers exposed. R7's right heel was golf-ball sized and was covered in eschar. R7's left heel was quarter-sized and beefy red. V22 (Agency LPN/Licensed Practical Nurse) verified R7 did not have a treatment to either heel, did not have on pressure relieving boots, and did not have his heels off-loaded. V22 stated, I am new here and am not sure what (R7's) treatments are. On 7-30-24 at 11:45 AM, V3 (R7's Family Member) stated, I got a call from hospice that (R7's) heels are bleeding and are getting really bad. (V5/Hospice Nurse) would go into assess (R7) and said the staff never had (R7's) heels elevated or heel boots on and a lot of times (R7's) heels were not getting treated. (R7) cannot turn and re-position himself and is always laying on his back. There is no reason (R7's) heels should not be getting treated. On 7-30-24 at 12:30 PM, V5 (Hospice Nurse) stated, I took care of (R7) quite a bit. The only time (R7) would get turned and repositioned was when hospice staff would do it. I would find (R7's) heels bleeding and laying directly on the bed without a treatment. On 8-2-24 at 2:30 PM, V6 (Assistant Director of Nursing) stated she was unaware of R7 having pressure ulcers to his bilateral heels. V6 verified R7 did not have Braden Scale Pressure Ulcer Assessments completed weekly times four weeks after admission or quarterly, does not have any wound measurements or assessments of R7's bilateral heel wounds within R7's medical record, and has not had treatments to the bilateral heels completed as ordered according to R7's TARs. On 8-2-24 at 3:00 PM, V29 (Care Plan Coordinator) stated, I was unaware that (R7) had pressure ulcers. (V11/Wound Nurse) never told me about (R7) having pressure ulcers so I never developed a pressure ulcer care plan. I get (V11's) wound report every week and not once was (R7's) heel wounds on the report. There are no weekly heel wound assessments or measurements in (R7's) chart. On 8-5-24 at 8:40 AM, V31 (Hospice Chief Executive Officer) stated, We (hospice) have weekly meetings about (R7's) cares. I know (R7's) wounds to the heels were caused from pressure or friction. (V5) did have concerns at times. (V5) would find (R7) without his heels off-loaded.

Based on observation, interview, and record review, the facility failed to adequately supervise a resident (R1); and failed to prevent resident-to-resident sexual and physical abuse for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for abuse in the sample of 50. These failures resulted in R1, a resident with a history of sexual aggression, sexually assaulting (R2, R5, and R11) on multiple occasions, R1 sexually groping a resident (R10), and R1 physically assaulting a resident (R6). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, dated [DATE], documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, and exploitation as defined below. This will be done by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of resident, and dementia management and resident abuse prevention. This facility is committed to protecting our residents from abuse by anyone including, but no limited to, facility staff, other residents, consultants, volunteers, and other agencies providing services to the individuals. Sexual Abuse is non-consensual sexual contact of any type with a resident. Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs. Possible sexual abuse: Determine if the allegation involves either physical sexual contact involving penetration, verbal harassment, or physical contact that did not involve penetration. V1's (Administrator's) Employee Business File documents V1's hire date was [DATE]. R1's Physician's Order Sheet (POS), dated [DATE] through [DATE], documents R1 has the diagnoses of Sexual Aggression, Dementia with behavioral disturbances, Anxiety, and Major Depression Disorder. These same POS's document R1 receives Depakote 125 mg (milligrams) three times daily for the diagnosis of Dementia with behavioral disturbance and Finasteride five mg one tablet daily for the diagnoses of Sexual Aggression and Benign Prostatic Hyperplasia. R1's Minimum Data Set (MDS) Assessment, dated [DATE], documents R1 is severely cognitively impaired. R1's Care Plan, dated [DATE], documents, (R1) has a history of sexual inappropriateness towards female peers. Resident, facility, and next of kin agree that (R1) is unable to consent to sexual relations at this time related to impaired cognition. Start: [DATE] (R1) to be one-on-one with staff at all times through duration of long-term care stay. Start: [DATE] (R1) placed in private room. (R1) has behaviors that other may find disruptive/socially inappropriate. (R1) likes to walk around the skilled nursing facility. (R1) will sometimes go into resident's rooms. Start: [DATE] 15 minute close and constant supervision to monitor whereabouts and proximity to those easily upset by behaviors as needed. Start: [DATE] Move (R1) to secure unit. R1's Behavior Tracking Records, dated [DATE] through [DATE], do not include tracking or behavioral interventions to address R1's sexual inappropriateness with peers. R2's MDS (Minimum Data Set) Assessment, dated [DATE], documents R2 is severely cognitively impaired. R2's Quality Committee Behavior Referral and Quality Care Reporting Form, dated [DATE], documents, Date of occurrence: [DATE]. Behavior: Another resident (R1) was masturbating (R2) in hallway. R2's IDT Progress Notes, dated [DATE] at 9:00 AM, document, (R2) touched inappropriately by peer (R1). R5's MDS Assessment, dated [DATE], documents R5 is severely cognitively impaired. R6's MDS Assessment, dated [DATE], documents R6 is cognitively intact. R10's MDS Assessment, dated [DATE], documents R10 is cognitively intact. R11's MDS Assessment, dated [DATE], documents R11 was cognitively impaired. R11's Progress Notes document R11 passed away on [DATE]. R1 and R2's IDPH (Illinois Department of Public Health) Facility Reported Incident Report, dated [DATE] at 12:37 PM, documents, Incident Category: Resident Abuse. Incident Description, On [DATE]th (2024) at approximately 5:30 PM, a nurse aide (V3) was alerted to check on (R2) because she heard grunting sounds coming from his room. Upon entering the room, (V3/Certified Nursing Assistant/CNA) saw (R1's) hand down the front of (R2's) brief. (V3) promptly separated both parties and called for the nurse (V4/Licensed Practical Nurse/LPN). R1's Staff Interviews, dated [DATE] regarding R1 and R2's Incident on [DATE], document V3 heard grunting sounds coming from R2's room, and upon entering saw R1's hands down the front of R2's brief. R1's Social Service Progress Notes, dated [DATE] at 9:00 AM and signed by V13 (Social Service Director), document V13 did a follow-up visit with R1, and explained to R1 that we (residents) have to keep our hands to ourselves. R1's Inter-Disciplinary (IDT) Note, dated [DATE] at 9:00 AM, documents, Quality Assurance team review of occurrence [DATE] (R1) inappropriately touching peer resident (R2). On [DATE] at 8:35 AM, R2 was sitting in a wheelchair watching television. R2 was confused to time and place and was unable to answer questions regarding the allegation of sexual abuse between him and R1 that occurred on [DATE]. On [DATE] at 9:10 AM, R7 was sitting in his room in a wheelchair. R7 stated, (R6) told me (R1) tried to rape him. On [DATE] at 9:15 AM, R6 stated, About one to two weeks ago, (R1) came knocking on my bedroom door and came into my room. (R1) told me it was one of his relatives' birthdays and he wanted to celebrate with me. (R1) said to me 'You have really nice feet.' (R1) tried to grab my feet. I could tell by the look in (R1's) eyes that he wanted to do something sexual with me. (R1) tried to force himself on top of me and I felt like (R1) was trying to rape me. I started kicking (R1) and yelling for help. I yelled at (R1) to 'Get out!' (R1) closed the curtain and I do not know where he went. I jumped out of bed and took off running to the nurses' desk. I told (V14/Agency CNA) what happened, and he just laughed. I have been raped before when I was younger, and do not want to be around (R1). (R1) was living on my hallway until this week. I still have to see him in the dining room. I try to ignore him. My right knee has hurt ever since I kicked (R1). On [DATE] at 9:20 AM through 9:40 AM, R1 was sitting in his room without staff supervision. During this time, R1 stated, I have given sexual pleasure to three guys (R2, R5 and R11). I got caught j***ing (R2) off and they sent me to this room. (R2) enjoys it and I do it whenever I get the urge. I have given (R2) sexual pleasure twice. I j****d (R11) off at least four to five times. (R11) has died now. I have j****d (R5) off twice. I do it in (R5's) room. I tried to give (R6) pleasure, but he wouldn't let me. They (R2, R5, and R11) could not do anything with my penis. They have tried but my penis is too small. I was told I broke a rule, and I cannot do it again. I have to try to keep myself busy with the radio and writing letters to keep my mind off of it. On [DATE] at 10:15 AM, R5 was sitting in a padded wheelchair in the dining room. R5 was confused to time and place and was unable to answer questions regarding any alleged sexual abuse that occurred between him and R1. On [DATE] at 10:20 AM, V4 (Licensed Practical Nurse/LPN) stated, I was working on [DATE]. Around 5:45 PM that night, (V3) was yelling for me. (V3) was standing in front of (R2) in the hallway right outside of (R1's) room. (R2) was sitting in his wheelchair. (R1) was standing to the right side of (R2). (V3) told me she caught (R1) masturbating (R2). (R1) has never had one-on-one supervision of staff since I have been here. (R2) is confused and yells out. On [DATE] at 10:25 AM, V3 (CNA) stated, I have worked second shift at the facility for six years. On [DATE] after supper around 5:45 PM, I was coming up the hallway facing (R2). (R2) was in his wheelchair in the hallway outside of (R1's) room, and (R1) was bending over top of (R2). (R1) had his hand down the front of (R2's) pants and was stroking (R2's) penis up and down. I could see exactly what (R1) was doing to (R2). (R2) was sexually groaning. I screamed at (R1) No! Stop! (R1) is alert enough to know what he is doing, and acts like he does not hear you when he is doing wrong. (R2) is confused. I took (R1) and (R2) to their rooms. Eight months or so ago, I walked into (R1's) room and caught (R1) sitting on his roommate's (R11's) bed with his hand on (R11's) penis. I saw (R1's) hand on (R11's) penis, and (R11's) brief was off. (R11) did not say anything and cannot move out of bed without the staffs help. (R11) was very confused. I reported this incident to (V1/Administrator). One night about a week ago, (R6) came up to a few of us at the nurse's station and said (R1) tried to attack him. (R6) told me he had been sexually assaulted before and did not know whether to cry or scream. I told the nurse (R6) felt like he was going to be sexually assaulted by (R1). I do not remember what nurse I told. Another day around a couple months ago, I found (R1) sitting beside (R5) in (R5's) bed. I reported this to the Social Service Director (V13). I feel sorry for (R5) if (R1) was masturbating (R5), as (R5) would not like it and was molested as a child. A week or two ago, (R10) was crying and I asked her why. (R5) said (R1) was rubbing her shoulders and kept rubbing lower and lower until (R1) started to rub her boobs. (R5) said she reported this to (V1). I know (V15/CNA) was aware of this incident also. (R1) has not had one-on-one staff supervision for over a year. On [DATE] at 1:35 PM, R10 was lying in her bed. R10 stated, Last week, I was in the dining room downstairs sometime between lunch and supper. I was waiting on activities to start and was reading a book. (R1) came up behind me and started to rub my shoulders. I told (R1) to get off of me. (R1) started to rub harder and then started to rub my boobs on the outside of my shirt. I did not want him to do that. I feel like that is sexual abuse. I started yelling and staff came. The staff came and told me to report this to (V1). I reported this to (V1) immediately and (V1) said he would keep a close eye on (R1). On [DATE] at 2:00 PM, V13 (Social Service Director) stated, I have worked here for a year and four months. I know around a year and a half ago, the hallways were split up with men on one due to (R1) having a sexual encounter with a female resident. On Monday ([DATE]), (V2) told me about what had happened between (R1) and (R2) on Friday ([DATE]). I went down on Monday and spoke to (R1). (R1) would not say much and ignored me. I told him it was inappropriate to touch another resident inappropriately and he needs to keep his hands to himself. (R1) replied, Ok. God bless. I then went to talk to (R2) about the incident, and he just asked me if he was in trouble. (R2) did not talk about the incident. I make (R1's) behavior tracking logs and put them out on the halls for the CNAs to track (R1's) behavior and to document what interventions were used and if they are effective. I have not implemented a behavior tracking with interventions to address (R1's) sexual inappropriateness with other residents. I do not know of any interventions implemented after to increase supervision of (R1) after the incident between him and (R2) on Friday ([DATE]). I am responsible for (R1's) behavioral care plan. According to (R1's) care plan, (R1) should have had one-on-one staff supervision at all times. I was not aware of that. On [DATE] at 10:15 AM, V1 (Administrator) stated, I did not know (R1) had a history of sexual aggression or was care planned to have one-on-one supervision. I worked there for the past two years (since [DATE]) and (R1) never had one-on-one supervision during that time. On [DATE] at 10:20 AM, V17 (R2's Family Member) stated, (R2) is very confused now. When (R2) was alert and in his right mind, (R2) would have been disgusted by another man touching him sexually. (R2) would not have wanted anyone to know about it. (R2) would have been so embarrassed and had never showed any interest in men. On [DATE] at 10:36 AM, V18 (R1's Family Member) stated, (R1) would always be sexually interested in women. I never knew of (R1) having sexual interests in men. (R1) would not have told me if he does. The facility called my a few days ago and said they were moving (R1) to another room due to (R1) inappropriately touching another resident. On [DATE] at 11:45 AM, V15 (CNA) stated, Last week I heard (R10) crying outside of (V1's) office and reporting something to (V1) about something (R1) had done to her. I did not hear the entire conversation. On [DATE] at 1:00 PM, V14 (Agency CNA) stated, Around a week ago or so, I do recall (R6) coming out of his room and telling me that (R1) said (R6) had pretty feet and tried to touch him sexually. I went down to (R6's) room and removed (R1) from the room. On [DATE] at 10:20 AM, V16 (R5's Representative) stated, (R5) never had interest in men and would have been embarrassed if a man did anything sexual with him. The Immediate Jeopardy started on [DATE] when (V1/Administrator) was hired by the facility and failed to ensure facility staff were providing one-on-one supervision to R1, as implemented by R1's care plan on [DATE], to prevent R1 from abusing other residents. V6 (Assistant Director of Nursing) was notified of the Immediate Jeopardy on [DATE] at 9:20 AM. On [DATE] and [DATE] the surveyor confirmed through observation, interview, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. V1 is no longer employed by the facility, and last day worked was [DATE]. 2. On [DATE], R1 was placed on one-on-one staff supervision at all times to prevent recurrence. 3. An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance. 4. R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents. 5. On [DATE], the IDT met to discuss discharge planning for R1 to a more appropriate setting. 6. All staff were in-serviced on the facility's Abuse Policy and providing adequate supervision of residents to prevent further abuse from [DATE] through [DATE] by V7 (Corporate Manager). 7. Department supervisors conducted an abuse assessment on all residents on [DATE] and [DATE] to screen all residents for potential abuse, concerns, or incidences. 8. V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the state agency on [DATE]. 9. V13 (Social Service Director completed assessments to address psychosocial needs of R1, R2, R5, R6, R10 and R11's on [DATE].

Based on record review and interview, the facility failed to implement their Abuse policies and procedures to identify and report resident-to-resident suspected crimes and abuse immediately to the local law enforcement, the Administrator, the residents' representatives, and the State Agency for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for reporting of abuse in the sample of 50. These failures resulted in these residents being subjected to further criminal sexual and physical assault from the perpetrator (R1). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, dated [DATE], documents, Sexual Abuse is the non-consensual sexual contact of any type with a resident. Sexual Abuse the non-consensual sexual contact of any type with a resident. Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents to a supervisor and the Administrator (V1). If an allegation of physical sexual contact is involved: Contact the police. Staff obligations are to immediately report abuse, neglect, exploitation, and theft to supervisory personnel and administrator. Employees are required to immediately report an occurrence of potential/alleged mistreatment, exploitation, neglect, and abuse of residents they observe, hear about, or suspect to a supervisor and the administrator. The administrator or designee is also responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH (Illinois Department of Public Health) immediately after forming the suspicion. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential abuse of resident and that an investigation is being conducted. The administrator, or designee will inform the resident or resident's representative of the conclusions of the investigation. V1's (Administrator's) Employee Business File documents V1's hire date was [DATE]. R1's Minimum Data Set (MDS) Assessment, dated [DATE], documents R1 is severely cognitively impaired. R1 and R2's IDPH (Illinois Department of Public Health) Facility Reported Incident Report, dated [DATE] at 12:37 PM, documents, Incident Category: Resident Abuse. Incident Description, On [DATE]th (2024) at approximately 5:30 PM, a nurse aide (V3) was alerted to check on (R2) because she heard grunting sounds coming from his room. Upon entering the room, (V3/Certified Nursing Assistant/CNA) saw (R1's) hand down the front of (R2's) brief. (V3) promptly separated both parties and called for the nurse (V4/Licensed Practical Nurse/LPN). On [DATE] at 8:20 AM, V2 (Director of Nursing/DON) stated, On Friday ([DATE]), I was at church and (V4/LPN/Licensed Practical Nurse) called and reported to me that (V3/CNA/Certified Nursing Assistant) found (R1) masturbating (R2). Since (V1) had quit working here on Wednesday ([DATE]), I called (V7/Corporate Manager) and reported this to her. (V7) had me send an initial abuse report to IDPH on Friday, and then I sent the final report on Monday ([DATE]). I did not call the police or (R1 and R2's) family yet. On [DATE] at 8:30 AM, V8 (CNA) stated, (V1) used to be the Abuse Coordinator, but I was told he no longer works here. I do not know who the Abuse Coordinator is now. On [DATE] at 9:15 AM, R6 stated, About one to two weeks ago, (R1) came knocking on my bedroom door and came into my room. (R1) told me it was one of his relatives' birthdays and he wanted to celebrate with me. (R1) said to me 'You have really nice feet.' (R1) tried to grab my feet. I could tell by the look in (R1's) eyes that he wanted to do something sexual with me. (R1) tried to force himself on top of me and I felt like (R1) was trying to rape me. I started kicking (R1) and yelling for help. I yelled at (R1) to 'Get out!' (R1) closed the curtain and I do not know where he went. I jumped out of bed and took off running to the nurses' desk. I told (V14/Agency CNA) what happened, and he just laughed. I have been raped before when I was younger and do not want to be around (R1). (R1) was living on my hallway until this week. I still have to see him in the dining room. I try to ignore him. My right knee has hurt ever since I kicked (R1). I also told (V1) about this. On [DATE] at 9:20 AM, R1 stated, I have given sexual pleasure to three guys (R2, R5 and R11). I got caught j***ing (R2) off and they sent me to this room. (R2) enjoys it, and I do it whenever I get the urge. I have given (R2) sexual pleasure twice. I j****d (R11) off at least four to five times. (R11) has died now. I have j****d (R5) off twice. I do it in (R5's) room. I tried to give (R6) pleasure, but he wouldn't let me. They (R2, R5, and R11) could not do anything with my penis. They have tried, but my penis is too small. I was told I broke a rule and I cannot do it again. I have to try to keep myself busy with the radio and writing letters to keep my mind off of it. On [DATE] at 10:20 AM, V4 (Licensed Practical Nurse/LPN) stated, I was working on [DATE]. Around 5:45 PM that night, (V3) was yelling for me. (V3) was standing in front of (R2) in the hallway right outside of (R1's) room. (R2) was sitting in his wheelchair. (R1) was standing to the right side of (R2). (V3) told me she caught (R1) masturbating (R2). I was not sure who to call and report this to since (V1/Administrator) was not available. I called (V2/Director of Nursing) to report the incident. I do not know who the Administrator is. I did not contact the police or (R1 and R2's) family. On [DATE] at 10:25 AM, V3 (CNA) stated, I have worked second shift at the facility for six years. On [DATE] after supper around 5:45 PM, I was coming up the hallway facing (R2). (R2) was in his wheelchair in the hallway outside of (R1's) room, and (R1) was bending over top of (R2). (R1) had his hand down the front of (R2's) pants and was stroking (R2's) penis up and down. I could see exactly what (R1) was doing to (R2). (R2) was sexually groaning. I screamed at (R1) 'No! Stop! (R1) is alert enough to know what he is doing, and acts like he does not hear you when he is doing wrong. (R2) is confused. Around eight months or so ago, I walked into (R1's) room and caught (R1) sitting on his roommate's (R11's) bed with his hand on (R11's) penis. I saw (R1's) hand on (R11's) penis and (R11's) brief was off. (R11) did not say anything and cannot move out of bed without the staffs help. (R11) was very confused. I reported this incident to (V1/Administrator). One night about a week ago, (R6) came up to a few of us at the nurse's station and said (R1) tried to attack him. (R6) told me he had been sexually assaulted before and did not know whether to cry or scream. I told the nurse (R6) felt like he was going to be sexually assaulted by (R1). I do not remember what nurse I told. I do not know who the Abuse Coordinator is. Another day around a couple months ago, I found (R1) sitting beside (R5) in (R5's) bed. I reported this to the Social Service Director (V13). I feel sorry for (R5) if (R1) was masturbating (R5), as (R5) would not like it and was molested as a child. A week or two ago, (R10) was crying and I asked her why. (R10) said (R1) was rubbing her shoulders and kept rubbing lower and lower until (R1) started to rub her boobs. (R10) said she reported this to (V1). I know (V15) was aware of this incident also. I did not report any of these occurrences to the police. I thought that was management's job. On [DATE] at 1:35 PM, R10 stated, Last week, I was in the dining room downstairs sometime between lunch and supper. I was waiting on activities to start and was reading a book. (R1) came up behind me and started to rub my shoulders. I told (R1) to get off of me. (R1) started to rub harder and then started to rub my boobs on the outside of my shirt. I did not want him to do that. I feel like that is sexual abuse. I started yelling and staff came. The staff came and told me to report this to (V1). I reported this to (V1) immediately and (V1) said he would keep a close eye on (R1). After that I have seen (R1) in the dining room and I do not want him around me. On [DATE] at 10:15 AM, V1 (Administrator) stated, I did not know (R1) had a history of sexual aggression or was care planned to have one-on-one supervision. I worked there for the past two years (hire date [DATE]) and (R1) never had one-on-one supervision during that time. I do not recall any sexual allegations made regarding (R1) with any residents, therefore, there are no abuse investigations regarding (R5, R6, R10 and R11), and the families and police have not been notified. On [DATE] at 10:20 AM, V17 (R2's Family Member) stated, I have not talked to the facility in two weeks. No one from the facility has contacted me about another resident masturbating my husband. On [DATE] at 11:50 AM, V7 (Corporate Manager) stated, I have managed this home since February 8, 2024, and have not been aware of any abuse allegations regarding (R1), except for the allegation made on [DATE] regarding R1 and R2. I have searched (V1's) office and there are no abuse investigations regarding (R1, R5, R6, R10 or R11). On [DATE] at 1:00 PM, V14 (CNA) stated, Around a week ago or so, I do recall (R6) coming out of his room and telling me that (R1) said (R6) had pretty feet and tried to touch him sexually. I went down to (R6's) room and removed (R1) from the room. I told the nurse. I do not recall who the nurse was. I did not report this to the Administrator. I do not know who the Abuse Coordinator is. On [DATE] at 2:15 PM, V19 (CNA) stated she does not know who the Abuse Coordinator is to report abuse to. On [DATE] at 10:20 AM, V16 (R5's Representative) stated, No one from the facility has tried to call me or has left me a message regarding anything for over a month. I was not aware of any abuse allegations regarding (R5). R1, R2, R5, R6, R10 and R11's Medical Records do not include any documentation of investigations, police notification, resident representative notification, or IDPH notification of R1 sexually or physically assaulting R2, R5, R6, R10 or R11. The Immediate Jeopardy started on [DATE] when (V1/Administrator) was hired by the facility and failed to ensure facility staff were following the facility's Abuse Policy and reporting all allegations of abuse to the residents' representatives, the Administrator, the police, and the State Agency to prevent further criminal sexual and physical assault. V6 (Assistant Director of Nursing) was notified of the Immediate Jeopardy on [DATE] at 9:20 AM. On [DATE] and [DATE] the surveyor confirmed through observation, interview, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. V1 is no longer employed by the facility, and last day worked was [DATE]. 2. A mandatory All-Staff meeting was held by V7 (Corporate Manager) on [DATE] to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for reporting allegations of abuse. Those staff, including agency staff, not in attendance at this training will be in- serviced by a department head prior to their next scheduled shift. 3. V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency on [DATE]. 4. V20 notified R1, R2, R5, R6, R10, and R11's family representatives of all allegations of abuse on [DATE]. 5. V20 notified the police of all allegations of abuse of R1, R2, R5, R6, R10, and R11's on [DATE].

Based on observation, record review, and interview, the facility failed to implement their Abuse policies and procedures to thoroughly investigate all alleged violation of abuse, failed to prevent further abuse from occurring while the investigation was in progress, failed to implement measures to provide safety and supervision to prevent further abuse, and failed to submit a final report of the investigation report to the State Agency within five working days for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for protection from abuse in the sample of 50. These failures resulted in R1 having continual unsupervised access to the residents on two hallways and the dining rooms to where R1 has resided (R2-R10 and R12-R50) after R1 had sexually and physically assaulted R2, R5, R6, R10 and R11 on multiple occasions. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, dated [DATE], documents, Sexual Abuse is the non-consensual sexual contact of any type with a resident. Sexual Abuse the non-consensual sexual contact of any type with a resident. Upon learning of the report, the administrator, or designee, shall initiate an investigation. Possible sexual abuse: Determine if the allegation involves either physical sexual contact involving penetration, verbal harassment, or physical contact that did not involve penetration. As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Dementia management and resident abuse preventions include how to assess, prevent, and manage aggression. Through the care planning process, staff will identify problems, goals, and approaches which would reduce the changes of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor goals and approaches on a regular basis. Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Upon learning of the report, the administrator or designee shall initiate an investigation. Residents who allegedly mistreat or abuse another resident will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. The administrator or designee is responsible for forwarding the final written report of the results of the investigation and corrective action to the Department of Public Health within five working days of the reported incident. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including the steps the facility had taken in response to the allegation, will be sent to the (Illinois) Department of Public Health/IDPH. V1's (Administrator's) Employee Business File documents V1's hire date was [DATE]. R1's Physician's Order Sheet (POS), dated [DATE] through [DATE], documents R1 has the diagnoses of Sexual Aggression, Dementia with behavioral disturbances, Anxiety, and Major Depression Disorder. These same POS's document R1 receives Depakote 125 mg (milligrams) three times daily for the diagnosis of Dementia with behavioral disturbance and Finasteride five mg one tablet daily for the diagnoses of Sexual Aggression and Benign Prostatic Hyperplasia. R1's Minimum Data Set (MDS) Assessment, dated [DATE], documents R1 is severely cognitively impaired. R1's Care Plan, dated [DATE], documents, (R1) has a history of sexual inappropriateness towards female peers. Resident, facility, and next of kin agree that (R1) is unable to consent to sexual relations at this time related to impaired cognition. Start: [DATE] (R1) to be one-on-one with staff at all times through duration of long-term care stay. Start: [DATE] (R1) placed in private room. (R1) has behaviors that other may find disruptive/socially inappropriate. (R1) likes to walk around the skilled nursing facility. (R1) will sometimes go into resident's rooms. Start: [DATE] 15 minute close and constant supervision to monitor whereabouts and proximity to those easily upset by behaviors as needed. Start: [DATE] Move (R1) to secure unit. R1's Behavior Tracking Records, dated [DATE] through [DATE], do not include tracking or behavioral interventions to address R1's sexual inappropriateness with peers. R2's MDS Assessment, dated [DATE], documents R2 is severely cognitively impaired. R5's MDS Assessment, dated [DATE], documents R5 is severely cognitively impaired. R6's MDS Assessment, dated [DATE], documents R6 is cognitively intact. R10's MDS Assessment, dated [DATE], documents R10 is cognitively intact. R11's MDS Assessment, dated [DATE], documents R11 was cognitively impaired. R11's Progress Notes document R11 passed away on [DATE]. R1's and R2's IDPH (Illinois Department of Public Health) Facility Reported Incident Report, dated [DATE] at 12:37 PM, documents, Incident Category: Resident Abuse. Incident Description, On [DATE]th (2024) at approximately 5:30 PM, a nurse aide (V3) was alerted to check on (R2) because she heard grunting sounds coming from his room. Upon entering the room, (V3/Certified Nursing Assistant/CNA) saw (R1's) hand down the front of (R2's) brief. (V3) promptly separated both parties and called for the nurse (V4/Licensed Practical Nurse/LPN). R1's Inter-Disciplinary Note, dated [DATE] at 9:00 AM, documents, Quality Assurance team review of occurrence [DATE] (R1) inappropriately touching peer resident (R2). Increased Prozac and room move to private room with private bathroom. Continue 15-minute checks. R2's Quality Committee Behavior Referral and Quality Care Reporting Form, dated [DATE], (three days after occurrence) documents, Date of occurrence: [DATE]. Behavior: Another resident (R1) was masturbating (R2) in hallway. Describe interventions used to manage behavior: Separated residents to their own rooms. [DATE] Summary of event and actions taken: Separate perpetrator to another hallway. On [DATE] at 8:20 AM, V2 (Director of Nursing/DON) stated, On Friday ([DATE]) I was at church and (V4/LPN/Licensed Practical Nurse) called and reported to me that (V3/CNA/Certified Nursing Assistant) found (R1) masturbating (R2). I called (V4) back and told him to put (R1) on 15-minute checks. On Monday we (facility staff) met and decided to move (R1) to another hallway in a private room. (R1) used the dining room for that hallway. On [DATE] at 8:30 AM, V8 (CNA) stated, I have worked here for one month. (R1) likes to masturbate with himself and likes to go into other resident rooms. (R1) ambulates on his own and can go anywhere throughout the facility, except for on the secured unit. (R1) knows what is going on and if he does not want to answer questions, he will just stare. On [DATE] at 8:35 AM, R2 was sitting in a wheelchair watching television. R2 was confused to time and place and was unable to answer questions regarding the allegation of sexual abuse between him and R1 that occurred on [DATE]. On [DATE] at 9:15 AM, R6 stated, About one to two weeks ago, (R1) came knocking on my bedroom door and came into my room. (R1) told me it was one of his relatives' birthdays and he wanted to celebrate with me. (R1) said to me 'You have really nice feet.' (R1) tried to grab my feet. I could tell by the look in (R1's) eyes that he wanted to do something sexual with me. (R1) tried to force himself on top of me and I felt like (R1) was trying to rape me. I started kicking (R1) and yelling for help. I yelled at (R1) to 'Get out!' (R1) closed the curtain and I do not know where he went. I jumped out of bed and took off running to the nurses' desk. I told (V14/Agency CNA) what happened, and he just laughed. I have been raped before when I was younger and do not want to be around (R1). (R1) was living on my hallway until this week. I still have to see him in the dining room. I try to ignore him. My right knee has hurt ever since I kicked (R1). On [DATE] at 9:20 AM through 9:40 AM, R1 was sitting in his room without staff supervision. During this time R1 stated, I have given sexual pleasure to three guys (R2, R5 and R11). I got caught j***ing (R2) off and they sent me to this room. (R2) enjoys it, and I do it whenever I get the urge. I have given (R2) sexual pleasure twice. I j****d (R11) off at least four to five times. (R11) has died now. I have j****d (R5) off twice. I do it in (R5's) room. I tried to give (R6) pleasure, but he wouldn't let me. They (R2, R5, and R11) could not do anything with my penis. They have tried but my penis is too small. I was told I broke a rule, and I cannot do it again. I have to try to keep myself busy with the radio and writing letters to keep my mind off of it. On [DATE] at 10:15 AM, R5 was sitting in a padded wheelchair in the dining room. R5 was confused to time and place and was unable to answer questions regarding any alleged sexual abuse that occurred between him and R1. On [DATE] at 10:20 AM, V4 (LPN) stated, I was working on [DATE]. Around 5:45 PM that night, (V3) was yelling for me. (V3) was standing in front of (R2) in the hallway right outside of (R1's) room. (R2) was sitting in his wheelchair. (R1) was standing to the right side of (R2). (V3) told me she caught (R1) masturbating (R2). I called (V2/Director of Nursing) to report the incident. (V2) told me to put (R1) on 15-minute staff checks, but (R1) was already on 15-minute checks before. We just took (R1) and (R2) to their rooms for the night. (R1) walks independently throughout the facility. I was not told to do any further supervision of (R1). I did not work the weekend after that, so I do not know when (R1) got moved to another hallway. (R1) has never had one on one supervision of staff since I have been here. (R2) is confused and yells out. On [DATE] at 10:25 AM, V3 (CNA) stated, I have worked second shift at the facility for six years. On [DATE] after supper around 5:45 PM, I was coming up the hallway facing (R2). (R2) was in his wheelchair in the hallway outside of (R1's) room, and (R1) was bending over top of (R2). (R1) had his hand down the front of (R2's) pants and was stroking (R2's) penis up and down. I could see exactly what (R1) was doing to (R2). (R2) was sexually groaning. I screamed at (R1) 'No! Stop! (R1) is alert enough to know what he is doing, and acts like he does not hear you when he is doing wrong. (R2) is confused. I took (R1) and (R2) to their rooms. Nothing was done afterwards. (R1) did not have increased supervision afterwards. (R1) has not had one-on-one staff supervision that I am aware of. (R1) has always walked throughout the facility. I worked again on Sunday ([DATE]) and was told (R1) could not have a roommate, but then we had to move (R12) into (R1's) room that night. On Monday ([DATE]), (R1) was moved to another hallway. Around eight months or so ago, I walked into (R1's) room and caught (R1) sitting on his roommate's (R11's) bed with his hand on (R11's) penis. I saw (R1's) hand on (R11's) penis and (R11's) brief was off. (R11) did not say anything and cannot move out of bed without the staffs help. (R11) was very confused. I reported this incident to (V1/Administrator). One night about a week ago, (R6) came up to a few of us at the nurse's station and said (R1) tried to attack him. (R6) told me he had been sexually assaulted before and did not know whether to cry or scream. I told the nurse (R6) felt like he was going to be sexually assaulted by (R1). I do not remember what nurse I told. I do not know who the Abuse Coordinator is. Another day around a couple months ago, I found (R1) sitting beside (R5) in (R5's) bed. I reported this to the Social Service Director (V13). I feel sorry for (R5) if (R1) was masturbating (R5), as (R5) would not like it and was molested as a child. A week or two ago, (R10) was crying and I asked her why. (R10) said (R1) was rubbing her shoulders and kept rubbing lower and lower until (R1) started to rub her boobs. (R10) said she reported this to (V1). I know (V15) was aware of this incident also. On [DATE] at 1:35 PM, R10 was lying in her bed. R10 stated, Last week, I was in the dining room downstairs sometime between lunch and supper. I was waiting on activities to start and was reading a book. (R1) came up behind me and started to rub my shoulders. I told (R1) to get off of me. (R1) started to rub harder and then started to rub my boobs on the outside of my shirt. I did not want him to do that. I feel like that is sexual abuse. I started yelling and staff came. The staff came and told me to report this to (V1). I reported this to (V1) immediately and (V1) said he would keep a close eye on (R1). After that I have seen (R1) in the dining room and I do not want him around me. On [DATE] at 2:00 PM, V13 (Social Service Director) stated, I have worked here for a year and four months. I know around a year and a half ago, the hallways were split up with men on one due to (R1) having a sexual encounter with a female resident. On Monday ([DATE]), (V2) told me about what had happened between (R1) and (R2) on Friday ([DATE]). I went down on Monday and spoke to (R1). (R1) would not say much and ignored me. I told him it was inappropriate to touch another resident inappropriately and he needs to keep his hands to himself. (R1) replied, 'Ok. God bless.' I then went to talk to (R2) about the incident, and he just asked me if he was in trouble. (R2) did not talk about the incident. I know (R1) was not moved from his room to a room on a different hallway until Monday ([DATE]). I make (R1's) behavior tracking logs and put them out on the halls for the CNAs to track (R1's) behavior and to document what interventions were used and if they are effective. I have not implemented a behavior tracking with interventions to address (R1's) sexual inappropriateness with other residents. I do not know of any interventions implemented after to increase supervision of (R1) after the incident between him and (R2) on Friday ([DATE]). I am responsible for (R1's) behavioral care plan. According to (R1's) care plan, (R1) should have had one-on-one staff supervision at all times. I was not aware of that. On [DATE] at 5:50 PM, V19 (CNA) stated, I work third shift. (R1) was moved sometime this week to another hallway after masturbating (R2). (R1) never had one-on-one supervision and walks independently. (R8 and R38) always wander around and go into other residents' rooms. (R8 and R38) live on the same hallway as (R1). On [DATE] at 10:00 AM, V2 (Director of Nursing/DON) provided a list of all residents who reside on the same two hallways as R1 or use the same dining room as R1 (R2-R10 and R12-R50). On [DATE] at 10:15 AM, V1 (Administrator) stated, I did not know (R1) had a history of sexual aggression or was care planned to have one-on-one supervision. I worked there for the past two years (hire date [DATE]) and (R1) never had one-on-one supervision during that time. I do not recall any sexual allegations made regarding (R1) with any residents, therefore there are no abuse investigations regarding (R5, R6, R10 and R11). On [DATE] at 10:36 AM, V18 (R1's Family Member) stated, (R1) should be supervised so he is not able to do sexual things with other residents. The facility called my a few days ago and said they were moving (R1) to another room due to (R1) inappropriately touching another resident. On [DATE] at 11:45 AM, V15 (CNA) stated, Last week I heard (R10) crying outside of (V1's) office and reporting something to (V1) about something (R1) had done to her. I did not hear the entire conversation. On [DATE] at 11:50 AM, V7 (Corporate Manager) stated, I have managed this home since February 8, 2024, and have not been aware of any abuse allegations regarding (R1 and R2), except for the allegation made on [DATE] regarding (R1 and R2). I have searched (V1's) office and there are no abuse investigations regarding (R1, R5, R6, R10 or R11). On [DATE] at 1:00 PM, V14 (CNA) stated, Around a week ago or so I do recall (R6) coming out of his room and telling me that (R1) said (R6) had pretty feet and tried to touch him sexually. I went down to (R6's) room and removed (R1) from the room. I told the nurse. I do not recall who the nurse was. On [DATE] at 2:30 PM, V2 (DON) provided the a list of residents (R2-R10 and R12-R50) residing on the two hallways and the dining rooms to where R1 has resided after R1 had sexually and physically assaulted R2, R5, R6, R10 and R11 on multiple occasions. R1, R5, R6, R10 and R11's Medical Records do not include any documentation of investigations or IDPH five-day final report submission R1 sexually or physically assaulting R5, R6, R10 or R11. The Immediate Jeopardy started on [DATE] when (V1/Administrator) was hired by the facility and failed to thoroughly investigate all alleged violation of abuse, prevent further abuse from occurring while the investigation was in progress, implement measures to provide safety and supervision to prevent further abuse, and failed to submit a final report of the investigation report to the state agency within five working days resulting in R1 having continual unsupervised access to the residents on two hallways and the dining rooms to where R1 has resided (R2-R10 and R12-R50) after R1 had sexually and physically assaulted R2, R5, R6, R10 and R11 on multiple occasions. V6 (Assistant Director of Nursing) was notified of the Immediate Jeopardy on [DATE] at 9:20 AM. On [DATE] and [DATE] the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 is no longer employed by the facility, and last day worked was [DATE]. 2. On [DATE], R1 was placed on one-on-one staff supervision at all times to prevent recurrence. 3. An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance. 4. R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents. 5. On [DATE], the IDT met to discuss discharge planning for R1 to a more appropriate setting. 6. A mandatory All-Staff meeting was held by V7 (Corporate Manager) on [DATE] to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for thoroughly investigating all allegations of abuse, protecting residents from abuse while the investigation is underway, and reporting to IDPH with a five-day final report. Those staff, including agency staff, not in attendance at this training will be in-serviced by a department head prior to their next scheduled shift. 7. V20 (Administrator-In-Training) submitted final abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency on [DATE]. 8. Department supervisors conducted an abuse assessment on all residents on [DATE] and [DATE] to screen all residents for potential abuse, concerns, or incidences. 9. V13 (Social Service Director completed assessments to address psychosocial needs of R1, R2, R5, R6, R10 and R11 on [DATE]

Based on observation, interview, and record review, the facility failed to develop and implement pressure relieving interventions, failed to develop a pressure relieving care plan after being assessed as high risk for pressure ulcer development, and failed to immediately develop a pressure ulcer care plan once a pressure ulcer developed for one of three residents (R1) reviewed for facility acquired pressure ulcers in the sample of three. These failures resulted in R1 developing an unstageable, painful, deep tissue pressure ulcer to the left heel, after R1 had a decline in ADLs (Activities of Daily Living) following a left hip fracture. Findings include: The facility's Pressure Sore Prevention Guidelines policy, dated 01/2018, documents, Policy: It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as high or moderate risk for skin breakdown as determined by the Braden Scale (assessment for predicting pressure ulcer risk). The following guidelines will be implemented for any resident assessed at a moderate or high skin risk. High risk interventions: Care plan entry of skin risk and appropriate interventions are to be placed on the care plan. If despite interventions a pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of pressure ulcers. The facility's Decubitus Care/Pressure Areas policy, dated 05/2007, documents, Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. Initiate problem on care plan. The facility's Preventative Skin Care policy, dated 01/2018, documents, Policy: It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. 7. Pillows and/or bath blankets may be used between two skin surfaces or to slightly elevate bony prominence's/pressure areas off the mattress. Pressure relieving devices may be used to protect heels and elbows. R1's MDS (Minimum Data Set) Assessment, dated 9-5-23, documents R1 is moderately cognitively impaired, requires supervision of one staff for personal hygiene, walks independently with supervision, and had no pressure ulcers or skin conditions as of the date of this assessment. R1's Braden Scale for Predicting Pressure Ulcer Risk Assessment, dated 9-5-23, documents R1's risk of developing a pressure ulcer as low. R1's Operative Note, dated 10-2-23, documents, Preoperative Diagnosis: Left hip femoral neck fracture, displaced. Left hip hemiarthroplasty performed. R1's Nursing Admission Assessment, dated 10-6-23 and signed by V19 (Licensed Practical Nurse), documents R1 did not have any wounds except for a hip repair incision, upon re-admission from the hospital. R1's Braden Scale for Predicting Pressure Ulcer Risk Assessments, dated 10-6-23 (re-admission to the facility after fracturing R1's left hip) and 10-13-23, document R1 has a high risk of developing pressure ulcers. These same assessments, dated 10-6-23 and 10-13-23, document R1's heels were not floated and positioning devices such as pillows or cushions were not used within seven days prior to these assessments, even though R1 was assessed as high risk for development of pressure ulcers. R1's Care Plan was not updated to indicate R1 was at a high risk of pressure ulcer development with pressure relieving interventions, after R1's Braden Scale Assessment, dated 10-6-23, indicated R1 was at high risk for pressure ulcer development. R1's A.I.M. (Acute Illness Management) for Wellness, dated 10-16-23, documents, Assess: This change in condition, symptoms, or signs observed and evaluated are: pressure area. Functional Status Evaluation: Decreased mobility, total left hip replacement, needs more assistance with ADLs, and Weakness. Left heel. Intensity of pain (rate on scale of 1-10, with 10 being the worst): 8. Interventions: Apply skin prep every shift to left heel. R1's Weekly Wound Tracking Assessment, dated 10-16-23, documents, Area Location: Left Plantar Heel. Date of Onset: 10-16-23. Facility Acquired. Type: Deep Tissue Injury (DTI)/Pressure. 5.0 cm (centimeters) by 6.0 cm by undeterminable depth. Wound color dark. R1's Physician's Order, dated 10-16-23, documents, Left heel: Apply skin prep every shift. Heel protector to left foot at all times. R1's Weekly Wound Tracking, dated 10-25-23, documents, Unstageable DTI 5.0 cm by 6.0 cm unstageable. Wound dark. R1's Pressure Ulcer Care Plan with pressure relieving interventions was not developed until 10-27-23 (11 days after development of the pressure ulcer). R1's Pressure Ulcer Care Plan, dated 10-27-23, documents, Pressure reduction boots when up in wheelchair. Float heels when in bed. R1's emergency room Note Report, dated 10-20-23 and signed by V18 (emergency room Physician), documents, (R1) was admitted on [DATE] with a left hip fracture. (R1) was discharged on [DATE]. (R1) has not followed up with orthopedics. Today the nursing home sent (R1) for a wound check saying they were concerned about a dark spot on the bottom of his left foot, and they were worried about his circulation. (R1) is much more alert and can carry on a conversation, (R1) came with a very thick foam Decubitus boot on his left foot and ankle. (R1) has a large intact blister with ecchymosis (bleeding underneath the skin) inside covering the entire plantar left heel. No erythema. Continue Decubitus blister protections and follow-up with orthopedic. R1's Initial Wound Evaluation and Management Summary dated, 10-25-23 and signed by V13 (Wound Physician), documents, Wound Exam: Unstageable DTI of the Left Planter Heel. Etiology: Pressure. MDS 3.0 Stage: Unstageable DTI. Duration: Over 10 days. Wound Size: 5.0 cm by 6.0 cm x not measurable depth. Involves mostly plantar aspect of heel. Either (R1) had slid down against footboard or had foot on the metal footrest on his wheelchair without protection to lead to pressure injury to this heel. He has prevalon (padded heel protector) boot now. Recommendations: Off-load wound; Pressure Off-Loading Boot. On 10-27-23 from 8:25 AM through 9:00 AM, R1 was sitting in a wheelchair in the hallway. R1 had a padded boot to the left foot/ankle and R1's right foot/heel was resting directly on the foot pedal of the wheelchair. R1 stated, I could not move my left leg after breaking my hip. That is why I got a sore on my left heel. The sore hurts pretty bad. On 10-27-23 from 9:30 AM through 10:00 AM, R1 was lying in bed with his right heel lying directly on the bed without a pressure relieving device to off-load pressure from his right heel. R1's left heel had a padded boot. On 10-27-23 at 10:15 AM, V3 (LPN/Licensed Practical Nurse) lifted R1's left foot and assessed R1's left heel. R1's left heel had a golf-ball sized soft, mushy; fluid filled brownish-blackish wound. V3 stated, For now we (the facility) are just applying skin prep to the area. (R1) did not have heel protectors on or off-loading to his heels prior to developing the wound to his left heel. (R1) broke his left hip and returned to the facility on [DATE]. (R1) needed full assistance with re-positioning and transfers when (R1) returned on 10-6-23. Prior to breaking (R1's) hip, (R1) was ambulating, transferring, and re-positioning independently. The Physical Therapist (V16) found the wound to (R1's) left heel when doing range of motion with (R1). On 10-27-23 at 10:40 AM, V11 (Registered Occupational Therapist) stated, Everytime I worked with (R1) after his hip fracture he did not have on heel protectors or his heels offloaded that I can remember. When me and (V16/Physical Therapy Assistant) found the pressure ulcer to (R1's) left heel we immediately got (V3) to assess it and (R1) was provided a cushioned boot. On 10-27-23 at 11:00 AM, V2 (Director of Nursing) stated, We (the facility) did not implement any pressure relieving interventions or update (R1's) plan of care with pressure relieving interventions after (R1's) Braden scale indicated (R1) was at high risk for pressure ulcer development. (R1's) wound to the left heel was caused by pressure. (R1) should always have his heels offloaded. On 10-27-23 at 11:05 AM, V14 (CNA/Certified Nursing Assistant) stated, After (R1) returned from the hospital (10-6-23) I took care of (R1). I do not recall (R1) having heel protectors on or (R1's) heels being lifted off the bed. After (R1) got a wound to the left foot, (R1) had a boot put on. On 10-27-23 at 12:40 PM, V16 stated, I was doing range of motion exercises when I saw (R1) had a dark spot to his left heel. I went and got and had her look at the area as well. I then reported the area to V3 (LPN). After (R1) broke his hip and returned to the facility we (therapy staff) would work with (R1). I never saw (R1's) heels off-loaded and (R1) never had on pressure-relieving boots. The day I found the wound on (R1's) heel his heels were lying directly on the bed and (R1) did not have heel protectors on. On 10-27-23 at 12:25 PM, V13 (Wound Physician) stated, The wound to (R1's) left heel was caused by pressure after (R1) sustained a hip fracture. His heels were obviously not offloaded.

Based on interview and record review, the Facility failed to protect one resident (R6) from ongoing sexual abuse by two staff members, for one of three residents reviewed for sexual abuse. This failure resulted in R6 discharging from the Facility, relapsing on drugs, and requiring admission to an in-patient treatment center. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9/5/23, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: Facility Abuse Prevention Program Policy, revised 11/28/16, documents: the Facility affirms the right of our Residents to be free from abuse as defined below; this Facility therefore prohibits mistreatment or abuse of its Residents, and has attempted to establish a Resident sensitive and resident secure environment; the purpose of this policy is assure that the Facility is doing all within its control to prevent occurrences of abuse of our Residents; this will be done by conducting required pre-employment screenings, orienting and training employees on how to deal with difficult situations and how to recognize and report occurrences of mistreatment and abuse; training on activities that constitute abuse; establish an environment that promotes Resident sensitivity, Resident security, mistreatment and abuse; identifying occurrences and patterns of mistreatment and abuse; immediately protecting residents involved in identified reports of possible abuse; implementing systems to investigate all reports and allegations of mistreatment and abuse, promptly and aggressively making the necessary changes to prevent future occurrences; reporting of potential incidents of abuse; this Facility if committed to protecting our Residents from abuse by anyone including; but not limited to Facility Staff; Sexual Abuse is defined as non-consensual sexual contact of any type with a Resident; staff obligations to prevent and to immediately report abuse; staff will identify Residents with increased vulnerability for abuse or have needs and behaviors that might lead to conflict; employees are required to immediately report any occurrences of potential/alleged mistreatment or abuse of Residents; the Final Investigation Report will be forwarded to the Department of Public Health within five working days of the reported incident; the written report shall be sent to the Department of Public Health and include the name, age, diagnosis and mental status of the resident allegedly abused, type of abuse, date/time/location and circumstances of the alleged incident and steps the Facility has taken to protect the Resident; inform the Law Enforcement Authorities of sexual abuse of a Resident by a staff member; Sexual Abuse is non-consensual sexual contact of any type with a Resident; and determination if the allegation involved either physical sexual contact involving penetration, verbal harassment or physical contact that did not involve penetration. The Facility Assessment Tool, updated 9/19/23, documents: the Facility will manage Mental Health and Behaviors including medical conditions causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such a dealing with Anxiety, care of individuals with Depression and other psychiatric diagnoses; provide person centered/directed care for psycho/social support by building a relationship, find out Resident preferences and routines, what upsets him/her and incorporate information into the care planning process; make sure staff caring for Resident have this information, support emotional and mental health well-being, support helpful coping mechanisms; and prevent Abuse and identify hazards and risks for Residents. Facility Safe Working and Training (SWAT) Packet and Employee Handbook, for new Employees, effective 5/2021, documents: the Employee should receive training on Resident Rights and the Abuse/Neglect Policy; establish certain standards of personal conduct and work performance and insure that they are understood and followed by all employees; the intent of the Employee Handbook is a general guide for personnel policies, procedures and standards of personal conduct; our purpose is to provide specialized cafe and assistance enabling our Residents to attain their highest practical, physical, mental and psychosocial well being; our Facility is licensed by the State and Certified by the State/Federal authorities and therefore, employee's activities must be conducted in accordance with strict rules and regulations; employees are expected to be aware of, and follow all applicable State, Federal and local rules and regulations governing the operations of Licensed and Certified Facilities; each of us must observe basic rules of good conduct and treat our fell ow Residents with respect and courtesy; and the Facility strongly supports Resident's rights and protections and therefore will not tolerate the physical, emotional/psychological abuse of a resident; and if you ever witness a situation you believe the Resident's physical, mental or general well-being has been or may be, abused or neglected, you must protect the Resident and immediately report the incident to your supervisor, department head and the Facility Administrator. R6's Physician Order Sheet/POS, dated 6/16/23 to 8/21/23, documents an admitted [DATE] to the Facility with diagnoses including Anxiety, Depression, Insomnia, Heroin Addiction, Opioid Use Disorder, Methamphetamine Abuse and Seizures. The POS also documents R6's medication orders for (Seroquel 25 milligrams/mg twice daily, Hydroxyzine Hydrochloride 25 mg three times a day, Melatonin 3 mg at bedtime, Divaloprex 125 mg sprinkle cap three times a day, Venlafaxine 37.5 mg daily and Naloxine 4 mg Nasal Spray as needed for Opioid Overdose). R6's Preadmission Screening and Resident Review (PASRR) Level One Screen, dated 6/14/23, documents R6's suspected/confirmed Mental Health Disability. R6's Power of Attorney for Health Care, dated 5/24/2023, documents V20 (R6's Mother) and V21 (R6's Sibling). R6's current Psychosocial Discipline Care Plan documents: a history of substance abuse/chemical dependency related to Methamphetamine, heroin and occasionally cocaine use; R6 is still engaged in counseling to prevent breakthrough addiction; work with R6 to establish a verbal or written behavioral contract specifying what is or not allowed; meet with Interdisciplinary Team to discuss the extent of R6's illness; present R6 with a list of substance abuse treatment programs and confront concerning the illness and self destructive path; implement increasingly restrictive interventions in an effort to help break the addictive cycle; interventions may include supervision while in the community, restricted independent pass privileges and implementation of money guidance; and provide leisure counseling to help use free time in productive manner. R6's Psychosocial History, dated 6/30/23, documents R6's instability and homeless while in active addiction, at hospital before admission. The Psychosocial History documents R6's Depression, Anxiety, Heroin Addiction and Methamphetamine Abuse. R6's Minimum Data Set/MDS, dated [DATE], documents R6's birth year as 1987, and a Brief Interview for Mental Status/BIMS score of 13/15 (slight cognitive impairment). The MDS documents: R6 has little interest or pleasure in doing things; feeling down/depressed/hopeless, feels bad about self or feels like a failure; and trouble concentrating. R6's Cognitive Assessment, dated 6/30/23, documents R6's short term memory loss, difficulty focusing attention and easily distracted. R6's Social Service Assessment, dated 6/20/23, documents R6 as forgetful, withdrawn, anxious, sad and sad about being in a nursing home. The Social Service Assessment also documents a history of Drug Abuse, Depression and Anxiety. R6's Psychosocial Assessment, dated 6/20/23, documents R6 as easily distracted, forgetful short term memory loss, stress management, judgement, substance abuse, worried/fearful, withdrawn, depressed and anxious. R6's Mood Assessment, dated 6/20/23, documents R6 has little interest in doing things, feels down/depressed/hopeless, feels bad about self/failure to self or family and trouble concentrating. R6's Mood Assessment shows a score of Mild Depression. R6's Social Service Progress Notes, dated 7/12/23, documents R6 was interested and willing to receive therapy, and thinks it will be beneficial for R6's mental health. R6's Social Service Progress Notes, dated 7/13/23, documents an appointment for therapy at a behavioral health office was scheduled for 8/18/23. R6's Nursing Note, dated 6/24/23, documents R6 was concerned over smoking, loss of control of life, and upset that at the age of [AGE] years old, was in a nursing home. R6's Nursing Notes, dated 6/27/23, 7/5/23 and 7/6/23, documents R6 was transported by the Facility van to doctor appointments. R6's Release of Responsibility for Discharge Against Medical Advice, dated 8/21/23, documents R6 signed the request for discharge from the Facility. R6's Sign Out/Acceptance of Responsibility for Leave of Absence, documents R6 signing self in and out on 8/12/23, 8/13/23, 8/14/23 and 8/15/23. R6's sign out on 8/12/23 documents that R6 left the Facility at 2:10 pm and returned to the facility on [DATE] at 5:20 am. Facility R6's Timeline Statement, dated 8/15/23 at 8:30 am, documents V17 (Registered Nurse) dropped R6 off at a friend's house, and R6 stayed until around 4:30 am. R6 stated R6 goes to the library with V16 (Transportation Driver). Facility R6's Timeline Statement, dated 8/15/23 at 8:45 am, V21 (R6's Sibling/Power of Attorney/CNA) stated, That the Facility had been allowing (R6) to sign out and on Saturday (8/12/23), (V21) worked a twelve hour shift, and (R6) was already at (V21's) house when (V21) returned home from work. V21 states V16 (Transportation Driver) messaged V21 and then at 8:15 pm, V17 (Registered Nurse/V16's Husband) picked up R6 from V21's house, and took R6 to V16's and V17's house. V21 states, I missed a lot of calls from here (Facility) throughout the night and at 4:45 am (on 8/13/23), V21 responded to the Facility requests that R6 was not at the Facility, and the Facility asking V21 if R6 was with V21. V21 contacted V16 and V16 confirmed R6 was with them (V16 and V17). R6 did not receive R6's 8/12/23 nighttime medication, and V16 dropped off R6 around the corner from the Facility on the morning of 8/13/23. The Statement documents V16 was telling her (R6), that they are 'soul mates.' R6's Facility Sexual Abuse Investigation, dated 8/15/23, documents at 7:26 am, V18 (Regional Representative) was notified by V19 (Regional Representative) that V16 (Transportation Driver) and V17 (Registered Nurse) were having a sexual relationship with R6. At 9:30 am, V16 (Transportation Driver) was interviewed by V1 (Administrator) and V18. V16 stated V16 had been transporting R6 to appointments, as well as to the library. R6's Facility Sexual Abuse Investigation, dated 8/15/23, documents at 10:10 am, V18 (Regional Representative) spoke with R6. The Investigation documents R6 stated R6 had sexual relations with V16 (Transportation Drive/V17's Husband), while V17 (Registered Nurse/V16's Wife) watched on two different occasions. R6 also stated a sexual encounter was on Saturday (8/12/23), when R6 spent the night with V16 and V17. R6 stated V16's condom broke, and R6 would like to take a pregnancy test as soon as possible. R6 stated R6 received several messages to keep her mouth shut and not tell anyone what they had done. V18 (Regional Representative) did take photos of the messages. V18's (Regional Representative) typewritten statement with V23 (Licensed Practical Nurse/LPN), dated 8/15/23 at 3:15 pm, documents V23 stated V16 brought R6 back to the Facility before 10:00 pm on Friday, 8/11/23. V16 stated to V18 that V21 (R6's Sibling/Certified Nursing Assistant/CNA) asked V16 to bring R6 back to the Facility because V21 could not leave (V21's) daughter had a seizure and (V21) could not leave her. V18 states on 8/12/23, R6 did not come back to the Facility. On 8/31/23 at 6:43 am, R6 stated, I just got to inpatient drug rehab (rehabilitation) and have only been here about two days. I was getting kicked out of the Facility, and I had no where to go. I ended up relapsing, and that is how I got back to drug rehab. I have to call you back because I have to be to breakfast and I will have another break around 9:00 am. On 8/31/23 at 9:32 am, R6 stated, We started out what I thought was a real friendship and they took advantage of me, and it was unfair how I was treated. We (V16 and V17) started out as friends and after about three weeks, we started a sexual relationship. The first time it happened, V16 (Transportation Driver/V17's Husband) was picking me up from the Library, in the Facility van, and (V16) asked me if I wanted to stop by (V16's) house to smoke a cigarette before we went back (to the Facility), so I agreed. Hey, I was the youngest person in there and I would do anything to get out of there. While (V17/Registered Nurse) was in the house, we were in (V16's) garage smoking, and (V16) said 'there is just something you do to me, you make me so horny.' I am not claiming to be innocent, but honestly I am a mess myself anyway, but it made me feel uncomfortable. (V16) and (V17) knew my past, and knew that I had used drugs for years, and (V16) even knew that I had sold my body before so that I could get drugs. Then the next time, we stopped by (V16's) house to smoke, we ended up in the basement, and (V16) asked if I cared that (V16) 'pull his dick out', and I started giving (V16) a 'blow job' right there in his basement with (V17) home. Then after I was done, V16 said 'thanks, you just saved me a lot of money at the massage parlor.' (V16) told me that (V16) likes to go a lot the parlor in town for sex. That made me feel bad, I was like, you just took advantage of me and I thought we were friends. I ended up giving him blow jobs and having sex with him many more times. (V17) would sometimes sit on the bed and watch us, and (V17) also even wanted threesome, but I told them that I already have had threesome's and I was not interested, plus I was not even attracted to (V17). Another time, I was in (V16's) and (V17's) bedroom having sex, (V16) took his shirt off and threw it in the bedroom. Immediately after we started having sex, (V17) called (V16) and said, 'your shirt is on the camera and I cannot see anything.' I was like, what! That is when I found out (V16) and (V17) had a camera in the room. They both admitted to me that (V17) would watch me having sex with (V16). That camera made me very uncomfortable. (V17) knew the whole time what was going on, (V17) either watched or was in the room with us. There were many times that I would go to their house and I felt like they were fighting over me, even fighting who would be the one to sit next to me, now that made me uncomfortable. Looking back it was crazy. (R6) begins crying and states, I thought we were all friends and I even formed a relationship with their kids. They messed with my head and I even went back to using (drugs)again, and now I am in rehab, it is just not fair. They ended up getting fired over the whole situation. Then (V1) came to talk to me after I stayed out all night at (V16's) and (V17's) house on that last Saturday (8/12/23 to 8/13/23). (V1) said to me 'I had to fire two good employees over you, please just try and not sleep with anymore of my employees.' I was told by (V23/Licensed Practical Nurse) that I was going to have to be discharged , over the firing of (V16 and V17), so I ended up leaving the Facility on my own (AMA/Against Medical Advice), with no where to go, I ended up back where I started, and relapsed on drugs. On 8/30/23 at 10:18 am, V21 (R6's Sibling/Power of Attorney/CNA) stated, I am a CNA (Certified Nursing Assistant) at the Facility and (R6) is my sister. On 8/12/23, (R6) was at my house and I could not let (R6) stay all night because I am working on adopting a baby, and (R6) is a felon, and I do not want that screwing up my adoption. (R6) came to my house on Saturday (8/12/23), and got picked around 8:00 pm from my house by (V17). (V17) was working second shift that night, but was on break, so (V17) volunteered to come pick up (R6) from my house and was supposed to take (R6) back to the Facility, but I later found out that (R6) was taken back to (V16's and V17's) house. Then, the next day, on 8/13/23 at about 5:00 am, I woke up with about twenty missed phone calls from the Facility, they were trying to find my sister (R6). I called (V16) and asked if (V16) had heard from my sister (R6). (V16) stated, 'Yes, she is right next to me' and (V16) handed the phone to my sister. I knew she was close, because (R6) got on the phone immediately, I could not believe it. (R6) told me that (V16) told (R6) that they were soul mates, (V16) just told my sister (R6) what (R6) wanted to hear. (R6) is already broken down and has a bad past, and they used her. (V16) and (V17) and I were all friends outside of work before all of this happened, now it is a big mess. (R6) started doing meth (Methanphentamine) again after this, and just admitted to rehabilitation yesterday. I believe that my sister (R6) left the Facility because of all of this mess between (V16 and V17). I do not want my sister (R6) looking like a monster, she already has enough problems. (R6) was starting to do so good and had been clean for months. (R6) told me that they (V16 and V17) both were involved in all this sexual interaction and that (R6) did not want (V17/Registered Nurse) to join in on a threesome, so (V17) would just watch them have sex most of the time. This happened a lot according to (R6). I knew that (R6) was really upset about all of this because I could tell that is why my sister (R6) finally confided in me. On that Monday (8/14/23), I immediately went to tell V18 (Corporate Regional) and told them what I knew, no one had brought it to their attention. (R6) is now in drug rehab (rehabilitation) in (city) because she relapsed after leaving here. We did not want her to leave, we wanted her to stay here and get better. On 8/30/23 at 1:42 pm, V16 (Transportation Driver/V17's Husband) stated, (R6) and I just got to know each other because I would drive (R6) to doctor appointments, the library, and stuff like that. (R6) and I had each other's cell phone numbers because we needed it for dropping off and picking up from the appointments. (R6) had to go to a lot of heart doctor appointments in (city). (R6) had a long history of using drugs and was trying to get clean, and I just wanted to try and help (R6) with all of the stuff that (R6) was going through and (R6) was helping me also, because I was going through a lot of stuff of my own. We were just friends in the beginning because we would just talk on the long drives to (city) and after a course of a about a month, is when we started having sexual feelings and stuff like that. It went on until the Saturday night (8/12/23) that we got caught. (V17/V16's Wife) was working second shift that night and (V17) dropped (R6) off to our house so we could talk about our problems. My wife (V17) got home from work after second shift, and walked in on (R6) and me (V16) when we were in our bed. (R6) stayed until about 5:00 am the next morning (Sunday, 8/13/23), and had to leave because the Facility could not find her, and they kept calling (V21/R6's Sibling) looking for (R6), and finally found her at our house. So I drove (R6) back, in our personal car, and dropped (R6) off about a block from the Facility, so (R6) would not get in trouble. We had a friendship in the beginning and feelings just got in the way, and we ended up having a sexual relationship that has lasted at least the last month, until they fired my wife (V17) and myself over this. (R6) did give me 'blow jobs', and we did have sexual intercourse on different occasions. One time, the 'rubber' (condom) did break during us having sex, and we were scared that (R6) would get pregnant. I have went to the hospital for help over this whole situation because it has put me in a severe depression. My wife (V17) and I have young kids that we need to support and bills to pay, and now my wife has lost a job that she has been at for many, many, years. I really did care for (R6). I have tried to contact (R6) after we got fired, but now the whole thing is just a mess. I never did tell anyone else at the Facility, other than my wife, about the sexual relationship. On 8/31/23 at 12:35 pm, V17 (Registered Nurse/V16's Wife) stated, We began a friendship not long after (R6) admitted . We (V16 and V17) just felt sorry for her, she was young and we wanted to help her change her life. I did on occasion drive (R6) to my house so that my husband (V17) could help counsel (R6), and they would talk about problems. I also was (R6's), nurse and sometimes I would try and talk to (R6) about (R6's) problems. On Saturday (8/12/23) around 8:00 pm, I picked up (R6) from (V21's) house, and dropped (R6) off at my house to talk to my husband (V16), and went back to work, and later this night, after I got off of second shift, I walked in on them in my bedroom and they were laying on the bed. I did not stop any of it, and (R6) did not leave our house until the next morning around 5:00 am. We did have a camera in our room. I did not report any of this to the Facility that any of this was going on; it hit too close to home. I am not sure how the Facility found out, but we both got fired, and I do not remember what day it was that I got fired. (V1/Administrator) called and fired me over the phone because of all of this. The Facility Abuse In-service Attendance Record, dated 7/10/23, documents V16 (Transportation Driver) and V17 (Registered Nurse) were in attendance. V16's Employee File documents V16, was hired by the Facility on 10/26/20. V16's Employee File does not document a signature of completion for education on Policies Summary for Safe Working and Training (SWAT). V16's Employee File does document V16 completed Abuse and Neglect Policy Training on 11/2/20. V16's Receipt of Employee Handbook, signed 11/2/20, documents V16 received a copy of the Facility Employee Handbook and understands the responsibility for reading and abiding by the policies and V16 acknowledges receipt and understanding of the reporting of suspected Abuse of a Resident. On 8/30/23, 8/31/23 and 9/1/23, the Facility could not locate V17's (Registered Nurse) employee file. The Facility documented V17's Background Check. The Facility could not provide V17's Policies Summary for Safe Working and Training (SWAT). The Facility did provide the Department of Professional Regulation Lookup Detail View Electronic Computer print out, that documents V17's active Registered Nursing License, but could not provide a copy of V17's Registered Nurse License. On 8/30/23 at 10:46 am, V22 (Minimum Data Set/MDS/Care Plan Nurse) stated, (R6) left on the night of 8/12/23, with (V16 and V17) and did not return until the early morning of 8/13/23. Then I heard that (R6) signed herself out of the Facility, left with (R6's) ex-boyfriend and ended up relapsing and went back to Rehab. On 8/30/23, at 10:19 am, V5 (Housekeeping Supervisor) stated, (R6) was in a room by herself on (hallway). (V16) would drive (R6) to Doctor appointments (in city). After (V16 and V17) got fired, I did hear rumors that (V16 and V17) were having an affair with (R6). On 8/30/32 at 10:31 am, V2 (Resident Care Coordinator/RCC) stated, (V16) would take (R6) 'apparently' to the library all the time, but I never saw (R6) check out any books, I thought that was kind of weird. I have heard that (R6, V16 and V17) had a 'threesome.' I also heard that (R6) relapsed and ended up back in Rehab (in city). (V17) was also (R6's) Nurse, that took care of her. On 8/30/23 at 10:53 am, V14 (Social Service Director/SSD) stated, I did not know that anything was wrong until 'Corporate' showed up here, and then I heard about the sexual relationship between (R6, V16 and V17). (R6) did have a community pass, but I do not always know how to approach those forms, because (R6's) cognition was pretty good, so we granted (R6) a community pass. (R6) I did set up (R6) with a Behavioral Health Appointment, that I physically took her to myself and I was pushing for her to go get rehabilitation for drugs. (R6) expressed that (R6) did want to get out of here as much as (R6) could and (R6) would go to the library with (V16) a lot. On 8/30/23 at 10:02 am, V19 (Regional Representative) stated, I was notified by (V21) of (V16's and V17's) ill behavior with (R6) and I had to get with (V18/Regional Representative). When I spoke to (R6), (R6) told me that (V17/Registered Nurse) had picked up (R6) from (V21's) house, on (V17's) break and taken (R6) to (V16's and V17's) house around 8:15 pm on 8/12/23. The Facility kept calling (V21/R6's Sibling/Power of Attorney) because (R6) had not returned from the previous night, and finally got a hold of (V21) around 5:00 am on Sunday morning (8/13/23). Then, I think (V21) called (V16) around that time, because (V21) knew that (V17) picked up (R6) from (V21's) house and thought maybe (R6) was at (V16's and V17's) house. (V21) did make contact that morning with (V16) and (V16) admitted that (R6) had stayed all night. (V21) said that (V16) wanted (V21) to lie and say that (R6) had stayed all night at (V21's) house. On 8/30/23 at 9:48 am, V18 (Regional Representative) stated, I immediately went to the facility on [DATE] to interview (R6) and (V21/R6's Sibling/CNA) because (V19/Regional Representative) called me to tell me that she heard a rumor that (R6, V16 and V17) were having sexual encounters. (V21), (V16) and V17) were apparently friends and I knew that (R6) had been over to their house because (R6) told (V21). I am unsure how (R6) became friends with (V16 and V17) because they were not forthcoming. (R6) would not talk to (V19) during an interview. I heard that they had been together twice, but could not say when it happened. Both (V16) and (V17) were suspended and fired. I know that V20 (R6's Mother) did not want R6 leaving the Facility because of her past experience with drugs. We felt that (R6) was in her right mind, and (R6) became angry at me when I told (R6) that (V16 and V17) had been terminated. I was thinking that this was a ethical issues in my mind on their part. (V1) also talked to (R6), and (R6) admitted to sexual interactions with (V16 and V17). On 8/30/23 at 10:29 am, V1 (Administrator/ADM) stated, (V17/Registered Nurse) has worked here for about fifteen years, I cannot find an employee file on (V17). The only thing in (V17's) employee file is the Background Check. I will contact corporate and ask if they have anything. On 9/1/23, at 9:05 am, V1 (ADM) stated, I still do not have (V17's) employee file, we cannot find one. V1 verified V17's SWAT and Abuse training could not be located. On 8/29/23 at 1:00 pm, V1 (Administrator) stated, We took in (R6) kind of as a favor, even though (R6) was younger than most of our Residents. (R6) had issues and behaviors with drugs, because (V21/CNA/R6's Sibling) works here and the family wanted (R6) as far from (city) and (city) as they could get (R6), to keep (R6) safe and away from (R6's) lifestyle of doing drugs. We do not normally take Residents that are drug addicts, and looking back we probably should not have taken (R6), but (R6) got pre-screened for admission and had just heart surgery, so we admitted (R6) to help with the surgical incision. On 8/13/23, (V21/R6's Sibling/CNA) confronted our Regional (V19) and told (V19) that (R6) had confided in (V21), that (R6) was having sexual relations with (V16 and V17). I did not really think that anything was wrong, because (R6) was pretty cognitively intact, but did have short term memory loss. (R6) was signing self in and out of the Facility a lot, and we felt she was okay to leave all the time. On 8/12/23, the last time that (R6) did not come back that night until the next morning (8/13/23), I did find out that (R6) and (V16 and V17) were engaging in sexual relations. When I confronted (R6), (R6) denied this to me, and was angry that we fired (V16 and V17). I did not report this as abuse, because we felt that R6 was consensual to this. About a week after we fired (V16 and V17), on 8/21/23 (R6) left against medical advice. On 9/1/23 at 9:45 am, V1 (Administrator) stated, It was unethical and inappropriate for (V16/Transportation Driver) and (V17/Registered Nurse to have interactions with (R6) like this. The Immediate Jeopardy was to have started on or about 7/7/23, when R6 began sexual relations with V16 and V17. V1 (Administrator) was notified of the Immediate Jeopardy on 9/1/23 at 8:45 am. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Facility interventions put in place prior: Facility suspended and then terminated V16 (Transportation Driver) and V17 (Registered Nurse) on 8/13/23; In-service was conducted on 7/10/23 for all staff on Abuse. 2. New Transportation Driver hired 3. Local Police Department notified. 4. All Facility staff in-serviced, 9/1/23 through 9/5/23, on Abuse and Ethics as well as a comprehensive Education. 5. In-service conducted by Regional Team to V1 (Facility Administrator) on proper Abuse reporting. 6. In-service conducted by V1 (Administrator) on ethical decisions and Fraternization 7. Residents able to sign self out will be determined based on Community Skills Assessments and Brief Interview for Mental Status/BIMS score. This process will be completed by V14 (Social Services Director). 8. Quality Assurance/QAA process going forward will be overseen by V1 (Administrator) starting 9/1/23.

Based on observation, interview, and record review, the facility failed to identify a resident at high risk for elopement, failed to assess for the safety of a newly admitted resident with a history of delusional behavior, and failed to ensure a resident room was free from accidents and hazards for one of three residents (R1) reviewed for elopement in the sample of 12. As a result of these failures, R1 attempted to exit seek from the building and suffered a fall from a second floor window resulting in Bilateral C2 (2nd Cervical Vertebrae) Lamina fracture, T4 (Thoracic Lumbar 4)-3 Column Comminuted fracture, T8 (Thoracic Lumbar 8) 3 Column fracture with dislocations, Numerous Thoracic Spinous Process fractures, Posterior Element fractures of T2-3, [NAME] (American Spinal Injury Association) A SCI (Complete Spinal Cord Injury) at T8 (Thoracic Lumbar Vertebrae 8), Sensory Level, leaving R1 paraplegic. R1 was also diagnosed Spinal Shock, Paraspinal Hematoma, Right Hemothorax (collapsed lung) requiring a Chest Tube, Left sided 9th Rib fracture, Right sided 3rd, 5th-9th Rib fractures, Left Pulmonary Contusions, and Bilateral Pleural Fluid/Hemorrhages. These failures have the potential to affect 11 residents (R1, R3-12) that are at risk for elopement. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/17/22, the facility remained out of compliance at a Severity Level 2. The facility is ensuring all staff are in serviced on the facility's policies and procedures regarding the Admission process, Elopement Prevention, Emergency Care/Exposure to Cold, Missing Resident, and Resident Monitoring including 15 minute checks. The facility is ensuring the missing resident binder is audited weekly times four weeks and then monthly times three weeks for continued compliance. Findings include: R1's Hospital Inpatient Psychiatry History & Physical note, dated 2/22/22, documents, (Hospital) admitted : 2/19/22. Reason for hospitalization : [CONDITION(S)]. Chief Complaint: 'I was hearing voices.' History of Present Illness (HPI): Brought to the ED (Emergency Department) with reports of ongoing disorganized thinking, hallucinations, and was admitted for further stabilization and safety. The note also documents, Diagnosis: [CONDITION(S)] disorder, [CONDITION(S)] type. Plan: Requires inpatient psychiatric admission due to risk of self harm, for stabilization and ongoing medication titration and monitoring. R1's PAS (Pre-Admission Screening) Level II Assessment, dated 3/7/22, documents, (R1) reported that in January 2022, (R1) ran away to Indiana as she believed her brother was trying to kill her. R1's Nurses' Notes, dated 3/8/22 at 3:30 p.m., documents, Arrived to facility via facility transport. (R1) was admitted from hospital behavioral health. Alert to person, place, time-unable to tell me date of birth and gave incorrect name for daughter. Primary diagnosis of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. admitted to hospital for auditory delusions, visual hallucinations, and increased paranoid thoughts. Per (V13, R1's Power of Attorney)-(R1) was scared to be alone at home and was unsafe and trying to 'flee' with her belongings and car. Goal for (R1) and (V13) is to get medications stable and behaviors decreased to be able to return home independently. R1's Nurses' notes also document, Transfer/Ambulate independently with cane. R1's Nurses' note was signed by V7 (RN-Registered Nurse). R1's Nurses' notes have no other entries made to R1's medical record after this initial entry. R1's Elopement Evaluation, dated 3/8/22, documents a score of 5 putting R1 at a high risk for leaving the facility unattended. The evaluation also documents the interventions of visual checks every 15 minutes. R1's evaluation has a designated spot for the staff member who completed the assessment to sign, however there was no documentation of a staff member's signature. That line was blank. R1's Baseline Care plan, dated 3/8/22, documents, Identified Safety Risks: Safety plan of care: high risk fall assessment, poor safety awareness, high risk elopement assess, initiate behavior monitoring, 15 minute checks, [CONDITION(S)] medication use, gait, balance, elopement book. R1's Care plan has a designated spot for the staff member who completed the care plan to sign, however there was no documentation of a staff member's signature. That line was blank. R1's Ambulance Pre-hospital Care Report, dated 3/9/22, documents, Alarm time: 1:13 a.m.; At Scene: 1:17 a.m.; Patient contact: 1:18 a.m.; Leave Scene: 1:31 a.m. Narrative: Dispatched to facility for a [AGE] year old female patient (R1) fall from building. (R1) states that she jumped out of window. (R1) relates she was going to see God. (R1) relates she struck the ground and felt like her legs were floating. (R1) is unsure how long she was on the ground. (R1) complains of pain to spine directly between the shoulder blades, and not being able to feel from abdomen down. (R1) denies any head, and pelvic pain by palpation. Arrived on scene to find (R1) lying on the ground on her left side. Window is broken on 2nd story of building. (R1) appears to have landed on dirt. (R1) is conscious and alert but not fully oriented. Skin normal in color, cold, and dry. (R1's) back exposed with no bruising or swelling noted. (R1) does have significant pain while palpating in between shoulder blades. (R1) complains of pain while neck is palpated. (R1) is able to move upper extremities, but cannot move or feel lower extremities. R1's Emergency Department (ED) Intervention/Assessments, dated 3/9/22, documents, Time patient is triaged: 1:38 a.m. EMS (Emergency Medical Services) called (V13, R1's POA-Power of Attorney) of (R1), stated was called to facility for (R1) who fell out of 2nd story window onto ground. Reports unsure of how long (R1) was outside on the ground before staff aware (R1) was gone from her room, but her room window was open. Reports (R1) was admitted to facility just yesterday, and had been trying to get out all day. No report received from staff from facility. (R1) states she was, 'On her way to see God'. R1's emergency room Note Report, dated 3/9/22, documents, Chief Complaint Comments/Description: [AGE] year old female patient (R1) facility resident, history of [CONDITION(S)] disorder, Hypertension, jumped from second floor of the facility as she wanted to meet God. (R1) was lying in the cold weather for approximately 20 minutes. On arrival to the ED, (R1) is awake alert. She has no strength or sensation from the mid chest down. She also complains of neck pain and mild upper back pain. R1's Emergency Department note-Disposition/Discharge, dated 3/9/22, documents, 3:52 a.m.: Life flight arrived. 4:06 a.m.: Temperature 91.8. (R1) transferred. R1's Discharge Information, dated 3/9/22, documents, Emergency Discharge Disposition: Discharge/Transfer to General Hospital. Clinical Impression: Multiple vertebral fractures, Spinal cord injury, [CONDITION(S)] shock, Hypothermia. Emergency discharge comment: transfer to general hospital trauma. R1's Level 1 Trauma note, dated 3/9/22, documents, (R1) brought to Trauma 1 by EMS. R1 arrived to trauma room alert, disoriented to situation, fully immobilized in cervical collar. Per life flight, (R1) jumped out of a second story window, presumed suicide attempt. Life flight reports (R1) was down for approximately 30-45 minutes and found by staff of nursing home facility. In report from local hospital, (R1) has a C2, T4 fracture, T8 spinal cord injury and broken left sided 4 and 5 ribs, received 2 Liters Normal saline and was started on a [MEDICATION(S)] (medication to treat low blood pressure) drip. In report from lifeflight, (R1) has bilateral Hemothorax (collection of blood in chest wall). (R1) arrives alert but confused. On arrival, (R1) was noted to be hypothermic and placed on a bear-hugger; chest tube placed on right lateral side, bloody drainage observed in chamber and ART(Arterial) line placed for Blood pressure management. R1's Neurosurgery Consult Note, dated 3/9/22, documents, (R1) with a history of Hypertension, depression, and [CONDITION(S)] who presents after presumed suicide attempt jumping from a 2nd story window and found to have T2 lamina fracture, T4 3 column burst fracture, and T8 3 column fracture dislocation with associated [NAME] (American Spinal Injury Association) A SCI (Complete Spinal Cord Injury) at approximately T8. Given patient is [NAME] A SCI, no emergent Neurosurgical intervention. Patient will need fixation of her fractures when she is medically stable from her other injuries. HPI: (R1) states she is unable to feel her legs and unable to move them. She has no issues with her arms. She denies sensation changes in her arms. Most of her pain/complaints come from her right ribs where a chest tube was just placed prior to exam. R1's Hospital Physician progress note, dated 3/10/22, documents, Critical Care Attestation: The patient has critical illness or injury with acute organ system dysfunction. There is a high probability of imminent or life-threatening deterioration in the patient condition. Critical Care Diagnoses: [CONDITION(S)] shock, spinal cord injury, [CONDITION(S)] (paralysis of the legs and lower body). R1's Surgical/Trauma ICU (Intensive Care Unit) Daily Progress note, dated 3/10/22, documents, List of Acute Injuries/Acute Problems: Bilateral C2 Lamina fracture, T4-3 Column Comminuted fracture, T8 3 Column fracture with dislocations, Numerous Thoracic Spinous Process fractures, Posterior Element fractures of T2-3, [NAME] A Spinal Cord Injury T8 Sensory Level, Spinal Shock, Paraspinal Hematoma, Right Hemothorax status/post Chest Tube, Left sided 9th Rib fracture, Right sided 3rd, 5th-9th Rib fractures, Left Pulmonary Contusions, Bilateral Pleural Fluid/Hemorrhage. R1's Psychiatric Consult note, dated 3/10/22, documents, (R1) presented to the hospital after being life-flighted from a hospital in nearby city on 3/9/2022 with injuries from a fall from a 2nd story building. (R1) sustained serious back injuries. (R1) states she was at her nursing home when she jumped out of a window because she wanted to go home. (R1) indicates, 'Sometimes you just have to take a [NAME] of faith.' (V13, R1's Power of Attorney) indicates (R1) has had problems with believing there are demons around her and may have been trying to get away from the demons. The same day she arrived (to the facility), all the windows had been opened because of the warm weather, and this allowed (R1) to clear the screens and exit out the window. R1's Psychiatric Progress note, dated 3/14/22, documents, (R1) reports she was following the voice of God that she hears through her third eye, telling her that she needed to get out of the (facility) by midnight to come be the Queen by his side or she'd not see him again. (R1) used her cane to get the window cover out of the way, was having trouble getting out the window, prayed for assistance to shimmy down the wall 'like Spider- Man' and took 'a [NAME] of faith'. She reports she was going to be with God physically, not trying to end her life to go with God in that manner. She denies she was suicidal or that she has any desire to end her life at this time. R1's State Agency Notification, dated 3/9/22, documents, Date of Incident: 3/9/22. Time of Incident: 12:55 a.m. [AGE] year old newly admitted alert and oriented female (R1) with diagnoses to include [CONDITION(S)] disorder, Major mental health disorder, Depression, Chronic back pain, Hallucinations, Delusions, and [CONDITION(S)] was noted on the ground outside her bedroom window. Staff immediately responded and called 911 per Physician order. In conclusion, it is determined (R1) was attempting to exit the facility to return home and to go to God. (R1) has long standing history of delusions that include going to God or receiving messages from God. No history of any suicidal ideation's or attempts. Facility concludes that (R1) went out the window not realizing it was a 2nd story window. (R1) was noted to be on the ground on her side/back with no visible injury with complaints of loss of feeling in her feet. CT (Computed Tomography) at local ER concludes acute non-displaced fracture extending across C2 lamina and the base of C2 Spinous process, acute comminuted distracted fracture extending obliquely through the T8 and T9 vertebral bodies, acute non-displaced fractures involving T1-T4 Spinous processes, acute mildly displaced fractures involving the right T4-T10 transverse processes, and acute minimally displaced fractures involving the medial aspects of the left 4-9 ribs. Incident Investigation Form, dated 3/9/22, documents, Person Being Interviewed: (V7, Registered Nurse/RN). Describe: (R1) arrived and I went to her room, and introduced myself. Pleasant. Disheveled. Cooperative. Answered questions appropriately. Confusion with dates. Explained her psychiatric history to me, and said she was trying to get adjusted. I left and went back after medication pass and did her full assessment. She was cooperative. I went over her medications with her and talked about pharmacy's concern related to a potential drug interactions. (R1) was calm, no attempts to leave her room. Said she was waiting for her daughter (V13). On 3/10/22 at 1:50 p.m., V7 stated, I did (R1's) admission. I asked if she was having hallucinations or delusions. She didn't mention auditory, but said she said she was having visual hallucinations. (R1) was alert but had some confusion. She was calm, but she was disheveled. I had her from 3:30 p.m. to 6:00 p.m. I did not do (R1's) elopement evaluation. I put her on 15 minute checks because its just protocol for the first 3 days, but I didn't know that she was at risk for elopement. I started to fill out the initial care plan. I didn't know (R1's) required assistance so I didn't do that area. Under Safety plan of care, I only marked psych medication usage. I didn't mark any of this other stuff about elopement (pointing to the baseline care plan). I didn't finish the care plan so I passed it on to (V8 LPN-Licensed Practical Nurse). When (R1) got there, I discussed with the CNAs (Certified Nursing Assistants) to make sure they were doing their 15 minute checks right away. (V10-CNA-Certified Nursing Assistant) was on my hall that evening that was assigned to (R1). I never got any information from management regarding (R1's) behaviors or anything. I got a packet of papers when she got here from the hospital and that was it. No management staff was here when (R1) got here. On 3/10/22 at 2:45 p.m. V10 (CNA) stated, (R1) was on my hall that evening. She stayed in her room the whole night with the exception of when she needed her medication because (V13, R1's Power of Attorney) brought her dinner. She did not exhibit any behaviors. I spent some time with her. No wandering. (R1) did have me crack her window, because it was really hot in her room. I opened the window about two inches around 6:00 or 7:00 pm. We can open the windows at the request of the resident. A lot of the residents request their windows to be opened because of how warm it is up there (Second floor). I was assigned to doing her 15 minute checks when she got to the facility. V10 confirmed that (R1's) 15 minute checks started at 7:00 p.m. on the 15 minute check sheet. V10 stated, Honestly I don't do the 15 minute charting thru the night, I don't have time. So, I do it at the end of the night and I estimated that she had gotten to the building at approximately 7:00 p.m. I was surprised that this happened. I didn't get any information about her when she got to the facility. I thought she was just being admitted from home. I didn't even know she had a psychiatric background and behaviors until after the incident. We don't normally get that kind of information given to us, we have to feel the residents out for ourselves. I didn't know any of her history, so I couldn't pass it on to the next CNA working. Incident Investigation Form, dated 3/9/22, documents, Person Being Interviewed: (V9, CNA). Describe: Took report from (V10) about new resident (R1) that was very nice. I checked my paperwork to see (R1) was on 15 minute checks. I went and checked my other hall and (R1) was in the nurses' office with the nurse (V8, Licensed Practical Nurse). When I returned, (V8) had sent her to the bathroom. I went to check her room and she wasn't there. So, I started checking everywhere, and she was on another hallway downstairs. She then wouldn't respond to me verbally. So, I redirected her to her hall and room with (V8). (R1) was stating about God's will. I was doing cares and bed check and then we redirected (R1) back to her room. Helped her lay down. She complained of being hot and (I) cracked her window. I left with the door cracked open so I could see her. She was in the bed by the door, the other bed is vacant. (This was) at 12:45 a.m. When I came back for 15 minute checks, the door was shut. So I opened it and she was not in her room or her bathroom and the window was wide open. I went to the window and (R1) was outside on the ground. Myself and (V11, Licensed Practical Nurse) went to (R1) immediately. On 3/13/22 at 11:55 p.m., V9 (CNA) stated, When I got to work, the only report I got was that (R1) was a nice lady and possible one assist or a reminder to use the restroom. I had no idea of her psychiatric history and about leaving her home. I did not get that she was an elopement risk. She was 15 minute checks because she was new to the facility. When I got there she was talking to the nurse on the floor in his office. At that moment she was very talkative about her medicine so I had (V8, Licensed Practical Nurse) explain it to her. She asked me and I directed her to the nurse. I went to the other side of the floor, due to a resident needing my help during that time. (V8) directed (R1) to the restroom across from the office. When I came back to the hall around 12:00 am, I asked (V8) where (R1) was, and (V8) said he thought she walked towards me. I ran checked her room and she wasn't there. I went downstairs checked A wing she wasn't there, and as I was running to B wing I heard the door alarm on pathways. I ran that way as another CNA was meeting (R1) at the door before she went out. She wouldn't really talk to me she just kept saying 'Gods will God's will' over and over again. In my head, I was thinking maybe she's not all there. I redirected her upstairs to (V8) because she was adamant about her medications again. I went to do some cares. Then, I went back and directed (R1) to her room and helped her into bed. I asked if she needed anything, and (R1) said she was hot. (R1) asked if I could open the window for her, and I told her I could open the window just a bit. I put her roommate's, who was in the hospital, stuff like her wheel chair and bedside table in front of the window because I was afraid since she asked me to open the window and she tried to get out the door. At 12:45 a.m. I was leaving the room and (R1) asked if I'd shut the door. I didn't want to shut the door so I could still see her. I told her I would crack the door so I could still see her from the hallway. When I got back to my desk to check my 15 minute checks at about 1:00 a.m. her door was shut completely. I opened the door and the window was wide open. She wasn't in her bed. I ran to the bathroom, and I opened her bathroom door. She wasn't in there. At this time, V9 paused starting to cry, and stated, I'm sorry. I looked out the window and saw her body laying on the ground. V9 was crying unable to speak for a moment. Then, V9 stated, I immediately went to my nurse on the hall (V8) and told him (R1) had fallen out of the window. He was in shock, and ran to her room. Since we only have two nurses, one upstairs and one downstairs, in the building on third shift I ran downstairs and grabbed that nurse (V11) to run to her. When I got out there to (R1) she kept repeating, 'I can't feel my legs.' I let (V11) assess her because I had to take a step back and take a minute. (R1) didn't say anything about the fall she just kept saying she couldn't feel her legs. There was a pillow, her cane and a coin purse laying by her. The window screen was under her body. (R1) was facing the ground and her legs were twisted and her arms were weird. From the window view, you could tell something was going on with her spine. Her head was two inches from the cement block. I ran upstairs to get her paperwork and the nurse was getting a blanket for her when I got back out there. She didn't seem cold. It was cold outside. V9 also stated, I didn't want to go past the point I opened it (R1's window) to. It was really warm during the day, and our heat was on so it was warm in the building. She was one of a few residents who wanted to have her window open to get some air flow because it gets pretty warm up there. As far as I know, all of the windows open all the way. Incident Investigation Form, dated 3/9/22, documents, Person Being Interviewed: (V8/ LPN). Describe: (V9) was on (conducting) 15 minute checks and came running down the hall, and told me that the window was open and the resident (R1) was on the ground. I had her go down, get (V11/LPN) and go assess her because they could get there faster. I did look out the window, and (R1) was talking, and said she couldn't move her legs. So I went to nurses' station and called supervisors and started an incident report. On 3/14/22 at 11:06 am, V8 (LPN) stated, I came on (shift) at 6:00 p.m. I got in report that we had a new woman that was pleasant, very with it, but tends to wander in her mind in the way she talks. She had just got moved so keep an eye on her. (R1) was 15 minute checks that was about it. I did not do her physical assessment. I did not do the elopement nor the baseline care plan. I did not know she was an elopement risk. Shortly after I got to facility, (R1) wanted to know when her medicine would be in the building. I told her it should be anytime. She told me she'd wait until the medicine got here and she waited. I think it was around 11:00 p.m. that I gave her medications. We talked for about 45 minutes she was very lucid but every once in a while she would talk about people that weren't there. When she left she went to the right of the nursing desk towards D Hall, I told her she was going to the wrong way, because she lives on C Hall. I saw (V9/CNA) coming from the D Hallway. I told (V9) that (R1) had walked out of the wrong way. (V9) had soiled linens, so she had to get rid of those and then went looking for her. She didn't find her on C or D wing. When she got downstairs she checked A and B she heard alarm and (R1) was trying to go out Pathways door. (V9) got to her and redirected her back to the floor. (V9) took (R1) to her room. Next thing I know, (V9) came running up the hall and said the lady (R1) is outside laying on the ground and wasn't moving. I told her go downstairs and get (V11) that would be quicker. I went to (R1's) room, and the window was wide open. (V9) and (V11) were there at that time and (R1) was talking saying she couldn't feel her legs. V8 also stated, Staff often open windows to let air in. I started to suspect she was an elopement risk when she went to the right when I was trying to redirect her. Incident Investigation Form, dated 3/9/22, documents, Person Being Interviewed: (V11/LPN). Describe: At 1:00 a.m., I was headed to B wing and (V9/CNA) came running and asked me to come with her and then she told me that the new lady (R1) 'fell out of the window.' Going past (V14/CNA) I told her to call 911. I go outside and (R1) was laying on her back towards her right side. She told me her name and that she couldn't feel her feet. I took (V14's) phone and called 911 myself at 1:11 a.m. They were here by 1:15 a.m., (R1) had her cane, coin purse, and a blind maybe. No distress. Calm. I got her a blanket and then she said her back hurt. Right arm was under her. On 3/13/22 at 11:40 p.m., V11 (Licensed Practical Nurse-LPN) stated, I saw her one time when I delivered medications to the C wing nurse (V8). (R1) was in the medication room. (R1) came down to pathways hall and tried to exit the building. I was on A or B wing at the time. The CNAs from C wing and pathways stopped her and got her back upstairs. Around 11:00 pm or 11:30 pm, (R1) tried to go out the door. The CNAs said they redirected her. At 1:00 am, I was going from pathways to B wing to relieve a CNA for lunch, on the way there (V9) met me halfway. (V9) came running and said to drop my stuff and go with her. She said the new lady (R1) had fell out of the window. We ran out A wing door and around the corner. Between A Wing and the [NAME] shop building next door, (R1) laid on the ground in the grass. There was a cement block that the gutter sits on, her head was resting on the block. She said that she couldn't feel her feet. I asked her if she was hurting anywhere else and she said between shoulder blades and back. I got on the phone to 911 right after that. It was soggy outside. It was cold that night. (R1) was laying on the screen from her window. (R1's) cane was next to her and a coin purse. She was laying on her back towards her right side with her legs bent kind of like a side lying position. She didn't look like her legs were broken or anything. Her right arm was underneath of her, and her left arm was open back. She didn't say anything about what happened. I asked her if she was hurting, then got on phone with 911. After getting off phone I got her a blanket. V11 also stated, I have opened windows in the building when residents complain of being hot. On B wing (locked unit) the windows are screwed shut, but there are no stops on any of the other windows. They look like newer windows but hard to open. Once the window is open a little bit it makes it easier to open them all the way. The window opened enough that (V8) had his whole upper body out the window talking to us while we were with (R1). On 3/10/22 at 10:00 a.m., R1's room had two windows that slide up to open. The left window had no screen in it. This window was able to be opened approximately 24 inches. Outside of the 2nd story window is a direct drop to the ground. Window on the right side partially opened approximately 6 inches with a screen in the window. V12 and V17 (Both CNAs) present in R1's room. V12 stated, This is the window that (R1) went out. The one without a screen. On 3/14/22 10:00 a.m. V18 (Maintenance) stated, All of the windows with the exception of the locked unit and one room, are able to open all of the way with no stoppers. The residents get hot at times upstairs and want their windows opened for some fresh air and to cool it down. On 3/14/22 at 11:25 a.m., V4 (Resident Care Coordinator) and V5 (Care Plan Coordinator) were outside explaining the area where R1 was found. V5 stated, (R1) was found here. V5 was pointing to the wet ground directly underneath of (R1's) window. R1's window was approximately 15 to 20 feet from the ground. V4 and V5 confirmed the distance. Below the window to the right was a concrete gutter slab. V5 stated, I was told her head either hit that block or was right by it when they found her. Directly to the left of the area, but still under the window, was an electrical wire containment post. On 3/10/22 at 2:30 p.m., V2 (Director of Nursing) stated, Prior to (R1) coming (to the facility) we were aware that she had psychotropics and psychiatric diagnoses. The only thing in her (hospital) notes was that 'God would tell her to do things.' I accepted her weeks before she actually came. Her delusions and hallucinations were minimal. The admission process is to start all of their assessments, including physical, elopement, fall, Braden (skin risk) etc, Once high risk for elopement is identified the nurse will let us know (management). Every new admit is on 15 minute checks for the first 72 hours regardless. The interim care plan is marked by the nurse saying they are a high risk for elopement. The intervention put into place was 15 minute checks nothing else for (R1). V2 also stated, All of the windows open all the way. The windows should be closed with no staff in the room. (R1) had asked the staff member (V9/CNA) to open the window because she was hot. So (V9) cracked it open and left the door cracked open. When the door was closed (V9) knew something was up. When (V9) opened the door, she saw the window was completely open and the screen was pushed out. (V9) immediately looked out the window when she didn't see her in the room and saw (R1) on the ground. On 3/14/22 at 9:00 a.m. V15 (Social Services Director) stated, I saw (R1) for about five minutes, because she came at the end of my shift. My plan was to do her admission packet the following day. Prior to her coming, the behavior mentioned was God telling her to do things. She was hearing voices. If a resident comes in and they are an elopement risk we put them on B wing (locked unit) or put them close to the nurses' desk to be monitored. (R1's) room was not on the B wing or near the nurses' desk. Other than that, I don't know what we do for them. I would do behavior tracking for her, but I did not implement any behavior tracking for her prior to me leaving. Other than her hallucinations, I didn't get a whole lot of information that would trigger me to implement behavior tracking right away. Usually (V2) goes to the nurse directly on the floor to let them know the main thing they need to watch for. We knew she wasn't taking her medications and having highs and lows with the hallucinations that (V13) couldn't take care of her anymore. She seemed alert and with it. I didn't do the whole cognitive assessment. She answered the few questions appropriately that I asked her about. If there is an increase in behaviors, the staff are to fill out a behavior referral sheet so we can review it during the morning meeting to make any changes. I never did get one nor did I hear about her exit seeking. If she did attempt and opened the door, we normally move them to the secured unit, and there is a bed open at this time. If it happened during the day, we could have put a 1:1 with her but that's not feasible on third shift. The only windows in the facility that do not open completely are the windows on B wing because of the residents with Dementia. I'm sure there are other residents on the second floor that are elopement risks. On 3/15/22 at 9:15 a.m., V16 (Care Plan Coordinator-CPC) stated, When a resident is admitted , the admitting nurse does the initial assessments including the elopement risk and does the interim baseline care plan. If a resident is an elopement risk, they will notify Social Services and Nursing. (V2) does the communication with the nursing staff prior to admission to inform the floor nurse, and the floor nurse receives report from the hospital. V16 also stated, As far as I know all of the windows open completely because in the warm months, the rooms all have windows units so they would have to open. A few of the rooms get warm and the residents who would like it cooler want the windows opened. On 3/14/22 at 1:50 p.m., V2 stated, (V7, Registered Nurse) or (V8, Licensed Practical Nurse) should have been the ones to complete the baseline interim care plan and the elopement assessment. I did not complete them, and I know that no department heads were here when she was admitted . So the only thing I can think of is that they were filled out the following morning after the incident. On 3/14/22 at 3:10 p.m., V3 (Regional Director of Operations) stated, (V2, Director of Nursing) or (V4, Resident Care Coordinator) should be taking the admission screening paperwork, gather the information, and share it with the admitting nurse. Because of a late arrival of (R1), the floor nurse would do the initial baseline care plan. That nurse should be communicating that information with the other nursing staff. The nurse on duty would start the admission process and whatever doesn't get done would get passed on to the next shift to complete or get done as much as they can get done. V3 also stated, The windows were never assessed for potential accident hazards prior to this happening. On 3/15/22 at 8:30 a.m., V3 stated, No one is admitting to doing (R1's) elopement assessment prior to the incident. So it

Based on interview and record review, the facility failed to provide adequate supervision to prevent sexual abuse for two of three residents (R1 and R2) reviewed for abuse in the sample of three, and failed to send R2 for a medical evaluation following a possible sexual assault, resulting in a loss of potential evidence. These failures resulted in two residents with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was found lying face down on top of R2 with R1 and R2's genitals touching. R1 stated R1 and R2 had sexual intercourse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-2-22, the facility remains out of compliance at Severity level II as the facility continues to report all allegations of abuse to the regional consultants and the facility Quality Assurance Committee for follow-up and review, continues to in-service all staff monthly for three months and then quarterly for three more times on the Abuse Prevention Policy and reporting suspicion of a crime, and R1 and R2's sexual behavior interventions are implemented. Findings include: The facility's Abuse Prevention Program policy, dated 11-28-16, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, and exploitation as defined below. This will be done by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of resident, and dementia management and resident abuse prevention. This facility is committed to protecting our residents from abuse by anyone including, but no limited to, facility staff, other residents, consultants, volunteers, and other agencies providing services to the individuals. Sexual Abuse the non-consensual sexual contact of any type with a resident. Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs. Possible sexual abuse: Determine if the allegation involves either physical sexual contact involving penetration, verbal harassment, or physical contact that did not involve penetration. If an allegation of physical sexual contact with penetration is involved: Do not shower, bathe, or change the clothes of the person attacked. If clothes have been changed, save the clothes for inspection. Contact the police. In cooperation with the police, have the resident examined at the hospital. Leave any bed linens in place. Do not touch or move anything in the area of the alleged offence. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These same POS's document R1 receives [MEDICATION(S)] 250 mg (milligrams) three times daily currently for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Minimum Data Set (MDS) Assessment, dated 11-19-21, documents R1 has moderately impaired cognition. R1's Progress Note, dated 6-27-20 and signed by V27 (R1's Physician), documents, Increased behaviors. Sexually inappropriate. Grabbing at nurses. Sex comments to everyone. Will add [MEDICATION(S)] 125 mg (milligrams) daily for sexual behavior. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS Assessment, dated 12-30-21, documents R2 is severely cognitively impaired and is severely impaired with daily decisions regarding tasks of daily life. This same MDS documents R2 requires oversight/supervision with walking in R2's room, in the corridor, and off of the unit. V7's (CNA/Certified Nursing Assistant) Incident Investigation Form, dated 2-21-22 at 10:25 AM, and signed by V1 (Administrator), V2 (Director of Nursing), and V7 documents, (I) went into (R1's) room to get the television remote. (R1's) privacy curtain was closed. I went around the curtain and saw (R1) with (R2). (R1) was only wearing a shirt. (R2) had a shirt on. (R1) was laying on top of (R2). (I) could not tell if intercourse was happening. No pain or distress was noted with (R1 and R2). Immediately separated (R1 and R2). V16's (Housekeeper) Incident Investigation Form, dated 2-21-22 at 10:40 AM, and signed by V1, V2, and V16, documents, On B-wing with (V7). (V7) went to get the television remote from (R1's) room and (I) was called over to (R1's) room. (I) entered and saw (R1) on top of (R2). Both (R1 and R2) with only shirt on. (I) did not know if intercourse was happening. (R1 and R2) immediately separated by (V7). (I) went to get the nurse (V13/Registered Nurse/RN). Neither resident in distress. No further behaviors noted after incident. V13's (RN/Registered Nurse) Incident Investigation Form, dated 2-21-22 at 12:50 PM, and signed by V1, V2, and V13, documents, I was on A-wing and (V16) came and said I was needed on B-wing and told me about the incident (R1 and R2). (V16) said (R1 and R2) were separated. I got up there (B-wing) and (R1) was in the television room sitting and (R2) was still in the room being dressed. No distress or injuries noted. V26's (Activity Assistant) Incident Investigation Form, dated 2-21-22 at 11:50 AM ,and signed by V1, V2, and V26, documents, (R1) does make inappropriate remarks at times to women. The facility's IDPH (Illinois Department of Public Health) Notification Form, dated 2-25-22, and signed by V2, documents, Date of Incident: 2-21-22. Time of Incident: 8:42 AM. Name of Resident: (R1 and R2). Location of Incident (resident room). Alleged Sexual Abuse. Description of Accident, Causes, Injuries, and Action Taken by Establishment as a Result of Accident: (R2) with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1's) diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Both residents reside on the memory care unit of the facility. Upon staff assessment, residents were noted under the blankets and were unable to confirm if any inappropriate sexual behavior occurred. (R1 and R2) were immediately separated. After thorough investigation and interviews, the facility was unable to conclude if any sexual behaviors occurred, but was able to conclude that there was inappropriate touching. On 3-2-22 at 8:45 AM, V7 (CNA/Certified Nursing Assistant) stated, On 2-21-22 around 9:00 AM, the remote was missing to the television room and usually (R1) takes the remote to his room. I went to (R1's) room to get the remote and noticed (R1's) door was closed and (R1's) cubicle curtain was closed. When I went around (R1's) curtain I found (R1) lying on top of (R2) facing each other in (R1's) bed. Both (R1 and R2) were naked from the waist down and their clothes were on the floor. I yelled for help so I would have a witness (V16/Housekeeper) as to what I was seeing. (R1 and R2's) private parts were touching, but I did not look to see if (R1) had an erection or if (R1 and R2) had sexual intercourse. (R1 and R2) did not have a blanket on them. I was just trying to get (R1 and R2) separated and dressed as quickly as I could. The last time I saw (R1 and R2) was around breakfast time at 8:00 AM. (R1 and R2) are on 15-minute visual checks, but I do not remember if we were able to get those done that day. (R1) does like the female residents and does tell them they are pretty. (R1) will also hug female residents. (R2) wanders continuously in and out of other resident's rooms. It is hard to supervise all of the residents on this wing. On 3-2-22 at 11:50 AM, V16 (Housekeeper) stated, On 2-21-22 (V7) yelled at me to come help her in (R1's) room. When I entered (R1's) room, I saw (R1) on top of (R2) in (R1's) bed. Both (R1 and R2) were naked from the waist down and facing each other. (R1 and R2's) private parts (genitals) were together and touching. I am not sure if (R1 and R2) had sexual intercourse as I immediately left the room to get a nurse (V13/Registered Nurse/RN). I never returned to (R1's) room after that. (R1) makes remarks to most all of the female residents telling them they are attractive and pretty. (R1) also watches female residents adjust their bra straps. (R1) holds female resident's hands and pats female residents on the shoulders. I have never seen (R1) do any of this with female residents. On 3-2-22 at 9:45 AM, V2 (Director of Nursing) stated, I did the investigation from the incident between (R1 and R2) on 2-21-22. There were two employees (V7 and V16) that witnessed the incident. (V7) had went into (R1's) room to get the remote and saw (R1 and R2) naked from the waist down and (R1) on top of (R2) in (R1's) bed. (V7) stated she did not know if (R1) had an erection and was unsure if (R1 and R2) had sexual intercourse as she was just in a hurry to get (R1) off of (R2) and dressed. I interviewed (R2) and asked her if she and (R1) had sex. (R2) seemed embarrassed and wanted me to leave her alone. I think (R2) felt bad about herself. (R1) was moved to a different hallway with constant supervision and (R2) was moved to a different hallway and started on [MEDICATION(S)]. I know (R1) is on [MEDICATION(S)] for sexually aggressive behaviors, but I am not exactly sure what those behaviors are. When I did the investigation (V1/Administrator) was in the room during the staff interviews and was fully aware that (R1 and R2) were found in bed with (R1) on top of (R2), and naked from the waist down. (R1) is alert enough to know that if he said he had sex with (R2) then he did. We did not send (R2) in for an assessment or to have a rape kit done after this incident between (R1) and (R2). On 3-2-22 at 10:00 AM, V3 (Resident Care Coordinator) stated, I interviewed (R1) after the incident on 2-21-22. (R1) told me that he was on top of (R1) and could not control his emotions. (R1) stated he felt 'amorous' which means having a strong sexual desire. (R1) felt guilty that he could not control his sexual desire. On 3-2-22 at 10:30 AM, V12 (R2's Family Member) stated, (R2) was married to my dad for [AGE] years. He was (R2's) only love. After dad passed away in 2004, (R2) lived with her sister and with me for around [AGE] years. (R2) had no desire to have sexual relations with any other man and did not have a boyfriend. (R2) has Dementia and would be so embarrassed if she knew she was making sexual advances towards men in the facility. (R2) definitely would not want to have any kind of sexual interaction with another male. When (V1) notified me of the incident with (R1), (V1) only told me that (R1) and (R2) got 'handsy' with each other. I was not aware that (R1) was found on top of (R2), or that (R1) and (R2) were naked from the waist down. That is totally unacceptable that this happened. On 3-2-22 at 11:00 AM, V19 (R1's Family Member) stated, I know (R1) has to take medicine for sexual behaviors. (R1) got in trouble at the previous facility he lived at for taking pictures of female resident's butts. At the previous facility (R1) would bring different women into his room from out in the community. (R1) would know if he had sex with (R2). On 3-2-22 at 11:15 AM, V1 (Administrator) stated, (R2) wanders in and out of other resident's rooms. I know (R1) is friendlier towards female residents. (R1) pats female residents on the shoulders. I was not aware that when (R1) and (R2) were found together on 2-21-22 that both (R1) and (R2) were naked from the waist down. I was in with (V2) when the interviews were done, and I signed the witness statements. (R2) was not sent in for an examination to the hospital. On 3-2-22 at 11:45 AM, V25 (Social Service Director) stated, (R1) had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . I know (R1) tries to hug women residents. On 3-3-22 at 10:30 AM, V22 (CNA) stated, (R1) likes to hug on female residents. (R2) wanders in and out of all the resident's rooms. On 3-4-22 at 11:15 AM, V26 (Activity Assistant) stated, (R1) lives on the closed dementia unit. (R1) was always trying to put lipstick on the women residents. (R1) likes to rub the women resident's shoulders and backs. (R1) tries to get women residents to come into his room and has them sit next to him on the bed. (R2) would go into his room and sit next to him more than the other women residents. (R1) targets (R2) more than the other residents. (R1) targets the female residents that are more declined. (R1) knows what he is doing and looks around to see if anyone else is watching. (R1) knows what he is talking about and would know if he had intercourse with (R2). On 3-4-22 at 2:35 PM, V15 (CNA) stated, I have found (R2) straddling (R3) on (R2's) bed two different times. (R2's) genital area was straddling (R3's) genitals. (R3) has his hands on (R2's) breasts outside of her clothes. Both (R2) and (R3) had their clothes on when I found them. I separated (R2) and (R3) when I found them. I notified the nurse. I cannot remember what nurse I notified. I did not notify the Administrator. An Immediate Jeopardy was identified on 3-2-22 at 12:00 PM. The Immediate Jeopardy began on 2-21-22 when R1 was found lying face down on top of R2, with both R1 and R2 being naked from the waist down, exhibiting a sexual act. On 3-2-22 at 2:30 PM, V1 (Administrator), V2 (Director of Nursing), and V24(Director of Clinical Operations) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. An investigation of abuse was completed and reported to IDPH (Illinois Department of Public Health), and the alleged perpetrator's/victim's (R1, R2) family and physicians were notified of abuse. 2. Both R1 & R2 were immediately assessed for signs of injury or trauma with no evidence noted. 3. In-servicing was done by V24 (Regional Director of Clinical Operations) of all staff on the Abuse Policy and Sexual Harassment policy and R1 and R2's tracking of sexual behaviors and the implementation of new care planned interventions. 4. On 2-21-22, R1 was placed in a private room on a separate unit with 15-minute visual checks in place. 5. On 2-23-22, 1:1 (One on One) staff monitoring of R1 was implemented by V24. 6. On 2-21-22, R1 received an increase in his [MEDICATION(S)] medication and the increase was updated on R1's care plan. 7. On 3-2-22, R2 was placed on 1:1 staff monitoring. 8. On 3-2-22, V17 (Care Plan Coordinator) updated both R1 and R2's care plans to include inappropriate sexual behaviors towards peers with new interventions to include 1:1 supervision and their current ability to consent to sexual relationships. 9. On 3-2-22, V25 (Social Service Director) and V17 conducted interviews with all residents to ensure the residents currently feel safe in the home, and the residents were educated on whom they can report to should a fell ow resident make them feel uncomfortable. 10. On 3-2-22, V24 in-serviced V1 and V2 on facility abuse investigation procedures. 11. On 3-2-22, V25 completed an assessment that included interview and observation of R1 and R2 and consultation of R1 and R2's responsible parties on 3/2/2022, which determined that R1 and R2 were unable to actively consent or participate in consensual sexual behaviors or intercourse at that time. Completion date 3-2-22.

Based in interview and record review, the facility failed to provide R1 with care planned nutritional safety interventions; failed to provide adequate supervision and one staff physical assistance while eating as documented per R1's care plan and MDS (Minimum Data Set) assessment; and failed to make sure the care plan interventions were reflected on R1's physician order sheets (POS's) for one of three residents (R1) reviewed for supervision during meals in the sample of three. These failures resulted in R1 feeding himself, unsupervised, resulting in R1 choking which caused R1's death. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity level 2 as the facility continues to provide weekly in-services for 4-weeks on facility Policy and Procedures regarding Dining Room Procedures, Notification of Change of Condition, Advanced Directives, CPR, Emergency Care, Airway Obstruction & Thrust, Diet Orders, Therapeutic & Mechanically Altered Diets & POLST (Physician's Order for Life Sustaining Treatment). The Immediate Jeopardy began on [DATE] when the facility failed to provide adequate supervision and one staff physical assistance while R1 was eating R1's noon meal, as documented per R1's care plan and MDS (Minimum Data Set) assessment; and failed to make sure the care plan interventions were reflected on R1's Physician Order Sheets (POS). These failures resulted in R1 feeding himself, unsupervised, resulting in R1 choking which resulted in R1 experiencing brain [CONDITION(S)] which caused R1's death. The Immediate Jeopardy was identified on [DATE]. Findings include: R1's Profile Face Sheet, not dated, documents, Diagnosis: Diffuse tbi (traumatic brain injury) with loss of consciousness of unsp(specified) duration, [CONDITION(S)]. R1's Care Plan, dated [DATE], documents, Feed Resident Meal: Resident can at times eat very quickly, overfill mouth with food, will stand and pace while eating, res(ident) unable to follow basic commands including recognizing and adhering to safety; and Provide foods in forms easily picked up-sandwiches, finger foods etc(etera), as able and res(ident) tolerates. R1's Physician Orders Sheet, dated [DATE], does not include finger-foods as part of R1's dietary order. Dietary Admission Assessment, dated [DATE], documents, R1's Dental Status-few teeth poor condition. R1's Minimum Data Set (MDS), dated [DATE], documents, R1's Functional Status: H. Eating as Self Performance-2 (limited assist) and Support-2 (one-person physical assist). Court document entitled In the Circuit Court for the Twenty-Third Judicial Circuit [NAME], Illinois, dated [DATE] (fax), documents, Physicians Report (V14), as a physician licensed to practice medicine in all its branches in the State of Illinois, submits the following report on the above named (R1) alleged to be a disabled person, based on an examination of the respondent on [DATE]. 1. Describe the nature and type of the respondent's disability: Total cares ,d+[DATE] pt (patient) with severe traumatic brain injury, non-traumatic [CONDITION(S)], nonverbal, severe behavior issues, cannot do any activities of daily living. 3. State whether in your opinion, the respondent is totally or only partially incapable of making personal and financial decisions, and if the latter, the kinds of decisions which the respondent can and cannot make. Include the reasons for this opinion: Pt is totally incompetent & unable to do any personal cares or make any decisions. Facility document, entitled IDPH Notification Form, dated [DATE], documents, Resident (R1) diagnoses included: [CONDITION(S)], aggressive behavior, flat effect; [CONDITION(S)]; traumatic brain injury with impulsiveness; [CONDITION(S)]; and left frontal hematoma. During supervised lunch meal, staff noticed resident was eating quickly. Staff attempted to instruct resident to eat slower and resident did not follow direction. Resident noted to begin to choke. [MEDICATION(S)] maneuver was initiated immediately by staff. 911 was called. EMT's arrived and were unable to remove food. Resident was a DNR (Do Not Resuscitate) and time of death was 12:21 p.m. and announced by paramedics. [NAME] County Coroner Preliminary Investigation Report, dated [DATE] regarding R1's death, documents, Due to evidence from the body and the medical history my ruling is of an accidental death due to: Brain [CONDITION(S)], due to choking, due to previous Intracranial brain injury. On [DATE] at 12:50 p.m., V4 (Certified Nursing Assistant/CNA) confirmed on the day of R1's expiration [DATE], during the noon meal, R1 was not receiving staff assistance with eating and R1 was eating very fast and when asked to slow down, R1 stood up for the table and walked out of the dining room and started choking. V4 (CNA) initiated the [MEDICATION(S)] maneuver on R1. On [DATE] at 10:30 AM V6 (CNA) stated, Someone summoned staff to the B hall for help over the intercom. I went to B hall to help and found (R1) right outside of the dining room on the floor. (V4/CNA) was performing the [MEDICATION(S)] maneuver on (R1) and told me that (R1) had choked and collapsed in her arms. (V4/CNA) could not get her arms around (R1) to do the [MEDICATION(S)] right. I immediately took over the [MEDICATION(S)]. (R1) had a lot of sweet potatoes and pieces of ham coming up out of his mouth. (R1) did a lot better with finger foods. If (R1) would not get finger food, he would eat too fast and shove large amounts of food in his mouth. (R1's) meat needed to be cut up. On [DATE] at 10:55 AM V8 (Licensed Practical Nurse/LPN) stated, I was working on C-wing and heard a page for all nurses to report to B-wing. When I got to B-wing, (R1) was on the floor and (V5/LPN) was finger sweeping (R1). (R1) needed finger food or he would try to eat too fast. We never cut (R1's) meat up. No one assisted (R1) with eating that day. On [DATE] at 11:55 AM V17 (Cook) stated, I made (R1's) tray the day that he choked. I had put a slice of ham, soft sweet potato chunks, and a vegetable (unsure which one) on his tray. I did not cut the meat up. I was never aware of (R1's) care plan interventions indicating (R1) needed finger foods. I never look at the resident's care plans. The Immediate Jeopardy was identified on [DATE] at 3:13 PM, to have begun on [DATE] when the facility failed to provide supervision during the noon meal for R1, which resulted in R1 choking and R1 experiencing brain [CONDITION(S)] which caused R1's death On [DATE] at 12:40 PM V1 (Administrator), V2 (Director of Nursing), and V21 (Corporate Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1) The facility completed an audit of all diet orders & recommendations to assure accuracy between Physician Order Sheet, Care Plan, Dietary Card of all residents' current diet orders and assistance needs on [DATE]th, 2021 2) Nursing staff was in-serviced on the Policy and Procedures regarding Dining Room Procedures, Notification of Change of Condition, Diet Orders, Therapeutic & Mechanically Altered Diets on [DATE]th-7th, 2021 by V2 (Director of Nursing). 3) All staff shall assist in the dining room for at least part of the meal until all meals are served and the resident's needs are met. All residents shall be served in a dining room or multi-purpose room except for an individual with a temporary illness, who is too ill or for other valid reasons. Plates should be passed to all residents at one table at the same time. Residents must be at the table prior to serving. As the meal is delivered, a staff member will assist with and/or prepare the food as needed (i.e. - cut up meat, open milk, butter bread). When the meals of the residents who must be fed are served the certified staff will assist those residents as needed. Staff shall ensure that residents receive assistance as needed and check for the availability of ice water, coffee, and substitutes. Dependent residents: Each staff member can feed no more than 2 dependent residents at a time. Conversation with the resident shall be made. Any resident who has any ability to help him or herself shall be encouraged to do so. Hand-over-hand assistance is used as needed. Trained by V2 (Director of Nursing) [DATE]. Completion date: [DATE]

Based on observation, interview, and record review, the facility failed to implement the Centers for Disease Control and Prevention (CDC) guidance and the Facility's COVID-19 policy to prevent the potential spread of COVID-19. The facility failed to initiate isolation precautions and conduct COVID-19 testing for resident who presented with signs/symptoms of COVID-19, did not house exposed/quarantined resident in a private room or with other like residents, isolation precaution signage was not posted to designate residents on isolation or for the designated COVID-19 areas, and staff did not don/doff proper PPE (Personal Protective Equipment) and conduct hand hygiene/glove change appropriately. These failures resulted in unnecessarily potentially exposing unaffected residents and staff to a highly infectious disease. This had the potential to affect all 75 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6/01/21, the facility remains out of compliance at a Severity Level 2. The facility continues to screen residents for signs/symptoms of COVID-19 and when to isolate/test the residents, posting isolation precaution signage on resident rooms, as well as the entrances to the COVID-19 units, in-servicing and completing competencies for all staff and newly hired staff and conducting random audits of handwashing and quarantined isolated residents. Findings include: The CDC's Responding to COVID-19: Considerations for the Public Health Response to COVID-19 in Nursing homes, dated 4/30/20, documents, Place signage at the entrance to the COVID-19 care unit that instructs HCP (Healthcare Professionals) they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. The Centers for Disease Control and Protection (CDC) Preparing for COVID-19 in Nursing homes, dated 6/25/20, documents, Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). The facility's Releasing COVID-19 Cases and Contacts From Isolation and Quarantine, dated 5/1/20 documents, Cases-Symptoms: Must be isolated for a minimum of 14 days after symptom onset and can be released after afebrile and feeling well (without fever-reducing medication) for at least 72 hours or has two negative COVID-19 tests in a row, with testing done at least 24 hours apart. Close Contacts: Must be quarantined for 14 days after the last/most recent contact with the case when the case was infectious. If close contact develops symptoms, follow isolation rules for cases above. (Isolate for additional 14 days after symptom start. LTC (Long term Care) residents or Household Contacts that share a room/living quarters (i.e. have ongoing contact with or exposure to the case): quarantine during contact and for 14 days after case is released from isolation. The facility's Infection Control Program, no date available, documents, PPE-Personal Protective Equipment, or PPE, as defined by the Occupational Safety and Health Administration, or OSHA, is 'specialized clothing or equipment, worn by an employee for protection against infectious materials.' The facility's Cleaning and Transporting of Food Trays for Resident in Isolation policy, dated 12/17/18, documents, Policy: To ensure proper transporting and cleaning of resident food trays and to prevent the spread of microorganisms. If entering an isolation room, don appropriate isolation wear before entering the room and deliver the food tray to the resident. Dishes and/or food trays from any resident's room which are visibly contaminated with blood or body fluids should be placed in a clear plastic bag before returning to the dietary department or placing on the food care for return. Personnel who handle these dishes should wear gloves. The facility's How, When, Where is the testing for COVID-19 being done policy, dated 3/4/21, documents, We will be testing everyone with signs/symptoms of COVID-19, on a daily basis as needed. The policy also documents, If a staff member comes down with COVID-19, then we will test all of the residents in the building, and to do that you must use the contracted lab. The lab does take up to 72 hours to return results back to the facility. The facility's COVID-19 Control Measures policy, dated 2/15/21, documents, Purpose: To prevent transmission of the COVID-19 Virus and to control outbreaks. Symptoms: Fever, cough, shortness of breath, nasal congestion, runny nose, sore throat, diarrhea/vomiting, extreme fatigue, muscle pain, and loss of taste/smell. The policy also documents, Droplet Precautions-Post signage on door: Implement when a resident is suspected of having any fever, respiratory symptoms, sore throat, nausea, vomiting, extreme fatigue, muscle pain, loss of taste and/or smell. Restrict all residents with fever, respiratory symptoms, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste/smell to their room. Place symptomatic residents in a private room. Should a private room not be available, cohort residents with who have tested positive. Wear facemask/N95, gloves, gown, goggles, or face shields when entering room or when working within six feet of residents on droplet precautions. Place a facemask on the resident when providing direct care. Remove PPE when leaving resident's room and perform hand hygiene. The facility's Testing of Staff and Residents policy, dated 10/5/20, documents, Purpose: To enhance efforts to keep COVID-19 from entering and spreading through our facility. Testing of residents with COVID-19 symptoms: Resident displaying symptoms of COVID-19 must be tested . Notify physician of symptoms and orders for [MEDICATION(S)] or PCR testing. Residents with symptoms must be placed on transmission-based precautions until the test results are received. If a resident is displaying symptoms of COVID-19 and has an [MEDICATION(S)] test that is negative, the resident must be PCR tested and is to remain on transmission-based precautions until the test results are received. 1. A. R1's Nurse's notes, dated 4/30/21 at 12:00 p.m., document, R1 complains of headache and sore throat this morning. As needed Tylenol given. R1 with increased fatigue. R1's Nurses' notes, dated 5/2/21 at 8:00 p.m., documents, Complains of dry cough. Lung sounds clear with diminished bases. R1's [CONDITION(S)]-COV-2/COVID-19 test results, dated 5/27/21, document that on 5/2/21 R1's specimen was collected, and R1 was positive for COVID-19. On 5/26/21 at 3:30 p.m., V2 (Director of Nursing) stated, R1 had symptoms of COVID-19 prior to testing positive. R1 was routine tested on [DATE] when the whole building was tested because of her roommate (R9) testing positive on 5/1/21 while in the hospital. R1 was not isolated with her symptoms. No routine testing of residents was completed in April 2021 nor any individualized tests. We did not have any positives in the building, so we didn't need to do any testing. When (R1) was symptomatic COVID never crossed my mind of being a possibility. B. R3's Nurse's notes, dated 5/17/21 at 7 pm documents, R3's vital signs (temperature) 99.3 degrees Fahrenheit, (pulse) 120, (respirations) 22, (blood pressure) 118/62, (pulse oximetry) 89% on 4.5 litters of oxygen per nasal cannula. Complains of chills, poor appetite, and low energy. R3's Nurses' notes, dated 5/18/21 at 1:45 a.m., documents, Returned to R3's room with pulse oximetry. Pulse oximetry 89% on 4.5 liters of oxygen per nasal cannula. R3's Nurses' notes, dated 5/18/21 at 4:45 p.m., document, Physician office called with new order chest X-ray. R3's Chest X-ray report, dated 5/18/21, documents, Impression: Right basilar pneumonia. R3's Nurses' notes, dated 5/20/21 at 2:30 a.m., document, Temperature at 12:30 a.m. 101 degrees Fahrenheit. Tylenol administered. Cool wash cloth applied to forehead. Temperature recheck at this time 99.6 degrees F (Fahrenheit). Pulse oximetry 88% on 3 liters of oxygen per nasal cannula. Bilateral lung sounds diminished. Occasional productive cough. Is very weak. R3's Nurses' notes, dated 5/20/21 at 12:00 p.m., document, R3 COVID-19 positive. R3 with productive cough, increased shortness of breath, increased temperature at times. As needed nebulizers and inhalers utilized. Physician notified. R3 placed on droplet isolation. The facility's daily room rosters dated 5/17 to 5/19/21, document that while R3 was exhibiting signs of COVID 19, R13 remained residing in the same room as R3. On 5/25/21 at 10:15 a.m., V26 (Licensed Practical Nurse) stated, (R3) was having symptoms of an URI (Upper Respiratory Infection), but he wasn't on isolation until he tested positive for COVID-19. On 5/26/21 at 9:44 a.m., V2 (Director of Nursing) stated, (R3) was routine tested on [DATE], and we were awaiting the results. We did not do anything different testing wise when (R3's) symptoms arose on 5/17/21. We waited for his results to come back that we didn't get until 5/20/21. If a resident is showing symptoms I have them stay in their room. If their temperature is high I have them stay in their room as well. Once they test positive, they are put in isolation in the red zone. V2 also stated, (R3) was not put into isolation when his symptoms started; he was just encouraged to stay in his room. (R3) had a roommate, (R13) who never left the room. All (R13) likes to do is stay in bed. (R3) requires frequent nebulizer treatments. (R3) was put into isolation after we rapid COVID tested him on 5/20/21 and it came back positive. On 5/26/21 at 8:45 p.m., V27 (Registered Nurse) stated, (R3) has [CONDITION(S)] (Chronic Obstructive Pulmonary Disease), so he frequently gets nebulizer treatments as needed. (R3) was showing symptoms of an URI (Upper Respiratory Infection) before he tested positive for COVID, but I did not put him on isolation. That is not my call. I report the symptoms to administration, and they decide what to do with isolating and moving rooms. C. The facility Vitals Report sheet, dated 5/19/21, documents that R5 had a high temperature of 99.5 degrees F. The Facility COVID positive list, no date available, provided 5/24/21 by V1 (Administrator) documents that R5 was tested on [DATE] and his test results were positive for COVID-19 on the same day. The list also documents that R5 had signs of a cold. R5's Care plan, dated 5/20/21, documents, On droplet precautions due to highly contagious respiratory illness. Isolation: Start date 5/20/21 Positive COVID test. The facility's daily room roster, dated 5/19/21, documents that while R5 was exhibiting signs of COVID 19, R5 remained residing in the same room as R14 and R15. D. R6's Nurses notes, dated 5/20/21, document, Resident positive for COVID-19. Resident with nasal congestion and malaise. R6's Care plan, dated 5/20/21, documents, On droplet precautions due to highly contagious respiratory illness. Isolation: Start date 5/20/21 Positive COVID test. The Facility COVID positive list, no date available, provided 5/24/21 by V1 (Administrator) documents that R6 was tested on [DATE] and her test results were positive for COVID-19 on the same day. The list also documents that R6 had signs/symptoms of a cold. The facility's daily room roster, dated 5/19/21, document that while R6 was exhibiting signs/symptoms of COVID 19, R16 remained residing in the same room as R6. On 5/26/21 at 3:30 p.m., V2 (Director of Nursing) stated that R6 displayed signs/symptoms of a cough prior to being tested on [DATE]. E. R7's Nurse's notes, dated 5/11/21 at 11:45 p.m., document, R7 warm to touch. Temperature 101 degrees Fahrenheit. R7's Nurse's notes, dated 5/14/21 at 9:20 a.m., document, R7 positive for COVID-19. R7 transferred to COVID unit. The Facility COVID positive list, no date available, provided 5/24/21 by V1 (Administrator) documents that R7 was tested on [DATE] and the test results were positive for COVID-19 on 5/13/21. The list also documents that R7 had the sign of a fever. The facility's daily room rosters dated 5/11 to 5/13/21, document that while R7 was exhibiting signs of COVID 19, R18 remained residing in the same room as R7. The Facility COVID positive list, no date available, provided 5/24/21 by V1 (Administrator) documents that R18 later tested positive for COVID-19 on 5/20/21. F. R8's Nurse's notes, dated 5/9/21 at 7:45 p.m., document, Increased temperature of 100.9 degrees Fahrenheit. Complaining of not feeling well. The Facility COVID positive list, no date available, provided 5/24/21 by V1 (Administrator) documents that R8 was tested on [DATE] and the test results were positive for COVID-19 on the same day. The list also documents that R8 displayed signs/symptoms of a cold. R8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Initiate contact/droplet precautions. R8's Nurse's notes, dated 5/20/21 at 2:45 a.m., document, R8 in bed with no respirations. No heartbeat noted. The facility's daily room rosters dated 5/9 to 5/11/21, document that while R8 was exhibiting symptoms of COVID-19, R14 and R19 remained residing in the same room as R8. The Facility COVID positive list, no date available, provided 5/24/21 by V1 (Administrator) documents that R19 later tested positive for COVID-19 on 5/15/21. R1, R3, R5, R6, R7, and R8's medical records have no documentation of these residents being placed on isolation precautions when they started displaying signs/symptoms of COVID-19, nor of immediate COVID-19 testing being completed. On 5/26/21 at 3:30 p.m., V2 confirmed that R1, R3, R5, R6, R7, and R8 were displaying signs/symptoms of COVID-19 prior to testing positive, they were not tested on ce they began displaying signs/symptoms, and isolation precautions did not start until after the residents tested positive for COVID-19. V2 also stated, If a resident is symptomatic, we don't remove their roommates if there isn't any extra beds available. We did not put the residents in isolation when the symptoms occurred, only when they tested positive. On 5/27/21 at 12:00 p.m., V1 (Administrator) stated, If a resident tests positive we are going to test their roommate as well for COVID. If both residents are positive, they stay together in their room. If the roommate isn't positive, they would stay in the room, and we would move the positive resident to the designated COVID area. The exposed resident is on isolation precautions at this point. I can relocate another resident into that room that has been exposed as well, but not someone who hasn't been exposed. If a resident is symptomatic, they make sure they stay in their room, initiate isolation precautions, COVID test, and continue until results come back. If the resident has a roommate, I would leave them together to monitor them both. I wasn't aware that while we were awaiting test results the residents were not isolated. 2. A. The facility's COVID Positive list, no date available, provided 5/24/21 by V1 documents that R24 tested positive for COVID-19 on 5/4/21. The facility's Daily Roster, dated 5/4/21, documents that R24's roommate was R21, who was now considered exposed to COVID-19. The facility's Daily Roster, dated 5/5/21, documents that R21 was moved into a room with R22, who had not been exposed to COVID-19. The facility's COVID Positive list, no date available, provided 5/24/21 by V1, documents that R21 tested positive for COVID-19 on 5/10/21. B. The facility's COVID Positive list, no date available, provided 5/24/21 by V1, documents that R25 tested positive for COVID-19 on 5/5/21. The facility's Daily Roster, dated 5/4/21, documents that R25's roommate was R23, who was now considered exposed to COVID-19. The facility's Roster, dated 5/5/21, documents that R15, who had not been exposed to COVID-19, was moved into R23's room. The facility's Roster, dated 5/11/21, documents that R23 was then moved into a room with R26, who had not been exposed to COVID-19. The facility's COVID Positive list, no date available, provided 5/24/21 by V1 documents that R23 tested positive for COVID-19 on 5/15/21. C. The facility's COVID Positive list, no date available, provided 5/24/21 by V1 documents that R27 tested positive for COVID-19 on 5/11/21. The facility's Roster, dated 5/11/21, documents that R27's roommate was R28, who was now considered exposed to COVID-19. The facility's Roster, dated 5/12/21, documents that R28 was moved into a room with R29, who had not been exposed to COVID-19. The facility's COVID Positive list, no date available, provided 5/24/21 by V1 documents that R28 tested positive for COVID-19 on 5/15/21 and R29 tested positive on 5/13/21. D. The facility's Roster, dated 5/13/21, documents, that R19, who had been exposed to COVID-19 on 5/11/21, was moved into a room with R3, who had not been exposed to COVID-19. The roster also documents that R20 was relocated into R22's room. R22 had been previously exposed to COVID-19 on 5/10/21, and R20 had not been exposed to COVID-19 The facility's COVID Positive list, no date available, provided 5/24/21 by V1 documents that R3 and R19 later tested positive for COVID-19 on the following dates, 5/15/21 (R19) and 5/20/21 (R3). E. The facility's Roster, dated 5/14/21, documents that R2 and R30, both who were unexposed to COVID, were moved into a room with R31, who had been exposed to COVID-19 on 5/13/21. The facility's COVID Positive list, no date available, provided 5/24/21 by V1 documents that R2, R30, and R31 later tested positive for COVID-19 on the following dates, 5/15/21 (R31) and 5/20/21 (R3 and R30). On 5/26/21 at 3:30 p.m., V2 (Director of Nursing) stated, Exposed residents should be housed with exposed residents, and COVID positive residents should be housed with other positive residents. We had to put (R13), who had been exposed to COVID, with (R20), who had not been exposed, in a room together because I knew (R13) doesn't leave his bed. I put R21, who had been exposed to COVID, with R22, who technically had not been exposed to COVID, but because (R22) wanders and touches everything, technically he would be considered exposed. At the beginning of the COVID outbreak, I did not have any part in moving residents. Many residents were put into rooms they should not have been put into. (R15), who had been exposed to COVID, should not have been put into a room with (R23), who had not been exposed. 3. On 5/24/21 at 10:25 a.m., V24 (Helping Hand) applied a gown and gloves and entered R11's room. R11's door had two yellow signs stating, Yellow Zone and Donning. V24 came out of R11's with the same PPE supplies on, carrying two plastic water pitchers. Using her gloved hands, R11 opened a closet door. Once the door was opened, V24 set both water pitchers on the ice cooler cart that was inside of the closet. V24 removed her right-hand glove, and scooped ice into the pitchers using the ungloved hand. V24 applied a new glove to her right hand, and reentered R11's room setting the pitchers on a bedside table. V24 exited R11's room wearing all of her PPE. As V24 was walking up the hallway to the nurses' desk, V24 began removing her gloves and gown in the hallway bundling them in her hands and throwing them in the trash. Without washing/sanitizing her hands, V24 then entered R12's room that had no signage posted on the door. On 5/24/21 at 10:40 a.m., V24 stated, I am a helping hand, so I assist the CNAs (Certified Nursing Assistant) with handing out ice water and snacks and checking call lights. When I enter an isolation room, I apply gown, glove, mask, and face shield, and I remove them and wash my hands before leaving the room. When the sign 'Doffing' is on a room door that means they are on isolation. I didn't remove my gloves when I came out of (R11's) room because I was going right back in there with the pitchers of ice water. On 5/24/21 at 1:10 p.m., a designated COVID positive hallway had a keypad entrance with red sign stating, Red Zone. No signage was posted designating that active COVID cases were located on this hallway nor specific PPE precautions. Also, all the rooms on this hallway did not have specific isolation precautions prior to entering resident rooms. On 5/24/21 at 1:15 p.m. V10 (Housekeeper) was wearing a gown, mask and goggles. V10 entered R6's room that had a red sign that stated, Red Zone, with no gloves on and removed the soiled dishes from the room placing them on a dirty dish cart. A bucket with liquid was located on V10's dish cart. V10 removed a washcloth from the bucket and returned to R6's room to wipe off R6's bedside table. V10 exited R6's room and placed the washcloth back into the bucket. Then, without performing hand hygiene or applying gloves, entered R10's room and removed the soiled dishes from that room as well placing them on the dish cart. At 1:25 p.m. V10 stated, These resident rooms are positive for COVID. I'm supposed to wear gown, gloves, mask, and goggles in every room. I put a new pair of gloves on when I enter each room. On 5/24/21 at 1:40 p.m., V9 (Certified Nursing Assistant/CNA) entered R7's room that had a red sign that stated, Red Zone, wearing a gown, mask, and goggles. V9 did not apply gloves upon entry into R7's room. V9 was touching R7's bedside table, closet door, and R7's back. R7 was sitting up in her wheelchair. V9 proceeded to push R7 into the bathroom still not wearing gloves. On 5/24/21 at 2:00 p.m., V9 stated, In the red zone, I should be wearing a gown, mask, goggles, and gloves when I enter these rooms that are on isolation. On 5/26/21 at 2:00 p.m., V6 (Infection Preventionist) stated, Specific isolation precaution signage is not posted on the resident room doors nor the entrance of the hallways. The facility's room roster dated 5/24/21 and provided by V1, documents that 75 residents reside in the facility. An Immediate Jeopardy was identified on 5/28/21 at 2:30 p.m. The Immediate Jeopardy began on 4/30/21 when R1 was displaying signs/symptoms of COVID-19. R1 was not put on isolation precautions nor was R1 immediately tested for COVID-19. R1 continued to have signs/symptoms of COVID-19. On 5/1/21, the hospital notified the facility that R9 (R1's roommate) tested positive for COVID-19 while an inpatient in the hospital. A facility wide testing was completed on 5/2/21 in which R1's test results came back positive for COVID-19. This failure continued with R3, R5, R6, R7, and R8 all displaying signs/symptoms of COVID-19 without being tested immediately nor being placed in isolation precautions. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 5/28/21 at 2:30 p.m. On 6/1/21, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 5/25/21, V2 (Director of Nursing) placed isolation precaution signage and donning/doffing diagrams on all doors of residents who are in isolation, as well as entrances to units/hallways of confirmed COVID-19. 2. On 5/28/21, V1 (Administrator) in-serviced all facility nurses on COVID-19 assessments, isolation/zones, and testing. 3. On 5/28/21, V5 (Registered Nurse) began in-servicing and completing competencies for all staff on COVID-19 control measures, COVID Assessments, handwashing, PPE/zones, transmission based precautions (Standard, Contact & Droplet), entering/exiting of isolation rooms, and donning/doffing PPE. This in-service was completed on 5/29/21. 4. On 5/28/21, V1 put the following facility interventions into place to address resident screening: V1 or V2 will talk to charge nurse daily to follow up on the residents who present signs/symptoms of COVID-19 to ensure proper procedure of isolating and testing is followed for the next two weeks; Management staff will do daily rounds to ensure the proper signage is on each door in occupied rooms for 14 days post outbreak. 5. Random handwashing audits will be conducted by V5 and completed by 6/30/21. 6. Random audits of quarantined/isolated residents will be conducted by V2 or designee weekly to ensure CDC Contact and Droplet precaution signage, and donning/doffing diagrams are in place to be completed by 6/30/21. 7. All new staff will be educated and trained on COVID-19 signs/symptoms, COVID Control measures and assessments, PPE/Zones, all isolation precautions, and hygiene. The education and training will be completed by V1 or V2 during orientation of new staff.

Based on observation, interview, and record review, the facility failed to ensure a resident received their own Physician ordered medications for one of three residents (R1) reviewed for medication errors/discrepancies in the sample of three. This failure resulted in R1 receiving R3's medications along with R1's medications causing R1 to develop increased lethargy, an altered mental status, [MEDICAL CONDITION] activity, a critically low blood pressure and a low glucose level, which required R1 to be hospitalized in the ICU (Intensive Care Unit) for treatment. Findings include: The facility's Medication Administration Policy dated [DATE] documents, The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders [REDACTED]. Medications must be identified by using the seven rights of administration: Right resident, right drug, right dose, right consistency, right time, right route, and right documentation. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is cognitively intact. This same MDS Assessment documents R1 has [DIAGNOSES REDACTED]. R1's physician's orders [REDACTED]. one tablet, [MEDICATION NAME]-[MEDICATION NAME] (Opioid pain relieving medication) 5 mg-325 mg one tablet, and [MEDICATION NAME] (Muscle Relaxant) 10 mg one tablet. R3's POS and MARs dated [DATE] through [DATE] document R3 receives the following medications daily at 4:00 PM: [MEDICATION NAME] (Anti-psychotic medication) 10 mg one tablet, [MEDICATION NAME] (Iron supplement) 325 mg one tablet, [MEDICATION NAME] (Anti-Diabetic medication/blood sugar lowering medication) 10 mg one tablet, Potassium Chloride 20 mEq one tablet, [MEDICATION NAME] (Anti-psychotic medication) 50 mg one tablet, and Trajenta (Anti-Diabetic medication/blood sugar lowering medication) 5 mg one tablet. R1's Medication Discrepancy Report dated [DATE] at 4:20 PM documents, Type of Discrepancy: Wrong resident (R1 received R3's 4:00 PM medications). Possible Effects to the resident: Decreased blood sugar and increased sedation. Actual effects to the resident: [DIAGNOSES REDACTED] and altered mental status. R1's Nurse's Notes dated [DATE] at 4:37 PM and signed by V2 (Director of Nursing) document, New order received to complete accuchecks (blood glucose monitoring) every four hours for 24 hours. If blood glucose below 60 call medical doctor. BMP (Basic Metabolic Profile) in morning. Monitor for lethargy. R1's Nurse's Notes dated [DATE] at 6:45 PM and signed by V2 document, This nurse requested to address (R1) due to increased lethargy. Upon entering room (R1) noted to be sitting in a high back wheelchair with her eyes closed. (R1) unable to make eye contact when talked to. (R1's) pupils are pinpoint. Blood glucose reading 51. Blood pressure 79 systolic/55 diastolic. Pulse Oximetry 94 percent. Oxygen applied per nasal cannula at two liters. 7:05 PM Order received to send (R1) to the emergency department for evaluation and treatment. 9:00 PM admitted to Intensive Care Unit with the [DIAGNOSES REDACTED]. R1's Hospital History and Admission Physical Examination and emergency room Note Reports dated [DATE] document, History of Present Illness: (R1) long-term resident at nursing home presents after accidentally being given another resident's medications. (R1) was given [MEDICATION NAME], Iron, [MEDICATION NAME], Potassium, [MEDICATION NAME], and Trajenta which were not (R1's) own. (R1) became less responsive so EMS (Emergency Medical Service) was called. (R1) presents with decreased responsiveness. (R1) was noted to be hypoglycemic initially and was given D50 ([MEDICATION NAME]/glucose 50 percent). (R1's) initial sugar went up but then began to decrease so (R1) was started on a [MEDICATION NAME] drip. (R1's) blood pressure was extremely low. (R1) was given a total of two liters of normal saline in the emergency room and (R1's) blood sugar remained borderline low. (R1) has been started on [MEDICATION NAME] (medication used to treat life-threatening low blood pressure). Very lethargic and drowsy. R1's Hospital Discharge Summary dated [DATE] documents, Discharge Diagnoses: [REDACTED]. (R1) was admitted to the ICU with close monitoring. (R1) was given [MEDICATION NAME] fluids as well as pressors (blood pressure raising medications) to keep (R1's) blood pressure up. (R1) slowly improved and her mental status came back to normal. V4's (Licensed Practical Nurse/LPN) Notice of Termination dated [DATE] and signed by V2 (Director of Nursing/DON) and V1 (Administrator) documents, Substandard nursing care leading to medication discrepancy and hospitalization of resident (R1). On [DATE] at 9:00 AM, R1 was sitting up in her high back wheelchair and her left eye was twitching. R1 stated, (V4) gave me the wrong pills on ([DATE]). (V4) gave me (R3's) pills. I got a low blood pressure, low pulse Oximetry, and low blood sugar. I had to be admitted to the hospital. I passed out and woke up at the hospital. I could not remember anything. I was p***ed off because getting the wrong medications took my health backwards and caused me to have more [MEDICAL CONDITION], low blood sugar, and low blood pressure. I felt like s**t for days and have been so tired. I hated having to be admitted to the hospital and having to get IV's (Intravenous Medications). If I could, I would sue (V4) for what she did to me. On [DATE] at 1:40 PM V4 (LPN) stated, On [DATE] I had pulled up (R1's) 4:00 PM medications around 3:15 PM. I went to give (R1) her medications and she was in bed. (R1) is at risk for choking, so I told the Certified Nursing Assistants (CNAs) to get her up out of bed so I could give (R1) her medications. I put (R1's) cup of medications in the top drawer of the medication cart. Around 4:00 PM, the CNAs parked (R1) right by my medication cart. I had two or three other residents at my medication cart at the time trying to talk to me and I had pulled up (R3's) 4:00 PM medications. (R1) is very demanding and wanted her medications right now. I put pudding in with (R3's) medications and gave the medications to (R1). I then realized that I gave (R1) the wrong medications (R3's medications) and told (R1) to spit them out. (R1) had already swallowed the wrong medications. I then gave (R1) her 4:00 medications. I told (V5/Minimum Data Set Coordinator) that I gave (R1) the wrong medications. (V2/Director of Nursing) and (V3/Assistant Director of Nursing) then approached me and said that I was being suspended for three days for giving (R1) the wrong medications. (V2) stated that they had called and informed (V6/R1's Physician) that I gave the wrong medications, and (V6) told (V2) that I needed to be suspended. I was then told to come in on Tuesday ([DATE]). On [DATE] (V2) told me that (R1's) potassium was high and blood sugar dropped requiring (R1) to be hospitalized . (V2) told me that (R1) could have died from me giving (R1) the wrong medications. (V1 and V2) then terminated me due to (R1's) medication error. On [DATE] at 11:05 AM V2 (Director of Nursing) stated, I took over caring for (R1) on [DATE] after she received the wrong medications. (R1) was lethargic and not acting herself. I took (R1's) blood glucose level and it was 51. (R1) could not hold her head up and her blood pressure was extremely low. (R1's) blood glucose level dropped to 30. (R1) was sent to the hospital and admitted to the ICU unit with [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], altered mental status, and an adverse drug reaction. (R1) returned to the facility on [DATE]. (R1) still was not acting herself and could not hold her head up. (R1) has been twitching more than normal since receiving the wrong medications. (R1) receiving (R3's) medications was definitely a significant medication error. On [DATE] at 12:40 PM V6 (R1's Physician) stated, (R1) receiving the wrong medications caused (R1) to be hospitalized on [DATE] with an altered mental status, extremely low blood pressure, and a low blood glucose. (R1) had to be treated in the ICU (Intensive Care Unit).

Based on observation, interview, and record review the facility failed to plan and implement restorative programs for one of two residents (R61) reviewed for a decline in ADLs (Activities in Daily Living) in the sample of 24. These failures resulted in R61 significantly declining from requiring supervision only with ADLs and walking independently on admission to requiring extensive assistance of one staff for all ADLs and requiring a wheelchair for locomotion. Findings include: The Restorative Nursing Programs policy dated 09/2008 documents, It is the policy of (company) to facilitate resident independence in Activities of Daily Living and assist the resident to reach and maintain his/her highest practicable physical, mental, and psychosocial needs through the use of Restorative Nursing Programs where appropriate. Perform a comprehensive assessment of each resident to establish needs and strengths to determine the resident's readiness/capacity to learn and physical ability to participate. Develop goals and objectives per individual resident needs. Writing the program once the need is identified; Determine the nature of the need. Goal Statement with time frame based on individual schedule, needs, and preferences. Steps implemented to reach the goal (approaches). Implement the Program: Determine the setting to implement the plan. Consider the length of time, as well as the time of day involved for teaching. Consider the environment. Positive Reinforcement. Determine if group or individual setting. Evaluating the Program: Determine if the goal has been achieved by measuring and comparing objectives through observation of the resident's performance and interview with the resident. Documentation of the Program: Care Plan of problems, strength/needs, interventions and goals to be reviewed every 90 day or sooner if determined appropriate for level of care/needs established by IDT (Interdisciplinary Team). R61's Nurse's Notes dated 1-24-18 document R61 ambulates with a wheeled walker independently to reach destination. R61's Nurse's Notes dated 4-9-18 document R61 was having unsteadiness with gait while using the walker R61's Admission MDS (Minimum Data Set) Section G Function Status dated 1-31-18, documents R61 only requires supervision and set up help for all ADLs including bed mobility, transfers, walking in the room and corridor, locomotion on and off of the unit, dressing, eating, toilet use, and personal hygiene. This same MDS Section 0 Special Treatments, Procedures, and Programs documents R61 has not had Occupational Therapy, Physical Therapy, or Restorative Nursing Programs. R61's MDS Section G Functional Status dated 4-26-18, documents R61 had a decline in ADLs when compared to the last MDS on 1-31-18. This MDS documents R61 required Limited Assistance of One Personal Physical Assist for transfers, walking in the room and corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene. This same MDS Section 0 Special Treatments, Procedures, and Programs documents R61 has not had Occupational Therapy, Physical Therapy, or Restorative Nursing Programs. R61's MDS Section G Functional Status dated 7-26-18, documents R61 had another ADL decline when compared to the last MDS dated [DATE]. This MDS documents R61 needs Extensive Assistance of one person physical assist for bed mobility, transfers, walking in the room, locomotion off and on the unit, dressing, toilet use, and personal hygiene. This same MDS Section 0 Special Treatments, Procedures, and Programs documents R61 has not had Occupational Therapy, Physical Therapy, or Restorative Nursing Programs. R61's Resident Characteristic Reports dated 1-1-18 to 3-30-18 documents R61 only required supervision with all ADLs. R61's Resident Characteristic Reports dated 3-31-18 document R61 started to decline requiring a one person physical assist for ADLs. R61's Resident Characteristic Reports dated 5-1-18 to 8-31-18 document R61 started to require extensive assistance of one person physical assist in May, (YEAR) for toileting, and started to require extensive assistance of one personal physical assist for transfers, bed mobility, dressing, and personal hygiene in July, (YEAR). R61's Medical Record from admission 1-22-18 to 9-26-18 does not include any documentation of R61 receiving any services for the continual decline in R61's ADL's, or a comprehensive assessment with a plan to address R61's ADL decline. On 09/24/18 at 12:02 PM, V21 (Certified Nursing Assistant) transferred R61 from the wheelchair to the toilet using a gait belt and one person physical extensive assistance. V21 provided R61 with extensive assistance for peri-cares. V21 then transferred R61 back to the wheelchair and wheeled R61 from R61's room to the dining room. On 09/24/18 at 12:20 PM, R61 was in the dining room in a wheelchair. (R61) had plate guard to right side of plate. (R61) was served country fried steak, broccoli, mashed potatoes and gravy, chocolate cake with frosting, water, peach juice, coffee. V35 (R61's Family Member) was sitting with R61 and encouraging resident to eat. V35 also would feed R61 at times. On 9/24/18 at 12:55 PM, V35 (R61's Family Member) stated, When (R61) came here (R61) was walking independently. The staff never walked (R61). (R61) started to become weaker and now requires a wheelchair. (R61) needs therapy or something to get (R61's) strength up. (R61) needs help with everything, and when (R61) got here she was pretty much independent. On 09/24/18 at 03:32 PM, V14 (CNA) stated, (R61) walked on her own when she was admitted . (R61) has declined a lot. (R61) cannot walk now. (R61) transfers to the restroom with one assist. (R61) uses a wheelchair. (R61) does not receive any restorative services or therapy that I am aware of. On 09/25/18 at 02:50 PM, V2 (Director of Nursing) verified that R61 has never had restorative programs or therapy services since admission on 1-22-18. On 09/26/18 at 03:29 PM, V5 (Care Plan Coordinator) stated, When (R61) had a decline in Activities of Daily Living from the assessment of 1-31-18 to the assessment on 4-26-18, restorative programs should have been implemented to restore (R61's) ADL Function and to prevent a further decline. No restorative programs were implemented on 4-26-18, and since (R61's) ADLs have declined further, (R61) is still currently not on any restorative programs. On 09/27/18 at 09:32 AM, V4 (MDS Coordinator) stated, I should have done a Significant Change MDS Assessment on 4-26-18 when (R61) had a decline in ADLs. I did not do one. On 09/27/18 at 10:29 AM, V29 (R61's Physician) stated, Had I known that (R61) had a decline in ADLs I would have tried to diagnose the issue and given a plan to possibly restore or maintain (R61's) ADL function.

Based on observation, interview, and record review the facility failed to complete a pain assessment, develop and implement a resident specific Pain Treatment Plan, provide a physician's orders [REDACTED]. These failures resulted in R2 experiencing unrelieved excruciating pain to the left knee. Findings include: The facility's Pain Prevention and Treatment policy dated 6-25-14 documents, Policy: To assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. Definitions: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms of such damage. Pain is subjective and should be documented as perceived by the resident. Pain Management: The assessment of pain and if appropriate, treatment in order to assure the needs of residents who experience problems with pain are met. Pain Modalities: An intervention implemented to reduce pain which may include the use of medication, medical devices or treatments. Pain Rating: A tool that is age cognitive and culturally appropriate to the resident population to which it is applied and which results in an assessment and measurement of the intensity of pain. Pain treatment plan: [REDACTED]. Procedure: Each resident will be assessed for pain using the Pain Assessment Form including an appropriate Pain Rating Scale upon admission. The MDS Coordinator will complete the Pain Assessment Form at least quarterly and with any significant change in resident condition. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, [DIAGNOSES REDACTED]. Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan. The Care Process for Pain Management: Assess the potential for pain, assess the pain, treat the underlying causes of pain, develop and implement interventions/approaches to pain management, identify and use specific strategies for different sources of pain, monitor appropriately for effectiveness, and modify the approaches as necessary. Pain Recognition: The facility must recognize and address pain promptly. Examples of possible pain indicators include: negative verbalizations and vocalizations, facial expression, change in gait, skin color, vital signs, perspiration, behaviors, decreased participation in activities, loss of function or inability to perform ADL's, loss of appetite, difficulty sleeping. Pain is a subjective experience and it is what the resident says it is. Non-Pharmacological Interventions: The facility is responsible for developing a pain management regimen that is specific to each resident. An effective regiment may require repeated attempts to identify the right interventions. Administration of Meds: Very pertinent to administration of PRN (as needed) pain medications is documenting the administration of as needed medications including the justification and response. The facility's Notification for Change in Resident Condition or Status dated 12-7-17 documents, The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been any symptom, sign, or apparent discomfort that is un-relieved by measure already prescribed and abnormal complaints of pain. R2's Physician order [REDACTED]. These same POS's document an order since admission on 9-9-18 of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg (milligrams) one tablet every eight hours as needed for Moderate Pain (four to six). R2's Medication Administration Record [REDACTED]. R2's As Needed (PRN) Medication Record dated 9-16-18 to 9-24-18, documents R2 received [MEDICATION NAME] 7.5/325 mg on 9-21-18 at 8:00 P.M. for complaints of left knee pain that was ineffective. R2's Pain Management Flow Sheet dated 9-21-18 at 8:00 PM and 9-22-18 at 4:00 AM and signed by V22 (Licensed Practical Nurse/LPN), documents R2 had complaints of pain to the left knee of a 10 on a 1-10 pain scale, and received pain medications that were ineffective. This same form indicated a score of 10 is an indication of the most severe pain R2 can experience. R2's Controlled Substances Proof Of Use documents R2 was given a [MEDICATION NAME] 7.5/325 mg on 9-16-18 at 8:00 PM, 9-18-18 on 6:00 PM, 9-20-18 at 3:00 PM, 9-22-18 at 4:00 AM, 9-22-18 at 10:20 AM, 9-22-18 at 8:00 PM, and 9-23-18 at 4:00 AM. R2's PRN Medication Administration Record [REDACTED]. R2's PRN Medication Record dated 9-16-18 to 9-24-18, does not include documentation of V22 administering medication on 9-22-18 at 4:00 AM for R2's complaints of severe pain. R2's Nurse's Notes dated 9-16-18 at 4:00 AM and signed by V22 (LPN/Licensed Practical Nurse) document, Complained of bilateral knee pain at this time. PRN pain medication administered. (R2) complained of pain at a ten out of ten and states the [MEDICATION NAME] is not strong enough. V8 (R2's Physician) notified and awaiting new orders. R2's Nurse's Notes dated 9-19-18 at 2:30 PM, and signed by V6 (Registered Nurse/RN) document, Asked (V8) for a [MEDICATION NAME] order for (R2's) left knee. R2's Nurse's Notes dated 9-20-18 at 9:00 AM and signed by V6 (RN) document, Complains of pain in left knee. Did not request Requip or [MEDICATION NAME] at this time. (R2) started yelling at this nurse about issues not being addressed regarding pain and medicine ineffectiveness. Reminded that yesterday (V8) was notified later in the shift and still has not returned the call. Recalled (V8's) office at 9:45 AM. Will await return. R2's Nurse's Notes dated 9-20-18 document, [MEDICATION NAME] five percent apply to effected area left knee on twelve hours and off twelve hours. R2's Nurse's Notes dated 9-21-18 at 9:00 AM, document, (V8) notified of increased pain to left knee. Awaiting orders. 2:00 PM Complete view x-ray of left knee and [MEDICATION NAME] ten milligram twice daily times five days. R2's Nurse's Notes dated 9-21-18 at 8:00 PM and signed by V22 (LPN) document, (R2) in bed at this time in semi-fowlers position. Tearful, complaining of left knee pain and rates the pain at a ten out of ten. [MEDICATION NAME] given. At 8:30 PM, (R2) complaining of severe pain in the left knee. Left knee is [MEDICAL CONDITION] when compared to the right knee, warm, red, and painful to touch. (R2) unable to move left leg and states 'It feels like there is a blood clot in the left knee/leg. Asked (R2) if she wanted to go to the emergency room and (R2) replied, 'Yes I do' with tears in her eyes. At 8:40 PM, (R2) was crying out loud and stating, 'I don't want to die.' (R2) began hysterically crying and stated, 'I don't want to die.' 911 called and (R2) left facility on a stretcher with Emergency Medical Technician to hospital Emergence Room. R2's emergency room (ER) Record dated 9-21-18 documents, (R2) arrived to the ER with severe left knee pain. (R2) stated, 'It's been hurting for about a week. (R2) sent back to the facility with the [DIAGNOSES REDACTED]. Okay to apply ice to area. Physical and Occupational Therapy evaluation. R2's Nurse's Notes dated 9-21-18 at 11:35 PM documents, (R2) returned to facility. Complains of severe left knee pain and rates pain at a ten out of ten. (R2) states, 'The emergency room did not give me anything to help with the pain and and I just had [MEDICATION NAME] prior to arriving.' R2's Nurse's Notes dated 9-22-18 at 8:30 AM and signed by V6 document, (V8) here on rounds and use ice every shift on left knee. Refer back to surgeon whom did knee replacement. R2's Nurse's Notes dated 9-25-18 document, (R2) complains of left knee pain. [MEDICATION NAME]es arrived from pharmacy and will apply in the AM. R2's Pain Assessment form dated 9-9-18 and signed by V7 (RN) documents that a pain summary should be completed due to R2 having pain and receiving pain medication and pain interventions. The Pain Summary of this form documenting R2's site of pain, frequency, intensity, quality, any recent change, causes of exacerbation, treatment interventions, and treatment effectiveness, failures, and preferences is incomplete. R2's Current Care Plan does not include R2's pain, or interventions to manage R2's pain. On 09/24/18 at 11:20 AM, R2 stated with tears in her eyes, I have terrible pain in my left knee and the facility does not apply my pain patch. They say the patch is not covered by my insurance. I cannot take the pain anymore. On 09/24/18 at 12:15 PM, R2 was sitting upright in a motorized wheelchair in the dining room. R2 had facial grimacing and stated, I hurt so bad. My knee is hurting. 09/26/18 10:40 AM, R2 stated, I want to see an orthopedic doctor for my knee and not (V8). I am worried about not being able to discharge home due to the pain in my the left knee. On 09/24/18 at 03:04 PM V9 (CNA/Certified Nursing Assistant) stated, (R2) complains of pain to left knee every day I am working. I tell the nurse. The pain is worse when she transfers. I do not do anything else for the pain except for tell the nurse. On 09/24/18 at 03:27 PM V14 (CNA) stated, (R2) says she has pain to the left knee. (R2) does not like to walk. (R2's) pain is worse with transfers. I am not sure if anything relieves her pain. I just tell the nurse. We (the CNA's) do not do anything for her pain. If we lift (R4's) left leg it hurts worse. (R2) moans and groans and sometimes cries in pain. After lunch around 1:00 PM, (R2) was scooting herself back in the chair and was crying and moaning. Her pain is worse with activity. I did not report to the nurse (R2) having pain. I forgot. On 09/25/18 at 09:13 AM V13 (CNA) stated, (R2) complains of pain to her left knee twice a shift usually. The knee hurts worse when she transfers. I just tell the nurse. I really can't do anything for (R2's) pain. On 09/25/18 at 09:42 V10 (COTA/Certified Occupational Therapy Assistant) stated, I do a lot of things from (R2's) chair. Standing causes (R2) a lot of pain to the left knee. Just sitting causes (R2) a lot of pain. (R2) has a lot of pain when she re-adjusts in her electric wheelchair. (R2) frequently has shooting pain, facial grimacing, and sometimes cries. (R2) has pain to the left knee and says the pain pills do not touch the pain, and (R2) said she was supposed to have a pain patch to help control the pain. On 09/25/18 at 10:48 AM V5 (Care plan Coordinator) stated, (R2) has not had a pain care plan developed with pain interventions to control (R2's) pain. On 09/25/18 at 08:30 AM V2 (Director Of Nursing/DON) stated, (R2's) [MEDICATION NAME] was ordered on 9-20-18 and did not come in from pharmacy until 9-24-18. Insurance did not cover the medication, so we (the facility) had to get a prior authorization for the patch to be covered by (R2's) insurance. The facility should have paid for the [MEDICATION NAME] until it came in. The nurses did not let me know that the [MEDICATION NAME] was unavailable. If I was aware, I would have called the pharmacy and had the facility cover it and send it until the medication was covered by insurance. The [MEDICATION NAME] should have been obtained on the day it was ordered and therapy should have been started to manage her pain. The pain assessment dated [DATE] and signed by (V7) (Registered Nurse) is incomplete and should have had the pain summary completed with the site of pain, frequency, intensity, quality, any recent change, causes of exacerbation, treatment interventions, and treatment effectiveness, failures, and preferences. On 09/26/18 at 12:43 PM, V2 (DON) stated, On 9-16-18 when (R2) was complaining of excruciating pain and the [MEDICATION NAME] was not working, the nurse should have tried to call a different physician, when (V8) did not return the call, to get (R2) something for pain relief. If the nurse still can't get a physician, the nurse can send (R2) to the ER for pain treatment by nursing judgement. The nurse's should have kept trying to get ahold of a doctor to address (R2's) pain. It should not have taken from 9-16-18 to 9-20-18 for a doctor to be notified of (R2's) pain. When a nurse gives a [MEDICATION NAME] it should always be documented on the PRN MAR indicated [REDACTED].

Based on record review and interviews the facility failed to prevent one of three residents (R1) reviewed for elopement risk in a sample of three from leaving the facility unsupervised. On 7/20/17 R1 walked out of facility undetected and fell across from the hospital. R1 suffered abrasions to his forehead and an avulsion to his nose. Findings include: R1's current care plan dated 5/9/17 notes that R1 is at risk for self harm due to He wanders and will go into other residents rooms which is related to his dementia. Facility incident investigation form notes that R1 left the faciity on [DATE] by going out the door with another resident's visitor that would have dis-alarmed the door. Facility estimated that R1 left between 6 P.M. and 6:15 P.M. walked four tenths of a mile and fell around 6:20 P.M. across from the hospital. R1 was taken to the hospital per ambulance and treated for [REDACTED]. Hospital emergency room note report reads, Long history of dementia, at least 5 years, hx of seizures on Dilantin. Medics called because patient (R1) seen to be on the ground close to the hospital, was bleeding from avulsion on the nose, was groggy on arrival of medics, fall not witnessed, unknown if seizure, mentation improved enroute. Patient is a poor historian due to dementia but denies current illness. He struck right forehead and nose and says his cheeks hurt and left knee is a little sore but denies neck, back, rib or arm pain. On 7/21/17 at 9:13 A.M. E4 (R1's POA and Environmental Supervisor) stated that R1 had said that the reason he left the facility was he thought he had to go home and go to church. On 7/21/17 at 9:00 A.M. E1 (Administrator) stated that R1 must have gotten out with a visitor and that at that time there is no staff at the door to monitor. E1 stated that R1 is now on 15 minute checks and is now considered high risk for elopement.

Based on observation, interview, and record review, the facility staff failed to perform mechanical lift transfer in a safe manner for one of three residents (R3) reviewed for mechanical lift transfers on a sample of twelve. R3 fell during a mechanical lift transfer and sustained extensive bruising of her left lower leg, right knee and ankle and a laceration of her right knee which required twenty-six staples. Findings include: On 10/31/12 at 9:05 a.m., E5 and E6 (both Certified Nurse Aides-CNAs) prepared R3 to transfer from her bed to a wheeled recliner. R3's left lower leg has dark purple to green bruising present below her knee to her ankle. A 4 x 4 inch dressing is present on R3's right knee. R3's right lower leg has purple bruising on her lower shin, at her ankle area, and on upper foot. R3 stated she "didn't know" how fall happened. E5 and E6 transferred R3 from her bed to the wheeled recliner via mechanical lift. During this transfer, R3 moaned and grimaced. R3 stated "Oh ..oh my" during this transfer and nodded yes when asked if her legs hurt. At 11:00 a.m., on 10/31/12, E3 (Licensed Practical Nurse) checked R3's right knee dressing. R3's right knee has purple bruising, is swollen and has a large laceration approximately 3 1/2 inches long with staples noted. Nurses notes dated 10/22/12 at 11:30 a.m.stated that a mechanical lift transfer was being conducted when R3 moved forward and fell . Nurses notes state that R3 had bruising above her right foot and complained of pain in her left knee. Nurses notes dated 10/22/12 at 1:00 p.m., state that a laceration was noted on R3's right knee. Nurses notes document that R3's physician was notified and ordered R3 to be sent to the emergency room for treatment. The hospital's Physician's Clinical Report dated 10/22/12 at 2:24 p.m. states that R3 had a deep laceration to the right knee and multiple contusions with soft tissue hematoma of the right knee, right lower leg, left knee and left lower leg. This form stated that R3's laceration was greater than 8 centimeters in length and required twenty-six staples for closure. The facility's investigation report regarding R3's incident of 10/22/12 states that E7 and E8 did not follow proper protocol for safe mechanical lift transfer. On 10/31/12 at 10:10 a.m., E2 (Director of Nursing) stated that E7 and E8 improperly criss-crossed the mechanical lift sling underneath R3's legs and during the transfer R3 fell out the front of the sling and landed on her knees. On 10/31/12 at 10:40 a.m., E7 stated that she (E7) and E8 were transferring R3 from her bed to reclining chair by mechanical lift transfer. E7 stated that they did not apply the lift sling correctly and R3 fell out during the transfer. Facility's Notices of Termination dated 10/24/12 state that E7 and E8 failed to follow proper procedures when executing mechanical lift transfer, resulting in resident injury.

Based on interview and record review, the facility failed to immediately report allegations of abuse to the Administrator, failed to conduct thorough investigations into alleged abuse, and failed to immediately remove the alleged perpetrator to prevent further abuse for two of four residents (R2,R16) reviewed for abuse in the sample of 21. This resulted in a second incident of abuse by the same staff member. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9-20-12, the facility remains out of compliance at a Severity Level two as additional time is needed to determine the effectiveness of management and staff education on the importance of reporting allegations of abuse immediately, investigating all allegations thoroughly, and protecting all residents during the investigation. Finding include: The IDPH ( Illinois Department of Public Health ) notification report dated 4-20-12, signed by E1 (Administrator/Abuse Coordinator) documents that at 9:00p.m. on 4-19-12, E6 (Certified Nursing Aide) was yelling at R16 "stop being mean." Shortly after, E6 was holding down another resident's (R2) left arm in attempt to change her into her nightgown. The report documents that the statements were not brought to the Administrator's attention until 10:25p.m on 4-19-12 by E7 (Licensed Practical Nurse). Upon interview on 9-18-12 at 1p.m., E1 stated that on 4-19-12 he was notified at 10:30p.m. by E7, Licensed Practical Nurse, of a suspected allegation of abuse against R2. E1 stated that he left it up to E7 to ensure that E6, alleged perpetrator, was sent home and that he did not interview E6 until 4-20-12 at 4p.m. E1 stated that he could not remember if he came in the night of the suspected allegation to do witness statements or initiate the abuse investigation. E7's (Licensed Practical Nurse) untimed witness statement dated 4-19-12 documents the following information: E7 heard E6 (Certified Nursing Aide) arguing with R16 several times and asked E6 to leave the resident's room several times. E7 told E6 "you can't argue with (R16) when he is mad." E7 stated "(E6) kept going on that the residents can't treat me like that." According to this document E6 was very upset and agitated. E7 left the hall to get supplies from another hall and when he returned to the hall he heard R2 yelling from R2's room, "you are killing me." E7 went to R2's door and opened it. E7 witnessed E6 yanking R2's gown off and slamming it to the bed. E6 leaned over the resident and held her down and E7 heard a slap. E6 then turned around and saw E7 standing in the doorway. E7 asked E6 if she slapped R2 and she said "no". E6 stated that she was holding R2 down and grabbing her wrist and it popped. E7 told E6 she couldn't do that and leave R2 alone. E7 documented that he put a catheter in another resident and then called E3 (Resident Care Coordinator). E3 instructed E7 to walk E6 out of the building and to call E1. E7 documented that E6 stated prior to leaving the building that she grabbed R2's wrist and heard a pop and she was holding R2 down because R2 was fighting her. During Interview on 9-18-12 at 1:45p.m., E7 (Licensed Practical Nurse) stated E6 (Alleged Perpetrator) is "high strung and these people (the residents) get to her." E7 stated that "around suppertime, around 5:30 p.m"on 4/19/12 E6 made R16 "mad." E7 asked E6 to leave R16's room twice because E6 was arguing with R16. After asking E6 to leave R16's room twice, E7 later heard E6 and R16 arguing about a watch. E7 stated that he tried three more times to get E6 to leave the room but, E6 kept saying "no" and stated "why should I have to leave the room? (R16) is being mean to me." E7 stated that he had to make E6 leave the room. E7 states that around 6-7p.m. that same night, he heard R2 yelling and went down to R2's doorway. E7 observed E6's hand go down on R2's arm and heard a "pop" E7 stated he called E6 to R2's doorway and asked if E6 hit R2 and she stated no. R7 stated he then told E6 he thought she hit R2. R6 stated "no" to E7. E7 stated he was unsure if E6 hit R2. E7 then stated that after this occurrence he helped E6 put R2's gown on and sent E6 to go work with other residents while he put a catheter in another resident. E7 stated that after he placed the catheter he talked to his mom, who is an employee with the facility, about E6 arguing with R16 earlier that night and about E6 allegedly slapping and holding down R2. E7 stated that his mom told him he "better call and report it" to E3 (Resident Care Coordinator). E7 stated he called E3 around 7-8:30p.m. E3 instructed E7 to send E6 home. E7 stated he sent E6 home but did not explain to E6 why she was to go home. E7 stated he was unsure if called the Administrator about the above occurrences. Although E7 stated that he sent E6 home, E6's time card documents that E6 worked on 4-19-12 from 2:15 p.m. to 10:00 p.m. On 9/20/12 at 10:27 a.m. E1 (Administrator) verified that an entire second shift is 2:15 p.m. until 10:00 p.m. During interview on 9-18-12 at 3:07p.m., E3 (Resident Care Coordinator) stated she received a call around 7-8:30p.m., on 4-19-12, from E7 stating he saw E6 holding down R2's arms to put a gown on her and heard a pop. E3 stated she instructed E7 to have E6 leave the facility pending investigation. E3 stated she called E1 and Z1 (Corporate Nurse) later that night and reported the incident. E3 also stated that E7 told her that E6 was in a "bad mood" earlier that night . E3's (Resident Care Coordinator) untimed witness statement dated 4-19-12 documents she received a call at approximately 9:30p.m. from E7(Licensed Practical Nurse) stating that E6 (Alleged Perpetrator) had a verbal disagreement with R16 and E6 had been removed from the room. E7 states that later he heard R2 yell out, so he went to the room and observed E6 holding down R2's left arm, and heard a smack. E7 stated he told E6 to leave the room. E3 instructed E7 to remove E6 from the facility immediately pending investigation. E3 documented that she called E1 later that night. On 9-24-12 at 1p.m., E3 stated that her witness statement dated 4-19-12 was supposed to be dated 4-20-12, as she did not start taking witness statements for the investigation until 4-20-12 at 5:30a.m. According to the witness statement signed on 4-20-12, E3 (Resident Care Coordinator) did an assessment of R2's skin and bilateral arms. E3 noted R2 to be guarding her left arm. On 4-20-12 at 12:00p.m., a Doctor order was received to do a portable Xray of the left arm and elbow. On 4-21-12 at 1a.m., the X-ray report documents that R2 had an acute [MEDICAL CONDITION] forearm. According to E6's (Alleged Perpetrator) time card, the facility allowed E6 to continue to work with residents from around the evening mealtime, 5:30 p.m. to 10:00p.m. when E6's time card documented that she clocked out. On 9-19-12 at 2:20p.m., E2 (Director Of Nursing) states that no assessment, investigation, or internal incident report were done regarding the alleged verbal abuse on 4-19-12, for R16. On 9-19-12 at 10:30a.m., an Immediate Jeopardy was identified to have begun on 4-19-12 when facility staff failed to immediately report allegations of abuse the the Administrator, failed to conduct thorough investigations into both allegations of abuse, and failed to immediately remove the alleged perpetrator to prevent further abuse. E1, Administrator, was notified of the Immediate Jeopardy on 9-19-12 at 10:30a.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Licensed Practical Nurse (E7) involved in the occurrence on 4-19-12 was immediately terminated on 9/19/12 due to failure to remove the alleged perpetrator (E6), at time of first incident, from the facility. 2. The Regional Director (Z1) conducted Abuse Policy meetings with the facility staff at 3p.m. on September 19, 2012 and on September 20, 2012 at 10a.m. 3. The Administrator (E1) and the Director of Nursing (E2) were educated to the proper managing of abuse allegations within the facility on September 19, 2012. 4. Staff of the facility not in attendance at the mandatory Abuse Prevention Policy in servicing will not be allowed to work their scheduled shift until Z1 has provided an in service. 5. Facility began an Abuse Allegation Investigation on September 20, 2012 regarding the alleged occurrence involving R16 on 4-19-12.

Based on record review and interview the facility failed to operationalize their Abuse Prevention Program Facility Policy by failing to restrict employee E6 (Certified Nursing Aide), alleged to have committed resident abuse to two residents (R2,R16), from having direct contact with residents after the alleged abuse occurred. The facility failed to immediately notify the Administrator of the alleged abuse and failed to notify the Physician or Family in a timely manner after the alleged abuse. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9-20-12, the facility remains out of compliance at a Severity Level two as additional time is needed to monitor the effectiveness of management and staff education on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Findings include: According to the facility Abuse Prevention Program Policy last review dated 11-1-11, all employees of this facility who have been accused of mistreatment will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment shall not complete their shift as a direct care provider to residents. The Policy also states that employees are required to immediately report any occurrences of potential/alleged mistreatment they observe, hear about, or suspect to a supervisor and the Administrator. The Administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted. During Interview on 9-18-12 at 1:45p.m, E7 (Licensed Practical Nurse) verified he was aware of several verbal altercations between E6 (Certified Nursing Aide) and R16 on 4-19-12 around 5:30p.m. and a physical altercation between E6 and R2 around 6-7p.m but did not report either altercation to E3(Resident Care Coordinator) until between 7p.m to 8:30p.m. E7 verified that he did not ask E6 to leave the building until sometime after he spoke to E3. E7 was unsure if he reported the allegations to E1. Upon interview on 9-18-12 at 1p.m., E1 stated that on 4-19-12 he was notified at 10:30p.m. by E7, Licensed Practical Nurse, of a suspected allegation of abuse against R2. E1 stated that he left it up to E7 to ensure that E6, alleged perpetrator, was sent home and that he did not interview E6 until 4-20-12 at 4p.m. E1 stated that he could not remember if he came in the night of the suspected allegation of abuse to do witness statements or initiate the investigation. The IDPH ( Illinois Department of Public Health ) notification report dated 4-20-12, signed by E1 (Administrator/Abuse Coordinator) documents that verbal abuse occurred at 9:00p.m. on 4-19-12, when E6 (Certified Nursing Aide) was yelling at R16 "stop being mean". Shortly after, E6 was holding down another resident's ( R2) left arm in attempt to change her into her nightgown. The report documents that the statements were not brought to the Administrator's attention until 10:25p.m on 4-19-12 by E7 (Licensed Practical Nurse). E3's (Resident Care Coordinator) untimed witness statement dated 4-19-12 documents the following: E3 received a call at approximately 9:30p.m. from E7(Licensed Practical Nurse) stating that E6 (Alleged Perpetrator) had a verbal disagreement with R16 and E6 had been removed from the room. E7 states that later he heard another resident (R2) yell out, so E7 went to R2's room. E7 observed E6 holding down R2's left arm, and heard a smack. E7 stated he told E6 to leave the room. E3 instructed E7 to remove E6 from the facility immediately pending investigation. E3 then documents that she called E1 (Administrator/Abuse Coordinator later that night. According to E6's (Alleged Perpetrator) time card, although E3 documented that she told E7 (Licensed Practical Nurse) to remove the alleged perpetrator, E6 continued to work with residents from around the evening mealtime, 5:30 p.m. to 10:00p.m. when E6's time card documented that she clocked out. According to the witness statement signed on 4-20-12, E3 (Resident Care Coordinator) did an assessment of R2's skin and bilateral arms. E3 noted R2 to be guarding her left arm. On 4-21-12 at 1a.m., the X-ray report documents that R2 had an acute [MEDICAL CONDITION] forearm. On 9-19-12 at 10:45a.m., E1 provided all abuse allegations for the past year. E1 did not provide an investigation/report for 4-19-12 for R16. Upon interview on 9-19-12 at 2:25p.m., E2 (Director Of Nursing) stated that no internal investigation or incident report was done and the Doctor and Family were not notified of the alleged verbal abuse that occurred on 4-19-12 to R16. The Facility Incident Report Form for R2 documents that R2's family were not notified of the alleged physical abuse that occurred on 4-19-12 until 4-21-12 at 9a.m. On 9-19-12 at 10:30a.m., an Immediate Jeopardy was identified to have begun on 4-19-12 when facility staff failed to restrict employee E6 (Certified Nursing Aide), alleged to have committed resident abuse to two residents (R2, R16) from having direct contact with residents after the alleged abuse occurred. The facility failed to immediately notify the Administrator of the alleged abuse. E1, Administrator, was notified of the Immediate Jeopardy on 9-19-12 at 10:30a.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Licensed Practical Nurse (E7) involved in the occurrence on 4-19-12 was immediately terminated on 9-19-12 due to failure to remove the alleged perpetrator (E6), at time of first incident, from the facility. 2. The Regional Director (Z1) conducted Abuse Policy meetings with the facility staff at 3p.m. on September 19, 2012 and on September 20, 2012 at 10a.m. 3. The Administrator (E1) and the Director of Nursing (E2) were educated on the proper managing of allegations within the facility on September 19, 2012. 4. Staff of the facility not in attendance at the mandatory Abuse Prevention Policy in servicing will not be allowed to work their scheduled shift until Z1 has provided an in service. 5. Facility began an Abuse Allegation Investigation on September 20, 2012 regarding the alleged 4-19-12 occurrence involving R16.

Based on observation, interview and record review, the facility failed to notify R1's physician (one of four residents reviewed), that R1 was non compliant with non weight bearing status while healing from a fractured left ankle. R1 eventually had a left [MEDICAL CONDITION] after R1 developed Osteo[DIAGNOSES REDACTED],[MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) and an open compound fracture to his left ankle. Findings include: On 8-2-10 at 8:20 am, R1 was up in a reclining chair with oxygen on per nasal canula. R1 had a left [MEDICAL CONDITION]. R1's POS (Physician order [REDACTED]. Nursing notes dated 1-24-10 show R1 fell resulting in a fracture to his left ankle. R1 was sent to the hospital returning with a splint to his left leg and non weight bearing status. Nursing notes dated 2-8-10 shows R1 went to Z2, Orthopedic physician who performed X-rays showing the fracture to be in good position. Non weight bearing status to continue and follow up in two weeks. Physician order [REDACTED]. Non weight bearing to LLE (left lower extremity)." Nursing notes dated 2-26-10 show R1 went to see Z2 (Orthopedic physician) who discontinued his boot and stated to continue with non weight bearing status. Nursing note dated 2-28-10 at 5:30 pm states R1 "continues to transfer self. Aware of NWB (None weight bearing) status and need for assist." Nursing notes dated 3-1-10 states "... Res (resident) very non compliant with using call light for assist to transfers. Continue to be NWB left leg..." Nursing note dated 3-2-10 at 12:35 am states: "...left ankle with pinkness and [MEDICAL CONDITION]. Have foot elevated at this time...continue to NWB and non-compliance with NWB status." Nursing notes dated 3-9-10 show R1 sustained a fall. The notes states R1 did not sustain an injury other that scabs being knocked off R1's left foot and ankle. The quality of care reporting form for this fall shows R1 sustained a skin tear to bottom of left foot and a necrotic area on bunion. The nursing note and care reporting form state R1's physician was paged but there was no response. There is no other documentation of physician notification. Nursing notes dated 3-14-10 at 1pm states the wound to R1's left ankle increased in size and was draining copious amounts of serous sanguis fluid. The note states there appears to be bone exposed in the center of the wound. Note at 1:30 pm states the above was reported to R1's physician's office. Note at 4:15 pm states the facility will notify Z2 ( R1's Orthopedic physician) of R1's condition and noncompliance with weight bearing status. Emergency Department clinical nursing report dated 3-16-10 at 1833 (6:33 pm) states "...Alert. Appears in pain. Oriented x 3. The patient is in moderate distress...Multiple extremity wounds present (bottom of the left foot has a 1.5 cm necrotic, large bruise/blood blister noted to the top of the left foot that extends to the ankle, left inner ankle has about a 3-4 inch open area with complete bone exposure with creamy white drainage from the wound.)" Z2's Consultation Report dated 3-17-10 states "... (R1) presents with an open wound to the left ankle with approximately 1" of tibia sticking out of the wound medially. The patient suffered a bimalleolar nondisplaced ankle fracture on 1-24-10. The patient was treated conservatively. The ankle apparently displaced and was tinting the skin medially. The patient developed some [MEDICAL CONDITION] The patient is diabetic and does have some [MEDICAL CONDITION]." On 8-3-10 at 2:35 pm, E1 (Administrator) stated R1 had been non compliant with his non weight bearing status by walking on his left foot and transferring himself without help. E1 stated she could find no documentation that Z2, (R1's Orthopedic physician) had been notified of R1's non compliance with the left non weight bearing order. Facility's undated policy Notification for Change in Resident Condition or Status states: " The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: An accident or incident involving the resident, a significant change in the resident's physical/emotional/mental condition and refusal of treatment or medication." On 8-2-10 at 1:20 pm, Z2 (R1's Orthopedic physician) stated R1 was sent to the hospital on 3-14-10 and found to have an open compound fracture with bone poked through the skin. Z2 stated he did not know the ankle was in that condition until then. Z2 stated he discontinued the boot in 2-26-10 as R1's foot was developing pressure areas and he determined he could remove the boot if R1 remained non weight bearing. Z2 stated he was not aware that R1 was non compliant with the non weight bearing order. Z2 stated if he had known that, he would have used another treatment to keep the ankle aligned. Z2 stated if the bone had not poked through, the ankle would have been easier to heal. Since the ankle now had an open compound fracture along with R1's other conditions and age, Z2 and several other physicians agreed amputation was the best course as the ankle was unlikely to heal. Z2's note dated 3-19-10 states: "D/Ced (discontinued) boot because he (R1) was 4 weeks post injury and the boot was beginning to cause ulcers on his foot and ankle, it was a choice between continued immobilization and risking ulcers or risking displacement and stopping the boot to improve his ulcers: I felt that at 4 weeks post injury he had enough healing to remove the boot as long as he remained NWB which is what I ordered; I had no idea that he was so noncompliant nor did I expect him to walk on it as my orders stated NWB; I felt that there was risk to cause worse ulcers to immobilize the fx (fracture) or let the ulcers heal and risk displacement; I made the choice that at 4 weeks post injury that I would d/c the boot and allow the ulcers to heal and plan that he wouldn't displace the fracture without the boot if he remained NWB."

Based on observation, interview and record review, the facility failed to obtain timely medical care and failed to seek medical input when an order of nonweight bearing was not followed for one of four sampled residents, R1. R1 developed osteo[DIAGNOSES REDACTED] which resulted in a left [MEDICAL CONDITION]. Findings include: On 8-2-10 at 8:20 am, R1 was up in a reclining chair with oxygen on per nasal canula. R1 had a left [MEDICAL CONDITION]. R1's POS (Physician order [REDACTED]. Nursing notes dated 1-24-10 show R1 fell obtaining a fracture to his left ankle. R1 was sent to the hospital returning with a splint to his left leg and non weight bearing status. Nursing notes dated 2-8-10 shows R1 went to Z2 (Orthopedic physician) who performed X-rays showing the fracture to be in good position. Non weight bearing status to continue and follow up in two weeks. Nursing notes dated 2-26-10 show R1 went to see Z2 (Orthopedic physician) who discontinued his boot and to continue with non weight bearing status. Nursing notes dated 3-9-10 show R1 sustained a fall. The notes states R1 did not sustain an injury other that scabs being knocked off R1's left foot and ankle. The quality of care reporting form for this fall shows R1 sustained a skin tear to bottom of left foot and a necrotic area on bunion. The nursing note and care reporting form state R1's physician was paged but there was no response. Nursing notes date 3-11-10 at 1:55 am state "Res (resident) has multiple scabs on BLE (bilateral lower extremities) and toes. Lt ft et (left foot and) ankle swollen et red with warmth. Res complained of left leg discomfort. Res has feet elevated. Complained of feeling bad." Nursing note later that day at 6:35 pm states R1's temperature was 100.6. Nursing note dated 3-13-10 at 8:00 pm states the dressing to R1's left foot soaked with serous fluid and very [MEDICAL CONDITION] and the left ankle draining large amounts of fluid. Nursing notes dated 3-14-10 at 1pm states the wound to R1's left ankle increased in size and was draining copious amounts of serous sanguis fluid. The note states there appears to be bone exposed in the center of the wound. Note at 1:30 pm states the above was reported to R1's physician's office. Note at 4:15 pm states the facility will notify Z2 (R1's Orthopedic physician) of R1's condition and noncompliance with weight bearing status. Nursing notes dated 3-15-10 state R1 went out for x-ray of the left ankle. Nursing notes dated 3-16-10 at 3:40 am state "[MEDICAL CONDITION] present and deep purple in color to bunion area with an approx (approximately) 2.5 cm (centimeter) blister, fluid filled..." Nursing notes dated 3-16-10 at 5:00 pm state "...has 3 cm purple bubble to left side of foot that extends to the ankle. Has 3+ [MEDICAL CONDITION]" Notes continue stating R1 was transported by ambulance to the hospital. Note at 8:50 pm that night states the hospital said R1 was admitted with a [DIAGNOSES REDACTED]. E8, LPN (Licensed Practical Nurse) stated she was on duty when R1 was sent to the hospital. E8 could not remember any details stating only what was in her nursing note. E8 did state R1 had been noncompliant with his NWB status. Emergency Department clinical nursing report dated 3-16-10 at 1833 (6:33 pm) states "...Alert. Appears in pain. Oriented x 3. The patient is in moderate distress...Multiple extremity wounds present (bottom of the left foot has a 1.5 cm necrotic, large bruise/blood blister noted to the top of the left foot that extends to the ankle, left inner ankle has about a 3-4 inch open area with complete bone exposure with creamy white drainage from the wound.)" Z1's (R1's physician) hospital history and physical examination On presentation to the emergency department he was found to have an open fracture of his left lower leg. Had recent left ankle fracture treated with a boot." A Consultation Report dated 3-17-10 states "this patient was admitted through the emergency room because of a significant fracture/dislocation and osteo[DIAGNOSES REDACTED] of the left ankle. He had a bimalleolar fracture which has been managed conservatively however the the patient was brought to the emergency room with deformed ankle with tibia sticking out on the left ankle...he has a a large opening measuring at least 5-6 cm in diameter on the medial aspect with protruding tibial 3-4 cm sticking out, some purulent drainage is noted. Blisters are present on the dorsum of the skin. The ankle is so deformed that with the patient in the supine position it is completely rotated laterally." Z2's Consultation Report dated 3-17-10 states "... (R1) presents with an open wound to the left ankle with approximately 1" of tibia sticking out out of the wound medially. The patient suffered a bimalleolar nondisplaced ankle fracture on 1-24-10. the patient was treated conservatively. The ankle apparently displaced and was tinting the skin medially. The patient developed some [MEDICAL CONDITION] The patient is diabetic and does have some [MEDICAL CONDITION]." Facility's weekly wound tracking sheet states areas to R1's left foot were found on 3-2-10 and are as follows: Left plantar/great toe - 1.5 cm x 1.5 cm with depth that could not be determined. The area color was described as black eschar. This sheet shows assessment on 3-9-10 and 3-16-10 about the same. R1's Left Medial Calcaneous has an area described as 1.5 cm x 2.0 cm with a depth that could not be determined. The color was described as black eschar. On 3-9-10 the areas was described about the same. Below this entry is one noted as a skin tear measuring 4 cm x 2.0 cm. By 3-16-10, the areas was described as 5.2cm x 3.0 cm with heavy drainage and red in color. On 8-3-10 at 2:35 pm, E1 (Administrator) stated she was working as Director of Nursing on 3-14-10 when her nurse called her to report on R1's condition. E1 said she came in and looked at R1's wound and describes it as follows: Quarter size open area with a whitish area inside which appeared to be bone. E1 stated the bone was not sticking out but was in the wound. E1 told the on call physician it did not appear to be an acute injury. E1 reported the physician ordered an antibiotic, cultures and blood work. The results came back [MEDICAL CONDITION] in the wound and an elevated white count was found on 3-16-10. R1's physician then had R1 sent to the hospital. E1 stated it was decided with his condition and failure to heal, the doctors decided to amputate the leg. E1 stated R1 had been non compliant with his non weight bearing status by walking on his left foot and transferring himself without help. On 8-3-10 at 3:00 pm, E1 (Administrator) stated per their policy the physician should have been notified on 3-11-10 when the left foot area became red and warm. Facility's undated policy Notification for Change in Resident Condition or Status states: " The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: An accident or incident involving the resident, a significant change in the resident's physical/emotional/mental condition, refusal of treatment or medication." On 8-2-10 at 1:00 pm, Z1 (R1's physician) stated he doesn't remember being notified of a change of condition of R1's ankle until 3-14-10 when the on call physician was notified of changes. On 8-2-10 at 1:20 pm, Z2 (R1's Orthopedic physician) stated R1 was sent to the hospital on 3-14-10 and found to have an open compound fracture with bone poked through the skin. Z2 stated he did not know the ankle was in that condition until then. Z2 stated he discontinued the boot in 2-26-10 thinking the ankle had enough healing time. R1's foot was developing pressure areas and determined he could remove the boot if R1 remained non weight bearing. Z2 stated he was not aware that R1 was non compliant with the non weight bearing order. Z2 stated if he had known that, he would have used another treatment to keep the ankle aligned and heal. Z2 stated if the bone had not poked through, the ankle would have been easier to heal. Since the ankle now had an open compound fracture along with R1's other conditions and age, Z2 and several other physicians agreed amputation was the best course as the ankle was unlikely to heal.