Every finding on record at West Chicago Living and Rehab Center

Based on interview and record review, the facility failed to provide pain medication to a resident in pain per physician orders. This applies to 1 of 3 residents (R4) reviewed for pain in a sample of 8.The findings include: R4's Hospital Physical Medicine Physician progress note, dated 5/11/26, shows R4's diagnoses included chronic low back pain, right sciatica, and myofascial pain. R4 was referred for a nerve test of her legs and a trigger point injection of her low back. MAR (Medication Administration Record), dated May 2026, shows R4 received a physician order for tramadol as needed for pain on 5/18/26 at 7:48 PM . The MAR shows tramadol was first administered 5/19/26 at 4:37 PM for back pain described by R4 as 9 on a scale of 10 with 10 being the worst pain.On 6/2/26 at 11:05 AM, R4 stated once her Tramadol was ordered by V5 (Nurse Practitioner) it .took forever for them to give it to me once it was ordered. R4 stated her pain was a 9 on a scale of 0 to 10 with 10 being the most pain she had experienced. R4 stated she could get out of bed and could get herself dressed, but her legs hurt badly when she was putting on her pants and she felt like she could barely walk. R4 stated she had a high threshold for pain and was not crying, but she was in severe pain.On 6/2/26 at 10:00 AM, V7 (Registered Nurse) stated R4 complained of chronic pain in her back and received a physician order for Tramadol in the evening of 5/18/26. V7 stated he faxed the prescription to the pharmacy at the time he received it. V7 stated the prescription was received late for the next day delivery and it took two days for the pharmacy to deliver the Tramadol. On 6/3/26 at 11:32 PM, V6 (Registered Nurse) stated on 5/18/26 R4 was asking to receive her Tramadol but it was not yet delivered to the facility. V6 stated they called the pharmacy and requested a code for the emergency medication storage to be able to retrieve Tramadol for R4 until her medication delivery arrived. V6 stated the code was not opening the emergency medication storage and they were unable to retrieve the Tramadol until a staff noticed the electrical plug was not securely inserted into the machine on 5/19/26. Progress note, dated 5/18/26 at 7:52 PM, shows R4 complained of chronic back pain and V5 (Nurse Practitioner) ordered R4 Tramadol for her pain. The note shows the prescription was faxed to the pharmacy. Progress note, dated 5/18/26 at 10:48 PM written by V6 (Registered Nurse), shows the prior nurse received a physician order for Tramadol for R4 and faxed the prescription to pharmacy. At 9:09 PM V4 called the pharmacy to request the access code for the resident's medication. V4 received a reference number and was informed the after hours pharmacy would call back in 30 minutes. V4 received a call back from the pharmacist and was told the pharmacy did not receive a written prescription for R4's medication. V4 re-faxed R4's prescription and received a confirmation. V4 attempted to call the pharmacy back multiple times all the while R4 was requesting her medication. R4 became upset with V4 and stated, this is [NAME]---, you don't want to do it, I'm calling the state on this place. The note shows after multiple re-attempts with pharmacy V4 was able to reach a representative who would reach out to the overnight pharmacist and ask them to call the facility. The note shows V4 attempted to explain the status of the prescription to R4 but R4 continued to voice loudly that she was calling the state. The note shows at 11:11 PM V4 received a call back from the after-hours pharmacist who gave V4 an access code to the emergency medicine storage. V4 attempted to retrieve the medication twice with the after-hours pharmacist on the phone but the drawer containing the Tramadol would not unlock and open. V4 was instructed by the pharmacy to call the emergency medication storage company in the morning to service the machine. The note shows R4's Tramadol was not dispensed. Progress note, dated 5/19/26 at 6:40 AM shows V6 called the pharmacy and attempted to retrieve R4's medication from the emergency medication storage. The note shows V6 was told a pharmacy representative would call V6 back with a code to the emergency medication storage unit.On 6/3/26 at 3:41 PM, V8 (Corporate Nurse Consultant) stated the nursing staff could have re-ordered R4's Tramadol stat from the pharmacy when they could not retrieve it from the emergency medicine storage. Resident Pain Management policy/procedure, dated 1/2026, shows, Policy 1. To ensure residents are pain free as possible by using a variety of approaches in pain management of their pain. 2. To ensure residents are medicated for pain as per physician orders.Medication Administration Policy, dated January 2023, shows, Drugs will be administrated in accordance with orders of licensed medical practitioners of the State in which the facility operates. 11. In the event the drug is unavailable, the charge nurse shall be responsible for notifying the pharmacy for delivery. Medication convenience box may be utilized depending on type of medication.

Based on interview and record review, the facility failed to keep R1 free from abuse. This applies to 1 of 3 (R1) residents reviewed for abuse. The findings include:R1's final incident investigation report dated 3/11/26 shows On 3/6/26 at 9:40 PM, in the dining room area, (R1) was pushing a chair when (R2) was walking around the dining room and came up to him and pushed (R1) for no apparent reason, at which time (R1) fell to the ground. No verbal argument or words were exchanged prior to the incident. Both residents were immediately separated by staff that were in the dining room area and (R2) was placed one-to-one staff monitoring. (R1) was assessed by charge nurse and presents with no redness, bruising, complaints of pain or discomfort, and reports feeling safe in the facility. The medical doctor for both residents was notified, and police were called. Both residents' representatives were notified of incident. Investigated initiated. Physical abuse is founded. Conclusion: (R1) had moved (R2)'s phone from the table, not just a chair, which caused (R2) to verbally confront (R1). (R1) stated that, I don't want your phone on my table. He also called (R2) a curse word. This action caused (R2) to grab (R1)'s body and push (R1) to the ground and was standing over him until staff immediately separately residents. (R2) was witnessed continuing to be verbally and physically abusive towards staff while trying to be redirected and remained on a 1:1 staff monitoring until discharged to hospital per physician order. Police were notified of incident and report was made. (R1) was assessed at the time by charge nurse and no redness, bruising, or injury noted or complaint of pain. During investigation progress, (R1) noted with redness and bruise to right elbow which (R1) stated occurred when he landed on the floor.(R2) was admitted to (hospital) for evaluation and treatment where he currently resides. (R2) has had no behaviors or history of aggression at facility.R1's face sheet shows diagnoses of schizophrenia, major depressive disorder, recurrent, moderate, and generalized anxiety disorder. R1s MDS (Minimum Data Set) dated 1/5/26 shows that he is cognitively intact.R1's progress note dated 3/7/26 at 12:13 AM shows: At approximately 10:00 PM, (R1) was grabbed and pushed down on the floor by (R2). He was assisted to get up. He verbalized that he was okay, and he was not hurt. Upon assessment, (R1) sustained no injuries. Denied pain or discomfort. Slight redness was noted on his left elbow, which he stated he used to support himself when he was pushed down.On 3/27/26 at 10:45 AM, R1 stated that on 3/6/26 in the evening he was hanging out in the dining room with his friends. He stated that R2 kept walking back and forth, rapping really loud, swearing and using words like bitch and the n-word. R1 asked R2 if he could be quiet because residents were talking and trying to watch a movie. Instead, R2 started running back and forth. R2 took his phone and slammed it on the table that he was sitting at. R1 took R2's phone and put it on next table. R2 then jumped me from behind. He grabbed me and threw me on the ground. R2 was yelling something. He bruised by right elbow. I had pain in my lower back and elbow. Staff took me to the nursing station. R2 climbed on the table and then he came to the nursing station. V5 (CNA) came and took R2 out of the nursing station. R2 got angy and started punching the wall in the dining room. When the police came, I heard he tried to take one of the police officer's gun. R2 is not here anymore. They took him somewhere.On 3/27/26 at 11:44 AM, V4 (RN) stated on 3/6/26 she worked from 7pm to 7am. She was the assigned nurse for both R1 and R2. She said R2 was singing loudly in the hallway, running around and was not redirectable. She called V2 and told her that R2 was disturbing the residents. V2 came to the facility. R2 attacked R1. R2 jumped on R1, grabbed and pushed R1 down. R1 had some redness on his shoulder. I heard from staff that R2 put his phone on R1's table. R1 took it and put it on another table. We called the police and R2 was sent to the hospital. It's our job to prevent abuse in the facility. On 3/27/27 at 1:19 PM, V1 (Administrator) stated that she received a phone call at home that there was an incident between R1 and R2. She said I immediately did the initial report and sent it to IDPH (Illinois Department of Public Health). Then I went out of town. Yes, it is physical abuse and it's the facility's job to prevent abuse.On 3/27/26 at 11:01 AM, V2 (DON--Director of Nursing) stated that on 3/6/26 at 9:40 PM, V4 (RN-Registered Nurse) who was R1 and R2's nurse called her at home. She stated that R2 was running and walking fast down the hallways and talking to himself. V2 told V4 to keep an eye on him. She instructed V4 to call her if he starts escalating. V2 stated I came in eventually. I saw R2 walking between the main isle in the dining room. R2 put his phone on the table and then R1 picked it up and moved it to another table. By the time I got there, R1 was on the floor. V5 (CNA-Certified Nursing Assistant) brought R2 down to the tv area. R1 was taken to the nursing station. I talked to R2 and he told me that R1 took his phone. I told him that he shouldn't have handled it the way he did. I told him that I'm going to have to send you out. R2 started to get upset. He walked back to his room and came out. He said that he was going to get the cop's gun and blow things up. I called 911. When the officers came, R2 tried to go after their gun. They restrained him. R2 kept saying that R1 should not have taken his phone. R2 was sent to the hospital and he never came back. R2 should not have attacked R1 and put him to the floor, but he was instigated by R1. It is physical abuse. I know it's the facility's job to prevent abuse.R2's progress note dated 3/7/26 at 12:04 AM shows, At approximately 9:55 PM, R2 was heard singing loudly in the dining area. Staff advised him to keep his voice down as the other residents started to complain about the noise. (R2) was non-redirectable, and he was seen running back and forth in the dining area. (R2) became physically aggressive and grabbed (R1) and pushed him to the floor. Staff immediately separated the residents and (R2) was placed on 1:1. (R2) was sent to the hospital for further evaluation to prevent harm to self and others. R2 was unable to be interviewed as he was transferred to the hospital on 3/7/26 and never returned to the facility. R2's face sheet shows a diagnosis of schizoaffective disorder, bipolar type. R2's MDS dated [DATE] shows that he was cognitively intact.Facility's policy titled Abuse Prevention Policy (10/24/24) shows the following: Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.This facility desires to prevent abuse.by establishing a resident sensitive and resident secure environment. The facility affirms the right of our residents to be free from abuse.The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse.The facility is committed to protecting our residents from abuse.

Based on interview and record review, the facility failed to report resident allegations of abuse.This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 15.The findings include:On 2/24/26 at 1:36 PM, V6 (Psychiatric Rehabilitation Services Counselor) stated R1 reported that R2 threatened to hit R1 with a walker and he immediately told V2 (Assistant Administrator). On 2/24/26 at 10:01 AM, V2 (Assistant Administrator) stated she spoke to R1 who told V2 that a resident was shaking her walker at her so V2 reported the allegation to V5 (Former Administrator) who initiated an investigation. V2 stated R1 told V2 that R1 was scared and the facility sent R2 out to the psychiatric hospital. Investigation Assessment (Resident to Resident Aggression), dated 1/26/26 and completed by V5 (Former Administrator), shows an investigation was conducted regarding resident aggression between R1 and R2. Investigation document, dated 1/27/26, shows on 1/26/26 an incident occurred between R1 and R2 and R2 was placed on 1:1 monitoring. The document shows R1 was sitting in the dining room and R2 approached R1, grabbed R1's walker, began stating she would shove it up [R1's] ass and that R2 threatened to kill R1. The report shows R1 stated she was scared because she was unsure what R2 would do. The report shows video footage was reviewed and R2 walked to R1 and began talking to R1. The video showed R2 was speaking toward R1 and then placed both hands on R1's walker, lifted it slightly off the ground and pushed it toward R1. The document shows R2 was petitioned to the psychiatric hospital for evaluation and treatment of the exacerbation of her serious mental illness. The investigation document fails to show the allegation was reported to IDPH (Illinois Department of Public Health).Witness statement, dated 1/27/26, shows R1 was interviewed and R1 stated R2 walked to R1, grabbed R1's walker, threated to shove R1's walker up her ass, and threatened to kill R1. The document shows R1 was scared and did not know what R2 was going to do. Witness statement, dated 1/27/26, shows V2 (Assistant Administrator) stated R1 told her that R2 approached R1, grabbed R1's walker, and R2 stated she was going to hit R1 over the head with the walker as well as stated she was going to kill R1. The witness statement shows R1 expressed she was scared of R2. The statement shows V2 immediately reported the allegation to V5 and assigned a staff 1:1 supervision over R2. On 2/23/26 at 1:31 PM, V1 (Administrator) read the investigation report and stated, based on the threats made toward R1, the incident should have been reported to IDPH based on the verbal threats in spite of the walker not being thrown at R1. V1 stated she had no evidence the allegation was reported to IDPH by the facility.Facility Abuse Prevention Policy, dated 10/24/24, shows, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately. External Reporting 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator or designee, shall notify Department of Public Health's regional office immediately by telephone or fax.

Based on interview and record review, the facility failed to prevent the abuse of a facility resident.This applies to 1 of 4 residents (R7) reviewed for abuse in a sample of 15.The findings include: Facility Abuse Prevention Policy, dated 10/24/24, shows, The facility affirms the right of our residents to be free from abuse. The facility has attempted to establish a resident sensitive and resident secure environment. The policy shows, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Verbal abuse is the use of oral. language that willfully includes disparaging and derogatory terms to residents or families. regardless of an individuals' age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Face sheet dated 1/21/26 shows R3's diagnoses included schizoaffective disorder and dizziness and giddiness. MDS (Minimum Data Sheet), dated 2/17/26, shows R3's cognition was intact. Care plan, effective 11/16/25, shows R3 had a history of physical aggression such as throwing consumable liquid at a peer. Identified offender care plan, dated 2/2/26, shows R3's background check revealed R3 had a felony conviction for aggravated battery and R3 was to be monitored and supervised. R3's verbal abuse care plan, dated 1/4/26, shows R3 had a history of being verbally abusive toward staff and R3 was verbally abusive toward his roommate by calling him an 'idiot. R3's schizoaffective disorder care plan, dated 11/16/25, shows R3 had ineffective coping modalities, disorganized thought processes and mood patterns, delusions, hallucinations, and reduced insight and judgement. Illinois State Police Criminal History Record, dated 9/11/25, shows R3 had convictions of battery with bodily harm and disorderly conduct.On 2/24/26 at 3:20 PM, R3 stated he threw coffee on R7 because she would not stop talking and R7 was annoying R3. On 2/24/26 at 3:28 PM, R7 stated R3 threw hot coffee on her because R3 was arguing with R7. On 2/24/26 at 2:00 PM, V4 (Activity Aide) stated on 1/27/25 at approximately 12:15 PM he saw R3 and R7 speaking, R7 then got up and R3 threw coffee at her. V4 stated R3 most likely obtained the coffee during lunch service which can be obtained before and during lunch beginning at 11:45 PM. Final Incident Investigation Report, dated 1/27/26, shows R3 was observed throwing his beverage at R7. R3 was placed on 1:1 monitoring and R7 was assessed for injuries, and no abnormal findings were observed. R3 was sent to the hospital for evaluation. The report falsely claims R3 had no history of verbal aggression with his peers, and the investigation shows the allegation of abuse was unfounded. Progress notes, dated 1/21/26, show at 11:58 AM an activity aide reported that R3 threw coffee on R7 because R7 kept saying she was pregnant, and showed her belly, then stated she was annoying and wouldn't shut up so I threw coffee on her. The note shows R3 was referred to psychology and social services, was placed on 1:1 monitoring, and received orders to be transferred to the psychiatric hospital for evaluation and treatment. R3's progress notes show R3 was admitted to the psychiatric hospital with a diagnosis of schizoaffective disorder and was discharged back to the facility on 1/27/26. Involuntary petition, dated 1/21/26, shows R3 presented with extreme agitation and aggression, R3 threw his cup of coffee at another resident, was agitating other residents, was disrupting the environment, and was not redirectable. R7's diagnosis report, dated 1/21/26, shows R7's diagnoses included malignant neoplasm of the colon, liver, and intrahepatic bile duct, schizophrenia, epilepsy, and low back pain. MDS, dated [DATE], shows R7's cognition was intact. Review of R7's progress notes, dated 1/21/26, show R7 was involved in an altercation that resulted in a peer throwing a beverage on her. The progress notes show R7 stated she was ok and would change her shirt.

Based on interviews and record reviews, the facility failed to ensure residents were able to exercise their rights to retain personal items and failed to provide justification as to why those personal items were confiscated.This applies to 2 of 3 residents (R4 and R5) reviewed for resident rights in the sample of 15.The findings include: Face sheet, dated 2/25/26, shows R4's diagnoses included major depressive disorder.MDS (Minimum Data Sheet), dated 1/1/26, shows R4's cognition was intact.On 2/24/26 at 2:40 PM, R4 stated in October of 2025 R5 was having pain in his stomach which caused him trouble bending forward. R4 stated he ordered an object grabber for R5 and attempted to provide the grabber to R5 however V3 (Psychiatric Rehabilitation Services Director) and V5 (Former Administrator) both stated they were concerned the grabber could be used as a weapon, confiscated the object, and told R4 that R5 required a physician order to utilize an object grabber. R4 stated he and R5 obtained a physician order for the object grabber and V3 and V5 once again denied the use of the grabber R4 provided and the facility ordered a different grabber for R5. R4 stated the facility did not return his grabber to R4 and only offered to assist R4 to return the object for a refund. R4 stated he objected to the confiscation of the object and requested a policy which justified the confiscation of the object, the need for a physician order, and a policy stating the reason the original object grabber was of concern. R4 stated he felt disrespected and dismissed by the facility staff response to his requests for justifications of the confiscation and the denial of R5's use of the grabber R4 ordered. R4 stated he wrote two memos to the facility requesting a policy to justify the facility's actions and outlining his concerns his rights were being violated and he was being treated unfairly/disrespectfully, and R4 never received any written documentation in response. R4 stated he never received the grabber he purchased.On 2/24/26 at 3:00 PM, V2 (Assistant Administrator) stated she was aware R4 bought a object grabber for R5 and V5 would not allow R4 to keep the grabber or give the grabber to R5 because she was concerned it could be used as a weapon at the facility. V2 stated R5 later obtained a physician order for a object grabber and a different object grabber was ordered and provided to R5. V2 stated since V5 no longer worked at the facility, she could not locate the object grabber. V2 stated V5 was suspended pending an investigation regarding R4's accusation he was not treated fairly or respectfully. V2 stated the facility former corporate staff met with R4 to investigate his concerns of being treated disrespectfully and that his rights were violated and determined no abuse occurred. V2 stated she had no knowledge of R4's object grabber being returned to R4 or R4 being provided justification as to why his object grabber could not be utilized in the facility.On 2/25/26 at 11:49 AM, V3 (PRSD) stated she did not know what happened to the object grabber R4 purchased and stated V5 told R4 not to give the object grabber he purchased to R5. Social Services progress note, dated 10/8/25 at 1:00 PM, shows during a wellness check visit, R4 stated he was very angry and R4 was offered suggestions for coping including playing videos, writing and journaling, and talking to his therapist.Social services note, dated 10/8/25 at 5:46 PM by V3 (PRSD), shows R4 stated he purchased a grabbing device and wanted to give it to another resident. The note shows the staff explained to R4 that the shape of the object grabber could potentially render it usable as a weapon by another individual, and therefore not safe to have in the facility. R4 then stated he understood and wanted to give it to housekeeping staff but staff declined and suggested he return the object grabber. The note shows V3 offered to assist in returning the object and retrieving R4's money. The note shows R4 agreed and told V3 he would get the receipt. The note shows later R4 stated he wanted to give the object grabber to his peer and V3 told him if it was medically needed for a resident there would be a physician order. Resident memo, dated 10/8/25, shows R4 expressed his displeasure with the lack of professionalism, arbitrary denial of resident's rights and general discourtesy shown to R4 and R5. The memo shows R4 bought R5 an object grabber for picking up items. The memo shows when the item arrived at the facility, the receptionist instructed R4 to take the item to Psych Social and then to the facility administrator. The memo stated R4 remained silent, discounted and being rather offended and stunned by his treatment. The memo shows the administrator identified the object grabber as a weapon and parties agreed that if R5 obtained a physician order for the item, the item would be allowed to be given to R5. The memo shows V3 took the object grabber and offered to help R4 return the item but R4 offered to donate it to housekeeping which was rejected by facility staff. The document shows R4 felt he followed procedures and his request to give the item to R5 was denied and his item was confiscated. The document shows R4 was told V5 (Former Administrator) was not going to allow the object in the facility. The document shows R4 requested a policy showing his item was not allowed in the facility but a policy was not provided. The document shows R4 felt V5 denied his right to formal documentation as to why his object was not allowed.Social Services progress note, dated 10/10/25 at 3:35 PM, shows social services met with R4 regarding his concerns regarding the object grabber he purchased and R4 expressed he felt ambushed by staff interviewing him and felt his rights to possess or provide the object grabber to R5 were violated without justification. The note shows R4's concerns did not rise to the level of abuse, R4 was allowed to vent his frustrations, and R4 continued to assert he was not being listened to. The note shows R4 remained dissatisfied and R4 was referred to his therapist. An addendum, dated 10/10/25 at 6:16 PM shows social services attempted to follow up with R4 and R4 requested to involve peers in the meeting who were not available and social services told R4 the intent was to meet with R4 and R4's peers would be contacted as needed. The progress notes fail to show R4's request to meet with the staff and his peers was accepted.Resident memo, dated 10/10/25, shows R4 met with a facility corporate representative, V2, R5, and R6 (Former Resident Council President) shows corporate informed R4, R5 and R6 that the original concerns R4 raised was an error in communication and poor communications between V5, V3 and R4. R4's memo shows R4 disagreed with the assertion and stated he experienced an arbitrary violation in his and R5's rights. The memo shows R4 felt the facility staff was not listening to his concerns and stated R4 was attempting to help R5 within facility rules but was experiencing arbitrary decision making by the facility. The memo shows R4 felt discounted, ignored, and invalidated and experienced anger and anxiety regarding the facility's failure to address his concerns fairly - which was escalated by the subsequent meeting with corporate insisting there was poor communication.During the investigation, V2 (Assistant Administrator) and V7 (Director of Nursing) both stated V5 (Former Administrator) and V3 (PRSD) made the decision to confiscate R4's object grabber and neither have seen it since the concerns were first brought up and the object was confiscated. V7 stated R5 did receive a physician order for the grabber and received a different grabber ordered by the facility.Face sheet, dated 2/25/26, shows R5's diagnoses include major depression, anxiety, suicidal ideations, alcohol dependence, and insomniaMDS, dated [DATE], shows R5's cognition was intact. Physician order sheet, dated 2/25/26, shows R5 had a physician order (dated 10/10/25) for use of a grabber tool for personal assistance as needed.Social Services note, dated 10/625, shows R5 approached psych social and expressed he wanted to use a grabber that another resident bought for him. The note shows per the facility administrator, R5 was not allowed to have the grabber due to facility regulations and R5 was made aware of the information.Progress note, dated 10/10/25, shows R5 received a physician order for a grabber and was provided a grabber by the facility.Facility Resident Rights Policy, reviewed 1/2026, shows residents at the facility have the right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. The residents also have the right to retain and use or wear personal property in Resident's immediate living quarters, unless deemed medically inappropriate by a physician and so documented in the resident's clinical record. Facility Dignity document, undated, shows the facility staff will not speak in a manner that could be interpreted as even minimally condescending/critical or argumentative.

Based on observation, interview and record review, the facility failed to provide cool and comfortable room environments. This applies to 5 of 5 residents (R1, R2, R3, R5 and R17) reviewed for comfortable room environments in a sample of 17. The findings include: 1. Face sheet, printed 6/27/25, shows R1 resided on the A hall of the facility. MDS (Minimum Data Set), dated 5/5/25, shows R1 was cognitively intact. On 6/23/25 at 11:45 AM, R1 stated at that moment her room temperature was acceptable but for the prior two weeks the temperature of their room was very hot, uncomfortable and unbearable. R1 stated her room was so hot she threatened to call IDPH (Illinois Department of Public Health) if the air conditioning was not repaired. R1 stated facility administration offered to move her to a different room but R1 stated she felt like all of the rooms were too hot in the facility because the air conditioner was not working correctly. At 1:50 PM, R1 stated the facility needed to fix their air conditioner that had not worked properly for days instead of asking her to move rooms. On 6/23/25 at 11:00 AM, V1 (Administrator) stated the air conditioners were breaking recently and the facility had repair services out to repair the air conditioners. At 1:04, V1 stated air conditioners at the facility were broken on 6/17/25, 6/21/25, 6/22/25, and 6/23/25 including the air conditioner that supplied cool air for R1's room. On 6/23/25 at 11:32 AM, V3 (Maintenance) stated the maintenance department was trying to keep the air conditioners running. V3 stated there were two air conditioners for each of the five resident wings. V3 stated he replaced a fan on one of the E hall units, recently replaced freon in one of the C hall units, and one A hall unit was functioning intermittently since approximately one week prior. V3 stated the A hall unit would work for a few hours and then another part would break and require repair. V3 stated he was checking temperatures of rooms and one of the rooms reached 80 degrees F during his monitoring. On 6/23/25 at 1:18 PM, V4 (Regional Maintenance) stated several of the facility air conditioning units required repair and were not working for periods of time. V4 stated one of the A hall air conditioners was not working from 6/17/25-6/19/25 because they were trying to locate freon to repair the unit. V4 stated one of the E hall units broke overnight the night prior and the residents were opening windows which was causing the temperature to rise further. Grievance, dated 6/17/25, shows R1 complained her room was too warm. The grievance shows the facility offered a different room with air conditioning and R1 declined. Progress notes, date 6/17/25, shows R1 was offered an air conditioning room for sleeping while her air conditioning was being repaired bur R1 declined. 2. Face sheet, printed 6/27/25, shows R2 resided on the E hall of the facility. MDS, dated [DATE], shows R2 was cognitively intact. On 6/23/25 at 12:20 PM, R2 stated, It's hot at times. R2 stated his room temperature improved since the day prior when the room temperature was almost unbearable because it was so hot outside, and the temperature of his room became very hot. At 2:00 PM, R2 stated it was warmer than usual in his room and uncomfortable. R2's room temperature measured 78 degrees F (Fahrenheit) and the humidity measured 60%. 3. Face sheet, printed 6/27/25, shows R3 resided on the E hall of the facility. MDS, dated [DATE], shows R3's cognition was moderately compromised. On 6/23/25 at 12:18 PM, R3 stated his room becomes warm. R3's room temperature measured 80 degrees F and 61% humidity. At 2:00 PM, R3's room temperature measured 79 degrees F and the humidity measured 61%. 4. MDS, dated [DATE], shows R5 was cognitively intact. On 6/23/25 at 11:40 AM, R5 stated her room was warm on and off on 6/25/25 and at that time did not feel hot. R5 stated on 6/24/25 her room was very hot. R5's room temperature measured 76 degrees F and the humidity was 54%. 5. MDS, dated [DATE], shows R17 was cognitively intact. On 6/23/25 at 12:00 PM, R17 had his window open and V3 (Maintenance) asked R17 to close his window because the outside temperature was very hot. R17 replied that his room was very hot, and he needed his window open to provide air circulation. On 6/23/25 at 11:30 AM, the resident room temperatures were measured and showed the following: - Hall C temperatures measured between 77-78 degrees F and the humidity ranged between 60-62% - Hall E temperatures measured between 78-79 degrees F and the humidity ranged between 59-61%. On 6/23/25 at 2:00 PM, the resident room temperatures were measured and showed the following. - Hall E temperatures measured between 78-79 degrees F and the humidity ranged between 59-62%. - Hall C temperatures measured between 77-78 degrees F and the humidity ranged between 60-62%. During the measurements, V3 stated all of the facility air conditioning units were functioning. On 6/24/25 at 4:00 PM the resident room temperatures were measured and showed the following: - Hall C: 4 rooms measured 78 degrees, 1 room measured 79 degrees F, and 3 rooms measured 80 degrees F - Hall E: 2 rooms measured 79 degrees F, 4 rooms measured 80 degrees F, 3 rooms measured 81 degrees F, and 2 rooms measured 82 degrees F. On 6/25/25 at 4:00 PM, the resident room temperatures were measured and showed the following: - Hall E: 2 rooms measured 78 degrees F, 2 rooms measured 79 degrees F, and 3 rooms measured 80 degrees F. The hall rooms' humidity measured between 63-64%. On 6/25/25 at 11:24 AM, V5 (Regional Maintenance Supervisor) stated an air conditioning unit on the E hall froze the day prior and the staff defrosted the unit, got the unit running again, and the unit froze up again. On 6/25/25 at 5:45 PM, V1 stated she was aware of the elevated resident room temperatures and stated the E hall unit needed an additional repair. On 6/26/25 at 8:00 AM, V1 stated the E hall air conditioning unit was broken and maintenance was at the facility evaluating the units. On 6/26/25 at 9:04 AM, V7 (Regional Maintenance) stated they were repairing the E hall air conditioning unit. V7 stated he was not aware of the elevated temperatures in the resident rooms on 6/25/25 at 4:00 PM but would investigate. Facility Emergency Operations Plan, effective 6/2025, shows, 2. Maintenance will check all AC units to assure they are operating properly.

Based on interview and record review, the facility failed to protect a resident's privacy. This applies to 1 of 4 residents (R4) reviewed for privacy in a sample of 4. The findings include: On June 10, 2025 at 10:04 AM, R4 said her privacy rights were broken by her social worker. R4 said V3 (PRSC/ Psychiatric Rehabilitation Services Coordinator) released information that should only be discussed between case managers. R4 said V3 released her information to R1. R4 said V3 told R1 about her housing situation and the program she was a part of. R4 said this occurred about a week ago and she reported it to the administrator. R4 said R1's information was not spread, but hers was. On June 10, 2025 at 12:42 PM, V3 said R1 had come to him asking for a direct discharge, and he explained to her it was not always possible for residents to be discharged in the timeframe R1 expected. V3 said he told R1 even if she did everything right and got all the paperwork together, like R4, they still may not be able to get the housing accomplished. On June 10, 2025 at 2:54 PM, V2 (DON/Director of Nursing) said R4's rights were violated by one of her staff. V2 said she was told the staff member (V3) was talking to R1 and explained about discharge planning and housing, and even if everything was done correctly by R1, it could still take a long time to find housing. V2 said V3 then used R4 as an example and explained R4 had filled all her social security information and was still unable to find housing right away. V2 said V3 should not have included a specific resident's name, but used a generalized example. On June 10, 2025 at 2:34 PM, V4 (PRSD/Director) said she knew there was a resident's name brought up by staff when speaking to another resident. V4 said to her understanding, the staff told her no private information was disclosed. V4 said she would not recommend using another resident's name specifically as an example. On June 10, 2025 at 2:21 PM, V1 (Administrator) said R1 told R4 the staff had shared medical information about her to R1. V1 said she spoke with R4 and explained to her that V3 had been speaking with R1 about housing and explained there were steps prior to being discharged into housing, and V3 gave the example of R4, and how she had been working on those steps. On June 10, 2025 at 1:04 PM, V5 (PRSC) said he would not bring another resident's name into a conversation he was having with a resident mainly because the other residents do not want to be talked about. V5 said in certain situations, it could be a violation of their privacy. V5 said if he needed to give an example, he would use general terms like those people in the group instead of specific names. On June 10, 2025 at 2 PM, V6 (RN/Registered Nurse) said she would not give specific names, information, to a resident regarding another resident when trying to explain an example. R4's face sheet showed she was admitted to the facility with diagnose including schizophrenia. R4's MDS (Minimum Data Set) dated April 29, 2025 showed she was cognitively intact. R4's progress notes were reviewed and showed on June 3, 2025 at 4:06 PM, It was reported that residents [R4] name was mentioned by staff during a conversation with another resident, regarding discharge planning. [R4] stated she does not want her name mentioned again in conversation to another resident. The facility's Resident Rights policy dated March 2021 showed the resident has the right to privacy. The facility's Privacy Policy dated April 2020 showed That the facility is required by law to maintain the privacy of PHI (Protected Health Information) and to provide residents with notice of its legal duties and privacy policies.

Based on observation, interview and record review, the facility failed to ensure that the dishes are sanitized during dish washing procedure and failed to ensure that dented cans were separated from the in-use cans. This applies to all 88 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS Application Form for Medicare/Medicaid dated May 19, 2025, showed that the facility census was 88 residents. Facility provided information that there are no residents on NPO (nothing by mouth) status. On May 19, 2025, at 9:24 AM, the initial tour of the facility's kitchen was conducted in presence of V4 (Dietary Manager). The dry storage area had 3 cans (6 pounds, 6 ounce each) of Salsa Para Enchiladas that were dented at the seams. These cans were placed on shelving with other canned goods and had a handwritten delivery date of February 14, 2025, on them. V4 stated that the dietary staff must have missed the dents on top of the corners. At the dish machine, V5 (Dietary Aide) was seen washing the dishes at the dirty side of the machine and placing them on racks, which in turn were run through the dish machine. V6 (Cook) was at the clean side of the dish machine putting away the cleaned dishes. V4 stated that the dish machine uses Chlorine as a chemical sanitizer for the final rinse. V4 was requested to test the chlorine using a test strip, and he was hesitant to do so stating that he does not see the sanitizer coming through via the dispenser tubing. However, after waiting a couple minutes, when V4 dipped the test strip in the sanitizer well at the dish machine, the chlorine test strip remained white. V4 stated that he will call 'Maintenance' to check on it and left the area. When asked, V5 and V6 both stated that neither of them tested the dish machine prior to start of the dish washing procedure after breakfast. V6 pointed to a log where results are entered when tested . The Dish Machine (Low Temperature) log verified this information as the columns to test and enter the Wash temperature and the Final Rinse for chlorine in p.p.m (parts per million) prior to washing dishes from the breakfast meal were not filled on May 19, 2025. The dish machine also had qualification requirements posted on surface of the machine that included 50 p.p.m for available chlorine. On May 19, 2025, at 11:51 AM, V4 stated that V7 (Maintenance Director) came and fixed the piping that dispensed the chlorine sanitizer as it had gotten clogged. V4 added that the facility is planning to redo the piping. On May 19, 2025, at 11:57 AM, V7 stated that the dish machine sanitizer had a bad hose. Dish machine (Model AH, B and C) Operation Manual included the following: The AH, B and C Operational Cycle have a total cycle of 90 seconds steps listed below detail the individual functions that are executed during each operational cycle. 6. Cam switches 6 and 7 control the sanitizer and rinse pumps respectively. They turn ON at the beginning of the rinse cycle and run for a few seconds to provide sufficient sanitizer and rinse aid for a few seconds to provide sufficient and rinse aid for rinse cycle. These cams can be adjusted as necessary for proper chemical dosage. Dish machine Installation and Operational Manual included the following: Follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottom of the glasses. Concentration should be 50 p.p.m minimum to 100 p.p.m maximum. If concentration is incorrect contact your chemical supplier . Chlorine Test Paper strip color chart guidance showed that 50-100 p.p.m had color range of varying shades of purple.

Based on observation, interview, and record review, the facility failed to follow their water management program for Legionella. This applies to all 88 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated May 19, 2025, showed the facility's census was 88 residents. On May 20, 2025, at 3:39 PM, V7 (Maintenance Director) said for the facility's water management plan, he flushes the water in empty resident rooms. V7 said he uses an electronic maintenance work order system and documents his water management task in the electronic system. V7 continued to say when he documents the Daily Building Water Management Plan in the electronic system, it means he flushed the water in the empty resident rooms and the soiled utility room. V7 said the facility has an ice machine that he cleans every six months. V7 said he cleaned it when he started at the facility in December 2024 because it was obvious it had not been cleaned in a long time. V7 said the facility's water management plan was already developed when he started working in the facility in December 2024, and V7 did not assist in developing the plan. On May 20, 2025, at 4:05 PM, V1 (Administrator) said the facility's water management plan for Legionella does not include a control measure of flushing water. V1 said the plan does not identify building water systems which need control measures or include a level of risk hazard for those areas. V1 said the plan does not include a diagram to show how water is distributed throughout the facility. V1 continued to say the only diagram in the plan is of how water flows out of the building. V1 said the facility had a resident test positive for Legionella pneumonia July 2024, and the facility had the water tested for Legionella and the results were negative for Legionella. On May 21, 2025, at 11:17 AM, V12 (Housekeeping Director) said there is an eyewash station located in the laundry room which V7 installed a few months ago. V12 said the eyewash station is used if a staff member gets detergent in their eyes. V12 said no staff member has had to use the eyewash station. V12 said V7 will come in the laundry room and make sure the eyewash station works. The facility's laundry room eyewash station was located in the back of the laundry room and was a freestanding eyewash station next to a sink. On May 21, 2025, at 11:24 AM, V7 said he installed the eyewash station a couple months ago in the laundry room and has another eyewash station to install in the kitchen. V7 said he goes to the laundry room most days to check the eyewash station is functional. V7 said he turns the eyewash station on and makes sure the covers come off the spigots and then immediately turns it off. On May 21, 2025, at 1:33 PM, V1 said the facility's water management plan for Legionella should include the required documentation. The facility's undated Water Management Program showed 1. Purpose: A Water Management Program is designed to actively identify and manage hazardous conditions that support growth and spread of Legionella. The Water Management Program: Identifies building water systems for which Legionella control measures are needed; Assesses how much risk the hazardous conditions in those water systems pose; Applies control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; Makes sure the program is running as designed and is effective. 2. Background: Legionella is found naturally in [NAME] environments, like lakes and streams, but generally the low amounts in [NAME] do not lead to disease. Legionella can become a health problem in building water systems. To pose a health risk, Legionella first has to grow (increase in numbers). Then it has to be aerosolized so people can breathe in small, contaminated water droplets. Examples of where Legionella can grow: Hot and Cold Storage Tanks; Water Heaters; Faucets; Showerheads and hoses; Pipes, valves and fittings; Infrequently used equipment such as eyewash stations; Medical Equipment such as CPAP (Continuous Positive Airway Pressure, BIPAP (Bilevel Positive Airway Pressure) machines . 4. Water Management System: Here is a description of the water system; included is: Water Enters; Cold water is distributed; Cold water is heated; Hot water is distributed; Hot, cold and tempered water is discarded. See diagram in Figure A (attach appropriate drawing). 5. Control Measures: Temperatures at a variety of points; If levels below normal; corrective action taken. 6. What to do when Controls Not Met (examples): Daily flushing of sinks and showers; Emptying of the ice machine and cleaning per manufacturer's instructions; Testing of the water . The facility's Water Management Program does not include identification of building water systems for which Legionella control measures are needed and assessment of how much risk the hazardous conditions in those systems pose. The program does not show a diagram of the facility's water system.

Based on interview and record review, the facility failed to follow their policy for antibiotic stewardship and have a standardized tool to identify infections in residents. This applies to all 88 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated May 19, 2025, showed the facility's census was 88 residents. On May 20, 2025, at 1:08 PM, V3 (Infection Preventionist Nurse) said when a resident is started on an antibiotic, V3 will log the information into the EMR (Electronic Medical Record) Infection Control Module. V3 said this information includes the date of symptom onset, the signs and symptoms, if isolation is required, diagnostic results, and which anti-infective was prescribed. V3 said she does not use McGeer's criteria to determine if a resident has an infection. V3 said facility nurses will conduct antibiotic monitoring for residents receiving antibiotics, which includes the type of infection, vital signs, and if symptoms are improving. V3 said the facility nurses do not use McGeer's criteria. On May 21, 2025, at 12:55 PM, V2 (Director of Nursing) said the purpose of McGeer's criteria is to identify if a resident has a possible infection. V2 said from her understanding, the facility does not use McGeer's criteria due to a copyright issue and the facility uses the EMR infection module. On May 21, 2025, at 1:08 PM, V13 (Regional Nurse Consultant) said the purpose of a standardized tool like McGeer's criteria or Loeb's criteria is to determine if a resident has an infection or not by looking at specific symptoms and diagnostic tests. On May 21, 2025, at 1:15 PM, V2 said the EMR does not show a standardized tool to determine if a resident has an infection or not. V2 said the EMR infection control module does not show if a resident has met criteria for an infection to receive antibiotics. Review of the facility's infection tracking from November 2024 to present does not show a standardized tool was utilized when a resident was started on an antibiotic. The facility's policy titled Antimicrobial/Antibiotic Stewardship Program dated April 2020, showed Guideline: The facility antimicrobial stewardship program includes the following elements; a) Antimicrobial/antibiotic policy and procedure; b) Physician or extender involvement thru an interdisciplinary committee and meets quarterly; c) Pharmacy reports regarding antibiotic therapy; d) There is an identified person who has accountability and training in antimicrobial stewardship; 3) Working with Pharmacy, develop an antibiotic review and feedback process to optimize and monitor the use of antibiotics. Procedure: 1. The Infection Preventionist will collect the infection information use the McGeer Criteria or the [EMR] Infection Control Module .

Based on observation, interview and record review, the facility failed to provide a substitute meal option with similar nutritional content as the main entree for the lunch meal. This applies to 6 of 6 residents (R2, R10, R23, R34, R52, and R68) reviewed for dining in the sample of 18. The findings include: On May 19, 2025, at 9:32 AM, V6 (Cook) stated that she prepared baked chicken for the main menu entree and is going to prepare turkey sandwiches for the substitute menu. Facility Daily spreadsheet for spring summer menus for week 4 Monday included Baked chicken (1 portion=3 oz/ounce protein). On May 19, 2025, at 12:03 PM, at the lunch meal, residents who ordered the substitute meal received a turkey sandwich made with slices of deli turkey, chopped lettuce and tomato in between two slices of bread and R2, R10, R23, R34, R52, R68 were served the same. When asked, how many slices of deli turkey she used, V6 (Cook) stated that she added about 3 1/2 slices of turkey per sandwich. V6 showed a recipe for Deli Sandwich (serving size 4 oz/ounce =3 oz protein) she used to prepare the turkey sandwich. The same recipe included to place 3 oz (weighed) lunch meat and 2 slices of cheese on bread slice. V6 stated that she did not add cheese slices nor weigh the turkey slices. On request, V4 (Dietary Manager) weighed the slices of turkey that were added to a sandwich on a weighing scale, and it weighed 2.7 oz. On May 22, 2025, at 11:43 AM, V11 (Dietitian) stated that the substitute menu item should have equivalent protein serving portions as the main meal entree and the facility should follow the recipe specifications for the same.

Based on interview and record review, the facility failed to follow physician's order for ID (Infectious Disease) consultation. This applies to 1 of 1 resident (R59) reviewed for physician orders in the sample of 18. The findings include: R59 had multiple diagnoses including unspecified valve endocarditis, and infection and inflammatory reaction due to cardiac valve prosthesis, based on the face sheet. R59's quarterly MDS (minimum data set) dated March 22, 2025, showed that the resident was cognitively intact. On May 19, 2025, at 10:35 AM, R59 stated that she is on antibiotic therapy due to endocarditis. R59's order report showed an active verbal (over the phone) order since June 13, 2024, for, Doxycycline Hyclate oral tablet 100 mg, give 1 tablet by mouth one time a day for Endocarditis /heart valve. Give daily until seen by ID. R59's EMR (Electronic Medical Record) including physician orders and progress notes from June 13, 2024, through May 20, 2025, showed no evidence that the resident was seen by the ID to evaluate the need for continued use of the Doxycycline Hyclate (antibiotic) medication. R59's active care plan initiated on March 29, 2024, showed that the resident is on antibiotic therapy related to history of endocarditis and heart valve disorder. The same care plan showed several interventions including, Administer medication as ordered. On May 20, 2025, at 11:30 AM, V10 (MDS/Minimum Data Set Coordinator) was asked about R59's order for daily administration Doxycycline Hyclate medication until seen by ID. V10 stated that she was not aware that R59 had seen an ID practitioner. On May 21, 2025, at 10:00 AM, V10 stated that she had reviewed R59's EMR and confirmed that the facility did not follow up the physician's order for the resident to be evaluated by the ID for continued use of the Doxycycline Hyclate medication. V10 presented R59's progress notes dated May 20, 2025, at 3:04 PM which showed that the facility had spoken to the resident's physician and instructed the facility to continue the administration of the Doxycycline medication until seen by the ID practitioner due to history of endocarditis. On May 21, 2025, at 10:29 AM, V3 (Assistant Director of Nursing/Infection Preventionist) stated that she was made aware that the ID consultation was not scheduled for R59 since the antibiotic order was made on June 13, 2024, until asked by the surveyor on May 20, 2025. V3 acknowledged that the facility failed to follow the physician's order for R59 to be evaluated by the ID practitioner for the continued use of the Doxycycline medication for endocarditis. The facility's guideline regarding physician orders dated March 2021 showed in-part under the procedure for verbal orders, e) Follow through with orders as required.

Based on interview and record review, the facility failed to ensure a resident did not receive an unnecessary medication. This applies to 1 of 2 residents (R5) reviewed for antibiotic use in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, hypertensive heart disease without health failure, and type 2 diabetes mellitus. On May 20, 2025, at 1:08 PM, V3 (Infection Preventionist Nurse) said R5 received antibiotics for a facility acquired UTI (Urinary Tract Infection) in March 2025. V3 said R5 complained of swelling in her hands, feet, and face and requested a diuretic medication. V3 said laboratory tests were done, and an antibiotic was ordered. V3 said R5's laboratory results for R5's urine culture showed R5 did not have an infection and should not have received antibiotics. A progress note dated March 18, 2025, at 3:15 PM, by V8 (LPN/Licensed Practical Nurse) showed Resident complained of edema to bilateral hands/bilateral feet and face. Observed with some edema to noted areas. Resident requesting diuretic. Notified [V9 (Nurse Practitioner)]. Response pending. A progress note dated March 18, 2025, at 5:57 PM, by V8 showed, Per [V9] get stat order for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), and UA (Urinalysis) C/S (Culture and Sensitivity). Resident given specimen cup for urine specimen with instructions and notified to return to nursing station once one . A progress note dated March 19, 2025, at 5:52 PM, by V8 showed Initial results of UA/CS sent to [V9]. Waiting for response. A progress note dated March 19, 2025, at 7:09 PM, V8 showed Per [V9] start resident on [nitrofurantoin] 100 mg (milligrams) times five days. Order carried out/noted. R5's March 2025 Medication Administration Record showed from March 19 to March 26, 2025, R5 received Nitrofurantoin monohydrate macro (antibiotic medication) 100 mg for urinalysis results infection. R5's Laboratory Results Report dated March 21, 2025, showed Culture, Urine: Mixed gram-positive organisms. Mixed urogenital flora is present. These findings are usually not indicative of an infection. On May 21, 2025, at 2:13 PM, V9 said based on R5's symptoms of hand, feet, and facial swelling and R5's urine culture results, R5 should not have been given an antibiotic.

Based on observation, interview and record review, the facility failed to provide ground baked chicken to residents on mechanical soft diet. This applies to 2 of 3 residents (R1 and R79) reviewed mechanical soft diets in the sample of 18. The findings include: On May 19, 2025, at 12:03 PM, during tray line service, V6 (Cook) stated that she prepared mechanical soft diet by manually chopping the baked chicken and then added gravy to the same. V6 showed a container of chopped chicken cut up in varying pieces steeped in gravy. R1 and R79 whose diet tickets showed mechanical soft diet, were served the chopped chicken in gravy. Daily menu spreadsheet for week 4 Monday showed to serve ground deboned chicken with gravy. Recipe for ground deboned chicken with gravy showed to debone chicken and grind meat to correct consistency. On May 22, 2025 at 11:44 AM, V11 (Dietitian) stated that the facility should follow the recipe guidance for mechanically altered diets. Facility policy titled Therapeutic Diets (effective May 2020) Guideline: Therapeutic diets are prescribed by Attending Physician or extender to support the resident's treatment and plan of care and in accordance with his or goals and preferences. Process: 4. If a mechanically altered diet is ordered, the provider will specify the texture modification. Facility diet order listing included that R1 and R79 were on mechanical soft diets.

Based on interviews and record reviews, the facility failed to protect R2's right to be free of abuse from another resident. This applies to 1 of 4 residents (R2) reviewed for abuse. The findings include: R2's Face Sheet showed R2 had been residing at the facility since 8/31/2022 for mental health care with diagnoses including schizoaffective disorder, depressive type, personality disorder, schizophrenia, nicotine dependence, and prediabetes. R2's 3/10/2025 MDS (Minimum Data Set) showed R2's cognition is intact. The facility's Incident Report of 3/27/25 to IDPH (Illinois Department of Public Health) showed that on 3/27/25 at 8:30 am R1 and R2 were standing in a line and R1 threw her cup of coffee on R2 and hit and pushed R2. On 4/3/25 at 1:00 PM, V1 (Administrator) showed the State Surveyor the video of the 3/27/25 incident and the video showed R1 throwing her coffee on R2 and striking and pushing R2. R1's witness statement of 3/27/25 showed that R1 admitted to punching R2 and throwing her coffee on R2. The facility's 3/27/25 Incident Report to IDPH did not have a witness statement from R2. On 4/3/25 at 2:45 PM, V2 ADON (Assistant Director of Nursing) said that R2 did not want to give a statement. On 4/3/25 the day of this investigation, R2 was out of the facility on a pass. On 4/3/25 at 1:23 PM, R3, who's cognition is intact, said that he was standing in the smoking line in front of R1 and R2, and when he turned around, he saw R1 throw her coffee on R2. On 4/3/25 at 2:23 PM, V1 (Administrator) said that the incident of 3/27/25 was resident to resident physical abuse. V1 said that R1 physically abused R2. V1 said the facility failed to provide a safe environment free from abuse for R2. V1 said R1's actions were willful, intentional, and deliberate. V1 said it is the facility's policy to have a safe environment for the residents, and for them to be free from abuse from another resident. On 4/3/25 at 2:45 PM, V2 ADON (Assistant Director of Nursing) said that on 3/27/25 she was in charge of the facility. V2 said that when she came in that day, she was told by staff that there was an incident between R1 and R2. V2 said that she viewed the video tape of the incident and she saw that R1 threw her coffee on R2 and hit R2. V2 said that the incident was physical abuse from R1 to R2. V2 said that the facility failed to provide R2 with a safe environment and free from abuse. V2 said that R1's actions were willful and deliberate. On 4/3/25 at 12:12 PM, V3 (Nurse) said that on 3/27/25 at 8:30 AM she was in the nurses' station when she heard an altercation and ran out to the dining room and saw staff had separated R1 and R2. V3 said that she asked R2 what had happened and R2 told her that R1 had hit her in the mouth and threw coffee on her. On 4/3/25 at 3:05 PM, V4 CNA (Certified Nurse's Assistant) said that he was present in the dining room on 3/27/25 serving food to the residents. V4 said that he saw R1 throw coffee on R2 and that R1's actions were intentional. On 4/3/25 at 12:38 PM, V5 (Nurse) said that on 3/27/25 he was in the nurse's station and heard a commotion and came out and saw R1 push R2. V5 said that R1 was the aggressor. V5 said that the incident was physical abuse by R1 to R2. V5 said that he did not see R1 throw the coffee on R2, but he did see that R2's jacket was wet with coffee. R2's 3/27/25 at 8:28 AM Risk Management report completed by V3 showed that on 3/27/25 R2 reported to V3, that R1 struck R2 in her mouth and threw her coffee on her. R2's 9/9/24 care plan showed that R2 is at risk for abuse/neglect based on her comprehensive assessment related to her mental illness diagnosis with interventions including assure R2 is in a safe and secure environment. The facility's Abuse policy dated 3/2022 showed that the residents have a right to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. The policy showed that the facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The policy showed that the facility should established a resident sensitive and resident secure environment. The policy showed the definition of abuse meaning any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy showed the definition of physical abuse as the infliction of injury on a resident that occurs other than by accidental means. The policy showed that physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The policy showed that the prevention of abuse may be prevented by establishing a safe environment.

Based on interview and record review, the facility failed to have a system or any policies in place to identify services needed to meet the intimacy rights of mentally ill female residents of child-bearing age. This failure resulted in one female resident (R1) becoming pregnant by another resident and experiencing psycho-social harm when she was hospitalized and per the hospital Psychiatrist, is now in a catastrophic situation. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/21/2024 when R1 told staff that she had an interest in R2 (a male peer) and refused condoms and other forms of birth control. This applies to 1 of 10 residents (R1) reviewed for intimacy rights and has the potential to affect 6 other female residents (R12-R17) of child-bearing age living in the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 11/07/2024 at 8:58 AM and the IJ template was provided. V1 provided an Immediacy Removal Plan at 3:15 PM on 11/07/2024, which was rejected and returned to V1 at 4:10 PM. The facility's second Immediacy Removal Plan was provided by V1 at 8:20 AM on 11/08/2024, which was rejected and returned to V1 at 9:20 AM. The facility's third Immediacy Removal Plan was provided by V1 at 12:15 PM on 11/08/2024 and it was accepted at 12:25 PM. The Surveyor confirmed the immediacy was removed on 11/12/2024 at 2:40 PM, however the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of new policies and procedures and Quality Assurance monitoring. The findings include: On 11/06/2024 at 1:30 PM, V29 (R1's Hospital Psychiatrist) said R1 was inpatient at the hospital after experiencing a mental health crisis associated with her pregnancy. V29 said R1 was uniquely trapped due to her current situation. V29 said R1 was unable to care for a child because she herself requires 24-hour custodial care for her own mental health. V29 said the facility failed to adequately assess R1's ability to engage in safe sex practices which resulted in R1 becoming pregnant while residing at the facility, and now having no access to an adequate facility that can meet her mental and medical health needs. V29 said all of R1's pregnancy alternatives will result in a poor outcome to her mental health, adding that all of these events have placed her in a catastrophic situation. V29 stated she may have a natural miscarriage, or a judge may grant guardianship and/or she may have an abortion, or if she has the child and it is removed because of her capacity. V29 stated R1 won't understand, which would be catastrophic. V29 stated R1 thinks she is rich and has a rich man- she does not understand her current position. V29 stated a lot of [R1's] thoughts are 'child-like thinking' or 'magical.' V29 stated he feels the facility did not adequately provide contraceptives for her and now has basically kicked her out. V29 stated they give condoms to residents in hopes they use them right- mental patients- where the normal adult has difficulty even using them right. V29 stated it's an environment problem and in his opinion, the facility has failed her ethically. R1's Face Sheet showed R1 was a facility resident since 4/23/2020. Her Face Sheet showed R1's diagnoses included schizophrenia, anxiety disorder, epilepsy, and asthma. R1's 10/17/2024 Gynecology Consultation Summary Report confirmed R1's pregnancy by ultrasound with an Estimated gestational age: 6w3d (or becoming pregnant 9/2/2024), with an Estimated date of delivery: 6/9/2025. On 10/25/2024 at 12:37 PM, V7 (Licensed Practical Nurse/LPN) said on 10/18/2024 she was instructed not to administer R1's antipsychotic medications because R1 was confirmed to be pregnant on 10/17/2024. V7 said she was not aware R1 had been sexually active at the facility. On 10/23/2024 at 8:45 AM, V20 (R1's Brother) stated he was unsure if R1 and R2 (R1's boyfriend and presumed father) understood the consequences of unsafe sex. V20 stated R1 and R2 wanted to leave together on 10/17/2024 with no plan but to get an apartment. V20 stated neither R1 or R2 have no funds except for a little Social Security, but they have no way of getting funds and R1 has no skills to leave and find housing. R1's 9/23/2024 Level of Functioning assessment showed she needs significant assistance in the listed areas of- forming and maintaining friendships; pursuing appropriate leisure and recreational activities; taking care of own possessions and living space; money knowledge and money management skills; and recognizing and avoiding common dangers. On 10/25/2024 at 3:30 PM, V18 (R1's Brother) said R1 was currently at the hospital after the facility had her petitioned out for an involuntary psychiatric admission on 10/18/2024. V18 said R1 had experienced an emotional crisis after R2 reportedly told R1 he did not want to be involved with her pregnancy. R1's 10/18/2024 Petition for Involuntary Admission (timed at 9:30 AM) showed R1 presents with exacerbated psychosis, extreme agitation, aggression, and mania. The resident is pregnant and not taking psychotropic medication. On 10/25/2024 at 12:00 PM, V2 DON (Director of Nursing) said she responded to a code green (resident elopement) for R1 when R1 exited the building and then was subsequently petitioned out to the hospital. V2 said the facility could no longer care for R1 since she became pregnant by another resident while residing at the facility. V2 said the facility did not have policies and processes to monitor menstruation cycles, perform pregnancy testing, distributing contraceptives, completing intimacy assessments and consents, and pregnancy. V2 said she did not know much about the intimacy assessments because psychosocial staff were responsible for completing them. On 10/25/2024 at 11:17 AM, V3 PRSD (Psychiatric Rehab Social Director) said on 10/17/2024 when R1 found out she was pregnant, she expressed wanting to leave with R2. V3 then said on 10/18/2024 she was informed R1 was angry and screaming trying to leave the facility. V3 said after the incident she was asked to assist with R1's emergency transfer petition for acute psychiatric services because R1 was extremely agitated and a danger to herself and others. V3 said psychosocial staff completes intimacy assessments quarterly and annually but they did not maintain a list of residents engaging in intimate relationships. V3 said the questions on the assessments are asked of residents and if they apply, they are checked off. V3 said psychosocial staff also provide residents with condoms, but they did not maintain a tracking list of which residents asked for or received them, the amount provided, when they were given, or with whom the residents planned on having sexual relations. On 10/24/2024 at 4:33 PM, V6 PRSC (Psychosocial Rehab Services Coordinator) said R1 had been a long-term care resident at the facility for four years. V6 said she was familiar with R1's psychosocial needs and R1 required inpatient mental health care services. V6 said R1 had delusions about being pregnant in the past and has required multiple psychiatric hospitalization s. V6 said R1 was obsessed with wanting to get pregnant. V6 said R1 had been refusing contraceptives and was knowingly continuing to engage in unprotected sex with R2 and R3 at the facility. V6 said R1 came to her on 10/17/2024 with her ultrasound result and told her she was pregnant. V6 said she completes intimacy assessments to counsel residents on consensual sex and on the use of contraceptives and the assessment was a guide to help them educate residents about intimacy. V6 said she then initiates an intimacy care plan and updates it based on the assessments. R1's 6/21/2024 Social Services (SS) progress note from 11:35 AM showed Resident will exercise consensual, respectful, and appropriate intimate sexual relations. Resident has been counseled on the importance of using condoms and birth control to prevent pregnancy and any STDs [sexually transmitted diseases]. Writer to provide resident with condoms. Resident is refusing condoms and any form of birth control. Resident stated that she 'is allergic to latex.' Writer educated resident that intimate/sexual partners must be able to provide consent. Consent must be mutual. Writer will monitor. (R1's Electronic Medical Record does not list latex as one of her allergies.) R1's nursing progress note approximately 30 minutes later showed R1 .stated she was [NAME] Rican, and no one can understand her because she speaks another language and that she had an interest in peer [R2]. Writer notified [Psychiatrist] of resident statements. [No new orders.] (R1's 9/24/2024 Minimum Data Set showed R1's race is Black or African American.) R1's 6/26/2024 Intimate Relationship assessment (from five days later) does not show R1's refusal of the use of contraceptives and the consequences if she becomes pregnant, such as medication changes and discharge from the facility, and R1's intimacy care plan was not updated. R1's 9/23/2024 Intimate Relationship assessment does not acknowledge R1 wanting to get pregnant and her engagement in unprotected sex. The assessment does not identify education provided for any consequences for R1 if she became pregnant as a result of not using contraception and R1's intimacy care plan was not updated. The Self-sufficient in section of R1's Level of Functioning assessment (also from 6/26/2024, prior to R1's pregnancy) included boxes to check for 1. nutritional awareness, eating habits, health maintenance; 2. knowing the importance of medication management; 3. forming and maintaining friendships; 4. pursuing appropriate leisure and recreational activities; 5. washing, folding, and doing laundry; 6. taking care of own possessions and living space; 7. money knowledge and money management skills; 8. recognizing and avoiding common dangers. None of the numbered boxes were checked and instead, the 9 box was checked that showed None of the above, needs significant assistance in these areas. R1's Intimacy care plan (initiated 6/21/2024) showed [R1] is alert/aware and coherent about whom [she] chooses to exercise her right to engage with in an intimate/sexual relationship. An undated entry under the problem focus also showed Resident counseled: female contraception/nursing notified. Resident to start three-month Depo-Provera shot. The intimacy care plan goal showed [R1] will exercise safe, respectful and consensual intimate relations through the next review date. All interventions in the intimacy care plan were from 6/21/2024, and they included Discuss birth control options and consider pregnancy testing periodically for females of child-bearing age, Educate [R1] on safe sex practices includes types of condoms/contraception methods and importance of monogamy, Help [R1] maintain and preserve her dignity, integrity, and confidentiality by discussing these matters in a room that affords privacy, Provide [R1] with condoms, and Remind [R1] that intimate/sexual partners must be able to provide consent. Consent must be mutual. On 10/23/2024 at 10:15 AM, V15 (LPN) said she was taking care of R2. V15 said she was not aware of how long R1 and R2 were in a relationship. V15 said the facility does not track which residents are in intimate relationships. V15 said she believed psychosocial staff determines if residents can consent to sexual relationships and obtain resident intimacy contracts. V15 said she was unsure where intimacy assessments, consents, and contracts were in the residents' EMR (Electronic Medical Record). V1 (Administrator) and V5 (Regional Behavioral Director) confirmed the facility does not have intimacy contracts. On 10/23/2024 at 11:00 AM, V14 (Registered Nurse/RN) said residents are allowed to make their own sexual decisions. V14 said he cared for R1 and was not aware of her intimate relationship with R2. V14 said the facility provided condoms to residents but there is not a tracking list. V14 said he assesses residents' neurological function to determine if they know what sex means and educates on options. V14 said he was unsure how to determine if residents can practice safe sex. R1's 7/6/2024 SS progress note from 4:17 PM showed .Writer asked if this is where she wanted to live or if she didn't live [here] where she would live. Resident stated 'here.' Resident commented quietly, 'I have a boyfriend.' That was a surprise to writer. Writer asked who? Resident stated, 'you don't know.' Writer stated, 'I don't.' Resident's boyfriend is [R2] and has been. Writer counseled resident on the importance of having safe, consensual, and appropriate intimate relations using a condom and female contraception (if resident chooses). Writer counseled to go to nursing if resident wants female contraception otherwise condoms will be provided. Writer counseled to always be respectful of roommates. Writer counseled if either changes their mind and does not want to engage to communicate that clearly. Resident receptive to counsel. Writer will monitor. R1's 7/6/2024 SS progress note from a few minutes later showed Resident stated to writer that [R2] wants to 'bang' all the time. Writer tried to give resident condoms. Resident was embarrassed and told me to give the condoms to [R2]. Writer will do so and re-educate [R2] on consensual relations. Writer will monitor. A second SS note from 7/6/2024 showed Resident [R2] denies having a relationship with resident. Resident may be delusional or other resident may not be telling the truth as is the case at times. Writer will monitor. On 10/24/2024 at 9:05 AM, V11 (LPN) said condoms are provided to residents when they ask for them and there was no tracking list. V11 said she did not know how frequently residents were assessed for sexual consent but believes it is done during admission. V11 said she believes psychosocial does an assessment but does not know the name of the assessment and where it can be found. R1's 7/17/2024 nursing progress note showed It was reported by social services that resident has been having ongoing unprotected sexual intercourse with peer despite education/information related to negative potential consequences and refusal of protection such as condoms/abstinence. Resident agreed that she would be willing to start some sort of birth control and see gynecology. Notified [Nurse Practitioner] and referral left with scheduler to set up resident appointment with gynecology. No issues/concerns. The note does not address the risks if R1 becomes pregnant while residing at the facility. R1's 8/2/2024 nursing progress note showed Resident returned from OB/Gyn appointment in stable condition. Progress note blank. [No new orders] at this time. On 10/14/2024 at 9:45 AM, V8 (RN) said condoms are provided by nurses to residents when residents ask. V8 said he checks for sexual consent by talking to the residents and assessing for verbal cues such as alertness and orientation. V8 said he documents consents in the residents' EMRs. V8 then said he believed psychosocial staff also completes consent forms. V8 said he was not aware of the form's name and where it could be found. V8 said the facility did not have a tracking system for residents in intimate relationships. R1's 8/31/2024 SS progress note showed It was reported [R1] was threatening to harm another resident. This writer spoke with [R1]. [R1] stated another resident is bothering her 'boyfriend.' Staff counseled [R1]. [R1] accepted counseling. Staff re-directed [R1] to allow staff to address the matter . On 10/30/2024 at 11:38 AM, V10 (Certified Nurse Assistant/CNA) said residents were allowed to engage in intimate relationships at the facility. V10 said she reports to nursing and psychosocial if she suspects residents are having intimate relationships. V10 said if residents ask for condoms, she tells the nurses. V10 said she was responsible for monthly tracking of menstruation cycles in a yearly log. V10 said she was currently monitoring R5, R8, R12, R13, R14, R15, R16 and R17's menstrual cycles. V10 said she was never instructed to report or submit the data findings. V10 said she did not report R1's missed periods for August, September, and October 2024. On 11/06/2024 at 4:20 PM, V2 (DON) confirmed that out of those female residents being monitored, only R12, R13, R14, R15, R16, and R17 were able bear children and were not on contraceptives or had no known history of other forms of contraception use. V2 confirmed the menstruation monitoring logs were kept by V10 and not collected for review by other staff. On 10/24/2024, R1's Menstrual Tracking log for 2024 showed R1's last tracked menstruation was on 7/17/2024. The log included instructions to Notify MD or NP of any episodes of two (2) consecutive months without a menstrual cycle. On 10/23/2024 at 2:22 PM, V1 (Administrator) said R1 had always wanted to have a baby. V1 said the facility was aware of R1's intimate activity while residing at the facility. V1 continued to say the facility was also aware that R1 was engaging in unprotected sex and refusing contraceptives. V1 said R1 had an ultrasound on 10/17/2024 which confirmed she was pregnant. V1 said the facility completed R1's petition for involuntary psychiatric admission on 10/18/2024 because they were concerned for her safety after she became extremely upset about her pregnancy situation and said the facility was unable to care for pregnant residents. V1 said the facility did not have policies on caring for residents engaging in intimate relationships, intimacy consent, or caring for residents who become pregnant. V1 said the facility did not have a process to monitor residents in intimate relationships. V1 said the facility provided residents with condoms and if needed, the physician could be contacted for female oral or injection contraceptives. V1 said the facility did not have a policy regarding contraceptives. On 10/24/2024 at 12:31 PM, V5 (Regional Behavioral Director) said the facility did not have policies on intimacy, sexual consent, or pregnancy. V5 said psychosocial staff completed an intimacy assessment on admission and quarterly and residents' intimacy care plans should be updated based on the outcome of the assessment. V5 said the facility's IDT (Interdisciplinary Team) determines if episodic assessments are needed to give residents additional sex education and expectations of intimate relationships. V5 was unable to explain what those expectations were. V5 said that there had not really been a need to complete 'episodic' intimacy assessments at the facility. V5 said the intimacy assessments have questions followed by prompt (explorative) statements for the interviewer to determine if they apply to the resident. V5 continued to say that the assessment was to help check the residents' decisional capacity and judgment and not all the question prompt statements needed to be selected for determining consent. V5 stated the assessment does not give directions and there is no score for the outcome of the assessment and the assessment does not identify who the resident's partner may be or the partner's consensual capacity. V5 said staff were expected to check the assessments when they know residents are engaging in sexual activity. V5 said the facility did not have a process to track intimate relationships or the distribution of condoms. V5 was unsure how the facility would be able to assist residents who become pregnant at the facility. On 10/28/2024 at 3:25 PM, V21 (R1's Facility Psychiatrist) said he had been treating R1 for mental health services at the facility since 2020. V21 stated it is not black and white when it comes to competency, adding a resident can be competent to accept meds but not live independently. V21 said he was not specialized in caring for pregnant residents receiving antipsychotic medications as they require specialized facilities to ensure antipsychotic medications are administered safely since they can be very dangerous to a fetus during pregnancy. V21 said he was not notified R1 was actively trying to get pregnant at the facility. V21 said if V21 had been notified sooner he would have worked with the facility and R1's family to identify other interventions to implement in R1's plan of care. V21 stated R1 still requires 24-hour custodial care and now she knows she can do this- she needs to be monitored closely to make sure she takes meds to not repeat this. V21 said R1 was suffering and would continue to do so because she was now in unfavorable situation as she is unable to care for a baby. On 10/23/2024 at 3:45 PM, V4 (Medical Director) said he was the facility's Medical Director and R1's medical physician. V4 said R1 was sexually preoccupied. V4 stated he was unsure if there was a policy, and the psychiatric physician checks the resident's decisional capacity. V4 stated he did not know how they facility knew who was sexually active and the facility should have a process and policies when residents are sexually active. V4 said he expected the facility to have processes and policies to know how to care for sexually active residents, residents who want to get pregnant, and residents who become pregnant while residing at the facility. R1's comprehensive care plan reviewed on 10/23/2024 showed R1 chooses to exercise her right to engage within an intimate/sexual relationship initiated on 6/21/2024. R1's care plan did not have updated interventions to address R1 wanting to have a baby and engaging in unprotected sex. R1's care plan was not updated on 6/21/2024, 7/6/2024, or 7/17/2024 with interventions to address R1's verbalizations regarding desires to become pregnant and subsequent discharge, engagement in unprotected sex, or discharge planning. R1's Discharge Potential assessment dated [DATE] showed R1 had poor discharge potential and was expected to remain at the facility. The assessment said R1 was not able to be discharged to a less structured level of care because R1 has had problems complying with his/her psychiatric treatment regimen (including taking medications as ordered, following up with mental/psychiatric counseling, and case management recommendations) .has had physical and mental problems increase the resident's vulnerability and hydration/food/clothing and or may become a victim or perpetrator of abuse or neglect to avoid self-neglect lacks a support system that can provide housing, financial support, direction, guidance, physical care, and supervision. R1's Discharge Potential assessment does not address R1's goal of wanting to get pregnant and her risk of discharge if she becomes pregnant while residing at the facility. R1's Goals assessments dated 9/23/2024, showed R1's discharge goal was to age in place. The facility's policy titled Admission Criteria dated 4/2020, said Residents will be admitted to this facility as long as their nursing and medical needs can be met adequately by the facility. The facility does not have the capability for caring for residents who are pregnant . The policy does not address how the facility will care for long-term care residents who become pregnant while residing at the facility, and when to initiate discharge planning in such a case. The facility's policy titled Resident Rights dated 4/2020 said be informed about his or her rights and responsibilities .be informed of, and participate in, his or her care planning and treatment . The facility's March 2021 Care Plan Development policy showed A person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process, is developed and implemented for each resident .3. Discharge plans- Each resident's care plans will be prepared by an interdisciplinary team .8. Evaluations of the resident are ongoing and care plans are reviewed and revised by the interdisciplinary team after each evaluation .9. The Care Planning/Interdisciplinary Team is responsible for the reviews and updating of care plans; When there has been a significant change in condition, When the desired outcome is not met . 11. The services provided or arranged by the facility, as outlined by the comprehensive care plan will meet professional standards of quality and be provided by qualified persons in accordance with each resident's written plan of care . The 8/02/2024 Facility Assessment showed the facility provided a wide variety of services designed to maximize physical and emotional wellness, promote independence and healing, and preserve personal dignity .To comply with treatment plan that is focused on individual care planning . The Immediate Jeopardy that began on 6/21/2024 was removed on 11/12/2024 when the facility took the following actions: 1.The facility has taken the following actions concerning the Immediate Jeopardy: a) Policies have been developed for the following: Contraception Policy, Menstrual Cycle Monitoring Policy, Intimate Relationship Assessment and Education Form Policy, effective 11-7-2024. b) Nursing and PRSD/PRSC staff have been training re: Contraception Policy, Menstrual cycle Monitoring Policy, Intimate Relationship Assessment and Education Form Policy and responsibilities regarding all policies. Effective 11-8-2024 completion date 11-12-2024. c) Residents of childbearing age and who engage in sex are offered contraceptives by PRSC/PRSD staff. If resident chooses medicine-based contraceptive, they will be referred to nursing who will contact MD for orders. d) New admissions will have admission assessment completed and placed on menstrual cycle tracking as indicated. e) New admissions will have Intimacy assessment and Education Form completed upon admission assessment and will have contraceptives offered. If resident chooses medicine based contraception, MD will be contacted per nursing. 2. Measure the facility will take to ensure the problem will be corrected and not recur. a) The facility has developed new policies on Contraception use, Intimate Relationship assessment and education form, and Menstrual Cycle Monitoring. Policies effective 11-7-2024. Policies reviewed with Medical Director 11-8-2024. b) The facility will ensure that Nursing Staff and psych social staff are educated on responsibilities regarding the following policies: Contraception policy, Menstrual Cycle Monitoring Policy, and Intimate Relationship Assessment and Education Form Policy. Employees that are on vacation will be educated prior to returning to the facility. Education effective 11-8-2024, completion date 11-12-2024. c) The facility will audit residents medical record to identify female residents of childbearing age, these residents will have menstrual cycle tracking by nursing staff and will be offered contraception and education regarding contraception. If resident chooses medicine-based contraception, MD will be contacted for orders per nursing. Facility audit initiated by the PRSD on 11- 7-24, completed 11-8-2024. d) The facility PRSD and the PRSCs educated on intimacy assessment and education form policy, including review of intimacy assessment and education form, review of need to educate residents regarding contraception and safe sex practices, review of educating residents regarding risks of pregnancy which include an understanding that they will not be able to continue to reside in facility. Education provided by Regional Director of Behavioral Health beginning on 11-7-2024, completion date 11-12-2024. 3. The PRSD or designees will monitor continued compliance via the following Quality Improvement programs: a. A QA tool developed to monitor menstrual tracking. Beginning 11-7-24, Daily, for the next 30 days, during facility rounds, the DON or designee will ensure that menstrual tracking is completed, then 3 times per week for 30 days, and finally 1 time per week for 30 days. New admissions will be added to the QA tool. See attached. b. A QA tool developed to review status of contraceptive use for biological female residents of childbearing age. Beginning 11-7-24, weekly for next 30 days DON or designee will review orders to ensure that biological female residents of childbearing age have orders for medicine-based contraceptives or have documented refusal of medicine-based contraceptives, then monthly for 60 days. New admissions will be added to the QA tool. See attached. c. A QA tool has been developed to review status of intimate relationship assessments and education form. Beginning 11-7-2024, weekly for next 30 days PRSD or designee will review completed intimate relationship assessments and education form for completion and intimacy care plan, then 3 times per week for 30 days, and then 1 time per week for 30 days. New admissions will be added to the QA tool. See attached. d. The results of the monitoring completed under this plan are submitted to the QA/QAPI Committee for review and follow-up and reviewed with Medical Director. Next QAPI meeting scheduled for November 27, 2024.

Based on interview and record review, the facility failed to have physician documentation to show the specific resident needs the facility could not meet for residents who were involuntarily discharged , and the efforts the facility made to meet those needs for a resident. The facility also failed to re-evaluate if a resident was able to be readmitted at the time of discharge from the hospital. This applies to 2 of 5 residents (R1 and R7) reviewed for discharges. The findings include: 1. The EMR (Electronic Medical Record) shows R7 was admitted to the facility on [DATE], and was involuntarily discharged from the facility on October 22, 2024. R7 had multiple diagnoses including major depressive disorder, generalized anxiety, asthma, suicidal ideation, bipolar disorder, and psychotic disorder. R7's MDS (Minimum Data Set) dated September 13, 2024, shows R7 was cognitively intact and was independent with all ADLs (Activities of Daily Living). R7 was always continent of bowel and bladder. R7's MDS continues to show R7 had verbal behaviors directed towards others for one to three days during the MDS observation period, and other behaviors directed towards others daily. The EMR shows V3 (PRSD-Psychiatric Rehab Social Director) provided a Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form to R7, dated October 22, 2024. The form shows, The safety of individuals in this facility is endangered and R7 was being transferred or discharged to a local behavioral hospital. The form also shows, As discussed with [V7] on October 22, 2024, and as documented in your clinical record pursuant to Section 3-408 of the state law, the reason for this proposed transfer or discharge is: the physical safety of other residents, the facility's staff or visitors. On October 29, 2024, at 2:26 PM, V27 (Psychosocial Rehab Services Coordinator) said, she saw R7 punch R9 in the face. On October 22, 2024, at 6:08 PM, V15 (LPN-Licensed Practical Nurse) documented an altercation between R7 and R9. Facility documentation shows R7 was sent to the local hospital with emergency personnel and the involuntary discharge paperwork. As of October 30, 2024, at 1:04 PM, the facility did not have documentation by V4 (Physician), V21 (Psychiatrist), or V28 (NP-Nurse Practitioner) to show the specific needs the facility could not meet, the facility efforts to meet those needs, and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met by the current facility. 2. R1's EMR showed an admitted [DATE] with diagnoses of schizophrenia, epilepsy, anxiety, myopia, astigmatism, and hyperlipidemia. R1's MDS dated [DATE], shows R1 had behaviors not directed towards others daily. R1's MDS dated [DATE] showed she was permanently discharged from the facility and not anticipated to return. On 10/23/2024 at 2:22 PM, V1 (Administrator) said R1 had been a long-term resident at the facility for four years receiving inpatient mental health services. V1 said on 10/18/2024, R1 was upset regarding her pregnancy. V1 said the facility staff allowed R1 to leave the facility unsupervised and said the facility felt [R1] left the facility AMA (Against Medical Advice). V1 said R1 was found by her family and the local police soon after. V1 said the police informed her R1 was still the facility's resident and needed emergency psychiatric services for her safety. V1 said the facility completed R1's petition because they were concerned. V1 said the facility permanently discharged R1 on 10/18/2024 and had made no attempts to follow up with the hospital on R1's condition for readmission because they still felt R1 had left AMA from the facility, despite the facility indicating R1 was a resident at their facility when completing her petition. On 10/25/2024 at 12:00 PM, V2 (Director of Nursing/DON) said she was present on 10/18/2024 when R1 was upset and was allowed to leave the facility unsupervised. V2 said R1 was not informed or given an AMA form and an IVD notice on 10/18/2024 when she left the facility. V2 said the facility did complete a petition for R1 because they were concerned about her safety. On 10/25/2024 at 3:30 PM. V18 (R1's brother) said the facility had R1 petitioned to the hospital on 10/18/2024 due to an episode of a mental crisis. V18 said R1 remained inpatient at the hospital's psychiatric unit receiving mental health services and was being counseled on her pregnancy treatment options. On 10/29/2024 at 2:00 PM, V3 (PRSD/Psychiatric Rehab Social Director) said on 10/18/2024 she was informed R1 left the facility upset and AMA. V3 said R1's family found R1 shortly after she left the facility. V3 said then V1 (Administrator) instructed her to complete R1's petition for involuntary transfer from the facility to the hospital on 10/18/2024. V3 said the facility was concerned for R1's safety after she had an emotional crisis. V3 said R1 was not given an AMA form and an IVD (Involuntary Discharge) notice on 10/18/2024. V3 said V25 (Hospital Social Worker) called her informing her R1 was ready for readmission on 10/25/2024. V3 said she informed V25 that R1 could not be readmitted because she was permanently discharged from the facility on 10/18/2024 after they petitioned her to the hospital. R1's Petition for Involuntary/Judicial admitted d 10/18/2024, showed R1 was asserted to be required to be involuntarily discharged from the facility to an emergency inpatient admission to another acute facility by the facility due to acute mental illness symptoms. The petition said R1 The Respondent is currently detained in a mental health facility or hospital; name of facility where detained: [NAME] Chicago Terrace. The petition said R1 presents with exacerbated psychosis, extreme agitation, aggression, and mania. The resident is pregnant and not taking psychotropic medication. The petition was completed and signed by V3 (PRSD/Psychiatric Rehab Social Director). R1's Progress Note dated 10/18/2024 said The resident [R1] left the facility AMA and was seen walking approximately a mile from the facility by her sister. Police were called, and a petition was made to transport [R1] to the hospital . The progress note does not indicate if R1 was educated or given forms on leaving AMA or the IVD process. As of 10/30/2024 at 3:00 PM, R1's EMR did not include an AMA form or IVD (Involuntary Discharge) notice for 10/18/2024. The EMR does not show any documentation follow-up regarding R1's status at the hospital on 10/18/2024 or after. The facility's policy titled Against Medical Advice (AMA) dated 3/2021, said Guideline: To provide communication to the resident that their request for discharge is against medical advice .Procedure .3. Documentation should be entered in the residents record and should include education provided to the resident and/or family. The facility's policy titled Involuntary Transfer/discharge date d 3/2021, said It is the policy of the facility to transfer out or discharge from the facility residents/patients in accordance with state and federal laws and guidelines. Standard: According to federal regulations, the facility must permit each resident/patient to remain in the facility, and not involuntarily transfer or discharge the resident/patient from the facility unless: The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs.The resident's clinical or behavioral status (or condition) endangers the safety of individuals in the facility. Procedure: 1. If facility has determined it cannot meet the resident's need, the following information must be documented in the resident record by the physician: a. The specific needs the facility could not meet, b. The facility efforts to meet those needs, and c. The specific services the receiving facility will provide to meet the needs of the resident which cannot be met by the current facility .13. If there are concerns regarding a resident return from the hospital, the facility cannot evaluate the resident based on his or her concern when originally transferred to the hospital. If after evaluation at the end of the hospital stay the facility medical record must show the facility made efforts to: a. Ascertain an accurate status of the resident's condition through communication with hospital staff and/or visits by nursing home staff to the hospital. b. Find out what treatments, medications and services the hospital provided to improve the resident's needs and may consider initiating a discharge .

Based on interview and record review, the facility failed to inform and provide a resident with a notification of involuntary discharge. This applies to 1 of 5 residents (R1) reviewed for discharges. The findings include: R1's EMR (Electronic Medical Record) showed an admitted [DATE] with diagnoses of schizophrenia, epilepsy, anxiety, myopia, astigmatism, and hyperlipidemia. R1's MDS (Minimum Data Set) dated 9/25/2024, shows R1 had behaviors not directed towards others daily. R1's MDS dated [DATE] showed she was permanently discharged from the facility and not anticipated to return. On 10/29/2024 at 2:00 PM, V3 (PRSD/Psychiatric Rehab Social Director) said R1 was confirmed to be pregnant on 10/17/2024. V3 said on 10/18/2024 she was informed R1 left the facility upset AMA (Against Medical Advice). V3 said R1's family found R1 shortly after she left the facility. V3 said then V1 (Administrator) instructed her to complete R1's petition for involuntary transfer from the facility to the hospital on 10/18/2024. V3 said the facility was concerned for R1's safety after she had an emotional crisis. V3 said R1 was not given an AMA form and an IVD (Involuntary Discharge) notice on 10/18/2024 before she was transferred. On 10/25/2024 at 12:00 PM, V2 (Director of Nursing/DON) said she was present on 10/18/2024 when R1 was upset and was allowed to leave the facility unsupervised. V2 said R1 was not informed or given an AMA form and an IVD notice on 10/18/2024 when she left the facility. V2 said the facility did complete a petition for R1 because they were concerned about her safety. On 10/23/2024 at 2:22 PM, V1 (Administrator) said R1 had been a long-term resident at the facility for four years receiving inpatient mental health services. V1 said on 10/18/2024 R1 was upset regarding her pregnancy. V1 said the facility staff allowed R1 to leave the facility unsupervised. V1 said the facility felt R1 left the facility AMA. V1 said R1 was found by her family and the local police soon after. V1 said the police informed her R1 was still the facility's resident and needed emergency psychiatric services. V1 said the facility completed R1's petition because they were concerned. V1 verified the facility permanently discharged R1 on 10/18/2024 and confirmed that R1 was not notified or given an IVD notice. V1 said the facility had been aware R1 was engaging in unprotected sex and had always said she wanted a baby and R1 was confirmed pregnant on 10/17/2024 while residing at the facility. V1 said the facility was unable to care for pregnant residents. R1's Petition for Involuntary/Judicial admitted d 10/18/2024, showed R1 required an involuntary petition for admission and discharge from the facility to an emergency inpatient admission to another acute facility due to acute mental illness symptoms. The petition said R1 The Respondent is currently detained in a mental health facility or hospital; name of facility where detained: [NAME] Chicago Terrace. The petition said R1 presents with exacerbated psychosis, extreme agitation, aggression, and mania. The resident is pregnant and not taking psychotropic medication. The petition was completed and signed by V3 (PRSD/Psychiatric Rehab Social Director). R1's Progress Note dated 10/18/2024 said The resident [R1] left the facility AMA and was seen walking approximately a mile from the facility by her sister a petition was made to transport [R1] to the hospital . The progress note does not indicate that R1 was educated or given forms on leaving AMA or the IVD process. As of 10/30/2024 at 3:00 PM, R1's EMR did not show an AMA (Against Medical Advice) form and IVD (Involuntary Discharge) notice for 10/18/2024. The facility's policy titled Against Medical Advice (AMA) dated 3/2021, said Guideline: To provide communication to the resident that their request for discharge is against medical advice .Procedure .3. Documentation should be entered in the residents record and should include education provided to the resident and/or family. The facility's policy titled Involuntary Transfer/discharge date d 3/2021, said Guideline: It is the policy of the facility to transfer out or discharge from the facility residents/patients in accordance with state and federal laws and guidelines .7. Notice of Involuntary Transfer or Discharge and Opportunity of Hearing must be provided at least 30 days prior to discharge, except that it can be provided as soon as practicable before discharge .8. Copies must be provided to the resident, resident's representative, ombudsman and DPH .

Based on interview and record review, the facility failed to supervise a pregnant schizophrenic resident (R1) with a history of and known risk for elopement. This applies to 1 of 4 residents (R1) reviewed for safety. The findings include: R1's Face Sheet showed R1 had been residing at the facility since 4/23/2020 for mental health care with diagnoses of schizophrenia, anxiety disorder, epilepsy, and asthma. R1's 9/25/2024 MDS (Minimum Data Set) showed R1 experienced behaviors, including delusions. R1's 10/17/2024 Planned Parenthood progress note showed R1's pregnancy was confirmed by ultrasound with a gestational age of six weeks and three days. On 10/25/2024 at 12:37 PM, V7 (Licensed Practical Nurse/LPN) said she was R1's nurse on 10/18/2024. V7 said she was instructed not to administer R1's antipsychotic medications because R1 was confirmed to be pregnant on 10/17/2024. V7 said she observed R1 calm in the dining room that morning then she heard the announcement for code green (resident elopement). V7 said she went to the reception area and R1 was yelling and stating she wanted to leave. V7 said V1 (Administrator), V2 (DON/Director of Nursing), and other staff were with her, and then R1 was allowed to leave the facility. V7 said the facility usually has residents sign an AMA form (Against Medical Advice). V7 said the facility also calls emergency personnel when residents are a danger to themselves or someone else. V7 said she was unsure if R1 signed an AMA form because V1 (Administrator) and V2 (Director of Nursing) were addressing the situation. On 10/25/2024 at 2:30 PM, V13 (Receptionist) said on the morning of 10/18/2024, she called a code green because R1 was screaming and was attempting to leave the facility. V13 stated some staff walked out with R1 towards the parking lot. V13 said then the staff came back inside and let R1 leave by herself. On 10/25/2024 at 12:00 PM, V2 (DON) said the code green was called when R1 was leaving through the facility's front door. V2 said she responded to the code and R1 was angry and said she wanted to leave. V2 said R1 then left the facility. R1's progress notes showed other ongoing behaviors and history of elopement attempts: R1's 4/9/2024 nursing progress note showed .observed [R1] talking to DON in her office expressing not feeling safe, suicidal without a plan, and homicidal without a plan, and then this resident eloped from the facility via front door. The staff attempted to re-direct, but resident would not stop. Then 911 was called and resident has been sent out to [local hospital] via 911 with petition. R1's 4/9/2024 Social Services progress note from the same event showed Resident expressed not feeling safe. Resident expressed /feeling [suicidal/homicidal ideation] with no plan. Resident feeling like she is going crazy, crazy stating 'I want to K-ll myself.' Resident ran from the facility into the community with extreme agitation and anxiousness. ADMIN/DON notified. [Psychiatric Physician] ordered petition for hospitalization . R1's Progress Note dated 5/01/2024 said Resident pacing throughout the facility. Exhibits exit seeking behaviors. Resident has [history] of elopement .ADMIN/DON made aware. [Psychiatric Physician] ordered petition for hospitalization . R1's 6/6/2024 progress note showed Resident anxiously pacing throughout the facility daily affecting care and environment .Resident becomes verbally inappropriate if she feels that she does not have the undivided attention of who she is talking to and begins to act out. Resident made an unauthorized exit. Resident's family has made it known that resident has an intellectual disability . R1's 6/21/2024 progress note from 11:43 AM showed .Resident made a delusional statement that she is Guatemalan. Resident showed writer her phone showing that she is [NAME] Rican .Resident is paranoid . (R1's 9/24/2024 MDS showed R1 is not of Hispanic, Latino, or Spanish descent and lists her race as Black/African American.) R1's 6/21/2024 progress note from 12:20 PM showed Resident came to writer stating she was confused about her medications and like an updated list which writer provided stated that she was [NAME] Rican, and nobody can understand her because she speaks another language and that she had an interest in peer [R2] . R1's 7/3/2024 note showed Resident approached nursing station indicating she was feeling stressed out due to trauma from my past and couldn't focus or do anything right now . R1's 7/6/2024 progress note showed Resident expressed that some of these residents are hard to live with. Writer asked if this is where she wanted to live or if she didn't live here where would she live. Resident stated, Here. Resident commented quietly I have a boyfriend [R2] . R1's 7/14/2024 progress note showed Resident pacing back and forth in front lobby with backpack. Resident agitated/frustrated when nurse encouraged resident to come to the nursing station . R1's 7/31/2024 progress note showed Resident very agitated during med pass. Resident expressing paranoia and desire to leave facility .able to be redirected to take her meds . On 10/23/2024 at 2:22 PM, V1 (Administrator) said R1 was at the facility for care of her psychiatric illness. V1 said on 10/18/2024 R1 was angry and bolted out the front door because R2 told R1 he did not want to be in a relationship and did not want to support her with her pregnancy. V1 said she then called R1's family to inform them R1 had left the facility AMA. V1 said R1's family drove around and found her. V1 said R1's family informed the facility R1 was enraged and uncontrollable. V1 said then the police called her to inform the facility of R1's situation and requested the facility complete a petition for an emergency petition for involuntary admission. V1 said R1 had history of eloping from the facility. V1 said R1 had always wanted a baby and the facility was unable to care for pregnant women. On 10/25/2024 at 3:30 PM, V18 (R1's brother) said R1 was currently at the hospital. She was petitioned out on 10/18/2024 due to an episode of a mental crisis. V18 said he met with V1 (Administrator), V2 (DON), and V3 (Psychiatric Rehab Social Director/PRSD) on 10/18/2024 after the facility informed R1's family that R1 had been allowed to the leave the facility unsupervised. V18 said facility staff told him R1 left AMA (Against Medical Advice) that morning. V18 said R1 was found by another family member and emergency personnel approximately half a mile away from the facility. V18 said R1 was in a crisis reaction related R2's (R1's boyfriend) reaction to her confirmed pregnancy the day before. V18 said he was concerned about the facility's lack of response and letting R1 leave the facility without supervision. V18 said the local police suggested he have the facility petition R1 out. V18 said he told V1 and V3 obtained a petition for involuntary transfer to have R1 sent to an acute hospital for emergency psychiatric services. V18 said he asked V1, V2, and V3 why R1 had been allowed to leave the facility AMA this time when multiple times prior when R1 had tried to leave the facility unauthorized, the facility contacted the police themselves and had R1 petitioned to the hospital for acute psychiatric services. V18 stated when he asked them why their response that day was different, the facility was unable to give him a clear explanation. On 10/25/2024 at 11:17 AM, V3 PRSD (Psychiatric Rehab Services Director) said on 10/17/2024, V3 had contacted R1 and R2's family. V3 said R1's sister came to facility and R1 agreed to stay at the facility. V3 said R1's family had requested a meeting with the facility on 10/18/2024 to discuss R1's pregnancy. V3 said she was not present when the code green was called when R1 left the facility angry. V3 said when residents are aggressive, the facility calls emergency personnel to assist. V3 said after the incident, she was asked to assist with R1's petition. V3 said she was really worried when she found out R1 left the facility. On 10/24/2024 at 4:15 PM, V1 verified that it was R1's family that called the police and not the facility. R1's 10/17/2024 progress note (written by V3) showed The resident [R1] had a confirmed pregnancy evaluation, and she was counseled about the result. The resident's sister and brother were notified. [R1] stated she wanted to walk out of the facility, and staff counseled her to stay and talk with her sister. [R1's] sister came to the facility, spoke with the resident, and told her to stay until tomorrow. Sister stated she will come tomorrow and requested to meet with the Administrator. Staff will observe. A timeline of events was provided by V1 on 10/24/2024. The timeline showed 6. 10-17-2024- PRSD spoke with [R1's] family with [R1] present to inform of pregnancy per phone call. Resident's family indicated that they would be at facility in the AM to meet with resident and Administrator to discuss next steps. On 10/24/2024 at 4:15 PM, V1 stated the phone meeting was amicable and there was no yelling or screaming and they talked about moving out together, but nothing was set in concrete. V1 stated the meeting lasted around 15 minutes. V1's timeline continued 8. 10-18-2024- Resident left building due to being upset with boyfriend who informed her that he decided he did not want to be a father. On October 24, 2024, at 4:15 PM, V1 stated R1 left the building between 9 AM and 9:05 AM. R1's 10/18/2024 Petition for Involuntary Admission was timed at 9:30 AM (25-30 minutes later) and showed R1 presents with exacerbated psychosis, extreme agitation, aggression, and mania. The resident is pregnant and not taking psychotropic medication. R1's elopement care plan (initiated 5/4/2024) showed [R1] has a history of unauthorized departure from the facility. On 04/09/2024 Resident ran out of the facility into the community with extreme agitation and anxiousness. On 5/01/2024 resident exhibiting exiting seeking behavior. Interventions include Encourage [R1] to verbalize to psych-social her needs i.e , needing a pass to go with family, take a walk, transfer, etc., and monitor for any sign or symptoms or preparation for unauthorized departure . A 5/9/2024 intervention showed Provide safety-checks as appropriate. R1's care plan showed a focus from 3/8/2024 as [R1] is making paranoid delusional statements and having auditory hallucinations. Eight dates are listed where R1 experienced these delusions, including one from 9/25/2024 where Resident made a delusional statement about paying off a home/caring for a child. The care plan goal is to accept redirection with interventions to assess ability to maintain reality orientation. On 10/24/2024, V1 stated Our stance is that [R1] left AMA on 10/18/2024 because [R2] would not support her related to her pregnancy. R1's most recent Goals assessment from 9/23/2024 showed R1's discharge goal was to age in place. R1's 9/23/2024 Level of Functioning assessment showed she was not self-sufficient in recognizing and avoiding common dangers. R1's Progress Note dated 10/18/2024 said The resident [R1] left the facility AMA and was seen walking approximately a mile from the facility by her sister. Police were called, and a petition was made to transport [R1] to the hospital . The progress note does not indicate if R1 was educated on leaving AMA and R1's electronic medical record does not show an AMA (Against Medical Advice) form was completed 10/18/2024. R1's 9/23/2024 Risk of Self-Harm assessment showed R1 was at risk for self-harm because of her suicidal or self-harm ideations of Pessimism, anticipation of the worst. R1's 9/23/2024 Community Survival assessment showed R1 was not considered for independent privilege pass. The facility's 03/2021 Elopement policy showed 'Elopement' means the unplanned, unauthorized leaving of the facility by a resident who is unable to understand the risks of leaving the facility

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse. This applies to 1 of 3 residents (R9) reviewed for resident-to-resident physical abuse. The findings include: On 10/29/2024 at 11:15 AM, R9 said last week she told R7 to stop being rude to other residents in the dining room. R9 said R7 became upset and started to yell at her. R9 said when she was standing in line for her medications, R7 walked by her and shoved her against a bookcase. R9 said she sustained an injury to her left arm. R9 showed the surveyor her left arm, R9 had a linear abrasion to her forearm which appeared to be healing. R9 said R7 then walked by her again and punched her cold cut in her left eye. R9 said the staff then separated R7 from her. R9 said V15 (Licensed Practical Nurse/LPN) placed ice on her left eye and thankfully she did not get a bruise. R9 said she was scared. R9 said R7 then continued to be aggressive towards the staff and she had to be taken to the hospital. The EMR (Electronic Medical Record) shows R9 was admitted to the facility on [DATE]. R9 has multiple diagnoses including, bipolar disorder, anxiety disorder, and diabetes. R9's MDS (Minimum Data Set) dated September 30, 2024, shows R9 is cognitively intact and able to perform all ADLs (Activities of Daily Living) independently. R9's care plan, initiated June 20, 2024, shows R9 is at risk for abuse/neglect based on her comprehensive mental health. The EMR shows R7 was admitted to the facility on [DATE], and was involuntarily discharged from the facility on October 22, 2024. R7 had multiple diagnoses including major depressive disorder, generalized anxiety, asthma, suicidal ideation, bipolar disorder, and psychotic disorder. R7's MDS dated [DATE], shows R7 was cognitively intact and was independent with all ADLs. R7's MDS continues to show R7 had verbal behaviors directed towards others for one to three days during the MDS observation period, and other behaviors directed towards others daily. On October 22, 2024, at 6:08 PM, V15 (LPN) documented, [R7] and [R9] started fighting. [R7] hit [R9] to face. On October 22, 2024, at 5:07 PM, V27 (PRSC-Psychiatric Rehab Social Counselor) documented, Staff observed [R7] punch another resident (R9) in the face. Staff immediately intervened. On October 29, 2024, at 2:26 PM, V27 said, I saw [R7] punch [R9] in the face. On October 29, 2024, at 1:28 PM, V15 (LPN) said, I was [R9's] nurse the day of the incident. I told the resident to take her medications. She was taking her meds and [R7] came up from behind her and water went everywhere. I saw [R7] punch [R9] in the face. We called a Code Orange because there was a combative situation, and all the CNAs (Certified Nursing Assistants) came. It takes a lot of people to stop [R7]. [V26] (Activity Aide) was also punched by [R7]. [R9's] arm was injured during the situation. On October 29, 2024, at 2:00 PM, V3 (PRSD- Psychiatric Rehab Social Director) said she was present in the facility on the day of the situation between R7 and R9. V3 said R7 was screaming at R9. R7 walked towards R9 and punched R9 in the face. V3 said, I saw [R7] punch [R9] in the face. On October 30, 2024, at 9:07 AM, V26 (Activity Aide) said, I saw an altercation between two residents. [R7] was trying to attack [R9]. We tried to de-escalate the situation, and [R7] kept trying to move forward and she ended up punching me in the face. I had a bruise on my lip and a headache following the incident. The facility's policy entitled, Abuse, effective 3/2022 shows: Policy: This facility affirms the right of our consumers to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of consumers. Definitions: Physical Abuse is the infliction of injury on a consumer that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to protect a resident's (R1) right to be free from sexual abuse from another resident (R2) with known history of sexual behaviors. This failure resulted in R1 being sexually abused by R2. This applies to 1 of 6 residents (R1) reviewed for sexual abuse in the sample of 6. This resulted in Immediate Jeopardy. The Immediate Jeopardy began on January 4, 2024, when R2 was identified by the facility to be more hypersexual and no interventions were put in place to protect other residents, resulting in R1 being sexually abused. V1 (Administrator), V2 (Director of Nursing), V3 (Assistant Director of Nursing) and V13 (Human Resource) were notified of the Immediate Jeopardy on January 23, 2024, at 4:27 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on January 24, 2024, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1 has multiple diagnoses including schizoaffective disorder, hypertensive heart disease without heart failure, dystonia, and glaucoma, based on the face sheet. R1's quarterly MDS (Minimum Data Set) dated November 17, 2023, showed that the resident was cognitively intact. The MDS showed that R1 required partial/moderate assistance from the staff with regards to oral, toileting and personal hygiene, shower/bathing, and upper and lower body dressing. The same MDS showed that R1 was independent with eating, bed mobility, transfer, and ambulation. R1's risk for abuse assessment dated [DATE], showed an undetermined score. The risk for abuse assessment showed that Yes was answered for the following questions: Does the resident have a diagnosis of dementia or mental illness? Does the resident have current/history of social inappropriate behaviors (yelling, screaming, repetitive complaints, making false allegations, wandering, disrobing in public etc.)? and Does the resident have a history/current behavior of physical or threatening physical aggression towards others? The same risk for abuse assessment indicated that *If YES is answered for any of the above questions, resident may be at risk for abuse so initiate an at risk for abuse care plan. R1's active care plan initiated on May 23, 2023, showed that the resident was at risk for abuse/neglect based on the comprehensive assessment as evidenced by R1's diagnosis of mental illness. The goal of this care plan was for R1 to be treated with respect, dignity and be free from mistreatment while residing in the facility. The same active care plan documented, On [January 5, 2024] roommate made unwanted sexual contact to [R1]. On January 16, 2024, at 11:16 AM, R1 stated that he occupies the second bed, while his roommate (R2) occupies the first bed closest to the door. R1 stated that on the early morning (cannot give specific time) of January 5, 2024, he saw his roommate (R2) masturbating (R1 was gesturing this information) in bed. R1 stated that R2 would masturbate in bed almost daily, while naked, leaving the door and curtain open and most of the time he could see and hear R2 doing the act. According to R1, on that early morning of January 5, 2024, while R2 was masturbating in bed, he stayed in his (R1) bed to go back to sleep, then he was surprised when R2 got on top of him while he (R1) was in his bed. R1 stated that he does not know what was happening because his arms were held down by R2's knees and he was attempting to push R2 off him. R1 stated that while R2 was on top of him, R2 had his penis pulled out and R2's penis was rubbing and pushing up and down his face, chin, and neck areas. According to R1, he believes that R2 was trying to put his penis in his mouth, but he (R1) was able to finally push R2 away from him. R1 stated that after the incident he reported to the male staff at the facility's front desk. During the same interview, R1 stated that he does not know why R2 did what he did to him, he was fearful and does not know what was happening. R1 added that he does not want the incident to happen to him again. According to R1, the police came to the facility and had interviewed him with regards to the incident. The facility's final incident report to the State Agency submitted on January 10, 2024, showed in-part that on January 5, 2024, at 3:39 AM, [R1] reported that his roommate [R2] was sexually inappropriate with him by laying on top of him and giggling, then he pushed [R2] off of him. Nurses did a body assessment, and no injuries were found. [R2] stated that he was just playing with him. Nurses counseled [R2] on social boundaries and moved [R1] to another hallway. [R2] was put on 30 (minute) checks for increased supervision and MD (Medical Doctor) was notified and ordered a stat Haldol order. [R1] stated he feels safe in the facility, and emotional support was given and [R1] stated he was in no emotional distress. [R1] also denied police notifications at that time. [R1] has no family to notify and is responsible for himself. The final incident report showed in-part, Upon staff interviewing [R1] on (January 5, 2024) later that morning approximately around 8:30 am, [R1] wanted police notification and stated that [R2] laid on top of him, held his arms down with his knees and dry humped him. Then [R2] took his penis out and put it on his face, neck and chin in an attempt to put his penis in his mouth at that time he was able to push him off onto the floor. Police came to the facility and interviewed [R1] and [R2] with the PRSD (Psychiatric Rehabilitation Service Director) and DON (Director of Nursing) present. [R1] explained the above to the police and when the police interviewed [R2] he denied the event ever happened then eventually admitted that the above did happen. At that time the police arrested [R2] and took him to the county jail for processing. The same incident report showed that the allegation of R2's sexual inappropriate behavior towards R1 was substantiated. R2 was admitted to the facility on [DATE]. R2 had multiple diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, restlessness and agitation, violent behavior, psychosis not due to a substance or known physiological condition, based on the face sheet. R2's quarterly MDS dated [DATE], showed that the resident was cognitively intact. The MDS showed that R2 required substantial/maximal assistance with oral, toileting and personal hygiene, bathing/shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The same MDS showed that R2 was independent with eating, bed mobility, transfer, and ambulation. R2's aggression and violence history and screening assessment dated [DATE], showed that the resident had a history of aggression, had displayed verbal aggression and inappropriate behavior towards staff and co-peer. R2's progress notes from admission through January 5, 2024, showed multiple behavior notes including the following: - August 30, 2023, at 4:24 PM, R2 was sexually inappropriate to a female resident. R2 was luring the female resident back to his room. R2 was re-directed by staff although was not accepting redirection easily. - September 16, 2023, at 10:21 AM, R2 had exacerbation of psychosis and sexual inappropriate behaviors directed towards both female staff and female residents. He was making the females uncomfortable by following them around and asking them for a kiss. He was not redirectable and staring into space when redirected. The former PRSC counseled and educated R2. R2 stated that he wanted a girlfriend that he can have sexual intercourse with. R2 was transferred to the hospital as per petition for involuntary/judicial admission. - September 21, 2023, at 9:37 PM, showed that R2 was readmitted back to the facility from the hospital's behavior unit with multiple admitting diagnoses including aggressive behavior and psychosis. - September 23, 2023, at 11:39 AM, R2 made sexually inappropriate comment to a female resident. R2 asked the female resident if she would make love to me/sleep with me. R2 was counseled by Administrator with PRSC, Assistant Director of Nursing and CNA (Certified Nursing Assistant) present. - September 24, 2023, at 11:00 AM, the CNA reported that R2 started playing with his penis while the CNA was helping resident's roommate to move his belongings out of the room. R2 started lying sideways in bed while playing with penis and started staring at CNA. CNA asked resident to close curtain for privacy in which resident refused. CNA left R2's room and went across the hall to assist another resident. While assisting the other resident with the door closed, R2 entered the other resident's room without knocking. R2 then asked the CNA mom you ok. - September 25, 2023, at 5:05 PM, R2 was sexually inappropriate towards a female resident. R2 denied the allegation but stated that he did not mean it that way. R2 was educated on sexual behavior. R2 was counseled by the former PRSC to keep his hands to himself at all times and not cause trouble for himself. - September 25, 2023, at 5:33 PM, a female resident accused R2, he touched me in a sexually inappropriate manner. He grabbed my shoulder and he asked for a kiss. According to the female resident the incident happened couple weeks ago. R2 was put on 1 on 1 observation for monitoring for current shift. Director of Nursing, Administrator and Psychiatrist were notified. - September 27, 2023, at 10:16 AM, R2 had allegation that he enters the female rooms uninvited and at odd times. R2 confirmed that he goes to the room, but he does not know that the ladies don't like it. - October 2, 2023, at 6:32 PM, CNA reported that R2 was observed hugging and kissing a female resident on her neck. R2 was redirected and counseled about his inappropriate behavior. - October 15, 2023, at 5:30 PM showed, As per CNA and roommate, resident [R2] seen in bed naked masturbating without curtains in place. Also, a puddle of urine on floor. As per CNA, resident will not allow her to clean the urine and stated, I'll clean it, don't come inside. Roommate [R3] told to leave room until the mess is cleaned. Roommate also stated, he's been messing with my stuff, and he pissed on the floor and he's jerking off in his bed with no privacy. Writer approached resident [R2] in his room. Resident seen in bed naked rubbing his private parts. Writer stated, you have to do these things with the curtain closed. Resident stated, I'm just cleaning myself. Resident was told to put his clothes on so the staff can clean the floor. Resident stated, No, I'll clean it. Resident was told again to put his clothes on and that he can't clean it. Resident closed his curtains as told and put his clothes on. CNA was able to clean the urine off the floor. As roommate [R3] presents as uncomfortable, will be shifted to [a different room] temporarily. (Director of Nursing) notified. Resident will be seen by psych social tomorrow (October 16). On going care. - October 25, 2023, at 6:40 PM, a female resident reported that R2 grabbed her hand and the female resident told R2 not to touch her. The same female resident reported that she told R2 not to come to her room again during the night. - October 26, 2023, at 5:17 AM, R2 stayed up the entire night walking to and from his room. R2 was told several times not to go into other units/hallways, but resident remained adamant and kept on going to another male resident's room. R2 was verbally aggressive towards staff. - November 1, 2023, at 9:18 AM, R2 was invading the personal space of a nurse. R2 cornered the nurse behind medication cart making inappropriate comments. R2 was removed by the PRSC and was counseled about maintaining boundaries. R2 was also counseled regarding use of appropriate language, not [NAME], honey, momma to females. - November 1, 2023, at 12:58 PM showed, [R2] displayed behaviors of delusions pacing verbally disruptive socially inappropriate sexually inappropriate rejection of care. It was documented that R2 was redirected with rejection and was referred to social service. The same notes under comments showed, Writer followed up on a behavior that occurred on (November 1, 2023). Resident unable to maintain appropriate boundaries with female residents/staff. Resident following females around the facility. Attempted to touch female resident. Made an inappropriate comment to staff, Are you feeling my penis repeatedly. Delusional. Making gestures of by putting arms up wanting to fight. Resident non-redirectable. (Administrator)/DON notified. Resident put on 1:1 monitoring. [Psychiatric doctor] ordered petition for hospitalization . Writer will monitor. - November 1, 2023, at 1:50 PM showed, 10:35am - Resident is inappropriate with staff. Resident asked male activity staff to touch his penis. Resident has been following nurse (female) around and not respecting her personal space. Resident is making gesture of wanting to fight people with putting his fist up to them. Writer phoned [Psychiatrist]. Resident on 1:1 monitoring. R2 was transferred to a behavioral hospital. R2 was readmitted back to the facility on [DATE], based on the progress notes. - November 8, 2023, at 3:17 PM, R2 was again petitioned to be sent out to the psychiatric hospital because the resident pushed two residents and was making aggressive comments. On November 16, 2023, R2 was readmitted back to the facility from psychiatric hospital, based on the progress notes. - November 19, 2023, at 8:00 AM showed, 7:27am - Resident noted agitated, walked in nurses station targeting [V6 (female nurse)]. Resident walked up to the nurse invading her personal space and was non redirectable when asked to leave the nurses station. Resident stated, you use to be my girlfriend, can I take you out, my girlfriend got raped, then started making threatening comments of I will beat someone's a_ _ you know what I mean. Resident walked out the nurse's station. Upon resident leaving the nurses station, nurses locked the door. Resident then started knocking on the glass window, then started banging on nurse's station door then proceeded to banging on psych social door. Dining area cleared for other residents' safety. [Director of Nursing] and [Psychiatrist] made aware, orders to call 911 and send resident to the hospital due to his violent behavior. - November 19, 2023, at 3:07 PM showed, [R2] displayed behaviors of yelling/ screaming hitting, name calling hallucinations delusions pacing verbally disruptive verbally threatening socially inappropriate sexually inappropriate responding to internal stimuli. It was documented that R2 was redirected but it was rejected. The same notes showed under comments, Writer followed up on a behavior that occurred on (November 19, 2023). Resident psychosis exacerbated. Resident verbally aggressive, agitated and threatening, targeting a nurse. Resident would not leave nurse's station. Resident violated nurses' personal space by getting extremely close to nurse while agitated, verbally aggressive and yelling. Resident made a delusional statement, Nurse is my girlfriend, she got raped. A comment which makes no sense. Nurses had difficulty getting aggressive resident out of nurses' station. When resident out of nurse station police called; door locked. Resident continue to peer through window at targeted nurse. Resident began violently knocking on the door. Writer escaped to psych-social office when resident paced to hallway. Writer wrote petition. Resident came to psych-social office violently banging on door with increasing strength. Writer waited for police to arrive; knocking stopped. [Administrator]/ DON notified. [Psychiatrist] ordered petition for hospitalization . Resident went willing with police. Writer will monitor. R2's November 20, 2023, progress notes showed that the resident was diagnosed at the hospital with psychosis. R2's November 27, 2023, progress notes showed that the resident was readmitted back to the facility. - November 28, 2023, at 11:37 AM, housekeeper reported that R2 have been following her around. Housekeeper stated that R2 makes her feel uncomfortable. R2 was reminded by the nurse to keep his distance from staff and other residents. - December 26, 2023, at 3:53 PM, R2 made sexually inappropriate comment to the housekeeper. PRSC counseled R2. - January 3, 2024, at 10:27 AM showed, It was reported by a CNA that resident was sexually inappropriate. Resident rubbed CNA's butt as he walked by her with his hand. Resident was counseled about his behavior; to keep his hands to himself. Resident denied the behavior, stating that everyone thinks he is the antichrist. Resident takes no accountability for his actions. Writer will monitor. - January 3, 2024, at 4:30 PM showed, It was reported by [female nurse] that when she was walking with another staff member this resident grabbed her arm and was told to let her go. This resident then interrupted the other nurse while talking with another resident. Nurse asked resident multiple times to remove himself from between her and the other resident that she was speaking with. [Psychiatrist] called, per [Psychiatrist] give 10 mg IM (intra muscularly) Haldol stat. Writer attempted to give Haldol resident refused and started yelling; therefore, approved order for Haldol 10 mg po (by mouth) stat was given. Writer spoke with resident after giving prn (as needed) Haldol 10 mg po. Resident was redirected and said he's ok. Social department/DON made aware of situation. - January 4, 2024, at 5:42 PM, created by V5 (Psychiatrist) showed that he provided service to R2 on January 4, 2024. V5 documented in-part, F/U (follow up) psychiatric assessment/medication management. # pt (patient) is more hypersexual. Pt's case was discussed with DON and medication nurse. The same notes showed, Plan: add Haldol 5 mg bid (twice a day) po (by mouth). - January 5, 2024, at 3:45 AM created by V9 (LPN/Licensed Practical Nurse) showed, Resident's roommate [R1] reported that [R2] laid on top of him while he was sleeping and was giggling. [R2] stated he was just playing with him in a joking manner. Resident counseled on social boundaries, placed on half hour check, paged [V5/Psychiatrist]. R2's progress notes dated January 5, 2024, at 7:49 AM, showed that V5 was notified of R2's behavior with orders to give Haldol 10 mg once by mouth. - January 5, 2024, at 1:32 PM created by V4 PRSD (Psychiatric Rehabilitation Service Director) showed, It was reported by the resident's roommate that resident [R2] made unwanted sexual contact to roommate [R1] while [R1] was lying in bed. Administrator and DON were notified. Roommate [R1] was assisted by psych social to call the police. Roommate [R1] made a report to police with DON and PRSD present. Police officers also spoke with resident [R2]. Resident stated to police that he got on top of his roommate [R1] while roommate was lying in bed. Resident further stated that [R1] raised his arms and asking, What are you doing? Resident went on to state that he pulled out his private part and was pushing up and down on roommate's chest. After resident's statement, resident was told by police to put on his shoes. Resident was handcuffed and escorted from the facility by police. R2's active care plan until January 5, 2024, initiated on November 1, 2023, showed that the resident had inappropriate social boundaries as evidenced by inappropriate touching of others, invading resident or staff personal space and asking inappropriate questions about staff members personal lives. The care plan's goal documented, [R2] will have no incidents/behaviors of inappropriate social boundaries through next review. The target date for this care plan was February 5, 2024. There were three interventions for this care plan all initiated on November 1, 2023, showing, Contact psychiatrist/MD and any other mental health staff regarding behavior and interventions as needed, encourage resident to participate in psychosocial programming to assist him/her in gaining insight into illness/behaviors/inappropriate social boundaries and redirect and counsel resident when seen displaying inappropriate social boundaries. This care plan was not revised to include additional interventions after the resident manifested inappropriate social boundaries and inappropriate touching starting November 19, 2023, through January 3, 2024, as documented on R2's progress notes. R2's active care plan until January 5, 2024, initiated on November 1, 2023, showed, [R2] exhibits sexually inappropriate behavioral symptoms (as evidenced) by attempting to take advantage of a peer who lacks the ability to consent, manipulating others, crude comments/ sexually orientated profane or suggestive remarks. Physical touching, grabbing. On [December 26, 2023, resident made a sexually inappropriate comment to staff. On [January 3, 2024] reported by a CNA that resident was sexually inappropriate to staff. The care plan's goal documented, [R2] will act appropriately towards female residents/staff, using no derogatory language, keeping healthy boundaries (hand to himself), showing respect in all interactions. The target date for this care plan was April 5, 2024. There were three interventions for this care plan all initiated on November 1, 2023, showing, Educated resident on appropriate male to female interaction, encourage resident to attend psych-social groups and encourage resident to learn how to be friends with women. Encourage resident to defocus on the sexual aspect of women to see the person. This care plan was not revised to include additional interventions after the resident manifested inappropriate sexual behaviors starting November 19, 2023, through January 3, 2024, as documented on R2's progress notes. On January 16, 2024, at 12:23 PM, V4 (PRSD/Psychiatric Rehabilitation Service Director) stated that R2 was socially inappropriate as manifested by constant pacing around the facility, at times would be staring at staff, does not respect boundaries and personal space of the staff and residents and would constantly call staff, momma. V4 stated that R2 was also sexually inappropriate to staff, with a report of inappropriate touching of staff. According to V4, she was aware that R2 had sexual behavior of masturbating but was not aware that R2 does the act without privacy. V4 was aware that R2's sexual behavior was escalating due to multiple reported and documented incidents including R2's sexual comments to the housekeeper, R2 rubbing a CNA's bottom area and R2 grabbing the arm of a female nurse. V4 was asked what interventions were placed with regards to R2's escalating sexual behaviors. V4 responded that R2 was re-directed by the staff and counseled by the PRSC (Psychiatric Rehabilitation Service Coordinator), which according to V4, R2 at times does not respond well to redirection and counseling. V4 stated that R2 also does not attend any in-house or outside psychosocial program to address his mental illness and to manage/control his socially inappropriate and sexual behaviors. During the same interview, V4 stated that she was informed by V8 (PRSC) on January 5, 2024, at around 9:00 AM, that R1 reported to her (V8) that R2 went on top of him, R2's penis was out and was rubbing on R1's face and chest area. V4 stated that on January 5, 2024, at approximately 10:00 AM, she talked to R1 about his allegation of sexual abuse. R1 gave the same consistent information that R2 went on top of him, and R2 rubbed his penis on his face and chest area. According to V4, while R1 was narrating the sexual incident, R1 was anxious, and his voice was more shaken and stammering. V4 added that R1 appeared shaken and very disturbed about the sexual incident. V4 stated that she told R1 that the police will be called to report the sexual incident and R1 agreed to it. V4 stated that on January 5, 2024, at approximately 10:30 AM, a phone call was placed to the police department to report R1's sexual abuse allegation and within 10 minutes two police officers came to the facility to interview R1 and R2. V4 stated that V2 (Director of Nursing) and herself were present when the police interviewed separately, both R1 and R2. R1 was inside the psychosocial room and told the police officers that his roommate (R2) came to his bed, held his arms down, got on top of him on his chest area, R2's pants were pulled down and R2 rubbed his penis on R1's chest area, moving up and down from his chest to upper abdominal area and all over his (R1) face and chin. When the police spoke to R2 while the resident was inside his room, at first R2 denied the allegation and stated that they (R1 and R2) were just playing but eventually R2 told the police that while R1 was in his bed, he got on top of R1 with his pants pulled down, R1's arms were held out and was asking him, what are you doing? and he started to move his penis (R2) up and down R1's face and chest, while R1 was pinned down. According to V4, after the police interview with R2, the police officers told R2 to put on his shoes, handcuffed R2 and escorted R2 out of the facility. On January 16, 2024, at 2:45 PM, V2 (Director of Nursing) stated that on January 4, 2024, at approximately 10:30 AM, she talked to V5 (Psychiatrist) with regards to R2's increasing sexual behaviors, including making sexual comments or suggestive remarks to the female nurses, mostly towards V6 (Nurse). V2 stated that R2 would make remarks like, [NAME] do you want to go with me? R2 would go inside the nursing station and stare at V6 and R2 would also be staring at young female CNAs which made the female staff uncomfortable. R2 would walk against a resident, getting too close and not respecting residents and/or staff personal boundaries, manifesting, on your face behavior. According to V2 she was aware that R2 would masturbate in bed, naked with door and curtain open. Aware that nurses would inform the social service department including the PRSC and PRSD about R2's escalating sexual behaviors and when the PRSC or the PRSD would talk to R2, the resident was not directable or would say he was sorry for his behavior but still would repeat the same sexual behavior. According to V2, she was present when R2 was interviewed by the Police on January 5, 2024, at approximately between 9:15 AM and 9:45 AM. R2 told the Police that his penis was out, and he was straddling on R1's chest. On January 16, 2024, at 2:58 PM, V10 (CNA) stated that she is a full-time staff at the facility and regularly works from 11:00 PM through 7:00 AM shift, and at times picks up 3:00 PM through 11:00 PM shift. V10 stated that R2 would often make sexual suggestive remarks like, momma give me a kiss, then I'll go to bed and then laugh. According to V10, R2 regularly goes to all unit hallways at night, regardless of if the unit hallways are for male or female and when re-directed he would show his fist and say, You want this? Don't talk to me. V10 stated that R2 could be easily re-directed to stop and go back to his room, when he was wandering in the female unit, however, it was very hard to re-direct R2, when he was wandering in the male unit. V10 stated that he has seen R2 wander inside the male resident rooms and took out coffee from the table, a radio or other stuff. According to V10, it is hard to stop or re-direct R2 and stated, I'm afraid he will hit me, I'm scared of him. V10 stated that R2 does not listen to female staff and would only listen to the male staff. V10 stated that she remembers witnessing R2 hugging and telling a former female resident of the facility to come to his room at least twice and on both occasions she (V10) was able to stop R2. During the same interview, V10 stated that during her night shift rounds, she would observe R2 naked in bed, masturbating with the door and curtain open, and R2 would make sexual suggestive comments like, come join me, momma. V10 stated that this sexual behavior of R2 happens almost every time she was working, which was at least five times per week. According to V10, when R2 would manifest sexual behavior, she would attempt to re-direct R2, then inform the nurse on duty. V10 stated that R2 occupies bed 1 which was closest to the door while his roommate (R1) occupies bed 2. V10 stated that R1 was a very quiet and pleasant person and does not cause any problem to the staff and other residents. V10 stated that she was working on January 4, 2024, from 11:00 PM through January 5, 2024, at 7:00 AM. V10 denied seeing and/or hearing any sexual abuse from R2 towards R1 during her entire shift from January 4th through the 5th. On January 16, 2024, at 3:15 PM, V11 (CNA) stated that that she is a full-time staff at the facility and regularly work from 3:00 PM through 11:00 PM shift, and at times picks up 11:00 PM through 7:00 AM shift. V11 stated that R2 regularly wanders along the hallways and main dining area. R2 would wander inside other residents' room looking for food, mostly in the male units. V11 stated that R2 had behavior of attempting to hug staff and female residents. V11 added that R2 had attempted to touch her lower back or attempted to hug her, and when she told R2 to stop, the resident got aggressive and in a loud voice asked her, want some of this, momma while showing his fist. V11 stated that R2 does not want to be told, re-directed or be corrected. According to V11, one time (does not know specific date) she was asked by R2 if she wanted to go to bed with him. V11 stated that R2 makes her very uncomfortable and uneasy. During the same interview, V11 stated that most of the time when R2 was in his bed, R2 would be constantly masturbating, at times naked or hands under his pants without cover, curtain and door wide open. According to V11, each time she saw this sexual behavior of R2, she would close the door to provide privacy but R2 would get mad and aggressive, she then would tell the nurse on duty. The nurse would either talk to R2 or tell the psychosocial staff about the sexual behavior. V11 stated that she was the assigned CNA for R2 on January 4, 2024, from 11:00 PM through January 5, 2024, at 7:00 AM. V11 denied seeing and/or hearing any sexual abuse from R2 towards R1 during her entire shift from January 4th through the 5th. However, during the early morning of January 5, 2024, she saw R1 very upset and hyper while walking with a male reception staff towards the nursing station to report the incident with R2. On January 18, 2024, at 3:39 PM, V8 (PRSC) stated that she was the case manager of R2. V8 stated that R2 was a difficult resident and had required constant re-direction to make sure that he is behaving appropriately. Since R2's admission to the facility, the resident does not know proper behavior towards female residents and staff by addressing them in a derogatory and condescending manner like, hey, baby momma. R2 does not respect residents' and staff's personal boundaries by getting too close to them and the residents and staff do not feel comfortable, especially V6 (Licensed Practical Nurse) whom he cornered during medication pass. R2 constantly paces throughout the facility and had asked female residents to go back to his room, even though the female resident does not have the capacity to say yes or no to him. According to V8, a lot of residents both male and female, mostly female residents do not feel comfortable around him. V8 stated that since R2's last readmission to the facility on [DATE], from the behavioral hospital, the staff nurses and CNAs do not feel comfortable around him because they felt that something was just not right with him (R2). V8 stated that prior to the incident on January 5, 2024, with R1, R2's sexual behavior was escalating as documented on his progress notes. R2 was making sexual comments to the housekeeper, grabbing the arm of a female nurse and rubbing a CNA's bottom area. V8 stated that R2 receives constant re-direction from t [TRUNCATED]

Based on interview and record review the facility failed to review and revise a resident's (R2) plan of care, after the resident exhibited hypersexual behaviors. This failure resulted in R2 sexually abusing R1 on January 5, 2024, resulting in R2's arrest by the local police and charged with two counts of domestic battery. This applies to 1 of 4 residents (R2) reviewed for behavioral care plans in the sample of 6. The findings include: R2 was admitted to the facility on [DATE]. R2 had multiple diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, restlessness and agitation, violent behavior, psychosis not due to a substance or known physiological condition, based on the face sheet. R2's quarterly MDS (Minimum Data Set) dated December 5, 2023 showed that the resident was cognitively intact. The MDS showed that R2 required substantial/maximal assistance with oral, toileting and personal hygiene, bathing/shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The same MDS showed that R2 was independent with eating, bed mobility, transfer and ambulation. R2's aggression and violence history and screening assessment dated [DATE] showed that the resident had a history of aggression, had displayed verbal aggression and inappropriate behavior towards staff and co-peer. R2's progress notes from admission through January 5, 2024 showed multiple behavior notes including the following: 1. August 30, 2023 at 4:24 PM, R2 was sexually inappropriate to a female resident. R2 was luring the female resident back to his room. 2. September 16, 2023 at 10:21 AM, R2 had exacerbation of psychosis and sexual inappropriate behaviors directed towards both female staff and female residents. R2 was making the females uncomfortable by following them around and asking them for a kiss. R2 stated that he wanted a girlfriend that he can have sexual intercourse with. 3. September 23, 2023 at 11:39 AM, R2 made sexually inappropriate comment to a female resident. R2 asked the female resident if she would make love to me/sleep with me. 4. September 24, 2023 at 11:00 AM, the CNA reported that R2 started playing with his penis while the CNA (Certified Nursing Assistant) was helping resident's roommate to move his belongings out of the room. 5. September 25, 2023 at 5:05 PM, R2 was sexually inappropriate towards a female resident. R2 denied the allegation but stated that he did not mean it that way. 6. September 25, 2023 at 5:33 PM, a female resident accused R2, he touched me in a sexually inappropriate manner. He grabbed my shoulder and he asked for a kiss. According to the female resident the incident happened couple weeks ago. 7. September 27, 2023 at 10:16 AM, R2 had allegation that he enters the female rooms uninvited and at odd times. R2 confirmed that he goes to the room, but he does not know that the ladies don't like it. 8. October 2, 2023 at 6:32 PM, CNA reported that R2 was observed hugging and kissing a female resident on her neck. 9. October 15, 2023 at 5:30 PM showed, As per CNA and roommate, resident [R2] seen in bed naked masturbating without curtains in place. Resident seen in bed naked rubbing his private parts. Writer stated, you have to do these things with the curtain closed. Resident stated, I'm just cleaning myself. 10. October 25, 2023 at 6:40 PM, a female resident reported that R2 grabbed her hand and the female resident told R2 not to touch her. The same female resident reported that she told R2 not to come to her room again during the night. 11. October 26, 2023 at 5:17 AM, R2 stayed up the entire night walking to and from his room. R2 was told several times not to go into other units/hallways, but resident remained adamant and kept on going to another male resident's room. 12. November 1, 2023 at 9:18 AM, R2 was invading the personal space of a nurse. R2 cornered the nurse behind medication cart making inappropriate comments. 13. November 1, 2023 at 12:58 PM showed, [R2] displayed behaviors of delusions pacing verbally disruptive socially inappropriate sexually inappropriate rejection of care. The same notes under comments showed, Writer followed up on a behavior that occurred on (November 1, 2023). Resident unable to maintain appropriate boundaries with female residents/staff. Resident following females around the facility. Attempted to touch female resident. Made an inappropriate comment to staff, Are you feeling my penis repeatedly. Delusional. Making gestures of by putting arms up wanting to fight. 14. November 1, 2023 at 1:50 PM showed, 10:35 am - Resident is inappropriate with staff. Resident asked male activity staff to touch his penis. 15. November 8, 2023 at 3:17 PM, R2 pushed two residents and was making aggressive comments. 16. November 19, 2023 at 8:00 AM showed, that at 7:27 AM, R2 was agitated, walked in nurses station targeting [V6 (female nurse)]. Resident stated, you use to be my girlfriend, can I take you out, my girlfriend got raped, then started making threatening comments of I will beat someone a_ _ you know what I mean. 17. November 19, 2023 at 3:07 PM showed, [R2] displayed behaviors of yelling/ screaming hitting, name calling hallucinations delusions pacing verbally disruptive verbally threatening socially inappropriate sexually inappropriate responding to internal stimuli. 18. November 28, 2023 at 11:37 AM, housekeeper reported that R2 have been following her around. Housekeeper stated that R2 makes her feel uncomfortable. 19. December 26, 2023 at 3:53 PM, R2 made sexually inappropriate comment to the housekeeper. 20. January 3, 2024 at 10:27 AM showed, It was reported by a CNA that resident was sexually inappropriate. Resident rubbed CNA's butt as he walked by her with his hand. 21. January 3, 2024 at 4:30 PM showed, It was reported by [female nurse] that when she was walking with another staff member this resident grabbed her arm and was told to let her go. 22. January 5, 2024 at 1:32 PM created by V4 PRSD (Psychiatric Rehabilitation Service Director) showed that resident's roommate (R1) had reported that R2 made unwanted sexual contact while R1 was lying in bed. The Police incident report dated January 5, 2024 showed that two police officers responded to the facility on [DATE] at approximately 10:31 AM for a report of a sexual assault. The same police report showed that R2 was charged with two counts of Domestic battery and was transported to the County jail. R2's active care plan until January 5, 2024, initiated on November 1, 2023 showed that the resident had inappropriate social boundaries as evidenced by inappropriate touching of others, invading resident or staff personal space and asking inappropriate questions about staff members personal lives. The care plan's goal documented, [R2] will have no incidents/behaviors of inappropriate social boundaries through next review. The target date for this care plan was February 5, 2024. There were three interventions for this care plan all initiated on November 1, 2023 showing, Contact psychiatrist/MD and any other mental health staff regarding behavior and interventions as needed, encourage resident to participate in psychosocial programming to assist him/her in gaining insight into illness/behaviors/inappropriate social boundaries and redirect and counsel resident when seen displaying inappropriate social boundaries. This care plan was not revised to include additional interventions after the resident manifested inappropriate social boundaries and inappropriate touching starting November 19, 2023 through January 3, 2024 as documented on R2's progress notes. R2's active care plan until January 5, 2024, initiated on November 1, 2023 showed, [R2] exhibits sexually inappropriate behavioral symptoms (as evidenced) by attempting to take advantage of a peer who lacks the ability to consent, manipulating others, crude comments/ sexually orientated profane or suggestive remarks. Physical touching, grabbing. On [December 26, 2023, resident made a sexually inappropriate comment to staff. On [January 3, 2024] reported by a CNA that resident was sexually inappropriate to staff. The care plan's goal documented, [R2] will act appropriately towards female residents/staff, using no derogatory language, keeping healthy boundaries (hand to himself), showing respect in all interactions. The target date for this care plan was April 5, 2024. There were three interventions for this care plan all initiated on November 1, 2023 showing, Educated resident on appropriate male to female interaction, encourage resident to attend psych-social groups and encourage resident to learn how to be friends with women. Encourage resident to defocus on the sexual aspect of women to see the person. This care plan was not revised to include additional interventions after the resident manifested inappropriate sexual behaviors starting November 19, 2023 through January 3, 2024 as documented on R2's progress notes. On January 16, 2024 at 12:23 PM, V4 (PRSD/Psychiatric Rehabilitation Service Director) was asked what intervention were placed with regards to R2's escalating sexual behaviors. V4 responded that R2 was re-directed by the staff and counseled by the PRSC (Psychiatric Rehabilitation Service Coordinator), which according to V4, R2 at times does not respond well to redirection and counseling. V4 stated that R2 also does not attend any in-house or outside psychosocial program to address his mental illness and to manage/control his socially inappropriate and sexual behaviors. On January 23, 2024 at 2:06 PM, V12 (Nurse Practitioner) stated that for any behavior concerns, the facility usually calls the Psychiatrist. According to V12, as a best practice, a resident with hypersexual behavior should be residing in a room by himself or be with another resident that was not at risk for abuse. It is also best practice to place the resident with hypersexual behavior on a 1:1 monitoring until the behavior subsides or until any prescribed medication from the Psychiatrist had taken effect. On January 25, 2024 at 11:10 AM, V4 (PRSD) reviewed all of R2's electronic care plans. After reviewing R2's care plans, V4 stated that the resident's care plan regarding display of sexually inappropriate behaviors and inappropriate social boundaries like making sexual comments, physical touching and grabbing as well as invasion of resident or staff space and asking inappropriate and personal questions were not revised since it was initiated to reflect the ongoing and escalating sexual behaviors of R2. V4 stated that there were no revision on the above mentioned care plans to include additional interventions to address R2's hypersexual behavior. V4 was asked what intervention/plan the facility IDT (interdisciplinary team) put in place to address R2's hypersexual behavior. According to V4 the only plan that she was aware of was to re-direct and counsel R2 when the sexual behavior occurs, which at times were not effective because the sexual behavior kept on recurring.

Based on observation, interview and record review, the facility failed to protect a resident from sexual abuse by a facility staff member. This applies to 1 of 3 residents (R1) reviewed for abuse. As a result of this failure, R1 was exposed to sexually abusive behaviors from V11 (CNA- Certified Nurse Aide). The findings include: On 3/15/22 at 2:40 PM, V4 CNA (Certified Nursing Assistant) said R2 reported to her last week V11 CNA was always coming to their room, and R2 saw V11 trying to kiss R1. V4 said she immediately reported it to V5, Lead CNA. On 3/15/22 at 1:32 PM, V5 CNA said last week V4 informed her R2 told her V11 was always in their room and was hugging and kissing R1. V5 said she reported to V1 and V2 DON (Director or Nursing) immediately. On 3/15/22 at 2:09 PM, V2 DON said at the beginning of March, V5 CNA reported R2 had reported some inappropriate interactions between V11 and R1. She said R2 said she heard some kissing and some noises. V2 stated V1 was notified and initiated the investigation and V11 was suspended pending investigation. V2 said R2 does not have a history of making allegations. R1's Face Sheet dated 3/15/22, shows R1 is [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/22 at 11:06 AM, R1 and R2 were in the room they shared. R1 resided in the bed by the wall, and R2's bed was the first bed closest to the door. R1's MDS (Minimum Data Set) dated 2/28/22 shows R1's cognition is intact, the behavior section showed she does not exhibit physical or verbal behavioral symptoms directed towards others. R1 said V11 was gone on vacation for about a month and returned to work around the middle of February. R1 stated V11 came back, the advances got bad when he came back a little stronger with the attempts to kiss and hug her; he made around five different attempts in the previous weeks. R1 said sometimes her roommate, R2, would come into the room and interrupt him. R1 stated she told V11 he needed to stop, and saying things like I'm not interested, it is not good for your job, it is against the rules. R1 stated she tried to stress to him he would lose his job. R1 stated V11 asked her You like me, right? Maybe we can have something? R1 said V11 had touched her breast and kissed her twice on her lips since returning from his vacation. R1 said she told V11, no kissing but she would give him a hug, V11 would take advantage of the hug and kiss her on the lips. R1 said on some occasions, she would turn her head, and he would kiss her on her cheeks. R1 said while she was in bed, V11 would sit on her bed and rub her feet. R1 said she knew it was inappropriate but did not want to get him fired. R1 said she did not tell anyone about the incidents when V11 returned from his vacation. R1 said R2 (R1's roommate) was in the room when the abuse occurred, and it made R2 feel uncomfortable. R1 stated V11 would pull the privacy curtain and would kiss her while R2 was in the room. R1 said V11 would also buy her iced coffee, donuts, tacos, and a moisturizer even though she told him not to buy her anything. R1 said she felt she could not be safe in her room and was thankful R2 was in the room. R1 said she was not aware of when R2 reported the incidents to staff; but was thankful she did. On 3/16/22 at 11:40 AM, R1 said she did not know how to handle the situation because V11 was a staff member. R1 said V11 would hold on to her face and she could not pull away. R1 said she felt her safety was compromised, the situation was awkward, and was relieved V11 was gone. R1 said while the incidents were occurring, she felt depressed, and slightly suicidal. R1 said she had such tendencies due to her mental health condition; she felt like a recluse and did not want to talk about it. R1 stated, I feel bad and responsible it happened, I feel like it was my fault, I didn't know what to do. R1 said she also had history of sexual abuse. R1 said there were no other incidents with other staff. R1 said after R2 reported it to staff, V1 (Administrator) and V2 DON (Director of Nursing) interviewed her that day and the day after. R1 said she told (V1) and (V2) that V11 would come to her room hug, and kiss her, she denied telling them V11 touched her breast. On 3/15/22 at 11:30 AM, R2 said she reported to (V4, CNA) that V11 was being inappropriate with R1. R2 stated she reported it between one and two weeks ago; but was a week after she heard R1 tell V11 No. R2 said V11 would not take No for an answer. R2 said V11 would come to their room every night he worked, and he would try to hug and kiss R1. R2 stated R1 and V11 would stand by (R1's) bed and V11 would hug and kiss R1. R2 said she saw V11 kissing R1 on the lips in their room about three times before V11 went on vacation in January. R2 said she also saw V11 take off (R1's) socks and massage her feet. R2 said she was not comfortable when V11 was around, and V11 would not listen to R1 when R1 said no, adding it was frustrating. R2 said V11 had to know she was aware of what was going on because V11 would hug and kiss R1 in front of her. R2 said she watched R1 tell V11 no but V11 still hugged and kissed R1 before he left the room. R2 said she knew V11 bought donuts, tacos, and iced coffee for R1. R2 said she believed it was consensual for a short period of time initially, but it got to a point where R1 did not want the attention anymore. R2 said after a while, R1 would tell her not to leave the room because she did not want to be alone in the room with V11 describing that R1 was guarded and scared. R2 said she decided to report the incidents to staff because she felt like she was (R1's) bodyguard, was upset and frustrated about it because my friend was being abused. R2 stated R1 would tell her not to leave the room if we saw V11 in the hallway or see him coming to their room. R2 said during those times, R1 was anxious and uptight, she would see her clenching her hands. On 3/15/22 at 2:57 PM, V1 (Administrator) said on 3/2/22 around 3:00 PM, V5 CNA informed her R2 reported to V4 CNA she heard R1 and V11 were hugging and kissing in the bedroom. V1 stated she initiated an investigation immediately. V1 said they suspended V11 pending investigation. V1 said she met with V11 the next day and based on V11's interview, he violated the code of conduct by engaging in inappropriate behavior. He crossed the professional boundaries between staff and residents, the physical interaction, he was hugging and kissing R1 on top of her head and the gifting of items. V11 was terminated. V1 said they did not do a head-to-toe assessment on R1 because she told them nothing happened, and that she always stopped V11's attempts. R1's care plan dated initiated on 5/24/21 and revised on 11/17/22 shows, (R1) is at risk for abuse/neglect based on comprehensive assessment as evidenced by (R1) has a mental illness. R2's MDS dated [DATE] shows R2's cognition is intact, the behavior section showed that R2 does not exhibit physical or verbal behavioral symptoms directed towards others. On 3/16/22 at 10:35 AM, V9 (R1 and R2's Psychiatrist) via phone said R1 is at the facility for mental illness and has problems with social stability, the goal is to get her stable enough to live independently in the community. He said R1 has alcohol disease and is [CONDITION(S)]. He said staff should not be involved with resident, there is a line in the sand to be drawn. On 3/16/22 at 3:23 PM, V10 (R1's Nurse Practitioner) via phone said it is inappropriate for staff to hug or kiss residents, staff should know better and draw boundaries with residents. The facility's investigative report, Final Report of Abuse Investigation dated 3/2/22 states (V11) indicated that he has kissed (R1) on the top of her head and has hugged her many times and she has kissed him. He stated that he wants her to be supported and safe, and they often pray and talk about suicidal safety . (V11) considers (R1) like a family member. (V11) stated he never pressured (R1) and (R1) never told him to stop. (V11) stated he has brought her food before, but has never given her money. The facility's Abuse policy dated 4/2020, shows This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment Exploitation means taking advantage of a resident for personal gain using manipulation, intimidation, threats or coercion. 1. On March 22, 2022, re-education was initiated with facility staff, which includes nurses, CNAs and all other facility staff on the abuse prevention policy and procedures, identifying the different types of abuse and reporting abuse. This education will be for all staff and will be completed by March 24, 2022. 2. The facility conducted an emergency resident council meeting on March 22, 2022, to inform residents on different types of abuse, the abuse protocol, abuse investigation and how to communicate concerns about abuse. 3. Abuse was substantiated and reported to IDPH on March 22, 2022, employee (V11 CNA) does not work at the facility as of March 10, 2022. 4. A Quality Assurance tool was developed to monitor abuse and neglect. It will be done daily for the next 30 days during their facility rounds, then three times per week for 30 days, and then once a week for 30 days. 5. The DON will be responsible for the overall compliance to this plan of correction in conjunction with the PRSD and managers on duty. 6. The Quality Improvement Team will meet twice a month and the Quality Assurance team will meet quarterly. 7. A QA (Quality Assurance) meeting was held on March 23, 2022. They reviewed the plan of correction and the abuse policy. No corrections were made to their abuse policy.

Based on interview and record review the facility failed to monitor a male resident (R20) to prevent from getting into bed with a female resident (R19) against her will, unnoticed by staff. R20 engaged in sexually inappropriate action including kissing and groping R19 in her bed. R19 expressed she was in shock when she found R20 on top of her, in her bed, kissing and groping without her consent. R19 said she was emotionally distraught, felt unsafe and her rights were violated. This applies to one of three residents (R19) in the sample of 21 residents evaluated for safety of the residents. The findings include: On 5/18/16 at 4:00 PM R35 stated he witnessed a male resident who is only supposed to be in ' C ' hall, going into his girlfriend's room last Thursday. The incident was sexually inappropriate in nature, but the staff accused him of lying. R35 said the staff usually sits at the table and plays on phones. R19's 5/14/16 Progress Notes and the incident the facility sent to the Department on 5/14/16 involving R19 and R20 showed the facility received a call from a person from another facility because the person saw a post on Social Media stating R19 on Thursday a peer in the facility came to into her room while she was sleeping and was on top of her kissing and groping her breast without her permission. The facility investigation completed on 5/19/16 and concluded the allegation of sexual abuse was not substantiated. On 5/19/16 at 4:46 PM R19 over the telephone stated the night the incident occurred (5/11/16 night early morning of 5/12/16), she slept poorly, barely had couple hours of sleep. R19 said she was shocked to wake up to see R20 on top of her, hugging, kissing and groping her. R19 said her boyfriend (R35) who usually walks in dining room and halls, saw her room door was opened, R35 came up to her room and noticed R20 in her bed when he opened her privacy curtain, and R20 left her room. R19 said she was shocked, frozen, violated her space and felt very unsafe and did not know what to do. She thought R35 would do something about it, but he left on home visit. R19 said it was hard for her to process the trauma, and started to tell her peers about the incident and how upset she was. When one of her peers (R15) told E8 (Counselor), E8 spoke to her, but nothing was done. On 5/13/16 after R15 said she told her counselor (E8). E8 called me to speak to her, but she did nothing. R19 then posted the situation on a Social Media account. The facility then sent her to hospital on [DATE]. At the hospital she refused to have rape kit done, because there was no penetration and the hospital sent her back to the facility. On May 16, 2016 the facility sent her back to the hospital saying she was having coping problems. R19 continued to state the night staff sleeps at night and does little to monitor residents. R20 was supposed to stay in his hall (C - Hall) and day area at night. R20 had to pass his hallway, day area and pass several rooms in the hall (A - Hall) to come to her room. She said if the staff monitored R20, he would not have reached her room. R19 concluded she is still upset about whole incident. The facility identified R19 to be alert, oriented to time, place and person per her 4/5/16 Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 15 of 15. R19's January 2015 admission record showed she has recurrent depressive disorder with suicidal ideations. On 5/19/16 R35 volunteered to speak in detail and said he usually walks in the facility between 4:00 am and 6:00 am for his daily exercise. When R35 was walking in halls and day area, he noticed R19's room door was open and walked farther, opened the privacy curtain, found R20 lying on top of R19, his face nuzzled on her neck and R20 left the room when asked to leave. R35 said R19 verbalized to him, she was shocked, frustrated and feared for her safety. She was upset because he did not do anything about it. R35 had to go on pass with his family that morning. R35 stated he knows who was working (E9, E10, and E11 - Certified Nurse Aides - CNAs) at the time of the incident. The staff was sleeping at the time of the incident. The facility does not do much to protect the residents in the facility. The facility identified R35 to be alert, oriented to time, place and person per his 4/12/16 MDS with a BIMS score of 15 of 15. On May 19, 2016 at 4:50 PM interviewed E8 in the staff room. E8 stated she was not told about R20 being in R19's room on May 12, 2016 around 5:00 AM until next day. R15 is the one who told her. E8 said she spoke with R19, but she remained normal. Later the next day when the facility became aware from an another facility staff stating R19 posted the incident on Social Media. E8 said she proceeded to follow the facility protocol for reporting and the Administrator (E1) notified necessary authorities including Local Police Department. E8 said the night shift staff should have watched R20 for his wandering into other resident's rooms. On 5/20/16 at 6:00 am E9, E10 and E11 were interviewed over the telephone. None of these employees working on 5/11/16 were aware how R20 entered R19's room unnoticed by them. All three CNAs stated R20 lives in ' C ' hall and not supposed to go to other halls. E10 was assigned to ' C ' hall, but he was busy doing blood glucose checks. E11 was assigned to ' D ' hall, but he was also doing blood glucose checks. E9 was assigned to ' A ' hall, but he also had other assignment in ' E ' hall to get up residents for the morning. E9 also said, usually they have four CNAs, but on the day of the incident there were only three CNAs and they had to cover for the fourth CNA. The charge nurse stated she is busy passing medications on the day of the incident, but all staff is responsible for watching the residents and she did not know about the incident until couple days later. The facility December 2015 Resident Council Minutes showed the residents expressed concerns the night shift CNAs are hard to locate. The survey team calculated minimum required staffing ratio. On 5/11/16 and 5/12/16 the facility did not meet minimum staff hours. The minimum staff hours was 2.5 hours, where as the provided on 5/11/16 2.04 hours and on 5/12/16 the facility provided 2.06 hours. R20 ' s June 2012 admission record showed he is a [AGE] year old and has [DIAGNOSES REDACTED]. R20 ' s March 2016 MDS showed he has BIMS score 9 of 15, which meaning he is alert, but has memory impairment. R20's March 2016 Risk for abuse assessment showed he has current / history of social inappropriate behaviors including yelling, screaming, repetitive complaints, making false allegations, wandering, and disrobing in public. The assessment also showed R20 has a history / current behavior of physical or threatening physical aggression towards other. R20's March 2016 Aggression and Violence History and Screening Assessment showed he has current / history of self destructive statement / behaviors / threats, has [DIAGNOSES REDACTED]. R20 also has a history of suicidal ideations. R20's progress notes from November 2015 to May 2016 showed the behaviors including wandering into other rooms (November 19, 2015); hospitalized from November 20, 2015 to November 24, 2015, for his erratic behaviors and found a knife on him; November 27, 2015 found sharp objects; December 21, 2015 aggressive towards staff during room search; January 17, 2016 called 911 for feelings of unsafe in the facility; February 21, 2016 yelled and screamed at roommate and had to be moved to a different room; March 10, 2016 through May 2016 documented changes in his psychological condition, labile mood, disorganized thinking, rambling speech, hallucinations and delusions. R20's 13 pages care plan initiated in August 2013 included problems included Substance Abuse; unsafe smoking; resisting care; self harm threats; severe mental illness; verbal, physical aggression and inappropriate behavior; abuse and neglect; and other medical problems had no interventions to monitor him from wandering into others rooms. There were no interventions to show he was not allowed to wander into other halls other than where he lives. E1 (Administrator), E2 (Director of Nurses), E6 through E11 (all CNAs) stated R20 is allowed to wander into other halls or other residents rooms only, if someone invites him that too after breakfast hours till bed time.

Based on observation, interview and record review, the facility failed to identify, assess and prevent resident behavior of illegal drug use in the facility. This failure resulted in two residents overdosing on opioid narcotics which required emergency 911 services and the administration of narcan (an opioid antidote) to prevent respiratory arrest and death. This applies to two of five (R2 and R3) residents reviewed for behaviors involving substance abuse in a total sample of eight residents. The findings include: According to a Fire Department ambulance run report dated [DATE], the fire department arrived at the facility for two people showing signs of a drug overdose. The report shows both residents were unconscious with slow respiratory rates and pinpoint pupils. 1. According to the Hospital Emergency Department notes dated [DATE], R3 had [DIAGNOSES REDACTED]. EMS had given Narcan 2 mg(milligrams) intranasally and R3 responded. An ED note at 7:17pm shows R3 admitted to snorting heroin. On [DATE] at 9:55am R3 said he did one line of heroin but the heroin (he inhaled) must have been a bad batch, it may have been cut with fentanyl on [DATE]. R3 stated he almost died on [DATE] but admits to snorting one or two lines of heroin once or twice a week for the past six to seven months while a resident in the facility. R3 stated he would take the heroin with R2 and R5 and it was always in R5's room. R3 said R5 had gotten the heroin. R3 said Friday night was considered party night. On [DATE] at 9:15am Z2 (Emergency Department Doctor) stated R3 had admitted to snorting heroin when he had been brought into the ED with another resident from the same facility. He said R3 had responded to the administration of Narcan. Z2 said when a person has an overdose of heroin the person could go into respiratory arrest and eventual death if Narcan was not given. According to the [DATE] POS (Physician order [REDACTED]. The MDS (Minimum Data Set) dated [DATE] shows R3 is cognitively intact and does not need ambulation assistance from staff. A Substance Abuse assessment dated [DATE] shows R3 had previously used alcohol, marijuana and cocaine. R3 did not have a care plan for behaviors of substance abuse until [DATE]. 2. According to the ED records dated [DATE] R2 had a [DIAGNOSES REDACTED]. Hydrocodone is an opioid pain medication). The notes show R2's laboratory studies are not consistent with any sort of acetaminophen overdose and based on presentation to the ED, heroin is more likely the cause. The fire department run report dated [DATE] at 6:27pm R2 had a labored, irregular respiratory rate of 10 breaths per minute, bilateral decreased breath sounds and two millimeter constricted pupils bilaterally with a sluggish response. Narcan two milligrams was given via nasal atomizer at 6:29pm with improved respirations. Another dose of Narcan two milligrams was given at 6:31pm with an improved level of consciousness. According to the [DATE] POS R2 had [DIAGNOSES REDACTED]. The POS also showed an order for [REDACTED]. Review of the February and [DATE] MAR (Medication Administration Record) shows R2 had only received this medication twice on [DATE]; once on [DATE]; once on [DATE]; and none in February. A substance abuse care plan showed R2 had been sent to the hospital for intake of heroin on [DATE] and an episode of drinking on [DATE] while a resident in the facility. R2 also had a history of [REDACTED]. On [DATE] at 10:40am E2 DON (Director of Nursing) stated R2 reported he had taken a Norco overdose from medication he had been saving. E2 said she didn't believe R2 could have saved up any Norco because she has seen him take his medication and believes they would have been found during a room search. E2 stated R3 had admitted to her R5 had brought the heroin into the facility. E2 said she had heard R5 had brought in heroin in the past but R5 was never found with any heroin. She said she had heard a rumor R5 had been suspected of distributing narcotics at his previous facility. E2 stated random room searches had been done three times a week prior to the incident on [DATE]. When asked, E2 said the facility didn't do an incident report regarding the incident of [DATE] or notify IDPH (Illinois Department of Public Health) because it was a resident behavior and was treated as a behavior. E2 stated this was an unusual occurrence but did not think this behavior resulted in an injury. E2 said R2 and R5 could have died if they hadn't received Narcan and said Narcan administration was more than a first aid treatment. On [DATE] at 2:15pm E4 PRSD (Psychiatric Rehab Services Director) said both R2 and R3 were known substance abusers. E4 stated the facility had suspicions R5 was bringing heroin into the facility. On [DATE] at 10:15am E4 stated R5 had the same level of hourly monitoring checks as all the other residents. R5 did not have any increased behavior monitoring. The facility's Discharge Report show R5 was discharged to home on [DATE] and was no longer in the facility. While R5 was in the facility his room was the last room at the end of the hallway and his roommate was R7. On [DATE] at 9:45am R7 said R5 always had friends (including R2 and R3) and visitors in the room. On [DATE] at 9:50am R4 said R5 would have a male visitor several times a week come for short visits lasting approximately 10 minutes. R4 said R5 and the visitor would go to R5's room then leave after a short time. On [DATE] at 3:05pm E6 LPN (Licensed Practical Nurse) stated on [DATE] R3 who was unresponsive with a low heart rate. 911 was called. At the same time E6 said R2 had also become unresponsive. E6 said a room search was done after R2 and R3 were taken to the hospital but said he was unsure why the room search was done. On [DATE] at 9:42am E10 CNA (Certified Nursing Assistant) stated on [DATE]th at approximately 6:15 or 6:30pm during dinner in the dining room, an unidentified resident said R3 might be drunk. E10 said R3 was in the chair with his head back and looked like he was turning gray. E10 said R2 on the other side of the dining room as if he passed out and was leaning against the vending machine. E10 said 911 was called for both residents. E10 overheard the paramedics state it was definitely opioid use since the residents had responded to the Narcan given. On [DATE] at 4:15pm E7 (Psych Social Case Manager) stated on [DATE] around dinner time, E6 reported two residents might be high and 911 was called. E7 said R3 was unresponsive seated in a chair and had turned a dark blue color. E7 noticed R5 had hurriedly left the dining room while staff was responding to R2 and R3. When R2 and R3 had been with the paramedics, a room search was started. E7 said she first went to R5's room to search since he had left the dining room so quickly, he had an incident last year in which he tested positive for drugs. E7 explained R5 was a moderate risk identified offender for drug possession and had been suspected of substance abuse. She said R5's plan of care included weekly meetings but R5's supervision wasn't any different than any other resident. E7 said sometime after Christmas 2015 R5 had a new male cousin who started visiting several times a week for short visits. E7 stated R5 was an independent level for privileges and expectations. On [DATE] at 4:03pm E8 CNA stated residents including R2 and R3 would always go into R5's room. E8 stated she was unaware if R5 had any drug or substance abuse problems. E8 said R5 was monitored the same as all the residents. On [DATE] at 12:55pm R6 said several weeks ago (thinks it may have been in February 2016) she had opened R5's door and saw R2, R3 and R5 in the room. R6 said there was a white powder substance and thought R2, R3 and R5 might have been doing drugs so R6 closed the door and left. R6 stated she told several of the counselors but couldn't recall who she told. On [DATE] at 3:30pm E1 (Administrator) said he was the interim administrator from corporate and wasn't here on [DATE] but was aware of the event. E1 stated the facility along with the corporate office felt the incident was considered a behavior, treated as a behavior and didn't feel the incident required an incident report or notification to IDPH. The facility's policy of Admission of Residents with Severe Persistent Mental Illness, Substance Abuse Disorder and/or a Criminal History (part of the Resident Incentive and Contingency Management Program dated [DATE]) shows The IDT (Interdisciplinary team) is responsible for monitoring the resident for mental health symptoms, including mood state/behavior status changes, changes in level of anxiety, verbalization of threats (towards oneself or others) and any suspected use of alcohol or illicit drugs. The psychiatric rehabilitation staff will complete the organization's standardized assessment packet and develop an interim plan of care, as warranted. The program also includes residents must Abstain from possession or use of alcohol and non-prescribed drugs. Make sure you do not possess any weapons, objects that might be used as weapons, drug paraphernalia or other illegal/contraband items. The facility's undated Substance Abuse Policy includes The facility reserves the right to protect all residents, staff, and visitors from the negative effects of substance abuse. The facility will take all precautions necessary to prevent residents from using alcohol or illegal substances. On [DATE] at 10:35am E9 Assistant Administrator, stated the facility was suspicious R5 was involved with bringing heroin into the building on [DATE]. E9 said R5 had visitors several times a week but he would usually go outside with them. When asked if any of the multiple short visits were a concern, E9 responded the visitors were suspicious but the facility couldn't prove anything. The facility never found any drugs in R5's possession. E9 stated the police had explained heroin could be in a very small packet which is easy to hide and might not be able to find. R5's room was at the end of the hall with the same hourly observations as the rest of the resident population. When asked if this was an appropriate intervention for an identified offender for substance possession and the facility had suspicions of drug possession, E9 responded R5 liked his privacy; he was polite, nice, a model resident really. E9 said It is a fine line to respect someone's privacy or invading it. Regarding R2 and R3's heroin overdose E9 said this was resident behavior and didn't think an incident report or notification to IDPH needed to be done. It wasn't considered an emergency. According to the police report dated [DATE] the staff does not believe (R2) could have been saving the Norco as they conduct random room checks. It continues to include The staff felt that heroin coming in from the outside was far more likely. They also informed me (R2) often hangs out with another patient who has been caught bringing heroin into the facility in the past. On [DATE] at 10:32pm Z1 Police Officer stated he had been told by the nursing staff at the facility they had an idea of which resident was bringing it in. According to the Criminal History Analysis Security Recommendation Report dated [DATE], R5 had Mental Illness/Substance Abuse and was a Moderate Risk-The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the the level of supervision is sufficient. His compliance with psychiatric treatment and abstinence from alcohol/drug use should be closely monitored. In view of his criminal history and psychiatric history, a moderate risk supervision status is recommended. R5's Identified Offender care plan shows in intervention to provide closer observation or monitoring than the standard protocol. Based on the investigation, the facility failed to implement any additional interventions for R5 a known Identified Offender for illegal substance possession. They failed to have interventions in place for R3 a resident with history of substance abuse. As a result of these failures, two residents, R2 and R3 sustained a suspected overdose of heroin which required a call to 911 and the immediate use of narcan, an opioid antidote, to avoid death. The facility did not feel this behavior resulted in an injury. The facility did not do an incident report including an investigation or reporting of the incident to IDPH.

Based on interviews and record review, the facility failed to follow its abuse policy and procedure to notify administration of an incident involving potential abuse and mistreatment by staff to a residents, failed to ensure residents are protected from unnecessary physical force causing injuries and confinement when interacting with a resident who displayed an increased agitated behaviors. This is for 1 of 3 sampled residents, (R1) reviewed for aggressive behaviors and abuse. These failures resulted in R1 exhibiting increased agitated aggressive behaviors due to the staffs excessive use of force, inappropriate and nontherapuetic communication when," taking" down R1 to the floor to restrain him. R1 sustained multiple bruises during this event on the arms and hand and back and was involuntary transferred to the hospital for psychiatric evaluation. Findings include: E1 (director of nurses) on 10/22/13 at 10:30 a.m., said E3(nurse) notified her via telephone on the evening of 10/15/13, about R1's behavior and the facility was transferring R1 to the hospital for a psychiatric evaluation. The nurses notes completed by E 3 were reviewed. The nurses notes written by E3 on 10/15/13 at 6 p.m. show, R1 was trying to pry a window off track when confronted abut it. R1 became agitated and defiant, when asking to come to the dining room, resident punched E3 in the chest, then went to another resident's room an attempted to throw a chair, E3 shut the door and reopened the door and was then punched in the face by R1, 911 was called and R1 was sent to hospital for psychiatric evaluation. The final investigation incident report involving E3 (nurse) and R1 was reviewed with E1 (director of nurses) at 11:a.m. 10/22/13. The date and time of the incident was 10/15/13 between the hours of 6 p.m. and 6:15 p.m. said E1. The incident report show a resident to staff physical altercation occurred between E3 and R1. E1 stated residents approached her when arriving on 10/16/13 at 8 a.m. to tell her about what they saw happen between R1 and E3 last night. E1 said during interview that R3 was one of the residents and the other names she could not recall. E1 said she was told by the residents, E3 used physical force when bringing R1 down to the floor to restrain him. E1 said the facility has video cameras in the hall and through out the facility. E1 stated viewing the video recording on the morning of 10/16/13 for the incident on 10/15/13 at 6 p.m. E1 said after viewing the video it was clear that E3 used more physical force than necessary and did not follow the facility's procedure to call a code yellow. The code yellow procedure was requested and unavailable for review during the interview. E1 stated notifying E3 via telephone after viewing the video on the morning of 10/16/13 of what was seen in the video. E1 stated telling E3 he was suspended until an investigation was conducted. E1 was asked what other staff were involved in restraining R1. E1 was unable to give the names of other staff who assisted in restraining R1. The facility's abuse policy and procedure were reviewed with E1 on 10/22/13. The policy directs the facility staff to report any allegations of abuse and mistreatment. E1 stated being unaware of E3's abusive behavior until reporting to work on the morning of 10/16/13 when approached by residents. E1 did not say the staff reported the overly physical use of force by E3 to R1. On 10/22/13 at 12:30 p.m., E1 ( Director of Nurses) said E3 (nurse) was terminated on 10/17/13 after an abuse investigation was completed. E1 said E3 was terminated for not following the facility's protocol for not calling a code yellow and using improper take down method, ( more than necessary physical force) . E1 was asked to review the code yellow procedure which was unavailable for review. The procedure was not made available until 4 p.m. The Code yellow policy and procedure was reviewed with E1 at this time. E1 said the code yellow is part of the facility's "Behavior Management and Risk Management procedure. E1 said the purpose of calling a code yellow is to warn the staff of the presence of a high risk or crisis situation. E1 said E3 did not call a code yellow or follow the procedure when interacting with E1. The procedure directs the staff to use non-violent crisis intervention techniques/CPI (crisis prevention interventions) holds and are permissible only when the situation is not managed with the use of verbal de-escalation techniques. There was no indication that E3 used verbal de-escalation techniques. On 10/22/13 at 12:45 p.m., R1 stated during interview he was mistreated by E3. R1 said E3 accused him of trying to use a can opener to leave through a window. R1 said E3 asked for the can opener, I asked R3 and he told me to give it to E3 and I did. E3 kept talking to me, he pushed me and I pushed him. R1 said E3 kept accusing me of trying to break the window to leave. He would not listen to me, he got into my face, he was no more than a foot from my face, he was loud and yelling at me, I was intimidated and pushed him off of me, I tried to run from him, into another room, I did throw a chair at him, he closed the door and the chair did not hit him, when the door opened he grabbed me and dragged me down the hall and threw me down, I really don't remember anything after that". On 10/22/13 at 1 p.m., E1 said she and E12 (Administrator) have spoken to E3 on several occasions regarding the loudest of his voice and there are probably write ups in his file. E3's personnel file was reviewed with E1. There were no write up in E3's file. E1 said residents have said they find E3's voice to be loud and overbearing, and some residents do not react positively to E3's spoken voice. There were no performance evaluations found in the personnel file. E3 was hired on 11/12/12. The facility's employee handbook shows the practice of the facility is to conduct a performance evaluation during an employees orientation period. The employee handbook show evaluations will be conducted during the period of orientation to the facility. The facility could not show how they were monitoring the work performance of E3. On 10/22/13, E1 at 1:15 p.m., said R1 is a quiet person, have not had any other episodes of aggressive angry behaviors. E10 (nurse) at 3:55 p.m., said she was not present when the altercation took place. E10 said she only saw E3 sitting in the hall on top of R1's leg and there were others holding R1 down. On 10/22/13 at 1:30 p.m., R3 stated being present on 10/15/13 when E3 entered R1's room and saw R1 with a can opener. R3 stated R1 was doing something with a screw on the window. E3 requested R1 give him the opener. R1 asked R3 if he should and R3 told him yes. R1 gave E3 the can opener. E3 entered R1's room and was loud and accusing them of trying to break the window to leave. R3 stated R1 was trying to tell E3 that was not true. R3 said E3 would not listen and kept accusing R1. E3 shoved R1 against the wall into the corner next to the window and got really close to R1's face and body. E3 grabbed R1 and was dragging him down the hall. On 10/22/13 at 1:40 p.m., R4 stated during interview that looking down the wing where the altercation took place and seeing R1 on the floor and E3 grabbed R1's personals (scrotum). On 10/22/13 at 3:30 p.m., E4, who is R1's psychosocial case manager, said R1 has a laid back attitude, lacks motivation, attends anger management in order to have something to do; but has not expressed angry behavior. R1 is easy going said E4. R1's care plan was reviewed on 10/22/13. The facility did not identify R1 to have angry or aggressive behaviors. There was not a care plan developed with goals or interventions for aggressive, angry or abusive type of behaviors. E3 was asked if R1 was assessed for elopement risk or aggressive behavior. E4 sated R1 had not displayed that type of behavior. On 10/22/13 at 4:30 p.m., E6 CNA(certified nursing assistant) stated during interview that he worked the evening of 10/15/13. E6 sated he was not present when the altercation began; however when he arrived he recalls R1 was already down on the floor and he held his right arm and hand down to restrain R1. R6 said there were three other staff present, E13 (security guard) who he relieved, E3 (nurse) sitting on E3's holding legs and feet, someone else was holding R1's chest area and someone was holding the left arm. E6 stated holding R1 until the police arrived. E6 said R1 began kicking. E6 was unable to give the names of the staff involved in restraining R1. E6 was not sure what initiated the incident, only saw E3 attempting to restrain R1 and tried to assist him. Review of R1's nurses notes on 10/22/13 show R1 returned from the hospital on the 3-11 shift on 10/16/13. E1 stated assessing the skin of R1 upon return to the facility. R1's skin assessment showed the following bruised areas present, (left upper arm ,8cm X8cm), ( two areas left side of back 4 cm X 3 cm reddish purplish ), (3cm X 3 cm from intravenous site), (right lower arm, 2cm X 2 cm) and (7cm X 6 cm right hand). E1 was asked the causes of the bruised areas on 10/23/13 at 1p.m.. E1 stated she assumed they were caused during the incident on 10/15/13. On 10/22/13 at 10:23 a.m., E5 (nurse) during interview stated being surprised about what happened with R1 and E3 on 10/15/13 . E5 said she was in the dining room when the incident occurred. E5 stated R1 is very quiet, compliant with taking medication and causes no problems. E5 stated R1 was probably became agitated and intimidated by E3's loud voice.

Based on observation, interview and record review the facility failed to identify potential safety risks for a resident (R1) with a history of suicide attempts. The facility failed to develop a plan to supervise a resident with worsening behaviors and problems with insight, reasoning and judgement. These failures contributed to R1 enclosing herself in her room sustaining 2nd and 3rd degree burns to 11% of her body (upper torso and bilateral arms, chest and back) from a fire in R1s room. R1 required treatment at a burn unit and will need surgery to treat some of her burns. This applies to 1 of 4 residents (R1) reviewed for accidents/supervision in the sample of 4. Findings include: R1 was admitted to the facility 3/10/09, with [DIAGNOSES REDACTED]. The Pre Admission Screen-Mental Health assessment (PAS/MH Level II Notice of Determination dated 3/10/09 noted R1 to have absent motivation, limited insight and reasoning, delusions, poor judgement and was depressed upon admission. R1's Minimum Data Set, quarterly assessment ((MDS) dated [DATE] (completed two days prior to R1 being hospitalized for [REDACTED]. R1 scored a zero showing the resident was rarely/never understood. The Cognitive Patterns assessment showed short and long term memory problems, moderately impaired daily decision, making poor decisions, with cueing and supervision required. Section D of the MDS (Mood) was left blank and incomplete. The Behavior (section F) assessed R1 to have delusions, verbal threatening behavior to others, screaming and cursing at others daily. The assessment documented R1's behavior has worsened since the prior assessment. The Screening Assessment for Indicators of Aggressive and Harmful Behavior for R1, was reviewed with E5. E5 scored R1 a ..(zero) for category (1). The problems identified were, general insight, reasoning and judgement. These concerns were identified in R1's PAS upon admission but not scored in the assessment. On 1/31/13 at 1:45 p.m., E5 (psychosocial rehabilitee counselor) PRSC stated "R1 said during an interview that was documented on 3/15/09 in the initial social service interview, that there were two suicides attempts by R1, to overdose on medications in 1991. The facility did not complete an assessment to indicate the circumstances that precipitated the suicidal behaviors/overdose". E5 stated R1 had not had any other suicidal ideations since that time. R1 had another episode on 12/5/12. It was documented in the nursing notes by E2 (nurse) and on the involuntary transfer records where R1 voiced comments of, "going to end it all". "...resident attempted to run out of building into traffic...resident attempted to put hands around the staffs neck, yelling and screaming at staff, increased paranoia". On 1/31/13 E1, E5 (PRSC) said the facility does not have a policy and procedure for the management of residents who are admitted to the facility with a history of suicidal ideation's or for the residents who demonstrated signs and symptoms of self harm behaviors to themselves. The hospital discharge clinical summary on 12/28/12, shows R1 was admitted , " due to suicidal ideation and risk of harm and aggressive and paranoid behaviors". R1 was hospitalized for [REDACTED]. On 2/1/13, 1:00 p.m., E2 stated she was present when R1 stated, "wanted to end it all". E5 said we always send residents out when they are suicidal. E5 involuntarily transferred R1 to a psychiatric facility. E2 was asked if R1's (PSRC) E5 was notified of the suicidal behavior and the reason for discharge. E2 stated, "No". On 12/5/12, E2 documented in the nurses notes, "going to end it all and give us, 'staff and others ' what we wanted....attempted to run out of the building into traffic...resident attempted to put hands around the staffs' neck, yelling and screaming at staff, increased paranoia". E5 was asked about this incident. E5 stated, "The reason that R1 was sent out was for medication management and not for suicide". When the nurse's notes were reviewed with E5, E5 acknowledged not being aware of this. Thirty four days after readmission to the facility a large unwitnessed fire erupted in R1's bedroom on 1/30/13 around 11:30 p.m. R1 was found alone and a bed was pushed against the door not allowing staff to rescue resident. On 1/31/13 1:30 p.m., an interview was conducted with E1 ( Director of Nursing ) This was the morning after the fire in R 1' s' room. E1 said she was told on 1/30/13, by E4 (certified nursing assistant) that she went to the A wing after the fire alarm sounded. E4 said she saw thick black smoke in the hallway and coming from around R1's bedroom door. E4 opened the door and found the room full of thick black smoke. E4 stated, R1 refused to come out of the room after repeated coercing. E4 stated there was a bed in front of the door making it impossible to open the door. E4 stated she tried to push open the door but was unsuccessful while continuing to call out for R1 to come out. E3 (nurse) on duty the night of 1/30/13 verified a written statement from 1/30/13 and was interviewed on 2/8/13. E3 verified a written statement from 1/30/13 and E3 stated, "arriving to R1's room... called out to resident, R1 was talking to me but refused to come out". Z4 ( fire investigator) was present during the initial tour on 1/31/13. Z4 stated that the cause of the fire had not yet been determined, but was told by staff that R1 was caught smoking in her room some time ago. Z4 did not find any cigarettes or cigarettes butts, only a cigarette lighter which was found on the floor between the beds near the night stand of R1. On 2/1/13 at 10 a.m., Z9 (discharge planner) at the burn unit stated, that R1 was intubated at the emergency room and was sedated for suspected inhalation injury prior to transfer to the Intensive Care Burn unit on 1/31/13. Z9 said, R1 breathed in hot air and smoke and could not be interviewed at this time. The Bronchoscopy report from 1/31/13 for R1 while in the Burn unit documented," sustained a Grade I inhalation injury." Z9 stated R1 was assessed to have 11% burns, a mix of 2nd degree and undeterminable burns, some deep, some on the bilateral arms, abdomen, chest and back. Z9 stated after R1 was extubated on 2/1/13, R1 was voicing to the staff that they were trying to kill her and they were out to get her. On 2/6/13 at 11: 20 a.m., R1 was observed in a room on the burn unit, in bed lying on the left side. Z9 (discharge planner) and Z12 ( nurse) were present. There were bandages observed on the right and left arm. R1 was alert and oriented to time, place and person. R1 was asked how she acquires cigarettes. R1 stated she has not had any cigarettes for a while but she gets them from other residents in the facility. R1 said she is allowed to keep her smoking material and never has smoked in her room. R1 said, " I always follow the smoking rules." On 2/6/13 at 1:15 p.m., Z10 (physician) was interviewed at the burn unit. Z10 stated, "R1 would need to undergo surgery for [REDACTED]." The paramedic report from 1/30/13 was reviewed on 2/5/13. The paramedic report read, with Z1 (paramedic)," noticed...patient was wearing a bra, jeans, and had a blouse hanging from her waist...soot all over hair and face...bra was burned badly on the left breast cup and charred,..burned on the right side of neck up to right ear lobe, upper back on right side, and burns around umbilicus, chest, abdomen and both arms...burns were bright red with yellowish lines through skin...some areas of burns had skin peeling off"...R1 related pain 10/10 and was medicated with a narcotic and stated no relief. Z1 wrote in the report that R1 could state name; however when asked what happened, patient stated, 'I don't know, I don't know, They told me they would get me sooner or later without me knowing, They are out to get me.' When Z1 asked R1, who was out to get her, R1 responded, "They are trying to get me, they are trying to kill me. Z1 stated in the report that R1, during treatment asked, "Where's my lighter? Help me". R1 was transferred to a local community emergency room for injury's/burns to body. On 1/31/13 at 1:45 p.m. Interview with E1, E5 and E7 showed that facility does not have a policy and procedure for the management of residents who are admitted to the facility with a history of suicidal ideation's or for the residents who demonstrated signs and symptoms of self harm behaviors to themselves or how the facility plans to supervise and monitor residents. R1's psychosocial assessment and care plan were reviewed with E5 on 1/31/13 at 1:45 p.m. On 12/28/12 when R1 was readmitted to the facility E5 wrote in the psych-rehab notes that R1, "still very delusional upon return, but redirection/close observation will continue to be rendered." The facility did not determine or specify the extent of close observation needed. This was verified with E5. A care plan for redirection/close observation was not developed for R1 by the facility. The care plan was reviewed with E5. The review found the interventions in the care plan to be generalized and not specific to R1's suicidal behaviors/problems that occurred on 12/5/12. The contributing factors underlying the cause/effect of R1's behaviors were not assessed nor were interventions developed to prevent such behaviors from reoccurring. The interventions did not address how the facility will supervise and monitor R1 for the behaviors that sent R1 to the hospital. The facility assessed R1 to be able to smoke independently said E5 (psychosocial case manager) on 1/31/13 at 1:45 p.m. (which allowed R1 to keep cigarettes and lighter). The Smoking Safety Risk assessment dated [DATE] completed by E5 was reviewed on 1/31/13 with E5 . R1 had a total score of 2 which notes (follows rules/may independently be able to handle smoking materials) (score 0-2). E5 written comment was, "There has been no recent behavior of smoking in undesignated areas... Proceed to care plan". E5 was asked whether R1 had violated the facility's rules for smoking in an unauthorized area. E5 stated, "yes", was told this had happened, but was awhile ago. E5 was asked when this occurred. E5 was unable to state when. R1's medical record was reviewed for this information. There was no information regarding when this occurred. E5 was asked how often the residents are reassessed for smoking risk. E5 stated there were no specific guidelines that he was aware of. E1, E5 and E7 (psychosocial director) on 1/31/13 were asked to describe the procedure the staff would follow to document and monitor behaviors. E1 stated the psychosocial department had the policy and procedures. E1 and E7, were for the written facility policy's or procedures for the facility to follow monitoring and documenting behaviors, E5 and E7 stated their were none. The smoking safety risk assessment tool dated 3/7/12 completed by E5 for R1 was inaccurate and did not include R1's history in violating the facility's smoking rules. Interviews with E1 on 1/31/13 and review of the written Fire Protection report (1/31/13), the Police report 2/8/13 and interview with E4 (2/13/12), indicated that R1 had been caught smoking in her bedroom before. The care plan was reviewed on 1/31/13. The facility did not have a care plan developed for R1's unsupervised smoking or the supervision of R1 with smoking materials (cigarettes and lighter). The smoking assessment dated [DATE] in R1's record did not accurately reflect the resident's ability to handle smoking material safely. The facility has no system in place to assess or determine whether residents returning from an emergency psychiatric hospitalization are in remission or need individualized interventions to supervise/monitor them. R1's psychosocial assessment and care plan were reviewed with E5 on 1/31/13. On 12/28/12, R1's readmission, E5 wrote in the psych-rehab notes that R1, " still was very delusional upon return, but redirection/close observation will continued to be rendered." The facility did not determine or specify the extent of close observation needed. This was verified with E5.