Every finding on record at West Suburban Nursing & Rehab Center

Based on interview and record review, the facility failed to ensure that residents medications were given as ordered by the physician based on the facility's policy and procedure regarding drug administration. This applies to 2 of 3 residents (R2 and R3) reviewed for medications in the sample of 14.The findings include:1. R3 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anoxic brain damage, neuralgia and neuritis, chronic embolism and thrombosis, based on the face sheet.R3's quarterly MDS (Minimum Data Set) dated June 2, 2026 showed that R3 was cognitively intact.On August 26, 2026 at 2:32 PM, R3 stated that on August 15, 2026, V4 (agency RN, Registered Nurse) gave her morning medications late at around 2:00 PM.The facility's staffing schedule for August 15, 2026 showed V4 was the assigned nurse for R3 during the morning shift from 7:00 AM through 3:00 PM.R3's active order summary report showed multiple ordered medications including, Apixaban 5 mg (milligrams), one tablet by mouth two times a day for embolism and thrombosis of unspecified vein; Biofreeze (menthol topical analgesic), apply to the neck and lower back two times a day for pain; Diclofenac Sodium external gel 1%, apply to left shoulder topically two times a day for pain and Gabapentin 300 mg, one capsule by mouth three times a day for neuropathy.R3's medication administration audit report for August 15, 2026 showed the Apixaban 5 mg, scheduled to be given at 9:00 AM was administered by V4 at 2:00 PM; Biofreeze (menthol topical analgesic), scheduled to be given at 9:00 AM was administered by V4 at 4:43 PM; Diclofenac Sodium external gel 1%, scheduled to be given at 9:00 AM was administered by V4 at 4:43 PM and Gabapentin 300 mg, scheduled to be given at 9:00 AM was administered by V4 at 2:00 PM.R3's progress notes showed no documentation that the Physician or the NP (Nurse Practitioner) was notified that the above medications were administered late on August 15, 2026.On August 30, 2026 at 10:14 AM, V3 (ADON, Assistant Director of Nursing) confirmed there was no documentation made by V4 on August 15, 2026 with regards to late administration of R3's morning medications. 2. R2 had multiple diagnoses including stage 3A chronic kidney disease and unspecified low back pain, based on the face sheet.R2's quarterly MDS dated [DATE] showed R2 was cognitively intact.On August 27, 2026 at 9:50 AM, R2 was sitting in her wheelchair inside the room. R2 was alert and oriented. R2 stated that she had received her scheduled morning medications sometime in the afternoon after 2:00 PM, but she does not remember the specific date. According to R2, she believed it happened approximately two weeks ago on the weekend when an agency nurse was working.The facility's staffing schedule for Saturday, August 15, 2026 showed that V4 (Agency RN) was the assigned nurse for R2 during the morning shift from 7:00 AM through 3:00 PM.R2's active order summary report showed multiple ordered medications including Gabapentin 200 mg by mouth three times a day for nerve pain.R2's medication administration audit report for August 15, 2026 showed the Gabapentin 200 mg scheduled to be given at 9:00 AM was administered by V4 at 2:19 PM.R2's progress notes showed no documentation that the Physician or the NP (Nurse Practitioner) was notified that the above medications were administered late on August 15, 2026.On August 30, 2026 at 10:14 AM, V3 (ADON) confirmed there was no documentation made by V4 on August 15, 2026 with regards to late administration of R2's morning medications.On August 27, 2026 at 3:00 PM, V26 (Nurse Practitioner) stated the Gabapentin medication for R2 should be given three times a day as ordered within the required time frame per facility's policy and procedure and if the said medication was not given timely, the physician or the nurse practitioner should be notified. On August 30, 2026 at 2:53 PM, V2 (Director of Nursing) stated that according to the facility's policy, the nurses should sign the MAR (Medication Administration Record) right after the ordered medication was administered to the resident. For residents with medication orders twice a day like R3, her medications were scheduled at 9:00 AM and 5:00 PM. For residents with medication orders three times a day like R2 and R3, their medications were scheduled at 9:00 AM, 1:00 PM, and 5 PM. Both schedules allow for medications to be administered one hour before or one hour after the scheduled time. According to V2 if for any reason the ordered medication was administered late, the physician or the Nurse Practitioner should be notified, and the notification and/or any additional orders will be documented in the resident's progress notes. Review of the facility's undated policy and procedure regarding drug administration showed in-part under policy, Medications are administered as prescribed, in accordance with good nursing principles and practices. The same policy under procedure showed in-part, Medications are administered in accordance with written orders of the attending physician. Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's MAR at the time the medication is given. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility.The facility's ten rights for administration of medications showed in-part, The right time: Administer drugs as instructed on the MAR and within the time frame established by your facility.The facility's established medication administration schedule showed that for medications ordered twice a day, the medication administration times are 7:00 AM and 4:00 PM or 9:00 AM and 5:00 PM. For medications ordered three times a day, the medication administration times are 7:00 AM, 11:00 AM and 4:00 PM or 9:00 AM, 1:00 PM and 5:00 PM.

Based on interview and record review, the facility failed to address a resident's grievances in a timely manner. This applies to 1 of 3 residents (R1) reviewed for grievances in a sample of 3.The findings include: R1's face sheet showed he was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, atrial fibrillation, hypertension, osteoarthritis, chronic kidney disease, cardiac pacemaker, abnormalities of gait & mobility, bipolar disorder, affective mood disorder, and peripheral vascular disease. R1's MDS (Minimum Data Set) dated 04/13/26 showed R1 was cognitively intact. On 06/16/26 at 10:32 AM, R1 said he was waiting to hear about several things that he had filled out the grievance form. R1 said he had brought up concerns regarding his state ID (Identification), his community pass, and missing items since February 2026. R1 said when he would ask V3 (SSD/Social Services Director) about it, V3 would say it was being taken care of, but nothing was resolved. R1 said no one had explained to him why he was not permitted a community pass and had asked the nursing staff, V3, and V1 (Administrator) about it, and was not given a clear answer regarding why he was not allowed to have access to the community. R1 said he had books misplaced during a room change, and they had not been replaced by the facility. R1 said he needed assistance with getting his state ID, but there had not been any attempts for follow up. R1 said he filled out grievance forms because of the delay in response. R1 said he was trying to give the facility a chance to address his concerns but had not heard any updates since February 2026. The facility's Concern Form for R1 dated 04/06/26 (over two months earlier) showed the following: 1. I have had no follow up about my green pass.2. I would like to meet with my doctor about pass.3. I need help replacing my Chime card.4. I need help getting a replacement ID.5. I gave a list of missing items to [V3] ~3 weeks ago. He keeps saying he ordered it, but nothing ever comes. List I gave him is attached.Follow-up action taken: Resident educated on green pass restriction and the policy regarding appropriate green pass. Resident educated that he will be put on list for next trip to DMV for replacement ID. Missing items: missing books ordered through preferred website. Sardines, hot sauce replaced with a date of response of 06/10/26 by V1 (Administrator).The facility's Concern Form for R1 dated 06/09/26 showed the following:While speaking to DON and Admin, [R1] expressed frustration with not having an independent community pass. [R1] believes others that do have independent community access are bringing in contraband.Follow-up action taken: Guardian Angel program is now focusing on contraband. Rooms have been searched. Community access has been evaluated for residents. Per DON, [R1] is not a candidate for an independent pass at this time with a date of response of 06/12/26 by V1.On 06/16/26 at 8:30 AM, V7 (Ombudsman) said she had been working with R1 since 02/26 and mentioned to the facility R1's concerns. V7 said she filed a written grievance with the facility on 04/06/26 and they had not heard anything regarding the grievances. V7 said they were trying to give the facility a chance to correct the issues but had not heard any resolution since 04/06/26.On 06/16/26 at 10:32 AM, R1 said he was waiting to hear about several things that he had filled out the grievance form. R1 said he had brought up concerns regarding his state ID (Identification), his community pass, and missing items since February 2026. R1 said when he would ask V3 (SSD/Social Services Director) about it, V3 said it was being taken care of, but nothing was resolved. On 06/16/26 at 1:33 PM, V3 (SSD) said they had struggled with R1's grievance form and the ombudsman had gotten involved and assisted them. V3 said he ordered the books. V3 provided an undated order with the books and when asked, showed documentation that the books were ordered on 06/16/26 (during the survey). V3 said he had not taken R1 to the DMV (Department of Motor Vehicles) to get the temporary ID and was unable to show documentation of a scheduled visit to the DMV. On 06/16/26 at 2:45 PM, V1 (Administrator) said there was no policy on the timeline of when grievances needed to be addressed. On 06/16/26 at 2:45 PM, V1 (Administrator) said he did not have an answer as to why R1's grievances were not addressed, and they may have missed it. V1 said the Ombudsman emailed V1 about the concerns and that was the first time he had been notified of R1's concerns. V1 said there were a 'million things' occurring at the facility and they try to handle the concerns as quickly as possible. On 06/16/26 at 1:33 PM, V3 said he had purchased R1's books but was unable to provide a dated receipt of when the books were purchased. At 2:50 PM, V3 provided bank statements which showed R1's books were purchased on 06/16/26 (during the survey). At 4:12 PM, V3 said when a resident wanted community privileges, they needed to trigger the Community Survival Skills Assessment and notify the doctor for an order. V3 said R1 had initially requested community privileges around the end of February or early March, and he notified R1 he needed to check with the doctor first. V3 said by the time he looked through R1's chart, he saw R1 did not qualify for community access. V3 said he completed R1's Community Survival Skills Assessment in October 2025, when R1 was originally admitted (eight months earlier), but had not completed a new assessment when R1 requested community access. V3 said the October 2025 Assessment showed R1 was appropriate for community access. V3 said he did not notify the doctor of R1's request and was unable to provide a progress note showing he had spoken to R1 about why he was not allowed community access. V3 said he was not sure why he had not taken R1 to the DMV (Department of Motor Vehicles) during the facility's last trip to the DMV, which was on 05/08/26. V3 said R1's situation was a rare case. The facility's undated Grievances/Complaints/Missing Property policy showed There will be a clearly visible posting of the reasonable expected time for completing a complaint or grievance review as well as the fact that the person (resident/resident's advocate) who presented the complaint/grievance has the right upon request to receive in writing the decision or outcome related to the complaint or grievance. If necessary, taking any required immediate action to prevent further potential violations of any resident right while the violation is being investigated to include any notifications to the Administrator or any state agency or law enforcement agency. The facility's undated Outside Community Pass Privileges Policy showed During the 14-day observation period, residents will be assessed by their physician, psychiatrist, and Interdisciplinary Team (IDT) for: Cognitive status, Degree and severity of mental illness, Addiction history and present addictive behaviors, Community safety skills, Psychiatric status, Ability to follow the rules and procedures, Maintenance of appropriate grooming and hygiene. Once the resident is assessed, he/she will be placed on a pass status.A resident pass level will not automatically change once requested by the resident or family. If a resident would like to request a more independent pass level, that resident/Guardian must place that request with a member of social services. Social services will evaluate and approve appropriate requests and inform the resident if the request has been denied or approved. Doctor's orders will have to be obtained the day of upgrade.

Based on the interview and record review, the facility failed to schedule a follow up appointment with a recommended eye specialist for a resident experiencing blurry vision. This applies to 1 of 4 residents (R1) reviewed for appointments in a sample of 5. R1's face sheet showed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including type 1 diabetes with ketoacidosis, chronic kidney disease, lack of coordination, amputation of the left below-knee, anxiety, and depression. R1's MDS (Minimum Data Set) dated 03/15/2026 showed R1's cognition was intact and required supervision to touch-assistance for activities of daily living.On 05/01/2026 at 11:20 AM, R1 said the eye doctor saw him at the facility on 04/13/2026 and referred him to the retinal specialist. R1 said his right eye is blurred, and that when he closes his left eye, all he can see is a blur. R1 said he spoke to the V3 (appointment scheduler) and no appointment has been made yet.R1's eye doctor encounter report dated 04/13/2026 indicated the reason for the visit was due to the complaint of right eye blindness. Assessment and plan diagnoses of the visit included diabetes with proliferative diabetic retinopathy with traction retinal detachment involving the macula in the right eye and retinal hemorrhage in both eyes, with the instruction to consult with a retinal specialist.On 05/01/2026 at 12:12 PM, V4 (Nurse) stated that when the instruction was received on 04/13/2026, V3 was made aware to follow up on appointments.On 05/01/2026 at 2:30 PM, V3 said she called the insurance company, and they told her to advise R1 to call them for verification, but she did not communicate with the resident. V3 said the appointment needs to be done in a timely manner and should have communicated with R1.On 05/01/2026 at 3:00 PM, V1 (Administrator) stated the facility should have scheduled the appointment in a timely manner for the resident and was disappointed that the scheduler did not communicate with R1.The guidelines for resident appointments outside the facility, dated 05/2023, did not specify the original appointment schedule but did show the resident appointment as rescheduled appropriately.

Based on observation, interview and record review, the facility failed to safely transfer residents to prevent injury.This failure resulted in R2 falling and hitting her head, being admitted to the Intensive Care Unit for days to monitor a possible subarachnoid hemorrhage, and experiencing ongoing dizziness, headache, low back pain, and left hip pain with left leg spasms. This applies to 3 of 6 residents (R2, R6 and R7) reviewed for resident safety in a sample of 7.The findings include:1. Face sheet, dated 4/20/26, shows R2's diagnoses included atrial fibrillation, dementia, chronic kidney disease, obesity, sequelae of cerebral infarction, Diabetes Mellitus type 2, hypertension, kidney disease, dependence on renal dialysis, anxiety, and osteoarthritis. MDS (Minimum Data Set), dated 1/22/26, shows R2's cognition was intact and R2 required partial / moderate assistance from staff for tub/shower transfers as well as sit to stand transfers.Care plan, dated 2/9/26, shows R2 was at risk for falls related to atrial fibrillation, chronic kidney disease, sequelae of cerebral infarction, diabetes, morbid obesity, anxiety, and hypertension. On 4/17/26 at 11:13 AM, R2 stated V6 (CNA- Certified Nursing Assistant) provided R2 a shower, transported R2 to her room in the shower chair, and R2 began to transfer from the shower chair to the wheelchair. R2 stated she asked V6 if both the shower chair and the wheelchair were locked and V6 affirmed both sets of wheels were locked. R2 stated she placed her hands on the arms of the shower chair, began to stand, and the shower chair moved backwards. R2 stated she was unable to sit back down on the chair and fell to the floor. R2 stated she could not remember if her buttocks hit the edge of the shower chair, but she was sure her head hit the floor because she heard a loud thump. R2 stated V6 was in front of her near her wheelchair when she began to stand and not behind the shower chair securing the chair. R2 stated if V6 was trained properly, he would have known he needed to hold the back of the shower chair during transfers. R2 stated she normally transferred independently in the past with staff holding on to the back of the shower chair. R2 reiterated when she fell the shower chair slipped backward. R2 stated nurses assessed R2 and sent R2 via 911 to the hospital. R2 stated she later heard that staff alleged she held the wheelchair and not the shower chair when she began to transfer. R2 stated she became upset when she heard the allegation because if that was the case she would have fallen forward and not backward. R2 stated she was experiencing ongoing dizziness and vision difficulties, headaches, lower back pain, hip pain and spasms down her left leg.Hospital physician note, dated 4/7/26, shows R2 experienced head, neck and back pain radiating to her legs following a mechanical fall at the facility. The note shows R2 was getting out of the shower chair when the shower chair slipped and R2 struck her head. The note shows R2 had a possible 2-3 millimeter subarachnoid hemorrhage, trace hyper-density along the posterior interhemispheric falx / adjacent sulci measuring 2 to 3 millimeters not previously seen which may represent trace subarachnoid blood products given the history of the fall. The note shows R2 was admitted to ICU for close monitoring and was experiencing lumbar/sacral pain acute on chronic due to the fall.Hospital physician note, dated 4/8/26, shows R2 experienced a minimal left parieto-occipital region hematoma and mildly tender. Head CT result 4/8/26 unchanged 2 mm hyper-density along the posterior right parietal lobe, possibly representing a trace subarachnoid hemorrhage.On 4/17/26 at 11:30 AM, V7 (LPN - Licensed Practical Nurse) stated when she arrived at R2's room after she fell, she saw R2's shower chair between the doorway and the bed, R2 was on the other side of the shower chair on the floor, and V6 was standing on the far side of R2. V7 stated V6 told her that he was trying to fix the wheelchair in front of R2 when R2 fell. V7 stated the wheel of the shower chair did not fall off the chair last night. V7 stated R2 was normally able to transfer herself independently. On 4/17/26 at 10:41 AM, V6 (CNA) stated he showered R2 and brought her back to her room in the shower chair. V6 stated he locked the shower chair and the wheelchair and R2 began to stand up. V6 stated he offered to help but R2 stated she could transfer independently. V6 stated he stood behind the shower chair and R2 stood up and held on to the wheelchair with her hands when she stood up. V6 stated R2 appeared to become weak when she began to turn, sat back on the edge of the seat of the shower chair, and the back of the shower chair raised up and tipped forward because of the weight of R2's body on the front of the shower chair seat. V6 stated the shower chair had only two brakes - one on a front wheel and one on a back wheel.Facility incident note, dated 4/7/26, shows V6's statement included, After shower resident was transferring herself from shower chair to her wheelchair in her room. I was holding her wheelchair while she was transferring from shower chair to wheelchair and one of the wheels from the shower chair came out and she lost her balance, and she fall on floor.On 4/17/26 at 1:00 PM, V3 (Assistant Director of Nursing) stated she interviewed R2 in the hospital who told her that before she fell, R2 stood up and the shower chair moved. V3 stated R2 reported V6 was moving her wheelchair and R2 was trying to stand from the shower chair while holding the armrests of the shower chair. V3 stated she was clear R2 stated she was holding the armrests of the shower chair when trying to get up and not grabbing for the wheelchair when the shower chair flipped up. V3 stated she was told the back wheel came off the shower chair. V3 stated V2 (Director of Nursing) asked V8 (Maintenance) to check all of the facility shower chairs after R2 fell.On 4/17/26 at 9:33 AM in the conference room, V2 (Director of Nursing) stated R2 was normally able to transfer independently. V2 stated V3 was with her in the hospital when she interviewed R2 and R2 stated she grabbed the wheelchair armrests to stand from the shower chair and then fell. R2 reported she pulled up on the wheelchair, the shower chair popped out despite the wheels being locked, R2 lost her balance and fell to the floor. V2 stated her investigation showed V6 was beside the wheelchair when R2 attempted to transfer and fell. V2 stated the wheelchair and shower chair wheels were all locked and a wheel came off the shower chair when the chair went backward. The actual shower chair was in the conference room and examination of the shower chair showed it had plastic casters on all four legs. The casters were attached to the chair legs by bolts that inserted far into the plastic legs. The right front caster and back left caster had locks on the wheels. The left front and right back casters had no locks. When sitting in the chair with both casters locked, the chair was able to be propelled by using feet to push backward. The two locked wheels slid easily on the floor and then the wheels rolled backward despite being locked. On 4/20/26 at 10:21 AM, V8 (Maintenance Director) stated he inspected the facility shower chairs after R2 fell and had no concerns that the shower chair brakes were not functioning properly. V8 stated the facility CNAs knew they had to hold shower chairs because they slide on tile floors, and it did not matter if the wheels were locked. V8 stated he inspected the chair from which R2 fell and the wheels seemed brand new. V8 stated he could not make the wheels roll when the brakes were locked. V8 stated on 4/17/26 he removed all the shower chairs with plastic casters from the facility because he was told they were unsafe. On 4/20/26 at 10:45 PM, V8 stated he reexamined the shower chair from which R2 fell and despite the break mechanism being applied, the wheels did turn.On 4/17/26 at 12:17 PM in the second floor shower room, V10 (LPN) and V11 (CNA) locked all four wheels on two of the shower chairs with plastic casters. The staff demonstrated they could easily roll both the shower chair wheels despite all the wheels being locked. When the shower chair was pushed, all the wheels rolled despite the locks being applied on the wheels. On 4/17/26 at 12:15 PM, V10 (LPN) stated some of the shower chairs in the facility had plastic wheels and slide/roll on the tile even if all four of the wheels are locked. V10 stated that even if a resident can independently stand from a chair, a staff must hold the shower chair to stop it from moving when residents transfer. Review of R2's clinical record showed R2 was admitted to the hospital Intensive Care Unit with a subarachnoid bleed on 4/7/26 and returned to the facility on 4/9/26.Physician assistant note, dated 4/13/26, shows R2 reported experiencing headache (particularly in the frontal region) as well as dizziness, mild vision blurring, and improving lower back pain since her hospitalization due to her fall. The note shows R2 was seen by ophthalmology regarding her blurring vision and may need to see an outpatient ophthalmologist for further evaluation.Facility Transfers Policy, undated, shows, Stabilize or lock all surfaces including wheelchairs and beds. Have the resident lean forward and push up from the wheelchair armrests with both extremities if able. Instruct the resident to stand up as straight as possible to assist with maintaining balance. If the resident uses an assistive device, have him/her reach for the assistive device once standing erect. DO NOT allow the resident to pull up from the assistive device once standing erect. DO NOT allow the resident to pull up from the assistive device to achieve standing.As of 4/21/26, the facility was unable to provide a manufacturer's instruction manual for the chairs utilized by the facility.2. Face sheet, dated 4/20/26, shows R6's diagnoses included dementia, unsteadiness on feet, abnormal gait and mobility, lack of coordination, and weakness.MDS, dated [DATE], shows R6's cognition was severely compromised and R6 required supervision / touching assistance for all transfers.On 4/18/26 at 11:48 AM in the second floor shower room during transfer from his shower chair, V9 (CNA) asked R6 to hold the wall grab bars and asked R6 to stand from his shower chair. As R6 stood, the shower chair rolled slightly back as V9 was holding R6's incontinence brief and did not secure the shower chair. V9 then used one arm to easily move the shower chair away from the back of R6 while holding R6's incontinence brief. V9 stated the brakes were engaged on all the shower chair wheels when she moved it. V9 then rolled the wheelchair to the back of R6, placed her foot between the spokes of the wheelchair and stepped down on the wheel, and without locking the brakes of the wheelchair told R6 to sit in the wheelchair. V9 then locked the wheels of the wheelchair to reposition R6 in the chair. V9 stated the brakes on the shower chairs were not solid and even with the brakes engaged V9 could move the shower chair. V9 stated, Most of them are like that. I don't use the brakes to hold it. I use my muscles to hold it. I don't put my faith in the brakes. V9 then demonstrated that even with the brakes locked on the shower chair the wheels were able to roll when the chair was pushed on the tile floor.3. Face sheet dated 4/20/26 shows R7's diagnoses included Parkinson's disease with dyskinesia, bipolar disorder, depressive episodes, anxiety, congestive heart failure, cardiomegaly, osteoarthritis, transient ischemic attack and cerebral infarction. MDS, dated [DATE], shows R7 was cognitively intact and required only set up or clean up assistance for all transfers.R7's care plan shows R7 required partial/moderate assistance during transfers and R7 was at risk for falls. On 4/17/26 at 12:20 PM, V11 (CNA) brought a plastic-wheeled shower chair into R7's room and placed the shower chair near R7 who was sitting on the edge of his bed. V11 locked the wheels of the shower chair and began to transfer R7 to the shower chair using a gait belt. R7 began to stand up from the bed, grabbed the arm rests of the shower chair and easily pulled it closer and in front of him with the brakes still locked while V11 was holding R7's gait belt. R7 began to turn holding one armrest of the chair and R7 easily pulled the chair toward R7. As R7 sat in the shower chair, the chair slid backward. V11 then wheeled R7 out of his room and down the hall to the shower room with the brakes still locked. V10 (LPN) examined the brakes on the shower chair which were locked and rolling while the resident was transported down the hallway in the shower chair.

Based on interview and record review, the facility failed to provide bed hold information to residents who were transferred from the facility to hospitals.This applies to 2 of 3 residents (R1 and R3) reviewed for transfers in a sample of 7.The findings include: 1. Petition for Involuntary / Judicial Admission, dated 2/26/26, shows R1 was involuntarily transferred to the hospital after displaying aggressive behavior toward a peer. Review of R1's clinical record failed to show a facility bed hold notification was provided to R1.On 4/21/26 at 3:39 PM, V13 (Registered Nurse) stated on 2/26/26 she transferred R1 to the hospital after he displayed aggressive behaviors. V13 stated she did not provide a bed hold notification to R1 due to attending to multiple emergencies at the time of transfer. 2. Progress notes, dated 3/30/26, shows R3 complained of not feeling well and called 911 to be transferred to the hospital. On 4/21/26 at 3:39 PM, V2 (Director of Nursing) stated R3 did not receive a written copy of the facility bed hold policy but she verbally told R3 she could return to the facility when visiting R3 at the hospital. Review of R3's clinical record shows no evidence the facility provided a written copy of their bed hold policy at the time of transfer to the hospital. Facility Guidelines for Resident Bed Holds and Readmissions to the Facility, dated 2/20/25, shows, a) The second presentation of the State's (and therefore the facility's) bed-hold policy will be presented and discussed with the resident and/or their Responsible Party/POA at the time of transfer, or---in the case of an emergency transfer-within 24 hours and in writing. If this is not possible, it is expected of the facility to document multiple attempts to reach the resident's Responsible Party/POA, to include sending this information via certified mail with a signed return of acknowledgement of receipt requested-and when this was done. A copy will be maintained in the resident's medical record.

Based on observation, interview and record review, the facility failed to maintain safe shower chair equipment at the facility to prevent resident injuries.This applies to 3 of 6 residents (R2, R6, R7) reviewed for resident injuries in a sample of 7. The findings include: Facility Daily roster dated 4/20/26 was highlighted with residents who receive bed baths. The roster shows 164 of the 220 residents in the facility received showers at the facility including R2-R7. 1. MDS (Minimum Data Set), dated 1/22/26, shows R2's cognition was intact and R2 required partial / moderate assistance from staff for tub/shower transfers as well as sit to stand transfers.Care plan, dated 2/9/26, shows R2 was at risk for falls.On 4/17/26 at 11:13 AM, R2 stated during transfer from a shower chair to her wheelchair with V6 (CNA - Certified Nursing Assistant), the shower chair moved backwards as she stood causing R2 to fall. R2 stated she asked V6 if both the shower chair and the wheelchairs were locked and V6 affirmed the locks were on both chairs. Facility incident note, dated 4/7/26, shows V6's statement included, After shower resident was transferring herself to from shower chair to her wheelchair in her room. I was holding her wheelchair while she was transferring from shower chair to wheelchair and one of the wheels from the shower chair came out and she lost her balance, and she fell on floor.On 4/17/26 at 9:33 AM in the conference room, V2 (Director of Nursing) stated R2 reported she pulled up on her wheelchair during transfer from the shower chair to her wheelchair and the shower chair popped out despite the wheels being locked. R2 lost her balance and fell to the floor. V2 stated the wheelchair and shower chair wheels were all locked and a wheel came off the shower chair when the chair went backward. The actual shower chair was in the conference room and on examination, the shower chair had a white plastic frame and plastic casters on all four legs. The casters were attached to the chair legs by bolts that inserted into the plastic legs. The right front caster and back left caster had locks on the wheels. The left front and right back casters had no locks. When sitting in the chair with both casters locked, the chair was able to be propelled by using feet to push backward. The two locked wheels slid easily on the floor and then the wheels rolled backward despite being locked. V2 stated she asked V8 (Maintenance Director) to inspect all the facility shower chairs for safety after R2 fell.On 4/20/26 at 10:21 AM, V8 (Maintenance Director) stated he inspected the facility shower chairs after R2 fell and had no concerns the shower chair brakes were not functioning properly. V8 stated the facility CNAs knew they had to hold shower chairs because they slid on tile floors, and it did not matter if the wheels were locked. V8 stated he inspected the chair from which R2 fell and the wheels seemed brand new. V8 stated he could not make the wheels roll when the brakes were locked. V8 stated on 4/17/26 he removed all the shower chairs with plastic casters from the facility because he was told they were unsafe. On 4/20/26 at 10:45 PM, V8 stated he reexamined the shower chair from which R2 fell and despite the break mechanism being applied, the wheels did turn.On 4/17/26 at 12:15 PM, V10 (LPN) stated some of the shower chairs in the facility move and slide on the tile even if all four of the wheels are locked. V10 stated even if a resident can independently stand from a chair, a staff is needed to hold the shower chair. V10 stated the wheels were plastic on most of the shower chairs and shower chairs were able to slide and roll even if the brakes were locked.On 4/17/26 at 12:17 PM in the second floor shower room, V10 (LPN) and V11 (CNA) locked all four wheels on two of the shower chairs. The staff demonstrated they could easily roll both the shower chairs on the tile floor despite all the wheels being locked. When pushed, all the wheels rolled despite the locks being applied on the wheels. As of 4/21/26, the facility was unable to provide a manufacturer's instruction manual for the chairs utilized by the facility.2. On 4/18/26 at 11:48 AM in the second floor shower room, V9 (CNA) used one arm to easily move the shower chair away from the back of R6 while holding R6's incontinence brief. V9 stated the brakes were engaged on all the shower chair wheels when she moved it. V9 stated the brakes on the shower chairs were not solid and even with the brakes engaged V9 could move the shower chair. V9 stated, Most of them are like that. I don't use the brakes to hold it. I use my muscles to hold it. I don't put my faith in the brakes. V9 then demonstrated that even with the brakes locked on the shower chair the wheels were able to roll when the chair was pushed.On 4/18/26 at 11:55 AM, V2 (Director of Nursing) observed the shower chair slide on the floor with ease and the wheels roll despite all of the wheels being fully locked.3. On 4/17/26 at 12:20 PM, V11 (CNA) brought a plastic-wheeled shower chair into R7's room and placed the shower chair near R7 who was sitting on the edge of his bed. V11 locked the wheels of the shower chair and began to transfer R7 to the shower chair. R7 was able to easily slide the shower chair back and forth while holding the armrest during the transfer. When R7 sat down, the shower chair slid backward despite the brakes being locked. V11 then wheeled R7 out of his room and down the hall to the shower room with the brakes still locked. V10 (LPN) examined the brakes on the shower chair which were locked while the resident was transported down the hallway in the shower chair.On 4/17/26 at 12:12 PM in a first floor shower room, V2 (Director of Nursing) and V12 (Corporate Consultant) examined 2 plastic shower chairs with the brakes locked. All four of the wheels on both shower chairs rolled when the brakes were fully locked and the shower chair was able to be rolled on the floor.On 4/17/26 at 12:43 PM in a second first floor shower room, V2 and V12 inspected a plastic shower chair and locked all four wheels of the chair. The chair wheels moved and rolled on the floor despite the brakes being locked. A bariatric shower chair had only two locks (one each on the back two wheels) and no locks on the front two wheels. When pushed, the front of the shower chair swung from side to side and the back two wheels remained fairly in place.

Based on observation, interview and record review, the facility failed to provide toileting assistance to a resident dependent on staff for toileting. This applies to 2 of 5 residents (R1 and R7) reviewed for toileting assistance in a sample of 12. The findings include:1. Review of R1's care plan shows R1's diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting her left non-dominant side, anoxic brain damage, neuralgia and neuritis, depression, anxiety disorder, low back pain, weakness, cognitive communication deficit, and muscle wasting and atrophy. The care plan shows R1 requires a mechanical lift with two staff to assist for transfers. The care plan shows R1 was incontinent of bladder and R1 should be given the opportunity to use the toilet before and after meals, activities, laying down for naps, and at bedtime. R1 was to be toileted at regular intervals. MDS (Minimum Data Set), dated 12/8/25, shows R1 was cognitively intact and was dependent on staff for toileting, bed mobility, and transfers. The MDS shows R1 was frequently incontinent of bladder and bowel. On 1/23/26 at 9:21 AM, R1 stated the facility staff only change her brief when they get R1 up in the morning at approximately 11:00 AM and not again until approximately 6:30 PM when R1 is transferred back in bed. R1 stated the staff tell R1 if R1 wishes to have her brief changed after 1:00 PM, the AM shift will transfer R1 to bed and change her brief but R1 will have to remain in bed until after the 3:00 PM staff begin their shift to be transferred back to R1's wheelchair. R1 stated R1 did not want to remain in bed if her brief was changed after lunch so she chose not to be changed until the staff put her in bed after dinner. On 1/23/26 at 1:21 PM R1 was sitting in the activity room coloring and stated she needed her brief changed. At 1:25 PM, V22 (CNA - Certified Nursing Assistant) arrived to change R1 and told R1 she would transfer R1 to bed and change her brief, but that R1 would have to remain in bed until after 3:00 PM when the next shift arrives. V22 stated she had not yet had a break and needed to begin her resident rounds before her shift ended at 3:00 PM. On 1/23/26 at 1:57 PM, V2 (Director of Nursing) stated it is expected that if R1's brief needed to be changed after lunch that R1 would be transferred to bed, have her brief changed, and be transferred back to her wheelchair in a timely manner by the AM shift. V2 stated R1's AM shift CNA was not to make R1 wait until after 3:00 PM shift begins to be transferred back to her wheelchair if she is changed after lunch. V2 stated during one instance at approximately 2:50 PM R1 requested to have her brief changed. V2 stated R1's AM CNA was finishing her tasks and almost ready to leave her shift and V2 stated R1's PM CNA would transfer R1 back to her wheelchair. V2 stated R1 accused V2 of not prioritizing resident care. V2 stated she never told staff R1 should remain in bed from after lunch until after 3:00 PM shift change if R1 wanted her brief changed after lunch. On 1/23/26 at 1:54 PM, V1 (Administrator) stated it was his expectation that R1 have her incontinence brief changed and that R1 was transferred back to her wheelchair without waiting. Facility document Guidelines for Incontinence Care, dated 9/1/23, shows, It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care. Frequency depends on bladder diary results and/or routine minimal q (every) 2 hour checks as well as care planning. 2. Review of R7's care plan shows R7's diagnoses included cerebral infarction, cirrhosis of liver, depression, anxiety, seizures, encephalopathy, schizoaffective disorder, history of falls, dementia, hemiplegia and hemiparesis following cerebral infarction, abnormal gait/mobility, weakness, and transient cerebral ischemic attack. The care plan shows R7 was incontinent of bowel and bladder and R7 was to be checked every two hours, toileted at regular intervals, and assisted with toileting as needed. The care plan shows R7's ADL care needs, including transfers and toileting, may fluctuate due to the presence of potential acute changes with exacerbations of chronic health conditions. MDS, dated [DATE], shows R7's cognition was intact, R7 required substantial/maximal assistance for toileting, and required supervision/touching assistance for transfers. On 1/23/26 at 10:33 AM, R7 stated on 1/22/26 at approximately 10:30 PM R7 put her call light on because she needed to go to the bathroom. R7 stated she was not assisted until 1:30 AM and R7 wet her bed.

Based on interview and record review, the facility failed to provide transportation services for a resident requiring an appointment with a medical specialist.This applies to 1 of 3 residents (R127) reviewed for social services in a sample of 35.The findings include:On 11/23/2025, R127's family member (R128) said he was concerned about R127's general medical decline related to her abdominal mass that was found in June 2025. R127's family member said she missed her ordered oncology consultation appointment in July because the facility did not make proper arrangements. R127's family member said the facility informed him that her appointment was missed due to her insurance coverage. He said he then accompanied R127 to her rescheduled appointment on 8/28/2025. R127's family member said V21 (Oncologist/Physician) inquired why she did not follow-up sooner, as originally ordered. R127's family member said she was then referred to another specialist (gynecologist-oncologist) and now requires a biopsy to determine her cancer treatment. On 11/24/2025 at 1:40 PM, R127 was sitting up in her wheelchair. R127 said she had returned from the hospital but was unable to provide information regarding her recent hospitalizations and recently diagnosed cancer.On 11/24/2025 at 12:40 PM, V4 (Nurse Practitioner/NP) said he assessed and reviewed R127's hospital documents when she was readmitted on [DATE]. V4 said R127's hospital CT (computer tomography) scan in June 2025 showed an accidental finding of an ovarian mass. V4 said he informed the facility of R127's required oncology consultation. V4 said R127 was finally seen by the oncology team on 8/28/2025, after she missed her original appointment on 7/03/2025. V4 said R127 was then referred to a gynecologist-oncologist specialist on 10/30/2025 and now required a biopsy. V4 said residents should follow up with a specialist as ordered to prevent delay in care management.V4's progress note dated 7/10/2025 said the facility staff was to coordinate R127's ordered consultation with V21 (Oncologist) for her 13 cm (centimeters) complex cystic solid mass found in her uterus.On 11/24/2025 at 1:45 PM, V20 (Licensed Practical Nurse/LPN) said she believed R127 missed her original oncology appointment because of her insurance. V20 said nurses completed a Resident Doctor's Appointment Transportation form when they received an order for medical appointments. V20 said the forms were then given to V18 (Transportation Scheduler) to ensure transportation arrangements were obtained.On 11/24/2025 at 1:25 PM, V18 (Transportation Scheduler) said R127's oncology appointment on 7/03/2025 was cancelled due to transportation. V18 said outside transportation services required four-day advance notifications and did not include weekends, and the facility also had their own bus transportation available for appointments if needed. V18 said she was not notified of R127's rescheduled appointment on 7/10/2025. V18 said she was notified of her rescheduled appointment on 8/28/2025, and transportation services were done with the facility's bus. On 11/24/2025 at 1:20 PM, V19 (Oncology Receptionist) said R127's appointment records showed her 7/03/2025 appointment was cancelled by the facility because V8 (Registered Nurse/RN) reported R127 was not feeling well. V19 said on 7/10/2025 for R127 was no show for her rescheduled appointment. V19 said they called the facility and left a message with the receptionist to have the nurse call the office. V19 said the office did not have any conflicts with R127's insurance provider. R127's Resident Doctor's Appointment/Transportation form dated 6/27/2025 (5-weekday notice) showed a request for transportation for her oncology appointment scheduled for 7/03/2025. The form notes the appointment had to be rescheduled due to a 2-day notice and other appointments scheduled. The facility's policy titled Guidelines for Resident Appointments Outside the Facility, dated 5/14/2023, said transportation for residents with required doctor appointments, such as consults would be coordinated by the facility. The transport would be secured according to medical necessity, such as for routine non-emergency situations, transportation services may include local services or the facility's provider. And if, for any reason, an ordered/scheduled appointment was missed, the facility would notify all parties and reschedule as appropriate.

Based on observation, interview, and record review, the facility failed to ensure residents were informed in a language and terminology they understood when a third-party vendor enrolled residents in a new Medicare Advantage plan at the facility. This situation resulted in R23 displaying psycho-social symptoms including emotional upset and crying when discussing the changes to his insurance he was not aware of. This applies to 3 of 17 residents (R1, R19, and R23) reviewed for changes to Medicare Advantage plans in the sample of 23. The findings include:1. On September 2, 2025, at 12:36 PM, R1 was sitting in his room. R1 said several weeks ago he signed up for a new insurance plan. R1 said, I didn't understand what I was signing up for. [V3] (SSD-Social Service Director) talked me into it. Then after I signed up for it, I found out I wouldn't be able to get my cancer medication and I was panicking because I need my medication. I didn't understand the new insurance would change what was covered. Then I had to just keep begging them to change my insurance back to what I had. I've been very upset about this situation. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dementia, generalized anxiety disorder, hypertension, anemia, insomnia, history of skin cancer, major depressive disorder, epilepsy, cognitive communication deficit, lack of coordination, leukemia, toxic encephalopathy, urine retention, bipolar disorder, and psychosis. R1's MDS (Minimum Data Set) dated June 19, 2025 shows R1 has moderate cognitive impairment, is independent with bed mobility, requires setup assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. On September 2, 2025, at 10:02 AM, V2 (DON-Director of Nursing) said, Our facility is working with [outside insurance vendor] Managed Care plan and they take over Medicare and Medicaid. [R1] is no longer part of the new plan. He signed up for the new plan, and there was a window of time where we couldn't do much with it. His doctor was able to get [R1's] cancer medications through his old insurance plan. They did not think they would be able to get the cancer medications through the new Managed Care plan at the facility. [R1] wanted his old insurance plan reinstated, and so we had to help with that. There were a few days of time for that transition to occur. 2. On September 9, 2025 at 10:35 AM, R19 was lying in bed in his room. R19 was speaking with a very thick accent and said his first language is Polish. R19 said Signing up for that new [Medicare Advantage plan] was a joke. [V3] (SSD) brought an insurance guy around, and asked if I would meet him. The insurance guy told me if I signed up, I would get a visit from a nurse practitioner every other week. The guy cheated me and didn't tell me everything, like the fact that I don't get to keep my doctor. He made it sound like we were going to get more services, not less. I don't want to be signed up for that insurance. I didn't understand what I was signing. The EMR (Electronic Medical Record) shows R19 was admitted to the facility on [DATE] with multiple diagnoses including, mononeuropathy of left lower limb, PVD (Peripheral Vascular Disease), hypertension, heart disease, spleen infarction, depression, anemia, spinal stenosis of the cervical region, post-laminectomy syndrome, low back pain, thoracic aortic aneurysm, anxiety disorder, adjustment disorder, and presence of prosthetic heart valve. R19's MDS (Minimum Data Set) dated July 8, 2025 shows R19 is cognitively intact, requires setup assistance with eating and lower body dressing, supervision with oral and personal hygiene, substantial/maximal assistance with showering and personal hygiene, and is dependent on facility staff for all other ADLs. R19 is frequently incontinent of urine, and always incontinent of stool. R19's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP- Health Maintenance Organization Institutional Special Needs Plan). The Enrollment Form continues to show R19's name, date of birth , gender, permanent address as the facility, and R19's Medicare Number. R19's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging R19 read and understood the Enrollment Form. The Enrollment Form continues to show V15 (Agent) as the individual helping enrollee with completing this form only. On September 4, 2025 at 12:15 PM, V9 (Son of R19) said, I did not know [R19's] Medicare Advantage plan was changed. No one ever called me. I have Power of Attorney for [R19]. I do not trust that my father could make a decision for changing his health plan. English is not his first language, and I would not be confident he understood what he was signing. He speaks Polish.The facility does not have the documentation to show R19 has a Power of Attorney or Healthcare Surrogate form, or that V9 (Son of R19) was contacted regarding R19's Medicare Advantage plan. 3. On September 9, 2025, at 1052 AM, R23 was sitting in a wheelchair in the hallway outside of his room. R23 said, I signed some papers the other day, but they didn't tell me it meant I was getting a new doctor and a new nurse practitioner. I didn't understand it. I want to go back, but I have to wait. They lied to us. R23 became tearful and started crying out loud, saying he has many health problems including Parkinson's disease and depression and this insurance change was causing him to feel sadder and more depressed. The EMR shows R23 was admitted to the facility on [DATE] with multiple diagnoses including, degenerative disease of the basal ganglia, Parkinsonism, Type 2 diabetes, anxiety disorder, depression, repeated falls, abnormalities of gait and mobility, and Parkinson's disease. R23's MDS dated [DATE] shows R23 is cognitively intact. R23's Medicare Advantage Plan Enrollment Form dated August 19, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form continues to show R23's name, date of birth , gender, permanent address as the facility, and R23's Medicare Number. R23's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging R23 read and understood the Enrollment Form. The Enrollment Form continues to show V15 (Agent) as the individual helping enrollee with completing this form only. On September 3, 2025 at 9:41 AM, R23 was sitting in the hallway in his wheelchair. R23 said he was approached by V3 (SSD) to ask if R23 wanted to hear a presentation regarding insurance. R23 said he would gladly hear about it, but decided not to do it because he didn't like the sound of it. R23 said he has had the same insurance company his whole life and he did not want to change from that. R23 said, Then when I said no, [V3] came back to my room and was asking me why I didn't want the new insurance. I felt like he was pressuring me to change to their preferred insurance, which seemed unethical and makes me not trust [V3] anymore. R23's MDS dated [DATE] shows R23 is cognitively intact. On September 4, 2025 at 11:57 AM, V1 (Administrator) said the facility does not have a policy regarding obtaining consents. V1 provided the undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities brochure provided to every resident upon admission. The brochure shows, Your rights to participate in your own care: You have a right to complete information about your medical condition and treatment in a language that you can understand. Your rights as a citizen and a facility resident: If a court of law has appointed a legal guardian for you, your guardian may exercise your rights for you. If you have named an agent under a Power of Attorney for Health Care, our agent may exercise your rights for you.

Based on observation, interview, and record review, the facility failed to follow their policy to ensure a resident received routine and emergency dental services in a timely manner. This failure resulted in R1 experiencing severe pain and requiring a tooth extraction. This applies to 1 of 3 residents (R1) reviewed for dental services in the sample of 23.The findings include:On September 2, 2025, at 12:36 PM, R1 was sitting in his room. R1 had a piece of rolled up gauze in his mouth and said he had a tooth pulled on August 30, 2025. R1 said, I lost the filling back in May (2025) and have been telling so many people here that I needed to see the dentist, including [V3] (SSD-Social Service Director). I even called [V7] (Ombudsman) to help me because the pain has been so bad. When they finally got me to see the dentist, he wasn't able to replace the filling and my only choice was to have the tooth pulled. If only they would have let me see him sooner. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dementia, generalized anxiety disorder, hypertension, anemia, insomnia, history of skin cancer, major depressive disorder, epilepsy, cognitive communication deficit, lack of coordination, leukemia, toxic encephalopathy, urine retention, bipolar disorder, and psychosis. R1's MDS (Minimum Data Set) dated June 19, 2025 shows R1 has moderate cognitive impairment, is independent with bed mobility, requires setup assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The facility's Concern Form dated May 16, 2025 completed by V7 (Ombudsman) shows multiple concerns including, .3. Needs to see a dentist. On September 8, 2025, at 3:37 PM, V7 (Ombudsman) said she completed the grievance form for R1 on May 16, 2025 but did not submit R1's grievances to V1 (Administrator) until May 19, 2025 at 8:45 AM via email. V7 provided documentation to show V1 received her grievance on behalf of R1 on May 19, 2025 at 11:25 AM. V7 said she spoke to V11 (RN-Registered Nurse) regarding referrals to the dentist in mid-June 2025. On June 16, 2025 at 1:59 PM, V11 (RN) documented, Writer called [V12] (Insurance Case Manager) to fax doctor list for urologist, eye doctor, dental, audiologist doctor. He said he will fax the doctor list for urologist, eye doctor, dental, audiologist doctor. Will f/u (Follow up). Writer provided the fax number for the facility. On September 2, 2025 at 11:04 AM, V3 (SSD) said, Anytime a resident, nurse, or anybody asks, I will reach out to the dentist. He comes every Tuesday. Last week, he wasn't able to make it, so he came this past Saturday. I email the dentist if someone needs to be seen. On September 9, 2025 at 11:05 AM, V11 (RN) said, I notified the social worker back in June that [R1] needed to see a dentist. I used the communication tool in our EMR to communicate with him. I can tell you the exact date I communicated the request to see the dentist and audiologist to [V5] (SSD). It was June 16, 2025. I can tell by looking at my documentation in the medical record. V11 continued to show the process of using the communication feature in the EMR and showed her nursing progress note dated June 16, 2025. The facility's Admission/re-admission Screener for R1 dated July 2, 2025, signed by V10 (RN-Registered Nurse) shows 12. Teeth/Dentures: 1. Own teeth - yes.4. Broken or carious teeth? Yes. The facility does not have documentation to show facility staff followed up on the list of providers for R1 from his insurance provider. The facility does not have documentation to show R1 was seen by the dentist following the grievance dated May 16, 2025, or following the communication by V11 to social services on June 16, 2025, or following the assessment of dental concerns on the nursing assessment documentation dated July 2, 2025. The undated dental list provided by the facility does not show R1 was seen by the dentist during the dental visits at the facility from January 2025 through July 2025. Facility documentation shows R1's last dental visit at the facility was April 26, 2024. The Dental Consult form, dated April 26, 2024, shows V13 (Dentist) documented R1 received a dental exam and needed extractions of teeth number 8 and 9, asap (as soon as possible). The facility does not have documentation to show R1 was seen by the dentist following the dental exam on April 26, 2024, or that R1 refused to have the two teeth extracted as recommended by V13. The Dental Consult form dated August 27, 2025 shows R1 received a dental exam by V13, and R1 had red, puffy tissue, lost a filling in tooth number 19, and had continuing pain. V13 ordered an antibiotic for R1 and recommended an extraction of the tooth at the next visit. The Dental Consult form dated August 30, 2025 shows R1 had an extraction of tooth number 19, and recommended extractions of two teeth, number 9 and 10 at the next visit. On September 9, 2025 at 9:28 AM, V13 (Dentist) provided a timeline of his dental visits with R1, beginning on August 27, 2025. V13 said he visits the facility weekly. V13 said he sees residents routinely who are signed up for the dental program, and will see any resident in the facility, upon request, including residents who are not enrolled in the dental program. V13 said the last time he examined R1 prior to August 27, 2025 was on April 26, 2024, when V13 recommended extraction of two different teeth (8 and 9). V13 said, when he examined R1 on August 27, 2025, R1 had a lot of pain, swelling, and infection present due to a lost filling in tooth number 19. V13 was not able to extract the tooth on August 27, 2025 due to the swelling and infection and prescribed antibiotics with the plan to return to the facility in a few days to extract the tooth. V13 said he returned on August 30, 2025 to extract tooth number 19, and returned to the facility on August 31, 2025 for a post-operative follow-up and found R1 was experiencing a condition called dry socket. V13 said he again returned to the facility on September 2, and 7, 2025 due to R1 experiencing pain, and again on September 8, 2025 due to pain. V13 said if R1 had received prompt dental care when he voiced concerns regarding the lost filling, the tooth pain and infectious process R1 experienced could have been prevented. The facility's undated policy entitled Dental Services shows: Policy: it is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This includes meeting any need for dental/denture care to include routine as well as emergency indicated services. Procedure: 1. A licensed nurse will conduct a comprehensive, accurate, standardized assessment of each resident's functional capacity to include dental status. Note: Dental condition status refers to the condition of the teeth, gums, and other structures of the oral cavity that may affect the resident's nutritional status, communication abilities or quality of life. The assessment should include the need for and use of dentures or other dental appliance(s). 2. These assessments will be conducted initially upon admission, quarterly, annually, and when there is a significant change in the resident's condition that affects the oral cavity.6. The assessing nurse will physically inspect the resident's mouth (oral cavity) for any abnormalities. 7. The assessing nurse will monitor for: .Darkness on a tooth (likely decay) or broken natural teeth, bleeding or loose teeth, mouth, or facial pain - discomfort or pain when chewing. Note: Negative findings will be immediately addressed. The attending physician will be notified as well as the facility's dental provider. The DON (Director of Nursing), MDS (Minimum Data Set) Coordinator, and SSD will also be notified as well as the resident or their responsible party. 8. SSD will work with the resident, family, physician, and the dental provider to coordinate timely care. This includes arranging transportation and staff accompaniment as needed.

Based on interview and record review the failed to have documentation to show a resident's representative could legally make decisions regarding a resident's enrollment in a Medicare Advantage plan when a third-party vendor enrolled residents in a new Medicare Advantage plan at the facility.This applies to 8 of 17 residents (R6, R7, R10, R11, R12, R15, R16, and R18) reviewed for changes to Medicare Advantage plans in the sample of 23. Findings include: On September 2, 2025 at 10:02 AM, V1 (Administrator) said, Our company is working with [outside insurance vendor] and that vendor takes over Medicare and Medicaid. On September 2, 2025, at 11:04 AM, V3 (SSD-Social Service Director) said, The [outside insurance vendor] chosen by our company, goes into the long-term care buildings owned by our company and offers residents to change their Medicare coverage to the [outside insurance vendor's] Medicare Advantage Plan. The SSD has to do the first point of contact between the residents and the insurance representative. My role was to say this is a new thing coming to our building. I took the rep around and introduced him to the residents. I called the POA (Power of Attorney)/guardians of the non-responsive people and had the same conversation. We, the staff, were told they were coming into our facility, and we are offering the residents this plan. I had to identify who was cognitively intact. The decision was based on the BIMS score (Brief Interview for Mental Status) score, and I used a BIMS score of 12 or higher to say the resident is decisional. They needed to be oriented to person, time, and place. [V15] was the representative from the [outside insurance vendor] who spoke to the residents and got the consents to change the residents' Medicare Advantage plans. V3 continued to say he was not present in the room when V15 (Insurance Agent) presented the Medicare Advantage plan information to the residents or to witness the signing of the enrollment forms. The facility provided a list of residents whose Medicare Advantage Plan has been changed to an I-SNP (Institutional Special Needs Plan) Medicare Advantage Plan with the new insurance vendor. The undated list shows R6, R7, R10, R11, R12, R15, R16, and R18 with an effective date in the I-SNP Medicare Advantage plan of September 1, 2025. 1. R6's Medicare Advantage Plan Enrollment Form dated August 4, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO-Health Maintenance Organization I-SNP). The Enrollment Form shows R6's name, date of birth , gender, permanent address as the facility, and R6's Medicare Number. The Enrollment Form shows: Important: Read and sign below: I must keep both Hospital (Part A) and Medical (Part B) to stay in the [outside insurance vendor's] Health Plan. By joining this Medicare Advantage Plan, I acknowledge that [outside insurance vendor] will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement blow). Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan. I understand that I can be enrolled in only one MA (Medicare Advantage) plan at a time - and that enrollment in this plan will automatically end my enrollment in another MA plan. I understand that when my [outside insurance vendor] coverage begins, I must get all of my medical and prescription drug benefits from [outside insurance vendor] plan. Benefits and services provided by [outside insurance vendor] and contained in my [outside insurance vendor] Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor [outside insurance vendor] Health Plan will pay for benefits or services that are not covered. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person legally authorized to act on my behalf on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), the signature certifies that: 1. This person s authorized under State law to complete this enrollment, and 2. Documentation of this authority is available upon request by Medicare. V19's (Significant Other) signature is typed in a cursive font as the signature on the Enrollment Form acknowledging V19 read and understood the Enrollment Form for R6. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only.The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R6 has severe cognitive impairment, with a BIMS score of 5, on July 8, 2025. The facility does not have completed POA paperwork for R6. The POA paperwork in R6's medical record shows a Power of Attorney for Health Care form, signed by V19 on May 19, 2025. The paperwork does not show R6's name anywhere on the paperwork to indicate the POA paperwork belongs to R6. The POA paperwork was witnessed by V3 (SSD) on May 19, 2025.2. R7's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R7's name, date of birth , gender, permanent address as the facility, and her Medicare Number. V20's (Daughter of R7) signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging V20 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only.The facility did not have POA paperwork in the medical record for R7 on August 20, 2025, the date the Medicare Advantage plan paperwork was signed by V20. Facility documentation shows POA paperwork was completed for R7, with R7's signature, on August 22, 2025, two days after the consent for enrollment in the Medicare Advantage plan was signed. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R7 has severe cognitive impairment, with a BIMS score of 7, on August 14, 2025. 3. R10's Medicare Advantage Plan Enrollment Form dated August 1, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R10's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V21's (Spouse of R10) electronic signature on the Enrollment Form, acknowledges V21 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V21 is the POA or health care surrogate for V21. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R10 has moderate cognitive impairment, with a BIMS score of 10, on July 21, 2025. 4. R11's Medicare Advantage Plan Enrollment Form dated August 6, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R11's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V22's (Brother of R11) electronic signature on the Enrollment Form, acknowledges V22 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V22 is the POA or health care surrogate for R11. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R11 has moderate cognitive impairment, with a BIMS score of 11, on June 18, 2025. 5. R12's Medicare Advantage Plan Enrollment Form dated August 11, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R12's name, date of birth , gender, permanent address as the facility, and her Medicare Number. V23's (Son of R12) electronic signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging V23 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V23 is the POA or health care surrogate for R12.R12's MDS dated [DATE] shows R12 has moderate cognitive impairment, with a BIMS score of 8. 6. R15's Medicare Advantage Plan Enrollment Form dated August 28, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R15's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V24's (Brother of R15) electronic signature on the Enrollment Form, acknowledges V24 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V24 is the POA or health care surrogate for V24. R15's MDS dated [DATE] shows R15 has severe cognitive impairment, with a BIMS score of 7. 7. R16's Medicare Advantage Plan Enrollment Form dated August 19, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R16's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V25's (Sister of R16) electronic signature on the Enrollment Form, acknowledges V25 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V25 is the POA or health care surrogate for R16. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R16 has moderate cognitive impairment, with a BIMS score of 8, on June 23, 2025. 8. R18's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R18's name, date of birth , gender, permanent address as the facility, and her Medicare Number. R19's (Father of R18) signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging R19 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows R19 is the POA or health care surrogate for R18. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R18 has moderate cognitive impairment, with a BIMS score of 8, on August 15, 2025. On September 4, 2025 at 12:15 PM, V9 (Son of R19) said, V9 is not the POA for R18, did not sign the consent form for the change to R18's Medicare Advantage plan, and does not trust R19 could make an informed decision for changing R18's health plan. V9 said, English is not [R19's] first language, and I would not be confident he understood what he was signing. He speaks Polish. Guidance from CMS (Centers for Medicare and Medicaid) entitled, Medicare Advantage and Part D Enrollment and disenrollment Guidance Updated: 2024 shows: This guidance update is effective beginning with contract year 2025. All enrollments with an effective date on or after January 1, 2025, must be processed in accordance with the revised requirements. Plans are expected to use the updated model enrollment form for enrollment requests received on or after January 1, 2025. Organizations may, at their option, implement any new requirement consistent with this guidance prior to the required implementation date. 10.1 - Definitions: The following definitions relate to topics addressed in this guidance. Authorized Representative - An individual who is legally able to act on behalf of the beneficiary, as allowed by applicable state laws, in order to execute an enrollment or disenrollment request. A representative may be appointed by the individual (consistent with the standards under applicable law) or may be authorized under law without a specific or explicit appointment. 50 - Enrollment processing: The following should also be considered when processing an enrollment: .E. Signature and Date - The individual must sign the enrollment form or complete the enrollment request mechanism. If the individual is unable to do so, an authorized representative must sign the enrollment form or complete the enrollment request mechanism. If an authorized representative enrolls an individual, the authorized representative must attest to having the authority under State law to do so, and confirm that a copy of the proof of court-appointed legal guardian, durable power of attorney, or proof of other authorization required by State law that empowers the individual to effectuate an enrollment request on behalf of the applicant is available and can be presented upon request by the plan or CMS. On September 4, 2025 at 11:57 AM, V1 (Administrator) said the facility does not have a policy regarding obtaining consents. V1 provided the undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities brochure provided to every resident upon admission. The brochure shows, Your rights to participate in your own care: You have a right to complete information about your medical condition and treatment in a language that you can understand. Your rights as a citizen and a facility resident: If a court of law has appointed a legal guardian for you, your guardian may exercise your rights for you. If you have named an agent under a Power of Attorney for Health Care, our agent may exercise your rights for you.

Based on observation, interview and record review, the facility failed to protect the residents' right to be free from exploitation when the facility allowed an outside vendor to come into the facility and make unauthorized changes to cognitively impaired residents' Medicare Advantage plans. This applies to 3 of 17 residents (R5, R9, and R17) reviewed for changes to Medicare Advantage plans in the sample of 23.The findings include:On September 2, 2025 at 10:02 AM, V1 (Administrator) said, Our company is working with [outside insurance vendor] and that vendor takes over Medicare and Medicaid. On September 2, 2025, at 11:04 AM, V3 (SSD-Social Service Director) said, The [outside insurance vendor] chosen by our company, goes into the long-term care buildings owned by our company and offers residents to change their Medicare coverage to the [outside insurance vendor's] Medicare Advantage Plan. The SSD has to do the first point of contact between the residents and the insurance representative. My role was to say this is a new thing coming to our building. I took the rep around and introduced him to the residents. I called the POA (Power of Attorney)/guardians of the non-responsive people and had the same conversation. We, the staff, were told they were coming into our facility, and we are offering the residents this plan. I had to identify who was cognitively intact. The decision was based on the BIMS score (Brief Interview for Mental Status) score, and I used a BIMS score of 12 or higher to say the resident is decisional. They needed to be oriented to person, time, and place. [V15] was the representative from the [outside insurance vendor] who spoke to the residents and got the consents to change the residents' Medicare Advantage plans. V3 continued to say he was not present in the room when V15 (Insurance Agent) presented the Medicare Advantage information to the residents or to witness the residents signing the enrollment forms. V3 also could not say why he provided the names of R5, R9 and R17 to the insurance agent when they have a BIMS score of less than 12. The facility provided a list of residents whose Medicare Advantage Plan has been changed to an I-SNP (Institutional Special Needs Plan) Medicare Advantage Plan with the new insurance vendor. The undated list shows R5, R9, and R17 with an effective date in the I-SNP Medicare Advantage plan as September 1, 2025. 1. On September 9, 2025, at 10:49 AM, R5 was lying in bed in his room. R5 was not able to say what year it is, what day of the week it was, what time it was, or how long he had lived at the facility. R5 said he believed he had lived at the facility for two weeks, and asked if this surveyor was here to take him to his Alcohol Anonymous meeting. R5 said he did not know anything about signing papers to change his Medicare Advantage plan and could not recall if anyone had explained a new Medicare Advantage plan to him. R5 said, I'm on Medicaid, that's all I know. The EMR (Electronic Medical Record) shows R5 was admitted to the facility on [DATE] with multiple diagnoses including trans-cerebral attack, hemiplegia and hemiparesis of the left side, bipolar disorder, lack of coordination, weakness, and major depressive disorder. The EMR shows multiple MDS (Minimum Data Set) assessments for the period of December 2024 to July 2025 with documentation of R5's cognitive impairment, including: R5's MDS dated [DATE] shows R5 has severe cognitive impairment. R5's MDS dated [DATE] shows R5 was rarely/never understood, and therefore unable to complete the brief interview for mental status. The MDS shows R5 had moderate cognitive impairment at the time of the MDS assessment. R5's MDS dated [DATE] shows R5 had moderate cognitive impairment. R5's MDS dated [DATE] shows R5 had severe cognitive impairment at the time of his MDS assessment. R5's care plan, revised July 7, 2025 shows: My comprehensive assessment reveals a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase my susceptibility to abuse/neglect. The resident demonstrates: depression, diagnosis of mental illness, high level of hostility or irritability, history of drug and/or alcohol abuse, difficulty in adjustment and generalized mood distress. Symptoms may be manifested by behavioral symptoms. The facility does not have documentation to show R5 has a POA (Power of Attorney) or a legal healthcare surrogate decision maker. The facility does not have documentation to show R5's family members/emergency contacts were contacted regarding the changes to R5's Medicare Advantage plan or that the insurance agent would be speaking to R5. R5's Medicare Advantage Plan Enrollment Form dated August 19, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO-Health Maintenance Organization I-SNP). The Enrollment Form shows R5's name, date of birth , gender, permanent address as the facility, and R5's Medicare Number. The Enrollment Form shows: Important: Read and sign below: I must keep both Hospital (Part A) and Medical (Part B) to stay in the [outside insurance vendor's] Health Plan. By joining this Medicare Advantage Plan, I acknowledge that [outside insurance vendor] will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement blow). Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan. I understand that I can be enrolled in only one MA (Medicare Advantage) plan at a time - and that enrollment in this plan will automatically end my enrollment in another MA plan. I understand that when my [outside insurance vendor] coverage begins, I must get all of my medical and prescription drug benefits from [outside insurance vendor] plan. Benefits and services provided by [outside insurance vendor] and contained in my [outside insurance vendor] Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor [outside insurance vendor] Health Plan will pay for benefits or services that are not covered. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person legally authorized to act on my behalf on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), the signature certifies that: 1. This person s authorized under State law to complete this enrollment, and 2. Documentation of this authority is available upon request by Medicare. R5's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging R5 read and understood the Enrollment Form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. On September 8, 2025 at 12:56 PM, V16 (Physician) said he is the primary care physician for R5 and R5 has severe cognitive impairment and would not be able to read and understand a consent form. 2. On September 4, 2025 at 11:18 AM, R9 was sitting in his room. R9 said, Some people came in and talked to me. I don't know what they were doing! I didn't understand it at all. Something about insurance, I think. Did I want my insurance to change? No. I don't know why I signed the papers or what they said. The EMR shows R9 was admitted to the facility on [DATE] with multiple diagnoses including, prostate cancer, recurrent major depressive disorder, bipolar disorder, cocaine abuse in remission, and hypertension. R9's MDS dated [DATE] shows R9 has moderate cognitive impairment. R9's care plan revised on April 20, 2025 shows: My comprehensive assessment reveals a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase my susceptibility to abuse/neglect. The resident demonstrates: delusions/hallucinations, difficulty in adjustment and generalized mood distress. Symptoms may be manifested by behavioral symptoms. The facility does not have documentation to show R9 has a POA or a legal healthcare surrogate decision maker. The facility does not have documentation to show R9's family member/emergency contact was notified regarding the change of R9's Medicare Advantage plan or that the insurance agent would be speaking to R9. R9's Medicare Advantage Plan Enrollment Form dated August 15, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R9's name, date of birth , gender, permanent address as the facility, and his Medicare Number. R9's signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging R9 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. 3. On September 4, 2025, at 1:58 PM, R17 was lying in bed in his room. R17 was not able to say what year it is, what day of the week it was, what time it was, where he currently lives, or how long he has lived at the facility. The EMR shows R17 was admitted to the facility on [DATE] with multiple diagnoses including, dementia, convulsions, repeated falls, alcohol abuse, schizoaffective disorder, bipolar disorder, and major depressive disorder. R17's MDS dated [DATE] shows R17 has severe cognitive impairment. R17's care plan, revised January 25, 2023 shows: Potential Abuse Neglect: My comprehensive assessment reveals factors that may increase my susceptibility to abuse/neglect related to diagnosis of dementia, mental illness (bipolar disorder, schizoaffective disorder and depression), current or history of conflict between/with co peer. Given [R17's] poor and compromised health status, cognitive issues, physical decline and need for 24-hour care, the IDT (Interdisciplinary Team) recognizes that he is considered a vulnerable adult. R17's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R17's name, date of birth , gender, permanent address as the facility, and his Medicare Number. R17's signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging R17 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. R17's Power of Attorney for Health Care dated June 30, 2022 shows the POA for R17 as V17. The facility does not have documentation to show V17 (POA for R17) was contacted regarding the change of R17's Medicare Advantage plan or that the insurance agent spoke to R17. On September 11, 2025 at 9:13 AM, V17 (Son/POA for R17) said, I am the POA for [R17]. We set that up because my dad (R17) is not able to make his own decisions. I was not aware he (R17) consented to changing his insurance on August 20, 2025. I was not present for the presentation by the insurance agent, and I did not give my consent for that change to the new Medicare Advantage plan he is now enrolled in. Yesterday, [V3] (SSD) contacted me and told me they signed my dad up for a wellness program. It was not presented to me as a whole new insurance plan during the conversation; it was presented as a wellness plan. It is upsetting to think the consent for that insurance change happened on August 20, 2025 and yesterday is the first time the facility contacted me about it. How did [R17] even sign the paperwork? He can't even sign his own name. On September 8, 2025 at 12:56 PM, V16 (Physician) said he is the primary care physician for R17 and R17 has severe cognitive impairment and would not be able to read and understand a consent form. V16 continued to say he is the Medical Director of the building and, I was just told about the [outside insurance vendor] process and Medicare Advantage enrollment changes. I have no clue what they are doing. On September 4, 2025 at 9:51 AM, V18 (Compliance Officer Outside Insurance Vendor) said, the sales process for the Medicare Advantage plan from the outside insurance vendor starts with a designated person in the facility, in this case V3 (SSD), obtaining permission to contact the residents residing in the facility or the resident's POA/Healthcare Surrogate. Once the insurance agent receives permission to contact someone, the sales agent in the building does a presentation. V18 said the insurance company is not allowed, by law, to receive any information regarding any medical diagnosis or cognitive status of the resident. If the insurance agent is given permission to contact by the facility, then the resident is considered to be a self-signer and that information cannot be validated against any medical record until the insurance plan is in place. V18 continued to say a sales agent would not know if a resident had any cognitive deficit and relies solely on the facility to ensure the residents the insurance agent is talking to are cognitively intact and able to understand and sign the paperwork. V18 said, there are financial incentives, and the outside insurance vendor does quality bonuses. We reward quality care. When [outside insurance vendor] contracts with anyone, there are metrics of quality. For example, if the [outside insurance vendor's] member (resident) has hypertension, and it is controlled in the building over time; I cannot speak of a dollar amount but is a shared savings program. The money does not come back to the residents. The money is dispersed to the ownership. On September 9, 2025 at 4:43 PM, V1 (Administrator) said, The [outside insurance vendor] asked us for a list of who is conversational, and we gave it to them. We weren't there to hear what they presented to the residents or who signed what. The facility's Abuse Prevention Program Policy revised 3/1/21 shows: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party.VII. Prevention: The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

Based on interview and record review, the facility failed to follow physician orders to obtain an appointment for a neurology consult. This applies to 1 of 3 residents (R19) reviewed for appointments in the sample of 23. The findings include:On September 9, 2025 at 10:35 AM, R19 was lying in bed in his room. R19 said he went to see his neurologist about leg weakness a few months ago and the physician said R19 should get a second opinion from another neurologist. R19 said he is still waiting to see the neurologist and facility staff said it could be as long as February 2026 before the facility staff can find R19 an appointment. R19 said, Maybe I'll just give up and not go by the time they find me someone to go to. I can't wait this long. My legs won't work by that time. The EMR (Electronic Medical Record) shows R19 was admitted to the facility on [DATE] with multiple diagnoses including, mononeuropathy of left lower limb, PVD (Peripheral Vascular Disease), hypertension, heart disease, spleen infarction, depression, anemia, spinal stenosis of the cervical region, post-laminectomy syndrome, low back pain, thoracic aortic aneurysm, anxiety disorder, adjustment disorder, and presence of prosthetic heart valve. R19's MDS (Minimum Data Set) dated July 8, 2025 shows R19 is cognitively intact, requires setup assistance with eating and lower body dressing, supervision with oral and personal hygiene, substantial/maximal assistance with showering and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R19 is frequently incontinent of urine, and always incontinent of stool. The EMR shows the following order for R19 dated June 18, 2025 at 12:13 PM and signed by V14 (Physician): Order summary: Neurologist order: 2nd opinion for spine consultation at tertiary care center. On September 4, 2025 at 12:57 PM, V8 (Scheduler) demonstrated how she makes appointments for residents and sets up transportation to and from the appointments. V8 opened the facility's appointment calendar on the computer for the period of September 4, 2025 through February 28, 2026. V8 was unable to show a scheduled appointment for R19 to see the neurologist. R19 did not have a system in place to keep track of resident appointments, and went through many papers in her office, including sticky notes, scratch paper, and binders full of notebook paper, and was unable to find the appointment scheduled for R19. V8 said, Maybe the paper is in my backpack out in my car. The facility's policy dated 5/14/23 shows: Guidelines for Resident Appointments Outside the Facility shows: Purpose: While the facility has in-house physician visits to residents per policy and State/Federal regulatory mandates, there are times when the resident may need to be seen outside of the facility by a provider that does not physically travel to the nursing home. Procedure: Procedure: Upon receiving a physician's order for a situation or event that will require the resident to need transport services, the nurse who processes the order will notify the staff member who coordinates transport orders so that appropriate transport can be scheduled. The transport will be secured according to medical necessity-such as a medical emergency or an acutely ill resident requiring an ambulance, while a routine non-emergency situation could require the transport services of a local or facility provider. The nursing staff will be aware of the appointments that require residents to be transported from the facility. There will be a calendar/log to inform them of this. Residents who will be transporting on a given day/date will have their personal care done and their medications given in accordance with the time they will be away from the facility for the appointment. Dialysis residents will have a meal sent with them as indicated. If for any reason an ordered/scheduled appointment is missed, it will be re-scheduled as appropriate, unless there has been some change, and the order is cancelled. All parties to include the ordering physician, transport provider, resident and resident's responsible party/POA (Power of Attorney) will be notified of the re-scheduling or the cancellation of an appointment.

Based on interview and record review, the facility failed to ensure a resident requesting to see an audiologist, received assistance to make an appointment to see an audiologist. This applies to 1 of 3 residents (R1) reviewed for audiology services in the sample of 23. The findings include:On September 2, 2025, at 12:36 PM, R1 was sitting in his room. R1 said he has been having a difficult time hearing and has been asking to see an audiologist for a long time. R1 continued to say he would be happy to go out in the community if he could see an audiologist sooner, but facility staff have not assisted him with making an appointment to see an audiologist. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dementia, generalized anxiety disorder, hypertension, anemia, insomnia, history of skin cancer, major depressive disorder, epilepsy, cognitive communication deficit, lack of coordination, leukemia, toxic encephalopathy, urine retention, bipolar disorder, and psychosis. R1's MDS (Minimum Data Set) dated June 19, 2025 shows R1 has moderate cognitive impairment, is independent with bed mobility, requires setup assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The facility's Concern Form dated May 16, 2025 completed by V7 (Ombudsman) shows multiple concerns including, Needs to be seen by an audiologist. Has been asking since January 2025 and hasn't seen one. On September 8, 2025, at 3:37 PM, V7 (Ombudsman) said she completed the grievance form for R1 on May 16, 2025 but did not submit R1's grievances to V1 (Administrator) until May 19, 2025 at 8:45 AM via email. V7 provided documentation to show V1 received her grievance on behalf of R1 on May 19, 2025 at 11:25 AM. V7 continued to say she spoke to V11 (RN-Registered Nurse) regarding referrals to the audiologist in mid-June 2025. On June 16, 2025 at 1:59 PM, V11 (RN) documented, Writer called [V12] (Insurance Case Manager) to fax doctor list for urologist, eye doctor, dental, audiologist doctor. He said he will fax the doctor list for urologist, eye doctor, dental, audiologist doctor. Will f/u (Follow up). Writer provided the fax number for the facility. On September 9, 2025 at 11:05 AM, V11 (RN) said, I notified the social worker back in June that [R1] needed to see an audiologist. I used the communication tool in our EMR to communicate with him. I can tell you the exact date I communicated the request to see the dentist and audiologist to [V5] (SSD-Social Services Director). It was June 16, 2025. I can tell by looking at my documentation in the medical record. V11 continued to show the process of using the communication feature in the EMR and also showed her nursing progress note dated June 16, 2025. The facility does not have documentation to show facility staff followed up on the list of providers from R1's insurance company. As of September 2, 2025, the facility did not have documentation to show R1 was assisted with making an appointment to see an audiologist or had seen an audiologist.

Based on observation, interview and record review the facility failed to assist a resident in discharge planning. This applies to 1 of 3 residents (R1) reviewed for discharge planning in the sample of 9. The findings include: On April 28, 2025 at 11:28 AM, R1 was sitting up in his wheelchair in his room. R1 stated he wants to move to a different facility to be closer to his family. R1 has talked with V11 Ombudsman and V4 Social Services (SS) about it, and nothing has been done. On April 28, 2025 at 8:51 AM, V11 Ombudsman stated, R1 wants to go to a different facility to be closer to his family. R1 has provided a list to the facility of facilities that are closer, and they still haven't done anything. R1 has asked about the progress and V4 SS told R1 that V4 has sent the referral packet but V4's not actually reaching out to the facilities. On April 28, 2025 at 10:06 AM, V4 SS stated, he did not have anyone actively discharging at the moment. V4 had sent a referral to another local skilled nursing facility (SNF) for R1 a couple of weeks ago but that was it. At 12:56 PM, V4 SS stated, he was aware that R1 wanted to go to another SNF to be closer to his family. V4 said he has sent a lot over a year to get R1 moved but no one would accept R1. At 1:28 PM, V4 SS brought the referrals he had sent for R1. V4 had one referral dated January 31, 2025 that he sent to a local SNF. There was no fax transmittal that showed it was sent and/or received. V4 stated, he never heard anything back about it. V4 stated, he has called to follow up but they never tell him anything. There is nothing documented in R1's chart from December 2024- current about any referrals being sent or followed up on. On April 28, 2025 at 2:23 PM, V12 local facility Administrator stated, they have never received a referral for R1. The facility's email thread between V4 SS and V11 Ombudsman shows: an email dated January 31, 2025 from V11 Ombudsman to V4 SS showing, Good morning! So, I looked on Medicare.gov for SNFs that accept Medicaid near the location R1 wants to go to. Attached is a PDF of that list. I looked up a few (#1, #3, #5) since those were the closet to the location R1 wants to go to. Out of those 3, from the website I could only tell #1 for sure has onsite dialysis R1 actually mentioned by location. They have onsite dialysis. Could you apply him there? .As a start, though, could you guys apply R1 to the location he wants to go to and let him, and I know if he is or is not accepted once you hear back? Thank you! V4 SS replied on January 31, 2025 showing, Hey, no problem, I'll send to that location. It sounds familiar I believe I've sent in one there before, but enough time has passed to send another. Thanks for your help and research! V11 Ombudsman sent another email to V4 SS and CC'd V1 Administrator on March 14, 2025 (over a month later) showing, Hi! .I wanted to follow-up about how things went referring R1 to SNFs that have onsite dialysis. I know R1 himself mentioned the local facility he wanted to go to. Do you know if he was applied there since February? What was said about his referral? If he was applied there and denied, can you share with me (and R1) what places he was applied to and when? She continues to add more facilities they could referred R1 too that may take him. She ends the email with, Thanks for helping R1 out with this. He just wants to be back up north closer to his family so they could potentially visit him (or visit him more frequently). There is no reply to that email. V11 Ombudsman sends another email to V4 SS and V1 Administrator on March 19, 2025 showing, Hello! I was following back up from my email on Friday about R1 and his desire to transfer to another SNF further north by the location he wants to go too. Please see the original email below If anyone could shed some light on any progress in applying R1 to other SNFs since the beginning of February, I'd greatly appreciate it! There is no reply after that. On April 28, 2025 at 8:51 AM, V11 Ombudsman stated she last talked with the facility about R1's transfer/referrals on April 11, 2025 that started with emails back in January 2025 and still had not gotten anywhere in the process. R1's Minimum Data Set, dated dated dated [DATE] shows, he is cognitively intact. R1's care plan dated March 25, 2022 shows, Focus: Discharge potential-long term, R1 been evaluated for discharge potential and, at present, placement for him is identified as long-term secondary to medical, cognitive, mental health and behavioral challenges. Interventions: Assessment of d/c (discharge) potential quarterly. Document in the plan of care accordingly. Available options will continue to be identified. Referrals will be made to appropriate resources and services, as indicated. Goals will continue to be discussed with the resident/representative, clarified . The facility's discharge planning policy, protocol and procedure dated March 2025 shows, Purpose: To identify appropriate candidates for inclusion in active discharge planning facilitating the transition to a less structured environment and to coordinate adequate supportive community care services. This nursing facility strongly emphasizes preparation and preparedness.

Based on interview and record review the facility failed to ensure residents were supervised in the dining area to prevent a resident to resident incident resulting in a fall for 2 of 4 residents (R3, R4) reviewed for supervision in the sample of 9. The findings include: The facility provided roster shows R3 and R4 reside in the memory care unit of the facility. R3's Care Plan shows she has a diagnosis of dementia and has a cognitive deficit with periods of disorientation. R3's 4/17/25 Minimum Data Set (MDS) assessment shows she has a cognitive impairment and has periods of confusion and forgetfulness. R4's Care Plan shows she has a diagnosis of dementia and has a cognitive deficit with periods of disorientation. R4's 2/6/25 MDS assessment shows she has a cognitive impairment and has periods of confusion and forgetfulness. A facility Resident to Resident Altercation reported completed by V7 (Registered Nurse/ RN) on 4/19/25, shows during the noon meal on 4/19/25, R3 was found lying on the floor of the dining room. The report shows when V7 spoke with R3, R3 indicated that another resident (R4) had been trying to move R3 out of her way and it caused R3 to fall to the floor. R3 said that she had been trying to move in by R4 to get a spot at the table. A facility reportable incident completed by V1 (Administrator) on 4/19/25 shows R3 and R4 were in the common area of the facilities dementia unit when R3 was found on the floor and claimed R4 and made contact with her to move her. The report also shows that there were no staff witnesses to the incident. On 4/28/25 at 10:05 AM, R7 said she was sitting at the table when R3 and R4 had the incident. R7 said R3 was trying to move in by R4 because she wanted the same chair. R3 was sort of nudging R4 and R4 raised her arm up and this caused R3 to lose her balance and fall to the floor. R7 could not recall where staff were at the time of this incident. On 4/28/25 at 11:24 AM, V7 said on the day of the incident between R3 and R4 she was the only staff watching the dining room. V7 said the other activity staff had gone on lunch break and the CNA's (Certified Nursing Assistants) were passing meal trays. V7 said she was called away from the dining room to answer a telephone call and no one replaced her to monitor the dining room. V7 said she had been paged twice about the call, so she decided she had to go answer it. V7 said while on the phone she heard what sounded like a resident falling so she went to the dining room and found R3 lying on her side on the floor. V7 said when she asked what happened R3 reported that R4 had caused her to fall. V7 said R7 explained to her how R3 ended up on the floor, that it was due to R3 nudging and trying to move R4 out of her way for her to get a certain chair at the table. V7 said there should always be 2 staff present to monitor the dining room but that day there was not due to a staff on break and her leaving to answer a phone call. On 4/8/25 at 2:01 PM, V2 (Director of Nursing) said generally there is 3-4 CNA's, 1 nurse and 1-2 activity staff to monitor the resident dining area but that day the CNA's were passing trays and V7 had left to take a phone call. V2 said R3 was sent to the hospital emergency room due to complaints of hip pain and per facility protocol since no staff witnessed the incident. V2 said R3 did develop some bruising to her buttocks. R3's nursing progress notes show on 4/27/25 there is a purplish discoloration to her left buttock relative to the fall. The facility provided Standard Supervision and Monitoring policy dated 5/17/23 shows the facility will provide adequate supervision and guidance to meet the needs of the residents including meal times.

Based on interview and record review, the facility failed to protect residents from facility abuse. This applies to 2 of 7 residents (R5 and R7) reviewed for abuse in a sample of 11. The findings include: 1. Review of R7's care plan showed R7's diagnoses include anxiety disorder, dementia, depression, psychosis, cognitive communication disorder, bipolar disorder, toxic encephalopathy, and insomnia. Care plan, initiated [DATE] and revised [DATE], shows R7 hoards items related to his diagnoses of dementia including entering other resident rooms in search of items to hoard, rummaging through drawers/closets, and becoming angry and defensive when asked to remove items. The care plan also shows R7 had a history of abuse/neglect/exploitation/past trauma that may increase his susceptibility to abuse and neglect. MDS (Minimum Data Set), dated [DATE], shows R7's cognition was moderately impaired. Review of R6's care plan show R6's diagnoses include depression, anxiety, alcohol use, cannabis use, suicidal ideation, and injury of the head. Care plan, dated [DATE], shows R6 had a history of manipulative behavior and intimidating behaviors. Care plan, dated [DATE], shows R6 has a history of placing blame on others and projects anger onto others including excessively arguing and challenging views of authority figures, refusing to comply with requests without reason, expressing resentment toward care providers and seeking revenge towards those he feels wronged him. The care plan shows R6 distorts information to his favor, exhibits a sense of entitlement and beliefs he should receive special privileges, presents with self-defeating behaviors, does not learn from past mistakes and repetitive negative consequences, does not acknowledge personal responsibility, and identifies as a victim. Care plan, dated [DATE], shows R6 exhibits threatening physical violence, verbal abuse, and destroys property. Care plan, dated [DATE], shows R6 had a history of possessing prohibited/unauthorized items in his room including alcohol and illicit drugs. MDS, dated [DATE], shows R6's cognition was intact. On [DATE] at 12:44 PM, R7 stated on the day of the incident he was sleeping in his bed when R6 came into R7's room yelling. R7 stated R6 was good friends with R7's roommate and R6 yelled, I don't want you to mess with my buddy! R7 stated he told R6 he had not messed with the roommate and R6 replied, I want to kill you! R7 stated R6 made a fist and walked toward R7 and attempted to punch R7 in the face when R7 blocked the blow. R7 stated R6 would not leave and R6 was trying to protect himself and push R6 out of the room when R6 pushed R7 to the ground. R7 stated he hit the back of his head on the bathroom door and showed a lump on the back right of his head, a reddened knuckle of his left thumb, and a broken fingernail. R7 stated he started yelling for help and R6 walked out of the room yelling for staff and saying that R7 was attacking R6. On [DATE] at 12:27 PM, R6 was very agitated, speaking in a loud voice, and showed threatening body posture when speaking to staff and the state surveyor. R6 stated he witnessed R7 going through other residents' belongings several times over the last several months. R6 stated he was walking in the hall and walked inside the door of R7's room. R6 stated he told R7 not to mess with other people's stuff. R6 stated he did not inform staff of his concerns regarding R7 because he felt staff would not believe him. R6 stated he utilized a jiu-jitsu move to make R7 fall to the ground. R6 stated R7 then began hitting R6 but R6 denied any injuries. R6 stated R7 previously walked into R6's room but not at that time. R6 stated, He's lucky I didn't break his neck when he walked into my room. Progress note, dated [DATE], shows after R7 returned from the hospital he complained of discomfort of his left hand and a red/bluish area was noted on his left hand near his thumb. On [DATE] at 12:07 PM, V7 (Police Officer) stated two days prior R6 and R7 were involved in an altercation in which R7 told R6 to leave his room and R6 tripped R7 and pushed him to the floor where R7 hit his head. V7 stated R7 had a bump on his head, a swollen left finger, and a cut on his hand. V7 stated the facility revived the cameras which showed R7 had not left his room for at least 45 minutes prior to the incident. V7 stated she cited R6 with a ticket referencing a local ordinance. Initial police report, dated [DATE], shows V7 (Police Officer) was informed R7 had dementia but found him coherent and able to relate details about the incident accurately. The report shows at about 8:30 AM on [DATE], R6 began yelling at R7 and R7 did not know why. R7 told V7 he was smaller than R6 and tried to tell R6 to leave the room but R6 continued to approach R7 and continued to yell at R7. The report shows R6 then grabbed R7 and threw him to the ground and into the bathroom door. R7 stated R6 then began to exit the room and threatened R7 stating he would punch him and would kill him. The report shows there was a witness who heard R6 threaten to punch R7 out and kill R7. The report shows R7 had a small cut on his left thumb and the top of his head was sore. The report shows R6 was interviewed and claimed R7 was chronically entering other residents' rooms and going through their belongings without permission. The report shows R6 alleged that morning R7 entered R6's room and began looking through R6's roommate's belongings and R6 decided to take a stand and confront R7. The report shows R6 entered R7's room and R7 charged at R6 telling him to leave the room. The report shows R7 attempted to push R6 away and R6 then threw R7 to the ground. Police report, dated [DATE], shows V7 returned to the facility because R7 wished to press charges for battery. The report shows the facility reviewed video surveillance showing R6's claim that he followed R7 from R6's room and confronted him was false and showed R7 was in his room no less than 45 minutes prior to the altercation. The report shows V8 (Social Services) and R7 both felt R6's aggression was unprovoked. The report showed R7 had a lump and some discoloration on the top of his head as well as a small laceration on his left thumb. The report showed R7's thumb nail was broken and there was bruising where the laceration had been. The report shows V7 interviewed R6 who also made a threat to a nurse that morning which included shooting someone, which R6 denied. The report shows R6 was issued a local ordinance citation for assault/fights for the incident which occurred [DATE] between R6 and R7. Final facility Incident report, dated [DATE], shows R6 and R7 were separated at the time of the altercation and the police were called. The report shows R7 complained of pain, but no injuries were identified and both residents were sent to the hospital. The report shows R7 confronted R6 in his room about rummaging through R7's personal items and the police were called and left without further action. The report shows R6's room was moved to the other side of the facility and R7 was placed on continuous monitoring. Progress note, dated [DATE], shows, Staff observed a verbal altercation between this resident and a co-peer. Staff separated the resident and co-peer. Resident placed on 1:1 [supervision] pending a transfer to the ER (emergency room ) for evaluations. Behavior progress note, dated [DATE], shows R6 was demonstrating physical and verbal conflicts with peers, made idle threats and expressing intentions of violence when faced with challenges or inconveniences, and R6 required immediate hospitalization . Facility Abuse Prevention Program policy and procedure, revised ,d+[DATE], shows, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. Facility Abuse and Crime Reporting Policy and Procedure, revised ,d+[DATE], shows, 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm 4. Physical Abuse: Hitting, slapping, pinching, kicking, etc 2. Review of R4's care plan shows R4's diagnoses include bipolar disorder, depression, anxiety, schizophrenia, and cerebral infarction. Care plan, dated [DATE], shows R4 had a history of misinterpreting interactions/situations and responding with verbal and physical aggression toward others. MDS, dated [DATE], shows R4's cognition was severely impaired. Review of R5's care plan shows R5's diagnoses included depression, heart failure, epilepsy, and chronic kidney disease. The care plan, dated [DATE], shows R5 had poor frustration tolerance and maladaptive coping as manifested by aggression when agitated and/or conflicts/altercations with others. R5's behaviors included verbal aggression when challenged or redirected. MDS, dated [DATE], shows R5's cognition was moderately compromised. On [DATE] at 1:51 PM, R5 stated R4 approached him as they were both attempting to take pizza from a pizza box in the dining room. R5 stated R4 became upset with R5, pulled R4's arms back in attempt to keep him from the pizza, swung at R4 several times causing a scratch on his right cheek, and then pulled R5's sweatshirt hood back trying to pull him away from the pizza. MDS, dated [DATE], shows R2's cognition was intact. On [DATE] at 1:37 PM, R2 stated she was sitting in the dining room when she heard a commotion and saw R4 slap R5 in the face. R2 stated R4 then pulled backward on R5's sweatshirt hood trying to keep him away from a box of pizza on a table. R2 stated the altercation between R4 and R5 was traumatic and scary to watch. On [DATE] at 12:35 PM, V9 (Psychologist) stated she was in the dining room with a client when she saw a resident in a wheelchair move toward a box of pizza and R4 began to approach the resident. V9 stated she tried to redirect R4 away from the resident but R4 grabbed the resident by the shirt neck. V9 stated the residents were slapping at each other but V9 was unclear how much physical contact occurred. V9 stated she saw R4 grab the resident but the collar and pull him backwards in his wheelchair. V9 stated she was the only non-resident in the room when the altercation began and when left the room to retrieve staff to help. V9 stated when she returned to the room R4 again moved aggressively toward the resident in the wheelchair bur V9 stood between the two residents to de-escalate the conflict. V9 stated another resident witnessed the altercation and was screaming. Psychologists note, dated [DATE], shows V9 (Psychologist) witnessed R4 exhibiting physical and verbal aggression towards another resident, alerted staff, and attempted to assist in de-escalation and redirection. On [DATE] at 12:07 PM, V10 (Licensed Practical Nurse) stated she heard R2 screaming in the dining room and when she arrived at the dining room R5 was sitting in motorized wheelchair and R4 was pulling R5 backwards from a box of pizza. V10 stated the side of R5's cheek had a small laceration and there was blood on his cheek. Progress note, dated [DATE], shows R4 was witnessed pulling/tugging and attempting to strike at a resident. The note shows R4 expressed the other resident was taking someone's pizza and R4 felt it was not right. The note shows R4 held R5's hand which initiated an altercation and R4 then attempted to pull R5 away from the table using R5's sweatshirt. Progress notes, dated [DATE], shows R5 stated R4 came toward him when he wanted to see what was in the box. R5 reported R4 began striking R5 out of nowhere. R4 was noted to have a small abrasion (0.5 centimeters) near his right bilateral nose with oozing. The note shows the area was cleaned and treated. Final Incident Report, dated [DATE], shows R5 approached a pizza box in the dining room and R4 thought R5 was stealing pizza and R4 attempted to pull R5 away from the table by pulling R4's sweatshirt. The report shows R4 scratched R5, and staff witnessed the incident and separated the residents. The report shows small scratch was noted on R5's cheek and right wrist, the police were notified, investigated and a report filed. The report shows R4 was sent to the hospital and did not return to the facility.

Based on interviews and record reviews, the facility failed to provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11. The findings include: 1. Face sheet, dated 1/10/25, shows R2's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, congestive heart failure, osteoarthritis, and muscle wasting. MDS (Minimum Data Set), dated 1/1/25, shows R2's cognition was intact and R2 was dependent on staff for bathing. Care plan, dated 5/27/22, shows R2 required extensive assistance and one person support from staff for bathing. On 1/9/25 at 11:58 AM, R2 stated, It's not fair! I deserve my shower! It's all I have. I don't get my shower if there isn't enough staff. I didn't have a shower last week. I don't know the last time I had a shower. I am a very clean person. Shower sheets, dated 11/1/24 to 1/10/25, showed R2 was only offered 9 showers (11/8/24, 11/12/24 refused, 11/19/24, 11/22/24 refused, 11/26/24, 12/10/24 refused, 12/17/24 refused, 12/27/24, and 1/7/25 requested bath next day) during the 10 weeks reviewed. On 1/13/25 at 12:32 PM, V2 (Director of Nursing) stated the facility schedules two showers a week for each resident and staff are expected to offer residents showers twice weekly. Facility first floor shower schedule, provided 1/13/25, shows each resident was scheduled to receive two showers each week. 2. Face sheet, dated 1/10/25, shows R3's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, muscle wasting, paraplegia, seborrheic dermatitis, depression, and dependence on wheelchair. MDS, dated [DATE], shows R3's cognition was intact and R3 was dependent on staff for bathing. On 1/9/25 at 12:03 PM, R3 stated the facility did not have enough CNAs (Certified Nursing Assistants) to provide her scheduled showers. R3 stated she was supposed to receive two showers a week on Mondays and Thursdays but there were not enough staff to provide her showers twice weekly. Shower sheets, dated 11/1/24 to 1/10/25, showed R3 was offered only 9 showers (11/7/24, 11/14/24, 11/18/24, 11/21/24, 11/25/24, 11/28/24, 12/9/24, 12/30/24 refused and 1/3/25) during the 10 weeks reviewed. 3. Review of R8's care plan showed R8's diagnoses included heart failure, muscle wasting and atrophy, osteoarthritis, and lymphatic disorder. MDS, dated [DATE], shows R8's cognition was intact and R8 required substantial/maximum assistance from staff for transfers from chair to bed. Care plan, dated 11/14/24, shows R8 required extensive assistance from staff for bathing and dressing. Resident Council Meeting minutes, dated 11/13/24, shows residents stated, We feel ignored when we are asking them to do something. The residents also expressed concern that call lights were not answered in a timely manner especially on the second shift. On 1/9/25 at 11:57 AM, R8 stated two weeks prior she waited four hours for staff to transfer her to bed because there were not enough staff to help residents. R8 stated a CNA (Certified Nursing Assistant) came in and told R8 she needed to give a shower to another resident and would return to put R8 back in bed but the CNA left at the end of her shift and did not return to R8. R8 stated when the new CNA came in R8 asked if she could be transferred to her bed but the CNA never came back to transfer her because that CNA was having a problem with another resident. R8 stated after four hours she called the nurse on the phone and asked the nurse to transfer her to bed. R8 stated I was stuck there! R8 stated she gets very dizzy when she sits up to long and stated she was very dizzy when she became stuck in her chair and had to wait to be transferred to bed. Shower sheets dated 11/1/24 - 1/20/25, show R8 was offered only 7 showers (11/3/24, 12/7/24, 12/11/24, 12/25/24 refused, 12/28/24, 1/1/25 refused, 1/4/25) during the 10 weeks reviewed.

Based on interviews and record reviews, the facility failed to provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11. The findings include: 1. Face sheet, dated 1/10/25, shows R2's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, congestive heart failure, osteoarthritis, and muscle wasting. MDS (Minimum Data Set), dated 1/1/25, shows R2's cognition was intact and R2 was dependent on staff for bathing. On 1/9/25 at 11:58 AM, R2 stated, It's not fair! I deserve my shower! It's all I have. I don't get my shower if there isn't enough staff. I didn't have a shower last week. I don't know the last time I had a shower. I am a very clean person. Shower sheets, dated 11/1/24 to 1/10/25, showed R2 was only offered 9 showers (11/8/24, 11/12/24 refused, 11/19/24, 11/22/24 refused, 11/26/24, 12/10/24 refused, 12/17/24 refused, 12/27/24, and 1/7/25 requested bath next day) during the 10 weeks reviewed. On 1/13/25 at 12:32 PM, V2 (Director of Nursing) stated the facility schedules two showers a week for each resident and staff are expected to offer residents showers twice weekly. Facility first floor shower schedule, provided 1/13/25, shows each resident was scheduled to receive two showers each week. 2. Face sheet, dated 1/10/25, shows R3's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, muscle wasting, paraplegia, seborrheic dermatitis, depression, and dependence on wheelchair. MDS, dated [DATE], shows R3's cognition was intact and R3 was dependent on staff for bathing. On 1/9/25 at 12:03 PM, R3 stated the facility did not have enough CNAs (Certified Nursing Assistants) to provide her scheduled showers. R3 stated she was supposed to receive two showers a week on Mondays and Thursdays but there were not enough staff to provide her showers twice weekly. Shower sheets, dated 11/1/24 to 1/10/25, showed R3 was offered only 9 showers (11/7/24, 11/14/24, 11/18/24, 11/21/24, 11/25/24, 11/28/24, 12/9/24, 12/30/24 refused and 1/3/25) during the 10 weeks reviewed. 3. Review of R8's care plan showed R8's diagnoses included heart failure, muscle wasting and atrophy, osteoarthritis, and lymphatic disorder. MDS, dated [DATE], shows R8's cognition was intact and R8 required substantial/maximum assistance from staff for transfers from chair to bed. Care plan, dated 11/14/24, shows R8 required extensive assistance from staff for bathing and dressing. Resident Council Meeting minutes, dated 11/13/24, shows residents stated, We feel ignored when we are asking them to do something. The residents also expressed concern that call lights were not answered in a timely manner especially on the second shift. On 1/9/25 at 11:57 AM, R8 stated two weeks prior she waited four hours for staff to transfer her to bed because there were not enough staff to help residents. R8 stated a CNA (Certified Nursing Assistant) came in and told R8 she needed to give a shower to another resident and would return to put R8 back in bed, but the CNA left at the end of her shift and did not return to R8. R8 stated when the new CNA came in R8 asked if she could be transferred to her bed, but the CNA never came back to transfer her because that CNA was having a problem with another resident. R8 stated after four hours she called the nurse on the phone and asked the nurse to transfer her to bed. R8 stated I was stuck there! R8 stated she gets very dizzy when she sits up to long and stated she was very dizzy when she became stuck in her chair and had to wait to be transferred to bed. Shower sheets dated 11/1/24 - 1/20/25, show R8 was offered only 7 showers (11/3/24, 12/7/24, 12/11/24, 12/25/24 refused, 12/28/24, 1/1/25 refused, 1/4/25) during the 10 weeks reviewed. On 1/9/25 at 11:34 AM, V3 (CNA - Certified Nursing Assistant) and V4 (CNA) both stated they were often working short of staff on the first floor with only four CNAs (Certified Nursing Assistants) assisting approximately 88 residents. V3 stated she had eight residents requiring two staff for transfers and five residents who required feeding assistance. On 1/9/25, V5 (CNA) stated the facility was sometimes short of staff and had only four CNAs for the first floor and the staff are not able to give showers or turn and reposition residents in a timely manner. On 1/9/25, V6 (Licensed Practical Nurse) stated the first floor sometimes only had four CNAs for approximately 85 residents and they were sometimes not able to give residents showers. On 1/9/25 at 3:00 PM, V1 (Administrator) stated the average census for the first floor December 1, 2024 to January 9, 2025 was approximately 86 residents. Review of facility schedules, dated 12/13/24 to 1/8/24, show 14 (28%) of the 50 AM/PM first floor shifts reviewed had only 4 CNAs working on the first floor (1 CNA caring for 21 residents). On 1/13/25 at 10:00 AM, V2 (Director of Nursing) stated the facility was not allowed to use agency staff and the facility was experiencing resident/staff illnesses mid-December which resulted in many call-offs at the facility. V2 stated the facility goal was to staff the first floor with 6 CNAs (1 CNA caring for 14 residents) but 5 CNAs was the minimum the first floor should have working for an average census of 86 residents.

Based on observation, interview, and record review the facility failed to ensure food service pans, trays, and utensils were handled in a way to prevent cross-contamination. This applies to all 183 residents receiving food from the kitchen. The findings include: The Centers for Medicare and Medicaid form 671 dated 10/28/24 shows there are 188 residents residing in the facility. Facility provided list of residents who receive nutrition strictly via tube feedings dated 10/29/24 shows there are 5 residents that do not receive food from the kitchen. On 10/28/24 at 9:33 AM, V5 (Dietary Aide) said V10 (Food Service Director) was on vacation this week and would not be on site. On 10/28/24 at 9:35 AM, V4 (Dietary Aide) was wearing teal rubber gloves that extended up to his elbows. V4 was draining the water from the three-compartment sink. V4 was clearing food debris from the first sink which was a yellowish color from being soiled. As V4 removed food debris from the sink, V4 would transfer the food debris to the garbage can located next to the three-compartment sink. V4 continued to drain the water from each sink in the three-compartment sink, cleaned the sink, then refilled the sinks with the corresponding detergent and chemical sanitizer solution. At 9:43 AM, V4 was still wearing the same gloves used to clean and drain food debris from the three-compartment sink and placed two full size four-inch steam table pans onto a black roll cart that was in the dish pit area. At 9:45 AM, V4 ran the two full size four-inch steam table pans through the dish machine on dish racks, while still wearing the same gloves. At 9:46 AM, when the dishes came out the sanitized side of the dish machine, V4 removed the pans from the dish racks while still wet, stacked one inside of the other, and placed them onto the drying rack atop clean, sanitized, and dry pans. At 9:47 AM, V4 was still wearing the same gloves and took the clean and sanitized trays that were on the drying rack, stacked them on a different black rolling cart, and wheeled the cart in front of the rack between the two steam tables. V4 removed the gloves and returned to the dish pit to break down meal trays from the morning meal. On 10/28/24 at 9:54 AM, V6 (Dietary Aide) started to place dirty dishes received from V4 into dish racks and running them through the dish machine. At this time, V6 was handling plate lids and running them through the dish machine. After running two racks through the machine, at 9:56 AM, V6 left the dish pit area and grabbed the drying rack for the plate lids and returned to the dish pit area. V6 did not wash her hands before leaving or after returning to the dish pit area. When V6 returned with the drying rack, V6 placed the clean, sanitized plate lids into the drying rack. At 9:58 AM, V6 returned to the dirty side of the dish machine and continued to go between clean and dirty dishes without washing her hands. On 10/28/24 at 11:24 AM, V8 (Dietitian) said the standard of practice to wash hands includes before serving, before touching food, if they throw something in the garbage, or if they drop something on the floor, staff should wash their hands immediately after. V8 also said hands should be washed between handling dirty dishes and clean dishes. If a staff member's glove becomes soiled, the glove should be removed before handling clean dishes. V8 also said that pots, pans, plates, or trays should not be stacked unless dry to prevent bacteria growth and contamination. Facility Handwashing policy dated 4/2017 states, The facility will practice safe food handling and avoid cross contamination through proper and adequate handwashing techniques. Facility Machine Dishwashing policy dated 4/2017 states, . Once clean, pots and pans will be dried on a rack and will not be stacked until they are completely dry.

Based on interview and record review, the facility failed to ensure a resident was free from abuse/involuntary seclusion in his room. This failure resulted in R2 being involuntarily secluded in his room when an unidentified person tied a plastic bag from R2's door handle to the hallway hand rail, preventing R2 from being able to exit his room. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on July 3, 2022, when the facility failed to ensure a resident was free from abuse/involuntary seclusion when an unidentified person tied a plastic bag from R2's door handle to the hallway hand rail, preventing R2 from being able to exit his room. The Immediate Jeopardy was identified on July 14, 2022. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on July 14, 2022, at 12:53 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on July 15, 2022, at 4:40 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff. This applies to 1 of 3 residents (R2) reviewed for involuntary seclusion in the sample of 6. The findings include: On July 12, 2022, at 8:55 AM, R2 was ambulating in his room. Due to R2's cognitive status he was not able to be interviewed. R2 was walking back and forth from his bed to his doorway, opening and closing his room door with ease without staff assistance or the assistance of a mobility device. On July 14, 2022, at 2:17 PM, R2 was ambulating from his room to the hallway without staff assistance or the assistance of a mobility device. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE],0 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR continued to show R2 has resided on a secured unit since June 13, 2022. During a general tour of the facility on July 12, 2022, at 8:53 AM, the second floor of the facility was noted to have four separate units. Two of the units were unsecured units. Two additional units were secured units. To enter the first secured dementia unit where R2 resides, no code is required for entry, but to exit the secured unit, a security code is required. The second secured unit required a security code to enter and exit the unit. R2's MDS (Minimum Data Set) dated May 25, 2022, showed R2 had severe cognitive impairment. The MDS continued to show R2 did not require the assistance of a mobility device. R2's care plans entitled Potential Abuse-Neglect, initiated on May 25, 2022, showed [R2]'s comprehensive assessment . is at risk due to being a vulnerable person. [R2] demonstrates: depression, impaired cognition/communication, inadequate coping skills and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan showed multiple interventions initiated on May 25, 2022, including, observe [R2] for signs of fear & insecurity during delivery of care. Take steps to calm the resident & help him feel safe. R2's care plan, entitle, Physical and Psychosocial Needs, initiated on May 25, 2022, showed I display compromised mental status and I demonstrate movement behavior (wandering, pacing or roaming). I have trouble understanding the immediate environment. Symptoms include: pacing, roaming, or wandering in and out of rooms; demonstrating signs and symptoms of mood distress, for example, poor appetite, [CONDITION(S)] (often up at night, wandering and pacing, anxious). R2's care plan showed multiple interventions initiated on May 25, 2022, including, If I leave the building or go into a peer's room or become aggressive, redirect me by: use distraction or 'therapeutic fib' techniques with me . Avoid saying 'no' or 'you don't belong here' or using negatives in general. Tell me what can be done. The facility's undated initial report to the State Agency transmitted on July 4, 2022, at 4:10 AM UTC (Universal Time Coordinated), showed it was reported R2 received inappropriate care. The report continued to show immediate action taken: investigation initiated, family and physician notified, physical assessment done with no concerns noted, social service aware and performing well being checks, resident's needs were met via plan of care, care plans updated, and final report within five days. The facility's undated final report to the State Agency transmitted on July 12, 2022, at 12:09 AM UTC, showed a conclusion that it was reported R2's door was obstructed. Staff immediately removed obstruction and opened door to find R2 comfortably in the room. R2 is unable to say what happened. No person could be determined as responsible. All staff and residents on the unit interviewed, with none noting seeing the obstruction or it happening. R2 is safe and comfortable in the facility. Staff commended for immediately addressing and reporting. Assessment on R2 noted without concern or awareness of brief situation. Potential obstruction removed from unit. Family and physician aware of findings. Well-being checks in place. This will serve as the final report. On July 12, 2022, at 7:56 PM, V11 (CNA/Certified Nursing Assistant) said, On July 3, 2022, I started my rounds around 3:05 PM and saw [R2]'s door was tied shut with a plastic bag. I went and got [V13] (RN/Registered Nurse) right away and we cut the bag off [R2]'s door. Once the bag was cut, we still could not get the door open because [R2] was hanging on the door and pulling on the door knob. It took about ten minutes to get the door open after it was discovered. On July 13, 2022, at 11:55 AM, V9 (LPN/Licensed Practical Nurse) said, I was the nurse caring for [R2] on July 3, 2022 and had last seen [R2] at about 1:00 PM on July 3, 2022. On July 13, 2022, at 1:02 PM, V13 (RN) said, On July 3, 2022, we were short staffed that day with nurses and CNAs. Around 1:30 PM, on July 3, 2022, [R2] came out of the secured unit which is where he resides. [R6] started yelling at [R2]. I sent [R2] back to the secured unit, but he came back out again. [R6] looked like he was going to hit [R2]. I was able to get [R2] back to the secured unit. [R6] went downstairs to report this to [V14] (Housekeeping Director/Manager on Duty). [V14] and [V31] (Housekeeper) came upstairs and helped to supervise [R2] to keep him in the secured unit. [V14] and [V31] left the unit and went back downstairs around 2:00 PM. Before [V14] left, I asked him to stay because we needed the extra help to keep [R2] safe. The last time I saw [R2] was before 2:00 PM, and I did not see his room door because I did not know which room was his. The next shift started arriving around 3:00 PM on July 3, 2022. At 3:15 PM on July 3, 2022, I told [V11] (CNA) to go to the secured unit, and I went to another resident's room for about five minutes. When I came out of the other resident's room, [V11] was waiting for me at the nurse's station and asked if [R2]'s room was supposed to be tied shut. We rushed to [R2]'s room and I saw a plastic bag tied from the door handle of [R2]'s room to the handrail in the hallway. Because the bag was tied from the door handle to the handrail, the door could not be opened. I called through [R2]'s closed door, and he started pulling on the door handle, trying to open the door from inside his room. [V11] went and got scissors and cut the bag, but we still could not open the door. I called [V14] to let him know we could not get the door open, so I was not there when [V11] opened the door. On July 3, 2022, at 2:36 PM, V13 documented, R6 was very verbally aggressive, chasing another resident to the secured unit hall doors, toward the dining room trying to hit the resident with his leg. V13 continued to document R6 went to the first floor nurse manager on duty. R6's MDS, dated [DATE], showed R6 was cognitively intact. The MDS continued to show R6 was admitted to the facility on [DATE]. On July 13, 2022, at 9:39 AM, R6 said, [R2] used to wander the hall with his hands in his pants and touch other people's food trays. [R2] was moved to the [secured unit]. [R2] came out of the [secured unit] on July 3, 2022. The staff were not supervising him. I cannot stand [R2]. On July 13, 2022, at 2:01 PM, V14 said, I sat at the nurse's station for about ten to fifteen minutes on [DATE], but I could not stay because I was too busy. That was at about 1:45 PM. On July 15, 2022, at 12:38 PM, V29 (Psychiatrist) said, I just heard about [R2]'s incident on July 3, 2022, yesterday (July 14, 2022). I would expect them to inform me about this incident. When [R2] was involuntarily secluded, he would be more anxious, and panicky, and agitated. Staff could have protected [R2] by making sure he could not exit the secured unit he resides on. [R2] should not have been contained to his room by having a bag tied to his door, which is intentional seclusion. On July 14, 2022 at 1:58 PM, V4 (Agency CNA) said, If I was locked in a room I would be very upset. On July 14, 2022, at 2:01 PM, V9 (LPN), said, I would feel very bad if I got locked in a room. On July 14, 2022, at 2:03 PM, V23 (Agency CNA) said, I would be upset if I was locked in a room and could not get out. On July 14, 2022, at 2:06 PM, V24 (Housekeeper) said, I would be scared if I was locked in a room I could not get out of. On July 14, 2022, at 2:12 PM, V26 (Activity Aide) said, If I was locked in a room, I would feel bad. On July 14, 2022, at 2:18 PM, V25 (Agency LPN) said, I would feel terrible and upset if I was locked in a room. On July 14, 2022, at 2:58 PM, V27 (Agency CNA) said, I would be scared if I was locked in a room I could not get out of. On July 14, 2022, at 3:03 PM, V28 (CNA) said, If I was locked in a room, I would do everything I could to escape that room. The facility's undated policy entitled, Abuse Prevention Program, showed Policy: It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect or a resident by a third party. Abuse Reporting: Policy- this facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals . For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain . 5. Involuntary Seclusion: Separation of the resident from other residents or from his or her room or confinement to his or room (with or without roommates) against the resident's will, or the will of the resident's legal guardian or representative. The facility's undated policy entitled, Physical Restraints/Seclusion, showed Policy: It is the policy of the facility to use physical restraint only as a last resort and only after every other alternative to a physical restraint (based on assessment) that seemed to have the potential for being used successfully, has been tried, and has failed. The use of a physical restraint and/or device is to enable and promote functioning at the highest practicable physical, mental or psychosocial well-being. It will be used only after the resident has been assessed and it has been determined by the IDT (Interdisciplinary Team) that the restraint to be used is the least restrictive. Note: The facility does not practice 'seclusion' of residents for any reason with the only exception being used for monitoring a resident for a limited period of time to reduce agitation until professional staff can formulate a successful plan of care. Through observation, interview, and record review conducted on July 18, 2022, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: The housekeeping carts will be monitored in all halls at least daily seven days weekly by the Administrator/DON/Nurse Manager to ensure that no trash bags are accessible to a passerby. This monitoring will be done for four weeks. Afterwards, this monitoring will continue three days weekly for a period of not less than six months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be immediately addressed if found. All halls will be toured at least daily seven days weekly by the Administrator/DON/Nurse Manager to ensure that no doors of resident rooms are barricaded. And that no circumstances of involuntary seclusion exist. This monitoring will be done for four weeks. See attached audit tool. It will include various shifts as well as some weekend days. Afterwards, this monitoring will continue three days weekly for a period of not less than six months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be addressed if found. A member of the Regional Team, (RDO/Regional Director of Operations and RNC/Regional Nurse Consultant), will monitor housekeeping carts and tour the halls at least weekly for four weeks for additional oversight. The Regional Team, (RNC/RDO), member will review the monitoring being done by facility staff on the housekeeping carts and hall tours at this time. Any concerns will be addressed if found. At an in-service held July 14, 2022, for the Administrator and conducted by the RDO, the Abuse Policy was reviewed and discussed in detail, to include the Administrator's role in handling any allegation of abuse. At an in-service held July 14, 2022, for the DON and conducted by the RNC, the Abuse Policy was reviewed and discussed in detail, to include the DON's role in handling any allegation of abuse. At an in-service held for all staff on July 14, 2022, and conducted by, Administrator/DON/Nurse Manager, with Regional Team input, (RNC/RDO), the following was reviewed and discussed: Abuse Policy---with emphasis on different types to include seclusion to include: (any of the following scenarios, against the resident's will or the will of the resident's representative) a) Separation of a resident from other residents b) Separation of a resident from their room c) Confinement to his/her (resident's) room with or without roommate What should you do if you find a resident who is secluded a) Immediately stop the seclusion and intervene to provide resident safety b) Immediately assess resident head to toe for any injury or harm to include emotional upset c) Notify the Abuse Coordinator for further guidance and instruction, Abuse Policy will be implemented Use of trash bags within the facility to include: a) What type of bags are to be used and where they are to be used b) Where these bags are stored, and how to obtain a bag should you as a staff member need one c) Inappropriate use of bags: tied to a door, anywhere in a resident bed, near a heating element etc. d) Questions/Answers Any staff who fail to comply with the points of the in-service will be further educated and/or progressively disciplined as indicated. New agency staff who come to the facility after hours or weekends will be provided an educational packet regarding abuse, specifically related to involuntary seclusion and the prompt reporting of injuries of unknown origin. The education will be provided via phone through Administrator, designee, or charge nurse in the building. No staff will work after July 15, 2022, unless they have been in-serviced. This includes agency staff, PRN (as needed) staff, any staff on any type of vacation or leave, newly hired staff or any other staff. This education will be conducted by Administrator/DON/Nurse Managers/MDS Coordinator. All monitoring done by facility staff as well as by Regional Team staff (RNC/RDO), will be presented to the QAPI (Quality Assurance and Performance Improvement) Committee at their weekly meetings. Any concerns will have been addressed. However, any patterns will be identified. If indicated, an Action Plan will be written by the QAPI Committee. Any written Action Plan will be monitored by the Administrator weekly until resolution. A member of the Regional Team will attend the QAPI meetings either in person or remotely for a period of not less than 3 months to serve as additional oversight, reference, and support. Note: When the facility is placed back into substantial compliance, QAPI meetings will go to monthly. An Ad-Hoc QAPI meeting was held for the IDT (Interdisciplinary Team) on July 15, 2022, and conducted by the Administrator, with input from the Regional Team, (RDO/RNC) to discuss the points of this AOC (Allegation of Compliance).

Based on interviews and record reviews the facility in response to allegations of abuse and mistreatment failed to have evidence that all alleged abuse allegations are investigated, prevent further potential abuse during the investigation, and take corrective action because of the investigation. This failure resulted in the facility failing to validate abuse and act when R2 was noted secluded in his room by having a plastic bag tied from the door handle to hallway handrail. The facility failed to take action to prevent further incidents regarding seclusion during the investigation. The facility also failed to notify the abuse coordinator of an injury of unknown origin, investigate the injury and report the injury to the State Agency for R1 who was noted with bruising to the neck on July 5, 2022. R1's injury was not reported or investigated until July 12, 2022, during the survey. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on July 3, 2022, when the facility failed to ensure a resident was free from abuse/involuntary seclusion when an unidentified person tied a plastic bag from R2's door handle to the hallway hand rail, preventing R2 from being able to exit his room. The Immediate Jeopardy was identified on July 14, 2022. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on July 14, 2022, at 12:53 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on July 15, 2022, at 4:40 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff. This applies to 2 of 5 residents (R1 and R2) reviewed for abuse (involuntary seclusion and injury of unknown origin) in the sample of 6. The findings include: 1. On July 12, 2022, at 8:55 AM, R2 was ambulating in his room. R2 could not be interviewed due to his cognitive status. R2 was walking back and forth from his bed to his doorway, opening and closing his room door with ease without staff assistance or the assistance of a mobility device. On July 14, 2022, at 2:17 PM, R2 was ambulating from his room to the hallway without staff assistance or the assistance of a mobility device. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR continued to show R2 has resided on a secured unit in the facility since June 13, 2022. During a general tour of the facility on July 12, 2022, at 8:53 AM, the second floor of the facility was noted to have four separate units. Two of the units were unsecured units. Two additional units were secured units. To enter the first secured dementia unit where R2 resides, no code is required for entry, but to exit the secured unit, a security code is required. The second secured unit required a security code to enter and exit the unit. R2's MDS (Minimum Data Set) dated May 25, 2022, showed R2 had severe cognitive impairment. The MDS continued to show R2 did not require the assistance of a mobility device. R2's care plans entitled Potential Abuse-Neglect, initiated on May 25, 2022, showed [R2]'s comprehensive assessment . is at risk due to being a vulnerable person. [R2] demonstrates: depression, impaired cognition/communication, inadequate coping skills and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan showed multiple interventions initiated on May 25, 2022, including, Observe [R2] for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him feel safe. R2's care plan, entitled, Physical and Psychosocial Needs, initiated on May 25, 2022, showed I display compromised mental status and I demonstrate movement behavior (wandering, pacing or roaming). I have trouble understanding the immediate environment. Symptoms include: pacing, roaming, or wandering in and out of rooms; demonstrating signs and symptoms of mood distress, for example, poor appetite, [CONDITION(S)] (often up at night, wandering and pacing, anxious). R2's care plan showed multiple interventions initiated on May 25, 2022, including, If I leave the building or go into a peer's room or become aggressive, redirect me by: use distraction or 'therapeutic fib' techniques with me . Avoid saying 'no' or 'you don't belong here' or using negatives in general. Tell me what can be done. The facility's undated initial report to the State Agency transmitted on July 4, 2022, at 4:10 AM UTC (Universal Time Coordinated), showed, It was reported [R2] received inappropriate care. The report continued to show Immediate action taken: Investigation initiated, family and physician notified, physical assessment done with no concerns noted, social service aware and performing well being checks, resident's needs were met via plan of care, care plans updated, and final report within 5 days. The facility's undated final report to the State Agency transmitted on July 12, 2022, at 12:09 AM UTC, showed Conclusion: It was reported [R2]'s door was obstructed. Staff immediately removed obstruction and opened door to find [R2] comfortably in the room. [R2] is unable to say what happened. No person could be determined as responsible. All staff and residents on the unit interviewed, with none noting seeing the obstruction or it happening. [R2] is safe and comfortable in the facility. Staff commended for immediately addressing and reporting. Assessments on [R2] noted without concern or awareness of brief situation. Potential obstruction removed from unit. Family and MD aware of findings. Well-being checks in place. This will serve as the final report. On July 12, 2022, at 4:03 PM, V1 (Administrator) said, From what I can conclude, during my investigation, someone wrapped a bag around [R2]'s door knob to shut the door. I cannot substantiate this incident as abuse because I did not see it. Some staff have had abuse training since last week, but the training is still going on. On July 12, 2022, V1 provided a document entitled, Employee Education Record, dated, 7/5/22 - on. Topic of educations, Abuse Policy, what is abuse and reporting. The education record included 40 staff signatures. An undated list of facility staff, provided by the facility, listed 123 staff members employed by the facility. On July 12, 2022, at 4:40 PM, V1 said, [R2]'s door was locked for such a short amount of time, it didn't affect [R2], and there was no negative consequence, so we are unsubstantiating any abuse. On July 12, 2022, at 7:56 PM, V11 (CNA/Certified Nursing Assistant) said, On July 3, 2022, I started my rounds around 3:05 PM and saw [R2]'s door was tied shut with a plastic bag. I went and got [V13] (RN/Registered Nurse) right away and we cut the bag off [R2]'s door. Once the bag was cut we still could not get the door open because [R2] was hanging on the door and pulling on the door knob. It took about ten minutes to get the door open after it was discovered. I have not received any in-services or trainings after this incident On July 13, 2022, at 11:55 AM, V9 (LPN/Licensed Practical Nurse) said, I was the nurse caring for [R2] on July 3, 2022, and had last seen [R2] at about 1:00 PM on July 3, 2022. On July 13, 2022, at 1:02 PM, V13 (RN) said, The last time I saw [R2] was before 2:00 PM (on July 3, 2022), and I did not see his room door because I did not know which room was his. At 3:15 PM on July 3, 2022, I told [V11] (CNA) to go to the secured unit, and I went to another resident's room for about five minutes. When I came out of the other resident's room, [V11] was waiting for me at the nurse's station and asked if [R2]'s room was supposed to be tied shut. We rushed to [R2]'s room and I saw a plastic bag tied from the door handle of [R2]'s room to the handrail in the hallway. Because the bag was tied from the door handle to the handrail, the door could not be opened. I called through [R2]'s closed door, and he started pulling on the door handle, trying to open the door from inside his room. [V11] went and got scissors and cut the bag, but we still could not open the door. I called [V14] (Housekeeping Director/Manager on Duty) to let him know we could not get the door open so I was not there when [V11] opened the door. On July 15, 2022, at 12:38 PM, V29 (Psychiatrist) said, I just heard about [R2]'s incident on July 3, 2022, yesterday (July 14, 2022). I would expect them to inform me about this incident. When [R2] was involuntarily secluded, he would be more anxious, and panicky, and agitated. Staff could have protected [R2] by making sure he could not exit the secured unit he resides on. [R2] should not have been contained to his room by having a bag tied to his door, which is intentional seclusion. On July 14, 2022, V1 said, I did not interview the other nurses (V9 and V32) that were working on the second floor the day of the incident. On July 18, 2022, at 1:28 PM, V2 said, There was never an incident report done on [R2] regarding the incident on July 3, 2022. An incident report should have been done. 2. On July 12, 2022, at 9:00 AM, R1 was in his room, sitting on his bed eating breakfast. R1 was wearing a hospital gown that was not tied around his neck and was draped across his lap. R1 had two bruises, dark purple in color, on the left side of his neck. On July 12, 2022, at 1:35 PM, V8 (Wound Nurse) measured R1's neck bruising and said, He has two bruises, one on top of the other. The lower bruise measures two centimeters long by 0.5 centimeters wide. The top bruise measures 4.7 centimeters long by 0.8 centimeters wide. The bruises are deep red in color, kind of reddish purple in color. I have not assessed his bruises before. R1's EMR showed R1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS dated [DATE], showed R1 was severely cognitively impaired, required supervision for eating, and required extensive assistance of facility staff for all other activities of daily living. R1's care plan entitled, Potential Abuse- Neglect, initiated on March 30, 2021, showed [R1]'s comprehensive assessment reveals a history of factors that may increase my susceptibility to abuse/neglect related to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . During heightened periods of distress, [R1] may become agitated with verbal/physical aggression, [R1] has a history of verbal aggression/physical aggression towards other staff members and co-peers. R1's care plan showed multiple interventions initiated on March 30, 2021, including, Speaking calmly and professionally in a soft tone of voice. Staff should avoid raising own voice, since this tends to make [R1] more upset. This may cause the situation to escalate. R1's care plan entitle, Cognitive Impairment, initiated on March 30, 2021, showed [R1] is alert, oriented times one being noted to only identify self . [R1] is a poor historian, his attention span is delayed with response to stimuli and follows one step/verbal commands. His overall memory is decreased per any recall of recent events and short term/long term memory loss. R1's care plan showed multiple interventions initiated on March 30, 2021, including, Provide reassurance to help the resident feel safe and secure. Use a calming, soothing tone of voice. Repeat information politely and respectfully. Avoid phrases using words such as 'just' and 'already,' avoid 'I just told you that,' for example. The facility did not have documentation to show V1 (Administrator/Abuse Coordinator) was notified of R1's injury of unknown origin/neck bruising prior to July 12, 2022. The facility did not have documentation to show an abuse investigation had been initiated for R1's neck bruising prior to July 12, 2022. The facility's undated initial report to the State Agency transmitted on July 12, 2022, at 9:37 PM UTC (Universal Time Coordinated), showed: [R1] noted with a skin discoloration on left neck area. The report continued to show, Immediate action taken: head to toe assessment completed, no other injuries or pain noted, nurse practitioner in house and x-ray ordered; resident unable to provide details as to the cause of the discoloration; physician and family notified; resident placed on well-being checks and care plan to be updated accordingly; police notified, report number to follow. On July 12, 2022, at 1:53 PM, V2 (DON/Director of Nursing) said, There was no noted skin condition for [R1] on July 5, 2022. On July 6, 2022, when the CNA (Certified Nursing Assistant) went into [R1]'s room there was ecchymosis (bruising) on his neck. V8 (Wound Nurse) was supposed to follow up on this. I have not done an investigation into this as an injury of unknown origin. An investigation should be started within 24 hours. We do not know how [R1] obtained this bruising. V5 (RN/Registered Nurse) notified V10 (Nurse Manager), but V10 did not notify the abuse coordinator. On July 12, 2022, at 2:15 PM, V10 (Nurse Manager) said, [V5] (RN) mentioned [R1]'s bruising to me on July 6, 2022. I told her to notify the doctor. [R1] has behaviors of becoming aggressive and when you try to stop him he starts swinging. I did not assess [R1] right away because I was busy. I do not know how [R1] got the bruise, and I did not report this to the abuse coordinator. An investigation should have been done. On July 12, 2022, at 2:20 PM, V2 (DON) said, The nurse or the nurse manager should have reported this to the Administrator. A bruise of unknown origin is something that should be investigated. My expectation is staff should be reporting this as potential abuse. My expectation of V10 (Nurse Manager) is to investigate bruises immediately and report it. On July 12, 2022, at 2:49 PM, V1 (Administrator/Abuse Coordinator) said, I was unaware of bruising on [R1]'s neck from July 6, 2022. I will start the investigation now. On July 13, 2022, at 11:41 AM, V2 (DON) said, I have looked more into it and found out the bruise was there the day before on July 5, 2022. [V3] (Agency LPN/Licensed Practical Nurse) saw it, but did not report it because he thought it looked old. On July 18, 2022, at 10:43 AM, V3 said, I worked on July 5, 2022 and saw discoloration on [R1]'s neck. I rubbed it and could not see a skin tear. I looked in the chart and didn't see any documentation about it. I told the next shift nurse, and they were supposed to report it. On July 6, 2022, at 4:24 PM, V5 (RN) documented, the CNA on duty reported a skin discoloration on the left side of R1's neck, purplish in color. V5 continued to document the CNA observed the discoloration while in the process of getting R1 up for breakfast. V5 noted no swelling, no tenderness was noted at the site, the nurse practitioner was notified, and V5 called and left a message with POA (Power of Attorney). On July 8, 2022, at 10:33 PM, V7 (RN) documented R1 continued with deep purple discoloration on the left side of his neck. The facility's undated policy entitled, Abuse Prevention Program, showed Policy: It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect or a resident by a third party . IV. Identification: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator . V. Investigation: All incidents will be documented, whether or not abuse occurred, was alleged or suspected . Abuse Reporting: Policy- this facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals. This policy will define how the investigation of abuse allegations and mistreatment will be conducted and outline the process of reporting, investigating and arriving at a conclusion or disposition of the allegation. All personnel must promptly report any incident or suspected incident or resident abuse, mistreatment or neglect, including injuries of unknown origin. (An injury should be classified as an 'injury of unknown origin' when the source of the injury was not observed or known by any person, and the initial risk management investigation could not determine the cause of the injury.) . For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain . 5. Involuntary Seclusion: Separation of the resident from other residents or from his or her room or confinement to his or room (with or without roommates) against the resident's will, or the will of the resident's legal guardian or representative . Additionally, the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator or the individual in charge of the facility during the Administrator's absence . The Charge Nurse must complete an incident report and obtain a written, signed and dated statement from the person reporting the incident. Through observation, interview, and record review conducted on July 18, 2022, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: The housekeeping carts will be monitored in all halls at least daily seven days weekly by the Administrator/DON/Nurse Manager to ensure that no trash bags are accessible to a passerby. This monitoring will be done for four weeks. It will include some weekend days. Afterwards, this monitoring will continue three days weekly for a period of not less than six months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be immediately addressed if found. All halls will be toured daily seven days weekly by the Administrator/DON/Nurse Manager to ensure that no doors of resident rooms are barricaded. This monitoring will be done for four weeks. It will include various shifts as well as some weekend days. Afterwards, this monitoring will continue three days weekly for a period of not less than six months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be addressed if found. Residents were assessed for any injuries of unknown origin on July 12, 2022, through July 14, 2022, by DON and licensed nurses. None were discovered. Charge nurses and nurse manager were educated on proper reporting of injury of unknown origin to abuse coordinator/Administrator. Audit will be conducted two times a week for four weeks, then weekly for six months for residents with injury of unknown origin to ensure that proper reporting per policy is in effect. See attached audit tool. Any issues noted will be reported promptly to the Abuse Coordinator and all other required entities, to include the resident's physician, resident's responsible party, APS (Adult Protective Services), Ombudsman, authorities, State Board of Health as appropriate. Any concerns will be addressed if found. A member of the Regional Team, (RDO/Regional Director of Operations and RNC/Regional Nurse Consultant), will review the assessments done for unknown injury weekly for four weeks for additional oversight to ensure that any needed follow up occurred. Any concerns will be addressed if found. At an in-service held for all staff on July 14, 2022, and conducted by the Administrator/DON/Nurse Manager with Regional Team input, (RDO/RNC), the following was reviewed and discussed: Abuse Policy-with emphasis on different types to include seclusion and reporting (to include immediate need to report to the Abuse Coordinator/Administrator) Injuries of unknown origin---What to do in your role should you observe one or hear about the possibility of one? Whom do you immediately report this to? (Abuse Coordinator/administrator) When? Why it is critical that injuries of unknown origin be assessed/investigated/reported/addressed? Why it is important that you, as a staff member, promptly share any knowledge you have related to an injury of unknown origin? It is critical that upon discovery of an injury of unknown origin-the following must take place: a) Immediately report to the Abuse Coordinator/Administrator-who will initiate the investigation with assistance of appropriate staff b) Ensure the safety of all other residents to identify and immediately report any others who might have an injury of unknown origin c) Abuse sweep to be conducted to ensure that no other residents have been affected Use of trash bags within the facility to include: a) What type of bags are to be used and where they are to be used b) Where these bags are stored, and how to obtain a bag, should you as a staff member need one c) Inappropriate use of bags-tied to a door, anywhere in a resident bed, near a heating element, etc. Questions/Answers Any staff who fail to comply with the points of the in-service will be further educated and/or progressively disciplined as indicated. No staff will work after July 15, 2022, unless they have been in-serviced. This includes agency staff, PRN (as needed) staff, any staff on any type of vacation or leave, newly hired staff or any other staff. This education will be conducted by the Administrator/DON/Nurse Managers/MDS Coordinator. All monitoring done by facility staff as well as by Regional Team staff (RDO/RNC) will be presented to the QAPI Committee at their weekly meetings. Any concerns will have been addressed. However, any patterns will be identified. If indicated, an Action Plan will be written by the QAPI Committee. Any Action Plan will be monitored weekly by the Administrator until resolved. A member of the Regional Team, (RDO/RNC), will attend the QAPI meetings either in person or remotely for a period of not less than three months to serve as additional oversight, reference and support. Note: When the facility is placed back into substantial compliance, QAPI meetings will go to monthly. An Ad-Hoc QAPI meeting was held for the IDT (Interdisciplinary Team) on July 15, 2022, and conducted by the Administrator, with input from the Regional Team, (RDO/RNC) to discuss the points of this AOC (Allegation of Compliance).

Based on observation, interview and record review, the facility failed to provide incontinence care in a timely manner and thoroughly cleanse the perineum area during provision of care. This failure resulted in multiple patches and cluster groups of MASD (Moisture Associated Skin Damage) to R1's bilateral thighs and buttocks and caused R1 to suffer pain and aggravation. This applies to 3 of 3 residents (R1, R2, R3) reviewed for skin alteration and incontinence care. The findings include: 1) The Face Sheet showed that R1 was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted to the facility from the hospital on 5/19/2021. Review of the weight record history showed R1's weights: -06/18/2021= 629 pounds -06/25/2021=632 pounds -07/02/2021=633 pounds -08/09/2021=633.4 pounds -09/07/2021=608 pounds -10/01/2021=600 pounds On 10/04/2021 at 12:30 P.M., R1 was lying in her bariatric bed. The width's dimension of R1's bed showed that R1's had approximately 4-6 inches space between the side of her body and edge of the bed. The lack of space meant that R1 could possibly end up on the floor if R1 attempted to turn due to lack of space. R1 was alert and oriented times three. R1 said Don't worry, I cannot turn myself on my own and have to depend on 5 to 6 staff to turn me. If there is a male staff, then 5 staff will do, otherwise 6 staff if all females. The facility does not have enough people to handle me, so my diaper change was only 3 times a day at 10:00 A.M., 4:30 P.M. and 9:30 P.M. I am usually soaked with urine and stool. I have developed more skin sores and the sores do not heal because I am soaked with urine most of the time. My position in bed is the same and I am never turned to sides. Last time I was changed today was around 9:30 to 10:00 A.M. I never got out of bed or sat on a chair. It really does sting my skin when my diaper is soaked with urine. They don't apply my wound dressing most of the time to protect my skin from the burning sensation. It is a very aggravating situation. During this interview, R1 was calm, cooperative and was compliant when asked to check her skin and incontinence care. V5 (LPN/ Licensed Practical Nurse), V6 (LPN); V7 (CNA/Certified Nurse Assistant) were present when R1 talked about her schedule for incontinence care. They validated that R1 was scheduled to be changed 3 times a day. (10:00 A.M, 4:30 P.M. and 9:30 P.M.). After the interview with R1 on 10/4/21, the following staff were present to turn R1, V3 (Licensed Practical Nurse /LPN/Wound Treatment Nurse); V4 (LPN/Wound Treatment Nurse); V5 (LPN); V6 (LPN); V7 (CNA/Certified Nurse Assistant) and V9 (Male Restorative Aide). A total of 6 staff with 1 male and 5 females. R1 had to be moved towards the edge of the bed, to give room for turning to the opposite side. R1 was observed with 2 diapers under her buttocks and 1 diaper on the frontal aspect of her pubis area. R1 was saturated with urine. V7 said she just changed R1's diaper around 10:00 A.M. There was no wound dressing on R1's perineum or thighs. V7 failed to open R1's multiple skin folds, around the groin area and labial folds for thorough cleansing. V7 also failed to wipe and clean R1's buttocks and failed to apply skin ointment barrier. R1 was noted with multiple skin folds that were not easily accessible for visual skin inspection. On 10/4/21, R1 was compliant when was asked if we could do a thorough skin check. Same staff, except that this time 2 males were helping V9 and V8 (Restorative Aide). R1 was observed with multiple patches of open skin sores surrounding her posterior thighs (left and right) and left and right buttocks. V4 measured the wounds that V4 categorized it as MASD (Moisture Associated Skin Damage). The following measurements were provided by V4: V4 started measuring the biggest open skin area on the same group of clustered wounds. V4 failed to measure the surrounding open area with same cluster group of wounds. When V4 was asked if that was how she measured wounds (without measuring smaller size wounds and measuring the widest and longest part of wound), V4 said she was new to the job as a treatment nurse and was not trained. V4 then measured the cluster wounds from the longest and widest part of the wounds in a cluster group. 1) Right distal posterior thigh= 4 cm x 4 cm and 1.0 cm. 2) Right proximal posterior thigh= 1 cm x 1 cm. x 1 cm. 3) Left buttock= 1.5 cm. x 1.0 cm. x 0.5 cm. 4) Right buttock= 2 cm. x 1 cm. x 1 cm. 5) Left proximal posterior thigh= 1 cm. x 1 cm. x 0.5 cm. 6) Left distal/inner thigh= 0.5 cm. x 0.5 cm. x 0.2 cm. V3 (Licensed Practical Nurse /LPN/Wound Treatment Nurse) stated during the skin check observation that only the MASD (Moisture Associated Skin Damage) on the right proximal posterior thigh was observed on 10/3/2021 and that V3 applied foam dressing on it at that time. V3 also added that the rest of the MASD were new. V3 and V4 said R1 had history of MASD before but had healed and they were not as much as observed on 10/4/2021. The care plan dated 5/19/2021 and 8/19/2021 showed that R1 has alteration in skin integrity and is at risk of deterioration and or additional skin issues related to limited mobility, incontinence with bladder and bowel, [CONDITION(S)], [CONDITION(S)], refusing air mattress, refusing peri-care at times. The interventions to prevent deterioration and acquired additional skin alteration included but not limited to: good peri care; apply protective barrier; reposition frequently when in bed, chair, and or wheelchair; pressure redistributing mattress/air loss mattress; off load bilateral heel from pressure with pillow. Review of the care plan showed that R1's incontinence care to prevent skin sores was not addressed. The limited size of the bariatric bed which had no air mattress and prevented R1 from turning to sides was also not addressed. R1's refusal of treatment on the care plan showed no revised intervention. On 10/6/2021 at 3:00 P.M., V1 (Administrator) stated that the facility does not accept residents that weigh more than 350 pounds because it lacks staff to provide care. On 10/6/2021 at 5:00 P.M., V2 (Director of Nursing) added that V4 was new to her position as a wound treatment nurse and was not trained yet. V2 also said that facility does not accept residents that weigh more than 350 pounds. V2 also added that they try their best to provide care to R1 but R1's situation needed additional support. On 10/6/2021 at 6:30 P.M., V14 (Wound Care Physician Specialist) said he saw and examined R1 on 10/5/2021. V14 said R1 had multiple patches/clusters of MASD (Moisture Associated Skin Damage) on the posterior bilateral thighs and buttocks area. V14 said R1 was on a bariatric bed but the bariatric bed was only rated for a 350-pound person. R1 weighs ~600 pounds and her bariatric bed cannot accommodate R1 for turning and repositioning. V14 also validated R1 needed to be kept clean and dry from urine and stool and should be checked for incontinence care at least every 2 hours, should be turned every 2 hours to offload pressure and an air loss mattress be implemented to prevent pressure sores, MASD or other skin alterations. V14 also said these preventions should be implemented even if a resident has multiple comorbidities. V14 added that if these interventions were implemented and pressure sores and MASD still existed, then the sores were unavoidable. V14 stated all possible interventions should be provided to determine if sores were avoidable or not. V14 said if R1 had complained of burning sensation due to urine, then a foam dressing should be applied to protect the damaged skin. V14 said Peri-care that is not done timely, which is at least every 2 hours, causes urine and stool to saturate the skin and not cleansing the perineum thoroughly will cause MASD and pressure sores and even a non-medical person knows that. The undated facility's policy for incontinence care states, It is the policy of the facility to ensure that resident's receive as much assistance as needed for cleansing the perineum and buttocks after an incontinence episode . Frequency depends on bladder diary and /or routine of minimal every 2 hours. The policy also showed to .cleanse the peri-area and buttocks wiping from front of perineum toward the rectum. For a female resident, separate the labia and wash area using downward strokes from pubic area to rectal area and to cleanse in skin folds. The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS showed to change and clean (R1) daily on this time range 10:00 A.M., 4:30 P.M., and 9:30 P.M. There was no assessment to justify this time range for changing and cleaning R1's incontinence care. 2) On 10/4/2021 at 3:35 P.M., R2 was observed regarding her skin alteration. R2 has a stage 4 pressure ulcer on the sacrum. V4 (LPN/Wound Treatment Nurse) provided wound dressing to R2. R2 was saturated with urine and soft stool. V4 failed to cleanse R2 thoroughly by not cleaning the frontal/pubic area and separating labial folds to clean. V4 provided wound dressing change on R2's sacrum and the foam dressing were loosely adhering to the surrounding skin because it was still wet when V4 cleansed the rectal area. R2 was visibly dripping urine and V4 continued to fasten the incontinence brief with the wound dressing edges not sealed properly to the skin. The care plan dated 3/9/2021; 6/9/2021 and 9/7/2021 showed that R2 has alteration in skin integrity and is at risk for deterioration and /or additional skin issues related to limited mobility, incontinence of bladder and bladder. The interventions included but not limited to good peri care and drying of skin, apply protective barrier. 3) On 10/4/2021 at 3:45 P.M., R3 was observed regarding skin alteration. R3 has a stage 4 pressure ulcer on the sacrum. R3 was saturated with urine and liquid stool. V4 failed to provide R3 incontinence care. V4 proceeded to change R3's sacrum wound dressing without ensuring that R3 was clean and dry. V4 said I will let (V15, CNA) provide incontinence care to (R3). At this time, V15 was providing hygiene to R10. The care plan dated 9/7/2021 showed that R3 has alteration in skin integrity and is at risk for deterioration and /or additional skin issues related to limited mobility, incontinence of bladder and bladder . The interventions included but not limited to good peri care and drying of skin, apply protective barrier.

Based on interview and record review the facility failed to ensure two residents (R101 & R176) were free from physical abuse by R89 who has a history of physical aggression. The facility also failed to ensure interventions were in place for R89 after he physically abused R176 resulting in R101 being physically abused 20 days later. This failure resulted in R176 having a bruised eye and R101 having a bruised arm. This applies to 3 of 3 residents (R89, R101, & R176) reviewed for physical abuse in the sample of 35. The findings include: R89's electronic medical record (EMR) shows, he was admitted to the facility on [DATE] from another local nursing home. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R89's referral admission paperwork from the local nursing home documents his aggressive behaviors prior to being admitted to the facility. The progress notes show the following: July 7, 2021: Patient alert with periods of confusion. Patient showed signs of irritation this morning when being assisted with daily needs. Patient began to swear at staff then stood up and began to urinate on his bed. Patient ignored staff attempting to assist him . July 3, 2021: Patient is on unit wandering in and out of other residents' room. Patient has exit seeking behaviors and is becoming increasingly agitated, unable to redirect, behavior patient complained of some people sleeping in his room and he has to sleep on the couch, patient does not have couch in room and was observed lying in bed in AM . July 3, 2021: patient noted coming out of a female resident's room with a rolled up a linen . July 3, 2021: nurse on duty (NOD) notified by another patient that R89 was in and out of her room multiple times rummaging through her stuff. Resident said that R89 did not physically touch her, female patient said no . June 20, 2021: .patient started behaviors this morning by walking into other patient's room and had to be advised and redirected by staff that he is not allowed to go into other patients' rooms without permission. Pt (patient) repeatedly insisted doing so, several pts complained of pt. being in their room. Early afternoon, pt. attempted to leave facility by going down the stairs, CNA (Certified Nursing Assistant) redirected pt. back to 2nd floor and pt. held onto CNA arm and pulled her stating you are coming with me. Pt. back to floor and became aggressive with nurse by pulling on her computer cord and taking her belongings. Writer administered PRN (when needed) Ativan; pt. spit out. Writer advised pt. needs medication for anxiety; pt. took medication. Writer called primary physician to make aware that pt. is being unsafe to self, staff and patients-new order to send pt. if behaviors continue. June 20, 2021: Pt. sent to local hospital for psych evaluation . June 20, 2021: Received call from patient's brother, who expressed concern for his brother getting proper psych evaluation and shared concerns of past behaviors patient exhibited that are similar to behaviors patient is exhibiting now. June 6, 2021: Resident was lying on edge of bed. NOD and CNA attempting to straighten resident in bed. Resident became very combative and verbally abusive. Resident threatened to hit NOD. Resident verbalized I will hit you in head with shovel Resident attempted to hit NOD with his fist . R89's current facility progress notes, dated July 12, 2021, shows Resident admitted from local nursing home, alert and oriented x 2 to name and place with periods of confusion . R89's progress notes dated July 15, 2021 shows, Behavior note: Resident is alert and oriented x1 self only. Wanders and hard to redirect. Goes inside other residents' room and touches their things. R89's progress notes dated July 16, 2021 shows, Resident was sent out on involuntary petition yesterday after having hallucinations and wandering into other resident's rooms. He made allegation that co peer made contact with him while in the room. R89's progress notes dated July 27, 2021 shows, Readmission follow up . Patient alert oriented x1 to person, confused and agitated. Wanders and exit seeking. Difficult to redirect. Goes inside other patients' room and try to touch their things . R89's progress notes dated July 28, 2021 shows, Resident shows aggressive behavior to caretaker, going to other resident's room . R89's incident report provided by the facility for physical abuse dated August 22, 2021 shows, Staff heard someone screaming and noted resident (R89) inside one of the rooms punching him (R176) on the eye area . Notes: R89 just had an incident against another resident due to impulsive and sudden outburst by punching him (R176) on his left eye area . The facility's final abuse investigation dated August 22, 2021 shows, Conclusion: Based on investigation and interviews, resident R89 had an unprovoked aggression and made physical contact with resident R176 . R89's progress notes dated August 22, 2021 shows, Incident note: patient went to other patients' room and punched him on left eye, resident walked out to the room and does not remember what he did . Patient (R89) was sent to local hospital . The same progress notes show, the writer got a report from the hospital about resident (R89) that all the psych evaluation was done .and everything is ok. Doctor cleared him, no new order. Resident (R89) is back at the facility. On September 29, 2021 at 11:20 AM, R176 stated R89 hit him in the eye. R176 was lying in bed when R89 came into his room. R176 asked R89 to leave and R89 hit him in the eye. R176 had a bruised eye. R176 also stated, something like that happens, crazy and attack you, how can I feel safe? R176's minimum data set (MDS) dated [DATE] shows, he is cognitively intact. On September 29, 2021 at 12:00 PM, V23 Registered Nurse (RN) stated she was the nurse the day when R89 hit R176 in the face. V23 said, R176 came out of his room stating R89 hit him in the face. V23 sent R89 to the hospital after that. When he returned from the hospital, he did not have any new orders. R89's intervention was to be 1:1 with staff. Wherever R89 went, a staff member was to be with him. R89's progress notes dated September 3, 2021 shows, behavior charting: outburst behavioral, with episodes of angriness, and used not appropriate language, combative. Resident was wandering around and went to other residents' room . R89's progress notes dated September 11, 2021 shows, While entering resident room, observed this resident physically aggressive and hitting his roommates . The facility's abuse investigation dated September 11, 2021 shows, Brief description of incident: it is alleged that resident R89 made physical contact with resident R101 . The same assessment shows, R101 is alert and oriented X2. On September 29, 2021 at 11:30 AM, R101 stated R89 was his roommate. R101 stated when he went into the bathroom, R89 was sitting on his own bed. When R101 came out of the bathroom, R89 was sitting on his (R101's) bed. R101 asked R89 to get off his bed. R89 got mad and hit him in the face, grabbed his arm and started hitting his arm. R101 stated, R89 bruised his arm, and he had a big bump on it. R101 also stated, R89 has called him a nigger before and he was aware that R89 hit R176 in the face. R101 said he saw R89 go into R176's room that day and then R176 came out saying R89 hit him in the face. On September 29, 2021 at 12:00 PM, V23 RN stated she was R89's nurse in the morning but the incident with R101 happened on the evening shift. She stated, He (R89) was supposed to be 1:1. He was 1:1 in the morning, I don't know what happened in the evening. R89's screening assessment for aggressive and/or harmful behavior, dated August 23, 2021, shows Potentially able to integrate with structure, direction, and supportive counseling. (Additional dementia related interventions may include consideration of a more secured unit, dementia focused activities. Additional SMI (serious mental illness) interventions may include limited/supervised community access, group intervention and 1:1 intervention. Incident occurred on: 8/23/2021 with another co-peer resulting in physical aggression . R89's EMR did not show any previous screening assessments prior to incident on August 22, 2021. R89's care plan (no date) shows, Focus: R89 has a history of aggressive inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process & is therefore considered appropriate for admission. History/presenting includes conflicts or altercations with others. The same assessment also shows, Focus: R89 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming and problems understanding the immediate environment. Symptoms are manifested by: Pacing roaming or wandering in and out of peer's rooms, R89 is a new admission and not familiar with his environment and has periods of confusion. Wander guard was placed for safety and visual monitoring/1:1 dependent upon presenting mood/behaviors. Interventions: 1:1 if/as needed if resident is exhibiting increased mood/behaviors when in common areas. The facility's abuse prevention program last revised January 2019 shows, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on observation, interview and record review, the facility failed to thoroughly assess, closely monitor and refer a resident for additional evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to follow physician order [MEDICAL RECORD OR PHYSICIAN ORDER] This applies to 1 of 3 residents (R1) reviewed for foot ulcer. The findings include: The Face Sheet documents that R1, a [AGE] year-old was admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet documents that R1 was sent out on 7/2/2021 and returned to the facility on [DATE] with new onset of the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 19, 2021 at 11:20 A.M., R1 was observed lying in his bed. R1 was semi-alert and responded yeah, yeah, yeah to questions asked such as how are you?, responded yeah; have you eaten breakfast?, responded yeah; are you comfortable?; responded yeah; do you have pain?, responded yeah. Together with V3 (LPN-Licensed Practice Nurse/Wound Care Coordinator), V4 (LPN/Wound Care Nurse) and V5 (Wound Care Technician), R1's right lower leg stump was exposed. V3 changed the dressing on R1's right lower leg stump. V3 stated R1's entire right foot, all the way to the lower leg was amputated on 7/8/2021 due to a gangrene. The incision site was macerated (looked wet and pale) with approximately with 12 sutures. The incision site was covered with a gauze dressing and wrapped with Kerlix gauze dressing. The dressing was moderately soaked with serosanguinous drainage. V3 removed the soiled dressing, applied gauze, and wrapped R1's leg with Kerlix gauze dressing. The Social Service Notes dated 7/19/2021 showed (R1) scored an 8/15 (moderate cognitive impairment) on the BIMS (Brief Interview Mental Status) assessment. (R1) was able to repeat the three words at the beginning of the assessment but could not recall them at the end, even with the aid of a cue. (R1) was able to report the correct year and month but could not report the correct day of the week. (R1) disclosed feeling depressed, over-sleeping, having little energy, poor appetite, difficulty concentrating, and moving slower than usual. (R1) does not present with physical or verbal behaviors. (R1) does not refuse care/treatment. (R1) does not wander and appears to be at low risk for an elopement currently. (R1) presents with adequate vision, hearing, and unclear speech. The chronological timeline of R1's foot care were as follows as reviewed on the wound assessments and progress notes: -5/25/2021, R1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment showed: right heel diabetic ulcer; length measurement was 13 cm. x width was 7 cm. x depth was 0.2 cm., an exudate of moderate amount of serous drainage, no odor; the tissue type was identified as 30 % granulation; 0 slough; 40 % necrosis (dead tissue), skin was 30 %. There was fluid filled blisters around the wound. The treatment was to cleanse the wound with wound cleanser, chemical debridement, gauze dressing daily and if needed. -6/1/2021- was evaluated by wound care Nurse Practitioner (V8). The ulcer was described as follows: screw visible on top of the right second toe; had surgery at an unknown time ago; right foot pedal pulse --- (was left blank, not assessed) left foot pedal pulse --- (left blank, not assessed). The plan of care was to continue with dressing, prevent infection, and wound debridement as needed. V8 ordered Doppler study with ABI (Doppler, an ultrasound study that can be used to estimate the blood flow through blood vessel and determine poorly functioning valves in leg veins, and if there was a blocked artery that will impede circulation. ABI is ankle- brachial index, a test that compares the blood pressure in the upper and lower limbs. The normal ration is between 1.0 and 1.4. A ratio of 0.9 means patient has PAD (peripheral arterial disease). -6/2/2021, Doppler study and ABI was done on 6/2/2021 with results that showed: Segmented pressure measurements demonstrated ABI of 0.99 on the right foot, and 1.05 on the left foot. ABI is borderline on the right and normal on the left. No evidence of hemodynamically significant [MEDICATION(S)] stenosis (narrowing of blood vessel) on visualized vessels. Please correlate CLINICALLY to determine if further evaluation or follow up is indicated. - 6/1/2021, assessed by V3; right foot ulcer measures: length was 8 cm; width was 12 cm; depth was 0.2 cm. There was moderate amount of serous exudates. The granulation tissue was 20%; slough was 10%; and necrosis of 50%. The treatment was the same. -6/8/2021 assessed by V3; right foot ulcer measures; length was 5 cm; width was 12 cm; depth was 0.2. No slough; increased of necrotic tissue to 70% from 50% from a previous week assessment. -6/8/2021 assessed by V8; right and left pedal pulses were left blank--- (not assessed). V8 noted the 6/2/2021 Doppler Study and ABI result. V8 failed to provide order for close monitoring and thorough assessment to correlate clinically to determine if further follow was indicated for a proper treatment. -6/15/2021, assessed by V3; right foot ulcer measures; length was 5 cm. x width was 10 cm; and depth was 0.1 cm. There was moderate amount of serous exudates, necrosis was 50%. -6/22/2021, assessed by V3; right foot ulcer measures length was 5.5 cm. width was 9.8 cm. and depth were 0.2 cm. There was moderate amount of serous drainage that was FOUL in odor , necrosis was 60%. V3 assessed and documented that there was no S/S (sign and symptoms) of infection. This was a change of condition of the right foot ulcer because of the foul smell of the serous exudates. -6/29/2021, assessed by V3; right foot ulcer measures: length 5.5 cm. x 11 cm in width and 0.7 in depth. There was still a foul odor from the serous exudates coming from the foot ulcer. The necrosis had increased to 90%. The assessment also showed that the ulcer worsened. -6/29/2021, assessed by V8; No infection (Note: FOUL odor from the ulcer as documented by V3 on 6/22 and 6/29/2021 and a necrosis had increased to 90%.) Again, V8 left the capillary refill assessment of the feet to determine blood circulation flow was left blank and was not assessed. V8 also failed to order follow up referrals to a specialist such as a vascular surgeon since the necrosis was already had increased to 90% and this would help determine any circulatory blockage and further treatment. V8 failed to address and order diagnostic test that might determine [CONDITION(S)] and [CONDITION(S)], considering that there was a sign of infection due to foul smelling odor. The progress notes showed the following: -7/2/2021 at 7:41 A.M., R1 had a change in condition such as abnormal vital signs including fever, altered mental status change and functional decline. -7/2/2021 at 9:10 A.M., R1 was sent to the hospital for further evaluation. -7/2/2021 at 12:49 P.M., R1 was admitted with [CONDITION(S)]. The hospital records showed the following: -7/2/2021, (R1) from SNF (Skilled Nursing Facility), non-verbal, with fever of 102.7 and significant elevated WBC (White Blood Count) of 15.4. (R1's) right foot notably gangrenous on physical examination. X-ray were done showing soft tissue gas within the hind foot abutting the calcaneus with erosion of the posterior calcaneus with cannulated screw fixating the IP (intra phalanges) joint of the great toe, and lucency, with erosion also involving the 1st and 3rd metatarsal. Right heel with gangrene and malleolar surrounding by dry eschar. Admit to ICU (Intensive Care Unit), referred to ID (Infectious Disease Doctor); Podiatry, for surgical wound care, going for surgery. Guarded condition, and poor prognosis. The hospital podiatry notes dated 7/12/2021 documents Lower Extremity Focus Examination showed the following foot assessment: -DERMATOLOGY: skin cool and dry; right lower keg surgical incision is well coated with sutures, mild drainage, no signs of infection. - VASCULAR: 1. Dorsalis Pedis (dorsal artery of the foot, which is a blood vessel of the lower limb that carries oxygenated blood to the dorsal surface of the foot) was 0 for the right and 4 for the left. 2. Posterior tibial pulse: (delivers oxygenated blood to the posterior compartment of the lower leg) was 0 for the right /4 for the left. 3. CRTs to digits: (Capillary Refill Test; a rapid test used for assessing the blood flow through peripheral tissues, normal CRT time is 2 seconds or less) was 5 seconds to left foot. - NEUROLOGIC; Sensation to touch and pressure was absent to bilateral lower extremities The hospital final report dated 7/12/2021 showed: 1) Septic shock resolved. 2) Escherichia Coli and Proteus bacteremia, source was the right foot, on 7/2/2021, cleared 7/4/2021. 3) Gangrene and [CONDITION(S)] of the right calcaneus. 4) PVD (Peripheral Vascular Disease) with 100 % right occlusion. The progress notes dated 7/12/2021 showed R1 had returned to the facility with right foot amputated, covered with elastic wrap with order of DO NOT OPEN OR CHANGE THE DRESSING. To be changed by podiatrist on Wednesday. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 also has medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Wound Notes dated 7/15/2021 showed a call was made to V10 (Foot surgeon/podiatry) to set up an appointment but R1 already had an appointment for next week (7/21/2021) and not to touch the dressing until seen by V10. R1 verbalized understanding wearing the heel protector. The Nursing Progress Note dated 7/17/2021 showed that R1's dressing to right amputated lower leg had fallen off. The nurse updated V11 (R1's Attending Physician) who had not examined R1. -7/17/2021: Skin Wound Notes: R1's dressing to the amputated right lower leg had fallen off. There were 12 stitches to amputated foot with 6 tapes around it. V10 was paged, awaiting call back. There was no follow up noted when V10 did not call back. R1 was seen by V10 at his clinic on 7/21/2021. There was a new order from V10 to change the dressing daily on the amputated lower leg. V10 noted a seroma and to leave sutures intact for follow up visit on 8/4/2021. The Skin Notes dated 8/4/2021 showed that R1 went to V10's clinic. V10 ordered to keep dressing clean and do not change dressing. Call if concerns arise. R1 was reminded not to put pressure when transferring self without calling. R1 has tendency to transfer self without calling for assistance. The Nursing Progress Notes showed R1 saw V10 on 8/11/2021. The Skin/Wound Note dated 8/11/2021 showed R1 came back from follow up appointment with V10 with new order to change the dressing every other day with 4 x 4 gauze, thick pad and elastic bandage. Also, to call V10 if there is an issue. R1 scheduled for next appointment in 1 week. On 8/23/2021 at 2:00 P.M., V10 stated R1 should have been referred sooner for further diagnostic test and evaluation even if the Doppler study suggested borderline results. V10 stated close monitoring with comprehensive assessment that included capillary refill test for circulation, sensation and movement should have been done because of R1's right foot condition. V10 added if these were done sooner, R1's losing his right lower leg could have been avoided. V10 further stated that perhaps partial amputation of portions of the foot and some part of foot digits could not have been avoided. However, V10 stated the below right knee amputation could have been avoided. V10 explained that on 7/12/2021 he had ordered not to touch the dressing (dressing fell off 7/17/2021, R1 seen by V10 7/21/2021, V10 said he was not made aware). On 8/4/2021, V10 ordered again not to touch the dressing until seen on 8/11/2021. V10 said when he saw R1 on 8/11/2021, he was very upset that R1's right foot incision was improperly taken care regarding wound dressing treatment. V10 said that there were multiple tapes applied on the incision site that had compromised the stitches, had pulled the screw and cement and that it had appeared that it was ripped out of R1's bone. V10 said that he had sent his notes each time R1 had his appointment with him. V10 said that the facility had changed the wound dressing between 8/4/2021 and 8/11/2021 because it was not the dressing he had applied when R1 came to his clinic on 8/4/2021. V10 said he was not made aware why the dressing was changed. V10 said the way facility changed the dressing was inappropriate and that had compromised the bone screw and cement. V10 added, It had looked like it (dressing) was ripped off since the screw was attached to the bone 10 cm. How would it be possible for the bone to be exposed at the surgical site? V10 said there were approximately 2 fingers width that the surgical wound was dehiscence (splitting/ bursting) and sutures were missing. V10 provided pictures and notation of R1's amputated right lower leg during the appointment. The pictures/notation validated V10's statement. R1 had a dehiscence wound on 8/11/2021 appointment. The record review of R1's facility EMR (Electronic Medical Record) did not show documentation of R1's visit to V10 on 8/11/21. During the survey, V2 (Director of Nursing) was asked for documentation of R1's visits to V10. On 8/25/2021 at 9:30 A.M., the facility provided a Physician Clinic Communication note from V10 to the facility regarding R1's 8/11/2021 appointment to V10. There were no further progress notes or communication provided by the facility for other clinical visits of R1 to V10. The Physician Clinic Communication Notes dated 8/11/2021 from V10 for R1 showed Every other day dry dressing changes .CALL ME if there is an issue. I am PISSED I was not informed that bone and screw came out from his wound! Either somebody went digging into the wound OR magically it found its own way out. He (R1) also had tape directly on the incision 2 weeks ago, clearly somebody does not know wound care! On 8/19/2021 2:01 P.M., V8 (Wound Care Nurse Practitioner) stated she saw R1 on 6/1/2021. V8 said she saw a screw sticking out of R1's foot from a previous unknown surgery. V8 stated the screw that was sticking out of R1's foot was not significant since it did not bother R1. V8 stated she was aware of R1's Doppler Study result and did not make a referral to a vascular surgeon because she does not think there was an urgency. The care plan dated 5/28/2021 showed R1's skin to be checked daily and any skin changes reported to nurse and physician for treatment. The care plan did not address any interventions to ensure dressing of the amputated leg stay intact. On 8/19/2021 at 11:30 A.M., V3 (LPN-Licensed Practice Nurse/Wound Care Coordinator) and V4 (Wound Treatment nurse) stated there was no report received for any skin changes except from V3's assessment. V3 and V4 said there was weekly wound assessment for R1, but it did not include monitoring of the CMS (Circulatory/capillary refill; movement and sensation).

Based on observation, interview and record review, the facility failed to protect residents from mental, physical, and sexual abuse. This failure resulted in an Immediate Jeopardy (IJ) and has the potential to affect all 191 residents residing at the facility. As a result of this failure, R9 and R10 were exposed to abusive behaviors from R2 and R13 was physically attacked by R12. The IJ began on 1/7/21 at 8:24 PM when R2 was originally admitted to the facility and ended on 3/1/21 at 5:00 PM when the facility's removal plan was accepted. V2 (Acting Director of Nursing/Nurse Consultant) and V24 (Regional Director of Nursing) were notified of the IJ on 2/24/21 at 9:30 AM. V2 was provided with the IJ Template outlining the failures. Although the immediacy was removed on 3/1/21, the facility remains out of compliance at Severity Level II due to the need to evaluate and implement new policies and procedures and Quality Assurance monitoring. The findings include: Facility Daily Census, dated 2/17/21, shows the total resident census was 191 residents. MDS (Minimum Data Sets) show R1 (12/22/20), R6 (2/2/21), R7 (2/23/21), and R18 (1/18/21) were all cognitively intact. MDSs show R8 (2/1/21), R9 (2/10/21), and R13 (1/26/21) had cognition that was moderately impaired, however were interviewable. 1. Face sheet, dated 2/19/21, shows R2 was [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was originally admitted to the facility on [DATE] and R2 was readmitted again to the facility on [DATE]. Prior facility psychiatric nurse practitioner notes, dated 12/11/20, shows, Nursing reports episodes of disrupted behavior. R2 broke two televisions, urinating and defacating in inappropriate areas. The note shows R2 began on [MEDICATION(S)] and PRN [MEDICATION(S)] for agitation. R2 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior facility nursing notes show R2 showed behaviors of agitation, pacing, throwing items on the floor of the hallway, publicly disrobing and wandering in the facility, impulsiveness, behavioral disturbances, throwing food, taking drawers out of dressers and placing them on the floor, wandering into other resident rooms, waving scissors at staff, and playing in his feces. The prior facility notes show the facility sent out referrals to behavioral health hospitals and the physician increased R2's doses of [MEDICATION(S)] and [MEDICATION(S)] with little to no effects. Prior facility social services note, dated 1/6/21, which shows, spoke with R2's cousin in regard to resident's increasing behaviors. Notified [family] R2's behaviors are increasing, and the facility cannot handle these types of behaviors resident is displaying. [Family] stating resident would need to be sent to another facility. R2 was admitted to the facility on [DATE] with this history of abusive, aggressive behaviors. Review of R2's clinical record failed to show R2 was assessed for the risk of abusing residents or for the risk of being abused, related to his behaviors. No individualized treatment plan was identified to address R2's history of behaviors. Nursing admission progress note, dated 1/7/21, shows, According to nurse to nurse report from facility resident is having behavior issues as alert and oriented times 1, he doesn't know what he is doing. Care plan, dated 1/7/21, shows R2 was receiving [CONDITION(S)] medication to help manage and alleviate agitation and aggressive behavior, mood swings, mood liability, anxiety, neurosis, anxiety disorder, [CONDITION(S)], and sleeping disorder problems. Care plan interventions, dated 1/7/21, include 13. Continue to monitor and attend needs due to developmental delay for safety and precaution. Visual supervision provided for continuity of care related to safety concerns. Nursing note, dated 1/8/21, shows, R2 was restless, going into several rooms and throwing objects in the hallway, able to redirect but goes back to doing the same thing after a few minutes. Spoke with nurse practitioner and she informed writer that was part of his behavior before coming to this facility. Social Services note, dated 1/18/21, shows, Resident continues to be redirected by staff members due to his impulsive mood/behaviors (Resident exhibits very destructive behavior, throwing objects into the hall way from his room, digging into the garbage can and throwing trash out onto the floor in the hall way, resists care some of the times and is not easily redirectable at times. No interventions are discussed regarding R2's identified behaviors or history of behaviors. Social Services Screening Assessment for Indicators of Aggressive and/or Harmful Behavior, dated 1/10/21, shows R2 was Potentially able to integrate into the peer community, minimal risk for aggression. Dementia related interventions include re-orientation, re-assurance, emphasis on safety/security. SMI related interventions include stress management/stress relief, improving communication skills, harm reduction. The assessment showed R2 was assessed as not having concerns regarding awareness/insight/judgement/reasoning concern in spite of a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment also shows R2 did not have a history of, or recent episode of, aggressive/agitated behavior (aggression towards others including destruction of property) in spite of behaviors documented in prior facility transfer documents. No further assessments / re-assessments were identified in R2's clinical record despite R2 being sent to the hospital after punching R10, having worsening aggressive behavior at the facility, and being readmitted back to the facility on [DATE]. On 2/22/21 at 3:53 PM, V11 (Social Services) stated social services should have completed a reassessment of R2's Screening Assessment for Indicators of Aggressive and/or Harmful Behavior within 24 to 48 hours of R2's readmission on 2/9/21. V11 stated when R2 was readmitted , the plan of care for R2 was R2 was to have 24 hour 1:1 supervision. V11 stated she was not aware R2 masturbated in a resident's room or heard he was taking items out of others' rooms until just recently. V11 stated when R2 was initially admitted on [DATE], R2 was not having behaviors like those described at the previous facility and the only aggressive behavior reported to her was when R2 hit R9. Care plans, dated 1/14/21, shows R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's behaviors included wandering, pacing, and motor agitation, verbal behavioral/aggression, physical behavior/aggression, and socially inappropriate and/or maladaptive/disruptive behavior. Care plan, dated 1/14/21, shows R2 had a cognitive impairment related to mental illness, mental [CONDITION(S)], which manifested in impaired decision making, poor logic, poor ability to understand cause and effect, poor ability to recall names/places/objects, poor judgment/insight/reasoning/impulse control, and poor ability to control anger and frustration. Care plan, dated 1/19/21, shows R2 was developmentally disabled with symptoms which included going into other peers' rooms. The care plans fail to show individualized approaches related to R2's behaviors. Review of R2's clinical record, including assessments and care plans, fail to show R2 was assessed for the risk of being abused, or for the risk of abusing other residents, related to his behaviors. Nursing note, dated 1/11/21, shows R2 exhibits very destructive behavior, throwing objects into the hallway from his room, digging into the garbage can and throwing trash onto the floor in the hallway, resists care some of the times and is not easily redirectable. No new or revised interventions were identified regarding R2's destructive behaviors. Social Services Admissions note, dated 1/18/21, shows, Resident continues to be redirected by staff members due to his impulsive mood/behaviors (Resident exhibits very destructive behavior, throwing objects into the hall way from his room, digging into the garbage can and throwing trash out onto the floor in the hall way, resists care some of the times and is not easily redirectable at times. No new or revised interventions were identified regarding R2's ongoing behaviors. On 2/19/21 at 11:00 AM, R9 stated several weeks prior R2 had come into her room twice already that day and R9 told R2 to get out of the room each time. The third time R2 entered R9's room, R9 got upset, stood up, walked within three feet of R2, shook her finger at R2, and said, No NO! R9 stated R2 hit R9 in the upper torso near her shoulder with a closed fist. R9 stated the area R2 hit hurt when she was hit and hurt afterward. R9 stated, It hurt me! .You could tell something wasn't right with him. He was very unpredictable. He caught me off guard! It shocked me! Then I got really mad! R9 stated she told the facility R2 hit her and stated, He did not accidently push me! He intentionally hit me! He knew what he was doing! The was no accident with what happened. They knew what I was saying was true and they knew I didn't initiate it! He could have walked right in here at night because we don't have locks on the doors! I just thought of that! Final Incident report, dated 1/19/21, shows R9 stated that [R2] entered her room and picked up her belongings. When she tried to get back her belonging from resident [R2], he accidently pushed her. The report shows R2 was sent to the hospital for further psych evaluation and R2 was to be moved to another wing in the facility upon return from the hospital. Investigation statement shows R9 stated, When he came into my room and took my belongings, I tried to get it back from him and that is when he hit me in the shoulder. Facility Policy and Procedure Social Service Behavioral Monitoring, dated 10/2019, shows, Purpose: To assure that sufficient and appropriate Social Service assessments and interventions are provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being needs for each resident. Policy: The Social Service Director will review the 24 hour Nursing Report and/or unit Behavioral Occurrence forms daily and will discuss the occurrences with the management team in the Department Head meeting to attempt to identify the root cause and need for reassessment and/or need for new intervention strategies to address the problems identified. Procedure: 1. Social Service Director or Designee will hold a daily meeting with the facility Social Service team to discuss the newly identified Mood/Behavior Occurrences that were identified on the 24-hour Report and/or unit Behavior Occurrence forms. 2. The team will review the medical record of each identified resident exhibiting newly identified Mood/Behavioral problems and/or exacerbation of chronic Mood/Behavioral issues to try to determine the root cause and potential need for re-assessment and the addition of new interventions to manage the dysfunctional behavioral or mood pattern. 3. The Behavioral Management Committee will review the Mood/Behavioral Occurrence with focus on the time of the occurrence; interventions initiated immediately following the identified concern, the effectiveness of the interventions and whether the mood/behavior was easily altered/safely mandated. 6. The Social Service caseworker will provide documentation within the Social service progress notes related to the occurrence and the new interventions initiated in an attempt to manage/resolve concern. Facility document Abuse Prevention Program, revised 1/2019, shows, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. V. Identifications of Allegations/Internal Reporting Requirement - Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident is reported to a covered individual; covered individuals are notified annually of these reporting requirements Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the DON of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation. Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation VI. Investigation - All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. VII. Protection of Residents - Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. As part of the social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On a regular basis, supervisors will monitor the ability of the staff to meet needs of residents. The policy fails to show that other facility residents will be interviewed for potential abuse related to an alleged abuser during an investigation. 2. On 2/9/21, R2 was accepted back at the facility with a plan of care that included 24 hour 1:1 supervision to prevent further incidents. On 2/18/21 at 2:00 PM, V1 (Administrator) and V2 (Director of Nursing) stated the facility agreed to accept R2 back at the facility with a plan in place for 24 hour 1:1 direct supervision of R2 by staff. The clinical record fails to show R2 was reassessed for Indicators of Aggressive and/or Harmful Behavior following his readmission on 2/9/21. On 2/18/21 at 1:32PM, R8 stated that R2 was in her room three times the prior day and that R2 touched her on the shoulder. R8 stated, I don't want him in my room anymore! I don't want him touching me! R8 stated R2 also took a beverage from her room. Initial incident report, dated 2/18/21, shows, Residents reported they feel unsafe around R2. He currently has a one to one with him. Reports he is still walking around and in and out of resident rooms. Investigation question asked to interviewed residents showed, If a resident makes you feel uncomfortable, do you know who to talk to? The initial report did not show residents were assessed if they felt safe at the facility with R2. On 2/18/21 at 2:30 PM, V9 (Social Services) stated she immediately went to R8's room to interview R8 about the incident the prior night when R6 informed administration of the incident. V9 stated when she arrived, R2 did not have staff 1:1 directly supervising him. V9 stated she interviewed R8 who stated R2 only touched her shoulder and did not injure R8. V9 stated R8 told V9 that R2 also drank R8's beverage and while in R8's room unsupervised. V9 stated she had previously heard R2 had disrobed and masturbated at the facility, but she was not aware of any witnesses to R2's behavior. V9 stated R2 was immediately placed on continuous, 24 hour 1:1 supervision when he was readmitted to the facility on [DATE]. On 2/18/21 at 12:40 PM, R2 was observed in his room unsupervised by any facility staff. On 2/18/21 at 1:07 PM, R6 stated he did not feel safe with R2 entering his room unsupervised. R6 stated R2 entering his room unsupervised was a recurring occurrence and the facility was aware of it. R6 stated R2 was usually supervised until about 5:00 PM and, after 5:00 PM, R2 would chronically enter R6's room unsupervised. R6 stated he asks R2 to leave his room with volume. R6 stated, I don't feel threatened by some of the wanders, but because of the woman saying he was there three times and put his hands on her, I don't feel safe. I feel OK now that they are supervising, but if there is no one there he acts out. R6 stated R2 had been at the facility before and was aware R2 hit another resident and that R2 masturbates and walks around naked in the facility. R6 stated he reported his concerns regarding R2 to administration when R2 touched the resident residing across the hall from him. R6's stated the facility apologized and stated they took action to have staff monitoring R2. R6 stated he was concerned R2 would become a resident at the facility because R6 did not feel the facility was capable to meet R2's needs. On 2/18/21 at 12:00 PM, R1 stated he told V25 (Activities Director) he did not feel safe at the facility. R1 stated, I don't know what this guy is up to! R1 stated he witnessed R2 masturbating in the hall, but no staff intervened. R1 stated R2 was standing in the hall naked from the waist down and his pants were around his ankles. R1 stated he was aware R2 was sent out of the facility previously for hitting another resident. On 2/18/21 at 3:58 PM, R7 stated, He was just here about an hour ago! R7 stated no staff were with R2 when he entered R7's room. R7 stated R2 chronically enters R7's room unsupervised and has tried to remove R7's bag from his room. R2 also took a sock from R7's dresser and left the room on one occasion. R7 stated one-night R2 came in no less than fifteen times unsupervised. Rj7 stated he reported R2 to the facility administration and the administration told R7 that R2 was taken care of. R7 stated R2 came into R7's room unsupervised approximately an hour later and left an empty milk carton on R9's dresser. Review of staff worked schedules, dated 2/9/21 - 2/18/21, show no staff were consistently scheduled to be assigned as 1:1 staff designated to supervise R2. On 2/18/21 at 2:00 PM, V2 (Director of Nursing) stated staff were not specifically scheduled to perform 1:1 supervision 24 hours a day for R2. V2 stated the staff assigned to the units would designate an individual to monitor R2 and the staff would take turns providing supervision for R2 throughout the shift as necessary to cover for each other. Facility Policy and Procedure Close Monitoring, dated 11/8/11, shows, Policy: To ensure that a resident is monitored close related to behaviors, falls, or a change in condition that warrants closer supervision. Procedure: 1) An IDT (Interdisciplinary Team) member indicates that a resident warrants close observation for specific reason notifies the nursing department who will then adjust schedule to have a staff member observe the resident and maintain them in their view. 2) Nurse scheduler will be notified to increase staffing to provide a staff member to oversee the resident. 3) Unit nurse will assist in giving and reassigning assistance with the resident as needed. 3. On 2/19/21 at 11:23 AM, V5 (Patient Tech) stated the prior week he was passing lunch trays and was looking for R2 so he could deliver R2 his tray. V5 stated he found R2 standing in R10's room masturbating while R10 was asleep in his bed. V5 stated he was passing lunch trays at the time and no staff was 1:1 supervising R2. V5 stated he redirected R2 to R2's room, placed him in bed, and walked down the hall to tell V6 (Certified Nursing Assistant). V5 stated V6 told V5 to report the incident to the V4 (Business Office Manager). V5 stated he walked to the front office and reported the incident to V4. V5 stated V4 responded, We need to tell V1 (Administrator) about that because that is sexual assault. V1 was not in her office, so V4 told V5 to go back to R2 and V4 would tell V1 when V1 returned to the office. V5 stated he waited for V1 to come talk to him for some time but had to leave at the end of his shift for a physician appointment. On 2/19/21 at 12:01 PM, about a week prior, V4 stated she asked V1 to go speak to V5, however did not express to V1 that there was a report of an allegation of abuse regarding R2. V4 stated she told V1 that R2 was having behaviors and V1 needed to talk to V5. V4 stated the incident did not come up in the daily administration meeting at the end of the day. On 2/22/21 at 4:16 PM, V10 (LPN - Licensed Practical Nurse) stated V5 told her R2 was standing in the doorway of the next-door resident's room masturbating. V10 stated she asked V5 if R2 was in the resident's room and V5 stated R2 was standing in the doorway. On 2/19/21 at 12:13 PM, V1 (Administrator) stated about a week prior, V4 told her she needed to go see R1 regarding having inappropriate behaviors. V1 stated she immediately went to the nursing station and talked to the nurse who told V1 that R2 was having behaviors masturbating but did not tell V1 that R2 masturbated in R10's room while R10 was in bed sleeping. V1 stated nursing reassured V1 that R2 had 1:1 supervision and R2 was redirected and the behaviors were managed. V1 stated the nurse told V1 that the physician had been called. V1 stated she read the nursing note which did not describe R2 masturbating in R10's room. V1 stated she was never told R2 was in R10's room masturbating. Nursing note, dated 2/15/21, shows, Staff reported that resident was observed exhibiting inappropriate sexual behavior but was stopped immediately. 1:1 in progress. Encouraged to staff in his room this shift. Initial Incident Investigation, dated 2/19/21, shows, Staff person reported to the surveyor that he witnessed R2 in the room of R10 standing over top of him masturbating. R10 was asleep and unaware. Interview of V5. He was passing trays, witnessed R2 standing in the room of R10 masturbating. V5 went into the room and redirected R2 back to his room and V5 reported this to the nurse. V5 stated resident was asleep and unaware of what was happening. Full investigation to follow. 4. The clinical record showed R12 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician note, dated 10/28/20, shows R12 was sent to the hospital from his prior facility after being accused of grabbing another resident's breast. Behavioral Neurology physician note, dated 12/17/20, showed R12 had memory issues and inappropriate sexual behavior including stealing women's underwear from the laundry room of his building and presenting them to the women as gifts, would make inappropriate sexual comments toward women in his assisted living facility, and was removed from his last facility for touching another resident's breast. The note shows a similar incident happened at the facility approximately two weeks prior. Physician note, dated 11/16/21, shows R12 had reports of alleged inappropriate sexual behavior of touching another female resident's breast. R12 was sent to the hospital and returned with no further recommendations. The note shows R12 was to continue his Depro-[MEDICATION(S)] (Medroxyprogesterone Acetate Suspension) injections monthly every Monday and staff were to continue to monitor for mood, behavior, and mental status. Final Incident Investigation, dated 11/18/20, shows on 11/14/20, R12 was accused by two residents of touching them inappropriately. The report concludes R8 had inconsistencies with her statements and R18 reported her allegation only when overhearing R8 report her allegation. Investigation Interview, dated 11/14/20, shows R8 was not sure at first what incident the interviewer was referring to when questioned, however R8 provided a description and a recount of the incident once she was clear about the subject and stated the man she described was standing over her when she woke from a nap with his hand on her crotch. However, an investigation summary refers to additional information not recorded on R8's interview regarding the incident. Investigation interview with R18 showed no inconsistencies and shows R12 was accused of hugging R18 and touching R18's breast.R18 stated she then went to the nurses station to report the incident and told the nurse she wanted to speak to Social Services. The investigation fails to show R12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/24/21 at 3:50 PM with V20 (CNA), R13 stated on 2/23/21 at approximately 8:30 PM, R13 was sitting on the right side of his bed watching television and R12 was asleep in his bed with his television on. R13's bed was the middle bed in a three-bed room. R13 stated R12, who resided in the bed by the window, began to talk in his sleep and yell out, so R13 called out to R12 that he should turn his television off and go back to sleep. R13 stated R12 stood up, walked past R13's bed, walked toward the room door, and walked back to R13 sitting in his bed with metal knife in his hand. While R12 was walking around the room, R13 stated R12 was threatening R13 saying, I kick your ass! and I'm gonna kill you M___ F___. R13 stated R12 stood in front of R13 and tried to stab R13 three times with the metal knife. R13 had three abrasions on his stomach. One abrasion was an approximately 1 cm (centimeter) cut above his right nipple that extended into the tissue of his nipple. The area around the cut was dark blue purple. The second abrasion was approximately three inches long to the right of R13's navel. The third abrasion was above the second abrasion on the right of R13's torso and was approximately two inches in length. R13 stated R12 stopped attempting to stab R13 because R12 was kicking R13 away. R13 stated he stood up, walked past R12, and walked out to the nurse's station to report what had happened. R13 stated the police were called and came to investigate as did several staff. R13 stated they all asked R13 if R12 had a plastic knife. R13 stated he continued to reiterate R12 stabbed him with a metal knife. R13 stated the police and staff searched for the knife and were unable to locate any. R13 stated R12 had threatened R13 before, but R12 did not report the incidents because R13 knew R12 did not take his medications and R13 was concerned R12 was not stable. R13 stated he had witnessed R12 not take his medications when provided, hide his medications, and offer his medications to R13 on occasions. R12's bedside tray table had a medication cup with eleven pills in the medication cup. R13 stated he thought the medication had been there since before the incident between R12 and R13. R13 stated, I feel safer because he is not here! R17's bed was located closest to the room door. R17's tray table had two metal spoons and a metal fork on his tray table. V20 (CNA) stated she was there when R13 reported the incident and R13's recollection was consistent with what he reported the night prior immediately after the incident. V20 stated no knife was found when the room was searched. Final incident investigation, dated 3/1/21, shows the allegation of abuse regarding R12 toward R13 was substantiated. Social Services Admission Note, dated 11/4/20, shows R12 was admitted from the hospital with a history of mood/behaviors per hospital paperwork but has not yet displayed any negative mood/behaviors while admitted to this facility The note fails to address R12's history of inappropriate sexual contact with other residents at his prior facility and fails to identify interventions to prevent resident abuse. The note also fails to identify specific interventions for R12's history of mood and behaviors to prevent abuse and fails to assess R12 for the potential of abuse related to his dementia and history of sexually inappropriate behaviors. 5. The clinical record showed R4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing note, dated 11/5/20, shows R4 was having increased agitation and aggressive behaviors toward staff and staff were unable to redirect R4. The clinical record showed no new interventions implemented regarding R4's aggressive behaviors to prevent facility residents from abuse. Nursing note, dated 11/9/20, shows R4 swung his cane toward R1, R11 pushed R4, and R4 responded by poking R11 with his cane. No new interventions were identified regarding R4's aggressive behaviors to prevent facility residents from abuse. Nursing notes, dated 11/13/20, shows R4 had increased anxiety, aggression, and agitation with hallucinations. R4 was throwing things inside the room, hit the nurse on duty, and attempted to hit his roommates with his cane. R4 became increasingly angry, moved back and forth in his wheelchair and did not want anyone to open his bedroom door and come inside. R4 denied access to staff who were attempting to check on R4's two other roommates. R4 exhibited agitation and moved with force towards other resident who came in his path R4 was cursing and screaming at staff and residents, blocking the Social Services door as well as pounding on the door. The note shows Social Services felt threatened by the resident because they were unable to exit their office. R4 was attempting to run over staff with his wheelchair. R4 received a dose of [MEDICATION(S)] but R4's anxiety continued, so R4 was administered [MEDICATION(S)]. R4's psychiatrist was contacted and an antianxiety and antipsychotic were ordered. Social services confiscated R4's cane and R4 again became wild and threatening staff, banging door and hurting staff whenever his behavior was redirected. R4 remained verbally and physically aggressive in spite of medications administered. R4 was sent to the hospital involuntarily and the clinical record shows R4 returned from the hospital the same day with no new interventions. Nursing note, dated 11/14/20, shows R4 was observed with troubled and nervous behavior . refusing to take all medications. Physician note, dated 11/16/20, shows R4 was refusing to take prescribed medications. A psychotherapy evaluation was initiated; however no new interventions were implemented to prevent residents from abuse. Nursing note, dated 11/18/20, shows R4 had increased agitation and aggression, episodes of on and off sudden outbursts and uncontrolled temper towards staff. R4 was prescribed an antipsychotic for seven days and staff were to monitor if R4 was compliant with taking the medication as well as the effectiveness of the medication. Nursing note, dated 11/20/20, shows R4 attempted to elope, threatened to elope again, and refused as needed injections for agitation and anxiety. R4 also refused all medications duri [TRUNCATED]

Based on observation, interview and record review, the facility failed to thoroughly investigate, prevent further potential abuse while investigating, and report the results of investigations to the State Survey Agency within five working days of the incident. As a result of this failure R9 and R10 were exposed to abusive behaviors from R2. This failure resulted in an Immediate Jeopardy (IJ) and has the potential to affect all 191 residents residing at the facility. The Immediate Jeopardy was noted to begin on January 19, 2021 when R2 was discharged from the facility for abusive and aggressive behavior after hitting R9 and ended on 3/1/21 when the facility removal plan was accepted. As a V2 (Acting Director of Nursing/Nurse Consultant) and V24 (Regional Director of Nursing) were notified of the IJ on 2/24/21 at 9:30 AM. V2 was provided with the IJ Template outlining the failures. Although the immediacy was removed on 3/1/21, the facility remains out of compliance at Severity Level II due to the need to evaluate and implement new policies and procedures and Quality Assurance monitoring. The findings include: Facility Daily Census, dated 2/17/21, shows the total resident census was 191 residents. 1. Face sheet, dated 2/19/21, shows R2 was [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was originally admitted to the facility on [DATE] and R2 was readmitted again to the facility on [DATE]. Prior facility records show R2 had behaviors of agitation, pacing, throwing items on the floor of the hallway, publicly disrobing and wandering in the facility, impulsiveness, behavioral disturbances, throwing food, taking drawers out of dressers and placing them on the floor, wandering into other resident rooms, waving scissors at staff, and playing in his feces. On 2/19/21 at 11:23 AM, V5 (Patient Tech) stated the prior week he found R2 standing in R10's room masturbating while R10 was asleep in his bed and was redirected by V5. V5 stated he walked down the hall to tell V6 (CAN - Certified Nursing Assistant). V5 stated V6 told V5 to report the incident to the V4 (Business Office Manager). V5 stated he walked to the front office and reported the incident to V4. V5 stated V4 responded, We need to tell V1 (Administrator) about that because that is sexual assault. V1 was not in her office, so V4 told V5 to go back to R2 and V4 would tell V1 when V1 returned to the office. V5 stated he waited for V1 to come talk to him for some time but had to leave at the end of his shift for a physician appointment. On 2/19/21 at 12:01 PM, V4 stated she asked V1 to go speak to V5, however did not express to V1 that there was a report of an allegation of abuse regarding R2. V4 stated she told V1 that R2 was having behaviors and V1 needed to talk to V5. V4 stated the incident did not come up in the daily administration meeting at the end of the day. On 2/22/21 at 4:16 PM, V10 (LPN - Licensed Practical Nurse) stated V5 told her R2 was standing in the doorway of the next-door resident's room masturbating. V10 stated she asked V5 if R2 was in the resident's room and V5 stated R2 was standing in the doorway. On 2/19/21 at 12:13 PM, V1 (Administrator) stated about a week ago, V4 told her she needed to go see R1 regarding having inappropriate behaviors. V1 stated she immediately went to the nursing station and talked to the nurse who told V1 that R2 was having behaviors masturbating but did not tell V1 that R2 masturbated in R10's room while R10 was in bed sleeping. V1 stated nursing reassured V1 that R2 had 1:1 supervision and R2 was redirected and the behaviors were managed. V1 stated the nurse told V1 that the physician had been called. V1 stated she read the nursing note which did not describe R2 masturbating in R10's room. V1 stated she was never told R2 was in R10's room masturbating, and therefore did not initiate an abuse investigation. Nursing note, dated 2/15/21, shows, Staff reported that resident was observed exhibiting inappropriate sexual behavior but was stopped immediately. 1:1 in progress Encouraged staff in his room this shift Initial Incident Investigation, dated 2/19/21, shows, Staff person reported to the surveyor that he witnessed R2 in the room of R10 standing over top of him masturbating. Review of facility abuse/incident reports fail to show the allegation of abuse was reported to the facility abuse coordinator or administrator, or to the State Agency until reported on 2/19/21 during a survey. Facility document Abuse Prevention Program, revised 1/2019, shows, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility V. Identifications of Allegations/Internal Reporting Requirement - Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident is reported to a covered individual; covered individuals are notified annually of these reporting requirements. Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the DON of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation. Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation. VI. Investigation - All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. VII. Protection of Residents - Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. The policy fails to show that other facility residents will be interviewed for potential abuse related to an alleged abuser during an investigation. 2. On 2/9/21, R2 was accepted back at the facility with a plan of care that included 24 hour 1:1 supervision to prevent further incidents. On 2/18/21 at 2:00 PM, V1 (Administrator) and V2 (Director of Nursing) stated the facility agreed to accept R2 back at the facility with a plan in place for 24 hour 1:1 direct supervision of R2 by staff. On 2/18/21 at 12:40 PM, R2 was observed in his room unsupervised by any facility staff. On 2/18/21 at 12:00 PM, R1 stated he previously told V25 (Activities Director) he did not feel safe at the facility. R1 stated, I don't know what this guy is up to! R1 stated he witnessed R2 masturbating in the hall, but no staff intervened. R1 stated R2 was standing in the hall naked from the waist down and his pants were around his ankles. R1 stated he was aware R2 was sent out of the facility previously for hitting another resident. R1 stated he turned in a concern form to the front desk on 2/17/21 expressing his fear of R2 entering R1's room unsupervised however R1 had heard no response from the facility. Review of facility concern forms fail to show R1's concern form turned in on 2/17/21. Review of facility incident/abuse investigations fail to show R1's safety concerns regarding R2 were reported to the abuse coordinator/administrator or were investigated. On 2/18/21 at 1:07 PM, R6 stated he did not feel safe with R2 entering his room unsupervised. R6 stated R2 entering his room unsupervised was a recurring occurrence and the facility was aware of it. R6 stated R2 was usually supervised until about 5:00 PM and, after 5:00 PM, R2 would chronically enter R6's room unsupervised. R6 stated he asks R2 to leave his room with volume. R6 stated, I don't feel threatened by some of the wanders, but because of the woman saying he was there three times and put his hands on her, I don't feel safe. I feel OK now that they are supervising, but if there is no one there he acts out. R6 stated R2 had been at the facility before and was aware R2 hit another resident and that R2 masturbates and walks around naked in the facility. R7 stated he reported his concerns regarding R2 to administration when R2 touched the resident residing across the hall from him. R7s stated the facility apologized and stated they took action to have staff monitoring R2. R7 stated he was concerned R2 would become a resident at the facility because R7 did not feel the facility was capable to meet R2's needs. Initial incident report, dated 2/18/21 at 2:00 PM, shows, Residents reported they feel unsafe around R2. He currently has a one to one with him. Reports he is still walking around and in and out of resident rooms. Investigation question asked to interviewed residents showed, If a resident makes you feel uncomfortable, do you know who to talk to? The initial report did not show residents were assessed if they felt safe at the facility with R2. On 2/18/21 at 3:58 PM, R7 stated, He was just here about an hour ago! R7 stated no staff were with R2 when he entered R7's room. R7 stated R2 chronically enters R7's room unsupervised and has tried to remove R7's bag from his room. Review of staff worked schedules, 2/18/21, show no staff were consistently scheduled to be assigned as 1:1 staff designated to supervise R2. On 2/18/21 at 2:00 PM, V2 (Director of Nursing) stated staff were not specifically scheduled to perform 1:1 supervision 24 hours a day for R2. V2 stated the staff assigned to the units would designate an individual to monitor R2 and the staff would take turns providing supervision for R2 throughout the shift as necessary to cover for each other. Facility Policy and Procedure Close Monitoring, dated 11/8/11, shows, Policy: To ensure that a resident is monitored close related to behaviors, falls, or a change in condition that warrants closer supervision. Procedure: 1) An IDT (Interdisciplinary Team) member indicates that a resident warrants close observation for specific reason notifies the nursing department who will then adjust schedule to have a staff member observe the resident and maintain them in their view. 2) Nurse scheduler will be notified to increase staffing to provide a staff member to oversee the resident. 3) Unit nurse will assist in giving and reassigning assistance with the resident as needed. 3. On 2/19/21 at 11:00 AM, R9 stated several weeks prior R2 had come into her room twice already that day and R9 told R2 to get out of the room each time. The third time R2 entered R9's room, R9 got upset, stood up, walked within three feet of R2, shook her finger at R2, and said, No NO! R9 stated R2 hit R9 in the upper torso near her shoulder with a closed fist. R9 stated the area R2 hit hurt when she was hit and hurt afterward. R9 stated, It hurt me! You could tell something wasn't right with him. He was very unpredictable. He caught me off guard! It shocked me! Then I got really mad! R9 stated she told the facility R2 hit her and stated, He did not accidently push me! He intentionally hit me! He knew what he was doing! The was no accident with what happened. They knew what I was saying was true and they knew I didn't initiate it! He could have walked right in here at night because we don't have locks on the doors! I just thought of that! Final Incident report, dated 1/19/21, shows R9 stated that [R2] entered her room and picked up her belongings. When she tried to get back her belonging from resident [R2], he accidently pushed her. The report shows R2 was sent to the hospital for further psych evaluation and R2 was to be moved to another wing in the facility upon return from the hospital. Investigation statement shows R9 stated, When he came into my room and took my belongings, I tried to get it back from him and that is when he hit me in the shoulder. The final incident report failed to show R2 hit R9 or that R9 was hurt when R2 hit her. The final report also failed to show other residents were interviewed to identify any other victims of abuse by R2. 4. The clinical record showed R12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Behavioral Neurology physician note, dated 12/17/20, showed R12 had memory issues and inappropriate sexual behavior including stealing women's underwear from the laundry room of his building and presenting them to the women as gifts, would make inappropriate sexual comments toward women in his assisted living facility, and was removed from his last facility for touching another resident's breast. The note shows a similar incident happened at the facility approximately two weeks prior. Physician note, dated 11/16/21, shows residents reported R12 allegedly displayed inappropriate sexual behavior of touching another female resident's breast. R12 was sent to the hospital and returned with no further recommendations. The note shows R12 was to continue his [MEDICATION(S)] Suspension injections monthly every Monday and staff were to continue to monitor for mood, behavior and mental status. Final Incident Investigation, dated 11/18/20, shows on 11/14/20, R12 was accused by two residents of touching them inappropriately. The report concludes R8 had inconsistencies with her statements and R18 reported her allegation only when overhearing R8 report her allegation. Investigation Interview, dated 11/14/20, shows R8 was not sure at first what incident the interviewer was referring to when questioned, however R4 provided a description and a recount of the incident once she was clear about the subject and stated the man she described was standing over her when she woke from a nap with his hand on her crotch. However, an investigation summary refers to additional information not recorded on R8's interview regarding the incident. Investigation interview with R18 showed no inconsistencies and shows R12 was accused of hugging R18 and touching R18's breast.R18 stated she then went to the nurses station to report the incident and told the nurse she wanted to speak to Social Services. The investigation fails to show R12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. The clinical record showed R4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing note, dated 11/5/20, 11/9/20, 11/13/20, 11/14/20, 11/18/20, 11/20/20, all document R4 as experiencing anxiety, aggression, agitation, and occasional hallucinations. Nursing note, dated 11/27/20, shows R4 was very angry, had increased anxiety, was purposefully increasing the temperature in his room to very high levels, was turning off his roommate's television, and was calling his roommate a N_ _ _ _ _. The clinical record failed to show R4's behavior was reported to the abuse coordinator. On 2/23/21 at 3:23 PM, V2 (Acting Director of Nursing) stated no abuse investigation was initiated for the incident between R4 and his roommate on 11/27/20. Review of facility incidents/abuse investigations fail to show an investigation was initiated for R4's 11/27/20 incident, or that the incident was reported to the abuse coordinator / administrator. 7. Initial incident/abuse investigation, dated 2/23/21, shows R12 and R13 engaged in a physical alteration. Final incident/abuse investigation, dated 3/1/21, shows the allegation of physical abuse regarding R12 was substantiated. The final investigation was submitted to the State Agency on 3/1/21. The facility submitted the following plan on 3/1/21 to remove the immediacy and the plan was verified by the survey team: Admission Process 1) Referrals to the facility for residents that are exhibiting behaviors of physical verbal mental and sexual abuse at prior facility need to be reviewed for acceptance or denial by Regional Nurse Consultants and final review by Clinical Nursing Officer. The facility will have a log of the referral specific to the behaviors and outcome of acceptance or denial. (Log will be kept by admission Director with save email from Regional Nurse with specific information) (See specific Admission Audit Tool Exhibit A) Audit of log will be sent to Regional Nurse Consultant 2/week. (Training completed by Regional Nurse Consultant 2/25/21 Admission Director on use of Audit Tool) 2) When a resident is accepted by Regional Team with a behavior that can be managed by the facility the referral is reviewed DON Administrator and Social service. The plan of care relating to the behavior is in place with interventions prior to the arrival to facility. The plan of care is explained to nursing staff and IDT with understanding of the specific interventions prior to resident arriving at facility. (Training to Nursing Managers on 2/25/21 By Regional Nurse Consultant, Nurse Managers, ADON (Assistant Director of Nursing), and Unit Manger initiated in servicing to Licensed Nursing Staff Facility rooster utilized to assure that nursing staff have received education Daily checking of Agency scheduled employees to assure that they have been in service) 3) R4 (Discharge 2/24/21) and R2 (Discharge 2/18/21) no longer reside in the facility. (See attached discharge census line Exhibit B} Assessment of Residents with Abusive behavior or At Risk for Abuse 1) The social service department ADON and Nurse managers are completing a house wide assessment of all residents for determination of abusive behavior or at risk for abuse. (The Social Services Department was educated on care plan revision and the MDS. The Social Services team have completed the care plan updates for the residents with behaviors as of 3/1/21) 2) The physical aggressive assessment will be completed on all residents in facility. (Abuse assessments have been completed on 3/1/21 assessments will be completed for newly admitted residents within 72 hours). 3) Residents who have abusive behaviors will have plan of care revised, updated, and individualized with interventions specific to those behaviors. (MDS Coordinator, MDS Consultant, Social Services Consultant educated Social Services Department on care plan revision and the MDS, and Social Services team have completed the care plan updates for the residents with behaviors as of 3/1/21) 4) Residents who are at risk for abuse will have care plan in place with interventions to protect from abuse. (The Social Services Department was educated on care plan revision and the MDS, and Social Services team have completed the care plan updates for the residents with behaviors as of 3/1/21) Reporting Abuse 1) Physical Verbal Mental and Sexual abuse will be reported to IDPH (Illinois Department of Public Health) within 2 hours of receiving information relating to altercation. Reported immediately including the details of the allegations as they are aware of too Administrator or DON. (Regional Director of Nursing in serviced the IDT (Interdisciplinary Team) members on abuse. (The IDT members then began in servicing the line staff on 2/26/21 and in servicing continues until every employee has been in service. Administrator is beginning All Staff in-services during all three shifts on Thursday 3/4/21, Friday 3/5/21, and weekend days if necessary, to achieve 100% of staff.) 2) When abuse occurs immediate separation and supervision will be maintained by close monitoring of the aggressor. (See Abuse Policy) Education was provided by the Regional Nurse Consultant to Nursing Managers ADON Unit Managers, and Nursing Supervisors on monitoring of residents and the Policy Standard Supervision and Monitoring 2/26/21) 3) Facility staff will have close monitoring of resident who is aggressor until they are instructed by Administrator or DON (Director of Nursing) Monitoring Log initiated immediately. (Education was provided by the Regional Nurse Consultant to Nursing Managers ADON, Unit Managers and Nursing Supervisors, and nursing staff on the monitoring of residents and utilizing the Monitoring Log a3/2/21) 4) Staff that have been educated and trained on close monitoring. Close monitoring will be assigned by Charge nurse. Education was provided by the Regional Nurse Consultant to Nursing Managers ADON, Unit Managers, and Nursing Supervisors on monitoring of residents who then educated the nursing staff on close monitoring initiated 2/26/21 and continues until all staff completed education. Close Monitoring of resident Policy explained to Nursing staff and IDT. (Education was provided by the Regional Nurse Consultant to Nursing Managers ADON, Unit Managers, and Nursing Consultants on monitoring of residents who then educated the nursing staff on close monitoring initiated 2/26/21 and continues until all staff completed education) Education * Facility wide Abuse Policy and Procedure education. Education provided Administrator and Regional Nurse consultant. IDT members then began in servicing the line staff 0n 2/26/21 and in servicing continues until every employee has been in service. Administrator began All Staff in-service all three shifts on Thursday 3/4/21 Friday 3/5/21 and weekend days if necessary, to achieve 100% of staff) * Staff interviews on if they have observed or verbally been informed of maladaptive behaviors that may constitute abuse to residents by other residents that have exhibited in the past or present. *Social Service Department provided education on Behaviors, interventions, individualized plan of care, interviewing residents and staff when abuse occurs and assessments for physical aggression by Social Service Consultant to the Social Services Department on 2/25/21 and 2/26/21. *Admissions department education on behavioral referrals and process for acceptance and denial of residents. (Training completed by Regional Nurse Consultant 2/25/21 to Admission Director on use of Audit Tool). *Job Description and expectations for those that will be providing close monitoring (Education has been provided by Regional Nurse Director to IDT Nursing Mangers and at this time we are in process of evaluating specific nursing staff other than Nurse Mangers, Supervisor, licensed staff, or IDT members who will be allowed to provide close monitoring of residents completion will be 3/5/21) *Education on close monitoring and competency test for all nursing staff. Education was provided by the Regional Nurse Consultant to Nursing Managers on monitoring of residents who then educated the nursing staff on close monitoring initiated 2/26/21 and continues until all staff completed education. * Social Service Behavioral Monitoring Policy Education was provided to Social Services Department on 2/25/21 and 2/26/21. * Social Service Behavioral Monitoring Audit Tool education was provided by the Regional Nurse Consultant to Nursing Managers ADON, Unit Managers, and Nursing Supervisors on monitoring of residents utilizing the Monitoring Log to the nursing staff 3/2/21. FACILITY EMPLOYEE LIST FOR SIGNITURE LIST UTILIZED TO INDICATE ALL STAFF EDUCATED All staff that are unable to attend the abuse training or in servicing relating to monitoring of residents must be in serviced prior to the start of their shift. The Information can be emailed and a verbal conversation over the phone indicating communication was on phone. The education document will be signed by educator with email confirmation attached to in service. Agency staff will have a copy of the abuse and monitoring packet send to their agency and they must email any potential employee that will be assigned to work the information. The agency staff before starting the shift will be asked by receptionist if they have received the abuse and monitoring documents and they will be given an in-service by the nursing supervisor or IDT member before the start of their shift.

Based on observation, interview, and record review, the facility failed to; 1. implement its skin-breakdown prevention care plan interventions, and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure has caused multiple wounds to one (R14) of four (R14, R15, R16, and R19) residents reviewed for pressure ulcer prevention and treatment in a sample of 20 residents. Findings include: Record review on skin/wound note dated on 12/26/20 document that R14 was readmitted to the facility on [DATE] with no open skin noted. Sacrum and buttocks were intact. Record review on physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on weekly skin assessment (electronic medical record - EMR) indicates a weekly skin assessment dated [DATE] with no wound noted for R14. EMR review indicates no other weekly skin assessments documented on the EMR system between 12/31/20 and 1/11/21. EMR weekly skin assessment dated [DATE] document loss of skin integrity with multiple wounds. Record review on weekly wound evaluation dated on 1/14/21 documented an inhouse acquired deep tissue injury with sacrum (9 x 6 x 0.1 cm), right buttocks (3.5 x 1.5 x 0 cm), left trochanter (2.5 x 1 x 0 cm), and right medial knee (1.5 x 2 x 0 cm). Weekly wound evaluation dated 2/16/21 documented in-house acquired pressure injury to the right ear (2.0 x 0.4 x 0.3 cm) Record review on hospital record dated on 2/19/21 document R14 was admitted with large stage 4 sacral decubitus, foul-smelling, older appearing packing noted in the wound with some overlying granulation tissue. On 2/26/21 at 2:10 PM, V34 (wound nurse practitioner) stated, Deep tissue injury (DTI) is considered as pressure injury caused by prolonged pressure to body parts. The damage can be superficial to deep muscle and can deteriorate to the unstageable wound. R14 developed DTI to the right buttocks, which deteriorate into an unstageable wound. She also developed DTI on the sacrum and her elbow. On 3/3/12 at 11:55 AM, V33 (R14's attending physician) stated, DTI develops on an immobile/bedrest patient when laying on the same position for such a long time. R14 developed DTI due to prolonged pressure on her body parts. DTI can be prevented by relieving pressure/turning/repositioning. If the facility could have followed the weekly skin check, they could have prevented wound deterioration and possibly preventing some of the wounds. Record review on facility provided (undated) risk and skin assessment document: II All residents will have a visual inspection of their skin. B. Skin checks are completed weekly by the nurse. On 2/24/21 at 4:50 PM, V16 in her office stated R15 has a low air loss mattress and a chair-cushion. V16 stated she knows he has a low air loss mattress because of his wound. Wound tech made rounds yesterday and verified all of the low air loss mattresses were in place. On 2/24/21 at 4:55 PM in R15's room, V15 and V16 examined R15's bed and determined R15 did not have a low air loss bed in place in his room. V16 stated, When did they change this?! R15 replied, I didn't work! R15 stated he had not had his low air loss mattress for weeks since he moved into his current room from a previous room. On 2/24/21 at 4:55 PM in R15's room, V16 examined R15 leaning to his right side in his custom wheelchair and stated, He should not be sitting like that! V16 examined both sides of R15's pressure relieving cushion and stated the right side was inflated, but the left side was deflated. V16 stated both sides should have been inflated. On 2/26/21 at 11:10 AM, observed R19 in the presence of V16 on his bed with bilateral heel-wounds and without having heel boots on. Observed heel boots left at the bedside, and R19 stated, They didn't put it back after wound care. V16 stated, The heel boots should have been applied to R19's foot. Record review on R19's skin care-plan indicates heel protector to bilateral heels. On 3/2/21 at 2:00 PM, V2 (Director of Nursing) stated, Staff was supposed to follow the care plan interventions and should have applied heel boots on R19. On 2/26/21 at 2:10 PM, V34 stated, Heel boots will help bed rest patient to prevent pressure ulcer with heels. If patients already have heel-wounds, heel boots will help to heal the wound.

Based on interview and record review the facility failed to have a system in place to ensure a newly admitted resident received [MEDICAL TREATMENT] treatments and failed to follow their policy to initiate and provide [MEDICAL TREATMENT] services for a resident. As a result of this failure, R4 required emergency room admission at the local hospital due to not receiving four [MEDICAL TREATMENT] treatments between 12/23/2020 and 12/31/2020. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on December 22, 2020 when the facility failed to ensure R4 received [MEDICAL TREATMENT] when the resident was admitted to the facility. This applies to 1 of 5 residents (R4) reviewed for [MEDICAL TREATMENT] services in a sample of 14. V1 (Administrator), V23 (Acting Director of Nursing/Nurse Consultant), V25 (VP of Clinical Services), and V26 (Regional Director of Operations) were notified of the Immediate Jeopardy on January 13, 2021 at 4:50 PM. V23 was provided with the Immediate Jeopardy Template outlining the failures. Although the immediacy was removed on January 14, 2021 the facility remains out of compliance at Severity Level II due to the need to evaluate and implementation of new policies and procedures and Quality Assurance monitoring. The findings include: On 01/13/2021 at 8:46 AM, V16 (Admissions Coordinator) said the facility was accepting new residents including residents who required [MEDICAL TREATMENT]. On 01/13/2021 at 8:49 AM, V13 ([MEDICAL TREATMENT] Center Registered Nurse) said the facility's in-house [MEDICAL TREATMENT] unit services were provided by ([MEDICAL TREATMENT] company) and currently had 14 [MEDICAL TREATMENT] residents. V13 said the [MEDICAL TREATMENT] unit had eight chairs which could accommodate [MEDICAL TREATMENT] residents three days a week on Mondays, Wednesdays, and Fridays in three shifts for a total of 24 [MEDICAL TREATMENT] residents. According to the Electronic Health Record (EHR) R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The incomplete Minimum Data Set ((MDS) dated [DATE] showed R4 needed extensive assistance of two people for bed mobility, dressing, and toilet use; and was totally dependent on two people for transfers. The MDS showed R4's cognition was intact. The Physician order [REDACTED]. R4 did not have a care plan for [MEDICAL TREATMENT] initiated on admission until 01/05/2021. The Hospital Records Nurse to Nurse Report dated 12/22/2020 showed R4 had received [MEDICAL TREATMENT] in the hospital on [DATE]. The Hospital Physician Notes dated 12/21/2020 at 11:08 PM showed R4 had acute [MEDICAL CONDITION] with [MEDICAL TREATMENT] per nephrology orders. The Nephrology Consult dated 12/21/2020 showed R4 had [MEDICAL CONDITIONS] continue [MEDICAL TREATMENT] Monday, Wednesday, and Friday. On 01/12/2021 at 9:31 AM, V6 (Medical Doctor (MD) Nephrology) said Luckily for (R4) he must still have some kidney function left. Most [MEDICAL TREATMENT] patients would die or get fluid overload then die. I have had people miss one [MEDICAL TREATMENT] treatment and die from missing just one. V6 said R4's BUN (Blood Urea Nitrogen) level in the emergency roiagnom on [DATE] was very high at 92 which indicates inadequate kidney functioning. According to V6, missing [MEDICAL TREATMENT] is harmful for the resident and has a risk of [MEDICAL CONDITION] and death. V6 said nobody from the facility had reached out to him regarding the situation. V6 said there has to be better communication between the floor nurses and the [MEDICAL TREATMENT] staff for a [MEDICAL TREATMENT] resident. laboratory results dated [DATE] showed R4 had: a BUN level of 92 milligrams per deciliter (mg/dl) (normal BUN range level is 5.0 to 28.0); a Creatinine level of 3.0 mg/dl (normal Creatinine range level is 0.70 to 1.30); and an alkaline [MEDICATION NAME] level of 291 units/liter (normal alkaline [MEDICATION NAME] level is 34-104). On 01/04/2021 at 12:54 PM, V3 (Nurse Practitioner (NP) Nephrology) stated she was informed by V19 (the facility's Nurse Practitioner) on 12/31/2020 at 7:35 AM, R4 had not received [MEDICAL TREATMENT] since admission to the facility on [DATE], nine days earlier. V3 said R4 should have been receiving [MEDICAL TREATMENT] three times a week on Monday, Wednesday, and Friday, missing four [MEDICAL TREATMENT] treatments, which prompted sending him to the hospital emergency room to receive [MEDICAL TREATMENT]. V3 said if a resident doesn't receive [MEDICAL TREATMENT], they have the potential for elevated Potassium from which they can die. V3 said the resident could also have a buildup of fluid in the lungs and heart resulting in pneumonia or possibly respiratory arrest. On 01/11/2021 at 4:10 PM, V21 ([MEDICAL TREATMENT] Company VP National of Compliance and Education [MEDICAL TREATMENT]) said R4 must have had substantial residual kidney function or had been receiving [MEDICAL TREATMENT] for less than six months or the outcome would have been more severe and possibly death. V21 said typically the facility admissions person or a nurse should notify the [MEDICAL TREATMENT] staff when the resident was admitted to the facility in order for them to start [MEDICAL TREATMENT]. According to V21, the [MEDICAL TREATMENT] center sends a list of the residents receiving [MEDICAL TREATMENT] to each nurse's station in the facility. The nurse should be responsible for contacting the [MEDICAL TREATMENT] center and asking why the person was not on the schedule. On 01/05/2021 at 2:43 PM, V19 (NP) said on 12/31/2020 at approximately 9:00 AM, R4 relayed that he had not been receiving [MEDICAL TREATMENT] since he was admitted to the facility nine days earlier. V19 consulted with V3 (nephrology nurse practitioner) and the decision was made to send R4 to the emergency room for [MEDICAL TREATMENT]. Nursing Progress Notes do not show any documentation of when R4 was sent to the hospital. The Hospital Emergency Department Notes showed R4 arrived at the hospital on [DATE] at 11:52 AM. On 01/07/2021 at 3:44 PM, V18 (Licensed Practical Nurse (LPN) agency) said she had admitted R4 but had not received report from the transferring hospital. V18 said as an agency nurse she had never been trained to do an admission at the facility. V18 said she will look through the hospital paperwork, enter the medication orders into the computer, and do the resident assessments. V18 did not call the physician to verify orders for R4. V18 was not certain but said she may have asked the night nurse to call the physician to verify orders. V18 denied notifying the [MEDICAL TREATMENT] center because she did not know how to notify them and had assumed they were aware of it during the admission process. On 01/08/2020 at 9:19 AM, V18 said she felt the facility should have a nursing manager or supervisor review the admission orders [REDACTED]. On 01/06/2021 at 11:56 AM, V16 (facility Admissions Coordinator) said prior to admission she sends a referral to in-house [MEDICAL TREATMENT] center admissions department regarding any incoming [MEDICAL TREATMENT] residents. V16 said she sent the referral information to ([MEDICAL TREATMENT] company) for R4 prior to his admission. According to V16, once R4 was admitted , she just checks that he was in the building and the floor nurses are supposed to notify the [MEDICAL TREATMENT] department that the resident was in the building. On 01/05/2021 at 12:55 PM, V5 (Acting Assistant Director of Nursing (ADON)) said with a newly admitted resident the nurse should enter the orders from the hospital and call the physician to verify the orders. V5 said usually the ADON will do an audit of the new resident orders. On 01/11/2021 at 11:58 AM, V5 stated she did the audit for R4's medications only. V5 said all [MEDICAL TREATMENT] residents should have orders for [MEDICAL TREATMENT] and the nurse should document the location of access site and the days of [MEDICAL TREATMENT]. V5 said when a resident comes in for [MEDICAL TREATMENT], the nurses would assume care had been coordinated with the [MEDICAL TREATMENT] center by the admission coordinator. V5 said it was the Admissions Coordinator's responsibility to coordinate [MEDICAL TREATMENT] with ([MEDICAL TREATMENT] company), the in-house [MEDICAL TREATMENT] center. V5 did not know why R4 didn't get [MEDICAL TREATMENT] for two weeks, I don't know what happened there honestly. No residents requiring [MEDICAL TREATMENT] will come into the building unless they are approved to receive treatments by the [MEDICAL TREATMENT] center. V5 said the [MEDICAL TREATMENT] nurse will send a list of any new [MEDICAL TREATMENT] residents to every station. V5 said the nurse had the responsibility to call the [MEDICAL TREATMENT] center when they noticed R4 was not being called for [MEDICAL TREATMENT], notify the [MEDICAL TREATMENT] center he was admitted to the facility, and ask why he wasn't being dialyzed. V5 stated I have no idea why none of the nurses picked up on it. On 01/13/2021 at 11:04 AM, V23 (Acting Director of Nursing from corporate) said V2, the previous Acting Director of Nursing from corporate was MIA (missing in action) and V23 was the acting DON since Friday 01/08/2021. V23 said she was not aware of R4 not receiving [MEDICAL TREATMENT] for nine days and would need to further investigate what happened. The facility's undated [MEDICAL TREATMENT] policy includes All residents that are admitted to the facility with needs for [MEDICAL TREATMENT] will have coordination of services between the facility and the [MEDICAL TREATMENT] unit prior to admission. [MEDICAL TREATMENT] services will be set up prior to admission .The facility will obtain orders from the physician for the resident [MEDICAL TREATMENT] days and be written on the physician order [REDACTED]. Through interviews and record review conducted on January 21, 2021 the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: All Licensed nursing staff will be educated beginning 1/14/2021 for the current staff that are employed by the facility; and Agency staff will be educated prior to the start of their shift for the following procedures: · How to review the resident's orders from the sending facility and determining [MEDICAL TREATMENT] treatment is required. · Physical assessment of resident to include access for [MEDICAL TREATMENT] treatment Central catheter and AV fistula. · Placing orders in PCC for [MEDICAL TREATMENT] treatment. · Communicating to the DON from the admitting nurse that a new resident admitted or readmitted to the facility requires [MEDICAL TREATMENT] treatment in house, this will be done via phone call (when not in building) or in person (when DON present in facility). · Utilizing the Admission Checklist and Audit Tool for all [MEDICAL TREATMENT] admissions to the facility or readmissions. · Documentation in the medical record that the [MEDICAL TREATMENT] Treatment center is aware of the new admission for [MEDICAL TREATMENT] and the days and time that the resident will be transported to the [MEDICAL TREATMENT] department. · Education on the use of the [MEDICAL TREATMENT] Communication Tool. · Education on the policy and procedure of In-House and Community [MEDICAL TREATMENT] · The Nursing Admission Process Quiz will be part of competency. · Education on the signs and symptoms of Fluid Overload and [MEDICAL CONDITION]. Admissions Director Education · If a patient is appropriate for acceptance to the facility for [MEDICAL TREATMENT], the admissions director will forward the patients information on to the [MEDICAL TREATMENT] center for in house [MEDICAL TREATMENT] approval. If this criterion is met, and the resident is scheduled to be admitted , the admission director, will notify immediately via (phone call /in person or email) to the DON/ADON/Administrator and [MEDICAL TREATMENT] center of accepted admissions with the probable date and time of the admissions or readmissions and if there are any delays from expected time admissions will be communicate as well. Admissions director will inform all IDT members (facility managers) any new [MEDICAL TREATMENT] residents during AM Meeting/Stand Down (Mon-Friday) and email daily. The Director of Admissions was educated on her responsibility of new and readmitted [MEDICAL TREATMENT] residents. The director of admissions or designee will utilize an admission department audit tool on all new or readmitted [MEDICAL TREATMENT] residents. Education initiated on 1/14/21 by the Regional Nurse Consultant to admissions Director/designee. The DON /ADON reviewed and verified all [MEDICAL TREATMENT] residents currently receiving [MEDICAL TREATMENT] have physician order [REDACTED]. The DON/ADON will continue to review the admission audit sheet for all new and readmitted [MEDICAL TREATMENT] residents. Initiated on 1/14/21 and will continue for all [MEDICAL TREATMENT] residents admitted or readmitted with no current stop date. The assigned unit/floor nurse will be responsible for initiating the [MEDICAL TREATMENT] communication form for all the residents receiving in house [MEDICAL TREATMENT] on the days that they receive [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] nurse will indicate the resident's status during and post treatment via the communication form and will send the form back to the unit via the transporting aide after the completion of [MEDICAL TREATMENT] services. The [MEDICAL TREATMENT] nurse will send a copy of the [MEDICAL TREATMENT] form via email to DON/ADON and Administrator at end of [MEDICAL TREATMENT] days. The [MEDICAL TREATMENT] communication forms sent with the residents will be placed in the residents' chart.

Based on interview and record review the facility failed to initiate CPR (Cardio-Pulmonary Resuscitation) rescue breaths for a resident designated as a full code. The facility also failed to ensure that staff had current healthcare provider CPR certificates for staff on duty, and failed to ensure that staff was knowledgeable and competent in assessing residents in cardiac/respiratory distress. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on (MONTH) 18, (YEAR) at 6:30 AM when facility staff failed to initiate CPR rescue breaths for R2. This applies to 4 of 7 residents (R2, R9, R10, R11) reviewed for improper nursing in the sample of 11. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on (MONTH) 26, (YEAR) at 3:03 PM. Although the immediacy was removed on (MONTH) 28, (YEAR), 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 (MONTH) 18, (YEAR), V3 (LPN-Licensed Practical Nurse) documented, 6:30 AM Observe (R2) was not responsive, not breathing but able to palpate pulse. O2 started at 10 LPM (Liters Per Minute) .Called 911. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on (MONTH) 15, (YEAR) at 6:00 PM with multiple [DIAGNOSES REDACTED]. The POS (Physician order [REDACTED]. On (MONTH) 26, (YEAR) at 10:00 AM, V23 (Paramedic) said, We responded to a call at the facility on (MONTH) 18, (YEAR). We went to (R2's) room. No staff was present in the room with the resident. I remember there was another resident in the room, so we weren't sure which resident we were supposed to attend to, and there was no staff in the room with the resident for us to ask. (R2) was wearing a non-rebreather mask with oxygen, and when we assessed him, we determined he had agonal breathing, which is ineffective breathing at a rate of 4 breaths per minute. A non-rebreather mask with oxygen would not be effective for this resident because of his poor respiratory effort. He had a low blood pressure and a strong pulse. This resident needed CPR support breaths. No one at the facility was providing that to the resident. Paramedic documentation dated (MONTH) 18, (YEAR) shows the paramedics were notified at 6:30 AM of a [MEDICAL CONDITION]/death event for R2. The primary symptoms were unconsciousness and unresponsive. Paramedic documentation shows the paramedics arrived at R2's bedside at 6:34 AM. Vital signs taken by the paramedics at 6:35 AM showed R2 was unresponsive, had a blood pressure of ,[DATE], a pulse of 74, a respiratory rate of 4 breaths per minute, and R2's respiratory effort was weak and agonal. At 6:35 AM, paramedics applied a bag-valve mask. At 6:38 AM the paramedics inserted an oropharyngeal airway, and at 6:58 AM the paramedics arrived at the local hospital. On (MONTH) 20, (YEAR) at 5:45 AM, V3 said, On (MONTH) 18, (YEAR), (R2) was sitting up in the [MEDICAL TREATMENT] chair waiting to go to [MEDICAL TREATMENT] in his room. I went back in the room about an hour after we got him up, which was around 6:30 AM. He was not responsive, and not breathing. I ran down the hall to get the RN (Registered Nurse). Somebody paged code blue overhead. I checked the pulse and it was weak. I did not check his blood pressure. I did not provide rescue breaths to him. We did not use the bag-valve mask on him. I did not do CPR because he had a pulse. On (MONTH) 19, (YEAR) at 4:45 AM, V10 (RN-Registered Nurse) said, (V3) called me around 6:00 AM to her resident's room because he was unresponsive. She always calls me to check her residents. I got to the room and the resident was in bed with a non-rebreather mask on. We never opened the crash cart. He never woke up to tactile stimuli. I did not provide rescue breaths. I left the room before 911 personnel came. On (MONTH) 20, (YEAR) at 5:38 AM, V4 (LPN-Licensed Practical Nurse) said, I responded to (R2's) room. I was not the first nurse in the room. The crash cart was in the room, but we did not use it. I did not provide rescue breaths to the resident. I was not in the room when the paramedics arrived. On (MONTH) 20, (YEAR) at 5:50 AM, V5 (LPN) said, We all went to (R2's) room. I don't know if he was breathing. He had a pulse. He was in the chair for [MEDICAL TREATMENT]. We used the sling and the mechanical lift to put him to bed. He had a pulse and a blood pressure so we did not do CPR. Me and (V24) (LPN) put a non-rebreather mask on him. I would say he appeared to be in a deep sleep. We were never able to wake him up before the paramedics came. On (MONTH) 24, (YEAR) at 9:40 AM, V12 (RN/[MEDICAL TREATMENT] Nurse) said, I am CPR certified. The day of (R2's) code, the nurses called me and asked me to come to the room to look at him. They had already called 911. I observed the resident. He was not breathing. I told them they needed to do something. I suggested putting him on a non-rebreather mask with oxygen. They were not giving him rescue breaths. On (MONTH) 20, (YEAR) at 9:50 AM, V16 (Physician) said, she expected the facility personnel to follow the order for R2's full code status and rescue breaths should have been provided to R2 if he was not effectively breathing. On (MONTH) 20, (YEAR) at 1:30 PM, V2 (DON-Director of Nursing) said she would expect facility staff to support respirations if the resident was a full code and was not breathing. No code blue sheet was filled out by the facility staff because R2's situation was not a code blue. The resident had a pulse. (V3) is very challenged in her nursing skills. I am going to have to bring her to day shift to keep an eye on her. On (MONTH) 26, (YEAR) at 11:45 AM, V1 (Administrator) said facility staff should fill out the code blue worksheet when a code blue situation is identified, and all facility staff are required to have current healthcare provider CPR certification. V1 said, The Business Office Manager is supposed to be keeping track of all facility staff to ensure their CPR certification is current. Facility documentation shows V3 (LPN), did not have current healthcare provider CPR certification. V10, the RN who was asked to assist V3 in assessing the resident did not have current healthcare provider CPR certification. As of (MONTH) 20, (YEAR) at 4:00 PM, the facility had documentation to show 6 nurses were working at the time of R2's respiratory arrest. Of the 6 nurses, only V24 (LPN) and V7 (CNA-Certified Nursing Assistant) had current healthcare provider CPR certification. The facility did not have documentation to show V24 or V7 provided rescue breaths to R2. The American Heart Association Basic Life Support Manual dated (YEAR) shows: Look for no breathing or only gasping and check pulse simultaneously). If no normal breathing, but has a pulse, Provide rescue breathing: 1 breath every ,[DATE] seconds, or about ,[DATE] breaths/minutes. Activate emergency response system (if not already done) after 2 minutes. Continue rescue breathing; check pulse about every 2 minutes. If no pulse, begin CPR. Respiratory arrest can be identified when the victim is found to be unresponsive, not breathing or only gasping, but still has a pulse. BLS (Basic Life Support) providers should be able to quickly identify respiratory arrest, activate the emergency response system, and begin rescue breathing. Quick action can prevent the development of [MEDICAL CONDITION]. In addition to R2, the facility provided a list of resident's code status. Multiple residents were identifed as full code on the facility's undated resident list including R2, R9, R10, and R11. The facility's Code Blue Medical Emergency Policy dated (MONTH) 5, 2012 shows: To provide care and services to residents in accordance with Advance Directives that have been discussed with the resident or resident's legal representative in advance of medical emergencies including medical interventions used to restore circulatory and respiratory function. 6. If a resident is determined to be a full Code (No DNR-Do Not Resuscitate), 911 will be contacted at the initiation of CPR. CPR will continue until such time that EMS has arrived at the facility and assumes treatment of [REDACTED]. The facility's undated Code Blue Worksheet shows the date and time and the person who found the resident. The worksheet shows resident assessment, including airway pulse and vital signs assessment including blood pressure, pulse rate, respiratory rate, pulse oximetry reading and blood glucose. Other documentation includes CPR initiation, oxygen, ambu bag assembled, 911, physician, and family notification. Through observation, record review, and interviews conducted (MONTH) 28, (YEAR), the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: The nursing staff will be re-inserviced on the CPR process by Nurse Consultant, DON, or designee, completion date [DATE]. These classes will be taking place in-house on days ,[DATE] and ,[DATE]. We will be monitoring this by an excel spreadsheet (see attached). The BOM (Business Office Manager) will be taking the lead with regards to monitoring CPR cards. In the absence of the BOM the administrator will be completing the spreadsheet. LICENSE STAFF WILL NOT BE PLACED ON THE SCHEDULE IF WE DO NOT HAVE THE PROPER D[NAME]UMENTATION THAT THE STAFF MEMBER IS CERTIFIED. Moving forward this will be our standard of practice, therefore we have no end date. However the facility's expectation is that we monitor this practice 1x per week as an on-going practice. · A pre and posttest will completed by the licensed staff will be completed by [DATE]. This quiz will be given at present time as well as upon orientation. The person reviewing this quiz will be DON or designee upon the DON absence. LICENSE STAFF WILL NOT BE PLACED ON THE SCHEDULE IF WE DO NOT HAVE THE PROPER D[NAME]UMENTATION THAT THE STAFF MEMBER IS CERTIFIED. This practice will be monitored by a QA tool weekly until [DATE] and then monthly to be reviewed in QA. · Mock codes will be conducted randomly throughout the quarter to include all 3 shifts. Facility has developed a drill evaluation grading their performance, those who do not perform well will be in-serviced 1:1. These mock codes will be performed by the facility consultant, DON, or designee 9 times per quarter with 3 mock codes being conducted on each shift until [DATE] and then monthly to be reviewed in QA. · The DON or designee will keep an organized binder separated by month. We will monitor this by filing their scoring evaluation in a binder and it is to be reviewed monthly by nursing consultant team with a QA tool. This will be on-going. · The licensed nursing staff will have current and valid CPR cards. A spreadsheet was developed (see attached) and will be monitored by the BOM or Administrator. Every Monday BOM, Administrator, and scheduler will meet and discuss whose CPR card is expiring. We will also communicate this to staff in writing. This letter will explain that their CPR card will be expiring and that the staff member will not be able to be on the schedule until the CPR certification is completed. This will be on-going. Administrator is expected to take notes during the Monday meeting. All new hires will be added to excel spreadsheet by BOM and will be reviewed during Monday's meetings. Spreadsheet will be updated by [DATE]. · If a resident has a change in status, American Heart Association's guidelines will be followed, per nurse's training. · A code blue will be called by a staff member and the emergency response will be initiated. · Rescue breaths will be initiated if the resident has respiratory arrest. · Additional staff will respond to the room to assist with the management of the code. · The licensed staff member will remain with the resident until resident is transferred for further treatment or the resident is expired. · A code blue worksheet will be completed by the assigned nurse. · The DON/designee will review and audit the code blue worksheet and the change of condition documentation after every code. (See QA tool) Please note, this practice will not change. It is the facility's expectation that these sheets will be reviewed by DON/designee after codes to ensure compliance. Any issues or discrepancies will be discussed in QA meeting and employee will be in-serviced 1:1 by DON/Designee. · All info with regards to new hires, CPR cards/classes, completion will be reviewed during monthly QA meeting as well as mock code results. At QA meeting effectiveness of plan and errors must be discussed and revisions made monthly if needed. ** Please note, those who were unable to be in-serviced due to FMLA, vacations or anything will not be able to work until the training has been completed** COMPLIANCE WILL BE TRACKED BY LOG SHEET THAT IS BEING MONITORED EVERY MONDAY BY ADMINISTRATOR OR DESIGNEE.

Based on interview and record review the facility failed to provide [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) equipment as ordered by the physician, for a newly admitted resident with a history of acute [MEDICAL CONDITION]. As a result of this failure, R2 experienced [MEDICAL CONDITION] on (MONTH) 18, (YEAR) at 6:30 AM, resulting in hospitalization , intubation, and the need for mechanical ventilation. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on (MONTH) 15, (YEAR) when the facility failed to provide R2 with the necessary [MEDICAL CONDITION] machine for use at bedtime, when R2 was admitted to the facility. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on (MONTH) 26, (YEAR) at 3:03 PM. Although the immediacy was removed on (MONTH) 28, (YEAR), the facility remains out of compliance at Severity Level II due to the need to evaluate the implementation of new policies and procedures and Quality Assurance monitoring. This applies to 1 of 3 residents (R2) reviewed for specialty care in the total sample of 11. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on (MONTH) 15, (YEAR) at 6:00 PM with multiple [DIAGNOSES REDACTED]. The POS (Physician order [REDACTED]. On (MONTH) 16, (YEAR) at 12:40 AM, V11 (RN-Registered Nurse) documented, [MEDICAL CONDITION] machine has to be ordered. (V16) (Physician) notified. On (MONTH) 17, (YEAR) at 11:05 PM, V11 documented, [MEDICAL CONDITION] at bedtime - still waiting for delivery. On (MONTH) 18, (YEAR), V3 (LPN-Licensed Practical Nurse) documented, 6:30 AM Observe (R2) was not responsive, not breathing but able to palpate pulse. O2 started at 10 LPM (Liters per Minute) .Called 911. Paramedic documentation dated (MONTH) 18, (YEAR) shows the paramedics were notified at 6:30 AM of a [MEDICAL CONDITION]/death event for R2. The primary symptoms were unconsciousness and unresponsive. Paramedic documentation shows the paramedics arrived at R2's bedside at 6:34 AM. Vital signs taken by the paramedics at 6:35 AM showed R2 was unresponsive, had a blood pressure of 74/42, a pulse of 74, a respiratory rate of 4 breaths per minute, and R2's respiratory effort was weak and agonal. At 6:35 AM, paramedics applied a bag-valve mask. At 6:38 AM the paramedics inserted an oropharyngeal airway, and at 6:58 AM the paramedics arrived at the local hospital. Hospital documentation dated (MONTH) 18, (YEAR) shows: (R2) presents with mental status change noted at nursing home. When paramedics arrived patient was bradypenic (slow respiratory rate) and no staff in room. Thready pulse. Oral airway placed and (R2) bagged during transport. Patient arrives obtunded, very shallow respirations assisted by bag-valve mask. Diagnostic impression: AMS (Altered Mental Status), acute hypercapnic (carbon [MEDICATION NAME] retention) [MEDICAL CONDITION] - patient intubated in the ER, acute [MEDICAL CONDITION], OSA (Obstructive Sleep Apnea). On (MONTH) 19, (YEAR) at 2:23 PM, V3 (LPN-Licensed Practical Nurse) said, Yesterday morning I went in (R2's) room. Me and a CNA (Certified Nursing Assistant) got him up from the bed with a mechanical lift and put him in the [MEDICAL TREATMENT] chair in his room, around 5:30 AM. We left him in his room. Around 6:30 AM we went in his room to take him to [MEDICAL TREATMENT]. I saw he wasn't responsive. I said his name and he did not wake up. He was not breathing but he had a pulse. He was a full code resident. V3 was again interviewed on (MONTH) 20, (YEAR) at 5:45 AM and stated, On (MONTH) 18, (YEAR), (R2) was not put on [MEDICAL CONDITION] because we never received the machine. He was sitting up in the [MEDICAL TREATMENT] chair waiting to go to [MEDICAL TREATMENT] in his room. I went back in the room about an hour after we got him up, which was around 6:30 AM. He was not responsive, and not breathing. I ran down the hall to get the RN (Registered Nurse). Somebody paged code blue overhead. I checked the pulse and it was weak. I did not check his blood pressure. On (MONTH) 20, (YEAR) at 9:50 AM, V16 (Physician) said, (R2) had a history of [REDACTED]. I expected the facility to have the [MEDICAL CONDITION] machine for the resident upon admission to the facility. I was aware he had a history of [REDACTED]. If the equipment wasn't there, how do we offer it to him to refuse? Without the equipment, there was no choice. As a result of not having the [MEDICAL CONDITION] equipment, (R2) went into respiratory arrest at the facility, got intubated, and is now in the ICU (Intensive Care Unit) requiring mechanical ventilation. The resident has had multiple episodes of [MEDICAL CONDITION]. The resident has never had an episode of [MEDICAL CONDITION] when he was wearing the [MEDICAL CONDITION] equipment. I expected the facility to start the [MEDICAL CONDITION] on (MONTH) 15, (YEAR), the night he was admitted to the facility. On (MONTH) 20, (YEAR) at 9:56 AM, V20 (Medical Records) said, I am in charge of ordering all equipment for the residents prior to admission. I was told by the Administrator on Monday afternoon, (MONTH) 17, (YEAR) that we needed to order a [MEDICAL CONDITION] machine for (R2). I called the company and they said they would deliver the equipment the next day on (MONTH) 18, (YEAR). We ordered the machine, but by the time it came, the resident had been sent to the hospital. I need to be notified, verbally, when a resident needs equipment. Someone should have called me and I could have ordered it right away. Even on the weekend, they can call me if they have to. V20 said she was never notified, prior to (MONTH) 17, (YEAR), that R2 needed a [MEDICAL CONDITION] machine. On (MONTH) 20, (YEAR) at 1:30 PM, V2 (DON-Director of Nursing) said, The [MEDICAL CONDITION] machine never came for (R2). The equipment should be in the building before the resident gets admitted . On (MONTH) 25, (YEAR) at 10:00 AM, V11 (RN-Registered Nurse) said, I admitted (R2) to the facility around 6:00 PM on Saturday, (MONTH) 15, (YEAR). The [MEDICAL CONDITION] machine wasn't available when he came to the facility. The nurse who gave me report from the hospital told me the resident had [MEDICAL CONDITION] orders and he didn't like to use the [MEDICAL CONDITION]. When the resident came to the facility, the hospital sent the tubing but not the [MEDICAL CONDITION] machine. I called the hospital and they said we had to use our own machine. This was the first time I ever admitted a resident to the facility who needed [MEDICAL CONDITION] so I didn't know what to do. I notified (V22), the MOD (Manager on Duty). She said the equipment needed to be ordered. I notified the physician that we didn't have the [MEDICAL CONDITION] equipment and the hospital had said he had a history of [REDACTED]. I endorsed the information to the next shift. I didn't return to the facility for a couple of days and when I came back, the equipment was not in the room. I asked (V20) (Medical Records), and she said no one ever told her the equipment needed to be ordered. On (MONTH) 25, (YEAR) at 12:01 PM, V22 (MOD/Activities Director) said, I was the last manager in the building on Saturday, (MONTH) 15, (YEAR). There was a report that there was an admission coming in that day. All the managers receive an email that there's a move in. It's generated from our Admissions Department. I think I saw the email on the morning of the admission. (V2) (DON-Director of Nursing) is the person who reviews the resident coming in and she alerts us to what is needed for the resident. We make sure that everything they need is in place. We don't usually get resident admissions on Saturdays. I didn't read the whole profile. I just read the part about activities. I was told by (V11) that the resident needed a [MEDICAL CONDITION] machine. I told her we don't keep those in the building. I told her [MEDICAL CONDITION] machines need to be obtained from an outside vendor. Medical Records should order needed equipment when they learn of the admission and get the information from (V2). When (V11) called me she said there's a resident coming and he needs a [MEDICAL CONDITION] machine. I told her to let the doctor know and get some other recommendations from her since we did not have the [MEDICAL CONDITION] machine in the building. I also told her to let (V2) know about the situation. I was told the hospital nurse reported that (R2) was refusing to use the [MEDICAL CONDITION] machine in the hospital. I told her to endorse the physician's orders [REDACTED]. It was (V11's) responsibility as a nurse to get the recommendations from the doctor to better serve the resident. Other options we could have explored would have been borrowing the equipment from our sister facility. I'm not sure if they ever explored looking at a sister facility for the [MEDICAL CONDITION] machine. The facility did not have documentation to show V16 (Physician) provided alternative orders due to the absence of the [MEDICAL CONDITION] machine. On (MONTH) 25, (YEAR) at 2:15 PM, V15 (Director of Admissions) said, (R2's) initial referral from the hospital was sent to us on (MONTH) 12, (YEAR). I went to the hospital that same day to verify the resident was not on a ventilator. I talked to the nurses and the case manager and confirmed he was not on a ventilator. The resident was approved for admission to our facility. We were told the resident would admit to our facility on (MONTH) 14, (YEAR) after he finished [MEDICAL TREATMENT]. I am not sure why, but the resident didn't end up transferring to our facility until Saturday, (MONTH) 15. The DON determines the medical equipment needed for the resident. On (MONTH) 25, (YEAR) at 2:40 PM, V2 (DON) said, All admissions come to me for clinical review. Initially we had a referral form with lots of information. Corporate changed the process and the form. We became a census-focused building and they wanted us to move people in quickly. That new process failed miserably. We had some resident readmissions under the new process, but (R2) was the only resident who was admitted through the new process. I did a quick scan of the record. Because of this process, the [MEDICAL CONDITION] was missed. Also, the nurse was instructed to call me about the missing [MEDICAL CONDITION] by the supervisor, but she never did. The facility's Admission Guidelines Policy shows: Procedure: 2. At the time each individual is admitted , the facility must have physician's orders [REDACTED]. Procurement of all medical equipment needed upon admission will be facilitated by admitting nurse per physician orders. As of (MONTH) 25, (YEAR) at 3:15 PM, V2 (DON) said the facility does not currently have a policy and procedure or protocol in place to ensure all facility staff are aware of the steps necessary to ensure physician-ordered medical equipment is available upon admission. The nurses need to be contacting me if they don't have the necessary equipment. I've met with many of the nurses throughout the week to tell them that, but not all of the nurses. Through observation, record review, and interviews conducted (MONTH) 28, (YEAR), the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: All nursing staff was provided training on the admission process by 10-1-18 by the Nurse Consultant, DON, or designee, that included: gathering information, giving and obtaining report, equipment required prior to admission, room readiness, physician verification of orders, proper assessment, documentation, admission medications ordered stat, nurse to nurse verification of medications ordered, assurance of timely medication arrival and nurse manager rotation and order verification. A posttest will be completed by licensed staff. 1. The facility adjusted the Pre-Admission screening form 2. Referral will be printed and given to DON or designee for clinical approval by Admissions Director or designee. The Pre-admission information form will be completed to assist in identifying the needs of the resident prior to admission by DON or Designee. The DON or designee will monitor and collect the forms daily and keep them in a binder. A QA tool (attached) will be completed by Administrator or designee weekly for compliance until 1/1/19, then monthly for 3 months and as needed. 3. The admissions will be tracked daily by the admission director/designee using a QA tool. The DON/Designee will audit the admissions tracking weekly until 1/1/19, then monthly for 3 months and as needed. 4. Once approved, the DON/designee will have the specialty equipment ordered and delivered to the facility prior to admission. DON/Designee will indicate on the pre-admission form IF the equipment is available and in house on the pre-admission sheet. Admitting nurse will verify that the specialized equipment is available/set-up or ordered per the pre-admission form. This process will be discussed monthly in QA meeting and it is on-going. 5. Verbal confirmation that the pending admission has a departure time will be conveyed to the admitting nurse by the admission director or designee. 6. The pre-admission information form and a verbal report will be given to the admitting nurse via the DON/designee. This pre-admission form will be updated by the nurse taking nurse to nurse report as indicated. The process will be monitored using a QA tool weekly by DON until 1/1/19, then monthly for 3 months and as needed. Again this is to be monitored in monthly QA meeting. 7. Personal verification that the room is aesthetically prepared and appropriate for pending resident. (clean, appropriate bed/bedding, welcome packet) If it is not prepared completely housekeeping/maintenance will be contacted to complete the task 8. A report will be given by the transferring facility to the receiving nurse. Information provided/asked will include: equipment, ABT, Oxygen Therapy (NC, [MEDICAL CONDITION]/[MEDICAL CONDITION]), Foley, Wounds (location, treatment, stage, wound vac) diet/feeding, fall risk. 9. If information is provided that equipment is needed after report is given by the transferring facility. The nurse manager/designee will verify that needed equipment is available and ordered. 10. If the equipment is not available the admission will be placed on hold until the equipment is available. 11. The admitting nurse will notify the DON/Designee and the unit staff via verbal report that equipment is needed and not available and that the admission is on hold. If a resident arrives the facility and equipment is required but was not reported to the admitting nurse during the nurse to nurse report or was not indicated in the hospital records the resident will not be accepted at that time and will be sent back to the discharge facility and the DON/Designee will be notified immediately. 12. The DON/designee will have the equipment ordered and delivered to the facility prior to the resident's arrival. The DON/Designee will assure that all needed equipment have arrived and is in working conditions. The DON/Designee will complete a QA tool daily to ensure prior to admission or within 24 hours of admission until 1/1/19, then monthly for 3 months and as needed. 13. The transferring facility will be notified via the admission director/designee that the facility has all the needed equipment to admit the resident. The DON/Designee will complete the audit tool daily as needed for compliance until 1/1/19, then monthly for 3 months and as needed. 14. Admitting nurse will review the discharge orders and verify medication with assigned MD or NP for assigned MD. Two licensed staff members will verify medication orders and sign the transfer form for accuracy. The DON/designee will audit the verification of medication orders weekly using a QA tool until 1/1/19, then monthly for 3 months and as needed. The admitting nurse will order the medication stat for a timely delivery. Resident assigned nurse will call pharmacy to verify that they have received the medication ordered. The oncoming nurse will verify the medications and orders upon delivery. Assigned nurse managers will be responsible for weekend rotation compliance with medication arrival, verification of medications orders and acquisition of equipment. 15. DON or designee will audit the admission process weekly using a QA tool for the gathering of information, giving and obtaining report, equipment gathered prior to admission, physician verification of orders, proper documentation, validation of physician orders, timely medication arrival, admission medications ordered stat, nurse to nurse medication checks, nurse managers rotation and verification of medications ordered arrival and acquisition of equipment until 1/1/19, then monthly for 3 months and as needed. 16. The process including steps taken will be reviewed and discussed in QA monthly. The Admission Process PIP Team will include the administrator, DON.ADON, admission direction, a floor nurse, CNA, maintenance, social service, housekeeping, and restorative. Staff unable to attend the training secondary to FMLA, vacation or other reason will be provided the training prior to being allowed to work

Based on interview and record review the facility failed to administer [MEDICAL CONDITION], anti-rejection, anticonvulsant and anticoagulant medications to residents as ordered by the physician, and failed to follow the facility policy for medication administration. This failure resulted in Immediate Jeopardy (IJ). The Immediate Jeopardy was noted to begin on (MONTH) 6, (YEAR) when the facility failed to provide the [MEDICAL CONDITION] medication, Nilotinib to R1 from (MONTH) 6, (YEAR) to (MONTH) 5, (YEAR). The facility also failed to administer R1's kidney transplant anti-rejection medication, [MEDICATION NAME] every evening from (MONTH) 9, (YEAR) through (MONTH) 15, (YEAR). The facility failed to administer R2's anticonvulsant medication, Lacosamide from (MONTH) 8, (YEAR) through (MONTH) 15, (YEAR). The facility failed to administer R4's anticoagulant medication, [MEDICATION NAME] as ordered from (MONTH) 15, (YEAR) to (MONTH) 25, (YEAR). The facility's Administrator (V1), Director of Nursing (V2), Nurse Consultants (V31, V32) and Regional Director (V33) were notified of the IJ on (MONTH) 26, (YEAR) at 9:10 AM. Although the immediacy was removed on (MONTH) 27, (YEAR) at 3:10 PM, the facility remains out of compliance at Severity Level II due to the need to evaluate the implementation of the new policies and procedures and Quality Assurance monitoring tools. This applies to 3 of 5 residents (R1, R2, R4) reviewed for improper nursing in the sample of 5. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1 returned to the facility on (MONTH) 9, (YEAR) following scheduled [MEDICAL CONDITION] monitoring at the hospital. Hospital orders dated (MONTH) 9, (YEAR) at 12:50 PM showed multiple medications including [MEDICATION NAME] (anti-rejection medication) 1 mg. by mouth nightly. The order was never transcribed to the POS (physician's orders [REDACTED]. The EMR shows R1 was on the [MEDICATION NAME] 1 mg. by mouth nightly prior to his hospitalization . On (MONTH) 19, (YEAR) at 10:43 AM, V23 (Nephrologist) said, (R1) could reject his transplanted kidney because of the missed doses of [MEDICATION NAME]. It isn't something that happens right away, it usually takes some time. Even if his lab work is normal right now, we still won't know the repercussions of this. Time will tell and we will have to monitor him closely. On (MONTH) 20, (YEAR) at 9:49 AM, V2 (DON) said the nurse missed the order for [MEDICATION NAME] 1 mg. every evening when she entered the orders into the computer, and therefore, R1 never received the medication as ordered by the physician. V2 said as of (MONTH) 14, (YEAR), the facility did not have a procedure in place to ensure the nursing staff accurately entered medications into the computer when a resident returns to the facility from the hospital. On (MONTH) 6, (YEAR), V13's (RN-Registered Nurse) documentation shows a refill of R1's Nilotinib ([MEDICAL CONDITION] medication) was requested from V5 (Oncologist) on (MONTH) 6, (YEAR). The nursing documentation shows R1's Nilotinib was not available at the facility from (MONTH) 6, (YEAR) at 5:00 PM until R1's discharge to the hospital for [MEDICAL CONDITION] monitoring on (MONTH) 5, (YEAR). Despite the medication not being available at the facility, V14, V15, V16, V17, and V18 (nursing staff) documented the medication was administered to R1 between (MONTH) 10 and 28, (YEAR). The facility did not have documentation to show V5 (Oncologist) was notified of the missed doses of Nilotinib. On (MONTH) 20, (YEAR) at 9:49 AM, V2 (DON-Director of Nursing) said R1 was never given the Nilotinib medication despite documentation in the medical record by five nurses showing the medication was administered. The nurses never gave the Nilotinib medication. This is not acceptable. On (MONTH) 19, (YEAR) at 12:10 PM, V4 (ADON-Assistant Director of Nursing) said, R1 did not receive the medication because the facility has been waiting for the insurance to approve the medication. Two specialty pharmacies were involved. V4 said, We didn't know the situation was all disconnected and all messed up. On (MONTH) 15, (YEAR) at 5:35 PM, V22 (Oncology Nurse) said, I work in the oncology office of (V5). We sent out the refill for the Nilotinib as soon as it was requested on (MONTH) 6, (YEAR). He had refills in (MONTH) (YEAR) of 120 pills, as well as 2 refills. No one ever called us and told us they were working on getting the medication filled and that he wasn't getting the medication. He was last seen at the office here on (MONTH) 16, (YEAR) and we verified he was taking the medication at that time. On (MONTH) 19, (YEAR) at 12:54 PM, V9 (Certified Pharmacy Technician, Public Aid Insurance Carrier) said, A pre-approval authorization is necessary to have this specialty medication approved by the insurance company. Physician notes, labs and other information needs to be sent to the insurance company. If the facility was having trouble getting the medication filled due to insurance issues, the DON or nurse manager from the facility should have contacted us about this and we could have helped them get the approval started. No one from the facility ever contacted us to make that happen. On (MONTH) 20, (YEAR) at 3:45 PM, V5 (Oncologist) said, (R1) will always have [MEDICAL CONDITION], but the medication Nilotinib is like a miracle drug for this type of disease. The medication keeps the [MEDICAL CONDITION] in check. I was not aware that (R1) is not receiving the medication. I have not spoken to (V20) (physician) or anyone from the facility about (R1) not receiving the medication. It is not ideal that he is off the medication. I'm hoping it won't be too detrimental. 2. The EMR shows R2 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. On (MONTH) 5, (YEAR), V4 (ADON-Assistant Director of Nursing) documented: (R2) went out to (local hospital) this morning for procedure, (family member) stays with her during procedure. Called (family member) at 7:00 PM to check out how is the procedure doing. (R2) is going to be admitted due to [MEDICAL CONDITION] after the procedure . Facility documentation shows R2 returned to the facility on (MONTH) 8, (YEAR). Hospital discharge orders showed an order for [REDACTED]. The EMR shows the Lacosamide was not available at the facility from (MONTH) 8, (YEAR) at 5:00 PM through (MONTH) 15, (YEAR) at 9:00 AM. Despite the medication not being available, V14, V24, V25, and V26 (nursing staff) documented the medication was administered to R2 between (MONTH) 8, (YEAR) at 5:00 PM through (MONTH) 14, (YEAR) at 5:00 PM. The facility did not have documentation to show the physician, pharmacy or DON were notified the medication was not available. On (MONTH) 15, (YEAR) at 4:00 PM, V12 (Pharmacy Consultant) said R2's Lacosamide was never sent to the facility because the medication is a controlled substance and the facility needed to send a hard copy of the order before the pharmacy would dispense the medication to the facility. The responsibility is on the facility to get the prescription over to the pharmacy when the medication is a controlled substance. Without the medication, (R2) would be at increased risk for [MEDICAL CONDITION]. On (MONTH) 19, (YEAR) at 9:30 AM, V2 said the facility missed sending the hard copy of the Lacosamide prescription to the pharmacy and 4 nurses documented they administered the medication to R2, but never did. On (MONTH) 20, (YEAR) at 11:20 AM, V19 (Physician) said, If (R2) doesn't receive the Lacosamide, she could have rebound [MEDICAL CONDITION]. The facility should have requested a hard copy of the prescription from us right away. Our turnaround time on those is 1 to 1-1/2 hours, especially in this case. I am concerned. How can they document they are giving the medication if the resident isn't receiving it. If I go there and look at the medical record and see that nurses are documenting they are giving the medication, I would assume she is receiving the medication. If she starts having [MEDICAL CONDITION], I would change her medications and that would be unnecessary since she never received the medication. That is a huge error. If the patient doesn't get the medication as ordered, she can end up back in the hospital and this could cause very bad problems. On (MONTH) 20, (YEAR) at 1:25 PM, V21 (Neurologist) said, We had to change the battery in (R2's) vagal nerve stimulator and she went into [DIAGNOSES REDACTED]. (R2) was started on the Lacosamide in the ICU (Intensive Care Unit) at the hospital and it worked quite well for her. The implication of her not receiving the medication would be she could go into [MEDICAL CONDITION] again. She has had a difficult go of it, and my plan was to take her off of some of her other medications and use the Lacosamide and one other medication. That wouldn't be safe if she had not been receiving the medication as ordered. 3. The EMR shows R4 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. Nursing documentation shows R4 was transferred to the local hospital on (MONTH) 9, (YEAR) with elevated blood sugar and was admitted to the hospital the same day with [DIAGNOSES REDACTED]. R4 returned to the facility on (MONTH) 12, (YEAR) with multiple medication orders including [MEDICATION NAME] Sodium Solution (anticoagulant) subcutaneously two times a day to treat a newly diagnosed splenic vein [MEDICAL CONDITION]. The facility does not have documentation to show R4 received the [MEDICATION NAME] medication 12 times during the period (MONTH) 15, (YEAR) through (MONTH) 25, (YEAR). Nursing documentation shows the medication was not available on (MONTH) 4, 5, 13 and 15, (YEAR). On (MONTH) 26, (YEAR) at 1:02 PM, V12 (Pharmacist) said, The pharmacy dispensed the [MEDICATION NAME] to the facility in five day increments. The facility documentation shows some missed doses for a whole day and other days where (R4) missed the medication one time during the day. The doses that are being missed coincide with the days the refills are due. The facility needs to order the medication before it runs out and then there won't be the gaps with missed medications. On (MONTH) 27, (YEAR) at 12:40 PM, V28 (Hematologist) and V29 (NP-Nurse Practitioner) said, (R4) should receive the anticoagulant medication [MEDICATION NAME] every 12 hours. If he does not receive the medication the clot will increase in size or another clot will develop elsewhere. He was already anticoagulated with another medication when he developed the splenic vein [MEDICAL CONDITION]. Now he is only on the [MEDICATION NAME] that must be given every 12 hours. The facility never contacted either of us to let us know that (R4) was having missed doses of the medication. On (MONTH) 27, (YEAR) at 1:18 PM, V30 (Medical Director) said, I was not aware that we had residents with medication concerns until this was brought to my attention in the past few days. Any medication not being given as prescribed is a concern. (R4) was very lucky he did not have any clotting issues after missing his anticoagulant medication. The other huge issue at the facility is the nurses signing the MAR indicated [REDACTED]. I am shocked this is even happening in this day and age. Maybe no one was aware of the problem because the nurses were signing the MARs that they gave the medications even though they did not. It was never brought to my attention that (R1) needed a [MEDICAL CONDITION] medication that he was not receiving or that his primary care physician was not comfortable monitoring the medication in the absence of the oncologist. The facility's Medication Administration Procedure dated (MONTH) 2011 shows: 3. Review the resident's Medication Administration Record [REDACTED]. Read each order entirely.17. Return to medication cart and document medication administration with initials in appropriate spaces on Medication Administration Record [REDACTED]. If medication is ordered but not present, call the pharmacy or supervisor to obtain the medication. Return locked medication cart to the medication room after use. The facility's undated Medication Reconciliation Policy shows: Purpose: To ensure that the resident's medications are reconciled. Standard: Medications that the resident has ordered by the physician are compared to those that the resident is actually taking or should be taking and any discrepancies are resolved. Discrepancies include omissions, duplications, contraindications, unclear information, and changes. II. Readmission: a) Identify current medications from the hospital, facility, or other living environment of the resident. b) Review previous medication orders with the current list of medications and identify any discrepancies. c) Review all medications with the physician when obtaining readmission orders [REDACTED]. If physician does not order medications that were previously being taken, indicate on the list that this is not currently prescribed by the physician. Through observation, record review, and interviews conducted on (MONTH) 27, (YEAR), the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: 1. R1 was seen by V5 (Oncologist) on 3/27/18 at 8:40 AM. V5's progress note indicates that V5 was aware of the stoppage of [MEDICAL CONDITION] medication (Nilotinib) and that medication can be resumed when insurance coverage is available on 4/1/18. R1 received [MEDICATION NAME] (anti-rejection) as per the physician's orders [REDACTED]. 2. R2 received Lacosamide (anticonvulsant) as per the physician's orders [REDACTED]. 3. The facility has made arrangements for R4 to receive thirty (30) day supplies of [MEDICATION NAME] Sodium Solution ([MEDICATION NAME]) upon reorder. The pharmacy has been instructed that medications are to be sent upon order/re-order unless a new order has been obtained with no delay in refill. 4. Nursing staff has been in-serviced by DON/Designee on 3/23/2018 to reconcile admissions and readmission orders [REDACTED]. Nurses will not be permitted to work until the in-service is completed. 5. Nursing staff has been in-serviced by the pharmacy representative, nurse consultants, and the DON regarding proper medication administration, administering medications as ordered, signing out only medication given, proper documentation for medication not given, and documentation of control medications. Nurses will not be permitted to work until the in-service is completed. 6. Nursing staff has been in-serviced by the DON/Designee on the process for obtaining controlled medications from the pharmacy including that when an order for [REDACTED]. 7. The facility has audited all admissions and readmissions from 3/25/2018 for medication reconciliation and to verify that all orders were transcribed correctly into the electronic system. 8. The facility has implemented an Admission/Readmission reconciliation audit sheet to prevent omission and transcription errors conducted by DON/Designee within 24 hours of admission/readmission. 9. All medication carts (ten out of ten) have been audited by nurse managers to ensure that all medications including controlled medications were present. Any medication that was lacking was located, ordered for stat delivery, and received. 10. The facility has implemented an unavailable medication report tool to communicate to DON/Designee within 24 hours of any medication that is not available for administration. 11. The facility has implemented a specialty medication review tool to track specialty medications. The specialty pharmacy medication review tool will be completed by the DON/Designee within 24 hours. The DON/Designee will be responsible for ensuring medication is obtained. 12. The facility policy for specialty pharmacy medications has been reviewed and revised to include the following process: 1) physician order [REDACTED]. The DON/Designee will be responsible for follow up through use of the specialty pharmacy medication review tool. 13. The Quality Assurance Performance Improvement Committee met to discuss the issue. The following policies and procedures were reviewed and revised: a. Medication Administration b. Controlled Substance Orders c. Ordering Medications (Electronic) The committee agreed to meet weekly for the 1st month, biweekly for the next month, monthly for the next 3 months, then quarterly thereafter until compliance is met.

Based on interview and record review, the facility failed to prevent verbal and physical abuse from occurring to 2 of 11 residents (R1, R2) reviewed for abuse in the sample of 11. This failure resulted in R1 experiencing sleeplessness and fearfulness after being punched in the face when calling out for staff assistance. R2's medical [DIAGNOSES REDACTED]. A reasonable person would not want to be verbally chastised or physically abused when requesting help. The findings include: 1. On December 28, 2016 at 9:30 AM, R1 said, On December 14, 2016, I was yelling for help and (E5) (CNA-Certified Nursing Assistant) came in my room and said, What do you want? Shut up! Then all of a sudden BAM, BAM, BAM, he punched me in the mouth three times. It hurt like heck. Then he held my hand and said he was so sorry and offered me some chocolate from my drawer and begged me not to report him. I didn't say anything to anyone that night, but I layed there awake because I was afraid he would come back. I did not call for help while (E5) was working. I told (E11) (nurse) in the morning what happened because I did not think that it was right for (E5) to yell at me and punch me when I asked for help. R1's face sheet dated December 27, 2016 shows R1 was admitted to the facility in October 2015 with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated November 7, 2016 shows R1 has moderate cognitive impairment and is totally dependent on facility staff for transferring, toileting and bathing, and requires extensive assistance for bed mobility, dressing and personal hygiene. The MDS also shows R1 is occasionally incontinent of bowel and bladder. On December 28, 2016 at 2:05 PM, E11 said, Around 9:00 AM on December 15, 2016, (R1) told me he was punched by (E5) the previous night. I immediately reported the allegation to (E1) (Administrator) and (E2) (DON-Director of Nursing) and they started the investigation. I did a total body assessment and there was no visible injury, discoloration or swelling on (R1's) body. Nursing documentation dated December 15, 2016 by E11 shows the same information as stated in the interview. The facility roster dated December 27, 2016 shows R1 and R2 are roommates. On December 27, 2016 at 4:00 PM, E1 (Administrator) said the facility conducted a full investigation of R1's abuse allegation. During the investigation, R5 (spouse of R2) stated she witnessed R2 being slapped by E5 (CNA) on December 14, 2016. E1 said the facility was unable to substantiate the abuse allegations made by R1 and R5 due to a lack of witnesses or visible injuries, and reported the same to IDPH (Illinois Department of Public Health) on December 19, 2016. On December 22, 2016, the local police department notified the facility of E5's confession of physical abuse towards R1. 2. R5 was interviewed at the bedside of R2 on December 28, 2016 at 9:35 AM with E1 (Administrator) and E2 (DON) present. R2 was not interviewable due to his medical condition and cognitive status. R5 said her native language is Chinese and speaks limited English. R5 is the spouse of R2, resides at the facility, and sits at R2's bedside, tending to his needs. During the interview, R2 was laying in bed and was non-verbal and did not participate in the interview. A Chinese interpreter was requested for the interview, however, E1 made assurances an interpreter was not necessary. It was difficult to interview R5 because of the language barrier. R5 used hand gestures at times to explain her statements. R5 said, My husband (R2) grabbed the CNA's upper arm (using hand gesture to show grabbing upper arm) during transfer from the wheelchair to the bed. (E5) abruptly removed my husband's hand and slapped him in the face (using hand gestures). R5 said she reported the physical abuse on December 15, 2016. E11's (nurse) documentation shows R5 reported the physical abuse of R2 on December 15, 2016. E11 reported the abuse allegation immediately to E1 and E2. E11 performed a full body assessment of R2 and no visible injuries were noted. Progress notes dated December 16, 2016 showed R2 was hospitalized the day following the abuse allegation, [MEDICAL CONDITION]. R2 was readmitted to the facility on [DATE]. R5 accompanied R2 to the hospital and remained with him during his hospital stay. R2's face sheet dated December 27, 2016 shows R2 was admitted to the facility in December 2015 with multiple [DIAGNOSES REDACTED]. R2's MDS dated [DATE] shows R2's native language is Chinese. R2 has moderate cognitive impairment, is rarely understood, is totally dependent on facility staff for transfers, eating, bathing and toileting, and is frequently incontinent of bowel and bladder. R5's MDS dated [DATE] shows R5 is cognitively intact and requires supervision with her ADLs (activities of daily living). On December 28, 2016 at 12:20 PM, Z1 (police officer) said he responded to the facility on [DATE] for an allegation of abuse. Z1 said there was no physical evidence of abuse on R1 or R2. Z1 said R1 explained how he was punched by E5 on the evening of December 14, 2016 after calling out for help from his room. Z1 said he was unable to interview R2 due to his medical condition and interviewing R5 (spouse of R2) was difficult due to a language barrier. Z1 said the facility did not provide an interpreter to speak to R2 or R5. Z1 said E5 confessed to physically abusing R1 within 4 to 5 days of of the incident and that no arrest was made because neither R1, R2, or R5 pressed charges against E5. Z1 said it was not clear if R2 or R5 understood the legal system due to the language barrier. The facility's shift assignment sheet dated December 14, 2016 shows E5 was responsible for the care of multiple residents, including R1, R2 and R5. The facility's policy and procedure entitled Abuse Prevention Program revised September 1, 2016 shows: Policy: It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property.For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: 1. Abuse: The willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. 2. Verbal Abuse: Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. 4. Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.