Does EL PASO HEALTH CARE CENTER have any serious inspection findings?

Yes, EL PASO HEALTH CARE CENTER has 6 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 96 total deficiencies from recent inspections.

Where is EL PASO HEALTH CARE CENTER located?

EL PASO HEALTH CARE CENTER is located in EL PASO, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does EL PASO HEALTH CARE CENTER have?

EL PASO HEALTH CARE CENTER has 123 certified beds.

Who owns EL PASO HEALTH CARE CENTER?

EL PASO HEALTH CARE CENTER is a for profit - limited liability company facility and is part of the PETERSEN HEALTH CARE chain.

Is EL PASO HEALTH CARE CENTER safe?

EL PASO HEALTH CARE CENTER has documented safety concerns including a substantiated abuse finding on record, 6 immediate jeopardy citations, placement on the CMS Special Focus Facility list. Families should ask about corrective actions taken.

Do nurses at EL PASO HEALTH CARE CENTER stick around?

EL PASO HEALTH CARE CENTER has high staff turnover at 60%. High turnover can mean less continuity of care as staff change frequently.

Was EL PASO HEALTH CARE CENTER ever fined?

Yes, EL PASO HEALTH CARE CENTER has been fined $486,689 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is EL PASO HEALTH CARE CENTER on any federal watch list?

Yes, EL PASO HEALTH CARE CENTER is on the CMS Special Focus Facility (SFF) list, which identifies nursing homes with a history of serious quality issues. Only about 1% of facilities are on this list.

What have inspectors found at EL PASO HEALTH CARE CENTER?

Medicare inspectors have found 96 deficiencies at EL PASO HEALTH CARE CENTER: 6 critical, 4 serious, 84 moderate, 2 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting EL PASO HEALTH CARE CENTER?

Families visiting EL PASO HEALTH CARE CENTER should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does EL PASO HEALTH CARE CENTER compare to other nursing homes?

EL PASO HEALTH CARE CENTER does not have enough inspection data for a CMS star rating yet. This may be a newer facility.

EL PASO HEALTH CARE CENTER

Name: EL PASO HEALTH CARE CENTER
Address: 850 EAST SECOND STREET, EL PASO, IL, 61738, US
Telephone: (309) 527-2700
Rating: 3.0

850 EAST SECOND STREET, EL PASO, IL 61738 · (309) 527-2700

For profit - Limited Liability company 123 Beds PETERSEN HEALTH CARE Data: November 2025 6 Immediate Jeopardy citations

Trust Grade

0/100

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EL PASO HEALTH CARE CENTER nursing home in EL PASO, IL

Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

El Paso Health Care Center has received a Trust Grade of F, indicating poor performance with significant concerns about resident safety and care. It does not rank among any facilities in Illinois or Woodford County, suggesting that there are no local alternatives that perform better. Although the facility is showing an improving trend, with issues decreasing from 40 in 2024 to 19 in 2025, it has a high staffing turnover rate of 60%, which is above the state average, raising concerns about continuity of care. The facility has also accumulated $486,689 in fines, which is higher than 97% of Illinois facilities, signaling ongoing compliance problems and issues with resident safety. Specific incidents include a failure to protect residents from physical and verbal abuse during altercations and a lack of investigation into allegations of sexual abuse, which indicates serious shortcomings in resident safety measures. Overall, while there are some signs of improvement, the facility's serious issues cannot be overlooked.

Trust Score: F
In Illinois: #112/223
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $486,689 in fines. Higher than 84% of Illinois facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 96 deficiencies on record. Higher than average. Multiple issues found across inspections.

☆☆☆☆☆

0.0

Overall Rating

☆☆☆☆☆

0.0

Staff Levels

☆☆☆☆☆

0.0

Care Quality

☆☆☆☆☆

0.0

Inspection Score

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Stable

2024: 40 issues

2025: 19 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

Staff Turnover: 60%

14pts above Illinois avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $486,689

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: PETERSEN HEALTH CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (60%)

12 points above Illinois average of 48%

The Ugly 96 deficiencies on record

6 life-threatening 4 actual harm

Aug 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to notify a resident's family of a resident's return from the hospital for one of three residents (R1), reviewed for family notification, in a sample of 5.FINDINGS INCLUDE:The facility policy, Significant Condition Change and Notification, dated 12/2024 directs staff, To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as: Transfer of the resident. Calls will be made to the resident's representative until they are reached. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given.R1's electronic medical record documents R1 was transferred to the local emergency room on 8/1/25 at 3:12 A.M. after experiencing increased behaviors and delusions. R1'S Nursing Progress Notes, dated 8/1/25 document, 8/1/2025 (R1) back from hospital at approximately 10:30 A.M., yelling and agitated and crying out, refused vitals, did report that she will run again. On 8/18/25 at 10:35 A.M., Z10/R1's Family Member stated, I am (R1's) guardian due to her mental health. They (facility staff) called me to tell me (R1) was running away and they had called the police and were having (R1) taken to the hospital. But no one ever called me to tell me (R1) came back (to facility). It wasn't until I called them (facility) on (8/2/25) and asked them, did I know what had happened to (R1). They (facility) are supposed to call me and let me know.On 8/19/25 at 1143 A.M., V1/Administrator verified that R1's mother (Z1) had not been called by facility staff to alert her that R1 had returned to the facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to update a plan of care after a resident made repeated attempts, on two different days, to elope from the facility, for one of one resident (R1), reviewed for care plans, in a sample of 5.FINDINGS INCLUDE:The facility policy, Care Planning, dated 12/2024 directs staff, Purpose: To address each resident's strengths, weaknesses and care needs. To use this assessment data to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning and wellbeing as possible. R1's Nursing Progress Notes, dated 7/29/25 at 3:35 P.M. document, (R1 is experiencing a change in condition. (R1) left building through the front door.Resident has had no further behaviors or attempts to exit building.R1's Nursing Progress Notes, dated 8/1/25 at 2:54 A.M. document,(R1) was observed by CNA (Certified Nursing Assistant) walking down the hallway, and turning towards the common room. A few seconds after it was observed by nurse on camera that (R1) was attempting to exit the facility. Writer, other nurse on floor, and (other staff) ran to front door as (R1) was observed walking out the door and into the parking lot. (R1) continued to walk forward and push past staff down the street and past the stop sign. (R1) continued to walk and push forward, while yelling throughout and became violent and combative swinging closed fists at nearby staff. (R1) repeatedly attempted to swing and physically assault staff. MD (Physician) was contacted and order received to send to hospital for psych (psychiatric) evaluation. Police were also then contacted as the facility staff was unable to get (R1) safely back to building. (R1) transported to local hospital.R1's Care Plan, dated (revised) 5/27/25 includes the following Focus Area: (R1) is an elopement risk/wanderer. This same plan of care includes the following Interventions: 4/10/25 Distract (R1) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 5/1/25 Monitor for fatigue and weight loss. 5/27/25 Calmly redirect (R1) and remind her that this is her home. Find a task, activity or simply a conversation to engage her in. No further interventions were implemented after R1's elopement from the facility on 7/29/25 or 8/1/25, were developed by the facility staff. On 8/19/25 at 1:10 P.M., V10/Care Plan Coordinator verified R1's care plan was not revised after R1's recent attempts on 7/29/25 or 8/1/25 to leave the facility unattended. At that time, V10 stated that the facility management team should have reviewed R1's plan of care after each elopement attempt and implemented new interventions to reduce the risk of R1 leaving the facility.

Aug 2025 2 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Menu Adequacy (Tag F0803)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow diet orders for residents who receive mechanical soft diets, failed to document residents' noncompliance with mechanically altered diets, and failed to educate facility staff on residents who are on mechanically altered diets. These failures resulted in R1, who has a history of choking and requiring the Heimlich Maneuver, being able to purchase snacks from V5 (Medical Records) that were not part of R1's physician ordered diet texture. These failures have the potential to affect all 20 residents (R1, R4 through R22) who reside in the facility that receive a mechanically altered diet.These failures resulted in an Immediate Jeopardy that began on 7/12/25. While the Immediate Jeopardy was removed on 8/08/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.Findings include: The facility Inservice Training Handout: Understanding Diet Types in Skilled Nursing Facilities (SNFs), not dated, documents, Mechanical Soft Diet (Mechanically Altered) Definition: Soft, moist foods that require minimal chewing. Meats are ground or finely chopped. No hard, crunchy, or sticky textures. Important Guidelines: Always follow speech-language pathologist recommendations. Do not serve foods outside of resident's prescribed texture level. Use visual cues, consistency checks, and documentation.The facility training policy, titled What is a texture Modified Diet, not dated, documents, Mechanically altered or soft diets is used when there are problems with chewing and swallowing. Changes the consistency of a regular diet to a softer texture. Includes chopped or ground meats as well as chopped or ground raw fruits and vegetables. Foods to avoid on a Mechanical Soft Diet: Nuts and seeds, non-ground meats, breads with hard crust, hard candy, and raw, crunchy fruits and vegetables.R1's admission record documents R1's date of admission to the facility was 8/9/22 and his diagnoses included: Diabetes Mellitus due to underlying condition without complications, Dementia in other diseases classified elsewhere moderate with agitation, Hyperlipidemia, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction without residual deficits.R1's Minimum Data Set (MDS) assessment, dated 7/1/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment.R1's progress notes dated 7/12/25 documents, RN (Registered Nurse) called to dining room with reports of Resident choking RN reported to the dining room, observed resident sitting in chair at table and taking several bites of food without swallowing between bites, color is good, V/S (vital signs) stable, afebrile, breath sounds are clear to auscultation bilaterally, SAO2 (arterial oxygen saturation) 98% (percent) on room air, resident reports I don't know why I choked this was the first time that has happened. RN completed assessment and remained with the resident to observe eating pattern and noted that resident was eating fast and taking several bites of salad without swallowing after each bite, RN encouraged resident to swallow after each bite and to follow up with a drink of water before taking additional bites, resident demonstrated appropriate swallowing. Dr. (doctor) V6 informed at 2000 (8:00pm), POA (Power of Attorney) (V7), brother notified at 2010 (8:10pm) per phone conversation, RN contacted (Contracted Diagnostic Company) services for STAT (immediate) chest X-Ray, spoke with (Contracted Diagnostic Company) staff, STAT chest X-Ray ordered. Facility manager on duty, V3 (Assistant Director of Nursing/ADON) notified.On 8/5/25 at 10:30am, V8 (Certified Nursing Assistant/CNA) stated, I was serving the supper meal in the dining room when I heard another resident yell 'He's choking.' I immediately went to R1 and saw that he was unable to breathe so I got him (R1) to stand up and performed the Heimlich Maneuver on him. It took approximately four good thrusts before a small piece of food was dislodged and he started coughing so I stepped back and let him continue and he was able to cough up the rest of the lettuce up by himself (R1) and began breathing and talking. After I knew he (R1) was ok I went and got his nurse who completed an assessment on him.R1's facility SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note dated 7/12/25, documents, resident (R1) had a swallowing issue.R1's Physician Orders dated 7/14/25 document that R1's diet was changed to CCD (Controlled Carb Diet) diet Mechanical Soft texture, Regular/Thin consistency, no lettuce, or green leafy vegetables for diet related to Diabetes Mellitus due to underlying condition without complications.R1's current care plan documents, (R1) is a risk for aspiration and choking related to impaired swallowing function evidenced by actual choking incident requiring Heimlich Maneuver and (R1) requires a modified diet (mechanical soft) with thin liquids.R1's Incident Report for Choking/Emergency Intervention dated 7/12/25, documents at approximately 6:45pm R1 choked requiring the Heimlich Maneuver, R1 was assessed post choking, chest X-Ray was ordered, R1 monitored every four hours for 72 hours for respiratory changes, a repeat chest X-Ray to be done 72 hours after initial chest X-Ray, diet temporarily downgraded to mechanical soft pending Speech Therapy evaluation, Speech Therapy referral for evaluation initiated, R1 to be supervised at all meals, R1's Care plan updated, entered on facility Risk Management log and POA (Power of Attorney) notified.On 8/1/25 at 11:50am, R1 noted to purchase a can of potato chips, chocolate wafer bar and a candy bar from V5 (Medical Records) at the snack room. R1 stated he does not have a swallowing issue and does not remember choking or getting the Heimlich maneuver a couple of weeks ago.On 8/1/25 at 12:00pm, V4 (Dietary Manager) stated, If someone is on a Mechanical Soft Diet, they definitely should not be eating potato chips. However, we cannot deny someone something if they want to eat it, we can only educate them.On 8/1/25 at 12:10pm, V1 (Administrator) stated, It's a double edge [NAME]. Residents have the right to refuse orders and we can't keep them from buying snacks from vending. That would be impossible to supervise. All we can do is educate when we see them not following dietary orders.R1's progress notes dated 7/17/25 at 5:17pm, documents, Resident was noted in the dining room eating flaming hot (brand name of type of chip) that he purchased from another resident. Resident was educated that he is a mechanical soft diet and that he should not be eating those at this time d/t (due to) risk of choking. Resident was reminded of choking incident and why his diet has been modified. Resident refused to stop eating Cheetos but was supervised while eating and had no issues during this time. MD (Medical Doctor) notified. No further documentation noted in R1's medical record regarding education on diet.On 8/1/25 at 1:40pm, V3 (Assistant Director of Nursing/ADON) stated, We do not have vending machines. We have a staff member who opens a snack room for a period of time during the day so the residents can buy snacks.On 8/5/25 at 10:20am, V7 (R1's Power of Attorney) stated, I'm not recalling them calling me to notify me of (R1) choking and requiring the Heimlich Maneuver. They haven't called me about buying snacks that are hazardous either. They have called me recently about fights he (R1) has and suggestions on looking at places closer to me with a dementia unit but nothing about him (R1) choking, his diet or needing to see Speech. I have my faculties about me, and I would remember a call like that. V7 also stated that he would be willing to come to the facility if needed to get the Speech evaluation done if the facility would give him prior notice to get there. V7 stated, Ultimately I want him to be safe so whatever is in his best interest I'm willing to do.On 8/5/25 at 10:35am, V6 (Medical Director/Physician) stated, I had been made aware of his (R1) choking episode, but the facility has not contacted me about his (R1) noncompliance with following his down-graded diet or to speak with him (R1) or his family to go over the risk of not following the prescribed diet. It would be futile to attempt to educate him (R1) on the risk of not following his diet due to his poor cognition, he (R1) would forget within an hour anything I've told him. The staff should provide him with safe food options in accordance with his diet but I'm not sure how they will be able to manage that with his (R1) cognitive impairments.On 8/5/25 at 10:50am, V5 (Medical Records) stated, I am in charge of opening the snack room so residents can buy snacks. I have been given no guidance on resident diets up until last Friday (8/1/25) when I was told that I let a resident (R1) purchase chips and he was not supposed to have them but prior to that they have said nothing to me about resident diets. I'm familiar with therapeutic diet consistencies like Mechanical Soft or Pureed but I have no clue what residents in this building are receiving those types of diets. V5 also stated that he opens the snack room from 11am-1pm on Monday, Wednesday, and Fridays and 12-1 on the other days typically.R1's Speech Therapy Evaluation dated 8/4/25, documents, The ST (Speech Therapist) discussed with the DON (Director of Nursing) and the dietary manager about continuing to provide mechanical soft solids, and thin liquids, as tolerated. Cut up solids prior to placement on the table and try placing solids in individual bowls to assist with reduced rate of intake. ST also encouraged the staff to remind the patient at each meal to slow down and take sips of liquids every 2-3 (two-three) bites.On 8/5/25 V10 (Certified Nursing Assistant/CNA), V11 (Licensed Practical Nurse/LPN), and V12 (Registered Nurse/RN) all stated that they had just received in-servicing on R1's diet.On 8/6/25 at 11:20am, V14 (Speech Therapist) stated, I evaluated (R1) this past Monday for swallowing concerns due to his recent choking. He (R1) was downgraded by the facility and his (R1's) physician to a Mechanical Soft diet. He (R1) was not very receptive about my recommendations while watching him eat, he (R1) ate extremely fast and is very impulsive. Potato chips would not be part of a Mechanical Soft diet. If he (R1) were to get a bag of potato chips from a vending machine and eat them unsupervised there is a potential for him to choke, aspirate, or even die from choking because of the way he eats.On 8/6/25 at 11:30am, V12 (Registered Nurse/RN) stated, I don't have all my residents' diets memorized, so no I would not know if they were eating what they shouldn't be without going to look at their orders and unless they were having issues when I saw them snacking, I wouldn't question their diet.On 8/6/25 at 11:45am, V17 (Certified Nursing Assistant/CNA) stated, I do not know everyone that receives a Mechanical Soft diet, but I do know a few. I also know that they should not be eating anything hard.On 8/6/25 at 2:19pm, V18 (Registered Nurse/RN) reports that the vending room causes problems because the residents buy whatever they want.2. R4's admission record documents R4's date of admission to the facility was 2/24/20 and his diagnoses included: Diabetes Mellitus due to underlying condition with Diabetic Autonomic (Poly)Neuropathy, Type 2 Diabetes Mellitus without Complications, Magnesium Deficiency, Hyperlipidemia, Gastro-Esophageal Reflux Disease without Esophagitis, Heartburn and Constipation.R4's Minimum Data Set (MDS) assessment, dated 7/1/25, documents R4 has a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognition is intact.R4's Physician Orders dated 2/4/25, documents R4 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 11:20am, R4 observed in his room with bag of chips, bag of cheese curls, and a chocolate candy bar on his bed. R4 reports that staff do not tell him what snacks he shouldn't purchase due to diet restrictions.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R4's current care plans lacked non-compliance with diet textures prior to 8/7/25.3. R5's admission record documents R5's date of admission to the facility was 7/26/22 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Hyperkalemia, Deficiency of other specified B Group Vitamins, Hyperlipidemia, and Gastro-Esophageal Reflux Disease without Esophagitis.R5's Minimum Data Set (MDS) assessment, dated 7/2/25, documents R5 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact.R5's Physician Orders dated 2/4/25, documents R5 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 11:16am, R5 observed sitting in his room with 2 cans of potato chips, 2 Chocolate candy bars, 2 bottles of soda unopened in front of him on bedside table. R5 states that he does purchase items from the vending room, and he usually gets cans of chips, candy bars, and soda. R5 stated that staff do not advise him on what he should not purchase or any risk to eating what I buy.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R5's current care plans lacked non-compliance with diet textures prior to 8/7/25.4. R9's admission record documents R9's date of admission to the facility was 2/10/21 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Hyperkalemia, Deficiency of other specified B Group Vitamins, Hyperlipidemia, and Gastro-Esophageal Reflux Disease without Esophagitis.R9's Minimum Data Set (MDS) assessment, dated 6/9/25, documents R9 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact.R9's Physician Orders dated 3/5/25, documents R9 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency, supervision for all meals.On 8/6/25 at 11:30am, R9 observed lying in bed with head elevated. R9 reports that he purchases popcorn and drinks from the vending room. R9 stated, They tell me I shouldn't have popcorn, but it is my life, and I am going to live it.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R9's current care plans lacked non-compliance with diet textures prior to 8/7/25.5. R12's admission record documents R12's date of admission to the facility was5/1/04 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Dysphagia Oropharyngeal Phase, Unspecified Dementia Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance. Mood Disturbance, or Anxiety, and Constipation.R12's Minimum Data Set (MDS) assessment, dated 6/24/25, documents R12 has a Brief Interview for Mental Status (BIMS) score of 14/15, indicating cognition is intact.R12's Physician Orders dated 3/5/25, documents R12 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 1:42pm, R12 reports that he purchases food items from the vending room, but staff do not advise him on what food items to avoid because of dietary restrictions.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R12's current care plans lacked non-compliance with diet textures prior to 8/7/25. V1 (Administrator) and V3 (Assistant Director of Nursing/ADON) were notified of the Immediate Jeopardy on 8/7/25 at 1:58pm.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R1 has remained free from any harm or poor outcomes since incident on 7/12/2025 through current date 8/7/20252. On 8/6/25 V1/Administrator completed educated 1:1 with V5 (Medical Records) on Modified Diets and Resident Rights 3. On 8/6/25 Education for all staff on Modified Diets and Resident Rights completed by Administrator/V1 and IDT (Interdisciplinary Team). 4. On 8/6/25 AD HOC QAPI/Quality Assurance and Performance Improvement meeting held by members of QA/Quality Assurance Team and noted opportunities for improvement and process changes. 5. On 8/6/25 the facility updated process on Vending: Staff members perform vending to obtain a current list of resident diets. Staff to encourage residents to obtain items that align with ordered diet. If a resident should use their right to choose items outside of modified diet, nurse to be alerted and resident to be educated, physician notified if necessary, and resident to be encouraged to consume said items in common area in staff visual to monitor for safety. 6. On 8/6/25 Administrator/V1 educated 1:1 with V5 on facility updated procedure for vending cart in relation to modified diet. 7. On 8/6/25 Education completed with other staff on updated procedure for vending cart in relation to modified diet staff completed by V1/Administrator and IDT. 8. On 86/25 reviewed current plan of care of R1 with V6/Medical Director. Consideration for resident physical, chronic mental health concerns, and well as resident rights and quality of life/preferred preferences reviewed. New orders received, responsible party made aware, and plan of care updated by V22/Care Plan Coordinator. 9. On 8/7/25 staff educated on plan of care changes by V1/Administrator and other IDT members completed. 10. On 8/6/25 staff educated by V13/Director of Nursing/DON and other IDT members on Electronic Medical Record and ease of noting current diet order in resident profile. 11. V1/Administrator or V13/DON to educate staff monthly on Modified Diets and Resident Rights and updated vending cart procedure through next QAPI review to assure understanding. 12. IDT to review all residents with modified diets to assure resident adherence to diet. If residents noted to utilize the right to choose or right to refuse and have noted to deviate from prescribed diet, IDT to assure education, notification to parties if applicable, and Refusal of Treatment consent and documentation if applicable, and updated plan of care.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to follow the facility's Discharge/Transfer policy for 1 resident (R2) of 3 residents reviewed for hospitalizations in the sample of 22.Findings include:The facility's policy Discharge/Transfer Out Checklist (undated) documents: SBAR (Situation Background Assessment Recommendation) assessment completed prior to calling the provider. Provider order obtained and entered in (electronic health record) to send to ER (Emergency Room)/hospital.R2's medical record documents R2's diagnoses include, but not limited to: Paranoid Schizophrenia, Major Depression Disorder, and Hypertension.R2's medical record documents: Resident complains of multiple episodes of loose stool, nausea and abdominal pain, resident able to make needs known, requested to be sent to the hospital. DON (Director of Nursing) informed; resident sent to (hospital) 3:00 pm via ambulance for further evaluation. Resident is own self POA (Power of Attorney). On 8/1/25 at 11:50 AM R2 verified that he went to the emergency room recently, however R2 unable to provide any details of encounter.On 8/1/25 at 12:21 PM V3 (Assistant Director of Nursing) verified that facility Discharge/Transfer Out Checklist is what the facility uses as the policy. V3 confirmed that nurses are to complete SBAR (Situation Background Assessment Recommendation) form and call the emergency room with report when a resident is being sent to the hospital. V3 verified that R2 did not have an SBAR completed for his transfer to the emergency room on 7/10/25.On 8/1/25 at 1:48 PM V2 (Registered Nurse) verified that she sent R2 to the emergency room on 7/10/25 and she does not recall if she phoned the emergency room and provided report of resident condition to an emergency room nurse. V2 verified she is aware that SBAR (Situation Background Assessment Recommendation) form should be completed prior to sending a resident to the emergency department for evaluation.The facility was not able to provide any type of documentation regarding the transfer On 8/5/25 V3 (Assistant Director of Nursing) verified that there is not an order from the physician to send R2 to the emergency room for evaluation on 7/10/25. V3 stated, We were not aware that it was in our policy to obtain an order from the physician to send a resident to the emergency room for an evaluation.

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from physical abuse for one of three residents (R2) reviewed for abuse in a sample of six. Findings include: The facility's Abuse, Prevention and Prohibition Policy, dated 3/2025, documents Statement of intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Resident to Resident Altercations: Resident to resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (example: muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact resident who is nearby. Definitions: Abuse- means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or physical condition cause harm, pain, or mental anguish. It includes verbal abused, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Physical Abuse- includes, but is not limited to, hitting, slapping, punching, biting, and kicking. R1 and R2's Final Five-Day Reported Incident to Illinois Department of Public health, dated 3/26/25, documents (R2) states (R1) was upset over having a towel, words were exchanged and then (R1) open handed struck (R2). A typed form dated 3/21/25 and signed by V14/Social Service Director, documents (R5) states she asked (R1) if he found towels, (R5) states (R1) cursed. (R2) then shouted at (R1) and (R1) hit (R2) on top of the head. R1's Face Sheet documents R1 is a [AGE] year-old-male admitted to the facility on [DATE] with the following but not limited to diagnoses: Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Dementia with Moderate Agitation. R1's MDS (Minimum Data Set) Assessment, dated 3/31/25, documents R1 is severely cognitively impaired. R1's current Care Plan documents (R1) has a behavioral problem related to Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Dementia. Verbal aggression, physical aggression, refuses meals a times, refuses assessments, refuses nail trimming, refuses medications, and refuses cares. This same plan of care documents R1 is an identified offender and has been determined to be moderate risk. R1's Criminal History Analysis Security Recommendation Report, dated 2/26/23, documetns (R1) is moderate risk. (R1) requires closer suprevision and more frequent observations than standard or routine for most residents in an open facility. Regular Monitoring should be attentive to behavior changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. R1's SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated 3/21/25 and signed by V10/LPN (Licensed Practical Nurse) documents (R1) involved in a physical altercation with another resident (identified as R2) and hit (R2) on top of the head. This same form documents (R1) is aggressive and not tolerating (R2). R2's Face Sheet documents R2 is a [AGE] year-old-male with the following but not limited to diagnoses: Major Depressive Disorder and Anxiety Disorder. R2's MDS Assessment, dated 3/12/25, documents R2 is cognitively intact. R2's Progress Note, dated 3/21/25 and signed by V10/LPN, documents This nurse was informed that (R2) was attacked by another resident (identified as R1). (R2) was hit on top of his head. R5's MDS Assessment, dated 4/18/25, documents R5 is cognitively intact. On 4/29/25 at 10:25 AM R1 verbalized he does not recall any situation where he hit another resident. R1 stated, I have a mental disorder, I am not going to remember doing something like that. On 4/29/25 at 10:45 AM R2 stated, I was sitting across from the nurse's station and (R1) and I had an argument. When we were arguing (R1) reached out and hit me on top of my head. I didn't like it, so I immediately started yelling for someone to help me. A staff member (I don't remember their name) came out and removed R1 away from me. On 4/29/25 at 11:06 AM V10/LPN stated, A little over a month ago I was passing medications down the hallway when I heard (R2) screaming help he's been hit. When I got to (R2) he stated (R1) had hit him on top of the head. (R5) was sitting by (R2) at this time and stated she witnessed (R1) hit (R2) on top of the head. On 4/29/25 at 12:40 PM R5 stated, (R1), (R2), and me were all sitting across from the nurse's station around a month ago. I asked (R1) if he had found towels yet to take a shower. (R1) told me not to worry about it. (R2) told (R1) not to talk to me like that. (R1) got mad and went over to (R2) and hit (R2) on top of the hit. (R2) then started screaming for help. (R2) was upset. I witnessed the entire thing.

Mar 2025 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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Based on observation, interview, and record review the facility failed to prevent resident to resident physical abuse by a known perpetrator for two (R22 and R23) of 13 residents reviewed for abuse in the sample of 36. This failure resulted in R22 hitting R23 in the mouth which caused R23 to suffer bleeding from her mouth. Findings include: The facility Abuse, Prevention, and Prohibition policy and procedure, dated 12/2024, documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and means the individual must have acted deliberately, not that the individual must have intended to inflict, injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. This policy also documents that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The Final Report to the State Agency, dated 1/1/2025, documents, Original Complaint: It was reported to the abuse coordinator on 12/27/24 of an alleged physical altercation. While in the dining room (R22) allegedly struck (R23). The Account of events documents R22 and R23 were sitting in the dining room, R23 put her hand on R22's shoulder and began shouting. (R22) appeared to be startled, stood up and started to flail arms. Staff were present and in between residents at the time of the event to deescalate the situation. Remaining staff cleared dining room to ensure the safety of all other residents. R22 does not recall the incident and denies hitting anyone. The facility's undated Abuse Investigation documents a physical altercation occurred in the dining room with R22 striking R23. No injuries to R23. R23 approached R22, tapped R22's shoulder and yelled out. R23 stood up startled and began swinging his arms. Staff were immediately between the two residents. R22 did hit a staff member. All staff have interviews included in the investigation. The staff interviews for V4 CNA, V10 CNA, V35 CNA, and V43 CNA document they witnessed R22 attempting to hit staff members. V4 CNA witnessed R22 hit R23 and V35 CNA. V9 RN (Registered Nurse) documented multiple staff stated R22 hit multiple staff members and (R23). The investigation documents other residents were removed from the dining room. V1 Administrator's Abuse Investigation does not include names of potential staff and resident witnesses, tablemates, or who was in the dining room at the time of the altercation. The Investigation includes random Resident Abuse Allegation Interviews which include three non-specific abuse questions as: 1. Has a peer ever become physically aggressive toward you in the past week; 2. If yes, who did you notify; 3. Do you feel safe? These statements all document No to questions number one and two and yes to question number three. Due to questions asked it is not possible to determine if they had witnesses or specific details regarding the actual incident between R22 and R23. The Clinical Record for R22, includes the following diagnoses: Schizoaffective Disorder, Alcohol Dependence with Alcohol - Induced persisting dementia, Mild Neurocognitive Disorder, Insomnia, and Severe Manic Episode with Psychotic symptoms. R22 has severe cognitive impairment and history of verbal and physical behaviors directed towards others. The current Care Plan for R22 documents R22 with history of behavioral problems exhibited by verbal and physical aggression. A Physician Progress Note for R22, dated 2/12/25 at 4:04 pm, documents: R22 with psychotic disorder in ETOH (ethyl alcohol) induced Dementia. (R22) remains on 1:1 supervision due to his highly impulsive behaviors and mood swings. This note also documents R22 is erratic in mood. The Progress Notes for R22, dated 12/27/24 at 7:52 am, documents R22 receives one-to-one monitoring with staff. In the dining room waiting for breakfast (R22) and another resident were talking, other resident touched (R22's) arm, (R22) escalated very quickly, and hit other resident in the face. Multiple staff members are present and attempted to redirect (R22). (R22) continued to hit two other staff members in the face. (R22) then left the dining room, with his 1:1 staff and went to couch to lay down. Administrator, Physician, and local Law Enforcement were notified. Local Law Enforcement took statements and (R22) was sent out to a local hospital for evaluation. 12/27/24 at 10:16 am, R22 returned from the local hospital with no new orders and continued with one-to-one staff. The Clinical Record for R23, includes the following diagnoses: Schizoaffective Disorder, Bipolar II Disorder, Drug Induced Subacute Dyskinesia, Delusional Disorders and Chronic Obstructive Pulmonary Disease. R22 is cognitively intact. The current Care Plan for R23 documents R23 with a history of behavioral problems of yelling, cursing at staff, exit seeking, refusing medications, verbal, and physical aggressions, making false accusations, and attention seeking. The Progress Notes for R23, dated 12/27/24 at 7:48 am, documents R23 stated I touched peer and said hi, peer then back slapped me. Residents were immediately separated. Incident was witnessed by staff. Resident was assessed and no bruises or lumps noted at that time. 12/27/24 at 9:13 am, Resident came into SS (social service) office to discuss how they were doing. Resident stated that they were doing fine but still upset. SS will continue to follow up with resident. On 3/14/25 and 3/18/25 between 8:00 am through 4:30 pm, R22 had a staff member assigned to do one-to-one monitoring and noted to be walking about the facility independently. On 3/18/25 at 10:05 am, V35 CNA stated she was R22's one-to-one monitor on 12/27/24 and was sitting in the dining with R22. (R23) was also at the table and reached over and touched (R22) on the shoulder and started yelling. (R22) stood up and was swinging his arms. R22 did hit (R23) in the mouth and she was bleeding. R22 also hit V35 in the arm. V35 CNA stated she put all the information in her statement. On 3/18/25 at 10:12 am, V10 CNA stated she did not see (R22) hit (R23) but did see blood on R23's nose. There were multiple staff already dealing with the incident so (V10) just helped get residents out of the dining room. On 3/18/25 at 10:40 am, V9 RN (Registered Nurse) stated It was a big incident. Stated she did not witness the incident just heard that R23 tapped R22's shoulder and R22 freaked out. After reading her typed interview, V9 RN confirmed that there were multiple staff who stated R22 hit multiple staff and hit R23. On 3/18/25 at 11:26 am, V4 Social Service Assistant stated she was in the dining room, heard someone yell and when looked saw R22 stand up really quick and his arms went up. V4 stated she thinks someone got hit and heard R22 hit R23 but did not see it happen. V35 CNA was at the table, another nurse and there were residents but does not remember who they all were. On 3/18/25 at 1:43 pm, V44 Agency RN stated she was working the day the fight happened in the dining room between R22 and R23. R22 was sitting at the end of the table with a resident on each side of him. R23 was on R22's right side. R23 said she went to rub R22's arm and R22 flipped out and stood up. R22 back handed her in the face. I had never seen him lash out like that before. R23 did tell (V1 Administrator) that R22 hit her. (R22) also hit three or four staff who were right there. The dining room was evacuated and R22 calmed down and stopped being belligerent. Oh yes he meant to hit her. It was very willful. He was angry. R22 hit R23 two times, hit V35 CNA, and another staff member. The police did come and R22 did go out to the hospital and came back later that same day with no new orders. On 3/18/25 at 1:32 pm, V1 Administrator stated she is the Abuse Coordinator, she did the investigation for the physical altercation between R22 and R23. V1 stated the altercation occurred in the dining room. R23 reported she put her hand on R22's shoulder, yelled and R23 raised his arms up. V1 Administrator stated V35 CNA said R22 stood up and had hit (R23) and a staff member. V1 Administrator confirmed R22 did hit R23 and stated, no injuries were noted that I can recall.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to complete a thorough abuse investigation for three (R22, R23, and R31) of 13 residents reviewed for abuse in the sample of 36. Findings include: The facility Abuse, Prevention, and Prohibition Policy, dated 12/2024, documents Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. 1. The Final Report to the State Agency, dated 1/1/2025, documents, Original Complaint: It was reported to the abuse coordinator on 12/27/24 of an alleged physical altercation. While in the dining room (R22) allegedly struck (R23).The Account of events documents R22 and R23 were sitting in the dining room, R23 put her hand on R22's shoulder and began shouting. (R22) appeared to be startled, stood up and started to flail arms. Staff were present and in between residents at the time of the event to deescalate the situation. Remaining staff cleared dining room to ensure the safety of all other residents. R22 does not recall the incident and denies hitting anyone. The facility Abuse Investigation documents a physical altercation occurred in the dining room on 12/27/24 between R22 and R23 alleging R22 striking R23. The investigation includes random staff and resident interviews were included on Staff Interview forms and Resident Abuse Allegation Interview forms. This investigation documents other residents were removed from the dining room and does not include potential staff or resident witnesses, table mates, or who was in the dining room at the time of the altercation. The Staff Interview forms ask four generic questions as: 1. Do you have knowledge of the alleged abuse? If so, describe; 2. What actions, if any, did you take in response to the allegation; 3. Did you report the alleged abuse? Who did you report it to? 4. What is 1:1 supervision? The random staff interview answers are handwritten on this form and then the answers are typed out by V1 Administrator for each staff person interviewed if they give details. The Resident Abuse Allegation Interview forms lists three non-specific abuse questions as: 1. Has a peer ever become physically aggressive toward you in the past week? 2. If yes, who did you notify?; 3. Do you feel safe? These random Resident interviews all document No to questions 1 and 2 and yes to question 3. There is no resident identified as witnessing the altercation between R22 and R23 during the meal service and no documentation of what residents observed during the meal service on 12/27/24. On 3/18/25 at 10:05 am, 10:12 am, 10:40 am, and 11:26 am, and 1:43 pm, V35 CNA, V10 CNA, V9 RN, and V4 Social Service Assistant, and V44 RN respectively stated staff write a statement and V1 Administrator types the interview out. On 3/18/25 at 1:32 pm, V1 Administrator stated she is the Abuse Coordinator and did not witness the altercation between R22 and R23 in the dining room on 12/27/24. V1 Administrator stated R23 reported she put her hand on R22's shoulder, yelled and R23 raised his arms up. V1 Administrator stated V35 CNA said R22 stood up and had hit (R23) and a staff member. V1 Administrator confirmed R22 did hit R23 and stated, no injuries were noted that I can recall. On 3/18/25 at 2:04 pm, V1 Administrator stated she always interviews staff and residents. V1 stated Social Service has helped with getting interviews. The Abuse Allegation Interview forms go out to the residents and come back to (V1). V1 stated the questions on the Abuse Allegation Interview forms are what is asked for the resident interviews. V1 Administrator stated she does not know who witnessed the altercation between R22 and R23, she did not have a list of witnesses for the incident, and confirmed she should know who witnessed is so-as-to interview them. V1 stated she does not keep the handwritten statements after typing them up. 2. On 3/7/25 at 10:35 am, V1 Administrator was informed by State Agency in the building of an allegation of V6 Consultant constantly calling R31 fat/ugly/broke/and to put a bra on. V1 stated, I have never had any complaints on (V6) or seen (V6) be inappropriate to the residents. (V6) mostly stays in my office. (R31) does not wear a bra. Is there an allegation? I don't have any reports with (V6 and V31), this is the first I am hearing of this; I will start an abuse investigation. The Initial Report dated 3/7/25 and the undated Final Report to the State Agency documents, Original Complaint: During the complaint survey (3/07) surveyor reported an alleged verbal/mental abuse allegation towards R31. There is no other documentation on the Initial or Final regarding the details of the allegation. The facility undated Abuse Investigation documents Staff to resident alleged verbal abuse. This Investigation documents R31's interview as: asked this resident if she has had any concerns with staff/male staff, resident states no. Asked resident if she was staff member by the name of (V6 Consultant), resident stated no. Resident stats she does not know this person, she has not had any concerns and she feels safe. The interview for V6 Consultant documents (V6) denies these allegations. The interview for V12 CNA documents Employee states she had no knowledge of this allegation. Employee states V6 Consultant is barely around residents. The Staff Interview forms ask three generic questions as: 1. Have you witnessed staff to resident mental/verbal abuse; 2. If yes, did you report it; 3. Who is your abuse coordinator? The random staff interview answers are handwritten on this form. All random staff answered No to question number 1, wrote nothing to question number 2, and wrote yes to question number 3. There is no further documentation as to questions regarding the allegation of abuse. These interview forms do not list detailed specific questions related to the verbal/mental abuse allegation. The Resident interview forms list three non-specific abuse questions as: 1. Has a staff member ever been mentally or verbally abusive to you? 2. If yes, did you report it?; 3. Do you feel safe? All random residents interviewed answered No to question number 1, answered NA or wrote nothing to question number 2, and answered Yes to question number 3. On 3/7/25 at 11:30 am, R31 was alert and oriented in the dining room sitting with other tablemates, dressed, and clean with no bra on. On 3/7/25 at 1:45 pm, R31 was lying in bed and stated (V6) has never called her fat, ugly, broke or to put a bra on. At that same time, R31 also stated she does not know who (V6) is; and staff and residents tell her she is fat, ugly, broke and to put a bra on all the time, but V12 CNA was not one of them. R31 also stated she does not like to wear a bra, so she doesn't. On 3/18/25 at 3:45 pm, V1 Administrator stated she understand the concern and confirmed her abuse investigation does not include detailed interviews from staff and residents regarding the physical altercation between R22 and R23 and the verbal/mental abuse allegation regarding R31. V1 stated going forward she would be detailed and ask specific questions with interviewing residents and staff versus using the facility interview form.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure continuous one-to-one supervision for one known physically aggressive resident (R22) of three residents reviewed for supervision in a sample of 36. Findings include: The facility's In-Service documentation titled, What Is 1:1 Supervision? dated 01/15/25, included the following bullet points: Resident should NEVER be out of sight; You should always be with the resident, resident should never be left unattended. R22's Physician/Practitioner Note, dated 02/12/25, documents Complaint: psychotic disorder in ETOH (Ethyl alcohol) induced dementia. HPI (History of Present Illness): [AGE] year-old male with ETOH induced Dementia with target behaviors of physical aggression towards others. He is not able to consent for his own meds and in the process of getting a State Guardian. He remains on 1:1 supervision due to his highly impulsive behaviors and mood swings. R22's clinical record documents the following diagnoses: Other Schizoaffective Disorder; Alcohol dependence with alcohol induced persisting dementia; Mild Neurocognitive Disorder due to known physiological condition with Behavioral Disturbance; and Manic episode, severe with psychotic symptoms. On 3/11/25 at 8:05am, R22's room door was closed, R22 was in his room and not visible from the hallway. V16 and V17 CNAs/ Certified Nursing Assistants Entered R33's room across the hall and transferred R33, from his wheelchair to his bed, utilizing a full-body mechanical lift. V16, CNA stated she was assigned to do one-to-one Supervision of R22 at the time. On 3/11/25 at 8:23am V16 CNA stated R22 is on one-to-one observation status 24 hours, 7 days a week. V16 verified R22 was in his room with the door closed and was not visible from the hallway. V16 stated R22 requires one-to-one observation due to physical aggression towards others and impulsive behaviors. On 3/12/25 at 8:40am, V2 DON/Director of Nursing stated when a resident is on one-to-one observation, staff must keep the resident within eyesight. V2 stated there is no policy addressing one to one resident observation. V2 stated V1 Administrator did give an in-service on one-to-one Supervision. On 3/18/25, at 3:45pm V1 Administrator confirmed that R22 is on one-to-one supervision and is not to be out of the staff person's sight. V1 stated that whoever did that will be fired.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter tubing was secured in place for one (R1) of three residents reviewed for indwelling urinary catheters in a sample of 36. Findings include: The facility's undated Catheter Care, Urinary policy documents Changing Catheters 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) R1's current Physician Order Sheet documents R1 has an indwelling urinary catheter. On 3/11/25, at 12:09pm, R1 sat in a wheelchair in her room. An indwelling urinary catheter tubing was hanging out of R1's incontinent brief with a clasp dangling on the tubing; tubing was not secured to R1's leg. At this time R1 stated This one is supposed to be strapped to my leg, but it isn't today. I am not okay with it because sometimes it gets yanked. On 3/11/25, at 3:21pm, R1 was lying in bed with an indwelling urinary catheter draining into a catheter bag. V14 Certified Nursing Assistant/CNA confirmed there is no leg strap, and she should have one. On 3/11/25, at 3:23pm, V3 Assistant Director of Nursing/ADON stated that resident urinary catheters should have a stabilizer for the tubing.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to ensure 2 residents (R11 and R31) were free from resident to resident physical abuse of seventeen residents reviewed for abuse in a total sample of 43. Findings Include: The Facility's Abuse, Prevention and Prohibition Policy dated 12/2024 documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or their agencies serving the resident, family members or legal guardians, friends or other individuals. The Facility's Abuse, Prevention and Prohibition policy dated 12/2024 documents the definition of abuse as means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, Instance of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm, The final abuse notification report to the state agency dated 10/8/2024 documents Brief Description of Incident: Allegedly (R17) made unwanted physical contact with (R11). Immediate Action Taken: (R17) and (R11) were immediately separated. (R17) went to ER (Emergency Room) for psych evaluation. Conclusion: A thorough investigation was completed by the facility. This investigation included interviews with staff and residents and chart review. The investigation showed that (V11) came out of her room and told (R17) to stay out of her (R11's) room. (R17) pushed (R11). R11's SBAR (Situation/Background/Assessment and Review) Communication Form dated 10/08/24 documents Resident pushed up against wall by another resident and fell to the ground. Did not hit head. On 2/11/25 at 10:30 AM R11with a BIMS (Brief Interview Mental Status) of 14 (cognitively intact) confirmed that a couple of months ago (R17) pushed her causing her to fall. Men should not be allowed on our hallway at all. R11 was unable to remember if there were any instigating factors prior to R17 pushing her. I don't know what his problem was. An abuse notification to the state agency dated 11/26/24 documents Brief Description of Incident: On 11/26/24 at 1800 (6:00 PM) (R34) and (R31) were in the dining room for dinner. Unwanted physical contact happened between the two. Investigation initiated. Final to follow. Immediate action taken: (R34) and (R31) were separated, and police were called and (R34) and (R31) are being sent to hospital. POA (Power of Attorney) and physician notified. On 2/11/25 at 1:00 PM R31 with a BIMS of 15 (indicating cognitively intact) stated (R34) did not like me trying to help pick up the meal tickets for (dietary staff) and he started yelling at me and he pushed me. He pushed me pretty hard, but I didn't fall.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to maintain the privacy of residents' health information for six of six residents (R5, R11, R40-R43) reviewed for confidentiality/privacy in a sample of 43. Findings include: The undated Residents' Rights for People in Long-Term Care Facilities documents Your rights to privacy and confidentiality - You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. The facility's undated Employee Handbook Acknowledgment Form includes but is not limited to the following: 507 - Non-Disclosure of Resident or Community Information: HIPAA (Health Insurance Portability and Accountability Act of 1996) grants significant privacy rights to our residents concerning the use or disclosure of their medical information. It is the policy of the Community to protect the privacy of Protected Health Information (PHI), and to ensure that such information is used and disclosed appropriately and in accordance with all applicable laws and regulations. PHI (Protected Health Information) is all individually-identifiable health information, including demographic information, collected from the resident or created or received by a health care provider a health plan, the resident's employer, or a health care clearinghouse and that relates to (i) the resident's past, present, or future physical or mental health or condition; (ii) the provision of health care to the resident; or (iii) the past, present, or future payment for the provision of health care to the resident. This information can be received and stored by the Community in many forms including faxes, e-mails, and all other electronic communications. It is important to remember that not every team member or resident's family has the right to access PHI. An anonymous undated group phone text message that was included in the complaint to State Agency documents a snapshot of six residents' dietary information cards. The residents' identified on these cards are R5, R11, R40, R41, R42, and R43 displaying their first and last names, room numbers and diet information. This phone text message documents the group involves 16 people. On 2/5/25 at 1:30PM, V1 Administrator stated, I termed a CNA/Certified Nursing Assistant (V22) for not creating a good work environment. V1 stated staff had text messages with names indicated but could not provide any proof; V1 gave an in-service to staff on 1/29/25 about HIPAA. I told staff if there was a group text messaging going around, they needed to delete it if they have names or health information because that was a HIPAA violation, but I was unable to find any proof of that. I also told staff they would be terminated if found. On 2/5/25 at 3:05pm, V1 Administrator stated (V22) said she had text messages but was never able to provide me with any text messages of residents. On 2/11/25, at 11:52 am V22 CNA stated V22 was on the group text that displayed the residents' dietary information cards and then V22 blocked it. V22 stated that there were 16 people, all CNAs, not all of them still work here now, but did at that time. V22 is unsure of who put the snapshot of the dietary cards on the group message. On 2/7/25, at 11:19 am, R38 stated that her personal/health information is no one's business and that she wouldn't want it shared. R38's clinical record documents R38 is cognitively intact. On 2/7/25, at 11:21 am, R37 stated R37 would not want her personal /health information shared because it is private. R37's clinical record documents R37 is cognitively intact. On 2/7/25, at 2:3PM, V1 confirmed the group text message including six residents' diet cards displaying their full names, room numbers and diet information. At this time V1 said V1 cannot say whether having residents' names, room numbers and diet information on a group chat is a HIPAA violation. V1 stated I will need to ask Corporate. On 2/7/25, at 3:10pm V2 Director of Nursing/DON stated that having residents' full names, dietary information, and room numbers on a group chat is absolutely a HIPAA violation. V2 stated that a HIPAA violation is patient information that shouldn't be shared and should be protected.

Jan 2025 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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2. R52's current care plan documents R52 has an indwelling urinary catheter and to keep catheter bag and tubing covered for dignity. On 01/07/25 at 11:46 AM, R52 was in the dining room with a urinary catheter bag partially filled with urine. The urinary catheter bag was hanging from R52's wheelchair without a privacy covering. On 01/08/25 at 12:15 PM, R52 was in the dining room with her urinary catheter bag wrapped with a blue absorbent pad and hanging from her wheelchair. On 01/08/25 at 12:30 PM, R52 stated her urinary catheter bag had not previously been covered and staff told her today the bag needed to be covered for privacy reasons. On 1/9/25 at 12:45 PM, V2 (Director of Nursing/DON) stated the facility did not have a policy regarding covering a catheter bag. Based on observation, interview, and record review the facility failed to ensure a resident's privacy was maintained (R59) and failed to cover a resident's indwelling urinary catheter bag with a privacy covering (R52) for two of 18 residents reviewed for privacy and dignity in a sample of 27. Findings include: The facility's undated Resident Rights for People in Long-term Care Facilities documents You have the right to .Your facility must provide services to keep our physical and mental health, and sense of satisfaction. And Privacy - Your medical and personal care are private. 1. On 1/07/25, at 10:20am, R59 sat on the bed in her room. As this writer closed R59's door for a private conversation, R59's door to the hallway would not latch closed. At this time R59 confirmed that the door will not latch shut. R59 stated that if the door closed all the way it would block out noise and when I get dressed, I would like it closed all way. I stand behind it (the door) or dress in shower room. The facility's folder of Pending Work Orders includes but is not limited to a Maintenance Work Order for R59, dated 6/29/24 that states The door to room will not latch shut. It hits before it can latch and makes a loud cranking noise. On 1/10/25, at 10:01am, V3 Maintenance Supervisor confirmed that R59's door to the hall will not latch shut and it should. V3 stated that he was aware of this but has been unable to get a replacement.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure the residents' activity calendar was able to be visualized for two of two residents (R46 and R60) reviewed for accommodation of needs in a sample of 27. Findings include: The facility's undated Resident Rights for People in Long-term Care Facilities documents You have the right to participate in your own care - Your facility must make reasonable arrangements to meet your needs and choices. 1. On 1/07/25 at 9:45am, R60 sat in a wheelchair in her room. R60 stated she is blind in her right eye. R60's activity calendar is taped on R60's bathroom door approximately five feet high. R60 stated that R60 cannot see it up there and R60 does not know what the activities are for today. R60 said I have torn it down and put it where I can see it. This writer took the calendar down and brought the calendar to R60. R60 stated I can't see that. I need bigger print. On 1/09/25, at 10:22am, R60 sat in a wheelchair in her room. R60 stated Sometimes I miss activities because I don't know what is going on. It makes me feel left out. Sometimes I like to look girlie. At this time, R60 confirmed R60 has missed the activity of nail care. R60's Minimum Data Set/MDS assessment, dated 5-10-24, documents that doing R60's favorite activities is very important to R60. R60's current face sheet documents R60 has Blindness right eye. 2. On 1/07/25, at 11:42am, R46 is in bed. R46's activity calendar is taped on R46's bathroom door approximately five feet high. R46 stated It is too high. I can't see it. R46's MDS assessment, dated 12/29/24, documents that doing R46's favorite activities is very important to R46. On 1/09/25, at 12:28pm, V2 Director of Nursing/DON asked R60 if she has been going to activities and R60 said no because R60 can't see what is going on. At this time V2 DON confirmed the activity calendar is posted up too high and is printed in a faint and small font size. V2 also confirmed that R46's activity calendar is posted too high and stated that R46 and R60 should be able to see the activities that are going on.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to develop a Care plan for Hepatitis C and Blindness for one resident (R60) of 18 residents reviewed for Comprehensive Care plans in a sample of 27. Findings include: The facility's undated Care Planning policy documents Policy: Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Purpose: 1. To assess each resident's strengths, weaknesses, and care needs. 2. To use this assessment data to develop a comprehensive Plan of Care (POC) for reach resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible. On 1/07/25 at 9:45am, R60 sat in a wheelchair in her room. R60's right eye appears cloudy and distorted. R60 stated she is blind in her right eye. R60's current Face sheet documents R60 has diagnoses including but not limited to Unspecified Viral Hepatitis C without hepatic coma and Blindness right eye. R60's current Care plan does not include Viral Hepatitis C or Blindness to R60's right eye. On 1/10/25, at 12:49pm, V10 Care plan Coordinator confirmed that R60's current Care plan does not include Hepatitis C or Blindness right eye. V10 stated Hepatitis C and Blindness are important enough that it should be on (R60's) Care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement nonpharmacological interventions for one (R13) of eight residents reviewed for mood behavior monitoring in a sample of 27. Findings include: Facility Behavioral Assessment, Intervention, and Monitoring Policy, dated 12/2024, documents Staff will evaluate the resident's patterns of mood and behavior; the care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice; Interventions and approaches will be based on assessment; and nonpharmacological approaches will be utilized to the extent possible to manage behavioral symptoms. R13's medical record documents R13 has the following diagnoses: Depression and Anxiety. R13's current physician orders for January 2025 document the following: Mirtazapine Oral Tablet 45 MG/milligrams give 1 tablet by mouth at bedtime related to depression; Bupropion ER/extended release oral tablet 300 MG give 1 tablet by mouth one time a day related to depression; Venlafaxine ER 150 mg capsule give 1 caplet orally one time a day related to depression; and Venlafaxine ER 75 mg capsule give 1 caplet orally one time a day related to depression. R13's current care plan has no nonpharmacological interventions identified for R13's behavior monitoring. R13's CNA/Certified Nurse Aid documentation reviewed for December 2024-January 9, 2025 (30 days) has verbal and physical behaviors documented, but no nonpharmacological interventions for R13's behavior monitoring charted. During the survey 1/7-1/10/25, V2 DON/Director of Nursing was unable to find any non-pharmacological interventions in R13's medical record. On 1/10/25 at 11:12 AM, V2 DON stated (R13) is only on antidepressants so there are no nonpharmacological interventions in place for her.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review the facility failed to provide a home-like environment including but not limited to chipped paint, holes, missing trim, loose cable cords and unpainted walls in resident rooms for eight (R10, R11, R17, R26, R46, R59, R66, and R86) of 18 residents reviewed for environment in a sample of 27. Findings include: The facility's undated Maintenance Supervisor Job Description documents the following: Position Description: Responsible for supervising and coordinating the activities of the maintenance department to ensure environmental center compliance in accordance to Federal, State and Local ordinance, regulations and building codes. Ensures center is maintained in a sanitary, attractive, and orderly condition; in good repair, free from hazards such as those caused by electrical, plumbing, ventilation, heating and cooling systems. Principal Responsibilities: Performs all routine maintenance and repair work for the center in accordance with Federal, State and Local ordinance, regulations and building codes. Picks up work order requests daily and establishes work priority. Maintains the grounds, facility and equipment in a safe and efficient manner in accordance with current applicable federal, state and local standards. The facility was unable to provide a Maintenance Policy. 1. The facility's undated folder titled Pending Work Orders includes a Maintenance Work Order dated 8/25/24 completed by V8/Housekeeper, reporting Holes in the wall on C Hall in R26 and R10's shared room. There is no documentation confirming or addressing the work order and no dates for repair are entered. On 1/10/25 at 10:20am R26 stated there were holes in the walls in his room, indicating the wall around his roommate's (R10) bed. On 1/10/25 at 10:22am V3 Maintenance Supervisor obtained measurements of and verified there were three holes present in the walls in R26's room around R10's bed: two deeply gouged holes behind R10's headboard with one hole measuring three inches wide by three inches in height and a second hole measuring four inches wide by three inches in height. A third hole exposed and penetrated through the wallboard on the wall near the door and measured three and one-half inches wide by seven inches in height, including ripped wallboard paper and exposed plaster. 5. On 1/9/25, at 11:47am, R17 sat on the bed in his room. R17's walls have multiple areas of chipped paint and a hole alongside the wall in which R17's bed is located up against. At this time when this writer asked if the look of this wall bothers R17 and if R17 wished that it looked nicer, R17 stated, yes. The facility's undated folder titled Pending Work Orders includes a Maintenance Work Order, dated 10/19/24, which documents that R17's room has baseboard off with hole by first bed coming into room. There is no documentation confirming or addressing the work order and no dates for repair are entered. On 1/10/25, at 10:08am, V3 Maintenance Supervisor confirmed the areas of chipped paint with non-covered dry wall screws and the hole in R17's wall. At this time V3 measured the largest chipped area and the hole each at two inches by two inches. V3 confirmed that this room does not look very appealing and needs a paint job. 6. On 1/07/25, at 10:20am, R59 sat on the bed in her room. R59's walls have numerous areas of paint chipping and two cable cords dangling from the ceiling tile, one above and to the left of R59's bed, and one across from the bed. Both cable cords are hanging down approximately three feet. At this time R59 stated that R59 rests in her room a lot and that sometimes the condition of the walls bothers her. R59 stated It would make me feel better and cleaner. I don't complain as long as I am getting by. On 1/10/25, at 10:01am, V3 Maintenance Supervisor confirmed that R59's room has two cable cords dangling from the ceiling and numerous areas of chipped paint. V3 confirmed that R59's room does not look very nice and stated that this room needs to be painted and the cable cords should be tucked up in the ceiling tiles. 7. On 1/07/25, at 10:01am, R46 was in bed. R46 stated that her room looks bad on the walls and that they (the facility) said they would put up paint, but it has been this way since R46 has been here for 10 years. R46's walls have numerous areas of chipped paint on the walls and corner trim that is cracked with parts broken off. On 1/10/25, at 10:05am, V3 Maintenance Supervisor confirmed that R46's room needs to be painted and has an area measuring one- and one-half inches by two inches that needs to be filled in and painted. V3 confirmed that the corner trim needs to be replaced. 4. During the survey conducted from 1/7/25-1/10/25, R86's bathroom door had a twelve by six inch, and three by three inch hole in the bathroom door where it was splintered and cracked in the middle of the door. On 1/10/25 at 10:25 AM, V3 Maintenance Director stated I am aware the door needs fixed, it has been needing fixed for a while, and I have a patch for it. 2. On 1/9/25 at 9:30am, noted a discolored area in R11's room on the wall next to the window. According to V3 Maintenance Supervisor, the area required sanding/smoothing and painting. This area measured three feet, four inches by seventeen inches. Another area located between the bottom of the window and above the heater/air conditioner unit had foam padding inserted and did not have dry wall or paint to cover. This area measured three feet, five inches long by two inches in height. (Noted measurements done by V3 Maintenance Supervisor.) On 1/10/25 at 10:20am, V3 Maintenance Supervisor stated that he has been the Maintenance Supervisor for the facility since August 2024 and had not noticed the areas on the wall in R11's room prior to today. 3. On 1/9/25 at 9:35am, noted a hole in the wall of R66's room on the left side of the room when facing the window. This hole measured four inches by four inches in circumference at the outer wall, tapered to one and a half inches deep within the wall, and did not go through the wall. This hole is eleven inches from the floor. (Noted measurements done by V3 Maintenance Supervisor.) On 1/10/25 at 10:25am, R66 stated, The hole has been in the wall ever since I've been in this room. (Documentation indicated R66 moved to the room on 6/6/24.) On 1/10/25 at 10:25am, V3 Maintenance Supervisor stated that he had not been aware of the hole in the wall in R66's room.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to process medication orders timely to ensure medications were given per physician order for six of 18 residents (R26, R37, R66, R72, R80, R85) reviewed for physician orders in a sample of 27 residents. Findings include: The Medication Administration Policy for Senior Living, undated, documented all medication orders must be prescribed by a licensed healthcare professional and documented accurately in the resident's medical records. The Medication Administration Record (MAR) should be maintained for each resident and must be up-to-date and medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose, and right route. 1. R26's Face Sheet documents R26 with a diagnosis of paranoid schizophrenia. R26's MAR documents on 1/8/25 Aripiprazole (an antipsychotic medication used to treat schizophrenia) 15 milligrams/mg each evening was ordered by V6. R26's MAR noted Aripiprazole was not administered on 1/8/25 or 1/9/25. 2. R37's Face Sheet documents R37 with a diagnosis of major depressive disorder. R37's MAR documents on 12/30/24 Nortriptyline (antidepressant) 10 milligrams at bedtime was ordered by V6. The MAR noted Nortriptyline 10 mg was not administered on 12/30/24 or 12/31/24. 3. R66's Face Sheet documents R66 with diagnoses of bipolar disorder and depression. R66's MAR dated 1/1/25 through 1/31/25 documents Quetiapine (an antipsychotic medication used to treat Schizophrenia) 50 milligrams at night was ordered by V6 on 12/30/24. The 12/1/24 through 12/31/24 MAR did not document V6's Quetiapine 50 milligrams order or that it was administered on 12/30/24 or 12/31/24. R66's MAR documented on 12/31/24 Escitalopram (antidepressant) 20 milligrams daily was ordered by V6. The MAR noted Escitalopram was not administered on 12/31/24. 4. R72's face sheet documents R72 with diagnoses of bipolar disorder, depression, and anxiety disorder. R72's MAR documents on 12/30/24 Trazadone 75 milligrams at bedtime was discontinued and Trazadone 150 milligrams at bedtime was ordered by V6. The MAR noted Trazadone 150 milligrams was not administered on 12/30/24 or 12/31/24. 5. R80's face sheet documents R80 with a diagnosis of generalized anxiety disorder. R80's MAR documents on 1/8/25 Lorazepam (used to treat anxiety disorders) one milligram at bedtime was ordered by V6. The MAR noted the Lorazepam was not administered on 1/8/25 or 1/9/25. 6. R85's face sheet documents R85 with a diagnosis of bipolar disorder. R85's MAR documents on 12/30/24 Quetiapine 50 mg at bedtime was ordered by V6. The MAR noted the Quetiapine 50 mg was not administered on 12/30/24 or 12/31/24. On 1/9/25 at 12:25 PM, V5 (Registered Nurse) V5 stated V6 (Psychiatric Nurse Practitioner) is the only practitioner that enters her own orders into the Electronic Medical Record (EMR) and that V7 (Licensed Practical Nurse/LPN) confirms V6's orders, not the floor nurses. On 1/9/25 at 1:30 PM, V9 (Registered Nurse/RN) stated V7 (Licensed Practical Nurse/LPN) gives the nurses a typed list of residents' names and new medication orders that were entered into the EMR by V6 (Psychiatric Nurse Practitioner). V9 demonstrated the typed list of new medication ordered by V6 on 12/30/24 which was kept at the desk. V9 stated V6 and V7 conducted rounds on residents on 1/8/25 although V7 was not working on 1/9/25, therefore a list had not yet been provided to the nurses. On 1/10/24 at 9:30 AM, V7 (Licensed Practical Nurse/LPN) stated that V7 does resident rounds with V6 (Psychiatric Nurse Practitioner). V6 completes her own documentation and enters orders into the residents' electronic medical record (EMR). V6's orders will remain in a pending status until V7 confirms the order in the EMR. V7 reviewed R26, R37, R66, R72, R80, R85 MARs and stated the changes in medications were not administered as ordered. V7 stated I had an appointment yesterday and didn't get the orders (V6's orders from 1/8/25) confirmed. The nurses should know how to do that (confirm pending orders to activate the order) but I do it, so they (nurses) didn't know. V7 stated that between 1:30 PM to 3:30 PM on 12/30/24, V6 conducted resident rounds and entered orders into the residents' EMR. V7 stated she verified and completed the pending orders by 1/1/25, therefore the new medications ordered were not activated for the nurses to administer on 12/30/24 or 12/31/24.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to have the survey book up to date with the most recent survey. This failure has the potential to affect all 88 residents in the facility. Findings include: On 1/10/25 the facility's survey book located in the front foyer area did not have the most recent survey in the book. The last survey in the book was dated 4/10/24. The facility has had complaints dated 10/5/24, 11/8/24, 11/22/24, and 12/18/24 to the State Agency that were investigated and were not in the facility's survey book. On 1/10/25 at 9:47 AM, V1 Administrator verified the last survey in their book titled Annual Health Inspections and Complaint Survey Findings was 4/10/24 and was not up to date. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form dated 1/7/25 documents 88 residents residing in the facility.

MINOR (C)

Minor Issue - procedural, no safety impact

Grievances (Tag F0585)

Minor procedural issue · This affected most or all residents

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Based on record review and interview, the facility failed to maintain the required minimum of three years of resident grievances results. This failure has the potential to affect all 88 residents residing in the facility. Findings include: The facility's Resident Grievance Process Policy Reviewed 8/2023 documents: Copies of all grievances will be maintained per the community record retention policy. The facility's Organization and Maintenance Retention of Medical Records Dated 1/2017 documents: The retention time for medical records is seven years from discharge or the last date of service provided unless the payer for the resident was a Medicare Advantage plan, the retention period is ten years. Best practice is to retain all records, on patients of age of majority, for ten years. If the resident/patient is a minor, the record will be retained for three years after the resident/patient reaches the age of majority or seven years, whichever is longer. The facility's Grievance Binder contained resident grievances for the years 2023 and 2024. There were no grievances maintained for a third year (2022) for the required minimum of three years of grievance results. On 1/8/25 at 11:45am, V2 Director of Nursing/DON stated that the 2022 grievance reports/results were not available; stated that the facility does not have three years of resident grievances on file and stated that only the two years (2023 and 2024) and any for 2025 were available. On 1/8/25 at 3:40pm, V1 Administrator confirmed that the facility does not have resident grievances prior to 2023. V1 stated, We cannot find them and not able to provide the years of before 2023 for review. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form dated 1/7/25 documents 88 residents reside in the facility.

Nov 2024 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected most or all residents

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Based on interviews and record reviews, the facility failed to maintain a bookkeeping system to adequately record individual resident accounts by not recording the date and amount of all financial transactions and failed to maintain the ongoing balance for any resident's account. This failure affected all 93 residents currently residing at the facility. Findings include: Facility daily census report for 11/07/2023 showed resident census of 93 in-house. On 11/07/2024 at 11:43 AM, V1 (Administrator) said he could not provide the current balance for any resident account because a few weeks ago, a discrepancy was found in that balances were not being carried over. V1 added that the last balance report available was from 09/30/2023. V1 then said that V4 (Payroll/Human Resources) and V8 (Medical Records) handled the banking days, and that V4 was supposed to be keeping track of resident account balances. V1 (Administrator) then said that all resident financial documents were turned over to the corporate office so that an audit could be conducted, and current balances obtained. On 11/07/2024 at 12:57 PM, V5 (Regional Revenue Cycle Manager) said the facility was using an electronic account ledger system that was hacked so the facility was supposed to convert everything onto manual ledgers, but this was not being completed. At 1:55 PM, V5 then said that she is creating manual account ledgers for each resident from the last balance report dated 09/30/2024 through current using bank statements, withdrawal sheets, deposits slips, and/or receipts. V5 added that she will need approximately four weeks to complete this audit to obtain accurate resident account balances. On 11/08/2024 at 11:57 AM, V4 (Payroll/Human Resources) said resident's financial accounts were done electronically but then the program was no longer available as of October 2023. V4 then said she was supposed to manually keep the account ledgers but couldn't always keep up with this process. V4 also said that this manual process has been ongoing for approximately one year and that maintaining individual resident account transactions and balances is too much for one person to handle. V4 added that V8's (Medical Records) role with banking was being the second signature, and that she (V4) was keeping track of balances and transactions for each individual resident account the best that she could. On 11/08/2024 at 12:20 PM, V1 (Administrator) said there was no system being followed to adequately maintain resident accounts since the start of his employment in May of 2024 and added that he had recently discovered V4 was not adequately keeping track of all resident accounts or submitting the required documents to their corporate office monthly as of 09/30/2023. Review of Facility Resident Trust Fund Policy for Illinois last revised 09/20/2012 indicated the following: Policy: It will be the policy of the management company that the resident trust fund is managed and accounted for in accordance with state and federal regulations. Each facility should follow the state guidelines of the payment programs using the greatest level of specificity if requirements vary in state and federal programs. Procedure: All facilities handling resident trust must have it set up on their A/R system and on a manual ledger. The facility shall maintain a full and complete separate accounting ledger for each resident. The facility shall maintain current written individual ledgers of all financial transactions involving personal funds. The resident fund bank account must be reconciled monthly immediately upon receipt of the bank statement. The bank statement must be reconciled by someone other than the individual handling the day to day transactions. A check and balance system must apply for the security of personnel and residents. The completed reconciliation (form D) along with copies of the bank statement must then be sent to the corporate office. The corporate office must receive these by the 6th business day of the following month. The above balancing should be done as close to month end as possible, any discrepancies or variances should be resolved immediately. Upon request the facility shall provide a list or copies of resident trust statements to comply with state and federal governed agency and participating program requirements. Facility agrees to allow the inspection of the resident trust fund records by state and federal agencies. The resident trust authorization form acknowledges this requirement.

Oct 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to prevent the physical abuse of one of three residents (R3)reviewed for abuse in the sample of eight. Findings Include: The Facility's Abuse, Prevention and Prohibition Policy dated 01/24 documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The policy documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also include the deprivation of an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm pain or mental anguish. It includes, verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enable using technology. The Facility's Abuse Investigation dated 9/24/24 documents The investigation shows that (R3) states that (R7) was messing with the diet cards of the residents. (R3) asked (R7) not to play with the cards so the residents will get the correct meals. (R3) continued to state that some of the cards were on the floor, and she bent down to pick them up and (R7) pulled her hair and pushed her head down. On 10/4/24 both R3 and R7 refused to speak about the incident on 9/24/24. On 10/4/24 at 12:30 PM V1 (Administrator) stated The incident on 9/27/24 between (R3) and (R7) would be considered founded physical abuse because (R7) did in fact pull (R3)'s hair and push her head. We were not able to get a reasoning because (R7) would not speak to us about it, but she (R7) did go out for a psychiatric evaluation and returned to the facility with no further aggressive behaviors.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to not base a residents involuntary discharge on the residents status at the time of transfer to an acute care facility and ensure a signed physician discharge order was in place when serving a notice of involuntary discharge for one of three residents (R1) reviewed for involuntary discharge in the sample of eight. Findings include: The facility's Facility Assessment, dated 8/16/24, documents the facility has an average daily census of 96 residents and the top three diseases and conditions among residents in the facility are Schizophrenia, Bipolar disorder and Schizoaffective disorder. This Facility Assessment also documents Services offered: Mental Health and Behavior. Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (Post Traumatic Stress Disorder), other psychiatric diagnoses, intellectual or developmental disabilities. R1's admission Record documents R1's date of admission to the facility was 1/30/24 and her diagnoses on admission included: Bipolar disorder, Generalized Anxiety and Conversion Disorder with Seizures or Convulsions. R1's Preadmission Screening and Resident Review (PASRR), dated 6/4/24, documents R1 Needs continued twenty-four/seven help from nursing facility staff with completing activities of daily living, maintaining safety, getting around, managing mental health symptoms and taking recommended medications in a structured setting. This same screening documents R1 will need to be provided the following services and/or supports: Crisis Intervention Services, Individual, group, and family psychotherapy and Formal Behavior modification programs. R1's Minimum Data Set assessment, dated 8/1/24, documents R1 has Severely Impaired Cognition with a Brief Interview for Mental Status score of five. R1's Care Plan, dated 8/9/24, documents (R1) has a behavior problem related to Bipolar disorder, Generalized anxiety disorder. (R1) has verbal and physical aggression towards staff and peers. Will state she needs to go to the hospital so she can get a turkey sandwich and soda. Interventions dated 2/19 and 2/20/24 on this same care plan document During episodes of agitation, divert (R1's) attention from stimulus. When (R1) becomes agitated/aggressive: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; offer activities. R1's Care Plan, dated 2/19/24, documents (R1) is at risk for elopement related to (R1) exhibits a tendency to seek to leave facility or wander near exits. Related diagnosis/condition- Poor safety awareness with Bipolar disorder, poor impulse control. (R1) has the potential to be verbally aggressive related to poor impulse control. R1's Progress Notes, dated 2/14/2024 at 2:34 PM, documents (R1) exited A hall door, stated she was walking home. Staff present with resident at all times while outside the facility. PD (Police Department) contacted by staff, resident asking to go to hospital. Ambulance contacted, ambulance took patient via stretcher to (local hospital) for psychiatric evaluation. R1's Progress Notes, dated 2/18/2024 at 6:00 PM, documents (R1) was at the nurses station just used the phone when another resident came up to use the phone. (R1) turned around not knowing another resident was there and bumped into this resident. This upset the other resident and he began yelling at (R1) to watch what she was doing. This resident then called the other resident a b***h and other resident said you're the b***h. The other resident then spit in (R1's) face. Residents were separated immediately. R1's Progress Notes, dated 2/19/2024 at 4:56 PM, documents An incident occurred and was reported this morning where (R1) walked by a resident who was sitting in a chair next to the sunroom, close to the nurses station at which time she called the resident a b***h and spat in his face twice. The other resident got up to grab his walker, spilled his water and then slipped down to his knees. Social Services arrived on the scene just as nursing staff was helping the resident back up and assessing his health and safety. Discussions then took place among social services, administrator, and operations manager. (R1's) POA (Power of Attorney, V13) was contacted and we then had (R1) transported to the hospital and we discussed future plans for the residence upon return to our facility. At this time it was agreed upon that the resident would be better suited to be nearer to the POA, which is her brother, and we are now working on this arrangement moving forward. R1's Progress Notes, dated 2/26/2024 at 12:58 AM, documents (Certified Nursing Assistant) notified this nurse and another nurse of (R1) involved in physical altercation with another resident in the living area. Residents separated and assessed for injury. No injury noted. (R1) sent out by ambulance for psych evaluation at (local hospital). R1's Progress Notes, dated 9/23/2024 at 6:00 PM, documents Late Entry: (R1) was having behaviors through early hours of shift, continuously running out doors, spitting at staff. (R1) stated that she wanted to go home. Successfully got out of the building two times with staff following. Was unable to redirect, came back to the facility with help of police. Called MD (Medical Doctor), got order for (Intramuscular) shot of Haldol (Antipsychotic medication). Once given to resident she attempted to go out door a few more times before settling down and sitting in the dining room for supper. Will continue to monitor for improvement of mood and behavior. R1's Progress Notes, dated 9/27/2024 at 10:40 AM and completed by V2 (Director of Nursing), documents (R1) ran out of A wing door with 1:1 (one to one staff member) right behind her. This writer was outside and went towards the 1:1 and (R1) to try to help. (R1) was trying to spit on the staff there (another Certified Nursing Assistant and Nurse manager came to help). (R1) continued to spit on staff and hit them as all attempted to calm her down. (R1) stated she was leaving. (R1) threw herself on the ground and refused to get up. Staff assisted resident up into a wheelchair and this writer pushed her wheelchair into the building. Resident attempted to kick the glass door on the way in stating she was going to shatter it. (R1) was rolled in wheelchair into her room. (R1) got up from wheelchair and began to throw everything in her room on the floor. She then tried to kick the screen out of her window in her room. (R1) hit the window with her fists stating she was going to break it. (R1) then went into adjoining room and tried to break the window. She ripped down the blinds in the other room as well. (R1) tried to attack the resident in the adjoining room and staff stood in between. (R1) tried again to spit on the other resident (did not make contact) staff stepped in the middle and (R1) spit on staff. Resident in adjoining room (R4) states she is scared of the other resident now and wants her away from her. 911 called for police assistance and transportation to the hospital. R1's Abuse investigation, dated 9/27/24, documents Staff and (R4) state that (R1) walked into (R4's) room and tore down her blind and broke it. They also stated that (R1) called (R4) a B***h. (R4) and staff deny that (R1) threatened (R4). On 10/4/24 at 11:45 AM, R4 stated I don't want to keep talking about this. I don't know why (R1) came in here and ripped off the blinds. I wasn't scared because there was a bunch of staff with her, she (R1) did not even get close to me or threaten me in any way. She pulled them (window blinds) down threw them on the floor and then left the room. That is it. R1's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form, dated 9/27/24 and signed by V1 (Administrator), documents R1 was issued an Emergency Transfer or Discharge due to The safety of individuals in this facility is endangered. This notice does not document a Physician signature or Medical Provider who gave the order. R1's electronic medical record does not document a signed Physician Order for Discharge. On 10/4/24 at 12:48 PM, V8 (Certified Nursing Assistant) stated (R1) was a required one on one care resident who needed constant supervision. It depends on (R1's) mood as far as behaviors. She'd act out and be aggressive, kick or spit when she didn't get her way. I wasn't working the day she was sent out and didn't return but I did hear she was upset over not getting noodles. We do have another resident who has one to one supervision with staff, that's (R8). I have worked on A-hall (R1's former hall) for about six months and (R1's) behaviors were always the same. This aggression and lack of impulse control was not new for (R1). She did take medication for anxiety it helped when she took them. On 10/4/24 at 12:55 PM , V9 (Registered Nurse) stated (R1) was a big elopement risk. She would also spit and be aggressive at times. I worked the day after she transferred out and talked with the other resident (R4). (R4) stated that (R1) broke blinds in her room and called her a b***h. (R4) said she stayed in bed and pretended to be asleep during it but that (R1) did not make contact or threaten her. That wasn't a new behavior for (R1). She has always been combative, verbal, spitting and trying to elope. (R1) was one on one the entire time. We have other residents that have similar behaviors just less frequent. (R1's) behaviors were more frequent and consistent. On 10/4/24 at 1:17 PM, V2 (Director of Nursing) stated In (R1's) progress notes on 9/27/24, I documented the conversation for Involuntary Discharge (IVD) with (V12, Psychiatrist). I don't have a signed order for the discharge or a communication form from a Physician. I don't know if (V10, R1's Primary Physician) was ever made aware of the IVD. (R1) had a one on one staff member at all times. We do have another resident who has one on one as well, it is (R8). (R8) requires this also due to aggressive behavior. On 10/4/24 at 2:04 PM, V2 (Director of Nursing) stated (R1) wasn't at all acting herself the day she was sent to the ER (Emergency Room) and issued the IVD. Yes, she's had behaviors since she was admitted here but that day was a new level and way worse. The ER was just going to send her back here after like an hour and a half and we didn't feel she was safe to do so.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to provide medically related social services for one of three residents (R1) reviewed for involuntary discharge in the sample of eight. Findings include: The facility's Facility Assessment, dated 8/16/24, documents the facility has a total of 123 beds and the average of Mental Health/ Behavioral Health Needs in the resident population ranges between 100-123. This Facility Assessment also documents Services offered: Mental Health and Behavior. Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (Post Traumatic Stress Disorder), other psychiatric diagnoses, intellectual or developmental disabilities. Provide person centered/directed care: Psycho/social/spiritual support: Provide opportunities for social activities/life enrichment (individual, small group, community). This assessment also documents the facility staff will include Social Services, Behavioral and Mental Health Providers. R1's Preadmission Screening and Resident Review (PASRR), dated 6/4/24, documents R1 has diagnoses of Bipolar Disorder, Generalized Anxiety Disorder and Conversion Disorder with Attacks or Seizures. This form also documents R1 Needs continued twenty-four/seven help from nursing facility staff with completing activities of daily living, maintaining safety, getting around, managing mental health symptoms and taking recommended medications in a structured setting. This same screening documents R1 will need to be provided the following services and/or supports: Crisis Intervention Services, Formal Behavior modification programs, Individual, Group, and Family Psychotherapy: Explanation- Counseling from nursing staff could help when you do not feel well. Group Therapy led by a social worker will allow you to be around others who share similar experiences as you. One on one meetings with a Psychologist, Therapist, or Social Worker can help you talk about and understand why you hear or see things others cannot hear or see, have false beliefs, think others are out to get you, or feel depressed and and will help you find ways to cope with your symptoms. R1's Care Plan, dated 8/9/24, documents (R1) has a behavior problem related to Bipolar disorder, Generalized anxiety disorder. (R1) has verbal and physical aggression towards staff and peers. Will state she needs to go to the hospital so she can get a turkey sandwich and soda. Interventions dated 2/19 and 2/20/24 on this same care plan document During episodes of agitation, divert (R1's) attention from stimulus. When (R1) becomes agitated/aggressive: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; offer activities. R1's Care Plan, dated 2/19/24, documents (R1) is at risk for elopement related to (R1) exhibits a tendency to seek to leave facility or wander near exits. Related diagnosis/condition- Poor safety awareness with Bipolar disorder, poor impulse control. (R1) has the potential to be verbally aggressive related to poor impulse control. R1's Care Plan, dated 7/14/24, documents (R1) may display ineffective coping or overt behaviors due to PTSD. Known triggers include; Not being able to see her kids and her brother. Known psychosocial issues/behaviors attributed to PTSD: Elopement. Interventions: Encourage and assist (R1) to identify factors that contribute to well-being given current ability and resources. Assist to fulfill within facility resources. R1's Nursing Progress notes dated 2/2024- 9/2024 document numerous episodes of behaviors exhibited by R1 including verbal and physical aggression, spiting and swearing towards facility staff and other residents in the facility. R1's progress notes also document numerous episodes of R1 exiting the building or searching for ways to exit. R1's Social Services notes, dated 6/13/24-9/27/24, do not document R1 was offered any Social Service one on one visits, group therapies, psychosocial therapies related to R1's medical conditions, or any behavioral management interventions from the social service department. The Social Service notes for this time frame only document multiple referrals seeking placement for R1 in other facilities. On 10/4/24 at 12:55 PM, V9 (Registered Nurse) stated regarding the incident that led to R1 being discharged from the facility That wasn't a new behavior for (R1). She has always been combative, verbal, spitting and trying to elope. She was one on one care the entire time. We have other residents that have similar behaviors just less frequent. (R1's) behaviors were more frequent and consistent. I am not aware of (R1) attending any mental or psychosocial/behavioral therapy. On 10/4/24 at 1:05 PM, V6 (Social Service Assistant) stated he has only worked in the facility for two weeks. V6 stated The Social Services Director (SSD V3) has not worked here for very long either, maybe a month or two, and she is sick today. We do not have any in house psych services that I am aware of. We don't have any groups or behavioral therapies at this times for social services. We are a new department and are working to get group therapies implemented. V6 denied ever dealing with R1 prior to her discharge. On 10/4/24 at 2:04 PM, V2 (Director of Nursing) confirmed the facility does not have in house psychiatric therapy or in person psychiatrist visits. V2 stated The psychiatrist visit are conducted through telehealth. On 10/5/24 at 4:15 PM, V1 (Administrator) confirmed R1 did not have any psychosocial therapies taking place in the facility during her stay. V1 stated Our SSD (V3) has been in the facility maybe three to four weeks. We have a brand new social services team. I can't be sure how long we were without someone in the SSD role but during that time other employees, including (V2) were covering those social service duties.

Jul 2024 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation and interview the facility failed to provide accommodations for shaving preferences for one of 19 residents (R35) reviewed for accommodation of needs in a sample of 37. Findings include: On 7/22/24 from 1:00 PM through 1:15 PM, four of four resident shower rooms were observed and did not have mirrors. On 7/21/24 at 10:40 AM, R35 stated he could not shave because there were no mirrors in the shower rooms to facilitate shaving. On 7/22/24 at 12:45 PM, V18 (Certified Nurse Aide) stated The mirrors in the shower rooms were removed when they (facility) remodeled a few months ago. The residents could ask the staff (to shave) and we would have to take them a razor and stand with them in their room since there were mirrors. The shower room is where they (residents) usually shave though.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to acknowledge and comply with the resident's request to discard odorous urine at the bedside for 1 of 19 residents (R60) reviewed self-determination in a sample of 37. Findings include: The Residents' Rights policy, revised 11/2018, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean and homelike. On 07/22/24 at 9:30 AM, R60 stated They (staff) do not empty my urinal at night. I call them to come empty my urinal, but they don't come. I have to sit in there (R60's room) and smell it (urine) all night long. That's gross. On 7/22/24 at 12:10 PM, V18 (CNA/Certified Nursing Assistant) stated Many times, the urinal is full when I get here. I see how (R60) might be wet and refuse to be changed at night, but the urinal should be emptied. I wouldn't like to smell my urine when I'm trying to sleep.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to give a bed hold notification to a resident that was transferred to the hospital for one of three residents (R14) reviewed for hospitalization in a sample of 37. Findings Include: The facility policy named, Bed Hold Policy and Agreement, dated February 2024, documents, Policy: Bed Hold Policy of the Management Company that the facility will establish a system to notify the resident/responsible party/resident representative of the facility bed hold policy. The daily rate required holding a Resident's bed is specific to the room and payment program criteria of the resident. Procedure: The Bed Hold Agreement is to be obtained for each occurrence- hospital or therapeutic home leave. R14's Progress Notes dated 3/13/2024 documents the resident was sent out to the hospital and admitted . R14's Progress Notes dated 3/15/2024 at 2:01PM documents, (R14) returned to the facility per company transport. R14's vital signs within normal limits. New orders for antibiotic/urinary tract infection. On 7/23/2024 at 9:00 AM, V1/Administrator stated, We could not locate that (R14) was ever given a Bed Hold notification for R14's stay in the hospital on 3/13/2024.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow their elopement policy to update a resident's elopement risk care plan and failed to assess a resident's elopement risk quarterly for one of one (R20) resident reviewed for elopement in a sample of 37 residents. Findings include: The Elopements policy, reviewed 5/2023, documents All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individualized care plans. 1. Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility: 1. Door Alarms on facility exits; and/or A personal safety device that will alert facility staff when the resident has left the building without supervision; and/or Staff supervision. 1. Using the MDS (Minimum Data Set) resident assessment schedule, all residents shall be reviewed for safety concerns and precautions. Residents at risk for elopement shall be identified and documented in the individualized plan of care. On 4/1/24, R20's Care plan documents R20 was admitted on [DATE] with the diagnoses of paranoid schizophrenia, anxiety disorder and lack of expected normal psychological development in childhood and is hard of hearing and blindness. R20's careplan documents R20 has the potential to be physically aggressive related to poor impulse control and has an intervention that the Interdisciplinary Team will educate staff to redirect R20 when found wandering. R20's care plan does not include an intervention to ensure R20 is wearing a personal safety device and/or ensuring facility doors are alarmed, as directed by the facility's Elopement policy. The Wandering-Elopement Evaluation Scale, last conducted on 11/6/23, documents to complete the evaluation quarterly, with change in condition and/or change in wandering habits. On 11/6/23, R20's evaluation scored a 14.0 High Risk to Wander/Exit Seek. R20's Medical Record does not include a completed wandering-elopement risk assessment since the last one completed on 11-6-23. R20's 2/20/24 Progress Note documents (R20) noted walking out front door and standing in front of building, R20 stated R20 was waiting to get in a car. R20's 5/1/24 Progress Note documents (R20) then went and sat by front door for a few minutes before exiting front door. R20's 6/25/24 Progress Note documents (R20) noted attempting to exit front door. R20's 6/26/24 Progress Note documents (R20) attempted to exit D wing door this morning. R20's 6/27/24 Progress Note documents (R20) attempted to exit B wing door this morning. (R20) stated (R20) was going out on a dinner date. On 7/21/24 at 2:00 PM, V17 (Registered Nurse) stated R20 has gone outside the facility's doors. V17 stated the facility does not use personal safety devices or alarms. On 7/22/24 at 2:30 PM, V1 (Administrator) stated the Wandering-Elopement Evaluation Scale was last conducted on 11/6/23. V1 confirmed the Wandering-Elopement Evaluation Scale should be conducted quarterly.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview the facility failed to ensure dialysis (artificial kidney treatment) care was provided per policy, communicate with the dialysis facility before and after treatments, collaborate with the Interdisciplinary Team and ensure a resident's care plan documents detailed dialysis care and required services for a resident receiving renal hemodialysis for one of one resident (R12) reviewed for dialysis in the sample of thirty-seven. Findings include: The Dialysis Services Coordination Agreement, signed 8/24/21, documents E. Mutual Obligations 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long-Term Care Facility and the End Stage Renal Disease Dialysis Unit. Documentation shall include, but not limited to, participation, as members of an interdisciplinary team. The Dialysis policy, revised 1/2002, documents If a resident has a fistula, contact the physician and/or the hemodialysis center for specific directions on care of the fistula. D. Fistula: Blood pressures and blood sampling are not to be taken in the fistula arm. The Dialysis Communication policy, reviewed 1/2017, documents 2. A dialysis communication form will be used to send information to and from the facility to the dialysis center and back. 3. The nurse in charge of the care of the resident on the days of scheduled dialysis shall initiate the dialysis communication form and will ensure the form is sent with the resident. 4. Upon return of the resident from the dialysis center, the nurse in charge of the resident will review the communication form and will obtain necessary post dialysis information. 5. If there are any questions regarding the completion of the form or needs of the residents, the nurse will call the dialysis center for a telephone report of any significant information needed. R12's Progress Notes between 4/27/23 and 7/17/24 lack documented evidence of collaboration of care between the facility and the dialysis unit. R12's 3/8/23 Nursing admission Assessment documents an A-V fistula (arterial vascular fistula/dialysis access site) in the left arm. R12's Care plan documents R12 is at risk for fluid overload related to Kidney Failure and needs dialysis related to End Stage Renal Disease. R12's Care plan documents R12 receives dialysis three days a week but does not specify which days of the week or the times of scheduled treatments. R12's Care plan does not include blood pressure monitoring and/or the dialysis access site type, location, or specific care instructions. R12's 4/4/23 physician's orders document to take a blood pressure every day shift on every Sunday and to check the thrill and bruit (assessment of functional status of the dialysis access site) every shift, although the orders do not specify the type and/or location of the dialysis access site and/or which arm to avoid or not to avoid when taking blood pressures and where to conduct the assessment of the thrill and bruit. R12's Dialysis Binder included a letter from the dialysis unit on 1/4/23 which documents R12's current dialysis appointment time is Monday, Wednesday, and Friday at 11:50 AM. R12's Dialysis Binder included twenty-six completed Communication Forms out of sixty-one dialysis treatments between 3/1/24 and 7/19/24. Eighteen of the twenty-six Communication Forms were completed by V17 (Registered Nurse); four of twenty-six forms lacked a signature of who completed the form; and 3 forms lacked a post dialysis assessment, therefore was unable to determine if R12 received dialysis or not. R12's room was observed on 7/21/24 at 10:00 AM, there were no signs or instructions regarding no blood pressures or blood draws from R12's left arm. On 7/23/24 at 2:00 PM, V17 (RN) stated the Communication Forms should be completed by the facility and the dialysis unit for each dialysis treatment and placed in the Dialysis Binder. V17 stated there is no specific order for the location of R12's dialysis access site or specific instructions in the Care plan but nurses should know the policy and give the instructions to the Certified Nurse Aides during report.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect facility residents from physical abuse by another resident (R32) for nine of nine residents (R2, R43, R55, R56, R57, R58, R67, R68, R89) reviewed for abuse, in a sample of 37. FINDINGS INCLUDE: The facility policy, Abuse, Prevention and Prohibition Policy, dated (revised) 01/24 directs staff, Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Resident-to-Resident Altercations: Resident to resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. R32's current Physician Order Sheet, dated July 2024 documents that R32 was admitted to the facility on [DATE] and includes the following diagnoses: Bipolar Disorder and Generalized Anxiety Disorder. R32's current Care Plan, dated 2/20/24 includes the following Focus Areas: (R32) is known as displaying inappropriate behavior. Specific behavior exhibited-Spitting on others, especially during mealtime. Also included are the following Interventions: Approach (R32) in a calm, non-threatening manner. Keep (R32) out of reach of other residents, provide a cup for her to spit. R32's Facility Incident Log, dated 4/14/24 at 8:30 P.M. documents, It is concluded that (R32) made physical contact with fellow resident (R68). Residents separated and (R32) sent to local hospital. R32's Facility Reported Incidents, dated 5/26/24 documents, (R32) and (R56) were eating lunch together, exchanged words and (R32) spat on (R56). (R32) continues to be on 1:1 supervision. (R32) will also sit by herself at meals to prevent further similar incidents. R32's Facility Incident Log Report, dated 6/7/24 documents, The investigation shows (R67) was sitting in a chair and (R32) wanted to sit in that chair. (R32) got upset and spit on (R67). The facility will continue 1:1 supervision and encourage (R32) to wear a surgical mask when in common areas. R32's Facility Incident Log Report, dated 6/9/24 documents, (R32) and (R58) were in the dining room and (R32) spat on (R58). The facility will encourage (R32) to wear a surgical mask when in common areas. R32's Facility Incident Log Report, dated 6/10/24 documents, (R32) was upset on the smoking area and spat on (R2 and R55) on her way back into the building. Waiting on psychiatrist to evaluate (R32). R32's Facility Incident Report, dated 6/12/24 documents, (R32) made unwanted physical contact and spit on (R89). The 1:1 will encourage (R32) to spit in a cup. The facility will attempt to keep (R32) out of reach of other residents. R32's Facility Reported Incident Report, dated 6/14/24 documents, (R32) made unwanted physical contact with (R57). The investigation shows (R57) went to sit down in a chair and (R32) pushed (R57) from in front of the chair, so (R32) could sit in it. The facility rearranged furniture so there is no chair in the location the incident occurred. R32's Facility Reported Incident Report dated 6/15/24 documents, (R32) spat on (R43). Encourage (R32) to wear a mask in common areas. R32's Facility Reported Incident Report, dated 6/21/24 documents, (R32) threw ice on (R67). (R32) was sitting in a chair dropping ice out of a cup on to the floor. When her 1:1 (staff) asked her to stop, (R32) reached around her 1:1 (staff member) and threw the cup of ice on (R67), which was sitting on a chair close to (R32). On 7/22/24 at 2:30 P.M., V1/Administrator verified the multiple occurrences of R32 spitting on other residents, kicking other residents, and throwing ice on a resident. At that time V1 stated the facility was having difficulty in meeting (R32's) needs and were attempting new interventions, almost daily, to prevent further instances of R32 abusing facility residents.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to have a Certified Dietary Manager employed in the kitchen. This has the potential to affect all 95 residents living in the facility. Findings: The document, Dietary Supervisor, taken from the Job Description Manual, no date given, states, Responsible for the daily operations of nutrition service within the dietary department. Collects data and participates in the nutrition assessment process. Provides routine progress notes in the resident's medical records. Participates in the interdisciplinary team concerning resident's plan of care during care conferences and participates in the development of baseline care plans. Ensure care plan interventions, regarding nutrition/hydration, must be based upon the resident's assessment and disease processes. Reviews weight records routinely and communicates variances to the Dietitian and Disciplinary Team. Completes the assigned Minimum Data Set (MDS) section according to required timeline. Qualifications: Trained as a Certified Dietary Manager, Certified Food Protection Professional, or a Dietetic Technician, registered preferred. On 7/21/24 at 10:30 AM, V15, Dietary Manager, stated, No, I am not Certified. They (Management) told me that I needed to be certified and would get me into a program but they haven't got me into the classes. No, I don't do any of the (clinical nutrition) things for the residents. I guess the dietitian does. I really don't know. I don't look at weights and no, I don't know what I should do in the Minimum Data Set (MDS). I'm working in Dietary all of the time, usually filling in when someone calls off. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7-21-24 documents 95 residents currently reside within the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to have sufficient staff to serve the residents. This has the potential to affect all 95 residents living in the facility. Findings: The Facility Assessment, dated 5/31/24, states, Based on resident population and their needs, staffing ensures sufficient staff to meet the needs of the residents at any given time. Budgeted hours per payroll (2 weeks) is 900 - 945 hours. The electronic, Time Detail Report, for a two week period, 7/07/24 through 7/20/24, was provided. This report shows that the Dietary Department total hours worked in that department during that two week period were 301.25 hours. On 7/21/24 at 10:20 AM, there were three dietary employees working. V21 was on pots and pans, V20 was on cold food preparation and one, V15, Dietary Manager, was cooking. According to the schedule, the morning cook was not there. V15 stated, The cook called off. Someone is always calling off. We are always working short. On 7/22/24 at 10 AM, during the Resident Council Meeting, R21, R29, R46, R67, R83, agreed that often the meals are not served at the time they are scheduled to be served, as much as 30 to 45 minutes and sometimes an hour late. When they ask what is taking so long the answer they get is that, Dietary is working short in the Kitchen, someone called off. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7-21-24 documents 95 residents currently reside within the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to maintain a clean kitchen including floors, walls, drawers, walk in cooler, reach in coolers, freezers, convection oven, range, grill and range grease trays, dishwasher area including the top of dishwasher, hand washing sink; label large food bins; label and date opened food items in the refrigerator; keep storage containers off of the floor; place eggs on the bottom shelf of refrigerator; maintain the correct chlorine level on the low temperature dish machine; keep a log of the dishwasher chlorine tests; check the sanitation buckets with the appropriate test strips and keep a log of the tests. This has the potential to affect all 95 residents who live in the facility. Findings: The document, Food Storage (Dry, Refrigerated, and Frozen), dated 2016, states, Food shall be stored on shelves in a clean, dry area. All food items will be labeled. The label must include the name of the food and the date by which it should be consumed or discarded. Store eggs separately. If they cannot be stored separately, place eggs on shelves beneath cooked and ready-to-eat items. Raw eggs should be stored in drip proof containers. The document, Sanitizing Solution, no date, states, Employees will prepare sanitizer solution in accordance with manufacture guidelines. Bleach solution be at a concentration of greater than or equal to 50 to 100 parts per million (ppm). If a dispensing system is used it will be tested daily to ensure solution is dispensed at the appropriate concentration level. The document, no title, (provided by facility as the cleaning schedule, no other cleaning documents provided), no date, states, AM Cook, Temperature book is complete for your schedule; complete cleaning tasks for the day; sweep your area and mop up spills. PM Cook, Temperature book is complete for your shift; Cleaning tasks are completed; Floor is swept and mopped. This surveyor entered the kitchen on 7/21/24 at 10:20 AM. The general appearance of the kitchen was unkept and dirty. V15, Dietary Manager, provided the kitchen tour. The convection oven had dried food splashes and food particles on the outside, top, and front, the splashes running down the leg of appliance, the windows on the oven doors were opaque from dried grease, food splashes and debris. The interior of the convection oven had baked on grease, food debris and splashes on the bottom, ceiling, walls. The splash guard on the range had dried black and brown grease and food splashes. The grease tray for the grill had a large one- to two-inch-thick buildup of thick, old, black gooey in appearance grease and food debris. The grease trays under the range burners were lined with tin foil that contained unrecognizable old food droppings and dried liquids. The shelf over the range had visible layers of dust and crumbs. The walls behind the steam table, food preparation areas and dish room area had splashes of unknown liquids and food debris. Drawers by the steam table that housed utensils (dishes, spoons, spatulas) had crumbs on the inside ledge and on the bottom of the drawer; plates, bowls and trays stored beside the steam table are right side up, not upside down, which allows possible contamination; three plastic multiple drawer storage containers were directly sitting on the floor. These held meal accompaniments such as sugar, sugar substitute. The containers were dirty, without labels on the outside of the drawers of their contents and the top of one container was warped, bent down in the middle, exposure to the interior from the top by an inch on both sides. This was no longer a sanitary cover for the contents of the drawer. Four large containers containing dry cereal, (Rice Cereal, Chocolate [NAME] Cereal, Frosted Corn Flake Cereal, Round Oats Cereal) did not have a label. A bin of Sugar did not have a label. The bins in use had previously used peeling stickers that had not been removed from the container prior to washing. This can allow for contamination. The reach in refrigerator and freezers were dirty on the outside and the inside. The handles were sticky and had a crusted dusting of unknown material. Crumbs, and food droppings were visible on the interior floor. The walk-in cooler was dirty on the outside and inside. The areas around the door and on the interior door had buildup of black grime. The cooler floor had spills and food debris. A case of raw eggs was sitting on the shelf, in a box, not inside a nonporous pan, sitting over the bottom shelf that a container of cheese had been sat. An opened five-pound container of Cottage cheese did not have an open date or label. Four 32-ounce containers, three of nectar thickened liquids, two iced tea and one cranberry and one honey thickened orange juice were 50 % full, no open date or label. The sanitation bucket, which contained quaternary ammonia, was sitting on the food preparation counter with cleaning rags inside. V15 got a chlorine test strip (not a quaternary ammonia test strip) and attempted to test the contents of the sanitation bucket. When asked, V15 stated, this is what we are to use to test it. V20, Dietary Aide, also stated, Yes, those are the strips that we are given to test the sanitation bucket. When it was noted that the test strip tested zero, V20 stated, Yes, they always do. When asked what they do since they do not know what the strength of the sanitation bucket was and if they keep a log of the test strips in the sanitation solution, V20 stated, We don't do anything, we just use it. No one has told us to do anything about it. No, we don't keep a log, either. When the chlorine level on the low temperature dish machine was tested post cycle, the chlorine test strip registered 100 - 200 parts per million (ppm). V15 stated, They just came out to increase the amount of chlorine as it wasn't testing high enough. When asked what it should test V15 stated, 100 to 200 ppm. V15 stated she would have Maintenance come check it before using again. V15 confirmed the above issues. On 7/21/24 at 11:00 AM, V15, Dietary Manager, stated, We do as much as we can with the help that we have. Staff are always calling off and I am cooking or doing food preparation. We don't have time to clean. It's a challenge just to get the meals out on time and that doesn't happen all the time. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/21/24 documents 95 residents currently reside within the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to keep the large outside garbage dumpster closed and the area surrounding the container free of debris. The is has the potential to affect all 95 residents living in the facility. Findings: The document, Garbage Disposal, no date, states, Storage areas will be kept clean at all times to discourage pests. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. On 7/21/24 at 11:30 AM, V20 and V21, Dietary Aides, took the Dietary trash containers out to the large outside garbage dumpster. The lid on the dumpster was open. Several items had dropped form the dumpster onto the ground. Weeds surrounded the dumpster. V20, Dietary Aide, stated, This happens a lot. It's usually full to overflowing, especially on the weekend. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7-21-24 documents 95 residents currently reside within the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to maintain a walk-in refrigerator at the correct temperature; repair/replace the gasket on the door to the walk-in refrigerator in order to seal the door when closed; failed to repair the condenser inside of the walk-in refrigerator; failed to correctly repair a rack on a shelf in the walk-in refrigerator. This has the potential to affect all 95 residents living in the facility. Findings: The document, Refrigerator and Freezer Temperature Checks, no date, states, In order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators in use. Dining Services will be responsible for taking temperatures on all kitchen refrigerators and recording temperatures on temperature report logs daily during each shift. Correct actions are taken as necessary to ensure only safely stored foods are served to residents. Each refrigeration unit in the main kitchen is checked at department opening and before any food product is used for the day. The employee ensures that all cold storage units are 41 degrees Fahrenheit (F) or below for refrigeration. Temperatures are taken from the thermometer located inside the unit. The document Maintenance Work Order was filled in by V15, Dietary Manager and dated 7/12/24, states, Vegetable, refrigerator high temperature. Pending, Waiting on comp. The document Walk in Refrigerator Log, for the month of June 2024 was provided. A Walk in Refrigerator Log had not been filled out and provided for the month of July 2024. On 7/21/24 at 10:35 AM, the inside thermometer in the walk-in refrigerator in the kitchen tested 50 degrees Fahrenheit. The door to the walk-in refrigerator had a gap and when opened, the black rubber gasket was hanging loosely off of the door frame. V15, Dietary Manager, unsuccessfully attempted to re-attach the gasket. A yellow bucket which is normally used for scrubbing the floor was sitting in the right back corner. The bucket was half full of black dirty water. There was a hose coming down from the fan box area into the bucket. V15 stated, It's from condensation. I've put in several work orders, but it never gets fixed. We have to empty the bucket every other day. The top shelf on the shelving unit on the back right side of the walk-in refrigerator held several foods items but was at a 45 degree angle. V15 stated, they fixed the shelf before using a zip-tie, but it broke. They say they can't get the metal clips to fix the shelf so will have to zip-tie it again when they have time. I've been asking for things to be fixed since I came in December, but nothing ever gets done. I made copies of the work orders. The temperature in the kitchen is so hot that it makes the refrigerator temperatures go up. It's so hot it's miserable in here even in the winter. On 7/21/24 at 11:30 AM, V16, Maintenance Supervisor, was shown the issues in the walk-in refrigerator. V16 stated, I didn't know there was anything wrong with the walk-in refrigerator. When V16 was asked if he had received the work order requests that V15 had sent to him over the past months, V16 stated, I've been the only Maintenance person here for the past four months. Last week they finally got me some help. I'm busy and have been busy. I'll have to check the 800 or so work orders sitting on my disk that I haven't had time to look at. At 12:20 PM, the inside thermometer in the walk-in refrigerator was again checked. It registered 52 degrees Fahrenheit. On 7/23/24 at 10 AM, copies of the work orders that were made by V15, Dietary Manager were requested. V22, Administrator in Training, stated, V15 (dietary manager) resigned on 7/21/24. The work orders that she said she copied can't be found. We only have the one work order that we gave you from 7/12/24. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7-21-24 documents 95 residents currently reside within the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to keep flies and gnats out of the Kitchen, Dining Room and Resident Rooms. This has the potential to affect all 95 residents living in the facility. Findings: The document Infection Prevention and Control, dated 2019, states, Pest Control. The facility maintains an effective pest control program to remain free of pests. Facility-wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundries, central sterile supply areas, loading docks, construction activities, and other regions prone to pest infestations. On-going measures are taken to prevent, contain and eradicate common household pests such as flies. On 7/21/24 at 10:20, the kitchen was entered for tour. Flies were observed during the three hours spent in the kitchen. Flies landed on food items being prepared, on the food items in the steam table, before and during service, on appliances, equipment, clean dishes glasses, plates and silverware. Flies were landing on V15, Dietary Manager, V20, V21, Dietary Aides. They were a constant issue. V15 stated, We have flies all of the time. They're in the dining room also. We are never rid of them. On 7/22/24, the Resident Council Meeting was held for the annual survey. R21, R29, R46, R67, R83, all stated that they have flies in the dining room, in their bedrooms and that flies and gnats are Bad when we're outside. R67 stated, The flies and gnats get really bad in my room. Sometimes I open my window to the outside and shoo the flies and gnats out of the window. There was an appliance attached to the wall in the dining room to eliminate flies, but the appliance was not plugged in and was not working. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/21/24 documents 95 residents currently reside within the facility.

May 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident to resident physical abuse did not occur for two residents (R6, R7) of four residents reviewed for abuse in a sample of four. Findings include: Facility's Abuse Prevention and Prohibition Policy Revised 1/2024, documents: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Facility's Initial and Final Reports to (State Department of Public Health) for R6 and R7 document: After investigation of the incident between residents (R6) and (R7) it has been determined that that R6 made physical contact with R7. R6 has been education on appropriate communication with fellow residents and to keep hands to himself. R6 and R7 have been sitting in separate areas in the facilities dining hall. There have not been any further incidents between R6 and R7. R7 states feeling safe in the facility. R6's diagnoses include: Mild neurocognitive disorder due to known physiological condition with behavioral disturbance, manic episode severe with psychotic symptoms, family history of alcohol abuse and dependence. R6's Minimum Data Set/MDS dated [DATE] documents R6 has a BIMS (Brief Interview of Mental Status) of 8 on a scale of 00 - 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R6's current Care Plan documents: The resident is/has potential to be physically aggressive when he feels provoked by another resident related to History of harm to others. R7's diagnoses include: Bipolar disorder, suicidal ideations, psychophysiologic insomnia, attention-deficit hyperactivity disorder, anxiety, post-traumatic stress disorder/PTSD, schizoid personality disorder, major depressive disorder. R7's Minimum Data Set/MDS dated [DATE] documents R7 has a BIMS score of 15 on a scale of 00 - 15. R7's current Care Plan documents: The resident is known to display fluctuations in mood related to PTSD, bipolar, suicidal ideation, schizoid personality, insomnia, anxiety. On 5/21/24 at 11:40am, R6 stated that he does not remember details of the incident with R7 on 5/15/24; stated that he did not get hurt and had no injuries. On 5/21/24 at 12:05pm, R7 stated: Is this about the fight? R7 stated that at the time of the 5/15/24 altercation with R6, that he was shocked when R6 hit him and that he was still processing what went on. At this same time, R7 stated, We were at lunch and (R6) hit me in my chest and started hitting me when I touched (R6) on his shoulder; I thought (R6) was going to steal my food, that happens; and (R6) turned around and started hitting me. On 5/21/24 at 1:10pm, V14 Registered Nurse/RN, stated that she was the Nurse for R6 and R7 and witnessed the 5/15/24 incident; stated that R6 went to sit in R7's chair where R7's meal was. Stated that R7 said to R6, That is my dinner; (R7) gets confused at times, and started sitting down anyway. Stated that R6 said to R7, Okay punk!, and then struck R7 in his abdomen and on his back.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow its abuse policy for a thorough investigation for two residents (R6, R9) of four residents reviewed for allegation of resident to resident abuse in a sample of four. Findings include: The facility's Abuse Prevention and Prohibition Policy Revised 1/2024, documents: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. R6 and R9's AIM/Assess, Intercommunication, Manage for Wellness Event Record Progress Note dated 5/13/24 documents: (R6) appears to have been involved in an altercation with a peer. Event was first noted on 05/13/2024 12:35pm. Just prior to/at the time of the event R6 appears to have been sitting in the dining room awaiting lunch. R6's account of the event is R6 states other res (R9) just came up and started swinging at him; verbal altercation escalated into a physical altercation. Facility staff actions/interventions and response at time of the event includes residents separated immediately, assessment completed. There were no documentation to indicate that information regarding this resident to resident abuse allegation was reported sent to (State Department of Public Health) for R6 and R9. R6's diagnoses include: Mild neurocognitive disorder due to known physiological condition with behavioral disturbance, manic episode severe with psychotic symptoms, family history of alcohol abuse and dependence. R6's Minimum Data Set/MDS dated [DATE] documents R6 has a BIMS (Brief Interview of Mental Status) of 8 on a scale of 00 - 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R6's current Care Plan documents: The resident is/has potential to be physically aggressive when he feels provoked by another resident related to History of harm to others. R9's diagnoses include: Acute hepatitis-C, alcohol use, unspecified with alcohol-induced persisting dementia, schizoaffective disorder, Parkinson's disease with dyskinesia. R9's Minimum Data Set/MDS dated [DATE] documents R9 has a BIMS (Brief Interview of Mental Status) of 14 on a scale of 00 - 15. R9's current Care Plan documents: (R9) is noted to have inappropriate behaviors and responses such as spitting on/toward staff and peers, knocking over ice carts and laundry carts. On 5/22/24 at 9:35am, V17 Certified Nursing Assistant/CNA stated that she was the caregiver for both R6 and R9 on 5/13/24; stated that she saw R6 and R9 sitting at table and both were talking. V17 CNA stated that R9 picked up a tea cup and threw it at R6 and R6 then threw his cup and hit R9. On 5/22 at 9:50am, V1 Administrator stated for the population at the facility, incidents happen and residents might have an altercation, and check with them later and everything seems to be fine. V1 stated that he talked with R6 and R9 and decided not to investigate further. V1 stated that he did not get interviews or witness statements from staff or residents for this incident. At this same time, V1 Administrator stated, There were no changes in their (R6 and R9) conditions; they said they were okay, so this was not investigated further.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interviews and record review, the facility failed to report allegations of abuse to the State Agency for two residents (R6, R9) of four residents reviewed for allegation of resident to resident physical abuse in a sample of four. Findings include: The facility's Abuse Prevention and Prohibition Policy Revised 1/2024, documents: The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated stated agency per reporting criteria. R6 and R9's AIM/Assess, Intercommunication, Manage for Wellness Event Record Progress Note dated 5/13/24 documents: (R6) appears to have been involved in an altercation with a peer. Event was first noted on 05/13/2024 12:35pm. Just prior to/at the time of the event R6 appears to have been sitting in the dining room awaiting lunch. R6's account of the event is R6 states other res(R9) just came up and started swinging at him; verbal altercation escalated into a physical altercation. Facility staff actions/interventions and response at time of the event includes residents separated immediately, assessment completed. On 5/21/24 at 12:50pm, V1 Administrator stated: We are supposed to send (State Department) reports whenever there is physical altercation, regardless if there is an injury or not. V1 stated that they did not report the altercation between R6 and R9 to (State) authorities.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interviews and record review, the facility failed to do a thorough investigation for an allegation of resident to resident abuse for two residents (R6, R9) of four residents reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prevention and Prohibition Policy Revised 1/2024, also documents: The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated stated agency per reporting criteria. R6 and R9's AIM/Assess, Intercommunication, Manage for Wellness Event Record Progress Note dated 5/13/24 documents: R6 appears to have been involved in an altercation with a peer. Event was first noted on 05/13/2024 12:35pm. Just prior to/at the time of the event R6 appears to have been sitting in the dining room awaiting lunch. R6's account of the event is (R6) states other (R9) just came up and started swinging at him; verbal altercation escalated into a physical altercation. Facility staff actions/interventions and response at time of the event includes residents separated immediately, assessment completed. On 5/22/24 at 9:50am, V1 Administrator stated that investigation interviews with the staff were not done and there were no witness statements for the 5/13/24 resident to resident altercation that occurred between R6 and R9.

Apr 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to provide evidence of facility's refusal to readmit a resident was not based on the resident's status at the time of transfer and failed to provide documentation by a physician regarding the basis of a resident's involuntary transfer/discharge with indications for why a resident should not return to the facility or what resident needs could not be met at the facility for one (R2) of three residents reviewed for Involuntary Discharge in a sample of three. Findings include: Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents You must be allowed to return to your facility after you are hospitalized as long as you still need that level of care. If you get Medicaid and are hospitalized for ten or fewer days, your facility must let you return when you leave the hospital even if the facility has given you a written discharge notice. If you are hospitalized for more than ten days, your facility must let you return if it has a bed available and you still need that level of care. If your facility is full, you must be allowed to have the first available bed, if you still need that level of care. The facility's undated Resident Involuntary Discharge policy documents It is the policy of this facility to only initiate involuntary discharge proceedings when the below listed situations exist. The facility's primary concern is for the health and safety of the affected resident and for the health and safety of other residents, visitors, and staff members. Criteria for Involuntary discharge: 1. The discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility. a. The justification must be documented in the resident record by the resident's physician .3. The safety of individuals in the facility would otherwise be endangered. a. The details must be documented in the record. 4. The health of individuals in the facility would otherwise be endangered. a. This must be documented in the resident record by any physician. R2's current Physician Order Sheet/POS diagnoses include Bipolar Disorder, Auditory Hallucinations, Suicide attempt, Antisocial Personality Disorder, Generalized Anxiety Disorder, and Schizoaffective Disorder Bipolar Type. R2's current Care Plan includes (R2) is known to display fluctuations in mood related to Bipolar, Schizoaffective Disorder, and (R2) is/has potential to be verbally aggressive related to ineffective coping skills. R2's Progress note, dated 3/3/24, documents R2 had increased confusion and hallucinations, was in an altercation with a peer, and sent out to the hospital for evaluation. R2's Progress note, dated 3/8/24 by V4 Social Service Director/SSD, documents Resident was taken to (named) hospital in (location) at approximately 4:30pm on 03/08/24 for psych evaluation per (V11 R2's facility physician and V12 R2's psychiatrist's) recommended hospitalization (after a session today) due to resident having delusions, suicidal and homicidal ideations, as well as engaging in self-harm by using her fingernails to cut herself. R2's clinical record does not include the reason for R2 not being readmitted to the facility, interventions/attempts to meet the resident's needs, notes of communication with the hospital, or what R2's status/condition was upon the hospital's request for return. R2's Hospital Medical Doctor/MD Psych Progress note, dated 3/19/24, documents Coherent, no psychotic or inappropriate thought content. R2's Hospital MD Psych Progress note, dated 4/16/24, documents recommendations that include Continue current inpatient psychiatric admission; Provide safe and secure environment .Patient is open to explore nursing homes. On 4/23/24, between 10:20am - 2:50pm, V2 Administrator in Training/AIT stated the following: (R2) was not accepted back due to not being able to meet her needs of needing a private room which we do not have. (R2) requires a private room due to her behaviors and aggression; threats and aggression against her roommate which is the reason we sent her out (on 3/8/24). (V2) is unsure of (R2's) status/condition on 4/5/24 when the hospital reached out .There were phone calls to the nurse (V5 LPN), V1 Administrator and V5 Social Service Director/SSD but no documentation was completed. V1 is out all week and unavailable for interview. On 4/24/24, at 11:19am, V4 Social Service Director/SSD stated the following: I was told no by Administration that we would not be able to take (R2) back due to not meeting her needs. At this time, V4 denied documenting what danger (R2's) return would pose or what needs needed to be met. I don't see where I documented anything after the note of (R2) going out .I don't know what (R2's) status was when they (hospital) called. I can't be 100% and don't have it documented .I dropped the ball on the notes for sure. On 4/25/24, at 12:29pm, V2 AIT stated As for an involuntary discharge, this was not an involuntary discharge. This was a 10-day bed hold discharge. After the 10 days, we no longer had a private room available to accommodate this resident. This resident required a private room to protect the other residents at (named facility) due to her homicidal ideation. V8 Hospital LCSW's e-mail, dated 4/25/24 at 11:40am, documents (V1) initially faxed us the (involuntary discharge) paperwork and wanted us to give it to (R2). We did not give it to the patient (R2) as we were under the impression that the (named facility) should be doing that in person. The facility's fax cover letter faxed to the hospital and dated 3/20/24, documents: Attention to (V8 LCSW), from (named facility), for (R2). R2's undated and unsigned Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents has State Proceeding marked. On 4/26/24, at 12:52pm, V11 R2's facility doctor stated the following: I could have very well been notified that they weren't taking (R2) back. However, I was not involved in whether or not (R2) was coming back so nothing is documented by me. V11 stated V11 is unaware that the facility did not accept (R2) back and that (R2) is still in the hospital waiting for nursing home placement. V11 stated they probably referred to (R2's) status at the time (R2) left if they said they couldn't meet (R2's) needs. On 4/26/24, at 2:50pm, V2 AIT denied knowing that on 3/20/24, V1 faxed Involuntary Discharge paperwork over to the hospital for R2 to sign.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to permit resident (R2) to be readmitted to the facility from the hospital after inpatient psychiatric hospitalization for psychiatric assessment and treatment and failed to develop and implement a policy for Transfer/Discharge that addresses permitting residents to return to the facility after a hospital or therapeutic leave for one (R2) of three residents reviewed for facility-initiated transfers in a sample of three. This resulted in the resident (R2) remaining in the hospital for more than 30 days while waiting for nursing home placement. Findings include: Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents You must be allowed to return to your facility after you are hospitalized as long as you still need that level of care. If you get Medicaid and are hospitalized for ten or fewer days, your facility must let you return when you leave the hospital even if the facility has given you a written discharge notice. If you are hospitalized for more than ten days, your facility must let you return if it has a bed available and you still need that level of care. If your facility is full, you must be allowed to have the first available bed, if you still need that level of care. On 4/23/24, at 10:00am, R2 was not residing in the facility and the facility's Resident Room Roster, dated 4/23/24, does not include R2. R2's Face Sheet documents R2's payer source as Medicaid. R2's current Physician Order Sheet/POS diagnoses include Bipolar Disorder, Auditory Hallucinations, Suicide attempt, Antisocial Personality Disorder, Generalized Anxiety Disorder, ands Schizoaffective Disorder Bipolar Type. R2's Progress note, dated 3/8/24 by V4 Social Service Director/SSD, documents Resident was taken to (named) hospital in (location) at approximately 4:30pm on 03/08/24 for psych evaluation per (V11 R2's facility physician and V12 R2's psychiatrist's) recommended hospitalization (after a session today) due to resident having delusions, suicidal and homicidal ideations, as well as engaging in self-harm by using her fingernails to cut herself. R2's Minimum Data Set/MDS assessment, dated 3/8/24, documents the following: Discharge assessment-return not anticipated; Type of discharge=unplanned; admission date 12/13/22; discharge date [DATE]; and no active discharge planning already occurring for the resident to return to the community. On 4/23/24, between 10:20am - 2:50pm, V2 Administrator in Training/AIT stated the following: (R2) was not accepted back due to not being able to meet her needs of needing a private room which we do not have. (R2) requires a private room due to her behaviors and aggression; threats and aggression against her roommate which is the reason we sent her out .The last we heard was on 4/5/24 when a nurse took a call from (named hospital) requesting belongings and that (R2) was accepted at (named) Mental Health hospital. (V2) is unsure of (R2's) mental status at that time .We weren't planning on discharging (R2) until the 10-day bed hold kicked in (3/18/24) and then we could decide whether or not to accept (R2) back. V2 stated that V1 Administrator is out of the facility all week and unavailable for interview. On 4/24/24, at 11:19am, V4 Social Service Director/SSD stated the following: (R2) had been saying (R2) was suicidal so I did that assessment. Initially (R2) was cooperative then she couldn't answer correctly and was in psychosis. Because of this I arranged for (R2) to see (V12) our psychiatrist through tele-health in the facility. After their session (V12) was very concerned and said (R2) needed to be hospitalized . (V12) sent us (V12's) recommendation then we sent (R2) out to the hospital. The hospital reached out about (R2) coming back after a couple of days, but we had told them we would be sending over (V12's) recommendation and wouldn't be able to care for (R2) at this point because of (R2's) homicidal and suicidal ideations. I was told no by Administration that we would not be able to take her back due to not meeting her needs. R2's HPI (History of Present Illinois) note, dated 3/8/24 and signed by V12, documents After discussion with the resident and clinical assessment, this writer recommends the resident be admitted voluntarily or involuntarily for psychiatric hospitalization. This would be for intensive medication and psychiatric evaluation, including consideration of the thoughts expressed by this clinician. R2's Hospital Nurse Practitioner Psych Progress note, dated 3/15/24, documents Psych Evaluation - Patient arrives from (named facility) after making suicidal statements. Patient has a history of mental health diagnosis and mental health hospitalizations .No homicidal ideations (HI) or suicidal ideations (SI), coherent, relevant and logical thought processes. Recommendations: Continue current inpatient psychiatric admission .Given her recent psych admission, will opt for long-term observation on an inpatient setting for now. On 4/24/24, at 1:21pm, V8 Hospital Licensed Clinical Social Worker (LCSW)/Case Manager stated the following: (R2) is still in the hospital looking for placement. (R2) came on 3/8/24 and was admitted due to HI (Homicidal Ideations) and SI (Suicidal Ideations) at the nursing home .On 3/12/24, (V4 SSD) stated (R2) was on day 5 of the bed hold, but not taking admissions until 5/1 and they would hold (R2's) bed hold until 5/1/24 to allow treatment (R2) needed. In my 3/13/24 note it states, met with patient (R2) and told (R2) that (named facility) would accept (R2) once (R2) was stable. On 3/15/24 I called to speak with (V4 SSD) but (V4) was unavailable. I got transferred to (V6 LPN) and wanted to stay in touch and give updates. I shared that (R2) might be ready for discharge next week and (V6) said thank you .V8 stated they (hospital Social Services) called and emailed the facility several times without any response. While this was going on our doctor tried to see if (R2) would qualify for a state hospital. On 3/20/24 we did a report to the court. The court did agree (R2) was appropriate for a state hospital. This can take a long time to get in to and we felt that (R2) may get better while waiting which she already has been .On 4/2/24 our psych doctor said (R2) is doing better and to see if (named facility) would accept (R2) back. We tried to call (V1 Administrator) on 4/2/24 to see and left message waiting to hear back. On 4/3/24 we tried to reach leadership of admissions at (named facility) for extension of bed hold and no call back. I emailed (V4 SSD) an update on 4/3/24 and asked for response back. On 4/4/24 did not receive any responses - called facility to speak with V1 Administrator around 11:20am and no answer at the facility's main line. V8 continued to state that (R2's Medical Doctor psych note) stated that (R2) was seen on 4/5/24 and that (R2) had moderate depression, no HI (homicidal ideations), no SI (suicidal ideations), no audio or visual hallucinations. Behavior normal and cooperative. Mood frustrated. Thought processes coherent. On 4/24/24, at 2:25pm V6 LPN stated the following: My last conversation about (R2) was on Friday (3/15/24) and (R2) was supposed to get discharged that day and come back to us, but (R2) did not come that day, but maybe would on the next Monday. That was my last conversation about that hospital stay .The next I heard was that (R2) got discharged from the facility and was somewhere else. The facility's March census summary documents R2 discharged /transferred to a Psychiatric hospital on 3/18/24. R2's Hospital Medical Doctor/MD Psych Progress note, dated 3/19/24, documents Coherent, no psychotic or inappropriate thought content. On 4/24/24, at 4:05pm, V5 Licensed Practical Nurse/LPN stated the following: I took a phone call (on 4/5/24) in which a nurse from the hospital and a Social Worker were asking about (R2's) belongings. They asked if we were able to bring her stuff, but couldn't have much due to not much room on the ambulance transferring to (named Mental Hospital) .They did not say anything to me about (R2) coming back. I hadn't heard anything since (R2) left. There wasn't any reason why we wouldn't have taken (R2) back. (R2) was okay. So I wasn't sure if this was a temporary thing or what. As far as I knew they were just trying to get (R2) stable because (R2) wasn't in her right state of mind. I didn't know we weren't going to take (R2) back. No one had said we weren't .I expected (R2) to come back. I was surprised. On 4/25/24, at 2:35pm, V8 LCSW stated that (R2's) doctor is okay with nursing home placement and (R2) is stable to go to a nursing home. (R2) has reached her baseline. If a bed comes open at the state hospital, then we would send (R2). Otherwise, if a nursing home takes (R2) we would dismiss that court order. She has been waiting so long now she is appropriate for nursing home if she could get accepted to one. We send out multiple referrals (over 25) and they were all denied. On 4/26/24, at 12:52pm, V11 R2's facility doctor stated the following: I do get phone calls from the nursing home periodically stating they don't want to accept certain residents back. There isn't anything I can do about it. I am an ER (Emergency Room) doctor so I know that they have to go home and then they can do discharge planning. I could have very well been notified that they weren't taking (R2) back. I am sympathetic with nursing homes but realize hospitals can't always find a place for them to go and then they end up staying longer in the hospital. V11 continued to state V11 was not involved in whether or not (R2) was coming back, is unaware that the facility did not accept (R2) back, and that R2 is still in the hospital waiting for nursing home placement. The facility was unable to provide a Transfer/Discharge policy. On 4/26/24, at 8:46am, V2 Administrator in Training/AIT stated, We do not have a discharge/transfer policy.

Feb 2024 18 deficiencies 1 Harm

SERIOUS (H)

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected multiple residents

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Based on interview and record review, the facility failed to prevent and protect residents from verbal, mental, and physical abuse from occurring for 15 (R8, R12, R25, R41, R46, R72, R77, R82, R87, R89, R91, R96, R108, R110, and R113) of 15 residents reviewed for abuse in the sample of 51. This failure resulted in R41 being punched in the nose causing R41's nose to bleed and R25 being pulled down a hallway by her hair. Findings include: The facility's Abuse Prevention Program, dated 11/28/16, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including; but no limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, and any other individuals. 1. R110's Face Sheet, dated 2/7/24, documents R110's diagnoses including Paranoid Schizophrenia, Suicidal Ideation's, Hallucinogen Dependence with Induced Psychotic Disorder, Anxiety, Huntington's Disease and Major Depressive Disorder. R110's Facility local State Agency Report, dated 12/3/23, documents an altercation between R110 and R8. R8 notified staff that R110 laid in R8's bed and R110 struck R8's leg. The Report also documents an Incident Investigation Form, dated 12/3/23 at 9:50 am, stating that R110 was in the hallway having a verbal outburst and jumped over the counter at the desk and started kicking and thrashing. No injuries were noted and all parties were notified. R110's Nursing Note, dated 12/3/23 at 10:31 am, documents that R110 was involved in an altercation with (R8) and R110 was kicking objects and jumped over the Nurses' Station Desk. The Nursing Note also documents that R110 had been kicking and hitting R110's roommate (R8). No injuries were noted. R110's Facility local State Agency Report, dated 12/26/23, documents an altercation between R110 and R91. R110 was in a state of delusion, being disruptive in room. Staff went to check on (R110) at this time. (R110) exits room and directed outburst towards staff. The Report documents that R91 stated that R110 was yelling at the nurse and (R110) approached (R91) and began swinging her arms, making contact. R72 states that there was shouting and that R72 tried to help staff. The Report's Incident Investigation Form, dated 12/26/23 at 10:45 am, documents that R110 was in R110's room shouting and came charging out of R110's room swinging R110's arms, then R110 shoved R72, and proceeded down the hallway, and started slapping R91. No injuries were noted and all parties were notified. R110's current Care Plan documents that R110 has the potential to be physically aggressive related to poor impulse control. 2. R113's Face Sheet, dated 2/7/24, documents R113's diagnoses including Schizophrenia, Major Depressive Disorder, Anxiety Disorder and Catatonic Disorder due to known Physiological Condition. R113's current Care Plan documents that R113 has the potential to respond physically when provoked by peers, is known to display fluctuations in mood and uses Psychotropic medications (Haldol) related to behavior management. The Facility local State Agency Report, dated 1/27/24, documents that R41 has diagnoses including Schizoaffective Disorder/Depressive Type, Major Depressive Disorder, Recurrent Severe Without Psychotic Feature, Attention Deficit Disorder, Insomnia and Anxiety. Facility local State Agency Report, dated 1/27/24, documents an altercation between R113 and R41. R113 and R41 were on the Facility Smoking Patio, and that (R41) punched (R113) in the back of the head, so (R113) punched (R41) in the face and R41's face was bleeding. The Report's Incident Investigation Form documents that R41 stated, that R113 was making fun of R41's girlfriend and was trying to get her in bed and (R113) would not stop saying things, so I palmed (R113) in the back of the head and (R113) punched me in the nose. R113's Nursing Progress Note, dated 1/27/24 at 9:45 am, documents that R113 and R41 were involved in an altercation on the Smoking Patio and that (R113) states that another Resident (R41) hit him. R113's Quality Assurance Progress Note, dated 1/30/24, documents an altercation on 1/27/24, between R113 and R41, wherein R41 struck R113 and that R113 struck R41 back. On 2/6/24 at 10:45 am, V11 (Certified Nursing Assistant/CNA) stated, (R113) was out smoking on the patio and someone yelled at me that (R41) had a bloody nose. (R41) said that (R41) hit (R113) in the back of the head, so (R113) hit (R41) in the nose. On 2/6/24 at 11:50 am, V20 (Certified Nursing Assistant/CNA) stated, (R113) and (R41) were on the smoking patio and (R41) had a bloody nose. I was told that (R41) smacked (R113) in the back of the head and that (R113) punched (R41) in the face and (R41) got a bloody nose. They were fighting over a girl. 7. The Facility's Final report for Incident on 10/5/23 documents that R87 he asked R72 to stop talking. R72's written statement documents R72 told R87 if he asked again she would strike him. R72 then stuck R87 on the arm and R87 backhanded R72 across the face. The Account documented that the account of the incident was taken by R72 and R87 and written statements from peers in the dining room during the incident that R72 slapped R87's arm and R87 smacked R72 with the back of his hand across the face. On 2/5/24 at 1:30 PM R72 stated I was only joking around with (R87) and lightly tapped him on the arm and he backhanded me across the face. It hurt, but I didn't have any bruising or anything. He apologized for over reacting. 8. The Facility's Final Report for incident on 11/1/23 documents that on 11/1/23 R72 got in R12's personal space and would not move. R12 then pushed R72 to the side. The Account section of the Final Report documented that the account of the incident was taken by R12 and R72 and V11(Certified Nurse Aide) who witnessed the incident and confirmed that R12 physically shoved R72 out of her way and walked past her. 9. The Facility's Final Report for incident on 12/1/23 documents that R72 was in the living room talking with R82 and R12 began being verbally aggressive towards both R72 and R82. R12 then got up and made contact with R72's arm before walking out of the room. The Account section of the Final Report documents the account of the incident by R12, R72 and R82 who witnessed the incident and V11 (Certified Nurse Aide) who overheard the incident and confirms that R12 made contact with R72's arm while walking away. On 2/6/24 V11 (Certified Nurse Aide) stated I didn't actually see (R12) make any sort of contact with (R72) but (all three residents) told me it was like (R12) just kind of bumped her arm against (R72)'s arm aggressively. On 2/6/24 at 1:30 PM R72 stated (R12) is just a b***h and thinks she runs this place, We can't sit by each other at anything anymore and our rooms had to get changed. 5. R89's Care plan, dated 11/15/23, documents, The Resident is known to display fluctuations in mood related to schizo-affective disorder, Parkinson. (R89) is noted to have inappropriate behaviors and responses such as spitting on/toward staff and peers, knocking over ice carts and laundry carts. A Facility Final Report (to State Agency) for incident on 11/14/23, no date available, documents, Original Complaint: It was reported to the abuse coordinator of an alleged altercation. While in the dining room R89 allegedly shouted at R96, R96 made contact with R89 after. Account: R96 states R89 was in the way. R96 asked R89 to move several times. R89 raised his voice at R96. R96 then made contact with R89 while making her way around him. Determination: It appears as the dining room was congested. R89 became over stimulated and started shouting. R96 was simply trying to pass by. Incident Investigation Form with V20 (CNA-Certified Nursing Assistant), dated 11/14/23, documents, I heard yelling and came around corner to see (R89) have a hold of (R96's) arm. On 2/6/24 at 11:20 a.m., V20 stated, I just came around the corner and saw (R89) holding (R96's) arm. Incident Investigation Form with V21 (CNA), dated 11/14/23, documents, (R96) had pushed elbow into (R89) and (R89) grabbed (R96's) wrist. 6. A facility Final Investigation Report (to State Agency), no date available, documents, It was reported to the abuse coordinator of an alleged altercation on 1/22/24. While in the common areas residents (R72 & R89) had a verbal disagreement that led to physical contact. Account: R89 states he was trying to retrieve a cup. R72 states she will not be disrespected in her house and shouted at R89. R72's statement, dated 1/22/24, documents, I won't be disrespected in my house. I got in his (R89's) face and yelled at him and he hit me for no reason. V12's (Business Office Manager) written statement, dated 1/22/24, documents, I was coming around the nurses station when I heard yelling in the living room. As I rounded the corner I saw (R89) and (R72) arguing. As I was walking towards them to separate them, (R89) reached out and struck (R72). I ran to them, (R89) had (R72) in a bent over hug from the side. On 02/07/24 11:13 AM V12 stated, I was coming from the nurses' station and heard yelling. When I got in the fireplace area, (R72's) back was to me, but I could see that (R89) had struck (R72) in the chest area. Then, he had her in like a bent over hug like position. 3. The current Care Plan for R108 documents (R108) has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against this Resident. Behavior exhibited: yelling, cursing, making animal sounds instead of words, throwing items, laying on the floor, and taking other's belongings. Type of reprisal to guard against: physical aggression toward others. Those who may seek reprisal: Other residents. Resident's specific information: Diagnosis: schizophrenia, anxiety, PTSD (Post-Traumatic Stress Disorder). The Facility Reported Incident, dated 1/31/24, documents a witnessed altercation occurred on 1/31/24 between R25 and R108 and the police were called. R25 was sitting in a wheel chair and R108 grabbed R25 by the hair and pulled (R25) down the hallway approximately 5 feet. The signed and dated witness interview statements, dated 1/31/24, from V5 Housekeeping Supervisor, V17 Activity Director, V16 and V21 CNA's (Certified Nursing Assistants) document R108 pulled the facility fire alarm and then began roaming the hallways. R25 was sitting in a wheel chair propelling in the hallway and R108 grabbed R25 by the hair and began pulling R25 backwards. These staff intervened and separated the residents. The Progress Note for R108, dated 1/31/24 and 1:56 pm, documents (R108) was being combative and we were not able to redirect her. (R108) involved in a physical altercation with another resident (R25). (R108) was sent out to hospital via ambulance. On 2/6/24 at 3:00 pm, V4 Regional Director of Operations stated she did this investigation, sent the initial and final together because it was a witnessed incident. R108 was agitated that day, pulled the fire alarm and then was wandering the halls. When R108 passed R25 in a wheel chair, R108 grabbed R25's hair and began pulling her wheel chair backwards by R25's hair, about five feet. R25 and R108 were separated immediately, R108 was sent to a local hospital for a psychological evaluation, R25 was assessed for injury, the police were called, and a report was filed with report number 24-ECPA-00205. V4 Regional Director of Operations confirmed this allegation as substantiated due to being witnessed by staff. 4. The facility's final Abuse Investigation dated, 1/23/24, documents an alleged physical altercation occurred between R46 and R77. This report documents V1 Former AIT (Administrator in Training) was notified on 1/19/24 that R77 impulsively reached arm out, made contact with R46 and R46 struck R77 back. V9 RN witness interview statement, signed and dated 1/19/24, documents (R77) sitting in w/c (wheel chair) hysterically laughing by Nurses Station. (R46) walking by, (R77) reached out arm impulsively and made contact with (R46). (R46) struck (R77) back on right arm/shoulder, was upset about situation. V24 RN witness interview statement, signed and dated 1/19/24, documents This RN observed (R77) reach out to strike at another Res (resident) as they walked past other Res. (R46) then turned and hit (R77) in the arm stating 'that's what you get for hitting me.' R77's signed and dated interview, dated 1/19/24, indicates R77 did not recall the incident. R77 made sexual comments to V2 DON (Director of Nursing) during interview. A second interview attempt was made on 1/20/24 with another related verbal response. R46's Statement, dated 1/19/24, documents resident stating The guy in the hallway punched me real hard so I hit him back. On 2/6/24 at 3:00 pm, V4 Regional Director of Operations confirmed this allegation as substantiated due to being witnessed by staff.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the PASARR (Pre-admission Screening and Resident Review) Level II recommendations for one of three residents (R70) reviewed for PASARR screenings in the sample of 51. Findings include: R70's PASARR Level II Notice of Determination, dated 1/23/20, documents that R70 is eligible to be admitted to the nursing facility level of care. However, the following Special services are recommended for R70 to receive while residing in the facility: Instrumental Activities of Daily Living training/reinforcement; Mental Health Rehabilitation activities; Illness self management; Community re-integration activities. R70's Psychiatric Physician/Practitioner note, dated 11/9/2023 at 02:55 a.m., documents, History of Present Illness: Follow up visit of R70 a [AGE] year-old admitted to facility for Long Term Care from status post hospitalization. patient has past medical history consisting of depression, schizophrenia, and antisocial personality disorder. R70's medical record has no documentation of R70 receiving the PASARR recommended special services. On 02/07/24 10:27 AM, V14 (Social Services Assistant) stated, Because I'm the only case manager it's impossible for me to have 115 individual programs. I'm not a Social Services Director I am a Social Services Assistant. I only have a high school diploma. I don't have a degree. I don't have anything to do with what the PASARR Level II recommends at this time. He is not on any type of individual or group programs. V14 confirmed that R70 was not receiving any special services as recommended by the PASARR Level II.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to provide incontinent care for one resident (R104) incontinent of bowel of 24 residents reviewed for ADL's (Activities Of Daily Living) in the sample of 51. Findings include: Facility Policy/Preventative Skin Care dated 3/16/23 documents: Keep incontinent resident's clean and dry. Facility Policy/Perineal Cleansing dated 9/21/10 documents: To eliminate odor, prevent irritation or infection and to enhance resident's self-esteem. Current Physician Report Summary indicates R104 has diagnoses that include Diabetes Mellitus, Diarrhea. Report indicates GI (Gastrointestinal) consult was ordered for R104 on 8/20/23 due to chronic loose stools. On 2/4/24 at 8:10am R104 was seen in bed with soiled sheets (top and bottom). Linens had brown stains smeared and scattered on bed linens; foul odor noted in area of 104's bed. At that time R104 stated no one (staff) had been in the room to check on him during the night. On 2/4/24 at 8:15am V15, CNA (Certified Nurse Assistant) stated R104 often has loose stools and the stains on the sheets were feces. V15 stated he was just coming on shift and would help R104 get cleaned up, but staff should have come in to check on R104 during the night and encouraged R104 to get cleaned up.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services to maintain or prevent further limitation in range of motion for one of two residents (R22) reviewed for range of motion in the sample of 51. Findings include: The facility's Splints/Appliances policy dated 9/2008, states A resident who has a contracture, or has a likelihood of developing a contracture, caused by physical condition and requires further evaluation will be assessed by the Occupational Therapist for a splint/appliance as ordered by the resident's physician. The program will be identified on the resident's care plan including the problem, approaches and goals. On 2/04/24 10:26 a.m. and 2/7/24 at 2:00 p.m., R22 was sitting in her wheelchair with her left hand curled into itself with her fingers also curled into the palm of her hand. R22 did not have any type of splint, brace, or washcloth on her left hand or under her fingers. R22's bedside dresser had a splint lying on top of it. R22 stated she cannot straighten out her hand or fingers without using her right hand to open them up. R22 stated staff do not apply the brace/splint to her left hand every day. R22 stated she believed she is supposed to wear the splint every day. R22's Minimum Data Set (MDS) assessment dated [DATE], documents R22 has Functional Limitation in Range of Motion of one side of her upper extremities. This same MDS assessment documents R22 did not receive splint/brace assistance or Range of Motion exercises. R22's current computerized medical record, including physician orders do not document an order for R22's limited range of motion in her left hand/fingers. On 2/7/24 at 2:05 p.m., V10 (Regional Nurse Consultant) stated R22 has no documented evidence that she was receiving any type of service to her left hand such as a splint, brace, or appliance to reduce R22's risk for contracture development or further decline in range of motion. V10 stated upon observation, R22 was not wearing any type of splint on her left hand. On 2/7/24 at 3:35 p.m., V2 (Director of Nursing) stated R22 did have a splint to wear on her left hand the last she recalled. V2 stated she thought R22 was supposed to wear the splint every day, but she did not know where the orders were documented. V2 stated R22's splint should be addressed on the physician order sheet and the care plan at a minimum.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to assess and prevent repeated falls for one of eight Residents (R110) reviewed for Accidents in a sample of 51. Findings include: Facility Safe Smoking and Vaping Policy, revised 10/27/22, documents: the Facility works to provide appropriate care for residents keeping safety and comfort in mind; Residents may have the desire to smoke/vape and accommodations will be provided as the Facility deems appropriate; the implementation of the Smoking Safety Risk Assessment will be conducted once the resident indicate they may want to smoke; development of the Resident Smoking Contract will be completed by the Social Service Designee and the Resident; and must be dressed appropriately for weather. QAPI (Quality Assurance and Performance Improvement) Plan Policy, undated, documents: the Facility is committed to providing specialized assistance and wide-ranging services that enable our Residents to attain optimal well being and create an environment where people are loved, valued, at peace and feel safe; strive to achieve improvement in specific goals related to falls; committed to balancing a safe environment with Resident choice; and assess Residents's strengths and needs to design, implement and modify person-centered measurable and interdisciplinary care plans. R110's Witnessed Fall Report, dated 1/9/24 at 1:45 am, documents that R110 is independent with ambulating and activities staff reported that (R110) fell into the wall and bumped head, then slid to ground during smoking pass. R110 did not sustain injuries and the intervention was to provide a chair when feeling disoriented and/or unbalanced. R110's Plan of Care Note, dated 1/9/2024 3:19 pm, documents that the Quality Assurance (QA) team met to discuss and review R110's change of plan on 1/09 and found the root cause to be that R110 was disoriented and unbalanced. The intervention was to provide R110 with a chair when feeling disoriented and/or unbalanced. R110's Witnessed Fall Report, dated 1/18/24, at 8:10 pm, documents that R110 is independent with ambulating and was informed by staff that (R110) fell outside, lost her footing on the ice while smoking a cigarette and was wearing flip-flops on the ice. R110 sustained a red spot on left side of the face and the intervention was to provide appropriate footwear. R110's Plan of Care Note, dated 1/19/2024 at 09:35 am, documents the Quality Assurance (QA) team met to discuss change of plan on 1/18/24 and found the root cause to be that R110 lost her footing. The intervention is to provide R110 with appropriate footwear. On 2/4/24 at 10:20 am, R110's current Care Plan does not document that R110 is a Smoker and the Facility could not provide a Smoking Safety Risk Assessment or Resident Smoking Contract. On 2/6/24 at 1:31 pm, R110 was on the Smoking Patio, smoking a cigarette. On 2/7/24 at 1:38 pm, R110 was on the Smoking Patio, smoking a cigarette. On 2/5/24 at 10:20 am, V2 (Director of Nursing/DON) stated, (R110) is a smoker and is on our smoking list. I cannot find any Smoking Assessments in R110's chart, but R110 is a smoker. I also do not see that smoking is on (R110's) Care Plan. On 2/6/24 at 1:15 pm, V2 (DON) stated, We have updated (R110's) Care Plan and added Smoking to it for a care area. We probably should have done all the Assessments and Smoking Contract before she fell out on the smoking patio.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to ensure urinary drainage collection bags and urinary catheter tubing were kept off the floor for two residents (R64 and R104) of three residents reviewed for catheters in the sample of 51. Findings include: Facility Policy/Suprapubic Catheter Care dated 3/15/23 documents: To provide daily and as needed catheter care to resident's with suprapubic catheters to reduce the incidence of infection. On 2/7/24 at 2:10pm V2, DON (Director of Nursing) acknowledged catheter drainage bags should be kept off of the floor. 1. On 2/4/24 at 8:10am R104 was seen in bed with a suprapubic catheter and was attached to tubing. The lower portion of the catheter tubing and the drainage collection bag was on the floor next to the bed. There was also a urinary drainage collection bag and tubing on the floor underneath the bottom of R104's bed that was not attached to R104. At that time R104 stated no one (staff) had been in the room to check on him during the night. On 2/4/24 at 8:15am V15, CNA (Certified Nurse Assistant) stated R104 takes care of changing the catheter bags himself, but shouldn't be using a dirty catheter bag from the floor.2. On 2/4/24 at 7:00 am, R64 was sitting in a wheel chair in her room. R64's urinary catheter bag and tubing were resting on the floor underneath R64's wheel chair. On 2/4/24 at 7:00 am, R64 stated it is always laying on the floor and is never in a bag.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to notify the Facility Ombudsman and the Residents/Resident Representatives, in writing, of Hospital Transfers/Discharges for four of four Residents (R64, R85, R108 and R110) reviewed for Bed Hold Transfer in a sample of 51. Findings include: Facility Transfer and Discharge Policy and Procedure Policy, undated, documents: it is the policy of the Facility not to transfer or discharge a resident unless the transfer or discharge is necessary to meet the Resident's welfare, and the Resident's welfare cannot be met in the Facility; the documentation in the Resident's clinical record shall be required; and the Facility shall notify the Resident ad the Resident's family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents: before the Facility can transfer or discharge you, it must prepare you to be sure that your discharge is safe and appropriate; and you must be allowed to return to your Facility after you are hospitalized for ten or fewer days, your Facility must let you return when you leave the hospital even if the Facility has given you a written discharge notice. On 2/7/24 at 1:42 pm, V3 (Receivership [NAME] President of Operations) stated, I do not think that they had been doing them, we cannot locate any written notifications of transfer for any of the discharges anywhere in the office or in the Resident charts and cannot find any notifications to the Ombudsman having been made. On 2/6/24 at 1:20 pm, V12 (Business Office Manager) stated, I cannot find any written notifications of transfer for any of our discharges and they have looked in all of the charts and all of our binders and we just do not have them. (V19 Ombudsman) is fairly new within the last 6 months or so, and said that she does not want us to call her or email her every time someone discharges the Facility, so I have not been doing it. 1. R85's Census List, dated 2/7/24, documents that R85 admitted to the facility on [DATE]. R85's Census List also documents that R85 discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. 2. R110's Census List, dated 2/7/24, documents that R110 admitted to the facility on [DATE]. R110's Census List also documents that R85 discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. R110 also discharged again to the hospital on 1/31/24 and readmitted to the facility on [DATE]. 3. The Progress Note for R64, dated 2/4/24, documents R64 complained of tingling in right arm and chest pain. Blood pressure was noted at 165/100. Physician notified and ordered R64 to be sent to local hospital for evaluation. Ambulance service called and resident transported to local hospital. The Facility was unable to provide written notification of reason for resident transfer to the local hospital. 4. The Census Report for R108 documents R108 was sent to the local hospital for evaluation on 1/31/24. On 2/7/24 at 9:15 am, V2 DON (Director of Nursing) stated there was no written notice of transfer provided when R108 went to the hospital.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to issue a Bed Hold Policy upon Discharge/Transfer to the Hospital for four of four Residents (R64, R85, R108 and R110) reviewed for Bed Hold Transfer in a sample of 51. Findings include: Facility Transfer and Discharge Policy and Procedure Policy, undated, documents: it is the policy of the Facility not to transfer or discharge a resident unless the transfer or discharge is necessary to meet the Resident's welfare, and the Resident's welfare cannot be met in the Facility; the documentation in the Resident's clinical record shall be required; and the Facility shall notify the Resident ad the Resident's family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents: before the Facility can transfer or discharge you, it must prepare you to be sure that your discharge is safe and appropriate; and you must be allowed to return to your Facility after you are hospitalized for ten or fewer days, your Facility must let you return when you leave the hospital even if the Facility has given you a written discharge notice. On 2/6/24 at 1:20 pm, V12 (Business Office Manager) stated, I cannot find any written bed holds for the transfer of any of our discharges and they have looked in all of the charts and all of our binders and we just do not have them. On 2/7/24 at 1:42 pm, V3 (Receivership [NAME] President of Operations) stated, I do not think that they had been doing them, we cannot locate any documentation of bed holds for any of the discharges anywhere in the office or in the Resident charts. 1. R85's Census List, dated 2/7/24, documents that R85 admitted to the facility on [DATE]. R85's Census List also documents that R85 discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. 2. R110's Census List, dated 2/7/24, documents that R110 admitted to the facility on [DATE]. R110's Census List also documents that R85 discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. R110 also discharged again to the hospital on 1/31/24 and readmitted to the facility on [DATE].3. The Progress Note for R64, dated 2/4/24, documents R64 complained of tingling in right arm and chest pain. Blood pressure was noted at 165/100. Physician notified and ordered R64 to be sent to local hospital for evaluation. Ambulance service called and resident transported to local hospital. The Facility was unable to provide documentation of a bedhold being given to R64 at the time of transfer to the local hospital. 4. The Census Report for R108 documents R108 was sent to the local hospital for evaluation on 1/31/24. On 2/7/24 at 9:15 am, V2 DON (Director of Nursing) stated R108 did not receive a bed hold policy provided to R108 at the time of hospital transfer.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/4/24 at 10:20 am, R110's current Care Plan does not document that R110 is a Smoker. On 2/6/24 at 1:31 pm, R110 was on the Smoking Patio, smoking a cigarette. On 2/7/24 at 1:38 pm, R110 was on the Smoking Patio, smoking a cigarette. On 2/5/24 at 10:20 am, V2 DON (Director of Nursing) stated, (R110) is a smoker and is on our smoking list. I cannot find any Smoking Assessments in R110's chart, but R110 is a smoker. I also do not see that smoking is on (R110's) Care Plan. On 2/6/24 at 1:15 pm, V2 (DON) stated, We have updated (R110's) Care Plan and added Smoking to it for a care area. 3. Progress Note dated 8/15/23 at 4:02pm indicates R82 and R41 came to Social Service office to ask if they could be care planned to be in each others room. Progress Note dated 11/12/23 at 9:21pm indicates R41 became upset when other resident (R82) was asked to leave R41's room, police notified and explained policy to R41. On 2/6/24 at 11:55pm R41 and R82 stated they wanted to be allowed to see each other in private, however staff in the facility are only allowing them to be in supervised areas when they are together. R82 stated that the police have been called to enforce this arrangement. On 2/6/24 at 12:20pm V14, Social Service Assistant stated R81 has been under guardianship by a juvenile State Agency since she was [AGE] years old. V14 stated that R81 is now [AGE] years old and in the process of transitioning out of that department and will no longer be under jurisdiction of that guardianship. V14 stated that her current legal guardian has declined to allow R81 to engage in an intimate relationship with R41. V14 stated that we are following the direction of R82's current guardian and in the process of appointing an adult guardian for R82. Court document dated 7/14/23 indicates Cause comes on for permanency review. (Juvenile State Agency) reports that they've obtained the physician's report and sent it to the State Guardian but there is still no progress. They are going to obtain a neuropsychological approval request for (R82) and hope to have that completed as (R82) turns 21 in a few months. Neither R41 or R82 had care plans developed indicating their request to be allowed a private relationship or the reasons this has not been allowed. No care plan was developed to identify the juvenile legal guardianship of (R82), a resident residing in a long term care facility. On 2/7/24 at 2:50pm V14 Social Service Assistant stated Care Plans - including Social Service care plans - where previously done by the MDS (Minimum Data Set) Coordinator who recently left facility employment. V14 stated I trusted the social service care plans were getting done, but recently found out they weren't being done. V14 stated we are now re-structuring and social service will do their own care plans. 4. Current Physician's Order Report Summary indicates R45 receives Seroquel (antipsychotic) 50mg (milligrams) twice daily for Depression (date ordered 8/18/23). Current Care Plan indicates R45 is known to display fluctuations in mood related to Bipolar, Major Depression and Anxiety. R45's Care Plan does not identify R45 receiving Seroquel, indication for use, behaviors, interventions or side effects. 5. Current Physician Report Summary indicates R104 has diagnoses that include Diabetes Mellitus, Diarrhea. Report indicates GI (Gastrointestinal) consult was ordered for R104 on 8/20/23 due to chronic loose stools. Report medication orders include: Cholestyramine (bile acid reducer) 4 Grams at bedtime for diarrhea (order date 12/22/23) Loperamide (anti-diarrheal) 2mg (milligram) every six hours as needed for diarrhea (order date 8/20/23) Probiotic one capsule in am for GI health/loose stools (order date 9/6/23) Omeprazole 20mg every morning related to diarrhea (order date 11/7/23) Progress Note dated 1/13/24 at 10:36am indicates stool sample collected, watery slimy stool noted. Progress Note dated 2/6/24 at 1:14pm indicates received order for Immodium (anti-diarrheal) for loose stools. On 2/4/24 at 8:10am R104 was seen in bed with soiled sheets (top and bottom). Linens had brown stains smeared and scattered on bed linens; foul odor noted in area of 104's bed. At that time, V15 CNA (Certified Nurse Assistant stated R104 often has loose stools and the stains on the sheets were feces. R104's Care Plan did not include identified focus area related to management of R104's loose stools. Current TAR (Treatment Administration Record indicates R104 receives a daily treatment for a third degree burn on his abdomen and also requires monitoring of a penile wound/fistula every shift. On 2/7/24 at 10:45am V9, RN (Registered Nurse) administered treatment to R104's new supra pubic catheter site. At that time visualized R104's abdominal burn which was almost healed but remained dark pink with several fragile areas. R104 acknowledged he had to get the supra pubic catheter placed due to the wound developed on his penis from a chronic indwelling catheter. R104's Care Plan does not include development of care areas for R104's abdominal burn or R104's penile fistula.Based on observation, interview, and record review, the facility failed to develop a person centered comprehensive plan of care for Mental illness/Psychtoropic medication use, limitation of range of motion, smoking, for 7 of 25 residents (R4, R22, R41, R45, R82, R104, R110) reviewed for care plans in the sample of 51. Findings include: The facility's Comprehensive Care Planning policy dated 11/1/17, states It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to the facility. The results of this Resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. 5. Program Plan- A structured program designed to change a specific need/problem. The Program Plan consists of, at minimum: a. Statement of the targeted problem/need. b. Goal stating the expected outcome of the reduction of the targeted problem. c. Interventions/Approaches aimed at reducing the causative factors of the targeted problem. 1. R4's current computerized Physician Order Sheet, documents R4 receives Zyprexa 5 mg (milligrams) one tablet in the evening for a diagnosis of Schizophrenia. R4's Physician Order Sheet also documents R4 has diagnoses of Bipolar Disorder, and Anxiety Disorder. R4's Care Plan dated 12/20/23, does not document R4's mental illness diagnoses, target behaviors, goals or interventions/approaches. On 2/7/24 at 11:10 am., V2 DON (Director of Nursing) stated R4's current care plan does not document R4's Mental Illness Diagnoses, target behaviors or interventions/approaches. 2. On 2/04/24 10:26 a.m. and 2/7/24 at 2:00 p.m., R22 was sitting in her wheelchair with her left hand curled in to itself with her fingers also curled in to the palm of her hand. R22 stated she cannot straighten out her hand or fingers without using her right hand to open them up. R22 did not have any type of splint, brace, or washcloth on her hands or under her fingers. R22's Minimum Data Set (MDS) assessment dated [DATE], documents R22 has Functional Limitation in Range of Motion of one side of her upper extremities. The facility's Splints/Appliances policy dated 9/2008, states A resident who has a contracture, or has a likelihood of developing a contracture, caused by physical condition and requires further evaluation will be assessed by the Occupational Therapist for a splint/appliance as ordered by the resident's physician. The program will be identified on the resident's care plan including the problem, approaches and goals. R22's Care Plan dated 1/10/24, does not specifically document R22's risk for contracture development or limitation of functional range of motion to her left hand/fingers. R22's Care Plan does not document any interventions, including use of a splint/brace, to prevent further decline of the left hand/fingers mobility. On 2/7/23 at 1:48 p.m., V2 DON stated R22's care plan did not address R22's limited range of motion in the left hand/fingers or any approaches/interventions to prevent contracture development or further decline in mobility.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. R10's Trauma Informed Care Assessment dated 8/25/23 documents That R10 answered yes to the question: Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: *a serious accident or fire *a physical or sexual assault or abuse *an earthquake or flood *a war *seeing someone be killed or seriously injured *having a loved one die through homicide or suicide. 1. Have you ever experienced this kind of event? R10's Trauma Informed Care Assessment dated 8/25/23 did not contain any information as to what R10's trauma was, what her triggers were or if she wanted any assistance with PTSD. R10's current Care Plan dated 8/25/23 does not include any mention of PTSD or triggers. On 2/7/24 at 11:20 AM V14 SSA confirmed that R10's Care Plan does not address that R10 has a history of PTSD or any associated triggers with that PTSD. 9. R'60s Trauma Informed Care assessment dated [DATE] documents that R60 answered yes to the question: Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: *a serious accident or fire *a physical or sexual assault or abuse *an earthquake or flood *a war *seeing someone be killed or seriously injured *having a loved one die through homicide or suicide Have you ever experienced this kind of event? R60's Trauma Informed Care Assessment documented that R60 had troubles with nightmares in the last month, has had to try hard to not think about the event()(s) or went out of their way to avoid situations that reminded them of the event, been constantly on guard, watchful or easily startled and felt guilty or unable to stop blaming their self or others for the event(s) or any problems the event(s) may have caused. R60's current care plan dated 11/3/23 documents that R60 is at risk for depression due to trauma assessment score, see PTSD score for details. Goal resident will be decreased episodes of depression/PTSD through next review date 3/19/24; Interventions: Assist the resident in developing a program of activities that is meaningful and of interest 11/3/23; encourage and provide opportunities for exercise, physical activity 11/3/23, Notify provider any risk for harm to self and/others 11/3/23 observe resident for any signs/symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, and tearfulness 11/3/23 Resident to attend group or 1:1 group services with SSD as resident allows. 10. R64's Trauma Informed Care assessment dated [DATE] documents that R64 answered yes to the question: Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: *a serious accident or fire *a physical or sexual assault or abuse *an earthquake or flood *a war *seeing someone be killed or seriously injured *having a loved one die through homicide or suicide. Have you ever experienced this kind of event? R64's Trauma Informed Care assessment dated [DATE] documents that R64 answered yes to the question have you been constantly on guard,watchful or easily startled? R64's current Care plan dated 11/3/23 documents Risk for depression due to trauma assessment score, see PTSD (Post Traumatic Stress Disorder) score for details. Goals: Resident will be decreased episodes of depression/PTSD through next review date. Approaches Encourage and provide opportunities for exercise, physical activity 11/3/23; Assist the resident in developing a program of activities that is meaningful and of interest 11/3/23; Notify Provider any risk for harm to self and/or others 11/3/23 Observe resident for any signs/symptoms of depression, including, haplessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, and tearfulness 11/3/23 resident to attend group or 1:1 group service with SSD as resident allows. 11. R72's Trauma Informed Care assessment dated [DATE] documents that R72 answered yes to the question: Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: *a serious accident or fire *a physical or sexual assault or abuse *an earthquake or flood *a war *seeing someone be killed or seriously injured *having a loved one die through homicide or suicide Have you ever experienced this kind of event? R72's Trauma Informed Care assessment dated [DATE] documents that R72 had had nightmares in the past month, or thought about the event(s) when they did not want to, tried hard not to think about the even(s) or thought about the event(s) when they did not want to, tried hard not to think about the event(s) or went out of their way to avoid situations that reminded them of the event(s). R72's current Care plan dated 11/3/23 documents risk for depression due to trauma assessment score, see PTSD score for details; Goals Resident will be decreased episodes of depression/PTSD through next review date 3/19/24 Approaches Assist the resident in developing a program of activities that is meaningful and of interest 11/3/23; encourage and provide opportunities for exercise, physical activity 11/3/23; observe resident for any signs .symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health related complaints and tearfulness; Resident to attend group or 1:1 group services with SSD as resident allows 11/3/23 On 02/06/24 at 3:00 PM V14 (Social Service Assistant) confirmed that R60, R64 and R72 Care plans for PTSD are exactly the same with no personalized interventions for either of the residents. 4. R70's Care plan, dated 9/7/23, documents, The resident is known to display fluctuations in mood related to mental illness diagnosis of PTSD, schizophrenia and major depression. The care plan also documents the following intervention: If resident becomes triggered by trauma induced triggers offer group therapy or one on one sessions with SSD (Social Services Director) or a member of the IDT (Interdisciplinary Team) team as resident allows. R70's Trauma Informed Care Assessment, dated 10/17/23, documents that R70 has experienced a unusually or especially frightening, horrible, or traumatic event. The assessment also documents that R70 has had nightmares about the event, and has tried hard not to think about the event or went of their way to avoid situations that reminded them of the event. R70's Psychiatric Physician/Practitioner Note, dated 11/9/2023 at 02:55 p.m., documents that R70 has a medical history of PTSD. On 02/07/24 at 09:07 AM, V11 (Regional Nurse Consultant) stated, There is no documented PTSD triggers for (R70). On 02/07/24 10:27 AM, V14 (Social Services Assistant) stated, I'm not aware of what (R70's) PTSD triggers are, and I don't have any triggers documented. 5. On 02/05/24 at 09:57 AM, R78 stated, My PTSD is all from my childhood, and I'm starting to have nightmares. So, I'm not sleeping and it's all I think about. R78's Care plan, dated 8/7/23, documents, Resident may display ineffective coping or overt behaviors due to PTSD diagnosis. The care plan also has the following interventions documented: Assist resident to identify trigger, how to avoid and what to do when the trigger does occur; Determine if behavior/mood changes is triggered by certain activities, noise levels, staff, peers, visitors, time of day, other precipitating events, etc. Encourage discussion of behavior changes among IDT to determine meaning behind behavior/mood occurrences/changes; Encourage discussion that led to PTSD Diagnosis and triggers that cause distress and resident feeling about it. R78's Care plan, dated 9/11/23, documents, The resident is known to display fluctuations in mood related to PTSD, bipolar, suicidal ideation, schizoid personality, insomnia, anxiety. The care plan also documents the following intervention: If resident becomes triggered by trauma induced triggers offer group therapy or one on one sessions with SSD or a member of the IDT team as resident allows. R78's Trauma Informed Care Assessment, dated 9/4/23, documents that R70 has had something happen to him that is unusually or especially frightening, horrible, or traumatic. The assessment also documents that he is constantly on guard, watchful, or easily startled, and that he has felt numb or detached from people, activities, or your surroundings. R78's Psychiatric Physician/Practitioner note, dated 2/3/2024 at 9:14 p.m., documents, Medical History: Anxiety, bipolar mixed, schizoid personality, Depression, Insomnia, Post-traumatic stress disorder. Complaint: feeling numb. History of Present Illness: [AGE] year old male male who lives at a skilled nursing facility, He has psychiatric history consisting of bipolar disorder, depression, schizoid personality disorder, ADHD, anxiety, PTSD, and insomnia. He independent in his ADLs. Patient reports 'feeling numb. R78's Current medical record has no documentation of what R78's PTSD triggers are. On 02/07/24 at 09:07 AM, V10 (Regional Nurse Consultant) stated that there is no documented PTSD triggers for (R78). On 02/07/24 10:27 AM, V14 (Social Services Assistant) stated, I don't know what (R78's) PTSD triggers are. I meet with them regularly, but that's not something we really talk about. There is no documented triggers for (R78). 6. Trauma Informed Care assessment dated [DATE] at 12:02pm indicates R41 was asked if he ever experienced an unusually or especially frightening, horrible, or traumatic event. Assessment indicates R41 answered yes. Assessment indicates R41 experienced nightmares, tried hard not to think about the event(s), was constantly on guard/watchful/easily startled, felt numb or detached from people, activities or surroundings in the past month. Current Care Plan indicates R41 is at Risk for depression due to trauma assessment score-See PTSD (Post Traumatic Stress Disorder) score details. Care Plan does not indicate source of trauma, triggers or interventions. 7. Trauma Informed Care assessment dated [DATE] at 9:12am indicates R104 was asked if he ever experienced an unusually or especially frightening, horrible, or traumatic event. Assessment indicates R104 answered yes. Assessment indicates R104 tried hard not to think about the event(s), was constantly on guard/watchful/easily startled, felt numb or detached from people, activities or surroundings in the past month. Current Care Plan indicates R104 is at Risk for depression due to trauma assessment score-See PTSD (Post Traumatic Stress Disorder) score details. R104's Care Plan does not indicate source of trauma, triggers or interventions.Based on interview and record review the facility failed to identify resident specific triggers to prevent re-traumatization for 11 (R10, R41, R60, R64, R67, R70, R72, R78, R93, R104, and R108) of 11 residents reviewed for Trauma Informed Care in the sample of 51. Findings include: The facility's Trauma Informed Care policy and procedure, dated 8/23/23, documents: Purpose: To ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Procedure: 1. Upon admission the Social Service Director will review hospital discharge records and interview the resident or the resident's representative to determine any history of trauma. 2 The SSD (Social Service Director) will complete a Trauma Informed Care Screen to evaluate for any history of a traumatic experience that a resident may have had. If the resident is unable to complete the screening due to cognitive deficit, the resident's representative will be interviewed and the Trauma Informed Care Screen will be completed by the representative. 3. If the resident has a cognitive deficit and no representative the IDT (Interdisciplinary Team) will review past medical records and any available psychosocial history to identify or suspect past trauma. 4. If a resident is determined to have suffered a traumatic event, the SSD (Social Service Director) will discuss with the resident or resident's representative regarding potential triggers that may cause re-traumatization and interventions or preferences that eliminate or decrease triggers that may cause re-traumatization. 5. The IDT (Interdisciplinary Team) will develop a resident centered care plan that will identify the stressor, triggers, clinical manifestations and interventions to mitigate against re-traumatization. 6. IDT will monitor the resident's response and adjustment to placement through collaboration and communication and input from the resident or resident's representative. 7. The Trauma Informed Care Plan will be updated and revised on an ongoing basis. 8. Residents will be assessed for any history of trauma annually, quarterly and with a significant change in condition. 9. IDT will develop a care plan with appropriate interventions to address the root cause for any resident who experiences a mood change such as: decrease in social interaction, increased anger or angry outbursts, and depressive symptoms. The facility's Trauma Informed Care Screen worksheet, dated 8/23/23, has two pages. The first page documents: Sometimes things happen to people that are, unusually or especially frightening, horrible or traumatic. Question 1. Have you ever experienced this kind of event? Responses include Yes or No. This first page also includes the following questions: In the past month, have you: 1. Had nightmares about the event(s) or thought about the event(s) when you did not want to? 'Yes' or 'No.' 2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? 'Yes' or 'No.' 3. Been constantly on guard, watchful, or easily startled? 'Yes' or 'No.' 4. Felt numb or detached from people, activities, or your surroundings? 'Yes' or 'No.' 5. Felt guilty or unable to stop blaming yourself or others for the event(s) may have caused? 'Yes' or 'No.' 6. Had irritability or outbursts of anger? 'Yes' or 'No.' The second page of this worksheet has two empty boxes. First box is for documenting Potential Trigger(s) That May Cause a Reaction from Trauma Event and the second box is for documenting Preferences or Interventions for Alleviating Reactions to Trauma Event with place for SSD to sign and date when completed. The EHR (electronic health record) SS-Trauma Informed Care Assessment - PTSD 5 only includes the first page of the facility policy. There is no section to document the Resident's potential triggers and no section for preferences or interventions for alleviating reactions to trauma event. On 2/7/24 at 10:15 am, V14 SSA (Social Service Assistant) stated he is not the SSD, does not have a degree, only has a high school diploma. V14 SSA stated he was the only one in the Social Services department for six months and Because I'm the only case manager it's impossible for me to have 115 individual programs. V14 SSA also stated, We do not have any individualized programs at this time for the residents. 1. The Face Sheet for R108 includes a diagnosis of Post-Traumatic Stress Disorder upon admission date of 5/25/23. The SS- Trauma Informed Care Assessment - PTSD 5 for R108, dated 10/23/23, documents R108 answered Yes to the following Assessment questions: Experienced unusually or especially frightening, horrible, or traumatic event; Having had nightmares or thoughts about the event that she didn't want to; Being constantly on guard, watchful, or easily startled; Felt numb or detached from people, activities, or surroundings; and Felt guilty or unable to stop blaming herself to others for the event(s) or any problems the event(s) may have caused. There are no documented potential triggers or interventions for alleviating reactions to the traumatic event. The current Care Plan for R108, documents the following Focus areas as: Resident has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against this Resident. Behavior exhibited: yelling, cursing, making animal sounds instead of words, throwing items, laying on the floor, and taking other's belongings . Diagnosis: schizophrenia, anxiety, PTSD, Malingerer. Often noted to be slamming doors; The resident is known to display fluctuations in mood r/t (related to) MI (Mental Illness) Diagnosis PTSD, Anxiety, Schizophrenia. Resident also has past trauma from her childhood, resident was abused when she was younger. The interventions document If resident becomes triggered by trauma induced triggers offer group therapy or one on one sessions with SSD or a member of the IDT team as resident allows. R108's current Care Plan does not include resident specific identified triggers to prevent re-traumatization. On 2/4/24 through 2/7/24 from 8:00 am through 4:00 pm, R108 was not seen outside of her room, room remained in disarray with soiled underwear, briefs, clothing, bed linens, books, empty food containers, boxes, books, random paper, and various items all over R108's room and on the floor. On R108's bedroom walls were foul words F**k you surrounding her bedroom door. R108 refused to speak, come out for meals or activities. On 2/4/24 at 1:22 pm, R108 was lying in her bed in her room with her eyes closed. There were empty food containers, soiled briefs and underwear, clothing, boxes, books, random paper, bed linens, and various items all over R108's room and on the floor. On the walls there are foul words F**k you written on and around the door inside of her room. R108 refused to talk at this time. On 2/6/24 at 10:00 am, R108 was in her room, lying in bed on her abdomen. R108 had a frown on her face with pouting lower lip with teary eyes. When asked why R108 appears sad, R108 picked up a writing pen, with and wrote I am on a piece of paper. R108 would not speak or answer any further questions. On 2/6/24 at 10:30 am, V25 CNA (Certified Nursing Assistant) stated R108 will have a couple of days of staying in her room, not talking to anyone, refusing to talk, and refuses to do anything. Usually lasts a few days and then will come out as if nothing is wrong, talks and interacts with everyone, goes to activity and meals for a few days. It all just depends on her mood and what's going on with her. We never know. On 2/7/24 at 10:15 pm, V14 SSA stated there are no documented triggers for R108 and We just communicate the behaviors. 2. R67's current computerized medical record, documents R63 has a diagnosis of Post Traumatic Stress Disorder (PTSD). R67's Care Plan dated 12/19/23, documents R63 is known to display fluctuations in mood related to his mental illness diagnosis of PTSD. R67's Care Plan does not document R67's trauma induced triggers for his diagnosis of PTSD or individualized interventions to reduce possible re-traumatization of R67. 3. R93's current computerized medical record, documents R93 has a diagnosis of Post Traumatic Stress Disorder (PTSD). On 2/7/23 at 1:38 p.m., R93 stated he had PTSD from his dad dying unexpectedly while in a car that R93 was driving. R93 stated I haven't been the same since that happened. I had to have an ambulance take me away when it happened because I lost it. R93's Care Plan dated 11/28/23, documents R93 is known to display fluctuations in mood related to his mental illness diagnosis of PTSD. R93's Care Plan does not document R93's trauma induced triggers for his diagnosis of PTSD or individualized interventions to reduce possible re-traumatization of R93.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R56's Face Sheet, dated 2/7/24, documents diagnoses including Schizoaffective Disorder, Bipolar Type, Borderline Personality Disorder and a history of Traumatic Brain Injury. R56's Physician Order Sheet/POS, dated 2/7/24, documents medication orders for Tardive Dyskinesia (Benztropine), Anxiety (Clonazepam), Schizophrenia (Fluphenazine and Trazadone) and Bipolar (Quetiapine). R56's POS does not document Resident specific identified behaviors. R56's current Care Plan does not document monitoring of Resident specific identified behaviors. R56's Behavior Monitoring and Interventions Report, dated 11/9/23 through 2/5/24, does not document monitoring of Resident specific identified behaviors. 5. R85's Face Sheet, dated 2/7/24, documents diagnoses including Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Suicidal Ideations, Cerebral Infarct and other specific Depressive Episodes. R85's Physician Order Sheet, dated 2/7/24, documents medication orders for Major Depressive Disorder, recurrent, severe with Psychotic Symptoms (Trazadone), Depression (Prozac) and Bipolar (Quetiapine). R85's POS does not document Resident specific identified behaviors. R85's current Care Plan does not document monitoring of Resident specific identified behaviors. R85's Behavior Monitoring and Interventions Report, dated 11/5/23 through 2/5/24, does not document monitoring of Resident specific identified behaviors. 6. R110's Face Sheet, dated 2/7/24, documents diagnoses including Paranoid Schizophrenia, Suicidal Ideations, Hallucinogen Dependence with Hallucinogen-Induced Psychotic Disorder, Anxiety, Huntington's Disease and Major Depressive Disorder, recurrent moderate. R110's Physician Order Sheet, dated 2/7/24, documents medication orders for Major Depression Disorder (Wellbutrin) and Psychotic Disorder (Haldol). R110's POS does not document Resident specific identified behaviors. R110's current Care Plan does not document monitoring of Resident specific identified behaviors. R110's Behavior Monitoring and Interventions Report, dated 11/5/23 through 2/5/24, does not document monitoring of Resident specific identified behaviors. 7. R113's Face Sheet, dated 2/7/24, documents diagnoses including Schizophrenia, Major Depressive Disorder, Anxiety Disorder and Catatonic Disorder due to known Physiological Condition. R113's Physician Order Sheet, dated 2/7/24, documents medication orders for Major Depression Disorder (Sertraline), Schizophrenia (Quetiapine) and Anxiety Disorder (Lorazepam). R110's POS does not document Resident specific identified behaviors. R113's current Care Plan does not document monitoring of Resident specific identified behaviors. R113's Behavior Monitoring and Interventions Report, dated 11/9/23 through 2/5/24, does not document monitoring of Resident specific identified behaviors. Based on observation, interview and record review the facility failed to have a clinical indication for use and failed to identify and monitor target behaviors for the use of psychotropics for eight (R10, R45, R56, R60, R85, R92, R110, and R113) of eight residents reviewed for unnecessary medications in a total sample of 51. Findings Include: The Facility's Psychotropic Medication Policy dated 11/28/2017 documents It is the policy of this facility that resident shall not be have unnecessary drugs. Unnecessary drug is any drug used: 1. In an excessive dose, including in duplicative therapy 2. For excessive duration 3. Without adequate monitoring 4. Without adequate indications for its use 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. The Psychotropic Medication Policy documents that a psychotropic medication is defined as a medication that is used for or listed as used for antipsychotic, antidepressant, antibiotic, antianxiety, behavior modification, or behavior management purposes. This Policy defines an antipsychotic drug as a neuropletic drug that is helpful in the treatment of psychosis and has a capacity to ameliorate (to make better/more tolerable) through disorders. The Facility's Psychotropic Medication Policy documents Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative Any resident receiving such medications shall have psychiatric diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which cause the resident frightful distress, The Behavioral Tracking sheet of the facility will be implement to ensure behaviors are being monitored. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. Reductions shall be attempted at least twice in one year unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such. Any resident receiving any psychotropic medication will have certain aspects of their use and potential side effects addressed in the residents care plan at least quarterly. The care plan will identify target behaviors causing the use of psychotropic medications, The care plan will address the problem, approaches and goals to address these behaviors, Any suspected problems will be reported to the physician. Attempts to rule out social environmental factors as causative agents will be made in the care plan assessment. 1. R10's current Physician Order Sheet dated February 2024 documents the following diagnosis: unspecified psychosis not due to a substance or known physiological condition, major depressive disorder recurrent, severe with psychotic symptoms, anxiety disorder, unspecified, unspecified dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety disorder, auditory and visual hallucinations. R10's Current Physician Order Sheet dated February 2024 documents R10 takes Risperidone 0.5mg (milligrams) every day for unspecified psychosis not due to a substance or known physiological condition, Risperidone 1 mg every night for unspecified psychosis not due to a substance or known physiological condition, Rivastigmine 4.6mg/24 HR (Hour) daily for unspecified psychosis not due to a substance or known physiological condition and Lorazepam 0.5 mg twice daily for anxiety. R10's current care plan dated 8/24/2023 documents I have anxiety and Resident has impaired cognitive abilities related to impaired thought process. R10's current care plan dated 8/24/23 did not contain any harmful or disturbing behaviors identified for the use of the antipyshotic Risperidone. R10's Behavior Tracking Forms from August 2023 through January 2024 all have no behaviors exhibited. A long list of available behaviors were listed on this form including hallucinations and/or delusions, neither was marked as occurring. R10's current Physician Progress Note dated 01/16/2023 documents Patient has psychiatric history consisting of schizophrenia, dementia, and anxiety, Staff report patient remains delusional at times but that is her baseline, they report that her delusions do not interfere with her ADL's (Activities of Daily Living) or her ability to interact with staff and other residents. R10s' Psychotropic Medication Review dated 01/16/2024 documents has had depression symptoms in the last 7 days, does not list what those symptoms were. R10's Psychotropic Medication Review dated 01/16/24 lists multiple Alternative Intervention Treatment Summary: diversion activity, on demand toileting, wandering path provided, guided ambulation, counseling, group program, rewards program, environmental adaptation (i.e. scents, lighting, music), provide unit specific placement, limit environmental stimuli (i.e. Remove from crowded room), promote group activity participation, facilitate one to one interactions, prompted conversation/reminisces, prompted snacking. food/hydration pain control treatment/monitoring. All of these provided areas were marked NA or UTD (Not Applicable or Undetermined). R10's Psychotropic Medication Review dated 01/16/2024 documents that no hallucinations or delusion had occurred in the past 7 days. R10's Psychotropic Medication Review dated 01/16/2024 documents R10 takes an antianxiety medication Lorazepam 0.5 mg twice daily for anxiety. The Target behavior related to anti-anxiety med (medication) use area was blank. R10's Psychotropic Medication Review dated 01/16/2024 documents R10 takes an anti-psychotic medication Risperidal in the morning and at night. The target behavior related to antipsychotic med use area was blank. 2. R60's current Physician Order Sheet dated February 2024 list the following psychiatric diagnosis: Schizophrenia, unspecified, Anxiety disorder, unspecified, major depressive disorder, recurrent, bipolar disorder, current episode manic without psychotic features, mild, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and Anxiety. R60's current Physician Order Sheet dated February 2024 documents that R60 takes divalproex sodium ER (Extended Release) 500 mg (milligrams) three times a day for schizophrenia, Lorazepam 0.25 mg one time a day for Anxiety Disorder, Mirtazapine 7.5 mg every night for depressive disorder, recurrent, unspecified, Quetiapine 25 mg twice daily for Schizophrenia, Sertraline HCL (Hydrochloride) 50 mg every day for depressive disorder, recurrent, unspecified. R60's current Care Plan dated 9/7/23 documents The resident has a behavior problem r/t (related to) verbal outburst at times and has diagnosis of schizophrenia, major depressive disorder and anxiety, This Care Plan does not have any goals in place for this problem at all. The current care plan does not address any target behaviors for the use of multiple psychotropic medications. R60's Behavior Tracking Forms from August 2023 through January 2024 have no behaviors exhibited. A long list of behaviors were listed to include anxiety, hallucinations, delusions, insomnia, and anxiety. R60's current Physician Visit Summary does not address R60's use of any psychotropic medications. The Physician Visit Summary list that meds (medications) were reviewed GDR (Gradual Dose Reduction) per Pharmacy Recommendation. R60's current Psychotropic Medication Review form dated 01/26/24 documents Presence of possible behavior/mood indicators, check all that apply in the last 7 days: depression symptoms, withdrawal from activities of interest, expression of loneliness/isolation, poor eye contact, loss of appetite, insomnia, trouble falling asleep or staying asleep, nightmares, loss of self control, verbal expressions of persecution/paranoia, verbal concerns regarding potential psychosocial situation, verbal expression of anger, fear, abandonment, nervousness/anxiety, repetitive verbalizations-calling out, ruminating over missing/lost item, other. No areas of possible mood indicators were marked for R60. R60's current Psychotropic Mediation Review form dated listed the following Alternative Intervention Treatment Summary options: diversion activity, on demand toileting, wandering path provided, guided ambulation, counseling, group program, rewards program, environmental adaptation (i.e. scents, lighting, music), provide until specific placement, limit environmental stimuli: (i.e. remove from crowded room), promote group activity participation, facilitate one on one interactions, prompted conversation/Reminisce, prompted snacking/food/hydration and pain control treatment/monitoring. All areas listed were marked N/A or UTD (Not Applicable or Unable to Determine) R60's current Psychotropic Medication Review Form dated 1/26/24 documents that R60 did have delusions during the last 7 days noted Often talking to self and to to others not present. The Psychotropic Medication Review form documents how does the resident's current behavior status, care, rejection or wandering compare to prior assessment? 0. Same R60s' Psychotropic Medication Review form dated 1/26/24 documents that R60 takes an anti-anxiety medication of lorazepam 0.25 mg every day for Anxiety Disorder. The target behavior related to anti-anxiety med (medication) use was blank. R60's Psychotropic Medication Review form dated 01/26/24 documents that R60 takes and antidepressant medication of Sertaline HCL (Hydrocholoride) 50 mg every day for major depressive disorder recurrent, unspecified. The target behavior related to anti-de[depressant med use area was blank. R60's Psychotropic Medication Review form dated 01/26/24 documents that R60 takes an anti-psychotic medications of Quetiapine 25 mg twice daily for Schizophrenia, unspecified. The target behavior related to anti-psychotic med use area was blank. R60's Psychotropic Mediation Review form dated 01/26/24 documents that R60 takes an anti depressant medication of Mirtazepaine 7.5 mg for Schizophrenia, unspecified, major depressive disorder recurrent, unspecified. The target behavior related to antidepressant med use area was blank. 3. Current Physician's Order Report Summary indicates R45 is [AGE] years old and receives Seroquel (antipsychotic) 50mg (milligrams) twice daily for Depression (date ordered 8/18/23). Current Care Plan indicates R45 is known to display fluctuations in mood related to Bipolar, Major Depression and Anxiety. On 2/4/24, 2/5/24 and 2/6/24 R45 was seen in his room at various times throughout those days. R45's behavior was calm and appropriate with no signs/symptoms of psychosis. R45's Care Plan does not identify R45 receiving Seroquel, indication for use of an antipsychotic medication, target behaviors, interventions or side effects. Psychotropic Medication Consent dated 8/18/23 indicates R45's POA (Power of Attorney for Healthcare) signed R45's consent on that date. Consent indicates Seroquel was used for Bipolar Disorder. Consent does not indicate identified behaviors or side effects of the medication. Current Comprehensive Assessment indicates R45 is cognitively intact. No documentation was found or presented to indicate why R45 did not sign the consent for Seroquel. No progress notes were found or presented to indicate why Seroquel was ordered for R45 on 8/18/23. Behavior Monitoring and Interventions Report dated 11/2023 through 2/7/24 indicate behaviors of accusing others, cursing at others, expressing frustration with others, threatening others, rummaging and agitation were identified on 1/17/24, 11/15/23 and 12/19/23. No delusions or hallucinations were identified. 8. The Face Sheet for R92 includes the following diagnoses: Anxiety Disorder, Depression, Alcohol Abuse, Suicidal Ideations, and Wernicke's Encephalopathy. The Order Summary Report for R92, dated 2/7/24, documents R92 started receiving the following medications on the following dates: 6/26/23 Chlordiazepoxide 5 mg twice daily for Anxiety; 11/15/22 Duloxetine 60 mg daily for Depression; 5/28/23 Remeron 30 mg daily for Depression; 11/18/22 Trazodone 100 mg two tablets at bedtime for Insomnia; 11/10/22 Melatonin 3mg as needed for Insomnia. On 2/4/24 at 11:56 am, R92 was noted to have pill rolling type movements of bilateral hand and fingers and occasional tongue thrusting while talking and when not talking. R92 stated she has been at the facility trying to get better but since being at the facility her mother commited suicide and her daughter overdosed and died. R92 stated she is sad and cries off and on frequently and has not gotten any better while being in the facility. The Annual MDS Assessment for R92, dated 11/15/23, documents R92 has moderately impaired cognition, none to mild Depression, and Delusions as an indicator of Psychosis otherwise, there are no documented behaviors for R92. The current Care Plan for R92 documents: The resident is known to display fluctuations in mood r/t (related to) anxiety, depression, and suicidal ideations; The resident is/has potention to be verbally aggressive toward staff and resident r/t Mental/Emotional illness; and (R92) has a behavior problem of making false allegations of others stealing/taking her perosnal belongings. This Care Plan does not document resident specific behaviors regarding anxiety, depression or suicidal ideations. The AIMS (Abnormal Involuntary Movement Scale) for R92, dated 12/8/23 documents R92 without Involuntary movements and R92 without awareness of abnormal movements with a total score of 0 out of 36. A Pharmacy MRR (Medication Regimen Review) for R92, dated 11/2/23, documents (R92) has received the antidepressants Duloxetine 60 mg po (by mouth) once daily, Trazodone 200 mg po q (every) HS (hour of sleep), and Mirtazapine 30 mg po q HS for management of depressive symptoms since May 2023 when the Mirtazapine was added. Recommendation: Please attempt a gradual dose reduction (GDR) for the above medications, perhaps by reducing the Trazodone to 150 mg q HS. A Pharmacy MRR for R92, dated 11/2/23, documents (R92) has received Chlordiazepoxide 5 mg po BID (twice daily) since at least November 2022 when she was admitted to this facility. She has diagnoses of alcohol withdrawal and anxiety. Recommendation: For the initial attempt at a gradual dose reduction (GDR), please reduce to Chlordiazepoxide 5 mg po q PM (nightly).R92's Physician declined the pharmacy recommendations and documented Target symptoms not met. See PCC (facility electronic health record) note 12/8/23.Unable to locate any documentation discussing R92's target symptoms or resident specific behaviors for the use of the psychotropic medications. The Behavior Monitoring and Interventions Report for R92, dated November 2023 through February 2024 do not document any resident specific behaviors or clinical indications for staff to monitor that justify R92's continued use of psychotropic medications. This same report documents a list of available behaviors that can be marked for any behaviors a resident may have. These Reports documents the following dates behaviors occurred: 1/16/24 Accusing of others, expressing frustration/anger at others, and agitated; 12/30/23 Hallucinations and wandering; and 12/6/23 Accusing of others. There are no other behaviors documented between November 2023 through February 2024. On 2/7/24 at 1:15 pm, V2 (Director of Nursing/DON) stated We do not have specific behaviors documented for any of our Residents, we just have general observations.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility failed to provide mail delivery on Saturdays. This failure has the potential to affect all 114 residents in the facility. Findings include: Resident Rights policy and procedure, dated 11/2018 documents The facility must deliver and send your mail promptly. On 2/5/24 at 10:45am during a resident group meeting, R52 stated mail is held on weekends and delivered on Mondays. On 2/7/24 at 1:30pm V17, Activities Director stated The mail has to go to the Main Office first. Activities delivers the mail after the business office sorts through the mail. There is no one here on the weekend from the Main Office to go through the mail on the weekends. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to provide a safe, clean and homelike environment at the facility. This failure has the potential to affect all 114 residents who currently reside in the facility. Findings Include: The Facility's Maintenance Person job description (undated) documents The Maintenance Person maintains all building, equipment, systems and grounds in good, safe and presentable conditions. He/She conducts a preventative maintenance program for all mechanical, signal and fire alarm and suppression and other systems. The solicitation of repair/replace construction and other bids from contractor for presentation to the Administrator and Corporate Maintenance Director is expected. The Facility's Environmental Supervisor job description (undated documents) The Environmental Supervisor is responsible for maintaining the facility and ground in a clean, safe, comfortable, sanitary condition. He/she insures that furnishings, fixtures, equipment, buildings and grounds are in good repair. During a group meeting held on 2/5/24 at 10:45am with the following residents (R7, R21, R39, R43, R57, R62, R95, R100), all acknowledged the facility was in disrepair and bathrooms, showers and rooms were unclean. At that time R21 stated Living in these conditions makes me feel like we don't matter. All eight residents stated they would not have these type of conditions if they were in their own home. On 2/5/24 between 2:10 PM and 2:40 PM the following observations were made: room [ROOM NUMBER] - Floor filthy in bathroom, tile/grout stained brown throughout and continued partially up walls. Bed pan with brown dried substance on bathroom floor behind toilet; privacy curtain between bed 1/bed 2 with brown stains; call light/cords with dark brown stuck-on substance on end near button. room [ROOM NUMBER] - Wall/baseboard missing, exposed dry wall behind bed 2. Bed 1 No pillowcase/pillow filthy, stained brown; Dingy, discolored, stained sheet on bed. room [ROOM NUMBER] bed 2 Filthy, discolored, tattered bottom sheet with brown stains, no pillowcase; soiled towels on floor at end of bed. room [ROOM NUMBER] bathroom with stained brown/black floor tile grout; shower in bathroom with black/brown/brown caulk around entire base of shower going up walls, especially corners. room [ROOM NUMBER] - lights above bed not working; bathroom sink pulling away from wall; bathroom floor tile/grout brown, leaking water from base of toilet. room [ROOM NUMBER] bathroom toilet tank cover missing, ceiling panel missing. On 2/6/24 between 8:00 AM and 9:15 AM the following observations were made: room [ROOM NUMBER]: No base boards in multiple sites throughout the room, ceiling tiles discolored a dark brown/rust color, the exhaust fan in the bathroom was covered in light fluffy gray dust and the exhaust fan was put in a hole in the ceiling that was to wide (had openings on either side of the fan). room [ROOM NUMBER]: the corner that sticks out between the bathroom and the first bed with exposed metal and dry wall. room [ROOM NUMBER]: panel missing in the bathroom ceiling, and the exhaust fan in the bathroom was covered with fluffy gray dust. A dark brown smear/smudge was on the privacy curtain pulled around the first bed. room [ROOM NUMBER]: multiple areas of chipped paint on walls and on both light covers above both beds in the room. room [ROOM NUMBER]: multiple areas of chipped paint, a hole in the wall had been patched with some sort of white chalky substance but had not been sanded or painted, the base board in the room was visibly pulling away from wall and misshapen. A lot of base board had been taped back to the wall with blue painters tape. The first closet had a deep gouge in the wall close to the bottom of the closet with drywall exposed. room [ROOM NUMBER]: multiple areas of chipped paint on both light fixtures above both beds in the room. room [ROOM NUMBER]: A dresser in the middle of the room was full of resident's belongings and was missing a drawer front. The drawer without the front had multiple items pushed into the drawer. room [ROOM NUMBER]: The exhaust fan in the bathroom was covered in light fluffy dust. The bathroom had multiple paint chips in the walls and a dark brown colored stain in the ceiling. room [ROOM NUMBER]: Base board was missing in multiple areas, dry wall with holes in multiple areas with dry wall exposed, the corner of the wall that comes out between the bathroom and the first bed was exposed with metal and dry wall showing. room [ROOM NUMBER]: Both light fixtures above both beds in the room had multiple paint chips. On 02/06/24 at 2:30 PM V3 (Vice President of Operations) stated We definitely need to work on maintenance and housekeeping. 2. On 2/4/24 at 1:22 pm, R108 was lying in her bed in her room with her eyes closed. There were empty food containers, soiled briefs and underwear, clothing, boxes, books, random paper, bed linens, and various items all over R108's room and on the floor. On the walls there are foul words F**k you written on and around the door inside of her room. 3. On 2/6/24 at 10:40 am, R77's bed was without linens on the bed, there were no pillows in the room, and the walls of the room were covered with faded foul language and various words and phrases. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility failed to inform residents of the facility's grievance procedure. This failure has the potential to affect all 114 residents in the facility. Findings include: Facility Policy/Resident Grievances/Complaints dated 11/1/17 documents: Grievances and/or complaints may be reported to the Administrator, any staff member, Resident Council and to State Agencies. The facility shall provide contact information including: grievance official name, business address, business phone; a reasonable expected timeframe for completing the review of the grievance and the right to contact outside agencies through required postings. Once a concern or grievance has been reported and is not easily resolved, a Grievance/Complaint Report form will be initiated. On 2/5/24 at 10:45am during a resident group meeting with the following residents (R7, R21, R39, R43, R57, R62, R95, R100), all eight residents did not know how to file a grievance and did not know there was a form to address and document grievances. On 2/6/24 at 12:50pm V14, Social Service Assistant stated if a resident has a complaint, it gets directed to Social Service and forwarded to the Administrator. V14 SSA was unsure if the grievance process was provided to all residents. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to provide sufficient staff to provide care and supervision for dependent residents. This had the potential to affect all 114 residents residing in the facility. Findings include: The facility's Nurse Staffing policy, no date available, documents, It is the policy of the facility to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the State Agency. On 02/05/24 at 09:57 AM, R78 stated, It's crazy in here and they don't have enough staff to take care of all of us. On 02/05/24 at 10:00 AM, R70 stated, They don't have enough staff around here for all of these people, and us residents just have to deal with it. On 2/7/24 at 11:00 am, V11 (CNA-Certified Nursing Assistant) stated, We should have six CNAs if we are fully staffed. That doesn't happen often. It's hard to get things done and supervise the behaviors when we work short. On 2/7/24 at 1:05 p.m., V16 (CNA) stated that they never work with six CNAS. V16 stated today we only have four CNAs. How are we supposed to take care of these residents with four CNAs for over 100 residents? Then you put behaviors on top of that. It isn't possible. V16, V11, V22 (CNA), and V20 (CNA) were observed as being the only CNAs working during 1st shift. On 2/7/24 at 1:10 p.m., V22 stated it's hard to do our job the way it's supposed to be done with anywhere from three to five CNAs. It doesn't happen often to have six CNAs. We need more staff. The facility's Daily Nursing Assignment Sheet, dated 1/21/24, document the following staffing numbers: 1st shift four CNAs; 2nd shift four CNAs; 3rd shift two CNAs. The facility's Daily Nursing Assignment Sheet, dated 1/22/24, document the following staffing numbers: 1st shift five CNAs; 2nd shift three CNAs; 3rd shift two CNAs. The facility's Daily Nursing Assignment Sheet, dated 2/1/24, document the following staffing numbers: 1st shift five CNAs; 2nd shift three CNAs; 3rd shift three CNAs. The facility's Daily Nursing Assignment Sheet, dated 2/2/24, document the following staffing numbers: 1st shift three CNAs; 2nd shift three CNAs; 3rd shift two CNAs. The facility's Daily Nursing Assignment Sheet, dated 2/4/24, document the following staffing numbers: 1st shift four CNAs; 2nd shift four CNAs; 3rd shift four CNAs. On 2/6/24 at 1:30 p.m., V23 (Medical Records/CNA Scheduler) stated that the minimum CNA staffing numbers are six CNAs for 1st and 2nd shift and four CNAs for 3rd shift. V23 also confirmed that on 1/21, 1/22, 2/1, 2/2, and 2/4/24 there were fewer CNAs than the facility's planned number of CNAs working on those dates. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review the facility failed to clean and maintain kitchen equipment. These failures have the potential to affect all 114 Residents residing in the Facility. Finding include: Facility Food Service Manager Job Description, revised 10/2016, documents V18's (Dietary Manager) job summary: to manage all aspects of the Food Service Department in the Facility including but not limited to Food Service personnel, supplies and equipment; take necessary measures to ensure that all food served to Residents has been prepared in a safe, sanitary manner while maintaining the highest quality; check all equipment for proper functioning and safety, responsible for overall sanitation of the department; responsible for overall sanitation of the department; and responsible for knowing Local, State and Federal regulations and policies and procedures which pertain to the Department. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility. On 02/04/24 at 7:00 am, the Facility oven and stove top control handles had built up debris/grease; the two tiered coffee pot machine metal shelving table had rust and built up debris on all four legs and areas on the shelve; there was a large amount of dried, white splattered areas of debris on entire coffee pot machine, a quarter full ten gallon bucket of brown colored liquid was under the preparatory sink by the serving window/food service table; multiple areas of built up debris/waste on floor tiles, floor tiles chipped and missing, white floor drain cover broken and leaning up against the wall by the serving window/food service table; steam serving table had built up debris in crevices around serving pans; toaster had a large amount of crumbs/debris and grease on the appliance and the control knobs; ice tea and water cart had a large amount of dried dark stains on a white towel that was placed under the ice tea/water containers; refrigerator and freezer handles had built up debris on the bottom shelves and handles; dark black spots and rust on the interior walk-in freezer door; and the metal room tray cart had built up debris on the tracking for the trays. On 2/5/24 at 7:30 am, the oven and stove top control handles has built up debris/grease; the two tiered coffee pot machine metal shelving table had rust and built up debris on all four legs and areas on the shelve; large amount of dried, white splattered areas of debris on entire coffee pot machine, a quarter full ten gallon bucket of brown colored liquid was under the preparatory sink by the serving window/food service table; multiple areas of built up debris/waste on floor tiles, floor tiles chipped and missing, floor drain cover broken and leaning up against the wall by the serving window/food service table; dark black spots and rust on interior walk-in freezer door; and the metal room tray cart had built up debris on the tracking for the trays. On 2/6/24, at 12:51 pm, V18 (Dietary Manager) stated, I just started implementing a cleaning schedule in the kitchen, we are continuing to work on these issues.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review the facility failed to remain in COVID-19 Outbreak Status for ten days after the last person tested positive for COVID-19. This failure has the potential to affect all 114 residents who currently reside in the facility. Findings Include: The Facility's COVID-19 Infection Control Measures Policy dated 5/19/23 documents A COVID outbreak is defined by one staff member or resident testing positive for COVID-19. The policy documents that during Outbreak Status all staff will wear well fitted surgical masks everywhere in the building that residents have access to and that residents would be encouraged to wear masks when out of their rooms. The Facility's COVID-19 Infection Control Measures Policy dated 5/19/23 documents that signs announcing a COVID outbreak status would be placed in visible areas of the facility for residents,staff and visitors information. The Policy documents that all visitors would be encouraged to wear masks at all times. The Facility's COVID-19 Control Measures Policy dated 5/19/23 documents HCP (Health Care Provider) with a confirmed COVID-19 infection should remain off work for 10 days OR 7 days with a 2 negative antigen tests completed on day 5 and day 7 AND should be asymptomatic or mildly symptomatic with improving symptoms and fever free for 24 hours without the use of fever reducing medications. The Facility's COVID-19 Control Measures Policy dated 5/19/23 documents HCP (Health Care Providers) with exposure should wear a well fitted facemask for 10 days, self monitor for symptoms and not report to work when ill. The Facility's COVID-19 Control Measures policy dated 5/19/23 documents Asymptomatic residents that have had prolonged close contact with someone confirmed positive for COVID 19 do not have to be placed on TBP (Transmission Based Precautions) but should be encouraged to wear a face covering for 10 dates from date of exposure while out in the facility. On 02/04/24 at 6:00 AM upon entry to the facility, there were no signs announcing a COVID outbreak status. On 02/04/24 during initial tour of the facility no residents or staff members were wearing face coverings of any kind. On 02/04/24 at 9:00 AM V8 (Licensed Practical Nurse/Infection Preventionist) stated that the facility had no active COVID-19 concerns in the facility. The Facility's All Employee COVID Testing list dated 01/27/24 documents that V9 (Registered Nurse) tested positive for COVID-19. The documentation did not clearly indicate why all employees were being tested for COVID on 1/27/24. The documentation did not include when and where V9 worked, any symptoms she was having or any indications of which residents and staff she may have had contact with for longer than 15 minutes. On 02/06/24 at 10:30 AM V7 (Licensed Practical Nurse/Infection Preventionist) and V8 Licensed Practical Nurse/Infection Preventionist) stated that V9 (Registered Nurse) had been working on 01/27/24 and started to feel unwell and went home. After V9 went home she tested herself for COVID and it was positive so she called and alerted the facility who then initiated all employee and resident testing with no other person having a positive result for COVID. No further resident or staff tested positive on the follow up COVID testing done in the building on 01/29/2024 and 01/31/2024. On 02/06/24 at 10:30 AM V7 (Licensed Practical Nurse/Infection Preventionist) and V8 (Licensed Practical Nurse/Infection Preventionist) both confirm that the facility went into outbreak status with staff and residents wearing face masks from 01/27/24 until 01/31/24 because that was when all of the testing was done and no one else was positive. V7 (Licensed Practical Nurse/Infection Preventionist) stated Our policy does say that it (wearing masks/outbreak status) would be for ten days after (V9/Registered Nurse) tested positive. Which would have made our last day of being outbreak status should have been today (02/06/24). On 02/06/24 at 2:00 PM V2 (Director of Nursing) stated All the nurses and CNA (Certified Nurse Aide) staff can and do go all over the building helping with all of the residents. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility failed to maintain an Antibiotic Stewardship Program. This failure has the potential to affect all 115 residents who currently reside in the facility Findings Include: The Facility's Antibiotic Stewardship Program dated 11/01/2017 documents the purpose is to improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished by utilizing the Core Elements. This Policy did not list what the Core Elements of Antibiotic Stewardship in Long Term Care are. The CDC (Center for Disease Control) website lists the Core Elements of Antibiotic Stewardship in Long Term care as enhancing infection prevention and control, controlling source control, prescribing antibiotic when they are truly needed, prescribing appropriate antibiotics with adequate dosages, reassessing treatment when culture results available, using the shortest duration of antibiotics based on evidence, educating staff, supporting surveillance if active medical infections and healthcare acquired infections and supporting an interdisciplinary approach. The Facility's Leadership Commitment Statement dated 11/01/2017 documents Antibiotics area among the most commonly prescribed pharmaceuticals in long term care settings, yet reports indicate that a high proportion of antibiotic prescriptions are unnecessary, The adverse consequences of unnecessary antibiotic use include adverse drug reactions or interactions, the development of Clostridium difficile infections, the emergence of multi-drug resistant organisms, antibiotic failure, increased mortality, and greatly increased costs The Centers for Disease Control and Prevention characterizes antibiotic resistance as 'one of the world's most pressing public health threat. Unnecessary prescribing practices by clinicians and overuse of newer, broad-spectrum antibiotics when either no antibiotic or an older narrow-spectrum drug would suffice are believed to primary contributors to this problems. as a result of the above complexities, nursing homes are increasingly recognized as reservoirs of antibiotic resistant bacteria. To address these issues, (This Facility) has developed an Antibiotic Stewardship Program. Antibiotic Stewardship is the act of using antibiotics appropriately--that is, using them only when truly needed and using the right antibiotic for each infections. This programs included tools, polices, and procedures that aim to guide our staff toward more responsible and effective use of antibiotics. The Facility's Resident Infection Control and Antimicrobial Log for August 2023 through January 2024 list all of the antibiotic use activity for the facility. These logs do not contain whether or not cultures were obtained (where appropriate), whether any testing was done to confirm infections (where appropriate) or if there were any trends in infections according to caregivers, location or any other sources that could be controlled. These logs did not document any attempts to use a standardized tool of any sort to decipher the need for the antibiotic. On 02/06/24 at 10:30 AM V7 (Licensed Practical Nurse/Infection Preventionist) and V8 (Licensed Practical Nurse/Infection Preventionist) both denied use of any tool or procedure to assess whether an antibiotic is needed. Both stated the doctors are going to write what they want. Both denied ever speaking with or attempting education with area doctors regarding the antibiotics when they are written. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility.

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to administer the proper insulin dose as ordered by the physician and report hyperglycemia results to the physician for one resident (R1) and failed to properly administer insulin to two residents (R1 and R2) out of three residents reviewed for diabetes in a sample of three. Findings include: The facility's Emergency Care policy dated 12/22/17 documents Hyperglycemia / Hypoglycemia: It is the policy of this Health Care facility to provide the necessary care and services of those residents with a diagnosis of Diabetes Mellitus. This is achieved through proper diet, monitoring of blood glucose levels, monitoring of symptoms related to abnormal blood glucose levels, and the administration of medications per the physicians order, in accordance with Residents Rights. The procedures that follow shall be initiated in the event that a resident's blood glucose level extends out of the normal accepted ranges. Hyperglycemia: Blood Glucose levels that exceed 300 shall be considered to be hyperglycemia and may warrant prompt action. 1. Symptoms which may occur: a. Greater than 300: Extreme thirst, frequent urination, fatigue, vision changes, dry skin and mouth. b. Greater than 350: Nausea, stomach cramps, fruity breath, ketones in urine, deep rapid breathing, drowsiness, loss of consciousness. 2. If symptoms occur, assess resident status including vital signs and test resident's blood glucose level through finger stick method. 3. If blood glucose level exceeds 300, and there are no specific orders as to when to notify the physician, call the physician immediately for instruction. 4. Document all observations and occurrences in the clinical record. The facility's Medication Administration policy dated 11/18/17 documents Procedure: 3. Medications must be prepared and administered within one hour of the designated time or as ordered. 1. R1's endocrinologist physician orders dated 7/28/23 documents Overall patient continues to experience wide glycemic excursions, continues to experience hypoglycemia when he refuses to eat, and hyperglycemia when he refuses insulin. Unfortunately, overall improved glycemic control has been a challenge due to patient's underlying severe psychiatric and mental health issues. Recommendations: 1. No change at this time with continued emphasis on consistent carbohydrate meal plan and dosing lispro before each meal as instructed. 2. Notify medical director of nursing home if patient is refusing insulin and monitor closely for hyperglycemia; recommend checking ketones in urine if patient is experiencing persistent hyperglycemia .6. Recommend calling in with BG (blood glucose) log only when the patient is experiencing recurrent and persistent hyperglycemia throughout the day or hypoglycemia which is not responsive to treatment. R1's endocrinologist physician orders dated 8/25/23 documents (R1) does not need any additional insulin with snacks (which should be less than 15 carbs) due to increased risk of hypoglycemia. He should be getting short acting insulin only with meals at which time he should also get a correction dose based on scale for glucose evaluation (scale was provided). No short acting insulin at bedtime. (R1) should be receiving: Lantus 40 units every morning. Lispro 10 units before meals plus correction scale of 1/50 greater than 150. Contact office with persistent hypoglycemia or hyperglycemia. R1's current physician order sheet documents Humalog (trade name/insulin pen injector) Subcutaneous Solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Lispro) and Inject 10 unit subcutaneously with meals and Humalog (trade name/insulin pen injector) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously with meals related to type I diabetes with sliding scale. Humalog (trade name/insulin pen injector) Subcutaneous Solution Pen-injector 100 units/milliliter (ml) (Insulin Lispro). Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 500 = 12 greater than 400 give 12 units and call MD (Medical Doctor), subcutaneously with meals related to type I diabetes plus 3 units with meals. R1's medical record documents the following blood glucose levels: 8/6/2023 8:12 AM 400.0 mg/dL (Milligrams per 100 milliliters) 8/5/2023 8:08 PM 400.0 mg/dL 8/5/2023 4:03 PM 400.0 mg/dL 8/5/2023 1:25 PM 400.0 mg/dL 8/5/2023 7:30 AM 390.0 mg/dL 8/4/2023 9:33 PM 370.0 mg/dL 8/4/2023 5:10 PM 400.0 mg/dL 8/4/2023 12:39 PM 400.0 mg/dL 8/4/2023 9:02 AM 400.0 mg/dL On 8/31/23 at 10:56 AM, V4, Registered Nurse (RN) obtained R1's blood glucose level of 246 mg/dl. On 8/31/23 at 11:15 AM, V4, RN, obtained R1's Humalog (trade name/insulin pen injector) from the mediation cart and an insulin pen needle. V4, RN, took the cap off the insulin pen, opened the needle, and attached the needle to the pen. V4, RN then dialed 14 units on the insulin pen, grabbed some alcohol pad and gloves and entered R1's room. V4, RN, then donned gloves, opened the alcohol pads, wiped the back of R1's right arm with the alcohol, took the cover off the insulin needle, pressed the pen into the back of R1's arm and depressed the insulin pen button and then removed the needle from the skin within two seconds and discarded the needle. R1's medication administration record dated 8/31/23 documents R1 received Humalog Insulin (Lispro) 14 units subcutaneous at 12:00 PM. On 8/31/23 at 12:05 PM, R1 received his lunch meal tray. On 8/31/23 at 1:52 PM, V3, Resident Care Coordinator (RCC) stated With meals means the resident should get their insulin when they get their tray. An hour before is not with meals. On 8/31/23 at 3:10 PM, V3, RCC, stated (R1) gets all his insulin orders from his endocrinologist. That's what we go by. On 9/1/23 at 8:49 AM, V2, DON, verified R1's doctor's orders document to notify the nursing home medical director of persistent hyperglycemia episodes and stated I would say running in the 400 range for three days would count as persistent hyperglycemia. I don't think anyone was contacted. On 9/1/23 at 11:16 AM, V7, Endocrinology Registered Nurse stated When we received (R1)'s blood glucose monitoring log, there were three days, 8/4 through 8/6 that he consistently ran around 400 and higher. We have no record that a physician was contacted about his hyperglycemia. The orders we sent to the facility dated 7/28/23 says they're supposed to be contacting the medical director of the nursing home when (R1) has consistent hyperglycemia episodes. The current order for his insulin has also changed and the facility is not administering it according to the last physician orders. It should be Humalog (trade name/insulin pen injecor) Subcutaneous Solution Pen-injector 100 units/ml (Insulin Lispro) Inject 10 unit subcutaneously before meals related to type I diabetes with sliding scale. Humalog (brand name) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 1; 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 7; 351 - 400 = 9; 401 - 500 = 11 greater than 400 give 12 units and call MD, subcutaneously with meals related to type I diabetes. The new set of orders were sent to the facility after (R1)'s appointment on 8/25/23. On 9/1/23 at 11:20 AM, V4, RN, verified she entered the blood glucose levels on 8/4 and 8/5 and stated I didn't notify the doctor when he was having the blood sugar of 400. I'm not sure why I didn't. I know the order says we're supposed to. On 9/1/23 at 12:10 PM, V2, Director of Nursing (DON) was asked to verify the amount of insulin R1 was to receive on 8/31/23 at 12:00 PM with a blood sugar of 246 mg/dl. V2, DON, stated He should have gotten 14 units because he has 10 units scheduled and then 4 units according to his sliding scale. V2, DON, was then asked about the additional 3 units per R1's order. V2, DON, stated It looks like the three units at the end of his sliding scale order, to me, means that he should be getting three additional units on top of his sliding scale plus the 10 units. Which means he should not have an even number dosing. It should always be odd. Looking through his administration record. He hasn't been getting the three additional units. He should have gotten 17 units yesterday. On 9/1/23 at 12:20 PM, V8, RCC stated The current sliding scale order (R1) has is from when he got back from the hospital. He got a new order on 8/23 for 10 units and we forgot to take the three units off the current order. It shouldn't be on there. On 9/1/23 at 12:45 PM, V2, DON, stated We looked for (R1)'s new insulin order and found them. We received them on 8/28, but the nurses didn't know what Lispro 10 units before meals plus correction scale of 1/50 greater than 150 meant, so the new orders never got put in. 2. R2's physician orders documents Insulin Lispro Injection Solution (Insulin Lispro) Inject 5 unit subcutaneously before meals and Insulin Lispro. Injection Solution (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 500 = 6 units, subcutaneously before meals and at bedtime. On 8/31/23 at 11:03 AM, V4, Registered Nurse (RN) obtained R2's blood glucose level of 177 mg/dl. On 8/31/23 at 11:11 AM, V4, RN, obtained R2's Lispro insulin (trade name/insulin pen injector) from the medication cart and an insulin pen needle. V4, RN, took the cap off the insulin pen, opened the needle, and attached the needle to the pen. V4, RN then dialed 6 units on the insulin pen, grabbed some alcohol pad and gloves and entered R1's room. V4, RN, then donned gloves, opened the alcohol pads, wiped the back of R2's right lower abdomen with the alcohol, took the cover off the insulin needle, pressed the pen into R2's abdomen and depressed the insulin pen button and then removed the needle from the skin within two seconds and discarded the needle. On 8/31/23 at 1:52 PM, V2, Director of Nursing (DON) stated The nurse should hold the insulin pen against the skin after pushing the button for seven to ten seconds. Pulling the needle out too soon and they won't get all the insulin. On 8/31/23 at 1:48 PM, V4, RN, stated With meals means one hour before or one hour after meals. Before you administer the insulin from the (trade name/insulin pen injector), you have to dial 2 units and press the button to prime it, then dial the dose to be administered. Once you give the insulin, you have to hold the needle against the skin for 30 seconds to ensure the delivery of all the insulin. I didn't prime the needle or hold the pen to the skin long enough for (R1 and R2). I just forgot.

Jul 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to identify an instance of abuse for two residents (R2 and R11) of five residents reviewed for resident to resident abuse. Findings Include: The Facility's Abuse Prevention Program dated 5/21 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by: Identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. The Facility's Abuse Prevention Program defines abuse as the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A 5 day Final Report of an alleged resident to resident abuse incident dated 6/26/23 documents that on 6/21/23 (R11) had a verbal outburst and tried to take an item that was not his. (R2) offered to help staff and in the process (R11) grabbed (R2)'s arm. (R2) had a natural reaction and swatted at (R11). On 6/27, 6/28 and 6/29 R2 and R11 both refused to speak about alleged incident on 6/21/23. R2's statement dated 6/21/23 documents spoke to (R2) about incident. States (R11) had something he wasn't suppose to have, staff tried to take it. (R11) became upset, (R2) tried to help staff, (R11) grabbed her hand and (R2) tapped him with the fly swatter. On 6/28/23 at 10:30 AM V1 (Administrator) stated (R2) had a fly swatter in her hand when (R11) grabbed her hand so she swatted him on the bottom and he let go. The 5 day Final Report dated 6/26/23 documents determination: upon investigation, the willful intent to cause harm has been unfounded. On 6/29/23 at 1:30 PM V2 (Administrator in Training) stated We considered that a behavior, not abuse.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide a clinical basis for discharge, and failed to ensure transfer and discharge information/documents were provided to the receiving provider for one (R6) resident reviewed for transfer/discharge in a sample of three. Findings Include: The Facility Assessment documents: (Facility) provides services to patients having a variety of mental health illnesses as well as medical needs. Category: Psychiatric/Mood Disorders. Common Diagnoses: Psychosis (hallucinations, delusions, etc.), impaired cognition, mental disorder, depression, bipolar disorder (i.e., mania/depression), schizophrenia, post-traumatic stress disorder, anxiety disorder, behavior that needs interventions. The facility's Transfer and Discharge Policy and Procedure, Undated, documents: It is the policy of (facility) not to transfer a resident unless: 1. The transfer or discharge is necessary to meet the residents welfare, and the residents welfare cannot be met in the facility; 2. The transfer is appropriate because the residents health has improved sufficiently so that the resident no longer needs the services provided by the facility; or 3. The safety of individuals in the facility is endangered; or 4. The health of individuals in the facility would be endangered; or 5. The resident has failed, after reasonable and appropriate notice, to pay for a stay in the facility; or 6. The facility ceases to operate. The facility's Bed Hold Guarantee Policy, Revised 8/1/17, documents: Upon leaving this facility for admission to a hospital or for a therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if: 1. The resident's condition is such that he/she is appropriate for the level of care provided by the facility; and, A Medicaid resident, whose hospitalization or therapeutic leave exceeds the 10 day bed-hold period, may return to their previous room if available or immediately upon the first availability of a bed I a semi-private room. R6's Minimum Data Set (MDS) (Dated 5/22/23) documents R6 has a BIMS (Brief Interview of Mental Status) score of 6. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R6's Diagnoses: Schizoaffective disorder, bipolar type, post-traumatic stress disorder, cannabis dependence, anxiety disorder, other sexual dysfunction not due to a substance or know physiological condition, drug induced akathisia. R6's 6/5/23 Progress Note documents: (R6) had increased aggression and combativeness. (R6) kicked wall punched wall, and punched vending machine Orders received to send to (hospital); 911 called. Police and ambulance responded (R6) sent to (hospital). Face sheet and medication orders sent. R6's Hospital Notes dated 6/5/23 document: (Emergency Medical Staff/EMS) states (R6) was complaining of a headache at his care facility, and became angry. Patient reportedly punched a vending machine and hit his bed. EMS was called, and states that (R6) has been calm and cooperative with them. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Comments: Appears to be mildly mentally delayed. R6's Hospital Notes dated 6/5/23 also document: Initially discussed with social work, and they are saying that prior care facility is refusing to take (R6) back due to assaulting staff. Patient with no acute psychological problems at this time, and do not feel patient needs medical clearance or evaluation by crisis counselor. (R6) will be kept in the emergency department, and tomorrow social worker can continue to find long-term placement for patient. On 6/28/23 at 9:40 am, V13 Psychiatrist to R6 stated that he got a call from (hospital) stating that R6 was still in the hospital; and that the facility had no formal process to discharge (R6) on an involuntary basis; that he called to talk to the facility about this but was unable to. V13 stated, The hospital staff said they had nowhere to send (R6). On 6/29/23 at 10:55 am, V15 Regional Clinical Director stated that R6 was not discharged from the facility; that his return was anticipated. Stated that discharge documents were not sent with R6 when he was transferred to the Emergency Department. At this time, V15 stated: (R6) was transferred to a (hospital) for acute psych care for increased psychosis. (R6) was hospitalized beyond our 10 day Bed Hold Policy period, and R6 would have been readmitted to the facility if space had been available. We were not trying to involuntarily discharge (R6). We were trying to find alternate placement for him since May 2023 and his family was agreeable to this. On 7/12/23 at 10:55 am, V15 Regional Clinical Director, RN, stated that the facility did not advise (R6) or his representative that (R6) would be able to come back to the facility when a bed was available for him. On 7/12/23 at 1:50 pm, V24 Social Worker at Hospital stated that (R6) was being discharged from the hospital on 6/13/23; that she spoke with V25 Community Relations Coordinator and V16 Social Services on 6/12/23 and 6/13/23 about R6's discharge and date. At this same time, V24 stated, If the facility was not taking (R6) back, immediate discharge paperwork was needed. (V25) told me that (R6) was not coming back; that the facility had no bed for him. We would have worked on placement (for R6) if we had the proper ITD (Involuntary Transfer or Discharge) paperwork from the facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to follow its policy to allow a resident to return to the facility following emergent hospital care for one (R6) resident reviewed for transfer/discharge in a sample of three. Findings Include: The Facility Assessment documents: (Facility) provides services to patients having a variety of mental health illnesses as well as medical needs. Category: Psychiatric/Mood Disorders. Common Diagnoses: Psychosis (hallucinations, delusions, etc.), impaired cognition, mental disorder, depression, bipolar disorder (i.e., mania/depression), schizophrenia, post-traumatic stress disorder, anxiety disorder, behavior that needs interventions. The facility's Transfer and Discharge Policy and Procedure, Undated, documents: It is the policy of (facility) not to transfer a resident unless: 1. The transfer or discharge is necessary to meet the residents welfare, and the residents welfare cannot be met in the facility; 2. The transfer is appropriate because the residents health has improved sufficiently so that the resident no longer needs the services provided by the facility; or 3. The safety of individuals in the facility is endangered; or 4. The health of individuals in the facility would be endangered; or 5. The resident has failed, after reasonable and appropriate notice, to pay for a stay in the facility; or 6. The facility ceases to operate. The facility's Bed Hold Guarantee Policy, Revised 8/1/17, documents: Upon leaving this facility for admission to a hospital or for a therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if: 1. The resident's condition is such that he/she is appropriate for the level of care provided by the facility; and, A Medicaid resident, whose hospitalization or therapeutic leave exceeds the 10 day bed-hold period, may return to their previous room if available or immediately upon the first availability of a bed I a semi-private room. R6's Diagnoses: Schizoaffective disorder, bipolar type, post-traumatic stress disorder, cannabis dependence, anxiety disorder, other sexual dysfunction not due to a substance or know physiological condition, drug induced akathisia. R6's Hospital Notes dated 6/5/23 document: (Emergency Medical Staff/EMS) states (R6) was complaining of a headache at his care facility, and became angry. Patient reportedly punched a vending machine and hit his bed. EMS was called, and states that (R6) has been calm and cooperative with them. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Comments: Appears to be mildly mentally delayed. R6's Hospital Notes dated 6/5/23 also document: Initially discussed with social work, and they are saying that prior care facility is refusing to take (R6) back due to assaulting staff. Patient with no acute psychological problems at this time, and do not feel patient needs medical clearance or evaluation by crisis counselor. (R6) will be kept in the emergency department, and tomorrow social worker can continue to find long-term placement for patient. R6's 6/5/23 Progress Note documents: (R6) had increased aggression and combativeness. (R6) kicked wall punched wall, and punched vending machine Orders received to send to (hospital); 911 called. Police and ambulance responded (R6) sent to (hospital). Face sheet and medication orders sent. On 6/28/23 at 9:40 am, V13 Psychiatrist to R6 stated that he got a call from (hospital) stating that R6 was still in the hospital; and that the facility had no formal process to discharge (R6) on an involuntary basis; that he called to talk to the facility about this but was unable to. V13 stated, The hospital staff said they had nowhere to send (R6). On 7/13/23 at 1:30 pm, V30 Registered Nurse/RN to V29 Primary Care Physician for R6, stated that she was V29's office nurse; that they were not aware that R6 was no longer at the facility. V30 stated, He has been inactivated in our system; but there are no discharge orders in system. On 6/29/23 at 10:55 am, V15 Regional Clinical Director stated that R6 was not discharged from the facility; that his return was anticipated. Stated that discharge documents were not sent with R6 when he was transferred to the Emergency Department. At this time, V15 stated: (R6) was transferred to a (hospital) for acute psych care for increased psychosis. (R6) was hospitalized beyond our 10 day Bed Hold Policy period, and R6 would have been readmitted to the facility if space had been available. We were not trying to involuntarily discharge (R6). We were trying to find alternate placement for him since May 2023 and his family was agreeable to this. On 7/12/23 at 1:50 pm, V24 Social Worker at Hospital stated that (R6) was being discharged from the hospital on 6/13/23, that she spoke with V25 Community Relations Coordinator at the facility regarding R6's discharge. V24 stated, (V25) told me that (R6) was not coming back; that the facility had no bed for him. We would have worked on placement (for R6) if we had the proper ITD (Involuntary Transfer or Discharge) paperwork from the facility. On 7/13/23 at 8:50 am, V14 Family Member to R6 stated, I went to the facility (on 6/5/23) after I found out (R6) was in the hospital; his belongings are still there now; the facility gave no reason why he could not go back. The ER (Emergency Room) staff said the facility would not take him back, and they were refusing to come and pick him up; and no medical reason for him to be there. He has been ready to be sent home; trying to find a place for him now.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review the facility failed to wear appropriate PPE (Personal Protective Equipment) during a COVID outbreak. This failure has the potential to affect all 53 residents who currently reside in the facility. Findings Include: The Facility's COVID-19 Control Measures policy dated 5/19/23 documents Upon notification of a single new case of facility associated COVID-19 infection in any staff member or resident, all staff and residents should have a series of (3) three viral tests. The first test should be completed, not earlier than 24 hours from time of exposure, if negative repeat testing 48 hours after finial test and if negative after 2nd test, repeat testing in another 48 hours. (This will usually be days 1,3 and 5 with date of exposure being day 0). If no further cases of COVID-19 are identified, then no further testing is required. If additional HCP (Health Care Personnel) and/or residents test positive during the initial outbreak testing, then residents and staff be retested every 3-7 days until testing identifies no new cases of COVID-19 involving HCP or residents for a period of 14 days since the most recent positive result. The Facility's COVID-19 Control Measures policy dated 5/19/23 documents In the event of a facility outbreak, all HCP (Health Care Personnel) must wear an N95 and eye protection when caring for all residents and/or are in an area where they may encounter residents, until testing indicates that no further cases are present. If an additional resident or HCP has a positive test during initial outbreak testing, HCP must continue to wear an N95 and eye protection until 14 days have passed with no further positive cases. The Facility's Face mask/Face shield/Goggles policy dated 04/02 documents Procedure: 3. Position the mask over your nose. Your nose and mouth must be covered. On 6/27/23 at 9:00 AM, the front door of the facility had a sign that said Attention: A resident or staff member of this facility has tested positive for COVID-19. The Facility's COVID positive resident list documents on 6/16/23 during routine testing that the following 7 residents tested positive for COVID and were place on a ten day contact precaution which ended 6/26/23: R3, R12, R13, R14, R15, R16, R17. The Facility's Staff COVID testing documents on 6/22/23 staff member V19 (CNA) tested positive for COVID-19. On 6/27/23 at 9:01 AM, multiple staff members were in the main dining room serving breakfast to the residents without any masks and no residents had on any masks. At 9:05 A.M. upon reentry of the main dining room multiple residents had on masks and V8 (Receptionist) was handing out surgical masks to staff in the dining room. The following staff members had not gotten a mask to put on yet were V4 (CNA), V5 (Unit Aide), V6 (Business Office Manager), V7 (CNA/Medical Records) and V11 (Housekeeping). On 6/28/23 at 10:00 AM, V9 (CNA) was sitting with a resident in a cushioned reclining wheelchair and was leaning over speaking to him with her mask under her nose. On 6/28/23 at 10:01 AM, V9 (CNA) stated My eye hurts I cannot pull the mask all the way up. (V2/Administrator in Training) is aware of this. On 6/27/23 at 10:00 AM, V1 (Administrator) confirmed the facility was still in COVID outbreak status due to a staff member testing positive on 6/22/23. V1 confirmed that the facility's policy requires N95 masks and eye protection for all staff members that are in resident care areas.

Jul 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to updated a resident's care plan after a fall for one of three residents (R3) reviewed for falls in the sample of three. Findings include: The facility's Comprehensive Care Planning Policy, revised 7/20/22, documents the Comprehensive Care Plan shall be revised as necessary to reflect the resident's current medical, nursing, mental and psychosocial needs. The facility's Fall Prevention Policy, revised 11/10/18, documents that all falls are discussed in the morning Quality Assurance meetings and new fall interventions will be written on the resident's care plan. The facility's Fall Analysis Log, dated June 2023, documents R3 fell on 6/26/23 due to self transferring in R3's room. This same Log documents a fall prevention intervention of Continue to educate resident to call for help when needing assist. R3's Incident Note dated 6/26/23 documents R3 was found on the floor in R3's room. R3's Plan of Care Note on 6/27/23 states, IDT (Interdisciplinary Team) met to discuss (R3's) fall on 6/26/23. Root Cause: Self transferring in room. Intervention: Continue to educate (R3) to call for help when needing assistance. R3's current Care Plan documents R3 is at risk for falls. As of 7/5/23 at 10:30 AM, R3's current Care Plan did not document R3's 6/26/23 fall or R3's newly implemented fall prevention intervention. On 7/5/23 at 12:58 PM, V5 (Registered Nurse/Minimum Data Set/MDS Coordinator) verified that R3's Care Plan was updated today (7/5/23) with R3's 6/26/23 fall and implemented fall prevention intervention. V5 stated R3's Care Plan should have been updated during the IDT meeting on 6/27/23 when R3's fall was discussed but it was not.

May 2023 5 deficiencies 1 IJ (1 facility-wide)

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from physical and verbal abuse by R16, a [AGE] year old independent ambulatory man, with a known history of frequent resident to resident altercations with 1:1 Staff present, failed to institute new safety interventions to protect against resident to resident altercations, failed to provide supervision to protect a resident R1, with offensive behaviors, from retaliatory physical and verbal abuse despite 1:1 supervision. These failures had the potential to affect all 118 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5/8/23, the facility remained out of compliance at a Severity Level 2 as the facility continues to conduct ongoing Abuse Identification and Prevention Training, protecting residents during an altercation training, and effectively providing 1:1 supervision training with all current staff, Agency Staff and newly hired staff and the Quality Improvement Program conducts random audits to ensure facility staff's compliance with resident behavior monitoring, implementing abuse interventions, staffs' understanding of what to do in a situation of an altercation and to effectively provide 1:1 supervision, and the Abuse Prevention Program. Findings include: The facility's Abuse Prevention Program, dated 11/28/16, documents, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This facility is committed to protecting our resident from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. The policy also documents, Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. 1. A Facility 5 Day Final Report, dated 4/28/23, documents, Original complaint: It was reported on 4/25/23 that while in the common areas R16 allegedly called R1 a 'b**ch' and told her she needed to go home. Residents will be offered 1:1 time with Social Services once a week for 3 weeks. A written statement signed by V19 (Business Office Manager), dated 4/25/23, documents, I was sitting in the office, on my computer. When I heard yelling in the TV room. I got up to see what was happing. (R16) was stood in front of the couch, in front of (R1). He called her a b**ch. Then, I overheard him threatening to cut (R1). As of 5/3/23, R1 nor R16's medical records have no documentation of 1:1 sessions with Social Services. On 5/2/23 at 10:00 a.m., R1 was sitting outside smoking. R1's 1:1 staff member, V17 (unit aide), was watching her through the window from inside of the facility. V17 stated, I have never witnessed a physical altercation with (R1) until today. She gets verbally aggressive a lot with other residents. Today (R1) and (R16) got verbal with each other and she started calling him a b**ch then he slapped her a few times in the face. On 5/2/23 at 1:30 p.m., R17 was observed propelling himself towards V1's Office. R17 was bleeding from his mouth and his right hand was actively bleeding. At that time R17 stated, He (R16) punched me in the mouth. All I was trying to do was help him open his ice cream. On 5/2/23 at 1:40 p.m., V13 (Social Services) stated, (R16) will walk down the hall and say stuff or come in here and if it's not taken care of right away he has an outburst. It's like something is going on with him. R17's Incident Note, dated 5/2/23 at 1:44 p.m., documents, R17 assessed with minor skin tear 0.2 cm (centimeters) x 0.2 cm to left hand and swollen bottom lip. R16's Incident note, dated 5/2/23 at 2:51 p.m., documents, R16 verbally aggressive with nurse during assessment and asking R16 about what happened. (R16) states that other resident (R17) spoke racial slurs to him so he punched him in the face. On 5/2/23 at 2:47 p.m., V18 CNA stated, I'm (R1's) 1:1 tonight. I was never told that (R1) and (R16) had an incident this morning. That would have been nice to know. I try to keep (R15) and (R16) away from (R1). (R16) is so unpredictable you never know what he's going to do. When he got in (R1's) face (4/25/23) (R16) told (R1) he was going to slice (R1). He's a little scary. (R1) likes to instigate things and get other residents upset then they want to go after her. (R16) is very hateful and gets angry with (R1) as well. He's hit her before. I don't know what to do in the case of another resident trying to hit (R1). All I know to do is to try and redirect them. I haven't had any training about these situations. I know that (R1) has spit on other residents and they've hit her. I can't believe (R16) hit (R17). (R17) is the sweetest man ever and wouldn't instigate anyone to hit him. See (R16) is unpredictable. On 5/3/23 at 12:20 p.m., V17 stated, (R1) and R16 had two incidents yesterday. The one where he slapped her across the face in the morning, and then in the afternoon they had a verbal altercation. Right after he hit her, (V1 Administrator in Training) came up on the commotion. (R16) went off on (V1). He started yelling and cussing at her. I didn't notify anyone about what happened because (V1) told me she had it all taken care of. Around 1:15 p.m., (R1) sat next to (R16). I asked her to not sit there and we could sit somewhere else, and she refused to move. She reached over and touched (R16's) hair, and he said, 'Keep your f**king hands off of me.' (R1) wouldn't move so I asked (R16) if he would move, and he told me, 'White lady you aren't going to tell me what the f**k to do.' The office door was closed when I left, so I put a note under the door to let (V2 Assistant Administrator in Training) know what happened with that incident. R1 and R16's current medical records have no documentation of abuse investigations regarding both altercations that occurred on 5/2/23. There is also no documentation of interventions implemented following each altercation to prevent R16 from further assaulting any other residents. On 5/3/23 at 11:25 a.m., V23 Registered Nurse stated, I was working yesterday when (R16) punched (R17) in the face. (R17) told me he was trying to help (R16) with opening his ice cream at lunch and (R16) said (R17) called him a racial slur. (R16's) baseline is agitated. It doesn't take much to get him worked up and he thinks everyone is against him racially. We didn't change anything supervision wise either for (R16). I had no idea that (R16) hit (R1) yesterday (5/2/23) morning. No one told me. On 5/3/23 at 11:38 a.m., R16 was ambulating independently down the hall. R16 stated, I don't know what you're talking about when asked about the 5/2/23 incident and started yelling and cussing. On 5/3/23 at 11:50 a.m., V21 Certified Nursing Assistant stated, I didn't know that (R16) and (R1) had an incident yesterday (5/2/23). He was irritable the whole day yesterday. It started even at breakfast he was antagonizing people and yelling so I took him back to his room for breakfast. Anyone that walked by him yesterday he would exchange words with them. When he got to lunch he was yelling at residents as well. He's like that today too. I came into the end of the argument yesterday. He had punched (R17). I took (R17) from the room. I'm not aware of us doing anything different with (R16). On 5/3/23 at 12:10 p.m. V22 Registered Nurse stated, I wasn't aware that (R1) and (R16) had an altercation yesterday morning and I was (R1's) nurse. V22 also stated that (R16) is able to independently ambulate throughout the entire facility. On 5/3/23 at 1pm, V13 (Social Services) stated, I didn't know that (R16) had an incident with (R1) in the morning. I knew he had two incidents in the afternoon. I never did work with him or do anything with him regarding the incidents. V13 also confirmed that she has not done any 1:1 sessions with R1 or R16 since their incident on 4/25/23. On 5/3/23 at 2pm, V1 (Administrator in Training) stated, I did not know that (R16) hit (R1) when I walked up on them yesterday morning. I knew he was irritated, and he started cussing at me, but V17 never told me R16 had slapped R1. I didn't know that there was a verbal altercation that afternoon either. (V17) should have verbally told us that the incident occurred, not put a note under the door. There was no note under the door. We have told them and told them to report everything to us, and that if they don't they will be fired. This is ridiculous. We didn't start any kind of investigation because we never knew he slapped her or had a verbal altercation with her. All we knew was he had hit (R17) that afternoon. On 5/4/23 at 9:30 a.m., R17 was sitting in his room watching television. He was completely alert and oriented. R17 had a scab on his left hand from what appeared to be a skin tear and his lower lip was swollen with a cut. R17 appears elderly and frail. R17 has a walker in front of him, but he said he is unable to ambulate more than a step or two, so he uses a wheelchair. R17 indicated he is currently on Hospice, because I'm just getting old and going downhill. R17 stated he's lived here about six months, but his family wants him to move because they are concerned this is not the safest place for him. R17 stated, I was in the dining room and he (R16) was sitting next to me. (R16) was trying to open his ice cream, but was having a hard time. He put his ice cream down and I picked it up to open it, before I could even react, he (R16) was standing up from his chair and punched me in the face. Somehow in the scuffle my hand got busted open and was bleeding, my lip was busted open and was bleeding. (R16) kept yelling that I called him a n****r, but I didn't. Someone separated us. (R16) moved so fast, I didn't even have time to push my wheelchair out and away from him. When R17 was questioned if he was afraid to live in this facility or if he was afraid of any of the residents, including (R16). R17 stated, I'm not going to be afraid. I know I can't defend myself very well, but I won't live like that. On 5/4/23 at 10:18 a.m., R12 stated he was a witness to the incident on Tuesday between (R17) and (R16). R12 stated, I was sitting at the table next to them. (R17) was trying to help the guy (R16) and he just stood up and started swinging. (R17) never had a chance. He's confined to a wheelchair, what could he possibly do to defend himself? I mean, the other guy can walk. He (R16) tried saying (R17) said racial slurs to him, but he never did. The guy (R16) got (R17) good. His lip was bleeding all over. I'm just over being in this place. I was supposed to just be here for therapy and then go home, but I'm not sure I can finish my last 30 days here. It's just chaos, all the time. On 5/4/23 at 10:40 a.m., R18 stated, I was out there when (R16) hit (R17). That poor old man (R17) is in the wheelchair and can't defend himself, and (R16) just hauled off and punched him (R17) in the face. I saw blood on (R17's) face. (R17) didn't do anything. (R16) gets irritated pretty easily especially with (R1). On 5/4/23 at 11:35 a.m., V1 confirmed that an investigation was not started immediately after the incidents on 5/2/23 between (R1) and (R16). Therefore, the facility did not implement anything to prevent R16 from further assaulting any other residents. The facility's Room Roster, dated 5/1/23, documents that 118 residents reside in the facility. 2. R1's Nurse's notes, dated 3/20/24 at 9:00 a.m., document, (R1) out on patio for smoke pass and spit in another resident's (R4) face. Continue 1:1's. R1's Nurse's notes, dated 3/24/23 at 6:00 p.m. document, (R1) spit on another resident (R15) while sitting on the couch. (R1) agitating resident previous to spitting on him by touching him when asked to stop. Facility Initial Report email, dated 4/11/23, documents, Resident to resident incident: Residents involved R4, R1. Alleged resident to resident physical altercation. V35's (Activity Assistant) written undated statement documents, I was on the patio when (R1) started calling (R4) names and then (R1) spit in (R4's) face. Then, (R4) got up and smacked (R1's) head on the wall. Then they stopped after I got in between them. V32's (Activity Assistant) written statement, dated 4/11/23, documents, (V35) and I were passing and lighting cigarettes (R1) and (R4) started to yell back and forth. (R1) then spit in (R4's) face. R4 then smashed the back of (R1's) head into the brick wall. CNAs (Certified Nursing Assistants) and nurses came out and had it handled. (R1) went in but then came out again. She was calling staff members, 'b**ch,' and spitting at them. R7's written but undated statement, documents, (R1) keeps spitting on people and (R4) pushed (R1) into the wall and spit back on (R1). Then they were separated. R2's written undated statement, documents, (R1) spit on (R4) twice and (R4) got up to defend herself and pushed (R1's) head against the wall. They were separated after that. R20's written undated statement documents, (R1) spit on (R4) and (R4) pushed her face and pushed her down. After that they were separated. R4's written undated statement, (R1) spit on me and so I pushed her head against the brick wall. Then we were separated. R5's written undated statement documents, We were out for smoke break and (R4) asked (R1) to not touch her when she sat next to (R4). (R1) then spit in (R4's) face then (R4) grabbed (R1) by the throat and smashed her head off the brick wall then I pulled (R4) off (R1) and the fight stopped. R19's written undated statement documents, I saw (R1) spit on (R4) and then (R4) punched her and beat her head against the brick wall. V4's (Resident Care Coordinator) written undated statement documents, (R1) ran out of the C wing door. (R1) upset because she got into an altercation with (R4). She was outside on patio and called (R4) a b**ch. (R4) stated say it one more time. (R1) did. (R4) struck her. (R1) struck back and they were separated. A facility 5 day Final Report, dated 4/16/23, documents, It was reported on 4/11/23 that while both residents (R1 & R4) were in the facility's courtyard during a scheduled smoke pass that (R1) allegedly called (R4) a derogatory name, (R4) then returned the verbal gesture. It was then reported that (R1) allegedly expectorated on (R4). Reports continued that (R4) then allegedly struck (R1) with her hand then (R1) allegedly struck (R4) in return. Both residents have been placed on list to be seen by Psych Nurse Practitioner for evaluation and recommendations for further treatment. On 5/3/23 at 2:35 p.m., V32 (Activity Assistant) was sitting outside of R13's room whom she was supervising as a 1:1. V32 stated, I was on the smoke patio the night that (R4) hit (R1's) head off of the wall. We were on smoke break. I don't know who (R1's) 1:1 was that day. The 1:1 tends to sit inside of the building watching her through the window. They are not always with her. I heard commotion and (R1) spit in (R4's) face. Then that's when (R4) smacked (R1's) head off of the wall. I ran inside to get help. I haven't ever been told what the rules are when it comes to supervising a 1:1 resident. I think you just have to visualize them. I work activities in the evening, but sometimes when I get here they tell me I have to do 1:1 with either (R13) or (R1). I'm not the person to ask what we are supposed to do in the case of a resident fight. I haven't gotten any training on this stuff. I just get handed the 1:1 sign off sheet. On 5/4/23 at 11:35 a.m., V1 stated, After the 4/11/23 incident, I talked to (R4) about controlling her anger. When the altercation starts staff should separate them immediately and get them calmed down. I don't know how (R1) ended up still getting hit even though she had a 1:1. I wasn't there to witness it. They should be interjecting and getting in between the residents. I've talked to (V31 Unit Aide) about stepping in when things are escalating. We have educated staff to de-escalate the situation. I don't think staff are afraid to intervene. (R1) is not instigating the other residents, it's the other residents that are having the behaviors towards (R1). There was no formal training done after this incident (4/11) just talking to the staff. R1's Behavior note, dated 4/13/23 at 9:19 p.m., documents, (R1) on patio calling people names threatening to spit on them. Residents came inside after smoke break. (R1) spit at (R2). (R2) told her to spit again. She spit again. (R2) attacked her. The residents were separated and they attacked each other again. They were separated and started spitting at each other in between staff. A facility 5 Day Final Report, no date, documents, It was reported that (R1) allegedly called (R2) a 'b**ch' which caused (R2) to return the verbal gesture. It was reported that (R1) then alleged spat in (R2's) face. (R2) allegedly hit (R1) in face and spat back on (R1). R2's Incident Investigation Interview form, dated 4/14/23, documents, (R2) stated that while near the nursing station (R1) spat on (R2). That is when (R2) hit (R1). R2's Nurse's Notes, no date, document, (R2) stated that (R1) was calling her names spitting at her and she pinned (R1) to the wall and hit her. R2's Behavior note, dated 4/13/23 at 9:29 p.m., documents, (R1) on patio calling people names threatening to spit on them. Residents came inside after smoke break. (R1) spit at (R2). (R2) told her to spit again. (R1) spit again. (R2) attacked her. The residents were separate and they attacked each other again. They were separated and started spitting at each other in between staff. On 5/4/23 at 10:35 a.m., R2 stated, (R1) had spit on me at least three different times, and I couldn't take it anymore. The last time she spit on me I punched her in the face twice. She had a 1:1 with her, but they don't do anything to interfere or stop anything. They might ask her to not spit and that's it. These little teenagers don't do anything. R1's Incident Investigation Interview, dated 4/25/23, documents, (R16) walked by and called me a f**king b**ch and a 'ho' and told me I needed to go home. Facility 5 Day Final Report, dated 4/28/23, documents, Original complaint: It was reported on 4/25/23 that while in the common areas (R16) allegedly called R1 a b**ch and told her she needed to go home. Residents will be offered 1:1 time with social services once a week for 3 weeks. R1's Incident note, dated 4/26/23 at 6:45 p.m., documents, This nurse was notified by staff member that this resident was exchanging curse words with a male resident (R15), this resident became increasingly agitated and spit on (R15) in his face. V33's (Unit Aide) written statement, no date, documents, (I) was walking with R1, she and R15 was exchanging words (cursing) with each other. R1 got mad and spit on R15 in his face and walked away to the nurses' station. R15's Incident Investigation Interview form, dated 5/1/23, documents, (R15) states (R1) got mad at him for not saying 'hi' they exchanged words and then she spit on him. A facility 5 day final report, dated 5/1/23, documents, It was reported on 4/26/23 that (R1) and (R15) allegedly exchanged curse words with one another. (R1) became upset and allegedly spit on (R15). (R1) still remains on 1:1 supervision. Residents will be offered 1:1 time with social services once a week for three weeks. A facility Five Day Final Report, dated 5/2/23, documents, It was reported on 4/27/23 that during an afternoon smoke pass (R4) had touched (R1). At that time (R1) was spitting everywhere and allegedly spit on (R4). (R4) states she just reacted and allegedly hit her. Residents will be offered 1:1 time with social services once a week for three weeks. R4's Incident Investigation Interview form, dated 4/27/23, documents, At 1:30 p.m. smoke pass out on patio, I was sitting in a chair (R1) touched me and I (said) don't touch me. She was spitting everywhere and then spit on me on my face. My reaction was to push her away but she was close and my arm and hand made contact with her. V34's (Activity Assistant) written statement, dated 4/27/23, documents, (R1) spit at (R4). Unit aides came between them. I continued lighting cigarettes. I turn around to yelling and (R4) hitting (R1). V17's (Unit Aide) written interview, dated 5/1/23, documents, Have you ever witnessed (R1) and (R4) be inappropriate towards one another? Yes smoke pass or in the TV room. Usually (R1) says hello and (R4) says, 'Don't talk to me.' R1's response is always, 'B**ch. On 5/2/23 at 10:50 a.m., R4 was alert lying in bed. R4 stated, (R1) spits at me and in my face all the time. No one does anything to stop her even her 1:1. Both times I hit (R1) I just got so fed up I couldn't take it anymore. R1's Care plan, dated 5/1/23, documents, (R1) has potential to be physically aggressive related to Bipolar and TBI with poor impulse control. The care plan also documents the following intervention: (R1) was called a 'b**ch ' and told to go home by another resident. Offered 1:1 time with social services once a week for three weeks. Still remains on 1:1 supervision. (R1's) care plan has no revision to include (R1's) behavior of spitting on other residents causing altercations. On 5/1/23 at 11:35 a.m., R13 stated, I never see the 1:1's for (R1) or (R14) and if I do they are on their phones not watching them. All you ever see is these little teenage 1:1's who are too busy texting their friends or taking pictures of themselves. They don't care about where their residents are at. On 5/2/23 at 10:00 a.m., R1 was sitting outside smoking. Her 1:1 staff member, V17 (Unit Aide) was watching her through the window from inside of the facility. V17 stated, I have never witnessed a physical altercation with (R1) until today. She gets verbally aggressive a lot with other residents. Today (R1) and (R16) got verbal with each other and (R1) started calling (R16) a b**ch then he slapped her a few times in the face. When she starts to get verbal with other residents, I try to remove her, but she's stubborn. I can't always get the other resident to leave either. When (R1) gets verbal, the other residents get mad and hit (R1). On 5/2/23 at 11:20 a.m., V33 (Unit Aide) stated, (R1's) behaviors depend on who she is sitting with. If she's sitting with (R16) or (R15) it's trouble. At smoke time, (R1) likes to cut in line and that does not go over well with the others. If (R1) is mad she will hit and kick other residents. I try telling her we need to leave or go for a walk, go for a break, we can go sit in her room or go down the hall. I try giving her ice too. Most of the time she will not get up. So, I have to go get the nurse. The nurse doesn't really help a lot of times because they just do the same thing I already did, and it doesn't help. I may ask the other resident then to move, and sometimes that will help. (R16) will just keep arguing with her. (R16) gets in her face. The other day I had to get (V1 Administrator in Training) because (R16) was in her face. The incident (4/13/23) with (R2) started outside. They were arguing about something during smoke pass. I told (R1) to put her cigarette out so we could go inside to get away from it. Then, (R1) came in and (R1) spit on (R2) and (R2) hit (R1). The incident (4/26/23) with (R15) was (R1) got done eating dinner and sat next to (R15). (R15) said he didn't want her to sit there and asked her to move. I tried to get (R1) to move. (R1) wouldn't move so (R15) started to get rude and then (R1) got rude and kicked (R15). Basically we are just taught to try to redirect them, and if that doesn't work then get the nurse. Not much else is taught to us if we aren't able to redirect them we have to leave the residents alone to get the nurse. On 5/2/23 at 1:40 p.m., V13 (Social Services) stated, (R1) has been on 1:1 ever since I got here. (R1) spits on other residents quite a bit. I talk to her about being inappropriate, but (R1) doesn't remember it. (R1) doesn't remember long term. (R1) wouldn't remember spitting on people. Certain people (R1) is not supposed to be by like (R16) because they get each other riled up. I haven't been documenting the 1:1 sessions because I haven't been doing them. On 5/3/23 at 12:20 p.m., V17 stated, (R1) and (R16) had two incidents yesterday. The one where he slapped her across the face in the morning, and then in the afternoon they had a verbal altercation. Around 1:15 p.m., (R1) sat next to (R16). I asked (R1) to not sit there and we could sit somewhere else, and she refused to move. (R1) reached over and touched (R16's) hair, and (R16) said, Keep your f**king hands off of me. (R1) wouldn't move so I asked (R16) if he would move, and (R16) told me, White lady you aren't going to tell me what the f**k to do. On 5/3/23 at 12:00 p.m., V12 Registered Nurse stated, I don't know how other resident's are able to hit (R1) if she has a 1:1 with her at all times. I question it all the time. I know (R1) likes to instigate and spit on residents and get verbal. She picks at other residents all the time. On 5/3/23 at 1:40 p.m., V36 CNA (Certified Nursing Assistant) stated, If you are 1:1 with (R1) she just has to be within visual distance. On 5/3/23 at 1:05 p.m., R1 was sitting on the couch in the TV room. R1's 1:1 staff member, V37 (CNA), was sitting approximately 15 feet away from R1. On 5/4/23 at 11:35 a.m., V1 stated, The staff are all educated on redirecting the residents and trying to deescalate the situation. When V1 was asked how the perpetrators are able to hit R1 even with 1:1 staff present, V1 stated, Are you expecting this little teenage boy to jump in between these residents who are fighting? Have you seen these residents and how big they are? I educate these teenagers but they don't process this information well. V1 also stated, The 1:1 staff member should be within arms' length of the resident they are supervising. On 5/4/23 at 12:05 p.m., V9 (Regional Clinical Director) stated, What are you wanting us to do? Do you want the staff members to push the resident out of the way so there is no physical contact. The staff member pushes the resident, and the resident gets hurt then you are after us because that staff member wasn't trained properly. Regardless of what we do is wrong. We are doing our best here with this population that we have in this facility. I've gotten IJs (Immediate Jeopardy's) for this. On 5/4/23 at 12:15 p.m., V4 (Resident Care Coordinator) stated, Can you tell us what we are supposed to be doing here if we aren't taking care of these residents like we are supposed to? What do you want us to do? We are doing everything we can with (R1). We have call's out to other facility's to see if they could take better care of her, but we haven't heard back from any of them. On 5/8/23 at 2:15 p.m., V31 was sitting in front of fireplace while R1 was sitting on the couch in the TV room. V31 stated he got training on Thursday and they went over that the 1:1's needed to watch their residents better. V31 also stated, When it comes to watching (R1) I just need to have visual contact of her (R1 was approximately 20 feet away from V31 sitting on a couch). R16 walked up in front of R1 bent over and grabbed her thigh and was laughing. R16's 1:1 staff member V28 (CNA) was walking with R16 and did not address the interaction. V31 stated, We are supposed to keep (R1) and (R16) separated they need to be at least six feet apart. The Immediate Jeopardy started on 4/25/23 when R16 called R1 a b**ch and threatened to cut R1. On 5/4/23 at 1:25 p.m., V1 (Administrator in Training), V2 (Assistant Administrator in Training), V3 (Director of Nursing), V4 (Resident Care Coordinator) and V5 (Corporate Staff) were notified of the Immediate Jeopardy and Substandard Quality of Care. On 5/8/23, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. V1 and V2 were educated on Abuse Identification and Prevention by V9 (Regional Clinical Director) on 5/4/2023. 2. V1 and V2 initiated staff education on Abuse Identification and Prevention on 5/4/2023. 3. V2 educated by V9 on what to do in the situation of an altercation to protect the residents on 5/4/2023. 4. V2 initiated education to staff on what to do in the situation of an altercation to protect the residents on 5/4/2023. 5. V2 educated by V9 on how to effectively provide 1:1 supervision on 5/4/2023. 6. V2 initiated education to staff on how to effectively provide 1:1 supervision on 5/4/2023 7. Residents with known history of altercations to be monitored through internal QAA process through behavior monitoring program and reviewed by Quality Assurance Team during weekly behavior QAA, Quarterly QAA and more frequently as needed. 8. Quality Assurance Team to be review implementation and effectiveness of interventions put into place to prevent further abuse through daily QA meeting 9. Facility newly hired PRSC to initiate Social Service programming with residents to include conflict resolution techniques and impulse control. 10. Quality Assurance Team to conduct random rounds/interviews ensure staff is aware of what to do in a situation of an altercation. This will be done weekly for four weeks by V2. 11. V1 or designee to ensure any staff member who is performing 1:1 duties will be educated on how to effectively provide 1:1 supervision. 12. In-servicing training by V2 on Abuse Prevention Policy with all staff will continue monthly for the next 3 months, then quarterly times three by V2 or V3 (Director of Nursing). 13. All new employees to be in-serviced on Abuse Prevention Policy upon hire during orientation process prior to working with residents.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to provide individual quarterly financial statements and ensure accurate documentation of financial transactions were maintained for four of four residents (R3, R6, R9 and R10) reviewed for resident funds in a sample of 20. Findings include: The facility policy, titled Resident Funds Policy and Procedure documents The Facility Health Care recognizes the resident's right to mange his/her own financial affairs and does not require the resident to deposit their personal funds with (the) facility. However, upon written authorization of a competent resident the facility will hold, safeguard, manage and account for personal monies deposited with the facility. If the resident has been determined to be incompetent, the written authorization may be signed by the resident's fiduciary guardian, legal representative, or immediate family. All accrued interest paid to the resident monies account is prorated among those residents having personal funds in the account. In this manner, the resident will have access to his/her monies within the same day. At least quarterly, the facility will provide the resident or his/her representative a written, itemized statement of all transactions to his/her account which occurred in the last quarter. A review of the resident's account status is available to the resident upon request and in a reasonable amount of time. The policy later documents, Further, the facility will require dual signatures on all banking transactions requiring signatures as well as require receipts for all purchases made from residents' personal monies that shall include the date of purchase, amount of purchase and detail of all items or services purchased. 1. R3's Electronic Medical Record documents she has the current diagnosis of Intellectual Disabilities and V6 is listed as R3's Mother and Power of Attorney. On 5/01/23 at 12:10 pm, V6 (Power of Attorney) stated R3 was discharged from the facility on 3/17/23. V6 indicated she was not certain how much money was actually in R3's resident fund account at the time of her discharge because she has never received a financial statement from the facility for R3's account. V6 stated she was aware that R3 had taken cash withdrawals from her account since she was admitted in December of 2021, but had no documented account of exactly how much money R3 withdrew or what the money was even used for. V6 stated she was told by the facility's Business Office that they were sending a check for the remaining amount of money in R3's account, which was around $1200. V6 stated she requested an itemized statement of R3's funds at that time. V6 stated she received a check via mail from the facility in the amount of $1221.26, but no financial statement was provided. R3's Trust Fund Statement documents during the last 12 months R3 took cash withdrawls from her account on the following dates, without a dual signature and/or evidence of receipt for purchase: 6/15/22 ($10), 6/22/22 ($10), 7/01/22 ($10), 7/13/22 ($10), 7/18/22 ($10), 7/20/22 ($20, $20, & $10), 8/01/22 ($10), 8/08/22 ($10), 8/12/22 ($30), 8/15/22 ($10), 8/26/22 ($20), 9/02/22 ($10), 9/09/22 ($10), 9/12/22 ($10), 9/19/22 ($10), 9/28/22 ($10), 10/03/22 ($10), 10/12/22 ($10), 10/26/22 ($10, $20 & $15), 11/02/22 ($10), 11/07/22 ($10), 11/18/22 ($10), 11/23/22 ($10), 12/14/22 ($30), 12/21/22 ($15, $15, & $15), 12/28/22 ($15), 1/04/23 ($30), 1/09/23 ($100), 1/18/23 ($15), 1/23/23 ($15), 1/27/23 ($10), 1/30/23 ($15), 1/31/23 ($30), 2/01/23 ($15), 2/06/23 ($15), 2/08/23 ($15), 2/15/23 ($30), 2/24/23 ($15), 3/08/23 ($15), 3/10/23 ($15), and 3/13/23 ($15). On 5/02/23 at 9:27 am, V7 (Business Office Manager) stated she did mail a check to V6 for the remaining money in R3's account to close it, but did not include a financial statement. 2. The Electronic Medical Record documents R9 has the diagnoses of Encephalopathy and Alcohol Abuse and has a Court Appointed State Guardian (V30). R9's Quarterly Financial Statement, beginning 2/01/23, documents R9 took cash withdrawls from her account on the following dates, without a dual signature and/or evidence of receipt for purchase: 2/15/23 ($10), 2/22/23 ($20), 2/24/23 ($20) and 3/29/23 ($10). On 5/08/23 at 8:51 am, V30 (State Appointed Guardian for R9) stated, I checked (R9's) file this morning, and I have never received a financial statement for (R9). She has been at (the facility) for about a year. I have that she moved to that facility on 5/19/22. 3. The Electronic Medical Record documents R10 has the current diagnoses of Schizoaffective Disorder and Cerebral Infarct. A Minimum Data Set assessment, dated 3/21/23, documents R10 has a current BIMS (Brief Interview of Mental Status) score of 10, indicating moderate cognitive impairment. R10's Quarterly Financial Statement, beginning 2/01/23, documents R10 took cash withdrawls from her account on the following dates, without a dual signature and/or evidence of receipt for purchase: 2/03/23 ($15), 2/08/23 ($15) and 3/06/23 ($15). 4. The Electronic Medical Record documents R6 has the current diagnosis of Chronic Paranoid Schizophrenia. A Minimum Data Set assessment, dated 3/21/23, documents R6 has a current BIMS (Brief Interview of Mental Status) score of 15, indicating no cognitive impairment. R6's Quarterly Financial Statement, beginning 2/01/23, documents R6 took cash withdrawls from her account on the following dates, without a dual signature and/or evidence of receipt for purchase: 2/01/23 ($20), 2/13/23 ($20), 2/15/23 ($20), 2/22/23 ($20), 2/27/23 ($20), 3/13/23 ($20), 3/15/23 ($20), 3/20/23 ($20), 3/22/23 ($20), 3/27/23 ($20) and 3/29/23 ($20). On 5/02/23 at 2:00 pm, R6 stated she does withdrawal money on occasion, but had not received any financial statement of the funds in her account in as long as I can remember. On 5/02/23 at 9:27 am, V7 (Business Office Manager) stated resident funds statements are to be mailed to responsible parties quarterly, but V7 stated her most recent common practice was to just print statements when resident's or family asked instead of mailing them routinely every three months. V7 stated she was unable to produce a record of who had requested a statement of their resident funds and/or received a copy. V7 concluded that mailing quarterly financial statements had fallen to the waste side because we are short staffed in the Business Office and it's too much for one person to do that. On 5/02/23 at 2:48 pm, V5 (Corporate Staff) concluded that the documentation associated with recent cash withdrawls from R3, R6, R9 and R10's accounts was not consistent with what was required per the facility's Resident Funds Policy. 5/02/23 12:40 pm V9 (Regional Corporate Nurse) confirmed that V7 is supposed to be sending quarterly financial statements to all residents or their responsible parties on a routine basis.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to ensure the administrator was notified immediately of an allegation of verbal and physical abuse, and an allegation of abuse was reported timely to the State Agency for four of 20 residents (R1, R11, R12, R16) reviewed for abuse in the sample of 20. These failures had the potential to affect all 118 residents residing in the facility. Findings Include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and administrator. The policy also documents, The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the State Agency within five working days of the reported incident. 1. On 5/2/23 at 10:00 a.m., R1 was sitting outside smoking. R1's 1:1 staff member, V17 (unit aide), was watching her through the window from inside of the facility. V17 stated, I have never witnessed a physical altercation with (R1) until today. She gets verbally aggressive a lot with other residents. Today her and (R16) got verbal with each other and she started calling him a b**ch then he slapped her a few times in the face. On 5/3/23 at 12:20 p.m., V17 stated, (R1) and (R16) had two incidents yesterday. The one where he slapped her across the face in the morning, and then in the afternoon they had a verbal altercation. Right after he hit her, (V1 Administrator in Training) came up on the commotion. (R16) went off on (V1). He started yelling and cussing at her. I didn't notify anyone about what happened because (V1) told me she had it all taken care of. Around 1:15 p.m., (R1) sat next to (R16). I asked her to not sit there and we could sit somewhere else, and she refused to move. She reached over and touched (R16's) hair, and he said, 'Keep your f**king hands off of me.' (R1) wouldn't move so I asked (R16) if he would move, and he told me, 'White lady you aren't going to tell me what the f**k to do.' The office door was closed when I left, so I put a note under the door to let (V2 Assistant Administrator in Training) know what happened with that incident. On 5/3/23 at 2pm, V1 (Administrator in Training) stated, I did not know that (R16) hit (R1) when I walked up on them yesterday morning. I knew he was irritated, and he started cussing at me, but (V17) never told me that he had slapped (R1). I didn't know that there was a verbal altercation that afternoon either. (V17) should have verbally told us that the incident occurred, not put a note under the door. There was no note under the door. We have told them and told them to report everything to us, and that if they don't they will be fired. This is ridiculous. On 5/3/23 at 12:10 a.m. V22 Registered Nurse stated that R16 is able to independently ambulate throughout the entire facility. The facility's Room Roster, dated 5/1/23, documents that 118 residents reside in the facility.2. The (undated) Facility Incident Report documents, It was reported that (R12) allegedly walked up to (R11) and hit him in the back. Residents separated immediately for safety precautions. Statements obtained by various employees and residents that may have witnessed alleged incident. Statements obtained by both involved residents to gather further information. (Physician), Power Of Attorney, (Local) Police Department contacted and informed of alleged incident. The (Local) Police Report for the incident between (R11) and (R12) documents, On 4/1/23 I received a call from the (facility) Charge Nurse (V12/Licensed Practical Nurse). (V12/LPN) stated she wanted to report an assault that occurred at about 12:15 PM between two residents (R11) and (R12). V12/LPN stated that she did not see the assault and was informed only. V12/LPN stated that (R11) was walking in the hallway and was struck in the lower back by (R12). (V12/LPN) stated that (R12) punched (R11) in his lower back with a closed fist. (V12/LPN) stated both residents were separated and returned back to their rooms without further incident. No arrests associated with this incident. On 5/2/23 at 1:08 P.M., (V11/Physical Therapy Assistant) stated on (4/1/23) she and (R12) were seated in the foyer doing seated exercises and (R11) walked past (R12), stopped and mumbled something and (R12) reached out and hit (R11) in the back, one time. (V11/PTA) further states both residents were immediately separated and returned to their rooms. (V11/PTA) states she immediately reported the incident to the charge nurse. On 5/2/23 at 1:58 P.M., V2/Assistant Administrator In Training verified the facility did not notify the State Agency of the final investigation of the incident from 4/1/23.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to investigate timely an allegation of potential sexual abuse and failed to ensure an alleged victim was protected from further abuse during the investigation for four of 20 residents (R1, R7, R8, R16) reviewed for abuse, in a sample of 20. This had the potential to affect all 118 residents residing in the facility. FINDINGS INCLUDE: The facility policy, Abuse Prevention Program, dated (revised) 11/28/2016 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation. This will be done by immediately protecting residents involved in identified reports of possible abuse, implementing systems to investigate all reports of possible abuse. 1. On 5/2/23 at 10:00 a.m., R1 was sitting outside smoking. R1's 1:1 staff member, V17 (unit aide), was watching her through the window from inside of the facility. V17 stated, I have never witnessed a physical altercation with (R1) until today. (R1) gets verbally aggressive a lot with other residents. Today (R1) and (R16) got verbal with each other and (R1) started calling (R16) a b**ch then he slapped her a few times in the face. On 5/3/23 at 12:20 p.m., V17 stated, (R1) and (R16) had two incidents yesterday. The one where (R16) slapped (R1) across the face in the morning, and then in the afternoon they had a verbal altercation. Right after (R16) hit (R1), (V1 Administrator in Training) came up on the commotion. (R16) went off on (V1). He started yelling and cussing at her. I didn't notify anyone about what happened because (V1) told me she had it all taken care of. Around 1:15 p.m., (R1) sat next to (R16). I asked her to not sit there and we could sit somewhere else, and she refused to move. She reached over and touched (R16's) hair, and he said, 'Keep your f**king hands off of me.' (R1) wouldn't move so I asked (R16) if he would move, and he told me, 'White lady you aren't going to tell me what the f**k to do. On 5/3/23 at 12:10 a.m. V22 Registered Nurse stated that R16 is able to independently ambulate throughout the entire facility. On 5/3/23 at 2pm, V1 (Administrator in Training) confirmed that she was notified of R1 and R16's two incidents by V17. On 5/4/23 at 11:35 a.m., V1 confirmed that an investigation was not started immediately after the incidents on 5/2/23 between R1 and R16. The facility's Room Roster, dated 5/1/23, documents that 118 residents reside in the facility. 2. R7's (May 2023) Physician Order Sheet documents that R7 was admitted to the facility on [DATE] with the following diagnoses: Schizoaffective Disorder, Bipolar Type and Moderate Intellectual Disabilities and Depression. The facility State Agency Form, dated 4/12/2023 documents, Resident to resident sexual allegation. Residents separated immediately. Investigation initiated. 5 day to follow. On 5/1/2023 at 12:45 P.M., R7 verified (R8) was his roommate for awhile. When questioned if episodes of (R8) placing his mouth on (R7's) genitals happened often, R7 verified, frequently. When asked if he had reported this to facility Management at any time, (R7) verified, Once. (R7) then returned to his noon meal and would not answer further questions. On 5/1/2023 at 1:26 P.M., V13/Social Services stated, (On) April 11th (2023) (the facility) held a resident council meeting, afterwards (R7) came to me and said he wanted to talk to me about his roommate (R8). (R7) told me (R8) would pull the room curtain, so that no one could see him if they opened the door, and would place his mouth on (R7's) genitals. (R7) told me it had been happening for a while and it had happened again last night (4/10/23). (R7) said he wanted it to stop. I went straight to (V1/Administrator in training) after (R7) told me about it and made her aware. I don't know if (V1/Administrator in training) called the Police. I interviewed (R8) on 4/12/23 and he told me the allegation was untruthful. On 5/1/2023 at 1:01 P.M., R8 stated that he and (R7) were roommates for about a year and recently staff asked him to move without giving him a reason why. States he and (R7) enjoyed watching television together and he liked helping (R7) with his wheelchair. When asked if he and (R7) had a sexual relationship, R8 stated no, they were just friends. On 5/1/2023 at 1:55 P.M., V1/Administrator in training stated V3/Director of Nurses told her about the incident on April 12th (2023) and she started an investigation then. She stated she did notify the Police. On 5/2/2023 at 12:08 P.M.,V3/Director Of Nurses stated she became aware of the situation of R7 accusing R8 of potential sexual assault on April 13th (2023). V3/DON further states they (V3 and V13/Social Services) went to V1/Administrator in training immediately and reported the incident. V3 stated they moved (R8) (out of the same room as R7) on that day, too. R8's (facility) Census Report documents, 4/12/23 C-Wing room [ROOM NUMBER]-1 and on 4/13/2023 C- Wing room [ROOM NUMBER]-1. On 5/2/2023 at 1:15 P.M., V13/Social Services stated, I became aware of R7's concerns (of potential sexual abuse against R8) on 4/11/23 right after the Resident Council Meeting. R7 came up to me and said he needed to talk to me about (R8). Notes provided by the facility document that the monthly Resident Council Meeting was held on 4/11/23, with R7 in attendance.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to provide sufficient social services staff to meet the behavioral needs of the residents. This has the potential to affect all 118 residents residing in the facility. Findings include: The Facility Assessment, dated 4/20/21, documents, The facility provides services to patients having a variety of mental health illnesses as well as medical needs. Resident support/care needs: Mental health and behavior: Manage the medical conditions and medication related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. The Assessment also documents, We are dedicated to assisting the elderly population in maintaining the highest possible quality of life. We believe that all aspects of a person must be considered physical, mental, spiritual and social, when assessing and providing care for all individuals. Facility 5 Day Final Report, dated 4/28/23, documents, Original complaint: It was reported on 4/25/23 that while in the common areas R16 allegedly called R1 a b**ch and told her she needed to go home. Residents will be offered 1:1 time with social services once a week for 3 weeks. A facility 5 day final report, dated 5/1/23, documents, It was reported on 4/26/23 that R1 and R15 allegedly exchanged curse words with one another. R1 became upset and allegedly spit on R15. R1 still remains on 1:1 supervision. Residents will be offered 1:1 time with social services once a week for three weeks. R1's Care plan, dated 5/1/23, documents, R1 has potential to be physically aggressive related to Bipolar and TBI with poor impulse control. The care plan also documents the following intervention: R1 was called a 'b**ch ' and told to go home by another resident. Offered 1:1 time with social services once a week for three weeks. Still remains on 1:1 supervision. A facility Five Day Final Report, dated 5/2/23, documents, It was reported on 4/27/23 that during an afternoon smoke pass R4 had touched R1. At that time R1 was spitting everywhere and allegedly spit on R4. R4 states she just reacted and allegedly hit her. Residents will be offered 1:1 time with social services once a week for three weeks. On 5/2/23 at 1:30 p.m., R17 was observed propelling himself towards V1's (Administrator in Training) Office. R17 was bleeding from his mouth and his right hand was actively bleeding. At that time R17 stated, He (R16) punched me in the mouth. All I was doing was trying to help him open his ice cream. On 5/2/23 at 1:40 p.m. V13 (Social Services) stated, A lot of the incidents occur in the evening when I'm not here. I haven't been documenting the 1:1 sessions because I haven't been doing them. With it just being me I can't do everything that we need social service wise. We aren't able to have group sessions. I used to be able to do it when there was three social services (staff) and the residents loved it. V13 confirmed that there was no documentation of 1:1 group sessions occurring. On 5/2/23 at 2:47 p.m., V18 (CNA-Certified Nursing Assistant) stated, (V13) is only one person and she can't provide all of the social services that these people need. On 5/3/23 at 11:50 a.m., V21 CNA stated, When we had more Social Service staff the behaviors weren't as bad. With only (V13) there is too much going on that she isn't able to do counseling or group sessions. On 5/4/23 at 11:35 a.m., V1 (Administrator in Training) stated, No we don't have social service programming going on. The social service program is broke down right now we don't have the staff. (V13 Social Service) is doing one on one meetings with some of the residents that are involved with these incidents. The intervention was the 1:1 session. (V13) was informed that she was supposed to begin them, and she told us she was. What am I supposed to do when I ask (V13 Social Services) if she is doing them, but then I find out she isn't doing them. The 1:1 sessions should be going on. The facility's Room Roster, dated 5/1/23, documents that 118 residents reside in the facility.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer a resident's physician ordered medication for one of three residents (R1) reviewed for medication administration in the sample of three. Findings include: The facility's Medication Administration Policy dated 11-18-17 documents, Document any medications not administered for any reason by circling initials and documenting on the back of the MAR (Medication Administration Record) the date, the time, the medication and dosage, and reason for omission and initials. If the medication is not available for the resident, call the pharmacy and notify the physician when the drug is expected to be available. Notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason. Report errors in medication administration immediately per policy. R1's Hospital Discharge summary dated [DATE] documents, A [AGE] year old male with Discharge Diagnoses: POTS (Postural Orthostatic Tachycardia Syndrome), self-catheterizes urinary bladder, Suicidal Ideation, Pott's Disease (Spinal Tuberculosis), Major Depression, PTSD (Post Traumatic Stress Disorder), Somatic Symptom Disorder, and Marijuana Use. This same Summary documents, History of suicidal attempts/self injury: Ten times-overdose, hanging, cutting wrist. R1's Physician's Order Sheets dated 4-1-23 through 4-30-23 document the following order: Emgality 120 mg/ml (milligram/mililiter) one ml subcutaneously every month given on the 10th of the month for Headache;Migraine, Gabapentin 400 mg two capsules in the morning for Pain, Gabapentin 400 mg three capsules at bedtime for Pain, Magnesium Oxide 400 mg at bedtime for Pain, Paroxetine HCL 30 mg two tablets daily for Major Depressive Disorder, Prazosin two mg at bedtime for Hypertension, Senexon-S 50-8.6 mg two at bedtime every other day for Constipation, Zaleplon 10 mg two capsule at bedtime for Insomnia, Ampicillin 100 mg two times daily for infection, Hydroxyzine HCL 50 mg two times daily for Anxiousness, Topiramate 100 mg two times daily for Headache, Butalb/Acet/Caff (Butalbital-acetaminophen-caffeine) 50-325-40 three times daily for headache, Pregabalin 50 mg three times daily for Pain, Hydroxyzine HCL 25 mg as needed for headaches three times daily, Hydroxyzine HCL 50 mg every six hours as needed for Anxiety, Melatonin 3 mg two tabs as needed for sleeplessness at bedtime, Ondansetron 4 mg every 8 hours as needed for Nausea and Vomiting, Oxycodone 5 mg as needed for Pain three times daily, Promethazine 25 mg two tablets every 12 hours as needed for sleeplessness related to Insomnia. R1's Medication Administration Record (MAR) dated 4-1-23 through 4-30-23 documents R1 did not receive his Hydroxyzine 50 mg on 4-4-23 at 9:00 PM, 4-5-23 at 9:00 PM, 4-6-23 at 9:00 AM and 9:00 PM, and 4-8-23 at 9:00 AM and did not receive any Hydroxyzine as needed on any of these days. The Hydroxyzine was signed out as given on 4-5-23 at 9:00 AM, and 4-8-23 as scheduled at 9:00 AM and 9:00 PM although the medicine was not available at the any of those times. This same MAR documents R1 received his Emagality one ml subcutaneously on 4-10-23, Although this was actually given to R1 on 4-13-23 (three days late). R1's Nurse's Notes dated 4/4/23 and signed by V22/LPN (Licensed Practical Nurse documents, Hydroxyzine HCL 50 MG TABLET Give 1 tablet orally two times a day for anxiousness not available. R1's Nurse's Notes dated 4/6/2023 at 8:18 PM and signed by V23/LPN documents, HYDROXYZINE HCL 50 MG TABLET Give 1 tablet orally two times a day for anxiousness. Resident does not have medication in stock at this time. Last reorder for medication was 3/24/23. Resident states he has not received medication since Sunday. R1's Nurse's Notes dated 4/8/2023 at 9:49 AM and signed by V24 (RN/Registered Nurse) Medication ordered in PCC (Point Click Care). Note on refill informing pharmacy that resident is out of medication. Will call and follow up with pharmacy to ensure they received order. R1's Nurse's Notes dated 4/8/2023 at 10:48 AM and signed by V24 documents, HYDROXYZINE HCL 50 MG TABLET Give 1 tablet orally two times a day for anxiousness. Medication not available. Pharmacy/physician notified. Resident aware. Will continue to monitor On 4-12-23 at 10:50 AM R1 was lying in bed. R1 stated, I have been here for about two and one half months. I don't get my medications on time and sometimes not at all. I need my medications. I have migraines and other issues that I can't deal with if I don't get my medications. On 4-14-23 at 9:20 AM, R1 stated, I have asked for my migraine injection for days and the nurses keep telling me they will look in to it but never have. I make them aware again this morning and now they said they would give it to me soon. I shouldn't have to keep asking for my medicines, I only get this medication once a month. I have not got any migraines yet without it but I don't want too either. On 4-14-23 at 9:34 AM, V2 (DON/Director of Nursing) came into R1's room and gave R1 his Emgality injection in the right arm. V2 stated, yes this should have been given on the 10th not the 14th. On 4-14-23 at 1:00 PM, V1 stated, I can't find a pharmacy Policy but we do have back up. If a resident does not have any of their medications and the pharmacy is not due to delivery them at the time they are needed we can order them STAT (urgent) and back up pharmacy will deliver them within two hours. None of the residents should have to go without their medications with this process in place. On 4-17-23 at 11:00 AM, V20 (R1's Physician) stated, No I was not aware of (R1) not receiving his medications of Hydroxyzine or his Emgality being given four days late. (R1) is a very anxious patient and I should have been aware of him not receiving his medications timely. I don't condone the nurses' not ordering medications and making sure the medications are there and given when scheduled. On 4-17-23 at 10:41 AM, V21 (Dispensing Pharmacist) stated, The facility did not re- order (R1's) Hydroxyzine until 4-8-23 and (R1's) Emgality injection was delivered to the facility on 3-20-23 for (R1's) April Injection. V21 also stated, We send refills out every evening but if the resident runs out of medications and needs them before that night we use a back up pharmacy they call and will receive the medications right away. Residents never have to go without their medications the way we have it set up.

Feb 2023 21 deficiencies 4 IJ (2 facility-wide)

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0692 (Tag F0692)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident (R20), who is non-verbal, received gastrostomy tube (g-tube) feedings for adequate nutritional intake as ordered by the physician, implement dietician recommendations to prevent further weight loss, obtain daily weights, and document dietary meal intakes to prevent significant weight loss for three of four residents (R1, R5, R20) reviewed for weight loss in the sample of 25. As a result of this failure R20 went nine days without receiving any type of nutritional intake causing her emotional/psychological distress as well as pain related to hunger pains. R20 has also lost 20 lbs (11.4% weight loss) since R20 was admitted on [DATE] (five months). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 2/23/23, the facility remained out of compliance at a Severity Level 2. The facility is ensuring all in-house licensed staff and QAT (Quality Assurance Team) members are educated on administering g-tube feedings, processing physician's orders, notifying the physician of dietician recommendations and a resident not receiving scheduled g-tube feedings. The facility is also ensuring that all licensed staff are educated on who to contact when needing g-tube feeding equipment that is not available within the facility, g-tube feeding pump safety, procedures during an emergency with a g-tube, and proper handling of g-tube equipment. Also, the facility is reviewing all of the residents for weight loss to ensure the physician and dietician were notified of any significant weight losses. As well as developing a system to audit the g-tube feeding formulas ordered and used. Findings include: The facility's Resident Weight Monitoring policy, dated 9/08, documents, If there is an actual significant weight change, the resident, family/guardian, physician, and dietitian are notified. The date of notification for physician and family/guardian is documented on the Report of Monthly Weight form. The Food Service Manager and/or dietician reviews the resident's nutritional status and makes recommendations for intervention in the nutrition progress notes. The Food Service Manager and/or dietitian notify nursing of any recommendations that have been documented. Nursing then contacts the physician to convey recommendations and obtain any new orders. Significant unplanned weight changes are reviewed in the weekly Weight Committee Meeting. The Weight Committee will also identify any gradual weight loss or gain trends. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. The facility's Therapeutic & Mechanically Altered Diets policy, dated 4/06, documents, It is the policy of the facility that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietician. A therapeutic diet is a diet ordered to manage problematic health conditions. Examples include caloric specific, low-salt, low-fat, low lactose, no sugar added, and supplements during meals. The policy also documents, A physician's order is written for all diets including therapeutic and mechanically altered diets. All physician ordered diets are planned in writing. Portion sizes are evident for each item on the menu extensions. The facility prepares and serves all therapeutic and mechanically altered diets as planned. The facility's Enteral Tube Feeding Bolus Procedure policy, no date available, documents, It is the policy of the Facility to provide nutrition via Nasogastric or Gastrostomy tubes when ordered by physician. The resident may receive nutrition and hydration either by intermittent, continuous, or bolus feeding into the stomach by means of a tube when the oral route cannot be used. The policy also documents, Report unusual observations/findings to the physician. Report observations regarding feeding tolerance to the dietician. Document information related to feeding on flow record and/or TAR (Treatment Administration Record)/MAR (Medication Administration Record). 1. On 2/6/23 at 2:00 p.m., R20 was lying in her bed on her right side with her eyes open. When spoken to she lifted her head, made eye contact and laid back down without responding. On 2/6/23 at 3:30 p.m., R20 was partially sitting up in bed with a flat affect and no verbalization. Questions asked to R20. R20 did not respond verbally. However, did respond at times with a thumbs up or thumbs down partially, but it was hard to understand her response. R20 became frustrated and laid back down facing the wall. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's admission weight on 8/6/22 was 176 lbs (pounds). R20's Physician's orders, dated 8/22, documents that R20 was admitted on [DATE] with an order to receive Jevity 1.2 237 ml (milliliters) via gastrostomy tube every three hours. R20's Dietitian Nutritional Assessment, dated 8/19/22, documents, (R20) admitted on regular finger food diet with thin liquids and chopped meats. Tube feeding order of Jevity 1.2 237 ml via gastrostomy tube every three hours for 24 hours if (R20) eats less than 50%. 60 ml FWF (Free water flush) before and after feedings. Tube feeding order provides 2275 kcals/day, 105 g (grams) protein/day and 1530 FW/day. FWF provides 960 ml FW (Free Water)/day. No intakes available for review at this time. CBW (Current Body Weight) 176 lbs. Weight trending down since admission. (R20's) meeting estimated fluid and kcal requirements with current tube feed order. Tube feed order provides above protein needs. Nurse reports encouraging resident to eat without success. (R20) is eating 0%. Tube feeding order fully utilized due to 0% intakes. Continuous feed not appropriate at this time due to (R20) attempts to elope. Recommend weekly weights. Monitor weight, intake, medications, labs, skin integrity, tube feeding tolerance. R20's Dietary Services Communication, dated 8/22/22, documents, Observations: Tube feeding to hold if GRV (Gastric Residual Volume) is greater than 100 ml. Aspen Guidelines state hold if tube feeding GRV is greater than 500 ml. Dietary Recommendations: Recommend discontinue current GRV order. Recommend hold tube feeding if GRV is greater than 500 ml. Recommend weekly weights. The communication also documents that R20's physician acknowledged and approved the recommendation. R20's MAR (Medication Administration Record), dated 8/6-8/30/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 8/7 - 6:00 p.m., 3:00 a.m.; 8/8 - 6:00 p.m., 3:00 a.m.; 8/9 - 3:00 a.m.; 8/10 - 6:00 p.m., 9:00 p.m., 3:00 a.m.; 8/11 - 6:00 a.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 8/12 - 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 8/13 - 3:00 a.m.; 8/14 - 6:00 a.m., 12:00 p.m., 12:00 a.m., 3:00 a.m.; 8/15 - 6:00 a.m.; 8/16 - 12:00 a.m., 3:00 a.m.; 8/18 - 9:00 p.m.; 8/19 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 8/20 - 6:00 p.m.; 8/22 - 9:00 p.m.; 8/25 - 9:00 a.m., 3:00 p.m., 6:00 p.m. 9:00 p.m.; 8/30 - 6:00 p.m.; 8/31 - 9:00 p.m. for a total of 36. R20's TAR (Treatment Administration Record), dated 8/6/22-8/31/22, documents that R20 is to be a daily weight. However, during the time span of 8/6-8/31 only one weight was obtained on 8/29/22. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 9/22 weight was 170 lbs (6 lbs 3.4% weight loss in one month). R20's Dietary Notes, dated 9/21/22 and signed by V40 (Registered Dietician), document, CBW 170 lbs. Gradual weight loss since admission. Regular pureed diet with thin liquids. 0% intakes recorded for three meals. Tube feeding order of Jevity 1.2 237 ml via gastrostomy tube every three hours for twenty four hours if less than 50% intakes. 60 ml FWF plus tube feeding order plus FW provides 2275 kcals/day, 105 g protein/day, 2490 FW a day. R20 meeting estimated kcal and fluid requirements with current tube feeding order. R20 tolerating tube feedings per nursing notes. Nurse reports R20 drinks but does not eat anything as per above. V40 recommendations for GRV signed last month; per nurse. Tube feeding not be held due to GRVs. Continuous feed would be appropriate overnight due to R20 receives 1:1 care. Continuous feed may assist with weight control. Recommend Jevity 1.2 at 150 ml/hour for twelve hours overnight with 200 ml FWF three times a day during feedings. Tube feeding provides 1800 ml volume/day, 2160 kcals/day, 99.9 g protein per day, 1453 FW per day. 200 ml FWF three times a day provides 600 ml FW per day. New tube feeding recommendations meet estimated nutrient needs. Monitor weight intake, medications, labs, skin integrity, tube feeding tolerance, tube feeding order. R20's Dietary Services Communication, dated 9/21/22 and signed by V40, documents, Observations: Nurse requests continuous feed for tube feeding. Gradual weight loss. Recommendations: Recommend Jevity 1.2 at 150 ml/hr for 12 hours overnight with 200 ml FWF three times a day during feedings. The communication also documents that the physician acknowledged and approved the recommendation on 10/20/22. R20's current medical record has no documentation of V40's 9/21/22 recommendation being followed through with until signed by the physician on 10/20/22. R20's MAR, dated 9/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 9/1 - 6:00 p.m.; 9/6 - 6:00 p.m., 9:00 p.m.; 9/7 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 9/8 - 9:00 p.m.; 9/10 - 9:00 p.m.; 9/11 - 12:00 a.m., 3:00 a.m.; 9/12 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/14 - 9:00 p.m.; 9/19 - 6:00 p.m.; 9/20 - 6:00 p.m., 9:00 p.m.; 9/21 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 12:00 a.m., 3:00 a.m.; 9/22 - 6:00 p.m.; 9/23 - 6:00 p.m.; 9/24 - 6:00 p.m.; 9/25 - 6:00 p.m., 9:00 p.m.; 9/26 - 12:00 a.m., 3:00 a.m.; 9/27 - 6:00 p.m.; 9/28 - 6:00 p.m.; 9/29 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/30 - 6:00 a.m. for a total of 40. R20's TAR, dated 9/22, documents that R20 is to be weighed daily as of 9/6/22 and there is no documentation of a weight being obtained on the following dates: 9/7, 9/15-9/17, 9/19-9/25, 9/29-9/30. R20's Food & Fluid Intake Sheet, 9/22, documents that R20 refused the following meals: 9/23 lunch, 9/24 breakfast & lunch, 9/26 breakfast, 9/30 breakfast & lunch. The sheet also zero documented for intake on the following meals: 9/1-9/2 all three meals, 9/4 all three meals, 9/6-9/7 all three meals, 9/8 supper, 9/10 all three meals, 9/14 supper, 9/15-9/16 all three meals, 9/25 lunch, and it has no documentation for R20's intakes on the following days: 9/3 all three meals, 9/5 all three meals, 9/8 breakfast & lunch, 9/9 all three meals, 9/11-9/13 all three meals, 9/14 breakfast & lunch, 9/17-9/19 all three meals, 9/20 breakfast & lunch, 9/21-9/22 all three meals, 9/23 breakfast & supper, 9/24 supper, 9/26 supper, 9/27-9/29 all three meals, and 9/30 supper. R20's Nurses' notes, dated 9/27/22 at 12:00 p.m., document, R20 continues to yell out and it is very difficult to understand her needs. Seems to be in pain. This date is also date in which there is no documentation of R20 receiving a scheduled g-tube bolus. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 10/22 weight was 160 lbs (10 lbs 5.9% weight loss in one month). R20's Dietary notes, dated 10/18/22 and signed by V40, document, CBW 163 lbs. Gradual weight loss for 30 days noted. Tube feeding order of Jevity 1.2 237 ml via gastrostomy tube every three hours for twenty four hours if less than 50% intakes. Tube feeding order plus FW provides 2275 kcals/day, 105 g protein/day, 2490 FW a day. R20 meeting estimated kcal requirements; however, receiving above protein and fluid requirements with current tube feeding order. Extra protein may be appropriate due to failure to thrive diagnosis and continued weight loss. 0% PO (by mouth) intakes recorded for three meals. V28 (Dietary Manager) confirms little to no intakes as per above. Continuous feed may assist with weight control as per previous. Recommend Jevity 1.2 at 150 ml/hour for twelve hours overnight with 200 ml FWF three times a day during feedings and 30 ml FWF twice a day before and after medications. New tube feed order provides 1800 ml volume/day. 2160 kcals/day, 99.9 g protein/day, 1453 ml FW/day. New tube feed order meets estimated nutrient needs. R20's Dietary Services Communication, dated 10/18/22 and signed by V40, documents, Observation: Gradual weight loss for 30 days. Tube feed bolus. Recommendations: Recommend Jevity 1.2 at 150 ml/hr for 12 hours overnight with 200 ml FWF three times a day during feedings and 30 ml FWF twice a day before and after medications. The communication also documents that the doctor acknowledged and approved the recommendation on 10/20/22. R20's Physician's orders, dated 10/22, document that R20 received an order on 10/20/22 for Jevity 1.2 at 150 ml/hr for 12 hours overnight with a 200 ml flush three times during feedings and a 30 ml flush twice a day before and after medications. R20's MAR, dated 10/22, has no documentation of R20 receiving her Jevity 1.2 237 ml every three hour bolus on the following dates/times: 10/1 - 3:00 p.m., 3:00 a.m.; 10/6 - 9:00 p.m.; 10/7 - 6:00 p.m.; 10/9 - 9:00 p.m.; 10/12 - 9:00 p.m.; 10/13 - 9:00 p.m., 12:00 a.m.; 10/16 - 9:00 p.m.; 10/17 - 6:00 p.m., 12:00 a.m., 3:00 a.m.; 10/27 - 12:00 a.m., 3:00 a.m.; 10/28 - 9:00 p.m., 10/29 - 9:00 p.m.; 10/30 - 12:00 p.m., 9:00 p.m.; 10/31 - 9:00 p.m. for a total 19. R20's MAR also documents that R20's order to receive Jevity 1.2 at 150 ml/hr overnight with 200 ml FWF three times a day during feedings was not started until 10/27/22 and there is no documentation of R20 receiving the overnight feeding on 10/29 or 10/30. The as needed medication information page of R20's MAR also documents that R20 received as needed Tramadol 50 mg for yelling out/symptoms of pain twice on 10/9, 10/17, 10/27, 10/29, and 10/30 which were also days that R20 has no documentation of receiving scheduled g-tube boluses. R20's Food & Fluid Intake Sheet, 10/22, documents that R20 had zero for intake on the following meals: 10/1-10/5 all three meals, 10/6 breakfast & lunch, 10/9-10/10 all three meals, 10/11 supper, 10/13 all three meals, 10/15 breakfast, 10/17 all three meals, 10/20 supper, 10/21-10/22 all three meals, 10/25 supper, 10/28 breakfast, 10/29 breakfast & lunch, 10/30 supper, 10/31 breakfast & lunch, and it has no documentation for R20's intakes on the following days: 10/6 supper, 10/7-10/8 all three meals, 10/11 breakfast & lunch, 10/12 all three meals, 10/14-10/15 lunch & supper, 10/16 all three meals, 10/18-10/19 all three meals, 10/20 breakfast & lunch, 10/23-10/24 all three meals, 10/25 breakfast & lunch, 10/26-10/27 all three meals, 10/28 lunch & supper, 10/29 supper, 10/30 breakfast & lunch, 10/31 supper. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 11/22 weight was 161 lbs (15 lbs 8.5% weight loss in three months). R20's MAR (Medication Administration Record), dated 11/22, documents that R20 was to receive Jevity 1.2 for twelve hours overnight at a rate of 150 ml/hr being turned on at 8:00 p.m. and turned off at 8:00 a.m. The MAR has no documentation of R20 being administered the feeding on 11/3, 11/5, 11/6, and 11/9 as well as 11/1, 11/2, 11/7, 11/8 were circled as R20's tube feeding was not administered. In the same section that this tube feeding is signed off is a handwritten statement, On hold; pending discontinue - R20 doesn't remain still. The MAR documents that R20 was restarted on Jevity 1.5 237 ml bolus every three hours on 11/9 at 12:00 p.m. There is no documentation of R20 receiving the bolus on the following dates/times: 11/9 - 12:00 a.m. & 3:00 a.m.; 11/10 - 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/12 - 9:00 p.m.; 11/13 - 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/14 - 12:00 a.m., 3:00 a.m.; 11/15 - 9:00 p.m., 11/16 - 6:00 a.m., 12:00 a.m., 3:00 a.m., 11/17 - 6:00 p.m.; 11/18 - 6:00 a.m., 6:00 p.m.; 11/19 - 6:00 p.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 11/20 - 6:00 p.m.; 11/21 - 6:00 p.m.; 11/22 - 6:00 a.m.; 11/24 - 6:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/25 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m.; 11/26 - 3:00 p.m.; 11/27 - 6:00 a.m., 6:00 p.m.; 11/29 - 3:00 p.m., 6:00 p.m. for a total of 41. The as needed medication information page of R20's MAR also documents that R20 received as needed Tramadol 50 mg twice on 11/5, twice on 11/6, and once on 11/9 for yelling out/symptoms of pain which were also days that R20 has no documentation of receiving any type of g-tube feeding. R20 also received the as needed Tramadol on 11/18, twice on 11/19, twice on 11/20, and on 11/25 which were days that R20 has no documentation of receiving scheduled g-tube boluses. R20's Psychiatric Nurse Practitioner Progress note, dated 11/8/22, documents, Assessment & Plan: Anorexia. R20's Physician notification form, dated 11/9/22, documents, R20 has gastrostomy tube and was ordered for 12 hour of Jevity 1.2 at 50 ml/hr. R20 does not remain still and is constantly getting up and walking halls. Unsafe to be hooked to machine for any length of time. Please consider returning to bolus feeds of Jevity 1.5 237 ml every three hours. The form also documents the physician's order to refer to dietician for orders. R20's current medical record has no documentation of V40 being notified regarding R20's continuous tube feeding being discontinued and boluses started. R20's Dietary Notes, dated 11/16/22 and signed by V40, document, CBW 161 lbs. Significant weight loss noted: 8.5% in 90 days. Tube feeding order of Jevity 1.2 237 ml bolus every three hours via gastrostomy tube with 60 ml FWF before and after feedings and 30 ml FWF twice a day before and after medications. Resident meeting estimated kcal and protein needs with current tube feeding order. Resident receiving above estimated fluid needs. Nurse reports continuous feed discontinued due to resident does not stay in bed for long periods of time throughout the night. Per nurse resident is tolerating feeds at this time. Recommend decrease flushes to 40 ml before and after feedings to provide 2290 ml FW/day. Meeting estimated fluid needs. Recommend 60 ml high calorie supplement twice a day by mouth to assist with weight control. R20's Physician's orders nor MAR, dated 11/22, have any documentation of V40's 11/16/22 recommendation being followed through with. R20's Food & Fluid Intake Sheet, 11/22, documents that R20 refused the following meals: 11/3 all three meals, 11/4-11/5 breakfast & lunch, 11/7 breakfast & lunch, 11/8 supper, 11/9 all three meals, 11/10-11/12 breakfast & lunch, 11/19 all three meals, 11/24 all three meals, 11/26 breakfast & lunch, 11/28 breakfast & lunch, and 11/29 supper. The sheet also has no documentation for R20's intakes on the following days: 11/1 breakfast & lunch, 11/2 all three meals, 11/4-11/5 supper, 11/6 all three meals, 11/7 supper, 11/8 breakfast & lunch, 11/10-11/12 supper, 11/13-11/18 all three meals, 11/22-11/23 all three meals, 11/25 all three meals, 11/23 supper, 11/27 all three meals, 11/28 supper, 11/29 breakfast & lunch, and 11/30 all three meals. R20's Behavior tracking, no date available however V1 verified on 2/16/23 this was R20's 11/22 behavior tracking, documents that R20's target behavior is Inappropriate Behavior. The tracking also documents that R20 exhibited this behavior continuously on 1st shift of 11/5-11/8, 11/12, 11/14-11/15, and 11/19-11/21. 11/5-11/8/22 were four days that the facility has no documentation of R20 receiving any type of g-tube feeding. There is also no documentation of R20 receiving scheduled bolus doses on 11/14, 11/15, 11/19 and 11/20/22. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 12/22 weight was 157 lbs (4 lbs in one month, 13 lbs 7.6% weight loss in three months). R20's Dietary notes, dated 12/13/22 and signed by V40, documents, CBW 157 lbs. Significant weight loss noted: 7.65% in 90 days. Weight trending down in 30 days. Refusals documented for three meals. Tube feeding order of Jevity 1.2 237 ml bolus every three hours via gastrostomy tube with 60 ml FWF before and after feedings and 30 ml FWF twice a day before and after medications. Resident meeting estimated kcal and protein requirements with current tube feeding order. Recommend: 90 ml high calorie supplement twice a day due to continued weight loss. Discussed continued weight loss with Director of Nursing who would like to trial bolus feeds four times a day. Recommend Jevity 1.2 474 ml bolus four times a day with 40 ml FWF before and after feedings and 30 ml FWF twice a day before and after medications. Meets estimated nutrient needs. R20's Dietary Services Communication, dated 12/14/22 and signed by V40, documents, Observations: Tube feeding. 7.65% weight loss in 90 days. Recommendations: Jevity 1.2 474 ml bolus four times a day with 40 ml FWF before and after feedings and 30 ml FWF before and after medications. 90 ml high calorie supplement twice a day. The communication also documents that R20's physician acknowledged and approved the recommendation. R20's MAR, dated 12/22, has no documentation of R20 receiving her Jevity 1.5 237 ml every three hour bolus on the following dates/times: 12/3 - 6:00 a.m., 6:00 p.m.; 12/4 - 3:00 p.m., 6:00 p.m.; 12/7 - 9:00 p.m.; 12/13 12:00 a.m., 3:00 a.m.; 12/17 - 6:00 a.m., 6:00 p.m., 9:00 p.m.; 12/19 - 6:00 p.m.; 12/21 - 6:00 p.m., 9:00 p.m.; 12/22 - 9:00 p.m.; 12/26 - 3:00 p.m. for a total of 15. R20's MAR also has no documentation of R20 receiving 60 ml of high calorie supplement twice a day nor the 12/13/22 recommendations of 90 ml of high calorie supplement twice a day due to continued weight loss. The as needed medication information page of R20's MAR also documents that R20 received as needed Tramadol 50 mg twice on 11/5, twice on 11/6, and once on 11/9 for yelling out/symptoms of pain which were also days that R20 has no documentation of receiving any type of g-tube feeding. R20 also received the as needed Tramadol on 11/18, twice on 11/19, twice on 11/20, and on 11/25 which were days that R20 has no documentation of receiving scheduled g-tube boluses. R20's TAR, dated 12/22, documents that R20 should be daily weights, however there is no documentation of any weights obtained for the month of December. R20's Food & Fluid Intake Sheet, 12/22, documents that R20 refused the following meals: 12/1-12/2 all three meals, 12/3 supper, 12/4 breakfast & lunch, 12/5 all three meals, 12/6 breakfast & lunch, 12/17 breakfast & lunch, 12/18 all three meals, 12/19-12/20 breakfast & lunch, 12/22 breakfast & lunch, 12/27 breakfast, 12/20 breakfast & lunch, 12/31 all three meals. The sheet also has no documentation for R20's intakes on the following days: 12/3 lunch, 12/4 supper, 12/6 supper, 12/7-12/10 all three meals, 12/11 supper, 12/12-12/13 all three meals, 12/14 lunch & supper, 12/15 all three meals, 12/16-12/17 supper, 12/19-12/20 supper, 12/21 all three meals, 12/22 supper, 12/23-12/26 all three meals, 12/27 lunch & supper, 12/28-12/29 all three meals, and 12/31 supper. R20's TAR, dated 1/23, documents that R20 is to be weighed on a daily basis, however no weights are documented for 1/1-1/4. R20's most recent weight documented was 156 lbs (weight loss of 11.4% since admission-five months) on 1/19/23, and then this order was discontinued on 1/20/23. R20's Dietary Services Communication, dated 1/19/23 and signed by V40, documents, Observation: Tube feeding assessment. Dietary recommendations: Jevity 1.5 375 ml bolus four times a day with 90 ml FWF before and after feedings and 30 ml FWF before and after medications. The communication also documents that R20's physician acknowledged and approved the recommendation on 1/20/23. R20's MAR, dated 1/23, documents from 1/7-1/20 R20 had an order to receive Jevity 1.2 474 ml bolus four times a day, and there is no documentation of R20 receiving the bolus on 1/11 at 6:00 a.m. and 12:00 a.m. The MAR also documents that this order was discontinued on 1/20/23 and Jevity 1.5 375 ml bolus four times a day was started. There is no documentation of R20 receiving that bolus on 1/21 at 6:00 p.m. or 1/30 at 12:00 p.m. Also, R20's dietician recommendation to initiate 90 ml of high calorie supplement twice a day was started on 1/7/23, however it was discontinued on 1/20/23. R20's Medical record has no documentation of an order to discontinue R20's 90 ml of high calorie supplement twice a day on 1/20/23. R20's Food & Fluid Intake Sheet, 1/23, documents that R20 refused the following meals: 1/1 all three meals, ½ breakfast & lunch, 1/3 all three meals, 1/5 breakfast & lunch, 1/6 lunch, 1/7-1/8 supper, 1/9 all three meals, 1/10 breakfast, 1/11 breakfast & supper, 1/12 breakfast, 1/13 all three meals, 1/14-1/15 breakfast, 1/16 breakfast & lunch, 1/17-1/19 breakfast, 1/20 all three meals, 1/21 breakfast & lunch, 1/22 breakfast, 1/23 breakfast & lunch, 1/24 breakfast, 1/25 all three meals, 1/27-1/29 breakfast & lunch, 1/30 all three meals, 1/31 breakfast. The sheet also has no documentation for R20's intakes on the following days: 1//2 supper, 1/4 all three meals, 1/5 supper, 1/6 breakfast & supper, 1/7-1/8 breakfast & lunch, 1/10 lunch & supper, 1/12 lunch & supper, 1/14-1/15 lunch & supper, 1/16 supper, 1/17-19 lunch and supper, 1/21 supper, 1/22 lunch & supper, 1/23 supper, 1/24 lunch & supper, 1/26 all three meals, 1/27-1/29 supper, and 1/31 lunch & supper. R20's Physician's orders, dated 2/23, document that R20 has an order dated 1/20/23 to receive Jevity 1.5 375 ml bolus four times a day via gastrostomy tube. However, there is no documentation of R20 having an order to receive the high calorie supplement 90 ml twice a day. R20's MAR, dated 2/23 obtained on 2/6/22 at 3:00 p.m., documents that R20 has an order to receive Jevity 1.5 375 ml bolus four times a day. The MAR also documents that as of 2/6/23, there is no documentation that R20 received her bolus on 2/4 at 6:00 p.m. & 12:00 a.m. and 2/5 at 6:00 a.m. and 12:00 a.m. nor that she received the high calorie supplement 90 ml twice a day from 2/1-2/6/23. R20's Food & Fluid Intake Sheet, as of 2/6/23 dated 2/23, documents that R20 refused the following meals: 2/1 breakfast & lunch, 2/2 breakfast, 2/3 all three meals, 2/4 breakfast, 2/5 all three meals, and 2/6 breakfast and lunch. The sheet also has no documentation for R20's intakes on the following days: 2/1 supper, 2/2 lunch & supper, 2/4 lunch & supper. R20's care plan, dated 8/19/22, has no documentation of a revision to include R20's significant weight loss. On 2/04/23 at 11:10 am, V32 (Registered Nurse/RN) stated, (V27/Licensed Practical Nurse/LPN) was not feeding (R20) who was to get a tube feed. Several weeks ago, I came on shift and (V27) was giving me report. She was saying how (R20's) tube feeding had been infusing all night. I started to question her, because (R20) didn't have an infusion pump or continuous feeding. (V27) argued that (R20) did have an infusion pump and I just let it go. As soon as (V27) left, I went to (R20's) room. The door was closed. I was right, they didn't' start (R20) on continuous pump, she was still on bolus feedings. (R20) can't talk much, but can say 'yes' or 'no.' She was really agitated when I went in her room, needed oral care, it was obvious it hadn't been done. I asked (R20) if she got fed by the nurse before me and she indicated 'No.' So I gave her her feeding. When I went to the MAR, it was signed off by (V27) as being given. Honestly, I don't think (V27) went into her room all night. We don't even have a tube feeding pump in the building. (R20's) behaviors will increase because she is hungry; I've seen it other times. I will come in and she will be agitated, and her feedings will not be documented as given. As soon as I feed her, her agitation stops. On 2/7/23 at 12:00 p.m., V11 (RN) stated, There was an issue with the facility getting a tube feeding pump when we first got the order. So, it wasn't started right away. I actually spoke with (V40) myself to try and do something different than boluses every three hours because when it's busy it's not easy to get them done every three hours. If you missed one dose by getting side tracked or busy by the time you were able to do it, she was due for her next one. So, she might miss a dose. On 2/7/23 at 12:40 p.m., V40 (Registered Dietician) stated, (R20) should not be losing weight with the amount of calories and protein that she gets on a daily basis from her tube feedings. It gets frustrating. I make recommendations and they don't get followed up with. I added the high calorie supplement twice a day hoping that would help. I was not notified when they changed the tube feeding from continuous overnight back to the boluses. I didn't know about it until I came in for my monthly visits. They should have consulted with me about what to put her on. On 2/7/23 at 1:20 p.m., V24 (Registered Nurse) stated, I don't know that (R20) always gets her feedings or if she does if they are late. I don't want to assume, but her behaviors are escalated when I suspect it. It seems like she has an increase in behaviors. She complains of pain at times too. She will normally tell me she has a headache which could be part of hunger pains. She doesn't eat, and then nurses may not be giving her all of her boluses. This breaks my heart. She can't verbalize. She can't tell us that she is hungry. On 2/7/23 at 4:10 p.m., V41 (Medical Director) stated, (R20) should not have gone without receiving her tube feedings. I agree that these issues needed to be addressed. The DON (Director of Nursing) should be overseeing these things and making sure they are followed through with. However, I know they haven't had a DON for a while. I should have been notified when the facility wasn't able to get the tube feeding supplies and (R20) went without feedings before 11/9/22. On 2/8/22 at 10:15 a.m., V11 (RN) stated, I know I don't give her high calorie supplement 90 ml with any of my medication passes. V11 confirmed there is no order on the 2/23 MAR for (R20) to receive high calorie supplements at all. V11 stated, (R20) doesn't have many behaviors. When she first got here, she was exit seeking mainly. Now though she will sit on the floor; she learned that from an old roommate. Now the only thing I really notice is the yelling out occasionally. Sometimes, if you ask her, she will say she's having pain; she will shake her head 'yes.' Sometimes, I feel like her yelling out is related to her feedings. I will ask her if she's hungry and she will say 'yes' at times. The yelling out is sometimes when she's due for a feeding as well. There's times too that it's hard to understand what she wants because she will shake her head 'yes' and 'no' to respond to our questions, but sometimes 'yes' looks like 'no' and 'no' looks like 'yes,' and I can't decipher what is wrong. On 2/8/22 at 5:20 p.m., V1 (Administrator in training) stated, (R20's) high calorie supplement was discontinued (1/20/23) in error by one of the nurses. There was no physician order to discontinue the high calorie supplement. On 2/1/23 at 2:25 p.m., V28 (Dietary Manager) stated, Significant weight loss is 5 lbs or more in one month. I don't know the significant weight loss percentages. The CNAs are responsible for charting the residents' intakes at meals. I use the meal intakes for my quarter assessments. I've noticed lots of holes where

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents (R6, R10, R11, R18) were free from sexual and verbal abuse by R9, who had known history of sexually inappropriate behaviors towards females, for five of 12 residents reviewed for abuse in a sample of 25. These failures resulted in R6 being groped in a sexual manner and verbally abused, experiencing psychological distress. This facility was previously cited for sexual abuse on 1/09/22 for R9 groping R6's breast. Additionally, the facility failed to prevent known, ongoing sexual relations between R9 and R6, who is Intellectually Disabled, unable to consent, and has a State Appointed Guardian. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02/03/2023, the facility remains out of compliance at a Level 2 as the facility continues to conduct ongoing Abuse Prevention Training with all current staff and newly hired staff and the Quality Improvement Program conducts random audits to ensure facility staff's compliance with the Abuse Prevention Program, with an emphasis on Abuse Reporting, Investigation of Abuse Allegations, and staff's understanding of Abuse Prevention Training. Findings include: The Facility policy, titled Abuse Prevention Program (revised 11/28/2016) documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitations defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent the occurrences of mistreatment, exploitation, neglect, or abuse of our residents. This will be done by: Conducting required pre-employment screening of employees; Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, exploitation, neglect and abuse immediately to supervisory personal; Training on activities that constitute abuse, neglect, exploitation and misappropriation of resident property; Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property; including, prohibiting staff from using any type of equipment to keep, distribute photographs and recording of residents that are demeaning or humiliating; Identifying occurrences and patterns of potential mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property; Dementia management and resident abuse prevention; Immediately protecting resident involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegation of mistreatment, exploitation, neglect, abuse or residents and misappropriation of resident property; promptly and aggressively, and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. This facility is committed to protecting our residents from abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. The Abuse Prevention Program documents Sexual Abuse is non-consensual sexual contact of any type with a resident. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their mental ability to comprehend or disability. 1. R9's Pre-admission Screening System, dated 11/18/21, from prior to R9's admission [DATE]) to the facility and obtained from R9's medical records at the facility, documents, Behavior Assessment Summary: (R9) is a [AGE] year-old male who was admitted to hospital due to being actively psychotic. (R9) has a history of hospitalizations and being aggressive. Behavior type: Antisocial behavior; Criminal justice system involvement; Fire setting or arson; Physical assault/injury threatening to others; Poor judgement placing self or others at risk; Property damage; Self injurious behaviors; Serious wandering, elopement; Sexual aggression. A Cumulative Diagnosis Log (no date) documents R9 has the current diagnoses of Schizoaffective Disorder, Bipolar Type and Hypersexuality. A Minimum Data Set assessment, dated 11/30/22, documents R9 can ambulate independently. A Final Incident Report to State Agency, dated 1/14/22, summarized that R9 had grabbed R6's breast as she was near the ice machine in the kitchen area, and R6's account of what had occurred was substantiated by resident interviews that had witnessed the incident. R9's current Plan of Care documents (beginning 3/15/22) (R9) has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against the resident. Behavior exhibited sexually inappropriate, yelling out, verbal outbursts, and instructs staff 1 on 1 (at) all times when out of room and council on appropriate interactions (with) peers (and) staff as needed per his behaviors. The Care Plan also documents, R9 has displayed verbal aggression, inappropriate touching, wanders, irregular thoughts. A Psychosocial Assessment, dated 11/30/22 identifies R9 has behaviors of being socially inappropriate, wandering, seducing/soliciting, seeking intimate contact, and masturbating. Daily Resident Monitoring documents R9 was decreased from 1 on 1 supervision to Resident Monitoring - 15 minutes - Staff (must) make visual contact with resident every 15 minutes on the following dates: 12/15/22, 12/16/22, 12/17/22, 12/18/22, 12/20/22, 12/21/22, 12/23/22, 12/25/22, 12/26/22, 12/27/22, 12/30/22, 12/28/22, 12/31/22, 1/01/23, 1/02/23, 1/03/23, 1/04/23, and 1/05/23. All of R9's 15 Minute Monitoring reports document his location as being in either the hallway, dining room, resident room, television room or patio. R9's medical record contains no documented rationale for decreasing his level of supervision to every 15-minute checks on those dates. Daily Resident Monitoring logs for the dates of 12/11/22, 12/13/22 and 12/14/22 indicate Resident Monitoring - One to One, however, on those three dates the One to One is crossed out with an ink pen and R9's location is only documented every hour on the hour. On 2/16/23 at 11:37 am, V9 (Unit Aide) clarified the December Resident Monitoring for R9, as her initials are on several of R9's monitoring logs. V9 was given R9's logs from 12/11/22, 12/13/22 and 12/14/22 and asked about the One to One that was crossed out on the top of the log sheet. V9 stated There was, like a week in December when we took (R9) off 1:1 and he was just on every 15-minute checks, so the 'One to One' was crossed out on certain days so people would know he (R9) was not 1:1 on those days, but a every 15-minute check. I'm not sure who made that decision to decrease his supervision. A Grievance/Complaint Report dated 1/05/23 and completed by V4 (Social Services), documents R6 complained (R9) rubbing on her butt, putting arm around her (and) saying 'Baby, give me a kiss,' touched her breast, looked up her dress. Also, going up (and) down A Hall (at) night, (R6) claimed, 'I can hear (R9) through the wall.' Resident Council Meeting minutes dated 1/10/23 document resident complaints that (R9) needs to be on a 1 on 1 at all times, overnights too. Residents are not comfortable in his presence and are scared of him. (R9 is) very violent, overly sexual, calling names, going through resident's rooms, (R10, R6, R11 and R12) have all brought attention to this. A Resident Council Concern/Complaint form, dated 1/10/23 by V16 (Activities Director), documents Residents would also like if (R9) was out of the facility because they feel unsafe. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: Other concerns: (R9) is touching and grabbing women in a sexual behavior. (R9) is pinning residents against walls and counters as well. (R6) stated that (R9) has looked up her skirt, grabbed her breast, and rubbed his penis on her many times. It was stated in resident council that (R9) does not have a 1:1 anymore, and (R13 stated R9) touched my boobs and rubbed his penis on me, and (R11 stated R9) is getting into people's faces and personal space and touching the way she don't want to be touched. On 1/26/23 at 4:11 pm, R9 was ambulating throughout the building, into the common areas and up and down hallways. R9 was being followed by V28 (Dietary Manager) who was approximately 15 feet or more behind him watching a video on her cell phone as he ambulated throughout the hallways. R9 eventually returned to his room and V28 sat down in chair outside his room. When asked why R9 needed 1:1 supervision, V28 stated for his behaviors. When V28 was asked as to what type of behaviors R9 exhibited, V28 stated she did not know. On 1/24/23 at 3:15 pm, V4 (Social Service) stated R6 told her on 1/05/23 that R9 was rubbing on her butt, breast and saying inappropriate sexual statements to her, wanting a kiss and telling her to drop that a**. According to V4, R6 stated she could hear R9 wandering the halls at night, all night, going into others' rooms. V4 stated R6 was very upset over the fact that R9 had been on 1:1 supervision in the past for similar behavior but was taken off 1:1 supervision and was allowed to do this to her. V4 stated she wrote up the statement from R6 on 1/05/23 and then took it to morning meeting with all the Department Heads on 1/06/23 to be discussed. V4 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present in that meeting. V4 stated R9 was eventually put back on 1:1 supervision, but not until another incident occurred a week later. V4 was uncertain of the details or nature of that incident. V4 stated she felt what R9 was doing to R6 was sexual abuse, but R9 doesn't have the ability to understand that his behavior is sexually inappropriate. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated she typed the 1/10/23 Resident Council Meeting Minutes and then completed a form with each concern on it and delivered those concerns to the appropriate Department Heads. V16 stated V1 was present at the 1/10/23 Resident Council Meeting, as she was invited by the residents due to all the concerns. V16 stated multiple residents brought up R9's behavior in that meeting, complaining that R9 is very sexual. (R9) will literally come up behind a person, grab their hips, get real close and dance with them. V16 stated residents complained that R9 would make sexual comments to people as well. They piped in and said (R9) had been overly sexual towards them. They didn't bring up specific times but chimed in when it was brought up. V16 stated she started at the facility in August, and in the last 3 months R9's sexual behavior has become more frequent. V16 stated R9 was taken off and put back on 1:1 supervision multiple times in a month and V16 discussed this with V1 several times, as it was concerning to her. V16 stated, I've brought this up to (V1) several times, but (R9) still does things. I really don't know if what he is doing is sexual abuse or not. I really can't say. I never received any kind of abuse training when I started in August or since then. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she attended the most recent Resident Council Meeting (1/10/23). V10 confirmed that V1 and V2 were present for that meeting. V10 stated during the meeting, R6 and some other female residents complained about R9 being sexually inappropriate. V10 stated R6 verbalized in the Resident Council Meeting R9 rubbed his penis on her and rubbed her boobs. V10 stated she was in the facility on 1/19/23 and R9 was roaming the hallway unsupervised and groped her buttocks. V10 indicated that each time she has been in the facility recently, on 1/03/23, 1/10/23 and 1/19/23, R9 was not on 1:1 supervision and residents have complained to her that R9 isn't supervised enough. V10 stated she spoke with V1 on 1/19/23 about R9's behaviors and lack of supervision, and V1 told her, The facility does not want to have (R9) on 1:1 at all times because it is expensive. V10 stated R6 tries to run away from the facility and recently cut her head when she put it through her bedroom wall. V10 stated she talked with R6 about this behavior and R6 stated she did all those things because staff wouldn't listen to what she had to say or help her. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated R9 had been on 1:1 supervision for his sexual behaviors, but it stopped because the facility didn't have enough staff to provide constant supervision of him. V32 stated she heard that R6 reported R9 touched her inappropriately on 1/05/23, but nothing was done about it. V32 stated a few days after 1/05/23, R9 went up to R14 and started humping her from behind, rubbing his crotch on her. V32 stated she texted V1 to tell her about the situation, since R6 had just reported something similar on 1/05/23, but V1 just got upset with her for texting her at night. V32 stated she was concerned because she thought R9 was to be supervised 1:1 all the time after the last abuse (Illinois Department of Public Health deficiency) written on him, from what I was told. V32 stated she has even witnessed R9 do sexually inappropriate dancing during Moves and Grooves, which is an activity ran by V16 (Activities Director). V32 stated It was almost like staff were encouraging this behavior from (R9) and didn't understand it was wrong and inappropriate. V32 stated she has witnessed night shift Unit Aides watching movies on their phones when they are to be providing residents, R9 included, with 1:1 supervision. On 2/01/23 at 5:40 pm, V34 (Unit Aide) stated about two months ago, R9 was going up to residents and 'air humping' them, rubbing himself on males and females. It was so bad the police had to be called, but the police said they couldn't do anything with him. V34 stated R9 was being supervised 1:1 that day and still acting out towards other residents sexually, because staff couldn't stop him. V34 stated he has provided R9 with 1:1 supervision before and R9 will not want to stay in his room and will want to walk around the building. He is fast. Some residents get scared of (R9) because he will yell at them. I've been told in the past, from other staff and (R6) that (R9) needs to be watched for doing inappropriate things to her. On 1/25/23 at 10:35 a.m., V19 (Certified Nursing Assistant) stated, (R9) likes pulling his pants down exposing himself and dancing around inappropriately laughing; it's common behavior. He wanders in and out of resident's rooms. On 1/25/22 at 10:50 a.m., V25 (Licensed Practical Nurse) stated, (R9) is like a vampire; sleeps all day then awake at night and starts acting out. He is very animated. He is sexually aggressive verbally. Last night he was sexually inappropriate with me. On 1/26/22 at 10:40 a.m., V14 (Social Service) stated, (R6) complained to me about (R9) because he grabbed her butt. I think this happened in about November. (R6) said she didn't like him talking to her because he touched her butt and things like that. I reported these things to (V4/Social Services Director). On 1/26/22 at 10:50 a.m. V15 (Social Services) stated she was aware of R9's sexual advances, stating for instance he went behind (R14), grabbed her breast and pretended to hump her. It happened over the weekend, and I was told about it the following Monday when I came in, so I didn't report it to anyone. It was either the weekend of 12/31/22 or 1/07/23. V15 then stated, The other thing I'm aware of is (R9) grabbing (R6's) breast. This incident wasn't long before (R14's) incident or maybe the same weekend. On 1/26/22 at 2:10 p.m., V8 (Certified Nursing Assistant) stated R9 will say sexually inappropriate statement to residents. V8 stated, I know he's tried to grab females, like (R6), going up behind her inappropriately. (R6) reported to me that (R9) wouldn't quit following her and tried to grab her. I told her to talk to Social Services, because I know something may have been done previously, but she still complains about it. I didn't report anything to (V1). I would say it was sexual abuse because (R9) is inappropriate with it. (R9) will randomly just get in a mood where he gets sexually inappropriate. I want to say he did have a 1:1, but he is quick (moving). I don't know who determines if he needs a 1:1. He has come off then he will be put back on is because he's been sexual or trying to poop outside. On 1/25/23 at 10:17 am, R10 stated R9 has never done anything sexually or physically inappropriate to her, but she has heard from other residents that he can be physically and sexually aggressive. R10 stated, (R9) will follow me a lot; he doesn't make sexual advances, just grabs his genitals in front of me. R10 stated she has told several staff that I think (R9) is at the point where he wants a woman; he is a young, after all. (R9) asked me to get him a {Name Brand adult men's magazine} magazine recently and that makes me think he is sexually frustrated. On 1/26/23 at 4:21 pm, R3 stated R9 has been on and off 1:1 supervision since he was admitted . R3 stated R9 was most recently returned to 1:1 supervision after the January Resident Council Meeting, when all that stuff was brought up about (R9) being really sexual with the female residents, touching them and rubbing himself against them. But even after that, (R9) will just roam free some nights. He goes in and out of other resident rooms. I think he looks for food, but who knows what all he's doing in there. I've seen (R9) come up behind the girls and be sexual with them, touching them in places he shouldn't, just out in the open and in front of staff. They don't do anything most of the time. Some of the staff will tell him to stop or distract him away from the girls, but (R9) pretty much does what he wants. On 2/01/23 at 12:50 pm, R18 stated, (R9) has grabbed my arm and pulled me in to him, making me sit on his lap. It made me uncomfortable. I didn't like it. Staff were around; it was by the fireplace, but they didn't stop him. I got up on my own after he let me go. This wasn't that long ago, maybe a month. On 1/25/23 at 10:34 am, R11 stated she did complain at the Resident Council Meeting this month about (R9). R11 stated, (R9) will get in my face and yell real loud at me, saying all sorts of mean stuff. R11 stated this had been going on for awhile and staff would see it happening and do nothing. R11 then stated, (R9) has touched me, but I don't want to say where; he scares me. On 1/30/23 at 10:18 am, R6 was interviewed over the phone, as she was admitted to the hospital. R6 stated R9 touches my boobs, tries to kiss me, and will come up to me and rub his penis on me through his clothes. (R9) will hold on to me from behind. It makes me feel uncomfortable and this happens almost every single day. R6 stated R9 will call her names, like N****r, C**t, and B***h when she pushes him away. R6 stated the problems with R9 started over a year ago, and she has told many staff, including V1 (Administrator in Training), V2 (Assistant Administrator in Training) and V4 (Social Services Director). R6 stated, Staff do nothing and (R9) is allowed to come down my hall all of the time. R6 stated sometimes R9 is 1:1 with staff and at other times he's not, especially at night. R6 described how she is afraid to come out of her room, unable to go get ice and eats meals in her room to hide from R9. R6 stated she is afraid of R9 and R9 makes her feel uncomfortable. R6 stated she is coming back to the facility soon and is very worried about what might happen with R9 still in the facility. R6 stated she recently put her head into the wall of her room because she was angry and frustrated with living in the facility. R6 also stated she tried to leave the facility last Sunday, which was why she was in the hospital. When R6 was asked why she tried to leave, she stated she was angry about everything. Having to live there. (R9) not leaving me alone. Staff not listening to me about (R9) and other things. Staff being mean to me. (R9) follows me around all the time calling me names. Staff don't stop him. When R6 was asked if she feels safe in the facility, she stated not at all. R6 stated the last time she tried to run away from the facility she was angry about everything and stated, It was not a good day. I had enough of that place. R6 stated she really wanted to kill herself that day, and just get it over with. R6 stated as she was leaving the building, V6 (Certified Nursing Assistant) was walking behind her and telling her to just go ahead and hang myself. So, that's what I was trying to do, get out of there and kill myself. R6 was interviewed again, after returning to the facility, on 2/01/23 at 12:48 pm. At that time, R6 stated, Just last night (R9) was following me around, he called me a Retarded B***h while staff were with him, following him as he walked around. On 1/31/23 at 1:45 pm, V30 (Police Officer) stated he said he has responded to the facility several times over R6's threats of suicide. V30 stated R6 always tells him that she can't stand to live there anymore because the staff don't listen to her or help her. On 1/25/23 at 12:59 PM, V1 stated R6 came to her with concerns that R9 was getting too close to her. V1 could not recall what day that occurred, but indicated it was recent, within the month. V1 stated, We had actually been trying to wean (R9) off 1:1. V1 stated she had no knowledge of the 1/05/23 grievance completed by V4; however, V1 acknowledged that R9's Resident Monitoring Logs document he was placed back on 1:1 supervision at 12:00 am on 1/06/23. V1 stated she did not know what behavior had occurred for R9 to be returned to a higher level of supervision, nor could she find documentation as to why. V2 was in the office during this interview and denied knowledge of the grievance as well. V1 and V2 denied V4 bringing to the attention of Management that R6 had complaints of R9 touching her sexually during the 1/06/23 morning management meeting. V1 stated, Had I known, I would have reported an allegation of sexual abuse. V1 stated the only thing R6 told her was that (R9) was getting in her personal space, but not that (R9) had physically touched her. V1 stated she did not have any documented evidence of this conversation with R6, or any subsequent actions taken. V1 explained, (R9) is able to be taken off and on 1:1 based on his behavior. They will review his behaviors and if they increase, or if he is not able to be redirected, it can be reimplemented. That's in his Plan of Care. V1 confirmed that she was in attendance for the Resident Council meeting on 1/10/23. V1 stated she did not interview the four female residents that spoke out about R9's behavior. V1 stated, I recall (R6) speaking out against (R9) and (R10) as well. I do not remember the other two residents having specific concerns with (R9). I can't tell you my exact immediate follow up. I did not interview any residents that had concerns. At some point, I had a conversation with (R6 about R9), but I do not know when and did not document the details. 2. An official court document, dated 4/10/2017 documents V30 (R6's Mother) and V37 (R6's Father) as being appointed Guardians of the Estate & Person of (R6), a disabled adult, and are authorized to have, under direction of the Court, the care, management, and investment of the ward's estate and the custody of the ward, and to do all acts required by them by law. A Resident Profile Face Sheet documents R6 was admitted to the facility on [DATE]. A Subpart S Eligibility Screening, dated 5/13/22, documents under Section B that R6 has the diagnoses of Schizo-affective Disorder and Bipolar Disorder, and under Section E - (checked for yes) Are impairments in these areas primarily due to the resident's serious mental illness listed in Section B. (Checked for yes) Resident's impairment cannot be primarily due to any of the following (Check box if impairment is due to diagnosis listed): with Mental Retardation circled. Physician's Orders, dated 1/01/23, document R6 has the current diagnoses of Anxiety, Schizoaffective Disorder, Intellectual Disability, and Chronic Post Traumatic Stress Disorder. R6's Current Plan of Care, which has not been updated since 9/09/22, documents R6 has Impaired Communication (expressive), ambulates independently and has risk factors that require monitoring and intervention to reduce potential for self-injury. A Hospital History and Physical, dated 1/23/23, documents R6 as alert and oriented, but with limited judgement and insight, and below average intelligence. Behavior Tracking for October, November and December 2022 and January 2023 documents R6 is being monitored for the following targeted behaviors: Self Harm/Suicidal Ideations, Repetitive Verbalizations, Physical Aggression Towards Others, Intrusive Thoughts, Verbalized Hallucinations/Delusions, Exit Seeking, Depression, Self-Isolation, and Verbal Aggression Towards Others. Nursing Notes, dated 10/22/22, document (R6) got upset because she was asked to leave boyfriend's room and move down to lobby. She went down D Hall to another resident room. She was redirected to leave the hall because of COVID. (R6) got agitated and walked out of the facility through D Hall. Resident was not easily redirected. Walked down to the graveyard, took off all her clothing and laid naked in (a) field. Stated 'I want to die.' The cops were informed. Effort to get (R6) up not successful. Rescue team informed, got her up and was taken to (hospital). Nursing Notes, dated 12/18/22, document (R6) found in male patient's bed. They were wearing clothes. (R6) said she thought it was ok, as long as they don't have sex. Encouraged (R6) not to go in male resident room. She was easily redirected. Physician's Orders, dated 2/01/23, document R15 has the current diagnoses of Schizoaffective Disorder, Bipolar type, Catatonic Schizophrenia, and Psychosis. A Surrogate for Decision Making form, dated 12/29/22, documents V36 (R15's Sister) is R15's legal Surrogate Decision Maker. A Social Service Progress Note, dated 12/29/22, documents (R15) has a girlfriend (R6) and family does not want them having sexual relations. R6 and R15's medical record contain no documented evidence of a plan developed or implemented to ensure R6 and R15 were not engaging in sexual activities with each other. On 1/31/23 at 1:05 pm, V10 (Ombudsman) stated V30 (R6's Mother) contacted her today, very upset and concerned about R6 being in a sexual relationship with a male resident in the facility. V10 stated V30 discussed this with the Social Services Department in December, but the facility was not doing anything to stop R6 from having sexual intercourse with this resident. V30 stated the concern is that R6 does not have the mental capacity to consent to a sexual relationship with someone. On 1/31/23 at 2:44 pm, V30 stated V30 found out this summer that R6 was in a relationship with R15. V30 stated she was concerned, because R15 is twice R6's age, but she was just calling R15 her boyfriend. V30 stated nursing staff in the facility started telling her she should press her daughter for more information about her relationship with R15. V30 stated it was as if the staff knew R6 needed to tell her what was really going on with her and R15. V30 stated, Around the beginning of November, (R6) told me she had been caught having sex with this man (R15), in his room and her room, multiple times, and I'm concerned because I'm (R6's) State appointed guardian and (R6) has the mental capacity of a 10-[AGE] year old. I spoke to (V1) immediately after I found out, and (V1) told me (R6) was a consenting adult and there was nothing they could do about her having sex with this man, who is twice her age. On 2/02/23 at 1:30 pm, V30 stated she reviewed her phone records and she spoke with V1 on 11/08/22 about R6 and R15 having sex. V30 stated V1 told her R6's BIMS (Brief Interview for Mental Status) was too high, and they were able to consent to a sexual relationship. V30 stated she told V1 that she did not agree, as (R6) has the mentality of a teenage girl. V30 went on to say, This is my baby (R6) and I feel like (R15) is a predator. On 2/01/23 at 12:52 pm, R15 stated he is in a sexual relationship with R6. R15 stated they have sex in his room or hers, or sometimes on the couch. R15 stated they had been having sex for a while now. On 2/01/23 at 1:17 pm, R6 stated she has sex with R15. R6 stated, (R15) is my boyfriend and we are going to get married. R6 was asked where she has sex with R15, and she stated, Wherever and Oh we've been caught by people. R6 was asked if she had sex with R15 in his room or hers, and she stated both. R6 was asked what happens when they get caught and R6 stated, They just tell us not to do it again. My Mom knows. I told her. I told her we want to get married. On 1/31/23 at 12:59 pm, R3 stated, (R6 and R15) are in a sexual relationship. Everyone knows, including staff. They will lay on the couch in the common area on the other side of the fireplace, where no one can see them if they walk through, make out and fondle each other. They are smart and try to hide it. Staff will let them sit real close on the couch during a movie and say 'Now don't touch each other,' but it doesn't work. This has gone on since I've lived here. On 2/02/23 at 1:59 pm, V4 (Social Services) stated she talked to both R6 and R15's families regarding their sexual relationship in December, but (R6 and R15) had a high enough BIMS, so they could not stop them. V4 stated, (V1) was fully aware (of their sexual relationship); she has talked to (R6 and R15's) family regarding this. V4 stated they did discuss developing a care plan with individualized interventions to keep R6 and R15 from having sexual relations, but that never transpired. V4 stated R6 openly talked about being sexual with R15. V4 stated, It was common knowledge amongst staff, that they would have sex; it would trickle down to residents and then to Social Services. On 2/01/23 at 2:33 pm, V14 (Social Service) stated R6 does think R15 is her boyfriend. V14 stated she has heard from multiple staff and residents that R6 and R15 are in a sexual relationship. V14 stated, The first time I heard about them having sex, (R6) was in the hospital. It was a couple of months ago. Since (R6) was in the hospital, it was after the fact, and I did not report it to (V1). V14 stated there was a recent Care Plan meeting with R6's parents, V4

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Investigate Abuse (Tag F0610)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate an allegation of sexual abuse made by R6 against R9 (on 1/05/23) and protect R6 from potential further abuse, failed to investigate and implement measures to prevent an ongoing sexual relationship between a resident (R6, who lacks the mental capacity to legally consent) and R15, failed to investigate multiple allegations of abuse made by residents during Resident Council meetings, which included sexual abuse, verbal abuse, staff retaliation and misappropriation, and failed to investigate an allegation of verbal abuse made by R3 against V3 (Registered Nurse) on 1/24/23. Additionally, the facility failed to investigate inner thigh bruising found on R1's inner thighs and facial bruising found on R5, both injuries of unknown origin. These failures have the potential to affect all 116 residents that reside in the facility, as no measures were taken by V1 (Administrator in Training) to ensure residents within the facility were protected from potential further abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02/02/2023, the facility remains out of compliance at a Severity Level 2 as the facility's Quality Improvement Program conducts random audits to ensure facility staff's compliance with the Abuse Prevention Program, with an emphasis on Abuse Reporting, Investigation of Abuse Allegations, and staff's understanding of Abuse Prevention Training. Findings include: The Abuse Prevention Program policy (revised 11/28/2016), documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. The policy later documents, The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse: Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Sexual Abuse is non-consensual sexual contact of any type with a resident. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident's consent. Mistreatment means inappropriate treatment or exploitation of a resident. Section IV of the policy documents, Internal Reporting Requirements and Identification of Allegations: Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property to a supervisor and administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. Section V of the policy documents, Protection of Residents: The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway. Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse or misappropriation of resident property shall not complete their shift as a direct care provider to residents. The policy further documents, under Section VI, Internal Investigation of Allegations and Response: 1. Appointing an Investigator. Once the administrator or designee receives an allegation of mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property: the administrator will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the Resident Protection Investigation Procedures. 2. Following the Resident Protection Investigation Procedures. The appointed investigator will follow the Resident protection Investigation Procedures, attached to this policy. The Procedures contain specific investigation paths depending on the nature of the allegation, procedures for investigation, interview parameters, and reporting requirements. 3. Confidentiality. The investigator shall do as much as possible to protect the identities of any employees and residents involved in the investigation until the investigation is concluded. After a conclusion based on the facts of the investigation is determined, internal reports, interviews and witness statements shall be released only with the permission of the administrator or the facility attorney. Even if the facility investigation is not complete the administrator will cooperate with any Department of Public Health investigation into the matter. 4. Updates to the Administrator. The person in charge of the investigation will update the administrator or designee during the progress of the investigation. The administrator or designee will keep the resident or resident's representative informed of the progress of the investigation. 5. Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The policy documents, under Section VII, External Reporting of Potential Abuse: 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. A written report shall be sent to the Department of Public Health. The written report should contain the following information, if known at the time of the report: Name, age, diagnosis, and mental status of the resident allegedly abused or neglected; Type of abuse reported (physical, sexual, theft, neglect, exploitation, verbal, or mental abuse); Date, time, location, and circumstances of the alleged incident; Any obvious injuries or complaints of injury; and, Steps the facility has taken to protect the resident. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property and that an investigation is being conducted. The facility policy, titled Injuries of Unknown Origin (revised 4/18/16), documents All injuries of Unknown Origin will be investigated to determine the potential cause of the injury. Upon identification of the cause, interventions will be established to prevent any further injury by the IDT (Interdisciplinary Team) or Administration. All Injuries of Unknown origin will be discussed at the daily (Quality Assurance) meeting. The policy advises, Determine if the injury may be related to mistreatment of a resident: Bruising noted about the face or neck area; Bruising/reddened areas noted on wrists or lower forearms - similar to finger placement, or any part of the body that may indicate finger placement; Handprints/bruising noted to buttocks. The policy instructs staff to Identify and establish interventions for prevention of any further injuries: Possible Abuse - Begin following Abuse Prevention Program. 1. A Grievance/Complaint Report, dated 1/05/23 and completed by V4 (Social Services Director), documents R6 complained (R9) rubbing on her butt, putting arm around her (and) saying 'Baby, give me a kiss,' touched her breast, looked up her dress. Also, going up (and) down A Hall (at) night, (R6) claimed, 'I can hear (R9) through the wall.' Resident Council Meeting minutes dated 1/10/23 document (R9) needs to be on a 1 on 1 at all times, overnights too. Residents are not comfortable in his presence and are scared of him. (R9 is) very violent, overly sexual, calling names, going through resident's rooms, (R10, R6, R11 and R12) have all brought attention to this. A Resident Council Concern/Complaint form, dated 1/10/23 by V16 (Activities Director), documents Residents would also like if (R9) was out of the facility because they feel unsafe. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: Other concerns: (R9) is touching and grabbing women in a sexual behavior. (R9) is pinning residents against walls and counters as well. (R6) stated that (R9) has looked up her skirt, grabbed her breast, and rubbed his penis on her many times. It was stated in resident council that (R9) does not have a 1:1 anymore, and (R13 stated R9) touched my boobs and rubbed his penis on me. (R11 stated R9) is getting into people faces and personal space and touching the way she don't want to be touched. Upon entering the facility on 1/24/23 at 9:10 am, V1 (Administrator in Training) was asked for all the facility's Abuse Allegations investigated and reported to the Illinois Department of Public Health in the last 90 days. V1 provided three separate investigations, none of which involved R9, and indicated those were the only Abuse Allegation Investigations she had. On 1/24/23 at 3:15 pm, V4 (Social Service Director) stated R6 told her on 1/05/23 that R9 was rubbing on her butt, breast and saying inappropriate sexual statements to her, wanting a kiss and telling her to drop that a**. According to V4, R6 stated she could hear R9 wandering the halls at night, all night, going into others' rooms. V4 stated R6 was very upset over the fact that R9 had been on 1:1 supervision in the past for similar behavior but was taken off 1:1 supervision and was allowed to do this to her. V4 stated she wrote up the statement from R6 on 1/05/23 and then took it to morning meeting with all the Department Heads on 1/06/23 to be discussed. V4 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present in that meeting. V4 stated she felt what R9 was doing to R6 was sexual abuse, but R9 doesn't have the ability to understand that his behavior is sexually inappropriate. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated she typed the 1/10/23 Resident Council Meeting Minutes and then completed a form with each concern on it and delivered those concerns to the appropriate Department Head, including V1. V16 stated V1 was present at the 1/10/23 Resident Council Meeting, as she was invited by the residents due to all the concerns. V16 stated multiple residents brought up R9's behavior in that meeting, complaining that R9 is very sexual. (R9) will literally come up behind a person, grab their hips, get real close and dance with them. V16 stated residents complained that R9 would make sexual comments to people as well. They piped in and said (R9) had been overly sexual towards them. They didn't bring up specific times but chimed in when it was brought up. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she attended the most recent Resident Council Meeting (1/10/23). V10 confirmed that V1 and V2 were present for that meeting. V10 stated during the meeting, R6 and some other female residents complained about R9 being sexually inappropriate. V10 stated R6 verbalized in the Resident Council Meeting R9 rubbed his penis on her and rubbed her boobs. On 1/25/23 at 10:34 am, R11 stated she did complain at the Resident Council Meeting this month about (R9). R11 stated, (R9) will get in my face and yell real loud at me, saying all sorts of mean stuff. R11 stated this had been going on for awhile and staff would see it happening and do nothing. R11 then stated, (R9) has touched me, but I don't want to say where; he scares me. On 1/30/23 at 10:18 am, R6 was interviewed over the phone, as she was admitted to the hospital. R6 stated R9 touches my boobs, tries to kiss me, and will come up to me and rub his penis on me through his clothes. (R9) will hold on to me from behind. It makes me feel uncomfortable and this happens almost every single day. R6 stated R9 will call her names, like N****r, C**t, and B***h when she pushes him away. R6 stated the problems with R9 started over a year ago, and she has told many staff, including V1 (Administrator in Training), V2 (Assistant Administrator in Training) and V4 (Social Services Director). R6 stated, Staff do nothing and (R9) is allowed to come down my hall all of the time. R6 stated sometimes R9 is 1:1 with staff and at other times he's not, especially at night. R6 described how she is afraid to come out of her room, unable to go get ice, and eats meals in her room to hide from R9. R6 stated she is afraid of R9 and R9 makes her feel uncomfortable. R6 stated she is coming back to the facility soon and is very worried about what might happen to her with R9 still in the facility. On 1/25/23 at 12:59 PM, V1 (Administrator in Training) stated R6 came to her with concerns that R9 was getting too close to her. V1 could not recall what day that occurred, but indicated it was recent, within the month. V1 denied knowledge of the 1/05/23 grievance completed by V4 regarding R6 and R9. V2 (Assistant Administrator in Training) was in the office during this interview and denied knowledge of the grievance as well. V1 and V2 denied V4 bringing to the attention of Management that R6 had complaints of R9 touching her sexually during the 1/06/23 morning management meeting. V1 stated, Had I known, I would have reported an allegation of sexual abuse. V1 stated the only thing R6 told her was that (R9) was getting in her personal space, but not that (R9) had physically touched her. V1 stated she did not have any documented evidence of this conversation with R6, or any subsequent actions taken. V1 confirmed that she was in attendance for the Resident Council meeting on 1/10/23. V1 stated she did not interview the four female residents that spoke out about R9's behavior. V1 stated, I recall (R6) speaking out against (R9) and (R10) as well. I do not remember the other two residents having specific concerns with (R9). I can't tell you my exact immediate follow up. I did not interview any residents that had concerns. At some point, I had a conversation with (R6 about R9), but I do not know when and did not document the details. On 2/02/23 at 1:59 pm, a follow up interview was conducted with V4 (Social Service Director) regarding R6's allegation against R9 and the 1/06/23 Morning Meeting with Management. V4 stated it was clearly discussed in that meeting that R9 had increasing behaviors, going in and out of resident rooms at night, and what R6 reported on 1/05/23. V4 stated Management suggested at that R9 go on 1:1 supervision or they find placement for him elsewhere. V4 stated they discussed R9 being placed back on 1:1 supervision so it didn't escalate to a reportable incident. If (V1 and V2) stated they didn't know this, they are lying. On 1/30/23 at 9:17 am, V1 stated in a follow up interview she has still not initiated any kind of formal investigation into the sexual abuse allegations reported to her last week involving R6 and R9. V1 stated she was completely unaware of R9's sexually tendencies until the survey team brought it to her attention last week. V1 stated V31 (Administrator) is still unaware of the allegations of sexual abuse by R9. 2. An official court document, dated 4/10/2017 documents V30 (R6's Mother) and V37 (R6's Father) as being appointed Guardians of the Estate & Person of (R6), a disabled adult, and are authorized to have, under direction of the Court, the care, management, and investment of the ward's estate and the custody of the ward, and to do all acts required by them by law. A Resident Profile Face Sheet documents R6 was admitted to the facility on [DATE]. A Subpart S Eligibility Screening, dated 5/13/22, documents under Section B that R6 has the diagnoses of Schizo-affective Disorder and Bipolar Disorder, and under Section E - (checked for yes) Are impairments in these areas primarily due to the resident's serious mental illness listed in Section B. (Checked for yes) Resident's impairment cannot be primarily due to any of the following (Check box if impairment is due to diagnosis listed): with Mental Retardation circled. Physician's Orders, dated 1/01/23, document R6 has the current diagnoses of Anxiety, Schizoaffective Disorder, Intellectual Disability, and Chronic Post Traumatic Stress Disorder. On 1/31/23 at 1:05 pm, V10 (Ombudsman) stated V30 (R6's Mother) contacted her today, very upset and concerned about R6 being in a sexual relationship with a male resident in the facility. V10 stated V30 discussed this with the Social Services Department in December, but the facility was not doing anything to stop R6 from having sexual intercourse with this resident. V30 stated the concern is that R6 does not have the mental capacity to consent to a sexual relationship with someone. On 1/31/23 at 2:44 pm, V30 stated, Around the beginning of November, (R6) told her me she had been caught having sex with this man (R15), in his room and her room, multiple times, and I'm concerned because I'm (R6's) State appointed guardian and (R6) has the mental capacity of a 10-[AGE] year old. I spoke to (V1) immediately after I found out, and (V1) told me (R6) was a consenting adult and there was nothing they could do about her having sex with this man, who is twice her age. On 2/02/23 at 1:30 pm, V30 stated she reviewed her phone records and she spoke with V1 on 11/08/22 about R6 and R15 having sex. V30 stated V1 told her R6's BIMS (Brief Interview for Mental Status) was too high, and they were able to consent to a sexual relationship. V30 stated she told V1 that she did not agree, as (R6) has the mentality of a teenage girl. On 2/01/23 at 1:17 pm, R6 stated she has sex with R15. R6 stated, (R15) is my boyfriend and we are going to get married. R6 was asked where she has sex with R15 and she stated, Wherever, and Oh we've been caught by people. R6 was asked if she had sex with R15 in his room or hers, and she stated both. R6 was asked what happens when they get caught and R6 stated, They just tell us not to do it again. My Mom knows. I told her. I told her we want to get married. On 2/2/23 at 10:00 a.m., R6 stated, We (R6 and R15) have sex. We've tried to have a baby three or four times to get out of here and move to Chicago, but I guess this thing is working (pointing to her birth control implant in her left upper arm). On 2/02/23 at 1:59 pm, V4 (Social Services Director) stated she talked to both R6 and R15's families regarding their sexual relationship in December, but (R6 and R15) had a high enough BIMS, so they could not stop them. V4 stated, (V1) was fully aware (of their sexual relationship); she has talked to (R6 and R15's) family regarding this. V4 stated they did discuss developing a care plan with individualized interventions to keep R6 and R15 from having sexual relations, but that never transpired. On 2/01/23 at 2:33 pm, V14 (Social Service) stated she has heard from multiple staff and residents that R6 and R15 are in a sexual relationship. V14 stated, The first time I heard about them having sex, (R6) was in the hospital. It was a couple of months ago. Since (R6) was in the hospital, it was after the fact, and I did not report it to (V1). V14 stated there was a recent Care Plan meeting with R6's parents, V4 (Social Service Director) and V15 (Social Services). V14 stated, The main topic of that meeting was (R6's) sexual relationship with (R15). On 2/01/23 at 3:55 pm, V1 (Administrator in Training) stated, All I know regarding (R15 and R6) is that (R6) told her Mom that they are getting married, and I have never been told they were in a sexual relationship. V1 stated she would expect staff to tell her if they had knowledge of them being in a sexual relationship. V1 stated she personally does not feel R6 has the mental capacity to consent to a sexual relationship. 3. Resident Council Meeting minutes, dated 1/10/23 document the following concerns: LPN (is) stealing narcotics, CNAs (Certified Nursing Assistants) yelling at residents is not okay and needs to stop, and (CNAs) retaliating with residents when they have an issue with things. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Administration, under Concern/Complaint it states in the notes section, CNAs and nurses are retaliating when they (residents) bring issues to them that staff does not agree with, and (R2) also brought up LPNs (Licensed Practical Nurses) stealing narcotics. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/18/23, documents Department: CNAs, under Concern/Complaint: Residents believe that the CNAs yelling at residents is not okay, and They are also concerned that the CNAs are retaliating when the residents bring up issues to them that they do not agree with. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Nursing, under Concern/Complaint: Certain Nurses are retaliating against residents who give them issues. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: (Nursing Staff) ignore residents when residents need help. One resident stated the less cognitive a resident is the worse it is for them, Residents being forced to stay in their rooms or go to their rooms, It was stated that when (R3) had a fainting episode staff makes fun of him because the staff think he is faking it (V11/Registered Nurse)(is the main one), (R3 stated) backlash is horrible from staff. Nurses get in your face and saying f**k you, you're going to your room. Resident is staying in his room due to being uncomfortable. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she was present for the 1/10/23 Resident Council Meeting and several residents attended. V10 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present for the entire meeting. V10 stated R2, who is the Resident Council [NAME] President, was voicing most of the concerns, and R2 even had all his concerns typed up, giving everyone a copy. V10 stated other residents were agreeing with R2's issues brought forth. V10 stated several resident concerns were abusive in nature. V10 stated R2 verbalized he has witnessed nursing staff, specifically V3 (Resident Care Coordinator), take resident medications home with her after she dispenses medication from the pill sleeve. V10 stated multiple residents complained of staff retaliating when they complain about something, staff will be mean to them, make fun of residents, and yell at them. V10 stated she has discussed abuse concerns with V1 before, but she does not act on them. At that time, V10 provided a copy of the typed concerns from R2 that was given to everyone in attendance at the 1/10/23 Resident Council Meeting. R2's documented Grievance List from 1/10/23, provided by V10, documents the following statements: (Licensed Practical Nurse, name withheld) pulls meds, while pulling meds, when she grabs meds out of lock box (for narcotics), she pops all meds into dispensing cup, except the narcotic, it gets popped onto the top of (the medication) cart and slipped into her pocket. On 1/24/23 at 3:45 pm, V16 (Activities Director) was interviewed regarding all the abuse concerns documented from the Resident Council Meeting on 1/10/23. V16 confirmed that V1 and V2 were present for the meeting that day. V16 stated that staff retaliation against residents was mentioned by R2, but he didn't expand on it so she was unaware of what R2 meant specifically. V16 stated it was discussed during the meeting that residents have observed nursing staff popped the narcotic pill out, put it to the side of the medication cart, then slide it into her pocket. V16 recalled R2 stating that if residents do something that the CNAs don't like, they will raise their voices at them. V16 went on to say that she documented all the resident concerns and gave specific concern forms to each Department Head, as well as a copy of the Resident Council Meeting Minutes to V1 (Administrator in Training). On 1/25/23 at 12:59 pm, V1 (Administrator in Training) confirmed that she was present for the 1/10/23 Resident Council Meeting, and she had received a copy of the 1/10/23 Resident Council Meeting notes. V1 stated, I still want to go through and talk to residents. When I get complaints, I don't always jump. V1 stated, My approach to the wrong medications being given and narcs (narcotics) being stolen was to wait and see how med (medication) pass was going. My thought process is it not over. I'm waiting to sneak up and see what I catch. V1 stated she did complete a Narcotic Count at the medication carts, which was fine. V1 stated she at some point asked V3 (Licensed Practical Nurse/Resident Care Coordinator) if anything had been reported regarding missing narcotics, and the answer was no. V1 stated she did not conduct a full investigation into the misappropriation of resident's narcotics, nor did she report the allegation to the State Agency. V1 stated she just started getting copies of the Resident Council Meeting minutes and she received the copy from the (1/10/23) meeting minutes last week. V1 stated she did read the minutes when she received them and acknowledged There were several serious concerns brought up at the meeting. V1 stated she did not interview any residents that had specific concerns, but she did have a conversation with R6. V1 stated she could not recall any specifics regarding the allegation of CNAs yelling at residents, but I decided to do a broad in-service regarding bedside manner and customer service that day, as it was a scheduled in-service day. V1 did admit that the allegations that came from the Resident Council Meeting could lead to an abusive situation. V1 stated she did ask R16 in that moment during the Resident Council Meeting what staff were yelling at residents and then R16 denied anything occurred. V1 stated she did not interview in private or probe further, with any other residents regarding the concerns. V1 stated, I didn't view the complaints warranted interviewing specific residents in private to determine what CNAs are yelling at residents and what they are yelling at them for. V1 stated she did not interview any staff regarding other staff's behavior. When V1 was questioned about the statement made by R2 that staff are retaliating against them when they complain, V1 stated she talked to my Department Heads and instructed them to do 'Angel Rounds,' inquiring as to if residents have concerns about retaliation. V1 was unable to provide any do[TRUNCATED]

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility Administration failed ensure a safe living environment and quality care and services were provided to all residents, failed to provide leadership and institute their Abuse Prevention program and failed to have an effective, comprehensive approach to numerous significant resident concerns regarding the quality of resident life within the facility. The facility has been unable to maintain consistent Administrative leadership over the last 12 months. V1 (Administrator in Training) failed to respond to resident allegations of abuse, neglect and mistreatment. Cross reference to F600, F610 and F692 (Identified Immediate Jeopardies) and additional findings at F584, F607, F609, F693, F741, F760 and F943. These failures have the potential to affect all 116 residents currently living in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02/02/2023, the facility remains out of compliance at a Severity Level 2 as the facility's Quality Improvement Program monitors Resident Council Meeting Minutes, reviews ongoing resident concerns obtained from Department Managers through daily rounds with the residents, monitors for compliance with the Abatement Plan submitted, and review Abuse Allegations and Grievances. Findings include: The facility's Administrator Job description summary documents, The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents, and equipment in a way that the purpose of the facility shall be maintained in accordance with all establish practices, policies, laws, and applicable state regulations. The Administrator will manage and conduct the business of the facility in a manner that protects the facility license and certification at all times. The major goal of the Administrator is to provide an atmosphere, in which residents may achieve their highest physical, mental, and social well-being. The job description summary further documents Responsibilities: 1. Operate a facility in compliance with all federal and state, rules, and regulations; 2. Operate the facility in accordance with establish policies and procedures; 3. Assist in developing and establishing a budget, and managing within it; 4. Appoint a Director of nursing and other department heads; 5. Supervise department heads; 6. Assure, proper facility and department operation through the implementation of the specified quality assurance program. A second Administrator Job description provided by the facility documents Job Summary: The Administrator is responsible for directing day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern long-term care facilities to ensure that appropriate care is provided to the residents in the facility. The administrator is responsible for delegating the administrative authority, responsibility necessary for carrying out the assigned duties. Job Relationships: works effectively and maintains a cooperative, working relationship with members of the regional team, Department heads, government agencies, personnel, visitors, family members, staff, and residents. The Administrator's Job description, further documents under Resident rights: 1. Maintain confidentiality of all resident information. 2. Ensure that the residence rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints are well established and maintained at all times. 3. Resident complaints and grievances and make written reports of actions taken. 4. Review and respond to resident/family council concerns as needed. The Facility Assessment, last updated on April 20, 2021, documents We are dedicated to assisting the elderly population in maintaining the highest possible quality of life, for the longest possible time. We are committed to providing an environment where the dignity of each individual is assured. We believe that a person is unique, deserving of dignity and respect. That each person possesses unique qualities which make up distinct personality. Although a person may lose the ability to function, as before, that person still possesses, this unique quality, which must be recognized and respected. That all aspects of a person must be considered: physical, mental, spiritual, and social, when assessing and providing care for all individuals, the staff must be accessible, perceptive and open to recognize needs and provide care for residence. That involvement with significance of others is beneficial to residents, family members, and staff in planning and providing quality care. During the last 12 months, the facility has been cited by the State Agency at F835 on 2/10/22 and 10/30/22 for lack of effective Administrative leadership. Upon entering the facility on 1/24/23 at 9:15 am, V1 (Administrator in Training) introduced V2 as her Assistant Administrator in Training and V3 (Licensed Practical Nurse/Resident Care Coordinator) as her Acting DON (Director of Nursing). V1 indicated this was the facility's current Administrative Staff. V31's (Vice President of Business Development and Strategy/Regional Director of Operations) Nursing Home Administrator's license is hanging on the wall of the facility. On 1/25/23 at 11:25 am, V1 stated she started as the facility's Administrator in Training under V31's (Vice President of Business Development and Strategy/Regional Director of Operations) Administrator's License on 8/22/22. V1 stated she stated she has the paperwork to apply for her Temporary Administrator License, but that documentation has not been submitted at of this time. V1 stated her testing date to become a Licensed Nursing Home Administrator is currently unknown. On 2/09/23 at 3:56 pm, V1 confirmed that V43 was the previous Administrator in Training (not a licensed) over the building, and he held that position from 2/16/21 - 7/15/22. According to record review and interviews, Administration failed to effectively act upon the following events regarding quality of care, quality of life and resident abuse: 1. Administration failed ensure all staff received necessary education and training. The following staff stated they had not received education on the Abuse Prevention Program since they began employment at the facility: V16 (Activities Director), V4 (Social Services), V25 (Licensed Practical Nurse), V21 (Unit Aide), V9 (Unit Aide), V18 (Certified Nursing Assistant), V34 (Unit Aide), V5 (Certified Nursing Assistant), V33 (Certified Nursing Assistant), and V23 (Housekeeper). Additionally, V1 confirmed the facility has not provided any education or training for new staff on managing residents with behavioral health needs. This includes: V2 (Assistant Administrator in Training), V3 (Resident Care Coordinator/Licensed Practical Nurse), V11 (Licensed Practical Nurse), V51 (Licensed Practical Nurse), V52 (Registered Nurse), V53 (Registered Nurse), V7 (Registered Nurse), V54, V63, V33, V64, V65, V19 (all Certified Nursing Assistants), V34, V55, V9, V35, V56, V57, V58 (all Unit Aides), V59 (Transportation Aide), V15 (Social Service), V14, (Social Service), V60 (Activities Aide) and V61 (Activities Aide), as cited at F943 and F741. 2. Administration failed to acknowledge, immediately report, and investigate allegations of verbal abuse, sexual abuse, and misappropriation, brought forth by residents of the facility during a Resident Council Meeting (1/10/23) in which V1 and V2 were present for, as cited at F600, F607, F609 and F610. 3. Administration failed to recognize that R9 was to be on 1:1 supervision when out of his room, per his Plan of Care, due to a history of sexually inappropriate behavior towards others, as cited at F600. This failure allowed R9 to have unsupervised access to female residents. R6 reported on 1/05/23, R9 had touched her sexually. R6, R11 and R13 reported on 1/10/23, R9 had touched them in a sexually inappropriate manner. 4. Administration failed to respond to numerous grievances and concerns voiced by residents during Resident Council (1/10/2023), affecting the quality of care and quality of life of those living in the facility, as cited at F584, F585, and F600. 5. Administration failed to recognize that R6, who has a State appointed Guardian, lacked the mental capacity to consent to known ongoing sexual relationship with R15, as cited at F600 and F610. 6. On 1/25/23 and 1/26/23, the State Surveyors discussed with V1 and V2 the following concerns regarding abuse within the facility: a.) R6 reported to V4 on 1/05/23 that R9 was touching her sexually. b.) R6, R11 and R13 reported in the January 10, 2023, Resident Council Meeting that R9 had touched them sexually, which was confirmed by V10 (Ombudsman). c.) R3 reported to V1, on 1/16/23, verbal abuse by V3. V10 reported R3's same allegation of abuse to V1 again, on 1/19/23, along with an allegation of physical abuse by V27 (Licensed Practical Nurse). d.) R1 was found to have suspicious inner thigh bruising of unknown origin when admitted to the hospital on [DATE], which was reported to the facility by hospital staff. e.) On 1/24/23, R5 had visible eye bruising of unknown origin, reportedly present for 2-3 days. At the time these concerns were originally discussed with V1 and V2, they had not been investigated or reported to the State Agency per the facility's Abuse Prevention Program. Upon returning to the facility on 1/30/23, V1 had yet to implement their Abuse Prevention Program regarding these allegations by initiating abuse investigations and suspending staff suspected of abuse, as cited at F607, F609 and F610. 7. Administration failed to ensure that R20, who is nonverbal and depends on enteral nutrition, received gastrostomy tube (g-tube) feedings for adequate nutritional intake and implement dietician recommendations to prevent significant weight loss. R20 went nine days without receiving any type of nutritional intake causing her emotional/psychological distress as well as pain related to hunger pains. R20 has also lost 20 lbs (11.4% weight loss) since R20 was admitted on [DATE] (five months). On 1/26/23 at 8:15 am, V10 (Ombudsman) stated, I'm in the building frequently, not as often as I'd like. At least 1-2 times per week. I come in and (V1's) door is always closed. If I go to (V1) with concerns she never acts on them. I've gone to her with abuse concerns that she doesn't look into. V10 went on to explain about an allegation of verbal and physical abuse she received from R3 on 1/19/23, that she spoke to V1 about that day. V10 stated she informed V1 that R3 told her V27 (LPN) would hit him in the leg when she passes his medication, and that V3 verbally abused him a few days prior. V10 stated V1 was not concerned with the allegations made and indicated that she had already discussed the situation with V27 and V3's behavior towards R3; however, V10 stated, I've discussed abuse concerns with (V1 before), but she doesn't act on them like she should. I'm concerned it wasn't reported or investigated as it should have been. V10 stated residents complain about the way V3 and V8 (Certified Nursing Assistant) speak to them, and she stated she has witnessed (V8) blow off medical concerns. V10 stated she was present for the 1/10/23 Resident Council Meeting, and V1 and V2 were in attendance, as they had been invited due to numerous resident concerns. V10 stated R2 (Resident Council [NAME] President) was voicing most of the concerns and other residents were agreeing with him. V10 stated some of the allegations made during the meeting were abusive in nature. V10 stated it was alleged that (V3) would take resident medications home with her. V10 stated R16 complained about staff not administering her pain medications. V10 stated residents complained of staff retaliating when they complain about something, like staff will be mean to them, make fun of residents, and yell at them. During the meeting, V10 stated she heard concerns about residents being yelled at by CNAs, nursing staff not doing their medication passes, giving medications late, and doubling up on medication passes. V10 stated, As soon as the State cleared the facility in November from their Annual Survey, everything changed back to how it previously was. When the facility was trying to get back into compliance, residents were happier, and Administration was responsive to my concerns. Residents felt like they could go to Administration at that time. But, since November, things have greatly changed. I will bring concerns to (V1), who acts like she cares but never acts on my issues. (V1) stands up for her employees, not the residents. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated she has been working as an Agency Nurse at the facility for several months now. V32 stated, Management is poor, and nothing gets done. V32 stated V1 will remove documentation from resident records and tell staff not to chart resident incidents, altercations, or elopements. V32 stated she had V1 tell her just last month not to document that R21 had eloped from the facility and had to be brought back by a member of the community that found her. V32 stated R6 and R15 have been caught having sex in their rooms and staff have been instructed by V1 to not let R6 in R15's room. V32 stated R9 has been taken off 1:1 monitoring for inappropriate sexual behaviors, because the facility didn't have the staff to constantly monitor him. V32 stated this even happened after State cited us for abuse (involving) R9 in 2022. V32 stated everyone, including V1, was aware that R6 had alleged sexual abuse by R9 on 1/05/23. V32 stated she texted V1 a few days after R6's allegation (1/05/23) was made, because R9 was being sexually inappropriate with R14, and V1 got upset with her for notifying her of the situation. V32 stated she has witnessed V3 yell at R3. V32 stated narcotics were reported missing about two months ago, but it was not investigated as diversion. V32 stated V3 will prep her medication prior to her medication pass, by putting the resident's pills in a cup so V32 can just hand them out to the resident. V32 stated she knows this is not proper practice, but it is how the medication is routinely handled. V32 stated she has noticed at times resident's that are to be receiving narcotics, the narcotic is not always in the cup prepped by V3. V32 stated, I have caught staff sleeping at night on third shift. I took pictures and sent them to (V1), but nothing happened to the staff. V32 indicated she has witnessed staff that are to be providing 1:1 supervision for resident watching movies/videos on their phone, especially at night. V32 stated new staff receive no training on how to handle the mentally ill population or abuse, and they have high school students providing 1:1 supervision at night, who have zero training. V32 stated V27 will hide in V3's office when she is supposed to be working on the floor. V32 indicated she has come on shift to find that V27 had not given R20 her bolus tube feedings or medications. V32 stated, I just told the Agency I couldn't work there anymore; residents are not taken care of, and there is such poor management in that building. On 2/02/23 at 1:59 pm, V4 (Social Services) stated she left her position on 2/24/23, because Administration was being extremely hostile to me after talking to you (State Surveyors). It was a very uncomfortable situation. V4 stated she came into her role in Social Services with no training from the facility on what her job was, what constituted abuse, or how to deal with the mentally ill population. V4 stated that V1 has known about R9's sexual behaviors. V4 stated R9 was openly discussed in the Morning Meeting with all of the Department Heads on 1/06/23. V4 stated they specifically discussed in that meeting, R9 going in and out of resident rooms at night, and that R6 reported R9 touched her sexually the day prior. V4 stated, at that time, it was suggested by the team that R9 go back on 1:1 supervision or they find placement for him elsewhere. V6 stated she recalls the discussion about placing R9 on 1:1 supervision, because Management didn't want things to escalate to a reportable incident. V4 stated the Social Service staff had also talked to both R6 and R15's family regarding their sexual relationship in December 2022. V4 stated V1 was fully aware of the situation, but V1 felt R6 and R15 had a high enough BIMS (Brief Interview for Mental Status) that they could not stop them from engaging in sex. V4 stated V1 spoke to both R6 and R15's families about their sexual relationship. The CMS-672 (Resident Census and Conditions of Residents), dated 1/24/23 and signed by V1 (Administrator in Training), documents 116 residents currently live in the facility. The Immediate Jeopardy began on 12/15/22 when R9 was removed from 1:1 supervision, giving R9 the opportunity to commit sexual and verbal abuse to female residents. V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were notified of the Immediate Jeopardy regarding R9 on 1/30/23 at 9:22 a.m. The facility submitted the original Abatement Plan to the State Agency on 1/31/23. A revision was requested and the final amended Abatement Plan was submitted on 2/01/23. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A Director of Nursing (V48) was hired and started 1/31/23. 2. V1 qualifies to be a LNHA (Licensed Nursing Home Administrator), has completed all portions of the application for Licensure with the IDFPR (Department of Professional Regulation), and her application was mailed 1/31/23. 3. V2 and V48 have mailed their applications to receive a temporary Administrator's License, so they can test to become a LNHA. 4. On 1/30/23, Regional Director of Operations in-serviced V1 on the Facility's Abuse Prevention Program, Abuse Occurrence Investigations form, CMS Abuse Critical element Pathway, Resident Rights, Injuries of Unknown Origin, QAA Policies and Processes and Resident Grievance/Complaint policies. 5. On 3/02/23, V1 is scheduled to attend LNHA training conference, provided by several members of the facility's Governing Body, contracted leaders, Regional Director of Operations,Regional Director of Clinical Operations and Wound Care Specialist. 6. Regional Team Members will be on site at minimum 3 days each week to monitor for continued compliance and training of Administration Team Members. 7. V49 (Serious Mental Illness Expert in Long Term Care) will consult with the facility quarterly, until deemed unnecessary. 8. V10 (Ombudsman) has been contacted to hold in-service on abuse with facility staff.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Tube Feeding (Tag F0693)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer a gastrostomy tube feeding as ordered for one of one resident (R20) reviewed for gastrostomy tube feedings in the sample of 25. As a result of this failure R20 had a significant weight loss of 20 lbs (11.4% weight loss) since R20 was admitted on [DATE] (five months). Findings include: The facility's Enteral Tube Feeding Bolus Procedure policy, undated, documents, It is the policy of the Facility to provide nutrition via Nasogastric or Gastrostomy tubes when ordered by physician. The resident may receive nutrition and hydration either by intermittent, continuous, or bolus feeding into the stomach by means of a tube when the oral route cannot be used. The policy also documents, Report unusual observations/findings to the physician. Report observations regarding feeding tolerance to the dietician. Document information related to feeding on flow record and/or TAR (Treatment Administration Record)/MAR (Medication Administration Record). On 2/6/23 at 2:00 p.m., R20 was lying in her bed on her right side with her eyes open. When spoken to, she lifted her head, made eye contact and laid back down without responding. On 2/6/23 at 3:30 p.m., R20 was partially sitting up in bed with a flat affect and no verbalization. Questions asked to R20. R20 did not respond verbally. However, did respond at times with a thumbs up or thumbs down partially, but it was hard to understand her response. R20 became frustrated and laid back down facing the wall. R20's Report of Monthly Weights and Vitals, dated 2022, documents: R20's admission weight on 8/6/22 was 176 lbs (pounds); 9/22 weight was 170 lbs (6 lbs 3.4% weight loss in one month); 10/22 weight was 160 lbs (10 lbs 5.9% weight loss in one month); 11/22 weight was 161 lbs (15 lbs 8.5% weight loss in three months); 12/22 weight was 157 lbs (13 lbs 7.6% weight loss in three months). R20's TAR (Treatment Administration Record), dated 1/23, documents R20's most recent weight was 156 lbs (20 lbs 11.4% weight loss in five months) on 1/19/23. R20's Physician's orders, dated 8/22, documents that R20 was admitted on [DATE] with an order to receive Jevity 1.2 237 ml (milliliters) via gastrostomy tube every three hours. R20's MAR (Medication Administration Record), dated 8/6-8/30/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 8/7 - 6:00 p.m., 3:00 a.m.; 8/8 - 6:00 p.m., 3:00 a.m.; 8/9 - 3:00 a.m.; 8/10 - 6:00 p.m., 9:00 p.m., 3:00 a.m.; 8/11 - 6:00 a.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 8/12 - 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 8/13 - 3:00 a.m.; 8/14 - 6:00 a.m., 12:00 p.m., 12:00 a.m., 3:00 a.m.; 8/15 - 6:00 a.m.; 8/16 - 12:00 a.m., 3:00 a.m.; 8/18 - 9:00 p.m.; 8/19 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 8/20 - 6:00 p.m.; 8/22 - 9:00 p.m.; 8/25 - 9:00 a.m., 3:00 p.m., 6:00 p.m. 9:00 p.m.; 8/30 - 6:00 p.m.; 8/31 - 9:00 p.m. for a total of 36. R20's Dietary Services Communication, dated 9/21/22 and signed by V40 (Registered Dietitian), documents, Observations: Nurse requests continuous feed for tube feeding. Gradual weight loss. Recommendations: Recommend Jevity 1.2 at 150 ml/hr for 12 hours overnight with 200 ml FWF three times a day during feedings. The communication also documents that the physician acknowledged and approved the recommendation on 10/20/22. R20's MAR, dated 9/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 9/1 - 6:00 p.m.; 9/6 - 6:00 p.m., 9:00 p.m.; 9/7 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 9/8 - 9:00 p.m.; 9/10 - 9:00 p.m.; 9/11 - 12:00 a.m., 3:00 a.m.; 9/12 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/14 - 9:00 p.m.; 9/19 - 6:00 p.m.; 9/20 - 6:00 p.m., 9:00 p.m.; 9/21 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 12:00 a.m., 3:00 a.m.; 9/22 - 6:00 p.m.; 9/23 - 6:00 p.m.; 9/24 - 6:00 p.m.; 9/25 - 6:00 p.m., 9:00 p.m.; 9/26 - 12:00 a.m., 3:00 a.m.; 9/27 - 6:00 p.m.; 9/28 - 6:00 p.m.; 9/29 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/30 - 6:00 a.m. for a total of 40. R20's Dietary Services Communication, dated 10/18/22 and signed by V40, documents, Observation: Gradual weight loss for 30 days. R20's Physician's orders, dated 10/22, document that R20 received an order on 10/20/22 for Jevity 1.2 at 150 ml/hr for 12 hours overnight with a 200 ml flush three times during feedings and a 30 ml flush twice a day before and after medications. R20's MAR, dated 10/22, has no documentation of R20 receiving her Jevity 1.2 237 ml every three hour bolus on the following dates/times: 10/1 - 3:00 p.m., 3:00 a.m.; 10/6 - 9:00 p.m.; 10/7 - 6:00 p.m.; 10/9 - 9:00 p.m.; 10/12 - 9:00 p.m.; 10/13 - 9:00 p.m., 12:00 a.m.; 10/16 - 9:00 p.m.; 10/17 - 6:00 p.m., 12:00 a.m., 3:00 a.m.; 10/27 - 12:00 a.m., 3:00 a.m.; 10/28 - 9:00 p.m., 10/29 - 9:00 p.m.; 10/30 - 12:00 p.m., 9:00 p.m.; 10/31 - 9:00 p.m. for a total 19. R20's MAR also documents that R20's order to receive Jevity 1.2 at 150 ml/hr overnight with 200 ml FWF three times a day during feedings was not started until 10/27/22 and there is no documentation of R20 receiving the overnight feeding on 10/29 or 10/30. R20's MAR (Medication Administration Record), dated 11/22, documents that R20 was to receive Jevity 1.2 for twelve hours overnight at a rate of 150 ml/hr being turned on at 8:00 p.m. and turned off at 8:00 a.m. The MAR has no documentation of R20 being administered the feeding on 11/3, 11/5, 11/6, and 11/9 as well as 11/1, 11/2, 11/7, 11/8 were circled as R20's tube feeding was not administered. In the same section that this tube feeding is signed off is a handwritten statement, On hold; pending discontinue-R20 doesn't remain still. The MAR documents that R20 was restarted on Jevity 1.5 237 ml bolus every three hours on 11/9 at 12:00 p.m. There is no documentation of R20 receiving the bolus on the following dates/times: 11/9 - 12:00 a.m. & 3:00 a.m.; 11/10 - 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/12 - 9:00 p.m.; 11/13 - 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/14 - 12:00 a.m., 3:00 a.m.; 11/15 - 9:00 p.m., 11/16 - 6:00 a.m., 12:00 a.m., 3:00 a.m., 11/17 - 6:00 p.m.; 11/18 - 6:00 a.m., 6:00 p.m.; 11/19 - 6:00 p.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 11/20 - 6:00 p.m.; 11/21 - 6:00 p.m.; 11/22 - 6:00 a.m.; 11/24 - 6:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/25 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m.; 11/26 - 3:00 p.m.; 11/27 - 6:00 a.m., 6:00 p.m.; 11/29 - 3:00 p.m., 6:00 p.m. for a total of 41. On 12/7/22 at 12:00 p.m., V11 (Registered Nurse) stated, There was an issue with the facility getting a tube feeding pump when we first got the order. So, it wasn't started right away. I actually spoke with (V40) myself to try and do something different than boluses every three hours because when it's busy it's not easy to get them done every three hours. If you missed one dose by getting sidetracked or busy by the time you were able to do it, she was due for her next one. So, she might miss a dose. R20's Nurses' notes, dated 11/9/22 at 9:00 p.m., document, Fax sent to doctor to discontinue pump feeds and continue with bolus feeds every three hours due to safety concerns related to inability to remain in bed for 12 hours. R20's Physician notification form, dated 11/9/22, documents, R20 has gastrostomy tube and was ordered for 12 hour of Jevity 1.2 at 50 ml/hr. R20 does not remain still and is constantly getting up and walking halls. Unsafe to be hooked to machine for any length of time. Please consider returning to bolus feeds of Jevity 1.5 237 ml every three hours. The form also documents the physician's order to refer to dietician for orders. On 2/7/23 at 1:20 p.m., V24 (Registered Nurse) stated, I don't work that hall too often. The facility was having difficulty getting the right equipment for (R20's) continuous feeding. We didn't have the equipment until the night of the 9th. I was the first one to hook her up for the feeding when we had the right equipment. I attempted to do the feeding and she wouldn't stay in the bed, and she was wanting to leave the room. The tubing was stretching, and it just wasn't working. So I contacted the doctor about getting them stopped and switched back to the bolus feedings. I did the bolus feedings as she previously had ordered. I mentioned it to the other nurses that nobody was signing out a bolus feed, but they were circling that the continuous feed wasn't getting done. It looks like we aren't feeding her. I don't know that all of the nurses were giving her the normal schedule of bolus feeding during that time. I know it wasn't on the MAR to give them. I was terrified to put my name in the book, so I contacted the doctor. If it's not signed off in the MAR, then you can only assume it's not done. I don't know of anyone notifying the physician prior to that evening. R20's Dietary Notes, dated 11/16/22 and signed by V40, document, CBW 161 lbs. Significant weight loss noted: 8.5% in 90 days. R20's Dietary notes, dated 12/13/22 and signed by V40, documents, CBW 157 lbs. Significant weight loss noted: 7.65% in 90 days. Weight trending down in 30 days. R20's MAR, dated 12/22, has no documentation of R20 receiving her Jevity 1.5 237 ml every three hour bolus on the following dates/times: 12/3 - 6:00 a.m., 6:00 p.m.; 12/4 - 3:00 p.m., 6:00 p.m.; 12/7 - 9:00 p.m.; 12/13 - 12:00 a.m., 3:00 a.m.; 12/17 - 6:00 a.m., 6:00 p.m., 9:00 p.m.; 12/19 - 6:00 p.m.; 12/21 - 6:00 p.m., 9:00 p.m.; 12/22 - 9:00 p.m.; 12/26 - 3:00 p.m. for a total of 15. R20's MAR, dated 1/23, documents from 1/7-1/20 R20 had an order to receive Jevity 1.2 474 ml bolus four times a day, and there is no documentation of R20 receiving the bolus on 1/11 at 6:00 a.m. and 12:00 a.m. The MAR also documents that this order was discontinued on 1/20/23 and Jevity 1.5 375 ml bolus four times a day was started. There is no documentation of R20 receiving that bolus on 1/21 at 6:00 p.m. or 1/30 at 12:00 p.m. R20's Physician's orders, dated 2/23, document that R20 has an order dated 1/20/23 to receive Jevity 1.5 375 ml bolus four times a day via gastrostomy tube. R20's MAR, dated 2/23 obtained on 2/6/22 at 3:00 p.m., documents that R20 has an order to receive Jevity 1.5 375 ml bolus four times a day. The MAR also documents that as of 2/6/23, there is no documentation that R20 received her bolus on 2/4 at 6:00 p.m. & 12:00 a.m. and 2/5 at 6:00 a.m. and 12:00 a.m. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated, (V27/Licensed Practical Nurse/LPN) was not feeding (R20), who was to get a tube feed. Several weeks ago, I came on shift and (V27) was giving me report. She was saying how (R20's) tube feeding had been infusing all night. I started to question her, because (R20) didn't have an infusion pump or continuous feeding. (V27) argued that (R20) did have an infusion pump and I just let it go. As soon as (V27) left, I went to (R20's) room. The door was closed. I was right, they didn't' start (R20) on continuous pump, she was still on bolus feedings. (R20) can't talk much, but can say 'yes' or 'no.' She was really agitated when I went in her room, needed oral care, it was obvious it hadn't been done. I asked (R20) if she got fed by the nurse before me and she indicated 'No.' So I gave her her feeding. When I went to the MAR, it was signed off by (V27) as being given. Honestly, I don't think (V27) went into her room all night. We don't even have a tube feeding pump in the building. (R20's) behaviors will increase because she is hungry. I've seen it other times. I will come in and she will be agitated, and her feedings will not be documented as given. As soon as I feed her, her agitation stops. On 2/7/23 at 12:40 p.m., V40 (Registered Dietician) stated, (R20) should not be losing weight with the amount of calories and protein that she gets on a daily basis from her tube feedings. It gets frustrating. I make recommendations and they don't get followed up with. I was not notified when they changed the tube feeding from continuous overnight back to the boluses. I didn't know about it until I came in for my monthly visits. They should have consulted with me about what to put her on. On 2/7/23 at 1:20 p.m., V24 (Registered Nurse) stated, I don't know that (R20) always gets her feedings or if she does if they are late. I don't want to assume, but her behaviors are escalated when I suspect it. It seems like she has an increase in behaviors. She complains of pain at times too. She will normally tell me she has a headache, which could be part of hunger pains. She doesn't eat, and then nurses may not be giving her all of her boluses. This breaks my heart. She can't verbalize. She can't tell us that she is hungry. On 2/7/23 at 4:10 p.m., V41 (Medical Director) stated, (R20) should not have gone without receiving her tube feedings. I agree that these issues needed to be addressed. On 2/8/22 at 10:15 a.m., V11 stated, (R20) doesn't have many behaviors. When she first got here she was exit seeking mainly. Now though she will sit on the floor; she learned that from an old roommate. Now the only thing I really notice is the yelling out occasionally. Sometimes, if you ask her, she will say she's having pain; she will shake her head 'yes.' Sometimes, I feel like her yelling out is related to her feedings. I will ask her if she's hungry and she will say 'yes' at times. The yelling out is sometimes when she's due for a feeding as well. There are times too that it's hard to understand what she wants because she will shake her head 'yes' and 'no' to respond to our questions, but sometimes 'yes' looks like 'no' and 'no' looks like 'yes,' and I can't decipher what is wrong. On 2/8/23 at 1:50 p.m., V3 (Resident Care Coordinator/Acting Director of Nursing/DON) stated, Nurses should be documenting when they administer medications or treatments on their MARs and TARs. If they don't sign it off, we don't know if it was done. The rule of thumb is if no signature, then it wasn't done. On 2/16/23 at 11:35 a.m., V48 (Director of Nursing) stated, The doctor and the dietician should have been notified prior to the 11/9 that there was no equipment to administer (R20's) continuous feeding. They should have known that we had to keep the boluses going, and then contact them letting them know when the continuous feeding was actually started. The boluses should have continued until the continuous feeding was started. I don't see where (R20) got any type of feeding from 11/1-11/9. V48 also confirmed the lack of documentation that R20 received her scheduled g-tube feedings.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Laboratory Services (Tag F0770)

A resident was harmed · This affected 1 resident

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Based on interview and record review, the facility failed to obtain laboratory draws as ordered by a physician for one of three residents (R1) reviewed for laboratory values in the sample of 25. This failure resulted in R1 being hospitalized with a critically low Valproic acid level. Findings include: The facility's Laboratory Tests policy, no date available, documents, Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations, and physician orders. Obtain laboratory orders upon admission, readmission, and PRN (as needed) for medication and condition monitoring per the physician's orders. R1's Physician's orders, dated 10/22, document the following orders: 10/18/22 Increase Depakote to 1125 mg by mouth three times a day. Check Depakote (Valproic Acid) level in one week. R1's most recent Valproic blood level, dated 9/30/22, documents a level of 46 low (Normal 50-100). The facility was unable to provide any Valproic acid levels after this date. R1's Hospitalist admission History and Physical, dated 1/17/23, documents, R1 with severe schizophrenia, tardive dyskinesia, seizure disorder brought in from facility with complaints of lethargy and worsening tremors. R1 is lethargic, barely responsive, and thus unable to contribute to the history. History was obtained from emergency department records and from her mother at the bedside. The History & Physical also documents, Depakote level is subtherapeutic. R1's Hospital Progress note, dated 1/19/23, documents that R1's Valproic Acid is less than 13 (Normal 50-125). On 2/2/23 at 9:30 a.m., V1 (Administrator in Training) confirmed that R1's most recent Valproic acid level was drawn on 9/30/22. On 2/8/23 at 1:50 p.m., V3 (Resident Care Coordinator/Acting Director of Nursing) stated, The laboratory comes to our facility every Monday, Wednesday, and Friday unless it is a stat (as soon as possible) order. If it is stat, they come right away. If the physician orders for a lab to be drawn I would expect it to be done on the next scheduled lab draw day.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform a thorough and timely investigation of a fall, complete neurological assessments following a fall with head involvement, implement new fall interventions, and assess a resident post fall to ensure no further injury for three of three residents (R1, R5, R7) reviewed for falls in the sample of 25. Findings include: The facility's Fall Prevention policy, dated 11/10/18, documents, Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unity nurse will place documentation of circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. Report all falls during morning Quality Assurance meetings Monday through Friday. All falls will be discussed in Morning Quality Assurance meeting and any new interventions will be written on the care plan. The facility's Head Injury policy, dated 12/22/17, documents, It is the policy of the facility to evaluate head injuries for a minimum period of 72 hours, to determine any negative effects, and to allow for immediate treatment to minimize permanent damage. The policy also documents, The following procedure focuses on proper assessment of residents who have sustained a head trauma. Determine if resident is on anti-coagulant or any medication that lends itself to the thinning of the blood. If a resident is on such medication they are to be sent out for evaluation. Ongoing assessment (vital signs and neurological checks) should take place as follows: Initially and every 15 minutes for one hour; Every 30 minutes for one hour; Every hour for four hours; Every four hours for 8 hours; Every shift for the remainder of 72 hours. 1. R1's Nurses' notes, dated 10/6/22 at 8:30 a.m., document, R1 found sitting on the floor in her room at this time. Unable to voice what happened but another resident reports that she saw her fall. Both witness and R1 report R1 did not hit her head. R1's nurses' notes have an entry on 10/6/22 at 5:00 p.m. and 10/7/22 at 5:00 a.m. However, no vital signs are documented in those entries. Also, there is no documentation of any type of assessment following R1's fall. The next documented entry in R1's nurses' notes is 10/14/22 at 6:00 p.m. R1's Quality Care Reporting Form, dated 10/6/22 at 8:30 a.m., documents that R1 had a fall in her room, and she has no injuries but complains of pain everywhere. The form also documents that the investigation was not completed until 1/3/23 and the new intervention was for R1 to be on 15 minute visual checks. R1's 15 minute visual checks, dated 10/1-10/6/22, document that R1 was on 15 minute visual checks prior to R1's incident on 10/6/22. R1's Nurses' notes, dated 11/19/22 at 1:30 p.m., document, R1 found on floor on right side in doorway. Wheelchair at feet with trash in seat. R1 denies injury but states did bump head on floor. No redness, bumps or bruises. R1 states had been taking trash to trash can and was pushing wheelchair when she fell. R1's nurses' notes have an entry at 4:00 p.m. on 11/19/22. However, no vital signs are documented in this entry nor is there any documentation of any type of assessment following R1's fall. The next documented entry in R1's nurses' notes is 11/24/22. R1's Neuro/Head Trauma Assessment, dated 11/19/22, documents, Record vital signs in appropriate box. Place NA (not applicable) in the box if the resident does not exhibit the symptoms. Place an X in each box for each symptom found. Notify the physician if any abnormal results are found. Assess as follows: a) initially and every 15 minutes times four; b) every 30 minutes times one hour; c) every one hour times four hours; d) every four hours times eight hours; and e) every shift for remainder of 72 hours. The Assessment has no documentation of R1 being assessed for the every four hours for eight hours nor for the every shift assessment. R1's Nurse's notes, dated 12/29/22 at 9:30 p.m., document, R1 found on floor in room. Laying on right side hanging onto bed rail. Legs bent. Moderate amount of blood coming from nares. Nose is red and swollen. Resident sent to emergency department for evaluation. R1's Hospital After Visit Summary, dated 12/30/22 at 6:56 a.m., documents, Diagnoses: Contusion of nose. R1's Neuro/Head Trauma Assessment, dated 12/29/22, documents that R1 had a neurological assessment initially at 9:20 p.m. then R1 was at the hospital for the every 15 minute checks x 4, every 30 minute checks x 2, every hour checks x 4 and the first every four hour check. There is no documentation of any further neurological checks being done from the second every four hour check x 2 nor the every shift assessment x 7. R1's Quality Care Reporting Form, dated 12/29/22 at 9:20 p.m., documents that R1 had a fall in her room, and she has an injury to her nose that is red, swollen, and bleeding. The reporting form also documents that the new intervention to prevent further falls is a medication review by R1's physician, and that the investigation for this fall was not completed until 1/3/23. R1's Nurses' notes, dated 12/29/22 to 1/16/23, have no documentation of R1's return from the hospital on [DATE] nor the three day post fall monitoring every shift. R1's Quality Improvement Review documents, 1/3/23: QA (Quality Assurance) meeting related to review of fall on 10/6/22. As root cause up with no assistance. No injury. Intervention resident will be placed on 15 minute visual checks; 1/3/23: QA meeting related to review of fall on 12/29/22 with root cause of resident up with no assistance with contusion to nose. Nursing intervention for resident's medication to be reviewed by physician. On 2/2/23 at 9:30 a.m., the facility was unable to provide documentation of a medication review being completed for R1 by a physician. V1 (Administrator in Training) confirmed that there is no medication review for R1. On 2/2/23 at 2:50 p.m., V47 (MDS/Minimum Data Set) Coordinator) stated, R1's care plan was not updated for her falls on 10/6/22, 11/19/22, and 12/29/22 until 1/3/23. V47 also confirmed that (R1's) neurological assessments were missing assessments. On 2/2/23 at 4:00 p.m., V6 (Certified Nursing Assistant/CNA) confirmed that R1 was on 15 minute checks prior to 10/6. 2. On 1/24/23 at 11:50 a.m., R5 was alert but nonverbal sitting up on the side of her bed. R5 sits up and then lies down with almost constant spastic movements. R5 had a purple and yellow bruise with swelling to the outer corner of R5's right eye. R5's Nurses' notes, dated 10/3/22 at 11:30 a.m. document, R5 was observed standing at nurses' station. Resident backed up over another resident wheelchair foot pedal and fell. R5's Quality Care Reporting form, dated 10/3/22 at 11:10 a.m., documents that R5 had a fall at the nurses' station. The form has no documentation of V44 (R5's Power of Attorney) being notified. The form also documents that the investigation for this fall as not completed until 11/7/22. R5's Nurses' notes, dated 10/27/22 but no time, documents, R5 had fall today. Reported by staff and other resident. R5's Quality Care Reporting form, dated 10/27/22 at 12:30 a.m., documents that R5 had a fall in R5's room. The form also documents that the investigation for this fall as not completed until 11/7/22 with an intervention for PT (Physical therapy)/OT (Occupational therapy) to evaluate R5. R5's Nurses' notes, dated 12/9/22 at 8:00 a.m., document, R5 was in dining room and went to sit in chair, sitting too hard on one side causing R5 to fall with chair coming on top of her. Bruising and skin tear noted to right hand. R5's Quality Care Reporting form, dated 12/9/22 at 8:00 a.m., documents that R5 had a fall in the facility dining room. The form also documents that the investigation for this fall as not completed until 12/22/22 with an intervention for R5 to have 1:1 supervision. R5's Quality Improvement Review documents, 11/7/22: QA team met for R5 fall on 10/13/22 at 11:10 a.m. R5 tripped over wheelchair. No injury noted. Educated staff on putting all equipment on one side of hallway for clearer paths. 11/7/22: QA team met for R5 fall on 10/27/22. R5 lost balance. No injury noted. Refer to PT/OT for further evaluation. R5's Resident Monitoring One to One, dated 12/31/22, documents that R5 was on 1:1 supervision on this date. R5's Current medical record has no documentation of R5 receiving a PT/OT evaluation from 10/22 to 1/23 nor any other 1:1 monitoring from 12/9-12/30/22. On 2/2/23 at 2:50 p.m., V47 (Minimum Data Set Coordinator) stated, (R5) was not on 1:1 until at least 12/31. The 1:1 for 12/31 was the only 1:1 for the month of December that was in her chart. There is no physical or occupational therapy evaluations in her chart from October to now. V47 also confirmed that (R5's) care plan was not updated with fall interventions. 3. On 2/1/23 at 1:20 p.m., R7 was alert walking around in his room. R7's right hand had yellow fading bruising to his middle and ring finger. R7 stated, I got mad and punched the door. I shouldn't have done that, and I know better. R7's Nurses notes, dated 10/26/22 at 7:00 a.m., document, R7 reported hitting head on nightstand while backing over to plug something in. No discoloration noted. R7 on Coumadin. Neuro checks initiated. R7's Neuro/Head Trauma Assessment, dated 10/26/22, documents that R7's neurological assessment was not completed on four of the seven shifts for every shift assessments. R7's medical record has no documentation of R7 being sent to the ER after hitting is head as a result of an incident. R7's Quality Care Reporting form, dated 10/26/23 then marked over to be dated 10/26/22 at 7:00 a.m., documents that R7 had an incident in his room. The form also documents, Pain location: Tenderness to area on hand. The form has no signature as to who completed this form, and its dated as being completed on 2/2/23. Also, the investigation portion of the form is blank as well as no new intervention to be implemented to prevent further incidents. R7's Nurses' notes, dated 1/5/23 at 9:50 a.m., document, R7 got up from bed, states he became dizzy causing him to fall falling backwards. Denies pain. Sent to emergency room for evaluation. R7's Quality Care Reporting Form, dated 1/5/23, documents that R7 had a fall on 1/5/23 at 9:40 a.m. in his room, and was sent to the ER. The form also documents the investigation was not completed until 1/9/23. R7's Physician's orders, dated 1/23, document an order received on 1/23/23 to x-ray R7's right hand due to pain and swelling. R7's X-ray report, dated 1/23/23, documents, Impression: The appearance of deformity of the distal aspect of the 5th metacarpal suggestive of acute fracture. R7's Nurses' notes nor rest of current medical record have any documentation of what occurred in order for the physician to order an x-ray for R7's right hand. Then, following the results there was no investigation completed nor follow up documentation. As of 1/25/23, the last Nurses' notes entry was 1/5/23. R7's care plan, dated 5/14/20, has no documentation of any revision following R7's incidents on 10/26/22 and 1/23/23. On 2/2/23 at 2:50 p.m., V47 confirmed R7's care plan was not updated following his incidents. On 2/2/23 at 3:30 p.m., V1 (Administrator in Training) and V31 (Vice President of Business Development and Strategy/Regional Director of Operations) confirmed that R7's Incident investigation was dated 2/2/23 and 10/26/22 and that there was not two separate investigations for each incident (10/26/22 and 1/12/23). They also confirmed that incidents when a resident hits their head require neurological checks, and sent to ER if on Coumadin, but (R7) was not sent to the ER on [DATE]. On 2/2/23 at 9:30 a.m., V1 stated, After a fall a resident should be charted on for 3 days every shift.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to administer insulin as ordered by the physician, for one of three residents (R4) reviewed for medication administration, in a sample of 25. Findings include: The facility policy, titled Medication Administration (revised 11/18/17), documents Policy: Drugs and biologicals are administered only by physicians and licensed nursing personnel. Definition: Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Responsibility: Licensed nursing personnel; Procedure: 1. Routine Times of Medication Administration: 2. Each facility shall establish a policy for the routine time of medication administration. 3. Medications must be prepared and administered within one hour of the designated time or as ordered. (I.e., Medication time is 9:00 AM. The medication can be administered as early as 8:00 AM and as late as 10:00 AM. Medication is ordered as daily then medication can be given during the day at resident's preference). 4. Set up medication cart to ensure all needed items are available (i.e., medication cups, water cups, applesauce, syringes, pill crusher, etc.). 5. Keep the medication cart in view at all times. If it is likely the medication cart will be out of visual control at any time, it must be locked. 6. Medications must be identified by using the seven (7) rights of administration: Right resident; Right drug; Right dose; Right consistency; Right time; Right route; Right documentation. A Physician's Order Sheet, dated 1/01/23, documents R4 has the diagnosis of Type 2 Diabetes Mellitus, and is to receive Insulin Glargine 10 Units sub-q once daily at 8:00 am and Lispro Insulin 100 Units/ml (milliliter) sub-q, based on a sliding scale, four times per day (8:00 am, 11:00 am, 4:00 pm, 8:00 pm). R4's Lispro Insulin Sliding Scale order is as follows: Accucheck of 151-180 administer 1 Unit Accucheck of 181-200 administer 2 Units Accucheck of 201-250 administer 4 Units Accucheck of 251-300 administer 6 Units Accucheck of 301-350 administer 8 Units Accucheck of 351-400 administer 10 Units Accucheck greater than 400 administer 12 Units R4's Medication Administration Record, dated 1/01/23, documents R4 has received Insulin Glargine 10 Units sub-q at 8:00 am and 8:00 pm on the following dates: 1/01/23, 1/03/23, 1/06/23, 1/08/23, 1/12/23, 1/13/23, 1/14/23, 1/17/23, 1/23/23 and 1/25/23. R4's Medication Administration Record, dated 1/01/23, documents R4 did not receive Insulin Glargine 10 Units sub-q at 8:00 am, but instead at 8:00 pm, on the following dates: 1/02/23, 1/10/23, 1/19/23 and 1/24/23. R4's Medication Administration Record documents the following errors: On 1/04/23 at 11:00 am - No accucheck and no insulin administered; On 1/06/23 at 8:00 pm an accucheck of 216 with no insulin administered; On 1/07/23 at 8:00 am an accucheck reading of 190 and no insulin was given and at 8:00 pm an accucheck of 327 with only 4 units of insulin given; On 1/08/23 at 4:00 pm an accucheck of 237 with no insulin administered; On 1/19/23 at 8:00 am an accucheck of 187 with no insulin administered and at 11:00 am an accucheck of 308 with no insulin administered; On 1/20/23 at 4:00 pm an accucheck of 1 and no insulin administered. On 2/02/23 at 10:04 am, V3 (Resident Care Coordinator/Licensed Practical Nurse) stated any areas on R4's Medication Administration Record that has no initials or is blank, would indicate that the medication was not given. V3 stated there should be a corresponding nursing note as to why the medication wasn't given, as well. V3 could not explain why R4 was receiving the scheduled Insulin Glargine 10 Units twice per day on some days in January and agreed the Physician's Order was for 10 units at 8 am only. On 1/24/23 at 2:00 pm, R4 stated she has frequent issues with staff either not giving her insulin or giving her the wrong dose. R22 (R4's roommate) stated there was a recent day when V27 (Licensed Practical Nurse) double dosed R4's insulin, giving her two doses within 90 minutes. R22 stated R4 became lethargic and wasn't responding to her, so she fed her yogurt. According to R22, V27 came in and was unable to even get a blood sugar reading on R4, because her blood sugar was so low. R4 then stated she barely remembers what happened that day because her blood sugar was so low, but she does remember telling V27 that she was giving her the insulin too early, but she didn't listen.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0776 (Tag F0776)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician ordered radiology services for two of three residents (R1, R5) reviewed for physician ordered radiology services in the sample of 25. Findings include: 1. R1's Nurses' notes, dated 9/13/22 at 5:50 p.m., document, Assistant Director of Nursing notifies this nurse R1 having choking episode to call ambulance. Ambulance contacted. Assistant Director of Nursing performing Heimlich as R1 is not responding and oxygen saturations decreased. Able to loosen obstruction. R1 responsive and breathing when ambulance arrives. Transported to hospital for evaluation. R1's Emergency Department discharge instructions, dated [DATE], document, Have speech pathology work with R1 and continue mechanical soft diet. Chief Complaint: R1 with report of choking on her food. Facility nurse able to clear obstruction prior to ambulance arrival. R1 with history of choking on food. Ambulance states R1 has chocked twice in the last month. R1's Physician's orders, dated 9/22, document the following order: 9/22/22 referral for cookie swallow - diagnosis choking. R1's Hospital Speech Therapy notes, dated 11/22/22, History and Physical: R1 was referred to speech therapy by physician for recurring episodes. Recommendations: If total feed assist can be provided then regular consistency with thin liquids is recommended. If total assist cannot be provided, recommend minced and moist with thin liquids. The notes also document that these recommendations are a result of R1's barium swallow results. On 2/1/23 at 1:49 p.m., V6 (Certified Nursing Assistant/Scheduler) stated, (R1) had her cookie swallow done on 11/22/22. V6 also confirmed that this cookie swallow was from the physician order on 9/22/22. 2. On 1/24/23 at 11:50 a.m., R5 was alert but nonverbal sitting up on the side of her bed. R5 sits up and then lies down with almost constant spastic movements. R5's CT (Computed Tomography) of head or brain without contrast results, dated 7/28/22, documents, Impression: Correlation with patient history and further evaluation with MRI is recommended. The results also document that the physician circled this statement and wrote get and signed his name. On 1/24/23 at 1:30 p.m., V11 (Registered Nurse) confirmed that R5's Physician order for R5 to get an MRI (Magnetic Resonance Imaging) in response to R5's CT results. R5's MRI of her Brain results, dated 12/29/22, document, Diffuse cerebral volume loss, advanced for the patient's stated age. No acute intracranial findings. On 1/24/23 at 12:50 p.m., V20 (Unit aide) was assisting R5 with her meal of mechanical soft Swiss steak, cheesy potatoes, carrots, cake, thin liquids, and a high calorie high protein ice cream cup. R5's Physician's orders, dated 11/22, document that on 11/7/22 R5's physician ordered a cookie swallow due to R5's difficulty swallowing. On 2/1/23 at 12:25 p.m., R5 was served pureed pulled pork, macaroni and cheese, pureed beets, chocolate pudding and nectar thick liquids. V8 (Certified Nursing Assistant/CNA) was coming from the kitchen with pureed peanut butter and jelly sandwich. V8 stated, (R5) went for a swallow study today and they changed her diet to pureed and nectar thick liquids. On 2/1/23 at 1:30 p.m., V6 (CNA) stated, I received (R5's) referral for a cookie swallow from an order on 12/7/22. She had the cookie swallow done today (2/1/23). Her MRI on 12/29/22 was from a referral after she had her CT scan done in July. V6 confirmed that R5's MRI was not completed until 12/29/22.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to serve physician ordered therapeutic diets for three of four residents (R5, R8, R16) reviewed for therapeutic diets in the sample of 25. Findings include: The facility's Therapeutic & Mechanically Altered Diets policy, dated 4/06, documents, It is the policy of the facility that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietician. A therapeutic diet is a diet ordered to manage problematic health conditions. Examples include caloric specific, low-salt, low-fat, low lactose, no sugar added, and supplements during meals. The policy also documents, A physician's order is written for all diets including therapeutic and mechanically altered diets. All physician ordered diets are planned in writing. Portion sizes are evident for each item on the menu extensions. The facility prepares and serves all therapeutic and mechanically altered diets as planned. 1. R5's Physician's orders, dated 1/23, document that R5 has an order to receive a high calorie high protein supplement shake three times a day and high calorie high protein ice cream at lunch. On 1/24/23 at 12:50, V20 (Unit aide) was assisting R5 with her meal of mechanical soft Swiss steak, cheesy potatoes, carrots, cake, and a high calorie high protein ice cream cup magic cup. V20 confirmed that R5 did not have a high calorie high protein shake. On 1/25/23 at 12:10 pm, V18 (Certified Nursing Assistant/CNA) was assisting R5 with her meal of grilled cheese, mashed potatoes, mixed fruit, yogurt, apple juice, and orange juice. R5 was not served a high calorie high protein shake or high calorie high protein ice cream cup as confirmed by V18. On 1/26/23 at 112:20 p.m., V17 (CNA) was assisting R5 with her meal of a grilled cheese, chocolate oatmeal pie, and yogurt. R5 was not served a high calorie high protein shake or high calorie high protein ice cream cup as confirmed by V17. On 2/1/23 at 12:25 p.m., R5 was served pureed macaroni and cheese and pork, pureed beets, chocolate pudding and nectar thick liquids. V8 (CNA) was coming from the kitchen with a pureed peanut butter and jelly sandwich for R5. R5 was not served a high calorie high protein shake or high calorie high protein ice cream cup as confirmed by V8. 2. R8's Physician's orders, dated 1/23, document the following orders: Diet: Regular, pureed meats, thin liquids, lactose intolerant, double portions. R8's Diet order form, dated 1/3/23, documents, Diet consistency: Mechanical soft, Pureed (meat only), double portions. On 1/24/23 at 12:54 pm, R8 was alert sitting in the dining room feeding herself mechanical soft Swiss steak, cheesy potatoes, carrots, and cake. On 2/1/23 at 12:50 p.m., R8 was served pulled pork macaroni and cheese, beets, butternut squash, and pudding. A dietary card sitting on table with R8's name on it states, Double portions pureed meat. At 12:55 p.m., V28 (Dietary Manager) confirmed that R8's card did state double portions and pureed meat, but R8 was served mechanical soft meat. V28 also confirmed that the portions on R8's plate were not double portions. R8's Current Care plan, dated 7/15/22, has no documentation of a comprehensive care plan addressing R8's dietary needs. 3. R16's Physician's orders, dated 1/23, documents a diet order for R16 of low carbohydrates and high protein, no fish, oranges, or pork. R16's Care plan, dated 6/9/22, documents, R16 in need of restriction of nutrition in form of calories/carbohydrates (salt, calories, fat, cholesterol, protein, nuts, etc.) related diagnosis/condition: Obesity, Crohn's disease. Other risk factors: Fibromyalgia, IBS (Irritable Bowel Syndrome). Interventions: Serve diet with restrictions ordered. On 1/30/23 at 12:10 p.m., R16 stated, They are not serving me the right food as what I'm supposed to have. Today is baked ham, potatoes, carrots, bread, and fruit. I can't have pork so obviously I can't have the ham, and what do you think they offered me. They want to give me a grilled cheese. Really, I need protein not the carbohydrates of the bread and the potatoes. I don't think that I'm getting enough protein. On 1/30/23 at 12:10 p.m., V28 (Dietary Manager) was present with R16 and confirmed that lunch for that day was baked ham. V28 stated she has worked as dietary manager since November and the meal substitutes have always been peanut butter and jelly, grilled cheese, and deli meat sandwiches. V28 stated, These are the only substitutes that we have for each meal. I'm not sure if the substitutes have the same amount of actual protein as the protein I served. On 2/1/23 at 2:25 p.m., V28 stated, (R16) has a high protein low carbohydrate diet. I don't follow any specific diet for her. I just try to give her extra of whatever the protein is that we are serving. On 2/2/23 at 12:50 p.m., V40 (Registered Dietician) stated, If a resident is high protein low carbohydrate then the facility would follow the CCD (carbohydrate conscious diet) diet and add an extra protein at breakfast or double protein at meals.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure resident records documented significant events that resulted in residents being transferred out of the facility, for two of nine residents (R2, R6) reviewed for accuracy of medical records, in a sample of 25. Findings include: The facility's policy, titled Nursing Documentation Guidelines advises nursing staff to chart the following, Behavior/Orientation Documentation: 1. Any changes in the resident's behavior or level of orientation. 2. Chart only objective terms, only the facts. 3. Description of symptoms. Document the resident's exact behavior. Accident/Incident Documentation: 1. The circumstances surrounding the accident/incident. 2. Where the accident/incident took place. 3. Date and time the accident occurred. 4. Name of witnesses and their account of the accident/incident. 5. The time physician was notified and what was ordered, if applicable. 6. The date and time the family was notified, if applicable. 7. The condition of the resident, including vital signs. 8. Disposition of the resident (i.e. transferred to hospital, put to bed, x-rays, neuro checks, etc.). 9. All pertinent observations. 10. Every shift documentation for 72 hours after the accident/incident occurred. 11. Date, time, signature, and title of person recording the data. 1. On 1/24/23 at 2:48 pm, V1 (Administrator in Training) stated just yesterday (1/23/23), R6 had been upset with her parents, got mad and just walked out of the facility in the presence of staff. V2 (Administrative Assistant in Training) immediately walked out with R6 and was following her. V1 stated she and V3 (Licensed Practical Nurse), V6 (Certified Nursing Assistant) and V7 (Registered Nurse) also went outside to follow R6 and try to redirect her back to the building. V1 stated R6 walked about four blocks as they followed and then ran into a field, took off all her clothes, grabbing loose grocery bags that were laying on the ground and threatened to hang herself with them. R6 then ran to the cemetery. V1 stated when they could not get R6 to comply with putting on her clothes and returning to the facility, they called an ambulance to take her to the local hospital, where she is currently admitted . V1 stated R6 was outside for approximately 30 minutes. R6's medical record contains no documentation of this incident. The last documented Nursing Note is dated 1/23/23 at 9:30 am, No adverse reactions from medication change. Able to focus on conversations briefly and express her needs. Ambulates in facility with steady gait. 2. On 1/24/23 at 12:10 pm, V1 stated R2 had attempted to sexually assault a Certified Nursing Assistant (V5) on 1/14/23. According to V1, who was not in the facility at the time of the incident, V5 called the police to report what R2 had done to her and R2 was arrested and charged with attempted sexual assault. On 1/31/23 at 1:45 pm, V30 (Police Officer) stated he was R2's arresting officer on 1/14/23. V30 stated he responded to a 911 call at the facility. V5 told him that R2 pulled her pants down and then pulled his pants down. R2 then pulled V5 in close, putting his penis between her legs. V5 indicated she distracted R2, and she got away. According to V30, R2 denied the assault and said all he did was hug V5 in his room. V30 confirmed that R2 is currently in jail and awaiting to appear before the Judge. R2's medical record was reviewed and contained no documentation of the alleged event, or that R2 had been taken from the facility and placed in jail. The last documented Nurse's Note, was on 1/14/23, which is (R2) returned to facility from (home visit).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

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2. R1's Report of Monthly Weights and Vitals, dated 2022, documents the following weight: 11/22, 204 lbs (pounds). R1's Dietary Services Communication, dated 11/18/22, documents, Observation: Gradual weight loss. Dietary Recommendations: 4 oz high calorie high protein shake at lunch. This communication has no documentation that the physician nor V45 (R1's Power of Attorney) was notified of this recommendation. R1's Report of Monthly Weights and Vitals, dated 2022, documents the following weight: 12/22, 199 lbs (pounds) which is a 17 lbs and 7.9% weight loss in three months (9/22, 216 lbs). R1's Dietary Services communication, dated 12/14/22, documents, Observation: 7.8% weight loss in 90 days. Dietary Recommendations: 4 oz high protein high calorie shake twice a day. This communication has no documentation that the physician nor V45 were notified of this recommendation. 3. R5's Dietary Services Communication, dated 10/18/22, documents, Observation: 12.23% weight loss in 180 days. Dietary recommendations: high calorie high protein ice cream cup at lunch. The communication was signed by the physician approving the dietician's recommendation. The form has no documentation of V44 (R5's Power of Attorney) being notified. R5's Quality Care Reporting form, dated 10/27/22 at 12:30 a.m., documents that R5 had a fall in R5's room. The form has no documentation of V44 being notified. R5's Dietary Services Communication, dated 12/14/22, documents, Observation: 7.59% in 30 days, 14.62% in 90 days, 18.44% in 180 days weight loss. Dietary recommendations: Chocolate high protein high calorie ice cream cup at lunch, 4 oz high calorie high protein shake twice a day, weekly weights for four weeks. The communication was signed by the physician approving the dietician's recommendations. The form also documents that this document was noted on 1/6/23, and there is no documentation of V44 being notified. R5's Dietary Services Communication, dated 1/19/23, documents, Observation: 15.15% (weight loss) in 90 days, 20.45% in 180 days weight loss. Dietary recommendations: 4 oz high calorie high protein shake three times a day. The communication was signed by the physician approving the dietician's recommendation. The form has no documentation of V44 being notified. On 1/24/23 at 11:50 a.m., R5 was alert but nonverbal sitting up on the side of her bed. R5 had a purple and yellow bruise with swelling to the outer corner of R5's right eye. On 1/24/23 at 4:30 p.m., V11 (Registered Nurse) stated, Yeah I guess (R5) does have a bruise on her eye. Supposedly, (V8 Certified Nursing Assistant/CNA) knew for a few days that (R5) had the bruise. I worked the weekend, and she never told me about it. I haven't done any kind of report on it. R5's Nurses' note, dated 12/28/22 at 9:30 a.m., documents, CNAs notified this nurse this morning that R5 was unable to bear weight on her right leg. R5 had to be placed in a wheelchair and placed on 1 on 1's as she was unable to ambulate independently. Also showing nonverbal signs of pain including crying and grimacing. Dr called and updated. He recommended sending R5 out. 911 called and R5 left for hospital via ambulance. On 1/25/23 at 1:25 p.m., V44 stated, They sent her to the ER (Emergency Room) the day before her MRI (Magnetic Resonance Imaging) because she wouldn't bear weight and she was showing signs of pain. I called the facility because they did not call me to tell me about the MRI being scheduled, and that's when I found out she was at the ER. They said, 'Oh yeah she's at the ER.' I don't trust this facility. They don't notify me of anything. I didn't know she was losing weight until I saw her at the neurologist appointment in November and she looked thinner than I'd ever seen her. 4. R20's Physician's orders, dated 10/22, document that R20 received an order on 10/20/22 for Jevity 1.2 at 150 ml (milliliters)/hr (hour) for 12 hours overnight with a 200 ml water flush three times during feedings and a 30 ml flush twice a day before and after medications. R20's MAR (Medication Administration Record), dated 10/22, documents that R20's order to receive Jevity 1.2 at 150 ml/hr overnight with 200 ml water flush three times a day during feedings was not started until 10/27/22 (7 days after it was ordered) and there is no documentation of R20 receiving the overnight feeding on 10/29 or 10/30. R20's MAR, dated 11/22, documents that R20 was to receive Jevity 1.2 for twelve hours overnight at a rate of 150 ml/hr being turned on at 8:00 p.m. and turned off at 8:00 a.m. The MAR has no documentation of R20 being administered the feeding on 11/3, 11/5, 11/6, and 11/9 as well as 11/1, 11/2, 11/7, 11/8 were circled as R20's tube feeding was not administered. R20's current medical record has no documentation of R20's physician being notified that the facility was unable to provide R20's tube feeding as well as R20 not receiving any tube feedings. On 2/7/23 at 4:10 p.m., V41 (Medical Director) stated, I should have been notified when the facility wasn't able to get the tube feeding supplies and (R20) went without tube feedings before 11/9/22. On 2/1/23 at 2:25 p.m., V28 (Dietary Manager) stated, The nurses should notify the doctor and families of significant weight loss. On 2/8/23 at 1:50 p.m., V3 (Resident Care Coordinator/Acting Director of Nursing) stated, The nurses should be notifying the family of all medication changes, falls, injuries, changes of condition, and weight loss. The physician should be notified by the nurses immediately of weight loss. V3 also stated, If they don't sign it off, we don't know if it was done. The rule of thumb is if no signature then it wasn't done. Based on record review and interview, the facility failed to notify the family/physician of a change in resident's medical condition and/or transfer to the hospital, for four of four residents (R6, R1, R5, R20) reviewed for change in condition, in a sample of 25. Findings include: The facility policy, titled Notification for Change in Resident Condition or Status (revised 12/07/17), documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Healthcare Power of Attorney, etc.) of changes in the resident's medical/mental condition or status. Responsibility: Administrator, Director of Nursing, Charge Nurse. 1. On 1/24/23 at 2:48 pm, V1 (Administrator in Training/AIT) stated the day prior (1/23/2023) R6 exited the facility in the presence of V2 (Administrative Assistant in Training), who immediately walked out with R6 and was following her. V1 stated herself and V3 (Resident Care Coordinator) and V7 (Registered Nurse/RN) also went outside to follow R6 and try to redirect her back to the building. V1 stated R6 walked about four blocks as they followed, and then ran into a field, taking off all her clothes, grabbing loose grocery bags that were laying on the ground and began threatening to hang herself with them. V1 stated R6 then ran to the cemetery. V1 indicated they could not get R6 to comply with putting on her clothes and returning to the facility, so they called for an ambulance to transport her to the local hospital. V1 stated V3 did not notify R6's State Guardian (V30), who is also R6's mother, of R6 leaving the building and threatening suicide or that R6 had been taken to the hospital. V1 stated staff should have notified V30 and the physician at the time R6 was sent out by ambulance of what had occurred and where R6 was being transferred to. On 1/25/23 at 12:07 pm, V30 stated she was unaware R6 had been transferred out of the facility on 1/23/23 until the hospital R6 was transferred to called her the day after (1/24/23). V30 stated R6 is at a hospital that is approximately 200 miles from the facility, and she knew nothing of R6's threats of suicide or that she left the facility. V30 stated, This happens all the time. (R6) had three prior hospitalizations this year that the facility did not notify me of, and (R6) has been sent out to the emergency room numerous times in the last few months that I was completely unaware of. On 1/24/23, R6's medical record, including Nursing Progress Notes and Physician's Orders, contained no documented evidence that R6 left the facility and threatened suicide on 1/23/24, or that R6 was transferred to the hospital by ambulance. R6's medical record contained no documented evidence of R6's physician being notified of her change in condition and transfer. Nursing Notes, dated 7/10/22, document Writer received call from (V30) stating (R6 is two hours away in a hospital). (V30) stated she was not contacted by facility about transferring her daughter out of the facility. Administrator notified.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to provide a clean, comfortable, and homelike environment for their residents. These failures have the potential to affect all 116 residents that currently live in the facility. Findings include: Resident Council Meeting Minutes dated 1/10/2023 by V16 (Activities Director), document resident concerns with adequate heat in some resident rooms, mice throughout the facility, mouse droppings in drawers in resident rooms and on the floors, lack of hot water, and feces being left in the showers and other areas of the facility. A Resident Council Issues Form, dated 1/10/23, documents Department: Maintenance. Concern/Complaint: No showers for a week while renovations are going on. No electricity in B-Hall is still happening. Residents are upset that they went 6 days without hot water. They would also like to know why they have to turn the hot water on in the sink for the hot water in the shower to work. Heating issues are still happening. Repairs need to be done to code. Mouse droppings in drawers, spiders and ants in building. Another Resident Council Issues Form, dated 1/10/23, documents Department: Housekeeping. Concern/Complaint: Residents would like more (housekeeping) staff. Feces are spread through the facility. When it happens, the floor needs to be sanitized right away. Sanitation tools still need to be provided for CNAs (Certified Nursing Assistants). Mouse droppings in drawers. A Resident Council Meeting Summary, dated 1/10/23 by V10 (Ombudsman) documents, Residents would like housekeeping to stay later as the aids do not have the things they need for cleaning up messes. Residents are finding (feces) on their toilets and sinks in their bathrooms and shower rooms. A resident stepped in (feces) and walked all through the facility tracking it everywhere and it was not cleaned up until housekeeping came back in. Residents reported their heat is not working in their rooms. I have talked to (V1/Administrator in Training) about this and every time it is bought up, (V1) states she has to follow up with (Maintenance). V10's documentation also includes, Mouse droppings all over facility. On 01/26/2023 at 11:10 am, V10 provided a copy of documented concerns that R2 handed out to everyone in attendance at the 1/10/23 Resident Council Meeting. R2 documented the following, We have very good housekeepers now. But they leave at 5:00 (p.m.) or so. This facility doesn't shut down at 5:00 pm. There needs to be a housekeeper to sanitize bodily secretions off of the floors and other issues. Yes, some things can be accomplished by CNAs (Certified Nursing Assistants), but this administration does not supply the CNAs with any tools and sanitation equipment to properly do it. We share bathrooms with 3 other people. Some residents have to be cleaned. The basins get used for this but never get sanitized, and We have gone extended periods of time without hot water. We have gone extended periods of time without electricity and lights in our bathrooms. Enough is enough. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she was present at the 1/10/23 Resident Council Meeting, along with several residents, V1 (Administrator) and V2 (Assistant Administrator in Training). V10 stated R2 (Resident Council [NAME] President) was voicing most of the concerns, as he had documented them and passed his concerns out to everyone at the meeting. V10 stated all the other residents present were agreeing with R2's concerns. V10 stated multiple residents had complaints about the heat not working in some resident rooms, mice in the facility, feces on the floor for extended periods of time, and resident drawers have mice droppings in them. V10 stated these concerns have been ongoing, and this is not the first time they have been brought to the attention of V1. V10 stated when she visits the facility, it is overall dirty, especially the floors. On 1/24/23 at 10:33 am, the floor of R3's room had noticeable buildup of dirt and grime in several locations. At that time, R3 stated, The two younger housekeepers are not sweeping or mopping his floor, but the two older housekeepers keep my floor clean when they are here. R3 stated he caught a mouse in his room the day prior, and then opened the bedside dresser drawer to show the mouse droppings in it. R3 stated he does not keep food in his room because of the mice problem throughout the facility. There were no mouse traps in R3's room on 1/24/23. On 1/24/23, at 2:00 pm, R4 was interviewed regarding mice in the facility and the cleanliness of her room. R4 stated, Oh, the mice are a real problem. I just had one crawl on my shoulder last night as I was laying in bed. You should look in those drawers. At that time, mouse droppings were observed in the top drawer of her dresser and in the bottom drawer of her nightstand. There was dirt and grime build up on the floor, along with pieces of trash. At 2:12 pm, while interviewing R4, a mouse ran across the floor and under R4's bed. R4 stated, See, there they (the mice) are! R4's roommate (R22) spoke up and stated, The staff just tell us this is an old building, and we need to just get used to the mice. They don't realize that they need to clean, too. R4 and R22's bathroom had feces on the toilet seat and mouse droppings on the floor under the sink. On 1/24/23 at 11:50 a.m., R5's room had mouse droppings scattered along the baseboards and behind the toilet. On 1/24/23, at 10:28 am, an attempt was made to interview R17 in his room, but he was not there. Upon entering R17's room, it was noticeably very cold, but it was assumed at that time R17 may have wanted his room cold. On 1/31/23 at 12:59 pm, R17 was in his room wearing a heavy jacket. The temperature in R17's room was very cold. R17 stated, It's so cold in here. I've told them that my heater stopped working one week ago and I was told they are waiting on a part to fix it. R17 stated, I have a mouse that lives under my nightstand. R17 opened the door to his nightstand, and it contained numerous mouse droppings. There were no mouse traps seen in R17's room. On 1/25/23 at 10:15 a.m., V22 (Housekeeper) stated, We have issues with mice. I haven't actually seen them, but I see where they are chewing on things like resident food. I see the droppings in drawers as well. The residents will say they see them running across the floor. On 2/1/23 at 1:15 p.m., R14 stated, We have mice. I've seen them go across the floor before. See there's mouse poop in my closet (pointing at closet). Mouse droppings were on the floor in her closet. On 1/24/23 at 3:45 p.m., V16 (Activities Director) stated residents continue to complain about the mice and there are mouse droppings in the vending cart. V16 stated, There are mice droppings everywhere, and I found a bag of pretzels with a hole chewed through it in a resident's bedside table. V16 stated recently a resident had a box of snacks that he kept in the Activity Room and mouse had gotten into the box eating a whole container of noodles. On 1/25/23 at 12:59 pm, V1 (Administrator in Training) was interviewed regarding the concerns brought forth in the 1/10/23 Resident Council Meeting. V1 stated she was present for that meeting and was aware that residents had numerous complaints. V1 stated the facility has tripled their pest treatments in the facility, and pest control now comes weekly. V1 stated the Regional Maintenance Supervisor has gone room to room to identify mouse holes in the walls and get them patched, but it is not 100% done. V1 stated Corporate Office was asked to hire more housekeeping staff to keep up with cleaning, as well. V1 was aware of electrical and hot water issues but did not know the status of those concerns. V1 indicated she has told housekeeping and the Certified Nursing Assistants to look through drawers and clean and sanitize if mouse droppings are found but is unaware if this is being done on a scheduled basis. On 2/06/23 at 2:09 pm, V37 (Maintenance Director) stated R17's heater in his room has been nonfunctioning for over a week now. V37 was advised that R17 stated on 1/31/23 the heater had been broken for a week and V37 confirmed that was true. V37 stated the part to repair R17's heater was not approved by Management to be ordered until 2/02/23. V37 stated he is not sure what date it was ordered after the approval, but stated they are awaiting the delivery of the parts. V37 stated other residents have had issues with the heaters in their rooms, but he repaired them. The CMS-672 (Resident Census and Conditions of Residents), dated 1/24/23 and signed by V1 (Administrator in Training), documents 116 residents currently live in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to make a prompt effort to resolve numerous resident grievances filed with Social Services and voiced during the Resident Council Meeting (1/10/23). This failure has the potential to affect all 116 residents that reside in the facility. Findings include: The facility policy, titled Resident Grievances/Complaints (no date), documents It is the policy of (the facility) to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others without discrimination or reprisal. Grievances and/or complaints may be reported to the Administrator, any staff member, the Resident Advisory Council, the Long-Term Care Advisory Board and to State Agencies. All staff is required to report any and all grievances and complaints received from Residents. The Administrator is responsible to promptly resolve complaints and grievances. Procedures for filing and handling grievances and complaints are: 1. Complaints and grievances may be presented to any staff member at any time. If possible, the staff person will resolve the problem immediately. 2. Resident Council meetings are to allow time for Residents to address complaints, grievances and other concerns which shall be reflected in minutes of the meeting. The facility liaison to the Resident Council shall direct complaints and grievances to the appropriate Department Head who will resolve the complaints and/or grievances. The Administrator shall also receive copies of the minutes so he/she can follow up to ensure resolution. 3. When a Resident [NAME] or complains to a staff member, that staff member shall explain the issue to his/her Supervisor and together they shall complete a Grievance/Complaint Form. The Supervisor shall then investigate and resolve the complaint. In some cases, it may be necessary for the Administrator to resolve the problem. 4. If it is determined that multi-disciplinary intervention is necessary, the grievance/complaint shall be presented at a regularly scheduled resident care plan conference or at a family conference. 5. Grievance and complaint investigations shall be completed within 15 days by the Investigator who shall distribute copies of the report to the Administrator and the Social Services Director. The Social Service Director shall keep complete forms on file. 6. The Investigator shall notify the Resident and document the results of the investigation and notification on the grievance/complaint form. The Social Service Director is responsible to notify the family and resident representative of the resolution. 7. The Social Service Director and the Administrator shall discuss the grievance or complaint with all persons involved. The 1/10/23 Resident Council Meeting minutes document the following concerns: Under Administration - lack of communication, V1 (Administrator in Training/AIT) has no training in Behavioral Health, requesting R9 be transferred out of the facility, retaliation by the staff towards residents, HIPPA (The Health Insurance Portability and Accountability Act) violations, staff need a chain of command. Under Nursing - insubordinate staff, medication passes being missed (at 4:00 pm specifically), (staff) ignoring residents, concerns with V3 (Licensed Practical Nurse/LPN) specifically, residents being given the wrong medication, V3 yelling at family members, V27 (LPN) is administering multiple medication passes at once and sleeps in the Nursing Office, LPN's (Licensed Practical Nurses) are stealing narcotics, Nurses retaliating when residents give them issues, and Diabetic (residents) need to be monitored. Under CNAs (Certified Nursing Assistants) - Yelling at residents is not ok and needs to stop and retaliating with residents when they have issues with things. Under Side Notes - R9 needs to be a 1:1 (supervision) at all times, over nights too. Residents are not comfortable in (R9's) presence and are scared of him, R9 is very violent, overly sexual, calling names, and going through other resident rooms. A Resident Council Concern/Complaint form given to Administration, dated 1/10/23 documents, Some residents feel like there is a lack of communication. Residents would also like if (R9) was (transferred) out of the facility because they feel unsafe, and Residents also think that staff, such as CNAs and Nurses, are retaliating when they bring up issues to them that staff does not agree with. A resident brought up the staff need a chain of command and (V27/LPN) is giving multiple (medication) passes at once. She takes naps in the nursing office. (V27) argues with other nurses. (R2) brought up LPNs stealing narcotics. The Response/Resolution part of this grievance is blank and has not been addressed by Administration as of 1/25/23. A Resident Council Concern/Complaint form dated 1/10/23 given to Department: Nursing, documents Residents feel the department is chaos. There are (medication) passes being missed. 4:00 pm pass especially. Nurses are ignoring residents. The residents would like a D Hall nurse established. Residents are being given the wrong medications. Certain nurses are retaliating against residents that give them issues. Our Diabetic residents need to be monitored more frequently when it comes to their blood sugar levels. They would also like the nurses to go over their medications with them. Residents feel that the nurses could work on their bedside manners. The Response/Resolution part of this grievance is blank and has not been addressed by Administration as of 1/25/23. A Resident Council Concern/Complaint form dated 1/10/23 given to Department: CNAs, documents Residents believe that the CNAs yelling at residents is not okay. Showers need to be cleaned and sanitized after each shower. They are also concerned that the CNAs are retaliating when the residents bring up issues to them that they do not agree with. CNAs need to be marking resident's belongings when they arrive, it's causing issues in other Departments. The Response/Resolution part of this grievance is blank and has not been addressed by Administration as of 1/25/23. A Resident Council Concern/Complaint form dated 1/10/23 given to Department: Dietary, documents Nutrition is horrible. Residents are leaving the tables hungry. Portions are too small. Food is not good. They want knives. Ham and beans are not good, they feel like it's just ham, beans and water. Kitchen is running out of food by the time the second (dining) is ready. (V28/Dietary Manager) is hard to talk to and approach. The Response/Resolution part of this grievance documents, Will try to do better, and is signed by V28. A Grievance/Complaint form, dated 1/05/23, by R23 documents, (R23) walked in the activity room with money and asked if he could get a soda. (V46/Activities) said yes, so (R23) went to get one off of the shelf and she yelled at him, saying 'NO! You guys need to stop getting stuff off the f*****g shelf.' (R23) replied 'O.K.' and walked out of (the) activity room. This Grievance was documented as being received by V15 (Social Services), with nothing documented by V1 under the Method of Correction or Disposition of Complaint. A Grievance/Complaint form, dated 1/02/23, by R22 documents, I was told by (V46/Activities) that I could not smoke because (V16/Activities Director) found two vapes in my room. She said it loudly in front of the other residents to embarrass me in front of people. I didn't want people to know I got in trouble. (R22) also stated (V46) will not look them in the eye or treat them with respect. (V46) will refuse to fill up their ice container. This Grievance was documented as being received by V4 (Social Services), with nothing documented by V1 under the Method of Correction or Disposition of Complaint. A Grievance/Complaint form, dated 1/07/23, by R16 documents, The D Hall Nurse did not arrive on time for morning (medication) pass. Resident was very upset and in pain. Writer spoke to B Hall Nurse and was told they were aware, and someone was on their way. Nurse said medication had been pre-prepped by the D Hall Nurse and she could not dispense it. Informed (R16) her nurse was running behind, but she was going to be here soon. (R16) went back to room, visible anger present with no comment. This Grievance was documented as being received by V4 (Social Services), with nothing documented by V1 under the Method of Correction or Disposition of Complaint A Grievance/Complaint Report, dated 1/05/23, documents R6 had concerns with (R9) rubbing on her butt, putting arm around her (and) saying 'Baby, give me a kiss,' touched her breast, looked up her dress. Also, going up (and) down A Hall (at) night, (R6) claimed, 'I can hear (R9) through the wall.' This Grievance was documented as being received by V4 (Social Services), with nothing documented by V1 under the Method of Correction or Disposition of Complaint. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated, when interviewed regarding the facility's resident grievance process, I have a paper that I made that has the concern on it. I write the concerns out and deliver them to the (specific) Department. The Department is supposed to respond back with a follow up that I then relay back to the resident council the following month. (During the 1/10/23 Resident Council Meeting) Retaliation was (mentioned by R2), but he didn't expand on it. (Medication) passes are (being) doubled up. This was from (R2), but this isn't the first time I've heard it. They mentioned (V27/Licensed Practical Nurse). They will point out (to V27) that it's the wrong pill and will tell (V27 but she) forces them to take it without explaining. This is the first time I've heard this. (R2) said (nurse) popped the narcotic pill out, put it to the side of the medication cart, then slide it into her pocket. V16 stated residents also complained, The diabetics don't get things to help with the blood sugars and it's brushed under the table. (R2) has brought it up, but I've seen it myself. The resident was (R4). (R4) gets pale and real shaky, voice wavering. The nurse was with (R4) but didn't do anything. Residents continue to complain about the mice. There are mice droppings everywhere, and I found a bag of pretzels with a hole chewed thru it in a resident's bedside table. (R9) had a box of snacks in the activity room. A mouse had gotten into a box of noodles and ate the whole container. Mouse droppings (are) in (the) vending cart. The vending cart has snacks they can buy. (R2) reported that if you don't do something the CNAs like, they will raise their voices. And (R9), he's very sexual. (R9) will literally come up behind a person, grab their hips, get real close and dance with them. Multiple residents have brought it up. (R9) is overly sexual. (R9) will make sexual comments to people as well. (Residents) piped in and said (R9) had been overly sexual towards them. They didn't bring up specific times but chimed in when it was brought up. (Complained that R9) would literally walk into a room and take stuff or go through drawers. I don't know if he was in rooms with residents who couldn't tell him to get out, but I wouldn't put it past him. I started in August, but within the last 3 months it's gotten more frequent. (R9) was taken off and put back on 1:1 multiple times for a total of 1 month. (V1/Administrator in Training) was at the Resident Council meeting. (V1) was invited by the residents. I've brought (R9) up to (V1) several times, but he still does things. V16 then confirmed that a copy of the Resident Council meeting minutes for January 2023 was given to V1 for further review. On 1/25/23 at 12:59 pm, V1 (Administrator in Training) confirmed that she was present for the 1/10/23 Resident Council Meeting and she had received a copy of the Resident Council Meeting notes. With regard to the resident concerns brought forth at the meeting, V1 stated, I still want to go through and talk to residents; when I get complaints, I don't always jump. V1 stated, My approach to the wrong medications being given and narcs (narcotics) being stolen was to wait and see how med (medication) pass was going. My thought process is it's not over. I'm waiting to sneak up and see what I catch. V1 stated she did complete a Narcotic Count at the medication carts, which was fine. V1 stated she at some point asked V3 (Licensed Practical Nurse/Resident Care Coordinator) if anything had anything reported regarding missing narcotics, and the answer was no. V1 stated she just started getting copies of the Resident Council Meeting minutes and she received the copy from the (1/10/23) meeting minutes last week. V1 stated she did read the minutes when she received them and acknowledged There were several serious concerns brought up at the meeting. V1 stated she did not interview any residents that had specific concerns, but she did have a conversation with R6 regarding R9. V1 stated she could not recall any specifics regarding the allegation of CNAs yelling at residents, but I decided to do a broad in-service regarding bedside manner and customer service that day, as it was a scheduled in-service day. V1 did admit that the allegations that came from the Resident Council Meeting could lead to an abusive situation. V1 stated, I didn't view the complaints warranted interviewing specific residents in private to determine what CNAs are yelling at residents and what they are yelling at them for. V1 stated she did not interview any staff regarding other staff's behavior. When V1 was questioned about the statement made by R2 that staff are retaliating against them when they complain, V1 stated she talked to my Department Heads and instructed them to do 'Angel Rounds,' inquiring as to if residents have concerns about retaliation. V1 was unable to provide any documentation related to the information gathered during 'Angle Rounds.' V1 stated she did not recall the word retaliation being used in the Resident Council Meeting but concluded retaliation is concerning. V1 denied knowledge of the other individual grievances filed by R23, R22, R16 and R6. The CMS-672 (Resident Census and Conditions of Residents), dated 1/24/23 and signed by V1 (Administrator in Training), documents 116 residents currently live in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to implement their Abuse Prevention Program, which requires the immediate reporting and investigation of all allegations of abuse, the immediate suspension of individuals alleged to have committed abuse, the immediate protection a residents from further abuse, and the investigation of injuries of unknown origin that could have been abusive in nature, for eight of 12 residents reviewed (R6, R10, R11, R12, R13, R3, R1, R5) for abuse in a sample of 25. These failures have the potential to affect all 116 residents that currently reside in the facility. Findings include: The facility policy, titled Abuse Prevention Program (updated 11/28/16) defines Abuse: Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy documents under, IV. Internal Reporting Requirements and Identification of Allegations: Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property to a supervisor and administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. Protection of Residents: The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway. Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse or misappropriation of resident property shall not complete their shift as a direct care provider to residents. Vl. Internal Investigation of Allegations and Response: 1. Appointing an Investigator. Once the administrator or designee receives an allegation of mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property; the administrator will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the Resident Protection Investigation Procedures. 2. Following the Resident Protection Investigation Procedures. The appointed investigator will follow the Resident Protection Investigation Procedures, attached to this policy. The Procedures contain specific investigation paths depending on the nature of the allegation, procedures for investigation, interview parameters, and reporting requirements. 3. Confidentiality. The investigator shall do as much as possible to protect the identities of any employees and residents involved in the investigation until the investigation is concluded. After a conclusion based on the facts of the investigation is determined, internal reports, interviews and witness statements shall be released only with the permission of the administrator or the facility attorney. Even if the facility investigation is not complete the administrator will cooperate with any Department of Public Health investigation into the matter. 4. Updates to the Administrator. The person in charge of the investigation will update the administrator or designee during the progress of the investigation. The administrator or designee will keep the resident or resident's representative informed of the progress of the investigation. 5. Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: Name, age, diagnosis and mental status of the resident allegedly abused or neglected; The original allegation (note day, time, location, the specific allegation, by whom, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries; Facts determined during the process of the investigation, review of medical record and interview of witnesses; Conclusion of the investigation based on known facts; If there is a police report, attach the police report; If the allegation is determined to be valid and the perpetrator is an employee, include on a separate sheet the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions, and current status (still working, suspended or terminated); and Attach a summary of all interviews conducted, with the names, addresses, phone numbers and willingness to testify of all witnesses. The administrator or designee will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The administrator or designee is also responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken. 6. Quality Assurance Review. Any investigation that concludes that abuse occurred shall be reviewed by the facility Quality Assurance committee for possible changes in facility practices to ensure that similar events do not occur again. VII. External Reporting of Potential Abuse 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. A written report shall be sent to the Department of Public Health. The written report should contain the following information, if known at the time of the report: Name, age, diagnosis, and mental status of the resident allegedly abused or neglected; Type of abuse reported (physical, sexual, theft, neglect, exploitation, verbal, or mental abuse); Date, time, location, and circumstances of the alleged incident; Any obvious injuries or complaints of injury; and steps the facility has taken to protect the resident. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property and that an investigation is being conducted. 2. Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The Public Health requirements for a final investigation report are detailed in paragraph 5 of the Internal Investigations section of this procedure. For the protection of all individuals involved, copies of any internal reports, interviews, and witness statements during the course of the investigation shall be released only with the permission of the administrator or the facility attorney. 3. Informing the Resident's Representative. The administrator or designee will inform the resident or resident's representative of the conclusions of the investigation. 1. A Grievance/Complaint Report, dated 1/05/23 and completed by V4 (Social Services Director), documents R6 complained (R9) rubbing on her butt, putting arm around her (and) saying 'Baby, give me a kiss,' touched her breast, looked up her dress. Also, going up (and) down A Hall (at) night, (R6) claimed, 'I can hear (R9) through the wall.' Resident Council Meeting minutes dated 1/10/23 document (R9) needs to be on a 1 on 1 at all times, overnights too. Residents are not comfortable in his presence and are scared of him. (R9) is very violent, overly sexual, calling names, going through resident's rooms, (R10, R6, R11 and R12) have all brought attention to this. A Resident Council Concern/Complaint form, dated 1/10/23 by V16 (Activities Director), documents Residents would also like if (R9) was out of the facility because they feel unsafe. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: Other concerns: (R9) is touching and grabbing women in a sexual behavior. (R9) is pinning residents against walls and counters as well. (R6) stated that (R9) has looked up her skirt, grabbed her breast, and rubbed his penis on her many times. It was stated in resident council that (R9) does not have a 1:1 anymore, and (R13 stated R9) touched my boobs and rubbed his penis on me, and (R11 stated R9) is getting into peoples' faces and personal space and touching the way she don't want to be touched. On 1/24/23 at 3:15 pm, V4 (Social Services Director) stated R6 told her on 1/05/23 that R9 was rubbing on her butt, breast and saying inappropriate sexual statements to her, wanting a kiss and telling her to drop that a**. According to V4, R6 stated she could hear R9 wandering the halls at night, all night, going into others' rooms. V4 stated R6 was very upset over the fact that R9 had been on 1:1 supervision in the past for similar behavior but was taken off 1:1 supervision and was allowed to do this to her. V4 stated she wrote up the statement from R6 on 1/05/23 and then took it to morning meeting with all the Department Heads on 1/06/23 to be discussed. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she attended the most recent Resident Council Meeting (1/10/23). V10 stated R6 verbalized in the Resident Council Meeting R9 rubbed his penis on her and rubbed her boobs and other female residents complained about R9 being sexually inappropriate with them. On 1/30/23 at 10:18 am, R6 was interviewed over the phone, as she was admitted to the hospital. R6 stated R9 touches my boobs, tries to kiss me, and will come up to me and rub his penis on me through his clothes. (R9) will hold on to me from behind. It makes me feel uncomfortable and this happens almost every single day. R6 stated R9 will call her names, like N****r, C**t, and B***h when she pushes him away. On 1/25/23 at 12:59 PM, V1 denied knowledge of the 1/05/23 grievance completed by V4 regarding R6 and R9. V1 confirmed that she was in attendance for the Resident Council meeting on 1/10/23. V1 stated she did not interview the four female residents that spoke out about R9's sexual behavior in the Resident Council Meeting. V1 stated, I recall (R6) speaking out against (R9) and (R10) as well. I do not remember the other two residents having specific concerns with (R9). I can't tell you my exact immediate follow up. I did not interview any residents that had concerns. At some point, I had a conversation with (R6 about R9), but I do not know when and did not document the details. On 1/30/23 at 9:17 am, V1 stated in a follow up interview she has still not initiated any kind of formal investigation into the sexual abuse allegations reported to her last week involving R9. 2. An official court document, dated 4/10/2017 documents V30 (R6's Mother) and V37 (R6's Father) as being appointed Guardians of the Estate & Person of (R6), a disabled adult, and are authorized to have, under direction of the Court, the care, management, and investment of the ward's estate and the custody of the ward, and to do all acts required by them by law. Physician's Orders, dated 1/01/23, document R6 has the current diagnoses of Anxiety, Schizoaffective Disorder, Intellectual Disability, and Chronic Post Traumatic Stress Disorder. On 1/31/23 at 1:05 pm, V10 (Ombudsman) stated V30 (R6's Mother) contacted her today, very upset and concerned about R6 being in a sexual relationship with a male resident in the facility. V10 stated V30 discussed this with the Social Services Department in December, but the facility was not doing anything to stop R6 from having sexual intercourse with this resident. V30 stated the concern is that R6 does not have the mental capacity to consent to a sexual relationship with someone. On 2/02/23 at 1:30 pm, V30 stated she reviewed her phone records and she spoke with V1 on 11/08/22 about R6 and R15 having sex. V30 stated V1 told her R6's BIMS (Brief Interview for Mental Status) was too high, and they were able to consent to a sexual relationship. V30 stated she told V1 that she did not agree, as (R6) has the mentality of a teenage girl, and there is a reason I'm her legally appointed Guardian. On 2/02/23 at 1:59 pm, V4 (Social Services Director) stated V4 talked to both R6 and R15's families regarding their sexual relationship in December, but (R6 and R15) had a high enough BIMS, so they could not stop them. V4 stated, (V1) was fully aware (of their sexual relationship); she has talked to (R6 and R15's) family regarding this. V4 stated they did discuss developing a care plan with individualized interventions to keep R6 and R15 from having sexual relations, but that never transpired. On 2/01/23 at 2:33 pm, V14 (Social Service) stated she has heard from multiple staff and residents that R6 and R15 are in a sexual relationship. V14 stated, The first time I heard about them having sex, (R6) was in the hospital. It was a couple of months ago. Since (R6) was in the hospital, it was after the fact, and I did not report it to (V1). V14 stated there was a recent Care Plan meeting with R6's parents, V4 and V15. V14 stated, The main topic of that meeting was (R6's) sexual relationship with (R15). On 2/01/23 at 3:55 pm, V1 stated she did not have an investigation initiated regarding R6 and R15's sexual relationship. 3. Resident Council Meeting minutes, dated 1/10/23 document the following concerns: LPN (is) stealing narcotics, CNAs (Certified Nursing Assistants) yelling at residents is not okay and needs to stop, and (CNAs) retaliating with residents when they have an issue with things. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Administration, under Concern/Complaint it states in the notes section, CNAs and nurses are retaliating when they (residents) bring issues to them that staff does not agree with, and (R2) also brought up LPNs (Licensed Practical Nurses) stealing narcotics. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/18/23, documents Department: CNAs, under Concern/Complaint: Residents believe that the CNAs yelling at residents is not okay, and They are also concerned that the CNAs are retaliating when the residents bring up issues to them that they do not agree with. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Nursing, under Concern/Complaint: Certain Nurses are retaliating against residents who give them issues. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: (Nursing Staff) ignore residents when residents need help. One resident stated the less cognitive a resident is the worse it is for them, Residents being forced to stay in their rooms or go to their rooms, It was stated that when (R3) had a fainting episode staff makes fun of him because the staff think he is faking it (V11/Registered Nurse is the main one), (R3 stated) backlash is horrible from staff. Nurses get in your face and say f**k you, you're going to your room. Resident is staying in his room due to being uncomfortable. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she was present for the 1/10/23 Resident Council Meeting and several residents attended. V10 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present for the entire meeting. V10 stated R2, who is the Resident Council [NAME] President, was voicing most of the concerns, and R2 even had all his concerns typed up, giving everyone a copy. V10 stated other residents were agreeing with R2's issues brought forth. V10 stated several resident concerns were abusive in nature. V10 stated R2 verbalized he has witnessed nursing staff, specifically V3 (Resident Care Coordinator), take resident medications home with her after she dispenses medication from the pill sleeve. V10 stated multiple residents complained of staff retaliating when they complain about something, staff will be mean to them, make fun of residents, and yell at them. R2's documented Grievance List from 1/10/23, provided by V10 (Ombudsman), documents the following statements: (Licensed Practical Nurse, name withheld) pulls meds, while pulling meds, when she grabs meds out of lock box (for narcotics), she pops all meds into dispensing cup, except the narcotic, it gets popped onto the top of (the medication) cart and slipped into her pocket. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated multiple concerns were brought up at the 1/10/23 Resident Council Meeting, which she documented and gave to V1. V16 confirmed that V1 and V2 were present for the meeting that day. V16 stated that staff retaliation against residents was mentioned by R2, but he didn't expand on it. V16 stated residents indicated they had observed nursing staff popped the narcotic pill out, put it to the side of the medication cart, then slide it into her pocket. V16 recalled R2 stating that if residents do something that the CNAs don't like, they will raise their voices at them. On 1/25/23 at 12:59 pm, V1 confirmed that she was present for the 1/10/23 Resident Council Meeting and she had received a copy of the 1/10/23 Resident Council Meeting notes. As a response to those concerns, V1 stated, I still want to go through and talk to residents; when I get complaints, I don't always jump. V1 stated she did not do a formal investigation into any concerns brought forth by the residents regarding abuse, retaliation or stealing of narcotics. On 1/30/23 at 9:17 am, V1 stated in a follow up interview she has still not initiated an investigation into the misappropriation of resident property (stealing narcotics). 4. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated 1/19/23, she informed V1 (Administrator in Training) that R3 had reported to her V27 (Licensed Practical Nurse) was hitting him in the leg when she passes medication and that V3 (Licensed Practical Nurse/Resident Care Coordinator) had yelled at R3 a few days prior. V10 said she specifically told V1 that R3 reported to her V3 yelled at him to Shut the f**k up and threatened to call the police on him. V10 stated V1 informed her that she had already spoken to V3 about the situation and that was not what had happened. V10 stated she was concerned that V1 did not report or investigate this allegation of abuse. On 1/24/23, at 10:33 am, R3 stated on 1/16/23 he had been waiting for his noon medications at the Nurses' Station for about 20 minutes. R3 stated V3 (Resident Care Coordinator) started walking away with the medication cart, heading to the dining room. R3 stated he spoke up and told V3 he didn't get his noon medication. R3 stated V3 told him that he would have to follow her to the dining room if he wanted his medicine. R3 stated he did state, Are you kidding me? as he had been waiting for 20 minutes and prefers not to take all his medication in the dining room. R3 stated another resident (R16) was waiting for her medicine at the nurses' station with him and had to follow V3 into the dining room. According to R3, once he and R16 entered the dining room and waited by the medication cart, V3 informed R16 she would now have to wait again for V3 to return to the nurses' station to receive her medication, because not all her medicine was in the medication cart, and she needed to access the medication room. R3 stated he did speak up and told V3 this wouldn't have happened had she just given them their medicine when they were waiting at the nurses' station. According to R3, at that point V3 leaned across the (medication) cart, towards me, and started yelling at me to 'shut the f**k up and leave' and when I didn't, she said 'get the f**k out or I'm calling the police. R3 stated he immediately told V1, who was in her office just outside of the dining room, what V3 yelled at him. R3 stated multiple other CNAs were present in the dining room when it happened and there are cameras in the area. R3 stated V3 stayed working in the facility the remainder of the day and he asked for a different nurse to give him is medication. R3 stated he also reported to V10 that V27 (Licensed Practical Nurse) will wake him up by smacking his leg to give him his medication. R3 stated he gave V10 permission to report that to V1, which she did that same day. R3 stated, Nothing was done about (V27) though; (V1) never even asked me about it. On 1/24/23 at 12:10 pm, V1 stated about one week ago, V3 came to her asking for help with R3, because of his behaviors. Immediately after that, R3 came to her and stated V3 had yelled at him when he was trying to get his medications that day during lunch. V1 stated R3 and V3's stories did coincide, apart from V3 denying yelling at R3. V1 stated she was in her office at the time this incident occurred, and her door was cracked, but she did not hear any yelling. V1 stated she did hear R3's voice elevated, but he has a loud voice, and does not know what he said. V1 stated R3 told her that V3 threatened to call the police on him if he didn't step away from her medication cart and that she yelled at him to get the f**k out of my face. V1 stated R3 admitted to her that he could have provoked V3. V10 stated V3 admitted that she firmly told (R3) to step away from her but denied cursing at him or yelling. V1 stated she did interview three CNAs that were in the area at the time of the alleged incident, along with V2 (Assistant Administrator in Training), who denied hearing V3 yell at R3. V1 stated she did not interview any residents that were in the dining room at that time, and V3 worked the remainder of the day without being suspended. V1 stated she would consider the statement get the f**k out of my face towards a resident abusive but considered the allegation at the time a grievance and did not report the incident or formally investigate it. V1 admitted there is surveillance footage she could have looked at in the dining room but did not. V1 confirmed that a couple of days later, the Ombudsman did speak to her about R3's allegations that V3 had yelled at him and stated get the f**k out of my face and his concerns with V27. V1 indicated she did not have any documented evidence of interviewing V3, R3 or the CNAs that were present in the dining room at the time of the alleged incident. On 1/24/23, R3's medical record contained no documentation related to his allegations of abuse. On 1/30/23 at 9:17 am, V1 stated she had still not initiated a formal investigation into R3's abuse allegations. 5. R1's TAR (Treatment Administration Record) dated 1/23, documents that R1 requires daily skin checks. The TAR has no documentation of these daily checks being completed on 1/13/23-1/16/23. R1's Hospitalist admission History and Physical, dated 1/17/23, documents, R1 with severe schizophrenia, tardive dyskinesia, seizure disorder, brought in from facility with complaints of lethargy and worsening tremors. She has not been taking her medication in the facility. R1 is lethargic, barely responsive. Physical exam: Skin, hair, nails: Ecchymosis in various stages of healing on bilateral legs and inner thighs. R1's Hospital History and Physical, dated 1/17/23, documents, Assessment/Plan: Multiple bruises especially lower extremities, present on admission. On 1/24/22 at 2:45 p.m., V13 (Hospital Registered Nurse) stated, I got concerned when I saw (R1's) bruising on her inner thighs that looked like fingerprints. The bruising was in the shape and pattern of fingers. There are pictures of the bruising in her chart that we took. She also had bruising on the outside of both of her hips in the same spot and in a circle like the size of a dollar coin. These bruises were not brand-new bruises; some of it was starting to fade out and had some yellow coloring. The facility was notified of the bruising by our staff the day she was admitted . I did not call the facility, but someone else did and the facility told them that they were not aware of any bruising on (R1). The facility stated when (R1) is in her room by herself she rests peacefully. Then, once we enter her room she starts shaking, her lips quiver, and she acts anxious and scared. When I went to change her (incontinence) brief she instantly squeezes her legs together tightly and gets nervous. It's like she's scared something is going to happen when we care for her. On 1/25/23 at 12:59 pm, V1 (Administrator in Training) stated, I'm unaware that the hospital reported any bruising injury to my staff for (R1). State surveyor reported R1's bruising at this time. On 1/26/22 at 12:00 p.m., V1 retrieved R1's hospital records on V1's computer. V1 received the photos of R1's bruising to R1's bilateral inner thighs. R1's Hospital Records document a photo of R1's left and right inner thighs. R1's left inner thigh has bruising in the shape of two lines, one being the length of half of R1's thigh. The bruising is located directly in the middle of R1's left thigh. R1's right inner thigh bruising is located from the middle of her thigh to the back of her knee area. R1 has a large circular bruise, and a bruise in a linear shape as well. On 1/26/22 at 1:30 pm, V1 stated, I've just started an investigation on (R1's) bruising. I've talked to staff, and they have all stated that R1 has had bruising on her legs and thighs before from putting herself on the floor and running into things. When I spoke with staff I didn't probe to ask specifically about her inner thighs. I asked a general question of where her bruising is located. (V8/Certified Nursing Assistant/CNA) and (V17/CNA) were interviewed, and both stated that (R1) had bruising on her inner thighs. I don't suspect sexual abuse whatsoever. On 1/26/23 at 2:00 pm, V17 (CNA) stated, I've seen bruising on (R1's) legs and arms. I've never seen any bruising on her inner thighs. V17 was showed the pictures from the hospital. V17 gasped and said Oh no, I have never seen any bruising like that. She wouldn't have bruising like that from the stuff she does that she gets bruises from. On 1/26/22 at 2:10 p.m., V8 (CNA) stated, I've seen bruising on R1's legs and arms before, especially her shins. She puts herself on the floor and falls a lot. V8 was shown the pictures of R1's bruising. With a surprised look on her face, V8 stated, No she's never had bruising like that! I've never seen bruising on her inner thighs before. A report to the State Agency, dated 2/3/23, documents, Original Allegation: State Surveyors reported to V1 that hospital reported to the State Agency bruising of unknown origin to lower extremities of resident signifying sexual abuse. Account: Police department, physician, and responsible party were immediately notified of allegation. Staff were interviewed of noted bruising on resident. Staff stated that bruising has been noted due to resident repeatedly putting self on floor and self-harming by hitting legs with bathroom door during moments of agitation. Determination/Conclusion: It is determined that the allegation of sexual abuse is unfounded. It is determined that the resident commits self-harm during episodes of agitation which is care planned. 6. On 1/24/23 at 11:50 a.m., R5 was alert but nonverbal sitting up on the side of her bed. R5 had a purple and yellow bruise with swelling to the outer corner of R5's right eye. R5's MDS (Minimum Data Set), dated 11/20/22, documents R5's BIMs (Brief Interview for Mental Status) had a score of 99 (severely impaired cognition). On 1/24/23 at 2:20 p.m., V17 (CNA) stated, I saw (R5's) bruise on her eye this morning and asked what happened. (V8/CNA) was sitting there with (R5) and said (R5) has had the bruise for a few days. V11 (Registered Nurse) was present as well and stated, (R5) has a bruise on her eye? I didn't even notice she had a bruise, and I gave her medicine today. On 1/24/22 at 4:30 p.m., V11 stated, Yeah I guess (R5) does have a bruise on her eye. Supposedly, (V8) knew for a few days that (R5) had the bruise. I worked the weekend and (V8) never told me about it. I haven't done any kind of report on it. I reported it to (V1/Administrator in Training) today. On 1/26/23 at 2:10 p.m., V8 (CNA) s[TRUNCATED]

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure all allegations of sexual abuse, verbal abuse, physical abuse, misappropriation of resident property and suspicious injuries of unknown origin were immediately reported to the facility Administrator and/or State Agency, for eight of 12 residents (R1, R3, R5, R6, R10, R11 and R12) reviewed for abuse in a sample of 25. These failures have the potential to affect all 116 residents that currently reside in the facility. Findings include: The facility policy, titled Abuse Prevention Program (revised 11/282016) documents VII. External Reporting of Potential Abuse: 1. Initial Reporting of Allegations - The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH (Illinois Department of Public Health) immediately after forming the suspicion (but not later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. A written report shall be sent to the Department of Public Health. The written report should contain the following information, if known at the time of the report: Name, age, diagnosis, and mental status of the resident allegedly abused or neglected; Type of abuse reported (physical, sexual, theft, neglect, exploitation, verbal, or mental abuse); Date, time, location, and circumstances of the alleged incident; Any obvious injuries or complaints of injury; and steps the facility has taken to protect the resident. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property and that an investigation is being conducted. 2. Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The Public Health requirements for a final investigation report are detailed in paragraph 5 of the Internal Investigations section of this procedure. 1. A Grievance/Complaint Report, dated 1/05/23 and completed by V4 (Social Services Director), documents R6 complained (R9) rubbing on her butt, putting arm around her (and) saying 'Baby, give me a kiss,' touched her breast, looked up her dress. Also, going up (and) down A Hall (at) night, (R6) claimed, 'I can hear (R9) through the wall.' Resident Council Meeting minutes, dated 1/10/23 document (R9 is) very violent, overly sexual, calling names, going through resident's rooms, (R10, R6, R11 and R12) have all brought attention to this. A Resident Council Concern/Complaint form, dated 1/10/23 by V16 (Activities Director), documents Residents would also like if (R9) was out of the facility because they feel unsafe. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: Other concerns: (R9) is touching and grabbing women in a sexual behavior. (R9) is pinning residents against walls and counters as well. (R6) stated that (R9) has looked up her skirt, grabbed her breast, and rubbed his penis on her many times, (R13 stated R9) touched my boobs and rubbed his penis on me, and (R11 stated R9) is getting into people faces and personal space and touching in the way she don't want to be touched. On 1/24/23 at 3:15 pm, V4 (Social Service Director) stated R6 told her on 1/05/23 that R9 was rubbing on her butt, breast and saying inappropriate sexual statements to her, wanting a kiss and telling her to drop that a**. According to V4, she did not immediately report this allegation to V1. V4 stated she wrote up the statement from R6 on 1/05/23 and then took it to morning meeting the next day with all the Department Heads and V1 to be discussed. On 1/25/23 at 12:59 PM, V1 (Administrator in Training) denied knowledge of the 1/05/23 grievance completed by V4 regarding R6 and R9. V1 confirmed that she was in attendance for the Resident Council meeting on 1/10/23. V1 stated she did not report to the State Agency the allegations made by the four female residents that spoke out about R9's sexual behavior in the Resident Council Meeting. V1 stated, I recall (R6) speaking out against (R9) and (R10) as well. I do not remember the other two residents having specific concerns with (R9). I can't tell you my exact immediate follow up. I did not interview any residents that had concerns. At some point, I had a conversation with (R6 about R9), but I do not know when and did not document the details. On 1/30/23 at 9:17 am, V1 stated in a follow up interview she had still not reported to the State Agency the sexual abuse allegations reported to her last week involving R9. 2. Resident Council Meeting minutes, dated 1/10/23 document the following concerns: LPN (is) stealing narcotics, CNAs (Certified Nursing Assistants) yelling at residents is not okay and needs to stop, and (CNAs) retaliating with residents when they have an issue with things. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Administration, under Concern/Complaint it states in the notes section, CNAs and nurses are retaliating when they (residents) bring issues to them that staff does not agree with, and (R2) also brought up LPNs (Licensed Practical Nurses) stealing narcotics. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/18/23, documents Department: CNAs, under Concern/Complaint: Residents believe that the CNAs yelling at residents is not okay, and They are also concerned that the CNAs are retaliating when the residents bring up issues to them that they do not agree with. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Nursing, under Concern/Complaint: Certain Nurses are retaliating against residents who give them issues. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: Residents being forced to stay in their rooms or go to their rooms; It was stated that when (R3) had a fainting episode staff makes fun of him because the staff think he is faking it. (V11/Registered Nurse) (is the main one); (R3 stated) backlash is horrible from staff. Nurses get in your face and saying f**k you, you're going to your room. Resident is staying in his room due to being uncomfortable. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she was present for the 1/10/23 Resident Council Meeting and several residents attended. V10 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present for the entire meeting. V10 stated several resident concerns were abusive in nature, including verbal and sexual abuse. V10 stated R2 verbalized he has witnessed nursing staff, specifically V3 (Resident Care Coordinator), take resident medications home with her after she dispenses medication from the pill sleeve. V10 stated multiple residents complained of staff retaliating when they complain about something, staff will be mean to them, make fun of residents, and yell at them. R2's documented Grievance List from 1/10/23, provided by V10, documents the following statements: (Licensed Practical Nurse, name withheld) pulls meds, while pulling meds, when she grabs meds out of lock box (for narcotics), she pops all meds into dispensing cup, except the narcotic, it gets popped onto the top of (the medication) cart and slipped into her pocket. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated multiple concerns were brought up at the 1/10/23 Resident Council Meeting, which she documented and gave to V1. V16 confirmed that V1 and V2 were present for the meeting that day. V16 stated that staff retaliation against residents was mentioned by R2, but he didn't expand on it. V16 stated residents indicated they had observed nursing staff popped the narcotic pill out, put it to the side of the medication cart, then slide it into her pocket. V16 recalled R2 stating that if residents do something that the CNAs don't like, they will raise their voices at them. On 1/25/23 at 12:59 pm, V1 (Administrator in Training) confirmed that she was present for the 1/10/23 Resident Council Meeting and she had received a copy of the 1/10/23 Resident Council Meeting notes. As a response to those concerns, V1 stated, I still want to go through and talk to residents. When I get complaints, I don't always jump. V1 stated she did not report to the State Agency any concerns brought forth by the residents regarding abuse, retaliation or stealing of narcotics. On 1/30/23 at 9:17 am, V1 stated in a follow up interview she has still not reported to the State Agency any of the issues verbalized or documented during the January Resident Council Meeting that involved verbal abuse, staff retaliation or stealing of narcotics. 3. On 1/26/23 at 8:15 am, V10 (Ombudsmen) stated on 1/19/23, she informed V1 that R3 had reported to her V27 (Licensed Practical Nurse) was hitting him in the leg when she passes medication and that V3 (Licensed Practical Nurse/Resident Care Coordinator) had yelled at R3 a few days prior. V10 said she specifically told V1 that R3 reported to her V3 yelled at him to Shut the f**k up and threatened to call the police on him. V10 stated V1 informed her that she had already spoken to V3 about the situation and that was not what had happened. V10 stated she was concerned that V1 did not report or investigate this allegation of abuse. On 1/24/23, at 10:33 am, R3 stated on 1/16/23 after he had verbalized his concerns to V3 over the noon medication pass, V3 leaned across the (medication) cart, towards me, and started yelling at me to 'shut the f**k up and leave' and when I didn't, she said 'get the f**k out or I'm calling the police. R3 stated he immediately told V1 (Administrator in Training) what V3 yelled at him. R3 stated he also reported to V10 (Ombudsman) that V27 (Licensed Practical Nurse) will wake him up by smacking his leg to give him his medication. R3 stated he gave V10 permission to report that to V1, which she did that same day. R3 stated, Nothing was done about (V27) though. (V1) never even asked me about it. On 1/24/23 at 12:10 pm, V1 confirmed, about one week ago, R3 came to her and stated V3 had yelled at him when he was trying to get his medications that day during lunch. V1 stated she would consider the statement get the f**k out of my face towards a resident abusive but considered the allegation at the time a grievance and did not report the incident to the State Agency or formally investigate it. V1 confirmed that a couple of days later, the Ombudsman did speak to her about R3's allegations that V3 had yelled at him and stating get the f**k out of my face and his concerns with V27. V1 indicated she still did not report the incidents to the State Agency. On 1/30/23 at 9:17 am, V1 stated she had still not initiated a formal investigation into R3's abuse allegations. 4. R1's Hospitalist admission History and Physical, dated 1/17/23, documents, R1 with severe schizophrenia, tardive dyskinesia, seizure disorder brought in from facility with complaints of lethargy and worsening tremors. She has not been taking her medication in the facility. R1 is lethargic, barely responsive. Physical exam: Skin, hair, nails: Ecchymosis in various stages of healing on bilateral legs and inner thighs. R1's Hospital History and Physical, dated 1/17/23, documents, Assessment/Plan: Multiple bruises especially lower extremities, present on admission. On 1/24/22 at 2:45 p.m., V13 (Hospital Registered Nurse) stated, I got concerned when I saw (R1's) bruising on her inner thighs that looked like fingerprints. The bruising was in the shape and pattern of fingers. There are pictures of the bruising in her chart that we took. She also had bruising on the outside of both of her hips in the same spot and in a circle like the size of a dollar coin. These bruises were not brand-new bruises; some of it was starting to fade out and had some yellow coloring. The facility was notified of the bruising by our staff the day she was admitted . I did not call the facility, but someone else did and the facility told them that they were not aware of any bruising on (R1). On 1/25/23 at 12:59 pm, V1 (Administrator in Training) stated, I'm unaware that the hospital reported any bruising injury to my staff for (R1). State surveyor reported R1's bruising at this time. On 1/26/22 at 12:00 p.m., V1 retrieved R1's hospital records on V1's computer. V1 received the photos of R1's bruising to R1's bilateral inner thighs. R1's Hospital Records document a photo of R1's left and right inner thighs. R1's left inner thigh has bruising in the shape of two lines, one being the length of half of R1's thigh. The bruising is located directly in the middle of R1's left thigh. R1's right inner thigh bruising is located from the middle of her thigh to the back of her knee area. R1 has a large circular bruise, and a bruise in a linear shape as well. V1 confirmed she had not reported to the State Agency any Injuries of Unknown Origin for R1. 5. On 1/24/23 at 11:50 a.m., R5 was alert but nonverbal sitting up on the side of her bed. R5 had a purple and yellow bruise with swelling to the outer corner of R5's right eye. R5's MDS (Minimum Data Set), dated 11/20/22, documents R5's BIMs (Brief Interview for Mental Status) had a score of 99 (severely impaired cognition). On 1/24/23 at 2:20 p.m., V17 (Certified Nursing Assistant/CNA) stated, I saw (R5's) bruise on her eye this morning and asked what happened. (V8/CNA) was sitting there with (R5) and said (R5) has had the bruise for a few days. V11 (Registered Nurse) was present as well and stated, (R5) has a bruise on her eye? I didn't even notice she had a bruise, and I gave her medicine today. On 1/24/22 at 4:30 p.m., V11 (Registered Nurse) stated, Yeah I guess (R5) does have a bruise on her eye. Supposedly, (V8) knew for a few days that (R5) had the bruise. I worked the weekend and (V8) never told me about it. I haven't done any kind of report on it. I reported it to (V1/Administrator in Training) today. On 1/26/23 at 2:10 p.m., V8 (CNA) stated, Monday night (1/23/23) at dinner time was the first time I saw (R5's) bruise on her eye. I heard (R5) had ran into a wall or something like that. I didn't talk to anyone because I assumed it was already documented as a fall. On 1/25/23 at 12:59 pm, V1 stated, Staff did report to me just this morning that (R5) does have a bruise to her eye. They (Nursing) are thinking the injury is from her head resting on her headboard and she moves around. They (Nursing) are going to try to come up with an intervention. I'm just going with what the nurse told me and going with that. I have not talked to any other staff regarding the injury and was not going to do an investigation. On 1/26/22 at 12:00 p.m., V1 confirmed she had not reported to the State Agency an injury of unknown origin for R5 at this time. The CMS-672 (Resident Census and Conditions of Residents), dated 1/24/23 and signed by V1 (Administrator in Training), documents 116 residents currently live in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to employ a Director of Nursing (DON) to oversee the operation of the Nursing Department and ensure quality of care. This had the potential to affect all 116 residents residing in the facility. Findings include: The Facility's Director of Nursing job description (no date) documents, Job Summary: To plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director to ensure that he highest degree of quality care is maintained at all times. The Director of Nursing job description outlines, under Nursing Care Nursing Care, 1. Participate in the screening of residents for admission to the facility. 2. Provide the Administrator with information relative to the nursing needs of the resident and the nursing service department's ability to meet those needs. 3. Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc. 4. Ensure that rooms are ready for admissions. 5. Make rounds with physicians as necessary. Schedule physician visits as necessary. 6. Encourage attending physicians to record and sign progress notes, physicians' orders, etc., on a timely basis and in accordance with current regulations. 7. Ensure that direct nursing care be provided by a licensed nurse, a CNA qualified to perform the procedure. 8. Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. 9. Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's needs. 10. Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled. 11. Provide direct nursing care as necessary. 12. Authorize the use of restraints when necessary and in accordance with our established policies and procedures. 13. Implement and monitor programs (falls, skins, weights, etc.,) in accordance with our established policies and procedures. The Staff Phone List, dated 1/25/23, documents the DON position is vacant. Upon entering the facility on 1/24/23 at 9:15 am, V1 (Administrator in Training) introduced V2 as her Assistant Administrator in Training and V3 (Licensed Practical Nurse/Resident Care Coordinator) as her Acting DON (Director of Nursing). On 1/25/23 at 11:25 am, V1 stated the facility has not had someone in the position of DON for some time, but V3 has been filling in until the new DON can start. On 2/01/23 at 9:58 am, V3 (Licensed Practical Nurse/Resident Care Coordinator) clarified that she was only hired in as an RCC (Resident Care Coordinator) and that she does the scheduling of nursing staff, but has not been doing any actual DON duties, such as over site of Physician's Orders or resident care delivered by the licensed nursing staff and CNAs (Certified Nursing Assistants). V3 was questioned about her lack of involvement in the operations of the Nursing Services Department, as she had been identified and introduced at the start of the survey as the Acting DON. V3 reiterated that was not her role. On 2/7/23 at 4:10 pm V41 (Medical Director) agreed during interview that the facility has had issues processing physician's orders correctly. V41 stated, The DON should be overseeing these things and making sure they are followed through with. However, I know they haven't had a DON for a while. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated the facility doesn't have a DON, and The lack of leadership is obvious. V32 stated basic nursing tasks are not being done, such as processing physician's orders (for medication, testing, labs), oral care and medication administration. V32 stated V27 (Licensed Practical Nurse) will sign off that medications have been given, when they have not, and she has caught CNAs sleeping at night. V32 stated this is reported to Management, but nothing is done about it. V32 stated V3 will prep the residents' medication, by popping them out into a cup and putting them in the drawer of the medication cart for other nurses to pass. V32 stated, I told the Agency I couldn't work there anymore; residents are not taken care of. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 1/24/23 and signed by V1, documents that 116 residents reside in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure all staff had the appropriate knowledge and training to care for residents with a mental disorder, for one of 24 residents reviewed (R3) with a mental illness diagnosis, in a sample of 24. This failure has the potential to affect all 116 residents currently living in the facility. Findings include: The Facility Assessment (updated 4/20/21) documents the facility provides services to patients having a variety of mental health illnesses as well as medical needs and identifies under Resident Support/Care Needs: Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues, such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (Post Traumatic Stress Disorder), other psychiatric diagnoses, intellectual or developmental disabilities. The Facility Assessment also documents, Staff training is required for all departments upon hire and annually. At the time of orientation, the SWAT program covers many of the required and necessary education needed to begin employment. General training topics (this is not an inclusive list): Communication - effective communications for all direct care staff; Resident's rights and facility responsibilities of a facility to properly care for its residents. The Facility Assessment documents the following individuals as being involved with its completion: V1 (Administrator in Training), V2 (Assistant Administrator in Training), V3 (Resident Care Coordinator/Licensed Practical Nurse), V31 (Vice President of Business Development and Strategy/Regional Director of Operations), V48 (Director of Nursing) and V41 (Medical Director). Resident Council Meeting Minutes, dated 1/10/23, document under Administration, resident concerns that staff are not trained in Behavioral Health Management. A Physician's Order sheet, dated 1/01/23, documents R3 has the diagnoses of Major Depression, Post Traumatic Stress Disorder and Somatic Disorder. R3's current Plan of Care (no date) document R3 is known/has history of displaying inappropriate behavior and/or resisting care/services and likes to call (Public Health) and encourages other residents to call (Public Health) and threaten nurses and staff he will call (Public Health) and lawyers. R3's Plan of Care instruct staff to Introduce self upon contact, make eye contact, approach from front, explain all procedures prior to beginning, seek resident input/reassurance with all cares; During periods of inappropriate behavior, use a consistent, calm, firm approach. Use resident's name to help divert inappropriate behavior; Provide reality orientation as tolerated; During episodes of inappropriate behavior, attempt to determine source of agitation by asking open ended questions and seek to resolve; Allow resident time and opportunity to express self and verbalize frustrations; Help resident to understand why behavior is inappropriate/disruptive and the impact it has on personal well-being of others. On 2/20/23, V10 (Ombudsman) documented via email that she received a call from R3, who was concerned because V3 (Resident Care Coordinator/Licensed Practical Nurse) had called the Police Department on him that day, alleging that he threatened her when he had not. According to V10's email, R3 was upset over a delay in his medication and V3 informed R3 she would not look into the issue and became verbally aggressive with R3 during the conversation. On 2/23/23 at 8:50 am, R3 stated he recently stopped taking his prescribed narcotic for pain, because he does not want to be on them any longer. R3 stated the Physician had ordered Topamax for him to try for his headaches, in place of the narcotic, approximately 7 days ago. R3 stated on 2/20/23, he approached V3 at the nurses' station and asked if she knew the status of his new medication. R3 stated V3 told him that she had submitted the order and that was all she was going to do at that point, as I've done my job. R3 asked V3 if she could do more to get his medicine, because I was in pain. R3 stated V3 started talking over him, put her hand up and said Bye! Go deal with (V1). R3 stated he did talk to V1, who was very helpful. R3 stated when he left V1's office and was walking past the nurses' station to go to his room, as he did, he told V3, (V1) is doing your job for you. R3 stated V3 started yelling and talking over me and said Get back, get the f**k back! R3 stated the wall of the nurses' station was between them, he never came towards V3. R3 did admit to saying you are being a b***h to V3. According to R3, V3 then yelled at him, I'm calling the police! and told the 911 Dispatch Operator that R3 was reaching across the nurses' station, threatening, and harassing her. R3 stated other staff were around, but no one intervened or did anything. R3 stated the police did come to the facility and talked to him, but nothing happened. R3 stated he feels like V3 is angry and retaliating over a prior dispute they had about medication in January. On 2/23/23 at 9:12 am, V3 was contacted via phone and asked if she could go into detail regarding why she called 911 on R3 (2/20/23). V3 advised she had written a progress note detailing what had occurred, and she was not able to be interviewed further at that time. A call back was requested, but not received. During a previous interview with V3, on 2/01/23 at 9:58 am, V3 stated she was hired by the facility as a Resident Care Coordinator (October 2022). During that interview, V3 stated she had not received any training on Behavioral Health or behavior management of mentally ill residents. V3's Nursing Note, dated 2/20/23, documents the following, (R3) came to the nurses' station with (V2). I was questioned about a medication that the resident was due to receive (at) 8:00 am. (At 8:00 am) the resident never asked me anything but waited (until) now to question it. I explained to both (V2 and R3) that in report I was told the proper steps were (taken) and that the facility signed for the (medication) and that it should be in this evening. (R3) continued to ask why it was not in and that it had been days. I again apologized on the staff behalf. (R3) got upset and started yelling that if it was insulin, this wouldn't happen and that the medication was important. I stated you are right, the Pharmacy provides back up for insulin and not that (medication). (R3) started talking with his hands and yelling. I stated I'm sorry I've done what I could, if you have any more concerns, please address (V1). (R3) continued to yell at me and call me stupid. I said could you please step away from the nurses' station. (R3) stated You can do your job b***h;' I stated this behavior will not be tolerated; can you please step away from the nurses' station. (R3) stated Shut the f**k up b***h.' I stated if you don't stop harassing me, I will have to call the police for harassment. (R3) walked away and stated 'I will be back b***h.' (R3) walked towards the front and came right back to the nurses' station where I was sitting and stated '(V1) is going to do your job b***h.' I again stated please top harassing me and he stated 'I don't care, call the police. I am going to call State. This is retaliation, you already have a case, you will be suspended and eventually fired.' I called 911 and he continued to talk and yell, telling the other residents what (happened). I did not say anything else at that time. Another resident came up and was looking for her nurse. I heard her say she was telling (V1). I said to the resident your nurse is right here. This resident stated there is another reason to call State on your a**. I said I'm sorry, I'm not her nurse. (R3) stated 'So what, (you're) head of nursing.' I feel attacked by this resident anytime I am a floor nurse. (R3) finds reason to argue with me. The (Topamax) was due to be given (at 8:00 am), (R3) never asked me questions, but went to (V2) to tell (her) that I didn't give it (at 12:45 pm). On 2/23/23 at 9:55 am, V1 stated R3 came to her on 2/20/23, asking about the process for getting his Topamax. V1 explained to R3 that there is an apparent insurance coverage issue, and he left her office. V1 stated after that, I did hear (R3) say 'f*****g b***h.' By the time I came out of my office to see what was going on, (V3) had already called the police because '(R3) flipped out on her.' V1 concluded that nothing was done by V3 or other staff to minimize the incident or avoid the police being called on R3. V2 was present during that interview and stated she was present at nurses' station for some of the incident but did not witness the entire thing. V2 described R3 as standing outside of the nurses' station and V3 was sitting behind the half wall. V2 stated she did hear R3 call V3 a b***h but was not at the nurses' station when V3 called the police on R3, so she cannot account for everything that occurred. V2 denied anyone trying to deescalate the issue or redirect R3 or V3 away from the situation. On 2/21/23 at 9:27 am, V26 (Registered Nurse) stated she was present on 2/20/23 at the nurses' station for the entire incident between V3 and R3. According to V26, R3 approached V3 and asked if his new medication had arrived. V26 stated R3 is currently trying to wean himself off a narcotic, which is why he was so concerned about the medicine. V26 stated R3 was initially calm, but V3 was immediately confrontational with R3. V26 confirmed that R3 did call V3 a b***h, but that was after V3 had provoked him. V26 stated she police should have never been called, because R3 never threatened V3. V26 stated the staff in the facility have no training in mental health, so they don't know how to handle behaviors of mentally ill residents. V26 stated, They (Staff) don't know how to redirect (residents), and staff escalate the problems sometimes. V26 stated V3's documented account of the incident in R3's medical record on 2/20/23 is not what occurred. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated there is no training on anything for new staff, on abuse or how to deal with (mentally ill population); it leads to lots of issues between residents and staff. On 2/7/23 at 1:20 p.m., V24 (Registered Nurse) stated, This facility does not offer any training to their staff when it comes to this population. I know we have to have dementia training, but this is Mental Illness. These residents could hurt someone. The staff do not know how to take care of these types of behaviors, and there's no one to turn to. So, they call 911 or send them to the hospital hoping they might spend a few days there. This doesn't help anything, and at times makes it worse. We have all these young kids working here, too. They don't know how to handle the situation, and they think the answer is to come to the nurse. Sometimes though it's too late, and someone could be hurt. On 2/02/23 at 1:59 pm, V4 (Social Service Director) stated when she started in her position as Social Services Director she had no experience with the mentally ill. V4 stated she received no training or education on how to help residents with mental illness. On 2/23/23 at 11:36 am, V50 (Police Chief) confirmed that on 2/20/23 a 911 call was received from V3, who told the dispatcher that a resident was threatening her. V50 stated they took the call as the resident was threatening to physically hurt the individual. V3 stated, when the responding officer arrived at the facility, he determined that R3 had yelled at the nurse and called her a name, and there was no real threat made to (V3). V50 stated 48% of this Department's calls come from this facility, and it's residents and staff calling. Staff have a hard time deescalating issues and call us for help; typically there is not much we can do to assist in the situation. On 2/23/23 at 9:44 am, V1 described the facility as, This is a Mental Health Facility. V1 stated V3 was hired in October 2022. V1 described V3 as a newer nurse, like a couple of years with no previous psychiatric experience that she is aware of. V1 stated she started as the Administrator in Training on August 22, 2022, and since she has been in that position, no new staff have received any behavioral health training. A Staffing List, dated 1/25/23, documents the following staff members as being new employees who started after V1 was hired on 8/22/22: V2, V3, V11 (Licensed Practical Nurse), V51 (Licensed Practical Nurse), V52 (Registered Nurse), V53 (Registered Nurse), V7 (Registered Nurse), V54, V63, V33, V64, V65, V19 (all Certified Nursing Assistants), V34, V55, V9, V35, V56, V57, V58 (all Unit Aides), V59 (Transportation Aide), V15 (Social Service), V14, (Social Service), V60 (Activities Aide) and V61 (Activities Aide). The CMS-672 (Resident Census and Conditions of Residents), dated 1/24/23 and signed by V1 (Administrator in Training), documents 116 residents currently live in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to provide a nutritive substitution for each meal. This had the potential to affect all 116 residents residing in the facility. Findings include: The facility's Meal Alternatives policy, dated 4/17, documents, It is the policy of the facility to provide appropriate alternates to those residents who dislike or do not eat the main entrée and vegetables to help ensure adequate nutritional intake. An appropriate entrée and vegetable alternate is prepared and readily available at meals. The alternate may be provided to a resident who dislikes the main entrée and vegetable and may also be offered to a resident who has not consumed at least fifty percent of their entrée and vegetable at the meal. Other dining options may be available as well; such as, but not limited to, an 'Always Available' menu, buffet or restaurant style menu. If a resident refuses the original entrée and/or the alternate, the nurse shall be informed. Refusal to eat or poor intake should be documented in the resident's medical record. A handwritten document, no date and provided by V28 (Dietary Manager) on 2/1/23 at 1:00 p.m., documents, Our current substitutions for the main entrée are: Grilled cheese sandwich, deli meat sandwich, peanut butter and jelly sandwich. The facility Resident Council minutes, dated 11/15/22, document, Dietary: Would like more meat in general. The facility Resident Council minutes, dated 12/13/22, document, Dietary: Would like to have grilled cheese with meat. The facility Resident Council minutes, dated 1/10/23, document, Dietary: Nutrition is horrible. Leaving table hungry. Portions are too small. On 1/30/22 at 12:10 p.m., R16 was yelling at V28 (Dietary manager) as she was leaving the dining room. R16 stated, They are not serving me the right food as what I'm supposed to have. I'm allergic to pork and when we have pork all I can get is peanut butter and jelly, meat sandwich that always has ham on it, or a grilled cheese. Today is baked ham, potatoes, carrots, bread, and fruit. I can't have pork so obviously I can't have the ham, and what do you think they offered me. They want to give me a grilled cheese. Really, I need protein, not the carbohydrates of the bread and the potatoes. I don't think that I'm getting enough protein when I have to get the substitute. It seems like all I eat is peanut butter and jelly because I feel like it's got the most protein out of all of my options. V28 was present and confirmed that lunch for that day was baked ham. V28 stated she has worked as dietary manager since November and the meal substitutes have always been peanut butter and jelly, grilled cheese, and deli meat sandwiches. V28 stated, These are the only substitutes that we have for each meal. I have a substitute menu from the dietician, but I haven't instituted it yet. I'm not sure if the substitutes have the same amount of actual protein as the protein I served. R16's Physician's orders, dated 1/23, document a diet order for low carbohydrates and high protein, no fish, oranges, or pork. On 1/31/23 at 12:59 pm, R3 stated the facility is not following their menus. R3 stated, There are times when I will only get a sandwich for dinner, peanut butter and jelly or grilled cheese. Also, those are the only (substitutions) they offer. The only reason we had two real meal choices today and yesterday is because State is in the building. The other thing they do is use the same meat for meals all week. Such as pork. Say on a Monday they will make pork roast, Tuesday they will have pork stew and Wednesday they will have BBQ pork. The facility's Week at a Glance Week 4, dated 1/29/23, documents that four of the fourteen meals served for the week's lunch and dinner are made of pork including, pork chop stuffing bake for lunch on Sunday, baked ham for lunch on Monday, pulled pork macaroni and cheese for lunch on Wednesday, and country style BBQ ribs for dinner on Saturday. On 2/1/23 at 12:50 p.m., the facility residents were served pulled pork macaroni and cheese, beets, butternut squash, and pudding. On 2/2/23 at 12:50 p.m., V40 (Registered Dietician) stated, I have provided the facility with a substitution menu and discussed it just last month with (V28). On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated, The food they serve is horrible. Sometimes residents will just get a peanut butter and jelly or bologna sandwich for a meal. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 1/24/23 and signed by V1 (Administrator in Training), documents that 116 residents reside in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Governing Body failed to be consistently involved in the management and operation of the facility, failed to implement policies related to facility operations and resident care, including Abuse Prevention, Significant Weight Loss, Processing of Physician's Orders, and staff education and training. The Governing Body failed to ensure Director of Nursing's responsibilities were completed. This failure has the potential to affect all 116 residents residing in the facility. Cross reference to F600, F610 and F692 (Identified Immediate Jeopardies) and additional findings at F584, F607, F609, F693, F741, F770, F760, F776, F808, F835 and F943. These failures have the potential to affect all 116 residents currently living in the facility. Findings include: Upon entering the facility on 1/24/23 at 9:15 am, V1 (Administrator in Training) introduced V2 as her Assistant Administrator in Training and V3 (Licensed Practical Nurse/Resident Care Coordinator) as her Acting DON (Director of Nursing). V1 indicated this was the facility's current Administrative Staff. V31's (Vice President of Business Development and Strategy/Regional Director of Operations) Nursing Home Administrator's license is hanging on the wall of the facility. On 1/25/23 at 11:25 am, V1 stated she started as the facility's Administrator in Training under V31's (Vice President of Business Development and Strategy/Regional Director of Operations) Administrator's License on 8/22/22. Additionally, V1 stated the facility has not had someone in the position of DON for a length of time, but V3 has been filling in until the new DON can start. V1 stated V31 is in the facility occasionally, and V31 and V42 (Regional Nurse) are who she is to seek corporate support from. On 2/23/23 at 11:36 am, V1 was questioned who comprised the facility's Governing Body. V1 stated, What is that? and a brief explanation of Governing Body within a Long-Term Care Facility was given. After that, V1 stated she didn't know who their Governing Body consisted of, and she would reach out to her corporate support for more information. At 12:30 pm, V1 presented the Corporate Compliance and Ethics Program Overview Policy and stated she was advised the individuals that are identified on that policy are who make up the facility's Governing Body (V66, V67, V68, V69, V70, V71, V72, V73). The facility's Corporate Compliance & Ethics Program Overview (5/2021) documents [NAME] Health Care's management staff (Directors, Regionals' and Administrators') are responsible for monitoring the compliance and ethics program. The Corporate Compliance & Ethics Program was reviewed, and the Code of Conduct was revised and distributed to all employees. [NAME] Health Care Operation and Nursing Policies and Procedures are in place and cover areas related to Corporate Compliance and Ethics. A Mandatory In-service List is provided to all Administrators to ensure education is conducted at least annually. Regional Directors conduct audits throughout the year during visits on areas of risk as identified. The Regional Teams and others identified by the Regional Teams conduct mock surveys annually. External Audits are conducted periodically. The following documents are incorporated within the Corporate Compliance and Ethics Program. This list is not all inclusive: Operational Policies and Procedures; Nursing Policies and Procedures; New Administrator Training Manual; New DON (Director of Nursing) Training Manual, Resident Admissions Packet, SWAT Programs; Quality Improvement Programs, Quality Assessment and Assurance Committee Policy Abuse Prevention Program, Employee Handbook, Employee and Resident Satisfaction Surveys, Equal Employment Opportunity policy False Claims, Whistle Blower & Drug Free Workplace Policy. 1. On 1/24/23 at 12:10 pm, concerns regarding allegations of staff to resident abuse, made by R3 against V3 and V27 (Licensed Practical Nurse), were discussed with V1 at length. V1 was aware of these concerns, as they had been previously reported to her by R3 and V10 (Ombudsman), on 1/19/23, and V1 failed to implement the facility's Abuse Prevention Program at that time. On 1/25/23 at 12:59 pm, the above-mentioned concerns and a continued lack of a thorough investigation was discussed further with V1 and V2. Additionally, concerns regarding allegations of sexual abuse, made by R6 towards R9 on 1/05/23, numerous allegations of verbal, sexual abuse, staff retaliation against residents and narcotic theft voiced by residents during Resident Council on 1/10/23, and injuries of unknown origin (R1 and R5) that had not been investigated, were discussed with V1 and V2 at that time. During that interview, V1 stated she was aware that there were numerous issues brought forth that were concerning. V1 indicated she was trying to see what her Department Heads could do to resolve some of the concerns. V1 was questioned if she had reached out to V31 regarding these specific issues and V1 indicated she had yet to do so. On 1/30/23 at 9:17 am, V1 stated the only investigations she had initiated or reported to the State Agency, since the Survey Team arrived on 1/24/23, was R1's injury of unknown origin that was brought to V1's attention on 1/25/23. This meant V1 had still failed to implement the facility's Abuse Prevention Program regarding the additional abuse allegations that were discussed on 1/25/23. V1 stated at that time, she had reached out to her Regional Advisor (V42) over the weekend for guidance, but she had not discussed the concerns with V31. Cross reference findings at F584, F600, F607, F609, F610, F741, F835 and F943. F600 and F610 was cited at the Immediate Jeopardy Level as a result of the Governing Body's lack of involvement and oversight of the facility's Abuse Prevention Program. 2. The Facility's Director of Nursing job description (no date) documents, Job Summary: To plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. On 2/01/23 at 9:58 am, V3 (Licensed Practical Nurse/Resident Care Coordinator) clarified that she was only hired in (on 10/17/22) as an RCC (Resident Care Coordinator) and that she does the scheduling of nursing staff, but has not been doing any actual DON duties, such as oversite of Physician's Orders or resident care delivered by the licensed nursing staff and CNAs (Certified Nursing Assistants). V3 was questioned about her lack of involvement in the operations of the Nursing Services Department, as she had been identified and introduced at the start of the survey as the Acting DON. V3 reiterated that was not her role. On 2/7/23 at 4:10 pm, V41 (Medical Director) agreed during interview that the facility has had issues procession physician's orders correctly. V41 stated, The DON should be overseeing these things and making sure they are followed through with. However, I know they haven't had a DON for a while. During the survey, numerous issues regarding the processing of Physician's Orders for medication, diagnostic testing, dietary orders, weight monitoring and the delivery of Parenteral nutrition have been identified. Cross reference findings at F692, F693, F770, F776, and F808. F692 was cited at the Immediate Jeopardy Level and F693 at a harm level as a result of the Governing Body's lack of involvement in the operation of the facility's Nursing Service Department. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 1/24/23 and signed by V1, documents that 116 residents reside in the facility.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to provide education and training to all staff on Abuse and Neglect. This failure has the potential to affect all 116 residents that currently live in the facility. Findings include: The Abuse Prevention Policy (revised 11/28/2016), documents, During orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs; Staff obligations to prevent and to immediately report abuse, neglect, exploitation, and theft (misappropriation of resident property) to supervisory personnel and administrator; and how to distinguish theft from lost items and willful abuse from insensitive staff actions that should be corrected through counseling and additional training; Dementia management and resident abuse preventions; Including, How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; and, How to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reactions to residents. Prohibition against staff using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep or distribute photographs and recordings of residents that are demeaning or humiliating. Annually, each covered individual will receive a review of the above topics. Annually, supervisory personnel will receive training on their obligations under law when receiving an allegation of abuse, neglect, exploitation or theft, and how to monitor and correct inappropriate or insensitive staff actions, words or body language. The Facility Assessment, which was last updated on April 20, 2021, documents, (Staff) Education needs to begin at employment. General training topics: Communication - effective communications for direct care staff. Resident's rights and facility responsibilities - ensure that staff members are educated on the rights of the residents and the responsibilities of a fallibility to properly care for its residents; Abuse, neglect, and exploitation - Training that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidence of abuse, neglect, exploitation, or the misappropriation of resident property; and care/management for persons with dementia, and resident abuse prevention. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated, I never received any kind of abuse training when I started in August or since then. On 1/24/23 at 3:15 pm V4 (Social Services) stated she was hired in October 2022 but has received no Abuse training since she started. On 1/25/22 at 10:50 a.m., V25 (Licensed Practical Nurse) stated, I've been working here since September as agency (staff). The facility hasn't provided me with any abuse training. I just use past knowledge from other facilities. I'm not sure who the Abuse Coordinator is. I would report abuse to (V1/Administrator in Training) I assume, since she is the Administrator. At least that's what I do in other facilities. On 1/25/23 at 10:30 a.m., V21 (Unit Aide) stated, I didn't get any formal training (on abuse). I'm not sure who the abuse coordinator is. If I witness abuse, I go to social services immediately. On 1/25/23 at 10:14 am, V9 (Unit Aide) stated she has worked at the facility since November 2022. V9 stated she does not know who the abuse coordinator is, and she did not receive any training on abuse when she started. V9 indicated she has had some training on Abuse with other employers in the past, but not with this facility. On 1/25/22 at 10:05 am, V18 (Certified Nursing Assistant), I've worked here for 6 months. I had some kind of abuse training done, but I'm not sure who the abuse coordinator is. If I witnessed abuse, I'd report it to the nurse. On 1/25/23 at 10:20 a.m., V23 (Housekeeper) stated, I've worked here for 5 months. I went over abuse paperwork on my own when I started. I don't know who the abuse coordinator is, and I don't know for sure who to report abuse to. On 2/01/23 at 5:10 pm, V34 (Unit Aide) stated he has worked at the facility since November 2022 and did not receive any training on Abuse when he was hired. On 2/01/23 at 5:45 pm, V5 (Certified Nursing Assistant) stated she has worked for the facility since September 2022 and had not received any kind of abuse prevention training, until 1/30/23. On 2/02/23 at 10:25 am, V33 (Certified Nursing Assistant) she did receive training on abuse, on 1/31/23, from administrative staff. V33 stated prior to that, she had never been trained on Abuse Prevention and reporting. On 1/25/23 at 12:59 pm, V1 stated Abuse Prevention training for all staff is the responsibility of herself and V2 (Assistant Administrator in Training). V1 stated there is no set schedule to the frequency of Abuse Prevention training, but there are to be random questions that are asked of staff as to who the abuse coordinator is and who to report to. V1 stated, upon hiring new staff, the specific Department Head or herself/V2 will do the abuse training. At that time, V1 stated she would provide the documentation to support such training, but that documentation was never given. The CMS-672 (Resident Census and Conditions of Residents), dated 1/24/23 and signed by V1 (Administrator in Training), documents 116 residents currently live in the facility.

Jan 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to secure medical records from resident access for two (R3 and R4) of four residents reviewed for secure medical records in a sample of four. Findings include: Facility Medical Records Policy, undated, documents the following: The facility shall have a medical record system that facilitates the retrieval of information regarding individual residents. Procedure: 1) Each resident shall have an active medical record. This medical record shall be kept current, complete, legible and available at all times to authorized personnel. Facility Resident rights for people in long term care facilities, revised 3/17, documents You have the right to privacy, your medical and personal care are private. On 1/10/23 at 9:50am, R4 stated the following: (R2) got ahold of my medical record and discontinued my pain medication so I filed a police report. She shouldn't be in my records. R4's medical record documents he is alert and oriented. On 1/10/23 at 10:00 am, R2 stated the following: I did take (R4's) chart and try to discontinue his pain (Norco) medication; I am not sure why. I was trying to help the nurses and was waiting for a fax when I took (R3's) orders off the fax machine and gave them to the nurse. I was spoken to by (V1/Administrator in Training/AIT) that I am not to be getting in people records because of privacy. R2's MDS/Minimum Data Set, dated [DATE] documents R2 is alert and oriented and independently ambulatory. On 1/10/23 at 11am, V10 (Licensed Practical Nurse/LPN) stated, I was here the night (R2) looked at (R3) and (R4's) medical records. (R2) was looking for more responsibility so she was given the job to answer the phone at the nurses' desk. (The facility nurses' desk is centrally located where it was two entry doors that have a slide lock, and the desk fully wraps around the residents' medical records which are not in locked cabinets.) (R2) was to answer the phone from the outside of the nurses' desk, she was not to come behind the nurses' desk. (R2) went behind the nurses' desk and got into (R4's) medical record and wrote d/c/discontinue next to (R4's) pain medication (Norco). (R2) also got (R3's) orders off the fax machine (verified it was the fax machine that sits out in the open by the front office; not behind the nurses' desk in an unsecured hallway between two bathrooms) and handed them to the nurse. (R2) is not to be behind the nurses' station; none of the residents are allowed behind the nurses' station. (R2) was talked to by (V1). On 1/10/23 at 11:40am, R3 stated On 12/17/22 (R2) got my faxed paperwork from the doctor on the denial of my medications and I told a nurse to make a report to management. (R2) went thru the fax machine papers and then I heard her say to the nurse (R3) has some denial paperwork. I heard her tell the nurse. (R2) also discontinued (R4's) pain medication and she said to me 'Guess what I did? I just discontinued (R4's) pain medication.' I did not hear anything from management from when (R2) got in my papers, so I filed a police report, but it wasn't until a little while afterwards. No one should be looking at my records except the nurses. On 1/10/23 at 2pm, V1 (AIT) stated (R2) was talked to about her being behind the nurses' station and getting into (R4's) medical record. I did not know about (R3's) orders being looked at by her. We have talked about moving the fax machine to a more private location. We are trying to keep (R2) busy. The nurses were passing medications when (R2) went behind the desk and got into (R4's) medical record. (R2) was removed from behind the desk, and I talked to her about the situation. (R2) and (R4) don't like each other. The fax and copier are not in a secured area, and I am not sure how to secure the medical records.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to secure electrical wires on a heating unit for one (R4) of four residents reviewed for safe electrical operating conditions in a sample of four. Findings include: Facility Maintenance Director Job description, undated, documents under responsibilities Managing and preserving equipment to keep in working condition, following state and federal safety regulations. On 1/10/23 at 9:50am, R4 was in his room alert and oriented and sitting in a manual wheelchair next to his heater. R4 stated Maintenance replaced my heater and left the wires exposed (wall heater had wires exposed with electrical tape and wire nuts in place on the outside of the unit where R4 was sitting in his wheelchair next to his closet). On 1/10/23 at 12:30pm, V9 (Maintenance) went on a tour with the surveyor and was shown the exposed wires in R4's room that connects his heater to an electrical source. R9 stated I had to replace two heaters and repaired three heaters which took about a week for parts. At that same time, V9 verified the wires were exposed outside of R4's heating unit posing a hazard and should not be. On 1/10/23 at 2pm, V1 (Administrator in Training/AIT) stated, The heaters were repaired the end of November or December 2022; we ordered more to have on hand.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to stop an infestation of mice in the facility. This has the potential to affect all 107 residents living in the facility. Findings include: Facility Insect and Pest Control Policy, undated, documents It is the policy of (facility) to contract with a duly licensed exterminating service to protect and/or control against infestations of insects and rodents. Facility local pest control company reports document the following: report dated 11/23/22 pipes extending thru wall allowing pest access, please fill in gaps between pipes and wall to prevent pest entry and all a/c units need to be inspected for gaps surrounding; dated 12/1/22 door gaps that allows pest access courtyard door and nurses break room please repair, cracks or damage along the building exterior please repair the majority of a/c units need repair the surrounding siding is allowing pests to protrude on interior; and dated 12/21/22 crack or damage to wall allowing pest access room [ROOM NUMBER] under a/c unit. As of the last report dated 12/28/22 the above had not been repaired/completed. On 1/10/23 at 9:15am, V5 (Housekeeping) stated, The mice here are bad. We have had a real bad mice problem for a while, and they are chewing through the floorboards. Maintenance has been filling holes and patching the walls, but the mice are still here and A hall where they chewed through the floorboards is the worst but those have been replaced. On 1/10/23 at 9:50am, R4 was alert and oriented and stated, The mice chewed through my floorboard in the wall (at that same time observed the floorboard pulled away from the wall and a hole in the wall). On 1/10/23 at 11:30am, V7 (Registered Nurse/RN) stated, Mice have always been a concern in this building. On 1/10/23 at 11:40am, R3 was alert and oriented and stated, I had my snacks eaten in my drawer and they chewed through the styrofoam container overnight that I got my meal in yesterday (observed styrofoam container on bedside drawer had been chewed on and in the bedside drawer table an individual snack packet of pretzels had been chewed through and small pieces of the wrapper were in the drawer with mouse droppings). On 1/10/23 at 12:15pm, V8 (Activities) stated, We do have a problem with mice. I have had mouse droppings on my snacks for residents (observed in the activity room there were blue bins that had no lids and snacks of raisins and crackers for the residents). We have a lot of residents who eat in their rooms, most of our population is ambulatory, and alert and oriented. The residents are not required to put their food in any bins in their rooms, we don't have the storage space to keep their snacks, no one has put any shelving in their room or any storage bins in their rooms to keep the mice out of it. No one has went through the residents' rooms to clean out their drawers either. We have been talking about doing it, but no one has done it.

Nov 2022 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review the facility failed to implement an effective pest control program to eliminate flies and mice within the facility. This has the potential to affect all 109 residents residing within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 11-4-22 and signed by V1 (Administrator) documents 109 residents currently reside within the facility. The facility's Insect and Pest Control Policy (undated) documents, It is the policy of (the facility) to protect and/or control against infestations of insects and rodents. Policy Interpretation and Implementations: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 3. Any employee observing insects or rodents shall inform their supervisor giving the exact location and type of infestation. 5. The employee shall fill out a work order form and give it to the maintenance person. 6. The maintenance person shall contact the contracted pest control company for eradication. On 11-4-22 at 8:50 AM a tour was conducted of the kitchen. The double kitchen doors were propped open to the outside, with puddles of water and wet leaves covering the area outside of the doors. Over 20 flies were observed landing on all surfaces of the kitchen, including utensils, stove, sinks, and dishwasher. Flies were also observed landing on the peanut butter that was inside a five-pound uncovered bucket, 17 individual uncovered cups of scooped peanut butter, three uncovered cups of thickened milk, and brown sugar located inside an uncovered bucket. The top of the dishwasher had multiple fresh and dried mouse droppings (feces). On 11-4-22 at 8:55 AM V3 (Cook) stated, I just saw a mouse running across the steam table two days ago. I see mice in the kitchen all the time. I have not told maintenance. We have flies in here, especially when it is warm outside. The fly trap machine on the wall does no good. I know the door should not be open, but it gets hot in here. The air conditioner does not work. On 11-4-22 at 9:10 AM V4 (Cook) stated, I saw a mouse in the kitchen yesterday. It does no good to report the mice. The mouse poop has been on top of the dishwasher for over two days. We (kitchen staff) do not have time to clean the kitchen. We have flies in here almost every day. On 11-4-22 at 9:45 AM V1 (Administrator) stated, I just told the kitchen staff yesterday that they are not to leave the kitchen doors propped open as it attracts flies and mice. The staff should have cleaned up the mouse poop and should have let maintenance know that they were seeing mice.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 6 life-threatening violation(s), Special Focus Facility, 4 harm violation(s), $486,689 in fines, Payment denial on record. Review inspection reports carefully.
• 96 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $486,689 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is El Paso Health's CMS Rating?

EL PASO HEALTH CARE CENTER does not currently have a CMS star rating on record.

How is El Paso Health Staffed?

Staff turnover is 60%, which is 14 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 75%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at El Paso Health?

State health inspectors documented 96 deficiencies at EL PASO HEALTH CARE CENTER during 2022 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, 84 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates El Paso Health?

EL PASO HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PETERSEN HEALTH CARE, a chain that manages multiple nursing homes. With 123 certified beds and approximately 98 residents (about 80% occupancy), it is a mid-sized facility located in EL PASO, Illinois.

How Does El Paso Health Compare to Other Illinois Nursing Homes?

Compared to the 100 nursing homes in Illinois, EL PASO HEALTH CARE CENTER's staff turnover (60%) is significantly higher than the state average of 46%.

What Should Families Ask When Visiting El Paso Health?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the facility's high staff turnover rate.

Is El Paso Health Safe?

Based on CMS inspection data, EL PASO HEALTH CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at El Paso Health Stick Around?

Staff turnover at EL PASO HEALTH CARE CENTER is high. At 60%, the facility is 14 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 75%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was El Paso Health Ever Fined?

EL PASO HEALTH CARE CENTER has been fined $486,689 across 4 penalty actions. This is 12.8x the Illinois average of $37,946. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is El Paso Health on Any Federal Watch List?

EL PASO HEALTH CARE CENTER is currently on the Special Focus Facility (SFF) watch list. This federal program identifies the roughly 1% of nursing homes nationally with the most serious and persistent quality problems. SFF facilities receive inspections roughly twice as often as typical nursing homes. Factors in this facility's record include 6 Immediate Jeopardy findings, a substantiated abuse finding, and $486,689 in federal fines. Facilities that fail to improve face escalating consequences, potentially including termination from Medicare and Medicaid. Families considering this facility should ask for documentation of recent improvements and what specific changes have been made since the designation.

Facility Details

Beds: 123
Avg. Residents: 98
Occupancy: 80.3%
Ownership: For profit - Limited Liability company
Chain: PETERSEN HEALTH CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
High Turnover: -5
6 Immediate Jeopardy citations: -72
4 Actual Harm citations: -20
96 Deficiencies: -10
Fines ($486,689): -15
Abuse Finding: -15
Special Focus Facility: -20
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 146097